The fate of devolution of administrative and financial autonomy to public sector teaching hospitals, envisaged under the Medical Teaching Institutions Act (MTI Act) is hinged on a departure from, or replication of, “autonomy for the sake of autonomy” introduced earlier during Gen Pervez Musharraf’s regime.

In a debate on MTI reforms during the third Universal Healthcare and Education Symposium, organised online by King Edward Medical College Alumni Association of the United Kingdom (KEMCA-UK) in collaboration with the King Edward Medical University (KEMU), the proponents and opponents of healthcare reforms agreed on the desirability of devolution of administrative and financial autonomy to hospitals. However, they locked horns privatisation of hospitals, free treatment for patients, accountability of healthcare providers and institution-based practice (IBP).

The debate on MTI reforms at an academic forum could not have been held at a better time. The government is all set to enforce the Medical Teaching Institutions (Reforms) Act 2019 in the Punjab notwithstanding the controversies that followed the implementation of the package in Khyber Pakhtunkhwa. In Punjab, the Pakistan Medical Association (PMA) and the Young Doctors Association (YDA) have already vowed to oppose the reforms tooth and nail.

Dr Aasim Yusuf and Dr Obaidullah’s presentations on Health Reform in KP, focusing on structure, legislation and implementation and impact on personnel and service delivery, respectively, set the tone before Dr Faisal Sultan, the special assistant to prime minister on national health services, and Dr Ashraf Nizami, the Pakistan Medical Association-Lahore chapter president, engaged in a debate on the controversial legislation.

Calling the reform package counterproductive, Dr Nizami contended that the end users will be at a disadvantage under the new system as there is no guarantee of free treatment unlike the current arrangement in the Punjab.

“If there are shortcomings in service delivery, the government should not expect more value with less funds,” he said. He said Rs 284 billion was allocated in the Punjab for 60,387 hospital beds, Rs 139 billion in Sindh for 38,600 beds and Rs 124 billion in KPK for its public hospitals. In comparison, Shaukat Khanum Memorial Cancer Hospital has Rs 17 billion at its disposal to manage 195 beds.

He suggested that it is only prudent for the government to correct its policies and rectify the administrative flaws rather than blame the healthcare providers for lack of service delivery or allege negligence.

Rejecting “change for the sake of change”, he said, Pervez Musharraf had also given autonomy to hospitals in the Punjab but the ‘reform’ proved a failure. “At least nine institutions in the Punjab are functioning under boards of governors (BoGs) or boards of management (BoMs) but there has been hardly any improvement in service delivery,” he added.

Had the MTI reforms in KPK been as effective as was claimed, he said, there would be no need for patients to pay Rs 20 an hour for a wheelchair and patients would not be dying at teaching hospitals in Peshawar for lack of oxygen supply. He added that many health professionals had left their jobs at teaching hospitals in KPK.

Article 23 Clause 8 of the MTI ACT provides for institution-based private practice (IBP). Medical specialists are thus required to help raise funds to help the institution attain self-sufficiency. Dr Nizami said this was a move towards privatisation. “The PMA will resist privatisation of hospitals as it did in the past,” he said. However, he said, he supported administrative and financial autonomy for the institutions.

SAPM Dr Faisal Sultan lashed out at critics of the MTI reforms, calling them dishonest for suggesting that the hospitals will be privatised. He said MTI reforms envisaged fundamental changes in governance and management structures. A single-line budget and institution-based practice, he said, would improve the delivery of quality healthcare services to the end users, i.e., the patients. “The treatment for patients who are unable to pay for it, will remain free under the criteria set by the board and the government,” he added.

“The boards of governors, comprising experts from the private sector, will manage the affairs at the institutional level. This will eliminate the role of the secretariat. However, they will remain accountable to the government,” he added.

Dr Sultan said at the Khyber Teaching Hospital, where he served as BoG chairman, the MTI reforms had resulted in an 18 percent increase in the number of outpatients attended from 1,139,253 to 1,347,499. He said there was a substantial increase in the number of out-patients attended in the morning from 496,026 to 633,886. Additionally, 115,779 patients were examined in the evening and 37,761 at night. He said 19,000 patients were treated between February and December 2017 and another 14,454 from January to April 2018 under the IBP arrangement. He said the casualty patient numbers had gone down from 643,227 to 561,073 as more patients were referred to non-casualty departments.

In the past, he said, the OPDs had been crowded in the morning and deserted in the evening. “Government properties thus remain under-utilised for a number of hours everyday… no private owner would waste resource like that,” he said.

At KTH, he said, there used to be two patients to a bed in some parts of the hospital and empty beds in other parts. “Now, no patients are lying on the floor despite a 95 percent occupancy in hospital,” he said. Similarly, he said, the operation theatres and diagnostic services, which used to function till 2 pm previously, were now available all day. The availability of teaching and technical staff had also gone up to 14 hours a day.

Dr Sultan said while worker satisfaction was vital the consideration for job security must not be above the concern for accountability. “Having said that, the number of employees sacked during my four-year tenure at KTH can be counted on fingers. Yet the accountability ensured better output,” he said. He said government servants could choose to remain in government service or opt to work for the MTI. Similarly, he said, the current healthcare professionals may or may not opt for IBP although new employees will be required to do so. “The IBP offers incentives to healthcare professionals as well as safeguards. It benefits the patients,” he said.

Dr Sultan also proposed setting up of a Patient Quality and Safety Department at the institutional level to redress complaints.

The writer is a reporter at The News. He is based in Lahore