Assessment of Patient Safety in a Low-Resource Health Care System: Proposal for a Multimethod Study.

BACKGROUND: The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources. OBJECTIVE: This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting. METHODS: We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization's Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility. RESULTS: The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs. CONCLUSIONS: A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non-resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50532.

Assessing the knowledge, attitude and practice of osteoporosis among Pakistani women: A national social-media based survey.

BACKGROUND: There are numerous risk factors for osteoporosis and understanding and recognizing these risk factors is critical when deciding whether to take preventive measures. It is critical to reduce the healthcare expenditure burden of the Pakistani population by raising awareness and implementing osteoporosis-preventable measures. This survey aims to assess the knowledge, attitudes, and practices (KAP) of Pakistani women as well as their misconceptions about osteoporosis. METHODS: A cross-sectional survey was conducted from August 2021 to January 2022 by the Bone & Mineral Disease research group at Section of Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, with exemption from the ethical review committee. Using snowball sampling, a validated Osteoporosis Prevention and Awareness Tool (OPAAT) was disseminated online via social media. With informed consent, 400 Pakistani women aged ≥ 18 years were included in the study. SPSS Statistics version 25.0 was used for data analysis. Chi-square test for association and Fisher-exact test were applied, and significance level was α<0.05. RESULTS: Based on the OPAAT scores of all (n = 400) participants, 22% (n = 88) had low knowledge, 44% (n = 176) had average knowledge, while 34% (n = 136) had good knowledge of osteoporosis. The most common misconceptions were about age-related risk, presentation of symptoms, radiation risk, associated risk factors like tooth loss, osteoarthritis, and knowledge about predictors of bone health. CONCLUSION: Adult Pakistani women have a fair understanding of osteoporosis, but the OPAAT tool clarifies some common misconceptions. There is a need to develop educational strategies to increase the knowledge of osteoporosis among Pakistani adults and to promote a bone-healthy lifestyle.

Resilience of primary healthcare system across low- and middle-income countries during COVID-19 pandemic: a scoping review.

INTRODUCTION: Globally, the coronavirus disease 2019 (COVID-19) pandemic tested the resilience of the health system and its shock-absorbing capacity to continue offering healthcare services. The available evidences does not provide comprehensive insight into primary health care (PHC) system functioning across low- and middle- income countries (LMICs) during the pandemic. Therefore, the objective of this scoping review was to generate evidence on the resilience of PHC systems in LMICs during the COVID-19 pandemic. METHODS: A scoping review was carried out utilizing an iterative search strategy using the National Library of Medicine (NLM) and the WHO COVID-19 electronic databases. Data from the identified studies in LMICs were charted in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist in the first step. The analysis framework was adapted and modified using COVID-19 and health systems resilience framework developed by Sagan et al., Blanchet et al., and the WHO position paper on 'Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond'. A total of 26 documents were included on the basis of predefined eligibility criteria for our analysis. RESULTS: Our review explored data from 44 LMICs that implemented strategies at the PHC level during the COVID-19 pandemic. Most of the LMICs developed national guidelines on sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH). Most of the countries also transformed and reoriented PHC service delivery by introducing digital healthcare services to continue essential services. Task shifting, task sharing, and redeployment of retired staff were some frequently adopted health workforce strategies adopted by most of the countries. Only a few of the countries demonstrated the availability of necessary monetary resources to respond to the pandemic. CONCLUSIONS: The functionality of the PHC system during the COVID-19 pandemic was demonstrated by a variety of resilience strategies across the six building blocks of the health system. To strengthen PHC resilience, we recommend strengthening community-based PHC, cross-sectoral collaboration, establishing surveillance systems, capacity building in financial risk planning, and investing in strengthening the digital healthcare system.

Gaps in hygiene promotion at schools in Pakistan: qualitative descriptive research.

School health remains an ignored domain in Pakistan. This article presents gaps in understanding hygiene promotion efforts in school settings in urban squatter settlements by exploring perspectives of the key stakeholders and undertaking a review of the education curriculum. Using qualitative methodology, 13 in-depth interviews were held with the key informants (teachers, health and education officers) and three focus group discussions were conducted with 36 mothers. The study setting includes three schools located in a semi-urban area in the province of Sindh, Pakistan. The semi-structured guide was utilized to obtain perspectives of key stakeholders on factors constraining hygiene promotion efforts in school settings. The primary education curriculum was reviewed using the content analysis approach to assess the integration of hygiene concepts into the curriculum. Analysis of qualitative interviews and curriculum review resulted in five categories under a theme that addressed multiple factors constraining hygiene promotion in the school settings. These include (i) Gaps in the school curriculum, (ii) Poor accountability of the local administration in the upkeep of schools, (iii) Parent's negligence toward children's hygiene, (iv) Inadequate training of school teachers on hygiene concepts, and (v) Lack of interdepartmental coordination between health and education sectors. Hygiene promotion at schools has been deterred by multiple factors at the selected primary schools in Pakistan. Recommended actions include integration of health and hygiene concepts into the education curriculum, capacity building of teachers, reviving water, sanitation and hygiene infrastructure, coordination among Education and Health Departments and ownership among the local government to ensure cleanliness at schools.

Schools are not only expected to provide education to children, their mandate also includes health and hygiene promotion. Keeping in view the dearth of evidence in understanding the role of schools in hygiene promotion in the local context, this research was conducted in three semi-urban school settings in Sindh province, Pakistan. We aimed to identify factors that constrain hygiene promotion efforts at the school level. As part of this research, we interviewed multiple stakeholders. This includes (teachers, mothers, education and health officers) at the primary school level. Our findings revealed serious gaps in hygiene promotion at schools. This includes inadequate attention to hygiene concepts in the curriculum books, inconducive school environment, teachers' and parents' negligence toward children's hygiene and communication gap among them, and absence of coordination between health and education sectors. To conclude, multiple actions are needed to emphasize hygiene promotion at the school level. This ranged from revision in the education curriculum and training of teachers in hygiene promotion to instituting accountability mechanisms at the local Education Department and building strong coordination between Education and Health departments.

Quality of care assessment for small and sick newborns and young infants in Pakistan: findings from a cross-sectional study.

INTRODUCTION: Pakistan is facing a challenging situation in terms of high newborn mortality rate. Securing pregnancy and delivery care may not bring a substantial reduction in neonatal mortality, unless coupled with the provision of quality inpatient care for small and sick newborns and young infants (NYIs). We undertook this study to assess the availability and quality of newborn care services provided and the readiness of inpatient care for NYIs in Pakistan. METHODS: We conducted a cross-sectional study across Pakistan from February to June 2019, using a purposive sample of 61% (23) of the 38 sick newborn care units at public sector health care facilities providing inpatient care for small and sick NYIs. We interviewed facility managers and health care providers by using structured questionnaires. We observed facility infrastructure and relevant metrics related to the quality of inpatient care such as types of infant care units and essential equipment, drugs, staffing cadre and facility management practices, quality assurance activities, essential services for small and sick NYI care, discharge planning, and support, quality of NYIs care record, and health information system. RESULTS: Of the 23 facilities assessed, 83% had newborn intensive care units (NICUs), 74% reported Special Care Units (SCUs), and only 44% had Kangaroo Mother Care (KMC) Units. All facilities had at least one paediatrician, 13% had neonatologists and neonatal surgeons each. Around 61 and 13% of the facilities had staff trained in neonatal resuscitation and parental counseling, respectively. About 35% of the facilities monitored nosocomial infection rates, with management and interdisciplinary team meetings reported from 17 and 30% of the facilities respectively preceding the survey. Basic interventions for NYIs were available in 43% of the facilities, only 35% of facilities had system in place to monitor nosocomial infections for NYI care. Most (73%) of reviewed records of NYIs at 1-2 days had information on the birth weight, temperature recording (52%), while only a quarter (25%) of the observed records documented danger signs. Mechanism to support discharge care by having linkages with community workers was present in 13% of the facilities, while only 35% of the facilities have strategies to promote adherence after discharge. Majority (78%) of facilities reported monitoring any newborn/ neonatal care indicators, while none of the sub-units within facilities had consolidated information on stillbirths and neonatal deaths. CONCLUSION: The study has demonstrated important gaps in the quality of small and sick NYI inpatient care in the country. To avert neonatal mortality in the country, provincial and district governments have to take actions in improving the quality of inpatient care.

Changing Perceptions of Rural Frontline Workers and Caregivers About Management of Childhood Diarrhea and Pneumonia Despite Several Inequities: The Nigraan Plus Trial in Pakistan.

PURPOSE: Diarrhea and pneumonia greatly contribute to high childhood mortality in Pakistan. Frontline community health workers or the Lady Health Workers (LHWs) provide care at the doorstep of over 60% of Pakistan's rural residents. Difficult terrain, lack of supplies, and inadequate supervision put these LHWs at an added disadvantage in the timely diagnosis and delivery of known treatment options to community caregivers (CCGs). This study aims to assess whether a supportive supervision intervention through Lady Health Supervisors (LHSs) using enhanced mentorship and written feedback cards have the potential to improve case management of childhood diarrhea and pneumonia. STUDY SETTING AND DESIGN: This perception-based qualitative inquiry nested within the Nigraan Plus trial included LHSs, LHWs, and CCGs as the participants. Twenty-two in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were conducted before a supportive supervision intervention in 2017, and 10 FGDs were conducted in 2019 once the intervention concluded. Data were analyzed using manual content analysis. RESULTS: The perceived ability of LHWs and LHSs to describe the danger signs of diarrhea and pneumonia, classify dehydration and relate respiratory rate to the severity of pneumonia improved over time. Appropriate prescription of zinc in diarrhea and antibiotics in pneumonia was noted. Furthermore, CCGs' trust in LHWs increased following the intervention, and they reported a growing inclination to contact LHWs as their first point of care. LHWs in the intervention arm were more satisfied with their job due to frequent supervisory visits and continuous feedback by LHSs. CONCLUSION: Despite geographic, social, and economic inequities, supportive supervision has the potential to improve knowledge, practice, and skills of frontline health workers related to CCM of childhood diarrhea and pneumonia in disadvantaged rural communities. Additionally, the trust of CCGs in the health workers' ability to manage such cases is also enhanced.

Quality of inpatient care of small and sick newborns in Pakistan: perceptions of key stakeholders.

BACKGROUND: In LMICs including Pakistan, neonatal health and survival is a critical challenge, and therefore improving the quality of facility-based newborn care services is instrumental in averting newborn mortality. This paper presents the perceptions of the key stakeholders in the public sector to explore factors influencing the care of small and sick newborns and young infants in inpatient care settings across Pakistan. METHODS: This exploratory study was part of a larger study assessing the situation of newborn and young infant in-patient care provided across all four provinces and administrative regions of Pakistan. We conducted 43 interviews. Thirty interviews were conducted with the public sector health care providers involved in newborn and young infant care and 13 interviews were carried out with health planners and managers working at the provincial level. A semi-structured interview guide was used to explore participants' perspectives on enablers and barriers to the quality of care provided to small and sick newborns at the facility level. The interviews were manually analyzed using thematic content analysis. FINDINGS: The study respondents identified multiple barriers contributing to the poor quality of small and sick newborn care at inpatient care settings. This includes an absence of neonatal care standards, inadequate infrastructure and equipment for the care of small and sick newborns, deficient workforce for neonatal case management, inadequate thermal care management for newborns, inadequate referral system, absence of multidisciplinary approach in neonatal case management and need to institute strong monitoring system to prevent neonatal deaths and stillbirths. The only potential enabling factor was the improved federal and provincial oversight for reproductive, maternal, and newborn care. CONCLUSION: This qualitative study was insightful in identifying the challenges that influence the quality of inpatient care for small and sick newborns and the resources needed to fix these. There is a need to equip Sick Newborn Care Units with needed supplies, equipment and medicines, deployment of specialist staff, strengthening of in-service training and staff supervision, liaison with the neonatal experts in customizing neonatal care guidelines for inpatient care settings and to inculcate the culture for inter-disciplinary team meetings at inpatient care settings across the country.

Health Systems Approach to Ensure Quality and Safety Amid COVID-19 Pandemic in Pakistan.

Ensuring quality and safe care during the coronavirus disease 2019 (COVID-19) pandemic offers a challenge to already strained health systems in low and middle-income countries (LMICs), such as Pakistan with less shock-absorbing capacities. There is a dearth of evidence on mechanisms to provide optimum quality care to COVID-19 patients in the resource-constrained healthcare environment. The lessons learned from the Ebola virus outbreak for the deficient health systems and quality improvement are considered to propose strengthening the health systems response to deliver quality-assured care to patients during the current pandemic. In this regard, the World Health Organization (WHO) health systems framework can serve as a guiding principle towards providing quality-assured and safe healthcare services during the ongoing pandemic in Pakistan by ensuring the availability of an adequate workforce, medical supplies and equipment, strong governance, active information system, and adequate health financing to effectively manage COVID-19. Research evidence is needed to be better prepared for an effective and coordinated health systems response to offer quality and safe care to patients. Key Words: Health systems approach, COVID-19 pandemic, Quality of healthcare, Safe care.

Perceptions and experiences of healthcare providers during COVID-19 pandemic in Karachi, Pakistan: an exploratory qualitative study.

OBJECTIVE: To explore healthcare provider's perspectives and experiences of the barriers and facilitators to treat and manage COVID-19 cases. DESIGN AND SETTING: We conducted an exploratory qualitative study using a purposive sampling approach, at a private tertiary care teaching hospital in Karachi, Pakistan. Study data were analysed manually using the conventional content analysis technique. PARTICIPANTS: Key-informant interviews (KIIs) were conducted with senior management and hospital leadership and in-depth interviews (IDIs) were conducted with front-line healthcare providers. RESULTS: A total of 31 interviews (KIIs=19; IDIs=12) were conducted, between April and May 2020. Three overarching themes emerged. The first was 'challenges faced by front-line healthcare providers working in COVID-19 wards. Healthcare workers experienced increased anxiety due to the fear of acquiring infection and transmitting it to their family members. They felt overwhelmed due to the exhaustive donning and doffing process, intense work and stigmatisation. The second theme was 'enablers supporting healthcare providers to deal with the COVID-19 pandemic'. Front liners pointed out several enabling factors that supported hospital staff including a safe hospital environment, adequate training, a strong system of information sharing and supportive management. The third theme was 'recommendations to support the healthcare workforce during the COVID-19 crisis'. Healthcare workers recommended measures to mitigate current challenges including providing risk allowance to front-line healthcare providers, preparing a backup health workforce, and establishing a platform to address the mental health needs of the healthcare providers. CONCLUSION: This study provides an initial evidence base of healthcare providers' experiences of managing patients with COVID-19 in the early stage of the pandemic and highlights measures needed to address the encountered challenges. It offers lessons for hospitals in low-income and middle-income countries to ensure a safe working environment for front-line workers in their fight against COVID-19.

Factors affecting Maternal-care during labour at maternity centres of Karachi, Pakistan: Exploratory study.

Globally 529,000 women die every year due to harmful consequences of childbirth. This study aimed to explore the barriers and facilitators that influence the provision of quality care during labour at maternity centres in Karachi, Pakistan. The qualitative exploratory study design was used to study such factors from public and private maternity health facilities of Karachi, Pakistan. A total of 12 in-depth interviews were conducted through purposive sampling by using validated semi-structured interview guide. Data was analysed using content analysis manually. Among major barriers, unhygienic environment, lack of basic equipment, supplies and medicine, unprofessional attitude of staff, physical infrastructre and shotrage of staff were explored. Among facilitators, caring and supportive attitude of healthcare personnel during labour were identified. These identified determinants would guide policy-makers, Maternal, Newborn and Child Health (MNCH) planners and health managers to take appropriate actions to enhance the quality of maternal care which will subsequently result in considerable reduction in maternal mortalities.

Management of maternal depression: Qualitative exploration of perceptions of healthcare professionals from a public tertiary care hospital, Karachi, Pakistan.

The lack of implementation and routine screening of management techniques at tertiary care hospitals leads to an increased burden of maternal depression. The consequences are borne emotionally, physically, and mentally by the mother, the child, the overall family, and society. Hence, it is vital to contextualize this mental disorder to design and implement effective healthcare interventions. The study is aimed to assess the knowledge and practices of healthcare professionals, in a tertiary care setting, who deal with depressive symptoms amongst mothers. It gauges whether a psychological screening criterion is being implemented by the clinical staff during prenatal and postnatal visits to recommend steps that can help develop a service framework. A qualitative, exploratory study design was implemented for this research. With purposive sampling, eight in-depth interviews (three nurses and five doctors) at a single tertiary care hospital were conducted categorically using a semi-structured (open and close-ended questions) interview toolkit. Content Analysis was carried out using information gathered from the unit of analysis. The study provided evidence of the existing gaps in one particular tertiary healthcare system, within Pakistan, concerning diagnosis and management of maternal depression. Results highlighted that providers were well-versed with explanations of maternal depression, the aftermath of it, and the current status of healthcare; however, they were minimally educated about the specifics and levels of treatment. The gathered information assisted in recommending steps to develop a service framework.

Health Systems Approach to Ensure Quality and Safety Amid COVID-19 Pandemic in Pakistan.

Ensuring quality and safe care during the coronavirus disease 2019 (COVID-19) pandemic offers a challenge to already strained health systems in low and middle-income countries (LMICs), such as Pakistan with less shock-absorbing capacities. There is a dearth of evidence on mechanisms to provide optimum quality care to COVID-19 patients in the resource-constrained healthcare environment. The lessons learned from the Ebola virus outbreak for the deficient health systems and quality improvement are considered to propose strengthening the health systems response to deliver quality-assured care to patients during the current pandemic. In this regard, the World Health Organization (WHO) health systems framework can serve as a guiding principle towards providing quality-assured and safe healthcare services during the ongoing pandemic in Pakistan by ensuring the availability of an adequate workforce, medical supplies and equipment, strong governance, active information system, and adequate health financing to effectively manage COVID-19. Research evidence is needed to be better prepared for an effective and coordinated health systems response to offer quality and safe care to patients. Key Words: Health systems approach, COVID-19 pandemic, Quality of healthcare, Safe care.

Why are the Pakistani maternal, fetal and newborn outcomes so poor compared to other low and middle-income countries?

BACKGROUND: Pakistan has among the poorest pregnancy outcomes worldwide, significantly worse than many other low-resource countries. The reasons for these differences are not clear. In this study, we compared pregnancy outcomes in Pakistan to other low-resource countries and explored factors that might help explain these differences. METHODS: The Global Network (GN) Maternal Newborn Health Registry (MNHR) is a prospective, population-based observational study that includes all pregnant women and their pregnancy outcomes in defined geographic communities in six low-middle income countries (India, Pakistan, Democratic Republic of Congo, Guatemala, Kenya, Zambia). Study staff enroll women in early pregnancy and follow-up soon after delivery and at 42 days to ascertain delivery, neonatal, and maternal outcomes. We analyzed the maternal mortality ratios (MMR), neonatal mortality rates (NMR), stillbirth rates, and potential explanatory factors from 2010 to 2018 across the GN sites. RESULTS: From 2010 to 2018, there were 91,076 births in Pakistan and 456,276 births in the other GN sites combined. The MMR in Pakistan was 319 per 100,000 live births compared to an average of 124 in the other sites, while the Pakistan NMR was 49.4 per 1,000 live births compared to 20.4 in the other sites. The stillbirth rate in Pakistan was 53.5 per 1000 births compared to 23.2 for the other sites. Preterm birth and low birthweight rates were also substantially higher than the other sites combined. Within weight ranges, the Pakistani site generally had significantly higher rates of stillbirth and neonatal mortality than the other sites combined, with differences increasing as birthweights increased. By nearly every measure, medical care for pregnant women and their newborns in the Pakistan sites was worse than at the other sites combined. CONCLUSION: The Pakistani pregnancy outcomes are much worse than those in the other GN sites. Reasons for these poorer outcomes likely include that the Pakistani sites' reproductive-aged women are largely poorly educated, undernourished, anemic, and deliver a high percentage of preterm and low-birthweight babies in settings of often inadequate maternal and newborn care. By addressing the issues highlighted in this paper there appears to be substantial room for improvements in Pakistan's pregnancy outcomes.

School-based interventions to promote personal and environmental hygiene practices among children in Pakistan: protocol for a mixed methods study.

BACKGROUND: Poor personal hygiene and inadequate sanitation practices among young children leads to communicable diseases. There remains a gap in the holistic assessment of school children's hygiene literacy, practices and effectiveness of school-based hygiene interventions in Pakistan. Therefore, a school-based intervention protocol has been designed to promote personal and environmental hygiene practices for primary school children. Towards improving children's hygiene behaviors, the study will also focus on enhancing mothers' hygiene knowledge and practices. METHODS: Using quasi-experimental design with mixed methods data collection approaches, this study will be conducted in schools located in an urban squatter settlements in Pakistan. To assess primary grade children and their mothers' hygiene status, a survey will be held in the pre-intervention phase. This phase also includes qualitative exploration of key stakeholders (mothers, teachers, health & education authorities representatives') perceptions about the factors facilitating and impeding the adaption of hygiene behaviors among school children. In-depth guides and focus group discussion tools will be used for this purpose. This will be followed by multi-component intervention phase with behavior change strategies to improve children's and mothers' hygiene literacy and behaviors. The post-intervention phase will assess the intervention effectiveness in terms of enhancing hygiene knowledge and practices among school children and mothers, alongside exploration of mothers and teachers' insights into whether or not the intervention has been effective in improving hygiene practices among children. Paired t-test will be applied pre and post-intervention to measure the differences between the mothers and children's hygiene literacy and knowledge scores. Similar test will be performed to assess the differences in children's hygiene knowledge and practice scores, pre and post-intervention (< 50 = poor, 50-75 = good and > 75 = excellent). Thematic analysis will be carried out for qualitative data. DISCUSSION: Multi-component intervention aimed at improving personal and environmental hygiene among primary school children offers an opportunity to design and test various behavioral change strategies at school and in home settings. The study findings will be significant in assessing the intervention's effectiveness in improving children's overall hygiene. TRIAL REGISTRATION: Retrospectively registered with ClinicalTrials.gov (NCT03942523) on 5th May 2019.

The state of diet-related NCD policies in Afghanistan, Bangladesh, Nepal, Pakistan, Tunisia and Vietnam: a comparative assessment that introduces a 'policy cube' approach.

We assessed the technical content of sugar, salt and trans-fats policies in six countries in relation to the World Health Organization 'Best Buys' guidelines for the prevention and control of non-communicable diseases (NCDs). National research teams identified policies and strategies related to promoting healthy diets and restricting unhealthy consumption, including national legislation, development plans and strategies and health sector-related policies and plans. We identified relevant text in relation to the issuing agency, overarching aims, goals, targets and timeframes, specific policy measures and actions, accountability systems, budgets, responsiveness to inequitable vulnerabilities across population groups (including gender) and human rights. We captured findings in a 'policy cube' incorporating three dimensions: policy comprehensiveness, political salience and effectiveness of means of implementation, and equity/rights. We compared diet-related NCD policies to human immunodeficiency virus policies in relation to rights, gender and health equity. All six countries have made high-level commitments to address NCDs, but dietary NCDs policies vary and tend to be underdeveloped in terms of the specificity of targets and means of achieving them. There is patchwork reference to internationally recognized, evidence-informed technical interventions and a tendency to focus on interventions that will encounter least resistance, e.g. behaviour change communication in contrast to addressing food reformulation, taxation, subsidies and promotion/marketing. Policies are frequently at the lower end of the authoritativeness spectrum and have few identified budgetary commitments or clear accountability mechanisms. Of concern is the limited recognition of equity and rights-based approaches. Healthy diet policies in these countries do not match the severity of the NCDs burden nor are they designed in such a way that government action will focus on the most critical dietary drivers and population groups at risk. We propose a series of recommendations to expand policy cubes in each of the countries by re-orienting diet-related policies so as to ensure healthy diets for all.

Measuring socio-economic status of an urban squatter settlement in Pakistan using WAMI Index.

OBJECTIVE: To determine the socio-economic status of a peri-urban community. METHODS: The cross-sectional study was conducted at Deh Chuhar village, Gaddap Town, Karachi from December 2015 to February 2016. The Water/Sanitation, Assets, Maternal Education and Income Index was used. All variables were given a score on the scale of 0-8. The resulting index was illustrated in the form of quintiles. RESULTS: : A total of 254 households were surveyed. Total population was 2117 with mean number of household members being 8±4. Mean index score was 0.39±0.14 and the median score was 0.375. Percentile distribution of the score indicated that 152(60%) households scored below 0.40 whereas, 51 (20%) were in the highest quintile with a score above 0.50. CONCLUSIONS: Water/Sanitation, Assets, Maternal Education and Income index suggested poor socio-economic status of the community studied.

Service quality in contracted facilities.

PURPOSE: The purpose of this paper is to explore the readiness of contracted and non-contracted first-level healthcare facilities in Pakistan to deliver quality maternal and neonatal health (MNH) care. A balanced scorecard (BSC) was used as the assessment framework. DESIGN/METHODOLOGY/APPROACH: Using a cross-sectional study design, two rural health centers (RHCs) contracted out to Aga Khan Health Service, Pakistan were compared with four government managed RHCs. A BSC was designed to assess RHC readiness to deliver good quality MNH care. In total 20 indicators were developed, representing five BSC domains: health facility functionality, service provision, staff capacity, staff and patient satisfaction. Validated data collection tools were used to collect information. Pearson χ2, Fisher's Exact and the Mann-Whitney tests were applied as appropriate to detect significant service quality differences among the two facilities. FINDINGS: Contracted facilities were generally found to be better than non-contracted facilities in all five BSC domains. Patients' inclination for facility-based delivery at contracted facilities was, however, significantly higher than non-contracted facilities (80 percent contracted vs 43 percent non-contracted, p=0.006). PRACTICAL IMPLICATIONS: The study shows that contracting out initiatives have the potential to improve MNH care. ORIGINALITY/VALUE: This is the first study to compare MNH service delivery quality across contracted and non-contracted facilities using BSC as the assessment framework.

Insight into implementation of facility-based integrated management of childhood illness strategy in a rural district of Sindh, Pakistan.

BACKGROUND: Integrated management of childhood illnesses (IMCI) strategy has been proven to improve health outcomes in children under 5 years of age. Pakistan, despite being in the late implementation phase of the strategy, continues to report high under-five mortality due to pneumonia, diarrhea, measles, and malnutrition - the main targets of the strategy. OBJECTIVE: The study determines the factors influencing IMCI implementation at public-sector primary health care (PHC) facilities in Matiari district, Sindh, Pakistan. DESIGN: An exploratory qualitative study with an embedded quantitative strand was conducted. The qualitative part included 16 in-depth interviews (IDIs) with stakeholders which included planners and policy makers at a provincial level (n=5), implementers and managers at a district level (n=3), and IMCI-trained physicians posted at PHC facilities (n=8). Quantitative part included PHC facility survey (n=16) utilizing WHO health facility assessment tool to assess availability of IMCI essential drugs, supplies, and equipments. Qualitative content analysis was used to interpret the textual information, whereas descriptive frequencies were calculated for health facility survey data. RESULTS: The major factors reported to enhance IMCI implementation were knowledge and perception about the strategy and need for separate clinic for children aged under 5 years as potential support factors. The latter can facilitate in strategy implementation through allocated workforce and required equipments and supplies. Constraint factors mainly included lack of clear understanding of the strategy, poor planning for IMCI implementation, ambiguity in defined roles and responsibilities among stakeholders, and insufficient essential supplies and drugs at PHC centers. The latter was further substantiated through health facilities' survey findings, which indicated that none of the facilities had 100% stock of essential supplies and drugs. Only one out of all 16 surveyed facilities had 75% of the total supplies, while 4 out of 16 facilities had 56% of the required IMCI drug stock. The mean availability of supplies ranged from 36.6 to 66%, while the mean availability of drugs ranged from 45.8 to 56.7%. CONCLUSION: Our findings indicate that the Matiari district has sound implementation potential; however, bottlenecks at health care facility and at health care management level have badly constrained the implementation process. An interdependency exists among the constraining factors, such as lack of sound planning resulting in unclear understanding of the strategy; leading to ambiguous roles and responsibilities among stakeholders which manifest as inadequate availability of supplies and drugs at PHC facilities. Addressing these barriers is likely to have a cumulative effect on facilitating IMCI implementation. On the basis of these findings, we recommend that the provincial Ministry of Health (MoH) and provincial Maternal Neonatal and Child Health (MNCH) program jointly assess the situation and streamline IMCI implementation in the district through sound planning, training, supervision, and logistic support.