Pakistan - International Development Committee Contents

6  Health programme

86. Pakistan ranked 133 out of 135 countries in the 2011 UN Global Gender Gap Report[117] The country has the fourth highest number of child deaths in the world for under-five children and is making slow progress towards the MDG target on child mortality . Over half of these deaths occur within the first month of a child's life due to the lack of availability of vaccines and under nutrition of pregnant women.[118] 12,000 women still die during pregnancy or childbirth each year and one million more suffer ill health or chronic disability.[119]

DFID's health projects

Table 6
Project title Description Budget
Maternal and Newborn Health To improve access to maternal and newborn health services especially for poor and marginalised £91,000,000
Delivering Reproductive Health Results Programme To improve reproductive health and enable women in Punjab(Pb), Sindh(Sd), Khyber Pakhtunkhwa(KP) and Federally Administered Tribal Areas (FATA) to exercise their right to choose whether, when and how many children they have. £17,139,100
Provincial Health & Nutrition Programme To improve reproductive, maternal, newborn and child health services to the population of Punjab (Pb) and Khyber Pakhtunkhwa (KP), which comprises 70% of the total population in Pakistan. £217,680

Source: DFID website

Box 6
DFID Pakistan's 2015 priority targets for health are:

?  prevent 3,600 mothers deaths in childbirth;

?  prevent half a million children from becoming under-nourished; and

?  help 500,000 couples choose when and how many children to have.

Source: DFID, UK aid: Changing lives, delivering results in Pakistan, Summer 2012

87. On our visit to Pakistan we were told that DFID's engagement in health in Pakistan over the past decade had mainly taken the form of financial support to national health programmes. Since the 18th Amendment devolved health and education responsibility from the Federal to the Provincial Governments, these national health programmes are gradually being passed to the provincial health authorities. DFID is, therefore, in the process of redesigning its health programmes to work directly with the provinces.


88. The Pakistan Maternal and Newborn Health programme supported by DFID was a national health programme, designed to reduce maternal and infant mortality by increasing the number of skilled birth attendants. It supported the training and deployment of a network of Community Midwives in rural areas, who were meant to work in parallel with the Lady Health Workers (women who provide community health services in rural areas— another Pakistan Government programme also supported by DFID).

ICAI Review

89. ICAI gave DFID's health programme a very poor review with a red/amber mark, especially on project design and the interaction between Lady Health Workers and Community Midwives. It found that the Lady Health Worker and Community Midwife programmes operated as rival schemes significantly constraining the effectiveness of each other; for example, Lady Health Workers were discouraged from referring cases to the Community Midwives. They received financial commissions for referring deliveries to private health clinics rather than the midwives and, in some cases, could assist with deliveries themselves for a fee.[120] Whilst visiting Pakistan we saw in one village how a Community Midwife and a Lady Health Worker were working well together but in other meetings with groups of Community Midwives and Lady Health Workers we also heard of dissatisfaction with the different remuneration and working arrangements between the two types of workers.

90. The ICAI report concluded that now that DFID's original counterpart, the national Ministry of Health, had been abolished and because ownership of the federal programme at provincial level had been weak, DFID could redesign its health sector programming to reflect the process of devolution.[121]

91. On 22 January 2013 DFID announced, as part of the Secretary of State's visit to Pakistan, new provincial support to prevent maternal and child deaths and unintended pregnancies.[122] The programme aims to prevent 120,000 child deaths, one million unintended pregnancies and 2,000 maternal deaths, whilst also helping 340,000 malnourished children. However, the programme seems not to have been significantly redesigned, just scaled up. The Secretary of State told us:

    It is a scale up of the general programme that we have. In a sense it matches some of the scale up we have done around education, where we have a sense of what works, so we are not creating things from scratch, but what we are doing is taking what works and doing more of it.[123]

92. The Department has since informed us that the programme is worth £160 million over four years (2013-17) and will focus on Punjab and Khyber Pakhtunkhwa. It will train a further 5,500 Community Midwives. However there is still no detail on how the problems highlighted by ICAI between the Community Midwives and Lady Health Workers will be resolved nor how the programme has been redesigned.


93. DFID said that 'levels of under nutrition are above emergency thresholds at 19%' in Pakistan.[124]However DFID currently has no nutrition specific programmes. On our visit to Pakistan we were particularly concerned about the levels of nutrition of pregnant and breast feeding mothers and about whether the school age children we met were receiving adequate nutrition to be able to learn. Moazzam Malik informed us that:

    We are not directly financing UN nutrition programmes in Pakistan from the DFID pot; we have general DFID to UN headquarters relationships that are helping some of those organisations with their work, but we are not financing it directly in the DFID Pakistan programme. We are working with them closely in policy terms, and indeed with the World Bank very closely in policy terms, as well as with the Pakistani authorities, to try to address nutrition. As you say, this is both a tragedy for the families involved as well as an economic tragedy. The cost of the malnutrition is estimated to be between 1% and 2% of GDP. For a country that is growing at 3% and needs to grow at 7%, that is a criminal waste. We are working with the UN organisations in policy terms on this issue.[125]

94. Following the evidence session with the Secretary of State she has written to tell us that the new Maternal New-born and Child Health programme discussed in the section above will also improve nutrition services in Punjab and Khyber Pakhtunkhwa by 'scaling up nutrition interventions' through the Lady Health Workers and by establishing centres to treat severely malnourished children. DFID is also 'looking at' providing direct support to mothers and new-borns through food fortification interventions in partnership with the World Food Programme, UNICEF and International NGOs.[126]

95. DFID needs to look carefully at its health programme following the ICAI criticism. We have not seen enough of a change in the design of the Maternal and Newborn Health programme to be reassured that the problems identified by ICAI at the national level will not just be replicated at the provincial level - mainly the interaction and relationship between the Community Midwives and Lady Health Workers. We support the basis of both programmes so are not asking for the funding to be stopped for either but that the remuneration packages and way of working are made complementary not competitive.

96. We welcome DFID's recognition of the need to improve the nutrition of mothers and new born children in Pakistan. However we are unconvinced that 'scaling up' the Lady Health Worker interventions is the solution until we see evidence of the redesign of the health programmes as suggested by ICAI. We ask DFID in its response to explain what has been done to date to rectify the issues. In addition we would like to receive information on the progress towards a food fortification intervention programme.

117   Ev 53 Back

118   Ev 54 Back

119   Ev 54 Back

120   ICAI, Report 15 Evaluation of DFID's Bilateral Aid to Pakistan, October 2012 Back

121   ICAI, Report 15 Evaluation of DFID's Bilateral Aid to Pakistan, October 2012 Back

122   DFID press release in Pakistan only: UK International Development Secretary Justine Greening unveils support to help prevent 120,000 child deaths, 22 January 2013 Back

123   Q143 Back

124   Ev 52 Back

125   Q140 Back

126   Ev 58 Back

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Prepared 4 April 2013