Laced with big numbers, the PM’s National Health Programme provided health insurance to the poor at secondary health level. Although a government intervention was needed, the question of universal healthcare begins at the foundations: are the most vulnerable sections of society able to access primary healthcare provided by the government? Does primary healthcare infrastructure even exist?
Talking basics
The PM’s health insurance scheme talks a big game for secondary healthcare but ignores the dire straits in which public sector primary healthcare finds itself
The launch of the PM’s National Health Programme is a silver lining for many in Islamabad — around 1.2 million families will get free secondary healthcare facilities in the first phase of the scheme, which has been launched in 15 districts of the country. In the second phase, the number of districts covered will be increased to 23, while the programme will also be expanded to all parts of Balochistan, the Federally Administered Tribal Areas (Fata), Azad Jammu and Kashmir (AJK) and Punjab.
In theory, the scheme sets right a historical wrong: even today, only 0.42pc of Pakistan’s GDP is allocated towards public healthcare, whereas the Pakistan Medical Association recommends a minimum 6pc of the GDP to be diverted towards health. Successive governments and regimes have paid only lip service to the health sector, and as a result, the system’s pipes are indeed ‘choked’.
An intervention was in order and the prime minister has sought to provide one.
Under the insurance scheme, relief has been provided at secondary level — each family is entitled to treatment of Rs250,000 under the category of priority diseases, which includes accidents, burn wounds, heart bypass and diabetic complications among others. Hospitals will only be able to charge Rs12,500 for the delivery of a child.
No doubt, the cost of treatment and recovery in such cases is beyond the reach of the poor, but is the prime minister’s scheme merely a grand gesture aimed at camouflaging larger systemic issues, particularly at the primary level?
For the poor and the most vulnerable of society, immediate healthcare arrives at the level of basic healthcare centres. More cases of malaria and tuberculosis are likely to be reported than a heart bypass or diabetic complaint, for example. Or consider the fact that at present, most births take place at home, often at the hands of untrained dais. Women frequently die in the process of giving birth as they lack antenatal care. While the PM’s scheme provides safeguards for the delivery of a child at a main hospital, most deliveries ought to happen at maternity hospital anyway.
Secondary safeguards are noble, but what of the primary defence?
A functioning, vibrant public primary healthcare system safeguards the health of vulnerable and impoverished populations often at the first, often the most critical point of medical intervention. In many cases, it is life-saving.
Ideally, one basic health unit (BHU) should be supporting a population of 10,000; and should be able to provide general examination and clinical management, or as the need may arise, to provide a referral to a specialist or higher centres. It provides essential emergency services such as suturing of wounds and cuts, dressing of burns and wounds, splinting and plaster casts.
A BHU should also be the primary point of help for family planning, immunisation matters, child growth monitoring, and ante- and post- natal care with basic obstetric care services.
Basic radiological and laboratory services are sometimes also provided by primary healthcare services.
Patients are therefore not compelled to go to secondary care centres for minor problems and receive appropriate treatment closer to home. Detection and diagnosis of disease can be made earlier at a primary health centre, before referring a patient to the appropriate specialist centre for treatment. This, in turn, reduces the burden of patients at the main hospitals.
It is not that we do not have such centres — in fact, our primary healthcare infrastructure is quite vast; we have BHUs, rural health centres, maternal and child health centres, and lady health workers. But functionally, they are left high and dry due to a lack of resources.
According to various reports published over the past decade, most BHUs suffer from lack of doctors and other staff, non-availability of medicine, and even fail to provide emergency treatment to a patient.
The PM’s scheme presents itself as an ambitious move towards universal health, laced with numbers that the government will spend on providing medical insurance to the poor. But in its details, it is neither ambitious nor sustainable when extended to the rest of the country. Although an intervention was needed, it should have come about as an overhaul at the primary healthcare level rather than as another grand measure for limited purposes.
The health system cries out for intensive surgery, but the PM is making do with a dose of aspirin.
Emergency in Fata
Decades of conflict have wiped away all primary healthcare facilities, leaving many new-borns and mothers to face the brunt
Sectarian conflict, militancy and neglect over the past few decades have crippled the health infrastructure in the Federally Administered Tribal Areas (Fata). Almost none of the basic health units (BHUs) are properly functional due to a lack of resources. Some have been extensively damaged by militant attacks. The insecure environment has scared away most health professionals from the area and even the larger government hospitals are unable to retain sufficient staff.
Due to this collapse of the primary healthcare system, the entire burden has fallen on the one secondary healthcare facility in the region: Taluka Headquarters Hospital, Sadda.
It is at the same hospital that we at Médecins Sans Frontières / Doctors Without Borders (MSF) are also stationed. We have been running a paediatric outpatient department (OPD) and an inpatient department for neonates and children under 12 years of age.
Last year, MSF carried out over 38,000 OPD consultations. The overwhelming majority of these were for conditions such as diarrheal illnesses and respiratory tract infections, which could have been easily managed in a primary care set-up
Usually by the time [patients] reach a doctor, their condition will have further deteriorated and they end up getting admitted in a near-critical condition.
Due to the non-functioning of the BHUs, patients and their families end up having to travel many hours, sometimes by foot, over the mountainous terrain before they reach the nearest health facility.
Usually by the time they reach a doctor, their condition will have further deteriorated and they end up getting admitted in a near-critical condition. Around 2,300 children were admitted at MSF’s health facilities in Sadda, Kurram Agency, Fata in 2015.
Had these children received care on time, many of these admissions could have been avoided. Many children arrive at our health facility with diseases such as measles; all such ailments could have been prevented by routine immunisations.
In August 2015 the Ministry of Health organised a measles vaccination campaign which had a 99.7pc coverage of all children aged six months to 12 years in Kurram Agency. Since the campaign, the Sadda Hospital has received no admissions for measles complications.
Patients who visit our facility are offered the first dose of immunisations, but more than often it is difficult for them to travel long distances to complete the course.
One of the most pressing issues in the Fata region is that women end up delivering their babies in unsafe conditions either at home or at private clinics.
There is generally a low level of awareness in the community regarding the importance of regular check-ups during pregnancy — and often women are unable to access a doctor.
Despite this, MSF carried out 5,584 consultations last year; however, most women arrive at the hospital for the first time right at the time of delivery. MSF works closely with MoH in the delivery of obstetric care at Sadda Hospital.
Unfortunately, by this time, it is already too late for some and the baby is either stillborn or dies shortly after delivery.
At times, the mother’s life may also be at risk. MSF has referred 531 high-risk pregnant women to specialised obstetric facilities in Peshawar including the MSF Women’s Hospital.
Of the babies that survive, a significant number of them sustain some form of brain damage during the birth process. With a lack of dedicated services available in Fata, these babies do not fare well in the long-term; however the babies do spend time in the High Dependency Newborn Unit at MSF Women’s Hospital in Peshawar. They also have the opportunity to be referred for longer term care at the Akbar Kare Institute.
In 2015, almost 680 new-borns were admitted for care with MSF at the New Born Unit in Sadda, Kurram Agency.
The writer is MSF Assistant Medical Coordinator for Islamabad, Peshawar, and Kurram Agency, FATA.
Punjab’s changing schemes
Electoral promises to revamp the BHU network have been put off till 2018
Consider this statistic: out of a total 2,461 basic health units (BHUs) in Punjab’s 36 districts, around 40pc are operating without doctors and are run by paramedics instead. In low-priority districts, where the state’s public healthcare system is almost non-existent, BHU property is being grabbed and occupied by land mafia.
This is a microcosm of the state of public healthcare in Punjab, perhaps Pakistan’s most-developed province.
The primary healthcare system in Punjab suffered a major dent when the government introduced a parallel set up in the form of Mobile Health Units (MHUs) in 2012, setting aside the significance of static facilities such as BHUs and rural health centres (RHCs).
Later on, a third party evaluation was conducted by HLSP-managed Technical Resource Facility (TRF) to assess the feasibility of the scheme in 2014. The TRF in its report declared the scheme unsuccessful, stating that twice the number of patients can be accommodated at a BHU as compared to the number being treated by MHUs.
Ignoring the TRF assessment, the government announced extending the MHU set-up from six districts to 16, providing the land grabbing mafia with ample opportunity to occupy valuable BHU property.
Land-grab complaints have, in fact, increased in many low-priority districts of the province. Officials have reported that the grabbers’ mafia has started illegally occupying BHU buildings by demolishing their boundary walls, but the matter lies pending at the Punjab health secretariat.
After pressure exerted by opposition parties to make BHUs fully functional, the Punjab government finally proposed a Rs1.41billion ‘Incentive Package’ for specialist doctors in its budget for fiscal year 2015-16. These doctors were to be appointed at 700 BHUs across Punjab.
This scheme, too, remained largely restricted to official documents, as medics refused to join duties at BHUs due to certain reasons. They were of the view that their postgraduate training would suffer if they opted for appointment at BHUs. Doctors also cited missing facilities including no official residence, insecurity, poor infrastructure and a low salary package.
“The non-availability of trained, qualified and experienced health managers who could run BHUs has been the main issue for the government,” says Jawad Rafiq Malik, who served as health secretary for 16 consecutive months.
“The government had announced a handsome financial incentive for doctors who’d discharge their duties at BHUs. This would have bagged between Rs50,000 and Rs150,000 for them, which is in addition to their regular monthly salary,” claims Malik, adding that the government had also announced that it would give additional marks to postgraduate trainee doctors working in BHUs.
“Although this scheme was not able to achieve its desired results, the Punjab government has allocated Rs34,157m to revamp the entire health infrastructure under the Punjab Health Sector Plan-2018 (PHSP-2018),” says the former health secretary, explaining that measures in this revamp include upgrading BHUs, establishment and upgrading of rural health units, as well as strengthening hospitals at tehsil headquarters and district headquarters level.
Instead of addressing medics’ reservations, the Punjab government came up with another scheme by the end of 2015: to “outsource” RHCs and BHUs of six low-performing districts in the province. This scheme is under fire by the medical community these days, as the Young Doctors Association (YDA)-Punjab has announced a strong reaction if the programme is not rolled back.
Missing in Balochistan: BHUs
There is no basic healthcare structure to talk about in Pakistan’s most under-developed province
While the national mainstream discusses children in Thar who die of malnutrition and other diseases, another humanitarian catastrophe is going unreported: the death ratio of children in Chaghi, the largest district of Balochistan, is a shocking 32.
There are no basic health facilities to talk about in Chaghi. There used to be a main hospital; Saudi Prince Fahd bin Sultan had financed the construction of a large and beautiful government hospital in Dalbandin, the headquarters of Chaghi district, but the facility is now no more than a showpiece. There are no doctors nor is there a medical superintendent; neither are any basic facilities available there nor any required medicines. Therefore, the residents of Chaghi, too, have to go to Quetta for treatment.
Except Quetta, the provincial capital, in almost all other 31 districts of the province, the health infrastructure is worsening by the day. Doctors mostly do not want to leave Quetta city because they are either running their private clinics or are too afraid to move out due to the dismal law and order situation that prevails in the province.
As a result, majority of the patients are brought to Quetta for treatment.
Unfortunately, there are also many people who cannot afford to take their patients to Quetta. In Balochistan, villages are often scattered, with each village struggling with numerous health problems. Although some basic health units (BHUs) and rural health centres (RHCs) do exist, most wear a deserted look or are functional for only an hour every day. There are no basic amenities to talk about at any of these primary health facilities.
Where there is great need for health services, trained midwives and doctors, the government has turned a blind eye. Without any media spotlight, rural communities are left to suffer in silence.
In the past, successive provincial governments have held the federal government responsible for all woes faced by Balochistan. The federal government would also be held responsible by the provincial administration for the poor state of health infrastructure in the province, which they themselves had failed to provide.
In Quetta, too, the health services are poor at govt-run hospitals. This is why the patients’ families prefer privately-run hospitals despite the fact that the same doctors are also posted at govt-run hospitals.
After the 18th amendment, when health affairs were also devolved, the buck now stopped entirely with the Balochistan government. When Dr Abdul Malik Baloch, Balochistan’s former and first middle-class chief minister, took charge in 2013, it was claimed that he would bring about remarkable changes in the health and education sectors of the province.
So far, nothing much has changed and Dr Abdul Malik has also departed. One of his ministers, Rehmat Saleh Baloch, still holds the portfolio of health. But in Panjgur, the constituency of Rehmat Saleh, mortality and children’s death ratio continues to be abysmal.
“My son was running a high fever one night, so I rushed him to Panjgur’s district headquarters hospital. There was not a single doctor present there,” says one resident, complaining about the non-availability of doctors. “One of the ambulance drivers mockingly said to me that he could treat my son instead.”
Barkat Jeevan, a local reporter Based in Balochistan’s Panjgur district, points to the abysmal state of BHUs and explains that except for a few medicines, these possess nothing.
“The health services provided by BHUs are not satisfactory. There are BHUs in Panjgur, but these all lack basic facilities and remain shut in the evening,” he says.
Elsewhere, the situation is similar.
“There are seven BHUs in the remote villages of Awaran with medical technicians; in Nondara, Methago, Bagari Zeelag, Nokjo, Malar, and Gishkore. And the People’s Primary Healthcare Initiative (PPHI), which is managing the affairs of the BHUs, provides medicines and equipment but their process is very inefficient,” complains Bashir Sajidi, president of the paramedics staff association of Awaran district.
Sajidi argues that although these basic centres remain open in order to provide some health services, almost all these facilities are severely lacking in basic facilities and hygiene standards. “No electricity, no gas supply, no accommodation for staff either,” he mourns.
In every district of Balochistan, there are only one or two gynaecologists, who are based in the headquarters. Allied with inadequate health facilities, untrained midwives, and underage marriages, it becomes clear why maternal mortality and infant mortality rates in Balochistan are frighteningly high as compared to the other three provinces of the country.
Fida Mengal, a student from Nushki district, mourns the death of his aunt during her pregnancy. “Had she been brought to Quetta on time, her life would have been saved. But due to poverty and lack of awareness, she could not be brought to Quetta to give birth.” He also complains of absence of health services in his village.
However, in Quetta, too, the health services are poor at government run hospitals. This is why the patients’ families prefer privately-run hospitals despite the fact that the same doctors are also posted at government-run-hospitals. Patients often complain that doctors in the public sector, despite being handsomely paid, do not perform their duties with utmost priority. On the other hand, in privately-run hospitals, they do so with urgency, care and responsibility.
Till now, the provincial government has been unable to tackle the matter of absent doctors, who do not perform their duties. As a result in Balochistan, particularly in rural parts, most hospitals wear a deserted look.
“In rural Balochistan, the primary health care system is inefficient. There is no laboratory; there is no machinery; there are no medicines; there are no good doctors. Therefore, you cannot get serious ailments treated if you belong to rural Balochistan,” argues Dr Ababagar Baloch, who is based in Quetta.
“On the other hand, the health department of Balochistan does not have the capacity to understand or tackle health-related problems, which is why there are no improvements seen in the health sector,” he claims.
In the budget for the health sector this time around, the provincial government has increased allocations to a greater extent. But on the ground, corresponding improvements simply do not exist.
The writer is a journalist and researcher.
He tweets @Akbar_Notezai
Out of the frying pan into Karachi
by Saher Baloch
In the absence of a vibrant primary healthcare system, citizens from all corners of Sindh as well as from Balochistan and KP travel to Karachi to seek treatment
Easily identified by their colourful attire, a family from Chachhro, Tharparkar sits in the front steps of the Sindh Institute of Urology and Transplantation (SIUT) on a Monday afternoon. They keep moving and shifting places near the hospital’s entrance.
For the past one week, these three young women and an old man with a toddler in tow have been accompanying the mother, Meena Devi, to the hospital to get her tests done. Their mother complained of liver pain, says Laxmi Kumari, the 20-year-old daughter, and when she was taken to a doctor in Chachhro Taluka Hospital, they referred them to Karachi.
Sitting alongside her father Kamlesh Kumar, Laxmi is the only one in the family who can understand Urdu somewhat; the other members either speak in Sindhi or look towards Laxmi to explain the questions to them.
Soon after getting the referral, the family hired a Suzuki pickup for Rs10,000 and travelled to Karachi. On arriving in the city and eventually at the SIUT, the doctor told them instantly that Meena has developed a cyst near the liver which is causing pain and that it can be dissolved by taking required tablets.
1,800-2,000
“She was in a lot of pain. We feared that the problem might recur, so we decided to stay back. We’ll leave as soon as she gets better,” adds Laxmi.
Out of the six talukas in Tharparkar district, the hospital in its capital Makli and Chachhro are the only ones that are functioning properly at the moment. According to a senior medical officer at Civil Hospital Makli, Dr Sahib Dino, the hospital receives referrals from Islamkot, Diplo, Nagarparkar, Umerkot and Chachhro. When patients don’t receive a satisfactory response to their disease, they prefer travelling to Karachi instead, as interviews with other families revealed.
Right opposite where they sat, an empty plot has transformed into a resting place for many such families who travel all the way from far away, and at times nearby, corners of Sindh in search of medical treatment.
The scene is similar in many of the public hospitals in Karachi, where around 1,800 to 2,000 patients come to the out patients department (OPD) on a daily basis. Apart from the three major public hospitals operating in Karachi — the Jinnah Postgraduate Medical Centre (JPMC), Civil Hospital and Abbasi Shaheed Hospital — there are others who receive as many patients on a daily basis as all three of them. These hospitals include, the National Institute of Cardiovascular Diseases and National Institute of Child Health.
Out of the 1,800-2,000 patients received in the respective OPDs of the three public hospitals, around 40pc are from Sindh, Balochistan, the Seraiki belt near Balochistan and Khyber Pakhtunkhwa. JPMC receives a sizable majority from Balochistan’s Turbat, Awaran, Khuzdar and Bela districts.
Besides, they receive Afghan refugees, who make a majority after Balochistan. From Sindh, the bulk of the patients referred to JPMC are from Thatta, Badin, Sanghar and Hyderabad.
Hypertension, diabetes, dermatology, TB, pulmonary diseases and hepatitis B,C,D and E are some of the diseases for which patients come to these hospitals. But majority of times, the diseases are not so major in nature.
“People come to us from all over Sindh and other provinces, seeking medical attention for, at times, curable diseases such as diarrhoea, flu, chest pain and gall bladder issues,” says head of the emergency department at the JPMC, Dr Seemin Jamali. Orthopaedics and trauma centre is another ward which is frequented the most by patients coming from towns close to Karachi.
Though men continue to be in the majority in terms of accessing the hospital, children come a close second, says senior paediatrician working with the Aga Khan University Hospital (AKUH), Dr Ghaffar Billoo. “Children continue to be the majority among the patients we receive from Thatta, Malir, Gadap and rural parts of Karachi,” he says.
The diseases usually include, but are not limited to, asthma, diarrhoea, typhoid, hepatitis E and pneumonia. At the same time, he said, these patients are coming from areas where immediate attention can’t be acquired. Women continue to be at the lower rung of accessing health care as they are dependent on two conditions; either they are accompanied by a man or an elder of the family or accompanying their children.
Those living within the 40- to 60-kilometre radius from Larkana find it easier to go to the Gambat Institute of Medical Sciences, in Khairpur district, which caters to the immediate as well as major medical needs of the people.
“After SIUT, many people in the area prefer going to Gambat hospital for dialysis and transplant services. But mainly, a second opinion is usually taken from the SIUT anyways which at times requires travelling to Karachi,” says Dr Inayat Magsi, psychiatrist and columnist from Larkana.
He argues that another teaching hospital within Larkana, Chandka Medical College, is among the best in terms of catering to the OPDs, but for further medical attention, the bulk of patients go to Karachi. Apart from that, he points to the rising discrepancy in the medical services in the province.
“The district hospitals in Sanghar, Badin, Mirpurkhas and Hyderabad are not working properly as a result of which the burden on the tertiary care hospital is increasing which in return is choking the entire health care system,” he adds.
Explaining further, he said that expenditure budget specific to the health care facilities in Sindh has not increased for the past many years. The case in point he says, is the Chandka Medical Centre in Larkana, which is a 1,300 bed hospital. Same is the case with Peoples’ Women University of Health Sciences in Nawabshah, Liaquat University of Medical and Health Sciences in Jamshoro and Hyderabad. Civil Hospital in Khairpur caters to a majority of patients coming from Sukkur as well, but the services facility for the hospital is less.
The reason for the decrease in facilities in all these centres, according to Dr Inayat, is increasing population.
“Healthcare in Sindh has been handed over to the tertiary care and the NGOs, which is wrong on many levels. For instance, if you get fever or flu, you don’t go to a tertiary care hospital rather a primary or a secondary one. The tertiary care cannot carry the rising burden of patients as a result of which a bulk of patients is referred to Karachi. Those who get referred to Karachi are mainly men and children, while women come last,” he contends.
Apart from that, he counts staff absenteeism, corruption and nepotism as the reasons behind the total dysfunction of the secondary and primary care hospitals.
Leading gynaecologists believe there are systemic issues to deal with in order to understand the overall picture. Senior obstetrician and gynaecologist, Dr Shershah Syed, whose hospital in Karachi’s Koohi Goth provides free of cost treatment for Obstetric Fistula to women coming from rural and urban centres of Sindh and Balochistan for the past 10 years now, explains that what the country needs is to put health on the priority list.
“I won’t say that Sindh doesn’t have any facility at all. But yes, those medical facilities are insufficient as a result of which people come to Karachi,” he adds. “The kind of burden it adds to the current health care system is enormous.”
Maternal care remains one of the least invested areas, adds Dr Syed, explaining that there are a few hospitals in Sindh which provide postnatal care as majority of the health facilities just can’t afford it.
“There’s a scarcity of health centres on the basic, primary and district level. We are opening medical colleges and universities, so far 140 of them have opened in the past two years all across the Sindh province, and it’s all for monetary purposes and vested interests,” says Dr Syed.
“That very action is compromising the standard of education in those medical institutions. As a result, the doctors coming out of those institutions are more into making money than actually understanding the larger issues at hand. We need to invest in prevention. We need 200,000 nurses and midwives, and the same amount of paramedics to run hospitals all across the country efficiently,” he concludes.
Published in Dawn, Sunday Magazine, February 21st, 2016
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