Doctors Role in Organizing Health Services

My own observations are a few:

1) Cut down the role of viva marks in medical exams..it gives too much discretion to professors

2) PMDC needs a total revamp..it needs to be devolved and restructured, to the provinces with better funding and a much stronger system of (re) validation of PMDC registration, with a prosecuting system to punish quacks and Doctors.

3)In NWFP they introduced the IBB which triggered protests from Doctors..but the scheme was rermarkably successful...in outlying areas..

4) They should consider launching a scheme similar to the Higher Education Commissions foreign faculty programme a to attract well qualified Doctors back to Pakistan in large numbers

5) Medical College Class sizes should be cut all across the board

6) The bulk of all funding needs to start going towards para medics..midwives and nurses..recuiting needs to be done ona large scale with proper facilities in poor areas to bring down infant mortality rates

7) Management staff salaries need to be revamped..the NHS has a system of specialised management training..similar to CSS for NHS management..

Re: # 6

Price tag of health management is not cheaper in Pakistan as well and it not solely USA where health segment is passing all the way through troubled waters. In point of fact Pakistan is in front of multifaceted tribulations. Financial constraints, dilapidated infrastructure, be deficient in of diagnostic services, obsolete national curriculum of Medical Colleges, unproductive role of PMDC, duty timing of doctors, nonattendance of consultants in Emergency Departments, salary structure, doctor -patient ratio, nurse-patient ratio, rely on trainee doctors etc are some of the most important hurdles in thriving health sector in Pakistan. Our aspire is not to merely criticize any person, institution or government but we are pointing out what we think is merited to be well thought-out on priority basis. Health care increasingly becoming a business in entire globe. But how to apply Adam Smith`s principles of economic here?

Re: # 5

And you think assaulting a doctor was the right thing to do obviously? You must have been exceptionally well-connected, in India, the doctor would have left and refused to come back.

Health care is a business. It is better to let laws of Adam Smith dictate the business of health care.

USA which has a great medical system faces bankruptcy thanks to sky rockeeting medical bills. There is no free lunch in the end.

Ahh its the ` Daaak - tar Sahib ` topic again and that too from my country where doctors asks for bribes , where doctor sahib is involved in politics and strikes - this is Pakistan . I was a student leader in Karachi we had fights and all sort of problems with admin. and other issues which we felt we were denied of , one day there was a fight between police and us in 2002 - yes for the first time APMSO and Jamat fought togather with the brutal police of Saddar. Six of my brothers and one sister was injured , the doctors of Civil Hospital were not there and we waited for 4o minutes waiting for the so- called god`s , no one came - then I personally went into one of there offices smashed a computer and slapped one of the doctors - suddenly the enviorement changed , my brothers and sister were treated not by 4 doctors but 9 specialists .
Imagine what a normal citizen ( whatever he or she is ) faces in ` SARKARI HASPATAAALS` ?

As a Pakistani doctor working in the UK, I can see that the Medical Establishment is reaping what it has sown for decades. In Karachi, where I grew up or from the Aga Khan University Medical College where I graduated, there always was a dearth of seniors and Consultants who were willing to stay and train young doctors like me. Consultants came to Pakistan and joined the Aga Khan Hospital in order to finish their two-year visa waiver from the US before applying for permanent residency and then left as soon as they became eligible for the Green Card. In the surgical fields The Aga Khan has an enviable American-style Residency training program for most specialties (the likes of which I have never seen in the UK) including General Surgery, Plastic Surgery, Trauma and Orthopaedics and Paediatric Surgery, but that program only graduated 3 Residents per year and was often times ``pyramidal`` with the first year intake of 8 Residents resulting in the expulsion of 5 Residents as only 3 Residents could have ever reached the top. In spite of that there was a willingness to train and teach young surgeons in the Aga Khan (although a few undesirable types still exert some schizophrenic control and harm over young surgeons-to-be). But that is enough said about the Aga Khan Hospital , a hospital with near limitless resources, where the clientele is Pakistan`s Corrupt ruling class consisting of the Army, Bureaucracy, Judiciary and Politicians who pay for the health care they receive in the hospital with the tax-revenue they have looted from middle-class tax-paying doctors like myself. In any case although I am proud to have graduated from the Aga Khan, the best Medical school I have ever seen even in the UK ever, is far beyond the reach of the common Pakistani.

After graduation I saw the condition in some of the government hospitals where things were medieval and pathetic. I am not talking from the consumer`s perspective which entailed patients dying like cockroaches in Civil and Jinnah Hospitals, but from a doctor and a Surgical Trainee`s point of view. Most of the Professors who worked in the Civil and the Jinnah Hospitals were corrupt, dishonest and frankly genocidal. They were employees of the Federal Government ( in Jinnah Hospital`s case) and the Sindh Government ( in Civil Hospital`s case), but they were people who did not deserve to bear the title of doctors. Far from teaching and training young people, the hospital job was run by political ``chamchas`` who sat in while these Consultants were away at their private practices. They rarely ever appeared in the hospitals and when they did, they behaved as if they expected all to fall in prostration before them. They had ``touts`` who pulled patients off waiting lists in clinics and wards and convinced them that ``Sahib`` would do a better operation if the patient paid up. Needless to say, the poor patients who hardly could afford to eat twice a day had a choice between paying up Professor Corruption Shah FRCS, FRCP and having the operation done privately or dying after being butchered on the table by the chamchas from post-operative complications.

Surgical Training too in Civil and Jinnah was allocated according to ethnic backgrounds with the more ``desirable`` ethnic groups being trained better than my ordinary Sunni, Mohajir, Urdu-speaking types. This was so because it was commonly perceived by the Feudal politician surgeons, that whoever learnt to operate would start minting money in Karachi`s lucrative private sector --which is why the Professors themselves had been posted into Karachi and which is why they refused to teach the art of surgery to anyone junior to them. What is more, the College of Physicians and Surgeons, the highest Training body in the medical profession which claims descent from the Royal College of Surgeons of Great Britain, was fully complicit with these monstrosities called government hospital Consultants in making a joke out of Surgical Training. With the refusal of the Consultants to train their juniors, the result again was that any of the young doctors who could go to the US or the UK left the country, and Pakistan became a country bereft of a whole generation of young surgeons. The older generation of surgeons in Civil, Jinnah and CPSP ensured that the art of surgery never passed into younger hands in order to keep all the money and the nation of Pakistan`s surgical career ended then and there. All this rigmarole of surgical training ran alongside the fact that the post of the medical superintendent of Civil Hospital Karachi is meant to be one of the most money-making and extortion-friendly posts in the Sindh province and is usually occupied by a Consultant Surgeon. One of the earlier MS`s of the hospital, Dr Shafi Qureshi FRCS was shot and permanently crippled for opposing the Corruption mafia of Civil Hospital. His assailants were never caught and Dr Qureshi lives in exile in London. There have been many proposals for re-organising the Sindh government health service on the pattern of the Aga Khan University hospital`s management system, but the Corrupt Consultant mafia of Civil and Jinnah Hospital hires a mullah to give a ``fatwa`` against the Aga Khan and the proposals for transparency, accountability and audit simply fall through. (A few of the most corrupt Consultants and Administrators of Pakistan`s hospitals also live in the US and UK with their ill-gotten wealth, looted from Pakistan`s poor and dying patients).



From 1997 when I graduated until 2002, there was no Public Service Commission Examination in Sindh province for doctors. The reason I was told was that one of the Ethnic groups was waiting to cheat Karachiites for jobs by using the defunct and expired Quota System . I am told that the present Governor Sindh, Dr Ishratul Ebad , himself a graduate of Dow Medical College has done a good job and considerably improved things, but in the Sindh province, only one return to Benazir`s rule can drive things back into insanity and chaos.

After many years of working in the UK and after meeting many Indian friends in the UK, I have come to realise that Pakistan`s health service should be organised on the pattern of the British NHS or at least the Indian health Service. It is not possible to unite all of Pakistan with all the different ethnic and sectarian divisions with the resources, discipline or accountability of the British NHS.

But the Indian Health Service too have a remarkable Postgraduate Training system which relies on exams and merit. After State and National exams, MBBS doctors are selected for postgraduate training and they are trained in a definitive and purposeful way for 18 months after which they graduate with an ``MS`` as specialists and then go on to finish their Sub-specialisation or remain in the job market as specialists. Their seniors in India do not feel threatened or insecure about training or teaching them or about controlling the private sector patients.

I think, that in Pakistan, doctors, in order to be respected in society have to respect each other first.
First the rot of Corrupt inertia in the older generation of Consultants whop are interested more in keeping their private practices than government jobs has to be eliminated.
All the paranoia about teaching and training junior doctors and the policy of exploitation and genocide by the Consultants in Civil and Jinnah Hospitals has to end.
The Consultants should be held accountable for their treatment of junior doctors just as they should be held accountable for killing patients (or stealing patients` medications from the Sindh government funds).
Finally the corrupt bureaucrats should be stopped from controlling the hospitals which should be given under control of qualified and honest managers.
The problem is that all this easier said than done as honesty like corruption percolates from the top.

In most countries, it is bureaucrats, not doctors, that frame health policies. This is apparently because politicians are answerable to tax payers! In Australia and the UK, to name 2 countries that I am aware of, doctors are being systematically disempowered, and I do not think it is a coincidence that the rise in female doctors has occured at the same time.
Doctors are so preoccupied with doing the best they can for their patients that all this plotting and planning goes on behind their backs and they only realise when it is too late to change the situation.

I work in a hospital as a small fry, I`m not a doctor. I do find it sad that doctors who are experts in, say tuberculosis, know how to treat horrid forms of the disease, fight for the lives of their patients, but do pretty little in preventing the disease in the population. The other even sadder thing is `cut` practice which seems to be getting worse by the year. Young registrars don`t have role models they can follow....most of them seem to have taken to the profession for greed, not led by any altruistic motive. However, I have also seen doctors who are so straight and good and strong, they hold up the name of the profession, they are true social leaders. They may be few, but I hope that....at least in India...in the years to come, their tribe increases.

Doctor Sahb… Here are some stats for you. I am giving the comparable data for the US (in brackets) so you can have some idea how the two compare.


I Pakistan there are 2000 (in US 300) people for each doctor.

50% (90%) of the people have access to safe water.

91 deaths per thousand (80 per 1 million) live births

Literacy rate is 41 % (98%) of population

Average life expectancy is 61 (76)

External debt is close to 40% of our GDP (n/a for US, but it don’t matter!)


What I am trying to say is that Physicians and scientists know jack about how to run a country, and healthcare is only a small part of running an economy. Doctors are trained to care for patient and treat the ill, and are not really trained to set health policy. Not to say that politicians are either. The input from physician community should be welcome, but only for what it is worth.

I will be interested to know if you have any insights into how to reduce the doctor to patient ratio in Pakistan. At present it is pretty ridiculous.