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A right, not a privilege

It is vital to improve public healthcare system if the lives of ordinary people are really a priority for the rulers

A right, not a privilege

The New Year is upon us and it is an election year. Suddenly, healthcare just might become a red hot election issue. The Pakistan Muslim League-Nawaz (PML-N) government in the Punjab has evidently decided to present improvements in health and education as some of their ‘great’ achievements.

For eight years both these issues were on the back burner but now everything concerning these issues is going to be silver plated and presented to the people as major accomplishments. A simple expression of this is the fact that for nine years we had no health minister in the Punjab and now we suddenly have three or is it four?!

There was a supposed privatisation of the rural healthcare a bit more than a year ago, haven’t heard about its success or failure since then. And yes that brilliant idea about motorcycle ambulances, whatever happened to those? And where are those ‘mobile hospitals’ from a few years ago?

And those health insurance cards for poor people, rule of thumb is that if we don’t hear about it, it probably did not work out. The same is true of the clean drinking water that we have been waiting for the last nine years.

There are two areas where some improvement has definitely occurred over the last couple of years and that is concerning vaccination and maternal and child healthcare. Of course much of the money and oversight for both of these initiatives is coming from foreign NGOs.

But as I have said before, and I will say it again, in my estimation the best criterion that demonstrates improvement in our great public hospitals is the state of the bathrooms available for use for patients and their attendants. Ah! But not even the Most Exalted Servant of the people would like to go down in history as the person who ‘cleaned’ up the bathrooms in Mayo Hospital.

I am sure that the present government is doing things to improve the quality and the availability of healthcare in the province. But it is mostly as an afterthought rather than a primary political goal. As I mentioned above, it is an election year and I hope that some major political party will take up healthcare as an election issue.

In the Punjab as well as much of the country, networks of Basic Health Units (BHU), Rural Health Centres (RHC) as well as Tehsil and District Headquarter Hospitals (THQ and DHQ) are already present.

In the Punjab alone, there are 2400 (functioning?) BHUs and 300 RHCs besides the Tehsil and District Hospitals and the tertiary care ‘teaching’ hospitals as well as specialised medical centres like the many cardiac institutes in different cities.

Of interest is the fact that the entire rural healthcare network was built in the nineteen fifties and sixties with money provided by United States Agency for International Development (USAID) from money received under PL480 (food for peace!) where the US would provide food (wheat) and the Pakistani government would pay in rupees and the USAID then spent that money in Pakistan. I am not sure if any BHUs/RHCs/THQ Hospitals have been added since then from local funds. Of course the entire system was designed for a population that was about a fifth of what it is today.

About five years ago during a discussion with a senior medical bureaucrat I asked him about this province wide healthcare network and its functional status. He responded that it was a third very effective, a third somewhat effective and a third essentially nonfunctional. From what I have heard from people living in rural areas, many of these centres are indeed nonfunctional. With more than twelve hour loadshedding in the rural areas, I can well imagine how effective these centres might have been.

There are two areas where some improvement has definitely occurred over the last couple of years and that is concerning vaccination and maternal and child healthcare. Of course much of the money and oversight for both of these initiatives is coming from foreign NGOs.

No, I am not just trying to criticise just this government for as I have said above; healthcare has not been a priority for any political party for as long as I can remember. And that is my point today. I hope that any or all of the three major parties will come up with some exact suggestions for making things better in an organised and sustainable way.

It is important to remember that most people in the rural and semi rural areas as well in big cities depend on the public healthcare system for medical treatment and only go to private hospitals and clinics when public hospitals prove inadequate. It is therefore vital to improve this system if the lives of ordinary people (the famous ‘masses’) are really a priority.

Another point worth making here. Fifty years ago when the Pakistan People’s Party raised the slogan ‘roti, kapra aur makan’ (food, clothing and shelter) as basic rights for citizens, that was revolutionary. Today it would have to include education and healthcare in that list. Indeed basic healthcare and education are today an established right and not a privilege.

So what can be done? First step has to be that the physicians that work in the public healthcare system have a proper ‘service structure’ that provides them with a living wage and pay increases as well as promotions based on seniority, specialisation and continuing medical education. And that structure must include all paramedical and ancillary staff.

During a recent discussion with a medical professional, I pointed out that if the ‘sweepers’ in Mayo Hospital went on strike, the hospital will grind down to a halt. All the ‘young doctors’ can go on strike and the hospital will function, albeit a bit less actively.

So here are my suggestions. First, BHUS, RHCs, all the way up to the THQs should be under local government. Let the elected representatives be responsible for them and let their electoral success or failure include their ability to run these centres.

Second, physicians and other members of the staff should be able to augment their incomes through ‘on the premises’ private practice. Here the concept of public and private collaboration can be made to work. The elected local government officials can raise money from the people in the area for defined trust funds to subsidise the health centres. A system is then developed to distribute this money to all employees based on performance and amount of work done.

Third, recent graduates from medical college are the least appropriate people to work in the rural environment. The College of Physician and Surgeons of Pakistan (CPSP) as well as the teaching universities should develop training programmes that prepare medical graduates to serve in rural areas as trainees and as full time professionals. I have written much about this before.

And finally, all physicians and ancillary personnel should be provided appropriate living facilities and security to encourage recruitment. In this connection hiring husband and wife teams to work in rural areas is an important consideration. Yes a joining bonus or a permanent increase in salary for such a couple might be an important incentive.

What I have written today is hopefully the beginning of an important discussion. Many things have been left out. I will have more to say as we come nearer to the elections.

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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