A STRATEGY TO REDUCE

MATERNAL MORTALITY IN
DISTRICT GUJRAT

Company
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GROUP - 5

MSPH - 2009
Health Services Academy

TEXT TEXT TEXT

Dr. Abdul Dr. Dr.
DR. Fizza
Wali Khan Shumaila Hammad
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LOGO Agenda

1.
1. INTRODUCTION
INTRODUCTION

2.
2. PROJECT
PROJECT

3.
3. STRATEGY
STRATEGY

4.
4. ACTIVITY
ACTIVITYPLAN
PLAN&&GANTT
GANTTCHART
CHART

5.
5. BUDGET
BUDGET

4.
4. LIMITATIONS
LIMITATIONS
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INTRODUCTION

DR. FIZZA
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LOGO INTRODUCTION
 Maternal health refers to the health of women
during pregnancy, childbirth and the postpartum
period
 Each year over half a million women in low-
income countries die from complications
associated with childbearing

 99% of maternal deaths occur in developing

countries.

 1/3 of them occur in SEA.

 Millions more suffer pregnancy-related

morbidities and chronic long-term disabilities
related to pregnancy and childbirth
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LOGO Introduction cont . . .
 How can one integrate nutrition and
reproductive health?
 Programs need to go beyond the global
aim of reducing fertility and mortality
 Adolescent girls should be included in
supplementary-feeding programs before
malnutrition becomes a causative factor in
maternal mortality
 The nutrition component of existing
prenatal programs needs to be stable
measured in terms of maternal
anthropometry instead of just infant
survival
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LOGO
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LOGO PREVALENCE OF ANEMIA BY PROVINCE (PERCENT)

80
Pregnant women All women

60

40

20

0
NWFP Punjab Sindh Balochistan Pakistan
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LITERACY RATES FOR PUNJAB DISTRICTS –
LOGO BY MALES AND FEMALES
Literacy Rates for Punjab Districts – by Males and Females aged 10+ years
Ranked from Highest to Lowest Rates for Males
Female Literacy Rates Male Literacy Rates

Rawalpindi 68 87
Chakwal 57 84
Jhelum 59 78
Sialkot 65 75
Lahore 67 75
Attock 40 73
Gujrat 57 73
Mianwali 37 73
Gujranwala 62 72
Narowal 49 72
Sargodha 46 69
T.T.Singh 46 68
Khushab 36 68
Faisalabad 52 68
Mandi Bahauddin 48 66
Hafizabad 44 64
Sahiwal 45 64
Khanewal 36 62
Jhang 31 60
Layyah 32 59 % Excess
Sheikhupura 41 58 of Males to
Multan 35 56 Females
Vehari 30 56
Pakpattan 30 55
Bahawalnagar 34 54
D.G.Khan 24 54
Okara 33 53
Bhakkar 20 53
Rahimyar Khan 31 52
Lodhran 23 51
Kasur 32 51
Muzaffargarh 22 48 Excess of Males
Rajanpur 20 47 Females over Females

Bahawalpur 28 47

0 10 20 30 40 50 60 70 80 90 100

% Literate
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LOGO Causes of Maternal Deaths
(Pakistan)

Hepatitis
Anemia Hospital Community
Abortion-related
Obst. Labor
Toxemia
Sepsis
Hemorrhage
0 5 10 15 20 25 30 35 40
 MMR 276
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276,000 women
suffer from
maternal illness and
disability
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GUJRAT
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AREA 3192 Sq .km

 District Gujarat an
ancient district of
POPULATION 2.54 MILLION
Pakistan located in
between two famous
rivers, i.e., River POPULATION 642/KM (2)
DENSITY
Jehlum and River
Chenab in Province URBAN 25.62%
Punjab POPULATION
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LOGO GUJRAT VS PUNJAB

Gujrat vs Punjab Health Indicators (MICS-Punjab; 2007-08)

Indicator Gujrat Punjab Year

Care provided by LHW 75% 50% 2007-08

Total fertility rate 5.5 4.7 2003-04

Use of contraception (any method) 37% 32% 2007-08

Ante-natal care 85% 53% 2007-08

Post-natal care 65% 41% 2007-08

Skilled attendant delivery 68% 43% 2007-08

Institutional deliveries 60% 38% 2007-08

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LOGO URBAN-RURAL POPULATION
DISTRIBUTION OF GUJRAT

Population distribution of dist. Gujrat

Urban
28%

Rural
Urban

Rural
72%
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PROJECT
DR. SHUMAILA
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LOGO ASSUMPTIONS FOR MATERNAL MORTALIY

Preventive Curative

1 Nutritional deficiency Home based deliveries

2 Lack of awareness Lack of skilled birth

attendants
3 Lack of family planning Post-partum hemorrhage

4 Lack of proper ante- Infection

natal care
5 Poverty Prolonged labour
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LOGO “NIGAR”
 TITLE OF PROECT
 Nutritional intervention in Gujrat for adolescent &
reproductive age group women (NIGAR).
 Aim of the project
 To reduce maternal mortality and morbidity in
Gujrat.
 Objective of the project
 To reduce maternal mortality by 40% through
implementation of a nutritional intervention
program in CBA in 3 years in district Gujarat.
Company
LOGO “NIGAR”
 Slogan of the program
 “MAAN TAWAANA,
KHUSH-HAAL GHARANA”
“NIGARPROJECT WORKER”
“NIGAR REGISTRATION CARDS”

“NIGAR BAGS”
 Logo of the program
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LOGO Coverage of the project

 Three tehsils of District Gujrat with

population of 2.54 million.

 Names of the tehsils:

1). Kharian
2). Gujarat
3). Sarai alamgir
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LOGO HEALTH FACILITIES AT GUJRAT
Name No.
Aziz Bhatti Shaheed 1
(DHQ) Hospital, Gujrat
T.H.Q. Hospital, Kharian 1
Maternity Hospitals 2
Civil Hospitals 2
Rural Health Centers 9
Basic Health Units 89
Blood Transfusion Centers 2
Civil Dispensaries 2
Rural Dispensaries 22
Govt. Rural Dispensaries 3
M.C.H. Centers 10
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LOGO UNION COUNCILS OF DISTRICT GUJRAT

 Achh 
Chak Manju  Langrial, Gujrat
 Addowal 
Chakori Bhalowal  Malka
 Ajnala, Pakistan 
Chakori Sher Ghazi  Mandeer
 Alamgarh 
Chechian  Miana Chak
 Amra Kalan 
Chopala 
Noonanwali
 Bagrianwala 
Deona 
Panjan Kissana
 Baharwal 
Dhoria  Sabour
 Bareela 
Fateh Bhand  Sehna
 Barnali 
Gochh  Sikaryali
 Baroo 
Haji Muhammad  Tanda, Gujrat
 Beharaj 
Jaura  Thikrian
 Bido Bhatti 
Khawaspur  Thutha Rai Bahadar

Chak Jani 
Kotla Arab Ali Khan  Warachanwala
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LOGO INSTITUTIONAL ORGANOGRAM OF HEALTH DEPARTMENT

D is t r ic t H e a lt h O f f ic e

D is t r ic t H o s p it a l P ro g ra m s A d m in is t r a t io n

T e h s il H o s p it a l L a d y H e a lt h W o r k e r s Im m u n iz a t io n

R u r a l H e a lt h C e n t e r

B a s ic H e a lt h U n it
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LOGO PROJECT IMPLEMENTING UNIT

 Project coordinator - EDO health

 Assistant project coordinator - 3
DDHO of three tehsils
 Training and monitoring facillators- 3
 Office assistant- 1
 Community Mobilizers 3
 Lab technician supervisor- 1
 Out reach workers- 18 - 20
 Drivers- 3
 Existing staff of the health facilities
 LHWs’ of district Gujrat
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LOGO

STRATEGY
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LOGO TARGET GROUP

 1).Primary target group -

Pregnant ladies

 2).Secondary target group-

Women of child bearing age
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LOGO STRATEGIC PLAN

1. PRIMARY TARGET GROUP 2. SECONDARY TARGET GROUP

(Pregnant women) (CBA women)

Key Strategy Key Strategy

Activities Activities

Key components Key components

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LOGO PRIMARY TARGET GROUP
(PREGNANT WOMEN)

 Key strategy:
 Improvement in anemia & malnutrition in
pregnant ladies.
 Improvement in ante-natal & post-natal
visits of the pregnant women.
 Improve FP services & TT vaccination
coverage
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LOGO

 Key components:
 Incentive based Registration of all pregnant
women for nutritional intervention.
 Providing iron, folic acid, vitamin A and
nutritional supplements (fortified oil) to pregnant
women on monthly basis during 3rd month of
pregnancy to 6th month after pregnancy.
 All registered pregnant women to be counseled
for family planning & given TT coverage.
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LOGO ACTIVITIES

 All ante-natal to be documented on registration cards

regarding nutrition, FP & TT services along with
complete checkup.
 LHW to be given incentives (Rs.50/client) on bringing
ante-natal to health facility (registration card will contain
referral name and signature of the LHW).
 Proper monitoring of anemia of high risk groups on
monthly basis at BHU.
 Referring to high risk groups from BHU to higher centers.
 Insuring follow up of referred patients from their
feedback & documenting that for future references.
 Training of health facility staff to identify anemic mothers
and refresher courses every 6 months.
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LOGO SECONDARY TARGET GROUP
(CBA WOMEN)

 Key strategy:
 Community based interventions:
 BCC intervention at community level
 Community mobilization
 Training of community based service
provider
 Mass media campaigns
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LOGO

 Key component:
 Method to improve nutritional status of
women and her family according to their
own socio economic and cultural
conditions.
 Importance of good nutritional status for
women of child bearing age and
pregnancy symptoms and complications
due to malnutrition and anemia.
Company
LOGO Activities for community based interventions:

 Arranging health education sessions at the

councilors house for women of child bearing age
by out reach workers.
 Distribution of health education material to them.
 De-worming the women in CBA group on six
monthly bases.
 Display of charts and health education material
at sessions
 Distribution of specially designed menu charts
designed according to anthropological and
economic conditions.
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LOGO

 Meeting with influential persons, orientation of

village health committee, imams and select
community volunteers from each area.
 Formation of community support groups.
 Training of community based service provider
like LHW,
 School teachers & dais to be invited with
incentives in these health education sessions
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LOGO Activities for mass media campaign

 Weekly based program on FM radio

stations.
(involving HCP, nutrition staff, community
personal, role models, success stories)
 Newspaper & local print media
 Wall painting with slogans
 Announcements in mosques by religious
people
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LOGO

ACTIVITY PLAN

DR. HAMMAD
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LOGO “NIGAR” ACTIVITY PLAN

WEEK 1-2 WEEK 3-4 WEEK 5-6 WEEK 7-8

PLANNING NUTRITION POSTS RECRUITMENTOF TRAINING (PHASE1)

ADVERTISEMENT NUTRITION STAFF NUTRITION STAFFTOT
BUDGET
FROM WFP (5 DAYS)
ALLOCATION
RENOVATION OF TRAINING (PHASE 2)
MEETING WITH REQUIRED
HEALTH STAFF PURCHASING FACILITY STAFF
BUILDINGS (5 DAYS)
MEETING WITH
OTHER DEPT TRAINING (PHASE 3)
PRINTING /
TRAINING FIELD STAFF
MOU MANUALS (5 DAYS)
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LOGO “NIGAR” ACTIVITY PLAN

WEEK 9-10 WEEK 11-12 WEEK 13-14 WEEK 15-16

REGISTRATION MASS MEDIA

PROJECT COMPLETES COMPAIGN
EVALUATION
LAUNCHING STARTS
OF STAFF
CEREMONY
HE SESSIONS FACILITIES
START SERVICES
START
PILOT TESTING REGISTRATION HANDING OF
OF PREGNANT EQUIPMENTS & DISTRIBUTION
WOMEN STARTS MEDICINES TO OF OIL &
FACILITIES MEDICINES START
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LOGO “NIGAR” ACTIVITY PLAN

MONTH 5-7 MONTH 8-10 MONTH 11 MONTH 12

REFRESHER
ACTIVE ACTIVE ACTIVE COURSES
MONITORING MONITORING MONITORING (2 DAYS)

END YEAR
EVALUATION
REFRESHER PROJECT
COUSES (2DAYS) PASSIVE PASSIVE
MONITORING MONITORING 1 YEAR
EVERY 6TH MONTH COMPLETION
CEREMONY

REPLANNING
FOR NEXT YEAR
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LOGO GANTT CHART
            1st YEAR

%
Duratio C
n o
( m
D p
a l
y e
s t
WBS Tasks Start End ) e !st quarter 2nd quarter 3rd quarter 4th quarter

1 PLANNING     3                          

2 BUDGET ALLOCATION     2                          

3 MEETING WITH HEALTH STAFF     3                          

4 MEETING WITH OTHER DEPT     4                          

5 MOU     2                          
NUTRITION POSTS
6 ADVERTISEMENT     10                          

7 RENOVATION OF BUILDINGS     10                          
RECRUITMENTOF NUTRITION
8 STAFF     10                          

9 PURCHASING     10                          
PRINTING / TRAINING
10 MANNUALS     12                          
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LOGO GANTT CHART
11 TRAINING (PHASE1)     5                        

12 TRAINING (PHASE 2)     10                        

13 TRAINING (PHASE 3)     10                        

14 EVALUATION     5                        

15 PILOT TESTING     5                        

16 PROJECT LAUNCHING CEREMONY     5                        

17 REGISTRATION OF PREGNANT WOMEN     12                        

18 REGISTRATION COMPLETES     12                        

19 HE SESSIONS START                              

20 HANDING OVER TO FACILITIES     7                        

21 MASS MEDIA COMPAIGN STARTS                              

22 FACILITIES SERVICES START                              

23 DISTRIBUTION OF OIL & MEDICINES                              

24 ACTIVE MONITORING                              

25 PASSIVE MONITORING                              

26 REFRESHER COURSES (2 DAYS)                              

27 END YEAR EVALUATION                              

28 PROJECT 1 YEAR COMPLETION CEREMONY                              

29 REPLANNING FOR NEXT YEAR                              

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LOGO

PLANNING

IMPLEMENTATION
EVALUATION
EVLUATION “NIGAR”

MONITORING
Company
LOGO

BUDGET
DR. ABDUL
WALI KHAN
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LOGO BUDGET DISTRIBUTION FOR 3 YEARS

TOTAL % % Allocated Remaining %

1st Year 100 40 60

2nd Year 70 30 30
3rd Year 30 30 00

Note: Initial budget subdivision will be

for 1 year. At the end of 1st year, next
year budget will be subdivided.
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LOGO ANNUAL BUDGET ALLOCAION

CONTINGENCIES Salaries and

Repair and 10% Allowances
Maintenance TA/ DA
10%
10% 5%

Medicine
Procurement of 15%
Durable Goods
15%

Utilities
10% Others Fortified Oil
STATIONARY
2% 18%
5%

Salaries and Allowances TA/ DA

Medicine Fortified Oil
STATIONARY Others
Utilities Procurement of Durable Goods
Repair and Maintenance CONTINGENCIES
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LOGO SALARY BUDGET DIVISION

Total cost % of total

per year annual
Line Item Unit No. Unit Cost (millions) budget
Salaries &
Allowances
      4 10

Regular
existing staff per month 1.1 0.083 million    
Staff hired
for project per month 1.2 0.25 million    
           
0.25
million/qu
TA/ DA Per visit 1.3 arter 2 5
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LOGO NON-SALARY BUDGET DIVISION

0.005
Million per
faciltiy
Medicine   1.4 Per month 6 15
per
Tab. Iron facility/month 1.4.1      
Per
Tab. Folic acid facility/month 1.4.2      
Syp. M/Vit with per
iron facility/month 1.4.3      
0.006
Million per
Per faciltiy
Fortified Oil facility/month 1.5 Per month 7.2 18
facility/3 0.0066
Stationary months 1.6 million/3 months 2 5
0.008
Others   1.7 million/annum 0.8 2
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LOGO Utilities 0.33
  1.8 million/month 4 10
Telephone
per month 1.8.1      
Electricity
per month 1.8.2      

Water per month 1.8.3      

POL per month 1.8.4      

Procurement
Of 6 million
Durable Goods   1.9 (capital budget) 6 15
Weighing Machines per T & M
officer 1.9.1      
Essential
Laboratory. Equ. per facility 1.9.2      

Suzuki jeep per

(total 3) subdivision 1.9.3      

Others   1.9.4      
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LOGO Repair and
1 million per
Maintenance   2.1 quarter 4 10
Transport
vehicle per
month 2.1.1      

per
Equipment six months 2.1.2      

Others Quarterly 2.1.3      

4 million per
CONTINGENCIES per annum 2.2 annum 4 10

TOTAL     40 million 40 100

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LOGO

INDICATORS
PROCESS OUTCOME
1. # of pregnant women registered 1. % of maternal deaths
2. # of A/N visits 2. % of normal deliveries
3. # of P/N visits 3. % of deliveries with
complications
4. # of iron & folic acid tablets
distributed
5. # of fortified oil cans (5L)
distributed
6. # of HE sessions held
Company
LOGO WHATS NEW ? ? ?
 INCENTIVES

20% extra salary to existing involved staff

T/A, D/A to all others
 REFRESHMENTS

After each health sessions
 GIFTS

To successful clients
 ROLE MODELS & SUCCESS STORIES

From the community on FM radios & print media
 LAUNCHING CEREMONY

Will involve high level officials & respected people from communities

Full media coverage
 ADVOCACY
 ANNUAL CEREMONY

Awards to best ten families

Awards to best facility & field staff
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LOGO LIMITATIONS

 Lack of political will, commitment & motivation

 Difficulty in access to all the women at house holds level
 Religious limitations for women regarding attending
health sessions
 Lack of motivation of HCPs’ specially lady health workers
 Lack of awareness due to illiteracy and poverty
 Lack of ownership among community for the project
 Lack of funds
 Sustainability ? ? ?
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LOGO

THANKS

QUESTIONS ACKNOWLE
??? TEXT TEXT
D-GEMENTS