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Background: Women in rural districts of Pakistan face numerous barriers to healthcare, rendering gender-responsive health programming important, including for Tuberculosis (TB). This study was conducted to assess the general understanding of TB and of access to healthcare for women, as a first step towards implementation of a gender responsive TB programme in TandoAllayar, a rural district of Pakistan. Methods: A total of 36 participants were interviewed. The focus group discussion guide comprised of questions on: (1) family/household dynamics (2) community norms (3) healthcare system (4) women’s access to healthcare (5) TB Awareness;, and (6) women’s access to TB Care. Results: Limited autonomy in household financial decision-making, disapproval of unassisted travel, long travel time, lack of prioritization of spending on women’s health and inadequate presence of female health providers, were identified as barriers to access of healthcare for women, higher in younger women. Facilitators to access of TB care included a reported lack of TB-related stigma, moderate knowledge about TB disease, and broad understanding of tuberculosis as a curable disease. Other suggested facilitators include health facilities closer to the villages and the availability of higher quality services. Conclusion: Significant barriers are faced by women in access to TB care in rural districts of Pakistan. Programme implementers in high burden countries, should shift towards improved gender-responsive TB programming.

IntroductionTuberculosis (TB) is the leading cause of avoidable deaths from an infectious disease globally and a large of number of people who develop TB each year remain undiagnosed. Active case-finding has been recommended by the World Health Organization to bridge the case-detection gap for TB in high burden countries. However, concerns remain regarding their yield and cost-effectiveness. MethodsData from mobile chest X-ray (CXR) supported active case-finding community camps conducted in Karachi, Pakistan from July 2017- March 2020 was retrospectively analyzed. After a CXR screening supported by computer-aided detection, those with presumptive TB were counselled to submit a sputum sample for Xpert MTB/RIF testing. Frequency analysis was carried out at the camp-level and outcomes of interest for the spatial analyses were mycobacterium TB positivity (MTB+) and X-ray abnormality ratios. The Moran’s I statistic was used to test for spatial autocorrelation for MTB+ and abnormal X-rays within Union Councils (UCs) in Karachi. Local Indicators of Spatial Autocorrelation analyses were performed for UCs within Karachi. Point-pattern analyses were carried out utilizing GPS coordinates recorded at the camp sites and were analyzed for spatial autocorrelation using Getis Ord Star tests.ResultsA total of 1,161 (78.1%) camps yielded no MTB+ cases, 246 (16.5%) camps yielded 1 MTB+, 52 (3.5%) camps yielded 2 MTB+ and 27 (1.8%) yielded 3 or more MTB+. A total of 79 (5.3%) camps accounted for 193 (44.0%) of MTB+ cases detected. Statistically significant clustering for MTB positivity (Moran’s I: 0.09) and abnormal chest X-rays (Moran’s I: 0.36) ratios was identified within UCs in Karachi. Clustering of UCs with high MTB positivity were identified in Karachi West district. Clusters of camp locations with high MTB+ ratios were identified in Karachi South and Karachi West districts and in several locations in the north and eastern peripheries of the city. ConclusionStatistically significant spatial variation was identified in yield of bacteriologically positive TB cases and in abnormal CXR through active case-finding in Karachi. Cost-effectiveness of active case-finding programs can be improved by identifying and focusing interventions in hotspots and avoiding locations with no known TB cases reported through routine surveillance.

Background Achieving universal health coverage (UHC) and reduction in out of pocket (OOP) expenditures on health, is a critical target of the Sustainable Development Goals (SDG). In low-middle income countries, micro-health insurance (MHI) schemes have emerged as a useful financing tool for laying grounds for Universal Health Coverage. The aim of this study was to provide evidence for designing a feasible health insurance scheme targeted at urban poor, by exploring preferences for an insurance benefits package and co-payments among women from low-income households in Karachi, Pakistan. Methods This was a descriptive cross-sectional study, conducted using household surveys between July–August 2015. A total of 167 female beneficiaries of Benazir Income Support Programme (BISP), a large-scale cash transfer scheme targeted at low-income households, were recruited in Karachi through a mix of convenience and snowball sampling. Hypothetical insurance benefits packages for a prospective health insurance scheme were formulated to capture respondents’ preferences for health insurance benefits package and co-payments. All data was analyzed using Stata (version 13). Results Respondents reporting expenditure on OPD and hospitalization in the last 2 weeks were 93.4 and 11.9% respectively. The highest median expenditure was incurred on medicines. Out of the proposed benefits package, a majority (53%) of the study participants opted for the comprehensive benefits package that provided coverage for emergency care, hospitalization, OPD consultation, diagnostic tests and transportation. For the co-payment plan, 38.9% participants preferred no co-payments that is 100% insurance coverage of medicines followed by hospitalization (25.9%). Nearly half of the respondents (49.4%) chose outpatient consultation for 50% co-payment. A majority of the participants (65.3%) agreed to 100% co-payment for the transportation cost. Conclusion Health insurance schemes can be introduced in urban areas, against collection of micro-payments, to prevent low-income households from facing financial catastrophe. A comprehensive benefits package covering emergency care, hospitalization, OPD consultation, diagnostic tests and transportation, is the most preferred among low-income beneficiaries.

We describe gender-based differences in a community-wide TB screening programme in Karachi, Pakistan, in which 311 732 individuals were screened in mobile camps using symptom questionnaires and van-mounted digital chest X-ray, between 1 January 2018 and 31 December 2019. Only 22.4% (69 869) of camp attendees were women. Female attendees were less likely to have sputum collected and tested (31.5% (95% CI 30.4% to 32.7%) vs 38.5% (95% CI 37.6% to 39.1%)) or to initiate TB treatment (75.9% (95% CI 68.1% to 82.6%) vs 82.8% (95% CI 78.9% to 86.2%)), when indicated. Among the participants, the age-standardised prevalence of active TB was higher among women (prevalence ratio 1.4, 95% CI 1.1 to 1.7). These findings underscore the importance of integrating gender into the design and monitoring of TB screening programmes to ensure that women and men benefit equally from this important intervention.

Objectives To assess spending by beneficiaries of Benazir Income Support Programme on monthly food commodities, and contribution of the cash grant programme on purchase of nutritious foods. Methods The descriptive cross-sectional survey of households enrolled in the Benazir Income Support Programme was conducted during July and August, 2013, in Matiari district of the Sindh province of Pakistan. Monthly household food expenditure on food commodities and use of the cash grant on type of food purchased was assessed through structured interviews of the beneficiaries. Results were computed in 2013 Pak rupees and converted to 2018 United States dollar. Women beneficiaries were also interviewed on decision-making regarding the use of the cash grant and on household food expenditure. Results The survey comprised 421 households. with a mean monthly expenditure on food of Rs 7,577, r 80.73 dollars. Women made decisions on food spending in only 135(32%) households, but in 235(56%) households, women were the primary decision-makers on cash grant spending. Conclusions Unconditional cash grant did not meaningfully translate into the purchase of nutritious foods even though it played an important role in increasing women's agency.

Background The rising co-epidemic of tuberculosis (TB) and diabetes mellitus (DM) is a challenge for constrained health systems in low and middle-income countries. Diabetes is a known risk factor for tuberculosis and associated with poor tuberculosis treatment outcomes, while tuberculosis is associated with worsening glycemic control. We investigated the performance of bi-directional TB and DM case finding approaches through a private-sector engagement model in Karachi, Pakistan. Methods Between July 2016 and July 2018, private health care providers were engaged to generate referrals for bi-directional TB and DM screening at private diagnostic and treatment centers in Karachi, Pakistan. Individuals diagnosed with TB underwent glycated hemoglobin (HbA1c) testing at the time of anti-tuberculous treatment initiation and at three -month follow up stage. All individuals with a history of diabetes or random blood sugar of greater than 200 mg/dl were screened for TB using a chest X-ray and Xpert MTB/RIF. Results A total of 6312 persons with tuberculosis were tested on HbA1c at treatment initiation, of whom 1516 (24%) were newly diagnosed with DM. About one third of those with HbA1c in the diabetic range (≥ 6.5%) at baseline were found to have a normal HbA1c ( 200 mg/dl, underwent chest x-ray and Xpert MTB/RIF testing, with 321 (13.4%) known and 54 (3.8%) new diabetics respectively identified with tuberculosis. Conclusion This study demonstrates a high yield of TB and DM through bidirectional screening and the feasibility of engagement of private sector in finding missing cases of tuberculosis and diabetes. Given the high prevalence of undiagnosed DM in individuals with TB tuberculosis patients, there is a need to scale-up DM screening within TB programmes. Increased awareness of the high risk of TB among individuals with DM is needed among private health providers and screening for TB among diabetics should be strongly considered.

SETTING: Pakistan ranks fourth among the countries with a high burden of multidrug-resistant tuberculosis (MDR-TB), with only 19.2% of the 15 000 estimated incident cases being notified. Increasing treatment coverage for MDR-TB is a key priority for Pakistan's National Tuberculosis Programme. The World Health Organization recommends the use of the Xpert® MTB/RIF assay as the first-line diagnostic test for individuals with presumed TB. OBJECTIVE: To describe a multifaceted case-finding intervention targeting public and private sector health care facilities that used the Xpert assay as a frontline diagnostic test for individuals with presumptive TB, in Karachi, Pakistan, and its impact on case notifications of MDR-TB. DESIGN: Cross-sectional study. RESULTS: A total of 51 168 individuals were tested using Xpert, of whom respectively 7581 and 1534 people were diagnosed with TB in the public sector (reverse public-private mix) and private sector (social business model) arms; 574 (6.3% of all TB cases) were identified as having rifampicin (RMP) resistance. A total of 517 (90.1%) people with RMP-resistant TB (RR-TB) identified through the project were initiated on second-line treatment. The intervention resulted in 194 additional cases of RR-TB, an increase of 43% over the baseline. CONCLUSION: This project, one of the largest Xpert testing programmes conducted at city level, resulted in significantly increased detection and treatment of MDR-TB.

Background: In Pakistan, structured guidelines for hospital infection control and prevention are deficient in most public sector facilities. There is dearth of literature available on management of hospital-care acquired infections and related issues. This study aims to understand infection control management as a proxy measure for quality of health care provided at a public sector tertiary care hospital in Karachi, Pakistan. In this study, we identify barriers to implementation of infection control measures and highlight key areas for quality improvement. Methods: A cross sectional study was carried out in 2008 using qualitative research methods. In-depth interviews were conducted with hospital staff belonging to three different management tiers. Results: There was lack of a centralized documented infection control policy, structure or management hierarchy in the hospital. The infection control mechanisms were managed at the individual ward level depending upon the interest of the individual Head of the Department. Lack of well-defined systems for human resource and financial management, resource allocation, documentation, communication, monitoring and evaluation for infection control further augmented the problem. Conclusion: Based on the results of this study, it is evident that quality infection control mechanisms must be organized and controlled at the hospital level not at the individual ward level. Human resource recruitment and training, budgetary allocation and designing of communication channels specific to infection control are needed at this tertiary care hospital. This is the first study to understand the management perspective for hospital infection control using 7S McKinsey framework of management in the largest tertiary care public sector hospital in Sindh.

Predictors of smear non-conversion at baseline can help identify cases at risk for failure of tuberculosis treatment. Retrospective data for smear-positive Category 1 patients in Karachi, Pakistan, was analyzed. Predictors of sputum conversion were determined using multiple logistic regression with sputum conversion as outcome variable and patient demographics, baseline weight, baseline sputum smear grade, case-finding approach as explanatory variables. Age ≥35 years, baseline sputum grade of 3+ were significantly associated with predicting sputum smear positivity at month 2 of treatment. Monitoring compliance to TB treatment should be considered amongst older patients and those with a high sputum grade at baseline. Keywords: Determinants, Non-conversion, TB, Treatment, Pakistan

Objective: According to guidelines, a patient who is sputum smear positive after 5 months of treatment is declared as treatment failure. The objective of this study was to determine predictors of treatment failure at 5 months of treatment among bacteriologically positive pulmonary TB patients diagnosed in Pakistan. Methods: We analyzed retrospective treatment and follow-up data from 1053 pulmonary TB patients, diagnosed on the basis of Xpert MTB/RIF test at baseline, registered at 60 private health care centers “Sehatmand Zindagi Centers” across Pakistan from July 2017 to June 2018. Statistical analysis were carried out using Stata/IC 12 (College Station, TX: StataCorp LP). Predictors of treatment failure were determined using multiple logistic regression with sputum conversion as the outcome variable and patient demographics, baseline weight, MTB burden on Xpert at baseline and month 2 sputum smear grade as the explanatory variables. Results: A total of 1105 patients diagnosed with pulmonary TB were analyzed, of which 549 (49.7%) were males. A total of 16 (1.5%) patients were smear-positive after month 5 of treatment, of which 4 patients tested positive for Rifampicin resistance when re-tested on Xpert MTB/RIF. Sputum grade of 3+ at 2 month of treatment was strongest predictor of treatment failure in the final adjusted model for 5 month smear positivity. Age >=35 years (aOR, 1.1, 95% CI: 0.36-3.34) and medium to high MTB burden at baseline (medium aOR 1.23, 95% CI: (0.32-4.73, high aOR 2.36 (95% CI 0.63-8.79) was positively associated with predicting treatment failure. Conclusion: Sputum grade at 2 month follow up, age and MTB burden at baseline are important predictors of failure.

Objective: Pakistan is ranked fifth among high Tuberculosis (TB)-burden countries. Globally, up to 25% of all TB burden may be accounted for TB cases in prisons. Unfavorable conditions of prison and stress coupled with inadequate medical access contributes to a higher risk of developing and spreading TB with poor treatment outcomes. The aim of this study was to estimate the yield of TB among the inmates screened through an active case finding approach in a prison of Karachi, Pakistan. Methods: Between September 2017 to December 2018, 57 mobile X-ray screening camps were conducted in “District Prison Malir, Karachi”. All prisoners were screened through computer aided detection for TB (CAD4TB) on chest X-rays. A CAD4TB cut-off of 70 was used to detect abnormal X-rays. Sputum was collected for Xpert testing from TB presumptive prisoners and a medical officer evaluated for clinical TB. Results: A total of 6,527 prisoners were screened for TB, of which 470 had abnormal x-ray. Xpert tests were run on 374 sputum samples, 17 were MTB positive and 100 prisoners were clinically diagnosed and registered for anti-tuberculous therapy. The TB yield was 1.8% out of screened prisoners and 24.9% out of all presumptives. (Table 1.) Conclusion: Active screening results in substantially high TB yield among prisoners. Screening for TB and ensuring treatment success among TB patients in the prisons in a high TB burden country is integral to TB control in the country.

There is a growing interest in the automated analysis of chest X-Ray (CXR) as a sensitive and inexpensive means of screening susceptible populations for pulmonary tuberculosis. In this work we evaluate the latest version of CAD4TB, a commercial software platform designed for this purpose. Version 6 of CAD4TB was released in 2018 and is here tested on a fully independent dataset of 5565 CXR images with GeneXpert (Xpert) sputum test results available (854 Xpert positive subjects). A subset of 500 subjects (50% Xpert positive) was reviewed and annotated by 5 expert observers independently to obtain a radiological reference standard. The latest version of CAD4TB is found to outperform all previous versions in terms of area under receiver operating curve (ROC) with respect to both Xpert and radiological reference standards. Improvements with respect to Xpert are most apparent at high sensitivity levels with a specificity of 76% obtained at a fixed 90% sensitivity. When compared with the radiological reference standard, CAD4TB v6 also outperformed previous versions by a considerable margin and achieved 98% specificity at the 90% sensitivity setting. No substantial difference was found between the performance of CAD4TB v6 and any of the various expert observers against the Xpert reference standard. A cost and efficiency analysis on this dataset demonstrates that in a standard clinical situation, operating at 90% sensitivity, users of CAD4TB v6 can process 132 subjects per day at n average cost per screen of \$5.95 per subject, while users of version 3 process only 85 subjects per day at a cost of \$8.38 per subject. At all tested operating points version 6 is shown to be more efficient and cost effective than any other version., Published in Scientific Reports

Background Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting. Methods We conducted a systematic search for published literature using the search terms “Community based health insurance AND developing countries”, “Micro health insurance AND developing countries”, “Mutual health insurance AND developing countries”, “mutual OR micro OR community based health insurance” “Health insurance AND impact AND poor” “Health insurance AND financial protection” and “mutual health organizations” on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization. Results Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns. Conclusion Our review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators.