Championing Less Invasive and More Effective Treatment for Clubfoot in Pakistan

By Tom Cook, Director of Global Operations, Ponseti International Association

The Ponseti International Association (PIA), headquartered at the University of Iowa, USA, with guidance from the USAID-funded Leadership, Management & Governance (LMG) Project, undertook a two-year, three-country (Pakistan, Peru, Nigeria) project to better understand and document how to strengthen essential elements of national clubfoot treatment programs and to impact the health of children with clubfoot through increasing access to the Ponseti Method. The Ponseti Method is a simple, inexpensive, non-surgical, and extremely effective treatment for children born with clubfoot. It consists of a series of specific gentle manipulations of the foot and ankle and application of a series of plaster casts followed by use of a brace.  It is the “gold standard” treatment for clubfoot, and costs less and delivers better results for affected kids than the traditional surgical treatment. Clubfoot is one of the most common birth defects, affecting approximately 150,000-200,000 children each year worldwide. The Ponseti Method offers children complete recovery from the deformity with no long-term disability, allowing them to gain full mobility and thrive as active participants in their communities.

In Pakistan, where an estimated 7,500 children are born with clubfoot annually, PIA worked with champions to provide leadership, energy, and direction to build a national program to diffuse the Ponseti Method throughout the country. The LMG Project shared with PIA its materials and approaches for leadership development and support of champions for change, including the Guide to Fostering Change to Scale up Effective Health Services, to apply in Pakistan as well as in the program’s two other focus countries. The Pakistan champions, mostly physicians, some with training in public health, used their contextual knowledge, change management approaches, and networks to identify needed scale-up activities. These included advocacy to government and media, training for more doctors in the Ponseti Method, and strategic networking with professional societies. They formed Ponseti International Pakistan in 2013 to serve as an umbrella organization and created a unique training model for the Ponseti Method, in which trainees spend one week in mentored training with rotations among three clinics. This model allows for access to a sufficient number of children with clubfoot for maximal hands-on training and shares the work of the mentoring across different mentors.  The Pakistan champions successfully advocated to the four provincial ministries of health to endorse the Ponseti Method as the standard of care in their respective provinces. The Sindh government, for example, has instructed hospitals to establish Ponseti clubfoot clinics and research centers, and to provide casting materials. The Pakistan champions actively engaged the media, participating in documentaries and radio shows to spread information to parents and communities about the Ponseti Method. In two years, the champions were able to facilitate the establishment of 20 new Ponseti treatment clinics. They also developed a manual on clubfoot clinics with information about how to operate and staff a clinic, promote the clinic, and recruit patients.

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The Pakistan champions made substantial efforts to become leaders in their country and overcome the challenges they identified at the beginning of the project–for example, combatting the perception that the Ponseti method is time-consuming. They trained new residents in hospitals in the Ponseti Method, and spread the word to the public and to ministries of health that this is a low-cost treatment with results that last for life. Their advocacy to the government to address the need for treatment supplies in some hospitals led to increased availability of braces and plaster.

Investing in local champions who took ownership of the process and who knew the right stakeholders to engage was a critical component for success in this project. Local ownership of the program contributes to more sustainable health systems strengthening, greatly impacting the lives of children in Pakistan for years to come.

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