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

巴基斯坦的产妇死亡率一直很高。政府经营的一级保健设施，即基本保健单位，是贫穷妇女和农村妇女在分娩和生产期间获得熟练护理的重要场所。然而，bhu每天只在上午8点至下午2点开放。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基本保健单位倡议，升级基本保健单位，以提供24小时护理。这种扩大是基于一个成功的试点项目，但初步报告揭示了推广新方法的挑战。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，解决一个关键问题：如何成功大规模实施24/7基本保健单位倡议，以便在偏远的旁遮普农村地区的一级保健设施中提供高质量、24小时熟练的产妇护理？该项目将包括两个重叠的工作包。第一份报告将提供对计划的当前状态和成功推出的障碍的详细了解。第二部分将确定和测试潜在的解决方案，以改进实施。工作包1从第1-36个月开始，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，以明确描述24/7 BHU倡议的组成及其运作方式。接下来，我们将评估该计划在全省的推广情况。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bhu的1500名新生儿的调查数据。这将提供有多少bhu表现良好，有多少表现不佳的图片。我们还将能够检查与更好或更差的表现相关的因素。最后，我们将花4-6个月的时间密切关注3个地区的4-5个bhu的情况。与医疗保健提供者、管理人员和患者的观察、访谈和小组讨论将使我们能够详细了解支持或阻碍成功提供24小时服务的因素。我们将特别寻找成功的bhu的运作方式，并确定任何有助于更好工作的创新。工作包2从第24-54个月扩展，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相关者定期举行会议，讨论在工作包1中产生的24/7 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，这些修改可能是可行的，可以更广泛地推广。接下来，研究小组将与旁遮普卫生部高级管理人员合作，选择优先的“改变想法”进行测试。我们还将确定一个地区和2-3个基本单位进行试点。然后，我们将以结构化的方式测试更改，记录它们在实践中的工作方式，并与涉众合作以商定下一步。我们将帮助旁遮普卫生部和地方利益攸关方制定一项长期计划，以实施全系统的改革，使24/7全天候卫生保健倡议更加成功。该项目将由一组经验丰富的研究人员完成。几名团队成员之前曾在巴基斯坦成功地进行过类似的研究。团队成员还与决策者和高级管理人员保持着良好的联系，他们将通过政策和规划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（PAG），包括妇女组织的代表，为该项目提供指导。研究成果将通过一系列适合政策、实践和非专业受众的形式，以及学术文章和会议演讲来分享。

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.