Political parties and medical profession continue to play politics with Health and Medical Education

Merit is often ignored or compromised during selection, appointments
Political parties and medical profession continue
to play politics with Health and Medical Education
Neither Politicians nor HCPs seem to be serious in meaningful reforms
in health sector as they try to promote their petty personal vested interests
A debt ridden country wastes billions of rupees annually on lunches and
dinners at Five Star Hotels during medical conferences some of which have
no worthwhile scientific programme
If political will is there, Simple administrative measures can check over 50%
of unethical practices by pharma industry and healthcare professionals

By Shaukat Ali Jawaid

KARACHI: None of the political parties of Pakistan has got any functioning Think Tank or Experts Group on Health to guide them with the result that whenever they get a chance to form government, they hand over the Health portfolio to their friends, relatives or party loyalists. It is not only the politicians alone, even the medical profession as a whole is also responsible for the present state of affairs in the health sector because it lacks sincere, honest representative leadership. In fact neither the politicians nor the healthcare professionals seems to be serious in any meaningful reforms in health sector as both have been found over the years trying to promote their petty personal vested interests rather than thinking what is good for the country.

One should also remember that any health reforms which are introduced, imposed without any meaningful discussions, deliberations with all the stake holders cannot work in the long run and that is what has been happening all these years. With the change of government, the plans and policies also change. The Health Train of Pakistan has too many drivers each one of them pushing it to a different direction with the result that we have failed till today to even provide essential primary healthcare to the entire population.

Failures of PPP and PML (N)

Pakistan People’s Party and Pakistan Muslim League (N) got chance numerous times to govern but they can claim only limited success in certain areas but none of them were ever able to have meaningful discussions with all the stake holders to plan a long term reforms in health sector. While PPP can take be proud of its NICVD project, Gambat Institute of Medical Sciences, conditions in many healthcare facilities in rural Sindh in particular even today present a dismal picture which needs immediate attention.

Both the parties played Football with the deceased PM&DC which over the years had become a den of corruption with the result that nothing could be done without greasing the palms of concerned staff. For every petty matter, even registration certificate had to be bought at a price. A few years ago even it was virtually converted into “Private Medical & Dental Council” since majority of the council members belonged to the primate medical institutions. The only thing it efficiently did was to allow each other increase in the number of seats in their respective medical and dental colleges, starting new programmes in different disciplines irrespective of the fact whether they had the requisite teaching and training facilities. So one should not blame the politicians alone but all those healthcare professionals who headed this body for many years from time to time are also guilty of this crime of destroying the healthcare and medical education system in Pakistan.

Failure of PTI Government

When Pakistan Tahreek-i-Insaf formed the government in 2018, it made the things worse. It not only disbanded the PM&DC but established Pakistan Medical Commission about whom and its performance, less said the better. A non-entity was selected to head this body while a lawyer it is alleged takes all the important decisions. It must be a matter of shame for the entire medical profession that the government could not find a suitable person to head this body. The mess it created with MDCAT examination, the way the contract for conducting this exam was given to an organization, the way it was established are all now a well-known secret. The matter eventually went to the courts and PMC had to withdraw many of its decisions.

When Dr. Zafar Mirza was brought in as Advisor on Health from overseas, I had told a common friend in WHO EMRO that he won’t survive for long and will be shown the door very soon. That is exactly what happened. Dr. Faisal Sultan is an eminent infectious disease specialist, a gentleman but running the Health Ministry efficiently was too big a task for him. However, he did commendable job in the Covid19 pandemic. Dr. Yasmin Rashid was given the responsibilities of Punjab Health Minister which was welcomed by the medical profession. An eminent Professor of Obstetrics & Gynaecology, she has remained an important leader of Pakistan Medical Association who had been struggling throughout his professional career for the rights of the medical profession and improvement of working conditions in the hospitals. But when she got a chance, she also failed to take along even the PMA leadership for reasons which are not difficult to understand. PMA has remained very critical of PTI Government’s actions, decisions in the health sector. The Government even formed a National Task Force on Health which included many distinguished healthcare professionals and one had high hopes that it might come up with some reforms but it never materialized. Once I asked a member of this Task Force as to what was happening, who pointed out that meetings are held, many important issues are discussed, and recommendations made but the decisions taken at the end are different. Fed up and frustrated with this state of affairs, some members of this task force resigned but the Prime Minister Imran Khan was quick to reconstitute this Task Force with new members.

During the PTI Government, guards of a provincial health minister injured a faculty member in Peshawar, lawyers ransacked the Punjab Institute of Cardiology which resulted in lot of damage to precious equipment, and patients had to be wheeled out of the ICU and Emergency to save their lives. Some patients also died. This is perhaps one of the unique incidents in the world but the Punjab Chief Minister was seen nowhere. However, it was very courageous on the part of Prof. Yasmin Rashid to have come to the rescue of the staff of PIC, she reached there and tried to control the situation for which she must be commended. Protesting young doctors were beaten, tortured, arrested in Quetta for demanding improvement in their working conditions. The problem with the PTI Government has been that most of its advisors were those who it is alleged are called as Part-time Pakistanis whose families are settled abroad, who have no stake here and they are also ignorant of the ground realities.

Sehat Card Scheme

Sehat Card was a good initiative take by the PML Government many years ago and it was later adopted by the PTI Government as well but the way it was used, left much to be desired. This Sehat Card should be only for those who have no source of income or extremely poor but not for everyone because a country like Pakistan do not have the finances to afford such initiatives. Even the former Prime Minister once announced that it was a revolutionary programme for the poor something which has not been taken even by the British Government. He was absolutely right because government in UK won’t initiate any programme which cannot be implemented for which it has no financial allocations and they also cannot take any U turn. In fact some were also playing politics with Sehat Card which is evident from the announcement made by Shahbaz Gill a member of the Prime Minister’s spokespersons that “A Sehat Card has also been issued in the name of Mian Nawaz Sharif, He can spend up to ten lac rupees and if need be, his allocations will also be increased”. This is the same Shahbaz Gill who had earlier commenting on the advisory role of Prof. Abdul Bari Khan and Dr. Saad Khalid Niaz, to the Government of Sindh on Covid19 pandemic had remarked that “both these persons are supporting the Sindh Government because they also wish to be appointed as Medical Superintendents of some hospitals.” Little did he know that Prof. Abdul Bari Khan is heading the well-known Indus Hospital Health Network which is running many healthcare facilities and Saad Khalid Niaz is a distinguished Gastroenterologist of Pakistan who has been offering his free services in Civil Hospital Karachi for the last many years and in recognition the Government of Pakistan had offered him a Civil Award. But since people like Shahbaz Gill do not live in Pakistan, they do not know these people and their statements bring lot of bad name and embarrassment to the party.

Positive steps taken by
PTI Government

However, it will be unfair not to commend some good things done by the PTI Government. One of this was the initiative taken to increase Drugs Exports. Speaking at the Pakistan Pharma Export Summit 2021 held at Islamabad on September 29th 2021 Mr. Abdul Razzak Dawood Prime Minister’s Advisor on Commerce announced that the decisions regarding pharma industry will henceforth will be taken by the Commerce Ministry and not the Health Ministry. The issues of drug pricing will be rationalized, pending issues of drug registration will be accelerated, DRAP will be strengthened and all government regulatory bodies will act as facilitators. The industry problems will be resolved on priority basis. In fact he announced the acceptance of all the demands by the PPMA leadership. The vital role in all this was played by Mr. Tariq Ikram who had rich experience of himself working in a Multinational pharmaceutical company. Later he also headed the Trade Development Authority of Pakistan. His professional advice was accepted. Even Mr. Razzak Dawood announced that members of the PPMA must benefit from Tariq Akram’s expertize as his presentation at the conference included many pearls of wisdom. Such positive decisions are only taken when the government listens to professionals. Sincere efforts and initiative taken by Prof. A.H. Amar insulin and free medications are being made available to the people suffering from diabetes in KPK.

Selection of a HCP for
President of Pakistan

The PTI leadership also needs to be commended for having selected a healthcare professional a distinguished dentist for the coveted post of President of Pakistan. However, it is another thing that Dr. Arif Alvi’s performance remains disappointing. He could not help his own dental colleagues by getting the Pakistan Dental Association and Dental Act for which he used to struggle in the past. He will be remembered not only for the number of Ordinances he issued but also for the reference he sent to the Supreme Court of Pakistan against an honest, upright man of integrity Mr. Justice Qazi Faiz Isa. For almost two years PTI Ministers ran a malicious character assassination campaign not only against him but also his wife. Now even the PTI leadership has admitted that sending this reference was a mistake but the damage is done. PTI needs a public apology to Justice Qazi Faiz Isa and his wife if they wish to close this chapter.

Imran Khan must have by now realized that leading a team of cricketers is different than a team of politicians in which he had no experience. He was let down by his own arrogance, sycophants who surrounded him, incompetent ministers and foolish advisors.

Unethical practices by
HCPs & Pharma Industry

Unethical medical practices by the healthcare professionals and unethical marketing practices by the pharma trade and industry can be effectively checked just by simple administrative measures to a great extent if there is a political will. The National Bioethics Committee had prepared the Guidelines which if implemented in letter and spirit can eliminate almost 50% of these unethical practices. I had personally presented a copy of these Guidelines to Saira Afzal Tarrar Federal Health Minister in the PML (N) last government but I am sure she never bothered to read it what to expect of its implementation. That only shows the non-serious attitude of those who are given the health portfolio. We are a debt ridden country which has successfully failed to throw away the begging bowl, we are all the time asking for help and assistance from friends. Hence how can we afford the luxury of wasting billions of rupees every year for lunches and dinners at Five Star Hotels in the name of medical conferences a vast majority of which are just social get-togethers of doctors with their families and have very little scientific value, of course there are always some exceptions. Why cannot these academic activities be shifted to medical institutions or if it is essential to hold them in a hotel, the expenditures can be reduced to a great extent since all this is sponsored by the pharma trade and industry which eventually passes it to the poor patients in the shape of expensive investigations and treatment.

Pharma industry is forced by some leading private hospitals to supply their drugs at almost 50% of the price and then they add another 15-20% as service charges while billing it to the patients. Not only that in some cases, the price charged is of brand name while the drugs dispensed are economically priced generics. This way these hospitals make lot of money even on drugs. This practice was first started by a leading private hospital in Karachi and later it was adopted by almost all the leading private hospitals. All this goes on unchecked due to lack of any monitoring and accountability by the regulatory bodies.

Essential Drugs List &
National Formulary

Many countries in the word have benefitted from the Essential Drugs List concept by WHO since many years but Pakistan has failed to implement it. We do not have a National Hospital Formulary though some steps were taken in late 80s but it never got implemented. Pakistan Pharmaceutical Manufacturers Association has offered to the government numerous time that it will just need about sixty to seventy billion rupees which can be shared by the Federal and Provincial governments and all the essential drugs which cover common diseases can be made available at all pubic healthcare facilities free of cost. Mr. Zahid Saeed former chairman of PPMA even offered this to Dr. Faisal Sultan Advisor on Health in the PTI Government at the Pakistan Pharma Drugs Export Summit held at Islamabad in 2021. It is high time that some measures are taken to control this CC virus (Corruption and Commercialization) which has infected the members of the medical profession.

Restore the autonomous
independent PM&DC

Let the government waste no time, start dialogue with all the stake holders, listen to the professionals, disband PMC, restore the independent autonomous Pakistan Medical & Dental Council with elected members which should also have some non-medical members (professionals from Trusts, Foundations running health and educational institutions not politicians) to check and monitor their performance. Decentralize PM&DC giving powers of registration and other routine things to the regional offices, use information technology and reduce the personal contact as far as possible. PM&DC in fact worked very well and most efficiently when it was headed by Retired Justice Shakirullah Jan. We do have many academicians, well known medical personalities with known professional integrity who can be given the responsibilities to head PM&DC.

Even it was for the first time that it also invited professional medical editors to be members of the Medical Journals Evaluation Committee on the advice of Prof. Arshad Javed, the then Vice Chancellor of Khyber Medical University. This committee did lot of useful work to help and assist, facilitate various journals to improve their quality and standard. Unfortunately once the PM&DC was disbanded, PMC was established, it shifted the evaluation of Health Science Journals to HEC which has no one with a medical background. A noted researcher and former faculty member from Aga Khan University, it is alleged has played a very dirty role and he can be given credit for all the problems and difficulties which the biomedical journals in Pakistan are facing these days. It has been pointed out time and again by Pakistan Association of Medical Editors (PAME) to Chairman HEC and other officials that the step they were taking will neither help to promote research culture in the country nor will it enhance Pakistan’s contribution to world medical literature. We need to promote our own journals providing opportunity to Pakistani researchers to publish their research work in Pakistani medical journals since publication overseas is very expensive and many researchers cannot afford it. PAME has offered it’s expertize to the regulatory bodies but no one seems to be interested.

Restore PKLI in its
original shape

Let the Government of Punjab restore Pakistan Kidney and Liver Institute in its original form. Hand it over to Prof. Saeed Akhtar the distinguished transplant surgeon whose brainchild it was and let him run and manage the way he had planned. It will encourage others Pakistani doctors overseas who wish to establish such institutions in Pakistan. They should not only be encouraged but also provided some incentives like free land etc. It is not the government’s job to run such facilities but manage them through public private partnership which is much more economical and can be managed efficiently as well.

Strengthening Public
Healthcare Facilities

Sehat Card scheme is useful and must be continued but limited to the most poor, deserving families only. Pakistan can ill afford the luxury of providing this card to everyone. Let us expand, strengthen the public healthcare facilities which remain the last ray of hope for millions of patients who visit them and get benefit daily. Policies of the previous government ignored the public hospitals and promoted the private health sector. Private medical and dental colleges can be given some incentives and in return they should be asked to provide basic healthcare facilities in their adjoining districts. They can take responsibility of different districts. Using the Public Private Partnership concept, they can use the BHUs, RHCs, collaborate with Tehsil Hospitals, and participate in preventive services as well. It will also provide an opportunity to their students for training. A proper referral system can be worked out so that only those visit public hospitals in major cities who really need specialized care. It will reduce rush in public hospitals as well. All this is workable provided long term plans are prepared after consultation and input from all the stake holders.

Since after the 18th amendment Health and Education is a provincial subject, let the respective provinces take control and run, manage the hospitals located in their provinces still under federal government. However, do strengthen their monitoring. In the past the medical profession used to complain that institutions like JPMC at Karachi were being managed with remote control from Islamabad. When they were transferred to provinces, it was again opposed by a section of the medical profession and staff. We have failed to resolve this issue for the last many years. Let this be resolved once and for all so that the development of these institutions is not retarded and checked any further.

Higher Medical Education

Ideally higher medical education should be taken over from HEC and shifted to Ministry of Health which should be renamed as Ministry of Health and Medical Education. Let us have eminent medical personalities, academicians and medical educationists run and manage this ministry which will result in rich dividends. We need to learn from the experience of countries in the region instead of looking towards Europe and America all the time. We need indigenous cost effective solutions to our problems and there is no death of talent within the country which once identified can be given these responsibilities.

Why Posts of Principals of medical colleges, Vice Chancellors of medical unvisited are kept vacant and people given acting charge on adhoc basis. If the decisions has to be taken on merit and not to favour friends and party loyalists, the health departments must make arrangements months before the incumbent of these institutions are due to retire. Search committees can be formed much in advance, interviews held and people selected who should take over the day people on these coveted posts retire. Even if someone has to be given an extension, it should also be decided much in advance.

We as a Nation need to do some soul searching. Listen to our conscience if it is not dead. Show tolerance and patience. Control our expenditures, contribute our share to strengthen Pakistan’s economy, start self-monitoring and self-accountability, and learn from our mistakes which we keep on repeating years after year. So far we have not learnt any lesson from our failures in different fields. We have all the resources, human resource as well, talent and capabilities to turn around the country into a progressive modern social welfare state as envisaged by our founder fathers. What we need is political stability, democratic order. All institutions working in their domain as defined in the constitution, ensure free and fair election, speedy justice and equal opportunities to all upholding merit all the time. Will the Pakistani politicians and the leadership of the healthcare profession wake up and decide to take the decisions in the national interest, prepare plans which are feasible, practical, can be implemented easily and sustain in the long run, only time will tell.