Health Sector in Pakistan - 4

POST GRADUATE TRAINING IN PAKISTAN:


A fresh M.B.,B.S. graduate of a Pakistani medical college is not fully ready to start independent work. This is irrespective of whether the individual wishes to become a specialist, or a family physician, or a teacher, or an administrator. All of them need further training, before they can work proficiently and productively. Thus, all M.B.,B.S.graduates need postgraduate training. The type of training that one needs will depend upon what the individual wishes to do.

The various career options open to MBBS graduate are to become a:

Health administrator

Specialist

Family Physician/General Duty Medical Officer

Teacher

Researcher

The above categories are not absolutely watertight. An individual physician could move from one to another with additional training. Similarly an individual could train to be a specialist and then train to become an administrator or a teacher as well. Postgraduate training can be a formal course (diploma) or an approved training programme (fellowship) or it can be on job training alone (Administration).

The different postgraduate training programmes available in Pakistan are:

For Health Administrators:

The university of Islamabad has a course in Hospital Administration but most of the individual who go for administration get on job training. Many do administrative courses in NIPA and other places along with other administrative cadres.

For specialists in clinical subjects:

The options are fellowship and membership of the college of Physicians and Surgeons Pakistan (CPSP) and M.D., M.S. or Diplomas of different Universities. For those wishing to specialize in Basic Medical Sciences there is the M.Phil and PhD programme.

For Family Medicine:

CPSP has a Diploma a Fellowship programme.

For Teacher:

There is no diploma or degree programme so for in Pakistan. CPSP is planning a Masters in Health Professional Education in collaboration with the University of Illinois at Chicago. However, the Department of Medical Education and National Teacher Training Center at CPSP conducts a number of 3-6 day workshops on educational methodology. The PhD, M.phil, M.D. and M.S. programme are based on research work and thus provide training in research.

Institutions offering postgraduate programme:

CPSP was founded in 1962 by an Ordinance and its major mandate is to raise the standard of medical practice in Pakistan. The college is patterned on the lines of the Royal Colleges of UK except that unlike UK there is single college for all disciplines. The college through its 27 Faculties lays down the training requirements of each specialty, the minimum standards for recognition of an approved training unit and the format of the examination. The training programmes are structured and logbooks have been introduced to keep a record of the day-to-day activities of the trainee. The FCPS trainee is also expected to submit a dissertation on a subject of their choice. The length of training varies between 3 to 5 years depending upon the particular specialty. In addition to the fellowship program, CPSP also has membership programme in 19 specialties. The training required for membership examination is 1 to 2 years. In addition, CPSP also offers a Diploma in Family Medicine.

A number of universities offer a 2-year M. Phil programme in basic medical sciences. This programme was first established in 1959 at Basic Medical Sciences Institute (BMSI), Karachi. Later Punjab University and some other universities have also established M. Phil, programmes in basic medical sciences. This programme has provided basic sciences teachers to all the medical colleges of Pakistan. BMSI has also produced about a dozen Ph.D. in Biochemistry, Pathology and Pharmacology. To the best of my knowledge, no other university of Pakistan has started a Ph.D. programme in basic medical sciences. Most of the universities with a medical faculty offer an M.D. and M.S. programme. The exact requirements of this qualification vary from university to university and it lacks a structured training programme. The popularity of this qualification has had its ups and downs. At the moment it is most popular in Punjab. The Universities also offer Diplomas in a number of specialties. These are courses of 9-10 months duration in which the major emphasis is on didactic teaching with some practical training. The standards of the diploma vary between different universities.

PRIVATE SECTOR AND MEDICAL EDUCATION:

In respect of public health facilities Pakistan is one of the most backward countries of the world. Health has remained neglected in every Five Years Plan, because of lack of interest by the government and the economists in favour of industry and commerce. The influence of vested interests has always prevailed over social concerns. Economists have considered health as "non- productive area" which does not deserve extensive financial allocations that are necessary to produce a significant change in the health situation.

Wastage of medical manpower due to emigration has reached a situation where half of all fresh graduates leave the country within a few months of their qualifying.

The Shift towards Western Medicine

The social, cultural, economic and political changes that followed the introduction of British rule in India dealt a fatal blow to the practice of Indian medicine. Almost every facet of life including the medical public health services were subordinated to the commercial, political and administrative interests of the Imperial Government in London. In developing health services for certain limited purposes (for example, the army), the emphasis was shifted from Indian systems of medicine to the Western. The decision to make this change appears to be amply vindicated by the spectacular advances in the different branches of Western medicine during the 19th and 20th centuries. The Medical Education in Pakistan is really a legacy of these very colonial times. There have been some additions to the quantum of curriculum but there have not been any changes in the basic approach, either in the method of teaching, or the objective of that education so far as the end product is concerned. Essentially the tendency has been to try and produce a medical graduate who is trained to perform ideally in a hospital setting. Because he is trained for a hospital he is trained for a good hospital with all the sophistications. The kind of training that is required to train him is very different to the actual objective situation that this young medical graduate will find in the field in the urban or in the rural areas of Pakistan. The cultural situation, the economic circumstances and the general pattern of life that he finds is very different to what he has been trained to work in. Again the requirements of entrance are such that it may attract the most talented candidate by the standards of examinations, as at present held yet this is not the candidate that will be motivated to serve in the rural areas of Pakistan. The kind of doctor that will serve him in these areas with dedication may or may not have the academic distinctions, which have been made essential.


Also, the kind of orientation towards the Society and its cultural pattern that is given to the student in his medical education is totally divorced from the existing realities with the result that his motivation in practice of medicine end up by becoming a pure mercenary. No wonder that the large majority of medical graduates produced in this country in the last 25 years have emigrated, and those that are still here are constantly agitating to leave the country. Before we go any further it is necessary that the reader has some ideas of the economics of health care. The total expenditure on health by the Federal and Provincial Governments is Rupees Nine billion. This constitutes 1% of the GNP. Non-development expenditure is 5 billion and development expenditure 3 billion. In 1991 the Federal Government spends 550 million as development and 800 million as non-development, a total of 1.35 billion. Of the total GNP in Pakistan 75% is with the private sector, while 25% is with the Government, less than 5% with the Provincial Government. Of the 25% with the Government half i.e., 12-1/2 percent goes to defence, debt, servicing and subsidies.

Indicated below are some of the Areas where change is absolutely essential:

1. The medium of instruction

2. Duration of the Pre-Medical Course

3. The Entrance Examination has become essential

4. The Teachers and their Qualifications need a total revision

5. Teachers training programmes

6. The quantum of Education and its Content

7. The location of training in medical education

8. The System of Examination

9. Use of teaching aids are now considered absolutely essential

10. Teaching a whole time profession must be adequately recomposed.

It is obvious that the public sector will be unable to make all the contributions where change is considered essential. With the present resource constraint it is unlikely that Government Institutions will be able to find resources that our need is to develop postgraduate training programme in institutions, which are already in existence. The possibility of starting new institutions is even more remote.

Entrance examinations which have now become essential because of the wide spread problems in the existing examination systems will have to be a private sector enterprise if it is to have any degree of credibility. A model for this exists in many countries. In India, a National Board holds an examination for entrance to the medical colleges. In the US the Association of American Medical Colleges holds a nation-Wide examination called MCAT, which is essential for entry into any one of the medical colleges. The Government of Pakistan has recently advertised seeking offers for holding national examinations, which will be in the private sector. Similarly teacher-training programmes will be needed more than the presenting available facilities can possibly provide. The quantum of medical education and its content is a longstanding debate. It will have to be released from the shackles of bureaucratic control if medical education has to make any progress. Finally, the two compulsions of needs, which must be fulfilled, and the present worldwide climate of encouragement to the private sector are compelling reasons for recognizing the increased role of private sector in medical education in Pakistan.

FAMILY MEDICINE POSTGRADUATE TRAINING IN PAKISTAN:

Since the creation of Pakistan the majority of its citizens have had limited access to effective and affordable basic health care services. Economic under-development, political instability and low levels of literacy have hindered process in the equitable distribution of health care services particularly to poor and rural inhabitants. Thus while 70% of population is living in rural areas, 85% of physicians and 95% of hospital beds are situated in urban areas of the country.

The Indo-Pak sub-continent has a long history of traditional healers including pirs, hakeems and village birth attendants or 'dais'. These traditional healers have provided access to health care when other options might not be available and vary in their effectiveness in treating psychosocial and biomedical problems. "Quacks", as labelled by the Pakistan Medical Association, have no formal medical qualifications but portray themselves as bonafide practitioners, are estimated to provide nearly half of the general medical care in Pakistan. This low quality of health care coupled with limited access to clear water, sewage facilities and a poor public health infrastructure has resulted in Pakistan's continued high burden of infectious diseases, maternal and child mortality and needless suffering.

In partial response to the above problems, Pakistan and its medical profession have emphasized the production of more doctors. The number of medical graduates has risen dramatically from only 1300 doctors per year in 1977 to over 3800 per year in 1988. Unfortunately despite this increase in the number of doctors there has been relatively limited improvement in the health status of the population. This is reflected by the fact that Pakistan ranks 34th out of the 131 nations of the world with the highest infant mortality rate, which dropped from 160 per thousand in 1960 to 106 in 1989. Additionally, infectious and parasitic diseases continue to account for more than two thirds of all deaths in the population.

Pakistan is experiencing transition in disease patterns secondary to demographic and socioeconomic shifts which have important implications for the provision of adequate primary health care. The high fertility rate (eight children per women during her child bearing years) and improved child survival has led to one of the highest rates of population growth in the world (nearly 3%). There is also substantial growth in numbers of the elderly. By 2020, the segment of the population over age 65 will increase by 10 million. A rapid trend towards urbanization is occurring. It is projected that by the year 2000,50% of the population will be living in the urban areas as opposed to the current 30%. Initially, the diseases of under development such as malnutrition and infectious disease predominated. Now, in addition to the diseases of under development, the diseases of development such as hypertension, diabetes, coronary vascular diseases, cancer and drug addiction are emerging as important contributors to morbidity and mortality.

The reasons for slow improvement in health are complex and inseparable from the problems of under development in Pakistan; However, an important factor which has not been systematically addressed by the profession is the lack of orientation of medical education at the undergraduate and postgraduate levels to meet the needs of primary health care. Though the Pakistan Medical and Dental Council states that the objective of the M.B.B.S. curriculum is to prepare a general-purpose community oriented doctor, only 10 hours of the overall curriculum time is officially assigned to the teaching of general practice.

While the teaching of primary care, family medicine, preventive and community medicine is limited in most medical schools, provision of this care become more complex. While medical students receive limited training at the undergraduate level in the delivery of primary health care, even less is available at the postgraduate level. While over 50,000 doctors graduated from the 17 medical schools in Pakistan from the period of 1979 to 1991, less than 1000 acquired postgraduate qualifications from the College of Physician and Surgeons of Pakistan. In Pakistan to date, there has been no organized system of postgraduate training or certification that would prepare a physician to address the basic primary health care needs of communities in both urban and rural areas.

Family Medicine

Family medicine is one of the primary medical care specialties. Like internal medicine and pediatrics, it is a specialty of first contact with patients and serves as an entry point for patients into the health care system. Family medicine, however, is not restricted by age or sex and is devoted to providing comprehensive preventive, promotive and curative care with emphasis on the family unit including the community and social environment. It is a specialty of breadth rather than depth and requires familiarity with all medical and surgical sub-specialties especially internal medicine, pediatrics and obstetrics and gynecology. It also includes familiarity with community, preventive and behavioral medicine.

Family physicians are trained to care for the majority of common health problems, recognize their limitations and make referral to specialists or for hospitalization when indicated. A family physician personally takes care of most of an individual's health needs or selects appropriate consultants, coordinating all necessary health services. In some areas, some family physicians maintain active hospital and obstetric practices, while in other areas their practice is limited to outpatient care. The expansion of family medicine has been an international movement over the last two decades. After World War II, there was global trend towards medical specialization linked to rapid advances in medical sciences and technology.

Associated with this increase in medical sub-specialization was a decrease in the availability of high quality primary medical care, particularly for the rural and urban poor. Responding to this trend, in its guidelines for training of health professionals, the World Health Organization has stressed the need for more family physicians and specific postgraduate training programmes to adequately prepare family physician for the needs unique to their communities. The shortage of adequately trained general physicians has been approached in different manners in various countries. Some have developed specific postgraduate residency training programmes from two to four years in duration and specialty board examinations and certifications. Others have emphasized general training in the undergraduate curriculum and some have not addressed this issue at all.

In Canada, residency training in family medicine lasts two years after graduation from medical school and over half of all Canadian doctors are family physicians. Additional training in surgery or anesthesia is available for doctors planning to practice in rural areas. In the USA, a long process of work recognition of the specialty resulted in establishment of the American Academy of Family Physicians, a three years residency training programme and requirements for continued recertification throughout the family physician's career. Fifteen percent of doctors in the USA are family physicians and there is greater demand for family physician than any other medical specialist. In Britain, 40% of doctors are general practitioners (the British equivalent of family physicians) who complete a tow to three years postgraduate training programme. Training programmes in Central and South America and in the East have been implemented and are underway. Egypt, Lebanon, India, Korea and Japan to name a few.

SOCIAL CONSIDERATION:

Pakistan, like most Afro-Asian countries has been at a crossroads that has turned into a challenge for development. Here, tradition and modernity wrestles for domination, and in the process vulnerability of the vulnerable deepens. The crossroads bristles with efforts and frustrations. Many a mirage is created by efforts that are sometimes well intended, but often made with a pathological indifference that is accepted either helplessly or cynically. To compound the state of being stuck at a cross-roads, the acceptance of pathology of indifference has become pathological!'

At this crossroads where modernity and tradition wrestle, a deeper struggle is also taking place. It is the struggle for survival by the most vulnerable. Here, categories of tradition are often the better-known allies, even as they are crowded by categories of modernity. The latter compete for short-term solutions that are oriented to individual behavior, and tend to overlook the long-term advantages of social cohesiveness - hence our greater emphasis on clinical work, and our enchantment of the high-tech services. Categories of tradition as allies in the struggle for survival are to be found in the existing social support systems. These, however, need to be separated from those categories of tradition that are detrimental to people and their health ~ for example, negligence on the basis of sex, and social status. Such considerations seldom attract health planners and practitioners, perhaps because choices have been made - i.e., modern are the best, and needs no social support.

Separation of categories of tradition and modernity, and differences within these two trends are often not easy. It requires the resolving of an inner conflict in those who plan, provide, and also in those who receive Health care. The conflict is nebulous because of its rooting in very deep socio-cultural trends and values. It is the conflict of what we think are the solutions, and the magical quality are cribbed to medicine and medical technology, and yet feel dissatisfied with what modern medicine has to offer. Many interventions, representatives of modernity, bypass the inner conflicts, and often fail to accommodate them even when community participation is explicitly declared as an objective and strategy. And in so doing they also treat community participation as medicine to be dispensed to cure an ailment.

In Pakistan, efforts for health care development need to be seen in the context of Pakistan's political instability that has been dominated by the manipulation of resources by the vested interest for its own interest. Efforts have focused more on developing physical infrastructure, especially in the rural areas, and furnishing it with tools of modernity in terms of both equipment and modern medical knowledge. What these intervention ignored were the inner conflicts the people, especially the more vulnerable, face when attracted by the glitter of modernity but unable to avail it because of internal and external constraints.

To expect that factors governing people's behavior will be automatically transformed at the sight of modernity is to commit two fallacies. Both can be called fallacies of false assumption. One assumes that socio-cultural factors are weak enough to wither away at the sight of modern services. The other false assumption has to do with the strength of modernity ~ i.e., that its mere presence would, as if by magic, bring about a social transformation that would make modern interventions effective. In view of the unsatisfactory results of the intervention made for the promotion of people's health, it seems imperative the larger social milieu is seriously examined and considered at every step of health planning and interventions.

Just as it is not enough to have a technically sound ship and no understanding of the sea, in health system development technically sound interventions are not enough, understanding the social context is imperative.

The social context of Pakistan, and especially of its troubled province of Sindh, can be seen with the help of the following two notions:

1 - The mind-set of people — i.e., how people think and behave when powerful or powerless.

In the case of Sindh, a feudal form underlies most behavior. In this pattern the aspirations and expectations of the powerful and the powerless are governed by the traditional pattern of feudal relationship, whereby the powerful believes that he must get whatever he wants. On the other hand, the powerless avoids displeasing the powerful, avoids confrontation and accepts the misappropriation of his rights. (But this is not to say that he is not resentful, even if his distrust and anger are well hidden).

This behavior pattern is to be kept in mind for understanding the attitude and behavior of health providers, and also his/her clients — especially the poor. In Health System Development, the interaction between the two is crucial for ensuring the functioning and efficacy of the system.

2 - Two basis of behavior-patterns

People, whether they be health-providers or planners, or those who are supposed to avail the health services, have two sources of behavior:


(a) traditional power-base of those concerned


(b) gender differences as the basis of behavior.

Gender differences though highly visible in health statistics, seldom attract specific intervention for gender sensitization. Similarly, though women are a major concern for all health planners, women's issues, especially those universally recognized as affecting their health are seldom addressed — except as platitudes! Women's social status and its relationship with women's health has been studied, but most health programmes do not integrate women's programmes into health-programmes, at best they assume the nature of token-activities on the periphery. Similarly, though quality of interaction between providers and clients is a major determinant of health-services utilization, it is seldom if even integrated in the training of medical staff. Finally, only a few questions can be raised. Who is to identify the role of social sector development in health care development? Who will take the lead ~ a few individuals, or some institutions?

SO-CALLED REFORMS IN EDUCTAION BY LAKHA COMMISSION (INCLUDES MEDICAL COLLEGES):

Even our medical colleges have not been free of Political unrest. The principals do not enjoy any authority. From admission to getting a lectureship, all fall under the purview of the provincial governments. Why does the “Reformers in the Govt” claim that fees for students will not rise to the point that they are prohibitive, not surprise anyone? Perhaps because we know that the Commission would find itself in a slightly awkward position if it acknowledged that very soon, the policy will eliminate all those ‘unlucky’ enough to be born rich. They will be relieved of the onerous job of going to classes and getting an education. Fees in some of the Lahore colleges where some version of BOGS has already been implemented now range from Rs. 32,000 to 40,000 per year, with the result that a student who topped her F.A. exams was unable to study at the prestigious Kinnaird College for Women (where fees currently stand at Rs. 38,000). It is not hard to see that this trend will and can only grow, depriving middle and lower middle class students of a decent education. Since most of the BOGS are composed of members of private corporations (some of which call themselves educational institutions), the members are lavishly paid with the salaries of some as high as Rs. 300,000 a month. Instead of the state supporting students, the students will end up supporting the BOGS.

The fact is that with the government clearly not having any intention of increasing spending on education, further fee rises are inevitable inspite of current government reassurances to the contrary. Mr. Lakha insists that parents must know the “true” cost of educating their children. In an interview to Herald, a monthly magazine, he said “we must inform them that even if their tuition fee is say Rs. 2000, the actual cost of education is around Rs. 80,000 and the state is paying as much as Rs. 78,000”. How will parents be informed of these “true costs” if not by bearing them, is anybody’s guess. The Model University ordinance has creatively spelt out all its activities in detail that will lead to privatization, without mentioning that word once. It must be commended on that. What is truly ironic is that the private universities themselves, upheld as examples would be unable to be what they are if it were not for government subsidies (access roads, electricity connections), international aid (CIDA, USAid) or simply the benevolence of their founders (e.g., the Agha Khan for AKU). And LUMS, AKU, GIK and IBA represent less than 1% of the total privatized educational institutes in Pakistan. The rest have no facilities, no open spaces, no libraries worth talking about, almost no permanent staff and produce lower quality graduates than the public institutions, while charging higher fees.

That the quality of Pakistan’s public universities will go down with these reforms is a foregone conclusion. Pakistan is not the first country to undergo privatization of education. In other developing countries, privatization has already reduced access and declined quality (see for example, Martin Carnoy and Patrick McEwan’s (both of Stanford University) study of Chile’s educational reforms). With universities and colleges being encouraged to become ‘sustainable’, they often have no resort but to drastically cut the number and quality of teachers. Although an individual teacher may earn much more, the student/teacher ratio increases in each class and teachers are unable to do anything more than deliver carbon copy lectures all day.

A case in point: Since being privatized, the English literature department at Government College has laid off most senior staff to reduce costs. They now hire recently graduated girls, who are not paid more than around Rs. 5000, or retired professors who again are happy to work for a pittance. There is no continuation, no commitment to research, and no quality control since teachers change from term to term. Similarly, in hospitals junior doctors with little or no experience are in charge as higher grade and senior doctors have been forced to retire to reduce costs. The quality of both education and health are being jeopardized under the new system. How the Commission has promised to be able to pay the new salaries to doctors and teachers without making fees for students and patients prohibitive (remember the common man whose average income is Rs. 2000 supports a family of at least four) is beyond human calculation.

As part of these reforms, educational institutions have been forced to introduce self financed seats. The idea is that students who may not have made it on merit to the prestigious state universities can pay extra for the privilege to study and since they would pay so much they would value their education more. One can only imagine how competitive and inspiring one can expect one’s fellow student to be given that 30-50% of them will have ‘won’ their seats in an auction. And expectedly, the ‘self-finance’ (a phrase which has a perverse, and no doubt deliberate resemblance to ‘self-made’) fee amount is now only the bare minimum that students seeking admission have to pay. The more they can “donate” above and beyond that, the better their chances of admission.

The fact is that the problems highlighted by the Lakha commission which is being taken as the basis for all these reforms, are not related to public spending vs. private but to the suffocating hierarchy that is present in all our institutions. The Model University Ordinance further consolidates that hierarchy by consolidating unprecedented power at the top, in addition to privatizing education. The key to useful change is not handing over government responsibility to BOGS but in fact diverting more state resources and responsibility to health and education. At a paltry less than 3% of GNP each it is a joke. There is no doubt that there are numerous problems within this system. However, the fact that these institutions are able to deliver any quality at all at these contribution levels from the government is a testament to the dedication of many within these institutions. In the final analysis, it would be naïve to consider only the Commission as the perpetrator of these reforms. These are a logical extension of the larger privatization agenda that is operative in the country, and driven by the IMF and World Bank. There is not just operational evidence like the meetings between the Higher Education Commission and World Bank officials reported in various newspapers, but also the imprint of the World Bank/IMF world view where so called “subsidies” to health and education are being trashed.

Subsidies to health and education are not just that, they are subsidies to the development and independence of a nation. We in Pakistan are well on our way towards the fate of country’s like Zambia where the World Bank practiced its privatization policies in health and education with predictably disastrous results. As it is the government currently only supports approximately 30% of the education sector and roughly the same of the health sector. The rest has been privatized already. This 30%of the overall health and education facilities has to support around 60% of our population that lives on or below the poverty line and another 20-30% that is marginally above it. There are already privatized schools, colleges, universities, and hospitals that provide services to the upper middle class onwards. Thus 70% of the health and education facilities already cater to the less than 10% of Pakistan’s population that constitutes the upper middle class and beyond. Privatizing the remaining facilities will not provide substantial gains to these upper classes but will mean absolute destitution for those below.

It is in this recognition of the role of IMF and World Bank, in this stance against the privatization of health and education and the imposition of corporate rule leading to further sharp divisions within the society, that the movement of these teachers, doctors and lawyers has taken on the role of a political movement.

Widespread protests against these reforms are taking place in all major and smaller cities all over Pakistan. A Joint Action Committee representing teachers, doctors and lawyers has been set up that is leading these protests. While media reportage of this movement has been extensive in the vernacular press, English dailies have tended to accord it less space. It would be foolish to dismiss these protests as the protests of the inefficient in the system who are going to be thrown out by the reforms. A case in point is the leadership of the movement in Punjab, which includes Dr. Yasmin Rashid, a renowned gynecologist in Lahore, a professor at Fatima Jinnah and King Edward Medical colleges and who has made important research contributions. She was the first person in the world to isolate the gene located in microcephly. She has been performing in-utero transfusion for free for poor patients and this is a procedure that costs around E 10,000 at the Cromwell Hospital in London. She is also associated with Ganga Ram hospital where she and some other doctors have been arranging for all patients in her ward to receive free lunch for the last three years.

She and others leading this movement have very little to gain from this rebellion but a lot to lose. As of November 26th, Dr. Yasmin Rashid, Prof. Nazim Hussain (chairman of the JAC) and five others in JAC leadership have been dismissed from their positions. These reforms are being pushed through at such speed and with such fierce disregard for the opinion of the all stakeholders that most people have not even had the time to realize exactly what the reforms will mean for the Pakistani society. Of course, the government has not helped matters by not releasing any details to maintain a level of ambiguity about the reforms. At the same time, this very disregard for whatever concerns they have voiced is making the protestors angrier by the day. These reforms strike at the heart of whatever meagre gains the middle class and below had made in the last fifty years in Pakistan. There is increasing awareness among the protesting groups that it is not just any other reform to the system but one which will mean massive disenfranchisement and a complete catastrophe for the fragile remanents of a civic society that exist in Pakistan.

The movement has made some significant gains including the reversal of a denationalizing order that was due to be implemented in July 2002. During the first week of December 2002, President or General Musharaf, depending on how he wants to be known that day, stated that the Model University Ordinance will not be repealed even though they are open to making some changes. All of this is significant for a protest movement that is trying to make inroads in a highly depoliticized society, in a country where none of the major political parties has shown any commitment to their demands. More importantly, the movement has the tide of history with it to some extent. All over the world, people are rebelling against the New World Order that has been plundering their resources and taking away any gains that might have been made in the 60s.

The result that anyone can open up a medical college in any apartment or a house and run it. Recently, when the King Edward Medical College principal refused admission to a son of a notable, he was forced to resign. These are not isolated incidents; these are links in a chain of events that betray our incapacity to behave modern nations. There are some poor countries where the Health Care System is impeccable and free of cost. They have primary and emergency health services available and their health care system is based on the premise that prevention is better than cure, like the immunization of preventable diseases. There is nothing wrong with over three-tier system with a Basic Health Unit (BHU), a Rural Health Centre (RHC) at the Tehsil level, and then a tertiary-care hospital in the urban area, but the problem is that these units are not equipped. In the BHUs, there are no doctors or even compounders.

An RHC should ideally have a physician, a gynecologist, a blood bank, transportation etc. but none of these basic facilities are there. If you see the 250 bed district hospitals in Thatta, you would be horrified. After partition West Pakistan only had one medical college, the King Edward medical college in Lahore. Later on the Nishtar medical college was set up in Multan. During the Ali Bhutto government a policy was adopted to increase the number of medical colleges, some of which were actually built while Bhutto was still in power and some were built by the subsequent regimes. As the plans of the Ali Bhutto government were subsequently taken up by those who did not believe in them, the whole of the public sector suffered from corruption and mismanagement. This was also consciously favoured by the government, as it played a role in undermining the ideas of nationalization and planned economy. The standard of education in these colleges was maintained to some extent due to the hard work of the doctors, but they never really enjoyed government support. In order to maintain the high standards of medical training the Ali Bhutto government had improved and revitalized the Pakistan Medical and Dental Council (PMDC). During the subsequent decades it also became a token institution used merely to reward loyal people with well-paid jobs. Now the government has allowed the setting up of private medical colleges with the excuse of improving medical training as the public sector institutions are inefficient and corrupt.



Cont/P-5