Karachi, the largest city in Pakistan, having high population growth and a complex health care environment, has highest density of unimmunized (zero dose) and under-immunized children. The main reasons of low immunization coverage in Karachi were lack of governance and accountability in a duplicative and fragmented health management structure, weak and inequitable immunization services, and lack of demand and trust among people for immunization services. The Expanded Programme on Immunization (EPI), Ministry of Health (MOH) in Sindh Province spearheaded a structured and collaborative process to develop strategies for addressing inequity in immunization services towards achieving Universal Immunization Coverage (UIC) in Karachi. The process included a situation analysis with gathering quantitative and qualitative information on the root causes of zero-dose and inequity of the immunization services. The strategies and interventions were developed with multi-layer input and feedback of the stakeholders and partners, and focusing primarily to address gaps in three program areas: governance, leadership and accountability; immunization service delivery; and building demand and trust among the people. The interventions were further prioritized for high-risk areas; identified based on maximum number zero-dose children, presence of large slum areas, measles outbreak and on-going circulation of wild poliovirus. Finally, costing for the Roadmap activities was done through consultation with partners and aligning domestic and external (donor) resources. In this paper, we have highlighted the unique process the Sindh Government undertook in collaboration with the stakeholders and partners to develop strategies and interventions for addressing inequity in urban immunization services in Karachi towards achieving Universal Immunization Coverage (UIC). Similar processes can be adapted, as a potential model, for developing strategies to achieve universal health coverage in the cities of Pakistan and in other countries.
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