HEALTHCARE is dangerous to your health. Ask your neighbour for verification. You will likely hear more than one first-hand experience of someone dead who should be very much alive.
This outcome is unsurprising for three principal reasons related to peculiarities of the industry, social attitudes of the population, and commercialisation of the economy.
First, the industry. Healthcare is a field exhibiting the starkest asymmetry of information between providers and consumers. Every incidence of illness is in some way new and patients have insufficient knowledge to question diagnoses or prescriptions without second opinions and retesting for which there is often no time. In healthcare, lives are literally at stake unlike, say, in education, where, if dissatisfied, one can change a child’s school and start again.
Second, social attitudes. People, by and large, still attribute unfavourable outcomes to divine will. Even when convinced of poor service, they rationalise that the intentions of providers must have been good but that the patient’s time to die, one way or another, had arrived. This no doubt provides solace to the bereaved but does nothing to hold poor service accountable or provide countervailing pressure for improvement.
Standards have slipped because regulatory capacity has been outstripped by the number of facilities.
Third, commercialisation. The logic of the market has now fully permeated the provision of healthcare, earlier regarded as a social service yielding providers a respected status in society. Income maximisation is now a much more salient motivation. In private conversations, medical professionals even point to the emergence of collusive networks among physicians, laboratory owners, pharmacists, and equipment and medicine suppliers aimed solely at fleecing patients without even the pretence of providing care.
As a result, standard norms of economic theory are upended — the free market in healthcare does not minimise cost of service, competition does not drive out bad providers, and it is not only the fittest that survive. Because patients do not have the luxury of withdrawing from the market, poor performance actually increases the revenue transferred to providers as patients shuttle helplessly from one facility to another.
Given these factors, the only way to protect patients is very tight regulation in which the state, the traditional regulator, despite continuing attempts, has failed to measure up to needs. In fact, standards of service and accountability have continued to slip simply because growth in the number of providers and facilities has outstripped regulatory capacity.
While there is no alternative to regulation, it is generally accepted that expecting the state to discharge that function in Pakistan is unrealistic. The record shows that the state politicises the operations of the regulatory body and compromises its independence. It uses its powers of patronage and does not appoint competent professionals to positions of leadership. Many of the officials it does appoint use the opportunity for rent seeking. There is no other explanation for the number of private medical colleges licensed without adequate faculty and the number of facilities advertising themselves as hospitals without fulfilling basic requirements.
Given that lives are at stake, citizens cannot afford to wait indefinitely for a caring state to emerge. A second-best solution is urgently called for. One alternative is to push to privatise the regulatory function while being cognisant of the private sector’s weaknesses and hedging appropriately in the interest of the citizens.
The only function remaining with the state regulator would be to bid out the regulatory contracts for predefined terms to established private audit firms with reputations to defend. Since this is a major departure, the experiment can be piloted in one sub-district or small city. The private regulator would categorise and register all facilities, ensure compliance with minimum requirements, introduce standard record-keeping protocols, and initiate a regime of random inspections. Based on a cumulative review of records, facilities would be assigned quality rankings to be disclosed to citizens. Facilities falling below acceptable standards would be given a limited time to improve to avoid losing their operating licence. Registration fees could partly finance the experiment.
In parallel with this privatisation, a board of credible individuals would serve as an independent watchdog on behalf of the local population. In addition, the federation of newspapers could nominate a set of journalists to report regularly on the experiment. Thus circumscribed, the second-best alternative could be expected to prove more effective than the state regulator. Based on the results of the pilot, the arrangement could be fine-tuned before expanding its coverage.
For the longer run, however, the existing model of curative care is unsuitable in a country where incomes are low, the incidence of ill-health is high, and basic public health infrastructure — safe water and sanitation, clean air, pest control, etc — is missing. Populist attempts to make curative care affordable will prove to be unsustainable. We need to transition to a wellness model based on preventive care in which households are visited, monitored, and guided at regular intervals independent of episodes of sickness.
Such a model could also be tried on a pilot basis in one jurisdiction. There are a number of very successful examples to learn from. In 2014, the director-general of the World Health Organisation recommended Cuba’s preventive healthcare model to the entire developing world even though it is not considered politically correct to applaud anything happening in that country. In Cuba, family physicians supported by paramedical staff deliver primary care and preventive services at the local level to panels of patients, about 1,000 patients per physician, with patients and caregivers generally living in the same community.
Even an affluent country like the UK subscribes to a similar model in which family practitioners and ancillary staff responsible for registered populations of patients act as gatekeepers to specialist care.
Healthcare in Pakistan is out of control and in bad shape and it is up to citizens to articulate alternatives to avoid more tragic losses. This can be a common cause for the rich and poor because not even all the well-off can travel abroad for their check-ups and medical needs.
The writer is a fellow at the Consortium for Development Policy Research in Lahore.
Published in Dawn, March 21st, 2017