research thesis on education in pakistan

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All Theses and Dissertations

The Electronic Theses and Dissertation Series showcases the intellectual assets of the institute’s postgraduate research scholars. The purpose of this collection is to optimize the exposure and visibility of the research outputs of MS and PhD scholars.

• PhD Dissertations - Computer Science
• MS Thesis - Economics
• MS Thesis - Mathematics

Submissions from 2021 2021

School quality and teacher quality - an impact evaluation on student's educational outcomes in a public-private partnership school program in Pakistan , Neha Ahmed

Oil prices and financial performance of firms in corporate sector of Pakistan , Zahra Mazhar Ali

Public debt and economic growth in Pakistan: evidence from a nonlinear analysis , Maha Asad

Hybrid query execution on linked data with complete results , Samita Bai

A bibliometric review of green financing, implication for Islamic Finance , Umaira Danish Dervi

Smokeless tobacco: socio-economic and environmental cost – a case study , Dania Farah

Forecast comparison of competing macro-econometric models of Pakistan economy , Uzair Bin Farid

Reexamining the EKC hypothesis in Pakistan: evidence from threshold regression , Tehreem Fatima

The product of well-composed sets , Arsalan Raza Hemani

Exploring the relationship between trade liberalization & environmental deterioration: role of governance , Iqra Hussain

Retrieval of mathematical information with syntactic and semantic structure , Sharaf Hussain

Exposure to information on family planning and its impact on fertility behaviour: evidence from Pakistan , Rimsha Irfan

Standard bases for modules over polynomial subalgebras , Nazish Kanwal

The asymmetric effect of interest rates on housing and plot prices , Shahbaz Lalani

Comparison of multidimensional and money metric poverty: insights from PSLM surveys , Muhammad Ali Raza

Deep habits: fiscal policy and banking implications , Danish Us Salam

Submissions from 2020 2020

Institutional quality and the economy , Ali Ahmed

Stress testing banks using the new Keynesian DSGE framework , Muhammad Shamil Akbar

Challenges in liquidity management faced by Islamic banking industry of Pakistan , Ehtisham Ali

A medium size macro-econometric model of Pakistan’s economy , Ijaz Ali

Hermitian Ricci Tensor of Twistor Space , Hafiza Rumlah Amer

Impact of Islamic banking on financial inclusion and economic growth , Ammar Awais

Assessment and comparison of wind potential of Berkhout and Debilt towns of Netherlands , Farheen Feroz

The determinants of household poverty and expenditure Inequality in Pakistan: evidence from the household income and expenditure survey , Afsah Khalid

Preemptive priority based data fragmentation scheme for heterogenous traffic in Wireless Sensor Networks (WSNs) , Anwar Ahmed Khan

(De) homogenization of Grobner basis for modules in a polynomial ring , Sanam Mehboob

Under-five mortality in Pakistan: the role of breastfeeding and immunization , Sumaya Falak Memon

Dust exposure and compensating wage differential: empirical evidence from textile industry of Karachi , Muhammad Zia Muneer

Performance of shariah compliant versus non shariah compliant listed companies: case study of Pakistan , Shaikh Noman

Diamond-Alpha Ostrowski Type inequalities on time scales , Danish Hafeez Rana

Re-examining the determinants of bond market development in Asia , Daniya Rana

The disposition effect in Pakistani investors , Sadaf Rauf

Estimating and forecasting term structure on interest rate (which three-factor affine model is better?) , Fatima Sadik

Infinitesimal Regulator in H3cts (GL2) (C€)), C) and Beilinson Element in H4D (BGL2(C€)), R(2)) , Muhammad Ashar Tafhim

Sierpinski cubical singular homology for finite spaces , Syed Hadi Ali Zaidi

Submissions from 2019 2019

Stock marker anomalies: empirical evidence from Pakistan Stock Exchange (PSX) , Naima Aziz

A framework of adaptive decision making for a team of autonomous agents , Asma Sanam Larik

Impact of exclusive breastfeeding and consultation with lady health workers on diarrhea in children under 5 years of age in Pakistan , Kiran Naseem

Submissions from 2018 2018

An investigation into the causes of low elasticity and buoyancy of major taxes in Pakistan : a historical perspective , Hania Afzal

Analog of Groebner bases in a polynomial ring with countably infinite indeterminates , Nazia Jabeen

An investigation into the determinants of maternal healthcare behavior in developing world , Muhammad Naumair Jadoon

Morphisms between additive higher Chow groups and cyclic variant of infinitesimal dilogarithm , Syed Ahsan Kamal

Stock market integration in South Asia: a multivariate GARCH with dynamic conditional correlations approach , Shah Munir Khan

Determinants of halal meat import demand in OIC countries: static & dynamic augmented trade Gravity Model , Imran Majeed

Understanding formal and informal financial inclusion in Pakistan – comparative study with Tanzania , Kanza Nauman

Analog of M-Grobner basis in convergent power series ring , Imran Shaheen

A study on channel polling mechanisms for wireless sensor networks , Shama Siddiqui

The impact of various entrepreneurial interventions during the business plan , Syed Waleed Mehmood Wasti

Submissions from 2017 2017

Comparison of forecasting performance of DSGE and VAR Models : the case of Pakistan , Shahzad Ahmed

Impact of corruption on economic growth through government size: an empirical analysis of three South Asian economies , Imran Ali

Welfare cost of inflation in Pakistan , Sumaira Ghafoor

Capital structure and corporate governance: evidence from Pakistan , Uroosa Jeelani

Trade openness and corruption , Ghazala Khan

Impact of indoor air pollution from cooking with solid fuels on the respiratory health of children :evidence from Pakistan , Mohammad Shayan Babar Khan

Two essays on behavioural finance issues in Pakistan stock market , Tayyaba Sami Khan

Cost efficiency of Pakistani banks: a stochastic frontier analysis , Shoaib Amin Sajwani

Guided personal learning environment model , Zaffar Ahmed Shaikh

Determinants of profit made by banks in developing countries , Sara Sharieff

Asymmetric effects of exchange rate changes on trade balances: Pakistan versus 20 major trading partners , Mutahir Sultan

Food consumption patterns and nutritional disparity evidence from Pakistan , Syed Masroor Hussain Zaidi

Submissions from 2016 2016

(DE) homogenization of Sagbi bases in free associative algebras , Anum Abbas

Impact of public-private-partnership programs on student's learning outcomes: evidence from a Quasi-experiment , Fatima Hafeez

A juxtaposition of tax expenditures and direct expenditures: case study of the manufacturing sector of Pakistan , Shagufta Hussain Lakdawala

Political and economic determinants of private investment: a case of developing and developed countries , Hasaan Anwar Mohiuddin

Approximate analytic solution of Hodgkin-Huxley equations , Khairun Nisa

A dynamic open economy model of aid-growth nexus in Pakistan , Sidra Rasool

Returns to Education and wage inequality in Pakistan: A quantile regression analysis , Syeda Subika Rizvi

Profitability and predictability of momentum investment strategy for stocks listed on Pakistan Stock Exchange , Sana Tauseef

Exchange rate pass through to consumer price: a TVP VAR analysis for Pakistan , Muhammad Zahid

On alleged defects in black-hole mathematics: black hole existence controversies hinging on solution of field equation , Muhammad Zikrya

Submissions from 2015 2015

Geometric mutigrid method with variable grid coarsening parameters, optimal parameters, analysis, and experimentation , Muhammad Shahid Ashraf

Existence of holomorphic functions with respect to almost complex structure on twistor spaces , Touseef Haider

Essays in land inequality, agrarian transition and agriculture taxation in Pakistan , Asim Bashir Khan

What influences the decision to opt for entrepreneurship? , Talha Nadeem

Child laborers and idle children: a provincial analysis of Punjab and Baluchistan , Sarah Nasir

Team learning from demonstration (Tlfd) , Syeda Saleha Raza

Homogeneous sagbi basis , Sarah Sarfaraz

Functor and categorical representation of Polylogarithmic groups , Muhammad Sami Siddiqui

Submissions from 2014 2014

Investment in non-financial corporations: a case of Pakistan , Ijaz Hussain Bajwa

A framework for the development of executable systems architecture , Imran Khan

Explaining stock returns in Pakistan: the CAPM, FAMA-French model and the Carhart model , Azam Yahya

Submissions from 2013 2013

Willingness to pay for improved water supply services in Karachi , Sidrat Asim

Load based approach for backoff process modeling & queuening analysis of IEEE 802.11 based wirless LANs , Syed Muhammad Faisal Iradat

Macroeconomic determinants of workers' remittances in Pakistan , Mirza Kaleem Ullah

Submissions from 2011 2011

A Bayesian network and ontology based semantic annotation framework , Quratulain Rajput

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• IED-PK | Master of Education (MEd.) Theses Guide
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Education in Pakistan: Problems and Their Solutions

This study was meant to explore and report the problems being confronted by the education in Pakistan and suggest for the resolution of these problems. Education plays the role of leadership in the society. The functions of the educational institutions are to develop the people physically, mentally, psychologically, socially and spiritually. It improves and promotes the economic, social, political and cultural life of the nation. There is no doubt in accepting the fact that education brings about a change in the social, political and cultural scenario of the country; though the change remains slow but it does have an impact on the society at large. Until now the role of secondary and college education in Pakistan has been simply preparation for tertiary education, which in the minds of most people means strictly a university education. All over the world universities are guiding and co-operating with the industrial and agricultural development organizations and they are developing their economics rapidly and meaningfully. There is a close link between education and development. In Pakistan, after more than five decades, the developmental indicators are not showing positive results. The participation rate at higher education is low comparatively to other countries of the region. There are problems of quality of staff, students, library and laboratory. Considering the gigantic problems of education in Pakistan, I select this topic for research.

Related Papers

Usman Amjad

Journal of Management and Social …

This paper reviews the current key issues and problems in the education system of Pakistan that pose a challenge for the future growth of the country. The paper uses documentary analysis as the research methodology for data collection. The paper attempts to understand which factors have contributed to the downfall of Pakistani education system. The first part of the paper explains how the system is operated by the government. Moving on, the problems be them external or internal in nature are highlighted and it is delineated how these problems have contributed to greater social demise. The paper further looks into some solutions to the problems aforementioned and urges the government to contribute in due diligence what is required to the education system.

International Journal of Academic Research in Progressive Education and Development

Hafsa Fayyaz

Dr. Z U B A I D A ZAFAR

Education is a key to political stability and socio-economic development of a nation. Unfortunately, there are diverse systems of education providing different types of education leading to stratified education system. The researchers investigated education system of Pakistan, its functioning and problems and used mixed method approach. In quantitative section researchers adopted survey method and questionnaire as tool for a sample of 210 respondents through multi-stage systematic sampling and SPSS for analysis. In qualitative part researchers used interview guide as a tool for 35 respondents (university level teaching faculty and students) and adopted Domain Analysis technique for qualitative data analysis. The results of present study indicate that education brings political stability by realizing the people their national rights and duties and thus through such awareness leads to harmony, participation and cooperation. Education shapes the personality of the people to play part i...

The Pakistan Development Review

Nadia Tahir

After six decades of its existence, Pakistan finds itself in an educational quagmire. There is not much to show in terms of national, provincial and local indicators of a standard variety. At the international level, the country has earned the notoriety of being regularly lower down on all known indices and league tables on human development, competitiveness and governance. Neglect of education lies at the heart of the problem. This is surprising because the thinking on the nature of the educational system required for the newly emerging country had started quite early. An All Pakistan Educational Conference was held on November 27, 1947 in Karachi. Education thus was the subject of the very first professional conference held in the country, bringing together all the stakeholders. The Father of the Nation set the guidelines in his detailed message: “Under foreign rule for over a century, in the very nature of things, I regret, sufficient attention has not been paid to the education ...

Eresearch Journal ISSN: 2706-8242 , Shamaila Hasan

This paper aimed to look at present education system of Pakistan. There exists an inherent promise and intensive potential in educational policies of Pakistan for revolutionizing socioeconomic change in the country through education. Pakistan since its independence in 1947 has faced the insufficient educational institutions and lack of qualified teachers which resulted in challenges of access and quality. To deal with educational problems, a number of educational policies were released. The policies came at different times, during different regimes, in with diverse policy document. They varied in their size, intention and seriousness. The existing education system in Pakistan is considered not being adequately responsive to the demand of quality education. There is a wide range of issues and concerns related to the teaching and learning setup. To improve the existing education system of Pakistan development of any strategy should give due consideration to these issues and concerns. Introduction:

Saadat Rana

Pakistan is a rapidly growing economy, with a strategy of reducing poverty and generating prosperity for all through industrial development by technology up-gradation and greater export orientation. Such circumstances define the relevance of a robust education sector in Pakistan, which would allow it to meet its human resource requirements. Pakistan needs to produce more workers, technicians, supervisors, managers, and researchers. It needs to expand its education base by improving the retention rate of students at primary, secondary and tertiary levels and by establishing more educational institutions across the country. Further, the quality of education needs considerable improvement by inducting better qualified teachers, adopting better education techniques and implementing effective examination mechanisms.

ashiq hussain dogar , intzar butt , Tahir Mahmood Butt

Pakistan Education System is not according to the Constitution of Pakistan 1973. It is moulding youth in divergent matrixes that cause injustice and disappointment in society. Therefore, it a barrier in achieving the goal of national harmony and social cohesion; and also, it is one of the contributory factors in dispersing the nation from its ideals. This paper discusses the key flaw in the educational structure of Pakistan, and suggests the ways to achieve the goal of " uniform, equitable and effective system of education " through a " national education system " as ensured in the Constitution of Pakistan.

Ashraf Muhammad Azeem

This paper aimed to look at past educational developments in Pakistan through case study and its analysis with the present world. It primarily addressed the causes of illiteracy in Pakistan, and overcame the flaws of earlier works. Pakistani government claims that they have accomplished significantly in the educational development. Pakistani law requests government to provide free basic education system to every citizen of Pakistan. However, the enrollment rate has remained below 60%. Similarly, literacy rate has also remained below 60%. Therefore, the government and other stakeholders in education sector could not perform well enough to provide the impressive results so far.

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Dissertations / Theses on the topic 'Pakistan education'

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Aslam, Monazza. "Gender and education in Pakistan." Thesis, University of Oxford, 2006. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.439699.

Naseem, Muhammad Ayaz. "Education, the state and subject constitution of gendered subjectivities inthrough school curricula in Pakistan : a post-structuralist analysis of social studies and Urdu textbooks for grades I-VIII." Thesis, McGill University, 2004. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=85025.

Tamim, Tayyaba. "Capability development : a sociological study of languages in education in Pakistan." Thesis, University of Cambridge, 2010. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.609049.

Bhutta, Sadia M. "Health education practice in primary classrooms in Pakistan." Thesis, University of Oxford, 2006. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.432110.

Haque, Mozammel. "Education and political instability in Pakistan, 1937-1971." Thesis, University College London (University of London), 1988. http://discovery.ucl.ac.uk/10020178/.

Malik, Rabea. "Exits, voices and social inequality : a mixed methods study of school choice and parental participation in Pakistan." Thesis, University of Cambridge, 2014. https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.707991.

Colbert, Jason M. "Pakistan, madrassas, and militancy." Thesis, Monterey, California. Naval Postgraduate School, 2006. http://hdl.handle.net/10945/2385.

Oppenheim, Willy. "Imagining 'demand' for girls' schooling in rural Pakistan." Thesis, University of Oxford, 2016. https://ora.ox.ac.uk/objects/uuid:6d27397d-b5f1-4a83-b423-382be42908f4.

Mansoor, Sabiha. "The role of English in higher education in Pakistan." Thesis, University of Reading, 2002. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.399883.

Faiz, Jalal. "Politics of education, conflict and conflict resolution in Balochistan, Pakistan." Thesis, University of Westminster, 2015. https://westminsterresearch.westminster.ac.uk/item/9v617/politics-of-education-conflict-and-conflict-resolution-in-balochistan-pakistan.

Anwar, Wasim. "Higher education in Pakistan : from state control to state supervision /." Oslo : Institute for Educational Research, Universitetet i Oslo, 2007. http://www.duo.uio.no/publ/pfi/2007/67351/thesisx291007.pdf.

Saleem, Mohammad. "A strategic plan for universal primary enrollment in Pakistan by the year 2000 /." Access Digital Full Text version, 1991. http://pocketknowledge.tc.columbia.edu/home.php/bybib/11167646.

Carrillo, Mora Felipe. "Impacts of the devolution reform in Pakistan on education outcomes and management." Thesis, University of Cambridge, 2013. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.607760.

Shah, Vyoma. "Inter-industry wage differentials and returns to education in Pakistan." Thesis, University of Portsmouth, 2010. https://researchportal.port.ac.uk/portal/en/theses/interindustry-wage-differentials-and-returns-to-education-in-pakistan(4896c426-fc38-4d56-a2bb-827966dffe7f).html.

Marland, Harriet Grieve. "Primary school supervision in Pakistan : practice, purpose and potential." Thesis, University of Hull, 1999. http://hydra.hull.ac.uk/resources/hull:8048.

Aftab, Asma. "English language textbooks evaluation in Pakistan." Thesis, University of Birmingham, 2012. http://etheses.bham.ac.uk//id/eprint/3454/.

Hassan, Syed Sabih Ul. "Recent education changes at higher education level in Pakistan : English language teachers' perceptions and practices." Thesis, University of Glasgow, 2016. http://theses.gla.ac.uk/7662/.

Malik, Mohammed Rehan. "Improving decision-making systems for decentralized primary education delivery in Pakistan." Santa Monica, CA : RAND, 2007. http://www.rand.org/pubs/rgs_dissertations/RGSD223/.

Channa, Anila. "Four essays on education, caste and collective action in rural Pakistan." Thesis, London School of Economics and Political Science (University of London), 2015. http://etheses.lse.ac.uk/3305/.

Khan, Khurshid Sana. "Secondary school choice of Ismailis from Gilgit Baltistan (GB) in Karachi." Thesis, University of Edinburgh, 2012. http://hdl.handle.net/1842/10435.

Daredia, Afshan Saleem. "Effectiveness of small-group sessions in enhancing students generic skills at the Shifa College of Nursing, Islamabad, Pakistan." Thesis, Stellenbosch : Stellenbosch University, 2013. http://hdl.handle.net/10019.1/85907.

Arshad-Ayaz, Adeela. "Education and technology : a critical study of introduction of computers in Pakistani public schools." Thesis, McGill University, 2006. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=102785.

Jaffery, Zafreen. "Making Education Accessible: A Dual Case Study of Instructional Practices, Management, and Equity in a Rural and an Urban NGO School in Pakistan." PDXScholar, 2012. http://pdxscholar.library.pdx.edu/open_access_etds/409.

Khan, Asima. "Education and Women: Non-Formal Education Among Lower Socioeconomic Status Women in Pakistan In Their Voice." Kent State University / OhioLINK, 2013. http://rave.ohiolink.edu/etdc/view?acc_num=kent1355698154.

Arthur, Linda. "Education reform in developing countries : decentralisation with reference to India and Pakistan." Thesis, University of Oxford, 2003. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.401500.

Bessingpas, Maureen Tyra. "Reforming primary education in Pakistan in the interest of U.S. national security." Connect to Electronic Thesis (CONTENTdm), 2009. http://worldcat.org/oclc/501000147/viewonline.

Ahmer, Zeshan. "Usage of Enterprise Resource Planning Systems in Higher Education Institutions in Pakistan." Thesis, University of Hertfordshire, 2017. http://hdl.handle.net/2299/19625.

Khurram, Bushra Ahmed. "Promoting metacognition of reading strategies in a higher education context in Pakistan." Thesis, University of Warwick, 2015. http://wrap.warwick.ac.uk/77510/.

Shaukat, Rumaisa. "A Qualitative Investigation of an Educational Reform Initiative in Pakistan." Thèse, Université d'Ottawa / University of Ottawa, 2013. http://hdl.handle.net/10393/23695.

Bashir, Humaira. "Rural females’ perceptions on the attitudes and barriers to education : an ethnographic case study." Thesis, Staffordshire University, 2013. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.599892.

Amir, Alia. "Chronicles of the English Language in Pakistan : A discourse analysis of milestones in the language policy of Pakistan." Thesis, Linköpings universitet, Institutionen för kultur och kommunikation, 2008. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-65526.

Ahmed, Mah-E.-Rukh. "Comparative perspectives on initial primary teacher education and training in England and Pakistan." Thesis, University of Hull, 2008. http://hydra.hull.ac.uk/resources/hull:5533.

Shah, Rakshinda. "Interpretations of Educational Experiences of Women in Chitral, Pakistan." Scholar Commons, 2015. https://scholarcommons.usf.edu/etd/5580.

Deeba, Farah. "The higher education curriculum development process in public and private universities in Pakistan." Thesis, University of Bristol, 2015. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.730823.

Azizi, Susanne L. "An Analysis of the Social Action program and Education of Women in Pakistan." Thesis, Virginia Tech, 1999. http://hdl.handle.net/10919/32614.

Ansari, Amna. "Children's capabilities and education inequality : how types of schooling play a role in Pakistan." Thesis, University of Cambridge, 2018. https://www.repository.cam.ac.uk/handle/1810/274874.

Khan, Muhammad Nasir Ayub. "Evaluation of the learning environment of teaching hospitals of twin cities in Pakistan." Thesis, Stellenbosch : Stellenbosch University, 2014. http://hdl.handle.net/10019.1/95846.

Hatfield, Randy Lee. "Management reform in a centralised environment : primary education administration in Balochistan, Pakistan, 1992-97." Thesis, London School of Economics and Political Science (University of London), 2001. http://etheses.lse.ac.uk/1612/.

Tahir, Muhammad Wajid [Verfasser]. "Is Higher Education Enough? Explaining Barriers to Women's Employment in Pakistan / Muhammad Wajid Tahir." Aachen : Shaker, 2017. http://d-nb.info/1138176869/34.

Niazi, Hamid Khan. "Manpower planning in Pakistan : a study of its assumptions concerning the education-occupation relationship." Thesis, University College London (University of London), 1996. http://discovery.ucl.ac.uk/10021610/.

Brohi, Mohammad Ismail. "A study of the supervisory system of school education in Sindh province of Pakistan." Thesis, University College London (University of London), 1991. http://discovery.ucl.ac.uk/10018503/.

Akhtar, Waheed. "Understanding Madrassah Education and Its Impacts. A Case Study of Chach (Attock) region in Pakistan." Thesis, University of Bradford, 2012. http://hdl.handle.net/10454/5659.

Halai, Anjum. "Role of social interactions in students' learning of mathematics (in classrooms in Pakistan)." Thesis, University of Oxford, 2001. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.367778.

Wisløff, Cathrine. "Utdanningsambisjoner blant norskpakistanere : hvordan virker sosial bakgrunn inn? /." Oslo : Institutt for sosiologi og samfunnsgeografi, Universitetet i Oslo, 2008. http://www.duo.uio.no/publ/iss/2008/86982/Wisloff.pdf.

Shaheen, Robina. "An investigation into the factors enhancing or inhibiting primary school children’s creativity in Pakistan." Thesis, University of Birmingham, 2010. http://etheses.bham.ac.uk//id/eprint/1239/.

Sarwar, Kafeel [Verfasser], and Stefan [Akademischer Betreuer] Klonner. "Essays on poverty, inequality and education in India and Pakistan / Kafeel Sarwar ; Betreuer: Stefan Klonner." Heidelberg : Universitätsbibliothek Heidelberg, 2021. http://d-nb.info/1228700699/34.

Tajammal, Fariha. "Gender inequalities in education : a case study of the girls' stipend programme in Punjab, Pakistan." Thesis, Manchester Metropolitan University, 2018. http://e-space.mmu.ac.uk/620937/.

Warraich, Muhammad Akib. "Social franchising in emerging markets : a multi-perspective approach in the education sector of Pakistan." Thesis, Rennes 1, 2017. http://www.theses.fr/2017REN1G015/document.

Chabot, Genevieve Walsh. "A case study of educational needs, obstacles and opportunities for girls, women and teachers in remote Pakistan." Thesis, Montana State University, 2009. http://etd.lib.montana.edu/etd/2009/chabot/ChabotG1209.pdf.

Tharani, Samira Kamil. "A slippery terrain : struggle and learning in Baltistan's women organizations." Thesis, McGill University, 2002. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=79811.

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Contents of Volume 37, Number 3 HTML articles powered by AMS MathViewer View front and back matter from the print issue

• Open access
• Published: 10 May 2024

Implementation of a clinical breast exam and referral program in a rural district of Pakistan

• Russell Seth Martins 1 ,
• Aiman Arif 2   na1   na2 ,
• Sahar Yameen 2 ,
• Shanila Noordin 2 ,
• Taleaa Masroor 3 ,
• Shah Muhammad 2 ,
• Mukhtiar Channa 2 ,
• Sajid Bashir Soofi 2 &
• Abida K. Sattar 2 , 4  

BMC Health Services Research volume  24 , Article number:  616 ( 2024 ) Cite this article

90 Accesses

Metrics details

The role of clinical breast examination (CBE) for early detection of breast cancer is extremely important in lower-middle-income countries (LMICs) where access to breast imaging is limited. Our study aimed to describe the outcomes of a community outreach breast education, home CBE and referral program for early recognition of breast abnormalities and improvement of breast cancer awareness in a rural district of Pakistan.

Eight health care workers (HCW) and a gynecologist were educated on basic breast cancer knowledge and trained to create breast cancer awareness and conduct CBE in the community. They were then deployed in the Dadu district of Pakistan where they carried out home visits to perform CBE in the community. Breast cancer awareness was assessed in the community using a standardized questionnaire and standard educational intervention was performed. Clinically detectable breast lesions were identified during home CBE and women were referred to the study gynecologist to confirm the presence of clinical abnormalities. Those confirmed to have clinical abnormalities were referred for imaging. Follow-up home visits were carried out to assess reasons for non-compliance in patients who did not follow-through with the gynecologist appointment or prescribed imaging and re-enforce the need for follow-up.

Basic breast cancer knowledge of HCWs and study gynecologist improved post-intervention. HCWs conducted home CBE in 8757 women. Of these, 149 were warranted a CBE by a physician (to avoid missing an abnormality), while 20 were found to have a definitive lump by HCWs, all were referred to the study gynecologist (CBE checkpoint). Only 50% (10/20) of those with a suspected lump complied with the referral to the gynecologist, where 90% concordance was found between their CBEs. Follow-up home visits were conducted in 119/169 non-compliant patients. Major reasons for non-compliance were a lack of understanding of the risks and financial constraints. A significant improvement was observed in the community’s breast cancer knowledge at the follow-up visits using the standardized post-test.

Conclusions

Basic and focused education of HCWs can increase their knowledge and dispel myths. Hand-on structured training can enable HCWs to perform CBE. Community awareness is essential for patient compliance and for early-detection, diagnosis, and treatment.

Peer Review reports

Introduction

Breast cancer is the most frequently diagnosed malignancy (barring skin cancers) and the fifth leading cause of cancer-related deaths worldwide [ 1 , 2 ]. According to GLOBOCAN 2022, 2.3 million new cases of breast cancer were diagnosed in 2022, with 666,103 patients dying from the disease [ 3 ]. Moreover, the incidence and mortality of breast cancer is expected to increase by 40% and 50% respectively by 2040 [ 3 ]. The rise in incidence is particularly steep in Asia, with these countries also seeing a significantly younger age of onset compared to the Western world [ 4 , 5 ]. In Pakistan, one in every nine women suffers from breast cancer, with the country having one of the highest incidence rates in the region (around 2.5 times higher than neighboring countries such as Iran and India) [ 6 , 7 ]. Breast cancer accounts for more than 20% of all malignancies in Pakistan, and almost half of all cancers in women [ 8 ].

The World Health Organization (WHO) has emphasized the role of early diagnosis of symptomatic breast cancer as a more feasible and economical strategy as compared to screening in resource-constrained countries [ 9 , 10 ]. Screening for breast cancer allows for detection of breast cancer at an earlier stage (especially when small enough to remain undetectable on clinical examination) and leads to significantly better management outcomes and less treatment expenditure [ 1 , 9 ]. While screening aims to identify lesions in asymptomatic and healthy individuals who have yet to develop clinical manifestations of disease, early detection of symptomatic breast cancer seeks to recognize individuals at an earlier stage than when they would otherwise present, allowing for more timely management and potentially better oncologic outcomes [ 9 ].

Early diagnosis and treatment are a cornerstone of efforts to reduce cancer-associated mortality in developed countries. In the United States (US), fewer than 20% of cancers present with advanced disease [ 11 ]. Data from Pakistan presents a stark contrast, with more than half of patients presenting with locally advanced or metastatic disease [ 11 ]. Mammography is the most effective screening modality for breast cancer in high-income countries. Multiple breast cancer screening trials have reported a reduction breast cancer-related mortality up to 25% among women undergoing mammography screening [ 12 ]. However, it remains under-utilized as a screening tool, both in developing and developed countries. Reasons for this range from misconceptions regarding screening methods, techniques, and radiation to lack of insurance or a care provider and fear of recall imaging, overdiagnosis leading to unnecessary biopsies and treatment and side effects [ 13 , 14 ]. In the US, more than 75% of eligible women are screened for breast cancer via mammography [ 15 ]. In a lower-middle-income country (LMIC) like Pakistan, access to investigations such as mammogram, breast ultrasound and needle biopsy is limited due to lack of availability of machines and trained personnel, lack of awareness and financial limitations (75% of healthcare financing in Pakistan is out-of-pocket and over one-third of the population lives below the poverty line) [ 16 , 17 ]. In addition, conservative sociocultural norms and religious factors also prevent women from seeking routine healthcare [ 18 ]. Given the lack of healthcare access coupled with a largely conservative culture, community outreach programs with home visits may be the ideal system for bringing initial breast cancer recognition home to the rural communities, enabling early confirmation of disease and initiation of treatment. Similar outreach programs have met with considerable success in other aspects of healthcare. These include programs improving screening and prevention of malaria, tuberculosis, and HIV and those targeting improvement maternal and neonatal mortality [ 19 , 20 ]. Thus, screening, and early detection interventions implemented in LMICs like Pakistan must take into account the local healthcare systems and social structures.

Clinical breast examination (CBE) is recommended as the preferred approach for early detection of symptomatic and clinically detectable breast cancer in LMICs such as Pakistan. It consists of inspection and palpation of the breasts and regional (axillary, supraclavicular, infraclavicular and cervical) lymph nodes of the patient in a sitting and supine position [ 21 ]. It can be readily performed by a primary care physician to identify abnormal breast findings and determine the need for further evaluation.[ 22 ], [ 23 ] In fact, while mammography is expected to miss over 20% of breast cancers, CBE is able to detect 3–45% of these false negative cases [ 24 , 25 , 26 ].

Due to the aforementioned sociocultural barriers towards mammographic breast screening in Pakistan, it is vital that early detection interventions employ more feasible methods such as CBE. Thus, the objective of this study was to describe the outcomes of a community outreach breast education, home CBE and referral program for early recognition of breast abnormalities and improvement of breast cancer awareness in a rural district of Pakistan. We conducted a community outreach and referral program where home CBE visits were conducted by trained healthcare workers (HCWs) for early detection of breast signs and symptoms, in a rural district of Pakistan. Women who had clinical abnormalities detected upon examination were then referred for further evaluation. During these visits, the women were also educated regarding breast cancer management. In this study, we report our results and experiences with this program. We believe that it is important to reinforce that early detection interventions for breast cancer may be implemented in LMICs like Pakistan using CBE as the preferred approach. Given that most patients with breast cancer present with advanced disease, CBE may be able to identify characteristic breast changes earlier and allow for timely treatment of the tumor at earlier stages [ 27 ].

Materials and methods

Study design and setting.

A quasi-experimental study was carried out over September 2021 - September 2022 in Sindh, Pakistan. The study team was primarily based at Aga Khan University (AKU) in Karachi, Sindh, while the field location where the community outreach program was implemented was situated in the Dadu district of Sindh, Pakistan. The Aga Khan University is an academic tertiary care private hospital and a health services agency of the Aga Khan Development Network (AKDN) in Pakistan. This study featured a collaboration between the Departments of Surgery and Maternal and Child Health at AKU. Ethical approval was obtained from the ethical review committee at AKU.

The Dadu district covers 19,070 km 2 in interior Sindh and is divided into four sub-divisions which are further divided into Union Councils (UC). The UC is the smallest administrative unit of Pakistan. The field location of our study consisted of five UCs within the Johi subdivision of the Dadu district. Some census data of the five included UCs, as collected by the AKU for local projects, are shown in Table  1 . Approximately 48.7% of the population is female. As of 2021, it has 47 Basic Health Units (BHU) and 5 Rural Health Centers (RHC) with a total of 503 beds (BHUs and RHCs are first-level primary healthcare facilities that serve rural populations). The doctor -to-patient ratio is 1:6,030, nurse-to-patient ratio is 1:39,629, and bed-to-patient ratio is 1:3,309 [ 28 ].

Study population and sample size calculation

The total population within the five target UCs was 64,023. Our target sub-population consisted of all adult women ≥ 18 years of age. Using an estimated 20% prevalence of abnormal CBE according to a similar study conducted in Tajikistan [ 29 ], 80% power, 95% confidence level, and design effect of 2, we calculated the minimum required sample size to be 547 individuals. This was inflated by 100% to mitigate against extreme rates of individuals being lost to follow-up, which we anticipated to be a significant real-world challenge, yielding a final minimum required sample size of 1,094. Cluster convenience sampling was used to identify women in the community.

Training workshop and outreach program

The study schema consisted of the following interventions in sequence as described:

Training of Health Care Workers (HCWs) : Non-physician HCWs received training at AKU, Karachi in September – October 2021. This specialized training program was designed to enhance HCWs’ skills in identifying suspicious breast problems, making appropriate and timely referrals, and improving general knowledge regarding breast cancer. This training was conducted and overseen by an attending breast surgeon at AKU. HCWs were taught how to perform clinical breast examinations (CBEs) and engaged in hands-on practice sessions with simulated breast disease models and real patients in clinics. In addition, the HCWs were educated regarding general knowledge regarding breast cancer, with special emphasis on treatment, evaluation and commonly held misconceptions among the public. Pre and post-intervention surveys were administered to evaluate improvement in knowledge.

Community outreach program with home visits : The HCWs were deployed into the community in the Johi subdivision in October 2021. The initial series of home visits took place between October 2021 to February 2022, with the HCWs performing home visits in groups of two. Each visit began with an introductory and informed consent-seeking debriefing, followed by CBE of all consenting adult women belonging to a household, an assessment of baseline breast cancer-related knowledge, and lastly, a brief, standardized educational intervention delivered verbally (Supplement). For each CBE performed, a checklist of examination findings was completed. In the event of any abnormal finding, a referral to a local gynecologist within Johi was made. All interactions during the home visits were conducted in the Sindhi language, which is the native language of the region.

Visit to the local gynecologist : Patients who complied with their referral (for a palpable breast concern) were evaluated by a gynecologist at the local District Health Quarter. The gynecologist repeated a CBE on all referred patients in order to validate the HCWs’ examination findings. All eligible patients were then referred for breast imaging, either mammography or ultrasound, to the nearest facility within Johi.

Follow-up home visits : The HCWs attempted to conduct follow-up home visits for all women who were non-compliant with initial referral to a gynecologist. These follow-up visits took place six months after the initial series of home visits. Patients were questioned as to the reasons for their non-compliance with referral using a self-designed structured questionnaire (Supplement: Sect.  4 ). In addition, the breast cancer-related knowledge survey was re-administered to the women to gauge improvement in knowledge since the educational intervention delivered at the initial home visits. Finally, the importance of complying with referral for future evaluation, diagnosis and management was re-emphasized to all patients.

Validation of Data Collection Tools :

CBE checklist : This was a self-designed checklist (Supplement: Sect.  3 ) that included all the important components of a CBE, including a brief history of relevant symptoms (pain, discharge), breast inspection (skin changes, or changes in breast size, shape, or symmetry, and nipple changes), and breast palpation (presence of lumps in the axilla or breast).

Breast cancer-related knowledge survey : Separate surveys were administered to the HCWs and the women within the general community (Supplement: Sects.  2 and 3 ). Both surveys were designed by faculty within the Section of Breast Surgery at AKU. Prior to its use, the survey for women within the community was pretested amongst 30 local women for content, comprehensibility, and language. Minor adjustments were made on the basis of this pilot procedure.

Statistical analysis

All analyses were performed using SPSS (Statistical Package for Social Sciences) version 23.0 (IBM Corporation, Armonk, New York). Descriptive analysis was performed whereby categorical values were reported using frequencies and percentages. McNemar’s test was used to compare changes in knowledge across the multiple administrations of the breast cancer-related knowledge surveys. A p-value less than 0.05 was considered significant for all the analysis.

Education and training of the HCWs

A total of 8 HCWs were trained. Tables  2 and 3 show the changes in breast cancer-related knowledge after the educational and training intervention for the HCWs. The absolute percentage increase in HCWs who correctly believed that breast cancer can occur in men, and in women despite breast feeding their children, was 50%. In addition, the percentage of respondents who believed that women with a painless lump should visit a healthcare professional increased from 87.5 to 100%. The absolute percentage of HCWs who correctly identified painless lump and bloody nipple discharge as a symptom suspicious of breast cancer increased by 12.5% and those that identified dimpling of skin as a suspicious symptom increased by 25%. The percentage of HCWs who correctly believed that a tissue biopsy could be used to diagnose breast cancer increased from 62.5 to 87.5%.

Implementation of the outreach program

A total of 8,757 women were screened by the HCWs in the field during initial series of home visits. A palpable breast lump was identified in 20/8,757 women, while other palpable or visible breast concerns warranting further evaluation were identified in 98/8,757 women. In addition, HCWs were unsure about the presence of a lump in 51/8,757 women. Keeping a low threshold for seeking a physician’s evaluation and prompt referrals, these 169/8,757 patients were all referred to a gynecologist for further examination. However, only 38/169 patients (ten with a palpable breast lump and 28 for which the HCWs exercised caution-either noted other breast concerns or were unsure) complied with initial referral to the gynecologist. Out of the 28 patients (where HCWs noted breast concerns or were unsure about a lump), none were found to have a lump on the gynecologist’s CBE examination. Out of the ten patients in which the HCWs had positively identified the breast lumps, nine patients (90% concordance) were confirmed to have a breast lump on the gynecologist’s CBE. However, all these ten patients were referred for imaging with only 4 of them complying. Amongst these 4 patients who had breast imaging, one patient had BI-RADS (Breast Imaging Reporting and Data System) category I finding (i.e. negative imaging) and 3 patients had BI-RADS category III findings (Lump with extremely low probability of malignancy). The outcomes of the CBE and referral program are illustrated in Fig.  1 .

Outcomes of community outreach Breast referral program. HCW: Health Care Workers; CBE: Clinical Breast Examination; FNAC: Fine Needle Aspiration Cytology

At the follow-up home visits to the 131 patients who had been non-compliant with initial referral, the most common reasons for non-compliance were assessed by the HCWs ( Table  4 ). The most common reasons for non-compliance were a belief that follow-up was not important (42.0%), lack of money to visit the gynecologist (24.4%), not having anyone to accompany them (9.2%), long distance to travel for the appointment (7.6%).

Increase in community awareness regarding breast cancer

A comparison of the women’s knowledge regarding breast cancer at the time of initial visit and later at follow-up is shown in Table  5 . The percentage of women who had heard of breast cancer increased from 54.6 to 100%, the percentage of women who were aware that breast cancer was treatable increased from 32.8 to 61.3%. The percentage of women understood the need to consult a healthcare professional upon finding a lump increased from 50.4 to 94.1%.

The purpose of this study was to evaluate the feasibility of the real-world implementation of a large-scale clinical breast examination and referral community outreach program in a rural district of Pakistan. Secondarily, we also explored the feasibility of delivering basic breast cancer-related knowledge to the community via non-physician HCWs. This program was the first of its kind for breast cancer detection in the country. The key positive takeaways from our experience were that it is: (i) possible to train non-physician HCWs to perform a comprehensive CBE and identify examination findings warranting referral and further evaluation, (ii) practically feasible to implement a large-scale community outreach program with home-visits for mass detection of breast cancer, (iii) possible to increase community knowledge and awareness for breast cancer by imparting education at the home-visits when CBE was performed. However, we encountered several real-world challenges that precluded the full realization of this outreach program’s impact. Only 50% of women initially identified by the HCWs as having a breast lump followed through with referral to the gynecologist, and only 40% of women followed up with subsequent referral for imaging. None of the patients eventually referred for histopathological evaluation ended up complying with the referral. However, prior experience with a similar program by the AKDN in Tajikistan demonstrated that with appropriate follow-ups, breast cancer may be detected in up to 0.2% of the women in the community [ 29 ]. Although this rate is slightly lower than the reported incidences of mammographic screening-detected breast cancers in the literature (0.5–0.8%), it underscores the potential for success of CBE-based programs as an early detection strategy in low-resource communities [ 30 , 31 ].

Accuracy of CBE by non-physician HCWs and effectiveness of educational interventions

Overall, the theoretical frameworks and foundations of this large-scale clinical breast examination and referral community outreach program were observed to be largely successful. We were able to achieve a high degree of concordance (90%) between the CBE findings of the HCWs and the gynecologist, indicating that it is possible and feasible to leverage HCWs for the early detection of symptomatic breast cancer. Another study carried out in Malawi to train community laywomen to conduct CBE in the community showed 88% concordance between CBE performed by the HCWs and those performed by the physicians [ 32 ]. This is exceedingly important in a LMIC like Pakistan, where the ratio of physicians to population is a major impediment to healthcare access. In Pakistan, there are only 170,000 general practitioners to serve a population of over 230 million individuals. Thus, a major bottleneck for the delivery of high quality breast cancer-related healthcare is the timely initial identification of these patients from the community. Utilizing existing community outreach frameworks, such as the Lady Health Worker (LHW) Program, cite which was in Pakistan in 1994 [ 33 , 34 ]. While the LHW Program was initially developed for promoting family planning and maternal health, the model has been adapted for other major public health interventions such as immunizations and basic preventative healthcare. These LHWs are salaried and recognized as part of the healthcare workforce. Since LHWs are recruited from within the community itself, one of the major strengths of such a program is their ability to deliver culturally appropriate healthcare to populations with limited access to healthcare facilities. Thus, based on the successful training of HCWs in our study, we believe that the LHW Program model can be effectively adapted for the early recognition of breast abnormalities in women who would otherwise go undetected. However, it is important to know that the training of the HCWs in our study was performed by a fellowship-trained breast surgeon at a tertiary care hospital in one of the major cities of Pakistan. To ensure the feasibility, uptake, and growth of our model throughout the underserved regions of the country, it is important that a certain degree of sustainability is achieved. In future iterations of this model, we plan to assess the effectiveness of cascade learning with peer-to-peer teaching. In such a model, HCWs initially trained by a breast surgeon will subsequently assume the role of trainers themselves and teach other HCWs/LHWs how to perform a CBE. Interestingly, the study conducted in Malawi trained non-HCWs to serve as “Breast Health Workers”, highlighting the potential to leverage non-HCW professionals to perform a health-related role in communities with low HCW-to-patient ratios [ 32 ].

Community education and awareness

Despite the successful and rigorous implementation of the CBE and referral community outreach program, the Achilles’ heel of this project was the pervasive lack of community awareness regarding the importance of following up with referrals. This was compounded by other sociocultural barriers such as financial constraints, transportation issues, and a lack of family support to visit the healthcare facility. Thus, it is important that future iterations of similar public health interventions be cognizant of these challenges and seek to mitigate them to the best of their ability. Indeed, the most modifiable of these obstacles is the lack of awareness which can be countered by greater community education during home visits, with a particular focus on emphasizing the potential consequences of non-compliance with diagnostic evaluations. Our results demonstrated the feasibility of educating HCWs to subsequently serve as teachers for the community, and that the newly gained knowledge remained reasonably intact even at a follow-up of six months. A study in Vietnam showed that repeated breast cancer-related educational interventions were successful in increasing compliance with referrals for breast cancer evaluation. [ 35 ] In addition, a more robust follow-up system including frequent interaction and monitoring of patients could help boost compliance with referrals and better continuity of care. For example, routinely scheduled phone calls could be made to the patient as a reminder to follow-up with their referrals. Moreover, for women who are not able to comply with their referrals because of the absence of a family member to accompany them, arrangements may be made whereby LHWs could accompany them as their attendants.

The other challenges, however, harken to well-known and longstanding problems with the healthcare system in Pakistan, where most of the population is unable to afford even basic healthcare. In such a setting, Universal Healthcare Coverage (UHC) emerges as the only viable solution to the masses. An attempt at such a system, the Sehat Sahulat Program (SSP; translates to Health Facility Program) was introduced in 2016 by the provincial government of Khyber Pakhtunkhwa, one of the five provinces of Pakistan [ 36 ]. The SSP was designed to cover a broad range of health conditions and services, including breast cancer diagnosis and evaluation. While the program was met with success in its initial years, and even expanded into some of the other provinces, instability in the political and economic infrastructures of Pakistan have limited its growth, uptake, and effectiveness. Ideally, mass community interventions for early breast cancer detection such as ours could be integrated with UHC programs such as SSP to ensure patient compliance, continuity of care, and maximization of invested resources most effectively.

Limitations

Our study has several limitations that we would like to acknowledge. Firstly, we were unable to calculate a study participation rate as the HCWs did not record the number of informed refusals that they received from women in the community. Secondly, as mentioned earlier, compliance with referrals was exceedingly poor and limited the realization of the true impact of the program. Thirdly, given the limited number of HCWs included, we were unable to perform statistical comparisons to evaluate the improvement in HCWs knowledge. Lastly, the evaluation of the long-term impact and sustainability of the program was limited, presumably due to the influence of sociocultural barriers on the health-seeking behaviors of the women.

This study describes the real-world implementation of a large-scale clinical breast examination and referral community outreach program in a rural district of Pakistan. Our study highlights the importance of CBE programs in early recognition of breast abnormalities/lumps, in regions where mammography is not feasible. Such training programs may lay the foundation for improved provider and community awareness, and examination at the patient’s doorstep and initiate referrals. However, for such programs to ultimately lead to earlier detection of breast cancer/downstaging of disease, community awareness and political buy-in from governmental stakeholders would be critical. Lastly, for such a program to have a truly national impact and be sustainable, more widespread training of HCWs using cascade learning and peer-to-peer teaching models would be necessary.

Data availability

The datasets generated and/or analysed during the current study are not publicly available since the Ethical Review Committee guidelines does not allow institutional data to be dispersed. However, the data is available on reasonable request to the corresponding author.

Abbreviations

Global Cancer Observatory

United States

Lower-Middle-Income Country

World Health Organization

Clinical Breast Examination

Aga Khan University

Union Council

Healthcare Workers

Breast Imaging Reporting and Data System

Lady Health Worker

Universal Health Coverage

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Acknowledgements

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No funding was received for this study.

Author information

Russell Seth Martins and Aiman Arif contributed equally to this work.

Sahar Yameen and Shanila Noordin contributed equally to this work.

Authors and Affiliations

Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health Network, Nutley, NJ, 08820, USA

Russell Seth Martins

Aga Khan University, Karachi, 74800, Pakistan

Aiman Arif, Sahar Yameen, Shanila Noordin, Shah Muhammad, Mukhtiar Channa, Sajid Bashir Soofi & Abida K. Sattar

Department of Surgery, John Hopkins University, Baltimore, MD, 21218, USA

Taleaa Masroor

Department of Surgery, Link Building The Aga Khan University, Karachi, 74800, Pakistan

Abida K. Sattar

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AKS was responsible for study conceptualization, design of the study. Project administration was overseen by AKS and SBS. Development of the curriculum and training of healthcare workers was conducted by AKS. Implementation of the study protocols and the acquisition of data was performed by SY, SN, SM, and MC. TM and RSM were responsible for formal analysis and data curation. AA was responsible for writing the original draft of the manuscript. Critical review and editing of the manuscript were conducted by RSM, AKS and AA. SM and MC were responsible for the supervision of the project on the field and AKS and SBS were responsible for the supervision of the entire project. AKS was involved in all aspects from conception and design, through implementation, monitoring, internal audits, study coordination, data analysis, manuscript concept, and critical review. All authors approved the final version to be published and agree to be accountable for all aspects of the work.

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Correspondence to Abida K. Sattar .

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The study was approved by the Institutional Ethical Review Committee at Aga Khan University Hospital, Karachi. Informed consent was taken from all study participants after debriefing them regarding the study. The reference number for the study was 2020-2047-14276.

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Written informed consent for publication was taken from all study participants as part of the informed consent.

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Martins, R.S., Arif, A., Yameen, S. et al. Implementation of a clinical breast exam and referral program in a rural district of Pakistan. BMC Health Serv Res 24 , 616 (2024). https://doi.org/10.1186/s12913-024-11051-7

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DOI : https://doi.org/10.1186/s12913-024-11051-7

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Pakistan PM Unveils Broader Plan to Sell Most State-Owned Firms

FILE PHOTO: View of a Pakistan International Airlines (PIA) passenger plane, taken through a glass panel, at Islamabad International Airport, Pakistan October 3, 2023. REUTERS/Akhtar Soomro/File Photo

By Asif Shahzad

ISLAMABAD (Reuters) -Pakistan will privatise all state-owned enterprises, with the exception of strategic entities, Prime Minister Shehbaz Sharif said on Tuesday, broadening its initial plans to sell only loss-making state firms to shore up its shaky finances.

The announcement came after Sharif headed a review meeting of the privatisation process of loss-making state enterprises (SOEs), according to a statement from his office, which discussed a roadmap for privatisation from 2024 to 2029.

"All of the state-owned enterprises will be privatised whether they are in profit or in losses," Sharif said, adding that offloading the companies would save taxpayers' money.

The statement didn't clarify which sectors would be deemed strategic and non-strategic.

The announcement came a day after an International Monetary Fund mission opened talks in Islamabad for a new long-term Extended Fund Facility, following Pakistan's completion of a $3 billion standby arrangement last month, which averted a sovereign debt default last summer.

Privatisation of loss-making SOEs has long been on the IMF's list of recommendations for Pakistan, which is struggling with a high fiscal shortfall and a huge external financing gap. Foreign exchange reserves are hardly enough to meet a couple of months of controlled imports.

The IMF says SOEs in Pakistan hold sizable assets in comparison with most Middle East countries, at 44 percent of GDP in 2019, yet their share of employment in the economy is relatively low. It estimates almost half of the SOEs operated at a loss in 2019.

PATCHY SUCCESS SO FAR

Past privatisation drives have been patchy, mainly due to a lack of political will, market watchers say.

Any organisation that is involved in purely commercial work can't be strategic by its very nature, which means there can't be any strategic commercial SOEs, former privatisation minister Fawad Hasan Fawad told Reuters on Tuesday.

"So to me there are really no strategic SOEs," he said.

"The sooner we get rid of them the better. But this isn't the first time we have heard a PM say this and this may not be the last till these words are translated into a strategic action plan and implemented."

Islamabad has for years been pumping billions of dollars into cash-bleeding SOEs to keep them afloat, including one of the largest loss-making enterprises Pakistan International Airline, which is in its final phase of being sold off, with a deadline later this week to seek expressions of interest from potential buyers.

Pakistan has listed 25 entities and assets on its privatisation list, including the PIA. A majority of the entities are in the power sector, including four power plants, two of which are over 1,200MWs, as well as 10 generation and distribution companies.

The list also includes the valuable Roosevelt hotel in New York's Manhattan and two insurance companies.

The pre-qualification process for PIA's selloff will be completed by end-May, the privatisation ministry told Tuesday's meeting, adding discussions were underway to sell the airline-owned Roosevelt Hotel in New York.

It said a government-to-government transaction on First Women Bank Ltd was being discussed with the United Arab Emirates, and added that power distribution companies had also been included in the privatisation plan for 2024-2029.

"The loss-making SOEs should be privatised on a priority basis," Sharif said.

(Reporting by Asif Shahzad; Editing by Tom Hogue, Jacqueline Wong, Kim Coghill and Christina Fincher)

Copyright 2024 Thomson Reuters .

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Fellowship recipients to continue their studies in the u.k..

Top row, from left, Paulina Pimentel-Mora, Tony Wang,Galia Newberger, Ellie Burke, and Giuliana Pavanelli Durón. Second row, Yosef Malka, Joshua Nguyen, Anjali Mangla, Sophie Kane, and Vijay Pathak.

Eight Yale seniors and two recent graduates have been awarded fellowships from various organizations for graduate study in the United Kingdom.

These are in addition to students, previously announced in Yale News, who have won Rhodes and Marshall scholarships.

The fellowship winners and their awards follow:

Ellie Burke , who is studying history at Yale, was awarded a Paul Mellon fellowship to pursue an M.Phil. degree in World History at the University of Cambridge. For her thesis project, Burke, who is originally from Kansas City, examined the impacts of the South African musical “Sarafina!” on anti-apartheid protest in the United States with advisor Professor Daniel Magaziner. At Cambridge, she will expand this project to more broadly examine the role of anti-apartheid theater in the United Kingdom. During her time at Yale, Burke produced multiple independent theater shows, sang in a cappella groups, and served in arts leadership roles including Outreach Coordinator for the executive board of the Yale Dramatic Association. She also worked as a barista in the Silliman student-run coffee shop, served as a First-Year Outdoor Orientation (FOOT) Leader, and is currently finishing her year as a First-Year Counselor in Silliman.

Giuliana Pavanelli Durón , who will graduate from Yale with a degree in Urban Studies and Architecture, was awarded a Paul Mellon Fellowship for graduate study at the University of Cambridge, where she will pursue an M.Phil. degree in Architecture and Urban Studies. As an Edward A. Bouchet Research Fellow, she has explored the history of landscape architecture in Mexico City, focusing on how the Mexican Revolution affected the design of urban parks and citizens’ relationship to land. In her thesis, she has explored the political and cultural dimensions of water infrastructure in Mexico City. She addresses how Indigenous histories and colonial legacies have been memorialized in hydrologic monuments within the city’s parks, specifically El Bosque de Chapultepec. She has also interned at the Housing and Health Equity Lab, analyzing the effects of pandemic-era moratoriums on housing-insecure individuals. As an Urban Fellow, Giuliana also works on data analysis for New Haven's Fair Rent and Housing Commission, advocating for tenant rights and healthy living conditions. Her research at Cambridge will focus on urban gardens in Mexico City, with an emphasis on how these community spaces serve as a source for alternative planning strategies based on grassroots practices. 

Sophie Kane , a Senegalese-American who has grown up across seven countries, is an American Studies major aspiring to a career at the intersection of law and social policy. On the Yale campus, she served as the first president of the Yale Votes student organization and led the Intercultural and Social Justice program at the AFAM House. In her senior thesis, she compares restorative and reparatory justice commissions in the United States and South Africa. As an undergraduate, she has worked on a presidential campaign, in Congress, and at two nonprofit policy advocacy organizations: Solitary Watch and the Legal Action Center. She has been a Women in Government and Arthur Liman Fellow and is a former student of the Brady-Johnson Program in Grand Strategy. This summer, she will work at the Public Defender Service for the District of Columbia before pursuing a Master of Science (M.Sc.) degree in comparative social policy at Oxford in the fall. At Oxford, she will investigate targeted universalism as a strategic tool to reinvent American welfare.

Yosef Malka , a history major whose academic interests lie in the history of political thought, modern Jewish history, and legal theory, was awarded a Paul Mellon Fellowship to pursue an M.Phil. degree in political thought and intellectual history at Cambridge University. Malka, who is from Rockville, Maryland, will examine 20th-century debates over minority rights, the nation-state, and liberalism while at Cambridge. During his time at Yale, Malka served as co-editor-in-chief of Shibboleth, Yale’s undergraduate journal of Jewish studies, worked as an editorial assistant for the Yale Law Journal, interned for the Office of the New York State attorney general, co-led a Sephardic singing group, and founded a student forum for the study of political theory.

Anjali Mangla , who is completing a double major in Neuroscience and Global Affairs, received a Rotary Global Grant Scholarship that will allow her to pursue a master’s degree in Global Health Policy at London School of Tropical Hygiene and Medicine and London School of Economics. Mangla is interested in global health policymaking, particularly in investigating sustainable financing mechanisms for global health care policy and community-based initiatives. She is currently leading the HAVEN Free Clinic’s pilot “Food as Medicine” program, and, as the clinic’s community relations and advocacy director, has started a variety of initiatives such as reproductive health workshops with Planned Parenthood, and advocacy with the HUSKY4Immigrants Coalition to expand access to public health coverage for all eligible Connecticut residents regardless of immigration status. She has also engaged with the New Haven community through Community Health Educators and volunteering at the hospital and with IRIS' family literacy program. During spring break, she traveled to Liberia to learn more about global health initiative funding for her capstone project on the need for more indirect cost funding for low- and middle-income countries. She hopes to pioneer sustainable global health financing policies with a focus on mitigating noncommunicable diseases in the future.

Galia Newberger  was awarded the King’s-Yale Fellowship to pursue an M.Phil. degree in politics and international studies at the University of Cambridge. She will study the rise of illiberalism in Central and Eastern Europe, particularly in the Czech Republic, Hungary, Poland, and Slovakia. At Yale, she double majored in Humanities and Political Science, and her joint senior essay explored what Plato’s Republic can teach modern readers about preventing a backsliding of democracy. Newberger competes on Yale’s Model United Nations team, and previously served as communications director for the Yale College Democrats and as managing editor at the Yale Daily News Magazine. Outside of Yale, she has served as a legislative and communications intern for U.S. Rep. Jan Schakowsky, D-Illinois, as a political advocacy intern at the ACLU, and as an intern at the Federal Defenders of New York.

Joshua Nguyen , who graduated from Yale in 2023 with a Bachelor of Science degree in Molecular, Cellular and Developmental Biology , was awarded the Rotary Global Grant Scholarship to pursue an M.Sc. degree in Digital Health at the University of Oxford. During his time at Yale, Nguyen worked as a research assistant at the Yale School of Medicine, investigating the underlying genetic mechanisms of lymphedema, and was recognized as a Dean’s Research Fellow and STARS II Scholar. His interest in health care equity will guide his studies at Oxford, where he plans to delve into leveraging digital health innovations to serve marginalized populations. While at Yale he spearheaded patient care initiatives for uninsured individuals at the HAVEN Free Clinic and Yale New Haven Hospital, and serving as an ESL tutor for refugees and immigrants in the New Haven area. He was also a peer liaison for Yale’s Asian American Cultural Center, the president of Yale Outdoors, and a clarinetist and recorderist in various music ensembles. He aspires to a career dedicated to improving health equity, with a focus on supporting uninsured and low-income communities.

Vijay Pathak , a senior from Luxembourg and France who will graduate with a Bachelor of Arts degree in Ethics, Politics, and Economics, has been awarded the Rotary Global Grant to pursue studies in European Politics and international conflict prevention in the United Kingdom. His academic interests lie at the intersections of statecraft, international law, and the foreign and security policies of the EU and United States. He has pursued these interests at Yale as a scholar in the Brady-Johnson Program in Grand Strategy and also as a Fellow of the Peace, Dialogue, and Leadership Initiative. Pathak has worked as a research assistant at Yale Law School on the United Nations Legal Committee’s efforts to introduce legal frameworks on crimes against humanity, and is also a European Studies Undergraduate Fellow at the Yale MacMillan Center. He has completed coursework in international relations at Bocconi University in Milan, international law at the University of Oxford, and South Asian Studies at the University of Wisconsin-Madison as a recipient of the Yale SASC Light Fellowship.

Paulina Pimentel-Mora , who graduated from Yale in 2023 with a Bachelor of Arts degree in political science, has been awarded the Sidney Hellman Ehrman Studentship pursue a M.Phil. degree in health, medicine, and society at King’s College, Cambridge. Her research will delve into the realm of reproductive autonomy within health care systems, employing a comparative approach to analyze reproductive policies and the diverse factors influencing women’s reproductive decisions. A first-generation community college transfer student at Yale, Pimental-Mora served as a transfer peer advisor, admissions officer blogger, and residential teaching assistant with Yale Pathways to Science and the Yale School of Art’s “The Way We See It” workshop. She was also a member of the Yale College Student Health Advisory Council and participated in the Political Science Undergraduate Advisory Committee, in addition to working at the Yale University Art Gallery. Outside of Yale, she was a 2022 Centers for Disease Control and Prevention Future Public Health Scholar at the University of Michigan, where she was awarded the 2022-2023 CDC Williams-Hutchins Health Equity Award for her work as a COVID-19 case investigator.

Tony Wang , a double major in Near Eastern Languages & Civilizations and History of Art at Yale, has been awarded the 2024 Henry Fellowship to pursue postgraduate studies in Asian and Middle Eastern Studies at Oxford University. His academic pursuits are deeply anchored in the ancient history and archaeology of the Silk Road, with a keen focus on the Buddhist and Persian material cultures that flourished within Central Asia's heartlands. An active member of the “Guardian of Bamiyan and Gandhara” initiative, Wang is committed to the preservation of cultural heritage and the advancement of local education in the historically rich regions of Afghanistan and Pakistan. He also served as a curator and educator at the Yale Art Gallery, the UNESCO-recognized Dunhuang Academy, the Iran National Museum, and the Tsinghua University Art Gallery. He served as a research assistant with Professor Valerie Hanson, in Yale’s Department of History, and as a junior researcher at the Institution of Global Art History at Shanghai International University.

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