MY friend’s father, who is in his late eighties, is ailing. He has a number of health issues. Some such as bone degeneration, hearing and sight issues are age-related, while others have to do with other problems.

The challenge for my friend is to find the right doctor(s) for his father. When his father has heart issues and visits a cardiologist, the latter deals only with that specific ailment; he does not even inquire about other health problems. He does not want to hear about them and does not take other ailments into account when prescribing medicines for the heart. The same is true for the gastroenterologist. And the same happens when the gentleman has to consult the nephrologist.

The poor gentleman takes a fistful of pills without knowing if all these medications should be taken together, how they interact with each other and how they are going to impact a body that has seen more than 80 years of life.

There is no primary doctor who coordinates with other specialists.

There is no single doctor who is able to provide the crosscheck that is needed, especially for the old. Geriatrics, even today, is not a very developed field in Pakistan.

But there is more to it than that. When each specialist is visited, they order a panel of tests to be done before they will even start talking of treatment.

For an old person to go through this battery of medical tests is not easy even if we put aside the cost issue. Maybe all these tests are essential or maybe they are not. There is no way for the patient to find out conclusively. Even if a second opinion is taken, there can be genuine differences in the opinions of different doctors. It is also not easy getting a second opinion even in big cities like Lahore and Karachi: most well-known specialists give appointments weeks, sometimes months, in advance.

Hospitalisation is sometimes the only option left if you want a team of doctors to examine the patient holistically. But even that is not easy. Getting admitted into a private hospital is costly and even there you are placed under the care of a particular doctor. It may not be easy to get other specialists to come and visit.

More importantly, even if they do, they still diagnose and prescribe in isolation. There is no primary doctor who coordinates with other specialists or looks at issues of medicinal interactions, the effects of one treatment on another, and so on. It comes down to the patient himself/herself or to the family of the patient to coordinate between doctors. But they have no way of knowing medicinal or treatment interactions.

There is no working regulatory framework that governs the health sector in Pakistan. Where markets are incomplete (no doctors for the old) and have large information asymmetries (where it is not clear if what is being prescribed is in the patient’s best interest), regulation becomes very important. Otherwise, the temptation to take patients for a ride becomes too much. Even if some doctors and hospitals do not indulge in unethical or illegal practices, it becomes impossible to differentiate between these and the less scrupulous ones. Word of mouth is not enough to make clear distinctions.

Almost every friend or relative I have spoken to about this, over the last few years, shared a story where he or she felt that they were unfairly treated by a doctor or a hospital. There are too many cases of women having to go through operations for childbirth. In fact, there are hospitals, especially in the peri-urban areas, whose main source of income is maternity-related surgical procedures. Has natural birth actually become more dangerous? Or does the fact that hospitals stand to make a lot more money from cases involving surgery have anything to do with it?

There are too many friends who mention that their loved ones were put under the knife even when the chances of success were very low. Hospital stays are strongly recommended or are extended even when they are not really needed. We have already mentioned excessive testing and diagnostics as a problem (many doctors and hospitals get a share of revenues from testing service providers).

We are not talking of errors of omission and commission here. There are too many cases in Pakistan that one hears of where mistakes have been made by doctors and care providers. Though even in that area we do not have effective remedies or censure mechanisms for the offenders, that is not what this article is about.

Here we are talking more about the incompleteness of medical markets, the information asymmetries present and the lack of an effective regulatory structure that should have been created for this sector.

In some places the laws are far more strict. Judicial institutions are also quick to dispense justice. This allows for a certain degree of remedy against malpractice. But not every dubious case can be taken to a court of law. Usually hospitals have strong internal peer group-based quality audit systems.

These are in place because the governments, usually local governments, impose strong external quality assurance audits on hospitals, medical practices and doctors. There are strict licensing requirements as well. And, usually, in an acknowledgment of the other problems in the sector, the medical profession also has membership requirements, standards and checks and balances.

The strength of each of these checks can vary across societies. Nonetheless, almost all checks and regulatory structures are in place in most societies. In some places we even have insurance companies and other intermediaries coming in on behalf of the patients. We have none of these in Pakistan. It is no wonder medical markets are lucrative in Pakistan but provide, on the whole, terrible service to the people.

The writer is a senior research fellow at the Institute of Development and Economic Alternatives and an associate professor of economics at Lums, Lahore.

Published in Dawn, January 15th, 2016