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Background: Pakistan faces a considerable burden of disease with regard to inherited blood disorder, i.e., Thalassemia Major. Its economic implications are least studied before, particularly when it comes to ascertaining a household’s out of pocket expense on treating the disease. This study was carried out to understand the current estimate of Out-of-pocket expenditure (OOP) expense and its implications on the household and livelihood, while seeking treatment for a child suffering from thalassemia. Methods: It was a descriptive cross-sectional study of 3 months’ duration. Patients were selected from Fauji Foundation Hospital (FFH) and Pakistan Institute of Medical Sciences (PIMS), through. The descriptive quantitative analysis and inferential analysis was carried through purposive sampling. Results: Treatment expense of entitled patients from FFH hospital (a public hospital which offers entitlement to the families of retired army personnel) was compared with that of non-entitled patients coming to PIMS (a public sector general hospital). Total expense incurred on treatment by the end of the month was PKR. 5000–10,000 (USD31-62) in FFH, while at PIMS, the total expense incurred on treatment by the end of the month was around PKR 80,000 (USD500). Around 37% families having an average monthly income of PkRs25000 (USD150) only, sold their livelihoods, 31% compromised on their children’s education expenses and 23% percent curtailed the health expenses of the other children. Conclusion: The out-of-pocket expenditure on treating TM is quite high and compels the families to borrow money and sell or mortgage their property, which puts a great deal monetary pressure given their socio-economic status. A practical solution would be to cover these families under the health safety net supported by the government.

In Pakistan, the Health and Population Think Tank was launched as an initiative to conduct programmes and policy analysis, as well as give an insight into the possible future policy options on various national health issues relevant to all the provinces. This forum has also served as a platform to discuss how provincial strategies could be aligned with the National Health Vision 2016-2025, which was developed with the consensus of all provinces and development partners. Main topics chosen for the round tables included local production of vaccines; social health protection; quality of care at the time of birth; human resources for health; and the challenge of tuberculosis in Pakistan. Policy briefs produced by the think tank will maximize the absorption of knowledge and will help implement the actionable items needed to speed up the progress towards achieving Sustainable Development Goal 3 (SDG3) national targets.

At the outset of year 2020, COVID-19 emerged as a new public health threat and the world resorted to a diverse range of combating plots including lock down downs, social distancing, advocating precautions like wearing masks, using sanitizers etc. Pakistan followed the same pathway despite the fact that the virus resulted in less severe morbidity and mortality as compared to the rest of the world. Nevertheless, the fear and panic it created due owing to virulence and subsequent outcomes of corona illness was of alarming magnitude. Pakistan went for smarter, conservative and prudent plans and kept the balance between saving lives and livelihoods. Health system showed its inherent weaknesses and it was soon realized that a multi-sectoral response would be needed to address the catastrophe. A large majority is inclined to call it a 'new normal' and is persuading to go on with life; for sure, by adopting a health system thinking.

In the wake of growing c- section rates around the developing world and likewise in Pakistan, there is paucity of knowledge about the preference of Pakistani women for the mode of delivery. Therefore, this study explored the reasons behind their preference.A cross-sectional study was conducted with a non-probability consecutive sampling technique including 232 pregnant women.Majority (87.5%) would prefer a vaginal delivery because it is the natural way of giving birth and its recovery is faster. Moreover, women perceive that it would be easier to provide immediate care and breastfeeding to the newborn. Fear of surgery was the main deterrent for a c-section. Nonetheless, there were 12.5% women in favour of caesarean section, among whom a majority feared birth trauma to the newborn, labour pain, or complications of vaginal delivery such as possible faecal or urinary incontinence.Pakistani women at large prefer a normal vaginal delivery and therefore the rising trends of c- section cannot be attributed to the demand of the expecting women. Hence, there is a need for elucidating and explicating the real and perhaps the undisclosed reasons for the rising rates of caesarean section as a mode of delivery in Pakistan.

Aim: To gauge the level of preparedness of health system of Pakistan in the wake of Corona Virus Disease 2019 (COVID-19) pandemic. Background: The global COVID-19 outbreak and its subsequent repercussions and implications, after being declared as a pandemic by the World Health Organization (WHO), exposed all the inherent, lingering, and acute shortcomings of the health systems in many developing countries and Pakistan was no exception. Methods: A detailed literature review was done which included peer-reviewed articles on COVID-19 and health system, published in local and international journals, WHO and World Bank’s publications, and the documents and official reports of the government. Focus was to glean and cite strategies adopted by the developing countries in response to COVID-19 and to see the applicability of those which are feasible for Pakistan. Findings: Level of preparedness was minimal and the response to manage the outbreak was weak. Based on toll of the cases and number of deaths, this public health threat turned out to be a catastrophe beyond the controlling authority and capacity of the health system, and hence other sectors and agencies had to be engaged for devising a concerted and integrated response to deal with the emergency. Governance was disorderly, financing was inadequate, human resources were not trained, supplies and logistic were not stocked, information system was patchy, and research capacity was limited, and most of all the service delivery was in a biggest chaos of times. COVID-19 demanded to re-configure the health system of Pakistan. Conclusion: Improving the emergency preparedness of the hospitals is the foremost and an urgent need. A strong national public health system in Pakistan is needed to rapidly investigate and analyze the reports, assess the magnitude of the public health risk, share real-time information, and implement public health control measures in a concerted and systematic demeanor.

Summary 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.

Background. Pakistan is a country with one of the highest burden of tuberculosis (TB) in the world, and therefore, it is imperative to revisit the design of behaviour change interventions in the program. This study was designed to understand and assess the knowledge, awareness, perceptions, and health-seeking behaviour of general and specifically TB-affected population and to determine the presence and level of stigma and discrimination toward TB patients. Methods. A mixed-method study was conducted in district Haripur of the Khyber Pakhtunkhwa province, comprising a household survey, whereby 526 individuals were interviewed, and five focus group discussions with various subgroups including TB patients and health workers and authorities. Study sought an ethical approval, and data of all respondents was kept confidential. Results. Quantitative results show that women were more knowledgeable on symptomatology and spread of TB, and with rising education, awareness on TB improves. The majority of our respondents had the understanding that it is a curable disease, yet some would avoid TB patients. Most of the respondents (both men and women) knew that one must go to a government facility for treatment. Only one-third would speak to doctor first, if they suspect TB-like symptoms. Television was a popular source of information on TB. Qualitative results captured people’s perceptions that TB was related with poverty and was still considered a stigma in the community; hence, patients afflicted feared disclosing the disease. Conclusion. With contextual understanding of communities’ knowledge, attitudes, health-seeking behaviour, and care-seeking patterns, it can be concluded that there is a need to increase the awareness about TB symptoms, mode of transmission, prevention, diagnosis and treatment, and destigmatization of the disease through health education.

Background. Dental students are exposed to various infections and infective sources during their training, and on this aspect, their level of knowledge is suboptimal and practices are risky. Therefore, improving their knowledge and practices would contribute significantly to infection control.Objective. To ascertain the level of understanding of senior dental students regarding the infection control in the dental practice.Methods. A cross-sectional study was conducted among dental students (3rd year and 4th year) of the Foundation University Dental College, Pakistan. The sample consisted of 100 third year dental students and 88 fourth year students. A self-administrated questionnaire was used for data collection which consisted of fourteen close-ended items. Frequencies of knowledge, attitudes, and practice were calculated separately by using SPSS 21.0 software.Results. Almost half of the students would not use any antiseptic for sterilizing their hands, and only two-third would ask their patient to use an oral mouth rinse before starting the treatment. Many students did not the optimal temperature of the autoclave for sterilization of the instruments. Only one-third would wear the personal protective equipment during a procedure. Around one-third of the study participants reported that ineffective sterilization during clinical practice can transmit infection from one patient to another.Conclusion. Knowledge on infection control among the dental students is though weak, practices are not as per standards but attitudes are positive and encouraging for taking steps and complying with measures on infection control.

Modern-day globalization means that many health issues cannot be resolved by the affected country alone, and this necessitates political consultations, diplomatic negotiations and cross-border solutions. A few examples that require health diplomacy efforts are: halting resentment towards immunization, addressing the burden of noncommunicable diseases, enabling access to drugs and technology, and liberalizing trade to reduce the cost of drugs. The agenda of Sustainable Development Goals (SDGs) demands a concerted effort to achieve the ambitious targets. This article reports the experience of health diplomacy training imparted to mid-level and senior officials in the public as well as private sector in Pakistan. Training was geared to inculcate an understanding of global health diplomacy and governance, and to develop an appreciation of the relationship of global health with other disciplines such as foreign affairs, economics, trade, climate change and human rights. Participants included health professionals, experts from departments other than health, government officials and diplomats. This training was expected to enhance their knowledge of health systems dynamics that are influenced by foreign policy and diplomatic discourses.

Background Delayed diagnosis of Oral Cancer (OC) can mean a difference in quality and expectancy of life for the patient. This delay could be from the healthcare side, or more importantly from the patient’s side. Globally, there are studies enumerating the causes for delays from the patients’ side in seeking healthcare for Oral Cancer; however, no similar research is found in the context of Pakistan. This study endeavoured to understand the health seeking behaviour, reasons for delay in consultation and the impact on OC patients’ lives. Methods In-depth interviews were conducted with randomly selected OC patients at a private sector tertiary care facility in Islamabad (who met the inclusion criteria of having successfully been treated for Oral Cancer) which caters to the most diverse population for the treatment of Oral Cancer. Theoretical saturation was achieved at 14 interviews. All participants gave verbal consent for participation, which was recorded prior to the interviews. Results Patients (age range 43–68 years) had received the surgical treatment and radiation. The reported delay before seeking a proper medical advice ranged from 1 month to 2 years. Lack of awareness about OC risk factors, symptoms, and whom to approach for treatment were the main reasons. Most respondents relied on self-treatment considering the non-healing wound/ulcer to be a minor issue until they were advised a consultation with a specialist. Treatment started within 1–3 months after a confirmed diagnosis on biopsy. The reported average expenditure on treatment was US$5000-10,000, mostly covered through a private health insurance and others borrowed the money. Conclusion A socio-behavioural change campaign for the general population can result in earlier presentation of the OC, minimizing the financial burden on the patient as well as the health system, and improving the quality of life of the patients.

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.

Background Pakistan’s National AIDS Control Program has registered 44,000 HIV/AIDS patients to date, but the actual number of cases have been estimated to be as high as 150,000–170,000. The health care system has a very important role to play in this equation and must be reformed to improve the health care services in Pakistan, with regards to HIV/AIDS. Methods It was a qualitative research employing a phenomenological approach. The principal researcher visited nine public and private health care facilities and conducted 19 key informant interviews with people working for providing preventive and curative services, in addition to the observations made on the site. Results Pakistan’s health system has a limited capacity to address the HIV spread in the country, with its current resources. There is an obvious scarcity of resources at the preventive, diagnostic and curative level. However, menace can be curtailed through measures taken at the service delivery level by checking the unsafe needles practices, unclean surgical procedures and an unregulated and untrained private health workforce which are dangerous potentials routes of transmission of the virus to the general population. Healthcare establishments carry the chances of nosocomial infections including HIV/AIDS. Poverty, illiteracy and stigma associated with the disease is compounding the overall situation. Conclusion Improved accessibility to service delivery with a greater focus on prevention would be imperative to address the threat of HIV/AIDS in Pakistan. A health systems approach would help in identifying gaps at both strategic and operational levels, and concurrently find and implement solutions.

Background In remote rural areas of Pakistan, access to the maternal, newborn and child health (MNCH) care provided by a skilled health provider is quite difficult. There are many reasons such as women’s restricted social mobility, lack of education, disenfranchised in decision making and poverty. To overcome these barriers and impediments in district Chitral, which is the largest territory in terms of geography in province Khyber Pakhtunkhwa, local women of reproductive age, were mobilized to form the Community Based Saving Groups (CBSGs) at the village level. In these CBSGs, they pool-in their money, and then provide soft loans to the expecting mothers to meet the expenses of delivery. Simultaneously, young literate women were identified from the local communities; they were trained as Community Midwives (CMWs), using national MNCH curriculum, and later deployed in their respective villages within the district. This study captured their perceptions about the formation of CBSGs to overcome the financial and social barriers, and subsequent use of CMW services. Methods A qualitative enquiry was conducted with the delivered mothers and their husbands through gender specific separate focus group discussions, with CBSG members and with non-members in four different sites of District Chitral. Results CBSG member women were far more aware on health issues. Information sought from these forums brought a noticeable change in the health seeking practices. Seeking care from a trained birth attendant in the community became easier. Women associated with the CBSGs as members, expressed an increased access to money for utilizing the CMW services, better awareness on MNCH issues, and empowerment to decide for seeking care. CBSG have been an instrumental platform for social networking, helping each other in other household matters. Conclusion Women have started using the services of CMW and the CBSGs have actually helped them overcome the financial barriers in health care seeking. Moreover, the CBSGs became a medium to improve the awareness of service availability, understanding the MNCH issues, and timely utilization of MNCH services.

Background Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme’s performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme’s insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities. Methods We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO’s six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes. Results The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines. Conclusions The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals. Electronic supplementary material The online version of this article (10.1186/s12961-019-0452-z) contains supplementary material, which is available to authorized users.

In Pakistan, the limited availability of oral health care and the high level of unmet oral health care needs are well documented. The recorded prevalence of dental caries is 50-70% and that of oral cancer is among the highest in the world. Although oral health care has been declared to be part of the primary health care system, oral health disparities between rich and poor, and emerging problems of access to and use of appropriate care have never been addressed, reflecting a lack of awareness among both patients and health system decisionmakers. Oral cancer screening and atraumatic restorative treatment for tooth decay could be included in a basic package of oral care that does not require qualified dental surgeons. This article develops an argument, based on literature review and an analysis of the health system in Pakistan, for how a basic oral health programme could be an accessible, affordable and acceptable component of the primary health care system.الرعاية الأولية لصحة الفم: حلقة مفقودة في الصحة العامة في باكستان.سارة بشارت، بابر تسنيم شيخ.إن قلة توافر الرعاية الصحية للفم في باكستان وكثرةَ احتياجاتها غر الملباة أمر موثق تماماً. فالانتشار المسجَّل لتسوس الأسنان يبلغ %50-70، وانتشار سرطان الفم يُعد من بن أعى المعدلات في العالم. وعى الرغم من الإعان عن جعل الرعاية الصحية للفم جزءاً من نظام الرعاية الصحية الأولية فإن الفوارق الموجودة بن الأغنياء والفقراء في مجال صحة الفم والمشاكلَ الناشئة عن إمكانية الوصول إلى الرعاية المناسبة والإفادة منها لم تعالج أبداً، مما يعكس قلة الوعي لدى كل من المرضى وصناع القرار في النظام الصحي. إن التحري عن سرطان الفم والمعالجة الترميمية غر الراضحة لتسوس الأسنان يمكن إدراجها ضمن الحزمة الأساسية للعناية بالفم التي لا تتطلب جراحي أسنان ذوي مؤهات عالية. إن هذا المقال يقدم برهاناً - يستند إلى مراجعة الأدبيات وإلى تحليل النظام الصحي في باكستان - عى الكيفية التي تمكِّن برنامجاً لصحة الفم الأساسية من أن يكون مكوِّناً متاحاً وميسور التكلفة ومقبولاً من مكوِّنات نظام الرعاية الصحية الأولية.Soins de santé bucco-dentaire primaires : le chaînon manquant de la santé publique au Pakistan.Au Pakistan, la disponibilité limitée des soins de santé bucco-dentaire et le niveau élevé des besoins non satisfaits dans ce domaine sont bien documentés. La prévalence enregistrée pour les caries dentaires est de 50 à 70 % et celle du cancer de la cavité buccale compte parmi les plus élevées au monde. Bien que les soins de santé bucco-dentaire aient été déclarés comme faisant partie du système de soins de santé primaires, les disparités en matière de santé bucco-dentaire entre riches et pauvres, et les nouveaux problèmes d’accès et de recours aux soins appropriés n’ont jamais été traités, ce qui démontre un manque de prise de conscience des patients et des décideurs du domaine des systèmes de santé. Le dépistage du cancer de la cavité buccale et le traitement restaurateur atraumatique pour les caries dentaires pourraient être inclus à un ensemble de base de soins bucco-dentaires ne requérant pas de chirurgien dentaire qualifié. L’article développe un argument, reposant sur une analyse documentaire et sur l’analyse du système de santé du Pakistan, qui présente la façon dont un programme de santé bucco-dentaire de base pourrait constituer une composante accessible, abordable et acceptable du système de soins de santé primaires.

SummaryOver 2 million abortions occur annually in Pakistan, mostly in a clandestine and unsafe environment. This is an area of grave concern for the reproductive health of women. A dearth of credible data and incomplete information make the problem more difficult to address. This qualitative study was conducted in semi-urban settings in Pakistan to record perceptions and practices concerning care seeking, experiences and outcomes regarding induced abortions and post-abortion care services. Women who had had induced abortions and abortion service providers were interviewed. Unwanted pregnancies and poverty were found to be the main reasons for seeking an abortion. Moreover, the unwanted pregnancies occurred due to low use of contraceptives, mainly due to a fear or past experience of their side-effects, unfamiliarity with correct usage and perceived inefficacy of the methods, especially condoms. There is an obvious need for practical and innovative interventions to address unmet need for birth spacing through improved access to contraceptives. Contraceptive providers should be provided with up-to-date and detailed training in family planning counselling, and perhaps allowed unrestricted provision of contraceptives. As a long-term measure, improvement in access to education and formal schooling could increase young girls’ and women’s knowledge of the benefits of family planning and the risks of unsafe abortion practices. Males must be involved in all the initiatives so that both partners are in agreement on correct and consistent contraceptive use.

Pakistan is considered as an intermediate zone of hepatitis B virus (HBV) infection, with an estimated population prevalence of 2-7%. This study assessed knowledge about HBV and vaccination among women of childbearing age in a rural setting of Punjab province, Pakistan. In 2012 a cross-sectional, community-based survey of 430 women was conducted using a semi-structured questionnaire. Less than half of the women (43%) surveyed had correct knowledge about HBV vaccination, and knowledge was especially poor among the low socioeconomic groups. Age, level of education and obstetric history of the respondents were significantly associated with knowledge about HBV and its vaccination. The main sources of information regarding HBV vaccination were lady health workers (53%) and traditional birth attendants (22%). Health promotion and behaviour change campaigns highlighting the importance of hepatitis B vaccine need to be designed to meet the needs of rural areas where women have little exposure to the mass media.المعرفة عن التلقيح ضد الالتهاب الكبدي (ب) لدى النساء في سن الإنجاب: دراسة مقطعية من منطقة ريفية في ولاية البنجاب بباكستان.نبيلة نورين، راميش كومار، بابار تسنيم شيخ.تعتر باكستان بمثابة منطقة متوسطة للعدوى بفروس الالتهاب الكبدي (ب)، حيث يراوح معدل الانتشار بن السكان بن 2-7% قامت هذه الدراسة بتقييم المعرفة عن فروس الالتهاب الكبدي (ب) والتلقيح ضده لدى النساء في سن الإنجاب في وسط ريفي في إقليم البنجاب بباكستان. فقد أجري في عام 2012 مسح مجتمعي مقطعي لـ 430 امرأة باستخدام استبيان شبه منظَّم. فكان لدى أقل من نصف النساء(43%) اللواتي خضعن للمسح معرفة صحيحة عن التلقيح ضد فروس الالتهاب الكبدي (ب)، وكانت المعرفة ضعيفة – بشكل خاص - لدى الفئات الاجتماعية والاقتصادية الدنيا. وقد ارتبط عمر المستطلَعات ومستواهن التعليمي وتاريخهن التوليدي - بشكل كبر – بالمعرفة عن فروس الالتهاب الكبدي (ب) والتلقيح ضده. وكانت المصادر الرئيسية للمعلومات المتعلقة بالتلقيح ضد فروس الالتهاب الكبدي (ب) السيدات العامات في مجال الصحة (53%) والقابات التقليديات (22%). فا بد من التخطيط للقيام بحمات لتعزيز الصحة وتغير السلوك تسلط الضوء عى أهمية لقاح الالتهاب الكبدي (ب) لتلبية احتياجات المناطق الريفية التي يقلُّ فيها تعرض النساء لوسائل الإعام العامة.Connaissances sur la vaccination contre l'hépatite B chez des femmes en âge de procréer : étude transversale dans un district rural du Pendjab (Pakistan).Le Pakistan est considéré comme une zone intermédiaire pour l'infection par le virus de l'hépatite B, et l'on estime que la prévalence dans la population est comprise entre 2 et 7 %. La présente étude a évalué les connaissances sur le virus de l'hépatite B et la vaccination chez des femmes en âge de procréer en milieu rural dans la province du Pendjab (Pakistan). En 2012, une enquête communautaire transversale a été menée auprès de 430 femmes au moyen d'un questionnaire semi-structuré. Moins de la moitié des femmes (43 %) ayant participé à l'enquête avaient des connaissances exactes sur la vaccination contre le virus de l'hépatite B, et les connaissances étaient particulièrement médiocres dans les groupes socioéconomiques inférieurs. L'âge, le niveau d'études et les antécédents obstétricaux des répondantes étaient significativement associés aux connaissances sur le virus de l'hépatite B et la vaccination. Les principales sources d'informations sur la vaccination contre le virus de l'hépatite B étaient les femmes agents de santé (53 %) et les accoucheuses traditionnelles (22 %). Des campagnes de promotion de la santé et de modification des comportements soulignant l'importance de la vaccination contre le virus de l'hépatite B sont à élaborer pour répondre aux besoins des zones rurales, où les femmes sont peu exposées aux médias.

BACKGROUND AND OBJECTIVE: Infectious waste management practices among health care workers in the tertiary care hospitals have been questionable. The study intended to identify issues that impede a proper infectious waste management. METHODS: Besides direct observation, in-depths interviews were conducted with the hospital administrators and senior management involved in healthcare waste management during March 2014. We looked at the processes related to segregation, collection, storage and disposal of hospital waste, and identified variety of issues in all the steps. RESULTS: Serious gaps and deficiencies were observed related to segregation, collection, storage and disposal of the hospital wastes, hence proving to be hazardous to the patients as well as the visitors. Poor safety, insufficient budget, lack of trainings, weak monitoring and supervision, and poor coordination has eventually resulted in improper waste management in the tertiary hospitals of Rawalpindi. CONCLUSION: Study has concluded that the poor resources and lack of healthcare worker's training in infectious waste results in poor waste management at hospitals.

consequences of 2011 reforms on the future roles demarcation between the federation and provinces for steering the health sector. The objective of this assessment study was to conduct an institutional appraisal of the provincial health department in Punjab to mark the achievements, problem areas and issues, as well as to formulate the recommendations in the post-devolution scenario. It was an in-depth literature review comprising papers found on PubMed/Medline, Google Scholar, reports published by the government departments, independent research works, academic papers, and documents produced by the development agencies in Pakistan, covering 18th constitutional amendment and its implications on health sector. Following 18th amendment, the Punjab Government formulated health sector strategy (2012-2017) which is being implemented in a phased approach. All districts have developed their three years rolling out plans. An integrated strategic and operational plan of MNCH, Nutrition and Family Planning is under review for approval. Punjab Health Care Commission has been established and is functional to regulate the health sector. Development agencies have in principle committed to support health sector strategy till 2017. Fair investments in improving governance, service delivery structure, human resource, health information, and medical products are expected more than ever in the post 18th amendment scenario. This is the chance for the health system of Punjab to serve the vulnerable people of the provinces, saving them from health shocks.

Anti-microbial or antibiotic resistance is a global public health problem, more dominant in the developing countries. Illiteracy and lack of awareness among the general population is a leading cause, compounded by lack of concern by the physicians and the pharmacists selling drugs over the counter. Another side of the phenomenon is attributed to profit making goals of pharmaceutical companies and weak regulation of the market. Nevertheless, misuse and overuse of antimicrobials accelerates this process. Besides, health issues, anti-microbial resistance also has economic implications on the health care system, where the simpler treatments are becoming difficult, day by day. Enforcement of standard treatment guidelines for the health providers and behavior changes at the patients’ end are likely to bring about a change in the situation.

Pakistan has been ranked highest and appears worst in stillbirths' rate according to the recent global estimates. Reasons could be manifold; socio-cultural, health system related country specific, and some of these of course déjà vu, i.e., the biomedical causes. Yet, a fresh stocktaking is necessary to understand the complex phenomenon in a country, awfully affected by this menace. Maternal, neonatal and child health program needs to be informed and geared up toward addressing the actual reasons behind this heavy toll of stillbirths in Pakistan. Maternal health indicators would never be improved, if the issue of stillbirths is not stalled at the earliest. Besides known medical reasons, this account attempts to document the health systems related factors, and more so the social determinants behind the whole scenario, so that appropriate and customized interventions could be suggested, developed and implemented. This paper will be a piece of evidence for policy corridors, program managers, development partners, non-governmental organizations, public health institutions, students, and researchers to enhance their understanding of a major public health problem, and to recognize the strengths and opportunities in the health system of Pakistan to cope with this challenge.

Background Sino-implant (II) is a two-rod subcutaneous contraceptive implant used up to 4 years, containing 150 mg of levonorgestrel. We conducted two observational studies of Sino-implant (II) to evaluate its performance in routine service delivery settings. Methods We enrolled 1326 women age 18–44 who had Sino-implant (II) inserted at clinics in Pakistan and Kenya. Women were followed-up using either an active or passive follow-up scheme in each study. Study outcomes were: one-year cumulative pregnancy and discontinuation rates; rates of insertion and removal complications; adverse event and side effect rates; reasons for discontinuation; and implant acceptability and satisfaction with clinic services. Results A total of 754 women returned for at least one follow-up visit. The overall Pearl pregnancy rate was 0.4 per 100 woman-years [95% confidence interval (CI) 0.1, 0.9] resulting from 1 confirmed post-insertion pregnancy in Kenya and 4 in Pakistan. Country-specific Pearl rates were 0.2 (95% CI 0.0, 0.9) in Kenya and 0.6 (95% CI 0.2, 1.6) in Pakistan. The total cumulative 12-month probability of removal was 7.6% (95% CI 6.1, 9.1), with country-specific removal probabilities of 3.7% in Kenya (95% CI 2.1, 5.3) and 10.8% in Pakistan (95% CI 8.5, 13.2). Four serious adverse events occurred in Kenya and none occurred in Pakistan; one SAE (an ectopic pregnancy) was possibly related to Sino-implant (II). Most women in both countries said they would recommend the implant to others. Conclusion The results from these studies reveal high effectiveness and favorable safety and acceptability during the first year of use of Sino-implant. Implication The favorable Sino-implant (II) findings from Kenya and Pakistan provide further evidence from disparate regions that Sino-implant (II) is safe, effective and acceptable during routine service delivery.

Background Immunization should be considered a basic human right to health and well-being. It is everybody’s business, and it is everybody’s responsibility: the individual, the community, the health system and the state. This paper attempts to review some of the literature that highlights the ethical and religious concerns surrounding polio vaccination and what approaches may be used to counter the problems faced in Pakistan. Methods This paper is developed through a literature review on public health and polio in Pakistan, consulting local, regional and globally published peer reviewed articles focussing on religion, culture, ethics and public health. Discussion Human behaviour, including the utilization and acceptability of healthcare services, is greatly influenced by religious beliefs and dogmas. Immunization, specifically for the purpose of polio eradication, has been a topic under focus and in the news in Pakistan. The government is doing its best through a variety of interventions to increase access, inform the public and increase vaccination rates. Nevertheless, the country still faces a huge challenge from certain stern pockets of uncompromising populations who resist and refuse vaccination. Beliefs, practices and cultural norms overshadow public health priorities and ethics. Understanding of the context, therefore, is critical to determine the social hindrances in polio eradication and strategize thereon. Conclusion Having programmatic, system-wide, socio-cultural and of course ethical dimensions, the policy makers and the programme managers in Pakistan must attempt to address the multitude of challenges to polio vaccination, whereby the plan of action developed within the ethical norms could potentially lead to an ultimate success.

Myths and fallacies have existed ever since societies began, influencing the perceptions about health, and the cause and cure of health related problems. The role of such myths in governing the health and health seeking behavior of people is quite explicit. Misconceptions about breast-feeding, pre-lacteal feed, weaning, dietary habits and other health related matters are commonly heard in the cultures of developing countries. False perceptions have undoubtedly an impact on the health seeking behavior. People coming from the low socio-economic strata in rural areas suffer the most. They lack access to formal health care services and are unable to afford specialized medical care. This gives rise to alternative health seeking behaviors. A considerable majority of people prefer to go to spiritual healers, quacks and other non-formal health providers for the treatment of their ailments. This paper has reviewed a variety of myths, fallacies and misconceptions collectively in the cultural context and has attempted to relate them to the health seeking behaviors of Pakistani people. The paper is based on the contemporary literature review and library work, focusing on finding the feasible strategies to address a variety of myths and misconceptions. Since myths have many adverse implications on the health of the people, an effective way of motivating low income and high risk people to adopt healthy behavior is 'social marketing'. Creating 'health promotion committees' at village level sounds like another doable strategy to ameliorate the situation in order to educate people to take care of not only their own health but of the future generations as well.

Among the healthcare financing techniques that exist, output-based financing or vouchers is a strategy that is growing in popularity. There is a need of an in-depth analysis of the impacts of vouchers on health indicators, particularly for Pakistan. Assessment of the existing evidence on how much the vouchers impact on health and healthcare utilization can be of greater value to the policy makers for informed decision making. This systematic review included 16 cross-sectional and quasi-experimental design studies. Service utilization, knowledge, service quality, cost-effectiveness of the programme and outreach of the population served were observed as outcomes. We found positive results in with regard to most of these outcomes. Physical accessibility, social mobility of women, security threats, and sustainability of the project after donor exit appear as serious challenges. Yet, lessons can be drawn for the scaling up of the reproductive health services in the country, through the use of vouchers.

Decentralization of government services may take various forms: (a) de-concentration, (b) delegation, (c) devolution and (d) privatization (Rondinelli et al. 1983). Any form of decentralization ought to improve the responsiveness and quality of health services delivery by better informing decision-makers and service providers, bringing them closer to the populations they serve and making them more accountable. Decentralization tends to simplify management structures and enhance the efficient use of resources, ensuring equity in terms of improved access to health services and delivery for underserved, marginalized, vulnerable and remotely located population groups (Frenk 1994). However, in the absence of a national health services policy, current inequities in the distribution of finances, it is possible that human resources and structures could deteriorate. There is a likelihood of increased inefficiency owing to gaps in the managerial capacity of subnational tiers of government, especially when subnational capacity and overall infrastructure are weak (Roy 1994). Thus, decentralization and devolution of powers in the healthcare and social sectors have yielded mixed results in various countries around the world. Efforts towards decentralization typically result from political decisions over which health functionaries have little control, and this is the case with Pakistan. The sixth most populous country in the world, located in southern Asia, Pakistan has recently enacted constitutional reforms that shift financial and administrative powers to the four subnational/provincial governments (Government of Pakistan 2010). The federal health ministry and many other social-sector portfolios have been transferred to the four provinces with the mandate of policy making, financing, regulation, service provision, administration and governance. This political transition has many implications for healthcare provision (Nishtar and Mehboob 2011). As a result of reforms initiated in 2011, high-priority preventive programs formerly managed by the federal government – such as family planning, primary healthcare (PHC), immunization, maternal/neonatal and child health, nutrition and programs targeting specific diseases – are now managed at the provincial level (Nishtar 2011). Pakistan has long had a mixed public–private healthcare delivery system with the conventional three tiers of primary, secondary and tertiary healthcare facilities (Shaikh 2011). Like many low-income countries, it relies on community health workers, who are a valuable resource in providing basic healthcare and MCH-related services at the community level (Kruk et al. 2009). Yet despite Pakistan's conventional healthcare system with vertically organized programs to deliver the first tier of care, 80% of the population uses the private-sector, fee-for-service system (Shaikh 2011; WHO 2007b). Pakistan has a high fertility rate, high maternal and under-five mortality rates and a low rate of contraceptive use (National Institute of Population Studies and Macro International 2008). As a signatory to the United Nations Millennium Development Goals (MDGs), the country is lagging in terms of reducing under-five mortality by two-thirds (MDG 4) and maternal mortality by three-quarters (MGD 5) by 2015 (Lawn et al. 2011). The attainment of MDGs could become an even bigger challenge given the present political transition. Decentralization in Pakistan is a consequence of domestic political decisions taken by the ruling party, which claims to have restored the constitution of 1973 in its original state. There are also economic, organizational and legal reasons behind the reforms, yet these have been subsumed by the overarching political environment, as have decentralization efforts in many parts of the world (Saltman et al. 2007). The variations evident within the four Pakistani provinces – in terms of population size, political and social set-up, and the structure and quality of healthcare delivery systems – have serious implications, particularly on MCH indicators. The process of reform offers an opportunity to confront long-standing challenges, constraints and inadequacies within Pakistan's health systems. Health planning at the provincial and district levels may be more effective at problem identification, prioritization and setting clear objectives within local budgets. Moreover, decentralization should ideally result in better governance, more effective service delivery and decision-making at the grassroots level, thus providing a platform for empowering citizens (Shaikh and Rabbani 2004). With the provinces having greater autonomy, primary healthcare, which is the core approach for expanding and strengthening the essential programs for MCH in any developing country, could be incidentally revitalized (Shaikh et al. 2007). This transitional phase is also an opportune time to foster intersectoral cooperation to address social determinants of health (WHO 2010a). However, success will depend upon strengthening the basic building blocks of the health system.

In Pakistan, absence of a nationwide surveillance mechanism and strategy is the main reason for the failure in effectively controlling communicable diseases. The seasonal outbreaks of various infectious diseases every year call for an integrated surveillance system on a national level for planning effective preventive strategies. Opportunity to adopt a tested and tried model exists at this time in terms of the “Disease Early Warning System” set up by World Health Organization in conflict-affected districts. Replicating this system in other districts is both practical and feasible as technical support is readily available through the World Health Organization. Such a system once put in place has potential to not only decrease morbidity and mortality through early detection and prompt control of outbreaks but also to facilitate effective financial, human resource, and materials management at the district level. This would be a step toward a more responsive health system at the local level.

Objectives Despite certain reforms undertaken in Pakistan to reorient its health system, the health-related millennium goals lagged behind many neighbouring and regional countries. This study was conducted to understand the implications of government reforms including the devolution on the National Maternal Newborn and Child Health (MNCH) programme; and to determine donors’ and development partners’ current and prospective role in the post-reform scenario. Setting The donor agencies based in the federal capital Islamabad, as well as the federal and provincial government offices involved in the financing, design, oversight and implementation of various MNCH initiatives in Pakistan, were included in the sample. Participants A descriptive qualitative study based on individual in-depth interviews with representatives from donor agencies and government offices (8 each) involved in programmes directly related to the MNCH sector. Results The reforms are denounced as deficient in terms of detailed planning and operationalisation of the vertical programmes including that for MNCH. The government had to face coordination challenges with the provinces, which has affected donor engagement and funding mechanisms to a great deal. Investment in MNCH, population and nutrition has been the topmost priority of development partners in Pakistan. Their contributions towards health systems also include assistance in developing and implementing provincial health sector strategies, establishment of Health Sector Reform Units and investments in service delivery, research and advocacy. Conclusions Any health sector reform must be complemented by a roll-out strategy, including robust support to the provincial health systems and to their capacity building. Development partners must align and coordinate their strategies with provinces to stabilise the MNCH programme in Pakistan. More coordination between the different tiers of the government and the donors could streamline MNCH partnership in post-reform times.

Background Each year an estimated 289,000 maternal deaths occur worldwide; of which 50 % of maternal deaths occur around labor, delivery and immediate postpartum period. Postnatal care (PNC) is crucial but relatively neglected component in the continuum of care, and hence a missing link toward safe motherhood. Despite the significant improvement in child health and safe motherhood interventions, maternal mortality ratio, perinatal mortality and neonatal mortality still remain a challenge in achieving the Millennium Development Goals 4 and 5 in Pakistan. Methods This was a descriptive cross sectional study carried out in the four union councils of Islamabad capital territory, to understand the determinants of postnatal health care seeking. The study sample comprised 225 postpartum women with a child 0 to 1 month of age, and the health care providers from both public and private sector. A pre-tested semi-structured questionnaire was used for data collection. One focus group discussion with health care providers was conducted, using open ended questions guide. Results Only 30 % women received PNC; amongst which 68 % went to a government health facility. According to the health service providers, 90 % women are not interested in PNC, and that is because they lack awareness, face mobility and transportation issues, and cannot afford the cost of health care. Besides many other determinants, women’s education was significantly associated with the PNC utilization. Conclusion More robust and culturally sensitive campaign on importance of PNC must be thought out by the national MNCH program to inform the less literate and peri urban inhabitants of Islamabad. Health providers ought to be sensitized and trained for promoting PNC to save maternal and newborn lives.

Primary health care (PHC) services in Pakistan, particularly in rural areas, are in a dismal state. Inadequacies, unfairness and ignorance about the importance of the basic health care provided by these facilitates have led to a disorganized and poorly performing system. This paper reviews the situation in certain PHC facilities in Sindh province. Inadequate medicines and supplies, underutilized family planning services, lack of human resources, faulty equipment, and absence of a proper referral mechanism were some of the key findings. There is therefore an urgent need for radical improvement in the PHC system in order to maximize the appropriate use of PHC facilities. In order to do this, the paper argues that the stewardship role of the State must be strengthened.

Babar T ShaikhPopulation and Reproductive Health Program, Department of Community Health Sciences, Aga Khan University, Karachi, PakistanAbstract: The recent data on unmet need in the Pakistan Demographic and Health Survey 2006–2007 shows a high unmet need for contraceptives, although family planning programs have been in place in this country since the late 1950s. The phenomenon presents a complex picture, as the contraceptive prevalence rate has remained almost unchanged over the last 10 years. To analyze this situation, a novel technique or a new lens would be required. This paper attempts to examine the problem at various levels: users, family, community, health system, other sectors, and the state. A multipronged and multisectoral approach is a prerequisite to institutionalize the family planning services all across the health sector. Studying health-seeking behaviors and conducting health systems research have the potential of delivering the desired recipe to address the high unmet need for family planning in Pakistan.Keywords: health-seeking behaviors, health systems research

According to the World Health Organization and the United Nations Children's Fund, developing countries carry a large share of neonatal mortality in the world. According to UNICEF, almost 450 newborn children die every hour, mostly from preventable causes. Restricted access to quality and hygienic delivery services and limited knowledge about handling the newborn aggravate the situation. South Asia, and Pakistan in particular, have reduced their child and infant mortality during the last decade; however, neonatal mortality still remains unacceptably high. There are multiple reasons, mainly related to practices and behaviours of communities and traditional birth attendants. Rural and poor populations suffer most in Pakistan, where three out of five deliveries still occur at home. Traditional community practices and conservative norms drastically affect neonatal health outcomes. Preventing sepsis at the umbilical cord, keeping the baby at the correct temperature after birth and early initiation of exclusive breastfeeding are three simple strategies or messages that need to be disseminated widely to prevent many neonatal mortalities and morbidities. Since inappropriate practices in handling newborns are directly linked with persistent and unremitting behaviours among health providers and the community at large, we suggest doing robust "social marketing" for saving newborn lives. The objective of the paper is to present a social-marketing strategy and a marketing mix that will help address and surmount actual barriers and promote alternative behaviours in early neonatal care.