IMPROVING ACCESS TO HEPATITIS PREVENTION AND CARE IN SINDH PAKISTAN

 

Problem: 

PROBLEM: National Picture Pakistan is a country of 170 million people where Viral Hepatitis has emerged as a significant public health problem. Various small research studies suggested that Viral Hepatitis in Pakistan has been on rise. Although a monovalent Hepatitis B vaccine was introduced in the National Expanded Program on Immunization since 2001 but the coverage rate was sub optimal (57.3%). (National Institute of Population Studies (NIPS) [Pakistan], 2006). A systematic review of the available literature was undertaken by the defunct Ministry of Health in 2005. The mean results of HBsAg and Anti-HCV prevalence on the basis of data aggregated from abstracts of 203 published studies was calculated which shows 2.3% and 2.5% prevalence of HBsAg and Anti-HCV in children, 2.5% and 5.2% among pregnant women, 2.6% and 5.3% in general population, 3.5% and 3.1% in army recruits, 2.4% and 3.6% in blood donors, 6.0% and 5.4% in health care workers, 13.0% and 10.3% in high risk groups, 12.3% and 12.0% in patients with provisional diagnosis of hepatitis and 25.7% and 54% in patients with chronic liver disease respectively. In current situation of preventive and control activities, it is estimated that the prevalence is tripled after every decade (Altaf Bosan, 2010). Provincial Context Other empirical evidence suggested that disease spread in Sindh is high due to e.g. (a) highest rate of unsafe injection delivery in the region (Janjua NZ, 2005) (b) lowest level of knowledge amongst female population about 03 established modes of disease spread (NIPS Survey 2003)  Used Syringes 9.84%  Used Blades 1.09%  Through Blood 4.37% Implication of this data is that 90% of the female population in Sindh does not know Hepatitis is spread by used unsafe syringes in a situation where every person is receiving at least 13 injections in a year and 7 times it is unsterile. Due to this rampant spread of disease a huge number of chronic liver disease were present in the population. Only a fraction of these has access to hepatitis care services prior to the launching of program, as only few (9) specialized centers in the country were providing the treatment (interferon α) with no diagnostic services. A huge market failure existed for these patients as not all had the access to the social safety net (Pakistan Baitul Maal) providing drugs. Hepatitis B vaccine for adults could only be purchased by out of pocket expenditure.

 

Intervention: 

 INTERVENTION

These preliminary results of the review stated above initiated the launching of a “National Program for the Prevention and Control of Hepatitis” in August 2005. The program was approved at the highest forum of country to have following interventions / components for implementation;

Hepatitis B Vaccination for High Risk Groups

Safety of blood and blood products against hepatitis

Safety of injection delivery, invasive medical devises & proper hospital waste management

Capacity building of health care providers for the prevention and control of hepatitis

Behavior Change Communication

Surveillance and Diagnostic Lab services for Viral Hepatitis and Epidemic Response

Establishment of Water Purification Plants

Operational Research Including M&E

Treatment Interventions at teaching and district headquarter hospitals

Formation of Program Implementation Units at Federal and provincial level with aims of technical assistance at all tiers of health sector.

 

 

Consequent upon launching of the program at national level, a provincial implementation unit was set up in five months’ time.

The program’s design in field had an overall emphasis on;

Passive laboratory (sentinel) based surveillance system of chronic Hepatitis B and C.

 

Vaccination of Hepatitis B to high-risk groups

Treatment Interventions at teaching and district headquarter hospitals

Installation of autoclaves, water purification plants and hospital waste incinerators.

At district level the portal of entry was the District Headquarter Hospital (DHQ) declared as sentinel site having all the above facilities under one roof.

 

Phase 1 (2006)

Phase 2 (2007)

Phase 3 (2008)

 

Jinnah Postgraduate Medical Center Karachi

 

People’s Medical College Hospital Nawabshah

 

Chandka Medical College Hospital Larkano

 

Civil Hospital Jacobabad

 

Civil Hospital Badin

 

Civil Hospital Mithi

 

Civil Hospital Dadu

 

Civil Hospital Khairpur

 

 

Civil Hospital Sukkur

 

DHQ Hospital Mirpurkhas

 

DHQ Hospital Kotri

 

Civil Hospital Karachi

 

Civil Hospital Mirpur Mathelo

 

Civil Hospital Thatta

 

Civil Hospital Naushahroferoze

 

Civil Hospital Shikarpur

 

Civil Hospital Sanghar

 

District Headquarter Hospital Tando Allahyar

 

District Headquarter Hospital Umerkot

 

 

 

Abbasi Shaheed Hospital, Karachi

 

Saudabad Hospital, Karachi

 

 

New Karachi Hospital

 

 

Paretabad Hospital, Hyderabad

 

Shah Bhitai Hospital, Hyderabad

 

Qasimabad Hospital, , Hyderabad

 

District Headquarter Hospital Kamber,

 

District Headquarter Hospital Tando Mohammed Khan

 

 

DHQ Hospital Hala, Matiari

 

District Headquarter Hospital Kandhkot,

 

 

COMPONENT WISE PERFORMANCE OF PROGRAM IN SINDH

 

The component wise performance of the Program is as follows;

HEPATITIS B VACCINATION:

PM’s Program on Hepatitis envisaged the interruption of Hepatitis B virus transmission by enhanced vaccination in the high-risk groups. The high-risk groups identified in the project PC-1 are as under;

 

High-Risk Groups identified in the Program

Health Care Workers

Prison Inmates

Family Members of the Health Care Workers

Patients on long term renal dialysis

Thallasemics and Hemophiliacs

Hepatitis C patients negative for Hepatitis B

Intravenous Drug Users

Mentally Retarded Persons

Other high-risk people screened in the high-prevalent areas

 

  

COMPARATIVE STATEMENT OF HEPATITIS B VACCINATION IN SINDH

 

Hepatitis B Vaccine Coverage of Various High-Risk Groups from 2006-2008

District

Health Care Workers

Prison

Inmates

Hepatitis C Pts.

Hemophiliacs / Thallasemics /

Dialysis Pts.

Injection Drug

Users

Others

Total

Vaccinated

Vaccine Vials

Supplied

Larkana

1224

1281

684

0

0

7557

10746

32238

Nawabshah

537

208

500

118

0

1050

2413

7239

Shikarpur

150

758

300

56

0

1300

2564

7692

Jacobabad

222

460

200

0

0

533

1415

4245

Mirpurkhas

500

292

300

10

0

300

1402

4206

Umerkot

366

0

150

0

0

8750

9266

27798

Thatta

550

0

161

0

0

0

711

7500

Badin

110

315

250

237

0

2088

3000

9000

Kamber

1836

35

0

0

0

6119

7990

23970

Mithi

80

0

340

0

0

150

570

1710

Hyderabad

96

3439

0

251

0

291

4077

12231

Jamshoro

150

0

810

5

0

1140

2105

6315

Karachi

874

9218

650

1331

0

0

12073

36219

Sanghar

73

359

75

0

0

2050

2557

7671

N.feroze

0

0

110

0

0

1000

1110

3330

Khairpur

10

904

259

0

0

150

1323

5969

Ghotki

25

0

50

0

0

120

1110

3330

Sukkur

10

2542

250

250

0

100

1323

3969

Tando Allahyar

100

0

294

0

0

500

195

585

T.M.Khan

275

0

0

0

0

0

3152

9456

Dadu

91

512

350

0

0

1200

2153

6459

TOTAL

7279

20323

5733

2258

0

34398

69932

209796

  

VACCINATION OF PRIMARY SCHOOL GOING CHILDREN:

 

In addition to the numbers vaccinated above; some special initiatives were undertaken to vaccinate the primary school going children against Hepatitis B. The activity was implemented by the respective District Governments, vaccine and syringes were being provided by the Expanded Program on Immunization. Prime Minister’s Program for Prevention and Control of Hepatitis Sindh took a natural role of leading the initiative and coordinating the activity. The details of the drive are as under:

  Hepatitis B Vaccine Coverage of Primary School Going Children

District

Children Vaccinated

Remarks

Larkana

1,197130

The vaccination campaigns were conducted utilizing the operational support from district governments. Nawabshah was provided exclusive financing for the activity from SDSSP.

Kamber

98000

Mirpurkhas

1,27,000

Hyderabad

10000

Benazirabad (Nawabshah)

1,16,000

Thatta

92,000

Shikarpur

30000

 

HEPATITIS DELTA AT KAMBER AND LARKANA:

Due to the ongoing spread of Hepatitis Delta at district Kamber and Larkana, a special initiative of vaccinating the general population near to their doorsteps was launched. Ring Vaccination methodology was adopted and from September 2007 onwards in which the adult Hepatitis B Vaccine is made available at all EPI centers in the district and vaccine was administered to general population. The impact of initiative was never fully evaluated. However it is assumed that vaccination of large number of people may have slowed down the virus transmission if not interrupted it. 

 

 

DISTRIBUTION OF VACCINE IN FY 2009-2010

Sindh PIU received 2nd consignment of its share in vaccine in July 2009. It is still in process of being distributed and reports are being collected. The distribution details of the vaccine received during financial year 2009-2010 is as under:

 Distribution of Hepatitis B Vaccine in 2009-10

 

Health Institute

Hepatitis B Vaccine Supplied

Civil Hospital Jacobabad

9000 Vials

Chandka Medical College Hospital Larkano

1000 Vials

The Health Foundation Karachi

15,000 Vials

Executive District Officer (Health) Naushahroferoze

15,000 Vials

People’s Medical College Hospital Benazirabad

5,000 Vials

Fatimid Foundation Hyderabad

500 Vials

Dow University of Health Sciences, Karachi

7622 Vials

Services Hospital Hyderabad

500 Vials

Principal Public Health School Hyderabad

663 Vials

HC Charitable Hospital, Karachi

300 Vials

Taluka Hospital Mehar, Dadu

3300 Vials

Liaquat University of Medical and Health Sciences Jamshoro

500 Vials

Executive District Officer (Health) Matiari

15,000 Vials

Tahafuz-e-Sehat (NGO) Hyderabad

900 Vials

Sukkur Blood & Drug Donating Society, Sukkur

4500 Vials

Director General Population Welfare Department

50 Vials

Executive District Officer (Health) Dadu

50,000 Vials

Executive District Officer (Health) Sukkur

100,000 Vials

Executive District Officer (Health) Benazirabad

107500 Vials

PMRC Karachi

10,000 Vials

Principal Chandka Medical College Larkana

6,000 Vials

Executive District Officer (Health) Shikarpur

20,000 Vials

 

  SAFETY OF INJECTIONS AND MEDICAL DEVICES

The category wise targets and achievements are as follows:

 

Targets and Achievements in Safety of Injections and Medical Devices

 

Category

Targets

Recipient Hospital

DHQ Hospital

Achievements

Safe Injection

Delivery

Provision of needle cutters and injections to sentinel sites as per demand

 

All sentinel sites in Sindh

40 needle cutters and 200000 syringes distributed to sentinel sites.

 

 

Autoclaves

08 sentinel sites to be equipped with autoclaves

Badin, Dadu, Tharparker, PMC Nawabshah, Khairpur, GMCH Sukkur, THQH Kotri, Tando Allahyar

08 are installed and functional

 

 

During project life Sindh PIU provided 2.0 Million Auto Disable Syringes to various hospitals for non-immunization use. These were distributed to various sentinel sites as per following demand

 

Table 17: Supply details of Auto-Disable Syringes to various institutes in province

 

Name of Institute

Syringes Provided

Civil Hospital Karachi

66,400

Executive District Officer (Health) Benazirabad

150,000

Executive District Officer (Health) Umerkot

100,000

Executive District Officer (Health) Naushahroferoze

150,000

Sindh Government Hospital Shah Bhitai Hyderabad

75,000

Sindh Government Hospital Kohsar Hyderabad

50,000

Sindh Government Hospital Qasimabad

25,000

Sindh Government Hospital Saudabad Karachi

50,000

Pakistan Medical & Research Council Karachi

50,000

District Headquarter Hospital T.M. Khan

50,000

Civil Hospital Thatta

75000

RBUT Civil Hospital Shikarpur

75000

Taluka Hospital Kotri District Jamshoro

75000

Executive District Officer (Health) Matiari

7500

Executive District Officer (Health) Jacobabad

100,000

Executive District Officer (Health) Shikarpur

50,000

 

 HOSPITAL WASTE MANAGEMENT SYSTEM

This component may be called as the Achilles’ heel of the program. The program envisaged installing a 50 Liters / hour capacity, double burner incinerator with scrubber. The technical specifications of the equipment are given as annexure. The equipment was planned to be installed all District Headquarter Hospitals and those teaching hospitals, where there is no incinerator. These centers were to be linked with clusters of geographically surrounding health facilities where infectious hospital waste is generated. The hospital waste vehicles would transport the waste from clustering hospitals to the main site of burning. To aid in the incineration consumable items like (1) Long Rubber Boots (2) Yellow Polythene Bags (3) Wheel Barrows (4) Three Colored Baskets were supplied. Government of Sindh nominated (08) hospitals as recipients of system at the outset. The details are as under;

 Status of Incinerators and supplies made to hospitals

District Headquarter Hospital

IncineratorStatus

Yellow

Bags

Color

Baskets

800 CC vehicle

Remarks

Badin

Functional

1000

90

1

Reasons for non-functioning are:

(1) General Hospital Renovation at Khairpur          

(2) Public objection at Sukkur &

(3) Non-availability of Natural gas @ Tharparker

Dadu

Functional

1000

90

1

Sanghar

Functional

1000

90

1

Tando Allahyar

Functional

1000

90

1

Khuda Ki Basti, Jamshoro

Functional

1000

90

1

Khairpur

Not Functional

1000

90

1

GMMC Hospital Sukkur

1000

90

1

Tharparker at Mithi

1000

90

00

ESTABLISHMENT OF WATER PURIFICATION PLANT

09 water purification plants are established at the DHQ level hospitals as under:

 

                                    Table 19: List of Hospitals where plants are installed

Civil Hospital Jacobabad

Civil Hospital Dadu

Civil Hospital Khairpur

Civil Hospital Naushahroferoze

Civil Hospital Badin

PMC Hospital Benazirabad

GMC Hospital Sukkur

THQ Hospital Kotri, Jamshoro

Civil Hospital Tharparker at Mithi

 

 

ADVOCACY AND SOCIAL MOBILIZATION

Advocacy and social mobilization was a neglected component in the project life, it would have been the otherwise. The lacunas were addressed as a stronger provincial  project in 2009.

 

Capacity Building of Health Care Providers:

The training guidelines of the program were finalized in January 2009. A training of provincial master trainers was conducted at Islamabad where 10 master trainers from the province were trained. The first formal training of the health care providers in Sindh province was undertaken in May 2009 by the Chief Minister’s Initiative for Hepatitis Free Sindh. In October 2009 World Health Organization supported the training of 60 Medical Officers and Senior Medical Officers from 10 districts of North Sindh at Sukkur. 

SURVEILLANCE AND LABORATORY DIAGNOSTIC SERVICES:

By supplying the laboratory equipments for Viral Hepatitis diagnostics, program has not only enhanced the district headquarter hospitals’ capacity but also upgraded these facilities for the registration with Sindh Blood Transfusion Authority. One of the major impediments in the registration was availability of ELISA Micro plate Reader. A standard set of equipments provided by the program in this component is given in table below;

 

                 Table 21: Standard Set of equipments supplied to sentinel sites in Sindh

Micro plate Reader and Washer

Pipette Adjustable Volume (5 sizes)

Chemistry Analyzer & Vortex Mixer

Pipette Multi-Channel (2 sizes)

Laboratory Centrifuge & Incubator Shaker

Yellow Tips , Blue Tips & Torpedoes

Water bath

Incubator and Hot Air Oven

Laboratory Refrigerator

Blood Collection Tubes ,Gloves & Beakers

P-IV Computers and dot-matrix printers

Pipette AID, Pipette Stand, Disposable Pasteur Pipette

 

 

Distribution Details of Hepatitis ELISA Kits in 2008-2009

Name of Recipient Institute

Distributed

EDO(Health) Kamber

10

Civil Hospital Karachi

65

Civil Hospital Dadu

15

Civil Hospital Thatta

10

Civil Hospital Tando Allahyar

10

Taluka Hospital Kotri

20

Civil Hospital Mirpurkhas

10

Civil Hospital Mithi

15

Civil Hospital Sanghar

10

DHQH Tando Mohd. Khan

10

DHQ Hospital Umerkot

10

SGH Shah Bhitai Hyderabad

05

SGH Qasimabad Hyderabad

07

SGH Saudabad Karachi

15

Abbasi Shaheed Hospital

10

SGH New Karachi

08

Liaquat University Hospital

05

Name of Recipient Institute

Distributed

Civil Hospital Sukkur

40

Civil Hospital Khairpur

35

Civil Hospital Naushahroferoze

15

Civil Hospital Mirpur Mathelo

10

RBUT Hospital Shikarpur

30

CMC Hospital Larkano

20

DHQ Hospital Kamber

10

Civil Hospital Jacobabad

35

DHQ Hospital Kandhkot

10

PMCH Benazirabad

20

EDO(H) Shikarpur

30

SGH Paretabad Hyderabad

08

EDO (H) Karachi

35

EDO (H) Thatta

20

Lyari General Hospital Karachi

10

SGH Qatar Hospital

05

Taluka Hospital Hala

35

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  A summary of screening statistics from September 2006 to June 2007 are as follows;

S.No

Sentinel Site

Screening Done

Results

Hepatitis B reactive

Hepatitis C Reactive

Health Care Workers

General Population

High Risk Groups

Total

Health Care Workers

General Population

High Risk Groups

Total

Health Care Workers

General Population

High Risk Groups

Total

1

JPMC Kcy

1641

1227

0

2868

26

48

0

74

32

59

0

91

2

CMCH LRK

1562

4466

450

6478

81

801

47

929

45

1327

45

1417

3

PMCH NWB

587

992

0

1579

39

228

0

267

33

396

0

429

4

GMCH Sukkur

344

2116

0

2460

20

528

0

548

35

653

0

688

5

CH Badin

1763

1635

389

3787

138

260

85

483

89

136

17

242

6

CH MPK

1432

2976

1364

5772

105

393

170

668

102

1358

335

1795

Outreach camps

2642

0

2642

0

268

0

268

0

483

0

483

7

CH Mithi

278

669

48

995

18

185

12

215

20

114

1

135

8

CH Dadu

713

1692

11

2416

100

389

0

489

77

659

1

737

9

CH KHP

815

2733

719

4267

105

745

12

862

95

674

131

900

10

Tando Allahyar

180

6

0

186

16

2

0

18

12

1

0

13

11

CHK

1051

871

0

1922

18

21

0

39

30

93

0

123

12

CH JCD

222

3898

25

4145

5

507

25

537

22

829

34

885

13

THQ Kotri

657

2430

0

3087

157

481

0

638

70

917

0

987

14

Umerkot

425

3084

37

3546

11

99

1

111

4

202

1

207

Outreach camp

1467

0

1467

0

61

0

61

0

164

0

164

15

Shikarpur

102

560

248

910

2

168

32

202

7

283

99

389

16

Sanghar

25

2132

0

2157

10

569

0

579

40

1338

0

1378

GRAND TOTAL

11670

35596

3291

50557

851

5753

384

6409

713

9686

664

11063

 

Dual Infection                                       

454

                 

 

Screening of Prison Inmates

During the project life Supreme Court of Pakistan ordered for the screening of prison inmates and providing treatment to patients. Almost 8000 prison inmates were screened, which to date remains the largest Hepatitis C seroprevalence survey amongst the prison inmates population. The results subsequently were published in an indexed journal in 2010. Copy of the paper is attached.

 

PCR Test

The program when designed at the Federal level could not envisage the provisions of PCR test. Contracting methodology was adopted for the services. The research and teaching institutes were having the PCR machines which were not used for the general public. The project engaged the academia in a manner where PCR services were opened for the general public on a no profit no loss basis and it was outsourced. At that time this mechanism was an innovation hitherto unheard of in Health Department. Before that all the patients were bearing the expenditure out of pocket.

 

TREATMENT FACILITIES AT DISTRICT AND TEACHING HOSPITALS:

Program envisaged provision of treatment to deserving and poor patients, however this component over shadowed all other interventions. The latent demand for Hepatitis C and B in the community became evident after the initial supply of Injection Interferon in June 2006. The demand supply mismatch was enormous. The treatment component of the program was actualized through the Viral Hepatitis Control Committees notified at each hospital.

 

Table 26: Distribution Details of Treatment during 2006-2007

S. No

Name of Sentinel Site

Injection Interferon

Capsule Ribavirin

Tablet Lamividine

1

C.M.C Hospital Larkana

46686

349920

20075

2

Civil Hospital Sukkur

16632

124740

20075

3

PMC Hospital Benazirabad

23400

175500

18250

4

J.P.M.C Karachi

3600

27000

0

5

Civil Hospital Jacobabad

23760

178200

3980

6

Civil Hospital Shikarpur

3600

27000

7300

7

Civil Hospital Dadu

19872

149040

10950

8

Civil Hospital Mirpur Mathelo

3600

27000

0

9

Civil Hospital Khairpur

18648

139860

29050

10

Civil Hospital Naushahroferoze

3600

27000

5420

11

Civil Hospital Sanghar

3600

27000

5400

12

Civil Hospital Mirpurkhas

19800

148500

10220

13

Taluka Hospital Kotri, District Jamshoro

30600

229500

14600

14

Civil Hospital Thatta

3600

27000

3650

15

Civil Hospital Badin

13320

99900

5425

16

Civil Hospital Mithi

15528

116100

1795

17

Civil Hospital Tando Allahyar

17424

115020

1825

18

S.G.H Qasimabad Hyderabad

0

0

1095

19

District Headquarter Hospital Umerkot

3600

27000

0

 

 

Distribution Details of Treatment during 2008-2009

S. No

Name of Sentinel Site / Recipient

Injection Interferon

Ribavirin

1

Civil Hospital Sanghar

1440

10800

2

SGH Qasimabad Hyderabad

1800

13500

3

Civil Hospital Badin

1440

10800

4

Civil Hospital Thatta

1440

10800

5

Civil Hospital Naushahroferoze

2520

18900

6

GMC Hospital Sukkur

1440

10800

7

Civil Hospital Jacobabad

1080

8100

8

Balochistan PIU

1440

10800

9

SGH Paretabad Hyderabad

528

3942

 

 

Distribution Details of Treatment during 2009-2010

S. No

Name of Sentinel Site / Recipient

Injection Interferon

Ribavirin

1

PMCH Shaheed Benazirabad

21800

163500

2

Executive District Officer (Health) Kamber

20000

150000

3

Chandka Medical College Hospital Larkana

8136

61020

4

Civil Surgeon Civil Hospital Naushahroferoze

10800

81000

5

Medical Superintendent RBUT Shikarpur

6656

49920

6

Civil Surgeon Civil Hospital Mir Mathelo

10800

81000

7

Medical Superintendent Shah Bhitai Hospital Hyderabad

10800

81000

8

Executive District Officer (Health) Matiari

7200

54000

9

Medical Superintendent DHQH Tando Mohammed Khan

7200

54000

10

Sindh Government Hospital Paretabad

5040

37800

11

Medical Superintendent Khairpur

14400

108000

12

Civil Hospital Tando Allahyar

1440

10800

13

Sindh Government Hospital Qasimabad Hyderabad

1440

10800

 

For Hepatitis C the End Treatment response was a major indicator and for Hepatitis B sero-negative state was taken as an indicator. End Treatment Response rate is as follows:

 

                                End Treatment Response for the year 2006-2008

Sentinel Site

End Treatment Response

Virus

Not Detected

Virus

Detected

Civil Hospital Jacobabad

100

31

Civil Hospital Mirpurkhas

175

25

RBUT Hospital Shikarpur

47

3

Civil Hospital Tando Allahyar

13

16

Civil Hospital Mirpur Mathelo

45

5

Civil Hospital Sanghar

26

Nil

Civil Hospital Thatta

27

25

Civil Hospital Dadu

79

9

GMC Hospital Sukkur

101

19

Civil Hospital Badin

102

26

DHQ Hospital Umerkot

24

6

NMC Hospital Nawabshah

97

12

Civil Hospital Khairpur Mir’s

176

04

Taluka Hospital Kotri

226

31

Civil Hospital Mithi

NA

10

 

 

DESIGNING THE PROVINCIAL AND DISTRICT INITIATIVES FOR HEPATITIS IN SINDH:

The PC-1 of the Prime Minister’s Program for Prevention and Control of Hepatitis alluded to a separate Provincial Hepatitis Programs from the 3rd year of the program implementation. Sindh took the lead in designing the provincial version of the National Hepatitis Program. It is pertinent to mention the factors affecting the design and launch of a provincial hepatitis program before any other province in country.

 

Political Will

The project was successful in generating a goodwill among the decision makers due to its performance from 2006-2009. Hence a public funded scheme was prepared and financed upto a scale which had no precedence in the province.

 

Demand and Supply Mismatch:

As described earlier a huge demand for hepatitis C treatment was lying latent in the community which surfaced itself after the launch of program. It was not possible for the program to cater to even 50% of the needs, e.g. in 2007, on an average more than 500 patients were booked for treatment at every one of 19 sentinel sites at some sites like Larkana and Karachi the figure rose up to thousands. This phenomenon put the Sindh PIU, Federal PIU and Government of Sindh in an obligation to deliver the public from this problem. Moreover Honorable High Court of Sindh gave a decision to screen all prisoners and provide treatment to the diseased. In this connection Provincial Coordinator appeared in the High Court of Sindh for 03 times along with Director General Health Services Sindh. The public discomfort was also voiced from time to time by the elected representatives in the National Assembly and Senate of Pakistan adding onto the pressure on Sindh PIU and Government of Sindh. All these factors demanded an innovative approach to the program.

 

Financing from District Government

Sindh floated the idea of district project of the Hepatitis Program and actively lobbied and pursued the idea with all District Nazims (Governors) from July 2007 onwards. Prototype letters describing the inputs of Prime Minister’s Program for Prevention and Control of Hepatitis in the district was sent to all Nazims. The effort was carried on for 02 years and by the end of 2nd year 20 out of 23 districts had allocated a cumulative sum of 350 million Rs in program interventions. Districts like Dadu / Umerkot / Jacobabad were supported in developing their independent PC-1s. The allocations were mainly utilized for purchase of injection interferon while some of the districts also managed the diagnostic services mainly the ICT Kits and PCR.  

 In table below the financial allocations from the various District Governments in year 2007-2008 are given;

 

 Details of financial allocations from the District Governments

S. No

District Government

Financial allocation in FY 2007-08

Finances allocation in FY 2008-09

Remarks

1.

Hyderabad

7.5 Million Rs

15 Million Rs

Grant in aid from District Nazim

2.

Dadu

10 Million Rs

20 Million Rs

A separate PC-1 is prepared

3.

Jamshoro

25 Million Rs

40 Million Rs.

Grant in aid from District Nazim

4.

Tharparker

A PC-1 of 10 Million was approved and 50% are released each year

5.

Umerkot

4.0 Million

0

 

6.

Mirpurkhas

20 Million

20 Million Rs

Grant in aid from District Nazim

7.

Tando Allahyar

6.4 Million Rs

20 Million Rs

Grant in aid from District Nazim

8.

Sukkur

0

10 Million

Grant in aid from District Nazim

9.

Shikarpur

2.5 Million Rs.

2.5 Million Rs.

Another 60 Million is demanded

10.

Kamber

0.5 Million Rs

25 Million Rs

Grant in aid from District Nazim

11.

Jacobabad

2.2 Million Rs

3.0 Million Rs

Grant in aid from District Nazim

12.

Naushahroferoze

2.26 Million Rs

10 Million Rs

A PC-1 is in making

S. No

District Government

Financial allocation in FY 2007-08

Finances allocation in FY 2008-09

Remarks

13.

Khairpur Mir’s

0

16 Million Rs

Financed by a CCB

14.

Matiari

0

5 Million Rs

Grant in aid from District Nazim

15.

Kashmore

0

5 Million Rs.

Grant in aid from District Nazim

16.

Larkano

1.7 Million Rs

12 Million Rs

Special Grant from Finance Department

17.

Nawabshah

2.0 Million Rs

10 Million

Special Grant from Finance Department

18.

Thatta

1.87 Million Rs

0

 

19.

Badin

0

7.0 Million Rs

Source of funding is SDSSP.

20.

Sanghar

0

2 Million Rs

Savings from SDSSP.

 

TOTAL

95.93 Million

227.5 Million

 

 

 

The initiative from these district governments created a sense of relief to patient population in these districts. The benefit incidence analysis of the effort has yet to be determined. However the provincial level institutes were lacking in this initiative which had to be dealt by a provincial scheme.

 

Provincial Hepatitis Control Program

In 2007 a small scheme of complimentary support to the Prime Minister’s Program for Prevention and Control of Hepatitis in Sindh was sent to Planning and Development Department at the cost of 5.0 Million Rupees. In a follow-up meeting it was decided by the P&D department that a complete and holistic scheme would be launched. Responsibility for developing a PC-1 was entrusted upon Sindh PIU. 

 

The idea of holistic scheme took shape because of following reasons;

 

1.      

High Court of Sindh was constantly pushing the health department for screening and providing treatment to diseased prisoners at all prisons. Responding to the decisions an amount of 150 million was allocated for the purpose in May 2008. The sum could not be utilized due to delayed release.

 

2.      

An obligation on part of provincial tier of government to allocate finances when compared with the fact that federal and district governments had allocated resources towards hepatitis.

 

3.      

Multiple organizations and districts were approaching Finance and Planning & Development Department with proposals for allocation towards Hepatitis. Government amalgamated all proposals under one ambit of provincial hepatitis control program.

 

From March 2008 to July 2008 Provincial PIU Sindh leading a core team of Hepatologists, Pathologists, Public Health Specialists and Planning & Development Department team, a PC-1 worth 2.35 Billion was prepared and it was approved in August 2008 for three years. The scheme was coined as “Chief Minister’s Initiative for Hepatitis Free Sindh”. In essence the project is an up scaled version and replica of interventions of Prime Minister’s Program on Hepatitis. The objectives are:

Preventing the acute infections

Addressing the chronic infections

 

Raising the public awareness

 

Changing the policy environment

 

Health System Strengthening

Under every objective a set of sub-objectives and activities are developed. The project has a detailed and elaborate logical framework for monitoring and evaluation. A copy of the project in winzip form is attached.

 

Results: 

The program was started in 2005 as a Federal initiative and it was evaluated by WHO and Pakistan Medical Research Council in 2009. It was observed that program reached out to the population groups it intended and as it was output oriented project a list of activities was matched with one intended.

There were some problem noted in the selection criteria of patients where a small fraction were selected against the medical criteria, which has more to do with patients' political influence rather than systes weakness.

 

Lessons: 

The project design and interventions makes it a unique project in the developing country setting which has not only provided increased access to services for a neglected yet substantial set of patients. The federal arm of the project was substantially augmented by the provincial government and its scope was increased many times.

The main lessons of the project was only a system wide approach is successful in implementing National Programs and all the collaborating partners if properly approached can turn a project into success.

However more important was the involvement of governments in markets. Before the launch of project Inj Interferon was being sold at exorbitant price and due to government intervention the price reduced 70%. 

Sero positivity of Hepatitis C in the prison inmates of Pakistan

Countries: 
Report Author(s): 
Z.A.Gorar, A.Beg, Z. Baloch, R.Kumar
Organization(s): 
Health Services Academy Islamabad
ASSIST publication: 
no
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