Developing countries have been facing difficulties in reaching out to low-income and underserved communities for COVID-19 vaccination coverage. The rapidity of vaccine development caused a mistrust among certain subgroups of the population, and hence innovative approaches were taken to reach out to such populations. Using a sample of 1760 respondents in five low-income, informal localities of Islamabad and Rawalpindi, Pakistan, we evaluated a set of interventions involving community engagement by addressing demand and access barriers. We used multi-level mixed effects models to estimate average treatment effects across treatment areas. We found that our interventions increased COVID-19 vaccine willingness in two treatment areas that are furthest from city centers by 7.6% and 6.6% respectively, while vaccine uptake increased in one of the treatment areas by 17.1%, compared to the control area. Our results suggest that personalized information campaigns such as community mobilization help to increase COVID-19 vaccine willingness. Increasing uptake however, requires improving access to the vaccination services. Both information and access may be different for various communities and therefore a “one-size-fits-all” approach may need to be better localized. Such underserved and marginalized communities are better served if vaccination efforts are contextualized.

Background Urban slums are home to a significant number of marginalized individuals and are often excluded from public services. This study explores the determinants of willingness and uptake of COVID-19 vaccines in urban slums in Pakistan. Methods The study uses a cross-sectional survey of 1760 respondents from five urban slums in twin cities of Rawalpindi and Islamabad carried out between June 16 and 26, 2021. Pairwise means comparison tests and multivariate logistic regressions were applied to check the associations of socio-demographic factors and COVID-19 related factors with willingness to get vaccinated and vaccination uptake. Results Only 6% of the sample was fully vaccinated while 16% were partially vaccinated at the time of survey. Willingness to receive vaccination was associated with higher education (aOR: 1.583, CI: 1.031, 2.431), being employed (aOR: 1.916, CI: 1.423, 2.580), prior infection in the family (but not self) (aOR: 1.646, CI: 1.032, 2.625), family vaccination (aOR: 3.065, CI: 2.326, 4.038), knowing of and living close to a vaccination center (aOR: 2.851, CI: 1.646, 4.939), and being worried about COVID-19 (aOR: 2.117, CI: 1.662, 2.695). Vaccine uptake was influenced by the same factors as willingness, except worriedness about COVID-19. Both willingness and vaccination were the lowest in the two informal settlements that are the furthest from public facilities. Conclusions We found low lived experience with COVID-19 infection in urban slums, with moderate willingness to vaccinate and low vaccination uptake. Interventions that seek to vaccinate individuals against COVID-19 must account for urban poor settlement populations and overcome structural barriers such as distance from vaccination services, perhaps by bringing such services to these communities.

Purpose This article aims to explore the areas of misalignment between the public financial management (PFM) and health financing during the COVID‐19 pandemic in Pakistan. Originality/Value To the best of our knowledge, it is the first study on South Asian countries to adopt a framework and bring forward the dominant themes that cause the misalignment between PFM and health financing. The timing of the research was excellent as the world was facing the biggest health challenge in the form of COVID‐19 which has put pressure on the PFM and has seriously hampered health service delivery. Therefore, the findings of the study are helpful for the ministry of health to draft policies to improve health allocations and move towards Universal Health Coverage. Design/Methodology/Approach In‐depth semi‐structured interviews of 15 participants were used to explore the areas of misalignment between PFM and health financing. Based on qualitative data, thematic content analysis has been carried out. Findings The findings of the study can be divided into five clusters and their explanations. First overall budget allocation has an impact on the health sector budget. For example, the budget for priority health interventions is not reflected in the budget allocation process. Further, the budget is classified by inputs rather than disease and finally, the budget is not released by the health priorities. The second cluster was the devolution of health to provinces which is unfinished agenda. Under this cluster fiscal decentralisation has been found to cause problems for the provinces as they have not provided fiscal autonomy to spend the money and there is a lack of coordination between the federal and provincial authorities. The third cluster was donor funding, and it was observed that it is not aligned with the government policies and priorities. Forth cluster was procurement and it was discovered that it is a lengthy process and caused delays in procuring the essential health equipment. The fifth cluster was an organisational culture that is not conducive to the health sector. Under this cluster, the attitude, knowledge, and practices of departments responsible for the health sector require complete revamping.

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Background: Urban slums are home to a significant number of marginalized individuals and are often excluded from public services. This study explores the determinants of willingness and uptake of COVID-19 vaccines in urban slums in Pakistan. Methods: The study is a cross-sectional survey of 1760 individuals from five urban slums in Rawalpindi and Islamabad. The survey was conducted between June 16 and 26, 2021 to ask about the experience of COVID-19 infection, willingness and registrations to receive, and actual vaccinations. Results: A prior experience of COVID-19 infection was uncommon in any locality in that only 2–17% had encountered the infection themselves or by a family member. Willingness to receive vaccination and uptake correlated with increasing age, education, employment, prior infection in the family (but not self), family vaccination, and knowing of and living close to a vaccination center. Both willingness and vaccination were the lowest in the two informal settlements that are the furthest from public facilities. Conclusions: We found low lived experience with COVID-19 infection in urban slums, which was associated with moderate willingness and low vaccination rates. Interventions that seek to vaccinate individuals against COVID-19 must account for urban poor settlement populations and overcome structural barriers such as distance from vaccination services, perhaps by bringing such services to these communities.