Characteristics of Health Markets

Khan, F. and Aziz, A. (2014).The Role of Community Spaces and Mechanisms in Health Promotion amongst the Poor Communities in Rural Pakistan.Rural Support Programme Network.
The report is a qualitative research on the role of community spaces and mechanisms in health promotion amongst the poor communities in rural Pakistan. The study was conducted by the Rural Support Programmes Network (RSPN) with support from the Maternal and Newborn Health Programme – Research and Advocacy Fund (RAF) in one district each from Sindh, Punjab and Gilgit-Baltistan, based on their deprivation ranking. The study identifies the different kinds of community spaces and explores if and how these spaces have included or excluded the poor and marginalized and contributed to their empowerment and health promotion. The findings of this report demonstrate that most MNCH programmes focus on creating large transitory and emerging institutional spaces that do not have a well-defined structure, membership criteria and functional mechanisms for including the poor and marginalized. Furthermore, the MNCH programme facilitators were selected on the basis of their educational level and belonged to the better-off castes, therefore in the formal spaces they tended to associate with their relatives or friends and continued to carry their prejudices against the poor and marginalized groups. Thus, the report suggests that formal spaces should be made more inclusive and representative of the whole community, and not merely limited to the inclusion of notables.
http://www.rafpakistan.org/userfiles/Final Summary Rep.pdf

K, Ayesha and K, Adnan. (2013). Key Findings of the National Nutritional Survey 2011.Research and Development Solutions, Policy Brief Series, 41.
This policy brief highlights the finding of the nutrition survey taken in 2011 and gives a brief overview of the nutritional status of women and children in Pakistan. It portrays the poor nutritional status of the Pakistani population and has consequent implications on the nutrition, growth and health of the population. The findings suggest very high rates of malnourishment of women and children and are extremely alarming.According to the policy brief, the lack of differences between rural and urban areas is unexpected and warrants a more detailed sub- provincial analysis. It also suggests that it would be more useful if data were disaggregated by wealth status, family size and correlated with economic indicators such as family income.While some level of malnutrition may be addressed using a program approach, as was seen for iodine deficiency, these findings suggest a more holistic economic and development approach to address malnutrition which ultimately is the end result of poverty.
http://www.resdev.org/files/policy_brief/41/Policy Brief 41 – Nutritional Status.pdf

Hadden, W. C., Pappas, G., & Khan, A. Q. (2003). Social stratification, development and health in Pakistan: an empirical exploration of relationships in population-based national health examination survey data. Social science & medicine, 57(10), 1863-1874.
This paper develops empirical measures for social standing along the poverty-affluence and two other dimensions of development, education and social development, and explores the relationship between these and health as measured by nutritional status. The results show that poor nutritional status measured with low BMI, anemia, or diet diversity becomes less common with increases in education, economic status, and community development. The univariate relationships, however, do not all hold up in multivariate analyses controlling for age and sex differences. In the multivariate model of under-weight, economic status is the only significant socio-economic indicator. This suggests that given sufficient resources households in Pakistan are able to obtain basic nutrition. Thus, these results are a first step toward understanding the complex process through which urbanization and evolving stratification systems affect diet and nutritional status. The findings of this paper highlight the importance of measuring multiple dimensions of socio-economic status in order to uncover the source of causal effects. The results show that community development and economic standing are often more closely related to nutritional status than is education. In contrast, in other studies level of maternal education has shown a particularly close association with infant and child health.
http://www.sciencedirect.com/science/article/pii/S0277953603000522

Financing Healthcare

Akram, M., & Khan, F. J. (2007).Health care services and government spending in Pakistan (No. 2007: 32). Pakistan Institute of Development Economics.
The current study explores the nature of incidence of public sector expenditures in Pakistan on health sector by using the primary data of the Pakistan Social and Living Standards Measurement Survey (PSLM), 2004-05. This data highlights the present scenario of incidence of the public spending on health and demonstrates to what extent health policy targets have been successfully achieved, who benefits how much and what kind of inequalities exist in distribution of benefits of government expenditure on health, region and income wise. The study shows that expenditure in health sector is overall progressive in Pakistan while being regressive in some sub-head expenditures of health at provincial and regional levels. However, there are great disparities and inequalities across regions and among quintiles. Thus, these findings imply that there is a need to reallocate resources and reformulate the health strategy that target to benefit the disadvantaged groups more and improve the low income people access to medical services is the desired need of the time. The study suggests investing in nursing colleges to overcome limited human capital in the health sector. Furthermore, while the private sector is playing a vital role in the health care service delivery in Pakistan, this study emphasizes that the sector needs to be regulated and monitored.
http://www.pide.org.pk/pdf/Working Paper/WorkingPaper-32.pdf

Health Care Service Delivery

Hammer, J. S. (2013). Balancing Market and Government Failure in Service Delivery. Lahore Journal of Economics, 18.
This paper argues that the design and implementation of effective policies in social sectors requires facing hard realities of the constraints under which governments operate. These constraints are not solely and not primarily, limited funds. The government is further hampered by endemic problems of governance when the stage of implementation is reached. Ignoring this fact has led to enormous sums of wasted money. It uses the example of the health sector in Pakistan particularly to illustrate the fact that the real, practical, problem that governments face is how to improve welfare given that both “unfettered private enterprise” (the market) and“public authority” (the government) have their shortcomings. According to the paper, for pure public health, the market failure is clear, the benefits to the poor are clear and (arguably) there are tried and true policies that are well within a government’s capacity to implement. Thus, the benefits to the poor depend entirely on how the policy is implemented (and the track record is not good), and the decision must be based on which modality is easier to implement. Hence, governments should learn to pick their targets carefully, understanding what the alternatives to public provision are and honestly assessing their own capacity to improve the status quo.
http://121.52.153.179/JOURNAL/LJE vol 18 se/01 Hammer.pdf

Callen, M., Gulzar, S., Hasanain, A., Khan, A. R., Khan, Y., &Mehmood, M. Z. (2013). Improving Public Health Delivery in Punjab, Pakistan: Issues and Opportunities. Lahore Journal of Economics, 18.
This paper presents a detailed qualitative and quantitative look at the institutional context in which such an intervention in the public health sector in Punjab would be trialed. It identifies important lessons for Punjab’s health sector managers. It postulates that facilities are distributed unevenly compared to the population catchment area, and need to be relocated. This means there are more doctors per facility in some areas at the expense of others, it also means that the administrative (monitoring) workload of district officers is uneven.Furthermore, facility attendance of health workers is extremely weak, and vacant positions are left unfilled on a very large scale. There is also widespread demand for the availability of medicines in the province and, more generally, the department must focus on supply chain improvements, adding new services, and improving management. Thus the paper suggests that these problems stem from managerial, not financial, constraints. Thus, one promising development, in the case for resolving absenteeism particularly, is the introduction of ICT. It could be the catalyst for necessary reforms in the public health sector.
http://121.52.153.179/JOURNAL/LJE vol 18 se/11 Callen, Gulzar, Hasanain, Khan, Khan, and Mehmood.pdf

Afzal, U., & Yusuf, A. (2013). The State of Health in Pakistan: An Overview. Lahore Journal of Economics, 18.
This paper provides an overview on the health sector and its outcomes. It postulates that the quality of public health services has seen a downturn over the last few decades, and the rising population is increasing pressure on state institutions. The landscape of public health service delivery presents an uneven distribution of resources between rural and urban areas.This has allowed the private sector to bridge the gap between rising demand and public provision of healthcare. The private sector’s role in the provision of service delivery has increased enormously. The paper also points out that Pakistan is going through an epidemiological transition where it faces the double burden of communicable diseases combined with maternal and perinatal conditions, and chronic, noninfectious diseases. Given the increasing burden of communicable disease, the budgetary share of preventive measure programs should also increase. In order to improve the current situation, the paper suggests aggressive intervention to strengthen the network of health services, expand the outreach of health programs, and introduce technologies to better monitor and strengthen the health programs in place. Furthermore, social protection in the form of health insurance could also play a critical role in protecting against health shocks.
http://121.52.153.179/JOURNAL/LJE vol 18 se/10 Afzal and Yousaf.pdf

Kazi, S., Haq, I. U., Laviolette, L., &Kostermans, K. (2013). Expanding Quality Health, Population, and Nutrition Services. Pakistan policy note no. 10. World Bank.
According to this policy note by the World Bank, health and population outcomes in Pakistan have improved over the last decade but at a slower rate than in most other South Asian countries. This is due to key issues that the health sector faces. This includes the low budgetary allocation to this sector and the fact that the public sector provides only a fifth of curative services, even for the poor and rural population. Furthermore, the policy note contributes poor health performance mainly to weak management and governance, including wide- spread staff absenteeism, centralized management, and weak stewardship. Thus, according to the note, in terms of reforms special attention will be required to ensure appropriate institutional arrangements to house federal functions, a clear delineation of responsibilities, and the building of capacities and structures at all levels. Actions to improve health sector performance should include improving health services targeting the poor; increasing health spending; strengthening health sector management and accountability with a greater focus on monitoring and information (in a context of devolution and contracting). Only then will Pakistan be able to catch up to the regional and global indicator averages.
http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2013/07/17/000442464_20130717123601/Rendered/PDF/795670BRI0SASE0box0377381B00PUBLIC0.pdf

Punjab Health Sector Strategy 2012-2020. (2012). Punjab Health Sector Reforms Programme.Government of Punjab.
Punjab Health Sector Strategy is designed to support the Department of Health (DoH) to progress further after the 18thConstitutional Amendment decentralization, with a sense of direction, by prioritizing policy related interventions consistent with availability of financial resources. The strategy initially discusses the various challenges that Punjab faces in this sector. It identifies how limited access to essential health services is mainly affecting the population residing in rural areas due to persistent urban-rural bias. It also questions the quality of health care both of public and private health facilities. In terms of governance, it is pointed out that the health department is overstretched and there is a serious lack of capacity to produce nurses and allied health professionals which further aggravates the poor availability of skilled human resource in difficult areas. Exacerbating these issues, is the low government funding. Thus, in order to overcome these challenges, this strategy focuses on improving access and quality of healthcare, ensuring an efficient system of health sector governance, accountability and regulation, creating a management system that provides incentives for performance and ensures accountability and enhancing public sector financing. Furthermore, it outlines the need for continuous monitoring for successful implementation of the strategy.
http://www.phsrp.punjab.gov.pk/hsspd.asp

Sindh Health Sector Strategy 2012-2020. (2012). Government of Sindh.
The document provides the strategic framework for 2012-2020 and serves as an over-arching umbrella to guide the operational plans of medium and long term programs and projects. It also provides estimates of resource envelopes, for the total budgetary outlays as well as costs of specific strategies requiring assistance. The document also specifies strategic directions for resource mobilization from the stakeholders including the public sector, international donors, corporate sector and philanthropic organizations. It stipulates that District Health Systems need strengthening more particularly in lower performing districts. Furthermore, human resource deployment, retention and capacity are sub-optimal in rural areas particularly for female staff. There is also lack of regulation despite highest private health sector concentration in Sindh. Therefore, the strategy suggestsimplementing an Urban PHC system built on public private partnerships andaddressing contextual needs of low-income urban population. It also recommends enhancing coverage and technical supervision of LHWs, and deploying community male and female volunteers in under-coveredremote areas using a modified package of services, as well as developing a trained administrative cadre to improve efficiency of health administration at district and provincial level.
http://www.trfpakistan.org/LinkClick.aspx?fileticket=1EyZSVfIMkg%3D&tabid=2618

Jooma, R., Khan, A., & Khan, A. A. (2012). Protecting Pakistan’s health during the global economic crisis. Eastern Mediterranean Health Journal, 18(3).
This paper explores the reduction in health spending due to the global economic turndown and its impact on the health of Pakistan’s population. According to the paper, the economic crisis has affected the health sector through a reduction in the government spending as well as donor funding, which constrains investment by limiting allocations for personnel, equipment and infrastructure that are crucial for health care provision, controlling preventable diseases and life-saving interventions. It also decreases the ability of the public to access health care. An impact through the food crisis is also seen as people may decide to shift to consumption of cheaper foods of lower nutritional value that compromise their health, eventually placing a greater burden on the health care system. Thus, the paper recommends strategies that minimize these adverse affects. It suggests carrying an updated assessment of the burden of disease so that few selected interventions must be adequately funded on priority diseases, rather than spreading the available funds across many interventions. It also suggests priority prevention efforts that foster behaviours that reduce or better manage diarrhoeal or respiratory infections. Optimizing human resources is also recommended through training and monitoring as well as providing social security safety nets.
http://www.emro.who.int/emhj-volume-18-2012/issue-3/article-14.html

K, Ayesha and K, Adnan. (2012). Health Systems Governance Challenges and Opportunities after Devolution.Research and Development Solutions, Policy Brief Series, 29.
This brief assesses the initial experience of health following devolution and proposes suggestions to build on this opportunity. After the devolution, the experience of Health and Population Welfare Departments has varied in different provinces. Some have allocated sufficient funds to them, while others have struggled. The main issue is of lack of feedback from district level or point of service and the lack of involvement of beneficiaries or district authorities in decision-making remains nearly unchanged even after devolution. This connects to the fact that programs are based on inputs (and some outputs), with little connection to health outcomes, therefore they ultimately don’t respond to the needs of target beneficiaries or deliver low results. Furthermore, there is political interference, corruption and weak monitoring to modify the program based on evaluations. In order for any reforms to succeed, a departure from the past is needed. Thus, the brief recommends measuring results not fund utilization. It also suggests involving communities in oversight over local health facilities by using community scorecardsand use of the results to determine funding levels of facilities and to reward or promote personnel. Electronic reporting can also be useful to make the system more transparent.
http://www.resdev.org/files/policy_brief/29/29.pdf

The Punjab ANC Services Assessment Study. (2011). Research Society, AllamaIqbal Medical College.
This research study evaluates the provision and quality of antenatal care (ANC) services provided at primary healthcare level in Punjab. Quantitative assessment was carried out to measure the institutional capacity in terms of quality of service and facility performance for ANC. Furthermore, qualitative study was conducted to explore the factors that influence the ANC services delivery service. The findings of the study suggest that there is little coverage and low quality of services provided which leads first time users to not follow up on their visits. The reasons associated with these issues are shortage of supplies like laboratory equipment, its non-functionality and human resource mismanagement. There is also weak target setting and it’s monitoring which leads to lack of accountability amongst the healthcare management. These issues are compounded by the fact that there is very little awareness for the need for ANC. Thus, there is need to not only raise client awareness but improve accessibility and capacity of the current facilities through training providers and addressing deficiency of resources.
http://www.rafpakistan.org/userfiles/file/PASA Summary Report.pdf

Bossert, T. J., & Mitchell, A. D. (2011). Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan. Social Science & Medicine, 72(1), 39-48.
This study analyzes relationships between three dimensions of decentralization: decentralized authority (referred to as “decision space”), institutional capacities, and accountability to local officials. Based on an analytic framework that includes these dimensions, this article assesses the degree of variation in actual decision-making exercised by local officials within the legally defined range of choice granted to officials, and relates those choices to concomitant institutional capacities and mechanisms of accountability. The study finds that districts in Pakistan are indeed at different stages of the decentralization process and district officials exercise varying degrees of decision space within a formal civil service structure that is highly bureaucratic and traditionally rule-oriented organizational culture. Thus, the paper raises important policy questions about relationships between decentralization and system-wide performance. Respondents from the economically and developmentally less well-off provinces of Balochistan and NWFP tended to be less likely to use the full extent of their decision space on the dimensions of decentralization analyzed, while those in better-off Sindh and Punjab reported relatively high levels.While the study could not assess the reasons for these differences, it does suggests that policymakers in Pakistan should be concerned about whether decentralization may be perpetuating inequities in the sector.
http://www.sciencedirect.com/science/article/pii/S0277953610007550

Tarin, E., Green, A., Omar, M., & Shaw, J. (2009). Policy process for health sector reforms: a case study of Punjab Province (Pakistan). The International journal of health planning and management, 24(4), 306-325.
This study is unique because no previous study reports on the policy process in the Punjab health sector. A stream of reforms was introduced in the Punjab health sector during the 1990s. This study investigates examples of a de-concentrated district health system and determines the causes of their failure. It attributes failure to firstly the roles and interests of the different groups and secondly the structural deficiencies in the government policy processes. The culture of policy making in Punjab leads to a very narrow involvement of stakeholders with policy-making being viewed in government as the sole domain of the cabinet, senior politicians and departmental officers. However, since different stages of the policy process require different types of input, from political leadership over principles to field and professional input on detailed implementation design, it leads to policy failure. Thus, this study provides insights into a country where policy process is thought to follow systematic bureaucratic procedures but which in practice are affected by a variety of factors including interests of key actor groups.
http://onlinelibrary.wiley.com/store/10.1002/hpm.1010/asset/1010_ftp.pdf?v=1&t=i35n76jw&s=272da6b23f545c6da1b15047e182d160e9603b1a

Khan, M. M., & Van den Heuvel, W. (2007). The impact of political context upon the health policy process in Pakistan.Public Health, 121(4), 278-286.
In many developing countries, the impact of the political context upon the health system and the health of people is ignored when health policies are analysed.This paper attempts to fill the gap for Pakistan, and presents an analysis of the political context in which the health policy is embedded. Using a qualitative method, it finds that political instability and frequent changes in regimes resulting in changes in health policies have resulted in not enough time being allowed for any health policy to be properly implemented. Moreover, the content of these health policies does not vary much in essence as considerable attention is still given to the delivery of healthcare services rather than to disease prevention and health promotion. Frequent changes of governments have also removed the political energy that is needed for the effective implementation of health policies and resulted in the wasting of resources. According to the paper, these political factors have undermined the effectiveness of the health sector. Thus, it suggests that Pakistan needs to develop a continuous democratic political system that can ensure sustainable health policies. A regular bottom-up communication, and its careful consideration at provincial and federal level, can make the health policy process flexible, participative, collaborative and effective.
http://www.sciencedirect.com/science/article/pii/S0033350606002885

Country Cooperation Strategy for WHO and Pakistan 2005–2009. (2006). World Health Organization.
This Country Cooperation Strategy (CCS) reflects a medium-term (6 year) vision and a strategic framework for WHO technical cooperation with Pakistan. It serves as a medium-term basis for key periodic planning and also aims at improving WHO’s support to Pakistan for achieving the Millennium Development Goals (MDGs). According to the report, with devolution being the main focus of governance, the most critical challenge is building the capacity of the health sector at all levels to respond to the requirements of a devolved health system. This would include improving the policy-making basis and governance, developing and managing human resources for health, improving service delivery, access and equity, and improving health financing. The other priority challenges are control of communicable diseases not just through eradication but also through immunization and disease early warning system, improving child and maternal health, and prevention and control of non-communicable diseases. The report also points to the importance of emergency preparedness and response by strengthening the role of the Federal Ministry of Health in the Country Disaster Management Team and in provincial units of States and Frontier Regions.
http://www.who.int/countryfocus/cooperation_strategy/ccs_pak_en.pdf

Health and Human Security Chapter 4. (2005). Human Development in South Asia: Human Security in South Asia.MahbubulHaq Human Development Centre.
According to the report, security encompasses more than protection from external threats; it also means human security, which includes health security. Health deprivation is measured by using the lack of access to safe water and malnourishment as indicators of poor health. The brunt of it is borne by women and children. Furthermore, the poor environmental conditions that result from widespread poverty in South Asia are responsible for a large burden of preventable diseases. According to the report, the primary cause of the large burden of disease and mortality in South Asia is the lack of government commitment to provide adequate and quality healthcare for the poor. Government expenditure on public health remains low and inadequate. Also, the focus of government expenditure on health is on urban and tertiary level care, and not on rural and primary healthcare. Furthermore, whatever little is spent is often wasted through a lack of adequate monitoring and delivery system. Thus, the report recommends improving the access, equity and quality of health services by focusing on the poor as well as on preventative health rather than curative. It also suggests improving public sector management and creating public-private partnerships.
http://mhhdc.org/wp-content/themes/mhdc/reports/HDSA_2005.pdf

Shaikh, B. T., & Hatcher, J. (2005). Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. Journal of Public Health, 27(1), 49-54.
This paper reviews the relationship of factors affecting health seekingbehaviour on use of health services in the developing world including Pakistan, encompassing public as well as private sector. The paper classifies these factors into categories such as cultural and socio-demographic factors in which case women are usually not allowed to visit a health facility or health care provider alone or to make the decision to spend money on health care. It also looks at factors economic in nature, which also affects the opportunity of health seeking since cost is undoubtedly a major barrier. The public health sector by and large has been underused due to insufficient focus on prevention and promotion of health, excessive centralization of management, political interference, and weak human resource development. Thus, the paper suggests undertaking measures such as raising the socio-economic status through multi-sectoral development activities such as women’s micro-credit, life-skill training and non-formal education which have been shown to have a positive impact on health seeking behaviour, morbidity and mortality. It also recommends introducing a ‘self care system’ in the community which includes early detection of danger signs in diarrhoea, malaria, pneumonia and where issues like family planning and personal hygiene could form a package of health education for any community setting.
http://jpubhealth.oxfordjournals.org/content/27/1/49.full.pdf

Mumtaz, Z., Salway, S., Waseem, M., &Umer, N. (2003). Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health policy and planning, 18(3), 261-269.
This paper highlights an important issue regarding the constraints faced by female health care providers. The findings of this paper highlight the fact that female health workers must operate within the same gender systems that necessitate their appointment in the first place. Thus, female workers in South Asia, like the women they seek to serve, are likely to be marginalized and disadvantaged by the male- dominated context within which they live and work. The survey conducted amongst female health workers demonstrated that respondents found the management structure and style of the public sector system to be unsupportive and complained of oppressive use of power. A particularly serious problem was sexual harassment, which was widespread, with serious effects on motivation. Distant placements and restricted mobility also led to high absenteeism and the fact that there was little career advancement meant low job satisfaction. Thus, the paper emphasizes on the need to encourage female employees to exercise ‘voice’, that is to individually and collectively challenge the existing system and to co-opt men in senior positions to support them. However, it must be considered these findings are based on opinions of current female workers and not ex-workers or men. Thus, it can bias the sample.
http://heapol.oxfordjournals.org/content/18/3/261.long

Complex Emergencies

Bokhari, A. et al. (2013). Care-Plus Delivery of MNH Services in Conflict Areas of KP, Balochistan and FATA.SoSec Consulting.
This qualitative research study was undertaken both at the demand and supply sides of the governance equation. On the demand side, the research assesses the influence of patriarchal power dynamics operating at the household level on decision making with regard to accessing MNH services in conflict areas and identifying factors, which can be mitigated to bring about a change. On the supply side, the study explored the availability and utilisation of MNH services at various levels in the supply chain system, the quality of services, the attitude and behaviour of the providers and responsiveness to consumer needs. Interviews and focus groups were carried out in the conflict districts of Balochistan, KP and FATA. Terrorism and militancy have adversely affected the MNH services in these areas. During the attacks, the roads get blocked, public transport disappears and both the health providers and patients find it difficult to reach the health facilities. Thus, the study recommends organising local health committees to keep a bridge between the users and providers; institutionalising local transport system for timely evacuating emergency patients; expansion of community level MNH services providers and paying more for work in the security compromised areas.
http://www.rafpakistan.org/userfiles/FINALReportBook2.pdf

Warraich, H., Zaidi, A. K., & Patel, K. (2011). Floods in Pakistan: a public health crisis. Bulletin of the World Health Organization, 89(3), 236-237.
According to this note by the WHO, the impact of floods in terms of health deserves immediate attention. Resources and rescue efforts have been spread thin due to the war in the tribal areas. Furthermore, widespread mistrust of governmental agencies, primarily stemming from perceived corruption and mismanagement, has hindered donors and citizens from cooperating with governmental initiatives. Thus, there has been a dire need for a coordinated public response, particularly to control the outbreak of infectious diseases. Meanwhile,despite the availability and recommendation of an oral cholera vaccine for use in humanitarian emergencies by WHO,it has not been used in flood-affected areas due to perceived logistic difficulties in delivery. Thus, the note recommends the use of early disease outbreak through geographic information systems software such as Google Earth. It advocates preventing infectious disease transmission as the main focus of relief efforts. This means providing adequate hygiene and sanitation particularly in diarrhoeal disease prevention. It also emphasizes on the flood victims’ need for safe water and information about the benefits of maintaining hygienic practices.Mass vaccination for children against measles and cholera has also been emphasized.
http://www.scielosp.org/scielo.php?pid=S0042-96862011000300016&script=sci_arttext&tlng=pt

Curative Healthcare

Zaidi, S., Bigdeli, M., Aleem, N., &Rashidian, A. (2013). Access to essential medicines in Pakistan: policy and health systems research concerns. PLoS One, 8(5), e63515.
This paper adds to the global evidence on access to essential medicines by sharing findings from Pakistan. It applies to both a health systems perspective and a local priority setting exercise. The paper sets out to identify policy concerns in access to medicines through desk review and key informant interviews; and present consultatively prioritized policy and research concerns. The results are intended to improve the use of evidence in medicines policies and forging integrated responses to related challenges within the heath systems. A synthesis of evidence found major gaps in essential medicine access in Pakistan related to weak regulation of quality assurance, poor affordability, and irrational use. These are driven both by weaknesses in pharmaceutical regulation with little attention to quality and cost efficiency in drug registration and a lack of creative and transparent pricing, as well as by health systems weaknesses involving unregulated provider prescriptions and weak supply management. Thus the Pakistan experience shows that policy concerns related to essential medicine access in Pakistan need integrated responses across various components of the health systems, are poorly addressed by existing evidence, and require an expanded health systems research agenda.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0063515

Siddiqi et al. (2002).Prescription practices of public and private health care providers in Attock District of Pakistan.The International journal of health planning and management, 17(1), 23-40.
This study carried out in Attock assesses the magnitude of the problem of drug use and misuse in the formal allopathic health sector in Pakistan, in order to compare differences in prescribing practices of providers working in the public and private health facilities. It uses WHO recommended drug use indicators to highlight the current status of prescription practices of health care providers in Pakistan. It highlights that there are deficiencies in prescription practices among all health care providers; however, the problem is more serious among the more qualified private practitioners. Not only are private practitioners prescribing the highest number of drugs per prescription anywhere, their prescription practices for common health problems are highly inappropriate. The study suggests measures that could improve prescription practices. These include regulatory measures that relate to the issuance of licenses to practice, criteria for promotion and quality assurance of pharmaceuticals prescribed. However, regulation alone is ineffective unless it is supported by a well-established institutional mechanism, which ensures effective implementation and strengthens the role of various agencies. In this context the role of the Pakistan Medical Association (PMA) is emphasized.
http://onlinelibrary.wiley.com/doi/10.1002/hpm.650/abstract.

Population Welfare and Family Planning

Sathar et al. (2013). Capturing the Demographic Dividend in Pakistan. Population Council, Islamabad.
This volume revisits the population and development debate through the demographic dividend framework, which links the issues of family planning, education, and employment in a single paradigm. According to this book, Pakistan is at a critical point in its demographic transition. After decades of rapid population growth, the prospect of slower growth lies ahead because fertility is declining. The future trajectory of population growth is very sensitive to the timing and extent of further fertility declines. Thus, there is need to strengthen the family planning program. Women in Pakistan have high levels of unmet need for contraception, and as a result many unplanned and unwanted pregnancies occur each year. Preventing such pregnancies and reducing fertility and population growth will lead to a variety of health, social, and economic benefits. There is now increasing recognition that the Departments of Health and Population Welfare have to collaborate more closely. The main advantage of having the health sector to focus on family planning is that its larger infrastructure and its wider reach can deliver family planning services much more effectively than Population Welfare departments. The health sector’s greatest shortcoming is that it has yet to make family planning a priority.
http://www.popcouncil.org/uploads/pdfs/2013_CapturingDemoDivPak.pdf

K, Ayesha and K, Adnan. (2012). The Contribution Of Lady Health Workers Towards Family Planning In Pakistan.Research and Development Solutions, Policy Brief Series, 15.
This policy brief looks at the Lady Health Worker program, which helps improve family planning, particularly amongst the poor. It shows that LHWs account for around a 10% increase in knowledge about the source of family planning (FP) methods and 6% increase in ever use of FP. However, there appears to be no mechanism to ensure that LHWs ask women about their FP needs or to ensure women use long term or permanent methods. The limited time spent on FP, the few women seen per week and the level of stock-outs have likely contributed to the limited progress the program has made during the past decade in family planning. Thus it is suggested that better programming may include development of institutional mechanisms such as checklists to ensure that LHWs ask about clients FP preferences and revisit these choices once or twice a year since they may change.There is also a need to ensure that remuneration to LHWs and their supplies of family planning commodities remain uninterrupted for the LHWs as well as for the facilities that LHWs refer to. These changes will help improve their performance.
http://www.resdev.org/files/policy_brief/15/15.pdf

K, Ayesha and K, Adnan. (2012).The Community Midwives Program In Pakistan. Research and Development Solutions, Policy Brief Series, 20.
This policy brief describes the experience of Pakistan with Community Midwives CMWs, to examine implementation issues and lessons from this experience. This policy brief shows that the community members are unaware about the availability and purpose of CMWs, which affects the success of the program. This is due to ineffective communication strategies and the non-engagement with the community at the time of deployment. Furthermore, there are problems like insufficient training, delays in certification and deployment of CMWs which results in them seeking jobs elsewhere, mobility and security problems particularly due to their young age and unmarried status and lack of coordination with other service providers like LHWs. Therefore, this policy brief recommends that the CMW program should be reviewed to incorporate comprehensive community participation and community representatives should be a part of their selection procedure. It should also ensure that the CMWs acquire a high standard of skill-set that is based on appropriate practical experience and better communication skills. This will allow better utilization of their presence.
http://www.resdev.org/files/policy_brief/20/20.pdf

Feisal et al. (2012). Are CMWs Accessible in Punjab & Sindh? Research and Advocacy Fund.
This qualitative research seeks to gauge whether the deployment of Community Midwives (CMWs ) in Punjab and Sindh, has improved the accessibility of skilled birth attendants to the rural population or not. The study used delivery as an indicator of accessibility, since the major goal of the Programme was to provide skilled birth attendants in low-income communities. The findings show that in Punjab, overall, the CMWs were accessing pregnant women in about two-thirds of the assigned areas. However, their utilisation as birth attendants was low, even within areas they were accessing. In Sindh particularly, CMWs are working in only a limited geographical area around their homes, as they have not been assigned any areas. However, even in these areas not many women are aware of their existence, and even if aware, many lack trust in them. Thus, the report recommends that the MNCH Programme should increase the awareness of the community people about CMWs, advocate CMWs as trained and competent birth attendants, and compare them with daiyanto increase trust in CMWs. Moreover, LHWs should be compelled to cooperate with CMWs and refer pregnant women to 
them.
http://www.rafpakistan.org/userfiles/S3_1_RAF Annual Conference_ AAA.pdf

Khan et al. (2012). How far can I go? Social mobility of CMWs in AJK.Research and Advocacy Fund.
This research was undertaken through the support of Maternal and Newborn Health Programme Research and Advocacy Fund (RAF) and assesses the social mobility of community Midwives with reference to geographical and economic accessibility, social acceptability and relationship of these Midwives with other care providers. A mixed method research was used including GIS Mapping of all the CMWs in AJK, as well as in-depth interviews and focus group discussions. Results demonstrate that accessibility is a very intricate issue, primarily due to distant locations of health facilities, lack of transport facilities, the cost of services and socio-cultural barriers. GIS Mapping of CMWs have shown that many areas have no CMW coverage and some overlap in terms of outreach and proximity with another CMW zone. Furthermore, awareness about availability of CMWs in the area was very low. Combined with paucity of skills and capacity of CMWs to tackle issues of maternity care in remote rural setting, it means that the services of CMWs were not used. Thus, the report recommends that there is a need to involve community representatives in selection of women for CMW trainings. This will help build ownership of community. The training of CMWs also needs revision and must be made more practical and skill based rather than theoretical.
http://r4d.dfid.gov.uk/pdf/outputs/raf/RAF_Report_final_CF.pdf

Dobson, S., &Lalji, N. (2011). Are community midwives competent to practice? Lessons from Pakistan.Technical Resource Facility.
The Technical Resource Facility conducted this assessment, on community midwives with support from HLSP. Using Pakistan as a case study, this paper considers whether the cadres of birth attendants being trained are adequately skilled to perform the services they are expected to deliver in the context of the training of Community Midwives (CMWs). Pakistan is facing challenges as it aims to achieve high training targets with limited resources. The paper examines these challenges and suggests approaches to help overcome them. One of the challenges is regarding finding suitable candidates, particularly in remote rural areas such as Baluchistan where education achievement is low. Furthermore, many tutors require more thorough training in helping students develop analytical skills and the ability to synthesize and apply knowledge. More broadly, CMWs are hindered in their work by the fact that efforts to strengthen the district health system are lagging behind the implementation of the training programme. Thus, the paper recommends that there is need to build capacity to ensure effective implementation of the midwifery curriculum to improve training. There is also need to stop focusing on the numberof CMWs without due attention to their specific role within the overall health system.
http://www.hlsp.org/LinkClick.aspx?fileticket=U8Qwkd2XqCw%3d&tabid=2439&mid=4674

Douthwaite, M., & Ward, P. (2005). Increasing contraceptive use in rural Pakistan: an evaluation of the Lady Health Worker Programme. Health Policy and Planning, 20(2), 117-123.
This paper assesses the impact of the Lady Health Worker Programme (LHWP) on the uptake of modern contraceptive methods using data from a national evaluation of the LHWP, completed in 2002. Because a major aim of the Programme was to increase access to services in rural areas, this paper focuses specifically on the impact of the Programme on rural women. Using logistic regression, this paper finds that the current use of reversible, modern contraceptive methods is significantly higher in rural areas served by the LHWP compared with control areas, even after controlling for a range of socio-economic factors. Despite some inherent design limitations, this study provides strong evidence that the LHWP has succeeded in integrating family planning into the doorstep provision of preventive health care and in increasing the use of modern reversible methods in rural areas. In a country like Pakistan, where women’s mobility is severely limited and female modesty highly valued, the provision of doorstep services through community-based female workers appears to be one model of service delivery that will help to achieve universal access to family planning.
http://heapol.oxfordjournals.org/content/20/2/117.long

Epidemics

Khan, A. A., Khan, A., &Bokhari, A. (2010).The HIV epidemic in Pakistan.Journal of Pakistan Medical Association, 60(4), 300-307.
This review describes the risks, prevalence and transmission potential of HIV among various population subgroups and the national response to the epidemic in Pakistan. It interprets the available data to explain Pakistan’s HIV scenario in terms of the roles of different population sub-groups and contextual factors that may influence the epidemic progression. According to the review, the HIV epidemic in Pakistan is well-established and expanding among Injection Drug Users (IDUs), Male Sex Workers (MSWs) and expatriated migrant workers. For the time being, the general population, may be more at risk from the over-use of unwarranted therapeutic injections with used equipment than from sex. However, once the epidemic reaches a critical threshold in FSWs and spouses of IDUs or sex workers it may spread to the general population. Thus, successful HIV prevention interventions should be epidemic-stage-specific and have scale and scope to reach most of the target populations with protective services. Current programmes provide social services, behaviour change counselling, condoms and syringes. Voluntary counselling and testing (VCT) has now been added. However, these interventions must address bridging groups. For now, truckers are the only bridge group receiving services and surveillance data does not capture any other bridge group.
http://www.jpma.org.pk/PdfDownload/2005.pdf

Water and Sanitation

Water for People’s Well-Being. (2013). Human Development in South Asia 2013: Water for Human Development. MahbubulHaq Human Development Centre.
The second chapter in the report emphasizes on the importance of clean water and sanitation for human development, with the arguments that they reduce income poverty and child mortality, break life-cycle disadvantages, enhance female education and free girls’ and women’s time from collecting water from long distances. While in the rural areas, poor human health is due to lack of necessary sanitation facilities and sometimes access to water at all, in urban areas population growth and urbanization contributes to poor human health, more so because of increasing water demand and water pollution. Furthermore, women feel the impact of these impediments more. Thus, using an integrated gender-sensitive approach to development, especially in line with the human development paradigm, can have a positive impact on the sustainability and effectiveness of water interventions in addition to water conservation. The chapter also points out that the actual financial and technical resources budgeted and utilized have varied substantially. The deficit in financing in the water and sanitation sector has resulted in lower coverage. Thus, it recommends that there should be provision for water as a human right in the legislation. There is also need for regulation and equity through pricing and subsidies so that the poor have access to this basic right.
http://mhhdc.org/wp-content/themes/mhdc/reports/HDSA-2013.pdf

Sanitation and Water for All. (2012). Pakistan Sector Status Report.
According to the report, 100-150 children die every day because of diarrhoeal related illnesses, despite the fact that many of these deaths can be prevented by adequate sanitation, safe drinking water and improved hygiene. Half of the rural population is without adequate sanitation and Pakistan is off-track to meet the projected MDG target of 67%. While the basic framework exists in order to improve the current dismal conditions in water and sanitation, the fact remains that there are some critical bottlenecks, which need to be addressed in order to meet MDG targets. These bottlenecks include institutional arrangements with overlapping of roles and responsibilities and weak coordination mechanisms; dysfunctional water supply schemes; ageing infrastructure; poor water quality from polluted and contaminated sources; and inadequate solid waste management. Thus, the report suggests taking action by developing a National Sector Action Plan comprised of Provincial Action Plans to effectively implement national policies on sanitation and drinking water. It also suggests prioritizing Sanitation and Drinking Water within MTDF, MTEF and enhance by 2015, the sectoral allocation for water supply and sanitation by 1% of overall PRSP. It further recommends establishing a national monitoring framework for sanitation and drinking water based on provincial monitoring frameworks.
http://www.un.org.np/sacosan/uploads/document/file/Water and Sanitation Sector Review Report 2012_20121130024145.pdf

State Of Water & Sanitation In Punjab Position Paper. (2011). Punjab Urban Resource Centre.
This paper analyzes the existing water and sanitation scenario in Punjab. It reviews the legislative, policy and institutional framework, statistical data, and significant issues in the sector and provides possible solutions to improve the state of affairs in water and sanitation sector. Key findings of the paper reflect that in Punjab provision of water from improved sources is not an issue as this is available to about 97% of the population. The issue is of quality as 49% of the water is contaminated due to poor sanitation arrangements. The situation of sanitation is worse in villages and small towns, as they have poor solid waste management systems. However, unsafe drainage and disposal of wastewater is predominant in both urban and rural settlements. Furthermore, regulatory framework for industrial, hospital and other waste management is too weak to enforce compliance. Therefore, the paper recommends that in order to improve the quality of water, more investment should be made in sanitation rather than in water, as improved sanitation will improve its quality. Water utilities should also improve chlorination facilities to ensure safe water supply. Moreover, maintenance of services can be transferred to the communities by formulating community organizations, which will further reduce the financial burden on WASA.
http://purclahore.org/images/documents/Position Paper-Web.pdf

The economic impacts of inadequate sanitation in Pakistan.(2011). Water and Sanitation Program. World Bank.
The study empirically estimates the economic impacts of current poor sanitationconditions in Pakistan as well as the economic benefits of options for improved conditions. It provides policy makersat both national and local levels with evidence to justify larger investments
in improving the sanitation conditions in the country. According to the report, the current status of sanitation and poor hygiene practices has led to significant public costs, such as premature deaths and economic and financial costs due to diseases attributable to poor sanitation. Furthermore, national figures hide rural-urban disparities. Furthermore, health impacts accounted for the vast majority of total economic costs. They occur due to premature mortality, loss of productivity due to illness or costs of treatment. Therefore, priority treatment needs to be given to the issue of poor sanitation at all administrative levels—local, provincial, and national—and investments should be made to build moderately improved and hygienic latrines in both urban and rural areas. Special treatment and attention are needed in the areas where the poor population lives and in rural areas, where children are more at risk from diarrhea and malnutrition. Furthermore, education and awareness campaigns are needed at all levels, particularly in schools, to promote personal hygiene.
http://www.wsp.org/sites/wsp.org/files/publications/WSP-esi-pakistan.pdf

Gupta, Anjali Sen. (2010).Water and sewerage services in Karachi: Citizen Report Card – sustainable service delivery improvements. Water and Sanitation Program, World Bank.
This report discusses the key findings and recommendations emerging from a pilot Citizen Report Card (CRC) on water, sanitation, and sewerage services in Karachi. This initiative comes, on one hand, in the wake of deteriorating services and dysfunctional governance structures and, on the other, an emergent consensus to bring in far-reaching institutional reforms that should move beyond financial and technical imperatives. However, what distinguishes a CRC from a regular survey is the post-survey strategy to build upon the ‘symptoms’ provided by the CRC, and design effective and focused responses. The findings of the CRC shows that Karachi W&SB’s services were found to be satisfactory and above average by 6.5 percent of the users and that both users and utility staff want improvement in systems and services. Thus, by assembling a set of credible and objective benchmarks, the CRC has provided a forum for different stakeholders to converge around issues and explore solutions and reforms. Furthermore, CRC studies are also a means for testing out different options that citizens wish to exercise, individually or collectively, to tackle current problems. Thus, CRC can be used for other services as well.
http://documents.worldbank.org/curated/en/2010/12/14892438/water-sewerage-services-karachi-citizen-report-card-sustainable-service-delivery-improvements

Jehangir Khan, F., &Javed, Y. (2007). Delivering Access to Safe Drinking Water and Adequate Sanitation in Pakistan. Working Papers & Research Reports, 30, PIDE.
The current study considers the redefined improved facility concept underlining improved access to safe water source and hygiene levels in sanitation. It attempts to assess the access to safe drinking waterand adequate sanitation facilities in all the provinces of Pakistan by the year 2015. To calculate the coverage projections with respect to expenditure, the study used the Pakistan Social Living-standard Measure (PSLM), 2004-05, and Pakistan Integrated Household Survey (PIHS), 2001-02, survey results. Projections based on respective actual elasticity show that a total number of approximately 38.5 million people lacked access to safe drinking water source and 50.7 million people lacked access to improved sanitation in 2004-05. The study also highlights that the national water and sanitation policies documents provide a 
broader framework of action. However, these policies need to be pro- poor and must be revised after every five years including an independent mid-term and post evaluation. It also suggests that the government should support cost effective and low cost maintenance WATSAN schemes. Moreover, offering subsidies to households underlining treatment of drinking water at consumer/household level should be considered instead of spending a lot of money in complex and costly schemes.
http://www.eaber.org/sites/default/files/documents/PIDE_Khan_2007_03.pdf

Nanan, D., White, F., Azam, I., Afsar, H., &Hozhabri, S. (2003).Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan.Bulletin of the World Health Organization, 81(3), 160-165.
This study examines the Water and Sanitation Extension Programme (WASEP) of the Aga Khan Development Network (AKDN), which it undertook in selected villages in Northern Areas and Chitral in northern Pakistan. The aim was to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour. The WASEP intervention seemed to account for an estimated 25% reduction in the incidence of diarrhoea in children. In addition, younger children, girls, and children of younger mothers were associated with a higher likelihood of diarrhoea. These findings are important in terms of refining the approach to future water, sanitation, and hygiene initiatives in northern Pakistan. The integrated approach adopted by WASEP, which incorporates engineering solutions with appropriate education to maximize facility usage and improve hygiene practices, is a useful example of how desired health benefits can be obtained from projects of this type. Although the evaluation was made at an interim point of a scheduled five-year implementation plan, some sites had not completed the programme, and unexpected funding difficulties were experienced, the findings indicate that WASEP positively influenced the health status of villages served by the project, by reducing the incidence of diarrhoeal disease.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2572415/pdf/12764511.pdf

Luby et al. (2001).A low-cost intervention for cleaner drinking water in Karachi, Pakistan.International Journal of infectious diseases, 5(3), 144-150.
This pilot study investigates an inexpensive, home-based water decontamination and storage system in a low-income neighborhood of Karachi.The preferred method to provide quality drinking water in Karachi would be to develop and maintain effective municipal water purification and delivery system and an effective sanitary sewerage system. However, the population growth rate of Karachi, the massive investment required to improve the poor quality and condition of the existing water distribution and sanitary system, make a central solution to cleaner water unlikely in the short or intermediate term. Thus, according to the study, use of a plastic water storage vessel with home chlorination potentially offers an inexpensive, sustainable means to achieve cleaner water. In this RCT, hypochlorite solution was distributed to families in small reusable plastic bottles, with each bottle containing sufficient hypochlorite that when added to the 20-l vessel it reliably produced residual free chlorine without unpalatable over-chlorination. While there is possible slightly increased risk of malignancy with long-term exposure to chlorination byproducts, untreated water with heavy microbial contamination presents a much higher risk of death from diarrheal disease, especially among children under 5 years of age in these communities. Thus, the study recommends use of this in-house treatment of water as a short-term solution.
http://www.cdc.gov/safewater/publications_pages/2001/luby_2001.pdf.

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

Maternal Health

K, Ayesha and K, Adnan. (2013). Using Demand-Side Financing in reproductive Health.Research and Development Solutions, Policy Brief Series, 34.
This brief discusses the role and challenges of Social safety nets (SSN) and Demand Side Financing (DSF) to help marginalized households and to promote positive reproductive health (RH) behaviors in them. Social safety nets and demand side financing can subsidize the high costs and facilitate uptake of family planning and reproductive health services for the marginalized, allowing the government (or other funders) to help overcome both demand side (lack of recognition of the value of services) and supply side (lack of availability or access to services) to providing women with reproductive health services. Until now most DSF schemes are project based with limited sustainability. Since behavioral change requires time, DSF schemes for short durations do not guarantee high impact. Thus, long-term sustainability needs to be built into programs. Furthermore, in order to provide health services to the poorest, large scale up of FP and RH servicesusing a DSF model must be consideredand it must be ensured that facility births in rural locations are ideally suited to a DSF scheme. In this case the government can develop vouchers that could be redeemed by private providers.
http://www.resdev.org/files/policy_brief/34/34.pdf

K, Ayesha and K, Adnan. (2013).Comparative Review of the Reproductive Health Sector: Strategies of Punjab and Khyber-Pakhtunkhwa. Research and Development Solutions, Policy Brief Series, 38.
This policy brief compares the reproductive health components in the health sector strategy for Punjab and Khyber Pakhtunkhwa (KP) and reviews the respective importance given to priorities assigned to different strategies and suggest recommendations for the Government and Donors. Both policies have heavily prioritized towards the public sector as a means to provide healthcare and make little distinction between provision of preventive health services such as immunization, family planning and safe birthing that improve the health of communities and provision of medical care that are often desired by communities but contribute less towards improving health status of communities. Thus, the policy brief recommends that beyond structural reforms, infrastructure and service delivery, the public sector must stimulate demand for preventive services such as safe birthing, vaccination and family planning; leaving the private sector to provide medical care. Furthermore, effective implementation of these comprehensive strategies requires a monitoring plan to measure and report performance, targets and operations. These then must be linked with performance based rewards and consequences.
http://www.resdev.org/files/policy_brief/38/Policy Brief 38 – Lessons from Health Strategies of Punjab and KPK.pdf

Bhutta et al. (2011). Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. The Lancet, 377(9763), 403-412.
This study is a randomized cluster trial in rural Sindh which seeks to test the effectiveness of a package of preventive maternal and newborn care strategies in rural Pakistan, delivered through LHWs in collaboration with voluntary community health committees (CHCs) and Dais. The intervention consisted of training of LHWs and Dais and promotion of liaison between them, together with facilitation of the creation of voluntary CHCs to promote maternal and newborn care in their villages. Despite low coverage and high complexity, the intervention was associated with significant reductions in stillbirths and neonatal mortality. However, in view of the geographical boundaries, the issue of contamination and diffusion between intervention and control clusters should be considered. Furthermore, data for household practices are based on mothers’ verbal reports of what they did, rather than observed behaviours. Despite these limitations and the known reduction in effectiveness when scaling up from efficacy trials,thetrial provides encouragement that a public sector programme promoting preventive maternal and newborn care can lead to behavioural change and careseeking for mothers during pregnancy and childbirth with resultant health benefits.
http://www.sciencedirect.com/science/article/pii/S014067361062274X

Khan, Y. P., Bhutta, S. Z., Munim, S., &Bhutta, Z. A. (2009). Maternal health and survival in Pakistan: issues and options. J Obstet Gynaecol Can, 31(10), 920-929.
This paper looks at the problem of maternal mortality within the context of the larger issue of women’s health and health-related development of Pakistan. According to the paper, most maternal deaths are attributed to delays in getting medical care during obstetric complications. The first delay is partly due to household constraints, i.e., ignorance on the part of women’s families and birth attendants (usually traditional midwives) that delays the decision to seek medical care. The second delay occurs, when precious time is lost in transporting women to hospitals because of the lack of telephones and regular ambulance services. The third delay occurs at the hospital and is largely due to the unavailability of trained staff, a lack of supplies and equipment, and poorly organized emergency services. Thus, the paper postulates that in order to overcome these obstacles to maternal health, delivering currently available and potential interventions, at pragmatic and universal levels of coverage, could prevent a large proportion ofmaternal deaths in both primary care settings and referral facilities. However, the prerequisites for scaling up such interventions are investments in the public sector health system and innovative financing strategies to provide incentives for quality care and public-private partnerships.
http://jogc.org/abstracts/full/200910_WomensHealth_3.pdf

Siddiqi, S., Haq, I. U., Ghaffar, A., Akhtar, T., &Mahaini, R. (2004). Pakistan’s maternal and child health policy: analysis, lessons and the way forward. Health policy, 69(1), 117-130.
This review analyzes Pakistan’s maternal and child health and family planning (FP) policy over the last decade, identifying strengths and weaknesses and factors underlying them. It broadly covers the period 1990–2002 and analyzes the last three health policies as well as the major national programs on MCH/FP during this period. The study demonstrates that institutional capacity and good governance is vital in translating policies into effective services. When this capacity is inadequate and governance poor, increased resource allocation even to the right programs, may lead to little actual provision of services. Moreover, frequent policy announcement sends inappropriate and confusing signals to the health managers and providers and weakens on-going implementation. Thus, the study recommends that there is a need for a Comprehensive MCH Framework comprising of an outline of a long term vision and objectives in line with MDGs. Furthermore, there is need to address gaps in MCH programs through effective programs to address nutritional deficiencies; access to good quality EmOC and referral services in the rural and hard to reach areas and emphasis on reducing neonatal and perinatal mortality. However, these measures need to be sustainable to be affective.
 http://www.sciencedirect.com/science/article/pii/S016885100300229X

Jalil, F. (2004). Perinatal health in Pakistan: a review of the current situation. ActaPaediatrica, 93(10), 1273-1279.
Pakistan is likely to fail to achieve the Millennium Development Goals (MDGs) regarding child survival because of persistently high perinatal and neonatal mortality. Thus, this paper reviews perinatal/newborn health in Pakistan to understand its current status. According to the paper, perinatal and neonatal health is influenced by care practices in the communities, at the home level. A vast majority of neonatal deaths also occur at home, and very often the families do not seek medical help for the mother and the new- born during illness in the traditional 40 days of confinement. However, one intervention carried out in Lahore, showed that low cost care practices could change the indicators for perinatal and neonatal death. These practices include literacy and skill-based training of traditional birth attendants (TBAs), including the use of a Safe Delivery Kit; health education and counselling of mothers, families, TBAs and school teachers in breastfeeding, nutrition, child care and in utilizing health services; and promotion of basic adult female literacy. While the paper describes a number of ongoing health programmes in the country, it postulates that the impact is slow and disappointing. However, it proposes that even today, without additional input, the programme activities that can be implemented include those related to training and information provision.
http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2004.tb02923.x/abstract.