Is Pakistan's Social Sector Making Progress?

[Riaz Haq]

If you read Pakistan media headlines and donation-seeking NGOs and activists' reports these days, you'd conclude that the social sector situation is entirely hopeless. However, if you look at children's education and health trend lines based on data from credible international sources, you would feel a sense of optimism. This exercise gives new meaning to what former US President Bill Clinton has said: Follow the trend lines, not the headlines. Unlike the alarming headlines, the trend lines in Pakistan show rising school enrollment rates and declining infant mortality rates.

Key Social Indicators:

The quickest way to assess Pakistan's social sector progress is to look at two key indicators:  School enrollment rates and infant mortality. These basic social indicators capture the state of schooling, nutrition and health care. Pakistan is continuing to make slow but steady progress on both of these indicators. Anything that can be done to accelerate the pace will help Pakistan move up to higher levels as proposed by Dr. Hans Rosling and adopted by the United Nations.

Pakistan Children 5-16 In-Out of School. Source: Pak Alliance For M...

Rising Primary Enrollment:

Gross enrollment in Pakistani primary schools exceeded 97% in 2016, up from 92% ten years ago. Gross enrollment rate (GER) is different from net enrollment rate (NER). The former refers to primary enrollment of all students of all ages while the latter counts enrolled students as percentage of students in the official primary age bracket. The primary NER in Pakistan is significantly lower but the higher GER indicates many of these kids eventually enroll in primary schools albeit at older ages. 

Source: World Bank Education Statistics

Declining Infant Mortality Rate: 

The infant mortality rate (IMR), defined as the number of deaths in children under 1 year of age per 1000 live births in the same year, is universally regarded as a highly sensitive (proxy) measure of population health.  A declining rate is an indication of improving health. IMR in Pakistan has declined from 86 in 1990-91 to 74 in 2012-13 and 62 in the latest survey in 2017-18.

Pakistan Child Mortality Rates. Source: PDHS 2017-18

During the 5 years immediately preceding the survey, the infant mortality rate (IMR) was 62 deaths per 1,000 live births. The child mortality rate was 13 deaths per 1,000 children surviving to age 12 months, while the overall under-5 mortality rate was 74 deaths per 1,000 live births. Eighty-four percent of all deaths among children under age 5 in Pakistan take place before a child’s first birthday, with 57% occurring during the first month of life (42 deaths per 1,000 live births).

Pakistan Human Development Trajectory 1990-2018.Source: Pakistan HD...

Human Development Ranking:

It appears that improvements in education and health care indicators in Pakistan are slower than other countries in South Asia region. Pakistan's human development ranking plunged to 150 in 2018, down from 149 in 2017.

Expected Years of Schooling in Pakistan by Province

There was a noticeable acceleration of human development in #Pakistan during Musharraf years. Pakistan HDI rose faster in 2000-2008 than in periods before and after. Pakistanis' income, education and life expectancy also rose faster than Bangladeshis' and Indians' in 2000-2008.

Now Pakistan is worse than Bangladesh at 136, India at 130 and Nepal at 149. The decade of democracy under Pakistan People's Party and Pakistan Muslim League (Nawaz) has produced the slowest annual human development growth rate in the last 30 years. The fastest growth in Pakistan human development was seen in 2000-2010, a decade dominated by President Musharraf's rule, according to the latest Human Development Report 2018.

UNDP’s Human Development Index (HDI) represents human progress in one indicator that combines information on people’s health, education and income.

Pakistan's Human Development Growth Rate By Decades. Source: HDR 2018

Pakistan saw average annual HDI (Human Development Index) growth rate of 1.08% in 1990-2000, 1.57% in 2000-2010 and 0.95% in 2010-2017, according to Human Development Indices and Indicators 2018 Statistical Update.  The fastest growth in Pakistan human development was seen in 2000-2010, a decade dominated by President Musharraf's rule, according to the latest Human Development Report 2018.

Pakistan Human Development Growth 1990-2018. Source: Pakistan HDR 2019

Pakistan@100: Shaping the Future:

Pakistani leaders should heed the recommendations of a recent report by the World Bank titled "Pakistan@100: Shaping the Future" regarding investments in the people. Here's a key excerpt of the World Bank report:

"Pakistan’s greatest asset is its people – a young population of 208 million. This large population can transform into a demographic dividend that drives economic growth. To achieve that, Pakistan must act fast and strategically to: i) manage population growth and improve maternal health, ii) improve early childhood development, focusing on nutrition and health, and iii) boost spending on education and skills for all, according to the report".

Pakistani Children 5-16 Currently Enrolled. Source: Pak Alliance Fo...

Summary: 

The state of Pakistan's social sector is not as dire as the headlines suggest. There's reason for optimism. Key indicators show that education and health care in Pakistan are improving but such improvements are slower than in other countries in South Asia region. Pakistan's human development ranking plunged to 150 in 2018, down from 149 in 2017. It is worse than Bangladesh at 136, India at 130 and Nepal at 149. The decade of democracy under Pakistan People's Party and Pakistan Muslim League (Nawaz) has produced the slowest annual human development growth rate in the last 30 years. The fastest growth in Pakistan human development was seen in 2000-2010, a decade dominated by President Musharraf's rule, according to the latest Human Development Report 2018. One of the biggest challenges facing the PTI government led by Prime Minister Imran Khan is to significantly accelerate human development rates in Pakistan.

Related Links:

Haq's Musings

South Asia Investor Review

Pakistan's Expected Demographic Dividend

Can Imran Khan Lead Pakistan to the Next Level?

Democracy vs Dictatorship in Pakistan

Pakistan Child Health Indicators

Pakistan's Balance of Payments Crisis

Panama Leaks in Pakistan

Conspiracy Theories About Pakistan Elections"

PTI Triumphs Over Corrupt Dynastic Political Parties

Strikingly Similar Narratives of Donald Trump and Nawaz Sharif

Nawaz Sharif's Report Card

Riaz Haq's Youtube Channel

PakAlumni Social Network

[Riaz Haq]

India falls behind Pakistan, Bangladesh, Nepal in global hunger index; ranks 102nd among 107 countries

https://www.businesstoday.in/current/economy-politics/102-india-fal...

India has ranked 102nd among 107 countries in the Global Hunger Index (GHI). In 2018, India had ranked 55 among 77 nations listed in the GHI. South Asian countries like Pakistan (94), Bangladesh (88) and Sri Lanka (66) have fared better than India, says a report prepared by Welthungerhilfe and Concern Worldwide.

India is among 45 countries that have serious levels of hunger. The report says several countries have higher hunger levels now than in 2010, and around 45 countries are set to fail to achieve low levels of hunger by 2030. The GHI report says hunger is the highest in South Asia and Africa South of the Sahara region. "South Asia and Africa South of the Sahara are the regions with the highest 2019 GHI scores, at 29.3 and 28.4 respectively, indicating serious levels of hunger," says the report.

India's 'child wasting rate' (low weight for height) is extremely high at 20.8 per cent -- the highest wasting rate of any country, says the report. Child stunting rate in India, 37.9 per cent, is also categorised as "very high" in terms of its public health significance. In India, just 9.6 per cent of all children between 6 and 23 months of age are fed a minimum acceptable diet, it says.

The report says as of 2015-2016, around 90 per cent of Indian households used an improved drinking water source while 39 per cent of households had no sanitation facilities. Contradicting the government's claim of making India open defecation free, the report says "open defecation is still practised" in the country. "In 2014, the prime minister instituted the "Clean India" campaign to end open defecation and ensure that all households had latrines. Even with new latrine construction, however, open defecation is still practised," it adds.

[Riaz Haq]

#Food data raises alert: #Indians are consuming less pulses (daal) and #milk . This is especially for the poorer sections, whose spending on #protein -rich “superior” foods tends to increase even more with higher incomes. | India News,The Indian Express


https://indianexpress.com/article/india/food-data-raises-alert-indi...


Is there stagnation in demand for pulses, milk and other protein-rich foods in India? The National Statistical Office (NSO) withheld its household consumption expenditure survey report for 2017-18 but alternative data sources do suggest a slowdown — at least in respect of the ubiquitous dal and doodh.

At a global Pulses Conclave held earlier this month in Pune, the overwhelming concern expressed by participants was: Why are we not eating enough pulses?

One of the presentations at the event was a detailed analysis of the estimated consumption of individual pulses — chana (chickpea), yellow peas, masur (red lentil), arhar (pigeon-pea), moong (green gram) and urad (black gram) — based on year-wise opening stocks plus domestic production and imports, and deducting exports, diversion towards seed and feed, and closing stocks.

The aggregate picture that emerged was simple: Pulses consumption in India is showing signs of flattening.

Between 2013-14 and 2017-18, it rose from 18.6 million tonnes (mt) to 22.5 mt, but fell to 22.1 mt in 2018-19 and is projected to further decline to 20.7 mt this year. Some of that may be attributable to prices. Thus, 2015-16 and 2016-17 recorded a consumption drop alongside double-digit dal inflation. The peak consumption in 2017-18 was when prices actually dipped 20.8 per cent year-on-year. The link between consumption and inflation, however, breaks down from 2018-19 (see table).

Saurabh Bhartia of the Indian Pulses and Grains Association (IPGA) — the apex organisation of dal millers, traders, exporters and importers that drew up the estimates — is convinced that the apparent demand slowdown is real.

“We need a National Egg Coordination Committee-like body for pulses to push consumption. The campaign they launched in the 1980s helped in positioning egg as a wholesome nutrition food. The time has come for a similar sustained drive promoting pulses as an excellent source of protein, micronutrients and fibre that is also low-fat and cholesterol-free,” he says.

Nitin Kalantri, a leading dal trader and processor from Latur in Maharashtra, traces the low growth in pulses consumption to 2015-16, when retail prices of arhar dal breached the Rs 200/kg level.

[Riaz Haq]

Half of the world's poor people live in these 5 countries

https://www.businessinsider.co.za/half-of-the-worlds-poor-people-li...

India, Nigeria, Democratic Republic of Congo, Ethiopia, and Bangladesh housed half of the world's extremely poor people, according to a World Bank report. In a recently released Poverty and Shared Prosperity report 2018, titled “Piecing Together the Poverty Puzzle,” by World Bank, 368 million, out of world’s 736 million extreme poor live in the five countries (in descending order) as at 2015.

These countries are also the most populous countries of South Asia and Sub-Saharan Africa, the two regions that together account for 85% (629 million) of the world’s poor.

The report states that “to make significant continued progress towards the global target of reducing extreme poverty (those living on less than R26.03 a day) to less than 3% by 2030, large reductions in poverty in these five countries will be crucial. The report using consumption in 2015 for both India and Nigeria based on projections, not direct enumerations of consumption from recent household surveys, suggests that Nigeria is now the country with the poorest people in the world.

https://blogs.worldbank.org/opendata/half-world-s-poor-live-just-5-...

[Riaz Haq]

The literacy rate increased by 1.6pc to 62.3pc in 2017-18, from 60.7pc in 2014-15, according to the Economic Survey of Pakistan launched on Monday.

The survey stated: “Pakistan social and living standards measurement (PSLM) survey could not be conducted in 2016-17 and 2017-18 on account of ‘Population & Housing Census in 2017’. However, according to Labour Force Survey 2017-18, literacy rate trends shows 62.3pc in 2017-18 (as compared to 60.7pc in 2014-15), males (from 71.6pc to 72.5pc) and females (from 49.6pc to 51.8pc).”

An area-wise analysis suggests that the literacy rate increased in both rural (51.9pc to 53.3pc) and urban (76pc to 76.6pc) areas

“It is also observed male-female disparity narrowing down with time span. Literacy rate increases in all provinces, Khyber Pakhtunkhwa (54.1pc to 55.3pc), Punjab (61.9pc to 64.7pc) and Balochistan (54.3pc to 55.5pc) except in Sindh (63.0pc to 62.2pc) where marginal decrease has been observed.”

Education expenditure

The survey said that expenditure on education was estimated at 2.4pc of GDP in 2017-18, compared to 2.2pc in 2016-17.

Education experts have called for at least 4pc of the GDP to go towards education.

The survey said the government is “committed” to increasing financial resources for education. It said education expenditure has risen gradually since 2013-14.

Enrolment

While discussing enrolment at the school and college level, the survey said that an increase of 7.3pc was observed in pre-primary enrolment at the national level, which increased 12.27 million in 2017-18 compared to 11.4m in 2016-17.

It said there were a total of 172,200 functioning primary schools – grades one to five – in 2017-18, with 519,000 teachers across the country. These schools had an overall enrolment of 22.9m students, an increase of 5.5pc from the previous year.

There were 46,800 middle schools in 2017-18, with 438,600 teachers and enrolment of 7.3m, an increase of 4.3pc from the enrolment level in 2016-17. Enrolment is estimated to increase by another 3.7pc to 7.6m in 2018-19.

There were a total of 30,900 high schools with 556,600 teachers functioning in the country in 2017-18. High school enrolment, at 3.9m, represents an increase of 7.4pc from the enrolment level of 3.6m in 2016-17.

High school enrolment is estimated to increase by another 6.6pc to 4.1m in 2018-19.

They survey said there were a total of 5,200 higher secondary schools and intermediate colleges with a teacher population of 121,900 in 2017-18.

It said the overall enrolment of 1.75m in these schools was a healthy increase of 9.8pc from the enrolment level in 2016-17. Enrolment is expected to rise to 1.84m, by another 5pc, in 2018-19.

A total of 3,700 technical and vocational institutes with 18,200 teachers were functional in 2017-18. The enrolment of 433,200 represents an increase of 25.6pc from the previous year. Enrolment is projected to increase by 8.7pc during 2018-19.

There were 1,657 degree colleges in the country with 42,000 teachers in 2017-18. That year, a significant decline of 47.3pc in enrolment to 503,800 was observed at the enrolment level, which is projected to decrease further by 4.3pc in 2018-19.

There were 186 universities in 2017-18, the survey said, with 56,900 teachers and a total enrolment of 1.6 million. Enrolment was 7.7pc higher than in previous years, but the survey said: “The growth in enrolment however is projected to decline by 0.2pc in 2018-19.”

https://www.dawn.com/news/1487420

[Riaz Haq]

Ticking Bomb of #Coronavirus? "..India will have a national disaster in a few weeks to months. SouthAsian nations have fragile & skimpy health management capacity in the best of times" #India has reported 102 cases, 2 deaths so far. #SouthAsia https://www.ozy.com/around-the-world/is-south-asia-a-ticking-time-b... via @ozy

The world’s most densely populated region, South Asia is home to a quarter of the planet’s people, yet has so far reported just 169 cases, or a little more than one in every thousand of the total 156,000 patients globally. India has reported 102 cases, Pakistan 31, Afghanistan 11, Maldives 10, Sri Lanka 10, Bangladesh 3 and one each in Bhutan and Nepal. Two people — both in India — have died.

But growing evidence suggests that the virus is far more widespread in the region, sparking concerns among leading public health experts and virologists that South Asia might be a time bomb waiting to explode. The region’s countries have focused their prevention strategy on scrutiny of incoming travelers at their international airports. India, for instance, said in early March it had screened 650,000 arriving passengers over the previous five weeks. But it was watching the vast majority for visible symptoms, and fewer than 1 percent actually underwent tests. And several cases appear to have slipped past, coming to notice only later, after they had been in contact with dozens of people.

On March 8, the Kerala government declared three confirmed cases of the virus — people who had returned from Italy more than a week earlier. A 76-year-old American tourist was diagnosed with COVID-19 in Bhutan, after he had spent several days previously in India, traveling up the Brahmaputra river on a houseboat. Bangladesh’s first three cases of the coronavirus were all people who had recently returned from Italy but weren’t identified as positive at the airport. The cases in Pakistan too — all involving recent travel to Iran or Italy — weren’t detected at airports.

Last week, the Indian government suspended most visas for foreigners until April 15, a drastic step that appeared to acknowledge its failure in screening visitors at airports. It has also banned passengers and crew from all foreign cruise ships until March 31. And on Friday, Indian Prime Minister Narendra Modi called on his other South Asian counterparts to prepare a joint regional strategy to combat the virus.

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What makes the challenge even more acute in the region is the lack of adequate basic facilities such as personal protective equipment, ventilators or intensive care units, says John. That makes any move to random testing among communities, as a strategy, difficult for countries like those in South Asia. It also means that death rates among vulnerable populations — such as patients who also have pneumonia or acute respiratory distress syndrome — could eventually prove higher in India than in the West, he adds.

A flood of misinformation over claimed cures that has swept the region is also worrying doctors and scientists. In India, some legislators have claimed cow urine and cow dung could heal you from the coronavirus — assertions with no scientific basis. India’s government has suggested that a cocktail of six herbs could help treat the virus. Meanwhile, in Sri Lanka, a misleading Facebook post suggested an incorrect way of wearing face masks.

The spread of misinformation, on top of the coronavirus, is a scenario South Asia — and the world — can ill afford.

[Riaz Haq]

#Pakistan is leading the way with its #welfare state – the world can learn from its innovation. PM #ImranKhan's #Ehsaas initiative is one of the most comprehensive welfare programs ever by a national government. #EhsaasEmergencyCash
https://www.telegraph.co.uk/global-health/climate-and-people/pakist... via @Telegraph

This is why we should all be looking with particular interest at the work underway in Pakistan to build a sustainable welfare state. Called Ehsaas, which in Urdu literally means ‘empathy’, the new initiative is one of the most comprehensive welfare programmes ever undertaken by a national government, with an underlying ambition to create a social safety net for Pakistan that could transform the lives of millions. It is enormously wide-ranging and ambitious.

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Despite some progress since the turn of the millennium, a quarter of people in Pakistan still live in poverty, with rates of rural poverty more than double those in urban areas. With one of the fastest growing populations in the world, Pakistan will have to create a million new jobs each year just to keep up with the number of young people entering the job market. Educational attainment is some of the worst in the region and health indicators are not promising, demonstrated by the fact that Pakistan is one of only two countries where the wild poliovirus remains endemic.

This is the context in which Ehsaas is seeking to end the cycle of poverty faced by many Pakistanis. Acknowledging that no single area will unlock this ambition alone, Ehsaas encompasses 134 policies that range from tackling corruption to creating educational opportunities to providing the elderly with decent homes.

The programme is led by Dr Sania Nishtar, Special Assistant to the Prime Minister of Pakistan on Poverty Alleviation and Social Protection, who has been mandated by Prime Minister Imran Khan to work in partnership across multiple federal ministries that these policies will be driven by, as well with provincial governments who have devolved powers including on education and health. Without a multisectoral approach, it would not be possible to create the welfare state envisioned by Ehsaas.

The launch of a countrywide public consultation was particularly important as it was the first time a public policy in Pakistan had been developed in this way and demonstrates a new level of openness and transparency. Ehsaas’s impact will hopefully go much further than the borders of Pakistan. It will provide many lessons for low-, middle- and high-income countries.

[Riaz Haq]

Pakistan's average daily per capita calorific intake was estimated by ADB at 2,440 kcal in 2013. Cereals accounted for 48% of daily calorific intake in 2013. Calorific intake from animal sources comprised 22%, while fruit and vegetables accounted for 2%. The average daily per capita protein consumption was estimated at 65.5 grams, while the average dietary energy supply adequacy was estimated to be 108% in 2015-2017.

https://www.brecorder.com/2020/01/08/559976/political-instability-d...

Approximately 46% of agricultural production comes from the cropping sector, compared with 54% from livestock. Buffalo meat was the single most valuable commodity produced in Pakistan in 2016 at around $9.8 billion. Other important commodities produced included buffalo's milk ($9.4 billion), wheat ($7.4 billion), beef ($5.5 billion), cotton ($3.3 billion), and chicken meat ($3.2 billion).

Sugarcane was the largest crop produced with 65 million tons in 2016. Other important products included wheat (26 million tons), rice (10.2 million tons), maize (6.1 million tons), and cotton (5.3 million tons). Around 4.5 million tons of fertilizers were used in Pakistan in 2016, and a further 913,000 tons were imported into the country that year.

Pakistan's livestock sub-sector, on the other hand, has demonstrated steady growth, especially in the face of increasing demand for livestock products due to a growing and rapidly urbanized population.

The country's livestock sub-sector represents approximately 56% of value addition in agriculture and employs roughly 30 million people. Despite the increased production of poultry products, its external trade is low and has not realized the potential experienced in other livestock sub-sectors. In 2016, total poultry exports were valued at $2.7 million.

Pakistan imported $7.1 billion worth of agricultural goods in 2016, compared with $3.7 billion in agricultural exports. Pakistan's main agricultural export commodities were rice ($1.7 billion), wheat flour ($173 million), tangerines and mandarins ($158 million), beef ($155 million), sugar ($123 million), and dates ($103 million). Palm oil was Pakistan's main food import at $1.7 billion, followed by cotton lint ($581 million), tea ($490 million), rapeseed ($464 million), soybeans ($383 million), and coffee ($329 million).

[Riaz Haq]

Estimation of Per Capita Food Consumption Patterns and Related Poverty
in Swat villege of Kabal in Pakistan

To analyze the per capita food consumption and related poverty, village Kabal a rural area of district Swat, Pakistan was selected. The average household size, based on 100 households was estimated as 6.5. It appears that on average an adult equivalent takes 372.51 g of flour, 74.68 g of meat, 70.29 g of rice, 177.12 g of vegetables, 28.31 g of pulses, 66.39 g of fruits, 166.34 g of milk, 53.60 g of fats, 6.76 g of black tea, and 73.21 g of sugar daily. Moreover, an average household spends Rs.16714.45 of their monthly income on food consumption. An individual member (adult-equivalent) of the surveyed household takes food, yielding 2857.27 calories per day. Since an adult person needs 2350 calories daily to live a normal life, this level is thus considered as the base to determine whether a person is on, above or below the poverty line. Based on average calorie intake, the surveyed households are found, on average, above poverty line (PL=1.2). The poverty status of the households surveyed shows that out of 100 households studied, 68.3% are above, 23.31% below, and 8.39% on the poverty line.

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Pakistan has made significant progress in increasing the per capita
availability of all major food items like cereals, meat, milk, sugar, and
eggs over time. Seasonal vegetables like cabbage, brinjal, ladyfinger,
onion, cucumber, better guard, tomato etc. [2]. Population with high
income consume more beef, mutton, poultry, and fruits. In pulses
mung, masoor, beans, and g while in tea black tea and green tea and
milk are the pillar of food consumption in rural and urban population
of Pakistan as a result, the average per capita calorie intake increased
from 2078 in 1949-50 to 2450 in 2012-13. Similar trends have been
reported for protein and fats


https://www.hilarispublisher.com/open-access/estimation-of-per-capi...

[Riaz Haq]

Per capita nutrition supply in India among the lowest in the world

https://www.livemint.com/Opinion/GzUIDPQXzktVDBEiE2ZPfI/Per-capita-...

When demand is low, an increase in local production need not translate into increased availability as a larger portion of the produce may be exported. In India’s case, it also depends on changes in government stocks. The Economic Survey show that net cereal production has hardly changed at 465gm per person per day from 2000 to 2013. However, per capita availability of cereals has increased from 422gm in 2000 to 468gm in 2013. However, it was largely a function of changes in government stocks. In the previous two years, availability of cereals was lower at about 410gm per person per day.

The average Indian had access to 2,455 kcal per day with protein and fat availability at 60gm and 52.1gm, respectively, according to OECD. This is far lower than the at least 3,000 kcal per day availability for OECD nations. Things have also not improved since the beginning of this century (see chart 3). Factors such as wastage of stocks are also to blame for poor availability. For instance, Food Corporation of India data show 3,000 tonnes of foodgrains were damaged in 2015-16. In 2014-15, quantity of damaged grains stood at 19,000 tonnes .

[Riaz Haq]

March 16, 2020—Aisha Yousafzai, associate professor of global health (at Harvard University), is the principal investigator of two large randomized controlled trials focused on early childhood development in Pakistan—Pakistan Early Child Development Scale-Up (PEDS) and Youth Leaders for Early Childhood Assuring Children are Prepared for School (LEAPS).

https://www.hsph.harvard.edu/news/features/helping-vulnerable-child...

What do you see as policy and research priorities in early childhood development?

We know that young children need good health, proper nutrition, and early learning opportunities. But they also need security and stability. It’s important that they have consistent caregivers in early life who they can trust and rely on. When children don’t have these things, it can be harmful to their development and impact their health and future prospects.

Policies that support families and help children thrive include investing in parenting programs and ensuring access to good quality, affordable child care and parental leave. And we should not be separating children from their caregivers who provide safe stable nurturing care.

We still need to better understand what works for the most vulnerable and disadvantaged children, such as those living through a humanitarian crisis. It’s not enough to focus just on the immediate emergency phase. We need to address the long-term needs of these children and their families. Another understudied population is children with developmental delays and disabilities. We need to look at how to strengthen health care systems to address their needs.

What results have you found from PEDS and LEAPS?

In the PEDS trial, we wanted to see if Pakistan’s Lady Health Workers (LHW) program—which provides home visits to promote health and nutrition in mothers and young children—could also effectively promote children’s development. Community health worker interventions like the LHW program were set up in recent decades in low- and middle-income countries to promote child survival. Now that we are seeing improvements in child survival in many countries, we need to think about how these programs can deliver interventions beyond survival that help children thrive.

For this study, we adapted a curriculum developed by the World Health Organization and UNICEF, and evaluated it in a randomized controlled trial. Results were favorable up to age two, and some of the benefits to children’s cognitive-language and motor development were sustained at age four.

But alarm bells were raised when we saw that only about a quarter of children in rural communities had access to preschool—and even those who did weren’t necessarily getting quality education.

That challenged us to think about the continuity of services for children, from the first 1,000 days of life to the early years of education and beyond. We developed a way to address the need for better preschool in Pakistan that also helped fill a gap in training and employment for young women. Working with Pakistan’s National Commission on Human Development, we established a training program for women ages 18–24 to become preschool teachers (LEAPS) and placed trainees in villages with no established preschool services.

Our pilot found that this program provided a good school readiness benefit for children as well as a boost to youth employment. Now, we’re scaling up across four districts, and also looking at how well the country’s education system is able to absorb this intervention.