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BACKGROUND: COVID-19 mass vaccination is the only hopeful savior to curb the pandemic. Vaccine distribution to achieve herd immunity is hindered by hesitance and negative attitude of the public against COVID-19 vaccination. This study aims to evaluate the vaccine hesitancy and attitudes in major cities in Pakistan as well as their determinants. METHODS: A cross-sectional telephonic survey was conducted in June 2021 in major cities of Pakistan including Karachi, Lahore, Islamabad, Peshawar, and Gilgit, from unvaccinated urban population aged 18 years or older. Random Digit Dialing through multi-stage stratified random sampling was used to ensure representation of each target city and socio-economic classes. Questionnaire collected information on socio-demographics, COVID-19-related experiences, risk perception of infection, and receptivity of COVID-19 vaccination. Multivariate logistic regression analyses were performed to identify key determinants of vaccine hesitancy and acceptance. RESULTS: The prevalence of vaccinated population in this survey was 15%. Of the 2270 respondents, 65% respondents were willing to vaccinate, while only 19% were registered for vaccination. Factors significantly associated with vaccine willingness were older age (aOR: 6.48, 95% CI: 1.94-21.58), tertiary education (aOR: 2.02, 95% CI: 1.36, 3.01), being employed (aOR: 1.34, 95% CI: 1.01, 1.78), perceived risk of COVID-19 (aOR: 4.38, 95% CI: 2.70, 7.12), and higher compliance with standard operating procedures (aOR: 1.72, 95% CI: 1.26, 2.35). The most common vaccine hesitancy reasons were 'no need' (n = 284, 36%) and concerns with 'vaccine safety and side effects' (n = 251, 31%), while most reported vaccine motivation reasons were 'health safety' (n = 1029, 70%) and 'to end the pandemic' (n = 357, 24%). CONCLUSIONS: Although our study found 35% hesitancy rate of COVID-19 vaccine, there were noticeable demographic differences that suggest tailored communication strategy to address concerns held by most hesitant subpopulation. Use of mobile vaccination facilities particularly for less mobile and disadvantaged, and implementation and evaluation of social mobilization strategy should be considered to increase overall COVID-19 vaccination acceptance and coverage.
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Vacunas contra la COVID-19 , COVID-19 , Humanos , Actitud , Ciudades , COVID-19/epidemiología , COVID-19/prevención & control , Estudios Transversales , Pakistán/epidemiología , Vacunación , Adolescente , AdultoRESUMEN
BACKGROUND: Pakistan is the fifth most populous country in the world, with a population that is growing at 2.4% annually. Despite considerable political will, including a national commitment that was endorsed by the president to raise the contraceptive prevalence rate (CPR) to 50% by 2025, it has stagnated at around 30-35%. Much of the dialogue on raising CPR is hypothetical and revolves around percentage point change rather than an actual number of women that must be served. METHODS: The Demographic and Health Survey 2017-18 (DHS 2017-18) provides information about the channels through which users receive family planning (FP) services and disaggregates this information at the provincial level. Proportions of users from each of these channels were multiplied by the Pakistan Census-2017 populations to arrive at the number of users. These users were compared with the total FP users and the number of women that had used any FP service in the past 12 months. Linear estimations of population were applied to calculate population numbers in 2025. RESULTS: The national target of 50% CPR by 2025 translates to a population of 20.02 million users. Currently, 11.26 million married women of reproductive age (MWRA) use any method, 8.22 million use a modern method and 4.94 million received this service in the past 12 months. Of these, 2.7 million did so from social marketing outlets, 0.76 million from public sector outreach through lady health workers (LHWs), 0.55 million from private sector and 0.88 million from public sector facilities. However, arriving at the CPR target means expanding annual service delivery from 4.94 to 13.7 million users. Since social marketing and LHW outreach may have become saturated, only public and private health facilities are the likely channels for such an expansion. CONCLUSIONS: We demonstrate triangulation of the survey data with the census data as a simple policy analysis tool that can help decision-makers estimate the quantum of services they must provide. Such an analysis also allows an understanding of the utilization patterns of each of these channels. In Pakistan's context, underutilization of funds and existing facilities suggests that increased funding or more providers will likely not be helpful. The policy changes that will likely be most effective include adding outreach to support existing public and private sector facilities while ensuring that procurement of commodities is prioritized.
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Anticoncepción , Servicios de Planificación Familiar , Femenino , Humanos , Lactante , Pakistán , Prevalencia , Servicios de Planificación Familiar/métodos , AnticonceptivosRESUMEN
BACKGROUND: Urban slums are home to a significant number of marginalized individuals and are often excluded from public services. This study explores the determinants of willingness and uptake of COVID-19 vaccines in urban slums in Pakistan. METHODS: The study uses a cross-sectional survey of 1760 respondents from five urban slums in twin cities of Rawalpindi and Islamabad carried out between June 16 and 26, 2021. Pairwise means comparison tests and multivariate logistic regressions were applied to check the associations of socio-demographic factors and COVID-19 related factors with willingness to get vaccinated and vaccination uptake. RESULTS: Only 6% of the sample was fully vaccinated while 16% were partially vaccinated at the time of survey. Willingness to receive vaccination was associated with higher education (aOR: 1.583, CI: 1.031, 2.431), being employed (aOR: 1.916, CI: 1.423, 2.580), prior infection in the family (but not self) (aOR: 1.646, CI: 1.032, 2.625), family vaccination (aOR: 3.065, CI: 2.326, 4.038), knowing of and living close to a vaccination center (aOR: 2.851, CI: 1.646, 4.939), and being worried about COVID-19 (aOR: 2.117, CI: 1.662, 2.695). Vaccine uptake was influenced by the same factors as willingness, except worriedness about COVID-19. Both willingness and vaccination were the lowest in the two informal settlements that are the furthest from public facilities. CONCLUSIONS: We found low lived experience with COVID-19 infection in urban slums, with moderate willingness to vaccinate and low vaccination uptake. Interventions that seek to vaccinate individuals against COVID-19 must account for urban poor settlement populations and overcome structural barriers such as distance from vaccination services, perhaps by bringing such services to these communities.
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Vacunas contra la COVID-19 , COVID-19 , Humanos , Estudios Transversales , COVID-19/epidemiología , COVID-19/prevención & control , Vacunación , Áreas de PobrezaRESUMEN
OBJECTIVE: Pakistan's struggle to revitalize its family planning is reflected in a very slowly rising Contraceptive Prevalence Rate (CPR) over the past decade and little change in demand indicators such as ideal family size and total fertility, despite considerable funding, limelight and resources. This review explores nationally available data to understand the causes for this limited success of family planning programming. METHODS: This is a thematic review of Pakistan Demographic and Health Surveys 2007, 2012 and 2017, with some illustrative examples from other local studies or evaluations. FINDINGS: National CPR changed from 30% in 2007 to 35% in 2012 and 34% in 2017 while CPR for modern methods changed from 22% to 25% and then remained unchanged. This corresponds to around 11.36 million users of FP but only 4.9 million that avail any family planning services each year - the rest had received a permanent or long-term method in a previous year. This means that only 15% of all Married Women of Reproductive Age (MWRA - i.e., married women between the ages 15-49) avail FP services each year - a proportion that has remained unchanged since 2007. Nearly half (44%) of all those who avail services buy a product directly from a store. The method mix is dominated by condoms and tubal ligation and does not change much by age, parity or when women say they want to space or limit children. Age of peak fertility remains in the 25-29 year bracket while age of peak family planning increased from 35-39 bracket to 40-44 in 2017. Although much of programming is supply driven, contraceptive supplies data do not match community uptake (as estimated from PDHS 2017) and mismatches vary from 16% to 1100% depending on the method. CONCLUSIONS: Key factors in lack of progress are limited demand creation, a lack of response to women's preferences during service delivery and the lack of consideration of coverage in programmes. Current programmes serve around 4.9 MWRA each year while an additional 12.8 million women must be served annually to reach Pakistan's goal of 50% CPR. To do this, a number of changes are needed, including demand creation, community contextualized programming, more accurate data about programming and commodities, and better use of this data in making programming and allocation decisions.
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Anticoncepción , Servicios de Planificación Familiar , Adolescente , Adulto , Niño , Conducta Anticonceptiva , Atención a la Salud , Países en Desarrollo , Femenino , Humanos , Persona de Mediana Edad , Pakistán , Embarazo , Educación Sexual , Adulto JovenRESUMEN
OBJECTIVE: We revisited the costs of Family Planning per woman served per year in the public sector using data from the Pakistan Demographic and Health Survey 2017-18. These costs were estimated previously in 2006-07. The public sector (Population Welfare Department and the Department of Health) accounts for around 35% of all family planning services provided each year. We looked at utilization patterns of public sector family planning services and estimated its costs of FP per woman served per year and cost per Couple Years of Protection (CYP). METHODS: Pakistan Demographic and Health Survey 2017-18 was used to estimate the number of users of public sector services and their usage patterns. These were depicted using simple tables and with binary logistic regression analysis. National Health Accounts 2012-16 were used to estimate government allocations for family planning. Costs of FP were estimated by simply dividing the allocation by the two public sector departments - Population Welfare (PWD) and Health (DoH) - with the number of users they serve each year. Costs were also depicted per CYP generated. RESULTS: Both the public and private sectors provide family planning services. The PWD serves an estimated 724,320 clients annually compared to 915,817 by DoH. Together these amount to around 5% of all MWRA, a proportion that remains unchanged over past decade. Due to their very different method mix PWD serves 2,344,411 CYP while DoH serves 988,603. DoH delivers most of its services in the form of condoms and pills which LHWs can carry. The PWD, having increased its range of products as compared to a decade ago, provides condoms, pills, IUDs and tubal ligations. Users of the public sector tend to belong to urban areas (AOR 1.2, range 1.2-1.2), are poor (AOR 2.7, range 2.7-2.7), and tend to have more children (AOR 1.1, range: 1.1-1.1). The exception is that DoH's lady health workers serve a large portion of rural population. Costs of FP per woman per year for PWD are USD 28 and for DOH are USD 14, costs per CYP are calculated are USD 9 and 13 respectively. CONCLUSIONS: The public sector fills an important niche by serving a poorer population and through rural household outreach. While costs have decreased since 2007, they remain higher than regional averages and suggest significant inefficiencies as both fixed facilities and lady health workers are considerably underutilized.
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Servicios de Planificación Familiar , Sector Público , Niño , Países en Desarrollo , Femenino , Humanos , Pakistán , Educación SexualRESUMEN
INTRODUCTION: Crowdsourcing pools together dispersed information that is considered public knowledge in an area, to form realistic estimates about the area, or to identify new ideas. The technique can be extremely helpful to develop estimates of public health indicators such as catchment area populations or healthcare providers; however, such uses must be scientifically validated. METHODS: We divided the community into 1040 discrete segments of similar lengths of streets (called spots) and then randomly selected 605 of these spots for crowdsourcing. Local respondents were asked to estimate the maximum and the minimum population residing in those spots. Five informants were interviewed per spot. Median values for the maximum and minimum were averaged to arrive at an estimate for the spot's population. Estimates for all spots were added together to arrive at the population of the community. One hundred spots from the 597 crowdsourced spots were revisited to conduct a household census as a "gold standard". RESULTS: Spots where both crowdsourcing and census estimates were computed had a crowdsource population estimate of 19,255 versus a census estimate of 18,119 - a variation of 5.9% (p: <0.001). However, within spot variation was a mean of 25%. CONCLUSIONS: Crowdsourcing communities for public knowledge information can yield more accurate information about public health indicators such as populations. In turn these estimates can help to better understand public health programme coverage. Other applications to consider may be missed children for immunization or schooling, deaths or births in communities or to identify total formal or informal healthcare providers in a community.
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Colaboración de las Masas , Niño , Humanos , Salud PúblicaRESUMEN
Introduction: Pakistan's private sector caters to around 65% of family planning users. Private sector family planning was promoted in the Delivering Accelerated Family Planning in Pakistan (DAFPAK) program by UK's Foreign, Commonwealth & Development Office (FCDO) in 2019. We use data from DAFPAK to analyze the clientele and products distributed by two major NGOs, Marie Stopes Society (MSS) and DKT Pakistan, that support private providers in Pakistan. We also examined the effect of COVID-19 on client visits and contraceptives uptake at private facilities in Pakistan. Methods: DAFPAK used field validation surveys to analyze the volume of clients and products of 639 private facilities across three provinces (Punjab, KPK and Balochistan) of Pakistan. The data was collected in two phases (February 2020 and 2021) using multi-stage cluster sampling at 95% confidence level. Using a generalized negative binomial regression, facility-level characteristics and impact of COVID-19 was analyzed with the volume of clients and products given out at 95% confidence interval alongside descriptive analysis. Results: DKT facilities covered 53% of the sample while MSS covered 47%, with 72% facilities in the rural areas. Average facility existence duration is 87 months (7.25 years). While the average experience of the facility staff is 52 months (4.33 years). MSS is serving more clients as compared to DKT during both phase 1 (IRR: 3.15; 95% CI: 2.74, 3.61) and phase 2 (IRR: 2.11; 95% CI: 1.79, 2.49). Similarly, MSS had a greater volume of products given out in both phases 1 (IRR: 1.89; 95% CI: 1.51, 2.38) and phase 2 (IRR: 2.57; 95% CI: 2.09, 3.14). In both phases, client visits and product distribution decreased when client privacy is invaded (IRR: 0.74; 95% CI: 0.67, 0.82 - phase 1) and (IRR: 0.83; 95% CI: 0.72, 0.97 - phase 2). Lastly, during COVID-19, products distribution decreased by a factor of 0.84 (IRR: 0.84; 95% CI: 0.72, 0.97) but client visits remain unaffected. Conclusion: Overall, clientele is low for all facilities. At a facility, privacy is a determinant of client visits and products given out per visit. Transiently, during COVID-19, client volumes decreased, with a shift from oral pills to condoms and emergency contraceptive pills.
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Hyperglycaemia is a life-threatening risk factor that occurs in both chronic and acute phases and has been linked to causing injury to many organs. Protein modification was triggered by hyperglycaemic stress, which resulted in pathogenic alterations such as impaired cellular function and tissue damage. Dysregulation in cellular function increases the condition associated with metabolic disorders, including cardiovascular diseases, nephropathy, retinopathy, and neuropathy. Hyperglycaemic stress also increases the proliferation of cancer cells. The major areas of experimental biomedical research have focused on the underlying mechanisms involved in the cellular signalling systems involved in diabetes-associated chronic hyperglycaemia. Reactive oxygen species and oxidative stress generated by hyperglycaemia modify many intracellular signalling pathways that result in insulin resistance and ß-cell function degradation. The dysregulation of post translational modification in ß cells is clinically associated with the development of diabetes mellitus and its associated diseases. This review will discuss the effect of hyperglycaemic stress on protein modification and the cellular signalling involved in it. The focus will be on the significant molecular changes associated with severe metabolic disorders.
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Hiperglucemia , Enfermedades Metabólicas , Procesamiento Proteico-Postraduccional , Transducción de Señal , Humanos , Hiperglucemia/metabolismo , Enfermedades Metabólicas/metabolismo , Enfermedades Metabólicas/etiología , Animales , Estrés Oxidativo , Especies Reactivas de Oxígeno/metabolismoRESUMEN
INTRODUCTION: Child immunization, though cost-beneficial, experiences varying costs influenced by individual facility-level factors. A real-time solution is to optimize resources and enhance vaccination services through proper method to measure immunization facility efficiency using existing data. Additionally, examine the impact of COVID-19 on facility efficiency, with the primary goal of comprehensively assessing child immunization facility efficiency in Pakistan. METHODS: Utilizing survey data collected in four rounds from May 2018 to December 2020, the research focuses on doses administered and stock records for the preceding six months in each phase. In the initial stage, Data Envelopment Analysis (DEA) is utilized to compute facility efficiency, employing two models with varied outputs while maintaining consistent inputs. Model 1 assesses doses administered, encompassing three outputs (pentavalent vaccine 1, 2, and 3). Meanwhile, Model 2, focuses on stock used featuring a single output (total doses used). The inputs considered in both models include stock availability, staff members, cold chain equipment, vaccine carriers, and vaccine sessions. The second stage involves the application of two competing regression specifications (Tobit and Simar-Wilson) to explore the impact of the COVID-19 pandemic and external factors on the efficiency of these facilities. RESULTS: In 12 districts across Punjab and Sindh, we assess 466 facilities in Model 1 and 455 in Model 2. Model 1 shows 59% efficiency, and Model 2 shows 70%, indicating excess stock. Stock of vaccines need to be reduced by from 36% to 43%. In the stage, COVID-19 period reduced efficiency in Model 1 by 10%, however, insignificant in Model 2. CONCLUSIONS: The proposed methodology, utilizing DEA, emerges as a valuable tool for immunization facilities seeking to improve resource utilization and overall efficiency. Model 1, focusing on doses administered indicates facilities low efficiency at average 59% and proves more pertinent for efficiency analysis as it directly correlates with the number of children vaccinated. The prevalent issue of overstocking across all facilities significantly impacts efficiency. This study underscores the critical importance of optimizing resources through the redistribution of excess stock with low efficiency.
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COVID-19 , Vacunas , Niño , Humanos , Pakistán , Pandemias , Programas de Inmunización , Vacunación/métodos , COVID-19/epidemiología , COVID-19/prevención & control , InmunizaciónRESUMEN
Introduction: In 2020, Pakistan faced the formidable challenge of the COVID-19 pandemic with an existing yet disjointed healthcare infrastructure, that included by over 18,000 public and an estimated 75,000 private health facilities and some elements of an epidemic surveillance and response system. This descriptive study examines how Pakistan developed a COVID-19 response, driven by establishing a central coordination and decision-making mechanism to overcome these systemic challenges. Methods: The study is based on interviews and interactions of the many actors in the response by the authors, who also participated in nearly all proceedings of the National Command and Operation Centre (NCOC) and many of the National Coordination Committee (NCC). This information is supplemented by reviewing documents, reports, news items, media and social media, and journal articles. Results: The study highlights the critical role of political arrangement, where the NCC, comprising of ministers, bureaucrats, and military personnel, facilitated federal and provincial integration. The NCC found resources and set policy. Its direction was implemented by the NCOC, a top-down yet inclusive platform, integrated political, military, and civil society actors, to ensure cohesive decision-making and implementation. It provided technical guidance, harnessed data for strategic decisions and held implementers accountable. At its peak, the NCOC boasted nearly 300 personnel, including high-ranking military officers, a stark contrast to the limited staffing in most ministries. In addition, the response's success is attributed to the perception of COVID-19 as an existential threat, leading to unprecedented collaboration and decisive actions that were enforced authoritatively. Conclusion: Pakistan's experience offers valuable insights for proactive management of health emergencies in resource-limited settings. It underscores the necessity for inter-sectoral dialog and data-driven policy implementation, especially in the context of political economies where activity-driven governance often overshadows objective-driven policy execution. However, the lessons from the COVID-19 response, including a blueprint for future epidemic responses and lessons for use of data and evidence in developing country health systems, if not institutionalized, risk being lost in the post-pandemic era.
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COVID-19 , Pandemias , COVID-19/epidemiología , Pakistán/epidemiología , Humanos , SARS-CoV-2 , Política , Política de SaludRESUMEN
INTRODUCTION: With the contraceptive prevalence rate (CPR) at 30% in 2006-7, the rates of contraception use among married women of reproductive age (MWRA) in Pakistan are among the lowest in the region. This paper explores some options of unmet need as a means of addressing the low CPR. METHODS: We conducted secondary data analysis of the Pakistan Demographic Health Survey (PDHS) 2006-7 to understand the context of unmet need in Pakistan. Univariate and multiple regression techniques were used to understand associations. The numbers of women with unmet need were calculated by multiplying PDHS proportions with actual population figures. RESULTS: There are 5.7 million women with an unmet need; 2.4 million with a need to space and 3.3 million with a need to limit. Unmet need decreases with age, increases with the number of children and increasing education, and is higher among poor women. Structural factors such as rural residence and exposure to family planning (FP) programmes and messages are relevant for unmet need for spacing, but not for unmet need for limiting. There are twice as many women in Pakistan with an unmet need for FP than those who avail FP services. Additionally there is much more need to limit than the need to space. In fact the need to limit is nearly 10 fold higher than the services for long-term methods. Structural interventions, that increase service delivery, quality, and uptake may address unmet need in the short-term, must be complemented with demand creation and behaviour-change interventions. All of these issues must be addressed concomitantly with research to understand how best to harness the "market forces" that are responsible for over half of all FP services.
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Anticoncepción/estadística & datos numéricos , Países en Desarrollo , Servicios de Planificación Familiar/organización & administración , Necesidades y Demandas de Servicios de Salud , Desarrollo de Programa/métodos , Adolescente , Adulto , Femenino , Encuestas Epidemiológicas , Humanos , Persona de Mediana Edad , Pakistán , Estudios Retrospectivos , Adulto JovenRESUMEN
INTRODUCTION: The public sector provides a third of family planning (FP) services in Pakistan. However, these services are viewed as being underutilized and expensive. We explored the utilization patterns and costs of FP services in the public sector. METHODS: We used overall budgets and time allocation by health and population departments to estimate the total costs of FP by these departments, costs per woman served, and costs per couple-year of protection (CYP). RESULTS: The public sector is the predominant provider of FP to the poorest and is the main provider of female sterilization services. The overall costs of FP in the public sector are USD 55 per woman served, annually (USD 17 per CYP). Within the public sector, the population welfare departments provide services at USD 72 per woman served, annually (USD 17 per CYP) and the health departments at USD 39 per woman per year (USD 29 per CYP). CONCLUSION: While the public sector has a critical niche in serving the poor and providing female sterilization, its services are considerably more expensive compared to international and even some Pakistani non-government organization (NGO) costs. This reflects inefficiencies in services provided, client mistrust in the quality of services provided, and inadequate referrals, and will require specific actions for improving referrals and the quality of services.
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Países en Desarrollo , Servicios de Planificación Familiar/estadística & datos numéricos , Sector Público/economía , Adulto , Costos y Análisis de Costo , Estudios Transversales , Servicios de Planificación Familiar/economía , Femenino , Humanos , Pakistán , Sector Público/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
INTRODUCTION: Contraceptive prevalence rate (CPR) is a widely accepted measure of maternal health and uptake of family planning (FP) services. However, the overall CPR obscures the actual utilization of FP services due to over-representation of long-term methods. This study used CPR from 2007 to arrive at and compare the number of actual number of women who availed different FP services in order to understand issues and gaps in FP services in Pakistan. METHODS: This study used secondary data from the Pakistan Demographic and Health Survey 2006-7 estimate the CPR and modern method mix for 2007.These were then multiplied by the estimated number of married women of reproductive age (MWRA) to arrive at the actual numbers of women using specific FP methods and utilizing FP services in a given year. RESULTS: In 2007 the CPR was 30% overall and 22% for modern methods. However, the number of women availing FP services decreased to 12% when adjusted for FP users who had availed services in the past 12 months. Within this "service mix", self-procurement of FP commodities directly from stores without a advice from a health provider constitutes around 37% of all FP "services" and the public sector accounts for another 33%. Condoms are the commonest method served, accounting for over half of all "services". CONCLUSIONS: The bulk of FP is self-procured and the service mixed is skewed towards client controlled methods that do not require medical advice. Thus, lack of quality for contraceptive services that require some form of supportive healthcare services and counselling may be a bottleneck to improving CPR.
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Anticoncepción/estadística & datos numéricos , Países en Desarrollo , Servicios de Planificación Familiar/organización & administración , Formulación de Políticas , Evaluación de Programas y Proyectos de Salud , Adolescente , Adulto , Femenino , Humanos , Persona de Mediana Edad , Pakistán , Estudios Retrospectivos , Adulto JovenRESUMEN
Despite six decades of government and private sector programs, CPR in Pakistan is among the lowest in the region. This article reviews published and grey literature to understand why despite sufficient time and usually sufficient funding, CPR remains low in Pakistan. This paper looks beyond the usual factors of quality of services, coverage and supplies and management issues to examine how family planning may be improved in Pakistan. Based on analysis of the Pakistan Demographic Health Survey 2006-7, the public sector provides around a third of FP services, while NGOs and private providers another 15%. More than half of all family planning users buy their methods directly from stores. Within the government, the services cost 5-8 fold more than the private sector. Nearly a fifth of pregnancies end in an abortion suggesting the role of abortions as a key FP method. This together with a high unmet need pose the question: why is there such low uptake of FP services in the country. To explain this lack of uptake, we explore the limitations of the public sector in providing services, the lack of effect of religious beliefs, of abundant, yet misdirected funding and gaps in demand creation. The increasing role of NGOs and donors in filling the void left by the public sector is discussed. Suggestions are provided about improving public and private sector services including better information gathering and use in defining needs, measuring results and creating demand for FP.
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Países en Desarrollo , Servicios de Planificación Familiar/organización & administración , Educación Sexual/organización & administración , Humanos , PakistánRESUMEN
INTRODUCTION: Female sterilization has long been the most popular method of family planning (FP) in Pakistan, and yet most public health experts feel it contributes little to controlling family size or to population welfare. We used Pakistan Demographic Health Survey (PDHS) data to understand the role female sterilization plays in the overall context of FP in Pakistan. METHODS: We performed a secondary analysis of data from the PDHS 1990-1 and 2006-7 to study factors that lead to sterilization and trends in the use of the procedure. In addition, census data were multiplied by proportions from PDHS data to estimate the number of women availing sterilization services. RESULTS: Around 1.9 million women in Pakistan are currently sterilized--up from 0.55 million in 1990-1, and around 173,867 undergo the procedure, annually. Women usually receive sterilization after 30 years of age (mean = 39) and after six children. The probability of sterilization increases with age, family size, and urban residence, and is unaffected by poverty, province of residence, or the woman or her husband's education. Most sterilizationis conducted in public sector facilities. CONCLUSIONS: Sterilization in Pakistan may be common, but occurs too late to have any significant effect on family size or benefit public health. Future avenues to make this option more useful to women and society would be to improve the repertoire and access and quality of FP services that are available, and to address governance issues that limit the performance and utility of government facilities.
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Anticoncepción/estadística & datos numéricos , Países en Desarrollo , Servicios de Planificación Familiar/organización & administración , Esterilización Reproductiva/estadística & datos numéricos , Adulto , Femenino , Humanos , Pakistán , Estudios Retrospectivos , Factores SocioeconómicosRESUMEN
INTRODUCTION: Community-based distribution (CBD) has been successfully applied to family planning (FP) services worldwide. It forms the basis for the large lady health worker (LHW) programme in Pakistan which serves a limited number of women with contraception services. Thus, the concept has seen limited application in Pakistan. We present the outcomes of a CBD model that was implemented in 49 districts across Pakistan by a non-government organization (NGO). METHODS: The Marie Stopes Society (MSS) developed a CBD model around its fixed centres and reached around half a million married women of reproductive age (MWRA) with services. The services provided included outreach, counselling, condoms, pills, injections, and referrals for intrauterine contraceptive devices (IUCDs) and other reproductive health services. Services were provided in peri-urban locations for a subsidized fee using a businesslike target setting approach. The results of the programme were assessed by triangulating inception records against a cross-sectional end-of-project survey and service delivery records. RESULTS: The contraceptive prevalence rate (CPR) had increased from 38% to 51% by project-end with modern method use increasing by 50-200% and traditional method use remaining unchanged. Unmet need and self-reported pregnancy rates fell correspondingly. Approximately 73,500 new users were added to the initial user registered numbers to a total of 132,300; MSS accounted for 53,000 per year at the end of the project, which matched the commodities supplied by the NGO. CONCLUSIONS: The MSS CBD model presents a viable option for scaling effective FP services that may be replicated and scaled up with either donor support or by contracting out by the government. Triangulation of multiple data sources can provide more in-depth assessment of service delivery programmes and provide inferences that can inform service delivery.
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Atención a la Salud/normas , Servicios de Planificación Familiar/normas , Modelos Teóricos , Indicadores de Calidad de la Atención de Salud , Adulto , Femenino , Humanos , Pakistán , Embarazo , Estudios RetrospectivosRESUMEN
Background: Pakistan's contraceptive prevalence rate (CPR) has remained static (less than 1% annual increase since 2006) due to several demand and supply issues. The Akhter Hameed Khan Foundation implemented a community-driven, demand-generation intervention with complementary supply side family planning (FP) services in a large urban informal settlement in Rawalpindi, Pakistan. Methods: The intervention recruited local women as outreach workers called Aapis (sisters), who conducted household outreach and provided counseling, contraceptives, and referrals. Program data were used to guide in-program corrections, identify the most willing to use married women of reproductive age (MWRA), and target specific geographic locations. The evaluation compared results from two surveys. The baseline survey included 1485 MWRA while the endline included 1560 MWRA that were sampled using the same methodology. A logit model was used with survey weights and clustered standard errors, to estimate the odds of using a contraceptive method. Results: CPR in Dhok Hassu increased from 33% at the baseline to 44% at endline. Long-acting reversible contraceptives (LARCs) usage increased from 1% at baseline to 4% at endline. Increase in CPR is correlated with increasing number of children and education of MWRA and is the highest between the ages of 25 and 39 and for working women. Qualitative evaluation of the intervention provided lessons about in-program corrections using data and empowerment of the female outreach workers and MWRA. Conclusion: The Aapis Initiative is a unique community-based demand-supply side intervention that successfully increased modern contraceptive prevalence rate (mCPR) by economically engaging the women from within the community as outreach workers and enabling healthcare providers to establish a sustainable ecosystem for increasing knowledge and access to family planning services.
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Servicios de Planificación Familiar , Áreas de Pobreza , Niño , Femenino , Humanos , Adulto , Pakistán/epidemiología , Ecosistema , AnticonceptivosRESUMEN
OBJECTIVES: The COVID-19 pandemic showed distinct waves where cases ebbed and flowed. While each country had slight, nuanced differences, lessons from each wave with country-specific details provides important lessons for prevention, understanding medical outcomes and the role of vaccines. This paper compares key characteristics from the five different COVID-19 waves in Pakistan. METHODS: Data was sourced from daily national situation reports (Sitreps) prepared by the National Emergency Operations Centre (NEOC) in Islamabad. We use specific criteria to define COVID-19 waves. The start of each COVID-19 wave is marked by the day of the lowest number of daily cases preceding a sustained increase, while the end is the day with the lowest number of cases following a 7-days decline, which should be lower than the 7 days following it. Key variables such as COVID-19 tests, cases, and deaths with their rates of change to the peak and then to the trough are used to draw descriptive comparisons. Additionally, a linear regression model estimates daily new COVID-19 deaths in Pakistan. RESULTS: Pakistan saw five distinct waves, each of which displayed the typical topology of a complete infectious disease epidemic. The time from wave-start to peak became progressively shorter, and from wave-peak to trough, progressively longer. Each wave appears to also be getting shorter, except for wave 4, which lasted longer than wave 3. A one percent increase in vaccinations decreased deaths by 0.38% (95% CI: -0.67, -0.08) in wave 5 and the association is statistically significant. CONCLUSION: Each wave displayed distinct characteristics that must be interpreted in the context of the level of response and the variant driving the epidemic. Key indicators suggest that COVID-19 preventive measures kept pace with the disease. Waves 1 and 2 were mainly about prevention and learning how to clinically manage patients. Vaccination started late during wave 3 and its impact on hospitalizations and deaths became visible in wave 5. The impact of highly virulent strains Alpha/B.1.1.7 and Delta/B.1.617.2 variants during wave 3 and milder but more infectious Omicron/B.1.1.529 during wave 5 are apparent.
Asunto(s)
COVID-19 , Pandemias , Humanos , Pandemias/prevención & control , SARS-CoV-2 , Pakistán/epidemiología , COVID-19/epidemiologíaRESUMEN
OBJECTIVE: To explore the healthcare providers' perspectives in the management of sexually transmitted infections. METHODS: The mixed-method qualitative study done in 2008 involved 51 general practitioners and specialists who are known among peers for managing sexually transmitted infections. Interviews were conducted using semi-structured instruments and recruitment was kept open within each provider type until specific themes were saturated. Providers were interviewed from 5 cities in Pakistan. RESULTS: Each type of provider was usually found dealing with a specific population sub-group. Nearly all providers were practising personal empiricism, rarely following any standardised guidelines. Testing for asymptomatic infections such as human immunodeficiency virus, syphilis or anal infections was rare as was counselling or partner management. CONCLUSION: Encounters with patients suffering from sexually transmitted infections seem to be missed opportunities to control community based transmission of such infections. Implementation research is needed to better understand how to induce healthcare providers to better manage these infections, test for asymptomatic infections and advise partner management.
Asunto(s)
Control de Enfermedades Transmisibles/organización & administración , Médicos/normas , Pautas de la Práctica en Medicina/normas , Enfermedades de Transmisión Sexual , Femenino , Accesibilidad a los Servicios de Salud/normas , Humanos , Masculino , Pakistán , Aceptación de la Atención de Salud , Servicios Preventivos de Salud/normas , Calidad de la Atención de Salud , Enfermedades de Transmisión Sexual/psicología , Enfermedades de Transmisión Sexual/terapiaRESUMEN
OBJECTIVES: To determine the extent of shortfall in syringes by measuring the need from nationally validated sources and comparing it with position on the supply side. This was done in order to contribute to the ongoing national discussions that have focused on increasing syringe supply to curtail syringe reuse. METHODS: Using 'Injections received' data from the Pakistan Demographic Health Survey 2006-7 (N: 5429) and the National Hepatitis Survey (N: 47,043), the study estimated the number of injections received in Pakistan. We matched these against the local syringe production figures from the syringe manufacturers' association and import figures from the Federal Board of Revenue (FBR). RESULTS: Approximately 731+/-867 million injections (5.1 12 injections per head) are received annually in Pakistan and around 861+/-961 million syringes are supplied to the open market. Overall, 52-77% Pakistanis receive at least one injection in any given year. CONCLUSIONS: Injection need in Pakistan is among the highest worldwide but is completely matched by available syringe supplies, suggesting lower reuse than previously considered. However, highly prevalent Hepatitis B and C viruses suggest that even this reuse is a major public health concern and measures directed at both providers and recipients of injections are needed to curtail high injection need and syringe reuse.