Thursday, 18 February 2016

Khyber-Pakhtunkhwa Healthcare Reforms: What is All the Fuss About?

A version of this Article was published by The NEWS on the 15 February 2016
Pakhtunkhwa Healthcare Reforms: What is All the Fuss About?

Dr. Arshad Rehan.
The writer is an ex-president of the Association of Pakistani Cardiologists of North America and the Khyber Medical College Alumni Association of North America.


The vested interests are out in force once again against the Pakhtunkhwa Medical Teaching Institute (MTI) reform act. The excuse taken this time is supposedly the dissolution of the Post Graduate Medical institute (PGMI). A small group of physicians has joined hands with the ancillary staff of the hospitals to take yet another stand to prevent the reforms taking root.

It has been obvious to all except may be the blind and deaf that the previous system was untenable. It was not a system at all, but an optical illusion to benefit only a few physicians and their cohorts. The previous attempts to change or improve that “non-system” failed as those efforts were only led by a bureaucracy that was clueless itself.

The MTI act was introduced in the Pakhtunkhwa assembly in January 2015 & passed by it unanimously in March 2015. The act called for giving autonomous status to the teaching institutions of the province under independent boards of governors (BoGs). The existing employees were given choice of becoming employees of the newly established MTIs or continuing as civil servants. Certain other changes were also introduced such as new administrative structures under the BoGs and introduction of institution based private practices of the consultants.

The new act immediately rang danger bells amongst the entrenched vested interests. For them, the situation was dire. If they remained “civil servants”, the institutions could return their services to the provincial government saying they were no longer needed. On the other hand, if they opted to be employees of the MTI, they would come under the discipline and rules of the MTI itself, jeopardizing the hitherto prevalent culture of rights without responsibility.

Various individuals as well as organizations of healthcare employees therefore took the matter to the court. The Peshawar high court stayed implementation of the MTI act. The remarks made by the honorable judges during the hearings gave hope to the vested interests that the court might block these reforms. The government also felt frustrated with the same and negotiated with the opposing individuals and organizations, conceding some of their demands. However, the high court in a pleasantly surprising decision upheld the MTI act. The decision went farther and declared any agreements reached between the government and doctors organizations null and void. It also reaffirmed its previous judgments calling healthcare “essential services” and asked the government to ensure implementation of the same.

The judgment of the high court, which in a way expressed the public’s mood against the physicians and healthcare system, came as a shot in the arm for the government and the architects of the reforms. Those watching the developments in the healthcare department know very well that the BoG at the Lady Reading Hospital MTI acts as the spearhead for the rest. In an unprecedented move, the MTI transferred services of a number of Deputy Medical Superintendents back to the provincial government. It also recruited professional directors and managers for human resources, finance, material management and facility management etc. Thus a new team with a fresh perspective was installed. The hospital employees have been issued clear guidelines regarding punctuality and work. It has been a pleasant surprise for many to see the consultants running the out patient clinics or OPD from 8:00 am till 4:30 pm.

The other step that the government took was the dissolution of the Post Graduate Medical Institute or PGMI. The PGMI was founded in the early 1980s in particular circumstances of the time. Having played its role then, it is long since past its use by date. Its role has been assigning trainee medical officers (TMOs) to various clinical units and disbursing their stipends. Other than these and may be conducting few minor diploma courses, it has no other significant role left to play. The problems that this created were multifold. For one, there was essentially no role of the supervising physicians or departments in selection of the trainees. The selection and subsequent training of TMOs everywhere else is a collaborative effort. The applicants to a particular program express their interest and apply to it, the programs shortlists candidates & conduct interviews; finally the candidates and the programs make lists of their priorities and a “match” is held. The PGMI model was none of this collaborative approach.

The TMOs selected and sent to various programs were under the rules of PGMI itself. Thus any disciplinary action had to be taken by the PGMI only and not the training facility. This created confusion, complacency and a culture where the TMOs would easily get away with violations of rules and discipline.

The present reforms seek to encourage discipline and rules. It therefore did away with the PGMI itself. In its place, each MTI will now have its own department of graduate and under-graduate medical education. Rather than welcoming these changes, some junior doctors are up in the arms against it. It is rather strange to see the trainees demanding to be the sole determinants of the nitty-gritty of their training. They want to be trained but on their own terms and conditions!

We can summarize the opposition to these reforms in three words: Fear of Accountability. For far too long, the pervasive culture has been that of avoiding responsibility. There has been little, if any discipline or accountability at all. Because the senior faculty is perceived as having no moral high standing, the junior doctors and the ancillary staff play by their own rules only. The lower staff, a number of them appointed as political favors, have been emboldened to the extent that they frequently threaten the administrators and physicians.

All these stakeholders are afraid that if a system of accountability is set in place, there will be consequences for their actions, negligence and malpractices. They know very well than that there will be repercussions for their acts of omission and commission.

We have heard a number of excuses and reasons bordering on the irrational and bizarre in opposition to the reforms. The most frequent has been that the current compensation structure does not justify a full shift of work. It is true that the compensation has been inadequate for the physicians and needs to be looked at seriously but at the same time, nobody forces them to work in the public sector hospitals. It is a choice, not a compulsion. If they find the compensation not good, they have the option to quit and devote themselves to private practices or employment only. When one signs for a job, one knows the terms and conditions and willingly accepts them. After signing on to the terms and conditions, one can not say that I will not quit, nor can you force me out; I will remain an employee but only work hours of my choice, as the compensation is not good.

The arguments of the junior doctors against the dissolution of PGMI are not valid neither. It is obvious that their strings are being moved from those behind the scenes. Their concern should only be getting quality training. The College of Physicians and Surgeons of Pakistan (CPSP) sets the standards of training. It is then for the management of the hospitals to ensure ways that those standards are met.

Once again, what everyone should understand is that a government job or training post is not a right but a privilege. One opts for these; nobody forces these decisions on us. If the terms and conditions are not to one’s liking, one is free to explore other avenues.

The supervising faculty and institution should have a full role in the selection of the physicians who aspire training. The selection like everywhere else should be made based not only on entrance examinations but other factors such as personality, aptitude and professionalism. The training should not only comprise medical education but ethics and character building as well.

The role of the political parties during this debate about health reforms has been far from ideal. It is surprising that the same parties that supported the MTI act in the assembly are now encouraging mischief against it. Politics is not a bad thing but it must never be at the cost of the people or principles. If any of the high and mighty or their dear ones have an acute illness or trauma, they will have to be treated, at least initially, in these same hospitals.

If the political parties have better ideas, they should publish their alternative plans in detail. There is always room for improvement and may be they would present a superior plan. Healthcare, however, should be spared the usual opposition for the sake of opposition. If healthcare is not an essential service, wonder what is? Are the political parties, by opposing bringing healthcare under the essential services act, giving a message to the people that healthcare is a choice and not a necessity?

It is not a question of one government or party, it is the future of the people and the province at stake. These reforms will only be as good as their implementation and it should be resolved by all that even a change of government would not wash away all the good work done. It should only be improved upon. It should be ensured by any coming government that competent, honest and dedicated people are appointed to the BoGs regardless of their political leanings or affiliations or. Let us, for a change, treat meaningful healthcare reform as a consensus national issue.

The political parties all talk of lofty principles and ideals. Perhaps a good start would be an unequivocal joint declaration stating that government employees should not join political parties or its wings such as Insaf Doctors Forum, Malgari Doctaraan, Peoples Doctors Forum and Islamic Medical Association. The government employees taking part in active politics is against their service rules and an end should be put to this practice without ifs and buts.

The government for its part should stand firm against the few that are out to cause mischief. It is good to see it adopt a no nonsense approach so far. It is hoped that it would not cave in to black mail or political expediency. If these reforms take root and last, it will be its best legacy ever.



Dr. Arshad Rehan.
The writer is an ex-president of the Association of Pakistani Cardiologists of North America and the Khyber Medical College Alumni Association of North America.






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