Project Description

Maternal, newborn and child health care statistics in Pakistan are some of the poorest in South Asia. Despite improvements in the 1990s, Pakistan lags many of its neighbors in health and population outcomes. Infant mortality rate of 78 per 1000 live births and a recently-calculated maternal mortality rate of 276 per 100,000 live births are higher than neighboring South Asian countries. Very high fertility rates, a high unmet need for family planning, and very low rates of skilled birth attendance are three fundamental underlying causes of poor health of women and children in Pakistan. Numerous additional factors contribute, 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, especially at the district level.

In the past ten years, the Government of Pakistan (GOP) has focused on this critical health area, by supporting and expanding the important Lady Health Worker Program (LHW) which has developed a network of 100,000 community-based primary care workers, creating the National Maternal, Newborn, and Child Health cell within the Ministry of Health to help build a national strategy and program, and selecting and training a new cadre of community-based midwives to address skilled birth attendance. USAID, DFID, the Norwegian government and other bilateral donors, began investing substantial funds to support initiatives to expand access to and quality of maternal, newborn, and child health (MNCH) care.

The USAID-funded Pakistan Initiative for Mothers and Newborns (PAIMAN) Project is an example. Launch in 2004 the six year project serves 24 districts, and two Frontier and two FATA Agencies. Led by JSI Research and Training Institute, Inc. (JSI), PAIMAN is a consortium of international and national partners, including Save the Children US, Population Council, Johns Hopkins University Bloomberg School of Public Health/Center for Communication Programs, Aga Khan University, and Contech International.

PAIMAN’s holistic approach to improve maternal and newborn health in its districts ranges from interventions within the community, within the public and private sector, and with district health systems. The community behavior change communication and mobilization component works to improve family awareness about maternal and newborn health issues. Its closely-linked second component improves access to and quality of public and private sector health care delivery at the district level by training public and private sector providers in essential and emergency obstetric and newborn care and emphasizing training of a new cadre of community-based midwife. This long-term solution will increase rates of skilled birth attendance. PAIMAN also refurbished and re-equipped selected public sector facilities to ensure 24/7 emergency care and has oriented traditional birth attendants (TBAs) with clean delivery techniques and referral mechanisms. As a cross-cutting intervention, PAIMAN worked on building capacity of district health mangers to plan for and evaluate district-level interventions using data from the revitalized district health information system.

To support and implement its program PAIMAN partners with a wide network, including district departments of health, public and private health care providers, community-based non-governmental organizations, traditional birth attendants, and stakeholders such as men’s groups and local political representatives. PAIMAN launched numerous innovative interventions, such as sub-awards to 96 local NGOs to extend information and health care coverage to communities outside the Government’s network of care by holding health camps and establishing birthing centers in remote rural areas. Another innovation was PAIMAN’s work with influential community opinion makers such as religious scholars, who were recruited to support in their areas, MNCH initiatives.

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PAIMAN fully endorses the National Maternal and Neonatal Health Strategic Framework vision:
“The Government of Pakistan recognizes and acknowledges that access to essential health care is a basic human right. The Government’s vision in MNCH is of a society where women and children enjoy the highest attainable levels of health and no family suffers the loss of a mother or child due to preventable or treatable causes. The Government of Pakistan henceforth pledges to ensure availability of high quality MNCH services to all, especially for the poor and the disadvantaged.” Major PAIMAN MNCH strategies were to: reduce maternal, newborn, and child mortality in Pakistan through viable and demonstrable initiatives and capacity-building of existing programs and structures within health systems and communities, to ensure improvements and to strengthen links in the continuum of women’s health care from home to hospital. Outcomes were:

• Reduced neonatal mortality rate

• Increased proportion of SBA assisted live births

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PAIMAN used the "Pathway to Care and Survival" continuum of care to respond to needs of mothers and newborns with life-saving, supportive care (Figure 1). Under Pakistan’s devolved system provincial Departments of Health provide safe motherhood and newborn care services through a four-tiered system: 1) community-based activities through LHWs and TBAs; 2) primary health care facilities, such as mother-child health centers, basic health units, and rural health centers; 3) first-referral facilities, such as tehsil headquarter and district headquarter hospitals; and 4) tertiary care facilities. PAIMAN works with all tiers to strengthen their capacity and ensure wider access to quality services through skilled attendance at all levels, including the community. 

To implement this strategic framework, PAIMAN is guided by principles:

• Involve all relevant stakeholders: To achieve its objectives PAIMAN includes communities, GOP, private sector, and donors. Without key stakeholder involvement and commitment, PAIMAN could not realize all its goals.

• Build integrated health systems: PAIMAN integrates interventions– at district, tehsil, and health facility levels and in communities, saving time and resources for providers and recipients while increasing quality of care, thus client satisfaction.

• Scale up activities: PAIMAN developed interventions that can be scaled up to expand primary maternal and neonatal health activities in all its areas. Proven successful, these interventions can be used in collaboration with donors and local partners to avail program benefits to all 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 successful MNCH projects in China, Honduras, Sri Lanka, and, particularly, other Muslim countries, including Egypt, Indonesia, Jordan, Malaysia, and Morocco. When interventions and activities meet client needs in similar settings, PAIMAN need not reinvent them.

• Develop locally-sustainable, replicable interventions and infrastructure: A sustainable health program in the Pakistani context depends upon provider and managerial capacity to deliver quality services. PAIMAN created an educated and empowered clientele that seeks quality health services with strong linkages among providers and communities.

• Information about maternal and newborn health care issues reached 7.3 million individuals in 24 PAIMAN districts.

• 97 public health facilities upgraded and equipped to provide emergency obstetric care services in 24 districts, two Frontier, and two FATA Agencies.

• 2,204 public health care providers trained in Essential Maternal and Newborn Care.

• More than 40 hours of diverse, film, television, and radio productions on MNCH issues---a commercial feature film, a drama series, a series of television magazine shows, and radio talk shows.

• 8.1 million women of reproductive age reached through the TV drama series Paiman.

• 40,000 villagers reached with MNCH messages via puppet shows.

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  300,000 delivered PAIMAN messages in remote areas via mobile TV vans.

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  1,000 ulama sensitized and networked on MNCH issues and their role in ensuring the same; in their Friday sermons, ulama now often preach about healthy and safe practices.

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  Over 400 journalists trained on reporting on MNCH issues.

• PAIMAN Communication, Advocacy and Mobilization Strategy adopted by National MNCH Program.

• 96 sub-grants awarded to local NGOs to reach non-covered population by organizing free health camps, establish birthing centers, and promoting MNCH awareness.

• 76 purpose-built ambulances provided for emergency obstetric cases and other emergencies.

• 50 Suzuki vans converted to ambulances for use by communities in five districts to transport patients to health facilities.

• 1,623 students supported for CMW training.

• 1,600 CMW homes being supplied with essential equipment and furnishings.

• 76 women who received PAIMAN support for under-matriculation (10th Grade) education successfully passed the matriculation examination and are available for CMW training.

• 82 women from remote Khyber Pakhtoonkhwa and Balochistan areas received educational support to under middle (8th Grade) education to qualify as LHWs.

• 189 private health care providers signed agreements to regularly provide data on key MNCH performance indicators.

• Functional Integration of Services between Health and Population Welfare Departments and integration of family planning services at the district level initiated in selected districts.

• 176,910 Clean Deliver Kits distributed.

• 3,000 insecticide-treated bednets provided to pregnant ladies for prevention of malaria.
   

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