Poliomyelitis, commonly known as polio, remains a critical public health challenge in Pakistan and Afghanistan, the only two countries where wild poliovirus type 1 (WPV1) continues to circulate. Despite substantial global progress since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, recent epidemiological trends, including the resurgence of WPV1 cases and positive environmental samples, underscore the fragility of eradication gains in both countries. Evidence indicates that the remaining barriers to polio eradication are not primarily technical or biomedical, but are rooted in social, gendered, religious, and structural factors that influence trust, access to services and household decision-making.

This evidence brief examines how faith, gender norms, and intersecting vulnerabilities shape immunization outcomes in Pakistan and Afghanistan. Drawing on a targeted review of academic and grey literature, national consultations, and insights from a regional dissemination dialogue convened with UNICEF and partners, the analysis explores why immunization efforts continue to miss children despite repeated campaigns, extensive surveillance systems and significant investments.

Key findings from the research indicate that:

• Immunization gaps are produced by intersecting inequities, not single barriers. Children are most likely to be missed where multiple disadvantages overlap, including poverty, displacement, insecurity, disability, and restrictions on women’s mobility. Evidence from both countries shows that inflexible or site-based delivery approaches disproportionately exclude households facing compounded vulnerabilities, indicating that uniform campaign models are insufficient in these settings.
• Women are central to childhood immunization outcomes but face layered constraints limiting their agency. Across Pakistan and Afghanistan, women carry the primary responsibility for childcare and health, yet their ability to act is often constrained by restricted mobility, limited decision-making power within households, and unequal access to trusted information. These constraints are intensified in contexts of poverty, displacement, insecurity, and disability, where caregivers face additional logistical and social barriers to access vaccination services. Hence, immunization programmes must account for women’s lived realities and systematically include strategies to reach women who are otherwise excluded.
• Faith is a critical system of trust, legitimacy and moral authority shaping immunization acceptance. Faith consistently emerges in the evidence as a significant determinant of immunization acceptance and access. Religious beliefs and leadership shape social norms, influence household decision-making, and mediate trust between communities and health systems, particularly in contexts marked by insecurity, political marginalization, and low confidence in state or international actors. When misinformation and mistrust go unaddressed, religious authority can reinforce resistance. Conversely, sustained engagement with locally trusted religious leaders and institutions can strengthen acceptance and legitimacy. The analysis shows that Islamic ethical principles related to the preservation of life, prevention of harm, parental responsibility, and collective duty provide a strong moral foundation for vaccination when translated into locally grounded narratives. Faith engagement in immunization efforts is most effective when it is institutionalized, relationship-based and embedded within immunization systems, rather than treated as a stand-alone communication or short-term advocacy intervention.
• Female frontline health workers are indispensable to immunization delivery but remain highly exposed. Female frontline workers (FFLWs) are indispensable in reaching households, building trust with caregivers, and navigating conservative social norms. However, they face heightened security risks, inconsistent institutional support, and restrictions that undermine their safety, legitimacy and retention. Areas where FFLWs are constrained or withdrawn showed greater difficulty sustaining immunization coverage.
• Immunization is more effective when framed as a shared social and moral responsibility rather than a stand-alone campaign activity. Evidence indicates that vaccination outcomes improved when immunization was integrated with broader maternal and child health services, grounded in faith-consistent narratives of care and responsibility, and delivered through trusted local systems. Approaches that reduce community fatigue and restore dignity and trust are more likely to sustain coverage in high-risk settings. Creative, future-oriented strategies include bundling polio vaccination with routine maternal and child health services, institutionalizing faith– health partnerships, elevating women’s roles through culturally legitimate pathways, and redesigning delivery models to reduce community fatigue while restoring dignity and trust.

Building on evidence, consultations, and a regional dialogue, this evidence brief advances six interlinked, strategic recommendations to support polio eradication in Pakistan and Afghanistan:

• Institutionalize faith engagement by embedding sustained partnerships with locally trusted religious leaders, scholars, and faith-based networks as a core component of immunization strategies rather than as a stand-alone intervention.
• Enable and legitimize the roles of women and girls by addressing constraints on mobility and decision-making, protecting and professionalizing female frontline health workers, and reinforcing these roles through faith-consistent narratives of care and responsibility.
• Strengthen and protect the female frontline workforce as a critical bridge to households and communities, recognizing their safety, legitimacy, and retention as decisive factors in sustaining access to children for vaccination and immunization coverage.
• Reduce community fatigue by shifting from narrowly focused, repeated polio campaigns towards integrated, dignified delivery of polio vaccination alongside maternal, child health and basic services.
• Rebuild trust and strengthen information ecosystems through locally tailored, faith sensitive communication delivered by trusted community and religious actors, supported by timely, credible information.
• Address intersecting vulnerabilities by designing adaptive strategies that respond to overlapping challenges related to poverty, displacement, disability, insecurity, and constrained caregiving environments.