BackgroundOut of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting.MethodsWe conducted a systematic search for published literature using the search terms “Community based health insurance AND developing countries”, “Micro health insurance AND developing countries”, “Mutual health insurance AND developing countries”, “mutual OR micro OR community based health insurance” “Health insurance AND impact AND poor” “Health insurance AND financial protection” and “mutual health organizations” on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization.ResultsTwenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns.ConclusionOur review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators.

Peer violence was remarkably high at baseline. Among urban public school students, 94% of 6th-grade boys and 85% of girls reported being victimized by peers in the last 4 weeks. And 85% of boys and 66% of girls reported perpetrating such violence. Boys scored worse on a number of mental health measures. A cluster RCT is underway to evaluate a well-established school-based intervention using sports and games to reduce peer violence.

BackgroundChild peer violence is a global problem and seriously impacts health and education. There are few research studies available in Pakistan, or South Asia. We describe the prevalence of peer violence, associations, and pathways between socio-economic status, school performance, gender attitudes and violence at home.Methods1752 children were recruited into a cluster randomized controlled trial conducted on 40 fairly homogeneous public schools (20 for girls and 20 for boys), in Hyderabad, Pakistan. This was ranging from 20–65 children per school. All children were interviewed with questionnaires at baseline.ResultsFew children had no experience of peer violence in the previous 4 weeks (21.7% of girls vs.7% of boys). Some were victims (28.6%, of girls vs. 17.9% of boys), some only perpetrated (3.3% of girls vs. 2.5%) but mostly they perpetrated and were victims (46.4%.of girls vs 72.6%. of boys). The girls’ multivariable models showed that missing the last school day due to work, witnessing her father fight a man in the last month and having more patriarchal gender attitudes were associated with both experiencing violence and perpetration, while, hunger was associated with perpetration only. For boys, missing two or more days of school in the last month, poorer school performance and more patriarchal attitudes were associated with both victimization and perpetration. Witnessing father fight, was associated with peer violence perpetration for boys. These findings are additionally confirmed with structural models.DiscussionPeer violence in Pakistan is rooted in poverty and socialization of children, especially at home. A critical question is whether a school-based intervention can empower children to reduce their violence engagement in the context of poverty and social norms supportive of violence. In the political context of Pakistan, reducing all violence is essential and understanding the potential of schools as a platform for intervention is key.

Background: Peer violence is common globally, but a little researched topic in low-and middle-income countries. This study presents the evaluation of a two-year randomized controlled trial of a structured play-based life-skills intervention implemented in schools in Hyderabad, Pakistan. Objective: To determine the impact of the intervention on school-based peer violence (victimization and perpetration) and depression among school children. Methods: 40 single-sex public schools were randomized into two study arms (20 per arm 10 of each sex). A total of 1752 grade 6 students (929 from intervention and 823 from control schools) were enrolled in the trial. The two-year intervention was a biweekly structured game led by a coach followed by critical reflection and discussion for 30 minutes. Primary outcomes (exposure to peer violence exhibited through victimization and perpetration and depression) were evaluated using generalized linear-mixed models. Results: Of the enrolled children (N = 1752) 91% provided data for analysis. There were significant decreases in self-reported peer violence victimization, perpetration and depression. For peer violence victimization, the reductions in the intervention and control arms were: 33.3% versus 27.8% for boys and 58.5% versus 21.3% for girls. For peer violence perpetration, the reductions were: 25.3% versus 11.1% for boys and 55.6% versus 27.6% for girls in the intervention and control arms, respectively. There were significant drops in mean depression scores (boys 7.2% versus 4.8% intervention and control and girls 9.5% versus 5.6% intervention and control). Conclusion: A well-designed and implemented play-based life-skills intervention delivered in public schools in Pakistan is able to effect a significant reduction in peer violence.

Background: Violence against women is driven by gender norms that normalize and justify gender inequality and violence. Gender norms are substantially shaped during adolescence. Programs offered through schools offer an opportunity to influence gender attitudes toward gender equity if we understand these to be partly shaped by peers and the school environment. Objective: We present an analysis of the baseline research conducted for a randomized controlled trial with 1752 grade 6 boys and girls and their attitudes toward gender roles, VAWG, and associated factors. Methods: We used baseline data from a  cluster randomised control study. Interviews were conducted in 40 public schools in Hyderabad, with 25–65 children per school. Questions were asked about attitudes toward gender roles, peer-to-peer perpetration, and victimization experiences, and family life, including father- or in-law-to- mother violence and food security. Multiple regression models were built of factors associated with gender attitudes for boys and girls. Results: Our result have shown youth attitudes endorsing patriarchal gender beliefs were higher for boys, compared to girls. The multiple regression model showed that for boys, patriarchal gender attitudes were positively associated with hunger, depression, being promised already in marriage, and being a victim and/or perpetrator of peer violence. For girls gender attitudes were associated with hunger, experiencing corporal punishment at home, and being a perpetrator (for some, and victim) of peer violence. Conclusion: Youth patriarchal attitudes are closely related to their experience of violence at school and for girl’s physical punishment, at home and for boys being promised in early marriage. We suggest that these variables are indicators of gender norms among peers and in the family. The significance of peer norms is that it provides the possibility that school-based interventions which work with school peers have the potential to positively impact youth patriarchal gender attitudes and foster attitudes of gender equality and respect, and potentially to decrease youth victimization and perpetration.

Violence against youth is a global issue; one form of youth victimization is school corporal punishment. We use baseline assessments from a cluster randomized controlled trial to examine the prevalence of school corporal punishment, by gender, and the relationship to levels of peer violence at school, parent corporal punishment, youth food security and youth academic performance and school attendance in Pakistan. Forty homogenous public schools in the urban city of Hyderabad, Pakistan were chosen for randomization into the trial evaluating a youth violence prevention intervention. 1752 6th graders, age 11–14 years, were selected as the target population. Since schools are segregated by gender in Pakistan, data are from interviews in 20 boys’ schools and 20 girls’ schools. Overall, 91.4% of boys and 60.9% of girls reported corporal punishment at school in the previous 4 weeks and 60.3% of boys had been physically punished at home in the past 4 weeks compared to 37.1% of girls. Structural equation modeling revealed one direct pathway for both boys and girls from food insecurity to corporal punishment at school while indirect pathways were mediated by depression, the number of days missed from school and school performance and for boys also by engagement in peer violence. Exposure to corporal punishment in school and from parents differs by gender, but in both boys and girls poverty in the form of food insecurity was an important risk factor, with the result that poorer children are victimized more by adults.

Background Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. Methods and findings We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial’s design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions’ socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants’ health costs. Conclusions We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

Background: Nearly half of the women experience violence across their lifespan in all the provinces of Pakistan at an alarming rate. Despite knowing the prevalence, there has been meager progress in developing strategies to combat violence at individual, family, or community level. Many interventions suggested in other countries have been pilot tested but the effects of those interventions had been limited. Therefore, the aim of this study is to understand the voices of stakeholders to reduce Violence Against Women (VAW) and to explore the possible community-based strategies that could be implemented in Pakistan. Methods: A total of 14 Key Informant Interviews (KIIs) and 18 Focus Group Discussions (FGDs) were held across all four provinces of Pakistan. Participants were purposefully recruited and all the interviews were audio-recorded. Transcriptions were open coded and content analysis was done to emerge codes, categories and themes. Ethical approval was obtained from Aga Khan University Ethics Review Committee. Results: Three major themes emerged on community members and stakeholders' views on VAW: a) community's perception of VAW b) the repercussions of VAW, and c) multiple voices regarding strategies to reduce VAW. Participants voiced the need of standing against the status quo, role of awareness and education: regarding capacity building skills, promotion of women rights and women empowerment through Life Skills Based Education (LSBE) through national health works program, has been proposed as an innovative strategy to reduce VAW. Conclusions: The responsibility to bring about a substantial change in behavior and attitudes must begin with engaging men in all the interventions that aim to reduce violence. Since, VAW is very much linked with the cultural norms, so, without community stakeholder's involvement and participation it could never be reduced. Keeping the existing socio-cultural dynamics in mind, the need of time is to design and implement innovative interventions that are culturally and contextually appropriate and can be expanded across the country.