People from across the country come to Karachi for the treatment of various health conditions. On arrival at the airport, railway station or bus stop, these unsuspecting patients are often met by taxi drivers who offer to take them to a hospital, clinic, nursing home or private doctor, without charging any fare. In reality, they are not doing it for free but are being paid by the hospital or medical service they are working for.
The patient, who may not have any contacts in the city, trusts the cab driver and is transported to a hospital or a consultant, is shuttled from one doctor to another, and asked to get a battery of a few necessary and some unnecessary tests done as well. Each time the doctor makes a referral to another doctor, he is earning a commission fee. The patient, poor or rich, has no option but to comply. The majority of these patients come from impoverished households. Because they don’t have much savings to begin with, they pay these fees either by selling off their jewellery, crop or cattle.
How has it come to this?
With provincial governments abdicating their responsibility to deliver healthcare, the system has been rigged to the benefit of private practice
The answer, in part, is in the abdication of responsibility for universal healthcare that the government ought to fulfil.
The health department in each province is responsible for providing basic and emergency care to the people of their province. The Punjab and Sindh governments have accepted their failure in delivering healthcare facilities and controlling corruption. And so, instead of controlling corruption and running efficient systems, they have opted to privatise health facilities to private parties altogether.
Meanwhile, in the public sector, provincial governments are keen to buy expensive equipment but are least bothered about trained personnel to operate them. During my surgical camps, I found an expensive operating microscope at the rural health centre (RHC) at Khuploo, Baltistan, an anaesthesia machine with a ventilator at the RHC Mastung, Balochistan, and some expensive lab equipment in the Taluka Headquarters (THQ) Sheikhupura, Punjab — all covered in plastic sheets, as nobody was able to use any of this.
Similarly, expensive mammogram machines are not functional in many places because the hospital has no female technicians. In Basic Health Units (BHUs), expensive dental chairs lie covered in plastic sheets, rusting away and waiting for a dentist to be appointed to use them.
Here’s the kicker: each year, expensive equipment is bought by government officials in connivance with the doctors at inflated prices so that everyone gets a cut in the deal.
COMMISSIONS FOR ALL
Patients visiting public hospitals are often referred to private hospitals, laboratories and X-ray centres. On the pretext that machines are out of order, for instance, many expectant mothers are sent to private ultrasound clinics to confirm foetal well-being, when often this test is simply not needed at that stage. The test may cost them about 800-1,500 rupees — out of this the referring doctor will receive 200-500 rupees as a commission.
This commission fee business is dicey.
Though sometimes tests are needed to confirm or rule out a suspicion, often they are done because many pathological laboratories — with the exception of a few — pay commission fees to physicians and consultants for getting these tests done. This is more so for patients whose bills are to be paid by the company, especially multinationals that they may work for. As secretary-general of Pakistan Medical Association (PMA), I was left speechless when the chairman of the Sui Southern Gas Company showed me bills of two private hospitals in which some of their male patients were charged for pregnancy tests.
To eke out a commission fee, not only minor tests but sophisticated investigations such as MRI and CT scans are also ordered. To benefit from this, people without any medical backgrounds are running centres with MRI and CT scan facilities. Their agents convince doctors to send their patients to these centres and in return receive a commission fee. Often these investigations are not necessary. This system is making doctors rich with no consideration for ethics, morality and honesty.
As if the unscrupulous relationship between doctors and laboratories were not enough, some multinational and local pharmaceutical companies are also paying doctors to promote their medicines. They not only give expensive gifts to doctors and organise family parties — even contribute to the wedding of doctors’ children — they pay air tickets of doctors travelling to attend conferences.
Another unique idea is to organise chartered flights for a plane full of doctors along with a few speakers and take them to destinations such as Dubai, Istanbul, Tashkent, the Maldives or some other exotic place in the name of continuous medical education. They all stay there for three to four days at five-star hotels, attend a few hours of sessions and, after shopping and holidaying, will come back to prescribe the medicine of the sponsors, whether needed or not.
In a country where there is no check on over-the-counter sale of drugs, and where even the medical store-keeper can prescribe medicines after listening to patients’ problem, some pharmaceutical companies are taking advantage of the situation and targeting medical stores for the sale of their drugs. This unchecked sale of drugs, in collaboration with pharmaceutical companies and shopkeepers, is creating havoc in the community and is responsible for resistant organisms, morbidity and unnecessary deaths.
Professors in medical colleges, busy medical consultants and family physicians are obliging the pharmaceutical industry with or without realising that the ultimate sufferer are the patients who are indirectly paying the price. And this mindset reflects in their students as well — young doctors today, even those in training at public and private medical colleges and universities, have no role models to follow. With the exception of a few, faculty members hardly give time to patients, students, teaching and academic activities. Many professors give more time to their private practice and go to college for a few hours in a month. One can imagine what a student attending these institutions will learn, and what kind of moral and ethical standards s/he will have when they become a doctor. Their training in corruption starts from the very beginning, when they need to be trained as responsible and ethical medical students.
Unfortunately, in most big cities of the country, there are doctors and hospitals that have no ethical considerations, nor are there any controls over their practice. The government, watchdog bodies, regulating agencies, civil society and even professional bodies are least bothered about this corruption and exploitation of patients. Occasionally, electronic and print media do highlight these issues but usually it’s ineffective as the media is more interested in sensationalism instead of correction and reform.
In order to understand this corruption at individual and hospital levels, it is important to take a look at the deteriorating conditions in different areas of the healthcare system. Corruption is widespread and it is not manageable without taking revolutionary steps for correction.
TURN OF THE TIDE?
Of late, we are seeing some reversals in the process but changing the status quo is still an uphill task.
In Khyber Pakhtunkhwa, the government is trying to run health centres by banning private practice of doctors and increasing their salaries. However, the move is facing a strong opposition from healthcare workers, especially doctors.
In Khyber Pakhtunkhwa, for example, the government is trying to run health centres by banning private practice of doctors and increasing their salaries. However, the move is facing strong opposition from healthcare workers, especially doctors.
The Sindh government recently began an initiative to activate every BHU in the province by training paramedics and midwives in large numbers and by hiring doctors on a competitive salary with benefits — albeit with no permission to do private practice. This drive is commendable, for it is the only scheme which will improve maternal and neonatal morbidity and mortality if allowed to continue for few years. It is, again, not surprising that this drive is being opposed by the health department.
Presently, doctors are posted in BHUs, RHCs, THQs and district general hospitals (DGH). But doctors attend these centres for a few hours at their convenience and spend the rest of the time in private practice. In some cases they do not even visit the health centre and just get their salary after paying a cut to the authorities concerned. This system is very well-organised and it’s difficult to subvert it. But there are other avenues where the government ought to, and must, introspect and introduce corrective measures.
In the last 70 years, for example, the government has failed to invest in preventive medicine. Two-thirds of our population does not have access to safe drinking water and proper sewerage systems. It’s heart-breaking to see rivers in northern areas, which are a source of water to the whole country, being used as a part of the sewerage system. Health needs to be looked at holistically; it is not simply a matter of constructing health facilities.
A long list of programmes such as the family health project, polio eradication program, malaria control programme, HIV-AIDS initiative, midwife training programme, family planning programme and many initiatives funded by UNICEF, WHO, UNFPA and other donor agencies have not produced the desired results. The reason is that, in all these projects, a project director (PD) is appointed by the government, but not on merit. The PDs are well paid, drive four-wheel-drive jeeps and spend money at their discretion but often are not held accountable for the lack of impact of their programmes. Unfortunately, donor agencies also ignore these manifest problems because of political reasons and corruption.
The healthcare system will not improve until the deep-rooted corruption within it is taken care of.
The writer is the former secretary general of Pakistan Medical Association
Published in Dawn, EOS, May 6th, 2018