**Immunization Gender Inequity in Pakistan: An Analysis of 6.2 Million Children Born from 2019 to 2022 and Enrolled in the Sindh Electronic Immunization Registry**

**Danya Arif Siddiqi 1,\*, Sundus Iftikhar 2, Muhammad Siddique 2, Mariam Mehmood 2, Vijay Kumar Dharma 2, Mubarak Taighoon Shah 1, Hamidreza Setayesh <sup>3</sup> and Subhash Chandir 1,2**


**Abstract:** Gender-based inequities in immunization impede the universal coverage of childhood vaccines. Leveraging data from the Government of Sindh's Electronic Immunization Registry (SEIR), we estimated inequalities in immunization for males and females from the 2019–2022 birth cohorts in Pakistan. We computed male-to-female (M:F) and gender inequality ratios (GIR) Tfor enrollment, vaccine coverage, and timeliness. We also explored the inequities by maternal literacy, geographic location, mode of vaccination delivery, and gender of vaccinators. Between 1 January 2019, and 31 December 2022, 6,235,305 children were enrolled in the SEIR, 52.2% males and 47.8% females. We observed a median M:F ratio of 1.03 at enrollment and at Penta-1, Penta-3, and Measles-1 vaccinations, indicating more males were enrolled in the immunization system than females. Once enrolled, a median GIR of 1.00 indicated similar coverage for females and males over time; however, females experienced a delay in their vaccination timeliness. Low maternal education; residing in remoterural, rural, and slum regions; and receiving vaccines at fixed sites, as compared to outreach, were associated with fewer females being vaccinated, as compared to males. Our findings suggeste the need to tailor and implement gender-sensitive policies and strategies for improving equity in immunization, especially in vulnerable geographies with persistently high inequalities.

**Keywords:** gender inequity; routine immunization; male-to-female ratio; female vaccination; timeliness of immunization
