SPECIAL NOTE | July 2023 Children and Their Families Six Months After Pakistan’s Floods Lauren Dahlin, Juan D. Barón From June to August 2022, heavy monsoon rains KEY TAKEAWAYS caused severe flooding in nearly one-third of By February 2023, six months after the Pakistan. By February 2023, flood waters have floods, economic activity, and health receded in most areas, allowing for rebuilding to and education indicators are improving for most households in flood-affected begin after widespread losses. areas. However, there continue to be substantial challenges for households in Based on satellite imagery, the United Nations Office for the areas that were completely flooded. Coordination of Humanitarian Affairs reports that 1.8 million → In completely-flooded areas, a quarter people lived near stagnant flood waters in February 2023, of households have returned home after down from 4.5 million in January (OCHA 2023C). At the onset living in temporary shelters. However, of the floods, an estimated 33 million people lived close to one-third of households in these flooded areas (UNOSAT 2022). The Pakistan Post Disaster Needs areas continue to reside in temporary Assessment estimates that economic losses from floods exceed shelters. 15 billion USD (Government of Pakistan et al. 2022). → Continued areas of concern for families Using a new round of household phone survey data, this in flooded areas include child mental note documents the progress and pain points in rebuilding health, food insecurity, and travel human capital in Pakistan after the floods, building upon the disruptions. For example, families in findings from the first-round survey. Results from the first- flooded areas were 50 percent more round survey show the floods’ widespread direct and indirect likely to be worried they would run out impacts (Barón et al., 2022). Direct impacts included the losses of food than those in un-flooded areas. of homes, incomes, crops, and livestock. Indirect impacts → In flood-affected areas, most schools included losing access to transportation, health, and education are reopening. Six months after the services. Children and families were particularly impacted, with floods, the share of households in an estimated one million out of school due to flooding and at flooded areas reporting their children’s risk of not returning. schools were not operating fell from 18 percent to 9 percent. However, only Both rounds of the survey focus on the impacts of the floods about 40 percent of children have on children and families. Each survey round sampled two returned to school in these areas. cohorts of 4,000 families with children ages 3 to 17. The first survey was administered in late September 2022, and the → Yet, the children still out of school second began roughly six months later, in February 2023. The are less likely to return. Parents who surveys were designed to be nationally representative. (See said their children were unlikely to the final section of this note for more on the methodology and return to school said the travel time caveats about the interpretation of results.) increase due to flooding was their top concern. ACKNOWLEDGMENTS | For this note, the team benefitted from comments by Freya Perry, May Bend, Toby Linden, Keiko Inoue, and other colleagues from the Education Global Practice at the World Bank. This note was made possible by generous funding from the United Kingdom’s Foreign, Commonwealth & Development Office (FCDO), through the Data and Research in Education (DARE) project. Juan D. Barón (jbaron@worldbank.org) and Lauren Dahlin are, respectively, Senior Economist and Consultant at the Education Global Pratice of the World Bank. Specifically, this note focuses on groups who may be left behind as others recover. The second-round phone survey reveals that households in areas most hit by flooding are the least Households in areas recovered. By some indicators of most hit by flooding recovery, such as time spent in are the least recovered. temporary shelters, all households appeared to recover at similar rates, regardless of their wealth or education levels. However, by other indicators, such as child work due to The note also examines indicators flooding, less-educated households of recovery of particular relevance need to catch up to their more- to children. For example, prior educated counterparts. These research has shown that even findings suggest that policymakers when adults are given substantial could ensure relief reaches the compensation following natural areas hardest hit by flooding and disasters and fully recover target at-risk groups in specific economically, such as the 2005 intervention areas. earthquake in Pakistan, children may continue to incur physical EQUITABLE IMPACT and educational deficits well beyond the impact of school Findings suggest that closures (Andrabi, Daniels, and Das policymakers could ensure 2021). As such, this note reports relief reaches the areas on both typical indicators of educational recovery, such as time hardest hit by flooding out of school, and more holistic and target at-risk groups indicators of well-being, like child in specific intervention mental health, which will continue areas. to impact the educational and economic outcomes of children in Pakistan for years to come. SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 2 I. Economic impacts on families with children six months after the floods The floods disproportionately impacted some provinces (Figure 1) and poorer households. While households in much of the country are recovering economically, families in severely-impacted areas continue to struggle, with many still residing in temporary shelters. The first-round phone survey showed that certain Figure 1. The provinces of Balochistan and Sindh provinces experienced more flooding than others. had the highest share of survey respondents from Poorer and less-educated families were more likely flooded areas. to live in flooded areas, but families with higher socio-economic status were also impacted (Barón et Households reporting flooding by province al., 2022). The provinces of Balochistan, Sindh, and KP each had at least half of all families living in flooded areas. To better understand the impact of the floods on affected families, the second-round survey included more respondents from these areas (we stratified to guarantee that 50 percent of the sample came from partially- or completely-flooded areas at the time of the initial floods). In the second round survey, half of the households from Balochistan, and 40 percent of households from Sindh, reported that their area remained completely inundated. Evidence from the second-round survey suggests that families are recovering from the loss of income, particularly in less-flooded areas. In the Despite evidence of income recovery, about a third first-round survey (September 2022), two-thirds of families still expect their children will need of families in flood-affected areas reported partial to work due to the economic conditions caused or complete income loss. Six months later, just 8 by the floods. In the round 1 and round 2 surveys, percent of families reported partial or complete respondents were asked, “Do you envision your child income loss. Families from completely-flooded areas will need to work in the future due to the economic were 31 percent more likely to have lost their primary difficulty caused by the floods?” One month after the means of earning a living, compared to somewhat floods, 28 percent of families believed their children flooded areas. As areas that were hit less severely would need to work. Six months later, 33 percent of recover, families from completely-flooded areas are families held this expectation. The interpretation of at risk of being left behind. these numbers is complex as this could compound the additional impacts of overall economic conditions in the country, including high inflation and economic slowdown. Percent of respondents in 40% flooded areas who reported losing their homes SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 3 Families where the primary breadwinner had less was 1.7 times higher in completely-flooded areas than a secondary education (class 10 or higher) relative to somewhat-flooded areas. were more likely to expect their children would In addition to losing household goods, nearly 40 need to work. Moreover, the gap in expectation of percent of households in completely-flooded areas work based on household education level grew larger lost their houses. However, rebuilding occurs, and six months after the floods, compared with one many families in these areas have left temporary month after the floods, as shown in Figure 2. shelters. More than half of families in completely- This reflects family responses to economic hardship flooded areas lived in a temporary shelter following documented by Khan and Hussain (2022); many the floods. Approximately 43 percent of families parents who lost income due to the floods withdrew in completely-flooded areas had left temporary children from school and put them to work. Girls are shelters by February 2023. The average time spent in particularly vulnerable to being compelled to work a temporary shelter was five weeks. or marry after climate disasters (Chuang et al. 2023). It is worth nothing that even among more-educated Yet, many poor families in completely-flooded households there is no decline in the proportion areas still reside in temporary shelters. As shown who expect their children will need to work. in the literature, disasters have a greater impact on poorer families (Hallegatte et al. 2020; Kousky Figure 2. Six months after the floods, families from 2016). Figure 3 displays this discrepancy between less educated households were more likely to the rich and poor in their likelihood of residing in believe their children would need to work due to a temporary shelter and continued residence six the economic difficulty caused by the floods. months later. Poorer families (in the bottom half of households by assets) were 30 percent more likely   Less than high school education than wealthier families (in the top half by assets) to   High school or higher live in temporary shelters and nearly three times as likely to still reside in a temporary shelter six months after the floods. Figure 3. Poorer families in completely flooded areas were more likely to live in temporary shelters following the floods and continue residing in shelters six months later. Households living in temporary shelters   Poorest half of households Asset losses are contributing to the poor economic  Richest half outlook in flooded areas. New evidence suggests of households household assets will be difficult to recover, given the magnitude of losses. A new question in the second round about the value of losses to household goods and other assets provides additional insight into the magnitude of the losses. About 23 percent of respondents from flooded areas reported a loss of household goods or other assets. The self- reported average value of lost household goods was approximately 2,479 USD, 1.4 times the average annual income in Pakistan.1 The value of lost assets 1 Estimate derived using household income provided in the Pakistan Economic Survey 2021-22 (Government of Pakistan, Finance Division, 2022) SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 4 II. Barriers to education and continued impacts on families There is strong global evidence that disasters negatively impact education and have potentially cumulative and long-lasting effects (Baez, de la Fuente and Santos 2010). The immediate direct effect on education can be found in the destruction of schools or reduced access to them due to the destruction of other critical infrastructure (e.g., roads, bridges). When instruction is disrupted, quality suffers and children’s human capital accumulation opportunities are reduced, in both the immediate and long term (Andrabi, et al. 2021; Husted, et al. 2022). Figure 4. More parents reported their child felt A. Child Mental Health sad or became quiet six months after the floods than one month after. The mental health of children in flood-affected areas seems to be getting worse. Prior research has shown that natural disasters profoundly impact child mental health, including sleep disturbances and depression (Kousky 2016). In the second-round survey, a larger share of parents reported that after the floods their child felt sad regularly (42 percent) or that their child had become more quiet (28 percent) relative to parents in the first round (37 percent and 19 percent, respectively) (Figure 4).   1 month post-floods Policy interventions to address   6 months post-floods child mental health In a recent literature review of interventions that could Additionally, 20 percent of parents nationwide help to address the child mental health crisis in Pakistan, reported that their child seemed anxious, nervous, or Cheema et al. (2023) recommend three interventions. The worried daily or weekly. Twenty percent also reported first two interventions could be implemented relatively cheaply using existing school personnel. that their child seemed sad daily or weekly. The second- round survey asked parents about the frequency of 1. Psychological First Aid (PFA) – Several models of PFA have been developed for use after natural disasters (see sadness and anxiety in their child as part of a nine- Wang et al. 2021). For example, the National Child Stress question module on child disability. These questions Network (NTSN) has adopted a PFA model specifically were derived from the UNICEF/Washington Group for training school personnel to address the needs Module on Child Functioning (UNICEF 2022B). The overall of children after disasters (NTSN 2014). Its eight core principles include stabilizing distressed individuals and rate of child disability in the survey population was providing information about stress reactions and coping 30 percent,2 significantly higher than the estimated 11 strategies to reduce distress. percent for the Southeast Asia region found by UNICEF (2022A) using the same survey questions. The high rate 2. Play and art therapies – Play and art therapies can help children to express their emotions after natural of disability in our survey is driven, at least in part, by disasters. Case studies in Pakistan concluded that the high rate of poor mental health in children in both drawing improved children’s mental health, even flooded and unflooded areas. if teachers were not formally trained in art therapy (Ahmed and Siddiqi 2006). 3. Telepsychiatry services – Phone or video conferencing 2 This disability rate excludes children who may have a disability solely can provide psychological evaluations and therapy to based on their difficulty getting dressed. Thirty-four percent of children and teenagers. parents reported that their child needed help getting dressed daily. Additional research is required to assess the reliability and validity of this instrument for assessing disability when using phone surveys. SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 5 Figure 5. Concern over running out of food has increased for families, particularly in flooded B. Food Insecurity areas. Compounded by inflation, food insecurity is more severe six months after the floods. As shown in   Not flooded area Figure 5, before the floods, households in flooded   Flooded area areas had a similar level of concern about food insecurity to households not in flooded areas (30 percent vs. 32 percent). After the floods, 75 percent of respondents in flooded areas were worried their household would run out of food. In areas unaffected by the floods, the share of households worried about food security increased to 52 percent. Inflation has contributed to food insecurity. In rural areas, food inflation has increased to 45 percent (OCHA 2023C). The United Nations estimates that 1.1 million people are at risk of sliding from acute food and livelihood crisis (IPC3) situations to humanitarian emergency (IPC4) food security situations (OCHA 2023B). Malnutrition can harm children’s development and learning ability. Children who are hungry and Figure 6. For the 16 percent of households with undernourished have trouble focusing, have problems disrupted commutes, almost half report their with attention and memory, and get sick more often, commute time increased by more than one hour. leading to missed school days (UNICEF 2019). In Punjab, malnourished 6-8 graders perform worse in school and have lower attendance and understanding A. Increase in than their well-nourished peers (Shabbir et al. commute time for 2019). Malnutrition is especially harmful during the daily trips among critical first two years of a child’s life. It can cause households whose stunted growth and permanent damage to cognitive commutes are processes that can’t be fixed with proper nutrition still disrupted later, leading to long-term effects on their ability to   0– 15 mins learn and achieve their potential (Hioui 2019).   15–30 mins   30–45 mins   45 mins–1 hr C. Travel Disruptions   More than 1 hr Although travel disruptions have lessened significantly in flooded areas, the disruption is significant for households whose commutes to work and school remain disrupted. About 16 percent B. Time for travel of households report that their commutes remain services to return disrupted. Nearly half of these households with to normal disrupted commutes report that their commute time has increased by more than one hour (Figure 6A).   0–3 days Additionally, more than one third of respondents   4–7 days reported it took four or more weeks for transportation   1–2 weeks services to return to normal (Figure 6B). As discussed   2–4 weeks in the next section, these disruptions impacted   4+ weeks children’s ability to return to school following the   Still disrupted floods and continue to impact families whose children are out of school. SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 6 III. Children’s education in recovery Six months after the floods, many children have returned to school. Yet, children whose education is still disrupted are at risk of falling severely behind their peers. Schools are reopening. The share of households Figure 7. Children from rich and poor families spent in flooded areas reporting their children’s schools a similar amount of time out of school. were not operating fell from 18 percent to 9 percent. Among households that reported schools had closed Time to return to school   Poorest 25% and reopened, the average time school was out of by household asset quartile  Richest 25% session was seven weeks. 100 There were few differences in weeks out of school based on observed household and child 80 characteristics such as household wealth, education level, and gender of the child. As shown in Figure 7, 60 the number of weeks for children to return to school More than half (56%) returned by week 5 was similar among rich and poor households. The 40 severity of the flooding was a major determinant of time out of school, with children in completely 20 flooded areas spending three more weeks out of school than children in somewhat flooded areas. 0 0 5 10 15 20 Though many children have returned to school, Weeks after flood those who are still out of school six months Poorest 25% Richest 25% after the floods are unlikely to return. The share of unenrolled children in flood-affected areas in Figure 8. Parents of children who were still out of surveyed families fell from 3.2 percent in September school six months after the floods were much less 2022 to 1.9 percent in February 2023, indicating that likely to report that their children were likely to about 40 percent of unenrolled children returned to return compared to one month after the floods. school. In the first round of the survey, 52 percent Likelihood of child returning to school by survey round of households with children out of school reported that their children were extremely likely to return.   Extremely likely In round 2, just 20 percent were extremely likely to   Very likely return, reflecting that children who can have already   Somewhat likely returned to school (see Figure 8). Among households   Not very likely where schools remained closed six months after the   Not at all likely floods, 92 percent still needed to learn when school would resume operation. FLOOD DAMAGES AFFECT MILLIONS The Pakistan Post-Disaster Needs Assessment reported that over 6,000 schools were fully damaged by the floods, and nearly 11,000 schools Round 1 Round 2 were partially damaged, impacting (1 month (6 months over 2.6 million enrolled children post-floods) post-floods) (Government of Pakistan et al., 2022). SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 7 In the survey sample, there are no difference Learning recovery remains challenging even among between boys and girls across different outcomes. schools that are operating normally. Mazari et al. Unfortunately, the phone surveys did not have (2023) interviewed flood-affected parents, teachers, a large enough sample size of households with and other key stakeholders in flood-affected areas. out-of-school children to accurately measure Teachers interviewed felt they had yet to receive differences between the share of boys and girls out official guidance on curricular adjustments, as of school. There are also challenges in using phone they had received after Covid-19 school closures. surveys to reach families of our of school children. Teachers were often tasked with responsibilities after However, findings from the Pakistan Social and the floods in addition to managing their classrooms, Living Standards Measurement (PSLM) have shown such as delivering a new curriculum or collecting that girls are disproportionally represented among data for the national census. out-of-school children. For example, in 2019 and 2020, 54 percent of out-of-school children were girls compared to 46 percent of boys, with an even greater difference in the share of girls versus boys in Using mobile phones to help address rural areas (Pak Alliance for Maths and Science 2021). challenges in education Due to lower enrollment rates, 37 percent of children (Mazari et al. 2023) in flooded schools were girls and 63 percent were boys (Pakistan Education Sector Group, EiE, 2022). Mazari et al. (2023) interviewed flood-affected The most common reasons for children being parents, teachers, and other key stakeholders in unlikely to return were the increase in travel time flood-affected areas. They suggest that technology due to flooding (22 percent), the cost of schooling has the potential to at least partially address some (18 percent), and the child needing to work due to of the challenges that prevent access to learning: economic difficulty caused by flooding (18 percent). In the first-round survey, the cost of schooling was 1. Returns to school can be improved through the most frequently cited reason. The increase in digital peer networks (over mobile phones) travel time and cost of schooling are likely related that can provide psychosocial support while since increased travel time increases the overall cost providing information on options for learning of sending children to school. In the communities and relief. hardest hit by the floods, children can return to 2. Flexible learning environments, like temporary school once travel infrastructure is rebuilt and learning centers or community-based learning children have access to safe commutes to school. environments, can be enhanced through The use of schools as temporary shelters in flooded multimodal EdTech approaches. areas may also continue to impact the quality and 3. Mobile phones can support remedial learning quantity of education children receive. Nearly 30 by delivering formative assessments and percent of respondents in the second-round survey educational content for some children. reported that schools were temporary shelters for flood victims after the floods, compared to 17 percent The authors recommend that Pakistan invest in in the first round. Twenty-six percent reported schools a more holistic strategy that identifies appropriate are currently in use as temporary shelters. Among multimodal teaching and learning content for households that reported schools were no longer emergencies while acknowledging the challenges used as temporary shelters, the average time schools of using cellular technology. were used as a shelter was five weeks. Improving ease of travel and developing safe school commute plans for children in the hardest hit areas will help more children return to school. SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 8 IV. Flood relief and health impacts At the International Conference on Climate Resistant Pakistan hosted by the U.N. in Geneva in January, multilateral and bilateral organiations pledged over 10 billion USD for reconstruction and relief activities (Nabi 2023). The Government of Pakistan has also created and prioritized interventions through its Resilient Recovery, Rehabilitation, and Reconstruction Framework (4RF) (Government of Pakistan 2022). Yet, awareness of relief activities has remained low six months after the floods. Awareness of flood relief activities has changed Table 1. Awareness of flood relief activities could have little in the six months since the floods. In the first been higher across relief activity types. round of the survey, 80 percent of respondents from flooded areas reported no relief activities Flood-Affected for flood victims. In the second round, 82 percent Relief Type Households Reporting reported no relief activities. Nevertheless, the (Percentage) United Nations Office for the Coordination of Raw food distribution 12.7 Humanitarian Affairs (OCHA) estimates that seven million people, roughly 21 percent of people in Clothing 4.4 flood-affected areas, have received aid (OCHA Distribution of cooked/prepared foods 4.3 2023B). This close correspondence between the Medicine 4.1 OCHA percentage receiving aid (21 percent) and the Tents 2.7 percentage reporting flood relief activities in our surveys suggests that families who are aware receive Potable water 1.6 aid. Raw food distribution had the highest level of Shelter 1.4 awareness; 13 percent of flood-affected households Seed distribution 0.5 reported raw food distribution to victims in their area Productive assets such as livestock 0.4 (Table 1). Temporary learning centers 0.1 Although awareness and receipt of relief activities were low, one quarter of respondents from flooded Figure 9. Fewer households reported outbreaks of areas received cash transfers from the Benazir mosquito-borne diseases six months after the floods Income Support Programme (BISP). Starting in 2007, compared to one month after. the government of Pakistan began providing BISP funds to the neediest families who are identified   1 month post-floods using a poverty scorecard (Government of Pakistan   6 months post-floods 2023). About 22 percent of respondents in flooded areas reported receiving BISP in the second-round survey, compared to 18 percent of respondents in areas unaffected by the floods. Additionally, interventions around mosquito-borne seemed to have worked. As shown in Figure 9, disease outbreaks have remained relatively stable, with the incidence of dengue decreasing significantly. The reduction in stagnant flood waters where mosquitoes breed and early diagnosis at over 4,000 Suspected malaria cases in camps fell from 38,000 medical camps has helped to decrease the incidence cases in October 2022 to 5,000 cases in December of mosquito-borne diseases (Vohra et al. 2023). 2022 (OCHA 2023A). SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 9 IN SUMMARY In summary, by February 2023, six months after the floods, economic activity, health, and education indicators are improving for most households in flood-affected areas. However, there continue to be substantial challenges for children in households in areas that were complety-flooded and where destruction was widespread. SPECIAL NOTE | Children and their Families Six Months After Pakistan’s Floods | July 2023 10 Methodology The data used in this note come from a nationally representative phone survey designed by the World Bank and implemented by Gallup Pakistan. Data collection was carried out in February 2023. 4,000 The survey was carried out using random digit dialing (RDD) of mobile phones using all four telecom providers with active numbers across Pakistan. Approximately 93 percent of households have access to a mobile phone (Government of Pakistan 2021). Despite the high-penetration rate of mobile phones, lower-income households are overrepresented in the remaining 7 percent Completed surveys in the study of those who do not have access to mobile technology. This likely means that in many cases, the results presented show an underestimation of The survey’s target population was parents or the true impacts of the floods on families and their caregivers of children ages 3 to 17. If more than one children in Pakistan. child lived in the household, one child was randomly selected as the subject of inquiry. The gender of Each random number was called to survey the child stratified the sample. The survey also households until a call was answered (with oversampled households that reported any impact a maximum of three attempts). Calls were of floods, aiming for a sample of at least 1,000 placed at different times on different days of the households that suffered the effects of floods in their week to maximize the response rate. Once an area. In addition, the survey collected information individual was contacted on his or her mobile on the education status of children, food security, phone, consent was obtained, a screening child work, health, environment, and household questionnaire was administered, and a unique composition. A limited set of sociodemographic study identification number was generated for characteristics was also collected, including parents’ the respondent. Next, interviewers entered data education, assets, gender, family composition, rural, into a tablet with Survey CTO software that had urban, district, and province. the preloaded questionnaire with automatic skipping patterns (Computer Assisted Telephone The survey randomly called 40,375 numbers, Interviewing, CATI). reaching 18,083 individuals who answered the phone, of which 5,449 agreed to the interview, In the sample: 1,449 with incomplete surveys, and 4,000 that (unweighted) have a complete survey. The survey was carried out 66% rural 34% urban using random digit dialing (RDD) of mobile phones using all four telecom providers with active numbers across Pakistan, except that 345 respondents from flood-affected areas in the first-round survey also participated in the second round. To better capture the aggregate impact, weights are created using quintiles from province, rural/urban, gender and education of household head. 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World Bank, Washington, National Child Traumatic Stress Network. 2014. “Psychological DC. https://openknowledge.worldbank.org/entities/ First Aid for Schools (PFA-S) Field Operations Guide publication/cd3e54af-1391-565b-b1f7-cf3b2e4abf26 IN THIS NOTE | Source for all data graphics: Authors’ estimates based on phone survey. Photography: Insiya Syed. Graphic design: Elizabeth Salud. © 2023 International Bank for Reconstruction and Development / The World Bank 12