AS we recover from Covid-19, we should start rethinking our national development agenda. This pandemic is not the last of its kind, although, for some known and unknown reasons, it did not hit us as hard as it did the Western world. Still, it tested our shallow limits. I remember during the second wave of Covid-19, critical care units in our hospitals quickly reached saturation point in terms of ICU beds, ventilators, oxygen and staff. This is not meant to undermine the national response effort, which is truly a bright chapter and which led to the country quickly jacking up its healthcare capacity as much as possible, but it is also true that we touched our limits very fast, and further morbidity could have led to a serious catastrophe. We were lucky that the wave receded just as our healthcare system hit rock bottom.

‘Build back better’ is the name of the game now. In low- and middle-income countries, the kind of political and financial attention that Covid-19 received is unprecedented. It is time for our policymakers on health to not allow the momentum to slow down and, instead, to turn their attention to reorienting and strengthening the healthcare system so that it becomes one that is fit for the purpose: resilient, well-resourced and which possesses a strong system of primary healthcare. Simply put, LMCs now need to heavily invest in establishing PHC-based universal health coverage. WHO Director General Dr Tedros says that global health security and UHC are two sides of the same coin. UHC is a comprehensive approach to establishing a healthcare system that caters to preventive, promotive, curative, rehabilitative and palliative needs, including health security issues, essential public health functions and the socioeconomic determinants of health through inter-sectoral collaboration.

UHC is the sine qua non of the third SDG goal of promoting “good health and well-being”. Pakistan’s national health vision has indeed incorporated the UHC agenda, and the government has been taking important steps towards advancing essential healthcare for all by developing essential health services packages and introducing social health insurance through a health card for those who cannot pay. In fact, it has now become universal, barring two provinces —though there are now questions about its sustainability.

The private sector plays a major role in healthcare in LMICs. In Pakistan, 60 per cent of the total health expenditure is made out of people’s pockets. The private health sector is hence thriving and expanding. And yet, in most cases, when we use the word ‘national’ while talking about the healthcare policy, we mean the public sector; there is only a passing reference to the private sector.

The private healthcare sector has not really become a partner to national health services.

The private healthcare sector has not really become a partner to national health services. The typical government approach towards the private healthcare sector is to regulate it, which it does poorly. Another approach seen in recent years is that of strategic purchasing of healthcare through public money for social health insurance. Currently, more than 750 hospitals are empanelled in the Sehat Sahulat Programme and a large majority of these are private hospitals providing secondary or tertiary inpatient care. The programme does not cover ambulatory patients.

UHC advancement is not possible without a comprehensive engagement with the private healthcare sector. Such a partnership needs to go beyond regulation and strategic purchasing.

Private healthcare providers need to be inducted in the national health service loop, not just for curative care but also for preventive, promotive, rehabilitative and palliative care. Private medical and public health education, as well as service provision, needs to be aligned with national health policy objectives.

Medical and public health education in Pakistan is divorced from needs on the ground. An average medical graduate in Pakistan has no idea about our national health challenges and policies. S/he is never exposed to a PHC setting during her/his training. They are exposed only to tertiary-level hospitals in their final years. There is hardly any family medicine training at the undergraduate level. To start practising as a general practitioner, one just needs a registration licence from the Pakistan Medical Council. The bulk of ambulatory PHC is provided by untrained GPs. A few universities have recently started certificate and diploma courses in family medicine, but these are not enough keeping in view the actual need. The medical and public health curriculum needs to be reformed to train future doctors, in accordance with the country’s healthcare needs.

In health service provision, private GPs, specialists’ clinics, and small, medium and large private hospitals, of all shades, are catering to more than half the patients who seek modern healthcare. Most patients also seek out alternative healthcare systems, such as hikmat, homeopathy etc. The government has not systematically approached this huge and growing sector from the perspective of expanding healthcare coverage, improving quality of services, curbing unethical practices and ensuring affordability.

There are currently 117 private medical colleges and dental colleges in the country. Each one of these requires a teaching hospital to be attached to it. This is an interface between education and healthcare. A policy can be made for these private institutions to cover a defined geographical area by setting up a system for healthcare, not just at the tertiary level but also at the primary and secondary levels. Healthcare should include not only curative care but also preventive, promotive, rehabilitative and palliative care. The government can develop a policy to incentivise private health education and healthcare institutions in this direction. Sustained implementation of such a policy can change the profile of healthcare in the country.

The government needs to develop a framework for engaging the private healthcare sector to advance universal health coverage.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.

zedefar@gmail.com

Published in Dawn, April 8th, 2022