MARIAM ALI BAIG: To what extent has the pandemic exposed the fragility of Pakistan’s healthcare sector?
Dr ABDUL BARI KHAN: Pakistan’s healthcare infrastructure is fragile; the overall health budget is less than one percent of the GDP. Furthermore, the devolution of the healthcare sector to the provinces was done in haste, and as a result, the required capacity was not there and with a few exceptions, most hospitals were not geared up to deal with the pandemic. Unfortunately, the designs of the majority of public sector hospitals are based on obsolete templates that are drawn up by the Pakistan Public Works Department, which do not have the expertise and nor do they consult with healthcare professionals. They are simply replicating a decades-old template despite the fact that the healthcare sector has changed and works according to new norms, be it in terms of the structure of the buildings, the flow of patients and the air conditioning and electrical systems.
MAB: How is the hospital system in Pakistan structured?
ABK: There are the primary healthcare providers, which, although may not be up to the mark, consist of Basic Health Units (BHU) and Rural Health Centres (RHC). At the secondary level there are Tehsil Headquarters (THQ) and District Headquarters (DHQ) hospitals and then the tertiary care or teaching hospitals. Unfortunately, none are integrated and are not manned properly; there is a lack of human resources and facilities. Patients should be going to their BHU, where about 60 to 70% of the cases should be resolved and about 30% would be referred to an RHC or DHQ hospital. Instead, all the load goes to the tertiary care hospitals.
MAB: Is the number of BHUs adequate?
ABK: They are in numbers, but they are not functional; they are just brick and mortar structures and when there is a vacuum, unqualified people and non-traditional caregivers take over.
MAB: Can Pakistan’s healthcare system be fixed?
ABK: The answer lies in public-private partnerships. Even internationally, the answer is public-private partnerships because many sectors are involved and each sector has its strengths and weaknesses. The public sector provides the infrastructure and the private sector makes it functional through efficient management. In addition, there is a third-party monitoring system, based on contractual KPI-based performance agreements between the two sectors. When we set up Indus Hospital, people said why are you doing this? It is the responsibility of the government to do it. My answer is that we have been in this situation for the last 75 years and nothing has changed. So we decided to develop a model that in time policymakers would be convinced about, and within two years we were given approval by the government to set up a private-public partnership – but without giving us administrative control. We said we would not do it without total administrative control and after two years they agreed to our terms – this was a big paradigm change; the fact that the government accepted that they could not do it alone.
The majority of the planning is done in drawing rooms by people who do not have data
MAB: In such cases, what does the government provide?
ABK: Typically, the government provides the infrastructure and equipment. There is also a budgetary provision in the agreement of three to five percent for the delivery of services.
MAB: Do the funds the government provides come out from that overall one percent they allocate to healthcare in Pakistan?
ABK: Yes. Another shortcoming is that the human capital planning in government-run hospitals is not up to the requirements. How can you run a 24/7 service with one gynaecologist, one surgeon and one physician? As a public-private partnership, IHHN provides them with the appropriate HR to run a service and that budget is provided by the government and monitored by a third-party auditor.
MAB: Where do you source qualified doctors and nurses? Or are they resources that need to be developed?
ABK: There is a shortage of trained HR. Another problem is the salary structures in public sector hospitals. You cannot ask medical care professionals to work on less than 10% of their earning capacity. In the rural areas, there are no adequate accommodation or schooling facilities. They have to maintain two homes; one in the city where their families live and another in the area they work in. We need to come up with out-of-the-box solutions and develop services that can be performed by trained paramedical staff, and most importantly, use telemedicine to enable rural areas to access services from the bigger cities. Unfortunately, most doctors end up going abroad because of the inadequate remuneration. At IHHN’s primary health clinics, doctors are required to work one week in a remote area and then three weeks at our city campus.
MAB: Are government-run medical colleges capable of turning out competent doctors?
ABK: Colleges in the big cities have maintained their standards. The problem lies with public sector medical colleges in the interior. However, the patient load there is so heavy; they interact with hundreds of patients on a daily basis, so their experiential learning is so vast and those eager to learn benefit from the exposure. Many go abroad for their residencies and on to higher positions.
MAB: What about nursing? Do most women from rural areas find it difficult to move to bigger cities for their training?
ABK: There are colleges in the interior. We have set up nursing colleges in Badin, Hyderabad and Sukkur. We need to develop short, intermediate and long-term strategies. In the short-term, we have to develop one-year diplomas, so that we can train nursing assistants (we need at least one nurse for 10 beds) and then move forward. It will take time to fill the gap, but a strategy and a plan must be put in place. Pakistan needs 1.8 million nurses. Typically, the doctor to nurse ratio is 1:4 (one doctor/four nurses); in Pakistan we have two doctors for one nurse – the reverse.
MAB: What are the biggest health issues in Pakistan?
ABK: According to the health indicators for Pakistan, we are among the countries with the highest maternal and infant mortality rates and the highest rate of stillbirths. Forty percent of our children are malnourished. In terms of non-communicable diseases, there are diabetes, hypertension and cardiac ailments. We are fifth in the world in terms of the highest TB ratio and one of two countries in the world to still have incidences of polio. These are the challenges and they have to prioritise. There is a lack of data and without data you cannot plan. The majority of the planning is done in drawing rooms by people who do not have data. When you use data efficiently, as we are seeing in this pandemic, with the role of the NCOC and the concentrated efforts made at the provincial and federal levels in analysing data, you get results.
MAB: Do you think the present government’s intent to provide Universal Health Coverage – the Sehat Sahulat Program (SSP) – is doable, and is it going about it the right way?
ABK: They are doing it in KPK and some areas in AJK, Balochistan and Punjab. However, they have to extend this to the primary healthcare sector. At the moment it is only available for in-patient treatment and emergency investigations. The problem is that in the rural areas there are only public sector hospitals, which are already free. A mechanism has to be developed to co-opt private sector hospitals. The government believes that if you provide an opportunity (create a demand), the supply will come and people will start investing in private hospitals, but it will be difficult as providing healthcare in rural areas is more expensive compared to the big cities because you have to pay extra to the doctors and nurses.
MAB: Has the Covid-19 experience proved to be an eye-opener in changing government mindsets?
ABK: The government realised they had to do something about Covid-19, because no one is spared, be it a chief minister or a simple worker. The day after the pandemic broke on February 26, when two patients were reported in Karachi and Islamabad, the CM house called me for an emergency meeting. The meeting lasted 12 hours and during that time, they were able to contact trace the people who had been in contact with the individuals concerned. They had the data from the Iranian embassy regarding how many visas were issued in the last three months and how many people had returned. Within a week we were able to establish two 100 bed isolation hospitals. Initially, the testing capacity was 200 tests per day; today it is about 15,000 a day in Sindh. All this was possible because the government embraced and asked for private sector help. I hope that this momentum and collaboration will continue. We should respect each other and take it forward from there.
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