Journal of Public Health, 2016 ( December ) Pak J Public Health Vol. 6, No. 4, 2016 Review Article

STATE OF HEALTHCARE QUALITY AND PATIENT SAFETY IN PAKISTAN

Mairaj Shah1, Shagufta Perveen 2

1Medical Director, Outreach Services, Aga Khan University Hospital (AKUH) and Honorary Lecturer, Department of Community Health Sciences, AKU and Family Physician, Community Health Centre, AKUH 2Senior Instructor, Health Policy & Management, Department of Community Health Sciences, Aga Khan University, . Corresponding Author: Shagufta Perveen, Senior Instructor, Health Policy & Management, Department of Community Health Sciences, Aga Khan University, Karachi. Email: [email protected]

Abstract Many low and middle income countries have developed their own national accreditation standards and accreditation systems for regulating and improving the quality of healthcare services. Healthcare quality is defined as the degree to which health services to individuals and populations increases the likelihood of desired health outcomes and are consistent with current professional knowledge. This paper attempts to assess the state of Pakistan's healthcare quality and patient safety in a structured way using Donabedian's model. Some of the key specific challenges identified for Pakistan's healthcare quality initiatives are lack of national healthcare accreditation system and integrated national guidelines, policies and procedures on healthcare quality and patient safety. Lack of national quality care indicators. Absence of an organizational culture that holds people accountable and lack of pre-service and in-service training for health staff in quality care management and leadership with little contextual research on quality care initiatives. Possible ways to improve the state of quality in Pakistan may include (i) up gradation and implementation of policies and procedures that regulate quality and patient safety issues in healthcare settings across the country (ii) introduction of a national healthcare accreditation programme across the nation (iii) development of networks and consortia between public and private sectors in Pakistan (iv) capacity building of health care professionals in quality and patient safety (v) Formulation of quality improvement teams at national and provincial level (vi) development of a culture of accountability and ownership (vii) learning from experiences of other countries and implementation quality care tools and locally validated indicators.

Introduction: allopathic physicians to faith healers operating in the Pakistan healthcare infrastructure include 919 informal private sector . hospitals, 5334 basic health units (BHUs) and sub- Up till recently, except for the Pakistan Medical & Dental health centres, 560 rural health centres (RHCs), 4712 Council (PM&DC) and (PNC) dispensaries, 905 maternal and child health (MCH) regulations there were no other regulations for the centres and 288 tuberculosis centres . The utilization of healthcare facilities in Pakistan. During the past three to this strong infrastructure has remained low over the five years, the and Healthcare years due to inadequate financing, lack of resources Commission bodies have been formulated. The and structural mismanagement. The country only commissions have formulated local acts known as spends 0.5-0.6% of its GDP on health. Punjab and Sindh Healthcare Commission Acts that Health care management in Pakistan is primarily the have been approved by the Punjab and Sindh provincial responsibility of provincial governments, except in case assemblies and are in the process of implementation. of federally administered territories. However, the The acts contain defined set of regulations for the federal government is responsible for planning and healthcare facilities in Punjab and Sindh . The prime formulating national health policies. Each provincial aim of these acts is to register all the healthcare facilities government has established a department of health with in Pakistan followed by licensing and accreditation the mandate to protect the health of its citizens by processes. For the nuclear imaging facilities, the providing preventive and curative services. The Pakistan Nuclear Regulatory Authority (PNRA) provide provincial health departments also regulate private regulations for safe operations of these facilities in the health care providers. Large variations are found in country and also ensure licensing of these facilities . For public sector spending on health care across provinces. regulating the use of blood and blood products, the Private sector serves nearly 70 percent of the Department of Health initiated a regulatory body with population. It is primarily a fee-for-service system and defined regulations to ensure safe blood and blood covers a range of health care provision from trained products transfusion services across the country .

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Many low and middle income countries have developed progress in effectively newly emerging and re-emerging their own national accreditation standards and health issues including non-communicable diseases accreditation systems for regulating and improving and disasters (ii) Improving access of essential and cost healthcare services. developed its national effective health services especially for the poor and hospitals accreditation system in late 2000 . To date vulnerable (iii) lack of emphasis on quality of care and Pakistan has no established national accreditation services at all levels (iv) Improving the institutional system in place but Pakistan's Punjab and Sindh Health arrangements and management of health care delivery Care Commissions have formulated a set of Minimal system (v) aligning outputs of the academic institutes in Service Delivery Standards (MSDS) for the purpose of line with the needs of and improving the accreditation of healthcare facilities . The Pakistan quality of education and training (vi) effectively engaging Standards and Quality Control Authority (PS&QCA) also private health sector and civil society organizations to formulated a set of national accreditation standards for i m p r o v e h e a l t h o u t c o m e s ( v i i ) d e v e l o p i n g and Secondary to Tertiary Care pharmaceutical sector and ensuring access to quality Hospitals recently . The Pakistan National Accreditation medicines (viii) ensuring effective research, monitoring Council (PNAC) started voluntary accreditation of & surveillance system to measure results and evidence clinical laboratories for ISO 15189 Certification . The based decision making at all levels previous government took an excellent initiative on Healthcare quality is defined as the degree to which introducing the Prime Minister Quality Award in the health services to individuals and populations increases sectors of manufacturing, finance, service, health and the likelihood of desired health outcomes and are education, but it did not materialize. The award consistent with current professional knowledge . framework was based on the USA's most prestigious Donabedian defined healthcare quality as desired Malcolm Baldrige National Quality Award . outcomes of healthcare delivery processes using As defined in the Pakistan's Health Policy 2000 , some various process inputs as illustrated in figure 1 below: of key challenges in the health sector include (i) slow

Figure : Donabedian Model of Health Care Quality requirement of certain CME hours for renewal of Assessing Pakistan's healthcare quality using above licensures. model will help us understand the phenomenon in a A machine in terms of appropriate medical and non- structured way. Let's begin with the inputs. Manpower or medical equipment is another challenge especially in the human resources in the form of qualified and the public sector. There are many examples where competent healthcare professionals in Pakistan are extremely expensive and high-tech equipment is seen really becoming scarce. Brain drain to UK, USA, Middle lying idle in the hospitals either because of lack of East and Saudi Arabia due to reputable training expertise or lack of maintenance. Reliability of medical programs, quality of life and difficult law and order equipment is another challenge where false results due situation in Pakistan is becoming a challenge. In order to to lack of periodic preventive maintenance and ensure ongoing clinical competency and knowledge calibration pose threats to patient safety. Materials in among the doctors, PM&DC recently made a mandatory terms of medical/surgical supplies pose risks to patients

02 Pakistan Journal of Public Health, 2016 ( December ) in an environment where there are no controls on facility in Pakistan resulting in mushroom growth of supply-chain management. The scope of these supplies inappropriate or unqualified facilities coming into encompasses medications, vaccines and all implants. existence. Flourishing of quackery practices in the Early this year, a federal regulation has been approved primary health care scope of Pakistan is determinant to cover this aspect of healthcare . Methods in terms of factor in the bad outcomes of care. Lack of control and policies, procedures, protocols and clinical practice regulation on other alternatives ways of medicine such guidelines to standardize care are lacking in most of the as , hikmat and spiritual treatments are also hospitals. Measures or indicators in terms of structures, contributing to the outcomes. processes and outcomes are either non-existent or Few studies using the SERVQUAL model has proved poorly selected and monitored in most of the hospitals. that the users of value reliability Except for few measures such as maternal mortality and assurance as important determinants to patient rate, under five mortality rate, disease burden, and polio satisfaction . The SERVQUAL model uses five eradication there are no standardized national measure dimensions (assurance, empathy, reliability, tangibles sets for measuring the disease outcomes at national and timeliness)of service quality as determinants of levels. customer gap in services marketing . Coming to the Donabedian Model's leadership, In the absence of a national healthcare accreditation management, communication, diagnostic and system in Pakistan, few healthcare organizations in the therapeutic process design, there is hardly any concept private and public sector have voluntarily opted for ISO of “process design” in most of the hospitals across the 9001:2008 Quality Management System. The Aga Khan country. There is a lack of effective leadership and University Hospital, Karachi, is the only tertiary care management processes from top to bottom in the overall academic hospital in Pakistan that is accredited by the national healthcare system. However, these processes Joint Commission International Accreditation (JCIA). are comparatively much organized in the private sector Shaukat Khanum Memorial Cancer Hospital and due to defined responsibilities, accountabilities and Research Center in , Shifa International sustainability of the organizations. Gap in commu- Hospitals in and Rehman Medical Centre in nications between the healthcare providers and Peshawar are among few other with best practices in between the providers and patients is among the top quality and patient safety. In the public sector, the Sindh root-causes for preventable medical mistakes (15) and Institute of Urology and Transplantation (SIUT), this is no different in Pakistan. Risky communications Peoples' Primary Healthcare Initiative (PPHI) and such as taking verbal orders, lack of medical record National Programme for Family Planning are few documentation, care without documented care plans, examples with best some best practices. lack of surgical notes, no system for panic lab results Looking at the above scenario some of the specific and no concept of surgical “time-out” are a norm in most challenges for Pakistan's healthcare quality initiatives of the hospitals in the country. Lack of right patient are lack of national healthcare accreditation system and identification, indications, specimen handling, quality integrated national guidelines, policies and procedures assurance, proficiency testing and calibrations of the on healthcare quality and patient safety. Lack of national diagnostic procedures are common findings in most of quality care indicators despite the fact that quality of care the diagnostic facilities. Lack of evidence based objectives are defined in the national health policy. No medicine, use of clinical practice guidelines, pathways regulatory audits for public and private sector health and protocols are also common across the healthcare facilities. Absence of an organizational culture that holds system in the country. This leads to too much variation in people accountable and Lack of Pre-service and In- the therapeutic processes and ultimately bad outcomes. service training for health staff in quality care The final component of Doanabedian Model is the management and leadership with little contextual healthcare outcomes in terms of clinical, functional and research on quality care initiatives. perceptions. The lack of proper health information Some of the options which can facilitate to improve the management system at the national level poses a great state of health care quality in Pakistan may include (i) up challenge in measuring the health outcomes. The gradation and implementation of policies and medical records management system has a great procedures that regulate quality and patient safety degree of variation across the nation at both the public issues in healthcare settings across the country (ii) and private sectors level. There is no concept of disease introduction of a national healthcare accreditation coding based on international ICD coding system and programme across the nation (iii) development of hence most of the healthcare facilities depend on networks and consortia between public and private manual registration systems despite the fact that IT is sectors in Pakistan (iv) capacity building of health care transforming the information management systems to professionals in quality and patient safety (v) provide real time data to its users. Formulation of quality improvement teams at national With no national regulations or poor implementation of and provincial level (vi) development of a culture of the existing regulations, there is no registration or accountability and ownership (vii) learnin g from licensing requirements to operationalize a healthcare experiences of other countries and implementation

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