Launched in 2004, this maternal and newborn project is working to reach 12 million people in 10 predominantly rural districts of Pakistan through a variety of approaches and media channels, including training 10,000 lady health workers (LHWs) and partnering with 32 non-governmental organisations (NGOs) at the grass-roots level. PAIMAN is seeking to reach a variety of groups with its messages and activities, including traditional birth attendants (TBAs), medical providers, women of reproductive age, gatekeepers (husbands, family members, and communities); and advocates (government officials, Ulamas (religious leaders), and journalists). Its framework outlines 5 strategic objectives: to increase awareness of and access to maternal and newborn health services, to improve the quality of services, and to increase the capacity of health care managers and providers. PAIMAN is funded by the United States Agency for International Development (USAID) and implemented by John Snow, Inc. (JSI) Research & Training Institute in conjunction with Aga Khan University, Contech International, Greenstar Social Marketing, Johns Hopkins University/Center for Communication Programs (CCP), Pakistan Voluntary Health & Nutrition Association (PAVHNA), The Population Council, and Save the Children USA [United States of America].
PAIMAN's evidence-based communication, advocacy, and mobilisation (CAM) strategy is based on quantitative and qualitative research and a global and in-country literature review. District roadmaps are drawn from the CAM strategy to ensure that activities are appropriate for the cultural context and are implemented on time. Tailored to meet the specific characteristics of each of its intended audience groups, with multiple messages for each, the strategy is described as using a "Pathway to Care and Survival" continuum of care to respond to the needs of mothers and newborns. In essence, the project promotes access to skilled birth attendants (SBAs) as a long-term goal to reduce mortality and assists in positioning community midwives (CMW) as the focal point for obstetric care. The project works at all four levels (community, primary health care facilities, secondary (referral) facilities, and tertiary care facilities) to strengthen local capacity and improve access to quality services.
Activities fall into 5 strategic objectives (SOs):
SO1: Increase awareness and promote positive maternal and neonatal health behaviours.
Key activities include:
- Home visits and small group activities, such as LHW and community health worker (CHW) home visits and support groups, private sector interpersonal communications (IPC), and theatre events:
- LHWs constitute a government-supported network of outreach workers; their coverage in PAIMAN districts is roughly 40%. LHWs are trained for 5 days in behaviour change communication (BCC) methodology so that they might lead support groups as part of their routine work. Community support groups meet every two weeks to give women the opportunity to discuss problems, issues, and solutions to their own health needs. LHWs also conduct home visits, and provide family planning and iron folate and other simple medicines, giving women an opportunity to address concerns they may not want to share publicly.
- Private Sector Outreach: Greenstar has promoted its Good Life private sector clinics through a variety of mass media (TV spots, billboards) and IPC activities). The project also ensures that providers conduct three Clinic Sahoolat days (free service days) to encourage uptake of services by disadvantaged women in their catchment area.
- Theatre: Includes community theatre, implemented at events or health facilities, and Putlee Tamasha (puppet theatre) incorporating maternal and newborn health (MNH) messages into a traditional form of community entertainment.
- Events, both local and mega events, and health camps: PAIMAN provided subgrants to 37 local NGOs to access underserved deep rural communities not currently reached by LHWs. These NGOs implement outreach activities in their communities, ranging from local events and community theatre to creation of approximately 740 CHWs, whose function is the same as the LHWs. PAIMAN events include mass and local events, village fairs, and health fairs or medical camps (e.g., tetanus toxoid (TT) vaccinations, antenatal checkups).
- Mass media initiatives:
- PAIMAN's 13-episode drama series called "Paiman" is being televised on Pakistan Television (PTV-Home) every Sunday at 10:00 pm. Each episode of the drama series is based on real-life issues of mothers and newborns in Pakistan that have been derived from the findings of qualitative research. The scripts of the drama series tackle sensitive issues such as family planning and breastfeeding.
- A 10-episode, district-specific TV talk show focusing on MNH situations was produced for national telecast on ATV. The weekly shows were aired for a period of 3 months beginning March 30 2007.
- Five 20-second television public service advertisements (PSAs), each addressing a key MNH area, were produced.
- PAIMAN's music video about male responsibility in pregnancy and childbirth aims to position pregnancy as a very special stage in the life of a woman. It also highlights the fact that the health and wellbeing of mother and child is a joint responsibility of husband and family members.
- A variety of community-based committees: 1) village health committees (VHCs) - consist of men who agree to help LHWs to spread important MNH messages to other men in the community, particularly if there is a husband who is not supporting his pregnant wife; 2) citizen community boards (CCBs) - government-recognised committees that receive funds from district governments to help them improve local conditions; 3) facility-based health committees (FBCs) - aimed at improving links between communities and the nearest health facility; the goal is for them to become sustainable CCBs that assist communities to better access quality care; 4) quality improvement teams (QITs) - same function as FBCs.
- Advocacy to government officials at all levels, journalists, and religious leaders - A mid-term evaluation (see Source section below) has found that "Of all the advocacy interventions, working with religious leaders to target men with messages during Friday prayers about their responsibility to safeguard pregnant women seems likely to have great impact; it is particularly crucial given the difficulty in reaching this target audience through other activities."
SO2: Increase access to and community involvement in maternal and child health services delivered through health and ancillary health services.
- PAIMAN has developed of a cadre of CMWs; the skills of midwifery tutors have been upgraded and the project has participated in curriculum development. CMWs are placed in district headquarters hospitals and tehsil (administrative division) headquarters hospitals (DHQs and THQs) for their practicum; they are supposed to conduct five deliveries there on their own and five home deliveries. (Evaluators have found that the caseloads in some facilities are not sufficient for the CMWs to achieve these targets.) Also, Greenstar trained 550 female private providers on essential maternal and newborn care (ENMC) using PAIMAN's trainers and curriculum. There was no clinical practicum, and there is no direct observation of skills.
Key community-level activities to increase access to health services:
- NGO activities, such as establishment of birthing centres and medical camps: PAIMAN has helped establish nine birthing centres at basic health units (BHUs) and helped rural communities buy two ambulances for transporting women in obstetrical emergencies. The ambulances attached to two of the birthing centers offer the option of giving birth in a district hospital or being transported to one in case of emergency. The communities are responsible for gas and ambulance maintenance.
- Creation of emergency funds and transportation networks: Throughout all 10 districts, LHWs, CHWs, community committees, and NGOs have worked to establish revolving funds and taxi networks for emergency transportation.
- Provision of 19 ambulances and training of staff in essential surgical skills and basic life support: Across the 10 districts PAIMAN has provided 19 of the 31 upgraded facilities with ambulances and staff trained to handle basic emergencies. Evaluators have found that 7 of the 10 districts have committed to giving priority to obstetric emergencies, though it is unclear how this actually works. Community awareness of the ambulances has been found to be low: they were not mentioned as a potential means of transport in community interviews.
- Training TBAs on clean delivery kits (CDKs) - Nearly 1,900 TBAs have been trained either by Greenstar or local NGOs on danger signs in pregnancy and childbirth, use of CDKs, and referral of emergencies.
SO3: Improve service quality in both the public and private sectors, particularly related to the management of obstetrical complications - PAIMAN activities to enhance the quality of MNC service include minor renovations, advocating for adequate staffing, and equipping 31 MOH facilities. PAIMAN has supported establishment of 13 basic emergency maternal and newborn care (BEmONC) services; some of the comprehensive emergency maternal and newborn care (CEmONC) facilities are not completely operational, largely due to lack of Department of Health (DOH) staff. PAIMAN has focused on the newborn complications surrounding birth in the facility. PAIMAN has bolstered the health management information system (HMIS) by providing registers to track obstetric complications and some training on complication definitions. The referral system is evolving as providers and health facilities become functional, but an evaluation team did not find a clear referral mechanism that can be communicated to women to ensure that they do not waste time going to facilities that cannot meet their needs.
SO4: Increase the capacity of MNCH managers and care providers - PAIMAN has worked to enhance the capacity of the Provincial (PHDC) and District Health Development Centers (DHDC) to conduct EMNC training, including 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. 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 brief sections on active management of the third stage of labour (AMTSL), communication skills, and infection prevention. Training materials and protocols are in English; PAIMAN is currently translating the materials into Urdu. Over a 10-day period, JSI also trained 47 out of a planned 70 providers (obstetricians, paediatricians, and anaesthetists) to deal with obstetric complications that require surgical interventions in addition to BEmONC services. Through a collaboration with the Midwifery Association of Pakistan (MAP), PAIMAN is training 400 female public sector providers on use of the partograph and AMTSL.
SO5: Improve management and integration of services at all levels - PAIMAN helped establish and reinforce district health management teams (DHMTs), provided management training to a broad range of health managers, and worked to improve the quality and utilisation of health information systems. Specifically, PAIMAN conducted trainings for all health managers on strategic planning, logistics management, financial management, human resources (HR) development, and supportive supervision. The training approach, based on experiential learning, incorporated presentations, brainstorming sessions, group exercises, and role-play. The project emphasised improving the quality and use of health information systems, such as DHIS, which has been piloted in 8 districts but which the Ministry of Health (MOH) plans to implement nationwide.
Children, Maternal Health.
According to USAID, Pakistan has some of the highest levels of maternal and newborn mortality in Asia. The maternal mortality rate averages 276 deaths per 100,000 live births. The infant mortality rate is 78 per 1,000 live births, and the newborn rate is 54 per 1,000 live births. The mortality rate for children under 5 is 94 deaths per 1,000 live births. Although Pakistan has an extensive network of public facilities, they only reach about one-third of the country's population. Most women (65%) deliver their babies at home; about 8% are assisted by a skilled birth attendant (SBA). Overall, only 39% of births are delivered by SBAs.
PAIMAN is a consortium that is led by JSI Research & Training Institute which includes: Aga Khan University, Contech International Health Consultants, Greenstar Social Marketing, John Hopkins University Center for Communications Programs (JHU/CCP), Pakistan Voluntary Health & Nutrition Association (PAVHNA), Population Council, Save the Children. Additional collaborating agencies of PAIMAN are: The National Commission on Maternal and Neonatal Health (NCMNH), Mercy Corps.
Mid-Term Evaluation of the USAID/Pakistan Improved Child Health Project in FATA [PDF], by Pinar Senlet, Susan Rae Ross, and Jennifer Peters through the Global Health Technical Assistance Project, September 2008; and PAIMAN website.