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Opinion: A critical sector ignored - The News

(4 July 2009)

With a maternal mortality ratio (MMR) as high as 276 per 100,000 live births, in the last 60 years, women die in childbirth with no obituary written to signify their deep loss. Similarly, Pakistan's neonatal mortality rate, at 53 per 1,000 live births, is the highest in comparison to all of its neighbors. What is worse, it has remained virtually unchanged between 1991 and 2007.

It just indicates that the progress in the country during all this time has completely bypassed the mothers, the newborns and the children while the nation's fate has oscillated between the generals and the politicians. Little wonder than the most vulnerable, in this power play, have been none other than the women. Nobody has ever mourned their death. Yet in their death, in such huge numbers, the policymakers have been able to cajole donors to pump in money into a plethora of impotent and ineffective maternal health programmes. With the country in the midst of war and a burgeoning internally displaced population, it would be highly improbable to expect a budget oriented toward social welfare. Nonetheless, it is disappointing that a meagre Rs6.5 billion were allocated to health in the federal budget (0.26 percent of total federal expenditure). Hopefully, the ongoing health programmes will not suffer from the economic crunch, particularly if foreign aid to the social sector continues as promised. Evaluating Pakistan's progress in women's health indicators over the last two decades, using the Pakistan Demographic and Health Surveys (PDHS) of 1991 and 2007, and comparing it to its immediate neighbours, including Bangladesh, India, Iran, Nepal and Sri Lanka, makes for dismal reading. Take, for example, the under-five mortality rate (U5MR). In 1970, it was the lowest at 184/1,000 live births amongst its neighbours, with the exception of Sri Lanka. But in 2007, all made progress, leaving Pakistan far behind with the highest U5MR at 90 with Bangladesh at 61, India 72, Nepal 55 Iran 33 and Sri Lanka at 21. In 1970, Pakistan's total fertility rate (TFR), which is the average number of births a woman has in her lifetime, (ideally two per couple), was comparable to that of present-day Bangladesh and Iran, and slightly higher than India. By 2007, all of our neighbouring countries were getting close to the ideal of two children per woman, but in Pakistan the TFR, at 4.1 was the highest, this despite the country's gross national product (GNP) per capita being higher than Nepal's and Bangladesh's. The percentages of pregnant women receiving prenatal care, of births conducted by trained health providers and of births occurring in health facilities, are important indicators of health services available to women. In Pakistan, a majority of births still take place at home and are attended by untrained dais (midwives) or family members. Although these rates are slightly better in Pakistan when compared to Bangladesh and Sri Lanka, they are significantly lower than India and Iran. In Sri Lanka, skilled birth attendance and institutional deliveries have become almost universal. Family planning, the cornerstone of women's health services, eludes millions. According to the 2007 PDHS, less than a third of married women use a family planning method and only 14 percent use a modern temporary method. In 2007, a quarter of married women wanting to delay childbearing (11 percent) or stop it (14 percent) were not using any family planning methods, although 96 percent of them knew of at least one modern method of contraception. The lack of supplies, services and information seems to be a huge barrier to their accessing of modern family planning methods. Pakistan is a signatory to the eight Millennium Development Goals (MGDs), of which the second, third and fifth goals are directly related to women's health and status. The fifth MDG calls for a 75 percent reduction (from the 1990 level) in MMR and achievement of 100 percent skilled birth attendance during delivery, both by the year 2015. Keeping in mind the current MMR of 276 and the skilled birth attendance of 39 percent, it seems highly unlikely that Pakistan will achieve either of these targets. In April 2005, the government unveiled a national strategy on maternal, neonatal and child health (MNCH), and in 2006 launched a national MNCH programme with the aim to improve accessibility and quality of the MNCH services. Although the initial plans were to integrate the various vertical programmes into maternal and child health (such as Expanded Programme on Immunisation and the Lady Health Workers Programme), this has not been achieved so far. The programme's website does not give any information on its operations and progress. Health experts have serious doubts about the quality of the programme, particularly with regard to training of community midwives and the emergency obstetric services at government hospitals in the rural areas. With frequent changes at the helm and political favours rather than merit taking precedence, there are doubts about the programme's efficacy. Programmes and projects have met a similar fate, due to nepotism, unabated corruption and lack of transparency and accountability. The USAID is currently funding two large projects for women's health – one in maternal and newborn health and another in family planning. Both projects are in operation for over four years; however, data on their progress and achievements are not available to the public. While the maternal and newborn health project boasts an impressive website, it does not provide any information on the project's progress in meaningful terms. The project on family planning does not seem to have a website at all. It is hard to say if these initiatives will have any tangible and lasting impact on the women's health status in Pakistan. The figures tell us that Pakistan has failed its mothers and children. Shamefully, the country has fallen behind all of its immediate neighbours, including Bangladesh and Nepal, despite allocation of vast resources to health and education sectors and foreign donors' keen interest in women's health programmes.

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