JSI Research & Training Institute, Inc.

Pakistan Initiative for

Mothers and Newborns

Consortium MembersThe PAIMAN consortium is led by John Snow Inc . ( JS I ) , a US-ba sed international public health organization. JSI is joined by a number of i n t e r n a t i o n a l a n d Pa k i s t a n i organizations to form a powerful team for implementing the project. The consortium partners are:lAga Khan UniversitylContech InternationallGreenstar Social MarketinglJohns Hopkins Bloomberg School

of Public Health Center for Communication Programs

lPopulation CouncillSave the Children – USlPAVHNA

Contact Information: House No. 6, Street No. 5, F-8/3Islamabad – Pakistan 44000Tel: +92 (0)51 111-000-025Fax: +92 (0)51 285-2638Email: info@jsi.org.pkWebsite: www.paiman.org.pk

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The vision for Pakistan Initiative for Mothers and Newborns (PAIMAN) is fully aligned with the National Maternal and Child Health (MNCH) Program of Pakistan. PAIMAN believes that success in improving the health of mothers, newborns and children rests with striving to achieve the following jointly held vision:

“The Government of Pakistan recognizes and acknowledges the access to essential healthcare as b a s i c h u m a n r i g h t . T h e 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 disadvantaged.”

The Pakistan Initiative for Mothers and Newborns (PAIMAN) is a comprehensive project designed to reduce the country's maternal, neonatal and child mortality. With funding from the United States A g e n c y f o r I n t e r n a t i o n a l Development, PAIMAN strives to:

lEnsure that women have access to skilled birth attendants during childbirth and the postpartum period;

lEnsure that newborns and children under 5 years are well nourished and protected from and treated for waterborne and other infectious diseases; and,

lFoster adherence to Integrated Management of Neonatal and Childhood Illnesses guidelines for childhood development.

lEnsure broadening the base of family planning services through functional integration of service intervention.

Launched in 2004, the initial 5-year project focused on maternal and neonatal health (MNH) and was implemented in 10 districts. In 2008, PAIMAN received a one year extension to include 14 new districts. In addition to tribal areas, the project currently operates in a total of 24 districts across all the four provinces of Pakistan including Azad Jammu & Kashmir. Beyond the MNH components, the extended project

now also focuses on child and reproductive health issues.

PAIMAN works at national, provincial and district levels to strengthen the capacity of public and private health providers and to improve health system infrastructure. The project has developed a community-based approach that provides a continuum of care to mothers, newborns and children through supportive linkages from home healthcare to hospital-based care. PAIMAN's key partners are the Ministry of Health, Ministry of Population Welfare, Provincial Health Departments and Population Welfare Departments, the private sector and PAIMAN consortium members.

The Pakistan Initiative for Mothers and Newborns

The Pakistan Initiative for Mothers and Newborns

Workers (LHWs), and NGO staff – in communication skills.

Accomplishments to date include:l3.1 million (out of 4 million in 10

districts) beneficiaries reached t h r o u g h i n t e r p e r s o n a l communication and group counseling interventions;

l8 , 5 0 0 L H W s t r a i n e d i n communication ski l ls and support group methodology, empowering them to create a total of 34,000 support groups that have drawn 1.5 million members;

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lMore than 30,000 people reached through innovative media (Puppet Shows, and TV mobile shows) in remote areas;

l490 Ulama and 200 journalists trained and are participating in PAIMAN's comprehensive c o m m u n i t y m o b i l i z a t i o n network;

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An estimated 10 million married women in their reproductive age reached through a 13-episode drama series and 5 television spots;

4,617 district assembly members and school teachers reached through seminars;Nearly100,000 men and women reached through 308 local events and theater performances.

Strategic Objective 1: Increase awareness and promote positive MNCH behaviors.

PAIMAN is implementing an evidence-based, multi-channel communication strategy to generate demand for maternal, newborn and child health and family planning services. The main aim is to increase positive MNCH behaviors at the household level through a strategic approach which includes:

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community mobilization and advocacy to reach a diverse range of communities and individuals across geographical areas and cultures;

lStrategic linkages among various communication approaches, from mass media enter-educate programs, music videos, and spots to localized MNCH initiatives led by community leaders, religious scholars and journalists. These mutually reinforcing linkages foster dialogue, address myths and misconcept ions , and motivate behavior change to improve maternal, newborn, and child health; and,

lCapacity-building for public and private providers - including doctors, LHVs, Lady Health

Use of mass and local media,

midwife or Lady Health Visitor (LHV).

A persistently high total fertility rate of 4.1 births over the past ten years continues to expose women and children to increased risks of mortality and morbidity. Although substantial gains in the contraceptive prevalence rate were made during the 1990s - contributing to a sharp decline in the rate of fertility – contraceptive use has stalled at approximately 30% among currently married women in the last decade.

Pakistan's extensive network of public sector health facilities reaches only about one third of the country's population. The remaining 70% of the population is served by the private sector, mainly for curative services. The public sector, an important service provider in isolated rural communities, needs improvements in physical infrastructure, safe water supply, provider capabilities, privacy for female clients, and regular supply of drugs and equipment. As such, the challenges are great: to address the dual need for increased awareness of positive maternal, newborn and child health (MNCH) behaviors along with increased access to quality and timely care.

Pakistan's maternal, newborn and child mortality and morbidity rates remain high in spite an extensive health service network. Insufficient awareness of major maternal, newborn and child complications among women, families and health providers persist. Most maternal, newborn and child deaths occur at home, with no skilled health provider in attendance. According to the 2006-07 Pakistan Demographic and Health Survey, two-thirds (66%) of all births are delivered at home, while only 39% births are delivered by a skilled provider such as doctor, nurse,

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training centers upgraded in 10 districts;

l50 health facilities, 15 training centers and 7 midwifery schools being upgraded in 14 districts;

l1,600 community-based midwifes enrolled in standardized 18-month course, with 110 certified and being placed in midwife homes;

l550 existing midwives trained in competency based refresher course;

l100,000 Clean Delivery Kits distributed or sold;

l1,900 TBAs oriented on clean d e l i v e r y p r a c t i c e s , e a r l y recognition of danger signs and referrals;

l31 health facilities strengthened to provide continuous care;

l65,000 beneficiaries reached through 3,000 Clinic Sahoolats; and

l70 local NGOs awarded sub grants to work in non-LHW areas.

22 midwifery schools and 14 Strategic Objective 2: Increase a c c e s s t o a n d c o m m u n i t y involvement in MNCH services (including emergency obstetric care) and ensure service delivery at designated sites, including ancillary services.

PAIMAN str ives to increase community-based access to quality MNCH-FP services by providing skills-based training to traditional birth attendants, LHWs, and LHVs. PAIMAN i s suppor t ing the Government of Pakistan's plan to introduce a new cadre of community-based skilled birth attendants by expanding and standardizing midwifery training programs. In addition, PAIMAN is working with the private sector and local NGOs to improve obstetrical emergency outcomes by involving communities and introducing innovative strategies to overcome delays. PAIMAN is engaged in the following to achieve Strategic Objective 2:

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in community integra ted management of newborn, and child illnesses;

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lHospital waste management programs including provision of l o w - c o s t c o n v e n t i o n a l incinerators piloted at two health facilities and in the process of expanding to three additional districts; and

lHealth facilities supported in developing and implementing Infection Prevention and Control policies and plans, including training for health providers.

6,570 LHWs undergoing training

34 quality improvement teams formed by the process of partnership defined quality implementation at 40 health facilities

Strategic Objective 3: Improve service quality in public and private sectors, particularly related to the management o f obs te t r i ca l complications and child survival.

PAIMAN provides extensive support to government health facilities in project districts by: lU p g r a d i n g p h y s i c a l

infrastructure; lEmphasizing high quality, client

focused maternal, newborn and child health services;

lStrengthening referral systems and quality control mechanisms alongside more integrated MNCH and family planning (FP) service delivery programs; and

lDeveloping protocols and guidelines for management of o b s t e t r i c a n d n e o n a t a l complications; improved child health management and delivery of family planning services.

Accomplishments to date include:l50 franchise GoodLife Surgical

Clinics and 569 non-surgical franchise clinics established in the private sector;

l85 Well Baby Clinics planned to be established at selected health facilities;

l155 ORT corners planned for public sector health facilities;

The Pakistan Initiative for Mothers and Newborns

The Pakistan Initiative for Mothers and Newborns

trained in emergency maternal and neonatal care (EMNC) and 73 health care providers trained in comprehens ive emergency obstetric and neonatal care (EmONC);

l8 , 5 0 0 L H W s t r a i n e d i n communication ski l ls and support group methodology, with training underway for an additional 2,500 LHWs; and

lHealth providers trained in active management of third stage of labour and partograph use; essential surgical skills; and client c e n t e r e d a p p r o a c h f o r reproductive health.

Strategic Objective 4: Increase capacity of MNCH-FP managers and health care providers.To improve quality of care within government and private health fac i l i t i e s , PAIMAN aims to institutionalize a comprehensive capacity building approach in both the public and private sectors. PAIMAN ensures that training activities – provided for thousands of health providers - are competency-based and include appropriate levels of follow-up, supervision and reinforcement.

Accomplishments to date include:l2,200 healthcare providers

Strategic Objective 5: Improve management and integration of services at all levels.In order to strengthen the health system, PAIMAN is:lEstablishing District Health

Management Teams (DHMTs) in project districts and agencies;

lI n c r e a s i n g t h e p l a n n i n g , management and leadership capacity of district managers;

lImproving logistics and supply management with supportive supervision; and

lE n h a n c i n g p u b l i c - p r i v a t e partnerships toward a more integrated service delivery system.

Accomplishments to date include:l24 DHMTs formed, with 10 teams

fully functioning ;l200 health managers from the

DHMTs trained in the areas of finance, logistics, human resources, and supportive supervision;

lTwo management sof tware packages created and distributed, with support and training, to facilitate development of financial management and district annual operational plans; and,

lNational Health Information Resource Centre, Ministry of Health staff supported in the implementation of the District Health Information System.

The Pakistan Initiative for Mothers and Newborns

PAIMAN is being implemented in 24 districts of Pakistan in all four provinces, Azad Jammu & Kashmir and to FATA agencies and two Frontier Regions apart from tribal areas. The targeted districts include:

lPunjab: Rawalpindi, Jhelum, D. G. Khan, Multan, Khanewal and VeharilSindh: Sukkur, Dadu, KhairpurlBalochistan: Jafferabad, Lasbela, Quetta, Sibi, Zhob, and GwadarlNWFP: Upper Dir, Buner, Charsadda, Peshawar, Mardan and D. I. KhanlAzad Jammu & Kashmir: Plundri and BhimberlFederally Administered Tribal Areas of Pakistan: Kurrum and Khyber

agencies and Frontier Regions of Kohat and Peshawar.

The total population being covered under the project is approximately 30 million.

PAIMAN continues to strengthen existing partnerships and build stronger linkages and cross referral mechanisms between academic institutions, the for-profit private sector and the public sector. The purpose of these partnerships is to maximize access, fill service delivery gaps, offer the widest range of services and payment options possible to clients, and divert able-to-pay clients to the private sector to reduce the public sector burden.

PAIMAN extended its scope of work in 2008 to include child health and family planning. With these additions, PAIMAN districts now have access to a holistic package of priority interventions to address the needs of mothers, newborns, and children in Pakistan. For example, FP counseling is integrated with pre- and post-natal care to prevent unwanted and mistimed pregnancies. Child survival activities are included in the Integrated Management of Newborn and Childhood Illnesses program to promote improved growth and development of young children. Families, communities, and health providers together implement preventive and curative child survival interventions.