MY quest for quality primary healthcare (PHC) continues. I see it as a panacea for health development in my country. We will never be able to improve our worst national health indicators without paying serious, sincere and sustained policy and fiscal attention to PHC. We have abysmal health indicators because we have abysmal PHC.

PHC is the foundation of universal health coverage. Without this footrest, UHC would remain a dream.

Somewhere in our minds we have all accepted that PHC means poor healthcare for poor people. And that this poor healthcare can be provided by any untrained health professional. In that sense, poor attention to PHC also reflects the elite nature of our health sector and society. The elite mindset is pervasive and hence the neglect of PHC is systemic. Governments spend relatively little on PHC; we don’t teach PHC to our medical students, nor expose them to its facilities; the discipline of family medicine is not developed enough. In most cases our young doctors have never set foot inside a PHC facility even after completing their house jobs.

When I took over as a special assistant to the prime minister in 2019, I personally visited BHUs and RHCs — 18 of them — in the rural areas of Islamabad Capital Territory. None of them had ever seen a properly appointed doctor and the required staff. Many were deserted or being operated at a very sub-optimal level by whatever staff was available. This was within the radius of a few kilometres from the seat of the federal government. We took some remedial measures. Through PC-Is, the buildings were upgraded and staff was appointed and now the situation is much better. But if this could be the situation in the capital, one can only imagine the situation in the remote parts of Balochistan and Gilgit Baltistan.

In the last two years I have travelled within the country and have visited many kinds of public and private health facilities, health projects and emergency situations. In all this, I have been mainly driven by my quest to see and learn from good practices in PHC.

Primary healthcare needs serious, sincere and sustained policy and fiscal attention.

In the public sector, PHC is developing at a snail’s pace and continues to suffer from lack of all kinds of resources. In the commercial private sector, our general practitioners are on their own except for a handful of NGOs working with a few of them on preventive care. Commercial private hospitals, barring a few big ones for the very rich, are outright exploiting the patients.

Unnecessary prescriptions on the behest of corrupted pharmaceutical marketing, unnecessary and expensive diagnostic tests with set rates of kickbacks for doctors who order them, and even unnecessary and unsafe surgeries are so common in the private health marketplace that it is now considered an accepted norm about which there is no need to even feel guilty!

However, there is a huge though unquantified not-for-profit sector in health. This sector is unfathomable and comes in all shapes, forms and scale. I have had the privilege of visiting some of them in the last two years. These initiatives are driven by passion fuelled by local and foreign philanthropy and development funds. Most of them are driven so much by a passion for service that they leave behind quality considerations and proper staff training, as well as give attention to developing systems.

In a recent visit to Karachi en route to Cairo for a WHO expert consultation on PHC, I had the privilege to visit two not-for-profit PHC projects and one not-for profit hospital. Visiting these organisations and spending hours in their facilities has given me a great sense of satisfaction and promise and has reinforced my belief that quality PHC can be organised and delivered to poor people in Pakistan, by respecting their dignity and in accordance with their needs.

First, I visited the Sina Health, Education & Welfare Trust which has matured the art of delivering quality PHC services over the last 25 years. Currently, they are operating 39 PHC centres in the slums of Karachi. All are purpose-built well-designed PHC facilities with a well-trained PHC team and a dedicated facility manager.

All operations are managed through an electronic medical record system. There is an in-house pharmacy and diagnostics services are offered. Special emphasis is put on mental health and there are dedicated teams for quality assurance, continuous staff-training, monitoring and research. Two aspects of this operation particularly impressed me: continuous development for improved systems and consciousness of the importance of developing a model of care that is replicable.

Secondly, I visited a similarly high-quality PHC organisation, Shine Humanity, which specialises in delivering quality health services in rural areas. Founded in 2009 by a few Pakistani doctors in the US, the organisation has gradually developed its system and currently operates 12 facilities, which include purpose built-fixed facilities, satellite clinics in the more remote rural areas of Sindh and mobile clinics. They also digitally manage the whole operation and have almost all the attributes of the Sina Trust.

Lastly, I spent half a day at the 200-bedded Koohi Goth Women Hospital in Landhi. It is now much more than a hospital — a sprawling healthcare complex over 14 acres. It is a labour of love. It now houses the largest programme for free midwifery training and a school of nursing. A new 100-bed children’s hospital and a medical college are under construction. All health services are completely free and resources are raised through local philanthropists.

Each one of the above examples is so inspiring and promising that they deserve separate articles. Most importantly, I have witnessed quality PHC at work for the underprivileged in Pakistan. How public-sector PHC can incorporate best practices from these PHC models should be the next discussion.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University, and WHO adviser on UHC.
zedefar@gmail.com

Published in Dawn, September 8th, 2023