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Clinical Laboratory Networks for Human and Animal Health in Pakistan and North America
PUBLIC HEALTH CLINICAL LABS IN PAKISTAN
Aamer Ikram welcomed the opportunity to speak about strengthening and sustaining a network of public and animal health clinical laboratories in Pakistan. He began by quoting Lucy Gilson of South Africa, who said, “It takes value-based leaders, throughout the health system, who are willing to take risks, learn through practice, and nurture relationships with others in the system.”
As background, Ikram noted that Pakistan is a country of about 800,000 square kilometers, and in 2016 had a population of more than 200 million (see Figure 2-1). The annual birthrate is about 4.2 million. The country is active in international public health efforts: It is a key member state of the World Health Organization (WHO) and has sought to fulfill the Millennium Development Goals and its obligations under the International Health Regulations (IHRs). In Pakistan in 2016, life expectancy was approximately 66.8 years, infant mortality was 60.5/1,000, and the population growth rate was 2.1 percent.1
Life sciences are considered a high-priority academic and research area, with a robust number of publications in agricultural and biological science (1,819 in 2013, up from 1,101 in 2009); pharmacology, toxicology and pharmaceutics (551 in 2013, up from 224 in 2009); veterinary science (166
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1 Data retrieved from https://data.worldbank.org.
SOURCE: Library of Congress, Geography and Map Division. 2010. Pakistan, administrative divisions.
in 2013, up from 78 in 2009); and immunology and microbiology (261 in 2013, up from 209 in 2009).2
WHO has identified six building blocks of national health services and systems: leadership/governance, health financing, health workforce, products and technologies, information and research, and service delivery.3 Ikram presented a situational analysis related to some of these elements. Pakistan has a three-tiered healthcare delivery system (primary, secondary, and tertiary), with a sizable private sector. At the community level, there are numerous healthcare professionals, including Lady Health Workers,4 who work at basic healthcare units.5 They provide referrals to rural health centers, tehsil hospitals, and district hospitals.6 It is at this level that diagnostics occur, free of charge for all patients. Teaching hospitals are at the tertiary level. In 2017, national expenditures on health in Pakistan were 0.9 percent of Gross Domestic Product, and about 14.1 USD per capita for domestic general government healthcare expenditures.7
Communicable diseases make up 40 percent of all disease in Pakistan.8 Surveillance mechanisms exist through the National Institute of Health, Pakistan. There are also some vertical programs, such as those fighting tuberculosis (TB), HIV, and malaria. A disease surveillance system is also currently operating in some parts of Pakistan. The District Health Information System records information on health events and monitors the availability of critical physical resources of peripheral health facilities. Diagnostic information has not yet been integrated into the system. Diagnostics are the backbone of a healthcare system, which depend on the clinical
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2 Ikram, Aamer. 2016. Strengthening and Sustaining a Network for Public and Animal Health Clinical Laboratories in Pakistan. A Joint Pakistan-U.S. Workshop on Strengthening and Sustaining a Network of Public and Animal Health Clinical Laboratories in Pakistan. Islamabad, September 27-29. See http://www.bwpp.org/documents.
3 For more information, see WHO. 2007. Everybody’s business—strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva. http://www.bwpp.org/documents.html.
4 See p. 45 of this report for more information about Pakistan’s Lady Health Worker program.
5 For more information see https://www.who.int/workforcealliance/knowledge/resources/casestudy_pakistan/en.
6 Tehsil and districts may be understood as roughly analogous to counties in the United States.
7 World Bank. 2020. Domestic general government health expenditure per capita (current US$)–Pakistan. https://data.worldbank.org/indicator/.
8 Ikram, 2016.
assessment quality of the staff and overall quality assurance. There is no lack of quality staff, but better organization is needed across the system to improve diagnosis and treatment, Ikram said.
Pakistan subscribes to the One Health approach that encompasses human health, animal health, agriculture, food safety, water and sanitation, and chemical and radio-nuclear safety labs. When considering a systemic approach to providing quality care for humans and animals, a balance must be found and maintained between public and private labs, large and small labs, and rural and urban labs. When the system is well balanced, patients will receive the correct diagnosis and treatment, Ikram said.
A system assessment and gap analysis conducted in Pakistan revealed where improvements are needed. Among the multiple challenges in the country are the need for a laboratory licensing system, the need for accreditation/certification, the need for additional qualified staff, the need for uniform adaptation of quality assurance standards, the need for additional authentic reagents/kits, and the need for safe and secure waste disposal. National initiatives to address these challenges are being conducted by national groups under the Ministry of National Health Services, Regulation and Coordination. The National Laboratory Working Group (NLWG) is addressing issues such as biosafety, biosecurity, and antimicrobial resistance, Ikram said. Requisites of an improved laboratory system include laboratory policy and strategic plan development, in-country training curriculum, attention to quality management and biosafety, and compliance with IHRs. WHO helped to conduct an initial exploratory mission with the NLWG to identify recommendations and activities necessary to achieve compliance.
Synergy develops through bringing different stakeholders together on one platform, facilitation by authorities, and support from international agencies. The key need is to strengthen the laboratory structure. An accreditation and certification program, audit and licensing bodies, and interdisciplinary approaches (One Health) are major components of this effort. Resource mobilization and collaboration are a necessary part of the strategic plan. Resources can be mobilized through strategic planning for program funding, efficient negotiation with bilateral and multilateral donors, skillful management, enhanced credibility, regionalization of healthcare services, integration of current vertical programs, and public-private partnerships. Through the National Action Plan,9 Pakistan seeks to promote cooperation
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9 Ibid.
and coordination among government departments and the private sector, academia, and non-governmental organizations. An oversight bod(ies) is needed to implement regular reviews of progress toward completing the National Action Plan and implementation of additional measures.
There should be a regionalization of healthcare services with functional specificity integrated into a comprehensive primary healthcare system at every level. Ikram emphasized that collaboration is needed to meet challenges and move ahead, including building epidemiological and laboratory capacity in the context of revised IHRs, addressing patents and intellectual property rights, and improving supply chain management. Pakistan has been supported in these efforts by WHO, including with technical assistance. Bilateral donors include the Central Emergency Response Fund, The European Commission Office for Humanitarian Aid, Finland, the Saudi Fund for Development, U.S. Agency for International Development, and AusAid.
Taken together, the multiple efforts of the government of Pakistan and multiple partners seek to create a robust Web of Prevention as seen in Figure 2-2.
LABORATORY NETWORKS: KEY TO SUSTAINING QUALITY MANAGEMENT AND COMMUNICATION—LESSONS LEARNED AND PRACTICAL CONSIDERATIONS
May Chu, a workshop participant from the United States, began her presentation with the concept of a network, which rests on the embedded “work” of all of the people who develop and sustain it over time. The success of any network requires a vision of success to bring people together to work toward that vision. Each country’s laboratory structure fits into the global network. The world needs Pakistan to be an active part of the global network, particularly on critical issues such as antimicrobial resistance. Given cell phone technologies and the interconnected nature of the world, there is no reason not to participate in these systems.
Laboratory Networks in the United States and Canada
U.S. laboratory services and networks encompass academic labs, animal health services, environmental health labs, clinical medicine labs, and public health labs. The U.S. Code of Federal Regulations describes the authority and limits of a public health lab, clinical testing, environmental
SOURCE: Ikram, 2016.
test standards, and agriculture or animal health test standards. The Food and Drug Administration (FDA) and Newborn Screening Labs have adopted International Organization for Standardization (ISO) 15189 and ISO 17926 standards, while the Environmental Protection Agency (EPA) has adopted Good Laboratory Practices and ISO 17025. In addition, clinical laboratories for human diagnostics must be compliant with the Clinical Laboratory Improvement Amendments of 1988 (CLIA), which is a combination of the two ISO standards. The EPA has divided the United States into 10 regions each with its own lab, most of which are housed in the state public health lab. The National Veterinary Services Laboratories of the U.S. Department of Agriculture operate under a Director, and there are four main divisions and a program office: the Diagnostic Virology Laboratory; the Diagnostic Bacteriology and Pathology Laboratory; the Foreign Animal Disease Diagnostic Laboratory; the Diagnostic, Bio-
analytical and Reagent Laboratory; and the National Animal Health Laboratory Network Program.10
In the United States, there are around 160,000 CLIA-certified laboratories, up from 150,000 in 1993.11 They include waived test laboratories12 (71 percent), moderate/high complexity labs (27.3 percent), as of June 2016, the Laboratory Response Network (LRN) of active sentinel labs (1.7 percent), and moderate/high complexity LRN reference labs (0.0005 percent, or just 135 in total). Most labs are located in physicians’ offices, but they are also in hospitals, tissue bank/repositories, stand-alone facilities, and other sites. CLIA labs require training of technicians, and inspections are conducted. If a lab does not meet the standards required, the cost for each violation is $5,000 per day until the issue is resolved.
Public Health Networks
Chu discussed two public health lab networks in North America. The Association of Public Health Laboratories (APHL) has a mission to “shape national and global health outcomes by promoting the value and contribution of public health laboratories and continuously improving the public health laboratory system and practice.”13 As of September 1, 2016, it had 869 members, both institutions and individuals. Institutional members of APHL include local public health labs, as well as environmental, agricultural, and state chemical labs. Corporations and individuals, including students and emeritus members are also among the APHL membership. Membership is voluntary and requires annual dues. APHL funding comes from membership fees, hospital programs, grants, and cooperative agreements, including with the U.S. Centers for Disease Control and Prevention (CDC), CDC-Biosafety, FDA, President’s Emergency Plan for AIDS Relief,
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10 See https://www.aphis.usda.gov/aphis/ourfocus/animalhealth/lab-info-services/sa_about_nvsl/ct_about_nvsl.
11 See https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA#:~:text=The%20Centers%20for%20Medicare%20%26%20Medicaid,covers%20approximately%20260%2C000%20laboratory%20entities [December 2020].
12 Waived tests are “laboratory examinations and procedures that have been approved by the Food and Drug Administration for home use or that, as determined by the Secretary, are simple laboratory examinations and procedures that have an insignificant risk of an erroneous result.” https://www.cdc.gov/labquality/waived-tests.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fclia%2Fwaived-tests.html.
13 For more information, see https://www.aphl.org/Pages/default.aspx.
Health Resources and Services Administration, and the EPA. APHL works best in collaborations.
APHL’s public health programs cover preparedness and response (e.g., the LRN and biosafety/biosecurity); environmental health (environmental tests and biomonitoring); infectious diseases (HIV, TB, and sexually transmitted diseases, as well as influenza and emerging issues); newborn screening and genetics (through a program called NewSteps), which is required by law in the United States; and food safety (including surveillance networks and food testing). APHL undertakes activities as an information broker, whether between the CDC and member labs or among labs or in other configurations. It supports technical transfer, partnership development and relationship management, policy, and best or exemplary practices. It also provides information through the internet, social media, publications, and surveys. It distributes the Public Health Lab Blog. A great deal of its training is available on YouTube.
Finally, APHL hosts the Public Health Laboratory Database Information System14 in which the 25,000 lab tests conducted in the 54 state labs have been coded following international standards (e.g., for Severe Acute Respiratory Syndrome).
The Canadian Public Health Laboratory Network15 is another example of a successful and sustained lab network. In 2016, it articulated its vision, mission, and mandate. Its vision is “a healthier Canada through connected public health laboratories.” Its mission is “strengthening Canada’s public health system through coordinated laboratory services and leadership.” Its mandate is “to assure an integrated public health laboratory network response to infectious disease that encompasses One Health.” As background, since 2003 it has grown to include expertise from an extensive spectrum of public health disciplines related to infectious diseases. In addition to lab specialists, expertise is also incorporated from the fields of epidemiology, bio forensics, high-performance computing, computer engineering, food inspection, national defense, and other areas. Members include subject matter experts and leaders from each provincial jurisdiction, federal representatives from multiple departments and agencies, and non-government stakeholders such as the Canadian Blood Services. The secretariat is led by the National Microbiology Laboratory’s Director of Networks and Resiliency Development, and includes an Information and
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Preparedness Coordinator, a Standards Development Office, and a Laboratory Network Coordinator.
Funding comes from the Public Health Agency of Canada through the National Microbiology Laboratory Budget. The Canadian Public Health Laboratory Network does not accept funding or gifts from external sources. The majority of the funding goes to finance the Secretariat. The remaining funding is applied to meetings, publications, training, and travel. It feels that a dedicated secretariat skilled in an array of areas allows the network to reduce costs by working on projects in-house.
Another network in Canada is the Canadian Network for Public Health Intelligence (CNPHI) dedicated to “fostering collaboration and consultation through innovation in disease surveillance, intelligence exchange, research, and response to protect, promote, and support public health.”16 See Figure 2-3 for a depiction of the CNPHI. It is much like the Pakistan Dashboard.17 It is an innovative public health informatics platform developed and supported by the Public Health Agency of Canada’s National Microbiology Laboratory. It includes technologies for collaboration, surveillance, alerting, knowledge management, lab systems, and event management; and it supports a large number of public health professionals in human, animal, and environmental health domains. It is recognized as a trusted platform providing key foundational infrastructure for public health surveillance in Canada.
CNPHI provides a secure public health intelligence cloud housed at the national lab in Winnipeg. Hospitals, epidemiology and environmental specialist laboratories, physicians, and others enter data in a secure environment. The network can provide integrated intelligence with the output being data, maps, tables, charts, reports, and notifications. The information can be used for outbreak detection and investigation and disease surveillance.
Conclusion
The broad objective of a network is to create an enduring and resilient community of public health and biomedical research laboratories. Networks can be small or large, and networks can connect to other networks (see Figure 2-4).
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16 Canadian Network for Public Health Intelligence. https://www.ncceh.ca/sites/default/files/Surveillance_Workshop_Feb_2013-Beattie.pdf.
17 See http://www.nhsrc.gov.pk/Detail/ZmM4OGZiMTUtY2RkNy00OWQ1LWE5NTgtZTQ3NWIzODU0MDgy.
SOURCE: Theodore Kuschak. 2016. Canadian Public Health Laboratory Network Overview. As cited in the following presentation: May Chu. A Joint Pakistan-U.S. Workshop on Strengthening and Sustaining a Network of Public and Animal Health Clinical Laboratories in Pakistan. Islamabad, September 27-29, 2016.
SOURCE: Kuschak, 2016. As cited in May Chu’s presentation (2016).
During the discussion following Chu’s presentation, a workshop participant asked whether there were any relevant models of laboratory networks from resource-constrained countries. Chu replied that the African Society of Laboratory Medicine is an example to consider. Similarly, China has an emergency response network that flows from the core principles outlined here in breadth and depth. Both APHL and the Canadian Public Health Laboratory Network are intensely building networks and making their information available. They also offer training opportunities. Regardless of the model, it is important to remember that the best networks are active, Chu said.
Another participant asked how the networks described here are funded, and whether the labs undertake other functions as well. Chu replied that the lab funding models are complex. Primarily the labs themselves pay to support their participation in the networks, but when there are outbreaks of diseases of concern at any point, more funds may be available to the labs. For example, during an outbreak of avian influenza, poultry labs may receive more support. Although the United States is a helpful model of lab networks in many regards, its financial model may not be the best due to sporadic and often inadequate funding.
STRENGTHENING THE NETWORK OF ANIMAL HEALTH CLINICAL AND DIAGNOSTIC LABORATORIES IN PAKISTAN
R. H. Usmani, Animal Husbandry Commissioner of Pakistan, spoke about the livestock population of the country and the associated veterinary system. Pakistan is a member of the World Organisation for Animal Health (OIE), and in 2015 and 2016, the livestock sector contributed 58.5 percent to the overall agriculture sector of the economy and 11.6 percent to the national GDP. A number of infectious diseases affect different types of livestock, including cattle and buffalo, sheep and goats, equine and camels, and poultry (see Table 2-1).18
The existing veterinary laboratory network consists of two national reference laboratories, and eight provincial veterinary research, diagnostic, and vaccine production institutes with 64 district diagnostic laboratories (DDLs) linked to them. There are 35 DDLs in Punjab, 7 in Sindh, 5 in Khyber Pakhtunkhwa (KPK), and 17 in Baluchistan.19 The mandate of the DDLs is provision of diagnostic facilities to livestock farmers, participation in field surveys and sample collection related to infectious diseases, and training of para-professional staff. Their challenges include a lack of necessary diagnostic equipment (therefore the majority of samples are simply forwarded to a Veterinary Research Laboratory), a lack of training on the latest techniques, a lack of transport facilities to conduct field work, and an inadequate operational budget. In addition, 963 civil veterinary hospitals at the tehsil level supervise the clinical work of 5,744 veterinary dispensaries at the union council level20 and more than 80 mobile veterinary clinics.21
The two national reference laboratories are the National Veterinary Laboratory, which serves as the national reference laboratory of livestock diseases, and the National Reference Laboratory for Poultry Diseases (NRLPD), which focuses on avian disease. These are the most well-appointed labs in the country with excellent equipment and trained staff. However, biosafety and biosecurity measures need to be upgraded. They should be upgraded from Biosafety Level 2 (BSL-2) to BSL-3 labs.
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18 Usmani, R. H. 2016. Strengthening a Network of Animal Health Clinical and Diagnostic Laboratories in Pakistan. A Joint Pakistan-U.S. Workshop on Strengthening and Sustaining a Network of Public and Animal Health Clinical Laboratories in Pakistan. Islamabad, September 27-29.
19 Ibid.
20 In Pakistan, tehsils and union councils are administrative jurisdictions within the local government.
21 Usmani, 2016.
TABLE 2-1 Infectious Diseases Affecting Livestock in Pakistan
| Species | Infectious Diseases |
|---|---|
| Multiple Species | Foot & Mouth Disease, Brucellosis, Crimean-Congo Hemorrhagic Fever, Anthrax, Rabies, Leptospirosis, Vesicular Stomatitis |
| Cattle & Buffaloes | Hemorrhagic Septicaemia, Bovine Tuberculosis, Bovine Viral Diarrhea, Bovine Babesiosis, Bovine Anaplasmosis, Theileriosis, Trichomoniasis, Trypanosomiasis |
| Sheep & Goats Equine & Camels | Peste des Petits Ruminants, Sheep/Goat Pox, Contagious Caprine Pleuropneumonia, Ovine Chlamydiosis Dourine, Glanders, Surra (Trypanosomiasis) |
| Poultry | Newcastle Disease, Low Pathogenic Avian Influenza, Avian Infectious Bronchitis, Fowl Cholera, Fowl Typhoid, Infectious Bursal Disease, Marek’s Disease, Avian Mycoplasmosis, Pullorum Disease |
SOURCE: Usmani, R. H. 2016. Strengthening a Network of Animal Health Clinical and Diagnostic Laboratories in Pakistan. A Joint Pakistan-U.S. Workshop on Strengthening and Sustaining a Network of Public and Animal Health Clinical Laboratories in Pakistan. Islamabad, September 27-29.
Provincial institutes, which are located in Punjab, Sindh, KPK, and Baluchistan provinces, have a wide mandate, including diagnostic reagents and vaccine production, provision of diagnostic facilities to DDLs, conduct of research on infectious disease, and development of training for professional and para-professional staff. Issues affecting these labs include shortages of advanced equipment and trained veterinarians and technicians. Most of the animal facilities do not have proper biosafety and biosecurity systems.
Communication and coordination among the facilities depend on timely sharing of information and initiation of response activities. However, inter-ministerial and inter-provincial coordination is limited to the heads of the concerned departments and agencies rather than occurring at the working level. Routine, formal communication between different provincial veterinary institutions and laboratories is also limited. Inter-provincial communication between various provincial veterinary institutions and labs is lacking. Within provinces, there are poor mechanisms for feedback from the institutions to the DDLs and from the DDLs to concerned field veterinarians. Communication channels need to be defined, and standard
operating procedures (SOPs) need to be developed for sharing information related to disease surveillance, diagnosis, and reporting.
Important zoonotic diseases in Pakistan include highly pathogenic avian influenza (HPAI), brucellosis, bovine tuberculosis, Crimean-Congo hemorrhagic fever, anthrax, and rabies. The One Health approach has tremendous potential to prevent and control these diseases.
Implementation of the One Health approach is in its infancy in Pakistan, but the implementation of a project supported by the U.S. CDC Field Epidemiology and Laboratory Training Program was successful. The NRLPD and National Institute of Health, Pakistan, are implementing a project in collaboration with six provincial public and animal health institutions to enhance capacity for conducting zoonotic animal health investigations, devising animal-human interface interventions, and supporting existing efforts.
Some problems remain, such as those that arose while attempting to control HPAI: poor coordination between human and animal health departments and lack of SOPs for joint epidemiological investigations; difficulties in the adoption of biosafety and biosecurity measures in research and diagnostic labs; shortages of trained epidemiologists, virologists, and vaccinologists; and a shortage of resources and expertise in controlling diseases of animal and/or public health significance.22
Usmani proposed the following activities for intersectoral cooperation to better control zoonotic diseases:
- Establishment of disease reporting and early warning systems by public health authorities and sharing of disease status with animal health authorities.
- Formation of a joint task force between the human and animal health sectors to develop a joint response strategy against zoonotic disease outbreaks.
- Development of coordination mechanisms between the two sectors for sharing data on disease prevalence in different parts of the country.
- Initiation of joint efforts for launching disease awareness campaigns through national and international agencies.
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22 See Food and Agriculture Organization. 2013. Report of the thirty-seventh session of the Animal Production and Health Commission for Asia and the Pacific (APHCA). Bangkok: 113-114.
- Development of SOPs for rapid response mechanisms and organization of joint training for professional and field staff of both sectors on sharing approaches to handle zoonotic disease outbreaks.
ANIMAL HEALTH LABORATORIES IN THE UNITED STATES
Corrie Brown explained that One Health is a multidisciplinary initiative to combine surveillance and diagnostics by physicians, veterinarians, and experts from other scientific and health-related disciplines to increase capacity to recognize, diagnose, and report disease. “One Health” does not mean “One Profession,” nor should animal health be interpreted as human health on a smaller scale, she said. Instead, it is designed so that the public and private sector work together, as do those involved in human and animal health. Diseases of concern addressed under the One Health concept include not only those originating with humans, but also those originating in animals such as rabies, rinderpest, brucellosis, foot and mouth disease, Newcastle disease, HPAI, footrot, bovine respiratory disease (BRD, also known as shipping fever), intestinal parasites, coccidiosis, and Marek’s disease.
The WHO IHRs of 2005 began as a mechanism for countries to notify WHO, and thereby the global community, about three diseases, namely cholera, yellow fever, and plague. The regulations were modified as a result of the 2003 SARS outbreak and went into effect in 2007.
In addition to WHO, two other organizations play key roles in addressing human and animal health from a One Health perspective: OIE, which has 180 member countries, and the World Trade Organization (WTO), which has 164 member countries. WTO has a broad mission beyond “liberalizing trade, and in some circumstances its rules support maintaining trade barriers—for example, to protect consumers, prevent the spread of disease or protect the environment.”23 Members have signed the WTO Agreement on the Application of Sanitary and Phytosanitary Measures (known as the SPS Agreement),24 which became the OIE guidelines and standards for national animal health systems.
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23 WTO. 2011. Understanding the WTO. https://www.wto.org/english/thewto_e/whatis_e/tif_e/utw_chap1_e.pdf.
24 For the text of the WTO Agreement on the Application of Sanitary and Phytosanitary Measures (known as the SPS Agreement), see https://www.wto.org/english/tratop_e/sps_e/spsagr_e.htm.
Each national animal health system is headed by a chief veterinary officer, has a field force capable of recognizing the diseases of concern and notifying the labs, and aims to foster productive connections among these sectors. What holds the system together is passive surveillance from the field. This public goods system is responsible for the economic health of animal agriculture, ensuring that agricultural industries remain robust and that trade can continue.
National Animal Health Systems
The U.S. National Animal Health System protects the public good, including the economic health of animal agriculture industries, food security, and prevention and control of zoonotic disease by annually reporting data from the chief state animal health officials about the presence of approximately 118 specific transboundary (transboundary diseases are capable of rapid spread and severe economic impact) and zoonotic diseases listed by the OIE as particularly critical to the well-being of animals. OIE member countries are required to report on these diseases annually. In addition, they must also report any disease that appears for the first time in their country, or is newly emerging, within 24 hours of detection. The OIE uses a system called the World Animal Health Information System. There is no subnational reporting, nor should there be, stated Brown, due to the severity of the consequences of a false positive. For example, in the United States, if an animal is suspected of having a disease, the state lab does an initial test, and the sample then goes to the central lab, and only then if it is positive, the chief veterinary officer reports to the OIE. Based on this OIE system, networks could be developed globally, especially if capacity was strengthened in the developing world. Areas in need of strengthening include communication between field and lab and disease control resources. If the national animal health network improves, the health of animals improves, the economic value of those animals improves, farmers’ livelihoods improve, and the rural sector thrives.
Countries that have strengthened their animal health system have effectively controlled or eliminated Newcastle disease, foot-and-mouth disease, brucellosis, HPAI, and rabies; they also have effective food safety measures in place, allowing them to focus on other needs and grow the industry so that it remains sustainable. Once these public good diseases are controlled, commonly the number of private veterinarians accredited by the national animal health system increases. These private veterinarians also report on
the required diseases, which is good passive surveillance. The incorporation of private veterinarians into the system also lowers the cost because they do not use public resources but feed their results into the national system. In higher-resourced countries, often up to 90 percent of the veterinary services are supplied by the private sector.
If the thousands of veterinary dispensaries at the local level in Pakistan were replaced by private practitioners, and the agricultural animal producers paid for the services, the system could become more sustainable. There are 11 veterinary schools in Pakistan, including excellent schools in Faisalabad and Lahore. There is a concern that as schools accept more and more students the profession may decline. All schools should have strict standards of curriculum and license of practitioners to ensure the quality of the profession.
Veterinary Education Around the World
Most countries have both public and private animal healthcare providers and labs. Previously, the large majority of veterinarians worked in public rather than private practice; the situation is now reversed. In 2016, OIE held its fourth global conference on veterinary education. The objectives were to analyze the current situation of education worldwide including the use of OIE recommendations on the competencies of graduating veterinarians and OIE guidelines for a core curriculum. At the time of the workshop, there were 36 programs in North America, 52 in Central America, more than 180 in South America, 126 in Europe, 50 in Africa, 98 in Asia, and 5 in Australia.25 This is a challenge, however, because not all graduates can find jobs and many end up not using their education in the arena of animal health.
The OIE recommended that competencies be developed and/or strengthened in the following four areas: (1) Clinical Practice, including communication skills, research, and animal welfare; (2) Veterinary Preventive Medicine, including disease prevention and control programs, veterinary products, management of contagious disease, and administration and management; (3) Public Health, including zoonoses (e.g., food borne diseases), emerging and re-emerging disease, epidemiology, food hygiene, and application of risk analysis; and (4) Global Animal Health Systems, including
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25 Brown, C. 2016. One Health–Talking Across the Divide. A Joint Pakistan-U.S. Workshop on Strengthening and Sustaining a Network of Public and Animal Health Clinical Laboratories in Pakistan. Islamabad, September 27-29.
transboundary animal disease, organization of veterinary services, general certification procedures, inspection and certification procedures, veterinary legislation and ethics, and international trade frameworks.
The OIE Performance of Veterinarian Services Pathway (PVS) is a global program for the sustainable improvement of a country’s Veterinary Services’ compliance with OIE standards on the quality of veterinary services.26 Through the program, a three-person team conducts an assessment and then produces a report, identifying gaps and opportunities, which provides the best way to determine means of assistance. It begins with PVS evaluation (“diagnosis”), PVS gap analysis (“prescription”), capacity building activities, projects and programs (“treatment”), and then follow-up missions as needed. OIE collaborates with governments, donors, and other stakeholders to implement this program in member countries.
Brown closed her presentation by stating that in her estimation, the One Health concept needs to support the national animal health systems. Sustainable progress cannot be made until these systems are strong. The national animal health systems need to support private veterinarians, because this will allow for greater sustainability and further economic improvements. A networked and certified laboratory system would be helpful in any country to ensure accurate diagnoses of notifiable diseases. Finally, a study of the workforce would also be helpful to identify the supply and demand of veterinarians, expertise needed, and how academic institutions can supply these professionals. This type of workforce study would be a very appropriate undertaking for the Pakistan Academy of Sciences. This assessment would help Pakistan avoid some obstacles that other countries face.
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26 For more information, see http://www.oie.int/support-to-oie-members/pvs-pathway.
