Scaling up the '24/7 BHU' strategy to provide round-the-clock maternity care in Punjab, Pakistan: A theory-driven, co-produced implementation study

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Pakistan has a persistently high level of maternal deaths. Its government-run first-level health care facilities, the Basic Health Units (BHUs), are an important place for poor and rural women to receive skilled care during delivery and birth. However, BHUs have only been open from 8.00 am to 2.00 pm daily. The provincial government of Punjab has recognized that these hours of operation severely constrain access to maternity services. Therefore the Health Department is implementing the 24/7 BHU Initiative to upgrade BHUs to provide round-the-clock care. This scale-up is based on a successful pilot project but initial reports reveal challenges in rolling out the new approach. In this 54-month project we will work closely with the Punjab Health Department and other stakeholders to address a key concern: How can the 24/7 Basic Health Unit initiative be successfully implemented at scale to provide high quality, round-the-clock skilled maternity care in its first level care facilities in remote, rural Punjab? The project will include two overlapping work packages. The first will provide a detailed understanding of the current status of the initiative and the obstacles to successful roll out. The second will identify and test potential solutions to improve implementation. Work package 1 extends from months 1-36 and consists of 3 modules. First, we will look at policy documents and interview policy makers to draw up a clear description of what the 24/7 BHU Initiative consists of and how it is meant to operate. Next, we will assess how well the initiative is being rolled out across the province. We will analyze the government routine monitoring data, alongside data from our own survey of 1500 births in up to 50 BHUs. This will provide a picture of how many BHUs are performing well and how many are not. We will also be able to examine factors that are associated with better or worse performance. Finally, we will spend 4-6 months looking closely at what is going on in 4-5 BHUs in 3 districts. Observations, interviews and group discussions with healthcare providers, managers and patients will allow us to understand in detail the factors that support, or get in the way of, successful round-the-clock service provision. We will particularly look for the ways in which successful BHUs are operating and identify any innovations that help things work better.Work package 2 extends from months 24-54 and includes two modules. First, we will conduct two workshops and engage in regular meetings with government officers and other stakeholders to discuss the detailed knowledge of the 24/7 BHU initiative generated during work package 1. We will work collectively to identify a series of promising modifications that might be feasible to roll out more widely. Next, the study team will work with Punjab Health Department senior managers to select priority "change ideas" to test. We will also identify one district and 2-3 BHUs in which to carry out a pilot. We will then test the changes in a structured way, documenting how they work in practice, and working with stakeholders to agree on next steps. We will help Punjab Health Department and local stakeholders produce a longer term plan for implementing system-wide changes that are needed to make the 24/7 BHU initiative more successful. The project will be delivered by an experienced team of researchers. Several team members have worked successfully together on previous similar research in Pakistan. Team members also have excellent links to policy-makers and senior managers who will be closely involved through a Policy and Programming Research Stakeholders Group (PPRSG). A Project Advisory Group (PAG) will also be formed, including representatives of women's organisations, to provide guidance to the project. Research findings will be shared via a range of formats tailored to policy, practice and lay audiences, as well as academic articles and conference presentations.