Dilemma of the Current Healthcare System of Pakistan and Feasible Solutions for Its Improvement
By Masoora Maqbool Bari
The first and foremost component of a Healthcare system is its mission and Health policy. The previous years have only seen a reactionary Health policy following any epidemic, or that implemented by International organizations. Pakistanâ€™s national Health services are multiple vertical programs for Hepatitis, AIDS, TB, Malaria, Influenza, Infection Control, Extended Program for Immunization, Integrated Reproductive Mother Neonatal Child Health Program and Nutrition Program Punjab (IRMNCH and NP) and Special Campaigns on Polio and Dengue.
Sadly, Pakistan has very undefined aims and objectives regarding its Health Policy. Recently, Pakistan signed Sustainable Development Goals ( STGs) in the UN where Goal 3: Good Health and wellbeing, has a target to end communicable diseases, achieve universal Health coverage and provide access to safe and effective medicines and vaccines by 2030. This is an unrealistic target which cannot be achieved even if it is enforced as an extreme priority politically and provided unlimited finance and enforced aggressively.
The solution is to identify key health issues, break them into workable components, select priority issues according to impact and risk analysis and customize them to the demographic needs of different regions, tailor the solutions for effective delivery and implementation by calculating probability of success for each problem in each area.
The fundamental structure of healthcare system in Pakistan is like a tree with extensively spread out roots with a 3-tiered structure: Primary care (Outreach and community based services), Secondary care and Tertiary care. Primary care consists of BHUs (Basic Health Units), RHCs (Rural Health Center) with a catchment population of 25000 and 100,000 people respectively and Dispensaries. Secondary Health Care consists of (THQ and DHQ) Tehsil Headquarter and District Headquarter Hospitals serve a catchment population of 0.5-1 million and 1-3 million people respectively. While Tertiary Health Care consists of Teaching hospitals and Specialty hospitals.
With a current population of 19.3 million, this structure ensures a maximum access to the population in rural as well as urban areas. The problem however, arises with the functioning of this proposed giant infrastructure. In this 3 tiered structure, the roots of this structure are provided with the least capital and manpower
The already allocated low budget on Health is then spent unfairly and taken up by the tertiary Healthcare centers followed by secondary Healthcare centers in the big cities of the state. This creates an imbalance in patient load which becomes rerouted to these centers.
The solution to the above mentioned problems is the reallocation of funds, increasing the quota given to the primary care level instead of the upper levels of health care. Revamping of all BHUs, RHCs and MHCs (Maternal and Child Care Centers) as well as THQs and DHQs, especially in areas with the lowest Healthcare access. Tertiary care hospitals are currently stretched past their capacities with the burden of patients from all over Pakistan, swarming over to receive advanced quality Healthcare. This however, reduces the quality of services delivered.
If BHUs and RHCs are constructed and installed to be within an access of 25000 and 100000 people respectively, then instead of a patient going to these centers randomly, they can have centers designated to them, other than in the case of emergencies. For starters, all Healthcare centers should have a database of their designated patients, which will aid in treatment, follow-up and provide positive clinical outcomes. A plan is in view to activate BHUs all over the cities, even having multiple tertiary care hospitals to help to distribute patients according to medical need and level of care needed. In this way only patients needing advance care will be sent to tertiary hospitals and the load of patients with minor problems .i.e. the OPD load will be distributed. This will also help to provide better distribution of funds to primary level care as well as increase ease of access to patients.
Another issue, is the provision of qualified medical teams and allied staff for all primary care centers and the problem with installation and running of these centers is hampered by security issues.
Out of the predominantly female students who get admitted into government medical institutes, some leave the degree without completion, some who complete their education are not allowed to practice and some donâ€™t practice by their own choice. Out of these, approximately half of this population pursues further post-graduate training. When these female doctors are allocated to these RHCs and BHUs in distant areas, they donâ€™t report for work due to societal and security issues. It is also professionally more rewarding for them to stay in teaching hospitals or specialty hospitals in big cities or even small cities instead of rural areas.
In a developing country like Pakistan, a practically contributing workforce is essential. If in every batch of students from medical universities, a minimum of 60% graduates are redundant, this creates a gap in demand and supply of doctors leading to lower rate of growth and development in the Health sector which is getting crucial with the passing of time.
Although, it is not welcomed or accepted socially, but at this point in time a male/female quota specially for medical students is necessary, with an increase in male students. Any such development is immediately contested in court as gender discrimination and the rule is reversed. Hence, one of the viable routes left is to bring change in the admission process, where scrutiny is performed on the basis of academic performance, aptitude, IQ, EQ as well as future feasibility.
Furthermore, graduates should be given penalties for wasting a seat in monetary terms. A procedure for proper investigation for such cases should be set and punishment should be applied accordingly.
This may help to ensure that only serious and worthwhile candidates are enrolled, who can serve in the system in the future. It should also be made compulsory in order for a doctor to complete post-graduation to serve at least 2 years in RHCs/BHUs. Similarly specialized doctors and allied staff should be offered additional incentives in order to make the post more attractive, albeit with proper security and additional services.
All government Healthcare centers regardless of their level in the system are currently operating under the banner of free medication. This strains the already limited Health budget and has not been shown to improve either patient compliance, positive clinical outcomes or even patient satisfaction. Instead of â€œfree medicationâ€ which has never been actually executed, the government should operate under the banner of â€œaffordable medicationâ€. This will offer quality medication to patients at prices lower than the current commercial prices. Integration of Pharmacists being experts on Pharmacoeconomics can help to efficiently deal with this problem.
This brings us to the cost of medication and treatment. The past years in the Pharmaceutical sector has only seen an annual increase in the price of medicines and the government should regulate this yearly inflation. We are also dealing with fake and substandard medication. After the formation of DRAP in 2012 and the installation of Drug Courts, improvements are being made and changes have been made in the law, regarding these as cognizable offences with proper punishments and law proceedings.
Nevertheless, there is a major need that we become self-sufficient regarding our medications and equipment, especially those used in hospitals. The raw material for medicines is imported from other countries and currently not even a single active ingredient is produced in Pakistan. Same is the case with equipment used in hospitals for surgical treatment, monitoring and diagnostic purposes. Until these components are not manufactured locally, the cost of running a Healthcare system cannot be brought down.
The 3 tier approach should be switched with a 4 tier approach, with the 4th pillar being preventive Healthcare. This is a very wide branch but if launched, could do wonders in our Healthcare system.
The official circle of Healthcare providers consists of a Doctor, nurse, pharmacists and paramedical staff.; This circle is currently incomplete in Pakistan with doctors, nurses and only few members of the paramedical staff working in our hospitals. Public Health and Community Medicine covers the most neglected area of preventive Healthcare, which needs to be addressed from grass roots by Public Health Education. Pharmacists are ideally placed in community pharmacies, but currently their role is just limited to that of an overly qualified medicine store keeper. If community Pharmacists are integrated in the current Primary Healthcare system : BHUs, RHCs & Outreach and Community Based Service, in lieu with THQs and DHQs, a functional and workable system of community medicine and public health can be implemented. If enacted properly, with cross-institutional collaboration, the plague of quackery can be gotten rid of forever. This will require training of all Healthcare professionals from an entirely new angle with a population centered approach that caters to the Socio-cultural and demographic needs of the population.
All Healthcare professionals shall have a defined job description and charter of duties. Also, Proper accountability mechanisms should be put in place that will be determined by the professionalâ€™s performance and code of conduct. Unlike the current system where once you are in, you are in and no power on earth can take you away from your seat, regardless of your performance or attitude. Annual boards should be set in place, and a patientâ€™s feedback should be crucial to the Healthcare professionalâ€™s future career prospects in the system.
Another major neglected area is the care for mental health. The most underrated albeit, exponentially prevalent and increasing at an alarming rate are mental disorders, and professionals qualified and trained to deal with these patients. It is a very sensitive and critical area that needs to be brought under the limelight immediately. It is the need of the hour that Psychotherapy should be made available to all patients as drugs are not the first line treatment for mental disorders.
Medical Research is another area, where Pakistan is well behind the world in terms of its indigenous diseases. A little of it is covered by undergraduate and post-graduate students of Medicine, Pharmacy, Psychology, Nutrition etc. However, the quality medical research, done from scratch, on the international standard of research is still lacking. These researches are mostly conducted in teaching hospitals in big cities. However, research needs to be redirected to all regions. If the proposed network of Healthcare system becomes functional, then quality documentation and reporting systems can be employed by all members of Healthcare system to contribute to research on diseases and their treatments specifically for our own population.
We are a developing nation and there is still a long way to go and our current Healthcare system is far from perfect. Nevertheless, one person can make a difference by at least doing their job to the best of their abilities in the circumstances that they find themselves in. Change is inevitable and it is up to us to make it for the better or for the worse. The encouraging element is that as a starting point, some of these solutions are already under process and in the coming years we will hopefully see improvements in our healthcare system.