I saw four patients during my visit to the hospital today. Each one of them has a story which reflects blatant policy inattention, which undermines the core prerequisites of human security.
First, there was a young woman who had attempted suicide by ingesting cheap corrosives because her sister-in-law beat her incessantly, now in the hospital with a badly damaged food pipe, unable to swallow. A young victim of a hit-and-run accident with a badly fractured pelvis and leg but with no one to take responsibility for the damage caused. A slightly older man, in state-employed police service, who whilst on state duty driving prisoners, had sustained multiple arm and leg fractures. And finally, an elderly housewife, who had broken her leg below the knee, which had been left untreated for two years, so that now her leg literally dangled sideways from the knee downwards. As always, there is one element common to all. Each of them was unable to pay the cost of treatment, which is why they were referred to Heartfile Health Financing.
Illustrated in each story is one clear failure of the country’s health system: its inability to protect its people from the issues of health and financial risk, which is one of the three salient indicators of health system performance assessment. That is where we as an NGO step in and are privileged to have developed a system to help such patients. But beyond the healthcare-system-failure illustrated in these stories, many other issues are also illustrated, ranging from illiteracy, poverty, malnutrition, social exclusion, gender discrimination and weaknesses in law enforcement. Indeed, we now know that these determinants deeply impact health status. In the case of the young man with the fractured pelvis, the person who caused the hit-and-run, presumably the more affluent of the two and the one behind the wheel, got away with the incident scot free. No charges at all. No hassle for them. The young victim on the other hand, now, not only suffers immense pain and disability with poor prospects of recovery, but is also out of a job and incurs a financial and emotional burden on the impoverished family of thirteen whose only other breadwinner is now attending to the patient—another foregone income. The family is being pushed deeper into poverty, further every day.
The third patient was a state functionary, but had it been a higher official, entitlement would have been invoked and support mobilized quickly. In the case of the poor driver, colleagues, similarly from meager means, pooled money to partly pay for his carriage and initial treatment to the hospital from where we took over. What this shows, is the erosion of state channels of support and protection but also a strong culture of community camaraderie and societal support, which is indeed very pervasive in Pakistan and is strengthened further as the state support system further crumbles by the day.
The woman with the dangling leg is also illustrative of issues around quality of care, geographic access to care and financial access impediments. In no civilized system of healthcare can it be regarded acceptable for a fracture of the tibia (main weight bearing bone below the knee) to remain unattended and for the patient to seek treatment two years after the injury, only to find that another barrier, that of financial access, now stands in the way of basic care.
The point of this piece is not that my organization has been able to help these patients, but to highlight the pervasive nature of problems inherent to the healthcare and societal systems in which people live, in countries like Pakistan. Fortunately for them, all four are now in a tertiary care hospital in Pakistan’s capital city: a state run facility, where ‘universal access principles’ apply and therefore the poor can theoretically be treated, but due to resource constraints, the state can only provide a free bed and a doctor. In each of these cases the additional cost of implants and disposables necessary for the operations are to be borne by the patients themselves. A balloon dilator was needed to cure the food pipe stricture, and orthopedic implants in the case of the other three. Through an innovative partnership with hospitals, our organization reaches out to such patients to identify their needs at a critical time in their lives.
But we are only able to help in overcoming financial barriers to seeking healthcare. It is gratifying to learn that we are able to do that and we feel privileged to be in a position to be striving to upscale the system. But every time I see a patient who has benefitted from our program, I am reminded of the quantum of need and the imperative that the dismal state of affairs creates for us to advocate change across the margins of the program.
Just when I thought I was done with my share of touring for Heartfile Health Financing, for the day, I came across an event that may well change the way in which we identify those in need of financial assistance for healthcare in the future. On the way back from the hospital, I stopped outside Shaheen chemist to buy Paracetemol where an old man lurched towards me, obviously distressed. He was holding a prescription for Zantac (medicine to treat peptic ulcer) and told me he didn’t have the money to pay for it. I quickly asked two questions, one to ascertain if he was not one of the professional beggars who lurk outside chemists’ shops with prescriptions asking for money. He didn’t look like one but I needed to be sure. Would he accept my paying for the medicines rather than giving money to him? He readily responded in the affirmative to this question. I then asked what his symptoms were, just to be sure, and spot on, he described what a peptic ulcer would cause. As many others would have done in my place, I bought him the medicines and gave him my number for follow up.
The pharmacist on the counter, told me that such patients were quite common, and that as a goodwill gesture the shop would help to a manageable extent, giving out for free, for instance, medicines up to Rs. 200—beyond that, he was honest enough, they were not in a position to help. The need was just so immense. I couldn’t help thinking that day about another incident, perhaps six months ago in the very same shop, when a disabled Parkinsonian suddenly collapsed on the floor, only to regain balance after he was helped. He was deeply incoherent and couldn’t communicate, struggling as an advanced Parkinsonian would. After much effort I understood that he had come to buy medication, which he had run out of and due to unaffordability had bought just a few days’ worth. A Parkinsonian at his stage of the disease, unattended and alone, buying medicines from the market and not being able to afford it, is unacceptable in any civilized society. The reason why I referred to him in today’s account is because both cases lead me to think about an additional way of helping patients. Ensuring financial access for people to medicines at the actual point where they are supposed to buy them would broaden the scope of our engagement beyond identification of such patients in health facilities which is what we currently do. Of course it would have its own set of challenges, procedurally and technically. I will reflect on these two cases to plan and conceptualize further and to analyze how these entry points can be leveraged better. It is patients who have been my inspiration for this program and it is their need which will continue to drive my efforts towards expansion and upscaling. I will be thinking about these two patients on my flight to Berlin tonight—my homework for today.