Provider cost analysis supports results-based contracting out of maternal and newborn health services: an evidence-based policy perspective

Background There is dearth of evidence on provider cost of contracted out services particularly for Maternal and Newborn Health (MNH). The evidence base is weak for policy makers to estimate resources required for scaling up contracting. This paper ascertains provider unit costs and expenditure distribution at contracted out government primary health centers to inform the development of optimal resource envelopes for contracting out MNH services. Methods This is a case study of provider costs of MNH services at two government Rural Health Centers (RHCs) contracted out to a non-governmental organization in Pakistan. It reports on four selected Basic Emergency Obstetrical and Newborn Care (BEmONC) services provided in one RHC and six Comprehensive Emergency Obstetrical and Newborn Care (CEmONC) services in the other. Data were collected using staff interviews and record review to compile resource inputs and service volumes, and analyzed using the CORE Plus tool. Unit costs are based on actual costs of MNH services and are calculated for actual volumes in 2011 and for volumes projected to meet need with optimal resource inputs. Results The unit costs per service for actual 2011 volumes at the BEmONC RHC were antenatal care (ANC) visit USD$18.78, normal delivery US$ 84.61, newborn care US$16.86 and a postnatal care (PNC) visit US$ 13.86; and at the CEmONC RHC were ANC visit US$45.50, Normal Delivery US$ 148.43, assisted delivery US$167.43, C-section US$ 183.34, Newborn Care US$41.07, and PNC visit US$ 27.34. The unit costs for the projected volumes needed were lower due to optimal utilization of resources. The percentage distribution of expenditures at both RHCs was largest for salaries of technical staff, followed by salaries of administrative staff, and then operating costs, medicines, medical and diagnostic supplies. Conclusions The unit costs of MNH services at the two contracted out government rural facilities remain higher than is optimal, primarily due to underutilization. Provider cost analysis using standard treatment guideline (STG) based service costing frameworks should be applied across a number of health facilities to calculate the cost of services and guide development of evidence based resource envelopes and performance based contracting

Coverage and predictors of vaccination among children of 1-4 years of age in a rural sub-district of Sindh

OBJECTIVE: To estimate the proportion of children 1-4 years of age vaccinated in the first year of their life and determine socio-demographic factors associated with vaccination in the rural sub-district Khairpur, Sindh, Pakistan.STUDY DESIGN: Cross-sectional study.PLACE AND DURATION OF STUDY: The study was conducted in 9 Union Councils of sub-district Gambat, district Khairpur, Sindh, from August to October 2008.METHODOLOGY: A questionnaire based representative multi-stage cluster survey was conducted. A total of 549 children aged 1-4 years were assessed for coverage and predictors of vaccination. Univariate and multivariate analysis was done using logistic regression to determine the unadjusted and adjusted relationship between socio-demographic predictor and outcome (vaccination status).RESULTS: The coverage for complete vaccination was 71.9% (95%CI=68.1%-75.7%). Educational level of mother (p=0.042), father (p=0.001) and child birth at hospital (p=0.006) were significantly associated with the vaccination status. Mother\u27s educational level of intermediate and above was the strongest predictor (OR=12.19, 95%CI=1.57-94.3) for vaccination.CONCLUSION: Education of parents, particularly mother\u27s education was important determinant of vaccination status of the children. In addition, distance from taluka health facility and misconception of parents were among the main reasons of not getting the children vaccinated. There is a need to educate the parents especially mothers about the importance of vaccination and organize EPI services at Basic Health Unit level to improve the vaccination coverage in rural areas of Pakistan

Effectiveness of training on de-escalation of violence and management of aggressive behavior faced by health care providers in a public sector hospital of Karachi

Background: Considering high burden of violence against healthcare workers in Pakistan APPNA Institute of Public Health developed a training to prevent reactive violence among healthcare providers. The purpose of this training was to equip healthcare providers with skills essential to control aggressive behaviors and prevent verbal and non-verbal violence in workplace settings. This study assesses the effectiveness of training in prevention, de-escalation and management of violence in healthcare settings.Methods: A quasi-experimental study was conducted in October, 2016 using mixed method concurrent embedded design. The study assessed effectiveness of de-escalation trainings among health care providers working in emergency and gynecology and obstetrics departments of two teaching hospitals in Karachi. Quantitative assessment was done through structured interviews and qualitative through Focus Group Discussions. Healthcare providers` confidence in coping with patient aggression was also measured using a standard validated tool .Results: The overall self-perceived mean score of Confidence in Coping with Patient Aggression Instrument (CCPAI) scale was significantly higher in intervention group (Mean= 27.49, SD=3.53) as compared to control group (Mean= 23.92, SD=4.52) (p\u3c0.001). No statistically significant difference was observed between intervention and control groups with regard to frequency of violence faced by HCPs post training and major perpetrators of violence.Conclusion: De-escalation of violence training was effective in improving confidence of healthcare providers in coping with patient aggression

Comparison of Outcome of one Versus two Drains Insertion for Seroma Formation Following Modified Radical Mastectomy in Breast Carcinoma

Objective: Comparative outcome of one versus two drains insertion for in the term of seroma formation following modified radical mastectomy in breast carcinoma. Methodology: This Prospective Interventional trial was conducted at Department of General Surgery, Liaquat University Hospital Hyderabad from February 2018 to January 2019.  Females with breast carcinoma admitted for modified radical mastectomy were included. Patients were divided into two groups.  Groups I underwent one drain placement and group II underwent two drains placement. All patients were observed to measure and record the volume of the fluid. Patients were discharged from Hospital in stable condition and after removal of drains, and followed up weekly for one month. Data was recorded on self-made proforma and analyzed by using SPSS-20. Results: Total of 80 patients were selected, 38 in group A and 42 in group B. Mean age of patients of group A was 49.08 ± 9.89 years and group B was 51.40 ± 13.59 years. , Excised Mass weight was lesser in group A as compared to group B. Mean volume of drain discharge was significantly higher in Group B 323.43 ± 158.88 ml, while it was in group A 230.29± 200.98, findings were statistically significant 0.013. Seroma formation was statistically insignificant among both groups as 8(21.1%) in group A and   10(23.8%) in group B, p-value 0.768. Conclusion: One-drain and two-drain insertion are equally effective to reduce the seroma formation after modified radical mastectomy; however, one drain insertion leads to more patient compliance and comfort with probably less morbidity and cost

Experience of devolution in district health system of Pakistan: Perspectives regarding needed reforms

Objective: To identify the strengths and weaknesses of the devolved district health system from the experiences of different stakeholders, and recommend direction for reforms in the existing system.Methods: Using qualitative exploratory design, the study was conducted in 3 cities of the province of Sindh in Pakistan--Karachi, Khairpur and Larkana--from January to March 2010. Nine in-depth interviews were conducted with multiple stakeholders (District Coordination Officer, Executive District Officer, Medical Superintendent, Medical officers, Health system experts) of the district health system. Interviews included questions on autonomy in decision-making at the district level and the effectiveness of the devolved health system. Data transcripts were made from the recorded tapes and notes taken during the interviews. Thematic analysis was done and the data was classified into 3 broad themes of governance, financing and factors related to resources and service delivery.Results: The main strengths identified included formation of District Health Management Team for wider inter-sectoral collaboration, creation of new posts at sub-district level for close monitoring and supervision, and greater financial autonomy to prioritise according to needs. The reported weaknesses included lack of team work, limited autonomy, lack of capacity, nepotism and poor accountability.Conclusion: While devolution has been scrapped in most parts of the country, the findings of the study provide recommendations for the delegation of further powers at sub-district and union council level, enhanced capacity and increased transparency and accountability to make the system work

Respiratory symptoms and illnesses among brick kiln workers: A cross sectional study from rural districts of Pakistan

Background: Occupational risk factors are one of the major causes of respiratory illnesses and symptoms, and account for 13% of chronic obstructive pulmonary disease and 11% of asthma worldwide. Majority of brick kilns in Pakistan use wood and coal for baking the bricks which makes the brick kiln workers susceptible to high exposure of air pollution. This study was designed to describe frequency of chronic respiratory symptoms and illnesses and study the association between these symptoms and different types of work.Methods: This was a questionnaire based cross sectional survey conducted among the brick kiln workers in Larkana and Dadu districts, Sindh, Pakistan. A total of 340 adult men were assessed using translated version of the American Thoracic Society Division of Lung Disease (ATS-DLD) questionnaire. Logistic regression analysis was done to determine the relationship between various socio-demographic and occupational factors (age, education, type of work, number of years at work, smoking status), and the respiratory symptoms and illnesses (chronic cough, chronic phlegm, wheeze, Chronic Bronchitis and asthma).Results: Results of the study show that 22.4% workers had chronic cough while 21.2% reported chronic phlegm. 13.8% had two or more attacks of shortness of breath with wheezing. 17.1% workers were suffering from Chronic Bronchitis while 8.2% reported physician diagnosed asthma. Amongst the non-smoking workers 8.9% had Chronic Bronchitis. Multivariate analysis found that workers involved in brick baking were more likely to have Chronic Bronchitis (OR= 3.7, 95% CI 1.1-11.6, p=\u3c0.05) and asthma (OR= 3.9, 95% CI 1.01-15.5, p=\u3c0.05) compared to those involved in carriage and placement work.Conclusion: A high frequency of respiratory symptoms and illnesses was observed among brick kiln workers. Age, nature of work and smoking were strong predictors of developing these symptoms and illnesses

Nicotine dependence and intention to quit among electronic, conventional and dual cigarette users in Karachi

Objective: To compare nicotine dependence and intention to quit among different types of smokers. Method: The comparative cross-sectional study was conducted from November 2018 to October 2019 in Karachi after approval from the ethics review committee of the Jinnah Sindh Medical University, and comprised conventional, electronic and dual cigarette users. Data was collected using a structured questionnaire regarding socio-demographics, usage characteristics, and intention to quit. The validated Hooked on Nicotine Checklist was also used. Data was analysed using SPSS 22. Results: Of the 246 subjects, 82(33%) were conventional cigarette users with a mean age of 27.41±8.7 years, 82(33.3%) were electronic cigarette users having mean age of 30.37±9.16 years, and 82(33.3%) were dual cigarette users with a mean age of 28.89±9.07 years. The use of electronic cigarette was more in people with higher age (p=0.01), married (p=0.001) and having higher income (p=0.05). Compared to conventional cigarette users, electronic cigarette users showed lower odds of high nicotine dependence (odds ratio: 0.38, 95% confidence interval: 0.18-0.80). No significant difference was observed in intention to quit among different types of cigarette users (p>0.05). Conclusion: Electronic cigarettes users were comparatively less nicotine-dependent compared to the users of other types of cigarettes. Electronic cigarettes should only be recommended to conventional users with the intention to quit. Key Words: Cigarette, Electronic, Nicotine dependence, Quit intention

Frequency and risk factors of musculoskeletal disorders in high risk occupation workers in Urban, Karachi

Objective: To determine the frequency and risk factors of musculoskeletal disorders in high-risk occupation workers in an urban setting. Method: The analytical cross-sectional study was conducted in Karachi from July to December 2020, and comprised office workers, operation theatre technicians and coolies. The presence of musculoskeletal disorders was assessed using the Nordic Musculoskeletal Questionnaire to determine factors associated with moderate to severe condition. Data was analysed using SPSS 20. Results: Of the 300 male subjects, 100(33.3%) each were office workers, operation theatre technicians and coolies. The overall mean age was 33.25±6.8 years (range: 18-50 years). The overall prevalence of musculoskeletal disorders was 179(59.7%). Besides, 117(65.4%) patients with musculoskeletal disorders had intermediate stage of the disease. The lower back and neck were the most common site of trouble involved in preceding 12 months 111(43.6%) each. Conclusion: Prevalence of musculoskeletal disorders was found to be a common problem affecting high-risk occupational workers. Key Words: High-risk occupations, Musculoskeletal disorders

Changes in caloric consumption, physical activity, body mass index and sleeping pattern during holy month of Ramadan among doctors of a public sector University

Objective: To determine the change in caloric intake, physical activity, body mass index and sleeping pattern during Ramadan among doctors. Method: The longitudinal study was conducted at a public-sector medical university in Karachi from April to May 2020, and comprised healthy doctors of either gender who planned to fast during Ramadan. Data was collected using a multitude of validated structured tools by trained data collectors. Data was analysed using SPSS 20. Results: Of the 193 subjects, 103(53.4%) were females and 90(46.6%) were males. The overall mean age was 30.05±9.4 years. Caloric intake in the month before Ramadan was significantly higher 2288±495kcal/day than during Ramadan 2089±491kcal/day (p<0.001). Calories from proteins decreased and those from fats increased (p<0.001). Metabolic equivalent of task per minute per week increased significantly during Ramadan (p<0.001). Overall sleep per day decreased significantly, and there was an increase in daytime sleep and a decrease in night-time sleep (p<0.05). Body mass index also dropped significantly (p=0.005). Conclusion: Fasting during Ramadan had a positive effect on body mass index and physical activity levels of doctors, while the quality of diet and sleep was affected negatively. Key Words: Caloric consumption, Physical activity, Body mass index, Sleeping pattern, Ramadan