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February 1997, Volume 47, Issue 2

Editorial

Improving the Links between Research and Health Policy in Pakistan

Shamim A. Qazi  ( The Children Hospital, Pakistan Institute of Medical Sciences, G- 8/3, Islamabad. )
Patricia Hibberd  ( Applied Diarrhoeal Disease Research Project, Harvard Institute of International Development, 1 Eliot Street, Cambridge MA 02138, United States of America. )
Ghaffar Billoo  ( Medical Faculty, University of Karachi. and Head of Pacdiatric Medicine, Dow Medical College, Karachi. )
Jonathon Simon  ( Applied Diarrhoeal Disease Research Project, Harvard Institute of International Development, 1 Eliot Street, Cambridge MA 02138, United States of America. )

Health policy makers thmughout the world claim that scientists are not providing them with infonnation relevant to their needs for decision making on health policy. The research results they do receivc often are difficult to understand and difficult to apply to policy development. Applied research, they! say, if reported clearly in an accessible format, would assist them in constructing better policies and programmes that would improve the health of the population. Health researchers, at the same time, argue that policy makers are not using the results of relevant research to improve policies and programmes. They belicye that well informed policy makers could effectively use research darn to improve health. These two communities, linked by common goals, arc divided by a lack of common professional language. How can the critical links between research and policy be strengthened to improve health in Pakistan?
Two special issues of the Journal of the Pakistan Medical Association (JPMA) focusing on child health arc an attempt to make applied research more accessible to policy makers and practitioners. This issue, focusing on acute respiratory infections and malnutrition in Pakistani children, is a companion special issue to the previous JPMA issue that focused on diarrhocal disease and preieribing practices. The two issues represent research from a geographically diverse group of Pakistani scientists drawn together into a research network by the Applied Diarrhoeal Disease Research (ADDR) Project of Harvard University. Strengthening national capacity to conduct high quality research that is relevant for health policy development is important for Pakistan. It is equally important. however, is translates it research results into improved health policies, health programmes and clinical practice.
Traditionally, the scientific community has focused on the generation of knowledge and has abdicated responsibility for the advocacy work that may be ncedcdfor knowledge to affect policy. Changes in health policies and practices occur when new technical infonnation based on relevant, valid research, which identifies and evaluates altemative approaches, is brought to the attention of policy makers by scientific advocates. The development of ‘policy champions” may be as important as the development of new information. For Pakistan to make better use of locally generated research, the research topics should be priorities for the health care system. Pakistan is fortunate that the priority health problems were identified in the Essential National Health Research Plan (ENHR) produced in 1991. This document lists malnutrition/low birth weight and communicable diseases as the two most important health problems facing the nation1. This issue of JPMA highlights research on topics within these two priority areas. Acute respiratory infections (ARI) are probably the single largest cause of death among Pakistani children underfive years of age (estimated 250,000 deaths per year in children under five2). Most deaths occur in the cormnunity as a result of ntis- diagnosis or delayed prcscntation to the health care facilities when it is too late for standard ART case management to save lives. Hussain et al3 investigated the household management of ART by mothers in a lower class and middle class locality ofLahore. Usc of home remedies and care-seeking patterns were studied. The results infonricd the physicians at the Sheikh Zayed Hospital in Lahore of the reasons for delayed presentation and the extent and patterns of use of alternative hcatlh care providers. The results formed the basis for the development of community health education outreach to better inform care givers of ART household case management.
Mehnaz and Billoo4 conducted a community-based intervention to determine whether community health workers (CHWs) could be tralncd to adequately assess, classify and manage cases of pneumonia in a rural area of Sindh Province, Their findings indicated that well-selected CHWs can be reliably trained to identify cases of pneumonia in the community and provide first- line level of care. Improving breast feeding and weaning practices was a core theme for several of the studies. Ume- Kulsoom and Saeed5 followed a birth cohort in a longitudinal study in urban Lahore and describes the initiation of breast feeding practices, the use of pre-lacteal feeds, the duration of breast feeding and the timing and selection of complementary foods and fluids during the first year of life. Mahmood and Atif6 report on the nutritional beliefs and practices of 100 pregnant and 100 lactating mothers. Their cross-sectional. Knowledge-attitudes-practices (KAP) study demonstrated that most mothers are aware of the need to increase dietary intake during pregnancy and lactation but often lack the necessary financial resources to change their diets. Badmddin S7 also was interested in the constraints mothers must overcome to adopt appropriate breast feeding practices in poor communities. The time committmcnt and competing labour demands on women appear to be a major constraint to the practice of exclusive and on-demand breast feeding. Badmddin questions the appropriateness of our health education campaigns to promote exclusive breast feeding given the realities of poor women’s lives in Pakistan. Akram et al8 conducted a prospective community-based pilot intervention to test whether breast teeding practices could be improved with simple messages and limited health worker contact during the antenatal period and shortly after birth. Their impressive results indicate that this approach can improve feeding practices and similar interventions need to be evaluated on a larger scale.
The mle of micronutrients in child health is a burgeoning area of interest. The ADDR supported work on both iron and zinc supplementation trials. Paracha et al9 report on the high prevalence of iron deficiency anaemia in two semi-urban areas of Pcshawar. This work is part of a community-based iron supplementation intervention. Bhutta10 has been investigating the role of zinc supplementation in impmving diarrhoea case management. His paper reviews the biological basis of zinc in child health and zinc’s effects on growth, diarrhoea morbidity and immune function.
The Pakistani child health research community has generated a tremendous amount of important information during the past decade. Although a fair number of researchers are working to unravel questions related to the local health problems, rarely are their research results translated into health policies. Too often medical researchers do not even think about the policy implications of their research results. Most of the time the research results are presented in the scientific meetings attended by theirown colleagues and some are published in the medical journals either nationally or internationally which are rarely accessible to policy makers. We need to improve the dialogue between researchers and policy makers in order to make research results available to policy makers in a format which they can understand. We hope the publication of the research results in JPMA is just one small step in the process of using the research to affect change. In addition to disseminating the findings in the JPMA, there is an urgent need to mobilize interest groups, find people who can champion the research findings among the health policy personnel and identify clinical leaders capable of changing medical community opinion.
The work of the research teams presented in this issue (and the companion special issue) represent a two to three years investment by highly motivated professionals committed to the goal of improving child health. The ADDR Project was fortunate to be able to collaborate with such outstanding individuals and to be able to help strengthen the scientific capacities of individuals and national institutions. We hope the network of scientists will continue to conduct applied health research, educate their peers, work with communities and train their students in improved case management of the majorchildhood causes of death. We hope to continue to put child survival and public healthinits rightful place at the forefront of medical practice in Pakistan.

References

1. Health Research in Pakistan: Action Plan for the 90s. Health Section Ministry of Planning and Development, Isismabad and Department of Community Health Sciences, Karachi, islamabad, Aga Khan University, 1991.
2. Health Division, Government of Pakistan, PC-I form (revised version), National Programme for the Control of respiratory infections. Health Division, Ministry of Health, Special Education and Social Welfare, Islamabad, Govem­ment ofPakistsn, Islamabad, 1993,p.5.
3. Hussain, W., Mahmood, N., Anwsr, M. et sI. Management of acute respiratory infection by mothers in the community. J. Pak. Med. Assoc,, 1997:47.
4. Mchnaz, A.,Billoo, A.G. Detection and management of pneumonia by community health workers. A community intervention study in Rehri Village. Pakistan. 7. Pak, Med. Assoc., 1997;47.
5. Ume-Kulsoom, Saeed, A. Breast feeding practices and beliefs about wesning among mothers of itifants aged 0-12 months. J. Pak. Med. Assoc., 1997:47.
6. Mshmood, S., Arif F. Assessment of nutritional beliefs and practices inpregnant and lactating mothers in an urban and rural area of Pakistsn. J. Pak.Med. Assoc., 1997:47.
7. Salma Badruddin, lnam, S.N.B., Ramsanali, S., Hendricks, K. Constraints to sdoption of appropriate breast feeding practices in a squatter settlement in Karachi, Pakistan. J. Psk. Med. Assoc., 1997;47.
8. Akram, D.S., Agboatwalls, M., Shamshad, S. Effect of intervention on prnmotion of exclusive breast feeding. 7. Pak.Med. Assoc., 1997;47.
9. Paracha, FL., Hameed, A., Simon, J. et sI. Prevalence ofanacmis in semi-urban areas of Peshswsr, Pakistan: A challenge for heslth professionals and policy makers. J Pak. Med. Assoc., 1997:47.
10. Bhutta, Z.A. The role of Zine in health and disease Relevance to child health is developing countries. 7. Pak. Med. Assoc., 1997;47.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: