After writing about how bad things are in public sector hospitals for two consecutive articles even I started to feel a little depressed. So I decided to write about something else for a change. And, if possible, at least something a bit less depressing. Rather than writing about what we don’t have or don’t do well I can mention some of the things that are indeed better.

The broadest measure of improvement in health for any country is the life expectancy of its people. When I graduated medical college, life expectancy in Pakistan was between 55 and 60 years. More than 40 years later it has gone up by almost 10 years. In most developed countries, life expectancy is now approaching almost 80 years. So there has been significant improvement in Pakistan though much more needs to be done.

The basic criteria to measure healthcare are availability, accessibility, quality and cost. Compared to how things were a few decades ago, availability and access has improved considerably. This is mostly due to the availability of motorised transportation and larger number of medical ‘professionals’ presence in many rural areas. The quality of care is, however, quite spotty and variable. The cost factor depends on whether medical help is sought in the private or the public sector. At present better care is probably available in the private sector but at a higher cost.

Much of the medical care available in rural as well as semi-urban areas is from nontraditional practitioners. These include healthcare providers that practice ‘Unani’ (Greek) medicine or Homeopathy. However, a major source of healthcare in many areas is people that might have been trained as nurses, pharmacists, lady health visitors or some that have worked in a hospital environment and picked up some basic medical knowledge. I strongly believe that this group of people should be absorbed in the formal healthcare system after being provided regular medical education at periodic intervals.

As we look at the development of medicine, a lot more is available in terms of advanced medical care than was there even a few decades ago. Latest diagnostic as well as methods of treatment of most diseases are now available at many urban and regional medical centres. Latest treatment for cancers and heart disease are now being provided in public as well as private hospitals. Basic investigations like X-Rays and blood tests are now available in many semi-urban areas. Most district hospitals can provide surgical and medical treatment for most diseases.

For my specialty at least I believe that district level hospitals and all teaching hospitals should provide basic cardiac treatments including angioplasty/stenting and open heart surgery. Development of regional cardiac centres is redundant and is definitely not cost effective. The excessive rush in tertiary care centres as well as specialised centres can be diminished by decentralising many of the advanced services. Even so most of these services are now available in public sector hospitals where the cost factor is often mitigated through government subsidies and philanthropic contributions.

Most public sector hospitals are capable of providing heavily subsidised care if the provincial governments are willing to use modern administrative methods. For almost five years of my stay at Mayo Hospital in Lahore, we were able to provide all sorts of major heart surgery at virtually no cost to the patients. This was done through proper utilisation of existing budgets and cost cutting where possible. And yes, a stricter inventory control to decrease the possibility of pilferage was also necessary.

Here perhaps an interesting anecdote is appropriate. When I arrived in the US some 45 years ago after having done my house job in Pakistan where I was ‘trained’ to use a surgical suture (thread) more than once. During my early years in America when I tried to do that, my consultant surgeons would laugh at me and say, America is a rich country, we don’t have to use the same suture twice. By the time I left America 35 years later, we had started using the same suture twice to cut medical costs in our hospitals. The point is that many costs can be cut without hurting the quality of medical care.

Also, I have been pretty harsh about the quality of doctors we are producing and the way we are training them. The rapid expansion of public and private medical colleges and the excessive increase in the number of seats available in existing medical colleges has severely stressed the quality of teaching. A simple example. The largest lecture theatres in King Edward Medical College/University (KE) have a maximum seating capacity of about 150 students. Presently, the average KE class has almost 300 students. I suppose even bureaucrats and politicians can figure out the effect this mismatch between capacity and the number of students has on the quality of medical education.

Most applicants for medical college are high achieving students. After they finish their medical education they fall into three basic categories. First are the top students that come out of the system with a more than adequate education, even though most of them are essentially self-taught. The second category is of those that were never really motivated to become doctors and went to medical college due to family pressure. Being high achievers they also end up graduating. Some of these do go on to become excellent doctors if and when they find an area of medicine that really interests them. Even if I say so, I fell into the second category 50 years ago.

The third category is the most problematic. That is of the women graduates. A medical degree evidently improves a woman’s chance for a better marital match. Presently two thirds of all medical students are young women and half of them will never practice medicine after they graduate and get married. For all practical purposes one third of the graduating doctors will be lost to the profession. This creates a shortage of doctors that are available to fill positions in public sector hospitals. Here I must add that I strongly support the right of women to get an education at all levels. And even if these women doctors never go into practice, their medical knowledge benefits their nuclear and extended families and even their overall communities.

As the next general election comes up there is now a palpable political need to expand the development portfolio beyond transportation projects. This will hopefully benefit the health and education sectors. Of course, the need to spend money on high visibility projects will be irresistible, but it is more important to improve and add to the existing infrastructure. There already exists a province wide medical infrastructure starting from the Basic Health Units all the way up to the major teaching hospitals. These are what need to be improved upon.

Finally, much is better than it was even a few decades ago. The private sector in major cities is thriving and is providing ‘state of the art’ medical care for most problems. The public sector is lagging and threatens to fall apart unless it receives appropriate attention.