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Bureaucracy and healthcare

The government will have to rein in corrupt physicians and bureaucrats to streamline public healthcare system

Bureaucracy and healthcare
Sadly many physicians working in the public sector are now a part of the bureaucratic nexus that is totally corrupt.

The time is upon us when we just might find out what exactly the new Punjab government is going to do with the public healthcare system. Transparency is promised but what exactly that means remains to be seen.

Personally, I am willing to give the new government a lot of time to fix the public healthcare system. Effects of willful neglect for decades cannot be undone in a few months. The major problem I do foresee is that the bureaucracy will try its best to prevent too much improvement and transparency.

Many years ago, I once asked a medical bureaucrat running a major tertiary care hospital as to why the hospital cannot be kept clean all the time. His response probably sums up why no bureaucracy wants to make things too much better than they are. He said; if we make the hospital too clean then we will have to keep it clean all the time and people might even expect it to become cleaner. That is a lot of hard work.

Therein lies the problem. It is not the politicians or any deep state or some shadowy ‘establishment’ that runs this country. It is the bureaucracy from the lowest to the highest level that really runs things and is basically responsible for much that is wrong.

Before I dump too much on the bureaucracy, it is appropriate to point out that our entire bureaucratic system, especially the senior bureaucracy that we inherited from the Raj, was trained to serve the colonial masters slavishly and without question. They essentially transferred that ‘ingrained’ loyalty to their new masters after the creation of the new country.

Clearly it is time to take away decisions about healthcare from people that cannot tell what the initials MRI (Magnetic Resonance Imaging-yup!) stand for and yet are the ones deciding to fund such expensive technology for public sector hospitals often entirely inappropriately.

Here a confession is in order. Sadly many physicians working in the public sector are now a part of the bureaucratic nexus that is totally corrupt and feeds at the trough of public largesse. The problem with corruption is that it is so endemic now that if you start getting rid of even just the overtly corrupt physicians and bureaucrats, soon you will have nobody left to run these medical departments and medical facilities.

One of the primary misconceptions that must be removed once for all is that a fresh medical graduate from even the best medical college in the country can actually run even the most basic health unit. Medicine especially diagnostic technology, laboratory testing and the large number of treatment modalities available has made it impossible for a fresh graduate to treat patients effectively without additional training.

This means that if we want to provide medical coverage in basic health units (BHUs) and the rural health centres (RHCs) that form the backbone of public health in the rural areas, we need to train a new ‘breed’ of general physician that can actually function independently in a rural environment.

For this new ‘cadre’ of doctors a new professional service will have to be created that provides a living wage, some opportunity for private practice, security and professional advancement with experience and more advanced medical training.

And yes, this means that nursing, lady health visitors, pharmacists, laboratory technicians and other members of a dedicated ancillary service will also be needed. One important area in the present technology heavy medical environment is that of ‘bio-medical engineers’. Sadly we have virtually no in-house or in-service technicians that can maintain and fix expensive machines.

During my years in Mayo Hospital, I saw many expensive machines lying unused because they were broken. Since their warranty had run out so the vendors were not willing to fix them except at an exorbitant price. And of course there were no adequately trained technicians in-house that could fix them.

All the things I have mentioned above cannot possibly be accomplished even in a year. That said, there are things that can be done urgently to facilitate some of these needed steps. The first and the most important step in my opinion is to devolve the management of almost all of the rural and semi-urban healthcare facilities to local governments.

The second step is to decentralise as much of the advanced medical care as is possible. As I have said previously that if cardiac ‘stent’ insertion and basic cardiac surgery can be performed in a ‘clinic’ with ten or twenty beds in a Lahore suburb, then why can it not be done in a two hundred bed District Headquarter (DHQ) Hospital.

Such decentralisation will also help to take pressure off our specialised medical centres as well as our major teaching hospitals. Also even relatively advanced medical care will become available closer to home saving the rural population the need to travel to big cities for almost all serious medical problems.

The third thing that needs major intervention is primary or preventive care especially in pregnant women and small children. The major increase in life expectancy that occurred in much of the West in the early part of the last century was because of decrease in ‘maternal’ and ‘child’ mortality.

And finally there is the pesky problem of population growth. There seems to be a national reluctance to address matters relating to sexual activity. Clearly without sex there can be no babies at least as a general rule. And to control population we need pregnancy prevention and that is a medical problem that can now be addressed by a physician in charge of the provincial healthcare system.

Based upon my rather dated personal experience in this field, of the contraceptive methods available, a condom is obviously most desirable since it can not only prevent pregnancy but will also prevent transmission of ‘sexually transmitted diseases’ (STDs). With all the recent conniptions about HIV-AIDs in Pakistan, condom usage in certain populations at risk must be strongly recommended.

After routine condom use, an intra-uterine device (IUD) is probably the most reliable and the least expensive form of ‘reversible’ contraception since it requires a single intervention without any elaborate medical setup. Of course, tubal ligation especially after multiple caesarian sections is quite appropriate but is essentially irreversible. The ‘pill’ for a mostly sub-literate rural population is not very useful.

To sum it up, my recommendations are diversification, decentralisation, development of a separate cadre of rural and semi-urban healthcare professionals, emphasis on basic healthcare and on population control.

During my six years in Mayo Hospital I did figure out that it is possible to provide free cardiac surgery within the available budget. But it takes determination, use of cost cutting techniques that are based on good medical practices and continuous vigilance against pilferage and corruption in the procurement process.

And my ultimate dream is that someday patient bathrooms in Mayo Hospital will be clean enough that even a visiting superior court judge can feel comfortable using them. But this will have to done on the sly since no politician really wants to be remembered for cleaning up the bathrooms in Mayo Hospital.

Syed Mansoor Hussain

syed mansoor hussain
The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.

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