93526 SAFANSI The South Asia Food and Nutrition Security Initiative EVIDENCE FROM PAKISTAN: CHILD NUTRITIONAL OUTCOMES AND COMMUNITY-BASED HEALTH SERVICE PROVISION Malnutrition among both women and children remains a major health issue in rural Pakistan. It is also seen as contributing to the high neonatal and under-5 mortality rates as well as to excessive maternal mortality. Almost 40% of children under the age of five are underweight, over 50% are affected by stunting and some 9% by wasting—these rates are much higher in rural areas. Malnutrition is also pervasive among women of reproductive age. In addition to the usual problems of poverty, poor infrastructure—particularly the lack of adequate sanitation and potable water—and weaknesses in the health care delivery system, Pakistan is also characterized by severe gender imbalances. Women have low mobility, and thus restricted access to health services. They also lack voice in relation to important health and nutritional decisions within their homes, (World Bank) for both themselves and their children, and they are communities into Village Support Organizations systematically excluded from decision making at the (VSOs) and providing them with village level grants for community level. community infrastructure development and livelihood This study assesses the extent to which: (1) Increasing enhancement. The grant totaled approximately US the participation of women in the public sphere results $30,000 per village. in an increased use of health facilities, particularly In order to test the impact of women’s involvement for child and maternal needs, and in improved health in village decision making bodies, half of the study outcomes; (2) Whether targeted interventions that villages were required to ensure that at least 40% of provide information on health status and health the members of the VSO were women—these will behaviors needed for better hygiene and disease henceforth be referred to as inclusion villages.1 In prevention are necessary for substantial improvements phase 1 of the study (concluded) the focus was on in health status, over and above any impacts of isolating the impact of female empowerment on health empowerment. outcomes and health behaviors. Since the village grant was disbursed after phase 1 was completed, there is Using the Inclusion Village Approach no concern of a lack of impact from the grant itself. The This study builds upon an existing evaluation of a grant effect will be captured at the start of phase II, Pakistan Poverty Alleviation Fund project (a World which will focus on targeted information interventions. Bank supported Community Based Development Initiative) which investigates the impact of mobilizing 1 The evaluation had a second treatment arm which is not relevant to this component of the study. October 2014 South Asia Region Measuring Impact • Disposal of Human and Other Waste Some highlights from the extensive data collected at ○○ More than one third of all households have no midline included key health indicators, private and access to toilet facilities and are defecating community health behaviors, the quality of public mainly in fields and private health services and conditions in study ○○ 90% of HHs dispose waste water through villages with regard to sanitation and drinking water. In open drain or open pits. particular, at midline the impact of empowerment alone ○○ More than 4/5th of all trash (organic and was assessed, since the midline was completed before inorganic) is thrown into backyards, villages any money had actually reached the treated villages— lanes or open places in the villages. though Village Development Plans (VDP’s) had been ○○ Interestingly, even though the VDP was not completed and approved. yet implemented at midline, there appears to The results reported fall under four broad categories: be about a 5% decline in the odds of open quality of water and sanitation; key health behaviors, drains and a 6% decline in open defecation in like hand washing, solid waste disposal and practices inclusion villages, relative to controls. around and; utilization and quality of health services, maternal and child outcomes. The sample consists of 5823 households (HHs) drawn from 5 districts in 3 province in Pakistan.2 Data was collected at the household and community level, including the testing of all water sources. In addition, all health facilities were surveyed through surprise visits and exit surveys were conducted with patients during these visits. All lady health workers (LHWs) assigned to each village were also surveyed and questions that assessed the quality of household information on the LHW were matched, and vice versa. Drinking Water and Sanitation • Water Contamination (mainly for presence of Ecoli): ○○ 35% of HH source water (largely hand pumps), 68% of water stored in the household, and (World Bank) 55% of the water in drinking water supply Health behaviors schemes at the community level was found to be contamination. • While knowledge regarding some aspects of hygiene appears to be relatively high: in ○○ Despite this, 98% of HHs do not treat their particular, 76% of HHs report that they wash their drinking water in any way hands in order to prevent disease, and only 7% • Water contamination levels appear to be profess to not knowing why it is important to wash unrelated to treatment status, suggesting that hands after using the toilet, the preponderance of the intervention had no impact on practices health behaviors suggests either poor knowledge surrounding drinking water treatment or storage. or some dissonance between knowledge and This suggests that information may be a constraint behavior. For example, on the one hand: on water treatment and or efforts to trigger a ○○ 94% of HHs report using soap when they change in private behavior may be required. clean their hands 2 Nowshera in KP, Mianwali and Bahawalpur in Punjab, and Tando Mohd.Khan and Hyderabad, in Sindh. 2 ○○ 90% report washing hands after defecating report that the BHU staff was competent and ○○ 88% report washing their hands before eating friendly in their interaction. food ○○ Cost differences between private and public • In contrast: facilities appear to be large with households paying only the administrative ‘token’ fee for ○○ A substantial proportion of adults (35%) and consultation (equivalent of $0.01) in BHUs children (48%) routinely walk barefoot as compared to about $2 charged by private ○○ Only 37% report washing their hands after providers. cleaning a baby’s bottom and only 15% ○○ BHU’s also appear to provide free medicines. report washing hands before feeding children ○○ Also, children’s health behaviors appear to Interesting, the study found some treatments impact be poorer as per the female head’s report: BHU wait times, which declined by about 6 minutes in only 65% of children wash their hands after treated villages while the time actually spent with the defecating and 73% before eating doctor is unaffected. Direct observation by enumerators indicates the Maternal and Child Outcomes absence of soap in about a 1/3 of all households, flies The general level of maternal care in the sample is around about a 1/3 of all toilets and open excreta in fairly low. For example, 20%. • 58% of HHs report having received any antenatal On balance, no significant impact of treatment and, in care and only 32% of HHs report receiving post particular, inclusion, on any health behavior was found. natal care Utilization and Quality of Health Services • Under one-half of pregnancies are registered and only 5% of babies have their birth weights • Only 24% of households report utilizing a recorded government health care provider when they are ill. A mere 10% of households utilize the Basic Health • About one-half of all households had at least one Unit (BHU) which is the lowest tier of health care pregnancy in the past three years and provided by the government and their first point of • Child mortality (based on the past 3 years of access to government provided health care. pregnancy histories) shows that about 2% of • The main reasons reported for low uptake of public pregnancies resulted in an abortion or miscarriage facilities were a perception that the medicines and an additional 3% died at birth or soon after. provided were not effective (38%), that the facility This implies a mortality rate of about 50 which is was too far (16%), that the level of care available consistent with national statistics. was not adequate for the condition (13%) and that there was not facility in/near the village (10%) • That said, among users (polled in patients exit surveys and in the HH survey) there appears to be an overall positive view of basic health units/ rural health centers, with over 90% of users giving the BHU a 4+ rating on a 5 point scale: ○○ Average wait and consultation time in BHU exit surveys is about 15 and 12 minutes, respectively. This is about the same time (15 and 10) as they get in private facilities, which are vastly preferred in terms of utilization. ○○ Nearly 90% of patients in exit surveys also Lady Health Workers (LHWs) weigh a child 3 LHWs are intended to be the first point of contact for Taken together, these results suggest that pregnant women. They are tasked with registering empowerment led to a rise in expectations about the pregnancies via the BHU, encouraging women to quality of care quality and that while the quality of care obtain antenatal and post natal care and conducting improved as well, the rise in expectations exceeded well baby visits. In practice, any actual improvement • Only 42% of HHs with pregnancies in the past 3 Looking Ahead: Empowering Women and years report having been visited by the LHW Using Health Score Cards • Less than a quarter of the women who received any antenatal care obtained this from a LHW. Overall, the findings suggest that empowerment alone Less than a fifth got postnatal care from the LHW does not lead to substantial improvements in Household and only 7% of HHs with pregnancies received or community health behaviors or health service delivery well baby visits from the LHW and there is considerable scope for more targeted interventions. In phase II of this study, the impact of Was there any improvement in LHW service quality in community health score cards, possibly combined with inclusion villages? The answer is a tentative yes. In the strengthening of doorstep health delivery through particular, inclusion HHs report: LHWs, on community and households health behaviors and the quality of service provision will be investigated. • A higher likelihood of being visited by a Lady Health The health score card will provide specific information Worker (LHW) during their last completed pregnancy regarding minimum standards of service delivery and • Higher odds of receiving antenatal and postnatal quality of care at the local level (BHUs, RHCs and care during the pregnancy and receiving this care LHWs). This will allow further exploration of additional from the LHW impacts of increasing awareness through targeted • Greater pregnancy registration and recording of information provision with and without a strengthening child’s birth weight of the door to door delivery system via the LHW. • More well baby visits, with higher odds of child height and weight being measured Ironically, however, the perception of LHW service quality is lower in inclusion villages • Inclusion HHs are more likely than non-inclusion HHs to report that the LHW spends insufficient time with them, and is less likely to discuss basic health matters concerning immunization, water purification, disease avoidance and family planning Partners (World Bank) SA FANSI Administered by: This results series highlights development results, operational innovations and lessons emerging from the South Asia Food and Nutrition Security Initiative (SAFANSI) of the World Bank South Asia region. Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.