1.Aga Khan Health Service, Pakistan Aga Khan Rural Support Programme TheChitral Child Survival Project: Community Midwives & Community Based Saving Groups: A Dual Approach to Improve MNCH in Chitral District, Khyber Pakhtunkhwa- Pakistan

2. Background In Pakistan, maternal, neonatal and child mortality remain high IMR is 74/1000 Live Births NMR is 55/1000 Live Births In Khyber Pakhtunkhwa province around 30,000 maternal deaths per year In Chitral, remoteness, poverty, illiteracy, poor transportation infrastructure, harsh weather and restricted female mobility are the major barriers to access MNCH services. PDHS 2012-2013 Baseline Survey CCSP: 2009 3. Total population of District Chitral is 500,000 based on 1998 census CMWs were deployed in 28 remote locations Program population of Chitral Child Survival Program 90,000 Geography & Demography 4. STRATEGIC OBJECTIVE AND EXPECTED OUTCOMES Strategic Objective: Increased utilization of obstetric and neonatal continuum of care Outcome 1: Increased awareness of obstetric and neonatal complications and informed demand for SBA, community financing, community-based transportation, and birth preparedness and complication Outcome 2: Strengthened CMW referral linkages for obstetric and neonatal care Outcome 3: Increased availability of trained community midwives Outcome 4: Increased financial access to emergency obstetric and neonatal care 5. Community Midwives (CMWs) Community selected local young women to send for midwifery training 12 months classroom & 6 months practical training Uniqueness: Five months supervised internship in AKHSPs secondary referral units. 6. Post training 28 trained CMWs deployed back in communities Work stations established with essential equipment, supplies and medicines VHCs established Supportive supervisory system established 7. Community Based Savings Group CBSG is a group of 15-25 people Save money together, and disburse small loans from those savings Provide social support to group members. Not health focused only 8. Status of CBSGs Groups formed 421 and graduated Total membership 7,988 Saving per member 5-20USD Loan utilization 63-86% Attendance 95.6% Retention rate 98% Per member cost 35USD 9. Operations Research (OR) and Additional Evaluations Purpose: OR was focused on evaluating CMWs training and deployment, and uptake of CMW services by the community in Chitral, as well as inform national CMW policy that at the time was just being rolled out. Methodology: Prospective, longitudinal comparative three phase research with quantitative and qualitative components Additional Evaluations: Baseline, Mid-term, Final, RAF, CBSG Supplemental 10. Research Framework utilized for the OR 11. Research Question How do the six factors of CMW utilization and retention influence the outcomes in terms of [a] competencies of CMWS, [b] client/community satisfaction, [c] favorable perceptions of the CMW by TBAs/LHWs, [d] market share of the CMW, [e] CMW turnover, and [f] adequate remuneration to CMWs? 12. Results: Percentage of mean scores in theoretical testing (2011, 2012 and 2013) 13. Results: Percentages of mean scores in skills assessment (2011, 2012 and 2013) 14. 33% 22% 47% 45% 82% 50% 82% 83% 0 10 20 30 40 50 60 70 80 90 Deliveries attended by SBAs Women who availed ANC Proportion of women who knew danger signs in new borns Proportion of women who knew danger signs of pregnancy %ofpregnantwomen Baseline Survey (2009) Endline Survey (2013) Results Improvement in Knowledge, Attitude and Competencies in the intervention areas 15. 59% 56% 49% 0 10 20 30 40 50 60 70 Money Trasport Blood %ofpregnantmothers% of pregnant women attended by CMWs who had made prior arrangements for delivery 16. CBSGs Membership Outcomes 17. Key Findings : Gender Successes for replication: Male motivators for conservative areas Positive inclusion of religious leaders Both female and male members for VHCs Female role modeling and empowerment through CBSGs and other interventions Challenges and lessons: Cultural and religious challenges Recognition of female mobility 18. Some Examples of What WorkedLessons for Replication 1.Community participation and ownership of CMW selection; 2.Five month additional on the job training for CMWs; 3.VHC structure for BCC and community mobilization; 4.CBSGs as platforms for BCC, knowledge and uptake of CMW services, and empowerment; 5.Engagement of male motivators and religious leaders to facilitate CMW uptake in conservative communities. 19. Some Examples of ChallengesWhat Didnt Work well 1.Work station versus home deliveries; 2.Referral and feedback; 3.Delayed and uncertain uptake of CMWs by DOH; 4.Emergency Transport limited success due to overly difficult terrain and weather; 5.CBSGs had limited success and impact as mechanisms to overcome financial barriers to health care seeking behavior unable to create 20. Replication, Sustainability, and Looking Ahead 1. AKDN as a Learning Agency: a) Internal learning process b) MOH at national and provincial policy levels c) Peer organizations in Pakistan and elsewhere publications, training materials, presentations, etc. 2. Sustainability and uptake of CMWs by KPK Government: a) Commitment b) Uncertainty around resources from KPK DOH 21. Replication, Sustainability, and Looking Ahead Continued: 3. Potential for franchising model 4. Building on the platform using evidence and results in other programs and initiatives 22. Thank You! sharifullah.khan@akdn.org david.hintch@akdn.org