Prior to designing and launching APPNA SEHAT project, Dr. Nasim Ashraf MD, the then president of APPNA and Dr. Frederick Shaw Dr.PH, MPH a renowned health and development expert, studied the health conditions of Pakistan for almost a year and a half during late eighties. They moved around all the four provinces, made first-hand observations in homes, and schools, in Basic Health Units and Rural Health Centers, in district federal and provincial hospitals and at almost every official level. Contrary to such expectations the feasibility team did not find Pakistan to be lacking in primary health care resources. Instead, they found that conditions they observed emerged from four problem areas. These were (1) providers had predominantly curative medical orientation, while the unmet health demands in Pakistan needed predominantly a preventive medical approach, (2) there was a dearth of reliable health information, (3) there was no pyramid-shaped administrative and clinical referral system, and (4) the number of people who were adequately trained in health education were insufficient to meet demands.

The team suggested a number of interventions and common to all of them were the five most important parameters. (1) Ideas of maximum participation by the public and health professionals alike individually and collectively in the betterment of health conditions and services. (2) Maximal utilization of resources. (3) Emphasis on health education and preventive medicine. (4) Firm focus on the achievement of well defined objectives. (5) Focus only at attainment of gains that are assured of being sustained.

It took them that long because their primary concern was to come up with a project that could target exactly the health problems in Pakistan as well as could produce an enduring impact on the health of deprived Pakistani rural population. In 1989, finally a project was designed and it was decided to pilot it for at least two years. Four rural locations were selected i.e., two in Punjab (Murree and Sahiwal) and one each in Sindh (Badin) and NWFP (Mardan). The pilot project was named as Village Improvement Model (VIM) that attracted tremendous support from the community and proved to be outstandingly successful in the evaluation that was conducted by impartial evaluators after its completion in early 1991. After the VIM was proved successful, it was replicated on a larger scale in the three subsequent projects named Village Improvement Projects (VIP) I (1992-95), II (1995-98) and III (1998 to date).

APPNA SEHAT Philosophy

All through the project period, right from the beginning the prime consideration, while planning for the project and developing project strategies, remained upon two utmost important factors. (1) The interventions must not create dependence of any kind on APPNA SEHAT or others, and (2) the focus must be on mobilizing and utilizing existing resources as well as developing communities' capacities so as to enable them to change their own lives. It is an attempt to having the communities realize that they should stop looking at and waiting for others for solutions of their prevalent problems, and start translating their existing potentials into actions. APPNA SEHAT firmly believes that nobody else from outside can bring about the required change in the community except the community itself.

Goals

The goals are set while taking into consideration what APPNA SEHAT envisages to achieve in a community that is included in the program. These are to:

Interventions

The APPNA SEHAT interventions are classified into seven main groups:

1. Men and Women Health Committees in each unit.

2. Health Board at regional level ensuring representation from each unit.

1. Immunization against tetanus for women of reproductive age (15-45 years).

2. Antenatal Care for pregnant women to identify at risk pregnancies.

3. Safe deliveries by training birth attendants.

4. Postnatal Care after delivery.

5. Referrals for identified high-risk cases.

6. Child Spacing opportunities.

1. Education of parents on importance and provision of immunization for children under five against tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles.

2. Control of diarrheal disease by educating communities on importance of ORT in diarrhea and recognition of signs of dehydration, and preparation of home-made ORS by mixing salt and sugar in water and its administration.

3. Growth monitoring of children under five: Education of importance and provision of regular growth monitoring of children under five to identify and correct the malnourishment.

4. Breast Feeding: education on importance of and provision of counseling for expectant and nursing mothers on appropriate breast-feeding.

5. Nutrition Education of mothers on importance of and how to obtain a balanced diet out of routine diet.

1. First referral facility for identified high-risk cases.

2. Resource generation to support field staff.

3. Appropriate birthing centre.

4. Curative facility to treat basic illnesses.

5. Child spacing promotion centre.

1. Water and sanitation: education of community on i) importance of using, identification and obtaining potable water, and ii) advantages of proper disposal of wastes.

2. Educating communities on importance of observing personal hygiene practices.

3. Prevention of Iodine Deficiency Disorders through utilization of iodized salt.

4. Training in First Aid procedures.

5. Prevention of Hepatitis through health education

6. Prevention of Tuberculosis through health education

Modus operandi

APPNA SEHAT is working by Units. A unit is a cluster of 500-550 contiguous households in one or adjacent villages (currently APPNA SEHAT is working in 20 such units). Each unit has the support of a facilitator. This volunteer enjoys the maximum trust of that community and provides support to APPNA SEHAT unit staff in their activities. In each unit there are five paid staff who perform pivotal role in conducting APPNA SEHAT interventions and in achieving its objectives. These are: Male Health Assistant - a male with high school education, two Female Health Assistants - village girls with high school education and two TBAs (traditional birth attendants). After the preliminary decision to include any unit is taken, the staff is trained in survey methodology and a house to house baseline survey of 100% households is conducted to confirm the decision or otherwise. The information thus collected helps to determine the exact number of individuals and related demographic information and data on health indicators.

The unit staff that belongs to the same unit area is adequately trained in project interventions with initial didactic training and on-job trainings thereafter. For each activity the 100% of the target group is registered for each and every intervention. The unit staff provide health education to the target population, MHA to male community and HA to female community, on each and every intervention over a period of time. The field staff also motivates the communities to adopt healthier life style. For example, to achieve immunization objectives all the children under five and women of ages between 15-45 are registered and later updated on monthly basis to include newborns or immigrants and exclude children due to any of the reasons like celebrating their fifth birthday, emigrants or deceased . Each unit's community is organized in a manner that ensures maximal representation starting from the household to the unit level resulting in the formation of male and female Unit Health Committees. The activities are conducted primarily at two levels: the households through household visits and the Community Organizations through their meetings. The unit staff collects data on health indicators during household visits and record on pre-designed data collection tools. The unit staff is monitored and supported by the staff at the regional level. The Training Coordinator, who has at least earned a LHV diploma, provides training support to the field staff. The Regional Supervisor monitors knowledge and skills of the field staff, and the out put and outcome of project activities at household level using well-defined monitoring tools. The Social Organizer ensures the formation and functioning of community organizations. The Regional Director is the chief supervisor of all the activities in the region. The regional offices secure all the support from head office.

Project Plan, Monitoring & Evaluation

Detailed Implementation Plan (DIP)

For each project, the management in consultation with the field staff and community prepares a detailed implementation plan (DIP). This plan clearly depicts sets of activities to be carried out to achieve each objective with clearly spelled time and place. The time is given in months and the place is the unit along with regions where that activity is to be performed. This document is reviewed annually to incorporate the changes that are deemed necessary based on experience gained during its implementation.

Project Monitoring

The monitoring of the project is conducted by three different means:

a) Monthly Reports
b) Assessment of field staff knowledge and skills
c) Assessment of project outputs through random field visits

a) Monthly Reports
Every month the information on Pregnancy, Birth Status and Maternal care (Antenatal & postnatal), Morbidity and Mortality, Immunization Status of kids and women, Child Spacing, Growth Monitoring, health education for school children, barbers and local practitioners, access of community to clean water and sanitary latrines etc. and Community Development is recorded and sent by each Male and female Health Assistant to Regional Director via the Regional Supervisor. These reports are validated before making summary reports and forwarding to head office. A Monthly Summary Report is sent from Regional Director to the Country Director. This contains a consolidated report of the information received from each field staff of a unit; a brief narrative report, in prescribed format showing progress with achieving each scheduled objective and activity; financial reports.

The Country Director compiles and summarizes the data mentioned above and submits it with his monthly discursive report to the Chairman. Monthly financial reports are submitted separately. The Chairman forwards the financial reports to the Treasurer APPNA SEHAT with his remarks.

At the end of each quarter year, Quarterly Narrative Reports take the place of progress report from the Country Director to the Chairman. The Chairman distributes such reports with his remarks appended to major donors, the members of APPNA, and other interested parties.

b)    Assessment of field staff knowledge and skills
Specific monitoring tool is used to assess the knowledge and skills of field staff on quarterly basis. This assessment is ultimately used to assess training needs of the field staff and provides the basis for designing and conducting training of the staff.

c)    Assessment of the project outputs
Specific monitoring tool, which is reviewed and revised periodically, is used to assess project outputs through household visits. This monitoring exercise helps to identify gaps in conducting project interventions. This exercise is regularly conducted by regional supervisory staff and supervisory staff from head office on monitoring visits to region. The data so collected is analyzed and shared with concerned staff to be used in monthly plan.

Project Evaluation

Two types of project evaluation are conducted: Ongoing and Periodic.

a. On-going Evaluation
Constant evaluation activities are going on at each supervisory level. There are two main aims of those activities. Firstly, to ensure that all objectives are being achieved as scheduled and secondly, to timely detect any possible impediment so that they may be isolated for close analysis and correction before they damage the project. This is also used to suggest early recourse and fine tuning of the project on the basis of information collected during internal evaluation.

b. Periodic Evaluations
For each project two formal evaluations are planned, one at mid-term and one at project's end. Experts of different disciplines from out side APPNA SEHAT are requested to participate and conduct the evaluation.