Kumari, lives in a remote desert village named Sadoori in district Umarkot, Sindh Pakistan. She is a housewife with three children. Her husband Mithan is a driver, her family income is so limited that most of the time they sleep empty stomach. Her life was limited only to her family and household chores, cooking, fetching water for home etc and in case get any time, it spends with gossiping with neighborhood women. One day few NGO workers came into her village they introduced themselves as an NGO worker name HANDS and explained their purpose of visit.
HANDS team visited again and initiated the formal process of formation of men and women organization. They also asked them to nominate few women to interview to work as Health Worker and few Dais. Finally Kumari was selected by the committee for this position along with Dai Kari. Later HANDS workers trained her for the training of Community Health Workers and Dai Kari in exclusive Trained Traditional Birth Attendants Training.
Kumari becomes MARVI worker after getting this training she feel that Dai Kari and she can bring lot of change in women’s lives of her village. She started her work as per assigned job, to register married childbearing age women, pregnant women, and children under 3 years old of the village with the assistance of Dai Kari. HANDS Lady Health visitor started visiting her regularly and assisting her to verify the cases for Contraceptives, high risk women and malnourished children.
One day a relative of the landlord came to her house and asked her husband to stop, as he don’t like at all, the services Kumari has given and the selling of contraceptives and medicines. Kumari was shocked and scared to continue her work but times passed away and on a dark night of winter, someone knocked Kumari’s door, she was surprised to found that the landlord, was standing at her door with his one year old son in his lap. He showed her the child; the baby had high fever, so much so that the child was having fits, Kumari given cold sponging and 2 tea spoons of syrup Paracetamol immediately, after half an hour the condition of the child improved. Kumari rechecked the fever and ask the father of the child that it was now safe to take the child to a clinic which she was told is declared as mother/child friendly by HANDS Staff.
The next day the landlord came again to Kumari’s house. He called Kumari and her husband and told them that the doctor of the clinic had informed him that the timely first aid to the child in the village had saved his life. He had tears in his eyes. He said, “From today, Kumari will hold a place of pride in this village”.
Pakistan with the population of 177 million is at the verge of population explosion, after 63 years of independence, 64 million Pakistanis do not have access to health facilities, 276 women die out of 100,00 while giving births. Only 41 percent of women attended by skilled birth attendant, 75 children out of 1000 live births die before their first birthday. Although 95 percent Pakistani Women have knowledge of at least one modern contraceptive but the Contraceptive Prevalence Rate is only 29 percent. Considering the low literacy among women folk’s, the LHWs program could cover only 54 percent of population. Thus leave huge 46 percent highly marginalized population vulnerable for ill health and hence deaths.
District Umerkot is the poorest district of the country located in Southern region of Sindh Province of Pakistan. It consists of barren tracts of sand dunes covered with thorny bushes. The population of the district is 860,000. The 49 percent population is non Muslim that is Hindu, and most of them (74 percent) are low cast, almost 74 percent of them are living under the poverty line with literacy rate of only 6 percent. 53.6 percent of the total population is deprived of Lady Health Worker Services in District Umerkot.
The Marginalized Areas Reproductive Health and Family Planning Viable Initiatives – MARVI, aims to pilot a model project for integrated project of community development. Word MARVI considered as dignity and women empowerment, is adopted from the name of women in folk stories.
The project linked livelihood with Reproductive health & family planning services in LHW’s uncovered areas. Health And Nutrition Development Society- HANDS implemented this project with the assistance of Thardeep Rural Development Program – TRDP and collaboration of district health and population welfare department. The financial assistance to the project is given by The David and Lucile Packard Foundation.
The first phase of MARVI project initiated from 1st November 2007 with baseline survey and has concluded on October 2010. The base line study was conducted before the start of intervention. The social mobilization strategy was initiated with the formation of 700 health committees or community groups. 1128 members of these groups trained. One MARVI worker and a Dai were selected per 700 to 1000 populations per village and hence 350 villages were identified. The total population benefitted from the project is 400,000 directly and whole district population of 858000 indirectly MARVI Workers and Traditional Birth Attendants (TBAs) were trained through 12 training events, which is over all 60 days for each provider.
The Project has trained 350 MARVI Workers and 350 TBAs and has supplied with health products which include basic medicine, ORS, Safe delivery Kits, sanitary pads, condoms and contraceptive pills and iodized salt on subsidized cost. Project also supported to MARVI workers with stipend of rupees 1200 per month and nearly 30 percent subsidy for each supply. Each Marvi Worker has asked to establish a “MARVI HOUSE” in one of the corner of their house. They are also supported by a record keeping system.
After 3 years of intervention the End line evaluation stated the mean age of MARVI workers was 30 years. The End line evaluation depicting that majority of 63 percent of the MARVI workers had attended at least primary schools. Printed material, posters, and flip charts sets were displayed by 93.3 percent MARVI Workers; it was almost same in MTR.
The knowledge of MARVI workers about the three years was found 90 percent. A referral strategy has developed by MARVI workers for their respective villages. The strategy was comprised of identification of women with danger signs during Antenatal, Natal and Post Natal period, identification of readily available vehicle with the contact number of driver. The volunteer blood donors have been identified in all 350 villages and their lists were developed, the village based telecommunication that is wireless phone / cell phone and transport sources were available and identified in all villages, their name and contact numbers were displayed in 74 percent of MARVI houses in end line findings.
MARVI has referred nearly 54255 women, 8594 children with complications to secondary care facilities and save their lives. TBA’s conducted 6951 normal deliveries by using 53 percent safe delivery kits while it was used 47 percent in MTR.
End Evaluation verifies that 83 percent of MARVI Workers know the recommended number of antenatal checkups that is at least 4 antenatal during the pregnancy. 100 percent MARVI workers reported 02 and more than 02 postnatal checkups necessary during the post partum period. 51 percent of the Marvi workers had knowledge of at least 4 danger signs of antenatal, natal and postnatal period. 41.1% of the TBAs have able to identify at least 04 danger signs during antenatal, natal and postnatal period.
HANDS designed its Behavioral Change Communication strategy on the basis of SMART Chart communication technique, 17 sets of posters; flip charts and other material were provided to MWs as health education material. MARVI is conducting health awareness sessions with the assistance of TBA by using this material. Up till now they have conducted 41316 health awareness sessions and 42000 women support group meetings during phase I and reached to 659196 participants. As part of advocacy strategy MARVI project organized many mass mobilization events like MARVI Health and Cultural Mela, Women Festivals, Children Mela etc.
The End Evaluation results revealed that 93 percent women knew about MARVI and 65 percent women knew about availability of Family planning methods with MARVI worker. In End Evaluation 96 percent women knew about at least one modern method of contraception. In the End Evaluation current users of Family Planning were 22 percent in comparison of 9.3 percent in Baseline.
It reflects that there is an increase of 12.7 percent in current user of Family planning from the baseline. 56.2 percent women identified MARVI House as a source of Family Planning methods in comparison of 41 percent in MTR. 37 percent of the married women sought antenatal care in their last pregnancy in End Evaluation, as compare to 31 percent in MTR. According to End line evaluation 93 percent of women knows MARVI house have present within their villages. 62 percent women mentioned TBAs as their health care provider within their community/village. 82 percent women identified MARVI workers as health worker within their Villages.
HANDS social marketing department ensured the smooth supply of health products throughout. MARVI worker were able to sale the health products of amount 2.3 million and earned average Rupees 1700 per-month.
End Evaluation results showed that 55 percent TBAs had knowledge of three cleans of delivery i.e cleaning of hands, clean place of delivery, use of safe delivery kit, while it was 31 percent in Baseline. End Evaluation results also observed that 70 percent TBAs have knowledge about three delays against 73 percent TBAs in Baseline.
MARVI project also supported 50 public sector health facilities through supplies, equipments, technical training and developed into women friendly health facilities.
HANDS Monitoring Evaluation strategy starts from community based record of MWs, reported through Health promoters and then district to office web base data base which link to the head office. There are regular supervisory / Orientation visits by HANDs senior and mid level management teams, monthly progress reviews, midterm reviews and annual reviews were conducted to maintain quality. District Government officials from Health & Population Department also supported in supervision.
MARIV pilot project model has proved that when there is no lady health worker, a low or no literate girl if trained as community health worker along with trained TBAs can deliver Reproductive Health and Family Planning Services with the support of community based groups.
The success of MARVI intervention already took her out of the boundary of District Umerkot. Million of Pakistani women and children are waiting for her. Let’s help us to scale MARVI intervention throughout Pakistan.
Marvi Case study downloadable pdf