The Impact of Climate Change on Health Services in Low- and Middle-Income Countries: A Systematised Review and Thematic Analysis.

Aim: The aim of this study was to assess the impact of climate change on health services as categorized by the WHO's Building Blocks for creating Climate-Resilient Health Systems. Objective: The objective was to conduct a systematized review of the published literature concerning the impact of climate change, using a thematic analysis approach to address our aim and identify areas for further research. Design: A search was conducted on 8 February 2022 using the Embase and PubMed research databases. Peer-reviewed scientific studies that were published in English from 2012 to 2022, which described at least one report concerning the impact of climate change on health services in LMICs, were included. Studies were organized based on their key characteristics, which included the date of publication, objective, method, limitations, participants, and geographical focus. The Mixed-Methods Appraisal Tool (MMAT) was used to assess the risk of bias in the included studies. Results: Twenty-three studies were included in this review. Five areas of health services which align with the WHO building blocks framework were impacted by climate change. These health service areas included: (1) Service Delivery, (2) Human Resources, (3) Health Finance, (4) Healthcare Products and Technology, and (5) Leadership and Governance. However, research concerning the impact of climate change on health information systems, which is part of the WHO building blocks framework, did not feature in our study. The climatic effects were divided into three themes: meteorological effects, extreme weather events, and general. The research in this study found that climate change had a detrimental impact on a variety of health services, with service delivery being the most frequently reported. The risk of bias varied greatly between studies. Conclusions: Climate change has negatively impacted health services in a variety of different ways, and without further actions, this problem is likely to worsen. The WHO building blocks have provided a useful lens through which to review health services. We built an aligned framework to describe our findings and to support future climate change impact assessments in this area. We propose that further research concerning the impact of climate change on health information systems would be valuable, as well as further education and responsible policy changes to help build resilience in health services affected by climate change.

Building confidence in the COVID-19 vaccine in a polio-endemic country: strategic communication lessons from Pakistan.

In a health emergency, governments rely on public trust in their policy, and anticipate its compliance to protect health and save lives. Vaccine hesitancy compromises this process when an emergency involves infections. The prevailing discourse on vaccine hesitancy often describes it as a static phenomenon, ignoring its expanse and complexity, and neglecting the exploration of tools to address it. This article diverges from the conventional perspective by explaining the case of Pakistan and its communication strategy for the COVID-19 vaccine. Decades of polio vaccine hesitancy, rooted in the country's fight against terrorism, constitute its history. On the other hand, the first-ever launch of typhoid conjugate vaccine involving 35 million kids during 2019-2021 was a success. Against this backdrop, the country considered vaccine hesitancy as a dynamic phenomenon, interwoven with the social ecology and the responsiveness of the healthcare system. Its communication strategy facilitated those willing to receive the vaccine, while being responsive to the information needs of those still in the decision-making process. In the face of both hesitancy and a scarcity of vaccine doses, the country successfully inoculated nearly 70% (160 million) of its population in just over 1 year. People's perceptions about the COVID-19 vaccine also improved over time. This achievement offers valuable insights and tools for policymakers and strategists focused on the demand side of vaccine programmes. The lessons can significantly contribute to the global discourse on improving vaccine confidence and bolstering global health security.

Protecting health care workers from COVID-19: implementing a training programme on personal protective equipment in Pakistan.

Background: Pakistan's Ministry of National Health Services, Regulations and Coordination, with support from the World Health Organization, developed and implemented the "We Care" programme to protect frontline health care workers engaged in the coronavirus disease 2019 (COVID-19) response. Aims: This paper reports on the training part of the programme, which aimed to train 100 000 frontline health care workers on the proper use of personal protective equipment (PPE) and on the lessons learnt from implementation of the training. Methods: A team of experts developed the curriculum and its accompanying material. Initial training was given to deans of all participating institutions and to master trainers from each university. Staff of all public and private hospitals enrolled in the training and other frontline health care workers were invited to register individually. Four types of educational material were produced and used a guidance booklet, a training video, a set of PowerPoint presentations to explain the PPE and their use, and a poster. Results: A total of 2000 training sessions were conducted across the country from May to December 2020 and 100 000 frontline health care workers were trained on the use of PPE. Of those trained, 25% were doctors, 35% were nurses and paramedics, and 40% were allied health staff, with an almost equal gender distribution. Conclusions: With limited resources and over a short period, the We Care programme trained a large number of frontline health care workers, which enhanced their safety and reduced the irrational use of PPE.

System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan.

BACKGROUND: Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme's performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme's insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities. METHODS: We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO's six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes. RESULTS: The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines. CONCLUSIONS: The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals.

Health system barriers and levers in implementation of the Expanded Program on Immunization (EPI) in Pakistan: an evidence informed situation analysis.

BACKGROUND: In Pakistan, immunization coverage has been quite low since the program's inception, and the 2012-2013 population-based survey recorded it at 54%. Much has been written about the issues, challenges, and constraints in the implementation of Pakistan's immunization program. However, there is a need to better understand the health system barriers as well as levers that influence progress. This review aims to bridge the information gaps on system-level barriers that currently impede the optimal delivery and uptake of immunization services to the children of Pakistan through the Expanded Program on Immunization (EPI). METHODS: We conducted a comprehensive literature review, using PubMed and Google Scholar to find peer-reviewed literature, and also reviewed EPI-related international and national reports. Additionally, we consulted government reports, surveys, and publications on the health system. Employing the basic tenets of WHO's health systems framework for health system strengthening, and a socio-ecological model, this study cataloged the service delivery and the demand side perspective on various pillars of Pakistan's immunization program. RESULTS: Themes generated from the literature review included financing, governance, service delivery, human resources, information systems, and supplies and vaccines. Findings suggest that certain areas in the larger health system need to be improved for a more coordinated implementation of EPI in Pakistan. Moreover, it is imperative to understand community behaviors and perceptions as well as demand side issues in order to achieve the desired results. CONCLUSION: For better immunization coverage and ultimately a reduction in child mortality due to preventable diseases, EPI operations and performance must be improved. Further systematic implementation research could help to develop an even finer understanding of the system-wide bottlenecks encumbering the coverage and efficiency of the program.

Distressed setting and profound challenges: Pandemic influenza preparedness plans in the Eastern Mediterranean Region.

BACKGROUND: Influenza pandemics are unpredictable and can have severe health and economic implications. Preparedness for pandemic influenza as advised by the World Health Organization (WHO) is key in minimizing the potential impacts. Pandemic Influenza Preparedness (PIP) Framework is a global public-private initiative to strengthen the preparedness. A total of 43 countries receive funds through Partnership Contribution (PC) component of PIP Framework to enhance preparedness; seven of these fall in the WHO's Eastern Mediterranean Region. We report findings of a desk review of preparedness plans of six such countries from the Region. METHODS: The assessment was done using a standardized checklist containing five criteria and 68 indicators. The checklist was developed using the latest WHO guidelines, in consultation with influenza experts from the Region. The criteria included preparation, surveillance, prevention and containment, case investigation and treatment, and risk communication. Two evaluators independently examined and scored the plans. RESULTS: Pandemic preparedness plan of only one country scored above 70% on aggregate and above 50% on all individual criteria. Plans from rest of the countries scored below satisfactory on aggregate, as well as on individual preparedness criteria. Among the individual criteria, prevention and containment scored highest while case investigation and treatment, the lowest for majority of the countries. In general, surveillance also scored low while it was absent altogether, in one of the plans. CONCLUSIONS: This was a desk review of the plans and not the actual assessment of the influenza preparedness. Moreover, only plans of countries facilitated through funds provided under the PC implementation plan were included. The preparedness scores of majority of reviewed plans were not satisfactory. This warrants a larger study of a representative sample from the Region and also calls for immediate policy action to improve the pandemic influenza preparedness plans and thereby enhance pandemic preparedness in the Region.

Dynamics of evidence-informed health policy making in Pakistan.

Incorporating evidence is fundamental to maintaining the general acceptance and efficiency in public policies. In Pakistan, different actors-local and global-strive to facilitate the development of evidence-informed health policies. Effective involvement however, requires knowledge of the country-context, i.e. knowing the intricacies of how policies are formulated in Pakistan. Obtaining this knowledge is one of the key steps to making interventions impactful. We carried out a qualitative study to explore the environment of evidence-informed health policy in Pakistan. The study involved 89 participants and comprised three phases including: (1) literature review followed by a consultative meeting with key informants to explore the broad contours of policy formulation, (2) in-depth interviews with participants belonging to various levels of health system to discuss these contours and (3) a roundtable with experts to share and solidify the findings. Policy development is a slow, non-linear process with variable room for incorporation of evidence. Political actors dominate decisions that impact all aspects of policy, i.e. context, process and content. Research contributions are mostly influenced by the priorities of donor agencies-the usual proponents and sponsors of the generation of evidence. Since the devolution of health system in 2012, Pakistan's provinces continue to follow the same processes as before 2012, with little capacity to generate evidence and incorporate it into health policy. This study highlights the non-systematic, nearly ad hoc way of developing health policy in the country, overly dominated by political actors. Health advocates need to understand the policy process and the actors involved if they are to identify points of impact where their interaction with policy brings the maximum leverage. Moreover, an environment is needed where generation of data gains the importance it deserves and where capacities are enhanced for communicating and understanding evidence, as well as its incorporation into policy.

Cognitive-behavioral counseling for exclusive breastfeeding in rural pediatrics: a cluster RCT.

OBJECTIVE: To test the effectiveness of cognitive-behavioral counseling on the rate and duration of exclusive breastfeeding (EBF) during the first 6 months of an infant's life compared with routine counseling. METHODS: A single blind cluster-randomized controlled trial was undertaken in 40 Union Councils of a rural district in the northwest province of Pakistan between May 2009 and April 2010. By simple unmatched randomization, 20 Union Councils were each allocated to intervention and control arms. Two hundred twenty-four third trimester pregnant women in the intervention and 228 third trimester pregnant women in the control arm were enrolled and followed-up biweekly until 6 months postpartum. Analyses were by intention to treat. Mothers in the intervention group received 7 sessions of cognitive-behavioral counseling from antenatal to 6 months postpartum, whereas the control group received an equal number of routine sessions. Proportion of mothers exclusively breastfeeding at 6 months postpartum and duration of EBF through these 6 months was assessed. RESULTS: At 6 months postpartum, 59.6% of mothers in the intervention arm and 28.6% in the control arm were exclusively breastfeeding. This translates into a 60% reduced risk of stopping exclusively breastfeeding during the first 6 months (adjusted hazard ratio, 0.40 [95% confidence interval: 0.27-0.60], P < .001). Mothers in the intervention group were half as likely to use prelacteal feeds with their infants (adjusted relative risk, 0.51 [95% confidence interval: 0.34-0.78]). CONCLUSIONS: Compared with routine counseling, cognitive-behavioral counseling significantly prolonged the duration of EBF, doubling the rates of EBF at 6 months postpartum.

Case Study: Effects of a Media Campaign on Breastfeeding Behaviors in Sindh Province, Pakistan.

A 2013-2014 media campaign in Sindh Province, Pakistan, promoted healthy breastfeeding practices. According to data from annual household surveys, 26.7% of mothers saw one television spot and 19.4% saw another. The proportion of mothers who received breastfeeding information via television increased from 8.3% to 29.4% after the campaign (p≤0.05) and the percentage receiving information from doctors, mothers-in-law and relatives/friends nearly doubled (p≤0.05). However, no improvements in breastfeeding practices were reported. The experience in Sindh suggests that, in order to change breastfeeding practices, mass media interventions should be linked with other interventions, such as provider counseling, that involve influential family members in addition to mothers.

Integrating maternal psychosocial well-being into a child-development intervention: the five-pillars approach.

Maternal psychosocial well-being (MPW) is a wide-ranging concept that encompasses the psychological (e.g., mental health, distress, anxiety, depression, coping, problem solving) and social (e.g., family and community support, empowerment, culture) aspects of motherhood. Evidence-based MPW interventions that can be integrated into large-scale maternal and child health programs have not been developed. Building on several years of research in Pakistan, we developed and integrated a cognitive behavioral therapy-based MPW intervention (the five-pillars approach) into a child nutrition and development program. Following formative research with community health workers (CHWs; n = 40) and families (n = 37), CHWs were trained in (1) empathic listening, (2) family engagement, (3) guided discovery using pictures, (4) behavioral activation, and (5) problem solving. A qualitative feasibility study in one area demonstrated that CHWs were able to apply these skills effectively to their work, and the approach was found to be useful by CHWs, mothers, and their families. The success of the approach can be attributed to (1) mothers being the central focus of the intervention, (2) using local CHWs whom the mothers trust, (3) simplified training and regular supervision, and (4) an approach that facilitates, not adds, to the CHWs' work.

Implementing a successful tuberculosis programme within primary care services in a conflict area using the stop TB strategy: Afghanistan case study.

INTRODUCTION: Afghanistan has faced health consequences of war including those due to displacement of populations, breakdown of health and social services, and increased risks of disease transmission for over three decades. Yet it was able to restructure its National Tuberculosis Control Programme (NTP), integrate tuberculosis treatment into primary health care and achieve most of its targets by the year 2011. What were the processes that enabled the programme to achieve its targets? More importantly, what were the underpinning factors that made this success possible? We addressed these important questions through a case study. CASE DESCRIPTION: We adopted a processes and outcomes framework for this study, which began with examining the change in key programme indicators, followed by backwards tracing of the processes and underlying factors, responsible for this change. Methods included review of the published and grey literature along with in-depth interviews of 15 key informants involved with the care of tuberculosis patients in Afghanistan. DISCUSSION AND EVALUATION: TB incidence and mortality per 100,000 decreased from 325 and 92 to 189 and 39 respectively, while case notification and treatment success improved during the decade under study. Efficient programme structures were enabled through high political commitment from the Government, strong leadership from the programme, effective partnership and coordination among stakeholders, and adequate technical and financial support from the development partners. CONCLUSIONS: The NTP Afghanistan is an example that public health programmes can be effectively implemented in fragile states. High political commitment and strong local leadership are essential factors for such programmes. To ensure long-term effectiveness of the NTP, the international support should be withdrawn in a phased manner, coupled with a sequential increase in resources allocated to the NTP by the Government of Afghanistan.

Understanding care and feeding practices: building blocks for a sustainable intervention in India and Pakistan.

Undernutrition and inadequate stimulation both negatively influence child health and development and have a long-term impact on school attainment and income. This paper reports data from India and Pakistan looking at how families interact, play with, and feed children; their expectations of growth and development; and the perceived benefits, consequences, opportunities, and barriers of adopting recommended feeding and developmental behaviors. These data were collected as part of formative research for the Sustainable Program Incorporating Nutrition and Games (SPRING) trial. This trial aims to deliver an innovative, feasible, affordable, and sustainable intervention that can achieve delivery at a scale of known effective interventions that maximize child development, growth, and survival and improve maternal psychosocial well-being in rural India and Pakistan.

Using cognitive-behavioural techniques to improve exclusive breastfeeding in a low-literacy disadvantaged population.

Despite being an important component of Pakistan's primary health care programme, the rates of exclusive breastfeeding at 6 months remain among the lowest in the world. Low levels of literacy in women and deeply held cultural beliefs and practices have been found to contribute to the ineffectiveness of routine counselling delivered universally by community health workers in Pakistan. We aimed to address this by incorporating techniques of cognitive-behavioural therapy (CBT) into the routine counselling process. We conducted qualitative studies of stakeholders' opinions (mothers, community health workers, their trainers and programme managers) and used this data to develop a psycho-educational approach that combined education with techniques of CBT that could be integrated into the health workers' routine work. The workers were trained to use this approach and feedback was obtained after implementation. The new intervention was successfully integrated into the community health worker programme and found to be culturally acceptable, feasible and useful. Incorporating techniques of CBT into routine counselling may be useful to promote health behaviours in traditional societies with low literacy rates.

Using TV talk show for public health media advocacy: a case study.

OBJECTIVES: Much of the focus of public health communication has been on bringing about individual change with relatively little attention to changing public policy through mass media. We conceptualized using TV talk shows as a tool to influence district level health policy. METHODS: A series of TV talk shows was recorded to present the maternal and newborn health situation and promises of public representatives and health officials from 10 project districts. The shows were aired on national circuit. Panellists were interviewed after the airing to know how much were they influenced by this advocacy intervention. RESULTS: Both public representatives and health officials remembered the issue of maternal and newborn health, the project and their participation in the show. Two third of the participants felt more accountable after having given on-camera commitments while half of them informed there were policy discussions or progress in implementation of decisions to improve maternal and newborn health after attending the show. The participants felt a sense of accountability after appearing on TV screen to make pledges on improving the health situation in their district. They appreciated this advocacy initiative and expressed their desire to participate in such shows in future as well. The cost of production and airing of the show was $1800 per episode. CONCLUSION: TV talk show is an effective media intervention having low costs, and can be used for public health advocacy in developing countries.

Knowledge and communication needs assessment of community health workers in a developing country: a qualitative study.

BACKGROUND: Primary health care is a set of health services that can meet the needs of the developing world. Community health workers act as a bridge between health system and community in providing this care. Appropriate knowledge and communication skills of the workers are key to their confidence and elementary for the success of the system. We conducted this study to document the perceptions of these workers on their knowledge and communication needs, image building through mass media and mechanisms for continued education. METHODS: Focus group discussions were held with health workers and their supervisors belonging to all the four provinces of the country and the Azad Jammu & Kashmir region. Self-response questionnaires were also used to obtain information on questions regarding their continued education. RESULTS: About four fifths of the respondents described their communication skills as moderately sufficient and wanted improvement. Knowledge on emerging health issues was insufficient and the respondents showed willingness to participate in their continued education. Media campaigns were successful in building the image of health workers as a credible source of health information. CONCLUSION: A continued process should be ensured to provide opportunities to health workers to update their knowledge, sharpen communication skills and bring credibility to their persona as health educators.

Birth preparedness and the role of the private sector: a community survey.

OBJECTIVES: To assess the birth preparedness and utilisation of services in an urban union council where only the private sector provided any healthcare. METHODS: Descriptive study design was adopted which had two components: 1) a cross-sectional community survey on birth preparedness and utilisation of services and 2) a provider survey with census of all eligible healthcare facilities. Door to door survey was conducted by visiting every tenth household. All allopathic healthcare facilities in the selected union council were visited for collecting information about the available services and amenities. RESULTS: Knowledge regarding danger signs during pregnancy and delivery was low. Sixty four percent women received some antenatal care while 45% deliveries were conducted at home. Among those having to seek emergency care during pregnancy, delivery or postpartum, 39% approached a health facility. Lack of preparation in terms of transport was reported in 83% cases. Two of the health facilities had a skilled birth attendant while four provided antenatal care services. Health education was provided by four; deliveries were conducted at one; while family planning services were provided by five facilities. CONCLUSION: Women and their families are not sensitised to prepare for safe deliveries. There is a need to improve the essential maternal and newborn health care services at the health facilities. The role of private health sector towards improving MNH; especially birth preparedness in the country needs to be explored at a larger level.

Job stress among community health workers: a multi-method study from Pakistan.

BACKGROUND: In low income countries, the task of providing primary health care is often the responsibility of community health workers. In Pakistan, community workers called Lady Health Workers (LHW) deliver basic health care at the doorstep in the rural areas and urban slums. Evaluations show that it is a successful programme but point out inconsistencies in the quality of service provided. In order achieve this, it would be important to obtain the workers' viewpoint on their job-description, the problems they face and the levels of stress they encounter. METHODS: We conducted a multi-method study to investigate the aforementioned issues. All LHWs from one typical rural sub-district in Rawalpindi were surveyed. Focus group discussions with a sub-set of these workers were also conducted. RESULTS: About a quarter of the LHWs were found to have significant occupational stress. Factors associated with stress included having low socio-economic status and having to travel long distances for work. Inconsistent medical supplies, inadequate stipends, lack of career structure and not being equipped to communicate effectively with families were the main factors for job dissatisfaction among these workers. RECOMMENDATIONS: Improvement in remuneration, better administration of supplies and a structured career path should be ensured for better performance of community health workers. In addition, communication skills learning should be an essential part of their training programme.