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.

Determinants of severe acute malnutrition among children under five years in a rural remote setting: A hospital based study from district Tharparkar-Sindh, Pakistan.

OBJECTIVES: To understand and catalogue the specific determinants of this alarming rate of malnutrition among children of Tharparkar district, Sindh Pakistan. METHODS: This was a hospital based analytical survey. Data was collected through a semi-structured questionnaire by interviewing mothers of the children (age 6-59 months), admitted in the hospital. Following WHO guidelines, weight and length/ height of 105 children were recorded. Study was conducted in District Headquarters Hospital, Tharparkar district of Sindh province. RESULTS: Almost 48% children admitted in the hospital were identified with severe acute malnutrition. More males (55%) were malnourished as compared to females (45%). Maternal education, household income, family size, breastfeeding, vaccination status, and frequent infections were found to be significantly associated with the severe acute malnutrition. CONCLUSION: Specific interventions on promoting exclusive breastfeeding, vaccination, and timely health care seeking behaviors would definitely improve the outcomes. Nevertheless, sector wide approaches would be needed on girls' education, poverty, and food security in the district in order to address the issue of malnutrition.

Gender: shaping personality, lives and health of women in Pakistan.

BACKGROUND: Gender norms determine the status of Pakistani women that influence their life including health. In Pakistan, the relationship between gender norms and health of women is crucial yet complex demanding further analysis. This paper: determines the reasons for reiteration of gender roles; describes the societal processes and mechanisms that reproduce and reinforce them; and identifies their repercussions on women's personality, lives and health especially reproductive health. METHODS: As part of a six-country study titled 'Women's Empowerment in Muslim Contexts', semi-structured group discussions (n = 30) were conducted with women (n = 250) who were selected through snowballing from different age, ethnic and socio-economic categories. Discussion guidelines were used to collect participant's perceptions about Pakistani women's: characteristics, powers, aspirations, needs and responsibilities; circumstances these women live in such as opportunities, constraints and risks; and influence of these circumstances on their personality, lifestyle and health. RESULTS: The society studied has constructed a 'Model' for women that consider them 'Objects' without rights and autonomy. Women's subordination, a prerequisite to ensure compliance to the constructed model, is maintained through allocation of lesser resources, restrictions on mobility, seclusion norms and even violence in cases of resistance. The model determines women's traits and responsibilities, and establishes parameters for what is legitimate for women, and these have implications for their personality, lifestyle and health, including their reproductive behaviours. CONCLUSION: There is a strong link between women's autonomy, rights, and health. This demands a gender sensitive and a, right-based approach towards health. In addition to service delivery interventions, strategies are required to counter factors influencing health status and restricting access to and utilization of services. Improvement in women's health is bound to have positive influences on their children and wider family's health, education and livelihood; and in turn on a society's health and economy.

Role of Community Based Savings Groups (CBSGs) enhancing the utilization of community midwives in Chitral district of Pakistan.

BACKGROUND: Maternal and infant mortality rates in the district of Chitral in Pakistan are alarmingly high. One of the major reasons for this is the inability of women to access skilled care due to the high costs associated with traveling and utilizing such services. The Aga Khan Health Services, Pakistan (AKHSP) in partnership with the national and provincial Maternal, Neonatal and Child Health (MNCH) program, deployed 28 community midwives (CMWs) in remote villages of Chitral district. This program has also established Community-Based Savings Groups (CBSGs) to support and facilitate access to MNCH services, in particular those delivered by the CMWs. CBSGs are a simple yet cost-effective and sustainable means of providing basic financial services to low income, marginalized, rural populations.The link between CBSGs and utilization of MNCH services is not well understood. This study will assess the relationship between women membership of CBSGs and their utilization of MNCH services, specifically those offered by CMWs, in the community. METHODS: The research question will be answered through guided interviews of women in the target population who have delivered within one month. The outcome variable will be the utilization of full continuum of skilled MNCH care (disaggregated by 1+ ANC, 1+ PNC and skilled delivery). The primary independent variable of interest will be participation in a CBSG.Focus Group Discussions (FGDs) will be conducted to generate further understanding and information about the social and financial factors that contribute to health behavior and health provider decision-making during pregnancy.Analysis will be tailored to answer how CBSGs, directly or indirectly, facilitate greater financial and/or social access to CMW services for pregnant women. Furthermore, the extent to which financial or social empowerment through a CBSG leads to greater utilization of CMW services. DISCUSSION: The role of CBSGs and their interlink with the CMWs services to be replicated in other comparable areas in Pakistan as a viable mean to increase MNCH service utilization amongst rural, low income, and marginalized communities. Findings from this research will be disseminated through community, national, and international channels consisting of policy makers and social society groups.

Social franchising and vouchers to promote long-term methods of family planning in rural Pakistan: a qualitative stocktaking with stakeholders.

BACKGROUND: The overall use of modern contraception in Pakistan is quite low, especially in rural areas. Several studies have demonstrated the effectiveness of social franchising (SF) approaches in increasing access to modern contraception and improving the quality of healthcare in resource-poor areas in Asia and Africa. Drawing on best practices in SF, the Marie Stopes Society (MSS) implemented an SF model in certain rural areas of Pakistan to increase access to affordable and quality family planning (FP) services. The model was branded as Suraj (sun) and complemented with an innovative voucher scheme for intrauterine contraceptive devices (IUCDs). This paper describes the perspectives of Suraj clients, field workers mobilization (FWMs), and providers on various components of the Suraj model. METHODOLOGY: A qualitative exploratory study was conducted in six randomly selected intervention districts in the Sindh and Punjab provinces. Data were collected using focus group discussions (FGDs) with clients and in-depth interviews (IDIs) with providers and FWMs. Data were manually analyzed using constant comparison and the thematic analysis approach. FINDINGS: Clients showed positive attitudes towards modern contraceptive methods and identified Suraj FWMs and signboards as sources of information. Almost all clients reported IUCDs as effective methods as they have manageable side effects and require fewer visits to clinics. They spoke highly of voucher schemes as these enabled them to avail free IUCD services. Clients also appreciated many components of Suraj clinics, including cleanliness, privacy, confidentiality, the sterilization of instruments, and courteous Suraj providers and FWMs. Most Suraj providers said that IUCD insertion and infection-prevention training enhanced their ability to provide IUCD services and increased their standing in local communities. They reported that the role of FWMs was crucial in mobilizing the community and increasing their FP clientele. The FWMs said that attitudes towards FP were changing because of economic pressure at the household level, increases in literacy, and community mobilization efforts. CONCLUSION: The Suraj intervention influenced attitudes towards FP and modern contraception, positively. Women using IUCDs showed greater satisfaction with the method. The findings emphasize that SF approaches like Suraj, when complemented with vouchers and community mobilization efforts, can improve the utilization of long-term contraceptive methods among rural and underserved women. The study also identified the need for integrating FP, antenatal care, and safe delivery services.

Delivering post-abortion care through a community-based reproductive health volunteer programme in Pakistan.

This qualitative study was conducted in May-June 2010 with women using post-abortion care (PAC) services provided by the Marie Stopes Society in Pakistan during the six month period preceding the study, more than 70% of whom had been referred to the clinics by reproductive health volunteers (RHVs). The aim of the study was to establish the socio-demographic profile of clients, determine their preferred method of treatment, explore their perceptions of the barriers to accessing post-abortion services and to understand the challenges faced by RHVs. The sample women were selected from six randomly selected districts of Sindh and Punjab. Eight focus group discussions were conducted with PAC clients and fifteen in-depth interviews with RHVs. In addition, a quantitative exit interview questionnaire was administered to 76 clients. Medical, rather than surgical, treatment for incomplete and unsafe abortions was preferred because it was perceived to 'cause less pain', was 'easy to employ' and 'having fewer complications'. Household economics influence women's decision-making on seeking post-abortion care. Other restraining factors include objection by husbands and in-laws, restrictions on female mobility, the views of religious clerics and a lack of transport. The involvement of all stakeholders could secure social approval and acceptance of the provision of safe post-abortion care services in Pakistan, and improve the quality of family planning services to the women who want to space their pregnancies.

Perceptions, interpretations and implications of abortions: a qualitative enquiry among the legal community of Pakistan.

BACKGROUND: The number of unsafe abortions is increasing across South Asia, also in Pakistan, where abortion is only permitted under special circumstances. The law on abortion is vaguely interpreted by the legal community. METHODS: Using Grounded Theory, 33 in-depth interviews of representatives of the legal profession and law enforcement agencies were conducted in 2010. RESULTS: Abortion is perceived as forbidden by both law and religion, and a punishable crime. Respondents believed that sentences are highly dependent on the social status of the woman who had the abortion. A few consider the current law as relevant and sufficient whereas the majority would support amendments. A number of them agreed that the high abortion rate reflects the denial of women's rights, social injustice, and a failure of public health intervention. CONCLUSION: To facilitate access of women to abortion and related care, the knowledge of the existing law among legal professionals must improve. The implications of abortion for maternal health and its repercussions on a community governed by the Islamic dogmas must be publicised. The legal community could have an instrumental role in bringing about attitudinal changes vis-à-vis abortions in the society.

Treating common illnesses among children under five years: a portrayal of health-seeking behaviours and practices in the northern areas of Pakistan.

BACKGROUND: Inappropriate practices and behaviours while treating a child's illness impede correct medical consultation. We studied the health seeking behaviours of people engaging with healthcare systems for the treatment of under-five children. METHODOLOGY: In the Ghizer District of the Northern Areas of Pakistan, a descriptive cross-sectional household survey was conducted in a random sample of 25 communities. Respondents were either a parent or caregiver of the child. RESULTS: Malaria, fever and diarrhea were found in almost one third of the children under five. One third of respondents did not know the cause of the child's illness. For seeking quality care, the majority visit private clinics, but home remedies, traditional practices and consultation with a faith healer were also common. Lack of knowledge about the child's illness and not making it a priority, lack of money and restricted women's social mobility are factors behind the delayed consultation (median delay: 2 to 3 days). CONCLUSION: Health education and health promotion programs must address the knowledge gaps about children's illnesses and advocate appropriate health-seeking behaviours. Issues around quality of care in government centres and affordability in the private health sector must be addressed in order to improve health service utilization.

NGOs and government partnership for health systems strengthening: a qualitative study presenting viewpoints of government, NGOs and donors in Pakistan.

BACKGROUND: Health systems are expected to serve the population needs in an effective, efficient and equitable manner. Therefore, the importance of strengthening of public, private and community health systems has been emphasized time and again. In most of the developing countries, certain weaknesses and gaps in the government health systems have been hampering the achievement of improved health outcomes. Public sector in Pakistan has been deficient in the capacity to deliver equitable and quality health services and thus has been grossly underutilized. METHODS: A qualitative study comprising in-depth interviews was conducted capturing the perceptions of the government functionaries, NGO representatives and donor community about the role and position of NGOs in health systems strengthening in Pakistan's context. Analysis of the data was done manually to generate nodes, sub-nodes and themes. RESULTS: Since many years, international and local non-governmental organizations (NGOs) have endeavored to fill the gaps in health service delivery, research and advocacy. NGOs have relatively performed better and achieved the results because of the flexible planning and the ability to design population based projects on health education, health promotion, social marketing, community development and advocacy. This paper captures the need and the opportunity of public private partnership in Pakistan and presents a framework for a meaningful engagement of the government and the private and nonprofit NGOs. CONCLUSION: Involving the NGOs for health system strengthening may eventually contribute to create a healthcare system reflecting an increased efficiency, more equity and good governance in the wake of the Millennium Development Goals. Nevertheless, few questions need to be answered and pre-requisites have to be fulfilled before moving on.

Marching toward the Millennium Development Goals: what about health systems, health-seeking behaviours and health service utilization in Pakistan?

Attaining the ambitious targets pronounced in the Millennium Development Goals (MDGs) will necessitate radical changes in policy as well as extensive reforms and strong inter-sectoral coordination in the healthcare system of Pakistan. While aiming for such macro-level achievements, it is imperative to analyze the on-the-ground realities of any health system. Improving health systems has the potential to assist progress toward MDGs in the near term by promoting more equitable access and introducing effective interventions. More money allocation and more health spending would not necessarily mean better health for Pakistanis. The complex composition of the healthcare system drives us to study the intricate phenomena of health service utilization and healthcare-seeking behaviours. Such an approach will thus provide evidence to sensitize health personnel to provide more empathetic care and to encourage the community at large to start seeking appropriate and timely healthcare. This paper advocates thinking beyond health services provision by reaching out to people and understanding their perceptions, practices and health-seeking behaviours. Achieving millennium development goals will necessitate interventions that address health issues of women, children and all other vulnerable groups in Pakistan.

Marching toward the Millennium Development Goals: what about health systems, health-seeking behaviours and health service utilization in Pakistan?

Attaining the ambitious targets pronounced in the Millennium Development Goals (MDGs) will necessitate radical changes in policy as well as extensive reforms and strong inter-sectoral coordination in the healthcare system of Pakistan. While aiming for such macro-level achievements, it is imperative to analyze the on-the-ground realities of any health system. Improving health systems has the potential to assist progress toward MDGs in the near term by promoting more equitable access and introducing effective interventions. More money allocation and more health spending would not necessarily mean better health for Pakistanis. The complex composition of the healthcare system drives us to study the intricate phenomena of health service utilization and healthcare-seeking behaviours. Such an approach will thus provide evidence to sensitize health personnel to provide more empathetic care and to encourage the community at large to start seeking appropriate and timely healthcare. This paper advocates thinking beyond health services provision by reaching out to people and understanding their perceptions, practices and health-seeking behaviours. Achieving millennium development goals will necessitate interventions that address health issues of women, children and all other vulnerable groups in Pakistan.

ICPD to MDGs: Missing links and common grounds.

The ICPD agenda of reproductive health was declared as the most comprehensive one, which had actually broadened the spectrum of reproductive health and drove the states to embark upon initiatives to improve reproductive health status of their populations. However, like all other countries, Pakistan also seems to have shifted focus of its policies and programs towards achieving MDGs. As a result, concepts highlighted in the ICPD got dropped eventually. In spite of specific goals on maternal and child mortalities in MDGs and all the investment and policy shift, Pakistan has still one of the highest maternal mortality ratios among developing countries. Lack of synchronized efforts, sector wide approaches, inter-sectoral collaboration, and moreover, the unmet need for family planning, unsafe abortions, low literacy rate and dearth of women empowerment are the main reasons. Being a signatory of both of the international agendas (ICPD and MDGs), Pakistan needed to articulate its policies to keep the balance between the two agendas. There are, however, certainly some common grounds which have been experimented by various countries and we can learn lessons from those best practices. An inter-sectoral cooperation and sector wide approaches would be required to achieve such ambitious goals set out in ICPD-Program of Action while working towards MDGs. There is a need of increasing resource allocation, strengthening primary health care services and emergency obstetric care and motivating the human resource employed in health sector by good governance. These endeavors should lead to formulate evidence based national policies, reproductive health services which are affordable, accessible and culturally acceptable and finally a responsive health system.

Women's social position and health-seeking behaviors: is the health care system accessible and responsive in Pakistan?

To make the health care system more accessible and responsive to women particularly in developing countries, it is imperative to study the health-seeking behaviors and factors determining utilization of health care services. This study was carried out in close collaboration with Aga Khan Health Services, Pakistan (AKHSP) and the Health Department of Northern Areas of Pakistan. Key findings indicate that more than one-third of women did not know the cause of their reported illness. There is a median delay of 3 days before a consultation. Local women utilize AKHSP services far more than other health services due to the quality of services offered and the availability of female health staff. The perception of receiving the required treatment is lowest for government health services. Consulting faith healers is a common practice. Health education and health promotion campaigns are needed to change existing health-seeking behaviors among women. Social arrangements should be thoughtfully considered to make the health system more responsive. More female staff needs to be deployed in government health facilities. A public-private partnership seems to provide a means to strengthen the health care system and consequently to promote women's health.

Where do they go, whom do they consult, and why? Health-seeking behaviors in the northern areas of Pakistan.

This study presents an ethnographic account of health-seeking behaviors and determinants of health service utilization of people living in the rural Northern Areas of Pakistan. Data was gathered from 2004 to 2005 through 10 gender-specific focus group discussions. Sociodemographic characteristics, economic conditions, cultural forces, physical and environmental conditions, and health care service features form the behaviors. The complex composition of health care systems drives us to study the most intricate phenomenon of health care-seeking behaviors. Inappropriate or delayed health care-seeking could lead to undesirable health outcomes, high fertility, unwanted pregnancies, medical complications, and amplified susceptibility to future illnesses. At times it results in a significant economic burden when a simple illness becomes drawn out because of improper health-seeking behaviors. This study is an effort to present relevant information to the policy makers to reorient the health care services to make them more acceptable. It is recommended that this research be used for designing behavior change communication modules or social marketing campaigns in raising awareness about health in the community and sensitizing health care providers to the needs of their clients.

Understanding social determinants of health seeking behaviours, providing a rational framework for health policy and systems development.

The concept of studying health seeking behaviours has evolved with the course of time and has ultimately become a tool for understanding how people employ the health care systems in their respective socio-cultural, economic and demographic circumstances. All these behaviours actually define social position of health and provide a better understanding of the disease process. It is therefore imperative to study the impacts of all the determinants, such as ethnicity, education of the mother, gender of child, lifestyles, or economics of a community. All the same, biomedical knowledge alone cannot guarantee better health. Health practitioners, managers and policy makers ought to reflect on social determinants while delivering services, designing health promotion interventions and developing policies. To build a responsive health system, there is a strong need to understand the health seeking behaviours on the demand side and that is the only way to expect improved health outcomes. This paper trails the history of pledges and promises, from Alma Ata declaration to Millennium Development Goals, to consider the importance of social determinants for a healthy public policy and health system development.

Studying health-seeking behaviours: collecting reliable data, conducting comprehensive analysis.

There is certainly a growing need to justify the significance of studying health-seeking behaviours for designing advocacy campaigns, lobbying for a policy shift and convincing donors to invest in priority areas. Moreover, policymakers need to be encouraged to design evidence-based policies that take into account information relating to health-promoting, -seeking and -utilization behaviour and the factors determining these behaviours. This paper primarily covers the 'methodology' used in the study of health-seeking behaviours and determinants of health services utilization in a predominantly rural district of Pakistan. The paper substantiates that this methodology is comprehensive and reliable, and there is potential for replicating this in similar settings. The approach of Kroeger in his research on the study of health-seeking behaviours, particularly in developing countries, provides the most holistic framework for examining, analysing and interpreting factors and determinants of health-seeking behaviours and health services utilization in developing countries. This study endeavoured to validate Kroeger's framework in a Pakistani setting, exploring all the factors listed through mixed method research, and qualitative supplemented by representative quantitative enquiry. This approach has also helped in understanding the inter-relationship of various factors and drivers of health-seeking behaviours from all angles.

Health seeking behaviour and health services utilization trends in national health survey of Pakistan: what needs to be done?

In developing countries, health seeking behaviours and health care services utilization patterns have been studied and the determinants have been classified in physical, socio-economic, cultural and political contexts. This paper is based on a systematic review of peer-reviewed literature on the relationship of factors affecting health service utilization and the focus has been on Pakistan. For this purpose, National Health Survey (NHS) of Pakistan, conducted in 1990-1994, has been critically reviewed. The review reveals specific behaviours following gender differences, socio-cultural milieu, disease patterns, household economics etc. Thus it becomes imperative to design evidence based policies by developing the understanding of health behaviours and health care utilization trends and to give enough credence to all determinants in the background. Health sector reforms therefore necessitate developing mechanisms to deliver more need based and quality services, considering thoughtfully users' concerns and perspectives. The advent of decentralization in Pakistan provides a unique opportunity for tackling multi-faceted issues by multisectoral approaches.

Thirty years of Alma Ata pledges: is devolution in Pakistan an opportunity for rekindling primary health care?

The 1978 Alma Ata Conference presented the manifesto to attain global health for the next century by providing basic health care aimed at the urban and rural poor of the developing world. While the goals of Alma Ata were noble, they were untenable. Today, developing countries face serious issues of equity in health care delivery and fairness in health care management with even a greater need to transform the management systems and practice. Primary health care remains a cornerstone of building the capacity of health systems. Devolution in health sector in Pakistan seems like a chance to re-exert Alma Ata agenda. To achieve the millennium development goals by 2015, revitalization and effective implementation of primary health care will be a vital reform.