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Healthcare stands on three pillars: Healthcare related policies; Public and private health infrastructure; and availability of diagnostic and treatment tools, the last one also includes easy access to drugs. We shall review each of these in some detail to understand the entire healthcare landscape. The information is gathered from several sources, and references are given at the bottom.
Public Health Infrastructure – Issues and Opportunities
Public sector hospitals have been the cornerstone of public health delivery since the inception of Pakistan. Private health facilities developed later and are still evolving but have become a major contributor already.
Governance of public health institutions has been challenging from the beginning. Almost fifty years ago, when I started working in Pharma sales, I was assigned the biggest hospital of Lahore, Mayo hospital. There were problems then and there are problems now. A 2020 article published by researchers at the Community Health Department, Aga Khan University Pakistan, titled ‘Review of Governance of Public Sector Hospitals in Pakistan: Lessons for the Future’ captures the present scenario at the policy level nicely (Link to article at the bottom). I shall also partake from the article on the policy matter.
Three major problem areas may be identified: Policy, Management, and Capacity.
Successive governments have shifted policy stances several times, mostly based on recommendations from donor agencies such as WHO, USAID, and other international agencies. These agencies have also invested in the health infrastructure, for example, Allied Hospital, attached to the Punjab Medical College Faisalabad, was largely built, and equipped by Japan government aid. Sheikh Zayed Hospitals at various locations were built by Sheikh Zayed bin Sultan Al Nahyan of UAE. Many policies emerged from the Millennium Development Goals – MDGs, and Sustainable Development Goals – SDGs set by the UN as a charter for developing countries. These policies provide a good framework for developing more detailed working in the light of our indigenous conditions. Sadly, it never happens. The conferences, workshops, meetups, are organized to discuss the generic agenda given by the agencies, with limited application and results. Or the work starts on projects which may not hold priority for us. For example, there is a lot of emphasis lately on digitization and information technology, without realizing that the basic ground for it, literacy, computer literacy, equipment, network, ICT infrastructure is rudimentary to the extent of being non-existent. Aga Khan article recommends three strategic priorities for policymakers to consider: first, demonstrate consistency and commitment in implementing policies related to hospital governance; second, launch a country-wide capacity development program for hospital managers; and third, establish e-governance to enhance accountability, transparency, and performance of hospitals. One could differ with the last recommendation which is ultimate in performance management but shall remain elusive for long.
Public hospitals have a built-in dichotomy of command; teaching hospital consultants run the patients treatment at the wards, while administration of facility is run by the Medical Superintendent and other administrative staff. The MS cannot control the teaching consultants, cannot control the quality of care, and cannot control the usage of diagnostic and treatment facilities. They are however supposed to provide readiness of all facilities and are required to handle any issues that may arise out of patient handling and treatment. This dichotomy is inherently counterproductive, but no solution has so far been suggested by the policy managers.
Most hospital managers do not have a degree in hospital management. The Diploma in Public Health, and Master degree in Public Health, being offered at few places has never been questioned for its content updating, and relevance to changed health landscape. Not all hospital managers are even equipped with these degrees; they get elevated due to experience. Hospital management has undergone huge changes due to emergence of several new sub-specialties, new diagnostic and treatment options, changes in diseases patterns, and occurrence of epidemics. The present system sometimes copes and sometime is unable to cope. Updating and retraining of hospital management is urgently required.
Performance is not measured because neither the performance metrics are clearly defined nor there is any reliable reporting system. Deaths of patients are not analyzed, rather, the dead bodies are quickly handed over to the relatives to take away for burial. Complications are never reported or analyzed to stop repetition. Infection control is the weakest link in the system and at so many forums the medical community has expressed their inability to maintain desired level of sterilization in the theaters and wards. As a result, antibiotics are used aggressively and ruthlessly, leading to development of resistance beside costing heavily to patients.
Availability of medicines is another huge grey area. From the rhetoric of providing hundred percent medicines free to every patient, to non-availability, all shades are available. Purchase of medicines for public health system is among the biggest and longest running scams which has benefitted thousands of purchasers over the year. Despite the promulgation of strict Public Purchase Rules, the matter of underhand percentage has never stopped. In fact, the percentage asked for by the purchase related departments has increased over time. Since every tier is involved, so no one stops anyone.
Quality of medicines purchased is another huge scam. Many small pharma companies have specialized in government supplies because they have perfected the art of under the table dealings. They supply low-priced, low-quality drugs at high prices and the whole chain reaps the unholy crop. It is such a strong network that no government can do anything about it.
The tertiary care hospitals, according to Aga Khan University study, consume 80% budget which is spent on 15% patients, while only 15% budget is available for 80% patients in secondary and primary care.
True, that tertiary care hospitals are overwhelmed with the number of patients due to long standing disparity between needed and available hospital bed. WHO recommends a ratio of one bed for 200 population; Pakistan has one bed for over 1600 population. The vast difference clearly shows why our public hospitals are perpetually overcrowded. If you go around the largest hospitals in any major city, you will see adult patients in corridors also, and it is common to see 2-3 child patients on one bed due to shortage of beds.
The ultimate sufferers of the issues at public health facilities are patients. They get variable quality of care, unreliable services, high out-of-pocket expenses, and fleecing by the lower staff of the hospital, from security guards to sweepers to ward staff. Nurses are a great exception who still work diligently without asking for or expecting any reward.
To be Concluded……
Disclaimer: Most pictures in these blogs are taken from Google Images and Pexels. Credit is given where known; some do not show copyright ownership. However, if a claim is lodged at any stage, we shall either mention the ownership clearly, or remove the picture with suitable regrets.