Aziz Ayesha, Khan Fazal Ali, Wood Geof
Research and Knowledge Management Section, Rural Support Programmes Network, Islamabad, 44,000, Pakistan.
International Development, University of Bath, Bath, UK.
Health Res Policy Syst. 2015 Nov 25;13 Suppl 1(Suppl 1):56. doi: 10.1186/s12961-015-0043-6.
The maternal, newborn, and child health (MNCH) indicators of Pakistan depict the deplorable state of the poor and rural women and children. Many MNCH programmes stress the need to engage the poor in community spaces. However, caste and class based hierarchies and gendered social norms exclude the lower caste poor women from accessing healthcare. To find pathways for improving the lives of the excluded, this study considers the social system as a whole and describes the mechanisms of exclusion in the externally created formal community spaces and their interaction with the indigenous informal spaces.
The study used a qualitative case study design to identify the formal and informal community spaces in three purposively selected villages of Thatta, Rajanpur, and Ghizer districts. Community perspectives were gathered by conducting 37 focus group discussions, based on participatory rural appraisal tools, with separate groups of women and men. Relevant documents of six MNCH programmes were reviewed and 25 key informant interviews were conducted with programme staff.
We found that lower caste poor tenants and nomadic peasants were excluded from formal and informal spaces. The formal community spaces formed by MNCH programmes across Pakistan included fixed, small transitory, large transitory, and emerging institutional spaces. Programme guidelines mandated selection of community notables in groups/committees and used criteria that prevented registration of nomadic groups as eligible clients. The selection criteria and adverse attitude of healthcare workers, along with inadequacy of programmatic resources to sustain outreach activities also contributed to exclusion of the lower caste poor women from formal spaces. The informal community spaces were mostly gender segregated. Infrequently, MNCH information trickled down from the better-off to the lower caste poor women through transitory interactions in the informal domestic sphere.
A revision of the purpose and implementation mechanisms for MNCH programmes is mandated to transform formal health spaces into sites of equitable healthcare.
巴基斯坦的孕产妇、新生儿和儿童健康（MNCH）指标显示，贫困和农村妇女及儿童的状况令人堪忧。许多MNCH项目强调让贫困人口参与社区活动的必要性。然而，基于种姓和阶层的等级制度以及性别化的社会规范，使得低种姓贫困妇女无法获得医疗保健服务。为了找到改善被排斥群体生活的途径，本研究将社会系统视为一个整体，描述了外部创建的正式社区空间中的排斥机制及其与本土非正式空间的相互作用。
本研究采用定性案例研究设计，在塔塔、拉詹布尔和吉泽尔地区有目的地选取了三个村庄，以确定正式和非正式的社区空间。基于参与式农村评估工具，通过与不同的男女群体进行37次焦点小组讨论，收集社区观点。审查了六个MNCH项目的相关文件，并与项目工作人员进行了25次关键信息访谈。
我们发现，低种姓贫困佃农和游牧农民被排除在正式和非正式空间之外。巴基斯坦各地MNCH项目形成的正式社区空间包括固定的、小型临时的、大型临时的和新兴的机构空间。项目指南规定在团体/委员会中选择社区知名人士，并使用了一些标准，阻止游牧群体登记为合格客户。医护人员的选择标准和负面态度，以及维持外展活动的项目资源不足，也导致低种姓贫困妇女被排除在正式空间之外。非正式社区空间大多按性别分隔。MNCH信息很少通过非正式家庭领域的临时互动，从富裕阶层向下传递给低种姓贫困妇女。
必须修订MNCH项目的目的和实施机制，将正式的健康空间转变为公平医疗保健的场所。
