Breaking bad news: A mix methods study reporting the need for improving communication skills among doctors in Pakistan.

BACKGROUND: Effective skills and training for physicians are essential for communicating difficult or distressing information, also known as breaking bad news (BBN). This study aimed to assess both the capacity and the practices of clinicians in Pakistan regarding BBN. METHODS: A cross-sectional study was conducted involving 151 clinicians. Quantitative component used a structured questionnaire, while qualitative data were obtained through in-depth interviews with 13 medical educationists. The responses were analyzed using descriptive statistics and thematic analysis. RESULTS: While most clinicians acknowledged their responsibility of delivering difficult news, only a small percentage had received formal training in BBN. Areas for improvement include time and interruption management, rapport building, and understanding the patients' point of view. Prognosis and treatment options were not consistently discussed. Limited importance is given to BBN in medical education. DISCUSSION: Training in BBN will lead to improved patient and attendants' satisfaction, and empathetic support during difficult times.

Universal health coverage in Pakistan: is the health system geared up to take on the challenge?

BACKGROUND: There is a strong and wide consensus that Pakistan must pursue universal health coverage (UHC) attainment as the driving force for achieving sustainable development goals by 2030. Nevertheless, several institutional and socioeconomic challenges may hinder the progress toward UHC. MAIN BODY: It is important that the health system of Pakistan must be transformed to strengthen all three dimensions of UHC i.e. maximizing the population covered, increasing the range of services offered, and reducing the cost-sharing. To make UHC dream a reality in Pakistan, there are some pre-requisites to meet upfront: a) budgetary allocation for health as percentage of GDP must be increased; b) health system's readiness especially in the public sector ought to improve in terms of human resource and availability of essential services; c) safety nets for health must continue regardless of the change in the political regimes; d) decrease the reliance on donors' funding; and e) accountability to be ensured across the board for service providers, managers, administrators and policymakers in the health system. CONCLUSION: COVID-19 pandemic has revealed some major gaps in the health system's capacity to deliver equitable healthcare, which is a cornerstone to achieving the UHC agenda. The priority-setting process will need to be aligned with the SDGs to ensure that the agenda for action towards 2030 is comprehensively addressed and successfully accomplished preferably before, but hopefully not beyond the targeted dates.

Correction to: Health seeking behaviour, delayed presentation and its impact among oral cancer patients in Pakistan: a retrospective qualitative study.

In the original publication of this article [1], an author's name needs to be revised from Babar Tasneen Shaikh to Babar Tasneem Shaikh.

Health seeking behaviour, delayed presentation and its impact among oral cancer patients in Pakistan: a retrospective qualitative study.

BACKGROUND: Delayed diagnosis of Oral Cancer (OC) can mean a difference in quality and expectancy of life for the patient. This delay could be from the healthcare side, or more importantly from the patient's side. Globally, there are studies enumerating the causes for delays from the patients' side in seeking healthcare for Oral Cancer; however, no similar research is found in the context of Pakistan. This study endeavoured to understand the health seeking behaviour, reasons for delay in consultation and the impact on OC patients' lives. METHODS: In-depth interviews were conducted with randomly selected OC patients at a private sector tertiary care facility in Islamabad (who met the inclusion criteria of having successfully been treated for Oral Cancer) which caters to the most diverse population for the treatment of Oral Cancer. Theoretical saturation was achieved at 14 interviews. All participants gave verbal consent for participation, which was recorded prior to the interviews. RESULTS: Patients (age range 43-68 years) had received the surgical treatment and radiation. The reported delay before seeking a proper medical advice ranged from 1 month to 2 years. Lack of awareness about OC risk factors, symptoms, and whom to approach for treatment were the main reasons. Most respondents relied on self-treatment considering the non-healing wound/ulcer to be a minor issue until they were advised a consultation with a specialist. Treatment started within 1-3 months after a confirmed diagnosis on biopsy. The reported average expenditure on treatment was US$5000-10,000, mostly covered through a private health insurance and others borrowed the money. CONCLUSION: A socio-behavioural change campaign for the general population can result in earlier presentation of the OC, minimizing the financial burden on the patient as well as the health system, and improving the quality of life of the patients.

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.

Capacity building on health diplomacy: a training experience from Pakistan.

Modern-day globalization means that many health issues cannot be resolved by the affected country alone, and this necessitates political consultations, diplomatic negotiations and cross-border solutions. A few examples that require health diplomacy efforts are: halting resentment towards immunization, addressing the burden of noncommunicable diseases, enabling access to drugs and technology, and liberalizing trade to reduce the cost of drugs. The agenda of Sustainable Development Goals (SDGs) demands a concerted effort to achieve the ambitious targets. This article reports the experience of health diplomacy training imparted to mid-level and senior officials in the public as well as private sector in Pakistan. Training was geared to inculcate an understanding of global health diplomacy and governance, and to develop an appreciation of the relationship of global health with other disciplines such as foreign affairs, economics, trade, climate change and human rights. Participants included health professionals, experts from departments other than health, government officials and diplomats. This training was expected to enhance their knowledge of health systems dynamics that are influenced by foreign policy and diplomatic discourses.

Anti-Microbial Resistance In Pakistan: A Public Health Issue

Anti-microbial or antibiotic resistance is a global public health problem, more dominant in the developing countries. Illiteracy and lack of awareness among the general population is a leading cause, compounded by lack of concern by the physicians and the pharmacists selling drugs over the counter. Another side of the phenomenon is attributed to profit making goals of pharmaceutical companies and weak regulation of the market. Nevertheless, misuse and overuse of antimicrobials accelerates this process. Besides, health issues, anti-microbial resistance also has economic implications on the health care system, where the simpler treatments are becoming difficult, day by day. Enforcement of standard treatment guidelines for the health providers and behavior changes at the patients' end are likely to bring about a change in the situation.

Stillbirths: What Can Be Done To Confront An Invisible Public Health Problem In Pakistan?

Pakistan has been ranked highest and appears worst in stillbirths' rate according to the recent global estimates. Reasons could be manifold; socio-cultural, health system related country specific, and some of these of course déjà vu, i.e., the biomedical causes. Yet, a fresh stocktaking is necessary to understand the complex phenomenon in a country, awfully affected by this menace. Maternal, neonatal and child health program needs to be informed and geared up toward addressing the actual reasons behind this heavy toll of stillbirths in Pakistan. Maternal health indicators would never be improved, if the issue of stillbirths is not stalled at the earliest. Besides known medical reasons, this account attempts to document the health systems related factors, and more so the social determinants behind the whole scenario, so that appropriate and customized interventions could be suggested, developed and implemented. This paper will be a piece of evidence for policy corridors, program managers, development partners, non-governmental organizations, public health institutions, students, and researchers to enhance their understanding of a major public health problem, and to recognize the strengths and opportunities in the health system of Pakistan to cope with this challenge.

INDUCED ABORTIONS IN PAKISTAN: EXPOSITIONS, DESTINATIONS AND REPERCUSSIONS. A QUALITATIVE DESCRIPTIVE STUDY IN RAWALPINDI DISTRICT.

Over 2 million abortions occur annually in Pakistan, mostly in a clandestine and unsafe environment. This is an area of grave concern for the reproductive health of women. A dearth of credible data and incomplete information make the problem more difficult to address. This qualitative study was conducted in semi-urban settings in Pakistan to record perceptions and practices concerning care seeking, experiences and outcomes regarding induced abortions and post-abortion care services. Women who had had induced abortions and abortion service providers were interviewed. Unwanted pregnancies and poverty were found to be the main reasons for seeking an abortion. Moreover, the unwanted pregnancies occurred due to low use of contraceptives, mainly due to a fear or past experience of their side-effects, unfamiliarity with correct usage and perceived inefficacy of the methods, especially condoms. There is an obvious need for practical and innovative interventions to address unmet need for birth spacing through improved access to contraceptives. Contraceptive providers should be provided with up-to-date and detailed training in family planning counselling, and perhaps allowed unrestricted provision of contraceptives. As a long-term measure, improvement in access to education and formal schooling could increase young girls' and women's knowledge of the benefits of family planning and the risks of unsafe abortion practices. Males must be involved in all the initiatives so that both partners are in agreement on correct and consistent contraceptive use.

Constitutional Reforms In Pakistan: Turning Around The Picture Of Health Sector In Punjab Province.

consequences of 2011 reforms on the future roles demarcation between the federation and provinces for steering the health sector. The objective of this assessment study was to conduct an institutional appraisal of the provincial health department in Punjab to mark the achievements, problem areas and issues, as well as to formulate the recommendations in the post-devolution scenario. It was an in-depth literature review comprising papers found on PubMed/Medline, Google Scholar, reports published by the government departments, independent research works, academic papers, and documents produced by the development agencies in Pakistan, covering 18th constitutional amendment and its implications on health sector. Following 18th amendment, the Punjab Government formulated health sector strategy (2012-2017) which is being implemented in a phased approach. All districts have developed their three years rolling out plans. An integrated strategic and operational plan of MNCH, Nutrition and Family Planning is under review for approval. Punjab Health Care Commission has been established and is functional to regulate the health sector. Development agencies have in principle committed to support health sector strategy till 2017. Fair investments in improving governance, service delivery structure, human resource, health information, and medical products are expected more than ever in the post 18th amendment scenario. This is the chance for the health system of Punjab to serve the vulnerable people of the provinces, saving them from health shocks.

Effectiveness of intensive healthcare waste management training model among health professionals at teaching hospitals of Pakistan: a quasi-experimental study.

BACKGROUND: Infectious waste management has always remained a neglected public health problem in the developing countries, resulting in high burden of environmental pollution affecting general masses. Health workers are the key personnel who are responsible for the management of infectious waste at any hospital, however, their proper training and education is must for an optimal performance. This interventional study was conducted to assess the effectiveness of Intensive healthcare waste management (IHWM) training model at two tertiary care hospitals of Rawalpindi city, Pakistan. METHODS: This study was quasi-experimental pre and post design with control and intervention groups. Out of 275 health care workers enrolled for the study, 138 workers were assigned for intervention group for 3 months trainings, hands-on practicum and reminders on infectious waste management; whereas 137 workers were assigned to the control hospital where routine activities on infectious health care waste management were performed. Pre and post intervention assessment was done for knowledge, attitude and practices (KAP); and was statistically analyzed. Bivariate and multivariate analysis, independent, paired and unpaired t-test, chi-square with p values, and mean of the responses were calculated. Overall the response rate was 92% at the end of intervention. RESULTS: During the baseline survey, 275 healthcare workers (HCW) included doctors, nurses, paramedics and sanitary workers, and after 3 months of intervention, 255 were reached out to complete the questionnaire. With regard to KAP at baseline, there were no significant differences between two groups at baseline, except for gender and department. However, in the post intervention survey, statistically significance difference (<0.05) between intervention and control group's knowledge, attitude and practices was found. Moreover, within the control group no statistically significant difference was reported (>0.05) after 3 months. CONCLUSIONS: Study results suggest that IHWM training could be an effective intervention for improving knowledge, attitudes and practices among health workers regarding infectious waste management. Such training should become a regular feature of all hospitals for reducing the hazards attached with infectious wastes.

PRIVATE SECTOR IN HEALTH CARE DELIVERY: A REALITY AND A CHALLENGE IN PAKISTAN.

Under performance of the public sector health care system in Pakistan has created a room for private sector to grow and become popular in health service delivery, despite its questionable quality, high cost and dubious ethics of medical practice. Private sector is no doubt a reality; and is functioning to plug many weaknesses and gaps in health care delivery to the poor people of Pakistan. Yet, it is largely unregulated and unchecked due to the absence of writ of the state. In spite of its inherent trait of profit making, the private sector has played a significant and innovative role both in preventive and curative service provision. Private sector has demonstrated great deal of responsiveness, hence creating a relation of trust with the consumers of health in Pakistan, majority of who spend out of their pocket to buy 'health'. There is definitely a potential to engage and involve private and non-state entities in the health care system building their capacities and instituting regulatory frameworks, to protect the poor's access to health care system.

EXPERIENCE OF VOUCHERS FOR REPRODUCTIVE HEALTH SERVICES IN DEVELOPING COUNTRIES: MAKING A CASE FOR PAKISTAN THROUGH A SYSTEMATIC REVIEW.

Among the healthcare financing techniques that exist, output-based financing or vouchers is a strategy that is growing in popularity. There is a need of an in-depth analysis of the impacts of vouchers on health indicators, particularly for Pakistan. Assessment of the existing evidence on how much the vouchers impact on health and healthcare utilization can be of greater value to the policy makers for informed decision making. This systematic review included 16 cross-sectional and quasi-experimental design studies. Service utilization, knowledge, service quality, cost-effectiveness of the programme and outreach of the population served were observed as outcomes. We found positive results in with regard to most of these outcomes. Physical accessibility, social mobility of women, security threats, and sustainability of the project after donor exit appear as serious challenges. Yet, lessons can be drawn for the scaling up of the reproductive health services in the country, through the use of vouchers.

Practices and challenges of infectious waste management: A qualitative descriptive study from tertiary care hospitals in Pakistan.

BACKGROUND AND OBJECTIVE: Infectious waste management practices among health care workers in the tertiary care hospitals have been questionable. The study intended to identify issues that impede a proper infectious waste management. METHODS: Besides direct observation, in-depths interviews were conducted with the hospital administrators and senior management involved in healthcare waste management during March 2014. We looked at the processes related to segregation, collection, storage and disposal of hospital waste, and identified variety of issues in all the steps. RESULTS: Serious gaps and deficiencies were observed related to segregation, collection, storage and disposal of the hospital wastes, hence proving to be hazardous to the patients as well as the visitors. Poor safety, insufficient budget, lack of trainings, weak monitoring and supervision, and poor coordination has eventually resulted in improper waste management in the tertiary hospitals of Rawalpindi. CONCLUSION: Study has concluded that the poor resources and lack of healthcare worker's training in infectious waste results in poor waste management at hospitals.

Health care seeking patterns and out of pocket payments for children under five years of age living in Katchi Abadis (slums), in Islamabad, Pakistan.

BACKGROUND: Since 1990, Pakistan has faced an unprecedented rate of urbanization, thereby resulting in the uncontrolled proliferation of slums (Katchi Abadis) in all large cities. These areas lack the basic municipal services such as safe water supply, sanitation and waste collection. There is limited access to quality health care services, both curative and preventive. Therefore, communities living in katchi abadis are faced with health seeking challenges and catastrophic expenditure to pay for health care services (formal or informal). METHODS: This cross-sectional quantitative study was conducted in Islamabad, using a semi-structured questionnaire with mothers of children 5 years of age. There are 34 katchi abadis, 11 are recognized by the Capital Development Authority, out of which seven were included in the study. The calculated sample size was 207. MAIN FINDINGS: Average household income was found to be Pak Rupee 10,000 (approx.US$100) per month. Diarrhea, fever, common cold and cough were common illnesses among under 5 children. Approximately 43% of the mothers were illiterate and they preferred consulting a private doctor or a private dispenser in the katchi abadi. Mother's level of education was significantly associated with the type of health provider consulted. Majority had to spend out of pocket, while many either borrowed money from relatives or friends or sold a household item. Delay in seeking health care added to the out of pocket expense. The mean cost on child's treatment was approximately PkRs400 (approximately US$ 4) for a single consultation. CONCLUSION: There are several factors associated with health seeking behavior of mothers of children under the age of 5 years, living in the katchi abadis of Islamabad. The latter population group is one of the most vulnerable given their poor standard of living conditions. A multi-sectoral approach is needed to address the provision of basic amenities, the availability of safety nets to pay for health care is crucial to avoid catastrophic expenditure and the provision of community-based health promotion programs are essential to improve health seeking behaviors whilst simultaneously promoting and protecting health.

A case study of outsourced primary healthcare services in Sindh, Pakistan: is this a real reform?

BACKGROUND: Since a decade, low and middle income countries have a rising trend of contracting their primary healthcare services to NGOs. In Pakistan, public sector often lacks capacity to effectively & equitably manage the healthcare services. It led the government to outsource the administration of primary health care services to a semi-autonomous government entity i.e. Peoples' Primary Healthcare Initiative (PPHI). This small scale study has assessed the quality of healthcare services at the contracted Basic Health Units (BHUs) with the PPHI and compared it with those managed by the local district government in the province of Sindh. METHODS: A cross-sectional mix methods survey was conducted in November 2011. Two BHUs of each type were selected from the districts Karachi and Thatta in Sindh province. BHUs were selected randomly and a purposive sampling technique was used to recruit the study participants at the two study sites. Focus group discussions were conducted with patients visiting the facility while in-depth interviews were conducted with service providers. An observation based resource availability checklist was also administered. RESULTS: There was a significant difference between the PPHI and the district government administered BHUs with regard to infrastructure, availability of essential medicines, basic medical appliances, mini-lab facilities and vehicles for referrals. These BHUs were found to have sufficient number of trained clinical staff and no punctuality and retention issues whatsoever. The district government administered BHUs presented a dismal picture in all the aspects. CONCLUSION: Out-sourcing of primary healthcare facilities has resulted in significantly improved certain aspects quality and responsiveness of primary healthcare services. This strategy is likely to achieve an efficient and perhaps an equitable healthcare delivery in low and middle income countries where governments have limited capacity to manage healthcare services.

Sustaining the stride of health agenda beyond 2015 in post mdgs scenario: a projected roadmap for the developing countries.

As the world is reaching toward 2015, the echoes of MDGs are becoming louder. Results with regard to achievements of the targets set globally, show mixed results. Very understandably, the developing countries will miss most of the targets by far, and the attributed reasons are obvious. Dearth of resources-financial and human, evidence for decision making, infrastructure, meaningful collaboration with developed countries, and overall governance of the health sector are some of the pitfalls on 2000-2015 screen. Nonetheless, international commitments are sending positive vibes and message that glass is half full. Countries must keep the pace and sustain the stride of MDGs agenda, with an appraised roadmap, of course. Poverty, natural and man-made disasters, and slow socio-economic development, and some incongruous technologies are the challenges en route. A holistic approach is the need of the time, and therefore this paper presents a strategic framework drawn from the WHO's proposed health systems building blocks, which might, help the developing countries and fragile health systems to turn around the state of affairs.

Confusion and denial: need for systems thinking to understand the HIV epidemic in Pakistan.

The first case of HIV appeared in Pakistan more than 25 years ago, and since then the prevalence of the disease is creeping up apparently at a dawdling pace, with only 3,983, cases registered till November 2010, of which 1,725 are undergoing treatment. The National AIDS Control Program is responsible for managing the epidemic. Pakistan has moved from a 'low prevalence-high risk' to a 'concentrated epidemic' state, yet the forcefulness required for managing this silent escalation of HIV infected numbers is not being highlighted, as it should be. A more holistic focus is the need of the hour, and for this purpose the WHO's Health Systems Building blocks have been used to discuss the state of affairs in Pakistan, with reference to the HIV/AIDS concentrated epidemic. This paper attempts to present a narrative, based on extensive literature review, with a focus on the six building blocks of health, systems strengthening. No doubt, the service delivery has to be responsive; but skilled human resources, a robust information system, an uninterrupted supplies and use of latest technology, adequate financing, and above all good governance at operational level are essential ingredients, which call for re-orienting the national programme today. Lack of coordination, capacity and interventions with questionable sustainability pave a perilous path. Hitherto the issue can be addressed by involving stakeholders from all levels of the society and managing the void between policy and implementation. Furthermore, interventions that focus on the long term future are imperative to combat the menace threatening the human lives.

Universal health coverage in Pakistan: exploring the landscape of the health system, health seeking behaviours, and utilization of health services.

The attainment of the noble objective of Universal Health Coverage (UHC)- 'leaving no one behind' necessitates sufficient financial resources, an ample supply of skilled healthcare professionals, and the availability of essential services as part of a basic package This paper presents an analysis of the health system, health seeking behaviours and health service utilization en route to UHC in Pakistan. We have used the UHC 14 tracer indicators of service coverage to see where Pakistan stands, what are the gaps and what needs to be done. Pakistan clearly is lagging behind its neighboring countries. The country's health system ought to work on health seeking behaviours and broader determinants of health. The pursuit of UHC demands a shared responsibility and collective action, with stakeholders from different sectors uniting their efforts and expertise. Together, they can establish robust systems, design comprehensive policies, allocate adequate resources, and implement interventions that transcend disciplinary boundaries.

Gender Difference of Burnout in Physicians Working in Tertiary Care Hospital: A Cross-Sectional Study.

Burnout and emotional exhaustion are becoming common among health workers in the busy teaching hospitals due to increased workload and the dearth of human resource. This study aimed to determine the causes of burnout among doctors and across gender differences. This was a descriptive cross-sectional study conducted in the Fauji Foundation Hospital, Rawalpindi, Pakistan, from 1st July to 30th September 2022. Two hundred and forty-five randomly recruited doctors who filled out self-administered questionnaires were included in the study. Independent samples t-test was used for comparison of the mean emotional burnout score. Female doctors felt more emotionally drained, more fatigued, and more worn out from work than male doctors (p < 0.05). Overall emotional exhaustion was also higher in female doctors (p < 0.05). This situation was more serious during the COVID-19 pandemic. Gender-sensitive environments, workplace policies, and necessary interventions will save physicians' burnout and brain drain. Emotional burnout is greater in female doctors as compared to their male counterparts. This evidence not only calls for prevention and treatment but also certain service-related reforms to facilitate female physicians to balance out their work and family lives more effectively. Key Words: Physicians, Emotional exhaustion, Burnout, Gender difference, Pakistan.