Elections are done with and by the time this article is printed, new governments will most likely be in place at the centre and in the provinces. Now hopefully healthcare will get the attention it deserves.

Over the last few decades healthcare has become an important part of what is generally referred to as the ‘safety net’. These are basic services that should be available to all citizens. In essence no civilised society can accept amongst other things that people die because they cannot afford treatment for medical problems.

Before I go on to discuss the concepts of healthcare, I want to make one assertion. I strongly believe that ‘affordable’ healthcare is a right and not a privilege. Affordable means essentially ‘free’ for those that are too poor to pay for even the most basic medical care.

Personally, I do not have an opinion on whether ‘State Owned Enterprises’ (SOES) like the Steel Mill or PIA should be privatised, but I do believe that the large network of publically owned and run medical facilities from basic health units (BHUs) all the way up to the tertiary care teaching hospitals and the specialised care institutes should remain in the public sector.

Having served in a major public sector teaching hospital for more than six years, I can say based on my personal experience that it is indeed possible to provide virtually free medical care including major open heart surgery to those that could never afford such care in the private sector.

At least in the Punjab there exists a partially functioning network of rural and urban health centres that has been in place. The Pakistan Muslim League-Nawaz government in the Punjab made some attempts to privatise it but that did not quite work out. It is imperative that this system is strengthened and kept in the public sector.

A few years ago I asked a senior medical bureaucrat about this system, especially the BHUs and the rural health centres (RHCs). His response was that a third are non-functional, a third are partially functional and a third are fully functional. Whether correct or not, it is imperative that all these should be made fully functional.

However to make this entire network function as it was originally planned, a few things will need to change. First of course is that all these centres going up to the tehsil level should be fully staffed and appropriately equipped.

The important thing to remember is that when originally planned these rural centres were not really expected to provide all the services that are considered necessary even at the basic level in the modern medical environment.

Today besides X-Rays, basic blood tests and ultrasound and echocardiography capabilities must be available in RHCs if not the BHUs. And of course it needs technicians that can perform these tests and physicians that can interpret them. Also capability for emergency surgical procedures is also needed.

Today I want to address the general rather than the specific requirements. First requirement in my opinion is that the entire public sector medical system up to the tehsil level should be devolved to local governments. The local elected officials are in the best position to make sure that the medical system works and fulfils the needs of their voters.

The second requirement is to develop a separate medical cadre for the non-teaching hospital medical environment. The old time generalists that just had an MBBS degree won’t do anymore. What are needed are doctors that have undergone at least two years of post-graduate training in different primary care branches of medicine. And yes they will have to be paid a living wage and will have to be provided appropriate housing, transportation and security.

The third requirement is a fully-trained ancillary medical staff. Nurses, pharmacists, lady health visitors, lab technicians and increasingly in this day and age people that can service and fix all the machinery that is used all make up an effective medical team.

When I mentioned ‘devolution’ above I also wanted to emphasise one particular point. Many treatment modalities that are being concentrated in specialised centres should be devolved. There will always be need for tertiary care centres for training of new ‘experts’ and for treatment of advanced and complicated medical problems.

However, treatment for much of heart disease can be devolved. If ‘stent’ procedures can be done in a four room ‘clinic’ in Lahore, they can definitely be done in district and divisional headquarter hospitals that have more than a hundred beds and all sorts of support facilities. The same is true of coronary bypass surgery.

Most importantly such devolution will cut down the rush at places like the Punjab Institute of Cardiology (PIC). As things stand, non-paying patients have waiting lists that stretch into years. If these procedures could be done at the ‘local’ hospitals, that would make things much easier for the patients.

And this brings me to an interesting problem about hiring and then keeping well trained physicians in this environment. The obvious answer to my question will be ‘money’. Indeed money is important but money is not everything.

Perhaps an example from my own family history might at least reflect the origins of my opinion in this matter. My late father attended the Glancy Medical School in Amritsar and came out in 1941 with a medical diploma (LSMF) that authorised him to practice medicine. He worked abroad after that but ten years later decided to return to Pakistan and obtain a medical degree (MBBS).

My father approached the principal of King Edward Medical College (KEMC) who told him that he should work in a rural area for two years before he could be admitted to KE.

My father went off to work in a rural ‘dispensary’ in the Punjab. In a matter of two years my father and mother developed a lucrative private practice besides their care for non-paying patients.

After two years my father was admitted to KEMC. As he was leaving that area, local landlords asked him to stay on. His response was, "I want my children to get a proper education, so I want to go to Lahore."

In the early period of their professional lives doctors will be attracted to opportunities that pay well and provide a good working environment. However, once they are married and have children they will start thinking about their long term future plans. So availability of educational facilities should also be considered.

Finally, the question that keeps coming up -- what about private practice? Some form of private practice will have to be built into the system. It should be an institutional private practice that is properly monitored to make sure that physicians are not transferring or charging patients that should receive free care.

To put it together, for today my major suggestions are to strengthen the public sector health care system, to transfer control of the rural and small town health facilities to the local governments and to develop a separate cadre of doctors for the non-tertiary care public healthcare system.

Over the next few months, I will present some thoughts that are more specific.

The author served as

professor and chairman,

department of cardiac

surgery, King Edward

Medical University