The objective of this study was to measure HIV prevalence and risk behaviour in injecting drug users (IDUs), male sex workers (MSWs), Hijras (transgenders), female sex workers (FSWs) and male truckers in Karachi and Lahore, Pakistan. The design was a linked-anonymous cross-sectional study of individuals identified at key venues or through peer referral. Approximately 400 respondents in each group (200 for Hijras) responded to a standardized questionnaire and were tested for HIV antibodies at each site. In Karachi, 23% of IDUs and 4% of MSWs were HIV positive, and HIV-positive individuals were identified in all risk groups in at least one city. Two-thirds of all IDUs used a shared needle in the previous week, and unprotected commercial sex activity with men and women was high. The HIV epidemic has entered IDU and male and female commercial sex networks in Karachi and Lahore. Targeted intervention services must be scaled up and risk group surveillance intensified.

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Please cite this paper as: Hussein J, Newlands D, D’Ambruoso L, Thaver I, Talukder R, Besana G. Identifying practices and ideas to improve the implementation of maternal mortality reduction programmes: findings from five South Asian countries. BJOG 2010;117:304–313. Objective  The successful implementation of programmes to reduce maternal mortality is constrained by a ‘know–do’ gap: the disparity between what is known and the application of that knowledge in policy and practice. This study identified innovations, practices and ideas aimed to improve project and programme implementation. Design  Cross‐sectional. Setting  Five South Asian countries: Afghanistan, Bangladesh, India, Nepal and Pakistan. Sample  Sixteen projects and programmes, and 100 key informants. Methods  In‐depth review of documents, key informant interviews and focus‐group discussions. Main outcome measures  Innovations and ideas to improve programme implementation, and their perceived effects. Results  Delegation of duties to intermediate‐level health workers, incentivisation of health workers, providing the means to overcome financial barriers for accessing care, quality improvements and knowledge transfer were examples of ideas put into practice to improve programme implementation. There was a perception that these improved service use and availability, but objective evidence was lacking. Conclusions  Some innovations, practices and ideas are supported by evidence of effect, and could be replicated, whereas others have not been formally evaluated. Testing of these innovations is required before more widespread adoption can be recommended, although experiences should be shared to narrow the ‘know–do’ gap, even though the evidence on beneficial effects remains unclear.

Background Globally the occurrence of disasters has increased more than fourfold during the last three decades. The main concern for the healthcare system responding to a disaster is its ability to deal with the sudden influx of patients and maintaining a certain level of surge capacity. Health workers are considered to be the major driving force behind any health system. Their role gets even more prominent during disasters or public health emergencies. With the lack of information on the health workforce in the tertiary healthcare system of Khyber Pakhtunkhwa, where most of the disaster surge is diverted, it is difficult to plan and respond to accommodate the sudden surge of patients. Methods This was a mixed method cross-sectional survey conducted in all the tertiary care hospitals of Khyber Pakhtunkhwa province of Pakistan to assess the current staffing situation and surge capacity based on the current workload. Annual service statistics of 2018 were collected from all the tertiary care hospitals of the province. WISN was piloted with only one healthcare staff category, i.e., for doctors in Ayub Teaching Hospital before assessment in all the tertiary care hospitals was undertaken. Results Overall, there were 1215 surplus doctors in medical and allied specialties and 861 doctors in surgical and allied specialties in the tertiary healthcare system. The health care system has an acute shortage of 565 emergency department doctors. The tertiary healthcare system of KP has an overall shortage of 1099 nurses. Based on the WISN generated numbers for doctors, the tertiary care system of KP has a combined healthcare staff (doctors and nurses) that can manage an additional surge of 6.3% of patients with the current patient workload. Conclusion The tertiary health care system of the Khyber Pakhtunkhwa Province of Pakistan does not possess the required ≥ 20% HR surge capacity indicating that the tertiary healthcare system is poorly prepared for disasters or public health emergencies. The lack of nursing staff, more than the doctors, is the major reason behind the lack of HR surge capacity of the tertiary health care system.

in 1989. On the positive side, fluoridation continues to provide substantial benefits for the dental health of six million people, many of them living in the west midlands and the north east of England.4 The arguments for extending fluoridation are not as overwhelming as they were in 1956. The prevalence of dental caries has fallen in both fluoridated and non-fluoridated districts,5 and the costs of fluoridation plant designed to meet modem operating standards are considerable.6 It is sensible therefore that the health departments should give priority for new schemes to areas such as the north west of England7 and the west of Scotland where the prevalence of dental caries remains high and where large water treatment works allow for economies of scale. The Water (Fluoridation) Act 1985 placed the responsibility for decisions on water fluoridation with district health authorities, who are required to consult locally before making a formal request to the water undertaker. It was assumed, incorrectly as we now know, that water undertakers would concern themselves mainly with the technical feasibility of the proposal.8 Experience in the North Western Region, where 18 district health authorities completed consultation in 1988, and more recently in Strathclyde, Yorkshire, Wessex, and Northern Ireland, clearly shows that health authorities can obtain substantial public and professional support for fluoridation, even though opinion among local authorities remains divided. It is also clear that the cooperation of the water companies cannot be assumed. For example, the chairman of Welsh Water stated recently that, in spite of assurances from the Drinking Water Inspectorate concerning the safety of fluoridation plant designed according to the Department of Environment's code of practice,6 his company would not continue fluoridation on Anglesey or extend fluoridation into the rest of Wales unless required to do so by the secretary of state. While ministers quite correctly point out that the act requires local consultation, it was surely not the intention of parliament that water undertakers should have such an absolute veto. The recent fundamental review of dental remuneration by Sir Kenneth Bloomfield called for "a more robust approach" to fluoridation "which would not allow for indefinite procrastination in adopting measures judged by the competent health authorities to be both beneficial and cost effective."9 The secretary of state should now require water undertakers to implement fluoridation schemes when they are requested to do so by health authorities, subject to assurances that the proposed schemes are technically feasible and economically sensible.