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A cross-sectional study of patient satisfaction with care was conducted over a period of 1 year from March 2004 to March 2005 in a secondary-level hospital in a peri-urban area of Karachi, Pakistan. Using the SERVQUAL tool and exit interviews, data were collected quarterly from a total of 1533 patients. Results sharing and capacity-building workshops were arranged during the 4 phases of the survey to sensitize the staff of the hospital to work towards improving patient satisfaction. The level of satisfaction of the patients with the outpatient health services provided showed a gradual increase from 34.4% to 82.0% over the 1-year period. [ABSTRACT FROM AUTHOR]

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

Women's right to health has been reiterated many times. However, there are social and cultural barriers in developing countries that hinder their empowerment. Women's low status, deprivation of education and lack of control over their own lives and bodies have a negative impact on their health status and that of their families. This paper discusses women's empowerment and health within the framework of the 4 institutions of power in a society-family, community, health care systems and the state--with special reference to the situation in Pakistan. It concludes that to improve women's health status, concerted efforts are needed by all these institutions of power to work towards gender equality and the greater empowerment of women. [ABSTRACT FROM AUTHOR]

Pakistan's health system has a critical role to play in global health security, however, it faces numerous structural and systemic challenges while contributing to international health efforts. Understanding the dynamics of health system is essential for developing effective strategies to prevent, detect, and respond to health emergencies, ensuring regional stability, and the overall global health security This paper documents the strengths and weaknesses of Pakistan's health systems, the impact of the COVID-19 pandemic, challenges such as funding constraints and fragmented healthcare delivery, threats including antimicrobial resistance, and the importance of international collaboration. Anti-microbial particularly multi-drug resistance, food safety in emergencies, surge capacity of the frontline workforce, patient safety at the health care facilities to curtail healthcare associated infections, and strengthening the points of entry are still the areas that need special attention. To optimise the system's performance, governance and accountability mechanisms are necessary to be put in place under the auspices of national public health agency. Pakistan has the potential to transform its health system by addressing these critical areas and improve its preparedness and readiness for any future health emergency of this scale., (© 2024 John Wiley & Sons Ltd.)

Depression among married women of reproductive age is on the rise in Pakistan, owing to post-COVID-19 phase, super-inflation, increasing poverty, deteriorating law and order situation and perpetuating the uncertain political situation in the country. This study aimed to investigate the factors associated with depression among married women of reproductive age in Pakistan, using a mixed methods approach. The quantitative phase utilized the Urdu version of the Patient Health Questionnaire-9 (PHQ-9) to assess depression among 340 married women. Twelve women with higher scores on the PHQ-9 were selected for in-depth interviews in the qualitative phase. The quantitative analysis revealed a higher prevalence of depression among women with poor socioeconomic status, lower educational levels, larger family sizes, and recent deaths in the family. In the qualitative phase, the main themes identified were the impact of social conditions, such as societal expectations and gender roles, the influence of medical conditions on mental health, financial difficulties, the stress associated with caring for a larger number of children, and the emotional burden of recent deaths in the family. This study highlights the importance of addressing depression among married women of reproductive age in Pakistan. It is crucial to focus on early diagnosis and prompt treatment to mitigate the adverse effects of depression on the affected individuals and their families. Targeted interventions should consider the social determinants of depression, including improving socioeconomic conditions through safety nets, providing mental health support at the primary health care level, and addressing the specific health issues and needs of women in the reproductive age group. A multi-pronged approach and health system's thinking can reduce the burden of depression among women, ultimately enhancing their overall well-being, productivity and quality of life., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Abdullah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The attainment of the noble objective of Universal Health Coverage (UHC)- 'leaving no one behind' necessitates sufficient financial resources, an ample supply of skilled healthcare professionals, and the availability of essential services as part of a basic package This paper presents an analysis of the health system, health seeking behaviours and health service utilization en route to UHC in Pakistan. We have used the UHC 14 tracer indicators of service coverage to see where Pakistan stands, what are the gaps and what needs to be done. Pakistan clearly is lagging behind its neighboring countries. The country's health system ought to work on health seeking behaviours and broader determinants of health. The pursuit of UHC demands a shared responsibility and collective action, with stakeholders from different sectors uniting their efforts and expertise. Together, they can establish robust systems, design comprehensive policies, allocate adequate resources, and implement interventions that transcend disciplinary boundaries., Competing Interests: None., (© 2024 Published by Elsevier Ltd.)

Background: Effective skills and training for physicians are essential for communicating difficult or distressing information, also known as breaking bad news (BBN). This study aimed to assess both the capacity and the practices of clinicians in Pakistan regarding BBN., Methods: A cross-sectional study was conducted involving 151 clinicians. Quantitative component used a structured questionnaire, while qualitative data were obtained through in-depth interviews with 13 medical educationists. The responses were analyzed using descriptive statistics and thematic analysis., Results: While most clinicians acknowledged their responsibility of delivering difficult news, only a small percentage had received formal training in BBN. Areas for improvement include time and interruption management, rapport building, and understanding the patients' point of view. Prognosis and treatment options were not consistently discussed. Limited importance is given to BBN in medical education., Discussion: Training in BBN will lead to improved patient and attendants' satisfaction, and empathetic support during difficult times., (© 2024. The Author(s).)

Burnout and emotional exhaustion are becoming common among health workers in the busy teaching hospitals due to increased workload and the dearth of human resource. This study aimed to determine the causes of burnout among doctors and across gender differences. This was a descriptive cross-sectional study conducted in the Fauji Foundation Hospital, Rawalpindi, Pakistan, from 1st July to 30th September 2022. Two hundred and forty-five randomly recruited doctors who filled out self-administered questionnaires were included in the study. Independent samples t-test was used for comparison of the mean emotional burnout score. Female doctors felt more emotionally drained, more fatigued, and more worn out from work than male doctors (p < 0.05). Overall emotional exhaustion was also higher in female doctors (p < 0.05). This situation was more serious during the COVID-19 pandemic. Gender-sensitive environments, workplace policies, and necessary interventions will save physicians' burnout and brain drain. Emotional burnout is greater in female doctors as compared to their male counterparts. This evidence not only calls for prevention and treatment but also certain service-related reforms to facilitate female physicians to balance out their work and family lives more effectively. Key Words: Physicians, Emotional exhaustion, Burnout, Gender difference, Pakistan.

Objective: In 2022, Pakistan witnessed unprecedented flooding, submerging one-third of the country under-water, ruining millions of houses, taking lives, afflicted injuries, and displacing scores of people. Our study documents not only the public health problems that have arisen due to this natural calamity but also the state of health systems' response., Methods: We conducted a qualitative study asking key questions around prevalent health problems, health-care seeking, government's response, resource mobilization, and roadmap for the future. We purposively selected 16 key frontline health workers for in-depth interviews., Results: Waterborne and infectious diseases were rampant posing huge public health challenges. Disaster mitigation efforts and relief operations were delayed and not at scale to cover the entire affected population. Moreover, a weak economy, poverty, and insufficient livelihoods compounded the tribulations of floods. Issues of leadership and governance at state level resulted in disorganized efforts and response., Conclusions: Pakistan is famous for its philanthropy; however, lack of transparency and accountability, the actual benefits seldom reach the beneficiaries. Such climatic disasters necessitate a more holistic approach and a greater responsiveness of the health system. In addition to health services, the state must respond to financial, social, and infrastructural needs of the people suffering from the calamity.

Objectives: Amidst inconsistent prescribing patterns and potentially harmful medication errors in the field of medical practice, this study endeavored to explore the prescription practices of physicians in Rawalpindi metropolitan city in Pakistan., Methods: A mixed method study was conducted based on the analysis of 1232 prescriptions gathered from 16 pharmacies, along with in-depth interviews with 13 practicing physicians. The prescriptions were assessed for legibility, polypharmacy, patient details, history, diagnosis, and other relevant information. Data were analyzed using descriptive statistics, and the prevalence of various aspects of prescription accuracy was calculated. Thematic analysis was conducted on the qualitative data., Results: Almost half of the prescriptions were from the private general practitioners, and the rest were from hospital-based doctors and consultants. Only a small percentage of prescriptions were fully legible, and many had incomplete or missing patient information, medical history, and diagnosis. Polypharmacy was also found to be prevalent, with significant differences in prescription accuracy across different medical specialties. The absence of continuing medical education, influence of pharmaceutical industry, and overcrowded practice settings drive the doctors to prescription practices. On the user side, perception of polypharmacy, patient-physician communication, and availability and cost of medicines emerged as major themes., Conclusion: There is an obvious need to improve prescription accuracy regarding patient safety on the whole. Increased investment in health-care infrastructure, greater access to continuing medical education, and a commitment to promote evidence-based medicine could make a difference. Prescription practices must be safe, effective, and aligned with the latest advances in medical science., (Copyright: © International Journal of Health Sciences.)

Background: Pakistan's health system over the past three decades has experienced social, economic, geopolitical instability, and notwithstanding man-made and natural catastrophes. Since 2001, the health system in Pakistan has undergone three phases of organizational and management reforms and does not have a unified national health policy since then. The aim of this research was to assess the factors behind the decision-making by policy planners in the health system of Pakistan., Methods: An exploratory qualitative study based on grounded theory was designed where in-depth interviews conducted with 20 representatives of the political constituencies, civil bureaucracy, health planners and managers, research and educational institutions, NGOs providing technical support in the health sector, development partners and media., Results: There leading reason cited was the dearth of leadership in health sector, which is compounded by a range of factors such as "institutional monopoly", "contextual deterrents", "power for turf"; "inadequate knowledge", and "design faults". Such factors were perceived to have a serious effect on the competencies, roles and responsibilities, use of knowledge for decision making. The behavioral aspects of decision makers include the "mindset," and "conflicting interests"., Conclusions: The multitude of factors and complexities within the health sector of Pakistan continue to widen the vacuum in the leadership echelons. Hence, there is a high probability of taking wrong decisions not based on evidence, and resulting in a grossly under-performing health system., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2023 The Authors.)

In April 2021, following the Federal government's decision, an intervention was designed to execute COVID-19 home-based care training program for the LHWs in all provinces to avoid overcrowding in large hospitals so that critically ill patients can get due attention and treatment. The training curriculum was developed in local languages following guidance from NIH and WHO. Basic health units were used as the venue for training and the doctors delivered the sessions as master trainers. Around 46,000 LHWs completed the training all over Pakistan and started visiting their catchment households to identify and counsel any COVID-19 patients and families on home-based care. Their post-training impressions showed that 97% were satisfied with the content, rigour, quality of training, and that they received the most updated information on COVID-19 from reliable sources. Training of these LHWs enhanced their skills for dealing with COVID-19 patients and helped ease the pressure on a stressed and over-burdened hospitals. This intervention exemplifies task shifting to LHWs, hence addressing the issue of insufficient health workforce in the hospitals and extending public healthcare to rural communities. Key Words: COVID-19, Home-based care, Health system, Lady health workers, Pakistan.

Background: There is a strong and wide consensus that Pakistan must pursue universal health coverage (UHC) attainment as the driving force for achieving sustainable development goals by 2030. Nevertheless, several institutional and socioeconomic challenges may hinder the progress toward UHC., Main Body: It is important that the health system of Pakistan must be transformed to strengthen all three dimensions of UHC i.e. maximizing the population covered, increasing the range of services offered, and reducing the cost-sharing. To make UHC dream a reality in Pakistan, there are some pre-requisites to meet upfront: a) budgetary allocation for health as percentage of GDP must be increased; b) health system's readiness especially in the public sector ought to improve in terms of human resource and availability of essential services; c) safety nets for health must continue regardless of the change in the political regimes; d) decrease the reliance on donors' funding; and e) accountability to be ensured across the board for service providers, managers, administrators and policymakers in the health system., Conclusion: COVID-19 pandemic has revealed some major gaps in the health system's capacity to deliver equitable healthcare, which is a cornerstone to achieving the UHC agenda. The priority-setting process will need to be aligned with the SDGs to ensure that the agenda for action towards 2030 is comprehensively addressed and successfully accomplished preferably before, but hopefully not beyond the targeted dates., (© 2023. The Author(s).)

Tuberculosis (TB) is on the rise in Pakistan and there could be multiple reasons including poverty, difficulty in access to TB treatment services, non-compliance with treatment, social stigma etc. According to the TB program managers, limited treatment and testing sites for tuberculosis and lack of trained human resources play a major role in compromising TB management. A major lacuna in the TB control program is the absence of active contact tracing strategy. This is essential for a disease where positive cases are known to be able to infect a further 10‒15 individuals in a year. Tackling tuberculosis in Pakistan has been beleaguered by funding challenges and other systems' bottlenecks such as lack of skilled human resources and insufficient supply of medicines, despite the fact that disease burden is one of the highest in the world. Although it is a notifiable disease, active case finding, contact tracing and reporting is notoriously low throughout the country. Access to diagnostics and treatment facilities has been limited and stigma attached to the disease remains deeply entrenched among the communities. Researchers have shown that enhanced and active approaches to contact investigation effectively identifies additional patients with TB among household contacts at a relatively modest cost. USAID's Integrated Health Systems Strengthening and Service Delivery Activity extended support to the Health Departments of Sindh and Khyber Pakhtunkhwa provinces. In collaboration with the two provincial TB programs, community based active contact tracing was conducted on 17,696 individuals, based on the index cases. Among the contacts traced, 243 cases were diagnosed as drug sensitive or drug resistant TB. Awareness sessions were conducted to sensitize people on the various aspects of disease and importance of getting tested. The project also supported establishing three satellite Programmatic Management of Drug Resistant Tuberculosis (PMDT) sites for drug resistant TB treatment, enhancing the programs' diagnostic and testing capacity., (© 2022. The Author(s).)

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., Conclusions: 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.

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., Competing Interests: The authors have declared that no competing interests exist.

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.

Background: 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., Methods: A cross-sectional study was conducted with a non-probability consecutive sampling technique including 232 pregnant women., Results: 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., Conclusions: 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.

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., (© 2020 John Wiley & Sons, Ltd.)

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., Competing Interests: The authors declare that they are no conflict of interests., (Copyright © 2020 Mariam Khan Qamar et al.)

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., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 Adeela Khan et al.)

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.

Background: Acute Respiratory Infections (ARIs) are among the leading causes of morbidity and mortality in children under the age of five in Pakistan. Gauging the knowledge and practices of mothers related to ARIs may hold a key role in reducing the incidence and complications. Our study assessed the knowledge of mothers regarding ARIs among children under five years in accordance with WHO guidelines, and its association with education and socioeconomic status of mothers. In addition, we studied the association between education of mothers and socioeconomic status with vaccination status of child., Methods: This cross-sectional study was conducted from May to December 2016 at Civil Hospital, Ziauddin Hospital and Gulshan-e-Sikanderabad PHC Karachi and involved mothers with at least one child under the age of five years. Four hundred mothers were interviewed using a questionnaire. Results were analysed using SPSS 20.0., Results: 51% of mothers were found to have an above average understanding about ARIs with a mean score of 13.35±3.03 out of a possible 20. There is no association between knowledge of mothers and their level of education. Education level of the mother was found to have a significant association with the vaccination status of youngest child. Mothers having no education or just religious education had the highest percentages of incomplete vaccinations., Conclusions: Most mothers had above average knowledge of what classified as an ARI and could identify the danger signs. Uneducated mothers had incomplete vaccinations of their youngest child. The majority of mothers had satisfactory breastfeeding habits.

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.

Background: In Pakistan, immunization coverage has been quite low since the program's inception, and the 2012-2013 population-based survey recorded it at 54%. Much has been written about the issues, challenges, and constraints in the implementation of Pakistan's immunization program. However, there is a need to better understand the health system barriers as well as levers that influence progress. This review aims to bridge the information gaps on system-level barriers that currently impede the optimal delivery and uptake of immunization services to the children of Pakistan through the Expanded Program on Immunization (EPI)., Methods: We conducted a comprehensive literature review, using PubMed and Google Scholar to find peer-reviewed literature, and also reviewed EPI-related international and national reports. Additionally, we consulted government reports, surveys, and publications on the health system. Employing the basic tenets of WHO's health systems framework for health system strengthening, and a socio-ecological model, this study cataloged the service delivery and the demand side perspective on various pillars of Pakistan's immunization program., Results: Themes generated from the literature review included financing, governance, service delivery, human resources, information systems, and supplies and vaccines. Findings suggest that certain areas in the larger health system need to be improved for a more coordinated implementation of EPI in Pakistan. Moreover, it is imperative to understand community behaviors and perceptions as well as demand side issues in order to achieve the desired results., Conclusion: For better immunization coverage and ultimately a reduction in child mortality due to preventable diseases, EPI operations and performance must be improved. Further systematic implementation research could help to develop an even finer understanding of the system-wide bottlenecks encumbering the coverage and efficiency of the program., Competing Interests: Not applicable.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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: 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: 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.

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.

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.

Background: Pakistan is unfortunately among the five countries that contributed to the most deaths due to diarrhea and pneumonia in 2010. To explore factors associated with diarrheal deaths we assessed care-seeking behavior and other predictors of diarrhea-related mortality in children in selected low-income peri-urban communities of Karachi, Pakistan., Methods: A mixed methods study (qualitative and quantitative) using matched case-control design and focus group discussions with parents of children with moderate to severe diarrhea (MSD) was undertaken. Cases were children  <5 years of age who died within 60 days of developing an episode of MSD. Controls were age-matched children who survived after 60 days of an episode of MSD. Demographic, clinical, and care-related behavioral predictors of mortality were assessed. Conditional logistic regression was performed, matched adjusted odds ratios (mOR) are reported., Results: Parents of 77 cases and 154 controls were interviewed. Cases were less likely to receive appropriate care compared to controls (mOR = 0.2, 95% confidence interval (CI) 0.05-0.91). Refusal for hospital admission (OR = 8.9, 95% CI 2.6-30.8), and delays in reaching the health facility (OR = 3.6, 95% CI 1.0-12.9) were significant independent predictors of mortality. We found strong beliefs in traditional and spiritual healing in the population; use of both modern and traditional/spiritual treatments concurrently was common., Conclusion: Appropriate care seeking behavior predicts survival in children with diarrhea in Pakistan. There is a complex belief system relating to traditional and standard therapies. Health education for appropriate health care seeking should be implemented in order to achieve a substantial decline in diarrheal disease mortality in Pakistan.

Over 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.

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.

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., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

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.

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.

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.

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.