November 2008, Volume 58, Issue 11

Editorial

Health care delivery in Karachi - The worst of both worlds

Suhail Anwar  ( Department of Surgery, Huddersfield Royal Infirmary, UK. )

Health care is the prevention, treatment, and management of illness and the preservation of mental and physical well being through the services offered by the medical, nursing, and allied health professions. According to the World Health Organization, health care embraces all the goods and services designed to promote health, including "preventive, curative and palliative interventions, whether directed to individuals or to populations".1
The health care industry is one of the world's largest and fastest-growing industries. Consuming over 10 percent of gross domestic product of most developed nations, health care can form an enormous part of a country's economy.
Health care delivery systems range from almost free provision of healthcare like the National Health Service in UK, to systems that are financed through a mix of public and private contributions; like most European countries. On the other extreme are systems like the United States with a majority-private health care system with residual public service i.e. Medicare, Medicaid.
Purely private enterprise health care systems are comparatively rare. Where they exist, it is usually for a comparatively well-off subpopulation in a poorer country with a poorer standard of health care-for instance, private clinics for a small, wealthy expatriate population in an otherwise poor country. Health care in Pakitan is a good example of such a system where the government provides a small amount of the total health expenditures, with the remainder being entirely private, out-of-pocket expenses.2
In countries where health service is prodominantly private, government agencies, medicolegal scrutiny and watchdog bodies need to be extremely vigilant as the lure of private income can bias medical judgment. In the United states the threat of law suits, to a degree, keeps the doctors on a straight and narrow path. Health care delivery in Pakistan on the other hand, is the worst of both worlds; not only the health care delivery is predominantly private there are no watchdog bodies, agencies or audit commisions to monitor the quality of health care delivered to the patient.
I have recently had an opportunity to spend twelve months in a large private hospital (800 beds) in Karachi. I also visited many other smaller hospitals and clinics in the city. The two large governamnet hospitals are completely inadequate to meet the demands of a city with population in excess of 20 million. According to the Economic Survey of Pakistan (2005-06)3 the government only spent 0.75 percent of GDP on health sector. As a result majority of the poor population of the country has to pay privately to get access to health services.
The result is a thriving private practice; which ironically, is completely unregulated and unmonitored. The Pakistan Medical and Dental Council (PMDC), equivalent of GMC in UK, was first constituted in 1947 with a view to regulating the Medical Education in the country. The PMDC4 states its objective as "to establish a uniform minimum standard of the basic and the higher education in medicine". In the last fifteen years the number of medical colleges has increased from three to eleven without any proportional increase in public hospitals. The qualifying doctors have no choice but to establish or join private facilities, which operate in all corners of the city. The College of Physicians and Surgeons of Pakistan (CPSP) that oversees teaching and training in Pakistan has also no control over regulating the private sector.
There is no concept of auditing results of surgery for instance. I did not come across many surgeons who kept a record of their mortality and morbidity. Multidisciplinary team approach exists in a very raw form in some of the big hospitals. Majority of clinicians in the city are practising without any accountability and are not answerable to any higher authority. More than often complex procedures are undertaken in clinics and smaller hospitals, which are totally unequipped to deal with the complications of these procedures. Health and safety regulations simply do not exist. Unfortunately because of this "blasé" approach to the practice of medicine, clinicians routinely attempt procedures for which they have not received any previous structured training. This is often to the detriment of the patient and deepens the already existing, huge chasm of mistrust between doctors and patients.
Paramedical and ancillary medical services are no exception. There is a sprouting business of Pathology labs and Radiology clinics, swarming with untrained staff and offering services that are neither monitored nor regulated in a through and unbiased manner. The only fleet of ambulances (if one can call them that) belongs to a philanthropist who runs them privately without any help from the government.
Many of the senior doctors in the city are locally trained individuals who do not believe in "Continuing Medical Education". Tricks of the trade learnt numbers of years ago serves them good and they continue to practice without attending seminars, workshops or conferences. These clinicians have gone on for years without being challenged; there is no existing process, which will examine and review their fitness for conducting scientific, ethical and moral medical practice. Even if these regulations do exist they are hidden somewhere in the deep crevices of some bureaucrat's office who is more than happy to ignore than in exchange of some "worldly goods".
Surely the people of Pakistan deserve something better. Health care is a basic and primary human right. In a country where individuals, albeit a very small number, lives a life of luxury, it does seem odd that common public is not only suffering due to a lack of health service provision but also they are exploited in the hands of private providers who are nothing more than "cowboys" taking advantage of the non existing medico-legal framework in this country.
Correcting this dire situation is a mammoth task, which requires a Herculean effort. PMDC need to construct a robust database detailing the qualification and whereabouts of all graduating from medical schools who subsequently decide to practice medicine. Postgraduate education should be split between various sub speciality colleges i.e. surgeons, physicians, radiologist, pathologists etc. These colleges should be responsible for promoting postgraduate education, examinations and maintaining high standards of specialist care. They should revalidate, audit and provide continuing medical education (CME) for all doctors involved in specialist practice at a secondary and tertiary level. Any compromise or breach of standards should be reported to PMDC who should take appropriate action.
The ministry of health should clamp down on all clinics, laboratories, hospitals and facilities where patient investigation, management and treatment are carried out. A stringent health and safety protocol should be implemented and standards should be set. These facilities should be regularly visited and any breach of protocol should be dealt with appropriately.
I think the bottom line is personal integrity, moral values and ethics. If the individuals and authorities responsible for policing others do their job in a responsible manner I don't see any reason why the situation cannot improve.

References

1. World Heath Organization Report. (2000). Why do health systems matter? WHO: 2000. URL at http://www.who.int/whr/2000/ media_centre/press_release/en/index.html accessed on 12 March 2008.
2. Gadit AA. Out-of-Pocket expenditure for depression among patients attending private community psychiatric clinics in Pakistan. J Ment Health Policy Econ. 2004; 7:23-28.
3. Akram M, Khan F. Health care service and government spending in Pakistan. Pakistan Institute if Development Ecnomics (PIDE working paper) :32; 2007. File URL:http://www.pide.org.pk/pdf/Working%20Paper/ WorkingPaper-32.pdf accessed on 12 March 2008.
4. Pakistan Medical and Dental Council What it is? website. Available from: www.pmdc.org.pk/. URL at http://www.pmdc.org.pk/what_it_is.htm accessed on 12 March 2008.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: