Community-based maternal and child health project prepared

Ministry of Health has prepared a new project "Community-Based Maternal and Child Health", which will be launched during next fiscal year 2004-05 with total cost of $315 million including foreign exchange component of $125 million for improving the Performance of LHWs through New Approaches to Management.
Development objective for proposed project is to improve maternal and child health outcomes through: (i) improved access to pro-motive, preventive, and curative services at community level particularly to women and children (as measured by, for example, a 20 percent increase in immunisation coverage, 10 percent increase in contraceptive prevalence, and 15 percent increase in skilled birth attendance, etc); and (ii) dramatically improved delivery of these services in poor and undeserved areas (as measured by increased coverage and decreased variance in the above indicators within and between districts).
Achievement of the development objectives will be measured through district-level household surveys (being financed from other sources) as well as special studies and project records.
Presently, Pakistan has very poor health outcomes for a country at its stage of development and is making very slow progress on the MDGs in health.
According to update submission, the under-5 mortality rate (U5MR) is currently 125/1000 and the contraceptive prevalence rate is 28 percent. Without a dramatic improvement in the delivery of basic maternal and child health (MCH) services, Pakistan will fall further behind its neighbours and will have little chance of achieving the health MDGs.
In order to improve MCH service delivery, the Government of Pakistan has requested bank assistance to expand and strengthen the National Program for Family Planning and Primary Health Care, better known as the Lady Health Worker (LHW) Program. LHWs are women with at least Grade 8 education who are paid a small stipend to provide simple preventive, pro-motive, and curative services in the communities where they live.
These services include promotion and provision of family planning services, nutrition promotion, prevention of childhood infectious diseases, and treatment of diseases like acute respiratory tract infections (ARI), diarrhoea, and tuberculosis.
COUNTRY CONTEXT AND THE CAS: Pakistan is currently decentralising authority to district level governments and below in order to increase accountability and improve the delivery of basic public services. The Pakistan CAS aims to support these reforms and help Pakistan implement its I-PRSP and achieve the MDGs. One of the three critical areas for Bank assistance is improving equity through policies that are pro-poor and improve the status of women and an important aspect of the PRSP is improving access to health services.
Proposed project provides an excellent opportunity to assist Pakistan achieve its I-PRSP goals and is completely consistent with CAS objectives.
LHW Program was conceived, designed, implemented, and has largely been funded by GOP. Since it's inception in 1994, GOP has provided more than 90 percent of the funding for the programme which currently employs about 70,000 LHWs nation-wide. The programme arose to overcome the restrictions in women's mobility that impedes their access to basic health services for themselves and their children. A very careful external evaluation was undertaken in 2001. It found that the LHWs, even correcting for their living in slightly better off areas with easier access to basic health units (BHUs), had an impact on important outputs such as immunisation coverage. However, even in villages with an LHW, levels of service delivery are still quite low (eg 56 percent full immunisation coverage compared to 38 percent in control areas). Thus, while the LHW programme is clearly making a difference, it needs to do much better.
ISSUES WITH THE LHW PROGRAMME: The external evaluation found that: (i) the programme is in danger of being "hollowed out" by lack of non-salary recurrent cost financing; (ii) there has been little discernible impact on U5MR or the total fertility rate (TFR), likely due to low coverage of services and the narrow scope of LHW services; (iii) LHWs had limited knowledge (especially in curative care), ineffective supervision, and often suffered from supply shortages; (iv) performance in interior Sindh and Balochistan is significantly worse than other parts of the country; and (v) there are large variations in performance among individual LHWs.
These latter two issues indicate serious problems with lower level management of the programme.
RATIONALE FOR WORLD BANK INVOLVEMENT: Rationale for Bank's involvement in the proposed project is that it can: (i) challenge the programme to implement global best practices with regard to interventions that could improve health outcomes for women and children; (ii) help GOP systematically introduce and evaluate management and organisational innovations such as focusing on outputs rather than inputs; and (iii) provide policy support and financial resources for the programme to prevent it being constrained by limited non-salary financing.
According to official sources, in order to make large improvements in the LHW programme in poorly performing districts, a number of managerial and organisational innovations that emphasise measurable results and outputs rather than inputs will be tested on a large scale.
THE TYPES OF APPROACHES ENVISAGED INCLUDE: (i) contracting out management of the whole LHW programme in some poorly performing districts to NGOs using performance-based contracts that specify measurable improvements in service delivery and in which NGOs are selected on a competitive basis; (ii) "contracting in" individual managers to run the LHW programme in other districts on performance-based contracts also awarded on a competitive basis; and (iii) providing performance-based bonuses to government staff who manage the district LHW program. (The LHW program provided bonuses to managers in the past but these were not directly related to performance.). This component will also support devolution of programme to selected districts. To be consistent with the ongoing devolution of authority to local governments for the delivery of social services, government wants to gradually shift responsibility and financing of the LHW programme to district governments.
Hence, project will provide funds to test new fiscal mechanisms that aid devolution and improve performance in districts where LHW programme is already well established. Exact nature of the mechanisms will need to be worked out but would be performance-based and would ideally involve some financial inputs from local governments. Modest amount of funds will be used to strengthen management of LHW programme at all levels.
In-depth evaluation of LHW programme found that LHWs were not overworked and that they could, in fact, provide more services to their communities.
Project will support the careful introduction of effective, scientifically proven, low cost, and appropriate interventions that could have a large health impact.
TYPES OF NEW INTERVENTIONS COULD INCLUDE: (i) providing LHWs with additional types of contraceptives; (ii) point of use dis-infection of drinking water and promotion of hand-washing to reduce diarrhea; (iii) more effective forms of health education and other demand side innovations; and (iv) new approaches to the care of neonates.
Extensive discussions will be held with other sectors, including education, water, and sanitation on what other interventions could be added the LHWs' tasks. These innovations will generally be introduced on a pilot basis and their feasibility tested before implementation is expanded. In order to effectively monitor and evaluate the various approaches being tested and to measure the achievement of the development objectives, the project will further strengthen the evaluation capacity of the LHW programme either directly or through a third party evaluation firm. Project will ensure that district level household surveys being financed from other sources identify whether the communities sampled have LHWs working in them or not and survey the LHWs themselves. The project will also help finance special studies aimed at rigorously evaluating the new approaches being tested under the project.
Strategic plan of the LHW programme calls for improving the efficiency of procurement and distribution of drugs, contraceptives, and other supplies that the LHWs need in the field through contracts with private firms.
Project will support this approach and will also support efforts to improve pre-service and in-service training of LHWs through mechanisms that link actual knowledge and skills of the trainees to payment. Project will also explore means for improving efficiency of field supervision through the introduction of job-aids and improved training of supervisors.