Rehan Khan ( Sindh Healthcare Commission, Karachi. )
Mouhammad Ayaz Mustufa ( Health Research Institute, National Institute of Health, Islamabad, Pakistan. )
January 2023, Volume 73, Issue 0
An empirical research study on deluging quackery outlets across Sindh, Pakistan and propositions to deal with confounding factors of rising quackery
Rehan Khan ( Sindh Healthcare Commission, Karachi. )
Objective: To estimate the prevalence of medical quackery, to identify the confounding factors of the rising trend, and suggest possible ways to eliminate the menace.
Method: This empirical study was conducted from July 2019 to June 2020 in six divisions of the Sindh province of Pakistan, and comprised field inspection reports and data collection based on healthcare establishments' physical inspection, verification, and action on non-compliant units. Data was qualitatively and quantitatively analysed.
Results: Of the 3,063 healthcare establishments, 568(18%) were visited in Larkana, 641(21%) in Shaheed Benazirabad (SBA), 527(17%) in Mirpurkhas, 700(23%) in Hyderabad, 110(4%) in Sukkur, and 517(17%) in Karachi.
Overall, 2,152(70%) outlets were shuttered and fined for violating anti-quackery laws, while 911(30%) were issued warning notices.
Conclusion: The healthcare system in the Sindh province was found to be struggling, with quackery continuing to proliferate.
Keywords: Healthcare quackery, Propositions, Sociological significance.
Submission completion date: 20-01-2022 Acceptance date: 30-06-2022
Quackery has spread across Pakistani healthcare system and has been one of the leading causes of increasing morbidities and mortalities.1-3 The nefarious business of quacks had reached an unprecedented height during the last couple of decades in Sindh province of the country, which was viewed by medical associations and state medical licensing boards with concern. The provincial government, therefore, prepared a legislation to curb the menace of quackery in all its forms and manifestations.4 Each year, thousands of people in Pakistan lose their lives as a consequence of quackery practices. The key cause for the spread of communicable diseases, such as hepatitis and human immunodeficiency virus (HIV), in urban and rural areas of Pakistan is due to the prevalent quackery practices.3,5,6 An important factor contributing to the increase in quackery practices in Pakistan is that healthcare practitioners do not take patient consultations seriously due to lack of ethical training and overburdened hospitals/clinics.7 Other factors may include the low doctor-patient ratio (approximately 1:1300) compared to the recommended ratio by the World Health Organisation (WHO).8 In Pakistan, community pharmacies are the most accessible and an integral part of the healthcare system and they have some role to play in promoting quackery9 as there is no restriction on buying pharmaceutical drugs without a registered doctor's prescription except in the capital territory of Pakistan where the federal government has decided to regulate the sale of antibiotics.10 According to estimates, more than 600,000 quacks are operating in Pakistan and around 150,000 to 200,000 quacks are practicing in Sindh alone,11 which is a far greater number than that of the legitimate doctors and an indication of a struggling healthcare system in Pakistan, where obviously very few people have access to authentic doctors. The quacks have been wreaking a medical havoc on patients for economic gain by exploiting human sufferings.12 The keyword "medical quackery" has reportedly been the subject of almost 38,000 research studies, according to Google Scholar.13 However, much has been published about healthcare quackery and its harmful aspects,14,15 but no empirical investigation has so far been reported which gives qualitative and quantitative information about the illegal healthcare establishments (HCEs) in administrative units across Sindh. According to Section 2(xxix) of the Sindh Health Care Commission (SHCC) Act, 2013, a 'quack' means a pretender providing healthcare services without having registration with the Pakistan Medical Commission (PMC) (formerly known as the Pakistan Medical and Dental Council [PMDC]), National Council for Tibb (NCT), National Council for Homeopathy (NCH) or the Pakistan Nursing Council (PNC).16
The current study was planned to estimate the prevalence of medical quackery, to identify the confounding factors of the rising trend, and suggest possible ways to eliminate the menace.
Materials and Methods
This empirical study was conducted from July 2019 to June 2020 in six divisions of Sindh, Pakistan, and comprised field inspection reports and data collection based on HCEs' physical inspection, verification, and action against non-compliant units. Predesigned templates of sealing memorandum and warning notices were used during physical inspection to collect information about quackery outlets and practitioners by the inspection and enforcement (I&E) teams from the Directorate of Anti-Quackery (DAQ). The sealing memorandum summarised details of health services provider, determination of health services being provided beyond the legal scope of practitioner's registration, determination of the legitimacy of the practitioner, and verification of the practitioner's identity. Warning notice summarised information and address of the practitioner and the HCE, findings about unhygienic conditions, sterilisation cycle verification prior to use in healthcare settings especially in dental clinics, details of recommended corrective measures to improve the quality of care, registration status of the practitioner with their relevant councils and the SHCC, details of non-qualified paramedical staff, and highlighting any issue that arose during inspection. Warning notices are typically handed for non-compliances other than quackery practices. A warning might occasionally be issued, though, if the practitioner at any HCE under inspection requests a few extra days and makes sure to submit all of his credentials to prove that he is a registered practitioner within the specified time. But given that, does the I&E team feel satisfied after receiving adequate answers to his cross-questioning on practitioners' medical knowledge in light of it? Data was qualitatively and quantitatively analysed.
Of the 3,063 healthcare establishments, 568(18%) were visited in Larkana, 641(21%) in Shaheed Benazirabad (SBA), 527(17%) in Mirpurkhas, 700(23%) in Hyderabad, 110(4 %) in Sukkur, and 517(17%) in Karachi.
Overall, 2,152(70%) outlets were shuttered and fined for violating anti-quackery laws. Of these, 293(10%) were in Larkana, 509(17%) in SBA, 362(12%) in Mirpurkhas, 466(15%) in Hyderabad, 89(3%) in Sukkur, and 433(14%) in Karachi. Further, 911(30%) HCEs were issued warning notices. Of these, 275(9%) were in Larkana, 132(4%) in SBA, 165(5%) in Mirpur khas, 234(8%) in Hyderabad, 21(0.7%) in Sukkur, and 84(3%) in Karachi (Figure).
Along with performance from July 2019 to June 2020 as described above, a Quality analysis based on all visits to HCEs (>7,500) from DAQ's commencement in 2018 to June 2020, demonstrated that the periodic actions taken against quacks had a positive affect, as about 434 quacks have now left quackery practices to start other businesses, 122 quackery outlets are permanently closed, about 1,700 healthcare providers (HCPs) have committed and submitted affidavit to the effect that have abandoned practices beyond their scope of training. Besides, social awareness has increased as the DAQ receives a large number of complaints and phone calls seeking action against quackery practices. Several quacks have now started providing their services on motorbikes, especially in the rural areas, instead of being present at any premises because of regular inspections. More than 1,500 quacks have been exposed in the community, several HCEs have significantly improved their waste management and even improved adherence to coronavirus disease-2019 (COVID-19) standard operating procedures (SOPs). Media teams have been found to be eager to accompany the anti-quackery teams for live coverage of the raids. About 177 homeopaths and 53 lady health visitors (LHVs) and nurses were sensitised not to continue services beyond their scope of training/registration. During the recent dengue outbreak in Sindh, quacks were prescribing large dosage of nonsteroidal anti-inflammatory drugs (NSAIDs) without running any diagnostic test. The community was alerted to the possible negative consequences and was urged to consult a qualified physician and/or visit a proper health facility. After an unprecedented HIV outbreak in Larkana city, a rigorous anti-quackery campaign was run from April to July 2019 which shuttered 408 quackery outlets and warned 188 HCEs against providing substandard practices.17 These interventions may have disrupted the HIV transmission chain. During the COVID-19 pandemic, actions were taken against 202 unauthorised HCEs making false claims about COVID-19 cure. Also, 504 warnings were issued on non-compliance with COVID-19 SOPs. Finally, 108 dental quackery outlets were shuttered for operating independently at independently owned dental clinics without employing licenced dentists.
Quackery constitutes one of the most serious threats to public health and safety. There are several steps that may help eliminate the menace of quackery from society. For instance, the anti-quackery teams operating in dangerous areas with threats need to be given due security cover. The judiciary needs to be sensitised to evolve procedures to simplify procedures related to getting hold of the quacks. In fact, the provincial government should ask the Sindh High Court (SHC) to appoint a special magistrate for speedy trials against quacks, and legal proceedings should be initiated against those who challenge the writ of the SHCC.
1- The local authorities should also play their role in the sustainability of DAQ actions against quacks and quackery outlets. Mechanism of real-time data-sharing is essential among various platforms, like law-enforcement agencies, the health department, drugs regulatory authorities and control units, the prosecution department, non-governmental organisations (NGOs), the environment department, the local administration, waste management cells, the central wing of the Pakistan Medical Association (PMA), media outlets, civil society organisations, and other health professional societies.
2- SHCC should bring on board all relevant stakeholders, including NCH, PNC and NCT, to develop a strong liaison before making strict laws to cancel the registration of HCPs who sell their degrees to quacks. This will improve the professional attitude of HCPs.
3- Accountable institutions should immediately address the shortage of qualified doctors and make sure the availability of HCEs.
4- Regular and free medical check-up camps and free medicines should be ensured by the government to encourage the poor communities living in remote and rural areas to seek professional care.
5- To ensure retention and distribution of qualified surgeons, physicians, medical practitioners and paramedical staff in public HCEs, especially in rural areas of Sindh, short-term rotation-based postings of biomedical doctors should be actively considered.
6- The environment department should accompany the anti-quackery teams since poor waste management by HCEs also cause environmental problems.
7- Oral health facilities are almost non-existent in many urban slums and rural areas of Sindh. Availability of qualified and affordable dentists may curb the menace of dental quackery.
8- Standards need to be set about what constitutes a health facility and a practitioner as per the demographic situation.
9- Finally, awareness campaigns about quacks and the hazards of quackery are essential to bringing about a behavioural change in society.
The healthcare system in the Sindh province was found to be struggling, with quackery continuing to proliferate.
Disclaimer: The propositions are the responsibility of the authors and do not necessarily reflect the official policy of the Sindh Healthcare Commission (SHCC).
Conflict of Interest: None.
Source of Funding: None.
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