Debates on health issues in Pakistan often revolve around a single-point agenda that focuses mostly on the callousness of doctors. Turn on any television channel, or go through any newspaper, and you will learn of the medical fraternity’s recklessness with their jobs. Incidents vary, from how a wrongly prescribed injection proved fatal for the patient, to how patients flounder for help as doctors shut down hospitals in demand of a pay raise or humane working hours.

The same is true for representatives of political parties who talk at length about healthcare reforms, but when asked to spell it out, the reforms are mostly about providing free or economical healthcare. At the core of this issue is the fact that patients cannot afford their medical bills, and that’s a fair argument to go with.

And that’s our bit of obsession with fixing the healthcare issue. Laypeople cannot be accused for this poor understanding of the problem. This arises from their grappling with healthcare, which is mostly limited to their consultations with physicians. The exorbitant prices of medicines are also blamed on the doctors under the blanket term of ‘colluding’ with pharmaceutical manufacturers. Thus, the healthcare issue for most people in Pakistan is, simply put, an issue of poor doctor-patient relations.

A public health specialist urges us to look beyond doctor-patient relationships and at the policymakers

For many such people, reading Dr Arif Azad’s book, Patient Pakistan: Reforming and Fixing Health Care for All in the 21st Century, may help in understanding that the doctor is merely a small piece in a larger jigsaw puzzle.

The key players that Dr Azad would like us to focus on are health officials or administrators, who may be far away from hospitals but who still chart the rules and policies that affect the working hours of the medical community, the prices of medicines, and so on. Then, there are the pharmaceutical companies eager to sell their wares. Our view of them is myopic, that they operate only with the aim of profiteering with no regard for human bodies. But any objection on them can be addressed through drug regulatory bodies — another piece in the puzzle and one about which we hear very little.

Non-governmental organisations have a role to play, too; while they have been providing medical services, there is less input from them on the policy side, as compared with, say, NGOs involved in education. Even international donors cannot be ruled out; they may be zealous in their support, but may have differing priorities. The media is a great, but underused, platform to raise awareness. And most importantly, it is the people or patients who — as Dr Azad says — need to review their own dietary habits. Many other actors are there as well, and almost all of them are beyond the control of doctors.

Each of these actors has a role to play. Take the case of antibiotics, which Dr Azad says are being overused and abused “almost on an industrial scale.” This problem arises as much from the pharmaceutical industry as from the doctors and even the media, and the author believes there has to be a “judicious use of antibiotics through public campaigning.”

Dr Azad expects a lot from the government to deliver on healthcare issues. He considers “public” health a “public” responsibility and takes a critical stance against privatisation. He shares his thoughts on properly regulating the medicine industry, gets wary of private-public partnerships and wants to learn from insurance schemes operational in other countries.

Certainly the government has a lot — in fact, the most — to answer for. But why is it not able to convince observers such as Dr Azad?

This, one would argue, has partly to do with each successive government’s inability to increase spending on healthcare. Here again, education saw some increase in spending — no matter if it was limited. It’s good that, thanks to advocacy campaigns, at least some spending has been increased. Not so for healthcare. Political parties often say they will spend more, but Dr Azad shows that the spending every year changes only very slightly. This is why parties that come into power mostly try to revise rules and regulations or opt for private-partnerships (as had been initiated by the Sindh and Punjab governments).

Many will respond that it is not rocket science to conclude that Pakistan needs more funds for healthcare. The problem is that this is hardly being pursued; one has yet to come across any sustained campaign on this.

Instead of increasing resources, our tack for fixing the healthcare issue is to assume that somehow, the various actors in the system are venal. Fixing the system means disciplining the medical staff for not performing their duty properly, or fining the chemist who charges a higher than listed price, and so on. Making accusations that everyone is corrupt and needs to be disciplined is our pet solution for all key policy matters, including healthcare. One only has to look around to see how popular this mindset has become. But because it is devoid of valid evidence, not to speak of the justification of such solutions, the upshot is the increasing afflictions of people and examples of these abound.

After all, without new resources in health sectors, the actors are so interconnected that the patient is going to suffer at some point or the other. Dr Azad writes that when one international donor tried to club the areas of two doctors in one — increasing the salary of one doctor by assigning him/her more than one health units — it only skewed doctor-patient numbers as the doctor only ended up seeing more than a manageable number of patients.

Also, as with many of our other fields, our approach towards health is curative, not preventive. We treat patients once they have become afflicted with disease, rather than stopping the spread of disease beforehand. Our healthcare system is, almost always, literally in the emergency department.

But this approach is not always inadequate. Individuals and organisations working for healthcare are often involved in distributing medicines or rations to those affected. Surely these noble actions are praiseworthy, too. In any case, a donor’s own self-satisfaction comes from dispensing aid to someone in dire need.

But at the same time, we need to chart a strategy of how best to allocate resources and energies to the long term responses, too. This has to be done consciously. Other than raising awareness, the government can come up with preventive programmes such as it has against polio. Dr Azad’s book essentially shares how we can get out of this ‘emergency’ mindset.

Although everyone talks about healthcare to the extent of it sounding clichéd, we lack the expertise — at least at the public level — to talk effectively about the issue. Contrast this with education, where newspapers are flooded with commentaries on reforming it and organisations are eager to work on making reforms happen.

Dr Azad himself is one of the few people writing on health and healthcare issues and this book is a compilation of the essays he has published, mostly in Dawn, over the years. After earning his medical degree, Dr Azad went on to specialise in public health. It is laudable that, in his essays, he explains what appear to be complex medical issues in plain, readable language. This, in itself, is his great contribution towards potentially opening the discussion on what ails Pakistan’s healthcare system.

The reviewer is a researcher based in Islamabad

Patient Pakistan: Reforming and Fixing Health
Care for All in the 21st Century
By Dr Arif Azad
The Iqbal International Institute for Research
and Dialogue, Islamabad
ISBN: 978-9697576395

Published in Dawn, Books & Authors, August 4th, 2019