Improving the quality of care available to the rural and semi rural population in the Punjab has finally found traction with the Pakistan Muslim League-Nawaz (PML-N) government that has run the province for more than seven years. Upgrading basic health units (BHUs), rural health centres (RHCs) and the tehsil-district level hospitals is necessary to assure proper and accessible healthcare for a majority of the population of this province.

The provision of relatively advanced healthcare at the tehsil-district hospital will require a real devolution of healthcare from the central to the local level. My purpose today is not to talk of the improvement at the BHU and the RHC level but rather slightly further up in the healthcare chain. As medical science has advanced, there was a tendency to centralise medical care. At a time when adequately trained physicians and appropriately equipped and staffed hospitals were only available in major urban centres, centralisation made sense. Unfortunately, the Punjab government is still stuck in the centralisation mode for many important medical conditions even though such centralisation is not only unnecessary but is actually counterproductive.

Heart centres, transplant centres, cancer hospitals, and children’s hospitals are all on the drawing boards and will require major financial investment even though many of these centres might not even be needed. Before I paint them all with the same brush, I want to make a few things clear. There are some problems that still need to be treated at specialised centres, the reason being that the medical expertise required, the technology and the level of ancillary care needed are only available at specialised centres. But most of such advanced and specialised centres should be associated with and be an extension of existing teaching hospitals. Freestanding single medical specialty centres are an anachronism.

Let us just consider specialised hospitals for children. Of course, these make tremendous sense ‘on paper’ but objectively speaking we have to consider what sort of medical problems we need to take care of. Obviously, a simple sore throat, a runny tummy or things like measles and chicken pox can easily be treated in regular hospitals and even in doctor’s clinics. But we do need some special treatment for problems of the newly born (neonates). These have to be treated where the baby is born and therefore neonatal centres have to be developed right next to maternity hospitals. Also, developing children’s hospitals that have extensive capabilities to treat childhood cancers and building separate, stand alone cancer centres at the same time is definitely redundant.

As it is, most of our major teaching hospitals already have well-equipped department for children’s diseases that include specialised surgery for children. Lahore for instance has a number of such teaching hospitals in existence. Instead of building more freestanding specialised children’s hospitals, the existing paediatric departments in teaching hospitals should be strengthened. More importantly adequately trained staff should be made available all the way down at the tehsil level so that most sick children can be taken care and if diagnosed with conditions that require advanced care they can then be rapidly referred before they become too sick. Two important examples come to mind. Childhood cancers and inherited heart problems. In both of these types of conditions, early diagnosis at a ‘local’ hospital and subsequent referral to an advanced centre can be lifesaving.

Before I discuss some of the stuff that should be done further down the medical chain, let me make an important observation. Major specialised medical centres are very popular with two types of people. The doctors that will run and profit from them and the politicians that will get to have their names put on the ‘foundation stones’. As I have said above, there was a time when it was necessary to have specialised centres because the medical expertise and the technology was not generally available but things have changed for many specialities. Cardiology catheter procedures and heart surgery for instance are being done in what are no more than ‘two room hospitals’ in Lahore. Clearly these procedures can then also be done in a properly equipped tehsil or district hospital.

And that brings up one of my pet peeves. It is indeed extremely unfortunate that the first medical college built after partition in the Punjab, Nishtar Medical College, even today does not have an adequate cardiology or cardiac surgical department while a freestanding ‘Pervaiz Elahi Institute of Cardiology’ is flourishing across the street and is reportedly going to be expanded. The same is true of medical colleges in Faisalabad and even Rawalpindi. So two things need to be done as far as cardiac care is concerned, it must be decentralised and second instead of building freestanding cardiac institutes, cardiac departments in existing teaching hospitals should be upgraded and expanded.

Now, I do know a bit about cardiac medicine and surgery and I strongly believe that most district level hospitals can and should have basic cardiac facilities including cardiac catheterisation laboratories capable of performing diagnostic procedures as well as stent implantations. Considering the fact that the best treatment for a heart attack today is early catheterisation and appropriate catheter based treatment (PCI), having such facilities widely available is not only good for the ordinary public but even for ‘very important people’ that might develop heart attacks while visiting their village homes. And of course basic heart surgical procedures can also be performed at such institutions.

Essentially any hospital where major abdominal surgery is being performed can easily be upgraded to perform cardiac surgery as long as a cardiology department with catheterisation capability is also functional on the same premises. One of the major advantages of decentralising cardiac care is that the pressure on the existing cardiac institutes will be relieved. And the existing specialised centres can then do what they should have been doing all along, training physicians and performing important academic functions.

Besides cardiac care, primary paediatric medicine and surgery, diagnosis and basic treatment of most cancers especially those at an early stage can also be managed at the tehsil or district hospitals and there is no reason why ‘chemotherapy’ cannot be available at a tehsil or district hospital. The important question that will need to be confronted is the cost of such devolution. The problem is not just of providing the infrastructure but also attracting appropriately trained staff to work in such places. In essence, it comes down to how these doctors will get paid. Well they will get paid the same way as other doctors working in these hospitals get paid. But that might need some reworking at all levels.

One of the much talked about option is of the so-called public-private partnerships. This should not mean that the government-owned hospitals are turned over to private entities to run. That in my opinion will be catastrophic. But once local government structures are in place then these hospitals can be run and supported through public-private collaboration. As I mentioned above, even the local VIPs wouldn’t mind having to avoid a dangerous hundred kilometre trip if they have a heart attack in the middle of the night.