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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.
Diagnostic and Treatment Infrastructure – Issues and Opportunities
We take up the third (last) pillar of healthcare infrastructure in Pakistan.
Diagnostics
Diagnostics as a medical arm has gone through enormous development. The number and variety of laboratory tests has increased manifold. Genetic markers are a whole new line of diagnostics and so are many other sophisticated tests. Among non-invasive tools, MRI, NMR, CT scan, PET scan, color doppler, are available easily in major cities, beside age-old X-ray which is still supreme. Ultrasound is now portable and can be done anywhere. For heart patients, CT angiograms, ABPM – Automatic Blood Pressure Monitoring, Echocardiograms, Angiograms, Thallium scan, ETT, and stenting are everyday procedures, besides basic ECG which is integral to diagnosis. Among other invasive procedures, endoscopy, bronchoscopy, colposcopy, and many other types of scopes are available, with the common principle of putting a camera inside and look through that, and to collect samples for further lab testing.
The availability of vast number and types of diagnostic facilities should have made diagnosis rapid and easier, but it is not so anywhere in the world. It has increased the burden on the patients for sure. The reason for this is as follows: the doctors have stopped applying their mind to clinical diagnosis. When a patient reports to a doctor, he takes a very brief history of symptoms and then prescribes a battery of tests to cover all possibilities, and then tries to reach a diagnosis. The horror occurs when nothing conclusive comes out of the tests, because it leads to another round of more expensive tests, because the quest for clinical diagnosis is still not there. This may keep going till the patient abandons the idea of getting treated.
Availability of improved and diversified diagnostic tools has facilitated the physician to diagnose more accurately. However, physicians in Pakistan have become rather over-reliant on tests, to the extent of misuse. Same tests are repeated if the physician is changed, labs are changed, or even manual testing for basic blood tests is recommended in the hope that the machine may not be reliable. Most physicians in Pakistan do not treat patients well, they do not give them required time and attention, they do not make an effort to diagnose on the basis of clinical judgement, they abuse testing, and they overprescribe drugs. Only a smaller number of foreign- trained, younger physicians take time with patients, explain to them, and try to diagnose and treat more judiciously. The sufferer is the patient who must follow instructions blindly. Patients with certain diseases like diabetes, heart disease, high blood pressure, need detailed guidance about medication, diet, lifestyle, and exercise. These are neither provided by the treating physicians nor by any of their assistants. The physicians would mostly prescribe drugs and that would be it. Patients suffering from diseases such as cancer need lot of understanding and reassurance about the progress of their disease and the outcome of treatment, but this area is completely neglected.
It is also a sad fact that the patients who are the source of living, earning, and growing for doctors are the least respected in this chain. From another perspective, patients are the clients/ customers, and all businesses treat their customers with care, deference, and respect. All of this is missing in the patient-doctor relationship, and that is why the treating physicians do not care about their patients the way they should. Senior/junior doctors in public hospitals are even worse; they know the patients have no choice but to come to the public hospital for treatment because they cannot afford to go for paid private healthcare. As mentioned in an earlier post, some of the best and the worst treatments are done at the public hospitals. Private healthcare facilities try to do better because they have to stay in business, but even there, there are numerous examples of wrong treatments and bad behavior.
The doctors-labs nexus has been the subject of discussion in Pakistan and other countries. The laboratories offer cuts to the doctors who prescribe tests. The very large ones such as Aga Khan, Shaukat Khanum, Chughtai are out of this because they have gained a high level of reputation among educated patients who will feel better if they get their tests performed there. The doctors comfortably recommend Aga Khan and Shaukat Khanum only because they understand that no one will think of them getting a cut from these two labs. All other labs are considered to be part of the nexus, disregarding whether they do it or not. In smaller towns, the situation is much worse. There are individual labs who are mostly implicated in offering share to doctors, and the patients are less discerning, and the better labs may not be there.
Knowing this to be a lucrative business, few foreign labs also launched themselves in Pakistan who offer that the tests would be performed in UK or Germany or UAE. For usual tests, no one uses these labs, however, for some specialized tests such as gene sequencing, their services are welcome.
Lab standards for the large number of labs are dubious. Except for the few very well-known ones, no one knows how the tests are performed, what quality of lab reagents are used, what is the quality of people working in the lab, and what is the authenticity of results. Certifications for clinical laboratories are available, but it takes lot of effort to qualify, much more than Quality Management Certification – ISO 9001, 14001, 45001 etc. It is even harder to stay certified. Some clinical labs display ISO 9001 certificate which is of no consequence, because it is not related to testing quality done at the lab.
I would like to bring back the topic of burden on patients because it is real. A typical consultant prescription for a serious looking case usually contains medicines worth a few thousand rupees, and lab investigation worth several thousand rupees. An MRI is around 10,000 rupees, while PET scan is now close to 60,000 rupees. Gold test for TB is 15000, so are ANA tests for autoimmune disorders. Imagine the cost that patients are bearing, and how much they would be relieved if the physician show more empathy and understanding.
Diagnostic tools, it appears, are more a money-making tool rather than disease diagnosis. Their importance and value in differential diagnosis is undisputed. The need is to regulate this business to improve quality and reduce patient suffering.
To be Concluded……
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