Citizen trust, administrative capacity and administrative burden in Pakistan’s immunization program

Pakistan has the highest infant mortality rate in South Asia, is one of two countries where wild polio is still endemic, and is ranked third for un- or under-immunized children. Why is this the case when considerable donor and government funds have been spent on Pakistan’s Expanded Program for Immunization (EPI)? Based on a year of mixed methods research in district Kasur in Punjab, Pakistan, we focus on vaccination as a site of interaction between citizens and the state and apply the concept of administrative burden to explain vaccine hesitancy in Pakistan. As immunization is a non-means tested program where the state approaches citizens expecting full compliance, we argue that learning, psychological, and compliance costs are exacerbated by the context in which parents interact with frontline bureaucrats. Citizens’ distrust of an often absent or coercive state and low administrative capacity (specifically overburdened staff, inadequate facilities, and rushed digitization) have a multiplier effect on administrative burdens imposed on parents of young children in accessing immunization programs. Therefore, attempts by the state to vaccinate citizens often exacerbate distrust, and limited capacity hinders the state’s ability to reduce the burdens experienced by citizens.