April issue 2002

The Frontier government’s decision to ban doctors’ private practice and introduce institution-based practice (IBP) at public sector hospitals from March 1 has created a wide gulf between the medical profession and the government.  The doctors are adamant in their opposition to the move and term it ‘a recipe for disaster.’  The government is determined to implement the plan in the ‘best public interest’.  Talks to bridge the gap have failed not only because the camps have divergent viewpoints but also because the end sufferers are the patients who have little role to play in the crisis.

“The private practice of all government doctors, including teaching staff at any place or premises, except within the boundaries of the health institutions/hospitals concerned, shall stand banned with immediate effect,” said a notification issued by the NWFP health secretary on February 2002.  In a press conference the same day, the acting health secretary, Brig. Habibur Rahman, gave a grace period of 15 days to the government doctors to wind up their private clinics.  He warned that following the expiry of this period stern action would be taken against transgressors for misconduct, according to the NWFP Civil Servants Removal from Service (special powers) Ordinance, 2000.

The ban was a sequel to an earlier notification in June 2001 that made four major health institutions, the Lady Reading Hospital (LRH), Peshawar, Khyber Teaching Hospital (KTH), Hayatabad Medical Complex (HMC), Peshawar, and Ayub Teaching Hospital, Abbottabad, autonomous both financially and administratively. According to Brig. Habibur Rahman, the government started institution based practice (IBP) in four major hospitals of the province on a voluntary basis out of good faith and asked the doctors to spare only two hours a week for IBP. “They did not cooperate and the plan proved a failure,” he remarked. “That was a half-hearted attempt and the government had to devise a new policy to deal with the situation and make it a success.”

According to the formula announced by the health department in its notification, the doctors will get 60 per cent of the revenue generated through the IBP of each institution.  The clinical and administrative support staff is assigned 20 per cent while the remaining 20 per cent revenue is allocated for the hospitals.  The patients are required to pay 300 rupees as fee to the consultant in IBP.

In a summary on regulation of private practice by doctors, Brigadier Habibur Rehman says the objective of the plan is ensuring quality treatment, a uniform fee structure, maximum utilisation of hospital equipment and infrastructure during off-hours, creating additional resources and documentation of doctors’ incomes.

The doctors, who closed their clinics throughout the province on March 1 in accordance with the notification, are up in arms against the ban since then. They have held talks with the NWFP governor, Lt General (Retd) Syed Iftikhar Hussain Shah, his advisor on health, Dr Robina Gilani, health minister Dr Mehr Taj Roghani, and the NWFP chief secretary to bring home to them that the doctors are not ready to accept the notification.  The doctors claim they are holding talks to convince the government that introducing IBP is not the right step and the ban on private practice is not fair.  The government side asserts it is ready for talks in order to facilitate IBP and remove the doctors’ apprehension, if any.

The Joint Action Committee, headed by Pakistan Medical Association (PMA), NWFP, president Umar Ayub, has filed a writ petition against the governor’s order in the Peshawar High Court (PHC) pleading that the notification is against the law. “Our meetings with the government so far have failed to bear fruit and find common ground,” says Umar Ayub.

“We have filed another petition against the notification in the Supreme Court on the ground that it is against fundamental human rights.”  “The IBP is a recipe for disaster,” the PMA provincial chief claims.  “The doctors have no option but to tender their resignations if the situation persists and no common ground is reached to resolve the issue,” he warns.

Though the doctors are enraged about the plan, few are vocal enough to criticise the scheme openly. “The chief secretary has warned us not to press our grievances,” says a cardiologist at the LRH.  Many doctors says the health department has banned private practice despite the fact that the hospitals do have not enough infrastructure, equipment and facilities to accommodate the influx of patients. “The ultrasound and X-ray machine at our hospital is a couple of decades old,” maintains  a doctor at LRH claims. “This random act will only lead to disastrous effects,” says another doctor.

The government, however, seems to be holding firm in its resolve to implement the plan. According to Brigadier Habibur Rehman it is holding talks with the doctors to resolve the issue. “As far as I know, the dialogue with the doctors is being held to discuss facilitation of IBP, not its revocation,” the health secretary says.  Though both sides stick to their guns and are not ready to show flexibility, Dr Robina Gilani is optimistic about the outcome of the dialogue. The doctors in their meetings contend that facilities at the hospitals are not adequate and the decision about IBP was a sudden one she says. “They have objections over facilities and the increased load of patients in hospitals, not over the IBP plan, which is understandable, and the government will definitely look into it to bring about an improvement.”

The patients have become pawns in this conflict between doctors and the government. Both sides say they are acting to protect the interests of the patients but this is yet to be proved. Financially, the patients are not better off with the new mechanism. They still have to pay 300 rupees to the consultants in IBP as they did in the private clinics. As the doctors are against the new mechanism, they are being non-cooperative. “We have confirmed reports that certain senior doctors have adopted a go-slow policy and are dumping patients in wards to stir up the public about infrastructural deficiencies in hospitals,” says Brigadier Habibur Rehman.

The doctors have also allegedly started prescribing highly expensive and rare diagnostic tests, which are not available in the hospitals, admitting unnecessary patients through morning OPD, and prolonging patients stay in the wards and rooms unnecessarily.  The administration of various hospitals has also complained that senior doctors are not paying attention to patients in the morning OPD. Also, there are complaints about the rude behaviour of orderlies and paramedic staff at the hospitals.

The introduction of IBP has also caused difficulties for patients in remote areas of the province and in the federally administered tribal areas.  Doctors used to go to the suburban and rural areas for private practice and provide healthcare to the people in their villages.  Now they cannot to do so and the patients have to come to the hospital, travelling on dilapidated roads.  Also, many doctors charge less at their clinics than the fees prescribed at the IBP.  This means increased healthcare cost in the rural areas where poverty is more pronounced and people cannot afford medical treatment.  Whether this will augment quackery in these areas or not is a question staring us in the eye.  Time alone will tell whether the government and doctors will be able to reach a common ground in their talks, resulting in better medical facilities at an affordable cost.