OTR

Americanization of Pakistan’s Health Services

Speaking at the convocation of King Edward Medical College held on December 16th 1987 which was chaired by the then President General Ziaul Haque, Principal of KEMC Prof. Iftikhar Ahmad had remarked that “In Pakistan it is Lassi which rules over the Cream”. In his speech Prof. Iftikhar Ahmad recalled that it is the cream of the society which gets admission to medical colleges after doing FSc science while the left over “Lassi” joins other services including bureaucracy, business and opts other professions. He then gave details how after graduation after five years hard work, doctors do House Job, then do post-graduation whether within the country or overseas, then go abroad for further higher studies, return back to Pakistan to serve their country. They start as Senior Registrar and then after being promoted as Assistant, Associate and then Professor after many years of service, some of them eventually become Principal of the medical college. However, the system is such that the Principal is rendered helpless, useless, worthless, and hopeless since he cannot even sign the leave application of his teaching staff. Above all as if it was not enough, they are ruled by the Section Officers in the Health Department who all belong to the Lassi Group. It sent the entire audience including the President laughing.

When the President Gen. Zai Ul Haque came to address, he instead of reading the speech provided to him, decided to speak his heart out. He accepted the narration of Prof. Iftikhar, and pointing towards the then Federal Health Secretary Mr. Fazlur Rehman who was sitting among the audience, by which he clarified he meant the entire bureaucracy to respect the doctors, listen to their genuine grievances, ordered that they too like the civil serviced get Graee-22. General Ziaul Haque however, warned Prof. Iftikhar that the bureaucracy will never forgive him for this sin of speaking the truth and he as well as his other colleagues should be prepared to face the music. Similar advice was given to Prof. Mahmood Ali Malik Principal AIMC by Prime Minister Mian Nawaz Sharif while addressing the convocation of Allama Iqbal Medical College after listening to his hard hitting speech against the bureaucracy. Mian Nawaz Sharif also stated that if the bureaucracy tries to hurt him, he can contact him and he will come to his rescue. Mian Nawaz Sharif kept his promise and when Prof. Mahmood Ali Malik was due for Grade-22, the bureaucracy kept the file pending. When two days before his retirement, Prof. Mahmood Ali Malik brought this to the notice of PM Nawaz Sharif he ordered that all the file work related to his promotion in Grade-22 should be completed, order issued and the compliance of his orders be communicated to him immediately. Hence Prof. Mahmood Ali Malik got the letter few hours before his retirement on March 30, 1998. Perhaps, he had gone to his Farms in Sharqpur and the bureaucracy was looking after him to deliver the order before reporting it to the Prime Minister. (Thank you Mian Nawaz Sharif for keeping up your promise). However the time has also proved correct the apprehensions expressed by both the former President and former Prime Minister of Pakistan how the bureaucracy will continue to deal with the cream of the society, members of the medical profession in Pakistan.

During the last couple of years we have seen many initiatives by the bureaucracy to improve health services through Board of Governors, Hospital Management Boards, the office of Principal instead of being given any respect has been rendered ineffective or almost redundant. More recently the government has come up with a Medical Teaching Institutions Ordinance promulgated in Khyber PK and Punjab without any worthwhile and meaningful discussion in the provincial assemblies. The government says that it has no plan of privatization of healthcare facilities but if you read the MTI Ordinance carefully, it states that “those opting for employment under the MTI shall cease to be Civil Servants”. One of its provisions also states that “The individual consultants shall be held responsible for the most efficient use of the facilities and shall be expected to provide cost and income projections for each new facility, equipment or service request with the support of Hospital Director and staff.” If these contract appointments are so good that they will go a long way in improving the services and efficiency of the staff, why not extend this “Benefit” to the entire government machinery including bureaucracy, Police, Revenue department and others. Why this special favour is reserved for the members of the medical profession? Let all segment of society in public service avail this facility if it is so good. If it is not privatization, one can also give it the name of “Americanization of Pakistan’s Health Services” which if implemented the way it is being pushed, will create serious problems. Our problems in medical education and health services like all other sectors needs indigenous solutions which are feasible, practical, doable and can be implemented in a phased programme. Part-time Pakistanis who have never lived in this country, have never worked in the public healthcare facilities cannot be expected to realize the ground realities and they are not capable to offer cost effective solutions to the problems we are facing.

If this was not enough, Dr. Arif Alvi, himself being a member of the medical dental profession has signed yet another controversial Ordinance which has dissolved the previous PM&DC which has been replaced with Pakistan Medical Commission. Principal of a medical college has called it a “Medical Martial Law”. It does contain lot of useful things as well but while the objectives and intentions may be good, the method adopted to implement it in a haste without going through the parliament and having meaningful discussions with all the stake holders is not only foolish but baffling. The PMC will have all members nominated by the Prime Minister and it gives too much autonomy to the private medical and dental colleges who will now be free to accept donations for admission, charge higher fees, choose a university of their own liking for affiliation, set their own criteria for acquiring the services of faculty and so on. When we ask the medical colleges to produce good quality doctors, it is just ridiculous not to allow them the right to admit the students of their own choice. They must have this right but the fee structure must be monitored and affiliation with university also needs to be decided instead of leaving it to the sweet will of the medical and dental colleges otherwise it will create a mess like we see in all others sectors.

We also need to look into the fact as to why the medical profession finds itself in serious crisis today? There is no denying the fact that “They asked for it”. It was failure of the medical profession to put its house in order which gave an opportunity to outside forces to intervene. We have time and again pointed out in these columns that medical profession must evolve a system or self-monitoring and self-accountability. Failure to do so will have serious consequences. During the last “engineered elections” of the PM&DC (which has now become a hall mark of our country) when Prof. Masood Hameed VC DUHS became the President, the PM&DC was virtually dominated and converted into “Private Medical & Dental Colleges Council”. Owners of medical and dental colleges in council meetings allowed each other not only increase in the number of annual admissions but also increase in fees and start of numerous new programmes without any correspondent increase in teaching and training facilities and inspection. Intellectual corruption had become order of the day and there were serious allegations of financial corruption in the PM&DC. Even routine matters of registration, issuance of experience certificate, equivalence of degrees and confirmation of teaching experience had become so difficult that files either disappeared or never moved unless those in charge were looked after. The PM&DC management miserably failed to check and eliminate this financial and intellectual corruption. Hence, it provided a golden opportunity to those waiting for this occasion to strike. So in fact it is the medical profession itself which has to be blamed for the present state of affairs. They not only lack unity among their ranks, but they also lack sincere, honest, dedicated leadership which does not have a price tag and which can plead their case effectively with the authorities. Hence, the bureaucracy is intelligent enough to pick up some amongst their ranks and then use them to come up with various schemes, initiatives. In a country where the monthly remuneration of Rs. Twelve lacs of a world renowned Transplant Surgeon is questioned, where he is publicly ridiculed, humiliated and whose character assassination continues in the media for months together forcing him to leave the country but where a Cricketer gets a salary of Rs. Twenty eight lacs per month and nobody questions it, what is the future of medical profession in Pakistan is not difficult to imagine.

The question arises how do we move forward. The most Honourable way for the authorities will be to go to the Parliament, discuss these issues there, have meaningful dialogue, negotiations with all the stake holders, listen to their grievances and redress them if possible, pass the legislation with the help of the opposition. If this is not possible, then let us have snap elections and if the government thinks it is very popular and it is taking most popular decisions, let it come back with majority, pass the legislation and go ahead with its agenda. In democracy there is no room for dictatorship and such draconian laws and ordinances.

According to a report appearing Daily DAWN of October 25th, a leader of PTI Syed Zafar Ali Shah visited the camp of protesting PM&DC employees who have all been sacked to offer sympathy. He is also reported to have said that “Such an ordinance cannot last for even five minutes in the Court. He was sure that the Prime Minister was not taken into confidence about the ordinance, otherwise he would not have allowed such things”. It simply seems unbelievable. The authorities will be well advised that instead of listening to the Part-Time Pakistanis, they must consult, seek advice from eminent medical personalities like Prof. Kh. Saadiq Hussain and Prof. Mahmood Ali Malik both of whom had served as Principals of KEMC, enjoy tremendous respect among the doctors, are well known for the intellectual integrity and honesty and having worked in public healthcare facilities are also fully familiar with the situation. They can offer cost effective practical solutions to our problems in medical education and health services which can be implemented to improve the quality of not only medical education but also healthcare. Finally Dr. Zafar Mirza the Minister of State for Health will go back from where he has come but Dr.Arif Alvi the President and Prof. Yasmin Rashid the Punjab Health Minister must realize that they won’t enjoy the present position for all times to come. One day they will have to come back to the profession and how do they wish to be remembered by their own professional colleagues? They should play their role, convince their government and if they fail, the Honourable course left for them will be to step down and resign but if they fully support and agree with the measures being taken by the Government, it is another thing. Wish them good luck.

REFERENCES

1. When Lassi rules over the Cream. (Milk-cream+ Lassi). “Conscience Speaks” by Shaukat Ali Jawaid published by Pakistan Medical Journalists Association, Karachi. January 2005. Page 122-131. (First published in Off the Record column in DOCTOR International December 1st 2003.
2. PM Nominates nine members of Medical and Dental Council. Ikram Junaidi. Daily DAWN October 25, 2019. Page-2.

Tail Piece: Let us hope and pray that Punjab does not get its Bhutto.