title: Who is excluded and how? An analysis of community spaces for maternal and child health in Pakistan.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  A revision of the purpose and implementation mechanisms for MNCH programmes is mandated to transform formal health spaces into sites of equitable healthcare.
authors.affiliation: Research and Knowledge Management Section, Rural Support Programmes Network, Islamabad, 44,000, Pakistan. ayesha.azi@gmail.com.
authors.forename: Ayesha
authors.initials: A
authors.lastname: Aziz
authors.affiliation: Research and Knowledge Management Section, Rural Support Programmes Network, Islamabad, 44,000, Pakistan. fazal@rspn.org.pk.
authors.forename: Fazal Ali
authors.initials: FA
authors.lastname: Khan
authors.affiliation: International Development, University of Bath, Bath, UK.
authors.forename: Geof
authors.initials: G
authors.lastname: Wood
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D000067576:Child Health; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D000068097:Maternal Health; D000068101:Maternal-Child Health Services; D008875:Middle Aged; D010154:Pakistan; D011203:Poverty; D036301:Qualitative Research; D012111:Residence Characteristics; D019035:Rural Health Services; D012424:Rural Population; D063507:Sexism; D012923:Social Class; D063508:Social Discrimination; D012944:Social Support; D055815:Young Adult