Basic Health Units (BHUs) are supposed to be the first point of contact between patients and health department officials but historically this has not been the case. For years, BHUs have remained unequipped, non-functional and deprived of doctors, paramedics and essential medicines. In certain cases, they were found to be under the control of locally influential people and even used as deras and barns to keep cattle and goats.
Furthermore, doctors have been reluctant to serve at BHUs, especially the remote ones. They try to find postings in urban centres. The incentives offered to them by the government have failed to bring them to more far-flung areas. Ultimately this adversely affects local populations and increases pressure on secondary and tertiary care hospitals that have to accommodate a huge number of patients. If the BHUs were performing well, most of these patients could be tended to at facilities closer to their homes.
Punjab, the most populous province in the country, has also been struggling to make BHUs effective. It has taken steps like the introduction of a biometric attendance system to check absenteeism at BHUs and systems to maintain inventories. While this will make a difference, there is no doubt that more needs to be done.
Ideally, a BHU located at union council level must serve a population of up to 25,000 and the services provided there should include preventive, curative and referral care. The provision of outreach/community based services should also be provided by BHUs as per Punjab health department rules.
The question is, how can such an important component of primary healthcare be made productive and public. Or should the project be side-lined and ignored, like it is at the moment, while the government makes heavy investments in building and upgrading big hospitals in urban centres.
The answer would definitely be in favour of making the BHUs functional because they help locals get tested and diagnosed for diseases in the early stages. Otherwise, patients are only rushed to hospitals when their medical condition is severe and most of the damage has already been done. But then comes the question on how to achieve this objective, especially when many incentive-based initiatives have failed to deliver?
A look at the performance of BHUs in some union councils of Sheikhupura district may be the answer. The said BHUs are performing far better than others across the country, courtesy a donor-funded TeleMedicine project launched last year after the Sheikhupura district government won the grant through a competitive process. The project aimed at replacing the missing doctor with a remote doctor based at the District Headquarter Hospital (DHQ), and it did so by providing the BHU with key diagnostic facilities and connectivity. A US-based technology provider J&B group has supplied the diagnostic equipment for these health facilities.
Zeeshan Bashir, 25, who lives in Chappa Minara UC, is one of the beneficiaries of this project. He had recurring fever so he took medicine for it and never bothered to get tested. On one of his many visits he was convinced by the BHU staff to get himself tested for some diseases as his fever would not go away. He agreed and was diagnosed with early-stage hepatitis. The BHU staff referred him to a senior doctor for treatment. Today, he has fully recovered from the disease. The BHUs in this district have the capability to conduct tests for blood pressure, pulse, chest congestion and hepatitis.
Experts who have analysed the project say it is working for a very simple reason of technology. Patients come here because they can consult a doctor through audio-visual links and get tested for many diseases, they add. This saves them the hassle of traveling to a secondary or tertiary care hospitals.
Muhmmad Ahmad Rajwana, District Team Lead (North) at Sub-National Governance (SNG) Programme — a 5-year DFID-funded initiative aimed at helping Pakistan improve governance in different fields — shares with The News on Sunday that the tele-diagnosis equipment at these BHUs can conduct 17 primary tests simply by the touch of a strobe. He says that the paramedics or Lady Health Workers at BHUs are trained to use the equipment — which has the capacity of being solar-powered and works on simple GPRS — to connect to a consultant sitting at a senior district hospital. The results of the tests, he says, are immediately shared live with the consultant and the patient can engage with the consultant in real-time consultation over video.
As per the project details, the system also has the capacity to centrally store the patient’s data; this can be used to generate evidence to predict disease patterns and to inform planning and budgeting for staff and medicines. The equipment is also capable of conducting almost all initial gynaecology tests including antenatal scans. The total cost of providing the equipment and its ancillaries was Rs 17.29 million, in addition to the cost of using government facilities, office space, and staff taken as in-kind contribution. The project has benefitted 87,836 patients who have visited these BHUs over the years. Earlier, patients could hardly be seen at these BHUs.
The key impact, Rajwana says, has firstly been an increase in the antenatal scan follow-up from 15 per cent to 60 per cent and secondly, the inflow of patients to BHU has increased by more than 50 per cent.
Independent survey results show that that patients agree that the need to go to the senior hospitals has substantially decreased now, meaning this service was successful in decreasing the inflow of patients at senior hospitals since they were receiving quality treatment at the BHU level. Punjab currently has over 2,461 BHUs and around 20 per cent of these may be considered as ineffective on the basis of non-availability of doctors and medicines. It is quite likely that the government may consider expanding the full solution (audio-video, diagnostics & patient health records) of the initiative to around 600 BHUs in the province.
Usman Khan, Team Leader, SNG programme, explains that the grant was released to Sheikhupura District Government under the District Delivery Challenge Fund (DDCF), a sub component of the SNG programme. He says the challenge fund was specifically designed to improve Pakistan’s provincial governments’ capacity to respond more efficiently and effectively to the public service needs of local communities.
The DDCF, he shares, was a competitive grant launched by DFID with the intention to identify and test innovative solutions to address the challenges of poor quality and inadequate governance in public education and health sectors. The Sheikhupura government submitted the application for the innovative TeleMedicine project that would connect BHUs with senior doctors and hospitals with the aim to help a large population of the district and won it, he adds.
This leads us to ask whether it will be possible to sustain such projects without foreign grants and how practical it is to replicate it in other districts.
Tahir Bashir, Country Director, J&B Medical — the company providing the diagnostic equipment at health centres — says the cost-effectiveness of this technological solution may attract governments to scale up the project. He shares that the equipment provided by their company is FDA certified, durable and highly cost effective. Today, he says, it is possible to have tests like blood glucose level, ultrasound, ECG, blood pressure, pulse rate, ENT view, pelvic scan, abdominal scan, detections through telestethoscope and antenatal scans at BHUs.
He says the diagnostic tests conducted at Sheikhupura’s BHUs in just one year are much higher in value than the cost of the equipment installed there. The good thing, he says, is that the Hafizabad district is launching a similar initiative and it is hoped that the Punjab government will be taking it to other districts as well.