Peshawar: Faiqa Bibi, 48years of age, was rushed to the nearest District Headquarters hospital, Gujjar Khan. She was brought to the Intensive Care Unit (ICU) unconscious and bleeding through her nose. According to the family, Faiqa was coming down the stairs carrying some luggage and tripped. Upon hearing her cry, they rushed to find Faiqa lying on the floor.
The accident happened in her village in Gujjar Khan, a one-hour drive from District Rawalpindi. According to the available staff at Emergency, Dr. Hameed, “the patient is in a very critical condition with a head injury. We do not have enough services therefore are referring her to DHQ Hospital, Rawalpindi.” The family faced the same dilemma many Pakistanis struggle with in the midst of a health crisis: whether to opt for public or private care for a loved-one. The family in distress immediately arranged a private ambulance and took her to Rawalpindi District Headquarters Hospital.
Reaching the DHQ hospital, the patient was admitted to ICU. “She is in comma and her 72 hours are very critical. If she survives, she can recover.” Faiqa survived, but was still in a coma. However after only a week, the doctors asked her family to take her home or to some other private hospital. “She might take a day, a week or a year to come back from comma. We cannot engage her in ICU indefinitely. There are more critical patients to be looked after.”
Faiqa was taken to another private hospital, and then moved home after one day. For one day the private hospital charged them 100,000 PKR for ICU, an amount unaffordable for the family. Faiqa is now brought to hospital every month for a checkup. A lot is being spent on her recovery phase. Pakistan’s public hospitals do not offer long-term care for patients in a coma.
An overwhelmed healthcare system
The 2017 census shows a picture of an overstretched national healthcare system that is trying to keep over 200 million people healthy through over 6,000 public health facilities. This means that on average, each healthcare facility is responsible for the health of 18,000 citizens.
Punjab province has almost half the public health facilities of Pakistan
The Pakistani government only spends about 1 rupee out of every 100 rupees of GDP (or of the money made in Pakistan) on public health. This is below the international benchmark. Data shows that the government spending on health sector has remained almost flat during the last decade with little money for upgrading the health facilities and controlling growing health menaces, like HIV and cancer, as the population swells. A rise in these diseases has been recorded since 2011.
How much the government spends on public sector health institutions?
Stagnant spending on public health by the Government in contrast with increase in population
Though, the percentage share of health care has increased from 2011 onwards, it is still negligible considering the population growth and number of people lacking access to health services. In terms of GDP, there is no considerable change on expenditure for public health.
Every two thousand people share one hospital bed in Pakistan
In 2009, Pakistan had just 100,000 beds available in all public facilities while the population for around 200million people, which means one bed for every two thousand people.
According to Pakistan Bureau of Statistics, the situation remains indifferent. As of today the doctor population ratio stands at 1: 997, dentist 1: 10658 and hospital bed 1:1584. Despite of significant investment in health infrastructure and reforms, the trend for health care delivery remains bleak. Key issues include a higher population growth rate, uneven distribution of health professionals, deficient workforce, insufficient funding and limited access to quality health care services.
What the government lacks in funding, it makes up for in specialized programs, often funded by donors. In Punjab, during the last ten years a lot of reforms including National Programme for Family Planning and Primary Health Care, expanded program for immunization, national HIV/AIDS control programme, Malaria control programme, TB control programme, health and mental illness programme have been implemented.
Due to this, the public health sector have highly capable centers for provision of specialized health facilities. These facilities range from basic medical services, outpatient services, emergency and accidental services, mother and child health services and specialized health services under all departments.
Public hospitals provide free of cost services (e.g. consultant fee, registration, admission etc.) or charge minimal rate (for tests and medicines). Basic tests are either free of cost or provided with minimal fee in public setups. Private hospitals charge two or three times more than public ones for the same services.
“The progress on indicators of health for women is alarming for Pakistan. Health budget is doubled and donors have also been extending aid in health sector especially reproductive health but unfortunately we fail to achieve the results,” said Ms. Khawar Mumtaz who is the Chairperson for National Commission for Social Welfare (NCSW).
According to Federal Minister for National Health Services, Regulations, and Coordination Ms. Saira Afzal Tarar “Our government recognizes access to quality health-care services an inherent right of every Pakistani. We have laid down health as a priority agenda, which is a clear reflection of our political manifesto.”
The Prime Minister National Health Program’s initiative is aimed to providing quality and affordable health services to all Pakistanis, providing financial protection to families in the form of free of cost Health Care services and Health Insurance. Thousands of poor patients benefit from the treatment facilities including deliveries, cardiac surgeries, cancer and other major diseases in the best private and government hospitals in their districts, without spending a single rupee. However, not all Pakistanis are privy to this benefit.
Public versus Private
The biggest question most Pakistanis have is whether the quality of care in private hospitals is actually better. Unfortunately, the data on the health of patients following treatment is a closely guarded secret, both by governments and private healthcare facilities. There are twice as many private health care centres as public in the twin cities (Rawalpindi and Islamabad). In contrast, for provision of services, only large scale private setups are equivalent to public hospitals, capable of providing comprehensive health services as that of public health centers, under one roof.
According to collected data, Public hospitals serve 200 people for every one person served in a private hospital. Every service in a private center comes with a cost, whether it be admission, registration, room, medicine, consultant, basic or specialized tests, advanced tests or therapies etc. These charges range and vary based on the setup and location of the private health center. There is no comprehensive study evaluating costs at different private hospitals or standardized fees. Nowadays private medical care is a money making business, whether it be a clinic, hospital or a teaching institution. Private medical colleges are charging beyond five million for MBBS studies.
Free medical and health services
Azeem, a 65 years old resident of Gulshanabad, Rawalpindi, got into an accident while riding his motorbike in August 2017. While taking a turn, he was hit by a car. He lost his memory due to a head injury. The emergency treatment was almost free at Benazir Bhutto hospital (BBH), Rawalpindi, a public institution. When referred for an MRI test at the same hospital, he received an appointment for two months later, due to a high volume of patients and shortage of MRI scanners. People suggested to bring a reference of a doctor/staff if they want the test report urgently. Having no reference, finally his family took him to a private hospital and paid around ten thousand rupees for this test.
Most of the patients are treated free of cost on daily basis in public institutions. Each doctor in a public hospital treats 10 times the number of patients treated by a doctor in a private setup. Due to continuous population increase, there is a long queue in public hospitals. This makes patients to wait for long hours. This, along with issues of staff attitude and poor hygiene motivates many people to invest in private care even if they have no idea of better quality.
“There are long, long queues. I have to wait for hours to get my turn. I have had to go through this since the private gynecologist takes 1000PKR for every visit. An ultrasound costs 2000PRK”, says Jamila who is pregnant and comes for a routine checkup at BBH, Rawalpindi.
“For minor tests and treatment, I prefer my family to nearby private clinic. It saves time and is a better alternative since we can afford it. Private hospitals give one to one service and they charge for it,” says Abdul Rasheed, who works in a private company in Islamabad.
Parveen Begum, a parent of three special needs children, all deaf and mute, resides in a poor area of Rawalpindi. “I work in people’s homes to make ends meet. Cost of health is an added expense every month. Public hospital is far from my home and there are long queues. I am illiterate, my kids need extra attention. It makes it difficult to get free services in hospital. I take kids to nearby private clinic.”
Health care specialists’ views
Health care specialists at public hospitals claim to be overwhelmed by the number of patients. Doctors cannot treat or see hundreds of patients daily. This forces them to treat them quickly, unlike the attention and care given in private centers. Many staff at public hospitals believe that there should be nominal charges at OPD so that patients are motivated to evaluate whether their problem is serious enough to warrant a visit to a medical facility.
“There are hundreds of patients in OPD on daily basis for only 10 doctors. We hardly get time to drink water or have a tea break. Most of them are from poor background and illiterate. It takes time and intelligence to ensure their health and hygiene,” says Dr. Rubina, a gynecologist working at DHQ Rawalpindi.
“I sometimes think of switching jobs. Treating patients, rushing constantly, frustrates me. Being a health care provider, I cannot respond to patients, often angry, for standing in long queues or not getting a turn”, says Jameela, a nurse in infant’s vaccination area, Paeds OPD in HFH, Rawalpindi. According to her she has to treat a thousand infants and children for basic vaccination on a daily basis, during her five-hours long duty (9am to 1pm).
“We cannot concentrate or give complete attention to patients, as we have to see all who arrive before 1pm every day. If they want attention they should go to some private clinic,” says Altaf, a technician at Eye department in Poly Clinic Islamabad.
“Our hospital is offering the best free-of-cost services in Rawalpindi district. Staff is capable and equipment is also available for 24×7 free facilities. It is always congested. On daily basis 2-3 patients have to share a bed for post-operation care. We cannot deny services. ” says Muhammad Khawaja who is next to Medical Superintendent at BBH, Rawalpindi.
“Population is growing and the resources are limited. Therefore patients are not satisfied. The best solution to semi-privatize the public hospitals,” says Dr. Aleem, an ENT specialist at Shifa International Hospital.
Informed healthcare decisions
Unfortunately, Pakistani families do not have enough information to make smart decisions about seeking the best healthcare in the face of a surging population and underfunded medical system. During the investigation some of the basic questions were found that the Ministry of Health makes it very difficult to answer:
- What is the quality of my local healthcare facility compared to the local private clinic?
- How has my public clinic been rated by the Ministry of Health compared to other facilities?
- How long is the wait for specialized treatment at my local healthcare facility?
- Does my public facility have any problems with staffing shortages or disease outbreaks based on hygiene that I should be aware of?
- How can I compare the quality and price of private healthcare in my region?
Midhat, a mom of two visits a nearby private health center for basic vaccination of her kids. “The nearby public hospital is so messed up. I have to wait in long queue, sometime an hour and more, to get my children vaccinated. So I pay extra to be served first in a private clinic”.
The plight of health care in Pakistan needs more attention and resources. The 18th Amendment has led provinces to manage their own priorities, each leading on a different agenda. However, a ray of hope exists. Midhat, Faiqa, Azeem and other Pakistanis are hopeful that Pakistanis will get an improved access to health care in near future.