Regional Policy Dialogue on Women’s Health and Rights Experiences from South Asia - Pakistan

1. Regional Policy Dialogue on Women’s Health and Rights Experiences from South Asia - Pakistan Dr. Zahid Larik DDG(PHC)/ National Coordinator Ministry of Health

2. South Asia – Profile of Human Deprivation Share of South Asia in World poverty South Asia 46% Rest of the World 54% South Asia 22% South Asia 40% Rest of the World 60% Rest of the World 78% Share of SAARC in World illiteracy Share of SAARC in World Population 40 million people in poverty 1/5th of World Population

3. Regional Share of Maternal Deaths

4. PAKISTAN • 151 million population • 35% Urban • 65% Rural • Federal government • 4provinces • 126districts • >33 million women • in RH group • Government Health Expenditure: 0.8% of GDP

5. Pakistani Women – a Statistical Glance • Female Population 71.376 million • Life Expectancy 66 years (64 years for men) • Female Literacy 40% (65% for male) • Ratio of girls to boys in primary education 0.55 • Labour Force Participation Rate (Refined) 16.80% • Female share of non agri. wage employment 8% • Women in Federal Govt. 4.2% • Women in legislature 33%

6. Pakistan – RH indicators • Fertility Rate 4.0 • Contraceptive Prevalence Rate 36% • Maternal Mortality Ratio 340 – 400/ 100,000 live births • Infant Mortality Ratio 75.9/1000 live births • Abortion ratio 20/ 1000 births • Skilled Birth Attendance 31% • 15 doctors and only 2.1 nurses/ 10,000 population • Lady Health Workers (CHWs) 85,000 • Low prevalence but high risk country for HIV/AIDS (2800 reported cases of HIV/AIDS against estimated No. of 70,000)

7. Pakistan – Gender related Indices Gender Empowerment Measure (GEM) Pakistan Ranks at 64 out of 175 Listed Countries Gender-related Development Index (GDI) Pakistan Ranks at 120 out of 175 Listed Countries (UNDP Human Development Report, 2004)

8. Pakistan – National Plan of Action (NPA) for Women • The NPA formulation process culminated on 14th August, 1998 when the Prime Minister announced the plan. • 184 actions • Broad categories of actions: • Policy oriented 59 • Legislative 25 • Financial actions 100

9. Pakistan – National Plan of Action (NPA) for Women Key Progress areas: • Honor killing bill • Devolution plan 2001 • Crises Center for Women in Distress • Women Political Participation Project • Women Political School Project

10. Pakistan – Women Sensitive Policies • Announcement of National Reproductive Health Policy 2000, and National Health Policy 2001 announced. Gender dimension incorporated • National Policy for Development & Empowerment of Women 2002, affirms government’s health policy • Population Policy 2002 • National Maternal and Child Health (2005-15) strategic framework finalized in May 2005

11. Pakistan – National Health Policy 2001 Forward looking National Health Policy. • “Health for all” concept. • Emphasis on preventive and primary health care services • Removing gender disparities • Special focus on women and girl health • Treats health sector investment as part of Government’s poverty alleviation plan

12. Pakistan – Initiatives of MoH targeting Women Health • National Program for Family Planning & Primary Health Care (LHWs’ Program) • Women Health Project • Reproductive Health Project • Maternal Neonatal Tetanus - Special Immunization Activities • Expanded Program of Immunization • National AIDS Control Program • National Nutrition Project • Other government run health program include: • Malaria Control Program • T.B. Control Program • National Hepatitis-B Control Program • A new National MCH Program is underdevelopment to address MCH issues in the country.

13. Pakistan – Experience in Women Health The Lady Health Workers’ Programme: Promoting Health and Reducing Poverty ……by bridging the gap between the Health Services and Communities by providing QUALITY Integrated Health Services at the Doorsteps of our Communities.

14. LHWs’ Programme – Targets 1994 to 2010

15. LHWs’ Programme – Maternal Health Women who had a birth since 1997 - reporting on last birth Third Evaluation conducted byOxford Policy Management Ltd – 2001-02

16. LHWs’ Programme – Family Planning Third Evaluation conducted byOxford Policy Management Ltd – 2001-02

17. LHWs’ Programme – Child Health Third Evaluation conducted byOxford Policy Management Ltd – 2001-02

18. LHWs’ Programme – Achievements in MCH areas • A significant role in women empowerment by creating job opportunities for 100,000 LHWs and 4000 supervisors • LHWs actively involved in EPI activities e.g • Polio National Immunization Days (NIDs) - Out of 30 million children, 16 million are immunized by LHWs • Maternal & Neonatal Tetanus Elimination Activities in high risk areas of 65 districts - Out of 5 million target women, 4.5 millions were vaccinated by LHWs • 40,000 LHWs have been trained in giving routine EPI vaccines

19. LHWs’ Programme – Achievements in MCH areas • LHWs involved in nutrition activities i.e. promotion of breast feeding, iodized salt, and vitamin-A supplementation • LHWs carry out AFP surveillance (community component) for detection of polio cases • Safe Motherhood activities - promotion of antenatal care, clean delivery practices and post natal care. • Iron and folic acid supplementation activities. • CPR increased to >45% in LHWs’ areas. • LHWs are distributing 90 million condoms and 8 million OCP every year. • Piloting for Involvement of LHWs in giving injectable contraceptives – 10 districts.

20. LHWs’ Programme – Future Programmatic reforms • Multi-micronutrients during pregnancy • TT Vaccination/ Routine EPI by all LHWs • Ensuring deliveries through SBA by linkages with CMW • Oral/Rectal Mesoprostol for managing PPH?? • Injectable contraceptive services through all LHWs • Post partum Vitamin A • Blood pressure measurement for prevention of Eclampsia

21. LHWs’ Programme – Future Programmatic reforms • Emphasized Interventions for Newborn Care • Basic Re-suscitation • Clean Cord Care • Prevention of Hypothermia • Colostrum administration and immediate breastfeeding • Low osmolality ORS • Zinc for diarrhea management • Community based management of childhood illnesses • Multi-Micronutrients (Sprinkles) • Vitamin A to newborn??

22. LHWs’ Programme – Management & Organizational Reforms • Tripartite agreement between MoH, DoH and District Government for block grant to implement whole Programme – 4 poor performing district and 4 good performing districts. • Contracting out Programme Management to Private sector – 7 average and poor performing districts. • Contracting in District Coordinator (District manager) – 4 poor performing districts • Contracting in Technical Assistance – 5 poor performing districts • Performance Bonus System for all districts (District management, LHWs and LHS) but 8 districts as control

23. LHWs’ Programme – Monitoring & Evaluation • Strengthening of LHW-Management Information System • Strengthening and expansion of Verbal Autopsy system for maternal and infant deaths • Household level evaluations in 2005-06 and 2008-09 • Performance Evaluation of LHWs/ LHS with system analysis – 100% districts in 2005-06, 2007 and 2009 • Monitor impact level indicators – National Surveys – all districts • Case-control studies on maternal and infant deaths • Computerization of Financial System

24. MCH in Pakistan – Future areas of attention • Strengthening of health care delivery system. • Increase number of community and facility based Skilled Birth Attendants and their linkages with LHWs. • Availability of 24/7 Basic and Comprehensive EmONC services specially in rural areas. • Emphasis on abortion care as an integrated approach • FP services in all health outlets. • Integration of MCH services/ interventions/ projects. • Management and organizational reforms. • Comprehensive Monitoring, Supervision and Evaluation system.

25. Thank You