by Dr Muhammad Abid

Report on “Public Health Systems in the Punjab and
Pakistan” by Dr Muhammad Abid
December 2015
Approved by:
Professor Mahmood Shaukat,
Principal, Allama Iqbal Medical College, Lahore
Acknowledgment:
It was a great privilege to contribute to the President’s Programme for Care of Highly
Qualified Overseas Pakistanis. I am especially thankful to Prof Mahmood Shaukat,
Principal, Allama Iqbal Medical College Lahore who is a very dedicated, visionary and
committed to improving healthcare and health education. He is dedicated to improving
the quality of the care provided by the medical institutions like Allama Iqbal Medical
College and without his commitment; this project may not have been possible.
I am also thankful to the experts and professionals from the institutions in Pakistan who
have made valuable contributions in preparing this report.
Most of the views, observations, and recommendations are based on my personal
discussions with relevant experts in key healthcare institutions and hopefully the
relevant authorities will implement these recommendations within their available
resources.
Dr Muhammad Abid
Consultant in Communicable Diseases
Public Health England
Chilton
Oxfordshire, UK
2
Contents:
Introduction……………………......................................................................................4
Background......………………......................................................................................5
Disease Surveillance in Punjab…………………………………………………………….6
Curriculum and Public Health Workforce Development………………………………….9
Royal College of Pathologists and Pathologists Association of Pakistan Conference.12
Ebuddi……………………………………………………………..…………………………14
APPNA Hepatitis C Awareness Initiative…………………………………………………14
APPNA Chest Initiative………………………………………………..……………………16
Health Education in Secondary Schools………………………………….………………17
Khawaja-Saraas Rehabilitation Project…………………………………………………...18
Recommendations…………………………………………………………………………..19
Appendix 1- List of institutions visited/consulted…………………………………………21
Appendix 2 - List of experts who were consulted………………………………………..22
Introduction:
Allama Iqbal Medical College, Lahore is actively involved in participating public health
awareness and prevention programmes for the diseases prevailing in the community. It
was agreed that Dr Muhammad Abid who is a known expert in Public Health in the UK
will visit the Allama Iqbal Medical College (AIMC) during 2015 and assist in improving
the public health practice and programmes, including:




Establishing surveillance and screening programmes for communicable and
chronic health diseases
Developing effective teaching and structured training plan for the Department of
Community Medicine
Assessing total quality control and improvement initiatives
Developing effective monitoring and sustainable evaluation strategies
To deliver the above objectives, the following areas were identified and agreed with the
AIMC:
•
•
•
•
•
Assess the existing system of surveillance of infectious diseases in Punjab
province in order to elicit any ways it could be improved further.
Assess the current capacity and workforce development in public health and
recommend improvements in these areas. This activity will include: an
assessment of curriculum for community medicine at graduate and post-graduate
levels; one to one meetings with relevant expertise and professionals (list of
institutions visited and different experts visited and consulted are described in
Appendix 1 and Appendix 2 respectively.)
Participation and contribution at the Joint conference of the Royal College of
Pathologists and Pathologists Association of Pakistan, including a paper
presentation on Mycobacterium bovis infection in humans and its transmission
from other animals, and chairing of scientific sessions on both Molecular
Pathology and Tuberculosis workshops.
Assess if an Ebuddi (on-line programme available on smartphones for infection
control training for healthcare workers) can be piloted in the Allama Iqbal Medical
College and Rawalpindi Medical College. This tool has a potential to be used for
infection control training of healthcare workers.
Assess other public health projects such as APPNA Hepatitis C Awareness
Initiative, APPNA Chest Initiative, Health Education in Secondary School pilot
and Khawaja-Saraas Rehabilitation Project.
4
Background:
Pakistan is a country in South Asia and is the sixth-most populous country with a
population exceeding 199 million people and comprises four provinces (Punjab, KhyberPakhtunkhwa, Sindh, and Baluchistan) and four territories, Figure 1. Punjab is the most
populous of the four provinces of Pakistan. It has an area of 205,344 square kilometres
(79,284 square miles) and a population of 91.379.615 in 2011, approximately 56% of
the country's total population. Its provincial capital and largest city is Lahore.
Figure 1;
Pakistan's healthcare system has both public and private options, Figure 2. There are
government-run hospitals which are low-cost and offer basic medical treatment, and
expensive private medical facilities. Healthcare is administered mainly in the private
sector which accounts for approximately 80% of all outpatient visits. 78% of the
population pay out of pocket at the point of health care. The public sector was led by
the Ministry of Health, however the Ministry was abolished in June 2011 and all health
responsibilities (mainly planning and fund allocation) were devolved to provincial Health
Departments. The federal government has constitutional responsibility of health
information, interprovincial coordination, global health, and health regulation. All other
health responsibilities are a provincial mandate.
Four provincial Health Department delivers preventive healthcare, as well as curative
care health care services from the primary health care level to the tertiary care level.
5
Figure 2;
Many diseases in Pakistan could have been controlled, if it were not for economical and
administrative problems. Some diseases in this category are gastroenteritis, cholera,
measles, viral hepatitis, dengue fever and polio. Pakistan is one of the two remaining
countries in the world where poliomyelitis (polio) is still categorised as an endemic viral
infection, the other being Afghanistan.
There is no single national coordination public health body which deals with surveillance
and response of communicable diseases.
Disease Surveillance in Punjab:
The Punjab province population totals more than 90 million, with 70% of its population
resident in rural areas. To provide healthcare, there are over 150 hospitals, 290 Basic
Health Units and 2450 Rural Health Units. Effective surveillance is the key to effective
disease control. Any epidemiological surveillance that is carried out through an
appropriate and mandatory reporting system not only prevents a problem but also
improves the control of outbreaks and epidemics. WHO Disease Early Warning System
Diseases recommends that cases with plague, dengue, polio, cholera should be notified
to Local Authority within 24 hours and there should be weekly reporting of cases of
measles, meningitis, malaria, viral hepatitis, diphtheria, pertussis, tetanus, typhoid and
influenza. These standards are currently not met within Punjab.
The private sector is the major service provider of both primary and secondary
healthcare services and generally they work independently without any collaboration or
6
coordination with the Punjab Health Department, which provides an obvious barrier to
an effective coordinated public health surveillance and response.
Doctors who are independent service providers see majority of cases of communicable
diseases in primary care and the majority do not take part in this reporting system for
many reasons such as lack of knowledge, confidentiality, lack of time, unavailable
means (such as IT support) or cumbersome reporting procedure.
Similarly, there are many independent laboratories, which process these samples but
do not report the results to Punjab Health Department or Institute of Public Health,
Lahore (IPH). This reporting is more likely happen with Dengue rather any other
disease.
Laboratories from backbone of health systems, providing health care workers with
critical test results for numerous deadly diseases, yet in Pakistan with the few
exceptions, laboratories are among the most ill equipped, poorly resourced and using
unstandardised kits. Generally, these laboratories are not part of any accreditation
scheme (for quality and competence) such as Pakistan National Accreditation Council.
There have been scanty and patchy disease surveillance and response systems until a
few years ago in the Punjab. In recent years in Pakistan, especially in Punjab and
particularly in Lahore, there has been a rise in vector-borne diseases. In 2011, Lahore
witnessed the biggest epidemic of Dengue Fever in the world. Alongside the Dengue
epidemic, floods often hit the area, which result in spreading of water borne diseases
such as typhoid fever, cholera, leptospirosis and Hepatitis A. Non-availability of
organised historical data in manner represented a challenge for early detection of any
future outbreaks, thereby limiting the capability of government for early preparedness
and emergency response. In 2012, the “Dengue Activity Tracking System” was
developed by the Punjab Health Department, Information Technology Board and IPH
with the purpose to log in real time all field activities related to the prevention and
eradication of Dengue. Public funded Teaching Hospitals, Tehsil Headquarters (THQs)
and District Headquarters (DHQs) were all equipped with dedicated data entry
operators, who were responsible to report cases in line with predefined templates. Each
data entry operator was equipped with a computer and an internet dongle (or another
means of internet connectivity). This surveillance was extended to the Basic Health
Units and Rural Health Units across Punjab to report disease cases via SMS. This
surveillance has been extended to other diseases including diarrhoea, acute respiratory
infections, pyrexia of unknown origin, scabies, dog/snake bite, malaria, TB, typhoid
fever, hepatitis, acute flaccid paralysis, leishmaniasis, diphtheria, HIV/AIDS, meningitis,
tetanus, pertussis, sexually transmitted diseases and viral haemorrhagic fever. These
infections are then reported in the Weekly Epidemiology Report, Figure 3.
7
There are many other healthcare programs in Punjab that run independently, with
variable quality of surveillance data in these programs. These include:
 TB control program
 Rollback – Malaria Program
 Punjab AIDS Control Program
 Prevention and Control of Hepatitis
 Extended Program on Immunisation (EPI) for children under 2 years and
pregnant women
The surveillance system in Punjab is incomplete and underestimates the true incidence.
During the 2009 Swine Flu epidemic, the numbers of cases reported in Pakistan were
far less than those reported from neighbouring countries including Afghanistan and
India. This is in part due to the underreporting by the doctors and limited capability and
capacity of the IPH which relies on an underdeveloped reporting infrastructure from both
public and private laboratories to the IPH.
Data Quality Assurance processes are non-existent which makes the data unreliable.
Quality of data available is also questionable as there are no mechanisms followed to
control its accuracy, consistency, completeness, precision and missing or unknown
information.
Although there have been some improvements recently, much work needs to be done
to strengthen both surveillance and response infrastructure to control outbreaks of
diseases.
Figure 3;
8
Undergraduate and Postgraduate Curriculum and Public
Health Workforce Development:
Faculty of Public Health in the UK launched its Global Health Strategy in June 2015 one of its goals is to support high standards of public health training, examination and
regulation globally. The Faculty has established Special Interest Groups (SIG) for each
country usually comprising of either Faculty members with a link to that particular
country or who are interested in working with the country. I am one of the members of
SIG for Pakistan and one of the tasks of my visit was to assess the curricula for
undergraduate and postgraduate training courses with the view to strengthen the public
health workforce development. After meeting the relevant expert in the Medical
Colleges/Universities, Health Services Academy, Institute of Public Health and College
of Physicians and Surgeons my observations are:
•
Community Medicine has gained recognition in Pakistan over last few years but its
reflection cannot be seen on the general population in terms of true public health.
Fellows of the College of Physicians and Surgeons and postgraduates with MCPS, and
MPhil qualifications tend to work in the academic departments, generally affiliated with
either medical college or Universities. Doctors with DPH, MPH qualifications generally
are employed into the management of hospitals, healthcare programmes or NGOs.
Lack of technical expertise and considerable amount of skilled personnel, shortage of
epidemiologists and other trained public health experts are major constraints in public
health programmes. There is very limited public health workforce to control and manage
outbreaks of communicable diseases. It is still considered an unrewarding profession,
certainly in terms of financial remuneration. Pakistan is far behind the health targets set
by the World Health Organisation for achieving health for all. There is no leadership in
the profession and public health programmes do not earn significant political
commitment.
•
The Pakistan Medical & Dental Council (PMDC) is a statutory body and is
controlled by its Council. One of its functions is to set down the minimum standard of
basic and higher qualifications in Medicine and Dentistry and prescribes a uniform
minimum standard of courses of training for obtaining these qualifications, including
examination standards. The National Curriculum Revision Committee prepares the
curriculum for each subject. PMDC recommends a system-based approach rather
subject based and most medical colleges are using the modular system based
approach. The objectives of the course in Community Medicine (Public Heath) are to be
achieved by the end of year 4th medical training. Students should have practical
experience in questionnaire development, data collection, compilation, presentation,
analysis and report writing. A number of visits to field sites with public health relevance
are required to be visited. The assessment includes theory papers (Multiple Choice
9
Questions and Short Essay Questions), internal evaluation and a practical assessment
(Objective Structured Practical Examination) in the year 4 examination.
•
The curriculum for Community Medicine (Public Health) is adopted by each
medical college/university for its implementation at local level. The delivery of this
curriculum is very much dependent on the availability, capacity and capability of the
teaching staff. There seems to be huge variation in staffing levels in the medical
colleges especially between public and private institutions.
•
Institute of Public Health, Lahore (IPH) runs master programme for medical
graduates in Community Medicine (MPhil – 2 years course); Master in Health
Management (MHM – 1 year course) and Masters in Maternal & Child Health (MMCH –
1 year course). The University of Health Sciences, Lahore approves curriculum for
these management’s courses.
•
Lahore School of Public Health, which is a part of the Lahore Medical & Dental
College, also runs 2 years Master course in Public Health (MPH). In 2014, they
developed the curriculum for MPH, which has been adopted by the University of Health
Sciences, Lahore, and it will be implemented to all its affiliated institutions, which offer
these master courses. The Dean of this institute has requested members of the SIG to
review their curriculum.

College of Physicians and Surgeons (CPSP) regulates specialist practice
(postgraduate) in medical specialities including Community Medicine (Public Health) by
securing improvements of training, conducting examinations for Membership (MCPS Diploma) and Fellowship (FCPS) of the College.
The MCPS programme consists of one-year training programme in the Community
Medicine with a final examination.
Entry to the FCPS programme is through successful completion of the FCPS-I
examination (Medicine). The FCPS programme is a 4-5 year programme, which
consists of an initial 2 year Intermediate Module (IMM), which when successfully
completed leads to the advanced phase of FCPS training, lasting 2-3 years, with
completion of FCPS-II exit examination. FCPS is a competency based training
programme and at the end of training in Community Medicine Program, the graduate
will be able to:
o
Develop, implement, manage and evaluate health programs and models of
public health both regionally and nationally.
o
Manage and prevent local common health problems
o
Train medical undergraduates, postgraduates and other complementary
healthcare workers in the practice of public health.
10
o
Develop and conduct research in public health issues.
In practice all graduate with the FCPS tend to be employed by the medical
colleges/universities for teaching/training medical undergraduates and postgraduates
•
Health Services Academy (HSA) is an autonomous training and research public
health institution in Islamabad. This is one of the first institutions of its kind in Pakistan
which offered a PhD programme in Public Health. It offers placements of FCPS
trainees and provides courses for MPH and MSc in Health Economics & Management.
The HSA is affiliated with Quaid-i-Azam University, Islamabad. They also provide short
training courses to in-service public health practitioners and professionals. They also
host national public health conferences.
•
The Centre for Disease Control and Prevention (CDC), Atlanta, USA works with
several key public health institutions in Pakistan. CDC has partnerships with Pakistan’s
National Institute of Health (NIH) as well as with its provincial and district level offices to
strengthen capacity and infrastructure for key public health issues, including workforce
development, hepatitis surveillance, and polio eradication efforts. CDC also has strong
partnerships with Aga Khan University to foster research in the areas of vaccinations
and neonatal infections. CDC continues to conduct activities in Pakistan through its
established relationships with provincial governments. One of the key areas of CDC for
Pakistan is Field Epidemiology & Laboratory Training Program (FELTP), located in
the Pakistan NIH. It offers medical doctors a two year specialised course to become
Field Epidemiologist. So far in 8 cohorts, 134 Field Epidemiologist have completed the
program. Currently, with 18 residents enrolled, the program will implement a polio/
immunisation track to provide assistance in 50 districts throughout Pakistan
•
The National Program for Family Planning and Primary Healthcare was
launched in 1994 in Pakistan, which is a community, based programme providing
primary healthcare services (health promotion, disease prevention, curative &
rehabilitative services and family planning) to about 80 million people, most of whom
live in poor rural areas. The programme set out to train and deploys 150,000 female
community healthcare workers (LHWs). These workers are trained for 15 months and
they are attached to a government health facility, serving a population of about 1000 or
150 homes by visiting 5-7 homes on daily basis. They also strengthen the Expanded
Immunisation Programme (EPI) to improve vaccination status of the women and
children. Since 2011, this programme has been devolved at the Provincial level.
Evaluation of the programme has found that the population served by the LHWs had
substantially better health indicators than the control population.
11
38th ANNUAL Conference/3rd Joint Conference of the
Societies of Pathology in Collaboration with Royal College of
Pathologists UK and British Association of Pakistani
Pathologists from 6th to 8th November 2015 in Lahore:
I am a member of the British Association of Pakistani Pathologists and was invited to
chair the scientific session on Molecular Pathology as I have expertise in TB,
particularly in the use of new technologies in early investigation and diagnosis of
suspected TB cases and their use in the cluster/outbreak investigation. Over 80
delegates attended the session, with representation from all over the country. The
topics covered were; Application of new technologies in Genomic Medicine; Molecular
characterisation of Extended Spectrum Beta- Lactamases (ESBL) in E.coli causing
urinary tract infections; Phenotypic and molecular characterisation of CTX-M encoding
Beta Lactamases from clinical isolates of Enterobacteriaceae; Gene Xpert – a new pillar
for the rapid detection of Rifampicin resistance in Mycobacterium tuberculosis;
Screening of laboratory workers for latent TB using Interferon Gamma Release Assays;
Evaluation of a real time PCR assay for the diagnosis of Tuberculosis and Molecular
detection of Mycobacterium tuberculosis by screening for IS6110. The highlight of the
workshop was sharing the use Whole Genome Sequencing and VNTR technology in
both investigating and managing clusters/outbreaks. Use of Gene Xpert is beneficial in
identifying the early cases of drug resistance cases, and thus improving outcomes
I chaired the scientific session on Infectious Disease Society of Pakistan, which was
attended by over 80 delegates, and with representation from all over the country. The
topics covered in this workshop were; overview of severe vivax malaria in Pakistan,
which causes increasing morbidity and mortality; detection of wild type MTB and its
genotyping of RIF/INH-Resistant MTB mutants with Gene Flow Hybridization and its
comparison with conventional PCR; comparison of TLA and MIGIT 960 – identifying
MDRTB in at least 3.6% samples; culture positivity rate for MTB in migrants from
Pakistan before immigration to other countries; pathogens causing blood stream
infections in cardiac patients & their susceptibility pattern from a tertiary care hospital;
reduction in blood culture contamination rate through dedicated phlebotomy staff
services at emergency department of Aga Khan Hospital, Karachi; comparison of
Tigecycline and Colistin among gram negative organisms, and possible effects of
ambient temperatures in transmission of malaria during off season. There was an
excellent quality of presentations by young trainees with interesting discussions on how
to integrate research findings into practice.
I gave a keynote lecture on the “transmission of Mycobacterium bovis to humans”
which was attended by over 100 delegates. I led an investigation in the UK to assess
12
the risk of transmission of TB (Mycobacterium bovis) from cats to humans. Household
contacts of these cats were followed up with the symptom checks, IGRA blood test,
chest x-ray to look for either latent or active TB infection. Four out of 25 contacts
screened developed the TB infection (two with active disease and two with latent TB
infection) and were treated accordingly with good outcome. This is the first study in the
literature to show the transmission of TB in pet cats to their human household contacts.
This study has led to change the national guidance in the UK when the M.bovis infection
in cats is identified and how the human household contacts should be investigated. The
lecture also covered the other risk factors for M.bovis infection in humans such as
drinking unpasteurised milk. Discussion led to the use of IGRA blood test in the
investigations of latent TB infection and management of TB cases with the quadruple
regimen of anti-tuberculosis drugs.
A study on the spectrum of HCV Genotypes in a tertiary healthcare centre in Karachi
(Liaquat National Hospital and Medical College) was presented concluding that
Genotype 3 is still the most common type in Pakistan.
The sexual health team presented a study on the prevalence of Human Papilloma Virus
(HPV) among Pakistani women from Dow University of Health Sciences, Karachi. It
was concluded that there is a high prevalence of HPV virus among women who attend
the sexual health clinic covering Korangi and Landhi areas. There are no sexual health
programmes to promote safe sex practices and HPV immunisation is not available to
such women.
The sexual health team presented a paper from the Dow University of Health Sciences;
to illustrate that HIV drug resistance is increasing in Karachi as HIV positive cases are
inappropriately treated.
I attended the “Train the Trainer” scientific session, which specially focused on the
engagement of Royal College of Pathologists, UK in supporting those trainees in
Pathology who wanted to gain experience in the UK or take Part 2 of the FRCPath
examination in the UK. The team from the Royal College of Pathologist shared the
systems used in improving the quality of training, and described the curriculum available
for Microbiology, Histopathology, Haematology and Chemical Pathology in the UK. As I
was representing the British Association of Pakistani Pathologist, I described the
opportunities available to Pakistani trainees in UK training programmes.
Since my return, I have secured 2 six months clinical attachments for two trainees from
the Armed Forces Institute of Pathology in the UK. We intend to strengthen this system
for a smooth journey to trainees from Pakistan to UK in order to gain qualifications in the
FRCPath.
13
Ebuddi:
Communicable diseases especially blood borne viruses such as Hepatitis B and C are
contributing to high mortality and morbidity in Pakistan. Hence, increasing its
awareness especially on infection control is crucial for the frontline staff. Ebuddi is a
digital training platform (smartphone technology) which is being used to train healthcare
workers. This tool was originally developed in response to Ebola to train healthcare
workers in Liberia on infection control and has played a major role in training the
healthcare workforce. Ebuddi has been designed to be easily adapted to local context
(settings, ethnicity, clothing and gender) and is able to provide feedback on the
progress/learning pattern of the individual. In longer term this tool has a potential to be
used in improving outbreak response, preparedness for emergencies, strengthening
capacity, empowering frontline healthcare workers and fighting antimicrobial resistance.
Currently the work is in a underway to develop the training module for infection training
especially for the blood borne viruses in Pakistan. During my visit, I had discussion
with Prof Mahmood Shaukat (Allama Iqbal Medical College) and Dr Altaf Ahmed (Indus
Hospital, Karachi) on the feasibility of doing a pilot of this tool once available. There
was a positive response on using the new technology to train the frontline staff in the
hospitals on infection control. It is proposed that a pilot of this technology, depending
on its availability, will most likely be piloted in 2016 at the following sites:



Jinnah Hospital, Lahore
Rawalpindi Medical College, Rawalpindi
Indus Hospital, Karachi
APPNA Hepatitis C Awareness Initiative:
There are at least 12-15 million people in Pakistan suffering with Hepatitis B and C and
this number is increasing daily. The majority of these patients will die early with liver
failure either due to infection or cancer of liver. This epidemic is mainly caused by poor
infection control practices, in particular the reuse of needles, the transfusion of
unscreened blood, the use of infected dental and medical instruments, and unhygienic
practices by barbers and beauty parlours. In 2012, APPNA (Association of Pakistani
Physicians in the North America), of which I am one of the leading experts, launched an
initiative to increase the awareness of hepatitis and its control in Pakistan. Since then
four national conferences have been held and awareness days are observed twice a
year (July and November) throughout Pakistan, from Peshawar to Karachi in more than
60 institutions. Allama Iqbal Medical College and University of Health Sciences, Lahore
are one of the major contributors at these events. Different participants contribute on
the day with organising the rallies, seminars, Hepatitis C screening camps, student
14
activities, poster competitions, plays and other outreach activities, Figure 4. We have
produced leaflets, posters, books, animated videos, which are disseminated during
these activities. Work is also going on for the safe blood initiative and stopping
unnecessary use of injections/drips etc.
I held the meetings with the clinicians to assess/review the progress of this initiative and
it was strongly felt that we need to use national media (TV and newspapers) to increase
the effectiveness of these campaigns, in order to reach a far wider population.
Medical Colleges and their Student Welfare Societies support these awareness
campaigns and their contributions are very valuable. It is vital that their support
continues in campaigns to be held in future.
Traditionally in Pakistan, focus has been on the treatment of Hepatitis C rather than
prevention. Yet it is only recently that more effective drugs have been available on the
market at a cheaper price. But still this progress has been blunted by the common
practice of prescription of treatment being led by non-specialists, and indeed by nonmedical professions.
It is clear that in order to control disease progression, the focus of the Hepatitis C
epidemic needs to be on prevention. There is need to improve infection control
measures both in primary care and secondary care, particularly by screening of donated
blood with reliable screening kits, ensuring proper medical waste disposal and reducing
the number of unneeded/inappropriate injections and drips given to the patients.
Figure 4;
15
APPNA Chest Initiative:
In 2015, APPNA launched this initiative to prevent Pakistani population from harmful
effects of smoking and anti-tobacco awareness days were held in March 2015
throughout Pakistan, Figure 5. Smoking imposes a significant burden on the mortality
and morbidity of the Pakistani population. Educational materials have been prepared
and are distributed on regular basis. There is a Facebook page available
(https://www.facebook.com/#!/APPNACHEST/timeline) for the users to access relevant
information. I held a meeting with the staff in the Respiratory Medicine department of
the Mayo Hospital, which is one of the largest public inner city hospitals in Lahore, who
was very appreciative of this campaign. They agreed to take part in the campaign and
use our material to be given to their patients on their consultations to stop smoking.
Figure 5:
16
Health Education in Secondary Schools:
Health education is not part of secondary school curriculum in the Punjab province. A
workbook was produced in 2013 by the APPNA Hepatitis C Initiative to increase the
knowledge and awareness of Hepatitis C infection in the secondary schools. It is hoped
that once children are aware about the spread and prevention of this infection, they can
influence their parents and family members to prevent its acquisition or transmission to
others. The workbook has been met with positive feedback, and as such, a DVD has
been produced and work is underway to reproduce a similar workbook for the primary
school children.
In May 2015, a modular course was developed to cover the topics such as human
body/mind, diseases/infections, healthy food, healthy lifestyle and harms of smoking,
drugs/alcohol etc. This course was piloted in one of the Allied Schools in Amar Sidhu
area of Lahore and targeted to the boys and girls of 9th and 10th class, Figure 6. A
trained graduate, who used the facility of computer presentations and other visual aids
such as posters etc, taught the course. Group work included monitoring the blood
pressure, respiratory rate, oxygen saturation and vision tests. This pilot has been
evaluated positively both by the pupils and staff from the school.
During my recent visit we have reviewed and updated the contents of the course. It is
proposed that this course will be available online and can be adjusted according to the
school timetable.
Figure 6;
17
Khawaja-Saraas Rehabilitation Project:
Fountain House is a unique charitable institution in Lahore that offers treatment and
rehabilitation services to those who suffer from various kinds of mental illness, in
addition to educational facilities for family physicians from all over the country. One of its
projects, which started couple of years ago, is the Khawaja-Saraas Rehabilitation
Project which provides services to the underserved and neglected members of the
society, Figure 7. Approximately, there are more than 1000 khawaja-saraas (eunuchs)
living in Lahore or surrounding areas and nearly 300 are given social and psychological
support in the Fountain House. They will usually visit for 2-3 hours on weekly basis.
Khawaja-saraas face extreme discrimination in health, housing, education and
employment. A local study has found an increased prevalence of blood borne viruses
(Hepatitis B &C and HIV) and sexually transmitted diseases, which is thought to be
secondary to an increase in prevalence of homelessness, substance abuse and unsafe
sexual practices within this community. This project aims to help khawaja-saraas adopt
healthy lifestyle and safer sex practices.
Figure 7;
18
Recommendations:
1.
Health Department Punjab needs to establish integrated disease surveillance,
early warning and response systems to prevent and control these diseases.
2.
Improve the quality of data by implementing Quality Assurance Scheme especially
from the laboratories and clinicians. All laboratories should be accredited for
quality and competence
3.
Leaders in the Public Health should work in collaboration with the Specialty
Interest Group (SIG) of the Faculty of Public Health, UK to strengthen the
professional development of the public health workforce
4.
A joint conference to be arranged between public health experts in the UK and in
Pakistan later in 2016 to improve the capacity and professional development of the
public health workforce
5.
Further work is advised to assess the delivery of the curriculum for community
medicine as recommended by the PMDC by each medical college or institution
6.
SIG members to consider offering to review the curricula including MPH and
others
7.
Provincial Health Departments and Healthcare Commission should take more
proactive actions on preventive measures to control the epidemic of Hepatitis C
and consider using national TV and newspapers to increase the awareness of
Hepatitis C and its prevention. Medical Colleges and their Student Welfare
Societies continue to take part in the awareness campaigns
8.
Consider offering human papilloma virus screening to women who attend the
sexual health clinics
9.
HIV positive cases should be treated according to the agreed protocols to reduce
the resistance to such drugs
10. Allama Iqbal Medical College to pilot the Ebuddi programme to improve the
knowledge and skills on infection control of the healthcare workers using the
smartphone technology once available. Other sites for the pilot may include Indus
Hospital Karachi and Rawalpindi Medical College
19
11. Consider including the health education programme in secondary schools
especially for pupils in 9th and 10th Class
12. Consider to include khawaja-saraas population in the public health campaigns to
reduce smoking, drugs/alcohol and other high risk behaviours
20
APPENDIX 1
List of institutions visited/consulted:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Allama Iqbal Medical College, Lahore
King Edward Medical University, Lahore
University of Health Sciences, Lahore
Institute of Public Health, Lahore
Lahore School of Public Health, Lahore Medical & Dental Medical College, Lahore
College of Physicians and Surgeon, Lahore
Mayo Hospital, Lahore
Jinnah Hospital, Lahore
Indus Hospital, Karachi
Heartfile, Islamabad
Ministry of National Health Services, Regulations and Coordination, Islamabad
Health Services Academy, Islamabad
Royal College of Pathologists UK and Pathologists Association of Pakistan
Conference 2015, Lahore
14. Field Epidemiology & Laboratory Training Program, CDC, Islamabad
15. Akhuwat, Lahore
16. Chughtai Laboratories, Lahore
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APPENDIX 2
List of experts who were consulted:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Prof Mahmood Shaukat, Principal, Allama Iqbal Medical College, Lahore
Prof Rakhshanda Fareed, Community Medicine, Allama Iqbal Medical College,
Lahore
Prof Junaid Sarfaraz Khan, Pro VC, University of Health Sciences, Lahore
Prof Muhammad Aslam, VC, University of Health Sciences, Lahore
Professor Maaz Ahmad, Dean, Institute of Public Health, Lahore
Dr Shakeela Zaman, Dean, Lahore School of Public Health, Lahore Medical &
Dental Medical College, Lahore
Dr Saira Afzal, Associate Professor, Community Medicine, King Edward Medical
University, Lahore
Dr Saira Tariq, Assistant Professor, Community Medicine, King Edward Medical
University, Lahore
Dr Assad Hafeez, DG Health, Ministry of National Health Services, Regulations
and Coordination and Executive Director, Health Services Academy, Islamabad
Dr Sania Nishtar, Chief Executive, Heartfile, Islamabad
Prof Saqib Saeed, Respiratory Medicine, Mayo Hospital, Lahore
Prof Arif Siddique, Gastroenterology, Jinnah Hospital, Lahore
Seemab Hassan, Hepatitis C Initiative Coordinator, Lahore
Prof Sohail Chughtai, Dean, Central Park Medical College, Lahore
Omar Chughtai, Chughtai Laboratories, Lahore
Dr Aamer Ikram, Consultant Microbiologist, AFIP, Rawalpindi
Dr Izhar Hashmi, Director, Akhuwat, Lahore
Dr Huma Chengez, Consultant in Microbiology, Glasgow
Dr Waheed-uz-Zaman Tariq, Consultant Microbiologist & Virologist, Tawam
Hospital, Al Ain, UAE
Dr Altaf Ahmed, Consultant Microbiologist, Indus Hospital, Karachi
Dr Rana Jawad Asghar, Field Epidemiology & Laboratory Training Program, CDC,
Islamabad
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