EducationHealth/Sci-TechVolume 14 Issue # 04

Towards improvement in the system

The entrance test for admissions to medical and dental colleges of the Punjab province was conducted on September 23, 2018. While these lines are being penned, the results are yet to be announced by the University of Health Sciences (UHS), Lahore, which conducts the test, officially called the Medical and Dental College Admission Test (MDCAT). Hopefully, this year the process would be completed smoothly and no controversy would be created, as in the year 2017.


Last year, a severe crisis developed after a paper was leaked. An official investigation committee later disclosed that a racket comprising the UHS officials and academics was involved in the leak of the paper. The controversy raised serious questions about the entire medical education and healthcare system in the province in particular and the country at large. However, the matter was hushed up as very influential people were found involved in the scam.


The change of governments at the Centre and Punjab has brought a new hope for those concerned about deteriorating medical education and healthcare system in the country.


They believe that to achieve the most challenging goal of a healthy nation, the newly-installed federal government would have to bring about systematic and massive reforms across the country.


Dr. Izhar Chaudhry, Pakistan Medical Association (PMA) Punjab president, admits that the medical sector of the country is facing gigantic problems. The new government will have to make major reforms with the help of all provincial governments, federal and provincial ministries of health, doctors’ associations, paramedical alliances, the PMDC and the Drug Regulatory Authority of Pakistan (DRAP), he tells Cutting Edge.


Quoting official statistics of the United Nations and the World Health Organisation, he says that the current maternal mortality rate in the country is 260/100,000 live births. Neonatal mortality rate is 46.6/1,000 live births; infant mortality rate is 72/1,000 live births; under age five mortality rate is 65.75/1,000 births.


To control such an alarming situation, the Pakistan Tehreek-e-Insaf-led federal and provincial governments would have to make healthcare their topmost priority. The system lacks in every department, the PMA office-bearer regrets. Only 7.8 physicians are available for a 10,000 population in the country. Nurses and midwives are 3.8/10,000 population, while the overall healthcare workforce (physicians, nurses and midwives) is only 11.6/10,000 population. The numbers are far less than the recommended strength of the WHO, adds Dr. Izhar Chaudhry.


The health expert stresses the checking of the brain drain from the healthcare system, as thousands of doctors and paramedicals leave the country every year for better prospects of earning abroad. The new government will have to provide quality healthcare services equally in urban and rural areas, he believes.


PMA Central General Secretary Dr. Qaisar Sajjad fully agrees with the Association’s Punjab president. Talking to Cutting Edge by telephone, he pinpoints some other health issues. He says only 33 per cent of births take place in a health facility, and less than two fifths (only 38 per cent) of births occur with the assistance of a skilled medical practitioner in the country.


The expert says that Pakistan has a high fertility rate with 4.2 million new births annually. This rapid population growth will further strain an already overstretched, overburdened and under-performing healthcare services delivery system, including deliveries by skilled birth attendants. There is a need for an effective family planning and population control policy as well, he points out.


Listing yet more issues, Dr. Sajjad says that the service structure for doctors, nurses and paramedical staff needs to improve. Currently it is not well defined, it favours tenure over competence; it largely ignores technical capacities and does not allow encouragement, incentives or rewards for performance. The conduct of education for medical, nursing and related cadres is mostly conventional and does not utilise recent developments in the field of medical and health education. There is a serious need to develop a well-organised system for continuing medical education for all health providers, he suggests.


Aamir Mehmood Kiyani, federal minister for the National Health Services, told a news conference recently that the federal government was not oblivious of its responsibilities as healthcare facilities to all people of Pakistan is on top of its agenda.


On September 23, 2018, the National Health Services and Regulation Ministry formed a task force on healthcare in line with the federal cabinet’s recent decisions. Sources in the ministry say the PTI government has decided to replicate Khyber-Pakhtunkhwa Medical Teaching Institutions Reforms Act, 2015 in Punjab, to grant full financial and administrative autonomy to hospitals and medical colleges.


Arshad Rehan, former president of the Association of Pakistani Cardiologists of North America, believes the Medical Teaching Institution (MTI) Reforms Act was a flagship legislation of the PTI government in Khyber-Pakhtunkhwa during its previous tenure. It sought to change the governance of tertiary-care hospitals in the province, giving them unprecedented autonomy and striving to change the prevalent decadent culture therein.


Mr. Rehan, also an adjunct faculty, Division of Cardiovascular Medicine, Ohio State University, terms the MTI Act of 2015 a bold piece of legislation. It looked good on paper and proved its worth in practice also. However, implementation of the act on the ground has also revealed certain weak points that need to be reviewed and remedied, he told Cutting Edge at a seminar in federal capital recently.


The health expert suggested revisiting the law, as the challenge of implementing reforms in Punjab would be more difficult keeping in view it size. Lessons learnt from KP would be crucial in enacting and implementing the law in Punjab, he added.


Shedding light on the system, he said that through the MTI Act, most government-run tertiary-care hospitals in KP were declared the Medical Teaching Institutions (MTIs). Each hospital or institution designated as an MTI was given autonomy under the act. Each MTI was run through a board of governors (BoG), and each BoG enjoyed immense powers and was custodian of millions of taxpayers’ money for running the hospitals, he said.

However, the expert has some suggestions to improve the system. The KP experience showed that the nominations to the BoGs needed to be more transparent and objective, as nominations to various boards for MTIs were not very transparent in the province, and the process had not been open to the public.


Dr. Arshad Rehan believes that the search and nomination committee should publicly invite names for inclusion on the boards. The short-listed names should be published on a public website. The details of the proposed members, with their educational qualifications and relevant experience, should be listed for all to see. Most critically, the proposed members should declare any conflict of interest – for themselves as well as for immediate family members – on the proposed website, he adds.


Dr. Rehan says that in its present form, the MTI fixes a term of three years for each BoG after which new nominations are to be made. The new members have a learning curve. “The KP experience tells us that it would be better if the terms were staggered for members on each board.” The term for the boards should be increased to four years, and half the members should retire after every two years. An example of staggered terms is the Senate of Pakistan. The staggered terms will ensure continuity and experience on the boards, he believes.


Another problem that revealed itself with the experience in KP is the lack of close coordination between the government and the MTIs. In the first draft of the MTI Act, it was mandated that the government secretaries of health, finance and establishment are also present on various BoGs in their ex-officio capacity. This mandate to have government members on the boards was, however, removed in a subsequent amendment. The absence of ex-officio members on the BoGs hampers coordination between the MTIs and the government in regards to budgeting and planning. Their presence is necessary to understand the needs and planning of the MTIs and also explain the position of the government, the health expert believes.


Dr. Arshad wants the government to amend the act to bring in accountability for the boards. This should be issue specific. “If on any specific issue, the government feels that a board is not acting in the best interest of the people, there should be a mechanism for putting the board on notice.


“And if the board fails to rectify the situation, the matter may be referred to a tribunal or another body. One such body that may be considered could comprise of the chairpersons of all the BoGs in the province,” he suggests


Regarding suggestions the federal minister for National Health Services told Cutting Edge by telephone that the government was open to any proposals, extended for improving the health sector. He said that hospitals enjoyed full administrative and financial autonomy in Khyber-Pakhtunkhwa under the MTI Act of 2015. He claimed that its implementation in the Punjab province with further improvements would produce good results and the people would discern a change in the healthcare system for themselves soon.