clubfoot in pakistan presentation by lubna in barcelona 2014
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Programmatic Management of Clubfoot in Pakistan: Initial Two-Year Experience
Lubna SamadFayez JawedZara Ansari
PQ Working GroupMuhammad Amin Chinoy
Mansoor Ali Khan
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Surgical procedures widely practiced
Ponseti method in use: non systematic, non programmatic
Late presentation
Financial, technical and equipment constraints
2010
Pakistan:Clubfoot Situation
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• Clubfoot program vs adhoc casting
Phase 1
• National, sustainable network• facility based• community based
Phase 2
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PehlaQadam: The First Step
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Community Perceptions
Toolkit
Community Mobilization
Weekly Casting Clinic
Programmatic Support
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Community Perceptions
In depth interviews and focus group discussions were held in the catchment community
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Iowa Orthop J. 2013;33:149-52.
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Toolkitwww.pehlaqadam.org
These contain all the tools required to start a clubfoot program in similar settings
Checklist
Transportation voucher
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Community Mobilization
Lady Health Workers 531Maternity Homes 87Vaccinators 33Lady Health Supervisors 21Private Hospitals 15Midwives 12Government Hospitals 6Dai 3Town Health Officers 3Local Support Organization 2Total 713
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Casting Clinic
Consent by Health Worker
Enrolment (Electronic
Documentation)
Pirani Scoring (Picture
Database)
CastingBracing
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Presentation at PQ ClinicReason n %
Clubfoot (within age limit) 337 55.5Normal feet 122 20.1> Age limit 43 7.1Anthrogryposis 20 3.3Cerebral Palsy 16 2.6Vertical Talus 16 2.6Neurological CF/MMC 13 2.1Other 40 6.6Total 607 100
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Data Entry
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Age at Enrollmentn=337
0 to 3 3 to 6 6 to 12 12 to 24 24-360
20406080
100120140160180 168
57 62
3218
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Summary of resultsRight Left Total
Feet enrolled 25551.7%
23848.3%
493
Weeks in cast* 11.4 (11.5) 11.3 (15.1) 11.3(8.4)
Number of casts* 6.03 (4.5) 6.4(5.7) 6(4.5)
Pirani score at casting* 3.9 (1.2) 4.0 (1.3) 4.0 (1.2)
Pirani score at bracing* 1.2 (0.6) 1.3 (0.6) 1.2 (0.6)
Tentonomy 88 feet17.8%
72 feet14.6%
160 feet32.4%
* mean (SD)
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Castingn=493
Bracing (at one year)n=365
Adherence 97.2% 97.4%
Default 6 4
Mortality 1 2
Transfer 1 2
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Team
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Quality
Equity
Local ownership
Sustainability
Judging Success
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Quality of care
• Orthopedic surgeon led service• Role of USAID funded capacity building• PIA training• M & E: Program team
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Equity
• Indus Hospital: completely free of cost• Programmatic Support: Pehla Qadam• Free treatment• Free braces• Transport allowance (used by 56%)
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Local ownership
• Community health workers• Local orthopedic surgeons and members• No continued reliance on “parachute”
experts
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Sustainability
• Local Ownership• Building on existing infrastructure• Within broader orthopedic services• Complementary resources
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Scale Up
Goal Sustainable scale up
StrategyCapacity building
Decentralize ownership
Interventions Human Resources Infrastructure Financial
Resources
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Pakistan Demographics
Total Population: 193,238,868
Annual birth cohort: 23.67 births/1000 population
Estimated annual clubfoot cases: 6000 to 7000 new cases per year
22.3% population below poverty line
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Human Resources
Resources available 91 medical colleges12000 medical graduates per year
725 orthopedic surgeons registered with CPSP = 10 cases of CF per surgeon per year!!!
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Human Resources
Pakistan Orthopedic AssociationTraining orthopedic surgeonsClubfoot centers within major centersInvolving residents and trainees in care
Tertiary care center led initiative
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Infrastructure
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Map
Map of Pakistan showing the existing Ponseti clubfoot clinics
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Phase 2 – Financial Resources
• Supplement existing public/private sector services– Program personnel– Supplies/equipment– M & E tools– Ensuring adherence (incentives, reminders)
• “Adopt a Clinic”• Local production of braces• Home/community based monitoring during bracing
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