8 research outputs found
Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme
Objective
To understand why skilled birth attendanceâan acknowledged strategy for reducing maternal deathsâhas been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions.
Design
Implementation research was conducted using an institutional ethnographic approach.
Setting and population
National programme and local community levels in Pakistan.
Methods
Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together.
Main outcomes
Alignment of programme theory with real-world practice.
Results
Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of publicâprivate sector cooperation. Uniform deployment policies failed to consider existing provider density and geography.
Conclusions
Greater attention to programme theory and the âreal-worldâ setting during design of maternal health strategies is needed to achieve consistent results in different contexts
Coverage of private sector community midwife services in rural Punjab, Pakistan: development and demand
Social determinants and causes of child mortality in Pakistan: Analysis of national demographic health surveys from 1990 to 2013
A case study of outsourced primary healthcare services in Sindh, Pakistan: is this a real reform?
Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan
Newborn survival in Pakistan: a decade of change and future implications.
Pakistan has the world's third highest national number of newborn deaths (194 000 in 2010). Major national challenges over the past decade have affected health and development including several large humanitarian disasters, destabilizing political insurgency, high levels of poverty and an often hard-to-reach predominately rural population with diverse practices. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Neonatal mortality declined by only 0.9% per annum between 2000 and 2010; less than the global average (2.1%) and less than national maternal and child mortality declines. Coverage of newborn care interventions increased marginally, with wide socio-economic variations. There was little focus on newborn health until 2000 when considerable policy change occurred, including integration of newborn care into existing community-based maternal and child packages delivered by the Lady Health Worker Programme and national behaviour change communications strategies and programmes. The National Maternal, Newborn and Child Health Programme catalyzed newborn services at both facility and community levels. Civil society and academics have linked with government and several research studies have been highly influential. Since 2005, donor funding mentioning the term 'newborn' has increased more for Pakistan than for other countries. The country faces ongoing challenges in reducing neonatal mortality, and in much of Pakistan, societal norms discourage care-seeking and many women are unable to access care for themselves or their children. The policy advances and existing delivery platforms offer the potential to substantially accelerate progress in reducing neonatal deaths. The recent decision to dismantle the national Ministry of Health and devolve responsibility for health sector management to the provincial level presents both challenges and opportunities for newborn health