Project Description

The situation of maternal, newborn and child health in Pakistan is one of the poorest in South Asia. Despite some improvements in the 1990s, Pakistan has lagged behind many of it neighbors in terms of health and population outcomes. The infant mortality rate of 78 per 1000 live births and a recently calculated maternal mortality rate of 276 per 100,000 live births are both higher than other neighboring South Asian countries. Very high fertility rates, a high unmet need for family planning and very low rates of skilled birth attendance are some of the fundamental underlying causes for the poor health of women and children in Pakistan. There are numerous additional factors affecting this situation, including political instability, poor governance, rising religious conservatism and militancy, a vastly under-resourced public social sector, and a poorly functioning public sector health service delivery system at the district level.

In the past ten years, the Government of Pakistan has begun to focus attention on this critical area of health, first by supporting and expanding the very important Lady Health Worker Program which has developed a network of 100,000 community-based primary care workers; second by the creation of a National Maternal, Newborn and Child Health cell within the Pakistan Ministry of Health to help build a national strategy and program; and third by the decision to select and train of a new cadre of community-based midwives to address the need of skilled birth attendance. Similarly bilateral donors, such as USAID, DFID and the Norwegian government have begun investing substantial funds in support of these initiatives that seek to expand access and quality of health care maternal, newborn and child health.

One such example is the USAID-funded Pakistan Initiative for Mothers and Newborns (PAIMAN) project. The original $50 million 10-district project was launched in 2004 for five years, led by John Snow Research and Training Institute. JSI has been collaborating with a consortium of international and national partners including Save the Children US, Population Council, John Hopkins School of Public Health, PSI’s Greenstar Social Marketing, Aga Khan University, Contech International, and PAVNHA. Recently PAIMAN was awarded an additional $6 million to add two new regions to its portfolio: two Agencies and two Frontier regions of the Federally Administered Tribal Areas (FATA) and District Swat in NWFP.

PAIMAN has undertaken a holistic approach for improving maternal and newborn health in the 10 districts which ranges from interventions within the community, within the public and private sector, and with district health systems. The community BCC and mobilization component has been working to improve families’ awareness about maternal and newborn health issues. This communication and mobilization strategy has been closely linked with a second component which seeks to improve access to and the quality of public and private sector health care delivery at the district level. This has included the training of public and private sector providers in Essential and Emergency Obstetric and Newborn Care, with a special emphasis on the training of a new cadre of community-based midwives as a long-term solution to increasing rates of skilled birth attendance. PAIMAN has also refurbished and re-equipped selected public sector facilities to ensure 24/7 emergency care, and has oriented Traditional Birth Attendants in clean delivery techniques and referral mechanisms. As a cross cutting intervention, PAIMAN has also worked on building the capacity of district health mangers to plan for and evaluate interventions the district level.

PAIMAN has worked with a wide network of partners to implement its program, including district departments of health, public and private sector healthcare providers, community-based non-governmental organizations, traditional birth attendants as well as other stakeholders such as men’s groups and local political representatives in order to garner support for the project. PAIMAN has also launched numerous innovative interventions such sub-awards to 37 local NGOs to extend information and health care coverage to communities that fall outside the government’s network of care by holding health camps and establishing birth centers in remote rural areas. Another innovation has been PAIMAN’s work with important opinion makers in the community such as religious scholars who are being harnessed to support maternal, newborn and child health initiatives in their areas.

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• Reduced neonatal mortality rate
• Increased proportion of live births assisted by SBA

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PAIMAN uses the "Pathway to Care and Survival" continuum of care to respond to the needs of mothers and newborns with life-saving and supportive care (see figure 1). Under the devolved system in Pakistan, Provincial Departments of Health provide Safe Motherhood and Newborn Care services through a four-tiered system: community-based activities through lady health workers (LHWs) and traditional birth attendants, (TBAs); primary health care (PHC) facilities, such as mother child health centers (MCHCs), basic health centers (BHUs), and rural health centers (RHCs); first-referral facilities such as THQ and DHQ hospitals; and tertiary care facilities. PAIMAN works with all these tiers to strengthen their capacity and to ensure wider access to quality services through skilled attendance at all levels, including the community.  

To implement this strategic framework, PAIMAN follows these guiding principles:
 

• Involve all relevant stakeholders: PAIMAN includes communities, the GOP, the private sector, and donors, in order to achieve its objectives. Without the involvement and commitment of these key stakeholders, PAIMAN could not succeed.
• Build integrated health systems: PAIMAN is promoting integration of interventions– at the district, tehsil, and health facility levels, as well as in the communities– that save time and resources for both providers and recipients, while increasing quality of care – and thus– client satisfaction.
• Scale-up activities: PAIMAN is developing a set of interventions that can be scaled-up to expand primary maternal and neonatal health (PMNH) activities in all ten districts. Once proven successful, these interventions can be used, in collaboration with other donors and local partners, to make program benefits available to the whole population of Pakistan.
• Address gender inequalities: PAIMAN promotes women's leadership in community-based activities and the realm of health care.
• Build on lessons learned: PAIMAN employs research and lessons learned from other successful MNH projects in China, Honduras, Sri Lanka, and particularly from other Muslim countries including Egypt, Indonesia, Jordan, Malaysia and Morocco to help inform program activities. When interventions and activities meet client needs in similar settings, PAIMAN need not reinvent them.
• Develop locally sustainable and replicable interventions and infrastructure. A sustainable health program in the Pakistani context depends upon the capacity of providers and managers to deliver quality services. PAIMAN works to create an educated and empowered clientele that seeks quality health services in an environment where there is a strong link between providers and communities.

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