Can Community Midwives establish financially sustainable practices in the private sector? Lessons from the Integrated Afghan Refugee Assistance Program Midwifery Training Project, Baluchistan

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  • Afghan refugees have been migrating to Pakistan to escape the recurring conflict in their home country since 1979. Most refugees are women and children, who need high quality maternal and child health services. However the host country itself has a fragile maternal and child care system, reflected in its high maternal mortality ratio of 276/100,000 live births. The province of Balochistan, which hosts the largest numbers of Afghan refugees, has the highest maternal mortality rate (785 per 100,000) in the country.1 Not surprisingly, maternal mortality among Afghan refugee women in Pakistan is the most common cause of death in women aged 15-49. Of the many challenges refugee women face in receiving maternal healthcare services, a lack of skilled birth attendance is one of the most important.2 A large body of evidence - both historic from Sweden and more recently from Sri-Lanka - suggests skilled birth attendance is a key intervention that reduces maternal mortality rates.3 However, worldwide, skilled birth attendant programs have had mixed results. A common variable in successful programs is their location in the public sector, while private-sector models have faced challenges in ensuring universal coverage and equity of care. In 2010-2011, Mercy Corps Pakistan (MC) introduced a midwifery training project as part of its poverty alleviation Integrated Afghan Refugee Assistance Program (IARAP). This project aimed to provide Afghan refugee women with self-sustainable, market-oriented, home-based livelihoods, while simultaneously improving maternal and newborn health status of these women’s communities. Four years after launch of the program, Mercycorps commissioned the present research to document if the Community Midwives trained in the IARAP project had managed to establish their practices, the quality of care provided and whether these practices were financially sustainable. The present research aimed to address these queries and in addition, identify factors that enabled (or disabled) establishment of such practices. Methods A mix of methods was used: document review, a financial analysis of CMW practices, in-depth interviews and observations. Data were collected from two primary sources: 1) Program personnel and program documents; 2) CMWs, their family members and female clients over a period of 14 days from June 2- June 20 2014. A total of 6 program personnel, 12 CMWs, 8 family members and 7 clients were interviewed using semi-structured interview guides. Financial data was collected from 11 CMWs using a piloted financial analysis tool. Findings Ten out of the sample of 12 CMWs were practicing midwifery. They earned a mean net income of Rs 8323 per month. When stratified by current MC support, CMWs no longer receiving MC support (in the form of supplies, drugs or stipends) earned Rs 16,975, while the CMWs currently supported by MC earned Rs 3,380. However, using Pakistan’s minimum wage (Rs 11,000 per month) as a benchmark and assuming it is a living income, the data show that two of three CMW practices previously supported by MC and only 1 of 8 CMW practices currently supported by MC were financially sustainable. The former is a small number, the result of loss of MC contact with CMWs after their repatriation to Afghanistan and the latter rate was not unexpected given these women had established their practices just 6-months prior to evaluation. Cost recovery ratio, a key indicator of financial performance, was Rs 3.32 amongst senior CMWs and Rs 1.75 amongst junior CMWs. General overhead ratios were, on the whole, low because most clinics were home-based. CMW productivity ratios, measured as the ratio of total income to number of hours worked, averaged Rs 4.24 for senior CMWs and Rs 4.11 for junior CMWs. In other words, the senior CMWs earned Rs 4.2 for every hour worked, while the junior CMWs earned Rs 4.1. These rates are comparable to the average income of Afghan refugee women in Quetta who work outside the home (Rs 3000 in 2014). Qualitative data identified poverty, family support, interest in practicing midwifery and professionalism as key individual-level factors that led young women to work as midwives. The program structures and processes - sensitive recruitment criteria, targeted advertisement, and on-going, active and continuous support - greatly enabled the CMWs to establish their practices. The overarching enabling program factor was that program plans were implemented as designed. The data suggested some concerns about the midwives’ practices when assessed against recognized standards of good practice. However, the CMW-clients were happy with the care they had received from our sample of CMWs. Conclusion Within the context of the sample, our data suggests CMWs can establish financially sustainable practices in the private sector, but only if they serve clients who can afford to pay their fees. It should be noted, however, that the poorest of the poor by definition will not be able to pay for services. Nonetheless, and despite this challenge, two out of the three senior CMWs have managed to establish financially sustainable practices. If we include CMW4, the Kabul-based CMW, this proportion increases to 3 out of 4. Amongst the junior CMWs, one out of eight had established a financially sustainable practice in only six months. These are not un-remarkable achievements given the context of poverty and the design of the strategy: serving a very poor population with private sector services. Nonetheless, there remains a need to devise more innovative ways to ensure the very poor women receive essential maternal care while the CMWs, themselves poor women, are fairly remunerated.

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    Attribution 3.0 International