When it comes to healthcare, the important things are availability, access, quality of care, and cost. In the Punjab, we have a pretty reasonable network of Basic Health Units (BHU), Rural Health Centres (RHC) and hospitals of increasing size in towns and cities that are headquarters of the different administrative units like tehsil, district and division, and then the teaching hospitals in major cities. Besides these the government also runs specialised cardiac centres and is planning to build a kidney and liver transplant centre. So, all told with all these centres, availability of medical care should not be a problem.

As far as access is concerned that has also improved considerably. Almost every village has some form of motorised vehicular transport available. However, it might be worthwhile if ambulance services in the public sector connect the different parts of this healthcare network, especially the RHC and the local hospital. As a matter of fact, the Punjab government invested heavily in ‘mobile hospitals’ a few years ago, these were really just well equipped ambulances. Whatever became of them I wonder?

As far as the rural and semi urban healthcare system is concerned, one third of the system that includes BHU, RHC and smaller hospitals is well staffed and equipped and is providing adequate care. One third is inadequately staffed and equipped and is providing inadequate care. A third is entirely non-functional. It is quite possible that my numbers might be off but the Punjab government’s attempts to ‘privatise’ rural healthcare does suggest that things are not going too well as far as public sector healthcare is concerned.

Clearly the first step to fix the quality of healthcare is to fix the medical centres that are offering basic services. Unfortunately, politics comes in at this point. The question arises whether healthcare is a right and the government should provide adequate healthcare to all citizens free of cost. Centre right parties like the Pakistan Muslim League-Nawaz (PML-N) that is in power in the Punjab believe that healthcare is not a right but a privilege. And under an Islamic ideation the party in power also believes that charity is the answer to those that cannot afford the cost of healthcare.

So, any discussion about how to improve the public sector system of healthcare must first posit that the government of the province actually wants to do that. That is a major problem. Much advice can be given, has been given and will be given but will inevitably be ignored. Pakistan is a poor country and the provincial budget just does not have enough in it to support the politically desirable mega projects as well as the badly needed improvement in healthcare. It is for this reason we hear a lot of noise about healthcare but see little action. Yes, some improvements will happen along the periphery but the primary problems will be ignored. And no, privatisation is not the answer.

Those of us that want to see the public sector healthcare system improve have to accept the present political reality and see what can be done within available financial support. Major changes will have to be made and for that political support is necessary. We have to cut out the waste and corruption, and we have to alter our priorities and change the emphasis from curative to preventive health. An ‘ounce of prevention’ etc.

What then can be done? First of course is to look at the different RHC/BHU and smaller hospitals to see which of them are working well and which ones exist only on paper. As I pointed out earlier, if almost a third of these medical facilities is non functional then these should be closed down. The money saved from that can be directed towards those facilities that are functioning below par and all these facilities should be upgraded with full staffing and all the basic medical support systems needed to make them properly functional. This is perhaps the most difficult step since the money earmarked for these ‘ghost’ facilities provides compensation up and down the food chain in the bureaucracies involved.

The second point about waste and corruption involves two areas. First the so called ‘disposable’ supplies that include everything from needles, injection syringes, all the way up to things like operation theatre supplies and laboratory reagents and equipment. The second area is of the medicines used. Very often medicines acquired are much more expensive than others that are equally effective but cost much less. Even though the law requires that the least expensive item used for the same purpose should be bought but that does not happen since two medicines that perform the same function can have two different names and chemical formulas, so they are not comparable!

Here a personal anecdote is worth presenting. During my time in Mayo Hospital, I tried very hard to get the hospital pharmacy to store Morphine as a pain killer for patients that just had heart surgery. Most of my attempts were unsuccessful. When I tried to figure out why, the real reason I found out was that a Morphine injection cost only a few rupees while the pain medicines being regularly used even though much less effective cost twenty to fifty times more. As the person explaining to me said, doctor sahib, there is no ‘margin’ in buying cheap medicines like Morphine. The official reason given was of course that Morphine was addictive and hospital staff would misuse it or steal it to sell to addicts on the ‘street’. So, proper monitoring of disposables and drugs being bought can cut down on expenses quite markedly.

A major problem in the rural and the small city hospitals is that of insufficient medical and other professional staff. Here again two factors are of importance. First is the remuneration available to physicians for working in public sector hospitals. This is pathetic. So most physicians prefer to work in the private sector or get a position in government hospitals but spend most of their time and effort on private practice. Unless incomes are brought up to a level that is commensurate with level of education, doctors will not work in the public sector at least not wholeheartedly.

The second factor is that many physicians especially women are afraid to work in rural and semi urban areas for security reasons. Also for physicians with families, inadequate educational facilities for children are also a major concern.

Innovative methods of incorporating private practice with public hospital work need to be done. Here local private-public partnerships and on the premises private practice should be considered. Another way to fill physician positions is by providing ‘honorary’ positions to outside physicians from the local area that can spend a day every week in the public hospital environment as a gesture of public service.

The aim should be to provide basic medical care to all citizens essentially free of cost. For advanced care, the larger hospitals are available. How care can be improved in these mega institutions is a topic for another day.