Rebuilding research capacity in fragile states: the case of a Somali-Swedish global health initiative.

This paper presents an initiative to revive the previous Somali-Swedish Research Cooperation, which started in 1981 and was cut short by the civil war in Somalia. A programme focusing on research capacity building in the health sector is currently underway through the work of an alliance of three partner groups: six new Somali universities, five Swedish universities, and Somali diaspora professionals. Somali ownership is key to the sustainability of the programme, as is close collaboration with Somali health ministries. The programme aims to develop a model for working collaboratively across regions and cultural barriers within fragile states, with the goal of creating hope and energy. It is based on the conviction that health research has a key role in rebuilding national health services and trusted institutions.

The imperative of functional integration for achievement of MDGs.

Pakistan launched its Maternal, Neonatal and Child Health (MNCH) programme in 2006 in collaboration with the World Health Organization (WHO) and other partners to bridge gaps and upscale interventions aimed at reducing mortality and achieving the Millennium Development Goals (MDGs). The country will have an uphill task in meeting by 2020, the 2015 targets set for attainment of MDGs 4 and 5. The current Contraceptive Prevalence Rate (CPR) level of 30% is considerably below the 60% target set for 2020 and the current Total Fertility Rate (TFR), estimated at 4, is significantly higher than the set target of 2.1. Similarly, the Infant Mortality Rate (IMR) of 78 per 1,000 live births is lagging behind the MDG target of 40 per 1,000 live births, while the Maternal Mortality Ratio (MMR) of 276 per 105 live births is higher than the MDG target of 140 per 105 live births. With the rural population at an added disadvantage by reporting 82% and 40% higher MMR and IMR respectively-relative to the population of urban and major cities-reducing the current population growth rate of about 1.7% to 1.3% in the envisaged limited timeframe appears challenging. To overcome these programmatic impediments, the existing fragmentation in implementation of MNCH/Reproductive Health (RH) and Family Planning (FP) services needs to be urgently addressed. To respond to this call, the ministries of Health and Population made a joint commitment at the end of 2008 to bring about functional integration by delivering the MNCH/RH/FP services in a unified manner and by setting up effective institutional, strategic and operational mechanisms that can enhance the implementation process. To significantly reduce IMR and MMR and improve RH/FP outcomes, the two ministries must challenge the status quo and promote the coordination of health and population policies, improve MNCH/RF and FP management practices including monitoring and supervision, deploy, train and motivate the health workforce and strengthen the health system. Functional integration must also aim at ensuring use of appropriate technologies and uninterrupted provision of supplies and equipment. This viewpoint, which is related to the Heartfile Report, aims at diagnosing outstanding challenges at the field level, as well as factors contributing to successful implementation of MNCH/RH and FP and their progress towards achieving Millennium Development Goals (MDGs) 4 and 5.

Investigating socio-economic-demographic determinants of tobacco use in Rawalpindi, Pakistan.

BACKGROUND: To investigate the socio-economic and demographic determinants of tobacco use in Rawalpindi, Pakistan. METHODS: Cross sectional survey of households (population based) with 2018 respondent (1038 Rural; 980 Urban) was carried out in Rawalpindi (Pakistan) and included males and females 18-65 years of age. Main outcome measure was self reported daily tobacco use. RESULTS: Overall 16.5% of the study population (33% men and 4.7% women) used tobacco on a daily basis. Modes of tobacco use included cigarette smoking (68.5%), oral tobacco (13.5%), hukka (12%) and cigarette smoking plus oral tobacco (6%). Among those not using tobacco products, 56% were exposed to Environmental tobacco smoke. The adjusted odds ratio of tobacco use for rural residence compared to urban residence was 1.49 (95% CI 1.1 2.0, p value 0.01) and being male as compared to female 12.6 (8.8 18.0, p value 0.001). Illiteracy was significantly associated with tobacco use. Population attributable percentage of tobacco use increases steadily as the gap between no formal Education and level of education widens. CONCLUSION: There was a positive association between tobacco use and rural area of residence, male gender and low education levels. Low education could be a proxy for low awareness and consumer information on tobacco products. As Public health practitioners we should inform the general public especially the illiterate about the adverse health consequences of tobacco use. Counter advertisement for tobacco use, through mass media particularly radio and television, emphasizing the harmful effects of tobacco on human health is very much needed.

The National Action Plan for the Prevention and Control of Non-communicable Diseases and Health Promotion in Pakistan--Cardiovascular diseases.

The National Action Plan for Non-Communicable Disease Prevention, Control and Health Promotion in Pakistan (NAP-NCD) incorporates prevention and control of cardiovascular diseases (CVD) as part of a comprehensive and integrated non-communicable Disease (NCD) prevention effort. In this programme, surveillance of cardiovascular risk factors is part of an integrated population-based NCD surveillance system. The population approach to CVD prevention is a priority area in this programme with a focus on broad policy measures and behavioural change communication. The former include revision of the current policy on diet and nutrition to expand its focus on under-nutrition; the development of a physical activity policy; strategies to limit the production of, and access to, ghee as a medium for cooking and agricultural and fiscal policies that increase the demand for, and make healthy food more accessible. The programme focuses attention on improving the quality of prevention programmes within primary and basic health sites and integrates concerted primary and secondary prevention programmes into health services as part of a comprehensive and sustainable, scientifically valid, and resource-sensitive programme for all categories of healthcare providers. It promotes screening for raised blood pressure at the population level and screening for dyslipidaemia and diabetes in high-risk groups only. It highlights the need to ensure the availability of aspirin, beta blockers, thiazides, ACE inhibitors, statins and penicillin at all levels of healthcare. The programme points out the need to conduct clinical end-point trials in the native Pakistani setting to define cost-effective therapeutic strategies for primary and secondary prevention of CVDs. Emphasis is laid on building capacity of health systems in support of CVD prevention and control and building a coalition or network of organizations to add momentum to CVD prevention and control efforts.

Diabetes prevention and control: National Action Plan for NCD Prevention, Control and Health Promotion in Pakistan.

More than 10% of the adult population in Pakistan suffers from diabetes. The National Action Plan for Non-communicable Disease Prevention, Control and Health Promotion in Pakistan (NAP-NCD) incorporates prevention and control of diabetes as part of a comprehensive and integrated national non-communicable disease (NCD) prevention effort. Building on existing data, the diabetes surveillance process has been integrated with a comprehensive population-based NCD surveillance system using waist circumference as a proxy indicator for the risk of diabetes in the short term; however, the surveillance strategy makes a case for future efforts to upgrade surveillance to allow a more comprehensive assessment incorporating biochemical assessments. The programme focuses on diabetes prevention by maximizing risk factor control as a common theme across the range of NCDs and lays emphasis on integrating prevention of'diabetes and intensified case finding in high-risk groups into health services as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resource-sensitive Continued Medical Education (CME) programme for all categories of healthcare providers. The programme also focuses on ensuring availability of anti-diabetics (insulin, sulphonylureas, metformin) at all levels of healthcare. Building capacity in the health system and coalitions in support of diabetes prevention has also been regarded as being critical.

Tobacco control: National Action Plan for NCD Prevention, Control and Health Promotion in Pakistan.

Reliance on revenue generated from tobacco is one of the fundamental barriers to effective tobacco control in Pakistan. The tobacco control component of the National Action Plan for Non-Communicable Diseases Prevention, Control and Health Promotion in Pakistan (NAP-NCD) deems it critical to address this issue. A range of policy and environmental strategies are part of this comprehensive effort; these involve regulating access and limiting demand through restrictions on advertising, marketing, promotion and through price and taxation. The NAP-NCD also encompasses community and school interventions, enforcement of tobacco control policies, cessation programmes, mass media counter-marketing campaigns for both prevention and cessation, and surveillance and evaluation of efforts. As part of NAP-NCD, surveillance of tobacco use has been integrated with a population-based NCD surveillance system. Featuring tobacco prominently as part of an NCD behavioural change strategy and providing wide-ranging information relevant to all aspects of tobacco prevention and control and smoking cessation have been identified as priority area in NAP-NCD. Other priority areas include the gradual phasing out of all types of advertising and eventually a complete ban on advertising; allocation of resources for policy and operational research around tobacco and building capacity in the health system in support of tobacco control. NAP-NCD also stresses on the need to develop and enforce legislation on smuggling contrabands and counterfeiting and legislation to subject tobacco to stringent regulations governing pharmaceutical products. The adoption of measures to discourage tobacco cultivation and assist with crop diversification; integration of guidance on tobacco use cessation into health services and insuring the availability and access to nicotine replacement therapy are also part of NAP-NCD.

Prevention and control of chronic chest diseases: National Action Plan for NCD Prevention, Control and Health Promotion in Pakistan.

The National Action Plan for Non-Communicable Disease Prevention, Control and Health Promotion in Pakistan (NAP-NCD) does not include surveillance of Chronic Respiratory Diseases (CRDs) into the integrated NCD surveillance model due to issues with assessing the magnitude of the burden of CRD in general and chronic obstructive pulmonary disease (COPD) in particular, within populations. Tobacco has been used as a proxy for the magnitude of COPD in the population. However, it stresses on the need to develop acceptable criteria for the diagnosis of CRDs and methodologies to monitor CRDs. The CRD component of the NAP-NCD integrates prevention of CRDs with a comprehensive NCD prevention and control framework with specific emphasis on tobacco as a cross-cutting theme. It prioritizes the examination of trends in outdoor air pollution levels and their determinants in order to develop appropriate public health interventions. Other priority areas include research to quantify the magnitude and determinants of chronic lung diseases attributable to indoor air pollution both in the rural and urban areas; the development of appropriate public health strategies to reduce risks in such settings and the integration of guidance on CRD prevention with an NCD behaviour change communication strategy. The cross-cutting theme of environmental pollution and occupational exposure to toxins develops common action areas for CRD and cancer prevention.

Prevention and control of cancers: National Action Plan for NCD Prevention, Control and Health Promotion in Pakistan.

The National Action Plan for Non-communicable Diseases Prevention, Control and Health Promotion in Pakistan (NAP-NCD) integrates prevention and control of cancers with a comprehensive NCD prevention framework with a specific emphasis on tobacco, diet and physical activity as cross-cutting risks. The programme prioritizes on sustainable institutional support for mature cancer registries in order to facilitate cancer surveillance; prevention of cancers and early detection as part of an integrated NCD behavioural change communication strategy and building capacity in the health system for cancer prevention and control. The programme's research agenda also includes appropriate studies to bridge critical gaps in evidence relating to appropriate and cost-effective strategies for preventing common cancers in Pakistan. To contain exposure to carcinogenic agents in the environment and in worksites, NAP-NCD stresses on the transparent enforcement of National Environmental Quality Standards; the institution to take proactive measures to contain potential risks to cancers in industrial settings; stricter enforcement of labour laws, stringent regulations governing chemical handling and the active incorporation of preventive health in the mandate of organizations providing health coverage for the labour workforce. It has also been deemed essential to study cancer trends in defined industrial settings at high-risk and to identify causal associations in order to delineate precise targets for preventive interventions in the native setting. NAP-NCD stresses on the development of institutional mechanisms with a regulatory function for cancer control; these include a National Cancer Control Council, with the mandate to uphold ethics and principles and guidelines on technical matters and a National Occupational Safety and Health Association. The Plan also prioritizes on pain relief and palliative care alongside prevention and control efforts and stresses on the need to integrate prevention efforts into health services as a sustainable and evidence-based activity.

Prevention and control of mental illnesses and mental health: National Action Plan for NCD Prevention, Control and Health Promotion in Pakistan.

As part of the National Action Plan for Non-communicable Disease Prevention, Control and Health Promotion in Pakistan (NAP-NCD), mental illnesses have been grouped alongside non-communicable diseases (NCD) within a combined strategic framework in order to synchronize public health actions. The systematic approach for mental illnesses is centred on safeguarding the rights of the mentally ill, reducing stigma and discrimination, and de-institutionalisation and rehabilitation of the mentally ill in the community outlining roles of healthcare providers, the community, legislators and policy makers. The approach has implications for support functions in a number of areas including policy building, manpower and material development and research. Priority action areas for mental health as part of NAP-NCD include the integration of surveillance of mental illnesses in a comprehensive population-based NCD surveillance system; creating awareness about mental health as part of an integrated NCD behavioural change communication strategy; integration of mental health with primary healthcare; the development of sustainable public health infrastructure to support community mental health initiatives; building capacity of the health system in support of prevention and control activities; effective implementation of existing legislation and harmonizing working relationships with law enforcing agencies. NAP-NCD also stresses on the need to integrate mental health into health services as part of a sustainable and integrated medical education programme for all categories of healthcare providers and the availability of essential psychotropic drugs at all healthcare levels. It lays emphasis on protecting the interests of special groups such as prisoners, refugees and displaced persons, women, children and individuals with disabilities. Furthermore, it promotes need-based research for contemporary mental health issues.

Injury prevention and control: National Action Plan for NCD Prevention, Control and Health Promotion in Pakistan.

The National Action Plan for Non-communicable Disease Prevention, Control and Health Promotion in Pakistan (NAP-NCD) incorporates prevention of injuries into a comprehensive NCD prevention effort. This encompasses the prevention of road traffic crashes (RTC)s, occupational injuries, falls, burns and other injuries. In this programme, surveillance of injuries--as part of comprehensive population-based NCD surveillance system, supplemented by multiple data sources--has been stipulated as an entry point, to injury prevention and control efforts. Actions areas for preventing RTCs include interventions to improve road safety education, identification and implementation of safety measures for traffic black-spots, enforcement of seatbelt and helmet laws and the development and implementation of highway ordinances. Recommendations have also been made to establish a road safety committee and to facilitate inter-sectoral action. It has also been deemed essential to enact and enforce legislation on locally manufactured vehicles, regulate drivers' training and licensing and evaluation of Highway Police Force from a performance and fiscal perspective. To prevent worksite injuries, a national consensus has been achieved to develop a comprehensive policy and to enact and enforce legislation for occupational health and safety; to include preventive health in the mandate of organizations dealing with worksite safety and to study patterns of occupational injuries and their determinants with a view to defining precise targets for preventive interventions. In addition NAP-NCD makes a strong case for the establishment of a National Safety Commission, the development of product safety standards for household usage, enforcement of legislation on building safety, and efforts to improve trauma care to the extent that a credible, cost-effective analysis suggests. It also calls for the need to formally evaluate interventions to reduce all forms of violence in Pakistan. Building capacity in the health system for injury prevention and building partnerships for sustainable outcomes in injury prevention have also been defined as priority areas.