Health
Panel 1: Sustainable Solutions in the Health Sector
Learning from the Past: Family Planning Communication Strategies in Pakistan from 1965—2003
by Fayyaz Ahmad Khan*
The main objective of this paper is to provide a comprehensive overview of Pakistan’s family planning communication strategies since the program’s inception in 1965 through 2003. The paper evaluates these strategies against basic components of a strategic plan and discusses the weaknesses of each strategy in detail. In addition, the paper proposes the development of research-based communication plans for improved results.
Despite a long history of family planning communication campaigns, Pakistan has seen little success in its effort to control the high population growth rate. This paper points out that lack of a research-based strategic approach as the primary reason that previous family planning communication campaigns have not produced desired results. It also identifies faulty message design and poor choices in the selection of media by which the messages are communicated as reasons for inadequate impact. The family planning program rarely had the services of professional communication staff capable of designing and implementing scientific communication plans that further multiplied its problems.
This paper makes an argument for a more focused, coordinated family planning communication policy at the national, provincial, and district levels. It examines previously unanalyzed data to provide new insights into family planning communication in Pakistan, and allows the program managers to learn from past mistakes.
Pakistan’s available communication strategies provided in various planning documents were reviewed to examine the following components:
- Situation analysis
- Strategic design (objectives, audience segmentation, message design and media selection)
- Monitoring and evaluation mechanisms.
An attempt has been made to study the impact of these strategies by examining available data relevant to each period and provide a critical analysis of the country’s family planning communication strategies and approaches. The following data has been reviewed to study the objective of this paper:
- Government of Pakistan Five Year Plans and other planning documents from 1955-2003
- Family planning communication, historical information from various sources
- Information Education and Communication (IEC) plans and PC-Is
- Personal interviews with population and family planning experts
- Pakistan census data, 1981and 1998
- Evaluations of IEC strategies and campaigns by National Institute of Population Studies
* Fayyaz Ahmad Khan is Behavior Change Communication Team Leader, PAIMAN Project at the Johns Hopkins University Center for Communications Programs, Islamabad, Pakistan.
Public Health Deprivation in Bangladesh: Causes and Consequences
by Monir Hossain Moni*
In Bangladesh, deprivation of the public health rights is a crucial challenge. The prime obstacle to the nation’s health sector is to build an overall public healthcare system, which addresses healthcare challenges in an integrated manner, starting from the local needs and realities. Although the government of Bangladesh has positive attitudes toward this sector to some extents, health conditions remain extremely poor and vulnerable, with the under-five infant mortality rate at 109/1000. Since hospitals and clinics as well as medical practitioners converge in cities/towns, much of the poor population is in reality unable to receive healthcare facilities and services. While the country’s healthcare delivery copes with a number of such crucial problems as absenteeism, informal payments, mismanagement, etc., very unfortunately the pervasive government corruption gloomily ponders the prospects for contributing to “health for all”. Moreover, the situation in Bangladesh is hindered by a serious absence of interaction and coordination among the government organizations (GOs), non-government organizations (NGOs), aid agencies and civil society. This study, which is intrinsically based on primary data sources, strives to critically explore the salient reasons behind health deprivation and inequality in Bangladesh as well as to summarily demonstrate the illustrative effects due to this hurdle facing the nation for a long time. The policy-relevant research piece surmises that “good governance” is one of the most decisive factors toward ensuring effective healthcare delivery, and that returns to investments in healthcare are low where the governance matters are not satisfactorily administered.
* Dr. Monir Hossain Moni is an Associate Professor in the Department of Political Science at the University of Dhaka, Bangladesh. He holds a doctorate degree from the Waseda University, Tokyo. His area of interest is international cooperation, sustainable development, and, political economy.
Health Costs of Biomass Fuel Consumption and Indoor Air Pollution among the Poor Inhabitants of Rural Nepal
by Krishna Prasad Pant*
Poor people in developing countries consume poor quality fuels because they are easier to collect and cheaper to purchase than modern fuels. Rural people, particularly women and children who have very low opportunity costs, collect fuel wood from forests and bushes. The environmental consequences of the fuel wood harvesting from common property resources are much discussed in the literature. But, limited studies are available on the health costs of the biomass fuel use and indoor air pollution. In addition, the health conditions of the household members may also affect fuel choice in turn. The study attempts to estimate the health effects and resulting costs of indoor air pollution by employing a survey of 600 rural households from the hills and plain, which has generated household information about energy use and respiratory health status of 2,739 adults and 301 children. Based on the data, the paper investigates the effects of indoor air pollution on chronic bronchitis and asthma among adults and acute respiratory infections among the children. Instrumental variable regression is used for the health effects and cost of illness approach for health costs. The study concludes that if the health costs are counted, the poor quality fuels are much more expensive than the modern fuels. Making the poor understand the fact and helping them in fuel switching can reduce the respiratory health problems in rural areas. The study has funded by South Asian Network for Development and Environmental Economics (SANDEE).
* Krishna Prasad Pant is a Senior Program Officer at the National Agriculture Research and Development Fund, and a Visiting Faculty member (Environmental and Resource Economics) in Kathmandu University, Nepal.
Strategies to Support Women in Rural Health Practices: Some Innovative Experiments from India
by Sakuntula Narashimhan*
India is home to over one billion people (one sixth of the world’s population). Of these, over 300 million are officially below the poverty line, with women making up the majority among the poor. Any sustainable solution that is also replicable elsewhere for improving women’s health is, therefore, of significant interest.
Literacy rates and health parameters are lower for women than for men, within the same income categories, as in most countries of Asia. Added to this is a socio-cultural matrix which decrees that a ‘good woman’ eats last (after feeding her husband and children, so that when there isn’t enough to go round, she goes hungry) and ‘bears pain without complaining’ (so that during illnesses she is not encouraged to seek immediate medical treatment, resulting in women’s health status lagging behind that of males). In a society that exalts male progeny and treats daughters as a ‘burden’, the girl child’s health needs get a low priority.
Conventional approaches by the government towards improving women’s health status (opening primary health centers in villages, for instance) have not made much difference because of bureaucratic and logistical problems, and resource constraints. Some NGOs have, however, succeeded in registering dramatic changes in women’s health status, through non-conventional approaches that prioritize awareness-creation about preventive medicine, nutrition and sanitation. These novel strategies bypass the hurdles of illiteracy and resource constraints, by co-opting the community as participants rather than as ‘recipients’ of benefits.
This paper, based on extensive field work in villages of south-central India, describes some of these path-breaking, ‘people-oriented’ strategies applied in over 8,000 villages in the poorest regions of the country, to lower maternal mortality and improve nutrition. A multiplier effect also operates -- improvements in health lead to betterment of economic prospects, and greater social empowerment. These experiments, based on the use of existing indigenous-traditional folk heritage and knowledge, for disseminating information and awareness about health, can also be replicated in other developing countries.
* Dr. Sakuntala Narasimhan is an author-resource person specializing in gender and development. Her book Empowering Women: An Alternative Strategy from Rural India (Sage, 1999) is a bestseller. She is based in Bangalore, India.
Magnitude and Dynamics of Physical Violence: Evidence from a Low Income Country
by Mufiza Farid,* S. Karim Mehtab, Sarah Saleem and Juanita Hatcher
Physical violence has a profound impact on women’s physical and mental health. Apart from causing physical injury, it is associated with an increased risk of sexual and reproductive health problems, with both immediate and long-term consequences. The objective of this study was to determine the magnitude and factors associated with spousal physical violence against women during pregnancy treated at tertiary care hospitals of Karachi, Pakistan.
This was a hospital-based survey, conducted in four tertiary care hospitals of Karachi. Five hundred women who delivered a live singleton baby were interviewed during the months of September - December 2005. Abuse was determined based on the WHO Domestic Violence Module. Data were analyzed using appropriate descriptive analysis and the relationship between spousal abuse and the risk factors were determined using multiple logistic regression methods.
Twenty nine percent of women reported lifetime marital physical violence, while 12.6 percent experienced physical violence during index pregnancy. Factors independently associated with abuse during pregnancy were the young age of the women, number of children, quarrels with in-laws and a history of husband’s maternal abuse.
The magnitude of domestic violence represents a serious reproductive health concern for Pakistan. It may be a more common problem for pregnant women than other conditions for which they are routinely screened and evaluated. Health-care providers should be alert to signs indicative of violence in order to protect the women from further abuse.
* Dr. Mufiza Farid is a Faculty member of Department of Community Health Sciences at the Aga Khan University, Karachi, Pakistan.
Pakistan Health System: Sustainable Solutions
by Talib Lashari*
This study aims to analyze – in a systematic way - the implementation on National Health Policy 2001. The implementation on the policy objectives is crucial for achievement of Poverty Reduction targets (PRSP) and Millennium Development Goals (MDGs). At the planning phase, National Health Policy’s ten key objectives have been translated into Medium Term Development Framework (MTDF) 2005-11; PRSP targets; and, preventive programs of the Federal Ministry of Health. While, for implementing purpose, the key areas of the policy are required to be reflected in the Provincial Operational Plans and subsequently in District Plans.
This is a qualitative study. The qualitative methods are traditionally very useful for in-depth analysis of any phenomenon. It helps in exploring the reasons behind issues. For this study, five different questionnaires were used at the provincial policy planners’ level, district health managers’ level, tertiary care managers’ level, DHQ level and RHC and BHU levels. The structure of questions was based on five parameters developed through literature search.
The review of available Provincial Operational Plans of Sindh and Balochistan and data collected from Punjab and NWFP revealed that implementation on policy ranged between weak to moderate. It was observed that the actions were suggested through implementation plans but necessary implementation mechanisms were not in place.
There are many challenges at the institutional mechanisms level, management level, service delivery level, monitoring and evaluation level and demand for services level in the health system. The study suggests some sustainable solutions in this regard. For instance a policy implementation framework is being suggested to be incorporated in policy planning and implementation. Moreover, roles and responsibilities of federal, provincial and districts tier need to be revisited.
* Dr. Talib Lashari is the Executive Coordinator of The Network for Consumer Protection, Islamabad, Pakistan.
Sustainable Solutions for Improving Mother’s Health in Pakistan
by Shafqat Shehzad* and Nabila Zaka**
Mother’s health in Pakistan remains neglected due to a multiplicity of factors--social, economic, and political. Many women lose their lives in the process of giving births to their children and this means that, in Pakistan, pregnancy is not safe in its effects on the mother, newborn and household. The overall development process also ignores of what is needed to improve the welfare of the vulnerable group such as the expecting mothers. Pakistan, therefore, represents an unacceptably high maternal mortality setting and needs an immediate attention for substantial and sustained reduction in the risk of dying during pregnancy. This paper present evidence from the 11 districts of the four provinces of Pakistan to see financial barriers responsible for very high maternal mortality rates and based on the evidence, suggests ways through which significant reductions in maternal mortality can be achieved. The main objectives of the paper are:
- Review the conceptual framework of Emergency Obstetric Care (EmOC) and its application to reduce maternal mortality rate (MMR) in Pakistan·
- Review financial costs and out of pocket expenses for clients seeking health care in general and for normal delivery and C-sections in selected districts.
- Identify gaps, suggest areas for further improvement and provide recommendations for developing sustainable solutions to overcome financial barriers for saving lives of mothers in obstetric emergencies.
The results of the study show that effective EmOC strategies have the potential of reducing maternal mortality in Pakistan. However, the package of EmOC should be evidence based and should not be limited in access and coverage due to lack of client's paying capacity. Reduction in numbers of maternal deaths depends on the effectiveness of integrated maternal health policies to reduce financial barriers for seeking care. Safety nets need to be made effective and innovative but sustainable means are required for longer term.
* Dr. Shafqat Shehzad is a Research Fellow (Health) at the Sustainable Development Policy Institute, Islamabad, Pakistan.
** Dr. Nabila Zaka is a Specialist, Mother and Child Health, UNICEF, Islamabad Pakistan.
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