Pakistan has many institutional mechanisms in place for the prevention and control of Pandemic Influenza H1N1 but these are plagued with fragmentation, duplication and resource constraints. Hence, the impression that compared to many other Asian countries, the outbreak of Pandemic Influenza H1N1 2009 was comparatively of minor concern to Pakistan, was misplaced. A lot of cases had been missed or under-reported due to the absence of a well-established and integrated countrywide surveillance system.
These views have been expressed by the president of Heartfile, Dr. Sania Nishtar, in a paper that has just been published by the Singapore-based RSIS Centre for Non-Traditional Security Studies. The paper focuses on one aspect of health security-epidemiological security-which deals with threats from emerging and re-emerging infections, in particular specific lessons from the recent H1N1 outbreak.
One of the key lessons that Pakistan has learnt during the outbreak of Pandemic Influenza H1N1 2009 and previous outbreaks of pandemic influenza is lack of inter-sectoral and intra-sectoral coordination between various institutional arrangements. Even in one province, there are instances of many duplicating donor supported structures. This lends ambiguity to the chain of command, responsibilities and roles.
In addition to duplicating structures, another lesson learnt after H1N1 relates to the realization that the International Health Regulations (IHR) 2005 signed by the government of Pakistan is not yet functionalized, Dr. Sania believes. “The considerably under-detected cases of H1N1 indicate that commitments under IHR 2005 have not been fulfilled,” she states.
The estimated population of Pakistan is around 165 million and the total number of laboratory confirmed cases is only 262, thus the approximate cumulative attack rate (AR) is 0.15/100 000. “This statistical measure suggests that the impact of H1N1 in Pakistan was the lowest in the world. It could also indicate that a lot of cases had been missed or under-reported due to the absence of an established surveillance system. The case fatality rate (CFR%) was considered the highest in the world. This figure (11.1%) may have been the result of a huge under-estimation of detected/reported cases of A/H1N1. The considerably under-detected cases of pandemic A/H1N1 (262 cases with 29 deaths), under-reported to WHO, might indicate that commitments under IHR 2005 have not been fulfilled,” Dr. Sania writes in the paper.
The analysis reveals that Pakistan does not have the fiscal space to support programmes that may need to be launched/scaled up in emergency situations. The heavy reliance of the National Programme for Prevention and Control of Avian and Pandemic Influenza on donor contributions makes it highly unsustainable in the future.
The paper also highlights the fact that despite the existence of an elaborate infrastructure to collect information, easy-to-bridge gaps still abound. For example, there is more than a three-month delay before information reaches from the districts to the central Health Management Information System (HMIS) level, which is where the analytical capability exists.
Although Pakistan has many health information systems-related institutional arrangements, there is no apex agency to systematically collect, consolidate, analyse and interpret information, and relay it in a timely manner for mainstreaming into the decision-making process. This is one salient aspect, which finds a mention in Dr. Sania’s paper. “The Ministry of Health should mandate apex responsibility to an agency that it should work closely with. However, the agency should have some degree of independence,” she recommends.
Referring to a host of other challenges, Dr. Sania eventually recommends the creation of a Health Incident Management System in Pakistan-a system, which incorporates disaster planning within its realm with a focus on preparedness, response, and recovery. Such an institutional entity should foster collective responsibility to complex and unique emergencies-natural or manmade.
In conclusion, Dr. Sania has identified poor performance of the country’s health system as being the foremost factor that stands in way of ensuring disease security. “The pervasive pattern of graft in the field delivery of services was a consistent observation in relation to delivery of vaccine and medicines in the wake of the H1N1 outbreak. In addition, factors related to security, law and order and energy security also impact field operations. In the event of another outbreak, Pakistan will be particularly vulnerable due to its many systemic constraints,” Dr. Sania warns.
The H1N1 outbreak, which was initially known as Swine Flu and subsequently recognized as the 2009 Pandemic Influenza A H1N1, emerged in Mexico in March 2009 and subsequently spread rapidly to many countries of the world. By November 2009 more than 622,482 cases and 13554 deaths had been reported. The WHO had officially declared much earlier in July 2009, that the world was in the midst of a novel H1N1 influenza pandemic.