MCHIP Pakistan End-of-Project Report PAKISTAN ASSOCIATE AWARD/COMPONENT 2 MATERNAL NEWBORN AND CHILD HEALTH SERVICES

Authors: Presha Regmi Farhana Shahid Kamran Baig Emma Williams

Reporting period: February 2013–March 2018

Submitted on:

Submitted to: United States Agency for International Development / Pakistan under Cooperative Agreement # 656- A-00-11-00097-00

The Maternal and Child Health Integrated Program (MCHIP) is the USAID Bureau for Global Health’s flagship maternal, neonatal, and child health (MNCH) program. MCHIP supports programming in maternal, newborn, and child health, immunization, family planning, malaria, nutrition, and HIV/AIDS, and strongly encourages opportunities for integration. Cross-cutting technical areas include water, sanitation, hygiene, urban health and health systems strengthening.

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-00-08-00002-00. 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.

October 2018 Table of Contents

List of Figures and Tables ...... iv Abbreviations ...... v Executive Summary ...... vii Key Achievements ...... ix 1 High-Level Results ...... 1 1.1 Survey Results ...... 2 2 Background ...... 4 2.1 Situational Analysis ...... 4 2.2 Landscape Analysis ...... 5 2.3 Rationale ...... 5 3 MCHIP Interventions ...... 7 3.1 Geographical Scope ...... 7 3.2 Project Strategic Framework ...... 9 4 MCHIP Associate Award Activities and Results by Objective ...... 12 4.1 Mapping Health Services in the Districts ...... 12 4.2 Strategic Objective 1: Increase Access to MNCH Services Through Community Mobilization ...... 13 4.3 Strategic Objective 2: Improve the Quality of MNCH Scope and Services at Public and Private Health Facilities ...... 17 4.4 Strategic Objective 3: Facilitate Referral and Transportation to Health Facilities ...... 23 4.5 Strategic Objective 4: Improve Quality and Scope of Comprehensive Emergency Obstetric and Newborn Care at Public and Private Hospitals ...... 25 5 MCHIP Associate Award Activities and Results by Technical Area ...... 29 5.1 Maternal Health ...... 29 5.2 Newborn Health ...... 32 5.3 Child Health ...... 36 5.4 Family Planning ...... 41 5.5 Nutrition ...... 43 6 MCHIP Associate Award Activities and Results by Cross-Cutting Area ...... 46 6.1 Quality Improvement ...... 46 6.2 Midwifery ...... 49 6.3 Training Institutes ...... 53 7 MCHIP Associate Award Program Learning ...... 55 7.1 By Objective ...... 55 7.2 By Technical Area ...... 57 7.3 By Cross Cutting ...... 59 8 Program Legacy ...... 61 8.1 By Objective ...... 61 8.2 By Technical Area ...... 62 8.3 By Cross Cutting ...... 64 Annex A: Performance Indicators ...... 66 Annex B: List of Materials or Tools Developed or Adapted by the Program ...... 67

MCHIP Pakistan End of Project Report iii List of Figures and Tables

Table 1. Six components of the Maternal and Child Health Program in Sindh (2013–2018) ...... 1 Table 2. Intervention districts by project year ...... 8 Figure 1. Map of project districts by project year ...... 8 Figure 2. The project strategic framework, based on providing a continuum of care to women throughout their reproductive lives ...... 9 Table 3. MCHIP interventions by space along the continuum of care model ...... 10 Figure 3. Geographic information system mapping of Tando Allahyar district showing facilities that offer five services: antenatal care, family planning, newborn care, normal vaginal deliveries, and postnatal care (BHU: basic health unit; DHQ: district headquarters hospital; GD: government dispensary; RHC: rural health center; THQ: tehsil [subdistrict] headquarter hospital) ...... 13 Figure 4. Distribution of 1,108 facilities by type across the 16 target districts ...... 18 Table 4. Criteria facilities must meet to be designated an MNCH center ...... 18 Table 5. MCHIP training packages by technical area ...... 21 Figure 5. Increase in average number of antenatal care (ANC) visits, total deliveries, and postnatal care (PNC) visits from 2014–2017, including number of facilities reporting ...... 22 Figure 6. Introduction and percentage completion rates of cesarean section surgical safety checklists (CS-SSCs) at CEmONC facilities, July 2016–September 2017 ...... 26 Figure 7. Number of cesarean sections and coverage of antibiotic prophylaxis, by quarter and project year ...... 26 Figure 8. Increased compliance to quality standards across 29 CEmONC centers ...... 28 Figure 9. Increased compliance to the QIPS respectful maternity care standards ...... 30 Figure 10. Increased use of uterotonics over the course of the project, 2014–2017 ...... 31 Figure 11. Timeline of chlorhexidine (CHX) for cord care in Sindh province (DoH: Department of Health, DRAP: Drug Regulatory Authority of Pakistan, EML: essential medicines list, MoHSRC: National Ministry of Health Services, Regulation and Coordination, LHW: lady health worker, SBA: skilled birth attendant) ...... 34 Table 6. MCHIP’s intensive technical support package for routine immunization ...... 37 Table 7. Vaccination status of registered children in eight intensive intervention districts (total children under age 2 registered from May/June 2016 to August 2017) ...... 39 Figure 12. Baseline and end-of-project registration status of children (0–23 months) in eight intervention districts in Sindh province ...... 39 Table 8. Nutrition indicators for pregnant women and young children from Pakistan nutrition surveys ...... 43 Table 9. QIPS standards by technical area ...... 46 Figure 13. QIPS scores overall and by technical area: percentage of facilities scoring fair, good, or very good in all rounds (R1–R4) ...... 48 Figure 14. Compliance to quality standards for 15 midwifery schools ...... 50 Figure 15. Average monthly income for 121 CMWs who participated in business skills training ...... 52 Figure 16. Increased compliance to quality standards over time as measured through quality improvement and patient safety (QIPS) for 117 community midwives with business skills training ...... 52 Table 10. Training institutes and number of master trainers trained ...... 54

iv MCHIP Pakistan End of Project Report Abbreviations

AHCS Aman Health Care Services ANC antenatal care ARI acute respiratory infection BCC behavior change communication BEmONC basic emergency obstetric and newborn care BHU basic health unit CEmONC comprehensive emergency obstetric and newborn care CHW community health worker CHX chlorhexidine CME continuing medical education CMW community midwife CSO civil society organization CS-SSC WHO Cesarean Section Surgical Safety Checklists CTS clinical training skills DAP district action plan DHIS district health information system DHMT district health management team DHQ district headquarters DIO district immunization officer DoH Department of Health EmONC emergency obstetric and newborn care EPI Expanded Program on Immunization FANC focused antenatal care FP family planning GIS geographic information system GMMMC Ghulam Mohammad Mahar Medical College HBB Helping Babies Breathe HCP health care provider HSS Health Systems Strengthening IEC information, education, and communication IFA iron-folic acid IMCI Integrated Management of Childhood Illness IPC interpersonal communication IPV inactivated polio virus vaccine IUCD intrauterine contraceptive device JIMS Jacobabad Institutes of Medical Sciences JSI John Snow Inc. KMC kangaroo mother care LDH Lady Dufferin Hospital LDHF low-dose, high-frequency LHS lady health supervisor LHV lady health visitor LHW lady health worker LRP learning resource package LUMHS Liaquat University of Medical and Health Sciences MAP Midwifery Association of Pakistan MCH maternal and child health MCHIP Maternal and Child Health Integrated Program MCPC managing complications in pregnancy and childbirth MCSP Maternal and Child Survival Program

MCHIP Pakistan End of Project Report v MER monitoring, evaluation, and research MERF Medical Emergency Resilience Foundation MIS management information system MIYCN maternal, infant, and young child nutrition MLBC midwife-led birthing centers MNCH maternal, newborn, and child health MoHSRC National Ministry of Health Services, Regulation and Coordination MSU mobile services unit NCMNH National Committee of Maternal and Newborn Health NGO nongovernmental organization NSP Nutrition Support Program OJC on-the-job coaching OJT on-the-job training OPV oral polio vaccine OSCE objective structured clinical examination PCPNC pregnancy, childbirth, and postnatal care PDHS Pakistan Demographic and Health Survey PDQ Partnership-defined quality PHDC Provincial Health Development Center PCPNC pregnancy, childbirth, and postnatal care PDQ partnership-defined quality PEI Polio Eradication Initiative PNC postnatal care PPFP postpartum family planning PPH postpartum hemorrhage PPHI People’s Primary Healthcare Initiative PPIUCD postpartum intrauterine contraceptive device PPP public-private partnership PWD Population Welfare Department QI quality improvement QIPS quality improvement and patient safety QIT quality improvement team RHC rural health center RI routine immunization RMC respectful maternity care SBA skilled birth attendant SBM-R® Standards-Based Management and Recognition SBMR-E Standards-Based Management Recognition-Education SBTP Safe Blood Transfusion Program SHCC Sindh Health Care Commission SIA subnational immunization days SMS Short Message Service TPTB threatened preterm birth ToT training of trainers USAID United States Agency for International Development USG United States government VNRBD voluntary nonremunerated blood donation WHO World Health Organization WSG women’s support group

vi MCHIP Pakistan End of Project Report Executive Summary

The Maternal and Child Health Integrated Program (MCHIP) was the United States Agency for International Development (USAID) Bureau for Global Health’s maternal, newborn, and child health/family planning flagship program from 2008 to 2014. MCHIP received funding from USAID Pakistan, an initial 1 million USD in 2011–2012 that expanded into the MCHIP Associate Award from 2013–2018. Jhpiego led the MCHIP Associate Award consortium of partners in Pakistan, which included Save the Children, John Snow, Inc., and the Program for Appropriate Technology in Health. MCHIP also partnered with local implementing partners and the Department of Health Sindh, People’s Primary Healthcare Initiative, Lady Health Worker (LHW) Program, and Maternal Newborn and Child Health (MNCH) Program, among others.

MCHIP in Pakistan was one of five components under Pakistan’s Maternal and Child Health (MCH) Program. The other four components were: • Strengthening Health Systems, led by John Snow, Inc. • Health Commodities, through the DELIVER Project, led by John Snow, Inc. • Family Planning/Reproductive Health, led by Marie Stopes Society • Behavior Change Communication, led by Johns Hopkins University Center for Communications Programs

USAID Pakistan designed baseline, midline, and endline surveys to evaluate the MCH Program’s impact. The survey results show that most of the MCH indicators improved in the MCH focus districts.1 For example, from 2013 to 2017, indicators improved in the following areas2: • Proportion of women receiving antenatal care (ANC) increased from 73.9% to 86%. • Attendance at four ANC visits increased from 31% to 41.8%. • Skilled deliveries increased from 55.1% to 69.9%. • Misoprostol use in home deliveries increased from 0.5% to 8.5%. • Proportion of women receiving postnatal care (PNC) within 2 days of delivery increased from 36.2% to 81.9%.

Similarly, use of a modern family planning method increased from 22.8% to 31.8% and any contraceptive use from 28.9% to 44.1%. The proportion of children who received all recommended vaccines increased from 15.3% to 56.7%.

MCHIP’s goal in Pakistan was to provide high-quality MNCH services in the 16 target districts of Sindh. MCHIP used a phased approach to expand geographic coverage from an initial five to 16 districts during the life of project. MCHIP selected and worked with more than 1,000 primary, secondary, and tertiary facilities and their coverage areas. MCHIP’s continuum of care model addressed barriers to access and care from the home to the facility. At the community level, MCHIP worked in close collaboration with the Department of Health Sindh to revitalize the LHW Program.

1 Dadu, Khairpur, Tando Allahyar, Tharparkar, Thatta, Sujawal, Jacobabad, Umerkot, Naushero Feroz, Sukkur, Shikarpur, Ghotki, Larkana, Mirpur Khas, Matiari, and Sanghar. In 2013, Thatta separated to become two districts: Thatta and Sujawal. 2 MCH performance indicators survey 2017, draft report, June 2018, PERFORM, Management Systems International

MCHIP Pakistan End of Project Report vii In the initial five districts (Dadu, Tando Allahyar, Tharparkar, Thatta, and Khairpur), MCHIP and the LHW Program helped to revitalize the women’s support group (JoanWSG) methodology to improve birth preparedness. MCHIP recruited 484 community health workers (CHWs) in areas of those districts where there were no LHWs. The LHWs and CHWs conducted two WSG sessions each month, reaching more than 1.8 million women through 169,134 WSGs over the life of the project. In the 16 districts, more than 15,336 LHWs were trained in counseling and distribution of the day of the birth package, which included chlorhexidine (CHX) and misoprostol for prevention of newborn sepsis and postpartum hemorrhage. LHWs distributed more than 700,000 CHX gel tubes to pregnant women.

Prior to MCHIP, referrals from the community to the health facility were not routinely /regularly documented. This may be due to a lack of printed referral slips. To improve referrals, MCHIP provided referral slips and oriented the LHWs and CHWs on their proper use. Throughout the project, LHWs and CHWs made a total of 317,832 referrals.

Communities in the target districts also identified transportation as a barrier to accessing health care. MCHIP identified and trained 2,605 transporters on safe transportation. Through September 2017, these transporters safely transported 27,596 patients to health facilities.

MCHIP is leaving behind 1,145 facilities (a mix of public, private, and nongovernmental organization-contracted facilities) that are capable of providing high-quality MNCH services. The health care providers and staff at these facilities received group-based and on-the-job training, followed by on-the-job coaching and supportive supervision sessions across several MNCH training packages. The trainings and reinforcements were provided within the context of a quality improvement (QI) process at the facilities. The QI process involved MCHIP, with a core QI team from the facility, conducting periodic measurements against quality standards across technical areas. The QI team also identified gaps and possible solutions to meet the standards. For example, on-the-job training or coaching sessions addressed gaps identified in staff and facility capacity; nonstructural repairs and renovations addressed facility improvements when possible; and linkages with the community through WSGs addressed gaps in demand.

Facilities’ compliance to quality standards increased overall, across technical areas, and across the targeted districts. The facility- and community-based quality and training interventions also aligned with an increase in the number of ANC contacts, total deliveries, and PNC visits at the facilities from 2014 to 2017. For example, between 2014 and 2017, ANC contacts increased on average from 127 to 176, total deliveries from 23 to 41, and PNC visits from 16 to 29 per month per facility.

MCHIP also worked across several cross-cutting activities, working to strengthen midwifery, nutrition, immunization, and training institutes. MCHIP introduced business skills training for midwives, mobile mentoring to reinforce provider knowledge, cooking demonstrations during WSGs, a Mother’s Booklet, etc.

MCHIP also introduced several interventions to Pakistan: respectful maternity care, surgical safety checklist for improving management of cesarean sections, Helping Babies Breathe (HBB), CHX for management of newborn sepsis, and kangaroo mother care. Between 2014 and 2017, approximately 9,000 babies in MCHIP program areas were successfully resuscitated using one or more steps of the HBB techniques.

viii MCHIP Pakistan End of Project Report MCHIP implemented an intensive technical support package when immunization was introduced in year 3. By project end, MCHIP had supported the registration of 28,566 villages, 830,610 children, and 348,315 pregnant women across eight intervention districts.3 Of the registered children, 52% were fully immunized, and 64% received their Penta3 vaccination, as compared to 27% at baseline. Of the registered pregnant women, 65% were vaccinated with two doses of tetanus toxoid vaccine, as compared to 26% at baseline.

From its beginning, MCHIP worked with the Population Welfare Department and DoH to develop capacity. It has worked with four vertical programs of DoH—the LHW Program, MNCH Program, Nutrition, and Expanded Program on Immunization—and other offices such as the Provincial Health Development Center and Director General Health Services. MCHIP also worked with public-private partnerships that were the implementing partners of government such as People’s Primary Healthcare Initiative, Medical Emergency Resilience Foundation, and Integrated Health Services. For example, MCHIP oriented and trained DoH and its implementing partners on various learning resource packages and job aids so DoH can continue to strengthen and provide MNCH/family planning services in Sindh.

KEY ACHIEVEMENTS Community Outreach During MCHIP: • CHWs visited more than 150,000 households and registered 37,704 families in 18 months. • LHWs and CHWs reached more than 1.8 million women through 169,134 WSG meetings, resulting in increased referrals from the community to health facilities (from 312 in December 2014 to 45,938 in December 2017). • MCHIP identified and trained 2,605 transporters on safe transportation. Through September 2017, these transporters had safely transported 27,596 patients to a health facility.

Facility-Based Care • MCHIP worked in 1,108 MNCH centers and 37 comprehensive emergency obstetric and newborn care (CEmONC) centers, completing nonstructural repairs and renovations in 66 facilities, six CEmONC centers, and two training centers. • MCHIP developed a pool of 46 master trainers across 16 districts who conducted training of trainer sessions to develop trainers at the district level. • MCHIP completed 24,517 supportive supervision visits to target MNCH centers in the 16 districts. • Between 2014 and 2017, monthly service volume increased at project facilities, from 127 to 176 ANC visits, from 23 to 41 deliveries, and from 16 to 29 PNC visits.

Technical Areas • As of December 2017, 141 infants received kangaroo mother care in the two hospitals where this practice was introduced. • A total of 1,620 health care providers from more than 750 health facilities received the 2-day HBB training, and ventilation areas called “HBB corners” were established and equipped in more than 750 health facilities.

3 Jacobabad, Kashmore, Matiari, Sujawal, Tando Allahyar, Tharparkar, Thatta, Umerkot.

MCHIP Pakistan End of Project Report ix • Between 2014 and 2017, approximately 9,000 babies in MCHIP program areas were successfully resuscitated using one or more steps of the HBB technique, with a survival rate of 98%. • CHWs distributed 3,616 doses of CHX to the community for the prevention of newborn sepsis. • As of December 2017, more than 520 MNCH and CEmONC centers in MCHIP-supported districts were implementing the updated pneumonia and diarrhea guidelines. During the project period (2013–2017), a total of 300,184 and 1,001,585 children under 5 years of age received treatment for pneumonia and diarrhea, respectively, from MCHIP-trained health care providers within the target 16 districts. • MCHIP supported the registration of 28,566 villages, 830,610 children, and 348,315 pregnant women for routine immunization. During project implementation, among registered children, the percentage fully immunized increased from 26% to 52%; among registered pregnant women, the percentage vaccinated with two doses of tetanus toxoid vaccine increased from 26% to 65%. • As part of the Expanded Program on Immunization/Polio Eradication Initiative, more than 16,835 outreach sessions were conducted during national and subnational polio immunization days and more than 300,000 children were vaccinated for different antigens (including oral polio vaccine and inactivated polio virus vaccine) from May 2016 to June 2017. • For all projectservice delivery points, including the training institutes, a total of 34,431 postpartum intrauterine contraceptive devices and 28,556 implants were inserted during the life of the project. • MCHIP conducted around 600 cooking demonstrations in 10 districts, reaching 2,000 women. Cooking demonstrations are now part of the LHW nutritional strategy. • Nutrition technical officers conducted male engagement sessions, attended by 2,800 men, in seven districts. MCHIP also supported DoH and the Nutrition Support Program with information, education, and communication materials for the Global Breastfeeding Week celebration in Karachi. MCHIP organized 15 events (one in each district) to celebrate Global Breastfeeding Week in collaboration with DoH in August 2016. • MCHIP implemented a QI approach at 1,040 health facilities in the 16 target districts of Sindh, and improvements in quality were measured across all technical areas. • MCHIP used the Standards-Based Management and Recognition-Education (SBMR-E) QI approach to improve the quality of pre-service education, initially in five schools and subsequently scaled up to another 10 schools across the 16 districts. One activity included revising the community midwife curriculum to include updated and evidence-based content so the lessons now include 60% theory and 40% clinical practicum (previously, no clinical practicum was provided).

x MCHIP Pakistan End of Project Report 1 High-Level Results

The Maternal and Child Health Integrated Program (MCHIP) Associate Award is part of the United States Agency for International Development (USAID) Pakistan’s larger strategic Maternal and Child Health (MCH) Program in Sindh (2013–2018), which aimed to improve women’s and children’s health status through increased service delivery and strengthened health systems. The MCH Program has six components (described in Table 1): family planning and reproductive health (FP/RH), maternal, newborn, and child health (MNCH) services, behavior change communication (BCC), health commodities, health systems strengthening (HSS), and Health Policy Plus (HP+) (the latter added toward the end of the program).

Table 1. Six components of the Maternal and Child Health Program in Sindh (2013–2018) Component Lead Key interventions Family planning/ Marie Stopes Society Build family planning networks and strengthen reproductive reproductive health health care in the public and private sectors through franchising, voucher systems, and community outreach models Maternal, newborn, and Jhpiego through the Introduce and scale up high-impact and evidence-based child health services Maternal and Child maternal, newborn, and child health interventions, Health Integrated incorporating birth spacing and family planning Program Behavior change Johns Hopkins Use commercial marketing techniques and behavior change communication University Center for communication methods to position products and services with Communications messages that increase knowledge, create demand, and Programs promote healthy behaviors Health commodities DELIVER Provide technical assistance to strengthen government’s capacity to estimate contraceptive commodity needs, undertake transparent procurement, manage supply chain distribution systems, and provide a logistics management and information system Health systems John Snow, Inc. Provide technical assistance to health and population sectors strengthening at the federal, provincial, and district levels to reform and improve service delivery in a postdevolution operating environment Health Policy Plus Palladium Strengthen population sector stewardship, engage private sector in high-quality family planning services, strengthen policy advocacy, and foster media engagement in family planning issues

To assess the MCH Program results, USAID Pakistan implemented baseline, midline, and endline surveys. USAID contracted with AC Nielsen to conduct a baseline survey of performance indicators in 2013, prior to the start of the MCH Program. The survey provided data on key indicators required to monitor implementation of the program’s MNCH and FP/RH interventions. AC Nielsen conducted another survey in 2014 as a follow-up to the baseline. The Performance Management Support Contract (PERFORM)4 conducted similar surveys in 2016 and 2017 to measure changes in key MCH performance indicators since the 2013 baseline survey.

4 Under PERFORM, a centralized management support contract, MSI provides performance management support to international development programs throughout Pakistan.

MCHIP Pakistan End of Project Report 1 1.1 SURVEY RESULTS The 2017 survey data reveals that most MCH indicators improved in the MCH Program districts.5,6 The findings, listed by MCH Program component, are summarized below.

Antenatal Care, Births, and Postnatal Care • Antenatal care (ANC) coverage increased not only in general but also among the poorest, rural, and uneducated women. The percentage of women in focus districts who received any ANC from a skilled provider increased from 73.9% in 2013 to 86% in 2017. • Similarly, the proportion of women having at least four ANC contacts with skilled providers increased from 31% in 2013 to 41.8% in 2017. • ANC services provided in public sector facilities in the focus districts increased from 22.5% in 2013 to 33% in 2017. • Skilled deliveries in focus districts increased from 55.1% in 2013 to 69.9% in 2017. • The use of misoprostol in home deliveries increased from 0.5% in 2013 to 8.5% in 2017. • The proportion of women who received postnatal care (PNC) within 2 days of delivery increased from 36.2% in 2013 to 81.9% in 2017. • Newborn care practices also improved in focus districts, for example, the practice of rubbing and massaging babies after birth increased while the practice of bathing infants within 6 hours of birth decreased, and there was an increased use of skin-to-skin touch with mothers after birth.

Family Planning • The percentage of women who reported that they have ever used a contraceptive method increased from 23% in 2013 to 32% in 2017. • The percentage of married couples using modern FP methods such as injectables, pills, female sterilization, and implants also increased. • The percentage of couple who said they intended to use contraceptives in the next year increased from 29% in 2013 to 44% in 2017. • There was increased uptake of contraceptives in public sector facilities in 2017 as compared to 2013.

Immunizations • Vaccination coverage improved for most types of vaccines, and the proportion of children who received all basic vaccines increased from 15.3% in 2013 to 56.7% in 2017. • The percentage of infants receiving DPT3 by the age of 12 months increased from 16.5% in 2013 to 48.3% in 2017.

5 Dadu, Khairpur, Tando Allahyar, Tharparkar, Thatta, Sujawal, Jacobabad, Umerkot, Naushero Feroz, Sukkur, Shikarpur, Ghotki, Larkana, Mirpur Khas, Matiari, and Sanghar 6 MCH performance indicators survey 2017, Draft Report, June 2018, PERFORM, MSI

2 MCHIP Pakistan End of Project Report Communication • The proportion of mothers who reported having received any information about MCH from various sources increased between 2013 and 2017, and the increase was evident for all information sources. • Among the 13 noted sources of MCH information, mothers from rural and urban areas considered doctors, lady health workers (LHWs), and television as most significant. • The percentage of women who recalled hearing or seeing a specific United States government (USG)-supported message on FP/RH increased from 11.7% in 2013 to 25.2% in 2017.

MCHIP Pakistan End of Project Report 3 2 Background 2.1 SITUATIONAL ANALYSIS Although the proportion of deliveries by a skilled birth attendant (SBA) (referred to here as SBA rate) in Pakistan increased substantially in the last 6 years, Pakistan did not meet its Millennium Development Goal target of 90% of deliveries assisted by an SBA. In Sindh, the institutional delivery rate increased from 42% to 59% (i.e., 17 percentage points in only 6 years7). This increase is in sharp contrast to less pronounced progress in other health service utilization indicators. For example, • The modern contraceptive use rate increased by 15 percentage points in 22 years in Sindh, to reach only 25% by 2012–2013.8 • The immunization rate actually decreased by 6 percentage points (from 35% in 1990–1991 to 29% in 2012–2013). • The 2006–2007 Pakistan Demographic and Health Survey (PDHS) estimated the maternal mortality ratio in Sindh (including both urban and rural areas) at 314 maternal deaths per 100,000 live births9; a 2012 The maternal mortality ratio in rural areas is expected to be significantly higher than the provincial average.

The 2012–2013 PDHS also puts rural Sindh in the lower ranks for MNCH indicators, such as SBA coverage, FP use, and neonatal mortality rate.

Sindh is unique in terms of its large urban population (more than 50%). Therefore, the indicators reported for the province do not necessarily represent the rural areas accurately. According to the 2012–2013 PDHS, in rural areas of Sindh,10 an SBA was reported to have been present at only 49% of births in the previous 5 years, and 46% of births occurred in a health facility (34% in a private health facility). Although about 68% of pregnant women received ANC from a skilled provider, only 36% were informed about signs of pregnancy complications; 0% received iron-folic acid (IFA) tablets; 26% had their weight measured during the ANC visit; and about 30% were not protected against tetanus. In addition, 38% of women and 62% of newborns received no postnatal/neonatal checkup. In contrast, 80% of pregnant women who came for ANC were given an ultrasound. In rural Sindh, 86% of women reported at least one barrier to accessing health care, including getting permission to go for treatment (30%), getting money to pay for treatment (48%), distance to the health facility (68%), and lack of transport (76%).

Although the institutional delivery rate has increased, there is little evidence that the quality of maternal health services has improved. For example, the 2013 MCH Indicator Survey (conducted by MCHIP to collect baseline information on MCH indicators in Sindh and Punjab) found that 76% of women in the project’s focus districts in Sindh attended at least one ANC visit during their last pregnancy. However, the survey found that only 4% of women received quality ANC care based on the seven selected services reflecting ANC quality.11 Similarly, MCHIP’s study of observed quality of care identified some crucial lapses. For example, oxytocin was administered within 1 minute of birth in 51% of cases, newborn vital signs and weight were measured in one of 10 cases, and breastfeeding was initiated during the first hour of birth in

7 Agha, Sohail. 2013. Key findings from the DHS surveys and the MCH Indicator Survey: substantial increases in institutional delivery in Sindh Province along with low quality services provision. Presented at the MCH Program Strategic Retreat, Karachi, Pakistan (September 16–19). 8 The 1990–1991 DHS showed that modern contraceptive use was 9%. 9 Pakistan Demographic and Health Survey [PDHS] 2006–2007 10 PDHS 2012–2013. 11 These services are measuring blood pressure, taking urine and blood samples, advising women to take iron tablets during pregnancy, giving women two tetanus shots, weighing women, and informing women about danger signs.

4 MCHIP Pakistan End of Project Report only one of five cases.12 Overall, these findings suggest that the quality of maternal health service provision needs a great deal of attention. In the absence of improved quality, increasing the SBA rate may not be sufficient to reduce maternal mortality.

2.2 LANDSCAPE ANALYSIS Public sector MNCH and FP services are present in all 29 districts of Sindh. The DoH is responsible for the services provided through public sector health facilities and community health workers (CHWs). These health facilities include tertiary hospitals, district headquarters (DHQ) hospitals, and tehsil [subdistrict] headquarters (THQ) hospitals for 24/7 comprehensive emergency obstetric and newborn care (CEmONC) services; rural health centers (RHCs) for 24/7 basic emergency obstetric and newborn care (BEmONC) services; and basic health units (BHUs) for preventive MNCH services. In the public sector, the Population Welfare Department (PWD) has the mandate to provide FP services.

Through its MNCH Program, the DoH also manages community midwives (CMWs), a relatively new cadre in Pakistan, introduced by the government in response to low SBA rates in rural Pakistan. Assessments to date have found that these CMWs have yet to emerge as significant providers for a number of sociocultural, geographic, and financial reasons.

The DoH also houses the LHW Program, which is responsible for LHWs, the frontline health workers in Pakistan. The DoH Sindh reports 23,185 LHWs currently deployed in Sindh. LHWs are generating awareness of primary health care services and linking the community to the facility. In Sindh, large areas are uncovered by LHWs. To address this gap, nongovernmental organizations (NGOs) have initiated other CHW programs.

The People’s Primary Healthcare Initiative (PPHI), initiated as a public-private partnership (PPP) of the DoH Sindh, is another important player in the province. The DoH Sindh gave PPHI responsibility for more than 1,140 rural health facilities in 22 districts of Sindh. PPHI recognized a lack of technical capacity in MNCH and FP at the facilities it was managing and showed a strong willingness to increase the uptake and quality of these services.

In Sindh, the private sector also serves as a primary source of maternal health services, including in the rural districts: seven out of 10 women who received ANC obtained this care from the private sector; eight out of 10 women who delivered in a health facility did so in a private sector facility. Little investment has been made in improving the quality of private sector maternal health services in Sindh.

2.3 RATIONALE In April 2005, Pakistan’s then prime minister approved the first national MNCH strategic framework. The framework called for the launch of a national MNCH Program to accelerate progress toward Millennium Development Goals 4 and 5. It recommended the following objectives for the national MNCH Program: • Improve access to high-quality MNCH and FP services. • Introduce a new cadre of community-based SBAs (CMWs). • Ensure 24/7 CEmONC services at all public sector secondary hospitals. • Provide FP services through all public sector health facilities.

12 Agha, Sohail, et al. Quality of labor and birth care in Sindh Province, Pakistan: Findings from direct observations at health facilities. Submitted to Plos One.

MCHIP Pakistan End of Project Report 5 • Provide information and education to families and communities with an aim to bring a positive change in MNCH-related behavior and create demand for high-quality MNCH services.

The national MNCH Program was launched in 2006 and was later devolved to provinces under the 18th Constitutional Amendment in 2010. In addition, several large-scale donor-supported MNCH and FP intervention projects were launched in selected districts. Increases in SBA rates and facility-based deliveries demonstrate the overall impact of these efforts.13 However, progress in other MNCH areas was less than satisfactory, as noted earlier, particularly for neonatal health and FP. Moreover, access to high-quality MNCH services remained severely limited in rural areas of Sindh.

The MCHIP Associate Award in Pakistan was designed to increase the SBA rate, resulting in a decline in the maternal mortality ratio and neonatal mortality rate. In its target districts, the project aimed to ensure that existing private and public sector facilities provide SBAs on a 24/7 basis. The project aimed to strengthen and advance the skills of the providers running these facilities through refresher training and clinical skills update programs.

The project aimed to establish 1,000 functional SBA facilities in its target districts, with links to high-quality 24/7 emergency obstetric and newborn care (EmONC) facilities through an active referral and transportation system. The project also focused on increasing community awareness of FP, MNCH care, and SBA services, and on mobilizing community resources to streamline pre-hospital transportation services.

13 PDHS 2012–2013

6 MCHIP Pakistan End of Project Report 3 MCHIP Interventions

MCHIP, the USAID Bureau for Global Health’s flagship MNCH program from 2008 to 2014, was designed to bring together multiple technically specific programs in MNCH/FP under one mechanism. MCHIP had a diverse portfolio and provided technical assistance in more than 50 countries. The MCHIP Associate Award in Pakistan was led by Jhpiego in collaboration with Save the Children, JSI, and PATH. MCHIP’s team combined technical leaders from across the spectrum of MNCH/FP intervention areas with operations experts in quality assurance, BCC, social mobilization, and high-quality research, analysis, and evaluation. MCHIP in Pakistan started in February 2013 and ended in March 2018, lasting 5 years and 2 months including start up and close out.

MCHIP’s goal was to facilitate provision of high-quality comprehensive MNCH services to all women, couples, newborns, and children under 5 years of age in 16 districts of Sindh. Five interrelated principles guided its strategic approach: • Expand interventions with proven effectiveness. • Maximize resources through proven strategies. • Leverage existing efforts of programs and partners. • Focus on program learning. • Assume a technical leadership role.

During its inaugural year, MCHIP set forth a vision and legacy to guide its activities: • Vision: MCHIP, the MNCH services component of USAID’s MCH Program, will prevent maternal, newborn, and child deaths by ensuring skilled birth attendance through a total market approach (public and private sector), empowered communities, timely referral to EmONC, and improved access to child health care. • Legacy: MCHIP will leave behind 1,000 MNCH centers—public and private health facilities that provide high-quality MNCH services and are linked with EmONC facilities through an active referral and transportation system.

These were slightly modified over the course of the intervention, but the central aim remained unchanged.

3.1 GEOGRAPHICAL SCOPE MCHIP worked in 16 of the 29 districts in Sindh.14 MCHIP implemented a phased approach (see Table 2), starting with five districts in years 1 and 2, adding five districts in year 3, and adding another five districts in year 4 (see Figure 1). The district of Thatta was split into two (Thatta and Sujawal) during the implementation phase, increasing the total number of districts to 16. These districts were selected in collaboration with DoH Sindh and USAID based on a rigorous analysis of key social indicators from the 2010–2011 Pakistan Social and Living Standards Measurements Survey.15 The selection criteria also sought balance between districts that were more and less accessible and more and less challenging to work in.

14 Dadu, Khairpur, Tando Allahyar, Tharparkar, Thatta, Sujawal, Jacobabad, Umerkot, Naushero Feroz, Sukkur, Shikarpur, Ghotki, Larkana, Mirpur Khas, Matiari, and Sanghar. 15 Pakistan Social and Living Standards Measurements Survey of 2010–2011

MCHIP Pakistan End of Project Report 7 Table 2. Intervention districts by project year Phase Project year Districts I Y1 Dadu, Khairpur, Tanda Allahyar, Tharparkar, and Thatta (Sujawal) I Y2 Dadu, Khairpur, Tanda Allahyar, Tharparkar, and Thatta (Sujawal) II Y3 Y1–Y2 districts, plus Naushehro Feroze, Jacobabad, Sanghar, Umerkot, and Sukkur II Y4 Y1–Y3 districts, plus Gothki, Shikarpur, Mirpurkhas, Matiari, and Larkana II Y5 Continuation and consolidation of work in all project sites

Figure 1. Map of project districts by project year (Note: Thatta was split into two districts after the start of MCHIP, but is treated as one district for project implementation and evaluation purposes.)

Year 1-2

Year 3-5

Year 4-5

8 MCHIP Pakistan End of Project Report 3.2 PROJECT STRATEGIC FRAMEWORK Village Figure 2. The project strategic framework, based on providing a continuum of care to women throughout their reproductive lives

The project strategic framework (Figure 2) revolved around the continuum of care. SBA services are only a part of the continuum of care that a woman needs during her reproductive life. Some services should be provided closer to the woman’s home, while other, more complex services can only be available in a hospital, to which women, newborns, and children should have easy access. The project worked to ensure continuum of care along two dimensions:

Time (stages in a woman’s reproductive life): • Pre-pregnancy: FP, nutrition, information, and preparation for pregnancy • Pregnancy: ANC, nutrition, information, birth preparedness, immunization, transportation, EmONC (basic and comprehensive), and postabortion care • Labor and delivery: SBA, transportation and referral linkages, EmONC (basic and comprehensive), misoprostol to prevent postpartum hemorrhage (PPH), Helping Babies Breathe (HBB), and chlorhexidine (CHX) to prevent infection • Postpartum and neonatal period: Postpartum and newborn care; early initiation of exclusive breastfeeding; maternal nutrition; postpartum FP, including postpartum IUD; transportation; and EmONC (basic and comprehensive) • Infant and child health: Exclusive breastfeeding until 6 months, FP, infant and child care, weaning and feeding practices, and immunization

MCHIP Pakistan End of Project Report 9 Space (location of MNCH care services) (see Table 3): • Providing information and education to communities: Women and their families, particularly their husbands, need accurate information about MNCH and FP. The LHW Program fulfills this need to some extent. Following a principle of information and education for empowerment and change, MCHIP’s integrated community mobilization strategy centered on married women of reproductive age, their husbands, and the communities at large. The community mobilization aimed to provide necessary and relevant information to create positive behavior change and uptake of MNCH care, particularly FP, ANC, nutrition, SBA use, postpartum care, and newborn care. Where LHWs were not available, the project planned to introduce CHWs. • Bringing high-quality SBA and BEmONC services closer to women’s homes: MCHIP adopted a total market approach16 to ensure that high-quality skilled birth attendance and BEmONC services were within reach of every woman in its target areas. MCHIP selected SBA facilities for technical support and quality improvement (QI) based on their location and accessibility. For remote areas of the districts, where no SBA facility was available, MCHIP introduced mobile SBA clinics led by CMWs or lady health visitors (LHVs). Finally, MCHIP introduced a telehealth service and an organized system for pre- hospital transportation with special consideration for remote areas. • Improving quality of CEmONC services at public and private health facilities: MCHIP recognizes that access to CEmONC services (mainly surgical obstetrics and blood banks) is key to reducing maternal and neonatal mortality. MCHIP worked with facilities in the public and private sector to provide high-quality CEmONC services.

Table 3. MCHIP interventions by space along the continuum of care model Home/village Skilled birth Linkages, referrals, Basic emergency Comprehensive (lady health worker/ attendant-led facility and follow-up obstetric and emergency obstetric community health (community midwife, newborn care and newborn care worker) lady health visitor, or (skilled birth (public/private doctor) attendant, rural hospital) health center, or private maternity home) . Information, . Safe and clean . Telehealth system . Injectable . Surgical education, and delivery antibiotics obstetrics (e.g., communication . Recognition of . Magnesium cesarean . Birth danger signs sulfate section) preparedness . Oxytocin . Blood bank . Recognition of danger signs . Postpartum . Postpartum . Pre-hospital . Manual . Training hemorrhage hemorrhage transportation removal of facilities for prevention prevention placenta skilled birth (misoprostol) (oxytocin and . Basic neonatal attendants . misoprostol) resuscitation . Postpartum IUD . Postabortion care and postabortion care

16 A total market approach is a coordinated approach that responds to a country’s health needs to ensure that the entire client market is covered. It accounts for differences in populations regarding willingness or ability to pay for health-related services and goods. The approach recognizes the contributions made by different public, NGO, and private suppliers in meeting client needs. It attempts to avoid duplicative efforts, inefficient use of resources, and undefined goals. (Definition by USAID’s DELIVER Project.)

10 MCHIP Pakistan End of Project Report Home/village Skilled birth Linkages, referrals, Basic emergency Comprehensive (lady health worker/ attendant-led facility and follow-up obstetric and emergency obstetric community health (community midwife, newborn care and newborn care worker) lady health visitor, or (skilled birth (public/private doctor) attendant, rural hospital) health center, or private maternity home) . Community . Postpartum family . Referral protocols . Removal of . mobilization planning retained . Nutrition in . Vaccination products (vacuum or pregnancy . Nutrition advice manual) . Vaccination . Postpartum family . Referral . . Assisted . planning vaginal delivery . Counseling Chlorhexidine . Quality improvement . Voucher management . Community engagement . Business skills training of community midwives . Refresher training programs . Clinical skills updates . Private sector partnership for infrastructure development and sustainability

MCHIP Pakistan End of Project Report 11 4 MCHIP Associate Award Activities and Results by Objective 4.1 MAPPING HEALTH SERVICES IN THE DISTRICTS Prior to starting the interventions, MCHIP invested in a mapping of health services in the districts. The purpose of mapping was to gather detailed information on the quantity, location, and capacity of health care services across the continuum of care to guide where and how to direct efforts.

MCHIP followed a two-step process for mapping: 1. Cross-referenced facility maps from districts and previous projects with secondary data from the USAID projects and partners who were functional at the time of the exercise. 2. Surveyed facilities using the geographic information system (GIS) survey method. The survey tool collected information on location, clinic type, provider qualifications, services offered, volume, and LHW availability in the surrounding community.

MCHIP mapped a total of 2,944 facilities in 10 An MCHIP data collector filling an electronic form after collecting information from a health target districts of Sindh (see Figure 3).17 MCHIP then provider. Photo: MCHIP uploaded the mapped information to the GIS web portal.

MCHIP used the data from the mapping exercise for the following purposes: • Select facilities to be part of the upgrading and QI interventions. • Identify SBAs and LHWs for MNCH interventions. • Identify areas not currently covered by LHWs.

After this baseline mapping, the activity was discontinued at the government’s request due to security concerns.

17 Dadu, Khairpur, Thatta, Tharparkar, Tando Allahyar, Sukkur, Umerkot, Jacobabad, Sanghar, and Naushero Feroz

12 MCHIP Pakistan End of Project Report Figure 3. Geographic information system mapping of Tando Allahyar district showing facilities that offer five services: antenatal care, family planning, newborn care, normal vaginal deliveries, and postnatal care (BHU: basic health unit; DHQ: district headquarters hospital; GD: government dispensary; RHC: rural health center; THQ: tehsil [subdistrict] headquarter hospital)

4.2 STRATEGIC OBJECTIVE 1: INCREASE ACCESS TO MNCH SERVICES THROUGH COMMUNITY MOBILIZATION Women and families in rural Sindh lack awareness of complications that may arise during pregnancy and the availability and importance of an SBA during pregnancy, birth, and the postnatal period.18 Additionally, access to care, social and cultural norms related to decision- making to seek care, and perceptions of low quality of care act as barriers to seeking care.19 The community plays a key role in building and maintaining support for health care seeking behavior, addressing maternal morbidity and mortality, and reducing delays in decision-making around critical care. Under MCHIP, community mobilization aimed to • Strengthen key home behaviors that support improved MNCH outcomes and • Create linkages between community members and health facility providers for increased dialogue and shared responsibility for providing quality MNCH services.

MCHIP’s community mobilization interventions, such as advocacy events, in the 16 target districts focused primarily on building capacity of LHWs and lady health supervisors (LHSs) (LHSs in six districts only), women’s support groups (WSGs), and service delivery. The interventions followed a community-based QI approach.

18 Maternal and Child Health Program Indicator Survey 2013. Sindh Province, MCHIP, unpublished. 19 Khan, S. 2012. Poverty, gender, inequality and social exclusion and their impact on maternal and newborn health in Pakistan. A briefing paper. Maternal and Newborn Health Programme. Research and Advocacy Fund (RAF), Pakistan. 62 pp.

MCHIP Pakistan End of Project Report 13 4.2.1 LHW Program Strengthening MCHIP worked closely with the Pakistan Ministry of Health to revitalize the LHW Program. Although this program is regarded as the most successful public sector program in Pakistan, after the 2010 devolution the LHW Program suffered in Sindh. When MCHIP started field activities in 2013, few LHWs were making routine home visits or conducting WSGs—the program’s two central functions. Together, the USAID MCH Program and the LHW Program developed a strategy to revitalize the LHW Program. MCHIP was primarily responsible for training LHWs in WSG methodology and interpersonal communication (IPC) in six districts, service delivery through the LHW Program in all 16 districts, and support to the LHW Program at the provincial level. Training of LHWs in WSG methodology and IPC in the other 10 districts was carried out by the communications component of USAID Pakistan’s MCH Program.

To build capacity of the LHW Program, MCHIP focused on the following areas: • Coverage for areas uncovered by LHWs • Implementation of WSGs • Real-time monitoring of WSGs • IPC toolkit • Distribution of CHX and misoprostol • Nutrition • Immunization • Mother’s Booklet

Coverage for Areas Uncovered by LHWs To increase coverage of primary health services in Sindh, MCH Program partners hired CHWs in areas not covered by LHWs. The CHW workforce aimed to create awareness and increase demand for quality MNCH/FP services at the community level. CHWs also ensured commodity security and strengthened the supply chain to the BHU level. The program hired CHWs using criteria and a process similar to that adopted by the LHW Program: • Resident of the assigned area/population • Minimum eighth grade education • Between 18 and 45 years old • Preferably married • Family support to perform assigned duties • Willing to go house-to-house for monthly visits

In year 2 of the project, MCHIP recruited and deployed 484 CHWs in six districts. The areas covered by CHWs had populations of 600–800, or about 100–120 households. The deployed CHWs used community mobilization to generate demand. They made regular household visits, registered all family members, including couples and children, eligible to receive MNCH/FP services, and conducted support group meetings using all the instruments used by LHW (khandan register, daily diary, etc.). Like LHWs, the CHWs each established four support groups in their catchment area and organized two support group meetings every month. They also coordinated with the local vaccinator to immunize children and women, and attended monthly LHW meetings at the respective health facilities when possible.

14 MCHIP Pakistan End of Project Report In 18 months, these CHWs visited more than 150,000 households and registered 37,704 families. They also distributed 3,616 doses of CHX for the prevention of newborn sepsis.

Implementation of WSGs MCHIP supported LHWs to organize WSGs to improve birth preparedness with an emphasis on ANC, SBA delivery, essential newborn and postpartum care, identification of danger signs in pregnancy and the postpartum period, and identification of transportation during emergency. These WSGs were moderated by trained LHWs and CHWs. The WSGs had 10 to 15 members, including pregnant women, lactating mothers, newly wed women, mothers-in-law, sisters-in- Lady health workers conducting support group meeting law, and experienced mothers. The WSGs in Tharparkar District. Photo: MCHIP promoted social networking and social support within communities and met regularly to develop and implement group problem-solving and self-help initiatives (moral, emotional, and financial).

MCHIP trained 781 provincial master trainers and district trainers in WSG methodology. Subsequently, 4,040 LHWs and CHWs were trained in six MCHIP districts (Tando Allahyar, Tharparkar, Dadu, Thatta, Sujawal, and Khairpur). Each LHW/CHW conducted two WSG sessions per month. These LHWs and CHWs reached more than 1.8 million women through 169,134 WSG meetings over the life of the project. At the WSGs, LHWs gave out referral slips to health facilities, which the health facilities collected when the women visited facilities. WSGs have ultimately led to increased referrals from communities to health facilities (from 312 in December 2014 to 45,938 in December 2017).

Real-Time Monitoring of WSGs MCHIP introduced an Android-based application for real-time monitoring of WSG quality and meeting frequency, including how facilitators introduced a topic, delivered content, facilitated question and answer sessions, managed interactive discussions, and summarized discussion and conclusion sections. Android tablets were provided to LHSs in 10% of WSGs in six districts. The LHSs used the tablets to document real-time feedback and observations, and gave feedback to LHWs, including actions they should take to improve in areas where their skills were weak. MCHIP, in collaboration with the LHW Program, has monitored about 13,014 WSGs in real time using this application.

IPC Toolkit Another important component in demand generation is appropriate communication with the community. A revised IPC toolkit, developed by the Johns Hopkins University Center for Communications Programs, enabled LHWs to effectively engage with clients and their families, impart knowledge, listen and empathize, support problem-solving, and ultimately help their clients to adopt the desired behaviors. MCHIP trained 224 trainers on IPC, and they subsequently trained 3,206 LHWs in the six MCHIP districts.

Distribution of CHX and Misoprostol MCHIP trained 781 provincial master trainers and district trainers on counseling, distribution, and use of CHX gel tubes for umbilical cord protection in newborns, and counseling women on the use of misoprostol to prevent PPH. Overall, 15,336 LHWs were trained in 16 districts.

MCHIP Pakistan End of Project Report 15 MCHIP procured and supplied CHX for distribution in the targeted districts. LHWs have distributed about 700,000 CHX gel tubes to pregnant women. MCHIP also pilot tested the distribution of a “day of birth” package to pregnant women during their last trimester. This package include a tube of CHX and three misoprostol tablets, along with pictorial guidelines on their use. The LHWs were trained to distribute the package to pregnant women in their villages and explain the instructions. The women were instructed to take the package when they visited a health facility for delivery or use it when delivering at home.

Nutrition MCHIP revised and updated the LHW Program’s nutrition curriculum to include maternal, infant, and young child nutrition (MIYCN), which the LHW Program reviewed and endorsed. MCHIP trained 20 LHSs from 10 districts on the MIYCN package, and the LHSs subsequently trained 3,155 LHWs. As a result, about 2,000 mothers of young children (6–23 months) attended cooking demonstration sessions about how to use locally available foods to feed their children. Finally, MCHIP-trained LHWs distributed 56,230 IFA tablets along with pictorial information brochures to pregnant women in 10 districts.

Immunization MCHIP trained 2,371 LHWs on routine immunization (RI) activities in eight districts where MCHIP implemented its outreach model for increasing immunization coverage. The LHWs worked closely with the district immunization teams, including vaccinators and village volunteers, to arrange immunization activities in villages (See Routine Immunization section for results).

Mother’s Booklet MCHIP developed Sehat se Zindagi (Health Leads to Life), also known as the Mother’s Booklet, in close coordination with the Sindh LHW Program. Sehat se Zindagi was intended to serve as supplementary material to an existing booklet, Sehat ki Dastak, used by LHWs and CHWs in Pakistan to educate women in their communities on MNCH best practices. MCHIP felt that women needed a booklet to keep at home as a reference. This booklet also helped LHWs and CHWs to educate rural, illiterate, and semiliterate families to take charge of their health and encourage them to seek care. The booklet was developed through a series of consultative meetings with stakeholders and another series of consultative meetings with LHWs. MCHIP oriented the LHWs on use of the Mother’s Booklet and provided more than 20,000 (5,000 Urdu, 15,000 Sindhi) copies for distribution to pregnant women in the catchment population.

4.2.2 Advocacy Events MCHIP also addressed male involvement, an important component of maternal and child health, through mobilization events. Mobilization events convened groups of 150 men from the district to generate awareness for improving maternal and child health, share information about services available at their respective health facilities, and show appreciation and recognition for quality improvement teams (QITs) and health facility staffs. MCHIP supported 25 events each year of phase I (at the initial five districts) at targeted health facilities.

16 MCHIP Pakistan End of Project Report 4.2.3 Partnership-Defined Quality To encourage community members to seek health services, MCHIP implemented a community mobilization methodology called partnership-defined quality (PDQ). PDQ aimed to improve the quality and accessibility of services by involving the community in defining, implementing, and monitoring the QI process.

In the Working in Partnership phase, QITs were formed in each community. In Sindh, a total of 150 QITs were formed. The QITs, composed equally of community members and health service providers, developed action plans to address priority issues, assigned roles, developed a timeline, and met monthly to maintain momentum.

The meeting proceedings and progress made by QITs were tracked through selected MNCH indicators at the facility level, as reported in the district health information system (DHIS). Facility supervisors and staff obtained additional progress indicators through biannual self- assessments using quality improvement and patient safety (QIPS) checklists. The QIPS self- assessments served as a direct measure of QIT progress because the initial assessment findings helped to identify quality gaps that were then included in the action plans. Whereas the DHIS provided key information on service utilization, the QIPS assessments provided information on quality and performance.

Most of the selected service indicators suggest substantive increases in the use of services from onset of the PDQ in January 2016 to September 2017.20 The selected DHIS service indicators and measured changes were: • Number of antenatal checkups attended by pregnant women increased by 33%. • Number of women who labored and delivered in health facilities increased by 46%. • Number of new mothers who sought PNC within 2 days of delivery increased by 80%.

4.3 STRATEGIC OBJECTIVE 2: IMPROVE THE QUALITY OF MNCH SCOPE AND SERVICES AT PUBLIC AND PRIVATE HEALTH FACILITIES 4.3.1 Creation of MNCH Centers Providing comprehensive, high-quality MNCH services close to women’s homes is a core strategy for reducing maternal and newborn mortality. To achieve this, MCHIP invested in the development of MNCH centers. The MNCH center concept evolved from CMW-led birthing centers, and was originally proposed for all health facilities providing a full spectrum of maternal, newborn, and child health services.

Through the life of the project, MCHIP worked in 1,108 MNCH centers and 37 CEmONC centers (Figure 4). (See Objective 4 for further discussion of CEmONC centers.)

In year 1, MCHIP worked with 32 midwife-led birthing centers (MLBCs). In year 2, because fewer CMWs were available than originally anticipated, MCHIP expanded the MLBC concept to include other SBA-led facilities, or MNCH centers. The shift in focus (from CMWs to all types of SBAs, in both public and private sectors) also expanded MCHIP’s efforts to encourage women and families to access quality health care within the existing system of facilities and providers. In year 2, MCHIP worked in 214 MNCH centers in five districts. This included five types of primary level health facilities: 1) government health facilities managed by DoH, 2) government health facilities outsourced to private organizations (PPHI, Integrated Health Services [IHS], Medical Emergency Resilience Foundation [MERF]), 3) NGO-run private health facilities, 4) for-

20 Details available in the MCHIP Pakistan report, Harnessing Participation to Improve Quality in Health Facilities, December 2017.

MCHIP Pakistan End of Project Report 17 profit (commercial) private health facilities, and 5) CMW-run private practices. Table 4 details the criteria MCHIP developed for MNCH centers.

In years 3 and 4, MCHIP expanded rapidly, ending with 943 MNCH centers and 37 CEmONC centers in year 4. In May 2016 (more than halfway through year 4), MCHIP no longer provided direct support to the 449 PPHI facilities; however, PPHI continued to implement MCHIP-led interventions at its facilities through MCHIP seconded technical staff, who became part of the regular staff at PPHI. At the end of year 5, after PPHI’s departure, MCHIP was directly supporting 483 MNCH centers and 37 CEmONC centers.

Figure 4. Distribution of 1,108 facilities by type across the 16 target districts

120

100

80

60

40 Number of facilities Number of

20

0

District

Private health facility People’s Primary Healthcare Initiative-managed health facility Nongovernmental organization-run health facility Department of Health-managed health facility Community midwife-led birthing center

Table 4. Criteria facilities must meet to be designated an MNCH center Criteria Details Facility operating hours . In addition to facilities open 24 hours/7days a week (24/7), work with selected facilities that are open 12 hours/6 days a week or 6 hours/6 days a week but have a skilled birth attendant on call 24/7. . Upgrade “non 24/7” facilities only when they: − Are located in remote areas where no other facilities are available, − Have the potential to be upgraded to 24/7 facilities later (for example, demonstrable commitment to expand hours and resources mapped), − Have linkages with higher-level facilities through functional referral and transport services, and − Have human resources adequate to their specific requirements.

18 MCHIP Pakistan End of Project Report Criteria Details Basic MNCH services . Antenatal care . Normal labor and delivery . Postnatal and newborn care including Helping Babies Breathe . Routine and postpartum family planning, with emphasis on long-acting reversible contraceptives . Basic emergency obstetric and newborn care . Maternal, infant, and young child nutrition . Child health (pneumonia and diarrhea, immunization) Quality of care . Greater focus on quality of care, defined as meeting quality performance standards for all service areas.

4.3.2 Nonstructural Repair and Renovation of Facilities Several MNCH centers needed basic nonstructural repairs and renovations to comply with quality of care standards. MCHIP completed nonstructural repairs and renovations in 66 facilities, six CEmONC centers, and two training centers. Examples of nonstructural repairs and renovations at MNCH and CEmONC centers included repairing and fixing doors and windows, plastering damaged areas of the walls and ceiling, repairing existing pits (for washroom waste and placenta disposal) and sewage lines, repairing taps, installing washbasins, and rewiring. For the training institutes, MCHIP focused on renovating the classrooms, such as painting, electrical wiring, and applying cement.

Tile work involved in a washroom renovation. Photo: MCHIP

4.3.3 Capacity-Building At the start of the project, SBAs in Sindh could not provide quality MNCH services at their facilities for several reasons, in particular knowledge and skills gaps.21 The knowledge and skills gaps can be attributed to several factors, including poor quality of pre-service education and limited opportunities for continuous education.

21 QIPS baseline results 2014. MCHIP, unpublished data.

MCHIP Pakistan End of Project Report 19 Through QIPS, MCHIP’s QI approach, MCHIP invested in building a culture of continuous learning. QIPS (detailed in the MCHIP Associate Award Activities and Results by Cross-Cutting Area section) involves the systematic use of performance standards for assessment, gap analysis, action planning to address these gaps, repeat assessment, and recognition of improvement.

Training Method Based on the periodic QI assessments, MCHIP identified the capacity-building needs of the SBAs at the MNCH centers and tailored its interventions toward these needs instead of imposing a generic learning model. MCHIP employed a mix of capacity-building activities to strengthen provider performance and achieve the QI performance standards. MCHIP delivered trainings in two ways: • Group-based training, where more than four participants gather at an offsite location for a competency- based learning activity, and • On-the-job training (OJT), where individuals or a team of providers participate in a structure learning activity at their facility.

Both group-based training and OJT were followed by continuous supportive supervision through facility-based coaching.

Trainer Development Pathway Before conducting any training in a given technical area, all clinical trainers had to complete the following training pathway: 1. A clinical training skills (CTS) course on best practices for facilitating learning activities and supporting effective knowledge and skills transfer to learners. 2. A co-training experience in which a new trainer is paired with an experienced trainer for mentorship. 3. Training of trainers (ToT) on a learning package to promote standardization of best practices in the technical area. 4. Six United Nations Population Fund e-learning modules on signal functions of BEmONC.

Through this training pathway, MCHIP developed a pool of 46 master trainers across the 16 districts. These master trainers conducted ToT to develop trainers at the district level. The district pool of trainers rolled out the SBA training in the districts shown in Table 5.

Learning Resource Packages MCHIP adapted/developed standardized learning resource packages (LRPs) or learning modules according to the global and national guidelines. Each LRP was prepared in consultation with and later endorsed by DoH Sindh.

20 MCHIP Pakistan End of Project Report Table 5. MCHIP training packages by technical area Technical area Training package Length Target audience Brief description Number trained (# of days) Maternal Pregnancy, childbirth, 6 Skilled birth Management of normal 1,652 (group health postpartum and attendants and routine evidence- based) newborn care based maternal, 4,267 (on-the- newborn, and child care job sessions) including postpartum hemorrhage, pre- eclampsia/eclampsia, and sepsis Management of 4 Skilled birth Postabortion care 546 doctors, complications in attendants (a (uterine evacuation by nurses, and pregnancy and separate manual vacuum lady health childbirth package aspiration or medical visitors without uterine management), assisted 166 community evacuation was vaginal delivery midwives offered for (vacuum-assisted community delivery), episiotomy, midwives) and repair Lactation management 2 Skilled birth Early initiation of and 184 community attendants exclusive breastfeeding midwives 1,375 lady health visitors and doctors (on- the-job training) Family Client-centered family 6 Doctors Client-centered family 880 planning planning and planning counseling, contraceptive implants insertion and removal of implants Advanced family 4 Skilled birth Interval IUCD service 78 planning: intrauterine attendants delivery contraceptive device (IUCD) Postpartum IUCD 4 Skilled birth Postpartum IUCD 681 attendants service delivery and technique Family planning 1 Family Planning policies 506 compliance for health care providers Newborn and Helping Babies Breath 2 Skilled birth Routine newborn care; 1,620 child health attendants resuscitation and ventilation of the newborns Case management of 2 Health care Management of 1,032 pneumonia and providers pneumonia and diarrhea diarrhea Kangaroo mother care 3 Health care Kangaroo mother care 346 providers for premature and low- birthweight babies Routine immunization 2 Vaccinators Routine immunization 89

MCHIP Pakistan End of Project Report 21 Supportive Supervisory Visits Onsite, team-based low-dose, high-frequency (LDHF) learning is more effective than offsite, group-based trainings. Following the LDHF model, MCHIP provided supportive supervisory visits at facilities for continuous learning. During these visits, MCHIP observed providers with clients (when possible) or used models to assess provider performance and service delivery skills. Providers then received real-time feedback and coaching on the particular technical skill area at the facility.

The visits were also guided by the technical capacity gap identified during the QI assessment. During the life of project, MCHIP completed 24,517 supportive supervision visits to the target MNCH centers in the 16 districts. Most visits addressed gaps in neonatal resuscitation, infection prevention, focused ANC (FANC), partograph use, and active management of third stage of labor. (Box 1 lists the range of topics covered during the supportive supervision visits.)

MCHIP is leaving behind 1,145 facilities (MNCH and CEmONC centers) with trained staff capable of providing high-quality MNCH services. With strengthened community and referral linkages, these facilities are also serving more clients than before. For example, between 2014 and 2017, the number of monthly ANC check-ups increased on average from 127 to 176, total deliveries from 23 to 41, and the number of monthly average PNC visits from 16 to 29 per month per facility (see Figure 5).

Figure 5. Increase in average number of antenatal care (ANC) visits, total deliveries, and postnatal care (PNC) visits from 2014–2017, including number of facilities reporting

200 ANC visits 180 160 140 120 100 80 60 Total deliveries 40 PNC visits 20 0 2014 (n=148) 2015 (n=929) 2016 (n=973) 2017 (n=535)

ANC visits Total deliveries PNC visits

22 MCHIP Pakistan End of Project Report 4.4 STRATEGIC OBJECTIVE 3: FACILITATE REFERRAL AND TRANSPORTATION TO HEALTH FACILITIES 4.4.1 Lady Health Worker Referrals MCHIP emphasized the importance of timely referrals to appropriate health facilities, and thus printed and provided referral slips to LHWs. These slips, adapted from the LHW Program, were not available to LHWs prior to MCHIP because of budgetary constraints that prevented the slips from being printed. Therefore, LHWs were not in the practice of systematically making referrals.

To strengthen the referral mechanism, MCHIP sensitized LHWs and health professionals at MNCH centers about their significance. Driver who was trained through MCHIP. Photo: MCHIP MCHIP also installed referral boxes at all MCHIP-associated MNCH health facilities for proper collection and reporting. LHSs collected the slips on a monthly basis and reported the number of referrals by LHW for community members to health facilities, and the number of referrals made between facilities by health care providers (HCPs) at the district and provincial levels.

During the life of the project, LHWs and CHWs made a total of 317,832 referrals from communities to MNCH centers. The number of referrals from the community to the health facility also increased, for example, 312 referrals in December 2014 to 45,938 referrals as of December 2017, or an average of 1,275 per month.

4.4.2 Transport Harsh landscapes, poor infrastructure, and lack of ambulances hinder women and families from reaching MNCH centers in a timely manner. Lack of local transporters adds to the problem. MCHIP identified private, commercial drivers near each health facility in the 16 targeted districts. MCHIP also trained ambulance drivers attached to public health facilities.

MCHIP identified people with a vehicle in each village who were motivated to serve the community. MCHIP trained these transporters on how to safely transport mothers, as well as roles and responsibilities in reducing maternal and child health mortalities and complications. Once trained, the transporters provided transportation services between the community and MNCH centers for emergency and nonemergency services. They charged minimal transport fees compared to their regular fees, and MCHIP reimbursed them for each ride. MCHIP also developed a contact list of these trained transporters to distribute to MNCH centers, to community members during WSGs, and to pregnant women during their visits to SBAs and during community interactions. This played a crucial role in overcoming the geographic and transportation barriers faced in several districts, which affected the accessibility of essential MNCH services.

As a monitoring mechanism, MCHIP developed and distributed transportation slips to trained transporters for recordkeeping. The slip has two parts. The transporter fills out both parts at the time of transportation. After completing the trip, the transporter gives one part of the slip to the MNCH health facility staff, which they place in the same box as the LHW referral slips. Transporters retain the second part for their records. LHSs collected the transportation slips from their respective MNCH centers during monthly meetings with LHWs and submitted them to MCHIP. About 10% of these slips were verified with the transporter and at the community. This helped to ensure the system’s functionality and allowed for feedback sharing.

MCHIP Pakistan End of Project Report 23 Overall, 2,605 transporters were identified and trained on safe transportation. Through September 2017, these transporters safely transported 27,596 patients to health facilities.

4.4.3 Telehealth To reduce the second delay of reaching care, MCHIP introduced telehealth services across 16 districts. MCHIP developed and tested a module for telehealth services, helpline 9123, in collaboration with Aman Health Care Services (AHCS). AHCS call agents were trained to filter emergency calls using an algorithm also developed by MCHIP. If the call is an emergency, the client is referred to a facility and a transporter, if needed. If it is not, the call agents consult with the client.

The helpline can also receive calls from SBAs needing expert guidance. In such a situation the call agent connects the SBAs to an ob-gyn expert. During implementation, the project found that senior gynecologists were often hard to get in touch with, which would translate into long waits for CMWs, who might call during a delivery with complications. To address this, AHCS recruited new graduates (MBBS doctors) through the Child Life Foundation and trained them to use an algorithm so they could receive calls and guide CMWs. Eventually AHCS hired three medical officers for the three shifts (morning, evening, and night) to replace the new MBBS graduates. AHCS trained the hired medical officers along with other call agents on EmONC as per the algorithms.

MCHIP promoted the telehealth helpline number (9123) at the MNCH centers through SBAs, at WSGs through LHWs, and through promotional and marketing material, such as stickers and caps, for transporters. MCHIP concluded the contract with AHCS in March 2017. Prior to closure, MCHIP visited each district and introduced AHCS to district teams, partners, and local NGOs so AHCS can function independently after MCHIP closes out. AHCS reported a total of 1,208 calls received from various districts of Sindh from February 2016 through March 2017.

These calls were not limited to maternal and newborn health but also included calls for transportation, referrals, and other health issues. The telehealth services did not pick up as quickly as MCHIP had anticipated. This may be due to telehealth being an innovation in interior Sindh and communities need time to build trust before discussing their health concerns and receiving health advice over the phone. However, after visiting the districts and communities with AHCS, and encouraging AHCS to follow up with callers and seek their health status, the frequency of the calls increased, from 456 in year 3 to 752 in year 4 (through March 2017).

4.4.4 Maternal and Child Health and Family Planning Camps Through eight small mobile service units (MSUs), MCHIP conducted 63 camps in 13 of its target districts and provided a variety of MNCH/FP services. The eight Bolan were deployed to government-recommended districts and were used by the MCHIP team in nearby intervention districts. In addition, government support, logistics, and human resources were crucial in organizing these MSUs. The camps were organized in collaboration with the DoH, PWD, World Food Program, Society of Obstetricians and Gynecologists of Pakistan, and APPNA Institute of Public Health. Around 5,255 clients visited the camps and received ANC and PNC services, Penta vaccines, and various FP methods.

24 MCHIP Pakistan End of Project Report 4.5 STRATEGIC OBJECTIVE 4: IMPROVE QUALITY AND SCOPE OF COMPREHENSIVE EMERGENCY OBSTETRIC AND NEWBORN CARE AT PUBLIC AND PRIVATE HOSPITALS CEmONC linked with MNCH centers by prompt and effective referral services is essential to the provision of high-quality, lifesaving, advanced MNCH services. CEmONC includes the seven BEmONC functions plus two more, cesarean section and blood transfusion.

Findings from the MCHIP baseline assessment of CEmONC facilities in Sindh found limited coverage of signal functions, unsatisfactory infection prevention practices in operating theaters, use of antenatal corticosteroids noncompliant with the World Health Organization (WHO) recommended guidelines, limited or no use of the birth planning and complication readiness chart, and lack of standard documentation of services.

MCHIP selected 21 public and 16 private CEmONC facilities across 16 districts of Sindh and implemented the following interventions at these facilities.

4.5.1 Perioperative Service Delivery Strengthening MCHIP introduced an innovative approach to improve perioperative service delivery. This innovative model uses a team-based OJT approach that minimizes provider time away from facilities. MCHIP adapted the WHO Cesarean Section Surgical Safety Checklist (CS- SSC), which consist of four components of perioperative care (pre-operative, operative, postoperative, and discharge). Each component has a specific list of items to be checked by HCPs during patient assessment. The checklist focuses on verification of diagnosis including potential complications and comorbidities, readiness of Surgical checklist on display in health facility. staff, and equipment. Photo: MCHIP

MCHIP used the CS-SSC to develop the capacity of perioperative staff including obstetricians, anesthetists, operating theater technicians, and nurses from pre- and post-operation wards. The checklist was introduced to the surgical team during a 2-day workshop, followed by onsite mentoring in the form of operating theater drills.

The CS-SSC included a cesarean section surgical safety checklist and guidelines for its use, and an immediate postoperative safety checklist and guidelines for its use. Additionally, for standardized reporting, MCHIP added a pre-operative checklist, operative notes, postoperative notes, and a discharge checklist. The project also advocated for and encouraged health care facilities to display the checklist in operating theaters for providers to follow during the procedure.

MCHIP collected data on CS-SSC compliance. As Figure 6 shows, the percentage of CS-SSCs fully completed increased from 12% to 24% between the fourth quarter of 2015–2016 and the second quarter of 2016–2017, but decreased to 19% in the final quarter at the 37 target facilities, after project implementation had ended. MCHIP subsequently conducted a qualitative study to understand the low level of CS-SSC compliance. Detailed findings are presented in the Program Learning section. Although the study identified several positive factors influencing the documentation, it also found that the facilities were using several methods to implement the checklist, such as verbal verification without documentation, referencing the job aid, and partial or incomplete documentation. Barriers to implementation of the checklist were unavailability of the printed checklist, length of the checklist, inadequate human resources, and lack of ownership at the district managerial level.

MCHIP Pakistan End of Project Report 25 All women undergoing elective or emergency cesarean section should receive antibiotic prophylaxis to prevent infection. At the MCHIP target facilities, the percentage of women receiving antibiotic prophylaxis prior to cesarean section increased from 78% to 89% toward the end of the project (see Figure 7).

Figure 6. Introduction and percentage completion rates of cesarean section surgical safety checklists (CS-SSCs) at CEmONC facilities, July 2016–September 2017

Figure 7. Number of cesarean sections and coverage of antibiotic prophylaxis, by quarter and project year

26 MCHIP Pakistan End of Project Report 4.5.2 Safe Blood Transfusion Practices MCHIP organized a 2-day “Safe Blood Transfusion Practices” workshop for 281 blood bank technicians and pathologists attached to the CEmONC facilities in 16 districts. The workshop covered the significance of and protocols for safe blood transfusion in obstetric emergencies.

MCHIP signed a memorandum of understanding with the Safe Blood Transfusion Program (SBTP), Islamabad, to engage DoH Sindh in improving the blood transfusion services. DoH Sindh is in the process of privatizing the four regional blood banks in the province. Nine seminars on the promotion of voluntary nonremunerated blood donation (VNRBD) were held in collaboration with SBTP in Thatta, Tando Allahyar, Tharparkar, Umerkot, Sanghar, Mirpurkhas, Matiari, Dadu, and Naushero Feroze; and six VNRBD seminars were held in collaboration with SBTP in Sukkur, Khairpur, Shikarpur, Jacobabad, Larkana, and Gothki. The objective was to list healthy donors at registered public sector blood banks for emergency, safe blood transfusion to build a stable pool of the safest possible blood donations, especially to prevent maternal deaths during labor. At the end of session, the list was available at blood banks with emergency donors’ relevant contact information.

4.5.3 Anesthesia and Analgesia Care in Obstetrics MCHIP organized a separate training session on strengthening anesthesia and analgesia care in obstetrics for operating theater staff and anesthetists. The 5-day workshop focused on the knowledge and skills of anesthetists and best practices in pain management. This workshop series trained 24 anesthetists from 17 CEmONC facilities on anesthesia and analgesia care best practices.

4.5.4 Case Management of Sepsis MCHIP trained 46 clinicians, including pediatricians and nurses, in three planned workshops on case management of sick young infants with possible serious bacterial infections in 13 selected CEmONC hospitals offering inpatient services. All trainings were organized in collaboration with the Child Survival Program of DoH Sindh. In addition, essential equipment for CEmONC, such as pulse oximeters and respiratory timers, were provided in all hospitals for timely and proper assessment and classification of sick young infants.

4.5.5 Quality Improvement and Patient Safety MCHIP assessed the quality of services in CEmONC health facilities biannually using the QIPS process. As part of its QIPS efforts, MCHIP renovated and equipped an operating theater at the DHQ hospital in Thatta to avoid delay in emergency obstetric services due to its heavy caseload. MCHIP also built placental pits, tiled floors, and painted walls to meet operating theater quality guidelines; placed necessary signage; maintained curtain partitions to ensure privacy of female patients; and placed required job aids in eight private CEmONC facilities. (See the Quality Improvement and Patient Safety section for results.)

Figure 8 shows QIPS scores for 29 CEmONC facilities that completed all three rounds of assessment. Between rounds 1 and 3, compliance to the QIPS standards increased. The round 3 results show that 52% of the facilities were complying to 80% or more of the quality standards, whereas in round 1 results show that 0% of the facilities were complying to 80% or more of the quality standards.

MCHIP Pakistan End of Project Report 27 Figure 8. Increased compliance to quality standards across 29 CEmONC centers

100% 90% 80% 70% 60% 50% 40% 30% Percentage compliant 20% 10% 0% Round 1 Round 2 Round 3

Round of assessment

QIPS scoring: Poor/very poor (not shown) <40% fair (40–59%), good (60–79%), and very good (≥80% )

Fair Good Very good

4.5.6 Threatened Preterm Births As part of ensuring quality CEmONC services, MCHIP put efforts into strengthening threatened preterm birth (TPTB) management. MCHIP conducted a 2-day training of 75 obstetricians and medical officers from 37 CEmONC health facilities following WHO’s preterm birth management guidelines. Experts from the National Committee of Maternal and Newborn Health (NCMNH) and Society of Obstetricians and Gynecologists of Pakistan conducted the trainings.

MCHIP also developed job aids on TPTB management at CEmONC facilities. Job aids include large pregnancy wheels to estimate gestational age, which are mounted on walls in ANC outpatient departments and TPTB care units; and drug information charts for displaying in labor rooms and ANC outpatient departments to prevent TPTB. The job aids have been endorsed by the MNCH Program and DoH.

28 MCHIP Pakistan End of Project Report 5 MCHIP Associate Award Activities and Results by Technical Area 5.1 MATERNAL HEALTH MCHIP focused on ensuring evidence-based practices for normal care, and screening, identification, and management of complications. Instead of implementing a vertical programming approach, MCHIP designed two training packages: pregnancy, childbirth, and postnatal care (PCPNC) to address normal care and screening; and managing complications in pregnancy and childbirth (MCPC) to address screening for, identification, and management of complications. The training packages also highlighted the component on respectful maternity care (RMC).

5.1.1 Key Achievements and Results Respectful Maternity Care RMC is an integral element of comprehensive, high-quality health services, yet many women around the world experience disrespectful, abusive, and harmful treatment throughout pregnancy and childbirth. Labor and childbirth can be complicated and painful, yet all too often, providers ignore a woman’s questions, preferences, and distress. Physical violence , such as a provider hitting a laboring mother to quiet her, is not uncommon.

A quality of care survey conducted by MCHIP in 2013 measured multiple facets of RMC, including whether providers greeted clients, whether they informed women before and after procedures or tests, and whether support people and alternate birth/labor positions were encouraged in 383 observations. Results were mixed. For example, although compliance to the standard “greet client in a friendly manner” was over 80% (Figure 9), visual privacy for the client was maintained in 62% of the examinations observed, and in less than half (44%) of cases, the health care worker explained the procedure to the client prior to examination.

To address these gaps, MCHIP introduced RMC content/messages in its PCPNC and MCPC training packages in Pakistan. The content stressed the importance of client communication, privacy, etc. For example, OJT module #8 on normal labor includes an objective of understanding “respectful maternity care,” and QIPS includes several RMC-focused performance standards. The nonstructural repairs and renovations were also geared toward RMC, for example, providing privacy curtains, clean examination rooms, new furniture, etc. The RMC agenda has now been taken up by the White Ribbon Alliance.

MCHIP Pakistan End of Project Report 29 Figure 9. Increased compliance to the QIPS respectful maternity care standards

Woman has a companion of her choice during labor and delivery

Provider explains the procedure and encourages the woman to ask questions RMC standard

Provider greets the woman and her companion

0% 20% 40% 60% 80% 100% 120% Percentage compliant

Round 4 Round 1

Postpartum Hemorrhage As is the case globally, PPH is the leading cause of maternal mortality in Pakistan. WHO guidelines for the prevention of PPH (regardless of location of delivery) recommend the use of a uterotonic. In health care facilities with refrigeration capacity, oxytocin is the first-line uterotonic. In Pakistan, however, the quality of the available oxytocin is a serious concern. Most providers are unaware of the need to maintain cool chain procedures for oxytocin, and they routinely administer dosages far above recommended amounts due to the compromised quality of the available supply of the drug. Oxytocin is also out of reach for the 32% of women in Sindh who deliver at home. Day of birth package: a plastic ziplock pack with IEC Misoprostol is the uterotonic of choice for materials for misoprostrol and CHX, CHX tube for cord care of baby, and misoprostrol tablets for mothers for community-based births. Community-based prevention of postpartum hemorrhage. Photo: MCHIP distribution of misoprostol by CHWs and traditional birth attendants has been carefully studied in Pakistan and elsewhere. It has been proven feasible, safe, and effective in preventing PPH at the household level.

At the facility level, MCHIP reinforced the use of uterotonics through the PCPNC training package. The orientation for counseling and distribution of misoprostol was also integrated into the PCPNC training. At the community level, MCHIP focused on training LHWs on counseling and distribution of misoprostol.

30 MCHIP Pakistan End of Project Report Misoprostol and CHX training was rolled out as a day of birth package to LHWs for delivery to pregnant women. As of October 2017, this rollout included training more than 13,000 LHWs and CHWs on the importance of CHX, counseling skills, and cord care practices. The training was also provided to more than 4,267 SBAs (doctors, nurses, midwives, and LHVs) through the PCPNC and on-the-job trainings.

Although misoprostol was part of the essential drug list, it was not available at the facilities or with LHWs for distribution. However, pharmacies in Sindh offer misoprostol for a low price. When funds were available, such as through public-private donations, MCHIP procured and distributed misoprostol. MCHIP advocated with clients to procure misoprostol and also advocated with local partners to make the drug available at their facilities. For example, following MCHIP’s advocacy, misoprostol was made available for distribution at all PPHI facilities.

Routine service delivery data on uterotonic use at the facility showed an increased use of uterotonics between 2014 and 2017, with 74% of women receiving uterotonics during delivery in year 2 and 90% in year 5 (see Figure 10).

Figure 10. Increased use of uterotonics over the course of the project, 2014–2017

200,000 100% [90%] 180,000 90%

160,000 [74%] 80% 140,000 70% 120,000 60% 100,000 50%

Number 80,000 40% 60,000 30% Percentage of deliveries 40,000 20% 20,000 10% - 0% Year 2 Year 3 Year 4 Year 5

Program year

# of deliveries # of uterotonics used Proportion of deliveries received uterotonics

MCHIP Pakistan End of Project Report 31 5.2 NEWBORN HEALTH Estimates from 2017 indicate that newborn deaths in Pakistan contribute to 10% of the global newborn death toll. For every 1,000 babies born in Pakistan in 2016, 46 died before the end of their first month—a staggering 1 in 22, with approximately 248,000 newborns dying every year. Ending preventable newborn deaths in Pakistan is an imperative, and is a lofty but realistic goal if met with concerted effort and action by all stakeholders. A mother with a newborn practicing kangaroo mother care. MCHIP introduced the following key Photo: MCHIP high-impact, low-cost interventions to reduce newborn deaths in 16 intervention districts: • Kangaroo mother care (KMC) • Helping Babies Breathe (HBB) • CHX for umbilical cord care

5.2.1 Key Achievements and Results Introduction of Kangaroo Mother Care MCHIP implemented KMC as a pilot in collaboration with DoH Sindh in two DoH-supported hospitals: Gambat Institute of Medical Sciences Khairpur and Rao Bahadur Udhawas Tara Chand in Shikarpur.

MCHIP conducted formative research in two pilot districts to understand opportunities and challenges specific to the local context for KMC. Study outcomes showed the feasibility of initiating KMC at the health facility and its continuation in the community, with recommendations that included focusing on HCP capacity-building, improving facility infrastructure, and introducing a community mobilization approach for KMC.

As of December 2017, 141 infants have received KMC in these two intervention hospitals (approximately one-third were premature and more than two- thirds had low birthweight). KMC practice was mostly intermittent (82.3%), but approximately 17.7% babies received continuous (more than 20 hours per day) KMC. Premature babies were more Family practicing kangaroo parent care at the than three times more likely to receive continuous KMC. Gambat Institute of Medical Sciences Khairpur with support from MCHIP. Babies who received continuous KMC gained Photo: MCHIP significantly more weight at discharge. With MCHIP support, indicators have steadily improved, such as admission rates and duration of stay in KMC wards, and continuous KMC has increased.

32 MCHIP Pakistan End of Project Report Introduction and Scale-up of Helping Babies Breathe to Manage Birth Asphyxia In 2014, MCHIP introduced HBB in five districts of Sindh, with subsequent scale-up in 2015 to an additional 11 districts. The phased scale-up provided quality coverage to more than 750 public and private health facilities and training and supportive supervision of more than 1,500 HCPs. Between 2014 and 2017, approximately 9,000 babies not breathing at birth in MCHIP program areas were successfully resuscitated using one or more steps of the HBB technique, with a survival rate of 98% among babies with birth asphyxia. MCHIP followed the HBB approach outlined in the global training package for the HBB program, with adjustments to fit the local context and respond to updated evidence.

The HBB implementation strategy included the following activities: • Trainings, on-the-job coaching (OJC), and supportive supervision: A total of 1,620 SBAs and other HCPs from more than 750 health facilities, including MNCH centers and CEmONC hospitals, received a 2-day training on the use of HBB technique at their facilities. MCHIP, with the DoH, supported regular integrated HBB coaching at least twice per month in supported facilities, which included observing provider skills and giving feedback during skills practice. This continuous OJC and supportive supervision by DoH staff was found to be critically important for knowledge and skills retention among trained providers. • HBB corners: Ventilation areas called “HBB corners” were established in more than 750 health facilities and equipped with a ventilation table, bag and mask for ventilation, suction device, acute respiratory infection (ARI) timer, and action plan poster at an approximate cost of RS 20,000 per corner (~$190 USD). MCHIP worked closely with the facilities to ensure a supply of HBB equipment was present in the facilities soon after training was completed. MCHIP also regularly monitored the user readiness of HBB equipment and supplies in the facilities. These efforts worked well: after SBAs received training, they immediately applied their skills using the available equipment. • Measurement: MCHIP adapted indicators on birth asphyxia and resuscitation from the global HBB framework developed by the American Academy of Pediatrics. Through advocacy and engagement with DoH, these indicators were included as stickers in the DHIS obstetrics register, and subsequently DoH added HBB indicators in the DHIS for routine data information. Previously, no information on newborn resuscitation had been captured; inclusion of these indicators now allow DoH and MCHIP to monitor progress on newborn resuscitation. As routine data started coming in during the early implementation stages, high survival rates for birth asphyxia cases were reported. This measurement and early success were valuable in obtaining stakeholder buy-in and support. With birth asphyxia a primary cause of newborn mortality in Pakistan, the value of bringing this high-impact intervention to additional districts was quickly obvious.

MCHIP Pakistan End of Project Report 33 Chlorhexidine for Umbilical Cord Care National and Provincial Policy Development To ensure clear endorsement, ownership, and coordination of CHX’s introduction at scale (in Sindh and Pakistan), MCHIP facilitated and contributed to the development of a national strategic and provincial plan and relevant guidelines. The policy journey began with provincial consultation in January 2014, and, through a series of similar meetings and dialogue with policymakers, MCHIP’s efforts led to a national process with key contributions from federal, provincial, and district officials, as well as professional bodies, development partners, and NGOs.

These efforts culminated in the following policy-level achievements (see Figure 11): • Approval of CHX policy recommendations by DoH Sindh and the National Ministry of Health Services, Regulation and Coordination (MoHSRC). • Inclusion of CHX in the approved essential medicines list. • Inclusion of CHX in all provincial health services packages. • Inclusion of a CHX indicator in the LHWs management information system (MIS) and DHIS to record data at facility and community levels.

Figure 11. Timeline of chlorhexidine (CHX) for cord care in Sindh province (DoH: Department of Health, DRAP: Drug Regulatory Authority of Pakistan, EML: essential medicines list, MoHSRC: National Ministry of Health Services, Regulation and Coordination, LHW: lady health worker, SBA: skilled birth attendant)

34 MCHIP Pakistan End of Project Report Pilot Implementation In July 2014, MCHIP started working with DoH Sindh and the MoHSRCto introduce CHX for cord care in two districts: Tando Allahyar and Tharparkar. The pilot was designed as a community- and facility-based intervention that used LHWs and SBAs to distribute and counsel on the use of CHX. MCHIP developed and facilitated relevant trainings, equipped LHWs and providers with job aids, and provided “birthday packets”22 for distribution to pregnant women with CHX gel and misoprostol tablets, along with instructions on their use. To target SBAs at the facility level, a session on CHX was added to the PCPNC training package. MCHIP documented the pilot implementation through a study in Tharparkar on the outcomes of community-based distribution and counseling of CHX and misoprostol, as well as an assessment in Tando Allahyar of mothers’ adherence to CHX application guidelines. These study findings provided a clear indication of the feasibility and coverage potential of advanced community distribution and the importance of timely counseling and availability at birth.

Implementation Strategy The pilot informed important elements of rollout: • Closing human resources gaps: MCHIP trained LHWs for counseling and community-based distribution of CHX. For geographic areas not covered by the LHW Program, MCHIP and another community mobilization partner (the Johns Hopkins University Center for Communications Programs) recruited, trained, and provided stipends for more than 1,740 CHWs. These CHWs were eventually hired directly by DoH. • Partnership with the private sector: MCHIP worked with private hospitals, NGO hospitals, and facilities that were contracted out by the government for private operation through PPHI to share materials and conduct trainings, thereby ensuring wider facility coverage. • Development of distribution and reporting strategy: As a new drug, CHX was not yet included in the LHW and DHIS facility reporting. MCHIP collaborated with the LHW Program, MNCH Program, and DHIS cell to streamline a distribution and reporting strategy within government channels at provincial, district, facility, and community levels.

Rollout of CHX in Sindh Province Informed by the positive outcomes from the pilot in Tando Allahyar and Tharparkar districts, in 2015, MCHIP began rolling out the CHX intervention to all 16 MCHIP intervention districts of Sindh. As of October 2017, this rollout included training more than 13,000 LHWs and CHWs on the importance of CHX, counseling skills, and cord care practices. This training was also provided to more than 3,000 SBAs (doctors, nurses, midwives, and LHVs) through the PCPNC and on-the-job trainings. Finally, MCHIP secured CHX from Nepal (in the absence of local production) to support its rollout in project districts, developed a distribution strategy with DoH, and started CHX distribution through health workers in the community and SBAs in facilities.

22 A pouch including both CHX and misoprostol

MCHIP Pakistan End of Project Report 35 5.3 CHILD HEALTH Vaccine-preventable childhood diseases are a major national health concern throughout Pakistan, where just slightly more than half of all children in 2017 were believed to be fully immunized. In addition, serious disparities in coverage exist between urban and rural areas. According to the PDHS 2012–2013, whereas the RI coverage in Sindh province as a whole was 29%, coverage in rural Sindh was merely 14%, and this pattern persists today.23 Chronic gaps in immunization service delivery as well as poor utilization of services by communities in the interior of Sindh, in the urban slums of Karachi, and in its other large cities are the known causes of this continuing problem.

MCHIP introduced the following key high-impact and low-cost interventions to reduce child deaths in the 16 intervention districts: • Case management of cough and/or difficult breathing (pneumonia) and diarrhea • Routine immunization (eight districts only)

5.3.1 Key Achievements and Results Case Management of Cough and/or Difficult Breathing (Pneumonia) and Diarrhea To address high rates of pneumonia and diarrhea—the cause of 27% of deaths in children under age 5 in Pakistan—MCHIP worked with the government to strengthen IMCI and integrated community case management (iCCM) strategies.

As a first step, MCHIP reviewed Pakistan’s 2010 IMCI guidelines for pneumonia case management against WHO’s updated IMCI guidelines, released in March 2014. The key change was in the pneumonia case management protocol—from an injectable treatment (2010) of chest in-drawing pneumonia to treatment with oral amoxicillin (2014).

Therefore, MCHIP embarked on a two-pronged strategy: (1) provide support for updating Pakistan’s 2010 IMCI guidelines, and (2) build capacity of providers in MCHIP-supported facilities in the 2014 WHO recommendations for case management of pneumonia and diarrhea.

MCHIP worked with MoHSRCand the WHO Islamabad office to revise the 2010 national Integrated Management of Neonatal and Childhood Illness guidelines. Updates included management of chest in-drawing pneumonia with oral amoxicillin. The MCHIP initiative in Sindh is one of the few in the world that has moved from an injectable to an oral antibiotic for management of chest in-drawing pneumonia. For babies under 2 months old (0–59 days), injectable gentamicin traditionally has been used, and no change in the practice was implemented. According to 2014 WHO guidelines for the treatment of pneumonia among children older than 2 months, the drug of choice was changed from cotrimoxazole to amoxicillin syrup.

For the capacity-building component, MCHIP worked with the director general office technical staff to develop a manual on case management of pneumonia and diarrhea based on the updated WHO 2014 IMCI guidelines. The MNCH Program Sindh and DoH endorsed the manual.

23 National Institute of Population Studies (NIPS). 2013. Pakistan Demographic and Health Survey, 2012–2013. Islamabad, Pakistan: NIPS. Available at https://dhsprogram.com/pubs/pdf/fr290/fr290.pdf.

36 MCHIP Pakistan End of Project Report In collaboration with the government of Sindh, MCHIP trained 40 district-based trainers in 10 districts. These trainers then offered training to a total of 599 health providers (doctors, LHVs, staff nurses, project staff, etc.) on revised WHO IMCI case management guidelines for pneumonia and diarrhea in those 10 MCHIP-supported districts. To ensure quality case management, MCHIP procured and supplied essential items to the facilities where trained providers were deployed.

As of December 2017, more than 520 MNCH and CEmONC centers in MCHIP- supported districts were implementing the pneumonia and diarrhea program. The training sessions conducted on case management of pneumonia and diarrhea by MCHIP included guidance on best practices related to assessment, classification, and treatment of children under age 5 suffering from pneumonia and diarrhea. A total of 1,032 HCPs (physicians, staff nurses, LHVs, etc.) were trained on WHO case management protocols for pneumonia and diarrhea.

The training significantly improved case management quality, as evidenced in all intervention districts’ pneumonia data. During the project period (2013–2017), a total of 300,184 and 1,001,585 children under 5 years of age received treatment for pneumonia and diarrhea, respectively, from MCHIP-trained HCPs within the target 16 districts.24

Through supportive supervision and coaching visits, trained providers were supported in the use of IMCI case investigation forms for proper assessment and classification of sick children with suspected pneumonia and diarrhea. MCHIP also organized 13 half-day orientation sessions (one per district) for pediatricians and HCPs on the revised WHO guidelines for classification and treatment of pneumonia. All sessions were organized in collaboration with the Child Survival Program, DoH Sindh, and the district chapters of the Pakistan Pediatric Association.

Routine Immunization Over an 18-month period, MCHIP worked with the DoH/Expanded Program on Immunization (EPI) to improve its immunization planning process, establish more regular vaccination services, provide information to parents and communities about immunization, strengthen the knowledge and capacity of vaccinators and district health managers, and monitor and refine its service delivery approaches. The program also mentored district managers during supportive supervision and hired 16 district immunization officers (DIOs) to support the government’s district health management teams (DHMTs). DIOs in eight of the 16 MCHIP-assisted districts were part of an intensive intervention that included community microcensus and registration of pregnant women and children under 2 years of age, immunization promotion, assisted microplanning, monitoring of individual and community vaccination status, and other activities that were not possible in the eight districts where MCHIP posted DIOs only. Table 6 describes the intensive intervention package implemented in Matiari, Tando Allah Yar, Umerkot, Tharparkar, Thatta, Sujawal, Jacobabad, and Kashmore.

Table 6. MCHIP’s intensive technical support package for routine immunization Title/name Description Posting district DIOs are district-based immunization program managers who work with and supplement immunization officers Expanded Program on Immunization (EPI) focal points on district health management (DIOs) teams (DHMTs). MCHIP posted DIOs in both intensive and nonintensive intervention districts in Sindh. House-to-house registration A local civil society organization (CSO) registered children under 2 years of age and (microcensus) pregnant women. Registration data were entered into a web-based database developed by MCHIP (see tracking and caregiver reminders below).

24 DHIS monthly report

MCHIP Pakistan End of Project Report 37 Title/name Description Microplanning House-to-house registration data, updated polio data, and community engagement were used to estimate target populations and vaccine and supply needs, and to rationalize fixed service delivery sites and the number and locations of outreach sessions. Outreach activities based Outreach plans are prepared and updated on a monthly and quarterly basis by DHMTs, on microcensus DIOs, and vaccinators to ensure that all registered children and pregnant women are reached. Fuel/POL support for Performance-based monthly POL support was provided to vaccinators for outreach vaccinators activities, with priority given to covering due and defaulter children. To reach hard-to- reach populations in Tharparkar district, MCHIP provided 4x4 vehicles. For coastal belts of district Thatta, MCHIP hired boats to transport EPI staff to vaccinate children and pregnant women. Community mobilization MCHIP enlisted CSOs, vaccinators, lady health workers (LHWs), and community leaders and engagement to raise awareness about the need for and availability of routine immunization (RI) services and to encourage community commitment to results. Tracking and caregiver MCHIP developed a management information system (MIS) and a Short Message Service reminders (SMS) system. The online MIS captures the name, gender, vaccination status, vaccine doses due, etc., for each registered child and pregnant woman. SMS messaging is built into the MIS platform to encourage caregivers to keep children’s vaccinations up to date. MCHIP has successfully transitioned the MIS/SMS to the government of Sindh. Active monitoring and MCHIP DIOs used EPI standard checklists and visited EPI centers, outreach points, and problem-solving house-to-house clusters to assess RI program performance and coverage levels in communities and use the data to take corrective action. DIOs assisted DHMTs to use registration and service data to monitor catchment area performance and assist in problem-solving. Capacity-building Capacity-building in the form of classroom and on-the-job training and supportive supervision targeted EPI managers, supervisors, vaccinators, LHWs, community leaders, and others. EPI-Polio Eradication MCHIP advocated with provincial/district health institutions and partners to release RI Initiative (EPI-PEI) synergy vaccinators during national and subnational polio immunization days and worked with them to implement EPI-PEI synergy (vaccination of children with not only oral polio vaccine but also all of the EPI antigens during polio campaigns). Establishment of EPI Although all public CEmONC health facilities provide RI services to eligible children and centers in private pregnant women, this is not the case in private CEmONC facilities. MCHIP supported a comprehensive emergency public-private partnership to establish EPI centers at high-volume CEmONC health obstetric and newborn care facilities, allowing for easier access to RI services for parents and their children. (CEmONC) health facilities

House-to-House Registration To better understand the target population (newborns, children under 2 years of age, and pregnant women) for the vaccination services, MCHIP first worked with civil society organizations (CSOs) to conduct a house-to-house registration (microcensus). The registration data was input into an adapted MIS and used to identify children and pregnant women due for vaccinations as well as those who had not returned for subsequent doses. The system then generated SMS messages to the children’s caregivers and the pregnant women to remind them to come for vaccination services. By project end, MCHIP supported the registration of 28,566 villages, 830,610 children (see Table 7 and Figure 12), and 348,315 pregnant women. To date, 77 DHMT staff members in eight MCHIP intervention districts are trained to register target populations post MCHIP.

38 MCHIP Pakistan End of Project Report Table 7. Vaccination status of registered children in eight intensive intervention districts (total children under age 2 registered from May/June 2016 to August 2017) Districts Total children Children vaccinated Children vaccinated Children fully registered during from Penta 1 through from BCG through vaccinated from BCG project life Penta 3 Penta 3 through measles 1 Number % Number % Number % Jacobabad 117,140 94,034 80 66,888 57 56,653 48 Kashmore 125,962 102,177 81 72,726 58 62,668 50 Matiari 77,151 47,468 62 42,352 55 31,115 40 Sujawal 68,909 46,086 67 41,268 60 29,199 42 Tando Allahyar 75,965 53,792 71 47,187 62 35,043 46 Tharparkar 155,511 136,838 88 103,834 67 89,838 58 Thatta 106,870 96,554 90 84,618 79 69,536 65 Umerkot 103,102 82,009 80 74,503 72 60,695 59 Total 830,610 658,958 79 533,376 64 434,747 52 Note: BCG: Bacille Calmette-Guerin

Of the total number of registered children, 52% were fully immunized and 64% received their Penta 3 vaccination, as compared to 27% at baseline. Of the registered pregnant women, 65% were vaccinated with two doses of tetanus toxoid vaccine, as compared to 26% at baseline.

Figure 12. Baseline and end-of-project registration status of children (0–23 months) in eight intervention districts in Sindh province

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MCHIP Pakistan End of Project Report 39 With information gathered during the microcensus and ensuing registration of villages, children, and pregnant women, the Sindh EPI could better plan and implement RI outreach sessions to target specific populations. With this data, the percent of planned outreach sessions conducted increased from October 2016 to September 2017 in all but two of the eight MCHIP- assisted districts (i.e., Thatta and Tharparkar) where completion of outreach sessions was already fairly Vaccinators and field assistant visiting islands in Thatta. Photo: MCHIP high at the start of the period. Of the six districts where the percent of planned outreach sessions conducted improved, the range of increase was 8% to 58% in Jacobabad and Tando Allahyar districts, respectively. One way that MCHIP revitalized RI services in hard-to-reach areas was by building the capacity of more than 3,500 district staff of different cadres, including vaccinators, LHWs, and CHWs on midlevel management, immunization in practice, microplanning, and outreach planning to bring RI services to remote villages.

Active Monitoring and Problem-Solving To ensure high-quality RI services and assess RI program performance and community coverage levels, MCHIP DIOs visited EPI centers and outreach points, and conducted house-to- house clusters as part of their monitoring and supportive supervision activities. The MCHIP DIOs used EPI standard checklists when conducting these visits. With the data collected, they assisted DHMTs to identify problem areas and take corrective action.

Community Mobilization and Engagement MCHIP also supported RI activities by establishing linkages between vaccinators and local communities to vaccinate children. The combined lack of understanding, awareness, and accessibility of vaccination services required educational sessions by trained members of the community to correct misinformation and generate demand for immunizations. MCHIP oriented 18,898 community resource persons and village volunteers on RI by holding awareness-raising sessions, addressing traditional barriers to create space for understanding around health and the benefits of vaccination, and gathering children and pregnant women for routine vaccination. These individuals are now equipped to raise and Community mobilization for immunization in Umerkot. maintain awareness about RI in their Photo: MCHIP communities, and have since been identified as potential sources of community support for future polio campaigns.

40 MCHIP Pakistan End of Project Report EPI-PEI Synergy in Sindh The concept of EPI-PEI synergy (undertaking polio eradication in ways that directly benefit RI in both long and short term) has been strongly and frequently endorsed globally and for Pakistan specifically. MCHIP made a concerted effort to implement EPI-PEI synergy in its intervention districts. By coordinating with provincial and district EPI management, MCHIP was able to negotiate the use of local volunteers to vaccinate during national and polio subnational immunization days (SIAs) since July 2018, as well as in three rounds of a maternal/neonatal tetanus elimination campaign and a measles SIA. Implementing this synergy freed up regular vaccinators to provide RI outreach sessions during and between the polio campaigns. These RI activities resulted in the vaccination of children under 2 years of age not only with routine polio doses (oral polio vaccine [OPV] and inactivated polio virus vaccine [IPV]) but also against all other vaccine-preventable diseases in Pakistan’s immunization schedule. As a result of this coordination, more than 16,835 outreach sessions were conducted during national and subnational polio days and more than 300,000 children were vaccinated for different antigens (including OPV and IPV) from May 2016 to June 2017.

Establishment of EPI Centers in Private CEmONC Health Facilities In Pakistan, public CEmONC health facilities provide newborn and maternal care services, including RI, to newborns delivered at the facilities as well as pregnant women. However, these same services were not provided in private CEmONC health facilities even though the target population for maternal and newborn care and immunization is the same. To increase RI coverage, MCHIP encouraged the establishment of EPI centers at private CEmONC facilities to ensure RI of newborns (BCG and OPV 0 birth dose) and pregnant women (tetanus toxoid) who attend the CEmONC for ANC services.

To establish EPI centers in these private facilities, MCHIP DIOs facilitated discussions with the facility owners, the district health officer, and the district EPI focal point to raise awareness of the importance of immunization for the local community and the opportunity such facilities offer to access key target populations in a place they already visit. As a result of these discussions, the district EPI focal point and facility owners signed a memorandum of understanding establishing EPI centers at CEmONC facilities in five districts.

To ensure high-quality immunization services at these newly established centers, MCHIP DIOs provided technical assistance through supportive supervision. Furthermore, the development and submission of a monthly coverage report, disaggregated by antigen, to the tehsil support vaccinators and district support vaccinitors allowed for review of progress and the opportunity to address any challenges unveiled by the data.

5.4 FAMILY PLANNING Pakistan faces several challenges in increasing modern contraceptive use. Although 55% of currently married women of reproductive age have tried a contraceptive method at some point in their lives, only 35% are currently using any method, and only 26% are using modern methods. A further 20.1% of women, both past and never users, are living with unmet FP need. Postpartum family planning (PPFP) could play a significant role in reducing maternal mortality by preventing unintended pregnancy and unsafe abortion.

5.4.1 Key Achievements and Results MCHIP focused on the following FP methods in the 16 target districts.

MCHIP Pakistan End of Project Report 41 Interval FP Long-Acting Reversible Contraceptives MCHIP provided a 6-day Client-Centered Family Planning and Contraceptive Implants training, which included skills-based training on FP counseling and insertion and removal of implants to 880 providers. Only doctors received training on implants, with male doctors (270 of the 880 providers) trained to address clients’ unmet need when female providers are not available.

The training was conducted in collaboration with PWD at Karachi, Hyderabad, Sukkur, and Larkana regional training institutes, with a total of 11 master trainers trained across six training institutes. In these trainings, MCHIP provided SBAs with training on effective counseling. Comprehensive FP counseling plays a key role in FP uptake and continuation and is essential for ensuring informed and voluntary decision-making, one of the three fundamental elements of FP care. MCHIP also trained 78 SBAs on interval IUCD through a 4-day advanced training.

Total insertions recorded through all program service delivery points, including the training institutes, were 34,431 PPIUCDs and 28,556 implants during life of project. As a province-wide intervention, MCHIP trained 299 PPHI medical officers, including 78 male providers, on the insertion and removal of implants. Male providers generally do not provide implant services. These PPHI medical officers inserted 1,131 implants through September 2014.

MCHIP conducted 23 training events on IUCD insertion and removal techniques in collaboration with PWD in four regional training institutes for PPHI providers at Hyderabad, Sukkur, Larkana, and Karachi. Of the 318 PPHI medical officers trained, 200 were from the 16 MCHIP target districts and the rest were from the non-MCHIP districts of Sindh.

Postpartum Family Planning MCHIP initiated PPFP services at four of the eight training institutes (Lady Dufferin Hospital [LDH], Liaquat University of Medical and Health Sciences [LUMHS] Civil Hospital, Ghulam Mohammad Mahar Medical College, and Jacobabad Institute of Medical Sciences), training and providing supportive supervision to SBAs to provide PPIUCD services. To generate clients for PPIUCD services, MCHIP placed PPFP counselors at the training institutes. At LDH, MCHIP trained CMW graduate students from the LDH midwifery school to counsel on PPFP. A total of 56 selected providers from these four institutes and the Rai Bahadur Udhawdas Tarachand hospital were trained as trainers on PPIUCD. MCHIP set up skills labs and classrooms at the four training institutes and provided equipment for PPFP and other services. MCHIP subsequently used the trainers and institutes to train a total of 681 SBAs from the 16 target districts on PPIUCD at the five institutes. Total insertions recorded through all program service delivery points, including the training institutes, were 34,431 PPIUCD and 28,556 implants over the life of the project.

Family Planning Compliance MCHIP trained a total of 506 HCPs on FP compliance. The training consisted of 1 day of orientation on FP policy compliance for service provision. MCHIP first completed the rollout of the FP compliance training to service providers in their respective districts who were then certified. MCHIP then trained trainers from the training institutes and District Health and Population Management Team (DHPMT) members on FP compliance for sustainability.

42 MCHIP Pakistan End of Project Report 5.5 NUTRITION Worldwide, approximately 155 million children under 5 years of age are stunted and 52 million are wasted, indicating a chronic state of malnutrition. Of these, half live in Asia. Pakistan has the second highest (43.7%) stunting rate in South Asia. In Sindh, the underlying causes of malnutrition are associated with low consumption (access) and low nutrition value of food (intake). The scarce amount of iron, zinc, iodine, and vitamin A in the diet, and poor infant and young child feeding practices, including poor exclusive breastfeeding practices and lack of knowledge about early initiation of breastfeeding (discarding of colostrum), contribute significantly to child malnutrition (see Table 8).

Table 8. Nutrition indicators for pregnant women and young children from Pakistan nutrition surveys Indicator Pakistan Nutrition Surveys National Nutrition Pakistan Demographic Health Survey Survey 2011 2012–2013 Children <5 years age Stunted 43.7% 45% Wasted 15% 11% Underweight 31.5% 33% Women of reproductive age Only 22% pregnant women taking iron- Anemia 51% folic acid tablets in 90 days of pregnancy Infant and young child feeding Exclusive breastfeeding (under 6 months of age) 12.9% 37% Continued breastfeeding until 2 years of age 77% 56% Complementary feeding (6–23 months) 7.3% 66% (6–8 months)

MCHIP introduced the following key high-impact and low-cost interventions to improve maternal and young child nutrition in the 16 intervention districts: • Maternal, infant, and young child nutrition • Lactation management • Recipe book and cooking demonstration • Community awareness session • IFA supplementation during pregnancy

5.5.1 Key Achievements and Results Maternal, Infant, and Young Child Nutrition Pregnancy and lactation are two important stages of human life. Promotion of nutrient-rich food (macro- and micro-nutrients) intake can prevent maternal anemia and undernutrition in the prenatal period, infancy, and early childhood. MCHIP introduced and promoted MIYCN practices in 10 districts of Sindh at community and facility levels to address maternal anemia and malnutrition.

MCHIP Pakistan End of Project Report 43 At the community level, MCHIP updated the LHW curriculum to include MIYCN best practices endorsed by the DoH Nutrition Support Program (NSP) and LHW Program. MCHIP, in collaboration with the DoH and LHW Program, trained 152 LHSs as master trainers and 2,211 LHWs from 10 districts on the MIYCN module. Through WSGs and house-to- house visits, the LHWs counseled pregnant and lactating women, mothers of infants and young children, households, and communities on MIYCN best practices.

At the facility level, MCHIP, in collaboration with DoH, trained 1,700 SBAs from 1,190 facilities across the 16 districts on nutrition during pregnancy and breastfeeding as part of a comprehensive PCPNC training package, instead of rolling out a separate vertical training. These SBAs counseled women during antenatal visits, labor and delivery, and postnatal visits on MIYCN best practices. During supportive supervision visits, the MCHIP team observed SBAs delivering MIYCN and mentored them as needed.

Lactation Management MCHIP introduced the concept of lactation management to promote optimal practices of immediate, early, and exclusive breastfeeding for infants from 0 to 6 months of age. MCHIP developed a manual on lactation management for SBAs. MCHIP provided a 2-day group- based training on lactation management to 184 CMWs and OJC sessions to 1,375 LHVs and doctors at their facilities in 16 districts.

Following the training, the SBAs were able to counsel women on the importance of breastfeeding during antenatal and postnatal visits. At MCHIP-supported health facilities, data show that immediate and early initiation of breastfeeding has increased for all facility-based deliveries, and 28,372 newborns in 10 districts were fed colostrum at birth.25

Recipe Book and Cooking Demonstrations A major factor contributing to malnutrition in rural Sindh is mothers’ limited awareness of healthy recipes for children ages 0–23 months. In 2015, MCHIP piloted cooking demonstrations in two districts (Dadu and Umerkot) and produced a recipe book with 16 local recipes. These recipes are easy to cook and meet children’s nutritional needs. Later, with the support of DoH and NSP, the book was distributed throughout the province.

MCHIP organized LHW-led cooking demonstrations as a strategy to introduce the recipe book. A total of 29 LHWs in 10 districts were trained to conduct cooking demonstrations at Cooking demonstration in Thatta. Photo: MCHIP a community member’s home as part of a WSG. MCHIP provided the ingredients and WSG participants provided the utensils and fuel for cooking. This activity was much appreciated by mothers as it differed from traditional counseling using information, education, and communication (IEC) materials. LHWs conducted around 600 cooking demonstrations in 10 districts, reaching 2,000 women. Cooking demonstrations are now part of the LHW nutritional strategy.

25 Source: Partograph forms

44 MCHIP Pakistan End of Project Report Community Awareness Sessions In collaboration with DoH and NSP and LHWs, MCHIP conducted sessions on the benefits of MIYCN, particularly exclusive breastfeeding and the use of colostrum at the time of birth. In addition to the regular women participants, these sessions also included men. These male engagement sessions were conducted by nutrition technical officers in seven districts, and were attended by 2,800 men. MCHIP also supported DoH and NSP with IEC materials for the celebration of Global Breastfeeding Week in Karachi. In August 2016, MCHIP organized 15 events (one in each district) to celebrate Global Breastfeeding Week in collaboration with DoH.

Iron-Folic Acid Supplementation During Pregnancy In Thatta and Sujawal, LHWs’ knowledge and understanding of the IFA brochure was assessed at the end of the orientation session. The results indicated that almost all 50 LHWs found the IFA brochure useful for counseling pregnant women on IFA tablet consumption. The LHWs also answered all knowledge-related questions correctly. DoH and NSP endorsed the IFA brochure and agreed to disseminate it province-wide through the LHW Program.

MCHIP Pakistan End of Project Report 45 6 MCHIP Associate Award Activities and Results by Cross-Cutting Area 6.1 QUALITY IMPROVEMENT MCHIP completed a quality of care study in 10 districts to inform QI activities. The observations are from 127 facilities on 375 ANC visits, 89 newborn/PNC visits, and 318 deliveries. The study findings showed that quality of care in the 10 study districts was alarmingly low, and unless focused interventions were made to improve it, an increase in SBA- supervised deliveries would not result in a decline in maternal and newborn mortality.

6.1.1 Key Achievements and Results Based on Jhpiego’s approach to performance and quality improvement and Standards-Based Management and Recognition (SBM-R®) and informed by the quality of care study findings, MCHIP implemented a QI approach at 1,040 health facilities in 16 districts of Sindh. QIPS aims to improve quality through standardization, establishing benchmarks, and continually engaging facility staff and stakeholders in the QI process. The QIPS approach identifies both strengths and weaknesses of the system, highlighting areas where corrective actions are needed.

The QI approach consisted of targeted and prioritized performance standards for MNCH services, periodic assessment based on these standards, identification of gaps in compliance with the standards (at various level of health system), implementation of corrective interventions (realistic targets, defining roles and responsibilities, and time bound), and effective incentives strategies and feedback mechanisms.

QIPS Assessment ToolThe QIPS standards were used for performance assessment in baseline and periodic follow-on assessments to measure progress. The 42 QIPS standards ranged across seven technical areas (see Table 9).

Table 9. QIPS standards by technical area Technical area # of standards Focused antenatal care 7 Labor and delivery 13 Postnatal care 5 Cough or difficult breathing and diarrhea 3 Postpartum family planning 8 Infection prevention 4 Linkages and referrals 2 Total 42

The QIPS tool was developed through a consultative process involving all stakeholders. NCMNH experts and DoH managers reviewed the draft tool, which included standards on safety, respectful care, and best clinical practices (effectiveness). Each standard included verification criteria that can be objectively assessed and scored. The MCHIP-targeted health facilities’ staffs and their supervisors were trained on periodic self-assessment using QIPS tools.

46 MCHIP Pakistan End of Project Report Implementation Process The MCHIP team and facility staff carried out the baseline assessment (the first round of QIPS facility assessments), identified gaps, and developed action plans. The interventions ranged from facility structural needs to technical capacity-building needs. The set of services was implemented in a step-wise manner depending on the success achieved in each area. For example, health facilities showing improvement in provision of quality normal labor and delivery services were gradually introduced to the seven signal functions of BEmONC. This step-wise method encouraged management and support systems to progress in small Orientation of district and health center team on QIPS but steady stages and make improvements more assessments. Photo: MCHIP sustainable. In subsequent rounds of assessments, most health facilities showed an increased ownership of the process, taking the lead in carrying out assessments, developing action plans, and following up, while MCHIP provided general oversight.

Capacity-Building: On-the-Job Training, Coaching, and Mentoring The capacity-building of the HCPs and staff at the targeted facilities was based on knowledge, skill, and behavioral gaps identified through the QIPS assessments.

A booklet with the QIPS tool and standard operating procedures and checklist was placed at the clinical areas for reference. The summarized standards from the assessment tools were also shared with facilities and providers as job aids to reinforce on-the-job learning at the health facilities between assessment periods.

This local approach helped health facility teams (including management and service providers) to address gaps identified during assessments by considering potential contributing factors such as lack of knowledge and skills; inadequate equipment, supplies, and other resources or policies; and lack of motivation. However, other gaps, such as human resources and procurement of regular supplies for infection prevention and waste management, were a constant challenge.

A standardized patient file was introduced at private and CMW-led MNCH centers. The file included a list of services provided at the MNCH center using variables from DHIS. MCHIP collected data from these sources on a monthly basis. Community and client feedback was encouraged through QITs formed at the health facility level where PDQ was implemented.

Assessment and Monitoring Facility-based QITs used the QIPS tool, with MCHIP providing supportive supervision and coaching during the assessments. Assessments were made every 6 months to determine the progress over time on implementation of quality standards.

The MCHIP Monitoring, Evaluation, and Research (MER) department independently conducted short and focused periodic monitoring of QIPS implementation on a sample of health facilities. The MER team shared the analysis of monitoring data with MCHIP technical staff and subsequently with facility staff on a quarterly basis. This quality assurance assessment aimed to ensure that findings from the self-assessment corresponded to findings by the MCHIP MER team as an independent assessment.

MCHIP Pakistan End of Project Report 47 Motivation MCHIP organized QIPS review forums for health facilities or used the existing DHPMT forums to motivate the facilities to achieve QI standards. At these forums, District Health Office Sindh and provincial health authorities recognized facility performance through certificates, rewards, and positive feedback in the presence of community.

MCHIP introduced a mechanism for recognizing higher performing facilities and presenting them with certificates. Based on their QIPS score, facilities were categorized into five quintiles: very poor (QIPS score ≤19%), poor (QIPS score 20%–39%), fair (QIPS score 40%–59%), good (QIPS score 60%–79%), and very good (QIPS score ≥80%). The QIPS performance certificates had a golden star for first position (scores of 80% and above), silver star for second position (scores of 70%–79%), and bronze star (scores of 60%–69%). Health facility recognition ceremony for QIPs compliance. Photo: MCHIP Scores for overall QIPS performance and by technical area (FANC, labor and delivery, PNC, pneumonia and diarrhea, PPFP, and infection prevention) across all districts showed higher levels of compliance to quality standards in rounds 3 and 4. The increase aligned with the training and frequent OJC visits at the facilities (see Figure 13).

Figure 13. QIPS scores overall and by technical area: percentage of facilities scoring fair, good, or very good in all rounds (R1–R4)

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0% RI RII RIIIRIV RI RIIRIIIRIV RI RII RIIIRIV RI RII RIIIRIV RI RIIRIIIRIV RI RII RIIIRIV RI RII RIIIRIV Overall FANC L&D PNC P&D PPFP IP

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Techical areas: Overall (All combined), focused antenatal care (FANC), labor & delivery (L&D), postnatal care (PNC), pneumonia & diarrhea (P&D), PPFP (postpartum family planning), infection prevention (IP)

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48 MCHIP Pakistan End of Project Report 6.2 MIDWIFERY CMWs are a relatively new cadre in Pakistan. In Sindh, the first batch of CMWs was enrolled in 2008. After an 18-month training, CMWs were deployed as private SBAs in remote and underserved areas. The trained CMWs are licensed by the Pakistan Nursing Council to practice MNCH/FP services with a scope of practice defined by the Council and the MNCH Program. Inadequate planning, insufficient training, deployment and financial issues, security concerns, and community acceptance all hindered CMWs’ success. As a result, many CMWs abandoned their private practices. CMWs who remained in practice received no ongoing support, in the form of structured supportive supervision or refresher trainings after deployment, resulting in poor quality of care and ineffective services. To improve the quality of midwifery education and practices in Sindh, MCHIP worked with the MNCH Program to address both pre-service and in- service education.

6.2.1 Key Achievements and Results MCHIP used the Standards-Based Management and Recognition-Education (SBMR-E) QI approach to improve pre-service education quality. This approach consists of repeated collaborative assessments of clinical and nonclinical services based on performance standards, implementation of corrective measures where gaps are identified, and rewards for achievement through a recognition mechanism. The intervention was implemented in an initial five schools, and subsequently scaled up to another 10 schools across 16 districts. Following the initial assessment of the quality of midwifery schools, MCHIP completed the following activities: • Revised the CMW curriculum to include updated and evidence-based content. Added 6 months of mentored clinical rotations after 18 months of classroom teaching. The revised curriculum was endorsed by the Pakistan Nursing Council and is now being taught in all 15 schools. As part of this new curriculum, faculty and staff set objectives and plan lessons according to the guidelines. The lessons now include 60% theory and 40% clinical practicum, whereas previously no clinical practicum was provided. • Built the capacity of tutors and preceptors through a clinical teaching skills course at the 15 midwifery schools. Additionally, tutors were trained on business management skills to build students’ entrepreneurial and business skills. Preceptor clinical practice and business skills training is now included as part of CMW training. • Introduced e-learning modules to complement traditional learning modules so teachers and students can easily access the reading content outside the classroom. Provided information technology support and equipment to 15 schools. • Deployed two program officers/clinical preceptors in five districts to support the teaching and learning of trainee CMWs. The clinical staff mentored the faculty and staff on classroom teaching and clinical practicum. The preceptors also supervised the trainee CMWs during their clinical rotations. • Provided supplies and equipment for the skills laboratories, computers, and libraries. Eight CMW schools received minor repairs and renovations to the classroom and skills lab. • Strengthened coordination between district managers, district health officers, district focal personnel, and medical superintendents of the DHQ hospitals, heads of ob-gyn departments, and labor room in-charges through regular coordination meetings.

MCHIP Pakistan End of Project Report 49 All 15 schools are now using SBMR-E for gap assessment, action planning, and decision-making for continuous QI. Comparison of SBMR-E scores across three rounds of assessments in five categories show an increase in scores in rounds 2 and 3 (see Figure 14). This means the schools are showing an increased compliance to quality standards with time. Significant increases were seen in the areas of faculty and clinical instructions, curriculum, and students compared to the other two areas, infrastructure and management and clinical practice. Four of the 15 midwifery schools were accredited by the Pakistan Nursing Council and the others are in the process of accreditation. In the annual academic results, students in high compliance schools scored highest; pass rates were also higher for high-performing schools.

Figure 14. Compliance to quality standards for 15 midwifery schools

100 86% 90 81% 84% 81% 78% 76% 76% 80 70% 67% 70 66% 60 55% 47% 50 45% 40 27% 27% Compliance 30 20 10 0 Infrastructure and Faculty and clinical Curriculum. (10) Students. (7) Clinical practice. (5) management. (18) instructions. (7)

Quality standard (no. of standards)

Round-1 Round-2 Round-3

Establishment of Birth Centers MCHIP established a memorandum of understanding with DKT International to establish MNCH centers for selected CMWs. DKT constructed 80 single-room and 100 double-room birthing centers (for the CMWs) with waiting areas and provided FP commodities. MCHIP developed the CMWs’ capacity and provided basic equipment for the MNCH centers, such as examination and delivery tables, screens, furniture, delivery kits, FP kits, and infection prevention supplies.

Community Midwife Capacity-Building Using the Quality Improvement Platform Clinical competency of functional CMWs was improved through in-service education and refresher training. MCHIP introduced the QIPS platform for continuous QI to all CMW clinics. This platform included gap identification and action plan development and implementation, followed by reassessment and public recognition of CMWs demonstrating remarkable achievements.

50 MCHIP Pakistan End of Project Report MCHIP worked with 186 CMWs from 16 districts of Sindh to improve their capacity and the quality of services provided. MCHIP introduced QIPS into these CMW practices. The QIPS assessment guided the subsequent training and supportive supervision of the CMWs. Training packages included PCPNC, MCPC, HBB, infection prevention, lactation management, and MIYCN. MCHIP also trained the CMWs on long-acting reversible contraception methods such as IUCD and postpartum IUCD insertion and removal.

Following the training, MCHIP provided Community midwife counseling a client. Photo: MCHIP supportive supervision at least twice a month to the CMWs in the form of OJC. The OJC was based on the LDHF approach to ensure maximum retention of clinical knowledge and skills through simulation-based activities and structured practices, spaced over time at the workplace.

The MNCH Program oversees the CMW program. The MNCH Program focal person visits deployed CMW clinics on a monthly basis to provide supervision and monitoring. Supervisors are medical doctors and are provided with a vehicle and fuel from the MNCH for visits. MCHIP built the technical and supervisory skills of MNCH Program focal persons to serve as a coaches/mentors to provide OJC to CMWs working in their communities.

The traditional training and practicums for CMWs were supplemented through m-mentoring. To keep providers abreast of evidence-based knowledge, a computer-generated quiz was frequently sent to participating CMWs via their cellphones. Upon receiving responses from the CMWs, the system would automatically send the correct answers. Almost 200 CMWs were reached three times each week with different technical questions and correct answers.

The QIPS scores show an improvement over time in compliance to the quality standards for the MNCH and FP services provided by these CMWs. For example, in round 1 of the assessment, completed in 2014, 87% of CMWs complied with minimum standards and only 0% with the maximum standard. In round 3, completed in 2016, 70% of the CMWs were achieving maximum standards, and only 34% were complying to minimum standards.

Business Skills Development To address the financial challenges of practicing CMWs, MCHIP introduced the Business Skills Development Program. The program’s objective was to develop the CMWs’ entrepreneurial skills to improve their clientele and income, providing financial stability. Through this intervention, MCHIP supported 183 CMWs in developing and improving their business and sustaining their midwifery private practice. Figure 15 shows that the average monthly income of 121 CMWs who regularly reported data on business performance increased across 3 program years. Their average monthly income increased from 22,500 PKR (approximately 182 USD) to 26,800 PKR (approximately 217 USD) from year 1 to year 3. The CMWs who took the business skills training also showed increased compliance to the quality standards as measured through the QIPS tool. For example, in round 1, none of the CMWs were meeting 80% of the standards; however, in round 3, 66% of the CMWs were meeting over 80% of the quality standards (Figure 16).

MCHIP Pakistan End of Project Report 51 Figure 15. Average monthly income for 121 CMWs who participated in business skills training

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Figure 16. Increased compliance to quality standards over time as measured through quality improvement and patient safety (QIPS) for 117 community midwives with business skills training

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Professional Networking MCHIP facilitated the membership of 539 practicing CMWs and 300 trainee CMWs in the Midwifery Association of Pakistan (MAP), the professional body for midwives in Pakistan. MAP provides a platform for midwives to network and share experiences.

52 MCHIP Pakistan End of Project Report MNCH Services Support Card To promote the use of CMW services and bring awareness to the community about the midwives, MCHIP distributed MNCH services support cards through LHWs to pregnant women in the lowest wealth quintile in the community. Pregnant women who brought these cards to CMW-led birthing stations received MNCH services such as ANC, delivery, and PNC at minimal rates. Over 18 months, pregnant women used 800 MNCH services support cards.

Mobile Mentoring MCHIP envisioned the m-mentoring intervention as a way of reinforcing the knowledge of trained providers. Following training, a set of questions was sent via SMS to selected providers based on the training content. Once the system received a response from the providers, it returned the correct answers to them via SMS. During the life of project, 11,731 SMSs were sent to 178 CMWs across 16 districts on the technical areas of HBB, CHX, misoprostol, PCPNC, PPFP, and nutrition.

6.3 TRAINING INSTITUTES To overcome gaps in the knowledge and skills needed to care for patients and manage emergencies, SBAs must have access to well-equipped training institutes for continuous education or in-service trainings. Although the government of Sindh has established resources for continuous education, they are nonfunctional or limited in their reach. For example, the DoH tertiary care hospitals in Sindh lack resources such as classrooms or skills labs where staff can maintain and upgrade their skills. To address this gap, MCHIP established training institutes in collaboration with the government of Sindh.

Key Achievements and Results MCHIP established eight high-quality training institutes in Sindh to serve as regional and provincial learning centers: • LUMHS Civil Hospital • LDH, Karachi • Ghulam Mohammad Mahar Medical College, Sukkur • Rai Bahadur Udhawdas Tarachand Civil Hospital, Shikarpur • Jacobabad Institute of Medical Sciences, Jacobabad • Jacobabad APPNA Institute of Public Health, Karachi • National Committee for Maternal and Neonatal Health (NCMNH), Karachi • Provincial Health Development Center (PHDC), Jamshoro

The sites were selected based on their access, coverage, and client volume, and were from four divisions: Sindh-Karachi, Hyderabad, Sukkur, and Larkana. PHDC is a government institute responsible for ongoing training and capacity-building of all public sector health care professionals. It is the largest resource for continuous capacity-building of HCPs in Sindh Province.

To develop these hospitals as training institutes, MCHIP completed the following activities: • Performed a needs assessment to identify strengths and gaps in antenatal and postnatal wards, outpatient departments, classrooms, skills labs, and labor rooms. Based on the findings, MCHIP instituted the QI approach to standardize quality of care.

MCHIP Pakistan End of Project Report 53 • Equipped skills labs and classrooms with advanced teaching and learning tools and materials such as simulators, HBB kit, newborn mannequin, vacuum extractor, implant arm model, ZOE model, delivery kit, manual vacuum aspiration kit, FP commodities, LRPs, and many other supplies to ensure that all trainees received standard training. • Developed master trainers on the training packages across the training institutes through the CTS for training and facilitation skills development followed by package-specific ToT training (Table 10).

Table 10. Training institutes and number of master trainers trained Training type Training institute LUMHS LDH NCMNH AIPH GMMMC RBUT JIMS Pregnancy, childbirth, and 42 3 0 1 2 1 21 postnatal care Managing complications in 0 14 0 2 2 1 0 pregnancy and childbirth Postpartum IUCD 24 16 0 0 8 7 1 Implants 17 5 3 1 2 3 0 Helping Babies Breathe 17 0 0 1 5 9 2 Chlorhexidine 17 0 0 1 20 10 0 Note: AIPH: Jacobabad APPNA Institute of Public Health, GMMMC: Ghulam Mohammad Mahar Medical College, JIMS: Jacobabad Institute of Medical Sciences, LHS: Lady Dufferin Hospital, LUHMS: Liaquat University of Medical and Health Sciences, NCMNH: National Committee for Maternal and Neonatal Health, RBUT: Rai Bahadur Udhawdas Tarachand Hospital

• Introduced PPIUCD practices at LDH and LUMHS. Trained service providers to provide PPIUCD services and generated demand for PPFP through the placement of PPFP counselors at these hospitals. A total of 40 PPIUCD service providers who had successfully provided PPFP services over a time period were further trained and mentored as trainers for PPFP including PPIUCD. • Advocated with DoH Sindh to engage PHDC Sindh to continue to provide continuous in- service education in Sindh. As a result, the 2016 budget and annual operations plan for PHDC included an approved trainer development plan for all of its vertical programs. MCHIP trained the selected trainers on MCPC and PCPNC. DoH Sindh subsequently used PHDC for trainings on PCPNC and MCPC in 2017. All of the financial and logistics arrangements were funded by the DoH Sindh as part of the district action plan (DAP) funds at the PHDC and the training was conducted by PHDC. MCHIP provided general technical oversight only.

54 MCHIP Pakistan End of Project Report 7 MCHIP Associate Award Program Learning 7.1 BY OBJECTIVE Strategic Objective 1: Increase Access to MNCH Services Through Community Mobilization • LHWs play a vital role in linking facilities to the community. Activities such as WSGs not only inform and empower women and families in the community regarding their health, but also empower LHWs as the frontline health workers for their communities. The LHW Program and DoH should continue to invest in capacity-building of LHWs in Sindh. • LHWs perform service delivery in addition to counseling and community mobilization. For example, in addition to distributing condoms and pills, LHWs in the 16 target MCHIP districts in Sindh have successfully counseled and distributed CHX and misoprostol to pregnant women in their communities for the prevention of newborn sepsis and PPH. • There are large areas where LHWs are not available. MCHIP’s strategy of recruitment and capacity-building of CHWs was successful, and showed that CHWs are equally capable. MCHIP also found that with proper encouragement and mentoring, there are candidates in the community who are willing to serve as CHWs and can further be groomed into LHWs. • PDQ provides an opportunity to select members of the QIT in a way that is unbiased and allows for equal participation and representation from the community and from health workers. Community participation in defining priorities, assessing quality, and addressing gaps has led to measurable improvements in quality. Community engagement through the PDQ for QI has proven effective for the social and cultural context of Sindh.

Strategic Objective 2: Improve the Quality of MNCH Scope and Services at Public and Private Health Facilities • The concept of an MLBC evolved into that of an MNCH center that could led by any type of SBA, including midwives. This shift of focus (from CMWs to all types of SBAs, in both public and private sectors) helped women and families to access quality health care within the existing system through diverse facilities and providers. In addition to the 24/7 facilities, facilities that are open 12 hours/6 days a week or 6 hours/6 days a week are also considered potential MNCH Centers with an SBA on call 24/7. Training resource center at Sujawal. • MCHIP launched a web portal of health facilities, displaying Photo: MCHIP locations, services provided, hours of operation, and number of HCPs. Outside of MCHIP, this tool was also being used by Aman Telehealth services to make referrals to clients by identifying the nearest appropriate facility. However, following restrictions from the government of Sindh on any kind of web-based data using the Global Positioning System, this site was abandoned. The web portal is an active data management tool that can facilitate program teams to select facilities and design program for implementation.

MCHIP Pakistan End of Project Report 55 MCHIP made significant investments toward the improvement of PPHI facilities and capacity- building of PPHI staff. PPHI also adopted MCHIP’s QIPS tool as its QI/assessment approach, and incorporated MCHIP designed learning packages into its continuing medical education (CME)/performance review. Additionally, MCHIP worked closely with other local organizations such as Rural Support Program Network (RSPN), IHS, Family Planning Association of Pakistan and MERF to improve their facilities, as well develop the capacity of their providers and staff. Given that Sindh has moved toward PPPs, capacity-building of the local organizations seems to be the way forward in terms of health investments. • Working with commercial facilities was challenging in that there was little to no accountability to a government entity; however, there were facilities keen on improving their services and hence part of MCHIP support. Commercial facilities were not available for group-based training and were supported through OJT and OJC sessions. These facilities also addressed their physical infrastructure needs with their own funds. CME models that incentivize the onboarding of private facilities onto improvement processes, such as QIPs ,or pay for performance is important. • In a current scenario where DoH has contracted out its health facilities, redefining roles and responsibilities of DoH at the provincial and district levels is required. Service delivery and management are now the responsibility of private organizations, and DoH must take charge of maintaining quality of services at these health facilities. • CMWs need continuous technical and management support to establish private practices. They need to be better integrated within the health system, and they need supervisory and monitoring support from the DoH. Professional associations such as MAP could play a stronger role in areas of accreditation. • DoH and PWD have to invest in capacity-building and supportive supervisory mechanisms put in place by MCHIP and use resources such as skills labs, training materials, and databases to continue to support these activities at the district and health facility levels. In DAPs, the districts now have resources to continue MNCH/FP-related trainings both at facility and community levels. However, district health offices may have to identify training needs, and plan and allocate sufficient resources on time during the fiscal year to avoid delays in implementation of activities during the year.

Strategic Objective 3: Facilitate Referral and Transportation to the Health Facilities • E-health/telemedicine, using technologies for long-distance consultation for complicated health cases, can be an alternative approach to the traditional health care delivery model in hard-to-reach places. However, promotion of these services is important to generate demand. • Given their popularity, the MCH and FP camps that MCHIP organized using MSUs can play an important role in providing integrated services, such as FP, vaccination and ANC, and PNC, to underserved, hard-to-reach areas. • Mobilizing local resources, such as community members with transport, to transport pregnant women can be a viable option, a win-win situation for all parties.

56 MCHIP Pakistan End of Project Report Strategic Objective 4: Improve Quality and Scope of CEmONC at Public and Private Hospitals • For strengthening perioperative service delivery, a team-based and onsite approach using checklists can improve patient safety. The barriers that will need to be addressed for continued implementation are organizational commitment and ownership, human resource shortage, and support for training and supportive supervision. • Prior to the interventions, CEmONC facilities were not recording and reporting data related to cesarean section. MCHIP provided supportive supervisory visits and registers to record information such as infection rate. The indicators need to be included in the DHIS and regularly monitored.

7.2 BY TECHNICAL AREA Maternal Health • Quality of care survey findings were alarming and highlighted the need for provider knowledge, skills, and practice in the maternal health area. MCHIP built SBA capacity to provide quality ANC, labor and delivery, and PNC at the health facilities. As a way forward, there must be a sustained effort from the government and stakeholders on capacity-building to improve quality of care. • Despite inclusion of misoprostol in the essential medicines list, unavailability of the drug at health facilities and in LHW kits during the project implementation period was a challenge. The regular supply of this lifesaving drug is crucial for reducing maternal mortality in the province. Availability of drugs at health facilities should be a priority for the facilities and the newly privatized management. • There is a need for an isolation ward for pre-eclampsia/eclampsia patients at health facilities. MCHIP identified a separate room to treat eclamptic patients and provided job aids on preparation of a loading dose of MgSO4 and treatment of eclampsia. To help HCPs to provide safe and effective care to women with pre-eclampsia/eclampsia, a separate space should be made available. • There was no in-service training mechanism in Sindh province. Training approaches were classroom-based didactic and participation and clinical practicum was limited. MCHIP introduced competency-based trainings. As a way forward, MCHIP established MNCH/FP training sites. Trainers and training materials should continue to build capacity of HCPs. • As per the Essential Public Health Services, BEmONC services should be made available at the facilities; however, these services are not being provided. MCHIP provided PCPNC training (including content to build capacity on seven signal functions of BEmONC except assisted vaginal delivery) to all available SBAs at the health facilities. MCHIP included best practices and replaced traditional assisted vaginal deliveries with vacuum-assisted delivery. The facilities will require continued use of best practices and monitoring of activities.

Newborn Health • Community-based distribution to achieve coverage at scale of CHX is not only feasible, it is essential. The CHX intervention in Sindh province was supported by other MCHIP activities to strengthen the capacity of CHWs, and specifically the LHW cadre. • Ensuring the CHX supply is a high priority for all CHX program implementers, and can be achieved through close coordination and planning with local manufacturers as well as procurement planning, with proactive efforts at the provincial level to ensure annual budget allocations for the commodity.

MCHIP Pakistan End of Project Report 57 • Measurement is a critical tool to effectively monitor and strengthen the intervention. There is an urgent need at the national level to integrate CHX indicators into DHIS/MIS software and dashboards, and to revise and print paper-based tools to capture CHX data at facility and community levels. • All SBAs and HCPs, including private providers, across all provinces and districts who work in labor rooms and operating theaters should have HBB training. All labor rooms and operating theaters (in both public and private facilities) should have HBB corners/ventilation areas that include essential HBB supplies (bag for ventilation, masks, ARI timer, suction bulb, stethoscope, action plan wall poster, and ventilation table).The Ministry of Health and DoH should provide a special rebate on HBB equipment for CMWs and private health facilities. • The Ministry of Health/DoH should ensure that the HBB and KMC curriculum for newborn resuscitation is included in pre-service and in-service curricula. DoH should ensure supportive supervision and continuous OJC of SBAs by technical supervisors to ensure HBB skills retention. Provincial health departments should incorporate HBB indicators in DHIS in all provinces to capture data on birth asphyxia and resuscitation. • Through national dialogue, consultation, and stakeholder endorsement, KMC should be incorporated as part of the national standard for low-birthweight/pre-term birth management with a clear KMC policy along with service guidelines. Provincial stakeholder meetings should be held to foster understanding, support, and local participation in KMC implementation. • Health workers (both facility and community based) must be trained in KMC, with this education reinforced through supervision, monitoring, and inclusion in job descriptions and hospital protocols. Facilities need to adapt KMC into their offered services and provide dedicated space and supplies. • Advocacy must be done to dedicate financial resources in government budgets for the introduction and ongoing support of KMC. The development of a costed plan along with national guidelines, as well as initial donor investments and dialogue may facilitate this. • KMC monitoring plans that align with and can be integrated into current data collection tools and supervisory checklists must be developed, along with training on their use. A KMC awareness and promotion strategy with appropriate materials should be developed for LHWs and CHWs.

Child Health • The presence of a DIO increased the monitoring and supportive supervision of RI activities and to some degree the quality and availability of vaccination services. • DIOs—plus an intensive package of registration, microplanning, capacity-building, community promotion, MIS/SMS, and enhanced performance monitoring—produced dramatically better immunization coverage than DIOs alone. • Properly developed and implemented microplans increase access to and use of RI services. • Exempting vaccinators from polio SIAs and involving them in RI activities during campaign days increased RI coverage of due and defaulter children. • MCHIP’s MIS made it possible to review the vaccination status of registered children on a continuous basis and to send reminders for vaccinations due. This system strengthened performance monitoring and improved management decision-making at district and provincial levels.

58 MCHIP Pakistan End of Project Report Family Planning • The original plan for FP training was through a local organization. MCHIP intended to implement a two-step process: first, MCHIP built capacity of a local organization, and second, the local organization developed capacity of the HCPs. MCHIP advertised for applications from local organizations but did not find any satisfactory applicants. MCHIP then diverted the strategy, focusing on capacity-building of training institutes vs. local organizations to build FP capacity. However, toward the end of the project, the Sindh DoH’s PPP node facilitated capacity-building of local organizations such as PPHI, MERF, and IHS on FP capacity-building. • MCHIP initiated the discussions around task sharing on implants: capacity-building of midlevel providers to provide implants services, and LHWs to provide first dose of injectable. Through the FP2020 group and other forums, MCHIP advocated for initiation of the task sharing. The MCHIP follow-on global project, the Maternal and Child Survival Program (MCSP), is taking on the advocacy through the FP 2020 forum. MCSP, in collaboration with Pfizer, is also conducting operational research to look at the feasibility of building LHW capacity to provide the first dose of injectable.

Nutrition • MCHIP worked in harmony with other partners in the province and filled the gaps in implementing promotion of MIYCN practices. MCHIP worked in those districts where no other partner was implementing MIYCN activities. The implementation of NSP was delayed for a year and the LHW Program did not have funds to procure commodities such as IFA. • DoH has initiated the Accelerated Action Plan Program and has taken up MCHIP best practices such as promotion of MIYCN practices at health facilities and the community level, QIPS, and CHX. The program will cover all districts in Sindh by 2020. • Pregnant and lactating women are time-poor and cannot attend nutrition counseling or study nutrition guidelines. Health-related decisions are made jointly by the family and influenced by community leaders, fear of side effects of IFA supplements, and cost of IFA supplements in private pharmacies.

7.3 BY CROSS CUTTING Quality Improvement and Patient Safety • Adapting Jhpiego’s global SBM-R tool for QI for Pakistan as QIPS—a shorter but targeted tool and checklist—led to its wider adoption. An inclusive and consultative implementation approach from the provincial health department to the community level is also essential. Promotion and recognition of achievements is another essential factor in the effective implementation of QIPS. • Linking QI data to an individual HCP’s performance to target refresher training, coaching, peer support, etc., and to the facility-level performance indicators is essential to maximize the benefits of QI. • An internal quality assurance team that looks at training, implementation, and periodic self-assessment of Sindh Health Care Commission (SHCC) standards at health facilities is essential for effective implementation of the QI process. This facility-based internal team should be monitored by QITs within DoH/PWD through periodic supportive supervision and assessment visits.

MCHIP Pakistan End of Project Report 59 • Linking the QI assessments and results to accreditation through a periodic external quality audit team through the DoH Sindh and/or SHCC directorate of clinical and governance can be an essential factor in sustaining the QI process. The SHCC can then provide technical support in registration, inspection, and accreditation of health facilities. • QI interventions and activities are not a one-time achievement; hence, health facilities must continuously implement QIPS cycles, which will eventually bring significant change in the health status of mothers and children in Sindh. • MCHIP observed that building in self-assessment and improvement to QIPS cycles helped reduce the blame culture and encouraged health facility staff to practice self-help and rely on their own resources at the health facility level to improve. However, motivation is critical in QI interventions, and DoH/PWD must devise mechanisms to review QI data and reward high-performing health facilities to continue progress toward QI and quality assurance. • During the no-cost extension period, MCHIP facilitated SHCC to register MCHIP-supported health facilities and inspect them using SHCC standards to get provisional licensing. The process needs to be followed up by DoH so that MCHIP-supported health facilities can be brought rapidly into the SHCC network.

Midwifery • MCHIP facilitated the development of the Pakistan Nursing and Midwifery Vision 2025 logistically and technically. This is the first time that the Pakistan Nursing Council and MAP have come together to develop a vision. The document aims to support the national nursing and midwifery educational institutions in bringing greater uniformity in the quality of education across Pakistan by setting standards for a QI system for educational institutions and programs. • Given the wide acceptance of m-mentoring via SMS messages in the MCHIP tested areas and the rural setting, m-mentoring can be a viable option to link senior ob-gyns with junior HCPs, or to reinforce the learning following training as a supplement to any supportive supervision that is provided. • Based on the findings from the evaluation, business skills training should be an essential component of the midwifery training. The MNCH Program should hire senior CMWs and train them to serve as mentors for the newly deployed CMWs. The CMW registers should be revised to include columns on income and expenses.

60 MCHIP Pakistan End of Project Report 8 Program Legacy 8.1 BY OBJECTIVE Strategic Objective 1: Increase Access to MNCH Services Through Community Mobilization • The LHWs trained on the WSG methodology and linked with the CMWs and health facilities are part of the health system and are available as resources to DoH and the LHW Program to increase access to quality MNCH/FP services. MCHIP-trained master, provincial, and district trainers are part of the LHW Program and are available for further capacity-building. • As per the Planning Commission One of the LHW Program 2018, an additional 2,000 LHWs are being hired across the Sindh province. At the MCHIP districts, the 484 CHWs that MCHIP recruited and trained have also applied for the posts. Under the Tharparkar district package, a total of 1,100 LHWs are advertised and 100 MCHIP-hired CHWs will be transitioned to the LHW Program to fill the need. • The in-service training package on the WSG methodology is part of the LHW Program and is now included in the revised LHW training curriculum. The districts’ budgets available under the DAP are being used for the WSG training activities. • The real-time monitoring mechanism was also adopted by the LHW Program. This technology was transferred to the LHW Program to make it a part of their routine monitoring system. DoH has committed to train LHWs and their supervisors in all districts of Sindh on real-time monitoring. • Under the PPP, the local NGO, IHS, has taken over 105 RHCs. IHS will continue PDQ at these facilities and the surrounding community. MCHIP has developed the capacity of IHS to implement PDQ.

Strategic Objective 2: Improve MNCH Service Scope and Quality at Public and Private Health Facilities • MCHIP developed the capacity of the DoH staff members to continue OJT and supportive supervision visits post MCHIP. A total of 44 HCPs nominated by DoH were mentored on conducting OJT post MCHIP. These providers included CMWs, midwifery tutors, LHW coordinators, senior female medical officers, and ob-gyns. Between September and December 2017, these trained DoH staff members and providers conducted 196 OJT sessions in various technical areas to their peers across 12 districts. • DoH Sindh has adopted the MCHIP-developed training packages as part of the DAP, which means that each district will continue MCHIP trainings with their own funding during their program year. For example, a total of 25 training events were held by 12 districts as part of DAP. MCHIP observed and provided feedback only; all facilitation and resources were from the DoH. • The MCHIP developed and adapted LRPs are accredited with CME hours and certified by Jinnah Sindh Medical University . SBAs and other HCPs can use the LRP to earn CME credits through trainings and OJT sessions.

MCHIP Pakistan End of Project Report 61 • Through the PPP node, the DoH Sindh has contracted out the majority of their facilities to PPHI, IHS, and MERF. MCHIP worked closely with PPHI, which has over 50% of DoH facilities in Sindh, to replicate MCHIP interventions. MCHIP also seconded senior-level technical staff to develop PPHI’s capacity in providing quality MNCH services. These two technical staff are now shifted to PPHI and working with PPHI full-time to replicate MCHIP interventions. Similarly, MCHIP developed capacity of IHS and MERF staff and HCPs on MCHIP interventions for replication and continuation at their facilities.

Strategic Objective 3: Facilitate Referral and Transportation to the Health Facilities • The MCHIP-trained private transporters are being used by the Poverty Eradication Initiative (PEI), a local NGO established under the PPP initiative of the DoH. The complete strategy for referral, including training material/manual, referral slips, and training database, was also shared with PEI. • AHCS has hired medical officers to continue the 9123 helpline and provide guidance and referral for EmONC services.

Strategic Objective 4: Improve Quality and Scope of CEmONC at Public and Private Hospitals • MCHIP handed over all CEmONC interventions, including training packages, CEmONC indicator registers with database, surgical safety checklists, job aids, QIPS, standard operating procedures for blood banks, and other endorsed material to the Directorate General of Health Services for continuation. • Blood transfusion standards are being used in blood banks. Job aids that MCHIP translated in Urdu are now available at the laboratories in Sindh. • Thirty-seven CEmONC facilities are implementing QIPS and compliing to evidence-based best practices including infection prevention and waste management. • Documentation has improved and data on additional indicators of preterm births and their management is being collected accordingly. • HCPs at CEmONC facilities were trained on threatened premature birth management and are now equipped to save preterm babies, reducing morbidity and mortality. • CS-SSCs are now part of patient files in all 37 MCHIP-supported CEmONC facilities, and the rate of implementation of CS-SSCs by the trained operating theater team is high in both public and private facilities.

8.2 BY TECHNICAL AREA Maternal Health • Resources to continue RMC practices were included as part of QIPS tools as well as PCPNC training package and facility staff were trained on RMC best practices. The White Ribbon Alliance will also continue the RMC initiative. • A day of birth training package that includes misoprostol and IEC materials on misoprostol was provided for counseling and distribution at facilities and community. LHWs and HCPs were trained on misoprostol counseling, and HCPs at the facilities were trained on uterotonic administration for PPH management.

62 MCHIP Pakistan End of Project Report Newborn Health • DoH will continue facility- and community-based distribution of CHX in Sindh. The CHX gel tube is now easily available in Pakistan, with five local manufacturers producing it. The CHX indicators are aligned with DHIS and LHW MIS system. • DoH will continue the facility-based provision of HBB services for prevention and management of birth asphyxia. In this regard, DoH Sindh has developed a strategy to ensure a track record of trained HCPs, essential supplies for HBB corners in all health facilities, and monitoring progress through two important indicators (number of cases with birth asphyxia and number of cases received neonatal resuscitation) in the DHIS system. • DoH and partners (Save the Children, Aga Khan University, UNICEF, PPHI, Nutrition International) are implementing KMC programs in various districts of Sindh using MCHIP resources. There is high demand and willingness within health authorities to scale up KMC interventions in other areas of the province.

Child Health • The DoH/EPI Sindh is in the process of adopting MCHIP’s DIO model for monitoring and supportive supervision. The government of Sindh has announced it is recruiting DIOs for all districts of Sindh province and is expanding the model to taluka immunization officers and is recruiting these officers for all of Sindh. • MCHIP provided technical support to EPI Sindh to clarify the need for vaccinators in the field. MCHIP first analyzed the existing vaccinators in each union council in the eight intensive intervention districts to the government of Sindh/EPI Project. MCHIP then used the National EPI policy to advocate for an increased number of vaccinators overall to cover villages that were previously not being reached with vaccination services. A summary of this analysis was prepared and shared with the Chief Minister of Sindh for the approval of posts. As of April 2018, the government of Sindh has recruited 2,118 vaccinators in addition to the 198 existing vaccinators in the Planning Commission One. The government of Sindh has approved Rs 4,000 per vaccinator per month for POL support, in addition to their monthly salaries, in all of Sindh starting in September 2017. This decision was based on results achieved with similar support provided by MCHIP to vaccinators to conduct outreach activities in the eight intervention districts. • UNICEF, in its proposed technical assistance through Gavi, is planning to scale up MCHIP’s microcensus approach in urban slums and 32 high-risk talukas in Sindh province. • EPI Sindh is in the process of adopting the MCHIP MIS, designed to register target populations for RI and conduct follow-up, and merging it with the previous systems, called IRD MIS and vLMIS, to make one MIS for RI in Sindh Province.

Family Planning • MCHIP provided capacity-building of training institutes, DoH, and PWD staff and providers, and DHMT to provide FP, LARC, and PPFP services and training and supportive supervision for these services. • Currently, 1,108 MCHIP-targeted MNCH centers can provide FP, LARC, and PPFP services and have the job aids, equipment, and supplies to facilitate the provision of FP services. Many of these facilities were not providing these services previously. • MCHIP developed the capacity of PPHI, IHS, and MERF, to whom DoH Sindh has contracted out facilities in Sindh to provide FP, LARC, and PPFP services, to continue these services at their facilities.

MCHIP Pakistan End of Project Report 63 • MCHIP initiated the training of male doctors on implants, which are predominantly provided by female doctors, to improve access to implant services.

Nutrition • Resources such as training manuals, job aids, checklists, and IEC materials are now part of DoH Sindh and NSP. • The provincial master trainers and MCHIP-trained trainers are also part of DoH and are currently being used by DoH and other collaborating partners such as UNICEF for training in non-MCHIP districts. • The MIYCN module was translated to Urdu and Sindhi for future training of LHWs in non- MCHIP districts. MIYCN and lactation management modules were shared with stakeholders such as UNICEF and World Vision nutrition teams for training community and facility-based staff at their project site in Sindh. • The IFA brochure is now part of the LHW Program and NSP is planning to print and disseminate it for non-MCHIP districts. • In addition to MIYCN and lactation management, in Tharparkar and Umerkot, MCHIP has left behind 200 DoH and NSP HCPs trained in community-based management of acute malnutrition.

8.3 BY CROSS CUTTING Quality Improvement and Patient Safety • MCHIP modified the QIPS tool for CMW-led clinics; BHU, RHC, and THQ level of health facilities; and DHQ hospitals. The tools for CMW-led facilities were translated to Urdu and Sindh. • MCHIP provided technical assistance to the PPHI-managed health facilities for implementing QI interventions. PPHI allocated technical positions at the district level and hired technical staff to replicate the MCHIP model. PPHI introduced the medical officer headquarters position to health facilities to observe quality of services and provide OJC to facility staff. • The QIPS database was established within the PPHI system to track progress at the provincial level. PPHI embraced the use of QIPS performance standards as easy-to-follow job aids to improve clinical performance at its facilities. • In 2016–2017, DoH outsourced its 101 RHCs in Sindh and 16 RHCs, THQs, and DHQs in Thatta and Sajawal under the PPP node. MCHIP built the capacity of MERF and IHS technical staff at district and provincial levels to implement QIPS. During the no-cost extension period, the DoH, IHS, and MERF conducted QIPS at their respective facilities with oversight from MCHIP.

Midwifery • The MNCH Program focal person visits deployed CMW clinics on a monthly basis for supervision and monitoring purposes. All focal persons are medical doctors, and the MNCH Program provides them with vehicles with POL support for the visits. MCHIP built the technical and supervisory skills of MNCH Program focal persons to work as coach/mentors to provide OJC to CMWs working in their communities. • The MCHIP-supported CMWs continuously assess their performance using the Urdu and Sindh translated QIPS tool to improve the quality of MNCH services.

64 MCHIP Pakistan End of Project Report • MCHIP developed linkages between LHWs, HCPs at health facilities, and private transporters with CMWs will remain in the community to serve the purpose. • All midwifery schools across 15 districts of MCHIP are now following the Pakistan Nursing Council curriculum where faculties and teachers set objectives, plan lessons, and conduct clinical work. The lesson plan is made according to the Pakistan Nursing Council curriculum, with 60% theory and 40% practical sessions. Previously, no practical sessions were conducted. • The objective structured clinical examination (OSCE) introduced by the Pakistan Nursing Council was not being implemented at the schools. Following MCHIP’s re-introduction of OSCE and orientation of faculty and students, the schools are using OSCE to assess student skills and competency. • MCHIP is also leaving behind a well-equipped skills labs for the students to continue to develop their competency.

Training Institutes • MCHIP is leaving behind eight training institutes in Sindh that are fully capable of organizing in-service training for SBAs in several areas of MNCH. DoH and other organizations are also using these training institutes for continued training for their providers. • MCHIP introduced and established new services such as PPFP in three of these training institutes. To generate the demand for PPFP services, MCHIP trained and hired PPFP counselors at these sites. Post MCHIP, the facilities have continued with the counselors using their own resources. Once the services were established, these training institutes also developed their capacity as training sites for PPFP. • MCHIP developed the capacity of PHDC Sindh, the official training institute of DoH Sindh, which was nonfunctional, for continuous training of SBAs to serve as a training institute for PCPNC and la training packages. MCHIP also provided a fully equipped skills lab and arranged classroom setting at the PHDC. PHDC has been linked to LUMHS for the clinical practicum piece. • MCHIP is leaving behind a pool of trainers and master trainers at these eight training institutes who can serve as resources for continuous capacity-building. MCHIP is also leaving being well-equipped skills lab at these facilities to further the capacity-building of SBAs.

MCHIP Pakistan End of Project Report 65 Annex A: Performance Indicators

Indicator Unit of measure Baseline Target Total 5.2d. Number of women and Number of clients — 3,900,000 6,417,729 children receiving family planning and maternal, newborn, and child health (MNCH) services in US government (USG)-assisted sites 5.2f. Number of children who Number of children — 163,165 191,022 received DPT3 by 12 months of age in USG-assisted programs 5.2g. Percent of births receiving Number of women who received at least 34.5% 75.0% 53.0% at least four ANC checks four antenatal care visits by a skilled birth attendant or trained community health worker during their most recent pregnancy/total number of women ages 15–49 who had a live birth in the 2 years prior to the survey 5.2h. Percent of women whose Number of women who received postnatal 34.0% 38.0% 31.0% newborns received postnatal care from a skilled birth attendant or trained checkup within 2 days of birth community health worker within 2 days of childbirth/total number of women ages 15– 49 who had a live birth in the 2 years prior to the survey 5.2.1d. Number of community Number of community support groups — 119,800 169,134 support groups conducted in USG-assisted sites 5.3a. Percentage of facilities Number of health facilities complying 75% or 7.0% 80.0% 30.0% complying with national above score for selected national standard guidelines/standards for labor for antenatal, labor and delivery, postnatal and delivery visits at USG- maternal and newborn care, infection supported facilities prevention and referral using the quality improvement and patient safety (QIPS) tool/total number of USG-supported health facilities where QIPS is implemented 5.3.2b. Number of people Number of persons 38,611 — 18,164 trained in family planning/reproductive health and MNCH through USG support

66 MCHIP Pakistan End of Project Report Annex B: List of Materials or Tools Developed or Adapted by the Program

Index of reports and informational materials developed or adapted during the MNCH Program, 2013–2018 Title Date Program reports Pakistan MNCH Quarterly Reports FY13 Q2–Q4 FY13 Pakistan MNCH Quarterly Reports FY14 Q1–Q4 FY14 Pakistan MNCH Quarterly Reports FY15 Q1–Q4 FY15 Pakistan MNCH Quarterly Reports FY16 Q1–Q4 FY16 Pakistan MNCH Quarterly Reports FY17 Q1–Q4 FY17 Pakistan MNCH Quarterly Reports FY18 Q1 FY18 Pakistan MNCH Annual Report FY 14, FY 15, FY 16, FY 17 Work plans Pakistan MNCH Annual Work Plan FY13 FY13 Pakistan MNCH Annual Work Plan FY14 FY14 Pakistan MNCH Annual Work Plan FY15 FY15 Pakistan MNCH Annual Work Plan FY16 FY16 Pakistan MNCH Annual Work Plan FY17 FY17 Training packages Comprehensive emergency obstetric and newborn care Anesthesia & Analgesia 2015 Perioperative Strengthening 2015 Safe Blood Transfusion Practices 2015 Threatened Preterm Births 2015 Community mobilization Women Support Group Methodology 2014 Transporters’ Training Package 2015 Newborn and child health HBB Training Manual (Sindhi) 2015 Training Manual: Application of 7.1% Chlorhexidine Digluconate 2014 for Prevention of Umbilical Cord Infections Training Manual: Case Management of Cough or Difficult 2014 Breathing and Diarrhea for Children <5 years Training Manual on Facility-Based KMC 2016 Mid-Level Management Training on Immunization 2015 Immunization Manual for SBA 2015 Maternal health 2014 Pakistan, Pregnancy, Childbirth, Postpartum and Newborn Care: 2015 A Guide for Essential Practice Managing Complications in Pregnancy and Childbirth (CMWs and 2015 other SBAs) Misoprostol Training Package 2014

MCHIP Pakistan End of Project Report 67 Index of reports and informational materials developed or adapted during the MNCH Program, 2013–2018 Title Date Guidelines Maternal, Newborn, and Child Health Center Implementation 2016 Guide Mother’s Booklet 2015 PDQ Facilitation Guideline 2014 Healthy Timing and Spacing of Pregnancy (Sindhi) poster 2015 Implants Insertion job aid (Sindhi) poster 2015 Others General Disease Modules for PPHI (Worm Infestation, Cataract, 2014 Trachoma, Glaucoma, Otitis Media, Snake Bite, typhoid, Meningitis, Measles, Scabies, Pneumonia, Nephritis Nephrosis) CMW Business Skills Training 2015 Maternal, Infant, and Young Child Nutrition (Sindhi and Urdu) 2015 Briefers and Reports Briefers Preventing Infections to Ensure Patient Safety and Save Lives 2018 Revival of the LHW Program in Sindh 2018 Promoting Maternal, Infant, and Young Child Nutrition Practices 2018 in Rural Sindh Comprehensive Emergency Obstetric and Newborn Care 2018 (CEmONC) Strengthening the Role of Community Health Workers as Change 2018 Agents Capacity Development of Skilled Birth Attendants and Training 2018 Institutions in Sindh Protecting Our Babies: From National Policy to Provincial Reality 2018 Supply and Demand of Maternal Iron-Folic Acid Supplementation 2018 and Infant and Young Child Feeding Counseling in Jamshoro and Thatta Districts, Pakistan Helping Babies Breathe technical brief 2018 MCHIP Routing Immunization Technical Assistance 2018 Improving Accessibility and Quality of CMW Services 2018 Quality Improvement and Patient Safety (QIPS) Intervention 2018 Report Introduction and Implementation of Safe Surgery Checklist in 2018 CEmONC Facilities of Sindh Technical Reports Case Study: Harnessing Community Participation to Improve 2017 Quality in Health Facilities Kangaroo Mother Care: Opportunities for National Scale-Up in 2017 Pakistan District Profiles as part of End-of-Project Dissemination UmerKot 2018 Thatta 2018 Sukkur 2018 Sanghar 2018 Matiari 2018

68 MCHIP Pakistan End of Project Report Index of reports and informational materials developed or adapted during the MNCH Program, 2013–2018 Title Date Larkana 2018 Jacobabad 2018 Gothki 2018 Mirpurkhas 2018 Dadu 2018 Shikarpur 2018 Research Reports Acceptability and Feasibility of Implementing Surgical Safety 2017 Checklist for C-Section Patients: A Case Study of Sindh Immunization Coverage Survey of Sindh: Eight Districts 2016 An Exploration of the Opportunities and Challenges for 2017 Implementation and Practice of Kangaroo Mother Care in Rural Sindh, Pakistan Impact of Innovative Strategies of Neonatal Outcomes: A 2017 Retrospective Study QIPS Assessment Analysis Report of Round One to Four 2017 Quality Improvement and Patient Safety (QIPS): Implementation 2016 of Continuous Quality Improvement Approach for Improved MNCH Care in Sindh Evaluation of the Business Skills Development Program 2017 Evaluation of the Mobile Mentorship Program 2017 Quality of Care Survey Report 2016 A Qualitative Assessment of Supply and Demand of Maternal 2017 Iron-Folic Acid Supplementation and Infant and Young Child Feeding Counseling in Jamshoro and Thatta Districts, Pakistan Mothers’ Use of Chlorhexidine and Misoprostol Distributed by 2016 LHWs in Sindh, Pakistan Manuscripts Quality of Labor and Delivery Care in Sindh Province, Pakistan: 2018 Findings from Direct Observations at Health Facilities Success stories Several

MCHIP Pakistan End of Project Report 69