The 'Brass Tacks' of Institution-Based Private Practice:
Myths and Reality
Dr Shaheen Sardar Ali
Reader of Law
University of Warwick
This commentary is being published as part of the open forum on Law, Social Justice and Global Development (LGD). It forms a part of three commentaries that have been published in this issue and contextualises the experience of an academic in the governmental processes. Readers are welcome to send in their comments and reviews to the author and/or the editors of this journal. Selected comments may be published subject to the editorial pen. Please send in your comments to Manish Narayan.
Keywords: Human Rights, Health Services, Gender, Development, Budgetary Processes, Governance, Human Rights.
This is a commentary published on 8 November 2002.
Citation: Citation: Ali S, 'The 'Brass Tacks' of Institution-based Practice: Myths and Reality', Law, Social Justice & Global Development Journal (LGD), 2002 (1)
<http://elj.warwick.ac.uk/global/02-1/ali2.html>. New citation as at 1/1/04: <http://www2.warwick.ac.uk/fac/soc/law/elj/lgd/2002_1/ali2/>
Reform, by its very definition, is an extremely slow and painful process. It strikes at the heart of long held concepts, established practices and vested interests. Change, no matter how sincere and altruistic in nature, is always looked upon with suspicion and doubt and various interest groups who have a lot at stake, set out to undermine this process by ensuring that the status quo is maintained. They invariably play upon fear of the unknown and plant doubts in the minds of a largely illiterate populace who devour any piece of information uttered carelessly by some passer-by before religiously disseminating this newly acquired knowledge to friends and neighbours. Thus starts a vicious cycle of misinformation and disinformation where all interested parties are able to put their own individual 'spin' on why governments adopt certain policies.
Reform initiatives of the present government are also subjected to numerous 'palace intrigues' as well as 'street' and 'hospital' intrigues and during my tenure as Minister, I was inundated with strange interpretations of some very straightforward measures adopted purely in the interest of the public. One example of the 'conspiracy' theory of why we took certain initiatives is that of Institution-based Private Practice (IPP) in public sector hospitals.
Since the 12th February 2002 decision of the government to introduce IPP across the board, newspapers carry at least one news item daily outlining diverse views on the subject. Wild assumptions and sweeping generalisations are being floated regarding implications of IPP for the health sector and service provision, health professionals and the general public or clients.
A number of questions come to mind. What is the myth and reality of IPP? What are its genesis and precursors? Is it a pro-people measure with a potential for alleviating the sufferings of the poor and improving service delivery or, will it contribute to their already numerous woes? Is it violative of the fundamental rights of the doctors to use their out of duty hours as they wish to? Has government come in to this arena 'cold' or has some thinking gone into this crucial policy line? Is government equipped to withstand the current onslaught of this hitherto powerful lobby that can hold the masses hostage by refusing basic health care and even life saving services if the need arises? And, is government capable of maintaining the moral high ground in the face of emotional blackmail to turn this selfless decision on its head, in the name of public suffering? In the following paragraphs, I propose to take you through the chronology of IPP over the past two years and address some mythical notions relating to it.
From the day I took over the health portfolio I became aware of the fact that one of the most difficult and challenging areas of reform was indeed the issue of the manner and mechanisms of private practice by public sector doctors. Pouring over statute law, notifications of the Department of Health, manuals governing civil servants, summaries moved for introducing private practice in previous regimes, as well as informal and formal discussions round the table, I could simply not fathom the glaring discord between regulatory frameworks for conduct of government servants and its almost non-existent implementation to the medical profession. Of course there were laws, rules and regulations for private practice, but it soon became adequately clear to me why these were gathering dust in government offices. Public sector doctors were a law and constituency unto themselves. For decades they had evolved their own rules of the game and no government had succeeded in making a dent in the arrogance of these highly skilled professionals.
Human nature can at times be amazingly parochial and myopic and, the most lethal combination in self-indulgence arises when human beings, aware of their talent and expertise, look upon themselves as invincible and above any law or regulatory framework. What we often lose sight of in this process of 'self-sufficiency' and self-aggrandisement is the foundation on which we venture to build our little empires and fiefdoms and the source from where we derive the strength to do so. In case of the medical profession, inflated egos are a direct result of the harsh reality of life that every single person will, at one point or another, require the services of a doctor. Hence the inference that doctors are an indispensable group of human beings who no one, not even the highest government functionary, can afford to annoy. What is forgotten is the fact, just as stark as the perennial needs of the people is, that this grandiose empire is dependent upon poverty and ill-health, misery and need, as well as ignorance of preventive health care of the unfortunate people of this country. What an irony of fate that the source of strength of our health care providers lies in the frailty, misfortune and weakness of their clientele, the teeming, hapless flood of humanity that we call the people of Pakistan.
A general assessment of private sector facilities around the province reveals that barring quality consultation provided by trained medical professionals, quality of services provided to patients by the private sector leaves much to be desired. Dingy and overcrowded waiting rooms, unnecessary diagnostic procedures and exhorbitant charges for low quality in-patient treatment is the reality of our much touted 'private practice.'
As far back as the early 1980s, efforts had been made by government to address these issues but with little success. I tried to ascertain the reasons behind what I saw was a very equitable and just reform initiative that would attract the support of the people and the health providers alike. I was sadly mistaken and disappointed at the lack of support, in fact active defiance from colleagues who strongly advised me not to risk ridicule and contempt from this highly influential and resourceful lobby. 'Views' communicated to me through friends and colleagues, quite gingerly expressed were along the following lines:
'The Health Minister appears to have taken leave of her senses. Who does she think she is? Does she consider herself stronger than General Fazle-Haq? Remember even he could not succeed in getting doctors to practice within public sector hospitals. She will suffer the same ignominious defeat. Why can't she confine herself to something simple and non-controversial? The best advice we can offer is: Tell her to back off!'
I responded by refusing to 'back-off' and instead started addressing meetings of representatives of doctors and explained the main objectives of IPP that were as follows:
a) To optimise use of expensive equipment in public sector hospitals, currently under-utilised;
b) Create additional financial space by generating additional income for hospitals and other staff;
c) Provide a patient-friendly atmosphere to private patients;
d) Provide better working environment to doctors for private practice.
2.1 The Salient Features of IPP Were
a) It would, in the first instance, be applied to the teaching hospitals of Peshawar and Abbottabad;
b) Earnings from IPP would be shared between doctors, paramedics and other staff and hospital @ 60:20:20 ratio;
c) Earnings accruing from IPP would be subject to income tax deductions;
d) A central registration system would be installed where fee would be deposited by patients;
e) Extended provision of treatment and diagnostic facilities would be provided during off-hours through a one-window operation;
f) Uniformity of fee structures would preclude exploitative rates in the private sector.
We had arrived at the above decisions after deliberations spanning more than 18 months. The major fear, lurking in the background was the state of un-preparedness of these four teaching hospitals to launch such a major and groundbreaking initiative. But, in the face of opposition, both overt and covert and lack of enthusiasm among the ranks I was leading, could I ever hope to achieve the desired level of preparation? On a fateful afternoon on the 14th May 2001 at about 2.30, I decided to take the plunge and issue a notification for private practice to be started from 15th May 2001 in four teaching hospitals of the NWFP. The atmosphere round the table was grim and tense as we debated vigorously on the pros and cons of this clearly controversial measure. My colleagues were still informing me of the dire consequences of the impending notification. We had debated ad nauseum whether there should be a complete ban on private practice of public sector doctors, and they should be offered the option to engage in institution-based practice (as the 12th February 2002 notification states). Or, whether IPP should be a voluntary contribution of the doctors towards productive use of public sector hospitals in the afternoon in addition to their privately run clinics and consultation chambers. In a bid to be democratic and inclusive, we went so far as to suggest that doctors would be asked to practice within the premises of the four teaching hospitals only once a week (more than once was again by choice) and that too, on a voluntary basis.
I took one last look round the room and saw the concern and troubled expressions on the faces of my colleagues. I was putting my reputation on the line by venturing into 'difficult' terrain. What if no doctor opted for IPP? Could I live with the humiliation? Could I not wait until September and maybe we could 'win' some more doctors over to our point of view? I responded by saying to my colleagues that I was fully cognizant of the gamble I was taking. I was also aware of the numerous vested interests I was challenging. But for me the most important question I had to answer was: How long can the people of this province wait to achieve and equitable, responsible and responsive health care system? Unless we took the first small step, how could we expect to make advances? Ideal situations rarely present themselves when the state of public sector institutions are in the state of disarray that they presently are. And last but not least, who was I, in this huge universe to consider my reputation and my name as more important than the province and her people that beckoned this initiative? I was certainly not afraid to get my hands dirty. I owed it to my country and my province and was ready to take the consequences of this decision. Good or bad, ill-conceived or not, it was taken with a clean, pure heart and its intention was to improve the lives of the common person in the street. Whether I succeeded or not is neither relevant nor important to me. What is important is that I took that first step towards a policy that will now, in the hands of the Governor and his team lead to a refined version of my 'work in progress policy.' The notification was therefore drafted, signed and circulated. Of all the moves towards reforming the health sector, this particular decision has attracted the most criticism on a number of counts and understandably so.
First and foremost was the allegation that I had dared to question the 'right' of public sector doctors to engage in private practice without giving them sufficient discussion time. Records of the department of health show that doctors got at least 18 months to make their views known and make suggestions. I had appointed the most senior and well known doctors as chairs of the committee on private practice who held many meetings with their constituents. But doctors had only a one liner to offer to government: we refuse to engage with you on this subject, full stop. We will seek legal remedy if you notify IPP. What options did I have under these circumstances?
The second point of criticism regarding my decision to make IPP voluntary was that it smelled of 'compromise'. In other words that since I did not have the nerve to go for an all out ban and face the consequences, therefore I settled for second best and made it optional. My honest response to this point is that I was guided by my sense of inclusivity. I realised that it would be difficult for doctors to simply wind up their clinics at the drop of a hat and come into the fold of public sector. Further I also believed that it was the younger professionals who had less at stake outside the public sector and had not yet invested large amounts in private clinics who would make take this policy along into the future and bring about a change in the work culture.
'Superior' peer pressure however wrought havoc with my assumptions and junior doctors and younger professionals who could have established their practices in the public sector dragged their feet on the initiative. In the first 2 and a half months we had logged less that 700 patients. With a handful of committed colleagues who whole heartedly immersed themselves into making IPP a success but with very poor response from doctors the initiative got on to a slow start. It appears that doctors who could have had their cake and eaten it by giving up only one day a week of their private practice, chose to follow the path on open confrontation. The Governor, in my view had no other option but to take the next logical step in the scheme of things.
I realised that one of the pillars of success for IPP was an excellent and contemporary diagnostic service. If we were to provide quality and competitive services under one roof, then laboratories and x-ray machines and other diagnostic services must run round the clock as well as provide credible results. We tried to address this problem as we went along and hoped that by generating some money, we would be able to plug it into these services. My deep regret is that I did not have anything in the kitty with which I could revitalise the system and afford a boost to diagnostic facilities. Reform has to be a holistic process and I discovered the hard way that without financial space, IPP could not achieve the desired results.
I had plans to spruce up private rooms and dedicate operation theatres for private surgeries to attract private patients into the public sector. That plan too required resources and with virtually no funds available that plan too had to be shelved for the time being.
I had been on leave of absence from the University of Warwick, England and had a commitment to join duty on 1st August 2001. This necessitated my exit from the provincial cabinet and I proceeded to the UK with a heavy heart worrying about the fate of the reform process so painstakingly initiated. I did however have the satisfaction that the dynamic Governor of the NWFP was holding the Health portfolio after my departure and, since we had conceptualised and together put in place the blue print of a re-structured people friendly health service, he and my successors, would follow these initiatives through.
The near collapse of my IPP initiative had been in the mind and thoughts of the Governor and on February 2002 he declared a complete ban on private practice by public sector employees. A hue and cry was raised immediately in the press, in public and private meetings. Each day brings a new twist and turn to the interpretations offered by various sections of society. In the following paragraphs therefore I propose to discuss the myths and reality of IPP and clarify certain misconceptions that seem to run rife.
Myth: Government servants, including doctors, are only accountable for their time during office hours. In their free time they can do exactly as they please. According to the statements of one senior doctor in the press, they can drive a taxi, sit in the park and watch the flowers and trees or engage in private practice after duty hours. That is their own business and no one can touch them. If teachers can engage in private tuition, so can they. The decision of the government to ban public sector doctors from engaging in private practice is therefore a violation of their fundament rights under the constitution.
Reality: Government employees, as all employees, whether public or private sector organisations, enter into a contract of employment. Rules governing a contract of employment are either explicit or implied. Explicitly stated rules are laid down in various statutes, rules of business and manuals for all interested parties to access as these are public documents. Additionally, evolutionary processes of governance have resulted in a plethora of implied rules that have a variety of sources including overarching constitutional dictums, court precedents in common law jurisdictions such as Pakistan and rules of justice, equity and good conscience.
Government servants, including doctors and teachers are NOT allowed to do exactly as they please during their free time. Specific rules and regulations govern their behaviour and conduct. A basic rule of government service is: Whatever outside/ additional work, paid and unpaid, government employees choose to engage in while on the payroll of government must be validated by the department that employs them. In summary, government servants drawing two sets of remunerations are liable to prosecution by their employer. Further, and most importantly, employers are permitted to draw up rules governing terms and conditions of employment including prohibition/permission for supplementary employment.
Myth: IPP is being imposed on doctors to 'extract' higher levels of taxes. Doctors are being wrongfully targeted by government to harass them into paying taxes. They already pay the highest levels of tax.
Reality: Our respected colleagues seem to enjoy the current hide and seek with income tax officials. For them it is a better option to be 'nice' to these petty and not so petty officers who pounce on them in the garb of patients in their private clinics and threaten to 'tell' if doctors fail to show 'generosity'. IPP delivers our highly respectable members of society from the clutches of these 'prowlers' and all earnings of doctors et al will be tax deducted and above reproach and harassment.
Myth: IPP has resulted in violation of the right of the public to exercise their option to seek consultation and treatment in private clinics in addition to government hospitals.
Reality: What about the right of the public to seek consultation within public sector hospitals? The reason why there is such a huge spill-over into private clinics is because after 1.00pm, you will rarely find a specialist in any public sector hospital. The orderly guarding the door to the office of the doctor will 'advise' you not waste your time, show you where the clinic of the boss is and ask you to let him get on with his work.
Furthermore, the public has the right to access all health facilities, whether in the public or private sector, that have been permitted to operate. There are currently dozens of private clinics operated by doctors in the private sector and these have NOT been banned.
Myth: Governments have, in the past, chosen not to get embroiled with government servants engaging in private work. This has therefore become a rule cast in stone and the writ of government should now and in future not be upheld. Government servants are at liberty to flout the rules governing their employment because the regulatory norms are either unclear or the system of implementation is weak and porous.
Reality: Two wrongs never make a right. Rules and regulations, no matter how dormant and ineffectively implemented, can never form a precedent for future cases of invalid conduct.
Myth: Private practice provides ADDITIONAL space including extra inpatient facilities thus helping to supplement government hospitals. IPP will cause overcrowding in public sector hospitals as there is not enough space for consultation rooms or for patients.
Reality: A cursory glance at the number of private clinics with facilities for inpatient services indicates that there are NOT more that 200 beds available in the private sector in the whole of Peshawar. (This is a very charitable figure and the actual number of beds in the private sector are much fewer than this.) Most specialist doctors in Peshawar and Abbottabad (and more recently Swat and D I Khan) are senior faculty members of teaching hospitals. What they provide is private consultation in their clinics outside their public sector workplace. But when it comes to admitting a patient for treatment/surgery etc., these doctors refer their patients and admit them as inpatients to public sector hospitals. It is a certifiable reality that IPP will not affect this inflow of patients from the private sector. The public sector is already absorbing it. I would strongly reiterate that it is a pure fallacy to state that IPP will bring a huge burden on public sector hospitals causing distress to the poor patients.
Myth: Private practice generates employment for low-income groups (mainly as support staff in private clinics) thus contributing towards expanding the base of private sector employment.
Reality: A random survey of Dabgari Gardens, and other prime private clinic places will indicate beyond doubt that the peons, dispensers, laboratory technicians etc., are the ward orderlies, dispensers, technicians etc., of the public sector hospitals who have been employed by their public sector bosses to earn some extra cash. We are all too familiar with the Anaar Guls and Khaista Guls of teaching hospitals who act as the right arm of many a senior professional in their private clinics. There is nothing in IPP that precludes these people from being gainfully employed within the public sector hospitals as well as provide employment for a good number of private employees on contract to supplement existing staff.
In summation, it may be argued that no matter which way one plays the discussion on IPP, the stark reality is that a group of people, riding on the wave of their professional success and the needs of the masses, are in open defiance of the government. Some have been of the opinion that like the good old days of yore, this 'bad time will pass and it will be business as usual. But knowing the present group of people at the helm of affairs, it is a different ball game. Why? Simply because the people in government today are professionals in their own right and do not have to play to the gallery to gain cheap and transient popularity. They have arrived at a decision that is in the best interest of the people of this province. In the past, compromises were struck on the basis that every person has a price tag, whether economic, social, or political. No matter how influential and affluent the lobby at the receiving end is, the 'price' and 'prize' of this lot is too high to be paid up in by anyone but Almighty God!
To the medical profession my sincere plea would be: Let us please give this country and her people a chance towards a better life. A little discomfort, a little loss in earnings will not harm either you or your family; you will come out as respected and loved members of society that already has given you its very best and placed you on a pedestal.
To the politicians of this country my earnest request is: In the name of anything you hold sacred, whether it be power or glory, accept and acknowledge that IPP is FOR the poor masses and NOT against them. By making rhetorical statements, you are harming the interests of those people whom you aspire to rule in the coming months and years. Remember if our leaders do not read the writing on the wall, a time may come when these very 'voters' who have been run into the ground by the elite of this country will turn round and say:
'Downtrodden people of Pakistan Unite. You have nothing to lose but your chains'
In the name of humanity, hold that disastrous moment at bay!