USAID/PAKISTAN: MATERNAL NEWBORN AND CHILD HEALTH ...

USAID/PAKISTAN: MATERNAL 

NEWBORN AND CHILD HEALTH 

PROGRAM 

FINAL EVALUATION 

October 2010 

This publication was produced for review by the United States Agency for International Development. It 

was prepared by Stephen J. Atwood, Judith Fullerton, Nuzhat S. Khan, and Shafat Sharif through the 

Global Health Technical Assistance Project.

USAID/PAKISTAN: MATERNAL, 

NEWBORN AND CHILD HEALTH 

PROGRAM 

FINAL EVALUATION 

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.

This document (Report No. 10-01-394) is available in printed or online versions. Online documents can 

be located in the GH Tech web site library at http://resources.ghtechproject.net/. Documents are also 

made available through the Development Experience Clearing House (http://dec.usaid.gov/). 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

ACKNOWLEDGMENTS 

The final evaluation team would like to acknowledge the assistance of the USAID/Pakistan team, 

particularly Janet Paz-Costillo, Miriam Lutz, and Megan Peterson, in providing support despite the 

difficult time of national crisis. We would also like to thank the entire PAIMAN team for their 

commitment to the project and to this evaluation. We particularly thank the Chief of Party, Dr. Nabila 

Ali. Finally, the consistent support provided by Taylor Napier-Runnels of GH Tech was invaluable and 

appreciated by all team members. 

USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION 

i

ii 

USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION

CONTENTS 

ACRONYMS .................................................................................................................................. v 

EXECUTIVE SUMMARY.............................................................................................................vii 

I. INTRODUCTION ..................................................................................................................... 1 

PURPOSE OF THE EVALUATION .............................................................................................................. 1 

EVALUATION METHODOLOGY AND CONSTRAINTS ................................................................... 1 

II. BACKGROUND ...................................................................................................................... 7 

MATERNAL AND NEWBORN HEALTH IN PAKISTAN ..................................................................... 7 

USAID/PAKISTAN HEALTH SECTOR ASSISTANCE ............................................................................ 8 

ASSISTANCE FROM OTHER DONORS IN MATERNAL AND NEWBORN HEALTH ............ 10 

III. OVERVIEW OF THE PAIMAN PROJECT ........................................................................ 13 

PROGRAM DESIGN AND IMPLEMENTATION ................................................................................... 13 

PAIMAN PROGRAM GOAL ....................................................................................................................... 14 

OBJECTIVES AND OUTCOMES ............................................................................................................... 14 

SCOPE, DURATION, AND FUNDING ................................................................................................... 15 

SELECTION OF DISTRICTS ....................................................................................................................... 16 

BENEFICIARIES ............................................................................................................................................... 16 

IMPLEMENTATION ...................................................................................................................................... 16 

MONITORING AND EVALUATION ....................................................................................................... 17 

RESEARCH ....................................................................................................................................................... 19 

MANAGEMENT AND ORGANIZATIONAL STRUCTURE ............................................................... 21 

RELATIONSHIPS, COORDINATION, AND COLLABORATION .................................................... 25 

IV. TECHNICAL COMPONENTS ........................................................................................... 27 

SO1. INCREASING AWARENESS AND PROMOTING POSITIVE MATERNAL AND 

NEONATAL HEALTH BEHAVIORS ......................................................................................................... 27 

SO2. INCREASING ACCESS TO MATERNAL AND NEWBORN HEALTH SERVICES ............ 31 

SO3. INCREASING QUALITY OF MATERNAL AND NEWBORN CARE SERVICES ............... 37 

SO4. INCREASING CAPACITY OF MATERNAL AND NEWBORN HEALTH CARE 

PROVIDERS ..................................................................................................................................................... 44 

SO 5. IMPROVING MANAGEMENT AND INTEGRATION OF SERVICES AT ALL LEVELS. .. 61 

V. IMPACT OF RECENT POLITICAL DEVELOPMENTS IN PAKISTAN ON MNCH ...... 69 

18 th AMENDMENT .......................................................................................................................................... 69 

LOCAL GOVERNMENT SYSTEM ............................................................................................................... 69 

VI. CONCLUSIONS .................................................................................................................. 71 

VII. RECOMMENDATIONS AND FUTURE DIRECTIONS .................................................. 75 


iii

APPENDICES 

APPENDIX A: SCOPE OF WORK ........................................................................................... 79 

APPENDIX B: PEOPLE CONTACTED ................................................................................... 93 

APPENDIX C: DOCUMENTS REVIEWED ............................................................................. 99 

APPENDIX D: ASSESSMENT TEAM SCHEDULE ............................................................... 101 

APPENDIX E: REFERENCES .................................................................................................. 111 

TABLES 

Table 1: Categories and Numbers of Stakeholders Interviewed by the FET .......................... 5 

Table 2: Population Demographic Indices .................................................................................. 7 

Table 3: Upgraded Facilities ....................................................................................................... 41 

Table 4: Training Conducted ..................................................................................................... 55 

Table 5: CMWs by Province ....................................................................................................... 58 

Table 6: Graduate Pass Rates CMW Programs ...................................................................... 60 

Table 7: Overall Increase in Health Budget ............................................................................. 64 

FIGURES 

Figure 1: Pakistan Maternal and Newborn Health Programs Strategic Framework ........... 13 

Figure 2: Key Maternal Services Original PAIMAN Districts ................................................. 35 

Figure 3: Obstetric Care in Upgraded Health Facilities - Original PAIMAN Districts ........ 42 

Figure 4: Availability of Basic EmONC Services ...................................................................... 42 

Figure 5: Availability of Comprehensive EmONC Services .................................................... 43 

Figure 6: C-sections as a Proportion of All Total Facility Births. ........................................... 43 

Figure 7: Nurses/LHV Active Management of Third Stage of Labor Skills ........................... 57 

iv 


ACRONYM LIST 

AKU 

ANC 

ARI 

AusAid 

BCC 

BEmONN 

BHU 

CAM 

CCB 

CEmONC 

CHW 

CIDA 

C-IMCI 

CMW 

COP 

DAOP 

DfID 

DHIS 

DHQ 

DHMT 

EDO 

EmOC 

EmONC 

EPI 

FATA 

FET 

FGD 

FHC 

FOM 

FP 

GIS 

GOP 

HMIS 

HQ 

IMR 

ICM 

IMNCI 

JHU/CCP 

JICA 

JSI 

KPK 

LHV 

LHW 

MAP 

MDG 

M&E 

MMR 

MNCH 

Aga Khan University 

Antenatal care 

Acute respiratory illness 

Australia Aid 

Behavior change communication 

Basic emergency obstetric and neonatal care 

Basic health unit 

Community advocacy and mobilization 

Citizen Community Board 

Comprehensive emergency obstetric and neonatal care 

Community health worker 

Canadian International Development Agency 

Community integrated management of childhood illness 

Community midwife 

Chief of Party 

District annual operational plan 

The United Kingdom Department for International Development 

District Health Information System 

District Headquarters Hospital 

District Health Management Team 

Executive District Officer 

Emergency Obstetric Care 

Emergency Obstetric and Neonatal Care 

Expanded Program of Immunization 

Federally Administered Tribal Areas 

Final evaluation team 

Focus group discussions 

Facility-based Health Committee 

Field Operations Manager 

Family planning 

Geographic information system 

Government of Pakistan 

Health Management Information System 

Headquarters 

Infant mortality rate 

International Confederation of Midwives 

Integrated management of newborn and child illness 

Johns Hopkins University/Center for Communications Programs 

Japanese International Cooperation Agency 

John Snow International 

Khyber Pakhtunkhwa (district) 

Lady Health Visitor 

Lady Health Worker 

Midwifery Association of Pakistan 

Millennium Development Goal 

Monitoring and evaluation 

Maternal mortality ratio 

Maternal, newborn and child health 


v

MOH 

MOPW 

MTE 

NATPOW 

NEB 

NGO 

NMR 

NPFPPHC 

PAIMAN 

PAVNA 

PDHS 

PIMS 

PNC 

PSLM 

QIT 

RAF 

RHC 

RMOI 

RN 

SBA 

SO 

SOW 

TACMIL 

TB 

TBA 

THQH 

TPM 

TRF 

TT 

UNICEF 

UNFPA 

US 

VHW 

WHO 

Ministry of Health 

Ministry of Population Welfare 

Mid-term Evaluation 

National Trust for Population Welfare 

Nursing Examination Board 

Non-governmental organization 

Neonatal mortality rate 

National Programme for Family Planning and Primary Health Care 

Pakistan Initiative for Mothers and Newborns 

Pakistan Voluntary Health & Nutrition Association 

Pakistan Demographic and Health Survey 

Pakistan Institute of Medical Sciences 

Pakistan Nursing Council 

Pakistan Social and Living Standards Measurement Survey 

Quality Improvement Team 

Research and Advocacy Fund 

Rural Health Center 

Routine monitoring of output indicators 

Registered nurse 

Skilled birth attendant 

Strategic objective 

Scope of work 

Technical Assistance for Capacity-building in Midwifery, Information and 

Logistics 

Tuberculosis 

Traditional birth attendant 

Tehsil Headquarters Hospital 

Team planning meeting 

Technical Resource Facility 

Tetanus toxoid 

United Nations Children’s Fund 

United Nations Population Fund 

United States 

Village health worker 

World Health Organization 

vi 


EXECUTIVE SUMMARY 

INTRODUCTION AND SCOPE OF THE PROJECT 

The Pakistan Initiative for Maternal Newborn and Child Health (PAIMAN) program is a United States 

Agency for International Development (USAID)-funded Cooperative Agreement managed by USAID’s 

Health Office and implemented by John Snow Incorporated (JSI) Research and Training Institute, Inc., in 

partnership with Save the Children-U.S., Aga Khan University, Contech International, Johns Hopkins 

Bloomberg School of Public Health Center for Communications Programs (JHU/CCP), and the 

Population Council. Two additional partners participated in Phase I of the project (October 2004 – 

September 2008): Greenstar Social Marketing, and the Pakistan Voluntary Health & Nutrition 

Association (PAVHNA). Project Phase II lasted two years (2008 – 2010) and included a one-year 

extension of the end date of the project from 30 September 2009 to 30 September 2010, and a no-cost 

extension from 1 October 2010 to 31 December 2010. 

The Life of Project was from 8 October 2004 to 30 September 2010, with an initial funding level of 

US$49,43,858 for work in 10 districts of the country. Various amendments to the original Cooperative 

Agreement expanded activities to an additional 14 districts, including the Federally Administered Tribal 

Areas (FATA) in Kyber and Kurram Agencies, Frontier Regions Peshawar and Kohat, as well as Swat. 

In a letter from USAID dated March 2008, USAID increased the project funding to a US$92,900,064 to 

cover geographic expansion and extended the project to 31 December 2010. The scope of program 

activities was also extended to add activities related to implementing an effective child health delivery 

strategy, which included strengthening child survival interventions through an integrated management of 

newborn and childhood illness (IMNCI) approach, including immunization, nutrition, diarrheal disease 

and acute respiratory infections (ARI) management, and interventions focusing on home- and 

community-based care and education of the mother and family to recognize signs of childhood illness for 

which to seek care. In addition, in the same letter, USAID asked PAIMAN to extend already ongoing 

activities—including the integration of family planning counseling and service delivery with antenatal and 

postnatal visits and community support group activities in those districts where the new USAID Family 

Advancement for Life and Health (FALAH) Project was not in operation—to the 10 to 15 border 

districts selected for expansion. 

BACKGROUND 

Pakistan is the sixth largest country in the world, with an estimated population of over 177 million. The 

country is considered to have achieved a medium level of human development; slightly more than sixty% 

(60.3%) of the population lives on less than $2.00 per day. The country ranks 99 th out of 109 countries 

in the global measure of gender empowerment. 

The maternal mortality ratio (MMR) was cited at 276 per 100,000 births nationwide in 2006-07, with a 

much higher rate in rural areas (e.g., 856 in Balochistan). The Millennium Development Goal (MDG) for 

the country is a reduction of MMR from 550 per 100,000 in 1990 to 140 per 100,000 in 2015. More 

than 65% of women in Pakistan deliver their babies at home. Key determinants of poor maternal health 

include under-nutrition, early marriage and childbearing, and high fertility. The leading causes of maternal 

mortality include obstetric hemorrhage, eclampsia and sepsis. The contraceptive prevalence rate (CPR) 

is 22%. 


vii

The infant mortality rate (IMR) for the country is cited as in the range of 64 to 78 per 1,000 live births. 

Causes of neonatal mortality include pre-term labor (fetal immaturity), intrapartum asphyxia and 

neonatal sepsis. Neonatal deaths account for 69% of all infant mortality and 57% of under-five mortality. 

According to the most recent Pakistan Social & Living Standards Measurement Survey (PSLM 2008-09), 

the vast majority of Pakistan’s citizens (71%) receive health services through the private sector in both 

rural and urban settings. This is a reflection of the low investment the Government of Pakistan (GOP) 

has made in health (only 29.7% of total health expenditures are from the Government) and the high outof-pocket 

expenses (57.9% of all expenditures) [WHO 2008]. Public health care services are provided in 

service delivery settings established under the authority of the Ministry of Health (MOH) (health care 

across the lifespan) and the Ministry of Population Welfare (MOPW) (reproductive health, family 

planning). Although services are provided free of charge in the public sector, informal charges are often 

levied. Service availability is further limited due to understaffing (including a lack of female providers), 

limited hours of service, and material shortages. 

Traditional birth attendants attend 52% of home childbirths in the country. The Government 

acknowledges that this cadre will continue to function for the foreseeable future. 

The private health sector offers primarily curative services, largely on a fee-for-service basis. Private 

maternity facilities offer 24-hour normal and operative delivery services for women and newborns, and 

tend to attract the largest proportion of patients from all socioeconomic groups. This sector has been 

described as loosely organized and largely unregulated. 

PROGRAM DESIGN AND IMPLEMENTATION 

The PAIMAN goal was 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. 

The original ten districts were selected by the GOP in negotiation with PAIMAN and USAID/Pakistan. 

The expansion districts (14) were selected in much the same way, but reflected USAID’s expressed 

interest in extending the full range of PAIMAN activities into 10 to 15 remote and vulnerable districts in 

Balochistan, Khyber Pakhtunkhwa and Azad Jammu and Kashmir, where access to Maternal, Newborn 

and Child Health (MNCH) services was severely limited. 

PAIMAN identified beneficiaries of the program as married couples of reproductive age (15-49) and all 

children less than five years of age. It was estimated that the program would reach an estimated 2.5 

million couples and nearly 350,000 children under one year of age in the first 10 districts, and an 

additional 3.8 million couples and 570,000 children under five years of age in the additional 14 districts. 

The PAIMAN strategy was designed around a strategic framework called Pathway to Care and Survival, 

which incorporated activities to address the interrelated problems that lead to delays in access to and 

receipt of quality maternal and child health services. The program had five strategic objectives. 

PROGRAM BENCHMARKS AND ACCOMPLISHMENTS 

SO1. Increasing Awareness and Promoting Positive Maternal And Neonatal 

Health Behaviors 

PAIMAN’s communication and advocacy strategy, implemented by JHU/CCP and Save the Children, 

approached health information dissemination through the use of Lady Health Workers (LHWs) and 

viii 


community workers, who were responsible for disseminating the messages at the community and 

household levels. Local NGOs implemented these same activities in selected districts. Key activities 

designed to increase awareness and demand for MNCH services included home visits and small group 

activities, such as LHW home visits and support groups, private sector interpersonal communications 

(IPC), theater events and health camps at the community level, mass media initiatives (TV drama, video, 

advertisements, music videos), formation of community-based committees to take local action, and 

advocacy to government officials at all levels, journalists, and religious leaders. 

PAIMAN reached its established benchmarks for beneficiary outreach. Individual events proved to be 

the best approach for reaching residents of community settings, but have likely not reached the number 

of the population that would be sufficient to produce evidence of a behavioral change. There were 

indications from anecdotal remarks gathered during this evaluation that some elements of the Mid-term 

Evaluation comments that ―all events taken together have reached only 2% of the population‖ may have 

held true in some parts of the country, particularly with the rapid expansion into more and more 

difficult-to-reach districts. The endline evaluation 1 revealed that 32.4% of women interviewed had 

watched a TV drama or advertisements about maternal and neonatal health. One staff member 

interviewed felt that it would have been better to increase coverage in the original ten districts rather 

than expand into the larger number ―with just about the same amount of money.‖ 

In fairness to PAIMAN, however, an impact evaluation of the mass media component was beyond the 

scope and the mandate of this evaluation and was not a part of the project design. Still, future programs 

might want to consider comments by some rural women suggesting that the mass media material was 

more suitable for an urban audience and had little application to or impact on their lives. Interventions 

that demonstrated the most promise for success included the outreach via LHWs and other means of 

interpersonal communication. This was in keeping with the mid-term recommendation to ―focus on the 

interventions with more reach or scaling one or two of them up significantly for greater impact,‖ such as 

the LHW and Community Health Worker (CHW) events, puppet theater, and the activities with the 

Ulamas. 

SO2. Increasing Access to Maternal and Newborn Health Services 

PAIMAN worked to involve private sector providers in the provision of maternal and newborn services 

through training in best practices provided by the collaborating partner, Greenstar. Activities conducted 

at the community level were intended to reduce the cultural and attitudinal barriers to health care for 

women through greater community involvement in MNCH promotion, and some limited activities 

related to advocacy for and community-based education about healthy timing and spacing of pregnancies. 

PAIMAN achieved its stated benchmarks for a number of pragmatic activities, including training of 

traditional birth attendants (TBAs) and promotion of emergency transport mechanisms (private and 

public ambulance services). The promotion of public-private partnerships included a pilot test of the use 

of voucher systems for payment for services. Challenges encountered in tracking data from private 

practitioners limited the ability to assess the utility of this strategy. 

SO3. Increasing Quality of Maternal and Newborn Care Services 

To enable the provision of basic and emergency obstetric and neonatal care, upgrades were made to the 

facility infrastructure in selected government health facilities. Public and private providers received 

training to deliver client-focused services, with an emphasis on standardized procedures, infection 

prevention and the strengthening of referral systems. Infrastructure upgrades contributed substantially 

1 The Final Evaluation Team (FET) only saw a .pdf file of a 20-slide PowerPoint presentation without notes of this evaluation and 

were not present for the presentation. It was not clear which districts were covered in this evaluation; data showed a 

comparison between the baseline and endline suggesting that the original ten districts were covered in each. 


ix

to enabling the provision of 24/7 basic and comprehensive emergency obstetric and neonatal care in 

each of PAIMAN’s original districts. Training providers to perform the signal functions of emergency 

obstetric and neonatal care (EmONC) was an essential corollary, and PAIMAN achieved each of its 

stated benchmarks for this activity. However, staff shortages and transfers have limited the ability to 

sustain this level of service provision and have muted the impact of the intervention. 

SO4. Increasing Capacity of Maternal and Newborn Health Care Providers 

PAIMAN undertook an ambitious training agenda to develop the capacity of MNCH providers for 

provision of basic and comprehensive emergency obstetric and neonatal care. PAIMAN addressed the 

training needs of all health service providers at all levels of care, from home through community-based 

services to referral services provided at tertiary-level facilities. PAIMAN also contributed substantially to 

the MOH strategy for training a cadre of Community Midwives (CMWs) to serve as private practice 

providers in their communities. Although PAIMAN met its training targets in terms of absolute numbers, 

follow-on assessments were limited in their scope; therefore, the extent to which trained participants 

retained new knowledge over the longer-term and the degree to which they were able to transfer new 

learning into daily clinical practice are uncertain. PAIMAN invested substantial funds in an effort to 

create training opportunities for the 2,354 CMWs for which it accepted responsibility (a portion of the 

MOH target of 12,000). 

Future efforts related to the CMW strategy should be reconsidered. The academic and clinical training 

efforts encountered substantial obstacles that greatly limited the quality of learning. PAIMAN worked 

with the Midwifery Association of Pakistan and also with a concurrent USAID-funded project (TACMIL) 

to introduce quality assurance strategies into the training and succeeded in the effort to improve clinical 

access opportunities at district levels by extending the length of training for some student cohorts. 

Nevertheless, a substantial number of the graduates failed to meet the objective standards (examination 

and registration) established by the regulatory authorities, and many graduates have not initiated a 

clinical practice. 

SO5. Improving management and integration of services at all levels. 

Interventions were designed to increase the capacity of district-level health administrators working in a 

decentralized environment. Training was provided in various topics related to health planning. A District 

Health Information System was developed, and users were trained in a variety of assessment and 

benchmarking exercises for monitoring and evaluation. PAIMAN met its training targets; however, the 

sustainability of essentially all capacity-building efforts is questionable because of frequent staff turnover 

and the lack of consistency in budget allocations to health. 

TRENDS IN IMPROVEMENTS IN MNCH INDICATORS 

Baseline and endline population and facility-based surveys provide some evidence of improvement in 

MNCH indictors that can be indirectly attributed to PAIMAN interventions. 

Key obstetric services provided in upgraded facilities over the period 2007 through 2009 included an 

increase in facility births of 33%. The proportion of women with obstetric complications admitted to the 

facilities increased by 74%, with a 40% increase in the performance of Caesarean sections in these 

upgraded facilities. Increases in Caesarean section rates must always be analyzed carefully; however, the 

fact that these upgraded facilities were referral centers for patients experiencing complications requiring 

surgical interventions can (i) account for the higher than the norm accepted on a population basis (i.e., 

WHO recommends 10-15% in the total population), and (ii) serve as a proxy indicator for improved 

referral services in the project. 

x 


Data from the endline household survey indicates that skilled birth attendance had increased from 41.3% 

to 52.2% and that the proportion of normal vaginal deliveries taking place in the home had decreased 

from 63% to 52%. Basic EmOC services were available in all the District Headquarters Hospitals 

(DHQs) at both baseline and endline. The proportion of Tehsil Headquarters Hospitals (THQs) in which 

these services were available improved from 38% to 100% and the proportion in rural health centers 

(RHCs) from 23% to 95%. Provision of comprehensive EmOC services increased from 75% to 100% in 

DHQ facilities and from 33% to 48% in THQs. However, newborns continued to be less well served 

than mothers in all DHQ and THQ facilities. Comprehensive emergency neonatal care (EmNC), 

although increased from baseline, was available in only 89% of DHQ and in 40% of THQ facilities. 

PAIMAN’s monitoring and evaluation (M&E) plan did not track indicators related to healthy timing and 

spacing of pregnancy in the original or expanded program. The M&E plan revised for Phase II did include 

a number of process indicators related to distribution of contraceptive commodities, but no indicator 

that could effectively track the impact of these activities. The assessment and attribution of 

improvement in MNCH indicators is limited because a between-districts comparison was not designed 

as a measurement strategy within the M&E plan. 

OUTPUTS, OUTCOMES AND IMPACT OF THE PAIMAN PROGRAM 

PAIMAN was recognized to be an administratively complex project that used very basic, time-tested 

approaches to increasing quality and capacity within the health system and its providers. A major portion 

of the project budget was invested in infrastructure development though there was evidence from field 

observations and from other development projects that this may be a difficult component of the project 

to sustain because of budget volatility within the MOH, the changes in priorities that occur with natural 

disasters and political change, and a general lack of ownership for the facilities. Community-oriented 

inputs were less expensive and likely more sustainable. Having said this, efforts by PAIMAN to develop 

both community and facility systems and structures are strategically sound, as both are necessary in 

cases of obstetric emergencies and for women in the community who need facility-based support and 

find it lacking and will die or, at the very least, drop out of the system. It may be that the speed and size 

of the transfers of funds and facilities need to be modulated along with careful incentives to motivate 

local governments to sustain these changes. 

PAIMAN approached communication and mobilization strategies through women’s and men’s support 

groups, training of health care workers, development and dissemination of communication media, 

linkages with information systems, and use of local non-governmental organizations (NGOs) for 

dissemination. PAIMAN made attempts to orient and adapt some of its general approaches to more 

specific audiences through the use of community-based organizations where LHWs were not operating, 

through its approach to religious leaders in conservative areas where men were otherwise difficult to 

reach, and, in less conservative areas, through traditional communication forms (e.g., puppet shows, folk 

media, and street theater). Two drawbacks in the approach observed by the FET were the lack of 

publicly visible materials in health centers and hospitals, and the language limitation of the materials 

produced, which did not seem to match the linguistic diversity in the country. Feedback from 

community members and some officials did not always confirm the local applicability of all 

communication materials. Requests were made to the FET for more participation by community 

members in material design. 

The women’s support groups served a social and an educational purpose as it gave women a chance to 

meet outside the home. Given the support plus a regular infusion of information, many of these groups 

could continue indefinitely because they answer women's needs to be and work together. Anything that 

can be done to enhance participation of support groups (e.g., revolving funds, microfinance) should be 

implemented by the MNCH. Much more work should be done to enhance the public-private partnership 

to expand access to health services, with a particular emphasis on the rural provider network. The 


xi

CMW program was well-intentioned, but was designed by the MOH and the Pakistan Nursing Council 

(as described in PC-1) and implemented by MOH and partners (including PAIMAN) well ahead of quality 

considerations. Substantial time, money and effort have been expended, but neither the public nor the 

individual CMWs have been well served in terms of the intention to provide skilled birth attendants for 

the community. The content of the academic and clinical training does not meet international standards, 

and many students do not have access to sufficient clinical experience to acquire or demonstrate clinical 

competencies. The regulatory system has not been fully developed; as a result, many program graduates 

do not yet have access to the examination and registration process. This program needs to be 

refashioned according to established quality standards. The United Kingdom Department of 

International Development (DfID) recently conducted an extensive review of this overall program 

(including the PAIMAN contribution) and offers recommendations for action. 

MAJOR CONSTRAINTS TO PROGRAM COVERAGE AND ACCESS 

PAIMAN operated during a period of great political and financial instability in the country, further 

compounded by the occurrence of three natural disasters affecting at least some of the original and 

expansion districts. PAIMAN relied on the services of local NGOs to implement its programming in 

areas of hostile insurgency. The substantial demographic, cultural and linguistic variance in the 24 

districts required that PAIMAN attend to the suitability of interventions for the intended beneficiary 

populations. Additionally, the passage of the 18 th amendment to the country’s constitution, while only 

now being implemented, nevertheless changed the thinking about strategies for strengthening districtlevel 

health systems that would be sustainable under new administrative lines of authority. 

FUTURE STRATEGIES 

PAIMAN should not be continued in its present form. It has served its purpose. The GOP should 

address future efforts for continuity and scale-up of the successful PAIMAN interventions by first 

investing in a critical causal analysis to find the factors that can be changed to prevent perinatal mortality 

at the community level. These factors will be socio-economic and based in equity (particularly gender), 

and will be related to disparities in health and nutrition. The GOP should widen the scope of 

interventions to include the reproductive health of youth, including healthy timing and spacing of 

pregnancies, delay of age at first marriage, and the special needs of the primagravida woman, who must 

be viewed differently by her family and in-laws. The focus on increasing skilled attendance for delivery at 

both community and facility levels has been proven to be an important strategy for reducing both 

maternal and neonatal mortality. The idea of ―midwife in community‖ is an ideal approach. However, the 

current approach to training the CMWs is fundamentally flawed in terms of educational quality and 

opportunities for supervised hands-on clinical training by the trainees, and by the lack of follow-up and 

supportive supervision in the community (as is explained in greater detail in this report) and must be 

deliberated to improve its quality before any positive impact could be anticipated. 

GENERAL RECOMMENDATIONS 

Exit Strategy and Future Directions 

1. Extend funding for technical assistance and monitoring of MNCH interventions (particularly in the 

14 expansion districts) for at least two years to transition from project to government ownership 

and to strengthen and consolidate PAIMAN Project inputs. The FET recommends supplementing 

internal technical resources with international experts who could continue to assist in the design, 

implementation and monitoring of the Clinical Nurse Midwife program. 

2. Support phased graduation of districts out of the technical support system according to a check-list 

of evidence-based capabilities. 

xii 


3. Increase program and project spending on interventions at the community level (e.g., community 

support groups, community NGOs) that lead to sustainable outcomes. 

4. Establish a rigorous joint monitoring team, including province, district and local officials along with 

staff of the MNCH, to sustain improvements and maintenance of the infrastructure development 

projects funded by PAIMAN and to identify future projects. A monitoring system of this nature 

would make infrastructure development more attractive to the GOP and to other donors. 

5. Focus in-service training of community health workers on community integrated management of 

childhood illness (C-IMCI) since impact on beneficiaries at the community level is greater. Continue 

the process of integrating the IMCI curriculum into pre-service training (e.g., medical and nursing 

schools.) 

Missing Elements for Consideration in Future MNCH Programs 

6. Increase the emphasis on reduction of low birth weight as an intervention to benefit both mothers 

and newborns (the present rate is 31%). 

7. In subsequent projects, introduce a new emphasis on premarital youth or at least increase the focus 

on the primagravida/newlywed. 

8. Introduce nutritional supplements to primagravida women with low body mass index. 

9. Introduce multi-micronutrient sprinkles to all primagravida women, or at least iron/folate to all 

women 19 to 25 years of age, given that the prevalence of micronutrient deficiency is so high in the 

communities served. 

10. Support development and finalization of the National Nutrition Strategy and incorporate it into 

MNCH. 

11. Encourage and fund research and evaluation of all key MNCH programs and interventions (including 

the communication and advocacy component), and use a comparison group design wherever 

possible in order to increase the possible attribution of effect. 

RECOMMENDATION SPECIFIC TO THE STRATEGIC OBJECTIVES 

SO1. Increasing Awareness and Promoting Positive Maternal and Neonatal Health 

Behaviors 

12. Sustain women’s support groups and increase membership to include young girls and young women. 

13. Consider expanding community-level consultations for the development of new communication 

material (including formats) and for establishing monitoring of their reach, appropriateness and 

utility. Local development and even production would allow greater sensitivity to the demographic, 

ethnic and linguistic profile of the communities in which they will be used. The detailed formative 

research 2 done by PAIMAN for the first phase was useful in developing messages and content. It 

could be more useful if it were linked to local materials and media development as well. 

14. Do formative research in all districts preceding communication and media interventions as each 

poses different problems of beliefs and practices. 

15. Mass media approaches can be effective in creating behavior change but are not invariably so. 

Evaluate the impact on behavior change of various communication and media strategy mixes and 

materials to identify those which have the greatest cost effectiveness in the Pakistan country 

context. 

2 Formative research done for the first 10 districts was not available to the FET for the districts of the second expansion phase. 


xiii


16. Explore a variety of options for increasing the proportion of private sector partners in the delivery 

of maternal and newborn health services, with particular outreach to providers who reside in rural 

and hard-to-reach areas. These options could include variations of voucher schemes or other public 

insurance mechanisms. 

17. Continue the emphasis in future TBA training on topics that evidence has demonstrated are useful 

and appropriate in the context of their practice, including but not limited to recognition of danger 

signs, referral, clean delivery, and the elements of essential newborn care. Promote and enhance 

partnerships between TBAs and the public and private health providers and systems to increase the 

degree to which referrals between the community and facility settings are encouraged. 

18. Establish appropriate budget and accountability policies and mechanisms to ensure that ambulance 

vehicles that have been transferred to District Health Departments and that are operated by the 

local community at the health facility level continue to be equipped and immediately available for 

emergency transport purposes. 

19. Establish and/or confirm budget and accountability policies and mechanisms that allocate and reserve 

a fixed portion of the health services budget directed to facility and equipment maintenance and 

enhancement, not subject to re-allocation to other purposes. 


20. Design and implement a quality assessment (QA) process to verify the retention of learning as an 

essential component of all training programs. Integrate this QA process into a longer-term 

continuous quality improvement (CQI) initiative. Ensure that both QA and CQI strategies include 

documentation of skills as applied in the workplace. 

21. Design and implement a continuing education program integrated and coordinated with other 

MNCH and national health programs to reinforce and update the skills and knowledge of 

community-level health workers. 

22. Continue a focus on training in infection prevention for all health providers, in all health facilities, 

including content on proper disposal of medical waste, as appropriate for the health care setting. 

23. Identify and enhance the education of LHWs, CMWs, and LHVs on perinatal care to include 

additional supportive strategies to prevent maternal deaths: 

 

 

 

Reduction of anemia 

Reduction of malaria in pregnancy, screening for TB/UTI/STD, etc. 

Family planning for healthy timing and spacing of pregnancies 


24. Suspend admissions to the NMCH CMW program for a period of up to two years. During that 

time, refocus the program so that it is in full alignment and compliance with current international 

standards for direct-entry (community) midwife programs. 

25. Educate a robust body of midwifery educators, well skilled in both teaching and midwifery clinical 

skills, and ensure their placement in each school of CMW education, preferably before additional 

enrollments are authorized. 

26. Create a separate regulatory body for all categories of midwives educated in the country (e.g., a 

Pakistan Midwifery Council), with authority and leadership vested in midwives, rather than in 

professionals of other disciplines. 

27. Design and test feasible models for supervision of the community midwife in practice, preferably in 

alignment with existing public-sector supervision strategies, with supervision provided by individuals 

qualified to provide clinical and technical guidance and support in the functional role of midwives. 

xiv 


28. Promote strong collaborative linkages with colleges and universities involved in the education of 

midwives to craft an education career ladder for midwifery professionals. 

29. Define the role and responsibilities of the office staff of the Executive District Officer (EDO) Health 

and MNCH program at the district level for the CMW cadre to increase accountability and to 

strengthen this private-public partnership. 

30. Define a method for including CMW statistical data into the District Health Information System 

(DHIS) so that a true picture of community-based maternal and neonatal morbidity and mortality 

can emerge (see SO5 #32, below). 

SO5. Improving Management and Integration of Services at All Levels 

31. Extend the decision space analysis to the MNCH program by training local researchers in its use. 

Use the results to identify the specific weaknesses in the health system in each district or tehsil, and 

design training and other interventions that are aligned with those particular weaknesses. 

32. Discuss with the Japanese International Cooperation Agency (JICA) the update of some of the 

indicators in the next iteration of the DHIS; one in particular—antenatal care (ANC) 1 coverage— 

would be meaningful if it reflected the WHO standard of four visits. The FET recognizes that a new 

indicator will not have a precursor for comparison. Nevertheless, continuing to collect data on an 

indicator that has little meaning is a waste of time and money. 

33. Challenge each District Health Management Team (DHMT) to develop ways to integrate NGO data 

into their system, possibly by inviting local NGOs to participate quarterly in the DHMT meetings 

and report on findings in remote areas. The same might be considered for private sector data 

(including CMWs). 

34. Use the experience of PAIMAN MNCH to examine interventions that would facilitate the process 

of integration of the MOH and the Ministry of Public Welfare (MOPW): joint training, joint M&E 

tools and indicators, application of decision space analysis broadened to encompass both ministries 

at the Provincial level, etc. 

35. Sponsor a study of system streamlining at the community level that would improve the efficiency of 

all vertical programs by identifying areas of synergy and collaboration in order to reduce resource 

demands. 

36. Encourage (or require) all MNCH-sponsored programs that operate concurrently to work 

collaboratively in the design of all program elements ( e.g., BCC and training materials) in the 

interest of avoiding duplication of effort and promoting harmonization of approaches. Encourage this 

same approach to be adopted by all international donors who contribute to the MNCH program 

portfolio. This includes the conduct of population baseline studies within provinces and districts. 


xv

xvi 


I. INTRODUCTION 

PURPOSE OF THE EVALUATION 

The purpose of this evaluation is to provide the United States Agency for International Development’s 

Mission to Pakistan (USAID/Pakistan) with an independent end-of-project evaluation of its Maternal 

Newborn and Child Health (MNCH) program. The MNCH program has been managed by USAID’s 

Health Office and implemented under a Cooperative Agreement by John Snow International (JSI) 

Research and Training Institute, Inc., in partnership with Save the Children-U.S., Aga Khan University, 

Contech International, Greenstar Social Marketing, Johns Hopkins Bloomberg School of Public Health 

Center for Communications Programs (JHU/CCP), Population Council, and the Pakistan Voluntary 

Health & Nutrition Association (PAVHNA). 

The Final Evaluation was commissioned to assess the effectiveness of the program components and, 

where possible, the resulting impact on morbidity and mortality. The Final Evaluation Team (FET) 

understood its role to document lessons learned, identify areas where the Government of Pakistan 

(GOP) could provide continuity in services and scale up those services, and make recommendations to 

both USAID and the Pakistan Initiative for Mothers and Newborns (PAIMAN) (and indirectly to the 

GOP) regarding elements of the project that were in need of strengthening prior to being scaled up. 

The objectives of the evaluation assigned to and expanded by the FET are to: 

1. Assess whether the MNCH program has achieved the intended goals, objectives, and outcomes as 

described in the Cooperative Agreement and its amendments and work plans; 

2. Evaluate the effectiveness of key technical inputs and approaches of the MNCH program in 

improving the health status of mothers, newborns, and children compared to baseline and midterm 

health indicators where available; 

3. Explore the impact of PAIMAN’s technical approach on maternal, neonatal, and child morbidity and 

mortality in at least the 10 districts originally covered by the project, as much as possible with the 

current available data; and 

4. Review the findings, conclusions, and recommendations, and provide brief suggestions and/or 

options for ways in which project components might be strengthened or continued and scaled up 

by the GOP’s health entities (Ministry of Health [MOH], Ministry of Population Welfare [MOPW], 

provincial and district counterparts). 

Findings and recommendations will be used to ensure that USAID’s MNCH program serves the overall 

objective of improving MNCH in Pakistan in the most effective way. 

EVALUATION METHODOLOGY AND CONSTRAINTS 

The evaluation was conducted in August and September 2010. The FET was composed of Stephen 

Atwood, Team Leader; Judith Fullerton, Maternal Health Specialist; Nuzhat Samad Khan, 

BCC/Community Mobilization Specialist; and Shafat Sharif, Field Specialist and Logistics. The latter is the 

Director of Eycon, a local firm hired to provide administrative and logistics support and to conduct 

interviews in areas of the country that could not be reached by the international members of the FET. 

The team used a variety of methods and materials to gather information and assess the effectiveness of 

the PAIMAN Project. 

Team Planning Meeting 

During an initial two-day team planning meeting (TPM), the FET (1) reviewed the Scope of Work 

(SOW) to clarify the objectives and tasks essential to the evaluation, (2) identified and prioritized key 

USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION 1

informants for interviews according to their involvement in the PAIMAN Project, (3) developed semistructured 

interview guides with evaluation questions suitable for each category of key informants from 

National Government partners to the community, (4) developed a calendar and timeline for completion 

of tasks and deliverables, and (5) drafted an outline for the final report, with sections assigned to 

different members of the team. A travel plan for field visits was developed in conjunction with the team 

member from Eycon, who arranged logistics and scheduled appointments for these visits, a process that 

continued throughout the evaluation period. The FET joined with the USAID/Pakistan team in a 

videoconference with GH Tech at the end of the TPM to review plans and materials. 

Review of Background Documents 

With the support of the PAIMAN partners, the local USAID mission, and GH Tech (who opened a 

project space site for the dissemination of the materials), the FET was able to identify and review an 

extensive list of briefing documents, many of which were provided in the week before the arrival of the 

team in Pakistan. At the request of the FET, the organization and prioritization of this list was done by 

the USAID mission in conjunction with PAIMAN in order to focus the limited time of the FET for this 

activity. Documents were constantly added to the list, some of them used for background and baseline, 

others for assessment of achievements (Appendix C: Documents Reviewed). 

Data Gathering 

Data were gathered using various methods from a number of different sources. The methods included 

document and media review, interviews and in-depth discussions, site visits and observation, focus group 

discussions, and informal group discussions. The data collected by the FET were both qualitative and 

quantitative. All quantitative data were secondary; qualitative data were both primary and secondary. 

Quantitative Data 

Among the sources of quantitative data were the individual 2005 baseline surveys of PAIMAN districts, 

2008 baseline surveys from other projects (e.g., Family Advancement for Life and Health [FALAH]), 

PAIMAN Mid-term Evaluation, the Mid-term Evaluation of the Improved Child Health Project in 

Federally Administered Tribal Areas (FATA), and the PAIMAN District Health System Strengthening 

Endline Evaluation. Data were also available from the national, province, and district Health Information 

System (DHIS) cells and from other partners. Recent data were used from the 2006-07 Pakistan 

Demographic Health Survey, the 2008 Multi-Indicator Cluster Survey 2007-08, the Pakistan Social & 

Living Standards Measurement Survey (PSLM) 2006-07, 2008-09, and individual district level reports 

prepared by the DHIS cells. There were three endline evaluations shared by PAIMAN: Endline analysis of 

decision space, institutional capacities and accountability in PAIMAN districts (in draft) by researchers from the 

Harvard School of Public Health and Contech International with a publication (2010), the District Health 

System Strengthening – Endline Evaluation completed in 2010 by Contech International and published by 

JSI, and a PowerPoint presentation of preliminary findings from the Population Council’s PAIMAN 

Evaluation: Baseline 2005 & Endline 2010 Household Survey (the evaluation document was yet to be 

finalized). These documents, supplemented by other data sources, including operational research results 

commissioned by the project and a series of baseline surveys done in each of the original ten PAIMAN 

districts, formed the significant sources of quantitative data. 

Qualitative Data (both primary and secondary) 

The major sources of primary data were derived from the key informant and group interviews, including 

Focus Group Discussions (FGDs) at the community level and interviews with local nongovernmental 

organizations (NGOs) for information on the community events within the PAIMAN districts and for 

feedback on the media campaign in both PAIMAN and non-PAIMAN districts. Qualitative responses 

2 USAID/PAKISTAN: MATERNAL, NEWBORN AND CHILD HEALTH PROGRAM FINAL EVALUATION

were quantified in the baseline KPC surveys done in the original ten PAIMAN districts and in the Process 

Evaluation of Community Mobilization Activities carried out by The Population Council. In addition, many of 

the quantitative sources mentioned above included qualitative data, some of it quantified during analysis. 

Comparison Districts 

In addition to measuring changes in Maternal, Neonatal and Child Health (MNCH) status in the PAIMAN 

districts from the onset of the project until its conclusion, the FET identified a number of comparison 

districts in order to compare the results with non-PAIMAN districts. This was done as a last-minute 

attempt to correct a gap in the evaluation design as there was, otherwise, no clear way to attribute 

causality to PAIMAN interventions for measured changes. A matrix was developed of all districts in the 

provinces of the country using a triangulation method developed by Chambers (Chambers, R., 2008). 

Three independent observers, each with longstanding knowledge of the country, were asked to identify 

districts that could be used for comparison—preferably drawn from the same division as the PAIMAN 

district in question. They were asked to use any criteria they found useful for comparison. On the basis 

of this triangulation, 19 districts were chosen. Basic MNCH indicators used to measure progress in 

PAIMAN districts were then compared from both groups of districts to see if there was a measurable 

difference between PAIMAN and non-PAIMAN districts. 

Site Visits 

The evaluation team, facilitated by interpreters provided by Eycon and PAIMAN, traveled to districts 

identified by PAIMAN in conjunction with USAID/Pakistan. In all, the FET visited four of the original ten 

PAIMAN districts (i.e., Rawalpindi, Jhelum, Khanewal, and Multan), all in Punjab Province. To expand the 

review, they intended to visit one district from the expansion phase of PAIMAN (i.e., Mardan) in Khyber 

Pakhtunkhwa (KPK) province, but a volatile security situation prevented that visit. Eycon was able to 

send staff to two less accessible districts (i.e., Buner and Lasbela), one in KPK and the other in 

Balochistan. Finally, the team made an impromptu trip to two non-PAIMAN facilities in the vicinity of 

Islamabad: the Rural Health Center (RHC) Bhara Khu in Islamabad Rural and the Basic Health Unit 

(BHU) Tret in Tehsil Murree, District Rawalpindi. They also visited available officials (e.g., MNCH, DHIS) 

and key institutions, including nursing and medical schools, (e.g., National Programme for Family Planning 

and Primary Health Care [NPFPPHC]) in Lahore and Multan. The site visits to Rawalpindi, Jhelum, 

Islamabad Rural, and Tehsil Murree were each one-day visits. The visit to Khanewal and Multan via 

Lahore was made in a four-day trip. 

The basic pattern of each site visit was to: 

 

 

 

 

 

Meet with the Executive District Officer (EDO) Health with his team; 

Tour a renovated facility (i.e., District Headquarters Hospital [DHQ] or Tehsil Headquarters [THQ] 

hospital) and a nursing/midwifery school; 

Visit a local NGO sub-contracted to the project; 

Sit in on a community women’s support group; and 

Visit a CMW in her home and/or birthing center. 

Key informants were interviewed using the semi-structured interview guides developed by the FET. The 

pattern of these visits was augmented by focus group discussions with community members organized 

by PAIMAN and run by Eycon staff to assess the access and acceptability of services provided through 

PAIMAN support to the government, by planned discussions with clients of the CMW as well as with 

men and other members of the community. The routine—well prepared and well organized by PAIMAN 

staff in each instance and taking into consideration both programmatic and security requirements— 

tended to lose spontaneity and precluded the FET from making impromptu visits to communities and 


other institutions that were not on the itinerary. The FET was not able to observe a men’s community 

group, although the Eycon team met with a group of men gathered for the purpose of discussion. 

Throughout, observations were made and noted of the environment for both health care providers and 

patients/clients, and the community as a whole: solid waste disposal (particularly of needles and syringes) 

by the CMWs, working conditions, and hygiene in local neighborhoods. 

To cover as much ground as possible in the short time spent in each district and because several 

interviews were scheduled for each day, the FET formed two teams in some instances to visit a number 

of facilities, coming together for the CMW visit. Most interviews were carried out in English. Where 

interpretation was needed, it was provided by Eycon or PAIMAN. 

The focus group discussions held by Eycon in the districts it visited were conducted by women trained 

by Eycon, using an interview guide developed by the FET and translated into Urdu for greater 

understanding by both the group facilitators and respondents. To guarantee that the discussion could be 

noted by one of the facilitators at all times, two facilitators ran each group. The results were 

summarized, translated back into English and submitted to the FET in Islamabad. 

A complete list of officials and key informants interviewed in government offices, regulatory bodies, 

hospitals, health centers, training institutions, consortium organization offices, and other development 

partner offices is presented in Appendix B. The following table shows the stakeholders interviewed by 

the evaluation team, including those by Eycon during the evaluation process. 


Table 1. Categories and Numbers of Stakeholders Interviewed by the FET 

Constraints and Concerns 

CATEGORY 

Government Officials 

Federal Level 7 

Provincial Level 4 

District Level 40 

National Programme Manager 2 

Partner Organizations (Consortium) 8 

Sub-grantees 4 

Independent Consultants 2 

Midwifery Associations & Consultants 5 

PAIMAN 10 

Physicians 10 

Medical Assistant 1 

Lady Health Visitor 1 

Lady Health Worker 3 

Community Midwife 3 

Traditional Birth Attendant 2 

Community Members 

Male 42 

Female 65 

Nursing/CMW School Principals 5 

Community Midwife Students 5 

Religious/Prayer Leaders 3 

Focus Groups 3 

Women’s Support Groups (with women 5 

and children present) 

Number 

The limited number of people interviewed in some categories reflected the security situation in the 

country, which limited the mobility and flexibility of the FET. This was arguably one of the most difficult 

times in the history of Pakistan to conduct this evaluation. The worst flooding in the history of the 

country started with flash floods in the Northwest at the beginning of the month, less than a week 

before the FET arrived. The conditions throughout the country continued to worsen, with one-fifth of 

the country affected from the far north and northwest to coastal communities in the south: the entire 

length of the Indus River and its tributaries. More than 20 million people were affected, as many as 8 

million displaced (as many as half of them without shelter), and millions were without food and living in 

highly unsanitary conditions with outbreaks of cholera, dysentery, and other infectious diseases that 

contributed regularly to the death rate. 

In addition, security in the country was also a critical concern before the flood situation, leading to 

limitations in the number of districts that could safely be visited. This concern increased with the 

bombing at the sacred site of Data Darbar in Lahore a month before the FET was to arrive. During the 

month: 


There were suicide bombings in Peshawar, Lahore and Quetta. 

The situation in Karachi was tense, with regular killings reported in the news. 

Aid workers participating in the humanitarian effort, particularly those from the United States (US), 

were threatened by Taliban and other insurgent groups intent on blocking the GOP’s relief efforts in 

favor of their own. 

The planned day trip to interview officials in Mardan was canceled following bombings in Peshawar, less 

than 62 km (40 miles) away. In addition, security forces were necessarily drawn into the relief 

operations for the floods. Air safety during the monsoon was also called into question, with a 

commercial jet crashing into the Margalla Hills approaching Islamabad International Airport on 28 July, 

killing all 152 aboard. 

Finally, the religious observation of Ramadan started a week after the team arrived, leading to a 

reduction in hours per day that government offices were open. (Budget restrictions had already led to 

closure of all government offices on Saturdays and Sundays.) Additionally, government officials and 

development partners in Islamabad and the provinces were almost uniformly involved and preoccupied 

with flood relief. 

The result was that appointments with government officials, particularly outside of Islamabad, were 

difficult to make and were considered tentative until the time the visit actually occurred. Project districts 

in Sindh were unreachable because of the floods, as were many in Balochistan. Impromptu access to 

communities and community members in all districts, but particularly those in the north and northwest, 

were constrained by security concerns, and even major cities such as Karachi, Peshawar, and Lahore 

posed risks to the FET. Anxiety about air travel during the monsoon led to changes in logistics. The FET 

was accompanied by an armed security detail throughout their three days in Multan and Khanewal, and 

on their drive back from Multan to Lahore en route to Islamabad. 


II. 

BACKGROUND 

MATERNAL AND NEWBORN HEALTH IN PAKISTAN 

Pakistan’s population is estimated to be over 177 million people, the sixth largest country in the world 

(CIA, 2010). Pakistan is considered to have achieved a medium level of human development (UNDP, 

2009) although slightly more than 60% (60.3%) of the population lives on less than $2.00 per day. The 

country ranks 99 th of 109 countries in the global measure of gender empowerment (UNDP, 2009). 

Table 2. Population Demographic Indices 

Indicators 

Figure (source) 

Population 

Population growth rate 1.513% (1) 

Adult literacy rate 52.2% (2) 

Males 67.7% 

Females 39.6% 

Maternal health 

Maternal mortality rate 2.6/1,000 live births (3) 

Proportion of births with skilled attendance 39% (3) 

Postnatal care within 24 hours of birth 22% (3) 

Neonatal and young child 

Neonatal mortality rate (NMR) 54/1,000 live births (3) 

Infant mortality rate (IMR) 64.3/1,000 live births (1) 

78 (3,4) 

Under-five mortality rate 94 (3) 

Morbidity indicators 

Expanded Program of Immunization (EPI) 79% (5) 

(measles vaccine coverage) 

Stunting 37% (6) 

(1) CIA, 2010 (2) UNDP, 2009 (3) PDHS, 2007 (4) UNICEF, 2010 (5) PSLM, 2008-9 (6) National Nutrition survey, 2001-2002 

Pakistan is signatory to the Millennium Development Goals (MDGs), which stipulate that the country’s 

maternal mortality ratio (MMR) be reduced from 550 per 100,000 in 1990 to 140 per 100,000 in 2015. 

The MMR was 276 per 100,000 live births nationwide in 2006-07 (PDHS; 2007), with a much higher rate 

in rural areas (e.g., 856 in Balochistan) (World Population Foundation, 2010). More than 65% of women 

in Pakistan deliver their babies at home. Key determinants of maternal health include under-nutrition, 

early marriage and childbearing, and high fertility (Khan et. al., 2009). The leading causes of maternal 

mortality are similar to those experienced worldwide and include obstetric hemorrhage, eclampsia and 

sepsis (Jafarey, 2002). 

The infant mortality rate for the country varies by citation (Table 2). A recent study of the causes of 

neonatal mortality indicated the primary obstetric causes of neonatal death were pre-term labor (fetal 

immaturity) and intrapartum asphyxia, both of which are potentially preventable or treatable conditions 

(Imtiaz et. al., 2009). Neonatal sepsis in the first week of life accounts for an additional 14% of all early 

neonatal mortality and increases to 47% of all late neonatal deaths (PDHS, NIPS, 2007). Fifty-eight% of 

neonatal deaths occur in the first 72 hours of life, the same period that the incidence of maternal deaths 

is highest. Neonatal deaths account for 69% of all infant mortality and 57% of under-five mortality—a 

proportion that is increasing as infant and under-five year old deaths slowly decrease over time 


(Shadoul, et.al., 2010). Of concern to the Government of Pakistan (GOP) is that these rates (MMR, IMR, 

NMR) have changed very little over the past decade, a significant challenge to achieving the MDGs. 

The majority of Pakistan’s citizens receive health services through the private sector (71%) in both rural 

and urban settings (PSLM 2008-09). This is a reflection of the low investment the GOP has made in 

health (i.e., only 29.7% of total health expenditures are from the GOP) and the high out-of-pocket 

expenses (i.e., 57.9% of all expenditures are out-of-pocket) (WHO 2008). Public health care services are 

provided in service delivery settings established under the authority of the MOH (health care across the 

lifespan) and the MOPW (reproductive health, family planning). Although services are provided free of 

charge in the public sector, informal charges are often levied. Service availability is further limited due to 

understaffing (including a lack of female providers), limited hours of service, and material shortages. 

The private health sector offers primarily curative services, largely on a fee-for-service basis. Private 

maternity facilities offer 24-hour normal and operative delivery services for women and newborns, and 

tend to attract the largest proportion of patients from all socioeconomic groups. This sector has been 

described as loosely organized and largely unregulated. The FET heard of some private sector 

practitioners, many of whom are also providers in the public sector, diverting public resources into their 

own clinics and undermining the effective administration of public facilities in order to reduce 

competition from that side. 

Traditional birth attendants (TBAs) attend half (52%, PDHS) of home childbirths in the country. The 

GOP acknowledges that this cadre will continue to function for the foreseeable future. However, there 

is both vision and commitment to forge stronger alliances with the public sector maternal, newborn and 

child health providers, including midwives, Lady Health Workers (LHWs) and Lady Health Visitors 

(LHVs), who function at the community level, and with government-employed midwives and physicians, 

who offer facility-based services. 

Responsibilities for management of health services were transferred out of national-level ministerial 

control in 2001. During the tenure of the PAIMAN Project, districts served as the basic administrative 

units for health and were charged with planning, budgeting, managing and implementing health services. 

Public Health Policy ―Amendment 18‖ has altered that management structure. Provincial health offices 

will assume administrative responsibility in the near future (further discussed in Section V) although the 

degree of responsibility and accountability to be retained at the district level is still being determined. 

USAID/PAKISTAN HEALTH SECTOR ASSISTANCE 

USAID’s health program in Pakistan supports 10 of the 12 health and population objectives outlined in 

the GOP’s Ten-Year Perspective Development Plan 2001–2011. The Government of the United States 

and the GOP signed an initial agreement in 2003, through which technical assistance would be provided 

to help the MOH, the MOPW, provincial and district governments, and the private sector to implement 

program activities. In consultation with the GOP, USAID agreed, as part of its larger health portfolio, to 

support provincial government programs to improve maternal, neonatal, and child health outcomes. The 

FY2009 project portfolio budget for health was approximately $254 million. 

The health program, which began in 2003, supports activities to improve MNH services, promote family 

planning, prevent major infectious diseases (HIV/AIDS, tuberculosis) and increase access to clean 

drinking water. The program is implemented throughout the country in underserved rural and urban 

districts in Sindh, Balochistan, Punjab, the Northwest Frontier Provinces, and the FATA. USAID, 

working through its implementing agencies and consortia, maintains close communication with other 

international donor agencies that are involved in similar work so that programming can be distributed 

across the country and not duplicated within single provinces or districts. 


The Pakistan Initiative for Mothers and Newborns (PAIMAN) is USAID’s flagship program in 

health. The project was initially designed to improve quality healthcare services for pregnant women and 

newborns, including inputs to pregnancy timing and spacing (activities shared in part with the FALAH 

project). In later years, the focus expanded to include the young child (an unduplicated program focus). 

PAIMAN is a seven-member consortium under the leadership of John Snow Research and Training 

Institute. The program timeline was October 2004 – September 2009, extended through December 

2010, with a funding portfolio of $92,800,000. 

The Family Advancement for Life and Health (FALAH) project addresses the need to increase 

and improve family planning services in 20 districts. The project is aimed at integrated family planning 

services both in the private and public health sectors. Program activities aim to increase the overall 

family planning market; therefore, they include activities such as community mobilization, capacity 

building of health providers, and family planning service delivery. This project complements the PAIMAN 

Project through its focus on healthy timing and spacing of pregnancies. FALAH is a nine-member 

consortium headed by The Population Council. The program was initiated in June 2007 and will end 

prior to its original date of May 2012. The project funding portfolio was $48,424,566. 

Two additional projects that incorporate maternal, child and family health within their focus have 

completed or are soon completing their program of work: 

 

 

Pakistan Safe Water Initiative and Hygiene Promotion, under the leadership of Abt 

Associates, offered technical assistance in hygiene and sanitation promotion, community 

mobilization, and capacity building to complement the GOP’s installation of water treatment facilities 

nationwide. This project, with a budget of $22,858,961, was inaugurated in October 2006 and began 

its close-out in March 2010. 

Technical Assistance for Capacity-building in Midwifery, Information and Logistics 

(TACMIL) was a two-year activity that aimed to strengthen capacity to deliver quality MNCH care 

services in Pakistan. TACMIL focused on improving the skills and competencies of community 

midwives, as well as the institutional capacity of training institutions, resources, and professional 

organizations. The TACMIL project ran concurrently with PAIMAN from December 2007 to 

December 2009, and worked collaboratively with PAIMAN in several capacity-building activities for 

tutors who served the Community Midwife Program. TAMCIL’s budget was almost $11,000,000. 

USAID works collaboratively with other international agencies to create a wide profile of programming 

that focuses on the country’s burden of disease and impact family health. The following programs are 

illustrative: 

 

 

Strengthening response to Tuberculosis and enhance the quality of the directly 

observed treatment strategy program in Pakistan 

This program complements the activities of the country’s national Tuberculosis (TB) control 

program. It aims to strengthen coordination and supervision of TB-focused activities at provincial 

and district levels by improving laboratory capacity; conducting advocacy, communication and social 

mobilization activities; and establishing referral links between public and private sectors. The WHO 

serves as project lead for this (estimated) $11,700,000 program operating over the timeline July 

2009 through July 2012. 

Pakistan Polio Eradication Initiative 

The program provides assistance to national polio immunization campaigns to eliminate polio from 

Pakistan. WHO (lead partner) and the United Nations Children’s Fund (UNICEF) contribute to this 

ongoing programming, which was initiated in September 2004. Current funding totals $1,800,000, 

with an additional $3,000,000 in field support to WHO and $3,000,000 in field support to UNICEF. 


Pakistan HIV/AIDS Prevention and Care Project 

This program worked in selected cities of Pakistan (including FATA) to complement the activities of 

the Government’s National AIDS Control Program by delivering preventive and treatment services. 

The program, headed by Research Triangle Institute, ran from February 2006 through June 2009, 

with a funding level of $3,300,000. 

Although not through USAID, the US Department of State announced the first phase of a 3-year, 

$28,000,000 Signature Health Program for Pakistan in July 2010. The program will undertake 

three projects for the renovation and construction of medical facilities, which will serve as clinical 

sites for service delivery and the education of health providers. 

ASSISTANCE FROM OTHER DONORS IN MATERNAL AND NEWBORN 

HEALTH 

Direct Assistance 

Several donor agencies and international organizations support the Pakistan MNCH program. Several of 

these collaborating agencies have selected similar or parallel interventions to improve maternal and 

neonatal health, using different approaches to implementation. A communication and collaboration 

network has been established among them so that activities can be aligned to reduce duplication within 

the various provinces and so that strategic approaches can be standardized. Health donors meet on a 

monthly basis. An MNCH technical advisory/interest group has been formed, but has become less active 

recently (USAID/P, 2010). 

The Government of Norway is funding a major mother and child health project in ten districts of 

Sindh province (the Norway-Pakistan Partnership Initiative) from 2009 through 2013. The 250 million 

kroner (US$40.6 million) project is being implemented in collaboration with the MOH by the United 

Nations Population Fund (UNFPA), UNICEF, WHO and other national partners. 

UNICEF supports a maternal and newborn project in 17 districts (UNICEF, 2010). UNICEF works 

within the MOH to support program activities in MNCH, EPI, family planning and primary health care. 

UNICEF works with the GOP national AIDS control program, the Health Management Information 

System (HMIS) unit, and the nutrition wing. The agency also engages with the Pakistan Nursing Council 

(PNC) in association strengthening activities. 

UNFPA supports reproductive health and safe motherhood activities in ten districts of the country. 

UNFPA programming is primarily focused on training in reproductive health and safe motherhood best 

practices. The UNFPA and the International Confederation of Midwives (ICM) have a collaborative 

program focused on strengthening professional midwifery associations. The UNFPA/ICM project is also 

positioned to provide consultation to countries that wish to develop or revise midwifery programs 

according to international standards. A regional country consultant has been placed in Afghanistan. 

The United Kingdom Department for International Development (DfID) places 33% of its 

Pakistan portfolio into the health sector. It provides direct budgetary and technical assistance support to 

the national MNCH program (DfID, 2010) in support of programming designed to improve access to 

maternal and newborn services through provider (including community midwife) training and behavior 

change communication strategies. DfID’s contribution to the national MNCH program is approximately 

£90 million (US$140.8 million) for the period 2008–13; £69 million (US$107.9 million) for direct support 

and £22 million (US$34.4 million) for technical cooperation through two funds: the Technical Resource 

Facility (TRF) and the Research and Advocacy Fund (RAF). This accounts for half of the MNCH budget. 

Prior programs in health, nutrition and infectious disease control are in the final years of funding; future 


investment in these focus areas is presently being deliberated. DfID provided additional support to 

health through a variety of multisectoral and humanitarian support programs. 

The World Health Organization provides policy and technical assistance support for reproductive 

health, including family planning and targeted MCH activities (WHO, 2010). WHO played an integral 

role in assisting the GOP in developing its MCH strategy, including consultation on the initial design of 

the community midwife program. 

Indirect Assistance 

Additional international development partners offer indirect assistance to Pakistan’s MNCH 

priorities through parallel or integrated programming that affects maternal, neonatal or child health. 

The Government of Australia (AusAid) is reportedly providing Aus$24.3 million (US $21.9 

million) for technical cooperation activities; the funding is unrestricted, so could be directed to 

MNCH needs. 

 

 

The Canadian International Development Agency (CIDA) has selected Pakistan as one of its 

20 focus countries under the terms of its aid effectiveness agenda (CIDA, 2010). This agenda is 

primarily focused on economic empowerment in pursuit of the country’s poverty reduction 

strategy. CIDA also focuses on children and youth through support of gender-equitable education 

programming. CIDA’s focus on maternal and newborn health is indirect. 

The Japanese International Cooperation Agency (JICA) offers technical assistance to the 

Pakistan Institute of Medical Science in health research related to safe motherhood. Other health 

programs are related to TB and polio control, and the expanded program of immunization (JICA, 

2010). JICA also funded the development of the District Health Information Management software, 

through which MNCH indicators are tracked. 



III. 

OVERVIEW OF THE PAIMAN PROJECT 

PROGRAM DESIGN AND IMPLEMENTATION 

Begun in 2004, the PAIMAN Project is aimed at accelerating the GOP’s progress toward achievement of 

MDGs 4 and 5 (reduce child mortality and improve maternal health, respectively). Data indicated that 

the peak incidence of maternal deaths and child deaths was occurring during the same period: the 

perinatal period from the onset of labor through the first week of life. The emphasis, therefore, was 

initially on interventions that would improve the outcome of labor, delivery and the immediate postpartum 

period for both mother and newborn. The key to reducing maternal and neonatal mortality was 

to improve a woman’s access to skilled midwifery care ―at her doorstep‖ through the creation of a 

cadre of community midwives and to improve her access to health care facilities of good quality with 

adequate measures taken to facilitate referral as needed. 

In order to create an enabling environment for improving the health care of women and newborns, the 

project developed a strategic framework called The Pathway to Care and Survival. The four steps of the 

Pathway took into consideration all of the elements of the ―Three Delays 3 ‖ that impact the safety of the 

birthing process. 

In the Pakistan context, these delays translate into five interrelated problems faced by women and 

children: 

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 socio-cultural) to and lack of community involvement in MNCH 

services; 

3. Poor quality of services, including lack of adequate infrastructure in the health facilities; 

4. Lack of individual capacity, especially among skilled birth attendants (SBAs); and 

5. Weak management environment and lack of health services integration. 

PAIMAN defined the following program goal and objectives to address each of these problems and went 

further by identifying expected outcomes to mark the achievement of each. 

3(1) delay in the decision to seek care, (2) delay in reaching a facility capable of providing care, and (3) delay in receiving quality 

care at the facility. 


Figure 1. Pakistan Maternal and Newborn Health Programs Strategic Framework 

PAIMAN PROGRAM 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 


OBJECTIVES AND OUTCOMES 

1. Increase awareness and promote positive maternal and neonatal health behaviors. 

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, of 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. 


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. 

SCOPE, DURATION, AND FUNDING 

The life of project was originally from 8 October 2004 to 30 September 2010, with an initial funding 

level of US$49,943,858. However, both the funding and the life of project changed over the course of 

the project, with various amendments to the original Cooperative Agreement between USAID and JSI. 

In December 2007, PAIMAN expanded activities in the Federally Administered Tribal Areas in Kyber 

and Kurram Agencies and Frontier Regions Peshawar and Kohat. PAIMAN also began working in the 

Swat district in April 2008. 

The major change came in September 2008, at the time of the Mid-term Review, when the Agreement 

was amended to increase funding by US$36,556,143, which, along with other amendments, brought the 

total project funding to US $92,900,064. This increase was to cover geographic expansion (i.e., it added 

14 more districts, bringing the total to 24 districts) and to extend the project by one year to 30 

September 2010 (which later, through a no-cost extension, was further extended to 31 December 

2010.) At the same time (i.e., July 2008), JSI received a formal letter from USAID requesting it to 

extend its programmatic activities to include ―an effective child health delivery strategy…through an 

Integrated Management of Newborn and Childhood Illness (IMNCI) approach, including immunization, 

nutrition, diarrheal disease and acute respiratory infection (ARI) management.‖ In the same letter, 

PAIMAN was asked to extend already on-going activities in the ten original districts (including the 

integration of family planning counseling and service delivery with antenatal and postnatal visits and 

community support group activities) to those districts where the new to 15 border districts were being 

selected for expansion. 


The decision to expand the project to more districts rather than extend it deeper into the districts 

already chosen was in keeping with the second phase plan as described in the original Cooperative 

Agreement. 

SELECTION OF DISTRICTS 

The original ten districts were selected by the GOP in negotiation with PAIMAN and USAID/Pakistan. 

The expansion districts (14) were selected in much the same way but reflected USAID’s expressed 

interest in extending the full range of PAIMAN activities into 10 to 15 remote and vulnerable districts in 

Balochistan, Khyber Pakhtunkhwa, Azad Jammu and Kashmir, where access to MNCH services was 

severely limited. 

BENEFICIARIES 

From the beginning, the project has worked with communities, government, and local NGOs to 

strengthen maternal, neonatal, and child health to increase the health status of women and children. 

PAIMAN originally identified beneficiaries of the program as married couples of reproductive age (15- 

49) and children less than one year of age, and later added children under five years of age. It was 

estimated that the program would reach an estimated 2.5 million couples and nearly 350,000 children 

under one year of age in the first 10 districts, and an additional 3.8 million couples and 570,000 children 

under five years of age in the additional 14 districts. 

IMPLEMENTATION 

The project was based on eight major inputs: 

 

 

 

 

 

 

 

A Communication, Advocacy and Mobilization (CAM) strategy based on quantitative and qualitative 

research and literature review that would focus on empowering communities to make appropriate 

choices in health-seeking behavior. This would be done through a combination of media events, 

formation of community-based committees, private sector outreach, and sub-grants to local NGOs. 

Establishment of a new cadre of Community Midwives drawn from the communities they would 

serve. They would be trained in an 18-month program with a follow-up of 3 to 5 months of practical 

experience and then returned to their communities and paid a temporary modest government 

stipend to help them become established as private practitioners within the community. 

Creation of Community Birthing Centers to bring access to safe delivery to the community and 

emergency transport schemes to facilitate transfer of complicated cases to the nearest emergency 

obstetric care (EmOC) facility. 

Training of TBAs, who are responsible for 52% of deliveries in the country, in safe-delivery 

techniques and recognition of danger signs requiring immediate referral. 

Up-grading selected facilities at the district and tehsil levels in order to create an environment for 

SBAs to work in. 

Training a variety of providers in normal deliveries, essential maternal and newborn care, 

comprehensive emergency obstetric and neonatal care (EmONC), the use of the partograph, and 

active management of the third stage of labor, infection prevention, and IMNCI. 

Strengthening health systems at the district level in recognition of the responsibilities for health care 

delivery that had recently been devolved to that level, which required establishment of multisectoral 

District Health Management Teams (DHMTs) and leadership and management training. This 

also required that the HMIS system be revised and a new District Health Information System be 

developed and rolled out. 


Integration of services, initially by coordinating inputs from both MOH and MOPH, and also by 

looking at ways to converge vertical national programs within the MOH for greater efficiency. 

MONITORING AND EVALUATION 

The PAIMAN Monitoring and Evaluation (M&E) Plan cites as its five purposes to: 

 

 

 

 

 

Track implementation of project activities as planned and suggest corrective actions where needed; 

Document and disseminate lessons learned from project planning and implementation; 

Evaluate the impact of the project on maternal and neonatal health status; 

Provide evidence regarding the effectiveness and reliability of interventions for possible scale-up; and 

Increase the capacity of the health system, especially at the district level, to monitor and evaluate 

MNH activities. 

Five primary MNH outcome indicators were selected in coordination with the then-current USAID 

strategic framework. The five indicators were: 

 

 

 

 

 

Percent of births assisted by skilled attendants; 

Number of (ten total planned) district referral facilities upgraded and meeting safe birth and 

newborn care quality standards; 

Percent of women aged 15-44 who received three or more antenatal care visits during last 

pregnancy; 

Percentage of women who report having a postpartum visit within 24 hours of giving birth; and 

Percentage of pregnant women who report receiving at least two doses of tetanus toxoid (TT) 

during last live birth. 

One additional indicator was proposed by PAIMAN that was outside the USAID strategic framework: 

 

District health facility budgets show an increase of 50% or more over life of project (all sources 

excluding USAID). 

The indicator percent of births that occurred 36 or more months after the preceding birth (i.e., healthy 

timing and spacing of pregnancy) appears in the M&E plan as a USAID SO 7 indicator, but does not 

appear to have been tracked by PAIMAN; reporting on this indicator is not readily identified in project 

reports and documents. 

The Population Council was engaged as the project partner tasked with M&E functions. The Council 

retained primary responsibility for project evaluation, including baseline and endline household surveys 

and the conduct of special operational research studies. Aga Khan University was engaged as a countrybased 

partner for the conduct of special assessments and (later) to design and conduct evaluative 

research studies. Project partner Contech International conducted the baseline and endline facility 

surveys envisioned in the M&E plan, and also conducted an assessment of the impact of the systems 

strengthening activities (SO5) of the project (which would have included the sixth outcome indicator 

noted above). 

The M&E plan states that the purpose of program monitoring activities was to enable the tracking of 

progress toward achievement of program targets across all activities. The responsibility for routine 

program monitoring of output indicators was devolved to other collaborative partners over the project 

lifetime. A Routine Monitoring of Output Indicators (RMOI) system was developed in the interest of 

standardization of definitions and a common data standard for tracking 17 output indicators, some of 


which are also cited in the project M&E plan. Project partners, in their turn, used a variety of 

computerized databases to collect RMOI data, including the (then current) Health Management 

Information System, the newly emerging District Health Information System, the Lady Health Workers 

Management Information System, and information from concurrently implemented programs, such as 

the Expanded Program on Immunization. Additional ―soft-copy‖ records—such as health facility records, 

quality review and training checklists, NGO grant reports, and reports from private partners (e.g., 

private doctors, NGO sub-grantees, and CMWs in community practice)—enriched the fund of available 

information. 

PAIMAN also kept very close account of the vast number of program activities (process indicators) that 

were proposed in annual work plans and detailed in annual reports. The Mid-term Evaluation (MTE) 

team recommended that PAIMAN turn its attention to the use of these data for decision-making, rather 

than simply counting activities performed. This recommendation was particularly timely as the MTE was 

conducted just prior to program expansion. PAIMAN had the opportunity to review the usefulness, 

efficiency and effectiveness of its interventions, and be selective in the types of programs that it would 

take forth for implementation in the 14 new districts as it negotiated contract modifications with 

USAID. Nevertheless, the vast majority of programs were replicated in the new districts, and new 

activities in child health were added. Annual reports indicate programmatic amendments only in the 

event of security situations, natural disasters, and an unstable national or regional political environment. 

Reporting and recording on each of these three sets of indicators was noted by the MTE team to be 

fragmented and uncoordinated. The FET noted a similar diffusion of information. More importantly, the 

organization of reports and visual presentation of project outcomes differ from the project M&E plan in 

both the statement of the 37 objectively verifiable outcomes and the definition of outcomes delineated 

in that document. The FET spent several hours in an attempt to track information in various evaluation 

reports and documents that could be matched to the indicators cited in the M&E plan. The attempt was 

not successful for a substantial number of indicators. Some were differently defined in various 

documents. Some reports used baseline data that differed from the information presented in the M&E 

plan. (For example, the indicator ―percent of births assisted by a skilled attendant‖ is reported in the 

endline survey as having increased from 41.3% at baseline to 52.2% at endline. The baseline figure cited 

in the M&E plan is 35.5%, with reference to the same pre-post household survey as the data source.) 

Other indicators simply could not be identified in the documents reviewed, although that does not 

discount the possibility that they were perhaps tracked, recorded and reported. Nevertheless, this 

finding does reflect the fact that the implementation of M&E was not in conjunction with the plan, which 

has an adverse impact on overall knowledge management for the project. 

The date of publication of the M&E plan is January 2007. The scope of work in the later years of the 

PAIMAN Project was modified to amend the maternal newborn project to activities that would create 

an integrated maternal, newborn, and child health project. The original plan includes only a single 

indicator for family planning (contraceptive prevalence rates for modern methods) and no indicator for 

child health beyond the neonatal period. PAIMAN states that a revised M&E plan with additional 

indicators on child health and family planning was submitted to and approved by USAID. (This document 

was not among the materials provided to the FET; information was shared in post-evaluation 

correspondence.) These additional indicators include six items related to the distribution of 

contraceptive commodities and procedures; three indicators that track stillbirths, low birth weight and 

neonatal deaths; and seven indicators related to well-child assessment and treatment of childhood 

disease. The USAID-funded FALAH birth spacing project was running concurrently in many of the same 

PAIMAN districts, but outcomes of that project should be separately attributed. Mortality estimates 

available to the FET (full endline analysis not completed at the time of the visit) indicated improvement 


(i.e., reduction) in perinatal, early neonatal and neonatal deaths for both skilled and unskilled birth 

providers, though only the reduction in early neonatal and neonatal deaths may be significant. 

Program evaluation activities, including operations research, were proposed to assess whether 

interventions had led to actual changes in both conditions and behaviors (project impact) and to assess 

whether new approaches are effective for adoption and scale-up. Accordingly, authors of the project’s 

M&E plan state that the plan was designed with the intention that it be able to define cause-and-effect 

relationships of the various project activities. The question arises, therefore, why the M&E plan did not 

propose from the outset to conduct a within-and-between-groups analysis of PAIMAN districts in 

comparison to demographically comparable non-intervention districts. The possibility to attribute an 

effect to PAIMAN interventions is severely constrained by this omission. 

One very useful product of the M&E strategy was the generation of a profile of each of the ten PAIMAN 

districts, using geographic information system (GIS) mapping. These data offer a clear picture of the 

design of the health system at the district level, which should surely be useful for district management, 

planning and decision-making. The GIS reports present information on the location, staffing, and 

functioning of both public and private health systems, as well as information on resources at the 

community level (e.g., LHWs, Community Citizen Boards [CCBs], functioning of NGOs). 

RESEARCH 

Special Studies 

Over the term of the project, several special studies were conducted which served a utilitarian purpose 

and were complementary to the routine project M&E agenda. Some of these studies are briefly 

described below for illustrative purposes: 

 

 

 

 

 

The Harvard School of Public Health, in collaboration with Contech International, conducted a study 

of the decision-making capacity of district-level health managers to assess their readiness to take on 

responsibilities related to district-level administrative tasks. Results of this decision space analysis 

were used to inform the system-strengthening components of the project (discussed in section 

SO5) and to shape the capacity-building training agenda (Bossert et. al., 2008). This study used a 

baseline and endline design with comparison districts. 

Contech International also conducted the baseline and endline assessment of health facilities. These 

data were used to inform the selection of facilities that would be upgraded via PAIMAN Project 

activities and then to attempt to attribute the positive impact of these upgrades in terms of 

utilization. Although it did not use comparison districts, it attempted to match results from PAIMAN 

up-graded facilities with other facilities in the same district that had not been upgraded. 

PAIMAN’s behavior change communication media component was the subject of a special evaluation 

report. This study assessed the effectiveness of exposure to various media-based community 

outreach strategies and their effect on knowledge, attitudes and practices related to key maternal 

and neonatal health behaviors. 

The overarching communication, advocacy and mobilization strategy was itself evaluated, including a 

special focus on the effectiveness of outreach to religious prayer leaders (ulamas) on their 

knowledge of and attitudes toward maternal and child health issues. 

A very pragmatic assessment was conducted concerning the effect on knowledge acquired by 

participants who received a 7-day versus those who received an 11-day training in Community IMCI 

(C-IMCI) to inform the format and sequencing of training to be conducted in the future. 


Operations Research 

The M&E plan proposed the conduct of operational research studies that would be designed to focus 

clearer attention on the effectiveness of PAIMAN interventions. To date, three operational research 

studies have been completed; results of a fourth study will be released in the near future. This list may 

not be all-inclusive, as project partners may have conducted other studies that are less prominent in 

their dissemination. 

 

 

 

 

The effect of Dai training on maternal and neonatal care (Population Council, 2010) explored the 

longer-term outcomes on knowledge and practice among dais who had been involved in an 8-day 

training program conducted in DG Khan. The content of this training focused on improving the 

ability of dais to recognize danger signs, conduct clean deliveries, and monitor the health status of 

mothers and their newborns in the immediate postpartum period. The results of this study are 

discussed in SO2. 

A qualitative study was conducted to assess the potential acceptability of the CMWs among rural 

residents of Pakistan. Results of this and the following study are discussed in SO4. 

An assessment of the CMW program was conducted, using both qualitative and quantitative 

approaches. The assessment addressed knowledge and skills retained and demonstrated, following 

graduation from the basic training program and establishment of the CMW practice. 

The details of the fourth operational research study are forthcoming, and full details were not 

available to the FET. The intervention tested in this study is inclusion of misoprostol as a component 

of the clean delivery kit. The availability of this temperature-stable oral uterotonic (Gülmezoglu et 

al., 2007; Sutherland et. al., 2010) would enable the practice of active management of the third stage 

in a wider variety of birth settings, including the home. 

Research Agenda 

Aga Khan University (AKU) was engaged as a project partner to conduct more formally designed 

research studies that would help to determine the impact of PAIMAN interventions. Knowledgeable 

informants indicated that USAID expressed substantial reluctance to the inclusion of formal research 

into the M&E plan. Moreover, AKU was initially required to work through the PAIMAN M&E partner, 

rather than receive independent funding for a program of research; this caused a substantial delay in the 

initiation and implementation of some research activities. Proposed comparative research designs were 

most adversely affected because of the delay in documentation of baseline figures. Nevertheless, a 

substantial number of applied research (cluster randomized trials) and operational research studies have 

been conducted, and results from a majority of these studies have been reported. Results of other 

studies are anticipated by the end of the 2010 calendar year. The following list, though not exhaustive, is 

illustrative of these studies. 

 

 

 

 

 

Five PAIMAN districts across the county are each being compared to two control districts in an 

assessment of the impact of upgrading health facilities to promote care seeking and improvements in 

maternal, newborn, infant and under-5 morbidity and mortality. 

Contributory causes of stillbirths have been explored. 

Several studies of nutritional supplementation, exploring the added value of selected micronutrients 

(maternal vitamin D, neonatal vitamin A), have been initiated. 

The effectiveness of chlorhexadine as a prophylactic agent in newborn cord care has been assessed. 

Various interventions for early treatment of childhood diarrhea and pneumonia have been evaluated. 


MANAGEMENT AND ORGANIZATIONAL STRUCTURE 

JSI Technical and Research Institute, Inc. (R&T) was the prime partner of PAIMAN in a consortium that 

began with seven partners and was then reduced to five at the mid-term of the project 4 . As Prime, JSI 

was responsible for the technical, administrative, and financial management of the Cooperative 

Agreement with USAID. Senior management included the Chief of Party (COP) and Deputy Chief of 

Party. PAIMAN had two COPs, and its last (and current) was a Pakistani national. The current Deputy 

COP is the only US national in the organization. All other members of the organization were Pakistani. 

Mid-level management includes Directors of Programs and Grants, Administration and Finance, a 

Technical Advisor for M&E, and indirectly, the five Country Directors of the Consortium Partners. All 

but the Administration and Finance Directors reported directly to the COP. Directors of 

Administration and Finance reported to the Deputy Director. The Table of Organization showed 90 

posts, not counting the consortium partners. 

JSI senior management was located in the main office in Islamabad. The country offices of the 

consortium partners were also in Islamabad and were maintained separately from the PAIMAN office. 

Even staff seconded to the PAIMAN Project maintained their office in the consortium partner country 

office, as many were involved in other development work outside of PAIMAN. The exception to this 

was the advisor from JHU who sat in the PAIMAN office as JHU did not have a Pakistan country 

presence. PAIMAN had provincial offices in each of the six provinces in which it worked, each headed 

by a JSI staff person as Field Operations Manager (FOM). As in Islamabad, the technical staff of 

consortium partners assigned to the provinces worked in their respective offices, although all PAIMAN 

activities in the province were coordinated by the FOM. There were five District Coordinators assigned 

to each of the provinces with the exception of FATA, where there was a Program Coordination Officer 

in the provincial office. 

Decision making in PAIMAN is largely centralized in Islamabad and passed down to the provinces. While 

this has the danger of creating an unresponsive top-down structure, most felt that the situation was 

redeemed by the leadership style of the COP. Still, the FET found instances where centralized decisions 

were neither sensitive to nor adapted to district and community differences. The creation of this 

organizational atmosphere, while efficient for decision making and useful in moving project 

implementation forward on a fixed time-line, may not have yielded the most effective programmatic 

results and may even have resulted in some inefficiencies as not all training, construction, supplies, or 

management directives were tailored to the needs of the personnel across the highly varied landscape of 

the districts. On at least one occasion, the management was advised to adapt to local conditions but did 

not: the baseline finding of the decision space analysis noted that the individual needs of the districts 

were so varied that a one-size-fits-all approach would not be effective. 

While some management decisions may have been called into question by participants, GOP, and even 

members of the consortium, the FET heard uniform praise for the COP’s leadership of the project and 

commendation for the COP’s ability to keep consortium partners working harmoniously together and 

with their counterparts in the national, provincial and district governments. 

4 As mentioned above, the original consortium was composed of JSI with Save the Children-U.S., Aga Khan University, Contech 

International, Greenstar Social Marketing, Johns Hopkins Bloomberg School of Public Health Center for Communications 

Programs (JHU/CCP), The Population Council, and the Pakistan Voluntary Health & Nutrition Association (PAVHNA). 

PAVHNA and Greenstar left the project at the mid-term. 


Financial Management 

PAIMAN was implemented by JSI Research & Training in collaboration with its seven consortium 

partners (four local and three US-based). Financial management, therefore, was done by the finance 

team of JSI, who coordinated with the financial managers of the resident partner organizations and also 

oversaw the grant activities of the sub-grantee NGOs in the project. PAIMAN produced quarterly 

reports that included a section in each on program management, including finances. In addition, there 

were quarterly financial reports submitted to USAID, monthly statements made to JSI/Headquarters 

(HQ), and periodic visits and reviews by the finance office from JSI/HQ in Boston. In this administratively 

highly complex project, the finance office provided guidance to and facilitated financial management of 

partner organizations, sub-grantees, provincial offices, and other staff relating to sub-awards and subgrants. 

In doing so, it reviewed, processed, and approved all expenditures of the project and disbursed 

monthly stipends to the CMW students. There were only two audits done: a performance audit, 

including sub-grantees in February 2007, and a mid-term assessment performance audit in June-July 

2008. There have been none since then. Audit reports were not available to the FET. 

The project had an initial funding level of US$49,943,858, which increased over the course of the project 

as 15 amendments were added to the original Cooperative Agreement between USAID and JSI. The first 

of the major budget increases came in December 2007, when PAIMAN expanded its budget by US$4 

million for activities in FATA. This was followed in March 2008 by an additional US$2.3 million for an 

expansion into the Swat district. These two brought the total project budget to US$56,243,857. 

PAIMAN began working in the Swat district in April 2008. 

The major budget expansion came in September 2008, at the time of the mid-term review, when the 

Agreement was amended to increase funding by US$36,556,143, which, along with other amendments, 

brought the total project funding to US$92,800,062. This increase was to cover geographic expansion 

(i.e., it added 14 more districts, bringing the total to 24) and it extended the project by one year, to 30 

September 2010 (which later, through a no-cost extension, was further extended to 31 December 

2010). An addition of US$100,000 in March 2009 for increased security brought the budget to its 

present level of US$92,900,062. This budget included a US$4,096,684 cost-share to be generated by JSI 

and the consortium partners, with more than half to be paid by JSI and JHU/CCP. 

The Consolidated Budget is divided between management costs (including salaries, overhead, travel, and 

equipment), program costs and sub-recipient grants. The document in the Appendix is confusing as it 

details the budget breakdown of JSI Research & Training Institute, Inc., but does not provide a detailed 

budget of overall PAIMAN expenditures. What is missing from the Consolidated Budget are the details 

of the consortium partner budgets, which are aggregated in a single line under Program Costs: Subrecipients. 

Despite frequent requests, a breakdown of this line was not available. Without having the 

detailed budgets of the consortium partners, it is not possible to determine the relative allocation of 

funds against approved Program lines, including allocation of funds to hospital renovations and purchase 

of ambulances, in order to allow comparison between the amount invested in infrastructure versus that 

invested in the training of health professionals, communication, M&E, etc. 

Having said this, the available figures indicate that management costs accounted for 20% of the budget, 

while Program costs were 46%, and sub-recipients (i.e., budgets allocated to Consortium Partners), 34%. 

The Program budget for JSI, which is not the same as for the whole PAIMAN Project, is divided between 

approved budget line items as follows (with percentage of program budget in parentheses): 

Health System Strengthening (9.52%), 

Hospital Renovation (28.15%), 


Communication (10.95%), 

Training (18.04%), 

Medical Equipment (8.69%), 

Baseline/Endline Survey (0.54%), 

Program Support Activity (4.84%), 

Hospital Waste Management (0.22%), 

 

Monitoring & Evaluation (0.08%), and 

Sub-grants (18.98%). 

Clearly, the highest priority for JSI programmatic funding went to hospital renovation, with sub-grants 

and training second and third, respectively. A total of 126 sub-grantee agreements were issued with 

approximate approved budgets totaling $6.8 million. Monitoring and Evaluation received the lowest 

share of the budget. It is not possible to say if these allocations represent a change over the past two 

years since the mid-term evaluation given that the figures in the mid-term included the disaggregated 

program budget lines of the consortium partners. 

Changes in proportions of budget expenditures can reflect alterations in the priorities of the project 

driven by programmatic or financial pressures, or they may reflect the dynamics of program 

expenditures with front-loading of expenses for communication and training, for example, matched by 

the slower uptake of construction projects in the more prolonged timetables of hospital renovations. In 

this case, the expansion into 14 additional districts increased construction costs at a rate higher than 

other line items. 

As of June 2010, the unspent portion of the budget was estimated to be US$527,266, although revisions 

in August 2010 put that figure closer to US$2.4 million 5 . This, along with USD$151,184 unspent in the 

FATA districts, amounts to approximately 2.75% of the total budget. This degree of spending over a 6- 

year period and for such a monetarily large project was reflected in a burn rate of US$1.2 million per 

month in the 24 PAIMAN districts (not including FATA). The burn rate (monitored carefully by both 

PAIMAN and USAID/Pakistan) was US$1.1 million at mid-term, and, although the project increased 1.5 

times in the number of districts, the expenditures per month remained essentially the same. 

Although the cost-effectiveness of interventions was not measured during the life of the project, there is 

intent to do so at its conclusion using final finance figures and results of research studies measuring the 

effectiveness of PAIMAN interventions. Although this clearly is too late to influence programming 

decisions for PAIMAN, it will be useful for subsequent decisions by other MNCH programs. 

Grants Management 

PAIMAN’s sub-grant awards to indigenous NGOs signaled its interest in building local capacity and 

extending its reach into underserved communities where there were no government workers (in this 

case, LHWs) in place. In the first half of the project (starting in 2006), sub-grants were awarded to 37 

provincial and district/community NGOs. PAIMAN had intended these grants to be for two years (2006- 

2008) and was intending to phase them out by the end of 2008. However, in 21 instances, work being 

done by the NGOs was extended by one to two years. There were an additional 55 grants awarded in 

the second half of the project (2009-2010) after expansion, although support was not confined to the 

new districts in the expanded project. Some grants were given as 1- to 2-year extensions of already 

5 US$1.5 million has been allocated for Pakistan Flood Relief, leaving US$900,000 unspent. 


funded grantees. Awards were approximately US$30,000 to US$40,000 per year, though some of the 

later second-half grants were half of that. PAIMAN also granted an award of US$959,608 to a US-based 

NGO (Mercy Corps) for community mobilization in Balochistan. This NGO did not continue its work 

for the second half of the project, as all community mobilization activities were consolidated under 

another US-based NGO, Save the Children-US. In total, the allocations to sub-grantees were 

US$6,869,656. Projected end-of-project expenditures were US$7,761,843 for a budget overrun of 

US$892,187. 

PAIMAN had instituted a transparent process for selecting NGOs to support with sub-grants. The 

process noted in the Mid-term Evaluation of widely publicizing the request for proposals, organizing preproposal 

workshops for the NGOs to explain the application and selection processes, and comprising 

selection committees of representatives of JSI, local communities, and district and provincial health 

officials to make the final selection was reportedly followed throughout the project to select 11 

additional NGOs in Swat and 44 NGOs in the remaining 14 new districts. Selected NGOs went through 

training organized by JSI on program and financial management and communication skills that included 

technical information about MNH. 

There was a standardized scope of work given to each of the NGOs that included community 

mobilization in non-LHW areas, including the formation of women’s support groups, improving 

emergency transportation, orientation of TBAs, TT vaccination campaigns, and strengthening routine EPI 

through tracing and reaching defaulters, organizing free medical camps, and providing support to new 

Birthing Centers staffed by the CMWs. 

Each NGO collected its own data on communities that were not being served by the public system and 

hence were outside of the DHIS. These data included information on births and birthing centers, 

immunization coverage, and vulnerable groups. Though the data may have assisted the NGO in its local 

decision making, because they were not being collated or aggregated as a part of the DHIS format, they 

did not fit effectively into that component of the District Health System Strengthening scheme. This may 

be understandable as the data collection methods of each NGO differed, which could lead to differences 

in the quality of data as well. PAIMAN reported that despite this, the data did not go unused: the NGO 

data were compiled at the national level (outside of the DHIS) and then shared back through PAIMAN 

quarterly reports and during district coordination meetings on a monthly basis. The degree to which 

these data were useful for district-level decisions was not clear. 

The FET interviewed selected groups of NGOs in Islamabad, Rawalpindi, Khanewal, Multan, Buner, and 

Lasbela to gauge their participation in PAIMAN and to understand what elements of the project they 

valued or were concerned about. They uniformly valued the institutional capacity development that was 

a part of the project and the resulting expansion in knowledge. This was a very successful part of this 

project. 

They did, however, express concern about the extension of work and sustainability of gains when 

PAIMAN was closed. Some had already started searching for replacement funds when PAIMAN grants 

were coming due; others were prepared to fall back on institutional funds that had sustained them 

before PAIMAN gave them their grants. Some were surprised to learn that the COP of PAIMAN (a 

member of the Board of Directors of the National Trust for Population Welfare [NATPOW]) 

approached NATPOW for support to sustain the activities of NGOs in underserved areas. NATPOW 

requested a list of sub-grantee NGOs, which was officially handed over to them. They have their own 

selection procedure and intend to contact the NGOs listed with the potential of registering some of 

them for NATPOW support. 


The point is this: NGOs from the community (assuming they were not being created by PAIMAN) were 

in the community before PAIMAN and will continue their work in the communities after PAIMAN is 

finished. They are accustomed to fund-raising, for this is how they have survived to the present. 

Furthermore, with the increased skills, recognition and connections provided by their participation in 

PAIMAN, they are more likely to sustain themselves in the future. Of the many interventions of 

PAIMAN, this is likely to be one of the most sustainable in terms of upgrading services to vulnerable 

communities. 

RELATIONSHIPS, COORDINATION, AND COLLABORATION 

PAIMAN was a consortium of seven partners, which presented its own challenges to coordination and 

communications. Major credit for the success of the PAIMAN collaboration will definitely go to the 

leadership, which seemed to be the main binding force. The evaluation team had the opportunity to 

meet or talk to the CEOs of each of the consortium partners. Respondents were unanimous in their 

opinion that each partner was provided a level field in terms of feedback on their proposed work plans, 

follow-up on activities, and some policy matters. However, it was the opinion of some that certain 

achievements at the partner level were not given due credit. It was also noted that partners were not 

invited to most meetings with the donor; these meetings were led by JSI and JHU/CCP. 

Some partners pointed out that an exit strategy was never discussed at meetings. Keeping a year’s 

extension in view, there was enough time to bring the exit strategy to the table. An exit strategy was 

provided to the FET, but the degree to which each consortium partner contributed to its development 

is unclear. Despite the complex nature of the project, which required implementation from policy to 

community levels, it was managed well. For example, when impediments occurred at the projectimplementation 

level in provinces, the leadership demonstrated the capacity to resolve them 

expediently. This led to the perception that decision-making was a top-down process. One person 

commented: ―[T]he process was very democratic, but decisions at times came as a surprise to 

partners.” 



IV. 

TECHNICAL COMPONENTS 

SO1. INCREASING AWARENESS AND PROMOTING POSITIVE MATERNAL 

AND NEONATAL HEALTH BEHAVIORS 

Communication, Advocacy, and Mobilization Strategy and Media Campaign 

JHU/CCP, a PAIMAN consortium partner, was responsible for the development of the design and 

strategies for the behavior change and the communication component of PAIMAN. 

Key activities designed to increase awareness and demand for MNCH services were: 

 

 

 

 

 

Home visits and small group activities, such as LHW home visits and support groups, and private 

sector interpersonal communications (IPC); 

Theater events and health camps at the community level; 

Mass media initiatives (TV drama, video, advertisements, music videos); 

Community-based committees, e.g., community board (CCB); and 

Advocacy to government officials at all levels, journalists, and religious leaders. 

Activities were implemented through four partner organizations: (i) JHU, which provided technical 

assistance for the development of mass media and innovative interventions; (ii) Save the Children, which 

conducted training for LHWs and community workers responsible for dissemination of the messages at 

the community and household level; and (iii and iv) PAVHNA and Mercy Corps, which collaborated in 

the first phase of the project. The activities of the latter two were undertaken by local NGOs, who 

implemented these same activities in selected districts. 

The Communication, Advocacy and Mobilization Strategy 

Project documents note that PAIMAN’s CAM strategy was based on the outcomes of formative 

research conducted among the intended beneficiaries in the original ten districts of the project. The 

CAM strategy appeared to be well designed in terms of the target audiences, key messages, strategies 

and media to be used for dissemination, and in its plan for wide coverage of the population. However, 

extensive interviews with stakeholders and a thorough review of the PAIMAN products made it evident 

that lessons learned from previous campaigns in the country may not have been optimally used at the 

production stage. Despite the fact that the intended outcomes of the CAM strategy had been well 

drafted, some of the messages failed to make a desired impact because the ―complete product‖ failed to 

convey the messages as intended. For example, the Behavior Change Communication (BCC) Media 

Evaluation Report by JHU/CCP mentions that only one third of the respondents in the survey reported 

being exposed to at least one episode of the drama series, but the overall exposure to the drama series 

was very low; therefore, viewers received only a very limited number of intended messages. 

Moreover, although a national implementation plan had been defined, due importance was not given to 

the suitability of the national plan among smaller provinces and ethnic groups. The commercial spots 

prepared for different ethnic groups were not presented in the local languages, but only mimicked the 

style of non-Urdu speakers. The young actors who portrayed the characters in various commercial 

spots imitated residents of cosmopolitan cities of Karachi or Lahore. This character profile did not 

resonant with a majority of the intended rural recipients of the messages. The evaluation inferred that 

activities set and designed in large urban centers were not appropriate for the multicultural, multilingual 

scene in Pakistan. Therefore, beneficiaries in the smaller provinces were unable to recall these 

messages—leading to a negligible response to questions of message recall in many districts of smaller 

provinces. 


Target Groups for the CAM strategy included: 

 

 

 

 

Traditional Birth Attendants (TBAs) and medical providers, 

Women of Reproductive Age, 

Decision-makers (husbands, family members, and influential members of the communities), and 

Advocates (government officials, ulamas, and journalists). 

The sub-grantees had a substantial role in the CAM strategy in terms of mobilizing the community to 

take part in events. For example, sub-grantee outreach workers made individual home visits to invite 

community members to Health Melas (health fairs), which had a large attendance, demonstrating their 

popularity. On the other hand, ensuring participation of currently married women of reproductive age in 

regular support groups was difficult, given cultural constraints in certain communities that restrict the 

mobility of women outside of their home. 

Dissemination to Outreach Workers 

Lady Health Workers 

LHWs are a government-supported network of outreach workers in PAIMAN districts. They are 

present in roughly 40% of villages. PAIMAN provided a 5-day training for LHWs in BCC methodology. 

The LHWs reported that they very effectively introduced support groups into their routine work. 

Community support groups met every two weeks to give women the opportunity to discuss problems, 

issues, and solutions to their own health needs. LHWs also conducted home visits and provided family 

planning, iron supplements, and other simple medicines. They gave women the opportunity to address 

concerns they may not otherwise have wanted to share. PAIMAN succeeded in training an already 

functioning cadre of government field workers to be behavior change agents. The support group 

strategy was a very effective medium for women to use for discussing health issues. It also provided a 

social venue in which women were able to meet outside of the house, often providing the only culturally 

acceptable opportunity to do so. 

PAIMAN reported in its life-of-project target document that 47,653 support groups were formed, 

437,396 support group meetings were held, and a total of over 4 million beneficiaries were reached. 

These numbers could not be substantiated by the FTE in any objectively verifiable manner. An estimate 

cited in one of the project documents was that 61% of beneficiaries of the CAM strategies were reached 

by LHWs. This intervention appeared to have the most impact and to be the most sustainable as the 

LHW is a government cadre and works within a well-structured network. 

NGO Sub-grantees 

Sub-grants were provided to 92 local NGOs, which were tasked with accessing underserved residents 

of deeply rural communities not currently reached by LHWs. These NGOs implemented MNH 

outreach activities such as local events and community theater in their communities. NGO 

representatives reported that they had developed a cadre of approximately 740 CHWs, whose function 

was the same as the LHWs. NGOs were also instrumental in initiating Citizen Community Boards 

(CCBs) to respond to community needs (NGO activities to increase access to services by the 

underserved are covered under SO2). 

Community-based Committees 

PAIMAN piloted four different types of community-based committees to promote messages based on 

the needs of pregnant women, newborns and young children: 

 

Village Health Committees (VHCs) consisted of men who help LHWs to carry important MNCH 

messages to other men in the community, particularly to non-supportive husbands. 


Facility-Based Health Committees (FBCs) created linkages between the community and the facility in 

collaboration with facility-based Quality Improvement Teams (QITs) in order to communicate to 

the community what level of health service might be most appropriate in time of need. 

QITs and FBCs were both aimed at improving links between communities and the nearest health 

facility, but the special role of QITs was to focus on the standards of care in the facility so that the 

health care required for a woman (or family members) could be of a high quality. The goal of QITs 

was to become a sustainable CCB that could assist communities to better access quality care. 

CCBs were government-recognized committees that received funds from district governments to 

help them deal with local issues. CCBs received 80% of the funding they required from the district 

but had to raise 20% within the community. However, the sustainability of CCBs is questionable, 

given the rollback of the local government program (including the budget that had been allocated for 

CCBs) in the districts, subsequent to Amendment 18. 

Strategies for Dissemination of the Messages to the Communities 

Mass Media (videos and film) 

PAIMAN produced five commercials that were aired on national television for a 3-month period of time, 

on at least a daily basis during prime time. A 13-episode video drama series was produced and also aired 

on Pakistan TV. The videos were presented sequentially over a period of three months and repeated 

several times during that period. These media materials were launched at very public ―mega-events‖ in 

order to draw attention to their release and stimulate interest in their dissemination. A feature film was 

produced, but, to date, only promotional clips have been viewed by a limited audience. 

Of the informants interviewed outside the urban settings, few were able to recall health-related 

messages from the mass media. However, the number interviewed was too small to allow 

generalizations to be derived from the findings. Another consideration applicable to this low recall may 

relate to inconsistent power supplies, which limit access to electronic mass media. The film itself has not 

been distributed for general viewing because of mixed reviews when the promotional video was shown. 

On the basis of the evaluative information available at this time, the cost-benefit of this approach is 

questionable. 

Theater 

Street theater and puppet shows are a traditional form of community entertainment. These CAM 

strategies were implemented by local NGOs during local events such as fairs or focal point gatherings. 

Community theater, particularly puppetry, had been used by other health programs and was thought to 

be an effective tool for communicating information because it was more likely to reflect the profile, 

language and interests of the community in which it was performed. The disadvantage of this form of 

media is in its limited audience reach, dependent as it is on a very high human resource commitment. 

The number of beneficiaries reached by this CAM strategy could not be ascertained by the FTE, so it 

was difficult to say what impact it might have made. Moreover, this outreach strategy had not been 

formally evaluated by PAIMAN in terms of effectiveness. The few community members interviewed by 

the FET could not recall the messages. 

Community Events 

PAIMAN also sponsored larger-scale events such as health fairs or medical camps, during which health 

messages were disseminated. Project documents from 2008 indicate that a total of 395 of these events 

resulted in outreach to some 82,500 individuals. While these events helped promote PAIMAN’s 

assistance to the MOH and the availability of improved MNH services in the area, their impact on 

uptake of messages had not been evaluated, and the reach was low compared to the work of LHWs and 

CHWs. However, health fairs in rural areas may improve access to needed services (e.g., TT 


vaccinations, antenatal checkups) and increase a community’s belief in government-run services 

generally, which may enhance the value of this type of event. 

Private Sector Outreach 

Greenstar, a consortium partner in the first half of the project, had promoted its Good Life private 

sector clinics (discussed further under SO2) through a variety of mass media (TV spots, billboards) and 

IPC activities. Greenstar’s commitment to the PAIMAN Project was to ensure that private providers 

conducted free service days to encourage uptake of services by disadvantaged women in their 

catchment area. The challenge was to reach rural areas, where women had less access to quality 

services, as Good Life clinics were mainly urban. 

Advocacy 

The PAIMAN Project strategized an outreach to groups—including members of the local government, 

ulamas, and members of the print media—that could influence and mobilize opinion. Messages were 

distributed to members of these groups through personal and organizational contact, and through 

orientation and training events that focused on the MNCH messages that PAIMAN hoped these groups 

would then transmit to others in their domain of influence. The FET thought this could be an effective 

strategy in order to achieve increased awareness of MNCH issues and enhance commitment to 

improving the situation for mothers and newborns because of the magnitude of the potential audience 

reach. 

Prayer Leaders and Ulama 

Friday prayers include a sermon that offers advice and guidance. Friday prayers are largely attended by 

all men in the community; therefore, including MNCH issues during Friday prayer sermons was an 

innovative and potentially effective CAM strategy. An evaluation conducted to assess the effectiveness of 

this strategy (JHU/CCP, 2010) indicated that men paid attention to these messages. Therefore, when 

such issues as the responsibility of men to safeguard pregnant women were highlighted with the support 

of quotes from the Quran and Sunnah, the messages were expected to have a greater impact. This CAM 

strategy was noted to be particularly creative and important, given the difficulty in reaching this target 

audience (men) through other activities. 

Conclusions 

The intended beneficiary population was very extensive and included a large number of target groups to 

be reached via an equally large number of activities and events. Some of these innovative strategies had 

the potential to have a substantial impact. 

The project had been using means of outreach to the various community groups that had been found 

effective in other settings; however, individual events in individual community settings have likely not 

reached the number of the population that would be sufficient to produce evidence of a behavioral 

change. Mass media approaches can be effective in creating behavior change but are not invariably so 

(Wakefield et. al., 2010) and depend on a successful and simultaneous mix of other media as was the 

goal in PAIMAN. All events taken together, including the effect of mass media (such as music and drama 

videos), have not been evaluated for their effect on behavior change. There was evidence (from Lot 

quality assurance sampling and anecdotally acquired by the FET during field visits) that community 

members had increased their knowledge about the importance of antenatal care attendance and had 

actually taken up this practice in their most recent or current pregnancy. Interventions that 

demonstrated the most promise for success included the outreach via LHWs and other means of 

interpersonal contact, including the women’s support groups and local NGOs. These could have been 

scaled up as the evidence of their effectiveness emerged over time. 


The budget for the CAM components of PAIMAN was substantial. Due both to the considerable budget 

allocation and the number of innovative activities, PAIMAN estimated that they reached several million 

individuals through home visits, support groups, events and mass media. The SO1 component of this 

project improved knowledge and awareness of MNCH issues, particularly among the LHWs who can 

sustain the dissemination of this awareness to their communities. 

SO2: INCREASING ACCESS TO MATERNAL AND NEWBORN HEALTH 

SERVICES 

PAIMAN worked at two levels to increase access to maternal and newborn health services. Two 

activities were conducted at the policy level. An effort was made to involve private sector providers in 

the provision of maternal and newborn services through training private providers in best practices by 

the collaborating partner, Greenstar. Pakistan’s private sector providers provide 35 to 60% of maternal 

health care services. Private sector providers include public sector employees (doctors, LHVs, etc.) who 

provide services in their off-hours. Substantial effort was invested in supporting the GOP PC-1 initiative 

to create a new cadre of community-based midwives, which is discussed more fully under SO4. The 

CMW is expected to join the private sector service cohort. 

Activities conducted at the community level revolved around the ―first delay‖ (the decision to seek 

care). These activities were intended to reduce the cultural and attitudinal barriers to health care for 

women through greater community involvement in MNCH health promotion. Pragmatic activities 

addressed the issues related to the ―second delay‖—physical access to first-level health care services, 

across the home to facility continuum. These included orienting TBAs to the use of clean delivery kits, 

promoting the establishment of birthing homes in which CMWs would provide their services, 

conducting short-term medical camps where community members could obtain ad hoc services and be 

informed about the availability of on-going (and improved) services at public health facilities, and 

providing emergency transport ambulances, including training of drivers and paramedics in basic life 

support. Community mobilization activities included the involvement of community members (e.g., men, 

religious leaders, TBAs, and women of all ages) in identifying the social, religious, and financial factors 

that constrained access, and finding solutions (e.g., broadening the scope of authority for making these 

decisions, creating emergency loan funds). 

Findings 

Greenstar 

Greenstar is a social branding enterprise that engages private sector providers in a quality service 

network. Providers who join the network receive continuing education on practice topics and assistance 

in social marketing of their services. Providers are entitled to place the Greenstar logo, a symbol of 

quality service provision, at their practice site. Providers, in turn, are expected to participate in quality 

improvement supervision activities and to offer a certain proportion of their services free of charge or 

at discounted rates. 

Training 

Greenstar’s contribution to PAIMAN activities included both training and service provision. Greenstar 

provided training to private sector lady doctors on MNCH practices, including basic and emergency 

obstetric and neonatal care. Greenstar notes that this ―refresher training‖ was actually, in some cases, 

training for new skills not acquired in pre-service education, particularly with respect to newer 

evidence-based practices. However, these trainings were criticized by several knowledgeable informants 


for the selective omission of certain skills, such as use of the partograph and the Active Management of 

the Third Stage of Labor (AMTSL) protocol, which were arbitrarily deleted from the training agenda. 

Clinical Services 

Private providers included those who did and those who did not offer maternity surgical services. The 

training of private doctors in Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) 

resulted in the creation of a network of franchised, trained surgical service providers in the ten original 

PAIMAN districts. Greenstar also introduced to communities Clinic Sahoolat, a free consultation day 

performed by health care providers in the GoodLife network for residents of low-income urban 

communities in PAIMAN districts. 

Some of these services were accessed by payment using a pre-paid voucher. A pilot program introduced 

in year 4 of the project in DG Khan enabled 2,000 pregnant women to purchase a voucher for Rs100 

that entitled them to receive two antenatal care visits, two tetanus toxoid (TT2) injections, 

uncomplicated vaginal delivery (C-section at a modest cost), and one postnatal and FP counseling 

session. The women were also reimbursed transportation costs to access the private doctor. The 

voucher program addressed both the demand and supply sides of a ―pay for performance‖ approach 

designed to increase access to health care services. Women were encouraged to seek care from 

Greenstar’s private practice network providers. The fee paid to providers was a financial incentive to 

provide covered services to women in need of such services who may not have previously looked to the 

private sector for this purpose. Greenstar reported that very little enthusiasm was generated by this 

scheme. Nevertheless, they were replicating the pilot in Jhang district. PAIMAN funds were replaced 

with funds from the German Development Bank (KfW) and the local government. 

Both Greenstar and PAIMAN reported that they encountered a substantial barrier in collecting data 

about services provided, particularly with respect to collecting data on the number of births and 

obstetric emergencies managed by these private partners and in maintaining contact for follow-up of 

those trained. Baseline data are not available; therefore, it has not been possible to quantify any impact 

the project may have made. PAIMAN points to this fact as a major reason for ending its contract with 

Greenstar in the final years of the project. Greenstar notes that they had little or no control over 

follow-up of private providers and that providers moved out of the network with high frequency. 

Greenstar did experiment with the use of mobile phones as a data collection tool and reports about 

50% efficiency from this pilot project. 

Traditional Birth Attendants 

The majority of births in Pakistan take place in the client’s home, and the vast majority of these home 

births (52%, cited in PDHS data) are attended by TBAs (a.k.a. dais). Therefore, an essential component 

of any strategy designed to impact the decision to seek care is the inclusion of TBAs in this decisionmaking 

process. The impact of training TBAs on maternal and neonatal outcomes has been studied 

extensively, using data from a quarter century of emphasis on this strategy. A meta-analysis of these 

findings indicated a promising role for TBAs in recognizing danger signs and encouraging referral to 

health facilities (Sibley & Sipe, 2006; Sibley et. al., 2007). Similarly, recent research has emerged that 

demonstrates the added value of the use of a clean delivery kit in reducing neonatal and maternal 

infections (Darmstadt et. al., 2009). 

The GOP/MOH acknowledges that TBAs (dais) will continue to be the first point of contact for many 

women in the country and particularly for rural residents. For that reason, PAIMAN included the 

orientation of TBAs as a core component of its strategy for increasing access to care. Two partners and 

two models were utilized. 


PAIMAN engaged Greenstar Social Marketing (the private practice collaborative partner) in the conduct 

of a 4-day TBA orientation. (Documents vary, some noting a 4- and others noting a 6-day program.) The 

agenda included discussion of clean delivery practices, an emphasis on recognizing danger signs during 

pregnancy and in the newborn, and creating networks and linkages between TBAs, the CMWs that 

would be moving into communities, and providers in the health facilities (LHVs and lady doctors). TBAs 

were introduced to the various outlets from which the clean delivery kits could be purchased. A oneday 

follow-up was conducted. The TBA orientations conducted by Greenstar were sub-contracted to 

the Midwifery Association of Pakistan (MAP) because Greenstar did not have prior experience in 

working with this cadre. PAIMAN states that the client-centered approach favored by PAIMAN was not 

included in the orientation agenda. However, a client-based assessment of the effectiveness of this 

orientation was incorporated into the program design. A health services officer went into the field to 

question mothers as to whether the TBA had used the clean delivery kits in any or all of the deliveries 

she had conducted. 

JSI also conducted a TBA orientation designed on the model established by the SMART Project in DG 

Khan (see below). The program included a client-centered 8-day orientation focused on clean delivery 

practices, recognition of danger signs, and referral to and coordination with other community-based 

workers. The strategies for provision of follow-up in the JSI program are unclear. 

The effect of dai (TBA) training was the subject of an operations research study conducted by The 

Population Council. The dais who were the subjects of this assessment were trained under the SMART 

project, a PAIMAN predecessor, in district DG Khan. The operations research study reviewed the 

retention of knowledge and the application of skills, using a prospective comparison design in which dais 

who had not participated in the training but who would have met eligibility criteria for training were 

used as the controls. Results of the study indicated that dais who had participated in the training 

demonstrated higher levels of knowledge about recognition of danger signs in pregnancy (including 

eclampsia) and actions to take in the event of postpartum bleeding. Trained dais were observed to 

perform cleaner delivery practices and were more knowledgeable about how to care for the newborn 

(resuscitation, warming, cord care and the initiation of breastfeeding). These orientation curricula used 

in the PAIMAN dai training had similar content; therefore, similar positive outcomes might be 

anticipated. 

Birthing Stations 

PAIMAN established birthing centers to improve access to MNH services via public-private partnerships 

in remote areas. These birthing centers were established by the sub-grantee NGOs in collaboration 

with the concerned district health departments at redundant and non-functional health facilities. The 

NGOs paid the salaries for the staff of these facilities, which included one LHV, one TBA and one 

security guard. These staff resided at the birthing center and provided round-the-clock services. District 

health departments were responsible for the supplies, utilities and repair/maintenance of the buildings. 

These birthing centers provide antenatal care, postnatal care, neonatal care services and TT vaccination. 

There is little discussion of this activity in the fifth and sixth year annual reports. PAIMAN Project staff 

noted that the project stopped providing financial support for these stations in the spring of 2010 and 

asserted that each of the stations is still in operation around the clock, with support received from local 

community committees, the Peoples Primary Health Initiative, or the government. However, the FET 

found during a site visit to Buner District that the birthing station at Basic Health Unit (BHU) Korea had, 

in fact, been closed as of August 30, 2010. The sustainability of other birthing stations under these local 

and government-supported strategies is certainly an open question. 


Emergency Transport 

PAIMAN’s approach to improving access to emergency MNCH services was multifaceted. Interventions 

at the grass-roots level included helping the community establish a variety of emergency loan schemes 

or transport services. For example, in one BHU visited by the FET, a male member of the community 

who owned his own vehicle had let community members know that they had only to call upon him and 

he would provide the necessary transport free of charge. A CMW at her own birthing station had 

identified several male community members who had agreed to arrange the transport of women 

experiencing complications at or following delivery, using any means available (e.g., tractor, motorbike, 

automobile). Men and women interviewed in various communities informed the team that they had 

established emergency loan funds for the purchase of vehicle fuel, to be repaid in installments over time. 

PAIMAN also provided substantial numbers of emergency transport vehicles to a broad variety of health 

service facilities, from BHUs through to tertiary care hospitals. The ambulance drivers and paramedic 

staff of these ambulances received training in basic life support. 

Community Involvement 

The gentleman who had offered the use of his personal vehicle was a member of a CCB. The 

development of CCBs had been fostered by PAIMAN as one strategy for promotion of greater 

community involvement and attention to community health challenges. CCBs were designed to serve as 

an intermediary between the community and the administration and staff of the associated government 

health facility; to share responsibilities for care, uptake, and improvements in the service delivery 

settings; and to solve community problems such as the need for emergency transport. 

Other community-focused activities to promote increased community involvement were less evident in 

project documents, through field visits or in interviews conducted at the community level. Certainly, 

some of the communication strategies, such as LHV support groups discussed in SO1, could be 

considered as one such strategy. The outreach to religious leaders could be another example. Various 

project reports speak about additional activities, such as medical camps and screening of blood donors, 

to create an available pool of identified blood group donors in the event of emergencies. The activities 

proposed in the Cooperative Agreement are worded very vaguely, and it is noted that this initiative will 

be left mainly in the hands of local community groups and largely unmonitored. 

Results 

The following project outcomes were anticipated for SO2: 

 

 

Higher use of antenatal and postnatal care services, of births attended by skilled birth attendants, 

contraceptive use, TT 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. 

Maternal Health Care Services - PAIMAN 

Figure 2 depicts project outcomes from 2007, 2008 and 2009, and the first half of 2010, drawn from 

health facility data in the ten original PAIMAN districts. The figures were generated by PAIMAN, and 

because numerator and denominator data are not provided, it is not possible to compare changes as 

rates, but only as changes in numbers. (Therefore, some of the increase could be attributed to an 

increase in population.) The figures denote that the number of women using prenatal care increased by 

60% and TT2 immunization by 54% over the 3-year period. These figures indicate a positive trend 


Thousands 

toward increases in two important maternal care services. However, as previously noted, without 

comparative data with non-PAIMAN districts, these increases cannot be conclusively attributed to 

PAIMAN’s efforts to increase access to services. 

The data in Figure 2 are drawn from the RMOI and thus do not reflect private provider services. 

Consequently, the figures cannot be compared to similar trends that might have been occurring in the 

general population as a result of generally increased community awareness of the importance of these 

health care services. Endline household survey data indicate that the vast majority of respondents in that 

survey (71.2%) were receiving antenatal care services from the private sector. 

The postnatal care visits by LHWs increased by only 10%. This less impressive finding has implications 

for the health of both the mother and her newborn because a large proportion of both maternal and 

neonatal morbidity is clustered in the vulnerable 72-hour post-birth period. It is likely that TBAs also 

visit the client home during this period, and it is therefore laudable that the TBA training orientation 

included alertness to danger signs and encouragement of referral when indicated. A total of 391 TBAs 

were oriented by Greenstar, and 1,884 were oriented by PAIMAN. A total of 50 facilitators were 

trained to conduct these orientations. 

Figure 2: Key Maternal Services Original PAIMAN Districts 

350 

Key Maternal Services 

Original PAIMAN Districts 

300 

250 

200 

60% 

54% 

150 

100 

- 

50 

10% 

2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 

Pregnant women receiving 

first ANC at Health Facility 

Pregnant women receiving 

at least 2 doses of TT 

Postnatal visits made by 

LHW 

Note: 2010 data is January-June only 

Source: Contech Endline Survey, 2010 

Data from the endline household survey indicates that skilled birth attendance had increased from 41.3% 

to 52.2%, and that the proportion of normal vaginal deliveries taking place in the home had decreased 

from 63% to 52%. Ignoring the minor differences in proportions, it is, in fact, possible that the majority 

of deliveries that occurred in places other than the client’s home were, in fact, facility deliveries assisted 

by SBAs, either as vaginal, operative-assisted or C-section births. (The very minimal proportion of births 

that may have occurred in CMW maternity homes are not addressed in this discussion.) These findings 

would indicate a positive trend toward SBA-attended births taking place in facilities in the PAIMAN 


districts in which these household surveys had been conducted. This interpretation is supported by 2008 

MICS data, which denote a facility delivery rate of 56.5% in all urban settings. 

Still, a majority of births occurred in the client’s home attended either by TBAs or some cadre of skilled 

provider (e.g., LHV, CMW). A total of 50 facilitators were trained by JSI for the purpose of orientation 

of TBAs to ways of attaining better/improved practice. A total of 2,275 TBAs were oriented (1,884 by 

JSI, 291 by Greenstar/MPA) against a total target of 2,250. The TBA is self-identified but very visible at 

the community level in the country. Informants stated that the TBAs invited to this training were those 

who practiced in the vicinity of health facilities and private providers. There would be little way of 

knowing what proportion of TBAs in PAIMAN districts were included in this training activity; 

nevertheless, this figure of over 2,000 training participants is remarkable. 

There are few data available in any PAIMAN-generated documents addressing contraceptive prevalence 

rates. It is not possible to comment on achievement of that objective. The case fatality rate indicator had 

been dropped on recommendation of the MTE team, given the small incidence per facility (and therefore 

unstable estimates and parameters). Enhancement of basic and emergency obstetric care is discussed in 

SO3. 

Maternity Health Care Services via Public/Private Partnership – Greenstar 

Given the high proportion of providers in the private sector, the number of private practice providers 

engaged by Greenstar could be considered rather modest. However, both end-of-project targets were 

achieved or exceeded. A total of 50 GoodLife surgical clinics and 569 non-surgical clinics were 

established. The Greenstar GoodLife network also provided free consultants through Clinic Sahoolat. The 

clinics are free consultation days performed by health care providers of the Greenstar GoodLife 

network. PAIMAN monitoring data indicate that more than 3,000 free days of service were provided 

and over 68,000 women benefitted from these services. 

Emergency Transport 

A total of 76 purpose-built ambulances were provided for emergency obstetric cases and other 

emergencies. An additional 50 Suzuki vans were converted to ambulances for use by communities in five 

districts to transport patients to health facilities. Thirty vehicles were distributed to district or private 

hospitals; 17 at the THQ and 29 at the RHC level in each of the country’s districts, FATA and KPK. At 

least one ambulance was provided at each of the 31 facilities upgraded by PAIMAN. The financial cost of 

these vehicles was not available to the FET, so it is not possible to comment on the cost-utility of this 

project activity. This was a major project expense and a very focused strategy for improving access to 

MNCH services; therefore, it is regrettable that PAIMAN did not do more to track the impact of this 

intervention following hand-over to the government and/or community. 

The vehicles were intended solely for the purpose of transport between facilities when referral to a 

higher level of care was required and were intended to be used primarily for transfers of those in need 

of MNCH services. The service is intended to be free of charge, but anecdotal evidence suggests that 

users are asked to offer small compensation to the driver or to pay for fuel. A structured system for 

tracking the appropriate intended use of these ambulances has not yet been developed. Accountability 

has not been assigned at any level. 

A second approach for provision of emergency transport services was the development of a 

comprehensive community emergency ambulance service strategy. Fifty Suzuki Bolan vans were 

procured and converted to ambulances. These vehicles were handed over to District Health 

Departments and in rural areas are operated by NGOs. There is little additional information available in 


project documents that describes the strategies employed to verify the use ―as intended‖ of these 

vehicles or their current operational status. PAIMAN reports this activity to be another example of 

public-private partnership. 

Finally, via a public-private memorandum of understanding, the private charity Edhi Ambulance Service 

agreed to give priority to all obstetrical/gynecological emergencies in seven of the ten original PAIMAN 

districts (excluding Jaffarabad, Upper Dir and Buner). Again, the FET could not derive any further 

information on this topic from project documents. 

The indicator of ―reduced cost, time and distance‖ is more difficult to quantify. The endline data show 

no difference from baseline in median time to get the transport (20 minutes) and median time to reach 

the health facility (30 minutes). These findings offer little information about the impact of the ambulance 

intervention on ―timely care.‖ However, the total of 50 minutes for seeking and reaching care is well 

within the limits cited in the United Nations Process Indicators for basic (2 hours) and comprehensive 

(12 hours) care. Anecdotal evidence derived from interviews conducted with community members 

indicated that local users of the ambulance service appreciated its availability. Interviews with health 

personnel indicated the perception that women had reached referral facilities in time to receive the 

benefit of more timely care (steps 3 and 4 of the pathway to care and survival; the second and third 

delays). 

Lessons Learned 

The voucher system for payment of MNCH services has proved promising in its applications in other 

countries. It did not receive the thorough evaluation it deserved in the context of the PAIMAN pilot. 

However, a replication project is ongoing in Jhelum, which was designed on the basis of lessons learned 

from the PAIMAN experience. These additional data may offer information about the suitability of 

voucher programs in Pakistan’s private sector market (Bashir et. al, 2009). 

Facility management contracting is another approach to increasing quality and access through publicprivate 

partnership. This approach has been tested through the Punjab Rural Support Program. 

Greenstar is replicating this approach in Sindh Province. They have upgraded two rooms in each of 10 

BHUs, displayed the Greenstar logo, and instituted a modest fee for services. This approach also 

warrants further assessment for client acceptability and financial viability. 

Conclusions 

Public-private partnerships offer another avenue for increasing access to services. They could prove to 

be of particular importance and value if avenues for penetration into the rural private practice network 

are exploited. 

The procurement and deployment of ambulances to public health delivery settings is an important asset 

for those facilities. However, budget commitments and allocations must be made to ensure fueling and 

proper maintenance of the vehicles over time. Accountability mechanisms must be established to ensure 

their free use by the public for the purposes for which they were intended. 

SO3. INCREASING QUALITY OF MATERNAL AND NEWBORN CARE 

SERVICES 

PAIMAN addressed the issue of quality of maternal and newborn care services through two primary 

approaches. First, PAIMAN supported upgrades to the facility infrastructure in selected government 

health facilities to enable the provision of basic and emergency obstetric and neonatal care. Second, 


PAIMAN provided training and re-training of providers in both the public (Save the Children) and 

private (Greenstar) sectors to deliver client-focused services, with an emphasis on standardized 

procedures, infection prevention and the strengthening of referral systems. 

Findings 

Contech conducted a baseline Health Facility Assessment (HFA) survey in 2005 to assess the existing 

status of health facilities regarding the quality and coverage of MNH services in the ten original PAIMAN 

districts. The list of indicators that would determine facility readiness or facility need was developed and 

agreed upon by a core team of consultants drawn from among consortium partners. The criteria that 

guided the selection of which facilities would be upgraded, with respect to all others also in need of 

upgrading, is not at all clear in any of the project documents provided to the FET prior to or during the 

site visit. Nevertheless, PAIMAN reports that consultation meetings were held and that minutes of 

those meetings (which would also include identification of meeting participants) are available. The facility 

assessment endline evaluation was conducted as a component of the District Health System 

Strengthening activities of the PAIMAN Project (SO5). 

Basic MNCH Care 

Findings from the baseline HFA indicated that only 23% of 44 RHCs, 40% of 20 THQs, but each of eight 

DHQs was capable of providing all essential BEmONC services. PAIMAN improved MOH facilities in 

the PAIMAN districts by upgrading building infrastructure and providing equipment and supplies 

necessary for the provision of basic MNCH care services. Living quarters for staff were also renovated 

where necessary in order to attract or retain service providers. This made the upgraded facilities 

capable of providing full-time (24 hour/7 day) services. 

In terms of underuse, misuse or overutilization, the FET received mixed messages regarding the 

equipment that was procured for the facilities. For example, evidence exists (directly observed by FET) 

that some deterioration (of both major and minor consequence) has already occurred in the 

infrastructure of renovated facilities and (via anecdotal evidence) that, in insurgency areas, some of the 

equipment has been intentionally damaged or used for unintended purposes (thus, of course, outside the 

control of PAIMAN). 

As noted, PAIMAN reported that consultations were held prior to infrastructure renovation and 

equipment upgrades. However, the FET observed several instances in different facilities in which new 

birthing tables had been pushed to the side of the room in favor of continued use of the older tables. 

When questioned about this fact, providers noted that they had not been queried about their 

preferences, were not in favor of the features of the particular bed-type, and were not inclined to use it 

except in cases when the older equipment was already in use. Site visits in Buner and Lasbela Districts 

identified the presence of anesthesia, ultrasound and computer equipment that was never put to use 

because the government had not assigned staff to the facility who had been trained in its operation. 

An ultrasound machine provided to one hospital visited by the FET was being used on a daily basis. 

Physicians noted with some pride: ―Now we can provide each woman with up to four ultrasounds 

during her pregnancy.‖ The physicians were also quick to note: ―We practice evidence-based medicine.‖ 

There are documented benefits for performing ultrasound in early pregnancy (Whitworth et. al., 2008) 

and for specific diagnostic purposes (such as measurement of amniotic fluid volume). However, there is 

little evidence to support routine repetition of the procedure (Bricker et. al., 2008). Clinical updates for 

evidence-based ―best practice‖ in use of obstetrical ultrasound was not noted on the clinical teaching 

topics agenda (see SO4). This could be considered both a missed opportunity and a training gap. 


Many respondents who held administrative responsibilities expressed the concern that the MOH would 

not provide sufficient budget allocations for maintaining the facility infrastructure or the equipment in 

the future. In fact, the FET was witness to discussions by some district health officers about reallocation 

of funds for the purpose of flood relief. There was evidence that renovation budgets were easily 

sacrificed to short-term needs. 

Management of Maternal and Newborn Complications 

The baseline HFA identified 20% of THQs and 63% of DHQs as being capable of providing 

comprehensive services, including obstetrical or gynecological surgery. The C-section rate as a 

proportion of total births was documented as 2.6% (189/7084) in THQs and 16% (1304/8069) in these 

facilities at baseline. Major infrastructure development occurred at certain hospitals. This included 

building and equipping operating theatres in a number of referral facilities. PAIMAN upgraded the 

existing maternal and newborn units in one hospital in Multan and built an entire second floor equipped 

to provide operative and interventive surgical services. Neonatal incubators were provided in selected 

settings, but the FTE did not observe them in use. 

Provider Training and Staffing 

PAIMAN’s ambitious training agenda is described in SO4. Public and private sector doctors received 

updates designed to improve quality performance of signal functions of basic and emergency maternal 

and neonatal care. PAIMAN also supported the salaries of staff members in selected facilities where 

there were not sufficient personnel to provide 24-hour coverage for delivery of CEmONC services. 

Gynecologists and anesthesiologists were contracted to enable performance of C-sections in selected 

upgraded facilities. 

The FET spoke with a number of these contract personnel. They expressed a high degree of satisfaction 

with the quality of the training they had received, noting in a few cases that the content of the training 

was new information, not re-learning or refresher training. 

The lack of available human resources, particularly lady doctors and surgeons, presented a substantial 

challenge to enabling around-the-clock MNCH services. Various PAIMAN reports indicate that the 

human resource issues were addressed first by advocating with district health governments to fill vacant 

positions and monitor the presence of providers where assigned. The engagement of staff on a contract 

basis was acknowledged to be a time-limited solution, concurrent with the availability of PAIMAN funds. 

Client-focused Services 

PAIMAN conducted training for all levels of health service workers on the provider/patient 

communication strategy called the client-centered approach for delivery of reproductive health services. The 

methodology, approach and outcomes are described in a peer-reviewed publication from the Population 

Council (Sathar et. al., 2005). A trainer’s guide was available from that PAIMAN collaborative partner. 

Standardized Protocols and Guidelines 

The annual work plans for later years of the PAIMAN Project set activity targets for ensuring that basic 

EmONC (BEmONC) and neonatal practice protocols and guidelines were available to private providers 

and would be present in each of the PAIMAN-supported facilities in each of the ten original districts. 

The work plans provided for the production of the protocols in both the English language and Urdu 

translations. However, the extent and format of these protocols, the process by which they were 

developed or adopted, and the identity of individuals who contributed to that process are not well 


described in the various quarterly or annual reports. It is to be noted that hospital-based protocols for 

newborns were prepared by Aga Khan University. 

The FET noted poster displays on the walls of essentially every facility visited depicting step-by-step 

procedural guidelines for management of emergency situations. The most commonly occurring poster 

theme was that of adult life support (adult resuscitation). Higher level health facilities also displayed 

protocols for management of hemorrhagic shock and newborn resuscitation. 

Referral System 

An important aspect of the home-to-facility continuum is development of linkages and strategies to 

ensure that providers at each level of health care delivery have a well-established referral mechanism. 

Components include a means of communication and transport system that is necessary for making the 

transfer to a higher level of care. The transport ambulances were an important asset to the referral 

system in every district facility to which they were deployed. 

PAIMAN documents speak about the identified need to develop linkages between TBAs, other health 

providers and health facilities, and to track the number and outcome of such referrals. Pictorial referral 

slips were developed for non-literate TBAs during Project Year 4. These slips were designed to have a 

second copy so that the client could bring this information back to her primary health facility after the 

personal situation had been resolved and be provided appropriate follow-up. 

Results 

The following outcomes were proposed as measures of project success: 

 

 

Greater utilization of services to improve maternal and newborn health outcomes 

Decreased case-fatality rates for hospitalized women and neonates 

The case fatality rate indicator was dropped in response to a recommendation from the mid-term 

evaluation team. Utilization of services was measured by changes in service uptake over time. 

Facility Renovations 

A total of 79 public health facilities were equipped to provide emergency obstetric care services in the 

original and expanded districts, the two Frontier and the two FATA agencies (information cited on 

PAIMAN website). This up-grading covered all district headquarters hospitals (one per district), about 

half of the tehsil headquarters hospitals (one per district) and a quarter of the rural health centers (one 

RHC or BHU) in the original ten districts (Table 3). Renovations also included the creation of 158 Oral 

Rehydration Therapy corners and 86 Well Baby Clinics. Fourteen hospitals were assessed for Baby 

Friendly Hospital criteria. 

A total of US$11.5 million was spent by JSI on facility upgrades and US$3.5 million on equipment to 

enable provision of both basic and comprehensive care 6 for mothers and newborns. An additional 

US$90,000 was used to improve hospital waste management practices. 

6 There are six basic EmOC functions. They consist of three related to administering medications by injection (antibiotics to 

treat an infection, anticonvulsants to treat a seizure, or oxytocics to treat excessive bleeding) and three manual life-saving skills 

(manual removal of the placenta, assisted vaginal delivery, and removal of retained products of conception). Comprehensive 

EmOC consists of these six, plus Caesarean section and blood transfusion. Basic newborn care includes newborn resuscitation, 

warmth (e.g., drying and skin-to-skin contact), clean cord care, early and exclusive breastfeeding, and eye prophylaxis. 


International standards suggest that for every 500,000 population, there should be at least four facilities 

providing BEmONC and at least one facility providing CEmONC. 

Table 3. Upgraded Facilities 

Type of facility Total in 10 districts No. upgraded by PAIMAN 

DHQ hospitals 9 9 

THQ hospitals 22 10 

RHCs 40 11 

BHUs 452 1 

MCH clinics 54 0 

Overall, anecdotal evidence obtained during site visits and on-site interviews was strongly in support of 

the benefit of these expenditures. For example, providers at DHQ Kanewal stated that obstetrical 

emergency services had been increased threefold following renovations in that particular facility. Vaginal 

deliveries had increased from about 35 to over 100 each month. As many as 30 elective C-sections were 

being performed on a monthly basis. 

The floods of 2010 damaged a number of these upgraded facilities: 

 

 

 

 

Two RHCs in Sibi were each approximately 60% damaged. 

RHC Paharpur in D.I. Khan was partially damaged. 

The DHQ female section Dera Allah Yar in Jafarabad was partially damaged. 

The Civil Hospital Madyan in Swat was lost completely. 

The findings presented below were generated prior to the floods. However, the same level of facility 

performance cannot be relied upon in the future until reconstruction has once again been accomplished. 

Key Obstetric Services 

The utilization indicator is derived from the endline facility assessment survey and is depicted in Figure. 

3. Key obstetric services provided in upgraded facilities over the period 2007 through 2009 included an 

increase in facility births of 33%, 74% more obstetric complications admitted to the facilities and a 40% 

increase in the performance of Caesarean sections. 

Comprehensive care includes the additional capacity to resuscitate the newborn and provide supportive care in incubators and 

special nursery environments. 


Figure 3. Obstetric Care in Upgraded Health Facilities - Original PAIMAN Districts 


Basic EmONC services were available in all the DHQs at both baseline and endline. The proportion of 

THQ hospitals in which these services were available improved from 38% to 100%, and from 23% to 

95% in RHCs (Figure 4). 

Figure 4. Availability of Basic EmONC Services 


The endline survey data also indicated an overall improvement in availability of comprehensive services 

for mothers and newborns (Figure 5). Newborns continue to be less well served than mothers in all 

DHQ and THQ facilities. Endline findings indicate that additional efforts are required to achieve 100% 

availability of comprehensive EmONC services (including blood transfusions), sufficient and reliable 

supplies of essential drugs, availability of current service delivery protocols, and a full complement of 

human resources. 


Figure 5. Availability of Comprehensive EmONC Services 


C-sections as a proportion of total births in health facilities have increased in both DHQ and THQ 

hospitals (Figure 6). The proportion has been raised from 16% to 21% in DHQs and from 3% to 7% in 

THQs in comparison to baseline. This indicator is positively associated with the improvement of 

facilities for comprehensive EmONC services. UN process indicators have established a benchmark of 

not less than 5% and not more than 15% as a proportion of all births in the population by Cesarean 

section as an indicator of a sufficient quantity of such services. Higher proportions of birth by C-section 

(above 15%) should trigger quality case reviews to identify overutilization of elective surgical procedures. 

While the figure in the DHQs may be excessive, it might also reflect an increase in the transfers of 

women with obstetrical complications that required surgical interventions (i.e., not elective) to that 

facility. The case fatality rate is an indicator of quality. That indicator has been deleted from PAIMAN 

M&E because the denominator of births by facility does not allow the computation of reliable estimates. 

Figure 6: C-sections as a Proportion of All Total Facility Births 




Infrastructure upgrades contributed substantially to enabling the provision of 24/7 basic and 

comprehensive emergency obstetric and neonatal care in each of PAIMAN’s original districts. 

Comparison data are not available for assessing this impact in the expansion districts. Nevertheless, 

infrastructure improvements, while necessary, are not sufficient to ensure that services will continue to 

be provided at a high level of quality. Training providers to perform the signal functions of EmONC is an 

essential corollary, and this was addressed by PAIMAN (see discussion in SO4). However, the role of 

the MOH in the deployment and retention of these personnel is critical to sustainability. The MOH also 

has an important responsibility to ensure a system of continuing education, supportive supervision and 

continuous quality improvement for providers, and for essential maintenance of the care environment. 

It is also clear that the costs of these improvements can be quantified but that cost-effectiveness remains 

elusive and challenging to measure. Trends in uptake of services are an indication of service quantity, but 

not necessarily of service quality. Comparative data are essential if a clear picture of the impact of 

interventions is to emerge. Although PAIMAN had this opportunity from the outset of the project, it did 

not craft the M&E strategy to accommodate such a between-groups design. An important learning 

opportunity has been lost. 

Conclusions 

The facility renovations were a very valuable investment that increased the ability of the MOH to meet 

international guidelines for provision of basic and comprehensive emergency obstetric and neonatal care 

in some of its service settings. Funds for the long-term maintenance of facility infrastructure must be 

given protected status in provincial and district health budgets. Human resource deployment policies 

that ensure that qualified staff are assigned to those facilities over the longer term must be a concurrent 

priority for the MOH. Infection-prevention procedures and policies and procedures for infectious waste 

management require urgent attention in all health delivery settings. 

SO4. INCREASING CAPACITY OF MATERNAL AND NEWBORN HEALTH 

CARE PROVIDERS 

The PAIMAN approach to developing the capacity of MNCH providers was to recognize the critical 

importance of the continuum of care and the essential importance of the enabling environment. This 

awareness required that PAIMAN address the training needs of all health service providers at all levels 

of care, from home, through community-based services, to referral services provided at tertiary level 

facilities. The importance of appropriate facility infrastructure as an element of the enabling environment 

has been addressed in the discussion of SO3 (strengthening quality of services). 

Findings 

Clinical and Leadership Training 

PAIMAN and its project partners, including Aga Khan University, were engaged in the development of 

competency-based training modules and materials on a wide variety of maternal and newborn health 

topics addressing current ―best practices‖ in the care of women and newborns. A cohort of master 

training teams drawn from each district was developed so that future training could be conducted at the 

district level. Training participants were drawn from both the public and private sectors, and 

represented the full continuum of community- and facility-based health providers, such as TBAs, LHWs, 

LHVs, the new cadre of CMWs, fully qualified midwives, and physicians. 


The focus of this training was fully described in the Mid-term Evaluation, and several suggestions were 

made for improvements in the content of training over the remaining life of project. Specific 

recommendations were made to include certain evidence-based ―best practice‖ topics in the training 

curriculum (in particular, use of the partograph and the AMTSL protocol) and to increase the 

opportunity for clinical practice of skills that were modeled by simulation only. The Karachi Declaration 

signed in October 2009 by leaders in the Ministries of Health and Population Welfare affirmed the 

commitment of the GOP to scaling up MNCH/FP practices and called for scale-up of seven clinical best 

practices, including the two named above. 

SAVE, the PAIMAN partner primarily responsible for the training agenda, developed the training 

strategy, designated the participants, adapted already developed competency-based training materials 

(for resource efficiency), and designed a quality assurance model for following up the short- and longerterm 

outcomes. SAVE chose to use an external monitor for assessing clinical skills in order to add 

objectivity to the process. 

The training agenda for facility-based providers included: 

 

 

 

 

Normal delivery; 

Essential maternal and newborn care (antenatal and postnatal care, management of normal 

deliveries, management of nonsurgical maternal complications, essential newborn care, and 

management of asphyxia, sepsis, jaundice and low birth weight); 

Comprehensive EmONC (surgical intervention skills); and 

Infection prevention. 

Essential maternal and newborn care training was offered to health care providers from all upgraded 

facilities and from all other facilities where a health care provider was posted. The coverage estimate 

was 80 to 100% of all eligible providers in Phase I. 

The later years of the project also included a focus on children. Consequently, topics in infant and young 

child feeding and community-based IMNCI training were introduced, but topics that might have 

improved the status of youth reproductive health were absent from the communication strategy and 

most programmatic content. 

Phase II training in EMNC, IMNCI and IYCF was provided primarily to staff in upgraded facilities and a 

very few other providers who were selected or designated to attend. The coverage approved by USAID 

was a target of 70% of facility-based staff and 60% of community-based staff in all districts. The criteria 

for selection and nomination of health staff are outlined in the training strategy developed by SAVE. 

Additional training was targeted to increase the skills of providers to be effective leaders at the facility 

level and among community members. These training topics included: 

 

 

 

How to organize and conduct community-based support groups; 

The client-centered approach to care; and 

Leadership skills. 

Many informants commented on the nature of these training events in terms of length, learning venue 

and value to practice. The majority of these informants spoke of the value of participation in the training. 

On the other hand, a number of individuals who had personally participated in one, and often more than 

one, of these training courses described them as ―duplicative,‖ ―uncoordinated‖ and ―fragmented.‖ 

Several informants stated their perception of a focus on ―numbers trained‖ rather than ―value acquired.‖ 


The Mid-term Evaluation had, in fact, recommended that training in EmONC be consolidated and unified 

so that the content of any single training event was consistent with international standards. PAIMAN 

apparently disputed the comment and recommendation of the Mid-term Evaluation and asserted that 

training materials were developed according to international standards and that training sessions were 

taught by tutors from highly respected teaching institutions (such as Aga Khan University). Since all 

training events had been completed by the end of the project, the training materials were not further 

evaluated by the FET. However, as evidence continues to emerge, training materials already developed 

would have to be reviewed and possibly amended to reflect clinical updates prior to any next use. 

Informants also noted that learning acquired in training conducted outside of the practice environment 

(e.g., in hotel venues) was not necessarily, readily, or easily transferred to the practice setting where 

specific equipment or supplies (as modeled in the training) might not be available and when there was no 

follow-up to ensure transfer of skills. The MTE had also called for a more judicious selection of training 

participants, i.e., those who worked in facilities which could be considered an ―enabling environment‖ 

for practice according to quality standards and for follow-up of lessons learned. The SAVE 

representative and the PAIMAN COP acknowledged that the project was handing over a list of 

participants to MNCH so that future training could be targeted to include those individuals who had not 

yet received any training and those who were more recently employed in relevant health delivery 

settings. 

The occurrence of the country’s flood disaster concurrent with the timing of this evaluation gave rise to 

the opportunity to inquire about the value that the training may have offered to the country in terms of 

disaster preparedness and disease mitigation. Provincial and district health officers who were 

interviewed stated quite affirmatively that the training related to basic maternal and child health and 

cIMNCI had been particularly valuable and important to the quality of the work conducted in the relief 

camps. The training provided to female health workers (e.g., LHVs, lady doctors, and even a few CMWs 

who were known to have volunteered their services) was particularly valuable. 

The training in infection prevention initiated at the midpoint of the project and the life-of-project was 

very modest (360 participants). PAIMAN joined efforts with UNICEF to build the capacity of health care 

providers and managers in infection prevention and control (IP&C) capacity. Lady Aitcheson Hospital, 

Lahore, was selected as a model hospital and training center for IP&C training. Two sets of training were 

designed: 3-day and 6-day versions. Facility IP&C plans for each facility were developed as a learning 

exercise and pilot tested in eight selected health facilities. Facility upgrades (discussed in SO3) included 

provision of incinerators in ten PAIMAN-supported hospitals. 

However, the observations of the FET concerning infection prevention practices generated some 

substantial concern, most particularly in practices surrounding solid waste management. These 

observations were consistent at all service delivery levels. Most facilities deposited their waste (including 

needles and sharps) in open pits, to be buried when the pit had reached three-quarter capacity. 

Incineration was used only by the higher-level facilities and, even then, not in all cases. The FET 

considered this to be a very weak element, if not a missed opportunity, for PAIMAN in its training 

agenda. 

Community Midwives 

According to knowledgeable informants, the need to increase access to SBAs at the community level has 

been acknowledged for some time and particularly since Pakistan became a signatory to the MDGs. The 

interest in achieving a rapid scale-up of the SBA workforce seemed to be a factor that prompted 

decisions by the GOP MOH and its MNCH program to move forward with creation of a new cadre of 

health workers to be recruited from the community and expected to return to live and work in the 


community (UNFPA, 2010). Development of this cadre is a specific strategy outlined in the GOP MOH 

National Maternal Newborn and Child Health (MNCH) Program plan for 2006 – 2012 (PC-1). 

PAIMAN’s commitment to this strategy as stated in the cooperative agreement was ―to assist the GOP 

in further testing an obstetrical support network in which the community midwife becomes the focal 

point of the community-based obstetrical services.‖ 

The PC-1 states explicitly that the CMW was expected to be educated to the level of ―skilled birth 

attendant.‖ WHO defines a skilled attendant as: 

an accredited health professional – such as a midwife, doctor or nurse – who has been educated and 

trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and 

the immediate postnatal period, and in the identification, management and referral of complications in 

women and newborns (WHO, ICM & FIGO, 2004). 

The International Confederation of Midwives defines the midwife as: 

a person who, having been regularly admitted to a midwifery educational program, duly recognized in 

the country in which it is located, has successfully completed the prescribed course of studies in 

midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice 

midwifery (ICM, 2005). 

Many countries have initiated national or local efforts to improve and expand maternal and newborn 

health services in both urban and rural settings through expansion of a midwifery workforce (Calrow & 

McCall, 2005; Currie et al., 2007; Ireland et. al., 2007; Temmar et. al., 2006; Rukanuddin et. al., 2007; 

Baker, 2009; Roxburg et. al., 2009). A synthesis of findings from evaluations of these expansion efforts 

indicates that improvements in maternal and newborn health have come when midwives have received a 

firm educational foundation for practice; receive ongoing continuing education, mentoring and support; 

and practice in an enabling work environment. Both the WHO and the ICM have established 

international standards and guidelines for quality of midwifery educational schools and programs (ICM 

2005; Morin & Yan, 2007). 

The cadre of ―community midwife‖ would be acknowledged as an SBA for the country of Pakistan as it 

meets the international definition of a midwife, according to country-based criteria. Ideally, however, the 

design of the education program should be in accord with the relevant international quality standards 

established for midwifery education (WHO and ICM). According to the WHO definition, the CMW 

would also be considered an SBA if the graduate has been ―trained to proficiency‖ in the basic 

knowledge and skills competencies related to the management of pregnancy, childbirth, and postpartum 

and newborn care. 

Accordingly, the ICM criteria have been used as a framework for the assessment of the education 

strategy as developed for the country. The outcomes (i.e., ―trained to proficiency‖) will be assessed 

using information generated by PAIMAN through operations research, through research conducted by 

other development organizations also engaged in support of the CMW strategy, and by the PNC, who 

administers the qualification examination. 

Pathway to Midwifery 

Pakistan has been engaged in the education of midwives for several decades, through various education 

access pathways: 

 

All registered nurses (RNs) in Pakistan are enrolled in a fourth academic year which provides 

midwifery training as an adjunct to nursing training. 


Lady Health Visitors, who are trained in their own network of public health schools, receive 1 year 

of midwifery training following their 1-year training in public health. 

A cadre of ―pupil midwives‖ is trained in a number of public and private hospital-affiliated schools in 

a 15-month course of direct-entry (non-nursing) studies. 

Aga Khan University has submitted a proposal for creation of the first baccalaureate (undergraduate) 

program in direct-entry midwifery. This pathway, if approved, will also provide for career ladder options 

for midwives who have been educated through other pathways. It will also provide the option for 

progression through graduate (master’s degree) studies. 

Graduates from each of these education pathways are eligible to register with the Pakistan Nursing 

Council and be acknowledged as a midwife. However, knowledgeable informants, including the Registrar 

of the Pakistan Nursing Council, noted that the majority of the approximately 40,000 RNs do not 

engage in the practice of midwifery. This dual licensure inflates the estimate of midwives included in 

country statistics about the midwifery cadre. 

The CMW cadre represents a new midwifery direct-entry pathway. There was an overlap in the 

timelines of the dissemination of the PC-1 and the development of the infrastructure for CMW 

education. Many informants have questioned whether it might have been a more useful, efficient, and 

cost-effective strategy to focus on enhancing the technical competence and educational profile of one or 

more of the existing cadres for which educational infrastructure is already established, rather than 

creating the new CMW cadre, which involved the reconfiguration of many existing nursing and 

midwifery educational institutions and a realignment of responsibilities for tutors. 

Where possible, PAIMAN engaged with existing public schools of nursing to serve as the educational 

setting for the Cooperative Agreement target of 2,000 CMW students (of a total government target of 

12,000 as stated in PC-1) who would be educated with project support. These schools were affiliated 

with secondary or tertiary care facilities where students were assigned for clinical experience. Students 

had to compete for access to clinical experiences with all other cadres of student learners in these 

settings. Tertiary level health facilities host the clinical education of many cadres of health workers, and 

CMWs had little or no priority for access to mentorship from either physicians or midwifery clinicians 

(preceptors) in that setting. There was no provision for midwifery academic educators to accompany 

students to the clinical setting; therefore, CMW students had no advocate for obtaining experiences, 

and little or no midwifery mentorship or supervision of the critical learning experiences. There was a 

distinct separation between teachers in the classroom and clinical settings. 

Each of the education program directors with whom the FET visited acknowledged that this fact 

represented a substantial challenge to acquisition of skills and demonstration of competence, and also 

noted that these decisions were not in keeping with the spirit of community-based midwifery education. 

Community-based immersion experiences at RHCs and BHUs were incorporated into the educational 

model as it evolved in order to address this need for clinical practice access, in general, and, in 

particular, for practice experience that reflected the realities of the community setting. Still, in many 

instances, students were allowed to exit the program without having had the minimum number of 

clinical practice experiences defined in the PNC curriculum. Some graduates noted that they have had as 

few as five (minimum criterion is five supervised and ten independent) ―hands-on‖ deliveries. 

Competency-based Curriculum 

PAIMAN Project personnel were involved in the earliest efforts to develop the curriculum of studies for 

the CMW cadre, in collaboration with other stakeholders (e.g., Pakistan Nursing Council), donor 


agencies (UNFPA) and international consultants. The curriculum development task was initially given 

over to a physician consultant. Informants noted that this consultant was not skilled in the theory and 

practice of curriculum design, and perhaps had little understanding of the practice outcomes expected of 

this new provider cadre. Initial discussions and working documents included consideration of a 6-month 

curriculum of studies, but this proposal received little support from educators and even less support 

from the PNC and the Pakistan Midwifery Association (PMA). An 18-month (1,800-hour) curriculum of 

study (398 hours of theory and projects [25%] and 1,402 hours of practical training and evaluation 

[75%]) was eventually designed by a coalition of stakeholders (described as ―curriculum by-committee‖) 

and approved by the PNC. The PNC has recently recommended an extension of the curriculum to 20 

months (or 24; informed sources vary) in order to accommodate the need and opportunities to acquire 

clinical practice experiences, but no practical implementation plan has yet been disseminated. 

There are many existing models of direct-entry midwifery curricula, including the model contained in 

WHOs Strengthening Midwifery Toolkit (WHO, 2000; revised 2010). It is unclear whether any of these 

models were ever fully exploited during the discussions leading to curriculum design for the CMW, and 

individuals who were interviewed for this evaluation were inconsistent in their report of the timing of 

inclusion of external consultants in the process. Nevertheless, the curriculum of study presently 

approved does not meet the competency-based standards established by either WHO or ICM for 

programs of midwifery study. Specifically, the presently approved Community Midwifery Curriculum (PNC, 

undated): 

 

 

 

 

Does not reflect the totality of basic (essential) competencies defined by the ICM; 

Does not provide for a career pathway through advanced education programs; 

Is not consistent with the designated balance of (minimum) 40% theory (minimum) 50% practice; 

and 

Does not meet the minimum length of 3 years of study for direct-entry midwifery education 

programs. 

Student Recruitment and Admission 

The CMW was envisioned in the PC-1 to be a community-based private practitioner. Accordingly, it was 

deemed appropriate that the applicants be recruited from their residential communities, to which they 

were expected to return to establish their practices. This recruitment strategy has been demonstrated 

to be very successful in other countries, such as Ethiopia (the Hamlin College of Midwifery) and 

Afghanistan (Currie, et. al., 2007). 

Eligibility to the CMW programs of study is restricted to females who have passed a matriculation 

examination (10 th grade equivalent) with a minimum of 45% marks and who are between the ages of 18 

and 30 (with some flexibility in special circumstances, such as lower or higher ages at entry). PAIMAN 

had difficulty in recruiting students from one province, as they could not identify a sufficient cohort of 

applicants who met these already very low eligibility benchmarks. PAIMAN provided an educational 

enrichment course that enabled the students to sit the matrix graduation examination and then proceed 

to application for enrollment in CMW studies. 

The eligibility criteria presently approved do not meet the standards established by ICM for programs of 

midwifery study. Specifically, the eligibility of applicants with a 10 th grade equivalent of education is not 

consistent with the standard of completion of secondary education as the minimum entry level of 

students. 


Midwifery Tutors and Preceptors 

The tutors and preceptors who were tasked (by government) or requested (by PAIMAN) to engage in 

the education of this new cadre were drawn from existing schools of nursing or public health in the 

country. RN instructors would have received midwifery education in their own basic program of study. 

It was the opinion of informants that some, if not all, of the ―nursing instructors‖ in the public teaching 

institutions were prepared for the teaching role through study in a two-year diploma program of ―ward 

and teaching administration.‖ The PNC noted that they were proposing development of a two-year 

program that would emphasize both teaching skills and midwifery clinical practice to generate a cadre of 

midwifery tutors, but that program has not been formalized. 

A universal opinion was expressed by each principal interviewed by the FET that few or none of the 

nursing instructors who were selected to teach the theoretical content had any recent clinical practice 

experience in the midwifery role and were therefore not fully prepared to teach the clinical skills 

component of the CMW curriculum, even in simulated practice. Principals of the teaching schools also 

expressed their concern that the preceptors (physicians and LHVs who supervised students in the 

clinical practice setting) were unfamiliar with the expected outcomes of CMW education and needed a 

more in-depth orientation to the scope of CMW practice. 

These plans and strategies for crafting a midwifery tutor and preceptor workforce do not meet ICM 

standards for midwifery education programs in all cases. ICM standards require that midwifery faculty: 

 

 

Demonstrate competency in midwifery practice, generally acquired through two years of full-scope 

midwifery practice; and 

Maintain competency in midwifery practice and education. 

PAIMAN and the USAID-sponsored TACMIL project that was conducted simultaneously with PAIMAN 

CMW training (December 2007 to December 2009) both provided extensive knowledge and skillbuilding 

―refresher‖ training to strengthen the capacity of tutors and preceptors. This training may 

actually have represented ―new learning‖ for tutors who had not been engaged in midwifery practice in 

recent years, as the scope of evidence-based midwifery practice has evolved. 

Several informed respondents expressed some regret about the awkward timing of the TACMIL project 

with respect to its role and responsibility for strengthening specific aspects of the CMW strategy (tutor 

training, regulation). These opinions serve to reinforce the concern that the PC-1 required that the 

CMW strategy be implemented prior to design and implementation of critically essential quality 

components (e.g., an established cadre of qualified tutors, sufficient academic and clinical infrastructure, 

and the existence of a strong regulatory process and authority). 

The director of the midwifery program at the Aga Khan University had a very recent opportunity to 

evaluate the PAIMAN- and TACMIL-affiliated tutors and preceptors across the country, and was of the 

opinion that they had benefitted from the skill-building sessions conducted by either of the projects and 

were functioning in the academic teaching role at a very satisfactory level. At the same time, the report 

repeats the finding of a disconnect between clinical and academic learning, and calls for action to 

strengthen the clinical aspects of teaching at the hospital and community level. 

The majority of physician preceptors in hospitals and in BHUs responsible for CMW education who 

were interviewed by the FET expressed some concern about the clinical competency of the students 

they had previously (PAIMAN-sponsored) or were currently (both PAIMAN- and MOH-sponsored) 

supervising. They stated rather affirmatively that the CMW required a much longer clinical learning 


experience, and a long-term (up to one year) period of close supervision after their graduation and 

deployment. 

Principals and tutors of the PAIMAN-affiliated schools expressed their support of the project for its 

efforts to: 

 

 

 

Engage tutors in competency-building training for both teaching and clinical skills; 

Provide certain teaching materials and educational supplies to the school; and 

Support the reinvigoration of a private school (United Christian Hospital), leading to its reaccreditation. 

However, principals and tutors of the PAIMAN-affiliated schools, reflecting on their past experience 

with PAIMAN-sponsored students and comparing that to their current engagement with students 

sponsored by the MOH, expressed the following concerns and opinions: 

 

 

 

 

 

 

 

 

Midwifery tutors in the schools of nursing were tasked to take on this new cadre even though the 

differences in curriculum between the RN-4 th year midwifery and/or LHV midwifery curriculum with 

which they were most familiar and expectations of the CMW scope of practice were not made clear 

to them. 

The eligibility criteria for students are problematic. Lack of education in the sciences is a particular 

deficit in their academic preparation for the content of the program of studies. A recent 

development has been the directive to lower the matrix mark from 45% to 40% in order to fill 

enrollment targets. These students were considered by the educators to be simply not well enough 

prepared for higher-level academic studies. 

Many students are simply too young (18 is stated as the minimum age) to accept the level of 

responsibility for the independent decision-making required of the midwife in practice. 

The community midwife should meet much higher standards of quality given that they are intended 

to practice independently; therefore, admissions and graduation and registration requirements 

should be at least equal to those of RN/midwives or LHV midwives. 

The very low teacher-to-student ratio made it impossible for tutors to accompany students to the 

clinical setting in most cases. The PC-1 designates 2 tutors for each 25 students. This ratio varied by 

education program; 2 to 3 tutors for up to 40 students was acknowledged by several principals. The 

theory/clinical interface was considered to be particularly important with respect to the distant 

community-based sites because immediate assistance is not readily available to the student in the 

event of an emergency, as it is in tertiary hospitals. 

This lack of continuity had a substantial adverse impact on the relationship between classroom and 

clinical learning, and led to ―de-skilling‖ of the academic tutors who had received the clinical upgrade 

training. 

The pass/fail standard for both written and oral examinations is set by the PNC and was believed by 

tutors to be too low for determining quality. The pass/fail standard is higher for LHVs who share the 

identical midwifery responsibilities. 

The supplemental monetary support given to tutors (including physician lecturers) authorized by the 

PC-1 was appreciated at the time. However, once the PAIMAN source funds ended and MOH 

became the source, receipt of payments was less reliable and timely, and many of these individuals 

are now refusing to provide the same level of service (Riddle, 2010). The lack of a reliable source of 

supplemental faculty salary has not been accompanied by any change in the teaching burden. Some 

MOH CMW classes are now being taught in the evening after a full day of RN teaching 

responsibilities have been fulfilled. 


Certain schools had, in fact, lost teaching positions following withdrawal of PAIMAN support, 

further increasing the teaching burden on remaining faculty. 

Administrators noted a perception (whether or not founded in fact) that other types of funding 

support had been given to PAIMAN students and to the schools in which they were educated (e.g., 

computers, printers, teaching equipment). They noted that this had created an unsustainable mode 

that did not reflect the program design realities which would be expected to be forthcoming from 

the MOH. 

The majority of administrators and tutors were of the opinion that the 18-month length of the 

academic program is simply not sufficient to achieve the intended outcomes of quality theoretic or 

clinical education for this cadre. 

The students do not acquire transferrable academic credits. There is no career pathway. 

The statements of midwifery students and their clinical preceptors concerning the lack of availability of 

clinical practice experiences, and the statements by graduates themselves that they had not acquired the 

minimum number of required clinical experiences raise serious questions about whether the current 

strategies for CMW education are capable of generating a CMW SBA workforce that has been ―trained 

to proficiency.‖ 

Accreditation of Schools and Regulation of the Practitioner 

The Pakistan Nursing Council serves as the regulatory authority for registration of midwives for entry 

into practice. The PNC grants approvals to the schools, sets standards for teachers, and establishes 

eligibility criteria for students. An independent Nursing Examination Board (NEB) functions in each 

province. The provincial boards develop and administer a qualifying examination and establish the 

pass/fail criteria, which (according to knowledgeable informants) has not been standardized across 

provinces from time to time. School graduates who pass the NEB assessment are awarded a diploma, 

which can then be presented to the PNC, and a license to practice (provisional or final) can then be 

awarded. Information from the PNC indicated that the NEB was challenged to keep pace with the 

examination of the volume of CMW applicants. The NEBs in two provinces were disputing several 

procedural matters, including the wording of the diploma that they would award. 

The Pakistan Nursing Council was involved in the early discussions about the creation of the new CMW 

cadre. The PNC informant indicated reluctance on the part of the existing nursing registry authority to 

become involved in the registration of the CMW, expressing the concern that there could be confusion 

about roles and responsibilities between the existing cadres of midwives already recognized by the PNC 

and this new ―direct-entry‖ (non-nurse) midwifery practitioner. However, the PNC recognized that 

having a role in approving schools and examining the candidates at the time of entry into practice would 

be in the best interest of maintaining some quality control; therefore, it accepted the responsibility for 

those activities. Nevertheless, to date, there are no written or approved standards of practice for the 

CMW. There are also no requirements for continued education and/or re-registration following initial 

licensure. 

The Pakistan Midwifery Association and several other key midwifery informants expressed the opinion 

that the PNC had no role in the regulation of midwives, who ideally should be governed by their own 

regulatory authority. The majority of midwives in the country are, in fact, not also educated as nurses, 

and the RN/Midwives already hold separate licensure in each discipline. 

The GOP has been engaged in extensive external consultation about this issue. The Global Consultation on 

Strengthening the Nursing and Midwifery Services was held in Islamabad in March 2008, as a collaborative 

effort between the GOP, WHO, ICM, and the International Council of Nurses. This meeting resulted in 


promulgation of the Islamabad Declaration, which outlines critical elements essential for strengthening 

both the nursing and the midwifery professions in the country (Searo, 2008). This meeting was followed 

by a national consultation that generated a road map for nursing, midwifery and LHV education reform. 

Governance and accountability of the midwifery profession is discussed in that document. 

Deployment and Retention 

The PC-1 anticipated that the CMW would be a private practitioner who would work in the rural 

communities. CMWs would have their most direct linkage with the Basic Health Unit, where physicians 

and LHVs would offer support and receive referrals. The LHV has emerged as the de-facto ―supervisor‖ 

of CMWs. Monthly meetings are arranged and seem to have been adopted as a uniform strategy across 

at least the PAIMAN-supported districts, although no formal supervision system has been approved to 

date. (Informants state that a plan has been developed and submitted to the MNCH program for 

consideration. This may be the same plan that can be found in the draft documents prepared by DfID 

that were shared with the FTE.) The CMW submits monthly reports of her activities to the LHV, who 

incorporates this information into the monthly reports from the facility. There is no clear or 

standardized mechanism for ensuring that these data are included in District Health Information 

Management system. 

DfID has developed an extensive deployment plan for CMWs that takes their intended independent 

status into account. PAIMAN offered substantial support to the CMWs trained by the project to 

establish their practice settings. The graduates were given essential equipment and supplies (e.g., birth 

tables, office furniture, expendable supplies) to enable the creation of maternity homes in their own 

residences or to establish a free-standing birthing center in the community. The national MNCH 

program has proposed that CMWs establish these independent free-standing facilities, rather than 

residential birth homes. The difference in community access as a function of either design has not been 

studied. A concern has also been raised about the issue of personal security in the free-standing settings. 

The GOP/MOH intends to provide each CMW with a monthly stipend of $2000 Rs as a retention 

strategy for at least two years. However, the GOP assumption of this responsibility has not been timely; 

payments have been delayed to CMWs currently in practice. 

The stipend was intended to be supplemented by fee-for-service income. PC-1 explicitly notes that the 

MOH will not set or recommend a standard fee as it is expected to vary from place to place. (There is 

also some disagreement in various documents [DfID and MOH] about the wisdom of establishing the 

CMW as a private practitioner, charging a fee for service.) The CMWs interviewed by the FET 

responded that they have set their fees according to their knowledge of the community economic 

profile. A sliding scale had been established by all CMWs interviewed, with fees ranging from free or inkind 

service (approximately 20% of clients) to as much as 5,000 Rs. The TACMIL project provided 

training in ―business skills‖ to some CMWs in recognition of their intended status as entrepreneurs. The 

infrastructure support provided by PAIMAN was likely a fundamental factor in making this business 

financially viable for the CMWs who established their business during the period of PAIMAN support. A 

few informants had had the opportunity to review the deployment guidelines developed by DfID and 

adopted by MNCH (according to informants) and noted that there is some discussion in that document 

about provision of similar infrastructure support. The FET did not have the opportunity to review that 

document during the site visit, although it was provided in the after-evaluation period. Dissemination of 

the document throughout the country has itself been delayed for an indefinite term. 

The success of the business will be largely dependent upon the trust that the CMW can establish in the 

community. The CMWs interviewed by the FET had conducted a community mapping exercise and had 


engaged in individual outreach to advertise their services. They were also being supported by LHVs and 

LHWs, who helped to spread the news of this new community-based service. 

An operational research study conducted by the Population Council assessed the potential of these 

CMWs to integrate their practices into the communities (Population Council, 2010). A major finding 

from focus groups conducted among district health personnel and community residents was that there 

was a perceived need for such a health worker and that the CMW would be accepted. LHVs and TBAs 

already present in the community noted that the CMW would be judged primarily on the quality of her 

performance and on how well she aligned her practice with that of other practitioners (both in terms of 

collaboration and in terms of fee for service). 

The FET made a visit to a non-PAIMAN-supported BHU and queried the facility personnel about the 

CMWs who were practicing in that community. Facility staff knew of four CMWs who were present in 

the community, but none of these women was conducting deliveries on her own accord. They were 

providing a valued antenatal care service and were referring clients to the BHU for deliveries. The LHV 

in the facility stated that she had offered to allow the CMW to observe the conduct of deliveries in 

order to gain additional experience. The LHV remarked that the CMWs lacked ―confidence‖ to perform 

their full function. 

Outcomes Assessments 

A second operational research study conducted by PAIMAN assessed community midwifery services in 

rural Pakistan (Population Council, 2010). The stated goal of that study was ―to provide necessary 

evidence for future decisions regarding the training, practice and placement of community midwives.‖ 

The sample of 106 CMWs interviewed in this study included CMWs who had received their training 

with PAIMAN support, either for training or for establishment of their community-based practices 

(Population Council, 2010). The findings from this study indicated that only half of the sample had met 

the clinical educational standard of 15 deliveries during the training period and that one fourth of the 

sample had experienced difficulties in arranging the community-based portion of their training, including 

lack of introduction into the community and reluctance of women to accept services from them due to 

the young age of the CMWs. 

An assessment of the knowledge acquired during training indicated a very poor level of performance on 

several key ―best practices‖ essential to skilled attendance of mothers and newborns. Less than half (for 

some skills, less than one third) of the respondents were able to state danger signs of pregnancy and 

delivery, the protocol of eclampsia management, the appropriate approach to management of prolonged 

labor, the steps of active management of the third stage of labor (AMTSL), or the essentials of infection 

prevention. Only one in ten could describe the appropriate steps in management of newborn care; only 

20% of respondents could describe how to prevent neonatal tetanus. 

These findings were augmented by an independent assessment conducted by the midwifery faculty of the 

School of Nursing & Midwifery, DHQ Hospital Jhelum, who were concerned about the quality of their 

graduates. A clinical checklist was used in the observational assessment of CMWs as they conducted 

AMTSL and postnatal care. Infection prevention practices and record keeping were found to be 

particularly poor, and family planning commodities were not available. Refresher training for these 

CMWs was arranged by the school in the interest of their own quality. 

An extensive evaluation conducted by DfID of the entire CMW strategy was reported in August 2010. 

This external evaluation is of particular importance because it reviews the CMW strategy as enacted by 

all implementing partners and thus offers an overall and objective view of the strategy. The assessment 

used random sampling methods within districts in which PAIMAN operated; as a result, some PAIMAN- 


supported schools and graduates were equally likely to have been among those included in the review. 

Findings included the following: 

With respect to training: 

 

 

 

 

 

 

 

Schools had an adequate number of theory tutors, but clinical trainers were not designated. 

The educational proficiency (educational knowledge and skills) of CMW tutors and clinical trainers 

reported and observed were deficient, and they lacked orientation to CMW training. 

Skill labs and labour rooms lacked equipment, drugs and supplies. 

Clinical training was extremely deficient both at the facility and in community settings; 16% of CMW 

graduates had not conducted a single delivery in the hospital or community (46%) independently. 

Supervision and monitoring were unrealistic. 

Logbooks did not include the full range of competencies to be mastered. 

Clinical experience logbooks were signed by faculty, but not verified prior to giving students 

permission to appear in the exam; more than 50% had not conducted the required number of 

deliveries (ten) to qualify for entry to the final exam, but were allowed to appear for the exam. 

With respect to capability and competence of the CMW graduates: 

 

 

 

73% of the CMWs were practicing, but 43% had not conducted any delivery in the last three 

months. 

Only 18% of CMWs could list all the activities included in their scope of work (as delineated in PC-1 

and the CMW curriculum). 

Significant proportions of CMWs had some theory-based information, though very few had 

comprehensive knowledge; they were unable to critically assess, synthesize and formulate 

appropriate responses to given clinical scenarios covering critical clinical topics (problem 

identification, management of bleeding). The DfID report noted the following: 

[T]his is alarming since one of the core responsibilities of these frontline skilled birth attendants 

is early identification of complication and timely referral which is vital to reduce maternal 

mortality in the country. 

Findings from these various studies clearly indicate the need for continued education and strong 

supportive supervision of this cadre. They also point to the need for some re-thinking about the basic 

approach to CMW education. 

Results 

Provider Training 

Table 4 depicts the topics addressed in the various ―refresher‖ trainings, the training participants, and 

the number of individuals trained by PAIMAN by end-of-project. 

Additionally, 164 women from the Khyber Pakhtunkhwa and Balochistan areas were supported to 

achieve 8 th grade education for LHW eligibility. 

End-of-training assessments conducted for many of these training courses indicated at least short-term 

improvement in knowledge. A strategy was developed by SAVE for follow-up of outcomes of learning 

over the longer term to address retention of knowledge and, even more importantly, to document that 

these trainings had changed provider behavior in practice, particularly in improvement in clinical skills. 

Only limited information concerning these follow-up assessments was available in project documents. 


Table 4: Training Conducted 

Focus of the training 

Provider cadre 

(Length of training) 

No. of training 

participants 

Essential maternal and newborn care Master trainers (6 days) 140 

Health care providers (6 days) 2,240 

Health care providers (4 days) 495 

EMNC monitors (1 day) 142 

Private providers 569 

Comprehensive EmONC training Health care providers (10 days) 74 

Specialists 42 

IUCD insertion Health care providers 120 

Minilap procedures Health care providers 35 

Essential surgical skills (MNCH/FP) Health care providers 312 

Vasectomy Health care providers 28 

Advanced maternal and newborn care Private providers 50 

IMNCI/C-INMCI Provincial trainers 122 

District trainers 642 

Facility level health care providers 1105 

LHWs 6,582 

IYCF Health care providers 384 

AMTSL and use of partograph Health care providers 622 

Clean delivery practices TBAs 2275 

Infection prevention Health care providers 360 

Basic life support Ambulance drivers and paramedics 276 

Support group methodology Master trainers 87 

District level trainers 1603 

LHWs 11,057 

Client-centered approach for delivering District trainers 27 

RH services 

Doctors and paramedics 402 

Leadership skills District management staff 161 

TOTAL 29,952 

Figure 7 depicts the very positive findings from one training assessment that did include a clinical 

performance assessment component at the end of training. Longer-term follow-up data to assess 

retention of learning or determine whether the skill had been incorporated into daily facility practice are 

not readily available for comparison. However, these results may re-open the question of whether to 

focus more training on the existing cadre of LHVs. 


Figure 7: Nurses/LHV Active Management of Third Stage of Labor 

Skills 

Nurses/LHV Active Management of third stage of labor Skill 

100.0 

95.3 

90.0 

80.0 

82.5 

Baseline result 

Post-test result 

Performance Assessment result 

93.6 

88.1 

70.0 

60.0 

50.0 

40.0 

30.0 

42.9 42.9 

35.3 

20.0 

10.0 

0.0 

14.4 

12.5 

4.7 

1.8 

0.0 1.0 2.1 

0.0 

41% for unskilled attendance. Maternal mortality estimates are currently being compiled and are 

anticipated to be available by late 2010. 

Community Midwives 

PAIMAN was instrumental in soliciting external technical assistance as it engaged in the development of 

its own CMW training activities. For example, a widely respected international consultant (Della 

Sheratt) was engaged to teach the master trainers and to critique the curriculum. The President of the 

International Confederation of Midwives, who was visiting at Aga Khan University, was invited by the 

University to comment on the program design. USAID also supported the TACMIL project, which ran in 

parallel to PAIMAN, and there was some interaction between the two USAID-funded projects. 

The MNCH PC-1 has established a target of 12,000 CMWs to be educated by 2012. DfID reports that 

6,574 CMWs were enrolled or had completed their training by January 2010 (Table 5). 

Table 5: CMWs by Province 

Province/Region 

Total planned 

Currently 

enrolled 

Completed 

training 

Total # of CMWs, 

currently enrolled and 

completed training 

Balochistan 1,200 344 221 565 

Punjab 6,355 2,099 1,570 3,669 

Khyber- 

1,810 1,451 27 1,478 

Pakhtunkhwa 

FATA 255 74 0 74 

Sindh 1,960 316 173 489 

Gilgit-Baltistan 140 61 0 61 

AJK 270 92 46 138 

Total 11,990 4,437 2,037 6,474 

The PAIMAN Project accepted responsibility in the Cooperative Agreement for training 2,000 of these 

providers. To that end, PAIMAN engaged in the following activities: 

 

 

 

 

 

 

44 master trainers were prepared to teach the new midwifery training curriculum. 

219 midwifery tutors were oriented to the elements of the CMW curriculum. 

22 tutors were prepared to conduct a 2-week refresher midwifery training. 

750 health care providers were offered refresher training in selected elements of birth attendance 

included in the midwifery curriculum. 

1,623 students were enrolled in the 18-month new midwifery training curriculum. 

80 women were supported to achieve a 10 th grade certificate to be eligible for CMW enrollment. 

PAIMAN supported a total of 31 CMW schools in five districts from December 2006 to March 2009. 

This support included substantial contributions to some schools to upgrade teaching facilities or student 

hostels and to subsidize the salaries of tutors (as provided in PC-1). 

Both PAIMAN and the various training institutions have attempted to keep track of student progression, 

graduation and deployment. For example, the principal of the School of Nursing and Midwifery at DHQ 

Hospital Jhelum reports that the 41 students from the first two cohorts who completed the program (of 

56 who entered) all passed the examination and have established birthing stations in their communities. 

Principals from other schools in the northern provinces report similar enrollment, progression and 


graduation rates. The experience of Balochistan, Buner and Lasbela is less favorable. The FET member 

who visited those provinces conveyed the information, imparted by knowledgeable informants, that 

many graduates have already been lost to follow-up or are known to have accepted employment in 

another field. 

PAIMAN reports the following aggregate statistics: 

 

 

 

 

1,623 admissions, 

142 drop-outs (8.7%) for personal or academic reasons, 

1,121 graduates who applied for the exam to date, and 

952 who passed the exam (varies from PNC information). 

The PNC Registrar reported that the number of PAIMAN-supported CMWs actually registered by the 

PNC as of August 2010 was 344. Some of the program graduates will take the examination in 

September 2010. It was also suggested that some of those who passed the examination were not aware 

that the PNC was, at least for a short period of time, accepting both the certificate of completion 

(awarded by the school) and the diplomas awarded by the NEB (which as noted below was delayed in 

two provinces) as evidence of eligibility for registration with the PNC. However, the discrepancy in 

numbers reported from the two sources cannot otherwise be resolved. 

PAIMAN paid the NEB examination registration fee for every student from PAIMAN-sponsored schools. 

The MNCH program had indicated its intention also to pay this fee, and MNCH has, in fact, paid the fee 

for four schools in Baluchistan Province. However, the Principals of two schools in Punjab Province 

noted that the registration fees for their most recent MNCH-sponsored student cohorts have not been 

paid; as a result, these students have not yet had access to examination (or therefore graduation, 

registration and deployment). It is very likely that these MNCH graduates will be asked to pay this fee 

directly. 

The PNC reported that the examination pass rate for 2009 was 71.6% at the national level. The total 

number of CMWs examined was 1,746, of whom 1,250 achieved a passing score. This figure is 

consistent with information reported by DfID (2010), in which they state that a total of 6,113 CMWs 

were enrolled and trained in the country by MNCH and other development partners through August 

2009; of that number, 1,501 took the midwifery examination and 72.2% (n=1085) passed. The next 2010 

examination is scheduled for September 2010. 

This favorable pass rate is tempered by the fact that the pass/fail score established by the NEB and PNC 

for this examination has been set at 50%, which raises substantial concern, given the critical ―life and 

death‖ decisions that these CMWs may face while in their clinical practices. This standard is even lower 

than the standard established for the RN/midwife or the LHV with midwifery skills. The pass/fail rate 

also differs by province. PAIMAN staff queried voiced no objection to changing these criteria and raising 

the standard to pass. 


Table 6. Graduate Pass Rates CMW Programs * 

Province/Territory N of applicants Timeline Pass (pass percentage) 

Punjab 955 Sept 2008 – March 2010 723 (78.8%) 

Sindh 

Sindh Province has had an acting Controller who did not have the authority 

to sign diplomas for those who passed the exam. The position has only 

recently been filled. Successful examinees are only now able to request 

registry with the PNC. 

Khyber Puktoonkhwa 591 March 2010 479 (81%) 

Balochistan 

Unable to contact NEB because of country situation 

* Information obtained through telephone inquiry of Province National Examination Boards; otherwise unverified. 


The rapid scale-up of the CMW cadre led to some unfortunate conceptual and practical gaps in both the 

academic and clinical programming for education of this cadre. Consequently, more than one 

knowledgeable informant noted that ―there is still no skilled birth attendant in the community.‖ 

The PNC and other informants stated that more attention should have been given to the strategy of 

expanding the education and scope of practice of the LHV because the educational infrastructure has 

already been established, the scope of their practice already included limited midwifery skills, results of 

assessments indicate a better grasp of material (see Figure 7), and the cadre has already been well 

integrated into and well accepted by the communities. 

Outcome evaluations clearly indicate that the CMWs educated to date require continued and refresher 

education and mentorship to increase their knowledge and reinforce their clinical skills in critical lifesaving 

BEmONC signal functions. As DfID noted: 

Urgent action is required to improve quality, particularly in all aspects of clinical training in order for CMWs 

to achieve a level of competency and proficiency which will allow them to practice safely, as an effective 

member of the primary level team. 

DfID has completed an exhaustive review of the current situation and has generated a substantial 

number of guidance documents (some in draft, others in final form) related to deployment, retention 

and supervision of the CMW cadre. UNICEF has also offered to do an evaluation of the CMW program 

to document gaps and opportunities for improvement. The FET strongly encourages that this evaluation 

be conducted and strongly recommends that (a) the international standards established by ICM (as 

endorsed by WHO) be used as the criteria for program assessment and incorporated into any effort at 

program redesign of the midwifery education program; and (b) an assessment of whether the present 

program design has the potential to ―train to proficiency‖ be used as the non-negotiable benchmark of 

program effectiveness. 

Conclusions 

The promotion of midwifery as a professional skilled birth attendant cadre for the country should be 

strongly encouraged. The deployment of SBAs, including fully qualified midwives to increase access to 

health care at the community level, is a solution that has been tested around the world and has been 

demonstrated in many countries to have a very positive impact on the reduction of maternal and 

neonatal morbidity and mortality. However, these improvements have been demonstrated only in those 

circumstances where midwives have received a firm educational foundation for practicing, receive 

ongoing continuing education, mentoring and support, and practice in an enabling work environment. 


The considerable expense of time and resources that the GOP and its international donor partners have 

invested in the training of CMWs who do not meet international standards of education and clinical 

proficiency, in the immediate interest of addressing health workforce needs, may have diverted attention 

from the priority of educating SBAs and may have created an unsustainable model of education and 

clinical deployment and practice. 

Professional (fully qualified) midwives must play an integral role in any deliberations about the future of 

midwifery education in Pakistan. The Midwifery Association of Pakistan should be strengthened through 

leadership development initiatives so that the future of midwifery in the country can be shaped by those 

who are most invested in the quality of midwifery education and clinical practice. 

SO 5. IMPROVING MANAGEMENT AND INTEGRATION OF SERVICES AT ALL 

LEVELS 

Findings 

This strategic objective grew out of the political atmosphere in Pakistan at the time when the project 

was being developed. The decentralization process written in the radical Local Government Ordinance 

of 2001 devolved power from province to district and rendered local governments directly accountable 

to the people by basing their tenure on the people’s vote. It also allowed public participation in decisionmaking 

and established the means for citizen participation in electing local government officials and for 

active participation in local development concerns. The changes brought about by the LGO 2001 have 

been summarized in five points 7 : 

1. Devolution of political power to the three tiers of district government (district, tehsil, and union 

administration) that are empowered to make decisions based on local conditions. 

2. Distribution of resources to the district: powers were given to district governments to raise 

taxes, along with the transfer of some fiscal responsibilities from higher to lower tiers of 

government, i.e., formula-based fiscal transfers to the districts through Provincial Finance 

Awards. 

3. Diffusion of the power/authority nexus: monitoring by citizens, civil society’s involvement in 

development work, and adequate checks and balances. 

4. De-concentration of management functions: focused approach, meritocracy, and performancebased 

appraisal systems. 

5. Decentralization of administrative authority: more operational autonomy to the district-level 

departments. 

This resulted in new accountability of the district administrations: downward to the population that 

elected them and upward to the province and Federal government, who continued to provide most of 

the funds. The new accountability included health services. It was felt that the districts were not 

prepared for this sudden change, and in the creation of the PAIMAN Project, this strategic objective was 

established to prepare district health sectors for their new responsibilities. 

Guidance for this process was provided by a 2005 decision space analysis conducted by researchers 

from the Harvard University School of Public Health and partners from Contech. This was done to 

appraise the preparedness of district administrations for decentralized decision making and to identify 

areas for PAIMAN intervention. The question examined was how health sector decentralization had 

7 Decentralization Support Program, at http://www.decentralization.org.pk/lg.asp, 3 September 2010, accessed 3 September 

2010. 


affected delivery of health services and the functioning of local health systems (and, by extension, health 

outcomes). It measured the degree of decision-making authority at the district level (the decision space), 

the institutional capacity of district-level officials to make decisions in that environment—including the 

availability and access to resources necessary for those decisions to be acted upon—and the 

accountability of local officials to make sure that decision choices actually led to improved services and 

care. It examined these three components as they affected performance in human resource 

management, budgeting, and service delivery. 

The decision space analysis revealed significant regional differences in all three components (i.e., decision 

space, capacity, and accountability) and recommended a district-by-district approach by PAIMAN to 

tailor this strategic objective to the specific needs of each of the ten districts. PAIMAN, however, opted 

to standardize its approach and introduced a standard set of interventions in each of the districts, under 

the unifying intervention of an established District Health Management Team (DHMT). The DHMT 

concept, not new to Pakistan, was underdeveloped in most provinces and, where introduced through 

previous programmes, had not been sustained. It was designed as a multi-sectoral body chaired by the 

District Coordinator, an official appointed by the provincial government but accountable to the elected 

head of the district, the Nazim. 

Other key interventions, selected according to the generic needs of a district administration in a 

decentralized environment, were (i) infrastructure development, (ii) training on various management 

topics, (iii) district health planning and the development of District Annual Operational Plans (DAOPs), 

and (iv) the development and implementation of a District Health Information System and a variety of 

assessment and benchmarking exercises for monitoring and evaluation. 

The strategic objective was evaluated through two major evaluations, with the participation of a key 

PAIMAN consortium partner: Endline analysis of decision space, institutional capacities and accountability in 

PAIMAN districts, published by researchers from the Harvard School of Public Health and Contech 

International in draft form in 2010, and the District Health System Strengthening – Endline Evaluation, 

completed in 2010 by Contech International and published by JSI. The findings from these two 

evaluations were supplemented and in some cases validated by FET interviews with officials at the 

provincial, district, tehsil, and union levels in the seven districts visited. 

Decision Space Analysis Results 

The decision space analysis provided a critical view of the potential for the interventions in this strategic 

objective to lead to changes in actual performance and health service outcome by: 

 

 

 

 

Sampling 15 districts, the original 10 PAIMAN districts plus 5 comparison districts; 

Comparing results of the 2007 baseline survey with data collected in 2009 from the same districts; 

Analyzing changes in decision making, institutional capacity, and accountability across four 

management areas: strategic and operational planning, budgeting, human resources and service 

organization and delivery; and 

Highlighting the difficulties in arriving at effective decisions when resource capacity constraints were 

present (e.g., limitations in human resources were a constraint to many decisions and led to 

significantly reduced institutional capacity). 

The results, though not statistically significant, showed general improvement in widening the Decision 

Space (i.e., resulting in greater opportunities to take decisions) in the PAIMAN districts, most notably in 

human resources and in service organization and delivery. Decision space in budgeting, however, 

remained unchanged. This could be interpreted as evidence of incomplete devolution of financial 

management from the federal and provincial levels to the districts. The data reflect the fact that district- 


level decision makers are not able to match fiscal resources to local health system needs, despite 

decentralization. Of note is that improvements occurred in both PAIMAN and comparison districts (in 

some instances decision space was better in comparison districts than in PAIMAN districts), which 

clouds the attribution of these positive changes to the effect of PAIMAN training and inputs. 

Where PAIMAN strengths were revealed, however, was in the increase in health workers’ training 

experiences in PAIMAN districts as opposed to comparison districts. In addition, there was a greater 

percentage of health officials in PAIMAN districts in 2009 who reported having been trained in 

procurement, preparing contracts, and logistics than in 2007 (2007 levels of training in 

strategic/operational planning were unchanged). This represents an important finding, as training can 

enhance institutional capacities, which can lead to a greater ability to use decision space. The findings 

were not strong enough to provide irrefutable evidence of positive impacts of PAIMAN interventions, 

but they do suggest that health sector officials in PAIMAN districts developed a greater potential to 

make choices consistent with good health sector performance compared to several years ago. The use 

of DHMTs as forums for sharing of training knowledge also increased between 2007 and 2009 among 

PAIMAN districts. 

To the analysts, the bottom line was how these changes in Decision Space, Institutional Capacity and 

Accountability impacted on MNCH outcomes. Here the data was confusing. Findings suggested that 

changes in MCH outcomes in comparison districts were better than in PAIMAN districts in the study 

period. Two examples were cited: (i) the percentage of women receiving ANC services and having a 

birth attended by an SBA increased in PAIMAN districts, but the increase was greater in comparison 

districts; and (ii) the percentage of children who received tetanus toxoid fell in both PAIMAN and 

comparison districts but, again, by a greater degree in PAIMAN districts. Without further analysis, it is 

difficult to know what to make of these findings, but they underscore the vital importance of introducing 

a comparison group in each evaluation design. 

Finally, there were two conflicting statements regarding increases in the share of district budgets for 

health. One said, ―Consistent with these survey findings, the health sector share of district governments 

budgets fell between 2006/2007 and 2009 in PAIMAN districts‖(Bossert, et. al., 2008), while the other 

stated: ―The percentage of the health sector budget in the overall district budget increased between 

2006/2007 and 2009, but decreased in comparison districts‖ (Bossert, p. 42). The table of results that 

was presented supported the latter statement. Regardless of which of these comments holds, it was 

clear that budget utilization rates in PAIMAN districts fell, indicating that while decision space may have 

increased, it needed to be matched by institutional capacities throughout the system so that decisions 

could be implemented accordingly. 

District Health System Strengthening – Endline Evaluation 

The Endline Evaluation of District Health System Strengthening was less useful as it examined only the 

PAIMAN districts without comparisons. It used a pre-test, post-test design, though it changed the 

selection of institutions (i.e., from public and private in the Baseline to just public in the Endline) and it 

changed some of the indicator criteria, particularly those measuring use of Out Patient Departments 

(i.e., it changed from women attending facilities for Ob/Gyn in 2005 to all women in 2010 and changed 

from baseline measures of visits by all children and neonates to only visits by children under 5 years old 

in the endline; the evaluation explained that due to a change in the questionnaire, the data on health 

facility management status was not comparable with 2005 and was not available for comparison.) 

There were also some discrepancies between text and figures: in the conclusions to the section on 

comparison of upgraded and non-upgraded facilities, the evaluation noted that daily Out Patient 

Department attendance of children in both THQ and RHC upgraded health facilities had increased, 


while the graph on the previous page showed that visits by children in non-upgraded RHCs were 

actually higher than in upgraded facilities (Bossert, p. 69). Such errors could undermine the credibility of 

the study. The methodological problems and interpretation of OPD visits was the most important since 

this was one of only two indicators that measured the impact on local health-seeking behavior of all the 

interventions in health system strengthening. 

These problems, however, should not detract from the real advances made in facilities over the course 

of the 5-year period under study. There were positive changes in availability of EmONC and EmNC 

services in the DHQH. This was not unexpected as these were the hospitals uniformly upgraded by the 

PAIMAN Project. Positive changes in availability were also measured in the THQs throughout the 

district, even though only one of these had been upgraded. There was an increase from 16% to 21% in 

C-sections done in DHQs. An increase in C-sections from 3% to 8% was also measured in the THQs 

from baseline to endline. This more modest improvement was of great importance as most of these 

facilities were not upgraded, yet they still showed the capacity to provide EmOC. Unfortunately, the 

study did not describe the causes behind the THQ improvements, and without comparison districts, it 

was not possible to tease out the PAIMAN effect from other temporal factors. 

Each Strategic Objective had a series of outcomes expected as a result of the PAIMAN interventions. 

The Study provided some positive evidence on each. Based on a desk review of meeting minutes, the 

survey showed that District Health Management Team meetings were held on the average of two to 

three times a year, and at almost all of these meetings the District Annual Operating Plan was discussed. 

The study reported on district budgets and noted that health sector budgets increased in nine of the ten 

districts by an average of 72%, though this figure was skewed by a reported 780% increase in the budget 

in Khanewal between 2005 and 2009, and by an 875% increase in Upper Dir. Other budget increases 

were more modest (see Table 7). 

Table 7: Overall Increase in Health Budget 

Sr. 

No. 

Health Sector Budget 

District 2005 2009 

Overall % of 

increase in health 

budget 

1 Rawalpindi 235,598,000 483,147,000 105.07 

2 Jhelum 158,081,000 280,085,000 77.18 

3 Khanewal 1,300,000 11,450,000 780.77 

4 DG Khan 175,657,312 393,805,000 124.19 

5 Dadu 330,302,700 332,414,600 0.64 

6 Sukkur 199,007,336 17,811,931 (10.50) 

7 Buner 49,636,171 90,266,424 81.86 

8 Upper Dir 12,555,519 122,488,140 875.57 

9 Lasbela 92,404,000 129,268,000 39.89 

10 Jafferabad 45,069,499 56,511,189 25.39 

Total 1,100,604,400 1,899,435,531 72.58 

Source: DSA study data collected from district 

Using data for decision making varied from district to district, from 54% in Jafferabad to 100% in Dadu. 

This assessment was made on the basis of a desk review of DHMT meeting minutes. The report says 

that a third of all decisions taken were implemented by the district. Based on the brief examples, 


decisions taken, many of them in provinces outside of Punjab, seemed related to functions and facilities 

at the district central level: the opening of a TB center, posting of specialists, civil work in the DHQ 

hospital, etc. In Punjab, more DHMT decisions related to decisions that improved MNCH services 

overall: increases in the use of contraceptives, EPI rates, and antenatal as well as postnatal coverage. 

Much as was described in the decision space analysis, human resources remain an obstacle to 

performance. The Endline Report notes increases in the numbers of gynecologists at the DHQH, no 

changes in the number of pediatricians, and an increase from 25% to 44% in the DHQHs that report 

having an anesthetist on staff. The numbers indicate once again how pervasive and persistent the 

problem of human resource sufficiency is, particularly in hospitals removed from the center. There was 

greater disappointment in the THQH data: fewer gynecologists and pediatricians in 2010 compared to 

2005. The only improvement was from 10% to 20% of THQHs reporting anesthetists—a positive 

improvement, but still a rate-limiting number as the practice of Comprehensive EmOC depends on the 

full-time availability of an anesthetist. 

Qualitative Data 

The FET visited health facilities at the provincial, district, tehsil and union levels. It met with health 

officials in all sites and interviewed key informants in an effort to validate findings in the two evaluation 

studies and to assess the opinions of the PAIMAN staff. Because of the security situation and flooding in 

the country, most of the visits were to districts in Punjab Province, two of them adjacent to the national 

capital. These visits provided examples of the best performance in this strategic area. In particular, the 

output from DHIS in all four of the Punjab districts visited was excellent. 

In the two other districts—one in Balochistan and one in Khyber Pakhtunkhw—visited by the Eycon 

team, the results were not as encouraging: they seemed to contradict some of the evaluation data and 

contrast with findings in Punjab. In Buner, information from DHIS was not being used in decision making, 

the health budget was not increased (in fact, there was some suggestion that it had been cut as a result 

of the donor input), and, in general, the management was unclear about how gains from PAIMAN would 

be sustained as the inputs from the government did not keep up with the donor’s in the upgrading of 

facilities. In addition, in both Buner and Lasbela, there was no follow-up of training to evaluate the use 

and impact of skills, optimize deployment or determine future training needs. Though the upgrading of 

equipment and facilities was appreciated, it was not based on need; equipment was standing unused after 

many months. Further, there was little evidence that deliveries had increased in the government 

hospital. The FET noted that the dual role of providers functioning simultaneously in the public and the 

private sector had created a serious conflict of interest, with the suspicion raised that private cases were 

being recorded as public hospital cases. Similarly, some data on increased utilization for ANC and 

institutional deliveries could not be verified by the FET, who felt that an independent review should be 

done. The conflict of interest issue was heard from other districts in Punjab as well and is serious. Some 

public sector doctors have a greater investment in their own nursing homes and private hospitals, and 

have no interest in seeing the public hospital take patients from their practice. As a result, they work 

against the promotion of the public sector and funnel patients to their own practice. 

Of the Health System Strengthening activities that were implemented by PAIMAN in these districts, the 

ones that stood out the most were the DHIS, the infrastructure improvements, and some examples of 

the management training. In Jhelum, Multan, and Rawalpindi, data were presented in a coherent fashion 

on a number of topics, some process oriented (e.g., utilization rates at BHUs and stock-outs of 

medicines and vaccines), some coverage related (e.g., measles vaccination rates), and some disease 

related (e.g., ARI, Malaria, and Diarrhea rates by Unions.) It was very clear from the enthusiasm of the 

staff assigned to the DHIS that the system had great potential for development and use, and could 

become a cornerstone for decision making at all levels of governance. While the minutes of the DHMT 


meeting from Rawalpindi showed how the data could be used for decision making, it was less clear to 

the team how these data were being used by decision makers at the RHC and BHU levels. In Buner, 

there was no dedicated computer staff, so the DHIS was maintained by a local clerk who handled the 

software and data entry. Without a DHIS coordinator, there is no feedback on data submitted, so no 

evidence-based decisions can be taken. 

There was general anxiety expressed about the future of the DHIS. This was also mentioned in the 

Contech Endline evaluation: district health managers said they would need on-going technical support to 

handle issues related to the software if DHIS was to be sustained. They expected ongoing support from 

donors and district governments. 

Training was also seen as a positive input by the PAIMAN Project, though the FET had less of an 

opportunity to gauge its impact. There was one comment by a member of the district management in 

Khanewal regarding the leadership training: ―It was very good, though we’re not sure how we can apply 

it to our situation.‖ The FET found that in most instances, a training needs assessment was not done in 

advance of training to guide curriculum in the training programs. Training impact was also lessened by 

the frequent transfer of staff and the lack of a continuing education approach that could offer 

reinforcement of lessons and refresher training on new materials. 

Finally, the upgrading of infrastructure facilities was very popular and was show-cased in all visits. It also 

formed the largest portion of project expenditures, made a significant difference to the work and care 

environment for staff and patients, and tended to draw more of both into the system. Its sustainability 

was frequently questioned by those both in and outside of the project. The FET saw an example of this 

in Multan, where PAIMAN had just added a floor of distinctively high quality to the hospital. A second 

floor was to be completed by the government, but it was already evident that with the flood crisis in the 

country, all funds for this kind of construction would be frozen and diverted to recovery activities. In 

another hospital, floor tiles were already coming loose, and when staff were asked why they did nothing 

to repair them, they said that they did not have the resources and that this was a PAIMAN Project 

improvement. The implication was that as long as these structures were viewed as a product of 

PAIMAN and not the government, the government would shrug off its responsibility, citing insufficient 

resources as its reason. 

Integration of Services 

From the onset of the project, it was recognized that the mother and child health functions of the MOH 

and of family planning and birth spacing services of the MOPW were closely related and should be 

synergistic. MOH staff offer counseling on family planning; staff from MOPW offer some MNCH services 

in their Family Welfare Clinics. However, staff from both ministries have traditionally operated 

independently and in some cases redundantly, with community-level facilities and staff operating in the 

same areas but without coordination or convergence. A trial in Rawalpindi completed at the time of the 

Mid-term Evaluation explored ways to bring the two ministries together at the national, provincial and 

district levels. The study identified nine areas for functional integration, among them service elements, 

utilization of providers, contraceptive logistics, monitoring, and communications. The pilot met with 

modest success. 

During this final evaluation, the FET saw some evidence of progress in integrating the functions of the 

two ministries at the national and province levels. It was less evident at the district and community level, 

although contraception and family size were discussed in the Women’s Support Groups. There was little 

question at the higher levels of government that functional integration would make sense and could even 

be used to improve the coverage and reach of both ministries without expanding either of their budgets. 

In conversation with the MOPW in Islamabad, senior ranking members of the Ministry pointed out how 


they could benefit from the integration by having access to the more extensive staff of the MOH 

throughout the country (i.e., LHWs and LHVs). All recognized that with the upcoming changes in 

government structure with the implementation of the 18 th Amendment, the question could become 

irrelevant, as the MOPW is scheduled to be abolished at the central level, while the MOH is exempted 

from that, at least for now. 

There was also discussion of another form of integration that many thought was as important as that 

between the MOH and MOPW: the need to integrate—or at least converge—the various vertical 

programs at the community level. There are six national programs that fall into this category, requiring 

greater coordination and collaboration to reduce inefficiencies: 

 

 

 

 

 

 

National Programme for Family Planning & Primary Health Care (LHW Programme), 

Expanded Program on Immunization, 

National Maternal, Neonatal and Child Health Programme, 

National Programme for Prevention and Control of Hepatitis, 

National AIDS Control Programme, and 

National Tuberculosis Control Programme. 

Each has separate staff with different, though often overlapping, mandates. There seems to be little 

initiative to bring these together, though the current health budget crisis brought on by the floods may 

prove to be the necessary catalyst to stimulate joint programming and integration. 


1. The discrepancies in the findings of the decision space analysis (which was reviewed in draft only) 

detracted from its full impact but did not minimize the importance of decision space analysis. 

Lessons can be taken from this exercise that can be used to evaluate the effectiveness of PAIMAN 

interventions and serve as inputs for future MNCH programming: the inter-relationship between 

Decision Space, Institutional Capacity, and Accountability suggests an indivisible triangle; success—in 

terms of MCH outcomes—is not likely unless progress is made in all three. Therefore, it would be 

unreasonable to expect a single project to be able to have an impact on so many fronts of 

government, politics, management, logistics, financial and human resources, etc. With even significant 

input to only one or two of these areas, evaluation will fail to show impact, despite marginal gains 

that result from those inputs. This underlines the fact that System Strengthening is a long-term 

process with multiple inputs (as proposed in SO5), but requiring multiple partners in both the public 

and private sectors and at every level of the government and the community. 

2. One cautionary pattern arose in the endline analysis of the use of the DHIS: although 100% of THQs 

and RHCs reported sending in DHIS reports in the previous month, only 40% received written 

feedback on their reports. If this pattern does not improve (i.e., acknowledged responses and 

oversight of data submissions), it is likely that the quality and quantity of reporting will deteriorate 

over time. 

3. It would have been helpful here to have comparisons with the private sector hospitals in the 

Contech Endline Evaluation as was done in the Baseline Survey. One of the intents of the upgradings 

was to create an environment for practice in the public sector that would be similar to that 

in the private sector and that would attract patients back into the public sector (most people still 

turn to the private sector for their health care). 

4. The feeling that the DHIS could not be sustained without outside input was disappointing. Of the 

elements that the FET reviewed in the field related to this Strategic Objective, the DHIS and the 

training that was imparted to district managers seemed like the most sustainable of activities. 

Following a capital investment, these systems once adopted by the government should be sustainable 


in a cost-effective way. The DHIS appeared to be the system with the greatest government 

ownership. The problem goes back to the decision space analysis: without greater institutional 

capacity (i.e., budgetary in this case), even correct decisions when taken by local officials will not be 

implemented. 

5. Integration of the MOPW and MOH seems inevitable and desirable within the current political 

climate. 

6. Equal emphasis should be put on the convergence (rather than integration) of vertical programs 

through a systems analysis at the community level to understand how efficiencies could be improved 

in staffing, training, supplies and logistics, and monitoring. 


V. IMPACT OF RECENT POLITICAL DEVELOPMENTS IN 

PAKISTAN ON MNCH 

Since the formation of a new coalition government early in 2008, there have been two major 

developments that will impact MNCH programming in the provinces and districts: (i) the 18 th 

Amendment, along with many other changes in the constitution, will result in partial or complete 

transfer of the powers and programs of certain ministries from center to province; and (ii) the local 

government system established in 2001, which formed the rationale behind the district health system 

strengthening component of PAIMAN, is temporarily suspended and undergoing revisions before the 

next local government elections are held. The details are as follows: 

18 TH AMENDMENT 

The National Assembly unanimously passed the 18 th Amendment (GOP, 2010) to the Constitution in 

April 2010. More than an ordinary amendment, it was a constitutional reform package aimed at 

restoring the constitution to its original form of 1973. It grew out of the unease that both major political 

parties had felt about repeated military takeovers and amendments under ―rubber stamp parliaments‖ 

that had weakened the constitution and dangerously distorted the balance of power in the democracy. 

One of the several amendments within the 18 th grants autonomy to provinces as stipulated in the 1973 

constitution. Complete provincial autonomy and federalism had been a long-standing issue that was 

brought to the forefront after the Pakistan People’s Party (PPP) came into power and formed a coalition 

government in the center and provinces. As part of the devolution to the provinces, many ministries, 

including health, education, and local government, will be transferred to the provinces by a June 2011 

deadline. Ministries have been tasked to prepare their respective transfer plans and submit them to the 

Implementation Commission. As the plans are still under preparation, the potential exists to influence 

future provincial health plans through the use of field- and research-based evidence. 

LOCAL GOVERNMENT SYSTEM 8 

The Local Government Ordinance promulgated in 2001 devolved the administrative and fiscal powers of 

provincial governments to the district and lower levels. Under this system, district, tehsil and union 

councils (assemblies) were formed and public representatives were elected to manage district affairs 

along with government functionaries. Line departments (e.g., health, education, social welfare, local 

government) were completely decentralized, with functions and resources transferred to district 

governments. 

The districts received their budgets from provinces as a single line item and then decided how to spend 

it. Twenty-five percent of district development budgets were set aside for Community Citizen Board 

(CCB) projects. This budget was fully protected and could not be re-allocated or lapsed if unspent. The 

CCBs were registered entities and could apply for district funds reserved for CCB projects 9 . 

However, after completion of the district assembly’s tenure in October 2009, the political parties and 

provinces sought to revise the local government laws as they considered them to be the legacy of a nondemocratic 

dictatorship in power at the time of their creation, which was dedicated to weakening the 

provinces and strengthening the rule at the center. As a result, until new amendments to the local 

government system are made and fresh elections are held, civil servants appointed as ―Administrators‖ 

8 Commonly known as ―Devolution of Power‖ or ―Devolution‖ for short. 

9 Government funds covered 80% of the project cost, whereas CCBs were required to contribute 20%. 


un the affairs at the district level. Due to the recent flood emergency, local government elections have 

been postponed and are not expected to be held until later this year. The extent of revision and the 

shape of a new and revised local government system are still unclear. 


VI. 

CONCLUSIONS 

The PAIMAN Project was a complex one—administratively more than programmatically. It was a 

complicated consortium of, at one point, eight partners with different agendas, varied work styles, 

different organizational structures, different accounting and reporting requirements, and staff from 

different cultural backgrounds—all at work in one of the most politically, socially, and geographically 

complicated countries in the world. Yet, to a large extent, it worked. Partners were able to combine 

their comparative advantages to bring together a remarkable array of skills and experience in training, 

communication and behavior change, monitoring and evaluation, information technology, construction 

and logistics, management, finance, and administration. It established a network from the national capital 

to provincial and district headquarters, and into the community through sub-grants to over 90 local, 

indigenous NGOs. Its leadership kept it visible, with a positive image and with brand and name 

recognition that matched organizations that had been working in the country for decades. 

By comparison, programmatically it was quite simple. It focused on maternal, neonatal and (recently) 

child health. It attacked clearly defined health problems with indicators that showed their size, scope, 

nature and even location. It worked to implement interventions that were not new: almost all were 

both time- and field-tested, evidence-based, research-proven, and effective. The interventions were 

known, and they were known to work, even in the difficult conditions of the developing world and in 

the challenging environment of South Asia. And there were new variants and types of interventions 

being added on a regular basis—programmatic up-grades resulting from continuous new efficacy and 

effectiveness studies published daily. 

The administrative complexity of PAIMAN was obvious. Ironically, the missing programmatic complexity 

was one of the PAIMAN Project’s biggest problems. There was little structure for continuous training of 

staff and beneficiaries to upgrade current knowledge and practice, or to reinforce previous training on 

topics of maternal and neonatal health and nutrition. Rather than take its initial approach and critically 

analyze it for weaknesses and potential dangers, and then identify ways to improve and enhance it, 

PAIMAN was urged to take a more standardized approach in topic and technique and duplicate it in an 

ever-growing number of districts. Where this was most evident was in the core of the PAIMAN Project, 

the development of the Community Midwife program. 

The recommendations made in this report are intended not only to consolidate the gains that were 

made in this project—the emphasis on community midwifery, using data for decision making, forming 

community groups and strengthening community NGOs, projecting a media mix for reaching a wide 

audience of people, analyzing decision space, linking communities with facilities, demonstrating that many 

different agencies can work together for synergy, and so on—but also to identify and suggest ways to 

strengthen those areas of intervention that must be improved before they are ready for future 

application. 

While there will be no recommendation to extend PAIMAN I into PAIMAN II, the first recommendation 

is that funding should be extended for technical assistance and monitoring of MNCH interventions 

(particularly in the 14 expansion districts) for at least two years to transition from project to 

government ownership and to strengthen and consolidate PAIMAN Project inputs. The PAIMAN 

Project in its present form has served its purpose with the remarkable number of lessons that can be 

learned from its strengths and its imperfections. It has put community midwifery on the map in Pakistan 

and has demonstrated both the need for this new cadre and the dangers of launching it prematurely. It 

was among the few large-scale maternal and child health projects that identified and then focused its 

interventions on the perinatal period as the most critical time for mother and child survival. When one 

―googles‖ mother and newborn care, PAIMAN is among the top three websites visited out of 240,000 


listed. The program designers of this project knew that this period was where the greatest risk and the 

greatest gains were in achieving the MDGs. 

It is understandable but somewhat regrettable that the project then lost that focus and moved into the 

more routine interventions of child health—diverting resources and effort to an age group and target 

population that was not as vulnerable as the newborn and not as dependent on maternal health for 

survival, into an area where others were already working and into an intervention (IMCI) that had been 

difficult to effectively implement in the countries in which it had been tried. It is perhaps this and the 

choice to rapidly expand geographically and economically, rather than to consolidate and extend deeper 

in the original districts, that have left the gains of the last half of this project more difficult to measure 

and harder to perceive. 

It has become increasingly clear in the recent literature that the secret to child survival, health, and 

development lies in maternal survival and health. Rather than push ahead to older age groups of 

children, the suggestion is that PAIMAN might have gone further back into the origins of the problems 

of the perinatal period by looking at the health and nutrition of women, particularly young primagravida 

women and adolescent girls, many of whom (13%) had started their childbearing by the age of 18, at a 

time when they themselves were still growing (PHDS 2006-7). By using its wealth of resources and 

abilities, further PAIMAN contributions could have come from its investigation of innovative ways to 

prevent early pregnancy and reduce intercurrent infections, anemia and other micronutrient deficiencies 

in pregnancy that contribute to maternal deaths, low birth weight of babies, and stunting of children and 

later mothers—all key components in the perinatal period. It might have used the power of its public 

image to address more complex problems of gender inequality and the consequences of women’s 

inferior status in the more conservative parts of the country, or tried to find ways to introduce topics of 

adolescent sexual and reproductive health into its beautiful communication materials to reach areas 

where a man will not even discuss his wife’s pregnancy in public. The challenge of adding this complexity 

to its programs would be to build this framework of prevention at the same time it was perfecting its 

more immediate and equally important lifesaving interventions in community midwifery—interventions 

that provided a safe delivery for all women by an accessible skilled birth attendant or provided a simple 

and affordable referral method should a woman need institutionally based emergency obstetric care. 

PAIMAN started on this road by organizing and promoting one of the most important and sustainable 

parts of the project—the Women’s Support Groups. These groups demonstrated many important 

lessons: they were community-based; they grew out of women’s needs for more knowledge and for a 

social environment where they could talk and share their ideas and news; women who participated 

seemed genuinely interested in attending; some even brought their adolescent daughters to participate 

with them. These groups reduced the house-bound isolation of women in conservative societies that 

had kept them from reaching their own full potential. In this way, they helped women begin the process 

of empowerment necessary to change the environment towards more healthy practices. Given the 

chance, and with a constant infusion of material from the LHWs, these groups could last indefinitely 

because they answer women's needs to be and work together. Anything that can support the support 

groups—revolving funds, microfinance, etc.—should be implemented in the follow-on to this project. 

The ―control‖ group in this experiment is the men's community committees. They were difficult to 

organize and difficult to sustain in part because they were not as well understood by men and did not 

answer a particular need (men had various other forums to meet and talk); moreover, there did not 

seem to be any particular demand for them. The FET saw no examples of men’s community groups that 

had become established and felt doubtful that they would be sustained beyond the end of PAIMAN’s 

interventions. 


PAIMAN’s other significant contribution was also at the community level. The sub-grants to indigenous 

local NGOs stood out as a notable success. With PAIMAN’s guidance, these organizations served 

vulnerable populations in the most-underserved parts of the provinces. They did this for, on average, 

$30,000 per year per grant. As mentioned in the text of this report, these were organizations that 

already worked in a difficult environment and had survived economically and administratively—some of 

them for years. They knew the community and, in reports to the FET, were accepted and trusted by the 

communities they served. They were eager to learn more to help the community and welcomed the 

capacity development that PAIMAN offered. They were in the community before PAIMAN, and it is 

likely they will continue their work in the communities after PAIMAN is finished. Small NGOs have 

learned to live within a shortened and more modest funding environment. The sustainability of this part 

of the PAIMAN Project will be a result of their survival skills in fund-raising and advocacy. With the 

increased skills, recognition and connections provided by their participation in the PAIMAN Project, 

they are more likely to sustain themselves in the future. 

The conclusions drawn by the evaluation team from these two examples—the women’s support groups 

and the sub-grants to local NGOs—were that community-oriented and community-based interventions 

were less expensive and more sustainable, and tended to have a greater impact on more people’s lives 

since they were functioning where the vast majority of the people targeted by this project lived: in 

underserved rural communities and urban slums. These conclusions apply to support groups, community 

health care providers, community-oriented communication strategies, information systems, NGOs, etc. 

However, for even these community-based interventions to succeed, the lesson from PAIMAN was that 

they should not be developed without consulting the community and responding to the community’s 

needs at every step along the way. 

In contrast to these community-based interventions, the larger share of the PAIMAN budget was spent 

on infrastructure development and up-grading of hospital facilities. There have been indications in the 

national press that in the present economic environment, budget cuts for POL, maintenance, and a 

general lack of government ownership could make this the least sustainable component of the project. 

Even prior to the recent national flood disaster, however, there was evidence that the up-keep of 

everything from floor tiles to incubators and operating tables was not sustainable because of ―insufficient 

resources.‖ The lack of ownership or commitment to take on improvements of institutions without 

donor funds was seen in the upgraded facilities themselves. Newly tiled and polished floors and walls 

were already stained by water marks from leaking roofs; dirty wards without hygienic or hand-washing 

facilities remained side by side with renovated labor rooms and delivery theaters; there was even a 

report of a recently installed air-conditioner in a lecture room that had no glass in the windows. At least 

some of the equipment purchased and provided was not based on need: there were reports of 

newborn incubators that were never used and of new and elaborate delivery tables pushed to the side 

to make room for older, more user-friendly models. 

The degree to which public institutions are ―sabotaged‖ by private practitioners intent on not seeing the 

public sector succeed lest it interfere with their own practice is apparently wide-spread. In addition, 

some of these same practitioners use the new equipment and materials to supply their own offices, 

often located within a short distance of the public hospital. This must be addressed directly, not by 

confrontation but through collaboration. New models of public-private cooperation need to be 

developed to turn the public and the private sector into partners rather than competitors. 

The questions most frequently raised by the FET are these: 

 

How will the gains that PAIMAN has created be sustained? 


Who will examine the CMW training schools and argue for improved teachers and tutors, or pay 

the stipend and the registration fees for the CMWs and give the incentives to keep tutors and 

mentors engaged in the CMW training? 

Who will maintain and continue to improve the work and care environments of the hospitals and 

health centers where the poorer members of the population have begun increasingly to go for care? 

Who will examine existing communication materials for those that are most effective, and continue 

to provide them to facilities and communities, while making decisions to drop the ineffective ones? 

Most importantly, who will become the monitoring presence in the field—the person who notices 

and reports on what is or is not being done, and who distinguishes good work from bad? 

These were all among the positive things that PAIMAN accomplished. 

PAIMAN Project activities have recently gained momentum. A level of trust has been built in the 

community around the work of indigenous groups and local health care providers like the LHW and 

LHV. CMWs, though presently poorly trained in hands-on practice, are increasingly recognized as 

necessary service providers in the community. Upgraded facilities and indicators point toward enhanced 

utilization of services provided in PAIMAN-supported facilities. The concern is that an abrupt transition 

to another program or a complete cessation of the PAIMAN approach without building on the lessons 

learned would be a setback for those who have committed years of hard work and funding resources. 

The following recommendations offer suggestions that the FET hopes will be used in answering these 

questions. 

The final conclusion is that the PAIMAN Project made a substantial contribution to the women and 

children of Pakistan. That contribution can be measured in its many positive and visible achievements in 

training, infrastructure development, district administration and community development. Its 

contribution can also be seen in the lessons learned mentioned in this report: that CMWs need more 

and different training in order to practice safely in the community and that community-based 

interventions are more likely to be sustained than those that focus on urban-based hospital 

infrastructure, even though both are important. The challenge is to find the right structure to move 

ahead so that the contributions of the past six years will not be lost. 


VII. RECOMMENDATIONS AND FUTURE DIRECTIONS 

GENERAL RECOMMENDATIONS 

Exit Strategy and Future Directions 

1. Extend funding for technical assistance to and monitoring of MNCH interventions (particularly in the 

14 expansion districts) for at least two years to transition from project to government ownership 

and to strengthen and consolidate PAIMAN Project inputs; supplement technical resources within 

MNCH with international experts to assist in the design, implementation and monitoring of the 

CMW program. 

2. Support phased graduation of districts out of the technical support system according to a check-list 

of evidence-based capabilities. 

3. Increase program and project spending on interventions at the community level (e.g., community 

support groups, community NGOs) that lead to sustainable outcomes. 

4. Establish a rigorous joint monitoring team, including province, district and local officials along with 

staff of the MNCH, to sustain improvements and maintenance of the infrastructure development 

projects funded by PAIMAN and to identify future projects. A monitoring system of this nature 

would make infrastructure development more attractive to the GOP and to other donors. 

5. Focus in-service training of community health workers on C-IMCI for greater impact on 

beneficiaries at the community level. Continue the process of integrating IMCI curriculum in preservice 

training (e.g., medical and nursing schools). 

Missing Elements for Consideration in Future MNCH Programs 

6. Increase the emphasis on reduction of low birth rate as an intervention to benefit both mothers and 

newborns (the present rate is 31%). 

7. In subsequent projects, introduce a new emphasis on premarital youth or at least increasing the 

focus on the primagravida/newlywed. 

8. Introduce nutritional supplements to primagravida women with low BMI. 

9. Introduce multi-micronutrient sprinkles to all primagravida women or at least iron/folate to all 

women 19 to 25 years of age, given that the prevalence of micronutrient deficiency is so high in the 

communities served. 

10. Support development and finalization of the National Nutrition Strategy and incorporate it into 

MNCH. 

11. Encourage and fund research and evaluation of all key MNCH programs and interventions (including 

the communication and advocacy component) and use a comparison group design wherever possible 

in order to increase the possible attribution of effect. 

RECOMMENDATIONS SPECIFIC TO THE STRATEGIC OBJECTIVES 

SO1. Increasing Awareness & Promoting Positive Maternal and Neonatal Health 

Behaviors 

12. Sustain women’s support groups and increase membership to include young girls and young women. 

13. Consider expanding community-level consultations for development of new communication material 

(including formats) and for establishing monitoring of their reach, appropriateness and utility. Local 

development and even production would allow greater sensitivity to the demographic, ethnic, and 


linguistic profile of the communities in which they will be used. The detailed formative research 10 

done by PAIMAN for the first phase was useful in developing messages and content. It could be 

more useful if it were linked to local materials and media development as well. 

14. Do formative research in all districts preceding communication and media interventions as each 

district poses different problems of beliefs and practices. 

15. Mass media approaches can be effective in creating behavior change but are not invariably so. 

Evaluate the impact on behavior change of various communication and media strategy mixes and 

materials to identify those which have the greatest cost effectiveness in the Pakistan country 

context. 


16. Explore a variety of options for increasing the proportion of private sector partners in the delivery 

of maternal and newborn health services, with particular outreach to providers who reside in rural 

and hard-to-reach areas. These options could include variations of voucher schemes or other public 

insurance mechanisms. 

17. Continue the emphasis in future TBA training on topics that evidence has demonstrated are useful 

and appropriate in the context of their practice, including, but not limited to, recognition of danger 

signs, referral, clean delivery, and the elements of essential newborn care. Promote and enhance 

partnerships between TBAs and the public and private health providers and systems to increase the 

degree to which referrals between the community and facility settings are encouraged. 

18. Establish appropriate budget and accountability policies and mechanisms to ensure that ambulance 

vehicles that have been transferred to District Health Departments and that are operated by the 

local community at the health facility level continue to be equipped and immediately available for 

emergency transport purposes. 

19. Establish and/or confirm budget and accountability policies and mechanisms that allocate and reserve 

a fixed portion of health services budgets directed to facility and equipment maintenance and 

enhancement, not subject to re-allocation to other purposes. 


20. Design and implement a quality assessment (QA) process to verify the retention of learning as an 

essential component of all training programs. Integrate this QA process into a longer-term 

continuous quality improvement (CQI) initiative. Ensure that both QA and CQI strategies include 

documentation of skills as applied in the workplace. 

21. Design and implement a continuing education program integrated and coordinated with other 

MNCH and national health programs to reinforce and update the skills and knowledge of 

community-level health workers. 

22. Continue a focus on training in infection prevention for all health providers, in all health facilities, 

including content on proper disposal of medical waste, as appropriate for the health care setting. 

23. Identify and enhance the education of LHWs, CMWs, and LHVs on perinatal care to include 

additional supportive strategies to prevent maternal deaths: 

 

 

Reduction of anemia, 

Reduction of malaria in pregnancy, screening for TB/UTI/STD, etc., and 

10 Formative research done for the first ten districts was not available to the FET for the districts of the second expansion 

phase. 


Family planning for healthy timing and spacing of pregnancies. 


24. Suspend admissions to the NMCH CMW program for a period of up to two years. During that 

time, refocus the program so that it is in full alignment and compliance with current international 

standards for direct-entry (community) midwife programs with respect to: 

 

 

 

 

education level of students at the time of recruitment (completion of secondary education), 

minimum length of direct entry education programs (3 academic years), 

clinical competence of midwifery educators (tutor) and midwifery preceptors 

(demonstration of competence in teaching and clinical practice, generally acquired after a 

minimum of 2 years of full-scope clinical practice prior to service as a tutor or preceptor), 

compliance of the curriculum with all basic content elements of the Essential Competencies 

for Midwifery Practice, and 

compliance with the proportional guidelines for theory (40%) and clinical practice (50%) 

within the curriculum. 

25. Educate a robust body of midwifery educators, well skilled in both teaching and midwifery clinical 

skills, and ensure their placement in each school of CMW education, preferably before additional 

enrollments are authorized. 

26. Create a separate regulatory body for all categories of midwives educated in the country (e.g., a 

Pakistan Midwifery Council), with authority and leadership vested in midwives, rather than 

professionals of other disciplines. 

27. Design and test feasible models for supervision of the community midwife in practice, preferably in 

alignment with existing public-sector supervision strategies, with supervision provided by individuals 

qualified to provide clinical and technical guidance and support in the functional role of midwives. 

28. Promote strong collaborative linkages with colleges and universities which are involved in the 

education of midwives to craft an education career ladder for midwifery professionals. 

29. Define the role and responsibility of the office staff of the EDO Health and MNCH program at the 

district level for the CMW cadre to increase accountability and to strengthen this private/public 

partnership. 

30. Define a method for including CMW statistical data into the DHIS so that a true picture of 

community-based maternal and neonatal morbidity and mortality can emerge (see SO5 #32, below). 

SO5. Improving Management and Integration of Services at All Levels 

31. Extend the decision space analysis to the MNCH program by training local researchers in its use. 

Use the results to identify the specific weaknesses in the health system in each district or tehsil, and 

design training and other interventions that are aligned with those particular weaknesses. 

32. Discuss with JICA the updating of some of the indicators in the next iteration of the DHIS; one in 

particular—ANC 1 coverage—would be meaningful if it reflected the WHO standard of four visits. 

The FET recognizes that a new indicator will not have a precursor for comparison. Nevertheless, 

continuing to collect data on an indicator that has little meaning is a waste of time and money. 

33. Challenge each District Health Management Team (DHMT) to develop ways to integrate NGO data 

into their system, possibly by invitations to local NGOs to participate quarterly in the DHMT 

meetings and report on findings in remote areas. The same might be considered for the private 

sector data (including CMWs). 

34. Using the experience of PAIMAN, have MNCH examine interventions that would facilitate the 

process of integration of MOH and MOPW: joint training, joint M&E tools and indicators, 


application of decision space analysis broadened to encompass both ministries at the provincial level, 

etc. 

35. Sponsor a study of system streamlining at the community level that would improve the efficiency of 

all vertical programs by identifying areas of synergy and collaboration in order to reduce resource 

demands. 

36. Encourage (or require) all MNCH-sponsored programs that operate concurrently to work 

collaboratively in the design of all program elements (e.g., BCC and training materials) in the interest 

of avoiding duplication of effort and promoting harmonization of approaches. Encourage this same 

approach to be adopted by all international donors who contribute to the MNCH program 

portfolio. This includes the conduct of population baseline studies within provinces and districts. 


APPENDIX A: SCOPE OF WORK 

FINAL Evaluation 

Maternal NewBORN and Child Health Program 

USAID/Pakistan 

(Revised: 07-28-10) 

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 end-of-project evaluation of 

its Maternal Newborn and Child Health (MNCH) program. The MNCH program is managed by USAID’s 

Health Office, and implemented under a Cooperative Agreement by JSI Research and Training Institute, 

Inc. 11 in partnership with Save the Children-U.S., Aga Khan University, Contech International, Greenstar 

Social Marketing, Johns Hopkins Bloomberg School of Public Health Center for Communications 

Programs, Population Council, and the Pakistan Voluntary Health & Nutrition Association (PAVHNA). 

As part of USAID/Pakistan’s due diligence, a final evaluation is being commissioned to assess the 

effectiveness of the program components and the resulting impact on morbidity and mortality, 

document lessons learned, and identify areas where the Government of Pakistan (GOP) could provide 

continuity in services and scale up. 

The objectives of the evaluation are to: 

1. Assess whether the MNCH program has achieved the intended goals, objectives, and outcomes as 

described in the Cooperative Agreement and work plans; 

2. Evaluate the effectiveness of key technical inputs and approaches of the MNCH program in 

improving health status of mothers, newborns, and children compared to baseline health indicators; 

3. Explore the impact of the Pakistan Initiative for Mothers and Newborns (PAIMAN’s) technical 

approach on maternal, neonatal, and child morbidity and mortality in at least the 10 districts 

originally covered by the project, as possible with the current available data; 

4. Review the findings, conclusions, and recommendations and provide brief suggestions/options for 

ways in which project components might be able to be continued and scaled up by the GOP’s health 

entities (MOH, MOPW, provincial and district counterparts). 

Findings and recommendations will be used to ensure that USAID’s MNCH program serves the overall 

objective of improving maternal, newborn and child health in Pakistan in the most effective way. 

This 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. 

II. 

BACKGROUND 

Pakistan’s maternal mortality ratio (MMR) is 276, which means that a woman’s lifetime risk of dying of 

maternal causes is roughly 1 in 89. A full third of all maternal deaths are due to hemorrhage, reflective of 

the inadequacy and poor quality of preventive measures and obstetric care. Sixty-one percent of 

pregnant women receive antenatal care from a skilled provider but 35% receive no prenatal care at all. 

11 JSI PAIMAN $92m five year Cooperative Agreement 2005 - 2010 


Sixty-five percent of women still deliver at home and only 39% of all deliveries are attended by a skilled 

provider. Fifty-seven percent of women receive no postnatal care. Pakistan’s child health indicators have 

improved little over the past several decades and are among the worst in Asia. Infant mortality is 78 

deaths per 1,000 live births and the under-five mortality rate is 94 deaths per 1,000 live births. Neonatal 

mortality represents more than half of this under-five mortality, at 54 deaths. The main causes of child 

death include birth asphyxia (22%), sepsis (14%), pneumonia (13%) and diarrhea (11%). 

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, 

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 either normal 

deliveries or 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%) is served by the private sector, at least for curative 

services. The public sector health program needs improvements in several areas, including: the number 

of female health care providers; physical facilities; safe water supply; privacy for female patients; supply of 

drugs; logistics and equipment; and provider capabilities, especially in counseling and clinic management. 

While most curative services are provided through private providers, private sector health services in 

Pakistan are unregulated, leading to questions of quality. While the GOP, as part of its devolution 

strategy, promotes delegation of health services planning and management responsibilities to the 

provinces, management systems at the provincial and district levels are weak, including referral systems, 

supervisory systems, health information systems, and coordination between the public and private 

sectors. With Pakistan’s planned devolution of health programs from the federal to the provincial level, 

provinces will need to take greater ownership of health programs, including vertical programs that are 

currently administered by the federal government. 

Pakistan’s Constitution guarantees basic human rights for all citizens, including equitable access to health 

and social services. The Government of Pakistan (GOP) is aware of the huge burden of preventable 

deaths and morbidity among women and children and is committed to improving the health status of 

these groups. 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 Maternal, Neonatal, and Child Health (MNCH) indicators. Such improvements can only 

be achieved through a national, comprehensive, focused and effective program that is owned and 

managed by the districts, and is customized to meet districts’ 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 sector staff. 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 jointly in 2000 by the 

Federal Ministries of Population Welfare and 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 pre-requisite 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. 

A 2010 Health Policy draft, not yet approved, aims to enhance coverage and access of essential health 

services, especially for the poor, by supporting primary and secondary health care facilities and 

preventive care. 

The Population Policy of Pakistan (2002) focuses on integration of reproductive health services with 

family planning, building on successful elements of the program, increased participation of the private 

sector, greater emphasis on social marketing, and broadening 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 salient features of the 2010 Population Policy include: attain 

the replacement level fertility by 2030; achieve universal access to safe reproductive health, including 

family planning, services by 2030; reduce the unmet need for family planning from the current 25% to 5% 

by 2030; and increase the Contraceptive Prevalence Rate from the current 30% to 60% by 2030. 

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 continuous shift from 

curative to promotion and preventive services through primary health care. 

Pakistan is signatory to several international agreements on improving MNCH, including the Millennium 

Development Goals (MDG): 

Goal 4 – Reduce child mortality by two-thirds between 1990 and 2015. The indicators to measure 

progress toward this MDG include the under-five mortality rate, the infant mortality rate (IMR), and the 

proportion of one-year-old children immunized against measles. Pakistan’s target is to reduce the IMR to 

40 deaths per 1000 live births and to increase measles the immunization rate to >90% 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 maternal 

mortality ratio and the proportion of births attended by skilled health personnel. Pakistan’s target is to 

reduce its MMR from 276 to 140 deaths or fewer per 100,000, and to increase skilled birth attendance 

from 39% of deliveries to 90% by 2015. 

In addition, Pakistan envisions increasing the Contraceptive Prevalence Rate to 60%, increasing the 

proportion of pregnant women receiving antenatal care to 100%, 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 

program 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 in 

underserved urban slums. Despite support from the UK, Australia, and Norway, the national MNCH 

program has had a slow start and GOP contributions are dismal. To date the GOP has released only 26 

% of the total budget. 

The primary MNCH implementing partner for USAID is JSI Research and Training Institute, 

Inc. (JSI), whose project summary is 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 seven. The PAIMAN Project promotes skilled attendance as the longterm 

goal for all deliveries in Pakistan. The Life of Project is 10-08-04 to 09-30-10; funding level is 

$92,900,064. 

Evidence in public health literature shows that maternal and neonatal survival depends upon a whole set 

of socio-cultural, 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. USAID’s MNCH program therefore calls for a multi-pronged 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” that 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, which prevent them from obtaining 

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 socio-cultural) to and lack of community involvement in MNCH 

services; 

3. Poor quality of services, including lack of adequate infrastructure in the 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 


Objectives: 

Based on the ―Pathway to Care and Survival‖ framework, PAIMAN has the following program objectives, 

interventions, and outcomes: 

1. Increase awareness of and promote positive maternal and neonatal health behaviors. 

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 MNCH 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, of 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. 


4. Increase capacity of MNH managers and care providers 

Outcomes: 

 

 

Increased skilled attendance for deliveries in the target districts. 


5. Improve management and integration of services at all levels. 

Outcomes: 

 

 

 

Beneficiaries: 

District MNH plans and budgets available. 

HMIS Information used for MNH decision making. 

Better coordination between public, private, and community health services. 

The project works with communities, government, and local 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 one year of age will benefit 

from the program. PAIMAN has identified beneficiaries of the program as married couples at 

reproductive age (15-49) and all children under one 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 Federally Administered Tribal Areas 

(FATA) in Kyber and Kurram Agencies and Frontier Regions Peshawar and Kohat. PAIMAN also began 

working in Swat district in April 2008. Today the project covers 24 districts total. 


Fit with the Mission’s Strategic Objective 

This evaluation will help the Mission plan effective health programs for the future within the context of 

U.S. foreign policy objectives for Pakistan. 

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: 

 

 

 

 

 

 

 

 

 

 

III. 

Maternal, Newborn, and Child 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 24 districts of four provinces of Pakistan. (Prime Partner: JSI Research and Training 

Institute, Inc.) 

Family Planning: USAID/Pakistan’s project to address the need to increase and improve family planning 

services including capacity building, monitoring and evaluation, and project management through a project 

called Family Advancement for Life and Health (FALAH). (Prime Partner: The Population Council) 

DELIVER: Commodity Logistics and Management (Partner: JSI Research and Training Institute, Inc.) 

Strengthening TB Prevention and Control: USAID assists the GOP to consolidate and accelerate complete 

treatment of TB patients. (Implementing Partner: KNCV TB Foundation) 

Polio Eradication: USAID provides assistance to national polio immunization campaigns and surveillance to 

eliminate polio from Pakistan. (Implementing Partners: WHO and UNICEF) 

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) 

Developing and Strengthening Institutional Capacity in Public Health Training and Research: (Implementing 

Partner: Health Services Academy, Islamabad) 

Field Epidemiology and Laboratory Training Program (FELTP). (Implementing Partner: U.S. Centers for 

Disease Control) 

Engaging Religious Leaders for Health: (Partner: Pathfinder International) 

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-U.S.) 

STATEMENT OF WORK 

The independent final evaluation team will review the technical, managerial, and programmatic strengths 

and weaknesses of the MNCH program as approved and financed by USAID – the Maternal and Newborn 

Health: The Pakistan Initiative for Mothers and Newborns (PAIMAN). Based on these findings, the team 

will formulate lessons learned as well as recommend future technical, programmatic, and administrative 

actions that will support overall strengthening of MNCH programmatic efficiencies and effectiveness. 

The team is expected to answer the following key strategic and priority questions: 


6. Has the MNCH program met its benchmarked activities as outlined in the Cooperative Agreement 

and subsequent 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 the PAIMAN program 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 into rural and higher poverty areas? 

10. What are the most important steps that USAID and the GOP should take to increase effectiveness, 

coverage, quality, and sustainability of USAID’s future MNCH program? 

11. What if any is the impact of PAIMAN’s technical approach on maternal, neonatal, and child 

morbidity and mortality in at least the 10 districts originally covered by the project? 

12. What could the GOP do to ensure continuity and scaling up of PAIMAN’s technical advances in 

project districts? 

13. As Family Planning/HTSP was added to PAIMAN's work program under the extension period, how 

has HTSP helped in improving family planning use in PAIMAN districts? Also, how has ―functional 

integration‖ worked? (this is the term for PAIMAN’s pilot efforts to co-locate and more closely 

coordinate the MOH and MOPW functions.) 

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 evaluation 

team will work in a participatory manner with the partners of the PAIMAN 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 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: 

1. Sampling Frame (determined by Evaluation Team with input from the local firm) 

2. Interview Guides 

3. Interview Questionnaires (for the Evaluation Team and the local firm to use during site visits 

with persons that interact with the PAIMAN and projects, i.e., LHWs, LHVs, physicians, nurses, 

district officials, etc.) 

4. Survey Questionnaires (brief client surveys conducted by the local firm in the PAIMAN districts) 

The data collection tools with be presented to USAID/Pakistan Health Team during the Team 

Planning Meeting (TPM) 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 and visits and consulting firm site visits, in order to ensure consistency and comparability of 

data. 

USAID/Health, Population, Nutrition (HPN) Team Briefing: The Evaluation Team will meet with the 

USAID/Pakistan Health Team in Islamabad to review the scope of the final 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 TPM). 

Team Planning Meeting (TPM): A two-day team planning meeting will be held in Islamabad before the 

evaluation begins. This meeting will allow USAID/Pakistan to present the team with the purpose, 

expectations, and agenda of the assignment. In addition, the team will: 

1. Clarify team members’ roles and responsibilities, 

2. Establish a team atmosphere, share individual working styles, and agree on procedures for 

resolving differences of opinion, 

3. Review and finalize the assignment timeline and share with usaid, 

4. Develop data collection methods, instruments, tools and guidelines, 

5. Review and clarify any logistical and administrative procedures for the assignment, 

6. Develop a preliminary draft outline of the team’s report, and 

7. Assign drafting responsibilities for the final report. 

Document Review: Review briefing materials that will be provided to the team. 

Information Collection: The information collected will be mainly qualitative guided by a key set of 

questions. Information will be collected through personal and/or telephone interviews with key 

contacts, through document review, and through field visits. The full list of stakeholders and 

contacts will be provided. Additional individuals may be identified by the Evaluation Team at any 

point during the final evaluation. Key contacts include: 

1. USAID/Pakistan Senior Management, HPN Team Members, Health Director, Deputy 

Director, AOTR for MNCH Program; 

2. PAIMAN briefing with key personnel; 

3. PAIMAN sub-grantees, sub-contractors, and other local partners; 

4. MOH and MOPW officials; and, 

5. Donors and International Organizations working in the Health and Population Welfare 

Sector. 

Site visits: The Evaluation Team will travel with JSI-PAIMAN Project staff to project sites for face-toface 

interviews and discussions with local stakeholders and beneficiaries. The Mission has suggested 

the following four sites for the Evaluation Team to visit: Rawalpindi, Jhelum, Khanewal/Multan 

(Annex 7). 

Site visits will focus on pilot activities (renovation of health facilities, community midwives, support 

groups, male volunteer involvement, internally displaced persons, and religious leader involvement). 

The areas of focus of the site visits will be clinical practices, skilled birth attendance, female medical 

providers, 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. 

Several interviews will be arranged and done in one day. The site visits to Rawalpindi and Jhelum will 

be done from the team’s base in Islamabad. The travel time to Multan is two hours by air and will 

require an overnight stay to reach Khanewal by road, requiring approximately three days. This 

estimates six days 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/Pakistan 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. 

A draft survey interview guide and questionnaire will be developed by the evaluation team in August. 

This draft survey guide and questionnaire will be shared with USAID/Pakistan and the local firm. Upon 

arrival in country, the evaluation team will meet with USAID/Pakistan and the local firm to discuss, 

review, and finalize the survey interview guide and questionnaire. The local firm will then translate the 

questionnaire (and guides); and proceed with training the local interviewers. The local firm will visit and 

be responsible for interviews and field visits in: a Sindh province site and a Baluchistan province 

site. The annex listing which sites are located in each province is attached (Annex 7). Depending on the 

security situation at the time of the TPM, site visits may be changed as necessary. 

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 needed information. They should meet 

with beneficiaries, local community members, NGOs, district officials, any persons who have interacted 

with or are aware of PAIMAN activities. 

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, midwives receiving refresher training 

Traditional birth attendants 

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, 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) 

1. National including MOH, provincial, district 

2. Pakistan Medical and Dental Council, Pakistan Nursing Council, principals of midwifery schools 


3. LHW Program, MNCH Program Coordinator 

Donor involvement in evaluation, for identifying gaps and complementary programs (illustrative) 

1. Open-ended questionnaires to donors 

2. One-on-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 and doing what? Mapping. Extent to which projects are integrating FP into 

MNCH now. How much work are other projects doing on vaccination, IMNCI, systems 

strengthening, infection control and hospital waste management, male involvement, private sector 

involvement? 

8. What are donors’ future plans in MNCH? Best practices? Integrated FP? Child vaccination? Systems 

strengthening? 

9. What role is each donor taking in planning, implementing, funding, policy development, support? 

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) HPN 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 

will be presented; 2) senior Mission management - incorporating the insights gained in the first debrief; 

and 3) Final briefing - for PAIMAN personnel, other donor partners, and key stakeholders (Government 

of Pakistan officials) and will focus 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 final Evaluation to the USAID/Pakistan Health Office Director and relevant HPN 

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. 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. After the Mission submits comments on draft evaluation report, the consultants will submit the 

edited draft within 10 working days of USAID/Pakistan feedback. Upon USAID/Pakistan 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/Pakistan final approval of the content. The final report will be an internal 

document and is to be submitted to the USAID/Pakistan Health Office Director, both in hard copy (6 

copies) via express mail and in electronic form. 


VI. 

DURATION, TIMING, AND SCHEDULE 

It is anticipated that the period of performance of this evaluation will be for six/seven weeks beginning o/a end July 

2010. A possible schedule of this activity follows (illustrative): 

Task/Deliverable 

Team Leader LOE 

Team Members LOE 

(2) 

1. Review Background Documents/Pre- 

6 days 5 days 

Evaluation Planning (out of country) 

2. Travel to Islamabad 2 days 2 days 

3. HPN Team Briefing 1 days 1 day 

4. Team Planning Meeting 2 days 2 days 

5. Meetings with 

7 days 7 days 

COP of PAIMAN 

GOP Officials in Islamabad (MOPW, 

MOH) 

Local consulting firm 

MNCH Donors and other Partners 

6. Visit field sites, including training centers, 

6 days 6 days 

clinics, etc. 

7. Debriefings with Health Office, USAID Sr. 

1 days 1 days 

Management, PAIMAN, other stakeholders 

8. Internal discussion meeting with local firm 

1 day 1 day 

and international team 

9. Analysis, discussion, and draft report writing 10 days 10 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 44 40 

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 seven 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 five 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 gaps for appropriate technical assistance in order 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 skills) 

as s/he will have a major role in drafting and finalizing the deliverables, and will have the overall 

responsibility for the final report. The individual considered for the team leader position is expected to 

provide a sample of a written report for consideration by USAID/Pakistan. 

Maternal Health Specialist: The second team member should have an advanced degree in health sciences or public 

health and at least five years experience in program management, implementation, and monitoring and evaluation of 

internationally-based maternal and child health programs. Further, s/he should have a comprehensive technical 

knowledge of and experience in maternal newborn and child health programs, and especially with 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 related disciplines and at least five years experience in the implementation of field behavior change 

communication (BCC) 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. 

VIII. RELATIONSHIPS AND RESPONSIBILITIES 

1. Overall Guidance: The USAID/Pakistan Health Office Director and Deputy Director 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 program 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 to. The Evaluation Team will provide mobile 

phone contact numbers to USAID/Pakistan Health Office so contact can be maintained as needed. 

Client Roles and Responsibilities – 

Before In-Country Work 

 

 

 

 

 

Consultant Conflict of Interest. To avoid conflicts of interest or the appearance of a COI, review 

previous employers listed on the CV’s for proposed consultants and provide additional information 

regarding potential COI with the project contractors or NGOs evaluated/assessed and information 

regarding their affiliates. 

Documents. Identify and prioritize background materials for the consultants and provide them, 

preferably in electronic form. 

Local Consultants. Assist with identification of potential local consultants and provide contact 

information. 

Site Visit Preparations. Provide a list of site visit locations, key contacts, and suggested length of visit 

for use in planning in-country travel and accurate estimation of country travel line items costs. 

Lodgings and Travel. Provide guidance on recommended secure hotels and methods of in-country 

travel (i.e., car rental companies and other means of transportation) and identify a person to assist 

with logistics (i.e., visa letters of invitation etc.) if appropriate. 

During In-Country Work 

 

 

 

 

 

 

Mission Point of Contact. Throughout the in-country work, ensure constant availability of the Point 

of Contact person(s) and provide technical leadership and direction for the team’s work. 

Meeting Space. Provide guidance on the team’s selection of a meeting space for interviews and/or 

focus group discussions (i.e. USAID space if available, or other known office/hotel meeting space). 

Meeting Arrangements. While local consultants typically will arrange meetings for contacts outside 

the Health Office, support local consultant(s) in coordinating meetings with stakeholders. 

Formal and Official Meetings. Arrange key appointments with national and local government officials 

and accompany the team on these introductory interviews (especially important in high-level 

meetings). 

Other Meetings. If appropriate, assist in identifying and helping to set up meetings with local 

professionals relevant to the assignment. 

Facilitate Contact with Partners. Introduce the Evaluation Team to implementing partners, local 

government officials, and other stakeholders, and where applicable and appropriate prepare and 

send out an introduction letter for team’s arrival and/or anticipated meetings. 

USAID/Pakistan will be responsible for providing security notices issued by the U.S. Embassy in 

Pakistan to which the Evaluation Team must adhere to. The Evaluation Team will provide mobile 

phone contact numbers to USAID/Pakistan Health Office so that contact can be maintained as 

needed. 

After In-Country Work 

USAID/Pakistan - 

 

 

Timely Reviews. Provide timely review of draft/final reports and approval of the deliverables 

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) incountry 

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/Pakistan may be able to assist the team on a limited basis. 

IX. MISSION POINT OF CONTACT – 

Janet Paz-Castillo, Chief, USAID/Pakistan Health Team 

jpaz-castillo@usaid.gov 

(+92 051) 2082762 

Shanda Steimer, Deputy Chief, USAID/Pakistan Health Team 

(+92 051) 2081158 

ssteimer@usaid.gov 

X. ANNEXES 

The documents listed below will be provided to the Evaluation Team prior to the start of the evaluation. 

Annex 1: 

Annex 2: 

Annex 3: 

Annex 4: 

Annex 5: 

Annex 6: 

Annex 7: 

USAID’s Health, Population, and Nutrition Program description 

Background documents as listed 

Key personnel contact information for PAIMAN 

Illustrative List with contact info of Key Stakeholders 

Cooperative Agreement 

Illustrative Questions to Guide the Evaluation 

MNCH Evaluation Site Visits 


APPENDIX B: PEOPLE CONTACTED 

PAKISTAN 

U.S. Agency for International Development (USAID) 

Janet Paz-Castillo, Director, USAID Health Office 

Miriam Lutz, Human Development Officer 

Megan Petersen 

Pakistan Initiative for Mothers and Newborns (PAIMAN 

Dr. Nabella Ali, Chief of Party 

Frank R. White, Jr., Deputy Chief of Party 

Bal Ram Bhui, Monitoring & Evaluation Advisor 

Kashif Hanif, Finance Officer 

Dr. Munazza Harris, Manager Program & Grants 

Dr. Nasir Idrees, National Manager Private Sector Initiative 

Dr. Nadeem Hassan, National Manager Child Spacing 

Dr. Shuaib Khan, Director, Programs & Grants 

Dr. Zareef Uddin Khan, National Manager Child Health 

Maj Javade Khwaja, Director Administration 

PAIMAN Sub-Grantees 

Iftikhar ur Rahman, Chief Executive, Community Uplift Program 

Porishka Ayub 

Abbas Gondal, Chief Executive, Friends Foundation 

Sarfraz Khan Khokhar, President, United Christian Organization 

Aga Khan Foundation 

Dr. Shazia Akbar, Asst Program Officer 

Dr. Qayyum Ali Noorani, Program Manager Health 

Dr. Saadia Shabbir, Sr. Program Officer 

Buner District 

EDO Health Office 

Dr. Maqsood, EDO (Health) (since July 2006) 

Dr. Fazle Azeem, CDC Coordinator 

Dr. Lal Bacha, Coordinator EPI 

Dr. Amir Zahir, District Coordinator, NPFPPHC 

Mr. Javaid Iqbal, District Superintendent Vaccination 

DHQ Hospital Dagar 

Dr. Shuaib Muhammad, Medical Superintendent 

Dr. Tahir, Deputy Medical Superintendent 

Civil Hospital Nawagai 

Dr. Sher Zaman, Senior Medical Officer 

Rahbar (local NGO) 

Mr. Simir Khan, Chairman 

Mr. Farid Khan 

Ms. Roshan Ara, TBA Master Trainer 


Others 

Mr. Zain-ul-Abdeen, District Coordinator, Merlin 

Ms. Najia, Lady Health Supervisor 

Ms. Nargis Jehan, Lady Health Supervisor 

Male Volunteer Group: 12 Participants 

Female FGD Participants: 18 + 20 = 38 

Contech International 

Dr. Naeem uddin Mian, CEO and Health Specialist 

Dr. Shahzad Hussain Awan 

Dr. M. Ashraf Chaudry, Executive Director Management & Development 

Department for International Development (DfID) 

Dr. Raza Zaidi, Health and Population Advisor 

Johns Hopkins University 

Bloomberg School of Public Health Center for Communication Programs 

Fayyaz Ahmad Khan, Country Representative 

Government of Pakistan/Ministry of Health 

Khushnood Akhtar Lashari, Secretary 

Government of Pakistan/Ministry of Population Welfare 

Shaukat Hayat Durrani, Secretary 

Shahzad Ahmad, Director General (Programme) 

Abdul Ghaffar Khan, Director General (Projects) 

Dr. Mumtaz Esker, Director General (Technical) 

Greenstar Social Marketing 

Dr. Maheen Malik, Deputy General Manager – Falah 

Dr. Haroon Ibrahim, Sr. Program Manger – RH 

Shirine Mohagheghpour, Technical Advisor 

Independent Contacts (in reference to CMW Program) 

Mrs. S. Anjum Ishfaq (Retired), Nursing Advisor, Ministry of Health, Islamabad 

Ms. Rafat Jan, Aga Khan University 

Ms. Imtiaz Kamal, Midwifery Consultant, President Midwifery Assn of Pakistan 

Patrice White, Ph.D., CNM, Sr. Technical Advisor, Pakistan Safe Drinking Water & Hygiene Promotion 

Project 

Clara Pasha, Abt Associate, Islamabad 

Reproductive Health Advisor, Welfare Center of Terlayi, Islamabad 

Medical Assistant, Population Center of Bara Kahu (RHU), Islamabad 

Lady Health Visitor, Health Center of Tret Syedan (BHU), Murree 

Jhelum District 

EDO Health Office 

Dr. Shahid Tanvir, Executive Director Health, District Jhelum (since October 2009) 

Dr. Capt. Asif, District Officer Health 

Dr. Rodab Irfan Majeed, DHIS Coordinator 

Dr. Khalid Mahmood, District Officer Health, Headquarter 


Dr. Muhammad Riaz Cheema, Deputy DOH, Tehsil Jhelum 

Dr. Imtiaz Hussain Shah, District Coordinator, National Programme for FP & PHC 

Dr. Naseer Ahmed, Program Director, District Health Development Center (DHDC) 

Dr. Imtiaz Dar, Program Manager MNCH 

Dr. Qambar Zia, Principal Paramedical School 

Ms. Tazeem Zahra, SCMO, PAIMAN (SCUS) 

Mr. Mudassir Ahmed, Training Assistant, PAIMAN (SCUS) 

District Headquarter Hospital, Jhelum 

Dr. Munawar Ahmed Ch., Medical Superintendent (since Dec. 2009) 

Dr. Zameer Haider, Senior Pediatric Consultant 

Dr. Shahida Arshad, Senior Medical Officer, Gyn. 

Dr. Naeem H. Gardezi, Senior Consultant Child Specialist. 

RHC Domeli 

Dr. Raja Riaz Ahmed Kiani, Medical Office 

Dr. Gul Nisar, WMO 

BHU Sohan 

Midwife 

Shab ub din, Dispenser 

School of Nursing and Midwifery, DHQ Hospital 

Ramida Sarwak, Principal 

Farzana Bibi, CMW Tutor 

Nasreen Aunev, CMW Tutor 

CMW 

Anika Samuel 

LHV and support group 

Abida Begum + 12 community women 

Khanewal District 

District Officials 

Dr. Muhammad Hussain Naqvi, Executive District Health Officer 

Dr. Muhammad Hassan Piracha, District Coordinator MNCH 

Dr. Ghulam Murtaza, District Coordinator NP for PHC & FP 

Qazi Ashfaq Ahmad, District Coordination Officer 


Representatives of three PAIMAN sub-grantee NGOs 

School of Nursing/CMW and affiliated hospital 

Dr. Muhammad Yousaf Sumra, Medical Superintendent DHQ Hospital 

Mrs. Surraya Ghuffran, Prinicpal, School of Nursing 

CMW 

Nizam Pur village 


Lasbela District 

EDO Health 

Dr. Abdul Wahid Baloch, EDO(H) 

Dr. Qamar Roonja, Coordinator, NPFPPHC 

DHQ Hospital Uthal 

Dr. Muhammad Hayat, Medical Superintendant 

Civil Hospital, Hub 

Dr. Bashir Ahmad Salosai 

Dr. Kawita, Lady Medical Officer, Gyn/Ob 

Cecilia, Nurse, Gyn/Ob 

Society for Social Development & Conservation (SSDC) 

Mr. Abdul Qayum, Project Officer, PAIMAN 

Mr. Kaleem Ullah, Finance Manager 

Mr. Shakeel Ahmad, Office Manager 

Ms. Riffat Shah, Social Mobilizer 

Ms. Najma, Social Mobilizer 

Others 

Mr. Khalid Ahmad Roonjha, District Coordinator, IDSP 

Ms. Saiqa Urooj, (former LHW), District Mentor, IDSP. 

Female FGD participants: 15+12 = 27 

Multan District 

District Officials 

Dr. Islam Zafar, Executive District Health Officer 

Dr. Muhammad Siddique Saqib, District Coordinator, MNCH 

Dr. Munawar Abbass, District Coordinator NP for PHC&FP 

Mr. Qaisar Abbass, Statistical Officer I/C DHIS Cell 

Fatima Jinnah Women’s Hospital 

Dr. Nighat 

Dr. Kuasar Sultana 

Nishtar Medical College 

Dr. Samee Akhtar, Professor of Gynecology & Obstetrics 

Dr. Imran Iqbal, Professor of Pediatrics 

Public Health Nursing School 

Ms. Nasreen, Principal 

Ms. Razia, Tutor 

NGOs 

Farid Ahmed, Bunyad Foundation 

Madni Asghar, Zakrna Development Association 

Amna Hashmi, Director, Maimoona Development Foundation 

Mr. Khurram Mushtaq, Bakhtawar Amin Memorial Trust 


Mr. Sarfaraz, UFAQ 

Madni Asghar Qureshi, National Rural Support Program 

Haliz Abdul Rehman, President, Zakarly Welfare Development Assn. 

RHC Mardanpur 

Mrs Samina Bukhari, LHV 


Members (3) of QIT from BHU Lutafabad 

Ministry of Health/Pakistan (Nutrition) 

Dr. Sher Baz, Asst Director General Health 

Dr. Baseer Khan Achakzai, National Program Manager (Nutrition) 

Muhammad Yaqoob Qureshi, Nutrition Education Officer 

National MNCH Program, Ministry of Health 

Dr. Farooq Akhtar, National Program Manager, 

Ministry of Health/Pakistan 

Makhdoom Shahabuddin, Federal Minister for Health 

Khushnood Akhter Lashari, Secretary 

Muhammad Yaqoob Qureshi, Nutrition Education Officer 

Dr. Suleman Qazi, Advisor – Health Leadership for Environment and Development 

Pakistan Nursing Council) 

Nighat Ejaz Durrani, Registrar 

Pakistan Voluntary Health and Nutrition Association (PAVHNA) 

Rehana Rashdi, Executive Director 

Population Council 

Dr. Zeba A. Sathar, Country Director 

Dr. Ashad Mahmood, Director, Research, Monitoring & Evaluation 

Dr. Sayed Zakir H Shah, Program Manager 

Punjab Provincial Health Office: Lahore 

Dr. Muhammad Aslam Chaudhry Director General Health Services, Punjab 

Dr. Muhammad Anwar Janjua Director Health Services MIS, Punjab 

Dr. Hijab Farrukh, Deputy Provincial Coordinator MNCH, Punjab 

Dr. Akhtar Rasheed, Provincial Coordinator, NP for PHC&FP 

Rawalpindi District 

Executive District Office Health, Rawalpindi 

Dr. Khalid Mehmood Randhawa, District Officer Health, Rawalpindi 

Dr. Shahid Pervaiz, District Officer Health, Headquarter 

Dr. Farzana Zafar, Programme Coordinator, MNCH 

Dr. Javaid Iqbal Chaudhry, Programme Director District Health Development Center / Coordinator 

National Programme on FP & PHC 

Mr. Muhammad Ali Ahsan, DHIS Coordinator 

Mr. Sajjad Nayyar, Senior Officer Community Mobilizer, SCF/US 


Tehsil Headquarter Hospital, Gujar Khan 

Dr. Muhammad Pervaiz Akhtar, Medical Superintendent 

Dr. Sadaqat Aftab, Gynecologist 

Dr. Sadia, Gynecologist 

Dr. Farhat Nawaz, Woman Medical Officer (WMO) 

Dr. Farhat Naveed, Woman Medical Officer (WMO) 

Ms. Fauzia Sohail, Trainee CMW 

Ms. Najum-un-Nisa, Trainee CMW 

Ms. Irfan Bibi, Trainee CMW 

Dr. Muhammad Arshad Arain, Pediatrician 

CMW House 

Ms. Mehnaz Zameer, CMW 

Holy Family Hospital Nursing School 

Principal and 2 Tutors 

Save the Children 

Dr. Amanullah Khan, Sr. Director, Health & Nutrition 

United Christian Hospital School of Nursing: Punjab 

Dr. Emmanuel Bhatti, Deputy Medical Director 

Dr. Benjamin, Medical Director 

Mrs. Nasim Pervaiz, Principal SON 

United Nations Children’s Fund (UNICEF) 

Dr. Hermlall Sharma, Health Specialist 

United Nations Population Fund (UNFPA), Serena Business Complex, Islamabad 

Dr. Naseer M. Nizamani, Assistant Representative 

Dr. Mobashar H. Malik, National Program Officer (RH) 

World Health Organization 

Dr. Ahmed Farah Shadoul, Medical Officer MNCH 

UNITED STATES OF AMERICA 

John Snow, Inc. 

Dr. Theo Lippeveld, Vice President 

DR. ANWER AQIL, SR. HIS ADVISOR 


APPENDIX C: DOCUMENTS REVIEWED 

GENERAL 

1. Midterm Evaluation of the USAID/Pakistan Maternal, Newborn & Child Health Program. 2008. GH 

Technical Project 

2. Midterm Evaluation of the Improved Child Health Project in Federally Administered Tribal Areas. 

2008 GH Technical Project 

3. Professional Development in Intrapartum care and infection prevention (Participant Handout) – 

TACMIL /ABT 

4. Professional Development in Intrapartum care and infection prevention (Lesson Plans) – 

TACMIL/ABT 

5. Professional Development in Intrapartum care and infection prevention (Curriculum) – 

TACMIL/ABT 

RESEARCH AND EVALUATION 

1. Assessment of knowledge and attitude of married women on maternal and new born health (MNH 

in selected union councils of project districts) – Population Council 

2. Assessment of quality of training of Community Midwives – Dfid – August 2010 

3. Assessing Routine Health Information System in Selected PAIMAN Districts by Using Lot Quality 

Assurance Sampling Technique – Population Council 

4. Process Evaluation of Community Mobilization Activities 

5. Assessing the Potential Acceptability of a New Cadre of community Midwives for Pregnancy and 

delivery-related Care in Rural Pakistan (Operations Research) – Population Council 

6. Initial Assessment of Community Midwives in Rural Pakistan (Operations Research) 2010 - 

Population Council 

7. Effect of Dai Training on Maternal and Neonatal Care (Operations Research) 2010 – Population 

Council 

8. District Health System Strengthening – Endline Evaluation (2010) by Contech International 

9. Endline analysis of decision space, institutional capacities and accountability in PAIMAN districts(in 

draft) (2010) Harvard School of Public Health and Contech International 

10. Mapping of Health and Reproductive Health Services Multan District – Population Council 

11. Mapping of Health and Reproductive Health Services Vehari District – Population Council 

12. Mapping of Health and Reproductive Health Services Khirpur District – Population Council 

13. Baseline Household Survey Rawalpindi District 2006 – Population Council 

14. Baseline Household Survey Khanewal District 2006 – Population Council 

15. Baseline Household Survey Multan District – Population Council 

16. Baseline Household Survey Jhelum District 2006 – Population Council 

17. Baseline Household Survey Mardan District – Population Council 

18. Baseline Household Survey Khairpur District – Population Council 

19. Baseline Household Survey Bhimber District – Population Council 

20. Baseline Household Survey Zhob District – Population Council 

21. Baseline Household Survey Sadhnoti District – Population Council 


22. Baseline Household Survey Vehari District – Population Council 

23. Baseline Household Survey Dera Ghazi Khan District 2006 – Population Council 

24. Baseline Household Survey Lasbela District 2006 – Population Council 

25. Baseline Household Survey Sukkur District 2006 – Population Council 

26. Baseline Household Survey Dadu District 2006 – Population Council 

27. Baseline Household Survey Upper Dir District 2006 – Population Council 

28. Baseline Household Survey Buner District 2006 – Population Council 

29. Baseline Household Survey Jaffarabad District 2006 – Population Council 

30. Baseline Assessment of Primary Health Care Services in Mansehra and Bagh Districts – 

JHPIEGO/PRIDE (2007, 2008) 

31. Programme assessment of training of community midwives trainers. 2009 – Aga Khan University 

GOVERNMENT OF PAKISTAN 

1. PC-1 for MNCH Programme 

2. Manual of National Standards for Family Planning Services - TAMA & MoPW 

3. District Health Plan - Jhelum (2010-2011) - Health Department, District Government, Jhelum 

4. National Population Policy 2010 – MoPW 

5. Aide Memoire. National Maternal, Newborn and Child Health Programme. Ministry of Health, 

Government of Pakistan. Second Joint Annual Review. August 2009 

PAIMAN: 

1. PAIMAN Media Products (Repository) 

2. PAIMAN Communication Advocacy and Mobilization Strategy 

3. Ulama Agents for Social Change 

4. Behavior Change Communication (BCC) Media Component Evaluation Report – JHU/PPC 

5. PAIMAN Newsletter Issue 01 2007-02-03-04-05-06-07-08-09 (Dec 2009) 

6. District Health System Strengthening Endline Evaluation (Contech) 

7. PAIMAN CA Modifications 1-3 






13. PAIMAN FATA Report 

14. Key personnel contact information for PAIMAN 

15. Cooperative Agreement-GH Tech 

16. Illustrative Questions to Guide the Evaluation 

17. MNCH Evaluation Site Visits 

18. Report Field Evidence. April 2010 


APPENDIX D: ASSESMENT TEAM SCHEDULE 

Day 

(6 day week) 

Wednesday 

8/4/10 

Thursday 

8/5/10 

(1) 

Friday 

8/6/10 

(2) 

Saturday 

8/7/10 

(3) 

Sunday 

8/8/10 

DETAILED ASSESSMENT SCHEDULE 

Activities/Sites Time Individuals Interviewed Team Participants 

ISLAMABAD PAKISTAN 

Arrival 0230 Dr. Judith Fullerton (JF) 

Arrival 2230 Dr. Stephen Atwood 

(SA) 

Team meeting 0900 – 1000 Nuzhat Samad (NS) 

SA, JF 

Meeting with local logistic team 1300 – 1400 Shafat Sharif Team (SA, JF, NS) 

 

Meeting with USAID Human 

Development Officer 

1700 - 1800 Miriam Lutz Team 

Team planning meeting 0900 – 1700 Team (SA, JF, NS) 

Introduction to PAIMAN COP 1700 – 1800 Dr. Nabeela Ali 

Miriam Lutz 

Team 

Team planning meeting 0900 – 1700 Team 

 

Skype videoconference with GH 

Tech Program Officer (USAID 

personnel in attendance) 

1700 - 1800 Taylor Napier 

Miriam Lutz 

Megan Petersen 

Team 


Day 

(6 day week) 

Monday 

8/9/10 

(1) 

Tuesday 

8/10/10 

(2) 

Wednesday 

8/11/10 

(3) 

Thursday 

8/12/10 

(4) 

 



Meeting with Director, USAID 

Health Office 

0830 - 0900 Janet Paz-Castillo Team 

Interview with MCH Consultant 0930 - 1030 Anjum Asfaq Team 

 

Interview with Contech 

(Partner Organization) 

1430 - 1530 Naeem Udddin Mian 

Shahzad Hussain Awam 

M. Ashraf Chaudhry 

Team 

Interview with JHP/CCP 0900 – 1000 Fayyaz Ahmad Khan Team 

Interview with Midwife Consultant Patrice White Team 

Overview with PAIMAN 1000 – 1300 Bal Ram Bhui 

Kashif Hanif 

Nadeem Hassan 

Nasir Idrees 

Shuaib Khan 

Zareef Uddin Khan 

Javade Khwaja 

Frank White 

Interview with National MNCH 

Program Manager 

 

 

 

Interview with Population Council 


Interview with Registrar, Pakistan 

Nursing Council 

Interview with SAVE 


Team 

1900 - 2000 Farooq Akhtar Team 

1030 – 1200 Zeba A. Sathar 

Syed Zakir Shah 

Arshad Mahmood 

Team 

1300 – 1430 Nighat Durrani Team 

1500 – 1600 Amman Ullah Team 


Day 

(6 day week) 

Friday 

8/13/10 

(5) 

Saturday 

8/14/10 

(6) 

Sunday 

8/15/10 

Monday 

8/16/10 

(1) 

Tuesday 

8/17/10 

(2) 

Wednesday 

8/18/10 

(3) 

 

 

 

 

 



Interview with UNFPA 

(Development partner) 

Interview with representative of 

USAID-funded PRIDE program 

Reading supplementary documents; 

report writing 

Field visit to representative health 

facilities 

Field visit to PAIMAN associated 

sites 

Rawlapindi 

1030 – 1200 Mobashar H. Malik 

Naseer Nizamani 

Team 

1430 – 1600 Shabana Zaeem Team 

0900 – 1700 Team 

0830 – 1400 Health facility personnel 

(LHV, Medical Asst, RH 

provider) 

0800 - 1600 EDOH 

Principal, School of Nursing 

Personnel: THQ Guiar 

Personnel: RHC Mandra 

LHW Women’s support 

group 

Men’s group 

Community Midwife 

Team 

SA, JF 

JF 

JF 

SA 

JF 

JF 

Team 

Interview with DfiD 1100 – 1200 Raza Zaidi SA, JF 

 

 

Interview with representatives of 

Nutrition Unit, GOP 

Interview with UNICEF 

(development partner) 

1330 - 1430 Baseer Khan Achakzal 

Sher Baz 

Muhammed Yaqoob Qureshi 

Suleman Qazi 

1700 – 1800 Hemlal Shama SA, JF 

Thursday Field visit to PAIMAN-associated 0830 – 1500 EDOH SA 

SA 


Day 

(6 day week) 

8/19/10 

(4) 

Friday 

8/20/10 

(5) 

Saturday 

8/21/10 

(6) 

Sunday 

8/22/10 

Monday 

8/23/10 

(1) 

 

 

 

sites 

Jhelum 



Telephone conference with 

PAVHNA 

Interview with WHO 

(development partner 

Interview with PAIMAN subgrantees 

o Community Uplift Program 

o Friends Foundation 

o United Christian 

Organization 

Principal, School of Nursing 

Personnel: RHC Domali 

LHW women’s support 

group 

DHQ (facility visit) 

Personnel: BHU Sohan 

Community Midwife 

SA, JF 

JF 

JF 

SA 

JF 

SA, JF 

1700 – 1800 Rhihana Rashdi SA, JF 

1000 – 1130 Ahmed Farah Shadoul Team 

1200 – 1330 

Iftikhar ur Rahman 

Poriska Ayub 

Abbas Gondal 

Muhsmmsf Ibraheem 

Sarfraz Khan Khokhar 

Munazza Haris (PAIMAN) 

Team 

Interview with JSI, Vice President 1430 – 1530 Theo Lippeveld Team 

Drafting report 0900 – 1700 Team 

 

 

Travel to Lahore 

Interviews with Punjab District 

Provincial Personnel 

0830 – 12:30 Dr. Muhammad Aslam 

Chaudhry 

Dr. Muhammad Anwar Janjua 

Dr. Hijab Farrukh 

Dr. Akhtar Rasheed, 

Team 


Day 

(6 day week) 



 

 

Site visit and interviews 

United Christian Hospital and SON 

Travel to Multan and Khanewal Districts 

1230 – 1500 Dr. Benjamin 

Dr. Emmanuel Bhatti 

Mrs. Nasim Pervaiz 

Team 

Tuesday 

8/24/10 

(2) 

 

 

 

Interviews with Khanewal District 

EDOH and District Health Officers 

Meeting with NGO Staff members, 

Khanewal District 

Site visit District Health Facility and 

School of Nursing, Khanewal 

0915 – 1145 Muhammad Hussain Naqvi 

Muhammad Hassan Piracha 

Ghulam Murtaza 

Qazi Ashfaq Ahmad 

SA, JF 

1145 – 1215 SA, JF 

1230 – 1400 Dr. Muhammad Yousaf 

Sumra 

Mrs. Surraya Ghuffran 

Site visit CMW home 1400 – 1430 JF 

JF 

 

Discussions with community 

members 

1430 – 1500 5 women, 2 men JF 

Site visit RHC Karcha Khoh 1230 – 1400 SA 

 

Meeting with Quality Improvement 

Team and LHW Support Group 

August 23-24: Visits conducted by Eyecon (Local Subcontractors) 

 

Interviews with Buner District 


1400 – 1530 SA 

Dr. Maqsood 

Dr. Fazle Azeem 

Dr. Lal Bacha 

Dr. Amir Zahir 


Day 

(6 day week) 



Mr. Javaid Iqbal 

Wednesday 

8/25/10 

(3) 

Site visit: DHQ Hospital Dagar Dr. Shuaib Muhammad 

Dr. Tahir 

Site visit: Civil Hospital Nawagai Dr. Sher Zaman 

 

Interviews with local NGO 

representatives and TBA MT 

Mr. Simir Khan 

Mr. Farid Khan 

Ms. Roshan Ara 

Interviews: Lady Health Supervisors Mr. Zain-ul-Abdeen 

Ms. Najia 

Ms. Nargis Jehan 

Focus groups Male Volunteer Group: 12 

Participants 

Female FGD Participants: 18 

+ 20 = 38 

 

 

 

 

Interviews with Multan District 


Site visit and discussions 

Nishtar Medical College Public 

Health Nursing School 

Site visit and discussions 

Fatima Jinnah Women’s Hospital 

Discussions with Representatives 

from 5 NGOs 

0930 - 1000 Dr. Islam Zafar 

Dr. Muhammad Siddique 

Saqib 

Dr. Munawar Abbass 

Mr. Qaisar Abbass, 

1030 - 1100 Ms. Nasreen 

Ms. Razia 

1115 – 1200 Dr. Nighat 

Dr. Kuasar Sultant 

1200 - 1230 Maimoona Devel Fdn 

Baktawar Amin Memorial 

Trust 

SA, JF 

SA, JF 

SA, JF 

SA, JF 


Day 

(6 day week) 



UFAQ 

Bunyad Fnd 

Zakrna Devel Assn 

Site Visit to RHC Mardanpur 1300 – 1330 SA, JF 

 

Interaction with community 

members 

1330 - 1400 Male volunteer (1) 

Male member of QIT 

committee (1) 

Male support group (1) 

LHV support group (8 

women) 

SA, JF 

 

Return travel to Islamabad 

Thursday 

8/26/10 

(4) 

 

Interview with representatives of 

Aga Khan Foundation 

(initial collaborative partner) 

1100 – 1230 Shazia Akbar 

Qayyum Ali Noorani 

Saadia Shabbir 

Team 

Friday 

8/27/10 

(5) 

Interview with midwifery consultant 1330 – 1500 Imtiaz Kamal Team 

 

 

 

Informal discussion with 

JSI/PAIMAN 

Interview with Secretary, Ministry of 

Health, and Director, MNCH 

Skype teleconference with midwifery 

tutor: Aga Khan University School of 

Midwifery 

(Collaborative partner) 

August 26- 27: Visits conducted by Eyecon (Local Subcontractors) 

0800 – 0930 Theo Lippeveld 

Nabella Ali 

1100 – 1200 Khushnood Akhtar Lashari 

Farooq Akhtar 

SA, JF 

Team 

1600 – 1700 Rafat Jan Team 


Day 

(6 day week) 

 



Interviews with Lasbela District 

EDO Health and staff members 

Dr. Abdul Wahid Baloch 

Dr. Qamar Roonja 

Site visit: DHQ Hospital Uthal Dr. Muhammad Hayat 

Site visit: Civil Hospital Hub Dr. Bashir Ahmad Salosai 

Dr. Kawita 

Cecilia (Nurse) 

 

Group Interview: Local NGO 

representatives 

Mr. Abdul Qayum 

Mr. Kaleem Ullah 

Mr. Shakeel Ahmad 

Ms. Riffat Shah 

Ms. Najma 

Individual interviews Mr. Khalid Ahmad Roonjha 

Ms. Saiqa Urooj 

Focus Groups 2 groups: 27 participants 

Saturday 

8/28/10 

(6) 

Sunday 

8/29/10 

Monday 

8/30/10 

(1) 

Team meeting; report development 0900 – 1700 Team 

 

Interview with Minister of 

Population Welfare and staff 

members 

1100 – 1230 Saukat Hayat Durrani, 

Shazad Ahmad 

Abdul Ghafar Khan 

Team meeting 1400 – 1700 Team 

Shafat Sharif 


Day 

(6 day week) 

Tuesday 

8/31/10 

(2) 

Wednesday 

9/1/10 

(3) 

Thursday 

9/2/10 

(4) 



Interview with Clara Pasha, Abt Asst 1300 – 1430 JF 

 

 

Interview with Greenstar 

(original project partner) 

Teleconference with Consultant, 

Aga Khan University 

Report writing 0800 – 1700 

1000 - 1130 Haroon Ibrahim 

Maheen Malik 

Sherine Mohagheghpour 

Team 

0730 – 0800 Zulfiqar Bhutta Team 

Friday 

9/3/10 

(5) 

 

 

Teleconference (cont.) with 

Consultant, Aga Khan University 

Meeting with USAID 

0930 – 1100 Zulfiqar Bhutta 

Miriam Lutz 

Report discussion and editing 0100 – 1700 Team 

Saturday 

9/4/10 

(6) 

Sunday 

9/5/10 

Monday 

9/6/10 

(1) 

Tuesday 

9/7/10 

(2) 

Report discussion and editing 0900 – 1700 Team 

 

 

Report writing and editing; 

Preparation of presentations 

Presentation to PAIMAN and 

stakeholders 

0900 - 1700 Team 

0900 – 1030 Team 


Day 

(6 day week) 



Presentation to USAID 1130 - 1300 Team 

Wednesday 

9/8/10 

(3) 

 

Departure 


APPENDIX E: REFERENCES 

Baker, M., 2009. ―Developing the Măori nursing and midwifery workforce.‖ Nursing New Zealand 15, 28. 

Bashir H., S. Kazmi, R. Eicher, A. Beith, and E. Brown. Pay for Performance: Improving maternal health 

services in Pakistan. Bethesda Maryland: Health Systems 20/20 Project, Abt Associates, 2009. 

Bossert, T., A. Mitchell, N. uddin Mian, and M. Janjua. District-level Decision Space Analysis in Pakistan: 

Relationships between decision space, capacities and accountability in five health functions with selected 

district performance measures. John Snow, Inc., 2008. 

Bricker L., J.P. Neilson, and T. Dowswell. ―Routine ultrasound in late pregnancy (after 24 weeks' 

gestation).‖ Cochrane Database of Systematic Reviews 2008, Issue 4: Art. No.: CD001451. DOI: 

10.1002/14651858.CD001451.pub3. 

Carlow, M. and M. McCall. ―Skilled birth attendance: what does it mean and how can it be measured? A 

clinical skills assessment of maternal and child health workers in Nepal.‖ International Journal of 

Gynaecology and Obstetrics 89:200-208, 2005. 

Canadian International Development Agency. Pakistan Program. 2010. Available at: http://www.acdicida.gc.ca/pakistan-e. 

Chambers, Robert. Revolutions in Development Inquiry. Institute of Development Studies. London, 2008. 

Contech International. District Health System Strengthening End-line Evaluation. John Snow, Inc., 2010. 

Currie, S., P. Asfar, P. and R.C. Fowler. ―A bold new beginning for midwifery in Afghanistan.‖ Midwifery 

23:226-234, 2007. 

Darmstadt, D., M. Hassan, Z. Balsara, P. Winch, R. Gipson, and M. Santosham.‖ Impact of clean deliverykit 

use on newborn umbilical cord and maternal puerperal infections in Egypt.‖ Journal of Health, 

Population and Nutrition. 27(6):746-754, 2009. 

DiFD. Assessment of quality of training of community midwives. Final Report, August 2010. 

DiFD. Pakistan. Where UK bilateral aid goes, 2010. Available at: http://www.dfid.gov.uk/Where-wework/Asia-South/Pakistan/Key-facts/ 

Gülmezoglu, A.M., F. Forna, J. Villar, and G.J. Hofmeyr. ―Prostaglandins for preventing postpartum 

haemorrhage.‖ Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD000494. DOI: 

10.1002/14651858.CD000494.pub3, 2007. 

Imtiaz J., H. Harris, S. Salat, A. Zeb, N. Mobeen, O. Pasha, E. McClure, J. Moore, L. Wright and R. 

Goldenberg. ―Neonatal mortality, risk factors and causes: a prospective population-based cohort study 

in urban Pakistan.‖ Bulletin of the World Health Organization. 87:130-138. doi: 10.2471/BLT.08.050963, 

2009. 

International Confederation of Midwives. Definition of a Midwife. 2005. Available at: 

http://www.internationalmidwives.org/Portals/5/Documentation/ICM%20Definition%20of%20the%20Mid 

wife%202005.pdf. 


International Confederation of Midwives. Essential competencies for basic midwifery practice. The Hague, 

Netherlands. 2002. Available at: 

http://www.internationalmidwives.org/Portals/5/Documentation/Essential%20Compsenglish_2002- 

JF_2007%20FINAL.pdf. 

International Confederation of Midwives. Global Standards for Midwifery Education. 2010 (pre-publication 

copy available on request from ICM). 

Ireland, J., H. Bryers, E. van Teijlingen, V. Hundley, J. Farmer, F. Harris, J. Tucker, A. Kiger and J. Caldow. 

―Competencies and skills for remote and rural maternity care: a review of the literature.‖ Journal of 

Advanced Nursing 58, 105-115, 2007. 

Jafarey, S.N. ―Maternal mortality in Pakistan – compilation of available data.‖ The Journal of the Pakistan 

Medical Association. 52(12): 539-44, 2002. 

Japanese International Cooperation Agency. Pakistan program. 2010. Available at: 

http://www.jica.go.jp/pakistan/english/. 

Khan U.P., S.Z. Bhutta, S. Munim, and Z.A. Bhutta. ―Maternal health and survival in Pakistan: issues and 

options.‖ Journal of Obstetrics and Gynaecology Canada. 31(10):920-9, 2009. 

Lawn, J.E., S. Cousens, and J. Zupan. ―4 million neonatal deaths: When? Where? Why?‖ Lancet. 365: 891- 

900. 2005, doi: 10.1016/S0140-6736(05)71048-5 pmid: 15752534. 

Morin, K.H. and J. Yan. ―Developing global standards for initial nursing and midwifery education.‖ Journal 

of Obstetric Gynecologic & Neonatal Nursing 36, 201-2, 2007. 

Norway Embassy in Pakistan. The NPPI Program, 2010. Available at: 

http://www.norway.org.pk/Embassy/development/MOU_ON_NPPI/. 

Pakistan Demographic and Health Survey 2006-2007. Islamabad, National Institute of Population Studies, 

2007. 

Pakistan Social & Living Standards Measurement Survey (PSLM) 2008-09 (District Results). Federal Bureau 

of Statistics, Statistics Division, Pakistan. 

Pakistan infant mortality rate 2010. Available at: 

http://www.indexmundi.com/pakistan/infant_mortality_rate.html. 

Rakannuddin, R.J., T.S. Ali, and B. McManis. ―Midwifery education and maternal and neonatal health 

issues: challenges in Pakistan.‖ Journal of Midwifery & Women’s Health 52, 398-405, 2007. 

Ridde, V. ―Per diems undermine health interventions, systems and research in Africa: burying our heads 

in the sand.‖ Tropical Medicine and International Health, 2010. Published on-line in advance of print. 

doi:10.1111/j.1365-3156.2010.02607.x 

Roxburgh, M., J. Taylor, and M. Murebwayire. ―Rwanda: A thousand hills, a thousand dreams, a thousand 

challenges for nurses and midwives and the Millennium Development Goals.‖ Nurse Education in Practice 

9, 349-350, 2009. 


Sathar, Z., A. Jain, S. RamaRao, Mul Haque, and J. Kim. ―Introducing Client-centered Reproductive 

Health Services in a Pakistani Setting.‖ Studies in Family Planning. 36(3): 221-234, 2005. 

Shah, Z. Process evaluation of community mobilization activities. Population Council, 2010. 

Shadoul A.F., F. Akhtar, and K.M. Bile. ―Maternal, neonatal and child health in Pakistan: towards the 

MDGs by moving from desire to reality.‖ Eastern Mediterranean Health Journal. 16:S25-S32, 2010. 

Sibley, L, and T. Sipe. ―Transition to skilled birth attendance: Is there a future role for trained traditional 

birth attendants?‖ Journal of Health, Population & Nutrition 24, 472-478, 2006. 

Sibley, L, T. Sipe, C. Brown, M. Diallo, K. McNatt, and N. Habartta. ―Traditional birth attendant training 

for improving health behaviors and pregnancy outcomes.‖ Cochrane Database of Systematic Reviews 

(Online) [Cochrane Database Syst Rev] (3). Cochrane AN: CD005460. Date of Electronic Publication: Jul 18, 

2007. 

WHO. Strengthening nursing and midwifery. Geneva, 2008. Available at: 

http://www.searo.who.int/LinkFiles/Nursing_and_Midwifery_EB122_Report_Jan2008.pdf 

Sutherland T., C. Meyer, D.M. Bishai, S. Geller, and S. Miller. Community-based distribution of 

misoprostol for treatment or prevention of postpartum hemorrhage: cost-effectiveness, mortality and 

morbidity reduction analysis.‖ International Journal of Gynaecology and Obstetrics. 108(3): 289-94, 2010. 

Temmar, F., B. Vissandjée, M. Hatem, A. Apale and D. Kobluk. ―Midwives in Morocco: seeking 

recognition as skilled partners in women-centered maternity care.‖ Reproductive Health Matters 14, 83- 

90, 2006. 

UNDP. Human Development Report, 2009. Available at: http://www.undp.org/hdr2009.shtml. 

UNFPA. Investing in Midwives and others with midwifery skills to accelerate progress towards MDG5, 

2010. Available at: www.unfpa.org. 

UNICEF. Pakistan country statistics, 2010. Available at: 

http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html. 

UNICEF. Pakistan health program. 2010. Available at: http://www.unicef.org/pakistan/partners_1784.htm. 

USAID. Pakistan health program, 2010. Available at: 

http://www.usaid.gov/our_work/global_health/mch/countries/asia/pakistan.pdf. 

United States Central Intelligence Agency. CIA Factbook, 2010. Available at: 

www.cia.gov/library/publications/the-world-factook/geos.pk.html. 

Wajid A., A.M. Mir and Z. Rashid. Assessing the potential acceptability of a new cadre of community 

midwives for pregnancy and delivery related care in rural Pakistan. Findings from a qualitative study. 

Islamabad: Population Council, 2010. 

Wajid A, Z. Rashid and A.M. Mir. Initial assessment of community midwives in rural Pakistan. Islamabad: 

Population Council, 2010. 


Wakefield, M.A., B. Loken and R. Hornik. ―Use of mass media campaigns to change health behavior.‖ 

Lancet. 376: 1261-1271, 2010. 

Whitworth M., L. Bricker and J.P. Neilson. ―Ultrasound for fetal assessment in early pregnancy 

(Protocol).‖ Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007058. DOI: 

10.1002/14651858.CD007058. 

WHO, ICM, FIGO. Making pregnancy safer: the critical role of the skilled attendant. A joint statement 

by WHO, ICM and FIGO. Geneva, World Health Organization, 2004. Available at: 

http://www.who.int/making_pregnancy_safer/documents/9241591692/en/index.html. 

WHO. World Health Report 2005: Make every mother and child count. Geneva, 2005. 

WHO. National health accounts: Pakistan, 2008. Available at: http://www.who.int/nha/country/pak/en/ 

accessed on 9 October 2010. 

WHO. Country program: Pakistan. 2010. Available at: 

http://www.who.int/hac/network/who/co_pakistan/en/print.html. 


For more information, please visit: 

http://resources.ghtechproject.net/

USAID/PAKISTAN: MATERNAL NEWBORN AND CHILD HEALTH ...

Create successful ePaper yourself

Delete template?

Save as template?