Partnership for Health
January - March 2008

Health in Pakistan

Pakistan's high maternal and infant mortality rates reflect the country's shortage of trained health workers and its inadequate health infrastructure in underserved districts throughout the country. Poor-quality water and sanitation and insufficient family planning resources exacerbate these problems in many regions. Moreover, alarming levels of infectious diseases, including tuberculosis, pose a threat that extends beyond Pakistan's borders.

Since USAID's $168.9 million Health Program began in Pakistan in 2003, activities have focused on improving maternal and newborn health services, enhancing the accessibility and availability of family planning products, preventing the spread of major infectious diseases, and increasing access to safe drinking water. The program works in underserved districts in all four provinces, Azad Jammu and Kashmir (AJK) and the Federally Administered Tribal Areas (FATA).

Improving Maternal Health

As many as 550 Pakistani women die for every 100,000 live births. Currently, more than 65 percent of women in Pakistan deliver their babies at home, and less than five percent of these home births are supervised by a trained attendant. Deaths among newborns, infants and children have not decreased in the past 10 years. Women and newborns die due to poor care and delays in receiving emergency help.

USAID's five-year Pakistan Initiative for Mothers and Newborns (PAIMAN) program is working in 10 districts, two FATA agencies and two frontier regions to reduce the newborn mortality rate and to improve the health of mothers by improving access to quality health care for pregnant women and their infants.

Only 36 percent of Pakistani mothers currently deliver their babies with the assistance of a skilled birth attendant. PAIMAN builds a new cadre of health workers (community midwives) and improves health infrastructure. PAIMAN has enrolled 750 women from rural villages in an 18-month skills-based course. These young women will return to their villages to provide pregnancy care and conduct safe deliveries for years to come. The Government of Pakistan (GoP) will train an additional 10,000 community midwives across the country.

PAIMAN has informed more than 1.5 million community members about pregnancy-related dangers. As a result, many remote villages in PAIMAN's 10 focus districts have been mobilized to plan emergency transport arrangements to take pregnant women to hospitals when bleeding or obstructed labor occurs.

Additionally, PAIMAN is renovating and equipping 31 hospitals and rural health centers. The facilities now provide around-the-clock care from 1,213 PAIMAN-trained doctors and Lady Health Visitors capable of handling pregnancy and newborn emergencies.

PAIMAN also trains doctors who work at private clinics located in communities and the mainstay of Pakistani village maternity care, Traditional Birth Attendants (TBAs). To date, 610 private clinic doctors have completed PAIMAN's courses, and 1,488 TBAs have learned to conduct clean deliveries and to recognize emergencies that require hospital referral.

PAIMAN benefits more than 2.8 million married couples and 420,000 newborns.

Improving Child Survival, Health and Nutrition

In FATA, an estimated 135 out of every 1,000 children under the age of five die - often from treatable ailments. Every year, more than 100,000 FATA children younger than five years old will suffer either diarrhea or acute respiratory infections.

USAID's three-year Improved Child Health in FATA program is delivering a health package for children under the age of five, covering immunization, prevention and treatment of respiratory infections and diarrhea. The package also provides newborn care and nutrition services. Over the next three years, the program will reach more than 1.5 million adults and more than 210,000 young children in FATA.

Improved Child Health in FATA trains health care providers, improves community knowledge and attitudes towards child health and increases access to quality health services. Thus far, 92 health providers have received training in newborn and child health care.

The program moves prevention and care services for children out to the community through "child health days," which are events designed to build long-term links between community members and their local health facilities. Through the first four child health days, the project provided 760 children with medical care and vaccinations and 379 women with tetanus toxoid immunization and counseling on newborn care and breastfeeding.

The program also strengthens agency headquarters hospitals, local health facilities, and agency health management teams. At six agency headquarters hospitals, the program has established staff learning centers and has improved medical stores. Improvements to child and infant wards have been completed in three agencies.

Providing Information to Make Public Health Choices

Countries must have accurate data for developing effective policies and programs to meet the health needs of their people. To provide Pakistan with vital information on its population, child and maternal health, and infectious disease status, USAID supports the Pakistan Demographic and Health Survey (PDHS).

The 2006-2007 PDHS is one of the largest household-based surveys ever conducted in Pakistan - collecting information from 102,900 households on the health of women and children in Pakistan. The results of this round of the PDHS will mark the first time in the history of Pakistan that the maternal mortality ratio will be determined through a survey. Previous estimates have been based on indirect methods and techniques.

The final report in April 2008 will provide reliable figures for Pakistan's maternal mortality ratio, as well as data on the direct and indirect causes of maternal and child deaths, family planning and other vital health issues. Preliminary findings have shown that deaths of infants and children have scarcely decreased in the past 15 years. The PDHS also reports that only 47.3 percent of children are completely immunized.

Supporting Reproductive Health and Birth Spacing

Pakistan has a total fertility rate of 3.7 children born per woman, one of the highest in South Asia. Many couples are unable to adequately provide for the health and education of additional children, but they lack access to modern family planning methods. Meanwhile, the contraceptive prevalence rate (CPR) has stagnated at around 30 percent for the past several years.

USAID's new Family Advancement for Life and Health (FALAH) supports reproductive health and birth spacing for Pakistani couples, a step that greatly improves survival rates for both mothers and infants. Working with community workers and health care professionals in urban and select rural areas, USAID helps couples gain access to information on reproductive health and modern family planning methods.

FALAH increases the availability of information and family planning services for low-income Pakistani women and operates in all four provinces of Pakistan, particularly in the rural areas of 20 districts. A nationwide contraceptive social marketing program is also a component of the project.

The project promotes birth spacing as an essential health intervention to reduce maternal and child mortality. It also increases the use of contraceptive methods among families that want to space their births. To remove barriers to contraceptive method use, the project works to increase community understanding of the value of birth spacing for family health and well-being. FALAH also improves access to quality care in both the public and private sectors.

Improving Water Quality, Promoting Hygiene and Sanitation

Poor water and sanitation pose serious public health threats to the Pakistani population, contributing to the spread of diseases and child malnutrition. The mortality rate for children under the age of five in Pakistan is 94 deaths per 1,000 live births. Water- and sanitation-related diseases are responsible for 60 percent of child deaths in Pakistan, with diarrhea estimated to kill 230,000 children under the age of five each year.

USAID's Pakistan Safe Drinking Water and Hygiene Promotion Project is reaching out to 30 million people in 31 districts of Pakistan, including three agencies in FATA and eight earthquake-affected districts. This project supports the GoP's Clean Drinking Water for All Project, an ambitious campaign by the GoP to install over 6,000 water filtration plants, with the aim of ensuring the provision of clean drinking water in every union council. The project will work with 200,000 people who recently gained access to government-provided water filtration plants to ensure that these plants are properly maintained and become sustainable.

Since most families in the target districts will not have access to water filtration plants in the near future, the project conducts campaigns that improve hygiene and sanitation practices, teach effective household methods of cleaning water and establish health education efforts in schools. Along with a comprehensive national radio campaign to promote good hygiene and sanitation, these steps will help ensure that this safe drinking water initiative will continue to benefit community members over the long term.

The project trains members of communities with water filtration plants and local government officials in water resources management, maintenance of water filtration plants, water quality testing and the use of simple household water treatment technologies.

The project also assisted the GoP in assessing the existing water filtration plants and applying geographic information systems (GIS) to depict the characteristics and performance of each plant. Data revealed that in 31 districts, only 48 of 93 plants installed (52 percent) were functioning. On the basis of this assessment, Pakistani Ministry of Industries is working to make these plants operational.

Controlling the Spread of Tuberculosis

Pakistan has the sixth-highest incidence of tuberculosis (TB) in the world. According to the World Health Organization (WHO), TB remains one of the leading causes of death due to infectious diseases in Pakistan and is responsible for five percent of the country's total disease burden. An estimated 280,000 Pakistanis contract the disease each year. Thirty percent of the afflicted never get diagnosed, due to limited awareness and abject poverty.

Since 2004, USAID's Strengthening Tuberculosis Control program has contributed nearly $6 million to the National TB Control program in Pakistan. Supporting a WHO community-based program known as DOTS (Directly Observed Treatment Short Course), USAID has provided training to the technical staff who deliver diagnostic services and treatment. USAID also supports district-level managers who supervise and monitor the quality of diagnosis, treatment and reporting at individual facilities.

All government health centers have now adopted the DOTS program. USAID is helping to expand this internationally-approved treatment regimen to the private sector, thus greatly improving identification and treatment throughout the country. Detection of TB cases has tripled since 2003, and the treatment success rate has shown solid improvement.

Building a Foundation for Surveillance and Disease Prevention

Pakistan lacks the epidemiological tools and trained professionals to provide proper disease surveillance - a necessity for health officials to identify, track and treat disease.

USAID's Pakistan Field Epidemiology and Laboratory Training Program (FELTP) is a two-year in-service training initiative developed on the model of the U.S. Centers for Disease Control and Prevention (CDC) Epidemic Intelligence Service.

The program, currently operating in 36 countries around the world, trains epidemiologists to determine disease patterns, conduct infectious disease outbreak investigations and institute control measures under the supervision of an experienced field epidemiologist. The Pakistan program also includes a strong focus on developing laboratory systems to support disease detection.

FELTP has recruited its first group of eight students, who will be graduating as field epidemiologists after two years. These students have completed their eight-week introductory course, learning to design and conduct field studies using the global positioning system (GPS). Efforts to accredit the program by well-reputed Pakistani universities are nearing completion.

Eradicating Polio

Pakistan (along with Afghanistan, India and Nigeria) remains one of the only countries in the world with endemic polio. Pakistan has seen tremendous progress in reducing the number of polio cases from 2,635 cases in 1994 to only 39 cases in 2006. The disease has now been geographically restricted with approximately 85 percent of the country's districts certified as polio free for nearly two years.

To build on this success, USAID provides funding to UNICEF through the Pakistan Polio Eradication Initiative to help strengthen routine immunization, hold national immunization days and conduct follow-on campaigns to reach all children who still are unvaccinated. Social mobilization is a particular focus of activities to ensure community demand for immunization. Since multiple doses of polio vaccine are required to achieve full immunity, all children under five must be reached in each campaign.

An ever-increasing number of children have been vaccinated during national immunization days: 29.8 million in 2004; 30 million in 2005; 32 million in 2006; and 33.5 million in 2007. USAID also provides funding to WHO to ensure a reliable polio surveillance system that will improve immunization and disease control efforts that contribute toward the complete eradication of polio.

KEY INDICATORS	2003	2004	2005	2006
Number of Polio cases	99	44	28	39
Polio affected districts	43	29	18	13

Reducing HIV/AIDS Transmission and Impact

Although Pakistan has a low overall HIV/AIDS infection rate, it has a concentrated epidemic of HIV/AIDS in high-risk groups. Among injection-drug users, infection rates can be as high as 51.5 percent depending on the geographic region. The infection rate among sex workers is four percent. The National AIDS Control Program reports 4,100 people living with HIV/AIDS in Pakistan. However, according to UNAIDS estimates, there are more than 80,000 HIV-positive individuals in the country. Pakistan risks the potential spread of the virus to the broader population if sustained, vigorous action is not taken to contain it.

Expected to benefit more than 122,500 high-risk individuals, USAID's three-year, $2.7 million HIV/AIDS Prevention and Care project promotes awareness about HIV-transmission modes, encourages the ABC (abstinence, be faithful, and use of condoms) approach, and provides voluntary counseling and testing for HIV to approximately 3,700 people.

Since it began in February 2006, the program has reached approximately 40,500 high-risk individuals. It has provided diagnoses and referrals for the treatment of sexually transmitted infections to 1,800 individuals. In addition, the program provides home-based care for 200 HIV-positive individuals and their 600 family members, helping to meet the physical, medical and psychological needs of people living with HIV/AIDS in Pakistan.

Strengthening Health Systems in Pakistan

Without well functioning administrative and logistical systems, health services are unable to meet patients' needs. In Pakistan, the country's health systems suffer from inadequate capacity to provide appropriate training for health practitioners, a lack of accountability to patients and insufficient logistical support for medicines.

In December 2007, USAID began a new project, Strengthening Health Systems in Pakistan. The project will focus on capacity building, disbursing targeted health information, correcting health system deficiencies through small grants and strengthening the logistical systems for essential drugs and contraceptives.

The project's capacity building component, will strengthen institutional faculty, increase sustainability, and improve the performance of services provided by selected organizations whose role in the health sector is critical for low-income and vulnerable populations.

The project will also provide capacity building assistance to two post-graduate nursing and midwifery institutions, the Nursing Council (NC) of Pakistan and the Midwifery Association of Pakistan (MAP). Primary activities will focus on developing a midwifery tutor specialization; strengthening administrative and governing capacity of the NC and MAP; training midwives, Lady Health Visitors and nurses to improve nursing and midwifery skills; and developing government capacity in health systems development and administration.

Through its targeted health information component, the project will raise public awareness and encourage citizens to hold government administrations and the private sector accountable for providing quality health services. Activities also will include training government officials and journalists in using data for decision making, including results from the PDHS. The project's grant program will address health systems' challenges in the public, private and commercial sectors, which can be resolved with modest grant assistance within a period of one year. The focus will be on public-private partnerships and innovation in addressing public health problems and health systems issues. A minimum of ten grants of $100,000 each will be awarded.

Through its essential drugs and contraceptive logistical system component, the project will strengthen the logistical system of essential medicines and contraceptives in the public sector at the national, provincial and district levels to ensure their availability throughout the country. This activity will work closely with the FALAH program to strengthen logistics at service delivery points below the district level in facilities and with Lady Health Worker supervisors.