Healthcare Landscape in Pakistan – Sum Up – Asrar Qureshi’s Blog Post #987

Healthcare Landscape in Pakistan – Sum Up – Asrar Qureshi’s Blog Post #987

Dear Colleagues! This is Asrar Qureshi’s Blog Post #987 for Pharma Veterans. Pharma Veterans Blogs are published by Asrar Qureshi on its dedicated site https://pharmaveterans.com. Please email to aq.pharmaveterans@gmail.com for publishing your contributions here.

Credit: Ahmet Kurt

Credit: Anna Shvets

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This is the 12th blog post on the topic of healthcare in this series. I have talked about all major stakeholders, their roles, and their issues. It is time to sum up the entire discussion, hence this post.

Rather than summing up all the points discussed so far, I shall talk about the impact of various stakeholders on the healthcare system in Pakistan. I shall focus on the system itself under various heads.

Strengths

Pakistan can rightly claim to have a highly developed, elaborate healthcare system among low-and-middle-income countries (LMICs). There are separate, dedicated institutes for heart patients, for cancer treatment, for kidney and liver transplants, besides several large multidisciplinary, tertiary care hospitals. These institutes are equipped with latest technology equipment.

Quality of Pakistani doctors has long been recognized the world over. Pakistani doctors have made great names in the USA, UK, Europe, Australia, and Middle East. The education and training at the public medical colleges is vigorous and formative. Postgraduate qualification is even more rigorous. In addition, the availability of a very large number of patients, gives our doctors ample opportunity to learn hands-on skills in all specialties. The patients at public hospitals are particularly numerous, poor, and docile, and let the doctors do whatever they do without protest. Behavioral complaints notwithstanding, Pakistani doctors get unprecedented opportunities to hone their clinical ability and skills.

Access to healthcare is quick. Since most care is paid, the patients can approach any specialist, and get any test done in a matter of hours. The emergency departments also dispose of patients in a matter of minutes, not hours. This is quite unlike US, Canada, UK where the emergency department may take hours, GP visit may take weeks, and specialist consultation and high-end testing may involve waiting for months. 

Access to drugs is easy. Most drugs are available as generic products which are manufactured by multiple companies and can be purchased anywhere without prescription. Drug prices are still comparatively low despite recent price hikes.

Most advanced techniques in surgery especially are practiced here, except where extremely sophisticated gadgets may be involved. Despite such handicaps, our doctors perform wonderfully well.

Issues

The first issue is that the number of doctors, all specialties put together, and hospital beds, are disproportionately less than the requirement. The population had been growing at an enormous rate and healthcare facilities have not been able to keep pace. 

Government spending on healthcare is shamefully low; 1.2% of the budget at federal level, and variable at the provincial level. Spending on healthcare is among the lowest in the region, and even among rest of the world.

Just like education, as more people got more expendable money, private healthcare grew much faster. People wanted good care in clean environment at good pace, and only private healthcare could provide that. Public healthcare has grown at a much slower pace and has become completely out of sync with the population growth, disease burden, or patient needs.

Burden of disease profile has changed over time. Lifestyle diseases like diabetes, high blood pressure, heart diseases, obesity, and mental disorders have risen at an alarming rate, but the relevant facilities did not evolve accordingly. 

Misuse/abuse of drugs is rampant. A consultant prescription may have 6-10 drugs, not based on diagnosis but on the reported symptoms. Antibiotic misuse has led to antibacterial resistance which is threatening us in the face. Antibiotic resistance is a global problem, we are fueling it further and suffering due to it. 

Weaknesses

There are several weaknesses, many of which are part of our system. Our biggest weakness is compliance to rules, laws, and regulations. The belligerent non-compliance shows in many ways, some of which are obvious; others may be less obvious.

Dishonesty runs in the fabric of society and healthcare. Private institutions’ purchasers try to extract more and more discount to maximize profits for the hospital. In addition, they also expect some kickback for themselves also, in whatever form it may come. While charging the patients, it has become common practice even in the reputed hospitals to use less, if not least, expensive drugs and charge for the most expensive ones. This is cheating at the institutional level, and it is rampant.

Public purchasers do not have to worry about profit, and they only worry about their own kickback. They negotiate hard to this end and make money. Money thus collected at one point is equitably shared till the top. Due to this environment, most top-tier companies have stopped supplying to government. 

Rules are not applied to doctors at all. They can do whatever they do, they will not be questioned. There are cases of wrong treatment, bad surgeries, poor focus, unnecessary deaths which are guised as Allah’s Will, but the doctors are not prosecuted. Couple of disgruntled people who took cases to courts could not get relief because no doctor was willing to give honest witness opinion against his fellow doctors. Due to this laxity, doctors mistreat patients with impunity bordering on crime. It has become common practice to do unrequired interventional procedures to make money. 

As mentioned in a previous post of this series, majority of doctors are issuing incentive-linked prescriptions. They are getting huge benefits from pharmaceutical companies and prescribing needed and not-needed drugs at the cost of patients. Almost all doctors in suburban and rural areas run a pharmacy inside the clinic where they buy drugs at big discounts and sell to patients at full price, if not more. Twice, government tried to bring these pharmacies under the licensing rule but failed miserably due to doctors’ severe resistance.

Private hospitals are only money-making machines and do not follow prescribed rules. Government has been trying to license hospitals and clinics, but it is already a lost cause. 

Diagnostic labs are involved in malpractices of various kinds, most common of which is giving commission to doctors for prescribing multiple tests. There are no licensing rules or check on quality practices.

Pharmaceutical industries are highly regulated at every step of business, but the regulators are ineffective by choice or due to capability. DRAP has been struggling since its inception in 2012 and still not as effective as it was intended to be.

Government can boast about files and files of policies and rules etc. but no government had the strength to implement these rules effectively.

Challenges

Our biggest challenge is to public healthcare to all. This will take investment and will both, but it a constitutional responsibility also.

Our second challenge is to regulate healthcare in public and private sector. There is huge money in private healthcare, and they do not want regulations, so they can influence the regulators. It is like narcotics business where money is so big, anyone can be influenced.

Our third biggest challenge is the rising cost of medical treatment, which is partly due to inflation, and mostly due to unbridled greed. It is double jeopardy for patients whose purchasing power has already been compromised due to inflation.

Our fourthe challenge is to make medical practice accountable. Even a few prosecutions can have a serious deterring effect.

Our fifth challenge is to make the governments increase spending on healthcare, rather than becoming Mughal Emperors and make only roads or distribute charity or do ceremonial, wasteful projects as if they own the country

Concluded.

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