Pakistan: FATA-KP Health Program

This report was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-08-00002-000. The contents are the responsibility of the Maternal and Child Health Integrated Program (MCHIP) and do not necessarily reflect the views of USAID or the United States Government.

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Better Health Care – Healthier Mothers and Children for a Roshan Pakistan

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BACKGROUND In Pakistan, the infant mortality rate (IMR) and under-five mortality rate (U5MR) have shown a downward trend (IMR 2008, 75/1,000 live births; IMR 2012, 69/1,000 live births; U5MR 2008, 92/1,000 live births; U5MR 2012, 85.9/1,000 live births), and the maternal mortality ratio (MMR) was estimated in 2010 at 260/100,000 live births. While these numbers are encouraging, they fall short of 2015 Millennium Development Goals (MDGs). The country also faces stark regional disparities between urban and rural areas (Pakistan One UN Programme Annual Report 2011). Similarly, Pakistan’s total fertility rate is 4.1 (Multiple Indicator Cluster Survey [MICS], 2009), which is quite high compared to neighboring countries in South Asia. Province- and sub-province-level disaggregation of data based on MICS 2009 statistics shows variations—the Federally Administered Tribal Area (FATA) lags behind, whereas Khyber Pakhtunkhwa (KP) appears to be marginally better than the national averages. Estimations of these indicators require large population bases and long durations. In particular, the key factors that underpin these larger and longer-term indicators require significant improvement to bring the FATA and KP regions to the forefront of development in health care and to achieve the MDGs.

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FATA-KP Health Program The FATA-KP Health Program (FKHP) is a five-year (September 2012 to October 2017) MCHIP Associate Award Cooperative Agreement under the Leader with Associate award, funded by the U.S. Agency for International Development, granted to Jhpiego as the prime recipient and Save the Children as the lead implementing partner. FKHP aims to save the lives of mothers, newborns, and children in seven target districts of Malakand Division (Malakand, Swat, Shangla, Buner, Upper Dir, Lower Dir, and Chital) and four selected agencies of FATA (Bajaur, Mohmand, South Waziristan, and Orakzai). Through this program, maternal, newborn, and child health (MNCH) outcomes will be improved in the target areas.

According to the 1998 census (annual growth rate of 2.8% adjusted for 2013), the population in these areas is 6,469,173 in KP and 2,034,057 in FATA. Of the total population in KP and FATA program districts and agencies, 22% are women of reproductive age, 2.7% are children ages 0 to 1 year, and 13.4% are children ages 1 to 5 years.

FKHP addresses the critical need to strengthen the provision and utilization of services proven to reduce maternal, infant, and child mortality and morbidity by improving the state of intermediary MNCH indicators. The program is designed to build a household-to-hospital continuum of care model to improve availability of and access to integrated, high-quality services for MNCH and healthy timing and spacing of pregnancy (HTSP). FKHP works closely with provincial and district/agency stakeholders to implement key evidence-based interventions to achieve the identified goals.

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PROGRAM SCOPE The goal of FKHP is “improved maternal and child health outcomes in the FATA and KP” regions, and the program’s strategic objective is “improved use of key MNCH and HTSP services and practices.” The program has four components that contribute to the achievement of the program’s strategic objective and goal. Components 1 through 3 address the three main aspects of the program vision, while Component 4 revolves around learning and accountability. The four components are described below.

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Component 1: Improve community-based access to integrated MNCH and HTSP services in targeted communities of FATA-KP.

Key Achievements There are 3,357 facility-based health care providers (HCPs) and 3,764 community-based health workers in the program impact areas (four agencies of FATA and seven districts of KP). The facility-based HCPs are made up of 719 medical officers, 47 woman medical officers (WMOs), 352 lady health visitors (LHVs), and 751 dispensers. Among the community-based health workers, there are 3,582 LHWs, 140 Lady Health Supervisors, and 182 community midwives.

One of FKHP’s most important contributions was the initiation of training programs to enhance the capacity of service providers to manage childhood- and maternal-related illnesses and issues. These training programs were organized at the provincial level for master trainers, followed by rollout training sessions in the field for facility- and community-based HCPs.

In FKHP’s first year, the program provided training to 2,465. Of this number, 193 HCPs were trained on integrated management of neonatal and childhood illnesses (IMNCI), 569 on essential maternal and newborn care (EMNC), 620 on infant and young child feeding and essential nutrition actions, 858 on community case management, and 225 on HTSP. Similarly, the capacity of providers on basic and comprehensive emergency obstetric and newborn care services was strengthened. A total of 32 obstetricians/WMOs and child specialists/medical officers from the district/agency headquarter hospitals participated in clinical attachments at tertiary care hospitals in gynecology and pediatrics units.

Training on IMNCI.

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In addition, 11 anesthesia technicians (one per agency/district) completed clinical attachments at tertiary care hospitals in anesthesia units.

These attempts to build HCP capacity were well-received by the stakeholders, HCPs, and the community. During an interview, the District Health Officer of Lower Dir proclaimed, “Training for building capacity is good and has a good outcome. It is mandatory for improving efficiency of HCPs; improved efficiency becomes visible consequent to the training programs, and a positive impact on the health-seeking behaviors is also seen. I have seen that the OPD [outpatient department] of most of the BHUs [basic health units] has increased during these recent months and similarly the LHWs monthly report also shows increase in the deliveries through skilled birth attendants.” Training of HCPs covered both theoretical and practical aspects. One of the LHVs in the Malakand District recalled, “Besides the classroom teaching, the practical session arranged in hospitals was very effective.”

The program is also providing health care services through Child and Maternal Health Days (CMHDs)1 and Mobile Health Units (MHUs).2 In Year 1, 95,916 people were reached with basic health services during CMHDs (43% boys, 41% girls, and 17% mothers). Similarly, MHUs provided services to 40,591 people (62% children and 38% adults).

Although private sector health care providers deliver health care

1 Child and Maternal Health Day is a single day activity that is conducted at a health facility or village. A team of doctors/medical technicians, and LHVs visit villages and provide basic health services. 2 Mobile Health Unit.

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to more than two-thirds of the population, no proper referral system exists between them and public health care providers and facilities. To strengthen referral mechanisms from the community to the facility, FKHP included private health care providers in its capacity-building initiative. Based on a needs assessment, 150 private health care providers were given essential equipment and supplies. In Year 2, referral mechanisms will be established.

The most important and critical element to improve service provision under this component is the repair and renovation of public health facilities. FKHP plans to repair/renovate 75 BHUs, 11 District/Agency Headquarter Hospitals and 24 rural health centers (RHCs) of the target districts/agencies. Needs-based assessments of these health facilities are in progress and renovations will start in Year 2.

Mobile Health Unit at the village Imam Baig in Mohmand Agency.

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Component 2: Improve key individual, family, and community behaviors and practices for maternal and child health through innovative and effective social and behavior change communication (SBCC) tailored to the FATA and KP context. Overview Component 2 focuses on the community’s critical role in improving the health of mothers and children. It examines the role and status of women and children in society, the attention they receive, and their lifestyle patterns so that they can live and enjoy the full potential of life and health.

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Key Achievements For areas with LHW coverage, FKHP initiated training of LHWs on support group methodology to strengthen their capacity in mobilizing communities through support group meetings. In Year 1, 276 HCPs were trained as master trainers in this methodology. To improve the LHW reporting system, FKHP will print recording and reporting tools for all LHWs in the target areas in Year 2.

Similarly, to cover the population living in areas not covered by LHWs, FKHP has hired four nongovernmental organizations that will work with communities to promote healthy behaviors related to MNCH and HTSP.

Community elders, ullemas, and opinion leaders play pivotal roles in influencing communities. FKHP engages community gatekeepers by organizing periodic MNCH/HTSP sensitization and dialogue sessions for religious leaders, community elders, and other opinion leaders at the district/agency level. The program mobilizes these influential community members to promote healthy behaviors and act to identify and change harmful beliefs and practices that are barriers to ensuring maternal and child health.

To implement a holistic approach, FKHP is finalizing an SBCC strategy. A media firm has been hired to produce and air a mass media campaign based on this strategy. To ensure a comprehensive strategy, FKHP also conducted a gender analysis in Year 1.

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Component 3: Strengthen citizen engagement in MNCH service delivery decision-making in FATA-KP. Overview Component 3 focuses on enhancing community engagement in the processes related to service provision, scope, planning, budgeting, and quality. FKHP aims to create platforms through which communities can be engaged as equal partners by offering opportunities to voice concerns to be incorporated in decision-making about health services. Component 3 also looks at establishing processes and mechanisms to ensure that services are provided according to a rational needs assessment.

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Key Achievements • A technical advisory and advocacy group of key players was established at the provincial level to focus on MNCH

and HTSP as an independent group, overseeing program implementation and provision of policy guidelines.

• To enable district- and agency-level administration to plan, manage, and provide locally relevant and effective health services, FKHP is supporting quarterly meetings of Agency and District Health Management Teams in FATA’s four agencies and Malakand’s seven districts.

• The Department of Population Welfare in KP and FATA has a significant role in planning and managing services related to family planning; therefore, mapping of family welfare centers was conducted to ensure their involvement in capacity-building interventions.

• To improve the quality of MNCH/HTSP services in the public sector, the innovative Partnership Defined Quality approach is being used to involve communities in defining, implementing, and monitoring quality improvement in health facilities. For this purpose, quality improvement teams (QITs)—made up of community representatives and staff from respective health facilities—are being established at BHUs and RHCs. The teams will bring together health care providers and community members to define common issues that hinder the perception of quality of services. The two groups will develop an agreement to work together to resolve and monitor progress on these issues. In Year 1, QITs were formed at 235 BHUs.

• To ensure round-the-clock (24/7) MNCH and HTSP service availability to communities, FKHP is piloting the Hub approach—a public-private partnership model that addresses chronic systemic issues by revitalizing RHCs to offer EmONC services 24/7—at the RHCs Yakaghund and Sakhakot. Under the FKHP, both the Yakaghund and Sakhakot RHCs have been renovated and provided with essential equipment and supplies, and staff was hired to support 24/7 service provision.

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After (RHC Ekka Ghund, Mohmand Agency)Before (RHC Ekka Ghund, Mohmand Agency)

Before (RHC Ekka Ghund, Mohmand Agency) After (RHC Ekka Ghund, Mohmand Agency)

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After (RHC Sakha Kot, District Malakand)

Before (RHC Sakha Kot, District Malakand) After (RHC Sakha Kot, District Malakand)

Before (RHC Sakha Kot, District Malakand) After (RHC Sakha Kot, District Malakand)

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Component 4: Promote learning and accountability through data collection analysis and presentation of data in FATA-KP. Overview Component 4 focuses on improving collection, analysis, and use of information for improved decision-making, planning, and monitoring and evaluation of MNCH and HTSP services. Additionally, the concept of accountability is emphasized so that attention remains on ensuring effectiveness and achieving results.

Key Achievements Equipment and supplies to strengthen the District Health Information System were procured and installation is in progress. In addition, a Logistic Management Information System will be installed at all agency and district headquarter hospitals. The relevant staff for both systems were also trained on data entry, recording, and reporting.

To enable the program to set a benchmark for comparison of project results and assess its effectiveness in the various areas of implementation, a baseline survey was conducted. Survey results will be disseminated at national, provincial, and district/agency levels in Year 2. FKHP will also conduct a public opinion survey to understand how communities view the provision or lack of provision of MNCH services, quality, and processes.

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