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.

Evaluation the Effectiveness of Abridged IMNCI (7-Day) Course v Standard (11-Day) Course in Pakistan.

BACKGROUND: The conventional IMCI training for healthcare providers is delivered in 11 days, which can be expensive and disruptive to the normal clinical routines of the providers. An equally effective, shorter training course may address these challenges. METHODS: We conducted a quasi-experimental study in two provinces (Sindh and Punjab) of Pakistan. 104 healthcare providers were conveniently selected to receive either the abridged (7-day) or the standard (11-day) training. Knowledge and clinical skills of the participants were assessed before, immediately on conclusion of, and six months after the training. RESULTS: The improvement in mean knowledge scores of the 7-day and 11-day training groups was 31.6 (95% CI 24.3, 38.8) and 29.4 (95% CI 23.9, 34.9) respectively, p = 0.630 while the improvement in mean clinical skills scores of the 7-day and 11-day training groups was 23.8 (95% CI: 19.3, 28.2) and 23.0 (95% CI 18.9, 27.0) respectively, p = 0.784. The decline in mean knowledge scores six months after the training was - 12.4 (95% CI - 18.5, - 6.4) and - 6.4 (95% CI - 10.5, - 2.3) in the 7-day and 11-day groups respectively, p = 0.094. The decline in mean clinical skills scores six months after the training was - 6.3 (95% CI - 11.3, - 1.3) in the 7-day training group and - 9.1 (95% CI - 11.5, - 6.6) in the 11-day group, p = 0.308. CONCLUSION: An abridged IMNCI training is equally effective as the standard training. However, training for certain illnesses may be better delivered by the standard course.

COVID-19 and fiscal space for health system in Pakistan: It is time for a policy decision.

Most developing countries with weak economies and low GDPs strive to invest an optimal amount of budget to health sector. Compounding on this state of affairs is their inherent inefficiency to spend even that meager amount on the welfare of the patients, improving service delivery, motivating their workforce and making their health systems responsive to the needs of the people they serve. With weak fiscal base and inelasticity in budget spending, when these countries face a catastrophe like COVID-19, there is a whole situation of havoc and lack of finances emerges as the biggest issue in such crises. Pakistan has been no exception to this kind of situation. Government funds allocated to other public sector development schemes are diverted to deal with the health emergency. Hence, the result is an overall socioeconomic shock that a country has to face. Amid such crises, other international commitments also face a state of uncertainty. With the changing disease patterns all over the world, the public financial management system for health sector needs to be revisited to devise a more sustainable and resilient mechanism not only to absorb shocks like COVID-19 but also to meet the international health commitments.

Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities.

Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We undertook an in-depth analysis of Pakistan's progress towards MDGs 4 and 5 and the principal determinants of health in relation to reproductive, maternal, newborn, and child health and nutrition. We reviewed progress in relation to new and existing public sector programmes and the challenges posed by devolution in Pakistan. Notwithstanding the urgent need to tackle social determinants such as girls' education, empowerment, and nutrition in Pakistan, we assessed the effect of systematically increasing coverage of various evidence-based interventions on populations at risk (by residence or poverty indices). We specifically focused on scaling up interventions using delivery platforms to reach poor and rural populations through community-based strategies. Our model indicates that with successful implementation of these strategies, 58% of an estimated 367,900 deaths (15,900 maternal, 169,000 newborn, 183,000 child deaths) and 49% of an estimated 180,000 stillbirths could be prevented in 2015.

Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial.

BACKGROUND: Umbilical cord infection (omphalitis) is a risk factor for neonatal sepsis and mortality in low-resource settings where home deliveries are common. We aimed to assess the effect of umbilical-cord cleansing with 4% chlorhexidine (CHX) solution, with or without handwashing with antiseptic soap, on the incidence of omphalitis and neonatal mortality. METHODS: We did a two-by-two factorial, cluster-randomised trial in Dadu, a rural area of Sindh province, Pakistan. Clusters were defined as the population covered by a functional traditional birth attendant (TBA), and were randomly allocated to one of four groups (groups A to D) with a computer-generated random number sequence. Implementation and data collection teams were masked to allocation. Liveborn infants delivered by participating TBAs who received birth kits were eligible for enrolment in the study. One intervention comprised birth kits containing 4% CHX solution for application to the cord at birth by TBAs and once daily by family members for up to 14 days along with soap and educational messages promoting handwashing. One intervention was CHX solution only and another was handwashing only. Standard dry cord care was promoted in the control group. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. The trial is registered with ClinicalTrials.gov, number NCT00682006. FINDINGS: 187 clusters were randomly allocated to one of the four study groups. Of 9741 newborn babies delivered by participating TBAs, factorial analysis indicated a reduction in risk of omphalitis with CHX application (risk ratio [RR]=0·58, 95% CI 0·41-0·82; p=0·002) but no evidence of an effect of handwashing (RR=0·83, 0·61-1·13; p=0·24). We recorded strong evidence of a reduction in neonatal mortality in neonates who received CHX cleansing (RR=0·62, 95 % CI 0·45-0·85; p=0·003) but no evidence of an effect of handwashing promotion on neonatal mortality (RR=1·08, 0·79-1·48; p=0·62). We recorded no serious adverse events. INTERPRETATION: Application of 4% CHX to the umbilical cord was effective in reducing the risk of omphalitis and neonatal mortality in rural Pakistan. Provision of CHX in birth kits might be a useful strategy for the prevention of neonatal mortality in high-mortality settings. FUNDING: The United States Agency for International Development.

Engagement of Lady Health Workers for COVID-19 Home-based Care in Pakistan: An Example of Task Shifting.

In April 2021, following the Federal government's decision, an intervention was designed to execute COVID-19 home-based care training program for the LHWs in all provinces to avoid overcrowding in large hospitals so that critically ill patients can get due attention and treatment. The training curriculum was developed in local languages following guidance from NIH and WHO. Basic health units were used as the venue for training and the doctors delivered the sessions as master trainers. Around 46,000 LHWs completed the training all over Pakistan and started visiting their catchment households to identify and counsel any COVID-19 patients and families on home-based care. Their post-training impressions showed that 97% were satisfied with the content, rigour, quality of training, and that they received the most updated information on COVID-19 from reliable sources. Training of these LHWs enhanced their skills for dealing with COVID-19 patients and helped ease the pressure on a stressed and over-burdened hospitals. This intervention exemplifies task shifting to LHWs, hence addressing the issue of insufficient health workforce in the hospitals and extending public healthcare to rural communities. Key Words: COVID-19, Home-based care, Health system, Lady health workers, Pakistan.

Supporting tuberculosis program in active contact tracing: a case study from Pakistan.

Tuberculosis (TB) is on the rise in Pakistan and there could be multiple reasons including poverty, difficulty in access to TB treatment services, non-compliance with treatment, social stigma etc. According to the TB program managers, limited treatment and testing sites for tuberculosis and lack of trained human resources play a major role in compromising TB management. A major lacuna in the TB control program is the absence of active contact tracing strategy. This is essential for a disease where positive cases are known to be able to infect a further 10‒15 individuals in a year. Tackling tuberculosis in Pakistan has been beleaguered by funding challenges and other systems' bottlenecks such as lack of skilled human resources and insufficient supply of medicines, despite the fact that disease burden is one of the highest in the world. Although it is a notifiable disease, active case finding, contact tracing and reporting is notoriously low throughout the country. Access to diagnostics and treatment facilities has been limited and stigma attached to the disease remains deeply entrenched among the communities. Researchers have shown that enhanced and active approaches to contact investigation effectively identifies additional patients with TB among household contacts at a relatively modest cost. USAID's Integrated Health Systems Strengthening and Service Delivery Activity extended support to the Health Departments of Sindh and Khyber Pakhtunkhwa provinces. In collaboration with the two provincial TB programs, community based active contact tracing was conducted on 17,696 individuals, based on the index cases. Among the contacts traced, 243 cases were diagnosed as drug sensitive or drug resistant TB. Awareness sessions were conducted to sensitize people on the various aspects of disease and importance of getting tested. The project also supported establishing three satellite Programmatic Management of Drug Resistant Tuberculosis (PMDT) sites for drug resistant TB treatment, enhancing the programs' diagnostic and testing capacity.

Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an Assessment of their training needs.

BACKGROUND: More than 450 newborns die every hour worldwide, before they reach the age of four weeks (neonatal period) and over 500,000 women die from complications related to childbirth. The major direct causes of neonatal death are infections (36%), Prematurity (28%) and Asphyxia (23%). Pakistan has one of the highest perinatal and neonatal mortality rates in the region and contributes significantly to global neonatal mortality. The high mortality rates are partially attributable to scarcity of trained skilled birth attendants and paucity of resources. Empowerment of health care providers with adequate knowledge and skills can serve as instrument of change. METHODS: We carried out training needs assessment analysis in the public health sector of Pakistan to recognize gaps in the processes and quality of MNCH care provided. An assessment of Knowledge, Attitude, and Practices of Health Care Providers on key aspects was evaluated through a standardized pragmatic approach. Meticulously designed tools were tested on three tiers of health care personnel providing MNCH in the community and across the public health care system. The Lady Health Workers (LHWs) form the first tier of trained cadre that provides MNCH at primary care level (BHU) and in the community. The Lady Health Visitor (LHVs), Nurses, midwives) cadre follow next and provide facility based MNCH care at secondary and tertiary level (RHCs, Taluka/Tehsil, and DHQ Hospitals). The physician/doctor is the specialized cadre that forms the third tier of health care providers positioned in secondary and tertiary care hospitals (Taluka/Tehsil and DHQ Hospitals). The evaluation tools were designed to provide quantitative estimates across various domains of knowledge and skills. A priori thresholds were established for performance rating. RESULTS: The performance of LHWs in knowledge of MNCH was good with 30% scoring more than 70%. The Medical officers (MOs), in comparison, performed poorly in their knowledge of MNCH with only 6% scoring more than 70%. All three cadres of health care providers performed poorly in the resuscitation skill and only 50% were able to demonstrate steps of immediate newborn care. The MOs performed far better in counselling skills compare to the LHWs. Only 50 per cent of LHWs could secure competency scale in this critical component of skills assessment. CONCLUSIONS: All three cadres of health care providers performed well below competency levels for MNCH knowledge and skills. Standardized training and counselling modules, tailored to the needs and resources at district level need to be developed and implemented. This evaluation highlighted the need for periodic assessment of health worker training and skills to address gaps and develop targeted continuing education modules. To achieve MDG4 and 5 goals, it is imperative that such deficiencies are identified and addressed.

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.

Research priorities to reduce global mortality from newborn infections by 2015.

BACKGROUND: Newborn infections are responsible for approximately one-third of the estimated 4.0 million neonatal deaths that occur globally every year. Appropriately targeted research is required to guide investment in effective interventions, especially in low resource settings. Setting global priorities for research to address neonatal infections is essential and urgent. METHODS: The Department of Child and Adolescent Health and Development of the World Health Organization (WHO/CAH) applied the Child Health and Nutrition Research Initiative (CHNRI) priority-setting methodology to identify and stimulate research most likely to reduce global newborn infection-related mortality by 2015. Technical experts were invited by WHO/CAH to systematically list and then use standard methods to score research questions according to their likelihood to (i) be answered in an ethical way, (ii) lead to (or improve) effective interventions, (iii) be deliverable, affordable, and sustainable, (iv) maximize death burden reduction, and (v) have an equitable effect in the population. The scores were then weighted according to the values provided by a wide group of stakeholders from the global research priority-setting network. FINDINGS: On a 100-point scale, the final priority scores for 69 research questions ranged from 39 to 83. Most of the 15 research questions that received the highest scores were in the domain of health systems and policy research to address barriers affecting existing cost-effective interventions. The priority questions focused on promotion of home care practices to prevent newborn infections and approaches to increase coverage and quality of management of newborn infections in health facilities as well as in the community. While community-based intervention research is receiving some current investment, rigorous evaluation and cost analysis is almost entirely lacking for research on facility-based interventions and quality improvement. INTERPRETATION: Given the lack of progress in improving newborn survival despite the existence of effective interventions, it is not surprising that of the top ranked research priorities in this article the majority are in the domain of health systems and policy research. We urge funding agencies and investigators to invest in these research priorities to accelerate reduction of neonatal deaths, particularly those due to infections.

Pakistan's Health and Population Think Tank: a policy platform for achieving Sustainable Development Goal 3 national targets.

In Pakistan, the Health and Population Think Tank was launched as an initiative to conduct programmes and policy analysis, as well as give an insight into the possible future policy options on various national health issues relevant to all the provinces. This forum has also served as a platform to discuss how provincial strategies could be aligned with the National Health Vision 2016-2025, which was developed with the consensus of all provinces and development partners. Main topics chosen for the round tables included local production of vaccines; social health protection; quality of care at the time of birth; human resources for health; and the challenge of tuberculosis in Pakistan. Policy briefs produced by the think tank will maximize the absorption of knowledge and will help implement the actionable items needed to speed up the progress towards achieving Sustainable Development Goal 3 (SDG3) national targets.

Evaluation of the uptake and impact of neonatal vitamin A supplementation delivered through the Lady Health Worker programme on neonatal and infant morbidity and mortality in rural Pakistan: an effectiveness trial.

BACKGROUND: Despite evidence for the benefits of vitamin A supplementation (VAS) among children 6 to 59 months of age, the feasibility of introduction and potential benefit of VAS in the neonatal period in public health programmes is uncertain. OBJECTIVE: The primary objective was to evaluate the feasibility and effectiveness of early neonatal VAS (single dose of 50 000 international units within 48-72 hours after birth) delivered through the public sector Lady Health Worker (LHW) programme in rural Pakistan and to document its association with a reduction in mortality at 6 months of age. METHODS: A community-based, cluster randomised, placebo-controlled trial was undertaken in two districts of rural Pakistan. LHWs dispensed vitamin A/placebo in identical capsules to newborn infants within 48-72 hours of birth. Follow-up visits were undertaken at 1 week of age and every 4 weeks thereafter until 6 months of age. RESULTS: Of a total of 15 433 consecutive pregnancies among eligible women of reproductive age, 13 225 pregnancies were registered, 12 218 live births identified and 11 028 newborn infants reached by LHWs. Of these, 5380 (49%) received neonatal VAS and 5648 (51%) placebo. The LHWs successfully delivered the capsules to 79% of newborns within 72 hours of birth with no significant adverse effects. Although the proportion of days observed with symptoms of fever, diarrhoea or rapid breathing were lower with neonatal VAS, these differences were not statistically significant. Mortality rates in the two groups were comparable at 6 months of age. CONCLUSIONS: While our study demonstrated that neonatal VAS was safe and could be feasibly delivered by LHWs in Pakistan as part of their early postnatal visits, the overall lack of benefit on neonatal and 6-month morbidity and mortality in our population suggests the need for further evaluation of this intervention in populations at risk. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT00674089.

Newborn survival in Pakistan: a decade of change and future implications.

Pakistan has the world's third highest national number of newborn deaths (194 000 in 2010). Major national challenges over the past decade have affected health and development including several large humanitarian disasters, destabilizing political insurgency, high levels of poverty and an often hard-to-reach predominately rural population with diverse practices. As part of a multi-country analysis, we examined changes for newborn survival between 2000 and 2010 in terms of mortality, coverage and health system indicators as well as national and donor funding. Neonatal mortality declined by only 0.9% per annum between 2000 and 2010; less than the global average (2.1%) and less than national maternal and child mortality declines. Coverage of newborn care interventions increased marginally, with wide socio-economic variations. There was little focus on newborn health until 2000 when considerable policy change occurred, including integration of newborn care into existing community-based maternal and child packages delivered by the Lady Health Worker Programme and national behaviour change communications strategies and programmes. The National Maternal, Newborn and Child Health Programme catalyzed newborn services at both facility and community levels. Civil society and academics have linked with government and several research studies have been highly influential. Since 2005, donor funding mentioning the term 'newborn' has increased more for Pakistan than for other countries. The country faces ongoing challenges in reducing neonatal mortality, and in much of Pakistan, societal norms discourage care-seeking and many women are unable to access care for themselves or their children. The policy advances and existing delivery platforms offer the potential to substantially accelerate progress in reducing neonatal deaths. The recent decision to dismantle the national Ministry of Health and devolve responsibility for health sector management to the provincial level presents both challenges and opportunities for newborn health.