Out-of-pocket expenses borne by the users of obstetric services at government hospitals in Karachi, Pakistan

Objective: Financing health services is a challenge for health policy makers world over, especially in developing countries. Alternate mechanisms such as user fees are being proposed. However, there is a feeling that in developing countries, users of government hospitals spend appreciable personal income to obtain free services at these facilities.Methods: This study aimed to measure the extent and the factors associated with of out-of-pocket expenses borne by the users of obstetric care at government hospitals. It also aimed to determine willingness of consumers to bear out of pocket expenses. It was conducted in three government hospitals in Karachi.Results: Seven hundred cases were registered in the study. Sixty-five percent of them had a monthly household income of less than Rupees (Rs.) 3000. Overall, users spent mean of Rs. 590 as out-of-pocket expenses for obstetric services. Of this Rs. 330 was spent on drugs and Rs. 24 on user fees. Thirty-nine percent of the patients were willing to spend out of pocket for services provided at government hospital and 39% declined to do so. Of the patients indicating willingness to spend, 98% agreed to do so for drugs.CONCLUSION: The results suggest that considerable expenses are borne out of pocket by the users of government hospitals for supposedly free services . If user fees are to be increased the government needs to provide services for which the people will pay, such as drugs, otherwise increase in this fees will simply add to financial burden on the users

Integrated community case management in a peri-urban setting: a qualitative evaluation in Wakiso District, Uganda.

Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas, but there is little evidence to support iCCM as an appropriate strategy in non-rural contexts. This study aimed to inform future iCCM implementation by exploring caregiver and VHT member perceptions of the value and effectiveness of iCCM in peri-urban settings in Uganda.A qualitative evaluation was conducted in seven villages in Wakiso district, a rapidly urbanising area in central Uganda. Villages were purposively selected, spanning a range of peri-urban settlements experiencing rapid population change. In each village, rapid appraisal activities were undertaken separately with purposively selected caregivers (n = 85) and all iCCM-trained VHT members (n = 14), providing platforms for group discussions. Fifteen key informant interviews were also conducted with community leaders and VHT members. Thematic analysis was based on the 'Health Access Livelihoods Framework'.iCCM was perceived to facilitate timely treatment access and improve child health in peri-urban settings, often supplanting private clinics and traditional healers as first point of care. Relative to other health service providers, caregivers valued VHTs' free, proximal services, caring attitudes, perceived treatment quality, perceived competency and protocol use, and follow-up and referral services. VHT effectiveness was perceived to be restricted by inadequate diagnostics, limited newborn care, drug stockouts and VHT member absence - factors which drove utilisation of alternative providers. Low community engagement in VHT selection, lack of referral transport and poor availability of referral services also diminished perceived effectiveness. The iCCM strategy was widely perceived to result in economic savings and other livelihood benefits.In peri-urban areas, iCCM was perceived as an effective, well-utilised strategy, reflecting both VHT attributes and gaps in existing health services. Depending on health system resources and organisation, iCCM may be a useful transitional service delivery approach. Implementation in peri-urban areas should consider tailored community engagement strategies, adapted selection criteria, and assessment of population density to ensure sufficient coverage

Ab-Externo MicroShunt versus Trabeculectomy in Primary Open-Angle Glaucoma: Two-Year Results from a Randomized, Multicenter Study

PURPOSE: To compare the effectiveness and safety of the MicroShunt (Santen Inc) versus trabeculectomy in patients with primary open-angle glaucoma (POAG). DESIGN: Prospective, randomized, multicenter trial conducted in the United States and Europe. PARTICIPANTS: Adult patients (aged 40-85 years) with mild to severe POAG inadequately controlled on maximum tolerated medical therapy and intraocular pressure (IOP) ≥ 15 mmHg and ≤ 40 mmHg. METHODS: Patients were randomized 3:1 to stand-alone MicroShunt implantation (n = 395) or trabeculectomy (n = 132), both augmented with mitomycin C (MMC) 0.2 mg/ml for 2 minutes. MAIN OUTCOME MEASURES: The primary effectiveness end point was surgical success, defined as ≥ 20% reduction in mean diurnal IOP from baseline with no increase in glaucoma medications. Secondary end points included changes in mean IOP and medication use from baseline and the need for postoperative interventions. RESULTS: At 2 years, the rate of surgical success was lower in the MicroShunt group than in the trabeculectomy group (50.6% vs. 64.4%, P = 0.005). Mean diurnal IOP was reduced from 21.1 ± 4.9 mmHg at baseline to 13.9 ± 3.9 mmHg at 24 months in the MicroShunt group and from 21.1 ± 5.0 mmHg at baseline to 10.7 ± 3.7 mmHg at 24 months in the trabeculectomy group (P < 0.001 compared with baseline in both groups). Mean medication use decreased from 3.1 to 0.9 in the MicroShunt group and from 2.9 to 0.4 in the trabeculectomy group (P < 0.001 compared with baseline in both groups). Adverse events at 2 years were generally similar in the 2 groups, except that hypotony was more common in eyes undergoing trabeculectomy (51.1% vs. 30.9%, P < 0.001). Repositioning or explantation of the implant occurred in 6.8% of MicroShunt patients. The majority of these patients had device removal at the time of subsequent glaucoma surgery. Vision-threatening complications were uncommon in both groups. CONCLUSION: At 2 years, both the MicroShunt and trabeculectomy provided significant reductions in IOP and medication use, with trabeculectomy continuing to have greater surgical success. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article

Electron Temperature Gradient Mode Transport

Anomalous electron thermal losses plays a central role in the history of the controlled fusion program being the first and most persistent form of anomalous transport across all toroidal magnetic confinement devices. In the past decade the fusion program has made analysis and simulations of electron transport a high priority with the result of a clearer understanding of the phenomenon, yet still incomplete. Electron thermal transport driven by the electron temperature gradient is examined in detail from theory, simulation and power balance studies in tokamaks with strong auxiliary heating.Physic

Assembling a global database of child pneumonia studies to inform WHO pneumonia management algorithm: methodology and applications

BACKGROUND: The existing World Health Organization (WHO) pneumonia case management guidelines rely on clinical symptoms and signs for identifying, classifying, and treating pneumonia in children up to 5 years old. We aimed to collate an individual patient-level data set from large, high-quality pre-existing studies on pneumonia in children to identify a set of signs and symptoms with greater validity in the diagnosis, prognosis, and possible treatment of childhood pneumonia for the improvement of current pneumonia case management guidelines. METHODS: Using data from a published systematic review and expert knowledge, we identified studies meeting our eligibility criteria and invited investigators to share individual-level patient data. We collected data on demographic information, general medical history, and current illness episode, including history, clinical presentation, chest radiograph findings when available, treatment, and outcome. Data were gathered separately from hospital-based and community-based cases. We performed a narrative synthesis to describe the final data set. RESULTS: Forty-one separate data sets were included in the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) database, 26 of which were hospital-based and 15 were community-based. The PREPARE database includes 285 839 children with pneumonia (244 323 in the hospital and 41 516 in the community), with detailed descriptions of clinical presentation, clinical progression, and outcome. Of 9185 pneumonia-related deaths, 6836 (74%) occurred in children <1 year of age and 1317 (14%) in children aged 1-2 years. Of the 285 839 episodes, 280 998 occurred in children 0-59 months old, of which 129 584 (46%) were 2-11 months of age and 152 730 (54%) were males. CONCLUSIONS: This data set could identify an improved specific, sensitive set of criteria for diagnosing clinical pneumonia and help identify sick children in need of referral to a higher level of care or a change of therapy. Field studies could be designed based on insights from PREPARE analyses to validate a potential revised pneumonia algorithm. The PREPARE methodology can also act as a model for disease database assembly

Road traffic injuries in Karachi: the disproportionate role of buses and trucks

Road traffic accidents result in substantial injury and death in Karachi. We reviewed the patient logs of the two largest government hospitals in Karachi between December 1993 and February 1994 to identify those persons most likely to be injured in a road traffic accident and to identify the vehicle types which were most likely to be involved. 86% of 727 road injury victims were male. Their mean age was 31 years. One hundred of thirty-one (18%) died. Pedestrians and motorcyclists were the most common victims accounting for 46% all injuries and 51% of deaths. Although buses and trucks were less than 4% of the registered vehicles in Karachi they were the striking vehicle among 49% of all injuries and 65% of the deaths. Road traffic accidents disproportionately affect wage earners. Specific interventions to improve the road safety of trucks and buses are needed

Maternal mortality in different Pakistani sites: ratios, clinical causes and determinants

Background: Population-based estimates of maternal mortality from Pakistan are inadequate to define the magnitude of the problem or provide information on clinical causes and determinants.Methods: Surveys were conducted in selected clusters in Karachi, Balochistan and North West Frontier Province from 1989-1992. Pre-coded questionnaires were administered to 38,563 households to ascertain household characteristics, complete pregnancy histories and deaths of household members in the five years preceding the survey. Verbal autopsy questionnaires were then conducted to establish cause of death to women in the reproductive age group. Descriptive, bivariate and multivariable analyses were carried out to determine the association between the background variables, biological and women\u27s status indicators and maternal mortality using a nested case-control design.Results: Overall, the estimated maternal mortality ratio combining the data from the different sites was 433 per 100,000 livebirths. The estimated maternal mortality ratios per 100,000 livebirths ranged from a low of 281 in Karachi to a high of 673 in Khuzdar [Balochistan]. Hemorrhage (52.9%), puerperal sepsis (16.3%) and eclampsia (14.4%) were the leading causes for direct maternal deaths. Logistic regression identified the important risk factors as poor housing construction material (OR = 2.1; 95% CI = 1.3,3.2), distance of 40 or more miles from nearest hospital (OR = 1.3; 95% CI = 0.9,1.8), grandmultigravidity (OR = 1.6; 95% CI = 1.1,2.4) and prior fetal losses (OR = 5.3; 95% CI = 3.8,7.4).CONCLUSION: Focusing on special groups of pregnant women with targeted programs such as training, monitoring and supervision of birth attendants for the provision of oxytocics, will go a long way in decreasing the proportion of maternal deaths attributed to direct, avoidable causes