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Development & Management of the

Reproductive Health Program to Reduce the

High Maternal Mortality in District Haripur,
• Dr Haris Habib
• Dr Nida Liaquat
• Dr Fariha Fatima
• Dr Muhammad Bilal Khan

MSPH 2009-10
Health Services Academy Islamabad
Reproductive health is “a state of complete physical,
mental and social well-being and not merely the absence of
disease or infirmity, in all matters relating to the
reproductive system and to its functions and processes”.
6 priority components of RH:
• Safe motherhood
• Ante-natal care
• Obstetric care
• Post-natal care
• Newborn care
• Family planning
These services were devised to address the issues of
maternal & neonatal deaths.
Other Components of RH: Control of STIs, HIV/AIDS,
Cancers of genital tract, Reproductive health in adolescence
& post-menopausal, Pre-marital & genital counseling.
• Maternal mortality is “the death of the women during
the pregnancy or within 42 days after the termination
of pregnancy by the maternal causes and absence of
the accidental or other causes.
• 1800 Women are dying /day globally due to maternal
• 78% of these deaths are occurring during the perinatal
• 90% of the deaths occurring in the SSA & SEA
including Pakistan.
• MMR in Pakistan is 276/100000 live births
• 82% of these deaths are preventable
Causes of Maternal
Deaths World Wide
History of Haripur
Hari Singh Nalva,General of Ranjit Singh’s army
Introduction of District
• Founded in 1822 by Hari singh Nalva
• Diverse Landscape
• Administrative boundaries touching Punjab and
Federal Capital.
• District Health system under the administration of
EDO Health consists of very vast infrastructure.
• Other Vertical Programs for reproductive health ;
– National Program for PH & FP
– District Population Office
– District MNCH program.
Map of Haripur and the
Beautiful Khanpur Dam
Urban-Rural Population
Distribution in Distt. Haripur

12% Rural
Population %
Demographic and Reproductive
Health Indicators of District
Source’ DCR (1998), District Population Office (2008), National Programme (2008) ,
FD (2008)

Population 0.8 Millions

Rural/ Urban % 88/12%
Male / Female % 49/51%
Growth Rate 2.19
Health Facilities 54
TFR 4.7
IMR 36/1000
MM Ratio 170/100000
Deliveries in Health 34223
% Deliveries by skilled in 11.7%
CPR 28.5
Public Sector Health Staff in
Haripur (Current Status)

D e s ig n a tio n
M e d ic a l O f f ic
Target Population
• Our Target population is all Pregnant
women in Haripur which constitutes 3% of
the total population.

• This population is spread over 1,725 sq.

km, with population density of 401.3
persons per sq. km.

• The average household size of the district is

6.6 persons per household.
Literacy Rate in Distt.
• The overall literacy rate for Haripur
district is 53.7%.
• The female literacy rate is dismally low
at 37.4% as against male literacy of
70.5 percent.
• The urban: rural break down show that
rural literacy is lower (51.4 percent)
than the urban literacy (69.7 percent).
Why Private Sector?
72 % Urban
70% 6 7%




2 0 % 2 1% 2 1%

10% 7%
5% 5%
4% 3%
2% 2% 2% 2% 2% 1% 2% 1%
1% 1%
Private Disp/ Public Disp/ RHC/BHUs Hakeem Homeopath Chemist Others
Hosp Hosp
Aim and Objectives
• Aim:
– To improve the quality of life through provision of
better reproductive health services to the women of
• Objectives:
– To reduce the maternal mortality in the district
Haripur by 75% in 03 years.
– To achieve the availability of skilled birth attendants
24/7 in 100% of the facilities of the district Haripur in
03 years
Preventive Interventions
Short Term Interventions Long Term Interventions

• Community awareness sessions • To improve knowledge, attitudes

regarding reproductive health and their beliefs regarding
approach. family planning.
• Involvement of influential • To provide comprehensive
people of district like religious family planning services
and political leaders as well as • Eradicate poverty and hunger
family heads & establishment of • To improve employment status
community groups. • Promote gender equality and
• Community based transport women empowerment.
system on subsidized rates, • Intersectoral approach
make available for 24/7. • Involvement of men in the
reproductive health issues.
Curative Interventions
Short term interventions Long Term Interventions

• Availability of the female • To improve the health care

staff at the facilities 24/7 system by increase the
• Hands on training to number of health
existing doctors, midwives personnel of the district.
and LHWs. Provide kits and • To provide cEmoC at BHUs
teach them how to greet level.
patients. • Develop public/private
• Improving access to health partnership.
facility by providing • To develop working
ambulance to the district. relationship among the
• Functionalize birthing CPSP, Federal MoH and
centers DHMT for sustainability of
• Provision of ante-natal care the program intervention.
• Provision of post-natal care
New Concept
• The Risk of the death in the women of child
bearing is un predicted.
• We always talk of 3 Ds.
• What is the limit of these delays???
• We should not delay in understanding the
magnitude of the problem!
• We would introduce 3 Ts concept
– Terrain
– Type of transport
– Travel Time
Selected Internvetions
• Curative; short term
– We as a DHMT selected the strategy of
availability of skilled birth attendants
24/7 in the BHUs.
• Preventive;
– Community awareness through the
multifaceted approach for the
sustainability of program intervention.
Steps Towards Better
• We made the 10 clusters of 40 BHUs along
with the 6 RHCs.
• For every cluster, gynecologist will be
hired with large monetary incentives;
• Training of the trainers for skilled birth
attendant will be done in Teaching
• Skilled development Training of the staff
working in the health facilities by the
master trainers.
• Making of support groups in the targeted
Steps Towards Better
Future (contd…)
• Community awareness sessions will be conducted
at the regular intervals in order to emphasize the
importance of reproductive health.
• To involve the influential people of the district
regarding the decision and policy making about
the service provision and service utilization in the
public sector health facilities.
• To involve the community transporter through
the community support group for providing the
ambulatory facilities to the referral cases on
subsidized rates.
• Purchase of the delivery equipments for the
Activity Plan for one Whole
Year(Revised Every Year)
• Ist month:
– Sensitization of the DHMT and
stakeholders about the program through
series of meetings.(1st Week’s)
– Hiring of the master Trainers in the
teaching hospitals.(1st & 2nd Week).
– Formulation of training manuals (3rd & 4th
– Printing & revising the TMs (4th Week).
Activity Plan (Cont…)
• IInd Month:
– Hiring and inducting the gynecologists &
other necessary staff(5th Week)
– Training of the trainers at selected
teaching hospital outside the district(6th
7th & 8th Weeks).
Activity Plan (Cont…)
• IIIrd Month:
– Training of rest of concerned female
staff by the trainers within the
district(9th, 10th, 11th Weeks)
– Evaluation of the trained staff through
role plays & hands on activity.(12th
Activity Plan (Cont…)
• IV & V Months:
– Purchase of the equipments and other
necessary items for the facilities.(13th & 14th
– Hiring of the social mobilizers & their
training(14th & 15th Weeks)
– Serial meetings with the community members
& identification of local influential people(16th,
17th,18th, 19th Weeks)
– Printing & revision of the social mobilization
material like pamphlets, posters ,banners
etc(20th week).
Activity Plan (Cont…)
• VI Month:
– Formation of community support
groups(21st week)
– Start of community awareness sessions
about the provision & utilization of
reproductive health services in the area.
(21st week & it is an ongoing activity).

Activity Plan (Cont…)
• VI------XII Months:
– Evaluation:
• Ongoing , for every cluster twice in a month
and for every facility once in a month visit.
• Feedbacks from the community support
groups regularly once in a month &
continuously through cellular phone.
• Every facility & every cluster will report its
performance in written every month and
cross checking of these reports by the
Revised Activity Plans
• As it is a 3 years program, activity
plans may be revised every year
according to the feedbacks by the
community and evaluation by DHMT.
• Rotation of the gynecologist may be
done after every six months.
• Budgeting adjustment according to
the need may be done.
Total Budget 100 Millions only

1 Training Expenses
Training of trainers (3 days course) 0.1 million Rupees

Training of WMO’s+LHVs+Nurses(6 Days with 0.3 million

Training of Social mobilizers 0.2 million

2 Printing Expenses
Printing of training 6 million
mannuals+Pamphlets+Multimedia & Other
Stationary Items

3 Transport Expenses
Trainers & social mobilzers Transport 4 million

Community Transporters 2 million

Budgeting (Conti...)
4 Awareness campaign
Community awareness sessions+formation of 5.0 Millions
community groups

5 Purchase of Equipment
Delivery tables, O2 Cylinder, 4 Ambulances, 4 10 Millions
Ultrasound Machines & other surgical equipments

6 Salaries & Overtime 35 Millions

7 Construction Charges 20 Millions

8 Repair and maintenance 10 Millions

9 Miscellaneous 5 Millions
Way Forward
• Sustainability: Program suggests
following steps to be taken for the
sustainability of the interventions
– Working relationship among CPSP, Fed. MoH &
– Formulation of the policy regarding the trainee
doctors .
– Formulation of the policy regarding induction of
the doctors in the basic health units and
revision of their pay /salary especially NWFP.
Thank you very much!