IMPROVING MATERNAL HEALTH MEASUREMENT CAPACITY AND USE NATIONAL DIALOGUE Photo Credit: White Ribbon Alliance Pakistan 22 OCTOBER 2019 Islamabad, Pakistan Special thanks to the White Ribbon Alliance Pakistan, the National Institute of 1Population Studies, World Health Organization Pakistan and Women & Health Initiative at the Harvard T.H. Chan School of Public Health. Acknowledgements The National Dialogue on Ending Preventable Maternal Mortality owes its successful execution to the dedicated and untiring efforts of different individuals and organizations. The dialogue was conducted under the aegis of Ministry of National Health Services Regulations and Coordination by the National Institute of Population Studies (NIPS), in collaboration with White Ribbon Alliance Pakistan (WRAP), Women and Health Initiative (W&HI) at the Harvard T.H. Chan School of Public Health, and the World Health Organization (WHO). NIPS is indebted to all these organizations for their support in conducting this dialogue. Conducting the dialogue was a complex assignment. Each member of NIPS team involved in this exhibited the highest level of professional commitment and dedication. We would particularly like to appreciate the efforts of: Ms. Azra Aziz, Syeda Rabia Zafar, Mr. Arif Luqman and Ms. Mehwish Khan for their instrumental role in organizing this dialogue. Dr. Tauseef Ahmed, Freelance Consultant and Principal Investigator for Pakistan Maternal Mortality Survey, who remained with us throughout and provided immense help and continuous support, deserves special mention. We would also like to acknowledge with deep gratitude, the relentless and committed efforts of Dr. Farid Midhet, Country Director, Palladium for facilitating the entire event. The technical assistance extended by Ms. Kim Whipkey also merits mentions. She was a source of inspiration and encouragement throughout the whole operation. Finally, we would like to thank the technical experts who attended the dialogue and provided their valuable input, in particular during the panel discussion and for finalization of indicators. Aysha Sheraz, Ph.D. Senior Fellow (R&S/HRD) 2 Abbreviations AJK Azad Jammu and Kashmir AMDSR Adolescent Maternal Death Surveillance and Response ANC Antenatal Care BMGF Bill & Melinda Gates Foundation BHUs Basic Health Units BISP Benazir Income Support Program CMW Community Midwife C-Section Caesarean Section DFID Department for International Development EmOC Emergency Obstetric Care EmONC Emergency Obstetrics and Newborn Care EPMM Ending Preventable Maternal Mortality ESP Essential Service Package EWEC Every Women Every Child FCI-MSH Family Care International Program of Management Sciences for Health GBV Gender-Based Violence GFF Global Financing Facility GIHQ Global Institute of Health Care HIV Human Immunodeficiency Virus HRC United Nations Human Rights Council ICD-10 International Coding of Death ICU Intensive Care Unit IMHM Improving Maternal Health Capacity and Use Project IUD Intrauterine Device JSI John Snow Inc. KM Kilometer KP Khyber Pakhtunkhawa LHV Lady Health Visitor MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MDGs Millennium Development Goals 3 MHTF Maternal Health Task Force MMR Maternal Mortality Ratio MNCH Maternal, Newborn, and Child Health MNHSR&C Ministry of National Health Services, Regulations & Coordination MSH Management Sciences for Health NCMNCH National Commission for Maternal, Newborn, and Child Health NCMNH National Commission for Maternal and Neonatal Health NIPS National Institute of Population Studies PAIMAN Pakistan Initiatives for Mothers and Newborns PIMS Pakistan Institute of Medical Sciences PNC Postnatal Care RH Reproductive Health RMC Respectful Maternity Care RMNCH Reproductive, Maternal, Newborn, and Child Health RSPN Rural Support Program Network SDGs Sustainable Development Goals SOP Standard Operating Procedures SRH Sexual and Reproductive Health SRMNCAH Sexual, Reproductive, Maternal, Newborn, Child, and Adolescent Health UHC Universal Health Coverage UN United Nations UNFPA United Nations Population Fund UNSG United Nations Secretary General USAID United States Agency for International Development W&HI Women and Health Initiative WASH Water, Sanitation, and Hygiene WHO World Health Organization WRA White Ribbon Alliance WRAP WRA Pakistan 4 Executive Summary Pakistan is the sixth country to organize the National Dialogue on Ending Preventable Maternal Mortality (EPMM). Held October 22, 2019, the Dialogue was sponsored by the White Ribbon Alliance Pakistan (WRAP) in partnership with National Institute of Population Studies (NIPS) and World Health Organization (WHO) Pakistan, through support provided by the IMHM Project led by the Women & Health Initiative at the Harvard T.H. Chan School of Public Health. The objectives were to review the ending preventable maternal mortality (EPMM) strategies and related indicators and their potential to advance maternal health in Pakistan; identify opportunities to integrate or strengthen focus on the social determinants of maternal health within relevant national policies, plans, and programs; identify ways to strengthen monitoring and use of data from distal and social indicators in Pakistan to measure progress and identify areas for improvement in maternal health; and build on the availability and use of robust monitoring data to identify key advocacy needs and opportunities for advancing maternal health and enhancing policy, programmatic, and resource-related decision-making. The dialogue had multisector representation and was attended by almost 60 participants, including representatives from Ministry of Health, Parliamentarian Health Committee, civil society, development partners, professional bodies, advocacy groups, and research institutions. The National Dialogue was structured in three sessions. The inaugural session focused on introducing the EPMM Strategic Framework and its 11 key themes and briefing participants about indicators that could be important for reducing maternal mortality in Pakistan. The prevailing issues in Pakistan were discussed and participants encouraged to comment and ask questions. The session’s focus was on encouraging, engaging, and sensitizing participants to the indicators and prioritizing those they see as most important to reducing maternal mortality in Pakistan. The key takeaways of the session were: • Respectful maternity care is essential both in public and private healthcare units. • Lack of human resources and funds lead to compromised quality of service in the public health sector. These gaps need to be filled in order to monitor the progress of maternal health. • It is important to integrate family planning with other health services provided in public health sector, as it will help create and increase awareness of family planning services. Most organizations are targeting young couples (ages 14–24) for family planning and birth spacing techniques. However, there is need to target all ages up to 50, because in rural areas older and younger couples have the same childbirth rate. • There should be social mobilization to improve the maternal health situation in Pakistan. Media and especially social media can play a critical role in this regard. • Accountability of all actors is a must to ensure implementation of quality health services in public health systems. The healthcare system needs to be structured with a human rights framework in mind. 5 • Integration of public and private partnerships with the education sector is important. The average healthcare provider does not understand population issues, the importance of family planning, or reasons for maternal mortalities. The education sector will not only impart basic knowledge but will also create awareness regarding health statistics and terminologies among students and health workers. The chief guest concluded the session by committing to ensure the inclusion of these recommendations in the respective policies. The importance of a multisectoral approach in policymaking, where everyone plays a role in preventing maternal mortality, was also stressed. The second session comprised group work. Participants were organized into four groups, each with a lead facilitator and a co-facilitator. The groups were encouraged to discuss and score all 11 key themes of EPMM and identify the top three priority themes with indicators in the context of Pakistan. The top three themes were identified after consolidating the results from all four groups. The top three priority themes that emerged for Pakistan were: • Theme 4: Apply a human rights framework to ensure that high quality reproductive, maternal, and newborn healthcare is available, accessible, and acceptable to all. Indicators identified for this theme were the proportion of women aged 15–49 who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive healthcare; and geographic distribution of facilities that provide basic and comprehensive emergency obstetric care (EMoC). • Theme 6: Prioritize adequate resources and effective healthcare financing. This theme was considered most important in Pakistan by all four groups and rose to the top of the prioritized themes. The indicators identified for this theme were percentage of total health expenditure spent on RMNCH; out-of-pocket expenditure as a percentage of total expenditure on health; conducting annual reviews of health spending from all financial sources, including spending on RMNCH, as part of broader health