SOME seven million plus viral Hepatitis-C sufferers are likely to have been left without access to relevant treatment under the ambitious Prime Minister’s National Programme for the Control and Prevention of Hepatitis, indicates data available with the cell, while an apparent lack of planning and coordination has left the project itself on shaky moorings.

For Hepatitis-C patients, the situation is dire since as Dr Masood Shaikh of Lahore’s Sir Ganga Ram Hospital pointed out, a patient who does not avail of the prime minister’s programme must alternatively spend at least Rs50,000 for a six-month treatment course, while private hospitals can charge far more. Under the PM’s project, however, treatment by conventional Interferon was brought down to between Rs16,000-20,000, according to Dr Sharif Ahmed Khan, the national programme manager of the hepatitis control programme.

Set up in August 2005, the Rs2.5 billion project was envisioned as a five-year exercise to prevent the spread of the viral forms of the illness, and provide subsidised treatment to patients registered under the programme. Figures available with Dr Khan indicate that about five to six per cent of the population is infected with Hepatitis-C (an estimate based on 220 healthcare facility-based studies conducted in different provinces). Even conservatively extrapolated over the country’s population, this would indicate that there are currently about 7.5 million Hepatitis-C patients in the country. The same baseline data suggests between three and four per cent of the country’s population is infected with Hepatitis-B.

Meanwhile, the Punjab provincial coordinator of the programme, Dr Abrar Baig, believes that around 16 million Pakistanis are currently infected with Hepatitis-B and -C, with the latter being more prevalent in Punjab.

It is worrying that three years of its active phase; the expensive programme has merely indicative data about the number of patients with viral hepatitis in the country.

A comprehensive survey is yet to be conducted, although Dr Khan informed Dawn that through the Pakistan Medical and Dental Research Council, the ministry of health is “in the process of finalising a viral Hepatitis-B and -C prevalence survey which will depict the representative disease burden in the provinces.”

Meanwhile, with the programme’s funding approved until 2010, the figures available with Dr Khan’s office show that even the numbers of patients registered under the programme are a mere drop in the ocean given the likely scale of the problem – nearly 34,000 Hepatitis-C patients have been registered across the country, of which over 10,000 patients are yet to receive treatment.

Hospitals and doctors on the ground, however, claim that the number of patients still awaiting treatment is much higher. Furthermore, as has been reported over the past years by this newspaper, bottlenecks in the process of getting oneself registered under the programme and glitches in the supply of Interferon injections appear to have left a very large number of patients without hope – although it must be noted that every Hepatitis-B or -C patient does not require Interferon injections.

Planning and execution

According to Dr Khan, 104 hospitals and healthcare facilities at the federal, provincial and district levels were equipped under the programme with facilities for carrying out diagnostic tests and providing treatment to eligible and poor patients.

But the situation on the ground shows a different picture. In the NWFP for example, while hepatitis control and prevention centres have been launched in all 24 districts of the province and in three of the seven Fata agencies, about half are yet to become functional – in some cases because the law and order situation has blocked progress.

There is also a contradiction in figures. The NWFP provincial coordinator of the programme, Dr Ihsan Turabi, told Dawn that about 2,000 patients had been given Hepatitis-C injections in the province and Fata, although the figures given by Dr Khan state that over 5,000 Hepatitis-C patients had been treated in the region.

Other issues being faced by the prime minister’s programme involve the apparently unequal priority being given to the programme in different provinces.

Each province receives its quota of assistance from the programme on the basis of population. The NWFP’s share is 14 per cent, for example, but doctors argue that this should be increased given the scale of the problem.

Dr Zulfiqar Ali Gorar, the Sindh provincial coordinator of the programme, told Dawn that that there was room for district and provincial governments to extend financial support to the federal government’s programme, and that at least eight districts in the province had already allocated funds ranging from Rs25 million (Jamshoro district) to Rs2.5 million (Shikarpur) to the prime minister’s programme.

In Balochistan, by contrast, although the provincial PC-1 has been developed, it is still in the process of being approved and neither the provincial/district governments nor the hospitals have so far allocated a budget for the activities of the prime minister’s programme in Balochistan.

Registration issues

In order to have themselves registered under the prime minister’s hepatitis control programme, patients must undergo a polymerade chain reaction (PCR) test. Most healthcare facilities charge around Rs4, 000 for this test and there are few places – such as the Liaquat University of Medical and Health Sciences in Sindh and the Hayatabad Medical Complex in the NWFP, where it is offered free of cost. This becomes an impediment in the path of citizens hoping to benefit under the programme.

Other healthcare facilities such as the Nawabshah Medical College for Girls send samples to Lahore’s Centre of Excellence in Molecular Biology, where the PCR test is carried out free of cost. However, doctors complain that the sample must be sent by courier, a process during which it is virtually impossible to maintain the cold chain for the samples, and that the Lahore centre’s turn-around time is three to four months.

In this regard, the national programme coordinator of the project told Dawn that according to the agreed-upon terms of reference regarding the roles and responsibilities of the federal, provincial and district levels, it was predominantly the responsibility of provincial and district health departments to make efforts in this regard – they were meant to take the supplies under the prime minister’s programme as supplemental to their own resources, which were to be explored and diverted in this regard. “However,” he said, “the programme has tried to ease their responsibilities by arranging this provision free of cost through the Centre of Excellence in Molecular Biology, Lahore.”

Dr Khan conceded that the inappropriate transport of samples, which could lead to deterioration, was an issue but maintained that this was solely the responsibility of the laboratory of the hospital sending the sample. “The concerned focal person for diagnosis and surveillance of the hospital may take the requisite remedial measures and ensure the transportation of serum (instead of whole blood) to the Lahore centre in proper cold chain,” he said.

More patients than resources

A number of hospitals and doctors contacted by Dawn complained about shortages and delays in the supply of Interferon injections used in the Hepatitis-C treatment. Dr Gorar, the Sindh coordinator of the programme, for example, said that supplies had been irregular since July 2007 as a result of which about 7,000 patients registered in various hepatitis centres were still waiting for the medicines.

But officials at the prime minister’s programme maintained that when the project was envisioned, treatment was only a minor part and it was projected that injections would only be provided to 2,000 patients a year. However, they alleged, hospitals registered far too many patients on their own initiative and started providing treatment from the resources made available for a limited number of patients. Because of this, the treatment of thousands of patients had to be stopped mid-way, they pointed out.

The truth behind the matter is perhaps safely shrouded in volumes of paper; yet as in the case of so many other well-intentioned but inadequately planned public welfare schemes in the country, the brunt is borne by ordinary citizens, particularly the poor. Having gone through the process of establishing his eligibility and getting himself registered under the programme, a sufferer is hardly likely to care whether delays or stoppages in his treatment are due to the programme management or the over-enthusiasm of hospitals. All he is concerned about is getting relief at a relatively affordable cost.