Ghutti: Tradition versus Science?

While doing our monthly shopping at a local superstore today, I noticed the popular "Ghutti" packed in nice colorful bottles on a shelf. For those who don't know, "Ghutti" is the South Asian name for a variety of herbal concoctions, which is traditionally given to newborns right after birth. It is supposed to improve digestion and make the baby feel better somehow. I myself, my sister and my brother also received Ghutti when we were born (I confirmed that with my mother). The World Health Organization, as part of its baby friendly hospital initiative, has clearly rejected feeding the baby anything other than the most obvious: the mother's milk. It was indeed disturbing to see this item being sold over the counter without any restriction or regulation. Several products are being advertised such as here and here. However, the companies producing them have been sensible enough to provide specific indications for such medicines, which would mean that these are not to be given to every infant born on the sub-continent (still physicians may not favor prescribing these). But, the average South Asian mother is driven much by tradition than by logical inquiry of our actions, and therefore would gladly choose to bless her babies with Ghutti.

There may be benefits to the use of such traditional medicine in certain situations, but until there is solid scientific evidence for that, the health authorities need to control the sale of such items. This is but a small part of the larger problem or OTC drugs in Pakistan. One can pretty much buy any drug from anywhere without a medical prescription. In fact, those who don't want to spend time/money seeing a physician will gladly be prescribed medicines by a pharmacist for free.

This issue, I believe, is going to grow even bigger for Pakistan after the implementation of the 18th Amendment whereby the Ministry of Health is abolished along with the national drug regulatory functions. Dr. Sania Nishtar has shared some thought provoking ideas on how to tackle this problem under a devolved system of health care.

Health Policy: A New Initiative

The article below is a guest post that was written some time ago by Dr. Obaidullah (FCPS, FRCS Ed) who is a renowned plastic surgeon of Khyber Pakhtunkhwa and a regular columnist on health care issues of the region. The piece below throws light on some grass roots level challenges that Pakistan is facing in its primary care system, along with some very interesting options to cure these problems. I hope the readers will enjoy reading this.


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HEALTH POLICY: A NEW INITIATIVE
Dr. Obaidullah FCPS, FRCS Ed, Plastic Surgeon
Email: dr.obaidullah@gmail.com

Since independence, there has been no change in the provision of health care to citizens of this country. A half-hearted effort here, and an NGO-initiated plan there have been all we have witnessed. Budgetary allocations have been dismal but perhaps more than the monetary side, proper utilisation of the available resources has never been the aim of any government. To provide health care on modern lines, a summary of a plan is presented. It must be understood that this is only an outline and a working group should be constructed to work further on this issue. Foremost, this plan should be carried out in one of the smallest Tehsil as a pilot project. Over a period of a couple of years, further improvements could be suggested after a thorough clinical audit of the process.

PRIMARY CARE:

All general practitioners in villages and towns should be registered into the pilot project. The government should finance this project. Each general practitioner should be asked to get a least number of families registered with him or her. A data sheet should be filled for each member of the family. These data sheets should be uniform and should be printed by the government. Those opting for computerization of the data should be encouraged. Thus a GP office will work as a resource centre for census, disease pattern and health statistics. Each GP should be given facilities of basic immunization and first aid. A single clinic can be used by a group of doctors on shift basis. One of them can remain on call on weekends. The government can help these doctors by providing interest free loans for up gradation of their clinics or provide nonrefundable aid. Each patient who is registered with the clinic can be charged a maximum fee of say Rs. 20/- per visit. Any unregistered patient can be charged more. Incentive for the doctor is his salary as medical officer in his own place, provision of better and purpose built clinic and a respectable status. Incentive for the patients is a better service at cheaper rate, provision of primary health care and without need to resort to quacks. A local committee can oversee care of poor patients through Zakat and Sadqat. Patients with chronic diseases can be issued with a “Permanent Zakat Card”. Specialists, Zakat committee and Nazim should testify it. Severe Punishment for undeserving enlistment must be defined and notified

PHARMACY:

A government sponsored or private but thoroughly supervised pharmacy should be attached to the clinic where subsidized medicine could be made available within the range of Provincial Formulary. Incentive for the pharmacist is honest and ensured earnings as no unauthorized sale of drugs would be allowed in the vicinity and without prescription. Incentive for patients would be exploitation free provision of only essential drugs at affordable prices. The provincial health department would be in a position to negotiate drug prices almost as monopoly. Incentive for the pharmaceutical would be elimination of promotion cost (which is substantial).

LABORATORY:

The total cost of a basic laboratory is not more than Rs. 50,000/-. The cost of routine blood and urine examination is also a few Rupees. A laboratory technician could be encouraged to establish a laboratory with the GP with or without state subsidy and provide basic tests at a fraction of the cost otherwise available in the open market. A Diabetes Association would be more than happy to provide surveillance and treatment of diabetic patients. It would even train the doctor, LHV and lab technician on guidelines for diabetes management. Incentive for the laboratory technician would be hassle free services without resorting to illegal gratifications. People of the area would be the ultimate winners. The lab would charge minimum charges from patients referred by the particular GP or registered in the same clinic and could charge a little more from other patients.

MOTHER AND CHILD CARE:

LHVs could be similarly attached to GP clinics. They will have their own registry of expected mothers. They could maintain pregnancy record of their population. Any expected mother, who has a normal progress of pregnancy, should be booked for delivery in the nearby BHU. Every BHU in return should be equipped with a simple labour room. LHVs should have a base in the BHU and should perform duties round the clock on shift basis. Majority of deliveries could be conducted by LHVs and patients charged reasonably. Set guidelines could be provided to these LHVs in conducting normal deliveries. Clear instructions of when to refer patients to a lady doctor or specialist would be made available to them. This could also act as a registration center for births. Birth certificates would be issued from here.

LHV would refer any expected mother for expert care if she has any complication during pregnancy or near her delivery. The next referral point could be a Tehsil Headquarter Hospital or a nearby female GP. Thus a vertical referral system could be developed with DHQ and Teaching Hospitals being next lines of referrals. Patients could be encouraged in many ways to enroll into this system. For example, patients coming through proper referral could be charged less in the next referral center than those jumping the queue or consulting the specialist directly.

Incentives for LHVs could be in the form of salaries, their extra topping from delivery charges, and working in a self-controlled environment. Incentives for patients are many as they could not expect more.

PROVINCIAL FORMULARY:

PROBLEMS: There are too many drugs available in this country. Each drug is available under numerous trade names. Prices range from very expensive to ridiculously low. Patients and doctors sometimes go for the most expensive one believing that goes for quality. Unnecessary drugs abound including dubious herbal ones. Especially a multitude of multivitamins abound, which have doubtful role in our community.

Because of a large number of pharmaceutical firms competing with each other for the same drug under different trade names, unethical marketing is rife. There is a large head on the expenses of promotion, which further adds to the price of drugs. At times doctors are paid in kind or cash for prescribing an expensive drug where another less expensive drug could equally work. There could be no one to challenge the doctors’ point of view. The sheer number of similar drugs also baffles doctors. Misadministration by the paramedical staff is because of the same reason.

SOLUTION:

Availability of a provincial (or perhaps a national) formulary would prevent irrational use of drugs or misappropriation of funds in purchase of drugs. Only a limited list of approved drugs would be available in every hospital, RHC or BHU. Even registered GPs could be asked to limit their prescription to that list.

A group of specialists and general practitioners should meet and make a list of essential drugs. Every one of those drugs is available under various trade names. Tenders could be called from various pharmaceuticals and the lowest bid could be accepted for supply of Provincial Health Department medicines. Even three or four companies could be short -listed. However, payment for these medicines should be conditioned to a positive report from the drug testing laboratory. Patients and doctors outside the registered population would be free to prescribe any drug from outside the formulary. As an example, paracetamol is available under various names. One or two could be short listed for their least price. Similarly, among antibiotics, only one antibiotic from each group could be selected and the least expensive listed in the formulary. Ciprofloxacin could, for example be selected from quinolones and one or two trade names could be listed on the formulary.

On health education...

One of the basic principles of health education is to understand the attitudes, beliefs, perceptions and feelings of population in question. At least in Pakistan (and perhaps other developing countries), based on personal experiences, I have found this be the oft forgotten component in health education. Many health education messages are designed primarily as translations of their successful and proven English versions. Some of these efforts even consider the cultural sensitivities of our local population, but few actually attend to the problem of methodically researching in depth, the views, beliefs and attitudes of the population towards the health issue being addressed. Without this knowledge, our health education messages may at best be slightly better than shots in the dark.

The issue was raised by Dr. Saeed Farooq (Professor of Psychiatry, Lady Reading Hospital, Peshawar) during one of our faculty CME sessions, while discussing our teaching methodology for medical students. It reminds me of Stephen Covey's famous book "The 7 Habits of Highly Effective People" where he suggests that we "Seek first to understand, then be understood". Indeed this principle applies to health education as much as it applies to personal communication.

Interestingly, a few days after this discussion, I met a far off relative who happened to visit Peshawar. She had brought her son for medical care because he was bitten by a dog 11 days ago. While inquiring about the details, I found out that she had told the doctor that the dog bite was only one day old. Surprised and annoyed, I asked her why she had done so, and she replied that she did so because she thought that the doctor would not give him any treatment if the dog bite was too old. If this is a common belief in a village, then perhaps doctors are receiving wrong history from these patients at times.

Now one might arrogantly conclude that she is an illiterate woman who needs to be educated on the seriousness of dog bites. However, if one wants to really design an effective health education message, it would be useful to consider her belief that an older wound will not receive treatment by a doctor. Perhaps a more penetrating message would explain to her that even an old dog bite should receive treatment because it can still increase the chances of survival (in case it was a rabid dog). The point here is not to ignore the bigger problem of her waiting too long for treatment, but only to explain how the knowledge of current beliefs of people could be useful in determining the appropriate messages for them, in order to induce healthy behaviors.

Following a discussion amongst faculty members at CHS, we have now decided to reduce our reliance on transplanted health education messages from developed countries, and inculcate a stronger "We don't know what they think" attitude in our health education efforts.

Helping the war afflicted...

The war against terrorism reached its peak last year when the military began its operations in the Swat region of Pakistan. Every day brought news of death and suffering. Besides those who were killed or injured, there were those four million who had left their homes in search of a shelter. Some settled in refugee camps set up by governmental and non-governmental organizations. A few rented houses in other cities. But initially, many had to spend their life in open grounds until help arrived.

In July 2009, I happened to visit one of the refugee camps in Jalalah, Mardan, as part of team of faculty and students of Peshawar Medical College, who were conducting a survey of the psychosocial services for IDPs. The survey was completed successfully, but we had a heart wrenching experience. The camp’s physical structure was commendable, which I believe was the result of Pakistan's experience with a major earth quake in the recent past. However, the services were nowhere near enough. Several NGOs were running small health centers in the camp, with a basic set of services and very limited supply of drugs. A number of refugees, after learning that I am a physician, came running after me, pulling my arm, begging me to help their loved ones. One man took me to his mother - a very old lady who had suffered a stroke ten days ago and was lying in scorching heat with no medicine. I heard the story of a young woman who gave birth to a baby with no medical assistance, and the baby died of infection. Psychiatric services were non-existent, as were any special facilities for the disabled. During our survey, we identified many children who were still not able to sleep because of what they had seen. The stories went on and I started getting uncomfortable. Luckily then, I got the chance to work on a collaborative project of International Development Relief Foundation and Peshawar Medical College. The project involved establishment of a Maternal, Neonatal & Child Health Center for these displaced persons. The project began in August 2009. Equipment was purchased and staff was hired. A reporting system was put in place and services started by end of August. These included services for expecting ladies and their newborn children, as well as children in general. A general medical outpatient clinic was also functional. Laboratory and pharmacy services were added alongside and by end of September home visits of Lady Health Workers had also started.
The greatest contribution of this project, I believe, is the provision of maternity services to the IDPs when there were none available inside or outside the camp. The free laboratory services provided by the center are also the only facility for the IDP population in the area. Since the arrival of IDPs in the region, drug prices in the market had risen due to high demand, and in this time, provision of free drugs to the needy by our MNCH center was of extreme importance.
Near the end of 2009, the IDP population had started decreasing and our project team decided to open up the services for local population with minimal user fees. From a sustainability point of view, the continuation of this center as a permanent facility is ideal. Since the locality of Jalalah until this time, lacked a well equipped maternal and child health service, the establishment of this center has been a significant contribution in improving the health care of this community. The general medical clinic is also now open to the natives of Jalalah and surrounding region and benefiting the host community as well.
It has been a satisfying experience helping those in great need. The war is not over though, and I hope to see a peaceful Pakistan someday.

Morbidity & Mortality Meetings - Why they don't work?

One of the oldest methods of Quality Improvement in health care delivery, is the 'M&M' or 'Morbidity and Mortality Meeting' usually held weekly or monthly in every department of a given hospital. Throughout my medical training, and later on, I noticed these classic 'M&M' meetings taking place in almost every hospital here. However, there is serious doubt that hospital care quality of most hospitals in the area has improved, if at all. I don't have a study to support this statement scientifically, but this is a ubiquitous opinion amongst physicians old and new, patients, administrators and general public.

M&M meetings here typically involve a discussion of how many and what kind of admission were done in the past week/month, what procedures were done, what adverse events occurred, which patients died, and then each and every mortality and mistake is discussed at length. Literature suggests that this review of mistakes was historically meant to act as a corrective force, and a learning opportunity for physicians and care givers. I submit here that this corrective action has not happened at least in my observation. The question is, if this beautiful mechanism is already incorporated in hospital practice, why has it not worked?

There are indeed many reasons, including environmental factors. I wish to point out three of them here:

1. Who attends M&M meeting?

In my 12 months of clinical clerkship as a House Officer, I was never asked nor allowed to attend a single M&M meeting! It was supposed to be for senior trainees and consultants. Now consider this...what percent of a patient's time is spent in contact with a house officer? Perhaps the greatest in the clinical team, sparing the nurses. Oh and that reminds me, nurses also do not attend these meetings. With such a large portion of patient contact left out of a learning opportunity, how can one expect it to work?

2. What is the meeting culture?

I recently interviewed a senior resident in a reputed public hospital of Peshawar, regarding M&M meetings. I asked this person, what do you typically discuss regarding any mistakes? The answer was, "Every TMO [trainee medical officer] who has made a mistake is insulted". While this may not be typical of every unit, in my opinion it should never happen in this way. With such a negative attitude, how can one expect the trainee to learn and maintain a friendly attitude with colleagues? How can one expect the physicians to try not to hide their mistakes, if they know hell is coming?

3. What is the final outcome of M&M meetings?

In the same interview, I asked another question, "What is the final outcome of these meetings?". The answer was a classic phrase I will never forget, "Every mistake is promptly repeated next week!". The problem I believe, is that these meetings usually end at the error identification stage. There isn't an actual decision at the end such as 'We are not going to do X procedure without precautions A, B and C'. While the west is talking about pay for performance, health organizations here don't even touch the basics. How can one expect an improvement in behavior if the loop is left open after identifying the error?

Until our physicians are ready for a quality culture, this tool seems to be of limited use.

ER visits, costs in Mass. climb - The Boston Globe

ER visits, costs in Mass. climb - The Boston Globe

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EMRs in developing countries - Tracking Patients

Experiencing the US health care system has been an awesome experience for me, as far as technology is concerned. My love for electronics drives me towards ideas of implementing Electronic Medical Records (EMR) in developing countries. A number of major obstacles exist before one even thinks about such endeavors, the biggest being the upfront cost of investing in the development of a good EMR system. Even in the US, despite the availability of technology, the cost has been a major deterring factor for smaller practices and hospitals.

Besides the cost however, implementation issues are equally difficult to tackle. Adoption of EMRs has been notoriously difficult in US, where people are supposedly more computer-literate than most developing countries. A variety of factors are involved here, ranging for workflow disruption to non-user-friendly interface.

There is one issue that is unique to developing countries however: The difficulty of tracking patients. From my own experience in Pakistan, rarely do people have any type of ID. Despite the efforts by tyhe government, the majority population in the rural areas does not have a national ID card. Even those who do have one, most do not use it or carry it. Having these people carry yet another card for healthcare purposes doesn't seem like a feasible option at this point in time. It is very common to see patients with chronic diseases who regularly do not bring their past records with them every time they come to see their physician.

In this context, multiple search methods are necessary to identify past records of patients if an EMR system is to be useful. One such method I have seen is the use of telephone/cellphone numbers for ID purposes. Most people in Pakistan do have access to a phone even if they don't carry any ID. Combining patient names with phone numbers will allow a good tracking method in the short term. Indeed there is a privacy concern here but as other forms of ID become common place, hopefully using EMRs will become much safer.