Bureaucracy and most others involved in decision making in Pakistan suffer from Processionary Caterpillar Syndrome – Prof. Shahzad Ali Khan

Reluctance to change, failure to opt for innovations, following old
customs & traditions, old habits have not helped us reach anywhere.
Surprise visits by Chief Ministers will not improve functioning
of hospitals as we need to change the system

ISLAMABAD: Some of the problems that we face in the field of medical education and healthcare need simple solutions and they can be easily managed while others need a revolutionary change in the system. However, since bureaucracy and most others involved in decision making process in Pakistan suffer from Processionary Caterpillar Syndrome, there is reluctance to change and failure to opt for innovations. We keep on following the old customs and traditions, are not prepared to change old habits, hence we seem to be going nowhere. This was stated by Prof. Shahzad Ali Khan a public health expert, Dean and Vice Chancellor of Health Services Academy Islamabad. He was making a presentation on “Leadership in Health in challenging times” in Institute of Leadership Excellence (ILE) Webinar series on Leadership in Healthcare on April 3rd 2024. The Webinar attracted a number of eminent medical personalities who also made some useful contribution by actively participating in the discussion which followed.

Prof. Shahzad Ali Khan

Explaining the concept of “Processionary Caterpillar Syndrome”, Prof. Shahzad Ali Khan pointed out that these Processionary caterpillar insects move through the forest in a long procession feeding on pine needles. They drive their name from their habit of following a lead caterpillar, each with its eyes half closed and head fitted snugly against the rear end of the preceding caterpillar. Jean-Henri Fabre a renowned French Naturalist did an experiment with these Processionary caterpillars. He was able to entice them on to the rim of a large flowerpot.

He succeeded in getting the lead caterpillar to connect up with the last one creating a complete circle which moved around the pot in a never ending procession. Fabre thought that after a few circles these insects would discover their predicament or become tired of their endless progression and move off in another direction. But they never varied their movements and kept on moving in the same circle.

Through the force of their habit the caterpillars kept moving relentlessly around the pot at about the same pace for a period of seven days. They might have continued even longer if they had not stopped because of sheer exhaustion and hunger. As part of the experiment, Fabre had placed food close by in sight of the group. However, since it was out of the path of the circle, they continued in the procession to what could have been the ultimate destruction. In the procession these insects were blindly following their instincts, old habits, past experience, past practices, traditions, customs and precedent, the way they always had done in the past. In reality eventually they died and got nowhere. This is exactly what our bureaucracy and most of those involved in decision making processing are doing for the past over seventy years. The decision makers want to know is there any precedent? No proposal will be approved by the bosses if there is no precedent. We all are working like caterpillars as we suffer from this syndrome. The result is before us all as we have failed to reach our desired destination to become a progressive, social welfare state where justice is seen being done, everyone gets equal opportunities to develop and progress. He then referred to a famous saying “It is a form of insanity to do the same things over and over again and then expect different results”, he remarked.

Dismal Health Indicators

Sharing the dismal health indicators of Pakistan, Prof. Shahzad Ali Khan pointed out that Paksitan has the highest number of people suffering from diabetes i.e. 17% of our people suffer from diabetes and another about twenty percent are in a pre-diabetes stage. We have the fifth largest number of patients suffering from tuberculosis. We have the highest neonatal mortality rate in the word and our struggle against polio continues as Pakistan and Afghanistan are the only two countries where polio cases are still being identified. The prevalence of diarrhoea is 21%, Pneumonia 11% in children, about 9% have Hepatitis-C and 4% suffer from Hepatitis-B.

Our 28.4% urban and 23.3% rural population are overweight, 20% population between 15-40 years have high cholesterol, and 25% over eighteen years and 36% above forty years are suffering from hypertension. Almost 40% of pregnant women suffer from anaemia, 65% urban and 79% rural population take less than one serving of fruit daily, 28% men and 8% women use tobacco daily. Almost 90% of our population do not take salad which has now become a luxury for the affluent class only. In leisure time, 90% of our population is inactive, every hour one Pakistani dies in road traffic accidents and every hour forty seven people die of heart diseases (60% under sixty years).

Nutritional Indicators in children

As regards our nutritional indicators among Under-5 children stunting is seen in 41%, 29% are underweight, 18% suffer from wasting, and 48% suffer from anaemia, 19% from Zinc deficiency. Only 36% are able to get some supplementary feeding. If this was not enough minimum dietary diversity is seen in 14% .Minimum acceptable diet is available to just 3.6% children. Deworming was routinely practiced in the past which had good results but one does not know why this useful practice has been abandoned and now we have just 13% deworming coverage. Another 13% children suffer from functional disabilities. Forty-four percent Pakistani women suffer from anaemia and Vitamin-D deficiency is seen in 79%.

Between sixty to seventy percent of our population in urban and rural areas are at the borderline of poverty. Out of pocket health expenditures by the population is the most common reason of their poverty. Public sector looks after health needs of just 30% while 70% of the population is looked after by the private sector.

Prof. Shahzad Ali Khan further stated that 21% of couples who wish to practice family planning are not getting the facilities at public hospitals. There are serious issues of supply chain management. If these issues are resolved at least it will reduce our fertility rate and check population explosion to some extent.

Per Capita Health Expenditures

Out of one hundred eighty-nine countries, Pakistan stands at 150th place as regards HDI. Government’s general health expenditures are about 9.7% of its total expenditures. About 34% of healthcare cost is born by government while 64.4% by private, almost 89% of these health expenditures are out of pocket by the public which then pushes many of them below the poverty line every year. Prof. Shahzad Ali Khan also disclosed that it was a misconception that donors are running our health programmes. Out of twelve hundred billion spent on health, donors contribute just 2% while 98% are paid by the people of Pakistan, he remarked.

Per Capita Health Expenditures: Paksitan Prof. Shahzad Ali Khan disclosed has the lowest per capital health expenditures in the region which is forty-five US dollars as against Sri Lanka 127 US$, India 76 US$, Afghanistan 50 US$. Paksitan spends just 1.1% of its GDP on health while it is 9.7% in Afghanistan, 3.6% in India, 3.8% in Sri Lanka and 2.4% in Bangladesh. In view of all this, we are passing through desperate times and need innovative solutions. But with Processionary Caterpillar Syndrome with which our planners and decision makers are afflicted, we cannot move forward. To bring in any change, it needs bold, courageous, decisions by the authorities.

Prof. Shahzad Ali Khan also disclosed that when President General Ziaul Haque came to inaugurate the Pakistan Institute of Medical Sciences built by the Japanese, he asked where is the Out Patients Department? He was told that it is a tertiary care hospital no walk in facility at which he got annoyed. Hence, in emergency OPD block was constructed. All teaching and other tertiary care hospitals, should not be a walk in facility but should only cater to the referred patients so that they can get specialized care. We should have a network of well-equipped Dispensaries in the big cities and with functioning Basic Health Units, Rural Health Centers which are properly monitored and every one held accountable, we need to establish a proper referral system so that only those referred from these facilities are entertained at the tertiary care facilities.

We need to study the rise and fall of various organizations, institutions. Critically look at their failures and try to learn some lessons. Similarly, our leaders should also look at their failures and try to learn some lessons, he opined.

Six Levers of Change

The six Levers of Innovation, Prof. Shahzad Ali Khan mentioned included value proposition, supply chain improvement and targeting the customers in the business model innovations while taking care of products and services, using the new technologies drawing benefit from revolutions in technology in different fields and enabling to use these technologies are covered in technology innovations. How many of our healthcare facilities and medical institutions are using the latest technology, Telemedicine, information technology, Electronic Health Records, Health Management Systems very few in the public sector while in the private sector institutions like Indus Hospital and Health Network, Shaukat Khanum Cancer Hospital and Research Center and a few others have become or are fast becoming paperless facilities.

While public hospitals have failed to make any progress, private hospitals are flourishing and they are expanding, have ambitious modernization and expansion plans for the future.

Fifth Discipline

Prof. Shahzad Ali Khan while talking about the solutions to the above mentioned problems, referred to the Fifth Discipline advocated by Peter Singe in 1990 which is based on Reactive Vs Creative, Creativity and Innovations. In this the most important he stated was Personal Mastery. The leader himself/herself should be competent and intelligent and earn Mastery in his subject of interest and discipline. There is always room for improvement and one keeps on learning every day. Anyone who thinks he or she knows enough is a failure. The next comes Mental Models. Day Dreaming he opined, is extremely important one should think in improvement in all directions. Before implementation do simulations. Those who are day dreamers are good leaders. They keep on doing something. Remember, all good leaders are a bit abnormal. Only they can think of innovations and have the courage to take bold decisions and do new experiments. Then leaders should have a shared vision. A leader might have his own viewpoint but he or she must listen to others. Look at the institution, organization from others eyes and try to read other peoples mind as to what they think about you.

Team Building was yet another important aspect of good leadership. Finally one should try to understand the system. Those who understand the systems becomes successful and we can see such people all around us. I do not mean that one should do or indulge in any unethical practices but try to understand the system in which you have to work. It requires to work in certain directions to be successful, Prof. Shahzad Ali Khan concluded.

Discussion

Mr. Shaukat Ali Jawaid Chief Editor of Pakistan Journal of Medical Sciences moderated the session. The first question he asked was that establishing of Filter Clinics should not be difficult in major hospitals and secondly why the clinicians are keen to occupy administrative jobs since hospital administration was a distinct separate discipline in itself. Prof. Shahzad Ali Khan responded by saying that that wherever a Filter Clinic is established, it is manned by Medical Officers.

They are the unwilling workers and it is said that only those who are to be punished are posted there. Filter Clinics should be manned by competent general physicians and general surgeons who can take care and dispose of many patients, referring only those who need specialized care.

Prof. Shahzad Ali Khan further stated that that we have been telling the government that their job is to make policy and give guidelines not service delivery. No country in the world can ensure hundred percent healthcare to its population. The Health Card should be only for the poor but all others must pay for the service through health insurance. It is not only those who do Masters in Public Health but also clinicians should learn hospital management. It is science.

All those who do MPH should have a few months extensive training in hospital management as well before they are given these responsibilities. When clinicians take up administrative jobs, it is double dis-service first they won’t do the job for which they are trained and supposed to do and secondly they being no experts in hospital management, will be failure. Posting them on administrative jobs was more dangerous and wastage of resources.

Participating in the discussion Prof. Maj. Gen. (Retd) Muhammad Aslam former Vice Chancellor of UHS Lahore pointed out that WHO recommends the utilization of 6% of GDP on health by the Asian countries. However, we in Paksitan spend just a little over 1% which is the lowest as compared to other countries in the region. Filter Clinics where established were just doing Triage of patients which does not serve the real purpose and there is tremendous rush at all the teaching hospitals and tertiary healthcare facilities.

Prof. Bashir Sheikh from Chandka Medical College remarked that nobody bothers to visit the centers located in the periphery in different regions. Resources are often misused. Bureaucracy gets everything but at hospitals and medical colleges, we always suffer from scarce resources. What and how we are doing in the periphery nobody bothers. Pakistan has been affected the most by climate change. We need to ensure judicious use of the available resources.

Prof. Shamsa Humayun from Lahore remarked that tertiary care hospitals are involved not only in service delivery but also teaching, training and to some extent in research as well. In view of the scarce resources it is not possible to come up to the expectations of patients visiting these hospitals. We need to promote life style medicine and prevention of diseases which should get preference, she remarked. Few others also participated in the discussion and one had to wind up the session because of Ramadan.

Institute of Leadership Excellence (ILE) it may be mentioned here is an entity established by PharmEvo Pharmaceuticals and it is one of its Corporate Social Responsibility projects. The company enjoys a leadership role in ethical marketing and is engaged in numerous initiatives aimed as professional capacity building of healthcare professionals.