ANNEXES: MID-TERM EVALUATION OF THE USAID/PAKISTAN MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM SEPTEMBER 2008 This publication was produced for review by the United States Agency for International Development. It was prepared by Pinar Senlet, Susan Rae Ross, and Jennifer Peters through the Global Health Technical Assistance Project. This document (Report No. 08-001-087) is available in printed or online versions. Online documents can be located in the GH Tech web site library at www.ghtechproject.com/resources/. Documents are also made available through the Development Experience Clearinghouse (www.dec.org). 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. PAIMAN REPORT ANNEXES DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. PAIMAN REPORT ANNEXES i ACRONYMS AMTSL Active management of the third stage of labor ANC Antenatal care BCC Behavior change and communication BEmONC Basic emergency maternal and newborn care CAM Communication, advocacy, and mobilization CCB Citizen Community Board CDK Clean delivery kits CHW Community health worker CIDA Canadian International Development Agency CMW Community midwife CEmONC Comprehensive emergency maternal and newborn care COP Chief of Party DFID United Kingdom Department for International Development DHIS District Health Information System DHMT District health management team DHQ District headquarters hospital EDO Executive District Officer EPI-MIS Expanded Program on Immunization Management Information System EMNC Essential maternal/newborn care ENC Essential newborn care FATA Federally Administered Tribal Areas FBC Facility-based committees FGD Focus group discussion FOM Field Operations Manager GOP Government of Pakistan HCP Health care provider HMIS Health Management Information System ICHP Improved Child Health Project IMCI Integrated Management of Childhood Illness IPC Interpersonal communications JHU/CCP John Hopkins University Center for Population Programs JSI John Snow, Inc. JICA Japanese International Cooperation Agency LHV Lady health visitor LHW Lady health worker LHW-MIS Lady Health Worker Management Information System LQAS Lot quality assurance sampling technique MAP Midwifery Association of Pakistan M&E Monitoring and evaluation MIS Management information system MNCH Maternal, newborn, and child health ii PAIMAN REPORT ANNEXES MNH Maternal and newborn health MOH Ministry of Health MOPW Ministry of Population and Welfare Norad Norwegian Aid PAIMAN Pakistan Initiative for Mothers and Newborns PDHS Pakistan Demographic and Health Survey PIMS Pakistan Institute for Medical Science PNC Postnatal care QIT Quality improvement team RHC Rural Health Center RMOI Routine monitoring of output indicators SBA Skilled birth attendant SO Strategic objective TBA Traditional birth attendant THQ Tehsil headquarters hospital TT Tetanus toxoid VHC Village health committee UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development WHO World Health Organization WMO Woman medical officer PAIMAN REPORT ANNEXES iii CONTENTS PAIMAN REPORT ANNEXES ACRONYMS ...................................................................................................................................... i ANNEX A: SCOPE OF WORK ........................................................................................................ 1 I. PURPOSE ..................................................................................................................... 1 II. BACKGROUND ............................................................................................................. 2 III. STATEMENT OF WORK ............................................................................................. 11 IV. SUGGESTED METHODOLOGY ................................................................................. 11 V. DELIVERABLES .......................................................................................................... 15 VI. DURATION, TIMING, AND SCHEDULE ..................................................................... 16 VII. TEAM COMPOSITION ................................................................................................ 16 VIII. RELATIONSHIPS AND RESPONSIBILITIES ............................................................. 17 ANNEX B: REFERENCES ............................................................................................................ 19 ANNEX C: PERSONS CONTACTED............................................................................................ 21 ISLAMABAD .............................................................................................................................. 21 LAHORE .................................................................................................................................... 23 KHANEWAL .............................................................................................................................. 23 RAWALPINDI ............................................................................................................................ 24 PESHAWAR .............................................................................................................................. 25 ANNEX D: FOCUS GROUP DISCUSSION (FGD) FINDINGS ..................................................... 27 KHANEWAL .............................................................................................................................. 27 SUKKUR ................................................................................................................................... 29 LASBELA .................................................................................................................................. 30 ANNEX E: ACTIVITIES OF OTHER DONORS IN MNCH AND HSS ........................................... 33 ANNEX F: PAIMAN INTERVENTIONS: PRIORITIZATION AND SUSTAINABILITY ASPECTS . 35 ANNEX G: ROUTINE OUTPUT MONITORING INDICATORS, JANUARY 2007–MARCH 2008 37 ANNEX H: ROLES AND RESPONSIBILITIES OF PAIMAN CONSORTIUM PARTNERS .......... 39 ANNEX I: PAIMAN PROJECT BUDGET ANALYSIS .................................................................... 41 ANNEX J: SAMPLE DISTRICT COMMUNICATIONS PLAN ........................................................ 43 ANNEX K: PAIMAN KEY MESSAGE AND TARGET GROUP TABLE ......................................... 45 ANNEX L: PRIVATE PROVIDERS ................................................................................................ 49 ANNEX M: INCREASING QUALITY OF SERVICES .................................................................... 51 AVAILABILITY OF FACILITIES FOR NORMAL MATERNAL AND NEWBORN CARE ........... 51 AVAILABILITY OF FACILITIES TO MANAGE MATERNAL AND NEWBORN COMPLICATIONS ..................................................................................................................... 54 SUPERVISION OF PUBLIC SECTOR PROVIDERS ............................................................... 56 HEALTH INFORMATION SYSTEM .......................................................................................... 56 STILLBIRTHS AND NEWBORN DEATHS ............................................................................... 58 ANNEX N: INCREASING CAPACITY OF HEALTH CARE WORKERS ....................................... 59 iv PAIMAN REPORT ANNEXES FATA REPORT ANNEXES ACRONYMS .................................................................................................................................. 67 ANNEX A: SCOPE OF WORK ...................................................................................................... 71 I. PURPOSE ................................................................................................................... 71 II. BACKGROUND ........................................................................................................... 72 III. STATEMENT OF WORK ............................................................................................. 81 IV. SUGGESTED METHODOLOGY ................................................................................. 81 V. DELIVERABLES .......................................................................................................... 85 VI. DURATION, TIMING, AND SCHEDULE ..................................................................... 85 VII. TEAM COMPOSITION ................................................................................................ 86 VIII. RELATIONSHIPS AND RESPONSIBILITIES ............................................................. 87 ANNEX B: USAID’S HEALTH AND POPULATION PROGRAM................................................... 89 ANNEX C: LIST OF DOCUMENTS ............................................................................................... 91 ANNEX D: KEY PERSONNEL ...................................................................................................... 93 3.1 JSI / PAKISTAN INITIATIVE FOR MOTHERS AND NEWBORNS (PAIMAN) ................... 93 3.2 SAVE THE CHILDREN / IMPROVED CHILD HEALTH IN THE FATA .............................. 93 ANNEX E: ILLUSTRATIVE LIST OF KEY STAKEHOLDERS ...................................................... 95 ANNEX F: COOPERATIVE AGREEMENT INFORMATION ......................................................... 97 ANNEX G: ILLUSTRATIVE QUESTIONS TO GUIDE THE EVALUATION .................................. 99 TASK 1: GOALS AND RESULTS ............................................................................................. 99 TASK 2: MANAGEMENT REVIEW ......................................................................................... 102 TASK 4: RECOMMENDATIONS ............................................................................................ 104 ANNEX H: MNCH EVALUATION SITE VISITS .......................................................................... 105 ANNEX I: REFERENCES ............................................................................................................ 107 ANNEX J: PERSONS CONTACTED .......................................................................................... 109 ISLAMABAD ............................................................................................................................ 109 PESHAWAR ............................................................................................................................ 110 PAIMAN REPORT ANNEXES 1 ANNEX A: SCOPE OF WORK MID-TERM EVALUATION MATERNAL NEWBORN AND CHILD HEALTH PROGRAM USAID/PAKISTAN (FINAL: 04/27/08) I. PURPOSE The purpose of the subject evaluation is to provide the United States Agency for International Development’s Mission to Pakistan (USAID/Pakistan) with an independent mid-term evaluation of its Maternal Newborn and Child Health (MNCH) programs. The MNCH programs are managed by the Office of Health and implemented primarily by two organizations, John Snow Inc.1 and Save the Children,2 both functioning under Cooperative Agreement mechanisms. The evaluation team will also be asked to include suggestions for the program design component (e.g., future directions) for potential expansion of the MNCH program. A program design activity by a separate team will follow this evaluation activity. As part of USAID/Pakistan’s due diligence, a mid-term evaluation is being commissioned to assess the effectiveness of the program components, document lessons learned, present results achieved to date, and provide recommendations for overall program improvement and strengthening. Recommendations for the follow-on project after the completion of the current projects will also be presented in a separate section of the report but as part of the evaluation for internal USAID use only. Suggestions for program design and scaling up for a more substantial program expansion should also be included in the evaluation report. Taking into consideration the challenges and constraints of the current working environment, the objectives of the evaluation are to Assess whether the MNCH program partners are achieving intended goals and results and meeting benchmarked activities in the cooperative agreements and work plans. Evaluate the effectiveness (objectives and results) of the management structures, administrative support, cost and partnerships, and collaborative plans. Evaluate the effectiveness of key technical components and approaches of the MNCH program given the health status and sociocultural and religious context in Pakistan. Establish whether the overall demand for maternal child health services is growing in project districts as a direct or indirect result of these projects. Document lessons learned and provide discrete management, administrative, and technical recommendations for improving overall efficiency and effectiveness in the context of the Ministry of Health programs in maternal and child health and related areas. Review the findings, conclusions, and recommendations and provide brief suggestions/options for future directions of the program with the potential for program expansion at various levels of additional funding. For example, what would the program look like with an additional $5–$20 million per year? What would be the team’s recommendations 1 JSI PAIMAN $50m five-year Cooperative Agreement 2005–2009. 2 SAVE The Children $11.5m three-year Cooperative Agreement 2007–2009. 2 PAIMAN REPORT ANNEXES for expanding the program in the current programmatic or geographic areas or adding program areas and districts? Provide key inputs, background information, and methodology suggestions that can be incorporated into an SOW for the final project evaluation in 2009. Findings and recommendations will be used to ensure that the MNCH program serves the overall objective of improving maternal, newborn, and child health in Pakistan in the most effective way. This mid-term evaluation will be shared with partners but not widely distributed. Sections of the evaluation may be shared with outside sources at the discretion of USAID management. The separate design/future directions section of the report will be kept for internal USAID use only. II. BACKGROUND Pakistan’s maternal and newborn mortality rates are high despite an extensive health service delivery network. The problem is well described in a qualitative study conducted by JSI’s MotherCare Project that found that awareness of major maternal and newborn complications among women, families, and attendants is insufficient. Most maternal and newborn deaths occur at home without a skilled health provider attending. According to available statistics, over 65 percent of women deliver at home. Trained health professionals conduct only 5 percent of these deliveries. Also, a high total fertility rate (4.1) continues to expose women and children to increased risks of mortality and morbidity. Many traditional social values discriminate against women, lowering their status and affecting their food intake and nutrition, education, decision making, physical mobility, and health care. Husbands, in-laws, and religious and community leaders all play significant roles in these customs. Women, families, and providers focus little attention on behaviors related to preventive care and planning for potential maternal and newborn emergencies. In addition, only a few women, families, or attendants are aware of newborn complications like fever, respiratory problems, pre-maturity, and cord infection. Although Pakistan has an extensive network of public sector delivery facilities, they reach only about a third of the country’s population: the rest (70 percent) is served by the private sector, at least for curative services. The public sector health program is still the main service delivery mechanism for isolated rural communities and for preventive services. It needs improvements in several areas, including physical facilities, safe water supply, privacy for female clients, supply of drugs, logistics and equipment, and provider capabilities, especially in counseling and clinic management. Health facilities are underutilized. They require better linkages with the communities they intend to serve. Lack of availability of providers, especially female providers, at public health facilities needs to be addressed. While most curative services are provided through private providers, private sector health services in Pakistan are unregulated, raising questions of quality. While the Government of Pakistan (GOP), as part of its devolution strategy, promotes delegation of health services planning and management responsibilities to the districts, management systems at the district level, including referral systems, supervisory systems, health information systems, and coordination between public and private sectors, are weak. The Constitution of Pakistan guarantees basic human rights to all citizens, which includes equitable access to health and social services. The GOP is aware of the huge burden of preventable deaths and morbidity among women and children and is committed to improving their health status. Unfortunately, concerted efforts to improve the health of mothers and children have been lacking. Short-term localized programs and projects have failed to achieve significant and sustainable improvements in MNCH indicators. Such improvements can only be achieved PAIMAN REPORT ANNEXES 3 through a national-level, comprehensive, focused, and effective program that is owned and managed by the districts and is customized to meet each district’s specific needs. In 1990 Pakistan adopted its first National Health Policy to provide vision and guidance to the development of the national healthcare delivery system. Its goal was to provide universal coverage through enhancement of trained health manpower. The policy put emphasis on maternal and child health and primary health care. The National Health Policy was revised in 1997 to introduce a vision for health sector development by 2010. The National Reproductive Health Services Package (NRHSP) was introduced in 2000 jointly by the Federal Ministries of Population Welfare and of Health. Its effectiveness and application since its introduction have remained incomplete and unsatisfactory. In June 2001 the Federal Cabinet approved the current National Health Policy, which envisages health sector reforms as a prerequisite for poverty alleviation, gives particular attention to strengthening the primary and secondary tiers of health services, and calls for the establishment of good governance practices in order to achieve high-quality health services. The Population Policy of Pakistan (2002) focuses on integration of reproductive health services with family planning, building on the successful elements of the program, increased participation of the private sector, greater emphasis on social marketing, and enlarging the scope of family planning services. The Ministry of Population Welfare has shifted its emphasis in mass communication campaigns from population control to women’s health. The Ten-Year Perspective Development Plan 2001–2011 places emphasis on improving the service delivery mechanisms for reducing preventable diseases. The policy focus is on a continuous shift from curative to promotion and preventive services through primary health care. Pakistan is signatory to several international agreements regarding improving MNCH, including the Millennium Development Goals (MDG) in MNCH, which are: Goal 4—Reduce child mortality by two-thirds, between 1990 and 2015. The indicators to measure progress toward this MDG include under-5 mortality rate, infant mortality rate (IMR), and proportion of 1-year-old children immunized against measles. Pakistan’s target is to reduce IMR to 40 per 1,000 live births and to increase the measles immunization rate to >90 percent by 2015. Goal 5—Improve maternal health by reducing the maternal mortality ratio (MMR) by three￾quarters, between 1990 and 2015. The indicators to measure progress toward this MDG include the MMR and the proportion of births attended by skilled health personnel. Pakistan’s target is to reduce MMR to 140 or less, and to increase skilled birth attendance to 90 percent by 2015. In addition, Pakistan envisions increasing the contraceptive prevalence rate to 55 percent, increasing the proportion of pregnant women receiving antenatal care from the current 61 percent to 100 percent, and reducing the total fertility rate from 4.1 to 2.1 by 2015 (DHS 2006–07). The Pakistan Planning Commission Form 1 (PC-1) for the National Maternal Newborn and Child Health states that in all districts of Pakistan maternal newborn and child health care services will be strengthened for the population through improving primary health facilities, secondary hospitals, and referral systems and placement of skilled birth attendants at the community level in rural areas and underserved urban slums. One of the most important areas identified by the government of Pakistan has been a focus on poverty reduction. The current Minister of Health emphasizes ―pro-poor‖ activities as his focus as well. The MNCH development partners are working on the development and revision of a Logical Framework of activities for the National MNCH Program prior to the actual start of the program in early 2008, likely following the national elections. 4 PAIMAN REPORT ANNEXES Several other foreign assistance programs are focusing efforts on MNCH, including the British, Norwegians and Australians. United Nations programs addressing MNCH include UNICEF and UNFPA. The two primary MNCH implementing partners for USAID are John Snow Inc. (JSI) and Save the Children. Their project summaries are included here. Pakistan Initiative for Mothers and Newborns (PAIMAN) John Snow Inc. Effective maternal and newborn care consists of a continuum of health care interventions, beginning before pregnancy and covering the prenatal, delivery, and postpartum periods, and addressing the individual health of women and children. In the Pakistan context, in order to have an immediate effect on mortality rates, the focus must be on labor, delivery, and the immediate postpartum period—from the onset of labor through day 7. The PAIMAN project promotes skilled attendance as the long-term goal for all deliveries in Pakistan. The project LOP is 10-08- 04 to 09-30-09; funding level is $56,243,858 (Annex 5). Evidence in the public health literature shows that the maternal and neonatal survival depends upon a whole set of sociocultural, economic, and geographic determinants in the Pakistan context. These factors need to be addressed to generate comprehensive and sustainable solutions to the problem of maternal and neonatal mortality. The MNCH program therefore calls for a multipronged strategic approach, combining individual health care with public health and community-based interventions. The JSI team bases the continuum of care represented in the MNCH program on a strategic framework referred to as ―The Pathway to Care and Survival,‖ which follows a series of steps necessary to increase the likelihood of survival of a mother and her baby in the event of complication or illness. At each step, Pakistani women and children face various interrelated issues that prevent them from reaching quality care and threaten their subsequent survival. We have classified these issues in five main categories: 1. Lack of awareness of risks and appropriate behaviors related to reproductive and neonatal health issues, resulting in poor demand for services 2. Lack of access (both geographic and sociocultural) to and lack of community involvement in MNCH services 3. Poor quality of services, including lack of adequate infrastructure in health facilities 4. Lack of individual capacity, especially among skilled birth attendants 5. Weak management environment and lack of health services integration. For each of these ―problem categories‖ PAIMAN has defined a program objective and a series of interventions to address them. PAIMAN Program Goal and Objectives 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: Based on the ―Pathway to Care and Survival‖ framework, PAIMAN has the following program objectives, interventions, and outcomes: 1. Increase awareness and promote of positive maternal and neonatal health behaviors. PAIMAN REPORT ANNEXES 5 Outcomes: Enhanced demand for maternal, child health, and family planning services through a change in current patterns of health-seeking behavior at the household and community level. Increased practice of preventive MNH-related behaviors. 2. Increase access (including emergency obstetric care) to and community involvement in maternal and child health services and ensure services are delivered through health and ancillary health services. Outcomes: Higher use of antenatal and postnatal care services, births attended by skilled birth attendants, contraceptive use, tetanus toxoid coverage, enhanced basic and emergency obstetric care, and reduced case fatalities. Reduced cost, time, and distance to obtain basic and emergency care, ultimately saving newborn and maternal lives. 3. Improve service quality in both the public and private sectors, particularly related to the management of obstetrical complications. Outcomes: Greater utilization of services to improve maternal and newborn health outcomes. Decreased case-fatality rates for hospitalized women and neonates. 4. Increase capacity of MNH managers and care providers. Outcomes: Increased skilled attendance for deliveries in the target districts. Decreased case-fatality rates for hospitalized women and neonates. 5. Improve management and integration of services at all levels. Outcomes: District MNH plans and budgets available. HMIS information used for MNH decision making. Better coordination between public, private, and community health services. Beneficiaries: The project will work with communities, government, and local nongovernmental organizations (NGOs) to strengthen maternal, neonatal, and child health to increase the health status of women and children. It is estimated that the program will reach an estimated 2.5 million couples, and nearly 350,000 children under 1 year of age will benefit from the program. As beneficiaries of the program, PAIMAN has identified married couples at reproductive age (15–49) and all children under 1 year of age. PAIMAN Time Frame PAIMAN originally planned to begin working in three or four districts and gradually phase in the remaining districts. In actuality they started activities in all ten districts from the beginning of the project. In December 2007 PAIMAN expanded activities in the FATA in Khyber and Kurram 6 PAIMAN REPORT ANNEXES Agencies and Frontier Regions Peshawar and Kohat. PAIMAN also began working in Swat district in April 2008. Improved Child Health in FATA, Save the Children Pakistan is lagging behind most countries in South Asia in terms of child health indicators. The under-5 mortality rate (U5MR) is estimated at 103/1,000 live births and IMR at 81/1,000 live births. Of the 560,000 under-5 deaths reported in 2001, 19 percent were due to pneumonia and diarrhea each, 18 percent to perinatal causes, 7 percent to measles, 5 percent to malaria, and 32 percent to other causes. Only 60 percent of children are immunized for measles at 1 year of age, and the overall chronic malnutrition rate among children less than 5 is 58 percent. A recent Lancet article estimated the neonatal mortality rate (NMR) at 57/1,000 live births, almost as high as Afghanistan and considerably higher than India or Bangladesh. Eighty percent of deliveries are conducted by an unskilled provider. Exclusive breastfeeding (4 months) is quite low as reported at 16 percent. FATA Overview FATA is a belt of seven semi-autonomous tribal agencies stretching north to south along the border between Pakistan and Afghanistan. With respect to population and health system administration, an agency can roughly be equated to a small district in Pakistan. Each has its own characteristics, with wide inter- and intra-agency variations in socioeconomic, cultural, and health status parameters. Project LOP is 09-01-06 to 08-30-09; funding level is $14,750,000 (listed in Annex 5). The people of FATA are almost exclusively ethnic Pashtun. The last national census in 1998 estimated the population at 3.6 million people, of which the government estimates 21 percent (756,000) are women of reproductive age (WRA) and 8.8 percent (316,800) are children under the age of 5. As children under 5 represent nearly 14 percent of the overall population in Pakistan, this figure may reflect substantial undercounting. More than 97 percent of the population lives in rural areas, with the average household size between 8.5 and 10.6 people across the seven agencies. Child Health While the number and type of health facilities varies widely, facilities are characteristically underequipped with high staff absenteeism. Community level maternal and child health care coverage through lady health workers (LHWs) is low, ranging from 13 percent in Bajaur Agency to 55 percent in Kurram. Facility-based reports for 2004 reflect newly registered pregnant women for antenatal care (ANC) at 11 percent, far less than the national average (43 percent). In a recent GOP report, maternal mortality in FATA was estimated at 600/100,000 live births and infant mortality at 83/1,000 live births. Health Management Information System (HMIS) data from Bajaur Agency for the first half of 2005 reflect an estimated U5MR of 135/1,000 live births. In a report published in the Bulletin of the World Health Organization (WHO) in 2002, tetanus was estimated as the cause of approximately 22 percent of all infant mortality in FATA and 36 percent of neonatal deaths. Overall, only 50 percent of pregnant women are vaccinated against tetanus. In 2004 antenatal care ranged from 0 percent in South Waziristan to 18 percent in Orakzai, and fewer than one out of six mothers deliver with a skilled birth attendant. Currently there are 926 LHWs in FATA covering approximately a third of the population based on the government’s commitment to have one LHW per 1,000 population. More than 2,500 additional LHWs are needed to provide this optimal level of coverage. It is not realistic within the scope and timeframe of this project to expect that this optimal coverage will be achieved PAIMAN REPORT ANNEXES 7 Socioeconomic Conditions FATA is a socially conservative society with very limited mobility for women and girls and the lowest levels of literacy for females in South Asia. Socioeconomically FATA is poorer than Pakistan in general. The economy is chiefly pastoral, with some agriculture practiced in the region’s few fertile valleys. In the past, some areas of FATA produced significant quantities of opium; however, this has been reduced in recent years. Communications in FATA are generally dispersed, although some are clustered in relatively accessible valley areas. In 1999–2000, FATA had a road density of approximately half the national figure. Approximately half of the total area is considered physically inaccessible; however, recent funding from the Asian Development Bank and other donors to build roads will likely substantially improve the situation in some areas. Security The political agent currently does not allow UN and WHO staff to enter North and South Waziristan Agencies, regardless of their nationality. Some places in Khyber, Bajaur, Mohmand, and Orakzai Agencies are also designated as ―no-go‖ areas. An unusually high number of criminals and proclaimed offenders (nearly 17,000) are now taking shelter in FATA, where provincial police are prohibited from entering. Tribal law, kidnappings, and a range of other criminal activities combined with post-Afghanistan conflict factors pose a formidable range of operating and security concerns for project implementation and monitoring in some areas. Local NGOs report freedom of movement and fewer restrictions on WHO/UN/INGO representative visits. [A local firm will be hired as needed to do any evaluation visits in FATA.] Improved Child Health in FATA Goal and Objectives To Improve the Health Status of Children in FATA is the overall goal of this project. To achieve this goal the strategic objective is ―Increased Use of Key Health Services and Behaviors,‖ which will be achieved through the following: 1. Increasing access to and availability of health services 2. Improving the quality of health services 3. Increasing the knowledge and acceptance of key services and behaviors at the community level. To improve the health of children up to 12 years, including health and nutrition programming in schools, Save will expand and package the project’s key interventions into the following groups: EPI - Immunization ARI - Acute respiratory infection CDD - Control of diarrheal diseases ENC - Essential newborn care Nutrition and micronutrients Beneficiaries There are an estimated 1,512,000 men and women of reproductive age in FATA. All of these will be project beneficiaries through community mobilization, particularly community awareness sessions. For children under 5 years of age, direct beneficiaries will be the two-thirds who suffer from either diarrhea or ARI—a total of 209,000 children. The rest of the under-5 population comprises indirect beneficiaries, approximately 108,000. 8 PAIMAN REPORT ANNEXES Improved Child Health in FATA Time Frame Phase I – start-up activities, including Agency Headquarters (AHQ) Hospital improvement and capacity building of health care providers at the AHQ level, launched simultaneously in all seven districts. Health facility strengthening and training of LHWs in rural health centers (RHCs) and basic health units (BHUs) will be carried out in Mohmand, Bajaur, and Kurram Agencies. Phase II – health facility strengthening and training of LHWs in Khyber and Orakzai. Phase III – health facility strengthening and training of LHWs in North and South Waziristan. Each phase is staggered by approximately six months. Community mobilization will accompany the above activities and agencies in the same sequence. As of January 2008, this project is working in all seven agencies and six frontier regions (FRs) of the FATA. Fit with the Mission’s Strategic Objective In May 2003 USAID/Pakistan approved an Interim Strategic Plan for fiscal years (FY) 2004– 2006, with the overall goal to ―promote equality, stability, economic growth and improved well￾being of Pakistani families.‖ Strategic Objectives (SOs) relate to education (SO3); democracy and governance (SO4); economic development (SO6); and health (SO7). USAID/Pakistan signed a new Strategic Objective Agreement (SOAG) with the GOP in 2005 and amended it to extend through September 2008; it outlines development activities agreed to by both parties. USAID’s SO7 aims ―to improve health in vulnerable populations in Pakistan.‖ Intermediate Results (IRs) include the following: IR7.1 Improved quality and use of maternal, newborn, and child health and reproductive services IR7.2 Improved administrative and financial management of primary health care programs IR7.3 Improved use of proven interventions to prevent major infectious diseases. PAIMAN REPORT ANNEXES 9 Figure A.1 depicts the Results Framework for SO7. Improved health in vulnerable populations Indicators Infant mortality rate (deaths 0-1 year per 1000 live births) Neonatal mortality rate (deaths below age 1 month per 1000 live births) Percent of births that occurred 36 or more months after the preceding birth Percent of deliveries assisted by skilled health personnel Contraceptive prevalence rate among married women aged 15-49 years IR 7.1 Improved quality and use of maternal, newborn, and child health and reproductive services Indicators CYP ANC coverage Post-partum coverage meeting international standards Referral facilities upgraded and meeting safe birth and newborn care quality standards IR 7.2 Improved administrative and financial management of primary health care programs Indicators Increased delegation of budgetary and administrative authority to provincial health officials IR 7.3 Increased use of proven interventions to prevent major infectious diseases Indicators Decrease in diarrheal disease in under-5s in target districts TB treatment success (DOTS) rate Non-polio Acute Flaccid Paralysis (AFP) rate Awareness of HIV prevention methods among MSM USAID/Pakistan SO7 Results Framework Illustrative indicators in support of IR7.1 include (1) couple years of protection, (2) antenatal care coverage, (3) postpartum coverage meeting international standards, and (4) referral facilities upgraded and meeting safe birth and newborn care quality standards. 10 PAIMAN REPORT ANNEXES USAID Assistance in Health The health program began in 2003 and includes activities to improve maternal and newborn health services, promote family planning, prevent major infectious diseases, and increase access to clean drinking water. The program is nationally focused, working in underserved rural and urban districts in Sindh, Balochistan, Punjab, North West Frontier provinces, and the Federally Administered Tribal Areas (FATA). Current health program areas include: Health Systems Strengthening (HSS): The HSS program seeks to support the Ministry of Health and the Ministry of Population Welfare in strengthening the community midwifery program; targeting health information for raising citizen’s awareness and holding government accountable; addressing health system challenges through modest grant assistance; and improving essential drugs and contraceptive logistics management system. (Implementing Partner: ABT Associates) Diversification of Family Planning Activities in Pakistan (DFPAP): USAID/Pakistan’s project to address the need to increase and improve family planning services includes capacity building, monitoring and evaluation, and project management. (Implementing Partner: The Population Council) Maternal and Newborn Health: The Pakistan Initiative for Mothers and Newborns (PAIMAN) is USAID’s flagship project designed to reduce maternal and neonatal mortality. The project is being implemented in 10 districts in all four provinces of Pakistan. (Implementing Partner: John Snow Incorporated) HIV/AIDS Program: USAID provides grants to seven local NGOs to increase HIV/AIDS awareness and to promote health behaviors in high risk groups. (Implementing Partner: Research Triangle Institute) Strengthening TB Control: USAID assists the GOP to consolidate and accelerate complete treatment of TB patients. (Implementing Partner: WHO) Polio Eradication: USAID provides assistance to national polio immunization campaigns and surveillance to eliminate polio from Pakistan. (Implementing Partners: WHO and UNICEF) Demographic and Health Survey (DHS): USAID provides funding and technical assistance for the Pakistan DHS and Maternal Mortality Study. (Implementing Partners: Macro International and National Institute of Population Studies) Disease Surveillance and Response: USAID supports the design of a National Integrated Disease Surveillance and Response Program and a Field Epidemiology and Laboratory Training Program. (Implementing Partner: U.S. Centers for Disease Control) Child Health in the Federally Administered Tribal Areas (FATA) of Pakistan: USAID is working to improve the availability, quality, and demand for child health services throughout the FATA. (Implementing Partner: Save the Children, USA) Safe Drinking Water and Hygiene Promotion: USAID is providing technical assistance in hygiene and sanitation promotion and community mobilization along with extensive capacity building in order to complement the GOP’s installation of water treatment facilities nationwide. (Implementing Partner: ABT Associates) PAIMAN REPORT ANNEXES 11 III. STATEMENT OF WORK The independent mid-term evaluation team will review the technical, managerial, and programmatic strengths and weaknesses of the two major program MNCH components as approved and financed by USAID: Maternal and Newborn Health: The Pakistan Initiative for Mothers and Newborns (PAIMAN) and Child Health in the Federally-Administered Tribal Areas (FATA) of Pakistan. Based on the findings, the team will formulate lessons learned as well as recommend future technical, programmatic, and administrative actions that will support overall strengthening of programmatic efficiencies and effectiveness. The team is expected to answer the following key strategic and priority questions: 1. Is the MNCH program meeting its benchmarked activities as outlined in the original cooperative agreements and presented in annual work plans? 2. What are the trends in terms of improvements in MNCH indicators (increased prenatal visits, tetanus toxoid [TT] boosters received during pregnancy, improved immunization coverage, etc.) in project districts in Pakistan and compared to GOP contributions to the program in those project districts? 3. What are the key outputs and outcomes of these two programs, PAIMAN and Improved Child Health in the FATA, that have been achieved to date? 4. What have been the major obstacles to program coverage and access, and what should the GOP, USAID, and other donors do to facilitate demand and utilization in rural and higher poverty areas? 5. What are the most important steps that USAID, the GOP, and other donors should take to increase effectiveness, coverage, quality, and sustainability of the MNCH program? In addition, the evaluation team is expected to use creative techniques and approaches to address the tasks listed in Annex 6, which includes illustrative questions to guide the evaluation. IV. SUGGESTED METHODOLOGY The evaluation team will use a variety of methods for collecting information and data. The team will work in a participatory manner with the partners of the MNCH program. The following essential elements should be included in the methodology as well as any additional methods proposed by the team. Reviewing briefing materials/pre-evaluation planning: A package of briefing materials related to the MNCH program will be made available to the evaluation team at least one week prior to the commencement of the mid-term evaluation. A complete list of background documents is attached in Annex 2. In addition to reviewing background documents, the evaluation team will have a preliminary planning period in which they will review the scope of the mid-term evaluation, begin to come to a consensus on the key evaluation questions, develop a proposed schedule, and begin the development of data collection tools. The data collection tools that the team will develop will include the following: Interview Guides Interview Questionnaires (for the evaluation team and the local firm to use during site visits with persons that interact with the PAIMAN and Save projects, i.e., LHWs, LHVs, physicians, nurses, district officials, etc.) 12 PAIMAN REPORT ANNEXES Survey Questionnaires (brief client surveys conducted by the local firm in the PAIMAN and Save districts) The data collection tools will be presented to USAID/Pakistan for discussion and approval prior to their application to verify their appropriateness. These tools will be used in all data collection situations, especially during team site visits and consulting firm site visits, in order to ensure consistency and comparability of data. SO7 Team Briefing: The evaluation team will meet with the USAID/Pakistan Health Strategic Objective Team (S07 Team) in Islamabad to review the scope of the mid-term evaluation, the proposed schedule, and the overall assignment. The initial briefing will also include reaching agreement on a set of key questions and will take place over one day (or could be incorporated into the Team Planning Meeting). Team Planning Meeting (TPM): A two-day team planning meeting will be held in Islamabad before the evaluation begins (depending on the location of consultants, the TPM may be held in the United States prior to the team’s departure for Islamabad). This meeting will allow USAID to present the team with the purpose, expectations, and agenda of the assignment. In addition, the team will: – clarify team members’ roles and responsibilities; – establish a team atmosphere, share individual working styles, and agree on procedures for resolving differences of opinion; – review and finalize the assignment timeline and share it with USAID; – develop data collection methods, instruments, tools, and guidelines; – review and clarify any logistical and administrative procedures for the assignment; – develop a preliminary draft outline of the team’s report; and – assign drafting responsibilities for the final report. Document Review: In addition to reviewing briefing materials that will be provided to the team, the evaluation team will be expected to collect and annotate additional documents and materials for the team’s and USAID/Pakistan’s future use. Self-Assessment Questionnaire: A self-assessment questionnaire will be given to both organizations by USAID prior to the team’s arrival in country. Prior to the team’s arrival, USAID will draft the self-assessment and administer it accordingly. The team will have access to the self-assessment results for their review and use. Information Collection: The information collected will be mainly qualitative guided by a key set of questions. As mentioned, information will be collected mostly through personal and telephone interviews with key contacts and through document review. The full list of stakeholders and contacts will be provided. Additional individuals may be identified by the evaluation team at any point during the mid-term evaluation. Key contacts include: – USAID/Pakistan Senior Management, S07 Team Members, Health Director, Deputy Director, CTO for MNCH Programs; – PAIMAN and Save briefing with key personnel; – PAIMAN and Save subgrantees, subcontractors, and other local partners; – MOH and MOPW officials; and PAIMAN REPORT ANNEXES 13 – Donors and international organizations working in the health and population welfare sector. Site Visits: The evaluation team will travel with JSI-PAIMAN and/or Save the Children project staff and/or the local contracted firm to project sites for face-to-face interviews and discussions with local stakeholders and beneficiaries. The mission has suggested four sites for the evaluation team to visit: Rawalpindi, Lahore, Khanewal, and Peshawar (Annex 7). Site visits will focus on pilot activities (DHIS, midwifery training, birthing centers, family planning integration, GoodLife clinics, Child Health Days). The areas of focus of the site visits will be clinical practices, behavior change communications (BCC), community mobilization, and training/supervision. Questions about equipment and ambulances or the emergency transport plan, facility upgrades, and improved access and quality should be included during discussions with the district officials. In some sites other donor agency staff may request to accompany the team as well. Several interviews should be arranged and done in one day. The site visit to Rawalpindi will be done from the team’s base in Islamabad. The travel time to Lahore is an hour by air, visits can be done during one day, move on to Multan to stay overnight, conduct interviews on day 2 in Khanewal, and return to Islamabad after 2, possibly 3, days depending on flight schedules. Peshawar would be a 2-day visit by car. Thus an estimated 5-6 days are needed for site visits by the evaluation team. (Annex 7) Should travel be restricted, conference calls or other mechanisms will need to be substituted. The Team Leader in collaboration with USAID will determine the appropriate course of action. The team will rent a vehicle locally in Islamabad for travel to some sites and travel to sites with project staff. Local Data Collection and Site Visit Support: A local firm will be recruited and hired to assist in conducting interviews, coordinate and manage in-country logistics, set up appointments and meetings, make travel arrangements, and assist with site visits for the evaluation team. The local firm will visit and be responsible for interviews and field visits in Sukkur, Lasbella, and a FATA site (Annex 7). Sukkur and Lasbella are PAIMAN sites. The FATA sites are Save sites. The local firm will have a team of two persons, at least one being a female interviewer. They may choose to conduct group interviews or focus groups to gather information needed. They should meet with beneficiaries, local community members, NGOs, district officials, and any persons who have interacted with or are aware of PAIMAN or Save activities. The firm will need to have experience working in the FATA. Important: The local firm must understand that USAID programs operating in the FATA function as part of the Government of Pakistan MOH programs and are completely ―invisible‖ in that sense, with no branding to distinguish the program in any way. The local firm will need to be briefed on how to conduct interviews with this in mind in that region. The firm will be engaged by GH Tech prior to the evaluation team arrival in country and will take direction from the Team Leader. Some of the tasks that the local firm will assist with may include but are not limited to the following: Conduct beneficiary interviews as available with: – families (wives, husbands, mothers-in-law) – imams – midwifery students and midwives receiving refresher training – traditional birth attendants (TBAs) 14 PAIMAN REPORT ANNEXES – physicians and LHVs who were trained – civil servants trained in management. Some topics to include in the questioning include: – Have they heard health messages from NGOs, LHWs, or in or through support groups? Any benefit or behavior change? – Have they used health services in refurbished facilities? What was the quality? Can they identify any improvements? – Are they aware that additional ambulances have been placed at facilities? Do they expect the community to benefit? (PAIMAN only) – Have they participated in any MNCH event? What was the impact for them, if any? 1. Interview or otherwise involve all levels of government where available in the evaluation (illustrative): 1) National, including EAD, provincial, and district as well as FATA Secretariat and FATA Health Directorate 2) Pakistan Medical and Dental Council, Pakistan Nursing Council, principals of midwifery schools 3) LHW Program, MNCH Project Head – Donor involvement in evaluation, for identifying gaps and complimentary programs (illustrative): 1) Open-ended questionnaires to donors 2) One-to-one interviews 3) Inbrief/outbrief 4) Invitation to participate 5) What’s working? Not working? 6) UNICEF, UNFPA, DFID, WB, Norad, AusAID, WHO, JICA, CIDA 7) Who is working where doing what? Mapping. Extent to which projects are integrating FP into MNCH now. How much work are other projects doing on vaccination, IMNCI, HSS, infection control and hospital waste management, male involvement, private sector involvement? – What are donors’ future plans in MNCH? Best practices? Integrated FP? Child vaccination? Systems strengthening? What role is each donor taking in planning, implementing, funding, policy development, and support? PAIMAN REPORT ANNEXES 15 V. DELIVERABLES Debriefing Meetings: At least two days prior to ending the in-country evaluation, the team will hold three meetings to present the major findings and recommendations of the evaluation: (1) SO7 team—that will focus on the accomplishments, weaknesses, and lessons learned in the MNCH program, including recommendations for improvements and increased effectiveness and efficiency of the MNCH program; (2) senior Mission management—incorporating the insights gained in the first debrief; and (3) Final briefing—for MNCH (Save and PAIMAN) personnel, other donor partners, and key stakeholders (GOP officials), focusing on major findings and recommended changes to increase program effectiveness for the life of the project. No evaluation or future directions recommendations will be shared outside of the USAID/Pakistan Mission staff. Succinct briefing materials will be prepared appropriate for each audience. Each meeting will be planned to include time for dialogue and feedback. Draft Report: The evaluation team will provide, prior to departure, a draft report which includes all components of the mid-term evaluation to the USAID/Pakistan Health Office Director and relevant SO7 Team members in hard copy (4 copies) and on diskette in MSWord format. USAID will provide comments on the draft report to the evaluation Team Leader within 5 working days. This will be followed by final unedited content that the contractor is required to submit within 10 working days after USAID feedback on the draft Report. Upon USAID approval of this final content, GH Tech will edit and format the report. The edited and formatted final report will be submitted within 30 days of receiving USAID final approval of the content. The final report is to be submitted to the Health Office Director, both in hard copy (6 copies) via express mail and in electronic form. The report will be presented in 12-point font, single spacing. Evaluation Report: The final evaluation report should include, at a minimum, the following: (1) Table of Contents; (2) List of Acronyms; (3) Executive Summary; (4) Background Statement; (5) Findings and Lessons Learned; (6) Prioritized Recommendations; (7) Future Directions, including scaling up and potential expansion possibilities; and (8) Annexes as appropriate, including list of people met and sites visited. A Report Outline will be prepared by the evaluation team before starting the field work and approved by the Mission. Pertinent information for the final program evaluation in 2009 should be presented in a separate document. GH Tech makes the results of its evaluations public on the Development Experience Clearinghouse and on its project web site unless there is a compelling reason (such as procurement sensitivities) to keep the document internal. Therefore, we are requesting Mission confirmation that it will be acceptable to make a version of this document publicly available, which will exclude the recommendations and future directions sections. The Mission will provide final approval of the public version before it is posted on any web site to ensure that all sensitive information has been removed. 16 PAIMAN REPORT ANNEXES VI. DURATION, TIMING, AND SCHEDULE It is anticipated that the period of performance of this evaluation will be for six/seven weeks beginning in May/June 2008. A possible schedule of this activity follows (illustrative): Task/Deliverable Team Leader LOE Team Members LOE (2) 1. Review background documents/pre￾evaluation planning (out of country) 6 days 5 days 2. Travel to Islamabad 2 days 2 days 3. SO7 Team briefing 1 day 1 day 4. Team planning meeting 2 days 2 days 5. Meetings with COPs of PAIMAN and Save GOP officials in Islamabad (MOPW, MOH) Local consulting firm MNCH donors and other partners 7 days 7 days 6. Visit field sites, including training centers, clinics, etc. 4 days 4 days 7. Debriefings with Health Office, USAID senior management, PAIMAN and Save, other stakeholders 1 days 1 days 8. Internal discussion meeting with local firm and international team 1 day 1 day 9. Analysis, discussion, and draft report writing 14 days 14 days 10. Presentation of draft report and discussion 1 day 1 day 11. Return travel 2 days 2 days 12. Complete final evaluation report (out of country) 5 days 2 days Total # days 46 42 A six-day work week is approved when the team is working in country. VII. TEAM COMPOSITION The team should have the following skills mix: maternal and child health service provision, project assessment and evaluation, program design, reproductive health care and service provision, health worker training, behavior change communication, community mobilization and participation, health systems services/management information systems, among others. Familiarity with the health service delivery system (both public and private sectors) in Pakistan would be a major advantage. Ideally, the Team Leader would be an expert with international experience while other consultants could be recruited from available contractors or consultant pool. A suggested team composition is given below: Team Leader: The team leader should be a public health generalist and an evaluation expert with practical knowledge in monitoring and evaluation of international public health programs in developing countries. A broad background in MCH is preferable. S/he should have an advanced PAIMAN REPORT ANNEXES 17 degree in public health. A minimum of 7 years experience in managing, monitoring, or researching international public health programs is required. S/he should also have a comprehensive understanding of maternal, newborn, and child health principles and practices. In addition, the Team Leader should have at least 5 years experience strengthening health systems, health sector reform, program component cost analysis, logistics of essential medicines and contraceptives, and addressing issues of quality and access improvement in health systems in developing countries. Identifying appropriate technical assistance needs to make improvements in the health systems, building capacity of local institutions and organizations, including the Pakistan Nursing Council, the Midwifery Association of Pakistan, and other interventions will be included in this position’s SOW. S/he should also have a keen awareness of health management information systems scenarios and the ability to recommend effective solutions for improvements to health data collection and reporting systems in the country. It is imperative that the Team Leader have excellent English language skills (both written and verbal) as s/he will have the overall responsibility for the final report, and will have a major role in drafting and finalizing the deliverables. The individual considered for the Team Leader position is expected to provide a sample of a written report for consideration by the Mission. Maternal Health Specialist: The second team member should have an advanced degree in health sciences or public health and at least 5 years experience in program management, implementation, and monitoring and evaluation of internationally based maternal and child health programs, as well as a comprehensive technical knowledge of and experience in maternal newborn and child health programs, especially service provider training. S/he should have a strong appreciation of partnership building and service provision in challenging environments. A nurse/nurse midwife is preferred for this position. BCC/Community Mobilization Expert: This team member should have an advanced degree in medical anthropology or a related discipline and at least 5 years experience in the implementation of field behavior change communication and community mobilization strategies. A comprehensive knowledge of the application of BCC strategies to alter behaviors related to maternal and child health is desirable. The evaluation team will be authorized to work a six-day work week while in country. Travel expenses and other communication costs incurred during the course of duty are authorized. The final travel itinerary of the evaluation will be contingent on the security situation and relative predictability of access to the project sites in general and target areas in particular. It is possible that evaluation team members will be asked to provide input and feedback in the redesign of the follow-on project or revision of the current Maternal and Child Health program. Team member involvement will be determined during the development of the scope of work for the redesign/revision. VIII. RELATIONSHIPS AND RESPONSIBILITIES 1. Overall Guidance: The Health Office Director and Deputy Director of USAID/Pakistan will provide overall direction to the evaluation team. Other USAID/Pakistan Health Office staff will interact with the evaluation team as needed to complete the evaluation activities. 2. Responsibilities: USAID/Pakistan will introduce the evaluation team to relevant implementing partners, government officials, and other individuals key to the accomplishment of this evaluation through introductory letters or advance phone calls. USAID/Pakistan will provide observers throughout the review from the PAIMAN and Save programs as feasible. 18 PAIMAN REPORT ANNEXES USAID/Pakistan will be responsible for providing security notices issued by the American Embassy in Pakistan to which the evaluation team must adhere. The evaluation team will provide mobile phone contact numbers to the USAID Health Office so that contact can be maintained as needed. GH Tech Evaluation Team will be responsible for coordinating and facilitating evaluation￾related field trips, interviews, and meetings. USAID will review and approve the schedule. The evaluation team will be responsible for making all logistical arrangements. The evaluation team will be responsible for all costs incurred in carrying out this review. The proposed costs may include, but not be limited to, (1) regional travel; (2) lodging; (3) M&IE; (4) in-country transportation; and (5) other office supplies and logistical support services (i.e., laptop, battery pack, paper, communication costs and teleconferencing cost, if needed, due to current travel restrictions). The local consulting firm will be responsible for assisting the evaluation team with site visits and conducting interviews in restricted travel areas as indicated in section IV above. This work will be coordinated by the evaluation Team Leader. The evaluation team will be responsible for arranging meetings and meeting spaces, laptop rentals, local travel, hotel bookings, working/office spaces, printing, photocopying, and other administrative support, as required. USAID may be able to assist the team on a limited basis. PAIMAN REPORT ANNEXES 19 ANNEX B: REFERENCES DFID, Skilled Attendance at Birth Report District Government Khanewal, Health Department, District Health Plan 2008–2009 Government of Pakistan, Safe Motherhood Alliance Assessment Government of Pakistan, Ten-Year Perspective Plan 2001–2011 Government of Pakistan, Unified Health Messages from One-Day Workshop, 2008 Ministry of Health, Community Midwifery Curriculum Ministry of Health, MNCH Logframe, 2008 Ministry of Health, Maternal and Child Health in Pakistan: Challenges and Opportunities: 2004. MCH-PC1 National Program for Population and Family Health, Government of Pakistan, LHW newsletter NORAD, Baseline Survey in Sindh NORAD, Maternal, Newborn, and Child Health Project Document Pakistan Demographic and Health Survey 2006–2007, Preliminary Report PAIMAN, Annual Report 2006–2007 PAIMAN, Annual Workplan 2007–2008 PAIMAN, Assessing Routine Health Information System in PAIMAN Districts by Using LQAS Technique, 2007 PAIMAN, Behavior Change Communication Success Stories PAIMAN, Communication, Advocacy, and Mobilization Strategy PAIMAN, Community LQAS, 2007 PAIMAN, Concept Paper: District Health Management Teams PAIMAN, District Baselines (Upper Dir, Buner, Jafferbad, Lasbella, Sukkur, DG Khan, Rawalpindi, Jhelum, Khanewal), 2006 PAIMAN, District Communication Action Plans, 2007–2008, Upper Dir, Buner, Rawalpindi, Jhelum, Khanewal, DG Khan. PAIMAN, District-level Decision Space Analysis in Pakistan PAIMAN, EMNH Pre-Post-Test and Checklists PAIMAN, EMNH Training Curriculum PAIMAN, FATA Government Program, presentation, June 2008 PAIMAN, Functional Integration of Services in Rawalpindi District: Assessment and Way Forward, 2008 PAIMAN, Functional Integration of Services in Rawalpindi District: Pilot Study 2007 20 PAIMAN REPORT ANNEXES PAIMAN, Health Facility Assessments (Upper Dir, Buner, Jafferbad, Lasbella, Sukkur, DG Khan, Rawalpindi, Jhelum, Khanewal), 2006–07 PAIMAN, Health Facility LQAS PAIMAN, Health System Strengthening, An Update, presentation PAIMAN, IEC Materials (LHW flipchart, support group manual, family booklet, Good Life materials) PAIMAN, M&E Presentation, June 15, 2008 PAIMAN, Mid-term Evaluation Briefing, presentation, June 11, 2008 PAIMAN, Monitoring and Evaluation Plan, January 2007 PAIMAN, NGO Reports from NRSP, HANDS, PAIMAN Project, and Pakistan Lions Youth Council, Jan–March 2008 PAIMAN, Performance Assessment, Strategy, and Workplan of EMNC Trained Public Sector Health Care Providers PAIMAN, Qualitative Formative Research Findings—Summary, July 2006 PAIMAN, Quarterly Report, Jan–March 2008 PAIMAN, Rawalpindi, District Health Annual Operations Plan PAIMAN, Review of Safe Motherhood Programs, Policies, and Research PAIMAN, Routine Monitoring of Output Indicators PAIMAN, Self-Assessment Questionnaire MNH Evaluation, April 2008 PAIMAN, Strategic Framework 2005 and Revised Framework 2006 PAIMAN, Television Talk Show Evaluation Report PAIMAN, Training Plan for Health Care Providers, 2006 PAIMAN/Greenstar, ―Increasing Demand for Maternal and Neonatal Health Care Services,‖ Training Strategy–Private Health Care Providers, December 2006 PRIDE Project, Antenatal Care, Childbirth and Post-Natal Care Standards Save the Children, Partnership Defined Quality Manual Social Policy and Development Center, List of Districts Ranked by Level of Poverty USAID, Operational Plan Indicators, Pakistan 2006–07 USAID Pakistan Interim Strategy, May 2003–September 2006 USAID, Pakistan Population Welfare and Health Logistics, 2006 USAID, SOAG–Health and Amendments 2005, 2006, 2007 USAID/Pakistan, Award of Cooperative Agreement 391-A-00-04-01037-00 PAIMAN REPORT ANNEXES 21 ANNEX C: PERSONS CONTACTED ISLAMABAD USAID Anne Aarnes, Mission Director Susan Thollaug, Health and Population Director William Conn, Acting Health and Population Director Maureen Norton, Senior Technical Advisor, Population and Reproductive Health Dr. Muhammad Ahmed Isa, Program Management Specialist, Health Saedar Talat Mahmud, SO7 Team Khalid Mahmood, SO7 Team Rushna Ravni, SO7 Team PAIMAN/JSI Dr. Nabeela Ali, Chief of Party Lauren Mueenuddin, Deputy Chief of Party Dr. Tariq Azim, Technical Advisor Program and M&E Dr. Schuaib Khan, Director of Programs and Grants Mohammad Babar Hussain Khan, Director of Finance Maj. Javade Khawaja, Director of Administration Mrs. Munazza, Deputy Programs and Grants PAIMAN/JHU Fayyaz Ahmed Khan, JHU BCC Team Leader Zayeem, BCC Deputy Team Leader Shareen, Senior Team Associate PAIMAN/POPULATION COUNCIL Dr. Arshad Mahmood PAIMAN/GREENSTAR Dana Tilson, Country Representative/PSI Mr. Haris, Program Manager Dr. Syed Abdul Qayoom, Senior Manager Interpersonal Communications, Greenstar Dr. Qayoom, Director, IPC Mr. Riaz, IPC Officer/Rawalpindi 22 PAIMAN REPORT ANNEXES Dr. Firdos, Assistant Manager, IPC Regional PAIMAN/SAVE THE CHILDREN Dr. Masood Ahmed Abbasi, Senior Manager Health, Save the Children Rukhsana Faiz, Senior Officer, Community Mobilization Sajjad Nayyer, Senior Officer, Community Mobilization PAIMAN/CONTECH INTERNATIONAL Dr. Muhammad Anwar Janjua, Executive Director, Policy Planning and Health Systems Dr. Naeem Uddin Mian, Health Specialist and CEO Dr. Shabana Haider, Manager, Marketing and Communications Dr. Ahmed Nadeem, Public Health Consultant Dr. Shahzad Hussain Awan, Consultant MINISTRY OF HEALTH Dr. Asad Hafeed, Director, LHW Program Dr. Fazle Manla, Deputy National Coordinator Dr. Saleem Mali Khan, Technical Advisor MINISTRY OF POPULATION WELFARE Mrs. Mumtaz Esker, Director General PAKISTAN NURSING SCHOOL Nighat Durrani, Director Patrice White, Technical Advisor UNITED NATIONS CHILDREN’S FUND Ibrahim El-Ziq, Chief of Health and Nutrition WORLD HEALTH ORGANIZATION Dr. Ahmed Shadoul, Medical Officer, MNCH UNITED KINGDOM DEPARTMENT FOR INTERNATIONAL DEVELOPMENT Dr. Michael O’Dwyer, Health Advisor GERMAN TECHNICAL COOPERATION Paul Ruckert, Principal Advisor CANADIAN INTERNATIONAL DEVELOPMENT AGENCY Pamela Sequiera, Program Officer PAIMAN REPORT ANNEXES 23 ROYAL NORWEGIAN EMBASSY Abdul Aziz Akhtar, Programme Officer JAPAN INTERNATIONAL COOPERATION AGENCY Masaharu Maekawa, Project Formulation Advisor Sohail Ahmad, Senior Programme Officer Dr. Ajmal Hamid, Chief Advisor Health LAHORE PAIMAN PROVINCIAL STAFF Dr. Fazal Mehmood, Field Office Manager, North Punjab Dr. Nuzhat, Field Office Manager, South Punjab Dr. Akhtar Rasheed, Save Provincial Manager, Punjab PUNJAB MINISTRY OF HEALTH MEETINGS Dr. Aslam Chaudhary, Director General, Health Dr. Akram Zahid, Director, PHDC Dr. Ameer Uddin, PHDC Program Director Dr. Tanveer, Provincial Coordinator, FP and PHC Dr. Sabiha Khurshid Ahmad, Provincial Program Coordinator, NMCH Program Dr. Usmani, Representing the DG Health MIDWIFERY SCHOOL, UNITED CHRISTIAN HOSPITAL Mrs. Naseem Pervaz, Principal, Midwifery School Mrs. Shabana Yousz, Clinical Teacher Mrs. Balqees Yousf, Nursing Superintendent Mrs. Teresa Niaz, Nurse 20 midwifery students KHANEWAL MINISTRY OF HEALTH Dr. M. Tariq Gillani, Executive District Officer, Health GREENSTAR Greenstar private provider (Ob/Gyn) trained in comprehensive emergency obstetric care Greenstar private provider (LHV) trained in basic emergency obstetric care 24 PAIMAN REPORT ANNEXES MIDWIFERY SCHOOL, KHANEWAL Mrs. Awest Aziz, Asst. Nursing Instructor Mrs. Bilques Akttar, Nursing Instructor Mrs. Tasmia Caveed, PH Nursing Supervisor Mrs. Riffat Pauveen, Nursing Instructor Mrs. Masarat Parveen, Nursing Instructor 20 community midwives THQ/DHQ Dr. Naeem Saidle Nachi, THQ Hospital, Medical Superintendent Dr. Lubaria Asad, THQ Hospital, Ob/Gyn Dr. Muhamed Rati, DHQ, Medical Superintendent Dr. Noshaba Ali, DHQ, Ob/Gyn 23 LHWs and 1 support group of 17 women RHC KACHA KU 1 LHV, 23 LHWs PAKISTAN LIONS YOUTH COUNCIL (NGO) Dr. Quaiser Javaid, Chairman Birthing center (LHV, 17 CHWs and TBAs, 20 beneficiaries) RAWALPINDI EDO HEALTH Dr. Zafar Gondal, Executive District Officer, Health Dr. Javad Iqbal Chaudhary, District Coordinator, National Program for FP/PHC Mr. Ali Ahsan, HMIS District Coordinator Dr. Khalid Randhawa, District Officer Health NAZIM Dr. Raja Javed Ihhlas, Zila Nazim POPULATION WELFARE DEPARTMENT Ms. Sheeren Sukhan, District Population Welfare Officer Mr. Babar, District Technical Officer RHC MANDRA Romana Kanwal, LHV Dr. Fayzana Mulojeia, WMO PAIMAN REPORT ANNEXES 25 Dr. Khalid, Medical Officer Dr. M. Ilyas, Senior Medical Officer Women’s Support Group: 13 women, 1 LHW, 1 LHS Yasmin, LHW Health House Male health committee (31 members) DISTRICT POPULATION WELFARE OFFICE Dr. Shirine Sukhunl THQ G. KHAN Dr. Swalindie Mir, WMO NATIONAL RURAL SUPPORT PROGRAMME (NGO) Asim Nazeer, Programme Officer, Health PESHAWAR PAIMAN Fazle Jamal Afridi, Field Operations Manager Dr. Roomane Andleds, Provincial Coordinator PROVINCIAL HEALTH SERVICES ACADEMY Dr, Fazal Mahmood, Director Dr. Mahmood Alzal, Deputy Director NWFP/FATA MINISTRY OF HEALTH MEETINGS Dr. Muhammad Zaffar, Additional Secretary of Health Dr. Muhammid Zubair Khan, Director, FATA Health Service Pervez Tamal, Director, MNCH 26 PAIMAN REPORT ANNEXES PAIMAN REPORT ANNEXES 27 ANNEX D: FOCUS GROUP DISCUSSION (FGD) FINDINGS KHANEWAL Lady Health Workers FOCUS GROUP DISCUSSION Date: _18_/_06___/ 2007 Time: From:_10:00_ To:_11:30_ (AM) Location:__Khanewal (RHC Kucha khoo)_ Number of Participants:_23________________ Moderator:_Mrs. Fahmida_______ Recorder:_Mrs. Saima_____________________ Traditional Birth Attendants FOCUS GROUP DISCUSSION Date: 18_/_06_/ 2007 Time: From:_01:30_ To:_02:45_ Location:__Khanewal (RHC Kucha khoo)_ Number of Participants:_20 ________________ Moderator:_Mrs. Fahmida_______ Recorder:_Mrs. Saima_____________________ Beneficiaries (Community Women) FOCUS GROUP DISCUSSION Date: _18_/_06___/ 2007 Time: From:_12:00_ To:_01:15_ Location:__Health Centre (Kucha khoo)_ Number of Participants:__18______________ Moderator:_Mrs. Fahmida_______ Recorder:_Mrs. Saima__________________ Summary of Findings, Khanewal Knowledge and Awareness Levels: Knowledge and awareness levels among LHWs were found to be considerably higher than among TBAs, and those of TBAs were higher than among beneficiaries. LHWs and TBAs were comparatively more knowledgeable about all PAIMAN messages in comparison to beneficiaries. Many key messages were not yet properly understood by the project’s beneficiaries. – All three groups were aware of the importance of antenatal visits and TT vaccination, even though most beneficiaries were not yet receiving the care needed. – Understanding of the importance of early breastfeeding ranged widely, from within the first half hour to three days after birth. The majority of respondents could not explain the benefits of early breastfeeding and spoke mainly of their traditional beliefs and practices. In contrast, both LHWs and TBAs had proper knowledge about the importance of immediate breastfeeding. Trainings: LHWs reported receiving 5-6 trainings, including one PAIMAN training of five days, whereas TBAs got one training one month before the FGD took place. Messages: Most of the LHWs do not regularly visit the households in their catchment area, though some mentioned that they do conduct monthly visits to pregnant women only. Supporting this, the majority of the community women were reluctant to comment on 28 PAIMAN REPORT ANNEXES receiving PAIMAN messages from LHWs through home visits. Primarily, LHWs conveyed messages to beneficiaries through support groups. Difference/Change in the Last Four Years: The majority of LHWs spoke of a marked difference in the last four years due to PAIMAN trainings, support groups, and health committees. Similar views were expressed by TBAs about the training they had received. TBAs also added other BCC activities as a source of change, awareness, and improvement in healthy behavior. In contrast, only a few beneficiaries had yet adopted improved behavioral changes due to LHWs, support groups, and health committees. Some did say that now they could discuss their problems with their families more easily and have more updated knowledge about MNH issues. Danger Signs: The majority of LHWs could identify danger signs of both pregnancy and delivery, whereas only some of TBAs could identify some of the danger signs. However, minor danger signs were not easily differentiated from those that were life- threatening (i.e., nausea and spotting versus signs of pre-eclampsia and heavy bleeding). Significantly smaller proportions of beneficiaries could identify complications and danger signs like excessive bleeding, positioning of the baby, and obstructed labor. Considerable work needs to be done regarding clarification of an obstetrical complication and when there is need for immediate action. Referral System: Both LHWs and TBAs emphasized that they knew to refer pregnant women to SBAs but that they could not confidently say when, where, and to whom they should refer. While the importance of referrals has been conveyed, there is still no proper referral system at the community level for them to follow. Beneficiaries knew they should have adequate funds for delivery, but saving was very difficult and beyond this they had no set birth preparedness plan (such as emergency transport). Support Systems: Family (especially men) and other community members were generally reported to be more cooperative although equally unaware of some key MNCH messages, such as birth preparedness, referrals, and danger signs. Source of Information: Only two mothers indicated LHWs; the majority mentioned elderly women in the family as the most important source of information. PAIMAN REPORT ANNEXES 29 SUKKUR Lady Health Workers FOCUS GROUP DISCUSSION Date: _18_/_06___/ 2007 Time: From:_09:30_ To:_10:45_ Location:__Sukkur_ Number of Participants:_26________________ Moderator:_Ms. Rubina_______ Recorder:_Ms. Kalsoom___________________ Traditional Birth Attendants FOCUS GROUP DISCUSSION Date: 18__/_06___/ 2007 Time: From:_11:00_ To:_12:30_ Location:__Sukkur_ Number of Participants:_20__________ ______ Moderator:_Ms. Rubina_______ Recorder:_ Ms. Kalsoom__________________ Beneficiaries (Community Women) FOCUS GROUP DISCUSSION Date: _18_/_06___/ 2007 Time: From:_12:30_ To:_01:45_ Location:__Sukkur_ Number of Participants:_16________________ Moderator:_Ms. Rubina_______ Recorder:_ Ms. Kalsoom___________________ Summary Findings, Sukkur Knowledge and Awareness Levels: LHWs demonstrated better knowledge of pregnancy and ANC issues than of childbirth, neonatal, and infant care. Mixed knowledge was observed among TBAs about pregnancy, childbirth, and neonatal and infant care. Knowledge and awareness levels of TBAs in Sukkur were higher than that of LHWs. Messages transferred to the beneficiaries was still relatively low. Trainings: The majority of both LHWs and TBAs reported receiving one PAIMAN training in the last year. LHWs requested more trainings on delivery and complications in labor. Messages: There was a noticeable variation in responses about community awareness about ANC/PNC, danger signs/referrals, birth preparedness, and SBAs. Responses indicated that both TBAs and LHWs were less knowledgeable and that is why beneficiaries were not receiving appropriate information. Difference/Change in Last Four Years: The majority of LHWs and TBAs believe there has been a positive change in the last four years due to PAIMAN trainings, support groups, and health committees. TBAs added that in the past they used to work on their own but presently they work with LHWs who visit them and conduct meetings with them to guide them on appropriate maternal and neonatal health practices. Conversely, there were mixed opinions about changes in recent years among community members. Some beneficiaries said that change has been occurring gradually due to LHW meetings at the community level, and others because LHWs came to their homes to educate them about MNH issues. Danger Signs: Mixed understanding of danger signs in pregnancy and childbirth was noted. Both LHWs and beneficiaries made minimal and superficial contributions about identifying 30 PAIMAN REPORT ANNEXES complications and danger signs of both pregnancy and delivery. Lack of understanding of the difference between a minor and a serious complication was once again noted. Referral System: Generally, communities reported going to unskilled TBAs because the RHC/Kindhra is only open until 2 PM. One of the women interviewed had 15 children, and she had given birth to all of them at home with TBAs. LHWs reported knowing about the importance of ANC visits but did not know enough about skilled delivery and complications in delivery to be able to recommend timely referrals. There was no proper referral system known or established in the community. Source of Information: Some respondents indicated LHWs, but the majority mentioned elderly women and TBAs in the community as their first source of information. Practice: There was little evidence noted among TBAs of change in practice regarding use of syntocin (the brand name for oxytocin), which is used inappropriately to induce labor, or for timely referrals. Similarly, LHWs also suggested the incorrect and dangerous use of syntocin injections to speed delivery. They also commented that pelvic examinations should be done when the patient feels pain. Correction of the inappropriate use of oxytocins needs immediate attention. LASBELA Lady Health Workers FOCUS GROUP DISCUSSION Date: _18_/_06___/ 2007 Time: From:_09:45_ To:_11:00_ Location:__ Lasbela _ Number of Participants:_20________________ Moderator:_Ms. Rubina_______ Recorder:_ Ms. Kalsoom___________________ Traditional Birth Attendants FOCUS GROUP DISCUSSION Date: __/_06___/ 2007 Time: From:_11:00_ To:_12:30_ Location:__ Lasbela _ Number of Participants:_21________________ Moderator:_ Ms. Rubina_______ Recorder:_ Ms. Kalsoom_____________________ Beneficiaries (Community Women) FOCUS GROUP DISCUSSION Date: _18_/_06___/ 2007 Time: From:_01:00_ To:_02:15_ Location:__Lasbela_ Number of Participants:_17________________ Moderator:_Mrs. Fahmida_______ Recorder:_ Ms. Kalsoom_____________________ Summary Findings, Lasbela Knowledge and Awareness Levels: Knowledge and awareness levels of LHWs were found to be higher than those of TBAs and beneficiaries. The majority of TBAs were unaware of the importance of or need for antenatal care, signs of obstetrical emergencies, obstructed labor, and what to do if these occur. PAIMAN REPORT ANNEXES 31 Trainings: LHWs reported receiving numerous trainings, including government training and PAIMAN training (for MNCH and support group). TBAs also received a one-day training from PAIMAN. Both LHWs and TBAs requested more trainings to improve upon and update knowledge and awareness of MNH issues. Message: Most beneficiaries were aware of the importance and need for timely ANC and PNC checkups, TT vaccinations, birth preparedness, and timely referrals. However, danger signs in both pregnancy and childbirth were not clearly understood, particularly the difference between those that are life-threatening and those that are not. Difference/Change in Last Four Years: All three groups, in general, believe that there has been positive change in the last four years due to PAIMAN trainings, support groups, and health committees. The majority of TBAs said that as a result of trainings they advocated against unhealthy customs such as discouraging early breastfeeding and giving honey and ghuti as first food. Danger Signs: Positive evidence has been seen of LHW awareness about danger signs of pregnancy and childbirth, such as heavy bleeding; high blood pressure; headaches; swelling in feet, arms, and face; lack of fetal movement; no weight gain or abnormal gain during pregnancy; delay in birth during delivery; release of placenta or amniotic fluid; excessive bleeding post-childbirth, and fever. Referral System: Most deliveries among respondents were done by doctors and LHVs but those by TBAs who received training from PAIMAN were also noted as using clean delivery kits. 32 PAIMAN REPORT ANNEXES PAIMAN REPORT ANNEXES 33 ANNEX E: ACTIVITIES OF OTHER DONORS IN MNCH AND HSS DONOR MNCH ACTIVITIES HSS ACTIVITIES TIMEFRAME LOCATION BUDGET FUTURE PLANS CIDA Planning to support UNICEF for a MCH project in 3 districts of Balochistan Health systems strengthening activities in 2 districts of Punjab HSS: 5 years, began in 2006 MCH: 3 districts in Balochistan HSS: 2 districts in Punjab HSS: CAN$10 m MCH: CAN$18 m Health is not a priority for CIDA DFID Budget and TA support to central government MNCH program 5 years, began in 2006 National Total MNCH budget support: £60 million New project to focus on systems assistance based on specific needs (£150 m) GTZ HSS in AJK Health sector reforms in NWFP and FATA Ongoing assistance AJK NWFP FATA Total agency budget €5 m annually Plans to support health financing mechanisms and HR development JICA Safe motherhood project: training of midwifery teams at PIMS Development of DHIS and implementation in 4 pilot districts DHIS: 2004– 2007 SM: 2003–2008 DHIS-4 districts SM- nationwide DHIS: Total budget US$2.5 m SM: US$16 m Additional support for DHIS for next 3 years NORWEGIAN EMBASSY MCHN program to be implemented by UN agencies (still in planning stage) MCHN program will include management assistance 5 years, beginning in 2008 10 districts in Sindh US$45-50 m for 5 years WHO Policy and TA support for MCH/RH/FP HMIS, community participation Ongoing assistance National Annual MCH budget: US$1.5 million MCH will stay as a priority UNICEF Policy and TA support for maternal, newborn, and child health, child spacing Planning HSS national support for 5 years, US$16 million MNCH: 6 years, began in 2004 17 districts in all provinces Total MNCH budget: US$57 million UNFPA Reproductive health with a focus on safe motherhood and child spacing Program includes improving management systems, e.g., logistics management 7 th country program: 2004– 2008 10 districts in all provinces US$35 m for 5 years 34 PAIMAN REPORT ANNEXES PAIMAN REPORT ANNEXES 35 ANNEX F: PAIMAN INTERVENTIONS: PRIORITIZATION AND SUSTAINABILITY ASPECTS SO INTERVENTION PRIORITY SUSTAINABILITY COMMENTS SO1: Increase awareness Training of LHWs H H Clarification of danger signs and SBAs is needed. Theater shows L L Needs evaluation. Mass media interventions H L Too early to evaluate impact Advocacy with religious leaders/ journalists H H Other BCC events L L Need evaluation to determine which should and can be scaled up or dropped. SO2: Increase access to SBA NGOs: Initiation of Citizen Community Boards (CCBs) H L Most NGOs will not be able to continue without external assistance. They should focus on establishing CCBs. NGOs: Birthing centers H M Will be sustained only where the MOH or CCBs can take on management. Community-based committees L L This should focus on establishing CCBs. Emergency transport: provision of ambulances H M Should only continue through CCBs. Orientation of TBAs H H TBAs are present in the community and provide manager services, not just deliveries Support establishment of community midwives H M Finalize plans for introduction into community; clarify relationships with LHWs/TBAs, access to supplies, supervision, reporting and referral systems Private provider networks H H Training needs to include clinical practicum. Reporting system needs to be improved. Private sector provider a large portion of MNH services. All private providers should be trained on partograph and AMTSL. H: High; M: Medium; L: Low. 36 PAIMAN REPORT ANNEXES SO INTERVENTION PRIORITY SUSTAINABILITY COMMENTS SO3: Improve Quality Upgrade MOH facilities H M Staff is a key limitation of the facilities. If more money is available, the 7 other THQs and key RHC (28) should be upgraded. Supervision H H DHMT has been trained on supervision, but this is still a challenge. Most supervision still has an administrate focus rather than being supportive. Referral system H H Providers do not know where (public or private providers) to refer for specific complications. It is essential that this be mapped out and communicated to providers and women. Reporting/data analysis H H There is confusion about obstetric complications. More support is needed for more accurate reporting and data analysis in both the public and the private sector. SO4: Increase capacity Train providers in EMNC H H Need to add a clinical practicum. Should only train providers in facilities that receive regular support. Partograph and AMSTL training H H All public providers trained on EMNC (941) should receive this training. All private providers should also receive this training Infection prevention H H Private providers should be trained on this. SO5: Health system Management training H M Sustainability varies depending on each district’s willingness to continue training. Strengthening District Health Management Teams H M Sustainability varies depending on each district’s willingness. Integration of family planning H N/A This would be a high priority activity for the FALAH project rather than PAIMAN. It is too early to assess sustainability. H: High; M: Medium; L: Low. PAIMAN REPORT ANNEXES 37 ANNEX G: ROUTINE OUTPUT MONITORING INDICATORS, JANUARY 2007–MARCH 2008 ROUTINE OUTPUT MONITORING INDICATORS JAN-MARCH 07 APR-JUNE 07 JULY-SEP 07 OCT-DEC 07 JAN-MAR 08 SO 1 # of beneficiaries of mothers’ support groups 83,056 70,238 110,328 139,638 213,198 SO 2 # pregnant women visited by LHW in the last month 120,025 152,664 155,957 147,528 156,343 # pregnant women receiving at least 2 TT shots during the current pregnancy 45,509 53,226 58,674 54,755 62,971 # women with obstetrical complications treated in upgraded PAIMAN EmONC facilities 1,421 1,598 1,616 1,362 1,608 # of pregnant women registered for ANC in target districts 38,191 42,012 44,833 45,994 50,438 # postnatal cases visited by LHW within 24 hrs of delivery 22,649 18,872 27,843 27,758 26,830 Total # of Cesarean sections 372 379 501 533 453 # of emergency C-sections 178 230 292 348 309 # of elective C-sections 194 149 209 185 144 # of intra-uterine fetal deaths (IUFD) 159 183 169 183 216 # facilities with basic EmONC in public sector 13 13 13 13 13 # facilities with comprehensive EmONC in public sector (see Note 2) 13 13 13 13 13 # facilities with basic EmONC in Greenstar Good Life Clinics network 123 207 343 432 432 38 PAIMAN REPORT ANNEXES ROUTINE OUTPUT MONITORING INDICATORS JAN-MARCH 07 APR-JUNE 07 JULY-SEP 07 OCT-DEC 07 JAN-MAR 08 # facilities with comprehensive EmONC in Greenstar Good Life Clinic network 0 13 42 42 42 # births in upgraded health facilities 3,498 3,379 5,098 4,731 4,816 # communities with functioning local transport system for emergency obstetric cases 182 301 308 362 388 SO 3 Case fatality rate for major obstetrical complications 9 13 13 21 9 SO 3 Case fatality for major newborn complications 59 69 194 146 163 SO 4 # of effectively functioning DHMTs 7 8 9 7 7 PAIMAN REPORT ANNEXES 39 ANNEX H: ROLES AND RESPONSIBILITIES OF PAIMAN CONSORTIUM PARTNERS CONSORTIUM PARTNER ROLE AND RESPONSIBILITY JSI Research and Training Institute Primary administrative and financial responsibility Monitoring of project implementation Health and training facility renovations Management of NGO grants Support for community midwives Training on infection prevention Contech International Health Consultants District level health systems strengthening Department of Pediatrics and Child Health, Aga Khan University (AKU) Training of trainers for EMNH and CEMOC Training in CEMOC Performance assessment of trainees Greenstar Social Marketing Establishment of private health care network Orientation of TBAs Marketing and sales of clean delivery kits Birth preparedness campaign Johns Hopkins University Center for Communications Programs (JHU/CCP) Development of communications strategy Mass media and interpersonal communication interventions Pakistan Voluntary Health and Nutrition Assistance (PAVHNA) Community mobilization in Sindh Mercy Corps* Community mobilization in Balochistan The Population Council Evaluation, operations research Leadership training Development of TBA curriculum Save the Children US Training for public sector Community mobilization in Punjab and NWFP *Mercy Corps is not a consortium partner; it is a subcontractor of PAVHNA. 40 PAIMAN REPORT ANNEXES PAIMAN REPORT ANNEXES 41 ANNEX I: PAIMAN PROJECT BUDGET ANALYSIS BUDGET LINE ITEM JSI AKU PAVHNA CONTECH GS JHU SC/US PC TOTAL Management Costs Salaries 4,160,545 281,590 306,190 258,377 693,366 1,229,588 925,105 7,854,761 Overhead 1,297,578 137,108 150,199 131,844 314,776 934,237 1,237,556 4,203,298 Travel/allow 1,454,550 77,573 14,080 309,092 193,920 265,661 2,314,876 Equipment 1,151,843 121,756 40,167 12,667 39,500 28,694 1,394,627 Other direct 768,569 20,228 167,981 95,508 48,333 69,402 152,225 187,483 1,509,729 Subtotal Management 8,833,085 638,255 664,537 498,396 755,779 693,270 2,549,470 2,644,499 17,277,291 Program Costs HSS 1,010,435 1,010,435 Renovations 7,971,679 7,971,679 BCC 486,987 2,278,040 5,515,294 1,716,273 9,996,594 C-B Training 850,000 412,907 1,908,560 2,034,589 5,206,056 M&E 702,029 189,097 1,590,676 2,481,802 Subgrants 6,000,000 6,000,000 Subtotal Program 15,523,708 412,907 486,987 1,010,435 4,375,697 5,515,294 3,750,862 1,590,676 32,666,566 TOTAL 24,356,793 1,051,162 1,151,524 1,508,831 5,131,476 6,208,564 6,300,332 4,235,175 49,943,857 * The Cooperative Agreement Budget including all expenses and obligations to date, and excluding additional budget for the FATA and Swat district As of March 2008, total expenses were $ 30,314,097 and $43,470,371 has already been obligated. 42 PAIMAN REPORT ANNEXES PAIMAN REPORT ANNEXES 43 ANNEX J: SAMPLE DISTRICT COMMUNICATIONS PLAN DISTRICT: Khanewal # UCS: 101 # LHWs: 2,040 POPULATION: 2,452,800 # Communities: 717 #CHWs: 63 WRA: 117,734 % rural: 82.50% Coverage 85% of pregnant women were reached through LHWs and CHWs Objectives: 60% of rural UCs were reached with one health mela (4 per month) 60% of all rural villages receive at least one puppet show (30 per month). 45 QIT were set up around functioning health facilities (50% of existing facilities). X% of QITs were turned into CCBs. X% of Ulamas give Friday prayers that included messages for men on male responsibility. BCC/CM PREGNANCY CHILDBIRTH POST/NEONATE CARE MALE RESPONSIBILITY ACTIVITY JAN FEB MAR APR MAY JUNE JULY AUG SEP OCT NOV DEC CM ACTIVITIES: Health melas X X X X X X X X X X X X Puppet theater X X X X X X X X X X X X QIT/CCBs X X X X X X X X X X X X AD: pregnancy X X X X AD: childbirth X X X AD: breastfeeding X X X AD: men X X X X X Video aired X X X Ulama X X X X X X 44 PAIMAN REPORT ANNEXES LHWS/CHWS: Support groups X X X X X X X X X X X X Home visits X X X X X X X X X X X X Key messages: 1) good nutrition and iron folate 2) 4 antenatal visits 3) 2 TT shots 4) danger signs 1) SBAs 2) birth preparedness 3) CDKs for TBAs 4) danger signs 5) first pregnancies should deliver in a health facility 1) visit within 24 hours 2) breastfeed within 1 hour 3) wrapping and delayed bathing of baby 4) exclusive breast￾feeding is best for baby 5) danger signs 1) pregnant women need extra food and care 2) support your wife to get help through pregnancy and childbirth 3) birth preparedness 4) danger signs PAIMAN REPORT ANNEXES 45 ANNEX K: PAIMAN KEY MESSAGE AND TARGET GROUP TABLE COMMUNITY EDUCATION AND MOBILIZATION MESSAGES FOR WOMEN AND GATEKEEPERS MESSAGE TARGET GROUP COMMENTS There are 7 key danger signs in pregnancy and childbirth, and 5 for neonates. Pregnancy and birth Heavy bleeding in pregnancy, childbirth, and immediately after birth Fever in mother with fouling smelling discharge Maternal swelling in face and hands, severe headache, blurred vision Convulsions Lack of fetal movement Labor for more than 12 hours Malpresentations Newborns Fever or low body temperature Does not feed. Difficulty breathing Redness around the cord Blue lips and/or nailbeds Women of reproductive age Gatekeepers (husbands, in￾laws, family members, community members) must support a woman or newborn who is suffering from danger signs at any stage to get to a health facility. These messages are consistent with internationally recognized standards. Clarification on how a woman or LHW can determine if bleeding is heavy or not (number of pads used per hour, etc.). Swelling in feet alone does not indicate pre-eclampsia. Vomiting and spotting are not signs of obstetrical complications. Language used to explain danger signs to LHWs and women is different to that used for providers (e.g., swelling in face and hands versus hypertension). Simplification of these messages will help women and families to seek care when truly needed. There are 3 key messages for antenatal care. Antenatal care Four ANC visits are necessary: one in the first trimester, one in the second, and two in the third. Two tetanus toxoid shots in pregnancy can save your babies life. Nutritious foods, including eggs, chicken, meat, fish, fruits, and vegetables, are vital to the health of the mother and fetus. Iron tablets will also keep a mother and growing baby strong. Women of reproductive age Gatekeepers: Husbands In-laws Community Unified health messages says TT shots are “useful” – sounds optional. There are 5 key messages for childbirth. Delivering with a skilled birth attendant can save the lives of mother and baby. Community midwives and LHVs are the only skilled providers at the community level. If delivering at home, ensure that your assistant has a CDK. Birth preparedness can save lives: make a plan in your family and Gatekeepers: Women of reproductive age Husbands In-laws Community There is an unfortunate amount of confusion about whether trained TBAs count as SBAs. The reentry of CMWs is likely to cause further confusion since both were trained by PAIMAN. The LHW can help clarify this as she helps the CMWs to integrate alongside TBAs into communities. 46 PAIMAN REPORT ANNEXES COMMUNITY EDUCATION AND MOBILIZATION MESSAGES FOR WOMEN AND GATEKEEPERS MESSAGE TARGET GROUP COMMENTS community for money and transport in case an emergency arises. Do not delay: at first sign of a problem, immediately move the mother to the nearest health facility. At least one postpartum checkup is required for a woman delivering at home. Special message for prima gravidas: It is highly recommended that you deliver your first baby in a health facility with a skilled provider. There are 4 key messages for postpartum and neonatal care. Mother should have at least one postpartum checkup within 24 hours of delivery. Baby should be wrapped in warm clothes and not bathed for at least six, but preferably 24, hours after birth. Breastfeeding must begin within the first hour of a birth. Exclusive breastfeeding is best for the baby’s health. Gatekeepers: Women of reproductive age Husbands In-laws Community The UHMs indicates PNC should occur six hours of delivery. The UHM messages do not give timing for delay in bathing the baby. CAM strategy says two hours. NOTE: While some danger signs in pregnant and birthing mothers may be inappropriate to discuss with men (especially religious leaders and political officials), to the extent possible all key messages should be shared, using consistent language, with these influential groups. PAIMAN REPORT ANNEXES 47 ADVOCACY MESSAGE TARGET GROUP There are 12 key messages regarding maternal and neonatal health for advocates: 22,000 women die every year in Pakistan from pregnancy￾related causes. It is your duty as a leader to help reduce maternal and neonatal mortality in your area. Maternal and newborn deaths can be averted if you help families to get the information and help they need. Help those in your area to understand the following key messages: - Any woman showing a danger sign in pregnancy, childbirth, or postpartum should be taken to hospital as fast as possible, - Pregnant women require rest, nutritious foods, and iron folate tablets to maintain their health and that of their baby. - All pregnant women require 4 antenatal visits, - 2 TT shots during pregnancy can save a baby’s life. - Women must deliver with skilled birth attendants only. - If delivering at home, women must have CDKs to ensure a clean procedure. - In case of emergency, families should have a plan for money and transport to the nearest health facility. Encourage them to do so. - Newborns must be breastfed within an hour of birth. This will provide them vital strength in their infancy. - Newborns must not be bathed for at least six hours and must be wrapped warmly to avoid illness. - Advocate for improved EmONC services in your areas. This can save many lives. Community leaders Ulamas Journalists Government officials 48 PAIMAN REPORT ANNEXES PAIMAN REPORT ANNEXES 49 ANNEX L: PRIVATE PROVIDERS Studies indicate that the private sector provides 35 to 60 percent of maternal and delivery care services. The private sector is quite complex, with a wide variety of types of providers and levels of care and quality. For example, many public sector providers also have private practices, but there are also unqualified providers. Women go to private providers because they are female and have medicines and diagnostics (ultrasounds) that are not available in public health facilities. Greenstar identified providers on the following criteria: (1) located in low-income areas; (2) owner of the facilities for one year our longer; and (3) adequate facilities and equipment to provide quality maternal and newborn care services. While these are useful indicators, a mapping exercise of where woman are currently seeking services was not conducted. This would be a useful process to conduct in the future, particularly in selecting rural health providers. Greenstar, through its Good Life Clinics, have trained 550 female private providers on maternal and newborn care services; ANC/PNC (8 hrs.); and EMNH care (12 hrs.). The training used PAIMAN’s master trainers and the essential maternal and newborn care (EMNC) training curriculum. The materials are available in both English and Urdu; the training schedule was adapted to facilitate greater participation of private providers, and desktop protocols were developed to better serve their needs. It should be noted that this training did not include use of the partograph. As part of the training these providers have to provide three free consultation clinics. The aims of these clinics are two-fold, (1) to introduce the community to these providers; and (2) to serve as supervised training sessions for the provider. During each session, the majority of clients are FP (15) followed by ANC (5), and one postpartum and newborn client. It is unclear how many new clients attend these clinics. A key weakness of this training is that there is no observation of delivery care or management of maternal or newborn complications. Greenstar has WMO who provide educational information in short sessions, but there is no direct observation, refresher training, or third-party monitoring. Table L.1 shows the distribution of BEmONC and CEmONC Good Life clinic facilities by district; they are primarily located in urban areas. The table also shows that there are dramatic variations in reporting levels across districts. Much more attention needs to be paid to ensuring that private providers are reporting and that the data collected accurately reflect the services, particularly the understanding of how to classify and report obstetric complications. TABLE L.1. DISTRIBUTION OF GREENSTAR-TRAINED PROVIDERS BY TYPE OF TRAINING, DISTRICT, AND REPORTING LEVEL Districts #BEmONC #CEmONC Total Total % of health care providers Providers Providers Provider Reporting Reporting Upper Dir 10 0 10 0 0 Buner 16 0 16 15 93.8% Rawalpindi 203 14 217 85 39.2% Jhelum 47 0 47 35 74.5% DG Khan 72 10 82 0 0.0% Khanewal 61 3 64 10 15.6% Sukkur 114 14 128 10 7.8% 50 PAIMAN REPORT ANNEXES TABLE L.1. DISTRIBUTION OF GREENSTAR-TRAINED PROVIDERS BY TYPE OF TRAINING, DISTRICT, AND REPORTING LEVEL Districts #BEmONC #CEmONC Total Total % of health care providers Providers Providers Provider Reporting Reporting Dadu 32 1 33 0 0.0% Jaffarabad 7 0 7 1 14.3% Lasbella 7 0 7 3 42.9% Total 569 42 611 159 PAIMAN REPORT ANNEXES 51 ANNEX M: INCREASING QUALITY OF SERVICES The key PAIMAN activities to enhance the quality of maternal and newborn care service are minor renovations, advocating for adequate staffing, and equipping 9 district headquarters hospitals (DHQs) and 9 tehsil headquarters hospitals (THQs) to provide CEmoNC services and 13 RHCs to provide BEmONC services. Three facilities were selected in each district to be upgraded. Health care providers, both public and private, received training to update their skills, as is further discussed under SO4. AVAILABILITY OF FACILITIES FOR NORMAL MATERNAL AND NEWBORN CARE The first aim of upgrading health care facilities and increasing the capacity of both public and private providers was to increase access to skilled birth attendants (SBAs) who could provide quality services. Many of these facilities, due to lack of staff and medicines, were previously not able to provide basic antenatal, normal delivery, or post-partum care, let alone manage complications. This has been a major task for the project, coordinating a variety of different inputs. PAIMAN has been successful in upgrading 31 MOH facilities to provide basic maternal and newborn care. In 2007, many of the facilities were being renovated and health care providers (HCPs) were being trained. Despite these limitations the total number of births in the facilities increased. Since many of the facilities did not provide any delivery services prior to this project, the percentage increase is quite large, as shown in Figure M.1. It is interesting to note that in Labella, Dadu, Jafferbad, and Buner the greatest increases are in the RHCs. Figure M.1. Percentage Increase of Births In MOH Upgraded Facilities, 2007 We compared the average number of deliveries in 2007, as a target, to assess if this increase continued in the first quarter of 2008. Most of the DHQ/THQ (12/18) met or exceeded the average number of births in 2007, as shown in Figure M.2. 52 PAIMAN REPORT ANNEXES Figure M.2. Comparison of Total Births from 2007 to 2008 in CEmOC Facilities It seems that the greatest percentage increases were in DHQ/THQ; only 2/13 RHCs were able to sustain the 2007 levels, as shown in Figure M.3. Figure M.3. Comparison of Total Births from 2007 to 2008 in BEmOC Facilities PAIMAN REPORT ANNEXES 53 Figure M.4 shows that while there have been increases in the total number of births in these facilities, their overall population coverage is still quite low; in 2007 only about 4 percent of births were in the upgraded facilities, which is not surprising at this point in the project. As previously stated the majority of women who deliver with SBA seek services in the private sector. While there are major reporting issues among the Good Life providers as mentioned under SO2, Figure 2 indicates that in Lasbela where only 42 percent of private providers reported the coverage of PAIMAN trained HCPs is about 19 percent. While there are some issues with reporting that need to be strengthened among the private providers, we believe that this is the type of analysis should be conducted by the project. Figure M.5. Population Coverage of Total Births by Upgraded Providers It should be noted that most (67%) of the HCPS that were trained on EMNC were not based in the upgraded facilities. Some of these providers may have been able to attend more deliveries after the training, although we know that training is limited and other inputs are not provided at the facility level. Currently the project is not collecting information on births at facilities that have not been upgraded, though that would be a useful exercise. Thus, PAIMAN has been able to increase the numbers of HCPs and facilities that can provide basic maternal and newborn care, which is a major accomplishment. Since this is the early phases of these facilities providing such services, population coverage is quite low, which is not surprising. It is clear, however, that sustained supported is required to achieve major population impact changes that will translate into reductions in maternal and neonatal mortality. The comparison of the baselines to the Fallah baseline in 8 districts found that delivery with SBAs increased significantly in Jhelum (8.4%); Sukkur (6.7%) and Buner (5.3%), and modestly in Lasbela (3.7%); and there was no change or a decline in Dadu (0.3%), Jafferbad (–1.9%), and DG Khan (–5.7%). 54 PAIMAN REPORT ANNEXES Figure M.6. Deliveries by Skilled Birth Attendants AVAILABILITY OF FACILITIES TO MANAGE MATERNAL AND NEWBORN COMPLICATIONS This intervention also aimed to enhance access to and quality of services that could appropriately manage maternal and newborn complications. International standards recommend that there should be at least one CEmOC facility and four BEmOC facilities per 500,000 population. In rural areas, more facilities may be required because of the geographical distances. Table M.1 outlines the number of required facilities, based on district populations, and of facilities upgraded by PAIMAN. TABLE M.1: AVAILABILITY OF EMOC FACILITIES BASED ON INTERNATIONAL RECOMMENDATIONS CEMOC MOH Good Total BEMOC MOH Good Needed Upgraded Life Needed Upgraded Life Dadu 3.4 2* 1 2 13.6 2 32 Sukkur 2.3 2 14 16 9.1 3 114 Jaffarabad 0.9 1 0 1 3.5 2 7 Upper Dir 1.3 2 0 2 5.1 3 10 Lasbela 0.6 1* 0 1 2.5 2 7 Buner 1.3 1 0 1 5.1 2 16 DG Khan 4 2 10 12 16 3 72 Rawalpindi 8 2 14 16 32 3 203 PAIMAN REPORT ANNEXES 55 TABLE M.1: AVAILABILITY OF EMOC FACILITIES BASED ON INTERNATIONAL RECOMMENDATIONS CEMOC MOH Good Total BEMOC MOH Good Needed Upgraded Life Needed Upgraded Life Jhelum 2.2 2 0 2 8.8 3 47 Khanewal 4.9 2 3 5 19.6 3 61 On paper there seem to be ample facilities to manage complications, but the facilities vary greatly in their ability to provide quality EmONC services. This is particularly true among private providers. PAIMAN has upgraded 13 RHC to provide BEmOC and 18 DHQ/THQ to provide CEmOC. However, 5 of the 18 CEmOC facilities (THQ KH Shah in Dadu and 4 hospitals in Balochistan) are not able to provide CEmONC because of shortages of blood supplies and lack of key staff (gynecologist, anesthetist). PAIMAN has advocated for these inputs, but this is beyond their control. However, they have been quite successful in facilitating 24/7 services, which are available in most of the facilities. This is an ongoing process, as there is frequent staff turnover and reassignments. In discussion with HCPs, many said that they had shortages of partograph forms and injectable antihypertensives; all of them said that there is no magnesium sulfate to manage pre-eclampsia. That will need to be addressed by the DOH. PAIMAN has developed a scoring index to assess progress in a facility’s ability to provide services; as of March 2008 most of the facilities scored above 95 percent. There are 7 THQ facilities (CEmOC) and 28 RHCs (BEmOC) that have not yet been upgraded in these districts. Routine monitoring of output indicators (RMOI) tracks obstetric complications at each of the upgraded facilities. The number of complications has increased, but as discussed below there is considerable confusion about what is an obstetric complication, so there may be some overreporting. TABLE M.2. NEEDS FOR OBSTETRIC COMPLICATIONS MET IN MOH UPGRADED FACILITIES IN 2007 Expected # Women w/ Complications # of Obstetric Complications Total C￾Sections % Emer C-Section C-Section as % of Complications Overall Met Need Dadu 11,501 1603 409 45.0% 25.5% 13.9% Sukkur 7,725 990 520 55.0% 52.5% 12.8% Jaffarabad 2,928 91 0 0.0% 0.0% 3.1% Upper Dir 4,273 315 86 98.0% 27.3% 7.4% Lasbela 2,115 128 0 0.0% 0.0% 6.1% Buner 4,292 199 101 60.0% 50.8% 4.6% DG Khan 13,530 1,216 266 45.0% 21.9% 9.0% Rawalpindi 27,060 411 70 45.0% 17.0% 1.5% Jhelum 7,482 160 257 82.5% 160.6% 2.1% Khanewal 16,574 868 118 56.0% 13.6% 5.2% Average 6.58% 56 PAIMAN REPORT ANNEXES Once again, it is a major achievement of have health facilities providing 24/7 EmOC services. Many of the facilities have only recently become functional, so it is not surprising that the numbers are low. However, it is important to have a baseline to move forward with; while the building blocks have been put in place, it indicates that much more work is needed to see significant changes at a population level. Even though the private sector is a major provider of maternal health services, their capacity and quality is a big unknown, particularly in terms of managing complications. Table M.3. looks at the achievements of upgraded MOH facilities and Good Life providers for January–March 2008. TABLE M.3. NEED FOR OBSTETRIC COMPLICATIONS MET IN MOH AND GOOD LIFE CLINICS, JANUARY–MARCH 2008] Expected # Women with Complications # of Obstetric Complications in MOH # of Obstetric Complications in Private Total Complications Overall Met Need Dadu 3,506 391 0 391 11.2% Sukkur 2,355 249 129 378 16.1% Jaffarabad 892 37 5 42 4.7% Upper Dir 1,302 91 0 91 7.0% Lasbela 644 33 0 33 5.1% Buner 1,308 60 448 508 38.8% DG Khan 4,125 183 0 183 4.4% Rawalpindi 8,250 145 5,474 5,619 68.1% Jhelum 2,281 57 215 272 11.9% Khanewal 5,053 194 61 255 5.0% Average 17.23 Although the same issues persist in terms of the quality of reporting on obstetric complications, with the inclusion of the private sector providers the met need increased 6.5 percent to 17.2 percent While it is challenging to determine denominators for met need, the project is entering a phase where this is something that should be included as part of their yearly analysis. The TAG may provide valuable insight into how the denominators may be best calculated. SUPERVISION OF PUBLIC SECTOR PROVIDERS The project also provided training on supervision. Very few staff have specific supervisory responsibilities, which vary greatly by province and district. From our discussions, it does not appear that PAIMAN conducts joint facility-level supervision training with DOH staff. The facility scoring sheets indicate that supervision visits have been conducted, but it is unclear what is reviewed during these visits, based on discussions with facility staff. HEALTH INFORMATION SYSTEM Throughout the project documents there is considerable confusion about the difference between minor pregnancy and newborn ailments (e.g., urinary tract infection (UTI), anemia, vomiting) and major obstetrical complications that lead to maternal and newborn deaths. The confusion began with the way the baseline findings are reported, leading to the development of the behavior change communication messages on danger signs, the HCP training curriculum, and record keeping. For example, the Buner baseline states that 49.7 percent of women experienced a complication, but we know that only 15 percent PAIMAN REPORT ANNEXES 57 of all pregnant women can be expected to have an obstetric complication. Of the 49 percent of women who had a complication, only 39 percent reported conditions that are obstetric complications; the other 61 percent reported minor ailments. A similar pattern was seen in all the district baselines. As a result, the BCC messages and training curriculum are not specific enough to make the necessary distinctions, adding to the confusion. PAIMAN provided registers to track obstetric complications and C-sections and also some training on complication definitions. It does not appear that there are any registers of newborn complications. The facilities that the team visited had total births, IUDs, and maternal obstetric complication as bar graphs on the wall. There was no information about newborn complications or deaths. Although the staff understood the key aspects of the data and what it meant, there was not a good understanding of how these figures related to basic population data (estimates of pregnant women in the area). Although registers have separate columns for the complications, they are reported as aggregates. It would be useful for facilities to track types of complications so they could see which are the most common complications. In discussions with HCPs during the field visit, they seemed to consider any reason that a woman was admitted as a complication (e.g., treatment of UTIs), even though the registers had the five major complications. This seemed to be most problematic for antepartum complications. As a result a significant percentage of what are reported as obstetric complications are incorrect. In the facilities visited, the majority of complications occurred during the antepartum period (see Table M.4). In addition, between 35-50 percent of these complications are due to incomplete abortions before the 20th week with the usual treatment being D&C. A provider told me that in 2007 these figures were not included in their obstetrical complication reports but in 2008 they have been included. TABLE M.4. COMPLICATIONS AND C-SECTIONS REPORTED May 2008 Total Births Total Complications Total C-Sections Khanewal DHQ 37 vaginal deliveries 48 total deliveries 4 IUD 44 total births 42 complications 11 C-section (2 IUD); 4 eclampsia; 2 PPH;2 APH; 19 UTI, false labor pain, incomplete abortion 11 C-sections 1 eclampsia 2 previous C-section 2 CPD;1 malpresentation 3 fetal distress Khanewal THQ 11 vaginal deliveries 13 total deliveries 13 total births 12 complications 2 anemia; 1 sepsis 9 incomplete abortion/D&C 2 C-sections Rawalpindi THQ 201 vaginal deliveries 209 total births 10 IUD 210/200 total births 39 complications 7 C-sections 8 APH; 2 PIH;1 Spotting 1 N/V; 3 preterm 17 incomplete abortion/D&C 7 C-sections 1 twins 3 previous C-section E eclampsia 2 fetal distress 58 PAIMAN REPORT ANNEXES These limited findings indicate that there are very few complications during childbirth, and women with postpartum hemorrhage are probably not able to reach the facilities. Thus, it would be useful for staff to track the five key complications. They will need more training to clarify both the diagnosis and reporting of these complications. The RMOI also tracks case fatality rates, but since the numbers are quite small, at this point in the project this is probably not a very useful indicator. As noted, basic reporting by private providers is a major problem. It is unclear what training these providers have had in reporting complications; that will need to be greatly strengthened. STILLBIRTHS AND NEWBORN DEATHS While there has been some progress in tracking maternal complications, there has been less emphasis on tracking newborn deaths and complications, which vary greatly by district (see Table M.5). It may be useful to have further discussions with HCPs to understand the causes of these deaths. TABLE M.5. STILLBIRTHS AND NEWBORN DEATHS Stillbirths Newborn deaths District Jan-Dec 07 Jan-Mar 08 Jan-Mar 08 Jan-Dec 07 Jan-Mar 08 MOH MOH Private GL MOH MOH BUN 44 6 32 58 30 UPD 24 16 15 4 Jaff 16 7 7 7 3 LAS 9 4 2 19 2 SUK 116 49 1 85 30 DADU 135 5 184 50 JHE 41 15 2 40 11 RAW 138 18 1 KHA 15 4 24 11 3 All HCPs the team met with commented that they feel more confident in doing neonatal resuscitation. It might be useful to track this as an indicator instead of case fatality rate, because the numbers are still quite small and not very meaningful at this stage in the project. PAIMAN REPORT ANNEXES 59 ANNEX N: INCREASING CAPACITY OF HEALTH CARE WORKERS Training on Normal Delivery: PAIMAN provided a one-month clinical training for 497 LHVs, nurses, and midwives on managing normal deliveries (see Table N.1). Unfortunately, the training did not include the use of the partograph or active management of the third stage of labor (AMTSL), which are key aspects of normal delivery. In addition, most of the DHQ/THQs used as training sites did not use these practices, so the LHVs did not learn these skills. However, in discussions with HCP who attended the training, they found it very useful. TABLE N.1. COMPARISONS OF HCPS WHO RECEIVED ONE MONTH CLINICAL TRAINING AND EMNC TRAINING, BY DISTRICT District # LHVs, FMT, Nurses # HCPs %HCP* received Name Clinical Training EMNC Training Both training Dir 28 30 107.1% Buner 27 16 59.3% Sukkur 42 14 33.3% Dadu 35 14 40.0% Jaffarabad 45 16 35.6% Lasbella 29 12 41.4% Rawalpindi 98 90 91.8% Jhelum 79 25 31.6% Khanewal 58 67 115.5% DG Khan 56 29 51.8% Total 497 313 63.0% As shown on average about 63 percent of HCPs who received the one-month clinical training also received the EMNC training. Not surprisingly, this ranges from a high of 115 percent in Khanewal to less than a half in Dadu, Jafferbad, Lasbella, Jhelum, and Sukkur. Essential Maternal and Newborn Care (EMNC) Training: Essential maternal care includes antenatal and postnatal care, management of normal deliveries, and management of nonsurgical maternal complications. The newborn component includes essential newborn care (ENC) and management of neonatal asphyxia, sepsis, jaundice, and low birth-weight babies. This is a five-day training with lectures and practice on models, but no clinical practicum. The training does not include use of the partograph and has only small sections on AMTSL, communication skills, and infection prevention. Training materials and protocols are in English; PAIMAN is currently translating the materials into Urdu. While the majority of the information in the EMNC curriculum is correct, it would be useful to conduct a technical review of the content to strengthen the training. For example, several of the danger signs listed (e.g., epigastric pain, vomiting in the fourth month) are not indicators of the five major causes of maternal mortality; they are minor ailments that can be addressed at the primary care level of the health system and are not urgent. These distinctions need to be made clearer to enhance the ability of HCPs to effectively 60 PAIMAN REPORT ANNEXES communicate which are the most important and where a woman should go if she experiences any of these conditions. Based on the information provided, HCPs need to complete four checklists during the EMNC training: (1) antenatal care, for use in the wards; (2) immediate care of the newborn; (3) management of postpartum hemorrhage; (4) newborn resuscitation. It does not appear that there is a checklist for normal delivery, AMSTL, or management of pre-eclampsia/eclampsia. On the ANC checklist, in the second trimester it would be useful to give the first dose of TT, take blood pressure, and provide counseling on key topics. Management of postpartum hemorrhage could be simplified, indicating that AMTSL had been conducted; thus, this is a case of uterine atony requiring bimanual compression. On the newborn checklist it would be useful to assess the one-minute and five-minute Apgar levels, provide eye ointment, and weigh the baby. There are several questions on the pretest that are very confusing. For example, question #5 states, a low birth weight baby is one who weighs: (a) less than 1.5 kg; (b) less than 2.0 kg; (c) less than 2.5 kg; or (d) less than 3 kg. These are overlapping answers, which means that a, b and c are all correct. The same problem occurs with question #2. On question #7, the EMNC training manual (p. 123) says that gentian violet should be given and the mother should be taught to do this, but this is not provided as an answer. In addition, there are no questions on AMTSL or maternal and newborn danger signs. To date a total of 1,599 providers have been trained on BEomNC. Of these, on average 60 percent were female. In the Punjab districts about 70 percent of the trainees were female, but less than a third in Upper Dir (33%) and Dadu (23%) were female. Because of the shortage of female HCPS in NWFP, PAIMAN is supporting training of 107 LHVs rather than CMWs. These providers will graduate in September and be placed in MOH facilities, which should increase access to SBAs in these districts. PAIMAN REPORT ANNEXES 61 TABLE N.2. EMNC TRAINING BY PROVIDER TYPE AND DISTRICT Cadre Dir Buner Sukkur Dadu Jaffar￾abad Lasbela Rawal￾pindi Jhelum Khanewal DGKhan Total Pediatrician 0 0 2 1 0 0 2 0 2 0 7 Obstetrician 0 0 2 0 0 0 2 0 3 1 8 Anesthetist 0 0 0 0 0 0 0 1 2 3 MO 26 19 71 115 35 56 51 34 58 30 495 MT/dispes 82 34 0 0 16 15 3 0 1 2 153 WMO 3 2 40 16 3 20 38 14 15 23 174 FMT' 2 52 0 20 16 2 4 3 14 113 LHV' 30 16 14 14 16 12 90 25 67 29 313 Nurse 20 43 28 4 12 18 35 29 53 38 280 Midwife 0 0 4 2 0 0 0 40 7 53 Total 163 166 161 152 102 137 223 147 211 137 1599 Female providers 55 113 88 36 51 66 167 112 148 105 941 Total BEMOC Trained 163 166 161 152 102 137 223 147 211 137 1581 % of female trainees 33.7% 68.1% 54.7% 23.7% 50.0% 48.2% 74.9% 76.2% 70.1% 76.6% 59.5% 62 PAIMAN REPORT ANNEXES PAIMAN REPORT ANNEXES 63 Having upgraded 31 MOH health facilities to provide BEmONC and CEmONC services, PAIMAN’s strategy is to train HCPs from both the upgraded facilities and those that have not been upgraded in the ten districts. The majority of HCPs (67%) that received EMNC training are from facilities that have not been upgraded (see table N.3). TABLE N.3. DISTRIBUTION OF HCPS WHO RECEIVED EMNC TRAINING BY UPGRADED AND NONUPGRADED HEALTH FACILITIES District HCPs Trained in Upgraded MOH Facilities HCPs Trained in Facilities Not Upgraded Total # trained % of HCPs Trained in Upgraded Facilities Buner 85 81 166 51.20% Upper Dir 83 80 163 50.92% DG Khan 35 102 137 25.55% Jhelum 36 111 147 24.49% Khanewal 58 153 211 27.49% Rawalpindi 22 201 223 9.87% Dadu 49 103 152 32.24% Sukkur 54 107 161 33.54% Lasbella 62 75 137 45.26% Jaffarabad 38 64 102 37.25% Total 522 1077 1599 32.65% While training is a key input, experience has shown that providing training alone without adequate facility-level inputs and trainee follow-up has limited success. The team found that some of the upgraded facilities lack basic inputs (e.g., mag. sulfate) that limit their ability to use the information gained during training. It is unclear what follow-up support is provided to these trainees. In addition, data are only collected from the 31 upgraded facilities so it was not possible for the team to understand what, if any, changes have resulted from training HCPs in facilities that have not been upgraded. Training on Use of the Partograph and Active Management of Third Stage of Labor: It does not appear that PAIMAN had identified use of the partograph and AMTSL as a weakness of EMNC training, despite studies that show health facilities and staff in Pakistan, including teaching hospitals, do not regularly utilize these tools. It was fortunate for the project that the Midwifery Association of Pakistan (MAP) developed this training, under different funding. The MAP training is three days with a clinical practicum; the PAIMAN training is two days without a clinical practicum. PAIMAN added the MAP training in June 2007 for one year. HCPs interviewed stated that none of them had used the partograph or AMSTL routinely before the training. To date 268 female HCPs have been trained, out of a target of 400, which constitutes 42 percent of the total female HCPs that received EMNC training. HCPs reported that the training was very useful; many said that they are regularly practicing these skills. The subcontract with MAP ends in July 2008; they have submitted a request for a no-cost extension through December 2008 and are awaiting approval. 64 PAIMAN REPORT ANNEXES A key weakness of the ENMC and MAP training was that they did not include a clinical practicum, which is necessary to effectively change HCP practices. International BEmOC training curricula are at least 10 days with a clinical rotation. UNICEF’s training on BEmOC in Pakistan is for 15 days, including a clinical practicum. Another weakness was omission of the partograph in the EMNC training. Overall, however, the EMNC training content is quite good, though several areas could be enhanced. Urdu training materials and protocols will enhance understanding of materials particularly for LHVs and CMWs. The ability of HCPs to understand the difference between minor ailments and major complications could be enhanced, as well as their ability to provide this information is a way that is easy for women to understand. Based on the performance assessment, it appears that the training has been effective in enhancing providers’ knowledge and ability to manage normal deliveries. It has been harder for them to retain their knowledge and skills for managing maternal and newborn complications. FATA REPORT ANNEXES 65 FATA REPORT ANNEXES 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. 66 FATA REPORT ANNEXES FATA REPORT ANNEXES 67 ACRONYMS ARI Acute respiratory infections AHQH Agency headquarters hospital AHMT Agency health management team ANC Antenatal care BCC Behavior change communication BHU Basic health unit CCM Community case management CD Civil dispensary CDD Control of diarrheal diseases CH Civil hospital CHC Community health center CHD Child Health Days CHW Community health worker CMS Community mobilization strategy ENC Essential newborn care FATA Federally Administered Tribal Areas FMT Female medical technician FR Frontier regions HCP Health care provider HF Health facility HMIS Health management information system ICHP Improved Child Health Project IMNCI Integrated management of newborn and childhood illnesses IMR Infant mortality rate IR Intermediate result LHV Lady health visitor LHW Lady health worker M&E Monitoring and evaluation MCHC Maternal and Child Health Center MNCH Maternal, neonatal, and child health MO Medical officer NGO Nongovernmental organization NMR Neonatal mortality rate ORS Oral rehydration salts QIT Quality improvement team RHC Rural health center SC Save the Children TBA Traditional birth attendant TT Tetanus toxoid 68 FATA REPORT ANNEXES USAID United States Agency for International Development WHO World Health Organization WRA Women of reproductive age FATA REPORT ANNEXES 69 CONTENTS FATA REPORT ANNEXES ACRONYMS .................................................................................................................................. 67 ANNEX A: SCOPE OF WORK ...................................................................................................... 71 I. PURPOSE ................................................................................................................... 71 II. BACKGROUND ........................................................................................................... 72 III. STATEMENT OF WORK ............................................................................................. 81 IV. SUGGESTED METHODOLOGY ................................................................................. 81 V. DELIVERABLES .......................................................................................................... 85 VI. DURATION, TIMING, AND SCHEDULE ..................................................................... 85 VII. TEAM COMPOSITION ................................................................................................ 86 VIII. RELATIONSHIPS AND RESPONSIBILITIES ................................................................... 87 ANNEX B: USAID’S HEALTH AND POPULATION PROGRAM................................................... 89 ANNEX C: LIST OF DOCUMENTS ............................................................................................... 91 ANNEX D: KEY PERSONNEL ...................................................................................................... 93 3.1 JSI / PAKISTAN INITIATIVE FOR MOTHERS AND NEWBORNS (PAIMAN) ................... 93 3.2 SAVE THE CHILDREN / IMPROVED CHILD HEALTH IN THE FATA .............................. 93 ANNEX E: ILLUSTRATIVE LIST OF KEY STAKEHOLDERS ...................................................... 95 ANNEX F: COOPERATIVE AGREEMENT INFORMATION ......................................................... 97 ANNEX G: ILLUSTRATIVE QUESTIONS TO GUIDE THE EVALUATION .................................. 99 TASK 1: GOALS AND RESULTS ............................................................................................. 99 TASK 2: MANAGEMENT REVIEW ......................................................................................... 102 TASK 4: RECOMMENDATIONS ............................................................................................ 104 ANNEX H: MNCH EVALUATION SITE VISITS .......................................................................... 105 ANNEX I: REFERENCES ............................................................................................................ 107 ANNEX J: PERSONS CONTACTED .......................................................................................... 109 ISLAMABAD ............................................................................................................................ 109 PESHAWAR ............................................................................................................................ 110 70 FATA REPORT ANNEXES FATA REPORT ANNEXES 71 ANNEX A: SCOPE OF WORK MID-TERM EVALUATION MATERNAL NEWBORN AND CHILD HEALTH PROGRAM USAID/PAKISTAN (FINAL: 04/27/08) I. PURPOSE The purpose of the subject evaluation is to provide the United States Agency for International Development’s Mission to Pakistan (USAID/Pakistan) with an independent mid-term evaluation of its Maternal Newborn and Child Health (MNCH) programs. The MNCH programs are managed by the Office of Health and implemented primarily by two organizations, John Snow Inc.3 and Save the Children,4 both functioning under Cooperative Agreement mechanisms. The evaluation team will also be asked to include suggestions for the program design component (e.g., future directions) for potential expansion of the MNCH program. A program design activity by a separate team will follow this evaluation activity. As part of USAID/Pakistan’s due diligence, a mid-term evaluation is being commissioned to assess the effectiveness of the program components, document lessons learned, present results achieved to date, and provide recommendations for overall program improvement and strengthening. Recommendations for the follow-on project after the completion of the current projects will also be presented in a separate section of the report but as part of the evaluation for internal USAID use only. Suggestions for program design and scaling up for a more substantial program expansion should also be included in the evaluation report. Taking into consideration the challenges and constraints of the current working environment, the objectives of the evaluation are to Assess whether the MNCH program partners are achieving intended goals and results and meeting benchmarked activities in the cooperative agreements and work plans. Evaluate the effectiveness (objectives and results) of the management structures, administrative support, cost and partnerships, and collaborative plans. Evaluate the effectiveness of key technical components and approaches of the MNCH program given the health status and sociocultural and religious context in Pakistan. Establish whether the overall demand for maternal child health services is growing in project districts as a direct or indirect result of these projects. Document lessons learned and provide discrete management, administrative, and technical recommendations for improving overall efficiency and effectiveness in the context of the Ministry of Health programs in maternal and child health and related areas. Review the findings, conclusions, and recommendations and provide brief suggestions/options for future directions of the program with the potential for program expansion at various levels of additional funding. For example, what would the program look like with an additional $5–$20 million per year? What would be the team’s recommendations 3 JSI PAIMAN $50m five-year Cooperative Agreement 2005–2009. 4 SAVE The Children $11.5m three-year Cooperative Agreement 2007–2009. 72 FATA REPORT ANNEXES for expanding the program in the current programmatic or geographic areas or adding program areas and districts? Provide key inputs, background information, and methodology suggestions that can be incorporated into an SOW for the final project evaluation in 2009. Findings and recommendations will be used to ensure that the MNCH program serves the overall objective of improving maternal, newborn, and child health in Pakistan in the most effective way. This mid-term evaluation will be shared with partners but not widely distributed. Sections of the evaluation may be shared with outside sources at the discretion of USAID management. The separate design/future directions section of the report will be kept for internal USAID use only. II. BACKGROUND Pakistan’s maternal and newborn mortality rates are high despite an extensive health service delivery network. The problem is well described in a qualitative study conducted by JSI’s MotherCare Project that found that awareness of major maternal and newborn complications among women, families, and attendants is insufficient. Most maternal and newborn deaths occur at home without a skilled health provider attending. According to available statistics, over 65 percent of women deliver at home. Trained health professionals conduct only 5 percent of these deliveries. Also, a high total fertility rate (4.1) continues to expose women and children to increased risks of mortality and morbidity. Many traditional social values discriminate against women, lowering their status and affecting their food intake and nutrition, education, decision making, physical mobility, and health care. Husbands, in-laws, and religious and community leaders all play significant roles in these customs. Women, families, and providers focus little attention on behaviors related to preventive care and planning for potential maternal and newborn emergencies. In addition, only a few women, families, or attendants are aware of newborn complications like fever, respiratory problems, pre-maturity, and cord infection. Although Pakistan has an extensive network of public sector delivery facilities, they reach only about a third of the country’s population: the rest (70 percent) is served by the private sector, at least for curative services. The public sector health program is still the main service delivery mechanism for isolated rural communities and for preventive services. It needs improvements in several areas, including physical facilities, safe water supply, privacy for female clients, supply of drugs, logistics and equipment, and provider capabilities, especially in counseling and clinic management. Health facilities are underutilized. They require better linkages with the communities they intend to serve. Lack of availability of providers, especially female providers, at public health facilities needs to be addressed. While most curative services are provided through private providers, private sector health services in Pakistan are unregulated, raising questions of quality. While the Government of Pakistan (GOP), as part of its devolution strategy, promotes delegation of health services planning and management responsibilities to the districts, management systems at the district level, including referral systems, supervisory systems, health information systems, and coordination between public and private sectors, are weak. The Constitution of Pakistan guarantees basic human rights to all citizens, which includes equitable access to health and social services. The GOP is aware of the huge burden of preventable deaths and morbidity among women and children and is committed to improving their health status. Unfortunately, concerted efforts to improve the health of mothers and children have been lacking. Short-term localized programs and projects have failed to achieve significant and sustainable improvements in MNCH indicators. Such improvements can only be achieved FATA REPORT ANNEXES 73 through a national-level, comprehensive, focused, and effective program that is owned and managed by the districts and is customized to meet each district’s specific needs. In 1990 Pakistan adopted its first National Health Policy to provide vision and guidance to the development of the national healthcare delivery system. Its goal was to provide universal coverage through enhancement of trained health manpower. The policy put emphasis on maternal and child health and primary health care. The National Health Policy was revised in 1997 to introduce a vision for health sector development by 2010. The National Reproductive Health Services Package (NRHSP) was introduced in 2000 jointly by the Federal Ministries of Population Welfare and of Health. Its effectiveness and application since its introduction have remained incomplete and unsatisfactory. In June 2001 the Federal Cabinet approved the current National Health Policy, which envisages health sector reforms as a prerequisite for poverty alleviation, gives particular attention to strengthening the primary and secondary tiers of health services, and calls for the establishment of good governance practices in order to achieve high-quality health services. The Population Policy of Pakistan (2002) focuses on integration of reproductive health services with family planning, building on the successful elements of the program, increased participation of the private sector, greater emphasis on social marketing, and enlarging the scope of family planning services. The Ministry of Population Welfare has shifted its emphasis in mass communication campaigns from population control to women’s health. The Ten-Year Perspective Development Plan 2001–2011 places emphasis on improving the service delivery mechanisms for reducing preventable diseases. The policy focus is on a continuous shift from curative to promotion and preventive services through primary health care. Pakistan is signatory to several international agreements regarding improving MNCH, including the Millennium Development Goals (MDG) in MNCH, which are: Goal 4—Reduce child mortality by two-thirds, between 1990 and 2015. The indicators to measure progress toward this MDG include under-5 mortality rate, infant mortality rate (IMR), and proportion of 1-year-old children immunized against measles. Pakistan’s target is to reduce IMR to 40 per 1,000 live births and to increase the measles immunization rate to >90 percent by 2015. Goal 5—Improve maternal health by reducing the maternal mortality ratio (MMR) by three￾quarters, between 1990 and 2015. The indicators to measure progress toward this MDG include the MMR and the proportion of births attended by skilled health personnel. Pakistan’s target is to reduce MMR to 140 or less, and to increase skilled birth attendance to 90 percent by 2015. In addition, Pakistan envisions increasing the contraceptive prevalence rate to 55 percent, increasing the proportion of pregnant women receiving antenatal care from the current 61 percent to 100 percent, and reducing the total fertility rate from 4.1 to 2.1 by 2015 (DHS 2006–07). The Pakistan Planning Commission Form 1 (PC-1) for the National Maternal Newborn and Child Health states that in all districts of Pakistan maternal newborn and child health care services will be strengthened for the population through improving primary health facilities, secondary hospitals, and referral systems and placement of skilled birth attendants at the community level in rural areas and underserved urban slums. One of the most important areas identified by the government of Pakistan has been a focus on poverty reduction. The current Minister of Health emphasizes ―pro-poor‖ activities as his focus as well. The MNCH development partners are working on the development and revision of a Logical Framework of activities for the National MNCH Program prior to the actual start of the program in early 2008, likely following the national elections. 74 FATA REPORT ANNEXES Several other foreign assistance programs are focusing efforts on MNCH, including the British, Norwegians and Australians. United Nations programs addressing MNCH include UNICEF and UNFPA. The two primary MNCH implementing partners for USAID are John Snow Inc. (JSI) and Save the Children. Their project summaries are included here. Pakistan Initiative for Mothers and Newborns (PAIMAN) John Snow Inc. Effective maternal and newborn care consists of a continuum of health care interventions, beginning before pregnancy and covering the prenatal, delivery, and postpartum periods, and addressing the individual health of women and children. In the Pakistan context, in order to have an immediate effect on mortality rates, the focus must be on labor, delivery, and the immediate postpartum period—from the onset of labor through day 7. The PAIMAN project promotes skilled attendance as the long-term goal for all deliveries in Pakistan. The project LOP is 10-08- 04 to 09-30-09; funding level is $56,243,858 (Annex 5). Evidence in the public health literature shows that the maternal and neonatal survival depends upon a whole set of sociocultural, economic, and geographic determinants in the Pakistan context. These factors need to be addressed to generate comprehensive and sustainable solutions to the problem of maternal and neonatal mortality. The MNCH program therefore calls for a multipronged strategic approach, combining individual health care with public health and community-based interventions. The JSI team bases the continuum of care represented in the MNCH program on a strategic framework referred to as ―The Pathway to Care and Survival,‖ which follows a series of steps necessary to increase the likelihood of survival of a mother and her baby in the event of complication or illness. At each step, Pakistani women and children face various interrelated issues that prevent them from reaching quality care and threaten their subsequent survival. We have classified these issues in five main categories: Lack of awareness of risks and appropriate behaviors related to reproductive and neonatal health issues, resulting in poor demand for services Lack of access (both geographic and sociocultural) to and lack of community involvement in MNCH services Poor quality of services, including lack of adequate infrastructure in health facilities Lack of individual capacity, especially among skilled birth attendants Weak management environment and lack of health services integration. For each of these ―problem categories‖ PAIMAN has defined a program objective and a series of interventions to address them. PAIMAN Program Goal and Objectives 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: Based on the ―Pathway to Care and Survival‖ framework, PAIMAN has the following program objectives, interventions, and outcomes: 1. Increase awareness and promote of positive maternal and neonatal health behaviors. FATA REPORT ANNEXES 75 Outcomes: Enhanced demand for maternal, child health, and family planning services through a change in current patterns of health-seeking behavior at the household and community level. Increased practice of preventive MNH-related behaviors. 2. Increase access (including emergency obstetric care) to and community involvement in maternal and child health services and ensure services are delivered through health and ancillary health services. Outcomes: Higher use of antenatal and postnatal care services, births attended by skilled birth attendants, contraceptive use, tetanus toxoid coverage, enhanced basic and emergency obstetric care, and reduced case fatalities. Reduced cost, time, and distance to obtain basic and emergency care, ultimately saving newborn and maternal lives. 3. Improve service quality in both the public and private sectors, particularly related to the management of obstetrical complications. Outcomes: Greater utilization of services to improve maternal and newborn health outcomes. Decreased case-fatality rates for hospitalized women and neonates. 4. Increase capacity of MNH managers and care providers. Outcomes: Increased skilled attendance for deliveries in the target districts. Decreased case-fatality rates for hospitalized women and neonates. 5. Improve management and integration of services at all levels. Outcomes: District MNH plans and budgets available. HMIS information used for MNH decision making. Better coordination between public, private, and community health services. Beneficiaries: The project will work with communities, government, and local nongovernmental organizations (NGOs) to strengthen maternal, neonatal, and child health to increase the health status of women and children. It is estimated that the program will reach an estimated 2.5 million couples, and nearly 350,000 children under 1 year of age will benefit from the program. As beneficiaries of the program, PAIMAN has identified married couples at reproductive age (15–49) and all children under 1 year of age. PAIMAN Time Frame PAIMAN originally planned to begin working in three or four districts and gradually phase in the remaining districts. In actuality they started activities in all ten districts from the beginning of the 76 FATA REPORT ANNEXES project. In December 2007 PAIMAN expanded activities in the FATA in Khyber and Kurram Agencies and Frontier Regions Peshawar and Kohat. PAIMAN also began working in Swat district in April 2008. Improved Child Health in FATA, Save the Children Pakistan is lagging behind most countries in South Asia in terms of child health indicators. The under-5 mortality rate (U5MR) is estimated at 103/1,000 live births and IMR at 81/1,000 live births. Of the 560,000 under-5 deaths reported in 2001, 19 percent were due to pneumonia and diarrhea each, 18 percent to perinatal causes, 7 percent to measles, 5 percent to malaria, and 32 percent to other causes. Only 60 percent of children are immunized for measles at 1 year of age, and the overall chronic malnutrition rate among children less than 5 is 58 percent. A recent Lancet article estimated the neonatal mortality rate (NMR) at 57/1,000 live births, almost as high as Afghanistan and considerably higher than India or Bangladesh. Eighty percent of deliveries are conducted by an unskilled provider. Exclusive breastfeeding (4 months) is quite low as reported at 16 percent. FATA Overview FATA is a belt of seven semi-autonomous tribal agencies stretching north to south along the border between Pakistan and Afghanistan. With respect to population and health system administration, an agency can roughly be equated to a small district in Pakistan. Each has its own characteristics, with wide inter- and intra-agency variations in socioeconomic, cultural, and health status parameters. Project LOP is 09-01-06 to 08-30-09; funding level is $14,750,000 (listed in Annex 5). The people of FATA are almost exclusively ethnic Pashtun. The last national census in 1998 estimated the population at 3.6 million people, of which the government estimates 21 percent (756,000) are women of reproductive age (WRA) and 8.8 percent (316,800) are children under the age of 5. As children under 5 represent nearly 14 percent of the overall population in Pakistan, this figure may reflect substantial undercounting. More than 97 percent of the population lives in rural areas, with the average household size between 8.5 and 10.6 people across the seven agencies. Child Health While the number and type of health facilities varies widely, facilities are characteristically underequipped with high staff absenteeism. Community level maternal and child health care coverage through lady health workers (LHWs) is low, ranging from 13 percent in Bajaur Agency to 55 percent in Kurram. Facility-based reports for 2004 reflect newly registered pregnant women for antenatal care (ANC) at 11 percent, far less than the national average (43 percent). In a recent GOP report, maternal mortality in FATA was estimated at 600/100,000 live births and infant mortality at 83/1,000 live births. Health Management Information System (HMIS) data from Bajaur Agency for the first half of 2005 reflect an estimated U5MR of 135/1,000 live births. In a report published in the Bulletin of the World Health Organization (WHO) in 2002, tetanus was estimated as the cause of approximately 22 percent of all infant mortality in FATA and 36 percent of neonatal deaths. Overall, only 50 percent of pregnant women are vaccinated against tetanus. In 2004 antenatal care ranged from 0 percent in South Waziristan to 18 percent in Orakzai, and fewer than one out of six mothers deliver with a skilled birth attendant. Currently there are 926 LHWs in FATA covering approximately a third of the population based on the government’s commitment to have one LHW per 1,000 population. More than 2,500 additional LHWs are needed to provide this optimal level of coverage. It is not realistic within the scope and timeframe of this project to expect that this optimal coverage will be achieved FATA REPORT ANNEXES 77 Socioeconomic Conditions FATA is a socially conservative society with very limited mobility for women and girls and the lowest levels of literacy for females in South Asia. Socioeconomically FATA is poorer than Pakistan in general. The economy is chiefly pastoral, with some agriculture practiced in the region’s few fertile valleys. In the past, some areas of FATA produced significant quantities of opium; however, this has been reduced in recent years. Communications in FATA are generally dispersed, although some are clustered in relatively accessible valley areas. In 1999–2000, FATA had a road density of approximately half the national figure. Approximately half of the total area is considered physically inaccessible; however, recent funding from the Asian Development Bank and other donors to build roads will likely substantially improve the situation in some areas. Security The political agent currently does not allow UN and WHO staff to enter North and South Waziristan Agencies, regardless of their nationality. Some places in Khyber, Bajaur, Mohmand, and Orakzai Agencies are also designated as ―no-go‖ areas. An unusually high number of criminals and proclaimed offenders (nearly 17,000) are now taking shelter in FATA, where provincial police are prohibited from entering. Tribal law, kidnappings, and a range of other criminal activities combined with post-Afghanistan conflict factors pose a formidable range of operating and security concerns for project implementation and monitoring in some areas. Local NGOs report freedom of movement and fewer restrictions on WHO/UN/INGO representative visits. [A local firm will be hired as needed to do any evaluation visits in FATA.] Improved Child Health in FATA Goal and Objectives To Improve the Health Status of Children in FATA is the overall goal of this project. To achieve this goal the strategic objective is ―Increased Use of Key Health Services and Behaviors,‖ which will be achieved through the following: Increasing access to and availability of health services Improving the quality of health services Increasing the knowledge and acceptance of key services and behaviors at the community level. To improve the health of children up to 12 years, including health and nutrition programming in schools, Save will expand and package the project’s key interventions into the following groups: EPI - Immunization ARI - Acute respiratory infection CDD - Control of diarrheal diseases ENC - Essential newborn care Nutrition and micronutrients Beneficiaries There are an estimated 1,512,000 men and women of reproductive age in FATA. All of these will be project beneficiaries through community mobilization, particularly community awareness sessions. For children under 5 years of age, direct beneficiaries will be the two-thirds who suffer 78 FATA REPORT ANNEXES from either diarrhea or ARI—a total of 209,000 children. The rest of the under-5 population comprises indirect beneficiaries, approximately 108,000. Improved Child Health in FATA Time Frame Phase I – start-up activities, including Agency Headquarters (AHQ) Hospital improvement and capacity building of health care providers at the AHQ level, launched simultaneously in all seven districts. Health facility strengthening and training of LHWs in rural health centers (RHCs) and basic health units (BHUs) will be carried out in Mohmand, Bajaur, and Kurram Agencies. Phase II – health facility strengthening and training of LHWs in Khyber and Orakzai. Phase III – health facility strengthening and training of LHWs in North and South Waziristan. Each phase is staggered by approximately six months. Community mobilization will accompany the above activities and agencies in the same sequence. As of January 2008, this project is working in all seven agencies and six frontier regions (FRs) of the FATA. Fit with the Mission’s Strategic Objective In May 2003 USAID/Pakistan approved an Interim Strategic Plan for fiscal years (FY) 2004– 2006, with the overall goal to ―promote equality, stability, economic growth and improved well￾being of Pakistani families.‖ Strategic Objectives (SOs) relate to education (SO3); democracy and governance (SO4); economic development (SO6); and health (SO7). USAID/Pakistan signed a new Strategic Objective Agreement (SOAG) with the GOP in 2005 and amended it to extend through September 2008; it outlines development activities agreed to by both parties. USAID’s SO7 aims ―to improve health in vulnerable populations in Pakistan.‖ Intermediate Results (IRs) include the following: IR7.1 Improved quality and use of maternal, newborn, and child health and reproductive services IR7.2 Improved administrative and financial management of primary health care programs IR7.3 Improved use of proven interventions to prevent major infectious diseases. FATA REPORT ANNEXES 79 Figure A.1 depicts the Results Framework for SO7. Illustrative indicators in support of IR7.1 include (1) couple years of protection, (2) antenatal care coverage, (3) postpartum coverage meeting international standards, and (4) referral facilities upgraded and meeting safe birth and newborn care quality standards. Improved health in vulnerable populations Indicators Infant mortality rate (deaths 0-1 year per 1000 live births) Neonatal mortality rate (deaths below age 1 month per 1000 live births) Percent of births that occurred 36 or more months after the preceding birth Percent of deliveries assisted by skilled health personnel Contraceptive prevalence rate among married women aged 15-49 years IR 7.1 Improved quality and use of maternal, newborn, and child health and reproductive services Indicators CYP ANC coverage Post-partum coverage meeting international standards Referral facilities upgraded and meeting safe birth and newborn care quality standards IR 7.2 Improved administrative and financial management of primary health care programs Indicators Increased delegation of budgetary and administrative authority to provincial health officials IR 7.3 Increased use of proven interventions to prevent major infectious diseases Indicators Decrease in diarrheal disease in under-5s in target districts TB treatment success (DOTS) rate Non-polio Acute Flaccid Paralysis (AFP) rate Awareness of HIV prevention methods among MSM USAID/Pakistan SO7 Results Framework 80 FATA REPORT ANNEXES USAID Assistance in Health The health program began in 2003 and includes activities to improve maternal and newborn health services, promote family planning, prevent major infectious diseases, and increase access to clean drinking water. The program is nationally focused, working in underserved rural and urban districts in Sindh, Balochistan, Punjab, North West Frontier provinces, and the Federally Administered Tribal Areas (FATA). Current health program areas include: Health Systems Strengthening (HSS): The HSS program seeks to support the Ministry of Health and the Ministry of Population Welfare in strengthening the community midwifery program; targeting health information for raising citizen’s awareness and holding government accountable; addressing health system challenges through modest grant assistance; and improving essential drugs and contraceptive logistics management system. (Implementing Partner: ABT Associates) Diversification of Family Planning Activities in Pakistan (DFPAP): USAID/Pakistan’s project to address the need to increase and improve family planning services includes capacity building, monitoring and evaluation, and project management. (Implementing Partner: The Population Council) Maternal and Newborn Health: The Pakistan Initiative for Mothers and Newborns (PAIMAN) is USAID’s flagship project designed to reduce maternal and neonatal mortality. The project is being implemented in 10 districts in all four provinces of Pakistan. (Implementing Partner: John Snow Incorporated) HIV/AIDS Program: USAID provides grants to seven local NGOs to increase HIV/AIDS awareness and to promote health behaviors in high risk groups. (Implementing Partner: Research Triangle Institute) Strengthening TB Control: USAID assists the GOP to consolidate and accelerate complete treatment of TB patients. (Implementing Partner: WHO) Polio Eradication: USAID provides assistance to national polio immunization campaigns and surveillance to eliminate polio from Pakistan. (Implementing Partners: WHO and UNICEF) Demographic and Health Survey (DHS): USAID provides funding and technical assistance for the Pakistan DHS and Maternal Mortality Study. (Implementing Partners: Macro International and National Institute of Population Studies) Disease Surveillance and Response: USAID supports the design of a National Integrated Disease Surveillance and Response Program and a Field Epidemiology and Laboratory Training Program. (Implementing Partner: U.S. Centers for Disease Control) Child Health in the Federally Administered Tribal Areas (FATA) of Pakistan: USAID is working to improve the availability, quality, and demand for child health services throughout the FATA. (Implementing Partner: Save the Children, USA) Safe Drinking Water and Hygiene Promotion: USAID is providing technical assistance in hygiene and sanitation promotion and community mobilization along with extensive capacity building in order to complement the GOP’s installation of water treatment facilities nationwide. (Implementing Partner: ABT Associates) FATA REPORT ANNEXES 81 III. STATEMENT OF WORK The independent mid-term evaluation team will review the technical, managerial, and programmatic strengths and weaknesses of the two major program MNCH components as approved and financed by USAID: Maternal and Newborn Health: The Pakistan Initiative for Mothers and Newborns (PAIMAN) and Child Health in the Federally-Administered Tribal Areas (FATA) of Pakistan. Based on the findings, the team will formulate lessons learned as well as recommend future technical, programmatic, and administrative actions that will support overall strengthening of programmatic efficiencies and effectiveness. The team is expected to answer the following key strategic and priority questions: 6. Is the MNCH program meeting its benchmarked activities as outlined in the original cooperative agreements and presented in annual work plans? 7. What are the trends in terms of improvements in MNCH indicators (increased prenatal visits, tetanus toxoid [TT] boosters received during pregnancy, improved immunization coverage, etc.) in project districts in Pakistan and compared to GOP contributions to the program in those project districts? 8. What are the key outputs and outcomes of these two programs, PAIMAN and Improved Child Health in the FATA, that have been achieved to date? 9. What have been the major obstacles to program coverage and access, and what should the GOP, USAID, and other donors do to facilitate demand and utilization in rural and higher poverty areas? 10. What are the most important steps that USAID, the GOP, and other donors should take to increase effectiveness, coverage, quality, and sustainability of the MNCH program? In addition, the evaluation team is expected to use creative techniques and approaches to address the tasks listed in Annex 6, which includes illustrative questions to guide the evaluation. IV. SUGGESTED METHODOLOGY The evaluation team will use a variety of methods for collecting information and data. The team will work in a participatory manner with the partners of the MNCH program. The following essential elements should be included in the methodology as well as any additional methods proposed by the team. Reviewing briefing materials/pre-evaluation planning: A package of briefing materials related to the MNCH program will be made available to the evaluation team at least one week prior to the commencement of the mid-term evaluation. A complete list of background documents is attached in Annex 2. In addition to reviewing background documents, the evaluation team will have a preliminary planning period in which they will review the scope of the mid-term evaluation, begin to come to a consensus on the key evaluation questions, develop a proposed schedule, and begin the development of data collection tools. The data collection tools that the team will develop will include the following: Interview Guides Interview Questionnaires (for the evaluation team and the local firm to use during site visits with persons that interact with the PAIMAN and Save projects, i.e., LHWs, LHVs, physicians, nurses, district officials, etc.) 82 FATA REPORT ANNEXES Survey Questionnaires (brief client surveys conducted by the local firm in the PAIMAN and Save districts) The data collection tools will be presented to USAID/Pakistan for discussion and approval prior to their application to verify their appropriateness. These tools will be used in all data collection situations, especially during team site visits and consulting firm site visits, in order to ensure consistency and comparability of data. SO7 Team Briefing: The evaluation team will meet with the USAID/Pakistan Health Strategic Objective Team (S07 Team) in Islamabad to review the scope of the mid-term evaluation, the proposed schedule, and the overall assignment. The initial briefing will also include reaching agreement on a set of key questions and will take place over one day (or could be incorporated into the Team Planning Meeting). Team Planning Meeting (TPM): A two-day team planning meeting will be held in Islamabad before the evaluation begins (depending on the location of consultants, the TPM may be held in the United States prior to the team’s departure for Islamabad). This meeting will allow USAID to present the team with the purpose, expectations, and agenda of the assignment. In addition, the team will: – clarify team members’ roles and responsibilities; – establish a team atmosphere, share individual working styles, and agree on procedures for resolving differences of opinion; – review and finalize the assignment timeline and share it with USAID; – develop data collection methods, instruments, tools, and guidelines; – review and clarify any logistical and administrative procedures for the assignment; – develop a preliminary draft outline of the team’s report; and – assign drafting responsibilities for the final report. Document Review: In addition to reviewing briefing materials that will be provided to the team, the evaluation team will be expected to collect and annotate additional documents and materials for the team’s and USAID/Pakistan’s future use. Self-Assessment Questionnaire: A self-assessment questionnaire will be given to both organizations by USAID prior to the team’s arrival in country. Prior to the team’s arrival, USAID will draft the self-assessment and administer it accordingly. The team will have access to the self-assessment results for their review and use. Information Collection: The information collected will be mainly qualitative guided by a key set of questions. As mentioned, information will be collected mostly through personal and telephone interviews with key contacts and through document review. The full list of stakeholders and contacts will be provided. Additional individuals may be identified by the evaluation team at any point during the mid-term evaluation. Key contacts include: – USAID/Pakistan Senior Management, S07 Team Members, Health Director, Deputy Director, CTO for MNCH Programs; – PAIMAN and Save briefing with key personnel; – PAIMAN and Save subgrantees, subcontractors, and other local partners; FATA REPORT ANNEXES 83 – MOH and MOPW officials; and – Donors and international organizations working in the health and population welfare sector. Site Visits: The evaluation team will travel with JSI-PAIMAN and/or Save the Children project staff and/or the local contracted firm to project sites for face-to-face interviews and discussions with local stakeholders and beneficiaries. The mission has suggested four sites for the evaluation team to visit: Rawalpindi, Lahore, Khanewal, and Peshawar (Annex 7). Site visits will focus on pilot activities (DHIS, midwifery training, birthing centers, family planning integration, GoodLife clinics, Child Health Days). The areas of focus of the site visits will be clinical practices, behavior change communications (BCC), community mobilization, and training/supervision. Questions about equipment and ambulances or the emergency transport plan, facility upgrades, and improved access and quality should be included during discussions with the district officials. In some sites other donor agency staff may request to accompany the team as well. Several interviews should be arranged and done in one day. The site visit to Rawalpindi will be done from the team’s base in Islamabad. The travel time to Lahore is an hour by air, visits can be done during one day, move on to Multan to stay overnight, conduct interviews on day 2 in Khanewal, and return to Islamabad after 2, possibly 3, days depending on flight schedules. Peshawar would be a 2-day visit by car. Thus an estimated 5-6 days are needed for site visits by the evaluation team. (Annex 7) Should travel be restricted, conference calls or other mechanisms will need to be substituted. The Team Leader in collaboration with USAID will determine the appropriate course of action. The team will rent a vehicle locally in Islamabad for travel to some sites and travel to sites with project staff. Local Data Collection and Site Visit Support: A local firm will be recruited and hired to assist in conducting interviews, coordinate and manage in-country logistics, set up appointments and meetings, make travel arrangements, and assist with site visits for the evaluation team. The local firm will visit and be responsible for interviews and field visits in Sukkur, Lasbella, and a FATA site (Annex 7). Sukkur and Lasbella are PAIMAN sites. The FATA sites are Save sites. The local firm will have a team of two persons, at least one being a female interviewer. They may choose to conduct group interviews or focus groups to gather information needed. They should meet with beneficiaries, local community members, NGOs, district officials, and any persons who have interacted with or are aware of PAIMAN or Save activities. The firm will need to have experience working in the FATA. Important: The local firm must understand that USAID programs operating in the FATA function as part of the Government of Pakistan MOH programs and are completely ―invisible‖ in that sense, with no branding to distinguish the program in any way. The local firm will need to be briefed on how to conduct interviews with this in mind in that region. The firm will be engaged by GH Tech prior to the evaluation team arrival in country and will take direction from the Team Leader. Some of the tasks that the local firm will assist with may include but are not limited to the following: Conduct beneficiary interviews as available with: – families (wives, husbands, mothers-in-law) – imams – midwifery students and midwives receiving refresher training 84 FATA REPORT ANNEXES – traditional birth attendants (TBAs) – physicians and LHVs who were trained – civil servants trained in management. Some topics to include in the questioning include: – Have they heard health messages from NGOs, LHWs, or in or through support groups? Any benefit or behavior change? – Have they used health services in refurbished facilities? What was the quality? Can they identify any improvements? – Are they aware that additional ambulances have been placed at facilities? Do they expect the community to benefit? (PAIMAN only) – Have they participated in any MNCH event? What was the impact for them, if any? Interview or otherwise involve all levels of government where available in the evaluation (illustrative): - National, including EAD, provincial, and district as well as FATA Secretariat and FATA Health Directorate - Pakistan Medical and Dental Council, Pakistan Nursing Council, principals of midwifery schools - LHW Program, MNCH Project Head – Donor involvement in evaluation, for identifying gaps and complimentary programs (illustrative): - Open-ended questionnaires to donors - One-to-one interviews - Inbrief/outbrief - Invitation to participate - What’s working? Not working? - UNICEF, UNFPA, DFID, WB, Norad, AusAID, WHO, JICA, CIDA - Who is working where doing what? Mapping. Extent to which projects are integrating FP into MNCH now. How much work are other projects doing on vaccination, IMNCI, HSS, infection control and hospital waste management, male involvement, private sector involvement? – What are donors’ future plans in MNCH? Best practices? Integrated FP? Child vaccination? Systems strengthening? What role is each donor taking in planning, implementing, funding, policy development, support? FATA REPORT ANNEXES 85 V. DELIVERABLES Debriefing Meetings: At least two days prior to ending the in-country evaluation, the team will hold three meetings to present the major findings and recommendations of the evaluation: (1) SO7 team—that will focus on the accomplishments, weaknesses, and lessons learned in the MNCH program, including recommendations for improvements and increased effectiveness and efficiency of the MNCH program; (2) senior Mission management—incorporating the insights gained in the first debrief; and (3) Final briefing—for MNCH (Save and PAIMAN) personnel, other donor partners, and key stakeholders (GOP officials), focusing on major findings and recommended changes to increase program effectiveness for the life of the project. No evaluation or future directions recommendations will be shared outside of the USAID/Pakistan Mission staff. Succinct briefing materials will be prepared appropriate for each audience. Each meeting will be planned to include time for dialogue and feedback. Draft Report: The evaluation team will provide, prior to departure, a draft report which includes all components of the mid-term evaluation to the USAID/Pakistan Health Office Director and relevant SO7 Team members in hard copy (4 copies) and on diskette in MSWord format. USAID will provide comments on the draft report to the evaluation Team Leader within 5 working days. This will be followed by final unedited content that the contractor is required to submit within 10 working days after USAID feedback on the draft Report. Upon USAID approval of this final content, GH Tech will edit and format the report. The edited and formatted final report will be submitted within 30 days of receiving USAID final approval of the content. The final report is to be submitted to the Health Office Director, both in hard copy (6 copies) via express mail and in electronic form. The report will be presented in 12-point font, single spacing. Evaluation Report: The final evaluation report should include, at a minimum, the following: (1) Table of Contents; (2) List of Acronyms; (3) Executive Summary; (4) Background Statement; (5) Findings and Lessons Learned; (6) Prioritized Recommendations; (7) Future Directions, including scaling up and potential expansion possibilities; and (8) Annexes as appropriate, including list of people met and sites visited. A Report Outline will be prepared by the evaluation team before starting the field work and approved by the Mission. Pertinent information for the final program evaluation in 2009 should be presented in a separate document. GH Tech makes the results of its evaluations public on the Development Experience Clearinghouse and on its project web site unless there is a compelling reason (such as procurement sensitivities) to keep the document internal. Therefore, we are requesting Mission confirmation that it will be acceptable to make a version of this document publicly available, which will exclude the recommendations and future directions sections. The Mission will provide final approval of the public version before it is posted on any web site to ensure that all sensitive information has been removed. VI. DURATION, TIMING, AND SCHEDULE It is anticipated that the period of performance of this evaluation will be for six/seven weeks beginning in May/June 2008. A possible schedule of this activity follows (illustrative): Task/Deliverable Team Leader LOE Team Members LOE (2) 13. Review background documents/pre￾evaluation planning (out of country) 6 days 5 days 14. Travel to Islamabad 2 days 2 days 15. SO7 Team briefing 1 day 1 day 86 FATA REPORT ANNEXES Task/Deliverable Team Leader LOE Team Members LOE (2) 16. Team planning meeting 2 days 2 days 17. Meetings with COPs of PAIMAN and Save GOP officials in Islamabad (MOPW, MOH) Local consulting firm MNCH donors and other partners 7 days 7 days 18. Visit field sites, including training centers, clinics, etc. 4 days 4 days 19. Debriefings with Health Office, USAID senior management, PAIMAN and Save, other stakeholders 1 days 1 days 20. Internal discussion meeting with local firm and international team 1 day 1 day 21. Analysis, discussion, and draft report writing 14 days 14 days 22. Presentation of draft report and discussion 1 day 1 day 23. Return travel 2 days 2 days 24. Complete final evaluation report (out of country) 5 days 2 days Total # days 46 42 A six-day work week is approved when the team is working in country. VII. TEAM COMPOSITION The team should have the following skills mix: maternal and child health service provision, project assessment and evaluation, program design, reproductive health care and service provision, health worker training, behavior change communication, community mobilization and participation, health systems services/management information systems, among others. Familiarity with the health service delivery system (both public and private sectors) in Pakistan would be a major advantage. Ideally, the Team Leader would be an expert with international experience while other consultants could be recruited from available contractors or consultant pool. A suggested team composition is given below: Team Leader: The team leader should be a public health generalist and an evaluation expert with practical knowledge in monitoring and evaluation of international public health programs in developing countries. A broad background in MCH is preferable. S/he should have an advanced degree in public health. A minimum of 7 years experience in managing, monitoring, or researching international public health programs is required. S/he should also have a comprehensive understanding of maternal, newborn, and child health principles and practices. In addition, the Team Leader should have at least 5 years experience strengthening health systems, health sector reform, program component cost analysis, logistics of essential medicines and contraceptives, and addressing issues of quality and access improvement in health systems in developing countries. Identifying appropriate technical assistance needs to make improvements in the health systems, building capacity of local institutions and organizations, including the Pakistan Nursing Council, the Midwifery Association of Pakistan, and other interventions will be FATA REPORT ANNEXES 87 included in this position’s SOW. S/he should also have a keen awareness of health management information systems scenarios and the ability to recommend effective solutions for improvements to health data collection and reporting systems in the country. It is imperative that the Team Leader have excellent English language skills (both written and verbal) as s/he will have the overall responsibility for the final report, and will have a major role in drafting and finalizing the deliverables. The individual considered for the Team Leader position is expected to provide a sample of a written report for consideration by the Mission. Maternal Health Specialist: The second team member should have an advanced degree in health sciences or public health and at least 5 years experience in program management, implementation, and monitoring and evaluation of internationally based maternal and child health programs, as well as a comprehensive technical knowledge of and experience in maternal newborn and child health programs, especially service provider training. S/he should have a strong appreciation of partnership building and service provision in challenging environments. A nurse/nurse midwife is preferred for this position. BCC/Community Mobilization Expert: This team member should have an advanced degree in medical anthropology or a related discipline and at least 5 years experience in the implementation of field behavior change communication and community mobilization strategies. A comprehensive knowledge of the application of BCC strategies to alter behaviors related to maternal and child health is desirable. The evaluation team will be authorized to work a six-day work week while in country. Travel expenses and other communication costs incurred during the course of duty are authorized. The final travel itinerary of the evaluation will be contingent on the security situation and relative predictability of access to the project sites in general and target areas in particular. It is possible that evaluation team members will be asked to provide input and feedback in the redesign of the follow-on project or revision of the current Maternal and Child Health program. Team member involvement will be determined during the development of the scope of work for the redesign/revision. VIII. RELATIONSHIPS AND RESPONSIBILITIES 11. Overall Guidance: The Health Office Director and Deputy Director of USAID/Pakistan will provide overall direction to the evaluation team. Other USAID/Pakistan Health Office staff will interact with the evaluation team as needed to complete the evaluation activities. 12. Responsibilities: USAID/Pakistan will introduce the evaluation team to relevant implementing partners, government officials, and other individuals key to the accomplishment of this evaluation through introductory letters or advance phone calls. USAID/Pakistan will provide observers throughout the review from the PAIMAN and Save programs as feasible. USAID/Pakistan will be responsible for providing security notices issued by the American Embassy in Pakistan to which the evaluation team must adhere. The evaluation team will provide mobile phone contact numbers to the USAID Health Office so that contact can be maintained as needed. GH Tech Evaluation Team will be responsible for coordinating and facilitating evaluation￾related field trips, interviews, and meetings. USAID will review and approve the schedule. 88 FATA REPORT ANNEXES The evaluation team will be responsible for making all logistical arrangements. The evaluation team will be responsible for all costs incurred in carrying out this review. The proposed costs may include, but not be limited to, (1) regional travel; (2) lodging; (3) M&IE; (4) in-country transportation; and (5) other office supplies and logistical support services (i.e., laptop, battery pack, paper, communication costs and teleconferencing cost, if needed, due to current travel restrictions). The local consulting firm will be responsible for assisting the evaluation team with site visits and conducting interviews in restricted travel areas as indicated in section IV above. This work will be coordinated by the evaluation Team Leader. The evaluation team will be responsible for arranging meetings and meeting spaces, laptop rentals, local travel, hotel bookings, working/office spaces, printing, photocopying, and other administrative support, as required. USAID may be able to assist the team on a limited basis. FATA REPORT ANNEXES 89 ANNEX B: USAID’S HEALTH AND POPULATION PROGRAM In FY 2005 and beyond, USAID will improve the quality of health care in Pakistan by focusing on three objectives identified in collaboration with the Government of Pakistan (GOP): improve the quality and use of maternal, newborn, child health, and reproductive services; improve administrative and financial management of primary health care; and increase the use of proven interventions to prevent major infectious diseases. The Strategic Objective for health—Improved health in vulnerable populations in Pakistan— helps the GOP provide accessible and quality health and reproductive health programs, especially for women and children. If it is successful, the Ministry of Health, provincial health departments, and district hospitals will also adopt planning and management systems—particularly planning, budgeting, financial management, and reporting on health expenditures—that will in turn improve delivery of quality health programs. Both the improved management and the improved services are captured at the IR level. The program also focuses on improving the health status with respect to infectious diseases of vulnerable groups, including infants, adolescents, and young adults. Success will be measured by readily available and standard measures that demonstrate the effectiveness of efforts in relationship to maternal and child health and reproductive health, including percent of births occurred 36 or more months after preceding birth, percent of deliveries assisted by skilled health personnel, and the contraceptive prevalence rate among married women aged 15–49 years. Among the major infectious diseases are water and blood-borne hepatitis, diarrhea and enteric diseases, polio, tuberculosis, and, in certain areas, leishmaniasis. HIV/AIDS is a growing problem, and Pakistan is now considered to have a concentrated epidemic. USAID supports GOP health programs and coordinates closely with other donors and partners. USAID funds health activities in the following areas: Developing new and improved maternal and newborn health care throughout the country by improving health services and upgrading essential equipment at selected health facilities; Continuing efforts to eradicate polio through vaccination programs; Improving surveillance and control of diseases of major public health importance (e.g., hepatitis, TB, HIV); Promoting greater awareness of HIV/AIDS and encouraging healthier behaviors among the most at-risk groups; Improving water and sanitation systems, including health and hygiene education to better ensure safe drinking water, storage, and end-use. Providing training and technical assistance to reproductive health service providers to improve the availability and quality of care in underserved areas, in accordance with the Mexico City Policy; and Helping health officials and local governments improve the planning, implementation, and monitoring of health programs. The program supports 10 out of 12 objectives outlined in the GOP’s reform strategies for the health and population sectors outlined in its Ten-Year Perspective Development Plan 2001–11. The program will promote the health of women and children through interventions that can be 90 FATA REPORT ANNEXES sustained over the long term by improving the utilization and quality of health services. The objective of this assistance is to help the GOP develop and deliver accessible and quality health and reproductive health interventions. USAID/Pakistan is in the process of awarding a two-year Health Systems Strengthening project to address health sector reform, capacity building of local institutions, including the Nursing Council and Midwifery Association of Pakistan, logistics management of essential drugs and contraceptives, and improving effectiveness of health systems and quality and access to healthcare services. FATA REPORT ANNEXES 91 ANNEX C: LIST OF DOCUMENTS (to be provided to the Evaluation Team one week in advance) 1. USAID/Pakistan’s Interim Strategy 2. SOAG-Health and amendments 2005, 2006, 2007 3. Operational Plan indicators 4. Pakistan 2006-07 Demographic Health Survey (DHS) 5. Program Descriptions Pakistan Initiative for Mothers and Newborns (PAIMAN) Save the Children’s Child Health Program in the FATA Work Plans; Annual and Quarterly Reports PAIMAN Save 6. SO7 Performance Management Plan (with SO7 Results Framework) 7. Ministry of Health documents and materials 8. Obligations and expenditures to date by fiscal year 9. Ten-Year Perspective Plan 2001-2011, Government of Pakistan 10. MNCH PC-1 11. Safe Motherhood Alliance Assessment 12. EMNC and EmONC training assessments 13. Save the Children agency baseline surveys and health facility and household surveys 14. Aga Khan training assessment 15. JSI district baseline surveys 16. JSI component evaluations 17. JSI audit report 18. Maps of districts 19. List of districts ranked by level of poverty (Social Policy and Development Center) 20. Other donor documents with program areas and geographic areas covered 21. Norway MNCH Project document 22. Baseline survey in Sindh (NORAD) 23. Provincial Health Plans, Sindh, FATA, NWFP, Balochistan, Punjab 24. FATA Sustainable Development Plan 92 FATA REPORT ANNEXES 25. WHO Systems reports 26. MNCH Logframe 27. EPI Program documents, IMCI materials 28. Evaluation of UNICEF and UNFPA projects 29. JICA HMIS Report 30. UNICEF, UNFPA, DFID reports FATA REPORT ANNEXES 93 ANNEX D: KEY PERSONNEL 3.1 JSI / PAKISTAN INITIATIVE FOR MOTHERS AND NEWBORNS (PAIMAN) POSITION/PERSON CONTACT NUMBERS 1 Chief of Party 111 000 025 Dr. Nabeela Ali 03005550473 2 Deputy Chief of Party Lauren Mueenuddin 03008565461 3 Operations Javade Khawaja 03005551230 4 M&E and HIS Advisor Tariq Azim 03005309126 5 Financial Officer Ext 109 Babar Hussain 03005001369 6 Grants Manager Dr. Shuaib Khan 03005551233 3.2 SAVE THE CHILDREN / IMPROVED CHILD HEALTH IN THE FATA POSITION/PERSON CONTACT NUMBERS 1 Chief of Party Dr. Amanullah Khan 03008580720 2 Deputy Chief of Party Fayyaz Ali Khan 03018546997 3 Operations Qamar Khursheed 03008565823 4 M&E Dr. Salim Sadruddin Dr. Sanam 03008522863 091 5703363 5 Financial Officer Mr. Nauman 03215172556 6 Grants Manager Mr. Aziz Zamir 03085052938 94 FATA REPORT ANNEXES FATA REPORT ANNEXES 95 ANNEX E: ILLUSTRATIVE LIST OF KEY STAKEHOLDERS 1. USAID/ Pakistan, SO7 core team, other SO team leaders as appropriate Mary Skarie, Health Office Director William Conn, Public Health Advisor Dr. Qadeer Ahsan, Project Management Specialist, Health Dr. Ahmed Isa, Project Management Specialist, Health Khalid Mahmood, Program Assistant Dale Lewis, Agreement Officer, Acquisition and Assistance Office 2. PAIMAN Staff Dr. Nabeela Ali, Chief of Party Lauren Mueenuddin, Deputy Chief of Party Dr. Shuaib Khan, Director Programs 3. Save the Children Dr. Amanullah, Chief of Party Fayyaz Ali Khan, Deputy Chief of Party 4. Ministry of Health Project Director, National MNCH Program Project Director, National FP and PHC 5. Ministry of Population Welfare Project Director, Technical Advisor 6. Development Partners DFID UNICEF UNFPA WHO CIDA JICA AusAID NORAD 7. Pakistan Nursing Council 8. Midwifery Association of Pakistan 96 FATA REPORT ANNEXES 9. District Nazims and EDOs Health in the project districts 10. Local community leaders, NGOs and beneficiaries in the districts where PAIMAN and Save work FATA REPORT ANNEXES 97 ANNEX F: COOPERATIVE AGREEMENT INFORMATION PROJECT LIFE OF PROJECT TOTAL OBLIGATION TO DATE JSI - Pakistan Initiative for Mothers and Newborns (PAIMAN) $56,243,858 5 years 2005-2009 $42,288,371 Save the Children - Child Health in the FATA $14,750,000 2 years 2007-2009 $4,078,088 98 FATA REPORT ANNEXES FATA REPORT ANNEXES 99 ANNEX G. ILLUSTRATIVE QUESTIONS TO GUIDE THE EVALUATION TASK 1: GOALS AND RESULTS Overall Aim: To establish whether the Maternal Child Health Program has achieved intended goals and results given the program design and operating assumptions. 1.1 PROGRAM DESIGN a) Review the original and subsequent assumptions in the program design and assess their validity. Are the program designs of both PAIMAN and Improved Child Health in FATA appropriate vehicles for USAID to achieve the Mission’s Strategic Objective 7 (SO7): ―Improved health of women and children‖? b) Are the two designs appropriate within the sociocultural and religious context of Pakistan? 1.2 Program Goals and Objectives a) To what extent have the two programs met their respective goals and objectives? Based on what evidence and indicators? b) To what extent are the USAID MNCH program achievements contributing to USAID/Pakistan’s SO7 and the Government of Pakistan’s health objectives? What is the evidence? c) What were the key constraints or setbacks that may have hindered the achievement of greater results? 1.3 Sustainability a) To what extent is the MNCH program sustainable from financial, institutional, and programmatic perspectives? What strategies are the two projects using to move toward institutionalization of these activities? b) Does each project have an exit strategy, and to what extent is each project accomplishing any benchmarks leading to exit? c) Which aspects of the program will be taken over by the national MCH program and to what extent? 1.4 Project components (strengths, weaknesses, challenges, sustainability, recommendations) Note: Project inputs will have to be stated/summarized for each component, HMIS: look for successes and challenges at district level where HMIS is implemented fully or partially (in Punjab, only Khanewal). – What is the impact of working with the District Health Management Teams (DHMT)? – Are staff and civil servants understanding how to use data in the interest of effective program management? 100 FATA REPORT ANNEXES – Is the HMIS component in Khanewal working to improve and strengthen the project and MNCH services? Quality in public and private sector (Good Life clinics) – Are midwifery training and services provided, such as refresher midwifery training and quality of midwife services delivered post-training? – Quality of counseling services provided on MNCH by project-trained physicians, Lady Health Visitors (LHV), Lady Health Workers (LHW) (counseling only)? Behavior change communication (BCC) – Interpersonal communication through LHWs, women’s and men’s support groups, mega events, mass media (PAIMAN only)? – Opportunities to integrate BCC with MOH, with donors, across projects? – Describe key BCC strategies and demand creation being used by each project. – Have the projects made progress in reaching vulnerable populations, how? – Are key messages technically valid and communicated appropriately? Community mobilization – To what extent have different community mobilization components been effective? – How can they be strengthened? – Which should be discontinued? Family planning/birth spacing – To what extent has FP has been integrated into MNCH, with a focus on Rawalpindi functional integration pilot project, LHW work in districts, and any FP services in Rural Health Centers (RHC), Tehsil Headquarters Hospitals (THQH) (PAIMAN only)? – What are opportunities to work more closely with Ministry of Population Welfare programs? Child Health Indicators, numbers of children treated and services provided compared with targets of the following: – Nutrition/malnutrition – Birth weight and monitoring – Diarrhea treated (CDD) – Acute respiratory infections (ARI) – Emergency neonatal care clients served – Number of Child Health Days conducted FATA REPORT ANNEXES 101 Immunization: Save (childhood and TT) and JSI (TT only) – Approaches used to increase TT and children’s vaccination? – Any efforts to strengthen data quality of reporting? – Linkage to government HMIS? – Efforts in Good Life clinics? – Linkage to polio campaigns? – Systems issues affecting success? Renovation, equipment – What has been the impact of upgrading and equipping 31 health facilities and in the FATA? – Was enough done, too much, or too little? Interview district officials, get community and services statistics. Midwifery schools and tutor preparation (Khanewal, Holy Family Hospital, Lahore, by interview) – What can be done in midwifery schools now that could not be done before inputs were provided? – What are the remaining gaps? Challenges? Recommendations? – What inputs were most important, and which made little difference? Infection control – To what extent have infection control and hospital waste management practices been addressed in the projects? – What has been accomplished to date in the Rawalpindi pilot (JSI)? Health systems, Interviews with district officials, project staff? – What has changed as a result of systems interventions? – What has not changed? – What do they think needs more emphasis? – What is the status of drug supplies for MNCH in project- supported facilities? Project management, including financial management – Are the projects being effectively managed? – Is the management structure appropriate? – How can management be improved? – How can USAID improve its oversight of the programs? 102 FATA REPORT ANNEXES Project monitoring and evaluation – To what extent are project results being achieved to date? – Are the indicators appropriate in number and content? Too many? Too few? – Are the project methods of evaluation (baseline/endline surveys, Lot Quality Assessment Surveys [LQAS]) timely, efficient, reliable? TASK 2: MANAGEMENT REVIEW Overall Aim: Conduct a management review to assess the effectiveness of the management structures, administrative support, cost, and partnerships 2.1. Administration and Management a) Do the implementing partner’s administrative and management structures appropriately support implementation of activities? b) Are the staffing plans and organizational structures of the two implementing partners adequate and appropriate to meet objectives? 2.2. Cost Analysis a) Review each partner’s financial management, expenditures, and program income use. Present the approved obligations versus expenditures to date in overall percentages and determine the cost-effectiveness against both deliverables and performance. b) Analyze cost per beneficiary to the extent possible, if applicable at this time. c) Based on the analysis, what are the implications for cost effectiveness for each implementing partner and the MNCH program as a whole? 2.3 Monitoring and Evaluation a) Do JSI and Save’s M&E systems support USAID/Pakistan’s PMP/Operational Plan? Does the reporting meet program management needs and USAID/Pakistan’s needs? b) Review program monitoring and evaluation plans, including program indicators and impact indicators in relation to the approved intermediate results/subresults. Do the indicators reflect the true nature of the activity and will they permit accurate impact analysis? Are the indicators comparable/uniform between the two programs? Have the two projects established reasonable mechanisms for gathering data for monitoring progress and impact? 2.4 Coordination, Collaboration, and Partnerships a) To what extent have the projects been successful in developing partnerships with the public sector, such as the MOH and MOPW? b) To what extent and how effectively did the MNCH teams coordinate and consult with others outside the MNCH network of partners, such as other bilateral and multilateral donors, universities, NGOs, and the private sector? c) To what extent is the MNCH program coordinating with other USAID Health Office program activities? What if anything should be done to improve collaboration? FATA REPORT ANNEXES 103 TASK 3: TECHNICAL REVIEW Overall Aim: Evaluate the effectiveness of key technical components and approaches of the MNCH program given the health status and sociocultural and religious context in Pakistan. 3.1 Training Approaches and Technical Assistance a) To what extent has the technical assistance (TA) provided under the MNCH program been adequate to meet host country needs? b) Review the training approaches, materials, and guidelines of both JSI and Save. Do the training materials reflect best practices in MNCH and are they consistent with established international guidelines and protocols? c) Assess the mechanisms and methodology for delivering training (e.g., training of trainers, working with subcontractors, through the MOH). Are delivery mechanisms effective and scalable? d) To what extent has the MNCH program contributed to maintaining and enhancing the ―Maternal and Newborn Health Standards‖ of the MOH and ―Reproductive Health Standards‖ of the MOPW so that standards of care, protocols, training and counseling materials, and information strategies promote consistent and uniform provider behaviors and practices? e) To what extent, if any, has the PAIMAN project supported optimal birth spacing, directly or through collaboration? Is the PAIMAN project using the training and counseling materials developed for this initiative? f) Are there opportunities for both JSI and Save to collaborate on training? If yes, please describe. 3.2 Quality a) What are the mechanisms, tools, and approaches being used to ensure quality of care and adherence to MNCH and reproductive health standards among providers? b) Assess the effectiveness, strengths, and weaknesses of the quality assurance techniques being used. c) What approaches might be adopted and/or enhanced to further pursue the transfer of skills and increase local ownership for quality health services provision? 3.3 Reaching the Underserved a) How do JSI and Save define the ―underserved‖ within the context of Pakistan? b) Based on these definitions, to what extent have the two grantees reached the underserved? What is the evidence? c) To what extent has coverage extended into rural areas? What is the evidence? d) What approaches can be applied to expand outreach to the underserved? 104 FATA REPORT ANNEXES 3.4 Overarching/Other Aspects of Evaluation Evaluators should look for examples where integration was attempted, such as in functional integration of FP and MNCH at district level in Rawalpindi. What worked? What didn’t? What are the recommendations for next steps, future? To what extent were the projects able to involve men in MNCH? What have been the challenges? Benefits? Were the project districts for JSI best suited for the MNCH project? After reviewing the site selection approach, should different criteria be applied in future? Ask of project staff and of provincial government. To what extent are gains in project components sustainable? How can these be enhanced? How should project results be most effectively disseminated? To what extent do beneficiaries and government recognize these projects as USAID? Re: New government MNCH Project, other donor projects (UNFPA, UNICEF) vis-a-vis PAIMAN and Child Health in FATA (from discussions and interviews) – Complementarities – Duplications – Lessons learned that should be disseminated – Quality and extent of collaboration, such as shared curricula, planning – Degree of inclusion of FP What are the policy gaps/issues that were identified during interviews with the government and donors/UN? How are different levels of government (including FATA) enhancing or impeding the success of the projects? (project staff views; government views) What are the likeliest interventions for scaling up efforts that would help Pakistan achieve the MDGs? TASK 4: RECOMMENDATIONS Overall Aim: To document lessons learned and provide discrete management/administrative and technical recommendations for improving overall efficiency and effectiveness in the context of the Ministry of Health’s program. 4.1 Recommendations for Continued or New activities and Program Changes a) Based on current experience and lessons learned, identify essential activities that should be continued or expanded over the life of the projects. b) What changes, if any, should be considered by the Mission to make the MNCH program more responsive in improving access to effective MNCH and reproductive health services? In view of experiences to date under the MNCH, suggest alternate management and administrative models and mechanisms, as deemed appropriate, to ensure overall effectiveness and efficiency. FATA REPORT ANNEXES 105 ANNEX H. MNCH EVALUATION SITE VISITS MNCH EVALUATION SITE VISITS Meetings at Site Project Components to Visit at Site Point of Contact Travel / Date Evaluation Team (with local firm) 1. Rawalpindi, Punjab PAIMAN staff EDO Health Nazim NGOs Lady health workers Community members DHMT Upgraded facilities Support groups Midwifery school Good Life clinics EMNC training Integrated family planning Sanitation/hospital waste pilot LHW training Dr. Shuaib Program and Grants Director 0300 5551233 JSI/PAIMAN Office Islamabad Car: 1 day Date TBD 2. Lahore, Punjab PAIMAN staff DG Health PAIMAN office Midwifery schools PHDC Dr. Nuzhat Rafiq Field Operations Manager Punjab North 0300 5551240 Air / car: 1 day 3. Khanewal, Punjab PAIMAN staff EDO Health Nazim NGOs DHMT Upgraded facilities Midwifery school DHIS Birthing center Good Life clinics EMNC training Dr. Fazal Mehmood Field Operations Manager Punjab South 0302 8506985 Air / car: 2 days 4. Peshawar, NWFP FATA Secretariat EDOs Health￾Buner & Upper Dir Save staff PAIMAN staff Midwifery school; Provincial Health Development Center Mr. Jamal Afridi Program Manager PAIMAN- FATA 0300 9596070 Car: 2 days Local Firm only 5. Sukkur, Sindh PAIMAN staff EDO Health Nazim NGOs Upgraded facilities Good Life clinics Trainings Dr. Iftikhar Mallah Field Operations Manager Sindh 0300 5551238 Air / car: 1 day 6. Lasbella, Balochistan PAIMAN staff EDO Health Nazim NGOs Upgraded facilities Good Life clinics Trainings Birthing center Dr. Syed Mehdi Zaidi Field Operations Manager Balochistan 0300 5551239 Air / car: 2 days 106 FATA REPORT ANNEXES MNCH EVALUATION SITE VISITS Meetings at Site Project Components to Visit at Site Point of Contact Travel / Date Evaluation Team (with local firm) 8. FATA site FATA Secretariat NGOs Save office Agency management team in 2 sites Health facility staff Community members Save sites Child Health Days ENC trainings Resource Center Agency stores PDQ training Check clinic records Dr. Amanullah Khan 0300 858 0720 Car: 2 days FATA REPORT ANNEXES 107 ANNEX I: REFERENCES Save the Children, Household Survey in FATA, March 2008 Save the Children, Improved Child Health in FATA, Annual Progress Report No. 1 October 2006-September 2007 Save the Children, Improved Child Health in FATA, Community Mobilization Strategy for LHWs and Non-LHW Covered Areas Save the Children, Improved Child Health in FATA, Health Facility Assessment, March 2008 Save the Children, Improved Child Health in FATA, Monitoring and Evaluation Plan 2006 Save the Children, Improved Child Health in FATA, PowerPoint presentation, June 12, 2008 Save the Children, Improved Child Health in FATA, Quarterly Report, Jan.-Mar. 2007 Save the Children, Improved Child Health in FATA, Quarterly Report, April-June 2007 Save the Children, Improved Child Health in FATA, Quarterly Report, July-Sept. 2007 Save the Children, Improved Child Health in FATA, Quarterly Report, Oct.-Dec. 2007 Save the Children, Improved Child Health in FATA, Quarterly Report, Jan.-Mar. 2008 Save the Children, Improved Child Health in FATA, Training Strategy 2008 Save the Children, Improved Child Health in FATA, Year One Workplan (06-07) Save the Children, Improved Child Health in FATA, Year Two Workplan (07-08) Save the Children, Self-Assessment Questionnaire Responses for the MNCH Evaluation, April 2008 108 FATA REPORT ANNEXES FATA REPORT ANNEXES 109 ANNEX J: PERSONS CONTACTED ISLAMABAD USAID Anne Aarnes, Mission Director Susan Thollaug, Health and Population Director William Conn, Acting Health and Population Director Maureen Norton, Senior Technical Advisor, Population and Reproductive Health Dr. Muhammad Ahmed Isa, Program Management Specialist, Health Saedar Talat Mahmud Khalid Mahmood Rushna Ravni Cecilia Scull, USAID Peshawar SAVE THE CHILDREN Dr. Amanullah Khan, Deputy Director Dr. Masood Ahmed Abbasi, Senior Manager Health Rukhsana Faiz, Senior Officer, Community Mobilization Sajjad Nayyer, Senior Officer, Community Mobilization MINISTRY OF HEALTH Dr. Asad Hafeed, Director, LHW Program Dr. Fazle Manla, Deputy National Coordinator Dr. Saleem Mali Khan, Technical Advisor MINISTRY OF POPULATION WELFARE Mrs. Mumtaz Esker, Director General UNICEF Ibrahim El-Ziq, Chief of Health and Nutrition WHO Dr. Ahmed Shadoul, Medical Officer, MNCH DFID Dr. Michael O’Dwyer, Health Advisor GTZ Paul Ruckert, Principal Advisor 110 FATA REPORT ANNEXES CIDA Pamela Sequiera, Program Officer ROYAL NORWEGIAN EMBASSY Abdul Aziz Akhtar, Programme Officer JICA Masaharu Maekawa, Project Formulation Advisor Sohail Ahmad, Senior Programme Officer Dr. Ajmal Hamid, Chief Advisor Health PESHAWAR NWFP/FATA MINISTRY OF HEALTH Dr. Muhammad Zaffar, Additional Secretary of Health Dr. Muhammid Zubair Khan, Director, FATA Health Service Pervez Tamal, Director, MNCH FATA Secretariat Mr. Habibullah, Additional Chief Secretary (ACS) Mr. Ghulam Qadir Assistant Chief Secretary Mr. Faheem Alam Agency Political Agent, Khyber Office Mr. Ghulam Habib, Political Agent, Khyber Agency. Community Elders Meeting SAVE THE CHILDREN/PESHAWAR Michael McGrath, Country Director Mr. Fayyaz Ali Khan, Project Director Dr. Saima Abid, Manager, ICH-FATA Dr. Murad Ali Afridi, Manager FR Dr. Khizar hayat, Manager, Training ICH-FATA Afnan Aleem, Manager, Security Dr. Khizat Hayat, Manager, Training Dr. Sanam Gul, Manager, M&E Mumtaz Ahmad Mehsud, Manager, CM FATA REPORT ANNEXES 111 CMDO (NGO) Fazie Mateen, Programme Manager PAIMAN ALUMNI TRUST (NGO) Ayesha Dia-ul-Dam, Regional Coordinator Zarmina Rafeeq, Programme Officer HOSPITAL STAFF Professor Liaqat Ali, Chief of Pediatric Services Professor Nadeem Khawar Gohar Rahman Hayatabad 112 FATA REPORT ANNEXES For more information, please visit http://www.ghtechproject.com/resources/ Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC 20005 Tel: (202) 521-1900 Fax: (202) 521-1901 www.ghtechproject.com