The King Edward Alumni Association of the UK has been holding an annual symposium on Universal Healthcare Access, with the help of the King Edward Medical University. We had our third symposium on December 20. We consider free or affordable access to healthcare and education a basic human right and a duty that the state and the society owe to the citizens. There is a need for healthcare professionals and health economists to bring their policy deliberations and arguments to the public and to put health and education on the political agenda.

The most important recent step in this direction has been the Sehat Card scheme for in-patient care. It is now available to all families in the Khyber Pakhtunkhwa province and is being implemented in the Punjab. It has an insurance-based funding model. The government enters into a contract with insurance companies on behalf of the citizens who don’t pay for services. The providers of healthcare, can be private facilities and they bill the insurance companies for reimbursement.

The advantage of this arrangement is that the healthcare infrastructure in private setups can be mobilised and the state does not have to make large capital investments at the outset. The disadvantage is that regulatory framework is difficult and costly to establish and currently does not exist in Pakistan. When health care providers are paid on the basis of interventions and not outcomes, they have an incentive to do interventions, regardless of the patient’s needs and best interest.

This model is the basis of healthcare in Canada, in the Medicare and Medicaid schemes in the US and more recently and quite successfully in Turkey. The state insurance in India has not been so successful, due to the rudimentary nature of regulatory capacity.

In the KP province, the PTI government had introduced health administrative reforms, starting in 2013, initially in the Medical Teaching Institutions. This came to be called the MTI Act. The main planks of this reform were financial and budgetary autonomy, the appointment of a dean for the medical college who was also the chief executive of the hospital and answerable to a board of governors. The job contracts of the employees changed as the MTI was given more control over the workforce with certain safeguards with regards to the accrued benefits. The consultants were asked to do their private practice within the institution or opt out with some loss of privileges. The workforce part of the legislation turned out to be controversial and led to prolonged and painful industrial action in the KP and the Punjab.

The system however seems to be entrenched in the KP after overcoming some of the legal challenges. There is a likelihood that over time if will improve healthcare delivery and accountability. There is a strong need for an independent, systematic and detailed appraisal of these reforms.

There is further legislation in the pipeline in the two provinces to devolve healthcare to districts and tehsils to make it more responsive to local needs. It is based on the same principles of administrative and financial autonomy, local decision making and accountability.

The infrastructure development in the Punjab, as outlined by Dr Yasmin Rashid in our previous meetings includes healthcare insurance in all 36 districts of the Punjab and building of 200 bedded mother and child hospitals in Lahore, Attock, Mianwali, Layyah, Bahawalnagar and Rajanpur. Nursing colleges will also be built alongside these hospitals. All the Basic Health Units in the Punjab are intended to be accessible round the clock by 2023. The introduction of the MTI Act and establishment of the regional and district health authorities in the Punjab are on the way. The infrastructure projects still awaiting completion are the endoscopy diagnosis and treatment centres and regular transplant facilities at the Punjab Kidney and Liver institute (PKLI).

The Sindh province has invested large amounts of funds in the National Institute of Cardiovascular Diseases (NICVD) and the Gambat Institute of Medical Sciences (GIMS), Gambat in Khairpur district. The GIMS is the only successful public sector centre for liver transplant in Pakistan, to date. The paradigm for employment of the medical staff in the NICVD is unique in that they pay market rates to their specialists and financial incentives to their workforce. This has resulted in the NICVD performing the highest number of primary PCIs, (coronary stents on an emergency basis after a heart attack), per day, in the world. They have also set up satellite centres in other cities for treatment of heart attacks, thus covering all the major population centres. It would be interesting to do a cost effectiveness study on the quality adjusted life years (QUALYS), gained by the patients treated.

Pakistan has dealt with the Covid epidemic quite well, although the second wave is posing new challenges. There has been a ‘Corona dividend’ in the establishment of a national coordination effort in the form of the NCOC, establishment of diagnostics, data collection, transmission and analysis. This capacity can be a legacy to make use of once the pandemic is over, for example to deal with the WHO Hepatitis C eradication target by 2030.

There have been new indigenous medical technologies developed, especially by the National University of Science and Technology (NUST). Telemedicine facilities have taken off in many places. Pakistan seems to have a good Covid vaccination plan.

The role of decision making informed by data cannot be over emphasised. There should be close interaction between the government and some outstanding non-government bodies such as Centre of Economic Research in Pakistan (CERP). The state has some excellent resources, such as the NADRA, the Pakistan Bureau of Statistics (PBS) and the Punjab Information Technology Board (PITB).

The media have a very important role to play. They should be asking the policy makers the right questions and holding them to account. They should keep the health agenda in public view. The medical establishment needs to open up to public scrutiny. As an example, publishing the data of the intensive care outcomes of the Covid patients could be a good start. The information asymmetry between the healthcare providers and the patient needs to be corrected.

Those most in need don’t have a voice. We all need to speak up for them. We need informed activism for health.

Epilogue

Project ECHO is an international organisation doing very valuable work in teaching community physicians, skills that are normally the domain of specialists. They have done valuable work in Pakistan.

The pandemic has given a tremendous boost to online teaching for doctors. A couple of Pakistani gastroenterologists are running, perhaps the world’s best teaching programme on line on ERCP and EUS, two specialist endoscopy techniques.

For an overview of the healthcare provision in Pakistan, the book, Choked Pipes by Sania Nishtar is a must read.

The author is the Universal Healthcare Programme Director of the King Edward Alumni Association, UK and a consultant gastroenterologist at Queen Elizabeth Hospital, Gateshead, UK