Sir Joseph Bhore was appointed the chairman of the Health Survey and Development committee in 1943 by the British colonial government to give recommendations about healthcare in colonial India. Three years later, Sir Joseph submitted a report which is known as the Bhore Committee Report. The committee recommended integration of preventive and curative services, and development of primary health centres in two stages; it also gave recommendations for medical education and the training of doctors.
As a short-term and immediate measure, the Bhore committee suggested developing one primary healthcare centre (PHC) for a population of 40,000 people. The proposed PHC was to be managed by two doctors, one nurse, four public health nurses, four midwives, four trained dais, two sanitary inspectors, two health assistants, one pharmacist, and 15 other class IV employees. It was recommended that the future secondary health centres would have a close coordination with the PHC. For the long-term, the Bhore committee report suggested a three-tiered healthcare system which featured a 75-bed hospital for 10,000 to 20,000 population; a 650-bed hospital at the secondary level; and a 2,500-bed hospital at the district level to provide health services to the people.
The committee also suggested some major changes in the medical curriculum, including three months of training in preventive and social medicine to prepare for what it called “social physicians”. It believed that doctors should realise their responsibilities by understanding the social and cultural aspects of the community they were serving.
A year before Partition, the British proposed radical changes to the healthcare system to deliver universal healthcare; 70 years later, the issues and shortcomings remain the same
The British colonial government left the country in 1947 without implementing the recommendations from the Bhore committee report. The new government of M.A. Jinnah in Pakistan was so busy in establishing the state that they didn’t have time to look at and implement the recommendations of the Bhore committee.
The successive governments lacked the necessary skills to run a new country in the best interest of the common people and deal with its dominant classes led by landlords, sardars, waderas and elites. The religious leaders were more interested in the Objectives Resolution than the miseries of farmers, labourers, women and the marginalised. They had no understanding of the suffering faced by the common man due to a lack of healthcare facilities nor did they have the political will to develop a system to address the health-related issues of the extremely poor population of Pakistan.
Unfortunately, the internal conflicts of the ruling classes and increasing religious intolerance gave a chance to the armed forces to intervene in politics and the first army rule was established in Pakistan in 1958. Under pressure from the US government, and on recommendation of the Harvard Group, the health managers of president Ayub Khan introduced a health structure in Pakistan probably on the lines of the Bhore committee report.
An infrastructure was suggested and established in the form of a basic health unit (BHU), rural health centre (RHC), taluka headquarter (THQ) and district general (DHQ) hospitals, and referral centres attached with medical colleges as tertiary healthcare centres. With massive funding from USaid, United States’ aid agency, a preventive programme was started in schools with the distribution of milk for children, vaccination against tuberculosis and other preventable diseases. The World Health Organisation (WHO) started a campaign to eradicate small pox and malaria as part of its global programme. Additionally, a ministry of family planning was established to deal with the challenge of over-population, especially in the then East Pakistan (now Bangladesh).
At the time of Partition, Pakistan had only three medical colleges; one each in Lahore, Karachi and Dhaka. The government established new medical colleges in Multan, Peshawar, Hyderabad, Chittagong, Mymensingh, Rajshahi, Sylhet, Barisal, a second college at Dhaka, and a medical college for girls at Lahore.
Initially, the medical colleges and the tertiary hospitals were established with the appointment of human resource to run the institute as per the requirement of people and patients. They were well-funded and followed the Indian Medical Council Act-1933 and the rules and regulation of the General Medical Council, UK, till the formation of Pakistan Medical and Dental Council (PMDC) in both provinces in 1957. In 1962, the provincial medical and dental councils were dissolved and the PMDC was established by an ordinance.
After losing the eastern wing in 1971, and the formation of new provinces (in the western part) the provincial governments established various BHUs, RHCs, and hospitals in rural areas but most of these health facilities were merely buildings without adequate human resources and necessary equipment.
It is not that new positions were not created and appointments were not made. It is just that doctors, nurses, health technicians, etc managed to get themselves transferred to large cities through sifarish after getting appointment letters. For all practical purposes, it was not possible to work in these centres as they lacked basic infrastructure and facilities.
As a matter of fact, the government machinery used these places for organised corruption in collaboration with the health professionals, especially doctors. Funding received from different countries and international donor agencies is often used by government officials for purchasing expensive medical equipment for BHUs and RHCs knowing that these centres have inadequate human resources to utilise such instruments. I have seen very expensive state-of-the-art anaesthesia machines in many RHCs in Balochistan. In some of the centres, expensive machines are simply lying in unopened boxes as the staff did not know how to use them.
In Sindh, Punjab and Khyber Pakhtunkhwa, dental chairs and ultrasound machines have been bought for centres where there are neither dentists nor doctors to carry out ultrasonic examination. All these machines were bought on inflated prices and obviously many people received commissions and other benefits (like paid vacations) for facilitating the purchase.
Surprisingly, donor agencies from Unicef to the World Bank, and from WHO to the Asian Development Bank and USAID do not have any effective system to control this kind of corruption. In some instances it is felt that some of the officials of these agencies were also involved in organised corruption in collaboration with government officials and doctors. Quite recently, the government of Norway stopped its funding for a project on improving maternal and child health in Sindh after 18 months, following observations of a high level of wastage in utilisation of the funds. It’s a loss of a great initiative taken by the ex-prime minister of Norway for maternal and new-born care in Pakistan.
Despite this gloomy scenario, some public-private partnership initiatives in Punjab and Sindh have shown very good results by reorganising the operations and human resources attached to basic health units. In Sindh, the programme was not allowed to operate in Karachi (by the then provincial health minister), and in Nawabshah (by the then city Nazim of Nawabshah) for reasons best known to them. The success of these programmes has shown that if the government is willing to provide basic healthcare to rural populations, it is possible to do so through a well-organised programme and within existing resources.
There is a need to learn from the success of these programmes and expand them to all parts of the country despite opposition from vested interest groups. There is room to improve them for the betterment of patients and make them more effective in far-flung areas where doctors will never go to work because of their poor understanding of social responsibilities.
At present, there are 5,499 dispensaries, 5,438 basic health units, 669 rural health centres, 671 mother and child health centres, and 334 tuberculosis centres in the country. There is a need to organise these centres in a way that they can actually serve the extremely needy population in our rural areas and city slums. We obviously do not have enough human resource, especially doctors, to run these centres. To make them work, the provincial governments will have to adopt an aggressive policy of training nurses, midwives and health workers to run these centres instead of spending money where it is used for corruption; they shall have to do this by using different means and ways.
It has been shown in many countries that trained nurses, skilled midwives and educated health workers have changed the healthcare structure with very good results. They were able to decrease maternal and neonatal mortality, and popularise the use of family-planning methods. They were successful in decreasing tuberculosis and preventable diseases in rural populations, too. The health workers were also involved in creating awareness about clean water, sanitation and proper disposal of waste.
We do not need doctors to run BHUs. It is a waste of human resource in a situation where doctors themselves don’t want to go to the rural areas. The new generation of doctors are more interested in their renumeration and are willing to go on strike, with or without reason, at any time, without realising the suffering they cause to families and communities. They don’t understand that the medical profession is not about money and power, it’s about service and scarifice at any cost and at any time.
The provincial governments should appoint trained and skilled nurses, midwives and heath workers to run BHUs, provide a career structure for them and encourage them to help and serve the people. It will take time but will bring positive changes in the lives of the people.
The government should also empower local bodies which can work and ensure the provision of potable water to the population and the establishment of sewerage systems in all areas — if it is really serious about improving the well-being of poor citizens of Pakistan. The government does not need extra funding for this task as this can be done within existing resources — as long as there is a political will, judicious planning, and transparent use of financial resources.
Published in Dawn, Sunday Magazine, June 12th, 2016