It is too early to say if there is anything on the table that will improve healthcare in Pakistan. So far it seems as if a scattershot approach is being adopted. Healthcare for more than a hundred million people in the Punjab alone is a major undertaking and cannot be fixed overnight.

An important point to remember is that the profusion of private hospitals is a response to the slow and steady decline in the quality of medical care available in the public sector. The situation at present is that real healthcare that is truly free or almost free for all comers is virtually non-existent especially when we go to semi-urban and rural health providers.

As a consequence those that have some money seek care in private ‘for profit’ hospitals or ‘trust’ hospitals that are mostly fee for service. And those that are at the bottom of the financial ladder end up searching for some help in state-run hospitals and after being disappointed end up going to non-qualified healthcare workers (quacks).

Everybody it seems is getting into the act of improving healthcare. However, it is important to remember that healthcare is a provincial subject. Ultimately it will be the government of the Punjab that will institute, maintain and run the public healthcare system in the province. And it is also a matter of political will that will initiate and fund any major improvements.

Before I discuss the public healthcare system, I do want to talk a bit about the privately run ‘fee for service’ hospitals and clinics. The private sector has a very important place in the overall healthcare system. Any attempt to control these private institutions beyond quality control efforts is not going to be successful.

If we start limiting what remuneration an individual physician or a hospital can charge a private patient then should we not also start limiting what a lawyer or an accountant or an architect or any other professional can charge a client?

The only way to limit what hospitals or physicians or for that matter any professionals can charge their clients is by assuring adequate competition. If in a city like Lahore you have five first rate hospitals in the public or private sector offering similar quality service, barring collusion you will soon see a decrease in their monetary charges.

The other way to bring down prices is to have a ‘third party’ (insurance) system of payments for medical care. When two competing businesses start negotiating prices then we also see a moderation in the prices being charged. In any case having the government set prices for services offered by private individuals is against the very concept of free market. Any such restriction will probably be overturned by the superior courts.

As long as there is income inequality there will be multiple tier systems of healthcare. The rich will always want a personalised and high quality care as well as an enhanced medical environment and they will get it as long as they are willing to pay for it.

What is needed is a medical care system that is either almost free or at least affordable for most people. During my years of practice both in the United States as well in Pakistan, I have seen many middle and lower middle class families driven into poverty due to the cost of medical care. And as far the poor in Pakistan are concerned, they are lucky if they even get to see a real doctor and get some appropriate care.

In my opinion it is a waste of time to try and correct too many things at one time. The primary aim should be to provide a good quality care to all comers at a reasonable cost and for the indigent at no cost. That can only be accomplished through the public-run health system. Most charity hospitals or trust hospitals do not provide free care except for the ‘poor’. And often the requirements to prove poverty are quite humiliating.

Ten years ago when my department in Mayo Hospital was providing free open heart surgery, I was often asked about my criterion for accepting patients for free surgery. My answer was simple. Any patient willing to be admitted to the general ward is, as far as I am concerned, deserving of free care. In essence, all patients willing to be treated like everybody else deserve the same treatment.

What needs to be done initially is to strengthen the rural healthcare system that includes the Basic Health Unit (BHU), the Rural Health Centre (RHC) and the Tehsil Headquarter Hospitals (THQ). Let us concentrate on these first. Adequate staffing, equipment, medicines and laboratory resources should be made available for them.

The first requirement is enough well-trained doctors, nurses, lady health visitors, and ancillary medical and laboratory staff. For this a proper service structure must be created. This must include a living wage, subsidised residential facilities, security, transportation, options for continued medical education (CME) and regular promotions based on performance and further education.

Once such a system has been developed then its functioning must be given to local governments that can then expand these facilities and improve them based upon local needs and resources. Of course, the larger medical facilities must also provide specialised care so that rural patients do not have to travel to urban hospitals for such care. Such decentralisation of care will also relieve the extreme pressure being faced by our specialised medical centres and teaching hospitals.

When I mentioned ‘well trained’ doctors and other staff, our teaching hospitals will have to collaborate with the College of Physician and Surgeons of Pakistan (CPSP) to develop a subspecialty in medicine that is aimed to staff our rural medical centres. As a part of qualification in such a specialty, extended periods of time must be spent by trainee physicians in these rural centres under the guidance of well-trained specialists. The same obviously is true of the ancillary medical staff. Working in an urban environment is different from what sort of medicine is practiced in rural areas.

Recently there has been some action, at least in a verbal fashion about population growth and birth control. All those high sounding ideas can only be translated into a functioning reality through a competent and functioning rural healthcare system. More importantly Pakistan’s dismal record concerning mothers and children that die during childbirth can be addressed by improved local healthcare.

In summary, the first step in the improvement of healthcare for ordinary people is to first concentrate on rural healthcare. That of course does not mean that larger hospitals should be ignored completely. But most of them are already well staffed and well equipped need administrative improvement to make them function better.

Finally, instead of closing down all non-formal medical practitioners (quacks), let us separate those with some medical related education from those that have never had any medical training at all. Let us register them and provide them with further medical training so that they can at least provide some basic medical care. Barefoot doctors?