Posts Tagged ‘Healthcare’

Living in Unhealthy Times

March 30, 2018

By Anjum Altaf

There was a time not too long ago when the burden of disease seemed disproportionately biased against the poor. That someone was always dying among ‘these’ people was the irritated refrain of many an exasperated ‘Begum.’ ‘Fauteedgi’ (an event of death) was a dreaded word that came to be interpreted as a ready excuse to buy a few days off for the staff.

Times have changed. It is hard now to find an affluent family without its own share of prolonged and painful illnesses and ‘fauteedgis,’ often premature. The speed at which graveyards are filling up in rich communities tells a story if anyone is willing to listen.

What happened? Simply, money reached its limit in the ability to buy health. It could protect against many of the factors that caused the most mortality amongst the poor but lost its edge once the factors proliferated.

Take the causes of the majority of the deaths amongst the poor — dirty water and unsafe sanitation. The rich could afford to boil water, filter it, or even switch to the bottled alternative. And everyone who could, moved to a faraway housing society served by water closets and underground sewers. ‘Whoosh’ and the offensive stuff was gone — out of sight, out of mind. Instead of cleaning up the city, the state obliged these fugitives from pestilence favouring them with ring roads and signal-free corridors to transport them back to their places of work quite oblivious to the toxic emissions being added to the environment.

More of this pursuit of one-dimensional progress led to pollution of the air which was a leveller in terms of its negative effects upon the citizenry. The rich could still isolate themselves partially by living in air-conditioned homes, travelling in air-conditioned cars, and working in air-conditioned offices. Still, the protection was not complete and the Begums walking briskly in the public parks and the menfolk indulging in outdoor sports were forced to inhale the same carcinogens that inhabited the air they shared with the have-nots.

Then, along the way, another discriminant between the haves and the have-nots, started to come undone. The quality of food in cities, both cooked and raw, took a nosedive with growing doubts about the safety of virtually any product on the market. The causes were many — plain greed on the part of producers, the failure of quality control on the part of the state, and industrial progress itself with the increasing use of chemicals and chemical processes to increase the weight and shelf-life of produce. There were few who could continue to source their ‘asli’ (pure) supplies from ancestral villages and, for once, the refuge of the rich — processed foods — only added to the likelihood of negative outcomes.

It took a while, but the burden of disease became much more equalized. It did not lessen for the poor but increased sufficiently for the affluent to become a matter of private concern and grief — the number of ‘quls’ (prayers for the dead) per month the affluent felt called upon to attend became occasions for the sharing of woeful tales.

Turn now to the other side of the picture. There was a time when the affluent could literally afford to inoculate themselves against the most common diseases of the poor like diarrhea, cholera, smallpox, measles, etc. But such inoculations were less effective against the carcinogens that began to percolate through polluted air, toxic waterbodies, and contaminated foods. Not only that, it became increasingly difficult to tell spurious medicines from the genuine articles and the overall quality of medical care declined precipitously with the glut of poorly trained providers graduating from substandard private colleges. Once again, the regulators turned a blind eye to what was happening in the pursuit of short-term gains as if money could ward off the damages being inflicted on their own bodies.

There are still a very few left who can afford to travel to Dubai or London or New York for their medical checkups but since they have been ruling the country there is no relief in sight for the rest, rich or poor. A government for the people would recognize that the path to good health requires attention to basics that are simple to conceive and implement — clean water and clean air, safe sanitation and safe food, unadulterated medicines and regulated healthcare, compact cities and public transportation.  

Simple as these measures are, there is little possibility of an intelligent response to the warning signs. In 1952, despite persistent warnings from scientists of precisely such a disaster, a killer smog descended on London killing 4,000 in less than a week and accounting for another 8,000 premature deaths in the months that followed. Do we need a catastrophe of such magnitude to wake up to the obvious dangers accumulating in our environment?

This opinion was published in Dawn on March 21, 2018 and is reproduced here with the author’s permission.

Back to Main Page

Advertisements

Healthcare Needs a Warning Label

March 22, 2017

By Anjum Altaf

Healthcare is dangerous to your health. Ask your neighbor for verification. You will likely hear more than one first-hand experience of someone dead who should be very much alive.

This outcome is unsurprising for three principal reasons related to peculiarities of the industry, social attitudes of the population, and  commercialization of the economy.

First, the industry. Healthcare is a field exhibiting the starkest asymmetry of information between providers and consumers. Every incidence of illness is in some way new and patients have insufficient knowledge to question diagnoses or prescriptions without second opinions and retesting for which there is often no time. In healthcare lives are literally at stake unlike, say, in education, where, if dissatisfied, one can change a child’s school and start again.

Second, social attitudes. People, by and large, still attribute unfavourable outcomes to divine will. Even when convinced of poor service, they rationalize that intentions of providers must have been good but that the patient’s time to die, one way or another, had arrived. This no doubt provides solace to the bereaved but does nothing to hold poor service accountable or provide countervailing pressure for improvement.

Third, commercialization. The logic of the market has now fully permeated the provision of healthcare earlier regarded as a social service yielding providers a respected status in society. Income maximization is now a much more salient motivation. In private conversations, medical professionals even point to the emergence of collusive networks among physicians, laboratory owners, pharmacists, and equipment and medicine suppliers aimed solely at fleecing patients without even the pretence of providing care.

As a result standard norms of economic theory are upended – the free market in healthcare does not minimize cost of service, competition does not drive out bad providers, and it is not only the fittest that survive. Because patients do not have the luxury of withdrawing from the market, poor performance actually increases the revenue transferred to providers as patients shuttle helplessly from one facility to another.

Given these factors, the only way to protect patients is very tight regulation in which the state, the traditional regulator, despite continuing attempts, has failed to measure up to needs. In fact, standards of service and accountability have continued to slip simply because growth in the number of providers and facilities has outstripped regulatory capacity.

While there is no alternative to regulation, it is generally accepted that expecting the state to discharge that function in Pakistan is unrealistic. The record shows that the state politicizes the operations of the regulatory body and compromises its independence. It uses its powers for patronage and does not appoint competent professionals to positions of leadership. Many of the officials it does appoint use the opportunity for rent seeking. There is no other explanation for the number of private medical colleges licensed without adequate faculty and the number of facilities advertising themselves as hospitals without fulfilling basic requirements.

Given that lives are at stake, citizens cannot afford to wait indefinitely for a caring state to emerge. A second-best solution is urgently called for. One alternative is to push to privatize the regulatory function while being cognizant of the private sector’s weaknesses and hedging appropriately in the interest of the citizens.

The only function remaining with the state regulator would be to bid out the regulatory contracts for predefined terms to established private audit firms with reputations to defend. Since this is a major departure, the experiment can be piloted in one sub-district or small city. The private regulator would categorize and register all facilities, ensure compliance with minimum requirements, introduce standard record-keeping protocols, and initiate a regime of random inspections. Based on cumulative review of records, facilities would be assigned quality rankings to be disclosed to citizens. Facilities falling below acceptable standards would be given a limited time to improve to avoid losing their operating license. Registration fees could partly finance the experiment.

In parallel with this privatization, a board of credible individuals would serve as an independent watchdog on behalf of the local population. In addition, the federation of newspapers could nominate a set of journalists to report regularly on the experiment. Thus circumscribed, the second-best alternative could be expected to prove more effective than the state regulator. Based on the results of the pilot, the arrangement could be fine-tuned before expanding its coverage.

For the longer run, however, the existing model of curative care is unsuitable in a country where incomes are low, the incidence of ill-health is high, and basic public health infrastructure – safe water and sanitation, clean air, pest control, etc. – is missing. Populist attempts to make curative care affordable will prove to be unsustainable. We need to transition to a wellness model based on preventive care in which households are visited, monitored, and guided at regular intervals independent of episodes of sickness.

Such a model could also be tried on a pilot basis in one jurisdiction. There are a number of very successful examples to learn from. In 2014, the Director-General of the World Health Organization recommended Cuba’s preventive healthcare model to the entire developing world even though it is not considered politically correct to applaud anything happening in that country. In Cuba, family physicians supported by para-medical staff deliver primary care and preventive services at the local level to panels of patients, about 1,000 patients per physician, with patients and caregivers generally living in the same community.

Even an affluent country like England subscribes to a similar model in which family practitioners and ancillary staff responsible for registered populations of patients act as gatekeepers to specialist care.

Healthcare in Pakistan is out of control and in bad shape and it is up to citizens to articulate alternatives to avoid more tragic losses. This can be a common cause for the rich and poor because not even all the well-off can travel abroad for their check-ups and medical needs.

This opinion appeared in Dawn on March 21, 2017 and is reproduced here with permission of the author.

Back to Main Page