Why not Pakistan?
By Arif Azad

THIS country has been falling behind in many social development indictors in comparison to regional countries. This comes out clearly when the recent trajectory of Nepal and Pakistan on mother, newborn and child health (MNCH) programmes is compared.

In recent decades, Nepal achieved huge strides on MNCH programmes, which have put the country in a position to meet the Millennium Development Goal (MDG) targets. Pakistan, however, is way behind.

Nepal forged ahead in dead earnest and the result has been astonishing. It is one of the few countries in Asia which are on course to meet MDGs 4 and 5. Its estimated maternal mortality incidence — or maternal mortality ratio — has been brought down from 850 in 1990 to 229 per 100,000 live births in 2011. By 2015, Nepal aims to reduce this to 135. In line with this trend, the under-five mortality rate declined from 118 to 54 per 1,000 live births in 2011.

This turnaround has been made possible because of strong political will and ownership of the programme, a sustained policy focus on MNCH and a progressive increase in the MNCH budget. This is in addition to a dedicated voluntary force of health workers, gross reduction in out-of-pocket expenses and a broader gender empowerment agenda alongside a considerable decline in poverty figures.

Pakistan set up its own MNCH programme between 2005 and 2007 and has made some headway since then. Yet it is nowhere near the pace required. At the end of 2012, various estimates put Pakistan’s maternal mortality ratio at 276, well behind the target of 175 per 100,000 live births by 2015. Similarly, the under-five mortality rate remains stubbornly high at 94 per 1,000 live births. The total fertility rate, too, remains high at 4.1, or four children per fertile mother, as compared to Nepal’s 2.6 — despite huge amounts of money being poured into the MNCH programme.

Pakistan has a limited-time window to get its act together on the MNCH front if we are to come within even striking distance of the MDGs. Nepal can serve as an example.

What essentially drove the Nepal programme was total governmental ownership. Similarly, in Pakistan, the government should wholly own the programme while making a strong case for indigenous investment in the MNCH programme as a top strategic priority.

This enhanced commitment should involve a reorientation of male-dominated political parties that tend to see the MNCH as a women’s health issue. Nepal has shown the way by enhancing MNCH budgets and empowering women, in addition to formulating integrated policies on safe motherhood.

The MNCH programme should be integrated into provincial health strategies. Currently, it appears as a stand-alone national programme unaligned with local health strategies and plans. There is poor alignment with the population welfare departments which focus on the provision of contraceptives and population control through birth spacing. A large part of Nepal’s MNCH success is owed to its seamless integration with other facets of the health system.

Nowhere is this coordination more pronounced than in the misalignment between the lady health visitors, lady health workers and community midwife programmes. Over the past decades, various donor-funded and government-initiated programmes have led to an army of trained LHVs, LHWs and CMWs. Yet they tend to work in isolation. They need to be brought in alignment under one unified vision on delivering MNCH goals.

The issue of induced and safe abortion remains an underemphasised and overlooked area, even though it contributes significantly to maternal and child deaths due to complications associated with poor health management and poverty. In a recent seminar, these issues surfaced as amongst the major concerns. This needs to be addressed as an urgent concern within MNCH programmes.

Most fundamentally, out-of-pocket expenses are an almost insurmountable barrier in accessing MNCH services here. Despite well-funded MNCH programmes, governmental health facilities are not equipped to provide the full care that mothers and newborns require. As a result, private-sector MNCH care has grown, to the detriment of poor families.

The large part of the Nepalese success story lies in making the MNCH services free and accessible at properly equipped health centres. Reducing out-of-pocket expenses assumes special significance in Pakistan against the backdrop of unregulated and growing private healthcare, runaway inflation, rising food costs, and increasing poverty that exacerbates existing female malnutrition with knock-on effects on maternal and child mortality.

What Nepal’s MNCH programme shows is that donor money, when leveraged wisely into well-resourced, politically championed and well-aligned national and local MNCH programmes, can not only reverse poor health outcomes but also put a struggling system on a healthy, sustainable track.

If Nepal can do it, why not Pakistan?

The writer is a development consultant and policy analyst.

drarifazad@gmail.com