Can healthcare in KP measure up?

The deterioration in the government-run healthcare system all over the country is now considered a given fact, but in some regions it is more pronounced. The Khyber Pakhtunkhwa (KP) province is one such unfortunate region where people in 23 out of 25 districts are contending with a virtually non-existent public healthcare system.

Meanwhile, the four-month old Pakistan Tehreek-e-Insaf government in the province is bogged down in paperwork and bureaucratic rigmarole. The government has set up several working groups to fix the issues of governance, but it has so far done little to improve the situation in the health sector.

Except for Peshawar and Abbottabad, there is no district in Khyber Pakhtunkhwa where the positions of junior doctors and specialists are not lying vacant in public health facilities – from basic health units (BHU) up to district headquarters hospitals (DHQs). Mansehra is another district where doctors’ availability is a little better than in other areas.

Doctors simply do not want to serve in these 23 districts. When they are appointed there, elected provincial assembly members rush in their aid to get them transferred to either Peshawar or Abbottabad. In the two fortunate districts, doctors are serving even against the position of nurses.

In the Swabi district hospital, only one specialist doctor is serving against the approved strength of eight. In the Kohistan district, there are only six MBBS doctors. After the building of the motorway, Charsadda and Mardan have become virtually twin cities of Peshawar, but most positions of doctors are lying vacant in district hospitals there as well.

Political interference in administrative affairs and corruption, the two chief factors responsible for the decay of the public health system, are still on play in the PTI government though the government has taken steps to address the issues of corruption.

In the distant past – when the rot was not so widespread – the provincial health secretariat used to make policies whereas the directorate of health used to run administration through posting and transfers. Owing to political interference and bad governance, the secretariat grabbed the administrative functions of the directorate and abdicated its policymaking role.

Now the provincial health department is largely busy playing one role – to accommodate political recommendations on transfer and postings and the award of contracts for purchases of medicines and equipment. Against this, no assessment system is in place to figure out service delivery at the government-run district and tehsil hospitals.

In recent past, the contribution of the foreign donors such as the World Bank and UKaid from the Development for International Development (DfID), the public health system has shot up from three to four percent to nearly 30 percent of the total development budget, but the impact is not visible in any field owing to maladministration.

For instance, the immunisation rate in Khyber Pakhtunkhwa for children hovers around 55 percent, which means nearly half of the children there do not receive immunisation and are at risk of deadly infections. One reason could be the extremism and militancy that oppose the immunisation programmes, but the neglect and inefficiency on the part of the health establishment cannot be absolved of the blame either.

The poor indicators of maternal and child health are also alarming. The prevalent maternal mortality rate is 275 per 100,000 live births against the MDG target of 140 deaths per 100,000 live births. The province’s infant mortality rate is 63 deaths per 1,000 live births against the MDG target of 14 deaths per 1,000 live births. The province lags far behind in achieving the Millennium Development Goals till 2015 for which it received generous foreign aid during the past 10 years.

In the absence of public healthcare, 76 percent of the people seeking medical care in KP spend out of their own pockets on consultation and medicines. Since a large majority of people are receiving healthcare through private hospitals and clinics, the government needs to strengthen its regulatory role.

A health regulatory authority was established in Khyber Pakhtunkhwa a few years ago, but it is not functional yet. The government did not appoint all members of the authority and those who were posted do not fulfil the specific criterion of the job. The authority has not even completed the tasks of licensing and registration as required in its mandate.

The government also needs to formulate a clinical audit system to evaluate the working of government-run health facilities so that service delivery could be improved in district and tehsil hospitals. In many countries, impartial probes are conducted into doctors’ alleged neglect and their licences are cancelled if they are found guilty, but that does not happen in our country.

The state of Khyber Pakhtunkhwa’s big hospitals, which are called tertiary and secondary healthcare facilities in academic jargon, is dismal to say the least though the government spends more than 75 percent of its health budget on these facilities. What is the plight of basic health units and rural health centres in small cities and towns or rural areas (called primary healthcare) can be well imagined. Only a quarter of the public spending goes to them.

For more than three-fourths of the 2.2 million rural population of the province, there is virtually no public healthcare system. There are neither doctors nor equipment and medicines in these primary health facilities. Even properly trained skilled birth attendants are not available in the public health facilities outside big cities.

In a province where more than 30 percent of the population lives below the poverty line (according to 2009 statistics), this is a quite a precarious situation. According to health experts in the province, only 30 percent of KP’s women and children have access to medical care.

The government has found an easy way out by abdicating its responsibility and contracting out primary healthcare facilities. It has privatised a large number of health facilities (BHUs and RHCs) and is set to do more in the coming months. Plans are underway to even contract out district and tehsil hospitals in six out of 25 districts.

It seems the PTI-JI coalition government in Khyber Pakhtunkhwa came to power without doing any homework on addressing key issues of public importance and now it is mired in confusion. On the one hand it reportedly plans to launch an integrated health programme at the primary level to combine the functions of different primary health care programmes for the sake of cost efficiencies. On the other hand, it’s going to contract out primary and secondary healthcare facilities to private parties.

On top of all, it is planning to devolve the subject of public health (except teaching hospitals) to the local governments under the new system under consideration. If this happens, a new Pandora’s box will open as local governments lack capacity to run these huge establishments when no senior officer or professional is willing to serve in areas like Buner, Shangla, Kohistan etc.

KP’s rulers might like to remind themselves of the promises they made with the public when they ran their election campaign and that there is no substitute to good governance. What can make a huge difference is an end to political interference in health administration.

The way the KP government created mobile courts, the same way it may set up mobile healthcare clinics and small hospitals to provide relief to people in distant places where doctors are unwilling to live for a variety of valid reasons including security and overall backwardness of these areas. Above all, the province needs to take quick and smart decisions to improve primary and secondary healthcare in the short run.

Email: adnanadilzaidi@gmail.com