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Basics of health

Can Pakistan ever have a decent public healthcare system?

Basics of health

For Pakistan, primary healthcare should be a national priority. Unfortunately, improvements in primary healthcare offer little political drama. Politicians would much rather talk of the medical colleges and specialised institutes that were built during their tenure. Saving a few thousand women who would have otherwise died during childbirth just does not have the necessary panache. Of course, the media also finds little ‘romance’ in decreasing ‘maternal mortality rates’ during child birth.

One of my pet peeves is the burning desire of the present Punjab government to build ‘liver transplant centres’. According to numbers released by the Punjab government a while ago that I quoted in a previous article, there are some 12 million people infected by the Hepatitis virus that can lead to the sort of liver damage requiring a liver transplant. Also about forty thousand people get infected every year. In a most conservative estimate, about one in ten patients suffering from this disease might end up requiring a liver transplant. This means that in the Punjab alone, half a million people might require liver transplants urgently. Of the patients being infected every year, about two thousand new patients might also require this operation every year.

The government cannot possibly build and adequately staff enough transplant centres to perform all these operations or even pay for a fraction of them. What will end up happening if a few such centres are built is what goes on in the cardiac centres built and financed by the government like the Punjab Institute of Cardiology in Lahore or the Pervaiz Elahi Institute of Cardiology in Multan. The rich and the well-connected patients get timely operations and ‘stents’ while the poor are placed on ‘waiting lists’ and sent home. These waiting lists are often much longer than a year. Essentially what happens is that the poor or what are euphemistically called the ‘non-affording’ patients are sent home to die. And exactly that is going to happen with these liver transplant centres if they ever get built.

I am not opposed to the creation of the state of the art medical institutions in the public sector but only if the government has the money to improve and expand the existing public health facilities first. About the creation of liver transplant centres, my basic point is that hepatitis that leads to the need for possible liver transplants is an eminently preventable disease. But prevention even though much ‘cheaper’ is hard work and is not at all glamorous. Prevention needs proper supervision of blood banking and control over unqualified medical practitioners (quacks) for starters.

Properly functioning Rural Health Centres, Basic Health Units as well as tehsil and district hospitals are what local government will concentrate on and by doing that will make accessible healthcare a possibility.

Clearly the chief minister of any province would be entirely loath to contest elections from a platform that includes arresting thousands of quacks or substandard blood bank owners and operators. But having built many liver transplant centres and heart institutes (properly equipped and adequately staffed or not) is definitely worth talking about during an election campaign. Ordinary people, however, have no interest in glamorous new transplant or heart centres. What most of them want is the availability of basic healthcare that is accessible and provides help to them when and where they need it.

The question then for those of us that care about such things is how to reorient government priorities towards primary and preventive healthcare. Here I believe one of the most important factors can be true decentralisation of power to a functioning system of local government. Local governments are by nature more responsive to local needs and have little interest in grandiose projects built in distant places. Properly functioning Rural Health Centres (RHCs), Basic Health Units (BHUs) as well as tehsil and district hospitals are what local government will concentrate on and by doing that will make accessible healthcare a possibility. At the same time, closer the government gets to the people, better it will become at prevention of disease as well providing adequate maternal and childcare.

The other problem with reorienting provincial or national politicians towards providing mostly free or heavily subsidised healthcare at the local level is of political philosophy. Centre right and religious political parties generally believe in ‘providing’ basic amenities for the poor and the deprived members of society but as charity and not as a right of the people to have access to such amenities. Centre left and liberal parties believe that the state should provide a social safety net for all citizens so that the poor are guaranteed basic amenities like a living wage, education, healthcare and food support.

Since Pakistan is a poor country and the government does not have adequate resources to provide advanced medical care and education for all its citizens therefore at the least basic healthcare is a must. Also even though education at the primary and secondary level is supposedly mandated by the constitution, for all practical purposes the government schools are in as bad a state as the primary healthcare infrastructure that also caters primarily to the poor.

Centre right political parties have a ‘knee jerk’ response that healthcare should be privatised as far as possible. The ‘private sector’ has stepped in to take up the slack but unfortunately in the rural areas as well as many small towns there are just not enough qualified physicians available to fulfil local needs. This by necessity has created a class of ‘quacks’ that are responsible to a great degree for the hepatitis epidemic that we are seeing in Pakistan.

As far as basic education is concerned, interestingly educating girls that grow up to become mothers is one of the most important public health actions possible. Educated women have fewer babies, are willing to seek out medical care for themselves as well as their children and are able to initiate basic precautions like boiling water before the family drinks it. In essence then basic education is necessary for basic medical care.

The point of difference between centre right/religious parties and the centre-left political parties about the provision of basic amenities to citizens is between charity and rights of the citizenry. But unfortunately we have seen a centre-left government running Sindh for almost seven years and Khyber Pakhtunkhwa for five years and a centre-right party running the Punjab for seven years, and all of them have treated basic health as well as basic education about the same way. Yes they all make appropriate noises but little gets done.

So then should we in Pakistan just abandon the idea that the governments will devote greater financial resources towards healthcare in general and basic and preventive health in particular? Here I think that I must return to the point I made earlier about local government. Indeed basic education and healthcare can only become a priority when effective and autonomous local governments are in place. Until such time that we reach that point, politicians running the provincial and central governments will keep squandering scarce resources on flashy, glamorous but essentially useless medical centres with the politicians own names on the foundation stones.

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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