By Prime Minister Imran Khan in his first address to the nation emphasised that work started in Khyber Pakhtunkhwa (KP) during the first PTI government (PTI-1) will be carried forward and expanded to Punjab as well. In this regard, the framework implemented for healthcare in KP was particularly mentioned.
The Medical Teaching Institution (MTI) Reforms Act is considered a flagship legislation of PTI-1. It sought to change the governance of tertiary-care hospitals in the province, giving them unprecedented autonomy and striving to change the prevalent decadent culture therein.
The MTI Act of 2015 was a bold piece of legislation. It looks good on paper and has proved its worth in practice. However, implementation of the act on the ground has also revealed certain weak points that need to be reviewed and remedied.
Revisiting the law is more important now that the challenge of enacting reforms in Punjab looms ahead. Just with its sheer size, the process in Punjab is going to be more challenging than it was in KP. Lessons learnt from KP will be crucial in enacting and implementing the law in Punjab.
Through the MTI Act, most government-run tertiary care hospitals in KP were declared MTIs. Each hospital or institution designated as an MTI was given autonomy under the act. Each MTI is run through a board of governors (BoG), and each BoG enjoys immense powers and is custodian of millions of taxpayers’ money for running these hospitals. The MTI hospitals have been getting a single-line budget from the government.
The KP experience has showed us that the nominations to the BoGs need to be more transparent and objective. There has been a feeling that in KP the nominations to various boards for MTIs were not very transparent, and the process had not been open to the public.
It is suggested that the search and nomination committee publicly invite names for inclusion on the boards. The shortlisted names should be published on a public website. The details of the proposed members, with their educational qualifications and relevant experience, should be listed for all to see. Most critically, the proposed members should declare any conflict of interest – for themselves as well as for immediate family members – on the proposed website.
Before confirming the names for appointment to the board, comments should be invited from the general public about each nominee. Only those that go through this rigorous vetting process should be nominated to the boards.
In its present form, the MTI fixes a term of three years for each BoG after which new nominations are to be made. The new members have a learning curve. The KP experience tells us that it would be better if the term were staggered for members on each board.
The term for the boards should be increased to four years. and half the members should retire after every two years. An example of staggered terms is the Senate of Pakistan. The staggered terms will ensure continuity and experience on the boards.
Another problem that revealed itself with the experience in KP is the lack of close coordination between the government and the MTIs. In the first draft of the MTI Act, it was mandated that the government secretaries of health, finance and establishment are also present on the various BoGs in their ex-officio capacity.
This mandate to have government members on the boards was, however, removed in a subsequent amendment. The absence of ex-officio members on the BoGs hampers coordination between the MTIs and the government in regards to budgeting and planning. Their presence is necessary to understand the needs and planning of the MTIs and also explain the position of the government.
The ex-officio members should be brought back on the boards, albeit in a non-voting role. The secretaries of health and finance must have a non-voting seat on each board. If the rationale behind removing them was fear of bureaucratic interference, a non-voting role should be enough to eliminate those fears.
The government should also amend the act to bring in accountability for the boards. This should be issue specific. If on any specific issue the government feels that a board is not acting in the best interest of the people, there should be a mechanism for putting the board on notice. If the board fails to rectify the situation, the matter may be referred to a tribunal or another body. One such body that may be considered could comprise the chairpersons of all the BoGs in the province.
The law should mandate certain non-negotiable performance parameters for the boards, including quality assurance and mechanism for regular review of morbidity and mortality. Failure to implement the compulsory parameters should be grounds for dissolution of the responsible BoG.
The MTI Act established a duopoly of a medical director (MD) and a hospital director (HD) to run affairs of the hospitals. These positions independently report to the BoG.
Those who have been watching the situation closely feel that this duopoly experiment is not working. The roles often overlap, there is no clear delineation of responsibilities and turf wars are feared. The smoothest running MTI in Peshawar has been the one that has practically abandoned the duopoly and the MD has been assigned that role on an ‘ad-hoc basis’ for more than a year now.
The role of the hospital director in the MTI Act should be eliminated. A position of chief operating officer (COO) may be created. The COO should report to the medical director in the day-to-day running of the hospital but also to the board independently as well. The nomenclature of the MD should be changed to executive medical director for clarity.
It has been noted with the KP experiment that a substantial number of board members take upon themselves the role of ‘administrators’ of the institutions. They have also been found lacking in the modern concept of running hospitals.
Seminars and educational sessions should be arranged for board members to educate them about their role and expectations. It should be emphasised that the role of a board is not to run the day-to-day affairs of the institution but provide oversight, policy and accountability.
Another significant problem that the MTI Act has run into is the assumption that all tertiary-care hospitals are teaching institutions. All tertiary-care hospitals are not necessarily ‘teaching’ institutions. Similarly, a tertiary teaching hospital might want to temporarily or permanently suspend its teaching programme for various reasons.
It is proposed that to eliminate this ambiguity, the act may be renamed as the ‘Tertiary Healthcare Institute’ Act and changes made therein accordingly. Even for teaching institutions, differentiation should be made between graduate and under-graduate medical education and training.
There is room for improvement with more aspects of the MTI Act but space limitations constrain this article from discussing them all. To summarise, a thorough and broad review of the act is a must to further improve tertiary care in KP and also to initiate changes in Punjab.
The writer is the former president of the Association of Pakistani Cardiologists of North America and adjunct faculty, Division of Cardiovascular Medicine, Ohio State University.