Message from the COP

Pakistan Initiative for Mothers and Newborns (PAIMAN) is a USAID-funded project designed to reduce maternal and neonatal mortality. Operating in 24 districts of the four provinces, AJK and 2 agencies of FATA, it covers a population of 34 million.

Various factors contribute to high maternal and infant mortality which are being addressed in the public sector by the programmes being implemented by the ministries and departments of Health and Population Welfare. Health departments have predominant focus on maternal and child health along with other health matters, certain family planning services are also provided. On the other hand, Population Welfare departments mainly provide full range of family planning services along with some elementary mother care and basic child health treatment. For complicated cases, its clients have to go to a health service outlet of another department at a different location. A client-centred approach would ideally require that all the needs of a client are met under one roof. This being not possible, the best alternative is to devise mechanisms and arrangements by which access of the client for her various needs from different

outlets is facilitated. Functional integration of services seeks to achieve this. Along with the functional integration of services, it is necessary that other associated and supportive activities are carried out cooperatively e.g. utilization of each others' training facilities, supplies of contraceptives and motivational efforts.

Here it needs to be clarified that functional integration neither means merger of one department, or a part thereof, in another department, nor change of the service conditions of the functionaries of either department.

Functional integration of services and inter-departmental coordination for meeting the needs of mothers and children is already taking place to varying extent. Examples are that the Lady Health Workers (LHWs) of the National Programme for Family Planning and Primary Health Care (NPFP&PHC) often accompany the desirous clients to the contraceptive camps of the PWDs and PWD personnel participate in district level events of DOHs such as polio campaigns. At the same time there are many areas where these linkages need to be strengthened or developed. JSI-PAIMAN, as a part of its programme to improve the services relating to mother and child health, plans to make functional integration of services effective and put it on a firm and permanent footing. For this purpose, before covering all the PAIMAN districts, a pilot study was carried out in Rawalpindi district. .

For identification and agreement on the areas of functional integration, a consultative process was followed by involving all the stake-holders including MOH, MOPW, all the four DOHs and PWDs and NGOs. Nine areas, as given below, were agreed for addition/institutionalization/strengthening the functional integration.

1) Monitoring and Supervision Mechanism 2) Contraceptive Supplies

3) Reproductive Health Camps 4) Mobile Service Units

5) Utilization of Male Motivators 6) Training of DOH personnel in FP by PWD/MOH

7) Collaboration in District Level events 8) Exchange of communication material

9) Strengthening the inter-departmental referral system.

The results were encouraging. PAIMAN is now scaling up the intervention to four new districts. Dr. Nabeela Ali

April - June, 2009 - Issue 7

PAIMAN Medical Camp, LasbellaGynecologists and Obstetricians Pakistan) and his team.The first ever PAIMAN Medical and Surgical Camp was held

at the District Head Quarter Hospital, Lasbella from June 15- EDO Health, Lasbella Dr. Abbas Lasi and all district partners 17, 2009. including Mercy

Corps, Green Star During the three day camp, 740 females visited the OPD and and Sub - Grantee received medical treatment with free medicines. NGOs including Furthermore, during this period 18 surgeries were performed, S S D C N a n d which included 6 tubal legations, 8-Utero-vaginal prolepses, SOHB facilitated 2-Abdominal Laprotomies and one Caesarean Section in in organizing the which a baby girl was born. The Caesarean Section was camp."performed by PAIMAN Postgraduate Dr. Asifa Nasir who is

working at DHQ Hospital Uthal, Lasbella. The operations were performed by Dr. Sher Shah Syed (President Society of

CMW's Graduation Ceremony in Balochistan

PAIMAN Succeeds in Institutionalization of DHMT By Providing Legal Cover In Gwadar

of the tutors. The attendance and number of deliveries have

improved in PAIMAN supported Health facilities in Jaffarabad

and Lasbella. A stage theatre was performed on the occasion by

girls form the local Midwifery School. The graduating CMWs The first PAIMAN Community Midwifes graduation took Oath and were awarded the certificates. ceremony from Balochistan was held at Quetta on June 11,

2009. The meeting was chaired by Mr. Qayyum Nazar

Changazi, Secretary Health Government of Balochistan

who praised PAIMAN's positive contribution in the

development of Health sector. Talking about the non

availability of female specialist doctors in many of

Balochistan's districts, Mr. Changazi said that so far only

the Lady health Visitors (LHVs) and Lade Health Workers

(LHWs)were working in the far flung rural areas but now Major challenges have been faced since the establishment of the graduated CMWs will be working in the Midwifery District Health Management Teams (DHMTs') in the PAIMAN Homes of rural areas which will decrease maternal d i s t r i c t s . These inc luded , d i s t r i c t owner sh ip , mortality and will provide Skill Birth attendance to the poor operationalization and regular functioning of DHMTs, which and marginalized population.were overcome with the continuous technical assistance

Seventy seven (77) CMWs belonging to district Jaffarabad provided by experts and by sensitizing higher officials on and Lasbella of Balochistan province studying at Aga Khan regular basis. During this process, it was felt that a mechanism Midwifery School Kharadar/Garden and Public Health may be devised to make this intervention more sustainable so Nursing School, Karachi appeared and passed in the annual that it can function as an independent body. In this regard, examination of Sindh Nursing Examination Board. A PAIMAN took the initiative and proposed to develop a remarkable achievement by these CMWs was that 7 out of legislative cover of DHMTs as a pilot in selected PAIMAN the top 10 positions were obtained by them. districts.

Dr. Nabeela Ali Chief of Party of JSI-PAIMAN at the Five intervention districts were selected for the occasion of the graduation ceremony admired the hard work implementation of this model. It was proposed that the of these CMWs and their teachers. She said that PAIMAN is respective district assembly would pass a resolution for now assisting these CMWs in establishing Midwifery approval of constituting this management team. Approval of Homes in their respective Union Councils. In this regard district assembly would provide a legal cover to already MNCH Program who is a partner in PAIMAN is providing notified DHMT under support of PAIMAN. This legal cover support in strengthening of Midwifery Schools and training would create an ownership of administratively independent

unit, the district, and also

entrusting obligation on the

notified team and its members to

deliver according to the defined

TORs and contribute in the

improvement of health care

delivery to the population.

This resolution was initially

passed by the district assembly of

district Swat and likewise district

assembly Gwadar has also

notified its DHMT through the

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legal cover. The main components of this resolution are the workshop. Participants were oriented in a simple and

interactive way about the sampling, LQAS, decision rule, composition of DHMT and its defined responsibilities like

LQAS table, Questionnaire, data collection and data entry and preparation of plans, approval of development schemes,

annual budget of health departments, monitoring of health finally, regarding interpretation of results. plan implementation. It is expected that in this way the respective DHMTs would Supervision of first batch of CCA trainings in Quetta respond more effectively and efficiently to the challenges of and Sibidecentralization. It would help in realizing the original Population Council supervised the first batch of Client concept of DHMT, as an administrative and multi- Centered Approach (CCA) trainings for Quetta and Sibi disciplinary (non-elected) body for managing all health districts from June 8 to 12, 2009. The trainings were related matters in the district through utilizing available conducted by the district trainers of Health Department of resources. Quetta and Sibi, previously trained by the Population Council

through TOT. The Provincial Secretary Health, DG Health, It is hoped that DHMT would emerge as the most

EDO Health Quetta, Chief of Party, PAIMAN and Director appropriate institutional support for evidence based

P&G JSI|PAIMAN also visited the trainings. collective decision making and streamlining the district

health system. This would also help in ensuring TOT for TBA Trainings

improvement and access of health services to the public and The 2-week long

designing specific programs for improving health of t ra ining of TBA

mothers, newborns and children. trainers (TOT) in

'Client Centered

S a f e D e l i v e r y

Practices' was held

from June 16 to 29,

2009 at Islamabad. LQAS workshop The main objective of The 2-day training workshop on Lot Quality Assurance the TOT was to Sampling (LQAS) Research Methodology, organized by d e v e l o p t h e the Population Council in close collaboration with JSI was participants as a TBA trainer for conducting the district level held from April 29-30, 2009 at Islamabad Hotel. Twenty TBA trainings with motivated spirit. The TOT was attended by

26 participants, belonging to 19 different NGOs/CBOs of 12

districts across Pakistan. These district trainers (LHVs) will in

turn train the TBAs of new PAIMAN districts and will be

supervised by the Population Council.

eight (28) District Health Managers/supervisors including

EDOs (Health), DOHs, Deputy DOHs, District

Coordinators LHW program and HMIS, ADC, MSs of

DHQ/THQ hospitals and District Supervisors Vaccination

(DSV) from Districts Peshawar, Charsadda, Mardan,

Vehari, Multan, Quetta and Sibi participated in the

Training and Supervision

Activities

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For feed back & suggestions please write to: Editor, PAIMAN News RoundupPopulation Council, H # 7, St. 62, F-6/3, Islamabad. Or E-mail: newsletter@paiman.org.pk

CA#391 A-00-05-01037 is funded by the United States Agency for International Development and implemented by JSI Research & Training Institute, lnc.

In conjunction with Aga Khan University, Contech International, Greenstar Social Marketing, Johns Hopkins University / CCP, PAVHNA, The Population Council, Save the Children USA

JSI Research & Training Institute, Inc.

Doctor Saves Mother's and Newborn's lives with skills learnt in a PAIMAN Training

In March 2007, Dr. Saeeda Bibi, a gynecologist, was the second woman doctor to join the district headquarter hospital in Dir Upper district of Pakistan's North-West Frontier Province. To improve her skills, Dr. Saeeda has been trained by the USAID-funded PAIMAN project on comprehensive emergency obstetric and newborn care. “The PAIMAN training is real life training; it has been

practical to me as it allows us to deal with what happens in Before Dr. Saeeda started working at the hospital, the doctors reality” Dr. Saeeda Bibireferred pregnant women experiencing complications to expensive private clinics because there were no doctors at the

Umar Bibi was 37 weeks pregnant when she was brought to hospital able to handle emergency care for mothers and the district headquarter hospital,Upper Dir with a case of newborns. Furthermore, the hospital lacked proper equipment serious shock in March 2009. The pregnant woman's for emergency deliveries. This meant many women's lives general condition was worsening by the minute and her were at risk. Bleeding after child birth can kill a woman in less pulse rate dropped alarmingly. Dr. Saeeda who attended than two hours, for other complications, a woman has between Umar Bibi explained that due to her baby's breech position 6 and 12 hours or more to get life-saving emergency care. and her severe bleeding and a healing jaw injury, it was not safe to use general anesthesia which limited the options for PAIMAN trained and appointed Dr. Saeeda to the district the delivery.” headquarter hospital for managing all maternal and newborn

cases. PAIMAN also provided all the necessary equipment for surgeries, deliveries, infection prevention and sterilization To respond to this medical while ensuring an admission fee of Rs. 10. Now when women emergency, Dr. Saeeda travel up to nine hours to reach the district headquarter hospital, used skills learned in a they will find quality care.PAIMAN training to treat

Umar Bibi and conducted Dr. Saeeda Bibi, now a master trainer for PAIMAN, is an emergency cesarean responsible for building the capacity of other healthcare section. Dr. Saeeda said, providers in her district. She reflects on the success of the “ I n t h i s d e s p e r a t e PAIMAN project in her facility, situation, I also gave her

local anesthesia which I learnt during PAIMAN's “In 2008, I was the only female doctor at the DHQ. I am proud emergency obstetric and neonatal care (EmONC) training.”to say that, even though we have had serious cases, there has been no maternal death since my training. We have proved that

As a result of Dr. Saeeda's skillful handling of the Umar obstetrical deaths are preventable even with minimum Bibi's complications, both mother and her new born baby facilities and fewer resources.” Dr. Saeeda Bibigirl are alive and healthy. Dr. Saeeda was able to discharge them six days later with no further complications. The PAIMAN training is real life training; it has been practical to me as it allows us to deal with what happens in reality.

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Umer Bibi with her new born baby girl