Pakistan’s Approach to and Experiences in Scaling-Up MNCH-FP Best Practices Rashid JoomaM D Director General Health Government of Pakistan

Maternal and childhood disease account for 40 percent of the burden of disease High maternal mortality in Pakistan due to PPH, more than a quarter deaths (PDHS ) High child mortality (94 per 1000 livebirths) High unmet need for contraception (25 percent) Large proportion of unplanned pregnancies end in induced abortion (PDHS ) High proportion of too closely spaced pregnancies Access to FP service through public facilities low Why BPs were selected in 2007?

Pakistan and MDGs Development Indicators2010 (most recent) MDG 2015 Maternal Mortality Ratio ( Rural ) 140 Child Mortality Rate 94 (06-07) 52 Neonatal Mortality 54 (06-07) 25 Skilled Birth Attendance 39 (06-07) 90 Ante Natal Care (4 visits)2890 Contraceptive Prevalence Rate3040

Best Practices Selected for Pakistan Active management of Third Stage of Labor (AMSTL) Healthy timing & spacing of pregnancies Expanding contraceptive method choice Post Abortion Care - FP Involvement of Ulema for MNCH/FP Newborn Resuscitation & Hypothermia Diarrhea- Introduction of Low Osmolarity ORS and Zinc Pneumonia Case Management by LHWs Post-natal care by LHWs

Consensus on Country Action Plan 2007 Country Team’s Follow-up and Advocacy Consensus building efforts at national level catalyzing in Karachi Meeting Partnerships developed – with bilateral and Multi-lateral Projects and espPvt Sector / NGOs Signing of Karachi Declaration (Federal and Provincial Health and Population Welfare) Scaling-Up Process - 1

Changes in Policy, Programmes and Five Year Plans, Strategies, and Implementation Measures Institutionalized for sustainability Political Commitment to move forward Opening up opportunities for civil society organizations Scaling-Up Process - 2

Progress to date

Child Health Prevention & Management of Diarrhea –Inclusion of Low Osmolarity ORS and Zinc by LHWs Program –Almost all LHWs already trained under Community IMNCI –Low osmolarity ORS and Zinc included in facility based IMNCI training module and HCPs trained –PNC Protocol of LHWs revised in the light of UN Joint Statement Post Natal Care (Results) * –30% reduction in neonatal mortality rate in intervention clusters –Skilled attendance at birth increased from 18% to 30%

Prevention & Management of Neonatal Hypothermia –Health care provider trained in EMNC (50 districts) –Almost all LHWs trained ( 60% Coverage of Pakistan) Neonatal Resuscitation –HCPs trained in EMNC on new born resuscitation in 50 districts –Preventive messages on birth asphyxia included in LHW manual –LHWs trained for mouth to mouth resuscitation –CMW curriculum includes hypothermia and resuscitation Prevention & Management of Pneumonia by LHWs –Syp amoxicillin included in LHWs and MNCH Programs Child / Newborn Health

Active management of Third Stage of Labor (AMSTL) Introduced in 34 focus districts across the country Active human resource development to promote AMSTL at national level –Training material –Pre-service Training of CMWs in AMSTL –Training to WMO/LHVs/Nurses in AMSTL and use of Partogram In districts selected for promoting use of AMTSL, facility level use rate has reached to 87%

Post Abortion Care –Training & infection prevention training in PAC/ MVA (in 10 districts) –LHWs and supervisors provided facility based orientation training on post-abortion care, FP counseling and services for post-abortion and postpartum –Active support in training and services by NGOs across many districts –Establishment of PAPAS – a consortium of stakeholders

Mobilizing Religious Leaders for RH/FP TA to the Ministries of Health and Population Welfare to design and support : –Government’s own initiative to address the barrier –Gazette notification of Core Group comprising Muslims, Christian and Hindu religious scholars –A compendium of Quranic injunctions, quotes from Ahadeeth, and decrees (Fatawa) pertaining to FP/RH –Acceptance and endorsement of this material by main religious authorities including Council of Islamic Ideology –Designing a Comprehensive training manual for orientation of RLs on FP/RH initially for Muslim population, and subsequently for other major minorities –Scaling up of RLs program across Pakistan by the Government

Healthy Timing and Spacing of Pregnancies HTSP approach included in new policies Ministry of Health new strategy to Reposition Birth Spacing as Health Approach Increased commodities/ better supply system for LHWs program Capacity building of providers and managers Introduction of newer technologies

Plans for the Future to Scale up Commitment and Road Map for scaling-up Best Practices especially integration of BPs through the Health Delivery System Incorporating birth spacing and FP services under MNCH/ LHW Programs addressing needs of poor women experiencing miscarriage / abortion / PP-FP Operational Plans – Provincial and District level putting BPs into practice Improving supervisory system and quality assurance

Involve civil society organizations to mobilize resources and promote all BPs esp birth spacing services Strengthening monitoring BP implementation Contraceptive Security and LMS Plans for the Future to Scale up - 2

Challenges Scaling up to reach the poorest and youth Ever increasing demand for services Training/ keeping providers, particularly outreach workers, up to date technically Involving health facilities in HTSP Maintaining consistent commodity security Financing –Addressing Resources Constraints Governance/ Monitoring processes –Provincial and District level ownership

Conclusion Government’s strong commitment to achieve MDG 4 and 5 Pakistan’s progress in BPs is on track Pilot test evidence used to scale up Support from private sector encouraging Development partners support is critical