USAID/PAKISTAN: MATERNAL NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION October 2010 This publication was produced for review by the United States Agency for International Development. It was prepared by Stephen J. Atwood, Judith Fullerton, Nuzhat S. Khan, and Shafat Sharif through the Global Health Technical Assistance Project. USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION DISCLAIMER The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. This document (Report No. 10-01-394) is available in printed or online versions. Online documents can be located in the GH Tech web site library at http://resources.ghtechproject.net/. Documents are also made available through the Development Experience Clearing House (http://dec.usaid.gov/). Additional information can be obtained from: The Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 info@ghtechproject.com This document was submitted by The QED Group, LLC, with CAMRIS International and Social & Scientific Systems, Inc., to the United States Agency for International Development under USAID Contract No. GHS-I-00-05-00005-00 USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION i ACKNOWLEDGMENTS The final evaluation team would like to acknowledge the assistance of the USAID/Pakistan team, particularly Janet Paz-Costillo, Miriam Lutz, and Megan Peterson, in providing support despite the difficult time of national crisis. We would also like to thank the entire PAIMAN team for their commitment to the project and to this evaluation. We particularly thank the Chief of Party, Dr. Nabila Ali. Finally, the consistent support provided by Taylor Napier-Runnels of GH Tech was invaluable and appreciated by all team members. ii USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION iii CONTENTS ACRONYMS v EXECUTIVE SUMMARY vii I. INTRODUCTION 1 PURPOSE OF THE EVALUATION 1 EVALUATION METHODOLOGY AND CONSTRAINTS 1 II. BACKGROUND 7 MATERNAL AND NEWBORN HEALTH IN PAKISTAN 7 USAID/PAKISTAN HEALTH SECTOR ASSISTANCE 8 ASSISTANCE FROM OTHER DONORS IN MATERNAL AND NEWBORN HEALTH 10 III. OVERVIEW OF THE PAIMAN PROJECT 13 PROGRAM DESIGN AND IMPLEMENTATION 13 PAIMAN PROGRAM GOAL 14 OBJECTIVES AND OUTCOMES 14 SCOPE, DURATION, AND FUNDING 15 SELECTION OF DISTRICTS 16 BENEFICIARIES 16 IMPLEMENTATION 16 MONITORING AND EVALUATION 17 RESEARCH 19 MANAGEMENT AND ORGANIZATIONAL STRUCTURE 21 RELATIONSHIPS, COORDINATION, AND COLLABORATION 25 IV. TECHNICAL COMPONENTS 27 SO1. INCREASING AWARENESS AND PROMOTING POSITIVE MATERNAL AND NEONATAL HEALTH BEHAVIORS 27 SO2. INCREASING ACCESS TO MATERNAL AND NEWBORN HEALTH SERVICES 31 SO3. INCREASING QUALITY OF MATERNAL AND NEWBORN CARE SERVICES 37 SO4. INCREASING CAPACITY OF MATERNAL AND NEWBORN HEALTH CARE PROVIDERS 44 SO 5. IMPROVING MANAGEMENT AND INTEGRATION OF SERVICES AT ALL LEVELS. 61 V. IMPACT OF RECENT POLITICAL DEVELOPMENTS IN PAKISTAN ON MNCH 69 18 th AMENDMENT 69 LOCAL GOVERNMENT SYSTEM 69 VI. CONCLUSIONS 71 VII. RECOMMENDATIONS AND FUTURE DIRECTIONS 75 iv USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION APPENDICES APPENDIX A: SCOPE OF WORK 79 APPENDIX B: PEOPLE CONTACTED 93 APPENDIX C: DOCUMENTS REVIEWED 99 APPENDIX D: ASSESSMENT TEAM SCHEDULE 101 APPENDIX E: REFERENCES 111 TABLES Table 1: Categories and Numbers of Stakeholders Interviewed by the FET 5 Table 2: Population Demographic Indices 7 Table 3: Upgraded Facilities 41 Table 4: Training Conducted 55 Table 5: CMWs by Province 58 Table 6: Graduate Pass Rates CMW Programs 60 Table 7: Overall Increase in Health Budget 64 FIGURES Figure 1: Pakistan Maternal and Newborn Health Programs Strategic Framework 13 Figure 2: Key Maternal Services Original PAIMAN Districts 35 Figure 3: Obstetric Care in Upgraded Health Facilities - Original PAIMAN Districts 42 Figure 4: Availability of Basic EmONC Services 42 Figure 5: Availability of Comprehensive EmONC Services 43 Figure 6: C-sections as a Proportion of All Total Facility Births. 43 Figure 7: Nurses/LHV Active Management of Third Stage of Labor Skills 57 USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION v ACRONYM LIST AKU Aga Khan University ANC Antenatal care ARI Acute respiratory illness AusAid Australia Aid BCC Behavior change communication BEmONN Basic emergency obstetric and neonatal care BHU Basic health unit CAM Community advocacy and mobilization CCB Citizen Community Board CEmONC Comprehensive emergency obstetric and neonatal care CHW Community health worker CIDA Canadian International Development Agency C-IMCI Community integrated management of childhood illness CMW Community midwife COP Chief of Party DAOP District annual operational plan DfID The United Kingdom Department for International Development DHIS District Health Information System DHQ District Headquarters Hospital DHMT District Health Management Team EDO Executive District Officer EmOC Emergency Obstetric Care EmONC Emergency Obstetric and Neonatal Care EPI Expanded Program of Immunization FATA Federally Administered Tribal Areas FET Final evaluation team FGD Focus group discussions FHC Facility-based Health Committee FOM Field Operations Manager FP Family planning GIS Geographic information system GOP Government of Pakistan HMIS Health Management Information System HQ Headquarters IMR Infant mortality rate ICM International Confederation of Midwives IMNCI Integrated management of newborn and child illness JHU/CCP Johns Hopkins University/Center for Communications Programs JICA Japanese International Cooperation Agency JSI John Snow International KPK Khyber Pakhtunkhwa (district) LHV Lady Health Visitor LHW Lady Health Worker MAP Midwifery Association of Pakistan MDG Millennium Development Goal M&E Monitoring and evaluation MMR Maternal mortality ratio MNCH Maternal, newborn and child health vi USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION MOH Ministry of Health MOPW Ministry of Population Welfare MTE Mid-term Evaluation NATPOW National Trust for Population Welfare NEB Nursing Examination Board NGO Non-governmental organization NMR Neonatal mortality rate NPFPPHC National Programme for Family Planning and Primary Health Care PAIMAN Pakistan Initiative for Mothers and Newborns PAVNA Pakistan Voluntary Health & Nutrition Association PDHS Pakistan Demographic and Health Survey PIMS Pakistan Institute of Medical Sciences PNC Pakistan Nursing Council PSLM Pakistan Social and Living Standards Measurement Survey QIT Quality Improvement Team RAF Research and Advocacy Fund RHC Rural Health Center RMOI Routine monitoring of output indicators RN Registered nurse SBA Skilled birth attendant SO Strategic objective SOW Scope of work TACMIL Technical Assistance for Capacity-building in Midwifery, Information and Logistics TB Tuberculosis TBA Traditional birth attendant THQH Tehsil Headquarters Hospital TPM Team planning meeting TRF Technical Resource Facility TT Tetanus toxoid UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund US United States VHW Village health worker WHO World Health Organization [...]... provinces and districts USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION xv xvi USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION I INTRODUCTION PURPOSE OF THE EVALUATION The purpose of this evaluation is to provide the United States Agency for International Development’s Mission to Pakistan (USAID/Pakistan) with an independent end-of-project evaluation. .. 2010) JICA also funded the development of the District Health Information Management software, through which MNCH indicators are tracked USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION 11 12 USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION III OVERVIEW OF THE PAIMAN PROJECT PROGRAM DESIGN AND IMPLEMENTATION Begun in 2004, the PAIMAN Project is... the second expansion phase USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION xiii SO2 Increasing Access to Maternal and Newborn Health Services 16 Explore a variety of options for increasing the proportion of private sector partners in the delivery of maternal and newborn health services, with particular outreach to providers who reside in rural and hard-to-reach areas These... and Newborn Health Programs Strategic Framework PAIMAN PROGRAM GOAL To reduce maternal, newborn, and child mortality in Pakistan, through viable and demonstrable initiatives and capacity building of existing programs and structures within health systems and communities to ensure improvements and supportive linkages in the continuum of health care for women from the home to the hospital OBJECTIVES AND. .. maternal and child health services and ensure services are delivered through health and ancillary health services Outcomes: 14 USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION  Higher use of antenatal and postnatal care services, of births attended by skilled birth attendants, contraceptive use, tetanus toxoid coverage, enhanced basic and emergency obstetric care and reduced... MNCH budget Prior programs in health, nutrition and infectious disease control are in the final years of funding; future 10 USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION investment in these focus areas is presently being deliberated DfID provided additional support to health through a variety of multisectoral and humanitarian support programs The World Health Organization... communication and advocacy strategy, implemented by JHU/CCP and Save the Children, approached health information dissemination through the use of Lady Health Workers (LHWs) and viii USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION community workers, who were responsible for disseminating the messages at the community and household levels Local NGOs implemented these same activities... in logistics The FET was accompanied by an armed security detail throughout their three days in Multan and Khanewal, and on their drive back from Multan to Lahore en route to Islamabad 6 USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION II BACKGROUND MATERNAL AND NEWBORN HEALTH IN PAKISTAN Pakistan’s population is estimated to be over 177 million people, the sixth largest... described as loosely organized and largely unregulated PROGRAM DESIGN AND IMPLEMENTATION The PAIMAN goal was to reduce maternal, newborn, and child mortality in Pakistan, through viable and demonstrable initiatives and capacity building of existing programs and structures within health systems and communities to ensure improvements and supportive linkages in the continuum of health care for women from... called Pathway to Care and Survival, which incorporated activities to address the interrelated problems that lead to delays in access to and receipt of quality maternal and child health services The program had five strategic objectives PROGRAM BENCHMARKS AND ACCOMPLISHMENTS SO1 Increasing Awareness and Promoting Positive Maternal And Neonatal Health Behaviors PAIMAN’s communication and advocacy strategy, . evaluation MMR Maternal mortality ratio MNCH Maternal, newborn and child health vi USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION. invaluable and appreciated by all team members. ii USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION USAID/PAKISTAN: MATERNAL, NEWBORN