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USAID/PAKISTAN: MATERNAL
NEWBORN ANDCHILDHEALTH
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 ANDCHILDHEALTH
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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION i
ACKNOWLEDGMENTS
The finalevaluation 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION
USAID/PAKISTAN: MATERNAL, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION iii
CONTENTS
ACRONYMS v
EXECUTIVE SUMMARY vii
I. INTRODUCTION 1
PURPOSE OF THE EVALUATION 1
EVALUATION METHODOLOGY AND CONSTRAINTS 1
II. BACKGROUND 7
MATERNAL ANDNEWBORNHEALTH IN PAKISTAN 7
USAID/PAKISTAN HEALTH SECTOR ASSISTANCE 8
ASSISTANCE FROM OTHER DONORS IN MATERNALANDNEWBORNHEALTH 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 ANDEVALUATION 17
RESEARCH 19
MANAGEMENT AND ORGANIZATIONAL STRUCTURE 21
RELATIONSHIPS, COORDINATION, AND COLLABORATION 25
IV. TECHNICAL COMPONENTS 27
SO1. INCREASING AWARENESS AND PROMOTING POSITIVE MATERNALAND
NEONATAL HEALTH BEHAVIORS 27
SO2. INCREASING ACCESS TO MATERNALANDNEWBORNHEALTH SERVICES 31
SO3. INCREASING QUALITY OF MATERNALANDNEWBORN CARE SERVICES 37
SO4. INCREASING CAPACITY OF MATERNALANDNEWBORNHEALTH 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION
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 MaternalandNewbornHealth 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION 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 Finalevaluation 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 newbornandchild 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 andevaluation
MMR Maternal mortality ratio
MNCH Maternal, newbornandchildhealth
vi USAID/PAKISTAN: MATERNAL, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION
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 andHealth 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION xv xvi USAID/PAKISTAN: MATERNAL, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION 11 12 USAID/PAKISTAN: MATERNAL, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION III OVERVIEW OF THE PAIMAN PROJECT PROGRAM DESIGN AND IMPLEMENTATION Begun in 2004, the PAIMAN Project is... the second expansion phase USAID/PAKISTAN: MATERNAL, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION xiii SO2 Increasing Access to MaternalandNewbornHealth Services 16 Explore a variety of options for increasing the proportion of private sector partners in the delivery of maternalandnewbornhealth services, with particular outreach to providers who reside in rural and hard-to-reach areas These... andNewbornHealth Programs Strategic Framework PAIMAN PROGRAM GOAL To reduce maternal, newborn, andchild 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. .. maternalandchildhealth services and ensure services are delivered through health and ancillary health services Outcomes: 14 USAID/PAKISTAN: MATERNAL, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION 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, NEWBORNANDCHILDHEALTHPROGRAMFINALEVALUATION II BACKGROUND MATERNALAND 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, andchild 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 maternalandchildhealth services The program had five strategic objectives PROGRAM BENCHMARKS AND ACCOMPLISHMENTS SO1 Increasing Awareness and Promoting Positive MaternalAnd 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