Pakistan is in the state of transition. Its economic base is broadening. With developments in healthcare, especially specialised healthcare in the shape of better qualified and experienced HR, premium diagnostics, treatments and affordability, the life expectancy is increasing, leading to an ageing population. Population growth seems uncontrollable.
Economic migration towards large urban hubs is on the rise. This has led to changing demography, rapid urbanisation but more importantly, an unhealthy lifestyle. Most of us are now couch potatoes – [we consume] more fast and precooked foods that are full of calories and [make us more prone to] non-communicable diseases especially diabetes and cardio vascular.
It would be safe to say that chronic and non-communicable diseases are overtaking communicable diseases as the former are now the leading cause of morbidity, disability and mortality.
The government is fully cognisant of this and has therefore invested in the three indicators that (in its opinion) can turn the situation around.
Firstly, the health sector’s overall budget has been increased from Rs18 billion in 2012-13 to the present Rs36 billion (this is based on eudget Estimates. Revised estimates will be much healthier).
This has improved the per capita spending indicator from $6.92 to $12.44. The positions of doctors have been increased from around 2,500 in FY 2012-13 to over 4,700 presently. This has improved the population per doctor ratio from 6312:1 to 4,249:1. However, we are still far short of the WHO standard – 1,000:1 – but we will get there in the next five-year plan.
The number of beds in government hospitals in KP have increased from 12,114 in 2012-13 to 18,185 at present, with around 5,000 more in the pipeline. This has improved the indicator of beds per population from 557 to 485. However, we are quite shy of the international average of 384.
The pertinent question to ask us is, is all this being done at the cost of primary and preventive healthcare where small investments now pay huge dividends in the foreseeable future? Are we stuck in the vicious cycle of strengthening tertiary care as compared to secondary and primary healthcare? And (my colleagues may not like it), are we wasting precious resources at Basic Health Units by posting too many doctors there (primarily meant for preventive healthcare).
That brings me to the most critical point (and issue) in any healthcare system – the three international frameworks – performance framework, control knobs framework and building blocks framework. All three have ‘financing’ in common. The only issue with the health sector now is health financing and this will hit the world hard in the future. Our demands are insatiable and ironically, our need is not. And that takes us to family medicine and family physicians.
Financing not only includes government investment but also out-of-the-pocket expenditure on health (read hospital) costs, drugs and so on which are galloping and out of reach from the public perspective.
On our part, we have started the Sehat Insaf Card as social health protection of the poorest indoor patients, but our lifestyle and habits have led to an extraordinary rise of non-communicable diseases. These require expensive and extensive, on the spot and easily accessible treatment and personalised care.
Let me deviate here and give an example. Our ageing population has led to multiple chronic illnesses (‘frailty’ connected with old age is the biggest). The chances of hurt multiplying for the old and mental health diseases like dementia etc have become a reality. We are working on a proposal which includes community geriatric nursing, chronic multiple illnesses management, mental health, hospices.
Now coming back to the issue at hand – family physicians at the primary level will be able to provide quality dedicated care at peoples’ doorsteps, reduce ‘unaccounted’ out-of-the-pocket expenditure, reduce dependence on self-medication and costs and regulate over-the-counter sale of medicine.
The ‘how’ part is the most important. We, at the KP health department, are willing to consider moving out of the BHU/Civil Dispensary structure and the monthly salary system to try this out. We can even consider paying the family physician a ‘retainership’ or a sum for the number of families registered or patients seen. We are also willing to try out social health insurance for non-communicable diseases and launch an advocacy.
Even the BHUs can be grouped together for a ‘surgery’ classification and childcare can be arranged for female family physicians who otherwise do not practice medicine after graduating, preferring to serve nearer to their houses or leave the profession altogether. We are also willing to consider investment in community nursing and pharmacies.
But we need an ironclad statement [assuring us] that we have trained family medicine specialists. We need a guarantee that there will be collaboration in piloting it and international organisations will provide sustained and meaningful handholding.
This article has been excerpted from a speech given by the writer at the eighth International Research Conference at Khyber Medical University on April 26, 2017
The writer is the Khyber Pakhtunkhwa
secretary for health.