Women's Health Project, 1999 Investing in Women's Health: Delivering Better Health Care to All/Pakistan

The aim of this ADB-funded project is to improve the health of women, girls and infants in 20 predominantly rural districts in four provinces - Punjab, Sindh, North-West Frontier Province and Balochistan. The project comprises three main components. The first is to work with the Ministry of Health to expand basic women's health interventions to under served populations. This will include the expansion of community-based health care and family planning services through the recruitment and training of an additional 8,000 village women as Lady Health Workers; a 'safe delivery' campaign; and the promotion of women's health and nutritional needs, family planning, and women's rights through the mass media.

The second component is the development of 20 woman-friendly district health systems to provide quality women's health care at community, primary and first-referral levels. This component will focus on women's reproductive and other health needs, including pre- and postnatal care, control of sexually transmitted diseases, family planning, and control of urinary and reproductive tract infections, as well as female nutrition, and the prevention and treatment of women's abuse, tuberculosis, pneumonia and diarrhoeal diseases.

The third component of the project will support institutional and human resources development within the Ministry of Health and provincial health departments in order to sustain improvements in women's health. This includes project coordination, capacity building, advocacy, monitoring, evaluation, research and policy development. In terms of human resource development the project supports four new public health schools for lady health workers; hostels for female midwifery students, 44 international scholarships in women's health management, and 276 domestic fellowships in mother and child health and family planning, community nursing, theatre nursing, lady health worker training, and diploma-level obstetric surgery.

Background
The health status of women in Pakistan is directly linked to women's low social status. Pakistan's poor position internationally is seen in UNDP's Gender related Development Index (GDI) 2000, where Pakistan currently ranks 135 out of 174 countries. On the Gender Empowerment Measurement (GEM) 1999, Pakistan ranked 100 out of the 102 countries measured. In terms of health status, the figures are galling. Some 30,000 women die each year due to complications of pregnancy, and 10 times more women develop life-long, pregnancy-related disability. Rural women's health is generally poorest due to the lack of health facilities and skilled health providers. For example, the maternal mortality ratio in predominantly rural Balochistan is 800 maternal deaths to 100,000 live births, compared to the national average of 340 per 100,000.

The untimely death or disability of a woman, a tragedy in itself, adversely affects the health of her children, household productivity and the national economy. About 25 percent of children are born with low birth weight due to maternal problems. Ten percent of children do not reach their first birthday. High fertility, with an average of six children per woman, has resulted in high population growth of three percent per annum. Consequently, improving women's reproductive health through the use of contraceptives and spacing of children will not only improve women's health but also reduce population growth and allow women more time to pursue economic activities.

There are also marked differences between the health status of women and men in Pakistan. For example, malnutrition is a major public health problem in Pakistan that disproportionately affects women and girls. More girls than boys die between the ages of 1 and 4; in fact the female mortality rate here is 12 percent higher than for boys. This is a direct consequence of the lower social status accorded to women and girls, who as a result tend to eat less and face additional barriers when accessing health care. Women, girls and infants most often die of common communicable diseases such as tuberculosis, diarrhea, pneumonia and tetanus, which could have been easily prevented and treated. The high prevalence of communicable diseases and malnutrition is not only related to poor living conditions, but also to the lower social status of women and girls. In addition, because of social stigma and gender norms, as many as fifty percent of women suffer from recurrent reproductive tract infections.

Consequently, poor women's health in Pakistan is as much a social as medical problem. Underlying factors here are the lack of awareness of, and attention to, women's health needs; women's lower education and social status; and social constraints on women and girls, including the practice of seclusion.

Gender Inclusive Design
The Women's Health Project contains elements specifically designed to raise the level of awareness and commitment to women's health in Pakistan. In doing so the project will also contribute to the general improvement of women's social status. The project design addresses issues of access and affordability, including the provision of socially acceptable services; societal attitudes towards women and women's health; and the attitudes of health care providers towards women.

Issues of access and affordability include factors such as the cost of transport and city hospitals, and restrictions on women's movement in public. Some of these issues will be resolved by the extension of health care services at community and primary levels. As identified in the PPTA, some villages within the project area lack community-level services. This can mean that poor women have no access to health services, as families are less inclined to allow women to attend more distant and costly hospitals. The project will overcome some of these constraints expanding community and primary level health services to such areas. In addition, NGOs will be contracted to provide services in areas were the provincial government is unable.

The issue of socially acceptable services is also critical here. Even where services are available, existing gender norms make it very difficult for women to attend clinics, which lack trained female staff and cannot guarantee privacy for examinations. The project design therefore covers a number of strategies to assist in the development of appropriate services. For example, there is a large investment in the recruitment and training of lady health workers, female midwives and other female nursing staff. Furthermore, institutional capacity and human resource development within government health services will also cater for women's needs, including changing the attitude of health workers towards poor women and providing woman-friendly services.

This woman-friendly attitude will be extended within the public health system across all decision-making levels, capacity building and human resource initiatives, and systems development. For example, the project design aims to strengthen the role of female managers in the health sector through the training and appointment of female health managers at provincial and district levels. The project also proposes a substantial role for NGOs in implementation, particularly NGOs with past experience in women's health and social mobilization programs directed at women.

Finally the project tackles societal attitudes towards women and women's health. As the PPTA and fact-finding missions found, poor women in urban areas close to specialist obstetric services still have very high maternal mortality ratios. The issue here then is not so much lack of services, but lack of regard for women's health needs. For this reason a number of strategies are included to raise the level of awareness of women and society in general on the issue of women's health. For example, the project has a major social mobilization component designed to advocate the importance of women's health needs and services among community-based organizations and local leaders, including school teachers. Where there is strong female leadership, communities will be helped to develop community-based health organizations to support women's health, nutrition and family planning. Safe houses for victims of violence will also be established in six districts. More generally, the mass media will be used to promote women's health. Campaigns in local languages through the mass media will disseminate information on women's health and nutritional needs, family planning, timely referral of obstetric emergency and public respect for women's rights. Various audiences will be targeted including school children, local leaders and information sheets provided to lady health workers.

While deep-rooted gender relations are difficult to change through health interventions alone, the design of the project recognizes that well-targeted health programs for women can nevertheless assist in reducing discrimination against women and improving women's social status.

source:www.adb.org