Addressing the UHC Challenge Using the Disease Control Priorities 3 Approach: Lessons Learned and an Overview of the Pakistan Experience.

BACKGROUND: Pakistan developed its first national Essential Package of Health Services (EPHS) as a key step towards accelerating progress in achieving Universal Health Coverage (UHC). We describe the rationale, aims, the systematic approach followed to EPHS development, methods adopted, outcomes of the process, challenges encountered, and lessons learned. METHODS: EPHS design was led by the Ministry of National Health Services, Regulations & Coordination. The methods adopted were technically guided by the Disease Control Priorities 3 Country Translation project and existing country experience. It followed a participatory and evidence-informed prioritisation and decision-making processes. RESULTS: The full EPHS covers 117 interventions delivered at the community, health centre and first-level hospital platforms at a per capita cost of US$29.7. The EPHS also includes an additional set of 12 population-based interventions at US$0.78 per capita. An immediate implementation package (IIP) of 88 district-level interventions costing US$12.98 per capita will be implemented initially together with the population-based interventions until government health allocations increase to the level required to implement the full EPHS. Interventions delivered at the tertiary care platform were also prioritised and costed at US$6.5 per capita, but they were not included in the district-level package. The national EPHS guided the development of provincial packages using the same evidence-informed process. The government and development partners are in the process of initiating a phased approach to implement the IIP. CONCLUSION: Key ingredients for a successful EPHS design requires a focus on package feasibility and affordability, national ownership and leadership, and solid engagement of national stakeholders and development partners. Major challenges to the transition to implementation are to continue strengthening the national technical capacity, institutionalise priority setting and package design and its revision in ministries of health, address health system gaps and bridge the current gap in financing with the progressive increase in coverage towards 2030.

Determinants of Adherence to Antihypertension Medications Among Patients at a Tertiary Care Hospital in Islamabad, Pakistan, 2019.

INTRODUCTION: Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension. METHODS: We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence. RESULTS: We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02). CONCLUSION: Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

Progress Toward Poliomyelitis Eradication - Pakistan, January 2018-September 2019.

Afghanistan and Pakistan are the only countries that continue to confirm ongoing wild poliovirus type 1 (WPV1) transmission (1). During January 2018-September 2019 the number of WPV1 cases in Pakistan increased, compared with the number during the previous 4 years. This report updates previous reports on Pakistan's polio eradication activities, progress, and challenges (2,3). In 2018, Pakistan reported 12 WPV1 cases, a 50% increase from eight cases in 2017, and a 31% increase in the proportion of WPV1-positive sites under environmental surveillance (i.e., sampling of sewage to detect poliovirus). As of November 7, 2019, 80 WPV1 cases had been reported, compared with eight cases by the same time in 2018. An intensive schedule of supplementary immunization activities (SIAs)* implemented by community health workers in the core reservoirs (i.e., Karachi, Peshawar, and Quetta) where WPV1 circulation has never been interrupted, and by mobile teams, has failed to interrupt WPV1 transmission in core reservoirs and prevent WPV1 resurgence in nonreservoir areas. Sewage samples have indicated wide WPV1 transmission in nonreservoir areas in other districts and provinces. Vaccine refusals, chronically missed children, community campaign fatigue, and poor vaccination management and implementation have exacerbated the situation. To overcome challenges to vaccinating children who are chronically missed in SIAs and to attain country and global polio eradication goals, substantial changes are needed in Pakistan's polio eradication program, including continuing cross-border coordination with Afghanistan, gaining community trust, conducting high-quality vaccination campaigns, improving oversight of field activities, and improving managerial processes to unify eradication efforts.

Development of a Costed National Action Plan for Health Security in Pakistan: Lessons Learned.

In order to assess progress toward achieving compliance with the International Health Regulations (2005), member states may voluntarily request a Joint External Evaluation (JEE). Pakistan was the first country in the WHO Eastern Mediterranean Region to volunteer for and complete a JEE to establish the baseline of the country's public health capacity across multiple sectors covering 19 technical areas. It subsequently developed a post-JEE costed National Action Plan for Health Security (NAPHS). The process for developing the costed NAPHS was based on objectives and activities related to the 3 to 5 priority actions for each of the 19 JEE technical areas. Four key lessons were learned during the process of developing the NAPHS. First, multisectoral coordination at both federal and provincial levels is important in a devolved health system, where provinces are autonomous from a public health sector standpoint. Second, the development of a costed NAPHS requires engagement and investment of the country's own resources for sustainability as well as donor coordination among national and international donors and partners. Engagement from the ministries of Finance, Planning and Development, and Foreign Affairs and from WHO was also important. Third, development of predefined goals, targets, and indicators aligned with the JEE as part of the NAPHS process proved to be critical, as they can be used to monitor progress toward implementation of the NAPHS and provide data for repeat JEEs. Lastly, several challenges were identified related to the NAPHS process and costing tool, which need to be addressed by WHO and partners to help countries develop their plans.