Sukh Annual Report Year V

Sukh Initiative empowers families to access
contraception by increasing knowledge, improving

quality of services and expanding the basket of
choices, contributing to the goals of FP2020.



Sukh Initiative is a multi-donor funded family planning and
reproductive health project of Aman Health Care Services,
implemented through a consortium of local and international
organizations in collaboration with provincial government
departments. The project aims to increase modern contraceptive
prevalence rate by 15 percentage points in the one million
underserved peri-urban population of Karachi city, Sindh, Pakistan

CONTENTS 5
7
Abbreviations & Acronyms 7
Progress and Results 9
Progress Details 13
Executive Summary 13
Location and Population coverage 13
Geographical coverage 15
Demographic profile 15
Summary of Program Performance in 2017-2018 21
Strategic Objective 1 34
Strategic Objective 2 36
Strategic Objective 3 37
Sukh PMU Updates 37
Capacity Development 37
Workshop on Strategic Leadership 37
Helpline Network Training 38
PMU participated in Scaling up and sustainability training 38
Workshop on Manuscript writing 42
Conference, meetings and events
Scaling up of Sukh Initiative best practices

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4 Annual Report | Year V

ABBREVIATIONS & ACRONYMS

ACHP Aman Community Health Program
AHCS Aman Health Care Services
AKU Aga Khan University
ANC Antenatal Care
ASRH Adolescent Sexual and Reproductive Health
ATH Aman Telehealth
AUHI Aman Urban Health Institute
CAC Community Advisory Committee
CBO Community Based Organization
CHS Community Health Supervisor
CHW Community Health Worker
CRG Community Representative Group
CTS Clinical Training Skills
DoH Department of Health
FLE Family Life Education
FP Family Planning
HTSP Healthy Timing and Spacing of Pregnancy
IUCD Intrauterine Contraceptive Device
KAP Knowledge, Attitude and Practice
LSBE Life Skills Based Education
LHW Lady Health Worker
MCPR Modern Contraceptive Prevalence Rate
MHFA Mental Health First Aid
MNCH Maternal, Newborn and Child Health
MoU Memorandum of Understanding
MVA Manual Vacuum Aspiration

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MWRA Married Women of Reproductive Age
NCMNH National Committee for Maternal and Neonatal Health
NGO Non Governmental Organization
PAC Post-Abortion Care
PAFP Post-Abortion Family Planning
PDM Permanent Door Marking
PMU Program Management Unit
PNC Pakistan Nursing Council
PPFP Post-Partum Family Planning
PWD Population Welfare Department
QIQ Quick Investigation of Quality
RTI Regional Training Institute
SMB-R Standard-based Management and Recognition
SRHR Sexual and Reproductive Health and Rights
STC Sukh Town Coordinator
TAG Technical Advisory Group
TDM Temporary Door Marking
TFMC Total Family Member Count
UNFPA United Nations Population Fund
USAID U.S. Agency for International Development
VCAT Value Clarification and Attitude Transformation
WPF World Population Foundation
 

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PROGRESS AND RESULTS

1. Progress Details

Provide information regarding the current period’s progress toward achieving the
investment outputs and outcomes as well as the work planned or anticipated for the next
period. In addition, submit the Results Tracker with actual results as requested. If this
investment has an Integrated Product Development Plan (IPDP) that was developed with
your foundation Program Officer, progress toward relevant outputs and outcomes should
be updated in that document.
Sukh Initiative is a six-year (2013-2019) multi-donor funded family planning and
reproductive health project of Aman Health Care Services, implemented through a
consortium of local and international organizations, in collaboration with provincial
government departments, by a Program Management Unit (PMU).
The current Annual Progress Report for year 5 (July 2017 – June 2018) shares key
project achievements and progress of different solution levers. The report also highlights
the best practices and lesson learned, that are now part of mainstream healthcare delivery
system.

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EXECUTIVE SUMMARY

Increase in Demand for FP Services is the first strategic objective of the Sukh Initiative
(SI), and It aims to increase demand for family planning services, especially amongst
women who have already expressed a desire to limit or space their children and aims to
promote the demand for more effective and long term methods leading to the goal of a
15% increase in the modern Contraceptive Prevalence Rate (mCPR) from current rates
of mCPR in the intervention communities. Sukh Initiative demand generation approach
prioritize women from lower income houses, women below 30 years of age, and women
of one or two children, to promote messages around healthy timing and spacing of
pregnancy.
The Sukh Initiative provides Door-to-Door services for demand generation, by reaching
out to a population of one million through Community Health Workers (CHW) of Aman
Community Health Program (ACHP) and Lady Health Workers (LHWs) of the Sindh LHW
Program. During the reporting period, 793,890 population was served by 189 Community
Health Workers (CHWs), while 202,031 population was served by 191 LHWs.
In year 5, 189 CHWs reached out to 140,365 Married Woman of Reproductive Age
(MWRA) making 594,000 household visits on regular basis (four touches in one year),
in addition to specific follow-up visits; giving Family Planning /Reproductive Health (FP/
RH) information, counselling and door to door supplies (Condoms, Pills and Emergency
Contraceptive Pills – ECP). Of the 27,877 clients referred for FP services by CHWs,
17,049 clients (61%) adopted FP methods of their choice. As of June 30, 2018,
73,813 MWRAs are currently using any modern method in CHW catchment population;
increasing mCPR to 53% from 49% in year 4. As for method mix, use of short term
contraceptive remains high at 65%, and includes 13% for injections and 8% for COCs. It
was noted that condoms preference decreased to 45%, whereas preference for long term
contraceptives was 17% (IUCD 8% and Implant 9%), while female sterilization was 9%.
For the purpose of capacity development, a total of 189 CHWs were given two refresher
training on comprehensive FP/RH and LSBE.
For the purpose of creating an enabling environment in the communities, ACHP organized
9 Community Advisory Committees (CAC) meetings which were attended by 109
community members. In addition to this, 1,185 Community Representative Groups (CRG)
meetings were organized and 11,320 community members have attended, who as FP
Champions, worked with CHWs to help them navigate within the community and support
them in counselling sessions with MWRAs, their husbands and youth.
Sukh initiative with 191 LHW covers a population of 202,031 and reached out to 28,706
MWRAs, providing them with FP/RH information and counselling. In year 5, a total
of 6,550 Family Planning (FP) clients were referred to public and private Health Care
Facilities (HCF) by LHWs, of these 44% (2,913 clients) adopted FP methods of their
choice. Based on the service data, mCPR stands at 51% as of June 30, 2018, in LHW
catchment population with 14,712 MWRAs currently using any modern contraceptive.
Method mix remains favorable for all methods. However, condoms users are the highest
at 38%, subsequently followed by sterilization at 18%, pills 14%, injectable 12%, IUCD

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10% and implants 8%. Under capacity development, two sets of refresher trainings on
comprehensive FP/RH including Value Clarification and Attitude Transformation (VCAT)
and Post Abortion Care (PAC) counselling were also conducted for LHWs during year 5.
Within the purview of the Sukh initiative, Jhpiego and dkt are focused on strategic
objective 2; to improve access to quality FP services with provision of broader range of
modern contraceptives including availability of PPFP, PAC and PAFP services. During
year 5, within the public sector 55,453 clients were served with modern contraceptive
methods at 43 public health facilities, that included 21 Family Welfare Center (FWC),
10 Dispensaries, 10 Maternal and Child Health (MCH) Centers and 2 Sindh Employees
Social Security Institution (SESSI) Center. This includes 33,088 new clients and 22,365
returning clients. In addition to this, 92 Family Health Days (FHD) were conducted at
Population Welfare Department (PWD) and MCH facilities, which served 2,039 FP clients.
For provision of hands-on clinical skills to HCP, 33 joint supportive supervision were
conducted by Jhpiego with representatives from DoH, Karachi Metropolitan Corporation
(KMC), SESSI and PWD departments.
Jhpiego provided refresher trainings to 99 Health Care Providers (HCPs) on
comprehensive FP services. In addition to this, 16 OT technicians, and male doctors
were trained on Healthy Timing and Spacing of Pregnancies (HTSP) and referral criteria
for FP and Postpartum FP clients along with 11 male motivators were trained on FP
counselling. A total of 42 support staff were trained on infection prevention protocols, and
11 facility staff were given training on Logistics Management Information Systems (LMIS).
It is important to note that acknowledging project success and results, the Director Health
Services selected the Sukh PPFP and Post Abortion FP model for scale up in all six
districts of Karachi.

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To assess quality of services, all 43 public facilities were assessed by Jhpiego in year
5. Results of Standards-Based Management and Recognition (SBM-R tool revealed that
30 facilities scored excellent (80-98%), 9 scored very good (70-79%) and 2 scored
good (60-69%). Whereas, 3 facilities were in need of further improvement in quality.
To address this concern, Sukh Jhpiego conducted on job sessions and increased the
frequency of supportive supervision.
Sukh continues to engage the private health care providers through a social franchise
network of 40 Dhanak Clinics under dkt that served 5,247 FP clients in year 5. Dkt
arranged 285 FHDs within these Dhanak Clinics providing free FP/RH consultations and
services to 3,451 clients out of the 6,125 that attended these FHDs. Jhpiego trained 38
private providers on comprehensive FP/RH including PPFP, PAFP and PAC. Aggregated
quality evaluation score for 33 percent providers was 80 % and for the remaining was 70
percent.
The ATH services are providing family planning and LSBE information to registered
callers, counseling through outbound calls, and sending SMS adherence reminders and
other information through a dedicated helpline 9123, accessible from all mobile networks
throughout the country. Sukh call center services are potentially helping to sustain the
community’s access to information, counseling and referral services as a cross cutting
partner, and the service is integrally linked with the all solution levers of Sukh. ATH also
provides youth helpline. ATH registered 40,276 MWRAs, husbands and youth during the
reporting period. A total of, 25,095 inbound calls from Sukh catchment were answered
and 60% of the 179,392 attempted outbound calls were successful. Furthermore,
1,393,680 SMSs were disseminated to registered Sukh clients in the community with
information related to FP, MNCH, Life Skill Based Education (LSBE) and giving alerts
on FHDs and other field activities. Quality of services at ATH remained at 75% using a
customize tool by Aman Quality and Assurance team.
Within Sukh catchment areas, Aahung engages youth (12 year to 19 years), at secondary
and high schools, vocational institutes and in the community. Aahung provides LSBE
to the younger generation with an objective to make them a responsible adult. Aahung
engagement with 30 schools and 2 Vocational Training Centers (VTCs) has enabled
5000+ young people to receive LSBE this year. This year 206 on-site support visits were
also conducted for LSBE integration within the schools and VCTs academic calendar. In
addition to this, 4 whole school activities were conducted, reaching out to 1,306 young
people, caregivers and teachers, providing them all an opportunity to recall their LSBE
learnings. At the community level, Aahung developed a Family Counselling (FC) Module
which aims to improve communication between mothers and daughters on Sexual and
Reproductive Health and Rights (SRHR) issues through 5-touch sessions conducted by
20 CHWs and 30 LHWs. A cohort study is designed to evaluate this approach, presently
the data collection is completed and analysis and final report is in process. At Sukh Youth
Friendly Space (YFS) in Korangi 228 new registrations were recorded, a total of 521
youth are participating at YFS activities, where 235 LSBE sessions and 48 counselling
sessions were conducted.
As Sukh implementing partner for strategic communications, Center for Communication
Programs Pakistan (CCP-P) supported Sukh by developing Information Education and
Communication (IEC) materials including Sukh information kit, advocacy kit; factsheets
and branding material for dissemination. Moreover, to generate interest among media
for raising awareness on FP, CCP-P established a health journalist network of 21

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journalists across Pakistan. CCP- also supported Sukh to develop four inspirational
videos with Shaheed Zulfikar Ali Bhutto Institute of Science and Technology (SZABIST)
on themes of ‘Youth and Women Empowerment, Family Planning and Health’. These
videos were developed in Sukh area of intervention and highlighted key achievements
and contributions in the field with an emphasis on responsible adulthood and behavior
change.
During year 5, Sukh PMU continued to strengthen coordination with implementing
partners and achieved 90+% of deliverables agreed upon in the integrated work
plan. SMT and FOM meetings were conducted regularly on a monthly basis with an
emphasis on project progress along with discussion on challenges and way forward.
PMU conducted dissemination of midline results in Karachi and Islamabad. These events
were well attended by health sector specialist, government officials and development
sector partners. Participants appreciated the learnings shared. Sukh also participated and
presented at local and international conferences to share key learnings. Furthermore, a
workshop on Leadership in Strategic Communications and another on SmartChart® were
organized for Sukh team members.
AKU partnership ended this year as an external evaluator for baseline and midline
evaluations. For the purpose of Sukh endline evaluation, Research and Development
Solutions (RADS) and Mathematica Policy Research (MPR) have teamed up and initiated
the initial process of questionnaire development. Regarding stakeholder engagement, two
Technical Advisory Group (TAG) meetings and one in-person Steering Committee (SC)
meeting was also held in year 5 with 8 teleconferences.

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LOCATION AND POPULATION
COVERAGE

Geographical coverage:

Sukh Initiatives serves in four towns of Karachi,
including Korangi; Landhi; Bin Qasim; and Malir.
Project sites were selected based on a criteria of
lower socio-economic income neighborhoods
where there are LHWs and area with no LHW
coverage and no other FP related organization
working on any demand creation activities.
Sukh Initiative aims to serve one million population.
Of this, 200,000 population is reached through
existing LHWs and the remaining 800,000 by CHWs,
locally hired community mobilizers.

Demographic profile:

The target populations is located in peri urban peripheries of Karachi. Majority community
is Muslim and speaks various languages including Balochis, Kashmiris, Seraikis, Pakhtuns,
Muhajirs, Punjabis, Memons, Bohras and other languages.
Through Sukh Initiative, we are covering 150,000 Married Women in Reproductive Age
(MWRA) groups from all four towns. Half of these MWRAs are between the ages of 25-
34 years with the median age of 30 years having an average number of three children
per women.

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SUMMARY OF PROGRAM
PERFORMANCE IN 2017-2018

Figure 3 indicates the rate of program performance against planned targets. In year 5,
About 90% plus targets were achieved / activities implemented. On an average, 3.5
percent of outputs were terminated / Cancelled, it is due to midyear corrections, revision
of targets in No Cost Extension (NCE) etc. While 5.5 percent were postponed, due to
unavailability of community members, government stakeholders on the day of activity.
However, all the postponed activities were adjusted later in next month / quarter activities.

Strategic Objective # 1: Increase in Demand for Family
Planning Services

This objective focuses on improvement in uptake of modern contraceptives by raising
awareness and promoting positive behaviors. Programmatic activities in this regard are
door-to-door services by ACHP, interpersonal communication with youth by Aahung, and,
access to FP / youth helpline for advice, counselling, referrals and follow-ups by Aman
Telehealth. Community events are also organized to raise awareness of the key messages
pertaining to FP/RH.

Progress update – Aman Community Health Program (ACHP)

ACHP works with 200 female CHWs and 30 male community mobilizers that reach out
to communities in project geographies where there are no government mobilizers – the
Lady Health Workers (LHWs). These CHWs provide door to door services to women and
men with a focus on FP related information, counseling and referrals. One female CHW
covers the population of 4,000 with average 500 – 700 households. The one cycle of

Annual Report | Year V 15

female CHW to reach each household complete after three months – consequently, one
MWRA is touched four times in one year. Additionally, CHWs also provide short acting
contraceptives; condoms and pills, along with emergency contraceptives. CHWs refers
women to Sukh’s inclusive health facilities within their geographies, both in public and
private sector for not only FP but also for maternity care and PAC. Women are also
counseled and referred for PPFP and PAFP services. CHWs provide young boys and girls
in the community, with LSBE. They also introduce ATH services to both married couples
and youth.
Of the 800,000 population under the CHW model, each CHW covers a population of
4,000 with 500 to a maximum of 700 household on an average. CHW works six days
a week, with five days for field coverage and one day for reporting at field office. ACHP
utilizes this reporting day for continuous medical education (CME) to the CHWs, which
is also augmented by other Sukh implementing partners. Despite exclusive focus on FP,
CHWs also provide MNCH services to the community, which makes up 30 percent of
their time. 20 CHWs are supervised by one CHS that provides supportive supervision and
monitors their progress. These supervisors are themselves mid-level providers and do
facilitate CHWs in FP counselling. For the purpose of digitalized data base system, CHWs
are provided handheld devices for data entry with customized android based application.
Sindh LHW Program for FP and Primary Healthcare manages 22,000 LHWs in Sindh
with 3,000 in Karachi alone. Of these, 200 LHWs are part of the Sukh community
mobilization initiative under ACHP, reaching a population of 200,000. CHWs are mirror
image of LHW except for the fact that LHWs only cover 1,200 population with 150 to
200 households and in addition to FP they are also responsible to provide PHC services.
As for contraceptive services, in addition to condoms and pills dispensation, LHWs can
administer injectable contraceptives to women at their homes once they are evaluated
by a health care provider who administers the first dose. Just like CHWs, LHWs work six
days a week, with one day for reporting at their base offices. 20 LHWs are supervised
by one LHS who reviews their weekly progress and compiles their monthly data, which is
later entered in an online application. The 200 LHWs in Sukh Initiative works in 3 towns,
with most in Malir and Landhi and some in Bin Qasim Townships.
ACHP administratively manages one million population with 10 Field Stations manned
by a Field Coordinators (FCs), Each Field Station oversees 100,000 population covered
by both LHWs, and CHWs. These stations also provide backstopping to other Sukh
implementing partners.
ACHP engages community at large with existing CBOs and especially formed CRGs,
which comprises of 7 to 10 community elders and gatekeepers. There are separate (50
CBOs/CRGs) for females and (50 CBOs/CRG) for males. Members of these groups
serve as FP champions and support and also promote the work of CHWs. Further to this,
10 CACs, one for each Field Station, with community notables as members, provide a
supportive environment for Sukh field operations.

Progress update - Implementing Partner ACHP

CHW Model - Key highlights: In year 5, at any one time ACHP had not less than 190
CHWs with 189 at the close of the year. The change is usually due to attrition.

16 Annual Report | Year V

i. Population coverage
As of June 2018, the Sukh Initiative reached 793,890 uncovered population, 140,365

MWRA were reached through 189 CHWs
ii. Household visits for FP counseling
CHWs made 594,000 regular household visits in four quarters, with more than

100,000 follow-up visits
iii. Referrals
A total of 27,877, potential FP clients were referred by CHWs in year 5, and 61% of

these (17,049) client’s availed FP services. Furthermore, CHWs also made referrals
for post-partum and post-abortion FP in addition to PAC; these were: for PPFP it was
1,653; for PAFP 100; and for PAC reported was 286.
iv. Current users
There were 73,813
MWRAs currently
using modern
contraceptive in Sukh
catchment area, with
addition of 9,894 new
users. Figure 5, show
a trend of year wise
increase in mCPR, at
the end of year 5 –
services data has shown 53% mCPR.
v. Provision of FP supplies
PWD has provided ACHP with contraceptives supplies. A total of 805,728 condoms,
41,594 contraceptive pills and 8,244 EC pills were provided by CHWs to the clients.
vi. Mobilization through CACs and CRGs
During the reporting period, 9 CACs meetings were organized, a total of 109
members attended these meetings. In addition to this, 1,185 CRG meetings were
conducted and about 11,320 community members participated in these meetings.
vii. Corner meetings for men
A total of 7,048 corner meetings were conducted during the reporting period. Over
17,995 participants attended these meetings. These meetings are monitored by FCs
and SMs. Results and feedback suggests that there is keen interest from husbands in
the community to gain knowledge on FP.
viii. CME sessions
During the reporting period, 511 CME sessions were conducted by CHS and FCs
for CHWs with topic varying from FP, PPFP, PAFP and PAC. Some of these sessions
were also led by Sukh implementing partners.
ix. Refreshers Training on FP
With an objectives to refresh the knowledge of CHWs on FP counseling and on social
mobilization, two refresher trainings were conducted in year 5. Additionally CHWs were
also trained on key concepts of VCAT.

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x. Re-orientation on Community Health Application
A two day reorientation workshop on “Community Health Application” was

organized for CHWs, CHSs, Office Executives (OEs) and FCs by ACHP. A total
of 206 participants from all 10 stations attended this workshop. This workshop
further improved the skills of participants for use of tablets to capture live data and
interpretate it accordingly. This participants gained an in-depth understanding to
prioritize and focus on clients.

Trends and Analysis

Socio demographic characteristics and use of modern contraceptives

The figure 6 shows, parity wise breakdown
of MWRAs using modern contraceptives
in CHWs covered areas, 38% (27,814)
MWRAs having parity of less than or equals
to 2 are using any modern method, while
62% (45,381) MWRAs having more than 2
children are using any modern method. The
graph indicates that the number of MWRA
having parity more than two are more than
less parity women.
The figure 7 shows, parity wise breakdown
of Short term, Long Acting Reversible
Contraceptives (LARC) and Permanent
method clients. The graph presents a high
proportion of short term FP methods use in
0-2 children (80%) and 2 or above (58%).
Following with LARC that is a bit higher in 2
or above parity (17%) comparing with 15%,
and a substantial amount of permanent D
The figure 8 shows, age wise breakdown
of MWRA using modern contraceptives in
CHWs covered areas, for age less than
25 years, 26 – 35 years and above 36
years. The graph presents a maximum
number of users in second age group that
is 51% service data shows 13% couple
less than 25 years using any modern
method, of which 80% are using short term
and 20% long term contraceptives. Further
breakdown is in tables below:

18 Annual Report | Year V

The figure 9 shows, age wise
breakdown of Short term, Long
Acting Reversible Contraceptives
(LARC) and Permanent method
clients. The graph presents a
high proportion of short term
FP methods use in less than 25
years age MWRAs (80%) for 26
to 35 year age MWRA (74%).
While, permanent method were
higher in 35 year plus MWRAs
that is 36%.
The figure 10 shows the method
mix of current users (N – 73,813), by
CHWs. Inner ring show the method mix
at baseline Aug, 2018, while outer line
shows update on June, 2018. This graph
clearly presents the improvement in long
acting reversible methods, while the use
of short term methods of decreased. 51%
MWRAs was using condom at baseline,
and this decreased to 45% at present (6%
reduce in condom use). 14% MWRAs
was using COC for spacing at baseline,
while at present it reduce to 8% - with
6% reduce. 12% of MWRAs was using
injection method at baseline, while use on
injection is improved by 1% - that is 13%
at present. 5% MWRAs was using IUC method at baseline, IUD use is also improved by
3% as 8% at present. A significant improve was seen in implant, at baseline it was 4%,
while with improvement of 5% it is 9% now. The graph also indicates 3% improvement in
use of tuba ligation that is now 17%, while there was no significant change in vasectomy.

mproved planning and management techniques:

In this year, Sukh ACHP continued with client mapping strategy and prioritized potential
clients, more focused on low parity and young couples. The population was segmented
into the three categories: high, medium high and low high priority. This methodology was
also helpful to monitor CHW performance and evaluate impact of the intervention.

LHW Initiative - Key highlights

In Sukh of the 200 LHWs, 191 LHW are associated to the project, as some have retired
after completion of their service.
i. Population coverage: During the reporting period, Sukh covered a total population of

one million through ACHP. Of this, 202,031 population was covered by LHWs.
ii. Referrals: A total of 6,550 clients were referred to public and private health care

facilities by LHWs. Out of these 2,913 clients adopted FP methods of their choice.

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iii. MWRAs reached: During year 5, ACHP reached out to 28,706 MWRAs through LHWs
to provide FPRH information and counselling services.

iv. mCPR users: A total of 14,712 users of modern contraceptive were reported in the
LHW covered areas.

v. First dose of injection: During the reporting period, a total of 1,137 new clients of
injection were served by Sukh LHWs.

vi. Family Counseling module: Sukh Aahung provided technical support to administer
Family Counseling Module (cohort study) across 450 households. 30 LHWs were
engaged for this study.

vii. Refresher Training on FPRH and LSBE: As a part of bi- annual refreshers, 183 LHWs
were given refreshers on comprehensive FPRH and LSBE. Moreover, awareness of
Sukh ATH and information of public health facilities was also given in these sessions.

Trends and Analysis

i. Support Group Meetings (FP, PAC, and MNCH): LHWs convene meetings with MWRAs
and young girls in any one of the neighborhood home or at their own ‘Health House’
on bi monthly basis. In year 5, LHWs conducted 4,141 such support group meetings
(SGM) on FP with 34,928 MWRAs and 818 SGMs on LSBE with young girls and
their mothers reaching out to 5,575 participants. These activities proved helpful in
generating new FP clients and also in educating young girls on LSBE. Details about
SGMs are as under;

Activities Activities

Support Group Meetings for Women (FP, PAC & MNCH & FLE) 4,141
MWRA’s participation in SGMs 34,928
Support Group Meetings for Girls (FLE) 818
95Girls (Aged 16-22 years) participation in SGMs 5,575

ii. Joint monitoring: Joint monitoring visits by ACHP are conducted in collaboration
with LHW Program Director, Senior Medical Officer, Deputy District Officer, District
Coordination Officer and LHS. Focus remained on data collection and reporting.
During year 5, a total of 265 supportive supervision and monitoring visits were
conducted by LHW management, LHS and ACHP.

# of IUCD clients referred 369

# of implant clients referred 726

# of TL clients referred 196

Total # of clients referred and received services 1,291

iii. Method wise referrals: It has been observed that referrals for implant show an upward
trend in the catchment of LHW initiative, with 1,291 clients using implants in the year
5. The following table shows method wise break down;
Door Step services by LHWs for FP: In door step services, condom clients decreased
by 5%, and injection users have increased by 1%.

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# of condoms clients served 18,864
# of oral pills clients
# of injection clients 7,676
4,410

Method wise Referrals availed services
Method mix (service data – baseline vs. current data) Chart shows comparison of June
2016 LHW service data, which was taken as base line in the beginning of project, and
June 2018 service data.
n Over all there is an increase of 10% in

mCPR
n Difference can be seen in percentage of

condom clients, which decreased from
43% to 38%.
n Other methods excluding injection and
TL have increased and decreased by 1%
respectively.
n The Data evaluation of MIS of Sindh LHW
Program have also shown that implant
in the LHW catchment is increasing and
considered as most opted method.
n Injection clients are also showing an
upward trend with an increase of 1% in
last year, mainly after trainings of first dose
of Injection at door step.

First dose of injection by LHWs:
Sukh have pioneered task shifting with LHWs who are now trained to evaluate clients
for injectable contraceptives using WHO Medical eligibility criteria, which was previously
done by midlevel providers. LHWs were trained on client evaluation (eligibility criteria) and
process by PWD over a period of six days including hands on training with a mandatory
requirement for LHWs to evaluate at least 10 clients under supervision of a midlevel
provider before they were allowed to do so on their own. 200 trained LHWs (under Sukh
Initiative) have introduced first dose of injection to 1,137 clients within a duration of six
months. Both clients and LHWs are appreciative of this practice. Task shifting is now
being scaled up in Sindh.

Strategic Objective # 2: Improved access to FP services (by
method) and with improved quality of service

Jhpiego, dkt and Aman Clinic are key partners for strategic objective 2. Jhpiego takes
the technical lead under this objective for both public and private health care facilities
that form part of the project. dkt has established a social marketing franchise model
with private practitioners and clinics in Sukh catchment area, whereas, Aman clinic,
an existing entity of Aman Health echo system, with Sukh Initiative, is also providing
FP services. Jhpiego leads the training of all HCPs and has placed monitoring and
hands on evaluation mechanisms across the board. All providers have been trained in
comprehensive FP services including PAFP, PAC and PAFP.

Annual Report | Year V 21

The Aman clinic also pro

vides; a) in-house services for long-term reversible methods for extended hours i.e. from
9:00 am to 5:00 pm; and b) door-step services by an outreach mobile unit. In outreach
services, staff provides injectable contraceptives by using medical eligibility criteria and
also give continuation doses, all in CHWs catchment areas, since CHWs are not trained
for this service provision, unlike their counterparts, the LHWs.

Progress update - Implementing Partner – Jhpiego

Presently, 43 public health facilities are on board within Sukh intervention areas including
dispensaries, FWCs and MCH. Over 90 providers are trained to serve FP clients in these
public facilities.
A glimpse of the achievements by Sukh Jhpiego during the reporting period is given
below:
i. Up gradation of health facilities

n Two MCH centers were upgraded for PPFP and PAFP service provision. Functional
registers tracking, PPFP and PAFP services were also introduced. As of June
2018, these two MCH centers reported 68% of antenatal and postnatal clients
receiving counseling on PPFP.

n A demonstration of up gradation of public FP clinic following the Costed
Implementation Plan (CIP) branding guidelines was done through Model Family
Planning clinic (FWC Nasir Colony). This facility was upgraded through major
repair and renovation work, by following Costed Implementation Plan (CIP)
branding guidelines. This effort was well received by the community and CIP team
and the new branding of the facility is now being scaled to all FWCs in Sindh.

ii. Provision of quality services
With comprehensive classroom and hands-on trainings and refreshers, along with

provision of required equipment and contraceptives; year 5 has seen tremendous
improvement in quality of FP services given by the providers, with score using
Jhpiego SBMR tools, going up to 82% from 32% on an average.
iii. Family Health Days (FHDs)
Sukh Jhpiego have conducted 92 FHDs and served 2,039 clients during year 5.
iv. Clients served
Sukh intervention public sector facilities served 55,453 clients with quality modern
contraceptive methods at 43 public health facilities.
v. Capacity Development
n 59 health providers (21 Public; 38 Private) were trained on comprehensive FP

services including PAFP, PAC and PAFP.
n Jhpiego helped build the competency and skill of a cohort of providers, based

on their individual learning and performance needs to enhance quality service
provision. Highlights of the trainings during the year 5 are as follows:
l 78 providers (gynecologists, women medical officers, senior registrars, staff

nurses, midwives, LHVs in-charges of family health clinics) received a refresher
on FP
l 21 MCH staff - nurses midwives and doctors were trained on comprehensive
FP

22 Annual Report | Year V

l 16 OT technicians and male doctors were trained on healthy timing and
spacing of pregnancy and PPFP/FP counseling and for referrals of eligible
clients for FP services

l 42 support staff including 12 newly inducted staff from all Sukh Jhpiego
facilities were given a refresher training session on infection prevention.

l 11 male motivators were trained on FP counselling skills
l 11 facility staff were trained on Logistic Information Management System (LIMS)
l First ever training of 14 male motivators on PPFP counseling skills and

value clarification was conducted to increase awareness of their roles and
responsibilities

vi. Joint monitoring visits
As a part of supportive supervision, 33 Joint monitoring visits were conducted with

representatives from DoH, KMC &SESSI and PWD departments

vii. Health System strengthening
Sukh with Jhpiego continued its efforts to create an enabling environment for

successful and sustainable provision of the PPFP and PAFP services at the project
intervention sites. Capitalizing the strong political commitment of GoS in achieving
provincial FP2020 goals across health and population welfare departments; Following
specific actions were initiated under Sukh by Jhpiego:
n Joint District Committees (JDC) were established in each in all of the six districts

across Karachi to integrate FP with maternity care services. These JDC are
responsible to plan for trainings of HCPs, ensure quality improvement of FP/PPFP
and PAC services, and ensure uninterrupted supply of FP commodities. In year 5,
a total of seven meetings of JDC were held and some important issues, especially
provision of FP commodities to maternity homes, dispensaries and SESSI facilities
were addressed. These facilities now are included in main stream commodity
supply.
n PPFP subgroup meetings were organized, jointly with USAID funded Maternal and
Child Survival Program (MCSP) for building consensus on Sindh PPFP strategy.
This provincial strategy was finally endorsed by the Government of Sindh in a
meeting held in March 2018

viii. Policy decisions
Consultative meeting on national PPFP strategy: Sukh with

Jhpiego took the lead to devise the national PPFP strategy,
and held consultative workshops in all provinces, with a focus
on providing guidelines and approaches for programmatic
intervention implementation of PPFP services across the
province, Sindh. The project contributed for the launch of the
Provincial and National PPFP Strategy along with revision of:

n Provincial standards for FP services Notification from PWD to
allow implant insertions

n Implant service provision policy, including task shifting/ sharing
Notification from PWD for implant insertion: Sukh Jhpiego successfully
demonstrated midlevel health care providers’ competency in providing
contraceptive implants that led to PWD’s task sharing notification in province Sindh.
A milestone was achieved as Secretary PWD Sindh enhanced FWW and FTOs
mandate by including provision of contraceptive implant insertion and removal
services through an official notification.

Annual Report | Year V 23

ix. Impact of dedicated counselors on FP uptake
Sukh Jhpiego provided evidence of impact of dedicated counselors in FP uptake

to Technical Advisor, CIP Sindh. This led to deployment of six FP counselors from
Sukh sites in the evening shift of high caseload hospitals in Karachi, including Sindh
Government Hospital, Korangi. PWD will compensate each counselor for the additional
duty hours.

x. Participation and sharing of Sukh updates on Provincial Technical Committee Meeting
The Provincial technical meeting was held at provincial headquarters of PWD in

September 2017. Gaps in district level contraceptive consumption, sales data and field
camps were main points of this discussion.

xi. DTC Meetings Director Health Services Dr.Tahir Aziz is chairing the
DTC is a monthly meeting led by DHS, and DTC meeting, Dr.Laila Shah Program Director Sukh is

attended by PWD, NGOs and other relevant reviewing the presentation
departments. Jhpiego is a member of this
forum and represents Sukh. During one of
these meetings, DHS acknowledged efforts of
Sukh Jhpiego for integrating PPFP services
with maternity services in selected districts.
DHS along with his team, planned to scale up
similar interventions in other districts across
Karachi.

An appreciation letter was also sent to Labor room in MCH Malir Shade 2
Sukh Jhpiego in this regard along with a
request for nomination of focal person to
facilitate scaling up and integration of PPFP
with maternity services in other districts. As
a follow-up, terms of references have been
drafted by DHS team and discussions are
in process to streamline the scaling up and
integration efforts.

xii. Uplifting and site strengthening of Health

facilities

a) Major repairing and renovation work MCH:
First time Labor room services initiated
in MCH Malir Shade 2 and MCH Shah
Faisal 2 hospitals: Both of the above
mentioned facilities were nonfunctional with
compromised infrastructure. District Health
Officer and his staff occupied the MCH
building and most of the rooms were used as FWC Nasir Colony after Up gradation

storerooms. These facilities were providing only general OPD and EPI services in the
morning shift. Jhpiego under Sukh Initiative mapped these facilities as its intervention
site and proposed the up gradation of labor room. After mutual consensus between
Jhpiego and the DoH, a plan was prepared to upgrade and revive labor room in
these facilities. Both these facilities were upgraded to a comprehensive MCH Center
providing FP services including PPFP and PAFP. The project was also able to arrange
availability for 24/7. During year 5, there were 8,063 deliveries conducted in these
facilities. A total of 5,068 FP and 3,456 PPFP clients were served.

24 Annual Report | Year V

xiii. Male motivator’s refresher training
Refresher training of 11 male motivators was conducted to facilitate demand

generation, counseling of husbands and referral of potential FP clients.
xiv. Capacity Building of HCPs of other NGOs
Under Public Private Partnership, some of the health care facilities in Sukh intervention

area of Malir district were handed over to HANDS, a local NGO. Jhpiego trained 15
HCPs of HANDS on comprehensive FP to ensure the learnings and execution of
services are same across the board. Additionally, 64 private health care providers
of Willows Foundation, an INGOs working in Sukh districts, were also trained on
comprehensive FP. All these organizations recognize Jhpiego as technical lead and
continue to benefit from Jhpiego.

Trends and Analysis

Facilitate demand generation at health
facilities
a. SBM-R and Supportive supervision:

A total of 44 facilities were assessed
for quality improvement during year
5. Of this, 30 scored excellent (80-
98%), 9 very good (70-79%) and 2
good (60-69%) whereas, 3 facilities
were in need further of improvement
in quality. For these 3 facilities, Sukh
Jhpiego conducted on job sessions
and increased the frequency of
supportive supervision.
LARC Client follow up: Among 268 follow up calls made to LARC clients to ask for their
satisfaction to the procedure, 79% reported being satisfied with their FP method. For side
effects; 19 clients complained of bleeding and spotting, three of pain in the arm and one
each citing: backache, amenorrhea and slight pain. Eight women reported removals –
four due to bleeding, three due to their desire to concieve and one due to high blood
pressure.

Annual Report | Year V 25

Method Mix – PPFP at MCH services
The PPFP services data is collected
routinely from facility registers, labor room
registers and monthly DHIS registers of
MCH centers.
A total of 5,068 clients were served in 10
MCH Centers during year 5. Of these 42%
(2,123) had post-partum implants, and
26% (1,333) had PPIUCD. In total, 74 % of
services opted were LARC and 26% were
short acting methods.
Prior to Sukh Jhpiego inception, only two
of the 10 MCH centers were providing FP
services including PPIUD services. However,
post Sukh Jhpiego intervention, FP and
PPIUC services have been introduced in the
remaining 8 MCH centers.
Method Mix- Dispensaries services
FP services data were collected from the
District Health Information System (DHIS)
monthly performance report of each facility.
HCPs at public dispensaries provided a total
3,639 FP services, of which 30% (1,106)
were implants, 28% (1,005) were injections,
20% (739) pills, 19% were condoms and
3% were IUCD. It is important to note that
before Sukh’s intervention, none of these
dispensaries were providing FP services.
Method Mix- PWD facilities services data
A total of 46,146 clients received FP
services from 23 PWD facilities of which
24,381 (53%) were new and 21,765
(47%) were returning clients. Among new
clients, 32% (7,795) FP users opted for
condoms, 28% (6,764) for injections, and
21% (5,116) for pills. Altogether 81% were
short-term methods and 19% were for
LARC.

Implementing partner
update – dkt

Dkt-Pakistan under Sukh Initiative has
established a social franchise network with
40 private facilities with providers trained on comprehensive FP services including PAFP
and PAC.

26 Annual Report | Year V

i. Family Health Day
Extending services through private sector, dkt reached 6,125 MWRAs by organizing

285 FHDs in Sukh catchment areas at selected Dhanak Health care Clinics (DHCC).
Of this, 3,451 availed FP method of their choice. Initially, dkt organized the FHDs but
later on, the activity was out sourced to a vendor. These FHDs offered free of cost
counseling of all FP services in the target communities
ii. Clients served
During year 5, a total of 5,247 FP clients were served. Of this, 907 were provided
condoms, 1,834 pills and 1,679 injections were given. Additionally, 459 IUCD clients
and 357 ECP clients were served.
iii. Capacity development
During the reporting period, dkt organized training of private providers on
comprehensive FP, PPFP and PAC. These trainings also included infection prevention,
use of HMIS and VCAT. As a technical lead, Jhpiego provided technical backstopping
in these training sessions. In addition to this, a total of 93 need based, on the job,
small training sessions were also conducted to improve the clinical skills of the
providers
iv. Up gradation of facilities
By year 5, dkt has franchised 40 clinics under DHCC. These facilities were not only
branded for DHCC but also provided with infrastructure support and equipment
required for implementing FP services. This also included an essential medical
instruments kit which comprised of 44 different items. In year 5, dkt reassessed
three clinics for rebranding due to relocation / wear-n-tear refurbishment reason for
maintaining quality.
v. Clinical quality assurance visits
During the reporting period, 40 DHCCs and their respective HCPs were evaluated at
different intervals for compliance to quality standards. A total of 281 evaluations were
conducted. Quality standards, including those of the providers in 33 of the 40 DHCCs
scored more than 80%, while the remaining clinics scored around 70%.

Implementing partner update: Aman Clinic

Aman clinic provides PHC services, which under Sukh
Initiative also include comprehensive FP services. As
public facilities working hours are till 2pm and the
private clinics usually open in the evening after 5pm,
extended 9am to 5pm working hours at Aman Clinic
have proved to be an advantage for the community.
This service is available to both MWRAs residing within
close proximity to the Aman clinics along with clients
from other Sukh field stations.

Key highlights

n During the reporting period 2,034 FP clients were served at Aman Clinic (In-house
services, excluding outreach services)

Annual Report | Year V 27

n Under outreach services, a total of 10,384 clients were served injections through
support of ACHP

n Moreover, 888 visitors to the clinic were given FP counselling
n IUCD insertions at Aman Clinic remained low with only 7 insertions during year 5
n Implants remained the most preferred method by the clients. A total of 638
Implants were given during year 5.

Supportive Interventions for Strategic Objective 1 & 2
Aman Telehealth and Aahung

Progress update implementing partner - Aman Telehealth (ATH)

At helpline # 9123, ATH registers FP clients, counsel them on different methods and
informs about the location of service providers nearest to them. In addition to this, ATH
makes outbound calls to follow-up on clients availing FP services and send SMS to
registered clients with health and FP messages. The service is integrally linked with
the all solution levers of Sukh. ATH also provides youth helpline for young girls and
boys for age appropriate information needs which can be accessed confidentially and
anonymously.

Key highlights

i. Registration
In year 5 ATH has registered 40,276 MWRAs, husbands and young boys and girls.
ii. Inbound calls
A total of 25,095 inbound calls were received and answered from Sukh catchment

areas.
iii. Outbound calls
During the reporting period, the number of outbound calls attempted were 179,392.
iv. Awareness through SMS
A total of 1,393,680 SMSs were disseminated in the community. With the continuous

hike in utilization of ATH as a SRHR helpline and the large numbers of MWRAs
contacting, Sukh ATH have demonstrated a sustainable option available to MWRAs for
receiving FP/RH related services.
v. Promotional activities
ATH promotional activities remains multi prong. Key achievements during the reporting
period include:- ATH has set up 21 telephone booths in the community with 24/7
free access to 9123 addressing the cost barrier to access 9123, but also promoting
the call center.
n Portable phone sets were given to the supervisors, both CHS and LHS to

encourage women and also men to dial 9123, register themselves and get to
know about the services offered at 9123.
n Airing TVC on local cable network to introduce 9123 and the services it offers.
n Sponsoring youth related activities to introduce 9123

28 Annual Report | Year V

Trends and Analysis

a. In House Capacity: ATH has dedicated in-house resources for arranging frequent
capacity building sessions for their call agents. Jhpiego and Aahung trained ATH staff

as master trainers on FP and LSBE protocols and algorithms. During the reporting
period, four training sessions were conducted for LSBE and VCAT for ATH call agents.
b. Increase in awareness and promotion of Sukh Aman
Telehealth Services (9123): As part of its promotional
initiatives in the field, Sukh ATH conducted 166
awareness sessions in which 125 promotion sessions
were conducted with community and 41 promotions
sessions were conducted with field workers and
with LHWs. The audience included both the males
and females. These sessions covered interactive
presentation for an orientation of the objective of Sukh
ATH, components of Sukh ATH services, call flow
process in ATH, as well as identification of emergency
and non-emergency situations. During the reporting
period ATH team attended 40 CAC/CRG meetings and
also participated in 35 FHD camps.
c. Marketing Activities: For the promotion of 9123 as SRHR and LSBE helpline, ATH
increased its promotional activities by including previously untapped marketing means
such as cable TV advertisement and sponsorship of sports tournament along with the
traditional options of giving away marketing collaterals among MWRAs, married men
and youth;. The giveaways included1) Brochures – 195,370, 2) Stickers – 77,300, 3)
Bags – 3,873, 4) Wall Clocks – 211, 5) Banners – 800, and, 6) other misc. items -
441
d. Sukh Telehealth 9123 Video for Promotion via TV/Cable: To further enhance the brand
image of ATH as SRHR and LSBE helpline, an extensive cable TV advertisement
campaign was introduced during this reporting period. The campaign had an overall
impact on the annual number of FP and LSBE call trends and helped sustaining the
upward trend of utilization of ATH as SRHR and LSBE helpline.
e. Sponsorships of sports Tournament in the
Community: ATH engaged youth through various
activities to create awareness about LSBE.
With the ongoing football fever and the biggest
sport event after Olympics i.e. Football World
cup going on, Sukh ATH organized a football
tournament at Korangi Town, Karachi. Teams
from Landhi, Korangi, Bin-Qasim and Malir
towns participated in this tournament. A total of
18 teams participated and this event was highly
appreciated by youth and community elders.
During this event 7,000 youth were registered
with ATH
f. Increase health seeking behavior related to mCPR methods through standard SMS on
FP, PPFP, PAFP and PAC and LSBE: SMS is considered to be one of most effective

Annual Report | Year V 29

strategies being applied for behavior change communication across communities. ATH
has been sending SMS to its registered clients from Sukh catchment areas not only
related to FP and LSBE but also on other health issues. During this year, 1,393,680
SMSs were disseminated. SMS were send in 59 batch pulses aligning with different
health and FP related activities being conducted in the field. These SMS contained
awareness messages on MNCH, FP and other call-to-action campaigns like breast
feeding, nutrition, etc. At the same time SMS were disseminated MWRAs, men and
youth to utilize 9123 services for SRHR and LSBE related quires.
g. Increase access to MWRA, husbands, young girls & boys for Telehealth services
through inbound calls: During the reporting period, a total of, 25,095 inbound calls
were received and answered from Sukh catchment areas. An increase in the number
of self-made calls from the community is a sign of positive change of people’s
acceptance and empowerment to talk about their health issues on phone. Even
though FP related call volume picked up momentum this year, in comparison to
previous years, the fact that community has access to CHWs and LHWs for their FP
related quires, remain the reason behind this slow pace.

h. Outbound calls: Outbound call follows
two basic steps: has a two prong
strategy: Firstly, it reaches out to the
community, MWRA, men and youth to
introduce them to 9123 and have them
register with the helpline. Secondly,
it provides follow-up services to
contraceptive users to address their
myths, misconceptions and also advise
them on side effect management.

A three phase strategy is applied; at
the first contact the client is registered
with Sukh ATH services; on the
second contact, all family members
are registered including MWRA and
children; and on the third ATH talks

30 Annual Report | Year V

about MNCH and FP related topics and also do follow-up of current clients. During
the reporting period, 179,392 calls were made. These calls were attempted on
the numbers of MWRAs and married men where ATH continued follow up for the
conversion and side effect management of FP, with regular outbound clients as well
as new clients registered during this reporting period.
During year 5, a total of 70,711 of the total attempted calls were successfully
connected. New clients registered during these calls was 19,367, with of 17,515
MWRA & married men and 1,852 youth.

i. Continuous monitoring and evaluation
of calls, customer satisfaction and call
agents performance: To ensure provision
of quality of services provided by ATH, a
Quality Assurance Unit randomly selects a
sample from all recorded call to monitor
customer satisfaction, and compliance to
protocols by ATH operators. Checked on
an exclusively build Quality and Assurance
checklist, it was observed that the quality at
ATH was very satisfactory, just below the
benchmark of 90%, but overall compliance rate remained sustained at an average of
75% throughout the year. Simultaneously, the customer satisfaction rate that had a dip
later this year has recovered considerably and is at an overall average of 75%. Sukh
ATH is still working in strong liaison with the Quality Assurance team to further identify
the areas and opportunities for continuous process improvement.

j. Technology Integration: Technology Integration is essentially one of the most important
components for the sustainability of Sukh ATH, as the end goal is to make the
beneficiaries information sharing a hassle free process. Sukh ATH has been constantly
working to improve and upgrade the information systems and integrity of data, and
eventually adopt a fully integrated CRM system. In this reporting period, technological
upgrade was implemented, enabling ATH to make automated outbound calls and
therefore resulting in increased number of attempts and an improved number of
Annual Report | Year V 31

connects. An integrated Voice Response (IVR) was introduced that helps ATH to
prioritize FP calls. This IVR also enables ATH to remind each and every caller of ATH
that this service can also be used for FP counseling. These new technology upgrade
have improved the overall customer experience and the number of unattended calls
has dropped down to a mere 2% which is an overall helpline industry’s best number.

Progress update - Implementing Partner Aahung

As Sukh implementing partner, Aahung is promoting LSBE with focus on boys and girls
of age 12 and above. Aahung supplements the outreach of Sukh Initiative by not only
approaching youth through existing secondary high schools, but also innovative ways to
access those who are in community or out-of-school, such as conducting support group
meetings by LHWs and mother/daughter counselling (family counselling) by both CHWs
and LHWs. Aahung also is reaching out to young boys and girls at vocational institutes.
LSBE has also been introduced at NASRA School System, a not for profit private school
network catering for children from low to middle income groups.

Key highlights

During year 5, Aahung has focused its efforts on implementing an exit strategy that would
ensure sustainability of quality SRHR information and services beyond the life of the
project.
Some of the key highlights are as follows:
i. LSBE integration
The school LSBE program with 30 schools and 2 VTCs has enabled 5000+ young

people to receive quality SRHR information this year. For the purpose of sustainability
of LSBE, Aahung provided teachers with tools and techniques for continued LSBE
implementation even after the project ends. Based on the willingness and capacity
to do so, 14 out of 30 schools were selected for implementation of SRHR protocol.
The staff in these schools was trained on integration of LSBE key messages into core
subjects using different techniques such as co-curricular activities.
ii. Institutionalization of LSBE
Overall, Aahung has reached 15,181 young boys and girls through its school
interventions during the project life time. To further streamline the LSBE efforts,
Aahung conducted 206 on-site support visits to these schools and provided technical
and supportive assistance. In addition to this, 4 whole school activities were also
conducted this year, reaching out to 1,306 young people, caregivers and teachers.
iii. Family counseling module
At the community level, Aahung piloted a Family Counselling (FC) Module which
aims to improve communication between mothers and daughters on SRHR issues
through 5-touch sessions conducted by 20 CHWs and 30 LHWs. Aahung conducted
trainings for 30 CHWs, 10 CHS, 29 LHWs and 10 LHS on FC module, 4 cycles of
this interaction were completed by 20 CHWs which covered 800 houses and reached
a total of 900+ young girls and their mothers. On an average, each session takes 40-
45 minutes per family. These sessions are conducted by CHWs / LHWs, who also
record their inputs on a pre-designed tool. The workers shared several challenges

32 Annual Report | Year V

they have faced during these sessions such as interference by male family members
and children, lack of privacy in the house, frequent electricity outages, and delays in
sessions due to the family’s commitments elsewhere.
Aahung conducted 80 onsite support visits to CHWs and LHWs to ensure smooth
and effective implementation of the FC module. Furthermore, 21 LSBE support
group meetings were also conducted with LHWs by Aahung field team. To know
the effectiveness of the processes, the pre and post tests were conduct during these
visits, the results of these tests have revealed that one touch sessions have increased
youth’s knowledge particularly around: legal age of marriage, importance of birth
spacing, impact of early age marriages.
iv. Youth Friendly Space (YFS)
With regards to Aahung’s Youth Friendly Space (YFS) in Korangi, 228 new
registrations were received this year and 235 health sessions were conducted. A total
of 521 youth attended these health sessions (409 boys and 112 girls). Additionally,
48 counselling sessions are also conducted over the year. Moreover, 1 Social Action
Project (SAP) training was conducted with 14 youth at YFS to develop confidence
among them to take on initiatives addressing social issues.

Aahung also built the capacity of 8 ATH master trainers on providing youth friendly
services through their helpline 9123. In order to assess the impact of this training
on call quality, 22 ghost calls were conducted over the year that highlighted the
importance for building more capacity of operators on general history taking and
VCAT. ATH master trainers conducted refresher training and on job sessions on this.
v. Youth Friendly Services
At the community level, Aahung selected and trained HCPs and support staff from
Aman Clinic, two dkt Dhanak Clinics and two public sectors facilities on providing
youth friendly services to youth, especially those on FP, puberty and sexual abuse.
In order to assess the impact of this training, 10 mystery client visits were also
conducted at these clinics on puberty and rape cases. An evaluation tool was
developed for assessing the HCPs consultation practice during the visit, according
to assessment, the approach of HCPs were positive and they have maintained the
privacy and confidentiality of the client and gave them enough time to discuss their
problems.
vi. Edutainment
Aahung made two docudramas and aired on local cable network reaching to 500,000
plus population residing in Sukh catchment areas. The 2nd docudrama was aired on
local cable TV focusing on women rights including age and consent for marriage,
importance of wedding documentation, and having CNIC; in year 5. A recall study was
conducted with in the catchment areas. Results showed that approximately 52% of the
respondents had seen the drama and could recall about 2-3 key messages.

Trends and Analysis

LSBE interaction: Aahung’s advocacy for integration of LSBE into the secondary school
curricula in Sindh saw significant strides this year. Aahung was due to begin a more
extensive pilot study of the Comprehensive Sexual Education (CSE) curriculum in 6

Annual Report | Year V 33

districts of Sindh with government schools at the beginning of 2018. However, the events
that unfolded in Kasur with the rape and murder of 7 year old Zainab, created an urgent
need to see content integrated into all public schools. In January 2018, the Chief Minister
of Sindh and Department of Education Sindh along with affiliated departments approved
the CSE content within the integrated framework for classes 6 – 9. Moreover, content
focused on body protection and rights was also subsequently approved for primary
classes 3 -5. Training and development plans in affiliation with the Provincial Institute for
Teacher Education (PITE) are underway, with the first phase including the training of 442
master trainers (secondary level) by Aahung.
Journalism Workshop on Early and Forced Marriages (EFM): Aahung conducted a Media
training workshop in April, 2018, for journalists and reporters to sensitize them about
the grave social issue of Early and Forced Marriage. The workshop was attended by 12
journalists from Karachi representing English, Urdu and regional language media in print,
TV, radio and online, to report on EFM. Journalists were de-briefed on the state of EFM
in Pakistan, keeping the legal as well as the health aspect in mind. The training sought to
build capacity of journalists to report effectively on stories and enable the media to report
violations of the Sindh Child Marriage Restraint Act (SCMR 2013).
Completion of Cohort Study with CHWs: Aahung with PMU initiated a cohort study to
evaluate and understand the effectiveness of Family Counselling (FC) module being
implemented by 20 CHWs and 30 LHWs in Sukh catchment areas. This study is in
progress and being conducted by a third party evaluator.

Strategic Objective 3: Ensure long-term sustainability of
program focus

Progress update - Implementing Partner CCP-P

Strategic Communication:
As a strategic communication partner of Sukh Initiative, CCP-P provides support to Sukh
Initiative for external communication activities for improved visibility and recognition of the
project. CCP-P works to achieve first and third objectives of Sukh Initiative. Summary of
the progress made by Sukh CCP-P during the reporting period is presented as below;
1. Communication and documentation
a. Developing branding and styling guide: During the reporting period, CCP-P drafted

a comprehensive Branding and Styling Guide for Sukh. All implementing partners
were oriented on these guidelines. CCP-P performs routine follow ups to ensure
adherence to these guidelines for all Sukh IEC materials for coherent communication.
b. Communication packages: CCP-P designed and published customized communication
materials featuring Sukh achievements and learnings. An information package was
designed that comprised of project introduction, partners’ profiles and factsheet.
Additionally, an advocacy kit was developed targeting key stakeholders especially
government counterparts. This kit comprised of human interest stories and case
studies from Sukh field along with a factsheet based on program data. Both
information and advocacy kit were disseminated with relevant stakeholders at

34 Annual Report | Year V

various occasions including mid line dissemination seminars, local and international
conferences.
c. Development and dissemination of bi-annual e-newsletter:
During the reporting period, CCP-P drafted and circulated
two editions of Sukh Initiative newsletters, while work on the
third edition is in progress. The first newsletter featured project
activities along with updates from all implementing partners.
The second edition of newsletter was thematic edition focused
on ‘Promoting Life Skills among Youth’. Furthermore, a
special edition newsletter was also published for the SOGP
conference held in Karachi.
d. Annual reports publication: CCP-P worked on design and
publication of three annual reports of Sukh Initiative. The first edition was a combined
report for year 1 and 2, while the next two editions covered project activities held
during year 3 and year 4, respectively. Reports from year 1-3 have been published,
whereas year 4 report is being processed for publication.
e. Production of a video documentary on Sukh Initiative: CCP-P worked on preparing
documentary for Sukh Initiative, featuring activities from the field along with comments
from key stakeholders. This documentary served as a communication and publicity
material and was also relayed at the program’s stall established at the International
SBCC Summit, Bali, Indonesia.
2. Training and Capacity Building
i. Establishment of journalists’ network by conducting a workshop CCP-P established a
journalist network in Karachi to generate interest from media to raise awareness on
health issues. An orientation workshop along with field exposure was organized for
a group of 20 health journalists, which was followed by a formal set up of journalist
network.
ii. Workshop on Leadership in Strategic Communication With an objective to build
capacity of Sukh Initiative consortium partners, PMU and other stakeholders,
CCP-P organized a two-week long training workshop on Leadership in Strategic
Communication. The aim of the workshop was to cognize the participants about the
strategic leadership and social and behavior change communication and to motivate
them to use these strategies in their projects. This training was held in Dubai in
January 2018. A total of 23 participants including Sukh PMU and implementing
partners, government, nongovernment and private sectors participated in the
workshop. The participants were introduced to concepts of strategic Communication,
planning and evaluation that helped them to develop skills to design, plan and
implement effective health communication projects.
iii. Training on Smart Chart for Social Media Campaign CCCP-P organized a two-day
training for selected group of 25 staff from Sukh PMU and implementing partners
on Smart Chart in March 2018 in Karachi. This training was second of the series.
The first took place in Dubai along with the Workshop on Leadership in Strategic
Communication. The training aimed at building capacity on developing effective
campaigns to raise awareness on health issues. The theme selected for the training

Annual Report | Year V 35

was development of social media campaigns around ‘Responsible Adulthood’, which
is an essential component covered under LSBE.
iv. Support young entrepreneurs in producing short videos for external audience: CCP-P
collaborated with SZABIST for a special assignment to support young entrepreneurs.
SZABIST students prepared four inspirational videos with themes of ‘Youth and
Women Empowerment, Family Planning and Health’. These videos featured stories
and protagonists from Sukh field. These short inspirational videos also posted on
Sukh’s website. A special video screening event was also held at SZABIST in May
2018. This event was attended by Sindh Government representatives and other FP
experts, who appreciated the collective efforts made under Sukh Initiative to foster
behavioral change.

Other activities

n To celebrate World Population Day, Sukh CCP-P provided IEC material and giveaways
for a walk organized by PWD on 11th July 201 in Karachi

n CCP-P provided support to manage stalls at two international events during the
reporting period, i.e., APCRSHR (27- 30 November 2017, Ha-long bay, Vietnam) and
SBCC Summit (16-20 April 2018, Bali, Indonesia)

n CCP-P designed and published report for midline dissemination seminars. The first
seminar was held in Karachi in November 2018 and the second event was held in
Islamabad in December 2018. Sukh CCP-P also designed the panels, walls, posters,
information and advocacy package and other branding material for the event held in
Karachi.

Sukh PMU update

The following are key highlights of activities
undertaken by PMU during the reporting
period.

Advocacy and coordination Technical Advisory
Group (TAG) serves as a coordination
mechanism and provides technical advice,
recommendations and support to SUKH for Sukh TAG meeting – August 2017

attainment of program goals. This committee
consists of eminent experts on FP/RH including members of provincial assembly,
government departments (health, population welfare, and education and youth affairs),
and members from private sector such as from Pakistan Nursing Council, USAID, UNFPA,
Rutgers WPF, NCMNH, social marketing companies.

During the reporting period, two TAG meetings were held in Karachi. This includes TAG
meeting in August 2017 and March 2018.

Sukh PMU team presented the project updates, along with highlights of midline survey
report and midcourse correction. The TAG members gave their technical inputs along
with commitment to support strengthening of FP efforts by Sukh. PMU also took
feedback and suggestions from TAG members on the study conducted on the Midline
evaluation of the LHW program comparing the status of FP in Sukh LHW area and non
Sukh LHW area.

36 Annual Report | Year V

CAPACITY DEVELOPMENT

i. Workshop on Strategic Leadership

Sukh organized a workshop
on ‘Leadership in Strategic
Communications’ in collaboration with
CCP-P. This workshop was held in
Dubai in January 2018. 23 selected
staff from PMU and implementing
partners along with Government
stakeholders participated in this
training. The trainees were oriented
on the theories and frameworks
applicable in health communications,
situational analysis, development and Workshop on Strategic Leadership Development, Jan 2018 – at Dubai

implementation of health communication campaigns including social marketing, face-to-
face communication, and new media. Participants were also oriented on the Smart Chart;
an innovative communication tool that helps in designing communication campaigns in
step-by-step manner and developing a shared understanding and common vision for
achieving stated goals and objectives.

In the last phase of training, the participants were distributed into 4 groups which
developed 4 Health Communication media campaigns pertaining to FP and Youth issues.
Sukh PMU is delighted to share that PWD have recently adopted a tag line developed by
one of the groups during this training in their new branding and communications material.
This tag line was titled ‘Aaj ki Mansuba Sazi – Khushal Kal Ki Zamanat / Today’s Family
Planning, a guarantee of happy life tomorrow’.

ii. Helpline Network Training

Sukh organized a 2 day training by Asia Safe Abortion Partnership, for 11 call agents
from ATH and Helpline network in Dubai in January 2018. Selected Sukh PMU, ATH
staff and nominees from the Telehealth Helpline network in Pakistan attended this
training which served as an exposure to best practices along with clarifying myths and
misconceptions. The training covered topics spanning from Post Abortion Care (PAC)
issues, its socio cultural context, overview of hotlines projects globally and in Asia, role
of data and monitoring, values clarification, hotline calls experience and problem solving,
WHO guidance for PAC and Family Planning.

iii. PMU participated in Scaling up and sustainability training

Three members of Sukh PMU participated in ‘Scaling up and sustainability training’ by
ExpandNet in London in May 2018. The objective was to develop a working draft paper
for publishing in a reputed journal. During this workshop, ExpandNet and Sukh teams
worked closely to identify, narrate and substantiate with measurable indicators, the journey

Annual Report | Year V 37

of best practices emerging in Sukh from the level of conceptual thoughts to actual scale
up. Over the years, Sukh PMU successfully implemented the ExpandNet’s sustainability
and scalability framework that lead to multiple Sukh practices being part of the wider
demand generation, service delivery and quality monitoring mechanisms of the PWD,
LHW program and Department of Education and Literacy, Government of Sindh.
The draft paper developed as a result to this workshop, documents the processes and
the outcomes of the management approach utilized in achieving the objectives. Sukh
Initiative takes pride in extending the benefit of current project to a much wider beneficiary
base i.e. reaching a population over one million in terms of youth being educated on
LSBE in government schools and the increase of availability of services through the task
sharing and shifting initiatives.

iv. Workshop on Manuscript writing’

Sukh Initiative signed a contract with Population Association of Pakistan (PAP) to provide
mentorship to develop at least five ready to be submitted manuscript in an international
journal. PAP is a non-profit, professional, academic and demographic organization with
the main objective to share scientific knowledge and experience and promote policy
advocacy on critical issues in population. The contract between Population Association of
Pakistan and Sukh Initiative will be effective from July 2018 – June 2019.

Conference, meetings and events

i. Dissemination

The first Midline Sukh Midline Dissemination - Islamabad
Dissemination seminar Sukh Midline Dissemination - Karachi
was held in Karachi on
7-8 November 2017 and
the second seminar was
held on 12th December
2017. The events
featured presentations
and interactive panel
discussions highlighting
fundamental elements of
Family Planning including
Community Mobilization,
Improving Access and
Quality of Family Planning
Services and System
strengthening. Critical
issues, challenges and
best practices of Sukh
were also discussed.

Primary audience of the dissemination in Karachi were the Government departments
of Population Welfare, Education and Health. The Health Minister Sindh, Costed

38 Annual Report | Year V

Implementation Plan Unit also shared encouraging remarks for the midline results.
Furthermore, research experts from local universities, public health professionals, NGOs
and health journalists attended the event.
The dissemination in Islamabad was also well attended by public policy professionals,
leading FP experts, government officials, health professionals and members of civil society.

ii. APCRSHR conference, Vietnam

SUKH PMU and selected staff from Sukh
implementing partners participated in 9th
Asia Pacific Conference on Reproductive and
Sexual Health and Rights (APCRSHR). The
theme of this conference was ‘Leave no one
behind! Justice in Sexual and Reproductive
Health’. This conference was held in Ha
Long Bay, Vietnam in November 2017. Sukh
attended learning sessions in the conference APCRSHR conference, Vietnam

and also set up a stall for dissemination of communication material. Dr. Haris Ahmed,
Head of Sukh Initiative also presented Sukh achievements in a panel discussion.

iii. Participation in Health service Academy conference, Islamabad

Sukh PMU team participated in the 8th Health Services Academy (HSA) conference, held
from 6-7 December 2017 in Islamabad. Sukh presented four abstracts including a poster
and three oral presentations. As a key note speaker, Head of Sukh Initiative, Dr. Haris
shared his thoughts, achievements and challenges faced by Sukh Initiative. The session
was well executed and led the audience towards the importance of planning and smart
implementation of health projects to make family planning more accessible.

iv. Participation in 18th Annual Population Research Conference, Lahore

Sukh participated in the 18th Annual Population Research Conference titled ‘Population
Growth and Investing Human Resource Development’. This conference was from
December 20 – 22, 2017, GC University in Lahore Pakistan and organized by Population
Association Pakistan (PAP). Dr. Haris Ahmed, Head of Sukh Initiative presented project
and its contribution to FP2020 along with approaches for FP in context of peri-urban
settings the plenary session. This conference was attended by leading FP experts,
development sector and civil society, media and students

v. SOGP conference, Karachi

Sukh participated in the 17th Biennial International Scientific Conference organized by the
Society of Gynecologist and Obstetrician, Pakistan (SOGP). This Conference was held from
23 - 25th February, 2018 in Karachi.
Sukh organized a pre-conference VCAT training for selected public and private health
care providers. This workshop was conducted by SOGP and helped improve providers’
behavior and attitude towards FP service delivery.

Annual Report | Year V 39

In addition to this, Sukh PMU also hosted
a panel discussion titled ‘Improving
Women’s Health in South Asia - Working
towards achieving SDG 3 and FP2020
goals’. Reputed FP leaders attended this
session and shared their experiences.
The panel discussion was followed by
experts’ presentation on Family Planning
related projects and experiences. This
session was attended by diverse audience
which included FP experts, health care
professionals and students, Government
dignitaries and civil society representatives. SOGP conference, Karachi

The session concluded with a token of thanks from Sukh Initiative for all the panelists
and presenters. The audience appreciated the learnings shared and Sukh’s valuable
contribution to health sector in Pakistan.

vi. Women’s Day celebration

During the month of March 2018, Sukh celebrated Women’s Day at Aman Foundation’s
office. Over 250 Community Health Workers and Sukh team attended this event. Illustrious
leaders including Dr. Yasmeen Qazi – Senior Country Advisor – Packard Foundation,
Shazina Masud – CEO, Aman Health, Dr. Haris Ahmed, Head of Sukh Initiative, Malik
Ahmad Jalal – CEO, Aman Foundation shared their experiences with the audience and
encouraged women participation and empowerment in the community.

vii. SBCC conference, Indonesia

Sukh PMU and one member from Aahung team participated in Social Behavior Change
Communication (SBCC) summit in Bali, Indonesia in April, 2018. This conference focused
on entertainment education and hosted a variety of learning sessions on behavioral
change communication and related aspects. CCP-P supported Sukh for hosting a stall
for dissemination of communication material. This conference served as a meaningful
learning experience for Sukh team along with networking and exposure to SBCC best
practices.

viii. SC engagement

Sukh PMU have been attending SC meetings on a regular basis – both in person and
telephonic conferences. Key updates are being shared by Sukh PMU and SC gives input
along with key discussions. Sukh PMU staff also attended the Steering Committee meeting
held in Vietnam in November 2018 and in Seattle, United States of America in June
2018.

Other activities

n SMT meetings were conducted on monthly basis and actively engaged all partners
to share progress and discuss challenges and way forward. Sukh PMU have been
actively guiding all implementing partners to deliver their best services in the field. In
addition to this, Field Coordination Meeting are also conducted on a routine basis to

40 Annual Report | Year V

review field operations and related matters. Proceedings of both of these forums are
documented and followed by Sukh PMU.
n Sukh PMU have also been actively engaged with all implementing partners to prepare
a realistic work plan along with strong follow-up for implementation. In addition to
the regular follow-up and meetings, PMU conducted Project mid-year review with all
implementing partners during February – March 2018.
n Sukh Initiative worked with the media sciences department of SZABIST and CCP-P to
develop four inspirational videos on the themes of ‘Youth and Women Empowerment,
Family Planning and Health’. This assignment was undertaken to support young
entrepreneurs in producing short videos and to capture key highlights from the Sukh
field. These videos were developed in Sukh area of intervention and highlighted
key achievements and contributions in the field with an emphasis on responsible
adulthood and behavior change. The videos have been disseminated across various
forums and also posted on Sukh’s website.
n A sub Award signing ceremony of Aman Health Care Services with RADS as an end
line evaluator for Sukh Initiative was held on 10th May, 2018

Scaling up of Sukh Initiative best practices:

Sukh Initiative has been instrumental in strengthening efforts of family planning with
Government department in Sindh. Some of the key contributions include:
n The concept of “Family Health Days” initiated by Sukh in Sindh, has been adopted for

scale by PWD and currently FHDs are being conducted in 26 Costed Implementation
Plan districts across Sindh. A total of 506 FHDs conducted and 8,193 client were
served
n Sukh is the first in the province to initiate Task Shifting, with LHWs being trained on
giving 1st dose of contraceptive injections, which previously were only given by a
mid-level provider (Lady Health Visitor and Lady Medical Officer) – Total 200 LHWs
were trained and they have served 1,037 clients till June, 2018
n Sukh has trained first batch of mid-level health care providers on implant insertion.
UNFPA is now leading this task to scale up at the provincial level
n Sukh was also instrumental in issuance of a directive from DG Health Sindh to pioneer
insertion and removal of implants by mid-level providers (Lady Health Visitors), a
procedure previously restricted to lady doctor only
n Sukh has been a forerunner in provision of FP counselling, services and postpartum
FP at MCH Centers, Social Security and Municipal Cooperation hospitals and
dispensaries
n Sukh Telehealth has established a consortium of organizations working on FP, LSBE
and women protection with a telephonic helping wing. The consortium members
include Green Star, Marie Stopes, Bedari, Rozan, Madadgar and Sahil
n Sukh entered into a MoU with Department of Education (DoE) Sindh to include Life
Skill Based Education modules in Secondary School Curriculum for Sindh. In only two
years’ time Sindh Textbook Board has included LSBE modules in the curriculum and
in its first phase, pilot testing of integrated LSBE curricula is under way at six schools

Annual Report | Year V 41





©Sukh Initiative 2017
The annual report for Sukh Initiative was prepared and designed by Center for Communication Programs Pakistan.
Information in this report was provided by project implementing partners Aman Community Health Program, Aman
Telehealth, Aahung, Agha Khan University, DKT Pakistan and Jhpiego, Information contained in this document does not

imply official endorsement of the donors.
Maps and illustrations included in this report are for illustrative purposes and are not for authoritative representations.

Photo credits: Sukh Initiative except where separately credited.
Any inquiries regarding this report should be sent to [email protected]

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