PEI-Micro Health Franchise Model

PEI is non-governmental, non-profit and non-political organization registered by a Pakistani expatriate in 2002 under society ACT XXI 1860:PEI is striving to alleviate poverty and bring about a positive change in lives of the poorest of the poor. Since the time of establishment, PEI has been striving in partnership with community.PEI working as a facilitator to initiate and sustain women and children oriented developmental processes both at policy and community level through its innovative approaches.It has been striving for easy accessibility, affordability, with improved medical service standards for the poor through functional health facilities by collaborating with the provincial and federal government in Pakistan. It supports strengthening of the capacity of these health facilities by identifying and bridging the existing gaps and by bringing innovative service delivery models to improve health services and their standards for the poor.

In our proposed project we are addressing the one of major problem of our society .i.e. High MMR and IMR, especially in rural or semi-urban areas of Pakistan.Most important reasons of high MMR and IMR are

• Unavailability of skilled birth attendants.
• Three Delays
• Ineffective referral mechanism

To overcome these issues,PEI proposed

• Empowering and strengthening the Community midwives (CMWs)- Real local stakeholders are living in community,this project will prepare CMWs as entrepreneurs,To provide MNCH & FP services to the community at door step.
• Midwifery Led Birthing Center Model- Sustainable solution for saving the lives of mothers and Newborns, especially in rural areas-Available, Accessible, Affordable services at their doorstep
• Provision and implementation of “Umeed Se”-Innovative mobile health application- For early identification of dangerous pregnancies and postnatal cases, ineffective referral and three delays.

In proposed project both the CMWs & rural women are vulnerable because they both require resources to solve their problems. 

We are working to decrease high MMR and IMR in Pakistan.UNICEF’s Global report on State of World’s Children 2019 revealed that“although much progress has made around the world in improving women’s access to maternal services,every day over 800 still die from pregnancy-related complications.At least 7,000 stillbirths also occur every day, half of these babies who were alive when labor began, and 7,000 babies die in the first month of life.The reality is stark for the poorest women.”In Pakistan,the maternal mortality has fallen by 59% since 1990,from 279 to 170/100,000 live births in 2018;However the rate is still unacceptably high.Similarly,in comparison child/infant health indicators improved over time,for instance in 2018 as per Pakistan (PDHS) 2017-18;the under five mortality is at 69/1000 live births.infant mortality is at 57/1000 live births and the neonatal mortality is at 42/1000 live births.Many of these deaths are preventable.To achieve  new targets of newborn mortality and stillbirth targets set by the Sustainable Development Goals (SDGs),Pakistan needs to accelerate the annual rate of reduction in neonatal mortality from 1.9% to 8.9% and stillbirth rate from 1.4% to 8.5%.Availability of android mobiles and internet for proper utilization of mobile application may be a factor to creates problem.

Our project based on high-impact and evidence based maternal,neonatal, and child health interventions as well as setting up effective referral, transport and telecommunication systems. In this project community based trained and interested midwives are identified for local business venture and are further trained through business skills and technical trainings as entrepreneurs. They are then supported by establishing, equipping a community based functional Birthing Station called Midwifery Led Birthing Stations. Within the established MLBCs; midwives charge agreed upon appropriate fee.The MBLCs function according to detailed strategic business and management plans, which will ultimately ensure that the MBLC approach as a long-term, self-sustaining, livelihood option for the CMW as well as ensure that all families have access to affordable quality services. It is a sustainable social investment with sound economic potential, in addition to saving the lives of mothers and babies. To provide MNCH/FP services, 24/7  to the community; aiming to reduce high maternal and neonatal mortality through following four interventions:

• Strengthening MNCH services through Micro Health Franchise Model(Use of mobile application for early diagnosis and  effective referral)
• Establishment and Strengthening of equipped Midwifery Led Birth Centers 
• Capacity Building Trainings of CMWs.
•  Sustainability of MLBCs by Capacity Building of CMW as Entrepreneurs

Our project will serve the following beneficiaries.

1. Rural & semi urban Pregnant and Postnatal women (including adolescent girls) 
2. Newborns and Children in the rural & semi urban areas.
3. Rural & Semi urban Midwives/community midwives
4. All women and young girls with disabilities

Main focus of project is to provision of sustainable, accessible, affordable quality MNCH/FP services, 24/7  to the community; aiming to reduce high maternal and neonatal mortality.

This project will have a great impact on overall lives of community people asfollowing, 

1. Directly PEI proposed model will strengthen the CMWs 

2. Indirectly all community including above mentioned beneficiaries will get benefits.

PEI will prepared CMWs as local self-sustainable entrepreneur. 

• All CMWs will prepare as local entrepreneur, where instead of depending on the government paid stipend they can charge for their services, thus becoming self-sustainable with no reliance on government/donors.
• The CMW will also be linked with major hospitals, for referral.
• Tele-health care through Umeed Say mobile app would also be made a part of model so that the doctors can provide remote health care to the patients with the support of CMWs.
• Other allied services like blood testing, paramedic, pharmacy and other such services can be later introduced

Our project are focusing are on first and last dimensions of elevate prize. All vulnerable rural women and girl don't have access to their basic rights of reproductive and sexual health and result in getting high MMR and IMR. On other hand, trained community midwives are not accepted as they should & supported by financial. In our project, we are supporting these both communities. PEI focus to elevate opportunities for all these women at their doorstep and strengthen the community midwives in their local area as local entrepreneur, changing people's attitude, belief and behavior about community midwives and women's rights

PEI is working as a facilitator to initiate and sustain MNCH Services both at policy and community level.The Government of Sind.Pakistan has formulated Health Sector Strategy 2012-20 and an operational plan 2014-17 to improve the health of its citizens and to live in Sind by following principles of universal health care.In view of  this, the GoS got benefited from the PEI’s innovative health model and improve the health service delivery in pilot districts in line with the Health Strategy with focus on child health, maternal and newborn health and linkage of LHWs and CMWs to Government Health Facilities and improving their performance.PEI supported GoS and help in to implement its innovative models by using its health sector experience and management skills.PEI signed an agreement for Sindh Medical Support Program (SMSP) with Government of Sindh.The MHFM as a viable option for improving MNCH services is based on three years of design, development, implementation and learning that PEI has gained through the recently concluded “Sindh Medical Support Program (SMSP)” during 2016-2019 and towards later part of project the proposed MHFM was finally piloted and refined and ready to be rolled out to scale provided the required financial and technical support is secured. 

PEI wants to save mothers and newborns lives which are basically due to preventable reasons.Major problem in Pakistan is high Maternal Mortality Ratio and Infant mortality Rate. One of the most important reasons of high MMR and IMR is "Three Delays", and an ineffective referral mechanism. The MMR and IMR are very high in rural or semi-urban areas of Pakistan. In the vast majority of rural areas and semi-urban areas, patients do not find healthcare providers, and usually the next health facility is financially and geographically inaccessible for them. PEI is committed to solve these problems, to overcome these issues, and decrease MMR and IMR, PEI proposed to initiated working with community midwives (CMWs)The real/local stakeholders are living in community, to provide MNCH & FP services to the community at door step, Promote effective referral and decrease three delays in the community. A sustainable solution for saving the lives of mothers and Newborns, especially in rural areas by introducing the Community Midwives (CMWs) as local best entrepreneur , model of “Midwifery Led Birthing Center (MLBC)" along with Umeed Se-Innovative mobile health application

PEI has long history of successful development,testing and rolling out of evidenced based solutions to health-related problems. In this particular case PEI is proposing a fully developed and tested MHFM platform which has capacity add value to the already known problems that the current health system in Pakistan and beyond are facing.The fact that the MHFM is ready to be rolled out with very minimal adaptation  efforts  and  that  it  covers  the  core  quality, accessibility, affordability, sustainability  as  well  as entrepreneurship issues related to MNCH status of the rural Sindh province of Pakistan;it certainly makes it the most viable intervention to make a dent to the unacceptable status of the MNCH.PEI Services will lead the project with technical and management.The project head office will be located in Karachi and it will engage the key stakeholders including the local community, provincial and national government and private institutions.The project will be operationalized under the umbrella support of the provincial Government of Sindh.The statistical information of the service providers including private clinic, basic health units,CMWs and SBAs will be collected in close collaboration of the public sector institutions.PEI has maintained the relevant core team from the SMSP as well through its existing network of expertise and resources is ready to launch this initiative.The fact that the SMSP has been recently concluded its first pilot phase,it is highly desirable that the gains of the pilot are not wasted and the successful models like MHFM are scaled up sooner with minimum disruption and extra cost. 

Challenges faced while operationalizing the MFHM:

• First time execution of mobile application in at very large scale in 10 districts of Health and training of Community midwives and collection of MNCH data from them and maintaining dashboard. 
• Availability of funds from government side.
• Very far away field areas and unknown address/wrong addresses of CMWs.Faced challenges in mapping and finalization of CMWs because they not available at actual addresses, mostly migrated to cities.Contact # unknown and at times cell phones were powered off by CMWs
• Several in-house and external delays were faced in getting office and equipment for the MLBCs.

• Most of the CMWs are not present in the sites which could not meet the criteria
• Unavailability of fuel for field visits was also faced due to fund flow challenges within SMSP.

 PEI has worked along with these issues and complete its project timely.

In Year 03, again we were facing funds problems so some targets like identification of 300 CMWs target and identification of 300 locations for MLBCs completed.Target of 15 trainings and renovation of 300 birthing stations were pending. PEI decided to at least train one batch of 171 CMWs on Umeed Sey mobile application and Pregnancy, childbirth, postnatal and newborn care Modules for 05 days. After training one clinical book on MNCH & EmONC, one android set with installed Umeed Sey application & monthly data package provide to 171 CMWs.

PEI develop one community-based model Midwifery Led Birthing Center at A.B Shoro village, Jamshoro. Sind and equipped with required instruments, supplies, IEC material and signboard for Birthing Stations of CMWs.

CMW Kiran Shoro was the owner of this community place. MNCH Coordinator Ms. Saima continuously provided on job coaching, mentoring to Kiran till end of project and made her able to run MLBC independently. It is best example of MLBC in Pakistan

PEI’s first MLBC started to provide MNCH & EmONC services, 

  PEI started on job coaching of 171-trained CMWs on Umeed Sey application and clinical procedure. PEI functionalized 170 existing birthing centers and start to provide MNCH & EmONC services. 

Maternal Newborn Health Component is one of major component of Poverty Eradication Initiative. MCNH team is working under management of PEI. All program and financial management is under PEI.

Micro Health Franchise model is unique in a sense as it provides the best functioning approach to the ever-desired continuum of care,from home to hospital,and from pre-pregnancy to newborn care along with providing entrepreneurship opportunities to the community midwives (CMWs) in the under-served areas across Sindh.MHFM is a paradigm shift from government dependable primary health care model to sustainable enterprise driven model.PEI provides an opportunity to CMWs in establishing sustainable enterprise and also addressing the MNCH issues through most accessible, affordable and quality services.PEI’s proposed franchise model for MNCH care is unique health sector due to following characteristics:

-MHFM is self-sustainable,thus will not depend upon donors after completion.
-The concept provides institutionalization of CMWs and shaping them in enterprise.The uniqueness of this idea is that, woman as an entrepreneur.
-The establishment of these health franchises alongside the capacity building would make these women attract the required basic capital from the savings and loan companies with the help of Micro insurance and MFI’s. Access to micro insurance will enable vulnerable communities to access quality health care services.

-Our approach will benefit CMWs and will build their capacity to work and perform standardized MNCH services, effective referral  and linked to  private training institutions and tele-health care systems for timely delivery of service in health care.
-The epidemiological surveillance will be strengthened via ‘Umeed Se’ web-based application as an enabler that facilitate Community Midwives and other service providers in prompt decision making for pregnancy,referrals that will provide instant monitoring system to timely detect diseases and trends.

our theory of change is that Implementation of ‘Micro Health Franchise Model’ will help shift the burden from Government dependable health care model to sustainable enterprise driven model through the auspices of public-private partnerships for inculcating technical and financial resources to improve the Maternal and Newborn Child Health in the unattended populated areas. PEI strongly believes that this franchise private public model to strengthen the MNCH System has the capacity first to be further rolled out within the province of Sindh where the needs for such strengthening are still huge, after the first phase of proposed implementation phase, second the proposed model can be easily adapted for the new and similar setting both within Pakistan and beyond and PEI stand ready and committed to rolling this out through minimum on-ground efforts with a potential to scale and success.

The broader outcomes expected from the proposed Micro Health Franchise Model include: 

• Access — Increase the number of MNCH service delivery points (providers) and services offered
• Cost-effectiveness — Provide the MNCH services at an equal or lower cost to other service delivery options, inclusive of all subsidy or system costs
• Women Empowerment – Under the proposed interventions women as CMWs will get an opportunity to become entrepreneurs and run independent businesses, which will achieve the goal of empowering women
• Economic Growth – In addition to women empowerment it will also generate economic growth of women by building the entrepreneurial/business capacity of CMWs and offering them a business venture in the form of the MLBC and thereby reducing the influence of undesired elements due to lack of economic activity

e)      Quality – Provide MNCH services that adhere to quality standards

f)        Equity — Serve all population groups, emphasizing those most in need and reach people who have no access to health care due to multiple factors but primarily poverty;

g)      Sustainability - Empower communities to access affordable quality MNCH services on a sustainable basis;

h)      Effective Referral System – established ensuring continuum of care from home to facility.

We are working with different partners it depends upon need of project. Currently we don't have any partner

Micro health franchising is a commercial franchising model,whereby PEI as coordinating organization,offers individual community midwives (CMWs) as operators,to join into a franchise network for the provision of MNCH services within their respective areas with an overall plan and agreed service quality standards.After joining the network,CMWs will be given the right to employ previously tested incentives including:professional training,subsidized or proprietary supplies and equipment,support services.It is expected that they will gain beneficial spin-off effects includings increased consumer volume and improved reputation due to brand affiliation.PEI’s proposed model will assists CMWs to become self-sustainable entrepreneur through becoming a franchisee.Key features  of model are as following:

• It help to CMW to establish as enterprise and become self-sustainable.
• CMW as franchisee will also be linked with major hospitals for effective referral.
• Tele-health care through Umeed Say mobile app would also be made a part of the franchise model so that the doctors can provide remote health care to the patients with the support of CMWs
• Franchisee can support Federal, Provincial and district level for better-quality service delivery
• Other allied services like blood testing,paramedic,pharmacy and other such services can be later introduced
• PEI would be responsible for providing training to the franchisee (CMW), as well as providing required supplies such as medicines,and equipment at subsidized rates/source
• Each franchise will consist of a CMW,who will be the entrepreneur,who can further engage services of TBAs and or para-medical staff and local transporters as ambulance service
• CMW’s,linkages could be established with the Insurance Companies or with national health card.