Rolling Out the MDGs - WHO · Rolling Out the MDGs Pakistan Initiatives for Mothers and Newborns...

Rolling Out the MDGsPakistan Initiatives for Mothers

and Newborns (PAIMAN)

Dr. Nabeela Ali, Chief of Party, PAIMAN

Peter Hatcher, Consultant & Former Deputy Chief of Party

16th Canadian Conference on International Health

Ottawa, October 28, 2009

http://paiman.org.pk/draft/design4

Situation of MNCH-FP in Pakistan


Pakistan Profile796,096 square kilometres

36th largest country/territory by surface area

Agricultural economy with vibrant, growing manufacturing sector

Semi-arid to arid agriculture based on irrigation – Indus River & tributaries

Two thirds population living in rural areas

29% of pop in the lowest wealth quintile living in rural areas

46% of pop the highest wealth quintile living in urban areas

Strong average economic growth of over 7.5 % 2003-07

Maintains Pakistan’s position as one of the fastest growing economies in the Asian regionalong with China, India, and Vietnam.

Source: PDHS 2006-2007


Demographic ProfilePopulation

167 million

6th most populated country in the world

Population Density

210 person/sq. km.

36th largest country/territory by surface area

Growth Rate

1.9%

Population will double in ~ 35 years

Total Fertility Rate

4.1 births/women

Target is ‘Replacement Level’ of 2.1 births by 2020

Currently married women using family planning

29.6%

Actual demand for family planning is ~ 67.0%


.Women of Reproductive Age in Pakistan

Projected increase in WRA 8.7 million

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

2007 2008 2009 2010 2011 2012 2013 2014 2015

Source: SPECTRUM 3.04 Projections


Health Facilities and Services

Public sector hospitals 906

Basic Health Units 5,290

Population/Bed 1,536

Doctors – 1/1,300* 122,798

Nurses – 1/4,600 57,646

Midwives 25,000

Lady Health Workers 110,000

*Source: PDHS 2006-2007


Health – HR Development

0

20000

40000

60000

80000

100000

120000

7th plan

1993

8th plan

1998

2000 2001 2002 2003 2004

Doctors Midwives Nurses LHVs LHWs

Status Quo in the number of LHV, Midwives and Nurses


Source: PSLSM 2004-05

Confidence in Public Sector Facilities?72%

20%

5%

2% 2%3%

1%

64%

21%

4%2%

1%

7%

2%

67%

21%

2% 2%1%

5%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Private Disp/

Hosp

Public Disp/

Hosp

RHC/BHUs Hakeem Homeopath Chemist Others

Urban

Rural

Overall

Quality issues lead to lack of confidence in Public sector with resulting high out of pocket expenditure for the poor


Tertiary Hospital

Secondary Health Care

PHC

1%

9%

90%

Population

Served

40%

45%

15%

Health

Expenditure

(Source: P&D Division 1994)

PHC Wing ,Ministry of Health

CBI-The Rationale: Inequitable Distribution of Health

Resources


20% of GoP reported expenditure is allocated to address 56% of disease

burden

Burden of Disease on Mortality in Pakistan

Communicable

, maternal ,

perinatal and

nutri tional

conditions

56%

Noncommunic

able diseases

34%

Injuries

10%


Maternal Mortality 276 - 500 per 100,000 live

births

Infant Mortality Rate 78 per 1,000 live births

Neonatal Mortality 54 per 1,000 live births

Under-five mortality 94 per 1,000 live births


MDG Health Indicators


Postpartum hemorrhage, 27.20%

Puerperal sepsis, 13.70%

Indirect maternal causes, 13.00%

Other direct causes, 10.50%

Obstetric embolism, 6.00%

Eclampsia, 10.40%

Iatrogenic causes’, 8.00%

Complications of abortion, 5.60%

Antepartum hemorrhage, 5.50%

Common Causes of Maternal Mortality

Source: DHS 2006


Mothers dying per 100,000 live births in selected districts, 1993

50

289

463

593

673

360

523

120

Karachi

Pishin

Lasbela

Loralai

Khuzdar

Abbottabad

Mansehra

Peshawar


Women whose last birth was not protected against neonatal tetanus

40.2%

Women who receive skilled care during pregnancy

39.1%

Percentage births attended by unskilled birth attendant

61.2%

Births delivered at home 65.7%

Women who did not receive postpartum care by skilled provider

73.7%


Maternal Health Indicators


Urban Rural Gap – “One” Antenatal Visit

Source: PSLSM 2004-05

22%26%

40%

60%63%

66%

Target 100%

0%

20%

40%

60%

80%

100%

120%

1998-99 2001-02 2004-05 2008 2012 2015

Urban Rural Target

Recommended Four Antenatal Visits !!

•There is wide Gap between urban-rural for one antenatal visit

•Further, it is required to have at least 4 antenatal

•From 40% we have to reach 100% rural women seeking at least one antenatal visit


One out of every ten children dies before reaching the fifth birthday

Under-five mortality

94

Almost 60% of under-five mortality occurs within the first month of life

Neonatal mortality

54

Half of all the children in Pakistan are anemic

Under-five anemia

50.9

Four out of every ten children are underweight

Under-five underweight

38.0

More than 60% children (12-23 months) in Pakistan do not have all the basic vaccinations

Basic Vaccination Coverage

39.2


Child Health Indicators


CountryLife

Expectancy

Infant

Mortality

Rate

Under 5

Mortality

Rate

Population

Growth

Rate

Pakistan 65 78 94 1.9

Bangladesh 64 47 61 2.0

India 65 54 72 1.5

Source: Pakistan Economic Survey 2008-09

Where do we stand?


Priority Areas! Creating awareness and demand for MNCH services

Community Midwives trained & placed in rural communities

Provision of Basic and Comprehensive EmONC & IMNCI services

Improved EPI coverage

Comprehensive family planning services

Nutrition interventions

All these priorities are supported by the National Program for PHC & FP


Pakistan Initiative for Mothers and Newborns-

PAIMAN


Pakistan Initiative for Mothers and

Newborns (PAIMAN)

USAID funded 6 year

project

Focus on Maternal,

Newborn & Child Health

& Family Planning

Health system

strengthening is a cross

cutting intervention.


Project Overall Goal

Pakistan Initiative for Mothers and Newborns is working 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 strengthen links in the continuum of health care for women and children from the home to the hospital


Strategic Objectives

Increase awareness and promote positive maternal,

newborn and child health behaviors

Increase access to emergency obstetrics, newborn and

child care, and reproductive health

Improve service quality in both the public and private

sector

Increase Capacity of Health Managers and Care

Providers

Improve management and integration of services at all

levels


PAIMAN’s Strategy

"Pathway to Care and Survival”

continuum of care from household to

hospital


Home

LHW

TBA

Village

CEmOc

DHQ/ THQ

Private Sector

BEmOC

BHU/RHC

BCC

1

Training2

Orientation

3

Upgrade, Train

6

Transport

4Upgrade,

Train

7

Intervention: Home to Hospital

CMW

9

Medical CampsMSU

FWCRHA Centre

5

8


So-1 Demand Creation

Increase awareness and promote positive maternal and newborn health behaviors


• Working through 11000

Lady Health Workers

(LHWs)

• Reached 2.41 million

beneficiaries through LHW

support groups

Revitalization of Village

Health Committees

Reaching Community through LHWs


Topics of discussion during SG meeting

ANC messages received by women of community (*multiple responses)

1

6

16

38

39

69

77

83

0 20 40 60 80 100

Hygine/cleanliness

Danger signs Pregnancy

Arrange SBA

Iron/FA Tablets

Arrange transport,money

TT vaccine

4 ANC Visits

Diet,rest in pregnancy

29


Reaching the underserved Areas through NGOs

78 NGOs have reached 1.45 million beneficiaries

in non-LHW areas.


Reaching the underserved Areas through NGOs

Scope of Work

• Advocacy

• Social Mobilization

• Improving emergency transportation

• Orientation of TBAs

• Strengthening of EPI, TT vaccination

Campaign

• Free medical camps


Awareness Raising Events

26,885 beneficiaries reached through 36 mega events


112,453 beneficiaries reached through 415 local events



1,934 District and Tehsil assembly members

participated in 41 Seminars



Reaching Diversity with Television Drama Series “Paiman”

• A 13-episode drama series on PTV Home

• Subsequent airing on national / regional terrestrial and cable television channels;

• Dubbing in regional languages for regional audiences

• Showing selected episodes through “Video–on–Wheels” approach

• TVC Newborn


Reaching through Ulama Intervention

• Only influential and those whose mosques are in far-flung areas uncovered by LHWs

• Delivering MNCH messages to men through Wa’az during Friday prayer and to women through Mufita lectures


Developing Capacity on communication skills

• Three annual one-week intensive workshops on “Leadership in Strategic Health Communication

• Participants learn to apply key leadership principals in designing strategic health communication programs.


Impact

Activities Beneficiaries

Support Groups by LHWs 2,411,613

IPC Beneficiaries-Greenstar 240,533

Sub-Grantee NGO

Beneficiaries

1,551,206

Totals 4,203,352


Level of Knowledge about Post Natal Care- Attitude towards PNC

Attitude towards need for Post natal care

0%

20%

40%

60%

80%

100%

Baseline 2005 44% 52% 60%

LQAS 2007 95% 95% 95%

Sukkur Jhelum Lasbella


Level of Knowledge about Pregnancy Care- No. of ANC visits

Knowledge about 4 or more ANC Checkups during pregnancy

0%

20%

40%

60%

80%

100%

Baseline 2005 22% 55% 15%

LQAS 2007 80% 80% 80%



Level of Knowledge about Pregnancy Care- First ANC visit

Knowledge regarding first ANC visit within 3 months of Pregnancy

0%

20%

40%

60%

80%

100%

Baseline 2005 29% 60% 21%

LQAS 2007 95% 90% 90%



SO-2&3 Improving Access and Quality

• Increase access to emergency obstetrics

and newborn care

• Improve service quality in both the public

and private sector


Access to skilled care at the time of birth

1. Short term Strategy

2. Long term strategy

3. Bridging the gap through TBAs


Hands on training of the existing midwives

• Four week training course offered

• 588/730 existing midwives in 24 districts have been trained

• One year post training assessment of knowledge and skills was conducted

• 6 days refresher training provided.

Short term strategy


• Enrollment of 1822 CMWs in 24 selected districts

• 446 CMWs have graduated and are under the process of Deployment in the community

Long term strategy


• Deployment of newly graduated CMWs• Establishment of 1100

Midwife Homes

• Image building in the community

• Linkages with other community and facility based HCPs

• Monitoring and reporting mechanism

Long term strategy


• Orientation of 1930/2250 TBAs in 24 selected districts on:• Clean delivery practices

• Recognition of danger signs

• Improved referrals

• Linkages with other community and facility based HCPs

• Client Centered Approach

• Assessment of retention of knowledge and practice

• Follow up & refresher orientation

Bridging the gap through TBAs


Emergency Obstetric and Newborn Care

• 31 HFs in 10 existing districts have been up-graded and 59 more in 14 additional districts are under process

• Civil works

• Electro-medical equipment and instrument

• Furniture

• Capacity building of HCPs

• Display of standard protocols


Addressing Human Resource Issue

• Advocacy for placement of HCPs through existing resources

• Involvement of teaching institutions

• Post-graduate trainee rotation

• Visit of consultants to CEmONC facilities for mentoring purpose

• Specialist surgical camps

• Hands on training of the local facility staff in teaching hospitals


Emergency Transport Management

24 ambulances have been handed over to the districts and 48 are under process


• MOU with EDHI ambulance services

• Community Operated emergency transport system (RESAI) in five districts

• Ten ambulances managed by each of five local NGOs

• Community transport arrangement through village health committees.

Emergency Transport Management


Routine Monitoring of output Indicators (RMOI)

Obstetric Complications Admitted in PAIMAN Upgraded

Health Facilities in Lasbella

(144% increase in 2008 from 2007)

0

20

40

60

80

100

120

Jan-Mar Apr-Jun July-Sep Oct-Dec

2007

2008

2009



Deliveries in PAIMAN Upgraded Health Facilities in

Jaffarabad


0

50

100

150

200

250


2007

2008

2009



Deliveries taking place in PAIMAN Upgraded

Health Facilities in Sukkur


0

100

200

300

400

500

600

700

800


2007

2008

2009



Obstetric Complications Admitted in PAIMAN Upgraded Hospitals in Dadu, Sindh


0

100

200

300

400

500

600


2007

2008

2009


20% increase in TT Immunization of Pregnant Women in PAIMAN Districts from 2007 to 2008

0

1000020000

30000

40000

5000060000

70000

Jan-Mar07

Apr-Jun07

Jul-Sep 07Oct-Dec07

Jan-Mar08

Apr-Jun08

Jul-Sep 08


ANC Visits at Government Health Facilities in PAIMAN Districts

(36% increase in ANC visits at HFs from 2007 to 2008)

0

10000

20000

30000

40000

50000

60000

70000

Jan

-Mar

07 Apr-

Jun

07

Jul-

Sep

07

Oct

-Dec

07 Ja

n-M

ar08 Apr-

Jun

08

Jul-

Sep

08


Obstetric services provided at Upgraded Health Facilities in

PAIMAN's Original 10 districts

0

1000

2000

3000

4000

5000

6000

Jan-Mar 07 3639 1460

Jan-Mar 08 4388 1440

Jan-Mar 09 5201 2013

Deliveries in HF Obs Complications Admitted

43% higher than

Jan-Mar 07

baseline

38% higher than

Jan-Mar 07

baseline


Private Sector Initiatives


Thematic Areas

• Improving Access and Quality

• RESAI :Rural Emergency Services Ambulance Initiative

• CMW’S prequalification for enrollment in Balochistan& NWFP

• LHW’S prequalification for enrollment in Balochistan& NWFP

• Blood Bank THQ Hospital Mian Channu

• Birthing Centers


Signing Ceremony with Private Health Care Providers


SO IV-Capacity Building

Increase capacity of MNH managers and

care providers


Providers Trained at Different Levels

Obstetrician,

Pediatrician,

Anesthetist

MO,WMO,

LHV,FMT,

Nurse midwife

& Midwife

TBAs

Community Midwife


In-Service Trainings

S.NO Type of Training Result

1 CEmONC

Advance training on MNH for private providers

100%

2 EMNC TOTs 100%

3 EMNC for Public Sector

EMNC for private providers

98%

100%

4 Training of Provincial Trainers for LHW trainings 94%

5 Training of District Trainers for LHW trainings 90%

6 Trickledown trainings of LHWs 98%


In-Service Trainings (cont…)

S.NO Type of Training Results

7 Refresher Trainings for CMWs and LHVs 96%

8 Evidence Based Decision Making 100%

9 Refresher Training on HMIS 100%

10 Leadership Training for District Managers 86%


In-Service Trainings (cont…)


12 Strategic & Annual Operational Planning 100%

13 Logistical Systems 100%

14 Financial Management 100%

15 IMNCI Trainings 68%

16 IYCF Trainings 72%

17 CCA training on RH services 84%

18 Clinical trainings for birth spacing 64%

19 ESS and BLS trainings 86%


Pre-Service Trainings


21 CMWs 100%

22 Accelerated educational program for LHWs

in Baluchistan

Enrolled

23 Accelerated educational program for CMWs

in Baluchistan

Enrolled


23.5

43.9

29.6

3.1

45.3

1.0 1.0

17.3

80.6

85.5

0.02.0

37.8

60.2

80.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

<=30 % 31%-50% 51%-79% 80+ % Mean

Nurses/LHVs Knowledge Assessment

Baseline result

Post-test result

Performance Assessment result


42.9 42.9

12.5

1.8

35.3

0.0 0.0

4.7

95.393.6

1.0 2.1

14.4

82.5

88.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

<=30 % 31%-50% 51%-79% 80+ % Mean

Nurses/LHV Active Management of third stage of labor SkillBaseline result

Post-test result



19.8

39.636.9

3.6

46.2

0.0 0.01.8

98.2

93.8

0.03.5

28.7

67.8

82.8

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

<=30 % 31%-50% 51%-79% 80+ % Mean

Medical Officers Neonatal Resuscitation Skill

Baseline result

Post-test result



Health Systems Strengthening

Improve management and integration of

services at all levels


Health System Strengthening Interventions

• District Health Management Teams

• Capacity building

• District Health Managers

• DHMT Members

• Facility In-charges

• Staff

• Management information system (MIS)

• District annual operational plan (DAOP)


• Sharing best practices• HealthPlan® Software

• FinSoft® Software

• DHIS software

• DAOP

• Budget Preparation

• MIS Reports

• M&E

• Health Planning

• Financial Management

• Logistics Management

• Supportive Supervision

• Use of information

• Target setting

Trainings Onsite

support

Experience sharing

visits

Innovative technology

Management Capacity Building


• All PAIMAN districts preparing DAOP

• Monthly MIS report generation

• Use of information

• Application of new techniques for supervision

• Increase budget allocation

Management Capacity BuildingOutcome/Impact


DHMTIncrease in District Health Budget

97%

57%

37%

14%

51%

32%

10%

16%

100%

56%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DG

Khan

Jhelu

m

Raw

alp

indi

Khanew

al

Jaff

era

bad

Lasbela

Dadu*

Sukkur*

*

Upper

Dir

Buner

Percentage Change in the Health Budget2005-06 v/s 2007-08


Thank You!

CA # 391-A-00-05-01037-00 project is funded by the United States Agency for International Development and implemented by JSI Research & Training Institute, inc. in conjunction with Aga Khan University, Contech International, Greenstar Social Marketing, JHU/CCP, PAVHNA, Population Council, Save the Children USA


Rolling Out the MDGs - WHO · Rolling Out the MDGs Pakistan Initiatives for Mothers and Newborns...

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Transcript of Rolling Out the MDGs - WHO · Rolling Out the MDGs Pakistan Initiatives for Mothers and Newborns...