SST: Tell us something about your educational and professional background?
I spent the first half of my life in Pakistan. Coming from an Army background, we moved a lot, hence I studied in various Army Public Schools. I went to the US when I was 19 and continued my education there. After graduation, I worked in New York for a year or so (in a completely different field – advertising) and then moved to Bahrain to join Ernst & Young in 2005, as a trainee in the new healthcare and life sciences consulting practice. I spent 10 years in EY working on over two hundred healthcare and life-sciences projects across the Middle East and North Africa – ranging from small DNA labs to a billion-dollar mega health city. I left as a Director, while I was leading the EY MENA Healthcare and Lifesciences practice and started my consulting firm.
This gave me a completely new insight into how the healthcare sector is evolving and how we can improve it. The biggest and most fulfilling project I worked on (until now) is the massive kingdom-wide healthcare transformation project. My role was to advise on various areas including, health capacity planning, pathway optimization, prevention initiatives, digitization, population clustering, performance and quality improvement etc.
I now work for one of the largest medical devices company, and lead the strategy advisory across Central Asia, Eastern Europe, Middle East and Africa. Pakistan is one of the key focus areas for me.
SST: How do you view Pakistan’s healthcare sector and what are the major problems in it?
Pakistan is, of course, a developing country – which brings about many, and in some cases, unique challenges. However, if I had to pinpoint the top 3, these would be first and foremost, deteriorating quality of care, secondly unequal distribution of healthcare resources, and lastly lack of financial coverage.
I have visited many healthcare facilities in various cities. I have seen some hospitals where patients (who can pay) enjoy luxury VIP inpatient rooms and somewhere patients are, unfortunately, being treated in hallways and corridors.
I have also heard harrowing tales of how women have died during labor while being driven to the nearest health facility which was 2 hours away. I have seen people treat themselves with herbs, plants, and in some cases dangerous chemicals, for major illnesses because they cannot afford conventional care, or the health professionals were not available.
This mostly stems from the lack of funding and inequitable distribution of government funds amongst various sectors. Healthcare gets one of the smallest shares in government budgets, which is then spent on building large tertiary care hospitals. Primary care – perhaps the most important part, gets a back seat.
I have realized, that healthcare budgets are politically driven and not needs-based. This then causes a disparity and lack of health care funding where it is needed the most.
Prevention is another area we tend to ignore. It is only after a break-out of disease, significant loss of life, or massive health concern, we start to manage it. Some most recent examples are dengue fever due to the lack of proper sanitation, the spread of HIV amongst children due to unsafe medical practices, etc. Pakistan is one of the only countries in the world where polio is still a problem, due to the lack of proper vaccine administration..
SST: Pakistan has relied heavily on public hospitals for providing health services. Do you think private sector should be encouraged to invest in the healthcare sector?
Indeed, this is what is visible. The situation is slightly different. The government spends money on building hospitals and clinics – and perhaps runs some primary care programs. And this is far more than what the private sector builds and offers in the healthcare economy. However, according to the World Bank, government spending is only around 30% of the total healthcare spending. The remaining 70% comes from private and out-of-pocket spending. Even though in theory, the government is providing free/subsidized care, it is actually, not. People are still paying to acquire these services. Interestingly, Pakistanis being one of the highest domestic charity donating people in the world, spends significant money on healthcare for others. There are several charity/private hospitals operate solely or in-part on donations from large corporations or community charity spending. And what I have seen, some of these hospitals are better run, better equipped and offer a better quality of services than government facilities.
One may argue as to why we give so much charity/zakat for the same purpose the government collects taxes. The answer is simple – inappropriate use of funds, which causes significant mistrust of the government. In this environment, people prefer to give money to the hospitals and directly to the patients rather than paying taxes.
The private sector as a provider, can and should take a leading role in our healthcare. But for this to happen the government needs to have significant checks and balances to maintain quality which it needs to apply to itself as well. I feel a good area to start is volume-oriented, low-cost primary care initiatives. The traditional model of “bed-per-1,000-people” is changing. With the shift towards using technology, more people can be served with lesser human resources – excluding pharmaceuticals and medical supplies which would still require physical presence and supply chain management. This can be done through PPP models and also on a purely private basis – as people are spending money anyway.
High-end private hospitals still tend to make significant margins but eventually serve on a small portion of the population. A combination of maintaining “appropriate” profits and serving the nation is the right place for the private sector to invest in. Let me suggest – a fully integrated, health system with primary clinics as feeders in rural areas with some secondary hospitals and finally a large tertiary care hospital would serve to be an optimal private sector investment.
SST: There is a concern that private healthcare is expensive and out of reach for ordinary people, how would you comment on that?
This is very true. Unfortunately, around 80% of the population uses some form of external funding to pay for healthcare costs they incur. The private sector tends to focus on the remaining 20% – and then there are further stratifications. You will find hospitals that are only catering to the top 5% as well. Although there are plenty of single-specialty clinics and small health centers that the population can access, the quality is lackluster. Ironically, this increases the costs of care for the people who couldn’t afford it in the first place.
The disparity between costs in the private sector and income is so big, that unfortunately, I don’t see the majority of the population using the private sector, without external funding, soon.
However, if the government decides to initiate a national health insurance program which then funds all healthcare needs, while maintaining checks and balances may close this gap. I will emphasize here that stringent policies and checks will be the basis for this, otherwise, there is a chance that this will be misused, causing further problems.
SST: Pakistan has consistently spent less than 3% of the GDP on healthcare, how do you view such meagre healthcare spending?
This is a major concern. Of course, as an economic factor, this could certainly be higher. The lack of this is visible in many areas – lower life expectancy, higher prevalence of chronic and communicable diseases, high death rate, etc. However, spending is relative. United States has one of the highest healthcare spend as a percentage of GDP in the world, but repeatedly, experts have deemed its healthcare sector not to be the best.
It is currently ranked 37th (according to World Population Review). E.g. only 3% of the GDP is attributed to healthcare in Qatar, it is ranked as one of the best healthcare systems in the world. On the other hand, France, Spain, Italy, Austria, Japan, etc. all have higher healthcare spends, reaching 8% and are some of the best healthcare systems in the world. There is no denying that there is a correlation between higher spending and better health outcomes, but it is not an absolute one. There are other factors to consider. Clearly, healthcare expenditure needs to increase due to intrinsic issues, but the bigger question will be in what areas.
A thorough assessment is required as to where the spending needs to go. We may end up doubling the expenditure and have a 200-bed hospital on every corner, this will still fall short of what we really need. If the government is willing to initiate healthcare reforms it needs to identify a list of issues and challenges and prioritize spending. I feel that a major focus should go on prevention and primary care rather than constructing large buildings.
SST: What is the way forward for an economically struggling country like Pakistan to provide better healthcare to its citizens?
I agree that the economic conditions and health of a nation are significantly interlinked. Where I differ from the usual norm, is regarding the “cause-effect”. Generally, healthcare spending is dependent on economic conditions – which is true for the most part, I believe, in some cases, it’s the other way around. An economy is made up of human resources that interact with assets to generate income which is then bought and sold. If the key component – human capital is unhealthy – the economy will suffer. At the very least, Pakistan should provide basic healthcare needs to improve the quality of life. Basic needs include sanitation, availability of clean water, appropriate measures against infectious diseases, unhygienic food, etc. Additionally, access to a community based licensed healthcare professional is required. Educational programs promoting prevention and a safe lifestyle are required. You will find that simple measures like these will have a significant impact in the long term – leading to an uplift in the general economy. If the income increases, people will automatically spend more on their health to remain healthier. Of course, I am simplifying it here. An economy’s health depends on many other factors, policies, corruption, etc. However, it still needs a solid healthy base to survive on.
SST: Are there any examples in developing countries where there has been an improvement in the healthcare system, despite economic constraints?
There are many examples of such nations. Senegal, Egypt, Philippines, Sri Lanka, etc. are all similar income countries in comparison to Pakistan, but have higher ranking healthcare systems. If you look further in history, you will find, some Central Asian countries, East Asian countries and some African countries which have now higher health rankings, started with very low healthcare expenditure. One thing that is mostly common is that they went through a period of reforms and healthcare transformation. Saudi Arabia, although not comparable to Pakistan when it comes to income, had a struggling healthcare sector a decade ago. Lack of attention, outdated policies, and general lack of interest by the government, led to significant challenges. In the last few years, and under the auspices of the new King, the healthcare sector went through massive reform and now, it is ranked 26th (higher than the US).
SST: Any advice for the government when it comes to the healthcare sector?
To overcome any major challenge, one must identify that there is a challenge, assess it, plan for a solution and implement it. Our focus is usually on planning and implementing. We are very good at spreading our limited resources on projects that only stand to serve egos with big buildings and large structures. We tend to forget that the common man does not have resources to avail these services. I also know that we cannot start a large scale transformation project as we have limited resources.
This is what I would suggest:
- Pick a reasonably sized city/district and assess its healthcare needs, challenges and opportunities.
- Take advice from subject matter experts, doctors, healthcare professionals to develop pertinent and practical solutions.
- Engage the population and the existing healthcare professionals to participate in the transformation.
- Start implementing quick-win and no regret initiatives.
- Keep steering the progress and measure results.
- Perfect the solutions and start implementing elsewhere.
I know this will be a slow process but it will certainly have long-lasting effects.