KEY EXPERIENCES AND ACHIEVEMENTS
The Association, in collaboration with its national and international partners, has been working on various research, development and implementation activities within and outside Pakistan. The encouraging achievements during last about fifteen years include:
A. Research for better health interventions
A randomized controlled trial of interventions to address the “decision” and “access” delays to the safe birthing services in Pakistan .
The project (October 2010 – May 2013) is being funded by Research and Advocacy Fund (RAF). The Association, being lead partner, is working jointly with Nuffield Centre for International Health and Development (UK), and Save the Children Federation USA. The main objective of the trial is to compare the effectiveness and feasibility of interventions to address the “decision” and “access” delays to the utilization of safe birthing services in Pakistan . The trial implementation in two selected districts of Pakistan (Jhang and Khanewal), will include strengthening 21 emergency obstetric and neonatal care (EmONC) facilities and enabling lady health visitors (110), lady health supervisors (130), and lady health workers (2100) for addressing the first two delays to safe birthing services. A total of 75,600 pregnancies will be registered and offered services as per trial protocols. The qualitative and economic studies would help to understand the trial results and the measures required to replicate these interventions under program circumstances.
A randomized controlled trial of tobacco cessation interventions in Pakistan .
The three-year project is being funded by International Development Research Center (IDRC) Canada . The Association, being the lead implementing partner, is working jointly with Nuffield Centre for International Health and Development (UK), and Tobacco Control Cell Pakistan . The main objective of the trial is to compare the effectiveness and costing of counseling and therapeutic agent use for tobacco cessation among patients suspected to have TB. A total of 33 health facilities have been strengthened, in two selected districts of Pakistan (Jhang and Sargodha ), for participation in the trial. A total on 1650 smokers will be registered and offered cessation services as per trial protocols. The qualitative and costing studies would help to understand the trial results and the measures required to replicate these interventions under program circumstances.
A randomized controlled trial to compare the effectiveness of health worker supported and family member supported DOT with an unsupervised treatment under operational conditions.
The randomized-controlled trial was conducted to assess the effectiveness of the direct observation component of the DOTS strategy for tuberculosis control under operational conditions in Pakistan . There were three trial sites that were selected to provide tuberculosis services, strengthened according to WHO guidelines for the purposes of research. A total of 497 adult patients with new smear-positive tuberculosis were randomized into three treatment options. 170 patients were assigned DOTS with direct observation of treatment by health workers; 165 were assigned DOTS with direct observation by family members; and 162 were assigned self-administered treatment. Every trial patient was provided the NTP recommended standard daily short-course drug regimen for eight months i.e. 2 months of isoniazid, rifampicin, pyrazinamide and ethambutal, followed by 6 months of isoniazid and ethambutal. The main outcome measures were cure and treatment success (i.e. cured plus treatment completed). Main analysis was by intention to treat. There was little difference in the distribution of socio-demographic, economic and access to health services factors of enrolled patients by trial group and study area. Within the strengthened tuberculosis services, the health worker direct observation, family member direct observation and self-administered treatment strategies gave very similar outcomes, with cure rates of 63%, 55% and 62% respectively, and treatment success rates (cured plus treatment completed) of 66%, 63% and 65% respectively. Women patients had significantly higher cure rates than men (71% and 49% respectively). The service strengthening was found to improve the cure and treatment success rates. A scientific paper was published in Lancet (2001).
Two qualitative studies , one preceding and one following the trial, on factors affecting the compliance of TB patients.
Qualitative Study (Preceding Trial) e xplored the extent to which factors related to individuals, the care provision process, and the cultural context influence the behavior of tuberculosis patients attending TB clinics in rural Pakistan , and examined the effects of disease on their personal lives. A total of 36 patients attending 03 TB treatment clinics were interviewed in depth. These patients were stratified by stage of treatment (treatment proceeding, treatment completed, default), sex and by rural/urban status. Results indicate that the majority of patients were very poor, but nonetheless initially chose to attend private practitioners. Normally their disease was correctly diagnosed as tuberculosis only after repeated visits to a succession of health care providers. Patients' knowledge about their disease was limited, and doctors gave incorrect or only very limited health education. Most patients reported dissatisfaction with care provided. Almost all patients reported problems with access to treatment, both in terms of time and money; this was particularly true of women, whose freedom to travel in Pakistan is limited. Potential causes of default appeared to be more closely linked to deficiencies in treatment provision rather than patients' unwillingness to comply. Largely because of a perception that TB was incurable, respondents were generally unwilling to disclose that they were undergoing or had undergone TB treatment. For reasons related to confidential access to treatment, this could lead to default, perpetuating the perception of incurability, and hence causing a vicious circle. For TB programmes to be successful in Pakistan it is essential that this circle is broken; and this can only be done through provision of good quality TB care and education to improve the population's understanding that TB can be cured. In addition, patients' unwillingness to disclose to health care providers that they had already received previous treatment meant that many patients were prescribed incorrect treatment regimes, potentially leading to the emergence of drug-resistant TB. In common with other researchers' findings, no clear differences were found between those who had completed treatment and those who had defaulted from treatment. This study was performed to provide information to assist the researchers to design potential TB treatment delivery strategies, and has proved invaluable for this purpose. A scientific paper was published in Social Science and Medicine (Jan, 2000, 50 (2); 247-54.
Qualitative Studies (during & Post) randomized controlled trial was carried out in Pakistan in 1999 to establish the effectiveness of the direct observation component of DOTS programmes. It found no significant differences in cure rates for patients directly observed by health facility workers, community health workers or by family members, as compared with the control group who had self-administered treatment. The social studies were carried out during and after this trial, to explain these results. They consisted of a survey of all patients (64% response rate); in-depth interviews with a smaller sample of different types of patients; and focus group discussions with patients and providers. One finding was that of the 32 in-depth interview patients, 13 (mainly from the health facility observation group) failed to comply with their allocated DOT approach during the trial, citing the inconvenience of the method of observation. Another finding was that while patients found the overall TB care approach efficient and economical in general, they faced numerous barriers to regular attendance for the direct observation of drug-taking (most especially, time, travel costs, ill health and need to pursue their occupation). This may be one of the reasons why there was no overall benefit from direct observation in the trial. Provider attitudes were also poor: health facility workers expressed cynical and uncaring views; community health workers were more positive, but still arranged direct observation to suit their, rather than patients', schedules. The article concludes that direct observation, if used, should be flexible and convenient, whether at a health facility close to the patient's home or in the community. The emphasis should shift in practice from tablet watching towards treatment support, together with education and other adherence measures. A scientific paper was published in peer-reviewed journal “Health Policy and Planning” (2006; Volume 20, Issue 6, Pg: 354-365).
An economic study to assess cost implications of DOTS to the health services and the patients and their families.
The study was conducted alongside a clinical trial at three sites in Pakistan to establish the costs and effectiveness of different strategies for implementing directly observed treatment (DOT) for tuberculosis. Patients were randomly allocated to one of three arms: DOTS with direct observation by health workers (at health centres or by community health workers); DOTS with direct observation by family members; and DOTS without direct observation. The clinical trial found no statistically significant difference in cure rate for the different arms. The economic study collected data on the full range of health service costs and patient costs of the different treatment arms. Data were also disaggregated by gender, rural and urban patients, by treatment site and by economic categories, to investigate the costs of the different strategies, their cost-effectiveness and the impact that they might have on patient compliance with treatment. The study found that direct observation, by health centre-based health workers, was the least cost-effective of the strategies tested (US$310 per case cured). This was an interesting result, since this is the model recommended by the World Health Organization and International Union against Tuberculosis and Lung Disease. Attending health centers daily during the first 2 months generated high patient costs (direct and in terms of time lost), yet cure rates for this group fell below those of the non-observed group (58%, compared with 62%). One factor suggested by this study was that the high costs of attending may be deterring patients, and in particular, economically active patients who have most to lose from the time taken by direct observation. However, without stronger evidence of benefits, it was hard to justify the costs to health services and patients that this type of direct observation imposes. The self-administered group came out as most cost-effective ($164 per case cured). The community health worker sub-group achieved the highest cure rates (67%), with a cost per case only slightly higher than the self-administered group ($172 per case cured). This approach should be investigated further, along with other approaches to improving patient compliance. A scientific paper was published in Health Policy and Planning (2002, Volume 17; Issue 2, Pg: 178-186).
A qualitative study on the causes and the strategies to counter stigma associated with tuberculosis disease and its treatment.
The overall aim of the research study remained gather new empirical evidence and further theoretical understanding of the causes of TB associated stigma in Pakistan, It involved qualitative research methods (in-depth interviews and focus group discussions) and applied the grounded theory approach; an established and rigorous approach to developing theories through the process of qualitative data collection. Two sites in Rawalpindi district, one urban and one rural were selected for inclusion in this study and contextual information wa collected during the initial preparatory stage. Thereafter, 16 in-depth interviews & 01 focus group discussion and fifteen interviews were conducted in urban and rural site, respectively, using the theoretical sampling method. This provided sufficient rich, in-depth data from which to develop and refine theories on the causes of TB-related stigma, while also providing sufficient contextual information to enable an assessment of the likely applicability of the findings to other contexts.Of the sixteen in-depth interviews conducted in the urban site, five were with female TB patients, five were with male TB patients, four were with family members of TB patients and two were with health workers. The focus group discussion was conducted with a group of seven married female community members. Of the fifteen in-depth interviews conducted in the rural site, five were with female TB patients, five were with male TB patients, three were with family members of TB patients and two were with health workers. Six effects of stigma associated with TB and their explanations were found: Perceived hatred towards TB patients; Concealment of a diagnosis of TB to people outside the immediate family; Reduced marriage prospects, particularly for woman; Family tension and (the threat) of divorce, particularly for women; Financial disruptiveness of TB, particularly men of working age with dependents; Blame and guilt for TB infection.
- Evaluation of the Vitamin A supplementation pilot project in Pakistan (Micronutrient Initiative support).
The MI funded alternate Vitamin A supplementation strategy in three provinces of Pakistan (except Sind) was piloted by the UNICEF and the national programs, The piloting in 14 EPI priority districts was undertaken during August-September 2005. The VAS piloting relied mainly on coordinated efforts of three workers. The Lady Health Workers covered all eligible children (aged: 06 – 59 months) in their respective catchment areas. In non LHW areas the VAS coverage was through Vaccinators. The child health weeks, through community volunteers, were used for children living in areas not covered by LHWs and not reached by Vaccinators. Evaluation of this early piloting experience was conducted to inform the future strategies and operations for countrywide Vitamin A supplementation in post-NID era. This qualitative study was based mainly on record reviews, interviews and focus group discussions. The mapping of the VAS delivery and management arrangements and processes, was accomplished during the initial phase. This enabled the team to elaborate on information needs, select a set of indicators to study the context as well as processes, and outline the data collection sources and arrangements. The stakeholders identified for inclusion in the study were: three national programs (i.e. EPI, FP & PHC, and Nutrition), two technical partners (i.e. UNICEF and MI), and six randomly selected pilot districts in three provinces. In the programs and two technical partners, both national and provincial/regional level key informants were identified and interviewed. In case of EPI and FP&PHC programs the district and grass-root level staffs (i.e. Vaccinators and LHWs) were also included. The Executive District Officer (Health) and District Officer Health in each of six selected districts were interviewed. Community volunteers in two of the selected pilot districts were also included in the study. The main recommendations included: Continue partnership approach to achieving optimal VAS coverage; Establish a Technical Working Group to spearhead and steer the process of identifying and addressing the development needs for scaling up the VAS intervention under routine program conditions; The refined set of interventions and strengthened arrangements for VAS implementation under routine program conditions to be further implemented and evaluated on a small scale before countrywide scaling-up through public sector programmes. The evaluation may cover effectiveness, feasibility and cost analysis ; The programs to consider getting public sector funds allocated for VAS intervention in particular implementation cost.
Assessment of reasons constraining compliance with DOTS regimen for treatment and control of TB by the tertiary level and private sector hospitals (DFID-TAMA supported)
The qualitative study was to understand the current situation and accordingly map further actions required for effective involvement of teaching and private hospitals in implementation of DOTS. A two-stage sampling was done. In the first stage three districts were selected in southern, central and northern part of the province. In the second stage, a sample of three public sector teaching and three private sector hospitals (both teaching and non-teaching) was included in the three selected study districts. A fourth private hospital with DOTS in place was added to enrich the private sector perspective. A set of individuals/positions was identified for key informant interviews in each of the six selected hospitals and each of the three selected district health offices. A separate checklist was drafted for each type of key informant, and interviews were conducted through PTP facilitation. In some of these hospitals where DOTS was found to be already operational, the patient registration and follow-up data were reviewed. The collected qualitative data was transcribed, collated and interpreted and a draft finding report was then shared and enriched in a provincial level consultation with the stakeholders. The participants helped to enlist ten priority program issues, and then identify, appraise, select and plan strategic options for each of the enlisted issues. The study findings have been described under seven key perspectives i.e. program, board executive, hospital manager, clinician, laboratory staff, district manager, and patient . Recommendations: TB Control Program, through a national level consultative exercise, to reaching an agreement on the case management protocols for patients attending the teaching and private hospitals; TB Control Programme, assisted by technical partners, to address the identified development needs for involving the teaching and private hospitals in TB care process; TB Control Programme, assisted by technical partners, to pilot and evaluate the guidelines, tools and materials to be developed for an enhanced DOTS implementation in teaching and private hospitals; TB Control Programme, with the help of partners, to plan and arrange for the countrywide scaling up of these revised guidelines and materials.
A study to assess the capabilities and potentials of 104 government health facilities , in four districts of Pakistan , to offer standardized care to tuberculosis patients.
The study was done as a baseline to inform the implementation of the TB-DOTS randomized controlled trial in Pakistan .
An evaluation of the National TB program guidelines and training materials , before countrywide scaling-up (DFID supported).
The NTP materials i.e. programmatic guidelines and training materials was used in eight early implementation districts. The evaluation, intending to inform the review & revision of material before scaling up, was designed and conduct by the jointly by the NTP, ASD and the concerned districts in collaboration with Nuffield Center for International Health & Development, UK. During the process, guidelines for health workers & managers and training modules for doctor, paramedics, CHW, supervisor and manger were evaluated. The methodology adopted included participants observation and trainees assessment (OPSE) through 60 trainee doctors and 130 trainee paramedics and 100 community Health workers (CHWs) followed by group discussion with mangers, supervisors, doctors, paramedics and CHWs. The study indicated a high level of involvement from trainers and 100% of trainees completed their course; trainees reported that the course was interesting, practical and relevant to the job; trainees reported that the course was comprehensive, easy to conduct and relevant to the context. The performance evaluation of 1) Health Worker: focused on use of desk guide and case management practices, 2) Managers: evaluated applicability & plausibility of district TB plans and supervision and monitoring practices and utility of the related observation/findings for proper management decisions. Recommendations : Revise the Pakistan version of guidelines and training materials; develop context sensitive patient education materials; field test the draft guidelines for diagnosing smear negative TB; develop guidelines for managing children with suspected TB; and develop and disseminate the generic version of district implementation planning material.
An assessmen t followed by strategic planning for introducing TB care (DOTS) in the countrywide network of Anti-TB Association clinics (World Bank supported).
The purpose was to undertake a situation analysis and develop strategies to strengthen the diagnosis and treatment of tuberculosis, by introduction of DOTS in Anti-TB Associations in Pakistan . The central and provincial Anti-TB Associations, the district Anti-TB Associations and TB clinics in each province have been assessed. The method-mix systematic approach to the assessment of situation was comprised interviewing the key informants (including patients), reviewing the records, administering the questionnaire and visiting the facilities. A set of specially designed tools were developed and used for collecting the required data. The situation analysis revealed province-specific strengths and weaknesses in the organization and functioning of Anti-TB Associations in four provinces. The findings in each province provided the base for strategy formulation exercise, carried out at the provincial and national levels. The provincial consultations in four provinces were held to discuss the main findings of the situation analysis and formulate context sensitive strategies for introducing DOTS, in the Anti-TB Association facilities in the province. The Anti-TB Association and the TB Control Programme personnel attended the provincial consultations. The four provincial consultations were then followed by a national workshop to formulate an agreed national strategy for implementing DOTS through public-private partnership between the Anti-TB Association and the TB Control Program Pakistan . Key individuals from the Anti-TB Associations (provincial and district) and TB Control Programme (national and provincial) attended the national workshop. The concluding session, chaired by the federal Secretary Health, was also attended by representatives of the development partner agencies including World Bank, DFID, JICA, European Commission, GTZ etc. The national workshop participants made some recommendations : Pakistan Anti-TB Association to adopt & implement policy guidelines of the NTP; Strengthen the central body of the Pakistan Anti-TB Association for overall leadership; Enhance the managerial, R&D, resource generation and technical support capacity of the provincial Anti-TB Associations; Enhance the capacity of the district Anti-TB Associations; TB control program to facilitate the capacity building process through enhanced coordination and technical support; A capacity building project based on agreed strategies, to be formulated and submitted to an appropriate funding source (including GFATM).
Qualitative review : Training of non-public doctors in Philippines (IUATLD supported).
The Public private partnership development (PPP), a relatively new approach in TB control, with gradually accumulating experiences, is now a recognized priority for an effective TB control. In order to develop PPP, context sensitive training remains an important event. However to guide the development of standardized but flexible training packages for non-public sector, enhanced learning from the ongoing PPP initiatives remains essential. The purpose of this review was to design and conduct a qualitative review of PPP training experiences in at least one selected country i.e. Philippines, with the objectives to study the ongoing Philcat PPP training experiences in Philippines; to draw lessons for developing guidelines; and standardized package for DOTS training in PPP. The m ethodology employed included a qualitative review of experiences including the review of training materials; interviews with key informants; participation in a training event; visit to DOTS Centers; review of quarterly reports and visit to a medical school. The e xperience gained, in general, was that PPP was gaining momentum in Philippines and gradually expanding support from international partners including USAID, GFATM etc. The partnership development was being expanded also to individual practitioners with PhilHealth (insurance) encouraging PPP in TB care. However it was observed that training of supervisors and refresher training of care providers was not yet addressed. The salient concluding features were: Coordinated efforts of multiple public and non-Public partners required to achieve the results; Adapt the current training packages before scaling-Up within the country; evaluate more rigorously the training experiences in Philippines and other sites; international technical support to help the development of adaptable guidelines & training packages for PPP context; encourage wider sharing of training resources &experiences across the countries and the regions.
Development and validation of guidelines and training material for diagnosing smear-negative TB (through DFID support).
The objective of this DFID supported exercise was to develop and validate clinical guidelines for diagnosis of smear-negative pulmonary tuberculosis (TB) in developing countries with low-HIV prevalence. According to the methodology, diagnostic guidelines for smear-negative TB were developed. Clinical diagnoses based on these guidelines were then compared with sputum culture, chest X-rays and reports of an expert panel results. The guidelines achieved a sensitivity of 0.59 [confidence interval (CI) 0.46–0.66] and a specificity of 0.86 (CI 0.84–0.88) in diagnosing smear-negative TB. A total of 6.8% of patients who initially improved after a course of antibiotics were later confirmed to have TB. Clinicians detected an abnormal chest X-ray in 92% (CI 88–96%) and radiological signs of pulmonary TB in 98% (CI 94–100%) of cases conclusions Experience highlighted a number of dilemmas faced in developing, testing and implementing diagnostic guidelines in poorly resourced conditions. Using radiological criteria for TB and appropriate training can help in improving the diagnostic skills of primary care clinicians working in low-HIV settings with access to X-ray facilities. But a significant number of apparently smear-negative TB cases may in fact be smear positive and TB programs should focus on improving the quality of direct acid-fast bacilli microscopy. The value of an antibiotic trial is questionable due to the relatively large number of false negatives generated by this approach.
Searching the best treatment supporter for DOTS implementation in Pakistan (through DFID support)
Adherence to treatment regimens is pivotal to TB control. The establishment of stronger national programs to fight TB was enhanced at the international level by promotion of a universal five-pronged strategy, DOTS that ensures that infectious TB patients are identified and cured using standardized drug combinations. Treatment supporters observe patients as they swallow their drugs daily. Currently three types of treatment supporters i.e. CHWs, LHWs and CVTs are involved in providing directly observed therapy to the TB patients. This study of direct observation experiences in 12 districts was meant to provide further insight into treatment support processes and outcomes. The records of 2929 new smear positive TB patients registered at 43 hospitals (district and sub-district hospitals and one teaching hospital) in 12 districts of Punjab province during April 2004 and February 2005 were retrospectively reviewed. Each of these patients selected his/her option for observed intake of TB drugs. The observed treatment options included LHWs, CHWs, and CVTs. A combination of quantitative and qualitative study methods was used. Quantitative method was used to compare the treatment outcome results analyzed according to the treatment supporter chosen for the patient's while qualitative methods were used to assess the attitude and perception of patients, treatment supporters, and DOT facilitators. The results of this study show significantly better treatment success rate and lower default rates among patients supervised by Lady Health Workers and Community Health workers as compared to those on self administered therapy and those supervised by the community volunteers. This finding reflects that DOT can play important role in the treatment of TB patients in Pakistan . However, there is a strong need to consider implementation of more flexible approaches to direct observation that are responsive to patient's preferences and circumstances. This supplemented by alternate measures to promote adherence can be helpful in achieving the desired levels of treatment outcome. Conclusion: It is important to remember that ‘DOTS' is more than DOT alone. DOTS as a whole emphasize providing an efficient program, which is able to maintain and sustain high quality laboratory diagnostics, regular drug supplies and a well-trained cadre of health workers who are responsive to patient, needs. There is a need for close monitoring of adherence during first two months of treatment and importance of directing energies to those found at risk of poor treatment outcomes.
Study on experience of introducing fixed-doze-combination drugs (FDCs) in Pakistan (ongoing through DFID support).
Fixed dose combinations tablets (FDCs) are recommended for the treatment of tuberculosis by the World Health Organization so as to improve patient adherence and prevent the development of drug resistance, which is a major concern internationally. However loose-drug formulations (LDC) are still being used in many countries, including Pakistan . In order to assess whether and why intermediate and final treatment outcomes differ according to whether TB patients receive FDCs or LDCs, both quantitative and qualitative data were collected and analyzed. The treatment outcomes were taken from the TB registers. Qualitative data was from in-depth interviews with care providers, patients and managers, to explore TB case management practices, drug management practices and the perceptions of patients in FDC and LDC sub-districts. Apart from the supply of FDCs and LDCs, the districts used the same case management and program guidelines and materials implemented. The findings show that patient treatment outcomes (two month sputum smear conversion, and treatment success rates were significantly better in the FDC sub-districts. There was no significant difference found in the cure rates. The default and transfer out rates were lower in the FDC sub-districts. Qualitative data suggests that the improved outcomes are likely to be due simplified management, prescription and dispensing of FDCs and greater provider and patient preference for FDCs. Conclusions: In Pakistan FDCs give better treatment outcomes for TB patients. These findings of support the WHO recommendation for the use of fixed-dose combination tablets in all countries. Pakistan is now implementing FDCs in all districts (Un published).
- A study on molecular epidemiology of Mycobacterium tuberculosis in Pakistan (IUATLD Journal 2003).
- A study on external quality assurance ( EQA ) arrangements for strengthened AFB microscopy in TB Control Programme (with DFID support)
The core objectives of the study were to develop, implement and evaluate the guidelines and materials for functioning of District Laboratory Supervisor (DLS) at district level; to refine the guidelines and materials, in light of the study results, and assist the program to prepare for scaling-up; and to disseminate the results to a wider interest groups, within and outside Pakistan. The initial seven-month implementation of the district based EQA model, with 03 different DLS types, was studied prospectively in 06 selected districts during the period May-November 2007. Two main methods used for gathering quantitative and qualitative data for the study were record/document review and key informant interviews. In line with the international guidelines on EQA, three key set of operational innovations introduced in our EQA model were: a) DLS onsite rechecking of slides and technical support to the facility staff, and combining smear assessment and slide reexamination for quality assurance, b) DLS defined role in uninterrupted availability of laboratory reagents/supplies at diagnostic centers, c) DLS supervision delineated into administrative and technical components. Results: At 78 health facilities in six selected districts, a total of 47,011 slides were examined for AFB during the seven months period (i.e. May – November 2007). About 14.4% (6,774) of these slides were found positive for AFB. The slide positivity rate in these six districts ranged between 09% – 22%. the six selected districts, a total of 16,494 suspects were examined for AFB. About 19.9% (3,293) of these suspects were found AFB positive. The suspect positivity rate in these six districts ranged between 13% – 34%. In the six selected districts, a sample of 3,219 slides was reexamined for smear quality as well as results. The quality of smear preparation was found acceptable in about 79% (i.e. 2,541) of these slides. Qualitative data support the operational innovations in this study. The data revealed that District based external quality assurance, based on lot quality assurance method, can be effectively implemented with minimal additional technical and material inputs from the program. Conclusions: District based external quality assurance, based on a lot quality assurance method, can be effectively implemented with minimal additional technical and material inputs from the program. The program facilitation helps build mutually dependent and supportive role of district health office and the provincial reference laboratory for effective planning and implementing EQA related activities. The use of context sensitive guidelines, tools and training materials help operationalizing and scaling-up the agreed institutional roles
- A study on approaches for promoting the use of impregnated bed nets , through primary health care facilities and a network of community-based workers (TDR/WHO).
Malaria is one of the most serious and complex health problems facing mankind at present. Pakistan like many developing countries is faced with the immense problem of controlling this scourge. Keeping in view the prevailing situation it was considered imperative that various control strategies are explored in order to prevent the spread of this problem. The main emphasis now is on sustainable control programs that can be implemented in the context of primary health care (PHC) systems through active community participation . A research project of 01 year duration was designed to develop potentially feasible and acceptable approach(es) for the social marketing of impregnated bed nets in a rural population, through PHC outlets. The specific objectives of the project were related to (a) enhance the understanding of the factors influencing the use of impregnated bed nets; (b) identify specific marketing approaches, acceptable to the key stakeholders, and (c) pilot testing the identified approach(es). The research project comprised of 03 phases: 1). Context analysis and strategy formulation, 2). Operationalization and field testing of strategy, 3). Evaluation and reporting. The joint executing partners were: 1). Association for Social Development (ASD), 2). Primary Health Care Outlets (PHC) of the pilot site and their community-based health workers with the assistance of District Health Office Islamabad, 3). Directorate Malaria Control Islamabad , and 4). Community-based organization(s) CBO, in project site.
- A study on “role of contractual arrangements in improving health sector performance in Pakistan ” A multi-country regional study by WHO EMRO.
The scope of this study was to undertake situation analysis, including exploratory case studies, and document experiences as well as recommendations for outsourcing of publicly financed health services to private sector organizations in Pakistan as a part of regional initiative to develop an evidence-based regional strategy on public private partnership in health in the Eastern Mediterranean Region (EMR). The purpose of the qualitative study was to review the arrangements and experiences of “contracting out” and furnish recommendations for future programming; Assess the environment and overall capacity of providers and purchasers in terms of contracting out health services to private sector, its implementation as well as evaluation; Assess the arrangements and experiences of a project/program in health that has taken up contractual arrangements as an implementation modality; and discuss findings on contractual arrangements with the key stakeholders to inform the study recommendations. A mix of methods to address the multiplicity and complexity of dimensions of the contractual arrangements for health services i.e. Literature/document Review, Focus Group Discussions (FGDs), Key Informant Interviews, Case Study, Consensus Building Workshop. R ecommendations: A further study covering the quality, effectiveness, cost-analysis, efficiency and equity aspects of the services provided through contractual arrangements; Assess the needs and plan capacity building of public and private sector partners for effective working under contractual arrangements; Develop transparent processes and tools for awarding and managing contracts; Encourage documentation and dissemination of experiences with contractual arrangements in the country/region.
- Evaluation of program monitoring plans and systems for GFATM Round-II projects (three) in Pakistan (for KPMG).
The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) initially signed a two-year phase-I tuberculosis grant agreement for US$2,248,800 with the Ministry of Health, Government of Pakistan. The tuberculosis component had three main objectives covering enhanced case management in private sector, strengthened referral of complicated adult TB cases and children with suspected TB, and behavior change communication. The National AIDS Control Program was nominated as Principal Recipient (PR) for this grant. Review of relevant documents and informant interviews with key stakeholders' forms the basis of observations and recommendations included in this report. Despite encouraging efforts to put in place the arrangements for optimal use of GFATM grant, monitoring and evaluation plans and arrangements still required further attention for achieving the desired results. During the evaluation, main o bservations where urgent attention was required included: a) Updating the M&E Plan in areas of M&E roles and responsibilities, methods, budget detailing, and partners' training, and b) Enhancing PR M&E capabilities in areas of staff number and expertise, monitoring guidelines and instruments, and role of CCM M&E Committee. The key recommendations include: Revision/updating M&E plans and data collection requirements; Tailor-made skill-enhancement training of PR, CCM and sub-recipient staff on GFATM related M&E instruments and operations; CCM and PR need to arrange ongoing expert technical support for the sub-recipients in light of GFATM requirements; The M&E human capacity requirement of the Central PR Unit need be further reassessed, and appropriate measures to be taken; Budgetary requirements for PR and TB Control Program M&E inputs and activities need be estimated in-detail, CCM to take appropriate measures required for operationalizing the CCM M&E Committee; PR is encouraged to reschedule (i.e. quarterly rather than once every second month) and redesign its periodic monitoring meetings with GFATM sub-recipients; PR and CCM need to ensure more planned field visits, on regular basis, according to an agreed M&E guidelines; TB Control Program is encouraged to arrange periodic systematic evaluation of the current monitoring arrangements and practices
- An illustrative study on child sexual abuse in Pakistan .
Sexual abuse, being a tabooed subject in Pakistan , is rarely discussed in most households. Due to this fact very few researches have been conducted in Pakistan . The purpose of the study was to explore information about the issue of CSA in Pakistan . The method used to collect the data./information was through self-administered questionnaire comprising of both open and close ended questions mainly focusing on the social profile, knowledge of CSA, incidence of abuse (if any), feelings and effects of abuse. The study was cross–sectional and information collected from 300 school children studying in class 8-10 both girls and boys of the schools (urban/rural) from Islamabad and Rawalpindi. The findings of the study showed that most of the children were not aware with the term “Child Sexual Abuse. The statistics reflected that 17% of the respondents were abused with one in every five boys and one in every seven girls becoming a victim of sexual abuse. The types of abuse varied from verbal sexual abuse to rape and anal sex. The study conclusively determines the fact that child sexual abuse is a phenomenon that is prevalent in our society and offers some recommendations by showing the dire need to address this issue. It highlights the significance of creating awareness among various sections of our society and the need to conduct large scale studies to identify the magnitude of the problem and to devise strategies to address the issue of CSA.
- Study on public-private partnership model s and experiences in Pakistan (DFID support).
The study was intended to review the experience of operationalizing the PPM development guidelines and training materials. The proposed study was also meant to find out to what extent the case management and organizational operations and tools have been feasible, effective and acceptable to providers as well as patients. This prospective study (January 2009-July 2010) studied the early implementation experiences of newly developed guidelines and training materials for enhanced public-private partnership in TB control. Four selected intervention districts and a control district in Punjab were selected for the project and the guidelines and training materials assessed included partner identification, enabling private providers, and enabling private laboratories. The study also covered two main areas: a) evaluation of training of doctors, b) feasibility, effectiveness and acceptability of the program operations and tools. The training events for doctors (4) and laboratory technicians (4) were evaluated. Presently, the data consolidation and analysis is in progress.
An evaluation of the National Malaria guidelines and training materials for countrywide scaling-up (DFID support).
Early diagnosis and prompt treatment of malaria cases is one of the key components of the national Roll Back Malaria (RBM) strategy. To standardize malaria case management practices, the malaria control program and its partners (ASD/Nuffield) developed context-specific operational guidelines and materials. These guidelines and materials were designed to be used for countrywide implementation of malaria case management strengthening in Pakistan . The aim of this prospective study was to review the experience of implementing context-specific malaria guidelines and training materials, in four selected districts of Pakistan . Methods: This multi-method study was conducted during the period May 2007 to November 2007 . The newly developed guidelines and materials on malaria microscopy, case management, and monitoring, were piloted in four selected districts of Punjab . Malaria performance data on selected inputs and case management indicators were compiled monthly on facility monitoring forms. The qualitative and quantitative data was used for assessing the feasibility and effectiveness of various intervention components. Microsoft Excel was used for data entry and SPSS for analysis. The qualitative data was transcribed and interpreted. Results: There has been a significant change in malaria diagnosis practices. A significant increase in the proportion of outpatients being referred to the laboratory for malaria parasite (MP) testing was observed. Overall, the number of MP slides being examined at microscopy centers has significantly increased in post intervention as compared to pre-intervention period. The proportion of MP slides found positive in these four districts ranged from 1% to 3%. This indicates a positive change in malaria case management practices. Conclusions: Context specific case management guides and materials were field-tested, revised, adopted and scaled-up by the malaria program Pakistan . As a result there was a significant increase in requests for parasitological confirmation of suspected cases. There was a significant increase in the number of slides examined and those found positive during post intervention as compared to pre-intervention period. This research indicates that the use of planning, monitoring and case management guidelines and tools do help in improving the quality of malaria care delivery through primary care facilities.
- Assisted data collection for study on district level variation in immunization coverage in Pakistan (World Bank support).
The purpose of this 3 weeks assignment (June 15 th to July 5 th 2003) was to determine the strengths and weaknesses of the EPI program at the district level to assess factors determining variation in immunization coverage. The Association for Social Development was the consultant organization responsible for facilitating a defined set of specific tasks: Assist in undertaking district level survey in 91 districts across Pakistan, by coordinating and logistically managing the study specially the training workshop of the interviewers and the data collection process; Identify and recruit 13 interviewers for data collection; Assist in organizing a one-day training workshop for 13 interviewers to administer the survey instrument; Dispatch these interviewers to the field to administer the interview of the executive district officer (health) and district EPI coordinator and collect data at the district level; Collect the interviewed questionnaire and dispatch the questionnaire to the World Bank Consultant; and Manage the cash disbursement from the World Bank to the Federal EPI cell and keep a record of the major payments i.e travel and per diem, daily fee, stationary etc. The survey instrument was a short questionnaire, easily administered in less than half an hour. It included questions on the presence of EDO (H) and district EPI coordinator, the existence of an EPI coverage plan, staff turnover, the presence of EPI district supervisors, the extent of documented supervision work, incentives for staff, the training and presence of field workers, and available infrastructure
- A study on strengthening internal and external linkages at teaching hospitals for better TB care delivery.
Pakistan has a countrywide network of more than thirty teaching hospitals as well as three hundred private hospitals. These hospitals, due to difference in organizational arrangements, pose different technical and management challenges for initiating and sustaining DOTS. The Programme and its partners have gained preliminary experience of implementing DOTS in few teaching hospitals. This adhoc implementation has been followed by a study to understand the context of DOTS implementation in teaching hospitals . A FIDELIS project support was made available to the Programme and its partner for implementing DOTS in sixteen selected teaching hospitals. However, context-adapted guidelines and materials were required for advocacy, implementation planning, internal monitoring, and external linkages activities at these hospitals. The COMDIS inputs have been used to develop and evaluate a set of guidelines and materials for implementation of DOTS in these teaching hospitals. This early implementation (through FIDELIS support) and evaluation (through COMDIS inputs) has been used to refine the guidelines and tools for scaling-up (through GFATM inputs) in other teaching hospitals .
B. Development for strengthened disease control programmes B.1 Policy and strategic development
- Development of four provincial strategic plans and the revision of national strategic plan for countrywide TB-DOTS implementation (2004/05 – 2008/09). The strategic plans (DFID-NHF supported) include the agreed roles and responsibilities, operational strategies, activity plans, resource estimation and gaps etc.
- Assisted the Malaria Control Programme to develop the national strategic plan (2000 – 2004) with defined roles, operational strategies, activity plans and resource estimation and gaps.
- Preliminary strategic planning exercise in four provinces of Pakistan , which resulted in formulation on context-sensitive strategic frameworks and programme plans for initiating and expanding DOTS in four provinces of Pakistan (2000 – 2004). The exercise led to the development of national strategic plan (2000 – 2004).
- National and two provincial TB control programme PC-1s (i.e. proposal for public funding) in light of agreed strategies and arrangements (2000 – 2004).
- National strategic framework as well as a project formulated for developing public-private partnership in TB Control in Pakistan .
- Assisted the drafting of National Strategic Plan for ITN promotion in Pakistan . The plan was then discussed and refined in the WHO EMRO regional meeting of national malaria programme managers (in Saudi Arabia ).
- Participated in the development of national strategic plan for nutrition programme in Pakistan .
- Currently assisting the National Tobacco control program to develop a strategic plan for tobacco control in the country.
B.2 Project formulation
- Participated in DFID Mission for developing “ National Health Facility ” to support seven-priority health programmes in Pakistan .
- Formulated the project outline for developing public-private partnership in TB control (DFID supported).
- Participated in development of a multi-country research consortium proposal for DFID support (COMDIS project, started in April 2006)
- Revised National PC-1 (2006–2010), in light of national strategic plan, with greater emphasis on developing public-private partnership for TB control (DFID-NHF supported).
- Assisted the National Nutrition Programme to formulate a project and develop a proposal for initiating wheat flour fortification through public-private partnership. The GAIN has recommended the proposal for a funding support of 3 million US$.
- Assisted the Nutrition Programme to complete the requirements and preparations for signing the GAIN grant agreement (Micronutrient Initiative support).
- Assisted the preparation of TB and malaria components for the Country Coordinated Proposals of Pakistan ( GFATM rounds I to VIII ).
- Assisted the preparation of HIV/AIDS component for Country Coordinated Proposal of Afghanistan (GFATM Round-V)
- Assisted the Azad Jammu and Kashmir ( AJK ) to develop a project and initiate wheat flour fortification in their roller flourmills (Micronutrient Initiative support).
- Assisted the National TB control Programme to design and plan an intervention to pilot conditional cash transfer ( CCT ) for TB patients (World Bank support).
- Technically assisted the NGO partners , including The Aga Khan Foundation, The Asia Foundation, Mercy Corps and Pakistan Anti-TB Association to formulate TB projects for their respective communities.
P articipated in the project formulation exercise for initiating and testing the wheat flour fortification at chakki mills in Pakistan (for ADB support).
B.3 Guidelines and materials development
- Developed TB case management guidelines and training packages for care providers (i.e. doctors, paramedics, laboratory staff, and lady healthy workers) as well as implementation planning and program monitoring guidelines for district and provincial managers (DFID support). These guidelines and training materials are being used for countrywide implementation of TB control program in Pakistan .
- Developed, in partnership with Leeds University UK , “Community based TB DOTS: Planning and training toolki t”. A set of generic and adaptable TB materials also developed for use in other developing countries. An example of such adaptation and use in other country programs is TB case management desk guide in China .
- Developed Malaria case management guidelines and training packages for care providers (i.e. doctors, paramedics, and laboratory staff) as well as implementation planning and program monitoring guidelines for district and provincial managers (GFATM and then DFID support). These guidelines and materials are currently being used, for program implementation in nineteen high-prevalence districts (GFATM support).
- Developed guidelines and training package for syndrome-based management of sexually transmitted infections . The guidelines are the simplified and concise presentation of all the detailed points of case management from symptom to cure, and incorporating the issues and wording to fit with the service delivery context (DFID support) .
- Developed operational guidelines and training materials for district-based external quality assurance of TB and malaria related microscopy at primary health care network. The system has already been piloted, evaluated and refined in sixteen districts of Punjab . The malaria EQA is being scaled-up in nineteen high-prevalence districts (through GFATM R-7 support).
- Developed operational guidelines and training materials for the delivery and monitoring of childhood TB care at district and sub-district hospitals. The package is being expanded in other districts of Pakistan (including 28 teaching hospitals). The package is currently being reviewed by international technical partners for possible wider dissemination.
- Developed operational guidelines and training materials for TB-HIV co-infection interventions at hospitals and ART centers. The package is being implemented at selected locations in all four provinces (GFATM R-6 support).
- Developing, in partnership with NTP, the operational guidelines and training materials for community based care and social support of MDR-TB patients. These materials will be piloted and evaluated at 3 – 4 selected sites, before scaling up in the rest of the country.
- Developing, in partnership with NTP and other partners, the operational guidelines and training materials to enable selected categories of advocates for TB related advocacy, communication and social mobilization.
- Developed, in partnership with the TB control program, a set of guidelines and materials to implement and monitor the district-led model of public-private partnership development. The model is currently being piloted and evaluated in selected districts, before wider scaling-up. The model is also being adapted for developing public-private partnership in malaria control.
C. Interventions for enhanced health impact
Multiple interventions to enable the district management and strengthen TB care at public sector health facilities (hospitals, rural health centers, and basic health units) in eighteen districts of Punjab and two district of NWFP (FIDELIS supported). The intervention components included: district level implementation planning; training of doctor, paramedics, laboratory technicians and lady health workers; supplement material inputs, enhanced facility and district level monitoring, external quality assurance, community mobilization, and enhanced patient-provider interaction.
Hospital DOTS Linkage (HDL) interventions to introduce and strengthen TB-DOTS in sixteen teaching and private hospitals of Punjab . The intervention components include: hospital level advocacy and implementation planning; staff training; material supplement inputs, enhanced intra-hospital monitoring, external quality assurance, and enhanced patient-referral linkages. This initial FIDELIS-supported work has been expanded (through GFATM Round 6 support) to about twenty two hospital in Punjab, NWFP and Islamabad . The scope of work has also been enhanced to include difficult to diagnose and treat adult TB cases, TB-HIV co-infection, and childhood TB components of the new Stop TB strategy
Technical partner of The Asia Foundation to mobilize communities for TB control in twenty districts of Pakistan (GFATM round-III support). Through GFATM Round 6 support, the advocacy-communication and social mobilization (ACSM) work has been extended to nine districts in Punjab and Balochistan.
Strengthening the district capacity to manage anti-TB drug in 50 districts of Pakistan . The intervention components include: storage capacity, distribution arrangements, staff skills, and monitoring at facility and district levels (through GFATM Round 8 support).
Interventions piloted in sixteen districts of Punjab to strengthen the malaria case management at public sector facilities. The intervention components included: district level implementation planning; training of doctors and laboratory technicians; supplement material inputs, enhanced facility and district level monitoring, and district based external quality assurance. The malaria case management strengthening in public and private sector has now been extended to four districts in Sindh (GFATM Round-7).
Technical partner of: “NRSP” for developing and evaluating an approach to promoting ITN use in rural areas of four selected districts of Pakistan (GFATM-II supported); and “AGEG” for providing five-year technical assistance to the TB Control Program in the North West Frontier Province (GTZ supported).