Integrated healthcare
LIKE most countries in the region, healthcare in Pakistan is delivered through a mixed public-private system.
While private healthcare provision was initially on a small scale, it has grown exponentially over the years, so much so that according to a recent study conducted by the Asian Development Bank and Australian Aid, private healthcare provision in maternal and child health accounts for over 70pc of overall healthcare provision. Publicly funded hospital-care provision, by contrast, accounts for only about 30pc.
This indicates a growing trend towards purchasing private healthcare, highlighting the state of the public health system that is creaking under the twin pressures of resource constraints and increasing patient-load. The indications are that this trend is set to grow, given the low priority accorded to health in government budgets.
According to an international finance corporation study conducted in 2011, there are 100 private healthcare establishments in Karachi’s Nazimabad, 40 in Lahore’s Allama Iqbal town and 30 in Faisalabad’s Jinnah colonies. This picture is replicated across the country. More significantly, big US-style corporate hospitals are also being built by investors (mostly doctors) with experience of America’s privately funded system.
The transplantation of a US-style private healthcare system onto a middle-income country such as Pakistan has all sorts of implications for healthcare provision and policy at large. Some of the issues are regulation, affordability, the accountability of private healthcare providers towards their clients and the sector’s integration with the larger public healthcare system. No wonder, then, that just as more and more people are being forced into seeking private healthcare options, their disillusionment is also growing. The spectrum of private healthcare users’ grouses range from botched or unnecessary operations to inadequate or poor services, high costs of surgical and post-surgical care and a total lack of accountability and transparency within the sector.
The government, however, has thus far desisted from any concerted move towards regulating the private healthcare sector and bringing it under a comprehensive regulatory framework. This step has acquired urgency now, as out-of-pocket medical financing has spiralled out of control and is tipping a growing number into unexpected poverty.
It is estimated in the ADB/Ausaid report that out-of-pocket expenses per person come to about $91 a year, which is way above the regional average. When translated into the financial burden on ordinary Pakistanis, the report estimates that in 2005-2006, 4.7pc of the population — or 7.5 million Pakistanis — were pushed below the international poverty threshold as a direct consequence of out-of-pocket medical expenses.
The situation calls for comprehensive governmental action to reduce medical impoverishment and get the healthcare provision mix right for greater health goals. The regulation of the private healthcare sector should form the first pillar of this action.
A beginning can be made by undertaking a comprehensive survey of the private healthcare landscape. This should be followed up with the establishment of a private healthcare regulatory authority which must take up the registration and monitoring of private healthcare facilities as its core function. The resultant register would serve not just as a referral centre for regulated private healthcare providers but also act as a weeding-out centre for under-qualified private providers.
The regulatory authority would have to frame rules and regulations requiring private healthcare providers to be transparent and accountable to the users of their services. An important aspect of this regulatory thrust should involve the establishment of complaints procedures regarding negligence, overcharging or poor care.
This would be a step towards not just making the sector transparent and accountable but also towards improving the standards of care, and increase confidence in the private healthcare-provision sector. Allied to this should be the provision that private healthcare entities should be statutorily compelled to frame and publish patients’ rights charters setting out a minimum standard of care.
As a further part of its regulatory regime, the government should devise standard treatment protocols/guidelines to be followed in the private sector as a way to prevent unnecessary surgeries and the over-prescription of medicines.
A report recently highlighted a growing trend in private hospitals to perform avoidable Caesarean sections in order to make money. There is also evidence, and everyday experience, of the over-prescription of medicines in the private sector. Two surveys published in the early years of the millennium established that private hospitals tend to prescribe 4.5 medicines per patient as compared to 2.77 medicines per patient in public hospitals. To curb these profit-maximising practices, some sort of ceiling can fixed.
A rigorous system of random annual inspections of private healthcare entities should be instituted, and those found wanting can be struck off the register or put under tight monitoring oversight. Here, the government can team up with consumer and patient rights groups, enabling them to act as permanent watchdogs. As a way to strengthen their oversight role, the inspection teams should include representatives from consumer and patient rights groups and other health rights groups.
Lastly, and most importantly, the private healthcare sector should be integrated into government health policy and planning. This can be done by making it mandatory for private healthcare providers to publish data on the number of patients and the types of ailments treated, the procedures performed and rationalising how the work done by the private sector aids governmentally defined health goals and policy.
In this way, both the private and public sectors can become conscious and responsible partners in the promotion of broader health goals while keeping healthcare costs for ordinary Pakistanis at the minimum.
The writer is an Islamabad-based development consultant and policy analyst.