Najwa Nadeem (Final Year M.B.B.S.)
It was a different world when she woke up. Blinking and coughing, the woman looked around only to find herself surrounded by anxious, inquisitive faces, staring at her in disbelief. Not her exactly, but a part of her. Her feet. Words seemed gibberish and the whole crowd a blur when the pain hit her. She shrieked, catching everyone’s attention. The surgeon bandaging her fractured tibia, her lacerated foot hanging on to her leg, asked her to calm down, all the while telling the medical students around him that she’ll definitely lose her right foot due to the extent of the damage in the accident. She kept screaming in pain, lying on the stretcher she came in, all covered in blood. The nurse waited as soon as the other surgeon filled her chart to maintain her IV line and give her the necessary pain-killers. The rest of the treatment would have to wait until all necessary investigations were done and she was moved to Bay-1 of the ER, still on the stretcher. She screamed one last time as the analgesics kicked in, looking at the room she was in, surrounded by strangers, old and young alike and then finally falling unconscious. Her husband was asked to take her samples to the lab for tests and also to arrange blood so that surgery can be started. He wanted to ask so many questions but the ER is a busy place, with everyone yelling around and he was pushed away, still confused about the whole procedure.
This is not an unusual scenario at a tertiary hospital in Pakistan. If the woman and her husband lived in a village, she would have been taken to a Basic Health Unit (BHU) first where the doctor would suggest her to be taken to the city for surgery and in the meantime during transport (if available), she could lose not just her foot but her life as well. Barriers to optimal surgical care in Pakistan affect surgical access to the patients, which we will discuss here in more detail.
In 2011, the World Health Organization (WHO) Alliance for Health Policy and Systems Research brought out their report “Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries.”  The barriers which the paper mentioned included:
Pakistan being a low- and middle- income country (LMIC), faces similar barriers to optimal healthcare conditions for its population, majority of which belongs to rural areas. With the ever increasing population, Pakistan is yet to address these problems. The specialist surgical workforce density is 5.53 per 100,000 population. Risk of impoverishing expenditure for surgical care is 62.8% and that of catastrophic expenditure for surgical care is 75.2%. 
A study conducted in 2011 addressed many such variables :
“Patient-related variables included age (elderly), gender (female), preferential use of alternative health providers (Hakeem, traditional healers, others), personal perceptions regarding disease and potential for treatment, poverty, personal expenses for healthcare, lack of social support, geographic constraints to accessing a health facility, and compromised general health status as it relates to the development of surgical disease. Environmental barriers include deficiencies in governance, the burden of displaced or refugee populations, and aspects of the medicolegal system, which impact treatment and referral. Barriers relating to the health system include deficiencies in capacity (infrastructure, physical resources, human resources) and organization, and inadequate monitoring. Provider-related barriers include deficiencies in knowledge and skills (and ongoing educational opportunities), delays in referral, deficient communication, and deficient numbers of female health providers for female patients.”
Surgery is described as an “indivisible, indispensable part of healthcare.” Unfortunately, in Pakistan, where the country is in a usual political turmoil, with only 2.6% of the GDP spent on healthcare, the situation is far worse. The government does provide some support to hospitals in urban areas but rural areas suffer from a lack of trained doctors and health facilities to treat major surgical ailments.
Patients in urban areas have access to emergency care and ambulances provide transport to the nearest care center. However those in rural areas reach a Basic Health Unit (BHU) first where only first aid and minor care can be provided (according to the competency of the duty doctor and the meager facilities available). They then have to travel miles away to a tertiary care center in urban areas to treat their ailment. Many lose their lives in the transit. Others can’t afford the treatment. Then there’s the issue of bed availability.
Emergency surgical procedures are done in a less than ideal setting where the patient is prone to all kinds of hospital-acquired infections. Even after the procedure the risk of surgical site infection is high. Patients’ families have to arrange blood on their own and are mostly seen running through the hospital looking for a referral or a familiar to doctor to help them out. Blood screening is another problem. Public hospitals don’t always provide a clean environment for the patients in general wards as those in private hospitals. Surgical waste once removed from the bedside is often heaped up outside, leading to environmental pollution.
A majority of the Pakistani population resides in rural areas and is illiterate which is another factor that affects treatment. Patients often have the wrong ideas about their illness (reinforced by the elders in the household) and avoid a visit to a medical practitioner. Instead, they seek help from hakims and quacks to heal. This worsens their condition. By the time they reach the doctor, it is already too late. The security threats pertaining to a BHU discourages female doctors to practice in distant rural areas and hence the female patients in the area suffer indirectly as the social setup discourages them to visit a male doctor.
The specialist surgical workforce density faces an imbalance as most specialists are concentrated in the urban areas and so people from villages have to travel a long way. Most avoid the transit and “wait it out”, unless it is absolutely necessary to go. Travel expenses, residence and arranging an appointment all add up to the patient and his family’s worries. Patients often refuse surgery and resort to medicines as they’re either afraid of the outcome or simply cannot afford it.
Government funding, proper planning and improvement in health facilities can help alleviate the situation. There’s a need for proper research into all these factors, development of policies and ensuring their implementation so to improve surgical access and its safety in Pakistan.
- Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Jacobs B. et al. Health Policy and Planning 2011;1–13. Available online at http://www.who.int/alliance-hpsr/resources/alliancehpsr_jacobs_ir_barriershealth2011.pdf
World Development Indicators, The World Bank. Available online at http://data.worldbank.org/data-catalog/world-development-indicators
Barriers to Accessing Surgical Care in Pakistan: Healthcare Barrier Model and Quantitative Systematic Review. Irfan, Furqan B. et al. Journal of Surgical Research , Volume 176 , Issue 1 , 84 – 94