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Healthcare as a political priority

Improvement in public health becomes a daunting task when ‘quantity and quality’ of healthcare is rarely of political benefit to politicians

Healthcare as a political priority

The honourable Chief Justice of Pakistan has ‘demanded’ that public hospitals be fixed and the problem of medical ‘quacks’ be taken care of. Fixing hospitals in the public sector is a difficult job even if the provincial governments were serious about it.

In the Punjab, healthcare was never a political priority for the Pakistan Muslim League-Nawaz government. A simple example of this is the fact that for the first eight years of the PML-N rule there was not even a minister of health to oversee the large medical system that is controlled by the government.

Of course it is difficult to contest elections on the basis of improvements in maternal and child mortality or decrease in the number of people dying from Tuberculosis (TB). It is an interesting historical fact that improvements in the ‘quantity and quality’ of healthcare is rarely of political benefit to the political party that initiates such changes.

In the United States, for instance, one of the major advances in the availability of healthcare was the creation in 1965 of Medicare, a government insurance programme to provide older Americans with subsidised healthcare. This was an initiative of the centre left Democratic Party. And yet the elderly Americans that benefit from this programme even today are mostly supporters of the Republican Party that, if it could, would dismantle this programme.

Just ten years ago, the Democrats under President Obama passed the Affordable Care Act (Obamacare) that provided healthcare to millions of Americans that were without health insurance. In spite of this major advance, the Democratic Party was routed in the midterm elections in 2010.

Most centre left political parties are committed to providing a ‘safety net’ for all citizens. At present in much of Europe, universal healthcare is an accepted right that is the responsibility of the state just as other rights guaranteed by the state.

Many decades ago, promise of a safety net (Roti, Kapra or Makaan — food, clothing and shelter) as a political slogan led the centre left Pakistan People’s Party (PPP) to victory in what was then West Pakistan.

Interestingly, universal healthcare that should also be a part of the safety net does not excite the voters too much. The reason is obvious. We need food, clothing and shelter all the time but healthcare becomes important only when we or a loved one becomes sick. And what does not excite a majority of voters does not excite the politicians either.

So, we have to wait for the emergence of a truly hard left political party in Pakistan that can actually win national elections. Once that happens there might be some real movement towards universal, affordable and adequate healthcare. Until that time we will just see some minor changes to bring about essentially cosmetic improvements.

In the past, I have often written about how to improve healthcare. So just a few words about what needs to be done. Hospitals are like computers. You can get the fanciest computer with the latest hardware but without proper software it is just a fancy box. In healthcare, the software is the people that work in hospitals.

This software includes the lowly ward boys, sweepers and ayahs all the way up through nursing and ancillary staff to doctors including the top consultants. Interestingly, the least important part of this hierarchy as far as adequate provision of healthcare is concerned is the senior consultants.

Before proper healthcare can be provided in the network of healthcare facilities starting from the Basic Health Units all the way up to the tertiary care teaching hospitals and specialised medical centres there first has to be a proper system of remuneration for all these parts of the medical software. By that I mean a ‘living wage’ commensurate with the educational and training level of the workers.

Every time doctors go on strike for some improvement in their wages or working conditions, the press starts talking about messiahs. Doctors are human beings with families and hopes for a comfortable future. More importantly as far as messiahs are concerned, history tells us that they never do well on this earthly abode.

Now to the problem of ‘quacks’. I prefer to call them ‘non-formal’ medical practitioners. Let us not forget that an experienced Dr. Mom can take care of a large number of basic household medical problems. A digression here. I am all for women that graduate from medical college and then allegedly never practice medicine. At least they are the first line of medical defense in any family.

And about quacks, let me say that there are many ‘qualified’ medical practitioners that have not opened a book of medicine since they graduated and that period might run into decades if not more. In my opinion these medical practitioners are often more dangerous to the health of their patients than many non-formal medical practitioners. As far as alternative systems of medicine are concerned, less said about them the better it is for my personal wellbeing.

Estimates of the number of non-formal medical practitioners in the Punjab alone run close to fifty thousand. These practitioners can be divided into three categories. Those with some medical background and training. Then there are those that practice truly non-formal medical practices. This includes bone setters and wrestlers that treat different orthopaedic problems. And then there are those that have no medical background and still practice medicine.

Clearly these non-formal practitioners exist because there is a need for them. If people that need medical help do not have access to proper medical care because of non-availability or cost, then the ones in need will find whatever help they can get. And such help is usually from these non-formal practitioners.

Trying to identify and arrest or otherwise restrain thousands of such practitioners is an impossible task. It is better to identify the ones with some formal medical training and register them and then have them go through a proper medical course that enables them to take care of basic medical problems. And have them go through yearly continuing medical education.

Let these be our ‘barefoot’ doctors that provide basic healthcare until such time that a proper system of healthcare becomes available. In many developing countries, some form of informal medical care system had to be established before proper healthcare facilities became the norm.

Perhaps it might even be worthwhile to bring back the system of licentiate medical practitioners (LSMF) that was prevalent in pre-partition India and in the early years of Pakistan. These doctors went through four years of medical education after completing high school and then were employed as assistant medical officers in the rural areas. For many years these practitioners formed the backbone of rural and semi-rural healthcare. And of course decreased the need for the non-formal medical practitioners.

After a number of years of work in rural areas, these practitioners were allowed to spend two years in a medical college and obtain a proper medical degree. The year I graduated from King Edward Medical College (1970), our principal and two senior professors had started out as licentiates.

Syed Mansoor Hussain

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

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