Child Health

National Emergency Action Plan 2014 for Polio Eradication. (2014). Government of Pakistan
Pakistan’s polio eradication programme faced a number of significant challenges in 2013, as the number of wild polio cases increased last year’s count. This was due to unprecedented violent attacks on health workers, and ongoing military operations in the tribal belt. Lapses in campaign quality and demand creation efforts are also partly to blame for the increase in the number of paralyzed children. However, despite these setbacks the programme also made progress. The number of districts infected with polio decreased, indicating that spread is more localized and type-3 of the poliovirus has not been detected for more than a year now. In 2014, the government is endeavoring to build on that progress. Thus, the National Emergency Action Plan focuses on tracking of missed children with special focus on clusters. It advocates conducting analysis to determine the underlying causes to be addressed through appropriate and targeted strategies. The analysis and the actions will then be disaggregated down to UC level. Furthermore, implementing special strategies for high risk populations such as Pashtun communities, and migrant and transit populations will also be needed, particularly by focusing on implementing high risk population strategies nationwide to map, track and reach these populations consistently and effectively.
http://www.polioeradication.org/Portals/0/Document/InfectedCountries/Pakistan/2014_NEAP_Pakistan.pdf

Majid, H. (2013). Increased Rural Connectivity and its Effects on Health Outcomes. Lahore Journal of Economics, 18.
This paper explores the impact of increased connectivity in rural areas to the outside world, on child health outcomes. It focuses on rural Pakistan, with outcomes examined over a 16-year period. In particular, it investigates whether rural areas’ improved access to markets through an upgraded road network and greater openness, as measured by village electrification status, has had a positive impact on child health outcomes and awareness of health practices such as immunization and prenatal care. Using a 16-year panel dataset on rural Pakistan, two iterations of a probit model were estimated: one examining the probability of child ibeing vaccinated and the second estimating the incidence of use of prenatal care. The results support the hypothesis that greater connectivity, as measured by road connectivity and electrification, improves health outcomes by increasing the likelihood of immunization and uptake of prenatal care. Furthermore, the presence of in-village health facilities has a positive effect on the probability of prenatal care, while the proportion of children vaccinated in 1986 has a positive effect on the likelihood of immunization in 2001.
http://121.52.153.179/JOURNAL/LJE vol 18 se/12 Hadia Majid.pdf

Owais, A., Khowaja, A. R., Ali, S. A., &Zaidi, A. K. (2013). Pakistan’s expanded programme on immunization: An overview in the context of polio eradication and strategies for improving coverage. Vaccine, 31(33), 3313-3319.
This review focuses on the performance of Pakistan’s Expanded Programme on Immunization (EPI), with an overview of the history, current effectiveness of the program, barriers to improving coverage, and strategies for strengthening program performance. This attention to Pakistan’s EPI is essential if Pakistan is to meet polio eradication and measles elimination targets. Historically, the main thrust of efforts aimed at increasing immunization coverage rapidly in a population has been through mass immunization campaigns. Although effective in decreasing the incidence of polio, mass vaccination campaigns have been unable to interrupt the transmission of poliovirus in the country due to the inability of vaccinators in reaching children in areas of conflict, migrant and marginalized populations, or where there is social or passive local governmental resistance to polio vaccine campaigns. Strategies, which may lead to improved routine immunization coverage in Pakistan include improving service delivery of EPI and investing in strengthening EPI infrastructure which are critical to increasing EPI coverage. There is also tremendous opportunity presented by the recent devolution of all health programs to the provincial levels to integrate all programs addressing maternal and child health and survival into one unit at the provincial and district levels, including immunization services.
http://www.sciencedirect.com/science/article/pii/S0264410X13005938

K, Ayesha and K, Adnan. (2013).Lack of Participation in Supplementary Polio Immunization Activities (SIAs): Parental Perceptions in Karachi. Research and Development Solutions, Policy Brief Series, 27.
This brief summarizes the key findings from a studythat assessed parents’ knowledge about polio, the extent and reasons for their non-participation in polio supplementary immunization activities (SIAs). Parents were surveyed through a cross sectional cluster survey in Karachi. According to the brief, parental refusal is the commonest reason for not participating in a polio campaign and accounts for 74% of all non-participation. Refusals are mainly among low income Pashtuns and among middle or high income families and in affluent residential neighborhoods. Considerable mistrust of the vaccine and of vaccinators as well as lack of appropriate engagement of communities like the Pashtuns contributes to lack of immunization uptake.Refusals from the well-off are mostly due to mistrust of government healthservices and most of these parents seek appropriate levels of immunization for their children from the private sector. Thus, the brief recommends that communities must be better engaged in raising awareness about polio and creating demand for vaccines. This will require better targeting of vulnerable communities with messages that are appropriate to them and address their misconceptions effectively.
http://www.resdev.org/files/policy_brief/27/27.pdf

K, Ayesha and K, Adnan. (2012). Childhood Immunization in Pakistan.Research and Development Solutions, Policy Brief Series, 3.
This policy brief describes an outline of childhood immunization program in Pakistan, focusing on the coverage and funding. According to the policy brief, more than half of the funding for immunization is for campaigns which are predominantly for polio and yet polio case numbers have been increasing since 2007. It questions the effect of this enhanced emphasis on polio campaigns on routine immunization activities and whether the nation and the polio eradication effort will be served better, by finding a better balance between routine immunization and the 8-12 periodic campaigns annually that essentially stop routine immunization efforts for 10-12 days every month. The brief also highlights that coverage has worsened in some areas despite increased funding. This may be due to mismanagement, political interference, and corruption, which limit the efficacy of campaigns in many areas. The policy brief also highlights that despite using same measures and sampling techniques, different surveys show different results in part due to the low reliability of mothers’ recall as the measure for these surveys. This may be overcome with better recording and reporting of immunization by health providers/ facilities, including the use of electronic technologies for recording vaccination. These improvements can better equip health providers in terms of accurate targeting of the population.
http://resdev.org/files/policy_brief/3/3.pdf

Mansuri, G. (2006). Migration, sex bias, and child growth in rural Pakistan.Policy Research Working Paper, 3946, World Bank.
This paper investigates whether economic migration allows households in sending communities to avoid costly risk coping strategies. It focuses on early child growth since there is considerable epidemiological evidence that very young children are particularly vulnerable to shocks that lead to growth faltering, with substantial long-term health consequences. The paper also examines whether migration induced resource flows allow households to extend better nutrition and health care protection to girls. Data from the Pakistan Rural Household Survey (PRHS) 2001-02 is used to develop the main child growth measures which are weight for age (WAZ) and height for age (HAZ) z-scores. The result of this regressional analysis shows that migration, appropriately instrumented, has a positive and extremely significant impact on height for age for girls. In contrast, the effects are much smaller for boys, suggesting that boys may get preference in terms of nutrition and health care when resources are stretched. Moreover, when the sample is split by age group, it is found that the height advantage of young girls is sustained in the older age group. This result underscores the long term salutary benefits of averting nutritional and other health shocks in early childhood. Estimation using child weight for age z-scores yield similar results.
http://elibrary.worldbank.org/doi/pdf/10.1596/1813-9450-3946

Loevinsohn, B., Hong, R., &Gauri, V. (2006). Will more inputs improve the delivery of health services?: Analysis of district vaccination coverage in Pakistan. The International journal of health planning and management, 21(1), 45-54.
In order to find ways of improving vaccination efforts, this paper examines performance of immunization programs at the district level in Pakistan. It shows that the variation in performance amongst difference is very large. However, since some districts are performing well, it indicates that it is possible to achieve high coverage under existing conditions. The large variation also provides a chance to study the determinants of success in vaccination, which may also yield insights for the delivery of other public health services. The results of this study show that EPI in Pakistan, has in fact, done a good job of ensuring adequate physical resources and technical inputs. However, this does not appear to be having much impact. Providing more resources, such as increasing the number of vaccinators or refrigerators, is unlikely to make much difference in vaccination coverage.The results also confirm the hypothesis of this paper that coverage is correlated to female literacy but not with infrastructure or simple inputs. It also dispels the hypothesis that coverage would be negatively correlated with turnover of key staff, such as the DHO and the DEO. Thus, it suggests the need for bolder initiatives and innovations. These may include changing incentive structures among managers and health workers.
http://onlinelibrary.wiley.com/store/10.1002/hpm.824/asset/824_ftp.pdf?v=1&t=i35ht923&s=a4efdba237014f6f920a07b0208066727b8b6e60

Luby, S. P., Agboatwalla, M., Painter, J., Altaf, A., Billhimer, W. L., & Hoekstra, R. M. (2004). Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. Jama, 291(21), 2547-2554.
This randomized control trial evaluates whether promoting washing hands with soap decreased diarrhea among children at the highest risk of death from diarrhea in Karachi squatter settlements. Washing hands with soap becomes particularly relevant for infants who cannot wash their own hands. Thus, infants might benefit from a lower rate of diarrheal pathogen transmission from parents and siblings who wash their hands more frequently with soap. The results of the study demonstrate that after 8 weeks, the incidence of diarrhea among children living in handwashing promotion neighborhoods was consistently lower than children living in control neighborhoods. Moreover, there was no significant difference in diarrheal disease among persons living in households receiving antibacterial soap compared with plain soap. However, this study has its limitations. It is possible that study participants in the handwashing promotion groups, recorded fewer episodes because of a desire to meet the expectation of study sponsors. More importantly, while visiting households weekly to provide free soap and encourage handwashing was effective in reducing diarrhea, this approach is prohibitively expensive for widespread implementation. The next essential step would be to develop effective approaches to promote handwashing that cost less and can be used to reach millions of at-risk households.

Arif, G. M. (2004). Child health and poverty in Pakistan.The Pakistan Development Review, 211-238.
This study contributes to the literature by understanding the relationship between health, poverty and utilization of medical services. It focuses on two indicators of child health; illness and malnutrition measured by weight for age and height for age. The demand for medical services is also examined. According to the study, child age has a positive correlation with illness, with breastfeeding coming out to be a significant explanatory variable in reducing illness. There is also a strong correlation between immunization and child health since immunization reduces the risk of being ill. In general the study finds that educated mothers have healthier children with the impact being greater in poor families. Furthermore, the study also demonstrates the benefit of family planning by showing the negative effect of birth order on nutritional status. In the case for demand for medical services, the child’s predicted health did not have a significant impact on demand. However, the three factors that were significant were immunization, distance to the nearest health facility and safe drinking water. Thus, the paper stresses on the need for focus on preventative health measures, rather than curative ones.
http://www.jstor.org/stable/41260606

Agha, S. (2000).The determinants of infant mortality in Pakistan.Social Science & Medicine, 51(2), 199-208.
This study is a comprehensive analysis of factors related to infant survival in Pakistan. It utilizes nationally representative data from the 1991 Pakistan Integrated Household Survey (PIHS), which includes a broad range of variables affecting child health and employs multivariate logistic regression as a statistical methodology. The findings show that the IMR has stagnated (at about 100 deaths per 1000 live births) which is extremely high. According to the paper, a large proportion of births in Pakistan occur to parents who are poor, have very little education and do not have access to sanitation. These factors are strongly associated with the risk of dying in the first year of life. The results of the paper also suggest that the negative association between the lack of maternal schooling and infant survival was stronger than for any other variable, with the exception of short birth intervals. High fertility and high infant mortality are significantly associated in Pakistan and fertility decline is likely to exert a downward pressure on the IMR. Thus, interventions that focus on improving the reproductive health of women are necessary for lowering the IMR. At the same time, improvements in the legal and economic status of women are essential for sustained long-term declines in the IMR.
http://www.sciencedirect.com/science/article/pii/S0277953699004608