Health Outcomes in Pakistan: Empirical essays for Policy Assessment

In resource constrained settings, missing markets and unregulated externalities can have a significant impact on human capital outcomes. High out of pocket expenditure due to the inaccessibility of insurance markets limits the use of healthcare, just as the inability to borrow in the face of a cash constraint may lead to below subsistence levels of consumption. Policy instruments designed around some of these market imperfections are gaining traction in developing countries influenced in large part by international experience. Global discourse around universal health care coverage and minimum basic income has given momentum to programs that provide some form of financial and risk protection to vulnerable populations in low -income countries. Yet, gaps in regulatory protection, for instance, ineffectual implementation of health, safety and environmental policies are also exacerbating the risks for disadvantaged groups. This research examines the health implications of public policy around three instances of market failures in the context of a developing country – Pakistan. The first study examines maternal healthcare utilization following the introduction of a public health insurance program for low-income families. The market for health insurance addresses the income shock that presents itself in the form of catastrophic expenditure due to a severe illness or injury. In developing countries, well-functioning private markets may not exist, or they may not cater to all segments of the population. Governments driven by equity concerns may then offer subsidized public insurance to protect families from high out of pocket costs. This paper is motivated by the consideration that institutional constraints within the health care system of a developing country may limit the effectiveness of even highly subsidized programs. Any gains in health outcomes are likely conditional on the adequate take up and low barriers to access for eligible population. Indeed, we find that the benefits of the program accrue largely to those in urban areas. The findings suggest that the lack adequately staffed health facilities may preclude the poorest groups from benefiting from such government initiatives. Given the potential of the program to improve health care utilization, complementary investment in infrastructure would make the program more inclusive and better address existing inequities in the use of healthcare. Missing credit markets also impact household welfare by limiting their ability to borrow in the event of an income shock. As a safety net mechanism, cash transfer programs serve to mitigate the effects of extreme poverty and protect against deprivations caused by adverse shocks. In the second paper, I examine nutritional outcomes following the provision of supplemental income to cash constrained families. Existing evidence suggests that the under accumulation of human capital begins while the child is in utero (Black et al., 2013; Fink & Rockers, 2014; Sudfeld et al., 2015). Consistent with that body of evidence, our analysis highlights the importance of providing cash support during the prenatal period. Additionally, we find that positive nutritional impacts are linked to the birth order of the child. To improve child anthropometric outcomes, a complementary role of informational interventions is recommended for cash transfer programs implemented in low-income settings. The third paper differs from the first two as it examines the public health implications of the absence of policy in regulating market failure. It explores the externality associated with the agricultural practice of stubble burning. In agriculturally productive regions with access to irrigation, residue burning is used to clear land between cropping cycles in order to plant two or more seasons of crops in a year. It is an unregulated source pollution that imposes a cost on society and on populations with already low access to healthcare. Findings suggest that individuals with high exposure to fire emissions experience higher incidence of respiratory illness. Together, these three papers highlight the health policy nuances that must factor into our efforts towards reducing inequities in health outcomes between countries and among populations

A Patient- and Family-Centered Care Approach to Orthodontics: Assessment of Feedbacks from Orthodontic Patients and Their Families

Objective:This study aimed to evaluate orthodontic patients and their families’ clinical satisfaction and their perception of dentists in the framework of the Patient and Family Centered Care (PFCC) concept.Methods:The study population comprised patients treated at the Orthodontics clinic and their families. A mixed method research with quantitative and qualitative components was employed by conducting questionnaires with 62 patients and 65 parents. Collected data were recorded on the computer, and analyses were performed.Results:A majority of the patients who received treatment at our clinic were high school graduates, while their parents were university graduates. The patient’s and their parents’ overall satisfaction were similar. We also found that the patients and their parents expected doctors to have ethical perception and professional behavior in the treatment process.Conclusion:According to the results obtained from the survey questionnaires, the patients and their parents expect a dentist to have the following qualities: courtesy, friendliness, respect, punctuality, communication skills, and knowledgeableness. Dentists can optimize clinical and patient satisfaction by providing care and attention based on the principles of patient centered care (PCC) and PFCC and shaped in accordance with the expectations of the patients and their parents

The Impact of Efficacy, Values, and Knowledge on Public Preferences Concerning Food–Water–Energy Policy Tradeoffs

Food, water, and energy (FWE) policies often entail contentious tradeoffs. For example, increasing food production may involve irrigation from riparian sources that may adversely impact fisheries habitats, the siting of solar energy on agricultural lands can impact food production, and increasing food production capacity may require pesticides in certain locations, resulting in environmental pollution. Because public preferences are an important component of support for and opposition to FWE policy design and implementation, it is important to understand the correlates of support and opposition to FWE policy tradeoffs. Using survey data from random household surveys conducted in western U.S. states during 2018, this study examined how environmental efficacy, values, and knowledge affected FWE public tradeoff preferences. The findings suggest that these characteristics do affect public FWE tradeoff preferences, with knowledge being a strong driver of support for food production over biofuels, water friendly crops over meat production and conservation over water intensive agriculture. Additionally, environmental efficacy and pro-ecological attitudes drive support for access to safe drinking water and sanitation over food security for a growing population

Knowledge, attitude and practices regarding sleep and sleep hygiene among patients presenting to out-patient and emergency room services at a teaching hospital in Karachi

Objectives: To study the knowledge, attitude and practices with regards to sleep and sleep hygiene among patients visiting the Out-Patient and Emergency Room services at a teaching hospital in Karachi, Pakistan. Methodology: A questionnaire-based cross-sectional survey was conducted at the Out-Patient and Emergency Room services of Aga Khan University Hospital, Karachi, Pakistan. The questionnaire included demographic profile of the participant and questions based on the study objective. The details of the study were explained to the participants, a written Informed Consent was taken and confidentiality was assured. Those who could not read or write or understand English were assisted accordingly. Results: Three hundred seventy six respondents were interviewed, the majority being women (57.7%) and married (62.2%). A majority 212 (56.4%) respondents were between 25 and 49 years of age. The majority of the respondents had acquired above grade X (Matriculation) education, and were either students or housewives or in private service. The mean number of hours of sleep per day was 7.03 hours. About 60.4% of the respondents sleep 6-8 hours and 23.7% of the respondents believe sedatives should be used in case of insomnia while 9.0% of the respondents actually take sleeping pills. Only 33.8% of the respondents always feel fresh on waking up in the morning. Disruptions and snoring during sleep have been reported. About 27.1% of the respondents have rated their sleep quality as five or less, based on the rating scale 1-10 with 10 being highest quality.Conclusion: Sleep and sleep hygiene is a neglected area of clinical care requiring further research and intervention in terms of educational programs for patients

Order acceptance and scheduling decisions in make-to-order systems

We examine simultaneous order acceptance and scheduling decisions where the orders are defined by their release dates, due dates, deadlines, processing times, sequence dependent setup times and revenues in a single machine environment. The objective is to maximize total revenue, where the revenue from an order is a function of its tardiness and deadline. We give an MILP formulation which can be solved to optimality up to 15 orders. We develop three heuristic algorithms to solve large sized problems. Computational tests indicate that the proposed algorithms are both computationally efficient and effective even for instances up to 300 orders.Order acceptance Single machine scheduling Sequence dependent setup times Heuristics

FXR agonist obeticholic acid induces liver growth but exacerbates biliary injury in rats with obstructive cholestasis

Cholestasis impairs liver regeneration following partial liver resection (PHx). Bile acid receptor farnesoid X-receptor (FXR) is a key mediator of liver regeneration. The effects of FXR agonist obeticholic acid (OCA) on liver (re)growth were therefore studied in cholestatic rats. Animals underwent sham surgery or reversible bile duct ligation (rBDL). PHx with concurrent internal biliary drainage was performed 7 days after rBDL. Animals were untreated or received OCA (10 mg/kg/day) per oral gavage from rBDL until sacrifice. After 7 days of OCA treatment, dry liver weight increased in the rBDL + OCA group, indicating OCA-mediated liver growth. Enhanced proliferation in the rBDL + OCA group prior to PHx concurred with a rise in Ki67-positive hepatocytes, elevated hepatic Ccnd1 and Cdc25b expression, and an induction of intestinal fibroblast growth factor 15 expression. Liver regrowth after PHx was initially stagnant in the rBDL + OCA group, possibly due to hepatomegaly prior to PHx. OCA increased hepatobiliary injury markers during BDL, which was accompanied by upregulation of the bile salt export pump. There were no differences in histological liver injury. In conclusion, OCA induces liver growth in cholestatic rats prior to PHx but exacerbates biliary injury during cholestasis, likely by forced pumping of bile acids into an obstructed biliary tree

BJS commission on surgery and perioperative care post-COVID-19

Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues experiences and published evidence. Methods: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. Results: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. Conclusion: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era