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
AKHSP’s 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
Worked…Lessons 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 Challenges…What
Didn’t 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