Strategy to streamline it in the interest of medical profession and the public

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 Private Practice by Doctors in Government Service

Strategy to streamline it in the interest of
medical profession and the public

Prof. Eice Muhammad * FCPS (Medicine) MA (History)

Our beloved country Pakistan was created in the name of Islam with an ambition that in all spheres of life guidance will be obtained from the basic principles and traditions of early period of Islam when the concepts as enunciated by the Prophet of Islam (PBUH) and emulated by four Caliphs of Islam were being practiced in an unblemished perspective. For a very extended period of time there were three professions in Islamic Society which were considered as non-profit making. These were the professions of.

  1. Tabib (Doctor)
  2. Teacher (Muallim)
  3. Khatib (Imam)


Prof. Eice Muhammad FCPS

The men engaged in these professions had other sources of income for substance and no charges were received by the men engaged in these professions. In later periods the state would allocate some land or property (Waqaf) for their subsistence and at no point these men or women will receive money directly from the public. The men engaged in this profession were thought to be above the vagaries of money and enjoyed great esteem in the public life. However with the degeneration in Islamic Societies this system broke down and doctors were forced to charge money from the public like any other profession. When public began to sense an abnormality in respect of medical charges or negotiations about charges of the treatment by the doctors, the image broke down and that prestige once enjoyed began to vanish.

From some years there is outcry the world over about the commercialization of medical charges and in USA. President Bil Clinton won the election and one cause of his success was the promise to bring down the costs of medical treatment. In Pakistan there is growing concern about the manner in which private practice is being done especially by doctors in government service. There seem to be a public outrage the way medical teachers and non-teacher doctors are doing the private practice.

The government has permitted private practice to Professors, Associate Professors, Assistant Professors and District and Tehsil Hospital Specialists and even to Medical Officers in Primary Rural Health Centers. The private practice is allowed after government duty hours at the residence of the concerned doctor and the government doctors are not permitted to associate themselves with any private hospital or laboratory.

However, these provisions are being openly flouted and the permission to do private practice is being misused and government doctors, including all the above mentioned categories of doctors are indulging in all types of irregularities. They visit and operate upon patients in private hospitals even during duty hours and charge exorbitant fees which have degraded the profession in the eyes of the society. As a result of misuse of private practice, the teachers tend to give less importance to medical education and as a result serious short comings have developed in this sector. Specialists in the District and Tehsil Hospitals have also openly associated themselves with private hospitals of those areas and are engaged in increasing the misery of the patients seeking specialist advice in those hospitals and government hospitals. Majority of these specialists have built their own hospitals against service rules.

The government doctors, teachers are actually only part time teachers or government employed and their basic interest now lies outside the medical colleges and hospitals. Instead of taking any sentimental or hasty decision, it is advisable first to analyze the factors which have led to the present state of affairs. These are as follows.

Analysis of the Present Situation:

The amount of pay in the categories mentioned is less. To give an example, a Professor’s pay was about 70,000/per month in basic pay scale No.20. An Assistant Professor of medical college used to draw about 40,000/- as basic pay and this also applies to the District and Tehsil Specialists. Keeping in mind the present inflation, prices of eatables and other essential services, like electricity, sui gas and fuel, water, education of children and pays of domestic servants and monetary help of parents, sisters or brothers if dependent on them, one can easily imagine the hardship. In addition, expenses on clothes, food etc. has also to be borne by the doctor. The above mentioned factors can easily explain why these doctors have gone astray in the matter of money making.

Some time back, the government employed doctors used to admit their patients or operate only in government hospitals where they were employed. The consultation fee, operation charges etc. used to go to the share of the doctor in total or at least seventy percent used to go to the doctor. To make it more clear let me give examples. Visit fee of a Professor or others to a private patient in AVH Ward of Mayo Hospital used be only Rs.40.00/- visit/day and the Professors used to get Rs.14.00 per visit from this. This was in the nineties of the last century (2016) when the rot started.

At that time, if a Professor of Surgery used to operate e.g. on Appendix, he used to get Rs.315/-out of Rs.900/- which were the operation fee charges of this operation. If he would operate outside in private hospital in those years he could charge between Rs.5000/- to Rs.15000/- for the same operation at that time and much more.

The same system of charges used to apply in the District and Tehsil Hospitals. With spiraling prices every month or so, the senior or junior, teaching or non-teaching doctors were forced to look out in private hospitals of their areas to cope with social necessities of life. Lack of any administrative check from the government also encouraged this indiscipline in government doctors including the teachers.


The situation has caused public outcry and unfortunate stories about the exorbitant charges and malpractices have come to the surface. Only last month i.e. April 2017, two government doctors were arrested for performing illegal kidney transplant in a residence of a colony in Lahore. One can imagine the gravity of this situation of private practice being indulged into by doctors in government service.Some Professors in Lahore and other major cities of Punjab have made teams of doctors working under them in their wards to perform duties in private hospitals where they assist them in performing operations and look after the patients after the operations have been done in private hospitals. You can easily imagine the level of degeneration in conduct of these professors and other ranks of medical teachers.  Not only from the point of view of public, but from the point of preserving noble traditions of medical profession and ensuring quality of medical education, in my opinion the private practice by doctors in government service needs streamlining in a scientifically planned and cool-headedly laid out program.

Proposals:

  1. The medical teachers of all categories should be banned from practicing in a private hospitals.
  2. District and Tehsil Hospitals specialists should also be banned to practice in private hospitals. The District and Tehsil Specialists may be allowed to practice at their residencies and should admit, treat or operate only in the hospital where they are employed.
  3. Similarly posts of Assistant District Health Officers, District Health Officers, Regional Directors and Director General Health and their equivalent in administrative posts should not be allowed to do private practice.
  4. To discourage the local attachment of government doctors in private hospitals in various cities, all doctors should be transferred every four years without fail. In case of medical teachers, the period may also be every four years and in both categories of teachers and non-teachers, they should not be transferred after fifty five years of age till the retirement unless there are serious administrative reasons. This will discourage local monetary bonds which at the moment are well knit and syndicated.
  5. In lieu of ban on private practice certain basic but drastic changes in the pay structure will be needed, the detail of which will follow.
  6. Many teachers and district specialists are earning more than one lac per month in private practice. When the government will try to put restrictions on their private practice, they may threaten to resign or maneuver through political and bureaucratic links to project the whole as not practicable and financially untenable. Once we are convinced that private practice in the present shape is detrimental to medical education and patient care in government hospitals, then no financial excuses etc. should be allowed to come in the way. If the government agrees to ban the private practice of the government doctors in private hospitals, then the following proposals are recommended.

The Medical Teachers:

This group includes Professors, Associate Professors, Assistant Professors and Senior Registrars. All these posts should be non-practicing. Institutional practice should be planned for them, the modalities of which are being mentioned as an example.

Professors on Clinical Side:

  1. Basic pay scale should remain as at present. However, promotion of Professors to grade 21 and 22 should be ensured according to the formula already sanctioned by the government.
  2. In lieu of ban on private practice a special pay increase per month above his pay in scale 20 should be given.
  3. Secretarial help should be provided to the professors of each unit. This will encourage medical writing. At the moment professors have to beg clerks for getting their articles typed or have to get these typed on payment.
  4. Government residences should be provided at all costs. If not provided by the government then facility of requisition should be allowed and for that purpose rules of central government as applicable in Islamabad should be allowed. On transfer from one city to other, Professor should not be allowed to suffer from misery of roaming the city to find the residence for which the major portion of rent he has to pay from his own pocket. From where that extra money will come. Obviously from illegal private practice.
  5. The additional pay per month of the professor should be tax free or heavily rebated.
  6. Non STD phone facility should be provided in the office and residence of each professor.

Associate Professors:

  1. He should also receive an extra special pay per month over and above his pay of grade 19 which he is already getting at the moment.
  2. Facilities of housing, transport and income tax relief should be same as for the professors.
  3. He should also be allowed institutional private practice.

Assistant Professors:

  1. A special pay per month should also be given over and above the present pay of grades which he or she is receiving. He should also be allowed institutional private practice.
  2. Facilities of residence, transport and income tax relief should be as for the professors.
  3. To solve problems of transport, low interest loan for purchase of car should be allowed.

Senior Registrars on clinical side should also receive an additional special pay per month over and above his present pay scale salary. Similarly the junior registrars and medical officers working on clinical sides are also indulging in private practice. The purpose of appointment to these posts is to train for post-graduation but these categories of doctors are now indulging in private practice to enhance their incomes at the cost of post-graduation.

Justification of Special Pay:

  1. If private practice is banned on clinical side, the professors, associate professors and assistant professors will suffer major loss of income which in some cases runs into lakhs per month.
  2. If compared with the pay of American, British or other European countries teachers who are not allowed private practice; this special pay will be extremely modest.
  3. Idea to ban private practice and to give them special pay is to improve medical education and patient care.
  4. The teachers will be officially bound to take evening rounds of their wards and teach medical students in the evening according to a weekly schedule in which they will fix days for this purpose.
  5. The nation should take a final decision, that whether medical teachers should spend their time in laboratories, research and teaching or should roam in private hospitals to amass money to fulfill their needs which may be justified or not justified.

Institutional Private Practice

This should be allowed to medical teachers and Specialists of District and Tehsil hospitals. Elaborating this point, the following practical shape is suggested.

  1. The government hospitals already have private rooms or wards for admission of private patients. The patients may be admitted in these wards as before. But methodology of admission will be as follows.
  2. Patients coming to the outdoor may like to be admitted in private room or ward under a teacher by name. That should be allowed.
  3. If the private patient dos not name particular teachers as his consultant then the patient will be admitted as private patient under the unit on call that day.
  4. Patients admitted in emergency section may like to be admitted in private room or ward. If the patient names a particular teacher under whom he wants to be treated then the patient will go under him, otherwise the patient will be admitted as private patient under the unit on call that day.
  5. The reason to allow institutional practice is
  6. Not to deprive the public of skill of highly qualified doctors.
  7. Medical teachers have not to waste extra-time on these private patients as they will be visiting these patients while on their routine duty hours.
  8. This will be source of extra income for teachers and government will not have to pay for that. In addition, income to the government from this source of private patients will go towards giving special pay to medical teachers, and for patient care in general wards.

Charges of Private Patients and Share of the Doctors

Visit Fee: In the past a visiting surgeon or physician used to get Rs.14.00 only/visit. The patient was charged Rs.40.00 by the government out of which the consultant used to get Rs.14.00 only per visit.

  1. This was a big joke. Why a person will not see or treat a patient in a private hospital where he is free to charge any amount.
  2. The visit fee should be immediately enhanced adequately per visit in government hospitals and 80% of this should go to the visiting consultant. This should be reviewed from time to time.

Existing rates of operations and procedures should be revised upwards. To give concrete examples take the operation of appendix removal. In the past if a professor would do this operation, the government used to charge Rs.900.00 out of which 35 percent used to go to surgeon i.e. Rs.315.00. If this operation was done by Associate Professor or Assistant Professor the charges used to be less. The charges should be same for an operation who so ever performs that. 70% of this should go to the surgeon so that patient knows exactly what money his surgeon is getting. Charges of anesthesia and others who assist in the operation should also be enhanced

Radiology and Pathology Departments

At the moment, charges of an X-ray chest done in government hospital is only Rs.100.00 out which 35% goes to the reporting doctor. Similarly charges of other radiological procedures are very small. These should be enhanced and share of the reporting doctor should be enhanced to fifty percent. Similarly rates of pathology tests and procedure should be revised and share of doctors should be enhanced.

To go into finer details of this aspect of charges, a committee consisting of the following may be formed to prepare a report,

  1. An officer of Law Department.
  2. An officer of Finance Department.
  3. Additional Secretary Health (Technical).
  4. Professor of Medicine.
  5. Professor of Surgery.
  6. Professor of Radiology.
  7. Professor of Pathology.
  8. Professor of Gynecology & Obstetrics.

 Report should be discussed and implemented as soon as possible.

Teachers of Basic Sciences:

These fall into following categories.

  1. Professors.
  2. Associate Professor.
  3. Assistant Professor.
  4. Demonstrators, Senior and Junior.

At the moment, allowances given to the basic science teachers are non-practicing allowance if a teacher does not want to practice, and basic science teacher allowance. Due to less pay these teachers are also doing practice like general practitioners as they cannot compete with teachers on clinical side as consultants. As a result of financial problem, the basic sciences teachers waste their time in earning extra money to support their families and no real basic research in basic sciences is being undertaken in these departments. The private practice by teachers of basic sciences should be banned.

In lieu of ban on private practice, the following steps should be taken:

Professors: At the moment this category of doctors are in basic pay scale No.20, like their counter-parts on clinical side. In addition, a monthly teaching pay is being given to them. The total pay of a professor comes to round about one lac or more per month at present. The professors should be getting same special pay per month in addition to his pay of scale 20 as will be given to their counterparts on clinical side. The private practice should not be allowed and their shares in fee of tests should be enhanced as already suggested. Other benefits or secretarial help, accommodation, Phone, transport should be same as for professors on clinical side.

Associate Professor/ Assistant Professor: They should receive pay in their present scales. The special pay in lieu of ban on private practice should be adequate. Other benefits should be same as for their counterparts on clinical side. They will be allowed share in tests done in pathology laboratories.


Demonstrators: These doctors of basic science should also draw a special pay per month, in lieu of ban on private practice. They will also be getting share in tests done in pathology laboratories if they are posted in pathology department. It may be mentioned that at the moment the teachers of basic sciences have option to do or not do private practice and if someone does not do private practice he gets NPA. Demonstrators also get NPA (Non-Practicing Allowance).

The above mentioned Committee will arbitrarily propose the amount of special pay for a start. As the value of money will be depreciated in comings years, in order to end repeated agitation and demands of increase in special pay in coming years, the committee should recommend that the special pay should be three times the substantive pay at any time. This formula will end repeated haranguing’s etc.

DOCTORS IN GENERAL CADRE

District and Tehsil Physicians and Surgeons and other Specialists:

As these doctors are not in teaching posts, they may be allowed institutional practice, the details of which have been given already and rates should be revised in a similar ways as for teachers of medical colleges and the share should be the same. Any specialist who has built his own hospital or is in collaboration with a private hospital should be transferred from that place. Consultation fee should Rs.300—500/-

Radiologists and Pathologists in general cadre:

These should be allowed institutional practice and charges and share should be consonant with that of teaching hospitals already suggested. They should not be allowed to open their own laboratories.

Medical officers working in B.H.U and primary rural centers:

These posts should be non-practicing. Their pay in a consolidated form should be about double the equivalent of the pay of a doctor working in urban hospitals like in Lahore. The NPA should be sixty percent of the pay he is drawing at the moment. Government accommodation should be ensured to these doctors who are serving that section of our population who are producing what we eat and provide soldiers, farmers, labourers etc. A contented doctor at that place will be a blessing for our rural population. Recently some provincial governments have greatly increased salaries of this group of doctors which is a welcome step.

Medical Officers working in Tehsil and District Hospital: Private practice by these doctors should also be banned. But in lieu of that their pay should be at par with doctor working as a Registrar, Medical Officer or Demonstrator of a medical college or teaching hospital of Lahore. Government accommodation should be provided to them.

Medical Superintendent (MS): If a Medical Superintendent happens to be specialist then he should be allowed institutional practice as by other specialists. If he is not a specialist then his no-practicing allowance should be sixty percent of his pay he is drawing at that moment.His share in medicolegal cases should continue and should be revised upwards.

Director General Health: In addition to the existing scale of pay, he should be given following facilities.

  1. Government Accommodation
  2. NPA. This should be enhanced adequately
  3. Special pay also should be enhanced

These recommendations also apply to Director Health of regions, Chief Operating Officers (Health) and their equivalents in administrative post in the Health Department and in the field.

Further Clarifications:

1.If private practice of medical teachers will be banned in private clinics or at their residence and as institutional private practice will be allowed, there will be rush of patients for admission in government hospitals and the space may not be available to admit these patients in government hospitals. The solution lies in  making a crash program of building of rooms. Banks or private building concerns may be asked to build the rooms/ or private wards within six or nine months. These private concerns may be allowed to charge room rent to recover their costs on build and transfer basis. This increased number of beds for private patients can solve the problem of institutional practice.

The special pay which has been proposed for medical teachers needs more monetary expenses. That money can be generated from enhanced rates of visit fee and operation fee or fee of procedures done and government will not have to spend a penny.

  1. Rate of share of doctors should be converted to 70% from 30%.
  2. If government does not want to take a precipitate step of banning private practice by teachers in private hospitals then the following alternate steps are suggested.
  3. The teaching posts of medical teachers in medical colleges may be made non-practicing. Also the posts of District specialists may be made non-practicing. Institutional practice will be allowed, as suggested earlier to both categories.
  4. Option may be given for opting to be non-practicing to medical teachers but this option will be once only.
  5. In future all teaching posts advertised or departmental promotions should be made non-practicing.
  6. The government may ask the option from medical teachers whether they want to do private practice or not. Two categories will emerge.
  7. Those who want to do private practice as stipulated already by the government in their orders on selection by the public service commission.
  8. Those who only want to do institutional practice as mentioned earlier in the recommendations and are prepared to receive special pay. This will mean that a new contract will be needed.


In my opinion, the medical teachers should opt for institutional practice and devote their evening and nights to the cause of medical education, research and try to evolve original ideas and become leaders of the world in the medical field. Let us think cool headedly and revert to our heritage i.e. knowledge. However one point should be clear that no government employed doctors should be allowed to work in a private hospital or laboratories. A midway solution can be offered. Those who want to do private consultations at their residence as already allowed will not receive special pay. And those who do not want to do private consultation at their residence should receive special pay. Institutional practice will be allowed to both these categories of medical teachers.

Financial Autonomy

  1. This should be given to professors, e.g. the annual budget for development should be known to all professors. Both on college and hospital side, the amount available should be placed for allocation in academic council or hospital committee. Each professor should be allocated money for development of his ward/department.
  2. Stress should be placed on improvement of teaching facilities in the teaching hospitals which are lacking at the moment.
  3. Secretarial help should be provided to all professors for organizing the teaching, research and communication with other departments.

Time for Decision

  1. The medical teachers should realize that they are the role models for the students and doctors. Actions on the part of the teachers are emulated and discussed (widely). It is time that we revert to old tradition of not bargaining with patients. Let us be paid indirectly. Similarly, the private health sector should not thrive at the expense of government doctors which are the situation at the moment.
  2. At the moment government employed medical teachers and consultants are providing their services to the private sector, thereby enjoying a sort of double employment.
  3. By this double employment, they are depriving hundreds of consultants who are unable to get employment in government hospitals, medical colleges or in private hospitals. If government employed medical teachers and consultants do private practice only in the government hospitals, a very large number of unemployed consultants will get jobs and private health sector will have independent growth.
  4. It is time that nation takes a decision on the issue of streamlining private practice in the country in the best interest of public and medical profession.

NOTE: A petition about private practice by government doctors is pending is Supreme Court of Pakistan. Federal Government had prepared a very comprehensive plan to streamline private practice in all provinces of Pakistan. All the four provincial governments had agreed to that plan. The plan was to be submitted in the Supreme Court of Pakistan before Chief Justice of Pakistan, but hearing could not be taken up as President Pervez Musharaf removed Chief Justice of Pakistan a few days before it was to be presented in Supreme Court. After that it was not taken up by the government. The report had a phase wise implementation plan. Report can be obtained by the Punjab Government and by Governments of other provinces of Pakistan for   implementation.

The author is currently serving as Professor of Medicine at Islam Medical College Sialkot.  He is also a member of Pakistan Medical and Dental Council. He has also served as Ex-Commissioner, Punjab Health Care Commission, Ex-Dean (Academics) University of Health Sciences, Lahore, is former Principal and Prof. of Medicine at QAMC Bahawalpur, AIMC Lahore, SZMC Rahim Yar Khan, Akhtar Saeed Medical College, Lahore, Sargodha Medical College, Sargodha. He also served as Prof. of Medicine at King Edward Medical College, Lahore, Chief Executive AIMCH Lahore and is Chairman, Board of Management, Khawaja Muhammad Safdar Medical College, Sialkot. In recognition of his services, he was recently awarded Sitara-e-Imtiaz by Government of Pakistan.

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