Showing papers by "Syed Iqbal Azam published in 2015"

Can contracted out health facilities improve access, equity, and quality of maternal and newborn health services? evidence from Pakistan.

Abstract: The case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services. We present an in-depth assessment of the comparative advantages of contracting out on MNCH access, quality, and equity, using a case study from Pakistan. An end-line, cross-sectional assessment was conducted of government facilities contracted out to a large national NGO and government-managed centres serving as controls, in two remote rural districts of Pakistan. Contracting out was specific for augmenting MNCH services but without contractual performance incentives. A household survey, a health facility survey, and focus group discussions with client and spouses were used for assessment. Contracted out facilities had a significantly higher utilization as compared to control facilities for antenatal care, delivery, postnatal care, emergency obstetric care, and neonatal illness. Contracted facilities had comparatively better quality of MNCH services but not in all aspects. Better household practices were also seen in the district where contracting involved administrative control over outreach programs. Contracting was also faced with certain drawbacks. Facility utilization was inequitably higher amongst more educated and affluent clients. Contracted out catchments had higher out-of-pocket expenses on MNCH services, driven by steeper transport costs and user charges for additional diagnostics. Contracting out did not influence higher MNCH service coverage rates across the catchment. Physical distances, inadequate transport, and low demand for facility-based care in non-emergency settings were key client-reported barriers. Contracting out MNCH services at government health facilities can improve facility utilization and bring some improvement in quality of services. However, contracting out of health facilities is insufficient to increase service access across the catchment in remote rural contexts and requires accompanying measures for demand enhancement, transportation access, and targeting of the more disadvantaged clientele.

Service quality in contracted facilities.

Abstract: Purpose – The purpose of this paper is to explore the readiness of contracted and non-contracted first-level healthcare facilities in Pakistan to deliver quality maternal and neonatal health (MNH) care. A balanced scorecard (BSC) was used as the assessment framework. Design/methodology/approach – Using a cross-sectional study design, two rural health centers (RHCs) contracted out to Aga Khan Health Service, Pakistan were compared with four government managed RHCs. A BSC was designed to assess RHC readiness to deliver good quality MNH care. In total 20 indicators were developed, representing five BSC domains: health facility functionality, service provision, staff capacity, staff and patient satisfaction. Validated data collection tools were used to collect information. Pearson χ2, Fisher’s Exact and the Mann-Whitney tests were applied as appropriate to detect significant service quality differences among the two facilities. Findings – Contracted facilities were generally found to be better than non-contra...

Gendered Disparities in Quality of Cataract Surgery in a Marginalised Population in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey

Abstract: Background Marine fishing communities are among the most marginalised and hard-to-reach groups and have been largely neglected in health research. We examined the quality of cataract surgery and its determinants, with an emphasis on gender, in marine fishing communities in Karachi, Pakistan, using multiple indicators of performance. Methods and Findings The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional study conducted between March 2009 and April 2010 in fishing communities living on 7 islands and in coastal areas in Keamari, Karachi, located on the Arabian Sea. A population-based sample of 638 adults, aged ≥ 50 years, was studied. A total of 145 eyes (of 97 persons) had undergone cataract surgery in this sample. Cataract surgical outcomes assessed included vision (presenting and best-corrected with a reduced logMAR chart), satisfaction with surgery, astigmatism, and pupil shape. Overall, 65.5% of the operated eyes had some form of visual loss (presenting visual acuity [PVA] < 6/12). 55.2%, 29.0%, and 15.9% of these had good, borderline, and poor visual outcomes based on presenting vision; with best correction, these values were: 68.3 %, 18.6%, and 13.1%, respectively. Of 7 covariates evaluated in the multivariable generalized estimating equations (GEE) analyses, gender was the only significant independent predictor of visual outcome. Women’s eyes were nearly 4.38 times more likely to have suboptimal visual outcome (PVA<6/18) compared with men’s eyes (adjusted odds ratio 4.38, 95% CI 1.96-9.79; P<0.001) after adjusting for the effect of household financial status. A higher proportion of women’s than men’s eyes had an irregular pupil (26.5% vs. 14.8%) or severe/very severe astigmatism (27.5% vs. 18.2%). However, these differences did not reach statistical significance. Overall, more than one fourth (44/144) of cataract surgeries resulted in dissatisfaction. The only significant predictor of satisfaction was visual outcome (P <0.001). Conclusions The quality of cataract surgery in this marginalised population, especially among women, falls well below the WHO recommended standards. Gender disparities, in particular, deserve proactive attention in policy, service delivery, research and evaluation.

Eye Care Service Use and Its Determinants in Marginalized Communities in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey

Abstract: Purpose: To examine gender, ethnic, and socioeconomic differences in access to eye care services in marine fishing communities in Karachi, Pakistan. Methods: The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, crosssectional survey conducted between March 2009 and April 2010 in fishing communities in Keamari, Karachi, located on the coast of the Arabian Sea. Adults aged 50 years living on three islands and in four coastal areas were enrolled. Participants underwent a detailed interview regarding sociodemographics, eye problems and eye care service use, testing of presenting and best-corrected visual acuity with a reduced logMAR chart, and detailed eye examination. Results: A total of 700 people were planned to be included in the study; 638 (91.1%) were interviewed and examined. Most participants were extremely poor and had no formal education. Only 45.3% (95% confidence interval, CI, 41.4–49.2%) of participants reported having had an eye examination in the past; 12.1% (95% CI 9.5–14.6%) and 30.9% (95% CI 27.3–34.5%) had seen an eye doctor within the last year or prior 5 years, respectively. In the multivariable analysis, ethnicity was the strongest independent predictor of eye care service use, followed by self-reported eye problems and diabetes. Ethnic Bengalis were 4.2 times less likely (adjusted odds ratio 0.24, 95% CI 0.15–0.38; p50.001) to have had an eye examination in the past than Kutchis. Conclusions: Despite a high prevalence of visual impairment and blindness, levels of eye care examinations in fishing communities, especially among ethnic Bengalis, are disappointingly low. Such communities deserve particular attention in Vision 2020 and other national and international strategies and plans.