Programmatic Management of Clubfoot in Pakistan: Initial Two-Year Experience

Lubna SamadFayez JawedZara Ansari

PQ Working GroupMuhammad Amin Chinoy

Mansoor Ali Khan

Surgical procedures widely practiced

Ponseti method in use: non systematic, non programmatic

Late presentation

Financial, technical and equipment constraints

2010

Pakistan:Clubfoot Situation

• Clubfoot program vs adhoc casting

Phase 1

• National, sustainable network• facility based• community based

Phase 2

PehlaQadam: The First Step

Community Perceptions

Toolkit

Community Mobilization

Weekly Casting Clinic

Programmatic Support

Community Perceptions

In depth interviews and focus group discussions were held in the catchment community

Iowa Orthop J. 2013;33:149-52.

Toolkitwww.pehlaqadam.org

These contain all the tools required to start a clubfoot program in similar settings

Checklist

Transportation voucher

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

Casting Clinic

Consent by Health Worker

Enrolment (Electronic

Documentation)

Pirani Scoring (Picture

Database)

CastingBracing

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

Data Entry

Age at Enrollmentn=337

0 to 3 3 to 6 6 to 12 12 to 24 24-360

20406080

100120140160180 168

57 62

3218

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)

Castingn=493

Bracing (at one year)n=365

Adherence 97.2% 97.4%

Default 6 4

Mortality 1 2

Transfer 1 2

Team

Quality

Equity

Local ownership

Sustainability

Judging Success

Quality of care

• Orthopedic surgeon led service• Role of USAID funded capacity building• PIA training• M & E: Program team

Equity

• Indus Hospital: completely free of cost• Programmatic Support: Pehla Qadam• Free treatment• Free braces• Transport allowance (used by 56%)

Local ownership

• Community health workers• Local orthopedic surgeons and members• No continued reliance on “parachute”

experts

Sustainability

• Local Ownership• Building on existing infrastructure• Within broader orthopedic services• Complementary resources

Scale Up

Goal Sustainable scale up

StrategyCapacity building

Decentralize ownership

Interventions Human Resources Infrastructure Financial

Resources

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

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!!!

Human Resources

Pakistan Orthopedic AssociationTraining orthopedic surgeonsClubfoot centers within major centersInvolving residents and trainees in care

Tertiary care center led initiative

Infrastructure

Map

Map of Pakistan showing the existing Ponseti clubfoot clinics

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