September 7, 2003

While on paper the healthcare delivery setup appears to be designed quite well, in reality it is on the verge of an implosion. Not only are we severely constrained by meagre resources, we are not even properly utilizing what little we have

PUT yourself in the shoes of an average Pakistani citizen in search of good healthcare. Private doctors and hospitals cost more than you can afford, so you would have to contend with government facilities. You start by going to the nearest facility, most likely a rural centre staffed by paramedics. Underwhelmed by their expertise, you consider a private clinic once again, but the thought of your household budget comes in the way.

You then decide to go to a large government hospital and find yourself braving the crowds at the teaching hospital located in your provincial capital. But you are in a sea of humanity and don’t get proper attention.

The ailment you were seeking help for runs its course and complications start setting in. Depending on your resolve, you could now accept your fate in silence, or sell belongings and borrow money and head towards a private hospital. Either way, the system has already shortchanged you.

Worse, your illness could well have been prevented had somebody only told you how. You, a proud citizen of your country, find yourself trapped in the vicious cycle of poverty and poor health as your government abandons you in illness. What is wrong with our health delivery system, you ask. Do we even have a health delivery system at all, you wonder.

The answer to the latter question is certainly in the affirmative. Indeed, on paper, the healthcare delivery setup in Pakistan appears to be quite well designed. At the base of the system are the Basic Health Units (BHUs) and Rural Health Centres (RHCs), which are meant to be the first point of contact for patients. Largely in rural areas, these centres are mostly staffed by paramedical personnel and deal with just elementary medical concerns.

For more complex problems, the BHUs and RHCs are supposed to refer patients to a tehsil hospital, which has non-specialist doctors and can admit patients and do simple diagnostic tests and minor surgeries. The next level up is the district hospital located in the district headquarters, usually a city of some importance but not a major metropolis. These hospitals are better equipped than tehsil hospitals and can manage medical and surgical problems of medium complexity. However, they lack advanced diagnostic facilities and have no intensive care beds; they usually don’t have any specialists either.

For the most serious illnesses, including life-threatening conditions like meningitis, cardiac complications and cancer, one has to turn to the large tertiary-care teaching hospitals. Located in our largest cities — Lahore, Karachi, Hyderabad, Faisalabad, etc. — these enormous mega-hospitals often comprise over 1,000 beds. They offer advanced technological facilities such as CT scanners and dialysis machines as well as a roster of highly trained and qualified specialists capable of delivering sophisticated treatments like brain surgery and cardiac bypass.

It all sounds quite fit and proper, but is it? In reality, this logically hierarchical health delivery system is failing. “The problems are so many, one doesn’t know where to start,” says Dr Asma Fozia Qureshi, dean of Ziauddin Medical College in Karachi and professor of paediatrics and community health.

“The BHUs and RHCs are often not accessible because of large distances or limitations on human movement imposed by feudal landowners; they are also often understaffed and frequent victims of absenteeism,” notes Dr Qureshi, who has spent a career analyzing public health problems and health systems.

She points out that entrenched problems exist at every level of the system. At the tehsil and district hospitals, for example, the allocated resources and medicines are commonly pilfered and end up in the wrong hands; there is also a gross lack of accountability, so countering such pilferage is almost impossible.

An important reason why the existing three-tier setup fails is that the system is ignorant of the needs and expectations of patients and their families. With poorly staffed non-functional local facilities, the lower tiers of our health system are frequently bypassed in favour of the apex institutions, the tertiary-care teaching hospitals.

People are free to access any part of the health setup, and they flock to the ones considered best staffed and best equipped. The inevitable result is that the primary-care centres — BHUs and RHCs — and the secondary-care facilities — tehsil and district hospitals — are underutilized, while the teaching hospitals are constantly overburdened and overextended.

Karachi’s Jinnah Postgraduate Medical Centre (JPMC) is the prototype public-sector tertiary-care hospital. Spread over several acres, the hospital comprises over a thousand beds in different wards, and offers a comprehensive range of medical services. Some of Karachi’s elite medical consultants are on its staff.

The hospital also consumes enormous resources, with an annual budget exceeding Rs250 million. The stark reality, though, is that hospitals like JPMC exist in a chronic state of exhaustion. For all the money and expertise, their ability to deliver quality healthcare is continuously compromised. According to Dr Tasnim Ahsan, professor of medicine and head of a major medical unit at JPMC, calling our teaching hospitals tertiary-care facilities is inaccurate. “We are constantly delivering a great deal of primary- and secondary-level care as well, which can easily be done at the rural and district levels,” she says, adding that the excess burden creates a never-ending strain that is manifested as a lack of consistency in care delivery.

“Take the case of a moderately severe disease like amoebic liver abscess,” continues Dr Ahsan, referring to an illness of fever and abdominal pain caused by an intestinal parasite invading the liver. “We can treat many of these patients just as well as at any medical facility in the world, but we can’t be sure of doing it reliably and consistently all the time.” In other words, the potential for top-quality care exists within the system, but it frequently goes unrealized.

Paradoxically, one of the impediments to medical care cited by Dr Ahsan is an excess of doctors. At JPMC, for instance, a 40-bed ward can often be staffed by 40-50 junior doctors in training. This fosters absenteeism and lack of accountability among the trainee doctors, creating an administrative nightmare for the professor heading the ward. Wards with a good reputation suffer the worst, as they are forced to take on more and more trainees through sifarish and other pressures.

A common refrain about our public-sector hospitals is that the top consultants frequently shun government duties in favour of their private clinics, but Dr Ahsan dismisses this criticism outright. Most consultants devote greater time to their public-sector wards than to their private work, she says, but the efficiency of the private sector is far greater. The implication is that doctors could spend all their time on government duty, but the quality of care will not change unless the systems and procedures are improved by promoting efficiency and eliminating nepotism and waste.

Undoubtedly, important lessons can be learnt from the private sector as well. According to the National Health Survey of Pakistan, a very large government study published in 1994, private-sector physicians are now the most common type of healthcare provider for all age groups of our population. While it remains the government’s responsibility to ensure appropriate and affordable healthcare for all citizens, clearly the private sector is stepping in where the state is failing to deliver.

Although quality varies, the best private setups in Pakistan are capable of healthcare delivery at par with international standards, albeit for a price. But is it simply a question of money and material resources?

“A number of factors contribute to proper healthcare delivery, material resources being only one of them,” says Nadeem Mustafa Khan, chief executive officer of Aga Khan University Hospital (AKUH) in Karachi, which is one of the premier medical facilities in the country.

Among the factors most important in delivering high-quality care, Mr Khan lists properly qualified personnel, consistent and reliable systems and procedures, clear quality standards, and professional management and leadership. He also underscores the need for continuous training of healthcare personnel at all levels — doctors, nurses, technologists, managers — to ensure that the workforce is always able to fulfil its duties in the best possible way.

A few years ago, Mr Khan served on a four-member commission constituted by the government to review and make recommendations on the performance of the Pakistan Institute of Medical Sciences (PIMS) in Islamabad, a national referral hospital and postgraduate institute, and our federal government’s flagship tertiary-care facility. The commission concluded that, in principle, a public-sector institute like PIMS is fully capable of performing at par with the best private centres. Among their recommendations were a revised organizational setup with clearly identified chain of command, institution of core financial management systems such as balance sheet accounting, and the strict upholding of merit in recruitment and promotions.

It is important not to overestimate the value of the private sector, however. In the absence of any accrediting body that can monitor hospital standards in Pakistan, private facilities lack accountability and unscrupulous and fraudulent practices go unchecked. Hospitals do exist that transparently adhere to acceptable standards, but for reasons of both cost and capacity, they can cater to but a fraction of the population. Ultimately, therefore, the responsibility for proper healthcare must rest with the government.

Pakistan is not the only country struggling with issues of appropriate and affordable healthcare, but we are doing worse than most. With an average per capita income of $420 and over 80 per cent of gross national income committed to debt servicing, ours is a poor and severely indebted economy, and it shows in the health statistics.

A Pakistani child born today can expect to live 63 years; by comparison, a child born in the Netherlands (to use an example of a developed economy served by one of the world’s best health systems) can expect to live 78 years. Pakistan’s infant mortality rate (number of infants dying before their first birthday, out of every 1,000 births) is 84; in the Netherlands it is 5. Pakistan’s under-5 mortality rate (number of children dying before their fifth birthday, out of every 1,000 children) is 109; in the Netherlands it is 6.

Staggering as these differences are, it is the comparison with regional countries that is especially galling (see the accompanying table). In 1970, Pakistan’s infant mortality rate was similar to that of India and Bangladesh (East Pakistan), while its under-5 mortality rate was lower. Over the last three decades, this has been reversed, and Pakistan’s infant mortality rate and under-5 mortality rate in 2000 were both worse off compared to figures for India and Bangladesh.

Most remarkably, Bangladesh has surged ahead of Pakistan in these crucial health indices even though its health expenditure has been less than Pakistan’s. The conclusion is straightforward: not only are we severely constrained by meagre resources, we are not even properly utilizing what little we have.

One is tempted to glibly dismiss public-sector efforts in healthcare, but it is worth taking a look at the problem from the government’s perspective. Even stable and wealthy countries like Britain and the United States struggle to provide comprehensive healthcare to their populations, so a developing state like Pakistan clearly faces formidable, almost overwhelming, odds.

A senior official at the Sindh Health Department (the provincial government organ responsible for health delivery) points out that since Pakistan is not a tax-paying country, our public’s “expectations of a government-supported quality health system are unrealistic” to begin with. The issue is severely compounded by the crushing twin handicaps of illiteracy and population growth, creating a near-hopeless situation.

Even so, the government is mounting a response to the crisis. According to Dr Srichand Ochani, another senior official from the Sindh Health Department who has served at multiple levels of the health administration, the need to strategically shift priorities from tertiary care towards primary and secondary care has been recognized at the highest levels of our national health policy setup.

The objective is to unburden the tertiary-care hospitals while strengthening preventive and promotive aspects of health delivery, which can be done with fewer resources and with greater long-term benefit to the population. Improved allocation of equipment and better incentives for staff at the Basic Health Units and Rural Health Centres are some of the measures under way to help redistribute the burden towards primary- and secondary-care facilities.

In response to particular health needs, a number of specific preventive initiatives are also under way. The flagship preventive programme is the Expanded Programme for Immunization (EPI), which now covers 56 per cent of the target population. (This is still an underachievement, because in a country like Egypt coverage exceeds 90 per cent).

Other prevention programmes include projects devoted to malaria, tuberculosis, blindness, and AIDS and other sexually transmitted diseases. Funding for these programmes comes from a variety of foreign sources such as the World Health Organization, World Bank and UNICEF. While the foreign support gives the programmes momentum, it also means that these disparate activities are difficult to integrate into a single national health policy framework. The programmes are also vulnerable to the myriad geopolitical and other forces affecting foreign aid.

Though they are making an important contribution, the existing programmes are barely scratching the surface of preventive medicine in Pakistan. The National Health Survey revealed that one out of every three Pakistanis over the age of 45 has high blood pressure, which leads to devastating complications like heart attack and stroke, if left untreated. An effective and coordinated national blood pressure control programme is, therefore, clearly a paramount need, but with other pressing priorities it is unlikely to be taken up in the foreseeable future.

Where does one go from here? The government for its part has formulated a strategic national health policy and taken advantage of international donor agencies to sustain targeted initiatives. But barely a fraction of our needs are being addressed.

In terms of proper health coverage, we have not achieved even five per cent of what a successful socialized health system in the West is able to deliver. Urgent reforms and reorganization in both the public and private health sectors are needed, but huge obstacles persist. Poverty and limited resources have been the traditional villains, but it is time now to recognize and confront the true enemies - nepotism, waste, corruption, pilferage and managerial ineptitude.

It is an axiom of professional management that leadership makes the difference. The recipe for progress is an open secret. Where are the leaders who will implement it for us? Our nation looks around with lonely eyes.

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