1. Assessment of Promoters and Barriers to Effective Health Services for Women and under 5 Children in Communities

2. Study Rationale 2 Baseline for CHN UC Kharak

3. Key Objectives 1.Identify the barriers and promoters for MNCH service availability, utilization accessibility and quality at the community level 2. Identify priority policies and interventions that can most reduce under 5 deaths & closely align with WV Pakistan’s MNCH program. 3.Guide CHN campaign strategy, in relation with WV Pakistan programs. 3

4. Demographic Profile District Population3.58 million Tehsil Muzaffargarh1.35 million Kharak (Rural Union council) 42,355 Estimated pregnancies/month 1524 Target Population in surveyed Households – Female Population51% – Male Population49% – <5 year38% 4

5. Study Methods HHS: 150 were randomly selected having children under 2 years or pregnant at the time of survey HFA: 3 BHUs, RHC and DHQH CCA: LHW, LHV & TBA (5 each) FGD: mothers and fathers (1 each) IDI: LHS and CMWs trainer (1 each) SSI: District and provincial health managers KII: Development partners 5

6. Some key indicators 6

7. Key Findings of our Research

8. Socio-economic Status No literacy (6 to 49 year)50% Primary Education28% Labourer/ daily wager36% (Govt/Private Employee & Private business 4% each while skilled labourer 8%) Main water source (hand pump) 95% Pour flush (with closed drainage) 47% No means of transportation51% (bicycle 23% & motor cycle 27%) Source of Information ( TV )44% 8

9. Socio-economic Status Average Monthly Income – Less than 7000 rupees 41% – 7000 to 10000 rupees 45% Socio-economic Scoring – Average Income (SES score: 15 – 21) 20 % – Low Income (SES score: 8 – 14) 63 % – Very Low Income (SES score: upto 7) 17 % Average Health Expenditure/month – 500 to 999 rupees 57% – 1000 to 2000 rupees 29% 9

10. Healthcare Seeking Behaviour 10

11. Healthcare Seeking Behaviour 11

12. Healthcare Seeking Behaviour 12

13. ANC During Pregnancy 13

14. ANC… 14

15. Delivery & Early Newborn Care 15

16. Delivery & Early Newborn Care 16

17. Safe Delivery Practices Hands washed with soap 72% Use of Clean Delivery Kit – Confirmed The Use 52% – Not Used 28% – Don’t Know 20% Measures taken for Clean Delivery when CDK is not available No. of respondents % Instrument Boiled00% Clean Sheet Used68% New Cord Clump Used11% Ligature for Cord Boiled3244% None of above11% Don’t Know3853% 17

18. Safe Delivery Practices 18

19. Safe Delivery Practices 19

20. Safe Delivery Practices Infants breast feeding after delivery – Immediately after birth 19% – Less than ½ hr 10% – ½ hr to 1 hr 17% – 1hr and 24 hrs 33% Infants who received Colostrum 63% Breast feeding awareness in CBAWs83% PNC-1 follow-up 29% 20

21. Birth spacing Opinion about Birth Spacing  2 years 57%  3 year 26%  more than 3 years 16% 21

22. Child Immunization Awareness among CABWs 90% Awareness about time schedule – One Month After Birth 40% – Immediately After Birth 37% – Minimum Gap Of 40 Days After Birth 14% – Vaccinator’s First Visit After Birth5% – Not Aware4% 22

23. Functional Status of Health Facilities Preventive MNCH & Basic EmONC Category Required Standard BHU Mondka BHU Makwal BHU Dewala RHC Shah Jamal Human Resource MO/WMO/ LHV AANA Equipment Against 7 at BHU & 12 at RHC 5555 Drugs and Supplies Against 2418221120 VaccinesAgainst 54553 FP Commodities Against 44424 Lab Tests Against 5 at BHU & 7 at RHC 3017 23

24. MNCH Service Delivery Preventive MNCH services available at evaluated primary and secondary health care facilities Basic EmONC service delivery was limited to normal deliveries at surveyed primary health care facilities Secondary health care facility (DHQH) was the only facility providing Comprehensive MNCH package 24

25. Management Basics Staff JDs were deficient at most surveyed facilities Service delivery protocols were not seen at any of the surveyed facilities IEC Material deficient at most surveyed facilities 25

26. ANC-1 at 3 BHUs 26

27. Normal Delivery at 3 BHUs 27

28. PNC-1 at Primary Health care Facilities 28

29. Level of satisfaction 29

30. Availability of medicines and lab services 30

31. Community Perspective LHWs and TBAs were recognized as “first approach” health care providers for the community because people preferred to deliver within their community Community recognition, demand for functional public health facility and utilization is existent 31

32. District Health Management System Muzaffargarh

33. Existing Opportunities Health facility infrastructure is well established and well defined Primary health care providers available within the communities Integrated service delivery approach initiatives being implemented CHARM initiative has functionalized 14 BHUs in the district for 24/7 Basic EmONC NMNCHP supporting 24/7 Basic EmONC from 13 RHCs DHQH & 2 THQH providing 24/7 Comprehensive EmONC Most LHWs functioning and Supervisory support is available by LHS 3 rd batch of CMWs rolled out, 4 th will be available for deployment by early 2013, the available strength will reach 137 against 57 at present 33

34. Development Partners & MNCH Initiatives Technical & Logistical Support

35. Intervention Areas Development Partners UNICEF :“newborn and child care at all levels of care” UNFPA: RH, including FP skill development and “establishment of Vesico-Vaginal Fistula (VVF) centres” Save the Children: CMAM in 4 UCs (till July 2012) SYCOP: Preventive MNCH in 6 HFs FPAP: Basic EmONC, Primary health care, in 4 HFs & 3 Model centers 35

36. Policy Areas Development Partners  Major focus is to provide technical support to the government  PLANNING AND DESIGNING PROJECTS  ANNUAL WORK PLANS  TRAININGS OF CARE PROVIDERS  ESTABLISHING INFORMATION  MONITORING  COMMUNICATION SYSTEMS 36

37. Recommendations 1.Community based care-CMWs 2.Referral mechanism 3.Increased awareness about ANC, SBA and PNC etc 4.Enhanced supervision 5.The HR -infrastructure -accessible health facilities 6.Data and information system utilization 7.Missed opportunities for Immunization 8.Local level advocacy 9.Horizontally integrated vertical programmes 37

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