Improving Health Indicators – post Devolution
Population, Health & Climate
Change
Policy & Research Issues for Pakistan
Muzaffar Mahmood Qurashi
February 15, 2013
Looking Forward and Looking Beyond
• How does one look forward? and beyond? Did we?
• Slow (delayed) wake up; if threat immediate
• Models? India; Sri Lanka; Europe; USA; new
medicines, new therapies? Replication here?
• Handicaps: Health Indicators already poor; Population programme
embarrassment; Devolution (after 2 years) lacks vibrancy; weaknesses
magnified
• The familiar pattern: trailing behind most (all) others
– Particularly in science and technology; A few fast track replications –
seldom abreast; Never, never, ahead; Even when we were (pop
programme) soon lost out
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Health endangered
by media-promoted habits
• Earlier attitudes (food, clothing, walking to work) demolished aggressive marketing of branded products; vulnerable
• No sponsor for promoting fruit, vegetables, milk
• “Shirt sleeve” comfort – over heating, over cooling; thin cloth for
winter suiting enhanced risk for unexpected weather
• Grandparents were immune to extreme weather (cold
baths at the best college; in villages, only cheddar during coldest winter,
never a jacket, sweaters were rare, blanket used as overcoat.
• free therapy - sunshine in winter and sleeping in the open during
summer nights - wasted ; AC/heater compulsion, vulnerability
• fast food, refined flour, chemical-loaded beverages undermined health: dependence on pharmaceuticals, loss of resistance
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Draft Chapter on Health in V Year plan
seeds for climate change protection
[prepared and circulated. But set aside, because the Plan was not launched]
After devolution, Health presents the following challenges:
• Capacity building , control of communicable diseases,
Improved child and maternal health, Prevention and control
of non-communicable diseases, Control and management of
accidents and trauma.
• Control of environment and unhealthy social habits.
• shift from curative to preventive and promotive care MDGs/PRSP
• assures health care to all on equitable basis
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Draft Chapter on Health in V Year plan
policy measures [also in Health Policy]
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access to health services for poor and vulnerable
reduce burden of disease among the vulnerable
Protecting the poor and under privileged subgroups
Strengthening stewardship for service provision
Improving access to and use of health information
evidence based policy making and strategic planning
social, economic and environmental determinants of
health through intersectoral action
• promoting health in all policies
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Strategic Priorities:
Draft Chapter on Health in V Year plan
• Ten strategies. last four focus vulnerable groups and
the threat of climate change:
• Protection of poor against catastrophic expenditure.
• Access of the poor to affordable quality drugs.
• social protection to assure provision of health care
to the poor for nationwide Health Care System.
• Social determinants of health: healthy environment,
health awareness community-based initiatives
• strengthening linkages with health-related
ministries, gender mainstreaming
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Health priorities - Annual Plan 2012-13
Ch 17 – Health, Nutrition and Population
Post dev: vertical programmes, funding NFC award,
lack of evidence based planning and decision
making; weak management, partially functional
system, motivation, inequitable distribution of expdr
• Strategic priorities: strengthen primary health care,
communicable disease control, social protraction
/health insurance; Need based funds for Tertiary
care; diagnostic facilities;
• National Zero Hunger Programme (UN);
• iron supplementation MCH; scaling up Nutrition
surveillance system
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Population increase – Fears, Hopes,
pointers for climate change thinking
• PDHS Survey (2006-07): births in serious health and
life risk conditions: (i) childbearing in teens; (ii)
childbearing beyond age 34; (iii) short birth interval
• urban agglomerates overstretch existing amenities
• population density, slums, declining water resource
• Ambition: every pregnancy planned; every child
nurtured, cared; Improve maternal health
• strategy - Healthy timing, spacing of pregnancies.
• aggressive communication campaign is required
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Very little progress in Mainstreaming
Population for Development Planning
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Universal safe family planning services - 2030 (2020)
Female education critical for fertility transition.
urbanization - pressure for services and amenities.
sectoral linkages - education, health, social welfare,
women development, labour and manpower, youth,
environment and urban growth.
• National Commission on Population Welfare
• youth for productive involvement in the society.
• Population Bomb – climate change threat multiplier
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Annual Plan 2012-13 – Population
Ch 17 – Health, Nutrition and Population
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Pakistan - highest growth rate (2%) in the world
TRF 3.5 is high, whereas CPR is lowest at 30%
ranked 6th in the world, 4th largest by 2050
FP services not kept pace with increased demand
stagnant CPR 30% - provision of fp services;
1 of 3 women want birth spacing, un-met need
one child out of 4 on average is unwanted
Strategy: commitment, pol will, PPP, M&E
Climate change Poor services to become worse
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Women and Population
seeds of climate change protection
• population policies have to address
– social development beyond family planning
services
– family planning (reproductive health care) to be
provided despite limitations of climate change.
• ensuring healthy and safe childbearing
• addressing other factors that contribute to
poor living and poor health
• Un-met need for contraception is unforgivable
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Most vulnerable: women, the elderly,
young children, the poor
• extreme weather affects all
• greater risk to women, the elderly, children, the
poor, the disabled, with heart problems or asthma.
• Women sweat less, have higher metabolic rate ,
thicker subcutaneous fat that prevents them from
cooling themselves as efficiently as men. less able to
tolerate heat stress. experience greater decline in
nutritional health, go hungry to protect families.
• Many have no access to health services, during
pregnancy and childbirth
• climate change - gaps in programme become bigger 12
Women Bear the Brunt of Climate
Change – can lead protection effort
• Women create family cohesion, give up jobs, but
more vulnerable.
Activist Role of Women
• meeting women’s needs of RH improves health and
wellbeing of women, increases resilience against
climate change, slows down population growth
(lessens greenhouse gas emissions)
• Climate protection needs women’s expertise, key
agents of change management(Nampinga 2008).
• consumers of resources, more vulnerable, agents of
relief against climate change.
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Policy vs. Reality
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Policies , Plans, schemes good: little accomplished
Population programme – a model; embarrassing
Private sector = 70% health services, unregulated
Devolution hasn’t made the Provinces vibrant
Donor support reinforced flour; not to prevent
depletion of wheat flour from whole meal to maida?
The Express Tribune dated February 13, 2013
• vaccination teams not under control of Health Minister; department failed
to control measles
• Security at hospital; doctors released from jail threatened to attack MS
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programme dimensions in response to
climate change issues
• infant mortality and child mortality – safeguards
• Poverty alleviation – missing components health
needs, breast feeding, food supplements for
maternity, new born, elderly, disabled
• Flood relief – delivery by rescued mother on boat
(transport need - one of the “four delays”)
• Documentation of experiences ; clinics, flood relief,
• ARE WE DOCUMENTING, PREPARING?
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Social Response to Hardship
• Weather effect - during pregnancy, delivery, on mother, new born
• medication, foods, habitation, living
• classification of desi foods suji, panjeeri, herbal therapy in terms of
“thandi (cold)” and “garam (hot)”; all of it couldn’t be trash
• Protecting new born from weather – blanket, wrapping
• cold, colder, freezing; warm, warmer, hot, sizzling heat
• search backwards -
healthy eating, protective clothing? the Gilgit
model
• attitudes in managing relief - Cards of IDPs, stocks, throngs of
claimants, managers under stress, complaints by local philanthropists,
reports of disorder
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NCCP 2012
• List 9 threats – health at serial 9: “increased health
risks and climate change induced migration.”
• population issues implicit as “health threat”
• The five GOP measures comprehensive. thoughts,
will they BECOME ACTIONS.
• Assess vulnerabilities of communities, ensure
“climate change issues incorporated in health plans”
• “Renewed efforts” involve communities in fp
• manage natural resources as training for economic
well being; model that can be replicated? Where to
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start? Stages?
Climate change tasks
• Replicate Murree, Gilgit, Chitral and Jacobabad experiences
– Falling ill, pregnancy, delivery during frequent visits, severe weather
• NCCP very recent; intersectoral programmes to be edited
• Lead initiative most timely, to be expanded
• Issues highlighted: health care cost, investment in health integral to
poverty alleviation, (faulty questionnaire for poverty survey; elderly,
women, disabled missed out; above all women who are elderly as
well as disabled); implement policy commitments not carried out
• Ratio of nurses to doctors; barefoot Para medics required; improve
primary health, reducing dominance of doctors
• Non Dev expdr; operational cost of social sectors ignored
• A new indicator needed for implementing what we have
• Social setting, attitudes, gaps, misreporting, care for the needy
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Looking for the doables
• Policies, plans, strategies visa vis performance: will
the policy we are making do what it says?
• Research – medical, sociology, management - 1950, 1970,1990, 2000
Changes in lifestyle, dress, food, one room habitats replaced by three
bedrooms + attached bath, Heating and cooling, beverages, snacks,
medication, care for the vulnerable, Costs (personal, social),pregnancy,
maternal mortality, missing work; New diseases; new drugs
• Understanding health impacts (increased communicable
diseases, malnutrition, food-borne illness, heat/cold-related exposure,
migration-related negative health effects, etc.)
• Decision making – SSCC (ECC for the poor)
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