Journey Through Adversity: Stroke Care Realities in Pakistan
By:
Fizza Javed: Alumna of the National University of Medical Sciences (NUMS) with a Bachelor`s degree in Public health. Fizza Javed is a member of the Media Team for the NGO "We Make a Difference” (WMD)
Noor-ul-Ain Shah: Graduated with a degree in BS in Public Health from National University of Medical Sciences (NUMS)
Introduction:
Did you know that stroke, despite its silent nature, ranks as the second-leading cause of death worldwide and the third-leading cause of death and disability combined? This insidious non-communicable disease wreaks havoc, particularly in populous nations like Pakistan. With an estimated population of 225 million and an annual stroke incidence rate of 250 per 100,000, the magnitude of this issue cannot be overstated. Yet, amidst the absence of comprehensive epidemiological studies, the true toll of stroke on Pakistani lives remains shrouded in mystery. In a country with a median age of 22.5 years, the implications for public health and well-being are staggering.
In Pakistan, despite a modest density of physicians and nursing personnel, with 11 and 4.69 per 10,000 population respectively in 2019, the country's universal health coverage (UHC) index remains dishearteningly low at 45 out of 100. Political instability has perpetuated economic crises, leaving many unable to afford out-of-pocket healthcare expenses. Consequently, government hospitals become the primary recourse for medical care, yet their efficacy is hindered by a myriad of issues. "Ghost Facilities," healthcare units lying dormant due to the absence of a healthcare workforce, exacerbate the strain on already overburdened tertiary hospitals. Compounding this, healthcare workers are often underpaid, and the geographical remoteness of certain facilities makes it challenging to maintain a consistent workforce. Amidst this backdrop, the dire lack of rehabilitation centres for stroke victims, coupled with a pervasive culture of negligence and limited awareness, further compounds the plight of those in need. This confluence of factors ultimately leads to compromised quality of care and leaves many vulnerable individuals without adequate support.
Patient-Centred Realities: Stroke Care in Pakistan
A survey conducted in the Neurology ward of Pakistan Institute of Medical Sciences (PIMS) Islamabad, involving 50 patients provided understanding into their experiences and challenges within the hospital. Despite the efforts of the staff, patients expressed dissatisfaction with the hospital's deteriorating conditions. They faced multiple problems during their stay, affecting both them and their attendants. The overall atmosphere was distressing, and patients lacked awareness about stroke, with only 24% knowing the type and 10% recognizing the signs. Many patients struggled with serious addictions like smoking and alcoholism, which weren't adequately addressed. Complications from stroke and its comorbidities, including cognitive and sensory impairments, and agitated depression, were reported by 22 patients, with others mentioning additional issues. Palliative care was deemed crucial by 43 patients, with only one dissenting. However, dissatisfaction with nursing and custodial staff was common. Regarding hygiene and physiotherapy practices, opinions were divided, with 25 patients feeling properly informed while an equal number disagreed. Preventive practices like physical activity were neglected by many, with only 18 patients engaging in such activities.
Steering Challenges: Nurses in Stroke Care:
Nurses are the backbone of healthcare institutions, yet in Pakistan, the profession suffers from stigmatisation and mismanagement, leading to its undervaluation and a decline in students pursuing nursing majors. This has resulted in a shortage of nurses that fails to meet the standards set by the World Health Organization (WHO) for both local and international demand, worsened by brain drain.
In a survey of 20 nurses in a tertiary care setting, all agreed on the importance of palliative care for stroke patients. However, only 11 nurses reported providing palliative care, citing feeling overburdened and lacking resources as common problems. They also expressed frustration at being targets of criticism and mistreatment by patients and staff, and acknowledged the challenge of providing comprehensive care to every patient, often opting for attendant counselling instead. One major issue highlighted by the nurses was the difficulty in maintaining patient histories. While the majority (13) agreed that this responsibility falls on both nurses and doctors, 5 nurses believed it was primarily the doctor's duty, with only 2 seeing it as solely the nurse's responsibility.
Physicians' perspective on Challenges in Stroke:
In a bustling tertiary care setting in Islamabad, 25 dedicated physicians highlighted the daily challenges they face. This included; burnout and exhaustion leading to unprofessional conduct among doctors. The outpatient department (OPD) receives over 300 patients daily, straining resources. Rehabilitation for stroke patients primarily relies on speech therapy, physiotherapy, and occupational therapy, with compromised nursing care and counselling in outpatient departments. Ageing paramedic staff and inadequate referral systems waste time for both patients and doctors, impacting service quality. During infectious outbreaks like dengue, shortage of spaces and resources forces patients to treat overcrowded wards without precautions, risking safety. Corruption and poor administration add pressure on recent Post-Graduates (PGs), affecting their learning and mental health. Lack of supervision and accountability worsens the situation, compounded by essential shortages in medicines, equipment, and resources. These challenges reflect stark realities of inadequate resources, administrative complexities, and limited human resources. Furthermore they emphasised that Ischemic stroke is the most common type of hospitalisation, followed by hemorrhagic stroke.
Insights from Custodial Staff:
Custodians expressed ambiguity in their assigned tasks. Regarding the frequency of duty execution, three staff members cited twice a day, while two mentioned all day long. Potential reasons for this discrepancy include staffing shortages, inadequate resources, and the complexity of tasks, which may necessitate more time and effort for thorough completion. Furthermore, environmental and behavioural issues could create disruptions, further impacting duty efficiency.
Conclusion:
Challenges proliferate for patients and healthcare professionals alike. Nurses, physicians, and custodial staff grapple with limited resources, staffing shortages, and administrative hurdles in their quest to provide quality care. Despite these obstacles, their resilience shines through as they work tirelessly to improve patient outcomes. Addressing these challenges requires collaborative efforts and a commitment to strengthening healthcare infrastructure. By prioritising awareness, appropriate resource allocation, and staff support, Pakistan can overcome these hurdles and ensure better stroke care for its population.
References:
https://www.world-stroke.org/news-and-blog/news/wso-global-stroke-fact-sheet-20
https://rho.emro.who.int/sites/default/files/Profiles-briefs-files/Pakistan-HWF-Snapshot.pdf
https://worldhealthorg.shinyapps.io/glass-dashboard/_w_5c9d9290/_w_391ca3d0/#!/amr
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