 So, I will now hand over to Farida, who is our presenter this morning. So, Farida Shah is a midwife with over 16 years experience working to improve nursing and midwifery education policies, curricula and educational standards in various countries with international organisations. Her expertise includes nursing and midwifery education policies, strategies, training curricula, quality assurance standards and assessment guidelines, and implementing policies in Afghanistan, Pakistan and Rosoto. Her areas of expertise include providing technical support to nursing and midwifery institutions, including training assessments and quality assurance and faculty development. Over the last five years, Ms Shah has been working with UNSPA, Rosoto, Paladin, Group Pakistan, to improve reproductive health services and trainings. And Farida has joined us this morning at the very early hour at five o'clock in the morning in Pakistan, so we really thank her for that. So, Farida, I'm just going to make you the presenter now and then you can unmute Thank you Justin, very good morning and good evening to all. Today I'm going to talk about, I will take you through the, you know, study we conducted at the development of workforce plan, excuse me, to make the demand and supply of community midwives in Pakistan. Over the outline of the presentation is, I'll take you through the background and objective of the study. We'll talk about the process, the conceptual framework used in these studies, the major challenges faced by the program and key recommendations provided to take all those challenges. So, talking about the background, like Pakistan key demographic health indicators are lagging far behind the desired level at the maternal mortality ratio stands currently at 186 per 100,000 live birds and new natal mortality is 44 per 1000 live birds and we are the major contributors of the newborn mortality across the globe. And similarly, the infant mortality is also, it stands at 55 per 1000 live birds. So it did situation now with the country and then the specialists, you know, the experts they thought how to take this, you know, how to improve these indicators. So one of the major solution they thought was a community medicine program and replacement of the traditional birth attendance with the trained community midwives. So the community midwifery program was introduced by maternal newborn and child health program that we call it in short MNCH program as a trained caterer of birth attendance in 2000 and back in 2006. The aim of this program was to select female from the rural areas, provide them 18 months pre-service midwifery training and then who will then establish their private practice in the rural communities. In order to help them establish themselves, it was also planned to provide them technical, administrative and financial support for initial two years. However, several challenges persist in this mode implementation of, you know, multiple aspects of the program is planned. Despite of, you know, passing etiquette, the challenges from selection till training and completion of the bound period, you know, those persist. And many of the program come, you know, meet their own set targets for the number of community midwives to be trained. So there was like, you know, we need a community midwives in a province because Pakistan is divided into four provinces and two regions. And every province and region, they have their own distinctive characteristic. We have mountains, we have deserts and we have a calculated community as well in the cities. So many, so many of the provinces, they were not able to meet, you know, set their own set targets for the number of CMWs to be trained. And significant number of community midwives have given up their practice or have de-linked themselves from the system. As soon as their stipend period, the bound period was completed. So this was the whole scenario. So we came up, you know, to help the country to, you know, the calculation of number of midwives. So how many midwives does a country and a province and even inside the province, a district needs. So we calculated that, you know, we came up with that number. So I'll talk about how we came up with those numbers. So background and the study objectives were coming up with the optimum number of community midwives. And then not only the number of the community midwives, the workforce projection and business model because the one who were trained was also leaving the program. So there was, you know, that was how to retain. There was another challenge. So we also came up with that, you know, retention and retention strategies and business model because this was the initial thinking was they should go back and they should do the private practice. So if they do the private practice, they should have the business model. They should have the business entrepreneurship skills. So we came up with that strategies as well. So talking about the process, we started with the literature review. In the literature review, we reviewed the workforce model used globally. And then, you know, we select the ones who applicable, which were applicable to Pakistan. So we didn't find any particular literature which was done for the, you know, community midwives or midwives projections. We got some of the physician projections in Netherland, in Canada and America. So those were like, you know, those were hospitable. Those were even hospital based physician models. So they were laking, you know, they were laking up literature to plan workforce planning for the larger population level. But we heard, you know, WHO HRH models, that was, that were, you know, that were there, but that was not being implemented anywhere, you know, we didn't get any particular literature in that. So we came up with the physician ones and then we got help from WHO HRH models. Then we draft a model. After drafting the model, modify it and, you know, and contextualize it into Pakistani setting. So we points discussed with the provincial MNCH programs and then we conducted consultative meetings. We took that model with our key stakeholders, discussing the stakeholders like MNCH provincial program, Pakistan Nursing Council, because they are the regulators of the profession and many free association of Pakistan. We gathered this community very free data from the database of MNCH program and nursing council. So we finalized, final, after the, you know, incorporation of the feedback of the key stakeholders, we finalized the model and we tailored it to each province. As I mentioned, our provinces are like, you know, we have provinces with mountains. So you can't project, you know, the number of deliveries, you know, and the union councils in those mountainous regions are very long. So you can't get the population even in deserts, so, and populated the provinces. So we, you know, we calculated based on the population density. So that was another interesting, you know, calculation. And then we came up with HR strategies, which focuses on the retention and then business model addresses the real challenges and incorporate best practices, the entrepreneurship trainings for the med-fives. And then we came up with the implementation plan for the five years, even the projection and both for five years. So these are some photographs of the consultative meetings in different provinces. So you can see lots of people but involved in the consultations. This is the conceptual model we utilized. As I mentioned, this was basically used for the physician projections in the different industrialized countries. But of course, we didn't take it as it is, but we got also help from the WHO HRH models. So if you look at this conceptual framework, it's divided into three components. The base year and the base year and then development, the development between base year and target years. So the base year, you can see we have the available supply and then we have a demand and then the gaps come in. In the development years, based between, you know, the base year and target year, this was the five years projection. We did projections for five years. So they're planning like from the enrollment to the, you know, enrollment and completion of the training comes in this development years. And the target years was after five years. So assessment, so that was after five years, the number of CMWs that comes in the target year. So in the base year, what we did was we had, you know, very good data with the MNCH program. They have their MIS where they had numbers of total CMWs they trained. So we took out total deployed CMWs. How many like deployed means the CMWs, they completed their training. After completion of their training, they were based in the rural community so they can work there. So after the deployment, what we have seen when we discussed with the people and they were like not all of the deployed were working. Only 40% of the deployed CMWs were working and 60% somehow left the program. So here, total active means those who are working, you know, as a med-wife. So we took them, we named them active CMWs. And the demand was how many additionally, you know, required CMWs. So then demands and then total deployed, of course, that, you know, how many additional we need. And then in the gap, total deployed CMWs came. So here the projection, like, you know, then we go to the development developments between the base year and target year. So we projected the number of enrolled CMWs. So here, again, when we were assessing the community med-free schools, so the attrition in some of the provinces, the attrition rate during the training was very high, 25% attrition rate in one of the province. So we took, we considered those elements like, you know, when you take this much of students and then keep the attrition rate in mind and then you can think about how many complete the training and how many would be deployed. So we projected that at the same time, we also came up with the suggestions of how they can reduce the attrition rate as well. The projected number of passing, of course, based on the attrition rate and all this, we projected the number of passing out, you know, who will complete the training. And project, we also projected number of deployed one, because even after the training, there are trends, they lift the program. And then how many desired number of active CMWs? Because based on the trends, we came up, who actually work, you know, desired number of the CMWs who really work and how many additional needed CMWs due to the demographic indicators, because our broad rate is a bit high. And so we considered those in the, you know, in the projections. So here that this model we utilized, I don't know if this is going for the projections. So here, you know, the optimal number of CMWs was calculated by taking into account a high rate of unskilled birth attendance of the respective province. So again, we took out the skilled birth attendance rate in each province because we were making tailor-made practical projections for the provinces. And then the challenges of retention of CMWs, the attrition rate during training, after passing out, and then even after the deployment. And then the geographical dispersion of the population, because it was not the equal, so the geographical, as I mentioned, the mountains, the deserts, and then the highly dense other population. So based on the population density, the districts and the provinces was, you know, classified into three categories. It's highly dense, it's medium dense, and low dense. So according to the density of the population, we came up with real projections, even the district level projections. So we took out the districts and we took out the latest census of the, you know, latest census, and then we took out each district of the province. And then according to the census, we classified the province into three, you know, the high dense, medium dense, and low dense. So accordingly, you know, if there is high dense, we can expect, for example, the best on the growth rate, 10 deliveries per month. So all the deliveries would not come to the med-vives. So some goes to the doctor, some goes here and there, and then, you know, maybe five to six deliveries come to the med-vives. So based on that, we did these, you know, projections. The major challenges of the program, the CMW program, was, you know, selection of the right candidate. So it started from the, you know, the problem was started from the selection because this program was made for the rural community. But the people who were domicile of rural community, you know, they're setting, but they were living in the city areas. So they were enrolled. And after the training, they were not willing to go back to the rural areas to serve there. So it was started from here. Then, then, you know, after the selection, the competitive skills and the quality of training, pre-service training was where. It was not up to the mark. So that was, again, you know, when they graduated, they were not having the required skills. So that was another problem. There were lots of, you know, projects comes to, you know, to do this, you know, to fulfill these gaps, the training gaps. So delayed in deployment, when they completed their training, there was funding issues. There was like, you know, bureaucracy, bureaucracy issues in the government setup. So the deployment was delayed. So lots of same defluse, you know, delos during this delay deployment period. They, you know, went away and then they had joined another jobs. So a small stipend and short retention period. In some of the provinces, that was not even equal. They were providing them 2,000 rupees for two years. In one of the provinces, they were providing 7,000 rupees for, you know, continuously. So that province, the retention was good when they were providing, you know, a good amount of money for the longer period, as compared to the province where they are, they were providing less amount of money for lesser, you know, bound time period. So CMW home-based workstation are the workstation unavailable in many areas. So these CMWs were, you know, the rural setting, they came from the poorest of the poor community. So from the, so they have only one room home, so all of the family members were in one room. So how can they afford to have another room for the birthing station? So even for the workstation, you know, portion of the room was, you know, you know, have been allocated for the birthing station. That was even maintaining privacy. And, you know, when anti-natal mothers come, even you can't think of delivery in that one room. So that was really issues. So here also, after our recommendations, the other development sector partners come in, they help the government to build, you know, birthing station. I will show you some slides of those as well. So irregular provision of medical supplies, medicines and supplies. So the program was, the MNCH program was supposed to provide them the regular supply of essential, you know, the medicines, which was approved for them, but they were not getting it. It was some of the majority of the provinces was, you know, they were not getting them on time. This was not regular. So the linkages with local competitors not developed. So local competitors were TV, and they trained by the tendons. They were very senior. They were well accepted by the community. They were there. So there were no, you know, linkages were developed and these CMWs were trained. They just, you know, sent them back, go back and, you know, establish their own system. So that support was not provided. And lack of demand generation, the CMW branding, CMW linkages through with Lady Health Worker program, which is a very successful program of community health, you know, based program of my country. But unfortunately, there was not linked with them. But in return, you know, implementation plan that was there, there will be linked. CMWs would be linked with them, but unfortunately it was not done. And lack of structure refresher training after the training. So everybody, you know, the developing countries, you know, how it is every donor and development agency that comes in and then, you know, that they are on driven things they provide. So the structure manner trainings were linking. So poor linkages with the referral health facilities, that was the biggest challenge because 85% normal cases, they can handle the 15%, you know, the complicated they were supposed to refer, the linkages were not developed. Administrative, their linkages with Lady Health supervisors, and then the technical with the Lady Health visitors, supervision did not materialized. So no entrepreneurship training, the small scale business planning and management. So this was like as a private sector provider in thinking there would be private sector provider, but the business skill training was not, there were not being trained on these skills. So it was very hard for them to manage their clinic, to manage their business. So the recommendation to take a, you know, to solve these, the key recommendation we provided to take all these challenges, the selection of the right candidate. It's scrutiny, like for in the beginning, involvement of community, from the particular community leaders, community forums, you know, and the selection of the candidates so that they would be accountable, though the community would be accountable and then they can take back, you know, their candidate at Boston in Afghanistan and it worked very well. So they, you know, involved the community leaders there. So we also, you know, recommend that improve quality of free service education of the community medwives that was a dire need and their timely deployment. Increase the duration of stipend period from two years to five years. So increasing of, you know, stipend and then increasing their period. So it during, after five years, so can they can establish themselves. Till five years, the government can pay them, they stipend, so that they would adjust and then they can make themselves, they can prove themselves in their community. So after five years, so they can run their own clinics. So CMW Home-Based Worker Station at Burthing Station, that was very, very important. And this was, this was one of the, you know, success of this project after so many, after the, you know, dissemination and discussion. So many development sectors, they come in and they help the government to build, you know, Burthing the stations for the community medwives. And so many organizations help them in the business skills training and then majority, you know, many of them now they are, you know, inter-fleur and they are working well in their clinics. So regular provision of medical medicines and supplies from the government and establish linkages with local competitors. So they can, you know, we can't deny a role of the trend-birth attendants. So they can trend-birth, utilize the trend-birth attendant identifying the client and refer them to the community medwives. And, you know, that kind of things, it was a real challenge. And then the people, you know, the government work with them so that they can have that kind of establishing. So that delivery there, you know, it should be conducted by the, because the medwife is a skilled-birth attendant and then the trend-birth attendant is not a skilled-birth, but she can refer, she can identify and refer and they can have some kind of, you know, she can get some kind of some money from the medwives, that kind of thing. So, clear demand, CMW branding, CMW linkages with the lady health market program and provide structure in-service refresher training. So this particular point was also taken up the sector, the UN agencies and they develop the structure in-service training program and establish linkages with the referral health facilities. So they're, you know, the diary was made, who are in the hospital, you know, BGYN, some traditions were there and then they were linked with the medwives. Medwives were linked with them. So they know this patient is coming from this particular medwife so they can, you know, take care, they can acknowledge, they can then, you know, give feedback on the referent. Improved administrative, you know, that support from the lady health supervisor of the LHW program and the technical support from the lady health visitor supervision. So that was also important. We provided their recommendation and provide entrepreneurship training, that small-skill business training. This was also like taken up very positively and this training were provided and then, you know, medwives are some of, you know, lots of success stories as well. So these are some glimpse of a situation of, you know, photos of community medwives in Pakistan. If you look at the first photograph, it's a classroom. So they are sitting in classroom and, you know, learning class in their classroom. So this one is a medwife. She's sitting in her birth registration. So you can see she has all these things, you know, the furniture, the bed, the scale and all this thing in her desk. So this particular one is, you know, the medwife, she is standing in her under construction birthing station. So when I was visiting this, it was under construction birthing center. So this one is newly developed birthing center. So you can see it's, you know, things are very clean and so many things are still, you know, they were waiting to come. But this was the newly constructed separate room for these medwives. So you can see the separate room so they can provide care with the privacy to their clients, to their mothers and their newborns. So this one is the establish the birthing centers, birthing their clinic. So you can see a young midwife, she is having all these, you know, supplies. And you know, this one, all the development sector partners, one partner in public-private partnership models, one developed the birthing center, another provide all this equipment and all these things, another came up when they provide the trainings. So now you can see the proud midwife, she's providing care to the mothers and newborns. So they are in action, you know, when you help them, they are really, you know, providing the compassionate care to their patients. So it's just a last slide going beyond the number, the essential element of success. I always encourage, you know, emphasis on this is, we should think about the effective coverage, not only number of medwives, we should think about the quality as well. So the effective coverage, it comes under this, it's called AAAQ model, which is the state of the world in a different report in 2014, this was, you know, they projected this AAAQ model. Availability of the medifree services. Availability means the availability of medifree services, accessibility of the community to this services, accessibility in terms of geographical accessibility and then financial accessibility. Sometime geographically the medwives or the healthcare facilities are nearby, but the community doesn't afford the, you know, fees. So that's why they can't go there. So accessibility of those services, both geographical and financial way, and then acceptability of the services from the community. And of course there's medifree services where we have high quality. If we, you know, overcome, you know, we take care of all these components, then we can think about the effective coverage. Thank you. Thank you so much. Now, if you have any questions, so I can stop here. Farida, that was a wonderful presentation. Thank you so much. I think it really fits in with the theme of this year's conference, the birth equity for all in your planning that you looked at. Ah, yes, okay. Are you? Hello? Sorry, I think I'm not sure if Marlene had a question. That, you know, your planning was so extensive, looking at all the regions and looking at the challenges of providing community medifree across the whole country in the different regions. And I think that you really captured that. My question would be Farida, how many in the five years of the program, do you know how many community medifers have been employed? Yeah. Yes, we have around 20,000. Yeah, around 20,000 have been trained and deployed across the country. Wonderful. What a great number. So I have a question here, Farida, from Catherine Salam about who provides the majority of women's health services in Pakistan. Is it community medifers or doctors or health workers? Well, yeah, well, when, you know, it's mostly these are the, we have this lady health worker program. So this lady health worker are not skilled birth attendant, but majority they can provide the family planning, you know, the antenatal care, immunization and family planning services, the short acting, you know, family planning services. So majority of women at community level, they can go to this area, to this community, you know, lady health workers. So this is lady health worker program is very successful program. They have, you know, integrated with every health system. Secondly, they go to the government hospitals because government hospitals, they provide free of, you know, cost services. And the people who can afford, they can go to the, you know, they utilize the private sector. So majority a lady health worker and then public sector and then of course the third one is, the third option is the private sector. Thank you. Any more questions for Farida? Farida, you talked about some equity about the stipend, depending on what region do you feel that that's going to happen all across the country. I think many requires are getting a similar stipend to support them. Yeah, now it's like after a long debate because now the health is, you know, that all these things is our, it's a provincial. Previously it was national level because the national ministry, national all these things. Then, you know, they have changed the constitution amendments. So after that is the province responsibility. So now it's provincial matter when you go there, every province have their own. But yes, after a lot of struggle, now it's all the provinces, they're providing the same amount of stipend and then for them, you know, about a period of five years. Oh, that's wonderful. And you talk about the provinces. So do you have a community midwife program in every province now in Pakistan? Oh, it's in every district. In every district when you go, yeah, we have not even province in every district. We have a community medifree school, a beautiful building, community medifree schools with established skills labs, classrooms. So there was lots of investment has been done on this. Yes, that's wonderful. Great to see and obviously it's great to see that women now have a choice of the lady health workers or the community midwives or, you know, so their books, their access to take care has been greatly improved. I'll just see if there's any other further questions for Farida. Farida, they're saying, what a great program that you faced a lot of challenges and that it was a really interesting presentation to see the challenges and how you overcame them. So that's great, thank you. Thank you, thank you for listening. Have a nice day.