Tuesday, November 23

'Our health policy consists of statements'

AAMER WAQAS CH. Talks to Dr. M. Owais Farooqi on the issues afflicting the health care delivery system of the country

Dr. M. Owais Farooqi has been in the field of Obstetrics and Gynaecology for over forty years. He received post-graduate education and specialisation from England and America. During his career, he earned many awards and degrees, including Fellowships of The Royal College of Obstetrician and Gynaecologists of England, American College of Obstetricians and Gynaecologists, American College of Surgeons, International College of Surgeons and Certification of The American Speciality Board of Obstetrics and Gynaecology. Dr. Farooqi has held many prestigious academic positions at The University of Rochester School of Medicine and Dentistry, Rochester New York and Planned Parenthood of upstate New York. He was also associated later with Department of Reproductive Medicine at The University of California at San Diego. Then in 1978, he moved to Fresno California, (Sister City of Lahore) to full-time practice and took courses in health care management.

After acquiring expertise in health care delivery system, he served on the Board of Governors of Hospitals and many health Organisations. In 1998, he decided to return to his motherland, and established his clinic in Lahore. He has been very vocal through out his career on the quality and reliability of health system, particularly women's health care. He believes that most women in Pakistan today, still have only limited access to proper education and health in its "symbolic health care system". Medical Profession has responsibility to bring awareness and disseminate information concerning health in general and reproductive health in particular to the public at large, as it plays a vital role in the well-being of a society. Following are the excerpts from an interview:

On the multiple pregnancies difficulties attached to it

This incidence of multiple Gestation is high due to advances in reproduction. As a result, the high risk of incidents associated with multiple Gestation needs to be re-emphasised and awareness to be brought about. The most important and major risk factor is the pre-maturity, which is responsible for high peri-natal mortality and morbidity. Hence it is imperative that a team comprising of obstetrician, neo-natalogist and skilled nursing care he available and co-ordinated in advance to reduce the complications. Similarly medical and obstetrical complications be managed to carry the pregnancy to Gestational age of maximum viability of the foetuses. One difficulty in the set up of this country is lacking of functioning equipment and vital pharmaceutical products, which make a significant contribution in the salvage rate. At a local hospital, the most important contribution and co-operation was extended by the administration and nursing staff, which is also possible in public hospitals if earnest efforts are made and interest in taken. This is substantiated by the fact of a recent achievement made when triplets were delivered seven weeks prior to due date because of uncontrolled pre-mature labour. Special medication were flown in from Dubai, required for the lungs' facilitation of expansion, sometimes required in pre-mature babies. We do not have such medicines in the country, family's resources were used for this purpose. What about the poor who do not have such resources and co-ordination! It becomes nearly impossible to achieve success. This existing equipment does not seem to back up. All babies have gone home.

Problems faced by the masses

If you look at the total population hospitals are catering, one can visualise the problems faced by the public. My judgement is that the number of hospitals have not kept pace with growth in population. It has enhanced huge pressure on hospitals to provide services. This equates further with the patient, clinics, laboratory services - imaging, diagnostic services and ambulatory services. Moreover, developments and resources are not equivalent to the population growth consequently resulting in poor quality of services. One can see long queues in all areas of health delivery system. This seems to be an ideal situation for the break down of the existing system. Despite planning and verbal implementation of the health policy, people from rural areas crowd the major cities and hospitals for minor treatments. One should have basic diagnostic facilities and pharmaceutical availability at the shortest possible distance from home. There should be a division between the management and professional responsibility, education and training as there exists no definable separation now due to which the health care system is not properly placed and organised to do maximum care and the quality service suffers. Expensive medical equipment is lying idle due to break down, lack of maintenance or operators. As a result, one has to postpone life saving procedures for unlimited duration. Moreover, there are no qualified operators, trained manpower and physicians for advanced diseases because the best of the crop has left the country and we do not replacements at the same pace. In our medical schools, there are fewer highly qualified teachers.

Emergency treatments

Due to the present political and economic situation - which has caused divergent polarisation in the population - one is faced with medical emergencies on daily basis. Even in a normal environment, we have significant increase in accidents, and there is no development to handle these untoward incidents. We are far from even providing the first aid to our population in case of an emergency. Consider the number of ambulances, their condition and training of the staff. There should have been hi-tech ambulances and advance infrastructure meeting all the requirements of the components of health care delivery system. There seems to be a constant tug of war between pharmaceutical industry and regulation authority, that is, the Health Department. The fact of matter is that physicians and patients are constantly faced with shortage or total non-availability of drugs - both imported and locally manufactured. The shortage is mostly artificial created either by manufacturers or suppliers. Then, the government has imposed sales tax on medicines.

Laboratories as commercial ventures

The cost of health care is becoming increasingly unaffordable for most of the people. The increased cost is multi-factorial issue. The quantity of medical care needs to very carefully measured and defined to preserve the financial resource of the population, but there appears to be a total freedom to set up all kinds of diagnostic labs. Some are not even operated and managed by properly qualified persons, and there is an ever-increasing business of ultra sound labs in every corner of cities. One of the most interesting factors is that the patients are encouraged to go to diagnostic labs for expensive test performed without proper examination. Unfortunately, there is no follow up and analysis of highly expensive tests are mostly questionable. This should be discouraged as the physicians are investing in lucrative ventures like laboratories and imaging centres. In America, doctors were not allowed to misuse or over-use their own labs for personal gains. But in Pakistan, there are no rules in this regard. There is a common practice of kickbacks or fee-splitting. This can cause various implications like that over-utilisation of tests. Where do their loyalties lie? That is why the machinery in public hospitals are not being used due to one reason or the other.

Private practice

There is a problem between the two sides - the government and doctors. Both need to understand the significance of the problem. The government expect from its employees certain level of commitment and honesty. But the government managers should realise that the financial mechanism is not enough to keep them in service. In the developed countries, they have developed an understanding that private practice needs to be allowed, so they supplement their income. There, the check and balance system is self-defined and based on certain parameters of disincentives in the system, which stopped practitioners from going beyond certain limit. In case of mismanagement by the practitioner, his contract might not be renewed next year. Here, if the government cannot pay the expected money to doctors, then they should be given some ways to ease their constraints. But this cannot be changed over-might. If private system is to be introduced within the government hospitals, then the same ambience of private hospitals should be provided in public hospitals as well, because when one pays, he expects services of a certain level. Certain mechanism between the consultants and government agencies needs to developed. Agha Khan is working very well and which is probably the only success story I have seen so far.

Ambiguous autonomy of hospitals

The real autonomy would be for institutions organised in corporate fashion. A board should comprise of society representatives and professional ones. Exclusion of any essential element would make it non-functional. These boards should be given a budget as it is government's responsibility to provide health care. The board should be solely responsible for its running. Moreover, we should be looking at population growth. Metropolis hospitals are attracting patients from the out lying areas. Data should be collected to forge policies and budget reimbursement. This is real autonomy. To me, just changing a name and carrying the same order of control is not autonomy and that is why this system has failed. A model should have been perfected first and then applied generally. While changing a system, duties should be assigned clearly, stating that what is expected from whom. There has been no division of powers and duties and as a result the Control has been confusing. Consequently, there is a chaos and everybody (the physicians and the patients) is unhappy. It is not a success story even economically and unfortunately, the ultimate sufferers are the patients.

Whether health care delivery system exists

According to various analysis, the main task facing the health delivery system is to assure one that the right patient receives the right service, at the right time and place. This is the crux. With developed nations, where financial constraints are minimal, failures represent organisational model. They are facing problems too. If you take finances out, then there are major problems in health care. For example, who should provide basic health services? Lahore is not the whole of Pakistan. We have to reach out to people in other areas - Sindh, Balochistan and down-country areas - where there is no conveyance to go for the service. The health care system should cover all areas of primary, secondary and tertiary health care system. Every tier should be working within its specified limits and co-ordinating with other tiers in turn. Budgetary allocations should be made in accordance with that. It is a co-ordinated effort. At each level, build a system of check-and-balance and develop transportation system. This also involves nursing, pharmaceutical, and machinery. Train the personnel accordingly. The government policy might have been there, but it seems to exist through statements. Nothing can be do provided at door step, if clean drinking water cannot be arranged, which is less costly. The biggest difficulty is the access to health care delivery of services where required, which is virtually non-existent. It has two components - ability to pay and availability of care within the reach of people. The barriers are financial - easier to define in the form of international health organisation and budgetary allocations of the government. And non-financial barriers - patients' own bias for health care, higher illiteracy towards medical care, lack of communication skills, long distances, interference by customs and relatives, and lastly, easy availability of home-made medicine. These play a great deal of role in health services. The health system should consider these barriers. There is no methodology for data collection, so that we can gear up for budgetary allocations. Hence, there is a difficulty in designing the system as these areas have been touch only superficially.

Over-utilisation of tests

The health is care. There is a lot duplication of tests - diagnostic and imaging. Every doctor has his own list of tests. Specialists should guide patients, which tests and from where to be done. There is no follow up. To me, duplication is bringing high cost to health care delivery system. This is again involved by self-diagnosis and contributing to cost. Unfortunately, general chaos in health care system has contributed towards this. A proper advice and diagnosis is not considered. We value little our health until we are very sick. In government hospitals, people get treated and at the time of payment, most of them disappear. They need to be educated that physicians are doing their best. Then payment becomes less painful, physicians should take the responsibility as patient is the focal point and system should benefit the latter. If the rich trust their country, we would save huge foreign exchange though level of service is better here for being personal rather than impersonal outside. Relative and friends are a great help here - taking care and encouraging the patient. Nursing and para-medical are very important apart from the physician. By and large, they are still looked down upon although the ill seek their help. They are the lowest paid and highly over-worked. Consequently, it adversely affects their working capability. The same is applied to young doctors, who are jobless or taking ordinary jobs. This is terrible.

Regulations for labs and hospitals

There is no regulation for constructing hospitals and laboratories. Most of these should not have been allowed in the first place. We need to look at environment, parking and other facilities at the hospital. Finding a parking space, can cause a heart attack if the patient is already critical. Facilities should be utilised properly. Title 22 of the United States medical directory specifies everything for a hospital and laboratories - building and operational codes. Hospitals should be incensed according to the services and the crew to back up care. Transport facility is not there even in this metropolis.

Quality of health care services

It entails that the patient lives a quality to the maximal level. The second component is adequate scientific knowledge of the physician. Third is competent health care provision and the fourth is separation of financial and clinical service. If we can provide these patients, it can make a great difference to them. Professionals should be familiar with it. The quality of education directly affects the quality of health service. The best brains are draining out. To lure them remain in the country, is the government's service. There should be minimal medical negligence -a failure to meet the standards of practice of an average qualified physician practising in the same capacity. Leaving a patient unattended is negligence. I feel that when you design a system, there should be programme to gauge the required delivery care. This is called quality assurance. It should be constant and not a day's job. Complex medical services should be of continuous quality with constant improvement. The outcome should be meeting the standards. Reports of upsurge of tuberculosis in Pakistan is one indicator and a crude reminder of our inability to even maintain that which was once achieved in the prevention of disease.


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