Can Pakistan Get its Resources Together to Provide Quality Universal Health Care?
Dr Nadir attended a Conference held in Rawalpindi and narrates the proceedings. This conference was held just before the Coronavirus emergency and its recommendations are even more relevant now.
A Perfect Day to Hold a Conference about Health Challenges and their Solutions in Pakistan
It was a perfect day on March 8 with the petrichor of rain left behind by the previous night’s downpour and the dark horizon brightened by the sun rays that had percolated through it. The atmosphere outside the Lateef auditorium of Rawalpindi Medical University (RMU) was electric with young doctors and students giving final touches to the collaborative conference of All Pakistani Physicians of North America (APPNA) and Higher Education Commission (HEC), Building Primary Care Capacity: Pakistan’s Critical Need.
The auditorium was filled to capacity and the conference began on time. Dr. Muhammad Umar, the Vice-Chancellor of RMU, with slick, straight and jet-black hair tightly combed down to his neck, was the first speaker invited to the stage. Clearly, he was a favourite in the auditorium as he received an enthusiastic welcome from the participants of the conference. Media was active with cameras constantly flashing and videographers anxiously moving in the auditorium with hand-held video cameras to capture every moment of the event from all possible angles.
Dr. Muhammad Umar, the Vice-Chancellor, Highlighted his Institution’s achievements:
Umar, a gastroenterologist by profession, reiterated the vision of Prime Minister Imran Khan to make Universal Health Care a real possibility in Pakistan. He heaped praise on RMU as the first medical school that has developed an integrated module of education, and the first hospital in the third world that introduced structured residency training for young physicians including first collaboration with Royal College of Medicine Foundation in the UK in emergency medicine training. The institution is providing primary, secondary and tertiary health care simultaneously with a free hepatitis program led by him as the leading gastroenterologist. We are training nurses, paramedics, phlebotomists, technologists, and other health care workers to fulfil the dire need of health care support services in Rawalpindi, he said.
Research is our emphasis, he highlighted, while showing the research wheel with eight spooks, all being active in RMU. Even basic research was emphasized and a research lab on the lines of National Institute of Health in USA was created in RMU with 1.5 billion rupees. Umar wished to implement HEC’s priorities of developing quality human resources and creating systems to bring about a quantum leap in the delivery of health care to the ordinary Pakistani citizens. He mentioned that while the Corona pandemic is a threat, his institution is working actively for the potential outbreak. RMU’s priority is patient first and despite delivering care to 3 million patients through 12 sub-specialty departments, throughout the history of the institute, safety has been remarkable. They procure good quality medications and aspire to run the institute in a flawless manner. He congratulated his students and colleagues who had migrated to the west but continued to contribute to the cause of their alma mater with passion and sincerity. Rawalpindi Medical City is in progress that will provide care for each specialty under one roof. Finishing his speech, he told the audience that the Family Medicine department was actively giving short courses for which certificates were awarded. He announced that a post for Assistant Professor of Family Medicine had been created and he hoped that HEC will contribute to the ongoing efforts of RMU.
Dr Tariq Banuri, Head of HEC, was Idealistic about his Vision for Higher Education Commission:
Dr. Tariq Banuri, the next speaker, completed his BE from Peshawar, following which he spent time in civil services in Pakistan and then went on to further his education in Williams College, UK and Harvard University, Massachusetts from where he received his PhD in Economics. Dr Banuri spent time in the United Nations and the state of Utah where he served as Professor, Department of City and Professional Planning at the University of Utah, before moving back to Pakistan as the Head of the HEC in June 2018.
L’Imagination Prend Le Pouvoir! (Imagination Usurps Power), read a placard widely publicized in 1968 from Paris. It caught his attention. He wanted to make a difference in Pakistan and Dr Naheed Usmani, current APPNA President as well as Health Minister Zafar Mirza were his contemporaries. With the current positions of authority, there is no other option for these people but to deliver in order to improve healthcare and education systems in Pakistan. He lauded the role of APPNA and Pakistani diaspora in the west who have helped uplift health care delivery in Pakistan. He was associated with Dr Naseem Ashraf and Dr Khalid Riyaz on the platform of APPNA Sehat, besides working for Human Development Foundation, another project of the APPNA physicians.
He strongly emphasized the need for the health care system to reach the ordinary people and make access to quality health care for every Pakistani citizen easier, a goal he was inspired to strive for while listening to a lecture by Dr Mahboob Ul-Haque, a noted Pakistani economist, in 1997. “Biggest challenge of health care is not the cure of illness; it is on the environmental and preventive side. Make water and environment safe for living”, he said. And while the access of health care to all is important, the need for the quality of care is tantamount for the system. “Increasing medical college seats led to poor quality education and the expansion of electricity to the rural areas led to load shedding”, he said. He felt Sehat and Ehsaas are good governmental programs, and strong family physicians with appropriate skill sets can help deliver these programs to the left-behind Pakistani citizens. He highlighted the importance of nurses and said that there should be no “caste system” in the health care industry as so many extremely educated people want to be nurses, and all health care providers are equally important. “Empower people to take care of their health, disseminate knowledge and improve people’s health using community nursing”, he said. He promised that HEC will support any high-quality programs in RMU or wherever HEC finds excellent performers.
Dr. Shahid Rafeeq, the Pakistani Physician of North America, Lauded for Making the Conference Possible
Dr. Shahid Rafeeq was the Chief organizer of APPNA for this event and he lauded all the parties and individuals who worked tirelessly to make this event happen. He stated that Dr. Banuri had been emphasising for two years on the need for family medicine to be the main theme for this event. He met Dr Nausherwan Burki, Imran Khan’s cousin, the implementer of the vision of Shaukat Khanum Hospital and adviser to the government on health policy, regarding holding of this conference and Dr Burki was very supportive. Dr Rafeeq quickly gave way for Dr Naheed Usmani, current APPNA President, to deliver her lecture.
Dr Naheed Usmani, The No-nonsense President of All Pakistani Physicians of North America (APPNA)
Dr Naheed Usmani has published 18 original papers, is currently on faculty of the University of Massachusetts and was part of Shaukat Khanum Memorial Hospital and Research Centre’s (SKMHRC) team for many years. She said, “I practice the daunting field of paediatric oncology as I am not afraid of taking challenges. Sri Lankan women live 12 years longer; their maternal mortality and vaccination rates are better; and the island nation puts a lot more resources on family planning, antenatal care, tobacco cessation, and sanitation compared to Pakistan”.
“In Pakistan, 70% of medical care is provided by the private sector, preventive efforts receive 4% of the budgetary allocation and most of the tertiary care is provided by large urban hospitals”.
She added, “Every hospital does not need to perform bone marrow transplantation, but all institutes should have a strong family practice department that focuses on improving the environment and prevention of illness.” She stressed the need for primary care, health promotion and disease prevention. “Every headache does not need to be seen by a neurosurgeon and all earaches don’t need ENT specialists. Family practitioners should be at the front for these complaints”. She further added, “Medical education can improve in Pakistan by meaningful engagement with Pakistani physician diaspora who can provide an online educational platform with recorded lectures available and the possibility of engagement with master trainers who can help create indigenous guidelines for our population.” As APPNA President she reiterated, “Let us know what you want and we will provide what we can, you need to just ask”. APPNA can help standardise coursework and certification throughout Pakistan in order to provide experience to allied health workers besides helping set up the Family Practice curriculum in medical schools.
Dr Faisal Sultan, CEO of Shaukat Khanum Hospital, was Poetic and Philosophical
Faisal Sultan is an infectious disease specialist, trained in the US. He has been with SKMHRC through thick and thin. He is serving as CEO at the institute for more than two decades. He mixed Urdu and English and quipped in rhythm while taking advantage of the homonyms in both languages, “I am APPNA and Paraya”; APPNA – your own in Urdu; but also, the physician organization – and Paraya – a foreigner – highlighting that he lived in his hometown Lahore barring only 6 of his 30-year professional life.
Sultan lamented the horrible health statistics in Pakistan and said that something needed to be done with a collective vision. As the member of Prime Minister’s task force on health, he reported that the task force is making policies and procedures, but the governance of institutions will be local. “There should be benchmarks for accountability, live dashboards need to be created to ensure administrators have access to accurate statistics so they are armed with data to know whether the desired goals are attained across time.” He tried to illustrate his point by the video game SimCity which has been around since the 1980s where a city with its entire infrastructure and administration can be created. “Let us make an integrated system from the Basic Health Unit (BHU) to Rural Health Centre (RHC) to the tertiary care institutions, just like the SimCity of health care.” He briefly explained, “Power in a few hands between health secretary and health minister is not a good idea, let us bring the action where people are and empower them.” He added, “The Punjab Local Government Act has been revised to ensure that there is local governance and citizens can run their own affairs.” That is why the new Medical Institution Act was promulgated by the Pakistan Tehreek-e-Insaf so that the institutions can be run by hospital administration, hospital board and there is coordination with the health secretary and the budget can be allocated properly and judiciously. “Each hospital board will have reputable doctors, ordinary citizens, a member of the provincial assembly and a nurse – yes, a nurse, we respect them and value their opinion.” He also said that districts will have their own boards as well with an administrative structure that will coordinate with district health officers to ensure that the emphasis is on quality improvement, health statistics, and good administration.
He was philosophical as well, “One final request: New things scare us, don’t look at things from the prism of self and let the nurses take their role in their hands. There is an acute shortage of nurses; we need one million of them and we just have 10,000. It will take a hundred years to train as many as we need so we need to think out of the box in order to train more nurses at a quick speed.”
Then he became poetic, “Aayen-e-Nau Se Darna, Tarz-e-Kuhan Pe Urna; Manzil Yehi Kathan Hai Qoumon Ki Zindagi Mein (To be afraid of the new ways, to insist on the old ones; this is the only difficult stage in the life of nations)”.
He closed his speech by saying, “Let’s do it together. The government has the desire and intention to do it right. I can’t even convince my two kids, but I am sure once citizens understand the sincerity and logic, they will embrace the new ideals of health care”.
Dr. Zafar Mirza, Health Minister of Pakistan, was Lucid and Calculated
Dr. Zafar Mirza was dressed in the traditional Pakistani salwar and tunic, while also donning a men’s coat; and used Urdu to communicate with the audience. He highlighted the government’s vision to provide quality, universal health care to all the citizens, without the monetary concerns. A Rawalpindi medical graduate, Zafar was delighted to be at his alma mater and echoed the views of his contemporary Dr Naheed Usmani another RMU graduate, about the poor health statistics of Pakistan. He acknowledged that 30,000, first-generation doctors of Pakistani descent abroad have helped, want to help and the government would like them to assist the health industry. A platform will soon be unveiled to communicate with this talented physician diaspora, he told.
Dr Mirza said, “We have a three-word vision: Universal Health Care. Unfortunately, we are at the bottom of health indicators for hepatitis, polio and neonatal mortality in the world and our population is expected to double in the next 30 years.” He further clarified his vision, “We need to define the essential health services that need to be delivered to our population and ensure that the majority of these will be delivered by the primary care physicians.”
He provided useful statistics. “50% of Pakistani population lives below the poverty line, 70% health care is provided by the private hospitals and 70% of the budget is spent on tertiary care which needs to be reversed in favour of primary care.” He reported, “Sehat Insaf cards have already been provided to 1.5 million families who will benefit from it and government pays the premium for health insurance of poor, but expects the delivered care to be of high quality.”
He highlighted the burning issue of health care infections and the fact that Pakistan has the highest per capita injection rate. He asked the audience if they had any idea about how many of these injections are unnecessary. And then he gave the incredulous answer, “95%!”
“Worse still, these unnecessary injections are being given to the unsuspected population by qualified physicians; we need to define who is a quack!”
He told the audience about the importance of BHUs, but Pakistani medical schools do not provide much training to the students about working in rural and less developed areas. He asked rhetorically, “Who is a GP?” and then replied, “There is no definition or training. Doctors learn GP on their own and ultimately commerce dictates how to treat patients.” He cited the glaring negligence in Larkana where recently HIV infection was inoculated among many residents who were exposed to the reuse of syringes.”
Dr. Mirza has rich experience of analysing health care systems of 22 countries of the Eastern Mediterranean region where he reported on the status of family practice. He said, “Pakistan is way behind even the other underdeveloped countries and has only 5000 properly trained family practitioners. We will need 100 years to train enough workforce and need to create short and long-term policies to serve our population.” He said the government is already thinking about developing one-year programs to upgrade the primary doctors in the context of Pakistani health problems. He finally stated, “We will give incentives to doctors to train in primary care”, and left the stage, while the audience clapped for the straight-from-the-heart speech.
Naya Daur Hopes for the Best:
This two-hour session was delivered by the most influential health care leaders in Pakistan. They are all well-educated, have loads of experience and exude good intentions. Naya Daur hopes that their ideals of universal health care for Pakistani citizens, empowerment, and training of family practitioners, who will deliver quality care with compassion and based on sound and scientific benchmarks in place, will become a reality. Naya Daur will continue to follow future developments in the health care sector in Pakistan.
Dr. Abdul Nadir M.D. is an Assistant Professor at University of Arizona, U.S. He is the head of Gastroenterology and Hepatology at Maroof International Hospital, Islamabad.