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.
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.
