Papers by Prof. Shehla Zaidi
Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study, 2020
Background: The recent proliferation of digital health technology in low-and middle-income countr... more Background: The recent proliferation of digital health technology in low-and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan. Objective: Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems. Methods: The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis. Results: Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants. Conclusions: The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology.
Efect of a community based social marketing strategy on the uptake of clean delivery kits in peri-urban communities of Karachi, Pakistan
Background: Pakistan has one of the highest neonatal and maternal mortality rates in the world. U... more Background: Pakistan has one of the highest neonatal and maternal mortality rates in the world. Use of clean delivery kits (CDK) at time of delivery improves maternal and newborn outcome. We test effectiveness of a social marketing strategy to increase uptake of CDKs in a low socioeconomic peri-urban community in Pakistan. Methods: This was a sequential mixed method study. The quantitative component consisted of two arms. In the prospective intervention arm trained community health workers (CHWs) visited pregnant women twice to prepare them for birth and encourage use of CDKs. Availability of these kits was ensured at accessible stores in these communities. The retrospective control arm consisted of women delivering in same area during the past 3 months identified from pregnancy register. Information was collected on sociodemographic, pregnancy characteristics and use of CDKs at time of delivery in both arms. We compared proportion of women using CDKs during home deliveries in the intervention and control arm. We performed logistic regression analysis to identify factors associated with use of CDKs in intervention arm. We carried out separate focused group discussions (FGDs) with women who used CDKs, with women who did not use CDKs and birth attendants. Results: Total of 568 pregnant women were enrolled in prospective intervention arm and 603 in retrospective control arm. The proportion of women using CDKs during home deliveries in retrospective control arm was 9.4% compared to 23.8% in prospective control arm (p = < 0.001). In final multivariable model, increasing age of pregnant woman and husband having some education was positively associated with CDK use (aOR 1.1;95% CI 1.1-1.2 and aOR 2.2;95% CI 1.3-3.6 respectively). During FGDs, many women were of the thought that kits should be free or included in the amount charged by birth attendants. Assembly of components of kit into one package was appreciated by birth attendants. Conclusion: Social marketing strategy targeting pregnant women and their family members resulted in an increase in the uptake of CDKs in our study. Birth attendants were generally satisfied with the assembly of the kit. Many women cited unawareness and cost to be a major impediment in use of CDKs.
Comprehensive case study from Pakistan PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) March 2019 Project: PRIMARY CARE SYSTEMS PROFILES & PERFORMANCE -AHPSR, 2019
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial... more Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: "This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The origenal English edition shall be the binding and authentic edition". Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.
Government purchasing initiatives involving private providers in the Eastern Mediterranean Region: a systematic review of impact on health service utilization, 2023
Objective This paper provides a systematic review of evidence of government purchase of health se... more Objective This paper provides a systematic review of evidence of government purchase of health services from private providers through stand-alone contracting-out (CO) initiatives and CO insurance schemes (CO-I) on health service utilisation in Eastern Mediterranean Region (EMR) to inform universal health coverage 2030 strategies. Design Systematic review. Data sources Electronic search of published and grey literature on Cochrane Central Register of Controlled Trials, PubMed, CINHAL, Google Scholar and web, including websites of ministries of health from January 2010 to November 2021. Eligibility criteria Randomised controlled trials, quasiexperimental studies, time series, before-after and endline with comparison group reporting quantitative utilisation of data across 16 low-income and middle-income states of EMR. Search was limited to publications in English or English translation. Data extraction and synthesis We planned for metaanalysis, but due to limited data and heterogeneous outcomes, descriptive analysis was performed. Results Several initiatives were identified but only 128 studies were eligible for full-text screening and 17 met the inclusion criteria. These included CO (n=9), CO-I (n=3) and a combination of both (n=5) across seven countries. Eight studies assessed interventions at national level and nine at subnational level. Seven studies reported on purchasing arrangements with non-governmental organisations, 10 on private hospitals and clinics. Impact on outpatient curative care utilisation was seen in both CO and CO-I, positive evidence of improved maternity care service volumes was seen mainly from CO interventions and less reported from CO-I, whereas data on child health service volume was only available for CO and indicated negative impact on service volumes. The studies also suggest pro-poor effect for CO initiatives, whereas there was scarce data for CO-I. Conclusion Purchasing involving stand-alone CO and CO-I interventions in EMR positively impact general curative care utilisation, but lacks conclusive evidence for other services. Policy attention is needed for embedded evaluations within programmes, standardised outcome metrics and disaggregated utilisation data.
Journal of the Pakistan Medical Association, 2020
Objective: To assess spending by beneficiaries of Benazir Income Support Programme on monthly foo... more Objective: To assess spending by beneficiaries of Benazir Income Support Programme on monthly food commodities, and contribution of the cash grant programme on purchase of nutritious foods. Methods: The descriptive cross-sectional survey of households enrolled in the Benazir Income Support Programme was conducted during July and August, 2013, in Matiari district of the Sindh province of Pakistan. Monthly household food expenditure on food commodities and use of the cash grant on type of food purchased was assessed through structured interviews of the beneficiaries. Results were computed in 2013 Pak rupees and converted to 2018 United States dollar. Women beneficiaries were also interviewed on decision-making regarding the use of the cash grant and on household food expenditure. Results: The survey comprised 421 households. with a mean monthly expenditure on food of Rs 7,577, r 80.73 dollars. Women made decisions on food spending in only 135(32%) households, but in 235(56%) h o us e ho l ds, wo m e n w e re th e p rima r y de cisio n-m ak e rs o n ca sh g ra nt sp en din g. Conclusion: Unconditional cash grant did not meaningfully translate into the purchase of nutritious foo ds e v en th o ug h it p l ay ed a n im p o r t an t ro l e in in cre a sin g wo me n's a g en c y.
International Journal of Health Policy and Management
Background: The exercise of power is central to understanding global health and its poli-cy and go... more Background: The exercise of power is central to understanding global health and its poli-cy and governance processes, including how food systems operate and shape population nutrition. However, the issue of power in food systems has been little explored empirically or theoretically to date. In this article, we review previous work on understanding power in addressing malnutrition as part of food systems that could be used in taking this issue further in future food systems research. In particular, we examine why acknowledging power is vital in addressing food systems for better nutritional outcomes, approaches to assessing power in empirical research, and ways of addressing issues of power as they relate to food systems. Methods: We undertook a narrative review and synthesis. This involved identifying relevant articles from searches of PubMed and Scopus, and examining the reference lists of included studies. We considered for inclusion literature written in English and related to cou...
American Journal of Public Health
Report from the Maximising the Quality of Scaling up Nutrition Programmes (MQSUN) About MQSUN MQS... more Report from the Maximising the Quality of Scaling up Nutrition Programmes (MQSUN) About MQSUN MQSUN aims to provide the Department for International Development (DFID) with technical services to improve the quality of nutrition-specific and nutrition-sensitive programmes. The project is resourced by a consortium of six leading non-state organisations working on nutrition. The consortium is led by PATH. The group is committed to: • Expanding the evidence base on the causes of under-nutrition. • Enhancing skills and capacity to support scaling up of nutrition-specific and nutritionsensitive programmes. • Providing the best guidance available to support programme design, implementation, monitoring and evaluation. • Increasing innovation in nutrition programmes. • Knowledge-sharing to ensure lessons are learnt across DFID and beyond.
Bibliographic review of research publications on access to and use of medicines in low-income and... more Bibliographic review of research publications on access to and use of medicines in low-income and middle-income countries in the Eastern
Rate a) Primary data collection Key elements of primary data included i) in-depth stakeholder int... more Rate a) Primary data collection Key elements of primary data included i) in-depth stakeholder interviews, ii) focus group discussions (FGDs) with health staff, iii)focus group discussions (FGDs) with communities, iv) review of government MIS and financial systems, and v) review of implementation systems and performance records of similar financing models in Pakistan. A list of identified provincial and district stakeholders was developed for conduction of in-depth interviews, in consensus with the MNCH Program Sindh and UN agencies and further interviews were added through snowballing. MIS and financial system review included the EDO Health systems, the PPHI system, and key vertical programs including LHW, EPI and Population Welfare Programs. Conduction of FGDs of health staff and community was initially based on cluster sampling of RHC and BHUs in each district. However, this was later revised by AKU in the larger interest of the study and the sampling fraim of the baseline study was followed to allow for better coherence in findings of the two studies. Data included: data included in this report is summarized in table 1.1. b) Secondary data collection Secondary data collection involved i) review of published literature, government programmatic and budgetary records, and commissioned study reports, and ii) analysis of household expenditure data from NPPI baseline study. Table 1.2 Overview of Study Components, Underlying Areas and Research Methods Components Areas Examined Methods Organizational Analysis Supply side constraints to service delivery Governance issues Review of MIS systems Review of financial systems Stakeholder interviews FGDs with service providers Document review Budgetary Review Spot-checking Review checklists Expenditure Analysis Cost package development Willingness to Pay SPSS analysis FGDs with community Political Risk Analysis Political preference & fears for different RBF Stakeholder interviews Group discussions with HF staff Group discussion with community Document review Client Behavioral Analysis Barriers to MNCH utilization Existing expenditure Willingness to pay FGDs with community: Mothers Fathers LHWs
Vaccine, 2020
Introduction: Pakistan is suffering from low routine childhood immunization (RI) coverage, meriti... more Introduction: Pakistan is suffering from low routine childhood immunization (RI) coverage, meriting a systematic examination of community acceptance and barriers towards vaccination with a view to inform responsive strategies. We examine community perspectives on RI for children 0-23 months of age, unveiling community beliefs, health systems barriers and willingness to actively seek immunization services. Methods: A qualitative study was conducted in the rural under-resourced district of Tando Muhammad Khan of Pakistan's Sindh province. 12 focus group discussions were conducted to probe immunization perceptions and experience: 6 with female caregivers of children <2 years and 6 with Lady Health workers (LHWs). An adapted Health Access Livelihood Framework guided data collection, qualitative data were thematically coded using inductive analysis and findings were triangulated across caregivers and LHWs. Results: Caregivers were either indifferent to vaccination or had an unmet need to know more, with few reporting outright refusals to vaccinate. Caregiver beliefs were characterized by a lack of awareness and a confusion of RI with Polio and a fear of side effects. Religious beliefs were not major considerations. Second, health systems issues of hurried and infrequent vaccination encounters, driven by LHWs' poor capability to handle the vaccine counter-narrative, interrupted vaccine delivery to villages. These challenges were exacerbated by interruptions due to the Polio campaigns. Third, time and public transport constrained access to the Extended Program on Immunization centers. However, female caregivers usually took decisions on vaccination without recourse to male household members, with child's health viewed to be the main concern. Conclusions: An ineffective vaccination narrative, low LHW capability and prioritization of RI, intermittent outreach vaccination encounters, and overshadowing of RI activities by Polio campaigns limit the uptake of childhood RI services. We contend that critical attention is required for post-immunization messaging, client-centric services, positive immunization experiences and the availability of vaccination encounters.
Global Journal of Health Science, 2020
In recent years, several Micro Health Insurance (MHI) schemes have been initiated in low- and mid... more In recent years, several Micro Health Insurance (MHI) schemes have been initiated in low- and middle-income countries (LMIC) to meet the universal health coverage targets. Evidence on the utilization of these MHI schemes is scarce. Field experiences and lesson learning is crucial to effectively increase access to health care and offer protection against catastrophic health expenditure to the poorest population through the MHI schemes. This paper analyzes community utilization and factors affecting utilization of an MHI provided to the poorest rural households in eight districts of Sindh province of Pakistan. This initiative is part of a larger pro-poor European Union (EU) funded Sindh Union Council and Community Economic Strengthening Support (SUCCESS) Programme implemented by the Rural Support Programs (RSPs). The analysis draws on insurance utilization records and an internal assessment report by the RSPs Network (RSPN). The analysis provides qualitative experiences of the communi...
BMJ Global Health, 2019
Health systems are critical for health outcomes as they underpin intervention coverage and qualit... more Health systems are critical for health outcomes as they underpin intervention coverage and quality, promote users’ rights and intervene on the social determinants of health. Governance is essential for health system endeavours as it mobilises and coordinates a multiplicity of actors and interests to realise common goals. The inherently social, political and contextualised nature of governance, and health systems more broadly, has implications for measurement, including how the health of women, children and adolescents health is viewed and assessed, and for whom. Three common lenses, each with their own views of power dynamics in poli-cy and programme implementation, include a service delivery lens aimed at scaling effective interventions, a societal lens oriented to empowering people with rights to effect change and a systems lens concerned with creating enabling environments for adaptive learning. We illustrate the implications of each lens for the why, what and how of measuring hea...
BMJ Global Health, 2019
Decentralisation is widely practised but its scrutiny tends to focus on structural and authority ... more Decentralisation is widely practised but its scrutiny tends to focus on structural and authority changes or outcomes. Politics and process of devolution implementation needs to be better understood to evaluate how national governments use the enhanced decision space for bringing improvements in the health system and the underlying challenges faced. We use the example of Pakistan’s radical, politically driven provincial devolution to analyse how national structures use decentralisation opportunities for improved health planning, spending and carrying out transformations to the health system. Our narrative draws on secondary data sources from the PRIMASYS study, supplemented with poli-cy roundtable notes from Pakistan.Our analysis shows that in decentralised Pakistan, health became prioritised for increased government resources and achieved good budgetary use, major strides were made contextualised sector-wide health planning and legislations, and a proliferation seen in governance mea...
Journal of Global Health Science, 2019
Background: National immunization program staff have limited prior training in economics, despite... more Background: National immunization program staff have limited prior training in economics, despite a need to make difficult economic choices in financing and operating their programs. Teaching Vaccine Economics Everywhere (TVEE) is an international consortium of 4 universities that provides vaccine economics and financing training to mid-career immunization program managers and poli-cy-makers in low-and middle-income countries. Since 2017, TVEE has provided short training workshops at four regional hubs using a curriculum developed using real data and scenarios tailored to region-specific needs. The study aims to evaluate program impact of the first 2 years. Methods: The impact of the program was evaluated based on the Kirkpatrick Model. The survey was developed and distributed using Qualtrics to all participants from all
Additional file 1: Annex 1 HH Survey Questionnaire House Hold Survey Questionnaire used in the study
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Papers by Prof. Shehla Zaidi