1. Name of the Project:
2. Location:
3. Authority responsible for:
 Sponsoring
 Execution
 Operation and
maintenance
 Concerned Federal
Ministry / Provincial
Department
4.
a) Plan Provision
PLANNING COMISSION PC –1 PERFORMA
Chief Minister’s Initiative for Hepatitis Free Sindh
Entire Sindh Province



Health Department Government of Sindh
Health Department Government of Sindh
Program Implementation Unit Health Department
Government of Sindh

Department of Health Government of Sindh / Ministry of
Health Government of Pakistan

Included in Health Sector Medium Term Plan
200 Million earmarked in the ADP for 2008-09

Indicators for the improvement in the health are based on reduction
of mortality and morbidity due to preventable diseases. Pakistan is a
country under epidemiological transition where almost 40% of the
burden of disease is accounted for by the infectious / communicable
diseases.
Following 03 areas of National Health Policy 2001 are related to the
proposed objectives of the project.
5. Project Objectives and
relationship with the
sectoral objectives:
1 Key area number 1 warrants the control of widespread
communicable diseases.
2 Key area number 06; removal of managerial and professional
deficiencies in the district health system
3 Key area number 09; creation of mass awareness in matters of
public health
Provincial Health Policy 2005 identifies that Viral Hepatitis prevalence
in Sindh is higher than the reported world average. It aims at
reducing the virus transmission by encouraging safe blood
transfusion, safe invasive procedures at health care settings and
discouraging unsafe injection delivery, tattooing, IV drug abuse &
unethical practices of quacks. Following key areas have direct
relationship to the program
Page | 1
1 Key area number 1.5 asking for interrupting the virus
transmission of Hepatitis B and C
2 Key area number 10 stressing upon training of paramedical
staff
3 Key area number 11 identifying need for a comprehensive
epidemic response
4 Key area number 18; warranting fresh health legislation.
Medium Term Development Framework envisages safe blood
transfusion and establishment of screening centers at District
Headquarter Hospital.
In recent years Viral Hepatitis has emerged as a leading cause of
mortality and morbidity. Ministry of Health estimates the number of
chronic carriers of Hepatitis B up to 06 million and that of Hepatitis C
up to 7.5 million carriers in Pakistan.
As a public health response Ministry of Health Government of
Pakistan launched a federal funded scheme in August 2005 under the
name of “Prime Minister’s Program for Prevention and Control of
Hepatitis”. Total cost of program is 2.56 billion rupees for five years
2005-2010, and the covenant elements of the program are as follows:
1) Hepatitis B vaccination for high risk groups
2) Safety of blood and blood products against hepatitis
3) Safe Injection delivery, invasive medical devises and proper
hospital waste management.
4) Establishment of water purification plants.
5) BCC strategy implemented through media and
interpersonal communication channel.
6) Capacities building of health care providers for the
prevention and control of hepatitis.
7)
a) Surveillance and diagnostic lab services for Hepatitis
and Epidemic response
b) Operational research including monitoring & evaluation
c) Counseling and treatment interventions at teaching
and district headquarter hospitals
d) Program management
However due to the enormity of the task, rising trends of the disease
and demand supply mismatch, a fresh initiative on part of the Health
Department Government of Sindh is needed.
Page | 2
Adopting a pro-poor approach the “Chief Minister’s Initiative for
Hepatitis Free Sindh” will work within a framework of following five
broad strategic areas.
1.
2.
3.
4.
5.
6. Description and
Justification of the Project:
Preventing the acute infections
Addressing the chronic infections
Raising the public awareness
Changing the policy environment
Health System Strengthening
For details see annexure 1(Framework of Action for CM Initiative).
A: BACKGROUND OF THE DISEASE
1.VIRAL HEPATITIS:
Viral Hepatitis is inflammation of the liver caused by 05 distinct types
of viruses.
 Hepatitis A: It accounts for 50-60% of the acute viral hepatitis
and is completely self-limiting disease. In most areas of the
developing world 97% of the population has had one episode
of Hepatitis A. Prevention is done through safe drinking water,
hygienic food and promotion of environmental sanitation and
personal hygiene.
 Hepatitis B: Hepatitis B is transmitted through contaminated
blood and blood products, body fluids and through sexual
contact. Infected mothers also transmit the virus to their
newborn babies during birth. The disease becomes chronic in
younger age group and spontaneously clears if contracted by
an adult. The graph shows relationship of chronicity with age.
Page | 3

Hepatitis C: It is also a blood borne virus spread through
infected blood and blood products. Unsafe use of medical
devises (injections) is major cause of its spread. 85% of the
people who are infected become chronic carriers.

Hepatitis D or (Delta ): see below

Hepatitis E: The mode of transmission is same as Hepatitis A.
The disease is endemic in Pakistan. Mortality is increased in
pregnant women only. In other population subgroups it is selflimiting leaving lifelong immunity.
2: EXTENT OF PROBLEM:
Viral Hepatitis has emerged as a serious public health threat in recent
years. There is a dearth of community-based data on the prevalence
of Hepatitis. On the basis of more than 200 research studies Federal
Ministry of Health has made mathematical estimates of presence 6
million patients of Hepatitis B and 7.5 million patients of Hepatitis C in
Pakistan.
Extrapolation of these figures gives us a staggering number of 1.5
million chronic carriers of Hepatitis B and 1.8 million chronic carriers
of Hepatitis C in Sindh. Empirical evidence suggests that Sindh may
have disease burden more than the current estimates. Reason being
the deepened poverty, statutory ambiguity in certain laws, health
practices of public & professionals and lack of universal access to
health care.
It is pertinent to note here that Pakistan Medical and Research
Council is in process of conducting a National Prevalence Survey of
Viral Hepatitis. The results of the survey will further fine tune the
interventions of Chief Minister’s Initiative for Hepatitis Free Sindh. Till
the results are available following direct and indirect evidence is to be
considered.
2.1. Indirect Empirical Evidence:
Janjua & Hutin (2005) have shown that Sindh has the highest rate of
per capita injection delivery i.e. 13 injections per person per year and
out of which 47% are unsafe1. National Institute of Population Studies,
in a survey conducted in 2003, has shown that unawareness about
1
Janjua, NZ, Hutin Y, International Journal for Quality in Health Care 2005; Volume 17, Number 5: pp.
401–408
Page | 4
the established modes of disease transmission is very high; proportion
of females in province knowing about the 03 established modes of
hepatitis C transmission is as follows:
•
•
•
Used Syringes
Used Blades
Through Blood
9.84 %
1.09%
4.37%
If we match these two separate pieces of information a bleak picture
emerges. That is, 90% of the female population in Sindh does not
know that Hepatitis is spread by used syringes in a situation where
every person is receiving at least 13 injections in a year and 7 times it
is un sterile.
Direct Evidence:
Recently published epidemiologic studies by Mujeeb and Pearce show
a steady increase in the prevalence of Hepatitis C in blood donors
from the interior Sindh over the period of 2004 – 2007. The overall
sero-prevalence was 7.5% and has increased from 7.2% in 2004 to
8.9% in 20072.
2.2. Screening Data of Hepatitis Laboratories3:
Screening data being generated from the District Headquarter
Hospital show a higher proportion of disease as under:
CATEGORY
NATIONAL ESTIMATES
Hepatitis Hepatitis C
B
PROVINCIAL DATA
Hepatitis Hepatitis C
B
Health
6%
5.4%
7.29%
Workers
General
2.6%
5.3%
16.32%
Population
High Risk
4%
6%
11.6%
Groups
NB: High Risk Groups include Thallasemics, Prison
Pregnant Women
6.16%
27.15%
20.17%
Inmates,
2
Mujeeb SA, Pearce MS, Temporal Trends in Hepatitis B & C in family blood donors from interior
Sindh, BMC Infectious Diseases 2008, 8:43
3
Sentinel Surveillance data of PM’s Program for Prevention and Control of Hepatitis. Aug. 2006Aug.2007
Page | 5
There is a significant difference among the national estimates and
provincial data. A detailed break up of these figures district wise is
attached as annexure II.
2.2.1.Epidemic Investigation Reports
Various epidemic investigations in general population has identified
clusters of high prevalence as under:
AREA
SAMPLE
SIZE
Nasarpur, Matiari
Kazi Ahmed,
N/shah
Shah Godryo,
Dadu
Shahdadkot,
Kamber
Matli, Badin
(LHWs)
HEP. B
HEP.C
565
70
(12.3%)
209
(37%)
48 (8.4%)
151
62 (41%)
4 (6%)
00
3 (4%)
00
91
694
30
(314%)
100
(14%)
195
14 (7%)
Mirpur Mathelo
135
19(14%
Tando Haider
Hyderabad
197
93 (47%)
118
(17%)
43
(22%)
29
(24%)
67(34%)
DUAL
INFECTION
00
00
00
00
2.2.2. Hepatitis Delta
Delta hepatitis is the uncommon and possibly the most severe form of
chronic viral hepatitis of humans. It is caused by an incomplete virus,
which needs the presence of Hepatitis B virus for causing disease.
Inoculation of HDV in the absence of HBV will not cause disease. Little
information is available about epidemiology of HDV in Pakistan. Dr.
Huma Qureshi et al describes identification of 531 patients of HDV,
68% belonged to Northern Sindh, followed by 17% from adjoining
areas of Balochistan. Dr. Badar Fayaz Zuberi et al identifies 28%
prevalence of Hepatitis Delta in Hepatitis B infected patients in Civil
Hospital Karachi. Most of them belonged to Larkana4. Saeed Hamid et
al (2005) calculated the prevalence of Hepatitis Delta in Pakistan as
16.4%. However the major burden of disease is in 02 districts of
Kamber and Larkana.
4
Personal Communication by one of the authors of the said paper published by CPSP in 2006.
Page | 6
A large pocket of Hepatitis Delta has been identified at Kamber and
the estimated quantum of disease at Kamber is 24000 patients as in
August 2007. The underlying assumptions are given as annexure III.
It is pertinent to note here that each patient is able to transfer the
virus even by co-habitation only. There is no effective treatment and
patient rapidly progresses to cirrhosis & liver failure. Mortality due to
Hepatitis Delta is 10 times higher than Hepatitis B alone.5
Presently the PM’s Program has adopted a three pronged strategy; to
address the presence of Delta in any area i.e.

Screening of all the household and close contacts of the
patient
 Vaccination of all the people who are negative of Hepatitis B.
 Interpersonal communication about the risk factors and
spread.
A strategy paper for combating the delta is attached as annexure IV.
As the knowledge about the epidemiology of Hepatitis Delta increases
the strategy will be modified.
The treatment of Hepatitis B super-infected with Hepatitis Delta very
limited success rate and vaccination against Hepatitis B is the most
cost effective intervention for reducing the virus transmission.
2.3. Economic and Societal Cost of the disease:
No economic studies have been conducted regarding Viral Hepatitis in
Pakistan. A conservative estimate of the direct and indirect cost of uncomplicated chronic liver disease is as follows


Direct Medical Cost
Indirect Cost
72300 Rs.
25000 Rs.
However the cost increases 4 times once the chronic liver disease
patient enters into the “Non-Responder” category.
For a patient of decompensate liver failure only viable option is the
Liver Transplant. The overall loss to the national productivity due to
the days out of work is also substantial.
5
Prevesani N, Lavanchy D, Hepatitis Delta, World health Organization document number
WHO/CDS/CSR/ NCS/2001.
Page | 7
2.4. Quality of Life for Chronic Liver Disease Patients:
The health related quality of life scores are higher for Hepatitis B
patients and lower for Hepatitis C patients. The quality of life is
decreased for Hepatitis C patients.
B:DESCRIPTION OF THE FRAMEWORK & PROGRAM OUTPUTS:
(A detailed Logical Framework is attached as annexure V)
As market failure exists in terms of treating the hepatitis and large
externalities are present if the government intervenes. The Chief
Minister’s Initiative will work in a pro-poor manner and will adopt the
Framework for the Prevention and Control of Hepatitis.
1.To prevent Acute Viral Hepatitis Infections
Any infectious / communicable disease needs a host, vector, agent
complex for its spread. The disease spread can be effectively stopped
by breaking this complex. For preventing the Hepatitis B & D virus, an
effective vaccine is available in the market since 1980’s. It is rightly
termed as the world’s first anti-cancer vaccine.
High level of HepB3 coverage among the newborns, safe blood
transfusion, vaccination against Hepatitis B amongst the high risk
groups and preventing iatrogenic infection will reduce the chances of
acute infections. The specific outputs of the component are:
Outputs:
1.1. To maintain the HepB3 coverage amongst newborns at 100%
1.2. To deliver birth dose of Hepatitis B vaccine to 100% children
through EPI.
1.3. To preferentially screen the pregnant women against Hepatitis
B
1.4. To vaccinate 75% high risk group population in province.
1.5. To provide Hepatitis B vaccine at the level of Rural Health
Center in districts/areas affected by the Hepatitis Delta.
1.6. To vaccinate hard to reach population groups like Hijra, MSM
& IDUs through special campaigns
1.7. Create a partnership among 03 tiers of governments for the
subsidy of Hepatitis B vaccine.
1.8. To ensure safe injection delivery at all public sector hospitals.
1.9. To strengthen the capacity of public sector hospitals in the
disposal of hospital waste.
1.10. To provide the Standard Operating Procedures and Quality
Assurance Tools in infection control practices to the public
Page | 8
sector hospitals.
1.11. To strengthen the capacity of public sector hospitals in
achieving the optimum infection control level.
1.12. To facilitate the public sector hospitals in quality assurance by
providing trainings in infection control practices.
Among the high-risk groups identified for the vaccination Chief
Minister’s Initiative will address the general population living in the
high-risk districts. The supplies will be complemented by the federal
supplies. For hard to reach groups like Men having Sex with Men, Hijra
Population and Intravenous drug Users the database available with
the Enhanced HIV/AIDS Control Program Service Delivery Providers
(SDP) will be utilized. Vaccine will be made available at STI Clinics of
the HIV/AIDS in public sector hospitals, for NGO SDPs Program
Manager HIV/AIDS will be made the Principal Recipient and vaccine
will be utilized through the vaccination center of nearest public sector
hospital. For general population program through its social
mobilization campaign will stress upon demand side of the
intervention. This will facilitate in the continuity of the vaccination.
The transmission of blood-borne infections within the healthcare
setting can occur in three directions:
 From patient to patient;
 From healthcare worker (HCW) to patient;
 From patient to HCW.
Although epidemiological evidence suggests that healthcare-related
exposures are not the primary source of hepatitis B virus (HBV) or
hepatitis C virus (HCV) transmission, the fact that any transmissions
occur within this setting gives rise to concern.
From Patient to Patient:
Patient-to-patient transmission is usually indirect and is often a result
of failure to adhere to basic principles of aseptic technique for the
preparation and administration of parenteral medications in multidose vials. The burden of disease associated with unsafe therapeutic
injection practices in Pakistan is very high. The number of injection
per person per year has been estimated to be in the range of 8.2 to
13.6, one of the highest in developing world. Extrapolating this
number to the whole country would result in 1.5 billion injections per
year. Approximately 4% (75 million) of these are administered for
immunization while the remainders are used for therapeutic use. Of
these, 94.2% are unnecessary. In Pakistan, an initiative for the safe
and appropriate use of injections would cost US$ 93 million in each
Page | 9
year in the country and would avert 168 191 DALY in 2000-2030 (cost
effectiveness ratio: US$ 553 per DALY averted). A high proportion of
the intervention costs are represented by the cost of single use
injection devices because of high injection use. This cost is often
covered by patients’ out-of-pocket expenses
From patient to healthcare worker (HCW):
This usually happens as a needle stick injury (NSI) or by a sharp
surgical instrument contaminated by the blood of an infected patient.
The risk of HBV infection in a HCW after a needle stick injury and in
the absence of vaccination or post-exposure prophylaxis is 37%- 62%
if the source patient is HBeAg positive and 23%-37% if the patient is
HBeAg negative. A research on NSI in Karachi show that at least 60%
of health care workers have had one episode of NSI in 12 months and
only 50% of them were vaccinated against Hepatitis B.
From health care worker to patient:
Surgery is a major risk factor for transmission from an HBV-infected
HCW, with the level of risk varying by the type of procedure (e.g.,
exposure-prone invasive procedures are associated with a higher risk
of transmission). No data is available currently about this mode of
spread in Pakistan.
1.1 Exposure prone procedures:
The risk of healthcare related transmission of HBV and HCV, and to a
lesser extent HIV, is increased during the performance of exposureprone procedures (EPPs). The EPPs are defined as, “invasive
procedures where there is a risk that injury to the worker may result in
the exposure of the patient’s open tissues to the blood of the worker.
These include procedures where the worker’s gloved hands may be in
contact with sharp instruments, needle tips, or sharp tissues (e.g.,
spicules of bone or teeth) inside a patient’s open body cavity, wound
or confined anatomical space where the hands or fingertips may not
be completely visible at all times
1.2 Risk Categories:
It is somewhat difficult to precisely define the degree of risk per
procedure, but an attempt has been made to divide procedures into
groups and categorize them as high, variable, or low risk:
High-risk: Any sub mucosal invasion with sharp, hand-held
instruments or procedures dealing with sharp pathology / bone
Page | 10
spicules, usually in poorly visualized or confined spaces (e.g.,
orthopedic surgery, trauma surgery, and internal cavity surgery).
Variable risk: Minor dental procedures (excluding examination),
routine dental extractions, internal / instrument examinations /
biopsy (e.g., endoscopy, vaginal examination, laparoscopy), minor skin
surgery
Low risk: Interview consultation, dental examination, non-invasive
examinations or procedures (aural testing, electrocardiograph,
abdominal ultrasound), intact skin palpation (gloves not required),
injections / Venipuncture (gloves required).
The initiative aims at reducing the virus transmission through these
known routes of transmission by following strategies:
1. Developing written Standard Operating Procedures SOPs in
local languages for health care workers working in high risk to
variable risk EPPs
2. Training of health care workers upon these SOPs
3. Integration of preventive messages for population in the
health promotion campaign to increase the awareness and
reduce the risk of virus transmission.
4. Supporting the hospital waste management system installed
by the federal program.
5. Provision of autoclaves and other sterilization material.
6. Monitoring and Supervision.
7. Encouraging the accreditation of hospitals
The hospital waste management system is envisaged to operate in
close coordination with local TMAs, EPA and community. To achieve a
broad based consensus and assure maximum cooperation 4
intersectoral meetings per year will be conducted.
1.3. Prevention of Perinatal Hepatitis B Transmission:
Vaccination against Hepatitis B has not gained attention of major
development stakeholders in the broader context of maternal and
child health. Perinatal transmission is responsible for 35-40% of new
HBV infections every year worldwide. For a newborn infant whose
mother is positive for both HBsAg and HBeAg (high-risk infants), the
risk for chronic HBV infection is 70%-90% by age 6 months when no
HBV vaccine or HBV immunoglobulin (HBIg)-prophylaxis is given. For
infants of HbsAg positive but HBeAg-negative mothers (low-risk
infants), the risk of chronic infection is <10%.
Page | 11
Large pockets of high prevalence of Hepatitis B have been identified
at Dadu, Hyderabad, Khairpur, Nawabshah, Kamber and Tharparker.
Among one of these pockets at Kamber high prevalence of Hepatitis
Delta is also identified. Isolated screening of pregnant mothers for
Hepatitis B at Mirpurkhas has shown that 13% mothers were Hepatitis
B reactive. Hence the perinatal transmission cannot be ignored in
Sindh.
The initiative aims at perinatal virus transmission interruption by:
1. Modulation of Political Will: Desire for improvement in the
MCH indicators exist at the highest level and incorporating the
agenda of perinatal hepatitis B transmission in a broader
context of Maternal & Child Health will help in reducing the
disease burden
2. At Birth Delivery of Hepatitis B Vaccine: There is enough
supportive evidence to prove that at birth administration of
Hepatitis B vaccine prevents 95% neonates from becoming
chronic carriers of HBV. Concomitant administration of HBIG
and HBV vaccine increases this proportion to 97%. The
marginal advantage is of 3%. Current EPI policy does not favor
at birth delivery of HBV vaccine to susceptible neonates. Till
the policy formulation, mothers in the high endemic districts
will be preferentially screened for Hepatitis B, and all outreach
staff will be utilized in vaccinating the neonate within 24 hours
after birth. An effective linkage will be developed with the
Expanded Program on Immunization for the provision of at
birth dose to the newborns along with BCG; the remaining
doses will be covered through routine immunization schedule.
In case of institutional deliveries the parents will be informed
about the follow-up vaccination schedule for Hepatitis B.
3. Screening of Mothers for Hepatitis B: At present ELISA
screening facilities are available at the district headquarter
hospital (DHQ) level. Antenatal Clinics in these DHQs will be
encouraged to do the screening of this group. At all other
antenatal
clinics
in
these
high-risk
districts
immunochromatogrpahy kits for Hepatitis B will be provided
and the staff will be trained to perform the test. Reactive
patients may get the confirmation from DHQ laboratory.
LHWs will be trained to refer the pregnant women registered
Page | 12
to the peripheral filter clinics for subsequent confirmation through
sentinel sites.
For a broader understanding of the issue and acceptance in the
medical community awareness seminars will be conducted at the
district level through active involvement of Pakistan Medical
Association.
2. To address chronic hepatitis infections
There are a substantial number of chronic liver diseases present in
Sindh. The estimations of Ministry of Health are as under:


Hepatitis B reactive population in Pakistan 6.0 Million
Hepatitis C reactive population in Pakistan 7.5 Million6
Estimations for Sindh are:
 Hepatitis B reactive: 1.5 Million
 Hepatitis C reactive: 1.7 Million
80% of the adult population if contracts Hepatitis B will automatically
clears the virus. 20% remains chronic carriers with variable viral
activity. For Hepatitis C 85% of the people who are infected will retain
virus and only 15% clears the virus.
Pakistan Integrated Household survey 2001 shows that 22% of the
population comes to a public sector hospital for curative care.
Based on these figures with underlying assumption that virus
transmission is halted it is estimated that an absolute number of
374000 patients of Hepatitis C will report to the public sector for
treatment. Similarly 66000 patients of active hepatitis B are expected
to come to public sector hospitals for treatment.
Matching the variables of Financial Allocations from District
Governments, Cold Storage Capacity and Health System’s Capacity to
manage the patient workload and information generated, initiative
will provide treatment to 1000 patients of Hepatitis C at each district
hospital.
This enormous task will be met through program allocations however
all the relevant partners like Pakistan Bait-ul-Maal, Social Security and
District Governments will be encouraged to contribute to the effort.
As the 22% of the chronic hepatitis C patients will go into
decompensate liver failure, hence the capacity building of medical
6
PC-1 Performa of the Prime Minister’s Program for Prevention and Control of Hepatitis, 2005
Page | 13
and paramedical staff of District Headquarter level in managing the
end stage liver disease will facilitate the patients in getting the expert
care near to their homes.
Currently the screening of the Viral Hepatitis B & C is offered in the
public sector at District Headquarter Hospital level through Prime
Minister’s Program for Prevention and Control of Hepatitis. For
Molecular Diagnosis of the Viral Hepatitis the expenditure is mainly
out of pocket. Under the Chief Minister’s Initiative the screening
facilities will be taken down to the THQ Hospital and RHC level. PCR
laboratory will be established at 02 divisional headquarter medical
college hospitals for molecular diagnosis of viral hepatitis.
The existing body of knowledge about the disease is rapidly changing
hence all cadres of health care delivery system needs to be trained in
the prevention and control of hepatitis.
The screening services will be strengthened and will work in
coordination with the Prime Minister’s Program work plans so as to
avoid duplications. As the kits for Hepatitis Delta and Hepatitis B
yenvelop antigen are not supplied through Prime Minister’s Program,
the Chief Minister’s Initiative will provide these kits and reagents. The
distribution of kits will be made on the average monthly consumption
of the stock as per standard operating procedures. The distribution
will be proposed by the Program Manager and is to be ratified by the
Technical Committee. The specific outputs of the component are:
Outputs:
2.1. To provide the E LISA screening facility at Taluka Hospital level
2.2. To provide ICT screening facility up to the Rural Health Center
level
2.3. To establish Molecular Biology Laboratories at three divisional
headquarters
2.4. To formulate the standard operating procedures and Quality
Assurance Tools for laboratories.
2.5. To provide curative support against Hepatitis C and B to the
eligible patient population.
2.6. To create an effective partnership with all the partners working
towards financing for cure of Hepatitis like Pakistan Bait-ulMaal and Social Security.
2.7. To train the staff at District Headquarter Hospital in managing
the viral hepatitis, liver failure and end stage liver diseases.
2.8. To train the health staff at sub-district level in diagnosis and
referral of Hepatitis patient
The aim of providing ICT kits to RHC level is to establish filter centers
Page | 14
around the central District Headquarter Hospital. Out of 112 RHCs in
the province 60 RHCs, where a LHV is posted with functional Antenatal clinic and the daily OPD is greater than 100 patients will be
strengthened as a filter centers.
Provision of drugs to the hepatitis delta patients and non-responders
will be done after the approval of technical and steering committee.
2.9. Polymerase Chain Reaction Test
The PCR Test is a confirmatory test for the presence or absence of the
virus in the blood and is mandatory in all cases of Viral Hepatitis.
Currently the only two public sector institutes viz: Liaquat University
of Medical and Health Sciences and Dow University of Medical and
Health Sciences offer PCR. Nawabshah Medical College Hospital has
recently established a PCR machine facility and it is anticipated to be
functional soon. Geographically the districts of north Sindh are devoid
of public sector PCR machine facility. The initiative aims to establish
PCR machine facility at 03 divisional headquarters viz Chandka
Medical College Larkana and Ghulam Mohammed Mahar Medical
College Sukkur and Civil Hospital Mirpurkhas. The diagnostic needs of
Mirpurkhas, Umerkot, Tharparker Tando Allahyar districts are being
catered through a public private partnership between Mohammadi
Medical College Hospital Mirpurkhas and Center of Excellence in
Microbiology Lahore. The functional frameworks of installing a PCR
machine will be reviewed after clearance from Steering Committee.
3. To Raise the Public Awareness
Improved health is the defining objective for any health system.
Together with fair financing and responsiveness it represents the
broader health system goals (WHO, 2000). Successful health system’s
performance is related to the degree population health is maximized
within the constraints of the available human, capital and financial
resources in a specific country. From this perspective, health
promotion programs play an important role to produce health gain
and to control costs.
It is already described earlier that Sindh has the lowest level of
awareness regarding hepatitis spread.
Analyzing the national data on Knowledge, Perceptions and Practices
reveals that populace is aware of the disease especially the term
Jaundice (Peelia) as most of the people have had at least one episode
of hepatitis A. 97% people were aware of the disease when compared
to 62.3% people who were aware of Hepatitis B & C (Kaari Kaman)
Page | 15
Qualitative data suggests that people are also aware of the possibility
of transmission of disease from parents to off springs though the
exact mode is not known.
Proportion of female population knowing about the modes of
Transmission of Hepatitis C is attached as annexure VI (a).
Launching a robust, sustained and effective health promotion
campaign, which addresses various sectors, is needed to stop the
virus transmission.
The health promotion campaign will address following sectors of
population on priority.
1. School going youth (specifically higher secondary & college
going students
2. Female Population
3. Health Care Providers.
4. Barbers and Beauticians
5. Population living in the high prevalence areas
The school going youth is group amenable to health promotion
messages and will be reached through innovative techniques of :
 Interactive health promotion sessions
 Poster Competitions
 Assembly speeches by the teachers in the schools
The barbers and beauticians are service delivery cadres spread out
deep into the communities. These groups will be reached out through
their respective associations and monitoring mechanism will be
planned out through the local TMAs.
The female population will be reached out through Interpersonal
Communication Model successfully in implementation at the Lady
Health Workers Program. LHW is a front line worker of the health
system and often is the population’s first contact with formal health
system. The orientation of LHWs about prevention and control of
Hepatitis at their continuous education sessions at the PHC facilities
will be coordinated by the health department.
It is anticipated that un-qualified health care practitioners may be a
hard to reach population group, but resources of District
Governments and Taluka Municipal Administrations will be utilized.
For reducing the unsafe injection delivery a campaign focusing on a
right-based approach will be launched, encouraging the safe injection
OR no injection. A mix media approach will be used to support the
campaign. The conceptual framework is attached as annexure VI (b) .A
parliamentarian’s network will be formed for advocacy.
The specific component outputs are:
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Outputs:
3.1. To incorporate the lesson on Hepatitis in the continuous
education sessions of LHWs
3.2. To raise the level of awareness amongst entire female
population covered through LHWs.
3.3. To disseminate the health promotion messages against Viral
Hepatitis to the population through the outreach health
staff in district other than LHWs.
3.4. To formulate targeted health promotion messages for
population to be disseminated through mix media
approach.
3.5. To launch a “Safe Injection or Say No to Injection”
campaign in the province.
3.6. To coordinate and formulate a network of parliamentarians
against Hepatitis.
3.7.
3.8.
To arrange interactive health promotion seminars in the schools
with the support from Health Education Cell.
To arrange health promotion seminars for barbers and
beauticians.
Raising the public awareness level is a multi-sectoral task and to
achieve it effectively, links with the National Rural Support Program,
Pakistan Medical Association and Community Based Organizations
working in the province will be made. The program implementation
unit will develop a communication plan every year to be presented
before technical committee and which will in turn be ratified by the
steering committee for implementation.
4. To Change the Policy Environment
Any government intervention cannot thrive until policies and laws are
not favorable. The most needed laws in context of Sindh are antiquakery law, regulation of a huge private sector. However to make
the process participatory a broad based consultation will be made
with all the relevant actors in the process of health care delivery in a
district health system and identify ambiguous statutes for a better
and comprehensive and effective legislation.
The specific outputs are:
Outputs:
4.1. To identify the statutory ambiguity in the law towards
communicable / blood borne diseases control.
4.2. To draft a law for the infectious diseases control in private and
public sector.
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4.3.
To re-draft the law against the quackery in the province
4.4. To enhance the capacity of District Governments for providing
stewardship to the special service delivery cadres.
5. To strengthen the Health System
In an order to effectively achieve the program objectives program
implementation unit at the Directorate General of Health Services
Sindh needs to be strengthened in terms of logistics and human
resource. Similar strengthening is required at the district level. The
positions thus created will be taken over to no-development budget
after the completion of program.
Currently Prime Minister's Program for Prevention and Control of
Hepatitis in Sindh is utilizing the cold storage facilities of Expanded
Program on Immunization at two divisional stores viz: Kotri & Sukkur.
The storage space at Kotri it is 7400 cu liters.
These cold spaces are inadequate for the dual storage of EPI and
Hepatitis Program. Hence a need is felt to install a separate cold
storage of at least 2500 cu Liters capacity at Kotri , Larkana and at
Sukkur. The sentinel sites will also be provided with an 800 liters
refrigerator under the Chief Minister’s Initiative.
The functional integration of program’s vaccination services at the
Voluntary Counseling and Testing Centers and at Blood Transfusion
Counters will improve the access to service.
5.1.
Surveillance and epidemic investigation capacity at
Provincial and District Level:
Surveillance and epidemic investigation is a basic function of any
disease control intervention. By surveillance trends of disease spread
can be assessed and future resource allocations can be made.
Key elements of a surveillance system are:
1. Detection and notification of a health event
2. Investigation and confirmation (epidemiological, clinical,
laboratory)
3. Collection of data
4. Analysis and interpretation of data
5. Feedback and dissemination of results
6. Response—a link to public health programs, specifically
actions for prevention and control
Program will extend operational support to the provincial epidemic
investigation cell at the Directorate General of Health Services Sindh.
The Deputy Program Manager will head the epidemic investigation,
who will be assisted by the Epidemiologist, Surveillance Officer and a
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computer operator.
The program will work in liaison with the provincial epidemic
investigation cell at DGHS to provide the leadership to the district and
coordinate with federal epidemic investigation cell. Similarly focal
points at the district level will also be identified and their capacity will
be built through short term and long term courses and trainings. This
cell will focus upon the epidemics of viral hepatitis on priority but not
be confined to hepatitis only and will provide leadership to district
epidemic investigation cells in matters related to all kinds of epidemic.
During the outbreaks / epidemic of Hepatitis A, chlorine tablets will be
distributed in the community for making the water safe.
5.2. Interventions at the Jails
The prison inmates have been identified as a high-risk group hardly hit
by the disease. Efforts will be taken under the aegis of Chief Minister’s
Initiative to institutionalize the activities of prevention and control of
Hepatitis in prisoners with the active collaboration of Jail authorities.
Specifically the orientation of Jail staff towards Hepatitis, vaccinating
all the inmates, screening the suspected cases of Hepatitis and
provision of syringes. Reputable Non-Governmental organizations will
also be taken on-board for these interventions
B: VACCINATION AND IMMUNIZATION:
An overarching phenomena behind all interventions will be availability
of Monovalent Hepatitis B Vaccine for adults and children so that all
high risk groups may be vaccinated when found non reactive against
Hepatitis B. Some of the union councils in the province are hyperendemic for Hepatitis B, a flexible policy of at birth vaccination
through outreach health staff including Lady Health Workers will be
adopted. Expanded Program on Immunization will be made a partner
in this. As a longer term measure those institutions will be
strengthened which intend to produce Hepatitis B Vaccine
indigenously like ASV and ARV Laboratory.
For a regular review of the activities a monthly review meeting
regarding the Hepatitis B vaccination of the neonates will be
conducted.
C: IMPLEMENTATION STRATEGY
Effective management is the key to success for any development
intervention. For a sustainable program management, a Program
Implementation Unit will be established at the Directorate General of
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Health Services Sindh. The details of the staffing position are given as
annexure VII (a) and their job descriptions are given as annexure VII
(b). Chief Minister’s Initiative will work as a gender sensitive program
and recruitment quota for females will be followed. Necessary
furniture and fixture will be provided to the staff for proper working
environment.
Directorate General of Health Services Sindh will be the focal point for
the program with Director General Health Services Sindh working as
the Chairman of the Program Implementation Unit. Overall steward
ship will lie with the Health Department Government of Sindh.
Following implementation strategies will be adopted:
 There will be a separate program implementation unit with a
Program Manager, Deputy Program Manager supported by the
pertinent work-force.
 For the purpose of developing a functional interface with
federal program, the Program PIU will be established in the
Directorate General of Health Services Sindh and Federal
Program will be made part of the program management.
 The Program Manager / Deputy Program Manager will develop
an implementation plan in line chart correlating with the
phasing of physical activities of the program and present it
before Technical Committee, later to be ratified by the
Steering Committee.
 Program Staff will be hired as per existing government rules &
procedures, following the laid down qualification and
experience criteria. If suitable candidates are not available
inside the department, hiring will be made from market on
contractual basis, later to be taken over to non-development
side.
 Provincial Coordinator Federal Program will serve as the Chief
Technical Advisor of the program.
 For an effective service delivery and to prevent the dilution
effect of the investments program will be launched in a phased
manner with a modular approach. In first phase five districts
will be selected for the program launch viz: Larkana, Khairpur,
Nawabshah, Badin, and Kamber. The subsequent phasing of
the program will be made on the disease trends and available
data.
 At present various cadres of service delivery management and
coordination are working as one “District Viral Hepatitis
Control Committee”. This team manages and monitors all the
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inputs received from Prime Minister’s Program for Prevention
and Control of Hepatitis. The composition of these crossfunctional multi-layered teams formed by the Program is as
follows:
At Teaching Hospital Level:
 Medical Superintendent
Chairman
 Physician/Gastroenterologist
Secretary/Convener
 Pathologist
Member
 Hospital Pharmacy I/Charge
Member
 Representative of Pakistan Bait-ul-Maal Member
 Social Welfare Officer
Member
 Representative of District Government Member
At District Headquarter Hospital Level
 Executive District Officer (Health)
Chairman
 Medical Superintendent
Secretary / Convener
 Physician
Member
 Pathologist
Member
 Hospital Pharmacy I/Charge
Member
 Representative of Pakistan Bait-ul-Maal Member
 Social Welfare Officer
Member
 Representative of District Government Member
Apart from these cross functional multi-layered team a District Task
Force for Hepatitis Prevention and Control Activities will be notified.
The composition will be as under:







District Coordination Officer
Chairman
Executive District Officer (Health)
Secretary
Medical Superintendent DHQ Hospital
Convener
Executive District Officer (Education)
Member
Executive District Officer Community Development Member
District Public Prosecutor / Attorney
Member
President Pakistan Medical Association
Member
The district task force will support the Viral Hepatitis Control
Committee in the implementation and integration of project activities.
The details of the existing standard operating procedures are given as
annexure 6.
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




For health education and promotion campaigns the pertinent
staff of health education cell will be taken on-board.
Training modules developed by the Prime Minister’s Program
for Prevention and Control of Hepatitis for the health staff in
diagnosis, prevention and cure of the disease will be
improvised and utilized for the training
Training will be done at the DHQ Hospital and nearest Medical
College Hospital by teaching staff of the college.
Specialized short course trainings on epidemiology and disease
investigation will be arranged for three people from one
district viz: District Officer Health (Medical & Public),
Epidemiologist and a medical officer with experience in field
epidemiology. Competency based trainings will be arranged at
PHDC; however options available in private sector with good
standing will also be explored.
A perinatal hepatitis B prevention unit will be set at
Directorate of Reproductive and Child Health at DGHSS to
implement the interventions smoothly.
D: MONITORING & SUPERVISION:
Monitoring and Supervision is the key to success in any programmatic
intervention. It provides a constant check through feedbacks and
keeps the interventions on track. Supportive supervision to the staff
produces ownership and enhances the performance of the staff in a
given task. For a comprehensive M&S of the project an internal
monitoring unit will be established headed by the Deputy Program
Manger. The unit will be supported by the Monitoring Officers who
will carry the desk and field monitoring of the activities. This unit will
review the progress of the project and submit reports to Director
General Health Services Sindh and Health Department Government of
Sindh on monthly basis. The unit will also generate monthly feedback
reports to various sentinel sites in the province.
The monitoring framework utilized will draw it’s base from the
systems model as under:
INPUT
PROCESS
OUTPUT
OUTCOME
It will be the first and prime responsibility of the Program Manager to
identify monitoring indicators after a broad based consultative
process and float these before Technical Committee. The HMIS does
not have the relevant disease specific indicators however efforts will
Page | 22
be taken to incorporate the Hepatitis specific indicators in the new
DHIS. The existing tools for monthly reporting and monitoring
developed by the Federal Program will be utilized and where
appropriate will be tailored to the provincial needs with the approval
of the National Program so as to ensure the uniformity of reporting at
the National Level. The tools will be made available through the
project at all sentinel sites of the province. The Technical Committee
in turn will recommend these indicators to the Steering Committee
for ratification.
At the district level monitoring units will work under the overall
guidance of Executive District Officers (Health) / Medical
Superintendent Teaching Hospitals and District Officer (Public Health)
/ a suitable officer of the teaching hospital shall be responsible for
running the monitoring units.
The key performance indicators identified in the Logical Framework
will be utilized for the monitoring. A quarterly review meeting of the
district / hospital authorities will be held under the chairman ship of
Director General Health Services Sindh. Twice in the year meeting will
be chaired by the Secretary Health Department and once a year the
meeting will be chaired by the Chief Secretary Sindh.
Stewardship of any public sector initiative is mandatory, in an order to
steer the project, identify the technical issues and provide the
necessary technical inputs, a technical committee will be constituted,
comprising of following.
1. Technical Committee
Director General Health Services
Chairman
Program Manager
Secretary
Provincial Coordinator PM’s Program
Technical Advisor
Additional Secretary Development Wing
Member
Provincial Hepatologist and Pathologist
Member
Secretary Blood Transfusion Authority
Member
Project Director EPI
Member
Program Manager HIV/AIDS Program
Member
Director Public Health DGHS
Member
Representatives of International
Members
Development Agencies in Sindh
Chief (Health), P&D Department
Member
Provincial Coordinator LHW-Program
Member
One Medical Superintendent and Executive District Officer (Health)
will be nominated on rotatory basis, for a better input from the end
user’s perspective.
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Committee will meet on quarterly basis and minutes will be shared
with all the partners. To provide an overall strategic guidance to the
program implementation unit a Steering Committee with following
composition. Committee will meet every two months to review the
progress.
2. Steering Committee:
To provide the strategic guidance to the program implementation unit
and strengthen the interdepartmental linkages a Steering Committee
with the following configuration will be notified:
Additional Chief Secretary P&D
Chairman
Secretary Health Department
Member
Director General Health Services Sindh
Secretary
Rep. Finance Department not less than AS
Member
Rep. Law Department not less than AS
Member
General Secretary Pakistan Medical Association
Member
Representative of NRSP Consortium
Member
Representative of AKHSP
Member
Director SIUT
Member
Vice Chancellor DUHS
Member
Program Manager
Member
For a broad based coverage of the population inputs in the patients’
selection will be taken from the NGOs working with Rural Support
Program and PPHI.
3. Procurement Committee:
The Procurement Committee will be formulated by the Project
Steering Committee with the incorporation of relevant experts.
4. Provincial Task Force
The objectives of the initiative need highest level commitment and
sustained inter-sectoral collaboration. For ownership and
stewardship at the higher level a Provincial Task Force will oversee
the implementation of the initiative. The task force will meet once a
year and provide necessary stewardship. The composition of the
task force will be as follows.
1. Chief Secretary Government of Sindh
Chairman
2. Additional Chief Secretary (P&D)
Co-Chairman
3. Secretary Health Department
Convener
4. Secretary Finance Department
Member
5. Director General Health Services
Member
6. Deans Faculty of Medical
Page | 24
LUMHS Jamshoro & DUHS Karachi
7. Program Manager CM Initiative
8. (3) District Coordination Officers
On rotation basis
7. Capital Cost Estimates
8. Demand and Supply
Analysis
Member
Secretary
Members
COST IN YEAR 1
COST IN YEAR 2
COST IN YEAR 3
795,141,368
797,020,168
735,186,668
The cost estimates are based on the market surveys and previous
experience of the Prime Minister’s Program for Prevention and
Control of Hepatitis, as on May 2008.
Total Project Cost:
Rs. 2350 Million in three years
See annexure IX
Viral Hepatitis has emerged as a common blood borne infection in the
community. High number of patients is identified through the
surveillance system of PM Program as given above. The current
estimate for number of Chronic Viral Hepatitis patients is 3.1 million in
Sindh alone. The number is likely to increase if a comprehensive,
vigorous and sustained provincial input is not provided.
A mismatch exists between the public demand for information,
vaccines, diagnostic and curative services.
At present the Federal Ministry of Health is providing;
1. Preventive Vaccine for 50,000 people per year
2. Screening Kits for 36000 patients per year
3. Free of cost PCR Test facility for 800 patients per month
4. Treatment for 250 patients of chronic Hepatitis B
5. Treatment for 1740 patients in year 1 and 2500 patients of
Hepatitis C in year 2
Details of the supplies made by the Federal Ministry of Health till date
is given as annexure X.
As per estimation Prime Minister’s Program for Prevention and
Control of Hepatitis is providing:
1. Vaccination to 1 in 800 persons.
2. Screening facility to 1 patient of Hepatitis in 86 patients.
3. Treatment of Hepatitis B to 1 in 6000 patients
4. Treatment of Hepatitis C to 1 in 450 patients.
On the contrary the demand side of the intervention mismatches the
supply. Substantial of patients are put on the waiting lists and supply
from Ministry of Health is outstripped by the demand.
The existing Program Unit has developed an effective linkage with the
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District Governments and has attempted to meet the demand side by
diverting the district finances into the Hepatitis Prevention and
Control Activities. The magnitude of district support has matched the
curative component of the federal program for the year 1 of its
implementation (see annexure XI).
Market failure exists in the provision of treatment against Hepatitis C
hence the government intervention is needed in the case.
The CM initiative will reach up to 1000 patients of Hepatitis C in each
district and 2000 patients of Hepatitis B per year for 03 years. As all
the 03 tiers of government are financing the treatment component
and program vouches to prevent the acute infections, it is anticipated
that community demand will be met.
9. Source of Financing
10.Program benefits and
analysis
Proposed financing of the scheme is as under
1. Federal PSDP
Rs.
2,350
Million
2. Provincial ADP
In three years
3. District Government
4. Pakistan Bait-ul-Maal
5. Donor agencies support
Viral Hepatitis B & C are chronic diseases, which by the morbidity
cause huge loss in the human capital and consequently the
consumption rate per capita and revenue generation for the state.
There exists a market failure in the treatment of Hepatitis and existing
interventions improve the health of population without increasing the
cost of society greater than benefit. Moreover large externalities exist
through preventive intervention.
Published Research, Needs Assessment Exercise and inputs from
various partners suggests that the disease is rampant in small towns
and peri-urban slums. An area with a low earning population referring
to a nearby quack for health needs and getting unnecessary injection
delivery is a typical scenario of disease spread in Sindh. Hence all the
District Headquarter Hospitals / Major Hospitals will be expecting at
least 1000 patients of Hepatitis B and C respectively for 10 years. In
the same context diagnostic needs of the population is expected to be
quadrupled in next five years owing to the level of awareness and
other variables.
The Chief Minster’s Initiative for Hepatitis Free Sindh has a larger
societal benefit of raising the awareness of people and hence
preventing the disease spread. The Program vouches to save the
valuable human resource from the morbidity and mortality due to
Page | 26
Viral Hepatitis and thus qualitatively contributes to the boosting of
local economy and National GDP.
The initiative will also create direct employment opportunities for the
skilled and un-skilled workforce. 25 vacancies will be generated
through this initiative which will serve to reduce the unemployment in
the province. The positions will be shifted to the non-development
side after 03 years of the program implementation.
Delay in the program implementation will increase the number of
patients and cost of equipments and consumables due to inflation.
Year of Start:
2008-09
11. Implementation schedule Year of End:
20010-11
of the project. (A)
The Item-wise/year-wise implementation schedule in line chart corelated with the phasing of physical activities will be prepared by the
Program Manager / Deputy Program Manager in the first quarter of
implementation.
As described above the initiative will be monitored on a systems
(B)Result Based Monitoring
model of input, process, and output. The logical framework will
Indicators
provide the major RBM Indicators. However by first quarter of the
implementation a detailed M&E Framework with indicators duly
approved by the technical committee will be formulated.
The Initiative will be implemented through a Program Implementation
Unit headed by a Program Manager. The details of the staffing
position are attached as annexure.
12. Management Structure
Provincial Coordinator PM Program will serve as the Technical Advisor
of the project
to the Health Department Government of Sindh on the interventions
of the program.
The steering committee will decide the strategic direction to the
program and technical committee will monitor the progress on the
Objectively Verifiable Indicators.

13. Additional Project /
Decision Required to
maximize the socio
economic benefits from the
project



Sustained political commitment to the slogan of Hepatitis Free
Sindh.
A potent and sustained anti quackery drive is required for the
success of the project
It is also pertinent that HepB3 Coverage of the province
reaches more than 98% to produce a birth cohort immunized
against Hepatitis B and hence producing the herd immunity in
the community.
Sustained supply of vaccine in the global market.
Page | 27
CERTIFICATE:
This is to certify that PC-1 has been prepared as per instructions
for the preparation of PC-1 for social sectors
Prepared By:
Dr. Zulfikar Ali Gorar
Provincial Coordinator (Sindh)
Prime Minister’s Program for
Prevention and Control of Hepatitis
Checked By:
Dr. Ghulam Nabi Memon
Director General Health Services Sindh
Verified By:
Dr. Srichand Ochani
Additional Secretary (Development Wing)
Health Department Government of Sindh
Approved By
Mohammed Hussain Syed
Secretary
Health Department Government of Sindh
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