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

Pakistan has a persistently high level of maternal deaths. Its government-run first-level health care facilities, the Basic Health Units (BHUs), are an important place for poor and rural women to receive skilled care during delivery and birth. However, BHUs have only been open from 8.00 am to 2.00 pm daily. The provincial government of Punjab has recognized that these hours of operation severely constrain access to maternity services. Therefore the Health Department is implementing the 24/7 BHU Initiative to upgrade BHUs to provide round-the-clock care. This scale-up is based on a successful pilot project but initial reports reveal challenges in rolling out the new approach.

In this 54-month project we will work closely with the Punjab Health Department and other stakeholders to address a key concern: How can the 24/7 Basic Health Unit initiative be successfully implemented at scale to provide high quality, round-the-clock skilled maternity care in its first level care facilities in remote, rural Punjab? The project will include two overlapping work packages. The first will provide a detailed understanding of the current status of the initiative and the obstacles to successful roll out. The second will identify and test potential solutions to improve implementation.

Work package 1 extends from months 1-36 and consists of 3 modules. First, we will look at policy documents and interview policy makers to draw up a clear description of what the 24/7 BHU Initiative consists of and how it is meant to operate. Next, we will assess how well the initiative is being rolled out across the province. We will analyze the government routine monitoring data, alongside data from our own survey of 1500 births in up to 50 BHUs. This will provide a picture of how many BHUs are performing well and how many are not. We will also be able to examine factors that are associated with better or worse performance. Finally, we will spend 4-6 months looking closely at what is going on in 4-5 BHUs in 3 districts. Observations, interviews and group discussions with healthcare providers, managers and patients will allow us to understand in detail the factors that support, or get in the way of, successful round-the-clock service provision. We will particularly look for the ways in which successful BHUs are operating and identify any innovations that help things work better.

Work package 2 extends from months 24-54 and includes two modules. First, we will conduct two workshops and engage in regular meetings with government officers and other stakeholders to discuss the detailed knowledge of the 24/7 BHU initiative generated during work package 1. We will work collectively to identify a series of promising modifications that might be feasible to roll out more widely. Next, the study team will work with Punjab Health Department senior managers to select priority "change ideas" to test. We will also identify one district and 2-3 BHUs in which to carry out a pilot. We will then test the changes in a structured way, documenting how they work in practice, and working with stakeholders to agree on next steps. We will help Punjab Health Department and local stakeholders produce a longer term plan for implementing system-wide changes that are needed to make the 24/7 BHU initiative more successful.

The project will be delivered by an experienced team of researchers. Several team members have worked successfully together on previous similar research in Pakistan. Team members also have excellent links to policy-makers and senior managers who will be closely involved through a Policy and Programming Research Stakeholders Group (PPRSG). A Project Advisory Group (PAG) will also be formed, including representatives of women's organisations, to provide guidance to the project. Research findings will be shared via a range of formats tailored to policy, practice and lay audiences, as well as academic articles and conference presentations.

Pakistan's public-sector Basic Health Units (BHUs) are open for short times limiting access by poor and rural women to maternal healthcare. Punjab province's 24/7 BHU Initiative aims to scale-up a successful pilot to provide round-the-clock services. This 54-month project will co-produce a detailed analysis of the scale-up process, test plausible improvement approaches, and plan a longer-term strategy to enhance performance.
We use socio-ecological systems theory to explore scale-up, examining the complex processes that emerge as the intervention encounters features in local settings, including gender and socioeconomic hierarchies. The range of system elements and processes is wide, so we also use an intuitive implementation framework to help stakeholders make sense of the complexity, determine critical factors and identify actionable strategies.
We adopt a mixed-methods approach with two overlapping Work Packages. WP1 consists of three modules. First, policy document review and theory-driven interviews with policy makers explicate the 24/7 BHU Initiative programme theory and begin to build a system model. Second, patterns and predictors of performance are examined through three quantitative components: analysis of routine data, a new survey of 1,500 women/births in up to 50 BHUs, and BHU profiling. Third, institutional ethnographies in 4-5 BHUs in three districts describe the processes that ensue as the initiative embeds in local settings and provide detailed system understanding.
WP2 includes two modules. First, two workshops and regular meetings with stakeholders integrate WP1 findings, identify feasible changes and establish priorities. Next, "change ideas" are selected for testing in one district and 2-3 BHUs through carefully documented pilots using the PDSA improvement approach.
A variety of outputs for different audiences result, including a co-produced longer-term plan for the Punjab Health Department future strengthening of the 24/7 BHU Initiative.

The ultimate aim of this study is to have an impact on women in Punjab by improving their chances of a safe pregnancy and childbirth, free from avoidable morbidity and mortality. The study aims to contribute to improved access to skilled and respectful birth attendance and emergency obstetric care for all women, but particularly disadvantaged women in remote, rural Pakistan, when they need it. Such improvements in maternal health will also benefit women's families and their communities.

A major impact of this study will be to enable the Punjab Health Department to deliver high-quality round-the-clock maternal health services in its first-level Basic Health Unit (BHU) facilities in remote, rural areas. The study will co-produce significant new understandings of the system in which the 24/7 BHU Initiative is implemented, and actionable knowledge that will highlight ways the implementation process might be modified to enable BHUs to meet service provision goals. These modifications to the programme scale-up may also promote coordination within the Punjab Health Department, with benefits to health system functioning at district and provincial levels. By working closely with members of the Health Department's Implementation and Monitoring & Strategy branches, this study will foster recognition of the value of mixed-methods research and the importance of empiric evidence in health system change. The study will also reveal obstacles and issues that require further attention and will aim to foster a culture of openness and 'learning from failure' as well as success.

The study will also help build research capacity in Pakistan, the UK and Canada. Junior researchers recruited to work on the project will receive a range of training and mentoring in methodological and conceptual development. They will also develop skills in developing manuscripts and communicating research findings to varied audiences. In Pakistan, government technical and managerial staff will develop applied research skills and, more importantly, an appreciation of the role and importance of evidence in policy and management decisions. Specific areas of capacity development include: systems thinking; integration of qualitative and quantitative data; and Plan-Do-Study-Act (PDSA) improvement cycles.

This study will also have an impact on a wider level, producing insights that will be relevant for other South Asian and LMICs that experience similar challenges of programme scale-up and the delivery of maternal health services to remote and marginalised communities. Our insights will help policy actors in these geographic regions identify and act upon what is required to successfully merge pilot projects into existing, but often fragile, health systems. It will also generate substantive findings that will be of interest both to a much wider body of researchers focused on the arena of global maternal healthcare, and an audience of health systems researchers working on issues including: scale-up; access to primary care; health equity; gender and health; and quality improvement. Conceptually we anticipate that the study will make an important contribution to the ways in which we can understand and theorise scale-up processes. This is a relatively new area and our use of systems thinking alongside implementation and improvement frameworks is innovative.

Within our co-production of knowledge approach, we will empower district-level, front-line staff to draw upon their grounded perspectives to generate actionable knowledge. By engaging these workers, we will empower district level systems understanding and improvement modifications. An additional impact of this research will be the introduction of the PDSA improvement approaches in LMIC settings, which to date have only been used on a very limited basis.