Almost 1,500 women die each day, half a million every year, as a result of causes related to pregnancy and childbearing. Nearly 99 percent of these deaths occur in the developing world, partic ularly in urban slums and rural villages where women experience poor health, ignorance, poverty, low social status and limited access to essential health care. In these areas, maternal mortal ity rates range from 300 to 800 per 100,000 live births. The lifetime risk of dying because of a pregnancy-related condition is one in 25 for women in developing countries, compared to only one in several thousand in the developed world. In Pakistan, it is estimated that around 500 maternal deaths occur per 100,000 live births.
Women who have had five or more pregnancies and women who are over age 35 also face substantially higher risks. The risk of death during pregnancy or childbirth is five to seven times higher for females under age 15 than for those in the 20-24 age group. Women who become pregnant within two years of giving birth face higher risks than women who space births more than two years apart. Additionally, frequent pregnancies can exacerbate many pre-existing chronic conditions such as heart disease, hypertension, diabetes and hepatitis, all of which can indirectly cause maternal death.
An Essential Tool in Preventing Health Care:
To improve maternal mortality, access to information and family planning services must be ensured. All couples should be able to decide freely and responsibly the number and spacing of their children, as a basic human right. Health service that provide the information, counseling and means needed to facilitate the adoption of the concept of family planning should be widely available and accessible, especially for the most deprived popu lation group. A woman who lacks family planning services and does not want to continue an unplanned pregnancy may have only two options - an unwanted child, or an induced abortion.
The rise in the number of women resorting to abortion testifies to the failure of family planning services to keep pace with the demand. The toll is great: complications from abortion kill an estimated 200,000 women per year. The best way to prevent abortion is to make family planning accessible to all women and men.
Implementing Family Planning Programmes Successful family planning programmes generally have most of the following characteristics: effective political support; wide spread, easily accessible services; multiple public and private delivery systems; a broad choice of contraceptive methods; personnel systems ensuring that the labour force is adequate and motivated; sound strategies for financing programme activities; adequate information, education and communication efforts; logistics systems that result in timely provision of supplies and equipment; strategic planning and flexibility; effective supervi sory system and well-functioning management information systems and research and evaluation mechanisms.
To be successful, a family planning programme must have political support at the highest governmental level, in the relevant minis tries (Health, Education, Planning, etc.) and also at the provincial and district levels. Political support is required not only for the initiation of these programmes; the commitment must be sustained to ensure that both laws and resources continue to support improved programme implementation.
Worldwide experience has shown that easily accessible services are necessary if programmes are to achieve relatively high cover age. In many developing countries, governmental social services focus disproportionately on "elite" group, in particular on the urban middle class. Scarce financial resources in the health sector are often concentrated on supported for curative services in urban hospitals. Most of these countries need to change priorities in order to: extend the service network; increase health coverage by targeting population group most in need; and intro duce preventive health care approaches, including family plan ning, within the set of basic health services. In particular, more efforts should be made to reduce the still conspicuous urban-rural differentials in contraceptive use.
In Pakistan only 6 percent of rural women currently use contraception compared with 31 percent of women living in major cities. By contrast in Indonesia, for example, the contraceptive prevalence rate is higher in rural than in urban areas. The type of provider and mode of delivery also affect the access sibility of family planning services. Pressure to keep physicians in control of some aspects of primary health care, including family planning, has slowed progress in making services widely available.
Abundant evidence demonstrates that trained non- physicians can safely and effectively deliver barrier and hormon al (oral and injectable) contraceptives, as well as perform IUD insertions. Geographic constraints, underdeveloped basic infrastructures, and dispersed populations are, among others, important factors af fecting programme achievement. The 1990-1991 Pakistan DHS reports that nearly 40 percent of women would have to travel more than one hour to reach the nearest source of family planning. The inaccessibility of family planning is likely to discourage women from obtaining family planning methods or advice. Successful programmes have risen to these challenges by developing "multi- source" strategies to promote services and make them widely available. Such strategies usually include supplementing clinical services with post-partum family planning services at all facili ties where births are attended, forming community-based networks to distribute contraceptives and involving the private sector in furthering government goals.
The private sector has proved a vital adjunct to government efforts to extend the accessibility of services and to improve contraceptive prevalence. Family planning associations and other NGOs, private pharmacies, physicians and social marketing schemes are responsible for half or more of the existing contraceptive prevalence in many countries.
Contraceptive accessibility and programme progress have been restricted by a limited choice of contraceptive methods. Pro grammes should make all methods widely available. This does not mean offering many varieties of each method; a few representatives of each should be carefully selected. Fetors thatlnhibit broadening contraceptive alternatives include uncertainty about safety, religious objections and socio-cultural resistance to certain methods. Disseminating international data on the safety and efficacy of family planning methods, conducting small- scale pilot tests of methods and retraining personnel to combat misconceptions and rumors are effective measures to overcome these problems.
Acceptance of family planning requires that services be adapted as much as possible to local customs and "user perspectives". Service agents and the contraceptive mix must be selected in accordance with cultural patterns; respect for privacy, modesty and anonymity are also important. Acceptability also encompases “quality of care” factors. Among the chief mechanism for improving quality are a broadened range of available contraceptives, easy access to information and counseling, training of personnel, adequate technical capacity and the existence of follow-up mechanism.
Family planning programmes have typically focused on married women; other groups have been less thoroughly addressed and sometimes neglected. Correcting this shortcoming constitutes a special challenge for the 1990s, as does the rise of AIDS and other sexually transmitted diseases (STDs). Adolescent reproductive behaviour is an issue with great poten tial for controversy in most societies. The comparative risks of morbidity and mortality for the adolescent mother and her child are unacceptably high. In addition to health risks, evidence is mounting that too early childbearing disrupts female education and reduces a women's opportunities for personal growth. Unfortu nately, not much progress has been made in providing services to adolescents; where this has happened at all, it has tended to be on a modest, experimental scale in a few major urban areas.
It has not been determined whether separate services must be established to win the acceptance of young people, whether pro grammes can use traditional agents to promote services, or whether er separate messages are required to reach males and females, the married and the unmarried. However, it is clear that adolescents should be a priority group for family planning programmes. Among the main issues that must be addressed are how to change tradi tional attitudes favouring early childbearing and how to over come the ambivalence (or actual resistance) of general society and service personel towards the provision of services to adoles cents. In Pakistan for example, although the majority of the people do approve of family planning, yet a substantial number (38 percent of women) still disapprove of contraception, many of them citing religion as an opposing force against the use of contraceptives.
To date, most efforts directed towards men have been limited to attempts to win their support for contraceptive use by their wives, through exposure to information about the negative impact of unregulated fertility on the health and socio-economic status of the family. Much more than mere acquiescence by men is needed; they must play a far more active role in promoting, supporting and using family planning methods. The need for such an active role by men is important in a country such as Pakistan where husbands usually have a predominant role in family planning decision. Moreover, men are more resistant to the idea of family planning than women. The family programme should increase efforts to provide and make easily accessible services tailored to men's reproductive needs.
Induced abortion remains highly controversial. It is estimated that between 25 million and 40 million induced abortions occur annually in the developing world - approximately one for every three to five live births, j Between 10 million and 20 million occur where abortion is illegal or where hygienic and affordable services are relatively inaccessible. Complications of abortions performed under unsafe conditions may be responsible for 10 to 50 per cent of maternal deaths in developing countries. The promotion and expansion of family planning services can lessen the resource to abortion. Family planning programmes will increasingly come under pressure to address the accelerating menace of STDs in general and AIDS in particular. Promotional home visits, clinic educational efforts and family life and sex education programmes present natural opportunities to inform the public on prevention of STDs. The provision of condoms and spermicide, a traditional responsibility of family planning programmes, may be expected to increase as the campaign against AIDS intensifies.
Health, population and development
Health, population and development are closely interwoven. High fertility rates and decreasing levels of mortality, for instance, are the main determinates of rapid population growth. Population dynamics, the environment and socio-economic development are also intimately linked. All of them, in turn or in conjunction, clear lee affect the health status of a population. The world population reached 5.5 billion by mid-1992 and will reach 6 billion by 1998. It is growing faster than ever before: three people every second, more than 250,000 every day. The "medium variant" or most likely projection for 2100 is now 11.2 billion.
This is 10 per cent larger than what was predicted in 1982. Growth is not expected to stop altogether until the year 2200, when world population may stabilize at approximately 11.6 billion - over twice its present level.
Approximately 95 per cent of the population growth is occurring in the developing countries. By 2000, the developing world will grow to nearly 5 billion, out of an expected world total of 6.26 billion. Continued rapid growth has brought human numbers into collision with the resources required to Sustain them. Increasing populations add to demands on land, air and water resources, making it more difficult to support growing numbers of people. Decisions leading to more healthy fertility patterns that can positively affect population dynamics, socio-economic develop ment, the environment and health require an adequate provision of family planning services, but involve other factors as well. The success of family planning depends on decisions made by billions of individual women and men. How parents greet the birth of a new child, whether a girl is as welcome as a boy, whether girls and boys are reared with equal chances of health and education and whether parents choose to plan the birth of a subsequent child all affect the opportunities and aspirations of the whole family. And these factors will have a bearing on how future generations perceive choices in their own family lives.
Conclusions and Recommendations
It is hardly necessary to labour the point that family planning represents an essential tool in preventive health care, in en hancing women's autonomy and in lowering population growth rates. Yet, the fact remains that even today, approximately as many as 300 million couples in developing countries do not have access to family planning services. Survey data indicate that at least half of these wish to use some method of family planning either to space or limit births. In Pakistan, 41 per cent of currently married women have expressed a need for family planning: 27 per cent to stop childbearing and 13 per cent to space their children. Since only 12 per cent of married women are currently using contraception, 28 per cent have unmet need for family planning services.
On the other hand, the experience of the past 30 years strikingly underscores that progress with respect to population concerns and socio-economic development is highly correlated with a number of factors, including population growth. Economic expansion and improvement of the quality of life have been fastest where population growth rates are moderate and family planning services readily available.
Thus, acknowledging that family planning can play a significant role in promoting maternal and child health as well as in con tributing to moderate population growth rates, it is essential that appropriate initiatives be designed to facilitate access to and increase the availability of quality family planning services. Further improvements in maternal and child health and decreases in population growth rates in developing countries will depend on the coverage and quality of maternal and child health services in general and family planning services in particular.
In order to achieve this goal, it is imperative that political commitment I family planning, which has waned in some countries and regions, b rekindled. Other considerations that government officials and programm managers in developing countries must keep in mind include:
• Family planning programmes must promote the concept of informed choice and a wide variety of methods, high quality services, full information to users and leave the choice of method to users.
• Considerable effort must be devoted to increasing the avail ability of family planning services, including wider use of the community-base distribution and social marketing programmes, without compromise quality.
• The private sector should assume a greater share of the responsibility for providing family planning services. Governments should consider delegating considerable responsibility to the private sector, while focusing government resources on under served subgroups.
• Programme managers have to identify the particular needs of target populations. Education and services for adolescents should be priority. More effective approaches are needed to better involve in family planning.
• Family planning programmes must play a more active role in preventing sexually transmitted diseases in general and AIDS in particular.
• Women in the developing world must become the designers and managers of family planning programmes, rather than remain pas siv beneficiaries of services, or serve only as low-level pro gramme staff.
PRIVATE MEDICAL COLLEGE:
The issue of private medical colleges in Pakistan has been a subject of serious debate on professional forums uses like Pakistan Medical and Dental Council and Pakistan Medical Association. It is a dilemma between projected need of the country (on the assumption that Health for all by the year 2000 will be pursued) and the pace of infrastructural development in the health sector.
In the absence of a comprehensive policy of future health delivery system there is no rational basis to calculate the number of doctors required. As such the present increase or decrease in the number of admission in medical colleges is arbitrary and subjective. 1972 before the opening of Sindh Medical College in the premises of Jinnah Postgraduate Medical Centre for entirely different reasons, there were only 9 medical colleges with 1568 admissions. (Highly trained clinical teachers were under-utilized for lack of enough postgraduate students. They were the hey days when going to UK or USA was not so difficult as today). Yet another plea frequently made by the government for not providing comprehensive medical cover was that there are not enough doctors and that they don't go to rural areas.
More due to political expediency in the considered plan, taking the example of Sindh Medical College (requiring minimum basic sciences component with limited funds of Rs.18 lac or so), two more colleges were setup, one at Larkana and the other at Nawabshah. Other provinces took the one from Sindh and as a matter of prestige new colleges were proposed up in Punjab, NWFP and Balochistan. The Armed Forces also decided to setup a college to overcome the resistance from the young doctors towards compulsory services. So by 1981 there were 16 colleges admitting 4239 students and producing approximately 3552 doctors every year. The number of admissions have now reached 4500.
The result of such disjointed action (not policy) was surplus doctors with little job opportunity or adequate postgraduate training programme. It coincided with doors firmly closed by Britain and United States. In the seventies His Highness Aga Khan made an offer to donate a medical college. It was time when the bureaucracy stile explained away the deter mating health scenes to lack of doctors. By the time Aga Khan Medical University was given a charter in 1985 the scene had changed radically. Yet the number of seats and the quality of education was maintained by them, and the first private medical college gave a better image while setting a precedence of feasibility of other colleges. We were at a threshold of an upsurge in the proliferation of medical colleges. The door was wide open.
We have the example of medical colleges at Dominican Republic and Sri Lanka. It caused problem to the quality of medical practice in Pakistan. The PMDC had to decide about re-examination of those graduates. This was inspite of an adverse report submitted by a committee of PMDC who visited the Dominican Republic. The Indian scene of private medical colleges was totally non-available. At present the decapitation fee in many so called Medical colleges there runs as several lac of rupees. They have problems in containing a large number of spurious 'institution' through a small number setup by philanthropists are functioning very well. They are based on public service and charitable point of view rather than profit making ventures.
The Pakistan Medical Association in 1987 pointed out the problem and demanded legislation to this effect. The Federal Ministry of Health or the PMDC had no legal grounds to check. (In Punjab various so-called medical colleges were operative without any hindrance). Today the situation is that anybody can start a medical college if certain paper requirements are provided to the university. Some political clout can facilitate the process. The worse is that medical college can be started, admissions made while the application remains pending with the university. We have similar situation at least in Karachi. Such fraud can be much worse than the Investment Company or cooperative financial scandal. Pakistan Medical Association conducted at seminar and formulated recommendations. Besides proposing the content of the curricula and the community oriented teaching the recommendations were made about the number of seats in medical colleges.
They were spelling out a policy by the government where new medical college could be opened yet the total number of seats should not be increased. After providing balance and checks through amendment in PMDC and University charter. The overcrowded medical colleges in state sector could surrender 50-100 seats to a newly approved college. This could also improve the standard of education in the current colleges.
Recommendation for Admission in the Medical Colleges
The number of admissions to the medical colleges should be based on the need of the community or in accordance with the projected commitments of public and private sector for the health needs of the country. This should be the overall consideration. Moreover the admission should also be related to a suitable ratio between number of students and teaching and training facilities at a certain medical college. For this criteria it is suggested that in one basic department for a batch of 60 students, there should be the following teaching staff:
Professor -1, Associate Professor 1, Assistant Professor 1, Lecturer 1 and Demonstrators 4.
In clinical subjects there should at least be 2 units of medicine, surgery, obstetrics and gynecology and pediatrics and one unit for each specialty. Each unit in clinical side should have similar teaching staff as suggested for basic sciences. The paramedical staff, the secretarial staff, library and audiovisual facilities should be complementary.Criteria for Admission Age should not necessarily be a criteria for admission. The emphasis should be on basic education background and capability. Eligibility for admission should be intermediate science (pre- medical group) or equivalent. Besides the minimum qualification it is suggested that MCQ computerized tests based on subjects of physics, chemistry, biology and general knowledge divided into equal parts to be conducted simultaneously at national and pro vincial level. Successful candidates physically and mentally fit and qualifying the exam are admitted according to merit. The object is that apart from educational qualification, motivation and proven ability to work hard should be made the criteria. Having suggested that we do realize that there is no foolproof method of selecting future doctors.
Medical education is a continuous process. It begins with under- graduate studies and continues throughout life. The physician has to be a life-long student. The administration, the medical institutions and the profession should collectively shoulder the responsibility of achieving and maintaining the required standard of under-graduate and post- graduate medical education and the quality of healthcare.
The following pre-requisites to establish and maintain certain standards for medical education are
Pre-Requisites Teaching of health-related subjects be introduced at school level. Selection of students must be based on individual's aptitude, qualifications and achievement, irrespective of age, sex and race. It should be free from political considerations or regional bias.
Students should be made to understand well the minimal level of competence and the basic goals they are supposed to reach within specified periods. Number of colleges should be reviewed keeping in view the requirements of various regions. New colleges may be opened without increasing the present total number of seats for MBBS. Available infrastructure and trained manpower be evaluated and expanded while others strengthened to undertake clinical teach ing. The ideal number of students admitted in a class and/or lecture should be 100, but in any case, should not exceed 150. Specific areas which need attention are curriculum, training facilities and evaluation methods.
Postgraduate education de serves a comprehensive plan based on national requirement and organised teaching and training programme.
1 - Radical change should be made in the curriculum of under- graduate studies in order to keep it in line with the actual helth needs of the country. Inclusion or deletion of a certain part in the curriculum does not serve well. Instead, what is actually required is a conceptual and qualitative change so as to widen the mental horizon of the student.
2 - The change should help prepare the student for administrative and leadership roles and not to make him a mere pill-prescribing clinician. Social sciences (including psychology, sociology and anthropology) and health economics must be part of the curricu lum.
1 - To provide for adequate training facilities for undergraduate students, as also to meet the future need of well-groomed physi cians, the district and other suitable non-teaching hospitals in the public sector should be properly staffed and equipped and affiliated to nearest medical college. The qualified personnel in such institutions should be given due rcog-nition and title of teachers. Thus the clinical component of a given college should be spread over varous parts of the surrounding area in the shape of satellite compuses.
2 - After being taught in the pre-clinical courses, batches of students should be placed in the district and other suitable non- teaching hospitals in rotation. The additional advantage of ths and the preceding recommendation would be an improvement in the healthcare of the masses.
3 - Part of the undergraduate clinical training should be imparted in settings outside the premises of hospitals, as majority of the graduates will eventually be working outside the hospi tals. Placing of teachers and students in the community-level health programme is absolutely essential.
1 - The method of evaluating the students' attainment should be uniform, objective and dependable. Expectations from students must be clearly laid down before training and evaluation.
2 - Frequent assessment of students' progress should be given more im-prtance than the end-of-the-year examination. Record of the grades achieved should be maintained and given weightage in final assessment.
3 - Quality of professional teaching and training should also be frequently assessed at regular intervals in evaluating the evalu ators. Pakistan Medical Association should be member of the assessing committees.
There is a pressing need of specialists in various fields. Ac cording to an estimate, Pakistan should produce 1300 specialists every year till 1993. Necessary resources will have to be geared to achieve this goal. Emphasis should be laid on the following points relating to post- graduate education:
1 - Actual need of specialists in the country should be assessed, through field research, keeping in view the job opportunities for them in public and private sector.
2 - Fresh graduates should be provided with expert advice regard ing their aptitude and aspirations.
3 - Dependable information should be available on the future need of all specialists for a rational choice of a particular speciality.
4 - Uptodate list of specialists working in various fields should be available.
5 - Training and examining bodies should be independent and sepa rate but complementary.
6 - Training programme should have a built-in system where the trainees, if they want/realise, have the freedom to upto out.
7 - All the trainee posts should be for a specified period, based on the length of training required for various speciali ties/examinations.
8 - All posts in teaching hospitals should be filled in through peer review and not through Public Service Commission. They must be on contract basis and not permanent. Renewal may be allowed, subject to satisfactory performance and peer review.
9 - More institutions (other than the existing postgraduate training centres) be created/upgraded and accredited by the examining bodies, so that the burden on the existing facilities is distributed and more specialists are produced.
10 - Failure in postgraduate studies must also be considered a failure of the training programme. The training programme should be evaluated is case of persisting failures of postgraduate trainees.
11 - The end-of-the-year examination system should be discarded and] regular evaluation, based on objective procedures, be adopt ed.
12 - Teachers should be trained in educational methodology and in scientific method of assessment.
13 - Foreign qualifications, which are not registerable in their own countries, should not be registered in Pakistan. PMDC should evolve a comprehensive method of evaluating other foreign de grees/diplomas.
14 - According to a well-drawn plan, acquiring postgraduate qualifications in foreign countries should gradually be discour aged and only training in reputed centres abroad be encouraged.
15 - The pressing and urgent need of popularising Family Medicine should be realised. Continuing medical education and post- graduate disploma in this field should be established. Training in this area should be imparted in community setting rather than in hospitals.
16 - Doctors with postgraduate qualifications acquired in Paki stan shouldj be sent to the centres of excellence abroad for training for a period of six months to two years.
17 - A programme of continuing medical education should be set up for the i graduates and incentives in the form of credit be given for knowledge acquired. The credit be counted for postgrad uate training.