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Health Management
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What is This?
Abstract
This article aims at exploring and analyzing reasons for the spread of dengue outbreak in Lahore,
Pakistan, in 2011. This led to about 300 deaths. Also, this study intends to review the appropriateness
of government response in managing the dengue outbreak. The contributing factors in the spread of
dengue disease included, among others, the demographic structure of Lahore district, environmental
conditions, and urbanization and slum development with lack of health facilities. Furthermore, mana-
gerial and coordination failures at the level of city district government aggravated the situation. The
governance failure was manifested by the non-framing of dengue disease as a public policy concern,
especially when it had affected almost 4,500 persons leading to three deaths in the year 2010. There
were coordination failures with tertiary level health institutions, and the city government was unpre-
pared. Concrete and effective steps were taken when chief minister of the Punjab province intervened
personally. The strategy adopted by the provincial government was so successful that in the year
2012, there were only 252 dengue cases and no deaths were reported. However, there is still need to
improve coordination at the city government level and to institute a preventive regime to manage an
outbreak in the future.
Keywords
Dengue epidemic, public health, health management, health systems, Pakistan
Introduction
Dengue fever (DF) is globally accepted as one of the most rapidly spreading vector-borne viral diseases.1
Current estimates are that 50–100 million people are infected by it every year (Jahan 2011; Porter et al.
2005; Sherin 2011). It has non-specific signs and symptoms (Hakim et al. 2011) and lacks specific treat-
ment (Sherin 2011). Only about 1 to 3 per cent dengue patients are diagnosed with dengue haemorrhagic
Iram Anjum Khan, Assistant Professor, Department of Management Sciences, COMSATS Institute of Information
Technology, Park Road, Chak Shahzad, Islamabad 44000, Pakistan. E-mail: ikhan@comsats.edu.pk
Faisal Abbas, Assistant Professor, Department of Management Sciences, COMSATS Institute of Information
Technology, Park Road, Chak Shahzad, Islamabad 44000, Pakistan. E-mail: fabbas@comsats.edu.pk
fever (DHF), requiring hospitalization and careful fluid management (World Health Organization
(WHO) 2010).
South Asian region has been found conducive to the spread of dengue and DHF. In 2011, virus
appeared in Lahore in the monsoon season, and though the number of suspected cases were 496,490
(WHO 2011), those actually infected were much less (see Figure 1). Figure 1 also substantiates the
panic-cum-crisis hypothesis when people started attributing even simple cold to dengue virus, which lab
tests showed was not the case. Analysis of data reported by WHO (2011) also indicates that out of all
suspected cases, about 4.15 per cent were found confirmed as dengue patients. Media further contributed
to the panic when it showed scenes of long queues outside hospitals and reported deaths occurring due
to the disease.
Scale of the outbreak, panic in the city and almost complete helplessness of the city administrators,
health officials and provincial government require that the whole episode spanning several months be
investigated. This article discusses reasons for the spread of the disease in the city of Lahore, the appro-
priateness of government response for managing it and the challenges for containing dengue virus in the
future (especially in cities as populated as Lahore).
The article is based on both primary and secondary sources. The primary sources of information are
the concerned public health officials in the city of Lahore. Different officers at City District Government,
Lahore, were approached to share their experience and knowledge of DF in the city, and discuss the
effectiveness of government response. For this purpose, an unstructured interview guide was prepared
and used at the time of interviews. The persons approached were four officials of City District
Government, Lahore, namely Director (Health), Executive District Officer (EDO Health), District
4000
Suspected
3500
3000
2500
2000
1500
Confirmed
1000
500
0
October November
Figure 1. Confirmed and Suspected Dengue Cases in Lahore (22 September–29 November 2011)
Source: Punjab Health Line (www.dengue.punjab.gov.pk). Accessed on 14 June 2012.
Officer (DO Health) and EDO Finance, as well as one health practitioner who attended training sessions
conducted by Sri Lankan experts, and who subsequently imparted training to his colleagues. The field
work also included interviewing one Sri Lankan expert who described his country’s experience of den-
gue virus management. The secondary sources are data and information available in published form by
the federal and provincial governments.
The rest of the article is organized as follows. The following section gives an overview of the dengue
disease in Pakistan. The next section gives basic information about the city of Lahore, its population and
health infrastructure, etc. Then different steps taken by the government for managing DF are discussed,
followed by discussion on reasons for the failure of government response. The last section analyzes the
efficacy of plans for the future and sums up the discussion.
SWMC
TMAs
DO (PH)
PHA
DDO (PH)
government rather than to the DCO (see Figure 2). These included, among others, Lahore Development
Authority, Water and Sanitation Agency (WASA), Solid Waste Management Company (SWMC) and
Punjab Horticulture Authority (PHA).3 This administrative polarization limited the effectiveness of the
DCO as a coordinating officer. The introduction of the district government system in Punjab in 2001 also
eroded his pivotal status as the lynchpin of administration at the district level (Khan and Ghalib 2012),
and this has persisted even after the district government system was rolled back in 2008.
Town and Municipal Administrations (TMAs), part of the City District Government of Lahore, had
their own rudimentary public health management system, primarily responsible for the spraying of
insecticide and fumigation to pre-empt malaria. However, they were constrained by shortage of staff and
lack of technical expertise to tackle the situation. They reported to the DCO, though in the now defunct
District Government (Zila Nazim) set-up; they also used to work independently of the DCO (Khan and
Ghalib 2012). The above discussion shows that there was unnecessary overlapping and bypassing of
higher authorities in the present city district government health management system.
Institutional Measures:
• Establishing a province level task force and steering committee to be headed by Chief Minister and
Chief Secretary of Punjab, respectively.
• At district level a district implementation committee formed under the aegis of DCOs.
• Chief Minister Dengue Research and Development Cell established in Lahore for the purpose of carry-
ing out applied and operational research in dengue.
Technological Measures:
• Provincial Government emphasized on utilizing latest technology in combating against dengue
epidemics.
• Online system of dengue surveillance put in place.
• Global positioning system (GPS) mapping of dengue cases, vectors and digital monitoring of dengue pre-
vention and control being carried out.
Environmental Measures:
• Environmental management measures taken, for example, proper disposal of waste water, repairing leak
pipes and plumbing system, using water filter for drinking water, management and regulation of used
tyres, etc.
Health/Medical Infrastructure:
• Isolation wards established in teaching hospitals and dependency units having all facilities.
• 200 extra beds in every teaching hospital allocated for dengue patients.
• 10,000 insecticide treated bed nets provided to each teaching hospital for dengue isolation wards.
• At Jinnah Hospital Lahore, Children Hospital Lahore and Lahore General Hospital, cell separator
machines with platelet kits made available on urgent basis.
• Remaining hospitals got centrifuge machines for platelet segregation.
Capacity Building Measures:
• Sri Lankan and Indonesian experts reviewed the strategies and provided guidance on larva surveillance
and capacity building on vector control and case management.
• 875 sanitary patrols, 337 CDC supervisors, 292 LHWs and 66 data entry operator job positions
created.
A toll-free hotline titled ‘Punjab Health Line Project for Dengue’ provided basic information about
dengue disease, and informed general public which hospital to approach in times of emergency and for
treatment. Experts educated the public about the symptoms of dengue disease. The Social Welfare
Department launched public awareness campaigns, and 49 camps were established in Lahore for this
purpose. UNICEF and WHO helped distribute 1.5 million pamphlets in the city. Private laboratories
were put under legal obligation to charge only PKR 90 for complete blood count test. Previously, they
were charging as much as PKR 500 per test.
The extent of panic can be gauged from the fact that Special Branch, Punjab police, was directed to
independently monitor the efforts of all the stakeholders and generate a report on a daily basis, while
daily progress report on disease spread monitoring was compiled from hospitals by the Irrigation
Department.
society in the elimination of larvae and adult vectors. However, no public awareness campaign was
launched in the initial days of the outbreak. The result was that the focus was mainly on clinical treat-
ment even after it had become clear that the best mode of combating the disease was through community
participation and changing the social approach.
with Lahore, there were four deaths in Karachi with more than 700 suspected dengue cases registered by
health authorities.8 This shows that the strategy adopted by the Government of Punjab for managing DF
was a successful one. Proactive and broad involvement of all stakeholders made it possible for the pro-
vincial government to control dengue virus.
Conclusion
The success of the dengue management strategy can be attributed to the initiative of the chief minister.
Unfortunately, despite personal interest taken by the chief minister, institutional bottlenecks continue to
persist due to myopic vision and prevalence of administrative expediency. Budgetary allocation for pre-
ventive health care continues to remain miniscule with the result that in case of another outbreak, suffi-
cient funds will not be available for media campaign or spraying activities. Ingrained weaknesses in the
coordinating role of DCO have also not been removed. In case of an emergency, he has no administrative
authority to rely on the support of autonomous agencies or tertiary medical units.
Dengue is closely related to the society (community) and the way it organizes its livelihood. The
experience of Lahore in the years 2011 and 2012 shows that there is a need to develop an optimal solu-
tion for instituting a comprehensive and sustainable policy regime which has the ownership of the public
and private sectors as well as the involvement of community at large. This requires close institutional
linkages and inter-agency coordination, specific job description, training and social awareness. The best
way to control dengue is to prevent it.
Notes
1. Before 1970, only nine countries had experienced dengue disease. However, the number increased to more than
100 in the year 2004–2005 (WHO 2009).
2. 1 US dollar = 99.50 Pakistani rupees.
3. This is an excerpt of the district administration in Lahore. The full organogram of city district government is very
complex and not relevant to this article. Hence, we rely on rather simpler version to elaborate our point as to how
various administrative bodies interact and coordinate in times of crisis (e.g., public health crisis).
4. Interview with District Officer (Health), City District Government, Lahore.
5. Interview with EDO Finance, City District Government, Lahore.
6. Budget Documents 2011–2012, City District Government, Lahore.
7. http://dawn.com/2012/11/11/steps-of-punjab-govt-against-dengue-hailed/
8. http://archives.dailytimes.com.pk/karachi/13-Dec-2012/4-dengue-fever-deaths-reported
References
Ahmed, S., F. Arif, Y. Yahya, A. Rehman, K. Abbas & S. Ashraf (2008). Dengue fever outbreak in Karachi 2006—a
study profile and outcome of children under 15 year of age. Journal of Pakistan Medical Association, 58(1),
4–8.
Chan, Y.C., N.I. Salahuddin, J. Khan, H.C. Tan, C.L.K. Seah, J. Li & V.T.K. Chow (1994). Dengue haemorrhagic
fever outbreak in Karachi, Pakistan. Transactions of the Royal Society of Tropical Medicine and Hygiene, 89(6),
619–20.
Hakim, S.T., S.M. Tayyab, S.U. Qasmi & S.G. Nadeem (2011). An experience with dengue in Pakistan: An expanding
problem. Ibnosina Journal of Medical and Biomedical Sciences, 3(1), 3–8.
Jahan, F. (2011). Dengue fever (DF) in Pakistan. Asia Pacific Family Medicine, 10(1), 1.
Jamil, B., R. Hasan, A. Zafar, K. Bewley, J. Chamberlain, V. Mioulet, M. Rowlands & R. Hewson (2007). Dengue
virus serotype 3, Karachi, Pakistan. Emerging Infectious Diseases, 13(1), 182–3.
Khan, I.A., & A.K. Ghalib (2012). Absence of vertical linkages and the quest for decentralized service delivery in
Pakistan: An innovation under constraints. International Journal of Public Administration, 35(7), 482–91.
Mazhar, F. & T. Jamal (2009). Temporal population growth of Lahore. Journal of Science Research, 39(1), 53–58.
Porter, K.R., C.G. Beckett, H. Kosasih, R.I. Tan, B. Alisjahbana, P.I.F. Rudiman, S. Widjaja, E. Listiyaningsih,
C. Ma’roef, J.I. Mcardle, I. Parwati, P. Sudjana, H. Jusuf, D. Yuwono & S. Wuryadi (2005). Epidemiology of
dengue and dengue hemorrhagic fever in a cohort of adults living in Bandung, West Java, Indonesia. American
Journal of Tropical Medicine and Hygiene, 72(1), 60–66.
Punjab Bureau of Statistics (2011). Punjab Development Statistics, 2011. Lahore: Government of the Punjab.
Sherin, A. (2011). Dengue fever: A major public health concern in Pakistan. KUST Medical Journal, 3(1), 1–3.
Shakoor, M.T., S. Ayub & Z. Ayub (2012). Dengue fever: Pakistan’s worst nightmare. WHO South East Asia Journal
of Public Health, 1(3), 229–31.
Siddiqui, F.J., S.R. Haider & Z.A. Bhutta (2009). Endemic dengue fever: A seldom recognized hazard for Pakistani
children. Journal of Infections in Developing Countries, 3(4), 306–12.
Vijayakumar, T., S. Chandy, N. Satish, M. Abraham, P. Abraham, G. Sridhavan (2005). Is dengue emerging as a
major public health problem? Indian Journal of Medical Research, 121(2), 100–07.
WHO (2009). Dengue Fever World Health Organization Fact Sheet No. 117. Geneva: World Health Organization.
——— (2010). Weekly Epidemiological Bulletin, 1(10), Nov. 4, 1–8. Islamabad: Federal Ministry of Health,
Government of Pakistan, National Institute of Health, Islamabad and World Health Organization.
——— (2011). Weekly Epidemiological Bulletin, 2(46), Nov. 21, 1–7. Islamabad: Federal Ministry of Health,
Government of Pakistan, National Institute of Health, Islamabad and World Health Organization.