Emerging role of traditional birth attendants in mountainous terrain: a qualitative exploratory study from Chitral District, Pakistan.

OBJECTIVES: This research endeavours to identify the role of traditional birth attendants (TBAs) in supporting the maternal, newborn and child health (MNCH) care, partnership mechanism with a formal health system and also explored livelihood options for TBAs in the health system of Pakistan. SETTING: The study was conducted in district Chitral, Khyber Pakhtunkhwa province, covering the areas where the Chitral Child Survival programme was implemented. PARTICIPANTS: A qualitative exploratory study was conducted, comprising seven key informant interviews with health managers, and four focus group discussions with community midwives (CMWs), TBAs, members of Community Based Saving Groups (CBSGs) and members of village health committees (VHCs). RESULTS: The study identified that in the new scenario, after the introduction of CMWs in the health system, TBAs still have a pivotal role in health promotion activities such as breastfeeding promotion and vaccination. TBAs can assist CMWs in normal deliveries, and refer high-risk cases to the formal health system. Generally, TBAs are positive about CMWs' introduction and welcome this addition. Yet their livelihood has suffered after CMWs' deployment. Monetary incentives to them in recognition of referrals to CMWs could be one solution. The VHC is an active forum for strengthening co-ordination between the two service providers and to ensure an alternate and permanent livelihood support system for the TBAs. CONCLUSIONS: TBAs have assured their continued support in provision of continuum of care for pregnant women, lactating mothers and children under the age of 5 years. The district health authorities must figure out ways to foster a healthy interface vis-à-vis roles and responsibilities of TBAs and CMWs. In time it would be worthwhile to do further research to look into the CMWs' integration in the system, as well as TBAs' continued role for provision of MNCH care.

Analytical, nutritional and biological evaluation of various brands of fortified and non-fortified wheat flour.

In Pakistan, a funded flour fortification program was launched for malnourished population, residing mainly in rural low income areas, but the urban population having comparatively better nutritional as well as economic status was focused wherein excessive intake of fortificants might cause complications. Therefore, the present study describes the physicochemical properties, elemental composition, nutritional components and hemoglobin/ferritin increasing potential of fortified and non-fortified flour. Domesticated chicken (Gallus gallus domesticus), either sex, age one month, weight 380 ± 18.28 g, were randomly segregated into 4 groups (n=6). The group I, II and III were fed on fortified flour, whereas group IV was fed on non-fortified flour for 30 days. The birds were weighed and blood samples of each of the birds were analyzed for determination of markers of iron status, hemoglobin (Hb) and serum ferritin (SF). Moisture, ash and iron contents were found to be lower in non-fortified flour than that of the fortified samples. Hb and SF levels in groups fed on fortified flour were significantly higher than the one received non-fortified flour (P < 0.05). The consumption of iron-fortified flour increases iron stores in the body without any further complication but long-term usage needs to be monitored.

Pakistan's health system: performance and prospects after the 18th Constitutional Amendment.

Pakistan has undergone massive changes in its federal structure under the 18th Constitutional Amendment. To gain insights that will inform reform plans, we assessed several aspects of health-systems performance in Pakistan. Some improvements were noted in health-systems performance during the past 65 years but key health indicators lag behind those in peer countries. 78·08% of the population pay out of pocket at the point of health care. The private sector provides three-quarters of the health services, and physicians outnumber nurses and midwives by a ratio of about 2:1. Complex governance challenges and underinvestment in health have hampered progress. With devolution of the health mandate, an opportunity has arisen to reform health. The federal government has constitutional responsibility of health information, interprovincial coordination, global health, and health regulation. All other health responsibilities are a provincial mandate. With appropriate policy, institutional, and legislative action within and outside the health system, the existing challenges could be overcome.