Delivery of MNH Services in Conflict Areas of KP, Balochistan, and FATA

Care-Plus Delivery of MNH Services in Conflict Areas of KP, Balochistan and FATA Implemented by: A Project Funded by: SoSec Consulting Services Maternal and Newborn Health Programme – Research and Advocacy Fund (RAF) Dr. Asma Bokhari Principal Investigator Principal Investigator Research Team Dr. Asma Bokhari Dr Muhammad Bashirul Haq Ms Sadia Batool Co-Principal Investigator Ms Meher Sana Arshad Prof Dr. Naveed-i-Rahat Mr Moin ud din i Table of Contents Balochistan Province 13 Table of Contents ii Providers Perspective 13 List of Abbreviation vi Users Perspective 17 Executive Summery vii Summary of findings and Conclusions 18 CHAPTER 1 1 CHAPTER 3 19 INTRODUCTION 1 ACCESS TO AVAILABLE MATERNAL AND NEWBORN HEALTH (MNH) Background 1 SERVICES KEEPING IN VIEW SECURITY SITUATION 19 Rationale of the Study 1 Introduction 19 Study Design and Methodology 2 Khyber Pakhtunkhwa Province and Federally Administered Tribal Areas 19 Study Objectives 2 Perspective of Users and Providers 19 Research Questions 2 Balochistan Province 23 Study Tools 2 Summary of findings and Conclusions 26 Mapping of MNH Services, Programmes and Initiatives 3 CHAPTER 4 28 Selection of Target Districts 3 REFERRAL LINKAGES TO HIGHER LEVEL HEALTH FACILITIES 28 Selection of Study Subjects 3 Introduction 28 Development of Research Tools 4 Khyber Pakhtunkhwa Province 28 Field Testing of Research Tools/Guidelines 4 Providers Perspective 28 Selection of Field Researchers 5 Users Perspective 30 Training of the Field Researchers 5 Federally Administered Tribal Areas 31 Supervision of Fieldwork 5 Providers Perspective 32 Strategy for Data Collection 5 Users Perspective 33 Ethical Considerations 6 Balochistan Province 34 Selection and Orientation of Data Analysts 6 Providers Perspective 34 Challenges in Implementing the Study 6 Users Perspective 36 Layout of Research Report 6 Summary of findings and conclusions 38 CHAPTER 2 7 CHAPTER 5 40 EXISTING MATERNAL AND NEWBORN HEALTH (MNH) SERVICES 7 PERCEPTIONS AND EXPECTATIONS OF USERS AND PROVIDERS TO THEIR Introduction 7 MATERNAL AND NEWBORN HEALTH (MNH) NEEDS 40 Khyber Pakhtunkhwa Province 8 Introduction 40 Providers Perspective 8 Khyber Pakhtunkhwa Province 40 Users Perspective 11 Providers Perspective 40 Federally Administered Tribal Areas 11 Users Perspective 43 Providers Perspective 12 Federally Administered Tribal Areas 45 Users Perspective 13 Providers Perspective 45 ii iii Users Perspective 46 GUIDELINES FOR IN-DEPTH INTERVIEWS AND FOCUS GROUP Balochistan Province 48 DISCUSSIONS 76 Providers Perspective 48 Guidelines for IDIs with Public Health Managers at District and Provincial level 76 Users Perspective 50 Guidelines for IDIs with Private Health Managers 78 Summary of findings and conclusions 52 Guidelines for FGDs with Lady Health Visitors/ Midwives 80 CHAPTER 6 54 Guidelines for IDIs with Mothers 82 HOW COMMUNITIES AND PROVIDERS CAN PARTICIPATE IN SERVICE Guidelines for FGDs with Lady Health Workers 85 DELIVERY 54 Guidelines for FGDs with TBAs 87 Introduction 54 Guidelines for FGDs with Pregnant mothers 89 Khyber Pakhtunkhwa Province 54 Guidelines for FGDs with Mothers having Child <1year 91 Providers Perspective 54 Guidelines for FGDs with Husbands 93 Users Perspective 56 Guidelines for FGDs with Mothers/ Mothers-in-law 95 Federally Administered Tribal Areas 58 Guidelines for FGDs with Fathers/ Fathers-in-law 97 Providers Perspective 58 Guidelines for FGDs with Community Influential 99 Users Perspective 59 References 101 Balochistan province 61 Providers Perspective 61 Users Perspective 63 Summary of findings and conclusions 64 CHAPTER 7 65 FINDINGS, DISCUSSION AND PROPOSED WAY FORWARD 65 Existing Maternal and Newborn Health (MNH) services 65 Access to available MNH services keeping in view security situation 66 Referral linkages to higher level health facilities 66 Perceptions and expectations of users and providers to their MNH needs 67 How Communities and providers can participate in service delivery 67 Discussion 67 Proposed way forward 70 ANNEXURE 73 ANNEX 1 74 PROJECT CORE TEAM 74 ANNEX 2 76 iv v LIST OF ABBREVIATIONS Executive Summary AHQ Agency Headquarters Hospital BCC Behaviour Change Communication BHU Basic Health Unit Introduction CBO Community Based Organisation CD Civil Dispensary Pakistan in recent years has faced ongoing conflict and insurgency in the provinces of Khyber Pakhtunkhwa CME Continuing Medical Education (KP), Balochistan, and the Federally Administered Tribal Areas (FATA). Hence, access to social services, CMW Community Midwife including Maternal and Newborn Health (MNH) services have been significantly reduced in the conflict areas, a DG Khan Dera Ghazi Khan crisis which has been further compounded by floods in the recent past. DHO District Health Officer DHQ District Headquarters Hospital The objectives of this qualitative research study are to: assess MNH situation in the conflict areas of Pakistan; DI Khan Dera Ismail Khan and identify factors that are detrimental for access to and utilisation of MNH services, especially for the most DoH Department of Health marginalised populations groups. Focus Group Discussions (FGDs) and In-depth Interviews (IDIs) were DPWO District Population Welfare Officer conducted with users and providers of MNH services to scrutinise both the demand and supply sides of the EDO Executive District Officer governance equation. The study also aimed to explore socio-cultural patterns at the community level to evaluate EDOH Executive District Officer Health their impact, if any, on the MNH services. EmONC Emergency Obstetric and Neonatal Care FATA Federally Administered Tribal Areas The qualitative research study explored five key thematic areas in nine districts and three FATA agencies. The FGD Focus Group Discussion themes explored included: existing MNH Services; access to the available MNH services; referral linkages to FMO Female Medical Officer higher level health facilities; perceptions and expectations of users and providers; and how communities and FP Family Planning providers can participate in the delivery of services. HHR Health human resource IDI In-depth Interview Findings of the Study IDPs Internally Displaced Persons KP Khyber Pakhtunkhwa The acts of terrorism and militancy have adversely affected the MNH services. During attacks, roads get LHS Lady Health Supervisor blocked, public transport disappears and both health providers and patients find it difficult to reach the health LHV Lady Health Visitor facilities. Insecurity, threats by Taliban, fear of militancy and target killing have also had a negative impact on the LHW Lady Health Worker overall socio-economic conditions and socio-psychological environment, resulting in major damage to the social MCH Maternal and Child Health fabric of the society. Most of the families and health workers have left the conflict areas and moved to safer MDG Millennium Development Goal places. MNCH Maternal, Neonatal and Child Health MNH Maternal and Newborn/Neonatal Health The quality, access and utilization of MNH services in the security-affected areas are compromised for a variety MO Medical Officer of reasons. The public sector staffing issues stand out prominently, such as the shortage of female health MSF Medecins Sans Frontieres providers, absenteeism and political interference in staff recruitment and posting. Another key challenge is the NATO North Atlantic Treaty Organisation deficiencies in health infrastructure such as the lack of repair and maintenance of buildings, and absence or NGO Non- governmental Organisation uninhabitable residential quarters affecting the working environment. The limited availability of utility services NP National Programme NWA North Waziristan Agency further compromises of the provision of services, e.g. shortage of electricity, gas and water supply. Staff in the OB/GYN Obstetrics and Gynaecology public sector complained of low salaries as compared to the private sector and even DoH employees in the ORS Oral Rehydration Salt Punjab province. Equal wages for working in both unaffected and security risk areas was also stated as an unjust OT Operation Theatre decision. PHC Primary Healthcare PHM Public Health Manager The users also face problems in access to and utilization of services due to short supply of medicines, lack of or PHP Public Healthcare Provider worn out equipment, indifferent staff behaviour, short working hours of health facilities, insufficient or remote PMA Pakistan Medical Association location of many primary healthcare (PHC) facilities, and lack of an organised transport system for referral PPL Pakistan Petroleum Limited services. The dominance of elders and/or male members of the family further restrict the mothers in timely QR Qualitative Research seeking MNH services. Hence, poor and marginalised families generally depend on traditional birth attendants RAF Research and Advocacy Fund (TBAs) while well off families prefer better equipped private sector facilities. The aforementioned challenges are RHC Rural Health Centre generally common to all areas, but are much more severe in FATA and Balochistan. SBA Skilled Birth Attendant SOP Standard Operating Procedure Most of the users were not satisfied with the public sector services and criticised the quality of care. According to TBA Traditional Birth Attendant them, private hospitals are mostly better equipped, provide better quality of care and staff behaviour is cordial. THQ Tehsil Headquarters Hospital However, the private sector charges heavy fees and thereby crowding out the poor and the marginalised.

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