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.
MATERNAL AND NEWBORN HEALTH
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.
Nutrition
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
|
