User:Saherdaredia/sandbox

Community Health in Karachi, Pakistan

For my practice experience, I will be traveling to Karachi, Pakistan to work at Aga Khan University (AKU), an independent research university with its primary campus in Karachi and additional campuses in East Africa and Central Asia. AKU’s Department of Community Health Sciences is a leading institution in advancing primary health, public health infrastructure, and other evidence-based approaches of health in urban and rural settings. The Urban Health Program (UHP), an initiative within the Community Health Sciences department at AKU, aims to provide health and socioeconomic support to the squatter settlement communities of Karachi.

For the duration of my practice experience, I will be involved in pre-project planning, design, and background research for a community health project being conducted by the Urban Health Program. Alongside a team of researchers from the UHP, I will develop surveys and prepare other methods for gathering quantitative data to better understand the impact of AKU’s health prevention advocacy in two distinct sites — Rehri Goth and Sultanabad. While visiting these sites, I hope to learn more about the daily lives and challenges of Karachi’s citizens, including the barriers they face in receiving proper healthcare for themselves and their families. Based on the quantitative and qualitative data I gather from my observations, I will evaluate my assigned project and write a report on its impact.

Wikipedia Article Selection

Area

Brainstorming Area Articles

• History of Karachi
• Feminism in Pakistan
• Women in Pakistan
• Health care in Karachi: This article is currently very sparse and could include more information about the general public health infrastructure in Karachi
• Urbanisation in Pakistan: This article has an interesting subsection titled "Effects of Urbanisation on Public Health"
• Family Planning in Pakistan

Final Area Article Selection: Healthcare in Pakistan

In order to better understand the area of my practice experience, I will need to learn more about the geopolitical and cultural history of Pakistan, specifically the port city of Karachi, following its fairly recent formation in 1947 after the end of British colonialism. Since Pakistan was founded on the basis of religion, I will also need to gain a better understanding of the importance of the country’s religion, Islam, on the day-to-day practices of its citizens and their customs. Through my PE org, I plan to conduct a community health research project in Pakistan so I will need to research the specific barriers that low-income populations in Karachi face in obtaining proper health care. I am still finalizing the details of the research project I will be conducting so I am not sure what demographic or health issue I will be working with. However, I am personally interested in learning more about the intersection between the social and religious norms and the health care of low-income women in urban Pakistan, specially in terms of their reproductive rights and family planning.

I am choosing the Wikipedia article "Healthcare in Pakistan" in order to contribute to the subsection titled Community Medicine. This subsection can use more information on community-level efforts like the lady health workers program that strive to promote the health of Pakistan's underserved while also being sensitive to cultural norms. I can also contribute more details about the existing governmental health programs in place such as the Social Action Program (SAP) and the National Health Policy Guidelines.

Sector

Brainstorming Sector Articles

• Gender disparities in health
• Women's health
• Social determinants of health
• Field research: This article has an interesting subsection titled "Field Research across Different Disciplines" which then has a subsection called "Public Health"

Final Sector Article Selection: Community health

I am planning to add a subsection called "Community Health in the Global South" or "Community Health in Developing Countries" since this article only focuses on community health from the perspective of a Westernized society in the Global North. In this section I can compare and contrast the approaches one must take to addressing community health in these geographic regions. I can also delve into the community-level approaches one must take to promoting health in the Global South through the lens of medical anthropology, sociology, and public health of course.

Article Evaluation

Evaluation of Health care in Karachi

This article is fairly sparse and has little specific details about the health care system in Karachi. The first paragraph of the article gives a lengthy, yet broad definition of health care. This definition is verbatim of the definition of health care in the Wikipedia article about health care. Currently the article begins to describe the health care system in Karachi, jumps to this general description of health care, and then returns back to describing Karachi's health system. This creates an awkward and abrupt flow in the article. While the article is unbiased, there are only four subheadings — public health care, hospitals, medical education, and medical tourism. Of these four subheadings, only public health care has text. The other three subheadings simply link to a list of hospitals and medical schools in Karachi. This article only has five citations. The links to the sources work and correlate to the claims in the article, but not all of the claims in the article have citations. A bubble at the top of the article states that the article needs additional citations for verification. The "Talk" page discussion rates the article as "Stub-Class" which is very poor quality. A couple of external links have been modified on the article.

Scholarly Sources

Area

Strikethrough = these are interesting sources that I found in my initial searches, but that I did NOT end up incorporating in my final drafting.

1. Ghaffar, Abdul, et al. “Health Care Systems in Transition III. Pakistan, Part I. An Overview of the Healthcare System in Pakistan.” ​Journal of Public Health Medicine,​ vol. 22, no. 1, 11 Oct. 1999, pp. 38–42.
   • Ghaffar et al. argues that after Pakistani independence, three social factions (the military, civil service, and politicians) rose to power, leading to the neglect of the social sector of Pakistani society, as seen by the lack of sustainable improvements in health. This article highlights recent initiatives to rethink the national health policy guidelines through programs like the Social Action Programme Project (SAPP) and Prime Minister’s Programme for Family Planning and Primary Health Care (PMP). These relatively new programs aim to provide communities with various outreach services related to reproductive health, maternal and child health, health education, and the referral of high-risk patients to facilities. The rise of these programs and public-private relationships within the Pakistani health sector is important for understanding how AKU closely collaborates with the Pakistani government. I used this article to add more information about the current public health infrastructure in Pakistan to the “Introduction” section of the “Healthcare in Pakistan” Wikipedia article.
2. Candland, Christopher. “Institutional Impediments to Human Development in Pakistan.” ​The Post-Colonial States of South Asia​, edited by Amita Shastri and A. Jeyaratnam Wilson, Palgrave Macmillan, 2001, pp. 264–283.
   • This article provides an overview of the historical events that have contributed to Pakistan's current status as one of the countries with the lowest rates of literacy, life expectancy, infant and maternal survival in the world. Candland raises the question of why Pakistan suffers such serious levels of deprivation in its social structure despite its recent economic growth. Candland also analyzes trends in the Pakistani government's expenditure on social sectors and evaluates the effectiveness of the Social Action Programme Project (SAPP).   I used this source to contribute to the “Community Medicine” subsection of the Wikipedia article “Healthcare in Karachi” in order to illustrate existing government healthcare programs like the Social Action Programme. Future restructuring of government expenditure and restructuring of government institutions can benefit from this historical analysis.
3. Akbari, Ather H., et al. “Demand for Public Health Care in Pakistan.” The Pakistan Development Review, vol. 48, no. 2, 2009, pp. 141–153., doi:10.30541/v48i2pp.141-153.
   • This report by the Pakistan Institute of Development Economics estimates a health care demand model for each province in Pakistan to explain the outpatient visits to government hospitals over the period 1989-2006. Explanatory variables in the model include the number of government hospitals per capita, doctors’ fee per visit at a private clinic, income per capita, the average price of medicine, and the number of outpatient visits per capita in the previous period. In most provinces, the demand for health care was positively related to the availability of health services, doctors’ fees at private clinics, and the past level of demand. The demand is negatively related to the price of medicine in most provinces. I used this source to contribute to the “Introduction” section of the Wikipedia article “Healthcare in Karachi” — the article I have chosen as my “area” article. The factors identified in this report and improved accessibility of health care facilities should be the focus of future public policy aimed at increasing the use of public health care facilities in Pakistan.
4. Akram, Muhammad, and Faheem Jehangir Khan. “Health Care Services and Government Spending in Pakistan.” Pakistan Institute of Development Economics Islamabad, Pakistan Institute of Development Economics, Islamabad, 2007.
   • This report by the Pakistan Institute of Development Economics reviews the national policies emphasizing health services as well as the trends in access to public health care facilities in Pakistan. Inequalities in resource distribution and service provision are analyzed against government health expenditures. The report finds that rural areas of Pakistan are more disadvantaged in the provision of healthcare facilities. The need for regulation in the private healthcare sector is also extensively discussed. With this information, private institutions like Aga Khan University can address issues with monitoring and fill in gaps where government provision of healthcare falls short.  I used this source to contribute to the “Introduction” section and “Community Medicine” subsection of the Wikipedia article “Healthcare in Karachi.”
5. Kurji, Zohra, et al. “Analysis of the Health Care System of Pakistan: Lessons Learnt and Way Forward.” Journal of Ayub Medical College Abbottabad, vol. 28, no. 3, 2016, pp. 601–604.
   • This article from the Aga Khan University’s School of Nursing and Midwifery identifies key components of the health care delivery system in Pakistan such as recent changes in the National Health Policy, participation in the Millenium Development Goals program, the Public Private Partnership, and improved infrastructure through Basic Health Units and Rural Health Centres. However, the article also outlines the weaknesses in these programs, such as poor governance, lack of access and unequal resources, lack of monitoring, and corruption in the health system. The article concludes that Pakistan has been improving very slowly in the health sector for the last five decades, but calls upon the government to take strong initiatives to catalyze this progress and change the current healthcare system. I used this article to contribute information about the private vs. public healthcare systems in Pakistan and Pakistan’s involvement with the Millenium Development Goals to the “Introduction” section of the “Healthcare in Pakistan” Wikipedia article. I also used this source to add details about the National Programme for Family Planning and Primary Health Care to the “Community Medicine” subsection of the “Services” section of this same article. Using the information in this source, private healthcare institutions, like AKU, must strive to fill in the gaps in the healthcare sector until public institutions are improved.
6. Shaikh, B. T., and J. Hatcher. “Health Seeking Behaviour and Health Service Utilization in Pakistan: Challenging the Policy Makers.” Journal of Public Health, vol. 27, no. 1, 2005, pp. 49–54., doi:10.1093/pubmed/fdh207.
   • This paper presents an extensive literature review of the physical, socioeconomic, cultural, and political factors that lead to the seeking of healthcare and health service utilization in Pakistan. It provides an overview of the country’s current public and private healthcare infrastructure. The article then considers the role of factors like cultural beliefs, socio-demographic status, women’s autonomy, economic conditions, physical and financial accessibility, and disease patterns in the poor utilization of primary health care services. To develop more effective policy that provides efficient and affordable services, these factors must be understood in both the country's public and private healthcare spheres. I used this source to add information regarding partnerships in the public-private healthcare sphere in urban areas of Pakistan to the “Introduction” section of the “Healthcare in Pakistan” Wikipedia article.
7. Nishtar, Sania, et al. “Health Reform in Pakistan: a Call to Action.” Lancet, vol. 381, 29 June 2013, pp. 2291–2297., doi:http://dx.doi.org/10.1016/ S0140-6736(13)60813-2.
   • This article evaluates the role of Pakistan’s macroeconomic, internal, and human security challenges in the attainment of its national health goals. It analyzes the role of the 18th Constitutional Amendment in bringing changes to federal-provincial relations and calls for health to be included in the nation-building agenda. By presenting a new detailed federal health sector framework that the government of Pakistan can adopt for greater accountability, this article identifies key debates surrounding the universalization of healthcare in the country. The historical background and goals for future universal and targeted health access provide insight into the complex development of community health infrastructure. I drew upon the historical background presented in this source to contribute to the “Introduction” section of the “Healthcare in Pakistan” Wikipedia article.
8. Shaikh, Babar Tasneem. “Private Sector In Healthcare Delivery: A Reality and a Challenge in Pakistan.” Journal Ayub Medical College , vol. 27, no. 2, 2015, pp. 496–498.
   • This article describes how the underperformance of the public healthcare sector in Pakistan has created a niche for the private sector to grow and become popular in health service delivery. Despite its questionable quality, high cost, and lack of regulation, the private sector has demonstrated a great deal of responsiveness, creating trust with the consumers of health in Pakistan. I added objective information about this paradox to the “Introduction” section of the “Healthcare in Pakistan” Wikipedia article. The article highlights the need to build the capacity and regulatory frameworks of private entities. With these transformations, players in Pakistan’s private health sector, such as AKU, will have the capacity to protect the poor’s access to healthcare systems.
9. Wazir, Mohammad Salim, et al. “National Program for Family Planning and Primary Health Care Pakistan: a SWOT Analysis.” Reproductive Health, vol. 10, no. 1, 2013, doi:10.1186/1742-4755-10-60.
   • This analysis of the National Program for Family Planning and Primary Healthcare identifies the 1994 program’s strengths, weaknesses, opportunities, and threats. Strengths of the program include its selection and recruitment of lady health workers, weaknesses include job insecurity and irregular payments, opportunities include the further widening of coverage and indirect benefits such as women empowerment, and threats the program may face include political interference and a lack of funds. In order to make the most efficient and effective use of the LHWs as a primary healthcare workforce, the program needs to be integrated properly into existing health structures. Mechanisms need to be developed to provide job security to workers and increase their motivation. I used this source to contribute to the “Community Medicine” subsection under the “Services” section of the Wikipedia article “Healthcare in Karachi” — specifically for details on the day-to-day activities of lady health workers.
10. Farooq, Shujaat, et al. “Welfare Impact of the Lady Health Workers Programme in Pakistan.” The Pakistan Development Review, vol. 53, no. 2, 2014, pp. 119–143., doi:10.30541/v53i2pp.119-143.
    • This report from the Pakistan Institute of Development Economics uses qualitative and quantitative approaches to analyze whether the LHWs serve the poor and vulnerable disproportionately, examine the contribution of the LHW program in improving child and maternal health, and evaluate the program’s poverty reduction impact. Findings from the study show that the LHW program has a significant and positive impact on contraceptive use, antenatal care and vaccination during pregnancy, and child vaccination. Despite the effectiveness of the program, delayed supply of medicines and irregularity in LHW visits can create mistrust among LHWs and the women they serve. I used this source to contribute to the “Community Medicine” subsection under the “Services” section of the Wikipedia article “Healthcare in Karachi” — specifically for the new paragraph on the lady health worker initiative. A better referral system, possibly through integration of the LHW program with private institutions like AKU, can be encouraged in order to streamline program effectiveness.
11. Khan, Ayesha. “Lady Health Workers and Social Change in Pakistan.” Economic and Political Weekly, vol. 46, no. 30, 29 July 2011, pp. 28–31.
    • This article provides a basic overview of the services offered by the Lady Health Workers Programme and outlines how the program’s achievements align with Pakistan’s Millenium Development Goals. In addition to case studies concerning the empowerment of LHWs, the article also sharings the growing resentment among the LHW community for the government due to their status as short-term service providers. Protests held by LHWs have called for an increase in salaries and government benefits. Violent controversies across the country have put some LHWs in danger as certain religious leaders disseminate the erroneous belief that vaccination campaigns are plots to sterilize Muslims. I used this source to contribute to the “Community Medicine” subsection under the “Services” section of the Wikipedia article “Healthcare in Karachi” — specifically for the new paragraph on the lady health worker initiative. Despite the drawbacks presented in this article, I believe LHWs have played an important role in revitalizing the public primary health care system. If universal coverage is reached, every community in Pakistan will have at least one working woman and potential leader, dramatically shifting the gender dynamics within the country’s community health sector.
12. “External Evaluation of the National Programme for Family Planning and Primary Health.” Oxford Policy Management, 2009.
    • This report summarizes the findings of a study undertaken as a part of the Third Party Evaluation of the Lady Health Worker Programme in Pakistan and focuses on the impact of LHW employment in terms of benefits for the LHWs themselves, their families, and their communities.  The report finds that the program’s visible nature of work, explicit focus on training, and high degree of mobility empowers women in ways that other work does not. I used this source to contribute to the “Community Medicine” subsection under the “Services” section of the Wikipedia article “Healthcare in Karachi” — specifically in regards to the new paragraph on lady health worker initiative. The conclusions from this paper would be beneficial for an expansion of the program into disadvantaged areas to potentially bring empowerment benefits to women from lower socio-economic backgrounds.
13. Afsar, Habib Ahmed, and Muhammad Younus. “Recommendations to Strengthen the Role of Lady Health Workers in the National Program for Family Planning and Primary Health Care in Pakistan: the Health Workers Perspective.” Journal of Ayub Medical College, vol. 17, no. 1, 2005, pp. 48–53.
    • This study by the Aga Khan University’s Department of Community Health Sciences assessed the strengths and weaknesses of the National Programme for Family Planning and Health Care’s Lady Health Workers initiative. An analysis of 20 interviews of LHWs found that permanent government employee status, raise in salary, and incentives such as skills training would increase the LHWs’ intrinsic motivation and acceptance by the communities they serve. Weaknesses in the patient referral system by LHWs also need to be addressed and communities must be educated about the assigned responsibilities of LHWs. This source provides a better understanding of the LHWs’ perspective in the effectiveness of their program. I plan to use this source to contribute to the “Community Medicine” subsection under the “Services” section of the Wikipedia article “Healthcare in Karachi” — the article I have chosen as my “area” article. Since the LHW initiative is a well-established community-based health worker program in Pakistan, partnership with institutions like AKU can bolster the importance of local discourse in the private healthcare sector. In order to strengthen these associations in the future, I believe the LHW Programme must first overcome its own challenges, mainly the agency given to the LHWs themselves.
14. Mahmood, Naushin, and Syed Mubashir Ali. “The Disease Pattern and Utilisation of Health Care Services in Pakistan.” The Pakistan Development Review, vol. 41, no. 4II, 2002, pp. 745–757., doi:10.30541/v41i4iipp.745-757.
    • This article describes the inefficiencies of the public health care delivery system in meeting the needs of the fast growing population, primarily due to difficulties related to access of facilities especially in rural areas. This article also explains how health-related data and statistics from both privately and public run health institutions is often incomplete and unreliable which limits the assessment of morbidity and mortality among subgroups of the country's population. The results of the authors' own study on disease incidence among different subgroups based on data from the 2001 Pakistan Socio-economic Survey is included in the paper.
15. Hyder, Adnan A., and Sarah Nadeem. “Health Ethics in Pakistan: A Literature Review of Its Present State.” ​Journal of Health, Population and Nutrition​, vol. 19, no. 1, Mar. 2001, pp. 6–11., doi:10.12816/0038111.
    • According to Hyder and Nadeem, there is a dearth of published discourse on healthcare ethics in Pakistan — a characteristic of the fact that Pakistan is still a developing country. Due to a very physician-dominant mode of health care, financial motivation has led to unethical practice as medical practices change and Pakistan’s developing national economy also changes. Dialogue about ethics may lead to better working solutions and methods to health inequality by addressing policy and legislation, the role of religion, and scarcity of resources. There is a subsection within my area Wikipedia article called “Resources” which is sparse and could use some more information regarding this discourse. AKU should also be implementing health ethics seminars designed for individuals who will be collecting samples from the field and directly interacting with populations.
16. Reading, Joshua P. “Who's Responsible for This? The Globalization of Healthcare in Developing Countries.” ​Indiana Journal of Global Legal Studies​, vol. 17, no. 2, 2010, pp. 367–387., doi:10.297x9/gls.2010.17.2.367.
    • In his article, Jeremy Reading discusses the phenomenon of globalization that is now arising in the developing world and how this has lead to the privatization of healthcare. He claims that despite this privatization, the standard of healthcare in developing countries has remained low and uses Pakistan as an example of this trend. Reading also argues that there should be an increase in government involvement to ensure proper levels of healthcare in Pakistan, despite help from foreign and nongovernmental organizations. Reading’s call for greater governmental involvement places my practice experience organization, Aga Khan University, in a unique position as an independent university that receives funding from and collaborates with the Pakistan government. The dominance of the private sector in healthcare, including Aga Khan University, raises questions about the effectiveness of my practice experience organization in promoting long-term health compared to a governmental organization.
17. Huda, Maryam, et al. “Inculcating Health Awareness in Karachi, Pakistan.” ​Gateways: International Journal of Community Research and Engagement​, vol. 10, 2017, pp. 78–96., doi:10.5130/ ijcre.v10i0.5481.
    • This article provides background information about the squatter settlements in Karachi and the types of conditions and diseases that residents of these settlements face. In addition, this article describes the AGAHI program, one of the initiatives of Aga Khan University's Urban Health Programme (UHP) to prevent and control hepatitis, dengue, and tuberculosis. UHP's four steps to community development are outlined. This article provides much insight on the reach and inner workings of my practice experience organization and the framework they use to develop new initiatives.
18. Qureshi, Salman. “The Fast Growing Megacity Karachi as a Frontier of Environmental Challenges: Urbanization and Contemporary Urbanism Issues.” ​Journal of Geography and Regional Planning,​ vol. 3, no. 11, Nov. 2010, pp. 306–321.
    • This article explores the key inequalities in wealth distribution in Karachi through a discussion of the city's landscape and the struggles associated with its urban planning and environmental quality. Besides offering a new environmental perspective to the conversation of healthcare and inequality in Pakistan, this article also addresses the role of the Pakistani government plays in addressing these intertwined issues. Through better governance and alertness of Karachiites to the problems of their city, sustainable initiatives can be developed that will make the city a globalized complex of economic activity and growth.
19. Hakim, Abdul. “Population Policy Shifts and Their Implications for Population Stabilisation in Pakistan.” The Pakistan Development Review, vol. 40, no. 4II, 2001, pp. 551–573., doi:10.30541/v40i4iipp.551-573.
    • This article discusses the history of population growth trends in Pakistan and the government's Five Year Plans that have characterized the country's development. Although family planning programmes have historically been neglected on political agendas, the most recent series of Five Year Plans have established more programs for fertility management and contraceptive options through the Ministry of Health.
20. Islam, A. “Health Sector Reform in Pakistan: Why Is It Needed?” Journal of the Pakistan Medical Association, vol. 52, no. 3, Mar. 2002, pp. 95–100.
    • This article from the Department of Community Health Sciences at AKU explores the many problems associated with the Pakistani health care system (i.e. gender insensitivity, resource scarcity, inefficiency) and the role of Pakistan's economic situation in contributing to its health infrastructure. This article also discusses the Devolution Plan of the Government of Pakistan which established district level elected local bodies to assess the publicly funded health care system and introduce reform in a more efficient manner.

Sector

Strikethrough = these are interesting sources that I found in my initial searches, but that I did NOT end up incorporating in my final drafting.

1. Corburn, Jason, and Alice Sverdlik. “Slum Upgrading and Health Equity.” International Journal of Environmental Research and Public Health, vol. 14, no. 4, 2017, p. 342., doi:10.3390/ijerph14040342.
   • This article expands upon the traditional use of settlement upgrading to enhance shelter and promote economic development by examining the role of upgrading in improving health equity. It defines the characteristics of slums and the community health risks associated with these characteristics. It also provides a review of urban slum upgrading projects and interventions in Latin American, African, and Asian cities including Karachi, Pakistan and discusses ways to integrate health equity into urban slum upgrading. By legitimizing the right of slum-dwellers to remain, slum upgrading not only brings structural improvements to community health, but it also incorporates these rights in state-wide policy frameworks. AKU’s Urban Health Programme bases its practices on a “doorstep” approach that legitimizes poverty as a problem of place and the right of settlement dwellers to receive proper health care directly in their own place. I explored this concept in the new “Community Health in the Global South” section that I added to the “Community Health” Wikipedia article.
2. Hossain, S M Moazzem, et al. “Community Development and Its Impact on Health: South Asian Experience.” BMJ Global Health , vol. 328, no. 7443, 2004, pp. 830–833., doi:10.1136/bmj.328.7443.830.
   • This article discusses some of the most prominent examples in South Asia of the involvement of the community in planning, managing, and evaluating health projects. It discusses the role of community health workers to act as a bridge between the community and health professionals, citing the Pakistani Ministry of Health's lady health worker program. Community participation has been the pillar of primary healthcare since the Alma Ata declaration, but few examples of true participation by local community members exist. Community development has coincided with improvements of health indicators in recent decades, but this causal link has only been established in a few small scale projects and remains to be observed at the national scale. I used this source to discuss the role of community development as a participation-related public health intervention in the Global South when contributing to the “Community Health” Wikipedia article.
3. Peters, David H., et al. “Poverty and Access to Health Care in Developing Countries.” Annals of the New York Academy of Sciences, vol. 1136, no. 1, 2008, pp. 161–171., doi:10.1196/annals.1425.011.
   • This article discusses the disparities in access to health services in low and middle-income countries using a framework that incorporates quality, geographic accessibility, availability, financial accessibility, and acceptability of services. The main challenge is finding ways to ensure that vulnerable populations have a say in how strategies are developed and implemented. Gaining a local understanding of the dimensions of access to health services is essential to provide access to health care in developing countries. I used Peters et al. to discuss the broad barriers to accessing health in the Global South in my sector Wikipedia contributions.
4. Orach, Christopher Garimoi. “Health Equity: Challenges in Low Income Countries.” African Health Sciences , vol. 9, no. 2, Oct. 2009, pp. 549–551.
   • This editorial provides an in-depth discussion on the concept of health equity and the structure of health inequities in low income countries. Coherent actions across government sectors such as finance, education, housing, employment, and transportation are needed to improve health equity. Involving private sectors is also vital for health equity and promotes fair decision making. Although individuals must be at the heart of empowerment to achieve health equity, achieving a fairer distribution requires collective social action through the empowerment of nations, institutions, and communities. This source discussed how countries in the Global South are undergoing the “epidemiologic transition” at a slower pace, creating larger divides in health equity — a concept I included in my Wikipedia drafting for sector.
5. Zwi, A. B, et al. “Private Health Care in Developing Countries.” Bmj, vol. 323, no. 7311, 2001, pp. 463–464., doi:10.1136/bmj.323.7311.463.
   • This article examines the increasing use of private healthcare in developing countries and outlines three objectives for private provision of care — widening access, improving quality, and ensuring non-exploitative prices. Community education strategies must be implemented to help people recognize how much they should be expected to pay for certain services. Accreditation schemes can be put in place to monitor the services offered by providers against agreed quality standards. Fee exemption schemes for specific target groups such as pregnant women, children, those with sexually transmitted infections etc. are costly to administer and scale up to the national level, but necessary in the public sectors of the poorest countries. State collaboration with private providers is needed to recognize that access to quality and affordable community healthcare is a right.
6. Whitehead, Margaret, et al. “Equity and Health Sector Reforms: Can Low-Income Countries Escape the Medical Poverty Trap?” The Lancet, vol. 358, no. 9284, 2001, pp. 833–836., doi:10.1016/s0140-6736(01)05975-x.
   • This article explores the phenomenon of the "medical poverty trap" in the Global South as a result of increased user fees for public services and the growth of out-of-pocket expenses for private services. Cultural access is a major problem within the public health sector, with a lack of responsiveness and disrespect shown towards disadvantaged groups. Evidence-based approaches are necessary to bring efficient, equity-oriented reforms within the health sector. Greater emphasis on equity must be placed when assessing the effects of proposed policy changes on the health and social wellbeing of communities.
7. Javanparast, Sara, et al. “Community Health Worker Programs to Improve Healthcare Access and Equity: Are They Only Relevant to Low- and Middle-Income Countries?” International Journal of Health Policy and Management, vol. 7, no. 10, 2018, pp. 943–954., doi:10.15171/ijhpm.2018.53.
   • This study examines the scope and potential value of community health worker (CHW) programs in Australia and the challenges involved with integrating CHWs into the health system. Semi-structured telephone interviews were conducted with policy makers, program managers, and practitioners. Findings showed that CHWs are well accepted and valuable, facilitating access to health services as “bridges” to communities. CHWs are most effective in healthcare systems that are less hierarchical and when action is based on the social determinants of health. Short term funding and lack of professional qualifications are the main challenges that CHWs encounter. CHWs offer promising opportunity to enhance health equity for the disadvantaged and marginalized by improving health education and community development, meeting the challenges of workforce shortages, and decreasing the burden of chronic and complex health conditions. I used this source to discuss the study’s findings that CHWs improved a vast range of health outcomes in my Wikipedia sector contributions.
8. Corburn, Jason. Street Science: Community Knowledge and Environmental Health Justice. MIT Press, 2005.
   • This book raises the questions of whether a community should defer to professionals, trusting that their findings are accurate, and if professionals have an obligation to take account of community-generated knowledge. “Street science” — a new framework for environmental health justice that joins local insights with professional techniques — is introduced as a way to democratize the decision-making processes in community development. Research institutions like AKU can incorporate local knowledge in public health development decisions to prevent the decontextualization of needs that often occurs within the private healthcare sector. I drew upon this source to discuss the role that community health workers play in promoting discourse based on local knowledge in the new “Community Health in the Global South” section that I added to the “Community Health” Wikipedia article.
9. Aginam, Obijiofor. “Global Village, Divided World: South-North Gap and Global Health Challenges at Century's Dawn.” ​Indiana Journal of Global Legal Studies,​ vol. 7, no. 2, 2000, pp. 603–628.
   • In this article, Obijiofor explains the why the global South-North gap is concerning and its implications for the globalization of public health. Obijiofor describes the the paradox of a global village — the phenomenon where inhabitants live so close in a global neighborhood, yet are so distant from one another in terms of access. Obijiofor argues that this paradox ultimately gives rise to adverse health consequences. This article gave me insight on the “globalization of poverty” through the conspiracy of international institutions and the globalizing private sector. As organizations like Aga Khan University attempt to bridge inequality, they must be aware of how poverty nurtures diseases in a manner that leads to an unequal distribution of the “global burden of disease” between populations in the Global South and Global North.
10. Lombe, Margaret, et al. “From Rhetoric to Reality: Planning and Conducting Collaborations for International Research in the Global South.” ​Social Work, vol. 58, no. 1, Jan. 2013, pp. 31–40.
    • This article explores the complexities of conducting health research in the Global South by exploring the process of collaboration formation, research plan development, funding, ethical concerns regarding human subjects, data analysis, and dissemination of research findings. In addition to explaining these frameworks, the authors address the importance of respect, mutuality, and science in conducting international research in resource-constrained countries in the Global South. When approaching community health research in the Global South and coming from a background within the Global North, it is important to keep these cross-cultural implications in mind.
11. Schatz, Enid, et al. “Working with Teams of ‘Insiders’: Qualitative Approaches to Data Collection in the Global South.” ​Demographic Research​, vol. 32, June 2015, pp. 369–396.
    • Schatz et al. discuss two qualitative methodological strategies — working in “teams” and with “insiders” to facilitate population health research in the Global South. According to this article, using local teams to collect community health data enhances data quality. Community-based participatory research (CBPR) approaches engage “insiders” of communities at the local level by building rapport and facilitating access, efficiency, and insights into research questions of interest to demographers. This approach to health research in the Global South highlights the nuances researchers must adopt to ensure efficient monitoring and data collection. These approaches may be implemented by organizations like Aga Khan University which are based in the Global South but often invite researchers from the Global North to spearhead community health research projects in impoverished communities.
12. Lysaniuk, Benjamin, and Martine Tabeaud. “Les Santés Vulnérables Des Suds.” Espace Géographique, vol. 44, no. 3, 2015, p. 229., doi:10.3917/eg.443.0229.
    • Using guidelines issued by the World Health Organization, this article defines health risks and vulnerabilities in the Global South. It then provides several examples from the Global South of the destabilization of health systems caused by "shocks" and "stresses" caused by external factors such as political changes.
13. South, Jane, and Gemma Phillips. “Evaluating Community Engagement as Part of the Public Health System.” Journal of Epidemiology and Community Health, vol. 68, no. 7, 2014, pp. 692–696., doi:10.1136/jech-2013-203742.
    • This paper proposes a new systems-level approach to the evaluation of community engagement in health promotion. Recommendations are given on how community engagement should be evaluated in order to capture the full range of health and social outcomes in a population

Summarizing and Synthesizing

Area

Based on the sources I have found so far, it is clear to me that Pakistan's brief history so far has been largely shaped by the institutions that still remain from the days of British colonialism. Since the country was founded in 1957, there have been efforts by the government, nonprofit organizations, and other institutions to develop the country's community health infrastructure. However, rampant poverty characterized by gender inequality and low literacy rates have resulted in slow progress on this front. In Karachi specifically, rapid urbanization has impacted the city's landscape and created struggles associated with its urban planning and environmental quality. As a result, the access and resource scarcity associated with poor environmental conditions is a major impetus for continued challenges in developing the health sector. National programs like SAPP and PMP have been established to promote health, but the increasing privatization of healthcare in Pakistan has been insufficient in providing a standard of care to the Pakistani people. I would like to further research specific health initiatives established by the Pakistani government such as the “lady health workers” — a community-based health initiative that serves women in rural Pakistani villages.

Sector

When addressing the development of the community health sector, one must be sensitive to the different approaches to community health that are taken in the Global North versus the Global South. The global burden of disease is unequally distributed between the Global North and the Global South. Community-based participatory research in the Global South uses “insiders” that understand the traditions and norms of the communities being studied. Aside from a sense of cultural sensitivity, the political and economic institutions within these hemispheres operate differently, creating a need for distinct approaches to promoting health at the community-level that draw upon localized knowledge. I would like to do further research about the major overarching distinctions between political and economic structures in the Global South versus the Global North and the impact of these differences on community health initiatives.

Drafting

Here, I will begin to draft sections to add to my selected Wikipedia articles. Citations to the scholarly sources I will be using will be added with the citation tool. Bolded text indicates new material that I propose to add to these articles. Non-bolded material is copied and pasted from the current Wikipedia article.

Area (Healthcare in Pakistan)

Introductory Section

The original introductory section is very unorganized. I would like to make some changes to the flow and order of the content. Below are my revisions to the introduction section.

Revisions to Intro (Consolidate with later section "Healthcare Delivery System")

*MOVE IMAGE IN CURRENT "HEALTHCARE DELIVERY SYSTEM" SECTION HERE*

The healthcare delivery system of Pakistan is complex because it includes healthcare subsystems by federal and provincial governments competing with formal and informal private sector healthcare systems. Healthcare is delivered mainly through vertically managed disease-specific mechanisms. The different institutions that are responsible for this include: provincial and district health departments, parastatal organizations, social security institutions, non-governmental organizations (NGOs) and private sector. The country’s health sector is also marked by urban-rural disparities in healthcare delivery and an imbalance in the health workforce, with insufficient health managers, nurses, paramedics and skilled birth attendants in the peripheral areas. Pakistan's gross national income per capita in 2013 was $5,041 and the total expenditure on health per capita in 2014 was $129, comprising 2.6% of the country's GDP.

Pakistan became a signatory to the UN Millennium Development Goals (MDGs) in 2000, adopting 16 targets and 37 indicators fixed by the UN Millennium Declaration for achieving the eight goals by 2015. After becoming a participatory body in the MDGs, the government of Pakistan restructured the national health policy in 2001 and began to initiate programs for preventative approaches and healthcare. The public sector was led by the Ministry of Health until its abolition in June 2011 when all health responsibilities (mainly planning and fund allocation) were devolved to provincial health departments. The Ministry of National Regulations and Services was reestablished in April 2012, reinstating a federal body to provide health services and implement healthcare policies. The public health sector is comprised of 10,000 health facilities with both Basic Health Units (BHUs) which cover around 10,000 people and Rural Health Centres (RHCs) which cover around 30,000 to 45,000 people. Initiatives implemented by the state, including the Social Action Programme and the National Programme for Family Planning and Primary Health Care, have aimed to provide communities with various outreach services related to reproductive health, maternal and child health, health education, and the referral of high-risk patients to specialized facilities.

Despite the increase in public health facilities, Pakistan's population growth has generated an unmet need for healthcare. Public healthcare institutions that address critical health issues are often only located in major towns and cities. Due to the absence of these institutions and the cost associated with transportation, impoverished people living in rural and remote areas tend to consult private doctors. Studies have shown that Pakistan's private sector healthcare system is outperforming the public sector healthcare system in terms of service quality and patient satisfaction, with 70% of the population being served by the private health sector. The private health sector operates through a fee-for-service system comprised of unregulated hospitals, medical general practitioners, homeopaths, hakeems, and other spiritual healers. In urban areas, some public-private partnerships exist for franchising private sector outlets and contributing to overall service delivery. Very few mechanisms exist to regulate the quality, standards, protocols, ethics, or prices within the private health sector.

"Services" Section ("Community Medicine" Sub-Section)

Pakistan's government has committed to the goal of making its population healthier, as evidenced by its support for the Social Action Programme (SAP) and by the new vision for health, nutrition, and population outlined in the National Health Policy Guidelines. The National Health Policy provides guidelines to provinces for improving health infrastructure and healthcare services while maintaining the role of the federal government in coordinating key programs such as communicable disease control. Initiated in 1992 by the Pakistan Peoples Party (PPP), the Social Action Programme aims to make advances in four social sectors: primary education, primary health, water supply and sanitation, and family planning. The goals of the program are to reform institutions and increase financing for social services within these sectors. SAP is largely financed by external organizations such as the World Bank, Asian Development Bank, Government of Netherlands, and Overseas Development Agency of UK.

In 1994, the Government of Pakistan launched the National Programme for Family Planning and Primary Healthcare. The main goal of the program is to provide primary health care to underserved populations, particularly women and children, through family planning services. Since its inception, the program has become one of the largest community health based programs in the world, providing primary healthcare services to 80 million people mostly in rural areas. One of the program's main initiatives, the Lady Health Worker Programme, trains women to serve as community health providers in areas across the country and has turned out to be a promising community-based health worker program. Lady health workers are local, literate women who undergo approximately 15 months of training after recruitment. Once training is complete, the lady health workers serve 100 to 150 homes by visiting 5-7 homes daily. The main responsibilities of lady health workers are to conduct screenings of pregnant women and refer them to clinical services if needed, distribute condoms and contraceptive pills, provide interventions for malnutrition such as nutritional counseling, and treat common diseases with special drug kits. There are currently approximately 96,000 women serving as lady health workers. Compared to communities not served by lady health workers, communities with access to this initiative are 11% more likely to use modern family methods, 13% more likely to have a tetanus toxoid vaccination, 15% more likely to receive a medical check-up within 24 hours of birth, and 15% more likely to have immunized children below the age of three years.

Despite the Lady Health Worker Programme's strengths, a study conducted in 2002 in Karachi has shown that many lady health workers feel that their salary is too low and their payment is too irregular. Lady health workers are not classified as permanent government employees and, therefore, do not have government benefits. The contractual nature of their job is a constant threat and source of anxiety. Other possible improvements include skill and career development opportunities for lady health workers and a stronger patient referral system within the program.

• Lady health workers: A recent initiative, lady health worker, has turned out to be a promising community-based health worker program. These workers bring health information, some basic health care and family planning services to doorsteps of women. Presently, 96,000 women are serving as in this initiative in their home villages.

*MOVE THE BELOW PARAGRAPH TO "EMERGENCE OF DIGITAL HEALTHCARE" SECTION*

In recent times, the startup culture in Pakistan has boomed with many players trying to change the healthcare segment as well.^{[45][46][47][48]}These startups are also helping patients to buy medicines online, order lab tests and get home sample collection done and maintain medical records so that all patient data & history is stored in one place.

"Healthcare Delivery System" Section

NOTE: I was originally intending on revising the current "Healthcare Delivery System" section, but after some thought, I would now like to consolidate it with the introduction for the article.

Healthcare delivery system of Pakistan is complex and both state and non-state actors play their role in delivering healthcare services, which is primarily the responsibility of state according to the Constitution of Pakistan. The private sector relies upon a fee-for-service system and includes a range of providers from trained allopathic physicians to faith healers operating in the informal sector. In the public sector, under the Devolution Plan of the Government of Pakistan in 2000, districts were given administrative and financial autonomy in many sectors, including health. While some healthcare delivery initiatives like the Lady Health Worker Programme fall under federal management, many other programs are managed by provincial departments of health. Community-based health workers are supported by a network of provincially managed health facilities ranging from Basic Health Units (BHU) which serve 10,000 people and larger Rural Health Centres (RHC) which cover around 30,000-45,000 people.

In 2018, a team of healthcare researchers at a Chinese university proposed the first "comprehensive healthcare delivery system" of Pakistan.

Sector (Community health)

New Proposed Section: "Community Health in the Global South"

Access to community health in the Global South is influenced by geographic accessibility (physical distance from the service delivery point to the user), availability (proper type of care, service provider, and materials), financial accessibility (willingness and ability of users to purchase services), and acceptability (responsiveness of providers to social and cultural norms of users and their communities). While the epidemiological transition is shifting disease burden from communicable to non communicable conditions in developing countries, this transition is still in an early stage in parts of the Global South such as South Asia, the Middle East, and Sub-Saharan Africa. Two phenomena in developing countries have created a "medical poverty trap" for underserved communities in the Global South — the introduction of user fees for public healthcare services and the growth of out-of-pocket expenses for private services. The private healthcare sector is being increasingly utilized by low and middle income communities in the Global South for conditions such as malaria, tuberculosis, and sexually transmitted infections. Private care is characterized by more flexible access, shorter waiting times, and greater choice. Private providers that serve low-income communities are often unqualified and untrained. Some policymakers recommend that governments in developing countries harness private providers to remove state responsibility from service provision.

Community development is frequently used as a public health intervention to empower communities to obtain self-reliance and control over the factors that affect their health. Community health workers are able to draw on their firsthand experience, or local knowledge, to complement the information that scientists and policy makers use when designing health interventions. Interventions with community health workers have been shown to improve access to primary healthcare and quality of care in developing countries through reduced malnutrition rates, improved maternal and child health and prevention and management of HIV/AIDS. Community health workers have also been shown to promote chronic disease management by improving the clinical outcomes of patients with diabetes, hypertension, and cardiovascular diseases.

Slum-dwellers in the Global South face threats of infectious disease, non-communicable conditions, and injuries due to violence and road traffic accidents. Participatory, multi-objective slum upgrading in the urban sphere significantly improves social determinants that shape health outcomes such as safe housing, food access, political and gender rights, education, and employment status. Efforts have been made to involve the urban poor in project and policy design and implementation. Through slum upgrading, states recognize and acknowledge the rights of the urban poor and the need to deliver basic services. Upgrading can vary from small-scale sector-specific projects (i.e. water taps, paved roads) to comprehensive housing and infrastructure projects (i.e. piped water, sewers). Other projects combine environmental interactions with social programs and political empowerment. Recently, slum upgrading projects have been incremental to prevent the displacement of residents during improvements and attentive to emerging concerns regarding climate change adaptation. By legitimizing slum-dwellers and their right to remain, slum upgrading is an alternative to slum removal and a process that in itself may address the structural determinants of population health.