Mercy Corps Report Balochistan PDF

Samreen Baloch, a Community Midwife from Quetta District, provides antenatal care to a client.
FINAL EVALUATION OF THE SAVING

MOTHERS AND NEWBORNS IN
COMMUNITIES PROJECT
A FOCUSED STRATEGIC ASSESSMENT OF
A COMMUNITY MIDWIVES PROGRAM IN
THREE DISTRICTS OF BALOCHISTAN
PROVINCE, PAKISTAN
CSHGP COOPERATIVE AGREEMENT NUMBER: AID-OAA-A-12-00093
November 2016
This publication was produced at the request of the United States Agency for International Development. It
was prepared independently by Kathy Tilford, External Consultant, with assistance from Dr. Sohail Amjad,
National Consultant.
ACKNOWLEDGEMENTS
First of all, my sincere thanks to the many individuals in Quetta, Gwadar and Kech who participated
in the focus group discussions and the key informant interviews – CMWs, DoH personnel,
beneficiaries, members of the policy forums, SMNC project staff and Mercy Corps senior managers.
Your perspectives and suggestions enriched the content of this report and helped to validate
findings from the stakeholders’ point of view.
Ahmed Ullah, SMNC Program Manager, was tireless in responding to my many requests for
additional documents, more information and clarifications and I am very grateful to him. He and his
colleagues, including Dr. Saeedullah Khan (Team Leader South), Dr. Shaihak Riaz and Ghulam
Haider (Security Officer), helped the field team organize their program, made logistical arrangements
for them and ensured that the team was able to conduct the qualitative research in a safe
environment.
I sincerely appreciate the time and effort that Ahmed Ullah, Dr. Farah Naureen and Jennifer
Norman devoted to reviewing the first draft of this document. Their observations and suggestions
were very helpful and made for a more accurate report.
Dr. Saima Hamid, the consultant who prepared the Learning Agenda report, kindly answered my
queries about the studies described in the report. My thanks to her.
My deepest appreciation goes to Dr. Sohail Amjad, the national consultant for the Focused Strategic
Assessment, who worked with me from beginning to end. His in-depth knowledge of the Pakistani
health system and the Community Midwives program were invaluable in helping me understand the
context of the project. In addition to contributing to the methodology and the development of the
qualitative research instruments, he led the team that conducted the field work, ensured that
transcripts were well-prepared and provided comments and input for the report. Thanks also to the
two senior research associates, Dr. Muslim Abbas and Ms. Saima Zeb Faredi, who conducted the
qualitative research in the field with Dr. Amjad and prepared detailed, high-quality transcripts with
pertinent observations and reflections.
Sincerely,
Kathy Tilford
External Consultant
FINAL EVALUATION OF
THE SAVING MOTHERS
AND NEWBORNS IN
COMMUNITIES PROJECT:
TESTING INTERVENTIONS TO STRENGTHEN A
PRIVATE-SECTOR COMMUNITY MIDWIVES
PROGRAM TO IMPROVE MATERNAL AND
NEWBORN HEALTH STATUS IN UNDERSERVED
AREAS OF BALOCHISTAN PROVINCE, PAKISTAN
DISCLAIMER: The author’s views expressed in this publication do not necessarily reflect the views of the
United States Agency for International Development or the United States Government.
CONTENTS
Acronyms ......................................................................................................................................................... i
Executive Summary .......................................................................................................................................... 1
Purpose of the Focused Strategic Assessment ....................................................................................................... 4
Questions for the Focused Strategic Assessment ............................................................................................ 4
Project Background........................................................................................................................................... 5
Situation of Maternal and Neonatal Mortality in Balochistan ............................................................................ 5
Project Summary ........................................................................................................................................ 5
Partnerships and Collaboration .................................................................................................................... 7
The Learning Agenda ................................................................................................................................. 7
Assessment Methodology and Limitations ........................................................................................................... 8
Principal Findings ........................................................................................................................................... 11
Progress Toward Project Goal and Objectives ............................................................................................. 11
Status of the Midcourse Corrections ........................................................................................................... 19
Key Strategies and Factors Affecting Results................................................................................................ 19
Sustainability and Potential for Scaling Up ................................................................................................... 22
Conclusions and Recommendations .................................................................................................................. 23
Recommendations .................................................................................................................................... 24
Annexes
Annex I. Focused Strategic Assessment Terms of Reference
Annex II. Assessment Methodology and Limitations
Annex III. Data Collection Instruments and Work Plan
Annex IV. Sources of Information
Annex V. Disclosure of Any Conflicts of Interest
Annex VI. Assessment Team Members, Roles and Titles
Annex VII. Stakeholder Debrief Powerpoint Presentation
Annex VIII. Learning Agenda Final Report
Annex IX. Project Data Form
ACRONYMS
Acronym Definition
ANC Antenatal Care
CMW Community Midwife
CSHGP Child Survival and Health Grants Program
DG Director General
DHF District Health Forum
DHO District Health Officer
DoH Department of Health
FGD Focus Group Discussion
FSA Focused Strategic Assessment
GoB Government of Balochistan
IEC Information, Education and Communication
IR Intermediate Result
KII Key Informant Interview
LHS Lady Health Supervisor
LHV Lady Health Visitor
LHW Lady Health Worker
LQAS Lot Quality Assurance Sampling
MCH Maternal and Child Health Program
MCSP Maternal and Child Survival Program
MIS Management Information System
MNCH Maternal, Neonatal and Child Health
MoU Memorandum of Understanding
PHS Public Health Specialist
October 2016 i
PKR Pakistani Rupees
PNC Pakistan Nursing Council
PSC Provincial Steering Committee
SMNC Saving Mothers and Newborns in Communities
SMS Texting
TBA Traditional Birth Attendant
ToR Terms of Reference
TWG Technical Working Group
USAID United States Agency for International Development
WSG Women Support Group
October 2016 ii
EXECUTIVE SUMMARY
Purpose of the Focused Strategic Assessment and Questions
This Focused Strategic Assessment (FSA), conducted in September-October 2016, serves as the
final evaluation of the Saving Mothers and Newborns in Communities (SMNC) project
implemented in Balochistan Province, Pakistan. The FSA provided an opportunity to take stock of
accomplishments to date and to listen to the stakeholders at all levels. The FSA report will be used
by the following audiences as a source of evidence to help inform decisions about future program
designs and policies: in-country partners at the national, provincial and local levels; USAID (Child
Survival and Health Grants Program [CSHGP], Global Health Bureau, USAID Missions), the
Maternal and Child Survival Program (MCSP) and other CSHGP grantees; and the international
global health community. The five overarching questions addressed in the FSA are:
1. To what extent did the project accomplish and/or contribute to the results
(goals/objectives) stated in the Strategic Work Plan?
2. What were the key strategies and factors, including management issues and policy
environment, that contributed to what worked or did not work?
3. Which elements of the project have been or are likely to be sustained or expanded?
4. What are stakeholder perspectives on the overall project implementation, the policy forums,
and the Learning Agenda implementation?
5. Working around strengthening community-based maternal and newborn healthcare
provision, to what extent has the project been successful?
In addition to answering these five questions, the FSA also focused on four Learning Agenda
themes, which were selected jointly with the Balochistan Department of Health (DoH) to provide
information needed to improve Community Midwives (CMW) policies and programs. These themes
were improving the selection process to more effectively recruit and deploy CMWs; promoting
financial self-sustainability for CMWs; ensuring that CMWs provide quality care; and streamlining
reporting using mobile phones.
Project Background
Compared to the other three provinces, Balochistan has the worst maternal, neonatal and child
health indicators in the country according to recent data provided by the Balochistan DoH: a
maternal mortality rate of 785 per 100,000 live births; a neonatal mortality rate of 63 per 1,000; and a
skilled birth attendance rate of only 17.8 percent. Eighty-three percent of women deliver at home
and 55.7 percent receive no antenatal care (ANC). To address Balochistan’s sustained high rates of
maternal and neonatal mortality and to ensure skilled birth attendance, the Government of
Balochistan (GoB) and the Balochistan provincial DoH have given top priority to training a cadre of
private-sector CMWs to provide much-needed maternal and neonatal services in underserved areas.
The DoH requested Mercy Corps’ assistance to address some of the underlying issues in the CMW
program; the result was a joint project with a dual purpose: 1) to demonstrate a health impact within
three target districts (Quetta, Gwadar and Kech) and 2) to test interventions and provide key lessons
October 2016 1
for developing an improved CMW program model that the DoH could replicate across the
province.
Working closely with the DoH, Mercy Corps is implementing a maternal, newborn and child health
(MNCH) project in Quetta, Gwadar, and Kech Districts of Balochistan Province, Pakistan with
support from USAID CSHGP (September 2012-September 2016) and the Scottish Government
(through March 2017). The Saving Mothers and Newborns in Communities (SMNC) project
seeks to improve maternal and newborn health status, especially for poor and marginalized women
of Balochistan (Goal), through increased use of quality essential maternal and newborn care
provided by private-sector community midwives (Strategic Objective). The project’s
Intermediate Results are:
1. Increased availability of quality maternal and newborn care in communities
2. Improved knowledge and demand for essential maternal and newborn care
3. Improved access to emergency transport in remote communities
4. Improved policy environment for improved maternal, newborn and child health care based
on evidence from the Operations Research (Operations Research later replaced with
Learning Agenda activity)
SMNC is an innovative model designed to reach 382,515 beneficiaries; it has been tested with 95
CMWs and includes the following main components: clinical refresher training; provision of
standard equipment and business skills training; mHealth, especially the use of mobile phones for
tracking data; reinvigorating Women Support Groups (WSGs) for behavior change; improving the
emergency transportation systems; policy initiatives including two provincial level forums and the
development of a five-year Balochistan MNCH Strategy; a voucher scheme to enable the poorest
women to access CMW services; and strengthening the referral mechanism between CMWs and
other health facilities.
Assessment Methodology and Limitations
Mercy Corps hired an external consultant to lead the FSA remotely from the U.S. She worked
closely with a well-qualified national consultant hired by Mercy Corps Pakistan who served as the
field team leader, working with two assistants experienced in qualitative data collection. The
methodology consisted of a participatory mixed-methods approach that included two principal
components: a comprehensive desk review of secondary quantitative and qualitative data sources
and the collection of qualitative data. Additional information was acquired through a series of Skype
calls and e-mail exchanges with project staff. The main limitation was that security concerns meant
that the evaluation field team could not access remote sites.
Project Findings
The SMNC project convincingly demonstrated that with appropriate selection, training and
continued support, the CMW can acquire the necessary skills, confidence and community
status to be a lifesaving provider of MNCH services, especially in rural areas with widely-
scattered populations where few if any other health services exist. The project achieved its main
objectives: it increased access to quality maternal and neonatal health services for families in
underserved areas and provided tested CMW program interventions for replication throughout
Balochistan. In doing so, it left lasting achievements such as:
• 95 midwives trained and equipped, the majority of whom continue to provide essential
services to women with few other options for skilled birth attendance
• A clinical skills refresher training course endorsed by the Pakistan Nursing Council (PNC)
October 2016 2
• A business skills course to be included in the 18-month midwifery training
• Increased demand for MNCH services at the community level
• A three-module set of materials for WSGs, available in four languages
• Two institutionalized provincial policy platforms, the Technical Working Group (TWG) and
the Provincial Steering Committee (PSC)
• A new five-year MNCH strategy for Balochistan with a major component for CMWs
• An mHealth application for improved data collection and reporting
That the project has been able to achieve this in only four years is a testament to the DoH’s
commitment, the strong partnership between Mercy Corps and the Government of Balochistan and
a sound project design that addressed high priorities for the stakeholders. While the successes are
evident, challenges remain, including: identifying enough qualified and interested women from rural
areas who meet the minimum requirements to become a CMW; ensuring that the CMWs have
sufficient monetary incentives to continue providing services; providing adequate support through
regular supportive supervision; improving linkages between the MNCH program and the CMW
program; strengthening the referral mechanism between CMWs and secondary facilities; and
overcoming GoB budgetary constraints.
Among the principal recommendations from the FSA are the following:
1. Prepare a briefing paper that summarizes the main findings and recommendations from the
Learning Agenda exercise; ensure wide-spread dissemination and follow-up.
2. Commit resources to continue supportive monitoring and supervision of CMWs and invest in
regular refresher training on technical themes and business skills for CMWs.
3. Continue with the plan to integrate the mHealth application into the MNCH MIS.
4. Continue the policy forums (Provincial Steering Committee and Technical Working Group),
especially for overseeing the implementation of the Balochistan MNCH Strategy.
5. Mobilize resources and partners for implementing the Balochistan MNCH Strategy.
6. Create a more collaborative working relationship between CMWs and Lady Health Workers
(LHWs).
7. Make quality staffing of midwifery schools a priority.
The Saving Mothers and Newborns in Communities project (SMNC) in Balochistan Province, Pakistan is supported by the American people through
the United States Agency for International Development (USAID) through its Child Survival and Health Grants Program. The SMNC project is
managed by Mercy Corps under Cooperative Agreement No. AID-OAA-A-12-00093. The views expressed in this material do not necessarily reflect
the views of USAID or the United States Government.
October 2016 3
PURPOSE OF THE FOCUSED STRATEGIC ASSESSMENT
This Focused Strategic Assessment serves as the final evaluation of the Saving Mothers and
Newborns in Communities (SMNC) project. USAID approved Mercy Corps’ choice of an external
evaluator who was hired with project funds; the external evaluator is an independent consultant and
had no previous connection with the project. USAID/CSHGP also reviewed and approved the draft
Terms of Reference (ToR). The ToR and proposed report outline were modified from the standard
guidelines to allow a more in-depth focus on key issues designed to assist the Balochistan
Department of Health (DoH) to improve and expand its Community Midwives program.
In addition to providing a review of the overall project, the purpose of the FSA is to focus on four
Learning Agenda themes, designed jointly with the Balochistan DoH, to provide them with the
information they need to refine Community Midwives policies and programs:
1. How can the Balochistan Department of Health improve its selection process to effectively
recruit and deploy CMWs in underserved areas?
2. How can CMWs become financially self-sustaining while serving the needs of the poorest of
the poor?
3. Do CMWs offer quality care? How?
4. How can the Balochistan DoH streamline CMW reporting using mobile phone technology
and expand mHealth in the province?
The FSA provides an opportunity for all project stakeholders to take stock of accomplishments to
date and to listen to the beneficiaries at all levels, including mothers and caregivers, community
members and opinion leaders, health workers, health system administrators, local partners, other
organizations, and donors. The FSA report will be used by the following audiences as a source of
evidence to help inform decisions about future program designs and policies:
• In-country partners at the national, provincial and local levels (e.g., DoH and other relevant
ministries, provincial and district health teams, local organizations, communities in project
areas).
• USAID (CSHGP, Global Health Bureau, USAID Missions), the Maternal and Child Survival
Program (MCSP) and other CSHGP grantees.
• The international global health community. The FSA report will be posted for public use at
http://www.mchipngo.net and the USAID Development Experience Clearinghouse at
https://dec.usaid.gov.
QUESTIONS FOR THE FOCUSED STRATEGIC ASSESSMENT
In addition to the focus on the four Learning Agenda themes, the ToR outlined five overarching
questions to be addressed in the FSA:
(goals/objectives) stated in the Strategic Work Plan, keeping in view the revisions in the
midcourse correction document?
October 2016 4
3. Which elements of the project have been or are likely to be sustained or expanded (e.g.,
through institutionalization or policies)?
4. What are stakeholder perspectives on the overall project implementation, the policy forums,
and the Learning Agenda implementation, and how could the Learning Agenda affect
capacity, practices, and policy?
For the more detailed list of questions, please see the ToR in Annex I.
PROJECT BACKGROUND
SITUATION OF MATERNAL AND NEONATAL MORTALITY IN BALOCHISTAN
Compared to the other three provinces, Balochistan has the worst maternal, neonatal and child
health indicators in the country as the following table (prepared by the Balochistan Department of
Health for a recent donor conference) shows:
Indicator Balochistan Khyber Punjab Sindh

Pakhtunkhwa
Maternal mortality ratio (per 100,000 live 785 275 227 314
births)*
Neonatal mortality (per 1,000) 63 41 63 54
Infant mortality (per 1,000) 97 58 88 74
Under five mortality (per 1,000) 111 70 105 93
Proportion of home deliveries 83.1 59.3 51.3 41.4
No ANC 55.7 37.5 19.5 20.9
Skilled birth attendance 17.8 48.3 52.5 60.5
Contraceptive prevalence rate 19.5 28.1 40.7 29.5
Fertility rate 4.2 3.9 3.8 3.9
All basic vaccinations 16.4 52.7 65.6 29.1
*Maternal mortality ratio is taken from Demographic and Health Survey (DHS) 2006-07. Remaining data is from DHS 2012-13.
A number of factors contribute to the poor health outcomes for women and children in
Balochistan. For pregnant women and newborns, a major constraint is the lack of skilled birth
attendants at the community level. As the table shows, less than one in five women in Balochistan
used a skilled birth attendant at her last delivery. Accessing care outside the community presents its
own set of obstacles: a poor transportation infrastructure, long distances to a health facility, cost and
societal norms that restrict women’s mobility. A pregnant woman may need a male relative escort to
go to a distant health facility, increasing costs and impinging on the time of the relative, especially if
the woman needs to stay for several days to receive care.
PROJECT SUMMARY
To address Balochistan’s sustained high rates of maternal and neonatal mortality and to ensure
skilled birth attendance, the Government of Balochistan and the Balochistan provincial DoH have
given top priority to training a cadre of private-sector Community Midwives to provide much-
October 2016 5
needed maternal and neonatal services in underserved areas. However, training alone has not been
sufficient to improve rates of skilled birth attendance and overall health indicators as most of the
CMWs have not been able to establish their clinics and attract clients. The DoH requested Mercy
Corps’ assistance to address some of the underlying issues in the CMW program and the result was a
joint project with two purposes: 1) to demonstrate a health impact within three target districts
(Quetta, Gwadar and Kech) and 2) to test interventions and provide key lessons for developing an
improved CMW program model that the DoH could replicate across the province.
As a result, Mercy Corps is implementing a maternal, newborn and child health (MNCH) project in
Balochistan, Pakistan with support from USAID CSHGP (September 2012-October 2016) and the
Scottish Government. The Scottish Government funding also covers a six-month extension phase
from October 2016 through March 2017. The Saving Mothers and Newborns in Communities
(SMNC) project seeks to improve maternal and newborn health status, especially for poor and
marginalized women of Balochistan (Goal), through increased use of quality essential maternal and
newborn care provided by private-sector community midwives (Strategic Objective).
The project’s Intermediate Results are:
4. Improved policy environment for improved maternal, newborn and child health care based
on evidence from the Operations Research (Operations Research later replaced by the
Learning Agenda activity as a result of midcourse corrections)
SMNC is an innovative model designed to enable CMWs to become self-sustaining, private MNCH
service providers. The model, which has been tested with 95 CMWs, contains the following main
components:
1. To ensure quality, Mercy Corps has provided CMWs with clinical refresher training,
supported CMW registration with the Pakistan Nursing Council (PNC) for those who were
not already registered and conducted joint supervision visits with the DoH.
2. To enable CMWs to set up home-based clinics, Mercy Corps has provided standard
equipment and business skills training for the CMWs.
3. Through Mercy Corps’ partnership with PakVista Technologies, CMWs have been using
their mobile phones to track patient data, send automatic reminders to clients and offer mass
SMS (texting) for awareness raising. Through automatic data transfer, the DoH is now able
to track uptake of CMWs’ services in real time. (Note that the automatic reminders and mass
SMS activities were discontinued in April 2016 based on midcourse correction
recommendations.)
4. For behavior change and demand creation, Mercy Corps reinvigorated the Women Support
Groups conducted by CMWs and Lady Health Workers. These groups also generate support
to facilitate access to emergency transport.
5. For timely referrals, Women Support Groups and CMWs have been linked with not-for-
profit ambulance services.
6. At the policy level, Mercy Corps has assisted the provincial DoH in developing a five-year
strategic MNCH plan and in establishing two policy forums, the Technical Working Group
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(TWG) and the Provincial Steering Committee (PSC).
7. A voucher scheme has been introduced to support the DoH in operationalizing plans that
address the needs of poorest women to access maternal and newborn health services.
8. Although it is not yet fully functional, Mercy Corps has also prepared and oriented DoH
staff on a referral mechanism between CMWs and secondary health facilities.
Over the life of the project, an estimated 382,515 beneficiaries will be reached:
Beneficiaries (National MNCH Program and provincial DoH Total
estimates)
Total Population 2,689,838
Total Neonates 11,093
Infants aged 0–11 Months 13,388
Children aged <5 Years 65,028
Women of Reproductive Age (15–49 years) 84,153
Total Beneficiaries 382,515
Expected Pregnancies 13,006
Community Health Workers or Volunteers (CHWs), Disaggregated 95 CMWs, 272 LHWs/Community
by Sex Educators (Female)
Community-based Structures 272 Women Support Groups
PARTNERSHIPS AND COLLABORATION

The principal partners are Mercy Corps and the Government of Balochistan, represented through
the DoH with which Mercy Corps has a long and productive working relationship. Within the DoH
key relations have been established with provincial-level senior managers and government
administrators; at the district level, the District Health Officers (DHOs) and his/her team are the
principal partners.
At the community level, the project works closely with the private-sector CMWs, the Women
Support Groups, Community Educators and community leaders. The main private-sector parties
participating in the project are PakVista Technologies, which provides technical expertise in
mHealth, and two private not-for-profit ambulance companies with which Mercy Corps has signed
Memorandums of Understanding (MoUs).
THE LEARNING AGENDA
Following discussions with USAID and the DoH, Mercy Corps proposed in 2015 to replace the
project’s Operation Research activity with a revised Learning Agenda as part of the overall
midcourse correction plan. It was anticipated that the Learning Agenda would enable Mercy Corps
and the DoH to measure the health impact of the project and to provide the DoH with the
information they need to improve their CMW policies and programs, contributing to Intermediate
Result (IR) 4: Improved policy environment for improved maternal, newborn and child healthcare
based on evidence from the Operations Research.
Mercy Corps and the DoH discussed the DoH’s priorities, which were to determine i) how to
improve selection and deployment of CMWs in a way that they reach underserved populations and
ii) how to keep CMWs engaged with the program. As a result, Mercy Corps and the DoH jointly
agreed on the four key Learning Agenda topics listed on page 4.
October 2016 7
The four sub-studies (one for each question) contributing to the Learning Agenda started in
February 2016 and were completed by the time the FSA began. Each study had a unique
methodology combining quantitative and qualitative instruments. The Learning Agenda consultant
prepared a comprehensive report which describes the methodology, presents the results and
proposes recommendations. (See Annex IX.) This report was one of the principal secondary data
sources for the FSA.
ASSESSMENT METHODOLOGY AND LIMITATIONS

Mercy Corps hired an external consultant, Kathy Tilford, to lead the Focused Strategic Assessment
remotely from the U.S. She worked closely with a well-qualified national consultant, Dr. Sohail
Amjad, hired by Mercy Corps/Pakistan. The national consultant had extensive experience in
evaluation, including CSHGP projects, and in-depth knowledge of the Pakistani health system, the
Community Midwives program and the local context. He served as the field team leader, working
with two assistants experienced in qualitative data collection: Dr. Muslim Abbas and Ms. Saima Zeb
Faredi.
The methodology consisted of a participatory mixed-methods approach that included two principal
components:
1. Comprehensive desk review of secondary data sources: Prior to developing the
instruments for the field work, the external consultant conducted an extensive desk review
of quantitative and qualitative data sources. These included project documents such as the
proposal, the Strategic Work Plan, surveys and assessments, routine monitoring updates and
the Case for Midcourse Corrections; background documents on maternal and child health
and the Pakistan health system; the Learning Agenda report; and DoH publications such as
the Balochistan MNCH Strategy for 2016-2020. (See Annex IV for a complete list of
documents consulted.)
2. Collection of qualitative data: Using semi-structured Key Informant Interviews (KIIs),
Focus Group Discussions (FGDs) and informal discussions with project stakeholders, the
external consultant and the three-person field team carried out qualitative data collection
over a three-week period in September 2016. (See Annex III for the data collection
instruments and work plan.)
Selection of data collection methods: In addition to KIIs and FGDs, the team considered other
data collection methods including observations and exit interviews. However, it would have been
difficult to organize observations of CMWs and exit interviews with clients for several reasons:
• a field team member would need to be present at the exact time a client came for a
consultation;
• for cultural reasons only a female team member would be able to conduct these data
collection activities;
• time constraints would mean a limited number of observations and/or exit interviews; and
• the data collection carried out for the Learning Agenda already included a large number of
observations of CMWs by trained health care providers.
Choice of groups to interview: In deciding which groups to include for the FGDs, the team
discussed the possibility of a FGD with male community leaders. However, the Program Manager
October 2016 8
suggested that this might not be as useful since men had not been very involved at the community
level and would likely not have a lot to share.
Standard themes: To facilitate the triangulation of data, the team selected a number of common
themes to include in all data collection instruments: support for CMWs, including monitoring and
supervision; role of the Women Support Groups; potential for sustainability and replicability; status
of the referral system and emergency transportation; contribution of the project to improving
MNCH; and challenges encountered.
Qualitative Data Collection
Field work: The national consultant conducted qualitative work in the field with his two assistants
over ten days (September 19-28, 2016). In each of the three districts (Kech, Quetta and Gwadar)
they executed three FGDs, with each group having eight to ten participants:
1. Community Midwives: To identify participants for this FGD, the field team leader selected
every third name on the list of project-supported CMWs and asked the Program Manager to
contact 11-12 women in each district in order to have 7-9 participants. The team leader
attempted to keep a balance between urban and rural CMWs but ultimately CMWs closest to
the district capital were invited so that the women could return home the same day.
2. Lady Health Workers, Lady Health Visitors (LHVs) and Lady Health Supervisors (LHSs):
Participants from the same geographic areas as the CMW participants and who had
remained active in monitoring and coordination comprised this FGD group.
3. Female community members: Participants for this FGD included Lead Mothers from the
Women Support Groups and women who had accessed services from the CMWs who were
in the CMW Focus Group Discussion.
Using semi-structured interview guides, the field team also conducted in-depth KIIs with four DoH
stakeholders in each district:
• the District Health Officer
• the Medical Superintendent of the District Headquarters Hospital
• the Public Health Specialist (PHS) for the Maternal, Newborn and Child Health (MNCH)
program who oversees the MNCH program at the district level
• the District Coordinator who oversees the LHW program at the district level
At the provincial level, the national consultant held KIIs with the following stakeholders: the
Director General Health Services for Balochistan Province; the Provincial MNCH Coordinator; the
Provincial LHW Program Coordinator; the Chairperson of the Technical Working Group (also a
member of the Provincial Steering Committee); and two other stakeholders, one each from the
Technical Working Group and the Provincial Steering Committee.
Interviews with Mercy Corps staff: The external consultant collected qualitative data through
Skype interviews with project staff (Program Manager, Project Officer, Security Officer and the
Monitoring, Evaluation and Learning Manager) and with two Mercy Corps Pakistan senior
managers, the Team Leader/South who has been very involved in the project since the beginning
and the Senior Director of Programs. It was not possible for her to conduct Skype interviews with
other stakeholders due to connectivity issues outside Quetta and Islamabad.
Limitations
October 2016 9
Since the project had recently completed several qualitative and quantitative community-level
surveys in the target area, the team ensured that engagement with stakeholders focused primarily on
information gaps. The field team could not visit remote areas for FGDs due to security issues and
therefore CMWs and the LHWs/LHVs/LHSs were invited to the project’s district field offices. The
FGDs with female community members were held in homes of Lead Mothers. In Kech the security
situation meant that male members of the team could not travel there; only the female team member
conducted interviews in this district. However, this did not appear to affect the quality of data
collected.
Ethical Considerations
The field team made it clear to all FGD participants that they were under no obligation to
participate but if they did participate, anonymity and confidentiality were assured. Verbal informed
consent from the participants was obtained. Where necessary, an interpreter assisted the team
members. For each encounter, the team obtained permission for taking photographs for reports and
presentations.
Quality of Evidence for Results
The SMNC project was well-documented and during the FSA the project staff provided a number
of additional documents requested by the external consultant. The three Annual Reports prepared
per USAID requirements were comprehensive with extensive annexes. Each of the major
interventions such as mHealth had accompanying explanations and periodic assessments that
provided a chronological description of how the intervention evolved.
The assessment team compared findings from the qualitative research with project documents,
external assessments from firms such as PakVista Technologies, the Learning Agenda report
produced by an independent consultant and documents produced during the project’s lifetime such
as the Balochistan MNCH Strategy 2016-20. The external consultant also checked facts with SMNC
project staff when preparing this report. The cross-checking of data and the triangulation of findings
both ensured that the evidence used for drawing conclusions was valid and reliable. However, it
should be noted that for information presented in project documents such as the quantitative data in
the three Annual Reports and routine monitoring documents, the external consultant relied on the
accuracy of the information at the source as there was no way to independently verify the
information.
Data Analysis
The information collected from key informants was compiled and tabulated using MS Office
software for each question and inputs were organized by themes and dimensions of program
intervention. Important quotes and observations were identified and used to build the analysis. Data
emerging from interviews was validated internally through triangulation with information from
project documents, routine monitoring, communications with project staff and other sources
gathered prior to and during the field work. The interpretations of triangulated thematic data were
discussed with Mercy Corps district and country office teams for further modification and
amendment. Information was synthesized by creating matrices around identified themes and the
findings organized accordingly.
For additional details on the methodology, see Annexes II, III, IV and VII.
October 2016 10
PRINCIPAL FINDINGS
This section of the report presents the principal findings for the questions posed in the ToR. The
findings are organized under four main themes: Progress toward Project Goal and Objectives; Status
of Midcourse Corrections; Key Strategies and Factors Affecting Results; and Sustainability and
Potential for Scaling Up. Under each of the four themes additional findings are presented for the
sub-questions from the ToR.
The analysis is based primarily on four sources: the qualitative research (the FGDs and KIIs carried
out during the FSA period); SMNC project reports; the Learning Agenda report; and other key
documents such as the Balochistan MNCH Strategy 2016-20 and the mHealth assessment reports
from PakVista Technologies.
PROGRESS TOWARD PROJECT GOAL AND OBJECTIVES
To what extent did the project accomplish and/or contribute to the results (goals/objectives) stated in
the Strategic Work Plan, keeping in view the revisions in the mid-course correction document?
The project has largely achieved three of the four Intermediate Results (IRs) and made significant
progress toward reaching the overall goal of “improving maternal and newborn health status,
especially for poor and marginalized women”. The following discussion describes progress made
for the components within each IR.
IR1. Increased availability of quality maternal and newborn care in communities
This IR included the largest number of components and activities: recruitment and deployment of
CMWs; provision of standard equipment and business skills training to promote financial self-
sustainability of CMWs; development of a clinical skills refresher course; mHealth for improved
reporting and tracking of client data; supportive monitoring and supervision; and the introduction of
a voucher scheme to enable the poorest women to access CMW services. By September 2016 the
project had achieved its major targets for all the IR1 components except for the voucher scheme,
which was introduced only at the beginning of Year 4 as part of the mid-course corrections.
Improving recruitment and deployment of CMWs: The project has helped the DoH improve its
selection, deployment and retention of CMWs in two ways: through actions undertaken during
project implementation and through the Learning Agenda exercise. Evidence gathered through the
project’s baseline survey, the LQAS survey (Lot Quality Assurance Sampling) and the CMW
mapping exercise conducted in April-May 2015 convincingly demonstrated that there is a shortage
of CMWs practicing in rural communities, especially in the more remote, underserved areas. This
evidence helped Mercy Corps and the DoH recognize that both the selection and the deployment
processes needed to be improved if underserved areas were to benefit from the CMW program. As a
result, the DoH is working closely with Mercy Corps to improve both processes.
As a first step, the MNCH Program has decided to use mapping exercises and assessments in all
districts to determine where CMWs are needed most so that underserved areas are a priority for
selection of new CMWs. A second important step is the revision of the selection committees: they
will now be smaller and include representatives from the underserved communities to reduce
nepotism and to streamline the process. A third step for increasing the number of CMWs practicing
in rural areas will be to explore how to overcome the fact that low literacy rates for women in rural
areas results in fewer CMW candidates with the requisite education level. One suggestion is to
institute a continuing education program so that young women who have completed some schooling
October 2016 11
can obtain the required 10 years of schooling. While such an initiative would require an inter-sectoral
approach, additional resources and time to develop, it is encouraging that the DoH is interested in
exploring such options.
Another important contribution of the project was to work with the DoH to improve the
deployment process so that the CMWs could begin to serve their communities more quickly.
Examples of actions that accelerated the deployment process include:
• Mercy Corps worked with the DoH to facilitate the PNC midwifery registration process for
the CMWs, shortening the time considerably so that they could begin providing services
sooner.
• The DoH allowed the CMWs to practice while waiting for their registration approval.
• At the request of the TWG, the PSC recommended that the CMWs be allowed to provide
services in their homes (work stations) rather than always going to a client’s home. This
recommendation was approved and the establishment of work stations was a positive
innovation mentioned often during the qualitative research, especially by provincial and
district health administrators.
In addition to these project-supported actions for accelerating the provision of quality and accessible
CMW services, the Learning Agenda included a sub-study on the question: How can the DoH improve
its selection process to effectively recruit and deploy CMWs in underserved areas? This sub-study resulted in a
solid analysis of some of the reasons for the lack of CMWs in underserved areas; a good discussion
of a range of incentive packages for retaining CMWs; and concrete recommendations for better
selection, deployment and retention processes for CMWs in rural areas. The discussion of different
incentive packages and the most important recommendations for increasing the number of qualified
CMWs providing services in underserved areas are summarized below:
1. Establish an accelerated education program for women and girls to increase the available
pool of CMW candidates.
2. Improve family (and community) support for CMW candidates through better orientation.
3. Ensure community involvement in the selection process.
4. Institute an inter-departmental coordination team to include the LHW and the MNCH
programs as well as development partners. This team would provide oversight for improved
recruitment, training and monitoring of CMWs.
5. Introduce an accelerated process for midwifery registration with the PNC.
6. Determine which incentives are feasible for CMW retention, including incentives for DoH
personnel conducting supportive monitoring and supervision.
7. Ensure that the federal government transfers the entire allocated budget for the MNCH
program to the provincial program in a timely manner.
Promoting financial self-sustainability for CMWs: Finding ways to help the CMWs become
financially self-sustaining as private health care providers was an important IR1 component; this
included providing standard equipment to the CMWs and developing a business training course for
them. Both initiatives were very much appreciated by the CMWs and the business training course
was a project activity recommended for replication by a number of respondents who participated in
the qualitative research.
October 2016 12
The FSA highlighted some of the constraints that hinder the CMWs’ financial sustainability:
• Competition, even in rural areas, from other providers such as traditional birth attendants
(TBAs)
• People’s inability to pay coupled with the perception that the CMW is a salaried employee
and should not charge fees
• Sometimes there is a relatively low demand due to the size of the catchment area
• Problematic transportation, limiting access to clients
• Lack of understanding of entrepreneurship, even among those CMWs who participated in
the project-sponsored business skills training course
Given the importance of this component for long-term sustainability of the CMW program, the
DoH and Mercy Corps included a second sub-study in the Learning Agenda to address the question:
How can CMWs become financially self-sustaining while serving the needs of the poorest of the poor? The
expenditure and investment assessment conducted as part of this sub-study showed that the
monthly salary for the CMWs participating in the study (both SMNC-supported and other CMWs)
ranged from a low of Pakistani rupees (PKR) 1000 to a high of 10,000. Among the SMNC-
supported CMWs, forty percent earned from PKR 1000 – 3000, well below the standard minimum
wage of PKR 13,000.
Although the project did not actually demonstrate how CMWs can achieve financial sustainability,
there were achievements for this component nonetheless that the DoH and its partners can build
on. For example, the Learning Agenda report highlighted the importance of the monthly stipend of
PKR 5,000 that CMWs receive from the DoH for two years following deployment. The report also
provided two major recommendations on financial sustainability:
1. Program support from the MNCH program is needed to provide supervision, stipends and
other support to CMWs for at least five years post-deployment.
2. Integrate training on business skills into the pre-service training curriculum for all CMWs.
The Learning Agenda report makes a compelling case for eventually integrating the CMWs into the
health system in the same way that LHWs became salaried employees. This was also a strong
recommendation made by a number of stakeholders (CMWs, project staff, two of the three DHOs
and DoH administrators) interviewed during the qualitative research. Recognizing that the long-term
success of the CMW program rests largely on the ability of CMWs to earn a decent wage, there is
heightened interest in exploring the possibility of integrating them into the DoH system in
Balochistan; this topic was a major point of interest at the recent Donor Conference organized by
the GoB to discuss the new Balochistan MNCH Strategy 2016-20. A provincial-level committee has
been formed and includes Mercy Corps’ Team Leader for the South, providing another opportunity
for the DoH and Mercy Corps to work together on this issue.
Enhancing quality of care through a clinical skills refresher course: This four-week course was
one of the biggest successes of the project. According to those interviewed during the qualitative
research, it clearly improved the quality of care the CMWs offer and bolstered their confidence in
their skills. The PNC has endorsed the course and it is slated to become standard throughout
Pakistan, a lasting contribution from the project.
Improving reporting and tracking of client data through mHealth: Mercy Corps, in
conjunction with its technology partner PakVista Technologies and the DoH, developed a mobile
October 2016 13
phone application for CMWs to use for reporting, including acquisition, storage and processing of
client records. The introduction of this mHealth application for streamlining data collection
was one of the most successful and appreciated project components, mentioned consistently
during the qualitative research by CMWs, their supervisors and the provincial and district health
administrators. FGD participants and key informants noted that the use of mobile phones for
collecting client data and preparing reports was particularly appropriate for CMWs in Balochistan as
distances to district offices and limited transportation options were obstacles to delivering written
reports in a timely fashion. Data transmission via mobile phones allowed for real time record
keeping.
The qualitative research findings from the FSA respondents – that mobile phone technology has
streamlined CMW reporting – mirror the findings in the Learning Agenda report. However, the
DoH respondents noted that this innovation will only be useful in the long run if it is integrated into
the MNCH MIS. A typical comment comes from the Kech District PHS: “I really appreciate the
mHealth intervention for registering cases and increasing the validity of the findings in real time but it has to be
integrated with our MNCH database.” (Note: This integration is planned for the extension phase, which
goes through March 2017.)
During the KIIs, DoH managers at both the district and provincial level consistently cited the use of
mobile phones for reporting when asked about project successes and which interventions showed
potential for scaling up. This interest in scaling up is echoed in the Learning Agenda report and in a
comment from PakVista Technologies: “In the long term, the provincial health department is clear on moving
towards a mobile-based system as they can see the process improvements in the three districts covered in the pilot
program.”
Responding to this interest, Mercy Corps contracted with PakVista Technologies to prepare
additional assessments. The September 2016 mHealth Assessment Final Report went into detail on the
possibilities for integration of the technology with the MNCH Program’s Management Information
system (MIS), covering technical and financial implications of several different options. The project
has laid a solid foundation for reporting through mobile technology and documented the
various options for the DoH to consider; given the DoH’s positive reaction, the potential for
eventually scaling up this initiative throughout the province is high. Further steps are on hold for
now: the DoH decided to discontinue its existing MNCH Program MIS and has contracted with a
local firm to develop a new, more comprehensive MIS.
PakVista and the project staff thoroughly documented the mHealth component at key points,
describing lessons learned, obstacles encountered and subsequent actions taken; this documentation
illustrated that the SMNC project is a learning project and provided a good example of how a
component was introduced, tested, evaluated and adapted.
Providing supportive monitoring and supervision: The project also invested resources in
monitoring and supervision, another component designed to improve quality of care. Resources
included transportation; incentives for the LHSs who provided administrative monitoring and for
the LHVs who ensured technical supervision; and project staff time for visits to CMWs, including
joint visits with DoH personnel. In addition to helping CMWs improve their skills, this monitoring
and supervision also provided much-needed moral support for the CMWs. Health administrators
observed that the project’s initiative to provide regular monitoring and supervision also improved
coordination between the LHWs and the CMWs at the community level.
Introducing a voucher scheme: To provide financial assistance for women too poor to pay for
CMW services, the project introduced a voucher scheme in 2016. Since this component is relatively
October 2016 14
new, a project-wide assessment was not available and few FGD and KII respondents were familiar
with this activity. Those who did know about it expressed concern that the eligibility criteria were
not always respected and that improvements needed to be made to ensure that the vouchers actually
reached those most in need. A strong assessment and verification system has been put in place to
verify beneficiary eligibility and satisfaction with services provided by the CMW. A September 2016
monitoring visit to Kech indicated that the five randomly-selected voucher beneficiaries were
eligible; the beneficiairies also declared that they were satisfied with the quality of care provided.
However, with an extension phase of only six months, it seems doubtful that the project will be able
to thoroughly test this mechanism. Nevertheless, if the project staff documents the activity well, it
will provide additional evidence for the government, which is interested in an improved voucher
scheme.
IR2. Improved knowledge and demand for essential maternal and newborn care
The project registered only moderate success with this Intermediate Result: the uptake of the
CMWs’ services indicates that demand was increased and the Learning Agenda report states that the
project-supported CMWs were conducting “significantly more deliveries” compared to CMWs in
non-intervention areas. However, since there was no final measurement of “improved knowledge”,
assessing the success of this IR also required examining the two approaches used.
Re-invigorating Women Support Groups: WSGs already existed in many of the project
communities. With the help of the TWG, the project refined three modules focusing on maternal
and child health and retrained the Lead Mothers, LHWs and Community Educators. During the
FGDs with CMWs, the participants mentioned that the WSGs had been very helpful in introducing
them to the community, generating demand for their services and carrying out health promotion
activities. However, the consensus from CMWs and LHWs seemed to be that the groups were no
longer meeting regularly and that incentives for the Lead Mothers were needed to encourage them
to continue their activities.
Using mHealth for health promotion: Also included as part of the mHealth component of the
project was the dissemination of Voice Over Internet Protocol (VOIP) messages to clients. This
included 12 behavior change messages for improved maternal and child health and automatic
appointment reminders through SMS. In spite of the messages being available in four languages and
tailored to the CMWs’ clients, this activity was not as successful as the use of mHealth for data
collection. In Year 3 for example, only eight percent of the CMW clients registered for this service
and of that small number, only 17 percent actually answered the calls to receive the messages. The
following table prepared by PakVista Technologies for a May 2016 report provides an indication of
the slow uptake of messages:
Quetta Kech Gwadar TOTAL
Total SMS 571 341 140 1,052

Total voice calls
2,146 1,356 540 4,042
generated
Confirmed/accepted
84 24 7 115
voice calls
Some of the reasons proposed for the low uptake on messages included the following: clients were
reluctant to provide their phone numbers; not all women had access to the phone on a regular basis;
October 2016 15
and since there was no caller name displayed, incoming messages were often ignored. In the end,
this mHealth activity was discontinued in April 2016.
IR3. Improved access to emergency transport in remote communities
Compared to the other three IRs, the SMNC project made the least amount of progress on this IR
due largely to circumstances beyond the project’s control. As of September 2016 the two
components – improving emergency transportation and strengthening the referral system – had met
with only limited success.
Improving emergency transportation for timely referrals: In Balochistan a major obstacle to
obtaining advanced medical care is the lack of accessible transportation to a secondary facility. To
address this obstacle, the project undertook two activities. First, the CMWs were encouraged to
work within their communities to identify drivers who could be hired to transport women to a
secondary facility and to publicize the name(s) and contact information. Second, the project
established Memorandums of Understanding with two private, not-for-profit ambulance companies,
Edhi Foundation in Quetta and Gwadar Districts and Al-Falah in Kech District. Routine monitoring
data from Years 3 and 4 indicate that on average 20-50 percent of those referred use the CMW-
linked drivers. The ambulance services are less frequently used due to how far away the ambulances
are stationed. In Year 4, for example, only 7 out of 1,056 referrals used them. While these were
positive steps, most respondents in the FGDs and KIIs noted that it is usually the family that
arranges transportation through its own means.
Reinforcing the referral mechanism between CMWs and secondary health facilities: In July
2016 the project conducted referral mechanism workshops in all three districts. DoH participants
included relevant staff (gynecologists, hospital Medical Superintendent, transport heads, labor room
managers and pediatricians). The not-for-profit ambulance service providers also participated. The
workshop participants drew up a list of suggestions, which were presented to the TWG for
discussion. The TWG recommendations are on the agenda for the October 2016 PSC meeting.
Although these steps are promising, it is unlikely that a viable, sustainable referral system will be fully
developed by the end of the project (March 2017). While the orientations and recommendations are
a good first step and may provide a point of departure for the DoH, establishing a permanent
referral system will require additional resources (especially adequate staff), reliable transportation and
sustained oversight by senior managers, systemic issues within the DoH that are beyond the
project’s capacity to address in the time remaining.
IR4. Improved policy environment for improved maternal, newborn and child healthcare
This IR, like IR1, was quite successful and there are strong indications that the achievements will
continue to positively influence the policy environment in the future. According to those
interviewed for the FSA, both of the components for improving the policy environment – the
establishment of forums and the development of a provincial five-year MNCH strategy – resulted in
long-lasting policy changes and a renewed commitment to CMWs.
Establishing forums at the provincial and district levels: One of the most well-regarded project
initiatives was the establishment of two provincial level forums, the Technical Working Group
(TWG) and the Provincial Steering Committee (PSC). The TWG met frequently and provided
guidance to the SMNC project and three other health initiatives. The members made
recommendations to the PSC and if the PSC agreed with the recommendations, they were passed on
to the DoH for action. Both forums have been institutionalized, receiving official government
approbation.
October 2016 16
Everyone interviewed about these two forums was highly complimentary and pointed out ways the
forum members had facilitated project implementation and made permanent improvements in
policies and procedures for the health sector. Concrete examples they cited include:
• Provided support on the mHealth design for reporting and made suggestions on how it can
be integrated with the MNCH Program MIS
• Played a vital role in designing the five-year Balochistan MNCH Strategy, including the
development of a communication strategy and a strong CMW component
• Advocated successfully for the establishment of CMW work stations, allowing CMWs to
provide services in their homes
• Successfully lobbied for an increase in the CMW stipend from PKR 2,000 to PKR 5,000 to
promote sustainability and retention and lobbied successfully for the value of the voucher to
be increased
• Successfully lobbied for the inclusion of chlorhexidine and misoprostol in the Essentials
Drug List
• Assisted with the development of training materials and IEC brochures for the WSGs ,
including translations into local languages
As for the district health forums (DHFs), whether they were successful or not seemed to depend to
a great extent on the leadership of the DHO. In one district, the DHO stated that he was too busy
to attend the DHF meetings. This was in stark contrast to another district where the DHO
organizes monthly meetings with his team (e.g., the Public Health Specialist for MNCH, the Medical
Supervisor for the hospital and the District Coordinator for the LHW program). The team members
interviewed all mentioned how useful these meetings were for discussing policies, solving problems
and improving coordination.
Developing and costing a MNCH strategy: A high priority for the DoH was to develop a five-
year provincial MNCH strategy for the 2016-2020 period and the project provided invaluable
assistance in helping the DoH achieve this milestone. Stakeholders characterized the process as
highly participatory, stating that it “involved all relevant stakeholders, especially the TWG” (KII
with forum members). The GoB approved the strategy and organized a donor conference on
September 28, 2016 to present the strategy and solicit resources. According to Mercy Corps staff,
the conference was well-attended by 10-12 donors and the strategy was well-received. The GoB is
reviewing its current budget to see what components of the strategy the provincial government can
fund and what activities donors may be interested in supporting.
Increasing Access to Quality Care
Achievements for each Intermediate Result, especially IR1 and IR4, demonstrate that the project
made significant progress toward improving access to quality health care for women and children.
The findings from the FSA provide a definite YES to an important question in the ToR: Do CMWs
offer quality care? The evidence from a number of sources used for the FSA – project reports, the
Learning Agenda report and the qualitative research – shows that the CMWs supported by the
SMNC project provide quality care and that their clients appreciate not only their technical
competence but also their interpersonal skills. Four sources of evidence are summarized below.
First, the project Performance Monitoring Indicator Table included approximately 15 quality of care
indicators covering the spectrum of maternal and newborn care from antenatal to postnatal services.
October 2016 17
CMWs recorded activities in their registers and brought a summary to the monthly meetings. During
monitoring visits supervisors would select a number of CMW registers to verify the quality of care
data. According to the registers, the CMWs routinely provided 90-100 percent of the actions
that comprise quality care. A notable exception was that the majority of their clients did not
complete at least four ANC visits. However, this indicator depends on factors beyond the capacity
of a CMW herself to control.
A second verification of quality care reflected in project monitoring reports was provided by the
LHVs who conducted the technical supervision of the CMWs using a standardized checklist. One of
the project indicators is “Proportion of CMWs who scored at least 80% on the Technical
Supervisory Checklist”, which indicates that the standards for quality care are met. The last Annual
Report (October 2014 – September 2015) showed that in the final quarter of Year 3 a total of 77
CMWs were supervised and all scored at least 80 percent. The data available for the period October
2015 through June 2016 corroborates this positive outcome as all of the CMWs supervised during
this nine-month period scored at least 80 percent.
A third source of information showing that CMWs provide quality care is provided in the Learning
Agenda report, which devoted one of the four sub-studies to exploring the issue of quality of care.
One of the sub-study methods used was to have independent LHVs observe the CMWs – both
project-supported and other CMWs – as they provided services to clients. The following table shows
how many CMWs were observed for each category of services:
Practices Project-Supported CMWs (N=50) Other CMWs (N=79)

Antenatal care 30 64
Natal care 37 62
Postnatal care 31 65
General care 48 76
According to the report, the CMWs supported by the project scored significantly higher with
96.6% providing services with “high competency” compared to 34.5% of CMWs from non-
project areas.
The Learning Agenda sub-study also measured client satisfaction, asking clients if the CMWs were
“acceptable health care providers at the community level”. Although both groups of CMWs were
rated positively by the clients, those from project areas had a higher level of acceptability, due
perhaps to the fact that they had more equipment, supplies and facilities for receiving clients. For
both groups, clients commented that they appreciated the CMWs not only for their technical skills
but also because they were always available, treated them with dignity and took a personal interest in
them.
The qualitative research conducted during the FSA provided a fourth source of information on
quality of care and client satisfaction. This information corroborated the findings in the Learning
Agenda report. FGD participants and key informants were all asked to rate the care provided by the
CMWs and the vast majority of respondents (CMWs’ clients, supervisors and other stakeholders)
rated the quality of services from Satisfactory to Excellent. In addition, women who had accessed
services from the project-supported CMWs were asked to comment on their interactions. Clients
October 2016 18
gave high marks to the CMWs and noted the personal touch and approachability of the CMWs,
mirroring the Learning Agenda results for this topic.
STATUS OF THE MIDCOURSE CORRECTIONS
The majority of the proposed actions described in the Case for Midcourse Corrections have been
completed. The following table summarizes the status of each major action.
Action Status Observations
Finalize the five-year Balochistan The strategy was finalized, costed and shared at a
Completed
MNCH strategy donor conference held in September 2016.
mHealth application: Transition the The DoH is in the process of revising its MNCH
server to the DoH and fully synchronize MIS. The plan is for the server to be housed in the
In progress
the application with the revised MNCH DoH by the end of the extension period (March
MIS. 2017).
Recruit, deploy and support 10 The new CMWs began providing services as of
Completed
additional CMWs in rural areas. December 2015.
The pilot began only in 2016 and will be
Pilot the use of vouchers to reach the
In progress documented and evaluated during the six-month
poorest women.
extension period.
Orient DoH staff and CMWs on a The project organized referral mechanism
referral mechanism between CMWs Completed orientation workshops in all three project districts
and secondary health facilities. in July 2016.
Although mentioned in the Case for Midcourse
Corrections, this action is beyond the project’s
Starting July 2015 the DoH will provide
control; ultimately it will depend on whether the
monthly stipends of PKR 10,000 to all Not done
MNCH department allocates resources. However,
CMWs.
the stipends have been increased from PKR 2,000
to PKR 5,000.
Carry out four sub-studies through the
A detailed final report with findings and
Learning Agenda to provide information
Completed recommendations is available and the project staff
for the DoH to improve policies and
is in the process of disseminating it.
procedures for the CMW program.
KEY STRATEGIES AND FACTORS AFFECTING RESULTS
What were the key strategies and factors, including management issues and policy environment,
that contributed to what worked or did not work?
One of the most important factors underlying the project’s achievements was the close working
relationship between the GoB, represented primarily by the DoH, and Mercy Corps. Project
documents, including periodic reports, illustrate the
degree to which the DoH was involved not only in the “The provincial forums have
design of the project but in every important decision played a pivotal role in directing
made during implementation, including the midcourse and suggesting objectives and
strategies at the conception of the
corrections, the different interventions selected for project and throughout its
testing and the themes for the Learning Agenda. It was implementation. They will remain
also evident in the KIIs conducted for the FSA that very useful to provide direction
the two parties worked well together. Informants and further refinement of
included SMNC project staff, senior program interventions and we will continue
managers from Mercy Corps, key DoH personnel at to support them." (Balochistan
DG/Health Services during a KII.)
October 2016 19
the district and provincial level and members of the PSC and TWG. In their remarks they gave the
same impression – that Mercy Corps was a responsive partner, testing approaches and interventions
to provide evidence for decision-making on the part of the government and facilitating activities
(such as the development of the Balochistan MNCH Strategy 2016-20) that were high priorities for
the DoH. The three members of the PSC and TWG, for example, attributed project success to
“…excellent coordination with government and strong working relationships with stakeholders”.
According to Mercy Corps staff and DoH interviewees, the active engagement of the two policy
forums was the most important factor ensuring a close partnership with the DoH; both forums
made significant contributions to project achievements and positively influenced policies and
procedures for current and future programming. Forum members include senior government
officials, key decision-makers in the DoH, Mercy Corps senior managers and other health sector
stakeholders such as the WHO representative for the province. Given their technical expertise, their
status and their knowledge of the context, they were able to facilitate project implementation and
advocate for changes that will have a lasting impact on the CMW program in Balochistan.
This effective partnership was likely strengthened by the fact that Mercy Corps has worked in the
health sector in Balochistan since 1986 and that there was little turnover in the senior Mercy Corps
personnel involved in managing and backstopping SMNC during its four years of implementation.
The fact that the key technical person for the project (Project Officer) was a government official on
loan to the project may also have been a contributing factor in building a strong partnership and
facilitating implementation.
Another factor contributing to the project’s success was that the SMNC design was multi-faceted
and took into account almost all the aspects that are critical to ensuring that the CMWs can provide
quality services. Project components addressed recruitment, deployment, financial sustainability,
quality of care, supportive supervision, community support, referrals and creating demand for CMW
services. Although not all components achieved their targets, all needed to be included for achieving
the objective of demonstrating a workable model.
Contextual Factors Affecting Implementation and Outcomes
A number of contextual factors affected project implementation and outcomes, including
characteristics of the health system in Balochistan Province. Ineffective human resources
management of DoH personnel negatively affected certain aspects of the project. Posts not filled
and a high rate of absenteeism, especially at the district level, sometimes hindered implementation.
This was especially true for midwifery schools which often lacked staff. Conversely, there were also
good examples where a dedicated individual with strong leadership qualities (e.g., the DHO for
Kech) embraced the CMW program and ensured that his entire team supported the CMWs, stating
that “We own and respect them as they share our burden.”
Along the same lines, a lack of government financial resources for items such as vehicles and
incentives for monitoring CMWs also negatively affected some outcomes and will likely also affect
sustainability. For example, Mercy Corps provided many of the resources, including transportation
and funds, for the LHVs to conduct CMW supervision. Without adequate resources, this support
for CMWs will not continue.
Demographics also influenced project implementation. Balochistan Province has approximately 44
percent of the country’s land but only 5-6 percent of the population. As a result, there are over
25,000 widely-scattered settlements, most of which have a relatively small population size. The lack
of transportation and difficult terrain hinders mobility in the rural areas both for the CMWs and for
October 2016 20
their clients. The mobility limitations and the relatively small catchment area for most rural CMWs
can mean that they may not have enough clients to make a living wage. On the positive side, these
same characteristics of the three districts also highlight the value of a program where CMWs live in
the community and can provide immediate and affordable quality services to people who cannot
easily access other health care options.
The nature of the patriarchal society in the project area sometimes imposed constraints on
women, especially their mobility. For example, women may require a male family member to escort
them to a meeting or a training. Families may also be unwilling for their female family members to
live in a hostel for an extended period to participate in training. As the Quetta CMWs expressed it
during their FGD: “The strong patriarchal mindset of the Balochistan culture discourages females working
independently and being mobile.”
Participants in the FGDs and KIIs cited a number of other factors that presented challenges for
project implementation. Illustrative examples include:
• Low literacy rate among rural girls and women means a limited pool of candidates for
CMW training.
• A lack of coordination between the MNCH program and the LHW program can
result in a fragmented approach to maternal and newborn care. This situation can result in
conflict between LHWs and CMWs in the same catchment area and negatively impacts the
level of support the CMWs need to feel valued and to deliver quality services.
• Poverty levels were such that not everyone is able or willing to pay for CMW services. Low
household income levels can also foster competition between LHWs, TBAs and CMWs, all
of whom are vying to bring earnings home.
• According to the CMWs in the FGDs for all three districts, some families do not consider
midwives to have the same status as a profession as being a teacher and/or consider it an
inappropriate vocation for an unmarried woman, limiting further the pool of prospective
CMW candidates.
• During the first two years of the project, security concerns preoccupied managers, leading
to a series of measures to prevent and mitigate security-related incidents. While the situation
has much improved, a number of those measures are still in place. Mercy Corps staff, for
example, cannot travel by road between the three districts and periodically call on local
government counterparts in Kech District to monitor eight CMWs because security issues
prevent Mercy Corps staff from visiting them.
Capacity Building
Capacity-building was another strategy to reinforce the potential for sustainability. The most
important contribution was reinforcing the technical skills and building the entrepreneurship
capacities of the 95 CMWs. Not only were capacities for this group strengthened but the courses
developed through the project have received official approval and will be adopted in future CMW
trainings in Balochistan and potentially throughout Pakistan. It should be noted, however, that
continuing technical skills education for CMWs is essential if they are to maintain their skills. It
would also be useful to provide refresher training on business skills since many of the concepts were
new and these skills are essential for financial self-sustainability.
October 2016 21
The project-supported CMWs were not the only groups to benefit from capacity-building. Other
examples include:
• The DoH gained valuable experience in crafting and costing a five-year MNCH strategy.
• The LHWs, Community Educators and Lead Mothers benefitted from capacity building in
health promotion techniques.
• At the provincial level, DoH technicians and managers as well as their colleagues from other
departments and organizations gained practical experience in advocacy and influencing
policy through their participation in the TWG and the PSC.
SUSTAINABILITY AND POTENTIAL FOR SCALING UP
Which elements of the project have been or are likely to be sustained or expanded (e.g., through
institutionalization or policies)?
The table below summarizes the potential for sustainability for key project elements; the assessment
is based primarily on the qualitative research and the desk review and presents the potential for
sustainability as of September 2016.
Project Element Potential for Observations
Sustainability,
Scaling Up
Four-week clinical refresher course Achieved PNC approval for scaling up.
Approved for incorporation into standard midwifery

Business skills course Achieved
training course.
Policy approved to allow CMWs to provide services
Work stations Achieved
from their own work stations, usually in own home.
Strategy developed, costed and approved. Resources
Balochistan MNCH Strategy High
required for implementation.
mHealth application for streamlined DoH committed to adapting application to their
High
reporting and client data retention system.
Have been institutionalized; keen interest in
Provincial forums (TWG, PSC) High
sustaining.
District health forums Medium Sustainability likely to depend on each DHO.
Regular monitoring and supervision Will depend on political will of GoB, DoH and
Low to medium
for CMWs by LHVs and LHSs resources.
Is a greater awareness of options, especially local
Emergency transportation system
Low to medium drivers, but obstacles remain for establishing a
established
reliable, affordable system.
Will require resources and commitment beyond
Improved referral system Low to medium project’s capacity, including improved management of
government ambulances.
WSGs continue health promotion,
Low May occur on individual Lead Mother level.
including periodic meetings
Too little time to adequately test a model; may result
Voucher scheme Low
in useful lessons learned for DoH to follow up on
October 2016 22
CONCLUSIONS AND RECOMMENDATIONS
The information collected during this FSA provided a resounding “YES” to one of the questions
Working around strengthening community-based maternal and newborn healthcare provision, to what
extent has the project been successful?
posed in the ToR: “Is the community midwife a suitable solution for contributing to reductions in maternal and
newborn mortality considering the quality of care of her services and in-line with cultural and economic constraints?”
The SMNC project convincingly demonstrated that with appropriate selection, training and
continued support, the CMW can acquire the necessary skills, confidence and community
status to be a lifesaving provider of MNCH services, “I would definitely recommend the
especially in rural areas with widely-scattered model to be replicated in other
populations where few if any other health services exist. districts of Balochistan, particularly
This was the unanimous sentiment expressed during the the ones which are the most remote.
qualitative research and is substantiated by the secondary We have included the deployment of
CMWs in our new five-year MNCH
data sources such as the recently-developed Balochistan
strategy and the DoH is committed
MNCH Strategy. The Strategy contains numerous to supporting them. We are having a
references to the DoH’s commitment to improve the donor conference next week
province-wide CMW program by incorporating [September 28, 2016] and will
successful components of the SMNC project such as the highlight this issue.” (Balochistan
clinical skills refresher course, the business training and DG/Health Services during a KII.)
the mHealth application.
The project achieved its main objectives: it increased access to quality maternal and neonatal health
services for families in underserved areas and it provided tested CMW program interventions for
replication throughout Balochistan. In doing so, it left lasting achievements such as:
• 95 midwives trained and equipped, the majority of whom continue to provide essential
services to women with few other options for skilled birth attendance
• A clinical skills refresher training course endorsed by the PNC, to be incorporated into all
midwifery training schools in Balochistan and eventually in Pakistan
• A business skills course to be included in the 18-month midwifery training
• Increased demand for MNCH services at the community level
• A three-module set of materials for WSGs, available in four languages
• Two institutionalized provincial policy platforms, the TWG and the PSC
• A new approved and costed five-year MNCH strategy for Balochistan with a major
component for CMWs
• An mHealth application for improved data collection and reporting ready to be integrated
with the DoH system
Perhaps one of the most useful contributions moving forward will be the Learning Agenda report.
The use of qualitative and quantitative methods for the research and the fact that the activity
compared SMNC-supported CMWs to CMWs in non-project areas result in a body of evidence that
provides convincing reasons how interventions such as those piloted by SMNC can strengthen a
CMW program. The findings documented through the four sub-studies, especially the studies on
October 2016 23
CMW recruitment and retention and on options for financial self-sufficiency, and the extensive set
of recommendations should promote continued dialogue and action for enhancing the CMW
program not only in Balochistan but in other underserved areas where access to skilled birth
attendance is limited.
That the project has been able to achieve this in only four years is a testament to the DoH’s
commitment, the strong partnership between Mercy Corps and the Government of Balochistan and
a sound project design that addressed high priorities for the stakeholders.
Challenges
While the successes are evident, challenges remain. The following list of major challenges comes
primarily from KII interviews with DoH stakeholders at the provincial and district levels:
1. Identifying enough qualified and interested women from rural areas who meet the minimum
requirements to become a CMW
2. Improving linkages between the MNCH program and the CMW program
3. Creating more harmonious working relationships between TBAs, CMWs and LHWs
4. Providing adequate support through regular supportive supervision
5. Ensuring that the CMWs have sufficient monetary incentives to continue providing services
6. Improving the referral mechanism between CMWs and secondary facilities
7. Establishing a reliable transportation system for referrals
8. Overcoming budgetary constraints within the GoB
To sum up the overarching challenge, one of the provincial senior managers stated: “It will be difficult
to sustain this model without political commitment, government ownership and adequate resource allocation.”
RECOMMENDATIONS
If the following recommendations are carried out, the potential for improving the Balochistan CMW
program will be increased and the lessons learned from the close collaboration between the GoB
and Mercy Corps will contribute to sustaining and scaling up SMNC achievements.
Learning Agenda Follow-up
1. Prepare a briefing paper that summarizes the main findings and recommendations from the
Learning Agenda; ensure wide-spread dissemination and follow-up conferences and working
commissions for key recommendations, especially those concerning i) improved selection,
deployment and retention and ii) adequate remuneration and incentives for CMWs. (DoH,
Mercy Corps)
Support for CMWs
2. Create a more collaborative and harmonious working relationship between CMWs and
LHWs. Methods could include regular meetings, joint community initiatives and strong
leadership and team building from senior DoH managers and community leaders. (DoH –
PHS and MNCH Coordinators at the district level)
3. Reinforce orientations for family members of CMWs and for their communities to create
sustained support for the CMWs. Examples could include i) community elders such as
October 2016 24
religious leaders exchanging experiences for creating a supportive environment for CMWs
and ii) calling on WSGs where they are active. The Quetta CMWs, for example, credited the
WSGs with paving the way for them to provide services. (MNCH District Coordinators,
District PHS, LHWs, community leaders, active WSG)
4. Consider integrating CMWs into the DoH to ensure adequate financial compensation,
supervision and support. (DoH)
5. Investigate creative options for accommodating married women with young children who
qualify for CMW training. (DoH)
Ensuring CMWs Provide Quality Care
6. Commit resources to continue supportive monitoring and supervision of CMWs. (GoB and
partners) 1
7. Conduct refresher training for LHSs on how to provide effective administrative supervision
and on-the-job mentoring for CMWs. (DoH)
8. Invest in regular refresher training on technical themes and business skills for CMWs. This
could include on-the-job training and mentoring during routine monitoring and supervision.
(DoH)
9. Make quality staffing of midwifery schools a priority. (DoH)
Sustaining and Scaling Up SMNC Achievements
10. Continue with the plan to integrate the mHealth application into the MNCH MIS. (DoH,
Mercy Corps)
11. Disseminate the voice messages in four languages developed under SMNC. CMWs and
LHWs can use these messages for health promotion and demand generation. (DoH)
12. Continue the policy forums (Provincial Steering Committee and Technical Working Group),
especially for overseeing the implementation of the Balochistan MNCH Strategy 2016-20.
(DoH and partners)
13. Document the voucher scheme activity at the end of the extension period and share findings
with DoH colleagues. (Mercy Corps)
14. Mobilize resources and partners for the implementation of the Balochistan MNCH Strategy
2016-20. (DoH)
15. Longer term: Consider integrating the MCH, MNCH and LHW programs. This would
enhance coordination within the DoH and contribute to improved supervision and support
for CMWs. (DoH)
Dissemination of FSA Findings
16. Consider publishing the FSA findings in the Global Health: Science and Practice Journal. (Mercy
Corps with the DoH)
1
The Balochistan MNCH Strategy 2016-20 and MNCH PC-1 provide clear methodology for supportive monitoring
and supervision of CMWs complemented by tools for monitoring and supervision in the CMWs Deployment
Guidelines. According to the methodology, the LHV from the nearest health facility is responsible for technical
supervision while the LHS is responsible for administrative supervision of CMWs.
October 2016 25
U.S. Agency for International Development
1300 Pennsylvania Avenue NW
Washington, DC 20523
October 2016
ANNEX I. FOCUSED STRATEGIC ASSESSMENT TERMS OF REFERENCE
Terms of Reference for

External Consultant for the Focused Strategic Assessment of the
Saving Mother and Newborns in Communities Project
in districts Quetta, Kech and Gwadar, Province of Balochistan, Pakistan
August 5, 2016
I. Introduction
Mercy Corps will hire an independent international consultant to lead a Focused Strategic
Assessment (FSA) for the Saving Mother and Newborns in Communities (SMNC) project
funded by USAID’s Child Survival and Health Grants Program (CSHGP), COOPERATIVE
AGREEMENT NUMBER USAID CA No. AID-OAA-A-12-00093, dated September 30, 2012,
of US$ 2,322,520 ($1,741,836 USAID contribution) in Quetta, Kech and Gwadar Provinces of
Balochistan Pakistan. As it currently not possible to obtain a visa for foreign nationals, the lead
consultant will remotely lead the FSA, working closely with an external national consultant
identified by Mercy Corps. USAID’s CSHGP supports community-oriented projects
implemented by U.S. private voluntary organizations (PVOs) and nongovernmental
organizations (NGOs) and their local partners. The purpose of this program is to contribute to
sustained improvements in child survival and health outcomes by supporting the innovations of
PVOs/NGOs and their in-country partners in reaching vulnerable populations.
This document describes the FSA international consultant’s Scope of Work (SOW) for the
Saving Mother and Newborns in Communities FSA.
II. Background
Mercy Corps is implementing a four-year maternal, newborn and child health (MNCH) Program
in Quetta, Gwadar, and Kech Districts of Balochistan, Pakistan with support from USAID
CSHGP and the Scottish Government. To address Pakistan’s sustained high rates of maternal and
neonatal mortality and to ensure skilled birth attendance, the Government of Pakistan (GOP) and
the provincial Department of Health (DoH) have given top priority to reach out to pregnant
mothers in remote communities by training a cadre of community midwives (CMW). However,
training alone has not been sufficient as most of the CMWs have not been able to establish their
clinics and attract clients.
Saving Mothers and Newborns in Communities (SMNC) seeks to improve maternal and
newborn health status, especially for poor and marginalized women of Balochistan (Goal),
through increased use of quality essential maternal and newborn care, through private-sector
October 2016
community midwives (Strategic Objective).
The project’s intermediate Results are:

4. Improved policy environment for improved maternal, newborn and child healthcare
based on evidence from the Operations Research
SMNC is an innovative model that was designed to enable CMWs to become self-sustaining,
private MNCH service providers. The program was designed jointly with the Balochistan DoH,
upon their request, to offer evidence for how to scale up high impact MNCH interventions in
Balochistan through the CMW. The model has been tested with 95 CMWs in Quetta, Gwadar,
and Kech districts of Balochistan. The project contains the following main components:
1. To ensure quality, Mercy Corps has provided CMWs with clinical refresher training,
supported CMW registration with the Pakistan Nursing Council (PNC) for those who
were not already registered, and conducted joint supervision visits with the DoH.
2. To enable CMWs to set up home-based clinics, Mercy Corps has provided standard
equipment and business skills training for the CMWs.
3. Through Mercy Corps’ partnership with Pak Vista Shared Technologies, CMWs have
been using their mobile phones to track patient data, send automatic reminders to clients,
and offer mass SMS’ for awareness raising. Through automatic data transfer, the DoH is
now able to track uptake of CMWs’ services in real time.
4. For behavior change and demand creation, Mercy Corps reinvigorated the Women
Support Groups conducted by CMWs and Lady Health Workers. These groups also
generate support to facilitate access to emergency transport.
5. For timely referrals, Women Support Groups and CMWs have been linked with not-for-
profit ambulance services.
6. At the policy level, Mercy Corps has assisted the provincial DoH in developing a five-
year strategic MNCH plan. The plan will be revised and updated based on findings from
the Learning Agenda which is exploring whether CMWs can become self-sustaining
private providers, while increasing access and utilization of high impact, quality MNCH
interventions.
7. To support the DoH in operationalizing their plans to address the needs of poorest of the
poor women in accessing maternal and newborn health services, a voucher scheme has
been introduced in the project.
8. Mercy Corps has also prepared and oriented DoH staff on a referral mechanism between
CMWs and secondary health facilities, which is not fully functional at the moment.
Through funding from USAID’s CSHGP and the Scottish Government, SMNC and its partners
will become key players within a global community of researchers supported by USAID seeking
to identify innovative solutions to scale up high impact MNCH interventions.
October 2016
III. Project Population
Beneficiaries* Total
Total Population 2,689,838
Total Neonates 11,093
Infants aged 0–11 Months 13,388
Children aged <5 Years 65,028
Women of Reproductive Age (15–49 years) 84,153
Total Beneficiaries 382,515
Expected Pregnancies 13,006
Community Health Workers or Volunteers (CHWs), Disaggregated by Sex 95 CMWs, 272
LHWs/CEs (Female)
Health Facilities (Hospital to Sub Health Post) N/A
Community-Based Structures (e.g., Village Development Committees [VDCs]) 272 Lead Mothers
Groups
*Source: * As per guidelines of National MNCH Program and provincial DOH estimates
IV. Partners
Department of Health, Government of Balochistan
V. Key Activities
Intermediate Result 1: Increased availability of quality maternal and newborn care in
communities
1.1 Selection and registration of Community Midwives (CMWs)
1.2 CMW refresher training
1.3 Financial and structural support to CMWs
1.4 CMW deployment
1.5 Supervision of CMWs in the field
1.6 Development of mobile phone application for CMWs to track clients, send reminders and
BCC messages
Intermediate Result 2: Improved knowledge and demand for essential maternal and
newborn care
2.1 Mobile phone mass SMS
2.2 Formation of Women Support Groups
Intermediate Result 3: Improved access to emergency transport in remote communities
3.1 Emergency Transport Services
Intermediate Result 4: Improved policy environment for improved maternal, newborn and
child healthcare based on evidence from the Operations Research
October 2016
4.1 Provincial MNCH Steering Committee formation and quarterly meetings
4.2 Provincial Technical Working Group formation and quarterly meetings
4.3 District Health Forum formation and quarterly meetings
4.4 Development of a 5 Year MNCH Strategy for the DoH
4.5 Implementation of learning agenda with the following four questions:
• How can the DoH improve its selection process to effectively recruit and deploy
CMWs in underserved areas?
• How can CMWs become financially self-sustaining while serving the needs of the
poorest of the poor? This will probe into issues of: establishment of workstations
(what the government should provide and what CMWs should source on their own)
monthly stipend from government; fee for services; and vouchers for the poorest of
the poor. How do the factors differ in rural versus urban areas?
• Do CMWs offer quality care? If so, how?

• How can the MOH streamline CMW reporting using cell phone technology and
expand mHealth in the province.
VI. Purpose of the Focused Strategic Assessment

The purpose of USAID’s CSHGP is to contribute to advancing the health system strengthening
goals of Ministries of Health toward achieving sustained improvements in child survival and
health outcomes, particularly among vulnerable populations, by supporting the innovative,
integrated community-oriented programming of PVOs/NGOs and their in-country partners.
CSHGP cooperative agreements offer unique opportunities to demonstrate the links between
specific delivery strategies and measured outcomes. The FSA is intended to focus on four
learning agenda questions (described above), which were designed jointly with the Balochistan
DoH to provide them with the information they need to improve their CMW policies and
programs, but will also cover the scope of the overall project as it will be broadly accessible to
various audiences including Ministries of Health (MOHs). It is important that the lead FSA
consultant consider the audiences listed below, when conducting the FSA and writing the report.
The FSA provides an opportunity for all project stakeholders to take stock of accomplishments to
date and to listen to the beneficiaries at all levels, including mothers and caregivers, other
community members and opinion leaders, health workers, health system administrators, local
partners, other organizations, and donors. The FSA Report will be used by the following
audiences as a source of evidence to help inform decisions about future program designs and
policies:
• In-country partners at the national, regional, and local levels (e.g., MOH and other
relevant ministries, district health team, local organizations, communities in project
areas).
• USAID (CSHGP, Global Health Bureau, USAID Missions), MCSP and other CSHGP
grantees.
October 2016
• The international global health community. The FSA report will be posted for public use
at http://www.mchipngo.net and the USAID Development Experience Clearinghouse at
https://dec.usaid.gov.
VII. Methodology
The FSA methodology consists of a mixed-methods approach comprising a desk review of
secondary data sources and the collection of qualitative data to complement existing data. The
written design of the FSA must be further defined and specified by the FSA lead consultant (e.g.,
number of key informant interviews, focus groups discussions, observations, and locations) and
must be shared with project stakeholders and implementing partners for comment before the
FSA commences. Mercy Corps will facilitate this sharing and feedback.
Secondary Data:
The FSA lead consultant will review documents mentioned in Annex A of the TORs. These
include; project reports, key MoH policy and strategy documents and, U.S.
Government/USAID strategic documents at the global and national levels relevant to the
content of project. As outlined in Annex A, one of the key documents that the FSA lead
consultant will review is the learning agenda report. The FSA will primarily focus on the four
studies conducted under the learning agenda. The four studies contributing to the learning
agenda started in February 2016 and will be completed by July 31, 2016. The reports from
these studies will be available for the final evaluator to review for the purpose of the FSA.
Each study has a unique methodology; the final evaluator will review the methodology,
findings and conclusions of each of the four studies contributing to the learning agenda as
part of the FSA. The Learning Agenda methodology is attached as Annex B. The following
are the expected outcomes of the learning agenda:
1. Recommended incentive package for CMWs and recruitment procedures for CMWs
2. Proposed financially self-sustainable model for a CMW
3. Documentation of best practices demonstrating the quality of care of services offered by
the CMWs
4. Identification of gaps in the existing reporting and monitoring system and

recommendations for improvement
Qualitative Data:
As part of the FSA, in-depth qualitative interviews or focus group discussions may be conducted
with stakeholders, including project staff, DoH staff, local NGOs and community-based
organizations (that are the part of policy forums established by DoH and MC), district health
teams, community and facility based health workers, community members, community leaders,
and mothers (exit interviews). In addition, review of policy forum meeting minutes may be
conducted. If possible, the assessment will also include observations of activities supported by
the project. This will involve site visits to one or more implementation area. The team lead will
develop the methodology and tools for the qualitative data collection, and will remotely guide
the national consultant to randomly select communities to visit from a list provided by Mercy
Corps. However, purposive sampling may be warranted in addition to explore certain areas in
October 2016
more depth to investigate particular results (e.g., high or low performance or unexpected results).
Team Lead will analyze the qualitative data collected by the national consultant and will be
responsible for the overall report writing.
Limitations:
The FSA report must include a discussion of the methodological limitations of the FSA.
Please refer to section XIII (proposed outline of the FSA) for guidance on the report template.
VIII. Focused Strategic Assessment Questions

The FSA lead consultant and the assessment team will use existing data collected or compiled
during the life of the project, as well as additional data collected during the FSA to answer the
following questions:
(goals/objectives) stated in the Strategic Work Plan, keeping in view the
revisions in the mid-course correction document?
• Specifically focusing on the four learning agenda questions (described above in Section
V. Key Activities) and how the project contributed to these:
o How has the project helped the DoH improve its selection process to effectively
o Has the project been able to demonstrate how CMWs can become financially self-
sustaining while serving the needs of the poorest of the poor? This will probe into
issues of: establishment of workstations; monthly stipend from government; fee
for services; and vouchers for the poorest of the poor. The FSA will look into how
these components have been implemented and what results have been achieved
and will specifically comment on how the factors differ in rural versus urban
areas in light of the results of the learning agenda studies.
o Do CMWs offer quality care? If so, how?
o How has the DoH streamlined CMW reporting using cell phone technology and
expanded mHealth in the province?
• What is the quality of evidence for project results?
• What progress has the project shown regarding the mid-course corrections (explicitly),
and what evidence has there been to show this progress?
2. What were the key strategies and factors, including management issues and
policy environment, that contributed to what worked or did not work?
• What were the contextual factors such as socioeconomic factors, gender, demographic
factors, environmental characteristics, baseline health conditions, health services
characteristics, * and so forth that affected implementation and outcomes?
*
See Table 1 in the document here: http://heapol.oxfordjournals.org/content/20/suppl_1/i18.long
October 2016
• What capacities were built (with a focus on CMWs, midwifery tutors, Department of
Health and other partners), and how?
• Specifically asses the policy-level interventions implemented under SMNC, including the
development of provincial MNCH strategy, and implementation of policy forums
(Provincial Steering Committee and Technical Working Group)?
3. Which elements of the project have been or are likely to be sustained or
expanded (e.g., through institutionalization or policies)?
• Analyze the elements of scaling-up and types of scaling-up that have occurred or could
likely occur (including mHealth, voucher scheme, refresher training, policy forums).
4. What are stakeholder perspectives on the overall project implementation, the
policy forums, and the Learning Agenda implementation, and how could the
Learning Agenda affect capacity, practices, and policy?
• Analyze the notifications and recommendations put forward by the policy forums
(Provincial Steering Committee and Technical Working Group), as well as their meeting
minutes.
5. Working around strengthening community-based maternal and newborn
healthcare provision, to what extent has the project been successful?
• Is the community midwife a suitable solution for contributing to reductions in maternal

and newborn mortality considering the quality of care of her services and in-line with the
cultural and economic constraints?
IX. FSA Consultant Characteristics and Expected Timeline
The international consultant will serve as the FSA team leader and is welcome to propose
additional assessment team members to round out the assessment team’s skill set in order to
ensure adequate representation of evaluation, technical, geographic, cultural and language skills.
Team members, their affiliations, and disclosure of conflicts of interest must be listed in an
annex to the FSA report. The lead consultant will coordinate closely with the Mercy Corps team
regarding tool finalization, FSA methodology, timeline, and draft report finalization.
Requirements:
The lead consultant must be approved by USAID CSHGP and should meet the following
minimum requirements:
• Proven expertise and leadership in

− integrated community-oriented reproductive, maternal, newborn, and child health
projects
− conduct of evaluations (baseline, endline) using mixed methods
• Experience with design, collection, and analysis using applied research methods in a
program implementation context
October 2016
• Familiarity with public health system in Pakistan and should be from Pakistan due to visa
constraints
• Demonstrated ability to communicate with and lead a team of stakeholders, staff, and
national experts in participatory evaluation
• Familiarity with USAID programming
• Skill or familiarity with methods for program assessments
• Excellent analytical and writing skills (English)
• Signed statement explaining any conflict of interest †
Key Tasks of the FSA Team Leader:

• Review project documents and resources to understand the project
• Review Learning Agenda sub-studies and their findings and assess if they address DoH
needs ‡
• Refine the evaluation objectives and key questions based on the CSHGP guidelines in
coordination with Mercy Corps team and its partners
• Develop detailed ToR for the national consultant and work with him or her to plan,
implement and complete the FSA.
• Develop the field FSA schedule and assessment tools
• Remotely train the national consultant (and other evaluation team members if applicable)
on objective and process of the FSA including evaluation tools
• Lead the development and methodology of data collection, as well as the data collection
tools, and work remotely with the national consultant to complete the collection, analysis,
and synthesis of supplemental information regarding the program performance
• Interpret qualitative results and draw conclusions, lessons learned, and recommendations
regarding project outcome
• Prepare presentation (a PowerPoint slideshow deliverable, no longer than 20 slides) for
an in-country debriefing meeting with key stakeholders, (with USAID/Washington, DC,
participation remotely, as able)
• Prepare draft report in line with the agreed upon FSA guidelines and submit to Mercy
Corps for review and feedback
• Respond to feedback from Mercy Corps in the Statement of Differences, if applicable,
and make any final revisions prior to grantee submission of the final report which is due
†
CSHGP grantees are required to hire an external evaluator for the final evaluation. That fiduciary relationship
creates a conflict of interest that is minimized by the CSHGP requirement of submission of a draft evaluation report
directly to the CSHGP.
‡
Mercy Corps and the Balochistan DoH jointly agreed on the key learning agenda topics which would equip the
DoH to better utilize the CMW as a resource to address MNCH outcomes. The DoH identified their main needs as
determining how: to improve selection and deployment of CMWs in a way that they reach underserved populations
and; to keep CMWs engaged with the program.
October 2016
to USAID CSHGP GH/HIDN/NUT office on or before 90 days after the end of the
project
Timeline: 1-MONTH TIMEFRAME FOR A TOTAL LEVEL OF EFFORT OF 24 DAYS. The
breakdown of the level of efforts is given in following table.
S. Number of Lead
Activities
No. Consultant’s Days
Online meeting with Mercy Corps team to discuss

1 the implementation of the FSA methodology and 0.5
related logistics
2 Desk review 4
3 Develop methodology data collection tools for FSA 2
4 Incorporate feedback and finalize tools 1.5
5 Mentoring of national consultant for data collection 2
6 Analysis of the data 5
7 Develop and share preliminary reports of the FSA 6
8 Submit final report after incorporating feedback 3
Total Days 24*
X. Focused Strategic Assessment Report

The FSA report should follow the agreed upon outline for this FSA. A draft and final report,
written by the FSA consultant, must be submitted to Mercy Corps. Mercy Corps is responsible
for submission of the final draft to the CSHGP and other required parties as indicated in the
guidelines.
XI. Budget
Total days 24; consultancy fee is $ 500 per day.
At the conclusion of the consultancy period, the consultant is expected to complete the following
deliverables:
October 2016
• Prepare presentation (a PowerPoint slideshow deliverable, no longer than 20 slides) for
an in-country debriefing meeting with key stakeholders, (with USAID/Washington, DC,
participation remotely, as able)
• Prepare a draft report in line with the CSHGP guidelines and submit to Mercy Corps for
review and feedback.
• Prepare the final report in time for formal submission by Mercy Corps. The final report
with all annexes is due at the USAID CSHGP GH/HIDN/NUT office on or before 90
days after the end of the project.
XIII. Proposed outline of the Focused Strategic Assessment
I. Cover page
II. Executive summary
III. Project background
a. Situation of maternal and neonatal mortality in the province
b. Project summary including mid-course corrections
c. Partnerships and collaboration
d. Learning agenda
IV. Purpose of the Focused Strategic Assessment
V. Evaluation methodology
VI. Main results
(goals/objectives) stated in the Strategic Work Plan, keeping in view the
revisions in the mid-course correction document?
• Specifically focusing on the four learning agenda questions:

o How has the project helped the DoH improve its selection process to effectively
o Has the project been able to demonstrate how the CMWs can become financially
self-sustaining while serving the needs of the poorest of the poor? This will probe
into issues of: establishment of workstations) monthly stipend from government;
fee for services; and vouchers for the poorest of the poor. The FSA will look into
how these components have been implemented and what results have been
achieved and will specifically comment on how the factors differ in rural versus
urban areas in light of the results of the learning agenda studies.
o Do CMWs offer quality care? If so, how?
o How has the DoH streamlined CMW reporting using cell phone technology and
expanded mHealth in the province?
• What is the quality of evidence for project results?
• What progress the project has shown regarding the mid-course corrections (explicitly),
and what evidence has there been to show this progress?
October 2016
2. What were the key strategies and factors, including management issues and
policy environment, that contributed to what worked or did not work?
• What were the contextual factors such as socioeconomic factors, gender, demographic
factors, environmental characteristics, baseline health conditions, health services
characteristics, § and so forth that affected implementation and outcomes?
• What capacities were built (with a focus on CMWs, midwifery tutors, Department of
Health and other partners), and how?
Specifically assess the policy level interventions implemented under SMNC including the
development of provincial MNCH strategy, and implementation of policy forums
(Provincial Steering Committee and technical working group)
3. Which elements of the project have been or are likely to be sustained or
expanded (e.g., through institutionalization or policies)?
• Analyze the elements of scaling-up and types of scaling-up that have occurred or could
likely occur (including mHealth, voucher scheme, refresher training, policy forums)
4. What are stakeholder perspectives on the overall project implementation, the
policy forums, and the Learning Agenda implementation, and how could the
Learning Agenda affect capacity, practices, and policy?
• Analyze the notifications and recommendations put forward by the policy forums
(Provincial Steering Committee and Technical Working Group), as well as their meeting
minutes.
5. Working around strengthening community-based maternal and newborn
healthcare provision, to what extent has the project been successful?
• Is community midwife a suitable solution for contributing to reductions in maternal and

newborn mortality considering the quality of care of her services and in-line with the
cultural and economic constraints?
VII. Conclusion
VIII. Recommendation
§
See Table 1 in the document here: http://heapol.oxfordjournals.org/content/20/suppl_1/i18.long
October 2016
ANNEX II. ASSESSMENT METHODOLOGY AND LIMITATIONS
Mercy Corps hired an external consultant, Kathy Tilford, to lead the Focused Strategic
Assessment (FSA) remotely from the U.S. She worked closely with a well-qualified local
Pakistani consultant, Dr. Sohail Amjad, hired by Mercy Corps/Pakistan. The local consultant had
extensive experience in evaluation, including Child Survival and Health Grants Program
(CSHGP) projects, and in-depth knowledge of the Pakistani health system, the Community
Midwives (CMW) program and the local context. He served as the field team leader, working
with two assistants experienced in qualitative data collection: Dr. Muslim Abbas and Ms. Saima
Zeb Faredi. (See Annex VII for list of team members, titles and roles.)
The methodology for the Focused Strategic Assessment was designed to answer five key
questions:
(goals/objectives) stated in the Strategic Work Plan, keeping in view the revisions in the
midcourse correction document?
3. Which elements of the project have been or are likely to be sustained or expanded (e.g.,
through institutionalization or policies)?
4. What are stakeholder perspectives on the overall project implementation, the policy
forums, and the Learning Agenda implementation, and how could the Learning Agenda
affect capacity, practices, and policy?
The methodology consisted of a participatory mixed-methods approach that included two
principal components:
1. Comprehensive desk review of secondary data sources: Prior to developing the

instruments for the field work, the team conducted an extensive desk review of quantitative
and qualitative data sources. These included project documents such as the proposal, the
Strategic Work Plan, surveys and assessments, routine monitoring updates and the “Case for
Midcourse Corrections”; background documents on maternal and child health and the
Pakistan health system; the Learning Agenda report; and Department of Health (DoH)
publications such as the Balochistan MNCH Strategy for 2016-2020. (See Annex IV for a
complete list of documents consulted.)
2. Collection of qualitative data: Using semi-structured Key Informant Interviews (KIIs),
Focus Group Discussions (FGDs) and informal discussions with project stakeholders, the
external consultant and the three-person field team carried out qualitative data collection over
a two-week period. (See Annex III for the data collection instruments and work plan.)
Focused Strategic Assessment: SMNC Project October 2016

Selection of data collection methods: In addition to KIIs and FGDs, the team considered other
data collection methods including Observations and Exit Interviews. However, it would have
been difficult to organize Observations of CMWs and Exit Interviews with clients for several
reasons:
- a field team member would need to be present at the exact time a client came for a
consultation;
- for cultural reasons only a female team member would be able to conduct such a data
collection activity;
- time constraints would mean a limited number of observations and/or exit interviews; and
- the data collection carried out for the Learning Agenda already included a large number
of observations of CMWs by trained health care providers.
Choice of groups to interview: In deciding which groups to include for the FGDs, the team
discussed the possibility of a discussion with male community leaders. However, the Project
Manager suggested that this might not be as useful since men had not been very involved at the
community level and would likely not have a lot to share.
Standard themes: To facilitate the triangulation of data, the team selected a number of common
themes to include in all data collection instruments: support for CMWs, including monitoring
and supervision and the Women Support Groups; sustainability and replicability; referral system
and emergency transportation; contribution of the project to improving MNCH; and challenges
encountered.
Qualitative Data Collection
Field work: The local consultant conducted qualitative work in the field with his two assistants
over ten days (September 19 – 28, 2016). In each of the three districts they conducted three
FGDs, with each group having eight to ten participants:
1. Community Midwives (CMWs): To identify participants for this FGD, the local
consultant selected every third name on the list of project-supported CMWs and asked
the SMNC Project Manager to contact 11-12 women in each district in order to have 7-9
participants. The local consultant attempted to keep a balance between urban and rural
CMWs but in the end, CMWs closest to the district capital were invited so that the
women could return home the same day.
2. Lady Health Workers (LHWs), Lady Health Visitors (LHVs) and Lady Health
Supervisors (LHS): Participants from the same geographic areas as the CMW participants
and who had remained active in monitoring and coordination comprised this FGD group.
3. Female community members: Participants for this FGD included Lead Mothers from the
Women Support Groups (WSGs) and women who had accessed services from the CMWs
included in the CMW group.

Using semi-structured interview guides, the field team also conducted in-depth KIIs with four
Department of Health (DoH) stakeholders in each district:
- the District Health Officer (DHO)

- the Medical Supervisor of the District Headquarters Hospital
- the District Coordinator for the Maternal, Newborn and Child Health (MNCH) program
- the Public Health Specialist who oversees the LHW program
At the provincial level, the local consultant held KIIs with the following stakeholders: the
Director General/Health Services for Balochistan Province; the Provincial MNCH Coordinator;
the Provincial LHW Program Coordinator; the Chairperson of the Technical Working Group
(also a member of the Provincial Steering Committee); and two other stakeholders, one each
from the Technical Working Group and the Provincial Steering Committee.
Interviews with Mercy Corps staff: The external consultant collected qualitative data through
Skype interviews with project staff (Project Manager, Project Officer, Security Officer and the
Monitoring, Evaluation and Learning Manager) and with two Mercy Corps/Pakistan senior
managers, the Team Leader/South who has been very involved in the project and the Senior
Director/Programs. It was not possible for her to conduct Skype interviews with other
stakeholders due to connectivity issues outside Quetta and Islamabad.
Limitations
Since the project had recently completed several qualitative and quantitative community-level
surveys in the target area, the team ensured that engagement with stakeholders focused primarily
on information gaps. The field team could not visit remote areas for FGDs due to security issues
and therefore CMWs and the LHWs/LHVs/LHSs were invited to the project’s district field
offices. The FGDs with female community members were held in homes of Lead Mothers.
In Kech the security situation and cultural sensitivities meant that male members of the team
could not travel there; therefore, the female team member conducted interviews in this district.
However, this did not appear to affect the quality and completeness of the data collected.
Ethical Considerations
The field team made it clear to all FGD participants that they were under no obligation to
participate but if they did participate, anonymity and confidentiality were assured. Verbal
informed consent from the participants was obtained. Where necessary, an interpreter assisted
the team members. For each encounter, the team obtained permission for taking photographs for
reports and presentations.
Quality of Evidence for Results

The SMNC project was well-documented and during the FSA the project staff provided a
number of additional documents requested by the external consultant. The three Annual Reports
prepared per USAID requirements were comprehensive with extensive annexes. Each of the
major interventions such as mHealth had accompanying explanations and periodic assessments
that provided a chronological description of how the intervention evolved.

The assessment team compared findings from the qualitative research with project documents,
external assessments from firms such as PakVista Technologies, the Learning Agenda report
produced by an independent consultant and documents produced during the project’s lifetime
such as the Balochistan MNCH Strategy 2016-20. The external consultant also checked facts
periodically with SMNC project staff when preparing this report. The cross-checking of data and
the triangulation of findings both helped to ensure that the evidence used for drawing
conclusions was valid and reliable. However, it should be noted that for information presented in
project documents such as the quantitative data in the three Annual Reports and routine
monitoring documents, the external consultant relied on the accuracy of the information at the
source as there was no way to independently verify the information.
Data Analysis
The information collected from key informants was compiled and tabulated using MS Office
software for each question and inputs were organized by themes and dimensions of program
intervention. Important quotes and observations were identified and used to build the analysis.
Data emerging from interviews was validated internally through triangulation with information
from project documents, routine monitoring, and other sources gathered prior to and during the
field work. The interpretations of triangulated thematic data were discussed with Mercy Corps
district and country office teams for further modification and amendment. Information was
synthesized by creating matrices around identified themes and the findings organized
accordingly.

ANNEX III. DATA COLLECTION INSTRUMENTS AND WORK PLAN
This Annex contains the following documents:

A. Detailed Work Plan for Field Work
B. Data Collection Instruments
1. FGD: CMWs
2. FGD: LHWs, LHVs, LHSs
3. FGD: Female Community Members
4. Semi-structured Guide for KII: Director General/Health Services (provincial level)
5. Semi-structured Guide for KII: Provincial Coordinator for LHW Program and
Provincial Coordinator for MNCH Program (provincial level)
6. Semi-structured Guide for KII: For forum representatives - PSC members and TWG
members (provincial level)
7. Semi-structured Guide for KII: District Health Officer (district level)
8. Semi-structured Guide for KII: District Coordinator for LHW Program and Public
Health Specialist for MNCH (district level)
9. Semi-structured Guide for KII: Medical Superintendent for District HQ Hospital
(district level)
10. Semi-structured Guide for KII: SMNC Project Staff and Mercy Corps/Pakistan Senior
Managers

Detailed Work Plan for FSA Field Mission
Travel to/
Date Name of Consultant Place Activities Travel from Remarks
Arrived at
Arrival at Quetta. Meeting with

SMNC Team, discussion and
Dr. Sohail Amjad finalization of detailed work plan,
Islamabad Quetta (12:25 printing instruments, training of
Sept 18, 2016 Dr. Muslim Abbas Islamabad Travel by air to Baluchistan
(11:05 am) pm) field team, skype call with
Ms. Saima Zeb Faredi international consultant,
clarification of questionnaires and
team orientation
Dr. Muslim Abbas

FGD with CMWs Morning (9 am-12 noon)
Ms. Saima Zeb Faredi
Quetta (SMNC Support required for language and
Office) interpretation
Dr. Muslim Abbas
FGD with LHWs, LHSs & LHVs Afternoon (3 pm -5 pm)
Sept 19, 2016 Ms. Saima Zeb Faredi
Provincial Coordinator LHW

Dr. Sohail Amjad Quetta Morning (11:30 am-1 pm)
Program (Dr. Noor Qazi)
Support of note taker
Local note taker (Kamal
Provincial Coordinator MNCH
Khan) Quetta Morning (9:30 am-11 am)
Program (Dr. Rafiq Mengal)

Quetta (SMNC FGD with female community Support required for language and
Sept 20, 2016 Morning (9 am-12 noon)
Office) members interpretation

Travel to/
Arrived at
Dr. Sohail Amjad KI with 2 members PSC (Dr.

Quetta Asfand WHO, Farooq Mengal Morning (9 am-11 am)
Dr. Muslim Abbas
and separately with 2
Sept 20, 2016 Support of note taker
members of TWG (Prof Aisha
Dr. Sohail Amjad
Quetta Sadiqa, Dr. Tahira Kamal, Dr. Morning (11:30 am-1 pm)
Dr. Muslim Abbas Mukthiar Zheri)
Dr. Sohail Amjad

KI with DHO Quetta (Dr. Shah
Dr. Muslim Abbas Quetta Morning (9 am-11 am)
Jahan)
Dr. Muslim Abbas KI with District Coordinator

Sept 21, 2016
Quetta LHW Program (Asst. Dist. Morning (11:30 am-1 pm)
Ms. Saima Zeb Faredi Coordinator)
Dr. Sohail Amjad

KI with PHS MNCH Program
Local note taker (Kamal Quetta Morning (11:30 am-1 pm)
(Dr. Zaheer Kakar)
Khan)
Dr. Muslim Abbas

KI with MS SPH Hospital,
Quetta Morning (9:30 am-11 am)
Quetta (Dr. Abdur Rehman)
Sept 22, 2016

Dr. Sohail Amjad
DGHS Baluchistan (Dr. Masood
Local note taker (Kamal Quetta Morning (9:30 am-11 pm)
Qadir Nowsherwani)
Khan)

Travel to/
Arrived at
Dr. Sohail Amjad
Sept 23, 2016 Dr. Muslim Abbas Preparation and refinement of transcripts with data editing and cleaning
Dr. Sohail Amjad Quetta Gwadar

Quetta Travel by air Morning-Afternoon
Dr. Muslim Abbas (11:45 am) (1:55 pm)
Quetta Karachi
Ms. Saima Zeb Faredi Quetta Afternoon-Evening
Sept 24, 2016 (5:20 pm) (6:45 pm)
Dr. Sohail Amjad
Dr. Muslim Abbas Gwadar FGD with CMWs, Gwadar Afternoon (3-5 pm)
Dr. Sohail Amjad

Gwadar FGD with female community members, Gwadar Morning
Dr. Muslim Abbas

Sept 25, 2016 Gwadar FGD with LHWs, LHSs and LHVs Gwadar Morning
Karachi
Turbat/Kech
Ms. Saima Zeb Faredi Karachi Travel by air Morning
(7:40 am)
(6:00 am)

Travel to/
Arrived at

Sept 25, 2016 Kech FGD with CMWs, Kech Morning (11 am to 1 pm)

Kech KI with MS DHQ Hospital, Kech Morning (9:00 am to 10:30 am)

FGD with female community
Kech Morning (11 am to 1 pm)
members, Kech
Ms. Saima Zeb Faredi FGD with LHWs, LHSs & LHVs,
Sept 26, 2016 Kech Afternoon (3 pm to 5 pm)
Kech
Dr. Sohail Amjad

Gwadar KI with DHO, Gwadar Morning (9 am-11 am)
Dr. Muslim Abbas
Dr. Sohail Amjad

KI with District PHS MNCH,
Gwadar Morning (11:30 am-1 pm)
Gwadar
Dr. Muslim Abbas
Dr. Sohail Amjad KI with District Coordinator

Gwadar Morning
LHW Program, Gwadar
Dr. Muslim Abbas
Sept 27, 2016
Dr. Sohail Amjad
KI with MS DHQ Hospital,
Gwadar Morning
Dr. Muslim Abbas Gwadar

Travel to/
Arrived at

Kech KI with DHO, Kech Morning (9 am-11 am)
Sept 27, 2016

KI with District Coordinator
Kech Morning (11:30 am-1 pm
LHW Program, Kech
Dr. Sohail Amjad Gwadar Karachi

Gwadar Travel by air Morning
Dr. Muslim Abbas (8:45 am) (10:25 am)
Ms. Saima Zeb Faredi KI with District Public Health

Sept 28, 2016 Kech Morning (10 am-12 pm)
Specialist MNCH, Kech
Karachi
Turbat/ Kech
Ms. Saima Zeb Faredi Turbat/ Kech Travel by air Afternoon
(2:30 pm) (4:00 pm)
Dr. Sohail Amjad

Preparation and refinement of transcript for Kech and Gwadar
Sept 28, 2016 Dr. Muslim Abbas Karachi
Debriefing meeting with Ahmed Ullah, SMNC Program Manager
Dr. Sohail Amjad
Sept 29, 2016 Dr. Muslim Abbas Karachi Travel to Islamabad from Karachi (3 pm flight)

Focused Strategic Assessment of Saving Mothers and Newborns
in Communities (SMNC) Project
FOCUS GROUP DISCUSSION WITH COMMUNITY MIDWIVES
(At Community Level)
FGD Study ID Number _________________
Date of FGD: ____/_____/____ Address: ___________________________________
Start time: ________ ___________________________________
Finish time: ________ District: ___________________________________
Language(s) of interview: _____________________________
Place of FGD: Health facility, CMW Station, Other (specify):______________________
FGD Facilitator’s Name: __________________________________
(Suggested participants of FGD: CMWs from rural SMNC locations (ensure 6-8 participants)
(for office use only)
Transcript prepared by: ______________________
Date prepared: _____/_____/_____
Transcript reviewed by: ______________________
Date reviewed: ____/____/_____
FACILITATOR NOTE: The discussion will take about two hours. If you don’t understand a
question, please tell me. If you don’t know the answer to a question, tell me and we will
go on to the next one. If you don’t want to answer a question, we will skip it. Is it OK to
begin now? Please confirm your consent to participate in this interview/discussion.

Attach List of Participants: Yes  No 
OVERALL QUESTIONS TO ANSWER IN FOCUS GROUP DISCUSSION:

Reminder to facilitator:
The purpose of this focus group is to determine the following:
1. Are CMW services available, accessible and acceptable?

2. What type and quality of support do the CMWs receive and how could it be improved?
3. Have the CMWs’ skills and capacities been strengthened?
PART ONE: INTRODUCTION
1. Good morning. My name is ________ and I am a member of the study team to guide this
discussion. First, I want to thank you all for taking the time to be with us today.
2. We will be discussing your thoughts and ideas about maternal and child health in general
and perception about MNCH services in your community. We are learning about CMWs and
other service providers’ role in the provision of these services. Our discussion will provide us
with information that will help us improve these services.
3. Before we begin, I’d like to explain what a focus group is and then give you some
information about this specific focus group. A focus group is like a discussion group. It’s a
way of listening to people and learning from them. In a focus group, people are asked to talk
with others about their thoughts and ideas about a subject. We are interested in hearing
what you think and feel about each topic. There is no right or wrong answer. We expect that
many of you will have different points of view.
4. Our discussion today will be about two hours. We’ll take a ten-minute break about halfway
through. I’d like the discussion to be informal, so there’s no need to wait for me to call on
you to respond. In fact, I encourage you to respond directly to the comments other people
make. If you don’t understand a question, please let me know. I am here to ask questions,
listen and make sure everyone has a chance to share.
5. We are interested in hearing from each of you, so if we seem to be stuck on a topic, I may
interrupt you. If I do, please don’t feel bad about it, it’s just our way of making sure we get
through all of the questions and everyone has a chance to talk.
Helping me is my associate ____________. He/She will be taking notes and be here to assist
me.
Let’s begin. I want to find out some more about each of you, so let’s introduce ourselves and tell
us your favorite food and sports/games. I’ll start.

Note to Facilitator: Do not correct misinformation about maternal and child health during
the focus group. Tell participants that they will have the opportunity to have all of their
questions answered at the end of our discussion.
PART TWO: DISCUSSION QUESTIONS
1. Accessibility, Availability and Acceptability of CMW Services
[Approx. 30 min]
Q.1. What are the challenges you face in setting up your services in the community? Please
elaborate.
⇒ PROBE: What are major difficulties encountered in encouraging women to access

your services? What difficulties do you encounter in attending deliveries?
Q. 2. Do you receive referrals from local MNCH service providers?
⇒ PROBE: Do LHWs or local TBAs (dais) refer cases? If not: why?
⇒ PROBE: Do CMWs get regular support and supervision from District Health
Department to strengthen coordination with local health workers or hospitals to
ensure service delivery? Examples?
Q. 3. In case of emergency, how do you transfer maternity case or sick child to a larger health
facility (hospital)?
⇒ PROBE: Availability of ambulance/transportation service
⇒ PROBE: Challenges and obstacles in transportation
⇒ PROBE: Are local Women Support Groups helpful to facilitate on financial

support?
Q. 4. Are you familiar with the health voucher scheme for clients who may have financial
difficulties?
⇒PROBE: What is your experience with the voucher scheme? Who are the
beneficiaries of the vouchers?
⇒PROBE: How many times have clients used the voucher system?
⇒PROBE: Do these vouchers compensate you for the services you provide?
⇒PROBE: Do you have suggestions for improving the voucher system?

2. Support for CMWs
[Approx. 20 min.]
Q. 5. Do you get regular supervision and monitoring? How often?

⇒ PROBE: Who provides Technical and Administrative Monitoring?
⇒ PROBE: When was the last supervision?

Q. 6. Do you receive any equipment or other supplies from the SMNC project? How often?
What equipment and/or supplies were given to you?
Delivery Table, Autoclave, Delivery Kit, BP Apparatus, Others (specify):
____________________________________________
Q. 7. Do you have Women Support Groups in your community? What is their role?
⇒ PROBE: Do they work with you? How?
⇒ PROBE: What motivates the Women Support Groups to work with you and the
community?
⇒ PROBE: Do you have any recommendations to help to improve collaboration with

Women Support Groups?
⇒ PROBE: Do you think the Women Support Groups will continue after the project
ends? Why/why not?
Q. 8. Do you work with other community health service providers? Who?

⇒ PROBE: How do you work together?
⇒ PROBE: Who refers maternity cases to you?
Q. 9. Who in your family and/or in your community supports you in your work?
⇒ PROBE: How?
⇒ PROBE: What additional support would you like to have from your community? (Be
specific about type of support needed, who could provide.)
3. Capacity and Skill Development
[Approx. 20 min.]
Q. 10. Do CMWs receive further refresher training or skill development opportunity after
deployment?

⇒ PROBE: What were the topics of refresher courses or skill development? Do these
refresher courses or skill development help improve your daily work? How?
⇒ PROBE: Do you think you need other trainings or skill development particular to the
local community needs? What specific types?
Q. 11. In addition to being able to provide maternal and child health services, what other
abilities or capacities have you acquired as a result of becoming a CMW?
⇒ PROBE: What are you able to do now that you did not do before?
Q.12. Has becoming a CMW changed your status within your family? In the community? How?
Q. 13. What is the biggest benefit to you of becoming a CMW?
Acknowledgements
Thank you very much for coming here today. We appreciate your thoughts and ideas. They will
be very helpful.
Name Occupation Address Contact Signature

FOCUS GROUP DISCUSSION WITH LHWs, LHVs, and LHS
Start time: ________ ___________________________________
Place of FGD: Health facility, Other (specify)_____________
(Suggested participants of FGD: LHS, LHVs, and especially LHWs from rural areas. (Ensure 7-8
participants)
Date prepared: _____/_____/_____
begin now? Please confirm your consent to participate in this interview.

• Are CMW services available, accessible and acceptable?

• Are the beneficiaries satisfied with the quality of healthcare services provided by the
CHWs?
• What were the factors (social contexts, perceptions, socio-cultural barriers and
obstacles, challenges, etc.) that impacted CMW uptake and performance in the target
communities?
• What is the role of LHSs, LHVs and LHWs in managing and supporting the CMWs?
• What type of community support do the CHWs receive? Who collaborates with them?
• What is the contribution of SMNC interventions in terms of service delivery and utilization
of MNCH services by the community?
• What is the potential of sustainability (defined as the majority of CMWs continuing their
work)?
Good morning. My name is ________ and I am a member of the study team to guide this
We will be discussing your thoughts and ideas about maternal and child health in general and
perception about MNCH services in your community. We are learning about CMWs and other
service providers’ role in the provision of these services. Our discussion will provide us with
information that will help us improve these services.
Before we begin, I’d like to explain what a focus group is and then give you some information
about this specific focus group. A focus group is like a discussion group. It’s a way of listening
to people and learning from them. In a focus group, people are asked to talk with others about
their thoughts and ideas about a subject. We are interested in hearing what you think and feel
about each topic. There is no right or wrong answer. We expect that many of you will have
different points of view.

Our discussion today will be about two hours. We’ll take a ten-minute break about halfway
through. I’d like the discussion to be informal, so there’s no need to wait for me to call on you to
respond. In fact, I encourage you to respond directly to the comments other people make. If you
don’t understand a question, please let me know. I am here to ask questions, listen and make
sure everyone has a chance to share.
We are interested in hearing from each of you, so if we seem to be stuck on a topic, I may
interrupt you. If I do, please don’t feel bad about it, it’s just my way of making sure we get
Helping me is my assistant ____________. He/She will be taking notes and be here to assist
me. Let’s begin. I want to find out some more about each of you, so let’s introduce ourselves
and tell us your favorite food and sports/games. I’ll start.
Note to facilitator: Do not correct misinformation about maternal and child health during the
focus group. Tell participants that they will have the opportunity to have all of their questions
answered at the end of our discussion.
Accessibility, Availability and Acceptability of CMW Services
[Approx. 30 min.]
Q.1. What obstacles have CMWs faced in setting up their practice and attracting clients?
Q.2. Who makes referrals to the CMWs?
⇒ PROBE: Do LHWs or local TBAs refer cases? If not: why not?
⇒ PROBE: How do LHWs/TBAs coordinate with CMWs for referral?
⇒ PROBE: Do CMWs provide feedback on outcome of referral?

Q.3. Are clients/communities satisfied with the CMW’s services in terms of maternal and child health?
⇒PROBE: How do you know this?
⇒PROBE: What do clients/the community appreciate most about the CMWs?
Support for CMWs
[Approx. 20 min.]

Q.4. For LHWs only: What is your role in relation to the CMWs in your communities?
⇒PROBE: Please provide some concrete examples of how you support the CMWs.
⇒PROBE: Do you have suggestions for how LHWs and CMWs can work even more effectively
together?
Q.5. For LHS and LHVs only: Please describe your role/responsibility in the management of CMWs.
⇒PROBE: On average, how many CMWs do you manage? On average, how often do you see
each CMW?
⇒PROBE: What are some of the reasons that LHSs and LHVs might not visit the CMWs as
often as they should?
[If the participants do not mention stipends or other incentives, ask:
- What incentives do you receive for managing CMWs?
- Are these incentives provided on a regular basis and in a timely fashion?
⇒PROBE: Please provide recommendations for improving the management of CHWs.
Q.6. What is the role of Women Support Groups in relation to CMWs? Would you be able to give some
recommendations to reinforce the collaboration between lead mothers in Women Support Groups and
CMWs?
Q.7. Are there other individuals or groups in the community that support the CMW in her work? Who?
How?
⇒ PROBE: Can you provide some suggestions for how the community can better support the
CMW?
Project Impact and CMW Sustainability
[Approx. 20 min.]
Q.8. Have the CMWs made a positive impact on the health of mothers and newborns?
PROBE: How do you know this?
PROBE: Please provide some concrete examples of how a CMW has helped her community.
Q.9. Has your participation in SMNC improved or added to your own technical and/or managerial skills?
PROBE: What new skills have you acquired?
PROBE: How have you benefitted from participating in SMNC?
Q.10. Please describe any innovations SMNC has introduced and the benefits of these innovations.
PROBE: Emergency transport? Health vouchers? Mobile technology for record-keeping?
Business training form CMWs? Refresher training for CMWs?
Q.11. Which of these innovations has the greatest possibility of being replicated in other areas? Why?

Q.12. What is the greatest barrier to sustainability (defined as the CMWs continuing to provide services
after SMNC ends)?
Q.13. Please provide a concrete recommendation for ensuring sustainability.
Acknowledgements
be very helpful.

FOCUS GROUP DISCUSSION WITH FEMALE COMMUNITY
MEMBERS AND SERVICE USERS
Start time: ________ ___________________________________
Place of FGD: Health facility, Other (specify):_____________
(Suggested participants of FGD: Priority participants are CMW service users and the
Women Support Group lead mothers or other members. Other participants may include
local female social worker/activist, female school teacher, focal CBO/NGO female
representative, female community elders. DO NOT INCLUDE LHW, LHV, etc. (Ensure 6-8
participants)
Date prepared: _____/_____/_____

begin now? Please confirm your consent to participate in this interview.

• Are CMW services available, accessible and acceptable?

• What were the factors (social contexts, perceptions, socio-cultural barriers and
obstacles, challenges, etc.) that impacted CMW uptake and performance in the target
communities?
• What type of community support do the CHWs receive? Who collaborates with them?
• Are the beneficiaries satisfied with the quality of healthcare services provided by the
CHWs?
• What is the contribution of SMNC interventions in terms of service delivery and utilization
of MNCH services by the community?
Good morning. My name is ________ and I am a member of the study team to guide this
We will be discussing your thoughts and ideas about maternal and child health in general and
perception about MNCH services in your community. We are learning about the CMWs’ role in
the provision of these services. Our discussion will provide us with information that will help us
improve these services.
Before we begin, I’d like to explain what a focus group is and then give you some information
about this specific focus group. A focus group is like a discussion group. It’s a way of listening
to people and learning from them. In a focus group, people are asked to talk with others about
their thoughts and ideas about a subject. We are interested in hearing what you think and feel
about each topic. There is no right or wrong answer. We expect that many of you will have
different points of view.
Our discussion today will be about two hours. We’ll take a ten-minute break about halfway
through. I’d like the discussion to be informal, so there’s no need to wait for me to call on you to
respond. In fact, I encourage you to respond directly to the comments other people make. If you
don’t understand a question, please let me know. I am here to ask questions, listen and make
sure everyone has a chance to share.

We are interested in hearing from each of you, so if we seem to be stuck on a topic, I may
interrupt you. If I do, please don’t feel bad about it, it’s just our way of making sure we get
Helping me is my assistant ____________. He/She will be taking notes and be here to assist
me.
Let’s begin. I want to find out some more about each of you, so let’s introduce ourselves and tell
us your favorite food and sports/games. I’ll start.
Note to Facilitator: Do not correct misinformation about maternal and child health during
the focus group. Tell participants that they will have the opportunity to have all of their
questions answered at the end of our discussion.
1. Perceptions about MNCH Issues and Services & Barriers to Health/Treatment

Seeking.
[Approx. 40 min.]
Q1. What kind of maternal and child health problems are common in this community?
⇒PROBE: What are common maternal and newborn complications in your
community?
Q2. Where would you go to seek medical help or treatment for maternal and child health
problems?
⇒PROBE: Personal physician, CMW, Govt. health facility, private hospital, Hakeem,
local TBA? Etc.
Q3. Why do you prefer to go to one type of provider as compared to others?

⇒ PROBE: What might prevent you from seeing a CMW or other medical
practitioner?
⇒ PROBE: For treatment cost, travel or other barrier.
⇒ PROBE: Are there some women in the community who do not want to go to the
CMW? Why?
2. Accessibility, Availability and Acceptability of CMW Services
[Approx. 30 min.]

Q4. Have you or anyone in your family received antenatal, delivery or postnatal care from
a CMW?
⇒ PROBE: How did you learn about the CMW and the services she provides?
⇒ PROBE: Is the CMW available whenever you or your family members need to visit
her?
Q5. What do you think of the services of CMWs?
⇒ PROBE: Acceptability of waiting time
⇒ PROBE: Cost of her services
⇒ PROBE: Quality of care provided by CMW
⇒ PROBE: Confidence in her skills
Q6. Have the CMWs made a difference in your community? How?
⇒ PROBE: What concrete contributions have they made?

Q7. In case of emergency, how do you transfer maternity or sick child to a larger health
facility (hospital)?
⇒ PROBE: Availability of ambulance/transportation service
⇒ PROBE: Challenges and obstacles in transportation
⇒ PROBE: Are Women Support Groups helpful in facilitating financial support for
transport? How?
⇒ PROBE: Have you heard of health vouchers? Do you think these vouchers are useful
to get timely services? To remove financial barriers?
3. Support for CHWs
[Approx 20 min.]
Q8. Do you have Women Support Groups in your community? What is their role?
⇒ PROBE: Do they work with CMWs? How?
⇒ PROBE: Do you have any recommendations to help to reinforce collaboration

between CMWs and Women Support Groups?
⇒ PROBE: Do you think the Women’s Support Groups will continue when SMNC ends?
Why or why not?

Q9. Are there other individuals or groups that support the CMW in her work? Who? How?
⇒ PROBE: Can you provide some suggestions for how the community can better
support the CMW?
⇒ PROBE: Would you be able to give some recommendations to improve the CMW’s
work?
Acknowledgements
be very helpful.

SEMI-STRUCTURED QUESTIONNAIRE FOR KEY
INFORMANT INTERVIEW WITH DGHS
KII Study ID Number _________________
Date of KII: ____/_____/____ Interviewee name: _____________________________
Start time: ________ Interviewee’s title: _____________________________
Finish time: ________ Language(s) of interview: ______________________
KII interviewer’s name: __________________________________
(Suggested participant: Director General/Health Services or his/her representative if DG

not available.)
Date prepared: _____/_____/_____
REASONS FOR INTERVIEW:

• Have a better understanding of MNCH services management at the provincial level as it
relates to CMWs, including barriers that may prevent the CMWs from working effectively.
• Determine the factors (social contexts, perceptions, socio-cultural barriers and obstacles,
challenges, etc.) that impacted CMW uptake and performance in the target communities.
• Determine the contribution of project interventions in terms of service delivery and
utilization of MNCH services by the communities.
• Determine whether the Provincial Steering Committee (PSC) and the Technical Working

Group (TWG) have made contributions to MNCH services at the provincial and district
levels.
• Discuss the potential for sustaining any positive impacts of the SMNC project and for
replication of any successful elements.
Instructions for the Interviewer:
Before the interview:
Make an appointment with the DGHS through SMNCP/MC Managers and explain to him/her the
objective of the Study and the reason for doing the interview.
At the time of interview:
a) Felicitate the DGHS and introduce yourself. Clearly explain to him/her the objective of
the Study and the reason for doing the interview with him/her. Explain how he/she was
selected for the interview. Also, request the DGHS to allow you enough time for
conducting the interview, highlighting the importance of his/her views. Discourage
prompting by other people in the room if their presence there is unavoidable.
b) Ask the questions one by one and note down the replies clearly. If the DGHS seems
not to clearly understand the question, explain further but avoid putting any leading
question that suggests the answer in itself. Facilitate discussion, if any, to remain
within the context of the interview. If you are not clear about the answer provided to
you, request the respondent to repeat his/her view on that particular question.
c) Before ending the interview session, reconfirm that all questions have been asked.
Thank the respondent at the end of the session.
After the interview:
Organize the answers according to the questions. Collate all other views expressed by
the DGHS that do not fall directly under any question in a separate section. Prepare a
summary of the interview session with each respondent.
PART ONE: INTERVIEW QUESTIONS
A. Management of MNCH Services
1. Coordination: How do you ensure coordination among various provincial Program

Service Providers in organizing MNCH healthcare services in your province?
a. How do you see the role of the SMNC Project/MC at the district level (Quetta,
Kech and Gowader) in improving MNCH outcomes?
b. Can a CMW model such as the SMNC project play an important role in reducing
maternal morbidity and mortality? How?

2. Emergency Referral/Transportation of Maternity: Does your provincial health system
have an operational referral system in place for complicated maternity referral from
primary and community based service outlets? Is it effective?
a. Do you have enough resources to manage referral cases? (Probe for

transportation mechanisms!)
b. How do you see the role of SMNC project strategies and interventions in
improving timely referral and transportation of complicated maternity?
3. Monitoring and Supervision: Could you describe the monitoring system for CMWs?
a. Who is directly responsible for administrative and technical monitoring of CMWs?
b. Are there any barriers that prevent regular monitoring?
c. Do you get feedback on the CMWs’ administrative and technical monitoring from
the districts?
B. Policy and Planning
4. One activity of the SMNC project was to work with the DoH on the development of the
provincial MNCH Strategy. Could you describe the process and the results?
a. What is the status of the strategy at this point?
b. Were you satisfied with the process and the results? Why or why not?
c. Is your department preparing or have you already prepared PC 1 for ‘Integrated

Primary Healthcare Services’ like Punjab and KP? If so what is its status, approved
or still pending?
5. As part of the SMNC project, two forums were established: a Provincial Steering
Committee (PSC) and a Technical Working Group (TG). Please describe what
contributions, if any, these forums made to the SMNC project in particular and to the
province’s MNCH program in general.
C. Sustainability and Scaling Up

6. What are your views on the CMW model used in the SMNC project?
a. What are strengths and weaknesses of the SMNC model?
b. Would you recommend that the SMNC model be replicated in other districts of
Balochistan and Pakistan? Why or why not?
c. What are some of the challenges linked with such replication? How can these
challenges be minimized?
7. Were there any innovations/new activities introduced by the SMNC project that could be
scaled up? (Probe for use of cell phone technology for record keeping, use of a
voucher scheme to reach poorer women, business training for CMWs, etc.)
Acknowledgements
Thank you very much for your time today. We appreciate your thoughts and ideas.

SEMI-STRUCTURED QUESTIONNAIRE FOR KEY INFORMANT
INTERVIEWS WITH PROVINCIAL COORDINATORS
FOR LHWs AND MNCH
Suggested participant: Provincial Coordinator/LHWs, Provincial Coordinator/MNCH

(Separate interviews)
Date prepared: _____/_____/_____

• Have a better understanding of LHW and MNCH services management at the provincial
level as it relates to CMWs, including barriers that may prevent the CMWs from working
effectively.

• Discuss the potential for sustaining any positive impact of the SMNC project and for
Make an appointment with the Provincial Coordinators through SMNCP/MC Managers and
explain to him/her the objective of the Study and the reason for doing the interview.
a) Felicitate the Provincial Coordinator and introduce yourself. Clearly explain to him/her
the objective of the Study and the reason for doing the interview with him/her. Explain
how he/she was selected for the interview. Also, request the Provincial Coordinator to
allow you enough time for conducting the interview, highlighting the importance of
his/her views. Discourage prompting by other people in the room if their presence there
is unavoidable.
b) Ask the questions one by one and note down the replies clearly. If the Provincial
Coordinator seems not to clearly understand the question, explain further but avoid
putting any leading question that suggests the answer in itself. Facilitate discussion, if
any, to remain within the context of the interview. If you are not clear about the answer
provided to you, request the respondent to repeat his/her view on that particular
question.
c) Before ending the interview session, reconfirm that all questions have been asked.
the Provincial Coordinator that do not fall directly under any question in a separate
section. Prepare a summary of the interview session with each respondent.
A. MNCH Services Management
1. Coordination of MNCH services: How do you ensure coordination of LHW [or

MNCH] program and other private MNCH service providers such as the SMNC
project?

2. In your opinion, what role can CMWs play in reducing maternal morbidity and
mortality?
3. Emergency Referral/Transportation of Maternity: Does your health system have

an operational referral system in place for complicated maternity referral from
primary and community based service outlets? Is it effective? Please explain
your responde.
a. Do the LHWs/CMWs coordinate to manage maternal referral cases? If yes,

ask approximately how many LHWs and CHWs coordinate:
MAJORITY ABOUT HALF LESS THAN HALF
b. Do you get feedback on the outcome of maternal referral from your staff? If
so, what is the source of the information?
c. Do CMWs receive feedback on the outcome of referrals they make? If yes,

who provides the feedback to them?
d. Do you have enough resources to manage referral cases?
e. How do you see the role of SMNC project strategies and interventions in
improving timely referral and transportation of complicated maternity? (Probe
for community-based transportation mechanisms!)
4. Monitoring and Supervision: Do you have regular supervision of outreach staff,

especially CMWs?
a. Who is directly responsible for administrative and technical monitoring of

CMWs?
b. How often are CMWs supervised? Who supervises them?
c. Do you have resources for CMW monitoring? Are the resources sufficient?
d. Do you get feedback on CMW’s administrative and technical monitoring from

her respective monitors?
e. Do you collect data from the CMWs on numbers of antenatal contacts,

deliveries attended, and/or referrals made? Is the data compiled and how do
you use it? Can you show me the numbers?
f. Overall, how would you rate the quality of care provided by the CMWs:

VERY GOOD – SATISFACTORY – BELOW AVERAGE
B. Policy and Planning
5. One activity of the SMNC project was to work with the DoH on the development
of the provincial MNCH Strategy. Could you describe the process and the
results?
a. What is the status of the strategy at this point?
b. Were you satisfied with the results? Why or why not?
c. Is your department preparing or have you already prepared PC 1 for ‘Integrated

Primary Healthcare Services’ like Punjab and KP? If so, what is its status,
approved or still pending?
6. As part of the SMNC project, two forums were established: a Provincial Steering
Committee (PSC) and a Technical Working Group (TWG). Please describe what
contributions, if any, these forums made to (a) the SMNC project in particular
and (b) to the province’s MNCH program in general.
For the TWG, you can probe using the following questions:
a. Did the TWG help SMNC overcome implementation barriers? If yes:

Please provide examples.
b. Did the TWG provide technical support in the development of a

communication strategy? If yes: Please describe the support.
c. Did the TWG contribute to helping the CMWs establish their home-
based private practices? If yes: Please describe how.
d. Did the TWG play a role in the development of training materials and
IEC materials for the Women Support Groups? If yes: Please describe
the support provided.
C. Sustainability and Replicability

9. What are the strengths and weaknesses of the SMNC model for CMWs?
10. What, if anything, would you change in the model to make it more effective?
11. Would you recommend that the SMNC model be replicated in other districts of
12. What are some of the challenges linked with such replication? How can these
D. Innovations and Capacity Building
13. Were there any innovations/new activities introduced by the SMNC project?
Probe for:
- use of cell phone technology for record keeping;
- use of a voucher scheme to reach poorer women;
- business training for CMWs;
- Other?
14. Were any of these innovations effective? Which and why?
replicated?
Probe for use of cell phone technology for record keeping, use of a voucher
scheme to reach poorer women, business training for CMWs, etc.
16. Was any capacity-building done as a result of the SMNC project? If yes, please describe
what was done and what the results are for your team.
Acknowledgements

INTERVIEWS WITH PSC, TWG REPRESENTATIVES
Finish time: ________ Language(s) of interview: ________________
Suggested participants: Active members of the Provincial Steering Committee (PSC)

and the Technical Working Group (TWG) – a separate KII for each forum, ideally with at
least 2 representatives per forum
Date prepared: _____/_____/_____

• Determine the impact of project interventions in terms of service delivery and utilization of
MNCH services by the communities.
• Learn about the potential for sustaining the positive impact of the SMNC project (e.g.,
capacity of CMWs trained within SMNC to successfully continue their activities post-
project).
• Understand the potential for and barriers to replicating successful elements of the project.

• Determine whether the Provincial Steering Committee (PSC) and the Technical Working
Group (TWG) have been able to facilitate the implementation of the SMNC project.
Make an appointment with the PSC and TWG members through SMNCP/MC Managers and
d) Felicitate the interviewee and introduce yourself. Clearly explain to him/her the
objective of the Study and the reason for doing the interview with him/her. Explain how
he/she was selected for the interview. Also, request the interviewee to allow you
enough time for conducting the interview, highlighting the importance of his/her views.
Discourage prompting by other people in the room if their presence there is
unavoidable.
e) Ask the questions one by one and note down the replies clearly. If the interviewee
seems not to clearly understand the question, explain further but avoid putting any
leading question that suggests the answer in itself. Facilitate discussion, if any, to
remain within the context of the interview. If you are not clear about the answer
question.
f) Before ending the interview session, reconfirm that all questions have been asked.
the interviewee that do not fall directly under any question in a separate section. Prepare
a summary of the interview session with each respondent.
Role of the PSC/TWG
1. Briefly explain the role/mandate of the PSC [or TWG] in relation to the SMNC project.
a. How long have you served on the PSC [or TWG]?
b. On average, how often do you meet? When was the last meeting?

2. Has the PSC [or TWG] influenced the direction SMNC has taken? If yes: How? Please
provide some concrete examples of specific actions or recommendations the PSD [or
TWG] made to guide SMNC or facilitate its implementation.
Impact of SMNC
3. In your opinion what were the biggest successes, if any, of the SMNC project?
4. What activities/ideas did not succeed? Why?
5. TWG only: What impact has SMNC had on MNCH at the community level? How do you
know this?
6. What impact has SMNC had on MNCH at the provincial level? How do you know this?
7. TWG only: Were there any innovations/new activities introduced by the SMNC project
that were successful?
Probe for use of:
- cell phone technology for record keeping;
- refresher course; etc.
8. TWG only: Which of these innovations/new activities would you recommend for
replication?
[TWG only] Sustainability and Replicability
9. What are your views on the CMW model used in the SMNC project? (Probe for
strengths, weaknesses, etc.)
Policy and Planning
13. One activity of the SMNC project was to work with the DoH on the development of the
provincial MNCH Strategy.

a. Were you involved with this process?
b. Were you satisfied with the results? Why or why not?
c. What is the status of the strategy at this point?
14. What do you consider the most important contribution(s) of the PSC [or TWG] to
SMNC? And to MNCH in Balochistan Province?
15. Is there a role for the PSC [or TWG] after the project ends? If yes, please describe how
you see this role.
Acknowledgements

INTERVIEWS WITH DHO
(Suggested participant: Executive District Officer-Health/District Health Officer
Date prepared: _____/_____/_____

• Have a better understanding of MNCH services management at the district level as it
relates to CMWs, including barriers that may prevent the CMWs from working effectively.
• Determine whether the District Health Forum has contributions to MNCH services at the
district level.

• Discuss the potential for sustaining the positive impact of the SMNC project and for
replication of successful elements.
Make an appointment with the EDOH/DHO through SMNCP/MC Managers and explain to
him/her the objective of the Study and the reason for doing the interview.
a. Felicitate the EDOH/DHO and introduce yourself. Clearly explain to him/her the objective
of the Study and the reason for doing the interview with him/her. Explain how he/she
was selected for the interview. Also, request the EDOH/DHO to allow you enough time
for conducting the interview, highlighting the importance of his/her views. Discourage
prompting by other people in the room if their presence there is unavoidable.
b. Ask the questions one by one and note down the replies clearly. If the EDOH/DHO
seems not to clearly understand the question, explain further but avoid putting any
leading question that suggests the answer in itself. Facilitate discussion, if any, to remain
within the context of the interview. If you are not clear about the answer provided to you,
request the respondent to repeat his/her view on that particular question.
c. Before ending the interview session, reconfirm that all questions have been asked.
the EDOH/DHO that do not fall directly under any question in a separate section.
Prepare a summary of the interview session with each respondent.
MNCH Services Management
1. Coordination of MNCH services: How do you ensure coordination of LHW

[MNCH] program and other private MNCH service providers such as the SMNC
project?

2. In your opinion, what role can CMWs play in reducing maternal morbidity and
mortality?
a. Emergency Referral/Transportation of Maternity: Does

your district health system have an operational referral
system in place for complicated maternity referral from
primary and community based service outlets? Is it
effective?
3. What is the transportation mechanism in the District Health system? Is it

operational and effective?
4. Do you have enough resources to manage referral cases/ transportation?
5. How do you see the role of SMNC project strategies and interventions in
improving timely referral and transportation of complicated maternity?
Monitoring and Supervision: Do you have regular supervision of outreach staff,

especially CMWs?
1. Who is directly responsible for administrative and technical monitoring of CMWs?
2. How often are CMWs supervised? Who supervises them?
3. Do you allocate resources for CMW monitoring? Are the resources sufficient?
4. Do you get feedback on CMW’s administrative and technical monitoring from her
respective monitors?
5. Do you collect data from the CMWs on numbers of antenatal contacts, deliveries
attended, and/or referrals made? How is this data used?
6. Overall, how would you rate the quality of care provided by the CMWs:
Policy and Planning
1. One activity of the SMNC project was to work with the DoH on the development
of the provincial MNCH Strategy.

a. Were you satisfied with the results? Why or why not?
b. What is the status of the strategy at this point?
c. Is your department preparing or have you already prepared PC 1 for

‘Integrated Primary Healthcare Services’ like Punjab and KP? If so,
what is its status, approved or still pending?
d. Please describe what contributions, if any, the District Health Forum

has made to the SMNC project in particular and to the MNCH
program in general.
Innovations and Capacity Building
1. Were there any innovations/new activities introduced by the SMNC project that
could be scaled up?
Probe for use of cell phone technology for record keeping, use of a
voucher scheme to reach poorer women, business training for
CMWs, etc.
2. Was any capacity-building done as a result of the SMNC project? If yes, please
describe what was done and what the results are for your district health team.
Sustainability and Replicability
2. What are Strengths and weaknesses of the SMNC model for CMWs?
Acknowledgements

SEMI-STRUCTURED QUESTIONNAIRE FOR KEY INFORMANT INTERVIEWS
WITH DISTRICT COORDINATORS FOR LHW, MNCH
Suggested participant: District Coordinator/LHWs, District Coordinator/MNCH (Separate

interviews)
Date prepared: _____/_____/_____

• Have a better understanding of LHW and MNCH services management at the district level
as it relates to CMWs, including barriers that may prevent the CMWs from working
effectively.

Make an appointment with each District Coordinator through SMNCP/MC Managers and explain
to him/her the objective of the Study and the reason for doing the interview.
a. Felicitate the District Coordinator and introduce yourself. Clearly explain to him/her the
objective of the Study and the reason for doing the interview with him/her. Explain how
he/she was selected for the interview. Also, request the District Coordinator to allow you
enough time for conducting the interview, highlighting the importance of his/her views.
Discourage prompting by other people in the room if their presence there is unavoidable.
b. Ask the questions one by one and note down the replies clearly. If the District
Coordinator seems not to clearly understand the question, explain further but avoid
question.
the District Coordinator that do not fall directly under any question in a separate section.
Prepare a summary of the interview session with each respondent.
1. Coordination of MNCH services: How do you ensure coordination of LHW

[or MNCH] program and other private MNCH service providers such as
the SMNC project?

a. In your opinion, what role can CMWs play in reducing maternal
morbidity and mortality?
2. Emergency Referral/Transportation of Maternity: Does your district health

system have an operational referral system in place for complicated
maternity referral from primary and community based service outlets? Is it
effective?
a. Do the LHWs/CMWs coordinate to manage maternal referral cases?

If yes, ask approximately how many coordinate:
MAJORITY ABOUT HALF LESS THAN HALF
b. Do you get feedback on the outcome of maternal referral from your

staff? If so, what is the source of the information?
(1) How do you see the role of SMNC project strategies

and interventions in improving timely referral and
transportation of complicated maternity? (Probe for
community-based transportation mechanisms!)
3. For District Coordinator/LHW only: Monitoring and Supervision: Do

you have regular supervision of outreach staff, especially CMWs?
a. Who is directly responsible for administrative and technical monitoring

of CMWs?
b. How often are CMWs supervised? Who supervises them?
c. Do you have resources for CMW monitoring? Are the resources

sufficient?
d. Do you get feedback on CMW’s administrative and technical

monitoring from her respective monitors?
e. Do you collect data from the CMWs on numbers of antenatal contacts,

deliveries attended, and/or referrals made? Is the data compiled and
how do you use it? Can you show me the numbers?
f. Overall, how would you rate the quality of care provided by the
CMWs:

1. Were there any innovations/new activities introduced by the

SMNC project?
Probe for:
- use of cell phone technology for record keeping;
- Other?
2. Were any of these innovations effective? Which and why?
3. Were there any innovations/new activities introduced by the
SMNC project that could be scaled up? (Probe for use of cell
phone technology for record keeping, use of a voucher
scheme to reach poorer women, business training for CMWs,
etc.)
4. Was any capacity-building done as a result of the SMNC project?
If yes, please describe what was done and what the results are for
your team.
2. What are strengths and weaknesses of the SMNC model for CMWs?
3. What, if anything, would you change in the model to make it more
effective?
4. Would you recommend that the SMNC model be replicated in other

districts of Balochistan and Pakistan? Why or why not?
5. What are some of the challenges linked with such replication? How
can these challenges be minimized?
Acknowledgements

SEMI-STRUCTURED QUESTIONNAIRE FOR KEY INFORMANT INTERVIEW
WITH MEDICAL SUPERINTENDENT OF
DISTRICT HQ HOSPITAL
Suggested participant: Medical Superintendent of the District HQ Hospital
Date prepared: _____/_____/_____

• Have a better understanding of MNCH services management at the district HQ hospital as
it relates to CMWs.

Make an appointment with the Medical Superintendent through SMNCP/MC Managers and
a. Felicitate the Medical Superintendent and introduce yourself. Clearly explain to him/her
the objective of the Study and the reason for doing the interview with him/her. Explain
how he/she was selected for the interview. Also, request the Medical Superintendent to
allow you enough time for conducting the interview, highlighting the importance of
his/her views. Discourage prompting by other people in the room if their presence there
is unavoidable.
b. Ask the questions one by one and note down the replies clearly. If the Medical
Superintendent seems not to clearly understand the question, explain further but avoid
question.
the Medical Superintendent that do not fall directly under any question in a separate
section. Prepare a summary of the interview session with each respondent.
1. Emergency Referral/Transportation of Maternity: Does your hospital have an operational

referral system in place for complicated maternity referral from primary and community
based service outlets? Is it effective?
a. Do you have enough resources to manage referral cases? (Probe for transportation
mechanisms!)

b. Do you get feedback on the outcome of maternal referral cases from your hospital
service providers? If yes, what is the source of information? Do you share the outcome
with referee or referral point?
c. How do you see the role of SMNC project strategies and interventions in improving
timely referral and transportation of complicated maternity?
scaled up? (Probe for use of cell phone technology for record keeping, use of a
voucher scheme to reach poorer women, business training for CMWs, etc.) [Note
to Interviewer: MS may not be aware of this.]
2. Was any capacity-building done as a result of the SMNC project? If yes, please describe
what was done and what the results are for your hospital team. [Note to Interviewer:
MS may not be aware of this.]
2. What are the strengths and weaknesses of this CMW model?
Acknowledgements

SEMI-STRUCTURED INTERVIEW GUIDE:
THEMES FOR SMNC STAFF AND MERCY CORPS SENIOR MANAGERS
1. Length of time in position? Role in SMNC?
2. Highlights of the September 28 Donor Conference and next steps
3. Clarification on sustainability and exit strategies
4. Are there notable differences across the three Districts in terms of performance? In terms of
potential for sustaining activities?
5. Learning Agenda report: What are the next steps for finalizing the report? For dissemination?
For using the results?
- Do you anticipate any important changes to the MNCH Strategy as a result of the
Learning Agenda findings?
6. Have there been any collaboration/coordination/exchanges with other organizations/donors

supporting CMW activities in Balochistan Province?
- Example: Save the Children supported some CMWs in Gwadar District.
7. Has the security situation and/or the political situation affected implementation? If yes: How?
When? Concrete examples?
8. The policy platforms: What have been their contributions? Will they continue?
- The DHF seems to have been less successful. Why? What is the future of this platform?
- What is the quality of collaboration with the DoH and other government bodies compared
to other government departments Mercy Corps works with in other areas?
9. Quality of monitoring during the project:

- Do they have records for each CMW: who visited her when? Results? Reports?
- Joint monitoring visits?
10. LLs by Mercy Corps to apply to future projects

- What worked/didn’t work
- Any LLs applied to current projects or future designs?
11. The Road Map: what happened with this document? Any monitoring done?
The following questions are directed more toward SMNC staff than senior managers:

12. Linkages, especially between LHWs and CHWs: Some “tension” comes out in field
interviews, FGD transcripts. Cause(s)? Solutions?
13. Creating demand for the CMWs’ services: The emphasis on WSGs started relatively late.
Field work indicates they may not be meeting regularly.
- Other options for community support? For creating demand?
14. Quality of care: This issue was raised in the Learning Agenda report. Does SMNC have other
data about the quality of care the CMWs are providing?
- Example: Are there any records of the Technical Supervisory List results during
monitoring visits?
15. mHealth: Status of the 2 components; potential for sustainability
16. Voucher scheme: Status
17. Referral mechanism: Update
18. Emergency transport: Status of MoUs with Edhi and Al-Falah?
19. Security concerns and impact, if any, on project
20. Are other organizations providing substantial support to the SMNC CMWs: DKT?
21. Other factors that affected implementation (positively, negatively)

ANNEX IV. SOURCES OF INFORMATION
This annex contains:
1. The list of Focus Group Discussions and Key Informant Interviews
2. The documents consulted during the desk review
October 2016
SMNC FSA Data Collection: List of FGDs and Key Informants
No. Name Designation Place
Provincial Level Key Informants
1 Dr. Masood Nowsherwani DGHS, Baluchistan Quetta
2 Dr. Rafiq Khan Mangal Provincial MNCH Coordinator Quetta
3 Dr. Noor Qazi Provincial LHW Program Coordinator Quetta
Chairperson Technical Working Group &

4 Prof. Dr. Aisha Sadiqa member Provincial Steering Committee, Quetta
Baluchistan
5 Dr. Asfand Yar Sherani Member Technical Working Group, Baluchistan Quetta
Member Provincial Steering Committee,

6 Mr. Farooq Mangal Quetta
Baluchistan
District Level Key Informants (Quetta)
7 Dr. Shah Jehan Panezai District Health Officer, Quetta Quetta
8 Dr. Sher Ahmed Satahakzai District LHW Program Coordinator, Quetta Quetta
District Public Health Specialist, MNCH

9 Dr Zaheer Ahmed Kakar Quetta
Program, Quetta
Medical Superintendent, Sandman Provincial

10 Dr. Abdul Rehman Quetta
Hospital, Quetta
Focus Group Discussions (Quetta)
11 CMWs SMNC-supported CMWs Quetta
CMW Coordinators, Administrative and

12 LHWs, LHSs and LHVs Quetta
Technical Monitors
Lead Mothers of WSG and

13 Members of WSG and direct beneficiaries Quetta
beneficiary mothers
District Level Key Informants (Gwadar)
14 Dr. Sher Dil District Health Officer, Gwadar Gwadar
15 Dr. Abdul Wahid Deputy District Health Officer, Gwadar Gwadar
October 2016
Medical Superintendent, DHQ Hospital,
16 Dr. Abdul Latif Gwadar/ Current Charge District Coordinator Gwadar
LHW Program, Gwadar
17 Dr. Ghulam Nabi Ex-District Coordinator LHW Program, Gwadar Gwadar

18 Dr. Shah Nawaz Gwadar
Program, Gwadar
Focus Group Discussions (Gwadar)
19 CMWs SMNC-supported CMWs Gwadar

20 LHWs, LHSs and LHVs Gwadar
Technical Monitors

21 Members of WSG and direct beneficiaries Gwadar
beneficiary mothers
District Level Key Informants (Kech)
22 Dr. Sajjad Ahmed District Health Officer, Kech Kech
23 Dr. Mohammad Ikram District LHW Program Coordinator, Kech Kech

24 Dr. Abdul Hameed Kech
Program, Kech
Medical Superintendent, District Headquarters

25 Dr. Mohammad Aslam Aazar Kech
Hospital, Kech
Focus Group Discussions (Kech)
26 CMWs SMNC-supported CMWs Kech

27 LHWs, LHSs and LHVs Kech
Technical Monitors

28 Members of WSG and direct beneficiaries Kech
beneficiary mothers
Skype Interviews with SMNC Staff and Mercy Corps/Pakistan Senior Managers
29 Ahmed Ullah SMNC Program Manager Skype
30 Dr. Shaihak Riaz SMNC Project Officer Skype
31 Dr. Saeedullah Khan Team Leader South Skype
October 2016
32 Dr. Farah Naureen Senior Director/Programs Skype
33 Mazhar Iqbal MEL Manager Skype + e-mail
34 Ghulam Haider Security Officer Skype
LIST OF DOCUMENTS REVIEWED

A. SMNC Documents
1. MC Pakistan CSHGP FY12 Final Proposal
2. Revised Performance Management Plan
3. Project Data Form
4. Consultative Workshop for MNCH Strategy – Workshop Report Final
5. Revised Strategic Workplan (December 2013)
6. Knowledge, Practice and Coverage Baseline Survey Report
7. Lot Quality Assurance Sampling Survey Report (April 2015)
8. Routine monitoring reports
a. CMW Services Data (Dec. 2013-Dec. 2014)
b. CMW Services Data (Jan-Dec 2015)
c. Quarterly M&E Report: October-December 2015
d. CMW Services and Indicators Progress Updated Last 3 Quarters
e. Field Monitoring Reports (from field visits conducted by Team leader/South,
SMNC Program Manager, SMNC Project Officer and MEL Manager)
9. Case for Midcourse Corrections – Revised (July 2015)
10. Annual Reports to USAID:
a. Mercy Corps’ First Annual Report for: Saving Mothers and Newborns in
Communities
b. Mercy Corps’ Second Annual Report for: Saving Mothers and Newborns in
Communities
c. Mercy Corps’ Third Annual Report for: Saving Mothers and Newborns in
Communities
11. SMNC Risk Management Plan Updated September 2015
12. Summary of Security Incidents in SMNC Districts (October 2014-September
2015)
13. Extension proposal - Description of Activities (April 2016 to March 2017)
14. Work Plan (USAID-CSHGP and Scottish Government Extension Grant): April
2016 – March 2017
October 2016
15. Voucher Scheme Mechanism Final (with annexes)
B. Learning Agenda
16. Learning Agenda Methodology
17. Final Draft Learning Agenda Report (30 September 2016)
C. MHealth Component – from PakVista Technologies
18. Saving Mothers and Newborns in Communities: Lessons Learned (May 5, 2016)
19. SMNC Assessment Report (August 22, 2016)
20. mHealth Assessment Final Report (September 26, 2016)
21. Journey of a 1,000 Miles (published in IEEE Pulse)
D. Pakistan Ministry of Health

22. National MNCH Program P-1: 2006-2012
23. National MCH Policy and Strategic Framework: 2005-2015
24. Balochistan MNCH Strategy: 2016-20 Final (April 2016)
E. Other Background Materials
25. Strategic road Map for Improving SBA Through CMWs: Balochistan (submitted by RH-
AID, 17 December 2013)
26. A Promise Renewed: Pakistan Updates
27. Acting on the Call: Ending Preventable Child and Maternal Deaths Report (2016)
28. Every Newborn: An Action Plan To End Preventable Deaths (WHO 2014)
October 2016
ANNEX V. DISCLOSURE OF ANY CONFLICTS OF INTEREST
DISCLOSURE OF ANY CONFLICTS OF INTEREST
Name Kathy Tilford
Title International Consultant

Organization None
Evaluation Position Team Leader
Evaluation Award Number (Contract or other N/A

instrument)
USAID Project Evaluated (Include project Saving Mothers and Newborns in

name(s), implementer name(s) and award Communities
number(s), if applicable) Mercy Corps
CA No. AID-OAA-A-12-00093
Ihave real or potential conflicts of interest to
disclose.
Icertify (1) that Ihave completed this disclosure form fully and to the best of my ability and (2)
that Iwill update this disclosure form promptly if relevant circumstances change.
Signature
Date October 16, 2016

ANNEX VI. ASSESSMENT TEAM MEMBERS, ROLES AND TITLES
NAME TITLE ROLE
Kathy Tilford External Consultant 1. Serve as FSA Team Leader

2. Conduct desk review.
3. Lead the development of the qualitative
research methodology and design of tools.
4. Interpret results and draw conclusions.
5. Prepare final FSA report and PowerPoint
presentation.
Dr. Sohail Amjad Local Consultant 1. Assist with development of methodology
and Field Team and preparation of qualitative data collection
Leader instruments.
2. Serve as field team leader for the qualitative
data collection.
3. Provide input into the Focused Strategic
Assessment report.
Dr. Muslim Abbas Senior Research Conduct qualitative data collection and prepare
Associate transcripts.
Ms. Saima Zeb Faredi Senior Research Conduct qualitative data collection and prepare
Associate transcripts.
October 2016
FINAL EVALUATION
Saving Mothers and Newborns
in Communities (SMNC)
Results of a Focused Strategic Assessment
Conducted in September-October 2016
SMNC Project in Brief
 Goal: Improve maternal and newborn health status, especially
for poor and marginalized women of Balochistan
 Strategic Objective: Increased

use of quality essential
maternal and newborn care
provided through private-sector
community midwives (CMWs)
 Timeframe: September 2012 –
September 2016 + 6-month
extension through March 2017
SMNC Project in Brief – cont.
 Location: Quetta, Gwadar and Kech District of

Balochistan Province
 Beneficiaries: 382,515
 Principal partners: Government of Balochistan,
Department of Health (DoH) and Mercy Corps
 Supported by: USAID with additional funding from the
Scottish Government
Intended Results
SMNC aimed to pilot interventions that would result in:

 Increased availability of maternal and newborn health
services at the community level
 Improved knowledge of behaviors and demand for services
 Improved access to emergency transport in remote
communities
 Improved policy environment based on evidence from the
Learning Agenda activity
Purpose of the Focused Strategic Assessment
5 questions from the Terms of Reference:

 Did SMNC accomplish the 4 intended results?
 What were the key strategies and factors that influenced
outcomes?
 Which elements of SMNC are likely to be sustained or scaled
up?
 What are the stakeholder perspectives on the project?
 Has SMNC been successful in strengthening community-
based maternal and newborn care provision?
FSA Focus on Learning Agenda Themes
In addition to the 5 questions in the Terms of Reference, the FSA

focused on the 4 themes examined in the Learning Agenda activity
(conducted by an external consultant in 2016):
 More effective recruitment and deployment of CMWs to
improve retention
 Promoting financial self-sustainability for CMWs, who are
private sector
 Ensuring that CMWs provide quality care
 Streamlining reporting via mHealth technology
FSA Methodology
Two main components:
 Comprehensive document review, including the Learning Agenda
report
 Qualitative data collection via key informant interviews and focus
groups:
CMWs, DoH personnel at district and provincial levels, Lady
Health Workers/Visitors/Supervisors, beneficiaries, SMNC
staff, Mercy Corps senior managers, etc.
 Used common themes across tools to triangulate qualitative
data collection: support for CMWs, monitoring and
supervision, sustainability, referral system, challenges, etc.
 Continual fact-checking with SMNC staff
Findings
 Increased access to essential maternal and newborn services for
families in underserved areas
 Successfully tested and documented interventions to assist the
DoH to improve CMW program design, policies and procedures
 Largely accomplished the 4 intended results, especially:
 Increased availability of maternal and newborn health
services at the community level
 Improved policy environment through provincial forums
(Technical Working Group and Provincial Steering
Committee) and and the new five-year MNCH Strategy
Potential for Sustainability and Scaling Up
 95 midwives trained and equipped, the majority of whom
continue to provide essential services to women with few other
options for skilled birth attendance
 A clinical skills refresher training course endorsed by the
Pakistan Nursing Council, to be incorporated into all midwifery
training schools in Balochistan and eventually in Pakistan
 A business skills course to be included in the standard 18-month
midwifery training
 An mHealth application for improved data collection and
reporting ready for DoH adaptation into the MNCH MIS
Sustainability and Scaling Up – cont.
 A new approved and costed five-year MNCH strategy (2016-

2020) for Balochistan with a major component for CMWs
 Increased demand for MNCH services at the community level
 A three-module set of materials for Women Support Groups,
available in four languages
 Two institutionalized provincial policy platforms, the Technical
Working Group and the Provincial Steering Committee
Key Factors Influencing Results
Positive factors:
 Excellent working relationship between the GoB, represented
primarily by the DoH, and Mercy Corps
 Active engagement of the 2 policy forums: facilitated project
implementation and successfully advocated for changes that will
have a lasting impact on the CMW program in Balochistan
 SMNC responded directly to DoH priorities and requests
 The SMNC design was multi-faceted and took into account the key
aspects of a successful CMW program: recruitment, deployment,
financial sustainability, quality of care, supportive supervision,
community support, referrals and creating demand for CMW
services.
Key Factors Influencing Results – cont.
Constraints:
 Widely-scattered population, limited mobility and relatively
small catchment areas = fewer clients, affecting financial self-
sustainability for CMWs
 Ineffective human resource management in some areas
(vacancies and absenteeism), affecting support for CMWs
 Inadequate GoB financial resources for CMW stipends,
incentives for supervisors, vehicles, etc.
 Patriarchal society norms can discourage women working
independently and women’s mobility.
Challenges Remaining
 Identifying enough qualified and interested women from rural

areas who meet the minimum requirements to become a CMW
 Providing adequate support to CMWs through regular supportive
supervision and better community support
 Ensuring that the CMWs have sufficient monetary incentives to
continue providing services
 Improving linkages between the MNCH program and the CMW
program
Challenges Remaining – cont.
 Creating more harmonious working relationships between TBAs,

CMWs and LHWs
 Establishing a reliable transportation system for referrals
 Improving the referral mechanism between CMWs and
secondary facilities
 Overcoming budgetary constraints within the Government of
Balochistan, including allocating funding for the new MNCH
Strategy
Conclusion
With appropriate selection, training and continued support

from the Department of Health and the community, the
CMW can acquire the necessary skills, confidence and
community status to provide lifesaving maternal and
newborn care, especially in rural areas with widely-scattered
populations and limited health services.
Principal Recommendations
Learning Agenda Follow-up
1. Prepare a briefing paper that summarizes the main findings and
recommendations from the Learning Agenda exercise; ensure
wide-spread dissemination and follow-up for key
recommendations, especially
those concerning:
i) improved selection,
deployment and retention
ii) adequate remuneration

and incentives for CMWs
Principal Recommendations – cont.
Support for CMWs

2. Create a more collaborative and harmonious working
relationship between CMWs and LHWs.
3. Reinforce orientations for family members of CMWs and for
their communities to create sustained support for the CMWs.
4. Consider integrating CMWs into the DoH to ensure adequate
financial compensation, supervision and support.
5. Investigate creative options for accommodating married
women with young children who qualify for CMW training
Ensuring CMWs Provide Quality Care
6. Commit resources to continue supportive monitoring and
supervision of CMWs.
7. Conduct refresher training for LHSs on how to provide
effective administrative supervision and on-the-job mentoring
for CMWs.
8. Invest in regular refresher training on technical themes and
business skills for CMWs. This could include on-the-job
training and mentoring during routine monitoring and
supervision.
9. Make quality staffing of midwifery schools a priority.
Sustaining and Scaling Up SMNC Achievements
10. Continue with the plan to integrate the mHealth application into the
MNCH MIS.
11. Disseminate the voice messages in four languages developed under
SMNC. CMWs and LHWs can use these messages for health
promotion and demand generation.
12. Document the voucher scheme activity and share with DoH
colleagues.
13. Continue the policy forums (Provincial Steering Committee and
Technical Working Group), especially for overseeing the
implementation of the Balochistan MNCH Strategy 2016-20.
14. Mobilize resources and partners for the implementation of the
Balochistan MNCH Strategy 2016-20.
Dissemination of FSA Findings
15. Consider publishing the FSA findings in the Global Health: Science
and Practice Journal
Saving Mothers and Newborns
in Communities
LEARNING AGENDA
Improving Maternal and Newborn Services: Strengthening

Community Midwives in Balochistan
Dr. Saima Hamid

Report Writer
Associate Professor, Health Services Academy, Islamabad, Pakistan
This document is made possible by the generous support of the American people through the United States Agency for
International Development (USAID). The contents are the responsibility of Mercy Corps and do not necessarily reflect
the views of USAID or the United States Government
2
Table of Contents
LIST OF TABLES....................................................................................................... 3
LIST OF FIGURES ..................................................................................................... 4
ABBREVIATIONS ...................................................................................................... 5
EXECUTIVE SUMMARY ............................................................................................ 6
INTRODUCTION ........................................................................................................ 9
SUB STUDY 1 .......................................................................................................... 15
METHODOLOGY ............................................................................................................ 15
RESULTS ........................................................................................................................ 19
SUB STUDY 2 .......................................................................................................... 42
METHODOLOGY ............................................................................................................ 42
RESULTS ........................................................................................................................ 43
SUB STUDY 3 .......................................................................................................... 57
METHODOLOGY ............................................................................................................ 57
RESULTS ........................................................................................................................ 59
SUB STUDY 4 .......................................................................................................... 86
METHODOLOGY ............................................................................................................ 86
RESULTS ........................................................................................................................ 86
REFERENCES ......................................................................................................... 93
ANNEXURES ........................................................................................................... 95
3
LIST OF TABLES
Sub Study 1
Table 1: National, Provincial and District MNCH Data ................................................. 122

Table 2: List of Respondents in In-depth Interviews ...................................................... 16
Table 3: Background Characteristics of participants in FGDs........................................ 18
Table 4: Relation of demographic variables with location of work preference in Non-Intervention
Group............................................................................................................................. 35
Table 5:: Job Attributes and their significance level ....................................................... 36
Table 6: Weighted Ranking of Preferences ................................................................... 37
Table 7: Potential Retention Packages .......................................................................... 38
Sub Study 2
Table 8: Demographic Information of Respondents....................................................... 44

Table 9: Cash Flow Data - Intervention ......................................................................... 45
Table 10: Cash Flow Data - Non-Intervention ............................................................ 4747
Table 11: Average costs of Setup and Services (Intervention) ...................................... 48
Table 12: Average costs of Setup and Services (Non-Intervention) .............................. 49
Table 13: -Profitable services provided by CMWs ......................................................... 50
Sub Study 3
Table 14: General characteristics of CMWs .................................................................. 59

Table 15: Knowledge of CMWs regarding antenatal care.............................................. 61
Table 16: Knowledge of CMWs regarding Natal Care ................................................. 622
Table 17: Knowledge of CMWs regarding new born care............................................ 633
Table 18: Knowledge of CMWs regarding postnatal care ............................................ 656
Table 19: Knowledge score of CMWs............................................................................ 68
Table 20: Attitude of CMWs towards Antenatal care ..................................................... 71
Table 21: Attitude of CMWs towards Natal care ............................................................ 71
Table 22: Attitude of CMWs towards postnatal care ...................................................... 71
Table 23: General Attitude of CMWs ............................................................................. 72
Table 24: Attitude score of CMWs ................................................................................. 73
Table 25: Practices of CMWs towards Antenatal care ................................................... 74
Table 26: Practices of CMWs towards Natal care.......................................................... 75
Table 27: Practices of CMWs towards postnatal care ................................................... 76
Table 28: General practice of CMWs ............................................................................. 77
Table 29: Practice score of CMWs ................................................................................ 77
Sub Study 4
Table 30: Demographic Information of Respondents..................................................... 78

4
LIST OF FIGURES
Study 1
Figure 1: Methodology Flow Chart.............................................................................................................. 15

Figure 2: Analysis Process from main theme to categories ........................................................................ 20
Figure 3: Analysis process moving from main theme to sub-themes to categories ..................................... 79
5
ABBREVIATIONS
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
BDoH Balochistan Department of Health
CMW Community Midwife
DoH Department of Health
EmOC Emergency Obstetric Care
DHF District Health Forum
DHIS District Health Information System
FPP Family Planning Program
IMR Infant Mortality Rate
LHS Lady Health Supervisor
LHV Lady Health Visitor
LHW Lady Health Worker
MMR Maternal Mortality Rate
MDGs Millennium Development Goals
MNCH Maternal, Newborn and Child Health
MPW Multi-purpose Worker
NMR Newborn Mortality Rate
SBA Skilled Birth Attendant
SMNC Saving Mothers and Newborns in
Communities
TBA Traditional Birth Attendant
PC-1 Planning Commision-1
PNC Pakistan Nursing Council
PNC Postnatal Care
PPHI People’s Primary Healthcare Initiative
U5MR Under 5 Mortality Rate
WB The World Bank
WHO World Health Organization
WMO Women Medical Officers
WSG Women Support Group
6
EXECUTIVE SUMMARY
According to the Pakistan Demographic and Health Survey (PDHS), Balochistan province has the
highest maternal mortality rate (MMR) in Pakistan. In 2006 the Government of Pakistan set-up the
national Maternal, Neonatal and Child Health (MNCH) program. This program implemented a
number of initiatives, including the introduction of Community Midwives (CMWs). The MNCH
program intended to recruit CMWs from rural and underserved areas of Pakistan, with the aim to
overcome the challenge women face in accessing skilled care before, during and after delivery.
Recruited CMWs in Balochistan would be trained for 18 months and serve a designated catchment
population of 5000 through a private health care model.
The Balochistan Department of Health (BDoH), in collaboration with Mercy Corps, have been
delivering the Saving Mothers and Newborns in Communities (SMNC) program that aims to
strengthen the CMW cadre to enable them to become long-term, financially sustainable, skilled
and quality maternal and child healthcare providers. The SMNC program was funded by USAID
and the Scottish Government to a total of $2.32m and delivered in three districts in Balochistan.
The program provided CMWs with clinical refresher courses, supportive supervision, business
skills training and small grants of standardized equipment. To support the program, a mobile
phone application for reporting health data was introduced, Women Support Groups (WSG) were
activated to deliver peer education on health and a Mamta Fund was distributed to provide
emergency transport to pregnant women. The results and learning from the project were to be
incorporated into the Government of Balochistan’s Planning Commision-1 (PC-1) for the 2015-
2020 MNCH Program.
From March to June 2015, the SMNC program underwent a midcourse correction where the
program’s Learning Agenda was revised. The new Learning Agenda initiated research that
comprised of four sub-studies that took place in both program intervention and non-intervention
areas. The aim of the research was to document the contributions of the program to increasing
women’s access to skilled care before, during and after delivery and to gather and share lessons
learnt. The four research questions for the Learning Agenda were:
1. How can the BDoH improve its selection process to effectively recruit and deploy CMWs in
underserved areas?
2. How can CMWs become financially self-sustaining while serving the needs of the poorest of
the poor?
3. Do CMWs offer quality care? How?
7
4. How can the BDoH streamline CMW reporting using cell phone technology and expand
mHealth in the province?
Four sub-studies were conducted to respond to the four Learning Agenda research questions, as
follows:
Sub-study 1 aimed to understand how CMWs could be effectively recruited and then retained in
the CMW system after deployment. It also aimed to identify CMW’s motivation for working in rural
and resource-constrained areas and to propose appropriate, cost effective incentive packages to
attract CMWs to austere environments and to ensure their retention. A qualitative study was
followed by a Discrete Choice Experiment (DCE) survey. The findings from sub-study 1 identified
that poor CMW retention was due to a lack of quality CMW training provision from the MNCH
program and the BDoH, an inadequate CMW deployment strategy and harsh environmental
conditions, particularly in rural areas. The findings from the DCE survey suggested that there might
be a number of effective strategies to attract and retain CMWs in rural and remote areas of
Balochistan. While a stipend was important to those interviewed, it was seen that when a
combination of other valued interventions was offered, a stipend became less important. The study
showed that preferences were given to a transport allowance, support in refresher training,
housing facility provision (basic amenities or allowance) and supervision (through government
Lady Health Supervisors (LHSs)/Lady Health Visitors (LHVs)/Woman Medical Officer (WMOs))
over the supply of medicines and equipment, and good schooling for their children. The right
combination of incentives can likely retain CMWS up to 89%.
Sub-study 2 identified the financial successes and failures of CMWs delivering private health care
by undertaking an expenditure and investment assessment of CMWs. It was evident that the
majority of the CMWs had been unable to sustain themselves financially, particularly those in non-
intervention areas. CMWs needed continued financial support from the program, as well as access
to business skills and management training. Furthermore, the study proved that it was essential to
integrate CMWs into the public sector health system of Balochistan for their survival as community
based maternal healthcare providers.
Sub-study 3 assessed the knowledge, attitudes and practices of CMWs, as well as client
satisfaction with the care provided by CMWs. In intervention and non-intervention areas, the study
showed that the overall knowledge of CMWs was poor. However, the practices of CMWs in
8
intervention areas were significantly better than those in the non-intervention areas. Overall
communities considered CMWs acceptable community-based trained health care providers.
Sub-study 4 explored the potential gaps in the mHealth reporting system adopted by CMWs in the
intervention areas and how the system could be improved, sustained and expanded in the
province by the BDoH. Despite the challenges in its use, most CMWs were using the technology to
report routine progress in patients’ antenatal check-ups. The BDoH, although supportive of the
technology, had limited systems in place to collect, analyse and report on data generated by the
CMWs in intervention areas.
9
INTRODUCTION
Globally, an estimated 3.6 million newborns and 360,000 mothers die every year. Of these,
maternal health complications contribute to 1.5 million neonatal deaths in the first week of life and
1.4 million stillbirths, suggesting that a major gap of intervention exists around childbirth and in the
early postnatal period, a time at which mothers and babies are most at risk1. This situation is more
alarming in low-income countries where 1 maternal death occurs in 44 as compared to 1 maternal
death in 3300 in high-income countries2, 3. Common reasons for maternal deaths are hemorrhage,
sepsis, obstructed labor and unsafe abortion etc. Prevention, detection, and timely management of
these complications are a primary health care need of any country. Reviews elicit that acceptance
and recognition of the midwifery model of care and delivery by a skilled birth attendant,
significantly has direct implications on the maternal mortality ratio. Different initiatives have been
taken globally to increase levels of skilled birth attendance for reducing maternal deaths. In
countries where home based deliveries are preferred or there is lack of capacity in facilities, the
focus has been on deploying community-based skilled birth attendants for providing domiciliary
care. Mixed results are depicted by these programs.
Sri Lanka introduced public health midwives in the early 1900s, and reduced its maternal mortality
rate (MMR) from 2000 to 31/100,000 live births between 1930 and 20114-7. Thailand and Malaysia
reduced their MMRs from 425 and 275/100,000 live births respectively in 1960 to <30 in 2010
using the same strategy8. This showed that attendance at delivery by well-trained public health
midwives with the back up of emergency obstetric care (EmOC) services helped in the reduction of
maternal mortality, even in resource-poor settings. In contrast, implementation of a community
midwifery program in Indonesia over 30 years has had disappointing results, stagnating at 220
deaths per 100,000 live births9. Afghanistan’s community midwifery program has produced little
change in its MMR; currently at 1400/100,000 live births8, 10.
As with the other developing countries, India also faces a dearth of skilled birth attendants (SBA).
In the rural healthcare system, the auxiliary nurse midwife (ANM) is the frontline (female) health
worker and is the central focus of all reproductive and child health programs. With changes in
program priorities, the role and the capacity of ANM have changed substantially over the years.
The role of ANM has transformed to a multipurpose worker (MPW) who is mostly involved in
implementing national health programs in contrast to the ANMs of the 1960s who were providing
delivery and basic curative services. The transformation of this role had direct implications for
maternal health and provision of maternal health services in India. The quality of nursing and
10
midwifery education has also deteriorated over a period of time, which has partly contributed to the
shortage of SBAs at health facilities11.
In a multi-country study in India, Malaysia, Sri Lanka, and Indonesia, the dramatic reduction in
maternal deaths was reported through a midwifery care model. The model had a universal
acceptance and focused on improving communication and collaboration between traditional
midwives who provided home care, with midwives with formal training. Support from gynecologists
when necessary, and participation of women in their own care was an additional integral part of the
intervention12. In Iran, community orientation in medical sciences has been discussed for many
years, but community orientation in midwifery needs more consideration due to the importance of
maternal and child health. In a survey conducted on all the midwives working in the provinces of
Kerman and Shahroud, Iran, in 2010–2011, the community-based midwifery knowledge of the
midwives of Kerman was at a low level, and for midwives of Shahroud, it was at a moderate
level13, 14. Cambodia is a recent example where maternal mortality declined remarkably from 472
per 100,000 live births in 2000-2005 to 206 in 2006-2010. The maternal mortality rate was reduced
by modifying the underlying social and structural factors related to health, for example, improving
girls education, improving roads, improving access to health information, and increasing the level
of communication and coordination within the health system. Improvements specifically related to
health systems included increased skilled birth attendance, investment in the training of midwives
and a monetary incentive for facility-based midwives for each live birth conducted15.
The Pakistan health system
As a federal state, the management of health services in Pakistan is devolved to a provincial level.
The federal Ministry of National Health Services, regulations and coordination is responsible for
setting national policies, strategies and targets. Provincial authorities interpret these policies,
strategies and targets and apply them to the local context, establishing provincial-level policies and
ensuring appropriate budgeting, planning and implementation. District health office who report to
the Provincial Department of Health manage most of the healthcare service delivery to
communities, including community outreach. Community based services are particularly important
in areas where access to health services is challenging due to geographical terrain, poverty and
cultural practices (e.g. limited travel for women and girls).
The national MNCH Program in Pakistan
Pakistan is among the few countries in South Asia that continues to have dismal maternal and
child health indicators. In Pakistan, the maternal mortality ratio (MMR) is high, ranging from 240 to
11
700 per 100,000 live births. National figures show that only 52% of deliveries are conducted by
skilled birth attendants (SBAs)16. Approximately two-thirds of all births (61%) take place at home
by traditional birth attendants (TBAs) or un-trained family relatives due to limited access to health
facilities. Realizing the need for a community health workforce, the Government of Pakistan
launched the national MNCH program in 2006 to help rural women deliver safely. The national
MNCH program was designed and implemented as a concerted effort to help achieve the
Millennium Development Goals (MDGs). The program required federal funds and some donor
funding in the form of grants, budgetary support and technical assistance. The national MNCH
program was inspired by the desire of the government to reduce maternal, newborn and child
morbidity and mortality, particularly among poor, marginalized and disadvantaged segments of
society by strengthening, upgrading and integrating ongoing interventions and introducing new
strategies17.
The national MNCH program, in order to increase women’s access to skilled care during birth,
introduced Community Midwives (CMWs) as a new cadre of community skilled birth attendants.
The program aimed to deploy 12,000 rural CMWs over a 5-year period. CMWs were expected to
provide domiciliary maternity care through the establishment of private practices in their home
villages. Rural women with ten years of education were recruited and provided with 18 months of
midwifery training. Their training included a 12-month classroom component followed by a 6-month
practical clinical component. After completing their training, CMWs were deployed back to their
home villages and expected to establish private practices and provide domiciliary maternity care to
a population of 10,000, in geographically defined catchment areas18, 19.
Different studies have been conducted in an attempt to map the coverage of CMWs outreach;
determine the barriers in CMW acceptance and their ability to provide relevant care and how
CMWs interact with other care providers in different parts of Pakistan20, 21.
Up until 2011, the country had trained and deployed 4,700 CMWs in all the four provinces. Yet, a
survey conducted in two districts of Punjab reported that only 3 - 11.7% births were attended by
CMWs22.
Recent literature shows that the selection, training and deployment process of CMWs needs
further improvement in all parts of the country. Owing to the ‘newness’ of the program, there are
many delays in the sequencing of activities, including the selection of candidates, the initiation of
training, the setting of examinations, the provision of certification and most importantly, the
deployment of CMWs. Communities in rural areas also have low awareness of the presence of
12
CMWs. The linkage of CMWs with other community health providers and relevant health facilities
has also not yet been fully established throughout the country23, 24, 25.
Various interventions on capacity building, business training and the use of technology in health
care reporting have been provided by donor agencies and this support has significantly enhanced
15
CMW performance . The most effective part of the training, as verbalized by the CMWs, was the
hands on practice opportunity in primary and secondary health care setups26, 27.
The Balochistan context
Balochistan has the worst maternal, neonatal and child health indicators in Pakistan. Delivering
quality healthcare services in Balochistan can be a challenge. Balochistan is made up of 32
districts and although geographically the largest province in Pakistan, Balochistan is the least
populated with less than 10 million residents spread across geographically challenging terrain. The
poverty of communities and cultural practices (limited travel of women) make reaching
communities more difficult for the Government of Balochistan. These challenges are compounded
by the security context. The literacy rates of Balochistan are low, with only 39% of men able to
read and write, and only 16% of women.
The Saving Mothers and Newborns in Communities (SMNC) Program, Balochistan
Mercy Corps implemented a four-year (2012-2016) program, Saving Mothers and Newborns in
Communities, in Quetta, Kech, and Gwadar districts of Balochistan to improve maternal and
newborn health status, especially for poor and marginalized women. The program is primarily
funded by USAID and co-financed by the Scottish Government. The strategic objective of the
program is to increase the use of quality essential maternal and newborn care, through private-
sector community midwives.
According to PDHS 2006-07 and 2012-13, Balochistan has the poorest maternal health indicators
of all the provinces of Pakistan (Table 1) 29.
Table 1: National, Provincial and District MNCH Data
ANC (skilled PNC (within 2

MMR U5MR IMR NMR SBA provider) days after birth)
MDG Target 140 89 74 N/A >90 N/A N/A
National 276 94 78 54 52.1 73.1 60.3

Balochistan 785 59 49 30 17.8 30.6 37.2
(rural-urban) (14.2-34.4) (24.9-53.8) (36.2-42.3)
13
Mercy Corps together with the BDoH, designed and implanted a program to test whether CMWs in
Balochistan could become self-sustaining maternal and child healthcare providers and increase
the coverage of high impact MNCH services. The project included a four-week clinical refresher
course, a business skill-training course, a mobile phone application for reporting health data, and
the establishment of WSGs to deliver peer education on health to women. The results of the
project were to be incorporated into the Government of Balochistan’s Planning Commision-1 (PC-
1) for the 2015-2020 MNCH Program. Under the MNCH Program, strengthening the capacity of
the CMWs is a major priority for the BDoH. While communities deserve access to high quality
care from well-qualified workforce, healthcare providers deserve to work in well-supported
environments. Therefore, CMWs collaboration with other providers in the health system is both
relevant and important. The need to balance the right number of CMWs, with the right level of
skills, in the right geographical areas, is a challenge for the BDoH, specifically given the security
context found in Balochistan.
From March – June 2015, the SMNC program underwent a midcourse correction where the
program’s Learning Agenda was revised. The new Learning Agenda initiated research that
comprised of four sub-studies carried out in both program intervention and non-intervention areas.
The aim of the research was to document the contributions of the program to increasing women’s
access to skilled care during delivery and to gather and share lessons learnt, in order to generate
30
evidence to inform MNCH policies and strategies for the province . The objectives of the four
sub-studies undertaken were:
Sub-study 1:
Research Question: How can the BDoH improve its selection process to effectively recruit and
deploy CMWs in underserved areas?
Objectives:
1. To understand how CMWs could be effectively recruited and retained in the system after
deployment.
2. Identify preferences of CMWs (qualified and current students) for working in rural and
resource-constrained areas and to propose appropriate, cost effective incentive packages
for attracting/retaining CMWs.
Sub-study 2:
14
Research Question: How can CMWs become financially self-sustaining while serving the needs
of the poorest of the poor?
Objectives:
1. To identify successes and failures of CMWs by undertaking an expenditure and investment
assessment of CMWs.
2. To propose a sustainable model based on the findings of objective 1.
Sub-study 3:
Research Question: Do CMWs offer quality care? How?
Objectives:
1. To assess the knowledge, attitude and practices of CMWs in the intervention and non-
intervention areas.
2. To understand the satisfaction of clients with the services of CMWs.
Sub-study 4:
Research Question: How can the DoH streamline CMW reporting using cell phone technology
and expand mHealth in the province?
Objectives:
1. To document experiences of CMWs and gaps in the reporting system in order to potentially
expand mHealth services.
15
SUB STUDY 1
RESEARCH QUESTION
How can the DoH improve its selection process to effectively recruit and deploy CMWs in
underserved areas?
METHODOLOGY
An exploratory study using a mixed study approach was undertaken, including qualitative methods
and a Discrete Choice Experiment (DCE). DCE is an analytical method that can be used to
quantify a respondent’s preferences for various attributes of a service or good. DCE is used to
systematically identify and evaluate interventions, which are more effective in attracting and
retaining the needed human resource. DCE data is being increasingly used in health services to
quantify the degree to which healthcare providers in developing countries perceive and accept
various incentives and it models the likely impact of different human resource strategies on rural
recruitment in resource poor countries. This methodology was used to investigate the motivation of
CMWs for working in rural and resource-constrained settings using a systematic analysis
technique.
Figure 1: Methodology Flow Chart
Discrete Choice Experiment
Qualitative Study Quantitative Study
In-depth Interviews to
develop insight into the Focus Group
Discrete Choice
barriers faced by the Discussion to
Experiment
already deployed determine attributes
CMWs and levels
DCE was conducted with
50 CMWs of Intervention
IDIs with Government FGDs with CMWs of
and 60 Non-Intervention
officials, CMW tutors Intervention and Non-
areas
and Mercy Corps Intervention areas
Program Team
16
Phase I: Qualitative Study
Thirty-eight key informant interviews were undertaken with Mercy Corps project staff and relevant
district and provincial health officials (Annex: 1) to develop an understanding of the barriers faced
by the already deployed CMWs and how to improve CMW recruitment and retention. Interviews
with CMW trainers were carried out to investigate their role in recruitment, along with the facilities
available for CMWs during training. Interviews focused on the interest of the CMWs to continue to
work especially in rural and remote areas after their training. In addition, Focus Group Discussions
(FGDs) were conducted with qualified CMWs working in intervention and non-intervention areas to
identify factors and incentives that would attract women to take up the profession of a CMW
deployed to a rural area and to examine how to retain CMWs in rural areas. Table 2 gives the
description of the respondents.
Table 2: List of Respondents in In-depth Interviews
Respondents Designation
Director General Health, Balochistan
Department of Health at Provincial Lead, MNCH Program, Balochistan
Provincial Level Provincial Epidemiologist, Balochistan
Deputy Coordinator, LHWs Program, Balochistan
District Health Officers (DHO) – Kech & Gwadar
District Coordinator MNCH Program - Kech
Health Department at Deputy Program Manager, HIV/Aids Program – Quetta
District Level Medical Superintendent District Headquarter Hospital –
Gwadar
Ex Deputy DHO – Gwadar
LHS - Quetta, Kech, Gwadar
LHV - Quetta, Kech, Gwadar
CMW tutors - Quetta, Kech, Gwadar
Mercy Corp Program Team Leader
(SMNC) Staff, Quetta Monitoring, Evaluation and Learning Manager
Project Officer
Community Midwives* Intervention areas: Quetta -14, Gwadar -9, Kech -12
Non-Intervention areas: Quetta -7, Gwadar -3, Kech -19
*CMWs list in Annex 2
The CMWs invited for FGDs were selected with the help of the BDoH and Mercy Corps project
staff. Only those CMWs were included who had at least 6 months of post-training experience in the
field. Prior to FGDs, permission was taken for recording and photographing the participants. Seven
FGDs were conducted in total (two each in Quetta and Gwadar and three in Kech). At the end of
17
each FGD, the participants were requested to list four priority attributes for working in resource
constrained/underserved areas.
The FGDs were transcribed verbatim. The data was reviewed by the research team and coded
independently by two members of the research team who had experience of working in public
health research projects. Through deliberations the research team reviewed statement by
statement to identify similarities and differences. Graneheim and Lundman’s content analysis
method was undertaken. Codes were then categorized followed by identification of three sub-
themes and a main theme.
At the end of each FGD, participants were requested to list four priority attributes that they deemed
important when working as a CMW in rural areas.
Phase II: Discrete Choice Experiment Survey
Using the most frequently listed priorities by CMWs, a list of top six attributes was generated for
the DCE questionnaire. Each attribute was assigned sub-levels, endorsement for which was taken
from the policy makers in the BDoH and Mercy Corps project team before finalization of the DCE
survey questionnaire. This survey was then designed in Sawtooth Software and results were
analyzed using statistical analysis software Stata. In the survey, respondents were presented with
12 paired job scenarios on the most important attributes identified. The minimum sample required
for statistically significant results was 50. Through the assistance of BDoH and Mercy Corps staff,
a list of deployed CMWs was generated and they were administered the questionnaire during their
monthly reporting period.
The demographic information of DCE participants was analyzed using descriptive analytics and
choice data was analyzed through inferential statistical analysis. Responses of participants from
intervention and non-intervention areas in districts Quetta, Kech and Gwadar of Balochistan were
comparatively analyzed. In descriptive analysis, simple frequencies and percentages of
background information were calculated. In inferential analysis the choice data was analyzed using
mixed logit model, which allowed modeling of repeated choices. Mixlogit regression analysis was
undertaken in Stata on job pairs to identify the job preferences of CMWs. This comparative
analysis within and across different individuals in the DCE survey, generated the significance of
each attribute through p values and coefficients. These were then used to compare the relative
importance of attributes. Finally, the result of the mixed logit models was used to predict the effect
of different attributes on proportion of CMWs retaining their rural job. The DCE Questionnaire and
FGD guide are attached in Annex 4 and 5.
18
Table 3: Background characteristics of participants in FGDs
Age Intervention (N=35) Non-Intervention (N=30)

f (%) f (%)
20-25 years 16 (46%) 16 (55%)
26-30 years 18 (51%) 4 (14%)
30-35 years 1 (3%) 4 (14%)
36 and above 5 (17%)
Marital Status
Married 14 (40%) 23 (77%)
Unmarried 19 (54%) 7 (23%)
Widow 2 (6%)
Years of work
experience
1-3 years 20 (57%) 9 (30%)
4-6 years 14 (40%) 21 (70%)
6 years and above 1 (3%)
Location
Urban 24 (69%) 15 (50%)
Rural 11 (31%) 12 (40%)
Not given (46%) 3 (10%)

19
RESULTS
Table 4: Background characteristics of participants in FGDs
Intervention (N=35) Non-Intervention (N=30)

f (%) f (%)
Age
20-25 years 16 (46%) 16 (55%)
26-30 years 18 (51%) 4 (14%)
30-35years 1 (3%) 4 (14%)
36 and above 5 (17%)
Marital Status
Married 14 (40%) 23 (77%)
Unmarried 19 (54%) 7 (23%)
Widow 2 (6%)
Years of work experience

1-3 years 20 (57%) 9 (30%)
4-6 years 14 (40%) 21 (70%)
6 years plus 1 (3%)
Location
Urban 24 (69%) 15 (50%)
Rural 11 (31%) 12 (40%)
Not given (46%) 3 (10%)
Phase I: Qualitative Analysis
All together thirty-eight interviews with DoH (at the provincial and district level) and Mercy Corps
project team and seven FGDs with 64 CMWs were conducted in intervention and non-intervention
areas of Districts Quetta, Kech and Gwadar (Participant details in Annex 3). Table 3 shows the
background information of the FGDs participants.
FGDs were conducted with 35 participants from intervention areas and 30 participants from non-
intervention areas. The majority of participants in the intervention areas were aged 26-30 years
(51%). 54% were unmarried in the intervention areas whereas in non-intervention areas, 77%
were married. The majority of participants (57%) in intervention areas had 1-3 years of experience
20
as CMWs whereas 70% in non-intervention areas had experience of 4-6 years. 69% of
respondents in intervention areas and 50% from non-intervention areas were located in urban
areas.
Interviews and FGDs data were analyzed using content analysis approach. Figure 2 shows the
analysis process moving from main theme to sub-themes and categories.
Figure 2: Analysis Process from main theme to categories
Poor Retention of CMWs in Balochistan
The main theme grounded in the data was “poor retention of CMWs in Balochistan”. Provincial
level and project level respondents reported that CMWs were trained healthcare professionals that
received 18 months of training to earn certification to provide maternal and neonatal services at a
community level. According to the records of BDoH, approximately 800 CMWs had been trained to
date with an additional 350 undergoing training in different midwifery schools of the province. All
respondents shared that retention of this trained workforce was a challenge for the province. The
BDoH respondents were aware of the problems related to the retention of CMWs but felt that due
to financial constraints, poor human resource management, political influence and a lack of
consistency in government policies, this important workforce was neglected. Respondents
reported that even after eight months, less than half of the MNCH program budget had been
released from the federal authorities and given to provinces. This added to the complexity of the
situation and made retention of CMWs more challenging. Particular challenges included a lack of
21
funds to provide stipends to CMWs and implement adequate supervision. Additional challenges
faced by the provincial level policy makers included the lack of quality teaching in midwifery
schools and poor ownership of CMWs by the BDoH and district offices. There was also an issue
with the deployment strategies initiated by the BDoH due to a lack of coordination and weak
linkages with the private sector. For example, some health facilities were run under the public
private partnership of the Peoples Primary Healthcare Initiative (PPHI) and the BDoH - CMWs
working in the PPHI run facilities were not adequately linked with the solely government-led health
facilities. The geographical terrain of Balochistan only added to the magnitude of the challenges.
Senior Health Department officials stated:
“To date we have received only 45% of the total budget allocated to the MNCH program.”
“Unless CMWs get the registration card from Pakistan Nursing Council they are not allowed
to touch any patient. And if the government continues to give a stipend of Rs. 5000 per
month to each of the registered CMWs, then that amounts to a lot of money……. we don’t
have such funds at the moment. So far the CMW work plan has been approved but
unfortunately there is no money for deployment” [Government official, Quetta]
“There is no proper planning at a district level. The PPHI is an independent body and
working at a district level and doesn’t involve the Health Department. They directly hire
people on contract and we don’t know where they have hired people and from where they
are giving them salaries. They hire people and then come to DHO and ask for all details of
vacant seats at BHUs. They approach the finance department directly to release budget for
vacant seats. So the budget of the health department is given away without us being in the
loop. Also linking up CMWs with their staff is difficult. We don’t even know who is working
where.” [Government official, Quetta]
“The majority of midwifery schools don’t have qualified tutors. Also tutors have not been
given any refresher training for years. Also the midwifery school budget is very little. Going to
a tertiary hospital during training is a challenge - even transportation is a basic issue.” [Mercy
Corps SMNC program staff]
The three sub-themes contributing to the main theme are detailed further in the following sections.
1. Lack of Quality Teaching and Training
A lack of quality teaching in midwifery schools was highlighted by the respondents as a challenge
to the recruitment and retention of CMWs in Balochistan. In the urban setting of Quetta, midwifery
22
schools were functional and the teaching staff were well trained. However, outside of Quetta the
situation was drastically different with poor infrastructure and a lack of qualified staff. There was no
available trained teaching staff and some of the midwifery schools were housed in a single room.
The learning environment was perceived as being highly inadequate by all respondents. This was
particularly pointed out by the staff of the midwifery school of Quetta but applied to all schools
providing training to CMWs. In addition to this, practical midwifery training was being delivered at
the tertiary hospital in the Obstetrics and Gynecology department in Quetta, resulting in CMW
trainees not gaining work experience in community-based health services. There was also no
mechanism of coordination between the midwifery schools to facilitate student or faculty exchange
to enhance learning. In addition to this, according to the provincial level respondents, most of the
midwifery schools lacked the capacity to provide quality training and ad hoc teaching staff posted
were not familiar with their roles and responsibilities. Some of the trained teachers who were
politically well connected did not want to serve in the remote areas and were never transferred to
such locations. School management was also poor. It was reported that even for successful basic
administration of the schools, such as procurement of supplies and equipment, linkages with
politically higher authorities was required. The midwifery school respondents shared that most
schools in the districts of Balochistan were run solely by the Principal.
One respondent stated:
“As per the recommendation of the Pakistan Nursing Council, tutors should hold a post-
graduate nursing degree. In Balochistan there are very few post-graduate nurses and when
we transfer them they don’t go to the outskirts. In rural districts there are schools where only
a principal is working.” [Representative BDoH, Quetta]
Another participant said:
“There are very few trained tutors, we need to train the faculty of the midwifery schools first
and then only can we produce a quality product.” [Mercy Corps SMNC program staff]
All respondents were of the view that if the teaching staff were strengthened and given improved
facilities, the situation could be improved substantially. They agreed that even by improving the
working condition of the teaching staff in the periphery, many midwives would be willing to work in
the remote districts.
23
Regarding revisiting the content of the curriculum and practical training, many respondents
expressed the need to allocate more time to hands on training in a community setting. They
believed that this aspect was neglected in the current training. CMWs received training in a tertiary
care setting that did not prepare them for their work at a community level.
“We can see that theoretically everything is remarkably good but when we talk about
practical exposure, we came to know that the majority of CMWs have not attended any
deliveries during their 18-month training course. So either they didn’t get a chance or their
tutors were not playing their role properly. Even it’s written that during the course they will
go to the community and serve, that component is never implemented.” [Mercy Corps
SMNC program staff]
The lack of quality training stemmed from the poor ownership of the CMWs by the BDoH and poor
Human Resource management as detailed hereunder:
a. Poor ownership of CMWs by the BDoH
By design, CMWs were to work in the communities and after training sustain themselves as
trained private health care providers deployed with minimal support from the BDoH. The CMWs by
design were to be selected from the communities so that after deployment they would serve in
their respective areas. There were many gaps between the design and implementation. When the
midwifery schools advertised admissions, applicants fulfilling the educational criteria were offered
places. Remote areas lacked applicants that met the minimum education criteria for admission and
this resulted in CMWs being recruited and trained from urban settings. Recruitment of rural CMWs
was also undermined by the lack of rural community representation during the CMW selection
procedure. The CMW selection process led to a concentration of trained CMWs in urban
environments. While establishing their health practices in urban areas, CMWs had to compete with
higher qualified health care providers, including doctors and Lady Health Visitors in both the
private and public sector. This meant that CMWs were not deployed to areas that lacked trained
health care providers. Many CMW respondents indicated that at the time of training they were
explicitly told that they would be given permanent government jobs on completion of the CMW
course. Post-deployment when the CMWs realized the nature of the work and their roles, they lost
motivation to establish their own practices. This is reflected in the quote below:
“At the time of admission, the applicants should be informed fully about what this job
demands and what it actually is. This is one of the biggest reasons for drop-outs because
24
some CMWs have the expectation that they will gain proper government employee status.”
[CMW, Quetta]
The participants shared that as per the government policy, trainees were required to stay at the
hostel during the training period. Since there was no accommodation for married women with
children in hostels, most of the CMWs that completed their training were unmarried. The potential
for CMWs to set-up clinics after training was not checked at the admission stage and often CMWs
left training without the space or resources to establish a clinic. It was also mentioned by BDoH
respondents that after training, many CMWs did not turn up to collect delivery kits provided to them
by the BDoH.
“When we called deployed CMWs to collect supplies and equipment from the department
only 30 out of 180 came. The rest of them said that they did not have the space in their
homes.” [MNCH program respondent, Quetta]
CMWs also cited that they were demotivated after their initial post-deployment two-year stipend
was stopped and they were expected to sustain themselves through private enterprise. They
perceived this as a lack of ownership by the BDoH. The Government of Balochistan was indecisive
about whether CMWs should be made part of the government structure or a private entity.
However, it was repeatedly mentioned by all respondents that for the successful retention of
CMWs, the government has to take major steps, including providing incentives.
“If you have to retain them then incentives should be increased to at least a minimum
monthly wage of Rs. 13,000.” [MNCH program respondent, Kech]
“The government should provide CMWs a monthly salary package of at least Rs 5000 or
7000. Besides that, CMWs should run their own businesses. In this way it will work. The
government should provide training, do monitoring and CMWs should generate reports and
should not sit idle.” [Government Official, Quetta]
It usually took one year from a CMW to complete their training to being deployed. During that time
period CMWs were not provided with any refresher training by the government. Also, no support
was given to CMWs to maintain their workstations. CMWs in the program intervention areas
highlighted the support provided by Mercy Corps. The respondents confirmed that not only were
Mercy Corps providing refresher training to CMWs before deployment, they were also providing
support to CMWs in the maintenance of their home set-ups.
25
“The refresher trainings are very beneficial for us. They should be conducted regularly. We
learn a lot and get new knowledge during such trainings. Our knowledge gets revised if we
forget our lessons.” [CMW, Kech]
b. Poor Human Resource Management
Efficient and proper utilization of human resource requires financial and technical management of
investments. The respondents shared that for the long-term sustainability of the program, the
national MNCH program should ensure timely deployment of CMWs after training, regular
monitoring and supportive supervision, and an appropriate stipend. They also shared that career
advancement was necessary for retention within the system. It was feared that without proper
management of CMWs by the health department, this trained workforce would be lost.
One respondent said:
“The Balochistan Health Department trained thousands of TBAs and now no TBA is seen.
Similarly, if we don’t bring CMWs within our system they will also be gone like TBAs.” [BDoH
respondent, Quetta]
Another issue that respondents raised was that when offering admissions to the CMWs, the same
geographical areas were repeatedly considered for the selection of girls. Therefore, the balance
between those trained and the need of CMWs in a particular area was not achieved. This was
especially evident in urban areas of Balochistan. As a result, a larger number of CMWs were
concentrated in urban areas instead of in rural settings where their services were needed the
most.
“When I visit my village, I find that the residents badly need a CMW. There is no one to
attend to the needs of women. When I was visiting for a wedding, I was called to attend to a
seven-month pregnant woman who had been in labor for over 48 hours. She had been
advised by her relatives to rest as it was too soon for delivery. What I saw was that the baby
was almost out. She had been in a lot of pain and no one had taken her to a doctor.” [LHS,
Quetta]
The provincial and district level health department respondents were of the opinion that mapping of
CMWs should be done to identify areas which required CMWs. The tutors of Midwifery schools
shared that the BDoH had recently advertised names of the union councils from which applicants
were required. Unfortunately, very few of applicants from the specified areas fulfilled the admission
criteria.
26
“We normally advertise and do not mention the Union Councils where the applicants are
encouraged to apply from. Then when we tried to select girls on the basis of UCs, only eight
girls qualified. The rest did not meet the required minimum qualification. It is not cost effective
to run a training program for only eight students.” [Midwifery school respondent, Quetta]
It was suggested that CMWs should replicate the regularization process previously followed by the
LHW cadre. The respondents felt that the two types of workers could work together to provide
services. However, many respondents believed that since LHWs were busy with other activities,
for example implementing polio campaigns, they could not extend support to CMWs. This gap was
evident from the small number of pregnant women being referred to CMWs by LHWs. Traditional
birth attendants/ Dais (TBAs) were also in competition with CMWs. Dais have been involved in
home based deliveries for generations and people tended to trust them and their skills more.
“We are facing problems from Dais. We are in competition with them. They socially
boycotted us and our families and proactively stopped people from coming to us for
treatment.” [CMW, Gwadar]
However, CMWs from intervention areas felt that the communities were gradually appreciating
their skills and were willing to accept CMWs as a trained health care provider. This was considered
as being the result of CMWs having their own setup and treating their clients with respect.
“The community welcomed us when we started our work in our areas. The community is
happy with our work because it is much better than Dais.” [CMW, Kech]
Another respondent said:
“There are some clients who are unable to pay for our services. Some pay later. If we insist
on payment they go to the Dai instead. We then have to convince them by showing them
the difference in our work…… They like it when we conduct delivery behind a curtain, giving
them privacy (sharam parda) whereas Dais do not take care of such things. Whosoever
wants enters that room. Mother-in-law is often sitting nearby smoking huqqa and no one
cares about the feelings of the patient. Now many clients prefer our setup.” [CMW, Quetta]
2. Neglected Deployment Strategy
Upon completion of their 18 months training CMWs had to wait one or two years before
deployment. As a result, many trained CMWs moved towards other career options including
teaching in schools, working as a midwife in a hospital or as an assistant to a doctor. Many
employers hired them at a lesser remuneration than a nurse. A major chunk of CMWs were
27
therefore ‘lost’ to the system and of no value to the health infrastructure. Because of the time gap
between training completion and deployment, refresher training of CMWs was needed but no such
opportunity was given to them. The delay in deployment was primarily due to the delayed
registration of midwives by the Pakistan Nursing Council (PNC). The registration processing time
of 6 weeks was often extended to over a year.
“Many girls start working as a teacher or substitute for nurses in hospitals. They earn around
Rs. 10,000.” [CMW, Quetta]
Another respondent said:
“Deployment is delayed to such an extent that a CMW forgets everything. Initially the
midwifery school registers students with the PNC as students. Later registration became the
responsibility of the MNCH program. In PNC the process takes 6 weeks. But that 6 weeks’
registration period was delayed to 1 year or even more. “[Mercy Corps SMNC program Staff]
The respondents attributed this neglected deployment strategy to poor coordination between the
government stakeholders, including the BDoH, the national MNCH Program and the PNC.
Respondents from the Mercy Corps project team shared that according to the deployment
guidelines, CMWs were supposed to be introduced to the communities at a public event to confirm
their credibility and facilitate acceptance by the community. Mercy Corps arranged community
sensitization meetings for CMWs in intervention areas. However, no such measures were
undertaken for CMWs in non-intervention areas. Some CMWs, especially those from the
intervention areas, introduced themselves and their services to communities:
“My parents told the community that their daughter is taking training and she will become a
doctor or baji. Otherwise, we introduce ourselves as a CMW in the community. We educate
people about health and people respect us and our work. We are successful in conducting
safe deliveries and people appreciate our work.” [CMW, Kech]
a. Lack of Coordination Between Stakeholders
In the design of the CMW program, different stakeholders were supposed to provide technical and
administrative support to recruit, train and retain CMWs. However, a lack of coordination between
the BDoH MNCH program, the PNC and the National Program for Family Planning and Primary
Health (NPFP&PHC) was evident. The PNC, although involved in the registration of CMWs
delayed the process. One reason for the lack of coordination mentioned by the respondents was
the financial constraints of the BDoH.
28
“We faced many hurdles. For deployment we have registered 102 CMWs who have
qualified but we have some financial constraints. This project had Rs. 2600 plus million
budget and it was supposed to close in 2012. However, by 2012 no province had achieved
the targets so they extended it to 2015. But unluckily no province, except Punjab, got the full
budget.” [MNCH respondent, Quetta]
LHWs were recognized as a government health cadre and have been regularized by the BDoH. By
design, technical and administrative supervision of CMWs was to be provided by LHVs and LHSs
respectively, with support in community mobilization provided by LHWs. However, because of a
lack of coordination within the BDoH supervision of CMWs was neglected. Respondents said that
although the MNCH program and (NPFP&PHC)program, aimed to reduce maternal and child
mortality, it worked independently from the CMW program. This lack of coordination resulted in a
duplication of activities. This not only led to a waste of resources but also resulted in inefficient
service delivery. It was also expressed during the interviews that integration of both programs
should be proactively implemented to enhance the planning of activities and achievement of
outcomes. The MNCH program had developed a complete checklist for monitoring and supervision
of CMWs. However, it was only used for Mercy Corp supported CMWs whereas in non-
intervention areas, CMWs were not evaluated on the basis of the checklist. Also, all the reports
with related information were not shared across departments and programs and instead sent to
District Health Information System (DHIS) only.
“Family planning and MNCH programs personnel sit together but there is gap in information
sharing. Their implementation is not aligned. So if the level of coordination is improved
between these two departments, things in the field will also be improved.” [Mercy Corp
SMNC program staff member]
There was a lack of coordination between CMWs, LHWs, LHVs and LHSs in non-intervention
areas. Mercy Corps had however facilitated establishing such linkages. LHWs in intervention areas
provided great support in community mobilization.
“There are some areas where linkages between LHWs and CMWs were facilitated. Actually
in a monthly meeting a LHW was called and told that they have a CMW in their area. So a
communication link was created between them and it has helped a lot.” [CMW, Quetta]
Mercy Corps extended support by expediting the process of PNC registration of CMWs. This
reduced the delay in deployment of CMWs and potentially reduced their drop out. In the interim
29
period i.e. between completion of training, PNC registration and deployment, the CMWs were
forced to either stay at home or seek gainful employment elsewhere.
“Mercy Corps helped us in our registration with the PNC as without it we could not start our
work. Also the MNCH program would not take responsibility in case something happened to
the clients.” [CMW, Quetta]
b. Weak Linkages with Private Sector
CMWs were required to eventually sustain themselves as private practitioners. During the
interviews respondents expressed the need for the government to take a multi-dimensional
approach. They believed that the government and donor organizations could not work in isolation.
CMWs expressed that through support of donors, they could establish their own service delivery
setups. However, they still preferred to be seen as part of the public sector. They recognized the
role of donors in the completion of their training and the continuation of maternal healthcare
services in the field. CMWs were given by Mercy Corps, a stipend, provided support in registration,
provided with equipment and supplies, supported to set-up of workstations, provided with refresher
training and supported to market their services through community mobilization. Such steps led to
the CMWs being motivated and committed to serve the communities in the intervention areas.
“Mercy Corps is doing our appraisal and they also monitor us and supervise us and give us
feedback after evaluation. We are also getting good technical support from LHV/LHSs and
field officers. Their staff is very good and helps us if there is some problem in our work and
suggestions on ways for improving our services are given.” [CMW, Gwadar]
Regarding the support provided to CMWs in the marketing of their services to communities, one
respondent said:
“Initially we informed people in the community about our work. We conducted meetings and
went to their homes so now they are aware of our work. The introductory meetings were
conducted by Mercy Corps in the communities. They also supported us in putting sign
boards outside our houses for our marketing.” [CMW, Gwadar]
Government officials were in favor of taking measures to ensure the induction of young women
from the remote areas. One official was of the view that an accelerated learning program for girls
from remote areas should be started so that local residents could be enabled to train as CMWs:
30
“The government lacks experience. For retention of CMWs, they should be given some
incentive. They should be enrolled in accelerated education programs, or should be properly
allocated, or Mercy Corps or UNICEF or some other organization should support them.
Regularizing them will become very costly for the government.” [Government official,
provincial level]
3. Harsh Environment
The terrain of Balochistan added to the challenges of delivering the CMW program in Balochistan.
The geographical distances between settlements affected the decisions of young women to opt to
train as CMWs and also hindered the pursuit of their careers. Harsh weather conditions and
traveling without availability of transport in a patriarchal society made their service delivery difficult
and challenging.
“It took almost a year for me to gain recognition in the community. I made regular door-to-
door visits for a year or two. But now it’s not needed. Two years were tough but now people
come to me themselves.” [CMW, Quetta]
“We went from door-to-door initially. The security conditions were not good here, so people
would not welcome us in their homes. Once a client came to me and left happy with
treatment…. that’s how I gained people’s trust.” [CMW, Gwadar]
The make-up of trainee CMWs was influenced by the fact that there was a lack of hostel facilities
for married women and because families were often reluctant to send their girls to hostels. After
post-training deployment, the cost of travel to provide services within communities often cost more
than the income generated from the services provided. CMWs often had to be accompanied by an
escort when travelling which obviously incurred additional costs. The majority of CMWs said that
they are supported by their parents in their work. However, it was also mentioned that after
marriage, mobility of CMWs would be determined by the husband and his family.
a. Geographical Terrain Challenges
The geographical terrain of Balochistan is very challenging especially for the mobility of young
women. With consideration of the scattered settlements in the catchment areas of CMWs in
Balochistan, their client coverage was considerable reduced (as stated in the design document of
the Balochistan MNCH program). A catchment population of 5000 households for CMWs could not
be followed. The dispersed population on one hand reduced the clientele of CMWs while on the
other hand made their sustainability a big issue.
31
“There are CMWs who leave their homes at 5am in the morning and change many buses
before reaching the training institutes. During training we had to spend on transport from our
own pockets. That was a very difficult time as some of us were pregnant, some had small
children………. it was a difficult time. In Quetta too there are settlements that are widely
spread out.” [CMW, Quetta]
“We don’t get matriculate girls from every union council, and we cannot send CMW from one
union council to the other. In some areas they are deployed on populations of 4000 whereas
in others only 1000 to 2000 households fall in their vicinity. Some have even lesser numbers
of households.”[MNCH, Quetta]
The clientele was thus reduced. Most families with low income perceived CMWs as government
employees and expected free treatment.
“There are some clients that can’t afford giving money at all, there are others who say the
will give money later. This is because people think that we are attached to the government
and we are getting salary from there. They want us to treat them for free.” [CMW, Quetta]
b. Patriarchal Culture
Respondents expressed that because Balochistan has a male dominated society, most families
discourage women from working alone outside their homes. In poor families women are married at
an early age and polygamy with multiple children borne by each wife is often witnessed. The
needs of a mother were often ignored. In communities that were unaware of the services of CMWs
for maternal and child health, the situation was considered worse. The respondents shared that
Dais (traditional birth attendants) were preferred by many families. They were respected for their
services because of their age and experience - the trained cadre of CMWs were not valued.
“People who are educated understand easily but it gets very difficult to communicate with
those not educated and to make them understand. They come to you every other day
asking you the same thing again and again. A girl came to me and said she is bleeding. So I
took her to the hospital and the doctor said that we have to operate. Her relatives took their
time deciding. What if she died who would be responsible? You see they do not understand
things.” [CMW, Quetta]
Respondents expressed the need to counsel families and inform them of the importance of utilizing
CMWs’ services.
32
CMWs who had established their clinics had done so with support from their families. They shared
that most families accepted young women pursuing teaching because it was considered a
respectable profession for women. The community midwifery profession has not yet received such
recognition.
“CMW service recognition by the society is important so that CMWs can continue to work
even after they get married.” [CMW, Kech]
Most respondents reported that with time, the acceptance of CMWs is increasing. However, the
need for efforts to mobilize communities was highlighted. Respondents were of the opinion that
LHWs could support the promotion of CMWs within communities.
“This is because the LHWs that are working, they know which house has a pregnant
woman and can refer them to a CMW.” [LHV, Kech]
Phase II: Quantitative Analysis
Based on qualitative results from the interviews and focus groups, a final list of job attributes for
rural CMWs and the relevant levels was developed (given in Box 1). For each of the attributes, two
to three levels were determined. Each level represented a privilege that the government could
potentially offer the CMWs for working in rural areas.
Box 1 – Attributes and levels
Job Attribute Attribute Level

1 Housing None
Housing allowance
Housing with basic amenities
2 CMW practice setup Seed money for set up
Regular continuous supply of medicines/ delivery
kits
3 Transportation None
Transport allowance
4 Supportive management No supervision
Supervision through program (LHS/LHS/WMO)
Refresher courses
5 Stipend PRs. 5000/ month
PRs. 7000/ month
PRs. 12000/ month
6 Good schooling for Yes
children
No
33
From the list of attributes, twelve pairs of incentive packages were designed using Sawtooth
software. An example of one pair of incentive packages is given in Box 2 (see Annex 4 for the 12
pairs included in the survey).
Box 2: Paired Incentive Packages
Job Package 1 Job Package 2

Housing None Housing with Basic Amenities
CMW Practice Setup Seed money for setup Regular continuous supply medicines/
delivery kits
Transportation None Transport Allowance
Supportive management No supervision Refresher courses
Stipend Rs. 7000/ Month Rs. 5000/ Month
Good schooling for children Yes No
A total of 110 respondents participated in the DCE survey. The sample included 50 respondents
from intervention areas and 60 from non-intervention areas. Five sets of questionnaires were
generated through Sawtooth. Each set of questionnaires was administered to a minimum of 10
CMWs each from intervention and non-intervention areas. All the respondents were residents of
Balochistan. The respondents profile is given in Table 3.
34
Table 3: Socio-demographic description of CMWs
Intervention Non Intervention P value

(n=50) (n=60)
f (%) f (%)
Age
17-20 years 10 (17%) 0.038
21-25 years 23 (46%) 32 (53%)
25-29 years 22 (44%) 15 (25%)
30 years and above 5 (10%) 3 (5%)
District
Quetta 20 (40%) 8 (13%) <0.001*
Gwadar 10 (20%) -**
Kech 20 (40%) 13 (22%)
Other 39 (65%)
Marital Status
Married 18 (36%) 29 (48%) 0.134
Unmarried 32 (64%) 31 (52%)
Current Work Location
Rural 28 (56%) 30 (50%) 0.569
Urban 22 (44%) 30 (50%)
Work Experience (Years)
No Experience 1 (2%) 6 (10%) 0.012
1-2 years 9 (18%) 10 (17%)
3-4 years 27 (54%) 20 (33%)
5-6 years 10 (20%) 13 (22%)
More than 6 years 3 (6%) 7 (12%)
Average Monthly Income
Not given 1 (2%) 8 (13%) <0.001*
Less than 3000/month 21 (42%) 29 (48%)
Between 3000-5000/ month 9 (18%) 21 (35%)
Between 5000-7000/ month 6 (12%) 1 (2%)
Between 7000-10000/month 13 (26%) 1 (2%)
Average Monthly
Household Income
Not given 1 (2%) 0 (0%) 0.111
Less than 10,000/month 10 (20%) 19 (32%)
Between 10,000-20,000/ 18 (36%) 27 (45%)
month
Between 20, 000-30,000/ 15 (30%) 8 (13%)
month
More than 30,000/month 6 (12%) 6 (10%)
Work Preference .007*
Preferred working in rural 42 (84%) 36 (60%)
over urban areas
Didn’t prefer working in rural 7 (14%) 24 (40%)
over urban areas
* Statistically significant at p<0.05 between intervention versus non-intervention areas**All the CMWs in
Gwadar were from intervention areas. Only 13 CMWs were working in Kech in non-intervention areas. CMWs
from Nushki and Harnai (neighboring districts to Gwadar and Kech) were also included in the non-
intervention area sample.
35
No significant difference was found in the ages of CMWs in intervention and non-intervention
areas. The majority of CMWs from both groups were less than 25 years of age. There were very
few CMWs in non-intervention areas so additional CMWs were included from the neighboring
districts of Nushki and Harnai. The majority of the participants (64% in intervention areas and 52%
in non-intervention areas) were unmarried. Participants from rural and urban settings were
included in the sample. The number of years of experience in the two groups was comparable.
The majority of participants (54% from intervention and 33% from non-intervention areas) had
work experience of 3-4 years. The average monthly income of participants from the intervention
areas was higher than those in the non-intervention areas. However, the average monthly
household income was similar in both groups.
Participants in intervention and non-intervention areas when asked whether they preferred
practicing in a rural versus urban setting indicated preference for working in rural areas. 84% of
respondents in intervention areas preferred working in rural settings as compared to 60% in non-
intervention areas. The relation between preferred work location with marital status, age and
current work location was also explored (). No significance association was seen. Married CMWs
preferred working in rural areas.
Table 4: Relation of demographic variables with location of work preference in non-

intervention areas
Prefer working in rural (N=36) Don’t prefer working in P
rural (N=24) Value
Intervention Non-intervention Intervention Non-Intervention
f % f % f % f %
Marital Status
Single 16 38% 17 47% 2 29% 12 50% 0.246
Married 26 62% 19 53% 5 71% 12 50%
Age
21-25 years 19 45% 23 64% 3 43% 19 79% 0.15
25-30 years 18 43% 10 28% 4 57% 5 21%
31 years and above 5 12% 3 8% -
Current Work
Location
Rural 24 57% 22 61% 3 43% 8 33% 0.568
Urban 18 43% 14 39% 4 57% 16 67%
* Statistically significant at p<0.05 between intervention versus non-intervention areas
36
Inferential Analysis of Choice Data
The data generated in the DCE job scenario pair section were analyzed using the mixed logit
regression function of STATA program. This modeling technique was used to determine the
statistical significance of each job attribute.
Analysis of job pair data from intervention and non-intervention groups was carried out separately
(Annex 5). However, since the results of both groups were similar, a combined analysis is
reported. All the attributes yielded statistical significance as factors influencing the choice of a rural
job (at the p<0.05 level), except for support with setup and schooling for children (Table 5).
Table 5: Job Attributes and their significance level
p values
Stipend 0.000*
Housing Allowance 0.000*
Housing Amenities 0.000*
Setup 0.366
Transportation 0.000*
Supervision by Government 0.008*
Refresher Course 0.000*
Schooling 0.698
* Statistically significant at p<0.05
The raw output from STATA includes the p-values as well as coefficients of each of the sub levels
within the job attributes (Annex 6). This output was then used to determine the weighted
preference ranking of each job attribute by the CMWs. Weighted preference ranking provided a
priority ranking order of respondents’ preferences for the job attributes or factors
surveyed, and showed how much more respondents favor the most preferred attribute to
all the others—i.e., the “weight” or value they placed on an attribute as compared to the
other factors/attributes. This ranking was determined by comparing the mean coefficients
resulting from the mixed logit regression analysis of the 12 job scenario pairs and listing
them from the most (highest mean coefficient) to least preferred (lowest mean coefficient)
attribute.
Table 6 illustrates the weighted ranking of job attributes in order of highest to least mean
coefficient value.
37
Table 6: Weighted ranking of preferences

Job Attribute Coefficient
1 PRs 10000/month 1.433
2 PRs 7000/month 1.0031
3 PRs 5000/month .7165
4 Refresher courses .5482413
5 Transport allowance .5441802
6 Housing with basic amenities .5319988
7 Housing allowance .35678
8 Supervision through program (LHS/LHV/WMO) .3001255
9 Regular supply of medicines/ delivery kits .0731114
10 Good schooling for children .0290965
Stipend was the most important motivation factor for the CMWs. The degree to which this
influenced the CMWs’ preferences depended on value of the stipend. Highest preference was for
PKR 10,000/month followed by 7,000 and 5,000/month. Refresher courses were valued higher
than supervision while housing with basic amenities was valued more than a housing allowance.
Good schooling for children was the least preferred job attribute.
Retention Packages
In order to develop options for job packages, coefficient values of the job attributes were used.
Different potential packages of retention incentives were developed to estimate predicted
preference impact. For this purpose, a ‘Preference Calculation Worksheet’ developed in MS Excel
32
by Capacity Plus was used (Annex 7). Attributes for developing packages were selected based
on their weighted ranking, discussions with policy makers, project team members and CMWs.
The preference impact measure estimates what percentage of the CMWs would prefer a job
posting that offers the presented package of incentives to other available jobs that do not have
those benefits. In other words, the preference impact measure looks at how the probability of
selecting a given post changes as the attributes and levels of those attributes change. The
preference impact measure can assist stakeholders in determining which incentives and in what
specific combination will be the most attractive to health workers and more likely to motivate and
retain them to work in rural and remote areas.
38
Only those packages are presented which showed a preference impact of 80% and above (Table
7).
Table 7: Potential retention packages

Salary Amount PRs 0 PRs PRs PRs
3000 5000 10,000
Incentive Package 1
Housing allowance 72% 78% 82% 89%
Transport allowance
Supervision through program (LHV/LHS)
Refresher courses
Incentive Package 2
Transport allowance 69% 75% 79% 87%
Supervision through program (LHV/LHS)
Refresher courses
Incentive Package 3
Supervision through program (LHV/LHS) 60% 67% 72% 82%
Refresher courses
Package1
Package 1 proposes provision of housing allowance, transport allowance, supervision through

program (LHV/LHS) and refresher courses. Results showed that if no extra stipend is given to
CMWs and just these four incentives are provided, the rate of retention will increase from the
current 50% to 72%. Similarly, if the stipend is increased to PKR 3000, retention rate will further
increase to 78%. A further increase in the stipend amount will result in retention of up to 89%.
Package 2
Package 2 proposed transport allowance, supervision through program (LHV/LHS) and refresher
courses. Results showed that in the absence of a financial stipend, retention will increase to 69%.
A progressive increase in the stipend from PKR 3000, PKR 5000 and PKR 10,000 will increase
retention to 75%, 79% and 87% respectively.
Package 3
In Package 3 is proposed - supervision (through program by LHVs or LHS), and refresher courses
only. Results showed that provision of these incentives without stipend will increase retention to
60%. Similarly, progressive increase in stipend from PKR 3000 to PKR 5000 and PKR 10,000 per
month will potentially increase the retention to 67%, 72% and 82% respectively.
39
Conclusions
The study identified that a lack of quality training services, an inadequate deployment strategy and
the harsh environmental conditions of Balochistan led to the poor retention of CMWs, particularly
in rural areas.
• The BDoH saw retention of CMWs as a challenge for the province due to the geographical
terrain of Balochistan and the patriarchal culture that limited the mobility of women.
Furthermore, financial constraints, poor human resource management, inadequate
deployment strategies, and insufficient training provision resulted in CMWs being poorly
trained and utilized.
• The BDoH was keen to train CMWs from remote areas but no accelerated learning program
for girls was in place to support rural girls to train as CMWs.
• CMWs trained were concentrated in certain geographical areas where they had to compete
with more qualified health care providers and also traditional birth attendants (Dais).
• The CMWs expected employment with the government after the completion of their training.
The expectation to sustain themselves in the communities through private practice was
perceived by them as a lack of ownership by the government.
• Deployment guidelines were published but only implemented in intervention areas.
• Supportive supervision was in place for the CMWs in the intervention areas. Intervention
area CMWs were able to establish linkages with LHWs, LHVs and LHSs. The monitoring
and supervision checklist prepared by the MNCH program was being used in the
intervention areas but was not utilized in the non-intervention areas.
• CMWs in both areas voiced a need for refresher training. They welcomed support by
International NGOs and development partners to establish their service delivery but at the
same time wanted to be recognized as a public sector workforce.
The findings from the DCE survey suggest that there may be a number of effective strategies to
improve the recruitment and retention of health workers in rural and remote areas of Balochistan.
CMWs expressed a willingness to take jobs in rural areas if the postings were made more
attractive. While a stipend was important, it was seen that when a combination of other valued
interventions was offered, a stipend became less important. This finding is consistent with World
Health Organization (WHO) and World Bank’s (WB) recommendations for Human Resources for
Health (HRH) retention, which contend that increasing salary alone is not enough to motivate
40
health workers in rural and remote areas. Appropriate incentive packages such as housing
allowances, transport allowances, supportive supervision and refresher courses are required.
• The majority (84%) of respondents in the intervention areas preferred working in rural areas
as compared to 60% in non-intervention areas. The preferred work location had no
statistically significant association with marital status, age and current work location.
• Three packages have been proposed that may improve retention of CMWs:
o A package including the provision of a housing allowance, transport allowance,
supervision through program (LHV/LHS) and refresher courses with no extra stipend
to CMWs suggested an increase in the rate of retention from the current 50% to
72%. If, however a monthly stipend was to be increased to PKR 3000 and PKR
10,000, the retention rate would increase to 78% and 89% respectively.
o A package including a transport allowance, supervision through program (LHV/LHS)
and refresher courses in the absence of a financial stipend would increase retention
to 69%. An increase in stipend from PKR 3000, PKR 5000 and PKR 10,000 will
increase retention to 75%, 79% and 87% respectively.
o A package with supervision (through program by LHVs or LHS), and refresher
courses without stipend would increase retention to 60%. Increase in monthly stipend
from PKR 3000 to PKR 5000 and PKR 10,000 will potentially increase retention to
67%, 72% and 82% respectively.
Recommendations
1. Selection criteria and accelerated education programs: To counter the low retention of
CMWs in the rural and remote areas of Balochistan, new selection criteria for CMWs must
be introduced. The health department should seek active collaboration to establish
accelerated education programs to provide women and girls with the opportunity to
complete higher secondary level education through a fast-track course. A higher secondary
accelerated education program in chosen rural areas would raise the education attainment
levels of local women and girls and therefore increase the number of women and girls
meeting the minimum education standards of CMWs. Steps must also be taken to ensure
family support for selected candidates through a thorough orientation for candidates and
their families.
41
2. Community involvement in the CMW selection process: Community representation in

the CMW selection committee must be implemented to ensure fair selection from each
community.
3. Inter-Departmental Coordination: The development of a functional coordination team

representing stakeholders from the BDoH health worker programs (LHW, MNCH) and
development partners should be considered. The purpose of this coordination team should
be to provide oversight for improved recruitment, training, monitoring and supervision of
CMWs, through information exchange and inter-departmental collaborations. An
accelerated process for midwifery registration with the PNC needs to be instigated, followed
by the expedited deployment of CMWS to relevant areas.
4. Functional Human Resource Management (HRM) System: The MNCH program should
develop an integrated human resource management system to maintain a record of all
CMWs under-going training and deployed. GIS mapping of functional CMWs may also be
integrated in the HRM system.
5. Incentives for CMW retention: The decision regarding which incentives or interventions to
include in a provincial CMW retention strategy needs to be determined by stakeholders
based on political and economic feasibility, with a focus on capacity to deliver. For example,
to provide supervision to CMWs, there must be an adequate number of qualified
supervisors in the department, trained in the use of modern/current monitoring tools with
access to transport and other services for ensuring regular supervisory support within the
challenging geographical terrain.
6. Transfer of allocated funds: The allocated program budget for the MNCH program must
be transferred from the federal level to the provincial program accounts in its entirety
without delays to ensure continuity in the implementation of program goals and objectives.
42
SUB STUDY 2
RESEARCH QUESTION
How can CMWs become financially self-sustaining while serving the needs of the poorest of the
poor?
METHODOLOGY
An expenditure and investment assessment of CMWs was undertaken. As this was not a
conventional costing model (cost effectiveness or cost utility), the analysis for this was based on
an average of various costs to determine operational costs incurred by CMWs. A key objective of
the CMW business training program offered by Mercy Corps to CMWs in intervention areas was to
improve livelihood opportunities for them while providing community based maternity care. In order
to evaluate the impact of the business skills training a comparative financial analysis of deployed
CMWs in both intervention and non-intervention areas was undertaken. Using the same sampling
strategy and size as sub-study 3, a minimum of 50 CMWs from each of the intervention and non-
intervention area were included in the survey. In all 63 CMWs from the intervention areas (who
had undergone business skills training) and 72 CMWs from the non-intervention areas were
included. Reaching out and identifying CMWs in the non-intervention area was a challenging task.
In the absence of a sampling frame, the District Health Office and Mercy Corps staff made multiple
field visits to identify practicing CMWs. The CMWs were asked to maintain a daily expenditure log
for a month on a structured checklist. Based on this daily log, direct (mobile phone charges,
personnel at market rate, medicines, equipment, etc.), indirect (travel, food, chaperones, etc.) and
opportunity costs (other best alternative) for delivering the CMW health care services were
reported. Additional investments such as establishing their clinics, enhancing
networking/marketing, financial management, maintaining quality practices and others investments
were recorded as well.
The financial data was entered into Microsoft Excel. Income and expenditure statements for each
CMW were developed. Income was generated by CMWs through patient fees for services,
charges for diagnostic tests and medicines sold to clients. Expenditures included direct and
indirect costs of providing care. Direct costs consisted of the cost of drugs, diagnostic kits and
other supplies required to provide clinical care. Indirect costs consisted of rent for the clinic facility,
monthly costs of procuring drugs and other supplies, and payments made to any hired transport
vehicle (if applicable). Opportunity costs, based on market rates, were also added as expenditure
(see tools in Annex 8). Net income was calculated by subtracting total expenditures from total
43
income. The average costs of services provided by CMWs were also calculated. This data was
then categorized and analyzed in SPSS, along with background information collected from CMWs.
The background information included socio-demographics, use of Tameer (or any other) loan and
initial investment in establishing the clinical facility.
These findings were supplemented by FGDs with CMWs and key informant interviews with the
concerned officials of the Health department (at the provincial and district level) and Mercy Corps
staff.
RESULTS
The socio-demographic characteristics of CMWs in intervention and non-intervention areas are

outlined in Table 8. A total of 63 CMWs were randomly selected from intervention areas (Quetta,
Kech and Gwadar) and 72 from non-intervention areas (Quetta, Kech, Gwadar, Noshki and
Harnai). The majority of the CMWs from both areas were between the ages of 21 to 30 years.
More than 45% of the participants had 12 years of education (Intermediate). Most of the
participants in both areas were unmarried (Intervention 76%, Non-Intervention 54%). The reported
monthly income of the CMWs ranged between PKR 1000 to 10,000. Forty % of CMWs from
intervention areas reported a monthly income of PKR 1000 to 3000.
44
Table 8: Demographic information of respondents
Intervention Non-intervention
(N=63) (N=72)
f (%) f (%)
Age
Not given 4(6%) 1(1%)
Less than 20 5(8%) 9(13%)
21-25 years 28(44%) 31(43%)
26-30 years 23(37%) 25(35%)
More than 30 years 3(5%) 6(8%)
Education
Secondary 12(19%) 19(27%)
Intermediate 29(46%) 34(47%)
Graduate and above 21(33%) 19(27%)
Madrasah 1(2%) 0(0%)
Marital Status
Married 15(24%) 33(46%)
Unmarried 48(76%) 39(54%)
Monthly Income
None 1(1%) 0(0%)
<1000 3(5%) 3(4%)
1000-3000 25(40%) 12(17%)
3000-5000 10(16%) 17(24%)
5000-7000 4(6%) 1(1%)
7000-10,000 5(8%) 3(4%)
Don’t Know 0(0%) 34(47%)
Not given 15(24%) 2(3%)
Financial Analysis of CMW practices

Financial data of only ‘functional’ CMWs was analysed. A functional CMWs was defined as one
who had worked for a minimum of 7 days in that month and maintained a complete record of her
activities in the logbook. Findings in this section are based on cost data (complete records) from
29 of the 63 CMWs from intervention areas, and 8 of the 72 CMWs from non-intervention areas.
One outlier in the intervention area was excluded as she was working at a clinic with a doctor due
to which her reported income was considerably higher. Cost data was entered and analysed in
Microsoft Excel to make calculations of net income of each CMW and the average cost of various
activities was calculated. Net income was calculated by subtracting total expenditures from total
income. Averages were calculated for the start-up costs, materials purchased, travel and fees
charged for services. All costs are reported in Pakistani Rupees.
45
Cash Flows and Net Income

Table 9 shows the income and expenditure statement of CMWs from the intervention districts.
Overall the mean net income was PKR 2581 (ranging from negative 4910 to 13450 rupees).
Excluding the negative cash flows, average income was calculated to be PKR 4510 per month.
Seven of the Mercy Corps supported CMWs had negative cash flows as per the reported data. A
negative cash flow is indicative of investment being higher than monthly income i.e. CMWs were
earning less than their monthly expenditure on service provision. Only two of the respondents had
a net income above PKR 10,000, while only one CMW was earning the standard minimum wage of
PKR 13,000. Details of the cash flows are in the table below.
Table9: Cash flow data – intervention areas
Monthly
expense
(Maintenance, Total Net Income
ID HR, Utilities) Direct Indirect Expense Total Income (per month)
1 0 2180 3300 5480 3450 -2030
5 100 380 0 480 3925 3445
9 100 0 0 100 4600 4500
10 500 1400 1000 2900 4000 1100
11 100 5500 1650 7250 2340 -4910
12 50 2500 500 3050 5310 2260
32 0 100 1500 1600 15050 13450
40 10000 1265 0 11265 16380 5115
41 1600 2550 400 4550 6478 1928
42 0 710 0 710 2540 1830
44 4800 3218 50 8068 11070 3002
45 4300 6305 0 10605 20790 10185
46 4500 6875 480 11855 15700 3845
47 0 1855 0 1855 5410 3555
48 0 1060 0 1060 3560 2500
49 8500 1200 0 9700 6825 -2875
50 6500 4470 600 11570 20930 9360
46
52 100 1300 0 1400 9720 8320

53 0 2591 0 2591 9780 7189
54 4750 1210 0 5960 6320 360
55 4700 1800 0 6500 5580 -920
56 3000 820 970 4790 9500 4710
57 3000 3915 200 7115 2700 -4415
58 1200 3090 0 4290 4555 265
59 5000 3240 320 8560 13945 5385
60 2300 820 0 3120 1230 -1890
47
Monthly
expense
(Maintenance, Total Net Income
61 2000 0 0 2000 180 -1820
62 0 695 200 895 3300 2405
63 5000 1950 0 6950 5950 -1000
Average income (all inclusive) 2581
Average income (only those with positive net income) 4510
Table 10 shows income and expenditure statements from 8 CMWs from non-intervention areas.
Overall the mean net income was negative 462 (ranging from negative 7015 to 17300 rupees).
Excluding the negative cash flows, average income was calculated to be PKR 4510 per month.
Four of the CMWs reported negative cash flows in the recorded data. Only one respondent had a
net income above the standard minimum wage of PKR 130,00. Details of the cash flows are in the
table below.
Table 10: Cash flow data - non-intervention areas
Monthly
expense
Respondent (Maintenance, Total Net Income
21 0 5000 915 1100 0 -7015
22 0 0 840 0 895 55
23 0 0 905 210 1220 105
24 0 0 980 0 1560 580
25 0 5000 65 20 760 -4325
27 0 0 2000 0 19300 17300
28 0 4500 570 80 1270 -3880
31 0 6000 305 210 0 -6515
Average income (all inclusive) -461.875
Average income (only those with positive net income) 4510
The CMWs in the intervention and non-intervention areas were also asked about how they
perceived their own business skills. Only 24 of the CMWs from non-intervention responded to this
48
section of the survey. More than 90% of CMWs from both areas responded as being well aware of
business skills required for the set-up of a maternity care services clinic, including the principles of
financial management, investment rules and regulations, and knowledge of business plan
development. The use of telephones, fax machines and personal computers for establishing and
maintaining a business was identified as being important by almost 70% of the respondents. The
findings of the perceptions survey are in stark contrast to the costing analysis as several of the
respondents were incurring losses in their clinical set-up.
Average costs of setup and services

The CMWs were asked to record their initial investment in developing a functional clinic, expenses
incurred due to the purchase of medicines and diagnostic kits, costs incurred due to travel, as well
as the fees they charged for services offered (Table 11). Using this data, the average of each
category was calculated and is reported in PKR. The average initial investment was PKR 51552,
ranging from nil to a maximum of 662,000. Costs above PKR 10,000 were explored by the field
staff. It was revealed that costs above PKR 10,000 were often due CMWs investing in construction
work to establish a separate clinical space. The average fee charged for a delivery, was PKR
1736, ranging from nil to 3000. The lowest fee charged was for family planning services (average
charge PKR 46, ranging from nil to 225). Post-natal care was the least popular service provided,
based on the reported services. Details of charges for other services are detailed in Table 4.
Table 11: Average costs of setup and services (intervention areas)

Materials Services (Charges)
Purchase
d
(medicine
s, Post- General
Start-up diagnosti Antenata natal Deliver Family Healthcar Medicine
ID costs c kits) Travel l Care Care y Planning e s
1 0 390 250 233 0 850 0 0 210
5 455 127 0 0 0 2500 0 83 588
9 2000 0 0 100 0 1250 0 0 2000
10 500 675 500 225 0 2000 0 0 220
11 1000 589 100 50 0 750 200 0 77
12 0 321 150 200 0 1350 0 0 157
32 3000 100 200 100 0 2000 0 0 1390
40 2500 38 0 100 0 2600 113 0 117
41 100000 319 400 163 0 2000 0 0 229
42 10700 355 0 0 0 2000 20 87 240
49
44 37000 402 50 150 0 3050 0 0 388

45 110000 370 30 478 30 2786 98 395 674
46 40000 313 200 125 0 2000 90 103 313
47 60000 368 15 113 0 850 177 50 372
48 10000 177 0 50 0 2000 50 0 177
49 10500 400 0 0 0 3000 0 50 242
50 662000 574 90 579 283 2375 115 0 409
52 60000 650 0 26 0 4000 0 0 650
53 8500 288 0 50 0 2667 30 0 333
54 168750 130 0 117 0 2500 0 0 89
55 31200 360 0 275 0 2250 0 0 446
56 11110 164 194 0 0 1740 0 0 200
57 45000 260 100 125 0 0 225 275 242
58 35000 224 0 317 0 0 80 162 206
59 15000 183 160 58 500 1972 100 77 147
60 33000 410 0 50 50 0 0 515 0
61 10300 111 160 142 680 680 30 45 137
62 16500 232 0 100 88 0 0 500 475
63 11000 279 0 78 0 1167 0 0 250
Average costs of setup and services (PKR)
51552 304 90 138 56 1736 46 81 379
Investment and expenditure records of CMWs from non-intervention areas were also analysed to
understand their initial investment in developing a functional clinic, the cost incurred by purchasing
medicines and diagnostic kits and the expense of travel, as well the fees charged for services
delivered (Table 12). Averages of each category were calculated and reported as PKR. The
average initial investment was PKR 14000, ranging from 4000 to a maximum of 25,000. The
average fee charged for a delivery was calculated to be PKR 1681, ranging from 750 to 2600,
while the lowest fees were charged for family planning services (average PKR 46, ranging from nil
to 225). From the data reported, it appears that postnatal care (PNC) were not provided by any of
CMWs in non-intervention areas. Details of charges for other services are detailed in Table 12.
Table 12: Average costs of setup and services (non-intervention areas)
Start- Materials Services (Charges)

ID up Purchase Travel Antenatal Post Delivery Family General Medicines
50
costs d Care - Planning Healthcar

(medicin natal e
es, Care
diagnosti
c kits)
21 4000 390 250 233 0 850 0 0 210
22 4000 127 0 0 0 2500 0 83 588
23 25000 0 0 100 0 1250 130 0 2000
24 15000 675 500 225 0 2000 0 98 220
25 9000 589 100 50 0 750 200 50 77
27 15000 321 150 200 0 1500 0 0 157
28 25000 100 200 100 0 2000 0 200 1390
31 15000 38 0 100 0 2600 113 0 117
Average costs of Setup and Services (PKR)
14000 280 150 126 0 1681 55 54 595
The CMWs are required to provide all services associated with maternity care including antenatal
care, delivery, post-natal care; family planning services and general health care and advice. As per
the program policy, CMWs can charge their clients a fee for these services. Survey respondents
were asked to identify services that were the most and least profitable (Table 13). Delivery
services were identified as the most profitable activity by CMWs from both intervention (65%) and
non-intervention (29%) areas. The other two services deemed profitable were general health care
(36.5%) and antenatal care (31.7%). Less than 3% of the CMWs from non-intervention areas
identified general health care and family planning services as being profitable.
Table 13: Profitable services provided by CMWs

Most profitable services provided by CMWs
Intervention Non-intervention p-value
areas areas
(N=63) (N=72)
f (%) f (%)
Answer not given 5 1
Antenatal Care 20(31.7) 1(1.4) <0.001*
Delivery 41(65.1) 21(29.1) <0.001*
Postnatal Care 16(25.4) 1(1.4) <0.001*
51
General Health Care 23(36.5) 2(2.7) <0.001*

Family Planning 12(19.0) 2(2.7) 0.003*
Least profitable services provided by CMWs

(N=63) (N=72)
f (%) f (%)
Answer not given 5 7
Antenatal Care 22(34.0) 11(15.2) 0.009*
Delivery 2(3.1) 3(4.1) 1.000
Postnatal Care 15(23.8) 2(2.7) <0.001*
General Health Care 24(38.1) 6(8.3) <0.001*
Family Planning 14(22.2) 1(1.4) <0.001*
* Statistically significant at p<0.05 between Intervention versus non-intervention areas
CMWs in intervention areas categorized general health care (38%), antenatal care (34%) and
family planning (22.2%) as being some of the least profitable services. CMWs from non-
intervention areas also identified the same services as being the least profitable.
With reference to financial sustainability, CMWs were asked whether they took any loans (Tamer
loans, personal loans etc.) to establish themselves as community based maternal care providers.
None of the CMWs in the non-intervention areas reported taking loans to set-up their clinics. In
intervention areas 32 CMWs took out a personal loan to support the establishment of their clinics.
Reasons given for not taking a Tameer loan included the interest rate on the loan (by 25.3% of
respondents) and a lack of need for the loan (by 19% of respondents). Some of the CMWs who
had taken loans from their family members reported using the loan to set-up a workstation
(28.5%), purchasing equipment (20.6%), buying medicines (41.2%) and purchasing diagnostic kits
(22.2%).
Six of the respondents from intervention areas indicated that there was no demand for services at
a community level or there was presence of other competitors providing maternal care. This
resulted in CMW respondents not investing in the establishment of their own maternity care set-
ups. Respondents also identified the need for refresher training in business and midwifery skills.
More than 50% of the CMWs from intervention areas and 32% from non-intervention areas
52
expressed the need for training on business skills. More than 20% of the respondents identified
need for refresher courses on midwifery skills.
Challenges to achieving financial sustainability

The qualitative study to understand challenges in achieving financial sustainability of CMWs as
community based maternal care providers supplemented the quantitative findings. The following
three themes were identified from the data (FGDs with CMWs and IDI with the officials of the
BDoH and Mercy Corps):
i) Barriers to achieving financial sustainability
ii) Entrepreneurship – concept and initiatives
iii) Health Department and program support for financial viability
i) Barriers to achieving financial sustainability

In discussions with CMWs in both intervention and non-intervention areas, many challenges in
establishing services as maternal health care providers were identified. A major barrier to the
establishment of financially sustainable services was a low demand for their particular services
due to issues of access because of the challenging geographical terrain. The CMWs highlighted
that due to the challenging geographical landscape they found it difficult to visit households in their
catchment population and encourage women to utilize their services. In the interviews with the
Mercy Corps team it was mentioned that special permission had to be taken from the BDoH to
allow CMWs to establish workstations in their homes. This step was taken to encourage CMWs to
establish themselves within their communities.
CMWs in intervention areas were also trained by Mercy Corps in business skills and management.
Most of the participants appreciated the business skills training and found it informative and useful.
However, the majority of CMWs trained in business skills were unable to utilize it effectively. Some
of the participants from intervention areas shared that they had established clinics following the
training but due to a low demand for services, they were forced to work either as school teachers
or start home business such as a salon for women.
Some of the participants raised the issue of community members being unwilling to pay for CMW
services as they considered the CMWs as public sector employees. Communities were of the view
that CMWs were salaried government staff and therefore should not demand a fee for services nor
53
should they charge them for medicines or other materials used for purpose of treatment. The
majority of the participants shared that this community attitude was primarily due to their
experience of interacting with LHWs who provide free health advice and medicines.
ii) Entrepreneurship – concept and initiatives

The participants were probed to establish their understanding of entrepreneurship and whether
they had successfully used this skill for establishing their CMW services. The participants’ views
were consistent with the survey findings. The majority of CMW respondents were not aware of the
concept of enterprise and had been unsuccessful in utilizing their business skills training for
initiating and sustaining their health services. Very few CMWs had taken any initiatives for
collaboration with other service providers. Another salient finding was the difference in
understanding of the concept of enterprise between participants from intervention and non-
intervention areas. This maybe attributable to the training CMWs in intervention areas were
exposed to and the lack of training in non-intervention areas.
Some of the participants shared that that they had taken some steps to establish themselves in
their communities. These included efforts to work with the local TBAs commonly known as Dai.
Some had been successful in developing a working relationship with TBAs whereas most of the
participants were unable to foster similar arrangements. Some of the participants had also worked
in private health care facilities as support staff to doctors or LHVs. However, this was a temporary
working arrangement for most CMWs.
Some CMWs took on the initiative of providing free services in the initial days of their deployment.
Participants highlighted that they did this to make community members aware of their particular
skill set and to establish their worth. This practice had been beneficial to them allowing them to
demand a fee for services from their clients, based on a positive reputation.
Members of the Mercy Corps SMNC program team were of the view that CMWs should be given
regular refresher training on business skills and management as it was a difficult concept for
CMWs to understand in a one-off training course, especially considering their educational
background. The project team members expressed that CMWs should be given an interest free
loan so that they are able to establish their CMW workstation.
54
The qualitative findings are in stark contrast to the survey responses regarding CMW’s own
perceptions of their business skills. The majority of CMWs responded that they are well aware of
the skills required to set-up and run a small business, that they are able to develop a business plan
and that they can manage services according to the need of their respective communities.
iii) BDoH and program support for financial viability

A significant finding from the discussions and financial survey was the importance of the monthly
stipend to ensuring the sustainability and survival of the CMWs. Although the value of this stipend
was capped at PKR 5,000 (~USD 50) per month, it was highlighted to be useful in ensuring
continuity of maternity care services provided by the CMWs. The stipend release was linked with
submission of monthly progress reports by the CMWs. Due to this conditionality, CMWs were
compelled to achieve some of the targets set for them. Participants who had been unable to
establish their clinics highlighted that this stipend assisted them in managing their expenses such
as purchasing medicines, paying for travel costs and other related expenditure for the delivery of
their service. Continuity of the monthly stipend was the single most fervent demand of the CMWs
from non-intervention areas. In the absence of this, the majority of the CMWs were apprehensive
about whether they would be able to sustain their services.
Another issue raised by the CMWs was their integration within the BDoH. Many CMW respondents
expected to be incorporated into the government structure of health workers. Their expectation
was based on the previous assimilation of LHWs into the government health system. The CMWs
were of the view that as part of the government system, they would have access to much needed
support (such as medicines, equipment, transport etc.) to enable their provision of services to
target populations. Participants highlighted that at the time of induction into the CMW program,
they were given the impression that upon completion they would become part of the public sector
health system. However, the reality turned out to be starkly different. The CMWs were required to
establish private healthcare services that would be independently financially sustainable.
The BDoH and Mercy Corps SMNC program team members were in agreement with the CMW’s
need for long-term support from the health system and/or development partners. It was their view
that the government’s support for LHWs resulted in their long-term sustainability and facilitated the
achievement of program goals. Similar steps for CMWs would ensure their survival as skilled
maternal healthcare providers.
55
Conclusions
Considering the results of the survey and discussions with CMWs, it is evident that the majority of
the CMWs have been unable to establish financially sustainable services, particularly those in non-
intervention areas.
The CMWs in intervention areas were provided with significant support from the Mercy Corps
SMNC program team. This support resulted in some CMWs successfully establishing themselves
as maternal healthcare providers in their respective communities. However, all CMWs struggled to
achieve financial sustainability. This is evident from the fact that the net income of only two CMWs
(one from an intervention area and one from a non-intervention area) is above the standard
minimum wage of PKR 13000 per month. The average income of CMWs in both areas is
approximately PKR 4500 per month. The data also shows that several of the CMWs were failing to
get any significant returns on their investment. The majority of the CMW’s clientele is either unable
to pay for services due to poverty or they were unwilling to do so. In both scenarios, it is evident
that the CMWs need continued support for their survival as community based maternal healthcare
providers.
Recommendations
1. Program support for CMWs: Support from the MNCH program is direly needed to provide
supervision and stipends to CMWs for at least five years post-deployment. This would
enhance continued service delivery in rural communities. Program support to improve
referrals to CMWs, logistics and travel services for CMWs working in rural areas is
especially required.
2. Business Skills and Management trainings: There is the need to integrate training on
entrepreneurship and small business management into the pre-service CMW training
curriculum. The development of such skills can be beneficial to all midwives regardless of
development partner support after deployment.
Proposed Sustainability Model: Based on the findings of this survey, it is evident that to be an
effective and functional community based maternal healthcare provider the CMWs need
continuous support from the MNCH program and the BDoH. The majority of CMWs have been
unable to capitalize on the entrepreneurial skills they were taught and establish functional services
within the community that made the required profit. Those CMWs who have managed to establish
56
a working set-up, rely very much on the monthly stipend they receive from the MNCH program.
The BDoH needs to take the lead in the development of a pathway for the integration of CMWs
into the provincial health system. This could safeguard the achievement of program objectives and
improve maternal and child health indicators in the province. Integration of the CMWs within the
provincial health system may ensure long-term sustainability of this workforce and the continuity of
available maternal care services in community settings.
57
SUB STUDY 3
RESEARCH QUESTION
Do CMWs offer quality care? How?
METHODOLOGY
A comparative cross sectional study was undertaken to assess the quality of care offered by
CMWs in the intervention areas and the non-intervention areas. A sampling frame was developed
for the number of CMWs trained and deployed in the three intervention districts. Non-intervention
areas with working conditions similar to those in intervention areas were selected in consultation
with the BDoH and Mercy Corps SMNC program staff. All the CMWs in the selected areas were
listed to generate a sampling frame and proportionate sample from the three districts (20 each
from Quetta and Kech and 10 from Gwadar. Samples were taken from both intervention and non-
intervention areas in target districts, making a sample size of 50 CMWs from intervention and 50
CMWs from non-intervention areas). Through simple random sampling, the selected number of
CMWs were invited to participate in the study. While this was the case in the intervention areas,
drawing of the sample was a challenge in the non-intervention areas as the ground reality was
different. Many CMWs in non-intervention areas on record were no longer providing services. Only
those CMWs working and/or reporting to the health department were included in the sample. At a
confidence level of 90% (z value 1.645), error 10% (0.1) and with assumption of 20% improvement
in practices among intervention areas as compared to the control (n=z2 p(1-p)/e2=(1.645)2
(.20)(.80)/(.1)2) the sample size required was 43. Including a 10% non-response rate, the
minimum sample size = 47 So 50 CMWs in each area (intervention and non intervention) were
included in the study. (see tools in Annex 9)
Quantitative Survey
A structured KAP (knowledge, attitude and practices) questionnaire was used to collect information
from 100 CMWs (50 from intervention and 50 non-intervention areas). The pre-tested structured
questionnaire and observation check list was based on the scope of work of CMWs covering
antenatal, natal and postnatal services in addition to assessing familiarity with cross cutting
themes such as communication skills, ethical practice, updating knowledge etc. (Annex 3.1). The
feasibility of assessing the practices of CMWs was worked out in consultation with the Mercy
58
Corps SMNC program team. Independent LHVs were hired to visit the CMWs in their clinics and
shadow CMWs for 1-2 days to observe their practices. Due to time constraints only those services
delivered within the days of observation could be assessed. The quality of care offered by the
CMWs in intervention and non-intervention areas was then compared.
Although the questionnaire used for assessing KAP consisted of three main domains, including,
knowledge, attitude and practices, in order to have a better assessment these domains were
further divided into 4 main sections i.e. antenatal care, natal care, post-natal care and general
care. The knowledge section of the questionnaire consisted of 20 questions. Each correct answer
in the knowledge domain carried 1 mark while wrong or ‘don’t know’ answers carried a 0 mark.
This gave a score range of 0 – 20 for the knowledge section.
The attitude and practice section of the questionnaire consisted of 41 and 33 questions
respectively. In the attitude section, ‘not responded’ carried 0 marks while negative attitude such
as strongly disagree and disagree were given “1” and “2”, respectively. Positive attitude such as
definitely agree and strongly agree carried a score of “3” and “4” respectively. This gave a score
range of 0 to 164 for the attitude section. The practices of CMWs were observed during the data
collection period. Due to the time limitation, some practices were not possible to observe. So in the
case of practice section, ‘not practiced’ was scored 0 while ‘can’t perform’, ‘not competent’,
‘competent’, ‘very competent’ and ‘not observed ‘were scored as “1”, “2”, “3”,” 4”, and “5”
respectively. This gave a score range of 0 to 132 for the practice section. The scores in
knowledge, attitude and practice domains were categorized as poor (less than and equal to 60 %),
moderate (61 to 70 %) and good (above 80 %).
Statistical Analysis:
For the analysis of data, Statistical Package for Social Sciences software, version 16.0 (SPSS Inc.,
Chicago, IL) was used. Initially, all information gathered via questionnaires was coded into
variables. Both descriptive and inferential statistics involving Chi square test were used to present
results. For each test, a p-value of less than 0.05 was considered statistically significant.
Qualitative Assessment
FGDs were conducted with clients who had received CMW services in the intervention and non-
intervention areas. FGDs gathered client perspectives on the care they were given by CMWs and
their views on how it could be improved. Ten FGDs were conducted altogether; five in intervention
59
and five in non-intervention areas (Annex 3.2-FGD Guide). Altogether 59 female clients from
intervention areas and 50 from non-intervention areas participated in the discussions. Information on
age, number of children, education, husband’s education and household decision maker were also
noted. The FGDs included the perspective of women of reproductive age on the quality of care
given by CMWs and their knowledge on MNCH issues (knowledge attained through women groups
where applicable, nature of knowledge received and how it affected their decision making regarding
the use of services offered by CMWs). Content analysis of the data was undertaken to understand
clients’ satisfaction with CMW services.
RESULTS
Knowledge Attitude and Practices of CMWs
The socio-demographic characteristics of CMWs in intervention and non-intervention area are
described in Table 14. A total of 50 CMWs were randomly selected from intervention areas and 79
from non-intervention areas (details in Annex 10). 23 (29.1%) CMWs in non- intervention areas
and 8 (16.0%) in intervention areas had an educational level of graduation (14 years of education).
The majority of CMWs in both areas were married and had 2-5 children. The majority of CMWs
had a monthly salary of < 10000 rupees and lived in a home where the total household monthly
income from all sources was less than Rs. 20000 – this income supported up to 10 people. The
majority (above 60%) of the CMWs in both areas owned a television, refrigerator, motorcycle and
washing machine and < 15% of CMWs possessed assets such as an air conditioner and a car.
38% of CMWs in intervention areas owned computers, compared to 20.3% of CMWs in non-
intervention areas. No difference was observed in the experience level of CMWs in both areas.
However, the CMWs in intervention areas were conducting significantly more deliveries compared
to those in non-intervention areas (p-value< 0.05) and had significantly better income (0.006).
Table 14: General characteristics of CMWs

Intervention areas Non-intervention areas p-value
(N=50) (N=79)
f (%) f (%)
Educational status
Madrasah 0 (0.0) 2 (2.5) 0.029*
Secondary 10 (20.0) 24 (30.4)
Intermediate 32 (64.0) 30 (38.0)
Graduate & above 8 (16.0) 23 (29.1)
Marital status
Single 16 (32.0) 35 (44.3) 0.164
Married 34 (68.0) 44 (55.7)
No of alive children
1 6 (25.0) 6 (19.4) 0.096
2-5 15 (62.5) 25 (80.6)
60
>5 3 (12.5) 0 (0.0)

Monthly salary (PRs)
< 10000 43 (86.0) 78 (98.7) 0.006*
11000-15000 6 (12.0) 0 (0.0)
>15000 1 (2.0) 1 (1.3)
Overall household income per
month (PRs)
< 10000 12 (24.0) 32 (41.0) 0.024*
11000 – 20000 18 (36.0) 31 (39.7)
> 20000 20 (40.0) 15 (19.2)
No of supported people
<5 14 (29.2) 14 (17.7) 0.320
6-10 19 (39.6) 36 (45.6)
>10 15 (31.2) 29 (36.7)
Own
Television 44 (88.0) 60 (75.9) 0.112
Refrigerator 41 (82.0) 55 (69.6) 0.148
Air Conditioner 6 (12.0) 11 (13.9) 0.797
Motorcycle 34 (68.0) 44 (55.7) 0.197
Washing Machine 34 (68.0) 59 (74.7) 0.427
Computer 19 (38.0) 16 (20.3) 0.041*
Car 6 (12.0) 9 (11.4) 0.989
Experience as CMW (years)
<1 4 (8.0) 16 (20.3) 0.226
1.0 -3 23 (46.0) 26 (32.9)
3.01-5 16 (32.0) 26 (32.9)
>5 7 (14.0) 11 (13.9)
Number of deliveries per month
None 6 (13.3) 33 (42.9) 0.003*
1 5 (11.1) 12 (15.6)
2-5 28 (62.2) 26 (33.8)
>5 6 (13.3) 6 (7.8)
Training was adequate for 50 (100) 78 (98.7) 0.999
working in the field
The knowledge required by CMWs was sub-divided into four sections including antenatal, natal,
newborn and postnatal care. These four sections covered all services that should be provided by
CMWs. The correct responses are given in bold in the following tables (15-18). As shown in Table
15, the knowledge regarding the antenatal care was similar in intervention and non-intervention
areas, 84.0 % CMWs in intervention areas and 84.8% of CMWs in non-intervention areas were
aware of the total number of antenatal check-ups required during pregnancy while 66% of CMWs
in intervention and 57% of CMWs in non-intervention areas were able to explain educational
messages required for pregnant women. About 60% of CMWs in both groups correctly mentioned
focused antenatal care comprising of the monitoring of women’s blood pressure at every visit.
61
Table 5: Knowledge of CMWs regarding antenatal care

areas areas (N=79)
(N=50) f (%)
f (%)
Antenatal checkups during pregnancies
05 Antenatal checkups 7 (14.0) 5 (6.3) 0.119
04 Antenatal checkups 42 (84.0) 67 (84.8)
03 Antenatal checkups 1 (2.0) 7 (8.9)
Pregnant women should receive what educational
messages
Personal Hygiene, rest and exercise during pregnancy 3 (6.0) 10 (12.7) 0.591
Diet and nutrition during pregnancy 10 (20.0) 16 (20.3)
Danger signs during pregnancy 4 (8.0) 8 (10.1)
All of the above 33 (66.0) 45 (57.0)
Focused antenatal care includes what actions
Checking the baby’s position at 28 weeks 15 (30.0) 17 (21.5) 0.643
Checking the woman’s blood pressure at every visit 29 (58.0) 50 (63.3)
Assessing ankle edema at 36 weeks 2 (4.0) 6 (7.6)
Counseling the women about danger signs only at the 4 (8.0) 6 (7.6)
last visit
CMW knowledge of natal care was assessed through five questions and similar level of knowledge
was observed in both intervention and non-intervention areas. A significant lack of knowledge
regarding natal care was observed in both intervention and non-intervention areas. The majority of
CMWs (86% in intervention and 77.2% in non-intervention areas) correctly explained that the
active management of the third stage of labor was required. However, only 30% of CMWs in
intervention and 36.7% in non-intervention areas were able to correctly demonstrate the
appropriate order of steps in active management of third stage labor and plot the cervical dilation
on the partograph. In addition to this, only 44% of CMWs in intervention and 40.5% in non-
intervention areas were able to correctly interpret the findings. Only 20% of CMWs in intervention
and 22.8% in non-intervention areas were aware of measures to decrease the risk of infection
during childbirth (table 16).
62
Table 16: Knowledge of CMWs regarding natal care

areas n=50 areas n=79
f (%) f (%)
rd
Active management of the 3 stage of
labor should be practiced….
Only for women who have a history of post- 1 (2.0) 5 (6.3) 0.446
partum hemorrhage
Only for primipara 4 (8.0) 11 (13.9)
Only for multipara 2 (4.0) 2 (2.5)
For all women in labor 43 (86.0) 61 (77.2)
Appropriate order of steps in active
management of the third stage of labor
include
Controlled cord traction, fundal massage, and 30 (60.0) 40 (50.6) 0.521
oxytocin
Intravenous oxytocin, cord clamping and 3 (6.0) 3 (3.8)
cutting, and fundal massage
Cord clamping and cutting, controlled cord 2 (4.0) 7 (8.9)
traction, ergometrine administration, and
inspection to be sure the placenta is intact
Intramuscular injection of oxytocin, 15 (30.0) 29 (36.7)
controlled cord traction with
countertraction to the uterus, and uterine
massage
areas n=50 areas n=79
f (%) f (%)
If a woman is admitted during the active
phase of labor cervical dilation is initially
plotted on the partograph
To the left of the alert line 22 (44.0) 23 (29.1) 0.058
To the right of the alert line 17 (34.0) 30 (38.0)
On the alert line 4 (8.0) 2 (2.5)
On the action line 7 (14.0) 24 (30.4)
Cervical dilation plotted to the right of the
alert lines indicates
Satisfactory progress in labor 22 (44.0) 32 (40.5) 0.544
Unsatisfactory progress in labor 10 (20.0) 24 (30.4)
The end of the latent phase 7 (14.0) 11 (13.9)
The end of the active phase 11 (22.0) 12 (15.2)
Risk of infection during childbirth
decreases by…
Performing frequent vaginal examination 7 (14.0) 12 (15.2) 0.015*
Rupturing membranes as soon as possible in 3 (6.0) 16)0 (20.3)
the first stage of labor
Routine catheterization of the bladder before 11 (22.0) 22 (27.8)
childbirth
Reducing prolonged labor 19 (38.0) 11 (13.9)
All of the above 10 (20.0) 18 (22.8)
* Statistically significant at p<0.05 between intervention areas versus non-intervention
areas
63
Significant variation in responses was observed in the assessment of CMWs knowledge regarding
newborn care in intervention and non-intervention areas (Table 17). The assessment showed that
knowledge regarding the natal care was minimal in both areas. However, in comparison, CMWs in
intervention areas had better knowledge regarding immediate care for newborns. Only 30% of
CMWs in intervention and 30.4% in non-intervention areas were aware of the main causes of
hyperthermia in newborns and appropriate care of umbilicus (22% in intervention and 13.9% in
non-intervention areas). Only one quarter of CMWs (24% in intervention and 26.6% in non-
intervention areas) correctly specified the best way to determine need for resuscitation.
Table 17: Knowledge of CMWs regarding new born care
Intervention Non-intervention p-
areas areas (N=79) value
(N=50) f (%)
f (%)
Immediate care for a normal newborn
includes
Skin to skin contact followed by placing the 5 (10.0) 9 (11.4) 0.043*
baby in a warning incubator
Drying the baby, removing the wet cloth 15 (30.0) 36 (45.6)
and covering the baby with a clean, dry
cloth
Stimulating the baby by slapping the soles of 1 (2.0) 2 (2.5)
the baby’s feet
Deep suctioning of the airway to remove 1 (2.0) 8 (10.1)
mucus
All of the above 28 (56.0) 24 (30.4)
Which of the following can contribute to
hypothermia in newborns
The baby is not dried thoroughly 15 (30.0) 24 (30.4) 0.094
immediately after birth
The baby is bathed immediately after birth 18 (36.0) 23 (29.1)
The baby is dried and placed in skin to skin 4 (8.0) 14 (17.7)
contact with the mother
A and B 11 (22.0) 8 (10.1)
All of the above 2 (4.0) 10 (12.7)
64
(N=50) f (%)
f (%)
Care of the umbilicus should include
Cleaning with Alcohol 26 (52.0) 46 (58.2) 0.543
Covering with sterile compress 11 (22.0) 11 (13.9)
Cleaning with cooled, boiled water and leaving 4 (8.0) 4 (5.1)
uncovered
Applying antibiotic cream 9 (18.0) 18 (22.8)
The best way to determine if a new born
needs resuscitation is to
Wait until one minute after birth and assign the 17 (34.0) 13 (16.5) 0.019*
Apgar score
Listen to the baby’s heart rate 10 (20.0) 10 (12.7)
Observe respirations immediately and begin 11 (22.0) 27 (34.2)
resuscitation if they are less than 30 per minute
Perform resuscitation only if central cyanosis is 0 (0.0) 8 (10.1)
present
Apgar score at the time of birth 12 (24.0) 21 (26.6)
CMWs knowledge of postnatal care was assessed through eight questions and a significant
variation in responses was observed in intervention and non-intervention areas. Overall, a
noticeable proportion of CMWs reported a lack of knowledge regarding postnatal care. However,
CMWs in intervention areas were well aware of postpartum hemorrhage, control of eclampsia
convulsions, the signs and symptoms of a ruptured uterus, postpartum examinations and danger
signs. However, CMWs in non-intervention areas reported better knowledge of how to palpate the
uterus and how to provide immediate care within two hours of delivery compared to CMWs in
intervention areas (Table 18).
Table 18: Knowledge of CMWs regarding postnatal care 65
(N=50) f (%)
f (%)
Immediate postpartum hemorrhage can be
due to
Uterine atony 8 (16.0) 14 (17.7) 0.023*
Genital trauma 5 (10.0) 11 (13.9)
Retained placenta 3 (6.0) 19 (24.1)
All of the above 34 (68.0) 35 (44.3)
The most effective way to immediately
control eclamptic convulsions is to
Give diazepam 4 (8.0) 17 (21.5) 0.014*
Give magnesium sulfate 42 (84.0) 47 (59.5)
Deliver the baby as soon as possible 4 (8.0) 8 (10.1)
Give nifedipine 0 (0.0) 7 (8.9)
A woman with ruptured uterus has which of
the following signs and symptoms
Rapid maternal pulse 6 (12.0) 8 (10.1) 0.037*
Persistent abdominal pain and suprapubic 11 (22.0) 24 (30.4)
tenderness
Fetal distress 1 (2.0) 12 (15.2)
All of the above 32 (64.0) 35 (44.3)
66
(N=50) f (%)
f (%)
During the first 2 hours following birth, the
provider should
Measure the woman’s blood pressure and 22 (44.0) 19 (24.1) 0.104
pulse once, and insert a catheter to empty her
bladder
Measure the woman’s blood pressure and 14 (28.0) 31 (39.2)
pulse, and check the uterine tone every 15
minutes
Not disturb the woman if asleep because her 2 (4.0) 7 (8.9)
rest is more important than her vital signs
Measure the woman’s temperature and pulse, 12 (24.0) 22 (27.8)
massage the uterus, and perform a vaginal
examination to remove clots
After childbirth, the mother should have a
postpartum visit with a skilled provider
Once, at 3 weeks postpartum 8 (16.0) 11 (13.9) 0.206
Once, at 6 weeks postpartum 5 (10.0) 7 (8.9)
Three visit times 30 (60.0) 37 (46.8)
Only if she has danger signs 7 (14.0) 24 (30.4)
By the tenth day postpartum, you should be
able to palpate the uterus
Just below the umbilicus 21 (42.0) 22 (27.8) 0.414
At the level of the umbilicus 8 (16.0) 14 (17.7)
Just above the symphysis pubis 9 (18.0) 19 (24.1)
Halfway between the symphysis pubis and the 12 (24.0) 24 (30.4)
umbilicus
67
(N=50) f (%)
f (%)
Each postpartum examination should
include
Measurement of blood pressure and…
Measurement of blood pressure and 15 (30.0) 23 (29.1) 0.318
temperature, and assessment of conjunctiva,
breasts, abdomen, perineum, and legs
Observation of breastfeeding 2 (4.0) 11 (13.9)
Information about contraception, safer sex, and 1 (2.0) 2 (2.5)
counseling and testing for HIV
All of the above 32 (64.0) 43 (54.4)
At each postpartum visit, mother should be
counseled to seek care of the following
danger signs
Normal lochia, temperature 370 C, or slight 3 (6.0) 6 (7.6) 0.395
breast engorgement
Edema of hands and face, severe abdominal 12 (24.0) 25 (31.6)
pain, or sore, cracked nipples
Severe headache, foul-smelling lochia, or calf 5 (10.0) 5 (6.3)
tenderness
B and C 11 (22.0) 24 (30.4)
All of the above 19 (38.0) 19 (24.1)
68
Using a chi-square test, knowledge scores were categorized into three categories: good (>80%),
fair (61-70) and poor (<60) [1]. The results of this categorization are shown in (Table 19). The data
revealed that CMW’s knowledge of all domains (antenatal care, natal care and new born care was
minimal in both intervention and non-intervention areas. CMW’s knowledge of postnatal care was
better in intervention areas compared to non-intervention areas.
Table 19: Knowledge score of CMWs
(N=50) (N=79) value
f (%) f (%)
Knowledge score regarding antenatal care
Poor 28 (56.0) 47 (59.5) 0.739
Moderate 21 (42.0) 29 (36.7)
Good 1 (2.0) 3 (3.8)
Knowledge score regarding natal care
Poor 45 (90.0) 73 (92.4) 0.193
Moderate 3 (6.0) 6 (7.6)
Good 2 (4.0) 0 (0.0)
Knowledge score regarding new born care
Poor 46 (92.0) 72 (91.1) 0.386
Moderate 3 (6.0) 7 (8.9)
Good 1 (2.0) 0 (0.0)
Knowledge score regarding postnatal care
Poor 31 (62.0) 64 (81.0) 0.017*
Moderate 19 (38.0) 15 (19.0)
Overall score
Poor 47 (94.0) 76 (96.2) 0.429
Moderate 3 (6.0) 3(3.8)
* Statistically significant at p<0.05 between intervention areas versus non-intervention areas
Poor score: <60%, Moderate score: 60-80%, Good Score: > 80
69
Similarly, the attitude domain was divided into four sections including antenatal, natal, postnatal
and general care questions. Attitude was measured through the Likert scale ranging from 0 to 4,
‘Never’ was scored as 0 while ‘can’t perform’, ‘not competent’, ‘competent’ and ‘very competent’
were scored as “1”, “2”, “3”, and "4”, respectively.
CMWs attitude towards antenatal care varied in intervention and non-intervention areas as
indicated in Table 20. The findings are based on how CMWs perceived their own performance in
delivering care. While the majority of CMWs in intervention areas felt satisfied with their
performance in delivering antenatal care services, CMWs in non-intervention areas reported
dissatisfaction with the antenatal services they delivered, indicating that CMWs in non-intervention
areas did not feel competent in delivering antenatal care.
70
Table 20: Attitude of CMWs towards antenatal care
Average Score^ p-value

areas areas
I feel confident that I register pregnant 94 80 <0.001*
mothers as per the guidelines
I am trained to prepare mothers for 96 84 <0.001*
examination
I am competent to discuss mothers’ problems 95 85 <0.001*
individually
I can perform abdominal examination for: 95 67 0.014*
Assessing fetal growth
Determining the lie of fetus
I am confident in:
Counting fetal heart sounds 92 79 0.009*
Measuring maternal blood pressure 96 84 <0.001*
Identifying impending eclampsia 87 74 0.146
Weighing mothers 96 84 <0.001*
Recording weight in maternal record 96 85 <0.001*
Advising on maternal nutrition 94 87 0.006*
Correcting retracted nipple 84 75 0.940
Determining expected date of 90 76 0.023*
Delivery
I am competent to take appropriate action 81 65 0.75
regarding varicose veins
I can diagnose the onset of labor 91 77 0.027*
areas areas
I am confident that I give appointments to 90 79 0.112
come to health facilities as per protocol
I am competent in instructing how to take the 94 84 <0.001*
supplementary nutrition
Overall Score 92 79 0.009*
^On 100 point scale, a higher score indicated a higher participant’s agreement with the item tested
CMWs attitude towards natal care is significantly different between intervention and non-
intervention areas as described in Table 21. CMWs in intervention areas were satisfied with their
71
performance in delivering natal care, while CMWs in non-intervention areas reported that they
were dissatisfied with their natal care service delivery.
Table 21: Attitude of CMWs towards natal care

Intervention Non-intervention P
areas areas
Performing a delivery without assistance 84 68 <0.001*
Managing a post-partum hemorrhage 88 69 0.001*
Action to be taken of retained Placenta 88 69 0.004*
Assessment of progress of labor 89 72 0.033*
Performing an episiotomy 82 60 0.022*
Deciding when to perform an episiotomy in 83 58 0.012*
multipara
Aseptic severance of umbilical cord 91 70 0.003*
Clearing of airway of newborn 93 80 .001*
^ On a 100 point scale, higher score indicated a higher participant’s agreement with the item
tested
Significant diversity was found in the attitudes of CMWs in intervention areas regarding post-natal
care as compared to CMWs in non-intervention areas as shown in Table 22. The majority of
CMWs in intervention areas were satisfied with the post-natal care services they delivered, CMWs
in non-intervention area scored significantly less in this domain.
Table 22: Attitude of CMWs towards postnatal care

Intervention Non-
areas intervention
areas
Identification of abnormalities of lochia 92 79 0.039*
Identification of involuted uterus 94 76 0.005*
Cleaning episiotomy wound 91 76 0.034*
Examination of breasts for infection 95 77 0.020*
Measuring mothers' temperature 94 84 0.004*
72
Teaching a family member to care for 97 85 <0.001*

mother
Advising on maternal nutrition 96 87 <0.001*
Overall Score 94 80 0.001
^ On 100 point scale, a higher score indicated a higher participant’s agreement with the item
tested
A noticeable difference was found in the general attitude of CMWs in intervention and non-
intervention areas as indicated in Table 23. The majority CMWs in intervention areas were fully
confident in the services they delivered in general care i.e. creating awareness regarding
breastfeeding, child spacing etc. while CMWs in non-intervention areas reported a relatively poor
attitude towards general care.
Table 23: General attitude of CMWs

Delivering a health education talk regarding 96 88 <0.001*
general care of newborn, breastfeeding,
immunization, child spacing
Deliver all services in friendly and helpful 96 88 <0.001*
manner
If you were to recommend a healthcare 94 84 0.001*
provider to a friend or a close relative to
avail antenatal, neonatal or perinatal
services etc. (for example services given by
a CMW), you would recommend seeing a
CMW
CMWs are a preferred choice health care 95 82 <0.001*
provider because of convenience and
providing home-based care
If your sister was to go into labor I would 94 83 <0.001*
call a CMW
My community is well informed about CMW 93 81 <0.001*
services
My community’s preferred choice of 92 84 0.001*
73
healthcare provider for antenatal, perinatal

and neonatal services is a CMW
My community needs to get more 94 87 <0.001*
information about a CMW
In my opinion CMWs are doing a good job 95 84 <0.001*
in the field
In my opinion quality of service provided by 95 85 <0.001*
a CMW is good
tested
Attitude scores were categorized into three categories: good (>80%), fair (61-70) and poor (<60)
according to the quartile distribution. The results of this categorization revealed (Table 24) that the
attitudes of CMWs in all domains i.e. antenatal care, natal care, newborn care and postnatal care
were significantly better than the CMWs in non-intervention areas.
Table 24: Attitude score of CMWs

areas areas
Attitude score regarding antenatal care
Poor 0 (0.0) 7 (8.9) <0.001*
Moderate 8 (16.0) 34 (43.0)
Good 42 (84.0) 38 (48.1)
Attitude score regarding natal care
Poor 4 (8.0) 34 (43.0) <0.001*
Moderate 11 (22.0) 22 (27.8)
Good 35 (70.0) 23 (29.1)
Attitude score regarding postnatal care
Poor 0 (0.0) 5 (6.3) <0.001*
Moderate 7 (14.0) 36 (45.6)
Good 43 (86.0) 38 (48.1)
Attitude score regarding general health care
Poor 0 (0.0) 4 (5.1) <0.001*
Moderate 7 (14.0) 28 (35.4)
Good 43 (86.0) 47 (59.5)
Overall score
Poor 0 (0.0) 7 (8.9) <0.001*
Moderate 9 (18.0) 38 (48.1)
Good 41 (82.0) 34 (43.0)
^ On 100 point scale, a higher score indicated a higher participant’s agreement with the item tested
74
CMWs practices regarding antenatal care were scored on a scale of 100. The average scores for
CMW respondents are shown in Tables 25. Significant variation was observed during the
assessment of CMW practices in intervention and non-intervention areas. Antenatal practices of
CMWs in intervention areas were significantly better than those of CMWs in non-intervention
areas.
Table 25: Practices of CMWs towards antenatal care

Intervention Non-
intervention
Confident in registering pregnant mothers as per 94 79 <0.001*
the guidelines
Trained to prepare mothers for examination 95 81 <0.001*
Competent to discuss mothers’ problems 95 81 <0.001*
individually
Competent to perform abdominal examination for: 92 72 0.014*
Assessing fetal growth
Determining the lie of fetus
Confident in:
Counting fetal heart sounds 94 78 0.009*
Measuring maternal blood pressure 98 89 <0.001*
Identifying impending eclampsia 93 69 0.146
Weighing mothers 99 88 <0.001*
Recording weight in maternal record 99 84 <0.001*
Advising on maternal nutrition 98 86 0.006*
Correcting a retracted nipple 89 68 0.940
Determining expected date of 94 70 0.023*
Delivery
Competent to take appropriate action regarding 86 61 0.75
varicose veins
Trained in diagnosing onset of labor 94 73 0.027*
Confident to give appointments to come to health 92 77 0.112
facilities as per protocol
Competent in instructing how to take the 96 83 <0.001*

Significant difference in CMW practices in the delivering of antenatal care was observed in
intervention and non-intervention areas as outlined in Table 26. CMWs in intervention
areas were more competent in delivering natal services with an average of 94%, while
75
CMWs in non-intervention areas (average score 61%) were not confident in delivering
natal care services i.e. performing episiotomy, retaining placenta, managing a post-partum
hemorrhage and performing delivery without assistance.
Table 26: Practices of CMWs towards natal care

areas areas
Competent to:
Perform a delivery without assistance 95 61 <0.001*
Manage a post-partum hemorrhage 95 61 0.001*
Take action for a retained Placenta 95 60 0.004*
Assess progress of labor 94 65 0.033*
Perform an episiotomy 89 53 0.022*
Decide when to perform an episiotomy in 92 49 0.012*
multipara
Aseptic severance of umbilical cord 96 67 0.003*
Clear airway of newborn 97 75 .001*
Significant diversity was found in the postnatal care practices of CMWs in intervention areas
compared to CMWs in non-intervention areas as shown in Table 27. The majority of CMWs in
intervention areas were confident in conducting postnatal checkups i.e. identification of
abnormalities of lochia and involuted uterus, cleaning episiotomy wound, examining for breast
infection etc.
76
Table 27: Practices of CMWs towards postnatal care

areas areas
Confident in:
Identification of abnormalities of lochia 98 77 0.039*
Identification of involuted uterus 96 75 0.005*
Cleaning episiotomy wound 96 67 0.025*
Examination of breasts for infection 93 74 0.020*
Measuring mothers' temperature 96 84 0.004*
Teaching a family member to care for mother 97 85 <0.001*
Advising on maternal nutrition 98 88 <0.001*
^ On 100 point scale, a higher score indicated a higher participant’s agreement with
the item tested
A noticeable difference was observed in general practices of CMWs in intervention and non-
intervention area as indicated in Table 28. The majority CMWs in intervention areas were fully
confident about the general services they provided i.e. creating awareness of breast-feeding, child
-spacing etc. while CMWs in non-intervention areas were performing low in general care.
77
Table 6: General practice of CMWs

areas areas
Confident in:
Delivering a health education talk regarding 96 86 <0.001*
Deliver all services in friendly and helpful 98 88 <0.001*
manner
tested
Scores were categorized into three categories: good (>80%), fair (61-70) and poor (<60). The
results of this categorization (Table 29) revealed a clear gradient within the different levels of CMW
practices in antenatal, natal, and postnatal care in intervention and non-intervention areas. CMW
practices were significantly poorer in non-intervention areas as only 34.5% CMWs in non-
intervention areas were competent in delivering services whereas 96.6% of CMWs in intervention
areas were performing their services with high competency.
Table 7: Practice score of CMWs

areas areas
Practice score regarding antenatal care
Poor 0 (0.0) 11 (17.2) <0.001*
Moderate 0 (0.0) 24 (37.5)
Good 30 (100) 29 (45.3)
Practice score regarding natal care
Poor 1 (2.7) 34 (54.8) <0.001*
Moderate 3 (8.1) 17 (27.4)
78
Good 33 (89.2) 11 (17.7)

Practice score regarding postnatal care
Poor 0 (0.0) 7 (10.8) <0.001*
Moderate 2 (6.5) 32 (49.2)
Good 29 (93.5) 26 (40.0)
Practice score regarding general health care
Poor 0 (0.0) 4 (5.3) <0.001*
Moderate 3 (6.2) 27 (35.5)
Good 45 (93.8) 45 (59.2)
Overall score
Poor 0 (0.0) 10 (17.2) <0.001*
Moderate 1 (3.4) 28 (48.3)
Good 28 (96.6) 20 (34.5)
^ On 100 point scale, a higher score indicated a higher participant’s agreement with the
item tested
Client Satisfaction
Altogether 59 clients from intervention areas and 50 from non-intervention areas were included in
the FGDs to explore their satisfaction with CMW services. A description of the respondents is
given in Table 30 (Annex 10).
Table 8: Demographic Information of Respondents
Intervention (n=60) Non-Intervention (n=50)

F (%) F (%)
Age
less than 25 years 11(15%) 11(33%)
26-30 years 10(14%) 9(18%)
31-35 years 18(25%) 16(32%)
36-40 years 28(39%) 11(22%)
more than 40 years 5(7%) 3(6%)
No. of Children
no child 4(7%) 2(4%)
1-4 children 34(57%) 28(56%)
5-8 children 20(34%) 17(34%)
9-12 children 1(2%) 3(6%)
Education
Illiterate 37(63%) 37(74%)
Primary 5(8%) 2(4%)
79
Secondary 11(19%) 6(12%)

Matric/FSc 4(7%) 5(10%)
Graduation 2(3%)
Household Decision Maker
Husband 55(92%) 39(78%)
Mother in law - -
Self 5(8%) -
Other - 11(22%)
Figure 3: Analysis process moving from main theme to sub-themes to categories

.
CMWs as acceptable health care providers at a community level
The main theme grounded in the data was “CMWs as acceptable health care providers at a
community level.” Women in intervention and non-intervention areas considered CMWs as
acceptable trained healthcare providers. Not only were they satisfied with their availability but
expressed the need for the government to support them to be more effective.
“We visit the CMW, as she is near and can provide us with satisfactory services. If there is
an issue or complication, she refers us to a hospital.” [Client - Intervention Area, Kech]
“We prefer visiting the CMW for the first time as she is nearby and can advise us better.”
[Client – Non-Intervention Area, Gwadar]
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The two sub-themes contributing to the main theme pertained to the perceived quality of care
provided by CMWs and are described in the following sections.
1. Provision of Care by CMWs
The different types of services provided by CMWs was stated as an important reason for
community members to access CMW care. This was identified during the FGDs with clients from
both intervention and non-intervention areas. The FGD participants regarded CMWs as trained
healthcare providers who empathized with them and were accessible.
“We visit the CMW for her advice but if she had the required equipment for pregnancy and
delivery we would prefer her as she is near.” [Client – Non-Intervention Area, Gwadar]
“She informs the client about the complications during ANC checkups and refers her to the
hospital. In case of an emergency she even accompanies women to the hospital.” [Client -
Intervention Area, Gwadar]
a. Trained Health Care Provider
Women interviewed trusted CMWs as a trained health service provider who took care of clients
and who would not leave in the middle of an emergency. The respondents expressed their
intentions to continue to seek care from CMWs and to advise their families to do so too.
“She is trained and treats us well, we are satisfied with her services.” [Client -Intervention
Area, Gwadar]
“For our relatives and family members we would prefer to consult the CMW for her advice
and suggestions. When our relatives visit us we take them to the CMW’s workstation for a
checkup and advice.” [Client - Intervention Area, Kech]
It was also mentioned that CMWs were more knowledgeable than the traditional birth attendants
and were better trained to advise women on maternal and child health issues. They were preferred
by the women as they treated their patients with respect and dignity, even at the time of delivery,
ensuring that their privacy was maintained. Women shared that they felt comfortable discussing
and sharing their problems with CMWs.
81
“She is trained and has knowledge and she is better than a Dai. We can easily share our
issues with the CMW. The doctors on the other hand don’t give us proper time or listen to
us.” [Client - Intervention Area, Quetta]
However, respondents from non-intervention areas were of the view that CMWs were potentially a
good healthcare provider provided that they had the equipment and supplies to serve community
needs. For delivery, clients had to go to the hospitals. However, CMWs helped them in injecting
prescribed medicines at home.
One of the respondents said;
“She has knowledge but she lacks equipment, otherwise for injections and drips she is
always available at home.” [Client – Non-Intervention Area, Gwadar]
b. Timely Referral
The FGD participants in intervention and non-intervention areas expressed that CMWs provided
timely referrals when their clients faced complications. CMWs being knowledgeable and easily
accessible were able to assess the condition of the women during antenatal visits and refer them
to hospitals or nearby health facilities if required. Women in intervention areas shared that in thee
case of an emergency CMWs would go out of their way to arrange for transport and at times
accompanied clients to hospital.
“She is well trained and knows when to refer to a hospital in case of such complications or
issues. She refers us with a referral slip and arranges a vehicle in the neighborhood to take
us to hospital and at times comes with us to the hospital as well.” [Client - Intervention Area,
Kech]
Another respondent said;
“She advises and refers us to the referral health facilities in case of complications, and we
go there ourselves.” [Client – Non-Intervention Area, Quetta]
c. Close Proximity/Availability
CMWs were within the reach of the community. This was mentioned by all the respondents. They
were of the opinion that such a workforce was an asset to the community given the long distance
to the health facility, non-availability of transport and restricted mobility of women.
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“We are satisfied with her and she is near, we don’t need any transportation to visit her.”
[Client - Intervention Area, Gwadar]
Many women preferred to visit CMWs first. The other facilities being far away and expensive were
only utilized in serious cases. It was stated that hospitals were visited in case of an emergency
only. The women in the non-intervention areas suggested that CMWs be given equipment so that
their services can be utilized more.
“To visit hospital, we require transportation as they are at some distance so we don’t go
there until there is an emergency or when we are advised to have a blood or sugar test as
CMW doesn’t have equipment.” [Client – Non-Intervention Area, Kech]
“We have long waiting times at the hospital. Here at the CMW workstation, she takes
proper care and being a female we feel comfortable with her. She is nearby and available
all the time.” [Client - Intervention Area, Quetta]
2. Experience of Care from CMWs
Overall the respondent’s experience with CMWs was good, especially in the intervention areas.
CMWs showed personal interest in their clients and this was appreciated. All participants agreed
that CMWs were knowledgeable and had facilities to treat their clients. It was also mentioned that
CMWs are a source of information for women in the community. This was true for the women in
the intervention areas. CMWs provided information about antenatal and postnatal visits, delivery
complications, family planning, nutrition and vaccinations.
“She prefers her clients over everything and she tries her best to provide services, she
never takes her clients for granted.” [Client - Intervention Area, Kech]
Participants stated that CMWs were reachable and willing to provide treatment at any time as they
worked out of their own homes. The level of services provided however varied greatly between
CMWs working in intervention areas and CMWs working in non-intervention areas. Only a few
CMWs in non-intervention areas had maintained their set-up to provide services. CMWs would
also make home visits if required.
“She is always well prepared and her clinic/workstation is ready for client check-ups and
delivery as well. She brings a bag with delivery equipment when she conducts delivery at a
client’s home.” [Client - Intervention Area, Quetta]
83
a. Availability of Facilities/Use of Appropriate Technology
Participants mentioned that CMWs were trained and well prepared to serve their clients especially
the ones in the intervention areas. CMWs also visited homes of the clients with portable equipment
and were available to their clients.
“She has equipment and is knowledgeable, whenever we need her, we visit her or she
comes to our homes but she always treats us well.” [Client - Intervention Area, Kech]
Those CMWs that lacked medicines, prescribed medicines to clients for safe delivery. It was also
mentioned that CMWs charged minimal fees and provided support to the people in the best
possible way. Some of the CMWs in the intervention areas would do simple tests at home as well.
“We are satisfied with the way she treats us but she doesn’t have equipment herself for
deliveries. She writes prescriptions for her clients and once they bring them, she conducts
deliveries. Overall she is good at providing services.” [Client – Non-Intervention Area, Kech]
b. Contribution in Raising Awareness
Respondents in the intervention areas highlighted the Women Support Groups (WSG) initiated by
the CMWs. The women found the WSGs very informative. The WSGs had generated awareness
amongst the communities about the services provided by the CMWs. They indicated that CMWs
were a rich source of information to the communities. Being qualified and knowledgeable, women
trusted the opinions of CMWs. This was evident in the respondents from the intervention areas.
Information about family planning including healthy birth spacing and the use of contraceptives
was also given to the clients by CMWs.
“We visit the CMW sometimes for advice, otherwise we visit doctors at hospitals or private
clinics as CMW doesn’t have equipment.” [Client – Non-Intervention Area, Quetta]
“At least 2-3 years gap between births i.e. birth spacing is essential for health of mother and
child. Besides, post-natal care check-up within first day of birth is also a must.” [Client -
Intervention Area, Kech]
“We learned about the importance of antenatal and postnatal visits and that at least four
antenatal checkups are a must. We have also learned about the birth preparedness and
birth spacing.” [Client - Intervention Area, Gwadar]
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It was evident from the FGDs that participants from the communities in intervention areas knew
about WSGs. FGD participants in intervention areas knew that CMWs select a group of active
women from within the community and these women attend CMW-led sessions about maternal
and child health. These women mobilize the community to access CMW services. Women who
attended WSGs were given information about antenatal visits, postnatal care, blood pressure,
anemia, complications of delivery and vaccinations by CMWs. Information about family planning
and birth spacing was also provided. These sessions were considered useful by the clients.
“CMW and other educated women in the community have taught us about maternal and
child health topics in classroom like sessions.” [Client - Intervention Area, Kech]
“These meetings are very useful, we have learned a lot and now we can take care of
ourselves during pregnancy and ensure appropriate immunization and nutrition of newborns
and children.” [Client - Intervention Area, Kech]
Conclusions
Sub-study 3 revealed that the knowledge of CMWs regarding midwifery services (antenatal, natal,
post-natal and general services) in both intervention and non-intervention areas was poor. The
majority of the CMWs in both areas had been deployed in the field for more than a year, having
completed their formal training some time before that. Many CMWs achieved a low knowledge
score, probably due to poor recall. However, the attitudes and practices of CMWs in intervention
areas scored better compared to those from non-intervention areas. This higher score may be
attributable to the regular use of learned skills, supportive supervision and the refresher training
CMWs were exposed to via the Mercy Corps SMNC Program. Additionally, the acceptability of the
CMWs as trusted health care providers was higher in communities from intervention areas
compared to non-intervention areas. This may be due to the adherence of CMWs in intervention
areas to the deployment guidelines, and in particular, the introduction of CMWs to communities
through the existing network of LHWs. The quality of care provided by CMWs was also better in
intervention areas because of the availability of resources (equipment and supplies) and Mercy
Corp program support in supervision.
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Recommendations
1. Quality of care: The MNCH program should mobilize resources (financial and technical)
through donor support and private organizations to support CMWs in improved service
delivery. This could be achieved through the provision of equipment, supplies, medicines,
support in the maintenance of workstations and a continued series of refresher trainings
opportunities.
2. Capacity development: The midwifery training curriculum must be implemented in its
entirety, including hands-on practical training opportunities and adequate field exposure to
support the appropriate skills development of midwives. The training of CMW trainers needs
to be improved, including improved training on clinical skills, teaching and student
assessments. CMW trainers should receive regular re-orientation. CMW training institutions
should be integrated into the existing public health school system
3. Community interaction to improve the acceptability of CMWs as trained healthcare
providers: Orientation sessions promoting the services of the CMWs must be designed
and conducted with communities of interest before the selection and after the deployment of
CMWs. This will ensure the selection of suitable candidates and improved community
uptake and support after deployment.
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SUB STUDY 4
RESEARCH QUESTION
How can the DoH streamline CMW reporting using cell phone technology and expand mHealth in
the province?
METHODOLOGY
The implementation of a mHealth application implies multiple features. As per the BDoH’s request to
Mercy Corps, the digitalization of the health recording and reporting process for all CMWs living in
mobile coverage areas was envisaged for Balochistan. Hence this study focused on exploring the
status of the digitalization of the health reporting system in Balochistan, including the identification of
system gaps.
MHealth was introduced in Balochistan in November 2013 and CMWs started reporting data from
their work via mobile phone applications from the 1st January 2014. CMWs were invited for a FGD
to examine the acceptability of the new system and key barriers to its implementation. FGDs were
conducted with CMWs using mHealth application from all three intervention areas of the program.
Discussion was directed about advantage of mHealth application, feasibility and gaps. For
completeness, IDIs were also conducted with the Mercy Corps SMNC team to gain an
understanding of the mHealth application and its relevance (see study tools in annex 11). The data
collected was manually analyzed using thematic analysis and the gaps in the online system were
reported.
RESULTS
Interviews and FGDs were conducted with field staff from the Mercy Corps SMNC program and
CMWs in the three intervention districts of Quetta, Kech and Gwadar. Participants were asked
about the useful features of the mHealth mobile application and the challenges they faced in using
it. The mHealth application is a mobile phone application developed for improved monthly
reporting and monitoring of CMWs’ activities, including improved acquisition, storage and
processing of client data. The application was installed on smart, touch screen phones given to the
CMWs working in intervention areas. The Mercy Corps SMNC program team and CMWs were the
two main actors interfacing with the system. The BDoH, especially the MNCH program at a
provincial and district level were also reviewing the CMW reports on an mHealth dashboard. Core
functions of the application for CMWs included registering clients, scheduling follow-up visits and
87
the closing of client cases. As soon as clients were registered and their contact numbers recorded,
CMWs could generate and relay tailored behavior change messages and send reminders for
follow up visits. A CMW could also close a client’s case following completion of services. The data
was accessible to the Mercy Corps SMNC program team and BDoH staff through a dashboard
accessible through a web application. The website supported the review of data, the generation of
behavior change messages for registered clients and the analysis of data through customized
reports (Annex 12).
The transcripts of interviews with the Mercy Corps SMNC program team and CMWs were
analyzed through content analysis and the results described below. The themes emerging from the
data were; how the mHealth application was being used, challenges faced in the use of the
application and the potential benefits the application holds for both the program and the BDoH.
1. Utility of the mHealth application

The utility of the mobile application for reporting and monitoring was discussed with the
participants in interviews and FGDs and all agreed that the application was useful for both the
CMWs, program teams and the health departments. In general, all participants considered the
mHealth application a useful tool for reporting and monitoring. The use of the application increased
after it was made available in the Urdu language. Compared to the previous practice of recording
CMW activities on paper registers, the use of the application was convenient and allowed for the
rapid syncing of field data.
“Previously we used to carry our registers or we would come home and make our
notes in the registers. But now with the phone, we can record everything in the form
instantly.” (CMW, Quetta)
The Mercy Corps SMNC program staff responsible for providing technical support to the CMWs,
agreed that the application allowed for the integration of health data from CMWs into program
reporting. This facilitated timely intervention and supervisory support. The system had several set-
up issues which included system adaptation, system implementation, the training of CMWs and
project teams on application usage, coordination between all stakeholders to utilize the application
and the continuous oversight of the mHealth program in intervention districts. Despite these
issues, the CMWs and Mercy Corps program staff believed that the system had improved
reporting times. Client records were no longer delayed.
88
“They (CMWs) used to enter information in registers but now we stay updated
through this e-system about which CMW is going to which patient, nature of the visit
and other details. So we also stay updated. The mHealth system is used and
owned by Mercy Corps through which the program staff get all the information from
CMWs and can keep a track of the CMWs activities.” (Mercy Corps SMNC program
field officer, Gwadar)
The CMWs were still, however, required to record activity in the registers they were given, which
some of the CMWs considered a duplication of work. The Mercy Corps SMNC program staff cross-
checked the hard copies of the registers with the online report submissions.
Despite its usefulness, some issues regarding the use of the mHealth application were highlighted.
The mHealth application developers trained the Mercy Corps SMNC program team members
(program focal person and five other team members) and three members of the MNCH program in
the management of the system. This training included data generation, device installation
management, the backup of system records and the troubleshooting of any application related
issues at a data entry, collection and review level. Understanding how to use smart phones and
relevant functions related to the application was a significant problem for some of the CMWs,
especially those from rural areas. Although the CMWs were trained for using this technology and
were provided with support from the program team, participants expressed that there should be
regular refresher trainings as well. Members of the Mercy Corps SMNC program team also
highlighted that CMWs from Quetta were more qualified than those from other areas and were
therefore better at using smart phone technology. The CMWs approved of the two-day training
given to them on the use of the application but also expressed that refresher training at regular
intervals was also required.
Mercy Corps SMNC program team members shared that several CMWs required regular
assistance from them to use the application properly, for which purpose they visited them
frequently. The program team members were of the view that trainings could be improved by
increasing the number of training days and incorporating more practical work during the training so
that those participants not familiar with the functions of a smart phone may improve their ability.
“Before usage of this software, a two-day training session was given to CMWs in
which they were told about ways of reporting. This training can be made better.
Because some CMWs are from rural areas they take time in understanding, so two
days is not enough for them. For them 4-5 days are needed and they should be
89
given time to practice during the training so that they understand it completely
during the training.” (Mercy Corps SMNC program field officer, Gawadar)
Another issue highlighted was a lack of certain data fields in the mobile application for recording
observations of clients. This was a cause of confusion and incomplete reports. However, it was
mentioned that this issue was resolved by Mercy Corps through the hiring of Pakvista technologies
to assess the mHealth application and make the required changes. One of the application features
was voice messages and alerts for community members regarding maternal and child health care.
However, the CMWs highlighted that either the people in their catchment community did not share
their contact numbers or they would not respond to the alerts. Community members often mistook
health information messages as advertisements. Considering this, they were restricted to mostly
using the reporting feature of the application. Furthermore, voice messages were removed (after
April 2016) from the mHealth component by Mercy Corps on the basis of the mid-course review.
2. Challenges in using the mHealth application

The recurrent challenges faced by the CMWs and Mercy Corps SNMC program team members in
using the application were also discussed. Several issues were highlighted including technical
problems with the application, hardware issues, slow network speeds and no cellular network
coverage.
The participants shared that the mhealth application frequently responded very slowly and
sometimes would stop working. This usually happened when there was a new version of the
application and the CMWs were required to update it but were unable to do so because of slow
network speeds or poor internet connectivity. The participants identified that the application also
had a slow response when other applications were open on the smart phone. This was brought to
the notice of the Mercy Corps team during the routine monthly meetings. To combat this issue, the
CMWs were advised to limit their internet usage and avoid installation of other applications on the
phone, which resulted in improvement. However, when such issues arose, it required the CMWs to
frequently visit the program office and get the application re-installed along with their client data, as
the backup was only available at the program office.
“Because the application is not updated it stops working after some time. So they
come to us. Sometimes the whole application needs to be uninstalled and then
downloaded again. So sometimes it takes two days because of URL code, which is
not accepted by software. These are the issues we commonly face. Even if internet
90
is available sometime it isn’t updated anyway.” (Mercy Corps SNMC program field
officer, Kech)
During the field visits, due to the slow processing speed of the smart phones (with the application
installed) participants would sometimes get held up while they were in process of entering a
record. This required them to re-start their device and enter the data again. Sometimes the screen
would become non-responsive. This was particularly the case with any old handsets the CMWs
had been provided with. Participants suggested that the handsets they had be upgraded so that
the problems encountered may be reduced. Similar views were also shared by the Mercy Corps
SMNC program team members interviewed. They highlighted that the utility of the application is
appreciated by the CMWs as well as by development partners but its entire potential is not being
utilized. This was not just because the data is not being utilized but also because the system
keeps getting jammed and hence the records are not updated regularly, with the result that
sometimes reports are delayed by weeks. To counter this problem, the project officer also made
the suggestion to give the CMWs handsets with faster processors and having a 4G network
adaptability for better internet connectivity. These upgrades would obviously have financial
implications.
“The mHealth system is better than registers but if the quality of phones is improved
it will reduce problems because the phone gets jammed during reporting. Other
than that, they should be given 4G system rather than card of Rs. 500 for SIM
Internet (which does not provide good service). CMWs do appreciate this system,
and even our stakeholders do but the quality of the phone sets has to be improved.”
(Mercy Corps SMNC program project officer, Quetta)
Another significant issue raised by all participants was poor network coverage in several parts of
the intervention areas, especially in rural areas. Due to this, syncing of the records with the main
server was often delayed, sometime for weeks at a time. A review of the cellular network coverage
in intervention areas shows that Quetta and Gwadar are being provided services by all the telecom
networks, whereas Kech has services only by the three major networks. The coverage is
concentrated in urban areas and rural areas are not well covered (coverage maps in annex II).
The CMWs shared that to overcome this problem, they saved the records and as soon as there
was network coverage, they uploaded their reports. In contrast, Mercy Corps SMNC program staff
shared that network and coverage issues caused a delay of up to three to four weeks in the
syncing of records as records had to be manually synced in monthly review meetings with the
91
main server. The suggested solution for this was to provide the CMWs with a system that allowed
for automatic syncing of saved data, as soon as CMWs were in the range of a network. The issue
of poor network speed and low coverage was found to be common in most intervention areas,
except those that were in the vicinity of a cellular network towers. Improving this, however, was out
of the remit of Mercy Corps SMNC program team.
3. Potential benefits for the program and the BDoH

The potential of the application and the benefits of such a system for the Mercy Corps SMNC
program and the BDoH were also discussed. The CMWs were appreciative of the fact that the
system allowed for rapid monitoring of their work as previously their registers were reviewed only
whenever a supervisor visited. After implementation of the mHealth system, their reports were
managed, evaluated and reviewed through use of a dedicated dashboard managed by the
program team.
The Mercy Corps SMNC program team members interviewed were of the view that even though
there were gaps and flaws in implementation, the information uploaded had potential for effective
monitoring and management of the CMW services. This was however, not being fully done by the
Mercy Corps program team and BDoH. Currently the online reports were being used to keep track
of a CMW’s monthly activity and timely online submission was required for payment of the monthly
stipend. Feedback on CMW’s performance was also based on the submitted reports. Mercy Corps
also utilized the mhealth generated reports to inform decision-making and is in the process of
integrating the mHealth application into the MNCH management information system.
“The Mercy Corps program took the initiative of developing an online system of
reporting for CMWs to improve reporting practices; the system evolved over time
with errors corrected. As a routine, CMWs submit a monthly report and after
verification, they are paid their monthly stipend. Similar practice is also followed by
the CMWs in other districts, but they submit a paper report.” (Project Manager,
SMNC Program, Quetta)
The mHealth system is currently not integrated in the district health information system,
contributing to its underutilization. The need to work on information sharing between the Mercy
Corps SMNC program team and district and provincial health departments was emphasized by the
program staff interviewed. It was pointed out that many of the government health system officials
were unaware of the existence of this system and the monthly reports generated. This limited
92
awareness amongst government staff of the mhealth data contributed to a lack of productive
utilization of the information generated.
The Mercy Corps SMNC program staff were of the opinion that using a comprehensive approach
to regularly monitor and review the range of outreach services provided by CMWs would enhance
the tracking of program performance, successfully monitor strategy implementation and support
the achievement of the MNCH program targets.
Conclusions
The mHealth application has the potential to play a significant role in improving reporting and
monitoring of CMW services and of advancing the objectives of the MNCH program. The BDoH
however lacks the capacity to take up mHealth technology and to expand its use across the
province. Support in terms of infrastructure, capacity building (IT and health professionals) and
integration with existing BDoH reporting systems is required. The following are recommendations
for improved implementation and utilization of the mHealth system tested by the Mercy Corps
SMNC program.
1. Inter-Departmental Integration: Automated reporting system should be integrated into the

district health information system and concerned officials briefed on distinctive feature so
they can utilities the online reporting. Real time monitoring of service utilization patterns can
be initiated, thereby improving outreach of services to underserved areas. Uptake of this
system for the monitoring and evaluation of services by the BDoH, as well as development
partners will require financial support, technical oversight and effective leadership.
2. Switch over to Personal Digital Assistants: Smart phones given to the CMWs may be
replaced with Personal Digital Assistant (PDA) devices. These are touch screen devices
that have better processing speeds than a smart phone, innate ability to manage
information and wireless networking capability. Use of PDA devices will eliminate the data
management problems arising from the use of the smart phones for other purposes such as
phone calls, internet browsing and use of other applications. Additionally, cost implications
for scaling up will be substantially reduced with the use of PDAs.
3. Refresher trainings: Regular refresher training for CMWs and Mercy Corps SMNC
program field officers must be scheduled to ensure continuity in the use of the online
reporting system. To tackle the problem of frequent support required from CMWs,
instructional videos should be developed and included in the application. The CMWs can
use these to guide themselves through the process and troubleshoot any issues arising.
93
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April 2016]. Available from: http://can-mnch.ca/wp-content/uploads/2013/09/National-
Maternal-Newborn-and-Child-Health-Programme.pdf
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18. Sarfraz M, Hamid S. Challenges in delivery of skilled maternal care-experiences of

community midwives in Pakistan. BMC Pregnancy and Childbirth. 2014; 14(1):59.
19. Mumtaz Z, Levay A, Bhatti A, Salway S. Good on paper: the gap between programme
theory and real-world context in Pakistan's Community Midwife programme. BJOG: An
International Journal of Obstetrics & Gynaecology. 2014;122(2):249-258.
20. Journal of Asian Midwives (JAM), Vol. 2, Iss. 2 [2015] Published by eCommons@AKU,
2015
from:http://r4d.dfid.gov.uk/pdf/outputs/raf/Are_Community_Midwives_Accessible_RAF_Fina
lReport.pdf
21. Rehman S, Ahmed J, Bahadur S, Ferdoos A, Shahab M, Masud N, Exploring operational
barriers encountered by community midwives when delivering services in two provinces of
Pakistan: A qualitative study. Midwifery. 2015; 31(1), 177-183.
22. USAID, the Community Midwives Program in Pakistan; Research and Development
Solutions Policy Briefs Series No. 20, October 2012. Available from:
http://www.resdev.org/files/policy_brief/20/20.pdf 23. Mumtaz Z, O’Brien B, Bhatti A, S
Jhangri GS. Are community midwives addressing the inequities in access to skilled birth
attendance in Punjab, Pakistan? Gender, class and social exclusion. BMC Health Services
Research. 2012;12(1):326
23. Jan Y. Community Based Midwives Practice in Patriarchal Social System [Internet].
Ecommons.aku.edu. 2015 [cited 3 April 2016]. Available from:
http://ecommons.aku.edu/cgi/viewcontent.cgi?article=1029&context=jam
24. Faisel A, Shoaib S, Ahamad M, Suleman S, Imran M, Are Community Midwives Accessible
in Punjab and Sindh. Maternal and New-born Health Programme Research & Advocacy
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25. Khan SA, Zaman T, Shams B, Shehzad M, Yaqoob A, How far can I go? Social mobility of
community midwives in Azad Kashmir. Research Advocacy Fund 2012
26. “How far can I go? Social Mobility of CMWs in AJK” [Internet]. RAF; 2012. Available from:
http://r4d.dfid.gov.uk/pdf/outputs/raf/SummaryReport_SocialMobility_of_CMWs.pdf
27. Abbas S. Enhancement of knowledge and skills of community midwives in Sindh, Pakistan
[Internet]. Ecommons.aku.edu. 2015 [cited 3 April 2016]. Available from:
28. Lalji L. Birth Centre Management and Business Skill Training for Community Midwives of
Pakistan. Journal of Asian Midwives [Internet]. 2014 [cited 3 April 2016];. Available from:
29. PDHS 2012-13 [Internet]. 2014. Available from:
http://www.nips.org.pk/abstract_files/Priliminary%20Report%20Final.pdf
30. Case for Midcourse Corrections Saving Mothers and Newborns in Communities Revised
July 2015. Mercy Corps; 2015.
31. CapacityPlus [Internet]. Capacityplus.org. 2016 [cited 30 June 2016]. Available from:
http://www.capacityplus.org/
32. Rapid Retention Survey Toolkit: Designing Evidence-Based Incentives for Health Workers |
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http://www.capacityplus.org/rapid-retention-survey-toolkit
95
ANNEXURES
ANNEX 1: Study 1-List of IDI Participants

ANNEX 2: Study 1, 2, 4-List of FGD Participants
ANNEX 3: Study 1-IDI & FGD Guide
ANNEX 4: Study 1-DCE Questionnaire
ANNEX 5: Study 1-Mix Logit separate results of intervention and non-intervention group
ANNEX 6: Study 1-Raw output from STATA
ANNEX 7: Study 1-Preference calculation worksheet
ANNEX 8: Study 2-Study Tools
ANNEX 10: Study 3-List of FGD Participants
ANNEX 12: Study 4-Pakistan Telecommunication Footprints
LIST OF PARTICIPANTS IN IDIs
Sub Study 1- Quetta
Participants: Mercy Corps’ project staff, concerned district and provincial health officials,
LHV/LHS and CMW Tutors
Interviewer: Dr. Saima Hamid & Sana Azmat Rana
Sr No. Name Designation and Organization Contact Detail
1 Dr. Abdul Qadir Nuashewani Director General Health Services,

Balochistan 081-9211356
2 Dr. Abdul Wahid Baloch Provincial lead MNCH program 081-9211352
Balochistan
3 Dr. Naqeebullah Provincial Epidemiologist 0300-3869070
4 Dr. Dawood Achakzai Deputy Coordinator LHWs Program 3337828649
5 Aster Noveen Principal Midwifery School 3458323038
6 Azra Joseph Tutor Midwifery School 081-9213020
7 Rukhsana Dost Mohammad Tutor Midwifery School 081-9213020
8 Abida Ashraf Tutor Midwifery School 081-9213020
9 Sajida Saeed Tutor Midwifery School 081-9213020
10 Salma Faiz Non- Intervention group- LHS 3013786702
11 Niamat Bibi Intervention group- LHS 3338899578
12 Gohar Taj (from Hazara town) Intervention group- LHS 3138741192
13 Razia Non-Intervention group- LHV 3342324961
14 Saeeda Intervention group-LHV 3313153331
15 Rubina Amjad Non-Intervention group- LHV 3337814347
16 Shaheen Kousar Intervention group- LHV 3323968242
17 Dr. M. Daood Deputy Program manager HIV/Aids

program
18 Dr. Saeedullah Team Leader South, Mercy Corps Pakistan 3008500374
19 Mr. Mazhar Iqbal Monitoring, Evaluation and Learning 3458347987
Manager South
20 Dr. Shaihak Riaz Project Officer, Saving Mothers and 3003401486
Newborns in Communities (SMNC)
21 Ahmed Ullah Project Manager, Saving Mothers and 3003819133
Newborns in Communities (SMNC
Sub Study 1- Kech
Participants: Concerned district and provincial health officials, LHV/LHS and CMW Tutors
Interviewer: Dr Tahira
1 Dr.Sajjad Ahmad District Health Officer ( DHO ) 3212691332
2 Dr. Mohammad Ikram Baloch District Coordinator National Program ( 3132823255

DC-NP )
3 Dr. Abdul Hameed Public Health Specialist (PHS) MNCH 3332377026
Program
4 MailaAyaz LHV – BHU Sarikhan 3222641991
5 TohfaNisa LHV MCH Absar 3232073689
6 ZarGul Allah Bukhsh LHS – CD Kallag 3213593312
7 Hozira LHS- CD Shahrak 3361181603

Sub Study 1- Gawadar
Participants: Concerned district and provincial health officials, LHV/LHS and CMW Tutors
Interviewer: Dr Tahira
1 Rozina Asghar LHV DHQ Hospital 3243251861
2 Rahila Abdul Rasool LHV BHU Dor 3248039274
3 Shahida LHS Ormara 3422389604
4 Farida Mohammad LHS Gwadar Town 3352173714
5 Dr. Akhater Ali Buladi DHO Gawadar 3218090878
6 Dr. Abdul Lateef MS DHQ Hospital 3 Years / DC-NP 3218623955
7 Dr. Ghulam Nabi Ex - DC – NP / Deputy DHO 3218081350
8 Dr. Shahnawaz PHS MNCH Program 3218064646
9 Ms Razia Principal Midwifery School 3228192456
10 Ms Farida Tutor Midwifery School 3337957932

LIST OF PARTICIPANTS (Study 1, 2 & 4)
Study 1: FGD Quetta FGD (Intervention Group):
Participants: CMWs
Moderator: Dr. Saima Hamid
Sr Name Contact No. No. of Domicile Residence Work Distance Age Marital No. Experien
N Family Place from Status of ce
o. memb home Kids
ers
1 Rehana 0347-1815716 No Local Urban Urban In home 24 Un- 0 4 years
yaar married
Muha
mmad
2 Rubina 0346-8344558 4 Local Urban Urban In home 38 Un- 0 6 years
Yaqoob married
3 Arifa 0310-8179681 No Local Urban Urban In home 24 Un- 0 3 years
married
4 Sadeeq 0347-1800330 No Local Rural Urban In home 24 Un- 0 3 years
a married
5 Rukhsa 0312-8032588 No Local Rural Urban In home 30 Un- 0 3 years
na married
Irshad
6 Fatima 0313-8832873 No Local Urban Urban In home 22 Un- 0 3 years
married
7 Nargis 0347-1815765 No Local Urban Urban In home 24 Un- 0 5 years
married
8 Hasina 0347-8376515 No Local Urban Urban In home 24 Un- 0 4 Years

married
9 Zahra 0335-2527663 3 Local Urban Urban In home 27 Married 3 6 years
10 Dozina 0313-8045086 5 Local Urban Urban In home 29 Married 5 3 years
11 Khursh 0347-1803196 1 Local Urban Urban In home 42 Widow 5 10 years

eed
12 Samina 0333-7618876 1 Local Urban Urban In home 28 Married 1 2 years
13 Mah 0303-3344064 No Local Urban Urban In home 24 Married 1 2 years
Jabeen
14 Naz 0310-8102287 No Local Urban Urban In home 24 Un- 0 2 Years
bibi married
Study 1: FGD Quetta FGD (Intervention Group):
Participants: CMWs
Moderator: Dr. Saima Hamid
Sr Name Contact No. No. of Domicile Residence Work Distance Age Marital No. Experien
N Family Place from Status of ce
o. memb home Kids
ers
1 Sareeta 0334-2481860 - Local Urban - Kawari 32 Married 2 6 years
Kumari Road
2 Bushar 0332-875339 - Local Urban - Madni 40 Married 5 6 years
a Restura
Sultana nt
3 Sabira 0344-1478097 - Local Urban - Kali Paid 36 Married 3 6 years
Khan
4 Rukhsa 0344-0236599 - Local Urban - Arbab 36 Married 4 6 years
na Karam
Gulzar Road
5 Rout 0333-7847388 - Local Urban - TWFC 37 Married 4 3 years
Anwar cant
6 Asia 0312-9957337 - Local Urban - Kali 32 Married 2 2 Years
Nasir
7 Sarwat 0346-8062144 - Local Urban - Kansi 26 Married 2 3 years
Road
Study 2 & 4: FGD Quetta (Intervention Group):
Participants: CMWs
Moderator: Dr. Tahira
SrN Name Contact No. of Domic Reside Work Distance Age Marital No. Experience
o. No. Family ile nce Place from Status of
members home Kids
1 Nargis 0347- No Local Urban Urban in home 26 Single 0 5 years
Parveen 181776
5
2 Bushra 0300- No Local Urban Urban in home 24 married 1 5 years
Jabeen 955188
5
3 Samina 0333- No Local Urban Urban in home 27 married 1 2 Years
Ramzan 781886
7
4 Rukhsan 0312- No Local Urban Urban in home 30 married 0 2 Years
a Arshad 803250
8
5 Fatima 0313- No Local Urban Urban in home 22 married 0 2 Years
883287
8
6 Mahjabe 0303- No Local Urban Rural in home 24 married 0 2 Years
en 334406
4
7 Farazana 0331- No Local Urban Rural in home 25 Single 1 2 Years
850900
7
8 Khurshe 0347- No Local Urban Urban in home 42 Widow 0 2 Years
ed 180319
6
9 Ayesha 0344- No Local Urban Rural in home 20 married 0 2 Years
105123
7
10 Bibi 0333- - Local Urban Urban in home 30 married 0 2 Years
Yaseen 272967
2
11 Bakht 0301- 5 Local Urban Rural in home 27 married 3 2 Years
bibi 371020
0
12 Zahra 0335- 4 Local Urban Rural in home 27 married 3 5 years
252766
3
Study 2 & 4: FGD Quetta (Non- Intervention Group):
Participants: CMWs
SrNo. Name Contact No. of Domi Reside Work Distance Age Marital No. Experience
No. Family cile nce Place from Status of
memb home Kids
ers
1 Wasia 0346- 4 Local Urban Urban in home married 4 5 years
Yaqoob 8344558
2 Abida 0331- 5 Local Urban Urban in home married 4 6 years
8029452
3 Norren 0332- 5 Local Urban Urban in home married 3 6 years
9989677
4 Sadiqa 0347- 0 Local Urban Urban 5 Mint Single 0 3 years
1800830
5 Rozina 5 Local Urban Urban 5 Mint married 5 3 years
6 Rehana 0347- 0 Local Urban Urban 5 Mint Single 0 4 years
1815716
7 Sadiqa 0335- 0 Local Urban Urban 5 Mint Single 0 4 years
Rustam 274613
8 Hasina 0342- 0 Local Urban Urban in home Single 0 4 years
8326515
9 Zakira 0335- 1 Local Urban Urban in home married 1 6 years
0233425
10 Arza 0 Local Urban Urban in home Single 0 3 years
Ackazai
Study 1, 2 & 4: FGD Gawadar (Intervention Group):
Participants: CMWs
Serial Name Contact No. of Domicile Residence Work Distance Age Marital No. Experience
No. No. Family Place from Status of
members home Kids
1 Hafeeza - No Local New Urban 0 24 Single NA 2
Wahid Town
Buhksh
2 Tahira - 4 Local Bal Nagor Rural 0 23 Single NA 2
3 Majida - No Local Pasni Urban 0 27 Married 2 3
Tahir
4 Bilqees - No Local New Urban 0 26 Single NA 3
Faiz Abad
5 Habeeba - No Local Shumby Urban 0 29 Married 4 3
Sabzal Ismail
6 Samina - No Local Dasht Rural 10 26 Married 1 3
Abid Khndaan minutes
7 Shazia - No Local Koh bin Urban 0 23 Single NA 2
Dawood
8 Sakeena - No Local Baloch Urban 0 24 Single NA 2
Ghafoor Ward
9 Nadia Gul 0335- 3 Local Suhrabi Rural - 24 Single NA 2
2527663
Study 1, 2 & 4: FGD Gawadar (Non-Intervention Group):
Participants: CMWs
Serial Name Domicile Residence Distance Age Marital No. Experience

No. from Status of
home Kids
1 Summaiya Local Koh Ban Kawari 20 Single NA 2 years
Ward Road
2 Assia Local New Madni 21 Single NA 2 years
Abad Resturant
3 Tasleema Local Chabari Kali Paid 25 Married 0 3 years
Ward Khan
Study 1, 2 & 4: FGD Kech (Intervention Group):
Participants: CMWs
Seria Name Contact No. Domicil Residence Work Distance Age Marital No. Experience
l No. e Place from Status of
home Kids
1 Dar Gul 0347-9745086 local Kakan Rural 0 25 Married 0 3 years
2 Beebal 0321-3822452 Local Kalatuk Rural 0 25 Single 0 3 years
3 Hameed 0322-2882679 Local Singani Sar Urban 0 29 Married 3 6 Years
a
4 Rahat 0321-2677379 Local Fish Urban 0 27 Married 0 6 years
Noor Market
5 Shireen 0321-8092005 Local Degari Rural 0 23 Married 0 3 years
6 Zohra 0321-3733695 local MalikAbad Urban 0 28 Single 0 4 years
7 Assia 0323-3293148 Local Koshkalat Rural 0 27 Single 0 6 years
8 Rubina 0323-0225009 Local Nasir Abad Rural 0 25 Married 0 6 years
9 Humaira 0311-1077398 Local Jammuk Rural 0 26 Married 1 6 years
10 Haan Not given Local Niami Rural 0 25 Married 0 6 years
Bibi Kalag
11 Gul Afroz 0320- local Bahkter Urban 0 27 Married 3 6 years
92866274
12 Naheeda 0323-3705784 local Abser Rural 0 22 Single 0 6 years
Study 1, 2 & 4: FGD Kech (Non- Intervention Group):
Participants: CMWs
Seria Name Contact No. of Domicil Residence Work Dista Ag Marital No. Experie
l No. No. Family e Place nce e Status of nce
memb from Kids
ers home
1 Shaista - - local Jummak Rural 25 25 Married 0 5 Years
Gor
2 Shahnaz 0316- - Local Jummak Rural 20 24 Married 2 5 Years
2479395 Gor
3 Meena 0316- - Local Jummak Rural 0 26 Married 2 5 Years
2743402 Gor
4 Sheema - - Local Absar Urban 0 25 Married 0 5 Years
Naseem
5 Rakhsha 0323- - Local Singani Sar Urban 0 25 Married 1 4 Years
nda 2160849
6 Zakia 0322- - local Singani Sar Urban 0 27 Single 0 4 Years
3611540
7 Rajda 0321- - Local Jummak Rural 0 23 Married 1 4 Years
2694918 Gor
8 Humma 0333- - local Shahpuk Rural 0 22 Single 0 4 Years
3490643
9 Murad 0322- - Local Shahpuk Rural 0 23 Married 0 4 Years
Bibi 051190
10 Sabeeta 0323- - Local Pedark Rural 0 23 Single 0 6 Years
3173942
11 Yasmeen - - local Perak Rural 0 24 Married 0 6 Years
Study 1, 2 & 4: FGD Kech (Non- Intervention Group):
Participants: CMWs
Seria Name Domic Residence Work Distance Age Marital No. of Experience
l No. ile Place from Status Kids
home
1 Ruqia Sabir local Singani Sar Urban 0 30 Married 3 4 Years
Ali
2 Zahida local Shahpuk Rural 0 32 Married 0 5 Years
3 Meher Jan local MalikAbad Urban 0 40 Married 2 5 Years
4 Meena local Shahpuk Rural 0 22 Single 3 years
5 Rubina local Singani Sar Urban 0 25 Married 0 3 years
Abdullah
6 Zarina local Shaikhani Urban 0 27 Married 1 3 years
Moosa Bazar
7 Aangal local Pedarak Rural 0 25 Married 0 5 Years
Akhter
8 Naila Sher Local Gulshan Abid Urban 0 25 Married 2 5 Years
Mohammad
Study 1: FGD guide (CMWs deployed in Intervention and Control group and trainees)
After consent and addressing queries, begin as below:

I will circulate this sheet for everyone to sign and record your details. We will begin with the
introductions once everyone has filled out the sheet.
Name Area of residence Area of Work Distance from Age Marital Number of Experience
(rural/urban) (rural/urban) area residence Status Children (if working as a
to area of work applicable) CMW in
months
Introductory question
1. Can you all please introduce yourselves one by one? If deployed state where you work and
since when have you been working there.
Main content
1. What motivated you to become a CMW?
a. Financial benefits
b. Position in the society,
c. Interest/ inspiration,
d. Chances to get government job
e. Expectations from work
f. Support of family
g. Security/safety in mobility
2. How were you recruited in the training for CMWs?

a. Logistics
b. Application process
c. Costs incurred
d. Positive experiences e.g. any form of facilitation from any authority etc
e. Negative experiences
3. What were the eligibility criteria to become a CMW? In your opinion are they relevant
or should they be revised? If so, how?
4. What were the important issues you considered when taking up this job? (skip this
question with trainees)
5. Were you adequately trained to take up your current roles and responsibilities? (skip
this question with trainees)
a. Clarity on Roles and Responsibilities
• Role in the community for providing maternal health services?
• What maternal services/how
• Training and skills taught in the school
• Importance of their role in improving maternal health
• Any reservations/difficulties in providing these services
• Marketing of Midwifery services in community
• How do the clients come to know about your services? (Source of
introduction in community, success factors, communication barriers)
6. Now that you have worked in the field please suggest how the recruitment processes
may be improved to better equip you to fulfill your roles and responsibilities? (skip this
a. Barriers from supervisors, communities, Health Department
i. From supervisors (financial, logistics, lack of support)
ii. From community (acceptability, image, respect, age, mobility, access,
security, catchment population
iii. Competition with local TBAs and other health providers)
iv. Mentorship programs
v. Refresher trainings, Incentives
vi. Linkages with the Health Department (coordination –feedback systems)
vii. Appraisal
7. Do you think working in rural areas (urban) allows you to provide the kind and quality of
health care you want to provide (e.g., the scope of practice you were trained to
provide)?
8. How important is this to you when deciding where you would like to work?
9. What are the factors that you deem essential for work in rural settings?
10. How would you compare the quality of services provided to you (e.g., cleanliness,
availability of equipment, access to referral services etc.) in rural areas as compared to
urban areas?
11. How do you compare the CMWs working in rural or urban areas?
(Satisfaction from work, motivation, willingness to do work)
12. How would additional support from the Health Department to CMWs working in rural
areas retain them?
a. Salary increase for those working in rural areas? (how much)
b. Living conditions (communication, transport, phone, water, electricity etc)
c. Social environment (access to social activities)
d. Availing leave, substitute worker, opportunities of refresher trainings (How
would you compare opportunities for in-service training if you work in a rural
area and an urban area? What should the in-service training opportunities be to
make working in a rural area more attractive? How important are in-service
training opportunities when considering where you will work?)
e. Considerations/benefits to children as support for education etc.
f. Appraisal
g. Timely promotions
h. Supportive Supervision
i. Security
j. business skills workshops
k. Mumta fund
l. provision of equipment
m. Technical/monitoring support from LHV/LHS etc.
13. Are there any other allowances/bonuses that would be important to motivate CMWs to
work in rural areas? What should allowances/bonuses be given for? How much should
they be?
14. How would you compare the opportunities for your career development if you work in a
rural area versus urban areas? What should the career development opportunities be to
make working in a rural area more attractive? How important are these opportunities
when considering where you will work?
15. How would you compare community support given to CMWs in rural areas than in
urban areas? How important is community support to you when considering where you
will work? (any stigma associated with the work)
16. Are there any other factors, which have not yet been mentioned, that are important to
you when deciding where you will work (rural /urban)?
I thank you for your contributions in the discussion. I will now circulate a list of factors that
we have discussed that affect your decision to serve as a CMW in rural area/urban area.
Please rank the 4 most important factors that you consider when taking the decision of
where to work. These include:
• The types of health care you may provide (scope of practice)
• The quality of facilities, including availability of equipment, drug supply, etc.
• Supportive management
• Career mentoring programs
• Salary
• Housing
• Living conditions (electricity, water, social activities)
• Transportation
• Performance bonuses
• Children’s education
• Career advancement/promotion opportunities
• Opportunities for continued education
• Community support
• Security
• Supportive supervision
• (Add any other factors mentioned that seem important).
(Facilitator: Distribute a copy of the table below to each participant for them to rank their top
four choices. Collect the form from the participants when they are done.)
PS. Before adjourning, after consent to include the photo in the final report of the project, take
a photograph while sitting in a circle
Study 1
Consent Form
Introduction
Thank you very much for coming to this meeting. I welcome you on behalf of the Department of
Health, Mercy Corps and Health Services Academy. This study is being undertaken to learn
about Community Midwives’ motivation for working in rural districts of Balochistan. We are
interested in understanding the how the health department can better recruit CMWs to retain
them in the system. This focus group would approximately take an hour. Your participation will
help us to create a survey questionnaire that will be administered to other CMWs as part of this
study. If you have any queries I would be happy to address them.
If you agree to participate in this study, please sign at the bottom and if not then please state
the reason for refusal.
Agreed Reused
Reason for refusal
Phase I: Qualitative Section

In-depth Interview Guide (CMW Trainers, LHS, Health Department Officials –
district/provincial level, Mercy Corps Project Team)
After consent and addressing queries begin the questions as below:
1. Can you all please introduce yourself? State where you work and since when have you been
working there.
Main content
1. How is your current job related to the CMWs? Please explain
2. In your experience how should the CMWs recruited to improve their retention in rural
settings?
a. Selection Process
b. Training Program
c. Deployment- When a CMW is deployed in your area, how does community know
about her?
i. Coordination between LHWs and CMWs (introduction, referral,
information sharing)
ii. Communication and coordination barriers /solution
d. Role and responsibilities
e. Post deployment support
f. Monitoring
g. Technical support
i. Service delivery set up (home delivery, workstation, charges)
ii. What is your opinion regarding maternal services delivered by CMWs?
1. Skills of CMWs
2. Performance/issues
3. Community perception about CMWs
h. Refresher trainings – training needs
i. Other incentives, bond
j. In your opinion what are the barriers faced by CMWs in delivery of these
services?
• Age, image, branding
• Acceptability
• Motivation, family support
• Mobility, catchment area/Logistic support
• Retention
• Competition with Dais, charges
• Work load
• Social factors
• Private practice
k. In your opinion how can these issues be addressed?

• Quality supportive supervision/training/authority
• Refresher trainings of CMWs
• Coordination between LHWs and CMWs
• Communication skills
• Appraisal
PS. Before adjourning, after consent to include the photo in the final report of the project
Study 1: FGD guide (CMWs deployed in Intervention and Control group and trainees)
After consent and addressing queries, begin as below:
I will circulate this sheet for everyone to sign and record your details. We will begin with the
introductions once everyone has filled out the sheet.
Name Area of residence Area of Work Distance from Age Marital Number of Experience
(rural/urban) (rural/urban) area residence Status Children (if working as a
to area of work applicable) CMW in
months
1. Can you all please introduce yourselves one by one? If deployed state where you work and
since when have you been working there.
Main content
1. What motivated you to become a CMW?
a. Financial benefits
b. Position in the society,
c. Interest/ inspiration,
d. Chances to get government job
e. Expectations from work
f. Support of family
g. Security/safety in mobility
2. How were you recruited in the training for CMWs?

a. Logistics
b. Application process
c. Costs incurred
d. Positive experiences e.g. any form of facilitation from any authority etc
e. Negative experiences
3. What were the eligibility criteria to become a CMW? In your opinion are they relevant
or should they be revised? If so, how?
4. What were the important issues you considered when taking up this job? (skip this
5. Were you adequately trained to take up your current roles and responsibilities? (skip
this question with trainees)
a. Clarity on Roles and Responsibilities
• Role in the community for providing maternal health services?
• What maternal services/how
• Training and skills taught in the school
• Importance of their role in improving maternal health
• Any reservations/difficulties in providing these services
• Marketing of Midwifery services in community
• How do the clients come to know about your services? (Source of
introduction in community, success factors, communication barriers)
6. Now that you have worked in the field please suggest how the recruitment processes
may be improved to better equip you to fulfill your roles and responsibilities? (skip this
a. Barriers from supervisors, communities, Health Department
i. From supervisors (financial, logistics, lack of support)
ii. From community (acceptability, image, respect, age, mobility, access,
security, catchment population
iii. Competition with local TBAs and other health providers)
iv. Mentorship programs
v. Refresher trainings, Incentives
vi. Linkages with the Health Department (coordination –feedback systems)
vii. Appraisal
7. Do you think working in rural areas (urban) allows you to provide the kind and quality of
health care you want to provide (e.g., the scope of practice you were trained to
provide)?
8. How important is this to you when deciding where you would like to work?
9. What are the factors that you deem essential for work in rural settings?
10. How would you compare the quality of services provided to you (e.g., cleanliness,
availability of equipment, access to referral services etc.) in rural areas as compared to
urban areas?
11. How do you compare the CMWs working in rural or urban areas?
(Satisfaction from work, motivation, willingness to do work)
12. How would additional support from the Health Department to CMWs working in rural
areas retain them?
a. Salary increase for those working in rural areas? (how much)
b. Living conditions (communication, transport, phone, water, electricity etc)
c. Social environment (access to social activities)
d. Availing leave, substitute worker, opportunities of refresher trainings (How
would you compare opportunities for in-service training if you work in a rural
area and an urban area? What should the in-service training opportunities be to
make working in a rural area more attractive? How important are in-service
training opportunities when considering where you will work?)
e. Considerations/benefits to children as support for education etc.
f. Appraisal
g. Timely promotions
h. Supportive Supervision
i. Security
j. business skills workshops
k. Mumta fund
l. provision of equipment
m. Technical/monitoring support from LHV/LHS etc.
13. Are there any other allowances/bonuses that would be important to motivate CMWs to
work in rural areas? What should allowances/bonuses be given for? How much should
they be?
14. How would you compare the opportunities for your career development if you work in a
rural area versus urban areas? What should the career development opportunities be to
make working in a rural area more attractive? How important are these opportunities
when considering where you will work?
15. How would you compare community support given to CMWs in rural areas than in
urban areas? How important is community support to you when considering where you
will work? (any stigma associated with the work)
16. Are there any other factors, which have not yet been mentioned, that are important to
you when deciding where you will work (rural /urban)?
I thank you for your contributions in the discussion. I will now circulate a list of factors that
we have discussed that affect your decision to serve as a CMW in rural area/urban area.
Please rank the 4 most important factors that you consider when taking the decision of
where to work. These include:
• The types of health care you may provide (scope of practice)
• The quality of facilities, including availability of equipment, drug supply, etc.
• Supportive management
• Career mentoring programs
• Salary
• Housing
• Living conditions (electricity, water, social activities)
• Transportation
• Performance bonuses
• Children’s education
• Career advancement/promotion opportunities
• Opportunities for continued education
• Community support
• Security
• Supportive supervision
• (Add any other factors mentioned that seem important).
(Facilitator: Distribute a copy of the table below to each participant for them to rank their top
four choices. Collect the form from the participants when they are done.)
PS. Before adjourning, after consent to include the photo in the final report of the project, take
a photograph while sitting in a circle
Survey 1
Survey 1
Improving Maternal and Newborn Services: Strengthening Community Midwives in

Balochistan
Introduction
Thank you very much for taking out time for this survey. I welcome you on behalf of the
Department of Health, Mercy Corps and Health Services Academy. This study is being
undertaken to learn about factors that would motivate Community Midwives for working in
rural districts of Balochistan. We are interested in understanding how the health department
can improve recruitment of CMWs and retain them in the system.
Since you have completed your 18 months training and are looking towards the future, we are
interested in knowing more about incentives or characteristics that would influence your
decision to work in a rural area as a CMW. This survey should take approximately 20-30
minutes.
You will be asked questions to obtain demographic and other background information. Then,
there will be a series of questions about hypothetical job postings. Your participation will help
us in identifying appropriate incentives and characteristics to motivate CMWs to work in rural
areas. Please read the question carefully and give your most honest responses throughout the
questionnaire. There is no right or wrong answer.
We will ensure confidentiality of the information you share.. If you agree to participate in this
study, please sign at the bottom and if not then please state the reason for refusal. If you have
any questions during the survey, please feel free to ask me.
Thank you for your participation!
Agreed Reused
Reason for refusal

Survey 1
Background Information
1. Name
2. Contact Number
3. Domicile:
a) Punjab
b) Sindh
c) Balochistan
d) KPK
e) AJK
4. Age:
a) 14-16
b) 17-20
c) 21-25
d) 25-30
e) 31 and above
5. District:
a) Quetta
b) Gawadar
c) Kech
6. Marital Status:
a) Single
b) Married
c) Divorced
7. Current location of work:

a) Rural
b) Urban
8. Name of area where you work
9. Your average monthly income

a) Less than 3000/month
b) Between 3000-5000/ month
c) Between 5000-7000/ month
d) Between 7000-10000/month
10. Monthly household income

a) Less than 10,000/month
b) Between 10,000-15,000/ month
c) Between 15,000-20,000/ month
d) Between 20, 000-30,000/ month
Survey 1
e) More than 30,000/month
11. No. of dependents
12. Number of children?
13. Work experience as a CMW (in years)
14. Would you prefer working in a rural area over urban area?
Yes/N
Survey 1
Scenario
Imagine that you have just successfully completed your 18 months CMW
training. Through newspaper, radio, and other sources, and you find that there
are two work packages that health department offers. For both packages, the
location is rural Balochistan. However, each of the two postings provides
different characteristics or benefits. Please imagine yourself in this situation and
make a decision as to which of the two presented work package you would
prefer. For the sake of this survey please assume that you would indeed receive
the full benefits described for the package. In making your choice, please
carefully read the full list of benefits for each work package and do not imagine
any additional features of it.
There are 12 different scenarios presented. Please note that while they may look
similar at a quick glance, they are indeed each very different.
Survey 1
Which of these job postings do you prefer? Select one by marking the circle under the job you
prefer.
Job package 1 Job Package 2
CMW Practice Seed money for setup Regular continuous supply
Setup medicines/ delivery kits
Transportation None Transport Allowance
Supportive No supervision Refresher courses
management
Stipend Rs 7000/ Month Rs 5000/ Month
Good schooling yes No
for children
Survey 1
prefer.
Housing House Allowance Housing with Basic Amenities
CMW Practice Regular continuous supply Seed money for setup
Tranportation Transport Allowance None
Supportive Supervision through Supervision through
management program(LHV/LHS/WMO) program(LHV/LHS/WMO)
for children
Survey 1
prefer.
Housing House Allowance None
CMW Practice Seed money for setup Seed money for setup
Setup
Supportive No supervision No supervision
management
Good schooling No yes
for children
Survey 1
prefer.
Housing Housing with Basic Amenities House Allowance
Supportive Refresher courses Refresher courses
management
for children
Survey 1
prefer.
Housing None House Allowance
CMW Practice Regular continuous supply Regular continuous supply
Setup medicines/ delivery kits medicines/ delivery kits
Supportive Refresher courses Supervision through
management program(LHV/LHS/WMO)
for children
Survey 1
prefer.
Tranportation None None
for children
Survey 1
prefer.
management
Good schooling yes yes
for children
Survey 1
prefer.
Tranportation Transport Allowance Transport Allowance
Good schooling No No
for children
Survey 1
prefer.
management
for children
Survey 1
prefer.
Supportive Supervision through No supervision
management program(LHV/LHS)
for children
Survey 1
prefer.
Setup
Supportive Supervision through Refresher courses
for children
Survey 1
prefer.
for children
Survey 2
Survey 2

Balochistan
Introduction
minutes.
Agreed Reused
Reason for refusal

Survey 2
1. Name
2. Contact Number
3. Domicile:
a) Punjab
b) Sindh
c) Balochistan
d) KPK
e) AJK
4. Age:
a) 14-16
b) 17-20
c) 21-25
d) 25-30
e) 31 and above
5. District:
a) Quetta
b) Gawadar
c) Kech
6. Marital Status:
a) Single
b) Married
c) Divorced

a) Rural
b) Urban


Survey 2

Yes/N
Survey 2
Scenario
Survey 2
prefer.
Tranportation None Transport Allowance
for children
Survey 2
prefer.
for children
Survey 2
prefer.
Setup
for children
Survey 2
prefer.
Supportive No supervision Supervision through
for children
Survey 2
prefer.
management
for children
Survey 2
prefer.
for children
Survey 2
prefer.
Housing None None
management
for children
Survey 2
prefer.
for children
Survey 2
prefer.
management
for children
Survey 2
prefer.
Housing Housing with Basic Amenities None
Setup
for children
Survey 2
prefer.
management
for children
Survey 2
prefer.
management
for children
Survey 3
Survey 3

Balochistan
Introduction
minutes.
Agreed Reused
Reason for refusal

Survey 3
1. Name
2. Contact Number
3. Domicile:
a) Punjab
b) Sindh
c) Balochistan
d) KPK
e) AJK
4. Age:
a) 14-16
b) 17-20
c) 21-25
d) 25-30
e) 31 and above
5. District:
a) Quetta
b) Gawadar
c) Kech
6. Marital Status:
a) Single
b) Married
c) Divorced

a) Rural
b) Urban


Survey 3

Yes/N
Survey 3
Scenario
Survey 3
prefer.
for children
Survey 3
prefer.
management
for children
Survey 3
prefer.
Setup
Supportive Refresher courses No supervision
management
for children
Page Break
Survey 3
prefer.
for children
Survey 3
prefer.
for children
Survey 3
prefer.
for children
Survey 3
prefer.
for children
Survey 3
prefer.
Housing None None
management
for children
Survey 3
prefer.
for children
Survey 3
prefer.
for children
Survey 3
prefer.
Housing Housing with Basic Amenities Housing with Basic Amenities
Setup
management
for children
Survey 3
prefer.
Setup
for children
Survey 4
Survey 4

Balochistan
Introduction
minutes.
Agreed Reused
Reason for refusal

Survey 4
1. Name
2. Contact Number
3. Domicile:
a) Punjab
b) Sindh
c) Balochistan
d) KPK
e) AJK
4. Age:
a) 14-16
b) 17-20
c) 21-25
d) 25-30
e) 31 and above
5. District:
a) Quetta
b) Gawadar
c) Kech
6. Marital Status:
a) Single
b) Married
c) Divorced

a) Rural
b) Urban

Survey 4

Yes/N
Survey 4
Scenario
Survey 4
prefer.
management
for children
Survey 4
prefer.
management
for children
Survey 4
prefer.
Setup
for children
Survey 4
prefer.
for children
Survey 4
prefer.
management
for children
Survey 4
prefer.
for children
Survey 4
prefer.
Housing House Allowance House Allowance
management
for children
Survey 4
prefer.
for children
Survey 4
prefer.
for children
Survey 4
prefer.
for children
Survey 4
prefer.
for children
Survey 4
prefer.
Supportive Refresher courses No supervision
management
for children
Survey 5
Survey 5

Balochistan
Introduction
minutes.
Agreed Reused
Reason for refusal

Survey 5
1. Name
2. Contact Number
3. Domicile:
a) Punjab
b) Sindh
c) Balochistan
d) KPK
e) AJK
4. Age:
a) 14-16
b) 17-20
c) 21-25
d) 25-30
e) 31 and above
5. District:
a) Quetta
b) Gawadar
c) Kech
6. Marital Status:
a) Single
b) Married
c) Divorced

a) Rural
b) Urban

Survey 5

Yes/N
Survey 5
Scenario
Survey 5
prefer.
management
for children
Survey 5
prefer.
for children
Survey 5
prefer.
management
for children
Survey 5
prefer.
for children
Survey 5
prefer.
Housing House Allowance House Allowance
for children
Survey 5
prefer.
for children
Survey 5
prefer.
Housing None None
management
for children
Survey 5
prefer.
for children
Survey 5
prefer.
management
for children
Survey 5
prefer.
Setup
for children
Survey 5
prefer.
management
for children
Survey 5
prefer.
management
for children
ANNEX 5
Mix Logit Regression Analysis

Intervention Non Intervention
p values p values
Stipend 0.000* 0.000*

Housing Allowance 0.001* 0.058*
Housing Amenities 0.000* 0.025*
Setup 0.078 0.747
Transportation 0.000* 0.000*
Supervision by Government 0.025 0.106
Supervision Refresher 0.002* 0.000*
Course
Schooling 0.711 0.853
---------------------------------------------------
name: <unnamed>
log: C:\Users\hp\Desktop\New folder\combine
> d.log
log type: text
opened on: 13 Jun 2016, 12:57:27
. insheet using "C:\Users\hp\Desktop\New folder\com

> bined.csv", comma
(26 vars, 2640 obs)
. recode stipend (1=5000) (2=7000) (3=12000)

(stipend: 2640 changes made)
. gen housing_no = (housing == 1)
. gen housing_alwnc = (housing == 2)
. gen housing_amen = (housing == 3)
. gen supervision_no = (management == 1)
. gen supervision_govt = (management == 2)
. gen supervision_ref = (management == 3)
. mixlogit choice stipend, id( respond_id) group( pair) rand( housing_alwnc housing_amen setup transportation
supervision_govt supervision_ref
> schooling) nrep(500)
Iteration 0: log likelihood = -826.79575 (not concave)

Iteration 3: log likelihood = -824.49748
Mixed logit model Number of obs = 2626

LR chi2(7) = 7.36
Log likelihood = -823.67376 Prob > chi2 = 0.3928
------------------------------------------------------------------------------
choice | Coef. Std. Err. z P>|z| [95% Conf. Interval]
-------------+----------------------------------------------------------------
Mean |
stipend | .0001433 .0000158 9.07 0.000 .0001123 .0001743
housing_al~c | .35678 .096239 3.71 0.000 .1681551 .545405
housing_amen | .5319988 .10859 4.90 0.000 .3191663 .7448314
setup | .0731114 .0808991 0.90 0.366 -.085448 .2316707
transporta~n | .5441802 .0782899 6.95 0.000 .3907348 .6976256
supervisio~t | .3001255 .1122887 2.67 0.008 .0800436 .5202074
supervisio~f | .5482413 .121033 4.53 0.000 .3110209 .7854617
schooling | -.0290965 .0748789 -0.39 0.698 -.1758563 .1176634
-------------+----------------------------------------------------------------
SD |
housing_al~c | -.0174106 .1976786 -0.09 0.930 -.4048536 .3700324
housing_amen | .3527573 .1938986 1.82 0.069 -.0272769 .7327914
setup | .3245795 .1599245 2.03 0.042 .0111331 .6380258
transporta~n | .065078 .4015999 0.16 0.871 -.7220434 .8521994
supervisio~t | .3426816 .2266149 1.51 0.130 -.1014754 .7868386
supervisio~f | .4124563 .2025801 2.04 0.042 .0154066 .8095059
schooling | .2879158 .142358 2.02 0.043 .0088993 .5669324
------------------------------------------------------------------------------
The sign of the estimated standard deviations is irrelevant: interpret them as
being positive
. log close
name: <unnamed>
log: C:\Users\hp\Desktop\New folder\combined.log
log type: text
closed on: 13 Jun 2016, 13:02:55
-----------------------------------------------------------------------------------------------------------------------------------------------
FGD-STUDY 2
1. What are your views regarding the field challenges in establishing yourself as a health
provider in the community?
a. How can sustainability be achieved?
2. Major initiatives you undertook in this regard
a. Lessons learnt (positives & negatives)
i. (e.g. small loans, process of getting the loans, role of women’s groups to
sustain mumta fund, ambulance service, charge for services, etc )
3. Are you aware of the Entrepreneurship initiatives? Was the Business Skills Training
offered (to some of you) useful?
4. For those who attended the training,
a. What did you learn and implement? Please elaborate
b. What did you learn but was not feasible?
c. What was learnt, feasible but not done?
d. What was found useful? Other comments.
5. What are your suggestions to the Health Department for facilitating CMWs in becoming
self-sustainable
Study Two
Expenditure and Investment Assessment of CMWs
Consent Form
Introduction
In collaboration with the Department of Health, a study to assess how can CMWs become
financially self-sustaining while serving the needs of the poorest of the poor is being
undertaken. We are interested in understanding the details regarding the expenditure and
the investments you have made to establish yourself as a healthcare provider in the
community. There are no harms associated with your participation in the study. However,
your participation will have the policy makers to move towards effective implementation of
the CMW program. You will be required to fill out one month’s log about the investment
and expenditure made. If you have any queries I would be happy to address them or you
could contact the focal persons in the Mercy Corps team in Quetta or Department of Health.
(Contact: Dr. Shaihak Riaz – phone:03003401486 )
If you agree to participate in this study, please sign at the bottom and if not then please
state the reason for refusal.
Agreed Reused
Reason for refusal

Section I – Socio-Demographic
Respondent ID No.
Name
Age
UC/Tehsil
Site Intervention/Control
Skip Response
Q# Question Code
pattern
Primary …………. 1
Secondary ……..... 2
Intermediate …...... 3
Graduate & above..4
Q#1 What is your current status of education?
Madrasah ……..… 5
Can read & write…6
Illiterate ………….7
Other ……………. 0
Single ………...…. 1 If 1, go
Q#2 What is your marital status?
Married ………..…2 to Q # 4
Q#3 How many alive children do you have? Actual (in numbers)
Q#4 What is your place of job?
Q#5 Do you receive a monthly salary? Actual (in Rs.)
Q#6 What is your total monthly income? Actual (in Rs.)
Q#7 What is overall household income? Actual (in Rs.)
How many people are supported on this

Q#8 Actual (in numbers)
income?
Do you own? (in your home)
Yes………………1
(a) Television
No ………………2
Yes………………1
(b) Refrigerator
No ………………2
Yes………………1
(c) Air Conditioned
No ………………2
Q#9 Yes………………1
(d) Motor-Cycle
No ………………2
Yes………………1
(e) Washing Machine
No ………………2
Yes………………1
(f) Computer
No ………………2
Yes………………1
(g) Car
No ………………2
Section II – Tameer Loan and Refresher Training
Q# Question Response
1 Did you receive a Business Skills Yes/No
Development training
2 When (date, Year)
3 Who conducted the training
4 Where was this training arranged
5 Was this training helpful?
6 Have you taken any loan? Yes/No
7 If yes, specify from where and how
much and on what terms and
conditions.
8 Why have you not taken loan

from ‘Tameer Bank’? Please
explain
9 Have you used the training to Yes/No

establish maternity health services
If Yes, how was the fund used - Establish work station
(check all that apply) - Purchase equipment
- Purchase medicines
- Advertising
- Any other (list)
If No, what were the challenges - Lack skills to manage business

faced - Too many competitors
(check all that apply) - Community unwilling to use services
- Any other (list)
10 In your opinion, how can your - Refresher training on business skills
services be improved - Skills development
- Any other (list)
11 Among the services you provide -

a. Which are the most -
profitable
b. Which are the least -

profitable
Section III – Services Cost Assessment
Investment in establishing services

Record details of initial expenses incurred under the following budget heads
No. Budget Head Expense

1 Establishment of clinic
2 Marketing – printing of business cards,

flyers/brochures, banner, billboard
3 Materials – Medicines, equipment purchased
4 Routine clinic maintenance – cleaning, sterilization
5 Personnel hired
6 Others: Specify
A. Expenditure - Direct Month
Instructions: The purpose of the table below is to maintain a record of information about
the expenses that you incur while providing antenatal, natal, postnatal and child health
services to your communities. Please include expenditures related only the activities related
to provision of services according to the list 1 provided on the next page
Date Activity Materials Purchased Additional costs Time taken to

+ Cost (Phone calls, complete
Personnel) activity
List 1 – CMW services list
B. Expenditure – Indirect
Instructions: The purpose of the table below is to maintain a record of information about
the additional expenses that you incur while providing services. Please include expenditures
related to support of other persons accompanying you, travel costs or any other costs that
were incurred which were needed for you to deliver your services
Date Activity Travel Chaperone Any other expenses –

food, fuel
Mode (on foot, Cost Accompanied Occupation Travel Item Cost
taxi, Suzuki, by costs
bus, rickshaw,
own transport,
any other)
C. Income
Instructions: The purpose of the table below is to maintain a record of income from
various services or materials sold to the client/s.
Date Activity* Did you Payment received – Materials Cost

charge the cash or other sold to client
client
Section IV:
Please Tick (√) for “YES” and Cross (X) for “NO”.
1. I am aware of my skills and personal qualities. Yes No
2. I can identify the needs for products and services in my community Yes No
3. I can decide on additional business that suits my skills and talents Yes No
4. I can work out the price for my services / products Yes No
5. I know who my patients / customers will be Yes No
6. I know where to sell my services and products Yes No

.
7. I know how much money, I need to start my business Yes No
8. I know how much material, I need to start my business Yes No
9. I know about basic principles of financial management Yes No
10. I understand how important it is to keep personal money and Yes No

business money separate.
11. I can give out receipts for money which I earn from my business receives Yes No
12. I can keep a cashbook Yes No
13. I can talk to new clients easily Yes No
14. I know how to follow the debtors Yes No
15. I can organize my time well for my personal life and business Yes No
16. I know about my community’s rules and regulations for business Yes No
17. I know where are the possible referral facilities Yes No
18. I know the re-payment plan for my loan Yes No
19. I know how to calculate profit and loss Yes No
20. I have worked out my business plan Yes No
21. I understand how a small business could use a telephone, fax Yes No
machine and e-mail
22. I understand how some businesses use computers Yes No
** Please attach a copy of the monthly report of the same period submitted to the
Department of Health
CMWs
1. What are your views regarding the field challenges in establishing yourself as a
health provider in the community?
a. How can sustainability be achieved?
2. Major initiatives you undertook in this regard
a. Lessons learnt (positives & negatives)
i. (e.g. small loans, process of getting the loans, role of women’s groups
to sustain mumta fund, ambulance service, charge for services, etc )
3. Are you aware of the Entrepreneurship initiatives? Was the Business Skills Training
offered (to some of you) useful?
4. For those who attended the training,
a. What did you learn and implement? Please elaborate
b. What did you learn but was not feasible?
c. What was learnt, feasible but not done?
d. What was found useful? Other comments.
5. What are your suggestions to the Health Department for facilitating CMWs in
becoming self sustainable
Study 4
Documents required
1. 6 months reports submitted prior to mHealth introduction (completeness and
missing information- hard and soft copy)
2. Manually entered data files and digitalized data files during the study period shared
as soft copy (excel sheets or specify the software used) to check for accuracies (in
built checks for errors).
3. Manual tallying of the records 5-10% by Mercy Corps staff and results submitted to
consultant
4. Time of submission of reports before and after the introduction of mHealth project.
Note the above documents relevance became redundant after meeting with project
staff
5. Relevant reports of the project indicating uptake of mHealth app by the CMWs and
the project meetings and outcomes if documented. Unstructured interviews with
the Mercy Corps Project staff will be undertaken.
Qualitative study
Focus Group Discussion
Introduction and Consent
The Mercy Corps upon request by the Department of Health is interested in improving the
quality of the new reporting and monitoring system in Quetta/ Balochistan. In this context
we would like your candid opinion regarding your experience with this service and request
you to answer a few questions.
Findings from the study will help the relevant authorities to take appropriate steps to
improve CMWs performance. The information collected will be kept confidential and you
have the right to withdraw from the study at any time. Your responses will have no bearing
on your current position with the Department of Health. If you have any queries I would be
happy to address them.
Agreed Refused
Reason for refusal

1. Before the mHealth system, how did you report your work progress report to the
program/Department of Health /Supervisor?
2. How long have you owned a mobile phone?
a. Type of phone (manual or touch screen, simple without applications, smart
phone etc)
3. What is the most common feature of the phone that you use
a. Voice calls
b. Text messages
c. Internet surfing/browsing
4. Did you receive any training for proper use of the mHealth system?
a. If not, will such a training be useful?
b. If yes, was it useful, what are your recommendations to improve the training
to facilitate the use of the technology by the CMWs.
5. Do you currently use the mHealth system for reporting?
a. Are you confident in using it?
b. If no – why not
c. Are there any gaps in the current mHealth application?
i. Issues faced during reporting
ii. Technical failures
iii. Others
6. If you were to compare, is the mHealth system better than the manual system?
a. Why? Which features made that system better?
b. Voice messages
c. Alerts
d. Feasibility
e. Uptake by the clients etc
7. How do you think can the mHealth system be made better?
Study 3
KAP Survey of CMWs
Consent Form
Introduction
Department of Health and Mercy Corps is conducting a study to assess the knowledge,
attitude and practices of the Community Midwives. This study is being undertaken to learn
about Community Midwives gaps in knowledge so that appropriate support may be
provided through feedback to policy makers. The information collected will be kept
confidential and you have the right to withdraw from the study at any time. Your
performance will have no bearing on your current position with the Department of Health. If
you have any queries I would be happy to address them.
Agreed Refused
Reason for refusal
Skip
Q# Question Code Response
pattern
Graduate & above..4
Other ……………. 0
Single ………...…. 1 If 1, go

income?
Yes………………1
(a) Television
No ………………2
Yes………………1
(b) Refrigerator
No ………………2
Yes………………1
(c) Air Conditioned
No ………………2
Q#9 Yes………………1
(d) Motor-Cycle
No ………………2
Yes………………1
(e) Washing Machine
No ………………2
Yes………………1
(f) Computer
No ………………2
Yes………………1
(g) Car
No ………………2
How long have you been working in the
Q#10 In months
area as a CMW
Q#11 Number of deliveries per month
Do you think that the training you
received in midwifery school was
Yes………………1
Q#12 adequate for working in the field?
No……………….2
How do you think the quality of care of

Q13
offered by you may be improved?
Section 01: Knowledge Assessment of CMW
Please (√) single best answer.
1.1 During pregnancy a woman should have at least following number of antenatal
checkups
a. 05 Antenatals
b. 04 Antenatals
c. 03 Antenatals
d. 02 Antenatals
1.2 Pregnant women should receive educational messages about which of the
following?
a. Personal Hygiene, rest and exercise during pregnancy
b. Diet and nutrition during pregnancy
c. Danger signs during pregnancy
d. All of the above
1.3 Focused antenatal care includes which of the following actions?
a. Checking the baby’s position at 28 weeks.
b. Checking the woman’s blood pressure at every visit.
c. Assessing ankle edema at 36 weeks.
d. Counseling the women about danger signs only at the last visit.
1.4 At each postpartum visit, the mother should be counseled to seek care if she has
which of the following danger signs
a. Normal lochia, temperature 370 C, or slight breast engorgement
b. Edema of hands and face, severe abdominal pain, or sore, cracked nipples
c. Severe headache, foul-smelling lochia, or calf tenderness
d. B and C
e. All of the above
1.5 Active management of the 3rd stage of labor should be practiced
a. Only for women who have a history of post partum hemorrhage
b. Only for primipara
c. Only for multipara
d. For all women in labor
1.6 The appropriate order of steps in active management of the third stage of labor
include
a. Controlled cord traction, fundal massage, and oxytocin
b. Intravenous oxytocin, cord clamping and cutting, and fundal massage
c. Cord clamping and cutting, controlled cord traction, ergometrine administration,
and inspection to be sure the placenta is intact
d. Intramuscular injection of oxytocin, controlled cord traction with countertraction
to the uterus, and uterine massage.
1.7 If a woman is admitted during the active phase of labor cervical dilation is initially
a. To the left of the alert line
b. To the right of the alert line
c. On the alert line
d. On the action line
1.8 Cervical dilation plotted to the right of the alert lines indicates
a. Satisfactory progress in labor
b. Unsatisfactory progress in labor
c. The end of the latent phase
d. The end of the active phase
1.9 Which of the following will help to decrease the risk of infection during childbirth
a. Performing frequent vaginal examination
b. Rupturing membranes as soon as possible in the first stage of labor
c. Routine catheterization of the bladder before childbirth.
d. Reducing prolonged labor.
e. All of the above
1.10 Immediate care for a normal newborn includes

a. Skin to skin contact followed by placing the baby in a warning incubator
b. Drying the baby, removing the wet cloth and covering the baby with a clean, dry
cloth
c. Stimulating the baby by slapping the soles of the baby’s feet
d. Deep suctioning of the airway to remove mucus
e. All of the above
1.11 Which of the following can contribute to hypothermia in newborns?
a. The baby is not dried thoroughly immediately after birth
b. The baby is bathed immediately after birth
c. The baby is dried and placed in skin to skin contact with the mother
d. A and B
e. All of the above
1.12 Care of the umbilicus should include

a. Cleaning with Alcohol
b. Covering with sterile compress
c. Cleaning with cooled, boiled water and leaving uncovered
d. Applying antibiotic cream.
1.13 The best way to determine if a new born needs resuscitation is to
a. Wait until one minute after birth and assign the Apgar score.
b. Listen to the baby’s heart rate
c. Observe respirations immediately and begin resuscitation if they are less than 30
per minute
d. Perform resuscitation only if central cyanosis is present.
e. Apgar score at the time of birth
1.14 Immediate postpartum hemorrhage can be due to

a. Uterine atony
b. Genital trauma
c. Retained placenta
d. All of the above
1.15 The most effective way to immediately control eclamptic convulsions is to

a. Give diazepam
b. Give magnesium sulfate
c. Deliver the baby as soon as possible
d. Give nifedipine.
1.16 A woman with ruptured uterus has which of the following signs and symptoms
a. Rapid maternal pulse
b. Persistent abdominal pain and suprapubic tenderness
c. Fetal distress
d. All of the above
1.17 During the first 2 hours following birth, the provider should
a. Measure the woman’s blood pressure and pulse once, and insert a catheter to
empty her bladder.
b. Measure the woman’s blood pressure and pulse, and check the uterine tone
every 15 minutes.
c. Not disturb the woman if asleep because her rest is more important than her
vital signs
d. Measure the woman’s temperature and pulse, massage the uterus, and perform
a vaginal examination to remove clots.
1.18 After childbirth, the mother should have a postpartum visit with a skilled provider
a. Once, at 3 weeks postpartum
b. Once, at 6 weeks postpartum
c. Three times: at 6 hours, 6 days, and 6 weeks postpartum and any time she has
danger signs
d. Only if she has danger signs.
1.19 By the tenth day postpartum, you should be able to palpate the uterus
a. Just below the umbilicus
b. At the level of the umbilicus
c. Just above the symphysis pubis
d. Halfway between the symphysis pubis and the umbilicus
1.20 Each postpartum examination should include
a. Measurement of blood pressure and temperature, and assessment of
conjunctiva, breasts, abdomen, perineum, and legs.
b. Observation of breastfeeding
c. Information about contraception, safer sex, and counseling and testing for HIV
d. All of the above
Section 02: Attitudes of CMWs regarding women health
Please tick under the appropriate box
Score 1 - 4, (1=Strongly Disagree, 1=Disagree, 3=Agree, 4=Strongly agree)
Antenatal care 1 2 3 4
1. I feel confident that I register pregnant mothers
as per the guidelines
2. I am trained to prepare mothers for examination
3. I am competent to discuss mothers’ problems

individually
4. I can perform abdominal examination for:
• Assessing fetal growth
• Determining the lie of fetus
I am confident in:
5. Counting fetal heart sounds
6. Measuring maternal blood pressure
7. Identifying impending eclampsia
8. Weighing mothers
9. Recording weight in maternal record
10. Advising on maternal nutrition
11. Correcting retracted nipple
12. Determining expected date of
Delivery
13. I am competent to take appropriate action
14. I can diagnosis onset of labor
15. I am confident that I give appointments to come
to health facilities as per protocol
16. I am competent in instructing how to take the
Natal Care : I feel that I am competent to attend to
the following:
17. Performing a delivery without assistance
18. Managing a post partum Hemorrhage
19. Action to be taken of retained Placenta
20. Assessment of progress of labor
21. Performing an episiotomy
22. Deciding when to perform an episiotomy in
multipara
23. Aseptic severance of umbilical cord
24. Clearing of airway of newborn
Postnatal care: I feel that I am competent to attend
to the following:
25. Identification of abnormalities of lochia
26. Identification of involuted uterus
27. Cleaning episiotomy Wound
28. Examination of breasts for infection
29. Measuring mothers' Temperature
30. Teaching a family member to care for mother
General: I feel that I am competent to attend to the
following:
32. Delivering a health education talk regarding
33. Deliver all services in friendly and helpful manner
34. If you were to recommend a healthcare provider
to a friend or a close relative to avail antenatal,
neonatal or perinatal services etc (i.e services
given by a CMW) , you would recommend seeing
a CMW
35. CMWs is a preferred choice health care provider
because of convenience and home based skilled
36. If your sister were to go into labour I would call a
CMW
37. My community is well informed of CMW services
38. My community’s preferred choice of healthcare
provider for antenatal, peri-natal and neonatal
services is a CMW
39. My community needs to get more information
about a CMW
40. In my opinion CMWs are doing a good job in the
field
41. In my opinion quality of service provided by a
CMW is good
Section 03: Checklist Practices of CMWs regarding women health
List of activities to assess practices of CMWs by monitoring staff.
Instructions: During the supervisory visits, the LHS/LHV (preferably not the regular
supervisor) will observe the activities conducted by the CMWs and report in appropriate box
in the table below:
Score 0 - 4, (0=Not responded, 1=can't perform, 2=not competent, 3=competent, 4=very
competent)
Antenatal care 0 1 2 3 4 5
42. Registration of pregnant mothers
43. Prepared mothers for examination
44. Discussed mothers’ problems individually
45. Abdominal examination for:
49. Weighing mothers
Delivery
54. Appropriate action regarding varicose veins
55. Diagnosis of onset of labor
56. Giving appointments to come to health facilities
57. Instructing how to take the supplementary
nutrition
Natal Care (it should be likert scale i.e whether they
are competent enough to manage a delivery or not
?)
multipara
Postnatal care (yes/no)
General
74. Friendly and helpful manner
Comments:
Qualitative Component
Community/Clients FGD Guide
Introduction and consent

Department of Health and Mercy Corps is conducting a study to examine the quality of
services provided by the Community Midwives. This study is being undertaken to learn
about the quality of care provided by Community Midwives. In this context we would like
your candid opinion regarding quality of the care services provided by CMWs and request
improve their performance. The information collected will be kept confidential and you
have the right to withdraw from the study at any time. Your performance will have no
bearing on your current position with the Department of Health. If you have any queries I
would be happy to address them.
Agreed Refused
Reason for refusal
Serial # Name Age Number of Education Husband’s Decision

children occupation maker in
household
1. How long have you lived in this area?
2. Who are the health care providers you prefer to seek care from for maternal and
child health and for delivery?
3. Where do you get information on maternal and child health?

4. Is there a CMW in your area? If so then,
a. Since when
b. Have you attended any health education sessions given by her? What is your
opinion about the sessions?
i. What was learnt? Were they useful, informative? How so?
ii. What knowledge was attained through women groups conducted by

CMWs, nature of knowledge received and how it affect/affected the
decision making regarding use of services offered by CMWs
5. Have you utilized the CMW’s services?
a. Which service (Maternity, Family planning, others) was availed?
6. What is your opinion about the services used? Were you satisfied with the quality of
care offered by them? Please explain.
a. CMW was well prepared and gave necessary information
b. Service quality
c. Treatment provided (adequate or not)
d. Follow up services
e. Identification of complication and referral, etc
7. In future would you use her services again –
a. If yes, why
b. If no, why not
8. Would you recommend your family members/relatives to the CMWs
a. If yes, why
b. If no, why not
9. How do you think the services of CMWs can be improved?
Once the group has no more suggestions, wrap up discussion. Thank the participants for
their participation.
Study 3
Qualitative Component
Community/Clients FGD Guide
Introduction and consent

Department of Health and Mercy Corps is conducting a study to examine the quality of
services provided by the Community Midwives. This study is being undertaken to learn
about the quality of care provided by Community Midwives. In this context we would like
your candid opinion regarding quality of the care services provided by CMWs and request
improve their performance. The information collected will be kept confidential and you
have the right to withdraw from the study at any time. Your performance will have no
bearing on your current position with the Department of Health. If you have any queries I
would be happy to address them.
Agreed Refused
Reason for refusal
Serial # Name Age Number of Education Husband’s Decision

children occupation maker in
household
1. How long have you lived in this area?
2. Who are the health care providers you prefer to seek care from for maternal and
child health and for delivery?
3. Where do you get information on maternal and child health?

4. Is there a CMW in your area? If so then,
a. Since when
b. Have you attended any health education sessions given by her? What is your
opinion about the sessions?
i. What was learnt? Were they useful, informative? How so?
ii. What knowledge was attained through women groups conducted by

CMWs, nature of knowledge received and how it affect/affected the
decision making regarding use of services offered by CMWs
5. Have you utilized the CMW’s services?
a. Which service (Maternity, Family planning, others) was availed?
6. What is your opinion about the services used? Were you satisfied with the quality of
care offered by them? Please explain.
a. CMW was well prepared and gave necessary information
b. Service quality
c. Treatment provided (adequate or not)
d. Follow up services
e. Identification of complication and referral, etc
7. In future would you use her services again –
a. If yes, why
b. If no, why not
8. Would you recommend your family members/relatives to the CMWs
a. If yes, why
b. If no, why not
9. How do you think the services of CMWs can be improved?
Once the group has no more suggestions, wrap up discussion. Thank the participants for
their participation.
Study 3
KAP Survey of CMWs
Consent Form
Introduction
Department of Health and Mercy Corps is conducting a study to assess the knowledge, attitude
and practices of the Community Midwives. This study is being undertaken to learn about
Community Midwives gaps in knowledge so that appropriate support may be provided through
feedback to policy makers. The information collected will be kept confidential and you have the
right to withdraw from the study at any time. Your performance will have no bearing on your
current position with the Department of Health. If you have any queries I would be happy to
address them.
Agreed Refused
Reason for refusal
Skip
Q# Question Code Response
pattern
Graduate & above..4
Other ……………. 0
Single ………...…. 1 If 1, go


income?
Yes………………1
(a) Television
No ………………2
Yes………………1
(b) Refrigerator
No ………………2
Yes………………1
(c) Air Conditioned
No ………………2
Q#9 Yes………………1
(d) Motor-Cycle
No ………………2
Yes………………1
(e) Washing Machine
No ………………2
Yes………………1
(f) Computer
No ………………2
Yes………………1
(g) Car
No ………………2
How long have you been working in the
Q#10 In months
area as a CMW
Q#11 Number of deliveries per month
Do you think that the training you
received in midwifery school was
Yes………………1
Q#12 adequate for working in the field?
No……………….2
How do you think the quality of care of

Q13
offered by you may be improved?
Section 01: Knowledge Assessment of CMW
Please (√) single best answer.
1.1 During pregnancy a woman should have at least following number of antenatal
checkups
a. 05 Antenatals
b. 04 Antenatals
c. 03 Antenatals
d. 02 Antenatals
1.2 Pregnant women should receive educational messages about which of the following?
a. Personal Hygiene, rest and exercise during pregnancy
b. Diet and nutrition during pregnancy
c. Danger signs during pregnancy
d. All of the above
1.3 Focused antenatal care includes which of the following actions?
a. Checking the baby’s position at 28 weeks.
b. Checking the woman’s blood pressure at every visit.
c. Assessing ankle edema at 36 weeks.
d. Counseling the women about danger signs only at the last visit.
1.4 At each postpartum visit, the mother should be counseled to seek care if she has which
of the following danger signs
a. Normal lochia, temperature 370 C, or slight breast engorgement
b. Edema of hands and face, severe abdominal pain, or sore, cracked nipples
c. Severe headache, foul-smelling lochia, or calf tenderness
d. B and C
e. All of the above
1.5 Active management of the 3rd stage of labor should be practiced
a. Only for women who have a history of post partum hemorrhage
b. Only for primipara
c. Only for multipara
d. For all women in labor
1.6 The appropriate order of steps in active management of the third stage of labor include
a. Controlled cord traction, fundal massage, and oxytocin
b. Intravenous oxytocin, cord clamping and cutting, and fundal massage
c. Cord clamping and cutting, controlled cord traction, ergometrine administration, and
inspection to be sure the placenta is intact
d. Intramuscular injection of oxytocin, controlled cord traction with countertraction to
the uterus, and uterine massage.
1.7 If a woman is admitted during the active phase of labor cervical dilation is initially
a. To the left of the alert line
b. To the right of the alert line
c. On the alert line
d. On the action line
1.8 Cervical dilation plotted to the right of the alert lines indicates
a. Satisfactory progress in labor
b. Unsatisfactory progress in labor
c. The end of the latent phase
d. The end of the active phase
1.9 Which of the following will help to decrease the risk of infection during childbirth
a. Performing frequent vaginal examination
b. Rupturing membranes as soon as possible in the first stage of labor
c. Routine catheterization of the bladder before childbirth.
d. Reducing prolonged labor.
e. All of the above
1.10 Immediate care for a normal newborn includes

a. Skin to skin contact followed by placing the baby in a warning incubator
b. Drying the baby, removing the wet cloth and covering the baby with a clean, dry
cloth
c. Stimulating the baby by slapping the soles of the baby’s feet
d. Deep suctioning of the airway to remove mucus
e. All of the above
1.11 Which of the following can contribute to hypothermia in newborns?
a. The baby is not dried thoroughly immediately after birth
b. The baby is bathed immediately after birth
c. The baby is dried and placed in skin to skin contact with the mother
d. A and B
e. All of the above
1.12 Care of the umbilicus should include

a. Cleaning with Alcohol
b. Covering with sterile compress
c. Cleaning with cooled, boiled water and leaving uncovered
d. Applying antibiotic cream.
1.13 The best way to determine if a new born needs resuscitation is to

a. Wait until one minute after birth and assign the Apgar score.
b. Listen to the baby’s heart rate
c. Observe respirations immediately and begin resuscitation if they are less than 30 per
minute
d. Perform resuscitation only if central cyanosis is present.
e. Apgar score at the time of birth
1.14 Immediate postpartum hemorrhage can be due to

a. Uterine atony
b. Genital trauma
c. Retained placenta
d. All of the above
1.15 The most effective way to immediately control eclamptic convulsions is to

a. Give diazepam
b. Give magnesium sulfate
c. Deliver the baby as soon as possible
d. Give nifedipine.
1.16 A woman with ruptured uterus has which of the following signs and symptoms
a. Rapid maternal pulse
b. Persistent abdominal pain and suprapubic tenderness
c. Fetal distress
d. All of the above
1.17 During the first 2 hours following birth, the provider should
a. Measure the woman’s blood pressure and pulse once, and insert a catheter to empty
her bladder.
b. Measure the woman’s blood pressure and pulse, and check the uterine tone every 15
minutes.
c. Not disturb the woman if asleep because her rest is more important than her vital
signs
d. Measure the woman’s temperature and pulse, massage the uterus, and perform a
vaginal examination to remove clots.
1.18 After childbirth, the mother should have a postpartum visit with a skilled provider
a. Once, at 3 weeks postpartum
b. Once, at 6 weeks postpartum
c. Three times: at 6 hours, 6 days, and 6 weeks postpartum and any time she has danger
signs
d. Only if she has danger signs.
1.19 By the tenth day postpartum, you should be able to palpate the uterus
a. Just below the umbilicus
b. At the level of the umbilicus
c. Just above the symphysis pubis
d. Halfway between the symphysis pubis and the umbilicus
1.20 Each postpartum examination should include
a. Measurement of blood pressure and temperature, and assessment of conjunctiva,
breasts, abdomen, perineum, and legs.
b. Observation of breastfeeding
c. Information about contraception, safer sex, and counseling and testing for HIV
d. All of the above
Section 02: Attitudes of CMWs regarding women health
Please tick under the appropriate box
Score 1 - 4, (1=Strongly Disagree, 1=Disagree, 3=Agree, 4=Strongly agree)
Antenatal care 1 2 3 4
1. I feel confident that I register pregnant mothers
as per the guidelines
2. I am trained to prepare mothers for examination
3. I am competent to discuss mothers’ problems

individually
4. I can perform abdominal examination for:
I am confident in:
8. Weighing mothers
Delivery
13. I am competent to take appropriate action
14. I can diagnosis onset of labor
15. I am confident that I give appointments to come
to health facilities as per protocol
16. I am competent in instructing how to take the
Natal Care : I feel that I am competent to attend to
the following:
multipara
Postnatal care: I feel that I am competent to attend
to the following:
General: I feel that I am competent to attend to the
following:
33. Deliver all services in friendly and helpful manner
34. If you were to recommend a healthcare provider
to a friend or a close relative to avail antenatal,
neonatal or perinatal services etc (i.e services
given by a CMW) , you would recommend seeing
a CMW
35. CMWs is a preferred choice health care provider
because of convenience and home based skilled
36. If your sister were to go into labour I would call a
CMW
37. My community is well informed of CMW services
38. My community’s preferred choice of healthcare
provider for antenatal, peri-natal and neonatal
services is a CMW
39. My community needs to get more information
about a CMW
40. In my opinion CMWs are doing a good job in the
field
41. In my opinion quality of service provided by a
CMW is good
Section 03: Checklist Practices of CMWs regarding women health
List of activities to assess practices of CMWs by monitoring staff.
Instructions: During the supervisory visits, the LHS/LHV (preferably not the regular supervisor)
will observe the activities conducted by the CMWs and report in appropriate box in the table
below:
Score 0 - 4, (0=Not responded, 1=can't perform, 2=not competent, 3=competent, 4=very
competent)
Antenatal care 0 1 2 3 4 5
42. Registration of pregnant mothers
43. Prepared mothers for examination
44. Discussed mothers’ problems individually
45. Abdominal examination for:
49. Weighing mothers
Delivery
54. Appropriate action regarding varicose veins
55. Diagnosis of onset of labor
56. Giving appointments to come to health facilities
57. Instructing how to take the supplementary
nutrition
Natal Care (it should be likert scale i.e whether they
are competent enough to manage a delivery or not
?)
multipara
Postnatal care (yes/no)
General
74. Friendly and helpful manner
Comments:
DETAILS OF PARTICIPANTS
Study 3 –FGDs with CMW’s Clients / Community
District: Gwadar
CMW: Nadia (SMNC Intervention area)
Community: Sohrabi ward, Gwadar
S# Name Age # of Education Husband’s HH decision Area/ street

children occupation maker
P-1 Rehana 30 6 Eight grade Bank Job Husband Sohrabi ward first street
P-2 Saeeda 35 7 Never attended Fishing Husband Sohrabi ward first street
P-3 Gul nisa 30 5 Never attended Fishing Husband Sohrabi ward first street
P-4 Shahnaz 35 4 Eight grade Fishing Husband Sohrabi ward second street
P-5 Rukhsana 30 4 Eight grade Bank Job Husband Sohrabi ward second street
P-6 Fahmeeda 35 7 Never attended Fishing Husband Sohrabi ward third street
P-7 Waseela 60 4 Never attended Died Self Sohrabi ward third street
P-8 Shaheena 35 7 Never attended Fishing Husband Sohrabi ward third street
P-9 Fazila 30 3 Never attended Daily wager Husband Sohrabi ward third street
P-10 Sabira 35 3 Never attended Fishing Husband Sohrabi ward third street
P-11 Hani 23 1 Never attended Fishing Husband Sohrabi ward third street
District: Kech
CMW: Rahat (SMNC- Intervention area)
Community: Machli Market

P- 25 5 Never Attended Daily wages Husband Machli Market

Amber
1
P- 40 2 Eight Grade Govt. Job Husband Machli Market

Nagina
2
P- 21 3 Never Attended Daily Wages Husband Machli Market

Ashrat
3
P- 29 4 Never Attended Teacher Husband Malik abad

Shari
4
P- 38 6 Never Attended Private job Husband Malik abad

Waseela
5
P- 25 7 Never Attended Daily wages Husband Malik abad

Naseema
6
P- 38 01 Graduate Daily wages Husband Koshk

Nusrat
7
P- 27 5 Eight Grade Daily wages Husband Koshk

Rhima
8
P- Shah bibi 40 4 Eight Grade Daily wages/ Self Koshk

9 Embroidery
P- Shargul 39 6 Never Attended Daily wages Husband Malik abad, sari

10 bazar
P- Parihatoon 21 4 Never Attended Clerk Husband Malik abad, sari

11 bazar
District: Kech
CMW: Asia (SMNC Intervention area)
Community: Kahnay Pusht

P-1 Sameena 25 3 Never Attended Daily wages Husband Kahnay Pusht
P-2 Taj bibi 39 7 Never Attended Daily wages Husband Kahnay Pusht
P-3 Hameeda 27 4 Never Attended Daily wages Husband Kahnay Pusht
P-4 Sabira 21 3 Never Attended Daily wages Husband Dabuk Bazar
P-5 Shaida 40 8 Never Attended Died Self Dabuk Bazar
P-6 Waheeda 31 2 Never Attended Daily wages Husband Dabuk Bazar
P-7 Granaz 39 3 Never Attended Shop keer Husband Koshkalat
P-8 Jan bibi 35 4 Never Attended Driver Husband Koshkalat
P-9 Memona 32 3 Never Attended Daily wages Husband Koshkalat
P-10 Adeela 20 1 Never Attended Daily wages Husband Mullahani

bazar
P-11 Gulbano 25 2 Never Attended Daily wages Husband Mullahani

bazar
District: Quetta
CMW: Sadiqa Barat Khan (SMNC Intervention area)

Community: Sabzal Raod Quetta

P-1 Fatima 40 3 Never attended Died Self Barech street
P-2 Shehzadi 35 6 Never attended Daily wager Husband -
P-3 Lal Khatoon 40 6 Never attended Nothing Husband -
P-4 Hurmat 45 8 Never attended Driver Husband -

Khatoon
P-5 Haleema 32 1 FA Driver Husband Sasooli Chowk
P-6 Rabia 32 5 Two grade Farmer Husband -
P-7 Saleema 35 3 Three grade Farmer Husband -
P-8 Sajida 40 7 Never attended Farmer Husband Uzbak Chowk
P-9 Naimat Bibi 28 0 BA Teacher Husband -
P-10 Jannat Bibi 40 11 One grade Driver Husband Muslimabad
P-11 Rubina 38 4 Two grade Driver Husband -

District: Quetta
CMW: Rubina Sajjad (SMNC Intervention area)

Community: Municipal Corporation Brewery road, Quetta
S# Name Age # of Education Husband’s HH Area/ street

children occupation decision
maker
P-1 Nasreen 45 5 Never attended Died Self Same street
P-2 Salma 50 6 Eight grade Works at private Husband Same street

hospital
P-3 Farzana 32 5 Eight grade Driver Husband Killi Muhammad Hasni
P-4 Samina 40 4 Matric Driver Husband Killi Muhammad Hasni
P-5 Asia 25 0 Never attended Driver (own car) Husband Killi Muhammad Hasni
P-6 Reha 30 2 Six grade Works at BMC Husband Raisani Town

Tharia hospital
P-7 Muniza 20 0 Never attended Computer Assistant Husband Raisani Town
P-8 Kareema 35 4 Matric Govt. Job Husband Raisani Town
P-9 Naila 40 3 Primary Govt. Job Husband Raisani Town
P- Sonia 35 3 Never attended Govt. Job Husband TB Sanatorium

10
P- Aeren 35 3 Six grade Tailor master Husband TB Sanatorium

11
P- Moniqa 60 2 Never attended Masonry Husband TB Sanatorium

12
P- Sareeta 35 0 Matric Shopkeeper Husband TB Sanatorium

13
P- Maryam 30 2 Eight grade Works at BMC Husband Railway society

14 hospital
P- Mah bibi 35 1 Never attended Nothing Husband Railway society

15
District: Gwadar
CMW: Sumaiya (Non-intervention area)

Community: Kohbun Ward near Mullah Moosa Chowk, Gwadar

P-1 Zakia 23 3 Eight grade Shop keeper Husband Factory side street
P-2 Razia 35 1 Never attended Fishing Husband Factory side street
P-3 Jameela 30 2 Never attended Nothing Husband Factory side street
P-4 Shahida 30 7 Never attended Fishing Husband Factory side street
P-5 Nazia 23 3 Never attended Fishing Husband Koh bun ward
P-6 Gul Bibi 17 0 Never attended - Father Koh bun ward
P-7 Basria 23 0 Eight grade - Father Mullah moosa

chowk
P-8 Noor Nisa 30 4 Never attended Shop keeper Husband Mullah moosa
chowk
District: Kech
CMW: Rukhshenda (Non-intervention area)

Community: Singani sar Turbat

P-1 Jameela 40 7 Never attended Driver Uncle Riyaz Mohalla
P-2 Bilques 35 4 Intermediate Driver Father in Riyaz Mohalla

Law
P-3 Fahmida 21 2 Never attended Daily wages Uncle Riyaz Mohalla
P-4 Buloor 20 2 Never attended Working in Gulf Brother in Abdul Sallam Muhallah
Law
P-5 Zainab 21 1 Never attended Clerk Husband Abdul Sallam Muhallah
P-6 Rehana 29 3 Never attended Daily wages Father in Abdul Sallam Muhallah
Law
P-7 Ruqia 25 2 Matric Shop keeper Husband Abdul Sallam Muhallah
P-8 Shabana 32 3 Never attended Teacher Uncle Singansi sar
P-9 Durgul 29 4 Intermediate Daily wages Grand father Singansi sar
P-10 Humaira 38 4 Never attended Daily wages Uncle Singansi sar
P-11 Hani 36 6 Intermediate Working in Gulf Husband Singansi sar
P-12 Faiza 32 3 Never attended Daily wage Husband Singansi sar

District: Kech
CMW: Muard bibi (Non-intervention area)

Community: Absor

P-1 Waseela 35 1 Never attended Suzuki driver Husband Absor
P-2 Sabira 38 7 Eitht Grade Suzuki driver Husband Saith aslam Bazar Absor
P-3 Zargul 35 5 Eight Grade Driver Husband Saith aslam Bazar Absor
P-4 Jangul 35 5 Never attended Daily wages Husband Saith aslam Bazar Absor
P-5 Haseena 40 8 Never attended Driver Husband Saith Yaseen Bazar
P-6 Waheeda 40 6 Never attended Clerk Husband Saith Yaseen Bazar
P-7 Hemna 39 5 Never attended Barber Husband Kauda Yousuf bazar

Absor
P-8 Zarhatoon 40 4 Never attended Daily wages Husband Kauda Yousuf bazar
Absor
P-9 Gulbbi 31 3 Never attended Hawaker Husband Kauda Yousuf bazar

Absor
P-10 Zarbano 32 3 Never attended Daily wages Husband Kauda Yousuf bazar
Absor
P-11 Mehr a 38 2 Never attended Daily ages Husband Kauda Yousuf bazar
hatoon Absor
District: Quetta
CMW: Sareeta Kumari (Non-intervention area)

Community: Kawari road, Quetta

P-1 Rubina 35 5 Never attended Govt. Job Husband Kawari road

Shaheen (Masonry)
P-2 Aglia wanti 45 6 Never attended Shopkeeper Husband Kawari road
P-3 Sapna 25 2 Never attended Govt. Job Husband Kawari road
P-4 Pauki 20 1 Eight grade Unmarried Father Near Golmandi
P-5 Hakim bibi 35 6 Six grade Govt. Job Husband Near Golmandi
P-6 Rahila 35 5 Matric Nothing Husband Near Golmandi
P-7 Raj bibi 40 9 Never attended Nothing Husband Faqeer Mohammad

road
P-8 Bakht Taj 35 3 Never attended Own business Husband Faqeer Mohammad
road
P-9 Bakht Nasir 45 10 Never attended Shopkeeper Husband Faqeer Mohammad

road
District: Quetta
CMW: Jameela (Non-intervention area)

Community: Gulshan Hassan Colony Brewery road, Quetta

P-1 Gul Plari 35 6 Never attended Shopkeeper Husband Gulshan Hassan Colony
P-2 Naz bibi 25 3 Five grade Daily wager Husband Gulshan Hassan Colony
P-3 Imam 45 9 Never attended Daily wager Husband Gulshan Hassan Colony
Khatoon
P-4 Lal bibi 30 2 Never attended Govt. Job Husband Gulshan Hassan Colony
P-5 Pari Gul 32 5 Never attended Driver Husband Aminabad
P-6 Gul Khatoon 28 4 Never attended Driver Husband Aminabad
P-7 Taj Bibi 35 5 Never attended Shopkeeper Husband Aminabad
P-8 Haleema 28 4 Never attended Shopkeeper Husband Allahabad street
P-9 Zareena 38 7 Never attended Daily wager Husband Allahabad street
P- Fareeda 28 2 Five grade Daily wager Husband Allahabad street

10
Study 4
Qualitative study
Focus Group Discussion
Introduction and Consent
The Mercy Corps upon request by the Department of Health is interested in improving the
quality of the new reporting and monitoring system in Quetta/ Balochistan. In this context we
would like your candid opinion regarding your experience with this service and request you to
answer a few questions.
Findings from the study will help the relevant authorities to take appropriate steps to improve
CMWs performance. The information collected will be kept confidential and you have the right
to withdraw from the study at any time. Your responses will have no bearing on your current
position with the Department of Health. If you have any queries I would be happy to address
them.
Agreed Refused
Reason for refusal
1. Before the mHealth system, how did you report your work progress report to the
program/Department of Health /Supervisor?
2. How long have you owned a mobile phone?
a. Type of phone (manual or touch screen, simple without applications, smart
phone etc)
3. What is the most common feature of the phone that you use
a. Voice calls
b. Text messages
c. Internet surfing/browsing
4. Did you receive any training for proper use of the mHealth system?
a. If not, will such a training be useful?
b. If yes, was it useful, what are your recommendations to improve the training to
facilitate the use of the technology by the CMWs.
5. Do you currently use the mHealth system for reporting?
a. Are you confident in using it?
b. If no – why not
c. Are there any gaps in the current mHealth application?
i. Issues faced during reporting
ii. Technical failures
iii. Others
6. If you were to compare, is the mHealth system better than the manual system?
a. Why? Which features made that system better?
b. Voice messages
c. Alerts
d. Feasibility
e. Uptake by the clients etc
7. How do you think can the mHealth system be made better
ANNEX 12
Pakistan Telecommunication Footp1int
Figure 1-PTC Coverage Footprint- Baluchistan
Pakistan Telecommunication Coverage Footprint

Click on a marker to check GSM coverage for a location
Choose Serv ice Cellular Service BChoose Technology GSM BChoose Operator All B Show Coverage Home
Kech r· l
sate lne
Zahedan0
ul-">1,
Bare
0
B1kaner
0 u
PR ,
RAJASTHAN
Jodhpur 0 Gwahor
0 AJmer 0
Udaipur
G. llorOman 0
Musca t
u........
Figure 2-PTC Coverage Footprint - Quetta
Figure 3-PTC Coverage Footprint - Gawadar

Figure 4-PTC Coverage Footprint- Kech
Pakistan Telecommunication Coverage Footprint

Click on a marker to check GSM coverage for a location
Choose Servi ce Ccllulor Service B Choose Technology GSM B Choose Operator All B Show Coverage Home
Kcch
Map Satellite
Gtehk
Child Survival and Health Grants Program Project Summary
Nov-16-2016
Mercy Corps
(Pakistan)
General Project Information
Cooperative Agreement Number: AID-OAA-A-12-00093
MC Headquarters Technical Backstop: Jennifer Norman
MC Headquarters Technical Backstop Backup:
Field Program Manager: Ahmed Ullah
Midterm Evaluator:
Final Evaluator:
Headquarter Financial Contact: Jamey Pietzold
Project Dates: 9/30/2012 - 9/29/2016 (FY2012)
Project Type: Scale
USAID Mission Contact: Randolph Augustin
Project Web Site:
Field Program Manager

Name: Ahmed Ullah (Project Manager)
Address: H.No-10, Dr. Mustafa Khan street,
Arbab Karam Khan Road
Quetta , Balochistan 87300 Pakistan
Phone: +92 81 2470863
Fax: +92 81 2470240
E-mail: [email protected]
Skype Name: ahmedullah34
Alternate Field Contact

Name: Arif Noor (Country Director)
Address: Pak Palace, Murree Road, Near Rawal Chowk
Islamabad 44000 Pakistan
Phone: +92 (0)300 838 0169
Fax: +92 51 2878082
E-mail: [email protected]
Skype Name: arif.noor65
Grant Funding Information
USAID Funding: $1,741,836 PVO Match: $580,684

General Project Description
Mercy Corps’ four year (Sep 30 2012-Sep 29 2016) SCALE program in Quetta, Kech, and Gwadar districts seeks to improve maternal and newborn
health status, especially for poor and marginalized women of Balochistan (Goal). Saving Mothers and Newborns in Communities’ (SMNC)
Strategic Objective to increase use of quality essential maternal and newborn care, through private-sector community midwives seeks to facilitate
uptake of high-impact MNCH interventions, with a focus on maternal and neonatal health outcomes. SMNC directly contributes toward
USAID/Pakistan’s strategic objective of improving MCH in Pakistan and complements USAID’s new MCH Program in Sindh. SMNC is well
positioned to directly influence the MNCH sector in Balochistan, as it was designed jointly with the Balochistan Department of Health (DoH) and
upon their request. The DoH is keen to test this model to determine whether CMWs can become self-sustaining private providers in Balochistan
and increase coverage of high impact MNCH services. The Operations Research was replaced with a revised Learning Agenda in year 3 which
was designed to provide the Balochistan DOH with the evidence and information they need to operationalize CMWs to meet their MNH need. The
revised learning agenda topics (jointly agreed on by Mercy Corps and DOH) will equip the DOH to better utilize the CMW as a resource to address
MNCH outcomes. The DOH is mainly interested in exploring answers to the following four questions:
1. How can the DoH improve its selection process to effectively recruit and deploy CMWs in underserved areas?
2. How can CMWs become financially self-sustaining while serving the needs of the poorest of the poor?
3. Do CMWs offer quality care? If so, how?
4.. How can the MOH streamline CMW reporting using cell phone technology and expand mHealth in the province?
This is an ideal time to document and test these innovations, as the DoH is just now preparing its strategic plans and policies within the newly
devolved context.
Project Location
Latitude: 26.16 Longitude: 63.01

Project Location Types: Rural
Levels of Intervention: Home
Community
Province(s): Balochistan
District(s): Quetta, Gwadar, and Kech Districts
Sub-District(s): --
Operations Research Information

There is no Operations Research (OR) component for this Project.
Partners
Government of Balochistan (Collaborating Partner) $0
Strategies
Social and Behavioral Change Strategies: Community Mobilization

Group interventions
Interpersonal Communication
Social Marketing
Mass media and small media
Health Services Access Strategies: Emergency Transport Planning/Financing
Addressing social barriers (i.e. gender, socio-cultural, etc)
Community-based health insurance scheme/Community financing mechanisms
Implementation in a geographic area that the government has identified as poor and
underserved
Health Systems Strengthening: Quality Assurance
Supportive Supervision
Task Shifting
Providing feedback on health worker performance
Coordinating existing HMIS with community level data
Community input on quality improvement
Strategies for Enabling Environment: Create/Update national guidelines/protocols
Advocacy for revisions to national guidelines/protocols
Stakeholder engagement and policy dialogue (local/state or national)
Advocacy for policy change or resource mobilization
Tools/Methodologies: Community-based Monitoring of Vital Events
Mobile Devices for Data Collection
Capacity Building
Local Partners: Business/Private Sector
National Ministry of Health (MOH)
Dist. Health System
Government sanctioned CHWs
Private Providers (Other Non-TBA)
Interventions & Components

Maternal & Newborn Care (90%) CHW Training
- Emergency Obstetric Care
- Neonatal Tetanus
- Recognition of Danger signs
- Newborn Care
- Post partum Care
- Child Spacing
- Integation. with Iron & Folic Acid
- Normal Delivery Care
- Birth Plans
- STI Treat. with Antenat. Visit
- Home Based LSS
- Control of post-partum bleeding
- Emergency Transport
- Kangaroo Mother Care (skin to skin care)
- Misoprostol
- AMTSL
- Pre-eclampsia
Operational Plan Indicators
Number of People Trained in Maternal/Newborn Health

Gender Year Target Actual
Female 2013 200
Female 2013 45
Male 2013 0
Male 2013 0
Female 2015 26570
Female 2015 30110
Male 2015 0
Male 2015 0
Female 2016 31746
Male 2016 24
Number of People Trained in Child Health & Nutrition
Female 2013 200
Female 2013 45
Male 2013 0
Male 2013 0
Female 2015 26570
Female 2015 30110
Male 2015 0
Male 2015 0
Female 2016 31746
Male 2016 24
Number of People Trained in Malaria Treatment or Prevention
Female 2013 0
Female 2013 0
Male 2013 0
Male 2013 0
Female 2015 0
Female 2015 0
Male 2015 0
Male 2015 0
Female 2016 0
Male 2016 0
Locations & Sub-Areas

Total Population: 382,515
Target Beneficiaries
Pakistan - MC - FY2012
Children 0-59 months 61,202
Women 15-49 years 84,153
Beneficiaries Total 145,355
Rapid Catch Indicators: DIP Submission
Sample Type: 30 Cluster

Confidence
Indicator Numerator Denominator Percentage
Interval
Percentage of mothers with children age 0-23 months who received at
least two Tetanus toxoid vaccinations before the birth of their youngest 588 1940 30.3% 2.9
child
Percentage of children age 0-23 months whose births were attended by 1618 1940 83.4% 2.3
skilled personnel
Percentage of children age 0-5 months who were exclusively breastfed 953 1940 49.1% 3.1
during the last 24 hours
Percentage of mothers of children age 0-23 months who had four or 1145 1940 59.0% 3.1
more antenatal visits when they were pregnant with the youngest child
Percentage of mothers of children age 0-23 months who are using a 1079 1940 55.6% 3.1
modern contraceptive method
Percentage of children age 0-23 months who received a post-natal visit 1154 1940 59.5% 3.1
from an appropriately trained health worker within two days after birth
Rapid Catch Indicators: Mid-term
Sample Type: LQAS

Confidence
Indicator Numerator Denominator Percentage
Interval
Percentage of mothers with children age 0-23 months who received at
least two Tetanus toxoid vaccinations before the birth of their youngest 137 228 60.1% 6.4
child
Percentage of children age 0-23 months whose births were attended by 187 228 82.0% 5.0
skilled personnel
Percentage of children age 0-5 months who were exclusively breastfed 130 228 57.0% 6.4
during the last 24 hours
Percentage of mothers of children age 0-23 months who had four or 107 228 46.9% 6.5
more antenatal visits when they were pregnant with the youngest child
Percentage of mothers of children age 0-23 months who are using a 89 228 39.0% 6.3
modern contraceptive method
Percentage of children age 0-23 months who received a post-natal visit 166 228 72.8% 5.8
from an appropriately trained health worker within two days after birth
Rapid Catch Indicators: Final Evaluation
Rapid Catch Indicator Comments

The Baseline survey was conducted as part of the original Operations Research by University of Alberta and has been reported under the DIP
tab. Data was collected in May/June 2014 and therefore was conducted only with batch 2 CMWs who had been deployed in August 2014 (Batch 1
was deployed in September 2013). Due to security concerns, th e majority of the rural project areas were dropped from the survey.
A follow on LQAS survey was conducted 9 months after the baseline survey was done; results are reported under the midterm tab. This survey
captured batch 1 and batch 2 CMWs (data reported is for all CMWs) A signigicant portion of rural areas were also dropped from this survey due to
security challenges. The LQAS survey was re-designed to provide:
i) A mid-term assessment of project across key selected indicators;
ii) An overall comparison between the results of the LQAS survey and those of the UoA baseline;
iii) A comparative analysis of performance of each district and each batch.

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Samreen Baloch, a Community Midwife from Quetta District, provides antenatal care to a client.

FINAL EVALUATION OF THE SAVING

ANC Antenatal Care

CMW Community Midwife

CSHGP Child Survival and Health Grants Program

DHF District Health Forum

DHO District Health Officer

DoH Department of Health

FGD Focus Group Discussion

FSA Focused Strategic Assessment

GoB Government of Balochistan

IEC Information, Education and Communication

KII Key Informant Interview

LHS Lady Health Supervisor

LHV Lady Health Visitor

LHW Lady Health Worker

LQAS Lot Quality Assurance Sampling

MCH Maternal and Child Health Program

MCSP Maternal and Child Survival Program

MIS Management Information System

MNCH Maternal, Neonatal and Child Health

MoU Memorandum of Understanding

PHS Public Health Specialist

PNC Pakistan Nursing Council

PSC Provincial Steering Committee

SMNC Saving Mothers and Newborns in Communities

TBA Traditional Birth Attendant

ToR Terms of Reference

TWG Technical Working Group

USAID United States Agency for International Development

WSG Women Support Group

Indicator Balochistan Khyber Punjab Sindh

PARTNERSHIPS AND COLLABORATION

ASSESSMENT METHODOLOGY AND LIMITATIONS

Quetta Kech Gwadar TOTAL

Total SMS 571 341 140 1,052

Practices Project-Supported CMWs (N=50) Other CMWs (N=79)

Action Status Observations

KEY STRATEGIES AND FACTORS AFFECTING RESULTS

SUSTAINABILITY AND POTENTIAL FOR SCALING UP

Approved for incorporation into standard midwifery

Terms of Reference for

The project’s intermediate Results are:

• Do CMWs offer quality care? If so, how?

VI. Purpose of the Focused Strategic Assessment

4. Identification of gaps in the existing reporting and monitoring system and

VIII. Focused Strategic Assessment Questions

• Is the community midwife a suitable solution for contributing to reductions in maternal

• Proven expertise and leadership in

Key Tasks of the FSA Team Leader:

Online meeting with Mercy Corps team to discuss

3 Develop methodology data collection tools for FSA 2

4 Incorporate feedback and finalize tools 1.5

5 Mentoring of national consultant for data collection 2

6 Analysis of the data 5

7 Develop and share preliminary reports of the FSA 6

8 Submit final report after incorporating feedback 3

Total Days 24*

X. Focused Strategic Assessment Report

Date of FGD: __/_/ Address: _________________________________

Start time: ___________________________

Finish time: District: ___________________________

Date prepared: ___/_/___

Date reviewed: //_