iven that diseases such as the Plague, SARS, HIV/AIDs and Avian Flu do not respect national boundaries, the news of Avian Flu in our immediate neighborhood, left a slim choice between treading the prevent-prepare-control options a week ago. However its detection on an NWFP farm yesterday, made choices much clearer. Ever since Avian Influenza (H7N3) hitPakistanin 2003-04 and was subsequently curbed at source in the agriculture and health sector through implementation of animal and human health surveillance, disease control and mitigation measures, some level of gearing up for another outbreak had been witnessed. Evidenced by news and other forms of reporting, efforts included the establishment of surveillance laboratories equipped to diagnose bird flu; enhanced allocations for strengthening surveillance and emergency preparedness and clinical, serological, and virological surveillance in migratory birds from different parts of the country. It is hoped that these investments will pay off given the recent emergence of the virus in NWFP.
However, the situation specific to Avian Flu and the earlier experience relating to the health situation consequent to the October 8 earthquake raise several policy questions for medium- and long-term planning. These relate to striking a balance between the short and the long-term measures; the capacity within the system to respond to a health crisis; the level of preparedness of the health systems to deliver emergency services; and most importantly, the extent to which a credible cost-effective and equity-focused analysis supports investments in these within a long term context. Three overarching issues of concern have been flagged here particularly with regard to medium and long-term planning.
Strengthening health systems: the threat of the Avian Flu looming has once again highlighted the need for strengthening what is generally the ‘invisible’ in the social sector – institutional systems and capacity. Decades of focus on programme-based service delivery and an over-emphasis on infrastructure development have led to neglect at the health systems level. On-ground analyses indicate that the success of any health programme depends on the robustness of the health systems; indeed one of the markers of such systems’ strength is the degree of preparedness and responsiveness to public health emergencies. Indeed many of the measures necessary to address the current challenge—particularly at the health sector level—are embedded in systems-level solutions. For instance, bulk purchase of anti-virals for people and vaccines for birds links in with procurement mechanisms in the public sector; their inventory management and distribution from central base/s to the grass roots level is dependent on a friction-less Federal-Provincial-District service delivery interface; the missed opportunities to deliver them through private sector health care providers ties in the need to leverage on the private sector to deliver state-mandated-health-related public goods and the ultimate provision of these vaccines and medicines at the grass roots levels forms an integral part of the service delivery potential of basic health infrastructure. Furthermore, designating hospitals for the treatment of the infected and equipping them to treat and care for affected individuals links in with issues of efficiency and sustainability. Prompt dissemination of standard treatment guidelines and training health workers in such diseases ties-in the role of continuing medical education programmes – currently nonexistent in the country. Systems-level solutions also need to be placed in the right structural, fiscal, and regulatory parameters; for example, another Avian Flu imperative which involves identification of laboratories for testing human and animal blood samples highlights the need for establishing a legal system that mandates the notification of diseases and regulates laboratory practices.
Strengthening systems must also proceed in tandem and with careful attention to the state asserting a stronger normative role. In the present situation guidelines for prevention and control of human cases of Avian flu influenza disease have been established by the National Institute of Health in collaboration with international partners; these must be widely disseminated. In addition, the State’s normative role in this situation needs to be further augmented within the broader context of the prevention- and control-focused methodologies and instruments.
Health Disaster Preparedness: secondly crises – natural or manmade – are marked by increased level of death and suffering and put health systems through complex and unique emergencies. Health policies should, therefore, incorporate disaster planning within their realm with a focus on preparedness, response, and recovery fostering collective responsibility to act effectively and enabling the development of new mechanisms and systems for health governance in the wake of these considerations. A National Health Disaster Preparedness Plan developed within an overarching disaster management framework is therefore, a strategic imperative; this must pay careful attention to mapping human resources and infrastructure, inventorising demands and developing contingency plans.
Health’s inter-sectoral scope: thirdly, it is well established that much of the scope of the public health work is conventionally placed outside the medical care service and that factors which determine health status range much broader than those which are within the realm of the health sector. Environmental changes such as global warming and changing ecosystems may have implications for spread of disease and its control; mass damage by biological weaponry is a possible threat to civil infrastructure with serious public health implications; natural disasters raise public health issues of great significance; humanitarian crises as a result of conflict and acts of terrorism are known to impact health status of those affected and global pandemics such as the recent SARS and Avian flu epidemics have cut health across the global economy and allied sectors, taking health concerns to a completely different level.
It is therefore imperative that alternative policy approaches be developed for health within an inter-sectoral scope. This necessitates a redefinition of objectives and targets within the health sector in order to garner support from across the sectors. However, these need to be set within a more explicit policy framework in order to foster inter-sectoral action. Relevant ministries and organizations need to own this approach and participate in a manner, which is mutually supportive of common goals. Support for this should come from the highest ministerial level in each instance and should also reflect the support of the Cabinet. Within this context, Avian flu is a case in point which ties the role of many government departments and the private sector.
With the threat looming, it is understandable that policy objectives must focus on short term planning; as part of such efforts mobilizing the public as a key partner in beating the disease, measures to compensate poultry owners and encouraging them not to conceal a bird flu outbreak by providing specific incentives, and formulating a short-term incident management program with clear designation of roles and responsibilities and a command and control system to effectively minimize loss in the event of an outbreak are therefore justified. However, daunting as they may seem – these should not prevent institutionally sustainable action set within the long term perspective given that this would be critical to strengthening the systems’ ability to cope with such disastrous events in future.