JPMA. The Journal of the Pakistan Medical Association
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Randomized Controlled Trial Comparative Study
Management of acute asthma in children using metered dose inhaler and small volume nebulizer.
To determine whether the administration of beta2-agonist by Metered Dose inhaler (MDI) with accessory device (AD) is a as effective as the administration of beta2-agonist by small volume nebulizers (SVN) for the treatment of acute asthma. ⋯ The data suggested that MDI/AD is an effective alternative to nebulizer for the treatment of children with acute asthma exacerbation in the ER.
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As an opening of a dialogue on health reforms in Pakistan, the Gateway Paper presents a viewpoint on its proposed directions making a strong case for systems reforms, which need to scope beyond the healthcare system. Positioning the reform process to strengthen Pakistan's health policy cycle, the paper articulates a roadmap for a paradigm shift to achieve health outcomes in Pakistan with major structural reorganization within the health system. The proposed reform points in the four areas namely, reforms within the health sector, overarching measures, reconfiguration of health within an inter-sectoral scope and generating evidence for reforms. ⋯ The third area of reform involves broadening health to its inter-sectoral scope, redefinition of objectives and targets within the health sector and garnering support from across the sectors to forester inter-sectoral action particularly with reference to the social determinant of health. The fourth area of reform focuses on generation of evidence around which several priority areas for health systems and policy research have been flagged. The Gateway Paper also underscores the need to develop norms and standards and points to institution mechanisms which need to be created to support the reform process.
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As opposed to preventive healthcare where State mandated healthcare agencies play a pre-dominant role, a number of actors within the healthcare system other than the State play a role in providing personalized curative healthcare within the country. The sector constitutes a set of diverse group of doctors, nurses, pharmacists, traditional healers, drug venders as well as laboratory technicians, shopkeepers and unqualified practitioners. The services they produce include hospitals, nursing homes, maternity clinics, clinics run by a range of healthcare providers, diagnostic facilities and the sale of drugs from pharmacies and unqualified sellers. ⋯ With this as a context recommendations focus on the nature of regulatory mechanisms and the institutional arrangements necessary support them with particular reference to quality and continuing medical. In regard to traditional medicines directions focus on exploring ways to harnessing the potential within the system in order to leverage its outreach and integrate it with the formal healthcare system. The Paper also stresses on the need to fully exploit the potential within behavioral change interventions in order improve health systems performance in Pakistan and to broaden its scope from lifestyle and prevention behaviors in a health education paradigm to impact the performance of all the actors in the health care system.
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The Gateway Paper recognizes three system interfaces as being critical to the delivery of healthcare within Pakistan. These include the federal/provincial interface, the provincial-district interface and the public-private interface. A number of gaps in each area have been highlighted. ⋯ The clear delineation of these issues provides a substrate, which need to be at the heart of strategic reform within the context of the recent devolution initiative. At the public-private interface the absence of locally established principles, legislative frameworks, policies and operational strategies have been contributing to the adhoc nature of public-private engagement within the country, which leads to skewed powered relationships and lack of clarity in combined models of governance. Within this context the Gateway Paper makes a strong case for developing a set of norms and ethical principles, developing legislative and policy frameworks, and specific guidelines to steer such relationships with careful attention to accountability and sustainability related parameters.
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Pakistan's public health interventions include a range of programs lead by the federal government with implementation arms at the provincial and district levels. Some of the programs are disease specific such as the respective programs on HIV/AIDS, Malaria, Tuberculosis, non-communicable diseases and Hepatitis; others are specific to life cycle domains such as in the case of maternal and child health whereas still others such as the National Program for Family Planning and Primary Healthcare and the National Expanded Program for Immunization are cross-cutting. Although these programs have contributed to improving health outcomes at intermediate outcomes level, a number of critical impediments to maximizing their impact have been noted. ⋯ The Gateway Paper makes a number of recommendations to obviate these issues such as recommendations to integrate programs, strengthen surveillance systems, and with reference to obviating issues to implementation, emphasis is laid on decentralizing decision-making and central control, institutionalizing managerial audit, and prioritizing specific governance and management reforms. The Paper also stresses on the need for establishing a national coordination mechanism for fostering federal/provincial harmony and ensuring the creation of appropriate counterpart institutional arrangements in the provinces and districts. Recommendations on restructuring BHUs at a management, oversight, quality related and community participation level will play a vital role in determining the manner in which the efficiency of these public health programs can be enhanced.