Improving Health Indicators – post Devolution Population, Health & Climate Change

1. Improving Health Indicators – post DevolutionPopulation, Health & Climate Change Policy & Research Issues for Pakistan Muzaffar Mahmood Qurashi February 15, 2013

2. Looking Forward and Looking Beyond • How does one look forward? and beyond? Did we? • Slow (delayed) wake up; if threat immediate • Models? India; Sri Lanka; Europe; USA; new medicines, new therapies? Replication here? • Handicaps: Health Indicators already poor; Population programme embarrassment; Devolution (after 2 years) lacks vibrancy; weaknesses magnified • The familiar pattern: trailing behind most (all) others • Particularly in science and technology; A few fast track replications – seldom abreast; Never, never, ahead; Even when we were (pop programme) soon lost out

3. Health endangered by media-promoted habits • Earlier attitudes (food, clothing, walking to work)demolished - aggressive marketing of branded products; vulnerable • No sponsor for promoting fruit, vegetables, milk • “Shirt sleeve” comfort – over heating, over cooling; thin cloth for winter suiting enhanced risk for unexpected weather • Grandparents were immune to extreme weather (cold baths at the best college; in villages, only cheddar during coldest winter, never a jacket, sweaters were rare, blanket used as overcoat. • free therapy - sunshine in winter and sleeping in the open during summer nights - wasted ; AC/heater compulsion, vulnerability • fast food, refined flour, chemical-loaded beverages - undermined health: dependence on pharmaceuticals, loss of resistance

4. Draft Chapter on Health in V Year plan seeds for climate change protection [prepared and circulated. But set aside, because the Plan was not launched] After devolution, Health presents the following challenges: • Capacity building , control of communicable diseases, Improved child and maternal health, Prevention and control of non-communicable diseases, Control and management of accidents and trauma. • Control of environment and unhealthy social habits. • shift from curative to preventive and promotive care-MDGs/PRSP • assures health care to all on equitable basis

5. Draft Chapter on Health in V Year plan policy measures [also in Health Policy] • access to health services for poor and vulnerable • reduce burden of disease among the vulnerable • Protecting the poor and under privileged subgroups • Strengthening stewardship for service provision • Improving access to and use of health information • evidence based policy making and strategic planning • social, economic and environmental determinants of health through intersectoral action • promoting health in all policies

6. Strategic Priorities: Draft Chapter on Health in V Year plan • Ten strategies. last four focus vulnerable groups and the threat of climate change: • Protection of poor against catastrophic expenditure. • Access of the poor to affordable quality drugs. • social protection to assure provision of health care to the poor for nationwide Health Care System. • Social determinants of health: healthy environment, health awareness community-based initiatives • strengthening linkages with health-related ministries, gender mainstreaming

7. Health priorities - Annual Plan 2012-13Ch 17 – Health, Nutrition and Population Post dev: vertical programmes, funding NFC award, lack of evidence based planning and decision making;weak management, partially functional system, motivation, inequitable distribution of expdr • Strategic priorities: strengthen primary health care, communicable disease control, social protraction /health insurance; Need based funds for Tertiary care; diagnostic facilities; • National Zero Hunger Programme (UN); • iron supplementation MCH; scaling up Nutrition surveillance system

8. Population increase – Fears, Hopes, pointers for climate change thinking • PDHS Survey (2006-07): births in serious health and life risk conditions: (i) childbearing in teens; (ii) childbearing beyond age 34; (iii) short birth interval • urban agglomerates overstretch existing amenities • population density, slums, declining water resource • Ambition: every pregnancy planned; every child nurtured, cared; Improve maternal health • strategy - Healthy timing, spacing of pregnancies. • aggressive communication campaign is required

9. Very little progress in Mainstreaming Population for Development Planning • Universal safe family planning services - 2030 (2020) • Female education critical for fertility transition. • urbanization - pressure for services and amenities. • sectoral linkages - education, health, social welfare, women development, labour and manpower, youth, environment and urban growth. • National Commission on Population Welfare • youth for productive involvement in the society. • Population Bomb – climate change threat multiplier

10. Annual Plan 2012-13 – PopulationCh 17 – Health, Nutrition and Population • Pakistan -highest growth rate (2%) in the world • TRF 3.5 is high, whereas CPR is lowest at 30% • ranked 6th in the world, 4th largest by 2050 • FP services not kept pace with increased demand • stagnant CPR 30% - provision of fp services; • 1 of 3 women want birth spacing, un-met need • one child out of 4 on average is unwanted • Strategy: commitment, pol will, PPP, M&E • Climate change Poor services to become worse

11. Women and Population seeds of climate change protection • population policies have to address • social development beyond family planning services • family planning (reproductive health care) to be provided despite limitations of climate change. • ensuring healthy and safe childbearing • addressing other factors that contribute to poor living and poor health • Un-met need for contraception is unforgivable

12. Most vulnerable: women, the elderly, young children, the poor • extreme weather affects all • greater risk to women, the elderly, children, the poor, the disabled, with heart problems or asthma. • Women sweat less, have higher metabolic rate , thicker subcutaneous fat that prevents them from cooling themselves as efficiently as men. less able to tolerate heat stress. experience greater decline in nutritional health, go hungry to protect families. • Many have no access to health services, during pregnancy and childbirth • climate change - gaps in programme become bigger

13. Women Bear the Brunt of Climate Change – can lead protection effort • Women create family cohesion, give up jobs, but more vulnerable. Activist Role of Women • meeting women’s needs of RH improves health and wellbeing of women, increases resilience against climate change, slows down population growth (lessens greenhouse gas emissions) • Climate protection needs women’s expertise, key agents of change management(Nampinga 2008). • consumers of resources,morevulnerable,agents of relief against climate change.

14. Policy vs. Reality • Policies , Plans, schemes good: little accomplished • Population programme – a model; embarrassing • Private sector = 70% health services, unregulated • Devolution hasn’t made the Provinces vibrant • Donor support reinforced flour; not to prevent depletion of wheat flour from whole meal to maida? The Express Tribune dated February 13, 2013 • vaccination teams not under control of Health Minister; department failed to control measles • Security at hospital; doctors released from jail threatened to attack MS

15. programme dimensions in response to climate change issues • infant mortality and child mortality – safeguards • Poverty alleviation – missing components health needs, breast feeding, food supplements for maternity, new born, elderly, disabled • Flood relief – delivery by rescued mother on boat (transport need - one of the “four delays”) • Documentation of experiences ; clinics, flood relief, • ARE WE DOCUMENTING, PREPARING?

16. Social Response to Hardship • Weather effect - during pregnancy, delivery, on mother, new born • medication, foods, habitation, living • classification of desi foods suji, panjeeri, herbal therapy in terms of “thandi (cold)” and “garam (hot)”; all of it couldn’t be trash • Protecting new born from weather – blanket, wrapping • cold, colder, freezing; warm, warmer, hot, sizzling heat • search backwards - healthy eating,protective clothing? the Gilgit model • attitudes in managing relief - Cards of IDPs, stocks, throngs of claimants, managers under stress, complaints by local philanthropists, reports of disorder

17. NCCP 2012 • List 9 threats – health at serial 9: “increased health risks and climate change induced migration.” • population issues implicit as “health threat” • The five GOP measures comprehensive. thoughts, will they BECOME ACTIONS. • Assess vulnerabilities of communities, ensure “climate change issues incorporated in health plans” • “Renewed efforts” involve communities in fp • manage natural resources as training for economic well being; model that can be replicated? Where to start? Stages?

18. Climate change tasks • Replicate Murree, Gilgit, Chitral and Jacobabad experiences • Falling ill, pregnancy, delivery during frequent visits, severe weather • NCCP very recent; intersectoral programmes to be edited • Lead initiative most timely, to be expanded • Issues highlighted: health care cost, investment in health integral to poverty alleviation, (faulty questionnaire for poverty survey; elderly, women, disabled missed out; above all women who are elderly as well as disabled); implement policy commitments not carried out • Ratio of nurses to doctors; barefoot Para medics required; improve primary health, reducing dominance of doctors • Non Dev expdr; operational cost of social sectors ignored • A new indicator needed for implementing what we have • Social setting, attitudes, gaps, misreporting, care for the needy

19. Looking for the doables • Policies, plans, strategies visa vis performance: will the policy we are making do what it says? • Research – medical, sociology, management - 1950, 1970,1990, 2000 Changes in lifestyle, dress, food, one room habitats replaced by three bedrooms + attached bath, Heating and cooling, beverages, snacks, medication, care for the vulnerable, Costs (personal, social),pregnancy, maternal mortality, missing work; New diseases; new drugs • Understanding health impacts (increased communicable diseases, malnutrition, food-borne illness, heat/cold-related exposure, migration-related negative health effects, etc.) • Decision making – SSCC (ECC for the poor)