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.

Non-overlapping sets of neurons encode behavioral response determinants across different tasks in the posterior medial prefrontal cortex.

Higher mammals are able to simultaneously learn and perform a wide array of complex behaviors, which raises questions about how the neural representations of multiple tasks coexist within the same neural network. Do neurons play invariant roles across different tasks? Alternatively, do the same neurons play different roles in different tasks? To address these questions, we examined neuronal activity in the posterior medial prefrontal cortex of primates while they were performing two versions of arm-reaching tasks that required the selection of multiple behavioral tactics (i.e., the internal protocol of action selection), a critical requirement for the activation of this area. During the performance of these tasks, neurons in the pmPFC exhibited selective activity for the tactics, visuospatial information, action, or their combination. Surprisingly, in 82% of the tactics-selective neurons, the selective activity appeared in a particular task but not in both. Such task-specific neuronal representation appeared in 72% of the action-selective neurons. In addition, 95% of the neurons representing visuospatial information showed such activity exclusively in one task but not in both. Our findings indicate that the same neurons can play different roles across different tasks even though the tasks require common information, supporting the latter hypothesis.

Contraceptive access, choices, and discontinuation among the urban users in Karachi, Pakistan: Findings from a comparative analysis of Pakistan demographic and health survey 2012-12 and 2017-18.

OBJECTIVE: To explore and assess the contraceptive access, choices, and discontinuation among the urban users in Karachi using the last two Demographic and Health Surveys in Pakistan. METHODS: A comparative analysis of the six districts of Karachi (Urban only) using Pakistan Demographic and Health Survey 2012-13 (sample size 2324) and 2017-18 (sample size 2896) of the currently married women of reproductive age 15-49 years was designed and conducted. For the current study, we used descriptive statistics on contraceptive use, method-mix, unmet need for family planning, method-specific discontinuation, sources of modern contraceptive use by channel (public and private), and exposure to family planning messaging. RESULTS: The analysis of the PDHS indicated that the mCPR for Karachi Urban remained stagnant at 35%. However, CPR (all methods) improved from 48% to 52% mainly because of an increase in the traditional contraceptive methods. On the other hand, there was an increase in unmet need between the two DHS surveys from 13% to 16%. The possible explanation is inadequate resource allocations, affordability of the services, poor quality of care, and fear of side effects, among other factors. The supply-side situation indicates that the private sector holds a significant share of family planning service delivery. However, the decline of 15% in the current share of services from the private sector in Karachi's urban areas since 2012-13 PDHS data. The desire for pregnancy, method failure, and side effects remained three significant reasons for the method discontinuation. CONCLUSIONS: The present study reports a high unmet need for family planning and a stagnant mCPR for urban Karachi between the two demographic surveys. In addition, the data reveals private sector taking over the public sector for the delivery of modern contraceptive methods while the major reasons for method-specific discontinuation illustrates a similar trend at national and urban Karachi level.

Uptake, satisfaction, and quality of family planning services in Pakistan: before and during Covid-19 outbreak: Stocktaking with clients of a private sector organisation.

OBJECTIVE: To report the uptake, satisfaction, and quality of family planning services in the clients of a private sector organisation during Covid-19 in Pakistan and compare it with the situation before Covid-19 pandemic. METHODS: This paper is based on the client exit interview data collected before and then after the outbreak of Covid-19, using a structured questionnaire. Clients were chosen at the exit of the social franchise (SF) clinics, situated in rural and peri-urban areas, and beneficiaries of the outreach services delivery channel in the remote rural area. Descriptive analysis was carried out in SPSS, and frequencies and percentages were computed. RESULTS: All respondents were married women of reproductive age (MWRA) with an average age of 30 years, with either no or very low literacy levels. During the pandemic, overall utilization of the intrauterine contraceptive devices (IUCDs) declined, while the condom remained popular. Client satisfaction remained high in both service delivery channels during a pandemic. However, some results varied vis-à-vis the residence of the client. CONCLUSIONS: All respondents were married women of reproductive age (MWRA) with an average age of 30 years, with either no or very low literacy levels. During the pandemic, overall utilization of the intrauterine contraceptive devices (IUCDs) declined, while the condom remained popular. Client satisfaction remained high in both service delivery channels during a pandemic. However, some results varied vis-à-vis the residence of the client.

Prevention of Pulmonary Cement Embolism by Inferior Vena Cava Filter following Vertebroplasty-related Cement Intravasation.

A 77 year old woman with recent history of vertebroplasty for treatment of multiple osteoporotic lumbar vertebral body compression fractures presented for post-procedure care. A series of radiographs and cross-sectional imaging of the lumbar spine revealed an unexpected finding of cured bone cement within a small lumbar vertebral vein, the inferior vena cava and within the spokes of an inferior vena cava filter which had originally been placed two years earlier. Inferior vena cava filters have become the standard of care to prevent pulmonary embolism in the setting of deep venous thrombosis. However, cases of foreign materials becoming entrapped in filters are uncommon despite the documented frequency of intravasation of bone cement into the circulatory system following vertebroplasty procedures. This case is significant because it illustrates the rare occurrence of an inferior vena cava filter capturing intravasated bone cement and preventing its migration to the pulmonary circulation.

Neuronal Representations of Tactic-Based Sensorimotor Transformations in the Primate Medial Prefrontal, Presupplementary, and Supplementary Motor Areas: A Comparative Study.

Adaptive context-dependent behaviors necessitate the flexible selection of multiple behavioral tactics, i.e., internal protocols for selecting an action. Previous primate studies have shown that the posterior medial prefrontal cortex (pmPFC) contributes to the selection, retention, and use of tactics, but the manner in which this area employs selected tactics to convert sensory information into action and how that manner differs from downstream cortical motor areas have yet to be fully elucidated. To address this issue, the present study recorded neuronal activity in two monkeys as they performed a two-choice arm reaching task that required the selection of multiple tactics when converting spatial cue information into the direction of arm reaching. Neuronal populations in both pmPFC and presupplementary motor area (pre-SMA) represented tactics during their selection, maintenance in memory, and their use in determining an action. Additionally, they represented the monkeys' action in the behavioral epoch in which the direction of reaching was determined. A striking contrast between the pmPFC and the pre-SMA was the representation of the spatial cue location in the former and its absence in the latter area. In individual neurons, neurons in pmPFC and pre-SMA had either single or mixed representation of tactics and action. Some of the pmPFC neurons additionally encoded cue location. Finally, neurons in the supplementary motor area mainly represented the action. Taken together, the present results indicate that, of these three areas, the pmPFC plays a cardinal role during the integration of behavioral tactics and visuospatial information when selecting an action.

Assessing Family Planning Service Quality And User Experiences In Social Franchising Programme - Case Studies From Two Rural Districts In Pakistan.

BACKGROUND: Studies have documented the impact of quality family planning services on improved contraceptive uptake and continuation, however, relatively little is known about their quality of service provision especially in the context of social franchising. This study examined the quality of clinical services and user experiences among two models in franchised service providers in rural Pakistan. METHODS: This facility-based assessment was carried out during May-June 2015 at the 20 randomly selected social franchise providers from Chakwal and Faisalabad. In our case, a franchise health facility was a private clinic (mostly) run by a single provider, supported by an assistant. Within the selected health facilities, a total 39 user-provider interactions were observed and same users were interviewed separately. RESULTS: Most of the health facilities were in the private sector. Comparatively, service providers at Greenstar Social Marketing/Population Services International (GSM/PSI) model franchised facilities had higher number of rooms and staff employed, with more providers' ownership. Quality of service indices showed high scores for both Marie Stopes Society (MSS) and GSM/PSI franchised providers. MSS franchised providers demonstrated comparative edge in terms of clinical governance, better method mix and they were more user-focused, while PSI providers offered broader range of non-FP services. Quality of counselling services were similar among both models. Service providers performed well on all indicators of interpersonal care however overall low scores were noted in technical care. For both models, service providers attained an average score of 6.7 (out of the maximum value of 8) on waste disposal mechanism, supplies 12.5 (out of the maximum value of 15), user-centred facility 2.7 (out of the maximum value of 4), and clinical governance 6.5 (out of the maximum value of 11) and respecting clients' privacy. The exit interviews yielded high user satisfaction in both service models. CONCLUSIONS: The findings seem suggesting that the MSS and GSM/PSI service providers were maintaining high quality standards in provision of family planning information, services, and commodities but overall there was not much difference between the two models in terms of quality and satisfaction. The results demonstrate that service quality and client satisfaction are an important determinant of use of clinical contraceptive methods in Pakistan.

Biomonitoring of Toxic Effects of Pesticides in Occupationally Exposed Individuals.

BACKGROUND: Workers in pesticide manufacturing industries are constantly exposed to pesticides. Genetic biomonitoring provides an early identification of potential cancer and genetic diseases in exposed populations. The objectives of this biomonitoring study were to assess DNA damage through comet assay in blood samples collected from industry workers and compare these results with those of classical analytical techniques used for complete blood count analysis. METHODS: Samples from controls (n = 20) and exposed workers (n = 38) from an industrial area in Multan, Pakistan, were subjected to various tests. Malathion residues in blood samples were measured by gas chromatography. RESULTS: The exposed workers who were employed in the pesticide manufacturing industry for a longer period (i.e., 13-25 years) had significantly higher DNA tail length (7.04 µm) than the controls (0.94 µm). Workers in the exposed group also had higher white blood cell and red blood cell counts, and lower levels of mean corpuscular hemoglobin (MCH), MCH concentration, and mean corpuscular volume in comparison with normal levels for these parameters. Malathion was not detected in the control group. However, in the exposed group, 72% of whole blood samples had malathion with a mean value of 0.14 mg/L (range 0.01-0.31 mg/L). CONCLUSION: We found a strong correlation (R (2) = 0.91) between DNA damage in terms of tail length and malathion concentration in blood. Intensive efforts and trainings are thus required to build awareness about safety practices and to change industrial workers' attitude to prevent harmful environmental and anthropogenic effects.