Still very weak and fragile, young Rehan doesn’t look his age when his mother helped the doctor examine him. "He had fever, was sweating and struggling for breath, literally heaving", narrates Rehan’s mother. That’s when she decided to rush to the hospital.

Dr Mulazim Khara, the doctor on duty at OPD at the Pakistan Institute of Medical Sciences (PIMS) Islamabad, wants him to be hospitalised. The little boy had pneumonia when he was two months old. Although he survived, the recovery is still very slow, rather negligible. Although the high season is winter, Pneumonia takes its toll, especially in the northern areas of Pakistan. But, according to Dr Khara, it is a problem all year round.

According to a Johns Hopkins study, a projected 5.9 million children around the world will die in 2015, before reaching their fifth birthday. Together, these diseases claimed the lives of nearly 1.5 million children under the age of five in a single year. This report evaluates the progress using the most up-to-date information. Pakistan is one of the 15 countries, with the greatest number of deaths from pneumonia and diarrhea in children under the age of five years.

Compared to 2013 (6.4 million), there has been a decrease in child deaths in 2015, nevertheless pneumonia and diarrhea have steadily contributed (pneumonia 16 per cent) to those deaths over the two years.

In 2012, Pakistan became the first South Asian country to roll out Pneumococcal Conjugate Vaccine (PCV 10) with support from Gavi, the Vaccine Alliance, when it had already helped children in many other countries avoid pneumonia.

"The vaccine has the potential to save thousands of lives in Pakistan’s under-five children. Proved prohibitively expensive to an average Pakistani family, (around Rs12000 in open market) it is available free of cost in the government’s immunization programme," informs Dr Saqlain Gilani, National Programme Manager, Expanded Programme on Immunization (EPI).

Routine childhood immunisation is a set of scheduled inoculations, free of cost, given from birth to 15 months to protect the child from diseases like diphtheria, pertussis (whooping cough), measles, pneumonia, tetanus, meningitis, polio, tuberculosis, and hepatitis B. Booster doses are later required for some vaccines.

Although the vaccines are available for the entire cohort (6 million a year) of Pakistani children, due to the low immunisation coverage almost half the children remain unimmunised and vulnerable to pneumonia.

The last Pakistan Demographic and Health Survey (PDHS 2012-13) shows country’s immunisation coverage around 54 per cent which means almost half the children are not receiving the vaccine. If the vaccines are available in the country, why don’t they reach those in need?

"EPI vaccines, by the grace of God, are being provided for children absolutely free of cost. Even if a child belongs to the poorest of households in a community, he would have access to these costly vaccines from health centres. Not to take advantage of such a blessing is absurd," Dr Zulfiqar Bhutta, senior scientist at The Hospital for Sick Children’s Research Institute.

He believes that for health vaccines to prove effective, it is extremely important that they are provided to as many children as possible. Even if one child remains unvaccinated, he or she is also vulnerable to risk.

A doctor working for UN agency believes "polio has seriously affected the ability of vaccination staff and health workers to deliver routine immunisation services," giving reasons for low coverage.

Justifying, she says, as door-to-door services have become commonplace during these campaigns, people have become accustomed to such service delivery and expect the same doorstep service for routine immunisation; a situation that consumes far too many resources and vaccinators’ time.

"It has also been observed that the programme performance of RI contrasts markedly with that of polio campaigns. This could perhaps be likely due to the performance-based incentives and other support structures including financial and technical support from donors for the Polio Eradication Initiative," added the doctor who did not want to be named.

To initiate immunisation practices as a norm of the society, in April 2015, Senator Ayesha Raza Farooq, Prime Minister’s Focal Person on Polio, took an unprecedented step in Pakistan’s effort to eradicate vaccine preventable diseases by introducing a "The Mandatory Vaccination and Protection of Health Workers Bill 2015" in the Senate of Pakistan.

This was to make the caregivers, health providers and heads of learning institutions of children, responsible to ensure that a child is fully protected against all diseases being covered under the country’s immunisation programme.

"In Pakistan, a large number of children die of diseases that can be prevented through vaccination. Access to immunisation is the right of every child and duty of the state to ensure the services reach every child. Any hindrance caused to provision of immunisation services causes grievous harm to a child and exposes him or her to highly infectious diseases that cause death or disability," said Senator Farooq while presenting the broad features of the bill at the occasion of the public hearing.

Discussing the need of a uniform immunisation law across the country, Senator Farooq opined that advocacy and efforts are required at provincial level to introduce same legislation or authorise the Parliament to legislate for the entire country through Article 144 of the Constitution.

Mortality due to childhood pneumonia is strongly linked to poverty-related factors such as malnutrition. This must be addressed where disease burden is still high and access to care is insufficient. Other factors include lack of safe water and sanitation, indoor air pollution and inadequate access to healthcare.

"As a result children have a weakened immune system and therefore when faced with an infectious threat their system is poorly equipped to respond and defend the body. A vicious cycle of a vulnerable immune system and severe illness commences increasing the risk of mortality," adds Dr Khara.

Dr Bhutta also believes that close attention should be given to the environment the children are being raised in. For instance, congestion in the household proves to be a problem in case the family size is large. In those cases, all kitchen and cooking-related activities should be carried out in the open.

"The smoke and pollution also proves to be a risk and cause for children being infected with pneumonia. Then, smoking inside the house is synonymous to making the children smoke as well. This can lead to countless health issues for children regarding breathing and pneumonia as well," he adds.

Immunisation saves lives and offers children a better chance of a healthier and more economically productive future. It is one of the most successful and cost-effective health interventions and can help give each child a chance of survival beyond their fifth birthday. Immunisation is also great value for money -- every $1 investment is estimated to reap a $16 return in economic progress.

There is no second opinion that improvements in immunisation coverage contributes to reduced child deaths. Dr Gilani believes, "In order to improve equitable coverage, it is crucial to strengthen the supply side but at the same time we need to work on demand generation as well as too few parents know that the vaccine is necessary for child health, free-of-cost and available at immunization centers nationally."