Creating a frontline

Two important world reports were released in the past month, with direct links to newborn and maternal survival. The first, release by the World Health Organisation on May 3rd, ranked Pakistan fourth in the world for preterm births, at 748,100 per year. The report, Born too Soon, argued that shortages in qualified health workers and inadequate capacity for the care of premature babies are a major reason for the lack of progress in reducing neonatal deaths. It went on to explain how investment in health workers can considerably reduce maternal and child mortality ratio.The lack of health workers directly impacts the quality of life for mothers. This was reflected in the second report, released by Save the Children on May 8th, where Pakistan was ranked 78 out of 80 countries under the less developed countries category on the annual Mothers’ Index. The State of the World’s Mothers, released for the thirteenth year, ranked 165 countries for being the worst and best places to be a mother. It echoed the views of Born too Soon – that health workers are the key to success. Frontline health workers have a vital role to play in promoting good nutrition in the first 1,000 days in impoverished communities in the developing world where malnutrition is too common, doctors and hospitals are often unavailable, too far away, or too expensive.Indeed, we need more frontline health workers who are skilled and confident in newborn care. We need health clinics equipped with life-saving commodities. We need community health workers and midwives to screen children for malnutrition, treat diarrhoea, promote breastfeeding, distribute vitamins and other micronutrients, and counsel mothers on good nutrition, hygiene and sanitation. The “lifesaving six” interventions highlighted in the State of the World’s Mothers report can be delivered in many remote and impoverished places through well-trained and well-equipped community health workers. In a number of countries – including Cambodia, Malawi and Nepal – these health workers have contributed to broad-scale success in fighting malnutrition and saving lives.Save the Children says nearly 1.3 million children’s lives could be saved each year if six interventions are fully implemented at scale in the 12 countries, including 100,000 in Pakistan, most heavily burdened by child malnutrition and under-5 mortality. With the help of frontline health workers, all six of these interventions can be delivered fairly rapidly using health systems that are already in place.What is lacking is the political will – the will to invest in inexpensive yet proven solutions that are essential to the women and children who need them most. Three of the six solutions – iron, vitamin A and zinc – are typically packaged as capsules costing pennies per dose, or about $1 to $2 per person per year. The other three solutions – breastfeeding, complementary feeding and good hygiene – are behavioural change solutions, which can be implemented through outreach, education and community support.In Pakistan, about 100,000 Lady Health Workers (LHWs) and 4,000 Community Midwives (CMWs) exist at community level. While the government’s LHW Program is present in all districts, in reality only 60% to 65% of the whole population is covered, with many of the poorest and hardest to reach without any access at all. The Prime Minister announced an increase in the number of LHWs to 120,000 and CMWs to 16,000, although about 12,000 more CMWs need to be deployed in order to meet the World Health Organisation (WHO) criteria.The Government of Pakistan should live up to its commitment to increase the number of LHWs and extends its commitment to increase the number of CMWs. These increases would help close the gap in health promotion and provision of services. Both the federal and provincial governments and donors should work together to fill this frontline health workers gap by recruiting, training and supporting new and existing health workers, and deploying them where they are needed most.The provincial governments and donors are now playing a larger role in the post 18th constitutional amendment scenario as the LHW program has devolved to provinces. The appointment and training of CMWs have become provincial subjects as well and should now be prioritized by the provincial leaders.The provincial governments now need their own frontline health workers policies and strategies in light of their respective Millennium Development Goal (MDG) targets. This needs to be done with great urgency, given high maternal mortality ratios like that of Balochistan, at 785 per 100,000 live births. All provincial governments and the Federally Administered Tribal Areas (FATA) secretariat will need to come up with policies and strategies about increasing frontline LHWs and CMWs quickly in order to put provinces and FATA on the right track towards achieving MDGs 4 and 5. Donor agencies are also required to align their support in the post 18th constitutional amendment scenario and extend technical assistance to provinces to respond to the demands in an effective manner.The writer is an advocacy manager for Save the Children and tweets at @amahmood72.

Published by The News on Sunday on June 17, 2012 http://jang.com.pk/thenews/jun2012-weekly/nos-17-06-2012/dia.htm#4

Published as a blog on Save the Children Asia's website http://save-the-children-asia.mynewsdesk.com/blog_post/view/in-pakistan-health-workers-are-crucial-in-delivering-life-saving-support-to-newborns-and-mothers-13075

Published as a blog on Every One Campaign's website http://everyone.org/saving-newborns-in-pakistan/

Pakistan’s human rights scrutiny

The Universal Periodic Review (UPR) Working Group’s 14^th session is scheduled to take place from October 22 to November 5, 2012 in Human Rights Council, Geneva, Switzerland. Pakistan’s review is scheduled from 09:00 to 12:30 hours on Tuesday October 30, 2012 while the report on Pakistan will be adopted on Friday November 02, 2012. The UPR is a United Nations review mechanism of the overall human rights situation of all UN Member States, by all UN Member States. This includes child rights issues.

The review is based on three reports: 1) the State’s national report, 2) a compilation of UN information on the State prepared by the Office of the High Commissioner (OHCHR) and 3) a summary of other relevant stakeholders’ information, including NGOs’, prepared by the OHCHR. From Pakistan a number of stakeholders’ reports have been submitted by different civil society organizations focusing on different areas such as human rights, women’s rights, minorities’ situation, labour rights, right to information and child rights. I’ll briefly discuss the concerns and recommendations raised by the Child Rights Movement (CRM), a coalition of 108 national and international organizations working for child rights in Pakistan in its report.

The CRM report highlights the fact that there is no an independent body at the federal level with a statutory status for reporting, coordination and monitoring for the implementation of the United Nations Convention on the Rights of the Child (UNCRC) and its Optional Protocols and have recommended that the Government of Pakistan should establish an independent National Commission on the Rights of Children (NCRC) by passing the long pending NCRC bill.

While highlighting the issue of malnutrition, the civil society report states that malnutrition is contributing to 35 percent of all under-5 deaths in Pakistan. According to UNICEF, 32 percent of infants have low birth-weight (recorded in 2006 and 2010). In 2010, the infant mortality rate was 70/1000 and under-5 mortality rate was 87/1000. As a result, Pakistan is at risk of failing to reach its MDGs targets on maternal and child health. Pakistan should take all legislative, administrative and other appropriate measures to develop and implement comprehensive food security and malnutrition prevention and response programmes recommended the CRM.

The report further states that Pakistan has ratified three conventions related to children: UNCRC and ILO’s Conventions 138 (the Minimum Age Convention) and 182 (Convention on the Worst Forms of Child Labour) however, little progress has been made in amending existing or introducing new legislation to comply with the provisions of these conventions. The report also highlights cases of severe torture and abuse of child domestic workers. The civil society report recommends that Pakistan should introduce new laws and where required amend existing laws to implement the provisions of these conventions and to ban child domestic labour under the Employment of Children Act (ECA) 1991.

The report also highlights child protection issues like corporal punishment and child marriages and recommended to immediately enact the long awaited Prohibition of Corporal Punishment and the Child Marriages Restraint (Amendment) Bills to prohibit corporal punishment in all its forms and raise the minimum marriageable age for girls from 16 to 18 years, along with strict penalties for violations.

The CRM report highlighted stark statistics related to the number of child sexual abuse cases (1,839 in 2008, 2,012 in 2009, 2,595 in 2010): On average, six children are sexually assaulted every day, but reported cases are only a fraction of all cases due to social taboo. CRM recommends that Pakistan should ensure that professionals working on the front line with children, such as teachers, medical professionals, school counselors, and police personnel, are sensitized and trained to appropriately respond to child sexual abuse, including prevention, detection and management.

There are an estimated 1.2 million children living and or working on the streets in major cities of Pakistan. Following the floods in 2010 and 2011, and ongoing conflict in the tribal areas, there has been a surge of street children. The federal and provincial governments in Pakistan should support mechanisms for rehabilitation and reunification of children living and or working on the streets recommended the CRM.

The civil society report further states that the Juvenile Justice System Ordinance (JJSO), 2000, is little recognized or known among law enforcement agencies, and officials are generally not sensitized or qualified to deal with children’s issues. Furthermore, the law does not override, but is in addition to, several laws such as  the Army Act, Frontier Crimes Regulation, Action (in Aid Civil Power) Regulation, Anti-terrorism Act, Control of Narcotics Substance Act, Punjab Prohibition of Kite Flying Ordinance and the Railways Act to name a few. Under these laws, harsh punishments including death sentence and life imprisonment can be imposed upon children. The Government of Pakistan should take measures to ensure that the JJSO overrides other laws in cases involving children and take solid steps for the implementation of the JJSO including the establishment of exclusive juvenile courts, appointment of probation officers and budgetary allocation.

Similarly, the minimum age for criminal responsibility that currently stands at 7 years under Section 82 of the Pakistan Penal Code (PPC) should be increased immediately to an internationally accepted level i.e. 12 years. A Child Protection Criminal Laws (Amendment) Bill has been pending since 2009 in which the minimum age of criminal responsibility was proposed to increase from 7 to 10 years under Section 82  and from 12 to 14 years under Section 83 of the PPPC.

National birth registration average is at a dismal 29.5 percent as Pakistan has not taken sufficient measures to remove structural obstacles to birth registration and harmonize birth registration systems across the country. The CRM recommended that Pakistan should take legal and administrative measures to remove obstacles to birth registration (particularly for marginalized segments of society, e.g. single parents children, children out of wedlock, street children and orphans) and harmonize laws related to birth registration across the country by 2015.

While highlighting the state of education in the country, the report stated that about 7 million children are not attending primary school in Pakistan; approximately 60 percent of these are girls. Accordingly, more than 50 million Pakistanis above 10 years of age are illiterate. Through a positive constitutional amendment Article 25A was inserted in the Constitution of Pakistan in 2010, where education has been made a fundamental right of every child from 5 to 16 years of age however; neither the federal nor provincial governments have introduced laws to implement the Article. Both the federal and provincial legislature should enact laws Pakistan that should comply with Article 25-A (the Right to Education).

Pakistan ratified the Optional Protocol to the UNCRC on Sale of Children, Child Prostitution and Child Pornography in October 2011; however, the Child Protection (Criminal Law) Amendment Bill 2009, which would provide for preventive and protective measures against sale of children, child prostitution and child pornography is still pending to be placed before the National Assembly of Pakistan for enactment. Pakistan should translate ratification of the Optional Protocol on Sale of Children, Child Prostitution and Child Pornography into national laws.

Pakistan has introduced the Action in Aid for Civil Power Regulations (AACPRs) for the Federally Administrated Tribal Areas and Provincially Administrated Tribal Areas. These regulations allow for the confinement of an individual for 120 days without the authority of the magistrate. Furthermore, the Regulations state that for 120 days, there will be no legal representation or trial, and a single statement by an official from the Law Enforcement Agencies is sufficient to prove a suspect guilty of an offence and set a death sentence, which cannot be challenged at any other legal forum. Pakistan should immediately abolish the AACPRs and proper administrative and judicial procedures should be applied in accordance with the Constitution of Pakistan in FATA and PATA.

The issues raised and recommendations made in the civil society report clearly highlight the state of affairs in the country as for as child rights are concerned. Pakistan’s periodic report being party to the Convention on the Rights of the Child is also due later this year. Therefore, its high time for the both the federal and provincial legislature to respond to the state of child rights in the country and immediately enact all pending bills related to child rights. Similarly, budgetary allocation should also be made to ensure that the laws are not limited to law books only and a visible change is witnessed in the child rights situation in the country.

The writer is a member of the Child Rights Movement and tweets @amahmood72

 

Published in The News on Sunday http://jang.com.pk/thenews/Oct2012-weekly/nos-27-10-2012/pol1.htm#6 and http://www.trust.org/alertnet/blogs/asia-views/pakistans-human-rights-scrutiny

 

Malnutrition: A hidden crisis in Pakistan

Malnutrition is the underlying cause of 35 per cent of under-5 deaths in Pakistan. It is considered one of the hidden crises. The stunning results from the recent National Nutrition Survey (NNS, 2011) show an alarming nutrition situation in Pakistan. Under-nutrition is one of the main causes of death among infants and young children. Those who survive have less learning capacity that reduces their productivity as adults, which impact negatively on the economy. At least 2% of GDP is lost every year on account of current levels of malnutrition in Pakistan. Addressing the problem would only cost a small fraction of that amount. Reversing adverse trends in nutrition needs appropriate policy direction, political commitment and a concerted effort from all sectors.

The main indicators of malnutrition include stunting, wasting and micronutrient deficiencies. Stunting is when a child is too short relative to her/his age. It is a form of “chronic” malnutrition, which is accumulated over long period of time. Stunting generally occurs before the age of two and is largely irreversible. According to Save the Children’s State of the World’s Mothers 2012 report, the period from the beginning of pregnancy to 24 months of age – the first 1000 days – are critical for nutrition – and the window to prevent malnutrition. The main causes of malnutrition include poor nutrition for mothers during pregnancy, too few calories, poor quality of food (e.g. micronutrients), repeated infections (e.g. diarrhoea, malaria), and poor feeding practices (e.g. not feeding colostrum). According to the findings of NNS 2011 43.7% of children under five are stunted in Pakistan.

Wasting is when a child’s weight is too low for her/his height. Wasting is usually the result of acute significant food shortage and/or severe disease. Children suffering from wasting, particularly in severe cases of wasting, are more likely to die. According to the findings of the NNS 2011, 15% of children under-five years in Pakistan are wasted. As per World Health Organization’s standards, a national average of 15% or above is labelled as an “EMERGENCY”.

The survey results also highlight micro-nutrient deficiencies including vitamin A, iron, zinc, iodine and vitamin D. It is clear now that malnutrition is not just a food problem or the result of displacements, floods or other emergencies. Malnutrition is a national calamity. It is indicative of the underlying issues the country is facing including poor infant feeding practices, poor sanitation and hygiene habits, increasing food insecurity and lack of awareness about child and maternal nutrition.

Traditionally nutrition has been viewed as a problem to be looked after only by the health sector - planning commission or Ministry of Health at the federal level and Department of Health at the provincial level. This narrow approach then excludes those remedies  which would cater to the wider economic and social contexts which predispose a community to poor nutrition. Major findings of the NNS 2011 clearly indicate the urgent need to address malnutrition through an integrated approach, which addresses immediate, underlying and basic causes of malnutrition. This is a challenge to mainstream nutrition and to ensure that all relevant departments and stakeholders are cognizant of their roles and have effective coordination.

There is now real evidence that most of our children are under-nourished in many ways … ways which affect the development of their brains in the first two years of life, with negative impact on their performance in or out of school and subsequently in their work productivity.

Devolution is an opportunity to scale up investment in health and nutrition after a long period of stagnation. It is high time that the provincial governments make specific budgetary allocations for nutrition programs. Social protection schemes (like Benazir Income Support Program and Pakistan Bait-ul-Maal ) allocate increased resources and have increased focus on nutrition outcomes.

According to Save the Children’s State of the World’s Mothers 2012 report, “In developing countries, breastfed children are at least 6 times more likely to survive in the early months of life than non-breastfed children”. It further states that “Breastfeeding is the single most effective nutrition intervention for saving lives”.

In Pakistan, we need to work hard both at the grassroots level for behavior change where health workers can play a crucial role. The provincial governments should adopt and take practical steps for the implementation of the Protection of Breastfeeding and Young Child Nutrition Ordinance 2002 and it’s 2010 rules to help prevent illegal promotion of formula milk and promote the importance of exclusive breastfeeding for the first six months of a child.

Keeping in view, Pakistan’s nutrition situation, it is time for Pakistan to join the Scaling up Nutrition (SUN) Movement like other regional countries such as Bangladesh and Nepal. This will help bring in technical and financial assistance for improving the nutrition situation in the country on a sustainable basis.

One does not need to be an expert to understand how important political commitment is to improve the nutrition situation in the country. With political commitment we can ensure not only strong leadership and the much desired coordination at the high level but also sustainable funding. High level coordination, strong leadership and funding can then result in comprehensive programs and cost effective interventions.

(The writer is a development practitioner and tweets @amahmood72)