There was a recent news item that in Gujranwala district alone, hundreds of doctors are being hired to work in Rural Health Centres (RHCs) that were without adequate medical coverage. I would presume that this is a good thing but two important questions need to be answered. First, why were these RHCs without doctors in the first place and second, why the present Punjab government that has been in power for more than five years just thought of taking care of this problem?

Here a couple of things need to be stated. First, the present government of the Punjab has never thought of healthcare as an important issue. Second, that this government is run through ‘favourite’ bureaucrats. Most bureaucrats of the ‘elite’ services just don’t like doctors for ‘obvious’ reasons and have no desire to support or help them develop into effective professionals. I have seen obvious expressions of these two tendencies over the time I spent working in King Edward Medical College/University (KEMC/KEMU). 

For almost five years, the Health Department bureaucrats ran a running battle against the Young Doctors Association (YDA). Even now some of the issues brought up at that time have not been resolved. Interestingly, the report of the ‘judicial commission’ that supposedly tried to allocate blame for patient mortalities due to YDA strikes was never issued. Was it suppressed because it also blamed the ‘un-blameable’?

The second experience I had was three years ago when the senior Health Department bureaucrat, twenty years my junior and totally incapable of any serious comprehension of matters relating to cardiac surgery tried to lecture me on the finer points of cardiac services. After listening to what he had to say, I politely told him exactly what I thought of his ‘ideas’ and also said in so many words, if you want to fire me, do so but please don’t act as if you know more about cardiac surgery than I do.

Soon thereafter my contract as professor and chairman of the department of cardiac surgery was terminated. That said, the aforementioned bureaucrat was also subsequently replaced as the head of the Health Department since one of the primary demands of the YDA was that he must be removed. But he went on to ‘bigger and better’ things.

And that is the major problem with much that goes wrong. Incompetent bureaucrats never face any serious consequences for their actions especially if they are in the ‘good books’ of their masters. But doctors can always be fired or suspended or worse accused of murder. And yes, even after years of service doctors will never get official cars, big homes, servants and protocol.

Another personal anecdote is worth mentioning. In 2004 just before I took over as the professor and head of department of cardiac surgery in King Edward Medical College I was asked to ‘present’ myself to the health secretary of the government of the Punjab. The ‘gentleman’ behind the desk said to me, “Doctor Sahib you have just come from America and I am sure you will return to America in six months”. Ironically, I served for almost seven years in KEMC/KEMU and during those seven years I saw about ten or so health secretaries come and go. There were a couple that did not even last a few weeks in that position!

I have nothing against all the decent and hard working bureaucrats. Many of them try to do the best they can often under extremely difficult circumstances. The problem is that in specialised departments like medicine, by the time a non-medical head of the Health Department gets some idea about how things work, he or she is replaced or transferred.

Interestingly, there are two separate parts of the healthcare bureaucracy and rural healthcare essentially is under the control of the Directorate of Health, government of the Punjab. And the Directorate of Health is headed by a doctor but unfortunately members of the permanent healthcare bureaucracy do not belong to the elite civil services and so do not have the panache or the connections to run their departments effectively. They are always under pressure from Health Department bureaucrats and politicians to make decisions about appointments and financial allocations.

And that brings me back to where I started from. The appointments in RHCs in Gujranwala are an important first. Over the last five years, the government of the Punjab has concentrated on building high profile medical institutes and medical colleges. But now hopefully the government has realised that strengthening the RHCs is more important. After all close to 70 per cent of the population of Punjab lives in rural areas and receives medical care from RHCs and the Basic Health Units (BHUs).

A quick primer albeit not complete about the RHC/BHU scenario is in order. There are over 400 RHCs in the Punjab. Each RHC has an ‘approved’ staff of at least four physicians, one dentist and about ten ancillary staff. Each RHC has anywhere between five and ten BHUs attached that have at least one physician and about four ancillary staff. Essentially, every ‘union council’ has one BHU. Besides the RHCs and BHUs, there are also Tehsil and District Hospitals and of course divisional medical centres.

Interestingly, all the RHCs were built in or around 1962 with USAID financing and no new RHCs have been built since then. That said, clearly there already exists an infrastructure that if developed and made fully functional can play an important role in provision of basic healthcare where it is needed the most and that is at the village level. Unfortunately, this system has been neglected over the last many decades. Of all the existing RHCs, most ‘educated’ estimates suggest that roughly a third do not work at all, a third work partially and only a third work properly and at full capacity.

In the ones that do not work at all, often the physicians and their staff just don’t come to work but collect a salary. Of the ones that only work partially, it is often that a full staff, medical supplies and adequate equipment is not available. For instance a dentist cannot work without a functional dental chair, or physicians cannot perform minor operations or emergency surgical procedures like appendectomies or caesarean sections without working anaesthesia machines, anaesthetic medicines and appropriate operating room staff. And of course laboratories that provide basic blood tests, blood banking, X-Rays and ultrasounds among others are often just not available.

The BHUs provide basic ‘preventive care’. This includes immunisation, pre and post-natal care, nutritional support and education about ‘hygiene’. Clearly, the BHU is the first line of defence and the RHC the backup as far as primary healthcare and preventive healthcare are concerned. If these two can be made fully functional then besides improving basic health the pressure on regional medical centres and the tertiary care centres will be diminished.

I have said this before and I will repeat it most emphatically, instead of building big and expensive medical edifices for personal aggrandizement, it is definitely better to strengthen the RHC/BHU system and develop the Tehsil and District level hospitals to provide much of the relatively advanced medical care that, at present, is only available in big city medical centres.