In 1965 Chairman Mao Zedong criticised the doctors for not providing healthcare to poor peasants of China. He was critical of the doctors who wanted to serve in big cities only. He called for a system with greater focus on the well-being of the rural population. As a result, the country opted for a programme to produce bare-foot doctors to serve in rural China through an initiative known as the rural cooperative medical system. Under this programme, thousands of high school graduates went through an 18-month-long basic training in preventive medicine.
The training focused on the promotion of preventive measures against epidemic diseases as well as treatment of simple ailments through Chinese and Western medicine. By 1968, bare-foot doctors became an important part of the Chinese health system. The Alma Ata health conference, organised by the World Health Organisation in 1978, recognised and praised the scheme as a revolutionary scheme for the rural population with inadequate healthcare system.
Abolishing the scheme in 1981, the Chinese government asked all bare-foot doctors to appear in a national examination. Those who passed the exam were appointed as village doctors and the rest as village health aides. It is widely accepted that the bare-foot doctor scheme played a very important role in providing primary healthcare to people of China, before the advent of a modern and advanced healthcare system there.
As governor of California, President Ronald Reagan signed a bill in 1970 allowing paramedics to provide intravenous therapy and give emergency treatment when doctors were not available. At that time, the American Medical Association and nursing associations opposed the bill and tried to block its implementation. With its implementation the management of emergency situations such as road traffic accidents, natural disasters, and clinical emergencies such as heart attacks changed in the USA. Very soon the services of paramedics were also recognised all over the world.
State-of-the-art hospitals and thousands of doctors are not enough to run a healthcare system.
Where are the paramedics?
At present, paramedics play a very important role in health-delivery systems. The profession has evolved significantly in the last 50 years or so, and qualified and trained paramedics are providing services in almost every branch of medicine. In fact, it is impossible to run a modern healthcare system without paramedics. In the developed countries, paramedics receive structured and rigorous training. They are also well paid and have an attractive career structure. No wonder millions of young men and women opt for this profession and are considered valuable members of the healthcare system.
Paramedics in Pakistan
In Pakistan, however, paramedics are poorly trained. There is no organised system for their education and training, and there is no regulatory body or authority for the standardisation of their skills and monitoring of their activities. It is unfortunate that they have been exploited by different political forces for their vested interests.
The provincial health education boards are responsible for monitoring education and the training of paramedics at different recognised centres, as well as for the certification of candidates after examination. The boards are, however, not responsible for their career structure and advanced training, and they do not monitor their activities. Yet, despite a lack of resources and the absence of any health policy regarding development of human resource, the health education boards have produced paramedics who are working in different hospitals and healthcare centres.
Historically, the missionary hospitals, established in the 19th and 20th centuries, started the training of paramedics in their hospitals to help doctors. Initially operation-theatre technicians, laboratory workers, anaesthetic assistance, radiographers, physiotherapists, dental assistants, vaccinators, dispensers and dressing-masters were trained.
It seems there is lack of political will at all levels against an organised healthcare system in Pakistan for the poor and needy.
With time new kinds of paramedics such as intensive and neonatal care technicians, dialysis assistants, psychiatric attendants, MRI and CT scan technicians and ward workers were trained to cope with the ever-increasing work load.
The Aga Khan Hospital and Sindh Institute of Urology and Transplantation (SIUT) at Karachi and Christian Mission Hospital at Sialkot have notable structured training programme of paramedics for their own consumption.
The Edhi Foundation tried to train their emergency ambulance service workers with the help of the Pakistan Medical Association but it wasn’t possible to develop a system on permanent basis. An initiative was taken by the Rescue Academy Lahore to train paramedics for emergency services and a good number of emergency health workers have been trained in Punjab and KP.
The Aman Foundation in Karachi has also started an ambitious and successful programme to train paramedics for their emergency ambulance service. The Pakistan Army runs a school of paramedics at Abbottabad providing structured training to paramedics in different fields who are later employed by the army medical core and have a career structure in army.
The KP and Punjab governments recognised paramedics as healthcare professionals in 1995 and 2005 respectively. Despite that, both the governments have not been able to develop a proper career structure for them, and they are still struggling for a respectable status in the healthcare system. In other provinces the authorities are not ready to accept them as professionals. It seems there is lack of political will at all levels against an organised healthcare system in Pakistan for the poor and needy.
Global success stories
If the government is serious about the health of people they should try to learn from the experiences of China, Europe and America in resolving the health issues in their countries and recognise the role of paramedics in the healthcare system.
Recently the prime minister of Pakistan announced that the government would establish 46 state-of-the-art hospitals in the country. The chief minister of Sindh announced the intention to appoint 7,500 unemployed doctors to run the health system in the province. It is very easy to spend billions to construct hospital buildings and on the purchase of expensive state-of-the-art equipment.
It is also very easy to hire doctors to run the healthcare system where the system does not even exist. The cost of construction and massive hiring are prohibitive and also practically unsustainable when it comes to maintenance and retention.
On the other hand, it is a significantly less expensive but challenging to develop a human resource base consisting of paramedics, nurses and midwives to work in the healthcare system at various levels. A doctor in a centrally air-conditioned building with state-of-the-art equipment cannot run a hospital or a healthcare centre alone. They need dedicated and well-trained paramedics, nurses and midwives.
What needs to be done now
We need a strong, independent, autonomous professional council of paramedics on an emergency basis in Pakistan. The government should support and finance the council to organise, monitor and regulate this important profession. Each provincial government should announce a proper career structure for them and the profession should be treated with respect and dignity. Doctors, nurses, midwives and paramedics are part of the team that could provide the best possible preventive and curative healthcare to the people.
We are facing a serious situation as far as epidemics are concerned. Yet our healthcare system is in a shambles. It would help a lot if we could learn from developed countries about developing a healthcare system that works for the people.
The writer is ex-secretary general of the Pakistan Medical Association
Published in Dawn, Sunday Magazine February 12th, 2017