Decentralization of the health system - experiences from Pakistan, Portugal and Brazil.

BACKGROUND: Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies - Pakistan, Brazil and Portugal. MAIN BODY: This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes. CONCLUSION: Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.

Assessment of Patient Safety in a Low-Resource Health Care System: Proposal for a Multimethod Study.

BACKGROUND: The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources. OBJECTIVE: This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting. METHODS: We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization's Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility. RESULTS: The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs. CONCLUSIONS: A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non-resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50532.

Impact of haemodialysis on plasma carnitine concentrations in haemodialysis patients.

Objective: To evaluate the impact of haemodialysis on plasma carnitine levels. METHODS: The cross-sectional study was conducted from April 20, 2020 to May 10, 2022, at the dialysis unit of the nephrology ward of Jinnah Postgraduate Medical Centre, Karachi, and the Pakistan Navy Ship Shifa Hospital, Karachi, in collaboration with the Department of Biochemistry, University of Karachi, and comprised patients of either gender aged >18 years. They were divided into chronic kidney disease group A and end-stage renal disease group B. Control group C included subjects from the general population. Free carnitine and total carnitine values were detected using enzyme-linked immunosorbent assay. Acyl carnitine was estimated by applying the standard formula, and the ratio between acyl carnitine and free carnitine was calculated for accurate assessment of the carnitine status. Data was analysed using SPSS 23. RESULTS: Of the 203 subjects, 143(70.44%) were cases and 60(29.55%) were controls. Among the cases, 120(84%) were recruited from Jinnah Postgraduate Medical Centre and 23(16%) from Pakistan Navy Ship Shifa Hospital. There were 60(29.55%) patients in group A, 83(40.88%) in group B and 60(29.55%) in group C. The mean age in group A was 47.90 5.±65 years, it was 44.10 ±8.92 years in group B and 40.90 ± 6.73 years in group C. There was a significant difference related to free carnitine, total carnitine, acyl carnitine values and the ratio between acyl carnitine and free carnitine values in groups A and B compared to control group C (p<0.05). Conclusion: Patients on maintenance haemodialysis developed were found to have developed carnitine deficiency.

Are women with disabilities less likely to utilize essential maternal and reproductive health services?-A secondary analysis of Pakistan Demographic Health Survey.

BACKGROUND: People with disabilities deal with widespread exclusion from healthcare services, including sexual and reproductive health (SRH) rights. Studies analyzing the relationship between disability and key SRH utilization outcomes have often reported mixed findings. In Pakistan, very little to no literature is available on this topic, therefore we aim to determine inequalities in the utilization of essential maternal and reproductive health services between women with and without disabilities in Pakistan. METHODS: This was a secondary analysis of Pakistan Demographic Health Survey 2017-18 performed on a weighted sample of 6,711 women aged 15-49 years with a live birth in the 5 years preceding the survey. Six types of disabilities were assessed i.e. vision, hearing, communication, cognition, walking and self-care. Utilization of essential maternal and reproductive health services was assessed through a set of four outcome variables: (i) modern contraceptive use; (ii) skilled antenatal care (ANC); (iii) skilled birth attendance (SBA); and (iv) skilled postnatal care (PNC). Multivariate Cox regression analysis was performed to determine the association between dependent and independent variables. Data were analyzed using Stata MP Version 16.0. RESULTS: A total of 6,711 women were included out of which 14.1% (n = 947) live with at least one form of disability. Mean age was 29.4 (S.E = 0.13) years. The most prevalent form of disability was vision (7.0%), followed by walking (4.8%), cognition (4.8%) and hearing (1.8%). Women with disabilities were comparatively less educated, belonged to older age group, and had higher parity than their non-disabled counterparts. With the exception of modern contraceptive use, which was more prevalent in the group with disabilities, women with disabilities were less likely to utilize skilled ANC, SBA and PNC in bivariate analysis. However, these associations turned insignificant in the adjusted model. Overall, no statistically significant differences were observed in the utilization of essential reproductive health services between women with and without disabilities after adjusting for important covariates. CONCLUSION: Our analyses did not find any statistically significant differences in the utilization of essential maternal and reproductive health services between women with and without disabilities. In-depth research utilizing qualitative or mixed methods is required to understand how well the healthcare system in Pakistan is responsive to the different needs of disabled women.

Factors associated with home delivery in rural Sindh, Pakistan: results from the global network birth registry.

BACKGROUND: According to global estimates for 2017, nearly 295,000 maternal deaths occurred worldwide. Thus, approximately 810 women die every day due to pregnancy-related complications. This burden of maternal deaths in LMICs is primarily due to poor healthcare service utilization, as indicated by relatively low rates of institutional deliveries and skilled-birth attendance (SBA). We conducted this study with an aim to assess the factors associated with home delivery and its subsequent effect on the pregnancy outcome in rural Sindh, Pakistan. METHODS: Data for this study were taken from The Global Network's Maternal Newborn Health Registry (MNHR), which is a prospective, population-based observational cohort study. Registry data for 2018-2019 for District Thatta, Pakistan was retrieved for the analysis. Multivariable logistic regression models were used to determine the effect of each independent variable on the place of delivery by including all predictors and covariates. Results of the regression analyses are presented with crude odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULTS: A total of 4649 women were included in the study, of these, 1286 (27.7%) women had delivered at home. Of those who delivered at home, a larger proportion was illiterate (90%), had a BMI of less than 18.5 kg/m2 (26.0%), had parity of 3 or more (48.1%), and had a history of pregnancy loss as compared to women who had institutional delivery. In addition, two-thirds of women (63.4%) who had delivered at home had less than 4 ANC visits, whereas 15.6% did not receive any ANC. On multivariable logistic regression we found that home delivery was significantly associated with being illiterate (aOR = 1.60; [95% CI: 1.34, 2.04]), having high parity (aOR = 1.91; [95% CI: 1.58, 2.32]), and no ANC visit (aOR = 14.8; [95% CI: 10.2, 21.5]). CONCLUSIONS: More than a quarter of our study sample women delivered at home. These women were illiterate, multiparous, and did not receive antenatal care during pregnancy. It is essential to conduct extensive educational interventions for the women and their family members regarding the potential benefits of delivering in a safe and skilled environment. Moreover, the provision of comprehensive and quality antenatal care should be ensured as it improves the mothers' health-seeking behavior and helps them make informed decisions about their health and well-being.

Upper extremity deep venous thrombosis prevalence in the NHS Grampian Medical Ambulatory clinic: diagnostic, therapeutic, and prognostic considerations in oncology patients.

INTRODUCTION: Whilst upper extremity deep vein thromboses (UEDVT) account for approximately 5 to 10% of all cases of DVT, rigorous guidelines regarding diagnosis and management of presenting patients remain to be developed. The association of UEDVT with concurrent asymptomatic pulmonary embolism as well as the first presentation of malignancy deems essential rigorous research and clinical guideline development to ensure optimal patient care. METHODS: This retrospective audit study is the first to provide estimates of UEDVT prevalence in the North-East Deanery main hospital centre, Aberdeen Royal Infirmary (ARI). RESULTS: Of the 605 patients attending the ARI Ambulatory Emergency Care (AEC) clinic with clinical suspicion of UEDVT, 38 (6.2%) had a confirmatory diagnosis. Underlying malignancy, presence of PICC line, and cardiovascular co-morbidities were identified as common confounding factors. Subclavian vein with concurrent extension to primarily the cephalic vein thrombosis was identified as the most commonly thrombosed venous territories. Importantly, oncology patients were found to have poorer survival outcomes following an UEDVT, in comparison to patients with other significant co-morbidities (cardiovascular, chronic renal disease, inflammatory bowel disease): HR 5.814 (95%CI 1.15, 29.25), p 0.012. Lastly, genetic associations were drawn between patient genetic status as tested for other co-morbidities and prothrombotic cellular cascades, suggesting rigorous VTE assessment in patients identified with congenital or acquired mutations, namely, in CALR, JAK, MSH 2/6, MYC, and FXN. CONCLUSIONS: Overall, this study offers the first report of UEDVT presentations in the UK with no restrictions of patient performance status or underlying co-morbidities and provides a rounded clinical picture of patient characteristics, diagnosis, management, and prognostic associations in view of rigorous guideline development.

Knowledge, attitudes and practices towards COVID-19 among Pakistani residents: information access and low literacy vulnerabilities.

BACKGROUND: Coronavirus disease (COVID-19) has accentuated the need for speedy access to information. Digital divide and socio-demographic disparity create an information hiatus and therefore unhealthy practices with regard to dealing with COVID-19, particularly in low- and middle-income countries. AIMS: We assessed knowledge, attitudes, practices and their determinants regarding COVID-19 in Pakistan during March-April 2020. METHODS: 905 adults ≥18 years (males and females) participated: 403 from a web-based survey; 365 from an urban survey; and 137 from a rural survey. Frequency of adequate knowledge, attitudes and practices for the three populations was determined based on available global guidelines. Multivariable logistic regression analysis determined factors of adequacy of knowledge, attitudes, practices, and association of knowledge with attitudes and practices. RESULTS: Mean age of the participants was 33.5 (+ SD 11.1) years, 51% were females. More females and young adults (18-30 years) participated in the web-based survey. The urban survey and web-based survey participants had significantly higher adequate knowledge (2-7 times) and practices (4-5 times) towards COVID-19. Adequate knowledge had a significant influence on healthy attitudes and practices for COVID-19, after adjustment for covariates. Overall, two-thirds of the population had high levels of fear about COVID-19, which was highest among the rural survey population. CONCLUSION: Substantial gaps exist in adequate knowledge, attitudes and practices, particularly among rural populations, and underscores the variation in access to information according to level of education and access to the internet. Thus, a comprehensive, contextually congruent awareness raising strategy is urgently needed to confront COVID-19 among these populations.

Burn first aid knowledge and its determinants among general population of Rawalpindi.

OBJECTIVE: To assess the general knowledge and practices related to burn first aid treatment (BFAT) and to examine age, gender, socioeconomic status, education and previous history of exposure to burn (self/family member) as factors influencing burn first aid knowledge among the general population of Rawalpindi. STUDY DESIGN: A cross-sectional, descriptive survey. PLACE AND DURATION OF STUDY: Three major tertiary care hospitals of Rawalpindi, from August 2017 to May 2018. METHODOLOGY: All consenting people ≥ 18 years of age, with or without a prior history of burn, accompanying patients to three major tertiary care centers of Rawalpindi were administered a pre-tested structured questionnaire. The questionnaire was divided into two sections; socio-demographic section and knowledge on BFAT. Those who were illiterate and could not fill the questionnaire were interviewed and their responses were marked by the researchers themselves. Data were analyzed using SPSS version 21. RESULTS: A total of 400 participants comprising 205 (51.3%) males and 195 (48.8%) females with a mean age of 38 ± 10.3 years were included. The majority (58%) were educated up to 12th grade or higher. "Toothpaste" (47.5%) followed by "cool running water" (20.3%) were the two most frequently applied items following a burn injury. Only 8.8% respondents applied cold water for the ideal time duration. Overall, 83% of the participants provided correct answers for 25-50% of the survey questions. Socioeconomic and educational status of the participants had a significant association with burn first aid knowledge. CONCLUSION: A significant limitation of knowledge regarding BFAT was seen among the general population of Rawalpindi.

A Case of Waardenburg-Shah Syndrome Type 4 Presenting with Bilateral Homochromatic Blue Irises from Pakistan.

Waardenburg syndrome (WS) is a rare genetic disorder. It is caused by multiple mutations affecting the melanocytes, leading to a multitude of skin, hair, and eye symptoms. It is an autosomal dominant disease with four subtypes, each presenting with varying degrees of sensorineural hearing loss along with a constellation of other symptoms. Hirschsprung disease is unique to Waardenburg-Shah syndrome subtype 4 and is not associated with any other subtype. We present a case of this subtype 4 that presented with a bilateral sensorineural hearing loss, mutism, delayed milestones, white forelock, Hirschsprung disease, and bilateral blue homochromatic irises, a finding which is not typical for this subtype. This is the first case of WS with homochromatic irises and the fourth case to be reported from Pakistan.

Spinal cord injury without radiographic abnormality (SCIWORA) in adults: A report of two cases.

Spinal cord injury without any radiographic abnormality (SCIWORA) is rare in adults. We describe here two case reports of adult patients, who presented to us with quadriplegia, following a road traffic accident. Plain radiography and computed tomography (CT) of cervical spine were normal. Hence the patients were diagnosed as cases of adult SCIWORA. However, subsequent magnetic resonance imaging (MRI) of the two patients revealed cervical cord injury in the form of cord contusion and disc protrusion, respectively. Patient with cord contusion was managed medically, whereas the patient with disc lesion was treated with discectomy. Patient treated with discectomy showed marked improvement. Therefore, patients having no osseous injury on X ray and CT scan should have an MRI study done to look for surgically correctable pathology. As in such rare patients of SCIOWRA an early diagnosis and timely intervention is crucial; with MRI playing a pivotal role.

Monocyte Chemoattractant Protein-1 (MCP-1/CCL2) Levels and Its Association with Renal Allograft Rejection.

BACKGROUND: CCL2 is a chemoattractant for monocytes/macrophages, T cells, and natural killer cells. It is shown to be involved in the immunological responses against renal allograft. This study was conducted to access the role of urinary CCL2 expression in predicting the rejection episodes in renal transplant patients. METHOD: A total of 409 urine samples included in this study. The samples were consisted of (a) biopsy-proven graft rejection (n = 165); (b) non-rejection (n = 93); (c) non-biopsy stable-graft (n = 42), and (d) healthy renal donors (n = 109). The samples were quantified for the CCL2 using the MCP-1/CCL2 ELISA kit. The data were analyzed using the Statistical Package for Social Sciences (SPSS®) and MedCalc® statistical software. RESULTS: Results showed that the CCL2 levels were significantly increased in rejection group when compared with the non-rejection, stable-graft, and control, P < 0.05. The receiver operating curve's characteristics illustrated that the urinary CCL2 level is a good predictor for graft rejection, with an area under the curve of 0.81 ± 0.03 with optimum sensitivity and specificity of 87% and 62%, respectively, at a cut-off value of 198 pg/mL. Kaplan-Meier curve also showed better cumulative rejection-free graft survival time in group with less than 198 pg/mL of CCL2 as compared to those with expression levels of more than 198 pg/mL (30 weeks vs. 3 weeks; log-rank test, P < 0.001). CONCLUSION: In our study, noninvasive investigation of CCL2 levels in urine has showed potential to predict rejection episodes. It is suggested that the CCL2, with others markers, may help in early detection and monitoring of graft rejection episodes.

Regression of hepatocellular carcinoma after treatment with Sofosbuvir - A case report.

Spontaneous regression (SR) of hepatocellular carcinoma (HCC) is a rare event. Several factors have been suggested as the underlying mechanism but the exact pathogenesis is not understood. The role of sofosbuvir in HCC regression has not been established yet. We report here a case of a 59 years old male who developed HCC secondary to chronic HCV infection. He failed treatment with interferon but the tumour regressed completely after treatment of hepatitis C with sofosbuvir and ribavirin for 48 weeks.

NUTRITIONAL STATUS AND ASSOCIATED FACTORS IN UNDER-FIVE CHILDREN OF RAWALPINDI.

BACKGROUND: Malnutrition is a serious child health issue throughout the developing world. Pakistan has the second highest infant and child mortality rate in South Asia. This study was carried out to assess the nutritional status of children under 5 years of age and to determine the frequency and association of malnutrition with various demographic variables in the study group. METHODS: A multi-centre, cross sectional study was conducted at the immunization centres of the 3 allied hospitals of Rawalpindi Medical College during March-May 2014. Healthy children of under 5 years of age without confirmed diagnosis of any disease/ailment were included. Guardians of 100 children were interviewed using a structured questionnaire. Demographic variables include age, gender, family size, family income, breastfeeding, maternal education, presence of a family member with special needs and presence of siblings under 5 years in family. Weight (kg) was measured and malnutrition was assessed by weight for age. RESULTS: Malnutrition was found to be present in 32% of children. Adequately nourished children were 68%, while moderately and severely malnourished children were 14% and 18% respectively. Our study indicated malnutrition to be significantly associated with maternal illiteracy (p = 0.01) and presence of a family member with special needs (p = 0.05). No significant association was found between malnutrition and gender, family size, family income, breast feeding and presence of siblings under 5 years of age. CONCLUSION: There is a need to plan composite interventions to elucidate the factors that place children at greater risk for malnutrition.