ZINDAGI MEHFOOZ (SAFE LIFE)
Increasing Immunization Rates in
Pakistan’s Sindh Province
Interactive Research & Development
Acknowledgements
As part of a series led by the Every Woman, Every Child
Innovation Working Group (IWG) catalytic mHealth grants
program, this case study aims to illustrate the process,
partnerships, and sustainability model of an mHealth
program as it scales up, in addition to outlining challenges
faced and key lessons learned. The Interactive Research
and Development program was selected because it serves
as an excellent model for other organizations by leveraging
mHealth technology to scale and establishing a social
enterprise model to achieve sustainability.
The IWG mHealth grant program is generously supported
by the Norwegian Agency for Development Cooperation
(NORAD) and led by the United Nations Foundation (UNF) and
the World Health Organization Department of Reproductive
Health and Research (WHO/RHR). Since 2012, the program
has awarded 26 catalytic grants across 15 countries, to
support mHealth solutions that are used by over 8,000
health workers in over 13,000 facilities, impacting health
service delivery for nearly 1.5 million people.
Special thanks to Aamir Khan, Asad Zaidi, Saira Khowaja,
Subhash Chandir, Ali Habib, Imran Zafar, Uyen Tang,
Francis Gonzales, Carolyn Florey, and Abigail Manz for their
contributions to this document.
Table of Contents
Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . 5
Overview: An Introduction to IRD and the
Immunization Challenge . . . . . . . . . . . . . . . . . . . . . . 6
Immunizations: A Public Health Opportunity . . . . . . . . 6
About IRD: Innovation in Research and
Healthcare Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Understanding the Immunization
Challenge in Pakistan . . . . . . . . . . . . . . . . . . . . . . . . 7
A Model Program: IRD’S Safe Life Program . . . . . . . . 8
How it Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Fine-Tuning the Technology . . . . . . . . . . . . . . . . . . . . 9
A Strong Foundation: Building on
Evidence-Based Research and Partnerships . . . . . . . 11
Building An Evidence Base Through Research . . . . . 11
Strategic Engagement Of Government
And Vaccinators . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Partners, Donors and Funding . . . . . . . . . . . . . . . . . 12
Evolving Business Model . . . . . . . . . . . . . . . . . . . . . 15
Delivering Impact and Results . . . . . . . . . . . . . . . . . 16
Looking Forward: Scaling In Pakistan and Beyond . . . 18
Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Challenges to Scaling Up . . . . . . . . . . . . . . . . . . . . . 19
Resources Needed for Sustainability and Scale . . . . 19
A World of Difference . . . . . . . . . . . . . . . . . . . . . . . 20
Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Acronyms
B2B
Business-to-Business
CHS
Community Health Solutions
DTP3
Diphtheria-tetanus-pertussis
EPI
Expanded Program for Immunization in Pakistan
GP
General Practitioners
IHS
Interactive Health Solutions
IRD
Interactive Research and Development
IWG
Innovation Working Group
mHealth
Mobile Health
NGO
Non-governmental organization
NORAD
Norwegian Agency for Development Cooperation
QR
Quick Response Code
RFID
Radio Frequency Identification
SMS
Short Message Service
TB Tuberculosis
UNF
United Nations Foundation
WHO
World Health Organization
Executive Summary
Immunizations save the lives of millions of children each year, are inexpensive and
are routinely available throughout most parts of the world. However, despite being
a free public good, in some districts in Pakistan, less than 40% of children are
immunized. This high rate of unvaccinated children not only puts the child at risk, but
poses a public health issue for the entire community.
Interactive Research and Development (IRD), a non-governmental organization (NGO)
operating in Pakistan has come up with a mobile health (mHealth) program that
combines SMS alerts and interactive messaging with a mobile cash transfer incentive
program that rewards both vaccinators and caretakers for vaccinating children. Over
the course of several years and a number of studies, IRD has devised a program
that has successfully increased the immunization coverage and completion rates for
children using the right formula of incentives and delivery mechanisms.
This case study shows how IRD built the Zindagi Mehfooz (Safe Life) Immunization
program. It discusses how IRD is using a hybrid funding model of seeking traditional
donor funds while also engaging in a social enterprise solution in order to make
the program sustainable in the long run. IRD has paired the Safe Life program with
Community Health Solutions (CHS), a clinic that provides lab tests, diagnostics
and treatments. The match has added value for both sides, drawing in new
customers for CHS and providing a funding stream for Safe Life. We learn how
this partnership and other strategies aim to ultimately increase the number of
vaccinations throughout Pakistan.
OVERVIEW:
An Introduction to IRD and the
Immunization Challenge
This case study is about
how Pakistan’s IRD tackled
the vaccination challenge.
IRD created the Safe Life
program designed to
increase vaccination and
immunization rates
at scale.
IMMUNIZATIONS: A PUBLIC HEALTH OPPORTUNITY
Worldwide in 2014, 86% of infants received the third dose of diphtheria, tetanus, and pertussis vaccine
(DTP3) vaccine, a key indicator of national immunization program performance.1 Yet 1.5 million children
still die each year from vaccine-preventable illnesses.2 Pakistan, in particular, lags behind in global
immunization rates. In some Pakistani regions, less than 40% of children are fully immunized.3,4 According
to the Government of Sindh Bureau of Statistics Planning and Development’s Multiple Indicator Cluster
2014 survey, only 35% of children in the Sindh region, where Karachi is located and where IRD operates
the Safe Life program, have received all of their basic vaccinations.5 Achieving a high rate of immunization
is an important public health goal. It not only protects an individual from contracting a disease, but also
can lead to the elimination of the disease entirely from the community.
It is clear that immunizing children could save millions of lives. In Pakistan, vaccines are already provided
free of charge and government policy is to make vaccines available through routine immunization, so why
are immunization rates still so low? What are some of the barriers that prevent children from completing
their vaccination schedules?
This case study is about how Pakistan’s IRD tackled the vaccination challenge. IRD created the Safe Life
program designed to increase vaccination and immunization rates at scale. IRD formed strategic partner-
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ZINDAGI MEHFOOZ (SAFE LIFE)
ships with the government, created incentives for actors along the value chain, and leveraged mHealth
technology to track, monitor, and remind mothers and caretakers to complete vaccination schedules on
time. To help the program become sustainable, IRD integrated Safe Life with its own social enterprise,
CHS, and is on its way to becoming self-sustaining.
ABOUT IRD: INNOVATION IN RESEARCH AND HEALTHCARE DELIVERY
IRD is a nonprofit research organization, headquartered in Dubai, but with deep roots and origins in
Karachi, Pakistan. IRD’s mission is to “improve the well-being of vulnerable communities through
innovation in research and health delivery.”6 Founded in 2004, IRD currently operates in 15 countries and
reaches 70 million people.
IRD’s mission is to
improve the wellbeing of vulnerable
communities through
innovation in research
and health delivery.
The core team working on the IRD vaccination program is led by IRD’s Founder, Dr. Aamir Khan and Dr.
Subhash Chandir, IRD’s Director of Child Health & Vaccines Program. Other instrumental members directly
contributing to the program’s development and execution include: Imran Zafar (CEO of CHS), Ali Habib
(CEO of Interactive Health Solutions (IHS) and Developer of Vaccine Registry), Saira Khowaja (Director
of Program Development), Asad Zaidi (Program Manager, CHS), Vijay Kumar and Danya Arif (Program
Managers, Child Health & Vaccines Program) among others.
IRD has a wealth of expertise and over 10 years of experience in delivering innovative health programs
in Pakistan. It had worked on similar mHealth programs such as disease surveillance projects that used
mobile phones to send alerts to healthcare workers to collect samples. This experience puts IRD in a
unique and advantageous position to tackle the vaccination challenge in Pakistan.
Dr. Aamir Khan and his team have spun off two social enterprises: IHS, an information technology
company, and CHS,7 a company that links public sector services with private clinics. Both are for-profit
organizations with a focus on delivering healthcare services to vulnerable populations. IRD’s experience in
establishing social enterprises strengthens its ability to find a financially sustainable model for Safe Life.
UNDERSTANDING THE IMMUNIZATION CHALLENGE IN PAKISTAN
Although vaccines are offered for free through Pakistan’s public health system, some women and children
were still falling through the cracks. Reasons for incomplete vaccinations include mothers or caretakers
losing track of the vaccine schedule, moving away from the vaccine center, incurring transportation costs
while traveling to the center, and a mistrust of vaccines.
As IRD began investigating the vaccination challenge further, it uncovered problems specific to the
healthcare system. For example, the Pakistani government requires all vaccinators to submit vaccination
data via paper. A paper system is more prone to human errors, is not easy to track, and requires administrative time on the vaccinator’s part. Most notably, if a child does not return to the same clinic for all doses
of a vaccination, it will be difficult to track the paper records to verify which vaccines the child may have
already received, when he/she had the vaccinations, and how many doses.
Another issue was that overall, vaccinators were not providing quality care. Some vaccinators in Pakistan
are volunteers; others received low wages, which were not enough to motivate them to provide high
quality care or information, or follow up to ensure children completed their vaccinations. Regardless
of how many children they vaccinated, they would get paid the same amount. This flat compensation
model led some vaccinators to charge unofficial fees of US$0.20 to US$0.30 per vaccination,8 deterring
low-income families from obtaining multiple vaccines.
To help improve the immunization challenge in Pakistan, IRD would have to tackle the problem from the
demand and the supply side. What type of incentives would IRD need to put in place to help mothers
to get their children vaccinated? How could IRD change the vaccinators’ behavior so that they would
proactively ensure more children were vaccinated?
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A MODEL PROGRAM:
IRD’S SAFE LIFE PROGRAM
HOW IT WORKS
IRD’s goal is to increase the number of children who complete their vaccination schedules on time. It
would not be enough to simply raise awareness of the need for vaccines and give an infant his/her first
vaccines. In order for a child to be immunized, he/she needs to receive a complete series of vaccinations
over time. This requires tracking, monitoring, and issuing reminders to ensure that vaccines are given at
the right time.
IRD designed an mHealth program that uses incentives for multiple players along the value chain including
vaccinators and mothers to increase the timely completion of the vaccine schedule for each child.9 The
following are the steps in the Safe Life program:
SAFE LIFE PROCESS
Caregiver enrolls in lottery
system during EPI center visit
Caregiver receives SMS reminders
about vaccination appointments
Child receives vaccination
Reminders sent
for scheduled
vaccinations
until complete
Rs
Lottery: caregiver eligible to
win cash prize per vaccination
completed on time or late
Vaccine provider also receives
payment of 40% of lottery prize as
incentive and tracks child’s progress
Vaccine
BCG
Penta 1
Penta 2
Penta 3
Measles 1
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ZINDAGI MEHFOOZ (SAFE LIFE)
On due date
Rs 200
Rs 300
Rs 500
Rs 600
Rs 700
Late
Rs 200
Rs 250
Rs 350
Rs 400
Rs 450
Safe Life:
• Step 1: Mother is given a Quick Response (QR) code sticker with the child’s unique
ID at enrollment.
• Step 2: Child’s biodata such as the child's name, date of birth, parents' names, contact number,
address, and vaccine data are recorded at enrollment on the cloud.
• Step 3: Mother receives automated reminder on her mobile phone each time the child is due for
a vaccine.
• Step 4: Mother brings child back to health facility for next vaccination.
• Step 5: Using a mobile phone to scan the QR code, data is retrieved from the cloud during
follow-up visits.
Key design decisions for
the Safe Life program took
into consideration user
needs and scalability.
Lottery System for Safe Life:
• Step 1: Mother opts in to play the lottery for the chance to win between US$2- US$8 in shop
credit. The vaccinator is also enrolled in the lottery and if the mother wins, the vaccinator wins
40% of the mother’s lottery prize.
• Step 2: Mother and vaccinator receive a mobile cash transfer, if he/she wins.
FINE-TUNING THE TECHNOLOGY
The initial idea for the program was a basic electronic vaccine registry that would use Short Message
Service (SMS) alerts to remind mothers or caretakers to get their children vaccinated. However, over the
course of developing and testing the program, several technology and process changes were made.
Paper to Electronic: The Pakistani government uses a paper-based system to track vaccinations and still
requires paper copies for their records. In order to accommodate this need, IRD tailored the mobile-based
form that vaccinators use to record patient data to match the government’s paper forms. Vaccinators can
now print out these forms to submit to the government. This design decision was crucial because it meant
that engaging in the Safe Life program would not create extra work for the vaccinator.
When it came to implementing the incentive rewards, the IRD team considered paper vouchers, rather
than executing through a mobile system. While less expensive, paper vouchers could be easily lost or
replicated to redeem excess rewards, which would undermine the program.10 Ultimately, the solution was
a compromise that included QR codes printed on paper. The QR codes were more difficult to replicate and
were tied to an electronic system that could verify and track the reward.
Java to Android: The program was originally developed using Java for Nokia phones, which were
mainstream at the time. IRD then switched to the Android platform since 80% of mobile users in Pakistan
now own an Android phone.11 Android phones had become cheaper and offered more advanced technology than the older Nokia phones.
RFID to QR Codes: When the program officially started in 2012, IRD began by using Radio Frequency
Identification (RFID) bracelets. The RFID bracelets were placed on the child and healthcare workers could
scan the bracelet to identify the child and pull up the data related to its vaccine history. However, IRD
switched to QR codes because they were less expensive and could be easily printed and distributed to
mothers. The RFID technology was sourced from China and shipments were sometimes delayed due to
import and customs issues. Moving away from RFID technology meant that expansion would not depend
on the supply from China.12
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ZINDAGI MEHFOOZ (SAFE LIFE)
A STRONG FOUNDATION:
Building on Evidence-Based Research
and Partnerships
BUILDING AN EVIDENCE BASE THROUGH RESEARCH
IRD’s deep expertise in evidence-based implementation and delivering health programs gave it a head
start on developing the Safe Life program. IRD leveraged the lessons learned and technology it had
already built.
In 2005, IRD conducted a study on “conditional cash transfers” for immunizations. The study followed
two cohorts: one as intervention and one as control. The results showed that in the intervention cohort,
SAFE LIFE MILESTONES
2005
IRD conducts study on
conditional cash transfers
2011
IRD conducts study on 2-way
SMS vaccination reminders
2012
IRD receives formal approval to start
Interactive Alerts program activities in Karachi
October 2013
IRD develops Android app and begins
integrating with social enterprise
December 2013
IRD begins collaboration with Punjab
province and program expansion
2015
IRD enrolls over 75,000 children in Karachi
and launches a mobile cash transfer
method to deliver rewards
INCREASING IMMUNIZATION RATES IN PAKISTAN’S SINDH PROVINCE   |  
11
IRD leveraged the IWG
grant to develop Safe
Life and address key
programmatic barriers to
scale. The grant allowed
IRD to test hypotheses
around the use of
incentives at a large
scale and demonstrate
that incentives are an
effective tool to increase
vaccination rates.
immunization coverage rates improved 2.2 times the baseline rate, which was only 20%. The study
showed positive results, but questions remained whether the program could be scalable to provide
incentives to the entire country.13 From this study, IRD knew that it should incorporate incentives into the
Safe Life program.
IRD conducted a second, highly relevant study in 2011 in Karachi at the Indus Hospital Center. The study
targeted children under two years of age and the objective was to test the use of mobile phones to
increase vaccination rates. Over the course of 15 months, IRD used two-way SMS texts to engage with
the community and send reminders for them to get their vaccinations. Users could also ask questions
through the system and the team could respond to simple questions.14 Analysis from the study showed
that the SMS reminders and additional interaction over messaging improved completion rates and
timeliness.15 For example, results from the study indicate that 68% of users who received the Safe Life
intervention completed their Measles 1 vaccination compared to 32.7% of the control group which
received no intervention. Similarly 53.4% of users in the Safe Life group received the Measles 2 vaccination compared to 21.4% of the control group. Experience building out this program helped to develop the
system for Safe Life.
STRATEGIC ENGAGEMENT OF GOVERNMENT AND VACCINATORS
Before launching Safe Life, IRD would need to get the government’s approval and assistance in order to
successfully implement their program. Safe Life’s mission was attractive to the government because they
wanted to make sure that the people were receiving the free vaccines that the government provided. In
order to get the government on board, IRD engaged them from the very beginning of the project, and
provided regular progress reports and project outcomes. IRD also presented at ministry and departmental
meetings.16 Additionally, they needed to secure permission from the executive director of health, the town
health official, the director of EPI programs, and numerous hospital and clinic officials, among others.
IRD knew that obtaining these permissions would be difficult and that engaging with the government
at multiple levels (national, regional, and local) would be a lengthy, ongoing process, especially as they
continued to expand. To address this challenge, IRD hired a Sindhi-speaking field manager who would
be responsible to continuously engage the health officials and secure the regulatory permissions. This
step was important because it also gave IRD access to a network of vaccinators. The field manager
was a dedicated resource who was essentially responsible for managing a business-to-business (B2B)
relationship in order to furnish the “supply” of hospitals, clinics and vaccinators.17
Next, IRD had to get the vaccinators on board. Initially the vaccinators were reluctant and each had to
be convinced individually. To accomplish this, IRD recruited a well-respected veteran vaccinator as a
champion for the program. This particular vaccinator was a key element18 because he was credible and
instrumental in convincing vaccinators to participate in the program. He also conducted some of the
initial trainings.
PARTNERS, DONORS AND FUNDING
IRD is a recipient of the IWG catalytic mHealth grant, aimed at supporting the scale-up of mHealth
programs focused on reproductive, maternal, newborn, and child health. IRD leveraged the IWG grant to
develop Safe Life, and address key programmatic barriers to scale. The grant allowed IRD to test hypotheses around the use of incentives at a large scale and demonstrate that incentives are an effective tool to
increase vaccination rates. Testing at a large scale in the real world environment was important because
IRD could draw lessons that may not have arisen during a small pilot program where the challenges
encountered would be different.
IRD works closely with the Sindh province government and EPI staff to run the program. It has a network
of healthcare facilities including hospitals and clinics where it reaches vaccinators and mothers. Other
partners who have provided funds or advisory services include: Government of Pakistan; openXdata.org
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ZINDAGI MEHFOOZ (SAFE LIFE)
INCREASING IMMUNIZATION RATES IN PAKISTAN’S SINDH PROVINCE   |  
13
IRD’s business model
and value chain have
changed over time in order
to achieve efficiencies
while still offering a high
quality service.
(Bergen, Norway); Indus Hospital (Karachi, Pakistan); Johns Hopkins Bloomberg School of Public Health
(Baltimore, United States), United Nations Foundation, and WHO/RHR. Private sector partners include
MNOs Zong and Telenor who provide their services at a reduced cost.
IRD’s total budget for the 2-year pilot of the Safe Life program starting in June 2012 was approximately
US$200,000.19 Costs included:
• Server maintenance, backup, and connectivity charges
• Mobile technology updates, ongoing development
• MNO data service
• Phones for vaccinators
• Phones for shopkeepers
• Training for vaccinators
• Marketing campaigns to educate doctors, promotions such as giveaways, billboards, and
cable advertisements
• Program costs which include staff costs
The Safe Life program currently relies on donor funding. Government EPI centers provide vaccines for free
throughout most areas in Pakistan. Even at facilities where healthcare workers may charge an “unofficial
fee,” the price is rarely above US$0.50. Free and low cost vaccines make it difficult for IRD to charge a
meaningful fee that would recover costs. However, the low quality of public healthcare, high incidents of
vaccine stock-outs, and long wait times could present an opportunity in the private sector for IRD.
ORIGINAL SAFE LIFE PROGRAM VALUE CHAIN
Donors
Government
IRD
RFID
Supplier
MNOs
Vaccinator
Shopkeeper
Mother/
Child
NEW SAFE LIFE VALUE CHAIN
Donors
14   |  
Government
ZINDAGI MEHFOOZ (SAFE LIFE)
IRD
RFID
Supplier
MNOs
Vaccinator
Shopkeeper
Mother/
Child
EVOLVING BUSINESS MODEL
The Safe Life program’s value lies in its ability to target and reach low-income communities that may not
be aware of or able to access free vaccines in Pakistan. IRD’s program is the first of its kind in Pakistan to
utilize mobile phones to track and remind mothers to bring their children back to the clinics for vaccinations. Mobile phones provide a fast and streamlined solution and can be used to scale and reach millions.
Over time, as IRD evaluated its program, and looked for ways to achieve sustainability, it recognized that
more efficiencies could be achieved, while still being able to meet its value proposition. Since starting
the program, IRD has managed to reduce overhead costs, transportation costs, duplicate field teams,
and even the costs of incentives. This meant that its business model and value chain changed in order
to achieve efficiencies. For example, RFID technology was swapped out for QR codes, which could be
printed easily and did not rely on a supplier. IRD also originally partnered with a network of shopkeepers to
distribute rewards, but removed the network from its value chain in favor of transferring rewards directly to
mothers and vaccinators through mobile cash transfers.
In November 2015, IRD launched a new method of delivering rewards through mobile cash transfer in two
sub-districts in Karachi. IRD is working with Telenor and its branchless banking program Easy Paisa to
implement the mobile transfers. The rewards will now be provided to the vaccinators and mothers directly
as mobile cash transfers that they can withdraw at any of the 70,000 cash points across the country.
Partnering with one of the largest MNOs in Pakistan gives IRD access to a wide network that can distribute
the rewards.
Given its past experience, IRD knew that in order to be sustainable, it would have to pursue a hybrid
funding strategy. Currently, the program relies on government support and donor funding. The first part
of IRD’s strategy is to continue pursuing these sources of grant funding. The second part of the strategy
SAFE LIFE SUSTAINABILITY MODEL
Donor Funding
CHS
Social Enterprise
CHS Revenue
Safe Life
Vaccine Program
Main Lab
Vaccines provided
for clients
Satellite
Clinics
INCREASING IMMUNIZATION RATES IN PAKISTAN’S SINDH PROVINCE   |  
15
is to integrate the Safe Life program with CHS (one of IRD’s social enterprises), so that CHS’s revenue
can subsidize Safe Life operations. Safe Life is currently being implemented in some of the CHS clinics.
As a social enterprise, CHS has a double bottom line and aims to make a public health impact first and
financial profit second. With the double bottom line in mind, CHS offers free vaccines, as part of the Safe
Life program, free lab tests for TB, malaria, asthma and chronic obstructive pulmonary disease hepatitis,
and diabetes. These free services would serve as loss leaders in hopes that patients would come back for
other services such as blood tests that they would pay for.20
CHS’s system of lab centers and clinics is a hub and spoke model that makes it amenable to scaling.
The system operates with one major central lab with equipment necessary to conduct tests and provide
treatments. Its satellite clinics would be lab collection centers and require less capital to set up. The
satellite clinics would send their samples back to the central lab for testing. If a patient needed additional
care, they could be referred to the central lab. CHS is currently testing this model before expanding it to
other regions.
DELIVERING IMPACT AND RESULTS
IRD’s original goal was to demonstrate scale by enrolling at least 15,000 children in the vaccine program.21 IRD exceeded its goal. During the duration of the IWG grant program (2012-2013), IRD enrolled
18,547 infants in the electronic vaccine registry, trained 25 healthcare workers and partnered with 12
public and private healthcare facilities.22
The Safe Life program has continued to deliver impressive results beyond the IWG grant funding.
In 2014-2015 IRD has enrolled over 75,000 children in Karachi,23 nearly half (48.6%) of whom are
female.24 While the enrollment number appears high, it is only 20% of the birth cohort, and IRD aims
to grow to meet that need. The true success of the program is gauged by the immunization rate. The
Safe Life program’s Penta3 (or DTP3) completion rate is 84%. DTP3 is a key indicator of vaccination
completion. Between June 2012 and October 2014, the fully immunized child rate25 in the IRD registry
was 54%, which is 25% higher than a baseline cohort of children surveyed in the Pakistan Demographic
Health Survey. These initial results indicate that IRD is a program that can and should be scaled-up in
order to immunize more children.
In addition to the measurable results, there were unanticipated, intangible, but highly valuable consequences. One such result was that vaccinators who have participated in the program have stopped taking
unofficial fees. They report they are now motivated by the incentives provided through the program to earn
their pay.26 Previously, vaccinators earned a flat rate of about $60/month from IRD, in addition to their
monthly salary from the government. This payment structure did not affect the vaccine enrollment rate.
Providing vaccinators pay-for-performance incentives was game changing. They spent more hours at the
healthcare facilities, they kept the centers clean, and they also provided more information and guidance to
mothers. Now vaccinators earn on average $65/month from the program,27 and while it is only approximately 8% more than they previously earned, they reported that they were motivated to work longer hours
because they felt their services were valued and impactful.28
Another positive result is that IRD has established a close working relationship with the Sindh province
government and the local EPI program staff at the city level. IRD staff has supported EPI on a number of
projects, such as providing statistical analysis of vaccine data. The close working relationship means
that the government views IRD as a reliable long-term partner and will likely continue supporting IRD on
future projects.
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17
LOOKING FORWARD:
SCALING IN PAKISTAN AND BEYOND
“Wherever possible,
create models that are
hybrids, that rely on
both public and private
sources of revenue, not
one or the other.”
- Aamir Khan, Founder, IRD
IRD is exploring multiple paths to scale. First, it has been working with the Sindh provincial government
to roll out Safe Life in 8 out of 23 districts by 2018. It also has plans to expand beyond the region. IRD is
currently collaborating with the Punjab government and WHO Punjab to execute a similar program and is
trying to engage other province level governments.
Currently IRD’s CHS program operates three main lab centers in Karachi. Using its hub and spoke model,
CHS has a plan to continue scale-up over the next three years. In the short term, over the course of
the next 12 months, CHS aims to open two satellite clinics and expand its partnerships with general
practitioners (GPs) who can help refer patients to CHS. By 2018, CHS would like to expand throughout
Karachi with 15 centers in total including the three main lab centers and 12 satellite clinics. CHS also
aims to partner with over 900 GPs.
“If you want to scale,
you need to work with
the government.”
LESSONS LEARNED
- Ali Habib, CEO, CHS
Utilize a hybrid business model: Users are unwilling to pay for vaccines because they are a free public
good. To continue offering this effective health service, IRD has integrated the Safe Life program into its
social enterprise, CHS. CHS leverages a hybrid model that combines funding streams from public and
private sector grant donors with market-driven revenue streams and commercial investments, which
makes it a more sustainable model. IRD is continually working to diversify its revenue streams so that if
one source of funding dries up, the business can rely on other sources to keep operations running.
Through the course of the IWG grant, IRD uncovered valuable lessons in sustainability and scale that are
applicable to other mHealth programs.
Involve stakeholders from the top down and bottom up: IRD made sure to include the Sindh
government at the highest appropriate levels. Without fully informing the government at all levels, IRD may
have faced resistance or delays and may not have been able to execute the program. Equally important
was including on-the-ground operators, such as vaccinators, from the beginning.29 Early buy-in gives
stakeholders a sense of ownership and power in the process and keeps them engaged.
Integrate user feedback along the way: IRD started by testing their program with one clinic and then
expanded. The vaccinators were early adopters and beta testers and helped to make the app more
user-friendly in order to increase the adoption rate.30 It is because of their early involvement that IRD was
able to move quickly on making well-informed changes to the program.
Leverage an existing network to scale: One of the reasons IRD cut the shopkeeper out of its value
chain was because it realized that the logistics of managing the individual shopkeepers as the program
scaled up were prohibitive.
Maximize existing technology: Introducing new technology, such as RFID bracelets, results in a
steeper learning and adoption curve and can be more expensive than existing technology. Using existing
technologies such as QR codes can often times be just as effective. The IRD team learned to identify the
problem and then apply the most appropriate solution for the context, rather than applying new technology
and expecting users to adopt it.31
18   |  
ZINDAGI MEHFOOZ (SAFE LIFE)
CHALLENGES TO SCALING UP
As IRD begins to experiment with scaling the Safe Life program, it will first tackle the challenge of
scaling-up in Karachi by using the hybrid social enterprise model with CHS. Expanding beyond Karachi will
require adapting the program to local contexts and partnering with local government, as IRD is beginning
to do in Punjab with the Punjab Information and Technology Board. The challenges that IRD faces when
scaling within Karachi and beyond are:
Competition: There are at least three different mHealth vaccination programs in Pakistan, all of which
have a different method for collecting data.32 In order to have an effective and accurate national vaccine
registry, these different programs need to collaborate. IRD reached out to the Punjab Information Technology Board in early 2014, to share its experience and results from the Safe Life program to help them build
a similar program in Punjab province.33 IRD is actively collaborating with other stakeholders to share its
best practices so that others can learn from its years of experience without having to reinvent the wheel.
As a social enterprise, CHS is subject to the high amount of competition in the market. Karachi already
has several labs and many use a revenue share agreement with doctors and hospitals where they pay up
to 40% for client referrals. To compete with other labs, diagnostic centers and clinics in the city, CHS will
have to effectively market its services to draw in new customers.
As IRD scales in Karachi
and beyond it will have to
adapt to local contexts,
partner with local
governments, compete or
find ways to collaborate
with similar programs,
continue to determine the
best role for incentives in
the program, and deal with
changing operating costs.
Geographic diversity: Pakistan is a country with over 60 languages. In order to scale the program nationally, the software and on-the-ground program management would have to be tailored to each language.34
One of the benefits of the software that IRD developed is that the data captured is coded, which means
that even if the language is changed, the data can still be stored and analyzed.35 While the software that
IRD has developed can be adapted to different languages, the challenge of rolling out the program on the
ground requires local knowledge and a strong network of healthcare providers.
Determining optimal incentives: IRD is currently conducting studies to determine what the optimal
incentive would be to produce the desired behavior.36 These studies are focused on the incentives for
mothers as well as the vaccinators. The data is important as IRD begins its mobile cash transfer program
because donors will want the program to be as cost effective as possible.
Changing mobile rates: IRD is in the early stages of implementing rewards through mobile cash
transfers and there will be valuable lessons to learn. One challenge to consider is that program operating
costs have changed. The service charge for mobile money transfer is variable depending on how much
money is being transferred. IRD is in the process of negotiating with the MNOs to bring down the costs.
Obtaining donor agreement to use incentives: Some donors may be averse to using incentives as a
reward, regardless of whether they are cash-based or store credit. Using a mobile cash transfer program
will allow IRD to build in transparency, accountability, and security mechanisms.
RESOURCES NEEDED FOR SUSTAINABILITY AND SCALE
By the end of 2016, CHS expects to earn US$25,000 in monthly revenue, or US$300,000 in annual
revenue, which will cover 50% of their operating expenses. If CHS can obtain a capital investment of
US$1.5 million, it expects to cover all of their expenses within three years. In the near term (within the next
five years) IRD would like CHS to be self-sustaining and even grow within Karachi.
In order to scale up and reach a wider target audience within the next 12 months, IRD needs US$400,000
to subsidize CHS’s total operating costs of US$600,000. These funds will be used to vaccinate 50,000
new infants and identify 3,000 new TB patients and 2,000 new diabetic patients. The social enterprise’s
monthly costs are estimated at US$50,000 and its current projection in monthly revenue within one year
will be US$25,000, meaning that IRD expects it will recover 50% of its costs within one year. Already,
due to its initial success IRD has received funding and support from WHO-Pakistan, NORAD and Gavi to
expand the program in another two to three districts.
INCREASING IMMUNIZATION RATES IN PAKISTAN’S SINDH PROVINCE   |  
19
IRD paired an effective
mobile technology platform
with robust partnerships
with the government,
health facilities, and
vaccinators to build
a program that helps
Pakistan improve its
infant vaccination rates
and save lives.
Over the next three years through 2018, IRD would require US$1.5M. These funds would be used to
expand IRD’s program to cover all of Karachi, resulting in 100,000 more infants vaccinated annually. They
will also be used to identify 8,000 new TB patients, and 5,000 new diabetics. Additionally, a portion of this
investment (approximately US$700,000) will be used to invest in setting up a laboratory for CHS. The lab
will allow CHS to continue to generate additional revenue from conducting lab tests for other partners and
will save CHS money because it will no longer have to outsource lab tests. This investment of US$1.5M
will help the social enterprise be fully sustainable and not have to rely on an operating cost subsidy within
three years.37
A WORLD OF DIFFERENCE
IRD’s Safe Life program is addressing a critical public health issue. It helps to increase immunization
coverage, reduce the risk of disease outbreaks, and decrease the costs associated with addressing public
health crises.
Through several iterations of testing, IRD structured an elegant program using mobile phones to send
reminders to mothers to get their children vaccinated. Along with these reminders, it incentivized mothers
to vaccinate their children on time and complete the vaccination schedule so that their children would be
immunized from specific diseases.
It paired an effective mobile technology platform with robust partnerships with the government, health
facilities, and vaccinators to build a program that helps Pakistan improve its infant vaccination rates
and save lives. IRD was also able to create a plan for sustainability by linking it to a revenue generating
social enterprise.
IRD’s Safe Life program is an example of a scalable mHealth program that can be adapted around the
world to achieve higher vaccination rates. Globally, if all children are immunized by 2020, 25 million lives
could be saved.38
20   |  
ZINDAGI MEHFOOZ (SAFE LIFE)
INCREASING IMMUNIZATION RATES IN PAKISTAN’S SINDH PROVINCE   |  
21
ENDNOTES
1“Immunization Coverage.” Media Centre Fact Sheet No 378. World Health Organization, Sept. 2015.
Web. 26 Oct. 2015. <http://www.who.int/mediacentre/factsheets/fs378/en/>.
2“Immunization.” Stopping Disease in Its Tracks. UNICEF USA, n.d. Web. 26 Oct. 2015.
<http://www.unicefusa.org/mission/survival/immunization>.
3“Young Child Survival and Development.” Young Child Survival and Development - Immunization.
UNICEF ROSA, n.d. Web. 26 Oct. 2015.
<http://www.unicef.org/rosa/survival_development_2542.htm>.
4“Small Incentives Improve Vaccine Coverage in Pakistan —IRD’s Safe Life.” Innovations Catalyst
(2013): n. pag. World Health Organization, 2013. Web. 26 Oct. 2015.
5“MULTIPLE INDICATOR CLUSTER SURVEY.” Sindh Bureau of Statistics Planning Development
Department. Sindh Bureau of Statistics Planning Development Department, n.d. Web. 09 Dec.
2015. <http://sindhbos.gov.pk/mics/>.
6“About Us.” About Us. Interactive Research and Development, n.d. Web. 26 Oct. 2015.
<http://www.irdresearch.org/about-us-2/>.
7“About Us.” About Us. Interactive Research and Development, n.d. Web. 26 Oct. 2015.
<http://www.irdresearch.org/about-us-2/>.
8Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
9“Small Incentives Improve Vaccine Coverage in Pakistan —IRD’s Safe Life.” Innovations Catalyst
(2013): n. pag. World Health Organization, 2013. Web. 26 Oct. 2015.
10 Habib, Ali. “Interview with Ali Habib.” Telephone interview. 15 Oct. 2015.
11 Zaidi, Asad. “Interview with Asad Zaidi.” Telephone interview. 13 Oct. 2015
12Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
13Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
14Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
15 Khowaja, Saira. “Interview with Saira Khowaja.” E-mail interview. 9 Nov. 2015.
16 Chandir, Subhash. “Follow Up Interview with Subhash Chandir.” E-mail interview. 29 Oct. 2015.
17 Zaidi, Asad. “Interview with Asad Zaidi.” Telephone interview. 13 Oct. 2015.
18 Zaidi, Asad. “Interview with Asad Zaidi.” Telephone interview. 13 Oct. 2015.
19 Chandir, Subhash. “Follow Up Interview with Subhash Chandir.” E-mail interview. 29 Oct. 2015.
20 Zaidi, Asad. “Interview with Asad Zaidi.” Telephone interview. 13 Oct. 2015.
22   |  
ZINDAGI MEHFOOZ (SAFE LIFE)
21Interactive Research and Development, comp. Interim Narrative Report for IWG MHealth Catalytic
Grant Mechanism. Rep. Karachi, Pakistan: n.p., 2015. Print.
22Interactive Research and Development, comp. Interim Narrative Report for IWG MHealth Catalytic
Grant Mechanism. Rep. Karachi, Pakistan: n.p., 2015. Print.
23Zaidi, Asad. “Interview with Asad Zaidi.” Telephone interview. 13 Oct. 2015. and Khan, Aamir.
“Scaling and Sustaining Innovations for Immunizations: Zindagi Mehfooz Immunization Registry.”
Nairobi, Kenya. 24 Aug. 2015. Lecture.
24Interactive Research and Development, comp. Interim Narrative Report for IWG MHealth Catalytic
Grant Mechanism. Rep. Karachi, Pakistan: n.p., 2015. Print.
25A fully immunized child is one who has completed vaccines for BCG, 3 does of pentavalent and
polio, and one does of measles vaccine.
26Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
27Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
28Khan, Aamir. “Scaling and Sustaining Innovations for Immunizations: Zindagi Mehfooz Immunization
Registry.” Nairobi, Kenya. 24 Aug. 2015. Lecture.
29Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
30 Zaidi, Asad. “Interview with Asad Zaidi.” Telephone interview. 13 Oct. 2015.
31Interactive Research and Development, comp. Lessons Learned. Rep. Karachi, Pakistan: Interactive
Research and Development, 2014. Print.
32 Habib, Ali. “Interview with Ali Habib.” Telephone interview. 15 Oct. 2015.
33Khowaja, Saira, and Subhash Chandir. “Interview with Saira Khowaja and Subhash Chandir.”
Telephone interview. 15 Oct. 2015.
34 Habib, Ali. “Interview with Ali Habib.” Telephone interview. 15 Oct. 2015.
35 Habib, Ali. “Interview with Ali Habib.” Telephone interview. 15 Oct. 2015.
36 Habib, Ali. “Interview with Ali Habib.” Telephone interview. 15 Oct. 2015.
37 Zafar, Imran. “Interview with Imran Zafar.” Telephone interview. 30 Oct. 2015.
38“Young Child Survival and Development.” Young Child Survival and Development - Immunization.
UNICEF ROSA, n.d. Web. 26 Oct. 2015.
<http://www.unicef.org/rosa/survival_development_2542.htm>.
INCREASING IMMUNIZATION RATES IN PAKISTAN’S SINDH PROVINCE   |  
23
PHOTOGRAPHY CREDITS:
Ahmed Shahjee Aijazi:
Page 10, 17, 21
Andrew Weller:
Front cover
Page 2, 4, 6, 13
Inside back cover
24   |  
ZINDAGI MEHFOOZ (SAFE LIFE)
Interactive Research & Development
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