KARACHI: The fate of fistula centres across the country hangs in the balance as the United Nations Population Fund (UNFPA) has substantially reduced its funding to the facilities while there has been no definitive indication from the government on how they will be run, it emerged on Sunday.

According to sources, the UNFPA has been funding initiatives for fistula treatment since 2005, though the memorandum of understanding the organisation signed with the Pakistan government was only for five years. Under the agreement, the government was supposed to take over the facilities developed by the foreign donor organisation.

Out of the 13 fistula centres established in the country by the UNFPA at public sector hospitals, two facilities (one at the Civil Hospital Karachi and the other in Larkana at Sheikh Zayed Women’s Hospital) have closed down, and as many shifted to private hospitals due to lack of government support.

Currently none of the public sector hospitals in Sindh are providing treatment for fistula.

It is estimated that 3,500 to 4,000 obstetric fistula cases occur in Pakistan every year. The birthing injury caused by prolonged obstructed labour results in a hole between the vagina and rectum or bladder that leaves a woman incontinent of urine or feces, or both.

Only a few hundred patients, however, receive treatment owing to a lack of relevant facilities.

“We have held meetings with respective provincial governments and though a lot of promises have been made, nothing has been done on the ground,” said a UNFPA representative on condition of anonymity as he wasn’t officially authorised to speak to the media.

The organisation, he said, had told officials in Pakistan that its funding support had already over-stretched and it was time the provincial governments took over the centres.

The governments of Sindh and Balochistan, he pointed out, had shown positive signs but had not implemented a single step, as discussed in the meetings, to create awareness, train doctors and set up fistula centres at public sector hospitals.

The Khyber Pakhtunkhwa government, he said, wasn’t ready to make any commitments since officials claimed the entire health system in the province had changed and so they were not in a position to provide any assurances. There have been no assurances from the Punjab government either.

“Treatment for fistula should be provided at public sector health facilities since it is the poorest of the poor women who suffer from it in the absence of emergency obstetric facilities in remote areas,” said the UNFPA representative.

It is noteworthy that the UNFPA officials at a press conference in Karachi a few months ago had publicly stated that they could no longer provide support to the fistula project currently being run across the country on account of serious resource shortage.

Current funding status

Sources at the UNFPA said that the organisation initially provided the infrastructure and training required for fistula treatment. Patient treatment and travel costs were also funded to the maximum on request.

“Earlier, we entertained requests for up to Rs30,000 per patient but this year a limit of Rs10,000 has been imposed,” an official said.

Dr Tayaba Majeed at the Central Park Teaching Hospital (CPTH), Lahore, believed that the amount was not sufficient to meet the needs of the patient. She, along with another doctor, took the initiative to start the UNFPA-supported fistula centre in Lahore at the private CPTH after the one at the public sector Lady Willingdon Hospital was closed down over three years ago.

The CPTH provides highly subsidised treatment with the support of the hospital and UNFPA, she said.

“The centre closed down at the public sector hospital because the government couldn’t take its ownership; patients were not given due attention after admission and gradually their number dropped,” she explained.

On an average a fistula surgery cost between Rs25,000 and Rs30,000 but this can increase due to upon complications, she said.

“Besides, there are bed, lab investigation and medicine charges. Right now, a major chunk of this amount is being paid from hospital funds,” she said.

“There is a serious funding issue. The amount set by the UNFPA is absolutely not sufficient, even to meet the cost of medicines.

“Patients of obstetric fistula must not be charged for treatment as they all belonged to poor families. The government must come forward, own and run fistula centres,” she observed.

Expressing a similar opinion, Dr Pushpa Srichand at the Irsa University Hospital, a private hospital in Hyderabad, that now runs the fistula centre earlier being run at the public sector Liaquat University Hospital (LUH), said the fistula centre closed down at the LUH following her retirement. It was started later at the Irsa hospital when she joined it.

“We provide free-of-cost service to all patients with hospital and UNFPA support,” she said.

Mukhtar Siyal, former fistula coordinator in Larkana said: “The centre at Sheikh Zayed Women’s Hospital had to be closed down because doctors were more interested in their private practice than in a welfare job. I think the government should have intervened and taken responsibility for fistula patients, all of whom are now referred to the Koohi Goth hospital in Karachi.”

Dr Shershah Syed representing the Koohi Goth charity hospital said the facility, initially developed for fistula treatment, now served as a general hospital exclusively for women.

“Without an endowment fund, it would have been very challenging to treat patients for free. The UNFPA funding has been cut down but still very critical since no support from the government is coming.”

Dr Shah, also a petitioner in a case seeking government support for fistula patients, said that three months ago the court had directed the government to set up a committee to suggest measures to address the issue but no action had been taken yet.

“This reflects official apathy,” he said.

Upon contact, the UNFPA avoided giving a statement on the funding status and its contacts with the respective provincial governments.

To a series of queries sent through email, the official response received from the UNFPA was that “the provincial governments’ response has been encouraging but there is much more which needs to be done to scale-up services.

“The UNFPA applies different funding modalities to countries based on the context of the country. The funding landscape, however, is changing globally, so we periodically reassess our interventions to ensure that they make a difference in the lives of women and young people.

“Since Pakistan is classified as a middle-income country, UNFPA’s support is focusing on policy-level work, building the capacity of institutions, and generating knowledge.”

No government official was available for comments.

Published in Dawn October 3rd, 2016