A study protocol for integrating outpatient services at the primary health care level as part of the universal health coverage benefit package within the national health insurance program of Pakistan through private health facilities.

Introduction and aim: Pakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country's health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services. Methods and analysis: A 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices. Conclusion and knowledge contribution: PHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality.

The need to sustain funding for Afghanistan health system to prevent excess morbidity and mortality.

Background: The Afghanistan Reconstruction Trust Fund, managed by the World Bank through a contracted-out instrument called Sehatmandi, financed health service delivery in Afghanistan, with substantial achievements in infant, child and maternal health. After the collapse of the Afghan Government on 15 August 2021, the health system has been on the brink of collapse. Aims: We assessed the use of basic health services and estimated excess mortality resulting from the interruption to healthcare funding. Methods: We conducted a cross-sectional study that compared health services utilization from June to September for 3 consecutive years, 2019, 2020 and 2021, using 11 output indicators reported by the health management and information system. We used the Lives Saved Tool, a linear mathematical model with input data from the Afghanistan Demographic Health Survey 2015, to calculate the additional maternal, neonatal and child mortality at 25%, 50%, 75% and 95% reduction in health coverage. Results: During August and September 2021, after the announced ban on financing, health service utilization decreased to a range of 7-59%. Family planning, major surgeries and postnatal care showed the greatest decreases. Uptake of child immunization showed one-third decrease. Sehatmandi provides around 75% of primary and secondary health services: pausing funds to this programme will result in additional 2862 maternal deaths, 15 741 neonatal deaths, 30 519 child deaths, and 4057 stillbirths. Conclusion: Sustaining the current level of health services delivery is crucial to avoid excess, preventable morbidity and mortality in Afghanistan.

An assessment of facility readiness for comprehensive abortion care in 12 districts of Pakistan using the WHO Service Availability and Readiness Assessment tool.

Although Pakistan's Essential Package of Health Services was recently updated to include therapeutic and post-abortion care, little is known about current health facility readiness for these services. This study assessed the availability of comprehensive abortion care, and readiness of health facilities to deliver these services, within the public sector in 12 districts of Pakistan. A facility inventory was completed in 2020-2021 using the WHO Service Availability and Readiness Assessment, with a newly developed abortion module. A composite readiness indicator was developed based on national clinical guidelines and previous studies. Just 8.4% of facilities reported offering therapeutic abortion, while 14.3% offered post-abortion care. Misoprostol (75.2%) was the most common method provided by facilities that offer therapeutic abortion, followed by vacuum aspiration (60.7%) and dilatation and curettage (D&C) (59%). Few facilities had all the readiness components required to deliver pharmacological or surgical therapeutic abortion, or post-abortion care (<1%), but readiness was higher in tertiary (22.2%) facilities. Readiness scores were lowest for "guidelines and personnel" (4.1%), and slightly higher for medicines and products (14.3-17.1%), equipment (16.3%) and laboratory services (7.4%). This assessment highlights the potential to increase the availability of comprehensive abortion care in Pakistan, particularly in primary care and in rural areas, to improve the readiness of health facilities to deliver these services, and to phase out non-recommended methods of abortion (D&C). The study also demonstrates the feasibility and utility of adding an abortion module to routine health facility assessments, which can inform efforts to strengthen sexual and reproductive health and rights.

Engagement of private healthcare sector in reproductive, maternal, newborn, child and adolescent health in selected Eastern Mediterranean countries.

Background: The private healthcare sector in the Eastern Mediterranean Region (EMR) is active and growing, providing curative, preventive, and promotive services related to reproductive, maternal, newborn, child, and adolescent health (RMNCAH). Aims: To understand the contribution of formal for-profit private health-care sector in delivering RMNCAH services and explore best practices for improvement. Methods: Desk review of available literature from Saudi Arabia, Oman, Iraq, Egypt, Sudan, Yemen, Pakistan, and Islamic Republic of Iran, followed by stakeholder interviews in Iraq, Pakistan, and Oman were carried out. Directed content analysis using Maxqda 2020 was performed, and information was triangulated according to a priori themes: governance, health information systems, financing, and service delivery related to RMNCAH. Results: Formal and informal public-private partnerships exist in RMNCAH but lack a strategic roadmap to guide collaboration. The private healthcare sector is minimally represented in the main policy stream at national and subnational levels due to resistance from the private and public sectors. They are weak in collecting, maintaining, and sharing health information. Data on abortion and postabortion complications are scarce. Various models of supply and demand financing (voucher schemes, private and social health insurance) related to antenatal care and contraception have been implemented in the EMR. Despite the higher cost of care in the private sector, limited training of providers, ill-defined service delivery packages, and lack of continuity-of-care and team-based approaches, the private sector remains the predominant sector providing RMNCAH services in the EMR. Conclusion: Partnering with the private sector has huge untapped potential that should be harnessed by national governments for expanding RMNCAH services and progressing towards Universal Health Coverage.

WHO's support for COVID-19 research and knowledge management in the Eastern Mediterranean Region.

Health research, innovation and knowledge management remain major priorities of the WHO's response to the COVID-19 pandemic. WHO's Eastern Mediterranean Regional Office (EMRO) supports priority research initiatives that address gaps in current knowledge regarding the COVID-19 pandemic. Through a specific call for proposals, 122 research proposals were received and reviewed in 2020, of which 17 were recommended for funding from eight countries. Ten countries in the region participated in the global solidarity trial to assess potential therapies for COVID-19. In addition, WHO advocated for early serological and epidemiological investigations ('COVID-19 Unity Studies') on the general population, healthcare workers, pregnant women and neonates, and extending technical, financial and material support for them.Starting in early 2020, scholarly articles on COVID-19 have been published in every issue of the Eastern Mediterranean Health Journal More than 6300 publications on COVID-19 were made available on the WHO knowledge management portal in the last year alone. WHO is also supporting countries in conducting studies to assess the field effectiveness of vaccines deployed nationally. To build and strengthen country capacities, regional webinars and intercountry meetings were conducted on research ethics, national health information systems and evidence-based health policy making. With support from WHO EMRO's new research and knowledge management pillar, countries in the region were well equipped to contribute to a global understanding of the novel virus's characteristics, as well as employ a national response based on informed evidence.

Benefit-risk analysis of maintaining essential Reproductive, Maternal, Newborn, and Child Health (RMNCH) services against risk of COVID-19 infection.

With the COVID-19 pandemic spreading across the world, its disruptive effect on the provision and utilization of non- COVID related health services have become well-documented. As countries developed mitigation strategies to help continue the delivery of essential health services through the pandemic, they needed to carefully weigh the benefits and risks of pursuing these strategies. In an attempt to assist countries in their mitigation efforts, a Benefit-Risk model was designed to provide guidance on how to compare the health benefits of sustained essential reproductive, maternal, newborn and child (RMNCH) services against the risk of SARS-CoV-2 infections incurred by the countries' populations when accessing these services. This article describes how two existing models were combined to create this model, the field-testing process carried out from November 2020 through March 2021 in six countries and the findings. The overall Benefit-Risk Ratio in the 6 countries analyzed was found to be between 13.7 and 79.2, which means that for every 13.7 to 79.2 lives gained due to increased RMNCH service coverage, there was one loss of a life related to COVID-19. In all cases and for all services, the benefit of maintaining essential health services far exceeded the risks associated with additional COVID-19 infections and deaths. This modelling process illustrated how essential health services can continue to operate during a pandemic and how mitigation measures can reduce COVID-19 infections and restore or increase coverage of essential health services. Overall, this Benefit-Risk analysis underscored the importance and value of maintaining coverage of essential health services even during public health emergencies, including the recent COVID-19 pandemic.

The role of partners in promoting self-care for misoprostol and subcutaneous DMPA in Pakistan.

BACKGROUND: Pakistan is among a number of countries facing protracted challenges in addressing maternal mortality with a concomitant weak healthcare system complexed with inequities. Sexual and reproductive health and rights (SRHR) self-care interventions offer the best solution for improving access to quality healthcare services with efficiency and economy. This manuscript documents country experience in introducing and scaling up two selected SRHR self-care interventions. A prospective qualitative study design was used and a semi-structured questionnaire was shared with identified SRHR private sector partners selected through convenience and purposive sampling. The two interventions include the use of misoprostol for postpartum hemorrhage and the use of subcutaneous depomedroxyprogesterone acetate (DMPA) as injectable contraceptive method. Data collection was done through emails and telephone follow-up calls. RESULTS: Nine of the 13 partners consulted for the study responded. The two selected self-care interventions are mainly supported by private sector partners (national and international nongovernmental organizations) having national or subnational existence. Their mandates include all relevant areas, such as policy advocacy, field implementation, trainings, supervision and monitoring. A majority of partners reported experience related to the use of misoprostol; it was introduced more than a decade ago, is registered and is procured by both public and private sectors. Subcutaneous DMPA is a new intervention, having been introduced only recently, and commodity availability remains a challenge. It is being delivered through health workers/providers and is not promoted as a self-administered contraceptive. Community engagement and awareness raising is reported as an essential element of successful field implementation; however, no beneficiary data was collected for the study. Training approaches differ considerably, are standalone or integrated with SRHR topics and their duration varies between 1 and 5 days, covering a range of cadres. CONCLUSION: Pubic sector ownership and patronage is essential for introducing and scaling up self-care interventions as a measure to support the healthcare system in delivering quality sexual and reproductive health services. Supervision, monitoring and reporting are areas requiring further support, as well as the leadership and governance role of the public sector. Standardization of trainings, community awareness, supervision, monitoring and reporting are required together with integration of self-care in routine capacity building activities (pre- and in-service) on sexual and reproductive health in the country.

Capacity-building of the allied health workforce to prevent and control diabetes: Lessons learnt from the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project.

In 2008, to tackle the exponential rise in the clinical burden of diabetes that was challenging the health systems in Sri Lanka, a shift in focus towards patient-centred care linked with community health promotion was initiated by the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project of the Sri Lanka Medical Association. Specific training of "diabetes educator nursing officers" (DENOs), field staff in maternal and child health, footwear technicians, and health promoters from the community, was instituted to improve knowledge, skills and attitudes in the area of control and prevention of diabetes. This article highlights some of the activities carried out to date with the allied health workforce and volunteer community. Specifically, it describes experiences with the DENO programme: the educational and administrative processes adopted, challenges faced and lessons learnt. It also highlights an approach to prevention and management of complications of chronic diabetic foot through training a cohort of prosthetics and orthotics technicians, in the absence of podiatrists, and an initiative to provide low-cost protective footwear. Harnessing the enthusiasm of volunteers - adults and schoolchildren - to address behavioural risk factors in a culturally appropriate fashion has also been a key part of the NIROGI Lanka strategy.

Qualitative assessment of breast cancer early detection services provided through well woman clinics in the district of Gampaha in Sri Lanka.

BACKGROUND: Breast cancer is the most common cancer diagnosed among women in Sri Lanka. Early detection can lead to reduction in morbidity and mortality. The objective here was to identify perceptions of public health midwives (PHMs) on the importance of early detection of breast cancer and deficiencies of and suggestions on improving existing breast cancer early detection services provided through Well Woman Clinics. MATERIALS AND METHODS: A qualitative study using four focus group discussions (FGDs) were conducted among 38 PHMs in the Gampaha district in Sri Lanka and the meetings were audio-recorded, transcribed and analyzed using constant comparison and identifying themes and categories. RESULTS: All the PHMs had a firm realization on the need of breast cancer early detection. The four FGDs among PHMs revealed non-availability of guidelines, inadequacy of training, lack of skills and material to provide health education, inability to provide privacy during clinical examination, shortage of stationery, lack of community awareness and motivation. The suggestions for the improvements of the programme identified in FGDs were capacity building of PHMs, making availability of guidelines, rescheduling clinics, improving the supervision, strengthening the monitoring, improving coordination between clinical and preventive sectors, and improving community awareness. CONCLUSIONS: Results of the FGDs can provide useful information on components to be improved in breast cancer early detection services. Study recommendations were training programmes at basic and post basic levels on a regular basis and supervision for the sustainance of the breast cancer early detection program.

A "usual occurrence:" stress incontinence among reproductive aged women in Sri Lanka.

Stress urinary incontinence (SUI) is a common condition among women of all ages, often with devastating consequences, such as depression, anxiety and reduced quality of life. Researchers have largely focused on its prevalence and clinical management, particularly in highly industrialized country settings. In this article, drawing on epidemiological, clinical and qualitative research undertaken in Sri Lanka, we discuss how stress incontinence affects women's lives and how they personally manage the problem. Quantitative data derive from a community-based descriptive cross-sectional study, conducted in 2006-2007 with 1718 ever-married women, aged 15-49, of whom 9.8% reported problems of stress incontinence. Six focus group discussions, eight key informant interviews and five case studies with women with SUI were also undertaken to gain insight and depth. Although incontinence affected outdoor activities, sexual life, and sense of wellbeing, women did not consider it a health problem, rarely discussed it with others, and rarely sought treatment. Barriers to help seeking included fear of vaginal examination, shame and embarrassment, and belief that SUI was a natural consequence of aging and childbirth. Women's reluctance to seek advice on their own initiative about managing incontinence indicates the importance for health providers to pay greater attention to the condition and introduce appropriate preventive measures for women. This might include creating greater public awareness of SUI as preventable and treatable, ensuring a clinical environment conducive to discussing problems related to bodily functions.