Evaluating Health-Related Barriers and Interventions in Sindh, Pakistan: A Qualitative Study Based on the Sehat Kahani Model

Written by APF Pakistan Virtual Fellow (2023) Alysha Siddiqi

A woman in Pakistan, a woman in the United States. Why is it that healthcare outcomes are so strikingly dissimilar when comparing both groups?

Although a rather complicated question, the answer may lie in a historically undermined aspect of health: social determinants of health. Health and healthcare delivery is often reduced to its clinical and biological components, which, although a significant component of healthcare, is now understood as only one aspect of a much larger conversation. This past summer, I had the ability to explore this and related questions through my work with APF’s summer fellowship with Sehat Kahani, a tele-medicine service for and by women in Pakistan. The Sehat Kahani model integrates equity into its approach, using telehealth services as a tool for increasing access to care in rural and low-income settings.

As a fellow, I had the opportunity to integrate my previous experiences and interests in global health during a research-project examining health-related barriers and interventions in Sindh, Pakistan. I approached this project in two-fold: first, using a literature review to understand the health-climate in Pakistan, and then using qualitative-level interviews with both physicians and patients in the Sehat Kahani system. Throughout the course of this project and fellowship, I worked to understand existing barriers and perceptions regarding health in Sindh, and how the Sehat Kahani model aims to address these. As an American-Pakistani, it is easy to become both disillusioned and disengaged from Pakistani health systems and delivery, however, as health disparities continue to grow between that hypothetical American woman and hypothetical Pakistani woman, amongst many other marginalized groups, it becomes more important we work to elucidate what barriers to care exist and how to address them, aiming to invest in a more sustainable Pakistan.

Alysha Siddiqi

Perhaps one day, through diligent work…from interactive learning experiences such as the APF/Sehat Kahani fellowship and more, health disparities between American and Pakistani women, amongst other groups, will decrease, working to develop and sustain stronger health initiatives across the world in marginalized groups.

Literature Review 

In the first stage of my research, I conducted a thorough literature review on existing barriers to health in Pakistan. Two predominant barriers to health I studied included socio-economic and geographical factors and gender stereotypes in the medical field. Notably, I found that the rural location of many patients poses a large barrier to health delivery in Pakistan, considering the cost of both travel and time in reaching clinics in urban settings. In rare scenarios where health-care services are offered in rural settings, a lack of both resources and physicians presents another barrier. In terms of gender-stereotypes, much of the literature agrees that a hiring-bias exists against women doctors, which, in turns, generates a shortage of providers for patients who exclusively seek care from women-doctors. Moreover, gender-roles significantly guide health-seeking behaviors, which creates a social-stigma around receiving care as a woman from both internal (intra-family) and external (societal perceptions) pressures. 

Qualitative Interviews 

After gaining a preliminary understanding of existing barriers to care in Pakistan, I was interested in understanding how the literature corroborates with actual patient- and provider- perceptions. To do this, with the exceptional help of the Sehat Kahani team in Karachi, I developed a questionnaire probing patient and provider understandings of healthcare barriers, and their opinion on the efficacy and sustainability of the Sehat Kahani model in addressing these. These interviews were conducted in Karachi with women patients and providers, who had been involved with the Sehat Kahani for the past two years, and (for patients) were from rural, low-income communities in Sindh. 

Notably, my finding agreed with the literature review – one of the largest barriers to health was in access to and cost of care, which was especially limited in rural settings. Many patients complained that the distance from their homes to clinics or healthcare providers was unfeasible, and providers agreed many of their patients felt the same way. Sehat Kahani’s telehealth model seemed to address this extremely well, with both patients and providers reporting positively on this aspect of the Sehat Kahani model. Beyond this, another barrier existed in the perceived quality of care provided in public hospitals. Patients felt that public hospitals faced a shortage of women-providers, which decreased their (patient) comfort and trust in their provider, and that care provided in public hospitals was not patient-centered. In turn, patients felt the Sehat Kahani model not only increased their access to women-doctors, but integrated awareness and educational modules which were extremely patient-centered and sustainable for developing future health outcomes. 

Extending Impact Beyond Borders

Although a relatively short study, I felt that my work with Sehat Kahani this past summer importantly elucidated a preliminary understanding and acknowledgement of sociocultural barriers in Pakistan. This was all accomplished due to the diligence of the Sehat Kahani team – although I partook in the fellowship from my hometown in Oklahoma, I felt largely connected with the Sehat Kahani team in Karachi, who worked tirelessly to bridge the gap between my virtual work and field-work to complete this research. As a fellow, I had the opportunity to hone my own research skills, particularly in qualitative data collection and analysis, growing with the constant feedback and educational initiatives from our fellowship coordinators. Over the course of multiple speaker sessions conducted over Zoom, I was also able to connect with various public health professionals in Pakistan, actively learning from interactive events ranging from topics of data analysis to mental-health advocacy.

The next step, for both myself and others, is to use our platform as American-Pakistanis to raise awareness of and invest in organizations like Sehat Kahani. Sehat Kahani uses a unique, innovative model that truly devotes considerable time and effort into both research and practice of equitable care. By placing a greater emphasis on culturally competent models, like the Sehat Kahani model, we can sustainably introduce health-education modules and techniques to level the playing field. Perhaps one day, through diligent work and experience from interactive learning experiences such as the APF/Sehat Kahani fellowship and more, health disparities between American and Pakistani women, amongst other groups, will decrease, working to develop and sustain stronger health initiatives across the world in marginalized groups.