79567 Pakistan Policy Note 10 Shahnaz Kazi, Inaam Ul Haq, Luc Laviolette, and Kees Kostermans 1 Expanding Quality Health, Population, and J une 2 0 1 3 Nutrition Services Pakistan’s health and nutrition outcomes and service than in other South Asian countries, and both coverage lag behind those in most other South Asian rates are the second highest in South Asia, as countries, despite slowly improving over the past is the total fertility rate (Table 1). High fertility decade. Key issues include persistent inequities in puts an enormous burden on women’s health, health and nutrition outcomes and service use by eco- as reflected in high maternal mortality ratios nomic status, gender, and region; poor governance (260 deaths per 100,000 births). and weak and centralized management; low public spending on health; and programmatic shortcomings Pakistani women and children also suffer from some in reducing fertility and improving nutrition—areas of the highest rates of malnutrition in the world, with cross-cutting impacts on human development and have seen little improvement in nutritional out- and economic growth. comes. The prevalence of nutritional stunting The adoption of the 18th Amendment to the con- among children under age 5 (43.7 percent) has stitution in 2010 and the subsequent devolution of remained virtually unchanged since 1965.1 The most federal responsibilities for health and popula- country has the second-highest rate of severely tion welfare to the provinces provide opportunities wasted children, after India: 15 percent of chil- for more responsive and accountable governance, dren under age 5 suffer from acute malnutri- THE WORLD BANK GROUP SOUTH ASIA REGION but they also pose severe challenges. Special atten- tion and 6  percent suffer from severe acute tion will be required to ensure appropriate institu- malnutrition. Malnutrition is also a significant tional arrangements to house federal functions, a problem among women of reproductive age, clear delineation of responsibilities, and the building as 14 percent have chronic energy deficiency. of capacities and structures at all levels. Actions to Micronutrient deficiencies are widespread improve health sector performance include improving with high rates of iron-deficiency anemia, with health services targeting the poor; increasing health 62 percent of children under age 5 and 51 per- spending; strengthening health sector management cent of pregnant women suffering from anemia and accountability with a greater focus on monitor- and persisting high deficiencies of zinc, iodine, ing and information (in a context of devolution and and vitamin A. contracting); and expanding family planning and nutrition services. Coverage of most maternal care services has improved significantly over the last decade but is Health and population outcomes in Pakistan have still far from adequate. During 2001–10, ante- improved over the last decade but at a slower rate natal care attendance increased from 35 per- than in most other South Asian countries. While cent to 60 percent, postnatal care attendance the infant mortality rate and under-five mor- from 9  percent to 28  percent, skilled birth tality rate have fallen, the decline is far slower attendance from 31  percent to 43  percent, Pakistan Policy Note—Expanding Quality Health, Population, and Nutrition Services Table Health, nutrition, and population outcomes in selected South Asian countries 1 Malnutrition prevalence, Under-five mortality rate Infant mortality rate height for age (share of Maternal mortality ratio Total fertility rate (per 1,000 live births) (per 1,000 live births) children under age 5) (per 100,000 live births) (births per woman) Country 2011 2011 2004–11 2010 2010–11 Bangladesh 46 37 43 240 2.2 India 61 47 48 200 2.6 Nepal 48 39 41 170 2.7 Pakistan 72 59 43 260 3.4 2 Sri Lanka 12 11 19 35 2.3 Source: World Development Indicators database. and tetanus toxoid 2 coverage in women from Over the last decade, Pakistan has aimed to improve 46 percent to 69 percent. Immunization cov- service delivery through management reforms and erage improved modestly, increasing from a stronger programmatic focus on strengthening 53 percent to 62 percent.2 Contraceptive prev- maternal and child health services. Fundamental alence (using modern methods) remained institutional changes enacted through the 18th stagnant at 22 percent (or less than half the Amendment have implications for health sec- rate of most South Asian countries). By prov- tor management. Key reforms include: ince, health coverage remains better in Punjab • Expanding access to maternal neonatal and child and Sindh, while Balochistan stays the most health services. The government made sub- underserved (Table 2). stantial investment over 2001–10 in expand- ing community-based programs, including The private sector is the main source of outpatient the Lady Health Workers (LHW) Program consultations and institutional deliveries. The and the National Maternal Neonatal and public sector provides only a fifth of cura- Child Health Program. This expansion sup- tive services, even for the poor and rural ports the provision of family planning, basic population. The use of the private sector for primary health care, community midwifery, outpatient consultations has increased from and emergency obstetrical services. 69 percent in the late 1990s to 78 percent in • The Devolution Plan of 2001 envisaged a shift 2010/11. Nearly 70 percent of institutional of responsibility for basic health services from the deliveries took place in private facilities in provincial governments to the newly created dis- 2011. The public sector remains the main trict governments, to improve service delivery by source of preventive services, particularly in bringing government closer to the people. The rural areas, and accounts for 90 percent of provincial and district departments were immunization coverage. restructured, and efforts were made to build Table Health service coverage, federal and by province 2 (percent) Treatment of diarrhea Proportion of pregnant Proportion of pregnant women in children with oral women who visited health receiving at least one tetanus Skilled birth Postnatal care by rehydration salts facility for antenatal care toxoid injection during pregnancy attendancea skilled provider Province 2001 2010 2001 2010 2001 2010 2004 2010 2001 2010 Pakistan 54 74 35 60 46 69 31 43 9 28 Punjab 44 64 40 63 53 77 33 44 10 28 Sindh 70 89 38 61 43 60 38 49 10 34 Khyber Pakhtunkhwa 58 83 22 50 35 61 26 37 4 23 Balochistan 70 90 21 40 17 31 14 23 7 18 a. Includes assistance from doctor, nurse, lady health worker, or midwife. Source: Pakistan Bureau of Statistics 2001, 2011. capacity of district health systems. Yet the intervention demonstrated that effective initiative stopped far short of full devolu- management could quickly increase use of tion of administrative and fiscal powers. public facilities without additional cost to District governments have limited admin- the government, thus increasing efficiency. istrative authority to hire and fire staff or The program was scaled up in 2006. Find- make senior appointments, which are within ings of an external evaluation of PPHI in the purview of the provincial government. Balochistan, Khyber Pakhtunkhwa, and The share of district governments in pub- Sindh confirm the rise in utilization. Out- lic expenditure increased, but the bulk of patient attendance increased (threefold in 3 spending comprised salaries that could not Khyber Pakhtunkhwa, twice in Balochistan, be altered. The impact on service delivery and by 25 percent in Sindh; TRF 2010). was limited. Staffing and physical conditions of facilities • The 18th Amendment enhances provincial improved. And there were greater levels of autonomy through devolving federal powers and satisfaction with PPHI managed services. responsibilities to the provinces of subjects in the • Health insurance for the poor. The Benazir concurrent legislative list, which includes health Income Support Programme (BISP) in 2012 and population welfare. The federal ministries launched a pilot health insurance scheme of health and population welfare have been in the first government initiative aimed at abolished. All vertical health programs that protecting poor households from the costs accounted for about 60 percent of Minis- of catastrophic illness that involves hospital- try of Health spending have been trans- ization. Coverage is limited to the beneficia- ferred to the provinces but will continue ries of BISP, who are identified through a to be financed by the federal government poverty score card. The State Life Insurance until the next National Finance Commis- Company has been contracted for manag- sion award, expected in 2015. Some health ing the inpatient package of services. The oversight functions have been retained at initiative is financed directly by the federal the federal level and assigned to various budget. Launched in Faisalabad District, federal entities, including health financ- BISP aims to expand the program to the ing, formulation of norms and standards, entire country. The progress of the pilot human resource planning, and information will be carefully monitored and evaluated collection and analysis. The reform has the before scaling up. potential to make the government more responsive and accountable and to develop Key Issues in the Health Sector a more cohesive public health system, yet it faces significant challenges that will require Health outcomes are influenced by several factors, attention, particularly during the transition some outside the health sector such as poverty, educa- phase. These include appropriate institu- tion (particularly for girls), and environmental (sani- tional arrangements to house federal func- tation and water supply) factors. With challenges tions, clear delineation of responsibilities in most of these, the sector faces a range of key within provincial departments, and capac- issues. ity building at all levels. The provinces are developing their own health sector strate- Inequities in health outcomes gies outlining their reform programs. and access to services • Contracting out health services management. More than half the districts adopted this Wide inequities persist in nearly all health outcomes approach, under the People’s Primary and access to services between rich and poor (the most Health Initiative (PPHI). The model was pronounced) and between rural and urban regions. first adopted in 2002 when Rahim Yar Khan Under-five mortality and fertility rates of the District in Punjab contracted the Pun- poor are twice as high as those for the wealthi- jab Rural Support Program to manage all est households, while malnutrition, particu- 104 basic health units in the district. The larly stunting, is more prevalent in rural areas: Pakistan Policy Note—Expanding Quality Health, Population, and Nutrition Services 46 percent of rural children are stunted com- Gender disparities have diminished over time. Sex pared with 37 percent in urban households. differentials in child mortality have narrowed Health service use also varies markedly by eco- but have not disappeared. The lower mortality nomic status and region, with the rural poor of boys ages 1–5 is attributed to better health having substantially lower use than the urban care (Table 3). Research on determinants of poor. 3 Immunization rates for children from nutrition in Pakistan has not found any sig- the poorest urban households are comparable nificant differences in nutritional outcomes with those of rural children from the rich- among boys and girls (Arif and others 2012; 4 est. Contraceptive prevalence among urban World Bank 2005). Differences in immuniza- households in the lowest quintile is higher tion coverage have also narrowed, although than for rural households in the top quintile. girls are still less likely to be fully immu- Significant interdistrict variations in coverage nized than boys. Improvements in women of health services are observed in Balochistan, (even in rural settings) seeking health care Khyber Pakhtunkhwa, and Sindh (Pakistan during pregnancy and in skilled birth atten- Bureau of Statistics 2011), which to some extent dance partly reflect efforts to address gender reflect differences in socioeconomic develop- constraints through expansion of the LHW ment and communities’ remoteness. Program and more deployment of trained community midwives in rural communities A few efforts have been made to target services to (see Table 2). poorer communities and to more remote districts, although the potential of the LHW Program and Low public spending on health contracting out to the nongovernmental organization (NGO) under the PPHI has not been fully exploited. Total health spending in Pakistan is extremely low With more LHWs, some progress is being relative to other countries in the region as well as to made to cover less advantaged areas, but the countries at similar levels of development. About program has been unable to reach the poor- $22 per person was spent on health in 2009 est areas due to difficulties in recruiting LHWs (against an average of $41 in Southeast Asian given the limited supply of women in these countries). About 70 percent comes from pri- areas who meet the program’s minimal educa- vate sources, mainly out of pocket by house- tional requirements (OPM 2009). To ensure a holds at the point of care. Few households have focus on the poor would require explicit men- access to financial risk protection against cata- tion of the objective in the service package to strophic diseases and accidents, even though be delivered by NGOs and in the monitoring such health shocks, attendant income losses, and evaluation (M&E) component of the PPHI and associated out-of-pocket payments greatly contract. increase the risks of impoverishment. Table Differences in health status and service coverage 3 Under-five Child Contraceptive Births attended by Prenatal care by Children ages Total mortality rate mortality rate prevalence rate skilled personnel skilled provider 11–23 months Indicators fertility rate (per 1,000 live births) (ages 1–5) (modern methods) (percent) (percent) immunized (percent) By wealth quintile Poorest 5.8 121 30 12.4 15.0 36.9 25.9 Richest 3.0 60 8 31.6 77.3 91.9 63.7 By area of residence Urban 3.3 78 13 29.9 60.0 78.1 54.2 Rural 4.5 100 20 17.7 30.0 53.4 44.0 By gender Male 93 14 49.8 Female 93 22 44.3 Source: National Institute of Population Studies and Macro International 2008. Public funding on health was less than 0.86 percent national priorities. Such resources include pre- of GDP in 2010, compared with at least 3–4  per- ventive and primary health care services and cent in other low-income countries, even though in nonsalary spending, all grossly underfunded 2008/09–2010/11 total public health and popu- and essential for facilities to function effec- lation welfare expenditure increased 36 percent in tively. Past trends in provincial spending raise nominal terms to more than PRs 122 billion ($1.34 some concerns about lack of prioritization and billion).4 The increase was largely attribut- political will to invest in these areas. Today, able to higher current spending, which rose there is no instrument to incentivize provinces from 66  percent of the total to 72 percent— to focus on priority services. 5 reflecting a 50 percent increase in salaries of provincial employees—while development Weak management and governance expenditures fell, even in nominal terms, from Poor health performance is due mainly to weak 34  percent to 28  percent. Population welfare management and governance, including wide- spending remained low, at 3.2 percent of the spread staff absenteeism, centralized manage- total, declining in real terms. ment, and weak stewardship. At a more disaggregated level, in provinces in Staff absenteeism is the most serious manifestation of 2008/09–10/11 district nonsalary expenditures weak management and governance, including lack stayed low (TRF 2011). District budgets cover pri- of accountability in public health services. Accord- mary and secondary care facilities, including ing to facility-based surveys in Balochistan basic health units, rural health centers, tehsils, and Sindh, most doctors were absent from and district headquarter hospitals. In Khyber their assigned posts. The absentee rate was 58 Pakhtunkhwa and Punjab, the district share of percent in Balochistan while in Sindh 45 per- overall expenditures remained at around 30 cent of doctors were absent from basic health percent, comprising current expenditures only units and 56 percent from rural health centers as the districts receive no allocation for develop- (World Bank 2010). They can get away with this ment funds. Nonsalary expenditure accounted because of political patronage and managers’ for only 14 percent of the total in Khyber Pakh- weak administrative authority, who are not in tunkhwa and 25 percent in Punjab. a position to fire public sector staff. Political interference is also prevalent in appointments Provincial revenues have recently increased. and postings, resulting in lack of merit-based Changes in the National Finance Commission recruitment and frequent transfer of managers. award have considerably enhanced the prov- inces’ fiscal space by sharply raising their share Poor staff performance reflects systemic problems of in the divisible tax pool, and the 18th Amend- weak motivation due to rigidity of civil service rules, ment devolved sales tax on services, a buoyant which provide few performance incentives or flex- source of revenue for the provinces. These ibility for managers to innovate. Contracting out decisions raised transfers to the provinces by management has worked in Pakistan and else- 23–28 percent, with greater benefits to Balo- where largely because it can circumvent civil chistan and Khyber Pakhtunkhwa. In addition, service regulations and provide the necessary the federal government is committed to financ- economic incentives and autonomy to manag- ing the devolved vertical health programs until ers (Loevinsohn and Harding 2004). The suc- the next award in 2015. The amounts involved cess of the PPHI and similar contracting-out are substantial. In 2010/11, the federal govern- experience after the earthquake in Battagram ment share of total expenditure was 19 percent, District in 2005 is thanks to capable managers nearly two-thirds for development programs who were motivated, well paid, and granted (including vertical national health and popula- wide autonomy. Such autonomy included tion welfare programs). f lexibility in fund management through a single line budget, full administrative author- A major concern since the 18th Amendment is whether ity for hiring and firing staff, and scope for the additional provincial resources will be used for providing financial incentives to attract staff, Pakistan Policy Note—Expanding Quality Health, Population, and Nutrition Services particularly female providers who were in dependency burden. The long-term benefits of short supply. early childhood interventions in nutrition on adult health, economic productivity, and life- Overly centralized management further erodes time earnings are well documented. accountability and efficiency. Efforts to decen- tralize service delivery under the Devolution Unmet need for family planning. Pakistan is the Plan of 2001 were unsuccessful as increased world’s sixth most populous country, whose responsibility for basic health services was not population of 180 million is likely to double in associated with the requisite authority at the about 39 years if current growth rates persist. 6 district level to allocate resources or manage It will face a huge challenge in meeting the human resources, both of which remained basic needs of this rising population, which largely with provincial governments. Thus pro- will undermine its ability to sustain solid eco- vincial governments remained occupied with nomic growth. Some of the indicators are wor- service provision, with little time for oversight. rying. The fertility decline from 5.6 children Centralized management of vertical programs per woman in 1990/91 to 4.1 in 2006/07 was and other service delivery institutions left little much slower (and later) than that in any of its time for the Ministry of Health to focus on its neighbors. The contraceptive prevalence rate stewardship role, causing neglect of key public has stagnated over the last decade at half the health functions including policy formulation, rate of other South Asian countries. And the oversight, M&E, surveillance, and regulation. unmet need for family planning is rising—as is Capacity for stewardship functions was lacking unwanted fertility. The increased demand with- at provincial and federal levels. out any changes in contraceptive use can partly be explained by access constraints and poor But the 18th Amendment provides an opportunity to quality of service provision. One in four women delineate clear channels of accountability, effectively who want to avoid pregnancy is not using any integrate services, and focus on stewardship roles, but form of contraception, while two-fifths of preg- also raises major challenges (WHO and others 2012; nancies are unwanted (National Institute of Nishtar 2010). The most pressing issue concerns Population Studies and Macro International inadequate federal institutional arrangements. 2008). Women from poorest households have After the Ministry of Health was dissolved, fed- the highest unmet need. eral functions were assigned to federal entities with little experience or motivation for taking Although Pakistan was one of the first countries to them on. The fragmented setup led to prob- establish a family planning program in 1965, the lems of coordination between these entities, decline in fertility that started in the early 1990s was between federal and provincial governments, much later than in most of South Asia. A compari- and with donors. The lack of a central author- son with Bangladesh is illustrative, as the two ity left the provinces with little technical sup- counties started with identical levels of fertil- port or guidance for their new responsibilities. ity and similar sociocultural contexts. Between 1971 and 2011, fertility in Bangladesh declined Programmatic issues—unmet need for family steeply from 6.3 children per woman to 2.3. planning and the burden of malnutrition Bangladesh virtually stabilized population growth as it made its program a top develop- Programmatic achievements have been few in reduc- ment priority with a broad coalition of support. ing fertility and tackling malnutrition, with barely In contrast, Pakistan’s program has suffered any change in outcomes or intermediate indicators. from wavering political commitment and has Family planning, in addition to reducing the not been central to the development agenda. mortality of mothers, infants, and children, Having two separate ministries (of population also greatly boosts primary schooling rates welfare and of health), with vertical structures and women’s empowerment. Fertility decline going down to service outlets, was not only also contributes to growth by increasing the inefficient but also marginalized population relative size of the workforce and reducing the issues at the Ministry of Health, which failed to fully own the program. Government spend- flexibility to reach out to populations in diffi- ing on population, which increased during the cult areas (see below). 1990s, also shows a declining trend in more recent years—for example, no new initiatives Increase expenditure on health have been launched to increase contracep- tive use since social marketing was introduced Efficiency of resource use can be greatly increased, and expanded in the late 1990s and the LHW but provincial governments also need to boost spend- Program was expanded in the first half of ing, given the very low public health expenditures. the 2000s. In particular, district budget spending on the 7 nonsalary component is grossly inadequate and Nutritional outcomes have not improved over the needs to be raised substantially. Stronger fund- last two decades—worse, they have deteriorated ing is also needed if the reforms and policy for some indicators. Pakistan has made little options in this note are to be carried out. attempt to systematically address the causes of malnutrition—it has not made them a priority, ­ Federal government support to vertical programs as reflected in the lack of an institutional home would be more effective and would inculcate greater or a clear strategy. It has carried out a few ownership if it were financed through development fragmented interventions, mainly to address grants and were incorporated in the provincial micronutrient deficiencies (primarily vita- annual development program. In the medium min A supplementation and salt iodization). term, provincial allocations need to expand More recently, Pakistan has started to develop considerably to finance the vertical programs, a broader nutrition strategy and program in particularly the LHW Program and other line with the international consensus on an devolved institutions now supported by the action framework for scaling up nutrition. The federal government. The federal government strategy needs to be based on a two-pronged may also need to provide conditional grants approach: addressing the determinants of to ensure that provincial policies are aligned nutrition through a multisectoral approach, to national priorities in areas such as fertil- and implementing and scaling up well-proven ity reduction and nutrition, as otherwise they direct nutrition interventions through the may not receive the required attention and health sector. resources. This support could be in the form of results-based financing or tied grants. Policy Recommendations Strengthen health sector Improve targeting of health management and accountability services to the poor The 18th Amendment will require a medium- to Interventions and resources need to be better targeted long-term implementation plan to fully realize its to the poor as well as to lagging districts and regions. potential for responsive and accountable governance. Further expansion of the LHW Program is nec- Supportive measures to manage the transition essary because those regions not yet covered by should include: it are the most disadvantaged. Yet a constraint • Establishing a federal institution, possibly to further expansion is the difficulty in recruit- under the Ministry of Inter-provincial Coor- ing workers with the minimum educational dination, responsible for national functions requirements as well as the lack of functional in health that are currently dispersed across health facilities in the underserved areas. different ministries. To increase coverage, condensed-education • Delineating and clarifying roles and respon- courses to motivate girls to become LHWs and sibilities for structures within provincial mobilization of disadvantaged communities departments. to support the LHWs should be implemented. • Expanding merit-based recruitment of staff Another promising option to expand cover- and building capacity in key areas at federal age is to contract NGOs, as they have greater and provincial levels. Pakistan Policy Note—Expanding Quality Health, Population, and Nutrition Services • Undertaking an assessment of staff capacity System data to monitor performance of gov- requirements to prioritize needs. ernment health services. In addition, informa- • Finalizing and approving provincial health tion from population-based surveys regularly strategies. conducted by the Federal Bureau of Statistics should be used. Service delivery should ideally be devolved to district governments along with the necessary administra- The PPHI model is a viable option for improving per- tive and spending powers. The 18th Amendment formance of first-level care facilities through greater recognizes the third tier of local government, managerial autonomy, including flexibility in fund- 8 but the district government’s role and respon- ing and full administrative powers to hire and fire. sibilities are defined by the provinces in the The approach should be further strengthened Provincial Local Government Ordinance Act. through the following measures at the provin- As all provinces have opted for greater provin- cial level: cial control, the best option would be a decon- • Adopting a package of primary health ser- centrated system, with administrative powers at vices covering preventive and promotive the district level. care. • Granting managers control of all aspects of A stronger focus on results and M&E is a central ele- the primary health system, including basic ment of the health sector management and account- health units, rural health centers, vaccina- ability reforms. The federal government has an tors, and LHWs. important role in M&E of provincial perfor- • Selecting NGOs through a competitive pro- mance to track progress toward priority areas cess and bring in performance-based con- and to serve as the basis for advocacy with the tracts with a greater focus on monitoring. provinces. A central role is also necessary for • Contracting NGOs to improve coverage of ensuring consistency in methods and instru- remote rural areas where provision of public ments in data collection and indicators, for services is constrained by staffing difficul- collating evidence, and for reporting progress ties with an explicitly stated objective of the at international forums. The provincial depart- service package and of the M&E component ments require data and analysis for feeding of the contract. into the planning and policy-making process, • Building capacity of government coun- to monitor implementation, and to improve terparts in contract management and service delivery. Given the wide variations in monitoring. health sector performance, provincial govern- ments should carefully track and then share Expand provision of family planning information on district health performance and nutrition services (partly as an accountability mechanism but also to find out where special efforts are required). Pakistan needs to prioritize family planning and Poorly performing districts should receive spe- nutrition. It needs to invest in improving pro- cial programmatic and technical support. vision and quality of family planning services, focusing on rural areas where supply con- A basic prerequisite for these tasks is a well-function- straints are more severe, and should pursue the ing M&E system. This entails sound informa- following measures: tion systems and strengthened capabilities for • Ensuring coverage of family planning ser- data analysis, possibly through existing struc- vices through all public health outlets. tures such as the National Health Information • Ensuring the provision of skilled staff and and Resource Centre or the Health Systems family planning products to make a broad Strengthening Project at the federal level and range of contraceptive methods available. the Health Sector Reform Units in provin- • Broadening social marketing of family plan- cial departments. Investment is required in ning by expanding services to rural areas, improving quality, completeness, and timely where possible using performance-based availability of District Health Information contracts with the private sector. • Promoting male involvement, including measles. In the case of other indicators through information and services by trained for maternal care services, the figures are male paramedics or doctors in health comparable across the different surveys. facilities. 3. A breakdown of data by expenditure quin- tile and by rural–urban status was avail- Pakistan has to invest heavily and systematically in able in PSLM only through 2005/06. order to address malnutrition on a broad scale. It 4. Data are from the Ministry of Finance’s should do this by: Poverty Reduction Strategy Progress • Prioritizing nutrition in the national devel- Reports 2003–08 and TRF (2011). Expen- 9 opment agenda and assuring resources to diture data for Azad Jammu and Kashmir, carry out multisectoral provincial nutri- Gilgit–Baltistan, Federally Administered tional plans through interventions in edu- Tribal Areas (FATA), and autonomous cation, agriculture, social protection, and organizations were not included. water and sanitation. • Ensuring implementation of provincial References plans for scaling up nutrition interventions Arif, Ghulam M. 2004. “Child Health and Pov- through the health sector for vulnerable erty.� Pakistan Development Review 43 (3): women and children. The plans include pro- 211–38. moting exclusive breast-feeding, promoting Arif, Ghulam M., Saman Nazir, Maryam Satti, adequate complementary feeding, address- and Shujaat Farooq. 2012. “Child Malnutri- ing micronutrient deficiencies, treating tion in Pakistan: Trends and Determinants.� severely malnourished children through Discussion Paper. Pakistan Institute of Devel- community-based approaches, and control- opment Economics, Islamabad. ling childhood infections and increasing Garcia, Marito, and Harold Alderman. 1991. immunization. “Patterns and Determinants of Malnutrition • Building institutional capacity for nutrition in Children in Pakistan.� Pakistan Development in the health sector and in a coordinated Review 28 (4): 891–902. multisectoral approach. Institute of Public Policy. 2012, “Economic Cost of Undernutrition in Pakistan.� Islamabad. Notes Loevinsohn, Benjamin, and April Harding. 1. All data are from the Pakistan National 2004. “Contracting for the Delivery of Com- Nutrition Survey 2011 unless otherwise munity Health Services: A Review of Global indicated. The 2011 survey is the first to Experience.� Health, Nutrition and Popula- provide representative data for each prov- tion Discussion Paper. World Bank. Washing- ince. By comparison, India is 48 percent, ton, DC. Nepal 45 percent, Bangladesh 43 percent, Masud, Tayyeb, and Kumari Navaratne. 2012. the Democratic Republic of Congo 43 per- “The Expanded Program on Immunization cent, and Sri Lanka 17 percent. in Pakistan: Recommendations to Improve 2. Indicators are based on the Pakistan Performance.� Health, Nutrition and Popu- Social and Living Standard Measurement lation Discussion Paper. World Bank, Wash- Survey (PSLM), except for immunization ington, DC. (Masud and Navaratne 2012). PSLM data Ministry of Finance. Various years. “Poverty were not used for immunization because Reduction Strategy Progress Reports.� Gov- of the large divergence between immuni- ernment of Pakistan: Islamabad. zation rates based on PSLM and other data National Institute of Population Studies [Paki- sources, including the Pakistan Demo- stan] and Macro International. 2008. Paki- graphic and Health Survey and Multiple stan Demographic and Health Survey 2006–07. Indicator Cluster Survey. The high rates of Islamabad. immunization reported in PSLM are also Nishtar, Sania. 2010. “Health and the 18th not in line with the continued outbreaks Amendment: Retaining National Functions of vaccine-preventable diseases such as in Devolution.� Heartfile, Islamabad. Pakistan Policy Note—Expanding Quality Health, Population, and Nutrition Services OPM (Oxford Policy Management). 2009. Differentials in Childhood Mortality. New York: “Lady Health Workers’ Program: Third Party United Nations. Evaluation of Performance.� Oxford, UK. WHO (World Health Organization), World Pakistan Bureau of Statistics. 2001. Pakistan Bank, DFID (Department for International Integrated Household Survey 2001. Govern- Development), USAID (U.S. Agency for ment of Pakistan, Islamabad. International Development), and TAUH ———. 2011. Pakistan Social and Living Stan- (Pakistan Technical Assistance Unit for dards Measurement Survey 2010/11. Gov- Health). 2012. “Devolution of Health Sector, 10 ernment of Pakistan, Islamabad. Post 18th Amendment to the Constitution Social Policy Development Centre. 2012. “Devo- of Pakistan: Opportunities and Challenges.� lution and Social Development, Annual Joint Mission Report, Geneva. Review 2011–12.� Karachi. World Bank. 2005. Pakistan: Country Gender TRF (Technical Resource Facility). 2010. “Third Assessment, Bridging the Gender Gap, Opportuni- Party Evaluation of the PPHI in Pakistan.� ties and Challenges. Washington, DC. Islamabad. ———. 2010. Delivering Better Health Services to ———. 2011. “Health Budget & Expenditure Pakistan’s Poor. Washington, DC. Analysis (2008–09 to 2010–11).� Islamabad. ———. n.d. World Development Indicators UNDESA (United Nations Department of database. http://data.worldbank.org/ Economic and Social Affairs). 2011. Sex data-catalog/world-development-indicators. © 2013 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street NW Washington, DC 20433 USA All rights reserved This report was prepared by the staff of the South Asia Region. The findings, interpretations, and conclusions expressed herein are those of the authors and do not necessarily reflect the views of the World Bank’s Board of Executive Directors or the countries they represent. The report was designed, edited, and typeset by Communications Development Incorporated, Washington, DC.