STTA for Social Cultural
and Economic Barriers to
Access Health and Nutrition

PROJECT BACKGROUND

A stable and prosperous Pakistan is a top priority in international development efforts of the UK Government. Empowerment and voice of women, girls and marginalized social groups is vital for these efforts to succeed. Therefore, enabling them to articulate their needs and influence legislation, policies and practices which affect them is at the heart of the UK’s development assistance. Better access to reproductive, maternal, new-born and child health and nutrition is an important entry point to achieve this objective.

Pakistan is off-track to achieve the health Millennium Development Goals (MDGs). DFID Pakistan (DFIDP) therefore is focusing on reproductive, maternal, new-born and child health (RMNCH) including nutrition to support effective implementation of health sector strategies that will lead to achievement of the health MDGs. DFIDP has recently signed a Memorandum of Understanding (MOU) with the Government of Pakistan on Provincial Health and Nutrition Programme (PHNP) to achieve RMNCH and nutrition results in KPK and Khyber Pakhtunkhwa provinces over four years (2013 to 2017).

The objective of EVA Project is to increase the demand for better RMNCH services and nutrition and empower citizens to hold the service providers to account. Women, girls and children with the greatest needs and from underserved backgrounds will be prioritized. The sub-programme will complement the supply-side interventions by increasing demand and strengthening mechanisms for greater and effective citizen participation and monitoring of health services. This includes:

• Influence health legislation, policy, practices, and service delivery through greater pressure and demand from the citizens. The supplier will work through a combination of empowerment, voice and accountability approaches including, but not limited to, awareness raising and mobilization, advocacy and lobbying, capacity building, coalitions and partnerships.
• Pilot innovative solutions for increasing access of the poor and women and girls to RMNCH and nutrition – with priority to increasing immunization coverage, skilled birth attendance, modern contraceptive usage, child and mother nutrition, management of common child ailments and usage of primary healthcare facilities, community workers, etc

OVERVIEW OF SOCIAL, CULTURAL AND ECONOMIC BARRIER PILOT

Pakistan has a very high maternal mortality rate of 276 per 100,000 live births (National Institute of Population Studies [NIPS] and Macro International Inc., 2008) and neonatal and child mortality rate of 55 deaths per 1,000 live births and 89 deaths per 1,000 live births respectively(PDHS2012-2013). This means that one in every 11 children will die before reaching the age of 5 years. Nutritional status of the women and children pose another major challenge and the cause of concern as it predisposes to poor MCH status. Besides gaps in service delivery, these poor health outcomes are underpinned by social and cultural barriers preventing women and children from accessing health services.

To provide an evidence base for the Social and Cultural Barrier Pilots, the project conducted a Desk Review during the inception phase and verified the key social and cultural barriers that prevent women from accessing RMNCH and nutrition services, as identified by Research and Advocacy fund Pakistan. It also   identified the most promising interventions to address these barriers based on global, regional and local evidence.

The interventions identified as a result of the desk review were then discussed in Regional and Provincial consultations with relevant stakeholders in both provinces. Subsequently, as a result of in depth analysis of the findings, Chief Minister Initiative in KP was identified as potential program to integrate the pilot into. The CM Initiative was introduced in 2013 in KP to increase the skilled birth attendance rate through cash incentives for the pregnant women seeking antenatal, postnatal and child birth services at public health facility/community midwife. Since its inception CMI has made good progress in establishing itself as a program and reaching out to communities but more focused efforts are required to increase the uptake of the scheme and reach the set target of 50 %.

The office of the CM Initiative and EVA-BHN have agreed to a way forward where technical assistance will be provided to CMI to facilitate the program  in focusing on the poor and marginalized segments of the population and suggest demand side and community based interventions to increase the uptake of the scheme. This pilot will be conducted in 3 phases a) designing the implementation strategy b) technical oversight for the implementation of the project c) Documenting the lessons learned

Scope of Work

The scope of work of this ToR relate to contract short term technical assistance for the first phase, that is to design an implementation strategy for SCEB pilot

• Enhanced utilization of CMI scheme by vulnerable and marginalized:The poor and socially excluded segments of population maybe the biggest category of the potential users of the services being offered by CMI. The findings of the consultations revealed that targeted awareness raising among this quantile of population may result in significant increase in the overall uptake of CMI scheme. The  STTA will work in close coordination with MNCH and EVA staff to develop and implement   a strategy to address the barriers and enhance the uptake of the scheme by the poor and marginalized in the target districts 
• Capturing citizen feedback using EVA opportunity platform:  Though CMI have launched systems to gauge beneficiary feedback, but a mechanism to capture general citizens perspective may be of added value. Community groups engaged at the Health facilities under EVA Project, can serve as bridge between the CMI program and the general community including poor and marginalized. The strategy for the pilot will be based on strengthening these linkages and providing the citizens feedback to the CMI program team for consideration to refine their approach and to address the needs of the community
• Piloting CBM within CMI: EVA initiative of Community based monitoring encourages the shared responsibility of citizens to monitor the health services in the Public health facility and work with the duty bearers to improve its quality by raising their voices/demands at district and Provincial advocacy forums. The STTA will design a strategy to pilot CBM I in target districts, aiming to improve the availability and quality of CMI scheme in Public health facilities
• Develop advocacy plan for scaling up :The STTA will STTA will the findings at the end of the pilot and develop a road-map for advocacy with the key policy maker for uptake of the pilot for scale up

Key Tasks

In order to accomplish the above SOW the STTA will perform the following tasks

• Deign the strategy for the pilot in consultation with the key stakeholders including CMI, MNCH, DoH and EVA and advice on implementation
• Develop a detailed implementation plan and budget.
• Consult the relevant stakeholders and decide a criteria to identify a target district for the pilot implementation.
• Link the deigned interventions with EVA platforms including community groups and Advocacy forums, to ensure that the citizen voices and demands are heard at appropriate level.
• Develop a mechanism aimed to ensure that the citizens feedback on CMI is collected using Community based monitoring and available for CMI program team to refine their  approach
• Suggest ways to strengthen linkages between LHWs and CMWs for identification and sensitization of marginalized and vulnerable segments of population and improved referral
• Develop a monitoring and evaluation plan for the pilot which may include but not limited to formative assessment , mid- term and end term evaluations
• Develop advocacy plan for the evidence generated from the pilot for scale up in other target districts across the province.

Duration of the Assignment: 2 months

Reports to: Senior Community Empowerment Advisor

Deliverables

1. 1-2 page brief of the assignment at the inception
2. Detailed implementation strategy endorsed by the MNCH on agreed template
3. Detailed budget for the pilot
4. Detailed operational plan /work plan
5. Monitoring and evaluation plan and tools for the pilot project
6. Advocacy plan for uptake of the pilot for scaling up.

Qualifications and experience

• Demonstrated experience of working in the public health sector with a focus on RMNCH
• Demonstrated experience developing Project designs and implementation plans.
• Post-Graduate qualification in Public Health, with at least 10 years’ experience preferably a medical 
• The interested individual shall possess excellent interpersonal communication skills
• He/ She must have excellent report writing skills
• Ability to travel to travel to the target districts in KP