Eastern Mediterranean La Revue de Santé de Health Journal la Méditerranée orientale
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Contents Letter from the Editor ...... S3 Message from the WHO Regional Director for the Eastern Mediterranean ...... S4 1BLJTUBOTėHIUBHBJOTUQPMJPNZFMJUJTJOUSPEVDJOHJOOPWBUJWFTUSBUFHJFTUPBEESFTTDIBMMFOHFTBOEBĨBJOUIFHPBMPGFSBEJDBUJPO N. Abid, O. U. Islam, A. Bosan, T. Iqbal,A. Darwish and K. M. Bile ...... S5 1SFWBMFODFPGIFQBUJUJT#BOE$WJSBMJOGFDUJPOTJO1BLJTUBOėOEJOHTPGBOBUJPOBMTVSWFZBQQFBMJOHGPSFĎFDUJWFQSFWFOUJPO BOEDPOUSPMNFBTVSFT H. Qureshi, K.M. Bile, R. Jooma, S.E. Alam and H.U.R. Afridi ...... 4 4NPLFMFTTUPCBDDPVTFJO1BLJTUBOBOEJUTBTTPDJBUJPOXJUIPSPQIBSZOHFBMDBODFS K.M. Bile, J.A. Shaikh, H.U.R. Afridi and Y. Khan ...... 4 "SFWJFXPG&1*QSPHSFTTJO1BLJTUBOUPXBSETBDIJFWJOHDPWFSBHFUBSHFUTQSFTFOUTJUVBUJPOBOEUIFXBZGPSXBSE Q. Hasan, A.H. Bosan and K.M. Bile ...... 4 .BUFSOBM OFPOBUBMBOEDIJMEIFBMUIJO1BLJTUBOUPXBSETUIF.%(TCZNPWJOHGSPNEFTJSFUPSFBMJUZ A.F. Shadoul, F. Akhtar and K.M. Bile ...... S39 5VCFSDVMPTJTDPOUSPMJO1BLJTUBOSFWJFXJOHBEFDBEFPGTVDDFTTBOEDIBMMFOHFT P. Metzger, N.A. Baloch, G.N. Kazi and K.M. Bile ...... S47 .BMBSJBDPOUSPMJO1BLJTUBOOFXUPPMTBUIBOECVUDIBMMFOHJOHFQJEFNJPMPHJDBMSFBMJUJFT Q. Kakar, M. A. Khan and K. M. Bile ...... S54 $SFBUJOHTZOFSHJFTGPSIFBMUITZTUFNTTUSFOHUIFOJOHUISPVHIQBSUOFSTIJQTJO1BLJTUBOmBDBTFTUVEZPGUIFOBUJPOBMFZF IFBMUIQSPHSBNNF A.A. Khan, N. Khan, K.M. Bile and H. Awan ...... 4 &OWJSPONFOUBMIFBMUIOFFETBOEMBVODIJOHPGBOFOWJSPONFOUBMIFBMUIQSPUFDUJPOVOJUJO1BLJTUBO M.Z.A. Khan, B.M. Kazi, K.M. Bile, M. Magan and J.A. Nasir ...... 4 -BVODIJOHUIFėSTUQPTUHSBEVBUFEJQMPNBJONFEJDBMFOUPNPMPHZBOEEJTFBTFWFDUPSDPOUSPMJO1BLJTUBO H.R. Rathor, A. Mnzava, K.M. Bile, A. Hafeez and S. Zaman ...... 4 -FBSOJOHUISPVHIDSJTJTEFWFMPQNFOUBOEJNQMFNFOUBUJPOPGBIFBMUIDMVTUFSTUSBUFHZGPSJOUFSOBMMZEJTQMBDFEQFSTPOT K.M. Bile, A.F. Shadoul, H. Raaijmakers, S. Altaf and K. Shabib ...... 4 4BGFXBUFSTVQQMZJOFNFSHFODJFTBOEUIFOFFEGPSBOFYJUTUSBUFHZUPTVTUBJOIFBMUIHBJOTMFTTPOTMFBSOFEGSPNUIF earthquake in Pakistan M. Magan, M.K. Bile and Z. Gardezi ...... 4 -BSHFTDBMFQIZTJDBMEJTBCJMJUJFTBOEUIFJSNBOBHFNFOUJOUIFBěFSNBUIPGUIFFBSUIRVBLFJO1BLJTUBO M. Mallick, J.K. Aurakzai, K.M. Bile and N. Ahmed ...... S98 &TTFOUJBMNFEJDJOFTNBOBHFNFOUEVSJOHFNFSHFODJFTJO1BLJTUBO S.K.S. Bukhari, J.A.R.H. Qureshi, R. Jooma, K.M. Bile, G.N. Kazi, W.A. Zaibi and A. Zafar ...... 4 ĉFJNQBDUPGUIFEJTFBTFFBSMZXBSOJOHTZTUFNJOSFTQPOEJOHUPOBUVSBMEJTBTUFSTBOEDPOĚJDUDSJTFTJO1BLJTUBO M. Rahim, B.M. Kazi, K.M. Bile, M. Munir and A.R. Khan ...... 4 i%FMJWFSJOHBTPOFu6/SFGPSNQSPDFTTUPJNQSPWFIFBMUIQBSUOFSTIJQTBOEDPPSEJOBUJPOPMEDIBMMFOHFTBOEFODPVSBHJOH MFTTPOTGSPN1BLJTUBO K.M. Bile, K.A. Lashari and A.F. Shadoul ...... 4 *NQMFNFOUJOHUIFEJTUSJDUIFBMUITZTUFNJOUIFGSBNFXPSLPGQSJNBSZIFBMUIDBSFJO1BLJTUBODBOUIFFWPMWJOHSFGPSNT FOIBODFUIFQBDFUPXBSETUIF.JMMFOOJVN%FWFMPQNFOU(PBMT F. Sabih, K. M. Bile, W. Buehler, A. Hafeez, S. Nishtar and S. Siddiqi ...... 4 1BLJTUBOIVNBOSFTPVSDFTGPSIFBMUIBTTFTTNFOU A. Hafeez, Z. Khan, K.M. Bile, R. Jooma and M. Sheikh ...... 4 *NQBDUPGXFBMUITUBUVTPOIFBMUIPVUDPNFTJO1BLJTUBO A.Y. Alam, S. Nishtar, S. Amjad and K.M. Bile ...... 4 )VNBOPSHBOBOEUJTTVFUSBOTQMBOUBUJPOJO1BLJTUBOXIFOBSFHVMBUJPONBLFTBEJĎFSFODF K.M. Bile, J.A.R.H. Qureshi, S.A.H. Rizvi, S.A.A. Naqvi, A.Q. Usmani and K.A. Lashari ...... 4 M. Haytham Khayat MD, FRSH, Editor-in-chief Muhammad Afzal MSc, MPhil, PhD, Executive Editor Editorial Board .PIBNNBE"CEVS3BC.##4 %5.) .1)5. 1I% /BFFNB"M(BTTFFS.4D 1I% .PIBNFE."MJ#4D .4D 1I% %5.) 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Message from the WHO Regional Director for the Eastern Mediterranean
Launched in the early 1950s, the joint technical collaboration between Pakistan and the World Health Organization (WHO) has substantially matured during the ensuing decades into a vibrant partnership exclusively focused on improving the health status of the country’s population. Pakistan has consistently endorsed the primary health care (PHC) principles and developed an elaborate health system infrastructure. The country has also established a large number of health training institutions in the medical, dental, pharmacy, nursing and midwifery fields and a range of allied health sciences, including postgraduate degree- awarding institutions and health professionals’ regulating bodies of international repute. Despite these rich assets, the country is progressing slowly towards achieving its health Millennium Development Goals (MDGs). The predominant challenges range from an overwhelmed health system that finds it difficult to generate the required support for the implementation of key PHC interventions to a rapid population growth that decelerates the reproductive health parameters. The enduring inequities affecting the rural and peri-urban underprivileged populations is another major contributing factor restricting their access to essential health services. WHO has been working with the Government of Pakistan on a wide range of strategic health policies, operational strate- gies, programmatic interventions, and on establishing normative standards to guide the nation towards the attainment of health MDGs. Pakistan has mobilized its inherent institutional and human resources capacities and endorsed a service delivery approach pursued in the framework of PHC. This commitment has been reiterated in the current National Health Policy which affirms its solemn pledge to universal coverage and access to essential PHC services by incorporating an Essential Health Services Package as well as by the creation of a robust workforce and skills mix at the peripheral levels. The focus on: maternal, neonatal and child health care, including reproductive health and family planning; control of key communicable diseases; universal access to vaccination, with poliomyelitis eradication as a high priority; ongoing health system strengthening efforts; design of social protection mechanisms; building institutional capacities for health emergency preparedness and response; and establishing a nexus between health and its social determinants are vital elements for translat- ing the established policy into actual practice. WHO has also remained in the forefront of the United Nations initiative to ‘Deliver as One’, which has been piloted in Pakistan over the past few years. This initiative presents an opportunity for enhanced partnerships for health development and increased aid-effectiveness for this resource-constrained sector. Against this backdrop, the publication of this EMHJ supplement dedicated to Pakistan’s key health areas is a remarkable achievement, which will document and provide impetus and focus to the Government of Pakistan’s efforts to attain better health outcomes. The twenty evidence-based papers included in this supplement on important policy and programmatic areas, prepared in association with senior national health managers, will provide policy-makers with key support to spearhead diverse interventions in this sector, which is so critical to building the nation. Furthermore, coinciding with the golden jubilee of the establishment of the WHO permanent office in Pakistan in 1960, this publication constitutes a significant milestone in an unwavering and mutually beneficial partnership. Many of these articles reflect valuable lessons from the disasters that have hit Pakistan in the recent past. Unfortunately, while this special issue was being finalized, Pakistan was confronted with another unprecedented major disaster, where much of the country was submerged in the monsoon floods. Although deeply saddened and grieved over the massive loss of life, national assets and property we strongly believe that the lessons learnt and capacities developed over the years will assist the nation, WHO and the humanitarian partners to respond effectively to this grave national emergency.
Hussein A. Gezairy, M.D., F.R.C.S. Regional Director
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Pakistan’s fight against poliomyelitis: introducing innovative strategies to address challenges and attain the goal of eradication N. Abid,1 O.U. Islam,1 A. Bosan,2 T. Iqbal,1 A. Darwish 1 and K.M. Bile 1
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ABSTRACT Pakistan, with Nigeria, India and Afghanistan, is one of the four remaining polio endemic countries in the world. Since the start of polio eradication initiative in 1994, the country has succeeded in reducing the number of polio cases from an estimated 20,000 annually to 89 in 2009. Furthermore, persistent transmission is largely localized to three transmission zones in which ten of the fifteen highest risk areas are situated. Insecurity, operational issues, governance lapses, low routine immunization coverage, inadequate trickle-down of the political commitment existing at the national level to sub-national level and extensive population movement are the main barriers to the process. A robust strategic plan was developed for 2010-2012 encompassing district-specific plans and focused strategy on security compromised areas, performance-based payment, independent monitoring, attention to migratory populations, social mobilization, and strategic cooperation with Afghanistan. This will provide Pakistan a strong and imminent opportunity to interrupt polio virus circulation.
Lutte contre la poliomyélite au Pakistan : mise en place de stratégies innovantes pour traiter les problèmes et atteindre l’objectif d’éradication
RÉSUMÉ Avec le Nigéria, l’Inde et l’Afghanistan, le Pakistan est l’un des quatre derniers pays endémiques pour la poliomyélite dans le monde. Depuis le début de l’initiative pour l’éradication de cette maladie en 1994, le pays a réussi à ramener le nombre de cas annuels alors estimés à 20 000, à 89 cas en 2009. En outre, la transmission persiste essentiellement dans trois endroits, dans lesquels sont situées dix des quinze zones les plus à risque. Les principaux obstacles au processus d’éradication sont l’insécurité, les problèmes opérationnels, les défaillances de la gouvernance, la faible couverture de la vaccination systématique, l’insuffisante propagation de l’engagement politique du niveau national au niveau infranational et enfin, les larges mouvements de population. Grâce à un solide plan stratégique 2010-2012, englobant des plans de district, la stratégie d’éradication a été axée sur les zones mal sécurisées, les paiements fondés sur les résultats, un suivi indépendant, l’attention portée aux populations migrantes, la mobilisation sociale et la coopération stratégique avec l’Afghanistan. Ce plan offre au Pakistan une occasion forte et immédiate pour interrompre la transmission du poliovirus.
1World Health Organization Country Office, Islamabad, Pakistan (Correspondence to N. Abid: [email protected]). 2Expanded Programme on Immunization, Ministry of Health, Government of Pakistan, Islamabad, Pakistan.
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Introduction poliovirus across the border, prima- immunization activities, reports of the rily resulting from the large population Technical Advisory Group (national The World Health Assembly (WHA) movement between the 2 countries— and international experts appointed through resolution WHA.41.28 there is traditional seasonal migration by the WHO Regional Director for adopted in 1988 called for the global and large numbers of mobile Afghan the Eastern Mediterranean Region) eradication of poliomyelitis. The sub- refugees [3]. meetings, the 2009 independent eval- sequent implementation of the Polio An independent 2009 external as- uation and published technical papers Eradication Initiative (PEI) strategies sessment was conducted in Afghani- relevant to polio eradication in Paki- has resulted in over 99% reduction stan, India, Nigeria and Pakistan, as stan. It aims to assess the current status in the global annual incidence of advised by the WHO Executive Board, of the PEI in Pakistan, evaluate the poliomyelitis, from an estimated total to evaluate the barriers to interrupting outstanding challenges and identify of over 350 000 cases prior to 1988 wild poliovirus transmission concluded the operational strategies necessary to only 1604 cases in 2009; and en- that global poliomyelitis eradication is and sufficient to interrupt poliovirus demic circulation has been localized possible provided that the remaining transmission in Pakistan with a view in 4 countries since 2006: Pakistan, problems, predominantly attributable to to ensuring further progress towards Afghanistan, India and Nigeria [1]. insecurity and operationally surmount- eradication. Pakistan has achieved significant able challenges, are addressed through progress since the inception of PEI commitment and action [4]. Building in the country in 1994. The number on the lessons learned, a new strategic Epidemiological of confirmed cases has dropped from plan was developed for 2010–2012 update estimates exceeding 20 000 per year by the Global Polio Eradication Initia- in the early 1990s to 89 cases in 2009. tive in consultation with local partners, Despite the persistent transmission of The overall coverage of vaccination ac- and endorsed by the WHA in 2010 wild poliovirus, currently 90% of the tivities has been sustained at over 90% [3]. The plan aims at interrupting wild districts/towns/agencies have not re- over the past 4 years, while inconsist- poliovirus transmission in at least 2 of ported any poliomyelitis cases over the ency in the quality of supplementary the 4 remaining endemic countries by first half of 2010. Since 1994, when the immunization activities at subdistrict the end of 2011, and globally by the first national immunization days were level has constituted a formidable chal- end of 2012. conducted in Pakistan, the growing lenge [2]. This paper is the result of a thor- experience of the programme and its Furthermore, Pakistan and Afghani- ough review of data from: acute flexibility in adopting new tactics and stan form a single epidemiologic bloc flaccid paralysis (AFP) surveillance, technologies has resulted in a reduction that allows the transmission of wild routine vaccination and supplementary of more than 99% in the annual number
3000 NIDs Launching The Pm’s Action Plans, IPCP, independent Monitoring & District Specific Plans 2500 AFP surveillance National laboratory performing genomic sequencing & rapid 2000 case response House to house campaigns
. of cases 1500 Further intensification of activities Strategic planning, Communications linking 1000 capacity enhanced & payment Estimated no mOPV3 with performance & bOPV 500 mPOV1
0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year
Figure 1 Poliomyelitis trends and significant milestones, Pakistan, 1994–2010
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of poliomyelitis cases in the span of 16 (OPV), 55% did not receive a routine the three districts of Quetta, Pishin years (Figure 1). OPV dose and 13% of the cases did not and Qilla Abdullah in north-western Between 1 January and 18 July receive any poliomyelitis vaccination Balochistan (Figure 2). Moreover, the 2010, 30 wild poliovirus cases were re- at all. data revealed an additional five highest ported from Pakistan compared to 23 Table 1 shows the association be- risk areas with repeated wild poliovirus in the corresponding period of 2009. tween age and probability of contracting infection. There has been confirmed Twenty (67%) of the 30 emerged from wild poliovirus infection in children with annual cross-border transmission and the conflict-affected areas of Khyber AFP between 2005 and 2009. Children sharing of wild poliovirus between Pa- Pakhtunkhwa (formerly known as aged 0–11 months, 12–23 months and kistan and Afghanistan over the past North-West Frontier Province) and the 24–35 months had significantly greater five years. Federally Administered Tribal Areas; 7 risk of acquiring wild poliovirus infec- were from Baluchistan, 2 from Punjab tion relative to those 36 months and and 1 from Sindh. Fourteen of the 30 over. Surveillance data showed that the Status of PEI strategies were type 1 and 16 type 3; 9 (64%) proportion of cases among the age co- in Pakistan of the type 1 cases were reported from hort under 6 months was 4.6%. Analyses North Waziristan, Bajaur, Khyber and also illustrate the significant inverse as- Routine immunization Mohmand agencies of the Federally sociation between the number of OPV The Pakistan Social and Living Stand- Administered Tribal Areas. In the two doses received by a child and the risk of ards Measurement Survey conducted most populous provinces, Punjab re- acquiring the disease; there was no such in 2008–09 revealed that diphtheria- ported two cases while Sindh reported association for sex-related differences. pertussis-tetanus vaccine (DPT3) cov- one case. In the Gilgit-Baltistan region Epidemiological data comple- erage in children aged 12–23 months of northern Pakistan no poliomyelitis mented by genetic analysis of isolated was 80% at the national level. How- cases have been detected for the past polioviruses substantiated the persist- ever, based on the AFP surveillance data 12 years, while Pakistan-administered ence of indigenous wild polio virus cir- analysis of non-poliomyelitis AFP cases Kashmir has not reported any cases for culation in three discrete transmission of the same age group in 2010, as of 5 10 years. During 2010, three genetic zones ,including three towns of Karachi July 2010, routine OPV3 coverage was clusters of type 1 and another of type (Baldia, Gadap and Gulshan-e-Iqbal); 70% at the national level. The variations 3 have been circulating, compared to Peshawar in Khyber Pakhtunkhwa; ranged from 80% in Punjab to 67% in four of type 1 and 3 of type 3 in 2009. the security-compromised Federally Khyber Pakhtunkhwa, 63% in Sindh, While 47% of cases received fewer than Administered Tribal Areas agencies of 38% in the Federally Administered four doses of oral poliomyelitis vaccine Khyber, Mohmand and Bajaur; and Tribal Areas and 22% in Balochistan,
Table 1 Comparative analysis of children diagnosed with acute flaccid paralysis classified into polio and non-polio cases, age and sex distribution and immunization profile for 2005–09 Variable All cases Polio cases Crude OR (95% CI) (polio and non-polio) No. % Age of child (months) 0–11 2 524 93 3.7 10.60 (7.31–15.42) 12–23 4 446 117 2.6 7.49 (5.24–10.74) 24–35 3 821 51 1.3 3.75 (2.46–5.71) 36 and above 12 516 45 0.4 1 Sex of child Female 9 846 130 1.3 1.01 (0.80–1.28) Male 13 461 176 1.3 1 All doses (routine and supplementary) 0 dose 534 56 10.5 17.06 (12.22–23.76) 1–3 doses 1 592 63 4.0 05.79 (4.23–7.92) 4–6 doses 1 492 50 3.5 4.87 (3.46–6.85) 7 and above 19 394 137 0.7 1
OR = odds ratio; CI: = confidence interval.
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before each campaign at the sub-union council level) are regularly reviewed and updated. In 2009, a decision was taken to regard finger-marking of the distal part and the nail of the left little finger using an indelible marker as the sole proof for child vaccination validated by a standardized process of independ- ent monitoring. A total of 38 million doses of OPV are provided during each national immunization day round, and their timely dispatch and distribution is an essential prerequisite for ensuring coverage to more than 30 million under five-year-old children. AFP surveillance system The AFP surveillance system was launched in 1997, and the non polio- myelitis AFP rate per 100 000 children below 15 years of age increased gradu- ally from 0.8 per 100 000 in 1997 to 2.0 per 100 000 in 2001. It was 6.13 in 2009 (the target is more than 2 per 100 000 children under 15 years). Similarly, AFP cases with adequate stool specimens increased from 31% in 1997 to 80% in 2001, while over the past three years the rate has remained at 90% or more. The supplemental surveillance activi- 7UDQVPLVVLRQ]RQH ties being implemented included the collection of samples from at least three Figure 2 Poliomyelitis cases in Pakistan and Afghanistan in 2009 and 2010 as of 5 contacts if adequate specimens could July 2010 illustrating shared transmission of zones not be obtained from an AFP case. This strategy was initiated in 2004 and has reached a completeness rate of 92% in illustrating the inequity in routine im- in 2001 to specifically target children 2010, contributing to the detection of munization coverage in the country. in high risk areas. For risk assessment 31 of 354 reported poliomyelitis cases. purposes, districts, towns and agencies Another supplemental surveillance Supplementary immunization were categorized into low, medium, activities activity introduced in 2009 is environ- high or highest risk areas, relative to mental monitoring. Samples are col- Supplementary immunization strate- surveillance data analysis including lected from Karachi and Lahore, and gies have been modified over the years poliomyelitis epidemiology and the recently also from Peshawar, Quetta in order to reach the maximum number performance quality of district health and Rawalpindi, demonstrating results of children. The provision of OPV teams during the supplementary immu- consistent with AFP surveillance, ex- through fixed points during national nization activities. High risk and highest cept for two genetically distinct chains immunization days, pursued from 1994 risk districts were targeted with more of type 1 poliovirus, 1 each in Karachi to 1999 (Figure 1) was replaced by a supplementary immunization activi- and Lahore, that were detected through house-to-house strategy from 2000 ties, intensified technical assistance and environmental sampling. The National onwards. With the localization of wild closer oversight (Table 2). The sup- Institute of Health in Islamabad, which poliovirus circulation, subnational plementary immunization activities’ houses the regional reference laboratory immunization days were introduced microplans (operational plans prepared for Pakistan and Afghanistan (which
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Table 2 Intensified operations plan based on risk categorization for 2010 Risk categorization Selection criteria No. of districts/ No. of No. of Additional of districts/ towns/ towns/agencies NIDs SNIDs technical and agencies in each group oversight support Low risk Very low probability of importation 59 4 – + Medium risk High probability of importation from high 49 4 2 ++ risk districts High risk Part of endemic transmission zones or 13 4 4 +++ geographically close to the highest risk districts or high population density and frequent population movement with active transmission zones Highest risk Persistent transmission districts/ towns/ 15 4 4 ++++ agencies (10) and repeatedly infected (5)
NIDs = national immunization days; SNIDs = supplementary national immunization days.
performs genomic sequencing), tested highest risk areas, representing districts, during 2010. The number of inacces- stool samples for polioviruses and re- agencies and towns promoting specific sible target children in the Federally ported diagnostic confirmation within operations relevant to routine immu- Administered Tribal Areas has conse- 14 days of receipt for 98% of specimens nization, supplemental immunization quently increased, from about 200 000 in 2009 (target ≥ 80%). activities, surveillance and communi- (18% of the operational target) during cations. The plans were designed to most supplementary immunization address the challenges encountered in activities in 2009 to more than 300 000 Operational strategies each highest risk area through targeted (27% of the target children) in 2010. and specific locally appropriate interven- To address this growing inaccessibility Strategic plan for 2010–12 tions. The impeded access to the target and guide the advocacy, negotiation The national Inter-Provincial Commit- population has been primarily related and intervention tactics that ensure the tee on Polio (IPCP), chaired by the to governance lapses or security-related safety of vaccination teams and facili- Federal Minister for Health and includ- challenges in the programme catchment tate access to the target child popula- ing all provincial ministers for health, areas. To improve the PEI performance tion, the region was categorized into approved a three-year plan to intensify in these areas, plans include additional three zones. operations with a major emphasis on en- supplemental immunization rounds hancing ownership and accountability. to boost immunity; enhancing techni- r Army-held zones where access is per- The committee approved the globally cal oversight to improve the quality of mitted with security being volatile: endorsed process indicators that set operations; ensuring that monitoring all efforts are to be made to achieve specific benchmarks for Pakistan, where activities cover all the union councils the best possible coverage through successful PEI implementation in Kara- (the lowest administrative units in a improved governance and tightened chi in 2010 would require that less than district) to achieve uniform quality; and supervision. 10% of the target children in each town convening monthly review meetings at r Army-held areas where access is de- are missed during every round in at provincial level and quarterly meetings nied owing to safety concerns: flexible least four supplemental immunizations. at federal level to assess the progress in plans are being prepared, including For the persistent transmission areas the fight against poliomyelitis. advocacy with army leaders, secured in Balochistan, Khyber Pakhtunkhwa The strategy for the Federally Ad- logistics and funds that allow swift and the Federally Administered Tribal ministered Tribal Areas focuses on vaccination drives including short- Areas, the proportion of missed target improving access of children to vac- interval additional dose strategy children was required to be lower than cination, considering the complex campaigns during windows of op- 15% in at least eight supplemental im- security situation due to active conflict. portunity created through formal and munizations carried out during 2010. This situation meant that children were informal negotiations. These efforts deprived of access to vaccination and are coordinated with the government District-specific plans this has resulted in a higher number and local community and jirga (tribal All districts in Pakistan have PEI- of wild poliovirus type 1 cases than assembly) leaders. specific plans; however, a more targeted other provinces of Pakistan and all r Areas where the government control approach is being adopted for the 15 other endemic countries collectively is particularly weak and access highly
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problematic: local community leaders delivery of immunization services and Independent performance monitoring were negotiated with and organized facilitate social mobilization to im- The outcome of the supplementary im- to carry out short-interval additional prove performance of supplementary munization activities is assessed regu- dose strategy immunization in liaison immunization activities. larly by independent monitors verifying with local authorities and advocating The district level plan for the highest the vaccination status of children PEI neutrality to gain access and pro- risk areas of Balochistan demands direct through finger-marking. Monitors, tection for vaccinators. oversight by the deputy commissioners preferably females and familiar with the The short-interval additional dose (the chief executives at district level), local language(s), are recruited from strategy was successful in Swat, where a with special emphasis on engaging the universities, colleges, nongovernmental poliomyelitis outbreak at the end of two leadership of the paramedical staff asso- organizations and the education depart- years of continuous inaccessibility was ciation, which has constituted the major ment. All the Union Councils from high effectively controlled with five rounds of challenge to PEI operations’ govern- immunization rapidly conducted over and highest risk areas are assessed, while ance in this province. Focused advocacy four months. 50%–70% of medium and 25% of low is being targeted to communities and risk districts are monitored, with special In Karachi’s highest risk towns, the the religious leadership to overcome the attention to areas having higher likeli- strategy focused on: enhancing the few existing pockets of chronic refusals active engagement of the health de- hood of underperformance. Monitoring to vaccinate against poliomyelitis result- partment leadership, with political par- results showed finger-marking coverage ing from baseless rumours concerning ties’ commitment to directly interact rates of at least 90% in all provinces and vaccine safety. and influence town health manage- regions except the Federally Admin- ment and catalyse community social These plans are monitored istered Tribal Areas where access was mobilization among the highest risk throughprovincial reviews on a seriously compromised (Figure 3). monthly basis and federally every and underserved populations; ensur- Performance based payment ing that all the vaccination teams were quarter to ensure progress in the im- selected from the local community plementation quality (consistently The IPCP decided to release the final in order to address prevailing cultural over 90%), particularly in Karachi and payment of the operational budget sensitivities; building operational Balochistan. Modest progress was conditional on monitors’ verification partnership with nongovernmental or- also attained in Khyber Pakhtunkhwa, of at least 90% finger-marking coverage ganizations and the private sector to but the situation in the Federally in a district. The proportion of districts supplement the overstretched public Administered Tribal Areas worsened in achieving at least 90% finger-marking sector services. The strategy allows 2010 due to the deteriorating security confirmed coverage, increased from local partners to participate in the situation. 61% in January 2010 to 82% in May
100 90 80 70 60
% 50 40 30 20 10 0 Punjab Sindh KPK (NWFP) FATA Islamabad Balochistan AJK Gilgit-Baltistan Pakistan Province Jan Feb Mar Apr May
Figure 3 Finger-marking coverage through independent monitoring in children under 5 years, Pakistan, January–May 2010 [adjusted coverage = assessed coverage × (1 – Po); Po = proportion of children inaccessible due to insecurity]. KPK = Khyber Pakhtunkhwa; FATA = Federally Ddministered Tribal Areas; AJK = Azad Jammu and Kashmir
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2010, demonstrating the positive im- immunization, leading to a consider- Cross-border collaboration with pact of this managerial decision. able reduction in refusals to vaccinate Afghanistan Migratory populations against poliomyelitis to less than 0.5%. The first cross-border immunization post was established in 2002 at Khyber Migratory groups, including nomads, An interreligious council on health with Pass (Torkham) and subsequently agriculture, construction and other representation from Islamic, Christian, extended to 10 other crossing points seasonal workers, internally displaced Sikh, Parsi and Hindu groups supports persons (IDPs) and Afghan refugees, the immunization programme with a along the 2430 kilometre border with often pose the risk of sustaining polio- stipulated plan for enhancing public Afghanistan. The fact that all genetic virus transmission between regions and awareness through activities at the lineages of wild poliovirus circulating districts owing to their high mobility and district level. in both countries in 2010 are related to each other, reflecting a shared transmis- settlement in underserved geographi- Knowledge, attitudes and practice sion between the two countries due to cal areas. The eradication initiative has studies have shown that parents’ aware- recently revamped a strategy to effec- extensive population movement, rein- ness of poliomyelitis as an important forces the need for closer cross-border tively cover these populations through health issue increased from 83.9% in specific microplans and mechanisms coordination and collaboration. During 2008 to 91.7% in 2010 [5]. Moreover, 2008 and 2009, two intercountry meet- to track their movement and enhance there were significantly more media their access to vaccination services. ings were held with senior health of- events that were supportive of the PEI Special vaccination teams are raised to ficials of the two countries for PEI joint (2500 of 2552) than those raising con- target these groups along known transit planning and coordination, leading to cern, e.g by questioning the efficacy or routes or while residing in temporary the synchronization of three of the five stay locations both during and outside safety of the vaccine. scheduled supplementary immuniza- scheduled supplementary immuniza- Government ownership tion activities in 2010. In 2009, approxi- mately two million border-crossing tion activities with close monitoring Poliomyelitis eradication has always of performance. Consequent to this eligible children were vaccinated by the been at the top of the health agenda of permanent cross-border vaccination strategy, the June 2010 special vaccina- successive Pakistani governments. To tion campaign reached approximately teams of the two countries. promote programme ownership and 250 000 children in 16 Union Councils commitment, advocacy efforts were of Sindh and Balochistan having a high launched with elected representatives concentration of migratory popula- Discussion tions. resulting in the formation of a caucus of parliamentarians to support poliomy- The 22-year old PEI has remained at the Enhancing communication and elitis eradication. The President and the top of the global public health agenda social mobilization Prime Minister of Pakistan launched with a remarkable restriction of wild As integral components of the PEI, the national immunization days in 2009 poliovirus circulation to localized ar- communication and social mobiliza- and 2010, while the IPCP has met three eas of the four remaining poliomyelitis- tion were intensified in 53 interven- times since its inception in 2009 and endemic countries compared with 125 tion areas including the 15 highest risk provided impetus to the government’s in 1988 [3]. The plausibility of poliomy- areas. To promote these initiatives, in- elitis eradication was further reinforced resolve on PEI at the sub-national as well novative partnerships were developed by the 2009 independent evaluation as the national level. At the district level, through the Prime Minister’s Action report, asserting the attainability of the district commissioner chairs the dis- Plan launced in early 2009 to enhance this goal [4]. Pakistan has reported trict polio eradication committee before intersectoral collaboration between the the highest number of poliomyelitis public and private sectors and with the each supplementary immunization to cases in 2010 relative to other endemic involvement of the civil society. mobilize support from government line countries. Although there are major A major component of the com- departments and other partners in the operational challenges, the country pos- munication strategy included the district. In the supplementary immuni- sesses several opportunities to make engagement of religious leaders. Key zation activities conducted during May a major breakthrough in interrupting religious scholars belonging to differ- 2010, district polio eradication commit- wild poliovirus circulation. This is cor- ent schools of thought have reiterated tee meetings were held before the cam- roborated by the fact that persistent their support for PEI by delivering 17 paign chaired by high level managers in transmission is restricted to three zones religious edicts or fatwas in support of 98% of the districts, compared to 76% in of central Khyber Pakhtunkhwa and the poliomyelitis eradication and routine the January round of the same year. Federally Administered Tribal Areas;
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Quetta, Pishin and Qilla Abdullah of Epidemiological data have revealed in immunization service delivery, while Balochistan; and the Karachi zone. Ac- a significant statistical association benefiting from the strong commu- cordingly, the majority (20/30) of the between the age of the child and the nication and social mobilization skills cases detected up to 18 July 2010 were probability of contracting poliomyelitis: developed over the years during sup- from these transmission zones, while the younger the child, the higher the plementary immunization activities. most of the viruses detected elsewhere risk of contracting the disease, with the Given the current low level of routine were genetically related to the same. exception of the low incidence in infants immunization coverage, Pakistan has It is also important to note that 10 of under six months of age, attributed to to conduct at least 4 national immuni- the 15 highest risk areas fall in the wild low exposure to the risk of infection zation days a year, although the latter poliovirus transmission zones. Like- and/or to passive immunity from would not be able to offset or substitute wise, most of the security-compromised maternal antibodies [9]. It is, however, the significant role of routine immuniza- areas are in or adjacent to the Khyber critical to reach out to this youngest age tion in poliomyelitis eradication [12]. Pakhtunkhwa–Federally Administered cohort during supplementary immuni- A uniformly high performance in Tribal Areas transmission zone. zation activities in order to reduce the supplementary immunization activi- Quite significantly, the law-and- pool of susceptibles and overcome the ties throughout the country at all levels order challenges are not restricted to habit observed predominantly in rural of government is central to the efforts the areas affected by the crisis in the areas, where access to newborn infants aimed at interrupting wild poliovirus Federally Administered Tribal Areas, as is impeded as they are concealed from circulation, complemented by further they occasionally hamper programme outsiders. intensification of programme opera- operations in Balochistan, Karachi and Moreover, the study corroborated tions in the transmission zones. Despite northern Sindh. These realities under- that children receiving seven doses or the observed overall high coverage rates, line the magnitude of the prevailing more were at significantly lower risk there are still supplementary immuni- challenge, while at the same time ac- of acquiring the disease compared to zation–related governance lapses such centuate the imperative to develop those receiving six or fewer doses. The as inefficiency or misuse of resources dynamic specific plans and adjust the latter finding is supported by other stud- in some districts and subdistricts be- PEI programme implementation, ies revealing that the immunogenicity cause of deficient vaccination teams, authenticating the validity of the risk of OPV is lower in infants in developing poor training quality, misreporting and categorization approach. However, the countries because of a higher prevalence delayed or denied payments to vaccina- predominant challenge facing the high- of competing enteroviruses, recent diar- tion teams in addition to the significant est risk areas of Karachi and Balochistan rhoeal episodes and malnutrition rela- number of unreached children in secu- are the inadequate management and tive to infants in industrialized countries rity-compromised areas [4]. To over- weak accountability observed, espe- [9–11]. This substantiates the need to come these challenges, district health cially at district level, though recently ensure access of every eligible child to teams operating in high risk zones have introduced efforts and strategies for all opportunities for routine and sup- to effectively pursue the area-specific enforcing accountability and closer plementary vaccinations. plans, the latter being crucial to the suc- oversight led by the health departments Improving routine immunization is cess of poliomyelitis eradication. The have produced tangible improvements one of the cornerstones of poliomyelitis recent government resolve of validating in the programme implementation [6]. eradication: combined efforts exerted at the coverage data through finger-mark- Genetic sequencing data showed the district, provincial and federal tiers ing, reliably generated by independent that the wild poliovirus had spread from of government should address current monitors, and the linking of payment these transmission zones to many for- programmatic weaknesses—correcting of campaign remunerations with this merly poliomyelitis-free areas such as the health workforce maldistribution performance, has proved operationally central Punjab, which suffered an out- and ineffective managerial and logistic effective. The regular appraisal meetings break in 2008 in which complacency, arrangements that impede access to held by the provincial chief secretaries reduced frequency of supplementary vaccination against poliomyelitis and and deputy commissioners are power- immunization activities, deterioration of other vaccine-preventable diseases. ful forums for tracking progress, rectify- routine immunization, high population Concerted efforts are therefore required ing governance faults and providing movement and an influx of internally dis- by the district health management team oversight to the entire implementation placed populations from poliomyelitis- to improve district immunization op- process [13,14]. Considering the proc- endemic, insecure areas played a major erational plans, and the equitable dis- ess indicators of the global strategic role in re-establishing wild poliovirus tribution of vaccinators with the active plan, the course of implementation in circulation [7,8]. involvement of Lady Health Workers Pakistan is confidently on track, though
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the security-compromised areas fall or jirga with a constant search for communication strategies to diffuse significantly short of expectations and windows of opportunity to conduct the effect of misinformation. merit stronger interventions. short-interval additional dose strategy The extensive cross-border popula- Since 2001, AFP surveillance indi- campaigns. Poliomyelitis vaccinations tion movement between Afghanistan cators in Pakistan have been meeting need also to be considered as “add and Pakistan necessitates the coordina- the WHO targets, and the strategy has on” strategies to ongoing health and tion of PEI interventions and the mo- successfully guided the PEI operations other community interventions to bilization of the required international that have led to a dramatic decrease in secure better access to vaccination. support for interrupting wild poliovirus poliomyelitis incidence, providing the Moreover, the establishment of vac- circulation in this region. opportunity in future to spearhead the cination posts on the exit and entry The strategic plan for 2010–12 establishment of an integrated disease routes of the crisis-affected areas and has laid down an operational course surveillance system in Pakistan [15]. efforts to maintain high coverage in all of action to which the national However, an AFP surveillance weakness accessible areas within the Federally and health sector political leader- was recently identified in the system Administered Tribal Areas and the ad- ship has subscribed, mandating the when some “long-chain” (“orphan”) jacent areas of Khyber Pakhtunkhwa convening of regular IPCP meetings polioviruses were detected through ge- are critical components of the strategy, to steer poliomyelitis eradication netic mapping of wild polioviruses [16]. aiming to create a barrier that buffers efforts; enhancing ownership and This suggests the need for enhanced virus transmission. This vision could accountability; improving quality of surveillance capacity as well as improv- be further consolidated by expanding implementation; reinforcing specific ing vaccination coverage among migra- the social health assets by promoting plans for the highest risk areas; re- tory and underserved populations. a comprehensive primary health care cruiting vaccination teams familiar The decision to set specific plans package in the area. Interventions that with local languages; applying ap- for the 15 highest risk areas was an were operationally consistent with the propriate communication strategies; effective strategic operation as these current Federally Administered Tribal and rationalizing resource use. In the areas produced 60% of the confirmed Areas strategy have led to the interrup- Federally Administered Tribal Ar- poliomyelitis cases in 2010, while the tion of wild poliovirus transmission in eas the strategic package needs to be wild poliovirus circulation elsewhere other conflict-affected areas such as pursued by closely liaising with gov- was also closely linked with the ongoing in Cambodia, Colombia, Somalia, Sri ernment institutions and influential circulation in these highest risk areas. Lanka and southern Sudan [2,18]. community partners, while flagging The recent improvement in programme Evidence-based and innovative and maintaining programme neu- performance in these areas validates communication strategies will remain trality and prioritization. Targeting the efficacy of this approach with the critical to the final push of poliomy- the high risk, underserved, migrant exception of the crisis-affected Federally elitis eradication [19]. The establish- populations while travelling and at Administered Tribal Areas [17]. ment of the National Polio Control temporary stay locations has also The first building blocks of the Cell (which provides information to proved to be a sound strategy. Federally Administered Tribal Ar- parents of children who have missed Given the coherent political com- eas strategy emphasize programme vaccination via a toll-free number) mitment currently evolving in all tiers neutrality and focus on child survival, through a coalition of public and pri- of government, the localization of wild regardless of which group or conflict vate television channels, community- poliovirus circulation, the availability of rivals the children come from. This based approaches in the Federally potent vaccines, improving leadership substantiates the legitimate prioriti- Administered Tribal Areas, and advo- commitment at all levels, the imperative zation of PEI and its neutrality, and cacy briefing endeavours for political of effective and high quality supplemen- hence the validity of the protection leaders, religious scholars and parlia- tary immunization activities, impec- demanded for vaccination teams: in mentarians have broadened the scope cable and highly sensitive surveillance, areas of active conflict it is important of the communication strategy and the extended support of development to ask the government authority and raised awareness among the public, partners and the district- and regional- the army as well as the local commu- attracting a greater number of stake- specific operational plans, Pakistan has nity leaders to provide protection and holders in support of the programme. every opportunity to interrupt endemic safe passage to the teams. The strategy Although numerically insignificant, wild poliovirus circulation, attain the engages local opinion leaders as focal the potential impact of negative me- globally set milestones and lead the persons; mobilizes support and ac- dia could be substantial, mandating nation to the goal of poliomyelitis eradi- ceptance from the tribal assemblies the proactive design of preventive cation in the near future.
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References
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Prevalence of hepatitis B and C viral infections in Pakistan: findings of a national survey appealing for effective prevention and control measures H. Qureshi,1 K.M. Bile,2 R. Jooma,3 S.E. Alam 4 and H.U.R. Afridi 2
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ABSTRACT A prevalence survey on hepatitis B and C infections was carried out to obtain national estimates and assess epidemiological dynamics and underlying risk factors. Overall prevalence of hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (HCV) of 2.5% and 4.8%, respectively, reflected a combined infection rate of 7.6% in the general population, consistent with an ongoing high burden of chronic liver disease (CLD). There was significant association of these viral infections with a range of risk factors led by reuse of syringes. These findings validate currently implemented strategies by the national programme for the control of hepatitis viral infections, including universal vaccination of newborns and high-risk groups, support of auto-disable syringes, promotion of infection control and patient safety, public health education, and management of needy CLD patients as a poverty-reduction health intervention.
Prévalence des infections virales de l’hépatite B et de l’hépatite C au Pakistan : résultats d’une enquête nationale appelant à des mesures de lutte efficaces
RÉSUMÉ Une enquête de prévalence sur les infections par les virus de l’hépatite B et de l’hépatite C a été réalisée afin d’obtenir des estimations nationales et d’évaluer la dynamique épidémiologique et les facteurs de risque sous-jacents. La prévalence globale de l’antigène de surface du virus de l’hépatite B et celle des anticorps antivirus de l’hépatite C étaient de 2,5 % et 4,8 % respectivement, reflétant un taux global d’infection de 7,6 % dans la population générale, ce qui est cohérent avec la charge actuelle élevée d’affections hépatiques chroniques. Une association importante de ces infections virales avec de nombreux facteurs de risque liés à la réutilisation des seringues a été observée. Ces résultats attestent du bien-fondé des stratégies du programme national de lutte contre les infections par le virus de l’hépatite, à savoir : vaccination universelle des nouveau-nés et des groupes à haut risque, soutien à l’utilisation de seringues autobloquantes, promotion de la lutte contre les infections et de la sécurité des patients, éducation à la santé publique et prise en charge des patients nécessiteux atteints d’affections hépatiques chroniques en tant qu’intervention sanitaire visant à réduire la pauvreté.
1Pakistan Medical Research Council, Islamabad, Pakistan. 2World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to K.M. Bile: [email protected]). 3Ministry of Health, Islamabad, Pakistan. 4Jinnah Postgraduate Medical Centre, Karachi, Pakistan.
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Introduction of a large pool of vulnerable patients territories of Pakistan, excluding the with HBV- and HCV-related CLD re- Federally Administered Tribal Areas Hepatitis B virus (HBV) and hepatitis quired a national hepatitis B and C con- and a few other security-compromised C virus (HCV) infections contribute trol programme with a preventive and areas, cumulatively accounting for to the global public health threats con- curative scope of implementation. The about 3% of the total population. The fronting most developing countries, high prevalence of HCV detected by applied sampling frame was designed by where health care systems lack the multiple cross-sectional studies added the Federal Bureau of Statistics and clas- safety measures necessary to avert the to the alarm, as it is known that over 80% sified cities and towns into well-defined risks of infection and public awareness of HCV-infected individuals progress enumeration blocks with 200–250 about the modes of transmission is insuf- into CLD [1,10]. In 2004, the Ministry households each, based on the 1998 ficient [1–3]. A large number of HBV of Health developed the first project census population update carried out in and HCV studies have been carried out document of a national hepatitis control 2004 for urban settings; for rural areas in Pakistan over the past two decades, programme with federal funding, tech- the 1998 census data were applied as no restricted to clinical and hospital-based nically supported by WHO. This land- similar update was available. settings, blood bank institutions and mark was substantiated in 2005 when These enumeration blocks and vil- small communities that could not val- the national exchequer earmarked a lages constituted the primary sampling idly demonstrate the distribution of 5-year budgetary allocation of Rs 2.594 units (PSUs), representing urban and HBV and HCV in the general popula- billion, then equivalent to US$ 43 mil- rural areas, respectively. The PSUs were tion, though corroborating the exist- lion. The launching of the programme further specified for a group of 14 large ence of a high burden of chronic liver was facilitated by the strong political mega-cities, each forming a separate disease (CLD) in the country [4–7]. support, the growing public concern and structure that was further subdivided the call for action resonated by profes- Since 1994, the World Health Or- into low-, middle- and high-income sional groups, civil society organizations ganization (WHO) has worked with groups, based on earlier data collected and the media, to contain an impending the Federal Ministry of Health substan- from these enumeration blocks. The public health disaster. The programme tiating the urgency of adding hepatitis B remaining urban areas constituted one scope included: vaccination of high- vaccine to the roster of the national Ex- structure labelled “the other urban ar- risk groups; safety of blood and blood panded Programme on Immunization eas”, while the rural area of each district products; safe injections and invasive (EPI) and of its provision to all newborn of the four provinces was considered devices; hospital waste management; children in order to build a nationwide as a separate structure, except in the behavioural change communication lifelong immunity against HBV and sparsely populated province of Balo- and hospital-based surveillance. eliminate the burden of HBV-related chistan, where the provincial adminis- To substantiate the high burden CLD, including primary hepatocellular trative divisions each aggregating several of HBV and HCV infections and in- carcinoma. This recommendation was districts were considered as the unit for fluence the government planning and outlined in 1992 by WHO, with the the stratum. financing institutions to offer a tangible, goal of integrating hepatitis B vaccine Considering the characteristics into routine EPI by 1997 [8,9]. long-term budgetary outlay, there was a need to undertake a nationwide HBV of the variables to be estimated, the This aspiration was realized in 2002, and HCV survey that would guide the population distribution and available re- through the financial support of the planning and implementation of hepa- sources, 7000 sample households were Global Alliance for Vaccines and Im- titis prevention and control interven- considered necessary to attain reliable munization (GAVI Alliance) and with tions. This paper reports the findings of estimates of HBV and HCV prevalence WHO technical support, leading to this survey, which generated credible for national and provincial levels and the procurement of HBV vaccines for and representative national data about indicative data about districts. Sample over 4 million newborns annually. This the high prevalence of HBV and HCV households were drawn from 350 PSUs, arrangement was sustained until 2008, infections, and established the basis for 138 urban and 212 rural. Relatively when the pentavalent diphtheria–teta- future national control interventions more PSUs were drawn from urban ar- nus–pertussis–hepatitis B–Haemophil- and outcome evaluations. eas to account for their socioeconomic us influenzae type b (DTP–HepB–Hib) diversity. In the sample selection, urban vaccine cofinancing mechanism was enumeration blocks and villages were introduced. Methods selected as PSUs, based on the “prob- However, in a populous nation like ability proportional to size” sampling Pakistan, the need for additional preven- The survey was conducted in urban method. Subsequently, households tive interventions and the management and rural areas of all four provinces and within PSUs were selected with equal
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probability using a systematic sampling gel tubes and serum was separated and families and individuals selected from technique with random start. Thus 3500 stored for further testing. the 350 PSUs outlined in the study households were selected from Pun- Hepatitis B e antigen (HBeAg) was sample size. The non-tested 4% were jab province; 1560 from Sindh; 1100 tested on all HBsAg-positive sera that due to migration, non-availability of the from Khyber Pakhtunkhwa, formerly were stored for future use using the household members at the time of the the North Western Frontier Province; chemiluminescence method, carbonyl- visit, or refusals. and 840 from Balochistan. An average metalloimmunoassay. Of the families in the sample, 87.6% family size was 6.5 persons. For sam- To access targeted PSUs and owned their residential homes. Of the ple testing for hepatitis B and hepatitis households to be tested, survey teams 7000 houses visited, 32.0% were made C, rapid tests were used which were contacted local health authorities and of mud, 45.4% were made of bricks and enzyme-linked immunosorbent assay Federal Bureau of Statistics staff, who plastered walls, 19.3% were of semi-solid (ELISA) compared, before being pro- provided names of the households, eas- material, while 3.3% of the houses were cured [Abbott Determine™ for hepatitis ing identification of the correct houses. well-furnished modern constructions, B surface antigen (HBsAg), Advanced At the household level, blood tests were indicating the wide socioeconomic di- Quality™ One Step HCV Test (Bionike run in a row on all individuals, rapid versity of the tested population. Inc.) for anti-HCV). tests carried out and results provided Piped drinking water was available A consent form to be completed before leaving the house within 15–20 in 52.7% of the houses; 21.8% of the by each family head, a family form, an minutes. families obtained water from nearby individual form and a report form for The house was marked after com- public taps; 9.7% used well water; 5% feedback of results were prepared. An pleting the survey. The teams were to fetched water from a spring, pond or information brochure was produced to visit all 20 houses of a PSU and seek river; and 10.8% received water through brief families about the objectives of the the help of the local statistical office for tankers, or mule or donkey carts. study. A referral form was also prepared replacement in the case of refusal or Sanitation conditions varied: 26.5% for those needing further medical inves- absence of family members. The Paki- did not have any toilet facilities at home; tigations. All forms were translated into stan Medical Research Council closely 18.5% used pit latrines; and 55% had the national language Urdu for easy field monitored the work of the survey teams, flush toilets. application and were field tested prior assessing the accuracy of their access to Excluding preschool children, 44.4% to survey implementation for validation the selected PSUs and contact with the of screened individuals were illiterate, and fine tuning. All testing surveyors identified households, and confirming while 17% had education below the pri- were laboratory technicians who were that tests had been carried out. Any mary level; of the remaining individuals operational inconsistencies observed further trained on how to share the who had completed primary education, were then rectified to sustain the validity information brochure with the fam- 2% had completed 10 years of schooling of the survey implementation. ily head, explain the survey objectives and only 1% had graduate education. and obtain consent for sampling family The survey commenced in July Of the tested adult populations members, either by signing a consent 2007 and was completed in May 2008. 41.4% were housewives or home-based form or through a thumb impression, The testing results were recorded using self-employed, 25.5% were students, SPSS, version 13.0 and subsequently in the presence of at least two fam- 15.5% were employed at private or pub- analysed. Statistical differences were ily members. The laboratory technician lic sector institutions, while the rest were estimated using the chi-square test, the surveyors were trained on how to run unskilled workers. odds ratio (OR) and 95% confidence HBV and HCV rapid tests using whole A history of jaundice was recalled interval (CI) measures. The data were blood, and on how to mark names on by 3% of screened individuals, while 3% disaggregated by province and district, the devices and on storage gel tubes reported having one family member although the district data were not ro- who suffered from liver disease. The where the PSU code, house number bust, thus allowing conservative infer- and person’s number and name were ences at that level. screened families also reported 496 to be recorded. The tested blood kit family members who had died from devices, once checked, were pasted on liver disease. In the study population, the individual report forms to keep a Results the overall prevalence of HBsAg was record, while the reports were written 2.5%, while anti-HCV prevalence was on the back of individual forms to en- This nationwide community survey 4.8%. sure that, if devices were lost, the written was concluded in 11 months and was Table 1 illustrates HBsAg and report remained. Blood was collected in successful in reaching out to 96% of anti-HCV prevalence in the study
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Table 1 Prevalence of hepatitis B surface antigen (HBsAg) and antibody to the 20 years and above age and gender hepatitis C virus (anti-HCV) by sex strata until the 40–49 years age group Sex No. of subjects HBsAg positive Anti-HCV positive (P < 0.01). No difference in HBsAg was No. (%) OR (95% CI) No. (%) OR (95% CI) found between the two youngest age Female 22 599 447 (2.0) 1 1 090 (4.8) 1 categories or between the 40–49 years Male 24 444 709 (2.9) 1.48 (1.31–1.67) 1 204 (4.9) 1.02 (0.94–1.11) age group and higher age categories. Total 47 043 1 156 (2.5) 2 294 (4.8) Currently married individuals had signif-
CI = confidence interval; OR = odds ratio. icantly higher HBsAg positivity relative to those having no history of marriage (OR = 1.96; 95% CI: 1.57–2.45). population, disaggregated by gender. Table 2 shows HBsAg prevalence Males with a history of injection use Prevalence of anti-HCV did not show disaggregated by age, gender, marital had significantly higher HBsAg preva- any gender difference, while HBsAg status and history of injection use. The lence relative to those not reporting prevalence was significantly higher in data illustrate age- and gender-related injection use; this was true for females males (OR = 1.48; 95% CI: 1.31–1.67). differences with a linear trend in the only when comparing those with 5–10
Table 2 Prevalence and factors associated with hepatitis B surface antigen (HBsAg) in Pakistan by age, marital status and history of injection use
Variable Males Females Total No. (%) OR (95%CI) No. (%) OR (95% CI) No.(%) OR (95% CI) Age (years) < 5 33 (1.6) 1 20 (1.0) 1 53 (1.3) 1 5–19 198 (2.1) 1.33 (0.90–1.96) 131 (1.5) 1.56 (0.95–2.57) 329 (1.8) 1.42 (1.05–1.92) 20–29 104 (2.4) 1.55 (1.03–2.35) 88 (2.1) 2.17 (1.30–3.64) 192 (2.2) 1.79 (1.30–2.46) 30–39 106 (3.7) 2.45 (1.63–3.72) 81 (2.8) 2.91 (1.74–4.91) 187 (3.2) 2.61 (1.90–3.60) 40–49 104 (4.5) 2.97 (1.97–4.50) 63 (3.0) 3.11 (1.83–5.34) 167 (3.8) 3.04 (2.20–4.20) 50–59 82 (5.5) 3.70 (2.41–5.68) 34 (2.6) 2.72 (1.51–4.92) 116 (4.1) 3.37 (2.40–4.75) ≥ 60 82 (5.0) 3.32 (2.16–5.10) 30 (2.7) 2.79 (1.53–5.13) 112 (4.0) 3.28 (2.33–4.62) Total 709 (3.0) 447 (2.0) 1 156 (2.5) Marital status (20–49 years) Never married 67 (1.9) 1 36 (1.7) 1 103 (1.8) 1 Married 245 (4.2) 2.32 (1.75–3.09) 193 (2.8) 1.70 (1.70–2.47) 438 (3.4) 1.96 (1.57–2.45) Divorced/separated/ widowed 2 (2.7) 1.49 (0.0–6.3) 3 (1.5) 0.88 (0.27–2.84) 5 (1.8) 1.01 (0.36–2.59) Total 314 (3.3) 232 (2.5) 546 (2.9) No. of intramuscular injections None 111 (1.9) 1 87 (1.7) 1 198 (1.8) 1 < 5 359 (3.1) 1.68 (1.35–2.09) 215 (2.0) 1.13 (0.87–1.47) 574 (2.5) 1.42 (1.20–1.68) 5–10 177 (3.3) 1.83 (1.43–2.34) 114 (2.2) 1.87 (1.54–2.26) 291 (2.8) 1.55 (1.29–1.81) > 10 62 (4.4) 2.43 (1.75–3.37) 31 (2.0) 1.17 (0.76–1.80) 93 (3.2) 1.78 (1.38–2.30) Total 709 (2.9) 447 (2.0) 1 156 (2.5) Types of syringes None 115 (1.9) 1 83 (1.7) 1 198 (1.8) 1 New disposable 201 (2.5) 1.35 (1.06–1.71) 124 (1.6) 0.96 (0.72–1.29) 325 (2.1) 1.16 (0.97–1.39) Re-used syringes 332 (3.7) 1.99 (1.60–2.49) 206 (2.4) 1.40 (1.08–1.83) 538 (3.0) 1.71 (1.44–2.02) Don’t know 65 (4.6) 2.48 (1.80–3.42) 30 (2.2) 1.30 (0.83–2.02) 95 (3.4) 1.92 (1.48–2.47) Total 706 (2.9) 450 (2.0) 1 156 (2.5)
CI = confidence interval; OR = odds ratio.
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injections with non-users. Males using distinctly in both genders of all age cat- non-users, while a similar difference disposable syringes had significantly egories relative to the two youngest age was found in both genders between the higher HBsAg prevalence relative to groups. The most prominent increase in different gradients of injection users. non-injection users, while this was not HCV infection rate was found among Anti-HCV was also significantly higher found among females. Likewise, no those aged between 20 and 49 years among persons exposed to reused sy- significant difference was found in HB- of age (P < 0.01). However, no anti- ringes relative to those with no history HCV gender-based differences were sAg prevalence between females with of injection use, while no difference was lesser numbers of injections relative to found. Individuals with history of mar- found between non-users and those those with higher numbers, while such riage had significantly higher anti-HCV using new disposable syringes. a difference was significant for males prevalence compared with those with with 10 or more injections relative to no history of marriage (OR = 2.01; 95% Overall HBeAg positivity in the those with less than five. Table 3 illus- CI: 1.72–2.34). HBsAg-positive cohort was 14.5%. trates prevalence of anti-HCV, disag- With regard to injection use, anti- When HBeAg positivity in the study gregated by age, gender, marital status HCV prevalence was significantly population was disaggregated by prov- and injection use. A significant increase higher among users of any number of ince, Khyber Pakhtunkhwa had a lower in anti-HCV prevalence was observed injections in both genders relative to HBeAg prevalence (8.5%); however,
Table 3 Prevalence and factors associated with antibody to the hepatitis C virus (anti-HCV) in Pakistan by age, marital status and history of injection use Variable Males Females Total No. (%) OR (95 %CI) No. (%) OR (95% CI) No. (%) OR (95% CI) Age (years) < 5 35 (1.7) 1 44 (2.1)1 1 79 (1.6) 1 5–19 192 (2.0) 1.21 (0.83–1.77) 187 (2.1) 1.00 (0.71–1.42) 379 (2.1) 1.09 (0.85–1.41) 20–29 170 (3.9) 2.43 (1.66–3.57) 205 (4.8) 2.33 (1.66–3.29) 375 (4.4) 2.38 (1.85–3.06) 30–39 204 (7.2) 4.62 (3.17–6.75) 247 (8.4) 4.23 (3.02–5.94) 451 (7.8) 4.41 (3.44–5.66) 40–49 261 (11.3) 7.56 (5.22–11.0) 182 (8.5) 4.29 (3.03–6.08) 443 (9.9) 5.75 (4.48–7.39) 50–59 162 (10.9) 7.29 (4.96–10.77) 128 (9.7) 4.96 (3.45–7.15) 290 (10.4 6.01 (4.63–7.81) ≥ 60 180 (10.9) 7.31 (4.99–10.76) 97 (8.6) 4.32 (2.96–6.32) 277 (10.0) 5.76 (4.43–7.50) Total 1 204 (4.9) 1 090 (4.8) 2 294 (4.9) Marital status (20–49 years) Never married 139 (3.9) 1 80 (3.7) 1 219 (3.8) 1 Married 403 (6.9) 1.86 (1.52–2.28) 532 (7.7) 2.17 (1.70–2.78) 935 (7.3) 2.01 (1.72–2.34) Divorced/separated/ widowed 5 (3.6) 0.93 (0.33–2.40) 20 (9.8) 2.82 (1.63–4.83) 25 (7.2) 1.99 (1.26–3.11) Total 547 (5.7) 632 (6.7) 1 179 (6.2) No. of intramuscular injections None 227 (3.8) 1 175 (3.5) 1 402 (3.7) 1 < 5 550 (4.7) 1.25 (1.07–1.47) 457 (4.2) 1.20 (1.0–1.44) 1 007 (4.5) 1.23 (1.09–1.38) 5–10 312 (5.9) 1.58 (1.33–1.89) 329 (6.4) 1.87 (1.54–2.26) 641 (6.1) 1.71 (1.50–1.95) > 10 115 (8.1) 2.25 (1.77–2.86) 129 (8.4) 2.54 (1.99–3.23) 244 (8.3) 2.38 (2.01–2.82) Total 1 204 (4.9) 1 090 (4.8) 2 294 (4.9) Types of syringes None 227 (3.8) 1 175 (3.5) 1 402 (3.7) 1 New disposable 300 (3.7) 0.99 (0.83–1.18) 252 (3.3) 0.95 (0.78–1.16) 552 (3.5) 0.97 (0.85–1.11) Re-used syringe 615 (6.8) 1.87 (1.59–2.19) 583 (6.7) 1.98 (1.66–2.36) 1 198 (6.8) 1.91 (1.70–2.15) Don’t know 62 (4.3) 1.15 (0.85–1.55) 80 (5.9) 1.71 (1.29–2.27) 142 (5.1) 1.41(1.15–1.72) Total 1 204 (4.9) 1 090 (4.8) 2 305 (4.9)
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Table 4 Prevalence of hepatitis B surface antigen (HBsAg) and antibody to the the detected interprovincial differences hepatitis C virus (anti-HCV) by key social characteristics of the tested population were not significant. Variable HBsAg positive Anti-HCV positive Table 4 illustrates prevalence of HB- No. (%) OR (95% CI) No. (%) OR (95% CI) sAg and anti-HCV in the study popu- Housing lation by housing structure, drinking Kacha home 696 (2.2) 1 1 726 (5.4) 1 water, sanitation, level of education and Pacca home 460 (3.1) 1.42 (1.25–1.60) 568 (3.8) 0.69 (0.62–0.76) employment status. HBsAg was signifi- Drinking water cantly higher among pacca dwellers, and Piped water at home 604 (2.4) 1 1 425 (5.7) 1 those using pit latrines or the open field, Fetched water from as well as in those with education less outside 552 (2.4) 0.98 (0.87–1.10) 869 (3.7) 0.64 (0.58–0.70) than the primary level, relative to those Sanitation living in kacha houses, or using flush Flush toilet available 555 (2.1) 1 1 318 (5.1) 1 toilets or having higher education than Pit latrine at home or the primary level respectively. HBsAg going to field 601 (2.8) 1.33 (1.18–1.50) 976 (4.6) 0.90 (0.83–0.98) was also significantly higher among Education persons working in the government/ Primary and above 411 (2.3) 1 729 (4.0) 1 private sector and among daily wage- Below primary 745 (2.6) 1.15 (1.01–1.30) 1 565 (5.4) 1.38 (1.26–1.51) earners, relative to those working from Employment home. Contrary results were found for Self-employed working anti-HCV with regard to housing and from home 418 (2.1) 1 970 (5.0) 1 sanitary facilities with a higher preva- Working in government lence among those with relatively better private sector 230 (3.0) 1.43 (1.21–1.69) 485 (6.4) 1.31 (1.17–1.46) facilities, while having a lower education Casual worker 51 (3.1) 1.47 (1.08–1.99) 99 (6.1) 1.23 (0.99–1.53) level and working in the public/pri- CI = confidence interval; OR = odds ratio.
Table 5 Prevalence of hepatitis B surface antigen (HBsAg) and antibody to the hepatitis C virus (anti-HCV) by culture-related risk factors Risk factor No. of HBsAg positive Anti-HCV positive subjects No. (%) OR (95% CI) No. (%) OR (95% CI) Shaving (male ≥ 20 years) None 5 288 180 (3.4) 1 295 (5.6) 1 Home 1 983 73 (3.7) 1.1 (0.8–1.4) 149 (7.5) 1.4 (1.1–1.7) Barber 5 419 244 (4.1) 1.5 (1.2–1.9) 532 (9.8) 1.8 (1.5–2.1) Sharing tooth brush/miswak (≥ 5 years) No 2 364 1 083 (2.6) 1 2 173 (5.1) 1 Yes 476 20 (4.2) 1.6 (1.0–2.7) 41 (8.4) 1.6 (1.2–2.4) Sharing cigarettes/hookah/bidi (adults ≥ 20 years) No 23 027 698 (3.0) 1 1 676 (7.3) 1 Yes 1 373 75 (5.5) 1.8 (1.4–2.4) 158 (11.5) 1.7 (1.4–2.0) Tattooing/acupuncture (≥ 5 years) No 42 606 1 095 (2.6) 1 2 195 (5.2) 1 Yes 229 8 (3.5) 1.4 (0.6–2.8) 19 (8.3) 1.6 (1.0–2.7) Ear/nose piercing (female ≥ 5 years) No 5 257 76 (1.5) 1 161 (3.1) 1 Yes 15 141 351 (2.3) 1.6 (1.2–2.1) 886 (5.8) 2.0 (1.7–2.4) History of surgery No 44 697 1 083 (2.4) 1 2 058 (4.6) 1 Yes 2 346 73 (3.1) 1.3 (1.0–1.2) 236 (10.1) 2.3 (2.0–2.7)
CI = confidence interval; OR = odds ratio. S20 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ
vate sector was associated with a higher shops or at home compared with those had significantly higher prevalence exposure to HCV infection. who did not shave at all. Both HBsAg and (6.7%) relative to Sindh (5.0%), which Table 5 illustrates prevalence of HB- HCV were more prevalent among those in turn had significantly higher anti- sAg and anti-HCV by exposure to several who shared tooth brush/miswak or ciga- HCV prevalence when compared to risk factors. In males aged 20 years and rettes/hookah and bidi, or had pierced Balochistan (1.5%) or Khyber Pa- over, HBsAg prevalence was significantly ears or nose, or had a history of surgery. khtunkhwa (1.1%). higher among those who were shaved Anti-HCV was also significantly more Overall prevalence of HBsAg was at a barber shop, relative to those who prevalent among those with a history of 2.5%, and Balochistan had the high- shaved at home or who did not shave tattooing and acupuncture, relative to est prevalence (4.3%) relative to Sindh at all, while no difference was found be- those who did not. (2.5%) and Punjab (2.4%), which in turn tween those who shaved at home, relative Figure 1 illustrates the differences had significantly higher prevalence in to those who did not shave at all. Anti- in prevalence among the provinces and comparison with Khyber Pakhtunkhwa HCV prevalence was significantly higher districts. While overall prevalence of (1.3%). among those shaving either at barber HCV was 4.8%, the Punjab province
Discussion
Hepatitis B virus The HBV and HCV epidemiological studies carried out in Pakistan during past decades had limited geographical scope, different time frames, applied diverse methodologies, and predomi- nantly focused on hospital and high- risk population groups [4–7,11]. Despite these considerable diversities and limitations, the studies supported the presence of high HBV and HCV en-
Legend demicity in Pakistan, promulgating the Province boundary % of hepatitis B high burden these viral infections pose <= 2.5 % > 2.5 % to 5 % to populations’ health. These studies > 5 % determined HBsAg prevalence to range from 2.6% to 3.5%, while anti-HCV prevalence ranged from 3.3% to 5.3%, although lower HBV prevalence was Hepatitis C virus reported from blood donors [12–14]. Among CLD patients, 10%–46% had HBV infections and 40%–86% had anti-HCV [15–18]. The current study has corroborated the above reported high endemicity of HBV and HCV infections in the country, where the overall HBsAg and anti-HCV cumulative prevalence was 7.6%, reflect-
Legend ing a population pool of about 13 million Province boundary being HBV and HCV chronic carriers. % of hepatitis C < 5 % 5 % to 7 % These findings are consistent with a cur- > 7 % rent or imminent high burden of liver disease where 25% of the HBsAg and 80%–85% of the anti-HCV positive indi- Figure 1 Maps illustrating the geographical burden of hepatitis B and C viral viduals may later progress to CLD [1,8]. infections in Pakistan. FANA = Federal Administered Northern Areas; FATA = The association of HBV infection Federally Administered Tribal Areas; NWFP = North West Frontier Area with increased age, marital status and
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exposure to a series of risk factors in- about this risk of infection transition integral part of a patient safety inter- cluding lesser education, outdoor [19]. vention with adherence to the funda- employment, poor sanitation, shaving The higher association of HBV infec- mentals of quality of care. The common at the barber, ear/nose piercing and his- tion with lower socioeconomic condi- use of multidose vials also needs to be tory of surgery corroborates the diverse tions and exposure to related risk factors discouraged and practice by quacks pre- complementary sources of infection categorizes hepatitis B as a disease of vented through the promotion of public and the need for universal hepatitis B poverty, where the aforementioned awareness against these risky though vaccination of all newborn infants and lower immunization coverage in chil- traditional practices. high-risk groups and other hepatitis dren residing in underprivileged areas The corroborated greater HBV and control preventive interventions. How- raises concerns of inequity. Moreover, HCV risk of infection associated with ever, the lower level of HBV infection in these finding give directions for ensur- the history of surgery substantiates the teenage groups in both sexes may reflect ing the vaccination of high-risk groups, need for improving the safety of surgical a lesser exposure at that age. especially the health workforce, and care. While transmission of HBV can In 2000, Pakistan introduced the promotion of infection-control safety be tangibly controlled in a few decades monovalent hepatitis B vaccine in the measures when undertaking traditional through an effective universal vaccina- national EPI and replaced it in 2008 with practices entailing the use of invasive tion of the identified target population the pentavalent vaccine where hepatitis devices. groups coupled with public education B vaccine is jointly administered with The incremental age-related preva- and behaviour change communica- diphtheria, tetanus, pertussis and Hae- lence of HCV infection reflects increased tion, for HCV, where vaccination is mophilus influenzae B vaccines, reducing exposure to high-risk practices such as not an option, public education and the number of child vaccination con- the widespread reuse of syringes and a advocacy control interventions must tacts to improve vaccine acceptability range of high risky traditional practices. be supplemented by the universal use and wastage control. Unfortunately, the These behaviours need to be controlled, of auto-disable syringes that should current performance of the EPI shows both among health providers and in the replace reusable disposable syringes in that a large number of newborns miss community at large, as out of 95% of the the country. Health authorities may also the opportunity of accessing these regu- globally used injections administered expedite the introduction of injection larly procured vaccines, reflecting the for therapeutic purposes, 50% were and patient safety measures in all health unnecessary avoidable harm to which unsafe while 80% were unnecessary facilities and the setting of strategic many children are exposed. [20,21]. This observation is strongly policies that curtail the use of multidose However, the study could not ex- substantiated by the evident correlation vials, including those obtained from vet- clude the importance of vertical trans- between anti-HCV prevalence and the erinary sources and misused by quacks. mission, a matter requiring a focused reuse of syringes and frequency of injec- Moreover, the currently pursued study to evaluate the need for corre- tion use. High community exposure to nationwide free treatment for under- sponding preventive interventions. The unsafe injections may also account for privileged CLD patients needs to be higher prevalence of HBV among mar- the observed lack of gender variation in sustained, as this constitutes a health ried individuals may reflect the potential HCV prevalence. These findings call for intervention mitigating poverty, gener- of sexual transmission, this being an the promotion of a nationwide injection ating public support for the programme epidemiologically recognized mode of safety programme in all health facilities and impacting on the quality of life of infection, mandating public education where related guidelines become an these patients.
References
1. Lavanchy D. The global burden of hepatitis C. Liver Interna- 5. Khan TS, Rizvi F. Hepatitis B seropositivity among chronic liver tional, 2009, 29(s1):74–81. disease patients in Hazara division Pakistan. Journal of Ayub 2. Shepard CW, Finelli L, Alter MJ. Global epidemiology of hepa- Medical College Abottabad, 2003, 15(3):54–55. titis C virus infection. Lancet, 2005, 5:558–567. 6. Raja NS, Janjua KA. Epidemiology of hepatitis C virus infection 3. Rantala M, Van de Laar M JW. Surveillance and epidemiology of in Pakistan. Journal of Microbiology, Immunology and Infection, hepatitis B and C in Europe – a review. Eurosurveillance, 2008, 2008, 41:4–8. 13(4–6):1–8. 4. Ali SA et al. Hepatitis B and hepatitis C in Pakistan: prevalence 7. Khan ZA, Aslam MI, Ali S. The frequency of hepatitis B and and risk factors. International Journal of Infectious Diseases, C among volunteer blood donors in Balochistan. Hepatitis 2009, 13:9–19. Monthly, 2007, 7(2):73–76.
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8. Van Damme P, Kane M, Andre M. Integration of hepatitis B 15. Masud I, Khan H, Khatak AM. Relative frequency of hepatitis B vaccination into national immunization programmes. British and C viruses in patients with hepatic cirrhosis at DHQ teaching Medical Journal, 1997, 314(7086):1033. hospital D. I. Khan. Journal of Ayub Medical College Abottabad, 2004, 16(1):32–34. 9. Global progress towards universal childhood hepatitis B vacci- nation. Weekly Epidemiological Record, 2003, 78(42):366–370. 16. Khokhar N. Spectrum of chronic liver disease in a tertiary care hospital. Journal of Pakistan Medical Association, 2002, 10. Hepatitis C. Weekly Epidemiological Record, 1997, 72(10):65– 52(2):56–58. 69. 17. Khan AA et al. Seromarkers of hepatitis B and C in patients 11. Farooqi JI, Farooqi RJ. Relative frequency of hepatitis “B” virus with cirrhosis. Journal of the College of Physicians and Surgeons– and hepatitis “C” virus infections in patients of cirrhosis in Pakistan, 2002, 12(2):105–107. NWFP. Journal of the College of Physicians and Surgeons–Paki- 18. Khan TS, Rizvi F, Rashid A. Hepatitis C seropositivity among stan, 2000, 10(6):217–219. chronic liver disease patients in Hazara, Pakistan. Journal of 12. Khokhar N, Gill ML, Malik G J. General seroprevalence of Ayub Medical College Abottabad, 2003, 15(2): 53–55. hepatitis C and hepatitis B virus infections in population. Jour- 19. Bile K et al. Late seroconversion to hepatitis B in a Somali village nal of the College of Physicians and Surgeons–Pakistan, 2004, indicates the important role of venereal transmission. Journal of 14(9):534–536. Tropical Medicine and Hygiene, 1991, 94:367–373. 13. Ali N et al. Prevalence of hepatitis B surface antigen and hepa- 20. Simonsen L et al. Unsafe injections in the developing world and titis C antibodies in young healthy adults. Pakistan Journal of transmission of bloodborne pathogens: A review. Bulletin of the Pathology, 2002, 13(2):3–6. World Health Organization, 1999, 77(10):789–800. 14. Kakepoto GN et al. Epidemiology of blood borne viruses: a 21. Kermode M. Unsafe injections in low-income country health study of healthy blood donors in Southern Pakistan. Southeast settings: need for injection safety promotion to prevent the Asian Journal of Tropical Medicine and Public Health, 1996, spread of blood-borne viruses. Health Promotion International, 27(4):703–706. 2004, 19(1):95–103.
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Smokeless tobacco use in Pakistan and its association with oropharyngeal cancer K.M. Bile,1 J.A. Shaikh,1 H.U.R. Afridi1 and Y. Khan2
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ABSTRACT Smokeless tobacco (ST), widely used in Pakistan, poses a high risk for oral cancer. Our hospital-based data illustrate that oropharyngeal cancer (9.9%) is the second leading malignancy after breast cancer (16.1%), and is significantly higher than in other Member States of the World Health Organization’s Eastern Mediterranean Region. Urdu-speaking communities had a proportionately higher rate of oropharyngeal cancer (20.4%), followed by Balochis (19.9%), Sindhis (16.8%), Punjabis (11.7%) and Pashtuns (9.6%). Association of oropharyngeal cancer with ST use was four times higher relative to no history of tobacco use after adjusting for age, ethnicity and gender. Our findings also show a predominance of this cancer among males relative to females and one-third of the reported cases occurred among individuals under 40 years. These findings have significant social impact, indicating the need for urgent intervention against the use of ST.
Consommation de tabac sans fumée au Pakistan et association avec le cancer oropharyngé
RÉSUMÉ Le tabac sans fumée, dont la consommation est largement répandue au Pakistan, induit un risque élevé de cancer de la cavité buccale. Les données obtenues auprès des hôpitaux montrent que le cancer oropharyngé est le deuxième cancer majeur (9,9 %) après le cancer du sein (16,1 %), avec un pourcentage nettement plus élevé que dans tout autre État Membre de la Région OMS de la Méditerranée orientale. Proportionnellement, les communautés parlant l’ourdou présentaient le taux de cancer oropharyngé le plus élevé (20,4 %), suivies par celles parlant le baloutchi (19,9 %), le sindhi (16,8 %), le pendjabi (11,7 %) et le pashto (9,6 %). Après ajustement des données en fonction de l’âge, de l’origine ethnique et du sexe, il a été constaté que les cancers oropharyngés étaient quatre fois plus fréquents chez les personnes qui consommaient du tabac sans fumée que chez celles qui n’avaient aucun antécédent de consommation de tabac. Nos résultats montrent également une prédominance de ce cancer chez les hommes. De plus, un tiers des cas signalés concernait des personnes de moins de 40 ans. Ces constats ont des répercussions sociales importantes et indiquent le besoin d’une intervention urgente contre la consommation de tabac sans fumée.
1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to K.M. Bile: [email protected]). 2National Tobacco Control Programme, Islamabad, Pakistan.
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Introduction led to this growing epidemic, despite burden of oropharyngeal cancer among the fact that it has multiple ill effects on cancer patients admitted in key teaching According to the World Health Or- human health [7]. and cancer hospitals in Pakistan, and ganization (WHO), tobacco is the Pakistan is one of the countries evaluate the frequency and association single most preventable cause of death where the use of ST is a culturally ac- of oropharyngeal cancer with the use in the world today [1]. It is estimated ceptable habit. Various studies have re- of ST. that 5.4 million deaths currently occur ported the prevalence of chewing habits every year due to tobacco use [2] and in different communities and locations. projected figures show that by 2030 Studies from Karachi have shown that Methods there will be more than 8 million deaths 21% of men and 12% of women use be- every year, of which 80% will take place tel [7], for both men and women 7.3% Data were obtained from five major lead- in middle- and low-income developing use pan, 6.7% chalia, 7.5% gutka, 14.6% ing institutions for cancer diagnostics and countries [1,2]. naswar [3] and use of betel and chewed management in Pakistan, namely Shau- Tobacco can be used in different tobacco is 20% and 17%, respectively kat Khanum Memorial Cancer Hospital ways, ranging from cigarette, cigar and [8,9]. In medical students, the rate of & Research Centre (SKMCH&RC) in pipe smoking to smokeless products, ST use was reported as 6.4% [7], while Lahore 2004–2007, Civil Hospital Ka- available in various forms and mixtures. among primary-school children, the use rachi (CHK) 2004–2008, Jinnah Post The most common forms of smoke- of areca and betel was 74% and 35%, Graduate Medical Centre (JPMC) less tobacco (ST) available and used in respectively [10]. in Karachi 2004–2008, Institute of Pakistan include: Several studies have shown a clear Radiotherapy and Nuclear Medicine independent link between the use of (IRNUM) in Peshawar 2005–2007, r Pan/betel with tobacco – a chewed and Nuclear Medicine, Oncology mixture of areca nut (Areca catechu), betel, areca and ST and oral submu- cous fibrosis, oral cancers, leukoplakia and Radiotherapy Institute (NORI) tobacco, catechu (Acacia catechu) in Islamabad 2006–2008. Only sum- and slaked lime (calcium oxide and and other head and neck malignancies [4,11]. Among the Indian population, marized data of 21 245 cancer patients calcium hydroxide), wrapped in a were obtained from SKMCH&RC and betel leaf (Piper betel) with sweeten- studies have estimated that 49% of oral NORI, showing ranking of the most ing agents. cancers among males and 90% among females are attributable to chewing frequently diagnosed cancers. Data of r Naswar – a mixture of sun-dried, habits [11]. A report from Pakistan has 29 307 cancer patients, including infor- sometimes only partially cured, pow- also shown that people using pan with- mation on use of ST and demographic dered local tobacco (Nicotiana rus- out tobacco and those using pan with details, were obtained from the Karachi tica), ash, oil, flavouring agents (e.g. tobacco were 9.9 and 8.4 times, respec- hospitals CHK and JPMC and from cardamom, menthol), colouring IRNUM in Peshawar. agents (indigo) and lime. tively, more likely to develop oral can- cer, after adjusting for covariates such as The assessed hospitals used different r Chalia/supari – areca nut (used plain, smoking, oral submucous fibrosis, use nomenclature to identify sites of differ- flavoured with essences or coated of alcohol and naswar [12]. Incidence ent cancers. SKMCH&RC classified with tobacco). rates of cancer of the oral cavity in both malignancies based on the International r Gutka – sun-dried roasted, finely males and females were found to be Classification of Diseases for Oncology, 3rd chopped tobacco, areca nut, slaked among the highest in all urban cancer Edition (ICD-O-3) code. NORI re- lime and catechu mixed with flavours registries of south Asia relative to global ported the most frequent cancers based and sweeteners [3–6]. data [4]. Similarly, cancers of the oral on site-based categories, i.e. cancers of Most people place these forms of cavity and pharynx are highly common the breast, larynx, liver, oesophagus, ST in the mandibular or labial groove malignancies among males and females lung, gastrointestinal tract (stomach, or simply apply them to their teeth in Pakistan [13]. The age standardized intestine, colon), blood cancers, cer- and gums and suck on them slowly for incidence rate per 100 000 population vix, oropharynx and others. Data from 10–15 minutes [7]. of oral cavity cancer in Karachi city from the Karachi and Peshawar hospitals ST is highly addictive and is a high- 1 January 1998 to 31 December 2002 outlined 50 different categories/sites risk factor for oropharyngeal cancers as was reported as 21.3 in males and 19.3 of cancer, classifying malignancies as well as cancers of the head and neck, in females, considered to be among the cancers of the breast, liver, oesophagus, oesophagus and pancreas [1]. The er- highest in the world [14]. pancreas, lung (lung, pleura, trachea, roneous belief that chewing tobacco is The objective of this retrospective bronchi), gastrointestinal tract (stom- a safe alternative to smoking may have hospital-based review was to assess the ach, small intestine, large intestine,
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colon), lymphoma (all types), leukae- representation (55.5%), while Baluchis Table 1 Social and demographic mia and multiple myeloma (all types), and Punjabis were least represented in characteristics of registered cancer patients in five leading hospitals in oropharynx (oral cavity and pharynx), the study population (Table 1). The Pakistan larynx and others (all other organs, e.g. group categorized as “Other” included Variable No. % skin, genitourinary, soft tissue, bone, Bengalis, Uzbeks, Afghans, Marwaris Age at time of etc.). Oral cavity included the buccal and Gujaratis. Overall, there were sig- diagnosis (years) mucosa, upper and lower alveolar ridges, nificantly more users of ST (37.4%) < 25 4 374 14.9 floor of the mouth, retromolar trigone, than tobacco smokers (23.6%). 25–34 2 8499.7 hard palate, tongue and lips. Pharynx Aggregated data from 2004–2008 35–44 4 813 16.4 included oropharynx, nasopharynx and from the five sources showed that 45–54 6 249 21.3 hypopharynx. among the 50 552 registered cases, ≥ 55 10 986 37.5 With regard to habits, patients were breast cancer was the most common Total 29 271a classified as: having a history of no ad- cancer (16.1%), followed by oropha- Sex diction; using ST (i.e. pan, naswar, gutka, ryngeal cancer (9.9%), which was sig- Male 15 529 53.0 chalia/areca nut); smoking tobacco; nificantly higher than all other cancers Female 13 758 47.0 using both ST and smoked tobacco; (P < 0.001) (Table 2). When data were Total 29 287 a and those addicted to other substances, disaggregated by reporting hospital, Ethnicity i.e. alcohol, bhang, opium, etc. oropharyngeal cancer was the most Pashtun 16 256 55.5 Permission was obtained from the frequent cancer in JPMC and IRNUM, Punjabi 1 035 3.5 hospitals, and a matrix was designed to and was ranked second in CHK, third Sindhi 3 019 10.3 generate retrospectively the cancer data in SKMCH&RC and fifth in NORI. available from these hospitals. Data Baluchi 895 3.1 Oropharyngeal cancer was signifi- Urdu 3 606 12.3 were entered and analysed using SPSS, cantly more frequent in Pakistan com- Other 4 496 15.3 version 13.0. pared with the other countries from Total 29 307 Descriptive statistics of sociode- WHO’s Eastern Mediterranean Region Habit mographic characteristics and use of (P < 0.001) (Table 3). No addiction 2 514 34.5 ST were carried out using frequencies, In the univariate analysis, there was Smokeless tobacco 2 730 37.4 while univariate and multivariate odds a significant linear trend of incremental Smoking tobacco 1 718 23.6 ratios (OR) with 95% confidence in- rise in the prevalence of oropharyngeal Both (smoking and tervals (CI) were obtained using the 2 cancer in the first 4 age groups (χ test smokeless) chi-squared test and logistic regression 306 4.2 for linear trend, P < 0.01) (Table 4). In Other 24 0.3 analysis. the multivariate analysis, the associa- Total 7 292a
tion of oropharyngeal cancer with ST aData for 36 cases on age, 20 cases on sex and 22 Results was also significantly more prominent 015 cases on habit were not available. among males than females (adjusted Data from 50 552 registered cancer pa- OR = 1.59; 95% CI: 1.438–1.82). tients were collected from five leading When controlling for ethnicity, age relative to other ethnic groups while hospitals that manage cancer patients and sex, multivariate analysis showed no such difference was found between admitted for diagnosis and care during that patients who used ST, smoked these 2 groups (data not shown in a period from 2004 to 2008. Table 1 tobacco, or practised both habits, had tables). Moreover, Sindhis had a sig- shows the sociodemographic charac- a 4.7 (95% CI: 3.92–5.54), 1.6 (95% nificantly higher oropharyngeal cancer teristics of registered cancer patients CI: 1.31–2.01) and 3.8 (95% CI: rate relative to Punjabis, who in turn in these five hospitals. Of these, 29 307 (1.31–2.01) times higher likelihood, had a significantly higher oropharyngeal patient records had demographic data, respectively, of having oropharyngeal cancer rate compared to Pashtuns. while only 7292 had data on tobacco cancer, when independently compared use. The mean age of the cancer patients with patients not practising any of these was 45 years at the time of diagnosis, habits and these were all statistically Discussion ranging from 1 to 100 years. significant (Table 4). Of the 29 307 cancer patients Oropharyngeal cancer was sig- The link between oropharyngeal cancer with demographic data, 53% were nificantly higher among native Urdu- and consumption of betel, areca nut males; ethnically, Pashtuns had more speaking and Balochi communities, and tobacco chewing is well established,
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Table 2 Cancers most frequently reported from five leading cancer diagnostic and management centres in Pakistana JPMC CHK IRNUM SKMCH & RC NORI Total Cancer No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) Oropharynx 1 922 (17.7) 487 (14.8) 1 444 (9.5) 796 (6.3)b 395 (4.60) 5 044 (9.9) Breast 1 508 (13.9) 613 (18.6) 1 392 (9.2) 2 856 (22.6) 1 790 (20.9) 8 159 (16.1) Liver 361 (3.3) 110 (3.3) 176 (1.2) 725 (5.7) 142 (1.65) 1 514 (3.0) Larynx 343 (3.2) 46 (1.4) 188 (1.2) – 189 (2.2) 766 (1.5) Abdomen and anal canal 698 (6.4) 320 (9.7) 898 (5.9) 540 (4.3)c 1 017 (11.9) d 3 473 (6.9) Oesophagus 496 (4.6) 117 (3.5) 1 171 (7.7) – 166 (1.93) 1 950 (3.9) Non-Hodgkin’s lymphoma 502 (4.6) 37 (1.1) 1 312 (8.7) 908 (7.2) – 2 759 (5.5) Hodgkin disease – – – 462 (3.6) – 462 (0.9) Lung 798 (7.3) 183 (5.5) 479 (3.2) 399 (3.2) 422 (4.92) 2 281 (4.5) Brain 265 (2.4) 21 (0.6) 851 (5.6) 257 (2.0) – 1 394 (2.7) Skin 180 (1.7) 26 (0.8) 830 (5.5) – – 1 036 (2.1) Uterus/ cervix 366 (3.4) 96 (2.9) 529 (3.5) – 197 (2.3)e 1 188 (2.4) Acute lymphocytic leukaemia 125 (1.1) 2 (0.1) 748 (4.9) 281 (2.2) – 1 156 (2.3) Leukaemia – – – 401 (3.2) 730 (8.5)f 1 131 (2.2) Others 3 322 (30.5) 1 241 (37.6) 5 104 (33.8) 5 039 (39.8) 3 533 (41.2) 18 239 (36.1) Total 10 886 3 299 15 122 12 664 8 581 50 552
aNomenclature variance is related to the use of different classification by the different centres. bOral cavity. cColorectal. dGastrointestinal (all other). eCervix. f Blood cancers. CHK = Civil Hospital Karachi; IRNUM = Institute of Radiotherapy and Nuclear Medicine; JPMC = Jinnah Post Graduate Medical Centre; NORI = Nuclear Medicine, Oncology and Radiotherapy Institute; SKMCH &RC = Shaukat Khanum Memorial Cancer Hospital & Research Centre.
and the habit is a commonly accepted fight against tobacco use and cigarette however, tobacco cultivation is a prima- cultural practice in south Asia [3,4]. The smoking in particular has become an ry cash crop in one province (Khyber demographic profile of the diagnosed area of major public health debate in Pa- Pakhtunkhwa) and this has brought cancer patients in this study represents kistan, where the government, civil soci- political sensitivity to this important a multi-ethnic group of Pakistan as it ety organizations and media attempt to debate. Moreover, the Government includes five major leading institutions control tobacco use in the country. On interpretation of the WHO FCTC for cancer diagnostics and management the other hand, tobacco manufactur- and the proposed control interventions from different parts of the country. ers have reignited fierce opposition to were almost exclusively directed to- Since the ratification of the WHO these national efforts. Pakistan, the sixth wards the control of cigarette smoking, Framework Convention on Tobacco most populous nation in the world, while the control of ST was ignored. As Control (WHO FCTC) in 2005, the has a high tobacco consumption rate; in most south Asian countries, the use
Table 3 Comparison of oropharyngeal and other cancers with selected countries in the Eastern Mediterranean Region Country Total Oropharynx Stomach, Liver Pancreas Larynx Lungs Oesophagus colon, rectum No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) No. (%) Lebanon [19] 7 888 111 (1.41) 839 (10.64) 67 (0.85) 120 (1.52) 135 (1.71) 875 (11.09) – Jordan [21] 3 142 75 (2.39) 385 (12.25) 74 (2.36) 27 (0.86) 50 (1.59) 211 (6.72) 27 (0.86) Kuwait [22] 584 15 (2.57) 69 (11.82) 13 (2.23) 12 (2.05) 5 (0.86) 44 (7.53) 4 (0.68) Islamic Republic of Iran [20] 47 217 1 206 (2.55) 8 616 (18.25) 283 (0.6) 211 (0.45) 785 (1.66) 1 506 (3.19) 2 584 (5.47) Pakistan 50 552 5 044 (9.90) 3 473 (6.90) 1 514 (3.0) 218 (0.43) 766 (1.50) 2 281 (4.50) 1 950 (3.90)
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Table 4 Univariate and multivariate analysis showing association between age, sex, ethnicity and habit of addiction with oropharyngeal cancer Variable All cases Oropharyngeal cancer Crude OR (95% CI) Adjusted OR (95% CI)a No. (%) Age at time of diagnosis (years) < 25 4 374 395 9.0 1 1 25–34 2 849 349 12.2 1.40 (1.2–1.63) 2.6 (1.7–4.05) 35–44 4 813 689 14.3 1.68 (1.47–1.91) 3.5 (2.4–5.2) 45–54 6 249 943 15.1 1.79 (1.58–2.02) 3.4 (2.3–5.0) ≥ 55 10 986 1 470 13.4 1.55 (1.38–1.74) 2.6 (1.8–3.8) Total 29 271 3 846 13.1 Sex Female 13 758 1 466 10.7 1 1 Male 15 529 2 384 15.4 1.52 (1.42–1.63) 1.59 (1.38–1.82) Total 29 287 3 850 13.1 Habit of patient No addiction 2 514 207 8.2 1 1 Smokeless tobacco 2 730 867 31.8 5.1 (4.4–6.1) 4.66 (3.92–5.54) Smoke tobacco 1 718 281 16.4 2.1 (1.8–2.6) 1.62 (1.31–2.01) Both 306 92 30.1 4.7 (3.6–6.3) 3.77 (2.80–5.08) Others 24 3 12.5 1.5 (0.4–5.3) 1.04 (0.30–3.56) Total 7 292 1 450 19.9 Ethnicity Pashtun 16 256 1 553 9.6 1 1 Punjabi 1 035 121 11.7 1.25 (1.03–1.53) 2.19 (1.58–3.04) Sindhi 3 019 508 16.8 1.92 (1.72–2.13) 3.05 (2.37–3.92) Balochi 895 178 19.9 2.35 (1.98–2.79) 3.03 (2.23–4.13) Urdu speaking 3 606 734 20.4 2.42 (2.20–2.67) 3.12 (2.47–3.93) Others 4 496 759 16.9 1.92 (1.75–2.11) 2.61 (2.05–3.32) Total 29 307 3 853 13.1
aAdjusted for the other variables shown in the table. CI = confidence interval; OR = odds ratio.
of ST products is a common practice Our analysis illustrates that oropha- in the world [17], while a later study did in Pakistan, although predominantly ryngeal cancer was the second most not include oropharyngeal cancer in limited to the lower socioeconomic prevalent malignancy in Pakistan, re- the 10 most frequent cancers in both strata of the population, except for the flecting the high burden collectively developed and developing countries occasional traditional use of these prod- experienced by most provincial cancer [18]. Oropharyngeal cancer was also ucts, particularly pan, in local groups, diagnostic and management centres significantly more frequent in Pakistan especially in Sindh province [3,7]. The [14–16]. When data from these sourc- relative to several other countries in the evident lack of regulatory attention may es were disaggregated, this cancer was Region with available data [19–22]. be attributed to the strong traditional the most frequent in 2 of the source Our findings therefore reveal a distinct base of the habit, the low social status centres, was ranked second and third regional public health problem, requir- of its prime consumers, the limited use in 2 other source centres and was fifth ing urgent action by the Pakistan Gov- of these substances in more prominent in the remaining source, indicating the ernment. public places, the lack of taxation inter- robustness of these findings. However, Among the patients whose expo- est by the Government, and insufficient it is important to note that an earlier sure to tobacco risk was recorded, there awareness and knowledge about the study of the 10 most frequent cancers was a significant association between health hazards and risks associated with globally ranked mouth and pharynx oropharyngeal cancer and ST use; in these products [3,6]. cancer as the sixth most frequent cancer fact twice as strong as that between
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oropharyngeal cancer and cigarette The observed greater occurrence this preventable killer and build an al- smoking, reflecting the burden that this of oropharyngeal cancer among native liance between the ministries of health, habit inflicts on the population’s health. Urdu-speaking and Balochi patients education, commerce, agriculture, the This association is explained by WHO’s relative to other ethnic groups in the Central Board of Revenue and the pro- recent confirmation of the presence of country may be explained by the differ- vincial governments to ban all forms at least 28 carcinogens in ST, including ent sociocultural traditions related to of tobacco advertisement, sponsorship non-volatile alkaloid-derived tobacco, ST use [13,23]. In Pakistan, the chewed and marketing, ban all forms of tobacco specific nitrosamines,N -nitrosamines, forms of ST, pan and gutka, are pre- consumption in all public places and inorganic compounds such as arsenic sumed to be more common among the increase the excise taxes on all forms and nickel, plus radio-elements such Urdu-speaking and Balochi commu- of tobacco. A national cancer registry as polonium, uranium, beryllium and nities, especially those living in Sindh should also be established to generate others [5]. province, while the relatively lower oc- an account of the incidence trends, the currence of the disease in individuals Although in both males and females, patterns and burden in the country, ST use was significantly associated with from other groups may be attributed to the population at risk, and the risk oropharyngeal cancer, male patients a relatively lower consumption of these factors engaged, especially smokeless had almost a 60% higher risk of devel- chewable ST products [23]. However, tobacco use. Such a knowledge base oping the disease than females. The this assumption is not conclusive, con- will facilitate the introduction of control significant incremental linear trend in sidering the limitations of the study, as the prevalence of oropharyngeal cancer the 2 hospitals in Lahore and Islama- interventions that consider the underly- in the first 4 age group categories of the bad did not have demographic data on ing social, economic and cultural fac- study population illustrates the poten- ethnicity or records on the habitués of tors and render the prevention of oral tial cumulative impact of the use of ST, tobacco. Moreover, the 7292 cases for cancer an integral part of the national an epidemiological observation cor- which information on tobacco use was cancer control programme. roborated by previous studies [5,14]. available had no account of the duration The association of oropharyngeal can- of exposure that could have an impact cer with ST was significantly higher for on the disease occurrence. According to Acknowledgement both males and females relative to non- the Pakistan Tobacco Board, the total ST users, although this relationship production of tobacco for 2006–2007 The authors thank the management of was more prominent among males. was 103 000 tons, of which about 50% the 5 hospitals: Civil Hospital Karachi; With the mean age of the patients being was used for cigarette manufacturing, Institute of Radiotherapy and Nuclear 45 years, a profound socioeconomic while the remaining quantity may have Medicine; Jinnah Post Graduate Medi- burden may be attached to the prema- been used in ST forms. In addition, cal Centre; Nuclear Medicine, Oncol- ture mortality likely to result from such exported and imported quantities were ogy and Radiotherapy Institute and early age diagnosis, indicating the need comparable, each being estimated at Shaukat Khanum Memorial Cancer for control interventions linking the 5% of the yearly production [24]. Hospital & Research Centre, who prevention of ST use to the ongoing Pakistan has to reinforce its politi- made their cancer data available for national action against tobacco use. cal and public health efforts to control this study.
References
1. WHO report on the global tobacco epidemic, 2008; the MPOWER 5. IARC monographs on the evaluation of carcinogenic risks to hu- package. Geneva, World Health Organization, 2008. mans. Volume 89: Smokeless tobacco and some tobacco-specific 2. Mathers CD, Loncar D. Project of global mortality and burden N-nitrosamines. Lyon, World Health Organization, Internation- of disease from 2002 to 2030. PLoS Medicine, 2006, 3(11):e442. al Agency for Research on Cancer, 2007. 3. Khawaja MRH et al. Chewing of betel, areca and tobacco: 6. Gupta PC, Ray C S. Smokeless tobacco and health in India and perceptions and knowledge regarding their role in head and South Asia. Respirology, 2003 8:419–431. neck cancers in an urban squatter settlement in Pakistan. Asian 7. Imam S Z et al.Use of smokeless tobacco among groups of Pa- Pacific Journal of Cancer Prevention, 2006, 7:95–99. kistani medical students – a cross sectional study. BMC Public 4. Nair U, Bartsch H, Nair J. Alert for an epidemic of oral cancer Health, 2007, 7:231. due to use of the betel quid substitutes gutkha and pan ma- sala: a review of agents and causative mechanism. Mutagenesis, 8. Mahmood Z. Smoking and chewing habits of people in Karachi 2004, 19(4):251–261. 1981. Journal of Pakistan Medical Association, 1982, 32:34–37.
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9. Qidwai W et al. Are our people health conscious? Results of a 17. Parkin DM, Pisani P, Ferlay J. Estimates of the worldwide inci- patient survey in Karachi, Pakistan. Journal of Ayub Medical Col- dence of eighteen major cancers in 1985. International Journal lege Abottabad, 2003, 15(1):10–13. of Cancer, 1993, 54:594–606. 10. Shah SM et al. Addicted school children: prevalence and char- 18. Mackay J et al., eds. The cancer atlas. Brighton, American Cancer acteristics of areca nut chewers among primary school children Society, 2006. in Karachi, Pakistan. Journal of Paediatric and Child Health, 2002, 38:507–510. 19. Salim M, Adib MD, Daniel J, eds. National cancer registry: cancer 11. Balaram P et al. Oral cancer in Southern India: the influence in Lebanon 2003. Beirut, Ministry of Public Health, 2003. of smoking, drinking paan-chewing and oral hygiene. Interna- 20. Mousavi SM, ed. Report of national cancer registration in Iran tional Journal of Cancer, 2002, 98:440–445. 2004–2005. Tehran, Ministry of Health and Medical Education, 12. Marchant A et al. Paan without tobacco: an independent risk 2006. factor for oral cancer. International Journal of Cancer, 2000, 86:128–131. 21. Al-Kayed S, Hijawi B, eds. National cancer registry: incidence of 13. Bhurgri Y et al. Cancer of the oral cavity and pharynx in Karachi cancer in Jordan. Amman, Ministry of Health, 1999. – identification of potential risk factors. Asian Pacific Journal of 22. Al-Hattab O, ed. Kuwait cancer registry: annual report 2003. Cancer Prevention, 2003, 4:125–130. Kuwait, Ministry of Health, 2003. 14. Bhurgri Y. Cancer and the oral cavity – trends in Karachi South 23. Mazahir S et al. Socio demographic correlates of betel, areca (1995–2002). Asian Pacific Journal of Cancer Prevention, 2005, and smokeless tobacco use as a high risk behavior for head 6:22–26. and neck cancers in a squatter settlement of Karachi, Paki- 15. Bhurgri Y et al. Cancer profile of Hyderabad, Pakistan (1998– stan. Substance Abuse, Treatment, Prevention, and Policy, 2006, 2002). Asian Pacific Journal of Cancer Prevention, 2005, 6:474– 480. 1:10). 16. Bhurgri Y et al. Cancer profile of Larkana, Pakistan (2000–2002). 24. Tobacco statistical bulletin 2007. Peshawar, Pakistan Tobacco Asian Pacific Journal of Cancer Prevention, 2006, 7:518–521. Board, Ministry of Commerce, 2007.
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Review A review of EPI progress in Pakistan towards achieving coverage targets: present situation and the way forward Q. Hasan,1 A.H. Bosan 2 and K.M. Bile1
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ABSTRACT Pakistan’s Expanded Programme on Immunization (EPI) performance has a significant impact on global and regional immunization indicators such as poliomyelitis eradication, maternal and neonatal tetanus and measles elimination. Despite significant efforts by the Government and partners, Pakistan’s immunization indicators have not met the expected benchmarks. Barriers to achieving immunization goals are related to limited access to immunization services, lack of parent awareness and weak management. With sustained Government commitment, predictable partner support and by adopting effective strategies, Pakistan can achieve the immunization targets set at the regional and global level and make strong progress towards achieving Millennium Development Goal 4. This paper reviews EPI coverage targets, constraints, costs and resource allocation, and financial impact of suboptimal performance, and indicates the way forward to overcome these challenges.
Examen des progrès du Programme élargi de vaccination au Pakistan vers la réalisation des cibles de couverture : situation actuelle et voie à suivre RÉSUMÉ Les résultats du Programme élargi de vaccination au Pakistan ont des répercussions importantes sur les indicateurs de vaccination mondiaux et régionaux, ainsi que sur l’éradication de la poliomyélite et l’élimination du tétanos maternel et néonatal et de la rougeole. Malgré les efforts importants du gouvernement et de ses partenaires, les indicateurs de vaccination du Pakistan n’ont pas atteint les niveaux escomptés. Les obstacles à la réalisation des objectifs de vaccination sont l’accès limité aux services de vaccination, le manque de sensibilisation des parents et la faible capacité de gestion. Avec un engagement gouvernemental durable, l’appui prévisible de partenaires et l’adoption de stratégies efficaces, le Pakistan peut atteindre les cibles de vaccination définies aux niveaux mondial et régional et progresser fortement vers la réalisation de l’objectif 4 du Millénaire pour le développement. Cet article examine les cibles de la couverture par le Programme élargi de vaccination, les contraintes, les coûts et l’allocation des ressources, ainsi que les conséquences financières de résultats perfectibles. Il indique la voie à suivre pour surmonter ces obstacles.
1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to Q. Hasan: [email protected]). 2Expanded Programme on Immunization, Ministry of Health, Islamabad, Pakistan.
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Introduction Table 2 Routine tetanus toxoid (TT) vaccination schedule for pregnant women, Expanded Programme on Immunization (EPI), Pakistan The Expanded Programme on Im- Vaccination Schedule munization (EPI) in Pakistan annu- TT–1 During the first pregnancy ally targets around 5.8 million children TT–2 1 month after the first dose aged below 1 year to protect against 8 TT–3 6 months after the second dose vaccine-preventable diseases and 5.9 TT–4 1 year after the third dose million pregnant women to protect TT–5 1 year after the fourth dose them and their newborns from tetanus through routine immunization services. The overall objective of EPI is to reduce number of children and women are not match the efforts and resources al- mortality and morbidity resulting from also targeted to receive immunization located for the purpose by the Govern- the 8 EPI target diseases. through different supplemental immu- ment and partners. EPI is almost the exclusive provider nization activities. Initially started with 6 The objective of this review is to of immunization service in Pakistan, antigens, the programme added 2 new explore the progress of EPI Pakistan in where the private sector provides ap- antigens, hepatitis B and Haemophilus terms of coverage of different antigens, proximately 3% of immunization in- influenzae type b (Hib), during the last current knowledge about the con- jections [1]. It delivers immunization decade. Over 30 million children are straints to achieving the desired level of services through more than 6000 fixed targeted for every round of polio supple- coverage, cost and resource allocation, centres and over a million outreach and mental immunization activities. Over financial impact of suboptimal perform- mobile vaccination sessions annually, 3.4 million women of childbearing age ance and the way forward to overcome involving more than 10 000 vaccina- were vaccinated with 3 doses of TT vac- the challenges in attainment of its goals. tors including paramedics trained in cine during 2009. EPI, 6000 lady health visitors (LHVs) At present, interruption of polio and other paramedics. Approximately transmission, elimination of measles Sources 100 000 lady health workers (LHWs) and neonatal tetanus along with reach- also assist in routine and supplementary ing high routine immunization coverage Several Government documents, survey immunization activities by social mobi- are the main priorities for EPI Pakistan. reports and unpublished programme lization, defaulter tracing and occasion- In the recent past, the programme intro- documents were reviewed and online ally providing vaccination. The current duced new vaccines and technologies, searches were made to find literature on routine immunization schedules for which created more interest and pa- EPI Pakistan in websites of the World children and pregnant women are de- rental awareness of immunization. This Health Organization (WHO), United scribed in Tables 1 and 2. was reflected in a slow but steady rise in Nations Children’s Fund (UNICEF) EPI began in Pakistan in 1976 on a different coverage indicators assessed and other sources. The EPI programme’s pilot scale and was expanded country- by independent organizations (Figure official database along with Govern- wide by 1978. Annually, the programme 1) [3]. However, these achievements ment financial documents were also procures vaccines for approximately 5.8 were inadequate to reach the country’s analysed to estimate costs and impact million children and 5.9 million preg- goal for polio eradication, measles and of suboptimal performance. nant women [2]. In addition, a large neonatal tetanus elimination and did Results Table 1 Routine immunization schedule for children, Expanded Programme on Immunization (EPI), Pakistan WHO and UNICEF had been estimat- Name of vaccine Number of doses Age at which administered ing the country’s immunization cover- BCG 1 At birth age every year using the country’s official reports and the available independent Trivalent OPV 4 At birth and then at 6, 10 and 14 weeks survey data (Figure 1) [3]. In the mid- Pentavalent (DPT–hepatitis B–Hib) 3 At 6, 10 and 14 weeks 1980s, EPI coverage with 3 doses of diphtheria–pertussis–tetanus (DPT3) Measles 2 At 9 months and in second year of life vaccine had been around 30% and with 1
BCG= Bacille Calmette-Guérin; OPV = oral poliomyelitis vaccine; DPT = diphtheria–pertussis–tetanus; Hib = dose of measles vaccine (measles1) had Haemophilus influenzae type b. been around 40%. Coverage with both
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to all surveys, the fully immunized child coverage ranged between 47% and 57% with an exception in the Pakistan Social and Living Standard Measurement Survey 2004–2005 [4], which reflected a high- er achievement. While Punjab came out as the best performing province, Balochistan’s achievement remained at the lowest, except in the Pakistan Integrated Household Survey 1995–1996 [5]. The most recent data in the EPI Coverage Evaluation Survey 2006 [1] and Pakistan Demographic and Health Survey 2006–2007 [6] indicated only half of the target children were fully Figure 1 WHO–UNICEF joint estimate of Pakistan national coverage of 3 doses of diphtheria–pertussis–tetanus (DPT3) and 1 dose of measles (measles 1), 1980–2008 immunized with all antigens. The key reasons for the Pakistan EPI not achieving the targets have been vaccines reached 50%, or above, for the figure had increased to 61%. Similarly, identified in different studies (Table 4). In spite of numerous successes, such first time in 1990. Coverage remained the proportion of districts that attained as the addition of new vaccines and below 80% for a decade and a half. How- 80% or more coverage for measles1 raising coverage to over 80%, EPI is still ever, DPT3 and measles1 coverage increased from 46% in 2008 to 54% in struggling to reach its polio eradication, 2009. reached the 80% benchmark for the first measles and neonatal tetanus elimina- time in 2005 and 2006, respectively, and Fully immunized child coverage tion goals. Inadequate service delivery, remained at 80% until 2007. In 2008, was determined through different sur- which leads to irregular access and poor DPT3 coverage dropped to 73%; how- veys conducted during the 1995–2007 service utilization, was found to be the ever, the official programme database period (Table 3). A “fully immunized key reason for this poor performance. indicates that DPT3 coverage bounced child” means a child who received at The long distance to EPI centres, un- back to 85% in 2009 and measles1 least 1 dose of Bacille Calmette-Guérin affordable cost to reach the centres, coverage remained at 80%. Whereas in (BCG) vaccine, 3 doses of oral polio and unavailability of vaccinators and 2008, only 30% of the districts attained vaccine (OPV), DPT3 and measles1 outreach services were found to be the 80% coverage for DPT3, by 2009 this vaccine. Over this 1 decade, according main reasons for limited access to the
Table 3 Fully immunized children coverage in Pakistan, assessed as percentage of the target in different surveys during 1995–2007 Surveys Year Pakistan Province (%) Punjab Sindh NWFP/FATA Balochistan (%) (%) (%) (%) Pakistan Integrated Household Survey [5] 1995–1996 47 49 45 40 60 1998–1999 55 62 39 57 55 2001–2002 57 63 46 59 38 EPI cluster surveysa 2001 – – 57 68 50 2003 – 66 – – – Pakistan Social & Living Standards Measurement Survey [4] 2004–2005 77 84 73 76 62 EPI Coverage Evaluation Survey [1] 2006 57 76 60 52 32 Pakistan Demographic & Health Survey [6] 2006– 2007 47 53 37 47 35
aUNICEF Pakistan. Coverage Evaluation Survey, Sindh, Balochistan, NWFP & FATA 2001 and UNICEF Pakistan/Director General Health Services Punjab. Coverage Evaluation Survey – Punjab 2003. NWFP/FATA = North West Frontier Province/Federally Administered Tribal Areas.
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service. The EPI Coverage Evaluation reasons (18% and 10.2%, respectively) Survey 2006 [1] indicated that 12.6% of by mothers for failing to immunize their mothers’ reasons for failing to immu- children.
nize their children was “the vaccination 2009 [7] The total routine immunization et al., Faisal centre is too far or the vaccinator was cost in 2008 was more than US$ 104 absent”. Distance to the health centre million. Over half of that total was used was again highlighted in a recent study to procure vaccines (Table 5). Per child undertaken by EPI with the assistance vaccination cost up to DPT3 was com-
of UNICEF in 2009, as 30% of mothers pared at actual coverage achieved in 2009 [16] reported that it was difficult or very dif- the same year against different levels Usman HR et al., ficult to reach the nearest health facility with a gradual increment up to 100% from their place of residence [7]. coverage. According to the WHO– Approximately 6000 EPI fixed cen- UNICEF Joint Reporting Form 2008, 2008 [20]
tres in the country (1 centre for about Pakistan [9], only 73% target children Mangrio et al., 27 000 population) provide immuniza- received all antigens up to DPT3 out of tion services to the people. However, total 5 830 739 surviving infants. If all
these are not uniformly distributed. intended target children had received ++ One in every 10 union councils (UCs) at least 3 doses of DPT vaccine, per 2007 [18] in Punjab province, the most populous child expenditure in that year would Siddiqi et al., province and recognized as having the have been US$ 17.89. But according most developed infrastructure, is with- to the baseline year (2008) data of out any EPI fixed centre. While at least the EPI Comprehensive Multiyear Plan 2 vaccinators are required in each UC 2011–2015, this expenditure was 2006 [1]
according to the national EPI policy, US$ 24.51, which is 37% higher [10]. EPI Coverage the real number is lower (1.3 per UC). This accounted for a total loss of value Evaluation Survey, Except in Sindh (115%), all provinces of routine immunization investment in had a much lower number of vaccina- 2008 equivalent to US$ 28 164 774. tors than required according to the na- The Government of Pakistan and tional policy. Proportions of vaccinators other international partners [e.g. Ca- 2004 [19] available against the standard were 52%, nadian International development immunization, UNICEF, Barriers in UNICEF, 70% and 72%, in Punjab, Khyber Pa- Agency (CIDA), Department for khtunkhwa and Balochistan provinces, International Development [DFID], respectively. Though some paramedic Global Alliance for Vaccine and Immu- cadres such as LHVs are engaged in vac- nization (GAVI), Japan International cination in some areas, other potential Cooperation Agency (JICA), Rotary 2003 [8]
resources, especially trained LHWs, are International, UNICEF, United States Survey Punjub,
restrained from providing vaccination Agency for International Development EvaluationCoverage independently. (USAID), WHO and World Bank]
Lack of recipient awareness about showed their interest and commitment + Baig,
the immunization service and its ben- for the immunization programme by 2003 [15] Mansuri & efits was found to be the second most investing sizeable resources over the common contributing factor for low past years. The Government of Pakistan
coverage. The Coverage Evaluation Sur- procures all necessary vaccines and in- ++ + +
vey – Punjab 2003 [8] highlighted that jection equipment for the programme 1999 [14] parental lack of awareness about the with its own resources except for a share need for vaccination was one of the of the pentavalent vaccine, which is sup- most important reason for low coverage ported by GAVI under a cofinancing in Punjab. The EPI Coverage Evaluation agreement. The total cost of the current Survey 2006 [1] supported this finding; five-year plan (PC-1) for 2009–1010
lack of awareness about the need for im- to 2013–1014 is PKR 26.422 billion studies, 1993–2009 in immunization indicated in different for failure reasons Key achievements in Pakistan
munization and the need for subsequent (approximately US$ 322 million) [2], status and parental education Reason Ahmed et al., Limited access to servicesLimited access + + + + + + Low socioeconomic Low Lack of of awareness the benefits of immunization
Management problem + + + + doses were the most commonly given which is almost 2 times larger than the 4 Table
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Table 5 Routine immunization expenditure of the Expanded Programme on Immunization (EPI) Pakistan in 2008 and comparison of per child vaccination cost and loss of value of annual expenditure at actual coverage versus different coverage levels if achieved Expenditure categories Total Cost per child (US$) expenditure in At actual If 80% If 85% coverage If 90% coverage If 100% 2008 (US$) coverage coverage achieved achieved coverage (73%) achieved achieved Vaccines 57 714 408 13.56 12.37 11.64 11.00 9.90 Injection equipment 3 894 360 0.92 0.83 0.79 0.74 0.67 Operations 42 705 209 10.03 9.16 8.62 8.14 7.32 Total 104 313 977 24.51 22.36 21.05 19.88 17.89 Loss of value of annual expenditure due to low coverage (US$ million) 28.16 20.86 15.65 10.43 Nil
last PC-1 of 2004–2005 to 2008–2009 Discussion in 2006, which required only 1 shot for [11]; 80% of the planned cost of the 4 antigens. current PC-1 will be from the Gov- After long slow progress in the initial two The programme faced another set- ernment’s own exchequer. The rise in decades, DPT3 coverage has started to back in 2008 during the addition of contribution towards EPI by provin- show a slow but steady rise since the another new vaccine, a combination cial governments has also been noted. late 1990s [3]. The addition of hepatitis pentavalent form (Hib–hepatitis B– Sindh provincial government budget B vaccine to the immunization pro- DPT), which replaced the then existing for EPI increased up to 400% and 155% gramme at the beginning of the new tetravalent (DPT–hepatitis B) vaccine. during the last 2 fiscal years, respectively. millennium failed to boost the coverage Unfortunately, due to delay in registra- Being one of the largest international as expected. Parents were less compliant tion and supply of the new product, the immunization partners, the total GAVI to accept 2 injections simultaneously introduction could not be timely initi- commitment to EPI Pakistan during for their infants [1]. Compliance was ated with the result that a total stock out 2001–2012 was worth US$ 313 mil- increased with the introduction of the of vaccine occurred for some months lion (Table 6). tetravalent vaccine (DPT–hepatitis B) and this was the most likely cause of
Table 6 Approved Global Alliance for Vaccine and Immunization (GAVI) support for Pakistan 2003–2012 GAVI support Total value of 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 windows support (US$) New and underused vaccine support (Hep. B vaccine) 25 504 000 New and underused vaccine support (DPT + Hep. B) 47 085 000 New and underused vaccine support (DPT + Hep. B + Hib) 159 266 000 Vaccine introduction grant 1 911 000 Immunization services support 45 769 740 Injection safety support 9 075 500 Health system strengthening 23 525 000 Civil society organization, type A 1 200 000 Total 313 336 240
Hep. B = hepatitis B; DPT = diphtheria–tetanus–pertussis; Hib = Haemophilus influenzae type b.
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the fall in DPT3 coverage to 73% in support and weak monitoring and nongovernment organizations to raise that year. The vaccine stock out was supervision. Daily provision of immu- community awareness about immu- indicated as the key reason for this drop nization services from all Government nization over the past years undoubt- in DPT3 coverage as a similar drop in health facilities would significantly raise edly has yielded some results. However, coverage was not observed for other access. more assertive steps are now required to antigens, such as BCG and measles1, An inadequate number of vaccina- convert this community awareness into in the same year [3]. By early 2009, the tors was one of the main reasons for a proactive demand for immunization. new vaccine introduction was complete limited access to service [7,15]. In an Community-based service provision throughout the country and DPT3 average-sized UC with a population through LHWs can help raise awareness coverage returned to a level above 80% of 25 000, a vaccinator working for 16 about the importance of completing the [12,13]. days every month would require to schedule and improve compliance by However, the fully immunized child make only 18–26 contacts each day. mitigating perceived difficulties in ac- coverage is still far behind the optimum. However, due to the wide geographical cessing the service. In spite of the high coverage claimed in dispersion of this target population the Insufficient management skills, lack the administrative reports, all surveys ex- task is more challenging. Moreover, the of motivation of health workers, inad- cept the Pakistan Social and Living Stand- unequal distribution of vaccinators has equate resources and poor monitoring ard Measurement Survey 2004–2005 left a significant proportion of the UCs and supervision were also reasons for conducted during 1995 to 2007 to as- uncovered. This inadequacy could be setback in immunization performance sess immunization coverage in Pakistan overcome by using EPI-trained LHWs [7,14,19,20]. Frequent turnover of dis- indicated that only around half of the for delivering vaccination services. As trict management due to political and targeted children were fully immunized LHWs are embedded in, and well ac- other reasons resulted in inexperienced [1,4–6,8]. The discrepancy between the cepted by, the community, they have managers with little immunization reported data and independent assess- substantial potential for enhancing background. In the absence of continu- ments raised concerns about the data EPI coverage in their catchment area. ity of service, organizational experience quality of administrative reports among Around 20 000 LHWs are ready to was lost and managers and vaccinators different stakeholders. Discrepancy in provide vaccination after completion were not accountable for their perform- provincial performance was also evi- of a 6-month training course on rou- ance as supervision and monitoring was dent in these surveys. Keen monitoring tine immunization, assisted by WHO not a regular practice. Retaining trained of the data quality at different level on a with GAVI health system strengthen- officers at management level for a pe- regular basis using the standard WHO ing (HSS) support. Redistribution of riod long enough to provide managerial Data Quality Self-assessment tool may vaccinators in UCs along with use of experience, creating career pathways to help improve this area. trained LHWs in immunization service motivate senior field workers and estab- The most common cause for the provision could be proven a very effec- lishing accountability are all required. poor performance of EPI Pakistan, re- tive and immediate measure and would Federal resources for EPI include vealed through a series of studies, was not incur additional cost. donor support, which is first deposited the limited access to the immunization Lack of information about immu- in the Federal Government account service [1,7,8,14–16]. Contrary to the nization was another key reason for not and is then distributed among prov- national policy [17], about one-third of utilizing the available service [1,8,14– inces according to population propor- UCs did not have fixed centres and the 17]. Earlier studies indicated that lack tion [2,9,21]. This does not help to get same proportion of government health of awareness among mothers about critical resources in areas where the facilities did not provide EPI services as the benefits of vaccination was one of programme is most vulnerable. Effec- revealed in different national and subna- the most important reasons for failing tive utilization of available resources tional programme reviews. Moreover, to vaccinate a child; however, a recent is another challenge. Moreover, low many fixed centres provided immu- study revealed evidence of improvement performance is reducing a significant nization service only once or twice a in this area [18]. About 84% of mothers portion of the investment. Taking 2008 week. With limited services through agreed that vaccination helps keep their as a baseline, the earmarked budgetary fixed centres, the only alternative to ac- child healthier, while about two-thirds outlay was invested in the programme, cess the intended target population was considered it a problem when a child although the vaccine utilization was not through outreach vaccination sessions, misses 1 or 2 doses (63.6%) and one- optimized. If all targeted children were which were again irregular and not well third stated that delaying vaccination vaccinated, the programme expenditure implemented because of limited hu- was not harmful to their children [7]. for each child vaccinated with DPT3 man resources, inadequate operational Continuous effort of Government and would be US$ 17.89 [9,10]. However,
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due to failure to reach about 27% of volume, the new and underused vac- Some specific actions can be taken to the targeted children, the actual cost for cine support was the largest and most scale-up EPI services in Pakistan: pro- every vaccinated child was US$ 24.51 cost intensive. However, direct support viding regular EPI service through all [10]. In other words, the programme to the programme was most critical in existing health facilities, establishing an lost benefits of more than US$ 28 mil- building capacity to yield maximum EPI centre in all UCs, redistributing lion of its annual investment in 1 year benefits from these new additions. Such available vaccinators and engaging all only. Beside this direct loss, the cost for direct support needs to be continued skilled manpower, including LHWs, for treatment of diseases incurred by un- by investing HSS support in a way vaccination could raise community ac- vaccinated children also added to public that directly benefits the EPI service cess and compliance to the service and expenditure. Half of this direct value loss delivery capacity and aligns with its thus raise coverage significantly within a could be averted if only 10% more target indicators, which in turn will enable very short time. Along with better access, children could have been vaccinated. In the programme to increase uptake of creating strong public demand for im- terms of resources, the value lost would new vaccines and thus render more munization through effective social mo- have been reduced to US$ 20.86 mil- benefits to children. At the same time, bilization and communication strategy, lion, US$ 15.65 million and US$ 10.43 reducing the global vaccine price to- raising motivation of field workers with million by reaching 80%, 85% and 90% wards an affordable level and a gradual proper logistics support, incentives and coverage rates, respectively. Just by incremental increase in allocation of effective supervision and monitoring, reaching more children, the programme public resources needs to be ensured coupled with competent management, can not only reach its goal but can also for sustaining the new costly additions could definitely enable the programme add effectiveness and value to its own when GAVI support ends. to reach more children which would in investment, which is worth millions of EPI Pakistan enjoys the highest level turn add value to the investment for the dollars. of political and administrative support programme and accentuate further im- With GAVI support, EPI Pakistan from the Federal Government as well as provement in performance. Being one added 2 important vaccines to its from provincial governments. The chal- of the most cost-effective public health childhood immunization schedule, lenge is to reflect these commitments interventions, immunization improve- introduced new technology and ex- from the highest level into real achieve- ment can make significant contribution panded its cold chain capacity and other ment by increasing vaccination cover- in Pakistan’s achievement of MDG 4 for infrastructure significantly. In terms of age and thus reducing child mortality. reduction in child mortality.
References
1. Coverage evaluation survey 2006. Islamabad, Ministry of Health, 9. WHO/UNICEF joint reporting form 2008, Pakistan. Islamabad, Expanded Programme on Immunization, 2007. Ministry of Health, Expanded Programme on Immunization, 2009. 2. Planning commission form – 1 (PC-1) 2009–2010 to 2013–2014. 10. Comprehensive multi-year plan 2011–2015. Islamabad, Min- Islamabad, Ministry of Health, Expanded Programme on Im- istry of Health, Expanded Programme on Immunization, munization, 2009. 2009. 3. WHO/UNICEF estimate of national immunization coverage 11. Planning Commission form 1 (PC-1) 2004-05 to 2008-09.. Is- 1980–2008, Pakistan. Geneva, World Health Organization, lamabad, Pakistan, Ministry of Health, Expanded Programme 2009 (http://www.who.int/immunization_monitoring/ on Immunization, 2004. en/globalsummary/timeseries/tswucoveragebycountry. 12. Immunization coverage data. Islamabad, Ministry of Health, cfm?country=PAK, accessed 24 April 2010). Official Database of the Expanded Programme on Immuniza- tion, 2008. 4. Pakistan social & living standards measurement survey 2004– 2005. Islamabad, Federal Bureau of Statistics, 2005. 13. Immunization coverage data. Islamabad, Ministry of Health, Official Database of the Expanded Programme on Immuniza- 5. Pakistan integrated household survey: round 1: 1995–1969. Is- tion, 2009. lamabad, Federal Bureau of Statistics, 1997. 14. Ahmad N et al. Immunization coverage in 3 districts of North 6. Pakistan demographic and health survey 2006–2007. Islamabad, West Frontier Province (NWFP). Journal of Pakistan Medical As- National Institute of Population Studies, 2008. sociation, 1999, 49(12):301–305. 15. Mansuri FA, Baig LA. Assessment of immunization service in 7. Faisal A et al. Understanding barriers to immunization in Paki- the perspective of both the recipients and the providers: a re- stan. Islamabad, Ministry of Health, Expanded Programme on flection from focus group discussions. Journal of Ayub Medical Immunization, 2009. College Abbottabad, 2003, 15(1):14–18. 8. Coverage evaluation survey – Punjab 2003. Lahore, Director 16. Usman HR et al. Determinants of third dose of diphtheria– General Health Services of Punjab, 2003. tetanus–pertussis (DTP) completion among children who
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received DTP1 at rural immunization centres in Pakistan: a 19. Report on assessment of barriers in immunization services in Paki- cohort study. Tropical Medicine & International Health, 2009, stan. Pakistan, United Nations Children’s Fund, 2004. 15(1):140–147. 20. Mangrio NK, Alam MM, Shaikh BT. Is expanded programme on immunization doing enough? Viewpoint of health workers 17. National EPI policy and strategic guidelines. Islamabad, Ministry and managers in Sindh, Pakistan. Journal of Pakistan Medical of Health, Expanded Programme on Immunization, 2005. Association, 2008, 58(2):64–67. 18. Siddiqi N et al. Assessment of EPI (expanded programme of 21. Country information fact sheet, Pakistan. GAVI Alliance (http:// immunization) vaccine coverage in a peri-urban area. Journal www.gavialliance.org/performance/country_results/index. of Pakistan Medical Association, 2007, 57(8):391–395. php?countID=52, accessed 10 April 2010).
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Review Maternal, neonatal and child health in Pakistan: towards the MDGs by moving from desire to reality A.F. Shadoul,1 F. Akhtar 2 and K.M. Bile1
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ABSTRACT Of the 10 million annual deaths of children below five years of age, four million are neonates. Pakistan’s neonatal mortality rate of 54/1000 live births, which accounts for 57% of the under-five mortality, the contraceptive prevalence rate stagnating at 30%, the meagre number of deliveries assisted by skilled birth attendants (39%) and the low coverage of cost-effective child survival interventions hamper the achievement of Millennium Development Goals (MDGs) 4 and 5. The Government launched the national maternal, neonatal and child health programme in 2007 to promote access to evidence-based cost-effective interventions; strengthen district health system capacities; empower communities; expand the community midwives’ cadre; and promote utilization of essential services. This paper reviews the implementation of the programme and the likelihood of attaining the MDG4 and 5 targets by 2015, and provides strategic directions for scaling-up programme implementation.
Santé de la mère, du nouveau-né et de l’enfant au Pakistan : atteindre les objectifs du Millénaire pour le développement en passant du rêve à la réalité
RÉSUMÉ Parmi les dix millions de décès d’enfants de moins de cinq ans, quatre millions concernent des nouveau-nés. Avec un taux de mortalité néonatale de 54 pour 1000 naissances vivantes (ce qui représente 57 % de la mortalité des moins de cinq ans), un pourcentage de prévalence de la contraception qui stagne à 30 %, un nombre très faible d’accouchements assistés par des professionnelles qualifiées (39 %) et une couverture insuffisante en interventions rentables de survie infantile, il est difficile d’atteindre les objectifs 4 et 5 du Millénaire pour le développement au Pakistan. En 2007, le gouvernement a lancé le programme pour la santé de la mère, du nouveau-né et de l’enfant, afin de favoriser l’accès à des interventions d’un bon rapport coût-efficacité et fondées sur des données factuelles, de renforcer les capacités des systèmes de santé de district, d’autonomiser les communautés, de former davantage de sages-femmes communautaires qualifiées et d’encourager le recours aux services essentiels. Cet article étudie la mise en œuvre du programme et la probabilité de réaliser les objectifs 4 et 5 du Millénaire pour le développement d’ici à 2015. Il propose aussi des orientations stratégiques en vue de l’extension de la mise en œuvre du programme.
1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to A.F. Shadoul: [email protected]). 2Maternal, Neonatal and Child Health Programme, Ministry of Health, Islamabad, Pakistan.
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Introduction high [11]. The contraceptive prevalence also has a flourishing network of private rate of 30%, the unmet need for contra- health care providers with a larger utili- More than 10 million children younger ceptive services of 25% and total fertility zation base. Most people initially seek than five years die globally every year rate of 4.1 would constrain the attain- curative care from the private sector; for [1,2]. About 41% of child deaths oc- ment of Millennium Development Goal instance 49% of diarrhoea cases initially cur in sub-Saharan Africa and 34% in (MDG) 5. The Pakistan demographic seek care from private practitioners, and south Asia [3]. Half of the worldwide and health survey (PDHS) 2006–2007 about 70% of private sector services are deaths in children under five years occur indicates that 39% of births were as- urban based [17]. Several nongovern- in six countries alone, which include sisted by skilled birth attendants , 34% mental organizations possessing varying Pakistan, and 90% occur in 42 countries were facility based and 66% were home capacities focus on provision of family [4]. These deaths are attributed largely based, while 68% occurred in periph- planning (FP) services, mainly in urban to diarrhoea (22%), pneumonia (21%), eral rural settings. Approximately 7.3% areas. Traditional birth attendants and malaria (9%), AIDS (3%), measles (1%) of births were delivered by caesarean relatives are the major providers of de- and neonatal causes (33%), while being section with wide disparities between livery care in rural areas [11]. underweight confers an additional risk urban and rural areas [12]. The health system’s ability to re- of mortality from infectious diseases The IMR of 78/1000 live births is [5]. Almost 4 million newborns suffer spond and provide adequate and com- higher than the averages of low-income prehensive quality services continues to from moderate to severe birth asphyxia, countries and south Asia by 10% and remain limited, as is access to and utili- with at least 800 000 dying and a higher 16%, respectively [13]. High levels of zation of preventive and curative health number developing sequelae every year child and maternal mortality and mor- services. Availability of lady health work- [6]. bidity in Pakistan result from the inter- ers and lady health visitors has increased World Health Organization play of a variety of factors, including the substantially; however, the availability of (WHO) and United Nations Chil- low status of women in society, poor dren’s Fund (UNICEF) have estimated nutrition, poor access to health services, women medical officers and commu- that one in every 38 women dies from particularly emergency obstetric and nity midwives (CMWs) remains very pregnancy-related causes [7]. Recent neonatal care (EmONC), rural–urban low. Similarly, basic and comprehensive estimates showed that 342 900 mater- disparity, and poverty and illiteracy EmONC is provided at various levels of nal deaths occurred worldwide in 2008, [14–16]. One-fifth of newborns are low the health system, though the coverage, down from 526 300 in 1980, showing a birth weight, and 38% of under-five chil- access and utilization levels are unsatis- 1.5% yearly rate of decline [8]. dren are underweight, while anaemia re- factory. One-tenth of global maternal deaths mains highly prevalent among women This paper aims to review the (around 53 000) occur annually in (40%) and under-five children (62%) progress attained on maternal neonatal WHO’s Eastern Mediterranean Re- [15,17]. Over the past four decades, and child health (MNCH) and evalu- gion. Pakistan is responsible for almost there has been a slow reduction in infant ate the likelihood of Pakistan achieving 20% (11 000) of the regional maternal mortality, while neonatal mortality has its MDG 4 and 5 targets by 2015. mortality, while more than 95% of this remained virtually static at 54/1000 burden is shared by seven countries, live births (PDHS 2006–2007) with namely Afghanistan, Iraq, Morocco, most deaths occurring during the Methods Pakistan, Somalia, Sudan and Yemen, early neonatal period or first week of which also suffer from high neonatal life. Moreover, high levels of perinatal More than 25 published documents and mortality rates (NNMRs) [9]. Ten mortality (159/1000 pregnancies) are national surveys relating to MNCH in countries harbour 67% of the burden of associated with events occurring during Pakistan were thoroughly reviewed, the neonatal deaths, with Pakistan being the late gestation, delivery, postpartum and major ones being PDHS 2006–2007; fourth country on the list, accounting the first week of life [11]. MNCH PC-1, National Health Policy for 7% of the global neonatal deaths Health care provision in Pakistan 2001 and the draft policy 2010; Paki- [10]. involves the private and public sectors. stan MDG reports and Pakistan Social The maternal mortality ratio The public sector is comprised of a and Living Standards Measurement (MMR) of 276/100 000 live births, large network exceeding 10 000 health Survey 2005–2006. Documents ad- under-five mortality rate (U5MR), in- facilities, in addition to around 3000 dressing MNCH policies, strategies and fant mortality rate (IMR) and NNMR family welfare centres run by the Min- related estimates, developed by WHO/ of 94/1000, 78/1000 and 54/1000 live istry of Population Welfare with limited UNICEF/United Nations Population births, respectively, are unacceptably functional integration [18,19]. Pakistan Fund (UNFPA) and the World Bank
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were also reviewed to measure the vaccine against diphtheria, pertussis between the functionally comparable progress towards MDGs in Pakistan. and tetanus in 2009 was 83% [20]. Ex- units operated by Ministry of Health/ clusive breastfeeding for 6 months was Department of Health and Ministry only practiced in 37% of infants (not of Population Welfare facilities. The Results shown in table). first-level care facilities (FLCFs) tradi- Table 2 shows that the pace of re- tionally affiliated and managed by the Table 1 illustrates maternal and repro- duction in IMR, NNMR and U5MR health sector, offered MNCH services ductive health (RH) indicators from over the past 16 years was relatively that were not comprehensive in terms 1990 to 2006 and shows improvement slow, with a yearly improvement of 1.5, of RH and FP, while the FLCFs man- in antenatal care, increasing from 15% 0.2 and 2.1 percentage points, respec- aged by the Ministry of Population to 61%, and tetanus toxoid coverage tively. The lowest gain was associated Welfare were less comprehensive in showing that six out of 10 women have providing EmONC and essential new- with neonatal mortality, already ac- been vaccinated (not shown in table). born care services, reflecting the missed counting for a major portion of infant Deliveries attended by skilled birth at- opportunities in the provision of these and under-five deaths (69% and 57%, tendants remained low (39%), 83% essential services. respectively). By then the MMR was on of which took place in health facilities track relative to the annual incremental Table 3 displays the challenges faced (not shown in table). The contracep- and the solutions required for achieving gains accrued since 1990. tive prevalence rate stagnated at 30%, MDGs 4 and 5 by 2015. Cost-effective although knowledge about FP reached Figure 1 reveals that the reduction interventions are identified, many of 90% (not shown in table). The U5MR of U5MR during 1990–2006 was these being under implementation. and IMR were estimated at 94/1000 predominantly achieved through a de- The table also outlines the operational live births and 78/1000 live births, re- crease in postneonatal (1–11 months) prerequisites necessary for universal spectively, while NNMR was 54/1000 and child deaths (1–4 years), while the coverage, access and utilization. These live births. Only 47% of children were NNMR (< 1 month) showed insignifi- include the training and deployment of fully immunized, the percentage having cant changes, accounting for more than 30 000 CMWs within five years; equip- dropped steadily since 1990 according 57% of U5MR on average. ping and manning 1200 referral facili- to PDHS 2006–2007, although the Figure 2 shows the disparity in ties for the provision of round-the-clock reported coverage of three doses of MNCH services, including RH/FP comprehensive EmONC services; and
Table 1 Analysis of status of maternal neonatal and child health (MNCH) indicators and Millennium Development Goals (MDGs) 4 and 5 targets in Pakistan, 1990–2015 Indicator 1990 2000a 2003b 2005 2006 2015 MDG (MDGR) (PSLM) (PDHS) targets Infant mortality rate (per 1000 live births) 102 77 103 70 78 40 Neonatal mortality rate (per 1000 live births) 56 52 – – 54 No target Under-five mortality rate (per 1000 live births) 140 105 75 – 94 52 Immunization 12–23 months (%) 75 53 55 49 47 > 90 Proportion of children under one year immunized against measles (%) NA 55 57 52 82 > 90 Prevalence of underweight/malnourished under- five-year-olds (%) 49 37c 40 37c 37c < 10 Maternal mortality ratio (per 100 000 live births) 550 350 350 350 276 140 Birth assisted by skilled birth attendant (%) 18 40 40 39 39 >90 Proportion of women 15–49 years who had given birth during past 3 years, who had attended at least one antenatal care consultation (%) 15 35 35 52 61 100 Total fertility rate (births/woman) 5.4 4.5 3.9 3.9 4.1 2.1 Contraceptive prevalence rate (%) 12 33 33 33 30 55
aPlanning Commission. bPakistan MDG report (baseline). cNational nutrition survey 2001–2002. MDGR = Pakistan Millennium Development Goals report; PDHS = Pakistan demographic and health survey 2006–2007; PSLM = Pakistan social and living standards measurement survey 2005–2006; NA = not available.
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Table 2 Reduction in mortality in 16 years, attained gains and required improvement to achieve Millennium Development Goals (MDGs) 4 and 5 by 2015 Indicator 1990 2006 Points 2015 expected MDG Yearly reduction baseline performance gained per mortality rates target 2015 pace to achieve (MDGR) (PDHS) yeara with the current (MDGR) MDG targets by pacea 2015a
Maternal mortality ratiob 550 276 3.1 139 140 3.1 Infant mortality ratec 102 78 1.5 66 40 4.7 Neonatal mortality ratec 56 54 0.2 53 18 7.8 Under-five mortality ratec 140 94 2.1 71 52 3.8
aCalculated from baseline (1990) and 2006 mortality rates; bper 100 000 live births; cper 1000 live births. MDGR = Pakistan MDG report; PDHS = Pakistan demographic and health survey 2006–2007.
the scaling-up of integrated manage- development. The relatively lower r integrating and promoting maternal ment of newborn and child illness/ reduction in the IMR and U5MR can and child nutrition; essential newborn care/prenatal care primarily be attributed to the nearly r encompassing social safety nets and coverage, by ensuring their effective stagnant NNMR, which progressed health insurance schemes; delivery in 90% of FLCFs from the cur- only 4% over the same period. rent level of 54%. r fostering behaviour change targeting Pakistan’s national MDG report of both men and women. 2004 charted a road map for enhancing Pakistan can timely achieve MDG5 Discussion maternal and child survival by placing if the reported pace of reduction in greater emphasis on reducing maternal MMR is sustained and accelerated; During the past two decades, Pakistan and neonatal mortality through: however, with a contraceptive preva- has accomplished reasonable gains in r training and deployment of commu- lence rate stagnating at 30%, a low rate of deliveries assisted by a skilled birth reducing maternal, infant and under- nity-based skilled birth attendants; five mortalities: from 1990 to 2006 the attendant (39%) and the lack of acces- MMR, U5MR and IMR have dropped r ensuring access to quality basic and sible and quality EmONC services, this by 50%, 24% and 33%, respectively. comprehensive EmONC referral task is most challenging. The prevention Despite this tangible progress, Pakistan services in the rural and urban mar- of unplanned pregnancies alone could may not advance sufficiently to reach ginalized areas; avert around one-quarter of maternal the set MDG targets by 2015, and r introducing a unified policy on ma- deaths, including those resulting from hence is lagging behind other coun- ternal and child health through holis- unsafe abortions, by addressing the tries of comparable socioeconomic tic interventions; large unmet need for child spacing [11]. Although a range of socioeconomic factors may influence maternal survival, the major focus needs to be directed to 38 health system strengthening, enabling 1-4 years universal delivery of essential MNCH 16 services that are effective and affordable to the underprivileged strata of society. 64 1-11 months The U5MR and IMR will only make a 24 real breakthrough when the stagnating 56 NNMR is addressed effectively. < 1 month The observed fragmentation in the 54 delivery of MNCH services, including RH and FP, by the Ministry of Health 010203040506070 and Ministry of Population Welfare U5MR 1990 baseline U5MR 2006 constitutes a major challenge, as close to 10 000 FLCFs run by the health sector Figure 1 Neonatal, infant and child mortalities: comparison between 1990 baseline need to strengthen their RH and FP and 2006 under-five mortality rate (U5MR) (per 1000 live births) by age group service delivery capacities to avert the
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Figure 2 Discrepancies in maternal neonatal and child health (MNCH) service delivery in comparable service delivery outlets administered by the health and population sectors and the need for comprehensive functional integration. B-EmONC = basic emergency obstetric and neonatal care; BHU = basic health unit; DHQ = district headquarters; DoH = Department of Health; C-EmONC = comprehensive emergency obstetric and neonatal care; ENC = essential newborn care; FP = family planning; FWC/MSU = family welfare centre/mobile service unit; HFs = health facilities; IMNCI = integrated management of newborn and child illness; MCH = maternal and child health centre; MoH = Ministry of Health; RH = reproductive health; RHC = rural health centre; RHSC = reproductive health services centre; SBA = skilled birth attendant; THQ = tehsil headquarters; WFCs =welfare centres.
huge quantum of missed opportunities and where the two ministries and their would have a significant positive impact resulting from the unsatisfactory provi- respective provincial and district coun- on maternal and child survival. sion of these essential services. On the terparts work closely together to up- A major driving force of the high other hand, the 3000 facilities operated grade their facilities. This would involve maternal and neonatal mortality in Pa- by the Ministry of Population Welfare the implementation of a package of es- kistan is the large number of mothers were primarily providing RH and FP sential MNCH services at each service assisted by unskilled birth attendants services but were less equipped to pro- delivery level, based on the concepts during delivery; out of the 66% home vide comprehensive preventive, promo- of functional integration and a mini- deliveries, only 7.6% were assisted by a tive and curative MNCH services at mum essential service package, enabling skilled birth attendant. Current coun- their outlets. These operational gaps mothers and children to avail the envis- trywide estimates of available skilled could be addressed through a coordi- aged MNCH/RH/FP services when birth attendants, including obstetricians, nated joint effort, where the planning, seeking care from any of these facilities nurses/midwives, lady health visitors financing, implementation, supervision [20]. The FLCFs run by the health sec- and CMWs, may not exceed 12 000, and monitoring of MNCH services tor should also provide comprehen- while the required midwifery workforce are regarded as a shared responsibility, sive EmONC referral support and this is estimated at 30 000 for the next 5
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Table 3 Challenges, solutions and operational implications to attain Millennium Development Goals (MDGs) 4 and 5 by 2015 Challenges Solutions Implications MDG 4 Vaccination coverage of Improving EPI coverage (pentavalent) Providing daily routine immunization, including measles, > 90% for 12–23 month through more than 15 000 health facility fixed sites (7000 children currently) Achieving > 90% Outreach services to 20 communities per union councils coverage of measles per month vaccination Orientation and involvement of 100 000 LHWs and private sector Scaling-up and Focusing on unreached and Mass training of > 15 000 FLCF staff on IMNCI, ENC and PNC implementing IMNCI, underserved populations in urban essential newborn care slums and rural areas Training of 100 000 LHWs on management of severe pneumonia, low osmolar ORS and zinc and postnatal care Involving the private sector and NGOs coverage to > 90% of FLCFs Introducing IMNCI and child survival Sustaining availability of essential drugs and equipment in projects in preservice training all FLCFs Accelerating the pace Ensuring ANC, PNC, skilled attendance Training and deploying a critical mass of more than 30 000 of reduction in neonatal at birth, and timely referral CMWs mortality More coordination between EPI, LHWs, Training LHVs/LHWs on ENC and PNC nutrition and MNCH Training all SBAs, paediatricians and WMOs on neonatal resuscitation MDG 5 Increasing number of Producing and deploying critical mass Training and deployment of more than 30 000 CMWs in the deliveries assisted by of CMWs/SBAs next 5 years in rural areas and slums SBAs and encouraging Raising public awareness regarding SBA facility-based deliveries Making SBAs available for assisted normal deliveries in 987 and facility-based deliveries THQ/DHQ, 607 RHCs, 279 RHCA&B and 3138 FWCs Availability of round-the-clock C-EmONC services in 987 THQ/DHQ and 279 RHCA&B Tangible improvement in Functional integration of FP services Providing FP services in more than 10 000 MoH health FP services between MoPW/MoH outlets facilities and 3417 MoPW WFCs Addressing unmet needs Training and involvement of all CMWs/LHVs and LHWs in Raising public awareness FP services Training staff and involving all private sector facilities Cross-cutting issues Increasing access to Providing FP services in all health Equipping more than 10 000 MoH health facilities and quality MNCH/FP outlets 3000 MoPW facilities to provide integrated MNCH/FP services Strengthening health system especially services, including neonatal resuscitation human resources (WMOs) Providing ORS, zinc, amoxicillin, FP commodities and clean Providing supplies, equipment and delivery kits to all LHWs, LHVs and CMWs timely referral Allocating more resources Addressing all forms Bridging deficiencies of both macro- Iron/folate supplementation for all pregnant women, of maternal and child and micronutrients (especially iron and vitamin A supplementation for all under-five children by malnutrition iodine) more than 100 000 LHWs Managing severe malnutrition and establishing therapeutic feeding centres in more than 987 DHQ/THQ hospitals Improving care-seeking Focusing on awareness, health Utilizing innovative ideas, e.g. vouchers schemes, cash behaviours and demand education and behavioural changes transfer and in-kind incentives (food rations, oil) creation Increasing emphasis on the poor, slums Developing prepayment mechanisms through revamped and vulnerable groups public sector or through social, private and community- based health insurance
ANC = antenatal care; C-EmONC = comprehensive emergency obstetrics and neonatal care; CMWs = community midwives; THQ/DHQ = tehsil headquarters/district headquarters; ENC = essential newborn care; EPI = Expanded Programme on Immunization; FP = family planning; FLCFs = first-level care facilities; FWCs = family welfare centres; IMNCI, integrated management of newborn and child illness; LHVs = lady health visitors; LHWs = lady health workers; MNCH = maternal neonatal and child health; MoH = Ministry of Health; MoPW = Ministry of Population Welfare; MNCH = maternal neonatal and child health; NGOs = nongovernmental organizations; ORS = oral rehydration salts; PNC = prenatal care; RHCs = rural health centres; RHCA&B = reproductive health centre type A & B; SBAs = skilled birth attendants; WFCs = welfare centres; WMOs = women medical officers.
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years. This estimate is determined by movement to attain this critical social identified by the Bellagio Study Group envisaging one CMW for every 5000 goal. A series of national meetings with on Child Survival, which were selected catchment area population, with the active interprovincial and district par- by the national MNCH programme CMW performing on average at least ticipation should be organized to build as evidence-based child health inter- 150 deliveries per year, in addition a nationwide consensus for this flag- ventions [23]. Three-quarters of peri- to over 1000 antenatal and postnatal ship health reform intervention. Once natal deaths and at least 30%–40% of visits. The proposed coverage is lower trained, the CMWs could maintain a infant deaths can be averted through than that indicated by the Safe Mother- contractual employment relationship improved maternal health, adequate hood Initiative, where one skilled birth with the national health system, similar nutrition during pregnancy, effective attendant is required for every 2000 to the approach pursued for lady health antenatal services and deliveries assisted population, but still challenging both workers. The latter will substantiate their by a skilled birth attendant with neo- in operational and financing terms, un- close affiliation with the health system in natal resuscitation and postnatal visits derscoring the need for international terms of supervision and monitoring, [24]. In addition, household and com- partnerships to successfully embark on recording and reporting, continuing munity newborn care, correct breast- this major undertaking [21]. education and the provision of basic feeding practices, keeping the baby Pakistan may repeat its globally supplies and equipment. warm, recognizing when to seek care acknowledged success in the training In view of the obvious preference and timely referral to RH centres and and deployment of over 100 000 lady of most rural mothers to give birth at hospital emergency neonatal care units health workers by assuming a similar home, it would be unrealistic to en- can contribute significantly to newborn political commitment and declaring a vision a CMW clinic for conducting survival [23,25]. crash programme for the training and deliveries, as opposed to the culturally Other critical interventions include deployment of CMWs. To accomplish preferred mode of attending births at maintaining full immunization cover- this mission within the set time frame, home. Organizing transport facilities age of children aged 12–23 months CMW training needs to be conducted to promptly access comprehensive at more than 90% and scaling-up and in all tertiary, district headquarter and EmONC services is another major un- implementing integrated management tehsil headquarter hospitals, securing dertaking, requiring active coordination of newborn and child illness, essential the necessary equipment and quali- of households and local community or- newborn care and prenatal care in more fied human resources. The initiative ganizations. As an intermediate strategy than 90% of FLCFs. will concurrently ensure the delivery of and based on recent evidence showing The private sector role in MNCH comprehensive EmONC referral serv- that traditional birth attendants can im- and RH service delivery is crucial to ices and allow assisted home deliveries pact on reducing perinatal and neonatal improving access to these vital serv- through community-based outreach mortality and stillbirths [22], their skill ices, hence the need to engage a large services. The placement of third-year training on clean deliveries, combined number of practicing family physicians. postgraduate students registered at the with improved linkages with the health A platform of advocacy and public edu- College of Physicians and Surgeons system, could be considered for rural cation on MNCH, RH and FP relevant of Pakistan in district and tehsil head- areas where access to CMW services to maternal and child survival has to quarter hospitals for 6–12 months as is remote. However, the ultimate ob- be generated. Demand creation, uti- part of their residence training and em- jective should be the deployment of lization of available services, support ploying 2–3 nurses/midwives in each skilled birth attendants in all rural areas through voucher schemes, conditional participating hospital unit would largely to ensure access to quality services. cash transfers, the possible link with the mitigate the human resource gap and From 1990 to 2006, the decline in Benazir Income Support Programme, render the process feasible. U5MR was mostly from reductions and development of prepayment This gigantic task should entail in postneonatal (1–11 months) and mechanisms through revamped public mobilizing support from the 64 medi- child (1–4 years) mortalities, while the sector or through social, private and cal universities/colleges of Pakistan, NNMR has remained almost stagnant, community-based health insurance College of Physicians and Surgeons indicating the need for enhancing ef- schemes for the poor, are critical ele- of Pakistan, Midwifery Association of forts to attain MDG 4 targets by 2015 ments that would improve access to Pakistan, Pakistan Nursing Council, with an unyielding focus on reducing these vital services. Society of Obstetrics and Gynaecology the NNMR. More than 62% of deaths The Federal Government approved of Pakistan and the 110 currently opera- in under-five children can be averted the national MNCH programme in tional nursing and midwifery schools in by ensuring universal coverage with 2007 at a cost of PKR 20 billion the country, generating a nationwide the 16 WHO-supported interventions (about US$ 333.3 million) to adopt
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and implement proven cost-effective Development (USAID) and World reducing maternal, infant and under- interventions and attain MDG 4 and Bank; GAVI Health System Strengthen- five mortality rates, as from 1990 to 5 targets. The programme has devel- ing Support (GAVI HSS); and bilateral 2006. Despite this tangible progress, oped strong partnerships reflected in initiatives such as the Norway–Pakistan achieving MDGs 4 and 5 may be de- the technical and financial support Partnership Initiative. The government layed unless the prospected range of provided by UN agencies, especially has to reinforce its commitment to maternal and child survival interven- WHO, UNICEF, UNFPA and the MNCH through an incremental budg- tions are scaled-up, with a strong focus “Delivering as One” joint programme; etary outlay and international resource on the production and deployment of health development partners including mobilization, while ensuring the effec- a critical mass of CMWs linked to the AusAID, Department for International tive and nationwide implementation of health system, and by a major improve- Development (DFID), Japan Inter- the programme. ment of RH and FP services, supported national Cooperation Agency (JICA), Over the past two decades, Pakistan by a strong partnership and active com- United States Agency for International has accomplished reasonable gains in munity participation.
References
1. Ahmad OB, Lopez AD, Inoue M. The decline in child mortality: 13. Siddiqi S et al. A critique of maternal and child health policy in a reappraisal. Bulletin of the World Health Organization, 2000, Pakistan. Oxford, Oxford University Press, 2004. 78:1175–1191. 14. Pakistan integrated household survey 2001–2. Islamabad, Federal 2. The world health report 2002: reducing risks, promoting healthy Bureau of Statistics, 2002. life. Geneva, World Health Organization, 2002. 15. Pakistan Medical Research Council, health survey of Pakistan. 3. Child mortality statistics. New York, United Nations Children’s Islamabad, Medical Research Council, Ministry of Health, Fund (http://www.childinfo. org/cmr/revis/db2.htm, ac- 1998. cessed 21 January 2010). 16. Pakistan demographic and health survey 2006–2007. Islamabad, 4. Hill K et al., eds. Trends in child mortality in the developing world, National Institute of Population Studies, 2007. 1960–1996. New York, United Nations Children’s Fund, 1998. 17. Pakistan integrated household survey 2001–2002. Islamabad, 5. Ezzati M et al., eds. Comparative quantification of death risks: glo- Federal Bureau of Statistics, 2002. bal and regional burden of disease attributable to selected major 18. Nishtar S, Amjad S. Synergizing health and population in Paki- factors. Geneva, World Health Organization, 2006. stan. Journal of Pakistan Medical Association, 2009 (Suppl.3):S3– 6. Costello AM. Prenatal health in developing countries. Transac- S20. tions of the Royal Society of Tropical Medicine and Hygiene, 1993, 87:1–2. 19. Bile K. The imperative of functional integration for achievement of MDGs. Journal of Pakistan Medical Association, 2009, 59(9 7. Maternal mortality in 2005: estimates developed by WHO, Suppl. 3):S34–38: UNICEF, UNFPA and the World Bank. Geneva, World Health Organization, 2007. 20. National EPI report. Islamabad, Ministry of Health, 2009. 8. Hogan MC et al. Maternal mortality for 181 countries, 1980– 21. The world health report 2005: make every mother and child count. 2008: a systematic analysis of progress towards millennium Geneva, World Health Organization, 2005. development Goal 5. Lancet, 2010, 375(9726):1609–1623. 22. Sibley LM et al. Traditional birth attendant training for improv- 9. Neonatal mortality in EMR, determinants and strategies for achiev- ing health behaviours and pregnancy outcomes. Cochrane ing MDG 4. Cairo, World Health Organization, Regional Office Database of Systematic Review, 2007, 3 (No.CD005460). for the Eastern Mediterranean, 2007. 23. Jones G et al. How many child deaths can we prevent this year? 10. Lawn JE et al. 4 million neonatal deaths: when, where and why? Lancet, 2003, 362:65–71. Lancet, 2005, 365(9462):891–900. 24. Bhutta ZA. Maternal and child malnutrition in Pakistan: chal- 11. Pakistan demographic and health survey (PDHS) 2006–2007. lenges and opportunities. Oxford, Oxford University Press, Islamabad, National Institute of Population Studies, 2007. 2004. 12. Pakistan country profile: analysis of demographic health surveys. 25. Bhutta ZA. Shaping policy for maternal and newborn health: a Geneva, World Health Organization, Department of Making compendium of studies. Baltimore, MD, Bill and Melinda Gates Pregnancy Safer, 2009. Foundation, 2003:5–12.
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Review Tuberculosis control in Pakistan: reviewing a decade of success and challenges P. Metzger,1 N.A. Baloch,2 G.N. Kazi1 and K.M. Bile1
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ABSTRACT Pakistan has shown drastic expansion of tuberculosis (TB) care during the past 10 years, increasing case notifications from 11 050 in 2000 to 248 115 in 2008. Over 1 million TB patients have been cared for since 2000, with a treatment success rate of 91% in 2007. This paper examines the strategic decisions and infrastructure improvements underlying this achievement, such as the implementation of universal DOTS coverage, expansion of the laboratory network, effective drug management systems, improved communication strategies, and inclusion of private practitioners, laboratories and hospitals in the TB control programme through the public– private mix strategy. The paper also outlines challenges faced in further expanding TB control within the private sector and parastatal health care institutions; strengthening the laboratory network for diagnosis of drug-resistant TB; and ensuring uninterrupted supply of quality anti-TB drugs, all requiring continued and coordinated technical and donor support.
Lutte contre la tuberculose au Pakistan : analyse d’une décennie de succès et de difficultés
RÉSUMÉ Au cours des dix dernières années, les soins concernant la tuberculose se sont considérablement développés au Pakistan. Ainsi, les cas signalés sont passés de 11 050 en 2000 à 248 115 en 2008. Plus d’un million de patients atteints de tuberculose ont été soignés depuis 2000, avec un taux de réussite thérapeutique de 91 % en 2007. Cet article étudie les décisions stratégiques et les améliorations des infrastructures à l’origine de cette réussite, comme la mise en œuvre d’une couverture universelle pour le traitement de brève durée sous surveillance directe, le développement du réseau de laboratoires, des systèmes efficaces pour la gestion des médicaments, l’amélioration des stratégies de communication et l‘intégration de praticiens, de laboratoires et d’hôpitaux privés dans le programme de lutte antituberculeuse, dans le cadre d’une stratégie associant secteurs public et privé. L’article met également l’accent sur les difficultés rencontrées dans l’extension de la lutte antituberculeuse au sein du secteur privé et des établissements de soins semi-publics, le renforcement du réseau de laboratoires pour le diagnostic de la tuberculose pharmacorésistante et la garantie d’une fourniture continue en médicaments antituberculeux de qualité. Ces trois points requièrent un soutien technique et un appui des bailleurs de fonds continus et coordonnés.
1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to P. Metzger: [email protected]). 2National Tuberculosis Control Programme, Islamabad, Pakistan.
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Introduction Government and health development 208 autonomous (parastatal) bodies partners, providing support for strategic provide health services to 389 923 Tuberculosis (TB) is globally the and infrastructure improvements by the employees and their dependants [10], second most common cause of death NTP. not including the Ministry of Defence, from infectious diseases, killing almost The World Health Organization which has its own specific budgetary 2 million people annually. An estimated (WHO) Directly Observed Treatment outlay for health services. 8 million new TB cases occur every Short-course (DOTS) strategy for TB In recent years, a high priority has year, of which 80% are among people was adopted and piloted in Pakistan been given to developing viable partner- in the most economically productive from 1995 onwards, but major progress ships with health care providers in the age groups [1], representing a major in TB control was only achieved after private sector, adopting a systematic economic burden for individuals and the revival of the NTP in 2001 when approach consistent with WHO guide-
countries [2]. Twenty-2 high-burden TB had been declared a national public lines [11]. Additional initiatives such as countries account for about 80% of the health emergency through the “Islama- an improved surveillance and laboratory total TB disease burden worldwide. bad Declaration”. The NTP functions network and improved follow-up and Although sub-Saharan Africa has the under the Ministry of Health and is treatment modalities, funded by global highest incidence rate, Bangladesh, responsible for overall coordination, and national sources, have contributed China, India, Indonesia and Pakistan policy direction and technical guidance to the significant improvement in case together account for half of the global for TB control, while actual implemen- detection and treatment success rates TB burden [3]. tation is the responsibility of the Pro- outlined above. The objective of this The 2008 estimated incidence in vincial TB Programmes (PTPs) and review is to highlight the achievements Pakistan of 181 cases of TB per 100 000 district health authorities. The NTP of Pakistan’s NTP over the past decade population, or 297 000 cases, and of 81 central unit links closely with PTP man- and to outline the outstanding priorities new sputum smear positive (SS+) cases agers and district TB coordinators. and challenges for the future. per 100 000 population, or 133 000 TB services are integrated into the cases, is likely an underestimate of the primary public health care system at true burden of disease [3]. The 2008 district level. However, the private sec- Methods estimates have recently been revised tor is regarded as the first point of entry An extensive literature review was un- through a consultative process with to the health care delivery system for dertaken. Research papers on TB in the country, applying a new methodol- most users, and the majority of private Pakistan, NTP annual reports, donor ogy that takes into account the “missed” providers are not following NTP guide- reports, joint partner review reports, cases and, in the absence of a prevalence lines [5–7]. A 2003 survey conducted technical guidelines and project propos- survey, uncertainties in estimates re- by the NTP and PTPs in Lahore and als were analysed. flected in large confidence intervals. Rawalpindi districts found that less than According to previous estimates, 3% of general practitioners (GPs) were the case detection rate for all TB cases following the national guidelines for Results gradually improved from 19% in 2002 diagnosis and management of TB, while to 84% in 2008; for new SS+ cases the 90% of GPs were relying on chest radi- Epidemiology of TB case detection rate increased from 13% ography for diagnosis [8,9]. TB is highly epidemic in Pakistan. Ac- to 74%. However, with the recent higher At the end of July 2009, 115 463 cording to the latest WHO estimations, estimates of TB incidence, the case de- doctors were registered with the Pa- the incidence, prevalence and mortality tection rate for all TB cases is about 60% kistan Medical and Dental Council of TB in Pakistan are 230 per 100 000, and for new SS+ cases is about 58% [4]. while 42 700 registered facilities were 310 per 100 000 and 39 per 100 000, Nevertheless, the Pakistan National providing formal and informal medi- respectively. This indicates 410 000 Tuberculosis Programme (NTP) has cal services, of which 69% were clinics incident cases of TB and 69 000 TB achieved a remarkable and steady im- and pharmacies, while 550 were private deaths in Pakistan every year. Pakistan is provement in numbers of TB cases de- hospitals. the sixth highest TB burden country in tected, from 11 050 in 2000 to 248 115 Parastatal health services form the world and by far the largest among in 2008, and treatment success rates another point of entry outside the the 22 countries of WHO’s Eastern reached 91% in 2007. This has been public health care system and NTP Mediterranean Region. The NTP achieved through extraordinary com- regulation. Overall, 32 federal minis- and partners are planning to conduct mitment and financial inputs by the tries and the cabinet secretariat with a disease prevalence survey for TB in
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Pakistan in 2010 in order to have more and TB control activities integrated network, availability of quality drugs, precise and comprehensive information into the primary health care system. surveillance, monitoring and evaluation, on the disease burden. DOTS implementation was character- intra- and intersectoral partnerships, The 248 115 cases of all types (Fig- ized by challenges concerning human research and development, public– ure 1) notified in 2008 included 99 670 resources, suboptimal quality of serv- private mix (PPM) and behaviour new SS+ cases (Table 1). The treat- ices at public health outlets and lack change communication. In order to ment success rate of 91% of new SS+ of commitment at peripheral levels. effectively complete these activities, cases notified during 2007 exceeded the District implementation plans were de- the NTP has expanded its central unit WHO target of 85% (Figure 2) due to veloped and executed through a phased with relevant expertise in laboratory, a reduction of the default rate to under approach until the expansion of DOTS monitoring and evaluation, programme 4%, and low death, failure and transfer services to all tiers of the district health planning and management, as well as in out rates (2%, 1% and 2%, respectively). system was achieved. The devolution advocacy, communication and social However, the increase in notifications process necessitated liaison with dis- mobilization and research. trict governments to ensure sufficient has slowed down since 2007, with only Partnership building Punjab province reporting a substantial allocations for the procurement of anti- increase in notified cases and the major- TB treatment (ATT) drugs, as 90% of An interagency coordinating committee ity of districts showing either stagnant or drug procurement was performed by guides donor support and the multiple declining case notifications (Table 1). provinces and districts. partners’ technical assistance for the pro- Universal DOTS coverage (DOTS gramme. The NTP and PTPs organize Programme planning and All Over) was achieved in the public sec- annual joint programme reviews on TB strategic framework tor in 2005. Reaching DOTS All Over care in Pakistan, in collaboration with all Following the “Islamabad Declara- signified the availability of free diag- partners [Department for International tion” the Government of Pakistan nosis and treatment for TB patients in Development (DFID), Family Health called upon its development partners all districts in the public sector health International (FHI), German Leprosy to make concerted efforts to control care delivery network. Subsequently, and Relief Association (GLRA), Ger- the disease. A 5-year plan was devised the government approved the NTP fed- man Development Bank (KfW), Ger- leading to universal DOTS coverage eral workplan (PC-1) for 5 years starting man Technical Cooperation (GTZ), in the public sector towards the end from the financial year 2006/2007 and Japan Anti-Tuberculosis Association/ of 2005. The funding was lined up allocated 1.181 billion Pakistan rupees Research Institute for Tuberculosis efficiently by the federal Ministry of (PKR), equivalent to US$ 14 million, (JATA/RIT), Japanese International Health and provincial Departments of for TB-related activities, including staff Cooperation Agency (JICA), Royal Health, with responsibilities delineated training, expansion of the laboratory Netherlands Association for the Preven- tion of Tuberculosis (KNCV Tubercu- losis Foundation), International Union 248 115 Against Tuberculosis and Lung Disease 250000 230 468 (The Union), United States Agency for International Development (USAID)] 200000 176 678 through WHO support. The recom- 142 211 150000 mendations of these reviews guide the follow-up action at the relevant op- 94 327 100000 erational level. A country coordination 70 485 52 762 mechanism has also been formulated to 50000 34 066 facilitate partners’ coordination, particu- larly for the implementation of grants 0 from the Global Fund to Fight AIDS, 2001 2002 2003 2004 2005 2006 2007 2008 Tuberculosis and Malaria (GFATM). Year Case detection through All forms New SS+ quality-assured bacteriology The laboratory network for TB diag- Figure 1 Number of notified tuberculosis (TB) cases (all forms and new sputum nosis by sputum smear microscopy smear positive [SS+]) (2001–2008) (SSM) and bacteriology is comprised
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Table 1 Number of notified new sputum smear positive (SS+) tuberculosis (TB) out. Currently, external quality assur- cases by province, 2004–2008 ance expansion is ongoing through Province 2004 2005 2006 2007 2008 GFATM R-6 with WHO support, cov- Azad Jammu Kashmir 1 353 1 221 1 086 1 297 1 271 ering 90% of SSM laboratories at the Baluchistan 1 859 2 720 3 343 3 660 3 558 end of December 2009. Federally Administered Tribal Area 918 1 033 971 1 043 1 215
a Standardized treatment with Gilgit–Baltistan 121 124 139 180 145 supervision and patient Khyber Pakhtunkhwab 5 887 8 554 10 063 11 874 12 342 support Punjab 7 527 17 010 30 172 47 926 57 992 According to NTP guidelines, treat- Sindh 12 078 16 055 18 799 21 591 22 038 ment is delegated from the diagnostic Islamabad Capital Territory 1 814 1 503 1 158 1 176 1 109 centre (rural health centres or hospitals) Pakistan 31 557 48 220 65 711 88 747 99 670 to the basic health unit (BHU) level. aFormerly Northern Areas; bformerly North West Frontier Province. Lady health workers are regarded as the Source: National TB Programme. main treatment supporters. A standard- ized 8-month treatment regimen for of the National Reference Laboratory collaborating with the network, raising new cases, with 6 months’ ethambutol in Islamabad (operational since Sep- their participation from less than 50 in and isoniazid (EH) in the continuation tember 2009), 4 Provincial Reference 2001 to over 900 in 2005. phase, is still in place. In all the provinces since 2008, a substantial proportion Laboratories, 3 intermediate (regional) Subsequently, the focus shifted of the management of the BHUs has laboratories, 112 district intermediary from expansion to consolidation and been delegated to the Peoples’ Primary laboratories and over 1100 peripheral improvements in quality, with external Health Initiative, a nongovernmental laboratories including 92 operated by quality assurance of SSM emerging as a entity to which most of the BHUs of not-for-profit civil society organizations. high priority. External quality assurance the country were outsourced, requiring Laboratory services are integrated in pri- by blinded rechecking was initiated in coordination links to be established for mary health care facilities at district level, 2005 (JICA/NTP) and the system was DOTS implementation. The Peoples’ serving an average of 140 000 individu- then piloted in 40 districts (Canadian Primary Health Initiative was launched als per facility. Through PPM activities, International Development Agency/ WHO) before being universally rolled initially by the Ministry of Industries another 52 commercial laboratories are and Special Initiatives and is currently managed by the Cabinet Division. In 120 Punjab, the Punjab Rural Support Pro- gramme runs BHUs in a number of 100 districts. Effective supply and drug 80 management system
% The NTP and provincial governments 60 have ensured the availability and acces- sibility of first-line ATT drugs at all levels 40 of the PHC system through locally produced drugs purchased through 20 the federal and provincial budgets or through interim grants from the Global 0 Drug Facility. 2001 2002 2003 2004 2005 2006 2007 2008
Year Monitoring, evaluation and impact measurement CDR (all types) CDR (new SS +) DOTS coverage TSR (new SS +) The NTP is responsible for monitoring the overall programme performance. Figure 2 Trends in Directly Observed Treatment Short-course (DOTS) expansion WHO programme officers, based at na- in Pakistan (2001–2008) (CDR = case detection rate; SS+ = sputum smear positive; tional, provincial and district levels since TSR = treatment success rate) 2003, play a critical role in monitoring
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TB control activities and providing organization clinics, GPs and private Rawalpindi are externally quality assured technical capacity building support to hospitals. for culture and drug susceptibility test- provincial and district health authorities A 2008 WHO-assisted mission ing (DST). The NTP is collaborating and professionals through district TB found that in the preceding year (2007), with the microbiology laboratory of Aga coordinators, who have the primary PPM initiatives contributed to nearly Khan University Hospital, Karachi for responsibility of implementing and 20% of total notifications (all cases and capacity building of the public sector. supervising TB control activities at the new SS+). Table 2 presents data from 3 TB/HIV diagnostic centres. Quarterly surveil- provinces with 90% of all notified cases lance meetings at district, provincial and in 2007. In the 3 provinces combined, Sixteen sentinel sites have been strength- national level ensure data verification 51% of all cases detected by non-NTP ened through collaborative efforts of the and validation between implementing providers were new SS+ cases, while NTP, the National AIDS Control Pro- partners. Findings and lessons learnt among those detected in the public sec- gramme and nongovernment partners from external joint partner reviews con- tor, only 39% were new SS+ cases. for screening, care and support of TB/ ducted annually by WHO, local and Another PPM strategy is “hospital HIV coinfected patients. international partners assist the NTP DOTS linkage” which is currently im- and PTPs in revising their implementa- Advocacy, communication plemented in 27 out of 67 public and pri- and social mobilization tion strategies. vate tertiary care hospitals by enhancing Extensive advocacy, communication laboratory services for SSM, introducing Public–private mix (PPM) and social mobilization activities in 57 standardized treatment and develop- districts have laid the foundation for ini- To introduce TB control according ing referral systems between the hos- tiating MDR-TB and TB/HIV coinfec- to NTP guidelines into the lagging pitals and peripheral treatment centres private sector, the NTP engaged 4 through DOTS centres (established tion interventions. Engagement of mass not-for-profit organizations for the under GFATM R-6). Data from dis- media took place to improve awareness implementation of PPM DOTS pilot tricts where DOTS linkages have been and reduce stigma. A national advocacy, projects in 30 selected districts (co- introduced showed an increase of up to communication and social mobiliza- funded by GFATM R-2 and R-3). Public 50% in case notifications during 2009. tion strategic framework, monitoring sector funds were allocated in 2003 for and evaluation framework, and trainer/ implementation of 1 district-led PPM Drug-resistant TB trainee manuals for quality assurance model, currently being implemented After achieving countrywide DOTS on interpersonal communication have in 6 districts. In addition, the Greenstar coverage in 2005, the NTP Pakistan been developed and disseminated. Social Marketing Pakistan (Guarantee) expanded the scope of its activities to Operational research Limited model was introduced in 5 met- include multidrug-resistant tuberculosis ropolitan cities through GFATM R-3, (MDR-TB) interventions, as recom- Operational research was a core com- involving private laboratories for SSM, mended in the new Stop TB Strategy. ponent of the national strategic and where more than 1000 GPs have been operational plans. The NTP has consti- engaged in TB DOTS. Further expan- Network for culture and tuted 1 national and 4 provincial research sion of PPM was based on a situational drug susceptibility testing of groups and developed partnerships with analysis and design of a range of PPM Mycobacterium tuberculosis the Pakistan Medical Research Council models suitable for private care provid- A few private and parastatal laborato- and linkages with international aca- ers, encompassing nongovernmental ries located in Karachi, Islamabad and demic and research institutions. WHO
Table 2 Contribution of public–private mix (PPM) to tuberculosis (TB) case notifications in 2007 Province or city Number of TB cases notified in 2007 Number of new sputum smear positive (SS+) cases notified in 2007 Total PPM % notified from Total PPM % notified from PPM PPM Khyber Pakhtunkwa 30 699 5 485 18 11 886 1 961 16 Sindh (excluding Karachi) 30 698 1 943 6 14 718 147 1 Karachi 14 887 7 531 51 6 882 3 625 53 Punjab 131 742 24 676 19 47 926 14 396 30 Total 208 026 39 635 19 81 412 20 129 25
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supported the programme through its for paediatric drugs) and GFATM losis Coalition Assistance Program initiatives of EMRO/Tropical Diseases R-8. However, long-term strategies supports the NTP in the revision of Research (TDR) Small Grants Scheme) for financing an uninterrupted supply drug management and forecasting and priority public health areas, involving of quality-assured first- and second- guidelines. As banning across-the- more than 20 research studies relating to line ATT drugs, including paediatric counter sales of ATT drugs is cur- DOTS expansion, defaulter tracing, drug formulations, are needed. rently not a viable strategy in Pakistan, management, external quality assurance, r Expansion of the TB surveillance sys- the NTP has opted to develop a “seal treatment support and drug side-effects. tem and preparation for the TB preva- of quality” for locally produced ATT Two new methodologies for indirect lence survey are ongoing. An electronic drugs that meets international quality estimation of disease burden have been nominal reporting system is being standards, while WHO is engaged in piloted. The research findings were trans- introduced through WHO technical providing technical assistance to local lated into policy through the necessary assistance. A nationwide prevalence drug manufacturers aiming to attain a changes in protocols and guidelines. survey is planned for 2010/2011 with prequalification status. technical assistance of the USAID- r Rapid improvements in the labora- funded Tuberculosis Coalition As- tory network for culture and DST Discussion sistance Program partners: WHO, for the diagnosis of drug-resistant TB KNCV, The Union and JATA. are prerequisites for its management. The significant achievements of the r The engagement of private care Nine laboratories (1 national, 4 pro- NTP in expanding DOTS to the public providers and parastatal health care vincial, 2 intermediate and 2 in terti- sector of every district, initiating PPM facilities, though limited, in establish- ary care hospitals) are currently being strategy [12,13], and steadily increasing ing DOTS linkages with 27 of 67 upgraded. Four TB culture district- case notification and treatment success teaching hospitals has substantially level laboratories (1 in each prov- rates [14,15] hinge on sustained Gov- contributed to the increase in case ince) will be made functional through ernment commitment and funding for notifications. GFATM R-6 support while through TB control, and technical and financial GFATM R-9 support the laboratory support from national and international r In view of the health-seeking behav- network for culture and DST will be partners, including WHO, USAID, iour in the urban and rural popula- further developed and rapid testing DFID, GTZ/KfW, JICA, World Bank tions, scaling-up of DOTS in the for MDR-TB introduced in 15 terti- and GFATM. private sector in the remaining 60 ary care teaching hospitals. A number of research studies con- districts has been recognized as a pre- requisite for increasing case detection, r Scaling-up of MDR-TB care is an ducted in Pakistan have significantly urgent task for Pakistan. WHO es- added value to the knowledge and op- provision of standardized care, and in- timates an annual incidence of over erational capacity of the programme, clusion of other health care providers 13 000 MDR, SS+ cases in Pakistan including the TB health-seeking behav- and the remaining parastatal organi- based on estimates of 3.5% MDR in iour and practices of the general popu- zations. Funding for these activities new cases and 35% in re-treatment lation, and have facilitated the design has been secured through GFATM cases [24]. A study conducted by the of effective communication strategies R-9 support. Aga Khan University [25] reports [16–21]. The predictors of default and r Rolling out of the new WHO-recom- 1.8% primary resistance in a specified major barriers to treatment adherence mended treatment regimen (2009) annual cohort of notified SS+ new were identified as poor patient–pro- will need strengthening of case man- and re-treatment cases. vider interaction and patients’ lack of agement, delegating supervision of A representative survey in 2010 will knowledge regarding side-effects and treatment from the diagnostic centres determine baseline drug resistance. This stigma [22,23]. to BHUs. Partnering with the Sindh is a follow-up on a MDR-TB preassess- Planned interventions to sustain Peoples’ Primary Health Initiative ment conducted by a WHO mission in and further scale-up the progress are and the Punjab Rural Support Pro- 2008. Based on the recommendations listed below along with challenges for gramme should enable the effective of this mission, public and private terti- the future: use of BHUs for TB suspect detection ary hospitals have been identified for pi- r An uninterrupted supply and fund- and treatment support. loting MDR-TB management through ing for first-line ATT drugs and r Effecting tangible improvement in GFATM R-6 support. The NTP and commodities has been assured until the drug management system is the partners have successfully applied to 2012 through funding from the Gov- prime objective of GFATM R-8, with GFATM R-9 to expand MDR-TB ernment, Japanese Counter Value Greenstar developing a drug manage- diagnosis and care to 80% of the esti- Funds, Global Drug Facility (grant ment logistics system. The Tubercu- mated SS+ cases by 2015. In 2009, the
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Green Light Committee approved ATT monitoring and evaluation of all pro- NTP nevertheless needs to pursue second-line drugs for 1500 cases. gramme elements; and adaptation of its activities with greater vigour and Identified challenges for further scal- ACSM strategies and correlation of op- expanded framework in order to ing-up of TB care include: integration erational research studies with ACSM achieve regional and global targets, of TB control strategies in preservice activities as relevant for all the 6 pillars including Millennium Development curricula; upgrading TB control in the of the Stop TB Strategy. Goals. The full adoption of the WHO new province of Gilgit–Baltistan and With TB DOTS in place at all Stop TB Strategy in the national plan intensifying TB control in underserved public facilities in the country, the of 2010–2015 will bridge the current areas; innovative approaches for en- focus needs to shift to increased case gaps. Moreover, the adaptation of hancing case detection in marginalized detection by involving the majority the current NTP managerial set-up groups with limited access to health of private providers and introducing to future challenges, with continu- services, such as workers in the informal standards of TB care in social secu- ous and coordinated technical and sector and periurban slum populations; rity institutions and the substantial donor support, will be instrumental introduction of an electronic nominal parastatal sector. Although sustain- for ensuring sustainability and further recording and reporting system for ing progress for over a decade, the success.
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Review Malaria control in Pakistan: new tools at hand but challenging epidemiological realities Q. Kakar,1 M. A. Khan2 and K. M. Bile1
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ABSTRACT Malaria is endemic in Pakistan and constitutes a national health priority However the parasite and vectors are showing resistance to common antimalarial drugs and insecticides. The provinces of Balochistan, Sindh and Khyber Pakhtunkhwa and the Federally Administered Tribal Areas have the highest malaria burden. Districts and agencies bordering Afghanistan and Islamic Republic of Iran account for 37% of the malaria burden with an annual parasite incidence (API) exceeding 4.5/1000 population per year. Moreover, there has been a growing risk of Plasmodium falciparum malaria incidence in areas where previously P. vivax was predominant. New and effective control tools have been introduced such as rapid diagnostic tests, artemisinin-based combination therapy and long-lasting insecticide-treated nets. This paper reports the progress achieved in the implementation of a malaria control strategy in Pakistan, shares major outstanding challenges and unearths the potential of performance-based implementation for advancing resource mobilization and collaborative partnerships.
Lutte contre le paludisme au Pakistan : disponibilité de nouveaux outils et difficultés des réalités épidémiologiques
RÉSUMÉ Le paludisme, endémique au Pakistan, constitue une priorité sanitaire nationale. Cependant, les vecteurs et le parasite se montrent résistants aux insecticides et aux médicaments antipaludiques habituels. Les provinces du Baloutchistan, du Sindh et du Khyber Pakhtunkhwa, ainsi que les zones tribales sous administration fédérale sont les plus touchées par le paludisme. Les districts et agences à la frontière de l’Afghanistan et de la République islamique d’Iran participent à hauteur de 37 % à la charge de morbidité du paludisme, avec une incidence parasitaire annuelle supérieure à 4,5/1000 chaque année. En outre, un risque croissant d’incidence du paludisme à Plasmodium falciparum dans des régions où auparavant prédominait le paludisme à P. vivax est apparu. De nouveaux outils de lutte efficaces ont été introduits, comme les tests diagnostiques rapides, les associations à base d’artémisinine et les moustiquaires imprégnées d’insecticide à longue durée d’action. Cet article fait état des progrès réalisés en matière de mise en œuvre de la stratégie de lutte antipaludique au Pakistan, expose les principaux défis et révèle le potentiel de mise en œuvre fondé sur les résultats afin de promouvoir la mobilisation des ressources et les partenariats de collaboration.
1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to Q. Kakar: [email protected]). 2National Malaria Control Programme, Islamabad, Pakistan.
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Introduction of comprehensive epidemiological and of a malariometric survey conducted in entomological information makes it 19 highly endemic districts during 2009 Malaria is a mosquito-borne parasitic difficult to generate reliable updates on using antibody-based rapid diagnostic disease which takes almost one million the coverage and effectiveness of disease tests. The districts’ and agencies’ results lives per year and afflicts as many as half control interventions at the operational were aggregated by province and region a billion people living in 109 countries level [8]. This paper aims to report the and, show the highest parasite sero- in Africa, Asia and Latin America [1]. progress achieved in the implementa- prevalence in the Federally Adminis- Malaria is predominantly a disease of tion of the Roll Back Malaria strategy in tered Tribal Areas (FATA), followed by poverty that is more prevalent in the rural Pakistan, share major outstanding chal- Balochistan and Khyber Pakhtunkhwa areas, where the majority of the popula- lenges and unearth the programmatic (KPK), this being consistent with the tion often lives, resulting in substantial potential for implementation, resource programme-reported high annual ma- economic loss [2]. Pakistan is among mobilization and the building of col- laria incidence from these areas. the countries with a perceived growing laborative partnerships. Table 1 describes the overall an- risk of infection, in view of the extensive nual parasite incidence (cases/1000 agricultural practices, vast irrigation net- population), showing no evident reduc- work and monsoon rains in addition Methodology tion between 2004 and 2009, with a to sizeable population movements and high annual parasite incidence being a complex political situation in certain An in-depth analysis of available sur- maintained both in Balochistan and the border areas that contribute to the coun- veillance data within Pakistan’s Ma- Federally Administered Tribal Areas try’s malariogenic potential [3]. laria Control Programme and Health as compared to other provinces, while In Pakistan, malaria is the second Management Information System was Punjab maintained a very low annual most frequent clinically suspected disease undertaken along with a Medline search parasite incidence of < 1 case per 10 000 entity after acute respiratory infection for national and international reports population during that period. Similarly, on the malaria situation in Pakistan. with 4.5 million probable cases reported for the same period, the proportion of National demographic and health sur- from district health system public sector falciparum malaria, out of the total con- veys and field study reports were also outpatient facilities in 2008. However, firmed cases, was highest in Sindh and reviewed, and major findings analysed. the estimated total number of malaria Balochistan compared to other prov- cases of 1.5 million cases per year is sig- inces and regions of the country. nificantly smaller [4], which suggests a Results The reported incidence of 2009 was risk of erroneous treatment to about 3 higher in all provinces when compared million non-malaria cases. Moreover, The prevalence and incidence of ma- to 2008 except in Sindh. In 2009 the the confirmed cases of malaria during laria in Pakistan varies from province to highest slide positivity rate was recorded the same period were only 104 454, of province and between districts within in the Federally Administered Tribal which 70% were due to Plasmodium provinces. Figure 1 illustrates the results Areas, followed by Balochistan. The vivax and 30% to P. falciparum, these being the only two prevalent malaria parasite species in Pakistan [5]. The Directorate of Malaria Control in the Ministry of Health endorsed the World Health Organization’s (WHO) Roll Back Malaria strategy in 2001 with the objective of halving the disease bur- den by 2010 and bringing the annual parasite incidence to 0.5/1000 [6]. The programme is being implemented in endemic areas and will continue to the end of 2010 though the target seems difficult to achieve within this time. The proposed target to be attained has con- siderable bearing on maternal and child Figure 1 Prevalence of malaria parasite in 19 highly endemic districts health and related Millennium Develop- (malariometric survey 2009) FATA = Federally Administered Tribal Areas; KPK = Khyber Pakhtunkhwa ment Goals [7,8]. However, the paucity
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Table 1 Annual parasite incidence (API) and falciparum proportion during 2004–09 by area Area API — cases/1000 population/year (falciparum proportion) 2004 2005 2006 2007 2008 2009 API (%) API (%) API (%) API (%) API (%) API (%) FATA 4.0 (17.0) 4.5 (14.9) 5.4 (17.4) 6.2 (16.0) 4.6 (15.6) 4.0 (31.0) Balochistan 4.2 (34.0) 7.4 (44.3) 6.2 (33.9) 6.3 (43.0) 4.6 (27.0) 5.8 (32.0) KPK 1.1 (9.0) 0.9 (10.5) 0.8 (9.2) 0.8 (10.0) 0.6 (7.0) 1.1 (10.0) Sindh 1.0 (33.0) 0.8 (36.7) 0.90 (44.6) 0.71 (33.0) 0.6 (32.3) 0.6 (31.0) Punjab 0.05 (11.0) 0.03 (2.6) 0.02 (5.4) 0.02 (2.0) 0.04 (1.8) 0.04 (5.0) Azad Jammu Kashmir 0.16 (19.0) 0.16 (23.4) 0.07 (21.5) 0.21 (19.0) 0.05 (29.9) 0.07 (13.0) Total 1.7 (20.9) 2.3 (22.0) 2.2 (21.8) 2.4 (21.8) 1.8 (21.0) 1.9 (19.0)
FATA = Federally Administered Tribal Areas; KPK = Khyber Pakhtunkhwa.
proportion of confirmed cases reported before the distribution of long-lasting to malaria. In this regard the following from Punjab (low endemic area) was insecticide-treated nets in 2008 attained key strategic elements were pursued: more in patients aged 15 years or more through Global Fund support for 19 r promoting appropriate strategies and (82%) and lowest among 5–10 year-olds highly endemic districts. processes with enhanced monitoring (3%), with higher rates among males The results of antimalarial drug ef- and supervision (61%) compared to females (39%). ficacy monitoring surveys conducted r extending and improving early diag- Table 2 shows the categorization of in the country are presented in Table nosis and rapid treatment services in districts based annual parasite incidence 4. The cure rate with chloroquine treat- all health facilities and applying these during 2004–08, where all the highly ment in 2004 was 58% in Punjab and when appropriate in the community endemic districts/agencies belonged to only 17 % in Sindh and Balochistan. Balochistan and Sindh provinces and While the efficacy of sulfadoxine/py- r promoting insecticide treated ma- to the Federally Administered Tribal rimethamine and amodiaquine in Ba- terials, the targeted use of residual Areas, while all the districts of Punjab lochistan resulted in a cure rate of 44 % spraying and health education and were clustered in the lowest endemicity and 47% respectively, the cure rate with introducing biological and environ- mental management approaches for rate category. artesunate + sulfadoxine/pyrimeth- integrated vector control Studies conducted on the vector amine in the Federally Administered fauna of Pakistan showed that 24 dif- Tribal Areas in 2004 was 97%. Likewise r improving preparedness, detection ferent anopheles species have been the tested efficacy of artesunate + sulf- and response to epidemics reported from Pakistan including adoxine/pyrimethamine in Sindh, Balo- r developing viable in-country pub- Anopheles culicifacies and An. stephensi, the chistan and the Federally Administered lic–private partnerships as well as vector species with known resistance to Tribal Areas gave a cure rate of 100% international partnerships to boost organochlorides (DDT, dieldrin), car- in 2008. Similarly in 2009, the cure rate programme implementation bamates (propoxur) and organophos- with artemether and lumefantrine in the r commissioning health system re- phates (malathion, fenitrothion) [9]. Federally Administered Tribal Areas, search interventions to enhance free Table 3 describes the findings of Balochistan, Khyber Pakhtunkhwa and access to quality care and promote the demographic and health survey of Sindh was also 100%, although such active community participation. Pakistan 2006–07 regarding access to studies need to be supported by inde- During its implementation process malaria preventive and curative services, pendent quality control measures. the programme made tangible efforts to which include possession and use of The national Roll Back Malaria stra- enhance partnerships at national, pro- mosquito nets and access to treatment tegic plan was first designed in 2001 and vincial and district levels with national services among children with fever, reviewed in 2007 to comprehensively nongovernmental organizations as well depicting the low coverage of both account for the evolving malaria epi- as with international partners, facilitated long-lasting insecticide-treated nets and demiological situation, harness greater by the receipt of grants from the Glo- treatment services and highlighting the partnership for the programme and bal Fund to fight AIDS, Tuberculosis need for prompt and effective action. scale up operations to attain the Millen- and Malaria (Global Fund; rounds 2, This survey was however conducted nium Development Goal 6 as relevant 3 and 7) and through sustained WHO
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technical support. These partners included Health Net International, National Rural Support Programme, Association for Social Development, Mercy Corps, Merlin, WHO Basic Development Needs programme for community-centred interventions and None Muzaffarabad Muzaffarabad Association for Community Develop- ment, all being engaged in Global Fund malaria grant projects as subrecipients. The Malaria Control Programme in Pakistan has also become an integral part of the United Nations (UN) “De- livering as One” initiative to generate None Kotli, Mirpur, Poonch, North Waziristan Bajaur, Orakzai, Orakzai, Bajaur, Mohmand, South and synergy of action and prevent unnec- essary duplication between different stakeholders. The Global Fund has been a major source for bridging the programmatic and financial gaps experi- enced by the programme, while WHO support has guided the implementation Swat, Dera Ismail Khan, Swat, Dera None Khyber Kurram, None Shangla Kohat, Nowshera, Kohat, Dir Upper and Lower, Kohistan, Peshawar, Buner, Lakki Marawat, Lakki Marawat, Buner, Hangu, Bannu, Tank, Karak, Mansehra, Abbotabad, Mansehra, Mardan, Malakand Mardan, Charsadda, Batagram, Charsadda, Batagram, Swabi, Haripur, Chitral, of the programme according to WHO standards (with required adaptation) through its headquarters, regional and country level professionals. Through its rounds 2, 3 and 7 of grants, the Global
Musakhel, Fund provided US$ 18 million to sup- port malaria control interventions in Nushki, Gwadar, Kech, Kech, Nushki, Gwadar, Naseerabad, Loralai, Loralai, Naseerabad, Pishin, Dera Bugti, Dera Sherani, Harnahi Barkhan, Awaran, Barkhan, Awaran, Lasbela, Kalat Mastung, Chagai, Jafarabad, Sibi, Kohlu Jafarabad, Qilla Saifullah, Bolan, Qilla Abdullah, Quetta, Qilla Abdullah, Quetta, Washuk, Khuzdar, Khuzdar, Washuk, Zhob, Panjgur, Kharan, Kharan, Panjgur, Zhob, Jhal Magsi, Ziarat, targeted highly endemic districts.
Discussion
Malaria poses a major public health challenge in Pakistan and the country Shahdadkot, Matiari,Shahdadkot, Nawabshah Sanghar Khairpur, Badin, Khairpur, Karachi Dadu, Sukkur, Tando Tando Dadu, Sukkur, Larkana, Hyderabad, Mirpur Khas, Umerkot, Mirpur Khas, Umerkot, Muhammad Khan, Jamshoro, Jacobabad, Jamshoro, Allahyar has been placed in the group of high burden countries of the WHO Eastern Mediterranean Region along with So- malia, Sudan, Yemen, Afghanistan and Djibouti, which collectively report more
Punjab Sindh Balochistan KPK FATAthan 95% of the AJK regional burden [10]. Malaria endemicity in Pakistan has been None Tendo Kashmore, None Mithi, Feroze, Naushahro All districts of Punjab Gotki, Shikarpur, Thatta, categorized on the basis of the average annual parasite incidence of the past five years. The majority of the districts . falling in the highly endemic category were from Balochistan, the Federally
a Administered Tribal Areas and Sindh, with an annual parasite incidence as
Categorization for five years) of incidence, 2004–08 (average malaria annual parasite districts based on reported high as 5.5/1000 and 3.9/1000 in Balo- chistan and the Federally Administered Endemicity: reported API reported Highly endemic: average Highly endemic: average Low endemicity: average endemicity: average Low Moderately endemic: Moderately cases/1000 population/year. population/year. cases/1000 API > 5 five-year API < 5 five-year average API < 1 five-year a KPK = Khyber Pakhtunkhwa. KPK = Khyber Pakhtunkhwa. Areas. Tribal Administered = Federally FATA API = annual parasite incidence. incidence. API = annual parasite Jamu and Kashmir AJK = Azad Table 2 Table Tribal Areas respectively, illustrating the
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Table 3 Coverage of malaria preventive and curative services as reflected by the findings of the demographic and health survey of Pakistan 2006–07 Variable/indicator Urban Rural Total n (%) n (%) n (%)
Household possession of nets (treated or untreated) 3159 (3.5) 6096 (7.8) 9255 (6.3) Households with at least one insecticide-treated net (ITN) 3159 (0.7) 6096 (0.8) 9255 (0.8) Children under 5 years who slept under a mosquito net the night before the interview 2636 (1.2) 6142 (1.8) 8778 (1.6) Children under 5 years who slept under an ITN the night before the interview 2636 (0.2) 6142 (0.2) 8778 (0.2) Pregnant women who slept under a mosquito net the night before the interview 364 (0.7) 829 (2.0) 1193 (1.6) Pregnant women who slept under an ITN the night before the interview 364 (0.0) 829 (0.0) 1193 (0.0)
Children under 5 years with fever in the two weeks preceding the survey who took antimalarial drugs 791 (2.5) 1777 (3.7) 2569 (3.3) Children under 5 years with fever in the two weeks preceding the survey who took antimalarial drugs the same day/next day 791 (2.0) 1777 (2.8) 2569 (2.6)
need for intensified and targeted control Federally Administered Tribal Areas comprehensive evidence on the morbid- efforts in these regions. (116 per 1000 population) followed by ity and mortality burden of the disease. All the districts of Punjab were ranked Balochistan (47.9 per 1000 population) P. falciparum and P. vivax are the only in the low endemic category with re- [13], a rate many times higher than the prevalent species of malaria parasite ported annual parasite incidence of < 0.1 reported yearly parasite incidence, cor- reported in the country; with P. vivax per 1000 population per year. The low roborating the high transmission poten- being the predominant species account- endemicity in Punjab was reported to tial in these districts and the rising trend ing for > 70% of the malaria burden have resulted from reduced densities of of malaria endemicity. in the country. The highest burden of Pakistan’s primary vector An. culicifacies The demographic information of vivax malaria was reported from Khyber due to large-scale ecological changes microscopically confirmed malaria Pakhtunkhwa and the Federally Admin- in this province related to waterlogging cases is limited and scattered; however a istered Tribal Areas, illustrating the need and salinization, which favour the breed- situation analysis conducted in the low for greater programmatic and health ing of the salt-tolerant and less efficient endemic province of Punjab in 2008 re- system strengthening in these regions vector A. Stephensi [11]. Moreover, the vealed that males of age > 14 were more [4]. Due to poor quality microscopy relatively better health infrastructure and affected by malaria infections compared practices, mixed infections are rarely di- socioeconomic status in the province to females of the same age group indi- agnosed and reported, as confirmed by a may have contributed to this difference. cating the low immunity linked with recent study carried out in the bordering Accordingly there has been a visible shift low endemicity and the relatively higher regions of Afghanistan, Islamic Republic in the spatial pattern of malaria endemic- exposure potential of males to vector of Iran and Pakistan [15]. ity from the eastern agriculture plains to bites during their late-evening agricul- Studies conducted on the genetic the north-western mountainous regions, ture activities [14]. characterization of Plasmodium vivax particularly those bordering the Islamic Information on severe and compli- populations have shown multiplicity Republic of Iran and Afghanistan, linked cated malaria cases and mortality is not of infections, genetic diversity and al- to a significant influx of refugees since routinely collected by the programme lelic distribution of both the species 1980s [12]. Results of a malaria anti- or district health information system. [15]. Marked polymorphism of P. vivax body seroprevalence survey conducted However, the evolving initiative, in populations indicated by the presence in 2009 during the non-transmission which the health information system of extensive allelic variation has been season in 19 highly endemic districts, will cover hospital inpatients, will fill linked to cross-border movement of showed a high prevalence rate in the this information gap and generate more populations living in border regions of
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Table 4 Antimalarial drug efficacy monitoring surveys conducted at selected sentinel sites 2004–09 District Province/area Survey year Drugs tested Cure rate (%) Khurram Federally Administered 2004 Sulfadoxine/pyrimethamine, artesunate 97 Tribal Areas 2008 Artesunate+sulfadoxine/pyrimethamine 100 2009 Artemether+lumefantrine 100 Muzaffargar Punjab 2004 Chloroquine 58 Mirpur Khas Sindh 2004 Chloroquine 17 Thatta Sindh 2008 Artesunate+sulfadoxine/pyrimethamine 100 2009 Artemether+lumefantrine 100 Zhob Balochistan 2008 Artesunate+sulfadoxine/pyrimethamine 100 2009 Artemether+lumefantrine 100 Kech (Turbat) Balochistan 2004 Amodiaquine 47 Sulfadoxine/pyrimethamine 44 Chloroquine 17 2008 Artesunate+sulfadoxine/pyrimethamine 100 2009 Artemether+lumefantrine 100
the country. The molecular characteriza- in the country. The effectiveness of indoor malaria in all parts of the country, while tion of P. falciparum field isolates in Paki- residual spraying depends on the efficacy resistance to sulfadoxine/pyrimeth- stan revealed that a majority of patients of the insecticides used and the timing amine has been on the rise. Moreover, having monoclonal infections had a and quality of the campaign. In Pakistan artemisinin-based combination therapy genetic diversity and allelic distribution resistance to previously used organo- has been found to be 100% effective in similar to those reported from India and chlorides (DDT, dieldrin), carbamates treating uncomplicated falciparum ma- other south-east Asian countries having (propoxur) and organophosphates laria cases; this is why artemisinin-based low malaria endemicity [16]. (malathion, fenitrothion) has been well combination therapy was officially Information on prevalent vectors documented [18]. The Malaria Control adopted as the first-line treatment for and their bionomics demonstrate that Programme has used pyrethroids for uncomplicated confirmed falciparum 24 species of anopheles are known to both indoor residual spraying and long- malaria. The absence of a external tech- occur in Pakistan with An. Culicifacies lasting insecticide-treated nets since nical moderator for quality assurance in being the primary vector active in rural 1992, and the efficacy of this group of the survey was a limitation to be consid- areas [9]. An. stephensi has also been insecticides needs further validatation. ered when conducting further surveys. incriminated in urban transmission; Resistance to the antimalarial drug The Roll Back Malaria initiative was nevertheless, its role as a major vector chloroquine was first detected in 1981 launched by WHO in 1998. Pakistan needs further evaluation. Both vectors in Sheikhupura district of Punjab. The as a signatory to the Roll Back Malaria are endophilic in resting habits and usu- consolidated analysis of nearly 20 years initiative commenced and has sustained ally bite from midnight till 2:30 a.m. The (1977–95) of susceptibility studies its implementation since 2001. The plan high density of these vectors during the conducted in the former National In- was reviewed in 2007 to improve the post-monsoon period is linked to the stitute of Malaria Research and Train- national Roll Back Malaria strategic seasonal peak of the disease. Of the five ing (NIMRT) in Lahore (closed in focus and recognize the existing epide- known sibling species of An. Culicifacies, 1997), published in 1997, revealed a miological diversities in the country. A and B have been reported from the widespread R1 level chloroquine resist- The national strategic plan is being re- neighbouring countries of Islamic Re- ance (good initial response to the drug viewed in 2010 and will be updated and public of Iran, India, Afghanistan and but parasitaemia reappears within one is considering a two-pronged approach China [17]; however, the lack of infor- month of treatment) in Pakistan, with for malaria control in Pakistan: first, mation on their role in malaria transmis- a frequency ranging from 30% to 84% to pursue a universal coverage of early sion requires further investigation. [19]. Programme surveys on the efficacy diagnosis, prompt effective treatment Indoor residual spraying and long- of antimalarial drugs from 2004 to 2009 and multiple prevention interventions lasting insecticide-treated nets are cur- have corroborated that resistance to and secondly to eliminate the residual rently the major tools of malaria control chloroquine is common in falciparum foci of malaria transmission in the low
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endemic province of Punjab through marketing of long-lasting insecticide- monotherapies, injectable chloroquine the launch of a pre-elimination strategy. treated nets using commercial channels and halofantrine, which had been inju- The efforts of the Malaria Control may help improve the delivery of long- diciously prescribed by care providers. Programme to scale up distribution of lasting insecticide-treated nets to those The latter was a major success achieved long-lasting insecticide-treated nets in at risk [21]. Pakistan is currently devel- through sustained joint collaboration high endemic districts did not achieve oping a proposal for the forthcoming between the government and WHO the desired coverage, as revealed by the Global Fund round 10 with the objec- [22]. To further enhance programme 2002 demographic and health survey of tive of mobilizing additional resources in capacity, the integrated vector manage- Pakistan, where the overall ownership order to consolidate the ongoing efforts ment approach needs be adopted as of one long-lasting insecticide-treated for universal coverage towards achieving national strategy, promoting also the net per household was only 0.8% and the defined Millennium Development control of other vector-borne diseases. the overall net use by pregnant women Goal targets for malaria control. Malaria constitutes a major public and children less than five years of age Ever since the inception of the health threat in the highly endemic dis- was only 4.2% [20]. However, one mil- Roll Back Malaria project in Pakistan, tricts and agencies of Pakistan, while the lion long-lasting insecticide-treated the programme has passed significant risk of impending epidemics in the low nets have since been distributed free of milestones in partnership-building and endemic regions of the country is loom- cost through the Global Fund round 7 development of policy guidelines for ing. The government, the private sector, grant in support of 19 target districts, the new interventions of long-lasting civil society organizations and devel- while maintaining a high coverage of insecticide-treated nets, rapid diagnostic opment partners have to merge their artemisinin-based combination therapy. tests and artemisinin-based combina- efforts and work together to expand the This should result in a significant en- tion therapy. The programme has also available effective malaria control inter- hancement in the coverage of and access enabled the imposition of a ban on the ventions for achieving the national Mil- to these important interventions. Social production and sale of oral artemisinin lennium Development Goal targets.
References
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Review Creating synergies for health systems strengthening through partnerships in Pakistan – a case study of the national eye health programme A.A. Khan,1 N.U. Khan,2 K.M. Bile 3 and H. Awan 2
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ABSTRACT Blindness and visual impairment are major causes of noncommunicable diseases in Pakistan. Two national population-based blindness surveys conducted in 1988 and 2002–04 demonstrated a reduction in prevalence of blindness from 1.78% to 0.9% with a significant drop in cataract blindness as a result of accelerated nationwide interventions and eye care integration in primary health care. In addition, between 2006 and 2008, 88 facilities were upgraded as a result of the national eye health programme. These measures resulted in a 279% increase in eye outpatient attendances and a 375% increase in eye surgeries performed. Investment in human resources development and policy change contributed significantly to the sustainability of the programme. Key challenges facing the programme include aligning national eye health strategies with health system strengthening informed through health systems research. This paper attempts to document this extraordinary success.
Création de synergies en vue du renforcerment du système de santé par le biais de partenariats au Pakistan : étude du cas du programme national de santé oculaire
RÉSUMÉ La cécité et les déficiences visuelles sont des causes majeures de maladies non transmissibles au Pakistan. Deux enquêtes nationales en population sur la cécité, réalisées en 1988 et entre 2002 et 2004, ont montré une baisse de la prévalence de la cécité de 1,78 % à 0,9 %, ainsi qu’une diminution sensible de la cécité due à la cataracte, grâce à des interventions plus rapides au niveau national et à l’intégration des soins oculaires dans les soins de santé primaires. Par ailleurs, entre 2006 et 2008, 88 établissements ont été modernisés dans le cadre du programme national de santé oculaire. Ces mesures ont entraîné une hausse de 279 % des consultations ophtalmologiques externes et une augmentation de 375 % des actes de chirurgie oculaire réalisés. L’investissement dans le développement des ressources humaines et le changement de politique ont largement contribué à la viabilité du programme. Le principal enjeu auquel ce programme est confronté est l’harmonisation des stratégies nationales de santé oculaire et du renforcement du système de santé, au moyen des recherches sur les systèmes de santé. L’objectif de cet article est de décrire cette exceptionnelle réussite.
1National Programme for Prevention and Control of Blindness, Islamabad, Pakistan. 2Sightsavers International, Islamabad, Pakistan (Correspondence to H. Awan: [email protected]). 3World Health Organization, Country Office, Islamabad, Pakistan.
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Introduction situation analysis of eye health in the sus building, multistakeholder efforts country. It found that over two-thirds of and enhanced synergies. The importance of blindness and visual the district (secondary-level) hospitals impairment as a global public health had no eye care services. The report issue is illustrated by the World Health further added that there were an insuf- Methods Assembly [1]. The State of the World’s ficient number of ophthalmologists Sight VISION 2020 report stated that, and that there was no paramedic cadre Desk reviews of key published peer based on available global data, 75% of to assist the ophthalmologists. It ob- reviewed articles and reports spanning blindness and visual impairment was served that the cataract surgical output the last 30 years were undertaken. avoidable [2]. According to World was very low and insufficient to address These were obtained from the archives Health Organization (WHO) esti- the backlog of cataract in the country. of the National Eye Health Committee, WHO Country Office, MEDLINE® mates, 314 million people worldwide Based on these recommendations, the search and situation analyses reports live with low vision and blindness [3]. Ministry of Health constituted a na- from donors. Health information data Of these, 45 million people are blind, tional team in 1982 to address this issue were obtained from the national health 269 million have low vision and over [6]. This team was called the National management information system and 50% of these are due to uncorrected Cataract Committee, which later in the national programme for family plan- refractive errors (near-sightedness, far- 1988 was changed to the National Eye ning and primary health care. sightedness or astigmatism). In most Camp Planning Committee, as the gen- cases, normal vision could be restored eral approach to reducing the burden of Two major population-based na- tional blindness surveys were analysed with eyeglasses. A total of 90% of blind cataract blindness in south Asia at the and compared. However, there were people live in low-income countries. time was through eye camps. Restoration of sight and blind- limitations in analysing the results from In 1987–90, the first national blind- ness prevention strategies are among the surveys as there were differences ness survey was conducted with support the most cost-effective interventions in methodology. The first survey [7] from WHO [7]. Theresults of the survey in health care [2]. Infectious causes employed a cluster random sampling, were so staggering that the Ministry of of blindness are decreasing as a result including all ages, in which several Health took a very serious note of the of public health interventions and so- small surveys were carried out in 17 prevailing situation of blindness in the cioeconomic development. Blinding locations in the country. In the second country, with the effect that the National trachoma now affects fewer than 80 survey [10,11] a multistage, stratified Eye Camp Planning Committee rapidly million people, compared with 360 mil- (rural–urban), cluster random sam- lion in 1985 [2]. Ageing populations evolved into the National Committee pling, with probability proportional to and lifestyle changes mean that chronic for Prevention of Blindness in 1991. In size procedures, was used to select a blinding conditions such as diabetic 2008, this committee was reconstituted cross-sectional, nationally representa- retinopathy are projected to rise expo- as the National Eye Health Committee. tive sample of adults aged 30 years and nentially. Women face a significantly This new committee formulated the first above. Thus, it needed a smaller sample greater risk of vision loss than men. national plan for prevention of blindness size than the first survey. 1994–98 [6]. Subsequently, two further Blindness also has profound so- Specific data relating to national cioeconomic implications [4]. It was national plans were developed – the sec- programmes for lady health workers noted that without extra interventions, ond national plan 1999–2003 [8] and (LHWs) and prevention and control the global number of blind individuals third national plan 2005–10 [9]. of blindness were obtained from their would increase from 44 million in 2000 The second national survey on blind- respective programme implementa- to 76 million in 2020 [4]. A successful ness and low vision was undertaken in tion units. Additional data on human VISION 2020 initiative would decrease 2002–2004 [10,11]. After almost 15 resources were obtained from various blindness to only 24 million by 2020 years of joint intervention, this survey training institutions, Pakistan Medical and lead to 429 million blind person- revealed that the prevalence of blindness and Dental Council and relevant na- years avoided. A conservative estimate had been halved to 0.9%. tional nongovernmental organizations. of the economic gain is US$ 102 billion The purpose of this paper is to dis- Information on cofinancing was ob- [4]. Similar studies in Australia have also cuss how this exceptional progress of tained from WHO, institutional donors demonstrated that vision disorders cost reducing the prevalence of blindness by and international nongovernmental Australia AUD 9.85 billion in 2004 [5]. 50% in less than 15 years was achieved organizations. In 1980, at the request of the Min- and scaled-up further, supported by a The data were organized into epi- istry of Health, WHO conducted a national strategy development, consen- demiological, disease specific, facilities,
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health information, health finance and have identified these conditions but Table 4 highlights the key eye health health workforce categories. The fa- these were not reported separately. cadres, their respective minimum train- cilities and health workforce data were Table 2 demonstrates a rising trend ing criteria and the current status of further disaggregated by province. All in eye care interventions every five years. production and deployment. analysed data were reviewed by the co- The period between 1988 and 1993 Table 5 shows the professional tasks ordinator of the National Eye Health serves as a baseline before any formal and roles assigned to the different levels Programme and relevant officials from national programme for prevention of of eye care facilities. The national pro- the respective training centres to check blindness was launched. As static facili- gramme identified these specific roles for any inconsistencies. ties were upgraded and new eye hospi- to ensure that the various levels of health tals established in the nongovernment care services could comprehensively sector, a corresponding decrease in eye implement the national eye strategy. Results camps is noted. Table 6 illustrates how integration Table 3 indicates the operational of eye health within primary health care Table 1 illustrates the key results of two outcome of interventions and upgrada- by LHWs expanded access and cover- national blindness surveys undertaken tion of district hospitals in the public age of eye health services at the primary about 15 years apart. The surveys re- sector. There was a threefold increase level. This step has led to promotion of vealed that while cataract (clouding in outpatient attendance rates and the eye health by a 100 000-strong force of the lens of the eye) still remained number of cataract surgeries increased of LHWs who are resident in their re- the commonest cause of blindness, by almost four times. Even in areas of spective communities. As a result of its proportion as a blinding cause had heightened security, there were modest institutionalization of eye health within reduced from two-thirds to about half increases. In Balochistan, 10 districts broader health initiatives, there has of all causes. This corroborated with were not upgraded owing to lack of staff. been a transition of facility-based care to the eye health workforce development A similar situation was found in two community-based primary health care. and simultaneous strengthening of districts each in Punjab and Khyber Pa- static facilities for eye care at the sec- khtunkhwa, formerly North West Fron- ondary level which took place during tier province, and one each in Sindh and Discussion this period. Furthermore, the second Pakistan Administered Kashmir. Data Cataract blindness is a major public survey identified diabetic retinopathy from districts that were not upgraded health problem in most developing and macular degeneration as emerging were not reliable as no systematic re- countries, and the availability of and causes of blindness. The first survey may porting was being followed. access to cataract surgical services often serves as a proxy indicator for the success Table 1 Causes of blindness in Pakistan obtained from two population-based of a national eye health programme as surveys far as reduction of avoidable blindness is Main cause of National blindness National blindness Odds ratio concerned [12]. The first national plan blindness survey 1988–89 survey 2002–04 (95% CI) estimated that in 1988, the total cataract No. % No. % surgery per annum was about 140 000 Cataract 342 66.7 289 51.5 1.83 (1.42–2.36) [6], whereas these efforts were scaled- Corneal opacity 66 12.6 66 11.8 1.10 (0.75–1.60) up during the second five-year plan. A Uncorrected refractive national mapping exercise substantiated errorsa 60 11.4 15 2.7 0.97 (0.70–1.35) the attainment of a significant reduc- Uncorrected aphakia NSR NSR 48 8.6 tion in the burden of blindness that Glaucoma 21 3.9 40 7.1 0.55 (0.31–0.98) was reported by the national blindness Macular degeneration NSR NSR 12 2.1 – survey of 2002–2004 [13] and revealed Diabetic retinopathy NSR NSR 1 0.2 – that at least 310 752 cataract surgeries Others 29 5.4 90 16.0 – were being performed annually. Of all Blindness sample total 518b 100.0 561c 100.0 – cataract surgeries, 55% were carried out Survey sample total 29 157 16 507 in the nongovernment sector, 39% in aIncludes uncorrected aphakia. the government sector and 6% by the bThis gives a prevalence of blindness of 1.78%. cThis gives a prevalence of blindness of 3.4%. However, when adjusted for all ages, the prevalence is 0.9%. forces services; 58% of these surgeries CI = confidence interval; NSR = not separately reported. were using intraocular lenses.
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Table 2 Eye care interventions carried out in Pakistan during 1988–2003 Year Type of service Estimated annual number of interventions carried out Total Institutionalized Non-institutionalizeda 1988–93 (pre-national Eye outpatients 1 600 000 500 000 2 100 000 programme) Refractive error examinations 160 000 100 000 260 000 Cataract surgeries 88 000 52 000 140 000 1994–98 (1st five-year plan) Eye outpatients 3 768 120 753 624 4 521 744 Refractive error examinations 565 218 113 044 678 262 Cataract surgeries 120 000 70 000 190 000 1999–2003 (2nd five-year Eye outpatients 6 782 616 1 356 523 8 139 139 plan) Refractive error examinations 1 017 392 271 304 1 288 697 Cataract surgeries 208 204 102 548 310 752
aThis includes eye camps, outreach and private practices.
In the second national blindness the link between poverty and blindness. least 6.2 million refractions were being survey, persons of less than 30 years of Gilbert et al. studied the association be- done annually (2.2 million by ophthal- age were excluded from the study. In a tween visual impairment and poverty as- mologists, 1.6 million at hospitals and review of global data on blindness [14] sessed by a cluster-level deprivation index 2.4 million by opticians). As part of a and a population-based study done in and household-level poverty indicator community-based study, the prevalence the Gambia [15] it was observed that [16]. They found that the prevalence of visually disabling refractive errors the prevalence of blindness in persons of total blindness was more than three was found to be about 3.5%–4.5% in 0–15 years or 18–29 years did not have times higher in poor clusters than affluent children and 4% in all ages [18]. any significant effect on the overall preva- clusters. They concluded that blindness is Refractive errors are the commonest lence determined by examining those 30 associated with poverty in Pakistan and cause of visual impairment worldwide years or older. This methodology saved lower access to eye care services was one [3]. A national study found that overall time and cost and provided comparable contributory factor. spectacle coverage (6/12 visual acuity results to all age surveys. A countrywide situation analysis cut-off) was 15.1%, indicating that re- Despite the reduction of the preva- of refractive error services conducted fractive error services were not covering lence of blindness by 50%, it still remains in 2006 gathered data from over 2000 the majority of the population in need a public health prerogative. This has im- optical outlets from all the districts in [19]. Trachoma endemic foci were also portant implications when one considers the country [17]. They found that at recognized, providing the evidence for
Table 3 Three-year operational outcome of upgrading district eye services Province Number of Eye outpatients seen in upgraded Eye surgeries performed in upgraded facilities district eye units district eye units upgraded 2006 2007 2008 2006 2007 2008 Federal 2 19 702 40 971 18 576 719 1 934 1 610 Punjab 34 45 461 132 917 259 385 1 584 9 757 13 898 Sindh 14 91 095 133 890 263 971 1 072 4 349 16 024 Khyber Pakhtunkhwaa,b 22 68 192 87 043 146 440 3 448 8 839 8 706 Balochistana 11 31 600 37 309 44 585 6 079 5 617 7 145 Northern Areas 2 2 055 2 122 4 440 179 187 351 Azad Jammu and Kashmir 3 21 081 22 495 41 151 498 1 047 3 148 Total 88 279 186 456 747 778 548 13 579 31 730 50 882
aThe outcome of interventions was greatly affected by the ongoing security situation in these provinces. bFormerly North West Frontier province.
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Table 4 Human resources development for eye health in Pakistan
Eye health workforce Criteria Number of centres Total number Total number of Total number trained at formally running an of specific specific cadre actively accredited training accredited training cadre produced available in deployed in centres programme annually country service Paediatric ophthalmologist Minimum one year of accredited training after qualifying as general ophthalmologist 5586 Vitreo-retina specialist Minimum one year of accredited training after qualifying as general ophthalmologist 5 8 20 18 Medical retina specialist Minimum one year of accredited training after qualifying as general ophthalmologist 12–– Cornea specialist Minimum one year of accredited training after qualifying as general ophthalmologist ––33 Oculoplastic and orbit Minimum one year of specialist accredited training after qualifying as general ophthalmologist ––22 General ophthalmologist – Minimum four years of FCPS, MS or equivalent accredited training 30 30 500 400 General ophthalmologist – Minimum two years of MCPS, DOMS or accredited training equivalent 30 30 1 500 1 500 Community Minimum one year of ophthalmologist accredited training 21589– Optometrist Minimum four years of accredited training 5306710 Refractionist Minimum two years of accredited training 5 80 319 40 Orthoptist Minimum four years of accredited training 4154010 Ophthalmic technologist Minimum four years of accredited training 4152712 Ophthalmic nurse Minimum one year of accredited training after general nursing 2204821 Ophthalmic technician Minimum one year of accredited training 6 100 1100 65 Lady health worker (LHW) Minimum two days of training in eye health as part of LHW training programme 4 20 000 90 000 90 000
FCPS = Fellow of the College of Physicians and Surgeons of Pakistan; MS = Master of Science; MCPS = Member of the College of Physicians and Surgeons of Pakistan; DOMS= Diploma in Ophthalmic Medicine and Surgery.
undertaking the necessary control inter- and referral pathways was adopted to expanded to 63 districts between 2000 ventions [20]. A district-based compre- address the scarcity of eye care services and 2005 with support from interna- hensive eye care strategy comprising of in many regions of the country [21]. tional partners, and then scaled-up to strengthening of facilities, training of eye It was piloted in one district in 1996 another 63 districts in the country by care staff, and strengthening detection and after a successful evaluation was the Government in the 2005–2010
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Table 5 Roles of primary, secondary and tertiary level facilities for eye care Type Tasks/role Centre of excellence ō Dedicated specialized eye care services for complicated and referred cases ō Training in general ophthalmology for ophthalmologists and medical graduates ō Subspecialty training in the areas of vitreo-retina, paediatric ophthalmology, cornea, glaucoma and community eye health ō Training for allied health personnel especially in ophthalmic services ō Coordination, facilitation and management of developing eye health services in the respective province and zones ō Lead on research/situation analysis of eye health, and advocacy for health system strengthening as part of sustainable development ō Serve as Master trainers for CME, and eye health component of primary health care, school health programmes and pilot initiatives Teaching hospital ō Dedicated specialized eye care services for complicated and referred cases ō Training in general ophthalmology for ophthalmologists and medical graduates ō Training of allied health personnel in ophthalmic services ō Facilitation to Centre of Excellence in developing eye health services, advocacy and research ō Support linkages development with district and subdistrict hospitals for referrals and medical education DHQ/civil hospital ō Dedicated eye care unit with an ophthalmologist and two or three ophthalmic assistants ō Diagnosis and treatment of common eye diseases ō Receiving referrals from basic health units/rural health centres and THQ hospitals for treatment, and referring the complicated cases to tertiary units ō Serve as trainer/technical expert for school eye health programmes in refractive errors and early detection of eye problems THQ/subdistrict hospital ō Dedicate eye care unit to be established where staff is available ō Diagnosis and treatment of common eye diseases ō Receiving referrals from basic health units/rural health centres for treatment, and referring the complicated cases to DHQ hospitals or tertiary units Rural health centre ō Dedicated vision screening and assessment ō Provision of eye health promotion as part of primary health care ō Early detection and identification of priority blinding conditions ō Referrals of the cases to THQ/DHQ hospitals for prescription and treatment ō Support in school eye health programmes especially for refractive errors Basic health unit ō Provision of eye health promotion as part of primary health care ō Early detection and identification of priority blinding conditions ō Referrals of the cases to rural health centre for vision screening and THQ/DHQ hospitals for prescription and treatments ō Support in school eye health programmes especially refractive errors
CME = continuing medical education; DHQ = district headquarter; THQ = tehsil/taluka headquarter.
national plan. The district programme there was a demonstrable increase in The combination of micro-surgical not only demonstrated the feasibility the number of women attending the training of district ophthalmologists, of the approach even in the most dif- district eye units for treatment and eye upgredation of district eye care services ficult districts, but also revealed that surgery [22]. and the establishment of more than 25
Table 6 Expanding access to eye health services through lady health workers (LHWs) Province Number of LHWs People with eye problems examined by LHWs at Percentage employed the primary level increase At start of programme – After five years – 2009 baseline in 2005 Balochistana 6 350 201 290 230 640 15 Khyber Pakhtunkhwaa,b 13 888 1 146 462 989 322 -14 Punjab 49 000 3 008 564 4 286 896 42 Sindh 22 621 1 325 357 1 680 880 27 Total 91 859 5 681 673 7 187 738 27
aThe data here show a reduction. This is due to the heightened security situation and internal displacement of people. Thus, there was a very low level of training undertaken during this period. bFormerly North West Frontier province.
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new eye hospitals in the non- govern- (NVICs) such as conjunctivitis, water- training of the much needed eye health ment sector contributed to the doubling ing of the eye, presbyopia (difficulty in workforce. of cataract surgical output and increased seeing near objects, e.g. during reading), Some of the key challenges facing uptake of services. The Layton Rahma- etc. that add to the burden of disease the national eye health programme tullah Benevolent Trust with its 15 eye that LHWs have to attend to as part include sustaining cofinancing for the hospitals in the country has contributed of their work [23]. This study found programme, ensuring creation of posts significantly to social protection. a prevalence of 30.6% for NVICs. If and deployment of eye care staff in all The uptake of services in the up- presbyopia was excluded, NVICs then provinces, aligning eye health strategies graded district eye units corroborated accounted for 14.6%. The main NVICs with health systems and improving eye closely with the increase in eye health included infections such as conjuncti- health information systems for planning treatments by LHWs delivering primary vitis. The average complaint frequency interventions at various levels of health health care. The upgraded district eye per month/1000 population was found care. Furthermore, the referral pathway units demonstrated a 279% increase in to be 55. This study demonstrated that between the community level, first level eye outpatient attendances and a 375% there was a significant burden of simple health facilities and the sub-district level increase in eye surgeries performed at eye diseases that could be treated at needs to be strengthened. The role of a upgraded facilities. primary level. The national programme rural health centre as a community eye for prevention of blindness has liaised In 1993 there were 1500 ophthal- health facility needs to be validated. with LHWs’ programmes to revise the mologists. Based on data from the In developing countries, success curriculum of LHWs and strengthen Pakistan Medical and Dental Council of eye health can be achieved pro- the eye health component of primary (personal communication 2010 – NK), vided there is strong policy support, health care. there were an estimated 2000 or more health interventions and programmes A vital element of any national health ophthalmologists in the country by are integrated into the district health plan is an effective health information 2009. The strategy also developed the system and that they avail the support system. The national health manage- concept of an eye care team, with allied of the national primary health care ment information system (HMIS) team health professionals supporting oph- community-based workforce. Such ac- conducted a survey of eye health infor- thalmologists. complishments are seen in Pakistan mation needs and included eye health where a vertical programme combines One of the key successes of the data in their national integrated report national plans for eye health has been horizontal health systems strengthening [24]. Eye health and disease indicators and requires creation of strong public– the development of provincial and na- also appeared in a Gateway Paper on tional centres for training an eye health private partnerships and collaboration health indicators [25]. There is a need with professional bodies to monitor and workforce. To address the paucity of to develop an eye health information guide progress. Pakistan’s eye health eye health professionals, the national system as an integral part of the HMIS. programme has demonstrated that in- committee for prevention of blind- The financing of the three national vestment in, and alignment with, the ness prioritized the establishment of plans has again been a combination of six building blocks of health systems at least one training centre in each state and non-state partnership and is (service delivery, health workforce, province. Two of the critical factors an example of conditional cofinancing. medical products and technology, in this regard were the identification The first two national plans were almost health information, health financing of eye health workforce development solely funded by international partners. and governance) and supporting pri- needs and the establishment of train- However, in 2005, after evaluating pilot mary health care reform can be a model ing institutions in the public sector in programmes and demonstration ap- for other developing countries. Such all four provinces. Similar efforts were proaches, the Federal Ministry of Health hard-earned success in Pakistan needs made by the nongovernment sector launched a five-year national plan for to be sustained. in key geographical regions of the prevention of blindness worth US$ 50 country illustrated by Al-Shifa Trust million. The Government now provides Eye Hospitals, operating as a WHO support to capital investment and de- Acknowledgements Collaborating Centre for prevention ployment of trained human resources, of blindness with its four eye care hos- and has committed to creating at least The authors acknowledge the many pitals, and by Ibrahim Eye Hospital. 2700 new posts for eye health workers. contributions of Pakistan Institute of A community-based study was con- In support of this commitment, the in- Community Ophthalmology, Pesha- ducted to determine the prevalence ternational partners continue to provide war, Jinnah Postgraduate Medical Cen- of non-vision-impairing conditions technical and financial assistance for tre, Karachi, College of Ophthalmology
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and Allied Vision Sciences, Lahore, Civil of Health; WHO; institutional donors International); corporate donors (es- Hospital, Karachi and Helper Eye Hos- (especially AusAid, European Com- pecially Standard Chartered Bank) and pital, Quetta who were the architects of mission and Irish Aid); international Pakistan’s national plan for the preven- nongovernment partners (CBM, Fred national nongovernmental organiza- tion and control of blindness; Ministry Hollows Foundation and Sightsavers tions.
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Report Environmental health needs and launching of an environmental health protection unit in Pakistan M.Z.A. Khan,1 B.M. Kazi,2 K.M. Bile,3 M. Magan3 and J.A. Nasir 2
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ABSTRACT Pakistan is seriously confronted by many complex and difficult environmental challenges related to air, water, soil, forests and food including issues such as climate change. The close link between environment and health is neither well understood nor appreciated. The annual cost of environmental degradation in Pakistan has been estimated to be around US$ 4.0 billion or at least 6% of the country’s GDP. Up to 35% of the burden of disease is attributable to environmental hazards and risk factors and most of this burden is preventable. A systematic process for identifying environmental health needs and issues as well as the efforts made by the government of Pakistan and the World Health Organization in establishing and launching an environmental health protection unit are described. Also presented are the mission, functions, structure (operational and logistical) and technical requirements as well as sustainability aspects of the environmental health protection unit.
Besoins relatifs à la salubrité de l’environnement et ouverture d’un bureau de protection de la salubrité de l’environnement au Pakistan
RÉSUMÉ Le Pakistan est sérieusement confronté à de nombreux problèmes environnementaux, complexes et difficiles, qui concernent l’air, l’eau, la terre, les forêts et les denrées alimentaires, et incluent le changement climatique. Le rapport étroit entre environnement et santé n’est pas bien compris et son importance est mal perçue. Le coût annuel de la dégradation de l’environnement au Pakistan a été estimé à environ quatre milliards USD et à 6 % du PIB du pays au minimum. Les risques et les facteurs de risques environnementaux représentent jusqu’à 35 % de la charge de morbidité, qui est en grande partie évitable. Cet article décrit un processus systématique d’identification des besoins et des problèmes relatifs à la salubrité de l’environnement, ainsi que l’action du gouvernement pakistanais et de l’Organisation mondiale de la Santé pour mettre en place un bureau de protection de la salubrité de l’environnement. La mission, les fonctions, la structure opérationnelle et logistique et les règles techniques de ce bureau sont également présentés, ainsi que les aspects relatifs à sa viabilité.
1World Health Organization, New York, United States of America. 2National Institute of Health, Islamabad, Pakistan. 3World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to K.M. Bile: [email protected]).
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Introduction cal requirements as well as sustainability environmental factors, air pollution and aspects are also presented. water safety (Table 3). Pakistan is one of the 22 Member States A comparative analysis of the seven of the World Health Organization’s countries of the Region with the lowest (WHO’s) Eastern Mediterranean Re- environmental health indicators shows gion (EMR). Its current population of Need & process for that Pakistan is still lagging behind in around 170 million makes it the most establishing the some of the key environmental health populous country in the Region [1]. The environmental health indicators in meeting the WHO’s country is seriously confronted by many protection unit Health for All targets as well as the Unit- complex and difficult environmental ed Nations’ Millennium Development challenges related to air, water, soil, The WHO’s Regional Office for the Goals (Table 4). Eastern Mediterranean (WHO/ forests, food and issues such as climate Considering the current situation in EMRO) has been providing technical change as well as a double burden of environmental health, the government assistance and support to the federal disease due to communicable and non- felt that there was an urgent need to Ministry of Health in Pakistan in plan- communicable diseases [2–6]. Several have a close collaboration, coordination ning and implementing its develop- agencies are mandated for the protection and cooperation mechanism between mental activities as well as meeting of environment. However none of them health and other sectors dealing with urgent environmental health needs in is responsible for protecting humans environmental risks and thus decided to emergencies and disasters. A team of from the adverse health effects of poor establish an environmental health pro- experts from WHO came to Pakistan environment. The close link between tection unit in the Ministry of Health, in 2009 and developed a “road map” environment and health is neither well Islamabad. In order to jump start the broadly defining the scope, need and process, “seed funds” and technical as- understood nor appreciated. Pakistan functions of an environmental health sistance and support were provided by has several national policies, guidelines, protection unit. As a follow-up to the the WHO office in Islamabad. The unit laws, ordinances, rules and regulations team findings and recommendations, was officially launched in March 2010. related to the protection of the environ- the WHO office in Islamabad recruited ment; however their implementation the services of an international expert and enforcement are very limited [2,4]. in environmental health (a former The annual cost of environmental Director of WHO’s Centre for Envi- Environmental health degradation, in the country, has been ronmental Health Activities) to further estimated to be around US$ 4.0 billion protection unit: assist the government of Pakistan in mission, functions or at least 6% of the country’s GDP determining the feasibilityof an envi- and requirements [2]. The two most significant causes of ronmental health protection unit and environmental degradation have been carrying out efforts towards its initiation A brief summary of the environmen- identified as: air pollution, both indoor and establishment. tal health protection unit’s mandate, and outdoor, making up 50% of the An overview of various environmen- functions and structure, priority areas, total environmental damage and result- tal health variables and their status in the linkages with other agencies and opera- ing in acute respiratory infections and country indicates that the environmen- tional needs are described below. premature mortality; and inadequate tal health situation in Pakistan is not water supply, sanitation and hygiene, very satisfactory (Table 1). Mission accounting for 30% of the total environ- A meta-analysis of four major envi- The mission of the unit is to contrib-
mental damage, causing diarrhoeal and ronmental health–related issues—water ute to the protection of human health, other waterborne diseases [2,5,7]. safety, air pollution, heath care waste and prevention of diseases attributable to A systematic process used for iden- food safety—was carried out highlight- environmental risk factors, promotion tifying environmental health needs and ing the main focus of the surveys/stud- of healthy environment and improve- issues as well as the efforts made by ies conducted by various agencies and ment in the quality of life. the government of Pakistan and WHO institutions. The analysis also included in establishing and launching the en- the key findings and gaps (Table 2). Functions vironmental health protection unit in World Bank and WHO studies in- Its main functions will be to: serve as the Pakistan are described. A brief summary dicate a substantial annual economic health sector front line body that will of its key mission, functions, structure loss and burden of disease in Pakistan ensure that health protection concerns (operational and logistical) and techni- resulting primarily from the two major are addressed through action by other
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Table 1 Overview of Environmental Health Situation in Pakistan Variable Status Overall environmental health situation in Pakistan Not very satisfactory Major environmental health issues Water safety, health care waste, air pollution, and food safety Mandate of agencies managing environmental risks and hazards Several agencies responsible, but none have the mandate of protecting human health from such hazards Coordination and collaboration between environmental and health agencies and with other stake holders Very little Implementation and enforcement of existing laws, rules and regulations Very weak and limited Level of awareness of the linkage between environment and health Very little Environmental health as a priority in the country Low as reflected by limited annual budget allocations Availability of human resources in environmental health Extremely limited Engagement of health sector in motivating action by other sectors for health protection Very limited, needing further efforts and urgent action Availability of evidence based information in environmental health for sound policies and decision making Extremely limited Regular surveillance and monitoring systems for air, water and food Very limited Availability of environmental management tools, resources and infrastructure to provincial and local authorities Very limited
sectors on environmental risk factors as The technical advisory group would However initially, due to limited re- well as contribute to developmental pol- advise on the development of the envi- sources, it was considered appropriate icies, rules, guidelines, protocols, setting ronmental health protection unit and to start with only the WSH and ERM of national standards and legislation and guide its work. departments, focusing on the two major programmes dealing with environmen- priority issues—water safety and health tal risks factors; undertake monitoring Priority areas of focus and structure care waste management—for the com- and surveillance of environmental health ing three years. factors (e.g. water); generate evidence- The following seven priority areas and based information for corrective action environmental health risk factors have Linkages and coordination and linkages to public health; and imple- been identified for action by the envi- with other agencies ment public awareness and education ronmental health protection unit: drink- The environmental health protection ing water quality, sanitation (including programmes and campaigns as well as unit’s operations will require very close solid waste) and hygiene; air pollution conduct evidence-based advocacy to coordination, collaboration and net- motivate health protection action by (indoor and outdoor); health care waste working with a multitude of agencies other sectors. and hazardous wastes; chemicals and dealing with environmental hazards and pesticides; environmental heath impact The unit will be headed by a coor- risk factors as well as with those which dinator, supported by four technical assessment; environmental health as- offer potential collaboration to the en- staff, experts in different environmen- pects of emergencies and disasters; and vironmental health protection unit in its tal health areas, such as water safety, food safety. priority areas of focus in environmental environmental risk assessment and The unit will comprise four depart- management, information manage- ments, namely the Water Safety, En- health (Figure 1). Additionally, the en- ment and networking. It is expected vironmental Sanitation and Hygiene vironmental health protection unit will that a technical advisory group will be Department (WSH); the Environmen- also draw on all the existing and available established that would ensure com- tal Health Surveillance and Monitoring, capacities—training, analysis, research, patibility and complementary action Risk Assessment and Management teaching, available networks, etc.—in and coordination amongst the key re- Department (ERM); the Chemical and other agencies, ensuring transparency, sponsible agencies which contribute Food Safety Department (CFS); and complementing and supporting activities to environmental health, especially the the Information, Networking and Data (planned to be implemented by others) ministries of health and environment. Management Department (INM). and avoiding duplication of any efforts.
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Operational requirements In order for this unit to function and operate efficiently and effectively, its basic and essential requirements (staff- ing, office space, information system, laboratory infrastructure and logistical facilities), detailed terms of reference and duties of the staff have been pre- pared. Regarding the sources of funding and the sustainability of environmental health protection unit, it was agreed with National health policy,2009 (draft) National health policy,2009 NIH, Epidemic investigation cell report, HSA annual report, 2008 HSA annual report, PCRWR surveys, 2005–06; NIH survey, PCRWR surveys, 2005–06; NIH survey, programme, 2005 programme, www.moenv.gov.pk www.moenv.gov.pk www.who.int/foodsafety MOH hepatitis and prevention control WHO report, 2002 WHO report, 2005; www.moenv.gov.pk 2003 ō ō ō ō ō ō ō ō
ō the Pakistan Ministry of Health, that the initial “seed funds” would be provided by WHO; however the major support and sustainability of the environmen- tal health protection unit will depend upon the availability of resources from the Ministry of Health and donors . It was also considered appropriate that fundraising proposals be prepared and health/diseases health/diseases hospitals Noncompliance to guidelines No national food strategy Lack of of enforcement Lack of technical and financial Improperly prepared, stored stored prepared, Improperly approach HACCP Lack of technical and financial programme regulations resources resources surveillance and monitoring Unsafe disposal and handled food Very limited regular limited regular Very Very limited linkages made to Very Lack of adequate facilities in Very limited linkages made to Very Absence of application of ō ō ō ō ō ō ō ō ō ō ō ō promoted to donors. Detailed plans of work for one year and three years have been developed. The one-year plan, starting in 2009 and costing about US$ 437 500, focuses on water safety and for managing health care waste (es- pecially safe disposal of syringes, sharps and needles), while the three-year plan, foodborne and waterborne hepatitis B and hepatitis C Particulates (i.e. PM10 and (i.e. PM10 Particulates WHO exceeds PM2.5) were unsafe for human were Majority of samples analysed, and nitrates exceeded WHO exceeded and nitrates guidelines guidelines consumption 12 million people exposed to 12 million people exposed 2009–12, costing US$ 1 115 000 deals 43% of were outbreaks Arsenic, cyanide, fluorides ō ō ō ō ō primarily with water safety and safe han- dling and management of health care waste, but also includes activities related to air pollution (especially indoor), and food safety. Injections and Monitoring of sampling and syringes disposal analysis and analysis Water quality Water outbreaks and outbreaks epidemics Air quality sampling
Key role of the environmental health protection unit
The role of the environmental health protection unit has been very care- Study/survey conducted by Main focus findings Key Gaps Source National Institute of Health in Water Resources (PCRWR); Resources in Water Pakistan Environmental Environmental Pakistan Agency(Pak-EPA); Protection Pak-EPA; World Health World Pak-EPA; Health Services Academy Organization (WHO) Organization (NIH) (HAS); Pak-EPA fully designed to address the urgent and priority environmental health issues, affecting human health in both the rural and urban settings in the country. Key environmental health issues, where Analysis of health-related major environmental issues hazard analysis criticalhazard points. control the unit has already initiated and/or planned practical interventions, are Health waste care Ministry of Health (MOH); Food safetyFood Health NIH; World Water safetyWater of Council Research Pakistan Variable and indoor) and Air pollution (outdoor HACCP = HACCP Table 2 Table listed below.
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Table 3 Economic loss and burden of disease resulting from environmental factors in Pakistan Environmental issue/factor Economic loss, in US$ Resulting diseases Annual burden of disease Source billion (% GDP loss) (DALYs/deaths) Inadequate water supply, 1.4 Diarrhoea, typhoid, 1.6 million diarrhoea DALYs World Bank, sanitation and hygiene (1.81% of GDP) hepatitis, intestinal worms, 900 000 typhoid DALYS 2006 (water safety) dengue fever, and others 250 000 infant deaths WHO, 2006 Air pollution Outdoor 0.8 ARI, heart ailment, lung 22 000 premature adult deaths World Bank, (1.08% of GDP) cancer, chronic bronchitis DALYS lost = 163 432 2006 and others WHO, 2006 Indoor 0.75 ARI, chronic bronchitis, 40 million cases ARI World Bank, (1.0% of GDP) cataracts, tuberculosis, low 28 000 deaths/year 2006 birth weight, and others Exposure to lead 0.53 Hypertension, blood DALYS lost = 355 918 World Bank, (0.72% of GDP) pressure, heart disease, 2006 and others GDP = gross domestic product; DALYs = disability-adjusted life years; WHO = World Health Organization; ARI = acute respiratory infection.
Water safety risk [8–11]. Waterborne diseases and proposed for safeguarding the health of The government has attempted to pro- outbreaks continue to rise [9]. The envi- the affected communities. vide safe water to its population under ronmental health protection unit plays an important role in providing the needed Health care waste a national project called “Clean Drink- management ing Water for All” [2]. This project has technical support in identifying, assessing not been, so far, very successful due and promoting appropriate technologies The federal Ministry of Environment, to inadequate water treatment facilities, for maintaining the safety of water at the as part of its mandate, has published and better management, improved in- household level through its strong water- the “Health Care Waste Management frastructure and sufficient resources for quality surveillance and monitoring Rules, 2006” (approved 2005) for hos- repair and maintenance of such facilities capacity. This should result in an overall pitals. However very few of them are are required. However, about 70% of reduction of diarrhoeal and waterborne actually follow these rules [12–15]. Re- the population still relies on contami- diseases. The unit has also undertaken an cent studies carried out in Rawalpindi nated water sources, and 60% of the rural initiative of mapping of drinking-water and Islamabad have demonstrated that schools and health centres lack safe water quality and linking it to health in vari- the toxic emissions from improperly and adequate sanitation facilities, thus ous districts in the country. Appropriate operated and managed hospital incin- putting schoolchildren, patients, and remedial and mitigation measures as well erators cause serious health problems health care workers at increased health as awareness-raising approaches will be for residents [16]. Unsafe management
Table 4 A comparative analysis of seven EMR countries with worst environmental health indicators Indicator (demographic, social and Afghanistan Djibouti Pakistan Palestine Somalia Sudan Yemen environmental) Total population (million) 24.5 0.72 170 3.76 7.96 37.2 21.5 Urban population (%) 22 83 35 57 36 38 29 Population under 15 years (%) 40.0 40.0 37.8 45.7 44.4 41.3 45.0 Population with access to sustained water resource (%) –849081295631 Population with access to improved sanitation (%) 67 85 54 97 37 31 23 Ministry of health budget as % of government budget 3.3 14.3 1.5 – – 7 5.6 Life expectancy at birth (total years) 46.0 44.1 65.0 72.5 47.0 58.0 61.1 Infant mortality rate (per 1000 live births) 129.0 67.0 78.0 24.2 86.0 81.0 68.5 Under-five mortality rate (per 1000 live births) 191.0 94.0 94.0 28.3 135.0 112.0 78.2
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EHPU’s priority environmental health issues Institutions offering potential collaboration with
1. Water quality, sanitation & 1. Pakistan Environmental Protection Agency hygiene ? Regulatory agency ? Developing, monitoring, enforcing standards ? Collection of data and information in environmental issues
EHPU 2. Ministry of Environment 2. Air quality (indoor and outdoor) ? Policy, planning, strategies ? Advocacy and awareness-raising
Water, 3. Pakistan Council of Research in Water environmental Resources ? Water quality analysis and monitoring sanitation ? and hygiene National reference laboratory infrastructure 3. Health care waste (including (19 offices all over Pakistan) solid waste) Environmental 4. Health Services Academy health ? Capacity-building/training surveillance ? Applied research monitoring risk assessment and 5. National Institute of Health ? 4. Chemicals and pesticides management Investigative/reactive environmental health laboratory ? Well established and reference facility
Emerging 6. National University of Science and issues Technology (climate, ? Capacity building and applied research 5. Environmental health impact health, noise, etc.) 7. International Union for Conservation of assessment Nature ? Advocacy and awareness-raising. ? National strategies and plans
Chemical 8. Pakistan Council of Science & Industrial and food Research ? safety Advocacy, capacity-building, research 6. Environmental health aspects of 9. Pakistan Department of Meteorology emergencies ? Advocacy and awareness-raising ? Advisory on climate and health
10.UN Agencies (WHO, UNICEF, UNDP,UN Habitat) ? Advocacy 7. Food safety ? Technical assistance and support ? Institutional strengthening
Figure 1 Environmental health protection unit (EPHU) and its linkages with other environment related agencies and institutions
of health care waste, especially the un- B and hepatitis C cases [13,15,17]. The three hospitals as pilots for identifying safe injection practices component, has environmental health protection unit and promoting the best practices for seriously resulted in the rise of hepatitis has already selected and sponsored hospital waste management.
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Food safety Air pollution well as develop and promote evidence- Foodborne diseases remain responsible Air pollution, both indoor and outdoor, based information. for high levels of morbidity and mortal- is the highest contributor to the envi- ity in Pakistan, but particularly at risk are ronmental burden of disease in Pakistan Conclusion infants and young children, the elderly [2]. Pakistan Environmental Protection and the immunocompromised [18]. Agency studies indicate that air quality This is confirmed by National Institute In view of the current environmental in most cities does not meet WHO Air of Health (Islamabad) studies indicat- health situation, the decision of the Quality Guidelines [19]. The extensive ing that the highest number of out- government of Pakistan to establish and data and information collected are breaks are of foodborne origin [9]. The launch the environmental health pro- environmental health protection unit, as not linked to the health situation of tection unit is very timely and a positive part of its workplan, will be promoting the population living in these affected step towards improving environmental the concept of hazard analysis critical areas. One of the major goals of the health in the country. The unit can act as control points (HACCP) systems in environmental health protection unit the front end leader that will play a piv- reducing the incidence of foodborne is to maintain a close link between the otal role in protecting and promoting diseases. ministries of health and environment as safer and healthier life in the country.
References
1. Population projections (1998–2023). Islamabad, Pakistan, Na- 11. Pakistan’s water at risk. Water and health related issues in Pakistan tional Institute of Population Studies, 2000. & key recommendations. A special report. Islamabad, Pakistan, 2. Pakistan strategic country environmental assessment. Islamabad, World Wide Fund For Nature Pakistan, 2007 (http://www. South Asia Environment and Social Unit, World Bank, 2006. wwfpak.org/pdf/water-report.pdf, accessed 22 June 2010). 3. Country profiles. Cairo, World Health Organization, 2009 12. Annual progress report for the year 2007–08. Islamabad, Paki- (http://www.emro.who.int, accessed 5 May 2010). stan, Health Services Academy, Ministry of Health, 2009. 4. The gazette of Pakistan: Pakistan environmental protection act, 13. Waste from health care activities Geneva, World Health Organi- 1997. Lahore, Environment Protection Department Punjab, zation, 2007 (WHO Fact Sheet, No. 253). (http://www.who. 1997 (No. F.9(46)/97-Legis). int/mediacentre/factsheets/fs253/en/print.html, accessed 3 May 2010). 5. Ustun AP, Corvalan C, eds. Preventing disease through healthy environments: towards an estimate of the environmental burden 14. The gazette of Pakistan: hospital waste management rules Paki- of disease. Geneva, World Health Organization, 2006. stan 2005.Islamabad, Pakistan, Ministry of Environment, 2005 (S.R.O.1013(1)/2005). 6. Kahlown MA , Tahir MA, Rasheed R, eds. Fifth water quality monitoring report 2005–06. Islamabad, Pakistan, Council for 15. Hospital waste factsheet. Islamabad, Pakistan, World Wild Fund Research in Water Resources, Ministry of Science and Technol- for Nature Pakistan, [Website] (http://www.wwfpak.org/ ogy, 2008. factsheets_hwf.php, accessed 22 June 2010). 7. The world health report 2002: reducing risks, promoting healthy 16. Javied-Sabiha, Tufail M. Heavy metal pollution from medical life. Geneva, World Health Organization, 2002. waste incineration at Islamabad and Rawalpindi, Pakistan. 8. Demographic and health indicators for countries of the Eastern Microchemical Journal, 2008, 90(1):77–81. Mediterranean. Cairo, World Health Organization, Regional 17. National health policy 2009 (draft 3 ): stepping towards better Office for the Eastern Mediterranean, 2004 (201 WHO-EM/ health. Islamabad, Pakistan, Ministry of Health, 2009. HST/181). 18. WHO Food Safety Programme. Geneva, World Health Organi- 9. Report 1998–2003. National Institute of Health, Public health zation, 2009 (http://www.who.int/foodsafety, accessed 10 laboratories, epidemic investigation cell, [Website] (http:// April 2010). www.nih.org.pk/eic.asp, accessed 22 May 2010). 19. The gazette of Pakistan: national environmental quality standards 10. National standards for drinking water quality (NSDWG ). Islama- for motor vehicle exhaust and noise. Islamabad, Pakistan, Minis- bad, Pakistan, Environmental Protection Agency, 2008. try of Environment, 2009.
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Report Launching the first postgraduate diploma in medical entomology and disease vector control in Pakistan H.R. Rathor,1 A. Mnzava,2 K.M. Bile,3 A. Hafeez 4 and S. Zaman 5
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ABSTRACT The Health Services Academy has launched a 12-month postgraduate diploma course in medical entomology and disease vector control. The objective is to create a core of experts trained to prevent and control vector-borne diseases. The course is a response to the serious health and socioeconomic burden caused by a number of vector-borne diseases in Pakistan. The persistence, emergence and re-emergence of these diseases is mainly attributed to the scarcity of trained vector-control experts. The training course attempts to fill the gap in trained manpower and thus reduce the morbidity and mortality due to these diseases, resulting in incremental gains to public health. This paper aims to outline the steps taken to establish the course and the perceived challenges to be addressed in order to sustain its future implementation.
Lancement du premier diplôme postuniversitaire en entomologie médicale et lutte contre les vecteurs de maladies au Pakistan
RÉSUMÉ Les Health Services Academy [Académie des services de santé] ont lancé un diplôme postuniversitaire d’une durée de 12 mois dans le domaine de l’entomologie médicale et de la lutte contre les vecteurs de maladies, dans le but de constituer un noyau d’experts formés à la lutte contre les maladies à transmission vectorielle. Cette formation est une riposte à la lourde charge sanitaire et socioéconomique que représentent un certain nombre de maladies à transmission vectorielle au Pakistan. La persistance, l’émergence et la réapparition de ces maladies sont essentiellement attribuées au manque d’experts formés à la lutte contre les vecteurs de maladies. La formation vise à combler ce manque et à réduire ainsi la morbidité et la mortalité dues à ces maladies, entraînant de ce fait une amélioration croissante de la santé publique. Le but de cet article est de mettre l’accent sur les mesures prises pour mettre en place la formation et les défis à relever pour soutenir sa future mise en œuvre.
1Medical Entomology and Disease Vector Control, Health Services Academy, Islamabad, Pakistan (Correspondence to H. Rathor: hamayun_r@ hotmail.com). 2World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 3World Health Organization, Country Office, Islamabad, Pakistan. 4Health Services Academy, Islamabad, Pakistan. 5Institute of Public Health, Lahore, Pakistan.
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Introduction ogy and disease vector control must be a Methods top priority for Pakistan. Vector-borne diseases, such as malaria, In addition to the damage caused Information was gathered from existing filariasis, leishmaniasis, schistosomiasis, by the known endemic vector-borne technical documents to design a course onchocerciasis, dengue and other ar- diseases, the presence of vectors capable curriculum that was unique to the needs boviruses, rodent-borne diseases, and of transmitting other diseases which, al- of Pakistan. Such documents included an existing curriculum from the WHO a number of other diseases transmitted though not yet reported from Pakistan, by insects, cause major public health Regional Office for the Eastern Medi- have caused outbreaks in neighbouring problems and burden of diseases in terranean, WHO regional courses, and countries and pose as an emerging risk. countries of the World Health Organi- curricula for other courses currently An important example was an outbreak zation’s (WHO)’s Eastern Mediterra- offered at HSA. The biggest challenge of plague in 1994 that caused serious nean Region, including Pakistan [1–6]. was to align this course with the require- Resurgence and re-emergence of some alarm in India [17,18]. ments of Quaid-e-Azam University, the of these diseases continues to take place WHO warned the health authorities diploma-awarding academic institu- in Member States [7]. In 2001, an esti- in Pakistan of the risks the country was tion. Teaching consultancy and course mated 14 657 000 disability-adjusted facing due to the persistence, emergence approval processes were reviewed. In- life years were lost in countries in the and possible re-emergence of vector- terviews with senior national and WHO Region due to infections from the top borne diseases and the country’s serious experts were instrumental in evaluating 10 vector-borne diseases, accounting lack of trained medical entomologists the opportunities and challenges that for 11% of the global burden in an area and vector-control experts to prevent would influence the sustainability of the where only 8% of the global population and control any adverse health impacts. course. lives [8,9]. To address this human resource gap, According to the annual report of the Ministry of Health asked WHO to the Directorate of Malaria Control, work with its Health Service Academy Results Islamabad, 2008, the incidence of Plas- (HSA), Islamabad to review and finalize Table 1 lists the diseases, their vectors, modium falciparum has been increas- the syllabus for a postgraduate diploma intermediate hosts and reservoirs found ing in Baluchistan, Sind, North-west course in medical entomology and vec- in Pakistan. Many of these vector-borne Frontier Province (NWFP) and Feder- tor control. This initiative was fully sup- diseases are endemic; for others the vec- ally Administered Tribal Area (FATA), ported in the Region’s 52nd Regional tor epidemiology and environmental causing serious health problems. Committee meeting [19]. Through conduciveness pose the risk of disease Crimean-Congo haemorrhagic fever the joint collaborative programme, resurgence, though cases have not yet has been reported from many parts of the blueprint of a medical entomology been reported in Pakistan. Baluchistan, Sind and northern Punjab and disease vector control (MEDVC) [10]. Cutaneous leishmaniasis of an- course was designed for implementa- Inception of the course throponotic and zoonotic nature, earlier tion of integrated vector management In order to launch the MEDVC course, only found in NWFP, has become en- (IVM) as the most suitable strategic ap- multisectoral discussions were held demic and often causes outbreaks in all proach to reduce the burden of vector- among the concerned national authori- four provinces [11–14]. An outbreak of borne diseases and reduce the critical ties and a plan of action was prepared. dengue fever was first reported from Ka- gap in trained manpower to carry out HSA agreed to take the initiative and rachi, Pakistan in 1994 [15] and since launched the MEDVC course. The syl- then various dengue outbreaks have indigenous applied research and vector- control operations [20–23]. labus, designed jointly by the Regional been reported from different regions of Office and HAS, emphasized both the In view of the above, HSA, with the Pakistan [16]. applied field aspects of disease vector support of WHO and the United States The control of vectors of dengue, control and indigenous research, to Agency for International Development malaria, leishmaniasis, etc, requires ensure the application of knowledge availability of medical entomologists (USAID), launched a postgraduate gained. and vector-control experts, not only to diploma in MEDVC in September 1 provide leadership but also to moni- 2009. MEDVC is a remarkable innova- Collaboration with Qaid-e- tor and evaluate the impact of existing tion for capacity building in a neglected Azam University vector-control interventions. Therefore, but essential preventive field of public HSA collaborated with Qaid-e-Azam capacity building in medical entomol- health. University, Islamabad, for the purpose
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Table 1 Risk of vector-borne diseases in Pakistan Disease Vector/intermediate hosts/ Vector status Environment Disease status reservoirs (habitat) Malaria Anopheles spp. Present Favourable Endemic Cutaneous leishmaniasis Sand flies, rodents Present Favourable Endemic Visceral leishmaniasis Sand flies, dogs, cats Present Favourable Endemic in north Dengue and dengue haemorrhagic fever Aedes aegypti, A. albopictus Present Favourable Endemic Crimean-Congo haemorrhagic fever Ticks (cattle, sheep) Present Favourable Endemic Yellow fever A. aegypti Present Unknown Not reported Japanese encephalitis Culex tritaeniorhynchus Present Favourable Not reported Filariasis C. quinquefasciatus, Anopheles spp. Present Favourable Reported Plague Fleas, rodents Present Favourable Not present Murine typhus Fleas, Rattus spp. Present Favourable Reported Salmonellas Rattus spp. Present Favourable Reported Dysentery, diarrhoea, cholera, typhoid, helminth infections, trachoma, poliomyelitis Housefly Present Favourable Present Relapsing fever Rattus spp., Acomys spp. Present Favourable Reported Leptospirosis Rattus spp., Mus spp. Present Unknown Not reported Louse-borne typhus Body louse Present Favourable Reported in north House dust mite allergies Dust mites Present Favourable Reported Guinea worm (dracunculiasis) Cyclops Present Eradicated 1996 Not present Haemorrhagic fever with renal syndrome Rodents Present Favourable Not reported Onchocerciasis Black fly (Simulium not reported) Present Unknown Not reported
of awarding diplomas to students. A in Pakistan, and the remainder were degrees in agriculture (2), biology (2), plan for collaborative teaching and international visiting faculty members. bio-informatics (2), medical technol- evaluation, along with the syllabus, ogy (5), pharmacy (1), microbiology Admission procedures was approved by the academic council (1), while 10 had MSc degrees in bio- of the university. Consequently, the As the course was expected to attract chemistry (1), zoology (4), botany (1), a large number of candidates from all course was offered by Quaid-e-Azam microbiology (1), agriculture (1), and over the country, an advertisement was University as a one-year programme to three had medical degrees. This clearly placed in different national newspapers. be administered by HSA. indicated that the course was of great The target was to admit 20 students. interest to students from many diverse Table 2 shows the course structure. A total of 96 candidates applied, 70 of biomedical backgrounds. This diversity There are two semesters, comprising whom were shortlisted on the basis was considered useful, as it would help of qualifications and experience and of six modules in subspecialties in the to promote multidiscipline interaction further screened by a written test and field of vector biology and control and within the class and an environment of interview. As detailed in the prospectus, a three-month research dissertation. A participatory learning. due consideration was also given to brief description of the syllabus, dura- By careful review of transcripts of tion and the credit hours allotted to other admission criteria such as age (maximum 30 years without experi- their undergraduate studies and from each module are explained. The table ence or 45 years with experience), the personal interviews that formed also includes arrangements for local and provincial quotas, English language, part of the admission process, it was international faculty in relation to each computer skills and no objection cer- determined that all students had a basic module of the syllabus. A total of 25 tificate requirement for those in service. knowledge of biosciences from their faculty were recruited: nine were from A batch of 26 students was finally admit- undergraduate studies. The only weak HSA, 11 were local visiting faculty from ted to the first MEDVC programme. area in the background of most stu- various universities and organizations Of these 26 students, 13 held BSc dents was a limited knowledge of basic
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Table 2 The Health Service Academy (HSA) postgraduate diploma course in medical entomology and disease vector control – semester-based syllabus outline Module Duration Credit hours Faculty (months) Module 1 Medical entomology, disease and vectors and vector-borne disease Identification, classification, bionomics of vectors and disease transmission mechanism and significance 1 6 HSA + local visiting faculty Module 2 Epidemiological investigations and statistics Epidemiological concepts, statistical principles and methodology, principles and methodology of study design, application of computers for vector and disease control 1 6 HSA + local visiting faculty Module 3 Entomological investigations Skills for sampling, monitoring, rearing, identification, incrimination of disease vectors, intermediate host and HSA + local visiting + reservoirs 1 6 international faculty Module 4 Vector control and management Concepts and techniques for vector pest prevention and control. Integrated vector management, safe use of HSA + local visiting + pesticides and insecticide-resistance management 1 6 international faculty Module 5 Principles of programme management: Main principals and methodology of programme management as related to vector control, especially integrated vector management 1 6 HSA faculty Module 6 Field training Skills for field work and community empowering and involvement 2 16 HSA faculty Total 60 25
medical entomology. This gap was to be with limited resources to start the pro- will be helpful for further training and expected and the syllabus was designed gramme; however, more appropriate, research. This team has locally devel- to address this weakness. The first part purpose-built laboratories will eventu- oped a number of field insect collection of module 1 deals with the basics of ally be needed. instruments and equipment. medical entomology right at the begin- ning of the course, thus students do not Medical entomology insectary MEDVC research centre face any difficulty in this respect. A small temporary insectary was es- A modest research centre has been tablished for rearing and processing established, supplied with computers, Medical entomology various insects of medical importance. It library items, WHO test kits, etc. A com- laboratory was automated for controlled humidity, puter laboratory has also been set up, A medical entomology laboratory was temperature and daylight periodicity. A where postgraduate students can search established from an existing laboratory number of colonized strains of anophe- literature on the Internet. A display and equipped with entomological dis- line, culicine and Aedes mosquito spe- corner for entomological journals has
secting microscopes, a CO2 circulat- cies are being maintained for teaching been established, where 16 of the most ing system for restraining insects for and research purposes. A team of important journals on disease vector observation and other essential instru- entomology technicians make routine biology and control can be accessed. A ments required by the students. The field collections of anopheline mosqui- small laboratory has been set up where existing laboratory was of modest size toes for teaching purposes and also for WHO insecticide susceptibility test kits, but functioned well. It was quickly set up establishing laboratory colonies that other rapid test kits supplied by WHO
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and facilities for malaria parasitology are potential. Indigenous research again not exist at HSA, modest facilities were available for students. The centre has requires technically trained staff. developed and at times equipment, ma- other facilities, such as photocopying, In view of the above, the WHO con- terials and facilities were shared with printing and scanning. To encourage sultations on IVM in 2007 and 2008 other national institutions. open dialogue between students and put considerable emphasis on capacity The first training course is nearing teachers on current vector-control is- strengthening, including infrastructure, its successful completion; however, sus- sues and promote a culture of continu- training and human resources for IVM tainability of the course depends upon ing education, a programme of weekly [24,25]. The 52nd regional committee availability of reasonable technical and talks by eminent vector-control experts meeting resolution strongly recom- financial resources. is planned. mended establishment of and support It is estimated that each district for a regional course in MEDVC [19]. in Pakistan needs at least two vector- In Pakistan, no university, institution control trained staff. Therefore, to fulfil Discussion or research centre provides formal edu- the immediate national requirement, cation in the field of medical entomol- the MEDVC course has the target of The key question is why vector-borne ogy, especially in disease vector control. producing at least 300 qualified profes- diseases continue to cause considerable The lack of interest in this field is largely sionals in the next 5–10 years. Those mortality, morbidity and retardation due to the fact that the significance and trained will go into operational disease of socioeconomic development when extent of the burden of vector-borne vector-control programmes in Pakistan. effective IVM vector-control tools are diseases has not been clearly under- This training programme will effectively available along with significant guid- stood and has been underestimated. respond to the priority need for training ance, both regional and global, for their Moreover, a focus on more lucrative of national vector-control staff at federal implementation [21,22]. Persistence and thus more prestigious curative level and in each district at provincial and increase of vector-borne diseases medicine, rather than on preventive health departments. in the Region may be explained by the medicine, may also explain the neglect In conclusion, it is expected that number of new natural and man-made in capacity building in this field. well-trained MEDVC postgraduate vector-breeding sources and increased The greatest hurdle faced in the es- diploma holders will form the back- transmission potential. However, one tablishment of this diploma course has bone of health services at the district of the most important factors appears been the acute shortage of appropriate level and be able to ensure sustainable to be the shortage of trained manpower faculty in the field of disease vector con- public health services at grass root level in the field of vector control. In the ab- trol. The Regional Office has provided through community empowerment and sence of technical capability, the avail- international experts to supplement the involvement. The course organization able vector-control tools are either not local faculty. The other major hurdle and its academic programme have been used or are used inappropriately. It is was the lack of understanding of the successful. In order to make the best of important to note that experts in disease gravity of the situation resulting from this new public health capacity-building vector control, not only in Pakistan but this disease burden and thus scarcity programme, a strong partnership needs also in other countries, are scarce. Thus, of financial resources. The most impor- to be developed between the Federal if research is not built into the national tant requirement for such training was Government and the provincial health programme for vector-borne disease finance for internal and external faculty, departments to sustain its implementa- control, the programme may not be field work, entomological laboratories tion, while the support of international successful or may not grow to its full and insectaries. As these facilities did partners will be an asset.
References
1. Guidelines for planning and implementation of malaria vector 4. Roosendaal JA. Vector control: methods for use by individuals and control at district level. Islamabad, Directorate of Malaria Con- communities. Geneva, World Health Organization, 1997. trol, Ministry of Health, 2007. 5. Bednets for all: regional consultation on preparation of a regional 2. Report on the regional workshop on the urban vector control. strategy on insecticide- impregnated bednets and other materials. Cairo, World Health Organization, Regional Office for the East- Cairo, World Health Organization, Regional Office for the East- ern Mediterranean, 1990 (WHO-EM/VBC/51-E). ern Mediterranean, 1998 (WHO-EM/VBC/097/E/L). 3. Geographical description of arthropod-borne diseases and their 6. Vector control for malaria and other mosquito-borne diseases: principal vectors. Geneva, World Health Organization, 1989 report of a study group. Geneva, World Health Organization, (WHO/VBC/89.967). 1995 (WHO Technical Report Series, No. 857).
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7. Rathor HR. The role of vectors in emerging and re-emerging 17. Dennis D. Plague in India. British Medical Journal, 1994, diseases in the Eastern Mediterranean Region. Eastern Mediter- 309:893–894. ranean Health Journal, 1996, 2(1):61–67. 18. Human plague in 1994. Weekly Epidemiological Record, 1996, 8. Integrated vector management: strategic framework for the East- 71:165–172. ern Mediterranean Region 2004–2010. Cairo, World Health 19. Report of the regional committee for the Eastern Mediterra- Organization, Office for the Eastern Mediterranean, 2004. nean, fifty-second session. Cairo, World Health Organization 9. The world health report 2002 – reducing risks, promoting healthy Regional, Office for the Eastern Mediterranean, 2005 (EM/ life. Geneva, World Health Organization, 2003. RC52/R6). 10. Waqar S, Tariq WZ. Crimean-Congo haemorrhagic fever (CCHF) 20. WHO position statement on integrated vector management. Ge- in Pakistan. Pakistan Journal of Pathology, 2006, 17(2):74–84. neva, World Health Organization, 2008 (WHO/HTM/NTD/ 11. Munir MA, ed. Guidelines for the treatment and prevention of cu- VEW/2008-2). taneous leishmaniasis in Pakistan. Islamabad, Ministry of Health 21. Integrated vector management: regional strategic framework and World Health Organization, 2002. 2003–2006. Cairo, World Health Organization, Regional Of- 12. Brooker S et al. Leishmaniasis in refugee and local Pakistani pop- fice for the Eastern Mediterranean, 2003. ulations. Emerging Infectious Diseases, 2004, 10(9):1681–1684. 22. Global strategic framework for the integrated vector manage- 13. Khan S J, Muneeb S. Cutaneous leishmaniasis in Pakistan. Der- ment. Geneva, World Health Organization, 2004 (WHO/CDS/ matology Online Journal, 2005, 11(1):4 (http://dermatology-s10. CPE/PVC/2004.10). cdlib.org/111/reviews/leishmaniasis3/khan.html, accessed 1 23. The work of WHO in the Eastern Mediterranean Region: annual May 2010). report of the regional director 1 January–31 December 2008. Cai- 14. Shakila A et al. Geographical distribution of cutaneous leish- ro, World Health Organization, Regional Office for the Eastern maniasis and sand flies in Pakistan. Turkiye Parazitoloji Dergisi, Mediterranean, 2009. 2006, 30(1):1–6. 24. Report of the WHO consultation on integrated vector manage- 15. Chan YC et al. Dengue hemorrhagic fever outbreak in Karachi, ment. Geneva, World Health Organization, 2007 (WHO/COS/ Pakistan. Transactions of the Royal Society of Tropical Medicine NTOWEM/2007.1). and Hygiene, 1995, 89:619–620. 25. Report on the WHO consultation on development of a global ac- 16. Siddiqui FJ, Hyder SR, Bhutta ZA. Endemic dengue fever: a tion plan for integrated vector management 1–3 December 2008. seldom recognized hazard for Pakistani children. Journal of Geneva, World Health Organization, 2009 (WHO/HTM/ Infection in Developing Countries, 2009, 3(4):306–312. NTOWEM/2009.1).
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Learning through crisis: development and implementation of a health cluster strategy for internally displaced persons K.M. Bile,1 A.F. Shadoul,1 H. Raaijmakers,1 S. Altaf 2 and K. Shabib 3
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ABSTRACT Five major disasters in Pakistan affected close to 8 million people from 2005 to 2009. The 2008–09 humanitarian crisis in Khyber Pakhtunkhwa and the Federally Administered Tribal Areas (FATA) of Pakistan resulted in 2.76 million internally displaced persons (IDPs), of whom 88% were off-camp IDPs hosted by the local population. The service delivery challenges posed by the IDPs, their sparse geographical distribution and phased displacement were managed through a successful health response strategy, which focused on 13 major interventions supplemented by a set of standard guidelines for field implementation. This study evaluates the process and results attained by this coordinated health cluster strategy that has guided the mobilization and implementation of a colossal humanitarian response to an unprecedented crisis in Pakistan’s history.
Apprendre grâce à la crise : élaboration et mise en œuvre d’une stratégie de groupe Santé en faveur des personnes déplacées
RÉSUMÉ Au Pakistan, près de huit millions de personnes ont été frappées par quatre catastrophes majeures entre 2005 et 2009. En 2008-2009, la crise humanitaire qui a touché Khyber Pakhtunkhwa et les zones tribales sous administration fédérale du Pakistan ont fait 2,76 millions de personnes déplacées, dont 88 % se trouvent hors des camps et sont hébergées par la population locale. En termes de prestations de services, les problèmes posés par les personnes déplacées, leur dispersion géographique et leurs déplacements par étapes ont été gérés grâce à une stratégie de riposte sanitaire couronnée de succès, comprenant treize interventions principales et un ensemble de directives standard de mise en œuvre sur le terrain. Cette étude évalue les processus et les résultats obtenus grâce à cette stratégie de groupe Santé coordonnée, qui a guidé la mobilisation et la mise en œuvre d’une impressionnante riposte humanitaire à une crise sans précédent dans l’histoire du Pakistan.
1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to K.M. [email protected]). 2Department of Health, Khyber-Pakhtunkhwa, Pakistan. 3World Health Organization, Geneva, Switzerland.
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Introduction and complex emergencies [5,6]. Dur- a hosting family adopted 1.3 families ing the IDP crisis (2008–09), WHO in their home and offered all affordable Humanitarian disasters are an increas- jointly assumed with the government basic needs to their vulnerable guests. ingly common global challenge, in ad- the health response coordination role. Figure 1 shows the humanitarian dressing which World Health Assembly The Organization was able to mobilize health response coordination frame- Resolution 58.1 of 2005 stipulated the and position, at short notice, competent work. The health cluster and the national scope of health action in crisis. The professional teams and critical health health sector authorities worked closely World Health Organization (WHO) technologies and assume the role as the together, while collaboratively interfac- focuses on rapid situation and needs provider of last resort in the emergency ing with other members of the humani- assessment, the coordination of health health response [6,7]. To generate a tarian country team (HCT) and the response interventions, identifying and unity of purpose among health cluster numerous clusters engaged in different filling critical gaps and revitalizing the partners and improve the quality and humanitarian response domains. capacity of a country’s health system effectiveness of response interventions Figure 2 illustrates the total number for preparedness and response. The for the IDPs, a health cluster strategy of displaced families and returnees by resolution requested Member States was developed. This article aims to il- area of origin from August 2008 to to integrate risk reduction in health sec- lustrate the components of this jointly March 2010 upon restoration of secu- tor development interventions, apply formulated strategy and exhibit its influ- rity in their home towns and villages. risk mapping in order to reflect the role ence on the nationwide access to quality Figure 3 illustrates the crisis-affected and importance of public health infra- and life-saving services. structure, to pay particular attention to areas, the routes of the IDPs’ migration mental health needs and gender-based and the hosting districts in which they violence, to improve national mecha- Methods temporarily sought sanctuary. The dis- nisms for emergency health response lodgment of the IDPs occurred in sepa- and to enhance financial contributions The emergency health response func- rate waves. IDPs from Swat and Buner to generate sufficient capacity at the tions stipulated in the Global Health shifted in July and August 2009, while national level [1]. Cluster Guide and the country-level the displacement from South Waziris- Valuable experience was gained harmonized roles of different humani- tan commenced later when the majority from the five disasters which affected tarian clusters, collectively steered of IDPs from Swat had returned to their Pakistan since 2005: the 2005 earth- by the UN Office for Coordinating homes. The large number of off-camp quake in northern Pakistan, the 2006 Humanitarian Affairs (OCHA), were IDPs and their scattered presence in cyclone and floods which affected 14 the basis of the health cluster strategy various districts and disjointed displace- districts in the provinces of Balochistan [6]. The participatory strategy-design ment required a health response strat- and Sindh, the 2007 earthquake in the consultations carried out by the health egy capable of addressing the evolving Balochistan districts of Ziarat and Pishin cluster, the health response operational operational challenges. and the 2008–09 crisis in the Federally needs reflected by the assessment teams Employing knowledge from previous Administered Tribal Areas and Khyber and the published literature, including disasters in Pakistan since 2005, it was Pakhtunkhwa (formerly North-West the WHA resolutions on the subject, evident that without a common shared Frontier Province), which resulted in were reviewed. health cluster strategy, the response in- 2.6 million internally displaced persons tervention carried out by 46 different (IDPs) [2–4] who were forced to flee health cluster partners would result in their homes but remained within their Results fragmentation, duplication and ineffi- country’s borders. ciency. Against this backdrop, WHO led The Health Cluster approach is a The Khyber Pakhtunkhwa and Federally a participatory process of consultations strategy developed to organize and co- Administered Tribal Areas humanitar- engaging the government and health ordinate cooperation among humani- ian crisis of 2008–09 displaced 2.76 mil- cluster partners. A comprehensive health tarian actors and build partnerships in lion people, creating a massive need for cluster strategy guiding the IDPs’ emer- planning and response during disasters. humanitarian action. The IDPs moved gency health response interventions was This approach, first tested on a large scale to safer and protected districts with 12% developed, unanimously endorsed and in Pakistan during the 2005 earthquake, settled in camps and 88% hosted by disseminated for implementation. The has generated successful outcomes, local communities, reflecting the gen- strategy had a well defined operational prompting its nationwide application erosity and compassion expressed by scope covering the following 13 health for managing humanitarian disasters the general population. On an average, response interventions.
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Humanitarian Country Team UN Country Government Team/ Humanitarian Resident Coordinator Coordinator
OCHA National Disaster Economic Management Health Sector Affairs Divisions Authority Inter -cluster Coordination Group
Ministry of Health Clusters constituted for Humanitarian Emergency Response Interventions Emergency Response Interventions
Provincial Disaster Provincial Health Management Department Authority WHO Coordinatimg Role Health Cluster District Health co-chairing WHO Health System Agency country 46 partners in the Cluster along IDPS crisis with representative MoH/HD Emergency Health Officer Health Cluster Coordinator
Figure 1 Humanitarian health response coordination framework in Pakistan (IDPs = internally displaced persons; OCHA = UN Office for Coordinating Humanitarian Affairs)
4 809 Kurram*
25 348 Orakzai* Agencies (*)/Districts (**)
38 524 South Waziristan* Total IDP families Returned families 12 547 Shangla** 7 933 Total IDPs Families: 446 755 Total returnees: 267 410 (60%) 27 462 Mohmand* Remaining IDPs Families: 179 345 (40%) 2 124 37 527 Lower Dir** 27 788 61 173 Bajaur* 26 346 75 255 Buner** 70 553 164 110 Swat & Malakand** 132 666
0 20 000 40 000 60 000 80 000 100 000 120 000 140 000 160 000 180 000
Figure 2 Total number of displaced families and returnees by area of origin from August 2008 to March 2010 (Source: Special Support Group (IDPs), PDMA (Provincial Disaster Management Authority) & CAR (Commissioner Afghan Regugees) as of 22 March 2010) Average family size: 7.3 IDPs = internally displaced persons
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and implement immediate control measures upon outbreak confirmation. The DEWS network covered all health facilities located in the crisis-affected region, while a WHO team in coordina- tion with government health authorities prepared and widely shared a DEWS weekly bulletin. To avert the risk of outbreaks, the DEWS intervention was coupled with promotive and preven- tive health advocacy and the provision of safe drinking-water and sanitation. DEWS was sustained by the health authorities during the post-disaster re- habilitation and reconstruction period, rendering its functions, through WHO technical support, a permanent feature of the district health system. Controlling disease outbreaks The validated DEWS findings were classified as sporadic cases or evolv- ing outbreaks, for which the relevant response was mobilized: intensive case management and timely dispatch of medicines and supplies, while maintain- Figure 3 The movement of the internally displaced persons from the crisis ing the supply of safe drinking-water affected agencies and districts of the Federally Administered Tribal Area and and sanitation, hygiene promotion and Khyber Pakhtunkhwa province vector control. The three diseases that caused over 70% of all outbreaks were diarrhoeal diseases, measles and hepati- Coordinating health action in crises population’s health status; their desired tis (A & E) viral infections, necessitating Coordination was recognized as the health needs and related perceptions. enhanced preparedness capacities. Dis- overriding strategic function providing Similarly the health system infrastruc- ease control efforts also encompassed an appropriate mechanism for manag- ture and the availability of human re- interventions for endemic priority com- ing health interventions. WHO assigned sources, medical supplies, equipment municable diseases such as tuberculosis a senior officer exclusively as cluster (including ambulances), logistics, for and malaria supported by a network of coordinator to facilitate the regular referral support were assessed as well as laboratories backed up by the special- health cluster meetings at national and physical access to health facilities within ized National Institute of Health. the prevailing security environment. provincial levels, improve information Essential services package: enhancing These data were the foundation for ef- sharing and joint planning, and rational- quality and equity ize resource mobilization, while effec- fective and need-based planning and The fielding of skilled human resources tively liaising with other clusters and enhanced the confidence of the health and the application of best health OCHA to align health with the overall cluster in estimating the resources nec- response practices was a key compo- humanitarian response coordination. essary for the response. nent of the health cluster strategy that Initial rapid assessment Establishing the disease early prompted the development of a set of In order to rationalize health response warning system institutional and service delivery guide- interventions and pave the way for The disease early warning system lines and standards for all catchment need-based resource mobilization and (DEWS) is designed to rapidly detect area health facilities including referral action, the health cluster mandated the the occurrence of 16 pre-selected dis- district hospitals. The package stipulated undertaking of rapid health assessment eases and conditions that would en- promotive, preventive and curative care at the outset. Data were collected on the able the health cluster to investigate services and the provision of a defined
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Table 1 Essential operational guidelines and standards for the provision of primary health care services at different health facilities during emergencies Standards for health post/basic health unit ōStructural standards for the establishment of a health facility/ ōEssential supplies and equipment for camp health post/basic basic health unit health unit ōStandards for the provision of essential health services in a ōHuman resources for camp health post/basic health unit camp health post/basic health unit ōRecording and reporting tools ōEssential medicines for a camp health post/basic health unit ōAmenities required at the camp level Standards for mobile health clinic ōHealth services provided by a mobile health clinic ōRecording and reporting tools ōEssential medicines for a mobile health clinic ōStandards of provision of an ambulance at a mobile health ōEssential supplies and equipment clinic ōHuman resources Standards for rural health centre ōStructural standards for a rural health centre ōHuman resources ōStandards for the provision of essential health services in a ōStandards for the provision of an ambulance at a rural health rural health centre centre ōEssential medicines for a rural health centre ōRecording and reporting tools ōEssential supplies and equipment for a rural health centre General guidelines ōDisease early warning system ōSurveillance system ōRapid health assessment ōAlert outbreak response and control Key communicable diseases ōAcute watery diarrhoea ōAcute respiratory infection control in adults ōAcute respiratory infections in children ōMalaria and tuberculosis Persons with disabilities ōHealth; promotive, preventive, medical care, rehabilitation ōLivelihood: access to livelihood opportunities ōEducation; access to educational services Environmental health ōWater facilities, access to water, water quality ōWater waste disposal and health care waste disposal ōExcreta disposal ōFood storage and preparation
essential list of medicines, supplies and IDPs, children between six months essential health services package. The equipment as well as the deployment of and 13 years were vaccinated against health workforce necessary to deliver human resources having the necessary measles, while the under-fives were maternal, neonatal and child health skills for effective health response. vaccinated against polio. Moreover, services was standardized with the in- Table 1 illustrates the salient tasks the backlog in routine immunization tention to field female care providers for which specific operational guide- services was covered to control the in all health facilities. These standards lines and standards were set. They have risk of vaccine-preventable diseases. were to cater for female care seekers induced uniformity, established mini- Likewise, tetanus toxoid vaccination who desired to be attended by female mal quality standards and enhanced was offered to all pregnant women. care providers while facilitating access the effectiveness of the implementation These vaccinations were planned and to basic and comprehensive emergency process. carried out by the government with obstetric and neonatal care services. UNICEF and WHO technical assist- Mass vaccinations Nutrition surveillance ance and with the active support of all Health cluster partners integrated Mass vaccination of target child cohorts health partners. was a priority component of the health nutrition surveillance into the health cluster strategy. During the crisis most Maternal, neonatal and child health cluster strategy, linked it operationally children lost access to routine immuni- The delivery of maternal, neonatal and with nutrition cluster operations and zation services. This was compounded child health services including repro- aligned it with DEWS implementation. by the departure of a significant number ductive health and family planning con- Accordingly, nutrition surveillance of the health workforce for security stituted a primary health cluster strategy and the management of severe child reasons. Following the migration of the pillar and a fundamental element of the malnutrition was placed in the WHO
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comparative advantage domain where medicines, medical equipment for by assessing the contamination and the organization has better capacity to hospital capacity-building and for life- chlorination levels of supplied water engage relative to other partners. These saving logistics (Figure 4). provisions. To fulfil this vital function, interventions contributed to child sur- The WHO logistic supply system WHO environmental officers closely vival and largely mitigated the risk of database was introduced in order to liaised with government institutions childhood mortality and morbidity. control the entry of procured or do- and operated mobile testing kits to Health promotion and education: nated supplies, facilitate the tracking regularly check water chlorination, community action for health of available stockpiles along with their both at the source and at the users’ end. Contamination of water sources with Displaced communities were exposed shelf lives and maintain an inventory of coliform bacteria, largely from shallow to unhealthy environmental conditions the stocks released to the field. WHO- procured medicines were distributed to wells, was blocked through coordina- resulting from the risk of unsafe drink- a large number of health cluster partners tion with WASH to avert the risk of ing-water, poor hygiene and sanitation, and government facilities, which de- waterborne disease outbreaks. To crowded makeshift shelters and defi- pended primarily on this supply chain enhance the use of sanitary latrines, the ciencies in food safety practices. Health for their field operations. WASH cluster was advised to separate promotion and education interventions male and female toilets to encourage Safety of drinking-water supply and were carried out as an integral compo- utilization and deploy sanitary workers sanitation nent of the health cluster strategy at all to safeguard their cleanliness. A health service delivery outlets and through The regular supply of safe drinking- education programme, promoting women’s focal group sessions promot- water to disaster-affected populations water safety and hygienic sanitation ing hand-washing, home health care was carried out by the Water, Sanitation was implemented to reinforce the im- practices and improved care-seeking and Hygiene(WASH) cluster. Similar portance of these practices. behaviour. To consolidate this process, arrangements were also pursued for WHO introduced the “Bangle Health the construction of sanitary latrines Mental health and psychosocial Education” initiative for mothers resid- for the affected population, especially support ing in the largest IDP camp. Colour- those residing in camps. WHO was The IDPs were predisposed to a range ful bangles, commonly worn by rural technically assigned to monitor water of mental and psychological conditions, women, were distributed when a group of mothers successfully completed a health education package, as a token Medical of their participation and learning, fa- warehouses/health facilities cilitating the dissemination pace and fehabilitation Resources 3% acceptance rate of these messages. assigned to Procurement, supply and management Implementing partners Emergency Health of essential medicines 25% Kits in support of IDP’s health This important strategic component response facilitated the setting of guidelines for 32% acceptable pharmaceutical donation, procurement, warehousing, stockpiling and distribution of essential life-saving National staff 9% medicines and supplies to which sub- stantial humanitarian health resources International staff 2% Medical equipment were assigned. Prequalification criteria for hospital and quality control measures were in- Field/operational capacity troduced by WHO covering all medi- costs enhancement 5% 9% cines, and a committee coordinated National training Ambulances, vehicles their acquisition. activities/capacity and generators building for hospitals The use of WHO-managed grants 2% 13% earmarked for the IDPs’ health response interventions during 2008–09 ensured Figure 4 Use and expenditure analysis of WHO-managed grants earmarked for internally displaced populations during 2008–09 (IDPs = internally displaced that over 50% of the resources were persons) used for the procurement of essential
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thus mental health was a key strate- populations resulting from natural or for the delivery of life-saving maternal, gic priority for the health cluster. The human-made disasters leads to the neonatal and child care services and Ministry of Health and the Khyber mobilization of humanitarian relief other vital emergency health response Pakhtunkhwa Provincial Health De- operations to mitigate suffering [1,7,8]. interventions within the framework partment together with academic insti- Commonly these interventions are of primary health care and consistent tutions and WHO mobilized a critical marred by a lack of coordination with with prevailing sociocultural norms mass of mental health teams to serve in fragmentation, implementation gaps, of Pakistani society [11]. Accordingly, the disaster affected areas on a rotational duplication and parallel implementa- humanitarian health relief operations basis. These professionals were also tion [9]. These operational paradigms were channelled through the existing required to mainstream mental health create inefficient distribution and use of health services network from the newly into the primary health care network scarce technical and material resources. established in-camp health facilities to to sustain these services. A limited list The enormous challenges posed by the the basic health units, rural health cen- of essential medicines was compiled 2008–09 IDP crisis in Pakistan led to tres, sub-district hospitals and district and procured for eligible mental health a serious societal disruption with grave hospitals, which received the bulk of cases. These interventions have offered health, economic and environmental life-threatening emergencies and clini- mental health and psychosocial support consequences, exceeding the coping cally severe referral patient load. The services the prominence they deserve; a capacity of the population affected. The strategy enabled federal, provincial paradigm replacing the traditional ne- large number of off-camp IDPs, their and district health managers to moni- glect or focusing solely on therapeutic sparse geographical distribution and tor and guide performance closely and psychiatric care. phased displacement, with certain IDPs objectively, oversee the flow of the Assisting persons with disabilities returning home while others were be- supply chain and appraise the results ing simultaneously displaced required attained. Among the IDPs, as in most humanitar- an immediate health response action ian disasters, a substantial proportion A key strategic component critical guided by a shared operational strategy of victims acquired disabilities, while at the outset of the emergency was the to address the acute health needs and others had disabilities before the disas- initial rapid assessment of the health sta- avert impending morbidities and mor- ter. During the crisis, displaced persons tus of the affected population, the health talities [10]. This vision was facilitated with disabilities were removed from system performance and the availability by the cluster approach first applied on a their traditional supportive environ- of human and supply resources, in ad- large scale during the 2005 south Asian ment and confronted serious adaptation dition to nutrition and safe water and earthquake, generating effective and challenges. To address these impedi- sanitation aspects, both in the crisis-af- cohesive partnerships among different ments, WHO, in collaboration with the fected districts and in the districts host- national and international humanitarian government and other interested health ing IDPs. The evidence generated was organizations [5,6]. The health cluster cluster partners, initiated a programme immediately used to revitalize primary strategy was designed to provide clearer offering rehabilitation and social sup- health care services, enhancing hospital avenues for effective coordination, port and offering access to specialized capacities in essential medicines, sup- joint planning, distribution of roles and diagnostics facilities and opportunities plies and equipment and other structur- responsibilities, resource mobilization for rehabilitation. These endeavours al and competency-related operational enabled many persons with disability and the creation of operational syn- priorities [12]. Essential medicines and to re-engage meaningfully in their social ergies, complementarities and shared supplies constituted the most cost- environment. To sustain the benefits of accountability between partners. These intensive strategic component, and the this intervention, the community-based capacities were unattainable without health cluster partners recognized the rehabilitation programme, successfully this shared strategic vision. The coor- value of using a common procurement implemented in the aftermath of the dination component had the greatest and supply system managed by WHO 2005 earthquake disaster, was also ex- bearing on the comprehensiveness and for greater economies of scale, quality panded to the IDPs. quality of emergency health response and efficiency [13]. interventions and enabled the partners To avert a second wave of death to work in unison for the delivery of following the initial devastation, an Discussion relief operations. epidemic control approach guided by In order to translate the 13 succinct DEWS was implemented [14]. The The immediate deterioration in access operational components of the strate- latter built on the surveillance of 16 to essential health care and the rapid gy into action, a functionally integrated critical notifiable diseases and condi- decline in the health status of affected essential service package was devised tions allowing for prompt investigation
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of all reported alerts, while the relevant care-seeking practice. The health clus- provide effective coverage and access disease control interventions were set ter strategy also emphasized extending to essential services with rational geo- in motion. Contrary to earlier reports health response interventions to include graphical distribution; apply key health underrating the effectiveness of dis- secondary prevention and treatment of indicators to monitor progress; define aster training for health care workers, chronic noncommunicable diseases, expected attainable results; promote the training on DEWS was effective in care of persons with disabilities and the gender equity in the response action; averting and controlling imminent epi- provision of mental health and psycho- recognize the perceived needs of the demics among IDPs and their hosting social support, conditions often missed affected population; and inculcate dis- communities [15]. Our observation is from the ambit of emergency health aster risk mitigation. These imperatives corroborated by an earlier experience response interventions [17–19]. should be put into operation to enable related to health workers’ training on Contrary to high level strategies an objective evaluation of the Pakistan essential surgical skills—emergency that cannot be drilled down to the experience and allow its subsequent maternal and child health following operational level, the health cluster replication in similar settings. the 2005 earthquake, with tangible strategy was an actionable tool, resolv- The recently established National improvements in maternal, neonatal ing key challenges often faced during Centre for Health Emergency Prepar- and child health outcomes [16]. This disasters and creating opportunities edness and Response by the Ministry experience illustrates the importance for cooperation, effective communica- of Health in Islamabad with WHO of across-cluster collaboration. These tion, collective efforts for health system efforts were supplemented by expand- technical support aims to provide lead- strengthening and shared compli- ing routine immunization activities ership in developing a national health ance with set operational, technical, and campaigns to promote awareness emergency mass casualty plan, scale up organizational and logistical norms of health and nutrition, which were hospital response capacity and organize and standards. It ensured the neces- sustained throughout the relief opera- the development of a health workforce sary access to life-saving services. The tion. possessing the required managerial and availability and prompt deployment of technical competencies to respond ef- The essential health care package a qualified national health workforce implied the implementation of a range fectively to future disasters following has characterized all subsequent Paki- of primary health care services of a the parameters set by the health cluster stani emergency health response inter- promotive, preventive, curative and strategy. The successful implementation ventions, an asset that has effectively rehabilitative nature defined for each of the strategy has generated a unity contributed to the success of these hu- level of care. The package included the of purpose, improved the quality and manitarian endeavours. This national provision of a standard list of life-saving effectiveness of health interventions capacity should be harnessed in the medicines, supplies and equipment as and strengthened the cooperation and future to promote greater self-reliance well as the deployment of a minimum coordination between the national and in emergency preparedness at national, number of qualified human resources international partners engaged in this provincial, district and community lev- possessing the necessary skills for the complex humanitarian endeavour. The job in hand. This has created a shared els with special focus on the safety of future application of this strategy would commitment to collectively meet the health facilities and strengthening the constitute a major asset in managing terms of an acceptable quality threshold capacity of the health system. disasters regardless of the size of the for service delivery. Maternal, neonatal To strengthen the capacity of hazard and level of population vulner- and child health including reproduc- this strategy in improving health re- ability. tive health and family planning was a sponse outcomes and attending to central pillar of this essential package. the unresolved gaps; humanitarian Accordingly, women requiring emer- partners have to adopt the necessary Acknowledgement gency referral support were accessing technical and managerial tools that comprehensive emergency obstetric would enhance the outcome and The authors wish to acknowledge and neonatal care facilities organized in impact of these strategic interven- the contribution of the UN Office for district hospitals with tangible maternal tions. To strengthen the level of ac- Coordinating Humanitarian Affairs and newborn survival outcomes, thus countability, an outcome and impact (OCHA) for providing updated in- transforming the prevailing traditional assessment monitoring system need formation regarding the internally dis- fatalistic perception about maternal to be established. The latter has to be placed families and their movement and and neonatal death into a purposeful able to respond to life-saving needs; returning trends.
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Safe water supply in emergencies and the need for an exit strategy to sustain health gains: lessons learned from the 2005 earthquake in Pakistan M. Magan,1 K.M. Bile,1 B.M. Kazi 2and Z. Gardezi 3
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ABSTRACT The bacteriological quality of drinking-water supply of five major urban centres affected by the October 2005 earthquake in Pakistan were assessed in three phases: onset of emergency, during emergency response and post-emergency. A total of 1850 samples were randomly collected from the study area during each phase, and faecal coliforms were detected in 100%, 28% and 91% in Battagram, 81%, 22% and 77% in Mansehra, 100%, 27% and 92% in Rawalakot, 100%, 23% and 65% in Bagh and in 30%, 14% and 5% in Muzaffarabad respectively. Faecal contamination was high during the onset of emergency and post-emergency phases in four out of the five surveyed towns. The organization of a timely emergency response intervention depends on the level of preparedness of local water-supply service providers as well as on their institutional capacities. Bacteriological water-quality improvements in emergencies may not be sustained unless complemented by a proper exit strategy.
Approvisionnement en eau saine lors des situations d’urgence et nécessité d’une stratégie de sortie pour conserver les gains de santé : enseignements du tremblement de terre survenu en 2005 au Pakistan
RÉSUMÉ La qualité bactériologique de l’approvisionnement en eau de boisson dans cinq grands centres urbains touchés par le tremblement de terre d’octobre 2005 au Pakistan, a été évaluée au cours de trois phases : apparition de la situation d’urgence, riposte à la situation d’urgence et phase post-urgence. Au total, 1850 échantillons ont été prélevés au hasard dans la zone d’étude au cours de chaque phase. Le pourcentage d’échantillons de chaque phase contenant des coliformes fécaux s’établissait comme suit : 100 %, 28 % and 91 % à Battagram, 81 %, 22 % et 77 % à Mansehra, 100 %, 27 % et 92 % à Rawalakot, 100 %, 23 % et 65 % à Bagh, et enfin 30 %, 14 % et 5 % à Muzaffarabad. On a constaté une contamination fécale élevée au cours des phases d’apparition de la situation d’urgence et post-urgence dans quatre des cinq villes étudiées. L’organisation d’une intervention de riposte opportune à la situation d’urgence dépend du niveau de préparation des fournisseurs locaux en eau et de leurs capacités institutionnelles. L’amélioration de la qualité bactériologique de l’eau lors des situations d’urgence peut être compromise si elle n’est pas complétée par une stratégie de sortie adaptée.
1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to M. Magan: [email protected]). 2National Institute of Health, Islamabad, Pakistan. 3Earthquake Rehabilitation and Reconstruction Authority, Islamabad, Pakistan.
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Introduction and disease surveillance hubs in these post-emergency period, 1 June 2006 affected towns. In each of these towns, to 30 January 2010, when emergency The associations between water, sanita- the drinking-water supply was obtained support interventions were phased out tion and health are well known, but these from surface water sources or shallow (phase 3). associations achieve greater importance springs that were easily contaminated Bacteriological water-quality data following a natural or man-made dis- by the disposal of untreated municipal collected in the three phases were aster, when waterborne disease out- wastewaters and drainage effluent from compiled and analysed, while obser- breaks may spread easily. Under such agricultural areas [6,7]. Earlier reports vations were made of the capacity of situations, adequate water supply and showed that surface water was faecally local authorities to sustain the attained sanitation are essential for the health contaminated and required elaborate improvements after scaling down the and well-being of affected communities. treatment for human consumption [8]. humanitarian support. Municipalities Diarrhoeal diseases are a major cause of To improve bacteriological water qual- and water authorities where support was morbidity and mortality among popula- ity, various types of water treatment provided during the emergency period tions affected by emergencies, mostly, system had been installed, but with the were revisited during the study in order caused by unsafe drinking-water [1]. exception of those in Muzaffarabad to determine the level of safe water-sup- Consumption of water contaminated by town, they never worked properly due ply services after the departure of the aid faecal matter is one of the major causes to poor management and lack of main- agencies and local emergency response of death in emergencies: for example, tenance funds. teams. To get representative samples for after the influx of 800 000 Rwandan Prior studies have shown also that the water-supply chain as a whole, water refugees into the Democratic Republic even fully protected sources and well samples were obtained from the exit of the Congo in 1994, 85% of the 50 000 managed systems do not guarantee that of the treatment plants, water storage deaths recorded in the first month were safe water is delivered to households tanks, various randomly selected water caused by diarrhoeal diseases resulting as water collected from safe sources is distribution lines, household water con- mainly from bacteriologically contami- likely to become contaminated during tainers and from places most vulnerable
nated water [2]. A compelling reason to transportation and storage [9]. to contamination. Water sampling was promote improvement of bacteriologi- The aim of this study is to evaluate performed daily during the early stages cal quality of water is the ability of this the bacteriological quality of drinking- of the emergency, but reduced later to health-related intervention to reduce water supply during emergency and weekly and monthly sampling depend- the infectious disease burden of the user post-emergency periods, assess its ef- ing on population size and overall risk population [3]. Microbial contaminants fects on the frequency of acute diar- of water contamination. of drinking-water are of a higher priority rhoea and advocate the formulation of First the survey team conducted than chemical contaminants, because proper exit strategies that sustainably desk analysis for identification of water their adverse health effects are usually improve the drinking-water’s bacterio- sources, water treatment plants, loca- immediate and more prevalent [4]. logical quality. tions of storage tanks and layout of the The 2005 earthquake in Pakistan distribution networks. To examine the affected a large population, a signifi- bacteriological quality of drinking-wa- cant proportion of whom were living Methods ter, survey teams measured water pH, without access to safe water and proper turbidity, residual chlorine and faecal sanitation even prior to the disaster. The study was conducted in five major coliform levels during the survey period. This situation was compounded by the urban centres of areas of Pakistan af- The detection of faecal coliforms in 100 devastating earthquake where 3880 wa- fected by the October 2005 earthquake ml of water sample was taken as an indi- ter-supply schemes were damaged and from October 2005 till January 2010. cator of bacteriological contamination needed rehabilitation and reconstruc- Bacteriological water-quality data were of drinking-water supplies. tion [5]. The five densely populated collected in three phases: in the imme- The sample size, collection, preser- urban centres of Rawalakot, Bagh, Mu- diate aftermath of the disaster, from 10 vations and analysis were conducted zaffarabad, Manshera and Battagram, October to 30 November 2005, when according to the standard methods which also hosted a large number of treatment systems were not fully in for bacteriological water-quality test- internally displaced persons in the after- operation (phase 1); during emergency ing [10], and proper procedures and math of the earthquake, faced high risk relief operations, 1 December 2005 to precautionary measures were followed of infectious disease outbreaks, which 30 May 2006, when the national and while collecting samples from the field. prompted the establishment of bac- international emergency response was During sample collection, sanitary sur- teriological water-quality monitoring in full swing (phase 2); and during the veys were conducted on the sample
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collection sites’ general cleanliness and of uniform pore diameter, 0.45 μm. water supplies during phase 1 and phase possible sources of contamination. Bacteria if present are retained on the 3 of the study (Table 1). It also demon- Water samples for microbiological surface of the membrane, which is strated how microbial quality of water contamination were collected in clean, placed on a suitable selective medium deteriorated in between the source and sterile plastic bottles (200 ml) and 1000 in a sterile container and incubated at consumer end. Phase 1 of the study ml sterilized glass bottles; and care was an appropriate temperature. If faecal or detected faecal coliforms in 100% of the taken to ensure that no accidental con- other coliforms are present in the water water samples obtained from various tamination occurred during sampling. sample, characteristic colonies form water sampling sites in Bagh, Rawala- Aseptic techniques were followed when that are counted directly. For treated kot and Battagram (Table 1). With handling the sterile sample bottles used water, 10 mg of sodium thiosulfate per the exception of Muzaffarabad, water for microbiological sample collection. 100ml of chlorinated water was added treatment plants in most of these urban The water samples for bacteriological to neutralize chlorine in the sample be- centres had never functioned properly quality were analysed for faecal coliform fore undertaking microbial testing. due to years of neglect and shortage of contamination only. Training was con- The reported incidence data of acute operational funds. ducted for local drinking-water service diarrhoea, compiled for over a period During phase 2 of the study, an providers on methods of conducting of four years were obtained from the extensive national and international sanitary surveys, water sampling and disease early warning system (a com- response was mobilized, and effective physical and microbiological testing of municable disease surveillance system measures taken to ensure the safety of water samples. designed to detect epidemics and guide drinking-water supplies by the govern- During the first seven months of timely response strategies) and analysed ment- and UNICEF-led Water, Sani- the emergency period bacteriological using EPI-Info software . tation and Hygiene (WASH) cluster. water-quality testing was carried out Dysfunctional water treatment systems using the H2S test kit, which has a high in Battagram, Mansehra, Rawalakot and level of specificity and an acceptable Results Bagh were immediately rehabilitated, level of enhanced sensitivity [9]. The and proper water treatment/disinfec- Oxfam DelAgua water testing kit apply- This study was conducted in five major tion systems introduced. This resulted ing the membrane filtration method for urban centres (Muzaffarabad, Bagh, in a tremendous improvement in the detecting faecal coliforms was used dur- Rawalakot, Mansehra and Battagram) microbial quality of the drinking-water, ing the remaining period of the study. affected by the 2005 earthquake, and where faecal coliforms were detected For H2S water testing, sample bot- water microbial quality was surveyed in only 23% of samples in Bagh, 27% tles were first sterilized with 6% bleach in three phases: in the immediate after- in Rawalakot and 28% in Battagram solution and then rinsed several times math of the disaster; during emergency (Table 1). with the sample water before collecting relief operations; and during the post- After May 2006, during phase 3 of the sample. A medium was then added, emergency period. the study, when the humanitarian situa- and the sample incubated at 25–35 °C During phase 1 some baseline data tion of the affected areas was stabilized, for 24 hours. If no black precipitate (a on the quality of the existing water- most international and national aid sign of test positivity) became appar- supply systems were obtained by the agencies scaled down their operations ent after 24 hours, it was incubated for environmental health teams who were in the field and consequently the sup- another 24 hours. If the sample still assisted by the World Health Organiza- port for bacteriological water-quality remained clear yellow, a negative test tion (WHO). The same bacteriological improvements dwindled substantially. result was recorded. Portable kits were water-quality parameters were tested Water treatment systems of four out used also for testing water pH, turbidity during phase 2 and phase 3 of the study of the five surveyed towns could not and residual chlorine levels. to determine any significant variation of be maintained by the local authorities During the post-emergency phase the bacteriological quality of the drink- due to lack of sufficient funds. It was (June 2006 to January 2010) the mem- ing-water supplies. All surveyed towns frequently observed that most water brane filtration method was applied to received most of their drinking-water treatment plants lacked sufficient water estimate microbial quality of drinking- supplies from surface water sources that treatment chemicals (alum and chlo- water by using the Oxfam DelAgua were susceptible to contamination, ex- rine). water testing kit for detection of faecal cept Bagh, which received water from a It was also observed that water mi- coliforms [11]. A measured volume spring source. crobial quality deteriorated in between of water was filtered, under vacuum, Results of the study revealed the the source and the consumer due to through a cellulose acetate membrane poor microbial quality of most available intermittent supply, cross-connections
S93 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF
with sewerage systems and unhygienic found to be within WHO pH guide ERRA’s water and sanitation sec- handling of water at household level. values (6.5–8.5). tion, UNICEF and water-supply service Sanitary surveys conducted in the urban Figure 2 illustrates a four-year providers jointly launched a compre- centres revealed that many sections of monthly trend of acute diarrhoea of the hensive bacteriological water-quality drinking-water distribution pipes were five major towns affected by the 2005 improvement and promotion of hygiene installed inside open wastewater chan- earthquake. The frequency of acute project in February 2009. Under this nels that were full of stagnant waste- diarrhoea during the monsoon period project, sanitary inspection surveys of water (Figure 1). Results showed that was significantly lower in Muzaffarabad over 3500 water-supply schemes will be although Muzaffarabad drinking-water relative to the other four towns with an carried out. supply was safe at the exit point of the odds ratio ranging from 2.81 to 12.72 treatment plant, faecal contamination and with 95% confidence interval of was detected during all phases of the 2.74 to 13.03. Discussion study at the household level, with the The dissemination of the results was presence of faecal coliforms in 60%, At the onset of an emergency, a ma- usually shared with various stakeholders 25% and 9% of water samples respec- jor strategic objective is to protect the through Water, Sanitation and Hygiene tively (Table 1). health and well-being of the affected (WASH) cluster meetings in order to population by focusing primarily on the Phase 1 results revealed also that adopt preventive measures and create residual chlorine was detected in only provision of essential health services, awareness amongst the population and safe drinking-water, food and shelter one of the five surveyed towns’ water- local authorities. supply systems (Table 2); 60% of Mu- [1]. WHO assigned high priority to zaffarabad water samples were found After the emergency phase and the the provision of safe water and proper to have residual chlorine levels match- scaling down of the aid agencies’ sup- sanitation as an integral component ing WHO guide range of values [12]. port, the water and sanitation section of the health response, complement- Water turbidity occasionally exceeded of Pakistan’s Earthquake Rehabilitation ing disease surveillance and epidemic WHO guide values during the rainy and Reconstruction Authority (ERRA) control interventions. season; however all water samples were and WHO put their emphasis on build- Phase 1 bacteriological water-qual- ing capacity of local service providers ity surveys revealed the poor microbial through structured multilevel training quality of most available drinking-water activities in order to raise awareness supplies mainly due to lack of prepar- among all stakeholders on the interlink- edness, corroborated by prior studies ages between safe water and health. To carried out by the Pakistan Council of make capacity-building interventions Research on Water Resources [13]. It more practical, basic bacteriological is worth emphasizing that preparedness water-quality testing equipment was is essential for dealing with emergency provided to various local water authori- safe drinking-water supply, especially ties. the predeployment and stockpiling To strengthen routine bacteriologi- of sufficient quantities of water treat- cal water-quality monitoring, WHO ment chemicals and storage containers. supported the establishment of nine Emergency preparedness and response bacteriological water-quality testing programmes can be used as an essential laboratories in nine districts of the af- link between emergency relief, rehabili- fected areas, where in addition 18 tation/reconstruction and development water-laboratory technicians received requiring institutional capacity-building bacteriological water-quality testing and and awareness promotion at the com- monitoring refresher training courses. munity level to reduce vulnerability and ERRA’s water and sanitation section the risks of waterborne diseases [14]. and WHO held several workshops and Surface water represented the most meetings with provincial authorities accessible supply of water to the affected where the results and conclusions of communities, but these sources were Figure 1 Typical practice of installing the WHO-supported bacteriological easily contaminated by pathogenic or- drinking-water delivery pipes inside open waste and storm water channels water-quality survey were presented to ganisms and could not be considered all stakeholders. safe without treatment [15,16]. The
S94 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ value WHO guide % not matching 37 46 30 50 20 77 70 0 40 50 Phase 3 Total # Total of tests Post-emergency Post-emergency (1 June 2006 to January 2010) and Regular Irregular Irregular Irregular Irregular Treatment Treatment disinfection value WHO guide % not matching 23 0 42 0 30 0 20 0 20 5 Phase 2 Total # Total of tests Emergency response Emergency response and Regular Regular Regular Regular Regular (1 December 2005 to May 30 2006) Treatment Treatment disinfection value WHO guide % not matching of tests Phase 1 Onset of emergency Storage tankStorage 5 100 10 10 28 78 Storage tankStorage 4 100 13 0 20 60 Storage tankStorage 2 50 11 0 22 72 Storage tankStorage 7 11 19 0 20 0 Storage tankStorage 3 100 7 0 10 100 Sampling Sites # Total Treatment plant exitTreatment 4 25 plant exitTreatment 3 100 Treatment plant exitTreatment 3 100 Treatment plant exitTreatment 7 100 Treatment plant exitTreatment 13 0 Distribution network 5 100 10 30 77 65 Distribution network 5 100 19 26 25 83 Distribution network 6 92 20 10 33 81 Distribution network 4 35 25 8 80 2 Distribution network 4 100 16 19 40 100 Household container 12 100 37 43 97 100 Household container 14 100 51 39 86 89 Household container 16 60 88 25 150 9 Household container 14 100 59 39 143 70 Household container 11 100 50 46 110 100 (October 10 to November 30 2005) Regular Irregular Irregular Irregular disinfection Treatment and Treatment Battgram 25 100 86 28 170 91 Mansehra 26 81 102 22 178 77 Rawalakot 25Rawalakot 100 96 27 190 92 Muzafarabad 40 30 174 14 320 5 Total samples for Total Total samples for Total Total samples for Total Total samples for Total water water water water Total samples for BaghTotal 26 100 112 23 280 65 water sources Bacteriological water-quality results from various sampling sites (WHO guide value: 0 colony-forming-units/100 mL) from results Bacteriological water-quality Battagram Surface Bagh Spring Irregular Rawalakot Surface Mansehra Surface Muzaffarabad Surface Town Main Table 1 Table
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costs and sustainability issues associ- humanitarian support agencies scaled ated with surface water treatment, down their operations in the field, particularly routine maintenance of the support for bacteriological water- water treatment plants, need to be quality improvements to various
guide value carefully considered before surface affected districts dwindled substan-
% matching WHO water sources can be exploited [17]. tially. Results indicated the dramatic A remarkable improvement of decline of the bacteriological quality water safety was attained during phase of most available drinking-water sup- plies in four out of the five towns sur- Phase 3 2 of the study, when the concern over a second wave of deaths from com- veyed. Post-emergency Post-emergency guide value municable diseases resulted in mas- Results in all three phases of the % matching WHO sive local and international support study revealed also that water micro- to ensure the provision of safe water bial quality deteriorated in between supplies to all affected communities. the source and the consumer end, These efforts led to a considerable reaffirming earlier findings that even No. ofNo. tests improvement in the microbial quality fully protected sources and well man- of water, with residual chlorine levels aged systems do not guarantee that measured in most drinking-water sup- safe water is delivered to households ply systems matching WHO guide [2]. Safe sources are important, but values . However, the Battagram sur- it is only with improved hygiene, bet- guide value
% matching WHO face water treatment system always ter water storage and handling and faced difficulties, due to its incomplete improved sanitation that the quality water treatment infrastructure. of water consumed by people can be The contribution of safe water assured. Extending bacteriological Phase 2 supply and proper sanitation to water-quality protection from the
guide value health must always be recognized as sources to point of use is increas- Emergency response Emergency response % matching WHO a priority area during emergencies ingly becoming a common strategy in and post-emergency reconstruction water-safety programmes worldwide and development phases for which [2]. the necessary resources are to be mo- The relationship between the
No. ofNo. tests bilized. frequency of diarrhoea diseases and During phase 3 of the study, the bacteriological quality of drink- when most international and national ing-water was substantiated by the guide value
% matching WHO 25
ions
20
Phase 1 15 guide value Onset of emergency
% matching WHO 10
h respect to total consultat Residual chlorine Turbidity Residual chlorine5 Turbidity Residual chlorine Turbidity
No. ofNo. tests 0 % AD wit Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Bagh Battagram Mansehra Muzafarabad Rawalakot Residual chlorine (WHO guide value: > 0.2 mg–0.5 mg/l) and turbidity (WHO guide value: < 5 nephelometric unit) Figure 2 Average monthly pattern of acute diarrhoea (AD) in five major towns affected by the 2005 earthquake in Pakistan during 2006–09 BaghRawalakotBattagram 25 26 25 0 0 0 75 90 78 96 112 86 71 77 70 97 98 89 190 280 170 12 3 02 94 78 86 Muzaffarabad 40Mansehra 60 26 0 95 174 80 85 102 78 99 320 98 80 178 15 98 86 Town Table 2 Table
S96 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ
evident inverse correlation between meet the necessary technical, manage- and institutional capacity-development the frequency of acute diarrhoea and rial and funding requirements to main- efforts undertaken by the government, bacteriological water quality: there was tain the quality of water-supply systems. assisted by WHO and UNICEF, could a statistically significant diarrhoea risk The latter illustrates the necessity of not produce the desired results due to variance between Muzaffarabad and formulating sustainable exit strategies paucity of recurrent financing, a matter the other towns surveyed. The latter during the emergency response phase, that needs utmost priority attention. illustrates that excess morbidity and recognizing the responsibility of the lo- mortality caused by diarrhoeal diseases cal authorities to maintain the provision are largely avoidable if bacteriological of safe drinking-water to the population Conclusion contamination of water is effectively [18]. To address the water-safety issues controlled [12]. in the long run it is vital to sensitize Emergency health and WASH response The necessary capacities of local all the stakeholders in such a way that interventions aim to promote earliest water-supply service providers need to water-supply service providers and possible actions to reduce any loss of be built to guarantee a sustainable exit consumers are fully aware of the link- life in the aftermath of disasters. This strategy after the emergency response ages between safe water and health. The adversity however needs to be seen as aid organizations cease their support. post-earthquake experience has shown an opportunity to build-back-better and To address this challenge, humanitarian the predominant focus of humanitar- develop the capacity of local institutions organizations and the government need ian partners on short-term water safety in order to attain a reliable level of water to establish the necessary operational solutions rather than developing sus- safety and pursue it as an integral part of steps during the early recovery phase tainable exit strategies that can build the exit strategies that render the humani- of the emergency response in order to local capacities. The human resource tarian response gains more sustainable.
References
1. Connolly MA ed. Communicable diseases control in emergencies: Water Works Association/Water Environment Federation, a field manual. Geneva, World Health Organization, 2005:33. 2000. 2. Connolly MA et al. Communicable diseases in complex emer- 11. DelAgua portable water testing kit. User manual. Marlborough, gencies: impact and challenges. Lancet, 2004; 364(9449):842– United Kingdom, DelAgua Water Testing Ltd, 2000. 843. 12. Guidelines for drinking-water quality 1, 3rd ed. Geneva, World 3. Sobsey MD. Managing water in the home: accelerated health Health Organization, 2008 (http://www.who.int/water_sani- gains from improved water supply water. Geneva, World Health tation_health/dwq/gdwq3rev/en/index.html, accessed 20 Organization, 2002 (WHO/SDE/WSH/02.07; http://www. July 2010). who.int/water_sanitation_health/dwq/wsh0207/en/print. 13. Kahlown MA, Tahir MA, Rasheed H. Water quality status in Pa- html, accessed 19 July 2010). kistan (third report 2003–2004). Islamabad, Pakistan, Pakistan 4. Thompson T et al. Chemical safety of drinking water: assessing Council of Research in Water Resources, 2005 (No. 131-2005). priorities for risk management. Geneva, WHO, 2007. 14. Policy: integrating relief, rehabilitation and development 2006. 5. Water and sanitation strategy July 2006–June 2009: Build back Geneva, International Federation of Red Cross and Red Cres- better. Islamabad, Pakistan, Earthquake Reconstruction and cent Societies, Disaster Preparedness and Response Depart- Rehabilitation Authority, 2006 (http://www.erra.pk/Reports/ ment, 2006. Watsan-Strategy/WatSan-Strategy8sep.pdf, accessed 19 July 15. Schmoll O et al, eds. Protecting groundwater for health. Manag- 2010). ing the quality of drinking-water sources. Geneva, World Health 6. Kahlown MA, Tahir MA, Rasheed H. Fifth water quality monitor- Organization, 2006 (http://www.who.int/water_sanitation_ ing report 2005–2006. Islamabad, Pakistan, Pakistan Council of health/publications/protecting_groundwater/en/index.html, Research in Water Resources, 2008. accessed 20 July 2010). 7. Aziz JA. Management of source and drinking water qual- 16. Hubbs SA. Understanding water supply and treatment for indi- ity in Pakistan. Eastern Mediterranean Health Journal, 2005, vidual and small community systems. Arlington, USA, Volunteers 11(5–6):1087–1098. in Technical Assistance, 1985 (Technical Paper 32; http://www. 8. Nasrullah et al. Pollution load in industrial effluent and ground- cd3wd.com/cd3wd_40/vita/wtrtreat/en/wtrtreat.htm, ac- water of Gadoon Amazai industrial estate (GAIE) Swabi, NWFP. cessed 20 July 2010). Journal of Agricultural and Biological Science, 2006, 1(3):18– 17. Guidelines on technologies for water supply systems in small com- 24 (http://www.arpnjournals.com/jabs/research_papers/ munities. Amman, WHO Regional Centre for Environmental jabs_0906_23.pdf, accessed 20 July 2010). Health Activities, 1993. 9. UNICEF handbook on water quality 2008. New York, USA, 18. Water and sanitation policy. Geneva, International Federation United Nations Children’s Fund, 2008 of Red Cross and Red Crescent Societies, 2003 (http://www. 10. Standard methods for the examination of water and wastewater. ifrc.org/Docs/pubs/who/policies/watsan-policy-en.pdf, ac- Denver, USA, American Public Health Association/American cessed 20 July 2010).
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Large-scale physical disabilities and their management in the aftermath of the 2005 earthquake in Pakistan M. Mallick,1 J.K. Aurakzai,2 K.M. Bile1 and N. Ahmed3
2005êmKëmSm<éÐ}TÛnRÐK9mvD ABSTRACT The October 2005 earthquake in Pakistan created a new generation of “persons with disabilities” (PWDs) in the affected districts. A total of 741 people suffered spinal injuries while 713 underwent amputations. A comprehensive response was launched jointly by the Ministry of Health, Earthquake Reconstruction and Rehabilitation Authority and the World Health Organization involving rescue and recovery, hospitalization, surgical interventions, building of infrastructure, development of technical guidelines to improve quality of care, human resource deployment and training. The first national megaproject for institutional and community-based rehabilitation (CBR) services was launched in the earthquake-affected areas. The institutional management of PWDs is now carried out alongside the CBR programme. This intervention also led to the concept of a national CBR programme. The study aims to identify the post-earthquake situation regarding the magnitude and type of physical disabilities and to highlight the rehabilitative interventions undertaken. L’incapacité physique à grande échelle et sa prise en charge à la suite du tremblement de terre de 2005 au Pakistan RÉSUMÉ Le tremblement de terre survenu en octobre 2005 au Pakistan a entraîné l’apparition d’une nouvelle génération de personnes handicapées dans les districts touchés. Au total, 741 personnes ont été victimes de traumatismes médullaires et 713 ont subi une amputation. Le ministère de la Santé, l’Autorité chargée de la reconstruction et de la remise en état après le séisme [Earthquake Reconstruction and Rehabilitation Authority] et l’Organisation mondiale de la Santé ont organisé conjointement une riposte complète, comprenant des opérations de secours, de relèvement et d’hospitalisation, des interventions chirurgicales, la construction d’infrastructures, l’élaboration de directives techniques sur l’amélioration de la qualité des soins, et le déploiement et la formation de personnel. Le premier projet national de grande ampleur pour les services de réadaptation institutionnels et communautaires a été lancé dans les zones touchées. La prise en charge institutionnelle des personnes handicapées est désormais assurée en commun avec le programme de services communautaires de réadaptation. Cette intervention a également débouché sur le concept de programme national de réadaptation communautaire. L’objectif de cette étude est de décrire la situation consécutive au tremblement de terre, notamment l’ampleur et le type d’incapacités physiques, et de souligner les interventions de réadaptation engagées. 1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to M. Mallick: [email protected]). 2National Health Emergency Preparedness and Response, Islamabad, Pakistan. 3National Disaster Management Authority, Islamabad, Pakistan. S98 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Introduction inclusive legislation capable of integrat- universities, along with their eligibility to ing a disability dimension at the national participate in competitive employment An estimated 650 million people live level also did not exist in the country exams within their allotted quota of 2%. with disabilities around the world, 80% prior to the 1980s. The above-mentioned initiatives of whom are living in low-income coun- Following the United Nation’s dec- notwithstanding, service delivery capac- tries with limited or no access to basic laration of 1981 as the International ity in terms of rehabilitation measures health services including rehabilitation Year of the Disabled and 1983–1992 remained highly institutionalized with a services [1].The link between conflict, as the Decade of the Disabled, the first top-down approach. The community’s emergency situations and disability is disability-specific sectoral legislation vital role in the provision of rehabilita- incontrovertible as conflict and natu- was promulgated by the Government tive services was recognized only in the ral disasters are a significant cause of of Pakistan, consisting of the Disabled aftermath of the October 2005 earth- impairment due to increased rates of Persons Employment and Rehabili- quake, resulting in the launch of the injury, lack of medical care and disrup- tation Ordinance 1981. Thereafter, a first community-based rehabilitation tion of medical health care services [2]. national policy for PWDs was formal- (CBR) programme in the country. The 40-second duration of the 8 ized in 2002 by the Ministry of Social The objective of this paper is to October 2005 south Asian earthquake Welfare and Special Education, whose evaluate the magnitude and types of emerged as the most devastating natural National Plan of Action is currently post-earthquake physical disabilities, disaster in the history of Pakistan and under implementation. In September assess their consequent rehabilitative the region over the past century. While 2008, Pakistan became a signatory to needs and highlight the efforts made the huge death toll exceeding 73 338 the UN Convention on the Rights of during the relief and recovery phase for was overwhelming, an estimated 3.5 Persons with Disabilities, which out- the provision of comprehensive reha- million people were rendered homeless lines the obligation of states to protect bilitative services for PWDs. and another 128 309 sustained serious and ensure the safety of people with causalities, including spinal injuries and disabilities in situations of risk, including limb trauma, some leading to amputa- armed conflict [8]. Methods tions [3,4]. Though the concept of medical re- In many rural communities of Pa- habilitation was introduced in Pakistan Data regarding major disabilities involv- kistan, disabilities among household during the late 1990s, only a few public ing spinal cord injuries and amputations members are normally concealed, sector institutions provide comprehen- were retrospectively collected in Octo- especially those acquired from birth sive rehabilitative services. Current esti- ber and November 2005 to assess the or developed soon thereafter [5]. As a mates show that in developing countries magnitude of the problem. A standard result, socioeconomic data regarding only 2% of PWDs receive some form of questionnaire was developed for data disabilities are not well documented. rehabilitation assistance [9]. collection and several visits conducted to According to the 1998 population cen- The Government has taken certain major hospitals in urban cities, field hos- sus, persons with disabilities (PWDs) tangible measures by establishing com- pitals and camps in the affected districts. constituted approximately 3.287 mil- prehensive rehabilitation services such Detailed interviews were also conducted lion (2.49%), including all types of dis- as special computerized identity cards with health managers, district adminis- ability [6], which was significantly lower for PWDs, free medical treatment at trators and patients in the provinces of than the World Health Organization government hospitals, and implementa- Khyber–Pakhtunkhwa and Punjab, in (WHO) estimate of 10% [7]. This can tion of a 2% quota for their employment. addition to the Pakistan-administered be attributed to the varying definitions However, the implementation rate of Kashmir (PAK) territory. A total of 20 of disabilities, methodology used and such initiatives remains very low. The health facilities for spinal cord injuries the limited capacity for data collection Pakistan welfare fund Bait ul Maal was and 36 facilities for amputations were at the national level. established in 1992 for the provision visited. On completion of data collec- Additionally, there are only a few of social services to PWDs along with tion and verification from all the districts, fragmented programmes and services other marginalized members of the so- a reconciliation exercise was initiated that address the needs of PWDs, most ciety. PWDs also benefit from the wel- to eliminate duplications. Finally, the of which are primarily confined to ur- fare fund of Zakat and from the recently cumulative figures of 741 for spinal ban areas, resulting in considerable so- launched Benazir Income Support Pro- cord injuries and 713 for amputations cioeconomic burden evidenced by the gramme. An education quota of 1% for resulting from earthquake hazard were limited access to health, education and PWDs has been recommended by the compiled and analysed. For a tangible employment opportunities. Disability- Higher Education Commission for all number of these patients, their age and S99 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF level of spinal injuries and amputations amputations: 179 (42%) were tran- Of the 916 recorded injuries, the were not effectively documented. stibial (below knee) amputations while greatest share, 443 cases (48.4%) were 65 (15%) were transfemoral (above at the lumbar level, followed by 301 knee) amputations and feet were sur- (32.9%) cases at the thoracic level, while Results gically removed in 67 (16%) cases. cervical injuries constituted only 5.4% Seventy eight (18%) cases were simply (50 cases) of the surviving cases with According to the data collected for labelled as leg amputations, without spinal injuries. Only 0.6% of the cases this study, a total of 741 spinal injury being disaggregated as transfemoral or experienced sacral injuries, while in cases, with and without neurological transtibial amputations owing to inad- 12.8% of the cases the level of the injury deficit, were received in major hospi- equate documentation. was neither documented nor ascertain- tals in Rawalpindi, Islamabad, Lahore able. Figure 1 illustrates the geographic and Peshawar in October 2005 related Of the upper-limb amputations car- distribution of spinal cord injuries and to the earthquake, and another 713 ried out, 192 (66%) were recorded as amputations by district of origin. The cases experienced various kinds of limb major upper-limb amputations, includ- highest percentage of patients with spi- trauma leading to major and minor ing 116 (40%) transhumeral (above nal cord injuries (46%) originated from amputations. elbow), 40 (14%) transradial (below elbow) and 36 (12%) hand amputa- Muzaffarabad district, which was also Table 1 shows the spinal injuries the district with the greatest devastation, detected and amputations carried out tions. In 65 cases, it was recorded that followed by Mansehra (20%) and Bagh post earthquake by age and gender. The the dominant right upper limb was (18%). A similar pattern was observed majority of the spinal injury cases were amputated, which aggravated patients’ with regard to amputations carried out, females (62%) and the predominant functional limitations and caused them with 36% of these in Muzaffarabad, 22% age group was > 18–40 years (57%). In difficulty in performing activities of daily in Mansehra and 16% in Bagh. 12% of the spinal injury cases, the age living. of the patient could not be ascertained. Table 3 provides details about the The capacity of tertiary-level hospi- Similar to spinal injuries, the majority of level of post-earthquake spinal injuries. tals in terms of provision of rehabilitative amputations were undertaken in females Among the 741 spinal cases, a total of services was suboptimal considering the (51.3%) while the predominant age 916 injuries were reported. This differ- massive requirements of the catastro- groups were > 18–40 years (33.3%) and ence was due to multiple-level fractures phe and included a shortage of trained 5–18 years (31.26%) with 6% of the total involving the cervical, thoracic, lumbar health professionals and necessary under 5 years old; in 13% of the cases age and sacral vertebral column. Out of equipment. As a result, these patients could not be ascertained. the total of 741 cases, 71.2% developed were scattered across different wards, Table 2 lists the amputations carried some neurological deficit resulting in corridors and makeshift arrangements out by age, gender and level of amputa- complete or partial paraplegia or quad- in various hospitals, leading to pressure tions. Out of 713 total amputations, 423 riplegia. However, among the 50 cases sores, urinary tract infections and deep (59%) were lower-limb amputations with cervical injury, only 13 cases de- vein thrombosis. and 290 (41%) were upper-limb ampu- veloped incomplete quadriplegia while In order to cater to the immediate tations. Of the lower-limb amputations the remaining patients survived without needs, a young cadre of 57 males and fe- undertaken, 389 (91%) were major any neurological deficit. males was given a short, 2-week training Table 1 Detected spinal injuries and amputations post-earthquake by age and sex Injury Age group (years) < 5 5–18 > 18–40 > 40 Not listed Total No. % No. % No. % No. % No. % No. % Spinal cord M 3 0.40 40 5.40 165 22.27 40 5.40 37 4.99 285 38.46 injury F 3 0.40 104 14.04 257 34.68 38 5.13 54 7.29 456 61.54 Amputation M 19 2.66 113 15.84 103 14.44 61 8.55 51 7.15 347 48.66 F 24 3.36 110 15.42 135 18.93 53 7.43 44 6.17 366 51.33 Total M 22 1.51 153 10.52 268 18.43 101 6.95 88 6.05 632 43.47 F 27 1.86 214 14.72 392 26.96 91 6.26 98 6.74 822 56.53 Total 49 3.37 367 25.24 660 45.39 192 13.20 186 12.79 1 454 100 M = male; F = female. S100 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 2 Post-earthquake injuries for which amputations were carried out by age, sex and level of amputation Type of amputation Age group (years) < 5 5–18 > 18 Not listed Total No. % No. % No. % No. % No. % Lower-limb Transfemoral M 1 0.14 9 1.26 15 2.10 1 0.14 26 3.65 F 1 0.14 11 1.54 24 3.37 3 0.42 39 5.47 Transtibial M 4 0.56 33 4.63 45 6.31 6 0.84 88 12.34 F 7 0.98 26 3.65 48 6.73 10 1.40 91 12.76 Leg amputation M 3 0.42 17 2.38 16 2.24 8 1.12 44 6.17 F 0 0.00 8 1.12 22 3.09 4 0.56 34 4.77 Foot M 2 0.28 12 1.68 10 1.40 6 0.84 30 4.21 amputation F 5 0.70 9 1.26 17 2.38 6 0.84 37 5.19 Foot digits M 1 0.14 3 0.42 9 1.26 5 0.70 18 2.52 F 0 0.00 7 0.98 8 1.12 1 0.14 16 2.24 Subtotal 24 3.36 135 18.92 214 30.01 50 7.01 423 59.32 Upper-limb Transhumeral M 2 0.28 14 1.96 27 3.79 9 1.26 52 7.29 F 2 0.28 17 2.38 37 5.19 8 1.12 64 8.98 Transradial M 1 0.14 3 0.42 9 1.26 4 0.56 17 2.38 F 1 0.14 10 1.40 10 1.40 2 0.28 23 3.23 Hand M 3 0.42 6 0.84 9 1.26 1 0.14 19 2.66 amputation F 1 0.14 8 1.12 6 0.84 2 0.28 17 2.38 Hand digits M 2 0.28 12 1.68 15 2.10 5 0.70 34 4.77 F 7 0.98 11 1.54 11 1.54 3 0.42 32 4.49 Type not M 0 0.00 4 0.56 9 1.26 6 0.84 19 2.66 ascertainable F 0 0.00 3 0.42 5 0.70 5 0.70 13 1.82 Subtotal 19 2.66 88 12.32 138 19.34 45 6.3 290 40.66 Grand total M 19 2.66 113 15.85 164 23.00 51 7.15 347 48.67 F 24 3.37 110 15.43 188 26.37 44 6.17 366 51.33 Total 43 6.03 223 31.28 352 49.37 95 13.32 713 100 M = male; F = female. course in basic rehabilitation techniques (NIRM), Pakistan Institute of Medi- disability, and the rehabilitation process for the prevention of secondary compli- cal Sciences (PIMS) Satellite Centre was initiated through a multidisciplinary cations, in collaboration with the non- and Cantonment General Hospital approach. governmental organization Handicap Rawalpindi by inducting 100 doctors, The skills of the newly recruited International in October 2005. This 100 physiotherapists and 50 psycholo- staff were enhanced through train- initiative provided services for spinal gists in December 2005. WHO and ing workshops and certificate courses injury patients, especially for those who United Nations Children’s Fund conducted at NIRM. The acute underwent spinal fixation in major hos- (UNICEF) established 100-bedded shortage of occupational therapists pitals of Islamabad/ Rawalpindi, and prefabricated spinal injury units at was addressed by organizing a 3-week presumably averted many impending PIMS Satellite Centre and NIRM in training course for paramedics using a complications including pressure sores, December 2005 and January 2006, special curriculum developed for this muscle wasting and contractures in the respectively, where all the spinal injury purpose. patients. patients were subsequently moved. A WHO training manuals on promot- The Federal Ministry of Health up- comprehensive rehabilitation plan was ing independence following spinal cord graded and strengthened the National developed for each spinal injury patient, injuries were adapted and translated, Institute for Rehabilitation Medicine according to his or her type and level of in order to provide the necessary skills S101 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 3 Post-earthquake spinal injuries by age, sex and level of injury Level of injury Age group (years) < 5 5–18 > 18 Not listed Total No. % No. % No. % No. % No. % Cervical M 0 0.00 2 0.22 13 1.42 5 0.55 20 2.18 F 0 0.00 8 0.87 16 1.75 6 0.66 30 3.28 Thoracic M 0 0.00 21 2.29 97 10.59 10 1.09 128 13.97 F 1 0.11 28 3.06 128 13.97 16 1.75 173 18.89 Lumbar M 2 0.22 30 3.28 110 12.01 23 2.51 165 18.01 F 1 0.11 66 7.21 176 19.21 35 3.82 278 30.35 Sacral M 0 0.00 0 0.00 2 0.22 0 0.00 2 0.22 F 0 0.00 0 0.00 3 0.33 0 0.00 3 0.33 Not ascertainable M 2 0.22 4 0.44 34 3.71 7 0.76 47 5.13 F 2 0.22 22 2.40 42 4.59 4 0.44 70 7.64 Total M 4 0.44 57 6.22 256 27.95 45 4.91 362 39.52 F 4 0.44 124 13.54 365 39.85 61 6.66 554 60.48 Total 8 0.87 181 19.76 621 67.79 106 11.57 916 100.00 M = male; F = female. to mid-level health professionals. A wheel chairs in public buildings as well As the Artificial Limb Centre at the manual was also developed for patients as in houses. In pursuance of directives Fauji Foundation Hospital was the only and their families, enabling them to of the Earthquake Reconstruction and public sector hospital providing pros- cope with their physical limitations and Rehabilitation Authority, the guidelines thetic (an artificial substitute for a miss- increase their independence by enhanc- provided in this manual were incor- ing body part, such as an arm, leg, eye, or ing their existing potential. Another porated into the reconstruction plan tooth, used for functional or cosmetic manual was compiled which provided of the earthquake-affected districts by reasons) and orthotic (an orthopaedic guidelines/designs for accessibility of National Engineering Service Pakistan. appliance or apparatus used to support, 50 45 40 Amputation carried out 35 Spinal cord injuries 30 % 25 20 15 10 5 0 Bagh Army Areas Mirpur Poonch Kohistan Peshwar Battagram Manshera addresses not listed Abbottabad Muzaffarabad District of origin Figure 1 Distribution of spinal cord injuries and amputations by district of origin S102 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ align, prevent deformities to improve of Prosthetic and Orthotic Sciences however, the majority of the services function of movable parts of the body) in Peshawar, which subsequently es- offered were for lower-limb prosthesis services in the twin cities of Rawalpindi/ tablished five satellite centres in the only. Islamabad, the provision of prosthesis earthquake-affected districts. A total of The major challenges that emerged to amputees was facing capacity limita- 11 prosthetic and orthotic workshops were the provision of long-term sus- tions in meeting the increasing demand were established by various national tainable support for PWDs in their generated by newly amputated patients. and international organizations for the districts of origin, as well as improv- Accordingly, a number of cases were provision of prosthetic and orthotic ing their quality of life in terms of dis- also referred to the Pakistan Institute services in the disaster-hit districts; ability awareness and social, economic and cultural inclusion. An innovative strategy envisaging a combination of Table 4 Post-earthquake initiatives for the provision of rehabilitation services to community- and institution-based reha- people with disabilities (PWDs), development of infrastructure and implemented bilitation was introduced by WHO and capacity-building interventions the Ministry of Health for both pre- and Outcomes Value post-earthquake PWDs. This strategy is Rehabilitation outcome being implemented by the Earthquake Independence in activities of daily living of spinal cord injury 62% Reconstruction and Rehabilitation Au- patients thority through the Medical Rehabilita- Spinal cord injury patients provided with livelihood 5% tion of the Persons with Disabilities in Provision of lower-limb prosthetic devices to amputees 100% the Earthquake Affected Areas project, Amputees provided with livelihood 8% with WHO technical assistance. Provision of medical rehabilitation services Table 4 illustrates the post-earth- Number of PWDs provided with rehabilitation services 35 873 quake initiatives undertaken for the Number of therapeutic sessions (speech, physiotherapy, provision of rehabilitation services to psychology) 57 506 PWDs, including, health, education, Provision of assistive devices livelihood and empowerment. It also Wheel chairs, spinal jackets, commodes, chairs, crutches, walkers, 5 457 hearing aids, low-vision aids, etc. gives details regarding development of infrastructure and implemented ca- Livelihood provided to PWDs pacity-building interventions, including Number of PWDs provided with livelihood 1 017 recruitment and training of rehabilita- Share of PWD in employment opportunities. 8% tion professionals and development of Inclusive education training manuals. Number of children with disabilities enrolled for inclusive 1 176 education Infrastructure Discussion 100-bedded spinal injury units established at Islamabad 2 50-bedded rehabilitation centres established at Khyber– In humanitarian emergency situations, Pakhtoonkhwa and Azad Jammu & Kashmir 2 disasters disproportionately impact Basic rehabilitation units in earthquake-affected districts 4 persons with existing disability and Resource information centres for CBR in earthquake-affected areas 4 create a new generation of persons Recruitment of health/rehabilitation professionals for 3 years with functional limitations in constant Doctors, nurses, physiotherapists, speech therapists, psychologists 366 need of rehabilitative services [10]. The Community rehabilitation workers for CBR programmes 372 most common disabilities following the Development of training manuals earthquake in Pakistan were spinal in- Management of spinal cord injuries 2 juries and those requiring amputations. Training manuals for CBR 4 The number of spinal cord injuries in Trainings sessions the aftermath of the October 2005 Training session each of 30 days for community rehabilitation earthquake in Pakistan were the highest 16 workers among injuries reported in earthquakes Awareness-raising workshops 10 occurring in other countries [11]. Training workshops for health/rehabilitation professionals 10 The reason for this can be attributed CBR = community-based rehabilitation. to several factors, including the mode S103 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF of evacuation, deficient seismic-proof in the morning when men had already to produce substandard prosthesis, building codes and the highly diversified left home for work but most of the causing complications in a number of rugged mountainous terrain, in addi- women were at the time either inside patients. tion to the magnitude of the disastrous their homes or rushed back inside their The analysis indicated that ap- earthquake of Pakistan. premises to save their children. proximately 581 amputees with major Prehospital management of spinal The peak incidence of spinal injuries amputations required various kind of injury is of critical importance since 25% was within the age group 18–40 years prosthesis, contrary to the initial per- of spinal cord injury damage may occur, comprising of 57% of the total. In the ception echoed by various nongovern- or can be aggravated, after the initial developing world, this group represents mental organizations that “thousands” event [12]. The first to respond after the largest and most significant human of artificial limbs were required for the earthquake in Pakistan were usually resource cohort, constituting the main rehabilitation of the post-earthquake untrained local community members, economic and social fabric of the com- amputees. It is therefore appropriate to being unaware of the importance of spi- munity. Lumbar-level injuries (48.2%) carefully and proactively identify a few nal immobilization to prevent second- were most commonly followed by in- qualified institutions that are recognized ary neurological damage, although they juries at the thoracic level (32.2%) as for designing, manufacturing and fitting worked frantically to rescue as many observed in the Gujarat earthquake, prosthetic devices rather than allowing people as possible. The use of a spinal India, in December 2001 [19] and the a large number of unskilled organiza- board is considered to be an integral Sichuan earthquake, China in May tions that would not be able to perform part of the standard operating proce- 2008 [20]. effectively. Almost all the amputees with dures for evacuation and transport of lower-limb amputations have been fit- With a total population of 725 000 spinal cord injury patients. On the con- ted with prosthetic devices; however and located only 19 km south-west of trary, spinal cord injury patients were due to limitations of technology in func- the epicentre, Muzaffarabad district ac- dragged and pulled out of the rubble tional ability and high manufacturing counted for the maximum number of and carried in a manner not conforming cost, a limited number of amputees with spinal injuries. This was also observed to international standards of transfer- upper-limb amputations were provided in the Northridge earthquake, United ring such patients. A similar practice with the required prosthesis. States of America, in January 1994 in of rescue and recovery of spinal cord A female predominance was evident which people were prone to injury risk injury patients was also observed in the among the cases with reported spinal due to the population density and prox- earthquake of Bam, Islamic Republic of injuries and amputations. In developing imity to the epicentre [21]. Iran in December, 2003 [13]. countries women with disabilities face Most patients with incomplete spi- The post-earthquake response in stereotypes and challenges posed by nal cord injuries reported that they were the disability sector included provision their femininity as well as by being a able to move their limbs while buried of immediate rehabilitative services, PWD. Out of the total reported victims, under the rubble, but during shifting while developing long-term sustainable 28.6% were below 18 years age; their to health facilities, their limbs were solutions. Although the majority of spi- observed disability-related functional completely paralysed [14]. By contrast, nal cord injury patients have completed limitations produced damaging socio- Japan's highly developed emergency their rehabilitation programme, a con- economic effects on individuals and preparedness and response system siderable risk of developing complica- families and posed disproportionate operating during the 1995 Hanshin tions yet remains for patients discharged psychological, emotional, social and earthquake resulted in only six spinal after the initial management and having financial hardship as they were com- injury cases with neurological deficit, inadequate follow-up. pelled to cope continuously with the out of a total of 140 reported spinal The lack of standardized protocols additional burden of providing care and fractures [15]. and guidelines for trauma management ensuring basic livelihood essentials. In developed as well as developing resulted in several unnecessary amputa- The major challenge was the countries the epidemiological data have tions, improperly fashioned stumps and reintegration of these large numbers shown male dominance in spinal cord peripheral nerve injuries. Many ampu- of PWDs back into their communi- injuries [16,17]; however, females were tations were necessitated due to the ties where environmental accessibil- the major victims in the earthquake of gravity of injuries or delayed referrals ity, non-availability of essential and Pakistan [18]. It is conjectured that the from remote areas during the first 48 rehabilitative health care facilities and high proportional risk of injury to which hours. The absence of regulatory norms attitudinal barriers continued to impede females were exposed may be explained for manufacturing and fitting prosthetic people from reaching their full potential by the fact that the earthquake occurred devices led many unqualified providers [15]. To surmount these difficulties, a S104 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ regional plan for CBR was designed for institutional and community-based re- level of emergency preparedness and the earthquake-affected districts in April habilitation was introduced successfully appropriate steps taken for disaster re- 2006, with WHO technical support. for the pre- and post-earthquake PWDs, duction, mitigation and preparedness, The CBR programme has increased with the intervention ultimately lead- particularly in the context of disabilities. public awareness regarding disability ing to the inception of a national CBR Timely and proper referral assumes issues, improved functional limitations, programme in the country. great importance vis-à-vis spinal injuries, facilitated the development of targeted The October 2005 earthquake was which necessitates mandatory training livelihood programmes, mandated a national wake-up call, as it highlighted not only for health professionals, but inclusive education and empowered and brought to the fore the issue of also for front-line rescuers who are the PWDs through the formation of village PWDs. It has also provided an oppor- first to reach a disaster site. Pakistan’s CBR committees and disabled people tunity for introspection on the state of 2005 earthquake experience should be organizations. disaster management related to disa- viewed in relation to the lessons learnt, The post-earthquake response bilities. Many preventable amputations in order to ensure that lapses in the re- relating to disabilities was unique as and incomplete spinal cord injuries sponse and management that occurred for the first time in the disaster-hit re- would not have resulted in permanent are avoided in future unforeseeable gion, an innovative concept combining damage had there generally been a high adversity. References 1. Kuipers P. Disability, health, and international development. 11. Handicap international rehabilitation activities during Pakistan Lancet, 2009, 374(9704):1813, 28. earthquake 2005. Handicap International, 2006 (http://www. 2. Emergency & humanitarian assistance and the UN convention on handicap-international.org.uk/, accessed 1 May 2010). the protection and promotion of the rights and dignity of persons 12. Castellano JM. Prehospital management of spinal cord injuries. with disabilities. Washington DC, International Disability and Emergencies, 2007, 19:25–31. Development Consortium, 2010 (http://www.iddcconsor- 13. Priebe MM. Spinal cord injuries as a result of earthquakes: les- tium.net/joomla, accessed 16 June 2010). sons from Iran and Pakistan. Journal of Spinal Cord Medicine, 3. EM-DAT. The international disaster database. Brussels, Centre for 2007, 30(4):367–368. Research on the Epidemiology of Disasters, 2006 (http://www. 14. Raissi GR. Earthquake and rehabilitation needs: experiences emdat.be/dat.net/disasters/Visualisation/profiles/natural- from Bam, Iran. Journal of Spinal Cord Medicine, 2007, 30:369– table-emdat.php, accessed 24 April 2010). 372. 4. Pakistan earthquake facts and figures sheet – 28 March, 2006. 15. Farooq A et al. Spinal cord injury management and rehabilita- International Federation of Red Cross and Red Crescent Socie- tion: highlights and shortcomings from the 2005 earthquake in ties, 2005 (http://www.ifrc.org/Docs/pubs/disasters/pakista- Pakistan. Archives of Physical and Medical Rehabilitation, 2008, near thquake/factsfigures0306.pdf, accessed 15 April 2010). 89:579–585. 5. Ahmad T. The population of persons with disabilities in Paki- 16. Hoque MF et al. Spinal cord lesions in Bangladesh: an epide- stan. Asia Pacific Population Journal, 1995, 10(1):39–62. miological study 1994–1995. Spinal Cord, 1999, 37:858–861. 6. Population census by nature of disability 1998. Islamabad, Popu- 17. Otom AS et al. Traumatic spinal cord injuries in Jordan: an epi- lation Census Organization, Ministry of Economic Affairs and demiological study. Spinal Cord, 1997, 35:253–255. Statistics, 1998. 18. Rathore MFA et al. Epidemiology of spinal cord injuries in the 7. Disability and rehabilitation: WHO action plan 2006–2011. Ge- 2005 Pakistan earthquake. Spinal Cord, 2007, 45:658–663. neva, World Health Organization, 2006. 19. Dong ZU et al. Spinal injuries in the Sichuan earthquake. New 8. Kett M, Ommeren MV. Disability, conflict, and emergencies. England Journal of Medicine, 2009, 361:636–637. Lancet, 2009, 374(9704):1801–1803. 20. Shoaf KI et al. Bourque injuries as a result of California earth- 9. Despouy L. Human rights and disabled persons (Study Series 6). quakes in the past decade. Disasters, 1998, 22(3):218–235. Geneva, Centre for Human Rights United Nations, 1993. 21. Prabhakar MM, Dhaval R, Jadav MB. Management of mass scale 10. Disaster disability and rehabilitation. Geneva, World Health Or- dorso-lumbar injuries for early rehabilitation. Asia Pacific Dis- ganization, Department of Injuries and Violence, 2005. ability Rehabilitation Journal, 2004, 15(1):57–82. S105 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Review Essential medicines management during emergencies in Pakistan S.K.S. Bukhari,1 J.A.R.H. Qureshi,1 R. Jooma,2 K.M. Bile,1 G.N. Kazi,1 W.A. Zaibi1 and A. Zafar1 ëmSm<9ÏÚÐ\TÐé°AogGmGúÐowíØúÐÒÚÐØÎ }aKphUnLºåxÛ{1ÌÞnSíºĽnSiêĆQºØe7d=hdBºp_+{hIÚºVx}ShA}UÐ3nL{hZ+ºïÚn={h_H{UnB{hHö UÙíº2005ênLënTn=éÐ~UÛ:nxn\dUp!n_CÐípxnL}UÐÊnxÎ:phHnHúÐpxíØúÐÒÚÐØÎéApcCÐÓÐF#ÐpSÚUÐì|wy>oåÉ°#Ð éĆBYØ}!ÐýÐSpSÐ}Yíºn)ÚÐ}eHøÐëe\CÐØÐ{YüÐíºphHnHúÐpxíØúÐpAn>Îph[UÐÓĆB{UÐqfe{Sí pUn_RíÒ{hIÚpbx}]=ö xUÐÊÐPUÐÒ{LnCíºn)âFCÐpxíØúÐébU nS}JënTn=q_í{Sí pxíرU{hI}UÐêÐ{HøÐéĆBYíºØÐ{Y³U-ð HnAên^i 12 :phfx~UÐRÐ}CÐ:p] \ó YÒÚÐ}AÓn@ÚØ:pxíرUýĆCÐëÐ~BøÐë5>{Sí NcdgCÐî{Upô @n"Ðd>{ýnLhe[UíºpxíرU ÒÚCÐJnfCÐ:ºéíúÐîCÐYphUíúÐpxnL}UÐRÐ}Y:ºTÐ}åå>ëÌëíØngTĆgHÐíºpxíØún=ÒE>UÐq=nUÐØÐ{YüÐ{LnH{Sí n_SYð ÓÐíØúÐØÐ{LÎ>{Sí â5HøÐJnfYëncH:phHnHúÐÓÐØÐ{Y³UíºphHnHúÐpxíرUhUncUÐíèĆgHøÐDLæ}_UÐDLºéÐ~U~Un=´ îØÌíºphUn_a=qY{HÐ{Sph]UÐÓÐØÐ{YüÐípxíØúÐëlRÐ|cwí n)èÚnZUÐíºng_S>íºÓÐØÐ{YüÐípxíØúÐpheTDLng]HÐ=æ´ }_iUÐ Ú{4ÐYc,Ú{SSÌOÎUÙ ABSTRACT This paper illustrates the experiences of essential medicine management in providing cure and care to victims of Pakistan’s 2005 earthquake in a safe, rational and effective mode. The health interventions assured access to essential medicine, sustained supply, inventory control through a computerized logistic support system and rational use of medicines. World Health Organization Pakistan outlined modalities for acceptance of donated medicines, assisted in speedy procurement of medicines and designed customized kits. Proper storage of medicines at controlled temperature was ensured in warehousing facilities in 12 locations. A steady supply of medicines and their consumption without stock-outs in the 56 first-level care facilities of calamity-hit areas helped to ascertain the average consumption and cost of essential medicines and supplies for the catchment population. Tools for quantification and forecasting of medicines and supplies were developed and shared. Medicines and medical supplies were efficiently used resulting in minimum wastage. Gestion des médicaments essentiels pendant les situations d’urgence au Pakistan RÉSUMÉ Cet article décrit les processus de gestion des médicaments essentiels ayant permis de fournir un traitement et des soins aux victimes du tremblement de terre de 2005 au Pakistan, de manière sûre, rationnelle et efficace. Les interventions sanitaires ont assuré un accès aux médicaments essentiels, à un approvisionnement soutenu et à la gestion des stocks grâce à un système de soutien logistique informatisé et à une utilisation rationnelle des médicaments. L’Organisation mondiale de la Santé au Pakistan a expliqué les modalités d’acceptation des médicaments provenant de dons, a contribué à l’achat rapide de médicaments et a conçu des kits sur mesure. Un stockage approprié des médicaments à une température contrôlée a été réalisé dans des entrepôts situés sur douze sites. L’approvisionnement régulier en médicaments et une consommation sans rupture de stock dans les 56 centres de soins de premier niveau des régions touchées par la catastrophe ont permis de définir la consommation et le coût moyens des fournitures et des médicaments essentiels pour les populations desservies. Des outils de quantification et de prévision des médicaments et des fournitures ont été élaborés et diffusés. Les fournitures médicales et les médicaments ont été utilisés efficacement, ce qui a permis de minimiser le gaspillage. 1World Health Organization, Country Office, Pakistan (Correspondence to S.K.S. Bukhari: [email protected]). 2Ministry of Health, Islamabad, Pakistan. S106 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Introduction valuable resources and deprive a suffer- Methods ing population from equitable access Medicines at the right time to treat in- to this primary assistance. The man- The data were generated through a re- jured or sick people are vital elements in agement components of an essential view of documents that included annual alleviating the anguish of people suffer- medicine distribution system, which reports on essential medicine manage- ing during catastrophes [1]. Experience include warehousing facilities, supply ment during and after the earthquake, with problems and solutions concern- chain system and inventorization, are reports of consultative workshops, ing the use of pharmaceutical agents interwoven, complex and crucial. World Health Organization (WHO) during disasters is very significant for Evaluation reviews, for example guidelines, standard operating proce- disaster health care providers [2]. Better from the Mexico 1985 earthquake or dures and information collected from anticipation of needs on the basis of the Armenia 1988 earthquake, have pharmacists located in the affected dis- epidemiological data of experiences and repeatedly indicated that much of the tricts. In addition, the relevant literature improved field disaster assessment can medical supplies received from donor was reviewed on the subject. The re- provide enhanced medical care during agencies as humanitarian assistance sults were also validated from the data disasters [2]. for the suffering population are not ascertained from the logistic support A comprehensive humanitarian appropriate to their needs [7,8]. Ra- system software, which was customized operation followed the massive earth- tional arrangements for negotiating and and installed to suit the requirements of quake (7.6 on the Richter Scale), which receiving need-based medicines has the warehousing, inventory control and devastated parts of northern Pakistan entailed formulation of guidelines and supply chain of the essential medicines,. and Pakistan-administrated Kashmir in standard operating procedures [9,10]. October 2005 affecting approximately Receiving inappropriate medicine sup- 3.5 million people and taking a toll of plies can cause management problems Results about 73 000 lives in an area of around and jeopardize an emergency opera- 2 WHO liaised with donors on essential 30 000 km [3]. The response addressed tion; individuals with pharmaceutical medicine needs, developed protocols the major challenges such as the harsh training may facilitate the sorting of pro- of pre-shipment approvals, and formu- terrain hampering access, devastation cured and donated pharmaceuticals lated and disseminated guidelines on a of 68% of the health care infrastructure, [11]. Pre-screened need-based medi- and lifesaving relief efforts for the af- cines customized in different types of kit number of critical issues. fected population residing in remote to cater to the requirements of suffering Preparation and adaptation of valleys. The special medical/surgical population may be one of the best prac- guidelines/standard operating needs for 70 000 severely injured pa- tices of essential medicine [10]. procedures tients were a priority matter [4]. Widespread devastation caused Table 1 exhibits the list of 12 guidelines Essential medicines that satisfy the by the earthquake in Pakistan neces- and standard operating procedures priority health care needs of the popula- sitated significant improvements to developed following global principles tion, in adequate amounts and appro- the existing medicine management and disseminated by WHO during the priate dosage form with uninterrupted system. The pharmaceutical products course of the emergency, as well as their supply, are an integral component of and equipment arriving at disaster sites objectives and the outputs received. primary health care [5]. During emer- posed serious logistic and management The management of essential medicines gencies, their significance increases challenges such as sorting tonnes of from receiving and warehousing to their many times while rational use assumes supplies while ensuring that urgently distribution to health facilities was regu- critical proportions for primary health needed items reached the disaster vic- lated by these guidelines and standard care delivery [6]. tims on time. operating procedures. However, during emergencies, The main objective of this paper is health service delivery infrastructure to document the experiences gained in Prequalification of may fail to provide essential medi- the management of essential medicines pharmaceutical products cines to the affected population, who during the severe and prolonged calami- During the emergency, humanitar- are often further poverty-stricken as a ties in Pakistan, highlighting the best ian agencies and donors commenced consequence of a calamity. Moreover, practices and lessons learnt in managing funding the humanitarium global inadequate attention to the manage- these essential medicines and supplies Health Cluster through WHO for the ment of medicines can result in waste of for the affected population. provision of essential medicines. The S107 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 1 Guidelines and standard operating procedures developed by WHO during the course of emergencies, their operational objectives and the expected outputs Guidelines/standard operating procedures Operational objectives Outputs ō WHO guidelines for medicine donations ō To streamline international and ō Process of medicine donations was local medicine donations regulated ō Unwanted, irrelevant medicines were eliminated from donations ō Medicine with prescribed shelf life received ō Promotion of rational use of medicines ō To promote evidence-based use ō Concept of rational use promoted of medicine ō Essential medicines put into practice ō Standard operating procedure for BHUs ō To establish primary health care ō Demand and supply of medicines and RHCs essential medicines supply chain need-based list of medicines rationalized management ō Stock-outs were avoided ō Standard treatment guidelines for ō To provide treatment protocols at ō Prescriptions rationalized outpatients for priority diseases/conditions primary health care level ō Supply of medicines facilitated ō Standard operating procedure on ō To adopt evidence-based method ō Medicine supply needs quantified quantification/forecast of needs of of quantifying medicine needs ō Stock-out avoided medicines ō Standard operating procedure for good ō To provide for the professional ō Medicines professionally stored resulting in storage and inventory control storage and inventory control of preservation of their efficacy medicines ō Development of expiry calendar ō To avoid expiry of medicine ō Minimum quantity of medicines expired/ ō Warehouse assessment tool ō To assess storage facility/capacity wasted ō Storage capacity/facility assessed for improvements ō Standard operating procedure for safe ō To dispose of unwanted ō Safe disposal of unwanted medicines disposal of unwanted/expired medicines medicines locally in safe mode ō Monitoring tool for essential medicines at ō To monitor essential medicines at ō The medicines supplied and used were BHUs/RHCs and secondary health care health care facilities monitored and gaps identified facilities ō Training manual for essential medicine ō To train dispensing personnel ō Dispensing personnel were trained on management on management components of management components of essential essential medicine medicine ō Standard operating procedure for ō To ensure professional ō Dispensation of child dosage rationalized dispensing child dosage form dispensation of child dosages ō Standard operating procedure on ō To facilitate timely procurement ō Quality medicines were procured in limited emergency medicine procurement of quality medicines during time emergencies ō Need-based list of medicines for ō To develop a rational list ō Unwanted medicines were neither earthquake devastated areas of essential medicines for requisitioned nor procured earthquake victims BHUs = basic health units; RHUs = rural health units. procurement of quality medicines in compliance with current good manu- to overcome size limitations, gaps and Pakistan had been a persistent concern facturing practices adopted by the Drug the cost of the available international of the donor agencies. The country has Control Organization of the Ministry kits, the medicine kits were customized more than 500 medicine manufactur- of Health, supported by its drug testing to address the specific needs of the af- ers and importers, having more than laboratories. fected population during all phases 50 000 registered products, making of the emergency. The MEHK was Preparation of customized kits procurement of cost-effective qual- based on per capita essential modified from the IEHK to cater for ity products complicated. To make the medicines needs primary health care needs including right selection, product-based prequali- Table 2 illustrates flexibility and useful- communicable, noncommunicable fication criteria for local procurement ness of the Mini Emergency Health diseases and maternal neonatal and were developed conforming to WHO Kit (MEHK) compared with the Inter- child health needs for a population of guidelines: bioequivalence of generics in agency Emergency Health Kit (IEHK) 6000 for one month. IEHK included comparison with the innovator brands, listed therapeutic category and the dos- 150 items: 51 medicines, 16 medical biopharmaceutical classification and age form along with their cost. In order supplies and 83 assorted supplies. By S108 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 2 Flexibility and usefulness of Mini Emergency Health Kit (MEHK) compared with Interagency Emergency Health Kit (IEHK) listed therapeutic category and the dosage form along with their cost comparison Therapeutic category No. of Dosage form in MEHK No. of Dosage form in IEHK items S L INH INJ Eitems S L INH INJ E Local anaesthetics/preoperative medication/anaphylactic shock 32 Antimalarial therapy 4 0 Medicines acting on gastrointestinal tract/antacids and other anti-ulcer 31 Antibacterial therapy 8 2 Medicines acting on cardiovascular system/antihypertensive 63 Antidotes for poisoning 2 1 Scabicides/pediculicides 1 1 Antiepilepsy/anticonvulsants 1 0 Ophthalmic preparations 3 1 Disinfectants and antiseptics 2 2 Antiallergics and drugs used in anaphylaxis 31 Antifungal preparations 2 2 Parenterals 5 3 Analgesics, antipyretics, nonsteroidal anti-inflammatory medicines 32 Antianaemic medicines 2 2 Diuretics 1 1 Antidiabetic preparations 3 0 Anti-infective medicines/ anthelmintic medicines/ antiprotozoals 22 Oxytocics 3 1 Oral rehydration therapy 1 1 Antispasmodic preparations 1 0 Topical antibiotics 2 1 Antiasthmatic therapy 1 1 Micronutrients 1 1 Water chlorination/purification tablet/sachet 11 Consumables/supplies 24 16 Costing US$ 1000 for providing one month US$ 1881 for partial coverage to 6000 coverage to 6000 population population for one month Per capita cost US$ 0.166 US$ 0.313 S = solid preparations; L= liquid preparations; INH = inhalation; INJ = injectable; E = external preparations. = dosage form available. contrast, the MEHK consisted of 110 or the dosage forms for all age groups surgery, trauma, mental health, safe birth items: 86 medicines and 24 medical and conditions. The per capita cost of and cholera. supplies catering for the treatment of an IEHK was estimated at US$ 0.313 In the earthquake affected areas, malaria, diabetes, abdominal spasms, compared to US$ 0.166 for a MEHK. 56 first-level healthcare facilities were epilepsy and acute bronchial asthma. The customized kits also included kits regularly provided with the essential The medicines and supplies in the IEHK for personal protective equipment, anti- medicines without stock-outs till their did not cover the diseases stated above scabies medicines and family hygiene, use had stabilized. This intervention S109 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF was regularly followed by monitoring Coordination with Health, WHO and Health Cluster part- to determine the consumption of es- medicine donors and major ners closely coordinated the provision sential medicines and supplies. Morbid- stakeholders and management of essential medicine ity data and consumption data were Through collaboration of the Minis- and information on their subsequent used for forecasting and calculating try of Health and WHO, a donation distribution was regularly shared with the demands. In the subsequent year, receiving centre was established at the Health Cluster partners. consumption data of the previous year Pakistan Institute of Medical Sciences, facilitated the estimation of per capita the largest tertiary care hospital in the Consultative workshop for sharing best practices consumption and cost. These data also capital. Contacts were established with assisted to determine the composition international donors informing them The Ministry of Health, in collabora- of the MEHK. of the essential medicines, vaccines, tion with the Pakistan Earthquake biologicals and surgical supplies needed. Reconstruction and Rehabilitation Au- Wastage of medicines and Almost 25% of the medicines offered for thority, International Health Partners supplies donations were not accepted as they and WHO, organized an international Figure 1 presents a comparison of wast- were either not relevant or possessed partners’ consultation for experience- age of medicines during major global a short shelf life. WHO established sharing on supply and management of disasters, where the authorities were sustainable partnerships with donors essential medicine during the disaster. confronted with operational challenges such as International Health Partners The deliberations identified the lessons such as short shelf life, lack of expiry (UK), Health Partners International learnt and developed pragmatic recom- date and unsolicited donation: much of Canada and AmeriCares (USA) to mendations for future reference. The medicine was wasted during major ensure donations conformed to WHO interventions that went particularly well emergencies in recent decades com- drug donation guidelines, rational se- included the speedy transfer of medi- pared to an average of 1.3% per annum lection and maximum shelf life. The cines by WHO from the ports to the waste in Pakistan varying from 0.8% to core principles of these guidelines are: end user, no stock-outs, sorting and 2.1%. This wastage was calculated from all donations should be based on an inventorying and the deployment of data ascertained from logistic support expressed need and that unsolicited pharmacists overseeing the key manage- system records. In accordance with the drug donations are to be discouraged; ment functions. The recommendations set standard operating procedures all donations should be supportive of exist- for the best practices include: the need the expired/wasted medicines were ing government health policies; there for technical expertise, development of recalled to a central warehouse and re- should be no double standards: if the standard operating procedures for fu- entered into logistic support system. quality of an item is unacceptable in the ture disasters; an agreed list of essential This revalidated the actual wastage and donor country, it is also unacceptable medicines for all three phases of disasters was disposed off according to WHO as a donation; and there should be ef- (trauma phase; relief phase and rehabili- guidelines at high temperature incinera- fective communication between the tation phase); establishment of a focal tion. donor and the recipient. The Ministry of point for medicine management; and information-sharing and a web-based network to facilitate communication Percentage of donated medicine wasted between medical teams, partners and 80 donors. 70 Supply chain management 60 50 Table 4 depicts the magnitude of medi- % cine donations received, medicines pro- 40 cured, the beneficiary population and 30 wastage of medicines during 2005–09. 20 The supply chain system was reinforced 10 by establishing warehouses conforming 0 to WHO standards such as good storage Albania Armenia Bosnia Kosovo Tsunami Pakistan practices and inventory control. One central warehouse was established in Is- Figure 1 Comparison of wastage of medicines during major global disasters lamabad, two in Khyber-Pakhtunkhwa and nine in Balochistan for ongoing S110 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 3 List of capacity-building training on essential medicine management carried out in Islamabad, calamity-hit areas and in IDP camps during 2005–09 by WHO and UNICEF coordination Scope of the essential medicine Location No. of days No. of No. of people Sponsoring organization management training trainings trained Concept of essential drugs Islamabad 3 1 8 TOT WHO Good storage practices KPK 3 4 126 WHO/UNICEF Prescription handling AJK 3 4 130 WHO/UNICEF Good dispensing practices KPK 3 3 40 WHO Guidelines for dispensing child dosage forms AJK 3 3 42 WHO Proper handling of pharmaceuticals Sindh 3 3 86 TOT WHO/UNICEF Guidelines for detecting and rectifying medication errors Islamabad 3 4 31 WHO Guidelines for disposing of pharmaceutical waste Balochistan 3 1 8 WHO Rational use of medicines IDP camps 1 18 192 WHO Handwashing Logistic support system WHO = World Health Organization; UNICEF = United Nations Children’s Fund; TOT = Training of trainers; KPK = Khyber Pakhtunkhwa; AJK = Azad Jamu and Kashmir; IDP = internally displaced persons. operations and emergency prepared- management carried out during 2005– of quality medicines well managed ness. Pharmacists were engaged on a 09 through WHO and United Nations and irrational medicine demands from priority basis in order to assist the local Children’s Fund (UNICEF) coordina- health facilities and outreach teams government’s health administration and tion. Training activities for health care carefully evaluated [12,14]. Good WHO field offices to sort medical sup- providers were carried out on capacity- pharmaceutical practices for inven- plies and manage their inventory using building in the management of essential tory control and storage regulated the the logistic support system. Pharmacists medicines and on improving pharmacy supply chain system and preserved the were assigned to monitor and evaluate practices in the public sector. Spe- medicines’ efficacy [15]. The prime the use of medicine, assist in avoiding cific training modules were developed dividend of the tested standard operat- stock-outs and promote rational use of keeping in view local needs, gaps in ing procedures that were adapted for medicine. capacity and areas for improvement. local conditions by following global principles was shown later on, during Logistic support system the crises in Khyber Pakhtunkhwa and Logistic and inventory software was Discussion the federally administered tribal areas, installed and operated in the WHO which have resulted in over 2.6 mil- central warehouse at Islamabad cat- The drug management cycle, sustained lion internally displaced persons; the egorizing medicines by their generic with the appropriate support services, emergency medicines were managed name, dosage form, strength, batch rational policy and legal framework, without problem [12]. number, expiry date, priority distribu- contributes significantly to maximize tion and source. The system was advan- The WHO initiative of customizing the output from the limited resources tageously used for generating reports of kits for local conditions and specific available for essential drugs, especially stocks distributed to suboffices, health diseases was beneficial to the health during emergencies [12,13]. facilities and mobile medical teams. care providers, and the compact size of Logistic and inventory software data Preparation and dissemination the kits made logistics easy [1]. Based also significantly facilitated WHO in of guidelines and standard operating on uninterrupted supply of essential the management audit of essential procedures on principal aspects of medicines to front-line health facili- medicines. medicine management proved to be ties, an attempt was made to compute rewarding for all stakeholders both at per capita consumption and cost of Capacity-building home and abroad [10,12]. As a result, medicines. These kits were need-based, Table 3 shows the list of organized donations of unwanted medicines were comprehensive and did not sup- training activities on essential medicine blocked, cost-effective procurement ply unwanted items. This innovative S111 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 4 The magnitude of medicine donations received, medicines procured, the beneficiary population and wastage of medicines, Pakistan, 2005–09 Year Population catered Donation of Procurement of Wastage (US$) Percentage for (million) medicines (US$) medicines (US$) wastage 2005 11 4 858 326 1 288 159 79 904 1.30 2006 15 2 728 640 557 446 69 431 2.11 2007 5 0 700 416 5 603 0.80 2008 16 795 180 806 838 25 632 1.60 2009 47 4 319 603 2 159 074 61 548 0.95 experience of tailored kits suitable for have been wasted [1]. The actual cost of the earthquake reflected the collective the local conditions was cost-effective disposing of unwanted medicines was wisdom of stakeholders regarding les- and convenient to primary health care significantly high [18]. A WHO audit sons learnt, interventions that went very providers [2,10]. of humanitarian medicine donations well and the things to bear in mind In the aftermath of the earthquake, received in Albania during May 1999 for future disasters. The factors that the bulk of the medicines first received for Kosovo refugees revealed that half of contributed to the successful operation was stored efficiently [15,16]. Concur- the medicines were inappropriate and in Pakistan included: effective liaison rent with the establishment of the central required elimination [19]. Similarly in with international donors; preparation warehouse, WHO acquired the services Bosnia, medicines were wasted due to of a list of essential medicines according of pharmacists for sorting and inven- either being inappropriate or lacking to the type and level of disaster; des- torying volumes of medicine stocks, expiry dates [20]. ignation of focal persons for medicine making expiry calendars and promoting On the contrary, operational management; induction of pharma- rational medicine use [2,11]. Installa- guidelines, prescreening of medicines, ceutical expertise to implement inven- tion of a logistic support system estab- placement of pharmacists, sorting and tory management software in disaster lished transparency and traceability in computerized inventorying, and good preparedness plans; preparation of a list the management of essential medicine storage practices have significantly con- of prequalified products; and continu- and humanitarian supplies, facilitated tributed to the limited waste of medi- ing communication between health audit of donated medicines along with cine in Pakistan which ranged between cluster partners for avoiding duplica- a record of an individual Health Cluster 0.8% and 2.1% during the past five years. tion and optimizing the use of existing partner’s transactions. These schemes The experience of essential medicine medical supplies. The collective experi- were instrumental in optimizing the management during emergencies in ences shared and discussed through use of procured and donated medicines Pakistan is marked by realistic planning, this consultative process was reliable during emergencies and resulted in a induction of operational guidelines and and provided practice-based evidence low level of medicine expiry. standard operating procedures, focused for the future. Experience has demonstrated that administration and continuous coordi- Preparation and dissemination of donated medicines can create serious nation of health cluster partners. standard operating procedures tailored problems. In the earthquakes in Mexico The medical and paramedical staff to local conditions are remarkably ef- City (1985) and Armenia (1988) the that were trained on essential medicines fective for coordination and optimal quantity of medicines and medical sup- management in the districts affected by use of resources. Effective manage- plies received far exceeded the need and emergencies during the past few years ment techniques prevent stock-outs, a significant percentage of the medicines were gainfully deployed by local govern- while sound selection criteria enable had expired by the time it arrived at the ments for good storage and dispens- filtering of quality products from a disaster site [7,8,17]. A sizable portion ing practices and proper handling of complex market. Medicine procure- was destroyed by frost, while the remain- pharmaceuticals. This pool of human ment and donations can be acquired der that was relevant to the emergency resources has been providing indispen- and used most efficiently, provided was labelled without generic names sable technical assistance in subsequent the requisite standard operating pro- [14]. In the Indian Ocean tsunami relief emergencies. cedures and trained human resources efforts in 2004, a substantial amount The essential medicines consulta- and management skills are in place of donated medicines was reported to tive workshop held eight months after from the start. S112 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ References 1. Hechmann R, Bunde-Birouste A. Drug donations in emer- 11. Nestor A et al. Pharmaceutical services at a medical site after gencies: the Sri Lankan post tsunami experience. Journal of Hurricane Andrew. American Journal of Hospital Pharmacy, Humanitarian Assistance, 2007 (http://jha.ac/2007/09/26/ 1993, 50(9):1896–1898. drug-donations-in-emergencies-the-sri-lankan-post-tsunami- 12. Management of drugs at health centre level: Training manual. experience/, accessed 13 July 1020). Brazzaville, Regional Office for Africa, World Health Organiza- 2. Hogan DE, Burstien JL. Disaster medicine. Philadelphia, Lippin- tion, 2004. cott & Williams, 2007. 13. Pomatto V, Schuftan C. Review of quality assurance (QA) mecha- 3. Khadim MT et al. 8th October 2005 earthquake: an experience nisms for medicines and medical supplies in humanitarian aid: of diagnostic laboratory services in disaster. Pakistan Armed guidelines. Aachen, Germany, European Commission, 2006. Forces Medical Journal, 2006, 56(4):433–437. 14. Guidelines for drug donation. Geneva, World Health Organiza- tion, 1999 (WHO/EDM/PAR/99.4). 4. Pakistan 2005 earthquake: preliminary damage and needs assess- ment. Islamabad, Asian Development Bank, 2005. 15. Whybark C. Issues in managing disaster relief inventories. International Journal of Production Economics, 2007, 108(1–2- 5. Understanding essential medicines and primary health care. ):228–235. Contact [Kenya] 2009, 187:2–3. 16. Autier P et al. HNP discussion paper: drug donations in post- 6. Van Damme WI, Van Lerberghe WL, Boelaert M. Primary emergency situations. The International Bank for Reconstruction health care vs. emergency medical assistance: a conceptual and Development, 2002. framework. Health Policy and Planning, 2002, 17(1):49–60. 17. Ciottone GR. Disaster medicine. St Louis, Mosby Inc., 2006. 7. Hairapetian A et al. Drug supply in the aftermath of the 1988 18. Guidelines for safe disposal of unwanted pharmaceuticals in and Armenian earthquake. Lancet, 1990, 335(8702):1388–1390. after emergencies. Geneva, World Health Organization, 1999 8. Zeballos JL. Health aspects of the Mexico earthquake—19 Sep- (WHO/HTP/EDM/99.2). tember 1985. Disasters, 1986, 10:141–149. 19. WHO drug donation audit in Albania reveals many expired and 9. Hogerzeil HV, Couper MR, Gray R. Education and debate: unusable “gifts”. World Health Organization, 1999 (http:// guidelines for drug donations. British Medical Journal, 1997, www.reliefweb.int/rw/rwb.nsf/db900SID/ACOS-64- 314:737–740. BF55?OpenDocument, accessed 13 July 2010). 10. Forte GB. Private donations for former Yugoslavia. WHO Drug 20. Essential Drugs Monitor. Geneva, World Health Organization, Information, 1994, 8(4). 1999, (27). S113 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Report The impact of the disease early warning system in responding to natural disasters and conflict crises in Pakistan M. Rahim,1 B.M. Kazi,2 K.M. Bile,1 M. Munir 1 and A.R. Khan 1 ëmSm<9âÐ}eTÐÓmXÛÌíog^g\TÐÔÚÐbcTo ABSTRACT The disease early warning system (DEWS) was introduced in the immediate aftermath of the 2005 earthquake in Pakistan, with the objective to undertake prompt investigation and mitigation of disease outbreaks. The DEWS network was replicated successfully during subsequent flood and earthquake disasters as well as during the 2008–09 internally displaced persons’ crisis. DEWS-generated alerts, prompt investigations and timely responses had an effective contribution to the control of epidemics. Through DEWS, 1360 reported alerts during 2005–09 averted the risk of disease outbreaks through pre-emptive necessary measures, while the 187 confirmed outbreaks were effectively controlled. In the aftermath of the disasters, DEWS technology also facilitated the development of a disease-surveillance system that became an integral part of the district health system. This study aims to report the DEWS success and substantiate its lead role as a priority emergency health response intervention. Effets du système d’alerte précoce pour les maladies sur la riposte aux crises entraînées par les catastrophes naturelles et les conflits au Pakistan RÉSUMÉ Le système d’alerte précoce pour les maladies a été mis en place immédiatement après le tremblement de terre survenu au Pakistan en 2005, dans le but d’entreprendre des recherches et d’atténuer rapidement les flambées de maladies. Le réseau de ce système a été remis en service avec succès lors des inondations et des tremblements de terre suivants, ainsi qu’en 2008–2009 lors de la crise des déplacements internes de population. Les alertes générées par le système d’alerte précoce pour les maladies, les recherches rapides et la riposte opportune ont contribué efficacement à la lutte contre les épidémies. Grâce au système, 1360 alertes émises entre 2005 et 2009 ont permis d’éviter le risque de flambées de maladies au moyen de mesures préventives, et 187 flambées confirmées ont été endiguées de manière efficace. Suite aux différentes catastrophes, la technologie liée à ce système a également facilité la mise en place d’un système de surveillance des maladies qui fait désormais partie intégrante du système de santé des districts. Le but de cette étude est de décrire la réussite du système d’alerte précoce et de prouver son rôle déterminant en tant qu’intervention prioritaire dans la riposte sanitaire aux situations d’urgence. 1World Health Organization, Country Office Islamabad, Pakistan (Correspondence to M. Rahim: [email protected]). 2National Institute of Health, Islamabad, Pakistan. S114 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Introduction 10 out of 11 measles’ outbreaks either investigated and the necessary response occurred in postconflict situations with action considered. In the past five years a range of humani- collapsed health systems and disrupted The objective of this paper is to re- tarian disasters has cumulatively affected immunization services or in settings view the DEWS implementation proc- over eight million people and mobilized characterized by poor or no vaccina- ess and report the outcomes attained enormous national and international tion of the target population prior to through this successful experience ex- humanitarian responses in Pakistan. The displacement; a high case fatality rate of tended over four major emergencies that earthquake of 8 October 2005, which over 5%, significantly higher than that affected Pakistan during 2005–2009. jolted the northern parts of the country, observed in a stable population, was was the most devastating humanitarian reported from six of the nine outbreaks crisis that has hit Pakistan for many dec- reviewed [6]. Methods ades. In June 2007, the cyclone Yemyin No fatalities were recorded among and flash floods devastated large parts Burundian refugees in Tanzanian camps The DEWS data included the number of Sindh and Baluchistan provinces, and and among tsunami victims in India, sub- of consultations and deaths disaggre- the situation was further exacerbated in stantiated by the active surveillance and gated by age and gender obtained from 2008 by an earthquake that affected two early case detection and management all participating units, including public districts of Baluchistan. In 2008–09, in both of these displaced populations sector health facilities, improvised facili- the evolving security challenges in the ties in camps and mobile medical teams, [7]. Applying disease-control measures Federally Administered Tribal Areas using a standard reporting form. A com- after an initial assessment of the emer- (FATA) and Khyber Pakhtunkhwa re- puter application in Microsoft Access gency situation is not a guarantee that sulted in the displacement of over 2.6 was utilized for data entry and analysis. communicable diseases will not spread million people. The collated information included the [8]. Conversely, the organization of an Massive population displacements weekly outpatient data, reported alerts early warning system, reporting a set of are generally associated with high rates and detected outbreaks during all four selected notifiable diseases and envisag- of mortality due to infectious diseases major emergencies in Pakistan from ing an effective investigation and rapid [1–3]. Death rates over 60-fold from 2005 to 2009. diagnostic confirmation, characterizes baseline have been recorded in refugee the core strategy for the effective con- The DEWS coverage expanded with and displaced people, with over three- trol of epidemics during emergencies the evolving situation and the number of quarters of these being caused by [8–12]. reporting units changed over time. To communicable diseases [2]. In 1994, adjust to this change, the reported data DEWS is a mechanism offering between 6% and 10% of the Rwandan were analysed by calculating the average prompt and early detection of potential refugee population died during their number of detected cases, alerts and outbreaks and providing opportunities early arrival in Zaire, a death rate that outbreaks per 100 reporting units, as a for immediate response [13,14]. DEWS was two to three times higher than standard measure for trend analysis that previous reports from Thailand, Sudan was introduced and implemented in the was carried out for four main diseases, and Somalia and predominantly related aftermath of the 2005 earthquake as the measles, acute watery diarrhoea, acute to acute diarrhoeal disease outbreaks disease-surveillance network of choice jaundice syndrome and dengue fever, as [4]. In the Darfur crisis between March and this successful system was replicat- they accounted for the majority of the 2003 and December 2008, 80% of the ed in subsequent disasters. Under the reported alerts and detected outbreaks. estimated excess deaths (300 000) reg- parameters of DEWS, a regular weekly istered during the stabilization period reporting system, covering 16 selected were caused by communicable diseases priority diseases and conditions of Results such as diarrhoea [3]. public health importance, was initiated Displaced populations in camp [15,16]. Utilizing the DEWS network, The DEWS network was implemented settings are at high risk of infectious health workers were able to detect the within two weeks following the 2005 diseases due to a range of risk factors first indication of a DEWS-notifiable earthquake and covered the affected that act synergistically, e.g. inadequate disease or condition, providing the districts in close collaboration with the shelter and overcrowding, unsafe drink- opportunity to prevent its spread and Ministry of Health, the Government of ing water supply system, poor sanita- related morbidity and mortality. Every Pakistan Administered Kashmir (PAK) tion, poor personal hygiene, low vaccine disease alert reported from any of the and Khyber Pakhtunkhwa province and coverage and disruption of health serv- participating health facilities operating health cluster partners. Standard case ices [5]. A review study reported that in the affected areas was immediately definitions were clearly outlined and S115 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF alert and outbreak thresholds for the pri- 2008 earthquake in Baluchistan and the epidemic threshold level or confirmed ority notifiable diseases and conditions 2008–2009 internally displaced per- evident outbreaks. explicitly defined, to ensure uniformity sons (IDPs) crisis in FATA and Khyber DEWS teams were deployed in the of reporting, timeliness and detection Pakhtunkhwa. By December 2009, the target districts to develop the surveil- accuracy and to undertake immediate DEWS network had expanded to 1319 lance network infrastructure and train control measures when necessary. health facilities in 50 emergency-affect- health care providers on standard case Table 1 illustrates the alert and ed districts. From October 2005 to definitions, data collection and report- outbreak thresholds for the priority December 2009, more than 28 million ing, including alerts, and to initiate an diseases and conditions under DEWS consultations were recorded, with acute immediate response when outbreaks surveillance. These stated definitions respiratory infection being the leading were confirmed. The district health of- and thresholds improved the sensitiv- cause and accounting for around seven fices were supported with information ity of reporting and impacted on the million (25%) consultations, followed technology equipment and software promptness of response interventions. for data collection and management. by acute diarrhoea (8%), suspected Contingency stockpiling of medicines An exhaustive surveillance network malaria (5%) and scabies (5%). was established and expanded, covering and supplies was organized at strategic all the functioning health facilities in Figure 1 illustrates the framework of district locations to ensure a prompt the affected districts. The number of the sequential tasks and related support, and effective response. Sample col- reporting sites in the 2005 earthquake- and capacity-building activities relevant lection and transportation were also affected districts had increased from an to DEWS. All detected alerts led to facilitated to access the specialized labo- initial 19 to 133 by December 2005. The verification, investigation, confirmation ratory facilities of the National Institute same DEWS network was established and mitigation response interventions. of Health, Islamabad, a World Health in all subsequent disasters, such as the Investigation results uncovered mis- Organization (WHO) collaborating floods in Sindh and Baluchistan, the diagnoses, detection of cases below the centre. Table 1 The set diagnostic thresholds for alerts and outbreaks relevant to the disease entities incorporated in the disease early warning system (DEWS) surveillance network Disease/condition Thresholds Alerts Outbreaks Acute lower respiratory Twice the average number of cases of the previous Clustering of cases in a single location above the infection three weeks for a given location alert threshold Acute upper respiratory Twice the average number of cases of the previous Not specified until infectious agent is identified infection three weeks for a given location Acute diarrhoea (non Twice the average number of cases of the previous Clustering of cases in a single location above the cholera) three weeks for a given location alert threshold Acute watery diarrhoea One suspected case A confirmed case, or a cluster of three or more (suspected cholera) suspected cases in a single locality Bloody diarrhoea Three or more cases in one location Doubling of case-load from alert threshold in one location Haemorrhagic fever One probable case One confirmed case Acute jaundice syndrome Three or more cases in one location A cluster of 8–10 cases in one location Malaria Twice the average number of cases of the previous Clustering of cases in a single location above the three weeks for a given location alert threshold Measles One case Five or more cases in a single location Meningococcal meningitis One case Two or more confirmed cases from a single location Acute flaccid paralysis One suspected case One confirmed case Unexplained fever One death or twice the average number of cases of Not specified until infectious agent is identified the previous three weeks for a given location Neonatal tetanus One case requires investigation for safe birth None (does not spread) practices Scabies Twice the average number of cases of the previous To be determined by trends (recently added to three weeks for a given location surveillance) S116 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Laboratory support was provided to Weekly case confirm the diagnosis and expedite field count of diseases investigations. For suspected cholera, /conditions 373 stool samples were collected, of which Vibrio cholerae was confirmed in 157 (42%). Blood samples from 190 Implementation of suspected cases of measles were tested Alert generation control measures serologically at the National Institute of Health and 125 (66%) samples were ? HR deployment confirmed. For acute viral hepatitis, 189 ? Capacity building blood samples were tested for labora- ? Stocking of medicines and tory diagnosis. Of these, hepatitis A was supplies confirmed in 54 (29%) samples (36 ? IT equipment & sporadic cases and 18 samples from software outbreak settings) and hepatitis E in 44 (23%) samples (30 from outbreak Confirmation Alert verification settings and 14 diagnosed as sporadic cases). Figure 2 illustrates the monthly trends for acute diarrhoeal disease, acute respiratory infection and measles from Investigation the onset of the earthquake till 2009. Acute watery diarrhoea, measles, dengue fever and acute jaundice syn- drome (viral hepatitis) accounted Figure 1 A framework of disease early warning system (DEWS) sequential tasks and for 56% of the alerts and 83% of the related support and capacity-building activities outbreaks. Detailed analysis of the out- breaks and reported cases, standardized per 100 reporting units, showed that Table 2 illustrates the alerts and food poisoning, mumps, tuberculosis, outbreaks of acute watery diarrhoea outbreaks reported for each disease or pertussis, diphtheria and typhoid. Two declined in all the emergency-affected condition by type of emergency and outbreaks of anthroponotic cutaneous areas although the seasonal incidence the affected area from November 2005 leishmaniasis were also identified and of diarrhoeal diseases was sustained. In to December 2009. During this period controlled during the IDP crisis in Khy- the 2005 post-earthquake period, there a cumulative total of 1368 alerts was ber Pakhtunkhwa, while three chicken were 20 outbreaks in the year 2006, reported from disaster-affected regions, pox outbreaks were identified in the followed by eight, two and one outbreak and investigation, prompt epidemic re- IDP camps and preventive and control in 2007, 2008 and 2009, respectively. sponse and control interventions were measures carried out. The measles outbreaks and cases re- carried out for all the 187 identified corded in the subsequent years follow- The study revealed that among pri- outbreaks. ing the earthquake were significantly ority epidemic-prone diseases, acute Through the DEWS network, 46 less frequent compared with the disease watery diarrhoea was the leading health alerts and 18 outbreaks were reported occurrence during the first year of the that were caused by diseases not includ- problem with 85 (45%) outbreak disaster [odds ratio (OR) = 0.04; 95% ed in the priority notifiable communi- events, followed by measles with 33 confidence interval (CI): 0.00–0.30. In cable diseases and conditions. Although (18%) outbreaks, dengue fever 21 the 2005 post-earthquake disaster, 17 outside the recognized notifiable dis- (11%) outbreaks and acute hepatitis measles outbreaks were confirmed in ease list, all the alerts and outbreaks viral infection with 16 (9%) outbreaks 2006 and three outbreaks were detected were investigated and control measures (of the confirmed cases, seven were in 2007 but no measles outbreaks were introduced as appropriate. These in- hepatitis E and three were related to recorded subsequently. In the flood- cluded avian influenza, influenza H1N1, hepatitis A), while bloody diarrhoea affected areas of Sindh and Baluchistan, cutaneous leishmaniasis, chicken pox, accounted for six (3%) outbreaks. and among the IDPs in FATA and S117 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 2 Alerts and outbreaks reported through the DEWS surveillance network related to the three natural disasters that hit Pakistan during 2005–2008 and the 2008–2009 IDP crisis Diseases/ Earthquake, Floods, Floods and IDP crisis, Total conditions PAK and Khyber Sindh earthquake, Khyber Pakhtunkhwa Baluchistan Pakhtunkhwa Nov. 05–Dec. 09 Aug. 07–Dec. 09 Aug. 07–Dec. 09 Aug. 08–Dec. 09 Alerts Outbreaks Alerts Outbreaks Alerts Outbreaks Alerts Outbreaks Alerts Outbreaks No. No. No. No. No. No. No. No. No. % No. % Acute flaccid paralysis 102 0 73 1 7 0 16 1 198 14.47 2 1.06 Acute jaundice syndrome 142 16 40 0 0 0 4 0 186 13.59 16 8.55 Acute respiratory infection 17 1 6 1 0 0 0 0 23 1.68 2 1.06 Acute watery diarrhoea 122 33 66 13 13 9 60 30 261 19.07 85 45.45 Bloody diarrhoea 42 3 15 0 2 0 5 3 64 4.67 6 3.20 Crimean-Congo haemorrhagic fever 4 0 0 0 0 0 2 1 6 0.43 1 0.53 Dengue haemorrhagic fever 20 3 24 13 0 0 11 5 55 4.02 21 11.22 Unexplained fever 3 0 0 0 0 0 0 0 3 0.21 0 0 Malaria 24 1 5 1 3 0 3 0 35 2.55 2 1.06 Measles 199 26 31 2 11 1 25 4 266 19.44 33 17.64 Meningitis 101 1 51 0 0 0 1 0 153 11.18 1 0.53 Tetanus 3 0 1 0 0 0 0 0 4 0.29 0 0 Neonatal tetanus 5 0 61 0 1 0 1 0 68 4.97 0 0 Others 14 7 3 3 0 0 29 8 46 3.36 18 9.62 Total 798 91 376 34 37 10 157 52 1368 100 187 100 PAK = Pakistan Administered Kashmir; IDP = internally displaced persons. Khyber Pakhtunkhwa, a declining mea- Discussion The close collaboration of the Min- sles trend was observed, though this was istry of Health and health cluster part- not significant. Communicable diseases are of major ners in DEWS implementation ensured During the four-year surveillance in public health concern in Pakistan, its acceptability, technical soundness all disaster-affected areas, no significant with yearly outbreaks of waterborne, and practical viability [17]. Alerts and decline was observed in the number vector-borne and vaccine-preventable outbreaks for priority diseases were frequently detected and controlled ef- of outbreaks or case-load of dengue diseases that worsen during emergen- fectively, including those encountered fever, or change in the seasonality of cies [1,10,17]. The prompt establish- but not officially recognized as DEWS- the disease occurrence. In the 2005 ment of DEWS immediately after the notifiable diseases, e.g. avian influenza, earthquake-affected area, acute jaun- October 2005 earthquake led to the influenza H1N1 and leishmaniasis. As early detection of potential outbreaks dice syndrome cases dropped gradually reported from previous humanitarian and prompted rapid control interven- and significantly over the subsequent interventions elsewhere, the majority of tions that prevented a large number of years as compared with the first post- outbreaks in Pakistan were encountered earthquake year (OR = 0.18; 95% CI: alerts evolving into full-blown disease at the outset of the emergencies [1]. 0.11–0.30). In the 2005 post-earthquake outbreaks, mitigating the risk among The successful implementation of the period, there were nine acute jaundice this vulnerable population. Drawing DEWS network in subsequent emer- syndrome outbreaks in 2006, followed experience from this successful lesson, gencies was substantiated by the merit by three and two outbreaks in 2007 and the DEWS surveillance network was of its operational feasibility, effective 2008, respectively, while no outbreaks replicated in subsequent emergencies disease-control impact, acceptability to were detected in 2009. in Pakistan. the health cluster partners and generous S118 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Acute diarrhoea the multiple unprotected water supply 16 sources and the difficulty in improving 14 12 drinking water safety for a large and 10 widely scattered population, as was the % 8 case in the post-earthquake period. 6 Hepatitis A cases were detected more 4 frequently in the population age group 2 of less than 15 years, while hepatitis E 0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec was more predominant in the older age bracket, consistent with the epidemiol- 2006 2007 2008 2009 ogy of these diseases. Two outbreaks of cutaneous leishmaniasis were identified in the IDP-crisis affected area and con- Acute respiratory tract infection trol measures were undertaken 35 30 The occurrence of communicable disease outbreaks was influenced by a 25 complex interplay of host, agent and 20 % environment-related factors [8,17,18]. 15 Setting priorities for disease surveillance 10 and risk assessment during humanitar- 5 ian emergencies therefore required a 0 careful consideration of the potential Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec interaction of all three factors consistent 2006 2007 2008 2009 with the specific geographical context and prevailing epidemiological vulner- ability of the population [16,19]. Measles 200 The declining rate of measles over time was partly attributed to the vac- 150 cination campaigns carried out in the immediate aftermath of every disaster. 100 This initial large-scale effort was further augmented by the robust surveillance No. of cases 50 system and mop-up vaccination cam- paigns conducted wherever a cluster- 0 ing of cases was reported. Through the Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec expansion of DEWS in 2006, measles 2006 2007 2008 2009 outbreaks were detected from remote areas that did not benefit from the earlier mass vaccination campaigns in the 2005 Figure 2 Monthly trends of acute diarrhoea, acute respiratory infection and earthquake-affected area. The two-dose measles following the 2005 earthquake prospectively recorded for a period of four years (2006–09) vaccination strategy for the target child population may be considered during emergencies for effective immunization and disease prevention while all efforts funding support by international part- were more frequently encountered need to be made to reach out to remote ners during the course of its implemen- in the flood-affected areas of Sindh localities where the impact of disease tation. and IDP-hosting districts in Khyber outbreaks would be more devastating. Acute watery diarrhoea (cholera) Pakhtunkhwa, while acute hepatitis A The higher frequency of waterborne and measles outbreaks were detected and E viral infections were more promi- diseases can be explained by the com- from most of the emergency-affected ar- nently seen in the earthquake-affected plexity of the interventions necessary to eas and effective control measures were areas of PAK and Khyber Pakhtunkhwa. change the unfavourable hygienic and introduced. Dengue fever outbreaks The latter may partly be explained by environmental conditions that allow S119 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF these diseases to spread. Undoubt- 2%, respectively, illustrating the capac- detection and control of communica- edly, lack of clean water is the most ity of the system to control epidemics. ble disease outbreaks and for averting obvious risk of infection and disease To sustain the technical role of DEWS, avoidable morbidity and mortality in outbreak. The latter was related to the trained human resources, the necessary the disaster-affected populations. The use of unprotected water sources or infrastructure and strong analytical and DEWS initiative can be organized with- unhygienic vessels for the transporta- response backup support capacities, in a week and implemented effectively tion and storage of water at homes including laboratory diagnostics, need in all disaster-affected areas, despite the and to the intermittent piped water to be ensured. The mobilization of these initial lack of accurate population data, distribution system that posed high risk operational capacities was the key as- limited communication network for of sewage contamination in most of set that led to the remarkable preven- data collection, scarcity of reliable labo- the affected towns [5,20]. To monitor tion and control of epidemics during ratory services, absence of prior logistic water quality, field water testing kits emergency response interventions in arrangements for the timely dispatch of were introduced to isolate the source Pakistan. The DEWS technology was samples to a reference laboratory and of contamination and implement further developed by introducing a the early coordination challenge with the necessary control interventions. new software package with automated health partners. The latter substantiates Health and hygiene promotion was surveillance bulletins, alert notification the robustness, reliability and effective- also carried out through behaviour- and disease-trend plotting, facilitating ness of this system, in an environment change communication interventions the work of surveillance officers and en- where health services are disrupted, alongside improvements in the water hancing their ability to detect potential their capacities overwhelmed and where supply infrastructure. outbreaks the prevention of epidemics becomes The successful implementation of A major contribution of DEWS both a life-saving entity as well as a cop- DEWS was helped by the cooperation was the concurrent capacity building ing necessity for the health system by between health cluster partners and the of local human resources, where district lowering the burden of disease. DEWS national and provincial health system. teams were trained on disease surveil- has become an effective, tested strategy Confidence in the system has contribut- lance, alert/outbreak investigation and for the control of communicable dis- ed to DEWS’ active case finding, prompt response. This process has enabled the ease outbreaks and epidemics during reporting ability, close analysis of disease district health system to sustain DEWS emergencies. The interest shown by the trends and early mitigation and outbreak surveillance, epidemic detection and health management teams to sustain control. In the first post-earthquake year, control capacity beyond the disaster DEWS in the post-emergency period 10% of the 336 reported alerts were re- period. was also supported by WHO to make ceived late, while the delayed alerts in Sensitive disease-surveillance sys- it an integral component of the district the second and third years were 6% and tems are absolutely essential for the health system capacity development. References 1. Paquet C, Hanquet G. Control of infectious diseases in refugee 7. Mohan A et al. Measles transmission following the tsunami in a and displaced populations in developing countries. Bulletin de population with a high one-dose vaccination coverage, Tamil l’Institut Pasteur, 1998, 96:3–14. Nadu, India 2004–2005. BMC Infectious Diseases, 2006, 6:143. 2. Connolly M et al. Communicable diseases in complex emer- 8. Abdallah S, Burnham G. Public health guide for emergencies: control of communicable diseases. United States of America, gencies: impact and challenges. 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Kouadio IK, Kamigaki T, Oshitani H. Measles outbreaks in disasters. Emerging Infectious Diseases, 2007, 13(1):1–5. displaced populations: a review of transmission, morbidity 12. Marfin AA et al. Infectious disease surveillance during emer- and mortality associated factors. BMC International Health and gency relief to Bhutanese refugees in Nepal. Journal of the Human Rights, 2010, 10:5. American Medical Association, 1994, 272(5):377–381. S120 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ 13. Valenciano M et al. Challenges for communicable disease sur- 16. Communicable disease risk assessment: protocol for humanitar- veillance and control in Southern Iraq, April–June 2003. Jour- ian emergencies. Geneva, World Health Organization, 2007 nal of the American Medical Association, 2003, 290(5):654–658. (WHO/CDS/NTD/DCE/2007.4). 14. Guidelines for disease surveillance/early warning and response: 17. Noji EK. ABC of conflict and disaster: public health in aftermath Middle East crisis. Geneva, World Health Organization, 2006 of disasters. British Medical Journal, 2005, 330:1379–1381. (WHO/CDS/NTD/DCE/2006.6) http://www.who.int/dis- 18. Epidemic-prone disease surveillance and response after the easecontrol_emergencies/guidelines/Middle%20East%20 tsunami in Aceh province, Indonesia. Weekly Epidemiological Crisis_WHO%20CD%20surveillance_early%20warning%20 Record, 2005, 80(18):157–164. guidelines.pdf, accessed 27 June 2010). 19. Setting priorities in communicable disease surveillance. Ge- 15. South Asia earthquake-affected areas, 2005: operational plan neva, World Health Organization, 2006 (WHO/CDS/EPR/ and communicable diseases surveillance/early warning and re- LYO/2006.3). sponse guidelines. Islamabad, Ministry of Health Pakistan and 20. Lee E J, Schwab K J. Deficiencies in drinking water distribution World Health Organization, 2005 (http://www.whopak.org/ systems in developing countries. Journal of Water and Health, pdf/PostAsiaearthquakeCDrisksinterventions.pdf , accessed 19 2005, 3(2):109–127. January 2010). S121 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF “Delivering as one” UN reform process to improve health partnerships and coordination: old challenges and encouraging lessons from Pakistan K.M. Bile,1 K.A. Lashari 2 and A.F. Shadoul 1 Òz@Ðíod]edSÒzBÐXúÐÊÐØÌ9ÓmXz#Ðwza=Ö°ÉÎ9ZTÐgeTÐíÓmSÐOTÐĵ´ éíØnIÖ}R{1̺ïÚnIø}åBÐØfIBºØe7d=hdBö ºpþhUÐíºphiniüÐÓÐ{LnCÐíºphefUÐÓøn6:^fUÐYnT:=Ð}åUn=phf_YîCÐp_hRÚpf!Ò{CÐY±Uên_UÐNYúÐHÌoåÉ°#Ð p[UÐ:pT}åZYsYÐ}=p2qþZiÌ{Sí =Ð}ådUpRØn4Ðn*ÚØnC¤Ò{AÐípe^feTÊÐØún=ÓnY{#Ðx{b>¯Ún_IpfdUÐì|wqf>í 2005ênL YúÐÓønTíYpUnTí14qY{S{Sí pþhUÐ:íºhbUÐ:íºÔÚÐcUÐ}Jn8ÒÚÐØÎ:íº}baUÐY{"Ðíphax}UÐphefUÐípLÐÚ~UÐ:íºëncUÐí ph=n«üÐýniëlRºÓnx{UÐY{x{_UÐ@Ðí{SsYniFUÐÐ|wëÌQÚí ì|haf>:qªnHíëncö UÐíp[dUè}åZCÐsYniFdUngeLØÒ{CÐ EQÓnhde_UÐíØg!ÐLn\>íÍ~Un=qeå>ÐUÐpb=nUÐÓnwxÚnfhUÐçnhH:ºÒ{AÐípe^feTÊÐØún=ÓnY{# Ðx{b> RnfYÓ{TÌ ênY~=|BúÐDL>Ú{SngfYíºëncUÐíp[UÐân]SnwÛ}AÌUÐÓÐÛniüÐpSÚUÐì|wß}_>íºpUí{UÐÓ5^fCÐ:ípYc"Ð:p]=Ð}åCÐ phh>Ð}åHøÐphfJUÐÓnxUíúÐDLphUnCÐípxPUÐØÚÐedUMbCÐ~hT}åUÐ Yº<í{UÐëín_UÐîSh@>íºÚYúÐ ABSTRACT The UN Secretary-General constituted a high-level panel on system-wide coherence in 2005 within the areas of development, humanitarian assistance and the environment. The panel adopted “Delivering as One” as a slogan for its coherence initiative. Pakistan was among eight pilot countries implementing this reform initiative. Five joint programmes were developed, on health and population; agriculture, rural development and poverty reduction; disaster risk management; education; and environment . Fourteen UN agencies supported the health and population joint programme and participated in its implementation. Although confronted by many challenges, the positive results of the joint programmes confirmed the advantage of Delivering as One over the past scenarios of fragmentation, duplication and incoherent government and UN strategic operations. The paper shares the accomplishments of the health and population sector including its ability to harness the power of intersectoral collaboration and prospectively concentrate human and financial resources around the strategic national priorities. « Unis dans l’action », processus de réforme des Nations Unies pour améliorer les partenariats pour la santé et leur coordination : anciens défis et enseignements encourageants au Pakistan RÉSUMÉ En 2005, le Secrétaire général des Nations Unies a formé un Groupe de haut niveau sur la cohérence de l’action du système des Nations Unies dans les domaines du développement, de l’aide humanitaire et de la protection de l’environnement. Celui-ci a choisi le slogan « Unis dans l’action ». Le Pakistan faisait parti des huit pays pilotes choisis pour mettre en œuvre cette réforme. Cinq programmes conjoints ont été conçus dans les domaines suivants : santé et population ; agriculture, développement rural et réduction de la pauvreté ; gestion des risques de catastrophe ; éducation ; et environnement. Quatorze agences de l’ONU ont soutenu le programme conjoint pour la santé et la population et ont participé à sa mise en œuvre. Malgré de nombreuses difficultés, les résultats positifs des programmes conjoints ont confirmé la supériorité de l’initiative « Unis dans l’action » par rapport aux scénarios précédents caractérisés par la fragmentation, la redondance et l’incohérence des opérations stratégiques gouvernementales et onusiennes. Cet article décrit les réalisations du secteur santé et population, notamment sa capacité à exploiter la puissance de la collaboration intersectorielle, et au préalable, à concentrer les ressources humaines et financières sur les priorités stratégiques nationales. 1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to K.M. Bile: [email protected]). 2Federal Ministry of Health, Islamabad, Pakistan. S122 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Introduction planning, monitoring and evaluation process and a desk review of the experi- [8]. ence gained since the Delivering as One The “Millennium Declaration” of 2000 To accommodate this vision, the initiative began in Pakistan. Focused provided a global vision offering greater United Nations Development As- interactions with health sector policy- maternal, infant and child survival, bet- sistance Framework (UNDAF) of makers, supported by a survey of UN ter education for children, equal op- 2003–08 was extended till the end of heads of agencies and the Resident portunities for women, a healthier 2010, reviewed and aligned with na- Coordinator of their perception of the environment and national and inter- tional development goals, expressed in work of the Delivering as One initiative national partnerships supporting the Pakistan’s medium-term development were carried out. The reports of different pursuit of a sustainable development framework, poverty reduction strategy UN visiting missions, proceedings of framework for action [1]. However, this paper, UN Millennium Development joint programme consultations and UN commitment was undermined by a lack Goals and Vision 2030. Nineteen UN intercountry, regional and global policy, of focus on results, thereby failing the agencies working in Pakistan endorsed strategic and programmatic delibera- aspirations of many developing nations, the Delivering as One arrangement tions on Delivering as One were also especially the vulnerable and the poor for 2009–10 and translated it into five scrutinized. [2–4]. Responding to this concern, thematic programmes: health and the United Nations (UN) Secretary- population; agriculture, rural develop- General constituted a high-level panel ment and poverty reduction; disaster Results on system-wide coherence in 2005 risk management; education; and en- within the areas of development, hu- vironment . These programmes were The Delivering as One initiative manitarian assistance and the environ- jointly formulated with federal and ment [5]. The panel reiterated the UN’s provincial governments and shared In Pakistan, the high-level panel delibera- support for the Millennium Develop- with civil society organizations and tions and established guiding principles ment Goals, sustainable development, other development partners [19–12]. [4] were endorsed in their entirety. The rapid response to humanitarian disas- They are currently being implemented Delivering as One initiative envisioned ters and for protecting the environment through a range of 21 joint programme a UN resident coordinator system that [4]. The panel outlined the fragmented components. include a country team led by a resident nature of UN work, policy incoherence, The Delivering as One initiative coordinator as the single leader but duplication and poor implementation. aims to attain the Millennium De- jointly assisting in the planning, imple- To overcome these challenges, it em- velopment Goals with a focus on the mentation, monitoring and evaluation phasized “Delivering as One” as the poor and disadvantaged; harness the of the UN reform process relevant to central theme of its recommendations expertise of different UN agencies for the five joint programmes (Table 1) and called for greater UN coherence, effective implementation and coher- that complement and support nation- while linking the UN funding process to ence with sectoral development plans; ally defined sectoral priorities. These performance and results. The panel rec- promote equity, universal access to joint programmes were developed ommended the pursuit of one strategy essential social services; and enhance through UN and government consulta- and one set of goals, while establishing intersectoral collaboration [4,8]. This tions examining the current progress in one UN presence at the country level, study aims to describe Pakistan’s Deliv- each sector, and the inherent strengths, with one leader, one programme, one ering as One implementation process weaknesses, opportunities and threats. budget and where appropriate one of- and the experience gained, and share A UN capacity assessment survey was fice [4]. the accomplishments of the health also carried out to build a broad based To promote the Delivering as One and population sector and its ability to consensus on each agency’s compara- initiative, eight governments, including harness intersectoral collaboration and tive advantages in support to these joint Pakistan’s, were entrusted to pilot im- focus the scope of future action on the programmes. plementation and generate lessons for set national strategic priorities. future potential replication consistent Translating the Delivering as with the principle of national ownership One initiative into action and “no one size fits all”, with promi- Methods To promote the Delivering as One joint nent UN support [6,7]. Since 2007, efforts, the UN and government part- Pakistan has introduced key reform The information in this paper was the ners laid down the following principles elements that synchronize joint efforts product of the authors’ direct participa- to enhance the development process to- and strengthen coordination, strategic tory insight in the Delivering as One wards Millenium Development Goals: S123 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 1 Government and UN designed joint programmes, their respective joint programme components and respective UN participating agencies Joint programmes (number of Joint programme components (JPC) participating agencies) Agriculture, rural ō Pro-poor sustainable agriculture and rural development developmentand poverty ō Decent employment and poverty alleviation reduction (11) ō Empowerment, mobilization and protection of poor and vulnerable groups ō Millennium Development Goals–driven pro-poor policy framework Disaster risk management (12) ō Disaster risk management: strengthened policies, norms, institutional capacities with emphasis on preparedness and response; integrated multisectoral knowledge, information and communication system and reaching out to the grass roots; human resource development at all levels Education (9) ō Preschool and elementary education ō Adult literacy and informal basic education ō Strengthening the education system ō Secondary education with a focus on technical and vocational education and life skills Environment (11) ō Strengthened and operational institutional mechanisms for integrated environmental management ō Integrated programme on access to safe water and sanitation ō Integrated natural resources management in demonstration regions ō Sustainable urbanization ō Support for green industries, waste management, energy and Jobs Health and population (14) ō Maternal, neonatal, and child health and family planning/reproductive health in the context of primary health care ō Communicable disease control ō Nutrition and health promotion ō Health system development ō HIV and AIDS ō Population and census r Align the delivery of UN develop- roles in line with the agencies’ man- r Assist national partners on emergen- ment support with key sectoral pri- dates and respective comparative ad- cy preparedness and response with orities and apply national systems vantages and integrate best practices focus on vulnerability and disaster and procedures for their implemen- in all joint programme components risk reduction and apply best prac- tation while engaging in “upstream” and assess the progress of imple- tices for planning and programme policy and programme dialogue and mentation, using jointly defined pro- implementation. promoting equity and capacity de- gramme indicators and targets, and r Revisit the existing interagency over- velopment synchronized monitoring, evaluation laps, duplications and operational r Promote the “managing for results” and audit systems. gaps, and identify solutions to rectify concept, by introducing perform- r Endorse the stipulated UN dual ac- these in the course of planning and ance-based criteria and effective re- countability management of the UN implementation of the Delivering as source targeting and allocation, while country team in the Delivering as One interventions. advancing ownership, coherence, One framework, mandating unity of Formulating joint reduced transaction costs and flex- purpose under the resident coordina- programmes ibility when responding to national tor system, while concurrently ren- The government-driven joint program- development challenges. dering UN country team members ming led to the formulation of five r Use existing UN funding mecha- answerable to their agencies’ respec- joint programmes and a subset of 21 nisms of core and voluntary con- tive organizational work. joint programme components (Ta- tributions effectively, as well as the r Assess the progress of mainstreaming ble 1). These joint programmes were supplementary expanded financing the cross-cutting issues of gender, hu- translated into common operational window, recognizing the need for man rights, civil society organizations work plans, involving two or more UN multi-year funding predictability. and refugees in view of their strong agencies along with their government r Foster harmonization by working to- relevance to the successful imple- counterparts. UN participation in one gether and promoting the division of mentation of joint programmes. joint programme ranged from nine to S124 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ fourteen agencies, reflecting the exist- for the joint programme component resource management centre, a common ing synergies and complementarities formulation, planning, implementation, procurement facility and standardized between different UN organizations. monitoring and coordination. The par- web-based material. A communication ticipation and co-chairing of the joint group was also launched to assist the Governance mechanisms for programme component task force is Delivering as One implementation. joint programming structurally identical to the joint pro- Headquarters and regional UN agen- The following mechanisms were es- gramme steering committee, but di- cies’ support mechanisms tablished for coordinating and man- rected by senior government and UN To promote UN system-wide coher- aging the Delivering as One reform professionals who are specialists in their ence and the Delivering as One initia- process. respective fields. tive, the following supportive structures Government and UN joint mecha- UN joint mechanisms at the country were established. nisms level The chief executive board is the The high-level committee and the joint At country level, UN development as- highest UN forum that brings together programme steering committee are key sistance is coordinated by the resident the executive heads of all UN agencies government and UN joint mechanisms coordinator system bringing together under the leadership of the UN Secre- established in support of the Delivering all resident and non-resident UN or- tary-General, mandated to promote co- as One process. ganizations engaged in the country’s ordination and cooperation on a range The high-level committee is chaired development support. of substantive and managerial issues by the prime minister or his/her rep- The resident coordinator leads the facing the UN system organizations. resentative bringing together federal UN country team, coordinates the De- The chief executive board is supported and provincial government line depart- livering as One initiative and facilitates by three high-level committees: the ments and UN and donor members. Its its implementation, while upholding United Nations Development Group job is to oversee the Delivering as One the UN-stipulated code of conduct (UNDG) consisting of 32 UN funds, reform process, monitor its progress and maintaining regular communica- programmes, agencies, departments and and provide necessary institutional sup- tion with the government, UN country offices. UNDG guides the management port. The high-level panel is assisted team and the higher tiers of the UN of resident coordinators, the regional by an executive committee entrusted system. management teams and promotes to support the implementation of the The UN country team led by the coherent oversight, capacity-building joint programmes and facilitate their resident coordinator consists of all heads and coordination of UN development resource allocation processes. The ex- of UN agencies, funds and programmes operations at country level including ecutive committee comprise the secre- and represent the interagency coordina- the implementation of the triennial tary of the economic affairs division, the tion and decision-making body. The comprehensive policy review of the UN UN resident coordinator and a donor UN country team provides support to System. The Development Operations representative. the different joint programmes and is Coordination Office assists UNDG Five joint programme steering com- responsible for achieving the Delivering by extending its technical and financial mittees guide the planning, resource as One results. To harmonize the UN support to the UN resident coordina- allocation, implementation and the technical support for this initiative, a tor system, conducting oversight of the management of joint programmes. Each thematic working group was created for multi-donor trust fund, coordinating joint programme steering committee is each joint programme, co-chaired by a the regional management teams’ and co-chaired by a government representa- lead substantive agency, permanently UN country teams’ support to the De- tive at the level of federal secretary (or assuming this role, and by a second par- livering as One initiative. The High-level equivalent) and the representative of ticipating agency rotating on a yearly Committee on Management works on a lead UN agency, with membership basis. An interagency working group system-wide administrative and man- from all UN and government partici- was similarly established to coordinate agement issues, and a the High-level pating agencies while civil society or- and enhance the UN in-house active Committee on Programmes addresses ganizations and donors can participate participation in the joint programme the global programmatic issues and as observers. Each of the 21 joint pro- component task force. To harmonize provides strategic guidance, leadership gramme components is managed by a and simplify business practices, an and coherent technical support to the joint programme component task force operational management team was UN agencies’ regional directors team, that reports to the joint programme established. The operational manage- resident coordinators and UN country steering committee and is accountable ment team identified a common human teams. In addition to these institutional S125 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF arrangements, each UN organization of funding, the projected budgetary the health and population joint pro- has established a focal desk in support of outlay of the five joint programmes was gramme, the participating UN agencies the Delivering as One initiative at their estimated at US$ 396 million per year, and their envisaged outcomes. Agen- regional offices and headquarters. In the whereas the proportional allocations cies’ participation in the different joint World Health Organization (WHO), for agriculture, rural development and programme components reflected the the Director-General and regional poverty reduction; disaster risk manage- scope of their technical engagement directors have recognized Delivering ment; education; environment; and mandates and operational capacities as One since its inception as the sine health and population were 21.3%, on the ground. qua non strategic policy choice of the 17.7%, 22.0%, 6.7% and 32.3%, respec- As a prototype of the joint pro- Organization and have drawn the at- tively. The collective resource gap of gramme components’ implementation tention of WHO Member States on the five joint programmes was 80.4 % paradigm, the field implementation of the potential of linking health to the at the planning outset, indicating the the joint programme component for prevailing challenges for resource mo- mainstream of the Delivering as One maternal, neonatal and child health is bilization. development process. shown in Table 4. This targets ten dis- The Regional Directors’ team pro- The health and population joint pro- tricts of Sindh province, with technical vides strategic leadership and policy gramme was designed in close collabo- roles of each participating UN agency guidance to the resident coordinator ration with federal ministries of health explicitly identified, while jointly as- system and supports the UN country and population welfare along with their sisting and monitoring implementa- team in promoting coherence of the UN provincial line departments, civil soci- tion to consolidate the Delivering as ety organizations and international part- work in the country, oversees perform- One principle. Figure 1 illustrates the ners. Apart from the population census ance and assumes a problem-solving existing nexus between the health and joint programme component, the re- role in difficult situations to consolidate population joint programme and other maining five health and population joint interagency collaboration. joint programmes whose operational programme components address key The Delivering as One joint pro- roles contribute to the social deter- public health priorities fully aligned with grammes are primarily financed by the minants of health. The dependence the poverty reduction strategy paper assessed and voluntary contributions of health development outcomes on provided to UN organizations. Funds and Millennium Development Goals strategies and targets. the performance scope of other joint are also obtained by the Delivering as programmes is illustrated, legitimizing Table 2 shows the UN agencies par- One incremental Development Op- the role of the health and population ticipating in the health and population erations Coordination Office manag- joint programme participating agen- joint programme. ing the expanded funding window of cies in strengthening and expanding the multi-donor trust fund and other Table 3 shows the six formulated the inter-joint programme synergies. contributions. Considering all sources joint programme components of In planning the health and popula- tion joint programme and related joint Table 2 Participating UN agencies in the health and population joint programme programme components, the evolving Abbreviated name Full name opportunities for intersectoral action ILO International Labour Organization were addressed, recognizing the effect IOM International Organization for Migration social determinants of health interven- UNAIDS Joint United Nations Programme on HIV/AIDS tions exert on health and population UNDP United Nations Development Programme outcomes. The latter is exemplified by United Nations Educational, Scientific and Cultural the incremental gains that would ac- UNESCO Organization crue to the health sector by improving UNFPA United Nations Population Fund the quality, accessibility and length of UNICEF United Nations Children’s Fund female education; improving cover- UN-HABITAT United Nations Human Settlements Programme Office of the United Nations High Commissioner for age of household level safe drinking UNHCR Refugees water and sanitation, creating means UNIFEM United Nations Development Fund for Women of livelihood, availing better nutrition UNODC United Nations Office on Drugs and Crime and disposal of hazardous solid waste, WFP World Food Programme all concerns that have a major bearing WHO World Health Organization on health. S126 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 3 The six health and population joint programme components, their envisaged outcomes and the UN agencies participating in their implementation Health and population joint programme components Joint programme component 1: maternal, neonatal and child health including reproductive health/family planning Outcome 1: (UNICEF, WHO, UNFPA) Infant and maternal mortalities reduced and integrated maternal, neonatal and child health, including reproductive health family planning and services, implemented Outcome 2: (UNICEF, WHO, UNFPA) Community demand and participation and intersectoral linkages for maternal, neonatal, and child health and reproductive health/family planning services are improved Outcome3: (UNICEF, WHO, UNFPA, Nutrition status especially of infants, young children and child-bearing women is WFP) improved Joint programme component 2: communicable diseases control Outcome 1: (WHO, UNICEF, UNHCR) Morbidity and mortality due to vaccine-preventable diseases reduced; polio eradication and measles elimination programmes have achieved their targets Outcome 2: (WHO, UNHCR, WFP, Tuberculosis and other priority endemic communicable diseases controlled IOM) Outcome 3: (WHO, UNICEF, UNHCR, Malaria incidence reduced and an integrated national programme for zoonotic and other FAO) vector-borne diseases launched to mitigate burden Outcome 4: (WHO, UNICEF) Hepatitis B and C are prevented and disease burden controlled Outcome 5: (WHO, UNICEF) National integrated communicable disease surveillance and outbreak response system made operational Joint programme component 3: health promotion and nutrition Outcome 1: (WHO, UNICEF, WFP, Knowledge and practices for health promotion (attitudes, behaviour/lifestyle) and UNFPA, UNESCO) avoidance of health risks and disease prevention are improved (including school health) Outcome 2: (UNICEF,WHO, WFP, Nutritional status of the population is improved UNHCR) Joint programme component 4: health system development Outcome 1: (WHO, UNHCR, UNICEF, An effective system of human resource development for health and population is adopted ILO, UNIFEM, UNFPA) Outcome 2: (ILO, WHO, UNICEF, An equitable, effective health and population financing system is in place UNFPA) Outcome 3: (WHO, UNHCR, UNICEF, Policy and management decisions by federal, provincial and district governments UNFPA) on health and population issues are evidence-based using research and improved information system Outcome 4: (WHO, UNHCR, UNICEF, Effective systems for management of medical technologies are used UNFPA) Outcome 5: (WHO, UNDP, ILO, Quality assurance and regulation systems of public and private providers of essential UNICEF, UNFPA) health services delivery are fully atained Outcome 6: (UNDP, UNFPA, UNHCR, Governance in health and population systems is significantly improved UNICEF, WHO) Joint programme component 5: HIV and AIDS Outcome 1: (UNODC, UNAIDS, HIV transmission is contained in the vulnerable groups by contributing 10% towards UNFPA, UNICEF, ILO, UNESCO, national strategic targets WHO) Outcome 2: (UNDP, UNAIDS, ILO, Multisectoral opinion leaders take up and integrate HIV, AIDS issues in their programme UNESCO, UNICEF, IOM) portfolios and policies (representatives from government, religious leaders, media, parliamentarians, employers, workers, educators and agriculture extension workers) Outcome 3: (UNICEF, WHO, WFP, ILO, Accessibility and use of quality treatment by all people living with HIV is improved (focus: UNAIDS, UNIFEM, UNFPA, UNDP, women and children). Support for all persons infected and affected by HIV is increased UNODC, UNHCR) through strengthening civil society organizations working with people living with HIV (focus: women and children) (support: social, spiritual, and economic) Joint programme component 6: population census Outcome 1: (ILO, UNDP, UNESCO, Pakistan census organization to adopt modern technology and approaches to conduct UNFPA, UNICEF, UN-HABITAT, accurate housing and population census UNIFEM) S127 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Discussion health system development, control management procedures with ease. of communicable and noncommuni- These programmatic and managerial The Delivering as One initiative has cable diseases, improving the health of experiences substantiate the feasibility of introduced coherence, effectiveness, women and children, addressing social the Delivering as One reform process, its accountability and management for determinants of health, emergency pre- capacity to assemble a wider participa- results, with UN technical assistance paredness and response and enhancing tory action and generate greater aspira- inextricably aligned with national pri- partnerships, all being priority subject tions to produce the anticipated results orities [4]. The alignment of the joint areas that have become integral com- [15]. This strategic and programmatic programmes with national priorities ponents of the health and population experience has enabled WHO to align required the channelling of 80% of UN joint programme [13]. WHO-assisted over 90% of its entire budgetary outlay agencies’ funding to Delivering as One interventions included a community of assessed and voluntary contributions with coordinated and shared plan- based, integrated and health centred with the Delivering as One–prescribed ning, implementation and monitoring, basic development needs initiative that health and population joint programme recognizing the UN agencies’ distinct produced capacity for intersectoral col- components. Moreover, the Deliver- mandates and capacities [8]. laboration [14]. Moreover, the appro- ing as One implementation process WHO technical collaboration with priateness of WHO business practices has demonstrated the essential WHO the government used to be coordinated of resource allocation and releases to coordination role, within the thematic and designed through a biennial joint support national health interventions working group and joint programme programming review aimed at assist- through the current mechanism of di- steering committee governing bodies, ing national core strategic health pri- rect financial contribution has enabled requiring the Organization to promote orities. The latter focused on policy and the Organization to use the national more partnerships for the health sector Table 4 Field implementation of the maternal, neonatal and child health joint programme component in ten districts where participating UN agencies share technical roles to assist programme implementation Participating UN agencies Assigned technical roles WHO ō Integrated maternal, neonatal and child health, including reproductive health and family planning services, in public sector facilities with focus on IMNCI/EmONC ; health system strengthening; provision of life-saving equipment and supplies and supportive supervision ō Ensuring that public sector resources are sustained ō Supporting operational research to improve provincial/district teaching institutions and building their staff capacity in operation research; serve as model service providers and produce knowledge to enhance maternal, neonatal and child health–related decision-making ō Implementation of community-based initiatives to enhance access and use of services ō Developing and initiating functional monitoring and evaluation system and information systems for results based management ō Strengthening community-based and outreach maternal, neonatal and child health, reproductive health and family planning services UNICEF ō Improving access to integrated maternal, neonatal and child health, reproductive health and family planning through contracting out services to private care providers ō Improving self-care and demand for maternal, neonatal and child health services by introducing voucher/incentive schemes and other innovative mechanisms ō Improving self-care and care-seeking through behaviour change communication ō Raising community awareness and micronutrient supplementation by implementing mother and child weeks UNFPA ō Improving access to integrated maternal, neonatal and child health, reproductive health and family planning services through contracting-out mechanisms ō Improving self-care and demand for maternal, neonatal and child health services through health vouchers and other incentive-based mechanisms ō Supporting outreach services for clean deliveries and postnatal care ō Raising community awareness and improving community support to referral to a health facility ō Improving family planning services through public–private partnership IMNCI/EmONC = Integrated Management of Neonatal and Childhood Illness/Emergency obstetric and newborn care. S128 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Health and population joint programme Increased livelihood School and occupational health Opportunities for Agriculture, rural Environment environment enhanced food security development and joint Hazardous solid waste and nutrition poverty reduction programme management joint programme Safe water and sanitation Food safety Emergency preparedness and response Disaster risk Skilled human resource development Education management Community risk management joint Child/female education joint Enhanced safety laws and infrastructure programme Literacy activities Safety of health facilities programme Figure 1 The positive nexus that links the health and population joint programme with the other four joint programmes enhancing collaborative synergies on the social determinants of health to facilitate further cohesion and focus on national priorities and results-based scale up coverage and access to these on results. action. This new paradigm promoted essential services. The health and population joint the role of civil society organizations and Delivering as One has converged programme components were im- grassroots communities as partners and the competencies and resource con- mediately launched with the active stakeholders rather than contractors and tributions of 14 UN agencies in sup- involvement of participating UN and beneficiaries, respectively [16]. How- port of the health and population joint government partners. A case in point ever, to maintain the effective course programme, replacing the past legacy was the maternal, neonatal, and child of this development process, the align- of little or no coordination. Moreover, health joint programme component ment spirit has to transcend the UN the initiative has enabled the health and implemented in ten districts of Sindh and government partners and influence population joint programme to liaise province, and executed by the provin- all stakeholders including international with other joint programmes, attract- cial health department, with assistance financial institutions and bilateral devel- ing their support on key social deter- from the Ministry of Health and the opment partners who need to fulfil their minants of health, thus expanding the three participating UN agencies. Similar global commitment to international gains accrued to this underfunded social arrangements were made for routine financial cooperation [17]. sector. This exercise unveiled the poten- immunization and polio eradication, tial for good that health and population control of HIV/AIDS, health system Within the health and population joint programme has, when other joint strengthening, school health and other domain, the Delivering as One initiative programmes coherently undertake the programmes. Through this process the was successful in bringing together the implementation of multisectoral health participating UN agencies coordinated Ministry of Health and the Ministry protection and promotion interven- their technical and operational roles, of Population Welfare through a joint tions that include safe drinking water benefiting from the capacity assessment memorandum of understanding aiming and sanitation, solid waste disposal, nu- survey and strengths, weaknesses, op- to forge functional integration, whereby trition and food safety, environmental portunities and threats analysis carried the package of maternal, infant and child health, girls’ education/female literacy out at the outset of the Delivering as health services, including reproductive and livelihood activities that collectively One process. health and family planning, is com- enable public policies to shape the social The Delivering as One initiative re- prehensively delivered by all facilities environment and prevent the underly- quired partners to end fragmentation, regardless of their managerial affiliation. ing causes of ill health. competition and operational verticality This expressed unity of purpose has in Mainstreaming the four identified that have long afflicted both government turn encouraged provincial and district cross-cutting issues of human rights, and UN operations, and focus instead counterparts of the two ministries to gender parity, civil society organizations S129 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF and refugees posed a challenge, as it the coherence envisaged at the country on maternal, neonatal, and child health, required the application of quantifiable level is matched by direct engagement health promotion and nutrition, and tools to assess the level of strategic and of the top executives at regional and the school health programme promot- operational integration of cross-cutting headquarters levels in the Delivering ed the introduction of pictorial health issues into the joint programmes and as One process, and the different divi- warnings on cigarette packs; enhanced addressing existing gender dispari- sions and technical units of an organi- immunization services by training ties and inequalities [18]. The latter zation persuaded to adopt an internal thousands of community-based Lady implied the application of direct and transformation process, committed Health Workers on vaccination skills, proxy measures to assess and monitor to achieve organization-wide results. accelerated poliomyelitis eradication their societal implications. Appointing Country offices should be supported in efforts; and engaged parliament in pol- focal points on cross-cutting issues to pursuing the targets set for the different icy dialogues on priority public health undertake the necessary oversight and joint programmes, rather than consid- fields such as the control of tuberculo- develop relevant advocacy and com- ering the Delivering as One initiative sis, hepatitis viral infections and HIV/ munication strategies for their effective as a function exclusively assigned to AIDS. To further enhance the quality implementation was another positive the UN field staff. The latter is even of joint programme components’ im- undertaking of the UN in Pakistan. more critical for achieving unified busi- plementation, UN participating agen- The Delivering as One initiative ness practices, why modest advances cies need to establish an interagency provided a road map for the sustainable were made in this field . Likewise, programme support teams at the op- implementation of joint programmes the perception of some government erational level, closely liaising with their [6]. To scale up the progress of this sectors that the channelling of jointly government counterparts and assisting evolving reform, UN agencies ought to mobilized resources through the UN the implementation processes of each recognize the government leadership will negatively affect government en- of the different joint programme com- role, adhere to the Paris Declaration of visaged budgetary support needs to ponents. Aid Effectiveness and endorse wider be mitigated. The latter is attained by The Delivering as One initiative partnerships as determined by the joint directing the focus on the significance also offers a framework of principles programmes’ operational scope, and of the jointly programmed interven- that guide the country-level operations work with different government and tions, the challenging milestones to be of the UN development system and nongovernmental organizations to ad- attained, the financing predictability substantiate the legitimacy of advanc- vance the Delivering as One initiative for sustained implementation and the ing and guiding the nationally owned [4,5,8]. The government and the UN management for results through joint programmatic interventions. Special need to realize that the reform process monitoring and evaluation. attention was also directed to the Pa- is not the end goal in itself, but rather The Delivering as One experience kistan humanitarian crisis where the a way to achieve the planned results in Pakistan offers the best opportunity principles of Delivering as One were [5,8]. Delivering as One delineated the for the UN to effectively engage in and readily applied with great success. Pa- four critical roles of the UN—being support the national efforts geared to kistan took bold steps along with the advisor to the government, convener attain the Millennium Development UN for scaling up and consolidating of stakeholders, advocate for interna- Goals, rendering the fragmented status Delivering as One and focused action tional standards and provider of tech- quo practices extinct. The health and on national priorities, acknowledging nical support. Moreover, the evolving population joint programme policy, that there must be no going back to the challenges for resource mobilization strategic and programmatic support fragmentation and unaffordable op- should not be allowed to hinder Deliv- significantly outweighs the disjointed portunity costs of the past. The health ering as One, as greater efforts need to single agency interventions of the past. and population joint programme at- be made, while the efficient use of avail- The programmatic strategies of this tracted the largest UN participation able resources would provide greater joint programme were streamlined in and enhanced agencies’ relevance, co- leverage to the UN to expand the value the 2010 national health policy; as- herence and comparative advantages of its resource outlay by achieving bet- sisted and influenced the work of the in support of national health priorities ter results and reducing its transaction Health System and Policy Unit of the and catalysed Delivering as One be- cost. Ministry of Health; catalysed public tween government institutions, while To promote horizontal collabo- sector investment in several joint pro- seamlessly interrelating health with its ration within the UN system, intra- gramme component domains; scaled social determinants, providing a value agency Delivering as One processes up the joint programme components’ added to Delivering as One imple- need to be actively introduced, where implementation with significant impact mentation. S130 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Acknowledgement on the collectively gained experience on the support and leadership provided by the Delivering as One UN reform proc- the ministries of health and population The authors wish to acknowledge ess in Pakistan. The authors equally ac- and by their respective provincial health the contribution of the UN Resident knowledge the collaboration extended departments as well as the coordination Coordinator/UN Country Teams for by the participating UN agencies in offered by the Economic Affairs Divi- responding to the given questionnaire the health and population joint pro- sion for the effective implementation of to assess their individual perceptions gramme thematic working group and this initiative. References 1. United Nations Resolution 55/2. United Nations millennium 11. Pakistan Millennium Development Goals Report 2006. Islama- declaration. New York, United Nations, 2000 (http://www. bad, Center for Research on Poverty Reduction and Income un.org/millennium/declaration/ares552e.htm, accessed 2 Distribution, Planning Commission, 2006 ) http://undp.org. July 2010). pk/images/publications/MDG%202006.pdf, accessed 2 July 2. Rome declaration on harmonization. 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Delivering as one: one UN in Pakistan 2008–2010. Islamabad, precourse-material/GA%20res%20TCPR%202007.pdf, ac- United Nations, 2009. cessed 2 July 2010). 9. Mid term review of medium term development framework 2005– 18. Women and health: today’s evidence, tomorrow’s agenda. Gene- 2010. Islamabad, Pakistan, Planning Commission, 2008. va, World Health Organization, 2009 (http://whqlibdoc.who. 10. Poverty Reduction Strategy Paper (PRSP) 2. Islamabad, Pakistan, int/publications/2009/9789241563857_eng.pdf, accessed 2 Finance Division, 2009. July 2010). S131 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Implementing the district health system in the framework of primary health care in Pakistan: can the evolving reforms enhance the pace towards the Millennium Development Goals? F. Sabih,1 K. M. Bile,1 W. Buehler,2 A. Hafeez,3 S. Nishtar4 and S. Siddiqi5 ÒD=íX^=ëÌowÚm!ÐÓm@°É³TbdwvëmSm<9ogTíúÐogZTÐowmK|TЫ ÚmIÎ9oa\edcTÉêm]h{g`e= Èog`T±Togý5hüÐXÐ|BÐhDTÐ bx{ÉNYnHº}åZhihinHºhaA{H̺}dw=}iERºØe7d=hdBºyhÉÖ}Rö ënTnUëÌQÚí phhý}UÐph[UÐÓnY{#ÐÊnxÎÒØ@ë5\UpdhHí\RÌnwÚnLn=phUíúÐph[UÐpxnL}Un=ÒØ{CÐpbUÐ{xÐ~>¬ oåÉ°#Ð éíÐ{@YpddHqQ~= ngfYp_SCÐÓÐÚ{bUÐê {b>3ilRºÚnZiøÐrhAY¬ nLn>Ð}TúÐJnfedUph[UÐ^fUÐÓncIYÒ{AÐíð ì|w:ÓnAnfUÐëlRºdTUÙQÚí ph[UÐÓnY{#ÐYphHnHÌpYe\YÚnc=ÐngfYíº¦n"ÐqSUÐ:[UÐên^fUÐÖĆÉüé5LúÐ [UÐên^fUÐ:dee=ÊÐØúÐNUn_Ye_UÐDLx}BùÐNð åhf_CÐî{UípYc"Ð:p?ĆUÐÓÐÚnJüÐÒÚ{SDL{e_HÓnAĆÉüЬ à5iúÐíºënTn=:phUíúÐph[UÐpxnL}UÐ:ÓnY{#Ðh^f>íºpb]fedU[UÐên^fdUphUÐphfUÐLpCpSÚUÐì|wê{b>í JnfedU¬ [UÐên^fdUphhý}UÐÒ{eLúÐphiÐ{hCÐphªúÐípxíÚZdUÒÚ]CÐ ABSTRACT There is growing renewed trust in primary health care as the best approach for ensuring equity in the delivery of essential health services. However, Pakistan with one of the most widely spread district health system networks in the region, has not delivered at the expected capacity. A series of health system reform agendas are now stipulated which include the promulgation of an essential health service package, public private partnerships and a people-centred focus. Nevertheless, success of these reforms will hinge on the ability of the three tiers of the government and other stakeholders to work together to improve the overall performance of the district health system. This paper provides an overview of the district health system infrastructure and organization of primary health care services in Pakistan, the evolving governance pattern and the operational significance and merit of health system pillars for effective service implementation. Intégration du système de santé de district dans le cadre des soins de santé primaires au Pakistan : les réformes évolutives peuvent-elles accélérer la réalisation des objectifs du Millénaire pour le développement ? RÉSUMÉ On observe une confiance renouvelée croissante dans les soins de santé primaires en tant que meilleure approche pour garantir l’équité dans la fourniture de services de soins de santé essentiels. Cependant, le Pakistan, dont le réseau de systèmes de santé de district est l’un des plus étendus de la région, n’a pas été en mesure d’assurer ces services au niveau attendu. Une série de calendriers de réformes du système de santé a maintenant été définie. Elle comprend notamment l’annonce d’un ensemble de services de soins de santé essentiels, des partenariats public/privé et une attention centrée sur l’individu. Mais le succès de ces réformes dépendra de la capacité de l’ensemble du gouvernement et des autres parties prenantes à travailler de concert pour améliorer les performances globales du système de santé de district. Cet article donne un aperçu des infrastructures de ce système et de l’organisation des services de soins de santé primaires au Pakistan, du mode de gouvernance évolutif et de l’importance opérationnelle des piliers du système de santé ainsi que de leur valeur pour l’intégration efficace des services. 1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to F. Sabih: [email protected]) 2Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva 3National Health Services Academy, Ministry of Health, Islamabad, Pakistan 4Heartfile (health sector nongovernment organization), Islamabad, Pakistan 5World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt. S132 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Introduction population. During 1999 to 2008, dis- community outlets operated by the tricts assumed even greater importance public sector and classified into the fol- The district health system in the frame- because of the devolution policy intro- lowing categories: work of primary health care is inextrica- duced by the previous government in Health Houses bly linked to the Alma Ata Declaration 2001. This paper provides an overview The Lady Health Workers’ programme of 1978 and has repeatedly regained of the district health system infrastruc- is arguably the largest public sector international interest and renewed fo- ture and organization of primary health community health initiative in the re- cus, exemplified in the Beijing Initiative care services in Pakistan, the evolving gion, covering most of the rural and and Qatar Declaration and the World governance pattern and the operational selected peri-urban population of the health report 2008 [1–4]. After decades significance of health system pillars and of focusing on vertical disease control country with a workforce of 100 000. their merit for effective service imple- The Health House, at the village level, programmes as prime drivers of health mentation and partnership. care development, a comprehensive constitutes the hub from where a Lady approach to respond to the needs and Health Worker carries out daily field legitimate health expectations of all Methods visits to her catchment area population citizens is back on the agenda. Effective of 1000. The scope of the Lady Health community participation is the key for Peer-reviewed articles on the framework Workers’ service covers health and nu- the successful implementation of PHC of primary health care, primarily from trition promotion, maternal, neonatal strategy; while the social determinants Pakistan, were retrieved from scientific and child health care including repro- of health offer a dependable avenue for databases along with official documents ductive health and family planning, pro- motion of personal and environmental intersectoral collaboration. of the government of Pakistan; grey hygiene, treatment of minor ailments The goal of “Health for All by the literature was also reviewed. Field visits with options for referral and support year 2000”, launched in 1977 through and interactions with key programme to communicable disease control in- the World Health Assembly Resolu- managers, primary health care staff and terventions. In 2009 LHWs’ direct in- tion 30.43, was endorsed in Pakistan, health policy-makers provided a valu- volvement in vaccination was launched by organizing delivery of health services able insight into the functioning of the by training them in Routine EPI skills. through a fairly elaborate network of district health system. Extensive use was first-level care facilities, mainly basic also made of the district information sys- Basic health units health units and rural health centres, and tem, which collects health information On an average, a basic health unit serves the establishment of hospitals at each data from the district health network a population of around 10 000–25 000, subdistrict level and district headquarter every month, to generate necessary providing a range of primary health care city [5]. Furthermore, in pursuance of evidence for analysis. services (Table 2) along with referral the Alma Ata Declaration, successive support for major health problems. A national health policies of Pakistan since Delivery of health services: basic health unit is usually staffed by 1990 have reiterated their commitment district health system a male medical officer, a Lady Health infrastructure to universal health coverage and afford- Visitor, a vaccinator, a health technician, able access to essential primary health The district health system in Pakistan is a dispenser/dresser, a sanitary worker care services [6]. At the grassroots level, organized into a network of public serv- and other support staff. ice delivery outlets of Health Houses the innovative concept of female com- Sub-health centres munity health workers led to the in- (community health outlets run by and ception of the national programme for set up in the homes of Lady Health These facilities are staffed with a physi- family planning and primary health care Workers), a chain of first-level care cian, one Lady Health Visitor and a in 1994, commonly known as the Lady facilities, and district and subdistrict midwife and provide primary health Health Workers Programme, linking hospitals. The district health system also care services to the catchment areas the community with the district health incorporates a network of private pro- where there are no basic health units. system service delivery network [7]. viders ranging from general practition- Rural health centres There are 136 districts in Pakistan, ers, clinics, hospitals and pharmacies Rural health centres function around and the district health system is a critical to numerous alternative care providers the clock and serve a catchment tier of the Pakistani health care system, including homeopaths and hakims for area population of 50 000–100 000, since it functions as an independent Eastern and Yunani medicine. providing a comprehensive range of administrative and organizational set- Table 1 shows the total number primary health care services (Table 2). up for the delivery of service to the and types of health facilities including Rural health centres are equipped with S133 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF a 346 3 133 1 293 6 437 13 983 50 361 22 054 Health House centres Subhealth centres child health Other facilities first–level care Dispensaries TB centres Maternal and reporting system. units Basic health centres Rural healthRural hospital) headquarter headquarter headquarter hospital/ tehsil Hospitals (district Lady Health Management Information Workers 2009. System, a ased the total number of districts to 136 shortly being reflected in the Total 989 596 4910 5007 381 1140 1017 99 097 Rural 159 476 4841 3282 115 502 929 Rural 14 – 6 13 19 23 2 ua6–––––– Rural6 Rural – 3 14 1 – – – RuralRural 23 6 228 59 2452 736 977 1112 – 36 90 38 493 2 RuralRural 107Rural 2 138 88 63 938 441 495 459 4635 533 3082 10 – 46 115 293 50 31 526 – Rural Urban 830 120 69 1,725 266 638 88 Urban 2 33 188 87 48 154 270 Urban 7 – – 40 – 4 – Urban 19 2 18 113 21 5 133 Urban 328 46 34 1001 150 113 – Urban 284 63 – 531 54 425 77 UrbanUrban 810 948 120 561 63 4698 1712 4794 247 293 615 908 86 612 93 181 Urban 95 4 4 106 20 30 – Urban 96 7 25 34 23 43 9 1 7 Rural – – – – – – – 1 490 7 rearrangement has incre Types and numbers of health facilitiesTypes in Pakistan Province/ RegionsProvince/ Districts Urban/ Sindh 23 Federally administered administered Federally Punjab 35 Islamabad Capital Islamabad Capital Khyber Pakhtunkhwa 23 Balochistan 30 Grand total 113 137Grand 132 Gilgit Baltistan 6 tribal areas tribal Territory Kashmir Azad Jammu and Total 112 Note: The recent administrativeNote: The Source: HealthSource: Management Information 2008; System, Table1 Table1 S134 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 2 Types of service available in first-level care facilities (basic health units and rural health centres) Types of service Service availability Basic health unit Rural health centre 1. Maternal and newborn health Prenatal and postnatal care Antenatal, normal delivery and postpartum care + + Laboratory support for antenatal care Diagnosis of pregnancy/anaemia + + Newborn care Antenatal, newborn and postpartum care + + Newborn resuscitation − + 24/7 Basic emergency obstetric and neonatal care Normal deliveries and obstetric first aid + + Complicated deliveries − + Post-abortion care − + Family planning counselling and provision of contraceptives Family planning counselling and provision of contraceptives + + Intrauterine device (IUD) services − + 2. Child health and development Immunization services (static facilities) + + Management of major childhood illnesses + + 3. Nutrition Nutrition advice, breastfeeding promotion and support, growth monitoring + + 4 and 5. Communicable and noncommunicable diseases Counselling and curative care + + Control of tuberculosis, malaria + + Detect, manage and refer common communicable illnesses and + + noncommunicable diseases 6. Basic diagnostic services Laboratory and X-Ray services Laboratory diagnostic facilities + + Routine examinations/X-rays − + 7. Drugs dispensing/management Dispensing, storage and record-keeping + + 8. Minor surgical services Minor surgical operations and stabilization of emergencies (trauma and −+ accidents) 9. Basic emergency/first aid Stabilize/refer minor injuries, insect/snake bites + + Poisoning, shock and minor surgical operations − + 10. Allied services Administrative activities + + Reception/registration, record-keeping + + Maintenance of drugs/store-keeping + + Sanitation + + Training activities/meeting of Lady Health Workers + + 11. Selective outreach services Immunization outreach and monitoring and supervision of Lady Health ++ Workers and community midwives 12. Dental care Dental caries filling and dental surgery − + Sources: Training 2000, Punjab; Essential Health Services Package for First Level Care Facilities, 2009. + Service available; −Service not available. S135 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF laboratory and X-ray facilities and a Tehsil headquarter hospitals programme on immunization, closely 15–20 bed inpatient facility. The mini- These hospitals serve a catchment interfacing with the primary health mum rural health centre staff comprises population of about 0.5–1 million, pro- care services at district level. Many of a senior medical officer, woman medical viding a range of preventive, clinical and these programmes have a dedicated officer, Lady Health Visitors, a midwife, rehabilitative services (Table 3). Pres- workforce at district level with varying a vaccinator, a health technician and a ently the majority of tehsil headquarter degrees of functional integration with dispenser/dresser as well as laboratory, hospitals offer 40–60 bed facilities and the district health system; the federal radiology, operation theatre and anaes- a range of outpatient services. There and provincial management units of all thesia assistants along with administra- are 44 sanctioned posts including nine these programmes providing the nec- tive and support staff. clinical specialists, of which at least an essary technical and logistics back-up obstetrician and gynaecologist, a pae- support for effective service delivery. Civil dispensaries diatrician and a general surgeon are These facilities were established in urban almost always available. Health workforce settings as part of the pre-independence District headquarter hospitals Diverse categories of health care provid- health care delivery system, forming ers serve in the district health system These hospitals cover a catchment the bottom of the health pyramid. Two network facilities; which range from population of 1 to 3 million, with an types of dispensaries are currently specialist physicians and surgeons to average of 125–250 beds. The district recognized: the municipal corporation medical officers, nurses and midwives, headquarter hospital provides promo- civil dispensary, headed by a dispenser Lady Health Visitors and different tive, preventive, curative, advanced diag- categories of paramedics along with and the health department dispensary, nostic and inpatient specialized services operated by a physician. (Table 3). There are 74 sanctioned posi- administrative and support staff, with the Lady Health Visitors operating at Maternal and child health centres tions of which 15 are clinical specialties, the grassroots level. On average, 50 These facilities provide maternal, neo- although the level of actual deployment may vary between provinces. public sector health workers, including natal and child health services including Lady Health Visitors, serve a 20 000 reproductive health and family planning; Contribution of the Ministry of Popu- population catchment area. The per- and are often located in urban and large lation Welfare to the district health formance of this workforce is critical for rural areas. Maternal and child health system the provision of essential health services centres are managed by Lady Health The Ministry of Population Welfare to the community. In addition to the Visitors and assisted by a facility-based operates a network of around 3000 human resource capacities at commu- trained traditional birth attendant. facilities for the delivery of reproduc- nity, first-level care facility and hospital tive health and family planning services Tuberculosis centres levels, the country has recently launched ranging from reproductive health cen- a large-scale training of community These centres detect and manage tres embedded in the tehsil headquar- midwives operating at the grassroots tuberculosis (TB) patients. The TB/ ter hospital and district headquarter level to enhance access to safe delivery DOTS Programme currently is also hospital service delivery domains and and facilitate early referral, each cov- implemented by most first-level care family welfare centres located at Union ering a catchment area population of facilities and hospitals of the district Council settings as well as mobile serv- 5000–10 000. Although the national health system network. ice units and community worker driven maternal, neonatal and child health Table 2 illustrates the primary health outreach services. programme has projected the train- care services offered by basic health units National priority programmes ing of 12 000 community midwives in and rural health centres to their respec- The district health system hosts and sup- five years, the current vision is to attain tive catchment area communities, the ports the implementation of numerous universal coverage through deployment basic health unit having an operational federally funded national programmes, of community midwives in all rural and scope comparable to 30% of the services that include the Lady Health Workers’ urban underprivileged communities. offered by a rural health centre. Despite programme; maternal, neonatal and Provincial and district health develop- this impressive network of first-level child health; national AIDS control; ment centres have been established care facilities, their utilization rate by Roll Back Malaria, national tuberculo- nationwide to act as resource training the catchment area population is low sis control; nutrition; prevention and centres for capacity-building. However, with less than one (0.6) patient visit/ control of blindness; control of hepa- these institutions have not received ad- person/year. titis viral infections; and the expanded equate support to operate effectively. S136 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 3 Types of service available in secondary-level care facilities (tehsil headquarter hospital and district headquarter hospitals) Types of service Service availability Tehsil District headquarter headquarter hospital hospital Preventive services Basic maternal care Antenatal, natal , complicated deliveries and post partum care, perinatal and maternal mortality reviews, family planning services, prevention and management of sexually transmitted illnesses and reproductive tract infections ++ Immunization Measles, diphtheria, tetanus, polio, pertussis, tuberculosis, hepatitis B and vitamin A supplementation ++ Mental health Identification, diagnosis, counselling and management and rehabilitation ++ Major micronutrient supplementation Iron , folic acid, iodine, vitamin A and vitamin D supplementation ++ Screening for common health problems Hypertension, diabetes mellitus, anaemia, malnutrition, obesity, visual acuity ++ Outreach and community services Health education and promotion on maternal, neonatal and child health issues ++ Promotive services Health education and promotion Creation of awareness and demand for immunization, prenatal, natal and post natal care, family planning, good nutrition and hygiene practices, healthy life style, environmental and gender health, health seeking behaviour ++ Curative services 24/7 Basic emergency obstetric and neonatal care Normal deliveries and obstetric first aid, newborn care and resuscitation, complicated deliveries, post abortion care ++ Comprehensive emergency obstetric and neonatal Caesarean section, blood transfusion, incubator, advanced resuscitation support & paediatric nursery ++ Child health care (integrated management of neonatal and childhood illnesses) Malaria, measles, ENT, tetanus neonatorum, malnutrition, anaemia, childhood TB & deworming ++ Medical outpatient department and indoor services Basic medical care including communicable and noncommunicable diseases + + Specialist medical care + + Surgical outpatient department and indoor services Basic surgical care (incision and drainage, splints and control of haemorrhage) + + Specialist surgical care + + Mortality reviews (hospital death reviews by a designated team) + + Emergency services 24-hour basic medical, surgical and other emergency services + + Trauma care (trauma centres) + + Burns (established burn units) − + Blood transfusion services Blood grouping, cross matching, screening for malaria, hepatitis B and C and HIV/AIDS ++ Diagnostic services Basic diagnostics (urine routine, urine sugar, blood routine and malarial parasite) Routine diagnostics (blood and urine complete examination , X-ray and ultrasound) + + Advanced diagnostics (histopathology, microbiology, biochemical, renal and lipid profile, + + gastroscopy, endoscopy) + + CT scan − + Rehabilitative services Physiotherapy, psychiatric, psychological, social and palliative + + Surgical −+ Source: Minimum Service Delivery Standards for Primary and Secondary Health Care in Punjab by the Punjab Devolved Social Security Program, 2008. Tehsil headquarter hospital sanctioned specialists include surgeon (general and orthopaedic), anaesthetist, physician, gynaecologist, radiologist, pathologist, ophthalmologist and paediatrician. District headquarter hospital sanctioned specialists additionally include urologist, cardiologist, neurosurgeon, psychiatrist, pulmonologist, dermatologist and paediatric surgeon. + Service available; − Service not available. S137 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Health information public sector procurement regulatory Health financing The national health information system authority, an autonomous body with the Health financing in the public sector has covers all first-level care facilities and responsibility of prescribing regulations long been suboptimal, with the allocated hospital outpatients of the district health and procedures and the monitoring of budgetary outlay for health constantly system. Data collection forms are filled public sector procurements. At district lagging below 1% of the GDP. The monthly by more than 110 districts. level the procurement of the medicines district health budget is released by the The facilities collect data on 18 priority has to conform to the national essential provincial government as part of a “one- health events, which along with malnu- drug list that consists of 345 medicines, line budget pool” allotted to 12 line trition account for 65%–70% of the departments of the district government, not restricted to generics, thus allowing care-seeking load, including information without any predefined preferential al- the procurement of different branded on a package of primary care services, locations to support efforts of the health essential drugs, contraceptives, vaccines, items with higher price tags. Currently, sector to promote delivery of life-saving supplies and equipment, and a range of the over 60 000 entities registered primary health care services. Moreover, of institutional data that include health under the Drugs Control Organization a large proportion of the first-level care education sessions, home visits and of the Ministry of Health, about 1300 facilities’ budgetary outlay (80%) is achievements and recommendations; are generics. The package of essential allocated for salaries and operational cumulatively covering 118 indicators. medicines procured for the first-level costs, while the allowance for medicines Table 4 shows the common dis- care facilities and hospitals include 30 does not exceed 6%. In tehsil headquar- eases and conditions diagnosed at dif- and 37 broad categories of therapeutic ter hospitals and district headquarter ferent levels of the district health system drugs respectively. In principle, health hospitals, however, the share for the pro- curement of medicines and equipment network. In the past few years, efforts facilities prescribe freely provided may reach 20% of the budget of these have been made to expand the scope medicines, when available; however, institutions. Although the formal sector of the health information system to in- most public sector facilities suffer from corporate information from hospital is covered by different forms of social frequent stock-outs that force patients inpatients and the private sector. The health insurance, the informal sector and families to procure drugs on their enhanced health information system has little or no social protection, making implementation has so far covered about own. the risk of out-of-pocket catastrophic 54 districts of the country. There is cur- Table 5 depicts the average number expenditures more likely to occur. rently, however, no provision in either of of days per month that essential drugs Table 5 illustrates the classification the systems to collect and incorporate remained out of stock in various dis- of the district health system budget- information from the tertiary care public trict health system outlets. On the other ary allocations earmarked for different hospitals and the private health sector. hand, procurement of medicines and health facilities. The yearly unit costs of a basic health unit and a rural health other supplies, equipment and related Medical products and centre vary between provinces, rang- technologies does not pursue nation- technologies ing from US$ 23 000 to US$ 65 000 The public sector procurement func- ally set technical guidelines. Likewise, (2005); with rural health centre alloca- tions of the district, including procure- there are no policies to replace used tions being 1.7 to 2.7 times higher than ment of medicines, are managed by a equipment after completing a defined the budget allocated for basic health special purchase committee. The proc- depreciation period, making it difficult units, while the allocated cost per Lady ess is governed through guidelines of the to sustain their functionality. Health Worker per year is US$ 675, Table 4 Essential drugs—days out of stock (mean number of days per month) Essential drug Hospital Rural health Basic health Dispensary Maternal and TB centre SSC SHC centre unit child health centre Oral rehydration salts 5 7 8 7 9 13 8 7 Co-trimoxazole tablets 5 6 6 7 8 8 7 3 Chloroquine tablets 9 8 9 9 9 12 9 3 Folate tablets 9 10 12 11 10 13 9 13 Iron tablets 8 9 11 10 10 11 9 10 Source: National Health Management Information System Data 2005–2008. TB = tuberculosis; SSC = social security centre; SHC = subhealth centre. S138 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ including stipend, training, procured c medicines and equipment and the ex- penditure incurred on monitoring and % supervision. diagnosed conditions 18 diseases/ Figure 1 shows the trend in alloca- Rate of commonly tions from 2005–06 to 2010–11 at the federal and provincial levels. Federal % health allocations increased over the years but decreased in 2010–11 due Malnutrition to the revised National Finance Com- mission award distribution, whereas % provincial shares from the divisible pool cholera lities in Pakistan (summarized from 480.50 lities (summarized from in Pakistan were enhanced significantly. Provincial Suspected shares have increased from the present b % 47.5% to 56% in the first year of the bites Animal National Finance Commission (2010– 11) and to 57.5% in the remaining years % of the award. However, provinces will Viral Viral hepatitis have to work to make the targeting of these additional resources transparent % and effective. Goitre Organization and management % Cough Cough The primary health care services in a suspected TB district are managed by an executive district officer overseeing the district a health system network operations, Reported in HMIS (except AIDS) along withReported in HMIS (except malnutrition than less in children 3 years. % c while the district headquarter hospital Vaccine Vaccine diseases preventable preventable is run by a medical superintendent. Both the medical superintendent and execu- % tive district officer report to the District Scabies Coordination Officer, provincial director-general for health services and % the recently re-established divisional Includes dog bites, snake bites; b Dysentery directors. The coordination between the executive district officer and medical % superintendent is often weak and de- Fever pends to a great extent on their efforts to generate partnerships and cooperation. % To improve the quality of service Diarrhoea provision in rural settings, the federal and provincial governments opted to % 15 6 6 3 3 0.04 1.26 0.03 0.14 0.24 0.01 33 68 19 6 10 3 4 0.02 0.84 0.02 0.07 0.18 0.01 21 65 19 7.04 10 3.55 2.50 0.03 0.17 0.02 0.03 0.06 0.00 21 63 18 7 11 3 5 0.04 0.54 0.03 0.03 0.04 0.00 18 63 23 8 12 4 5 0.01 0.38 0.01 0.03 0.07 0.00 20 73 22 8 13 4 4 0.04 0.56 0.03 0.03 0.04 0.01 22 74 36 1 1 0.41 1 0.02 27 0.02 0.01 0.00 0.02 3 70 ARI outsource a large number of basic health units on a nationwide basis to a non- governmental organization, the People’s Primary Healthcare Initiative (PPHI), introducing substantive changes in the management of these facilities. The Common diseases and conditions diagnosed in district headquarter hospital/tehsil headquarter hospitals and first-level care faci and conditions care diseases hospitals and first-level Common hospital/tehsil headquarter diagnosed in district headquarter scheme was initailly launched in 2006 (136.1) (76.6) (1.2) (16.0) (198.3) (45.3) (7.0) under the government’s new initiative Health institution millions) Hospitals Rural health centres Rural Basic health units Dispensaries Maternal and child health (total patient visits in Others centres Includes measles, neonatal tetanus, diphtheria, neonatal Includes measles, meningitis; whooping cough, TB clinic a Source: HealthSource: Management Information Data 2001-2009. Aggregated System million patient visits during 2001–09) ARI = acute respiratory infection;ARI = acute respiratory TB = tuberculosis. Table 5 Table sponsored by the Ministry of Industries S139 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF and Special Initiatives and currently coordinated by the Cabinet Division of % of total 1.16 2.05 the Federal Government. PPHI, a subsidiary of the provincial c b rural support programmes, in agree- US$ iii) Lady Health ment with the federal and provincial Workers programme Workers Allocation government, negotiates contracts with the district authorities for management % of total of basic health units and their service delivery. The provincial health depart- ments transfer all the yearly budgeted hospitals) funds for these facilities to PPHI, which US$ district headquarter district headquarter ii) Hospitals (tehsil & Allocation are managed independently by federal, provincial and district PPHI support units. % of total Medical officers in the basic health units under PPHI are given contracts with a higher salary package and mobil- US$ ity incentives. Currently, the provision Allocation of basic curative care remains the main focus of PPHI-managed basic health % of total units; with community support activi- Strategy 2005 and Treatment Cost at the Cost Basic Health Unit in North and Federally Frontier 2005 and Treatment Strategy Province West ties recently taken up through social or- ganizers and support groups. ommission Document 1 (2009-10) National Program for Family Planning and Primary Health Planning and Primary Document 1 (2009-10) National (Lady Health Care ommission for Family Program US$ Community-based initiatives Allocation and social determinants of (unit cost per annum only) a health Includes pay and allowances of other staff, pension and physical assets etc. of other assets pension and physical Includes pay and allowances staff, % of c total The implementation of community- based initiatives is led by the integrated and community centred Basic Devel- opment Needs approach, introduced US$ Allocation in selected districts of Pakistan along i) First-level care facility care i) First-level with other Member States of the World Health Organization’s (WHO) East- % of total ern Mediterranean Region, through WHO technical support. The Basic Punjab Sindh Khyber Pakhtunkhwa Balochistan Development Needs approach has 1.90 2.92 1.50 2.99 0.70 2.98 1.10 3.38 NA NA 5 560 6.37 5.60 8.62 4.90 9.76 2.30 9.79 3.10 9.54 1 410 5.84 700.23 0.8102 US$ Includes training of Lady Health only; Includes training Workers 50.00 76.92 37.10 73.90 17.50 74.47 23.80 73.23 7 190 29.77 59,050 67.49 b revitalized the fundamental principle Allocation of community organization, mobiliza- tion and participation in primary health care implementation, creating a direct connection between primary health care and social determinants of health and triggering health-centred integrated community action on water and sanita- tion, basic primary education, female literacy and participation and income generating livelihood activities leading Budget allocation of by type health facility in US$ thousands (US$ 1 = Rs 80) to a significant improvement in ma- ternal and child survival and nutrition Heads ofHeads Account Salary and allowances (establishment Non-salary (operating expenses) 1.90 2.92 1.60 3.19 0.80 3.4 1.10 3.38 4 300 17.81 1 010 Drugs and medicine 3.80 5.85 2.60 5.18 1.20 5.11 2.20 6.77 3 650 15.11 19 288 22.04 POL, printing, communication, Maintenance and Repair equipment/ Utilities 0.20 0.31 0.80 1.59 0.10 0.43 0.20 0.62 1 140 4.72 60 0.08 Others 0.80 1.23 0.70 1.39 0.30 1.28 0.40 1.23 6 130 25.38 1 790 General storesGeneral 0.80 1.23 1.00 1.99 0.50 2.13 0.50 1.54 330 1.37 0.13 0.0001 Includes Rural HealthIncludes Rural and Basic Health Centers Units only; charges) ransport/furniture-building department ransport/furniture-building transportation, advertising/BBC transportation, Total 65.00 100 50.20 100 23.50 100 32.50 100 24 150 100 87 500 100 a POL = Petrol, oil and lubricants; BCC = behaviour change communication; BCC POL = Petrol, oil and lubricants; NA not applicable. Source: i) Compiled by the Planning Commission of Pakistan from Pakistan Punjab Economic Report towards Medium Term Development Medium Term Report towards Economic Punjab Pakistan from by the i) Compiled of Pakistan Source: Planning Commission Workers Program) Program) Workers Administered Tribal Areas 2005; ii) District Health Areas Information Report Nov 2009 (Hospitals); and iii) Planning C Punjab Tribal System, Administered Table 6 Table health outcomes. S140 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ address the community health agenda and engage in strategic planning to pro- vide a coherent array of primary health care services. The government should expand the deployment of district health teams by enhancing the strength of Lady Health Workers, vaccinators and community midwives in all rural and urban slum settings, while in basic health units and rural health centres, the necessary female workforce should be guaranteed in order to improve social acceptability and access to the essential health service package [12]. Primary Figure 1 Federal and provincial health budgetary allocation trends (2005–06 to health care teams have to mobilize an 2010–11) (KPK = Khyber Pakhtunkhwa) active network of community participa- tion in health promotion and disease prevention activities with provision of necessary emergency referral sup- Discussion 6–related diseases continue to pose port. Furthermore, quality assurance serious burdens, despite the universal in workforce performance needs to be Pakistan has a widely spread district implementation of numerous commu- sustained through continuing profes- health system network, where the hi- nicable disease control interventions in sional development along with hospital erarchically organized first-level care every district. accreditation to deliver essential health facilities and hospitals exceed 10 000, In the service delivery component, services and improve patient safety. supported by a strong workforce of one of the constraints was the lack of an These formidable human resource Lady Health Workers covering defined essential health service package match- challenges need to be addressed at two rural catchment area populations. ing the health needs of the population, stages; first at the pre-service level, estab- However, this outstanding network has comprising of core essential primary lishing partnerships with undergraduate faced serious challenges to deliver at health care interventions of preventive, medical, nursing, midwifery and para- the expected capacity necessary for im- promotive, curative and rehabilitative medical institutions and inculcating proving health outcomes and achieving services that are minimally required by the concepts of community-oriented the Millennium Development Goals. the health system. Opportunely, the re- medical education, competence-based The most important impeding factor cent incorporation of an essential health training and the skill mix and sharing is an underperforming district health service package in the 2010 national principles of the district health team system unable to provide the necessary health policy with focus on maternal, [13–15]. This will enable the would-be platform for implementation, forcing neonatal and child health services could medical officers and other health work- two-thirds of patients in urban areas and enhance coverage and access to essen- ers in the primary health care network to one-third in rural areas to seek care from tial primary health care services, with become more attuned to the job at hand. formal or informal providers [8]. The national disease control interventions The second stage relates to the service low public health financing, unregulated becoming an integral component of delivery level, where the concept of the private sector and the governance chal- the district health system [10,11]. This district health team assumes greater lenges are important factors undermin- commitment, however, needs to be sup- significance, envisaging a needs-based ing the service delivery capacity of the ported by appropriate resources and human resource deployment, effective PHC system [9]. This is exacerbated by their effective use in order to ensure the geographical distribution, capacity de- the weak primary health care services desired impact. velopment, remuneration-based reten- where interventions such as maternal, The health workforce is another tion schemes and career development neonatal and child health including re- critical pillar of the district health sys- policies [16,17]. The collective account- productive health and family planning, tem, for which the largest proportion of ability and image of the health team as are progressing at a slow pace towards the health budget is allocated. Accord- the carer of the community, promot- Millennium Development Goals 4 and ingly, it is imperative to develop a dis- ing health and preventing disease, in 5, while Millennium Development Goal trict health team perspective in order to conformity with locally contextualized S141 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF needs, should become a major district district assemblies. Excluding the sal- operational planning, irregular moni- health system domain [18,19]. ary component, these funds are short of toring and supervision, an inadequate The district health system data per- satisfying the minimum service delivery accountability system and insufficient taining to inputs, processes, outputs package necessary to support primary community participation and intersec- and outcomes of the primary health health care implementation, although toral action [10,25–27]. The Pakistan care system should be readily available the recent National Finance Commis- Devolution Plan under the Local and continuously updated. In practice, sion Award distribution has enhanced Government Ordinance 2001 aimed the district information system solely provincial shares and created a larger to make the districts answerable to the covers the public sector district health fiscal space for the health sector. Moreo- elected chief executive of the district system outpatient data flow, while the ver, the 18th constitutional amendment (District Nazim) for better governance information systems of national pro- transferring larger budgetary outlay and improved service delivery. Analysis grammes, such as the Expanded Pro- to the provinces should endorse the of the district devolution impact on the gramme on Immunization and TB/ “managing for results” approach to en- governance of district health system gave DOTS, and the inpatient hospital data hance the pace towards achieving the mixed results, as shifting power without are reported separately in a fragmented Millennium Development Goals. The transferring knowledge and skills proved manner. Another major limitation to 2005–06 study of the national health counterproductive [28]. Even though be addressed constitutes the gap be- accounts indicated that district govern- the responsibilities of the district health tween the district information system ments are spending around half of the teams have increased, non-provision and the decision-making process, where total provincial budgets [22]. However, of adequate management training, lack the practice of data generation, analysis health system strengthening demands of managerial flexibility and the high and presentation is often delinked from greater allocation for health to at least turnover of executive district officers has the desired and indispensible evidence- 4% of GDP from the provincial share constrained implementation. based decision-making. of the National Finance Commission The managerial outsourcing of a The insufficient availability of medi- Award to sustain the expected level of large number of basic health units to cines has detrimentally affected the use implementation. PPHI was intended to improve the per- of public health services in Pakistan, Similarly, the health sector may formance and outcomes of this critical where a very limited proportion of pub- further explore fairness opportunities level of the district health system. PPHI lic sector facilities had an uninterrupted through greater access to essential serv- has shown an immediate enhancement flow of essential medicines [20,21]. To ices and protection against unafford- of attendance and use of basic health enhance access to life-saving primary able, out-of-pocket and catastrophic units which could be attributed to im- health care services, essential medicines expenditure. Accordingly, there is a need provement in availability of medicines should be procured in sufficient quanti- to enhance the public sector budgetary and waiver of user charges. PPHI is ad- ties along with efforts to reduce stock- outlay for health from its current level dressing the previous weakness in its outs caused by improper procurement of less than 1% of the GDP leading to model, with curative services being the and transport, storage and management potential out-of-pocket expenditure, exclusive focus, and is now working to- deficiencies. On the other hand, lack which is corroborated by a recent study wards making its BHU hubs for delivery of standard procurement systems and estimating the public and private sector of comprehensive primary health care effective use and maintenance of health health expenditure at 2.9% of the GDP services to the community [29,30]. In technologies for the primary health care [23]. However, through appropriate future, in order to improve the coor- network, pose serious limitations to the linkages with ongoing expansion of dination and quality of outsourcing, delivery of quality care. The concept social safety arrangements in Benazir transparent and merits-based contrac- of health technology assessment may Income Support Program the base of tual bidding and selection procedures therefore be introduced to rationalize PHC financing and mandatory essential must be designed, while the interface procurement, as this would enhance services’ utilization can be broadened between the contractual partner and the essential health service package’s [24]. the district health team must allow for a impact on prevailing health needs in a In Pakistan, similar to many other formal performance oversight, account- district. developing countries, the district health ability, greater community participation A major challenge relates to health system has been facing a range of and intersectoral action [29]. care financing, where the district health governance challenges impeding the On the other hand, provincial gov- system struggles to obtain a fair share organization, implementation and man- ernments when recruiting members of from the district’s one-line budget agement of essential health services; the district health team should be cogni- pool, distributed until recently by the poorly supported by weak strategic and zant of the necessity to engage the right S142 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ technical and managerial merit-based emergency preparedness and response Development Goals, while the district capacities and address the current rapid interventions into the district health sys- health system provides an ideal platform turnover of senior managers, which neg- tem’s operational plans is also required in for its implementation [19,33]. Health atively affects the district health system’s order to mitigate avoidable morbidities system strengthening in the framework operational sustainability. Special efforts and mortalities evolving during disas- of primary health care will require effec- need to be made to forcefully pursue the ters. A well performing district health tive deployment of coordinated strate- jointly promulgated memorandum of system would also strongly benefit from gies to ensure the provision of essential understanding for better coordination national and provincial efforts to regulate services, medicines and technologies, the and functional integration of reproduc- key public health policy dimensions that deployment of a qualified and account- tive health and family planning serv- cannot be executed independently at the able health workforce, use of evidence ices provided by the ministries of health district level. These include the prom- in decision-making and the allocation of and population welfare, especially at the ulgation and implementation of public predictable budgetary outlay supported grassroots level [31,32]. In their monitor- health legislation against the hazards of by an effective and transparent steward- ing capacities, the federal and provincial tobacco consumption; food fortification ship at all operational levels. To attain governments may jointly organize na- and safety; safe blood transfusion; safe significant progress towards the Millen- tionwide quality assessment and impact drinking-water and sanitation; solid waste nium Development Goals, the three tiers monitoring to enhance accountability disposal; road traffic safety; regulation of of the government (district, provincial and focus on results. the private sector; patient safety; and en- and federal) have to work together for Concurrently, district health hancing public private partnerships while better coordination and strategic unity, promotion network action should be promoting health in public policies. while forging purposeful alliances with established to reach out to local com- In conclusion, primary health care still civil society organizations, other relevant munities, households, schools, working remains the most rational way for achiev- public sector line departments and inter- places and market settings. 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Sheikh4 2009ëmSm<9ogZTÐowOTÐØÚÐBÐgåga= zhIPYºp_+{hIÚºØe7d=hdBºënBÚnbaUÐíÙºhaA{HÌö ên^fUÐpY{bY:Nåh[UÐNdYn_dUphhý}UÐyYĆCÐDLæ}_dUĽ}÷ LyYï}@Ì{Sí ph[UÐpxPUÐØÚÐCÐ:pYÛÌënTn=@Ð>ó oåÉ°#Ð :ên_UÐân]bUÐ:ph[UÐpxnL}UÐ:NdYn_dU]HUÐ}x{bUÐënTí ënTn=Ên@ÚÌd8:pLÛYnhÉð nbR}Yð 750yCÐeIí [UÐ ÓnhaZY:ëde_xnhJð 20 000ëÌn\xÌÚð {bx5T p}, 41 032ínhJð 46 153gfYºnhÉð ĆYnLð 417 288ënTn=:ph[UÐJnfCÐên^i 3549 LígdeLLwnÚéAph[UÐpxnL}UÐ:ĆYnLð YÓĆ=nbYëAnUÐî}@Ì{Sí ënTn=ÊniÌó I:phUnUÐph[UÐpxnL}UÐ ÓnHnhHÑnhQÓnHnhUÐ:Ò{ýnUÐØn_=úÐÓ}gKÌ5T ên_UÐân]bUn=piÚnbYe_UÐpþhU\RÌÐÛÐ}AÌÞn#Ðân]bUÐî{UëÌð N>í e_UÐpþh= UÐëÐ{dUÐDL`fxí NUÐOÎhRNdYn_UÐnÚíe_UÐpþh=YTÕn²íºNdYn_UÐbiYên_UÐân]bUЩn_xí ÓnHÚ5CÐéApYÚnÉ ÓnYÛúÐd>DLod`dU4L{UÐx{b>phefUÐén6:ÊnTPUÐDLíºÓÐF#ÐHnb>ëÌph[UÐpxPUÐØÚÐCÐ:ÓnYÛÌY©n_> ABSTRACT Pakistan faces a human resources for health (HRH) crisis. A cross-sectional survey was conducted to overview frontline health workers. A total of 750 health facilities were surveyed across Pakistan. The median estimate of public sector health care workers in the district health system in Pakistan is 417 288, including 46 153 doctors and 41 032 nurses. Another estimated 20 000 doctors work in public sector tertiary care hospitals across the country. A total of 3549 health care workers were interviewed regarding job satisfaction and work environment. The private sector had better work environment scores compared with the public sector. Policy dimensions showed an absence of robust policies in practice. The public sector is inadequately staffed and job satisfaction and work environment need improvement. HRH crisis countries should share experiences, and developmental partners should support them in overcoming the HRH crisis. Évaluation des ressources humaines pour la santé au Pakistan en 2009 RÉSUMÉ Le Pakistan est confronté à une crise des ressources humaines pour la santé. Une étude transversale a été réalisée sur les agents de santé en première ligne dans 750 établissements de soins pakistanais au total. Le système de santé de district pakistanais compte environ 417 288 agents de santé dans le secteur public, dont 46 153 médecins et 41 032 infirmières, Selon une estimation, 20 000 médecins travaillent dans les hôpitaux de soins tertiaires du secteur public dans tout le pays. Au total, 3549 agents de soins de santé ont été interrogés sur leur satisfaction et leur environnement professionnels. Le secteur privé a obtenu de meilleurs résultats que le secteur public en termes d’environnement de travail. Sur le plan politique, il a été démontré qu’aucune stratégie solide n’était mise en pratique. Le secteur public manque de personnel, et l’environnement de travail et la satisfaction des employés ont besoin d’être améliorés. Les pays affrontant une crise des ressources humaines pour la santé devraient partager leurs expériences. En outre, il serait souhaitable que des partenaires du développement les soutiennent afin de surmonter cette crise. 1Health Services Academy, Islamabad, Pakistan. 2World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to Z. Khan: [email protected]). 3Ministry of Health, Islamabad, Pakistan. 4Global Health Workforce, Geneva, Switzerland. S145 EMHJ r 7PM 4VQQMFNFOU r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Introduction Pakistan has been categorized as one Private sector facilities were classified as of 57 countries that are facing an HRH hospitals (having an indoor facility) and The World Health Organization crisis, below the threshold level defined clinics (with only outpatient consulta- (WHO) has defined the health work- by WHO to deliver the essential health tion) and a similar number was chosen force as “all people primarily engaged interventions required to reach Millen- from each district. An estimate of the in actions with the primary intent of nium Development Goals (MDGs) by total number of postgraduate trainee enhancing health”. This definition is 2015 [5]. doctors, faculty members of medical consistent with the WHO definition of Health workforce strategy is usually schools and medical officers of tertiary health systems as comprising all activi- low on a country’s agenda, despite the care hospitals in the public sector was ties with the primary goal of improving understanding that scaling-up health in- also obtained from the largest post- health. The health workforce is one of terventions to reach MDGs is not pos- graduate training body in the country, the most important pillars of the health sible without a minimum level of health the College of Physicians and Surgeons system. Adequate numbers and quality workforce. National health workforce Pakistan, Karachi, the Pakistan Medical of health workers have been positively strategies require reliable and timely in- and Dental Council and major tertiary associated with successful implementa- formation, rational system analysis and hospitals, respectively. tion of health interventions, including a firm knowledge base. However, data The tools for data collection were immunization coverage, outreach of analysis, research on HRH and techni- adopted and customized from available primary care, and infant, child and ma- cal expertise are still underdeveloped questionnaires obtained during a lit- ternal survival. [1]. in many countries, in part due to low erature search. Four types of tools were Pakistan needs to gauge strategically investment in HRH [6]. used: a data collection form for numbers the challenges to its health system, keep- Pakistan’s new draft National health and distribution, and questionnaires ing in view: policy 2009 mandated the development for HRH management policies, work of strategies in various key areas, includ- environment and job satisfaction. Pilot r demographic trends, such as the in- testing and validity checks were carried crease in population to around 295 ing HRH [7]. To develop evidence- based policy and a strategic framework, out for all tools before the survey and ap- million by 2030 at the current popu- propriate changes made based on feed- lation growth rate of 1.8% [2]; data on HRH are desperately required. Therefore, a countrywide HRH assess- back. The survey teams were trained on r the increase in life expectancy, rapid ment was undertaken. The objectives use of the tools in three stages. The first urbanization and epidemiological of this study were to collect data on the stage was a master training workshop in transition; numbers and distribution of the health Islamabad, followed by provincial work- shops to train district field surveyors. r the increased burden of chronic dis- workforce, to gather information about Supervisors were also given supervision eases such as cardiovascular diseases HRH management and policy, to col- training. and cancers; lect data on job satisfaction among the r trauma due to accidents, particular- health workforce, and to gather informa- Data were collected from federal ly among poor, disadvantaged and tion on the HRH work environment. and provincial health ministries, verti- high-risk groups in the community cal programmes and executive district [3]. officer health offices on numbers and distribution of health workers, job satis- r Methods The health workforce should not faction and work environment. Howev- only be depicted in terms of num- er, questionnaires on HRH policy were bers of doctors, nurses and dentists, A cross-sectional survey was carried only administered in federal/provincial etc. expressed per 1000 population, out throughout Pakistan over a period ministries and large private hospitals it should also give due consideration of 4 months (September–December in provincial capitals. In each category, to expected epidemiological tran- 2009). The total sample size was 750 sition, equitable distribution, new health facilities, with equal numbers 10% of the health workforce in every cadres, proper skill mix and types from the public and private sectors. In sampled health facility (not exceeding and nature of services to be deliv- order to obtain a representative sample, a total of six in each category) were ad- ered, as well as their demographic four districts from each province were ministered the job satisfaction and work distribution. It is clear that, without selected at random. Since the sampling environment questionnaires. prompt action, the human resources frame for the public sector facilities in Each health worker included in for health (HRH) crisis will worsen each district was known, a random sam- the survey was asked 32 questions on and health systems will be weakened ple of 22 facilities in the public sector job satisfaction and 34 questions on even further [4]. was chosen from each study district. work environment. Their response to S146 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ each question was scored as follows: 1 r interviewing techniques were part also carried out using Microsoft Excel® = agree; 2 = somewhat agree; 3 = neu- of surveyor training at the province (Microsoft Corp.). tral; 4 = somewhat disagree; and 5 = level; In view of the data quality issues disagree. A lower score was therefore r verbal consent was obtained from in the public sector records that were associated with agreement and higher respondents; experienced during this assessment, scores with increasing levels of disa- r connection between the district and an extrapolation analysis was also con- greement. Individual questions were provincial focal person was estab- ducted for various cadres; for example, grouped by aspect covered into several lished in order to address discrepan- to calculate the total number of doctors composite indices and the means of the cies that may have arisen during the for any province, the average of sam- responses for these composite indices survey; pled facilities was obtained by dividing were reported. Each question carried r the number of doctors in the sampled equal weight. detailed microplans indicating the number and location of health care facilities by the number of facilities The HRH policy questionnaire was facilities to be visited on a daily basis surveyed. This sample average was used for interviewing senior manag- were provided to enumerators; then multiplied by the total number ers from the public and private health r full details of the enumerator, includ- of respective facilities in the province sectors, at federal and provincial levels. or region to obtain the total estimated In the public sector, in each province ing contact details, were provided to facilities and provincial data coordi- number of doctors. This methodology a senior manager from the offices of was also helpful in obtaining national the Director General Health was inter- nators. consolidated figures for unsampled viewed. In the private sector, a senior Survey monitoring regions. manager from a private hospital was A “central monitoring cell” was es- interviewed in each province. Inter- tablished in the federal Ministry of views focused on the stages of the HRH Health to oversee the process of data Results management policy/plan and its im- collection, supervise the provincial plementation across various aspects of Results are given in two sections: the HRH management. The five main areas focal persons/survey coordinators first deals with the numbers and distri- of the questionnaire were: HRH man- and monitor the survey enumerators bution of health workers in the public agement capacity; HRH data; person- to resolve any issues at the grass-root sector and HRH policy analysis; the nel policy and practice; performance level. Data collection was monitored second describes the findings about job management; and training. On each of on a daily basis to assess the progress 24 components within these five areas, and implementation of the survey satisfaction and work environment in respondents were asked to rate the stage plan. The data entry team supervisors both the public and private sectors. their organization had achieved, and were instructed to communicate with the survey enumerators at 12:00 and Numbers and distribution of to indicate the level of policy develop- health workers in the public ment, from “no policy developed” to at 16:00 daily, collect any faulty ques- sector and HRH policies “more than five years of experience” tionnaires and report to the survey Table 1 shows the types of 349 dis- in the particular policy area related to coordinators twice a day to resolve any trict health facilities in the public sec- the component. Within each area, all issues and correct discrepancies. In tor from which data on numbers and the specific components for making a addition, the flagged faulty question- distribution were collected. Data for judgement for the organization were naires were sent back to be refilled by analysed. the survey enumerators. Data entry these 349 facilities were also collected from the office of the executive district Comprehensive data quality checks was successfully completed in the first officer (health) for cross-checking, giv- were performed during data collection week of December 2009. ing two data points for most facilities. and data entry. To reduce the number Data analysis In addition, consolidated data on health of non-respondents at the point of data workers were collected from the feder- collection and other reporting errors, Data were cleaned and validated in ally funded programmes, which have the following steps were adopted: Islamabad, before being transferred to an analysis team in Bethesda, Maryland, district-level implementation. There r introductory letters were sent to all United States of America. Data were were a large number of basic health concerned prior to initiation of field originally entered into SPSS software units in the sample. The oversampling activity; (SPSS Inc.) and converted to the Stata® of basic health units is rationalized, as r an ID card was assigned to each field version 9 format (StataCorp) for analy- this is the most numerous type of public surveyor; sis. Further analysis and charting was health facility in Pakistan. S147 EMHJ r 7PM 4VQQMFNFOU r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 1 Number of public sector district health facilities surveyed by type of facility positions indicate that provinces are across four provinces of Pakistan at different levels of achievement in Province DHQs THQs RHCs BHUs Dispensaries MCHC Total developing HRH management ca- Balochistan 3 2 10 59 13 5 92 pacity and systems; this achievement Khyber Pakhtunkhwa 4 3 6 61 4 5 83 varies from no policy experience to Punjab 4 4 8 62 4 4 86 extensive experience of more than five Sindh 4 4 8 44 24 4 88 years. The private facility managers Total 15 13 32 226 45 18 349 interviewed also had varying levels DHQs = district headquarters; THQs = tehsil headquarters; RHCs = rural health centres; BHUs = basic health of achievement. The private hospi- units; MCHC = mother and child health centres. tal managers interviewed in Sindh reported the strongest achievement with recent policy implementation Table 2 presents the median esti- major tertiary care hospitals revealed experience. Similarly, private hospital mates of total HRH in the public sector an estimate of 20 000 doctors work- managers from Punjab also reported by provinces and administrative areas of ing as postgraduate trainees, faculty strong achievement on some com- Pakistan. These estimates are based on members and medical officers in public ponents, e.g. establishing an Oracle- district-level facility averages for health sector facilities. About 50% of these are based hospital information system for workers. These do not include tertiary located in Punjab, 30% in Sindh and the employee data. hospitals, planning, supervisory, training remainder in the other two provinces. and budgetary staff in federal, provincial In the absence of other measures Job satisfaction and work and district health offices. From the total of the adequacy of front-line health environment front-line public sector health workers, workers, the population ratio is a proxy Regarding job satisfaction and work doctors and nurses are separated for indicator for adequacy. Table 3 depicts environment, 3549 health care work- further analysis, to illustrate the median district-level doctor:population and ers across public and private health estimate of doctors and nurses in the nurse:population ratios. facilities in Pakistan were interviewed, district health system in Pakistan in the Other estimates indicate that there about 40% from the private sector and public sector. Sindh province has the are 2.1 managers and administrative the remainder from the public sec- maximum number of doctors in the staff for every 100 health workers of all tor. The urban:rural distribution was public sector, whereas Punjab has the other cadres. The five-year total of at- 48%:52%. maximum number of nurses, including trition due to resignations, long-leaves, Table 4 compares the results on midwives and lady health visitors, in the retirement and deaths does not exceed job satisfaction and work environment public sector. 4% of the annual stock (using median indices for the public:private sectors In a separate exercise, data col- stock for 2009 as a baseline) in most and urban:rural distribution. The lected from the College of Physicians provinces for all the cadres. general direction of the public sec- and Surgeons Pakistan, the Pakistan The responses from our sample of tor scores is towards neutrality, with Medical and Dental Council and from interviewees in HRH management health workers neither agreeing nor disagreeing with the questions related to positive aspects of job satisfaction. Table 2 Estimated median numbers of total health workers, doctors and nurses Across the entire sample (public and working in the district health system in the public sector in 2009 private), comparisons for age, gender, a b Province/area Total health care workers Doctors Nurses location (urban/rural), provinces, ba- Balochistan 14 538 1 409 1 892 sic pay scale (BPS) cadres for federal Khyber Pakhtunkhwa 55 646 7 518 8 783 and provincial health workers, job type Punjab 91 696 12 601 17 773 (regular/contractual) and years of Sindh 95 263 20 639 8 169 service only show subtle differences in Islamabad Capital Territory 1 712 287 318 job satisfaction levels. Azad Jammu and Kashmir 12 931 987 1 246 Work environment compari- Northern areas 7 267 741 1 021 sons were also carried out across age, Total for Pakistanc 417 288 46 153 41 032 gender, location (urban/rural), BPS aDoctors include general practitioners and specialists. cadres for federal and provincial health bNurses include midwives and lady health visitors. cThis is not the sum of the individual medians and also includes federal vertical programmes (100 000 lady workers, job type (regular/contrac- health workers). tual) and years of service. No significant S148 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 3 Estimated district level public sector doctors and nurses per 1000 of Discussion population in 2009 Province/Area Doctors Nurses The problem in health service delivery Min. Median Max. Min. Median Max. in Pakistan has not been the unavail- Balochistan 0.15 0.17 0.24 0.21 0.23 0.24 ability of physical health facilities, but Khyber Pakhtunkhwa 0.28 0.33 0.35 0.20 0.39 0.48 rather their poor utilization and inability Punjab 0.03 0.13 0.19 0.08 0.19 0.22 to yield desired health outcomes [8]. Sindh 0.23 0.53 0.66 0.09 0.21 0.23 Equipping health facilities with ade- Islamabad Capital Territory 0.26 0.28 0.43 0.21 0.23 0.24 quate, well-trained and motivated health Pakistan 0.26 0.27 0.32 0.21 0.24 0.25 workers is the first step in improving uti- Source: extrapolated from growth in Pakistan population, 1998 census (Department of Statistics). lization and quality of care. In order to address HRH issues in the country, we need to know the distribution of health differences are seen in the responses for Sindh) have better scores for supplies workers across Pakistan, their total work environment across age or gender and logistics, machinery and equipment numbers, in terms of population, health subcategories, or for years of service and compared with Balochistan or Khyber needs and in proportion to each other BPS categories, but there are significant Pakhtunkhwa. The score on composite (e.g. nurse:doctor ratios). Similarly, to differences between urban and rural administrative facilitation is particularly improve utilization and quality of public facilities. poor for Balochistan. This composite in- health care services, we need to assess The survey results show that posi- dex captures responses related to clean the job satisfaction and motivation of tive aspects of the work environment drinking water, transport, security, food health care service providers. grow stronger with the size of the public and uniforms for the health workers The present survey is one of the sector health facility. The smallest fa- at the facility. Punjab and Sindh also largest surveys of health care workers cilities – dispensaries and basic health perform significantly better on cumula- conducted in Pakistan to assess their units – face the largest constraints in tive indicators. The score achieved by numbers and understand the realities terms of logistics and supplies in the Punjab, the most populous province, of their work conditions, motivation, opinion of the sampled health workers mirrors the higher performance of the job satisfaction and the adequacy of from such facilities. Teaching hospitals province on job satisfaction of sampled their equipment and instruments. are the best resourced with supplies and health workers. Federal workers show The median estimate of total health logistics as well as machinery and equip- reservations about their organizational workers employed in the district health ment. The larger provinces (Punjab and culture. system in the public sector for 2009 is 417 288; this number does not include Table 4 Composite scores on job satisfaction and work environment indices, by tertiary hospitals, or provincial, district location and sectora or federal staff at Ministry of Health Description of composite indices Urban Rural Public Private offices involved in planning, budget- Recruitment/career development/skills ing, training or research. The median and abilities 2.5 2.4 2.5 2.5 estimate of district doctors, both gen- Benefits and grievances 3.0 3.3 3.3 2.6 eral practitioners and specialists (not Salary 3.3 3.6 3.8 2.7 including dentists) in Pakistan for 2009 Motivation, recognition and respect 2.3 2.3 2.4 2.0 is 46 153 in the public sector, which Professional facilitation 2.2 2.3 2.4 2.0 compares with an earlier estimate of Workload 2.6 3.0 3.0 2.2 74 000 doctors in Pakistan in 2005 Retention 1.8 1.9 1.9 1.7 across public and private sectors [9]. Infrastructure 2.0 2.9 2.8 1.6 Estimates for tertiary hospitals show Logistics and supplies 2.5 3.3 3.0 2.5 that Punjab and Sindh provinces have Machinery and equipment 1.8 2.5 2.5 1.4 the highest number of doctors. This is Organizational culture 2.5 2.5 2.6 2.3 substantiated by Pakistan Medical and Administrative facilitation 3.1 3.6 3.5 2.9 Dental Council data, which show that Work environment (cumulative question, Sindh has the highest number of regis- positive) 1.6 1.8 1.8 1.3 tered doctors in both public and private aLower score is a better and more positive indication. sectors [10], followed by Punjab. S149 EMHJ r 7PM 4VQQMFNFOU r &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Pakistan has a shortage of nurses, development and implementation of the overall dissatisfaction with working further exacerbated by maldistribution HRH policies. This area needs further for their organization was quite high. across provinces. This shortage is par- exploration and insight. Though the salary-related dissatisfac- ticularly pronounced in Sindh, where The role of job satisfaction and the tion rates are lower than for the private they may not be adequate nurses and work environment on retention and sector, the “push” from such dissatisfac- midwives to assist doctors. In contrast, recruitment is increasingly recognized tion is much stronger in the private Khyber Pakhtunkhwa has the high- [11]. Health workers may feel demo- sector than in the public sector. est numbers of nursing staff, both as a tivated if their organization has not Regarding work environment, total and as a ratio to the population. equipped their facility with the right there are large differences between the The number of nurses and midwives equipment and supplies and a good public and private sectors. The private is particularly important in relation to infrastructure [12]. The results for job sector outstrips the public sector on the MDG target of all deliveries to be satisfaction indicate that, in general, all aspects of work environment. The attended by skilled birth attendants, public sector health workers are neither differences are particularly clear for because this shortage will be a barrier to satisfied nor dissatisfied but are broadly facility-level infrastructure, machinery achieving the desired target. The short- neutral. Based on specific, related and equipment, and administrative age of managerial and administrative questions, there is an indication that facilitation. Overall, considering both staff is also a challenge for a country public health workers across the cadres the job satisfaction as well as the work with the health care delivery complexity do not intend to leave. Male workers environment analysis, there is an indi- that Pakistan faces. Attrition in doctors were slightly less dissatisfied with their cation that health facilities in Punjab or nurses in the public sector does not salary and compensation than female province are much better than in other appear to be significant. workers. Urban workers are inclined provinces. The presence of a large work- to think more positively about their In conclusion, this HRH assess- force of lady health workers (almost workload than rural workers. The pay ment provides a wealth of information 100 000) has favourably affected the scales at federal or provincial levels are that could be used for policy forma- population:health worker ratio and not related to any distinct patterns of tion and to provide a basis for further gender balance in the public sector in differences in job satisfaction. Regular steps, including: development of Pakistan. It is particularly pertinent to employees are less satisfied on salary, strategies and plans; development of note that this large number is deployed motivation/recognition and profes- national HRH observatories; establish- in rural areas and is targeted towards sional facilitation compared with their ment of national HRH coordination the rural poor who have minimal or contractual colleagues. Regarding the mechanisms; building national HRH no access to the private sector. The work environment, the focus of assess- expertise, including leadership and importance of this cadre for making ment was on general issues such as management capacity; and primary crucial progress towards MDG 4 and organizational culture and administra- health care orientation of the health 5 has been recognized and the Global tive facilitation. Health workers from workforce. Countries facing a HRH Health Workforce Alliance, in a recent Punjab (both public and private), have crisis could benefit from each others’ experiences and develop a mutual meeting, Global consultation on com- the best job satisfaction scores com- mechanism for HRH capacity build- munity health workers, 29–30 April 2010, pared with provinces and the federal ing, with the help of WHO and other has concluded that community health Ministry of Health. development partners. workers should be included in the for- While there is considerable salary- mal health systems of countries. The related dissatisfaction in the public global body has recommended bring- sector at all levels compared with the Acknowledgement ing about uniformity in the selection, private sector, this does not necessarily training, operation and other aspects translate into a choice or desire to work This study was conducted with finan- of community health workers all over elsewhere, either full-time or part-time. cial and technical support from the the world. We believe that there is evidence for Global Health Workforce Alliance, The HRH policy dimension, though a lack of salary-related “push” factors WHO and the United States Agency very critical, is a less revealing area and for attrition in the public sector. For for International Development (US- survey results showed varying levels of the employees dissatisfied with salary, AID), Pakistan. S150 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ References 1. The world health report 2006: working together for health. Ge- 7. National health policy 2009. Islamabad, Ministry of Health (final neva, World Health Organization, 2006. draft) (http://www.health.gov.pk, accessed 5 May 2010). 2. Economic survey of Pakistan 2008–09. Islamabad, Finance Divi- 8. Medium term development framework 2005–2010. Islamabad, sion, 2009. Planning and Development Commission, 2008. 3. World health report 2002 – reducing risks, promoting healthy 9. Talati JJ, Pappas G. Migration, medical education, and life. Geneva, World Health Organization, 2002. health care: a view from Pakistan. Academic Medicine, 2006, 4. Birch S et al. Human resource planning and the production of 81(Suppl.);S55–S62. health: a needs-based analytical framework. Canadian Public 10. Pakistan Medical and Dental Council, Islamabad [website] Policy, 2007, 33(Suppl.):S1–S16. (www.pmdc.gov.pk, accessed 12 December 2009). 5. Global atlas of the health workforce. Geneva, World Health 11. McAuliffe E et al. Measuring and managing the work environ- Organization (http://www.who.int/globalatlas, accessed 12 ment of the mid-level provider – the neglected human re- December 2009). source. Human Resources for Health, 2009, 7:13. 6. Narasimhan V et al. Responding to the global human resources 12. Dieleman M et al. Identifying factors for job motivation of rural crisis. Lancet, 2004, 363:1469–1472. health workers in North Viet Nam. Human Resources for Health, 2003, 1:10. S151 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Impact of wealth status on health outcomes in Pakistan A.Y. Alam,1 S. Nishtar,2 S. Amjad3 and K.M. Bile4 ëmSm<9ogZTÐýmZ"ÐCKe_TÐ|>Ì Øe7d=hdBº{6ÌhgHº}åZhihinHº3nLÚínxMLö Ø{_Y¬ nh@Uð ĆhdĻëAnUÐî}@Ì{Sí ph[UÐâníúÐ:Óína>Ø@í YºënTn=ð :p_a>}YÓnhRUÐípÐ}CÐÓø{_YëÎoåÉ°#Ð – N=ÒnRí34íëÐ{UUÐN=ÒnRí25DL{x~xnYÐí{@ííº2007 2006Yn_UënTn=::Ð}Qex{UÐí[UÐyedUÓnh]_CÐÒ{LnbUÓÐE`CÐ p²PUÐî{UÓÐ kCÐhdLw5=nwiÚnSíº¬ Ð}bR{IúÐphe#Ðp²PUÐN=AØUYUÌcUpYn#ÐHëíØénaJúÐð N=ÒnRí41í }UÐ pxnL}UÐx{b>:ÓÐ}wnYÓĆYnLÚ\=ÒØøUÐÊnf?Ì:íº·35ÒØødUp]hCÐÒGaUÐ:pxnLÚDLé["ÐphU5AÐq`d=5hR fQ}TúÐ ÓĆB{>p]HÐ=NYí}edU RnfCÐ}x]>cexrh=phL5@øÐÒÐínCÐ~x~_UënTn=ÕnĻíº·20ÏÚÐ]UÐpxnLÚx{b>:íº1.38px{hUUÐ ~x~_>íº}baUÐÒjJíhaĺÓnhh>Ð}åHn=ßgfUÐ Yºph[UÐpxnL}UÐOÎéÉUÐYeH}UÐEQân]bUÐ{_xørh=ºphL5@øÐpx5"Ð :ph[UÐýn["ÐDLçí{[Yò ofYêÐ{Hn=hdLæ}_dUò nbRíf`dUbCÐ}?úÐpHÐÚ{UÐì|wð hb>5T ÓnLn]bUÐÒج {_CÐÓÐÊÐ}@üЬ ënTn= ABSTRACT Maternal and childhood morbidity and mortality are high in Pakistan and health disparities exist. Multivariate logistic regression analysis of the Pakistan Demographic and Health Survey database 2006–07 was performed. There was an excess of 25 neonatal, 34 infant and 41 under-five deaths per 1000 live births in the poorest quintile of wealth index compared with the richest. Women in the richest quintile had a 35%, 38% and 20% higher probability of getting prenatal care, delivery by skilled provider and emergency obstetric care, respectively. Pakistan needs to enhance social equity so development benefits can accrue to the underprivileged by introducing social protection interventions so that those in the informal sector are not excluded from accessing health care, scaling-up poverty reduction strategies and promoting intersectoral action. This study assesses the independent impact of wealth status, as determined by a validated index, on health outcomes in Pakistan. Statut économique et impact sur les résultats sanitaires au Pakistan RÉSUMÉ Au Pakistan, la mortalité et la morbidité maternelles et infantiles sont élevées, et des disparités sanitaires ont été observées. Une analyse de régression logistique multivariée a été effectuée sur la base de données 2006– 2007 de l’Enquête démographique et de santé au Pakistan. Le quintile le plus pauvre (selon l’indice de richesse) était touché par une surmortalité de 25 nouveau-nés, 34 nourrissons et 41 enfants de moins de cinq ans pour 1000 naissances vivantes, par rapport au quintile le plus riche. Les femmes appartenant au quintile le plus riche avaient une probabilité plus élevée de 35 % de bénéficier de soins prénatals, de 38 % d’avoir un accouchement encadré par un professionnel qualifié et de 20 % de recevoir des soins obstétriques d’urgence. Le Pakistan doit améliorer l’équité sociale pour que les bénéfices de cette amélioration puissent profiter aux plus défavorisés en mettant en place des interventions de protection sociale permettant de ne pas exclure le secteur non structuré de l’accès aux soins de santé, en élargissant les stratégies de réduction de la pauvreté et en encourageant une action intersectorielle. Cette étude évalue l’impact indépendant du statut économique sur les résultats sanitaires au Pakistan, selon une échelle validée. 1Community Health Sciences, Shifa College of Medicine, H-8/4, Islamabad, Pakistan (Correspondence to A.Y. Alam: [email protected]). 2Heartfile, Islamabad, Pakistan 3Public Health Consultant, Islamabad, Pakistan. 4World Health Organization, Country Office, Islamabad, Pakistan. S152 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Introduction as factors determining health status to most countries with DHS data: with the publication of the report of urban–rural status, house construction There is a fundamental difference be- the Commission on the Social Deter- material (usually floor material), edu- tween inequality and inequity. The former minants of Health, which firmly es- cational status of the mother and avail- is characterized by the determinants of tablished that inequities in daily living ability of electricity. The lower the asset health differentials between population conditions and inequitable distribution score, the higher is the probability (or groups or individuals that are related to of power, money and resources are the prevalence in aggregate terms) of child biological variations (e.g. genetic pre- most important determinants of health malnutrition. The authors assumed that disposition to disease) and freely cho- status achievement [2]. As opposed to the average prevalence of malnutrition sen health-damaging behaviours (e.g. the analysis of inequities through the for children with the lowest 31% of as- smoking). On the other hand, health social determinants approach, the ma- set scores equated to the prevalence inequities, which have been variably jority of published literature on equity in of malnutrition for those living on less defined, stem from health-damaging health focuses on access, utilization and than US$ 1 per day. conditions and determinants that are financing of health services, the extent of The above-mentioned studies have not based on informed choices and primary health care services, geographic demonstrated the existence of inequi- could be avoided. distribution and mix of health services. ties in health outcomes with reference The World Health Organization Health systems performance assess- to rural–urban and geographic status (WHO) defines health inequity as ment is an area where normative guid- of residence and wealth status as deter- “Differences in health status which are ance is currently being consolidated mined by income quintiles. However, unnecessary and avoidable, but in addi- [4]. However, experiences of countries the independent effect of wealth on tion, are considered unfair and unjust” that have developed health systems health outcomes has never been ascer- [1]. The WHO Commission on Social performance assessment frameworks tained in the Pakistani indigenous set- Determinants of Health further adds recommend that assessment of inequi- ting. The present study was conducted “Health equity is about equitable distri- ties is an increasingly challenging area to assess the independent impact of bution of health services in the society due to paucity of evidence. The frame- wealth status (as determined by a vali- and that means distribution in conform- work for health systems performance dated index) on health outcomes. ity with where the needs are greatest” assessment in Pakistan identified only a [2]. Another source adds that “Equity handful of studies that had examined in- in health is the absence of disparities in equities [Unpublished data]. Data from Methods the major social determinants of health” the Pakistan Social and Living Standards [3]. The concept of horizontal equity Measurement Survey give an insight into The 2006–07Pakistan Demographic states “Equity in health services implies prevailing social sector inequities by and Health Survey (PDHS), which was that there are no differences in health wealth quintiles [5]. The same survey part of the worldwide demographic services where health needs are equal”, shows that the overall national infant and health survey project, was the larg- while the concept of vertical equity em- mortality rate for urban areas was 45 per est household survey ever conducted phasizes “that enhanced health services 1000 live births whereas for rural areas in Pakistan to gather information on are provided where greater health needs it was 79 per 1000 live births. In addi- health and demographic outcomes. are present” [1]. Equity in policy and tion, rural–urban inequities and dispari- Its methodology has been published actions refers to “active policy decision ties were evident in these data trends. elsewhere [7]. and programmatic action directed at While there has been an increase in safe PDHS used a validated wealth in- improving equity in health” [1]. Equity drinking water supply and adequate dex, which was developed and tested in in research highlights “research to elu- sanitation facilities in Pakistan between a large number of countries in relation cidate the genesis and characteristics 1991 and 2007, the wide rural–urban to inequalities in household income of inequity in health for the purpose of differences have not narrowed [5]. [8,9]. The index, which is fairly widely identifying factors amenable to policy Existing evidence of inequities also used as a measure of economic status decisions and programmatic actions” comes from WHO’s multicountry as- in developing countries, is an indicator [1]. sessment of inequities [6]. In this study of the level of wealth that is consistent The determinant-based approach the authors constructed a global asset with expenditure and income measures to health inequities and broader issues score taking account of all the coun- [8]. This index was constructed using implicit in the social determinants of tries with demographic health survey household asset data, including owner- health (e.g. education, occupation, in- (DHS) databases, include Pakistan, ship of a number of consumer items come) came significantly to the fore using four variables that were common ranging from a television to a bicycle S153 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF or car, as well as dwelling characteris- STATA version 9.0. The lowest quintile Results tics, such as type of material used for (poorest) was used as the reference flooring, source of drinking water and category and all comparisons were Health outcomes are affected by sanitation facilities. Each asset was as- made with reference to that. In all three numerous factors. Figure 1 illustrates signed a weight (factor score) gener- databases the variables controlled in the conceptual framework of social de- ated through principal components’ the multivariate logistic regression terminants of health and other factors analysis and the resulting asset scores model were as follows: rural–urban affecting health outcomes. Among the were standardized in relation to a nor- residence, wife’s education, husband’s social determinants of health, level of mal distribution with a mean of zero education, wife’s occupation and hus- education, occupation, income, wealth and standard deviation of one. Each band’s occupation. For the birth and and rural–urban status are important. household was then assigned a score for child databases, sex of the child was also Outside of the social determinants, each asset and the scores were summed additionally controlled for. health systems performance, health- for each household; individuals were The study was not able to control seeking behaviour and several factors in ranked according to the score of the for other confounding variables, such the intersectoral domain also influence household in which they resided. The as health systems performance, access health outcomes. sample was then divided into quintiles to health care and health-seeking be- The distribution of children in the from one (poorest) to five (richest). haviour. births database was 20 269 (52%) male The index is fairly widely used as a meas- Multivariate logistic regression was children, while 24 623 (63%) children ure of economic status in developing used to assess the impact of wealth sta- belonged to rural areas of Pakistan. The countries [8,9]. tus (as evidenced by wealth index quin- distribution of children according to Raw data obtained from PDHS tiles). The adjusted odds ratios (OR) quintiles of wealth index was as fol- 2006–07 were analysed using SPSS and 95% confidence intervals (CI) lows: poorest 8191 (21%), poorer 8345 version 10.0 and STATA version 9.0. were obtained. Adjusted probabilities (21.4%), middle 7957 (20.4%), richer This dataset was made available to of each indicator variable across wealth 7808 (20%) and richest 6748 (17.3%). researchers through an online registra- index quintiles were obtained using the Table 1 shows the association of tion system [10]. Three PDHS data- adjust command of STATA after the wealth index quintiles with child health bases were used in this analysis. The regression command. outcomes. With reference to the maternal dataset consisted of 10 023 women aged 12–49 years, representing all the provinces of Pakistan. The births dataset consisted of 39 049 children, while the children’s vaccination data- set consisted of 9177 children. In the PDHS, mothers were asked to show the interviewer the health cards of all children under the age of five years [8]. If a child had not received a health card, or if the mother was unable to show the card to the interviewer, the mother was asked to recall whether the child had received Bacille Calmette-Guérin (BCG), polio, diphtheria–pertussis– tetanus (DPT) (including the number of doses for polio and DPT) and mea- sles vaccinations [7]. The births data were collected by asking ever-married women of reproductive age to provide complete birth histories of all their live births and those who had died [7]. Descriptive and analytical statistical analysis was carried out on all three Figure 1 Conceptual framework of social determinants of health datasets using SPSS version 10.0 and S154 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Table 1 Association of wealth index with child health outcomes (n = 38 900) doses of DPT (DPT3), three doses of Dependent variable Quintiles of OR (95% CI) Adjusteda mortality rates hepatitis B virus (HBV3) and measles wealth index adjusteda (per 1000 live births) vaccination. In absolute terms, adjusted Neonatal mortality rate Poorest 1.0 70 probabilities of childhood vaccination Poorer 0.98 (0.87–1.11) 63 status show that children in the rich- Middle 0.76 (0.67–0.87) 56 est quintile have an 18% higher prob- Richer 0.68 (0.58–0.79) 50 ability of getting polio 0 vaccination, Richest 0.67 (0.55–0.82) 45 19% higher probability of getting DPT3 Infant mortality rate Poorest 1.0 101 vaccination, 21% higher probability of Poorer 0.93 (0.84–1.03) 92 getting HBV3 vaccination and 18% higher probability of getting measles Middle 0.75 (0.67–0.84) 83 vaccination. Richer 0.72 (0.64–0.82) 75 Richest 0.66 (0.56–0.78) 67 Children in the richest quintile are 2.14 times more likely to get medical Under-five mortality rate Poorest 1.0 116 treatment for acute respiratory infec- Poorer 0.89 (0.81–0.97) 104 tions compared with children in the Middle 0.72 (0.65–0.81) 94 poorest quintile (P < 0.0001, result not Richer 0.69 (0.62–0.78) 84 shown in table). Richest 0.65 (0.55–0.76) 75 Table 3 shows the association of aAdjusted for sex of child, rural–urban residence, wife’s education, husband’s education, wife’s occupation, husband’s occupation. wealth index quintiles with reproductive OR = odds ratio; CI = confidence interval. health indicators. All the indicators of reproductive health show a higher OR favouring women in the richest quintile poorest quintile of wealth index (OR = 1.0) the adjusted ORs for middle, richer and richest categories of wealth Table 2 Association of wealth index with indicators of child health (n = 9177) index show a highly statistically signifi- Dependent variable Quintiles of OR (95% CI) Adjusteda cant lower odds of neonatal, infant and wealth index adjusteda probabilities (%) under-five child mortality. In absolute Polio 0 vaccination status among Poorest 1.0 44 terms, adjusted neonatal mortality rates under-five children Poorer 1.26 (1.11–1.43) 49 show an excess of 25 neonatal deaths Middle 1.41 (1.23–1.63) 53 per 1000 live births for neonates in the Richer 1.61 (1.37–1.89) 58 poorest quintile of wealth index com- Richest 2.13 (1.73–2.62) 62 pared with the richest quintile. Adjusted DPT3 vaccination status among Poorest 1.0 45 infant mortality rates show an excess of under-five children Poorer 1.25 (1.10–1.42) 50 34 infant deaths per 1000 live births for Middle 1.49 (1.30–1.72) 55 infants in the poorest quintile of wealth Richer 1.79 (1.52–2.11) 60 index compared with the richest quin- Richest 2.22 (1.80–2.75) 64 tile. Adjusted under-five child mortality HBV3 vaccination status among Poorest 1.0 42 rates show an excess of 41 under-five under-five children child deaths per 1000 live births in the Poorer 1.24 (1.09–1.41) 47 poorest quintile of wealth index com- Middle 1.55 (1.35–1.79) 52 pared with the richest quintile. Richer 1.88 (1.59–2.21) 58 Table 2 presents the association of Richest 2.18 (1.77–2.69) 63 wealth index quintiles with child health Measles vaccination status among Poorest 1.0 45 under-five children care services delivery. With reference Poorer 1.20 (1.05–1.37) 50 to the poorest quintile of wealth index Middle 1.46 (1.26–1.67) 54 (OR = 1.0) the adjusted ORs for poorer, Richer 1.81 (1.53–2.13) 58 middle, richer and richest categories of Richest 1.83 (1.48–2.24) 63 wealth index show a highly statistically aAdjusted for sex of child, rural–urban residence, wife’s education, husband’s education, wife’s occupation, husband’s occupation. significant higher odds of polio vac- OR = odds ratio; CI = confidence interval; DPT3 = 3 doses of diphtheria–pertussis–tetanus; HBV3 = 3 doses of cine dose given at birth (polio 0), three hepatitis B virus. S155 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 3 Association of wealth index with indicators of reproductive health (n = in the poorest quintile. In relation to 10 023) educational attainment (primary or Dependent variable Quintiles of wealth OR (95% CI) Adjusteda higher) the study showed that women index adjusteda probability (%) in the richest quintile were 54.4 times Prenatal care from skilledb Poorest 1.0 45 more likely to attain this level compared provider Poorer 1.49 (1.26–1.76) 56 with women in the poorest quintile. Middle 1.95 (1.62–2.34) 66 Richer 3.30 (2.67–4.09) 75 Richest 6.99 (5.21–9.38) 82 Discussion Tetanus injection (two doses) Poorest 1.0 61 before birth of child Poorer 1.53 (1.34–1.75) 70 The dynamic link between per capita expenditure and health outcomes is Middle 2.11 (1.82–2.45) 77 well established [11]. This study aims to Richer 3.16 (2.66–3.76) 83 assess the independent impact of this as- Richest 4.72 (3.77–5.90) 88 sociation in Pakistan, as determined by b Delivery by skilled provider Poorest 1.0 25 a validated wealth index formulated by Poorer 1.44 (1.19–1.75) 33 DHS. This index was constructed using Middle 1.86 (1.52–2.28) 43 household asset data, including owner- Richer 3.02 (2.43–3.76) 53 ship of a number of consumer items Richest 5.40 (4.16–7.01) 63 ranging from a television to a bicycle or Delivery in a clinic or Poorest 1.0 47 car, as well as dwelling characteristics, hospital Poorer 1.47 (1.29–1.67) 57 such as type of material used for flooring Middle 1.88 (1.64–2.16) 66 and source of drinking water and sanita- Richer 2.99 (2.56–3.50) 74 tion facilities, while variables related to Richest 5.73 (4.68–7.01) 80 urban–rural status, wife’s and husband’s Emergency obstetric care Poorest 1.0 42 education and occupation were not in- availability in the last Poorer 1.06 (0.87–1.29) 47 cluded in this wealth index. Conversely, delivery Middle 1.31 (1.06–1.62) 52 the variables of the global DHS asset Richer 2.0 (1.57–2.53) 57 score were used by a previous study Richest 2.01(1.51–2.68) 62 on Pakistan considering urban–rural aAdjusted for rural–urban residence, wife’s education, husband’s education, wife’s occupation, husband’s status, housing construction material occupation. (usually floor material), educational sta- bSkilled includes doctor, nurse, midwife or lady health worker. OR = odds ratio; CI = confidence interval. tus of wives and availability of electricity with asset score ranking formulated by the authors [6]. However, the wealth compared with women in the poorest getting prenatal care from a skilled pro- index used by this paper was advanta- quintile. All these adjusted associations vider, 27% higher probability of getting geous as the multivariate logistic regres- are statistically highly significant. Wom- two doses of tetanus toxoid injection, sion analysis enabled us to control the en in the richest quintile were 7 times 38% higher probability of delivery by effect of the aforementioned potential confounding factors. more likely to get prenatal care from a skilled provider, 33% higher probability skilled provider, 4.7 times more likely to of delivering in a clinic or hospital and Health outcomes are known to get two doses of tetanus injection before 20% higher probability of having access be influenced by a number of factors: biological, behavioural, socioeconomic, the birth of a child, 5.4 times more likely to emergency obstetric care, compared to have delivery by a skilled health care cultural, institutional and health sys- with women in the poorest wealth index provider, 5.7 times more likely to have tems performance related. The impact quintile. a delivery in a clinic or hospital and 2 of socioeconomic factors on health and times more likely to get emergency ob- Women in the richest quintile were well-being has been well documented stetric care (if need be) compared with 53% less likely to develop fever after [11]. This is evidenced by differentials women in the poorest quintile. In terms delivery, 61% less likely to have fits or in life expectancy across regions of the of absolute measures, adjusted prob- convulsions after delivery and 35% less world with different levels of economic abilities show that women in the richest likely of ever experiencing an obstetric development and mortality patterns quintile have 35% higher probability of fistula problem, compared with women according to the level of occupational S156 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ hierarchy [11]. It is further evidenced by prevalent, many overarching institu- overall improvements in survival and the observed differences in child mor- tional impediments also act as a barrier reductions in health care inequities tality according to the income level of for health systems performance. [18,19]. families and maternal level of education Countries that have shown recent The debate on health reforms and [11]. In many countries, the increased progress in improving child and ma- the divergent views on the type of level of female education has been the ternal health indicators and that have solutions needed centre on the issue single most important factor in decreas- experienced decreasing mortality of inequities in access to health care ing child mortality [12,13] Pakistan and morbidity trends have made im- and the right to health, among other suffers an inherent disadvantage in this provements on several fronts. Chile, a things. Equity assumes fundamental respect with high levels of poverty and medium-resource country, is one such importance not only as an aspirational illiteracy. example. A consistent increase in an- health goal but also, as being increas- Inequities in health and other social nual per capita income and decrease in ingly recognized, as one of the three outcomes have been described in the the number of people living in poverty desired health systems outcomes, the indigenous Pakistani population; how- between 1990 and 2004 are evidence other two being fairness in financing ever, the independent effect of wealth of Chile’s sustained economic growth and responsiveness. on health outcomes has not been as- [15,16]. In Chile, declines across mater- sessed. The main value of this study lies nal, newborn and child mortality indica- in demonstrating that for the first time. tors occurred in all five income quintiles, Conclusion Although the study was not able to with the largest proportional decrease in control for other confounding variables the poorest quintile. These representative data from Paki- such as health systems performance, In Sri Lanka where a third of the stan quantify the burden of morbidity access to health care and health-seeking population is estimated to live below and mortality and access to health care behaviour, it was able to control for the national poverty line, maternal associated with inequitable distribu- a number of other variables such as morality ratios (44 per 100 000 births tion of wealth in the society. The rural–urban residence, and level of in 2005) and under-five mortality rate country will have to make progress education and occupation of the head (13 per 1000 in 2000) are among the by enhancing social equity so that the of the household. The differentials in lowest in the developing world [17]. benefits of development can accrue outcomes are important evidence for All of this has been made possible by to the underprivileged sections of the health policy planners who predomi- targeting the social determinants of population. Social protection interven- nantly focus on the health care perspec- health: free provision of health services tions should also be introduced so that tive of interventions and often do not to all, provision of maternal and child those in the informal sector are not create the right linkages for intersectoral health care services at the community excluded from accessing health care, action. level, relatively high status of women, including: scaling-up the implementa- The impact of factors outside the 88% literacy rate among women, girls tion of poverty reduction strategies and health care system on health outcomes having free access to education until social sector investment, especially in can also be interpreted in another way university level, network of commu- health; promoting intersectoral action – health care is limited in its ability to nity midwives providing antenatal care to achieve better health outcomes; and improve health status, unless the under- to 75% of women, 96% skilled birth mitigating the ill effects of social deter- lying socioeconomic conditions and in- attendance rate, over 90% deliveries minants of health. The objective of this equities of power, money and resources in health facilities, a strong referral study is to assess the independent im- change in the desirable direction [14]. system in place to ensure transport pact of wealth status, as determined by It is precisely with this understanding in of women to one of the 45 hospitals a validated index on health outcomes view that a recently articulated agenda if complications occur, and all first in Pakistan. for health reforms for Pakistan lays great pregnancies and high-risk pregnan- emphasis on both the factors in the cies referred to health facilities with intersectoral domain as well as the over- obstetricians [14]. Acknowledegment arching factors responsible for health These findings parallel research systems performance [14]. Pakistan in developed and transitional coun- We are thankful to Yasir Abbas Mirza suffers a “double burden” in this respect. tries that has shown that reversals in for the formatting and layout of this Not only are its social disparities widely marginalization patterns can result in manuscript. S157 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF References 1. Macinko JA, Starfield B. Annotated bibliography on equity in 11. Achieving health equity: from root causes to fair outcomes. Ge- health, 1980–2001. International Journal for Equity in Health, neva, World Health Organization, Commission on the Social 2002, 1(1):1. Determinants of Health, 2007 (http://whqlibdoc.who.int/ 2. Closing the gap in a generation: health equity through action on publications/2007/interim_statement_eng.pdf, accessed 23 the social determinants of health. Final report of the Commis- June 2008). sion on Social Determinants of Health. Geneva, World Health 12. Kaber N. Gender equality and human development: the in- Organization, 2008. strumental rationale. Brighton, United Nation Development 3. Braveman P, Gruskin S. Defining equity in health. Journal of Programme, 2005 (http://www.hdr.undp.org/en/reports/ Epidemiology and Community Health, 2003, 57(4):254–258. global/hdr2005/papers/hdr2005_kabeer_naila_31.pdf, ac- cessed 25 June 2008). 4. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, World 13. Sri Lanka shines in slashing maternal, neonatal mortal- Health Organization, 2007 (http://www.wpro.who.int/sites/ ity: Unicef. (http://www.thaindian.com/newsportal/health/ hsd/documents/Everybodys+Business.htm, accessed 16 De- sri-lanka-shines-in-slashing-maternal-neonatal-mortality- cember 2009). unicef_100142713.html, accessed 27April 2010). 5. Pakistan social and living standards measurement survey 2006– 14. Nishtar S. Choked pipes: reforming Pakistan’s mixed health sys- 07. Islamabad, Federal Bureau of Statistics (http://www. tem. Karachi, Oxford University Press, 2010. statpak.gov.pk/depts/fbs/statistics/pslm2006_07/report_ 15. Bossert TJ et al. Decentralization and equity of resource alloca- pslm06_07.pdf, accessed 24 July 2009). tion: evidence from Colombia and Chile. Bulletin of the World 6. Blakely T, Hales S, Woodward A. Poverty: assessing the distribu- Health Organization, 2003, 81:95–100. tion of health risks by socioeconomic position at national and 16. Gwatkin DR. Health inequalities and the health of the poor: local levels. Geneva, World Health Organization, 2004 (WHO what do we know? What can we do? Bulletin of the World Environmental Burden of Disease Series, No. 10). Health Organization, 2000, 78:3–18. 7. Pakistan demographic and health survey 2006–07. Islamabad, 17. Health a key to prosperity, success stories in developing countries. National Institute of Population Studies and Macro Interna- (http://www.who.int/inf-new/mate1.htm, accessed 27 April tional Inc., 2008. 2010). 8. Gwatkin DR et al. Socio-economic differences in health, nutrition, 18. Braveman P, Tarimo E. Social inequalities in health within and population. Washington DC, World Bank, 2000. countries: not only an issue for affluent nations. Social Science 9. Filmer D, Pritchett LH. Estimating wealth effects without ex- & Medicine, 2002, 54:1621–1635. penditure data – or tears: an application to educational enrol- 19. The world health report 2005. Make every mother and child count. ments in states of India. Demography, 2001, 38(1):115–132. Geneva, World Health Organization, 2005. 10. Demographic and health surveys. Measure DHS. (http://www. measuredhs.com, accessed 25 September 2009). S158 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Review Human organ and tissue transplantation in Pakistan: when a regulation makes a difference K.M. Bile,1 J.A.R.H. Qureshi,1 S.A.H. Rizvi,2 S.A.A. Naqvi,2 A.Q. Usmani3 and K.A. Lashari4 ï|v?Dåg_=NÎÓm^wOTÐïØj=mXzeKëmSm<9owOTÐreTÐíÊm[KúÐoKÐÚÛ« ïÚnIø}åBÐØfZBº©5L}x{bUÐ{Lºîbi{1ÌÚÐiÌ{hHºïÚ"ÐoxØÌ{hHºVx}ShA}UÐ3nL{hZ+ºØe7d=hdBö ënTn=qÉÌ{Sí {dUÐenxØn[SÐíð nhL5@Ðíð nhfxØíð nhRnb?Ò{ýnUÐæí}^Un=n*nSĆLRíÊn\LúÐpLÐÚÛOÎ}^fUÐ`fxð oåÉ°#Ð eCÐÓ5^fe=íºphfgCÐ=Ðí}Un=pYL{YºphYc"ÐØg!ÐÓØÌ{Sí pYWfCÐpdhdbUÐØb_UÐéĆBphdcUÐâÚ~=Ún9ĆU~TÐ}CÐwÌ YÐ{AÐíð UÙíºÊn\Lún=Ún9øÐ ebxíºpHÚ5CÐì|w¬ ^fx xP>ØÐ{LÎOκphCn_UÐp[UÐpe^fYngY¬ {b>UÐphfbUÐÒ{LnCn=íºêĆLüÐýnH=íº©{CЬ Ýn_iÐDLíºæí}^UÐ:yÐíò ò ĻÔí{ADLÓnf´ h=ènfgRºëinbUÐ|haf>DLbRNfHÊn\biÐQÚí phUí{UÐpxØnIÚ¬ üÐýø{UÐ YnhIn/ð Ónx{UÐج {_>íº xPdUphhý}UÐyYĆCÐpHÐÚ{UÐì|wß}_>í ënTn=:ºënY´ ún=íºÓnhSĆBúÐ=Ð\={hbxï|UÐÊn\LúÐâÚ~=énYùÐ pdeCÐpýÚn]UÐÞ}aUÐí ABSTRACT Organ transplantation must be viewed in relation to the prevailing cultural, religious and socio- economic conditions of a nation. Over the past two decades, Pakistan has emerged as one of the largest centres for commercial renal transplantation. Government efforts, supported by professional associations, civil society organizations and the media, along with World Health Organization technical assistance, have led to the development of legislation regulating this practice and curbing organ trade in conformity with international guidelines. Although only two years have passed since the enactment of the law, there is evidence that conditions have significantly improved, raising hopes for ethical and safe organ transplantation in Pakistan. This study reviews the salient features of the legislation and lists the foreseeable evolving challenges and opportunities. Transplantation d'organes et de tissus humains au Pakistan : lorsque la loi fait la différence RÉSUMÉ Les transplantations d’organes doivent être envisagées en tenant compte des valeurs culturelles et religieuses d’un pays, ainsi que de ses conditions socioéconomiques. Au cours des vingt dernières années, le Pakistan est apparu comme l’un des plus hauts lieux du commerce de la transplantation rénale. L'action gouvernementale, soutenue par les associations professionnelles, les organisations de la société civile et les médias, avec l’assistance technique de l’Organisation mondiale de la Santé, a conduit à la rédaction d’une loi régissant ces pratiques et contribuant à réduire le commerce d’organes, conformément aux directives internationales. Même si sa promulgation ne remonte qu’à deux ans, il est évident que la situation s'est considérablement améliorée, ravivant l’espoir de transplantations éthiques et sûres au Pakistan. Cette étude analyse les principales caractéristiques de la législation et récapitule les futurs défis et opportunités prévisibles. 1World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to K.M. Bile: [email protected]). 2Sindh Institute of Urology and Transplantation, Karachi, Pakistan. 3Human Organ Transplantation Authority, Islamabad, Pakistan. 4Ministry of Health, Islamabad, Pakistan. S159 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Introduction creating a thriving market for kidney In the global debate on transplanta- sales [7,8]. tion, Islamic rulings have substantiated Human organ transplantation, involving As in the rest of the Islamic world, the legitimacy and religious acceptabil- the therapeutic use of organs obtained the development of organ transplan- ity of organ donation, consistent with from healthy living or deceased donors, tation legislation in Pakistan moved the internationally set ethical and tech- is the last resort for the survival and well- slowly, owing to the lack of an outright nical norms; however, the sale of organs being of thousands of men, women and consensus on religiously motivated and exploitative coercive donations children suffering from end-stage organ ethical questions regarding the practice. were termed un-Islamic [9]. To en- failure [1,2]. This essential medical serv- Key questions included: sure correct transplantation norms, the ice is viable only when the required pro- Government of Pakistan has success- r Does religion allow organ donation fessional skills and ethically approved, fully promulgated legislation. This study and, if granted, are restrictive condi- quality institutions are available and aims to review the salient features of the tions attached? when governed by sound legislation that legislation and its compatibility with generates sufficient societal support [3]. r Is donation limited to relatives only? international ethical transplantation At a global level, progress in setting uni- r Can organs be sold or is bestowing guidelines. It also lists evolving chal- versal guidelines has been made by the rewards and grants to donors accept- lenges and foreseeable opportunities for World Health Organization (WHO), able? building an ethically focused national the World Medical Association and the r Can organs be obtained from the de- capacity for this vital service. international Transplantation Society ceased, and how and when can death [4,5]. The guidelines cover: be firmly ascertained? Methods r organ donation by living adults; r Is the act of donation an exclusive r legal consent for organ removal from donor’s right or are relatives of the de- A desk review was conducted on the deceased persons; ceased allowed to donate and can the available literature in this specialized dis- Government perform this act in the r averting conflict of interest related to cipline using MEDLINE®. In addition, case of unclaimed deceased persons? a physician’s death determination; literature on the historical processes and r Is xenotransplantation permissible r banning exploitation and coercion; challenges regarding the regulation of [8,9]? organ transplantation in Pakistan, along r barring remuneration exceeding a Most of these challenging queries with the recorded contributions made justifiable fee for services rendered by were resolved and consensus delibera- by different partner institutions, was persons and for facilities involved in organ procurement and transplanta- tion attained through the promulgation studied. WHO literature in the context tion; of legitimate verdicts (fatwas) origi- of this legislation, especially the set nor- nated by Islamic scholars of jurispru- mative guidelines for organ transplanta- r allocating organs, cells and tissues dence such as the Al-Azhar of Egypt, tion, was also reviewed as well as the based on clinical need; the Council of Senior Scholars in Saudi Islamic verdicts on key religiously and r establishing criteria guaranteeing that Arabia, the International Union of ethically charged questions related to the result outcomes are transparent Islamic Jurisprudence, the Union of organ donation. and open to scrutiny, while at the Islamic Jurisprudence affiliated with same time protecting personal ano- the International Islamic Association nymity and privacy of donors and and by many regional associations [9]. Organ transplant recipients [4,5]. In the Islamic world, it is often manda- legislation During the past half century this tory to ensure that legislation, including field has progressed to a technologically that relevant to organ donation, does Prior to the legislation, the unethical advanced clinical specialty, although the not contradict the teachings of Islam, a practice of organ transplantation was practice of organ donation involves so- responsibility undertaken by officially constantly a major concern since renal ciocultural, legal and ethical challenges constituted Islamic foundations pro- transplantation surgery took root in [6]. viding legal opinions, including those Pakistan in early 1973. Institutions pur- Over a prolonged period, Pakistan relevant to the health and population suing and supporting ethical guidelines has emerged as one of the largest known sector. These foundations put an end for life-saving organ transplantation centres for renal trafficking owing to to misconceptions and speculation, were led by the Sindh Institute of Urol- a lack of regulation and the presence generate public acceptability and lead ogy and Transplantation. This institute of a large vulnerable rural population to greater service utilization. was founded in 1972 and became an S160 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ autonomous institution in 1991 and the successful enactment of legislation therapeutic purposes and related proce- is the largest centre in Pakistan offer- are summarized in Table 1. dural matters all over the country. The ing free dialysis and transplantation principal features of the ordinance, later Transplantation ordinance: services to the underprivileged, with efforts, achievements and promulgated as an act, are summarized a legacy of 2700 transplants until challenges below. 2009. However, commercial kidney Following the intervention by the Su- Donation of organ or tissue by a living transplantation flourished in many preme Court of Pakistan in July 2007, an person other institutions in Pakistan, where ordinance to regulate organ transplanta- The ordinance stipulated that a donor organs were advertised for sale on the tion and curb the burgeoning kidney should not be less than 18 years of age, Internet. In early 2005, an Internet trade was drafted by the Ministries of search for “kidney transplantation Health and Law. The Transplantation donation should be a voluntary act and in Pakistan” generated more than of Human Organs and Tissues Ordi- that donation should be permissible to 800 000 entries. Key milestones in the nance 2007 was then promulgated by a living person genetically and legally practice of kidney transplantation in the President of Pakistan, regulating related, i.e. a close blood relative. In the Pakistan and the chronological events the removal, storage and transplanta- case of regenerative tissues, such as that combated organ trade and led to tion of human organs and tissues for stem cells, there was no restriction of Table 1 Efforts to curb unethical practices related to organ transplantation in Pakistan and the processes pursued to attain this goal Year Events 1979 Renal transplantation started in Pakistan in public sector hospitals using living related family donors 1990s Renal transplantations exceeded 500 transplantations per year with first violations observed, whereby some hospitals shifted from dealing exclusively with living, related donor to unrelated, paid donors until these unethical practices accounted for more than 80% of all transplantations. Later in the decade transplantations exceeded 1000 per year. A transplantation bill was introduced by the Senate in 1992, based on ethical norms and conforming to World Health Organization (WHO) and International Transplantation Society guidelines, but the attempt was defeated by the then strong counter lobby. 2000s Opposition to promulgating the law was sustained and commercial kidney transplantation flourished with over 1500 expatriates receiving locally procured kidneys. The Ministry of Health, supported by SIUT, media and civil society organizations, sustained its efforts to promote legislation and bring an end to these unethical practices. WHO provided the necessary technical support through its country, regional and headquarter institutions. 2004 A bill was tabled in the Pakistan Senate by a member raising the momentum for action. Subsequently, the subject was tabled as an agenda item in the Federal Cabinet. 2006 The organ transplantation agenda submitted to the Cabinet in 2004 was deferred in October 2006. This action ignited an active campaign, where informed and investigative media reports and SIUT’s bold and challenging technical deliberations exposed the growing unethical lucrative kidney trade. 2007 Exploitative organ transplantation led to a judicial action in July 2007, whereby the Supreme Court of Pakistan took a suo moto notice advising the Government to promulgate the transplantation law. 2007 The transplantation ordinance was promulgated in September 2007 by the President of Pakistan. 2008 Attempts were made by the counter lobby through the Standing Committee for Health at the National Assembly to water down the law by introducing loopholes implicitly condoning organ sale and allowing expatriates to acquire kidneys for lucrative fees. These endeavours were rejected by the Standing Committees for Health and Human Rights. 2008 A case was filed before the Federal Shariat Court of Pakistan, challenging the law, whereby 12 hearing sessions were held in Islamabad, Lahore and Karachi, unanimously defeating all submitted objections and rendering all stipulated clauses of the law sustained, including the illegality of all forms of organ sale. 2009 On 23 June 2009, the Supreme Court took suo moto notice against private hospitals accused of violating the law and performing illegal transplantations, who when summoned by the court made commitments to comply with the law. 2009 On 12 November 2009, the National Assembly of Pakistan unanimously passed the bill on the recommendation of its Standing Committee on Health. 2010 On 10 February 2010, the Senate of Pakistan passed the bill. 2010 On 17 March 2010, the President of Pakistan signed the bill making it a law. SIUT = Sindh Institute of Urology and Transplantation. S161 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF age between siblings. The ordinance de- transplantation of a human organ into that the advertiser is willing to undertake fined “close blood relatives” as parent, any other body. any commercial arrangement. son, daughter, sister and brother, and Monitoring authority Furthermore, transplantations were included spouse provided that trans- A monitoring authority was established only to be carried out by transplan- plantation was voluntary, motivated headed by the Federal Minister for tation surgeons and physicians after and free of duress or coercion. How- Health and comprising of the Federal ensuring that written certification had ever, in the case of non-availability of a Health Secretary and seven eminent been obtained from the evaluation close blood relative donor, the organ transplantation surgeons. The authority committee. The monitoring author- transplantation evaluation committee is responsible for: ity was mandated to publish a list of had the prerogative to allow donation medical institutions and hospitals that by non-close blood relative donors r monitoring transplantations and were recognized for the practice of after ensuring that such donation was enforcing prescribed standards for operative surgery in transplantation of recognized medical institutions and voluntary. The ordinance was quite human organs and tissues. The Federal hospitals; unambiguous that the donation of an Government could revise this list when organ or tissue from a living national r investigating allegations of breach of necessary. should not be permissible to citizens of any provisions of the ordinance; other countries. r inspecting medical institutions and Implementation Donations of human organs or tissues hospitals to assess the quality of As stipulated in the legislation, soon after death transplantation; after the approval of the ordinance, the national Human Organ and Tissues The ordinance instructed that any per- r establishing a national registry and Transplantation Authority (HOTA) son not less than 18 years of age may, national and regional networks eval- was established. HOTA is led by an before his or her death, in writing duly uating the performance and quality administrator and has as members a signed by the evaluation committee, outcome of transplantation centres; number of senior medical experts nom- donate any of his or her organs or tis- r exploring and supporting interna- inated by the Ministry of Health. The sues, and may also assign a medical tional collaboration on xenotrans- WHO Representative is also a member, institution or hospital recognized by plantation. whose major role is to liaise WHO’s the monitoring authority for transplan- The monitoring authority is to ap- technical support and expertise with tation. This donation willed after death point an administrator and other offic- HOTA. This institution has the pri- could be revoked by the donor at any ers required to carry out its business. mary focus of framing rules, certifying time during his or her lifetime. Penalties for commercial dealings in eligibility of hospitals for transplantation human organs Evaluation committees services and the professional expertise Commercial dealings in human organs Evaluation committees were consti- required. These functions are carried were rendered an offence, punishable tuted through the legislation and out through performance-monitoring with imprisonment for up to 10 years consisted of surgical, medical and trans- inspections. The minimum basic cri- along with monetary penalty and pos- plantation specialists, nephrologists, teria set by HOTA as preconditions sible removal of the practitioner’s name a neurophysician and an intensivist for a hospital to be eligible to carry out from the register of the Pakistan Medi- transplantation procedures are outlined where available, along with two local cal and Dental Council, initially for a in Table 2. notables with a good record of social 3-year period and permanently for sub- service. They were accountable for: (a) sequent offences. Activities constitut- To permit donation by unrelated exercising control over transplantation ing an offence included: (a) making or individuals, HOTA pursues a verifica- procedures in medical institutions and receiving any payment for supply of, or tion checklist where the authenticity of hospitals for ensuring that no organ or for an offer to supply, any human organ; the recipient's claim of lacking eligible tissue was retrieved from non-related (b) seeking to find a person willing to family members is endorsed only upon living donor without the prior approval supply for payment any human organ; confirmation of lack of family members of the evaluating committee; (b) de- (c) offering to supply any human organ from the computerized National Da- termining brain death of a person; (c) for payment; and (d) publishing or tabase and Registration Authority and determining propriety of removal of a distributing any advertisement invit- from the local authority of the recipi- human organ from any living person ing persons to supply for payment any ent’s residential area, along with blood using brain death protocol; and (d) human organ, or offering to supply any grouping of any identified relatives determining fitness or otherwise for human organ for payment, or indicating when deemed necessary. S162 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ In the 2 years since the legislation was en- acted, HOTA has accorded recognition to 42 hospitals and medical institutions to perform organ transplantation, following a satisfactory evaluation outcome. The numbers of kidney transplants performed by 28 of the 42 HOTA-authorized hospitals, from the outset of the ordinance promulgation in 5 September 2007 to 31 December 2009 were recorded (Table 3). Most hospitals in Punjab performed transplantations from donors that were unrelated to their recipients; however, the biochemistry and microbiology biochemistry and microbiology Blood bank cross-matching facilities Blood bank cross-matching Round the clock availability of multi- Radiology facilities Ultrasound and Doppler Ultrasound available discipline testing facilities, especially ō ō ō ō donor–recipient analysis was consistent in all cases with HOTA legislation norms and guide- lines. Implementation challenges Challenging the ordinance at the Federal Shariat Court Counter lobby groups aspiring to sustain the prelegislation status quo attempted to revoke the effective implementation of the law through Management and care Diagnostics, and blood bank laboratories a petition filed before the Federal Shariat Court. The petition aimed to remove the limitations System for obtaining explicit consent from consent from System for obtaining explicit Patient record maintenance, manual or record Patient Library and Internet facilitiesLibrary facilitiesResearch Patient counselling facilities Patient Follow-up plan for recipients and donors plan for recipients Follow-up Medical audit system in place computerized donor and recipients Availability ofAvailability ethical committee imposed by the legislation on donors and ō ō ō ō ō ō ō ō prospective foreign recipients, claiming their inconsistency with Islamic principles. The peti- tion also requested that the clauses related to Section 3 of the legislation, addressing donation by close blood relative; Section 5, relating to the evaluation committee; and Section 7, bar- ring donations to foreign nationals, be declared un-Islamic and annulled. The Federal Shariat required Court, through 12 hearings where experts, reli- gious scholars, human rights activists and medi- cal professionals participated as amicus curiae, unanimously rejected the petition and affirmed facilities facilities (i.e. monitors, ventilators, arterial hospital beds beds for transplantation and isolation blood gas analysis, etc.) Suitable design of operating theatre, with Separate theatre for transplantationSeparate Hospital structure to be purpose-built Hospital structure ICU – minimum 4 beds with proper Hospital pharmacy with all necessary procedure desirable procedure power supply backup by generators with minimum of 3 dialysis machines Minimum 12 hospital beds with specified Communication system and continuous quality maintenance of and suitable wards essential medicines Availability ofAvailability dialysis facility in the ICU Infrastructures, equipment and facilitiesInfrastructures, that the ethical practice of organ transplantation ō ō ō ō ō ō ō ō is a noble act fully condoned by Islam, while the sale of human organs is not permissible. The court also upheld that the Transplantation of Human Organs and Tissues Ordinance 2007 does not contradict the principles of Islam. Notice of the Supreme Court of Pakistan On 23 June 2009, the Supreme Court of Pakistan expressed concern that the sale of human organs for transplantation was continuing, despite the ordinance. A member of the bench noted that Minimum basic criteria for the recognition of transplantation in Pakistan centres “It seems that provisions of the ordinance are pulmonology, cardiology and haematology cardiology pulmonology, staff, including staff for a fully functionalstaff, staff and medical social officer Gastroenterology, hepatology, hepatology, Gastroenterology, qualifications and experience consultants readily available round the available round consultants readily clock operating theatre facility, ICU and nursing operating theatre facility, 24-hour availability of medical and surgical Availability ofAvailability specialists with prescribed not adhered to strictly and despite prohibition Human resources ō ō ō ICU = intensive care unit. ICU = intensive care Table 2 Table of the sale of human organs in Pakistan, the S163 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF Table 3 Kidney transplantations performed from 5 September 2007 to 31 December 2009 by 28 of the 42 Human Organ Transplantation Authority (HOTA) authorized hospitals in Pakistan Hospitals with recorded transplantations Authorized hospitals Transplanted kidneys Public Private Total Live related Live Total unrelated Islamabad/Punjab 17 16 33 579 93 672 Islamabad Pakistan Institute of Medical Sciences 7 0 7 Shifa International Hospital 9 39 0 39 Islamic International Medical Complex 9 33 0 33 Rawalpindi Kidney Centre 9 45 32 77 Hearts International Hospital 9 23 5 Jinnah Memorial Hospital 9 73 0 73 Bilal Hospital 9 24 1 25 Armed Forces Institute of Urology 9 84 1 85 Lahore National Hospital 9 14 23 37 Sharif City Hospital 9 23 10 33 Ihsan Mumtaz Hospital 9 78 9 87 Sarwat Anvar Hospital 9 69 15 Mayo Hospital 9 48 3 51 Adil Hospital 9 35 1 36 Shaikh Zayed Hospital 99 29 0 29 Surgimed Hospital 9 11 0 11 SIMS Services Hospital 5 0 5 Allama Iqbal Medical college 9 0 9 Akram Medical Complex 9 40 4 Masood Hospital 9 20 2 Multan/Bahawalpur City Hospital Multan 9 21 3 Quaid-i-Azam Medical College 9 60 6 Sindha 4 4 8 1 033 1 1 036a Karachi Sindh Institute of Urology and 9 1 020 0 1 022a Transplantation (SIUT) Karachi National Hospital 8 1 9 The Kidney Centre, Karachi 2 0 2 Jinnah Post Graduate Medical Centre 3 0 3 Khyber–Pakhtunkhwa Centre for Kidney Diseases, Peshawar 1 1 12 0 12 Balochistan Gilani Hospital, Quetta 0 0 0 1b 01 Total 22 20 42 1 625 94 1 721a aTwo additional transplantations from deceased donors were performed at SIUT; bRecognition withdrawn. Source: HOTA, Pakistan. trade is going on allegedly in some As a result of this strong legal notice, Ratification of the bill by the hospitals”, the names of which were the owners of the private hospitals in National Assembly, the Senate mentioned in a letter sent by the question assured their full compliance and the President of Pakistan Transplantation Society of Pakistan. with the ordinance. On 13 November 2009, the National S164 PLÜØnUÐ{dCÐ HCÐçPUph[UÐpdCÐ ;nüÐØ{_UÐ Assembly took up the Transplantation between the Ministry of Health and the The success of this new law therefore of Human Organs and Tissues Bill im- Standing Committee for Health of the hinges on the collective efforts of the mediately on receipt of a supportive National Assembly, culminating in the Government and society to combat all report from its Standing Committee jointly mobilized technical and political possible violations of the law [18]. on Health. The house unanimously support that led to the promulgation of To attain self-sufficiency in organ adopted the bill, promptly signifying this law. transplantation, health professionals the importance that law-makers attach With the promulgation of the and their associations in Pakistan must to regulating organ transplantation in ordinance, opportunities for unre- adhere to the stated norms of the act Pakistan. Subsequently, on 10 February lated donations became limited to and perform transplantations from 2010, the Senate of Pakistan passed the exceptional cases envisaged by living donors with minimal physical the bill and on 17 March 2010, the the law, while buying and selling of and psychological risk [19]. This will President of Pakistan signed the bill to organs became illegal and punishable avert jeopardizing public trust and will make it a law. offences, resulting in a complete ban enhance the health system’s ability to of these practices, including organ operate effectively within the param- donations to foreigners unless accom- eters of the law, preserving the safety Discussion panied by related donors [15]. The and ethics of this practice [7,20]. The need to develop an effective deceased decision to donate should be made The evolution of organ transplantation donation programme to encompass in an environment that enables the and trade problems can only be truly the transplantation needs of the potential donor to decide independ- appreciated in relation to the prevail- population was clearly recognized ently, without coercion or duress [4]. ing socioeconomic environment of by the Government and professional Of the 42 HOTA-authorized hospi- any country [1,7,12]. In Pakistan, and medical organizations. Furthermore, tals, 28 have performed 1721 kidney elsewhere in developing countries, a measures to increase organ availabil- transplants following the legislation. tangible proportion of the population ity from deceased donors have been Prospective research studies should lives below the poverty line, predispos- strongly recommended. This could be be commissioned to evaluate the me- ing many underprivileged individuals substantiated by health professional dium- and long-term impact of the and families to coercive organ donation training, public advocacy and promo- legislation and to assess the extent to [13,14]. Major professional bodies, tion, mobilization of religious scholars which the number of kidney transplants including Sindh Institute of Urology and bestowing recognition to families performed responds to the anticipated and Transplantation, the Transplanta- of deceased donors [16]. load in organ donation in Pakistan. tion Society of Pakistan, the Pakistan In accordance with constitutional In the development of an organ Society of Neph rology and the Pakistan provisions, the Federal Shariat Court is transplantation structure in Pakistan, Association of Urological Surgeons, vested with the power and jurisdiction major areas require public education, supported by WHO, have been advo- to test the laws on the criteria of Shariat including the ethical and Islamic per- cating for legislation denouncing the with the assistance of religious scholars spectives related to live organ donation sale of kidneys for transplantation for [17]. With jurisdiction to determine in general and to cadaver donation in over 2 decades. Since 2004, WHO has laws on Islamic principles, the court particular [9]. Although this paper fo- provided extensive technical advisory declared that the transplantation bill was cuses on kidney transplantation, the support to the Ministry of Health on not contrary to the injunctions of Islam. legislation may be applied to other ethical regulation of organ transplanta- Implementation of the law con- forms of organ transplants from live tion and suggested the banning of organ stitutes an uphill task, not achievable and cadaver donors alike. It may hope- trafficking. The Ministry of Health and unless all stakeholders engaged in these fully encourage the transplantation of Sindh Institute of Urology and Trans- activities extend support. Until such other organs such as corneas and thus plantation pioneered the drafting of the time when deceased donations become rectify the current situation whereby law and took a catalytic role in speeding an operational reality, the Pakistan over 90% of corneas for transplants are up the technical processes for regulat- health system will face the challenge of imported. A better understanding is ing organ transplantation. This venture contesting the predicted temptation of also needed regarding “brain death”, was supported by numerous profes- organ trafficking, which poses serious legal heirs’ right of substitute decision- sional and civil organizations as well risk to the life of donors and recipients making in the absence of anticipated as the media, whose deliberations and alike as such illegal practices would will of the deceased, and the State’s advocacy generated sufficient voice for most likely be conducted in unaccept- role in the case of unclaimed dead action. These efforts forged an alliance able settings that would endanger life. bodies [9,14,21,22]. The transgressors S165 EMHJ r 7PM 4VQQMFNFOU &BTUFSO.FEJUFSSBOFBO)FBMUI+PVSOBM -B3FWVFEF4BOUÊEFMB.ÊEJUFSSBOÊFPSJFOUBMF involved in kidney trafficking may con- services, the Ministry of Health needs of Health should closely monitor sur- tinue appealing to the Supreme Court to establish a database, for both do- gical, medical and immunosuppressive Appellate Bench to revert the Shariat nors and recipients, supported by the protocols and establish a mandatory Court verdict, hence the need to in- centres providing these services. The 2-year follow-up of donors and recipi- culcate a high level of public education capacity of the health system to offer and build alliance with Islamic scholars dialysis to end-stage chronic renal ents to provide medical, emotional and and jurists. failure needs to be strengthened, to psychosocial support and also evaluate To evaluate the public health reduce patient morbidity and improve the outcome of these interventions contribution of organ transplantation quality of life. Moreover, the Ministry nationwide. References 1. Human organ transplantation in Europe: an overview. Luxem- Bulletin of the World Health Organization, 2007, 85(12):901– bourg, European Commission, Directorate-General Health 980. and Consumer Protection, Public Health and Risk Assessment 13. Rizvi AH et al. Regulated compensated donation in Pakistan Directorate, 2003. and Iran. Current Opinion in Organ Transplantation, 2009, 14 2. Hakim NS, Papalois VE. History of organ and cell transplantation. (2):124–128. 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