October 2021, Volume 71, Issue 10

Narrative Review

Nature and scope of Medical Social Work in Healthcare setting in Pakistan

Ibad Ullah Sajid  ( Social Welfare and Bait-ul-Maal Department, Rawalpindi, Pakistan. )
Aqib Shehzad Alvi  ( Department of Social Work, University of Sargodha, Sargodha, Punjab, Pakistan. )
Irfan Nawaz  ( Ministry of Human Rights, Islamabad, Pakistan. )

Abstract

The Social Work discipline emerged in the earlier 20th century globally and in 1953 in Pakistan. Medical Social Work, as a branch of Social Work, deals with non-medical factors affecting diseases. As the needs of a sick person are hardly ever simple, rather these are complicated and multifarious, requiring several kinds of assistance, medical social work, in addition to medicines, is a way to deal with them. Medical social workers, as part of multidisciplinary teams, are well equipped to deal with the multidimensional issues of the patients. However, this in-depth literature review exposed that in Pakistan, Medical Social Work is still vague in terms of skills and services required and is struggling to achieve professional status. The major challenge to the profession is its integration with healthcare services. The role of social workers in healthcare setting is very limited, and they are involved merely in disbursement of free medicines out of charity funds. In Pakistan, neither the Social Work discipline has been given a chance to expand, nor its available services are made effective enough to be considered essential in healthcare.

Keywords: Medical social work, Healthcare, Services, Hospitals, Pakistan.

DOI: https://doi.org/10.47391/JPMA.04-589

 

Introduction

 

The bio-medical model remained dominant in the field of healthcare till the end of the 19th century. The health, under this approach, simply meant the non-existence of disease or any biological disorder and medication or technical intervention was seen as the only treatment strategy. The concept of medication as a healing art was unheard of, and the psycho-social, behavioural and environmental aspects of illness were entirely ignored.1 At the start of the 20th century, researchers found a strong association between health and social functioning. It was acknowledged that health depends on multiple determinants which include not only psycho-social, economic and environmental elements, but also cultural values and beliefs.2 This conceptual development paved the ground for shifting the paradigm from the biomedical model of health to the socio-cultural and environmental approach. Consideration and dealing with socio-cultural, psychological and other non-medical factors within the context of illness was realised.

In 1905, Dr Richard Cabot, an experienced physician working at the Massachusetts General Hospital in the United States, introduced to the world a new discipline called Medical Social Work (MSW).3 He felt that the Social Work (SW) discipline had close association in terms of certain attributes with the medical discipline. The element of breadth in SW discipline captivated him and he realised that all helping professions, particularly healthcare, must have the same element. He found that the element of empiricism in healthcare had made the scope of this field too narrow by disregarding non-medical determinants of disease. He proposed that by incorporating some particular SW traits, like breadth, into the healthcare profession can make it more responsive and helpful.4 This innovative idea was appreciated widely and SW Units (SWUs) with the objective to deal with psycho-social, cultural and other non-medical factors in healthcare were soon established in hospitals. About 200 hospitals had SWUs by 1913 increased to around 400 by 1923. By the year 2000, more than 86% hospitals in the US had SWUs.5 The National Association of Social Workers (NASW) defines MSW as “...Medical Social Work is the application and adaptation of method and philosophy of Social Work in the field of health and medical care. Medical Social Work makes selected and extended use of those aspects of Social Work knowledge and methods which are particularly relevant to helping persons who have health and medical problems...”.6

It was 1953 when MSW formally entered Pakistan with the arrival of a panel of experts in response of a special request made by the government to the United Nations. A renowned Swedish MSW practitioner, Anna Ma Toll, was leading the delegation. In June 1953, the very first MSU was set up at the Tuberculosis (TB) Control and Training Centre in Karachi.7 Currently, 145 SWUs have been established and are rendering services in the country. The largest province, Punjab, has three-fourth of the total SWUs established in public hospitals ranging from Tehsil Headquarters (THQs) to the teaching hospitals under the administrative control of the Social Welfare and Bait-ul-Mal Department, Punjab.3

 

Why Medical Social Work?

The fact is that developing high-quality care in community is not the sole task of any single profession or discipline as no discipline has absolute control over wisdom. The task is only possible through close cooperation and collaboration of all the related disciplines. Correspondingly, multidisciplinary healthcare techniques and approaches are needed to deal with health issues efficiently rather than depending on any single discipline.8 A sick person’s needs are hardly ever simple. if anything, these are complicated and multifarious which require several kinds of assistance simultaneously. Medicine is one way, while MSW is the other.9

There was a time when a doctor or healer had a close and informal relation with patients. He was a friend, guide and a healer as well who had much time to spend with the community he practised in. But, today, the medicine profession has become very much commercial and formal. Doctors are hardly able to listen to the stories of the patients and to console them for their miseries. He has no time and interest to know the social, emotional and personal issues of the patients. This practice calls for the services of professional social workers in hospitals to deal with the socio-emotional needs of the patients with a firm belief in holistic care.10

Actually, psycho-social, economic, environmental and many other factors not only contribute to initiate and extend illnesses, but also hinder healing. A family having a sick person around may suffer from many kinds of tensions, stress and even superstition. In such a case, only a professional specialising in social services can help them proficiently to come out of that situation, especially if the case is related to mental illness in which case it can lead to social embarrassment and may aggravate fears. Quality psycho-social services by a professional worker are needed timely to deal and mitigate the fears, stress, anxieties and superstitions of the diseased person and the family.11

MSW mainly focuses on setting up a strong “person in environment” approach to work with individuals, families, groups and communities. A professional social worker in the field of healthcare helps in establishing and strengthening the necessary involvement within the psycho-social, cultural and economic aspects of health.12

 

Role of Medical Social Work in healthcare

The role of SW in healthcare is exclusively unique. SW focusing particularly on absolute care and capability to deal with complications from social, psychological, biological, ethical, legal and ecological perspective is playing a distinctive role as part of multidisciplinary teams in dealing with multidimensional issues of patients.13 This role has also been endorsed by the National Association of Social Workers comprehensively as hereunder:14

"...A Hospital Social Worker helps patients and their families to understand a particular illness and provide counselling about the decisions need to be made. Working in a team with doctors, nurses and allied health professionals, social workers sensitise other healthcare providers to the social and emotional aspects of a patient’s illness. They use case management skills to help patients and their families to address and resolve the social, financial and psychological problems related to their health condition..."

The discipline has its distinctive approaches including Social Case Work (SCW) and Social Group Work (SGW) to be applied within the existing healthcare settings depending upon diversity of cases in the best possible way. MSW believes in facilitating and assisting the ill person in recognising and mitigating the psycho-social, cultural and environmental factors contributing to his sickness.15 An MSW, as a member of s multidisciplinary team, renders mandated services in collaboration especially with the doctor, who is the team leader. Preferably, the team comprises a medical specialist, diseased person and a social worker.16

A patient, in the eyes of MSW, is not a diseased person, but an individual who is not feeling comfortable due to some factors. His responsibility is to make a skilled professional assessment by taking into the account socio-economic and general conditions of the patient.17 For this purpose, he investigates the factors responsible by conducting sessions with the patient and the family, visiting the home and workplace if required to furnish a comprehensive considerable finding report about the social and emotional state of the ill person. He is also required to initiate and launch systematic health awareness and education campaign in order to spread maximum awareness among the masses with reference to the common diseases, health issues, precautions, epidemics, and their solutions as well.18

The Australian Association of Social Workers also considers the role of SW within healthcare to be of great importance. By following the bio-psycho-social perception, SW identifies the influence of psycho-social environment on one's health and the needs and capabilities of the patients to be recovered and rehabilitated for normal social functioning. SW interventions are aimed at prevention or lessening the psycho-social implications of the sickness; something that is fundamental to general health and well-being.19

 

Scope of Medical Social Work in Pakistan

Pakistan, with about 207.77 million population, is the sixth largest nation.20 Human Development Report-2019 issued by the United Nations indicated that the ranking of Pakistan is very low compared to the other developing countries in the region pertaining to health and other socio-economic indicators. Pakistan, on the Human Development Index, was ranked at 152 out of 189 countries, while India was on 129 and Bangladesh on 135.21

Numerous studies conducted in Pakistan pointed out that illiteracy, poverty and several other social determinants as factors responsible for poorer health indicators in Pakistan.22-24 A report confirmed that health profile of Pakistan was not better enough and lacked awareness regarding nutritional needs, with less knowledge about the diseases, poverty, low literacy rate, low expenditure on health and many other socio-cultural factors also being responsible for low health indicators.25

The current health condition demands high-quality social services rendered by professional social workers in the field of health to deal with the responsible socio-economic factors in an effective way.

Conversely, various factors, such as non-caring attitude, impersonal and responsible behaviour of some medical professionals at public hospitals, leave no choice for the public except to choose private doctors, who are more responsive, caring and personal, but provide highly expensive services. A recent study reported that in Pakistan, about 70% people attend private healthcare givers despite the fact that they charge heavy amount for services.26 Provision of unsatisfactory services by the public health sector is one of the major causative factors responsible for increasing out-of-pocket health expenditure. SW is the only discipline which can bridge this gap between these two different standards of practices.27 By extending the psycho-social, financial and moral support at public hospitals, and the individual as well as community-based public health interventions of professional social workers can contribute largely towards achieving better health indicators as well as to make the health system more responsive and dependable for the public.28

 

Medical Social Work in Pakistan: facts and discussion

In Pakistan, first demonstration of MSW was conducted with the establishment of MSW unit at the Tuberculosis (TB) Control and Training Centre in Karachi in June 1953. This demonstration is evident that the role of MSW in disasters was well understood by the policy-makers after just six years of independence. One of the reasons of this realisation was the psycho-social problems along with biological treatment of the migrants who experienced trauma in the shape of loss of their beloved ones, property, and having new settlements. The adaptability of MSW increased in such a scenario, but it could not flourish the way it had to. Though MSW remained functional, the core responsibility was fulfilled by the charity workers or the doctors in addition to their duties of biological treatment. Within the next two years, two more SWUs were established; one at the Mayo Hospital in Lahore, and the other at Dhaka Medical College in Dhaka. In 1956, the government approved some more units to be established in Karachi, Lahore and Dhaka.29 Presently, there are 145 SWUs in Pakistan, with Punjab, the largest province in terms of population, having three-fourth of the total under a well-structured setup run by the Social Welfare and Bait-ul-Maal Department, Punjab.

A study on MSW units in Punjab revealed that all SWUs were delivering free medicines out of Zakat and the Pakistan Bait-ul-Maal funds, while other mandated services were being provided only by a few. A negative attitude by hospital administrations was recorded towards the efficacy of the units. About 87% heads of the hospitals did not consider the services being rendered “effective”. The study was of the conclusion that professional social workers have been de-tracked and they failed to undertake the primary tasks as per the spirit of the profession.30

In Sindh province, paucity of funds has caused the closure/ ban on MSW units. The interest of the authorities may be gauged by the fact that the social workers in three units, which were transferred by the federal government to Sindh subsequent to the 18th constitutional amendment, had been deprived of promotion by diminishing the line of promotion. They will work on the same position/ scale till their respective retirements.31 These highly de-motivated workers are supposed to work for relieving others of their sufferings. Four MSW units in Khyber Pakhtunkhwa (KP) and four in Baluchistan have been rendering services and perhaps considered enough to cater to the psycho-social and other non-medical needs of the entire population of the provinces.10

A study conducted at the University of Karachi indicated that, in Pakistan, professional social workers deputed at SWUs generally established a ‘Patient Welfare Society’ in hospitals with the help of hospital administrations and get busy in collecting donation for rendering financial help for poor patients. These units are also being funded by government departments, like Pakistan Bait-ul-Mal, to purchase and distribute medicines among the deserving patients.31 Astudy also validated the findings that the responsibility of the social workers appointed at hospitals is to buy and disburse the medicines out of Zakat and Bait-ul-Maal funds.7

The fact is that MSW in Pakistan has become a joint venture of two government departments; Zakat and Social Welfare. The former provides financial resources, while the latter provides technical support and manpower. About all the SWUs in the country are busy in the distribution of free medicines purchased through funds provided by the Zakat and Pakistan Bait-ul-Maal Department.

Although we cannot ignore the role of these units in mitigating the economic sufferings of the people with the provision of free medicines in the existing scenario of acute poverty and high cost of medicines, the question is; were the professional social workers trained for that purpose?

In 2018, the World Health Organisation (WHO) reported that non-communicable diseases (NCDs) were estimated to account for 58% of all deaths in Pakistan.32 The general underlying causes of NCDs are unhealthy lifestyles or dietary patterns, tobacco use, physical inactivity, anxiety or hypertension, and adverse socio-psychological and environmental determinants.33 Well-organized individuals as well as community-based health education and promotion interventions by professional social workers could be effective in addressing the health risk factors pertaining to NCDs in Pakistan.

Failing to channelize the full potential of MSW does not mean the spirit of this noble work disappeared. It remained alive by the number of charity workers, philanthropists and doctors in disasters, like the earthquake in 2005, floods in 2010, and the COVID-19 pandemic. Some of the stories are inspiring, and shed light on the need of MSWs in disasters and crises.

Ms. Gull was a survivor of the 2005 earthquake that did not only jolt the Azad Jammu and Kashmir region, but left painful stories of human misery.  She got injured, and lost her son and husband in the earthquake. She had to move to the Camp Village at Balakot in Kashmir. She had experienced severe trauma due to loss of her beloved ones, home and family. Besides medical assistance, she was in dire need of psycho-social support to get back to normal life. Church World Service, a non-governmental organisation (NGO), provided her therapy and counselling. The process involved establishment of rapport, trust with staff members, and engagement with other women in learning. With consistent bio-psycho-social support, she recovered from trauma and looked forward to building a new life.34

Such inspiring interventions are not limited to disasters alone, but are also witnessed in routine everyday situations. The story of Farzana Shakeel is one of hundreds of such stories. She was an experienced vaccinator; her stories showcased the need of community intervention for increasing vaccination coverage to the far-flung areas where people were unwilling to get their child vaccinated.  Working in such hard areas, where people pelt vaccination teams with stones, shout at them and slam the door shut on them, she did not quit her job and kept vaccinating the children despite the challenges.35

The lesson learnt from the latter story is that professional medical social workers can play their role proactively. The approach of SW to engage community for positive change, promote dialogue and generate indigenous support for health workers for spearheading the vaccination programme in far-flung areas is the significant component which is missing due to non-expansion of MSW within the healthcare setting.

It is true that in the countries ranked high in terms of health indicators, social workers are playing a crucial role. They, as part of multidisciplinary teams, are not only assisting in diagnosing and dealing with the psycho-social determinants of health, but have a central role in planning and policy formulation. They have been involved in teaching at medical schools to educate medical students regarding socio-psychological aspects of disease, and addressing strategies as well.36 But unfortunately in Pakistan, perhaps due to some confusion in the minds of those at the helms of affairs about the discipline, we have not been able yet to identify the role of professional social workers in healthcare settings.

Some other researchers are also of the view that the MSW profession in Pakistan seems nascent, rather in the formative phase. Decades since independence, it has failed to get accreditation in policy papers as well as in implementation stratagem. The profession has been a victim of state negligence and apathy.6,10 Though quick recognition of MSW could have been a great opportunity for the profession to have a greater impact on society, the opportunity was not channelized in letter and in spirit. Consequently, MSW remained limited to disbursement of Zakat fund only, which is just one of the components of the MSW profession. For instance, medical social workers could play a proactive role during the Afghan War, the War against Terrorism, and the current COVID-19 pandemic. With MSW being unable to contribute fully, the gap was filled by doctors, philanthropists and charity persons in Pakistan.

 

Conclusion

 

It is deduced that MSW profession is still in its developing stage even after more than seventy years of its introduction in Pakistan. MSW skills and services are still vague, followed by current practices without any rationale. SW services have not been fully integrated with healthcare administrators and even healthcare professionals. The role of social workers in healthcare setting is limited; they are not providing counselling and rehabilitation services to patients in the bio-psycho-social perspective. Resultantly, the very nature of the profession has been deformed and even the profession is outdated compared to international practices where licensing of the professional social workers is mandatory to practice SW in the field. In countries like Pakistan where adverse socio-cultural and environmental factors have considerable effect on public health, individual and community-based public health interventions of social workers can play a distinctive role in achieving better health indicators as well as to make the health system more responsive. Hence, SW services have a broader scope in the healthcare field in Pakistan, but unfortunately the existing scenario is dismal. The situation calls for a joint intervention of social welfare and health authorities for restructuring the services of MSW through legislation, registration of professional social workers, defining their role and integrating them into the healthcare system. This way, healthcare facilities in the country’s medical services would be primarily focussed on biological treatment, while professions like MSW will lessen the burden of patients on healthcare institutions and, thus, will contribute to improving the country’s ranking related to the human development index.

 

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

 

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