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Poor picture of health

January 17, 2013

RECENT months have seen the deaths of some 300 children in Sindh, due to measles which is both preventable and treatable.

No heads have rolled, however, and no sign of remorse on part of the authorities is in evidence even though the situation speaks volumes for their inefficiency. It is deeply disturbing that Pakistan has not been able to address a primary healthcare problem as basic as measles.

The measles outbreak was reported in the upper Sindh region late last year. The affected region is comprised of districts located on the right bank of the River Indus; this is the area that bore the brunt of the massive flooding in 2010.

That setback was compounded by belated monsoon rains in 2011, which caused enormous damage to farmland and left the peasantry devastated. Now, the people of this region are losing children to measles.

While the floods left millions homeless and displaced, as well as exposed them to food insecurity and malnutrition, such a high number of fatalities was not reported then. Many of these people are still living in makeshift camps in different areas and their condition has not on the whole improved much. In 2010, backed by Unicef, the Sindh government conducted a survey which revealed that children were facing serious nutritional problems. The National Nutrition Survey Pakistan 2011 later endorsed the findings of the provincial government.

While health authorities have cited post-measles complications as the main reason behind the children’s deaths, the facts above show that the situation should be viewed more thoroughly.

The authorities tend to ignore the reasons that caused a measles outbreak in the first place. The rates of routine immunisation and vaccination in Sindh remain highly questionable.

True, there are communities where there is resistance to such protective measures, and there is a tradition in some pockets to take a sick child to a faith healer instead of a doctor. But these challenges are hardly new and the authorities are well aware of them. The blame for not addressing these realities and putting in a greater effort to vaccinate children must lie on them.

The Sindh health department has its own expanded programme on immunisation (EPI) wing, which is headed by a dedicated project director.

It has close to 2,500 qualified vaccinators at its disposal at different tiers, such as those associated with the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation), permanent and contractual employees.

Despite this, according to the Sindh government’s own statistics, routine immunisation levels are below the accepted standard.

Sindh EPI figures claim a 65 per cent routine immunisation rate in the province during 2010, and no outbreak of measles. The routine immunisation benchmark for Pakistan is 80 per cent. In terms of measles, 81 per cent coverage is claimed and yet some 300 deaths have occurred. This renders the statistics doubtful.

The whole crisis can be summed up in one word: governance. At the level of the basic health unit, parallel systems are at work.

There is the NGO-run People’s Primary Healthcare Initiative (PPHI) that has its own interventions, and there’s the Sindh government. Both wrangle over their jurisdictions for the purposes of immunisation.

Meanwhile, it is well known that as in most government departments, in the provincial health department too transfers and postings are politically driven. The officers are apparently answerable to no one.

The Sindh health minister, Dr Saghir Ahmed admitted that the second-dose routine immunisation rate stands at 50 per cent. But he did not explain what action is taken against those responsible for this pathetic situation.

Health experts such as Dr Anita Zaidi, chairperson of the Aga Khan University’s Department of Paediatrics, say that as a component of the reduction of child mortality, immunisation is one of the eight main Millennium Development Goals.

To achieve the MDG target, we have to achieve 90 per cent immunisation in 80 per cent of the country. This target is likely to be missed.

By comparison, Bangladesh is reported as having achieved the 90 per cent immunisation benchmark, and has also been successful in eradicating polio. The country has seen significant success in controlling under-five child mortality, too.

Where Bangladesh has a child mortality rate of 50 per 1,000 live births, in Pakistan it is 80 per 1,000. The MDGs require member countries to reduce child mortality to two-thirds of what it was in 1990. For Pakistan, that was 150 per 1,000 live births.

The progress on immunisation is just as dismal. In 2009, an independent study was conducted in Karachi on the second-dose measles coverage. Randomly, 500 children were examined and it was found that the coverage was only 12 per cent. What this says about the likely figures in the rest of Sindh, especially in the interior, is downright depressing.

As far as immunisation is concerned, it seems there’s many a slip ’twixt the cup and the lip. The Sindh government has been unable to resolve its issues with the PPHI, which controls 1,135 health facilities in Sindh. The PPHI chief claims that immunisation is not part of its job under the memorandum of understanding, but the chief of the Sindh EPI insists that it is.

The performance of vaccinators, meanwhile, is poor. They complain that the government does not give them fuel expenses or a travel allowance. As a result, Lady Health Workers are tasked with carrying out vaccinations. These women are trained in maternal and newborn healthcare and the dissemination of primary health education. But measles vaccination requires greater expertise.

No wonder, then, that Sindh is seeing a measles outbreak. The province and other parts of the country need to put their house in order, or risk their future.

The writer is a senior reporter with Dawn.