Missing the target

By Tahir Ali

The Prime Minister’s programme for the Prevention and Control of Hepatitis (PMPCH) has failed to stem the growing incidence of hepatitis in the country. Dr Asif Khan, a community health expert, says mismanagement, corruption, irregular and insufficient supply of drugs, lack of laboratories and supply of allegedly non-WHO certified Chinese interferon have affected the programme and endangered the lives of millions of people.

Besides the law and order situation in the militancy-hit areas of NWFP and Balochistan and opposition to the immunisation programme by religious groups, difficulty in registration and flawed supply system of interferon injections are hampering the process.

The Rs 2.6 billion PMPCH was launched in August 2005 with the aim of 50 percent reduction in Hepatitis prevalence by year 2010 by utilising the existing health infrastructure. The amount is peanuts considering the fact that about eight percent of Pakistan’s population is infected with the hepatitis. The executive director of Pharma Bureau, Riaz Husain, says the PMPCH needs to allocate dedicated people, quality sources, and generous funds. "Half-hearted and non-serious efforts would not bring us anywhere near the programme goals and targets," he argues.

The programme lags far behind the target. So far, according to the ministry of health website, only 22,779 hepatitis C and 2,931 hepatitis B patients have been treated under the programme. The number may be termed as a drop in the ocean, keeping in view the estimated around 12 to 15 million hepatitis cases in the country.

But the figures seem exaggerated from another perspective. A six month interferon therapy for a patient consumes around Rs36000-180 injections at Rs 200 per injection daily for six months successively. "Even if we avoid charging for other relevant expenditures from the programme fund, the Rs 2.6 billion total fund of the programme will suffice for only around 7500 cases of treatment for hepatitis C. The treatment of all the estimated 8 million hepatitis C patients requires a hefty amount of Rs 2800 billion on that basis, says Naufil Shahrukh, Coordinator of Health Communication Forum (HCF).

The prime minister had announced in August that in the next five years, the government aimed to treat 72,000 patients of hepatitis C, over 30,000 of hepatitis B and would administer over 8 million doses of hepatitis B vaccine. The treatment of 72000 hepatitis C patients, by that count, will warrant over Rs 30 billion.

There is another thing that is also worth considering for the high-ups. The PMPCH has been purchasing interferon brands that are to be taken daily for six months. Other alternatives available can be taken with intervals of two days, once a week or even more. The official mechanism is simply agonising for the patients undergoing such treatment. Not only its quality and efficacy is being questioned, experts say that it is also expensive than other available variants.

"Interferon being supplied through the programme incurs an expenditure of Rs 36,000 for six months of initial therapy. Another alternate interferon brand available in the open market has a price of Rs 400 and it is taken every second day. Its total doze of 72 injections requires around Rs 28,000. It may not be that effective but it is more economical and less painful than that of the PMPCH. "More qualitative but expensive interferons are there in the market as well," says a doctor who wants to remain anonymous.

Although millions of Pakistanis are infected with the hepatitis virus, there is no authentic data on the number of hepatitis patients in Pakistan. The percentage of affected population ranges from 5 to 7 percent and the total patients are estimated between 11 to 15 million in Pakistan. According to Health Foundation and WHO, one out of 10 and 12 Pakistanis respectively suffers from either hepatitis B or C.

The province wise data shows that Balochistan has 4.3 percent hepatitis B prevalence in Balochistan; Punjab has the highest hepatitis C prevalence rate of 6.7 percent followed by Sindh which is at 5.0 percent. The NWFP coordinator of the PMPCH Dr Mohammad Azam Khan says that the "estimated current prevalence of hepatitis B and hepatitis C in NWFP and FATA was about 2.5 and 5-7 percent of the population; Mardan, Dir, Bannu and Hangu being the most affected districts."

Executive District Officer Health, Dr Arshad, says that 10-11 percent of Mardan’s population or around 0.2 million hepatitis cases are estimated in the district, "The district has six thousand hepatitis C registered patients but the quantity of injections it receives from the PMPCH is insufficient. Mardan needs a special consignment of dozes." Another official discloses that only 500-600 injections were available in Mardan last year. According to official data, 3025 hepatitis C and 332 hepatitis B patients were reported in financial year 2006-07. In 2008, only 150 hepatitis C and 150 hepatitis B patients were provided full treatment under the programme.

Dr Said Badshah, a medical specialist, says cure against hepatitis B was possible but there was no preventive vaccine available for hepatitis C in the market. "The latter had to be treated by anti-viral therapy and interferon injections which are costly. The Polymerase Chain Reaction (PCR) test, a must for starting therapy of hepatitis patients, should be provided free of cost. The government should ensure free investigation of the people and treatment for the patients."

The programme should also allow another free treatment for the patients who are tested positive after the first therapy of six months. The monitoring and evaluation department of planning commission should identify problems and suggest corrective measures. There is an acute shortage of technical staff and laboratory facilities in the health centres across the country for doing hepatitis tests. According to studies, Pakistan is second in the world in the maximum use of unnecessary injections. Capacity building of the human resource and financial allocation is vital for the success of the programme. Dr Khan, for example, says his office does not have the internet facility.

The government has integrated hepatitis B vaccination programme into the national immunisation schedule. But most people are unaware of this development. It should organise awareness campaigns and take action against quacks and unregistered blood banks.