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

巴基斯坦的孕产妇死亡率一直居高不下。它的政府运营的一级保健设施--基本卫生单位(BHU)--是贫困和农村妇女在分娩和分娩期间接受熟练护理的重要场所。不过，巴士总站的开放时间为每日上午8时至下午2时。旁遮普省政府已经认识到，这些营业时间严重限制了获得产科服务的机会。因此，卫生部正在实施24/7 BHU倡议，以提升BHU，以提供全天候护理。这种扩大是在一个成功的试点项目的基础上进行的，但初步报告显示，在推出新方法方面存在挑战。在这个为期54个月的项目中，我们将与旁遮普卫生部和其他利益攸关方密切合作，以解决一个关键问题：如何成功地大规模实施24/7基本医疗单位倡议，以便在旁遮普偏远农村的第一级保健设施中提供高质量、全天候熟练的产妇保健？该项目将包括两个重叠的工作包。第一部分将详细了解该倡议的现状以及成功推出的障碍。第二个将确定和测试潜在的解决方案，以改善执行情况。工作包1从1个月到36个月，由3个模块组成。首先，我们将查看政策文件并采访政策制定者，以起草一份关于24/7 Bhu倡议的明确描述，以及它将如何运作。接下来，我们将评估该倡议在全省的推广情况。我们将分析政府的常规监测数据，以及我们自己对多达50个公交车的1500名新生儿的调查数据。这将提供一个关于有多少BHU表现良好，有多少BHU表现不佳的图景。我们还将能够检查与更好或更差的性能相关的因素。最后，我们将花4-6个月的时间密切关注3个区的4-5个BHU正在发生的事情。与医疗保健提供者、经理和患者进行的观察、采访和小组讨论将使我们能够详细了解支持或阻碍成功提供全天候服务的因素。我们将特别研究成功的BHU的运营方式，并确定任何有助于更好地工作的创新。工作包2从24个月到54个月，包括两个模块。首先，我们将举办两次研讨会，并与政府官员和其他利益攸关方定期举行会议，讨论在工作方案1期间产生的全天候BHU倡议的详细知识。我们将共同努力，确定一系列有希望的修改，这些修改可能会更广泛地推广。下一步，研究小组将与旁遮普卫生局高级管理人员合作，挑选优先考虑的“改变想法”进行测试。我们还将确定一个地区和2-3个公交车进行试点。然后，我们将以结构化的方式测试这些更改，记录它们在实践中的工作方式，并与利益相关者合作，就下一步达成一致。我们将帮助旁遮普卫生局和当地利益攸关方制定更长期的计划，以实施全系统范围的改革，这是使24/7 BHU倡议更成功所必需的。该项目将由一支经验丰富的研究团队完成。几名团队成员在巴基斯坦之前的类似研究中成功地合作过。团队成员还与政策制定者和高级管理人员有很好的联系，他们将通过政策和方案编制研究利益攸关方小组(PPRSG)密切参与。还将成立一个项目咨询小组，成员包括妇女组织的代表，为项目提供指导。研究成果将通过一系列为政策、实践和非专业受众量身定做的格式以及学术文章和会议演示文稿来分享。

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.