Newborn Survival Strategy Report - Compressed

NATIONAL NEWBORN SURVIVAL STRATEGY AND PLAN OF ACTION 1
Designed by Human Design Studios

Table of Contents
List of Tables 5
List of Figures 5
Acronyms and Abbreviations 6
Message from the Health Minister, MoNHSR&C 8
Acknowledgements 9
Executive Summary 10
National Operational Targets (2023-2028) 14
Introduction and Rationale 16
Background 20
Global Context 20
Trends of Newborn and Child Health in Pakistan 22
Maternal and Neonatal Health Services 26
Critical Human Resources for Maternal and Neonatal Health Service Delivery 28
National /Provincial Maternal, Neonatal and Child Health Programs and New Initiatives
30
including NHSP (UHC)
Health Delivery System 34
Health Service Quality 35
Health Care Financing 37
Health Insurance 38
Natural Disasters and Humanitarian Situations 39
Need for a National Newborn Survival strategy 40
Vision, Goal and Objectives 42
Vision 42
Guiding Principles, Operational Targets, and Intervention Package 43
Guiding Principles 43
Theory of Change 46
Goal 51
Objectives 51

Strategic Intervention Packages for various Levels of Health Care 58
Implementation – Guiding Principles 66
Roles and Responsibilities at Different Levels of Health System 67
Monitoring & Evaluation 71
Annexures 74
Annex I: ENAP and EPMM Joint Action Plan 75
Annex II 79
Annex III 82
Annex IV: Levels of Neonatal Care 86
4 NATIONAL NEWBORN SURVIVAL STRATEGY AND PLAN OF ACTION

List of Tables
Table 1 Trends in Neonatal mortality and Still births 23
Table 2 Current Coverage of Key Maternal and Neonatal Health Indicators 27
Table 3 Human Resource Availability across Provinces/Areas 29
Table 4 Number of Priority Interventions across Platforms 31
Table 5 Operational Targets for Key Strategic Indicators 48
Table 6 Inpatient care for small and sick newborns: requirements for care at different
59
health system levels
Table 7 Key monitoring Indicators 72
List of Figures
Figure 1 Province/Area wise NMR 18
Figure 2 Global mortality rates and number of deaths by age, 2022 21
Figure 3 Current coverage of Key maternal and Neonatal Indicators in South Asia 21
Figure 4 Achieving the SDG targets for neonatal health in Pakistan 24
Figure 5 Trends of Neonatal and <5yrs Mortality over the Past years 24
Figure 6 Causes of Neonatal Mortality 25
Figure 7 Burden of Disease and DALYs Lost 26
Figure 8 Health System Interventions 32
Figure 9 Province/Area wise Population coverage by LHWs 33
Figure 10 Levels of Health Care 34
Figure 11 National Quality of Care Strategic and Accountability Framework 36
Figure 12 Resource Mapping of Health Sector Budget 37
Figure 13 Twelve Categories of Essential Package of Health Services (EPHS) Interventions 55

Acronyms and Abbreviations
ANC Antenatal Care
BEmONC Basic emergency Obstetrics and Newborn Care
BFHI Baby Friendly Hospital Initiative
BHU Basic Health Unit
CMWs Community Midwives
CRVS Civil Registration and Vital Statistics
DHIS District Health Information Systems
DHQ District headquarter Hospital
ECD Early Childhood Development
EPHS Essential Package of Health Services
EmONC Emergency Obstetrics and newborn Care
ENC Essential Newborn Care
ENAP Every Newborn Action Plan
EPMM Ending Preventable Maternal Mortality
FP Family Planning
HBB Helping Babies Breathe
HRIS Human Resources Information System
KFCPs Key Family Care Practices
KMC Kangaroo Mother Care
LBW Low Birth weight
LHVs Lady Health Visitors
LHW Lady Health Workers
LMIS Logistic Management Information System
MIS Management Information System
MNCH Maternal, Newborn and Child health

MPDSR Maternal & Perinatal Death Surveillance and Response
NHV National Health Vision
NICU Newborn Intensive Care Unit
PPRA Public Procurement Regulatory Authority
PSM Procurement and Supply Management
PSBI Possible Serious Bacterial Infection
PPA Pakistan Pediatric Association
PNC Post-natal Care
PNC Pakistan Nursing Council
QoC Quality of Care
RHC Rural Health Center
SBA Skilled Birth Attendant
SDGs Sustainable Development Goals
SBCC Social Behaviour Change Communication
SGOP Society for Gynae and Obs Pakistan
SNU Sick Newborn Units
SSNC Small and Sick Newborn Care
SWOT Strength, weaknesses, Opportunities and Threats
UHC BP Universal Health Coverage benefit Package
Unicef United Nations Children Fund
UNIGME United Nations Inter-Agency Group for Child Mortality Estimation
WASH Safe drinking water and Hygiene.

Message from the Health Minister,
Ministry of National Health Services, Regulations & Coordination
NATIONAL NEONATAL SURVIVAL STRATEGY & COSTED ACTION PLAN

A healthy start to life is vital in establishing the foundation of a healthy nation. Pakistan too has been
striving to fulfill its commitments towards improving maternal and child health especially neonatal. The
country has been making considerable efforts to improve child health, and eradication of polio. This is
fully in line with the goal of National Health vision 2025, which is to improve the health of all Pakistanis,
particularly women and children, through universal access to quality essential health services and
ensuring financial protection, with a focus on vulnerable groups, and to be delivered through resilient
and responsive health systems. The national Health Vision, within the framework of the post-18th
Amendment Constitutional roles and responsibilities, is fully aligned with the Pakistan’s Vision 2025.
Pakistan over the past two decades has made sustained progress in improving maternal health and
reducing maternal mortality. While the overall under-five and infant mortality rates has decreased over
the past decade, the progress on reducing the neonatal mortality has been painfully slow. The PDHS
1990-2018 trends in under-5 mortality show a reduction from 112 deaths per 1000 live births in 1990 to
74 per 1000 live births in 2018; and IMR declining from 86 per 1000 live births in 1990 to 62 per 1000 live
births in 2018 – about a 30% reduction for both rates. Whereas neonatal mortality has stagnated from
49 per 1000 live births in 1990 to 42 per 1000 in 2018. The current pace of reduction in neonatal deaths
can hinder our progress to achieve SDG 3 target of less than 12 per 1000 live births by 2030.
The Government of Pakistan is committed to ensuring basic health care services to all population,
particularly to the women and children. The main objective of the National Health Vision 2016-2025
is to improve the health of all Pakistanis, particularly women and children, through universal access to
affordable quality essential health services, delivered through resilient and responsive health system,
ready to attain Sustainable Development Goals (SDGs) and fulfill its other global health responsibilities.
However, there still exists gross disparity in terms of equity for maternal, neonatal and child health
services which need broader and continued attention.
I am delighted to know that Ministry of National Health Services, Regulations & Coordination
(MoNHSR&C) together with the Provincial and area Health departments, and key stakeholders has
taken steps to develop this National Newborn Survival Strategy & Costed Action Plan, which will
guide our policy makers, planners and programme people to implement appropriate cost effective
interventions that need to be scaled up rapidly with high coverage to address high burden of neonatal
morbidity and mortality in our country.
I congratulate everyone who was involved directly or indirectly in developing this very important
strategy document, and highly appreciate their commitment and engagement in this endeavor. I
sincerely appreciate and thank UNICEF and all our development partners for their continued support
in this initiative of MoNHSR&C.
I assure our government’s commitment to implement this strategy in letter and spirit. I believe that with
our collective efforts we will be able to achieve and sustain our achievements and reach our goal of
achieving SDG targets.

Acknowledgements
The Government of Pakistan is strongly committed to reduction in neonatal mortality and stillbirths
by improving coverage of quality maternal and neonatal health services. This to be achieved by
increasing investments and promoting partnerships to enhance the provision of integrated essential
health service delivery to be rolled out under the Universal Health Coverage (UHC) initiative. The
National Newborn Survival Strategy (2023-2028) and costed Plan of Action has been developed
following a detailed situation analysis of neonatal health both nationally and internationally, an
exhaustive consultative process to get wider perspectives, stakeholders buy in.
Detailed desk review was carried out and all available evidence was reviewed, presented, and
discussed in the national and provincial level discussions to identify the gaps and prioritize the key
areas for interventions. These together with findings from key in-depth interviews with national,
provincial, academia, professional organizations (MAP, SOGP, PPA etc.), and development partners,
results of bottleneck analysis (carried out using health systems building blocks) were triangulated and
the gaps identified became the basis for the development of the National Newborn Survival Strategy
(2023-28).
We strongly acknowledge United Nations Children Fund (UNICEF) support in completing this
important endeavor which shows their commitment to improving neonatal and maternal health
outcomes and reducing mortality especially neonatal.
The Strategy was developed by an extensive consultative process involving the public sector
stakeholders (national, provincial and Areas) but also by relevant UN agencies (UNICEF, WHO, WFP
and UNFPA), development organizations, civil society organizations, academia (AKU), and professional
organizations thus creating an ownership at all levels. Special thanks are due to all provincial / federating
areas Health Departments and more specifically MNCH and IRMNCH Programmes, Directors General
Health Services and provincial focal persons for their leadership and commitment towards improving
neonatal and maternal health.
The coordination efforts of the Ministry of National Health Services, Regulations and Coordination
(NHSR&C) is worth mentioning. The leadership role of Dr Baseer Achakzai, Director General Health
and facilitation and technical support by Dr. Khawaja Masuood Ahmed, Focal Person/National
Coordinator for developing the Strategy, is especially acknowledged. Special gratitude is due
to the team of consultants led by Dr. Asma Bokhari, Public Health Specialist. The Ministry highly
acknowledges the technical guidance provided by Dr. Samia Rizwan, Health Specialist UNICEF,
colleagues from UNICEF country and regional office for South Asia, UNICEF HQ New York and
Dr. Zulfiqar Bhutta, AKU/ Sickkiids Canada throughout the strategy development. The valuable
contributions of, representatives of Pakistan Pediatric Association (PPA) and Neonatology sections
all chapters, and Society of Gynecologists and Obstetricians (SOGP), Pakistan Nursing Council and
Midwifery Association of Pakistan are also highly appreciated. Finally Appreciation to the National
Steering Committee (NSC) for their effective coordination, technical oversight of the process under
the guidance of Director General Health.
We strongly hope that national, provincial and Areas are successful in achieving all the milestones and
targets set under the National Newborn Survival Strategy (2023-28). We expect that all provinces and
Areas with support of respective PPA and SOGP chapters will continue to play an effective role in the
achievement of health-related SDGs, especially neonatal and maternal health milestones and targets.

Executive Summary
Pakistan has faced major national challenges over the past decade, which affected health and
development that included major humanitarian disasters, destabilizing political insurgency, terrorism,
high levels of poverty and an often hard-to-reach and marginalized predominately rural population
with diverse practices. However, despite all these challenges over the past two decades, Pakistan has
made significant progress in reducing maternal and child deaths and related annual mortality burden.
Pakistan has the world’s third highest national number of newborn deaths (251,307 in 2021)1. Prior to
2000, newborn health did not feature prominently in the national health policy, despite major focus
on maternal and child health and delivery of essential primary health care services at community
level. As a result, neonatal mortality and stillbirths went largely under and or unreported.
Pakistan’s National Health Vision (NHV) 2016-2025 aims to ensure equitable, accessible, affordable, and
universal quality healthcare for all Pakistanis. The NHV in its third thematic pillar of “Packaging Health
Services”, focuses on providing an integrated approach to health delivery rather than a fragmented
system. Aligned with the NHV, the 12th Five Year Plan has set the strategic directions in Pakistan and
outlines how the federal, provincial and districts governments will proceed with the implementation
of its four strategic lines; ‘advancing universal health coverage (UHC)’ is the number one strategic
line of this plan. To attain NHV and SDGs targets, the National Action Plan (2019-2023) for National
Health Services, Regulation and Coordination Division2 was developed to augment the current health
sectoral and sub-sectoral strategies and plans.
Globally, much progress has been made over the past three decades in reducing newborn deaths
and stillbirth. However, despite all efforts, the continued burden of child mortality represents a huge
burden and major contributor to loss of life. In 2021, approximately 2.3 million children died during the
first month of life (about 6,400 babies/day). These deaths constituted nearly 47 per cent of the under-
five deaths that took place that same year. While another 5.0 (4.8–5.5) million children died before
reaching their fifth birthday. Over half of these deaths, 2.7 (2.5– 3.0) million, occurred among children
aged 1–59 months, while the remainder, 2.3 (2.2–2.6) million, occurred in just the first month of life.
In Southern Asia, reduction in newborn deaths and stillbirths, from 1990 to 2021 remained at a much
slower rate of 3.7% per annum than under 5 mortality reduction of 6.2% and maternal deaths3. This
period saw pandemic-driven disruptions to interventions like vaccination and nutrition programmes,
the effects of which on mortality and health may not become apparent for some time. This situation
raises an alarm regarding achievement of the SDGs targets.
Pakistan is off track in meeting both maternal and neonatal health targets outlined in the Sustainable
Development Goals by 2030. Key challenges to progress include insufficient investment in the health
sector and broader issues including political instability, security and conflict, vulnerability to natural
disasters, low female education and lack of women empowerment especially in rural areas. Marked
inequities in health outcomes are present between rural and urban areas and between lower and
higher socioeconomic levels. Shortages of health professionals, particularly of nurses and midwives,
are a significant constraint.
With the highest population growth and birth rates in South Asia, the population of Pakistan is
expected to surpass 300 million by 2050. The overall maternal mortality ratio (MMR) is currently
1 UNIGME Report 2022

2 https://www.health.gov.lk/moh_final/english/public.

estimated at 178/100,000 live births (199 in rural areas and 158 in urban areas)4, reflecting disparities
in availability of and access to skilled birth attendants (SBAs). The main causes of maternal death are
postpartum haemorrhage (27 percent), puerperal sepsis (14 percent), and indirect causes (13 percent.
Maternal health has a direct impact on that of the newborns. Improvement in antenatal care, postnatal
care, skilled birth attendance along with other determinants such as poverty, illiteracy (especially of
women) and nutrition also contributes greatly to determining maternal health outcomes. The early
marriages and repeated pregnancies negatively impact the adolescent health leading to increased
teenage pregnancies. In Pakistan, 8 percent of pregnancies are among adolescent girls of age 15-19
years5.
Key challenges facing the health sector in meeting its SDG targets for neonatal and maternal health
include;
y Shortage of skilled human resources for providing maternal and neonatal health care services,
especially in rural areas especially extreme shortage of nurses, LHVs and midwives that are key to
provide maternal and newborn care at primary health centers and health facilities.
y Equitable availability and distribution of key professionals for providing quality neonatal
management such as shortage of anesthetists, neonatologists, pediatricians, gynecologist etc
y Pakistan with already lowest investment in the health sector (<1% of GDP) faces a huge challenge
of increasing domestic financing and investments in the health sector.
y Slow roll out of the UHC-BP initiative under National Health Support Project (NHSP)
y Quality of care is the most neglected area at all levels of health services but more so at the
primary and secondary level of care. Despite increase in coverage of ANC, PNC and facility-
based deliveries, there is a failure to achieve desired impact on reducing neonatal morbidity and
mortality. Lack of inclusion of Quality of care (QOC) indicators in LHWs and CMWs MISs and
DHIS.
y The eligibility criteria under the Sehat Sahulat Program initiatives - Sahara Zindagi and Sehat
Salamat Plans do not cater to children less than 2months of age.
y Pakistan is a country prone to effects of the global warming and climate change, despite
contributing less than one percent to global greenhouse gas emissions. Pakistan has had more
than its fair share of emergencies and humanitarian disasters over the last two decade. Given
that women of reproductive age are a large proportion of those affected, and the extreme
vulnerability of newborns, the limited attention given in planning to the state of maternal and
newborn care during disasters/emergencies continues to be a major gap.
Pakistan needs an annual rate of reduction (ARR) in NMR of 11.6% to be able to meet the SDG goal for
NMR target 12/1000 live births from the current value of 41 live births/100 population. At the current
pace, Pakistan is not projected to meet the SDG goal for NMR by 2030. With this in mind, the Ministry
of National Health Services, Regulation and Coordination committed to meeting ENAP and SDGs
targets took on the challenge to meet these targets and initiated the process of developing National
Newborn Survival Strategy and costed Action Plan.
4 Pakistan Maternal Mortality Survey (PMMS) 2019

5 PMMS 2019

The strategy was developed through wide range of consultations at national and provincial, further
informed by the findings of the situation analysis, and consultations and in-depth interviews with
stakeholders (UN Agencies, development partners, public and private sector) at national and
provincial levels, representatives of professional associations (PNC, SGOP, PPA etc.), SWOT and
bottleneck analysis that identified critical factors, bottlenecks and proposed recommendations.
The Strategy provides an overarching framework through which to integrate improvements in maternal
and neonatal interventions. The MONHSR&C together with Provincial DOH and key stakeholders
(PPA, PMA, SGOP and private sector) will call on multilateral agencies, bilateral donors and other
partners to work together in the implementation of this Strategy to ensure efficient use of resources
to prevent fragmentation and duplication.
Overall focus for saving newborns will be on expanding universal access to all births being attended
by a skilled provider, expanding access to small and sick newborn care addressing maternal nutritional
deficiencies such as anemia and other micronutrients, infection control both during pregnancy, at
delivery and post-natal period. The proposed strategy calls for simultaneous efforts in advocating for
enabling environment, increasing demand for health services and supply of quality, client centered
and respectful health services.

Way Forward
It’s established from experience in multiple countries to improve survival and health of newborns and
end preventable stillbirths by scaling up cost effective key interventions at all levels of health care
especially so at community, primary and secondary care. These key interventions when scaled up can
help reduce morbidity and mortality for both mothers and newborns and include;
1. Scale up coverage of quality services, particularly around the time of birth and the first week of
life as most newborns are dying in this time period;
2. Improve the quality of maternal and newborn care from pregnancy to the entire postnatal period,
including strengthening midwifery;
3. Expand quality services for small and sick newborns, including through strengthening neonatal
nursing.;
4. Reduce inequities in accordance with the principles of universal health coverage, including
addressing the needs of newborns in humanitarian and fragile settings;
5. Promote engagement of and empower mothers, families and communities to participate in and
demand quality newborn care; and
6. Strengthen measurement, programme-tracking and accountability to count every newborn and
stillbirth.

National Operational Targets (2023-2028)
y Reduction of Neonatal mortality rate from 41 to 26/1000 live births
y Reduce stillbirth rate from baseline of 43.1 to 24/1000 live births.
y Increase in Skilled birth attended deliveries from 69 percent to 80 percent.
y Improve early initiation of breastfeeding (within 1 hour of birth) from 20 percent to 60 percent.
y LHW service coverage is increased from 52 percent to 70 percent
y 50 percent increase in number of facilities providing BmoNC services including ENC (4key
interventions) from the baseline (to be established).
y Increase in CPR from baseline of 48.7 percent to 60 percent.
y 75 percent of DHQs have established and operational SNCUs (Sick Newborn Care Units)
y ANC (+4 visits) by SBA increased from 69 percent to 80 percent.
y Women with preterm labour (24-34wks of gestation) receiving at least one dose of antenatal
corticosteroids (%) is increased from the baseline (to be established) to 60 percent.
y 50 percent (from the baseline) Newborn with low birth weight / Preterm provided with KMC
services at facility.
y 90 percent of all babies born in health facilities requiring resuscitation were resuscitated.
The implementation of the Newborn survival strategy will be based on and guided by ensuring
principles of;
i. Ownership, leadership, and accountability – National, Provincial and District

ii. Equity and Accessibility – reaching Zero dose communities and rural and remote districts.
iii. Community engagement, empowerment, ownership and responsiveness to community needs –
promoting Community Health Workers and Home-Based Care
iv. Integration – maternal nutrition; early initiation of breastfeeding; nurturing care, family planning,
water, sanitation and hygiene (WASH) and gender sensitive services
v. Partnership – Women’s groups; Health Professional Associations; Private Sector
vi. Low-cost high impact-effective interventions – KMC; PSBI; ANC; ENC
vii. Efficient use of resources
viii. Evidence based decision-making.
ix. Quality and continuum of care
x. Respectful care and Social Accountability Frameworks
In addition, the strategy places special emphasis on promoting accountability for ensuring successful
implementation of the newborn and child survival strategy and will rely on robust Monitoring and
Evaluation system. It is envisaged that using existing monitoring systems by inclusion of neonatal,
stillbirth and maternal health indicators in the DHIS2 and alignment with system to ensure that there
is adequate information available for scaling up quality and cost effective neonatal and maternal
interventions. Continuous monitoring of progress and evaluation of outcome and impacts will
provide opportunities for evidence-based decision making for effective, efficient and synergistic
implementation of programs.

National Newborn Survival Strategy

INTRODUCTION AND RATIONALE
Pakistan has faced major national
challenges over the past decade, Key milestones in
which affected health and Child Survival in Pakistan.
development including several large
humanitarian disasters, destabilizing y Launch of National Programme for FP and PHC
political insurgency, terrorism, high (MOH 1994) - provides community level MCH
levels of poverty and an often services
hard-to-reach predominately rural y A national situation analysis report was developed
population with diverse practices. in 2001, State of the World’s Newborns: Pakistan
However, despite all these challenges (SCF: Saving Newborn lives Initiative)
over the past two decades, Pakistan
y 1st appeared in National Health Policy and
has made significant progress in
Strategy (MOH 2001)
reducing maternal and child deaths
and the annual mortality burden. The y Newborn care was added to the Integrated
maternal mortality ratio has reduced Management of Childhood Illness (IMCI) strategy
by 51%; child mortality rate by 64% 2005
and newborn mortality rate by 38% y National Maternal and Child Health Policy and
compared to 2000. Pakistan has the Strategic Framework (2005–10)
world’s third highest national number y Establishment of the National MNCH Programme
of newborn deaths (251,307 in 2021)6. (MoH 2005)
Prior to 2000, newborn health did not
y PAIMAN -USAID funded project 2004-2010
feature prominently in the national
health policy, despite major focus on y 2nd national situation analysis - Opportunities for
maternal and child health and delivery Newborn Survival in Pakistan (Saving Newborn
of essential primary health care services Lives 2009)
at community level. As a result, neonatal y ‘Karachi Declaration on Scaling up MNCH-FP Best
mortality and stillbirths went largely Practices’ -2009
under and or unreported. Further,
y Launch of EVERY ONE Newborn and Child
Lady Health Workers (LHWs) were not
Survival Campaign in 2010
initially mandated to provide newborn
care under the National Programme y Provincial Health Sector Strategies – post
for Family Planning and Primary Health devolution 2011 - todate
Care7, launched by the Ministry of y Following ENAP 2014 Plan – MNCH Programme
Health (MoH) in 1994, which mandated revisited to include a separate component of
the LHWs to provide maternal and child neonatal health.
health services at the community level. y Joint ENAP-EPMM National Plan
y 4 Provincial Newborn Survival Strategies (2016 –
Newborn survival first appeared in
2018)
national health policies and strategies
in 20018, when a national report was y National RMNCH Strategy 2017-2021
developed as a follow up action to a
global report, to further advance newborn survival on national political and policy agendas. Prioritizing
Newborn survival further gained momentum, following Lancet neonatal series’ call for integrated
6 UNGIME Report 2022

7 Haines et al. 2007
8 Report on State of the World’s Newborns: Pakistan 2001 by Save the Children (saving Newborn Lives Initiative project)

national plans as well as national recognition of the need to address the fragmented MNCH (Maternal,
Neonatal and Child Health) services9 which led to the launching of the national MNCH framework.
Recently, the MoNHSRC (Ministry of National Health Services, Regulation & Coordination) together
with WHO and Unicef, in continuation of the work, has developed a Joint ENAP-EPMM National Plan
2023, for linking both frameworks (Annex-1).
It is a stated fact, that in addition to inadequate care of newborns, a major cause of neonatal deaths in
developing countries is poor health status, insufficient and poor quality of health services for mothers,
especially during pregnancy, delivery, and in early postpartum period. As in high fertility countries,
many pregnant women are inadequately nourished, overworked, and may still be recovering from a
previous pregnancy. For many mothers, health care during this critical period is virtually non-existent.
To achieve global goals for child heath, it will be essential to attain high-quality health services using
the life cycle and continuum of care approach, with focus on adolescent reproductive health care,
antenatal care, essential childbirth care, postnatal care and inpatient care for small or sick newborns,
by ensuring equitable universal health coverage at all levels of health care. In order to achieve this, it’s
important to build cross sectoral partnerships to address key challenges resulting from malnutrition,
clean water supply and sanitation, poor hygiene, infection prevention and control, poor practice
of birth registration, lack of mortality audits (for determining cause of deaths) and preventing early
marriages and equitable access to family planning services (modern contraceptive methods) for birth
spacing.
Given its demographic and cultural diversity, Pakistan faces numerous challenges with significant
rural-urban, poor, and rich, maternal education level, gender, socio-economic, and provincial and
regional disparities in maternal and newborn health status. More newborns are dying in the rural
areas among the poorer households; since evidence suggests that newborns delivered in rural
settings are twice as likely to die as those born in urban areas10. Furthermore, neonatal mortality
varies considerably between provinces and among districts within each province/AJK/GB and ICT
(Figure -1). While, stillbirths largely go unreported, as the health information systems fails to register
and report stillbirths. The causes of stillbirths and early neonatal deaths are closely linked, making it
difficult to determine whether a death is a stillbirth or a neonatal death. Punjab reported the highest
number of stillbirths at 129 per 1000 live births followed by Sindh (62), KP (37), Balochistan (16), ICT (2),
AJK (44) and GB (17)11.
9 Economic Survey of Pakistan - Ministry of Finance [Pakistan] 2003

10 PDHS 2017-18
11 PMMS2019

Figure 1: Province/Area wise NMR
Neonatal Mortality Rate (PDHS 2017-18)

60
50 51
47
42 42
40 38
34
30 30
24
20
10
0
National Punjab Sindh KP B’tan ICT AJK GB
National Punjab Sindh KP B’tan ICT AJK GB
Pakistan’s National Health Vision (NHV) 2016-2025 aims to ensure equitable, accessible, affordable,
and universal quality healthcare for all Pakistanis. The NHV in its third thematic pillar of “Packaging
Health Services”, focuses on providing an integrated approach to health care delivery rather than a
fragmented system. Aligned with the NHV, the 12th Five Year Plan has set the strategic directions
in Pakistan and outlines how the federal, provincial and districts governments will proceed with the
implementation of its four strategic lines; ‘advancing universal health coverage (UHC)’ is the number
one strategic line of this plan. To attain NHV and SDGs targets, the National Action Plan (2019-2023)
for National Health Services, Regulation and Coordination Division12 was developed to augment the
current health sectoral and sub-sectoral strategies and plans. Specifically, strategic priorities include
advancement of universal health coverage in addition to protecting people from health emergencies
and outbreaks, promoting healthier population, and an effective and efficient health system.
12 https://www.health.gov.lk/moh_final/english/public.

BACKGROUND
Global Context
Globally, much progress has been made over the past three decades in reducing newborn deaths and
stillbirth. However, despite all efforts, the continued burden of child mortality represents a huge
burden and major contributor to loss of life. In 2021, approximately 2.3 million children died during the
first month of life (about 6,400 babies/day). These deaths constituted nearly 47 per cent of the under-
five deaths that took place that same year. While another 5.0 (4.8–5.5) million children died before
reaching their fifth birthday. Over half of these deaths, 2.7 (2.5– 3.0) million, occurred among children
aged 1–59 months, while the remainder, 2.3 (2.2–2.6) million, occurred in just the first month of life. In
Southern Asia, reduction in newborn deaths and stillbirths, from 1990 to 2021 remained at a much
slower rate of 3.7% per annum than under 5 mortality reduction of 6.2% and maternal deaths13. This
period saw pandemic-driven disruptions to interventions like vaccination and nutrition programmes,
the effects of which on mortality and health may not become apparent for some time. This devastating
loss of life was mostly preventable with widespread and effective interventions like improved care
around the time of birth, vaccination, nutritional supplementation and water and sanitation
programmes. This situation raises an alarm regarding achievement of the SDGs targets.
Huge inequities in survival continues for

children aged 1–59 months with the majority of UNGIME Report 2022
perinatal and neonatal deaths occurring mostly
in conditions of socioeconomic deprivation y In 2021, 5.0 (4.8-5.0) million children died
in developing countries. The risk of dying is before reaching their fifth birthday.
highest at the time of birth and in the first y 2.7 million deaths were among children
month of life. Evidence shows that about a third 1-59 months.
of neonates die on the first day of birth, and
y 2.3 million children died during 1st month
almost three quarters die in the first week of life,
of life.
due to complications of premature births, birth
asphyxia, neonatal infections, and the birth y Neonatal deaths constituted 47 percent
anomalies. The small and sick newborns are the of all under five deaths.
most vulnerable and account for about 80% of
newborn deaths in South Asia and Sub-Saharan Africa. A child born in sub-Saharan Africa (27 (24–32)
deaths per 1,000 live births) is 11 times more likely to die in the first month of life than a child born
in the region of Australia and New Zealand, which has the lowest regional NMR in the world. Sub-
Saharan Africa is followed by Central and Southern Asia at 22 (20–24) deaths per 1,000 live births14.


Figure 2: Global mortality rates and number of deaths by age, 2022
Global evidence suggests that over 80 percent reductions in neonatal mortality can be achieved
through an integrated, high coverage programme of universal outreach and family-community care.
As per targets given in a recent joint ENAP and EPMM global monitoring Report 2021, the coverage
targets for achieving significant decline in neonatal mortality, the ANC4+, SBA, PNC and districts with
functioning SCNU Level II were given as 90/90/80/80 by 2030. However, looking at the overall situation
in South Asia, Pakistan (Figure 3) still has a long way to go.
Figure 3: Current coverage of Key maternal and Neonatal Indicators in South Asia
The Unfinished Agenda-Access to Care-ENAP Targets

Sri South
Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan
Lanka Asia
ANC 4 (90%) 24% 37% 85% 58% 82% 78% 52% 92.9% 55%
Skilled Birth
Attendance 54% 59% 96% 90% 99% 80% 73% 99.5% 82%
90%
PNC (80%) 19% 67% 74.6% 82% 82% 69% 64% 99.9% 75%
SNCU
(Level II) 94% 78% 15% 86% 83% 71% 15% 100% 74%
(80%)
Source: ENAP and EPMM global monitoring Report 2021P
In Pakistan, a community-based primary health care intervention package, was principally delivered
through Lady Health Workers in a rural district of Pakistan showed that stillbirths were reduced in
intervention clusters (39.1 stillbirths per 1000 total births) compared with control (48·7 per 1000) and the
neonatal mortality rate was 43·0 deaths per 1000 live births in intervention clusters compared with 49·1 per

1000 in control groups15. In the context of Khyber Pakhtunkhwa, where, although the levels of skilled birth
attendance have improved, due to low coverage of post-natal care and newborn care, many newborns
die at home without having had contact with health facilities, such community-based interventions offer
viable alternates. However, despite promising results there is little effort in scaling up these models.
As the health of the newborn infant is inexorably tied to the health of the mother, strategies to
improve the health, nutrition and care of women in low-resource communities and countries are
also expected to improve both pregnancy and neonatal health outcomes. However, although it is
true that poverty, illiteracy, poor status, and care of women, as well as dysfunctional health systems
are critical underlying factors that adversely affect maternal and child health in many developing
countries, ground realities in most developing countries are that these factors are relatively difficult to
change in the short term and thus countries require wide-scale implementation of evidence-based,
cost-effective health programs and interventions to improve child health outcomes.
Trends of Newborn and Child Health in Pakistan

Pakistan is a populous and geographically diverse country, facing a significant burden of maternal and
neonatal mortality. Maternal, newborn and child mortality constitute the largest share of preventable
deaths in Pakistan. Pakistan has a high maternal mortality ratio of 178 per 100,000 live births, which
translates into deaths of more than 9,700 women every year from pregnancy and childbirth-related
causes16. There are an estimated 4.7 million births annually with 9,700 maternal deaths, 248,000
newborn deaths, 184,000 still births and 405,000 under- five-year deaths17. In Pakistan, contribution of
newborn mortality to under five deaths is much higher – 62% of all child deaths reported in Pakistan
during 2021, were newborn deaths i.e., two out of every three child deaths happen during the first
few days and weeks of life18.
According to statistics, Pakistan is off track in meeting both maternal and neonatal health targets outlined
in the Sustainable Development Goals by 2030. Key challenges to progress include insufficient investment
in the health sector and broader issues including political instability, security and conflict, vulnerability
to natural disasters, low female education and lack of women empowerment especially in rural areas.
Marked inequities in health outcomes are present between rural and urban areas and between lower
and higher socioeconomic levels. Shortages of health professionals, particularly of nurses and midwives,
are a significant constraint on the provision of MCH services, specifically in the rural communities.
With the highest population growth and birth rates in South Asia, the population of Pakistan is expected
to surpass 300 million by 2050. The overall maternal mortality ratio (MMR), 276 in 2006–07, is currently
estimated at 178/100,000 live births (199 in rural areas and 158 in urban areas)19, with a much higher
ratio in rural areas compared to urban areas, reflecting disparities in availability of and access to skilled
birth attendants (SBAs). The main causes of maternal death are postpartum haemorrhage (27 percent),
puerperal sepsis (14 percent), and indirect causes (13 percent). Around one quarter of maternal deaths
could be averted if unmet need of contraceptives is met. Improvement in antenatal care, postnatal care,
15 Bhutta Z.A et al, 2011, Improvement of peri-natal and new-born care in rural Pakistan through community-based strategies: a
cluster-randomized effectiveness trial, The Lancet, Volume 377, Issue 9763, Pages 403 - 412, 29 January 2011
16 http://data.unicef.org/corecode/uploads/document6/uploaded_pdfs/corecode/Trends-in-MMR-1990-2015_Full-report_243.
pdf
18 Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (UN IGME) in 2023 Downloaded from
http://data.unicef.org

skilled birth attendance along with other determinants such as poverty, illiteracy (especially of women)
and nutrition also contributes greatly to determining maternal health outcomes. The early marriages
and repeated pregnancies negatively impact the adolescent health leading to increased teenage
pregnancies. In Pakistan, 8 percent of pregnancies are among adolescent girls of age 15-19 years 20.
The national under-five mortality has shown a decline, from 117 deaths per 1,000 live births in for the
1986–1990 period to 74 for the 2017–18 period. However, reductions in neonatal mortality rate have been
much slower. The pattern shows that over 57 percent of deaths under five years occur during neonatal
period (42 per 1,000 live births). Infant and under-five mortality rates for the five years preceding the
PDHS surveys confirm a declining trend in all mortality rates except neonatal mortality21.
Table 1 : Trends in Neonatal mortality and Still births

Indicator 2016 2017 2018 2019 2020 2021
Neonatal mortality rate 44.2 % 43.2% 42.3% 41.3% 40.4% 30.4%
Neonatal deaths as a
60.1% 60.7% 61.2% 61.9% 62.4% 62.9%
percentage of U5 deaths
No of Neonatal deaths 278383 272159 266520 261604 256892 251307
No of Still births 216,778 215,449 213,378 210,343 207,118 203,374
Source: Estimates generated by the UN Inter-agency Group for Child Mortality Estimation (UN IGME)
in 2023 Downloaded from http://data.unicef.org
Maternal health has a direct impact on that of the newborns. The neonatal mortality at 42 deaths
per 1000 live births means that 1 in 22 children born in Pakistan die during the first month of birth.
Neonatal mortality is mostly caused by prematurity, birth asphyxia, sepsis, acute respiratory infections,
and congenital anomalies followed by other factors. Over the past decade, neonatal mortality rate has
further fallen to 39 per 1,000 live births and still birth rate to 31 per 1,000 total births22. Both neonatal
mortality and stillbirth rates decreased slowly at an annual rate of reduction of only 1.6% in the last
decade. To meet the Sustainable Development Goals (SDG) target of 12/1,000 live births, Pakistan
needs an annual rate of reduction (ARR) in NMR of 11.6%. This would be a substantial acceleration from
its current ARR of 1.6% (2022, UNIGME- Inter-agency Group for Child Mortality Estimation- Table-1), by
which at the current pace, Pakistan is not projected to meet the SDG goal for NMR by 2030.
As per UNICEF supported Newborn Investment Case study (Nossal Institute, University of Melbourne),
achieving the SDG target in Pakistan would save 1 million additional newborn lives, prevent over
half a million stillbirths, and avert 21,015 maternal deaths, as compared to no change in coverage of
the package of interventions. Additionally, 174,178 newborns would have significant lifelong disability
averted. The additional cost over ten years, discounted at the standard 3% annual rate, would be USD
6.5 billion. This investment will provide economic returns of USD 13 for every dollar invested.
20 PMMS 2019
21 PDHS 2017-18

Achieving the SDG targets for neonatal health in Pakistan will mean
Figure 4: Achieving the SDG targets for neonatal health in Pakistan
588,815 174,178
Stillbirths Prevented Disabilities Averted
1,052,412 21,015 USD 13

Newborn Lives Mother’s Lives Saved Economic Returns
Saved for Every Dollar
Invested
According to latest figures from UN-IGME Child Mortality Report (2022), the NMR in Pakistan is 39
deaths per 1,000 live births, an improvement over the decade from 55 deaths per 1,000 live births in
2012. However, the rate of decline needs to be accelerated if global targets are to be achieved by
2030. The need for and importance of focused and scaled up interventions on ensuring neonatal
survival cannot be stressed enough in light of the progress over the past few decades. (Fig 3).
Figure 5: Trends of Neonatal and <5yrs Mortality over the Past years
Under-5 MR NMR IMR
120
112
110
100
94
90 86
80 89
74 74
70 78
62
60 54 55
50 49
40 42
30
1990-91 2006-07 2012-13 2017-18
YEAR
(Source: PDHS 2017-18)
Neonates are most vulnerable on the first day of birth with about one third of deaths occurring within 24
hours, and about 86% occurring in the first week of life23. Neonates die due to three main causes which
account for about 90% of the deaths – complications of pre-term (18%), neonatal infections (sepsis,
meningitis, pneumonia, and diarrhea) (32%), and intra-partum related complication (including birth
asphyxia) (36%). Some die due to poor quality of care, or because they did not receive any care at all.
23 PDHS 2017-18

Figure 6: Causes of Neonatal Mortality
Other specific perinatal causes 1%
3% Accidents/Injuries
Congenital malformations
4% 32%
Neonatal sepsis/Meningitis
Neonatal pneumonia
6%
Perinatal asphyxia Preterm birth complications

36% 18%
Source: PDHS 2017-18
According to Institute of Health Metrics & Evaluation (IHME)24, the annual rate of DALYs lost per
100,000 population indicates that Pakistan has very high BoD (Burden of Disease) among the regional
countries i.e., 42,059 DALYs/ 100,000 population in 2019, second only to Afghanistan. The IHME
classifies the Burden of Disease (BoD) into three major components:
1. Reproductive, Maternal, Neonatal, Child Health & Nutrition + Communicable Diseases

2. Non-Communicable diseases and
3. Injuries
It is evident from the data that RMNCH and Nutrition together with communicable disease is the
major contributor to the disease burden in Pakistan, thus making it imperative to invest in it to reduce
overall national disease burden.
24 https://vizhub.healthdata.org/gbd-compare/

Figure 7: Burden of Disease and DALYs Lost
RMNCH & CD NCD Injuries
70,000 2,958
DALYslost/100,000 population (%share)
(4.73%)
60,000
50,000 18,869 2,669

(29.9%) (6.35%)
40,000
30,000 40,962 18,385

(65%) (43.7%)
20,000
10,000 21,004
(49.9%)
0
2000 2019
Annual DALYs Lost: 89 million 94.2 million
Maternal and Neonatal Health Services

At present, in public sector, service delivery for maternal health includes comprehensive emergency
obstetric services at all district hospitals and some Tehsil level facilities, and basic obstetric care
at the level of RHCs including community based maternal and newborn services provided by
Community midwives and lady health workers. Community services are provided through planned
outreach activities and home visits, delivered by LHWs. Services like breastfeeding promotion,
fertility information, nutrition education and growth monitoring and selected maternal care services
are provided through household visits. However, there is a need to update the LHWs curriculum to
include new topics like care of small or sick newborns, KMC etc., and much needed improvement in
skills and quality of counselling. The partner funded MCH initiatives are implemented both through
government in form of upgradation of facilities (e.g., JSI in KP) in target districts. However, the overall
coverage of comprehensive cost-effective quality interventions remains suboptimal to be able to
achieve the SDG target for both maternal and neonatal health.
Pakistan has invested significantly in expanding access to skilled birth attendance in the last two
decades from a mere 23% in 2000 to 68% overall coverage in 2020. This was achieved through both
SBCC (Social Behaviour Change Communication) by LHWs and expansion of referral services to first
referral units as well as massive expansion in access to primary first referral delivery care facilities across
the country. However, despite these enormous gains, one out of every three mother-baby pairs face
the dangers of birth without a skilled birth attendance. However, the current level of service coverage
is highly insufficient to achieve the NHV and SDGs targets. Although, all provinces are keen to further
expand the coverage of quality maternal and neonatal health services including comprehensive
emergency obstetric and neonatal care (CEmONC), community-based skilled birth attendant (SBA)
training, and IMNCI under the umbrella of Universal health coverage (UHC) initiative at all levels. Filling
the gaps to universal access to skilled birth attendance is an urgent strategic intervention to rapid
accelerate progress in maternal and newborn mortality reduction.

Access to low-cost high-impact primary health care interventions – kangaroo mother care; antenatal
corticosteroids; neonatal resuscitation; Possible Serious Bacterial Infections treatment (PSBI) - has
steadily expanded over the past decade. MoNHR&C and provincial DoH are making significant
investment to expand these lifesaving services to all primary health care service outlets to reach the
most vulnerable mothers and newborn. Research showed major gaps in the quality of maternal and
neonatal interventions including non-use of partograph; gaps in optimal monitoring of labor; early
cord clamping; gaps in MPDSR; non-initiation of early breastfeeding and skin to skin contact; and
poor newborn resuscitation techniques.
The key quality services for maternal and neonatal health such as in continuity of care and missed
opportunities are not optimally covered fully under the current health services. The knowledge and
importance of these key services is deficient among both heath care providers and the beneficiaries
themselves. The country has seen huge improvements in the coverage of ANC1, skilled birth
attendance, institutional deliveries, and child immunization over the past two decades. However, the
gaps in continuity and quality of care are noticeable is all RMNCH services, for example more that
80% women received at least one ANC visit in last pregnancy but only 52% completed ANC+4 visits,
delivery by a Skilled Birth Attendance increased to 69%, only 16% babies were weighed at birth and
20% received early initiation of breastfeeding. For informed choice regarding FP services, only 19% of
women were informed about all three quality-of-service indicators (side effects, what to do in case
of side effects, and other available methods)25.
Table 2: Current Coverage of Key Maternal and Neonatal Health Indicators

Region ANC1 ANC SBA PNC* Baby Early Initiation CPR MMR NMR
4+ Weighed of BF
Pakistan (a) 87% 52% 69% 62% 16% 20% 25% 186 42
Punjab 94% 56% 71% 66% 18% 16% 27% 157 51
Sindh 87% 54% 75% 71% 21% 28% 24% 224 38
KP 81% 45% 67% 43% 7% 18% 23% 165 42
Balochistan 59% 23% 38% 38% 10% 60% 14% 298 34
AJK 91% 47% 64% 58% 22% 26% 19% 104 30
GB 81% 35% 64% 40% 22% 55% 30% 157 47
ICT 96% 80% 87% 78% 52% 40% 35% - 24
a Pakistan excludes AJK and GB
b For MMR, ICT is included in Pakistan and FATA in KP
*Both mother and newborn
To fast-track progress, attention is needed to ensure quality of care especially around the time of birth
and to invest in small or sick newborn care so as to prevent neonates to die from preventable causes
like hypothermia, birth asphyxia, infections etc. in line with WHO and global minimum standards
of care for antepartum, intrapartum and post-partum maternal and newborn care. Maternal and
Perinatal (newborn deaths and stillbirth) death reviews need to be integrated in the health information
systems at facility level nationalized for improving current practices and preventing perinatal deaths
and in helping identify gaps and needed quality improvements in current set of interventions for
reaching the desired results.
25 PDHS 2017-18

Poverty, malnutrition, and economic shock from COVID-19 pandemic and global economic challenges
increased risk of Asian population making them particularly vulnerable to neglected tropical diseases
(NTDs) alongside emerging infectious diseases from arbovirus infections, dengue, chikungunya,
Japanese encephalitis, and the continuing concern of a pandemic influenza outbreak. Furthermore,
drug- resistant infections caused 58,000 deaths in newborns every year, in India alone, and continue
to threaten the effectiveness of life-saving antibiotics across the region. Covid-19 has also disrupted
the control of other infectious diseases in myriad ways in South Asia.
Up to 15% of newborns delivered suffer complications that require in facility care for a few hours
to days in special newborn care units. Low birth weight (small) or sick (newborn suffering from
complications) require attention and care to ensure intact survival and future development potentials.
Pakistan has made considerable progress in increasing access to small or sick newborn care units
across districts. Level 2 small or sick newborn units have been established in 25 district hospitals and
efforts are underway to expand services to 75 additional districts by 2025 (2022 ENAP Updates, MoH
GoP). Universal access to care for all small or sick newborns is one of the critical interventions for
accelerating newborn mortality reduction.
The World Health Organization (WHO) emphasizes the importance of emergency medical services
(EMS) systems i.e. ambulances, which are usually the first point of contact with healthcare systems
for acute and emergency conditions including referral and transportation of sick neonates. There are
several ambulance services operating in various regions of the country which include philanthropic
organizations such as the Edhi Foundation with 1800 ambulances (nationwide)26, and Chippa Welfare
Association (Karachi)27. The Aman Foundation is another non-profit organization in Karachi which
deals with healthcare, education and skills, and nutrition for underprivileged28. In addition, some EMS
services were established due to efforts of provincial governments such as Rescue 112229 to deal with
emergencies and humanitarian disasters. However, these ambulance services currently work mostly
at the local level and are not part of an integrated emergency care system. In addition, these services
are mostly urban based and not appropriately equipped with transport incubators and trained
manpower for transporting small or sick newborns.
Critical Human Resources for Maternal and Neonatal

Health Service Delivery
Over the past decades, Pakistan has made significant investments in expanding its national health
workforce to meet the primary and health facility services in the public sector. This includes milestone
policy decisions to launch a national community health workers scheme (lady health workers program)
and introduction and gradual expansion of a professional midwifery cadre within the public sector.
Despite these significant initiatives however, Pakistan still has one of the lowest densities of health
workers in the region and globally, with an essential /skilled health professional (physicians including
specialists, nurses, lady health visitors (LHVs) and midwives) density of 1.4 per 1,000 population (2018),
which is much below the indicative minimum threshold of 4.45 physicians, nurses and midwives per
1,000 population necessary to achieve universal health coverage. For sustainable development, it is
not only adequate numbers, which is needed, but also a well and equitably distributed workforce
with appropriate skills mix to provide quality services.
26 http://www.edhi.org/
27 http://www.chhipa.org/
28 http://theamanfoundation.org/
29 http://www.rescue.gov.pk/

The National Human Resources for Health (HRH) Vision 2018-20 focuses on four strategic objectives:
y To establish a national and provincial health workforce planning and development capability that
provides the necessary tools (strategies, governance mechanism, legislation) and resources to
deliver a health workforce of sufficient size, composition, capability, and distribution to meet the
health needs of the population;
y To align investment in human resources for health labour market with the current and future
needs of the people and health system to address shortages and improve distribution of quality
health workforce, to enable maximum improvements in health outcomes and poverty reduction;
y To build the capacity of institutions at district, area/ province, and national levels for effective and
quality pre-service & in-service training and leadership of actions on human resources for health;
y To strengthen data collection, processing and dissemination of information related to human
resources for health for monitoring and ensuring accountability at different levels.
The above situation indicates how stretched the public health system can be in addressing health
emergencies, controlling infectious diseases, and offering essential services including neonatal and
maternal health services especially in the context of continuously emerging infections and pandemics.
Table 3: Human Resource Availability across Provinces/Areas
Province Registered Density Required Density/1000 Population

Physicians (including specialists)
Punjab + AJK + GB + ICT 123,344 1.11 0.97
Sindh 83,943 1.11 1.61
KP + FATA 34,637 1.11 0.88
Balochistan 7,447 1.11 0.53
Province Registered Density Required Density/1000 Population
NURSES (Nurse, LHV, MW, CMW, FWW)
Punjab +AJK + GB+ ICT 80,140 3.33 0.63
Sindh 29,637 3.33 0.57
KP + FATA 16,851 3.33 0.43
Balochistan 2,116 3.33 0.15
Residential status of additional 4,610 doctors and 9,363 nurses in not known
Pakistan is facing extreme shortage of nurses, LHVs and midwives that are key to provide maternal
and newborn care at primary health centers and health facilities. According to Pakistan Nursing
Council, a total of 14,943 nurses graduate annually in the various categories from both public and
private sector Nursing schools. We all know that nurses play a critical role in the management of small
or sick newborns as well as during institutional deliveries. In addition to nurses, the cadre of midwives,
community midwives and LHVs plays a critical role in the provision of primary healthcare services.
A total of 3196 midwives, 4416 CMWs and 2136 LHVs graduate annually across the country. The
meagre production capacity of nurse/midwives is a major challenge in achieving the desired targets
of reduction in maternal and neonatal mortality. In addition to annual training capacity, sufficient
motivation, constant capacity building, in service mentoring and retention are also key requirements
to ensure quality performance by health care providers.

According to findings of the LHW Programme Performance Evolution Report30, which measured
performance of LHWP against three key domains in line with the scope of work: family planning;
maternal healthcare; and infant and young childcare. At an aggregate level, there is significant
variation in the performance of the programme across various regions of Pakistan. Punjab and AJK are
higher performing, having achieved, or being close to achieving, approximately 70% of health outcome
targets. KP, Sindh, and GB are middle performing, having achieved, or being close to achieving,
approximately 50% of health outcome targets. Balochistan is the worst performer, having achieved, or
almost achieved, only 17% of health outcome targets.
Imbalance within the needed professionals e.g., shortage of anesthetists, neonatologists, pediatricians,
gynecologist etc is another major challenge. The essential HRH capacity compounded by high
attrition rate among the graduates (as a result of out-migration for jobs and more production of
female physicians not willing to perform duties in rural areas or not working after marriage etc.) can
potentially hinder achieving the strategic targets of newborn survival strategy and of UHC roll out.
National/Provincial Maternal, Neonatal and Child Health

Programs and New Initiatives including NHSP (UHC)
Considering the Coronavirus Disease 2019 (COVID-19) pandemic’s socioeconomic impact and climate
risks like recent unprecedented heavy rainfalls, glacier melting and resultant floods, Pakistan with
already lowest investment in the health sector (<1% of GDP) faces a huge challenge of increasing
domestic financing as well as mobilizing donors/financing institutions for improving investments in
the health sector and, at the same time, implementing health reforms in strengthening health systems
and making them efficient, equitable, sustainable and resilient.
In 2018, reaffirming its commitment to accelerating its progress towards Universal Health Coverage
(UHC) the Ministry of National Health Services, Regulation and Coordination in collaboration with
DCP3 secretariat with WHO support developed the Essential Package of Health Services (EPHS),
which was approved in 2020. The package (UHC BP) aims to address the current disparities and
inequalities in access to health care by establishing health priorities and clarity in resource allocation.
EPHS became cornerstone of Health chapter of the 9th Five Year Plan (2018-2023) and of National
Action Plan (2019-2023) of the Health Sector itself.
Universal Health Coverage Benefit Package (UHC BP) provides a policy framework for strategic
service provision based on scientific evidence on health interventions. It consists of Essential
Packages of Health Services (EPHS), comprising of twelve key interventions, for all levels of healthcare
services. Selection of interventions was based on cost-effectiveness, burden of disease, budget
impact, feasibility of implementation, equity and the social context of Pakistan. Among 218 DCP3
recommended interventions, the generic national EPHS included a total of 151 prioritized interventions
(Table 4). These services, except ambulance for referral, are provided free of cost i.e. medicines, in
patient care, blood transfusion. The diagnostics are provided at subsidized rates (cost per test varies
from province to province), while inpatient care is covered by Sehat Insaaf Card (Punjab, KP, AJK, GB)
at selected 1000 public and private hospitals.
30 LHW Programme – Performance Evaluation Report 2019 (OPM – commissioned by Unicef and MoNHSR&C)

Table 4: Number of Priority Interventions across Platforms
EPHS Immediate Priority Interventions

Platforms
Sindh KP Punjab Balochistan
Community level 21 21 19 23
PHC Centre Level 37 35 39 39
!st level Hospital 36 42 38 41
District EPHS 94 98 96 103
Tertiary Hospital 25 22 25 22
Population Level 12 12 11 12
All Five Platforms 131 132 132 137
a. National Health Support Project (NHSP)

Large-scale maternal, newborn and Child health interventions are planned nationally under Universal
Health Care (UHC) initiative through financing from World Bank (IDA $258M and GFF $42M
amounting to total US$ 300M). Additionally, there is support from BMGF ($50M and GF ($5M) for TB
interventions under the UHC initiative. The Government of Japan support, which was unspent from
the 2010 floods was renegotiated and was diverted to finance the ICT component. The PC-1 for
the same is approved, however, funding modalities are being discussed between Govt of Japan and
Economic Affairs Division.
The federal National Health Support Project (NHSP) PC-1 covering AJK (PKR1.52 billion), GB (PKR 1.03
billion) and Federal PMU (PKR 216.763 million) amounting to PKR 2.76 billion stands approved. The
provincial PC-1s are still in the process of approval. During discussions/dialogue with the provinces,
MoNHSRC advocated with provincial Health Departments to prioritize investments in 40 districts,
including infrastructure improvements and recruitment of additional HR, where gaps exist. It was
proposed that districts be selected the basis of available infrastructure, adequately trained HR
availability to facilitate smooth implementation of EPHS, to serve as pilot, before its fully rolled out
following a comprehensive evaluation and after incorporation of lessons learnt. However, the decision
of district selection for program’s implementation remains with the provinces.
In the first year of the project implementation is being planned for in 8 selected districts each of
AJK, GB, ICT, Punjab, Sindh and KP (where integration of services completed) in a phased manner.
Implementation in AJK, GB, Sindh, KP and Balochistan the project will be in a phased manner over a
period of 3 years, while implementation in Balochistan being planned from second year of the project
and will be financed from the grant component (GFF) only. NHSP is the vehicle for implementation
of the Essential Package of Health Services under UHC. The module on Reproductive, maternal,
Newborn, child and adolescent health and nutrition covers some interventions related to Newborn
Survival. However, the project is yet to be implemented and likely to affect the scope and scale of
coverage of proposed maternal and neonatal interventions.
The NHSP is envisaged to strengthen the health systems by investing in building resilient and
sustainable health systems through a series of interventions designed to keep in with the WHO
health systems building blocks. The key set of interventions are described in the below given figure.

Figure 8: Health System Interventions
Health Financing
Supervision Referral Drug supply WASH

System System management services
Capacity
development
in line with
UHC BP
Patient safety Governance & Information Service

mesaures coordination System delivery and
mechanisms quality
standards
Information Technology and Innovations
b. LHW and MNCH/IRMNCH Programmes

The LHW program in Pakistan is the mainstay of primary health care services, such as ANC, nutrition
counselling, family planning services31 in rural areas and provides a link between the community and
basic healthcare facilities. LHWs principally focus on health promotion, primary care level and family
planning services. It is well known fact that the majority of U5 and neonatal deaths are preventable
and both health facility-based and community-based interventions have been shown to considerably
reduce these deaths in high-risk populations. To strengthen the community-based health services
LHW Programme was launched in 1994 and MNCH Programme focuses on strengthening facility based
MNCH services including referrals. However, there are limits to what LHWs and other community
health workers can achieve in terms of reducing neonatal mortality in community settings, and the
importance of strong referral pathways and quality care in facilities has been underscored as a key
factor in reducing perinatal and neonatal mortality.
These large-scale MNCH and LHW programs do not offer the complete package of essential
interventions for all newborns. At the same time, the scale of the existing interventions are not
satisfactory. The recent LHW Evaluation, reports declining numbers of LHWs, since post devolution
period, in almost all regions of Pakistan, which has led to a decline in coverage in some regions of the
country, with no region of the country having met its population coverage target. Program quality and
progress are not always measured uniformly or appropriately. It is crucial to identify ways to integrate,
scale up, and sustain newborn health interventions within the existing service delivery platforms
and to formulate new strategies to combat local challenges to effective implementation. It is also
important to avoid wasteful duplication of efforts in the same geographical areas. A regular reporting
31 World Health Organization. Standards for improving quality of maternal and newborn care in health facilities 2016 Geneva.

system, with a common set of indicators, needs to be developed to monitor progress for all large-
scale programs. The MNHSR&C together with provincial counterparts with help of Unicef and WHO
are working on improving and upgrading the current health information systems by inclusion of all
requisite neonatal and maternal health indicators under the pilot and roll out of DHIS2 system. It is
envisaged that this will provide the needed information for realistic planning and resource allocations
for cost effective quality neonatal and maternal health interventions.
To-date the main responsibility for prevention and management of neonatal issues in Pakistan has
rested on the shoulders of the primary care programs especially the Lady Health Workers (LHW)
program with a focus on promotion of antenatal care, breastfeeding support, and immediate newborn
care. However, LHWs do not attend deliveries and given that about 30-40% of births still take place at
home, much of the neonatal mortality is clustered early and in facilities.
Efforts are underway by all provincial governments to strengthen maternal and child health care
and following devolution; provincial departments of health have actively worked on strengthening
scale up and implementation. Four provinces have implemented Provincial Newborn Care plans
since the last four years, which is one of the unique achievements of the decentralized health
management initiative in Pakistan. In this context a number of special initiatives have been launched
such as scaling up of the Sehat Insaaf Card Programme; doubling the size of the LHW programme,
(the current coverage is given in Figure 5); increasing number of 24/7 Basic Health Units (BHUs) and
Rural Health Centers (RHCs) equipped with a basic package of services, staff and ambulance service;
establishing training institutes for nurses and paramedical staff; upgrading secondary care facilities;
and building state of the art hospitals in major urban centers of the province in Punjab. While in
Khyber Pakhtunkhwa several steps have been initiated for up-gradation of BHUs to 24/7 RHC level
and integration of MNCH services and Sehat Sahulat Programme has been extended to 69 % of
the population of the province. The Government of Balochistan too has shown its commitment to
enhancing health infrastructure/facilities across the province. Construction of one new BHU/RHC in
each Tehsil and strengthening of 16 potential DHQs (50 Bedded Hospital) are planned.
Figure 9: Province/Area wise Population coverage by LHWs

Covered Population
2014 57
Pakistan 2018 58
Punjab 2014 69
2018 65
2014 34
Sindh 2018 47
2014 54
KPK 2018 58
2014 38
Balochistan 2018 34
2014 59
AJK 56
2018
2014
GB 2018 64
55% (Sindh) 80%

% of population
Source: LHW-MIS 2018 32
32 Performance Evaluation Report of LHW Programme 2019

Provincial MNCH programme units have continued through supplementary funding by subsequent -
PC-1s which have expired or are near expiration. Re-introduction of MNCH directorates in the provincial
departments of health is needed to continue the leadership and programmatic support for MNCH
programming for achieving SDGs on the reduction of maternal, neonatal and under-five mortality.
Health Delivery System

The healthcare services in Pakistan are provided by both public and private providers at five levels of
care, the government is by far the main provider of preventive care throughout the country and the
major provider of curative services in most of the rural areas. In the public sector, health services are
provided through a tiered referral system of community, primary health care and health care facilities;
with increasing levels of complexity and coverage from primary to secondary, tertiary, and specialized.
Figure 10: Levels of Health Care
1 2 3 4
Community Union Counsil Federal, Provincial Administrative
Tehsil District & Large District Level
Health House
- LHWs Rural Health Tehsil District
Centre / Tertiary Public Health
Outreach Headquarter Headquarter
Basic Hospital Facilities
Workers-CDC, Hospital Hospital
EPI etc. Health Unit
Referral
Community Based
Organisations Nursing Home / Small Hospital Large Hospital Tertiary Private Health
and Maternity Clinic (< 50 bedded) (>50 bedded) Hospital Facilities
Outreach Worker / Clinic
5
Population Level Interventions
At the community level services are provided by LHWs, CMWs and outreach workers (CDC, EPI
etc. Second level care is through primary care facilities include basic health units (BHUs), rural health
centers (RHCs), government rural dispensaries (GRDs), mother and child health (MCH) centers
and TB centers. All these facilities provide 8/6 OPD services for preventive and a limited number
of curative services, while RHCs provide a broader range of curative services, 24/7. Primary care
facilities also provide outreach preventive services to the communities, through vaccinators, LHVs,
sanitary inspectors, and sanitary patrol. Tehsil and district headquarter hospitals provide increasingly
specialized secondary health care, while teaching hospitals hospital to sub-health centers, in each
district of Pakistan was collected from the respective district health departments.
While level 3 services including referral are provided by Tehsil and District headquarter hospitals.
Level 4 institutions provide specialized and advanced management of medical and surgical services.
Level 5 interventions are mostly preventive, focusing on social and behavior change among population

at large. In the public sector, health services are provided through a tiered network of health care
facilities – First level hospitals and Tertiary hospitals. PHC centres include 670 RHCs, 5,472 BHUs/
Sub Health Centres and other Primary Health Centres, including Dispensaries (5,743), MCH (752), TB
Centres (412). The total number of hospitals in public sector was 1,282 in 202033.
For-profit private sector constitutes a diverse group of doctors, nurses, pharmacists, traditional
healers, drug vendors, as well as laboratory technicians, shopkeepers, and unqualified practitioners.
The facilities they provide services at include private hospitals, nursing homes, maternity clinics;
clinics run by doctors, nurses, midwives, paramedical workers, diagnostic facilities and the sale of
drugs from pharmacies and unqualified sellers. However, in some cases, the distinction between
public and private sectors is not very clear as many public sector practitioners also practice privately.
Not-for-profit private sector is relatively sizeable with more than 80,000 not-for-profit non-governmental
organizations (NGOs) registered under various Acts in Pakistan. More than 45,000 were included in the
database of Pakistan Centre for Philanthropy and six percent of these NGOs are working in health
sector. The health care delivery system is augmented by the rapid growth of the private-for profit
such as Nursing homes, clinics, small and large hospitals, and specialized institutions. The community
interventions are provided by NGOs sector that are playing significant role in expanding the health
service coverage and utilization. To catalyze the engagement of the private sector in health service
delivery and foster partnership between the public and private sectors the GOP as a policy decision
launched the Public Private Partnership (PPP) initiatives in the health sector, which were adapted and
expanded by the provinces in form of PPHI. The initiative has a strong base in Sindh province and
continues to be sustained alongside many other PPP initiatives. However, the government supported
initiative has been rolled back in all other three provinces, wherein emphasis continues to be on the
public sector. A situation which can be a major obstacle in achieving the coverage targets for services.
There has been a shift in the location of neonatal deaths over the last two decades with 58% of
all newborn deaths now taking place in facilities (public and private), compared to just a third in
2005. The knowledge base for reducing perinatal and newborn mortality is well established and it is
estimated that a package of 6 core interventions, if appropriately implemented in district facilities,
can reduce over 70% of preventable neonatal mortality, and improve quality of survival. These include
interventions that should be standard of care in all newborn care facilities in Pakistan and are not
complex such as appropriate use of antenatal steroids for prevention of prematurity, prevention and
appropriate treatment of neonatal infections, appropriate respiratory support for newborns in need
and early Kangaroo Mother Care (KMC) with promotion of exclusive breastfeeding.
Health Service Quality

Quality of care has been highlighted in the National Health Vision (2016-2025) as a coordinated priority
action and provides a unified direction for overcoming various health challenges, while ensuring adherence
to provision of Universal Health Coverage as the ultimate goal. In addition, the National IRMNCH+N
Strategy (2016-2020)34 identifies 10 priority areas for action including quality of care and accountability.
Programmatic interventions for reducing preventable maternal and child mortality and strengthening
family planning are dependent upon the ability of the health system to deliver equitable and quality
health services. Measuring coverage of key Family Planning and MNCH indicators has been the usual
practice. There is a growing realization globally that the increasing rates of skilled birth attendance
33 Pakistan Bureau of Statistics data for 2020 published in Pakistan Economic Survey 2020-21
34 https://phkh.nhsrc.pk/sites/default/-iles/2019-06/National%20RMNCAH%26N%20Strategy%202016-2020.pdf

and facility-based deliveries have not translated into equivalent health and survival outcomes for
mothers and newborns; and thus, measuring quality of care and outcomes is equally important.
Improving access and quality of outpatient and inpatient care as per WHO evidence-based standards of
care for ANC, Intrapartum care, postnatal and newborn care, is crucial to achieving the objectives of Every
Newborn Action Plan (ENAP) of ≤10 newborn deaths per 1000 live births by 2035. Appropriate perinatal
and neonatal care in any given circumstance in developing countries requires an integrated and holistic
program of interventions at various levels. Interventions must not only include health-related measures
that have a direct bearing on perinatal and/or neonatal outcomes but several other ancillary measures
of equal importance. These measures include poverty alleviation; improved opportunities for female
education; and improvement of women’s social status, including empowerment and improvement of
women’s decision-making ability. Family size and short interpregnancy intervals are also critical factors
in perinatal health. Appropriate health seeking behaviors among pregnant and newly delivered mothers
are critical for accessing services across the continuum of care. Community health workers play a key
role in identifying, registering, and providing key health information to the most vulnerable mothers and
newborns. SBCC on maternal and newborn health is a key strategy that requires strengthening.
Improving quality of care for small or sick newborns has shown significant impact on reducing
neonatal deaths rates. Having standardized recoding and reporting tools, setting up quality of care
teams and supporting them with training and enabling environment, perinatal death reviews and
family-centered care are some of the successful strategies that can be adopted. Pakistan adapted the
WHO standards and guidelines for Quality of Care through a consultative process and developed the
National Strategic and Accountability Framework for Quality of Care for RMNCH services (figure 7),
which is for use in all provinces and regions of Pakistan and is aligned with the National Health Vision
2016-2023, SDG targets and the UHC BP roll out. This framework will also be adopted and used for
monitoring quality of care of the National Newborn Survival Strategy.
Figure 11: National Quality of Care Strategic and Accountability Framework
Health system
Structure
Quality of Care
PROVISION OF CARE EXPERIENCE OF CARE

1. Evidence based practices for 4. Effective communication
routine care and 5. Respect and preservation
management of of dignity
complications 6. Emotional support
Process 2. Actionable information
systems
3. Functional referral systems
7. Competent, motivated human resources
8. Essential physical resources available
Individual and facility-level outcomes

Outcome Coverage of key practices People-centred outcomes
Health outcomes

Health Care Financing
Globally more than 100 million people are pushed into extreme poverty due to health-related
expenditures every year. In Pakistan major portion of all new entrants in poverty are also because of
catastrophic health expenditure. Having Out-of-Pocket (OOP) expenditure on health of more than
51.9 percent and one out of every three living in extreme poverty, Pakistan has been ranked as one of
the most exposed nations to poverty risk among 43 countries of Asia-Pacific region.
The affordability of healthcare is a key dimension for achieving UHC. In low- and middle-income countries,
the majority of people lack sufficient financial means to access health care services. Millions of people are
pushed into a vicious cycle of poverty every year due to compelling needs to pay for health care services.
Government has taken several steps to protect its citizens from financial risks. The top priority of the
government is to enhance government expenditures on health, which have reached to a level of PKR
1466.42 billion in 2019-20 and is around 1.2 percent of the Gross Domestic Product (GDP)35.
Most vertical programmes i.e., MNCH, LHW and IRMNCH are financed through development budget,
which raises concerns of continuity and sustainability. With continuing financial challenges in the
country, the health sector too has been facing the crunch. However, the recently developed National
Health Support project (NHSP) provides an additional source of financing for the health sector. The
initiative envisages to address prioritized area under Universal Health Coverage (UHC) including
roll out of the RMNCH module with additional financing for cost effective maternal and neonatal
interventions with the objective to enhance coverage and scale of equitable quality services.
A recently conducted resource mapping exercise for 2020-2021 (commissioned by the World Bank)
found that the of total national commitments to priority areas, RMNCH accounts for 23% of total health
allocations while in way of allocations/commitments child health amounts for 11% of the total budgets
and 3% goes towards maternal and newborn health, thus highlighting how underfunded is this important
area of maternal and newborn health for ensuring reduction in neonatal mortality and stillbirths.
Figure 12: Resource Mapping of Health Sector Budget

Key results from the RM activity - National (amount in PKR million)
Priority wise resource commitment Top-10 Sub-priority-wise
resource commitment
1%, 8,502
01 0%, 1,436 3%, 17,736
02 1%, 8,502 3%, 17,779
03 3%, 17,753
6%, 32,758
3%, 17,849
3%, 20,282
04 7%, 42,399 6%, 36,069
05 8%, 47,996 7%, 42,399
06 11%, 62,167
23%, 132,261
11%, 62,167
15%, 86,565
40%, 234,243 40%, 234,243
Services Access CD Hospital Reproductive
RMNCAH Child Health Health
Pandemic Pandemic
Administration Emergency Responce Administration Response
NCD Regulator Medical Education Neglected
Institution tropical diseases
Medical Education CVD Regulator
Maternal & New-born Health
Source: Resource Mapping and Expenditure Tracking for Universal Health Coverage in Pakistan for FY20-
22 Assessment report for the World Bank
35 Report of Horizontal PHC Integration Assessment Under Program of Advisory Services & Analytics (PASA), Chapeau Paper
World Bank October 2022

Health insurance
Sehat Sahulat Program is a milestone towards social welfare reforms; ensuring that the identified
under-privileged citizens across the country get access to their entitled medical health care in a swift
and dignified manner without any financial obligations. Sehat Sahulat Programme is a public sector
funded social health protection initiative of Federal and participating provincial and federating area
governments working to provide financial health protection to targeted families against catastrophic
(extra-ordinary) health care expenditure. Sehat Sahulat Programme is being implemented in a phased
manner, starting from below poverty families, and eventually targeting universal families and providing
coverage eventually to all people across Pakistan. To date, the programs have expanded to 65 districts
across the country with over 81 million individuals enrolled across Punjab, KP, AJK and Gilgit Baltistan
and 1 District of Sindh (Tharparkar), providing services to more than 18 million families. However, the
program is not yet implemented in the provinces of Balochistan and Sindh.
There are several Insurance packages defined under the programme that include the following;
1. Sahara Family Health Insurance Plan - provide inpatient hospitalization, day care surgeries and
benefits related to pre-and post-hospitalization costs incurred by the policyholder through
cashless mechanism from the network hospitals of State Life. And provide coverage to all Pakistani
families consisting of an individual and his/her spouse aged 18-64 along with their children having
age of 2 months to 17 years (if any) will be eligible.
2. Sehat Zindagi Health Insurance Programme - to provide financial protection to an individual
in case of unfortunate illness or accident that leads to hospitalization and provide inpatient
hospitalization, day care surgeries and benefits related to pre-and post hospitalization cost
incurred by the policyholder through cashless mechanism from the network hospitals of State
Life. All Pakistani male/females aged 18-64 will be eligible under the plan.
3. Sinf e Aahan: is cancer protection plan for women.
4. Haari Plan: This policy aims to provide financial coverage in case of hospitalization for treatment
of any ailment or, God forbid, an accident focusing on the rural population.
The services are provided through 1000 health facilities (30 percent public sector (up to district
Head Quarter level) and 70 percent private sector36). All newborns are eligible to avail indoor services
under the Health Insurance programme provided they are delivered to any of the panel hospitals.
The services include all medical and surgical management requiring hospitalization at tertiary care
level and at Secondary care, Advanced Package for neonatal care (Low birth weight babies<1500gms
and all babies admitted with complications like meningitis, severe respiratory distress, shock, coma,
convulsions and encephalopathy, jaundice requiring exchange transfusion and NEC)37. The cost of
treatment for basic and specific services varies across the provinces with basic ranging from PKR
40,000 in KP to 60,000 in ICT for each individual in a family and specific from 400,000 (KP) to 300,000
(ICT) for a family over a period of one year.
It is important to mention under the programme indoor health care services are provided which
include, but are not limited to, cardiac treatments (stents, open heart, valvular replacement),
oncological (cancer) management, burn management, organ failure management (dialysis), complication
of diabetes mellitus, accident / trauma management, neurosurgical procedures, abdominal surgeries,
36 list available on www.statehealth.com.pk

37 https://statehealth.com.pk/assets/pdf/diseases.pdf

fracture management and other medical & surgical interventions. However, it does not cover neonatal
health interventions, as the eligibility criteria under the above-mentioned Sahara Zindagi and Sehat
Salamat Plans do not cater to children less than 2months of age. There is need to undertake advocacy
with the relevant quarters to include neonatal, aged Zero up to months, interventions in the scheme
especially for small and sick newborns services at district level and those needing management of
serious complications at NICU (newborn Intensive Care Units at tertiary care and specialized facilities).
In addition, there is no provision within the plan to pay for the transportation cost of the mother/
caregiver and the newborn from home to the facility. The transportation cost is identified as a major
impediment towards seeking timely care for the newborns.
Natural disasters and Humanitarian Situations

Pakistan is a country prone to effects of the global warming and climate change, despite contributing
less than one percent to global greenhouse gas emissions. Pakistan has had more than its fair share
of emergencies and humanitarian disasters over the last two decade. Between 2000 and 2011, serious
drought conditions, earthquake in 2004 and the massive floods of 2010 and 2011 affected millions
of people, especially those living in rural impoverished areas. The recent 2022 floods are another
example of Pakistan’s high vulnerability to climate change that led to disaster that was much more in
scale than of damages resulting from 2010 floods. There were unprecedented rain resulting in one-
third of the country being under water, with 33 million people badly affected and nearly 8 million
people reportedly displaced38. As in most emergencies, the primary focus for Pakistan emergencies
has been on provision of shelter, prevention of communicable diseases through immunization, water,
sanitation and hygiene interventions and rehabilitation. Given that women of reproductive age are a
large proportion of those affected, and the extreme vulnerability of newborns, the limited attention
given in planning to the state of maternal and newborn care during emergencies is surprising.
The major concern is that frequency of such incidents is increasing and there is a need to have a
contingency plan for responding urgently and timely to emergency situations especially focusing on
pregnant women, newborns and children ensuring service availability and continuity, especially in
view if facility level service disruption. Due to societal norms/practices, many women are unable to
access care for themselves or their children.
Keeping all above mentioned in view, all provinces/AJK/GB/ICT need to take number of priority
actions, well in advance, including budgetary provision in the development budget and having a very
close liaison with NDMA/PDMA to align all interventions to maximize actions and results in dealing
with such emergencies. Moreover, they need to work closely with Controller General Accounts for
creating a budget line for Disasters and Emergency, developing a budget proposal for emergency
preparedness for dealing with epidemics, outbreaks, and disasters both natural and conflict related. It
is important that this head of account is operative and can be utilized to implement the Contingency/
emergency costed plan and can be quickly translated into action to deal with emergency situations
without delays. Disruption in health service delivery carry high risk of increasing health inequities
for the poor and disadvantaged due to hindered access to services such as immunizations, routine
medical care including medication for chronic disease, maternal and child health services, as well as
risk of higher out-of-pocket health expenditures.
38 Pakistan Floods 2022 – PDNA- Main Report by Ministry of Planning, Development & Special Initiatives

Need for a National Newborn Survival strategy
The National Health Vision (NHV) 2016-25 and the National Action Plan (2019-23) along with Provincial
Health Strategies provides an overarching vision and agreed upon common direction, harmonizing
federal and provincial efforts for achieving the desired SDG3 outcomes and impact, including
maternal and neonatal health.
The national newborn strategy fine tunes, contextualizes and incorporates high impact newborn
and child survival interventions and service delivery models that have gained global acceptance,
while keeping the primary healthcare approach at its core. The service delivery model will be
based on life cycle approach ensuring continuum of care across time: adolescence, pre- pregnancy
(Preconception), childbirth, and postnatal period, neonatal, childhood and through reproductive age
and service delivery levels: at home and community level, through primary and referral care services
of health facilities. The strategy also ensures linkage across maternal, newborn and child health service
delivery points within health facilities with the aim of avoiding missed opportunities and provision of
comprehensive service for mothers, newborns and children. This approach is based on the sound
premise that health of an individual across the life stages and levels of delivery are interlinked.
The strategy was developed through a wide range of consultations at national and provincial levels
(List of participants at Annex II), further informed by the findings of the situation analysis, that included
literature and document review, in-depth interviews with stakeholders (UN Agencies, development
partners, public and private sector) at national and provincial levels, representatives of professional
associations (PNC, SGOP, PPA etc.), SWOT and bottleneck analysis that identified critical factors, gaps
and proposed recommendations. A series of provincial and national level consultations were organized
to validate the findings from situational analysis as well as to suggest key components of the draft
strategy through an inclusive consultative process involving National Steering Committee, TWGs and
key stakeholders. The strategy also builds upon the existing provincial Newborn survival strategies,
ENAP progress review reports, global ENAP/EPMM guidelines and WHO QoC guidelines for antenatal,
intrapartum and post-natal care and learning from implementation of successful interventions under
MNCH and LHW programmes which can help strengthen effective universal coverage.
The strategy is developed around strengthening the health care delivery system in line with the
proposed horizontal integration in healthcare under UHC-BP, that refers to a healthcare system having
aligned all healthcare functions and delivery of healthcare services, along with successful change
management to achieve a truly integrated healthcare model (WHO, 2018). The process of integration
provides a significant opportunity to revisit the health system to implement the UHC Benefit Package
and to assess the feasibility and processes necessary for the horizontal integration at the primary care
level. Integration of vertical/preventive programs into broader horizontal primary healthcare services
has become increasingly crucial in view of UHC reform agenda, which has strengthened the argument
for integration to increase health system’s efficiency.
Thus, giving priority to universal coverage with special focus on addressing inequity in access to and
utilization of newborn and maternal health services, while ensuring improvement in quality of services
and focusing on community mobilization for demand creation and improvements in utilization of
health services. The strategy also fosters multi-sectoral (nutrition, family planning, WASH, gender,
SBCC) and interdepartmental collaborations and partnership of all stakeholders that share common
goals and vision for improved health outcomes with emphasis on the most vulnerable and underserved

sections of the population. The strategy builds and aligns with Strategic Vision 2030, Provincial Health
Sector strategies and UHC framework as well as aligning with supporting programmatic strategies for
WASH, FP, gender, human rights, Nutrition of other sectors.
The Strategy provides an overarching framework through which to integrate improvements in maternal
and neonatal interventions. The MONHSR&C together with Provincial DOH and key stakeholders
(PPA, PMA, SGOP and private sector) will call on multilateral agencies, bilateral donors and other
partners to work together in the implementation of this Strategy to ensure efficient use of resources
to prevent fragmentation and duplication.
The focus is on first using available opportunities to improve services standards at health facilities
such as 24/7 initiative at RHCs and BHUs, upgradation of tehsil and district hospitals and recruitment
of additional community health workers (LHWs, CMWs) under the UHC roll out plan (NHSP) to
expand services and coverage for adolescents, neonates and mothers. Similarly, outreach services
(EPI and SIDs/NIDs) can be used additionally for providing interventions for neonates especially Birth
Dose Initiative. The National Newborn Survival Strategy will play a central role in guiding this process.
In the context of Pakistan, as there is large rural community, community services are critical and must
be expanded to increase coverage neonatal and maternal health. Skilled care at birth is central to the
maternal health strategy and has significant implications for neonatal outcomes. The facts that in the
country’s context, many deliveries still occur at home, since there is very low coverage of skilled birth
attendants and with majority of neonatal deaths occur within the first 24 hours, justify the need to
recruit, train and deploy additional Lady Health Visitors (LHVs) and community midwives (CMWs) for
improving services for neonates and mothers to address this critical gap.

Guiding Principles
The following principles are considered key pillars of the National Newborn Survival Strategy and
costed Action Plan and expected to guide planning and implementation to ensure effectiveness,
ownership, and sustainability.
Integration of Services: integration being the key pillar of the UHC initiative. The proposed strategy
makes all efforts to align and integrate with proposed UHC RMNCH module interventions at various
levels of the health system in a coherent and effective manner. Efforts have been made so that
objectives and interventions are aligned with UHC-BP while being fully responsive to the needs of
the adolescents, women of reproductive age, mothers and the newborns to achieve scale, quality
and equity using the life cycle approach.
In addition, the strategy focuses on two important principles of integration, inculcating multisectoral
approaches by establishing operational linkages with family planning, nutrition and WASH interventions,
mainstreaming gender and rights based approaches, aligning with school health programmes (where
available) and lastly ensuring the inclusion of principles for addressing climate change are addressed
at all levels of health services for avoiding climatic impact on maternal and newborn health outcomes.
Linkage and alignment with UHC (BP) initiative for roll out of EPHS: Efforts have been made to
ensure that the strategic objectives, targets and interventions are cost effective and responsive to
the priority areas and needs identified under the NHSP (operational roll out of UHC-BP).
Increasing demand for quality, client centered and respectful sustainable services through
Social and Behavioral Change (SBC) interventions and enhancing accountability: Using family-
centered approach, where small or sick newborns are the focus of care, requires parents and families
to be actively engaged and empowered during hospitalization, at home post-discharge and in
the community. Education and empowerment of parents, families, and communities to demand
quality of care, being engaged meaningfully in that care and in improving follow-up care practices
is crucial. Promoting partnership, coordination and working with community to create demand and
accountability for quality services, address adolescent, maternal and newborn malnutrition, promote
family planning, preventing early marriages, promoting birth registration and creating a culture of
mortality audit and reporting (MPDSR).
Continuum of Care: Ensuring provision of continuum of care focusing on adolescents, women and
children health aligning with the Survive, Thrive and Transform agenda39 which strives for a world in
which every mother can enjoy a wanted and healthy pregnancy and childbirth, every child can survive
beyond their fifth birthday, and every woman, child and adolescent can thrive to realize their full
potential, resulting in enormous social, demographic and economic benefits. The continuum of care
should encompass pre-pregnancy, pregnancy, childbirth, neonatal, postnatal and Early Childhood
Development (ECD) periods across all services delivery levels - community, primary care and referral
to Secondary health including management at specialized tertiary care. Care around the time of birth
saves not only mothers and their newborn babies, but also prevents stillbirths and disabilities, thereby
yielding triple returns on investment. Quality of care is largely affected by issues related to human
resources at both the facility- and community/outreach level and supply of medicines and critical
commodities.
39 The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) -https://www.everywomaneverychild.org/
wp-content/uploads/2017/10/EWEC

Focus on small and sick newborn care: The Nurturing Care Framework for Early Childhood
Development, launched by WHO, UNICEF and the World Bank Group, demonstrates that focusing
on early childhood development is one of the wisest investments a country can make to boost
economic growth40. During the first month of life, the brain is highly vulnerable to birth and postnatal
complications. Infants who are born small or sick are at risk of disability and poor development and
require extra attention to promote optimal development. When a newborn is separated from the
mother, father or caregiver, there can be further adverse effects on brain development. Disabilities can
be prevented or mitigated with good-quality, developmentally supportive care. This can be achieved
by building on scaling up of existing interventions under MNCH and LHW programmes in improving
adolescent health, pre-pregnancy care, maternal health, early identification of sick newborns and
timely referral for quality management. Strengthening secondary level health facilities by upgrading
and or setting up sick newborn care units (SNCUs) for management of preterm and low birth weight
newborns at all district hospitals as per approved national guidelines and Standards.
Addressing Causes of stillbirths, Maternal, Neonatal and Perinatal mortality: Inculcating a culture
of multi-sectoral and partnership using the Life Cycle Approach to address the underlying causes of
maternal, newborn, and perinatal mortality e.g., high fertility, anemia, high blood pressure, diabetes,
malnutrition (ensuring coverage of health and nutrition interventions in all health service delivery
platforms and baby friendly facility initiative), early marriage, infections, birth asphyxia, low birth
weight, preventing stillbirths and congenital anomalies, before and during pregnancy.
Shared responsibility: Defining roles and responsibilities of all players and partners in implementation,
monitoring and evaluation of the activities for increased synergy. This includes; the family/household
being the primary institution for supporting holistic growth, development, and protection of children.
The community having the obligation and duty to ensure survival and health of mothers and children
and ensuring that every child grows to its full potential. The state, to ensure a conducive environment
through legislation, service provision, accountability for survival, growth, and development. Focus on
strengthening health management for maternal and newborn health at all levels including national
and provincial Technical Working Groups (TWGs) and departments and strengthening district health
management systems for maternal and newborn health.
Strengthening quality of care, including respectful care and service delivery: Upgrading
infrastructure, ensuring availability of medicines and supplies, availability of WASH services in health
care facilities (infection prevention and control, handwashing, clean water supply and functional
toilets). Inclusion of Quality-of-Care indicators in monitoring service delivery and implementing a
mechanism for supportive supervision. Ensure alignment to WHO minimum recommended standards
of care for antepartum, intrapartum and post-partum care.
Resilient Health Information systems for continuous accountability: Promoting a culture of

accountability at all levels i.e., beneficiaries and providers. Mainstreaming birth and death registry
and MPDSR with emphasis on P (stillbirths and neonatal deaths). Inclusion of key ENAP indicators for
monitoring of services and reporting ensuring implementation of quality of care.
40 WHO, UNICEF, World Bank Group. Nurturing care for early childhood development: a framework for helping children survive
and thrive to transform health and human potential. Geneva: World Health Organization; 2018

Theory of Change
In view of the findings of the situational analysis, the overall focus for saving newborns will be on
expanding universal access to all births being attended by a skilled providers, expanding access to
small and sick newborn care addressing maternal nutritional deficiencies such as anemia and other
micronutrients, infection control both during pregnancy, at delivery and post-natal period. The
proposed strategy calls for simultaneous efforts in advocating for enabling environment, increasing
demand for health services and supply of quality, client centered and respectful health services. It
requires prioritized action on bringing social and behavior change among the population, increasing
multisectoral partnerships, need for family planning and birth spacing, preventing early marriage,
clean drinking water and its role in preventing infections, improving sanitation, and making available
cost effective and sustainable services at community level. The strategy also focuses on equity
focus and systems strengthening focusing on primary health care and first referral facilities as well as
strengthening district health management systems focusing on the most vulnerable and zero dose
communities. Strengthening public private partnerships to address quality and equity issues will also
be a mainstay of the strategy.
The framework also calls for building strong linkages with a variety of stakeholders who directly, or
sometimes indirectly, contribute towards maternal and neonatal health outcomes. This will include
building stronger partnerships, integration of services (UHC), alignment with key vertical programs,
civil society, health professional associations and international donors for better outcomes that are
cost effective, efficient, and sustainable.
The proposed strategy aims to improve the knowledge, attitudes and health seeking behaviors of
communities, especially adolescent girls and women of reproductive age, thereby improving the
demand and uptake of services especially at the PHC level. These efforts will not only reduce the
neonatal mortality and morbidity but will also contribute towards triple mortality reduction and
improvement of overall health outcomes.
The TOC assumes that there will be political stability with strong commitment, financial resources
will be adequate and human resources needs will be fulfilled. The national and provincial/Areas
governments will ensure provision of infrastructure and an environment conduce to delivery of
quality adolescent, maternal and newborn health services.

Theory of Change
To scale up provision and quality of maternal and newborn health services (especially small and sick
newborn care) at all levels of health care to reduce neonatal mortality and still birth rate.
Sectoral Required Key Strategic
Challenges Actions Interventions Results Objectives
Low Coverage of • Improve infrastructure • Use and adherence to Improved coverage of Objective 1. Improve
maternal and neonatal and supplies – ensuring standardized service maternal and neonatal Home and Community
standards on key maternal
health services every district hospital has health services. based Newborn care
and newborns and small and
(emergency obstetrics, a neonatal unit, practices sick newborns promoted and IR Indicators 1, 2, 3 & 4 Practices focusing on
newborn care, small and ENC, Kangaroo Mother implemented KMC, SBC, Nutrition,
sick newborn care, Care (KMC) and all • Quality Emergency WASH, Birth registration
adolescent health, and health facilities have Obstetrics and Newborn care and FP
nutrition) functional equipment services scaled up (NICUs,
SSNCUs) Objective 2.
and essential drugs such
• Extended maternal and Strengthening of PHC
as gentamicin for treating neonatal services including and Secondary Health
neonatal sepsis small and sick newborn at the facilities (HR and
• Recruit and retain community level using LHWs
Infrastructure) to
quality staff – filling and CMWs
improve delivery of
vacant posts and
Quality Neonatal care
addressing turnover
• Health workers recruited as
Improved availability and services
among existing staff, per the requirement at all
ensuring competence in levels of health care (for competence of human Objective 3. Improve
key skills such as neonatal maternal and newborn care) resources for health availability and equitable
resuscitation • Trained cadres in short (HRH) distribution and
• Improve guidelines and supply IR Indicator 5 maintenance of quality
Shortage of skilled and • Expansion of In-service
service delivery – essential medicines,
competent human training programme through
establishing or improving medical equipment, and
resources for health introduction of mentorship
procedures for routine programme commodities for
postnatal care and • Capacitated selected maternal and Essential
management of preterm health training institutions for Newborn Care
and small and sick providing in-service training
• Improved capacity of health
Objective 4. Ensure
newborns effective universal
facilities to provide Increased number oof
Emergency services for referral cases managed at coverage of high impact
newborn care at each level of
facilities level neonatal and maternal
Weak system for • Integrate services – health care health interventions
management of linking emergency • Provinces/Areas with IR Indicator 6
especially for poorest and
emergencies and referrals obstetric services with established and functional
referral systems for neonates
marginalized sections of
newborn care and
• Functional and responsive the population focusing
improving transport and
systems (SSNCUs) at district on Areas/Districts
referral mechanisms and tehsil levels requiring equitable
• Use data locally for
development by
quality o improvement –
• Selected health facilities at
integrating and scaling up
recording and auditing
primary and secondary levels essential newborn care
neonatal deaths and still
upgraded, refurbished, and services (including KMC,
births equipped (for maternal and SSNC) at all 4 levels of
• Identify mechanisms to newborn care especially small health care aligning with
reach every mother and and sick newborns) Core UHC roll out
baby in the early maternal (including FP),
postnatal period (within newborn and nutrition
the first two days after commodities and supplies Objective 5. Promote
available at health facilities accountability for
birth) • Health facilities with resources and results at
• Strengthen community necessary utility services all levels of health care
based integrated (clean water, sanitation, and
Management of waste management).
• Number of health
Objective 6. Review
childhood Illness (IMCI) • Health facilities providing and update the District
services as per quality facilities functioning
to effectively reinforce Health Information
standards. according to established
healthy behaviours, System (DHIS2), MNCH
In effective Governance, • Coordination, approved standards
recognition of danger management, and and LHW/CMW MIS for
weak coordination, and
signs and timely care
IR Indicator 7 & 8 inclusion of key newborn
accountability mechanisms
accountability • Increased coordination
seeking, to identify strengthened at National and indicators and roll out of
mechanisms for delivery provincial levels and between capacities at national,
harmful traditional Perinatal and maternal
of quality neonatal and district and health facilities provincial and district
practices and awareness mortality surveillance
maternal health services • National/Provincial RMNCH levels
of key newborn health systems
(including Newborn health)
packages such as routine Committees /Task Forces • Functional perinatal and
post-natal care, KMC and strengthened and functional maternal mortality
IMNCI • Newborn health prioritized surveillance systems
• Engage communities in in DHMTs agenda (Quality
standards)
IR Indicators 9, 10, &
birth preparedness, 11
• Scaled up
including planning to give national/provincial and
birth at a health facility district capacities for
and emergency transport improved coordination and
• Strengthen accountability
coordination, • Scaled up maternal and
accountability/oversight perinatal death surveillance
and response system at all
and data quality/report- levels of health care
ing systems • Data utilization from
RMNCH dashboard for
planning and decision
making.

National Operational Targets
The Sustainable Development Goal 3.2.2 is to reduce national neonatal mortality and stillbirth rates
to less than twelve deaths per 1000 live births by 2030. However, keeping in with the national baseline
and the challenges at hand, the following Operational Targets have been agreed up through consensus.
Further, it is envisaged that in the beginning the progress will be slow, however, once the district
health systems strengthening has been completed, horizontal integration of services operationalized
with UHC BP fully rolled out, the progress in achieving the targets in subsequent years will be much
faster. However, it is important to note that the respective provinces will be adjusting and aligning as
per the targets mentioned in the Provincial ENAP and Health Sector Strategies.
Table 5: Operational Targets for Key Strategic Indicators
Baseline Year 2 Year 3 Year 4 Year 5

Indicator
2023 -24 2024-25 2025-26 2026-27 2027-28
Impact Targets
NMR (per 1000
41 38 34 30 26
live births)
SBR (per 1000
43.1 38 32 28 24
live births)
Coverage Targets
SBA attended
69% 72 75 78 80%
deliveries
Early Initiation
of Breastfeeding
20% 30 40 50 60%
(within 1 hour of
birth)
30% increase
Lady Health
52% 56 60 65 70%
Workers
Coverage
No of Primary
Health Facilities
providing
Baseline 50% increase
BMoNC
to be - - - from the
including
established baseline
ENC (4 key
interventions)
services
Increase in
48.7% 50 54 58 60%
mCPR
75% of
50% increase DHQ has
Baseline to be
in No of DHQ established
established - - -
with operational and
13.2%?
SNCU operational
units
ANC (4+ visits)
69% 73 76 78 80%
by SBA

Baseline Year 2 Year 3 Year 4 Year 5
Indicator
2023 -24 2024-25 2025-26 2026-27 2027-28
Women with
preterm labour
(24-34wks
of gestation)
Baseline to be
receiving at - - - 60%
established
least one dose
of antenatal
corticosteroids
(%)
Newborn with
low birth weight
/ Preterm Baseline to be
- - - 50%
provided with established
KMC services at
facility (%)
Babies born
in health
facilities with Baseline to be
- - - 90%
birth asphyxia established
received
resuscitation (%)
*Annual Contraceptive Prevalence Report 2019-2020 – downloaded from
https://www.pbs.gov.pk/sites/default/files/social_statistics/contraceptive_performance_reports/ACP_
Report_2019-20.pdf

Vision
To ensure the health of newborn, reduce neonatal mortality, and stillbirths by ensuring universal
access to affordable, equitable and quality, respectful maternal and newborn health services across
the continuum of care; delivered through a resilient, equitable and responsive health system.
To achieve global goals for newborn and child heath, the four best buy interventions include: high-
quality antenatal care, skilled birth attendance (essential childbirth care), postnatal care and inpatient
care for small and sick newborns (as per national guidelines – Annex III), ensuring equity at all levels of
health care services.
Goal
To reduce neonatal mortality rate to 26/1000 live births from the baseline (41 per 1000 live births) and
stillbirths to 26/1000 live births (43.1 per 1000 live births) by scaling up universal access to quality and
cost-effective Newborn and maternal health services within a functioning and equitable health care
delivery system.
Objectives
Strategic Objective 1: Improve Primary Health Care including Home and Community based maternal
and Newborn care Practices focusing on ANC, PNC, KMC, SBCC, Nutrition, WASH and FP.
Continuous engagement with community and advocacy with stakeholders is essential for increasing
awareness and motivation among the people to bring about a social behavior change in increasing
demand for maternal and neonatal health services. Advocacy will be supported by three main
activities focusing on knowledge synthesis, partner engagement and campaigns and outreach.
To address demand for MNCH care seeking, a unified approach with consistent behavior change
messages is critical. Moreover, there is a need to educate and constantly mentor communities about
the importance of correct nutritional practices including maternal nutrition, early initiation of and
exclusive breastfeeding, delaying early marriage, birth spacing for healthier children, importance of
safe drinking water and sanitation for infection control, birth, and death registry etc. suitable actions
among all categories of stakeholders. There is strong evidence that family planning and increased
empowerment of women, especially adolescents, plus improved quality of care before, between and
during pregnancy can help to reduce preterm birth rates. The focus of sensitization and demand for
services will be to promote behavior change among the community specifically on above mentioned
areas to improve pregnancy outcomes and health of newborns. The introduction of community-
based health workers i.e. LHWs and CMWs has contributed to improvements in ANC coverage and
percentage of deliveries by a SBA.
There is a need to develop and implement human centered/rights based comprehensive Social
Behaviour Change Communication strategy, targeting specific behaviors to be delivered through
multiple channels at facility level, in the community and during home visits. Multiple factors have
prevented care seeking behavior in Pakistan, such as physical distance, cultural and sociodemographic
and economic factors, women’s autonomy, and perceptions about health care quality and attitudes
of health care providers.
Community mobilization through Mother support groups, educational sessions and using community
influencers/champions has shown to increase demand for newborn care and improve neonatal
and maternal health and mortality outcomes. At the facility level, antenatal clinics and postnatal

wards offer good platforms for offering face to face messages to mothers and families. Methods can
include interpersonal communication, traditional methods such as street plays and the use of mass
media. Mass media (radio, social media and TV) has been shown to be useful for advocacy efforts in
promoting interventions such as facility-based deliveries, early initiation, and exclusive breastfeeding.
The key strategies for achieving the objective would be;
Key Strategies
y Community empowerment and demand creation using a comprehensive SBCC strategy on
neonatal and maternal health care.
y Provision of basic family-level counseling and curative services for early management of nutritional
deficiencies among mothers & newborns, infections control, improving hygiene/sanitation, Birth
registration and FP.
y Expand availability of essential medicines, commodities, and logistics (LHW coverage and CMW
Kits)
y Create awareness among adolescent girls, pregnant women, and mothers about maternal
and neonatal risks and associated danger signs for timely identification of complications, and
promotion of healthy practices that can improve maternal and neonatal health outcomes,
hygiene and sanitation, infection control, nutritional practices and FP methods by using Key
Family Care Practices (KFCPs) of Early Childhood Development (ECD)
y Strengthen capacity of LHWs and CMWs working at the community level on home based
maternal and newborn care provision to educate community, adolescent girls and mothers, and
also provide basic maternal and neonatal health services such as ANC, birth dose (immunization),
PNC, PSBI, community KMC etc.
y Strengthen capacity of community and women’s self-help groups on RMNCHA and maternal
nutrition support
y Strengthen the use of innovative digital technologies to support home based, community and
primary health care services.
Strategic Objective 2: Strengthening of PHC and Secondary Health facilities (HR and Infrastructure)
to improve delivery of quality maternal and newborn care services.
Skilled Work force is backbone of health system that is effective in prevention and control of disease.
In addition, it’s also important to have capacitated health managers who can provide guidance for
running an effective and resilient health system. To be able to ensure delivery of quality services as
per national standards for both neonatal and maternal health, availability of required staff and skill mix
at all levels is a must. Efforts to be made to fill in the vacant positions, posting dedicated staff with
requisite neonatal skills for providing optimum care at SNCUs and NICUs. Training need assessment
to be carried out to identify the gaps and then a comprehensive in-service training plan developed
using innovative approaches to capacity building like mentorships, certifications etc. staff motivation
to be increased with incentives like P4P (pay for Performance), recognitions, opportunities for higher
trainings etc.
Another important area is equitable staff deployment between urban and rural health facilities. It
is proposed that a comprehensive Staff deployment strategy is developed ensuring staff rotations
to avoid shortages and attrition. One proposed mechanism is making PG rotation for specified time

(3months) periods to peripheral facilities, which will also provide an opportunity on mentorship of the
permanent staff posted in enhancing their skills.
To ensure delivery of quality services, it is important that the health facilities are adequate in terms of
skilled staff, infrastructure and equipment/supplies needed. Facilities, especially at the district level,
will be assessed, gaps identified, and a plan developed for phased upgradation of both infrastructure
and equipment required. It is proposed that Sick Newborn care units (SNCUs) be established, as
per national guidelines and standards, at level of district hospitals to timely and promptly manage
the complicated cases for preventing neonatal morbidity and mortality, thus reducing workload on
tertiary care and specialized institutions. It is proposed to undertake rapid assessment of the available
pediatric nursery units at the divisional/district levels using a comprehensive assessment tool developed
using the minimum standards described in the “Management of small or Sick Newborn guidelines” for
developing a comprehensive plan for strengthening and upgradation of units. The plan should be
implemented in a phased manner starting from where basic infrastructure and key human resources
are available to the districts with major gaps or no availability. The Newborn Committees/task force at
the provincial level should be made responsible for planning and oversight of implementation.
Formulation of comprehensive HRH policy in consultation with key stakeholders including provinces,
strengthening capacities for task-shifting and multi-skill development of available staff, ensuring
quality trainings and effective supportive supervision, and building the programme management
capacity of the recruits to handle technical issues like maternal and neonatal health require focused
attention.
Key Strategies
y Strengthening capacity of provincial, district and facility managers, service providers, support
staff and improving human resource availability at all facilities for provision of care to neonates,
pregnant women, and adolescent girls. Expand LHW coverage (additional LHWs to be recruited
under NHSP) across the country as per national program standards and ensure they are supported
with required kits, logistics and supplies.
y Address staff shortages, poor deployment strategies, and inequitable distribution of staff between
urban and rural areas including through partnerships with health professional associations
to enhance private-public partnership focused innovative human resource approaches and
strategies to reach most vulnerable and remote districts.
y Adapt/ update training tools to ensure that they cover the components of newborn care (as
per revised SSNC guidelines) outlined in EPHS under UHC. Tools will include reference manuals,
guides, learning check lists job aids, and orientation guides for managers.
y Recruit and retain quality staff – filling vacant posts and addressing turnover among existing
staff, ensuring competence in key skills such as neonatal resuscitation, KMC, FP, Nutrition, ECD,
sanitation and Infection Prevention.
y Improve infrastructure and supplies – ensuring every district hospital has a neonatal unit for small
and sick newborn management, BFHI, practices Kangaroo Mother Care, institutes baby friendly
facility initiative (as per revised guidelines) and managing neonatal complications.
y Strengthen the Human Resources Information System (HRIS)
Strategic Objective 3: Improve availability and equitable distribution of quality essential medicines,
medical equipment, and commodities for maternal and essential newborn care.

The existing list of essential medicines, commodities and devices will be reviewed to ensure that it
has the critical supplies needed for neonatal and maternal care and management. If required, the
list will be reviewed and updated keeping in with the national case management guidelines and
standards. Capacities of the requisite staff will be built at provincial and district levels of calculating
the needs on the bases of disease trends, utilization data and be able to quantify, estimate and
procure in line with the relevant Public Procurement Regulatory Authority (PPRA) guidelines and rules
(national and Provincial). Prioritization and definition of the list will be carried out under the guidance
of the technical experts to ensure quality procurement. The day-to day use and maintenance of the
commodities will be included in the capacity building strategy related to health workers. Procurement
and distribution of the relevant commodities will be coordinated with training of health workers in
newborn and maternal care. LMIS systems at the facility levels will be reviewed and updated as per
the approved list of commodities and supplies.
Moreover, Quality of care continues to be a significant challenge, and if there is a rapid shift to facility-
based deliveries, facilities are likely to be overwhelmed and widens the gap between demand and
supply of services, for providing which medicines, supplies and commodities play an important
and significant role. To avoid such a situation, the strategy proposes to improve both supply chain
planning, avoiding supply disruptions by improving staff capacity and provision of basic equipment at
all requisite levels of health care delivery levels.
Key Strategies
y Ensure availability and timely supply of maternal and neonatal commodities (as per National
essential and Small and sick Newborn care Units standards), supplies and drugs at all levels of
healthcare delivery system.
y Inclusion of all neonatal related medicines in the essential Medicine List and made part of LMIS
system at the facility level.
y Strengthening overall logistics supply systems for community and facility-based service delivery
to ensure continuous availability of critical supplies at all levels of health care
y Develop a procurement plan for the five years based on the lists of essential medications,
commodities and medical devices (in accordance with SSNC guidelines) list developed by the
National and Provincial Newborn Steering committee or Task Force.
y Ensure equitable distribution of the commodities as per PSM Plan with focus on less developed
districts.
y Develop and implement a plan for proper maintenance and replacement of parts for newborn
care equipment/commodities with relevant actions based on the nature of the commodity.
y Ensure particular focus on strengthening facility oxygen systems and blood transfusion services.
Strategic Objective 4: Ensure high impact neonatal and maternal health interventions focusing on
Areas/Districts in need of upgradation/strengthening for integrating and scaling up essential newborn
care services (focusing on LBW, HBB, SSNC management) at all 4 levels of health care in alignment
with UHC-BP (EPHS) roll out.
The Provinces/ICT/AJK and GB are primarily responsible for implementation of interventions and
suitable service packages (Attached at Annex II) appropriate for the level of health care level.
Considering wide inter-provincial and intra-district variation in health systems capacity and available

supporting mechanisms, a phased approach is suggested to support the provinces and districts, taking
assessed institutional capacity into cognizance. As such, the interventions have been categorized as:
In addition to setting up and operationalizing quality services for newborn and maternal care,
increasing facility births have not led to a proportional decline in the neonatal mortality in Pakistan.
Poor quality of care at birth and during the postnatal period is evident in maternal counselling, skin
to skin contact after birth and measuring weight at birth, as they are particularly low in all provinces
and regions.
To address all the above highlighted gaps the system, it is very important to integrate Newborn and
maternal health care services at all levels of health care especially improving access to quality services
at the rural level. This is being proposed under the UHC-BP of services being rolled out under the
NHSP. The UHC-BP package include the following key services to be delivered at each level of health
care delivery.
Figure 13: Twelve Categories of Essential Package of Health Services (EPHS) Interventions
RH/Birth Spacing ANC Child Care
Nutrition & ECD Delivery care NCDs
Adolsecent School Age

Neonatal Care
Health Child Health
Infectious Health Services

Post Natal Care
Diseases Access
To ensure coverage enhancement of much needed cost-effective interventions, it is imperative to

recruit, train and make skilled staff available in adequate and equitable manner for providing neonatal
and maternal care services accessible and available. The basic comprehensive EmONC and ENC
services are available in increasing number of 24/7 RHCs and 1st level hospitals. However, the situation
at Tehsil level facilities is inadequate in most of the districts, which are not optimally resourced
in terms of staffing, medicines and needed supplies. In addition, under the EPHS package to be
implemented under National Health Support Project (NHSP), it is envisaged to strengthen the health
systems through a series of interventions based on health systems building blocks.

Key Strategies
y Availability of skilled and trained health staff in neonatal nurturing care at all levels of health
service delivery.
y Adapt/ update training tools to ensure that they cover the components of newborn care outlined
in EPHS under UHC BP. Tools will include reference manuals, guides, learning check lists job aids,
and orientation guides for managers.
y Integrate services – linking emergency obstetric services with newborn care and improving
transport and referral mechanisms.
y Expand and ensure 24 hours/7 days EmONC and ENC services (Neonatal stabilization &
resuscitation area (level 1 and 2 newborn care) at all delivery facilities in all RHC and Tehsil Level
facilities.
y Strengthen referral mechanisms for management of small and sick newborns with complications.
Strategic Objective 5: Promote accountability for resources and results at all levels of health care.
Strong governance can ensure accountability and transparency in health systems. Measuring impact
of governance on newborn health outcomes is difficult, but there are processes that can be measured
for good governance, such as community participation in decision-making process, regular audits of
clinical services, deaths, and adverse outcomes.
It is important to ensure accountability at all levels for achieving results. For this purpose, it’s
important to undertake routine supportive supervision, monitoring of results and then evaluating
to see if the desired targets has been met. Supervision is critical to support implementation, ensure
that standards of care are met, and to build capacity at various levels. Monitoring is the routine
tracking of the key elements of program/project performance (usually inputs and outputs) through
record-keeping, regular reporting, and surveillance systems, as well as health facility observation and
surveys. Indicators selected for monitoring will be different, depending on the reporting level within
the health system. It is very important to select a limited number of indicators that will be used by
program implementers and managers. In addition, monitoring is used for measuring trends over time,
thus the methods used need to be consistent and rigorous to ensure an appropriate comparison.
In contrast, evaluation is the episodic assessment of the change in targeted results related to the
program or project intervention. Evaluation helps program or project managers determine the value
or worth of a specific program or project. Cost-effectiveness and cost-benefit evaluations are useful
in determining the added value of a particular program or project. Operations research will provide
information about new approaches, which will then be modified and incorporated into the overall
strategy.
Key Strategies
y Improve Coordination, management, and accountability mechanisms between various levels of
National and provincial, district and health facilities levels.
y National/Provincial RMNCH (including Newborn health) Committees /Task Forces strengthened
and made functional and empowered for regular reporting and accountable to National Steering
committee.
y Scaled up national/provincial and district capacities for improved coordination and accountability.
y Advocate for a national maternal and newborn health service charter and client rights by
mandating the National and Provincial Health Care Commissions

y Strengthen social accountability systems for quality services at health facilities including client
exit interviews and other interventions.
y Develop and implement a national guideline on institution of respectful maternal and newborn
care services.
Strategic Objective 6: Review and update the District Health Information System (DHIS2), MNCH
and LHW/CMW MIS for inclusion of key maternal, stillbirth and newborn health indicators and roll
out of Perinatal and maternal mortality surveillance systems.
Monitoring the status of newborn and maternal mortality is an important step towards improving
maternal and newborn services that require reliable, timely, and realistic data. This would essentially
require timely and routine reporting of key neonatal (LBW, infection, small or sick newborns), stillbirth
and maternal health indicators (pregnancy, delivery and post-delivery) to ascertain the causes of
complications, morbidity and mortality. This information is vital for better planning and resource
allocation (human and financial). For the purpose, key maternal, neonatal and stillbirth indicators have
been agreed for inclusion in the upcoming DHIS2. Currently being piloted in selected districts in each
province. Tracking the progress on implementation, it’s important that the key maternal, stillbirth and
neonatal health indicators are routinely reported, analyzed and reported routinely. The reports to be
submitted and discussed for appropriate actions on the national and provincial RMNCH committees/
Task Forces setting a system of accountability at all levels. Data availability for most of the SDG related
indicators is reasonably adequate in Pakistan. However, huge gaps exist for CRVS (Civil Registration
and Vital Statistics); birth weight measurement, reporting of still births and standardized measures
for determining quality of care and cohort tracking. Moreover, recording of births, cesarean sections,
maternal and newborn deaths has to be part of the routine data collection system. Data on Maternal &
Newborn Mortality can be institutionalized by mainstreaming Maternal & Perinatal Death Surveillance
and Response (MPDSR) Guidelines across all levels of health care. Extensive investment is required to
scale-up and streamline MPDSR and link these efforts with continuous quality improvement.
Key Strategies
y Develop and roll out Maternal Perinatal Death surveillance and response systems (MPDSR)
y Review and update DHIS2, MIS of IRMNCH and MNCH Programmes for inclusion of key maternal,
stillbirth and neonatal indicators
y Strengthening the routine data collection system to generate and disseminate information for
advocacy on prioritizing stillbirths and Neonatal health issues.
y Ensure reporting of perinatal/ neonatal death audits, at primary health care and health facility
level
y Support data validation and analysis meetings for improving quality at all levels.
y Undertake quarterly monitoring visits from provincial to district and Union Council levels.
y Organize annual provincial stakeholder’s meetings on newborn care.

Strategic Intervention Packages for various Levels of
Health Care
A modelling exercise conducted for the recently launched Lancet Every Newborn series assessed the
potential impact of scaling up evidence-based interventions within the health systems of the high
burden countries. These interventions have been grouped into six packages corresponding to the
various life stages of newborn. It is estimated that high coverage of available intervention packages by
2025 could prevent almost three-quarters of the newborn deaths, one-third of stillbirths, and half of
maternal deaths. The levels of care are clearly defined41 wherein, the guidance is provided on type of
quality services are to be provided to the scale at various levels of health care. Accelerated progress
for neonatal survival and promotion of health and wellbeing requires strengthening quality of care as
well as ensuring availability of quality health services for the small or sick newborn.
Essential newborn care

y All babies should receive the following:
y thermal protection (e.g., promoting skin-to-skin contact between mother and infant);
y hygienic umbilical cord and skin care.
y early and exclusive breastfeeding.
y assessment for signs of serious health problems or need of additional care (e.g. those that are
low-birth-weight, sick or have an HIV-infected mother
y preventive treatment (e.g., immunization BCG and Hepatitis B, vitamin k and ocular
prophylaxis)
y Families should be advised to:
y seek prompt medical care if necessary (danger signs include feeding problems, or if the
newborn has reduced activity, difficult breathing, a fever, fits or convulsions, jaundice in first
24 hours after birth, yellow palms and soles at any age, or if the baby feels cold);
y register the birth.
y bring the baby for timely vaccination according to national schedules.
y Some newborns require additional attention and care during hospitalization and at home to
minimize their health risks.
Low-birthweight and preterm babies:

y If a low-birth weight newborn is identified at home, the family should be helped in locating a
hospital or facility to care for the baby.
y increased attention to keeping the newborn warm, including skin-to-skin care, unless there are
medically justifiable reasons for delayed contact with the mother.
y assistance with initiation of breastfeeding, such as helping the mother express breast milk for
feeding the baby from a cup or other means if necessary.
y extra attention to hygiene, especially hand washing.
y extra attention to danger signs and the need for care; and
y additional support for breastfeeding and monitoring growth.
41 SURVIVE and THRIVE Transforming care for every small and sick newborn – WHO and Unicef guidelines

Sick newborns
y Danger signs should be identified as soon as possible in health facilities or at home and the baby
referred to the appropriate service for further diagnosis and care.
y If a sick newborn is identified at home, the family should be helped in locating a hospital or
facility to care for the baby.
Keeping the above guidelines in mind the following maternal and newborn services are proposed to
be provided at various levels of health care are given below;
TABLE 6: Inpatient care for small and sick newborns: requirements for care at different health system levels
Levels of Care Strategic Aim Type of maternal and Neonatal services
Level I Raise communities’ y Community health workers should understand the

awareness of essential causes of hypothermia and know how to prevent
Home newborn care, danger this and can advise families appropriately.
Based and signs in pregnancy and y Educate and promote skin to skin contact (KMC)
Community newborns, appropriate y Promote Exclusive breast Feeding.
Care: action and reduce y Cord care
incidence of harmful
y Promoting hygiene practices
traditional practices
y Greater care and support of high-risk babies such as
through promotion of
LBW,
SBCC by CMWs/LHWs,
mothers’ groups and
y Early detection of Pneumonia and Sepsis and referral
to first level of care
other influencers.
y ANC services
Develop skilled attenders’ y Management of Anaemia
abilities to mobilize the y Birth preparedness
assistance of non-formal y Identification of danger signs in pregnancy and
care givers for neonatal newborns and timely referrals
care. y Maternal Nutrition
y Skilled attendants should be able to resuscitate
a baby asphyxiated by simple stimulation and
ventilation with mouth to mask.
y Skilled/trained health workers should provide post-
natal contacts at home within;
y 24/48 hours,
y Again within 6 days, and
y Again at 6 weeks at HF
y All CMWs should give breastfeeding advice and
support including early initiation and exclusive
breastfeeding.

y Skilled and trained health workers should provide

home based management of simple infections.
(Penicillin eye drops prepared at health facility, or of
tetracycline or chloramphenicol eye ointment for
eye infection; half strength (0.25%) Gentian violet
for oral thrush; gentian violet or Betadine solution
for skin infections and treat umbilical infections by
drying and adding Neosporin powder).
y CMWs should be included in pilot projects to
identify neonatal infections at home and if successful
could be trained to provide this service. This will
include home-based treatment with antibiotics such
as Cotrimoxazole/referral by first level care providers,
use of intramuscular injection Gentamicin (for use
by CMWs) or other appropriate oral antibiotics by
LHWs and CMWs. Other arrangements for treatment
may be considered as well.
y All LHWs should recognize danger signs and refer to
the appropriate level of care.
y LHWs should be supported to identify and provide
home care for >1800g, non-sick, suckling LBW
newborns and immediate referral of sick, non-
suckling >1800g LBW or any newborn<1800g.
y LHWs should promote birth and death registration.
A linkage chain should be established among
community level workers to notify stillbirths and
neonatal deaths

Level - II Develop and strengthen All of the above plus

facilities for maternal and y Conduct normal/uncomplicated deliveries and
Primary newborn care. Provide resuscitate newborn with Ambu bag and mask when
Health necessary.
full ANC and PNC.
Conduct clean and safe y Immediate newborn care (thorough drying, skin-
to-skin contact of the newborn with the mother,
Care Centres deliveries; offer essential delayed cord clamping, hygienic cord care)
newborn.
y Neonatal resuscitation (for those who need it -
BHUs/RHCs Manage newborns having birth asphyxia.
Care services, all health y Early initiation and support for exclusive
Essential breastfeeding; routine care (Vitamin K, eye care and
newborn care Staff conducting vaccinations, weighing and clinical examinations)
Feeding of non-sick LBWs with spoon or tube feeding
deliveries to be
competent in basic y Management and referral of bacterial infections
- treating new-born infections with appropriate
resuscitation using ambu antibiotics.
bag and mask. Staff y prevention of mother-to-child transmission of HIV;
able to recognise sick assessment
newborns and manage y management and referral of bacterial infections,
and refer to next level jaundice and diarrhea, feeding problems, birth
of care according to defects and other problems.
protocols. y pre-discharge advice on mother and baby care and
follow-up.
y Monitor and supervise level-I newborn care
activities.
y Staff seconded from level-III to provide on the job
training and mentorship for staff working at level-II
facilities (short term).

Level - III: Develop and strengthen All the above, plus:– Level III Neonatal care at THQs and
facilities for maternal DHQs (Annex IV).
THQs and and newborn care. Offer y Manage deliveries that might be anticipated to be
DHQs complicated and resuscitate with safe administration
complete newborn care
of oxygen
services with diagnosis
y Thermal care; comfort and pain management
Special and management of sick
newborn care y Kangaroo Mother care (KMC), Helping Baby Breathe
newborns. All health staff
(HBB) technique or other culturally appropriate
conducting deliveries to methods to manage non-sick pre-terms
be competent in basic y kangaroo mother care
resuscitation using an y assisted feeding for optimal nutrition (cup feeding
Ambu bag and mask with and nasogastric feeding)
intubation available from y prevention of apnea
specially trained staff. y detection and management of neonatal infection
y detection and management of hypoglycemia,
Develop technical, jaundice, anemia and neonatal encephalopathy
clinical and audit backup y I.V. therapy, phototherapy, provision of warming
from central specialists. devices for neonatal beds
y seizure management; safe administration of
intravenous fluids
y Basic lab services–Hb., TC, DC, blood grouping,
bilirubin, CSF cell count
y Accept in coming referral of LBW neonates,
neonates with feeding problems, serious sepsis, and
congenital abnormalities.
y Transition to intensive care: continuous positive
airway pressure; exchange transfusion; detection
and management of necrotizing enterocolitis;
specialized follow-up of infants at high risk (including
preterm)
y Detection and referral management of birth defects
and anomalies.
y Proper incubator care
y Exchange transfusion
y Management of preterm newborns.
y Cardio-respiratory monitoring
y Link up with Level-III and IV cares for referral of
appropriate cases of sick new-borns.
y Staff seconded from level-IIA to provide on the job
training for staff working at level-IB facilities (short
term).
y Perinatal and neonatal death audit
y Establish and operationalize Nurseries/Sick Newborn
Units as per national guidelines

Level – IV A: Establish, upgrade and All the above plus (Level III Neonatal Care - NICU)
strengthen physical
Tertiary infrastructure of health y Diagnosis and management of complicated neonatal
medical as well as surgical problems
Level/ facilities for provision
Teaching of quality maternal and y Mechanical Assisted ventilation, including intubation
Hospital newborn services. y Advanced feeding support (e.g. parenteral nutrition)
Intensive Establish, and strengthen y Surfactant treatment

newborn care a pool of technical and y Investigation and management of birth defects
clinical specialists for
y Advanced neonatal monitoring.
providing support to level
II and III health facilities. y Advanced lab services–blood gas estimation
available.
Develop communications y Advanced imaging services.
with peripheral
facilities and improve y Pediatric surgery; genetic services.
management and referral y Screening and treatment for retinopathy of
system. prematurity
y Short term rotation by staff working at level IV
Train and provide on job to provide on the job training for staff working at
trainings for MOs, Nursing levels-II and III facilities.
staff, gynaecologists/
Paediatricians at level-III
facilities
y Establish linkage with lower levels of care for proper

and efficient management and transfer of sick
newborns requiring level-III care.
y Establish NICU as per National standards and
guidelines

Level – IV B: Establish, upgrade and All the above plus (Level IV – Regional NICU)
strengthen physical y Diagnosis and management of complicated neonatal
Specialized infrastructure of health medical as well as surgical problems
Care facilities for provision y Mechanical Assisted ventilation (Ventilators)
Hospitals of quality maternal and including intubation.
newborn services. y Advanced feeding support - Parenteral nutrition
Intensive y Advanced neonatal monitoring.
newborn care Provide linkages with y Advanced lab services–blood gas estimation
technical, clinical and available.
audit backup services by y Advanced imaging services.
specialists to district and y Screening and treatment for retinopathy of
Tehsil level facilities. prematurity
y Surfactant treatment;
Develop communications y Investigation and management of birth defects and
with District facilities and anomalies;
improve management y Pediatric surgery;
and referral system. y Genetic services.
y Short term rotation by staff working at level VI to
provide on the job training and mentoring to staff
working at level-III facilities.
y Establish linkage with lower levels of care for proper
and efficient management and transfer of sick
newborns requiring level-IV care.
y Establish NICU (Details at Annex)
Source: the details of services have been derived from the SURVIVE and THRIVE Transforming care for every small
and sick newborn guidelines.
These interventions have been grouped into six packages corresponding to the various life stages of
newborn. It is estimated that high coverage of available intervention packages by 2028 could prevent almost
three-quarters of the newborn deaths, one-third of stillbirths, and half of maternal deaths. The packages
with the greatest impact on neonatal mortality (in decreasing order) include: (Attached at Annex -V)
1. Pre-conception and Antenatal care (care of caregivers)

2. Care during Labour and Childbirth
3. Nurturing Care of Small and Sick newborn
4. Nurturing Care of Healthy Newborn especially in the first week,
5. Healthy Newborn Care and Breastfeeding
6. Post-natal care

Implementation – Guiding Principles
The implementation of the Newborn survival strategy will be based on and guided by the following
principles;
i. Ownership, leadership, and accountability – National, Provincial and District

ii. Equity and Accessibility – Zero dose communities and rural and remote districts
iii. Community engagement, empowerment, ownership and responsiveness to community
needs–CommunityHealthWorkersandHome-BasedCare
iv. Integration – maternal nutrition; early initiation of breastfeeding; nurturing care, WASH and
gender
v. Partnership – Women’s groups; Health Professional Associations; Private Sector
vi. Low-cost high impact-effective interventions – KMC; PSBI; ANC; ENC
vii. Efficient use of resources
viii. Evidence based decision-making
ix. Quality and continuum of care
x. Respectful care and Social Accountability Frameworks
The Newborn Survival Strategy aims to accelerate the reduction of stillbirths, maternal and newborn
mortality with the aim to near achieve SDG 3.2.2 targets. It should be implemented jointly by all
stakeholders as a multi-sectoral strategy for comprehensive reproductive, maternal, neonatal and
child health care.
Good governance is a critical element for successful implementation of the strategic plan, right
from central level to the grass root level. Good governance is participatory, consensus-oriented,
accountable, transparent, equitable, and follows the rule of law. It assures that corruption is minimized,
and voices of the most vulnerable in society are heard in decision making.
The National Newborn Survival Strategy will be implemented in collaboration with relevant
stakeholders, which include related Ministries and agencies, development partners, the civil society,
community-based organizations, professional associations, faith-based organizations, voluntary
agencies, and the private sector, among others.

Roles and Responsibilities at Different Levels of Health System
MONHSR&C y Mobilize resources and advocate with policy makers, donors
and UN agencies for coordination of policy guidelines for
reduction of maternal, newborn deaths.
y Liase and Coordinate with Line Ministries
y Provide Technical and strategic Guidance – National Steering
Committee
y Responsible for overall technical leadership, guidance and
advice on the implementation and monitoring of the strategy.
y Develop a legislative framework for prioritization of newborn
health at all levels of policy and implementation.
y Review, adapt and develop standards and Guidelines
Provides policy guidance for strengthening neonatal health

Health Policy and
based on existing evidence for the effectiveness of a variety of
Strategic Planning Unit
interventions.
Health Departments y Mobilize resources and advocate for reduction of maternal,

newborn deaths. It will also be responsible for the overall
operational technical leadership, guidance and advice on the
implementation and monitoring of the strategy.
y ensure adequate budget allocation for RMNCH and
mainstreaming of RMNCH indicators into policy frameworks.
y ensure availability of essential drugs, supplies, equipment
and diagnostics by facilitating efficient procurement and
distribution to all levels of service delivery
y to review and update pre- and in-service curricula to ensure
relevant issues on MNCH are adequately addressed
y promote accelerated training of mid-level cadres in order to
increase the available number of skilled health workers, and will
facilitate effective development, recruitment and deployment
of skilled health workers at health units to address the human
resource issues
y Advocate for the implementation of the Newborn Survival
Strategic plan by coordinating advocacy activities with
stakeholders

y Involve and collaborate with various stakeholders at all levels for
planning and implementation of the Strategic Action Plan
y Facilitate capacity development at provincial, district and
PHC levels by developing protocols and training packages for
essential newborn care
y Design and develop communication materials as per
recommendations of the SBC strategy and disseminate them
to the intended users
y Identify and propose disaggregated indicators and update
monitoring data collection tools to include process indicators
for EmONC, newborn care, nutrition, and postnatal care
y Review and harmonize MNCH and LHW programmes MIS with
the DHIS in districts health offices
y Promote research on Maternal and newborn health including
FP and nutrition.
y Disseminate the Newborn Survival Strategic Plan to all districts.
y Support capacity development in maternal and essential
newborn care in the districts
y Conduct and build research capacity at the department and
districts.
District Health Offices y Disseminate MNCH Strategic Plan to all stakeholders in the
district including NGOs, UN organizations and other private
sector partners.
y District Health offices to ensure adequate resource allocation
in the budgets for implementation and monitoring of the
maternal and newborn care interventions.
y •Incorporate newborn survival action plan activities into the
District Health Plans
y Coordinate and supervise all maternal and newborn care
activities planned and implemented by all stakeholders in the
district.
y Coordinate and arrange technical support for staff development
to provide quality maternal and essential newborn care services.
y Capacity development for facility and community-based
health providers on maternal and essential newborn care
interventions
y Follow up on implementation of maternal, perinatal, neonatal

and child death reviews at health facility (dispensaries, health
centers, district hospitals, as well as voluntary agencies and
private hospitals) and community levels.

Health Facility y Incorporate maternal and newborn care activities into facility
health plans.
y Provide quality and respectful maternal and newborn care
services.
y Ensure timely availability of essential equipment, supplies and
drugs for service maternal and newborn care provision.
y Conduct maternal, perinatal, neonatal and child death reviews,
involving the community.
y monitor and ensure quality maternal and newborn care service
provision.
y Provide technical and supportive supervision to community
based maternal and newborn care interventions.
y Ensure social accountability for maternal and newborn health
services and respond to client needs.
y Establish and operationalize Primary Care Management

Committees (PCMCs) and health facility in charge will be
responsible for supervision and implementation of MNCH
activities in their areas.
y Facilitate monitoring of community-based interventions of the
maternal and newborn action plans.
Community
y Mobilize the community to participate in community
inter ventions.
y Establish and/or strengthen community-based support groups
for mothers, fathers, and community influentials.
y Leverage community resources for the implementation of
maternal and newborn interventions.

MONITORING & EVALUATION
Successful implementation of the newborn and child survival strategy will rely on robust Monitoring
and Evaluation system, which will be an integral part of the strategy. Continuous monitoring
of progress and evaluation of outcome and impacts will provide an evidence-based decision for
effective, efficient and synergistic implementation of programs. Moreover, it will be integrated into
knowledge management efforts that will help document lessons and sharing of experiences both
nationally and to international arena.
The M&E framework for national Newborn Survival Strategy will be linked with SDGs and UHC
related supervision, monitoring and evaluation activities for a comprehensive holistic approach. The
Strategy will use existing monitoring systems but will ensure inclusion of neonatal and maternal health
indicators to ensure that there is adequate information available for specific neonatal interventions.
While it is beyond the scope of this Strategy document to outline a full monitoring and evaluation
plan, a technical working group should review existing monitoring information, and recommend
changes related to neonatal interventions.
Periodic reviews should be done to identify best practices, more effectively address obstacles, strengthen
the partnership approach and accelerate progress in the implementation of this Strategy. Quality
assurance should be an integral part of the implementation of the Strategy at all levels. A comprehensive
monitoring and evaluation plan, including indicators for measuring progress must developed considering
the existing information and monitoring systems for maternal and neonatal health. Appropriate systems
need to be developed to ensure data quality, processing, and optimum use for decision-making.
Building strong monitoring, evaluation and knowledge management system requires effective
partnership and coordination among various units within the MNSR&C as well as with national and
international health development partners. In this regard, the National Task Force and RMNCH
Steering Committee under the leadership of the MNHSR&C should lead the coordination of partners
involved in newborn and child health in at national and provincial levels. As some of the newborn
and child health interventions are very much intertwined with maternal health interventions there
should be strong integration of the partners working on newborn/child health and maternal health.
In addition, the National Task Force will work closely with the Health Policy Strategic Planning Unit
(HPSIU), Health Services Academy and other agencies engaged in health systems research to ensure
there is regular measure of the progress made in the implementation of the strategy.
The newborn and child survival interventions adopted by the strategy (Annexure II) and, selected
indicators outlined for monitoring the progress of implementation of the strategy (Operational Targets)
provide guidance for action and accountability at all levels within the health system. Upcoming DHIS2
system will be strengthened, as it will be the main source of data for routine tracking of performance
of most of the interventions listed in the strategy. The MNCH and IRMNCH MIS will need to be
updated to reflect the new high impact interventions and used to track progress made by provinces
and districts to track performance with emphasis on ensuring equity in access and use of high impact
newborn and child survival interventions.
A set of high-priority indicators and operational targets will be objectively measured (Table …) and used
for monitoring and evaluation purposes, to understand the scale and outcomes of implementation;
and will be used for evidence-based decisions. The monitoring and evaluation of activities is broadly
divided in two: regular performance tracking system and operations research, studies and evaluation.

Table 7: Key monitoring Indicators
Key Interventions
Level of health
Continuum of
Care Delivery
Data Sources
Care Level
Indicators
Baseline
Targets
S. No.
- Nutrition All 4 levels of - % reduction in 37% 25% - PDHS

health care Stunting among
- Infection - NNS
including adolescent girls
Prevention
community - Baseline to be 75% - DHIS
Adolescents
- No. facilities
- WASH established
practicing infection - MICS
1
- Deworming control as per national
guidelines
- Social Protection - Baseline to be
- No of facilities with >80%
(Prevention of early established
marriage) clean water supply and
toilets
- DHIS
Pregnancy
- PDHS
- Family Planning
Pre-
2 - All 4 levels -mCPR 48.2% >60% -

(mCPR)
Programme
data
-Focused ANC (4/ - All 4 levels - ANC by SBA for 4 + -52.2% >80% - DHIS
more visits) of health visits
68% - PDHS
care
-Iron Folate - 30% reduction in Iron
60% of secondary - MICS
Supplementation deficiency Anemia
and tertiary
48% - Malaria
- Antenatal -Hospital - baseline to be hospitals
MIS
Corticosteroids for level (Sec. established
>90%
preterm labor and Tertiary)
Pregnancy
79%
3 -Tetanus Toxoid - all levels of
- % of women having
immunization during health care
access to ITNs during
pregnancy (2 doses)
pregnancy
-ITNs for pregnant
women (in malaria
endemic areas)
-Antenatal
Corticosteroids for
preterm labor
-Skilled attendance All levels of - SBA Attended 69% >80% -DHIS

at birth Health Care deliveries
To be established 60% -HRMIS
- Essential Newborn - No of facilities having from
No data -IRMNCH
care (ENC) skilled staff providing baseline
and MNCH
ENC 62.1%
- No. of facilities MIS
with operational - No of facilities with 19.6
-NADRA
SSNCUs functional SSNCUs of
53% database
post-natal visits within
Birth and post-natal care
- Postnatal visit
48 hrs after delivery
for mothers and
newborns within 48 - all 4 levels of health
hours care
4
- Screening - No of neonatal Sepsis
for congenital cases with antibiotics
anomalies
-all 4 levels of health
- Antibiotics for care
neonatal Sepsis
-all levels of health care
- Early initiation
- No of births
of breastfeeding
registered with NADRA
(within 1 hour of
birth)
- Birth dose
- Birth Registration

6
5
S. No.
% of facilities providing % of facilities providing Continuum of

CEmONC services BEmONC Services Care Level
Key Interventions
Level of health
Care Delivery
Indicators
NATIONAL NEWBORN SURVIVAL STRATEGY AND PLAN OF ACTION

Baseline
Targets
Data Sources
73
Annex

Annex I
A AJK Consultation (August 2022)

1. Dr. Farhat Shaheen Deputy Director Health Services/Coordinator MNCH
Program
2. Dr. Yasmin Abdullah UHC Coordinator, AJK
3. Dr. Shafaq Assistant Director M&E LHW Programme
4. Ms. Komal Bokhari Director Health Education
5. Dr. Samia Rizwan Health Specialist Unicef Islamabad
6. Dr. Asma Bokhari Consultant UNICEF
7. Dr. Moazzzam Khalil Consultant UNICEF
B Balochistan Consultation (August 2022)

1. Dr. Sarmad Saeed Khan Deputy Program Manager, MNCH Program
2. Dr. Mohammad Ismael Senior Pediatrician, PPA Quetta
3. Dr. Rohana Salam Assistant Prof. Dept of Obs & Gyna, BMC, Quetta
4. Dr. Grahnaz Mengal Consultant Gynecologist, SGOP Quetta
1. Dr. Rubeena Mengal MCH Program Balochistan
2. Dr. Asfandyar Sherani Head of Sub Office WHO
3. Dr. Syed Tahir Ali Health Officer Unicef Balochistan
4. Dr. Samia Rizwan Health Specialist Unicef Islamabad
6. Dr. Moazzzam Khalil Consultant UNICEF
7. Dr. Nabila Health Manager Unicef
C Punjab Consultation (July 2022)

1. Dr. Khalil Ahmed Project Director IRMNCH
2. Dr. Zulfiqar Ali Additional Director IRMNCH program
3. Prof. Khawaja Irfan Waheed Neonatologist
4. Dr. Samia Rizwan Health Specialist Unicef
5. Dr. Saira Khan Unicef, Punjab
6. Ms. Mashaal Pervaiz Khan Nutritionist, IRMNCH
7. Dr. Naila Shahid Unicef, Punjab
8. Dr. Khurram Khan Program Manager JICA, Punjab
10. Ms. Abida Consultant
11. Ms. Kausar Tasneem DG Nursing Punjab

12. Prof Dr. Tayyaba Wasim HOD Obs and Gyane
13. Dr. Farrah Haroon Associate Prof. Pediatrics, UCHS, Lahore
14. Dr. Asif Nazir HOD,
15. Dr. Zohaib Hassan Deputy Director IRMNCH, Punjab
16. Dr. Robina Sohail SOGP, Punjab
17. Dr. Sikandar AP of Pediatrics, UCHS, Lahore
D KP Consultation (July 2022)

1. Dr. Shaheen Afridi Director General Health Services KP
2. Dr. Sahib Gul ADG Admin, Program Coordinator MNCH program
3. Dr. Saeed ur Rehman Provincial Coordinator LHW Program
4. Dr. Fazal Majeed Director Nutrition
5. Dr. Hidayat Ullah Director Operations, Integrated Health Project
6. Dr. Tanveer Inam Deputy Director MCH
7. Dr. Shandana Sarir Deputy Director MCH
8. Dr. Hameed Bangash Paediatrician Khyber Teaching Hospital
9. Dr. Samia Rizwan Health Specialist UNICEF
10. Dr. Imran Ali Health Officer UNICEF
11. Dr. Nosheen Khan Health Officer UNICEF
12. Dr. Mazhar Khan NPO – WHO
E Islamabad Consultation (14-15 June 2022)

1. Dr. Fazal Majeed Director Nutrition, KP
2. Prof. Dr. Amin Jan PPA, KP
3. Dr. Hafeez Mengal Director Nutrition, Balochistan
4. Dr. Jamal Raza Executive Director SICHN and PPA President
5. Mr. Mushtaque Somroo Assistant Registrar, Pakistan Nursing Council
6. Prof. Dr. Irfan Waheed PPA, Punjab
7. Prof. Dr. Rubina Sohail SOGP, Punjab
8. Dr. Sikandar Associate Professor, Govt of Punjab
9. Dr. Wasal Nutrition Specialist UNICEF
11. Dr. Zazan Shahid National Coordinator MNCAH&N, Nutrition International
12. Dr. Fahad Samo Deputy Director MNCH, Sindh
13. Dr. Farhat Shaheen Regional Director MNCH, AJK
14. Ms. Mishaal Pervaiz Programme Officer IRMNCH Programme, Punjab
15. Dr. Asma Badar Nutritionist, WPF

16. Dr. Shandana Sarir DP MNCH, KP
17. Ms. Samra Hanif IMO UNICEF
18. Dr. Nabila Zaka Health Manager UNICEF
19. Dr. Khawaja Masoud Ahmad National Coordinator Nutrition and NFA, MoNHSR&C
20. Dr. Kamran Elahi DPC LHW Programme, Balochistan
21. Dr. Masood Jogezai Consultant/Public Health Specialist, ICT
22. Ms. Musarrat Rani Midwifery Association of Pakistan, Islamabad
23. Dr. Gul Afshan Khan Consultant Gynecologist, Maroof International, Islamabad
24. Dr. Samad S. Khan Deputy Director MNCH Programme, Balochistan
25. Dr. Asif Khan Niaz Deputy Director IRMNCH Programme, Punjab
26. Dr. Ayesha Shiraz Senior Fellow NIPS, Islamabad
27. Dr. Syeda S. Associate Professor and HOD, PIMS, Islamabad.
F Islamabad Consultation (May 2022)

1. Dr. Asheber Gaym Health Specialist UNICEF ROSA
2. Dr. Kazutaka Sekine Health Specialist UNICEF ROSA
3. Dr. Nabila Zaka Health Manager UNICEF Islamabad
4. Dr. Naila Shahid Health Officer UNICEF Punjab
5. Dr. Naila Yasmeen UNFPA
6. Dr. Shabina Arif AKU, Sindh
7. Dr. Amir Akram Health Specialist UNICEF Balochistan
8. Dr. Ghazala Ahsan Health Officer UNICEF Islamabad
9. Dr. Saira Khan Health Officer UNICEF Punjab
G Islamabad Consultation (Oct 2022)

1. Dr. Baseer Achakzai Director Programmes, MoNHSR&C
2. Dr. Fazal Majeed Director Nutrition, KP
3. Prof. Dr. Amin Jan PPA, KP
4. Dr. Hafeez Mengal Director Nutrition, Balochistan
5. Dr. Khalid shaikh PPA General Secretary, Karachi
6. Mr. Mushtaque Somroo Assistant Registrar, Pakistan Nursing Council
7. Prof. Dr. Irfan Waheed PPA, Punjab
8. Prof. Dr. Rubina Sohail SOGP, Punjab
9. Dr. Sikandar Associate Professor, Govt of Punjab
10. Dr. Wasal Nutrition Specialist UNICEF
12. Dr. Zazan Shahid National Coordinator MNCAH&N, Nutrition International

14. Dr, Sahib Jan Badar AAP Sindh
15. Dr, Farhana Memon Additional Director MNCH, Sindh
16. Dr. Farhat Shaheen Regional Director MNCH, AJK
17. Ms. Mishaal Pervaiz Programme Officer IRMNCH Programme, Punjab
18. Dr. Asma Badar Nutritionist, WPF
19. Dr. Shandana Sarir DP MNCH, KP
20. Dr. Nabila Zaka Health Manager UNICEF
21. Dr. Khawaja Masoud Ahmad National Coordinator Nutrition and NFA, MoNHSR&C
22. Dr. Masood Jogezai Consultant/Public Health Specialist, ICT
23. Ms. Musarrat Rani Midwifery Association of Pakistan, Islamabad
24. Dr. Syeda Batool Gynecologist, SOGP, Islamabad
H. Karachi Consultation (12th December 2022)

1. Dr. Khalid shaikh PPA General Secretary, Karachi
2. Dr. Jamal Raza Executive Director SICHN and PPA President
3. Prof. Dr. Tazeen Abbas SOGP, Punjab
4. Dr. Kamal Asghar Health Specialist UNICEF, Sindh
5. Dr. Farhana Memon Additional Director MNCH, Sindh
7. Dr. Sahib Jan Badar AAP Sindh
I. Team of Consultants
1. Dr. Asma Bokhari Team Lead
2. Dr. Moazzam Khalil
3. Mr. Wahaj Zulfiqar Costing Consultant

Annex II
Intervention Packages for Continuum of Care for Maternal

and Newborn Survival
A. Home based and Community care - Pre-conception and Antenatal care (care of caregivers)
1. Reproductive Health & Family Planning

1. Adolescent reproductive health
2. Delaying age of marriage and first pregnancy – prevent unintended pregnancies especially
during adolescence
3. Birth spacing
4. Screen for, diagnose and manage chronic diseases, including diabetes and hypertension.
5. Screen for and prevent RTIs/STIs including HIV and TB
6. Promote vaccination of children and adolescents g
2. Nutrition related interventions

1. Balanced energy protein supplementation
2. Pre-conceptional folic acid
3. Maternal calcium supplementation
4. Micronutrient supplementation (Iron, Folic Acid & Iodine)
5. Nutrition Counselling
3. Counselling & birth preparedness
4. Prevention against Malaria
B. Care During Pregnancy-Promote ANC for all women
At BHU and RHC Levels (PHC)

1. Antenatal screening for Anemia and Hypertensive disorders of pregnancy (PIH, Pre-
eclampsia, Eclampsia)
2. Antenatal screening for Malaria
3. Prevention and management of mild to moderate anemia
4. Maternal tetanus immunization
5. Adolescent friendly health services (nutrition and reproductive health counselling)

At THQ and DHQ Hospitals
1. Antenatal screening & management of Severe anemia, Hypertensive disorders of pregnancy
(PIH, Preeclampsia, Eclampsia), Gestational Diabetes, Syphilis
2. Antenatal screening & management of Hypothyroidism, Hepatitis B, HIV, Malaria
3. Post-partum family planning services including IUCD insertion.
C. Care during Labour and Childbirth

1. Skilled birth attendance
2. Clean birth practices
3. Identification of complications and timely referral
4. Pre-referral dose
- Antenatal corticosteroids in preterm labour
- antibiotics for premature rupture of membranes
5. Emergency obstetric care

- Basic and Comprehensive
6. Management of preterm labour

- Antenatal corticosteroids in preterm labour
- Antibiotics for premature rupture of membranes
D. Essential Newborn Care

1. Delayed cord clamping
2. Interventions to prevent hypothermia.
a. Immediate drying
b. Head covering
c. Skin-to-skin care
d. Delayed bathing
1. Early initiation and exclusive breastfeeding

2. Hygiene to prevent infection
3. Vitamin K at birth
4. Neonatal Resuscitation (assisted) and referral to next level of care
5. Advanced neonatal resuscitation (Mechanical)
E. Nurturing Care of Small and Sick newborn

1. Thermal care and feeding support (for home deliveries)
2. Integrated management using IMNCI and use of oral antibiotics
3. Injectable Gentamicin for sepsis (level II)

i. Pre referral
ii. Completion of antibiotic course in case referral is refused / not possible “OR” as
advised by treating physician
1. Kangaroo mother care at facility [
2. Full supportive care at Tehsil level (Level III)
3. SNCU at district level (Level III)
4. Intensive care services (NICU) at level IV(A) for
i. Assisted ventilation
ii. Surfactant use
iii. Surgery
F. Post-natal care
1. Screening for birth defects, failure to thrive and developmental delays
2. Follow up visits of
i. SNCU discharged babies till 1 year of age
ii. small and low birth weight babies till 2 years of age
iii. Newborn screening
iv. Management of birth defects
y Diagnosis - Treatment, including surgery
y Follow-up of high-risk infants (discharged from SNCUs, and small newborns) for
monitoring
» Developmental delay
» Appropriate management

ANNEX III: Levels of Neonatal Care
LEVEL CAPABILITIES STAFF EQUIPMENT
Level-I y Well newborn y Pediatricians y Infant warmers

nursery y Family physicians y Neonatal
(Basic
y Evaluation & y Nurses incubators
Neonatal
postnatal care of y Infusion pumps
Care)
healthy newborns
y Syringe pumps
y Stabilize & provide
care for infants y Equipment
born 35 – 37 for neonatal
Tehsil
weeks gestation resuscitation
Headquarter
Hospitals who remain y Phototherapy
physiologically units
stable y Regular oxygen
y Neonatal flow meters
resuscitation y Low flow oxygen
y Stabilization meters
and short-term y Pulse oximeters
ventilation (non-
y NIBP monitor
invasive & invasive)
of ill newborns until y Medicine trolleys
transfer to higher y Drip stands
level
y Central oxygen
supply/cylinders
y X-ray viewer
y Glucometer
y Bilirubinometer
y Suction
equipment
y Neonatal
ventilator
y High flow therapy
and CPAP
machine

Level-II Level – I capabilities y Pediatricians Level – I equipment

PLUS: y (with PLUS
(Special Care y Provide care for neonatology y Portable x-ray
Nursery) infants born >32 machine
experience)
weeks gestation y Family physicians y Blood gas analyzer
& wt >1500 g who
are physiologic y Neonatal nurse
District practitioners
immaturity or who
Headquarter
are moderately ill
Hospitals
with problems that
are expected to
resolve rapidly and
not anticipated to
need subspecialty
services on urgent
basis
y Provide care for
infants convalescing
after intensive care
y Provide mechanical
ventilation for brief
duration <24 hours
y Provide CPAP,
high flow oxygen
therapy or both
y Stabilize infants
born <32 wk
gestation & wt
<1500 g until
transfer to NICU
facility

Level-III Level – II capabilities y Neonatologists Level – II equipment

PLUS y Neonatal nurse plus
(Neonatal
y Provide sustained practitioners y HFOV
Intensive
life support y Pediatric medical y Invasive blood
Care Unit
(NICU) y Provide subspecialists pressure monitors
comprehensive care y Pediatric y Nitric oxide
for infants born <32 anesthesiologists y Ultrasound
wks gestation &
y Pediatric machine
Tertiary care wt <1500 gms and
infants born at all surgeons y Echocardiography
Hospitals/
Teaching gestational ages and y Pediatric machine
Hospitals birth weight with ophthalmologists y Point of care lab
critical illness facility
y Provide prompt
and readily available
access to full range
of pediatric medical
subspecialists,
pediatric surgical
specialists, pediatric
anesthesiologists
and pediatric
ophthalmologists.
y Provide full range of
respiratory support
that may include
conventional and/
or high frequency
ventilation and
inhaled Nitric Oxide
y Perform advanced
imaging with
interpretation
on an urgent
basis including
CT, MRI and
echocardiography

Level-IV Level – III capabilities Level – III healthcare Level-III equipment

PLUS provider PLUS PLUS
(Subspecialist
y Located within y Pediatric surgical y ECMO
Neonatal specialists
an institution y Neonatal
Intensive
with capability to transport system
Care)
provide surgical Ambulance
repair of complex
congenital or
acquired conditions
Specialized
Neonatology y Maintain a full range
units of pediatric medical,
surgical and
anesthesiologists at
the site
y Facilitate transport
and provide
outreach education

Annex IV: New born Survival Strategy Costing
Strategic objective Year 1 Year 2 Year 3 Year 4 Year 5 Year 1-5

Ensure effective
universal coverage of
high impact neonatal
and maternal health
interventions especially
for poorest and
marginalized sections
of the population
focusing on Areas/
37,368,488 56,472,654 35,802,419 64,338,911 41,490,802 235,473,274
Districts requiring
equitable development
by integrating and
scaling up essential
newborn care services
(including KMC, SSNC)
at all 4 levels of health
care aligning with UHC
roll out
Ensure quality
Neonatal health
service delivery by
454,659,716 3,996,657,915 4,369,346,757 4,802,875,014 5,280,433,433 18,903,972,835
strengthening human
resources for health
and Infrastructure
Improve availability and
equitable distribution
and maintenance
of quality essential
medicines, medical 56,439,500 15,496,250 3,961,540 1,876,710 2,064,381 79,838,381
equipment, and
commodities for
maternal and Essential
Newborn Care
Improve Home and
Community based
Newborn care
97,773,800 84,430,720 78,307,812 86,198,222 94,818,044 441,528,598
Practices focusing on
KMC, SBC, Nutrition,
WASH and FP
Promote accountability
for resources and
840,000 2,831,400 1,016,400 3,425,994 1,229,844 9,343,638
results at all levels of
health care
Review and update
the District Health
Information System
(DHIS2), MNCH and
LHW/CMW MIS
24,348,500 112,181,300 120,703,550 72,956,103 99,211,076 429,400,529
for inclusion of key
newborn indicators
and roll out of Perinatal
and maternal mortality
surveillance systems
Contingencies 24,667,820 27,134,602 29,848,062 32,832,868 36,116,155 150,599,508
Grand Total 696,097,824 4,295,204,841 4,638,986,540 5,064,503,823 5,555,363,736 20,250,156,764

Province Year 1 Year 2 Year 3 Year 4 Year 5 Year 1-5
AJ&K 24,701,233 35,692,614 37,628,375 37,229,176 41,827,625 177,079,022
Balochistan 78,783,347 110,463,324 117,344,232 115,140,423 130,527,742 552,259,067
Federal 164,757,636 3,578,960,903 3,870,260,409 4,279,980,675 4,676,044,525 16,570,004,149
GB 32,122,633 43,620,754 46,252,529 46,402,960 51,940,749 220,339,624
KP 103,862,164 138,470,521 148,717,823 151,780,973 170,250,368 713,081,849
Punjab 190,980,897 252,314,193 273,062,563 285,192,757 317,969,635 1,319,520,045
Sindh 100,889,914 135,682,532 145,720,610 148,776,859 166,803,092 697,873,007
Grand Total 696,097,824 4,295,204,841 4,638,986,540 5,064,503,823 5,555,363,736 20,250,156,764
Cost Centre Year 1 -5
1.1 Meeting/Advocacy/Workshop 3,517,907,432
2.1 TA Consultant Fee 434,280,450
3.1 HR Salaries 111,121,014
6.1 Office related work 60,957,048
7.1 Infrastructure 255,255,000
8.1 Medical Equipment’s 15,669,466,313
4.1 IT-Computers, Computer equipment, software, application 1,950,000
9.1 Vehicles 48,620,000
10.1 Contingencies 150,599,508
Grand Total 20,250,156,764


Newborn Survival Strategy Report - Compressed

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Newborn Survival Strategy Report - Compressed

Uploaded by

Copyright:

Available Formats

NATIONAL NEWBORN SURVIVAL STRATEGY AND PLAN OF ACTION 1

Designed by Human Design Studios

Acronyms and Abbreviations 6

Message from the Health Minister, MoNHSR&C 8

National Operational Targets (2023-2028) 14

Introduction and Rationale 16

Trends of Newborn and Child Health in Pakistan 22

Maternal and Neonatal Health Services 26

Health Delivery System 34

Health Service Quality 35

Health Care Financing 37

Natural Disasters and Humanitarian Situations 39

Need for a National Newborn Survival strategy 40

Vision, Goal and Objectives 42

Guiding Principles, Operational Targets, and Intervention Package 43

NATIONAL NEWBORN SURVIVAL STRATEGY AND PLAN OF ACTION 3

Implementation – Guiding Principles 66

Roles and Responsibilities at Different Levels of Health System 67

Monitoring & Evaluation 71

Annex I: ENAP and EPMM Joint Action Plan 75

Annex IV: Levels of Neonatal Care 86

4 NATIONAL NEWBORN SURVIVAL STRATEGY AND PLAN OF ACTION

Table 2 Current Coverage of Key Maternal and Neonatal Health Indicators 27

Table 3 Human Resource Availability across Provinces/Areas 29

Table 4 Number of Priority Interventions across Platforms 31

Table 5 Operational Targets for Key Strategic Indicators 48

Table 7 Key monitoring Indicators 72

Figure 2 Global mortality rates and number of deaths by age, 2022 21

Figure 4 Achieving the SDG targets for neonatal health in Pakistan 24

Figure 6 Causes of Neonatal Mortality 25

Figure 7 Burden of Disease and DALYs Lost 26

Figure 8 Health System Interventions 32

Figure 9 Province/Area wise Population coverage by LHWs 33

Figure 10 Levels of Health Care 34

Figure 11 National Quality of Care Strategic and Accountability Framework 36

Figure 12 Resource Mapping of Health Sector Budget 37

Figure 13 Twelve Categories of Essential Package of Health Services (EPHS) Interventions 55

NATIONAL NEWBORN SURVIVAL STRATEGY AND PLAN OF ACTION 5

ANC Antenatal Care

BEmONC Basic emergency Obstetrics and Newborn Care

BFHI Baby Friendly Hospital Initiative

BHU Basic Health Unit

CMWs Community Midwives

CRVS Civil Registration and Vital Statistics

DHIS District Health Information Systems

DHQ District headquarter Hospital

ECD Early Childhood Development

EPHS Essential Package of Health Services

EmONC Emergency Obstetrics and newborn Care

ENC Essential Newborn Care

ENAP Every Newborn Action Plan

EPMM Ending Preventable Maternal Mortality

HBB Helping Babies Breathe

HRIS Human Resources Information System

KFCPs Key Family Care Practices

KMC Kangaroo Mother Care

LBW Low Birth weight

LHVs Lady Health Visitors

LHW Lady Health Workers

LMIS Logistic Management Information System

MIS Management Information System

MNCH Maternal, Newborn and Child health