Decentralised care in Punjab

Project overview

This project aimed to develop, pilot and evaluate an integrated hepatitis C care package at 51 rural health centres (RHCs) in six high-burden districts of Punjab. The project aimed to achieve hepatitis C universal coverage in the entire Punjab region by catalysing evidence-based scale-up in the remaining 30 districts of Punjab. 

Context

Punjab province has 36 districts and a population of around 110 million. The seroprevalence of hepatitis C infection is exceptionally high at 8.9%. The project will pilot and evaluate integrated hepatitis C care at RHCs in the six highest-prevalence districts of Punjab. 12.5 million people live in these six districts, of which around 75% live in rural areas. All 22 district and sub-district hospitals are in urban settings, so program-supported hepatitis care at these hospitals is relatively inaccessible to most rural inhabitants, especially women and disadvantaged groups. In these districts, 51 RHCs are the primary source of general health care for more than 9.5 million rural inhabitants.

Outcomes

As part of this project, more than 78,000 individuals vulnerable to viral hepatitis were screened at the primary healthcare level in Punjab; 39% of the tests came back positive.
After confirmatory testing, almost 11,000 screened people received programme-supported HCV treatment at RHCs.
Decentralisation of care – to get closer to people vulnerable to viral hepatitis – was a vital aspect of the project: 461 basic health units were enabled and engaged in HCV rapid testing and were referred for care at RHCs. The integrated hepatitis C test-treat-prevent care intervention was adapted and piloted at 48 rural health centres in six selected districts of Punjab.

Catalytic impact

• The Punjab hepatitis control programme will continue the ongoing human, material and PCR testing inputs for sustained hepatitis care at 48 rural health centres in six districts of Punjab.
• The experience of integrated hepatitis care at RHCs and Basic Health Units has encouraged and informed the Sindh Hepatitis Control Programme to plan the province-wide implementation of similar programmes using the protocols and materials adopted and tested in the rural areas of Punjab.
• The project’s early implementation experience of integrated hepatitis care at primary-level health facilities is being considered to
  explore Global Fund funding to integrate hepatitis “test-treat-prevent” into the ongoing care of people living with HIV and key populations. ASD is now aiming to get additional Global Fund funding for extending hepatitis HIV co-morbidity care and prevention activity in Pakistan.
• A meaningful engagement of the Directorate General Health Services (DGHS) and the Hepatitis Control Programme in project development, implementation and evaluation has enabled the programme to sustain hepatitis care at rural health centres beyond the project life.
• The implementation has encouraged the government’s Provincial Hepatitis Control Programme to consider wider scaling of integrated hepatitis care in Pakistan. This province-wide scaling has also been facilitated by providing master trainers for training district-level trainers in the province.

Measures implemented for sustained hepatitis care include:

• The programme has now taken over the supply of rapid test kits, initially supported by the THF grant.
• PCR testing was supplemented through project sources for the first five months. Then, with DGHS endorsement, the activity was fully transitioned to the public-programme sources. This has been a significant development for sustained integrated hepatitis care at RHCs.
• For the length of the project, ASD was able to mobilise public resources for hepatitis care (rapid testing, PCR testing and HCV direct-acting antiviral, or DAA, drugs) at rural health centres. These programme inputs enabled the grantee to extend the implementation period, expand the scope and offer care benefits to more people. Also, by linking people with hepatitis to public-funded laboratory services at
  (sub)district hospitals, ASD has saved direct programme and project expenses.