usaid/pakistan’s mch program family …

USAID/PAKISTAN’S MCH PROGRAM, FAMILY PLANNING/REPRODUCTIVE HEALTH COMPONENT

QUARTERLY PROGRESS REPORT (January –March 2016) P/1

Cooperative Agreement No:

AID-391-A-13-00007

Submitted by:

Marie Stopes Society (MSS)

USAID/PAKISTAN’S MCH PROGRAM

FAMILY PLANNING/REPRODUCTIVE HEALTH

COMPONENT

Quarterly Progress Report: January – March, 2016



TABLE OF CONTENTS

LIST OF TABLES

P/3

LIST OF FIGURES

P/3

ACRONYMS

P/4

CHAPTER 2:

OBJECTIVE 1 - INCREASING

THE SIZE AND CAPACITY OF

HEALTH WORKFORCE

P/7

CHAPTER 3:

OBJECTIVE 2 - SCALING UP

FACILITY-BASED SERVICE

DELIVERY

P/9

CHAPTER 4:

OBJECTIVE 3 - SCALING UP

OUTREACH AND

COMMUNITY-BASED

SERVICE DELIVERY

P/11

CHAPTER 6:

IMPACT STORIES

P/23

ANNEX-1

P/26

CHAPTER 1:

EXECUTIVE SUMMARY

P/5

CHAPTER 5:

CROSS CUTTING THEMES

P/15



LIST OF TABLES

Table 1: KPIs achieved to-date (through Mar 2016)

Table 2: Region wise overview of SF providers Q2

Table 3: Region wise camp analysis

LIST OF FIGURES

Figure-1: CYPs generated during Q2 (Jan-Mar 2016)

Figure-2: Clients served in Q2 (Jan-Mar 16)

Figure-3: Comparison of participants trained in Q2, segregated by modules Q1 and Q2

Figure-4: Comparison of participants trained in Q1 and Q2, segregated by gender

Figure-5: Public and private service providers trained with USG Funds in Q2 (Jan– Mar 16)

Figure-6: Regional QA Scores and QA Visits in Q2 (Jan-Mar 16)

Figure-7: Comparison of services Q1 vs Q2 SF

Figure-8: CYPS generated by method mix in SF Q2 (Jan-Mar 2016)

Figure-9: CYPs Generated Q2 (Jan-Mar 2016)

Figure-10: Comparison of SF CYPs generated in Q1 and Q2, Segregated by method mix

Figure-11: CYPs generated by FP method

Figure-12: Parity distribution among TL clients in SF

Figure-13: Age distribution among TL in Q2

Figure-14: Comparison of services Q1 vs Q2

Figure-15: CYPs generated in Q2 (Jan to Mar 16)

Figure-16: CYPs generated by method in Q2 (Jan to Mar 16)

Figure-17: Average CYP generated per camp – monthly

Figure-18: Age distribution among TL Clients in Q2 (Jan-Mar 16)

Figure-19: Parity Distribution among TL Clients in Q2 (Jan-Mar 16)



ACRONYMS

BCC BEHAVIOR CHANGE COMMUNICATION

B&M BRANDING AND MARKING

CIO CHIEF INFORMATION OFFICER

CMW COMMUNITY MIDWIVES

CM COMMUNITY MOBILIZATION

CPR CONTRACEPTIVE PREVALENCE RATE

CYP COUPLE YEARS OF PROTECTION

DCO DISTRICT COORDINATION OFFICER

DO DEVELOPMENT OBJECTIVE

DOH DEPARTMENT OF HEALTH

EPI ENTERPRISE DISTRICT OFFICER

ERP ENTERPRISE RESOURCE PLANNING

FHE FIELD HEALTH EDUCATOR

FP FAMILY PLANNING

FP/RH FAMILY PLANNING/REPRODUCTIVE

HEALTH

FLAME FRANCHISE DATA UTILIZING LOCAL

APPLICATION

GOS GOVERNMENT OF SINDH

GM GENERAL MANAGER

HR HUMAN RESOURCE

HTSP HEALTH TIMING AND SPACING OF

PREGNANCY

HSSC HEALTH SYSTEM STRENGTHENING

COMPONENT

IPC INTERPERSONAL COMMUNICATION

IR INTERMEDIATE RESULTS

IRMNCH INTEGRATED REPRODUCTIVE

MATERNAL NEWBORN CHILD HEALTH

IT INFORMATION TECHNOLOGY

IUCD INTRAUTERINE CONTRACEPTIVE

DEVICE

JHU.CCP JOHNS HOPKINS UNIVERSITY CENTER

FOR COMMUNICATION PROGRAM

JSI JOHN SNOW INTERNATIONAL

KPI KEY PERFORMANCE INDICATORS

LAPM LONG-ACTING PERMANENT METHOD

LHS LADY HEALTH SUPERVISOR

LHV LADY HEALTH VISITOR

LHW LADY HEALTH WORKER

M&E MONITORING AND EVALUATION

MCH MATERNAL AND CHILD HEALTH

MCHIP MATERNAL AND CHILD HEALTH

INTEGRATED PROGRAM

MNCH MATERNAL, NEWBORN AND CHILD

HEALTH

MSI MARIE STOPES INTERNATIONAL

MSS MARIE STOPES SOCIETY

MWRA MARRIED WOMEN OF REPRODUCTIVE

AGE

NP-FP & PHC NATIONAL PROGRAMME FOR

FAMILY PLANNING & PRIMARY

HEALTHCARE

OMU OUTREACH MOBILE UNITS

OR OUTREACH

PMP PROJECT MANAGEMENT PLAN

PWD POPULATION WELFARE DEPARTMENT

QA QUALITY ASSURANCE

RH REPRODUCTIVE HEALTH

RME RESEARCH, MONITORING AND

EVALUATION

SDP SERVICE DELIVERY POINTS

SF SOCIAL FRANCHISE

SFS SENIOR FIELD SUPERVISOR

SMH SAFE MOTHERHOOD

SOPS STANDARD OPERATING PROCEDURES

SSF SURAJ SOCIAL FRANCHISE

ST SHORT-TERM

STI SEXUALLY TRANSMITTED INFECTIONS

TL TUBAL LIGATION

TMS TIME MANAGEMENT SYSTEM

TSD TECHNICAL SERVICES DEPARTMENT

USAID UNITED STATES AGENCY FOR

INTERNATIONAL DEVELOPMENT

USG UNITED STATES GOVERNMENT

UNICEF UNITED NATIONS CHILDREN'S

EMERGENCY FUND

VFM VALUE FOR MONEY



CHAPTER 1

EXECUTIVE SUMMARY

The Family Planning/Reproductive Health (FP/RH) project serves as Component 1 for the United States Agency for International Development (USAID) Pakistan’s Maternal Child Health (MCH) Program. FP/RH interventions contribute to achieving the fifth development objective (DO) of the USAID MCH Program: to improve MCH outcomes in the focused areas and support the following two intermediate results (IRs) under DO 5: IR 5.1 Improved utilization of quality FP/RH and Maternal, Newborn and Child Health (MNCH) services Couple years of protection (CYP) in United States Government (USG) supported programs Number of women and children receiving FP/RH and MNCH services in USG-assisted sites

IR 5.1.1: Improved availability of quality FP/RH and MNCH services Number of people trained in FP/RH and MNCH through USG support

Quarterly achievements against IRs for the period January to March 2016 are presented in this report. The practice of healthy timing and spacing of pregnancies (HTSP), particularly through the voluntary uptake of modern family planning (FP) methods, is fundamental to the wellbeing of mother and child. All married couples have a right to select their family’s size and the spacing between their children. Since its inception in October 2013, the FP/RH project has focused on building awareness of HTSP and FP methods amongst the women and communities it serves through Field Health Educators (FHEs) and providing married women of reproductive age (MWRA) access to a range of voluntary and quality modern FP methods. The FP/RH service delivery model operates through two interventions: the Suraj Social Franchise (SF) network and the outreach (OR) model. Additionally MCH Rohri also provides FP and MCH services. Both SF and OR are supported by demand generation activities conducted by FHEs. The project operates in 29 districts of Sindh, grouped into three regions: Karachi, Hyderabad, and Sukkur; and three districts of Punjab grouped into one region, Multan. The highlights for the reporting quarter i.e. January – March 2016 include: FP services were offered through a network of 301 SF Providers; 14 OR teams; and 4 Outreach Mobile

Units (OMU) A total of 303,099 MWRAs were reached through door to door visits, Mohalla and Mashwara

meetings in the SF channel, and 122,421 in the OR channel. 111,767 clients were provided voluntary FP services; 85,316 through the SF; 26,337 though the OR

Channel and 114 through MCH services. 279,632 Couple Years of Protection (CYPs) were generated; 214,604 through the SF; 64,790 though

the OR Channel and 238 through MCH services. As a result of services provided during the reported period, an estimated 88 maternal deaths and an

estimated 99,046 unintended pregnancies averted

During the reporting quarter FP/RH utilized various initiatives to enhance effectiveness and increase

access to voluntary FP services. These include an evolving model of community mobilization

(CM)interventions; organizational and system strengthening activities; the helpline service; effective

program management; a continued interest in building sustainability in project interventions; and

research, monitoring and evaluation activities focused on seeding evidence-based decision making.



Table-1: KPIs achieved to date (through Mar 2016)

Key Performance Indicators (KPIs)1

Year 12 (through Sep 2014)

Year 2 (Oct 2014– Sep 2015)

Year 3, Qtr. 1

(Oct 2015–Dec 2015)

Year 3, Qtr. 2

(Jan 2016– Mar 2016)

Results to date

(through Mar 2016)

Number of OR teams added 12 4 -13 -1 14

Number of OMU teams added 0 2 1 1 4

Number of SF providers added 135 165 +4 (-24)4 +41(-20) 301

OR camps held 825 1,361 479 489 3,154

CYPs generated 339,022 592,164 244,060 279,632 1,454,878

Total clients provided voluntary FP services

142,706 242,389 94,840 111,767 591,702

Voucher clients 88,403 146,859 57,277 67,283 359,822

Unintended pregnancies averted 159,956 242,155 87,053 99,046 588,210

Maternal deaths averted 218 287 79 88 672

Figure-1: CYPs generated during Q2 (Jan-Mar 2016)

Figure-2: Clients served in Q2 (Jan-Mar 16)

1KPIs related to unintended pregnancies and maternal deaths averted were estimated using MSI’s Impact2 model: https://mariestopes.org/impact-2 2In this report, Year 1 has cumulative figure of Year 0, i.e. the period from Dec 2012-Sep 2013 funded by SIFPO, and Year 1, i.e. the period from Oct 2013 – Sep 2014, funded by the Co-op Agreement. 3One OR team was converted to an OMU in Punjab 4During the reporting period, 4 providers were added and 24 SF providers separated from the network

+

279,632

CYPs Generated

104,049CYPs

Generated in Hyderabad

34,736CYPs

Generated in Karachi

32,203CYPs

Generated in Multan

108,644CYPs

Generated in Sukkur

279,632CYPs Generated

214,604 SF CYPs

64,790OR & OMU

CYPs

238MCH CYPs

111,767Clients Served

44,304Clients

served in Hyderabad

18,668Clients

served in Karachi

11,568Clients

served in Multan

37,227Clients

served in Sukkur

111,767

Clients Served

85,316 SF Clients

26,337OR & OMU

Clients

114 MCH Clients

https://mariestopes.org/impact-2



CHAPTER 2

OBJECTIVE 1: INCREASING THE SIZE AND CAPACITY OF THE

HEALTH WORKFORCE

Overview

Skilled health workers frequently prefer urban placement, rendering peri-urban and rural populations under-served with a proportionally higher unmet need for FP services. The clinical (hands on) and counseling trainings provided by the FP/RH project increases the availability of skilled service providers in rural and remote settings. Mid-level service providers and doctors are engaged in the FP/RH training component and trained according to their eligibility for FP service provision established by the concerned regulatory authorities. Simultaneously FHEs and senior field supervisors (SFSs) associated with each USG funded service delivery points (SDP) are trained on knowledge and communication skills which aid them in generating demand for FP services and removing barriers to the uptake of voluntary FP services by MWRAs in target communities. Once trained and inducted into the Suraj Network or recruited in the OR teams, the quality of FP service provision is monitored by the Quality Assurance (QA) teams. These teams facilitate a continuous loop of quality evaluation and service improvement by using the Marie Stopes International (MSI) QA guidelines adapted to local context. The FP service quality measures include technical competence, clinical governance, facilities and supplies.

Performance and Achievements

Training highlights:

Trained 802( 758 females and 44 males) participants in FP/RH with USG support

684 of those trained were from the private sector (525 from SF and 159 from OR) and 118 from

the public sector

684 private sector providers included 31 doctors, 38 nurses, 90 lady health visitors (LHVs), 96

community midwives (CMWs), 331 FHEs, 78 SFSs, 10 male mobilizers and 10 counselors

118 public sector providers included 9 Lady Health Workers (LHWs), 61 LHSs, 42 CMWs, 1 nurse

and 5 program manager

Out of the total trained, 572 received FP counselling training and 77 received FP clinical training;

A new module on community mobilization was introduced and 153 field staff attended this

training

In addition to the 802 participants, 98 project staff members were also trained

Quality Assurance (QA)

The quality assurance (QA) team made 127 visits to USG-supported SDPs Areas identified for refresher training included infection prevention and sexually transmitted

infections (STI) knowledge Internal QA scores for SF-A+ in Karachi improved over last quarter by 1%, with an average QA

score of 82% for SF-A and 90% each for SF-A+ and OR; QA scores for Sukkur decreased by 5% in SF-A and 3% in OR. This was primarily because, out of the 31 SF-A providers, 15 had been newly inducted. The average QA score were 83% for SF-A, 88% for SF-A+ and 95% for OR.

QA scores for SF-A for Multan improved by 6%, with an average QA score of 94% for SF-A; QA scores for SF-A for Hyderabad improved by 2%, with an average QA score of 90% for SF-A and 91% each for SF-A+ and OR in FP/RH Y3 Q2

OR channels of all three regions ranked green i.e. attained a QA score of over 90%



Figure-5: Public and private service providers trained with USG Funds in Q2 (Jan– Mar 16)

Figure-6: Regional QA Scores and QA Visits in Q2 (Jan-Mar 16)

Figure-3: Comparison of participants trained in Q2, segregated by modules Q1 and Q2

Figure-4: Comparison of participants trained in Q1 and Q2, segregated by gender Q1 and Q2, segregated by gender

83%82%

90%

88%

90%91%

95%

90%91%

75%

80%

85%

90%

95%

100%

Sukkur Karachi Hyderabad Sukkur Karachi Hyderabad Sukkur Karachi Hyderabad

SF-A SF-A+ OR

2077

136

572

0

153

0

100

200

300

400

500

600

700

FPRH Y3 Q1 FPRH Y3 Q2

FP Clinical FP Counselling Community Mobilization

6 44

150

758

0

100

200

300

400

500

600

700

800

900

FPRH Y3 Q1 FPRH Y3 Q2

Male Female

118

684

0100200300400500600700800

Public Service Providers trained Private Service Providers trained



CHAPTER 3

OBJECTIVE 2: SCALING UP FACILITY-BASED SERVICE DELIVERY

Overview

Suraj SF plays an essential role in addressing the unmet need for FP/RH in rural, remote areas. Two categories of Suraj providers (SFA5 and SFA+6) are located in underserved low income communities. To help facilitate community access to a range of quality voluntary family planning services, each provider is assigned an FHE. These FHEs reach the target population through household visits, Mohalla7 meetings, Mashwara8 meetings. They inform women about the Suraj facilities, promoting an informed voluntary choice regarding modern family planning methods. For clients of low socioeconomic status with minimal, if any, access to FP services, FP/RH provides vouchers to make the voluntary FP service of choice available to marginalized members of the community.


SF highlights:

Voluntary FP services were provided through a network of 301 SF providers across four regions: Karachi (52); Hyderabad (108); Sukkur (102); and Multan (39)

289 FHEs supported demand-generation for SF providers, with 255,099 household visits, 834 Mohalla meetings, and 212 Mashwara meetings, reaching 303,099 MWRA

A total of 214,604 CYPs were generated 89% of the CYPs generated were from voluntary uptake of modern long term (LT) FP methods 85,316 clients were served, of which 49% chose long-term FP methods, i.e. intra uterine contraceptive

device (IUCD) and implants 67,283 clients were given the FP method of choice using vouchers distributed by FHEs to eligible,

willing clients The highest uptake in SF was for IUCD (41,272) with only a 1% removal rate. This was followed by

injectable (15,452) 1,513 voluntary tubal ligation (TL) and 493 implant services were provided by population welfare

department (PWD)-certified doctors in the Suraj network (SF A) The majority of the women who opted for a permanent method service were aged between 25-35

years, opting for a voluntary TL service after having 5-6 children

Regional SF Performance

The highest number of CYPs were achieved by Sukkur region through its network of 102 SF providers: they also attained the highest CYP generated per provider

Hyderabad had the highest percentage of paying clients i.e. 28% of total clients

SF Quality Scores

The quality assurance (QA) team visited 32 providers in the Sukkur region (attaining an average QA score of 85%); 28 providers in Karachi (average QA score of 85%); four providers in Multan (average QA score of 94%); and 47 providers in Hyderabad (average QA score of 91%)

5SF A are mid-level providers who provide short-term and long-acting (IUCDS only) FP methods 6SF A+ are doctors who can provide a full range of comprehensive FP services (short-term, long-acting, and permanent) after receiving PWD certification for implants and TL 7Mohalla meetings are conducted by FHEs with a group of MWRA who are educated on women’s health issues, especially healthy timing and spacing of pregnancies and are provided information on FP methods and the voluntary FP services available in the community 8Mashwara (consultation) meetings include SSF provider’s participation together with FHE in a group meeting, where the community women get an opportunity to ask questions directly from the provider and seek consultation on FP Services.



4%

89%

7%

Short term Long term Permanent

Region Provider

SF-A Provider

SF-A+ Total

providers

Hyderabad 88 20 108

Karachi 42 10 52

Multan 36 3 39

Sukkur 89 13 102

Total 255 46 301

Table-2: Region wise overview of SF providers Q2

Figure-7: Comparison of SF services Q1 vs Q2

73,675

85,316

65,000

70,000

75,000

80,000

85,000

90,000

Qtr. 1 Qtr. 2

Figure-8: CYPS disaggregated by method mix in SF Q2 (Jan-Mar 2016)

Figure-9: CYPs Generated and MWRA reached in Q2 (Jan-Mar 2016)

285,894

303,099

182,376

214,604

110,000

160,000

210,000

260,000

250,000

270,000

290,000

310,000

Oct 15 - Dec 15 Jan 15 - Mar 15

MWRA reached CYP generated

Figure-10: Comparison of SF CYPs generated in Q1 and Q2, Segregated by method mix

Figure-11: CYPs generated by FP method in SF (Jan-Mar 2016)

6,888

163,688

11,8007,866

191,608

15,130

0

50,000

100,000

150,000

200,000

250,000

Short-term Long-term Permanent

Q1-FY 2016 Q2-FY 2016

2,293 1,711 3,863 158

189,630

1,714 10515,130

0

40000

80000

120000

160000

200000

Co

nd

om

s

Pill

s

Inje

ctio

ns

Mu

ltilo

ad

Co

pp

er T

Jad

elle

Imp

lan

on

Tub

al L

igat

ion

s

Short Term Methods Long Term Methods Permanent Methods

Figure-12: Parity distribution among TL clients in SF Q2 (Jan-Mar 2016)

Figure-13: Age distribution among TL clients in SF Q2 (Jan-Mar 2016)

40

440

681

270

6913

3% 29% 45% 18%5%

1%

0

200

400

600

800

1-2 3-4 5-6 7-8 9-10 10+

Nu

mb

er o

f TL

Clie

nts

Number of child(ren)

4

981

454

59 13 2

0%65% 30%

4% 1% 0%0

200

400

600

800

1000

1200

< 25 25 - 35 35 - 40 40 - 45 45 - 49 > 49

Age group

Nu

mb

er o

f TL

clie

nts



CHAPTER 4

OBJECTIVE 3: SCALING UP OUTREACH AND COMMUNITYBASED

SERVICE DELIVERY

Overview The Outreach intervention in the FP/RH service delivery model provides a comprehensive range of FP methods to underserved communities who do not have access to a full range of FP services; particularly long acting permanent methods (LAPMs). OR teams are trained and certified by the PWD in Implant insertions and TL. Leveraging public sector infrastructure, the outreach program utilizes public health facilities with functional operating theaters in close coordination with district health officials. Camp plans are shared and support from LHWs is solicited for making referrals for clients seeking to avail a voluntary LAPM. OR services are delivered across the four FP/RH project regions. An additional aspect of this intervention is the Outreach Mobile Unit (OMU) which enables access to clients living in communities who neither have access to public health facilities nor private clinics for availing an FP method of choice. Clients are provided with a voluntary short or long term method of choice by trained staff in a refurbished and equipped vehicle. The OMU staff in Punjab have PWD certified doctors who can provide voluntary implant services to clients in addition to IUCD and injectable services, thereby expanding choice.


OR highlights:

A complete range of voluntary FP services were provided through 14 trained/certified OR teams and 4 OMUs

489 OR camps were conducted across the four regions 138 FHEs supported demand-generation activities for the USG supported OR teams and OMUs,

conducting 101,556 household visits, 763 Mohalla meetings and 86 Mashwara meetings, reaching a total of 122,421 MWRA

64,790 CYPs were generated in the reporting period 64% of the CYPs were generated through provision of permanent methods A total of 26,337 clients were served 4,177 voluntary TL were provided, and 869 implants inserted by PWD-certified doctors in the OR

teams A majority of the women opting for permanent methods were in the 35–40 year age group; with the

majority opting for a voluntary TL after having 5-6 children

OR Quality Scores

The QA team visited:

Three OR teams in the Sukkur region, attaining an average QA score for this quarter of 95% Seven OR teams in the Karachi region, attaining an average QA score for this quarter of 90%



Region Total camps

Hyderabad 204

Karachi 63

Multan 99

Sukkur 123

Table -3: Region wise camp conducted in Q2 Figure-14: Comparison of services for OR in Q1 vs Q2

20,420

26,337

0

5,000

10,000

15,000

20,000

25,000

30,000

Qtr. 1 Oct 15 to Dec 15 Qtr. 2 Jan 16 to Mar 16

10%

26%

64%

Short Term

Long term

Permanent

402 4,845

578 352 - 132

13,409

3,302 - -

41,770

-

10,000

20,000

30,000

40,000

50,000

EC

Co

nd

om

s

Pill

s

Dep

o

No

ri

Mu

ltilo

ad

Co

pp

er T

Jad

elle

Imp

lan

on

Fem

pla

nt

Tub

al L

igat

ion

s

Short Term Methods Long Term MethodsPermanent Methods

6 11 10 9 14 1524 28 34 37 31 35

8291

11186

134 134

0

50

100

150

200

Oct 2015(138)

Nov 2015(174)

Dec 2015(167)

Jan 2016(157)

Feb 2016(153)

Mar 2016(179)

AV

G N

UM

OF

CYP

S /

PR

OV

IDER

/MO

NTH

Permanent

Long-Term

Short-Term

15

731

2080

1062

230 59

0%18% 50% 25% 6% 1%

0

500

1000

1500

2000

2500

1-2 3-4 5-6 7-8 9-10 10+

Nu

mb

er o

f TL

Clie

nts

hav

ing

Number of child(ren)

2

1156

1984

1017

18 0

0% 28% 47% 24% 0% 0%

0

500

1000

1500

2000

2500

< 25 25 - 35 35 - 40 40 - 45 45 - 49 > 49Nu

mb

er o

f TL

Clie

nts

Age group (Year)

Figure-15: CYPs generated in Q2 (Jan to Mar 16) Figure-16: CYPs generated by method in Q2 (Jan to Mar 16)

Figure-17: Average CYP generated per camp – monthly trend analysis for Q1 & Q2

Figure-18: Parity Distribution among TL Clients in OR in Q2 (Jan-Mar 16)

Figure-19: Age distribution among TL Clients in OR in Q2 (Jan-Mar 16)



Confronting Challenges QA scores for Sukkur decreased by 5% in SF. 15 new SF providers were added to the region this quarter. The QA made action plans following their QA visits which were followed up accordingly. Refresher trainings were arranged on infection prevention (IP) and STI. With more frequent visits by the QA teams in the coming quarter, it is expected that gaps will be addressed and QA scores will improve for the new providers. The OR intervention provides a comprehensive range of voluntary FP services, including LAPM, which is critical to expanding choice within the broader context where LHWs provide STMs. Although 90% of the CYPs in OR came from LAPM (64% from voluntary sterilization and the remaining 26% from LARC (21% from IUCD and 5% from Implants)). A gradual increase in the number of clients has been witnessed for short term methods, contributing to 10% of CYPs generated by OR in the reporting period. This is especially expected in areas not covered by LHWs and also where LHWs are out of FP stocks. FP/RH is working towards increasing the capacity of LHWs and equipping them with the knowledge of a full range of FP methods. This is expected to enhance their role in voluntary FP service provision; making referrals for LAPMs; and for addressing discontinuation by providing effective counselling to address their concerns during door to door visits. FP/RH is also supporting MCH partners in their advocacy for strengthening the LHW program by improving coordination and identifying and communicating service delivery gaps. Further advocacy is planned for strengthening the LHW Program through John Snow International (JSI), leveraging their government partnerships in public health. Effective provision of services in OR was a tangible challenge during the early half of Q2. Teams focused on better coordination with district health officials aiming at zero camp cancellations in public health facilities; quick adaption to changing field situations e.g. converting OR teams to OMU in the Rahim Yar Khan district where the environment is not conducive for TL camps. It was encouraging to note that service provision gradually increased over the three months of the reporting period, representing more effective utilization of project resources and increased access to voluntary FP for clients. Reaching MWRA in far flung and remote communities in the catchment populations is a challenge. The FP/RH team is working on a comprehensive community mobilization strategy to better reach these communities, with geographical zones being defined for each catchment population and districts identifying volunteers and communities in each zone. This is expected to build ownership of communities and facilitate reach to more challenging groups. Community social volunteers (CSV) and community resource groups (CRG) will be engaged to reach FHEs within catchment populations.

Lessons learnt for attaining success

The FP/RH service delivery model is carefully designed to complement FP service provision by the public sector. The SF intervention builds capacity of mid-level providers to provide LARC services in communities with access only to STM through LHWs (if operational in that area). The presence of an SF provider therefore expands choice by expanding the range of FP methods available. This is evidenced by 89% of CYPs generated in SF in the reporting quarter being from voluntary uptake of modern long term FP methods. The remaining 7% is generated though provision of voluntary sterilization by a small sub set of SF A+ providers who are doctors and are PWD certified for provision of LAPM. Only 4% of CYPs generated in SF are from short term methods, frequently provided in areas where there are no LHWs.



The OR intervention further compliments this service delivery approach through engaging doctors trained by the PWD in LAPM. This intervention addresses high unmet need for permanent methods as SF, being mid-level providers, can only provide IUCD as a long term method of choice. 64% of CYPs generated in OR were through the provision of voluntary TL. OR also provides access to voluntary uptake of implants which make up 5% of OR CYPs versus 1% in SF as SF is largely operated by mid-level providers who are not eligible for the provision of implants. OR camps are conducted at public health facilities. Through this effective public private partnership, FP/RH together with the support of Government of Sindh (GoS) is able to provide MWRA full range of comprehensive voluntary FP services to support the achievement of FP2020 commitments.



CHAPTER 5

CROSS-CUTING THEMES

Research The research department promotes data-driven decision making and strategy development. It provides contextual evidence to support improved organizational and national policies. Updates for the current reporting quarter are listed below. Client Exit Survey 2015: Data collection is complete and data analysis is underway. Report writing

and dissemination will take place next upcoming quarter. Provider insight study: This study explored social and organizational facilitators and barriers that

effect provision of family planning services. Findings of the study reflect sustainability options, quality of provision, and challenges in the service provision. The final study report is under review by the senior project management team.

Willingness to pay/financial sustainability study: To improve financial sustainability for family planning services in the Suraj Social Franchise network in Pakistan, FP/RH has planned a study to investigate clients’ willingness (current and potential) to pay. The study will also explore how changes in price would affect demand and how socio-demographic factors affect perception of clients, FHEs, and providers on ‘willingness to pay’ (WTP) for contraception. Study protocol and data collection tools are being developed with Marie Stopes International. Approval from local and international ethics review boards will be sought in the next quarter.

A study for non-user clients: To understand the beliefs and practices among non-users (males and females) in adopting voluntary family planning in Pakistan, FP/RH plans to conduct a qualitative study in upcoming quarters. The concept note of this study has been approved by the MCH Program monitoring and evaluation working group and suggestions incorporated in the study protocol.

Participation in events and training sessions: The research team attended an international conference on family planning in Indonesia. There is a global focus on reaching poor communities, adolescents, and those who are in most need using advanced technological tools. MSI organized a session on the definition of an ‘additional user’1 and how programs could align their goals with national/global FP2020 commitments.

Capacity building: The FP/RH research, monitoring & evaluation department promotes evidence-based decision making by building the capacity of its staff in research, monitoring and evaluation skills. This quarter, a survey on RME training needs was conducted to assess the knowledge of personnel in the organization. Based on this assessment, customized trainings will be organized next quarter. This will strengthen the research infrastructure by increasing the skill set of the staff and improving the quality of research throughout the project.

Monitoring and Evaluation The M&E component ensures the consolidation and reporting of key performance indicators. The component coordinates with FP/RH sub-departments to ensure the timely generation and dissemination of information to management for evidence-based decision making. This quarter the M&E team worked on: Performance Monitoring Dashboard: The M&E team is streamlining and integrating all data from

multiple sources, such as service provider profiles, service numbers of SF and OR, training and QA data. A consultant is developing interactive dashboards to improve program decision making.

9Refers to a net increase in the absolute number of users above a specified baseline



SF Trend Analysis: The RME department analyzed service data from the program’s inception through December 2015. This revealed: 1) a dip in client flow during scale up, but productivity soon returned; 2) SF providers take 7–9 months on average to reach peak productivity (client flow), then productivity can be expected to level off; and 3) The provider drop-out rate was about 19% (mainly due to failure to comply with MSS protocols, followed by personal reasons).

Implementation of TrainNET Software: The team is working on issues highlighted by the TrainNET software which were discussed during sessions led by USAID. Guidelines are being developed to optimize its implementation.

USAID Pak Info Training Session: The M&E team attended the MCH Pak-Info training session in quarter 2 of the reporting period. They were instructed to enter data against three indicators: number of women served, number of people trained, and changes in the sites (Suraj facilities). They agreed to upload annual reports, the updated M&E plan, success stories, and any relevant narrative reports on Pak-Info under the heading of USAID.

Sharing of Train-Smart software template: The team developed a report template for the Train-Smart software. The template has been shared with maternal and child health integrated program (MCHIP) for feedback. The software will be used for database management instead of Excel spreadsheets.

Project Monitoring Plan (PMP) for FP/RH sent for review: The M&E team developed a first draft of the FP/RH Project Monitoring Plan. The PMP draft is being reviewed by the project’s senior management team.

Helpline

During the reporting period, the helpline provided counseling/information (65% of total calls), referrals (19% of total calls) and side-effect management (16% of total calls) information to its callers. Outbound call facility contributed to 14% of total calls, indicating that the call back service is vital to the platform. The number of calls related to reproductive health increased during the reporting period. The main queries were about the human immunodeficiency virus (HIV), sexually transmitted infections (STIs), menstrual cycles, and infertility.

7,210 62% 22% 63% 15% callers served this quarter

of callers under the age of 30

referred via helpline cards

consented to being contacted back via

helpline

Male callers

Promotional activities to stimulate call volume were conducted during Q2:

Competence-building trainings

Refresher training –March 15, 2016 USAID compliance training by HSD – March 21, 2016

M-Heallth initiative

Helpline generates three messages a day, weekly to FHEs



Helpline promotion partner guidelines

Standardization guidelines for MCH partners Guideline presented to health communication working group (HCWG) – February 25, 2016

Leveraging strong on-ground presence

A ‘one call per FHE per day’ strategy – FHEs encouraging clients to avail MCH Helpline Demo calls and helpline promotion cards Regular field visits by program management

Helpline message handling compliance

Helpline has developed ‘guides’ to ensure compliance with USAID requirements, including US abortion and FP guideline compliant scripts.

Communications

Branding and Marking

To ensure compliance with USAID’s branding and marking policies, the FP/RH Technical Services Department (TSD) developed the Branding and Marking checklist for the project, regional and district offices. This checklist ensures that USAID-funded items are branded and marked according to USAID guidelines. To ensure the visibility of USAID’s brand and to acknowledge the assistance “From the American People,” TSD developed a dashboard to identify, monitor and address branding and marking compliance issues. Subsequent action plans will be guided by the dashboard results.

Behavior Change Communication (BCC)

Behavior change communication is an evidence-based, collaborative process. It consists of working with individuals, communities, and societies to develop communication strategies for positive behavior change and to create a sustainable environment for positive behaviors. Field teams and FHEs reach communities through door-to-door visits, Mohalla, and Mashwara meetings to mobilize MWRAs. One FHE supports each provider who serves a catchment population of around 25,000. For the FHE, coverage is a major challenge. Social mapping and formation of CRG and community social volunteers (CSV) were introduced to tackle this challenge.

Social Mapping

Social mapping is the division of a district into smaller, more manageable ‘zones’ for improved coverage and better monitoring.



Community Resources Groups (CRGs)

CRGs Are groups of influential volunteers which act as a link between the community and FP/RH teams. CRGs also provide logistic and communication support to the FP/RH teams.

Community Social Volunteers (CSVs)

CSVs are volunteer change agents within each zone. They help the FHEs with their insights into the community.

Family Planning Interpersonal Communication Toolkit (FP IPC Toolkit)

FP IPC toolkit was brought to its final stages of development after multiple revisions and consultations with PWD and the National Program for Family Planning and Primary Healthcare Sindh.

Community Mobilization (CM) trainings

The Kirkpatrick model for training evaluations is being applied to the CM trainings on a pilot basis. The model includes training evaluation at four levels i.e. Reaction, Level, Behavior and Results Level.

Program Management

People and development

The FP/RH people and development function hires, supports, and retains high-quality human resources. This quarter, 95 new people were hired to strengthen the program, especially in operations (92% of all Q2 hiring). An extensive performance-appraisal exercise was carried out in February, 2016, to ensure individual performance evaluations and to stay competitive. This was followed by the rollout and training of the human resource (HR) checklist to ensure pre- and post-hiring compliance.

In line with focus areas identified during the appraisal process, and as part of the P&D mandate of capacity-building, multiple trainings were conducted during the reported quarter. These included Microsoft Excel intermediate skills training, effective communication training, and time management training. FP/RH takes pride in its human resources, ensuring that they are empowered and trained to meet high project standards.

Information Technology (IT)

Tax Management System application: A tax management application was designed by IT mainly for procurement. Certain payments (above a set value) require additional authorization/ tax verification. The tax management application isolates these transactions within the system and notifies the procurement function to ensure appropriate treatment.

Technical assistance from MSI Marie Stopes International (MSI), as a sub-awardee to MSS for the Family Planning and Reproductive Health Project Component 1, funded by the USAID, is tasked with providing technical assistance to MSS. MSI brings to MSS its international wealth of experience through its staff who provide technical assistance remotely and in person as well as guidelines, systems and toolkits to further enhance the quality of MSS’s delivery of the FP/RH project.



During the reporting quarter, the regional research advisor visited Karachi and provided remote and in-country assistance for research activities including the willingness to pay study and the outreach continuation study. Support was provided to hire the new IT manager and MSI rolled out the ‘Success Models’ workshop, which will support implementation of good practice and sharing of best practices across projects.

Procurement & Logistics

Guidance on selection, sourcing, and procurement of rapid diagnostic tests that meet USAID quality requirements for Restricted Commodity Approval and facilitated final USAID approval for this.

Information Technology & Services

In January, a new IT Manager was hired to support all MSS projects including FP/RH. An induction was provided and together with MSI’s Chief Information Officer (CIO), they initiated a review of MSS’s IT organization design and identified priorities to be addressed. The CIO provided technical assistance for the implementation of an IT helpdesk and continued support for the Enterprise Resource Planning (ERP) system. This included its implementation in remote offices and integration with the corporate finance ERP which will support better visibility and control of the supply chain, particularly for inventories. In March, the CIO developed options to capture social franchise data utilizing local applications (Flame) and emerging global solutions (DHIS2) to improve the visibility of services provided by franchisees.

Security Management

The global security manager held weekly meetings with the GM security on context updates, traveler schedules and feedback. Three traveler briefings were conducted and four security incident reviews. Support was provided for the visitor standard operating procedures (SOP), the Proof of Life system and the Employee Travel Monitoring System.

Medical Development and Quality

Working closely with MSS, terms of reference have been developed for a training systems workshop to be held in Y3 Q3, and to plan all content for co-delivery by the global training lead, MSI’s regional medical adviser and members of MSS’ training team. The objectives of this workshop are: a) for six candidates from MSS's training team to receive instruction on how to conduct training of trainers and support the ongoing development of quality assured clinical trainers, and b) to agree a process and system-design by which candidates receive and act on the results of competency assessments carried out during continuous supportive supervision meetings. The workshop will include an interactive debrief session with FP/RH staff to plan their participation and cascading of the training.

Social Franchise and Health Financing

Support continued for the domestic diversified health financing strategy and work began on a voucher scoping study which will provide a comparative analysis between current practice and MSI’s voucher management standards. This will help guide improvements and technology innovations in the voucher management system.



A continued focus on sustainability has been supported through input into a video detailing the value proposition of the Suraj Social Franchise network and a technical review of FP/RH’s sustainability framework which builds upon MSI’s ‘sustainable health market for choice’ strategy to strengthen supply, consumption, support, and regulation of health care. Work has begun on provider behavior change and support was provided for the development of the IPC toolkit.

Research, Monitoring and Evaluation (RME)

MSI reviewed the methodology and liaised with potential partners for the willingness to pay study; reviewed the protocol before submission to the MSI and national Ethics Review Committee for the outreach continuation study; and reviewed the concept note and methodology for the safe motherhood (SMH) voucher study. The willingness to pay study will help teams understand how to make programs more sustainable while maintaining equity and the outreach continuation study will assist with understanding problems faced by clients to continue or discontinue a method in an outreach setting. At the end of March, an in-country technical visit provided in-person support for these studies and other ongoing research activities including mothers-in-law, never users and provider studies. The RME advisor and the FP/RH TSD team, conducted a review of the department structure and drafted a new organogram. Support was provided for M&E processes, including information analysis and dissemination, the helpline and social franchise data for the M&E working group.

Finance and Audits

Support was provided in valuation of donated stock, its associated clearing costs, and developing the accounting treatment for these costs to improve clearing cost attribution to the project. Technical assistance was also provided for the global audit, financial reporting, and financial compliance.

Other Technical Assistance

Technical assistance in USAID compliance included reviewing contract modifications, project reporting, and sub-awardee management was provided. In February 2016, the newly recruited Head of Program Support (for the MSI sub-award) received an induction in MSI’s London head office. This included meeting all technical teams, clarification of roles and responsibilities, and the ongoing development of MSI’s sub-award work plan. Unfortunately, the incumbent resigned shortly after her return to Karachi. Recruitment for a replacement is underway. In March, MSI held a ‘Success Models’ workshop in Bangkok. The FP/RH Director of Operations attended this workshop aimed at developing and sharing best practices to improve delivery through the social franchise and outreach channels. Workshop participants were challenged to identify key areas to improve implementation which will be tracked throughout the year.



Liaison

Government Liaison

One of the Sustainable Millennium Development Goals is to achieve a contraceptive prevalence rate (CPR) of 55% in Pakistan by 2020. FP/RH is working towards meeting these goals through partnerships with government and private stakeholders.

During the reporting quarter, a major victory was the achievement of a consensus on the FP messages drafted by Johns Hopkins University Center for Communication Program (JHU-CCP). With minor revisions, endorsement was received from the PWD, LHW program, and the MNCH program for the FP Messages. These would serve as the guiding principles for the FP IPC toolkit which is under development in close coordination with the LHW Program.

Technical Advisory Group meeting on Development of FP IPC Toolkit:

FP/RH hosted a meeting on January 20, 2016, to share developed content and insights with stakeholders. The meeting was attended by representatives from PWD-Sindh, MNCH Program, National Program for FP & PHC, and MCH partners.

Consultation Workshop with LHW Program on revising the content for the FP Curriculum: The project team met with the LHW program on January 20 to discuss the FP curriculum and IPC toolkit. A consensus was developed regarding toolkit approach, content, and layout.

Workshop with MNCH Program on Gap analysis for the FP IPC Toolkit from CMW Perspective: A meeting with the MNCH on January 21 further reviewed the FP IPC Toolkit from the perspective of its potential use by the CMWs.

Consultation Workshop with LHW Program on identifying the gap in the FP IPC Toolkit: With a high level of cooperation by the NP for the FP & PHC coordinator, a follow-up workshop was held in Hyderabad on February 29. LHS insights were helped in finalizing the content of the FP IPC toolkit. Some remarks by LHSs during the consultative workshops: “Previously we were just given material and trained on it, but for the first time we are getting to put forth our experience and integrate it into something that we will utilize in the field.”



IRMNCH visits OMU in Ahmed Pur East (Bahawalpur)

The OMU team was visited by the Deputy Program Manager Integrated Reproductive Maternal Newborn Child Health (IRMNCH) at Basti Kotana, Ahmed Pur East (Bahawalpur) on January 29, 2016 and was introduced to the working of OMU, the project, and overall MSS operations.

MCH Partners

The Bright Star Design Workshop: FP/RH participated in “The Bright Star Design Workshop,” conducted by the Johns Hopkins University Center for Communication Program (JHU-CCP) in Karachi from March 15–18, 2016. FP/RH has committed to assisting JHU-CCP identify Bright Stars in its program and communities of influence in order to promote talent within the organization and the sector.

After months of collaboration

and technical consultations, the

National Program for FP & PHC,

PWD and MCH partners finally

developed a consensus, with the

government turning into strong

proponents of the FP toolkit and

its messages.



Creating Exponential Impact: Maulana Siddique (’maulana’ is the reverential term for a senior cleric), resides in the village of Moluvi Haji Khaskheli, near Mirpur Khas. The village mainly comprises clerics who follow a conservative interpretation of Islam. His approach to family planning was also quite conventional. Traditionally, this village was very resistant to any family planning messages and as such, did not entertain FP teams in the district.

Clerics, almost always male, are influential in their communities. Their beliefs and approaches guide the whole community and determine many practices. Maulana Siddique would tell FP teams to leave immediately and not to come back again. But all that changed after a soul-searching dialogue between the FP/RH FHE and the cleric:

“They had a unique way of communicating with me. Despite my initial stance, they requested I listen to them and if I didn’t like

what they said, they’d go away and never bother us again. Then they asked if my wife was just as religious as I was, and if she

prayed five times a day and fasted during Ramadan? I said no, she doesn’t because she looks after our five children, does the

housework, and helps me in farming. And she cannot fast because she is very physically weak. And that is when I realized that

because our way of living was not healthy it was not only affecting her quality of life but was also hindering with her religious duties

as well. I am really thankful to them, if they hadn’t made me realize this, I would have never known.”

He further added, “This meeting has opened my eyes to the benefits my family can have by adopting family planning services. Now, not only have I helped my wife get a service (IUCD), but I have spoken to many people in the community and encouraged them to look after their families in a similar manner... I like the way they work, they listen to us and take their time in answering our questions and have never pressured us into making a decision.”

Changing the perspective of Maulana Siddique, a major influencer in his community, is likely to create a lasting impact. The village of Moluvi Haji Khaskheli is already on its way to a healthier future with greater access to FP resources and methods.

CHAPTER 6

IMPACT STORIES



Sharing Hope: Chandan Bhagwani (wife of Achar) is a resident of the village of Qurban Mangrio. Aside from being a housewife, she also helps out her husband, a tenant farmer. She has eleven children (six girls and five boys) and has taken a voluntary TL service from the FP/RH project. Chandan has lived all her life at Qurban Mangio and has very little exposure to the outside world. There are no healthcare facilities and hardly anyone from the nearby towns or city comes there. Her village is one of the few far-flung areas where the FP/RH project provides family planning services through its OR services. Previously, their village rarely had anyone visit for health-related matters.

“I thought that they would just provide the service and they would never come back, but their support has been

consistent. I now have a chance to live a much healthier life and look after my home.”

In the past, Chandan had very little knowledge of FP and would get pregnant frequently, resulting in her poor health and financial difficulty in looking after so many children. She states, “We had no information about this (FP methods), and my health suffered a lot because I had babies very frequently. This also compounded our financial problems, since we have meager resources and so many children to look after. But thanks to them (OR team), I was able to get the services I need.”



Terath - a Bright Star: Terath is a one of the few male community mobilizers working for the FP/RH project. He is a part of the OR team from Mirpur Khas in Sindh. His community comprises of mostly tenant farmers residing in remote villages, largely populated by a minority (Hindu) community. These villages are cut off from the main city and have a poor health and FP infrastructure. A further challenge is that these communities are miles away from any public or private healthcare facilities. In addition to the distance, village residents are further disadvantaged by a lack of transportation and inadequate funds to pay for transportation. The FP/RH project reaches out to these far-flung areas through Terath. As the district’s male mobilizer, his duties include talking to the male members of his community to tell them about family planning. He answers the queries they have and also refers them to the project’s OMU team in case of more technical questions. He takes pride in counseling people in his community, especially the males.

“Ours is a patriarchal society. The number of children a woman will have is mostly decided by the man, and, sadly, they too (like the women) have very little knowledge of FP

methods. Furthermore, this is a topic that is hardly ever discussed between them, and because of the social set-ups, it

is very difficult for them to admit that they have very little knowledge of such things, despite having a genuine need for

family planning methods. And since hardly anyone comes out here, getting the right knowledge and accessing services is

also very difficult.”

He further added. “But things are different now, thanks to them (FP/RH’s OMU team), we have managed to reach out and benefit so many people in my village and the areas near it. They are happy that someone out there cares for them, provides them a service of their choice, and has the patience to answer all the questions they have. I am extremely grateful to them, they took their time, trained me, made inroads into my community, and now people have an option of good quality services and healthier lives.” The FP/RH project is proud of the contributions Terath is making towards improving family planning and reproductive health access to underserved populations. Terath is a bright star.



ANNEX-1:

Key Performance Indicators (To-date)

Indicators

Year 1

(Through

Sep 14)

Year 2

( Oct 14 to

Sep 15)

Year 3 ( Oct 15

to Dec 15) Qtr.

1

Year 3 (Jan 16

to Mar 16)

Qtr. 2

Total to

date

Family Planning Clients Served

SSF Network 103,808 198,105 73,675 85,316 460,904

Outreach 38,898 40,389 18,382 23,363 121,032

OMU 0 2,205 2,038 2,974 7,217

HANDS 0 908 545 0 1,453

MCH 0 782 200 114 1,096

Total 142,706 242,389 94,840 111,767 591,702

CYPs Generated

SSF Network 212,863 419,001 182,376 214,604 1,028,844

Outreach 126,159 168,437 57,049 62,575 414,220

OMU 0 1,632 1,951 2,215 5,798

HANDS 0 1,432 2,414 0 3,846

MCH 0 1,662 270 238 2,170

Total 339,022 592,164 244,060 279,632 1,454,878

Maternal Deaths Averted

SSF Network 133 197 60 68 458

Outreach 85 90 19 20 214

Total 218 287 79 88 672

Unintended Pregnancies Averted

SSF Network 95,552 164,699 63,469 74,791 398,511

Outreach 64,404 75,806 21,966 23,577 185,753

OMU 0 518 565 594 1,677



HANDS 0 525 955 0 1,480

MCH 0 607 98 84 789

Total 159,956 242,155 87,053 99,046 588,210

Number of USG Supported Service Delivery Channels

SSF Network 135 165 +4(-24) 37 (-20) 300

Outreach Teams 12 6 0 0 18

Number of People Trained

FP Clinical 1,454 532 25 79 2,090

FP Counseling 288 2,058 188 659 3,193

Community Mobilization 162 162

SMH Clinical 0 19 0 0 19

SMH Counseling 0 43 0 0 43

Other 263 242 0 0 505

Total 2005 2,894 213 900* 6,012

Number of Calls on MCH Helpline

No. of Calls Received 72,010 36,512 9,806 7,210 125,538

*The total number trained includes 802 service providers and 98 project staff



USAID/PAKISTAN’S MATERNAL CHILD HEALTH PROGRAM

FAMILY PLANNING/REPRODUCTIVE HEALTH COMPONENT

Marie Stopes Society

5th Floor | Clifton Diamond Building | Block V | Clifton | Karachi | Pakistan

Tel: 92-21-35205596 | Fax: 92-21-35291049 | Web: www.mariestopespk.org

________________________________________________________

24 Hour Free Helpline – 0800 22333 Online Advice – www.srhmatters.org

http://www.mariestopespk.org/

http://www.srhmatters.org/

usaid/pakistan’s mch program family …

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