New research has confirmed what Pakistan’s public health sector has long feared: childhood immunisation, once a rare success story in a fragile system, is now in retreat. Globally, vaccination rates have stalled, with 15.7 million children receiving no routine vaccines in 2023. But Pakistan’s ranking stands out for all the wrong reasons: it now has the second-highest number of zero-dose children in South Asia, behind only India.
That figure–419,000 children left entirely unprotected from routine diseases–represents a collapse in state outreach, a growing trust deficit, and the gradual unravelling of decades of immunisation progress. Worse, it places millions of other children at risk of preventable outbreaks as diseases like measles and diphtheria exploit the gaps in coverage.
The reasons are layered. The COVID-19 pandemic severely disrupted routine health services worldwide, but Pakistan’s immunisation programme was already under strain before 2020. Floods, fragile infrastructure, and political instability have eroded consistent delivery. In rural Balochistan, former FATA, and parts of Khyber Pakhtunkhwa, the cold chain is unreliable, vaccinators remain understaffed and underpaid, and access is often dependent on local negotiations with tribal elders or security escorts. But infrastructure is not the only hurdle. Public trust in state vaccination campaigns, particularly in areas affected by conflict or displacement, remains low. Rumours of vaccine-related harm or foreign conspiracy have circulated for years, often finding fertile ground in communities that see little else from the state. That suspicion is now spreading beyond polio to routine childhood vaccines, compounding the problem.
Blaming foreign misinformation campaigns or logistical setbacks alone will not solve this. Pakistan must reckon with the deeper governance failure at hand. The response should be urgent and institutional. The Expanded Programme on Immunisation (EPI) needs full federal commitment, integrated with provincial priorities and backed by real-time data. Similarly, mobile teams must be expanded, vaccinators protected and supported, and digital records linked to national ID databases for targeted outreach. Public messaging should also shift from one-way announcements to trusted, community-led engagement. International support exists. Gavi and UNICEF continue to invest heavily in Pakistan’s immunisation system, including through new multi-year agreements. But no amount of external aid can compensate for a lack of domestic political will. A generation of Pakistani children is now at risk. The question is no longer whether the system can be repaired, and it is whether there is the resolve to do it before these numbers worsen.
