Post COVID-19: Fixing our primary and secondary healthcare system

Islamabad : COVID 19 has jolted the world’s public health systems to the core. As the Italian Prime Minister looked to the heavens for help against the pandemic, shallowness of what were considered to be one of the world’s premier health models stood exposed. It is no surprise then that public health has taken a front seat in national priorities across the world. President Trump, through an executive order, invoked the Defence Production Act allowing the auto-makers to manufacture ventilators. Thailand has announced a 550 million dollar cut in defense expenditure to direct more funds towards healthcare. After the IMF and G-20 countries allowed Pakistan a deferment of loan interest payments, it has also gained some fiscal space to prop up its health system. Amongst the many opinions on how this should be done, one that is gaining traction is to route the resources for construction of tertiary care hospitals. While this would surely be a popular decision given the visibility of the project, it would do little to actually address the deep rooted issues in the country’s healthcare system.

For Pakistan the solution to its health conundrum lies in fixing its primary and secondary health care system because of two reasons. Firstly, this will not require a huge budget outlay. In fact, a little administrative tweaking and executive decisions will help achieve the desired outcomes out of the existing public health system. Secondly, a well-functioning primary and secondary healthcare system will take the pressure off the tertiary healthcare since the former covers the majority of a person’s health needs throughout the life including prevention, treatment, rehabilitation and palliative care.

In my four years of working at the grassroots level, I have served as an Assistant Commissioner in Buner- one of the most backward subdivisions in KPK, Mardan- the second largest district in KPK, and the federal capital Islamabad. During these years, I have not come across a BHU, RHC or THQ that was not dilapidated or shabby. Moreover, they faced a shortage of common and life-saving drugs. In my tenure as an Assistant Commissioner in sub-division Khadukhel, district Buner I witnessed a perennial shortage of anti-rabies and anti-vemon medicines at the THQ. Basic medical equipment including X-Ray machines and sometimes the OTs were also dysfunctional. Another common feature was the absence of doctors and support staff. Although the KPK government has incentivized doctors to serve in remote areas by offering lucrative hard area medical allowances, the policy has not produced the desired result. My observation was that the doctors were able to circumvent the purpose behind the rule of spending 48 hours per week on rotation in a hard area by spending two days at a stretch in the remote health facilities and then running their private medical practice for the remaining five days. Resultantly, there is a serious mistrust amongst the people regarding the services offered at these government run health centers. It is no surprise therefore that in this scenario the practice of quacks is thriving in these areas. In fact, I remember placating a protest that was organized after I conducted raids against these quacks and nabbed them. As the locals accused me of taking away the little they had available in the name of a healthcare facility, I was shocked to see the miserable failure of our healthcare system.

As mentioned earlier, overcoming these ills requires a few administrative and policy decisions. To begin with, the THQs should be made financially independent. As of now, the THQs do not have a separate DDO code and are therefore totally dependent on the District Health Officers(DHOs) for everything from repair of machinery to procurement of basic medicines. It is lamentable that expensive medical equipment like ultrasound machines remain non-functional because minor repairs requiring only petty cash could not be approved by the overburdened DHO office. Additionally, the procurement and disbursement of medicines which is currently the responsibility of the DHO office is also not being done in the most equitable and efficient manner. Health centers in district headquarters and those which are frequented by political elites or government officials get a preferential treatment in terms of medical supplies, while those in remote areas remain wanting in basic supplies. Another issue is the pitiable condition of maintenance and repair of the health care facilities. The Communication and Works Department (C&W) which is to perform this function gets a district-wise budget for maintenance and repair of government buildings. Since health is not a priority area, majority of the budget is spent on other government facilities often leaving primary and secondary health care facilities in a dilapidated condition. A simple solution to the aforementioned problems is that the THQs and BHUs be made financially independent with their own DDO code. This fiscal decentralization is not only in line with democratic norms of devolution of power but would also allow the health facilities to make their own decisions based on their local needs and requirements. The KPK government has recently made police stations, the basic unit of law enforcement, financially independent and reduced their reliance on the heavily centralized District Police Office. A similar approach needs to be taken for Tehsil level health facilities.

To overcome the issue of doctor absenteeism, the basic needs of medical staff e.g. residence need to be met by the government. I observed that the THQ Khadukhel did not have adequate accommodation facilities for the doctors posted in the facility. The doctors were either sleeping at night in their offices or were commuting from nearby cities like Nowshera or Swat. It is not surprising therefore that there was little ownership for the facility amongst the doctors. Additionally, for the daily upkeep of the health facilities the appointments of janitorial staff need to be made on merit. Presently, most of these appointments are partial and made under the influence of political elites. During my visits to the health facilities as the administrative head of the Tehsil, I always found the janitorial staff absent. Upon further inquiry, I was told that the janitorial appointments had been made to appease the local MPA or MNA and therefore nothing could be done to reprimand them. To overcome this issue, a performance audit of the janitorial staff needs to be conducted and the ghost staff weeded out.

If the major issues in our already existing primary and secondary healthcare facilities are solved, a profound impact will be created. Moreover, these issues can be fixed without incurring a huge financial cost. For once, Pakistan needs a more thoughtful response than the knee jerk reaction of building more state of the art tertiary care hospitals.

Asadullah, the writer is Assistant Commissioner, Secretariat Islamabad and belongs to 43rd CTP, PAS