Objective: To assess the reasons for the problems faced by patients in the government hospitals to make an emphasis on higher authorities for identification of problems and implementation of effective measures.
Methods: A questionnaire-based doctor's survey was conducted at Jinnah Postgraduate Medical Centre (JPMC). The survey included 10 doctors each from 5 wards of JPMC. Informed consent was taken from study participants and ethical considerations were fulfilled. All the doctors were asked questions related to the problems created by hospital management, due to the irresponsibility and concerns of the doctors and also due to the patients themselves. The responses were evaluated separately.
Results: A total of 50 doctors participated. out of which, 19 were males and 31 females. Out of all the reasons listed, 84% doctors favored the reason of inadequate salary to doctors & paramedical staff by government while other two reasons favored by 80% doctors were lack of facilities and security for doctors and illiteracy and poverty of patients.
Conclusion: This hospital based study showed that the causes were related mainly to hospital management, doctors' attitude and responsibility and also to patients' illiteracy and poverty. This calls for adequate measures by higher authorities to rectify the situation (JPMA 55:45;2005).
It is recognized that in both developed and developing countries, the standard of health services the public expect are not being provided. A very high proportion of the population in many developing countries including Pakistan, and especially in rural areas, do not have any access to health services, which can be used by only the privileged few and urban dwellers. Although there is the recognition that health is a fundamental human right, there is a denial of this right to millions of people who are caught in the vicious circle of poverty and ill-health. In short, there has been a growing dissatisfaction with the existing health services and a clear demand for better health care.1
An Alma Ata declaration has stated that: "the organized application of local state, national and international resources to achieve "Health for All", i.e. attainment by all people of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life."2
How can we help to implement this declaration, while at level of tertiary health care especially government hospitals, poor patients that are the major population of Pakistan, are still facing problems for obtaining proper facilities for their treatment?
A WHO Expert Committee in 1963 proposed the following working definition of a hospital: "A hospital is a residential establishment which provides short-term and long-term medical care consisting of observational, diagnostic, therapeutic and rehabilitative services for persons suffering or suspected to be suffering from a disease or injury and for parturients. It may or may not also provide services for ambulatory patients on an out-patient basis."3
The criticism leveled, against the hospital is that it exists in splendid isolation in the community, acquiring the euphemism "an ivory tower of disease". It absorbs a vast proportion (50 to 80 %) of health budget; it is not people-oriented; its procedures and styles are inflexible; it overlooks the cultural aspects of illness (treating the disease without treating the patient); the treatment is expensive; it is intrinsically resistant to change, and so on. The relative isolation of hospitals from the broader health problems of the community, which has its roots in the historical development of health services, has contributed to the dominance of hospital model of health care.4
The victims of poor medical care are those who have to rely on government hospitals, which are overcrowded, short staffed and have meager funds to provide for medicines and health supplies. Moreover, syringes and surgical equipment are repeatedly used on different patients without adequate sterilization allowing further spread of deadly viral infections among unsuspecting patients. Worse still, medical waste is not disposed of properly and used medical equipment is scavenged outside hospitals only to be sold again. In fact this practice has been reported to become an organized profitable business. Many times the medical miracles in Pakistan lie in the idea that some patients actually survive their hospital stay. Sweepers, medical technicians, nurses and even physicians have been reported to be absent for months at a time and have been referred as "ghost workers.4
With large migrations occurring form rural to urban areas, urban health problems have been aggravated and include overcrowding in hospitals, inadequate staff and scarcity of certain essential drugs and medicine.2
As every person has his own opinion about these problems so a study was performed to analyse the reasons for the problems faced by patients, at Jinnah Postgraduate Medical Center, Karachi.
Materials and Methods
This study included 10 doctors each from 5 wards of JPMC i.e., from Gynae Ward, Obs. Ward, Medical Unit -II, Ward -6, Surgery Unit -II, Ward -2 and Orthopedics Ward.
Jinnah Postgraduate Medical Centre (JPMC), Karachi is one of the leading tertiary care hospitals in Pakistan. It started working in 1963 with 80 beds and is now an institution of about 1,185-beds/admission capacities with 28 wards. Its catchment area includes all parts of Pakistan but especially Karachi, interior Sindh and border cities of Baluchistan. It provides highest degree of medical care to a large segment of society. Besides Patients' care JPMC is the leading institute to provide training facilities to undergraduate medical students of Sindh Medical College and postgraduates in almost all specialties. It also provides teaching and training to undergraduate and postgraduate Nursing. It is also a pioneer institute to train for B.Sc physiotherapy and occupational therapy.
Informed consent was taken from study participants and ethical considerations were fulfilled. Self administered questionnaires related to hospitals, doctors and patients were designed and administered. All the doctors were asked questions related to the problems created by hospital management, due to the irresponsibility and concerns of the doctors and also due to the patients themselves. The responses were evaluated separately. Data is presented in the form of percentages.
The reasons for the problems, related to hospital, were six. Out of six reasons, third reason i.e. "lack of facilities & security of doctors" was marked true by 80% of doctors. Other reasons in a range of 30% to 60% are shown in Table 1.
The reasons for the problems related to doctors were four. Out of four reasons, second reason i.e., "Inadequate salary to doctors and paramedical staff by government" was marked true by 84% of doctors. Other reasons in a range of 30% to 50% are shown in Table 2.
The reasons for the problems, related to patients, were three. Of these three reasons, the last one i.e. "Illiteracy and poverty of patients are factors that create problems for them in government hospital" was marked true by 80% of doctors. Other reasons in a range of 30% to 60% are shown in Table 3.
The study was conducted to deduce certain root causes of major problems. Though a vast variety of problems were considered, three most significant ones emerged drew full attention.
The third query of the questionnaire which was regarding facilities and security of doctors was marked "true" by almost 80% responders, which is itself an indicator of still lasting fear regarding security probably due to killings of doctors in the recent past. This should ofcourse, be a main sector of concern for the higher authorities as no one can do their best until they feel adequately secured. As the questionnaire also focussed on the facilities for doctors, 80% responders were dissatisfied with the current privileges. This shows that peace of mind is an important factor for efficient working. This can be acquired by improving the facilities provided.
The provision of adequate, accessible, appropriate and affordable health is one of the fundamental rights, recognized by global leadership under banner of World Health Assemblies of 1978 and 1998.5
Improving health services in poor communities might involve changing the incentive structure for public providers. Introducing incentives in the public sector is often difficult due to non-flexibility of civil service rules. Incentives as paying extra allowances for hardship posts have been implied in many countries. All mechanisms of incentives have their own risks and none of them is problem free.5
The eighth query of the questionnaire dealt with inadequate salary of doctors and was also responded in affirmative was by 84%. This, indeed, reflects that doctors and paramedical staff are not satisfied or content with their current benefits rendered to them for their hard and diligent work. The query elucidates that performance of doctors and paramedical staff can be enhanced by giving appropriate incentives to them.
Lack of supervision from senior physicians, inadequate laboratory, radiology and pathology facilities do not allow thorough medical work up of patients.4
"Senior doctors including professors, who are paid meagre salaries of up to 20,000 rupees a month, are involved in lucrative private practice in order to lead a decent life and thus have no time or drive to care for patients or mentor medical trainees. Several physicians in the government hospitals solicit business and lure patients into seeing them in their private clinics. Moreover, doctors charge fees for their services without following any particular fee schedule.4 Job dissatisfaction and stress among doctors affect the quality of health care.6
Majority of doctors working at these teaching hospitals of Karachi had a poor satisfaction level and higher levels of job stress. This suggests that immediate steps should be taken for rectification.6
The last and the thirteenth query dealing with illiteracy and poverty of patients gave a positive response by 80% doctors, reflects that patients behavior with the doctors and to disregard doctors' advice. Patients usually don't observe the follow-up probably owing to overload in govt. hospital. Sometimes after initial response and feeling better they ignore doctor's advices. So measures should definitely be taken to improve the understanding, the importance of follow-ups and the doctor's advice. The results of this study warrant a prompt corrective action by the concerned authorities.
The authors thank Dr. Shaheen Agha from the Department of Community Medicine, Sindh Medical College, Mrs. Shaukat, Librarian, JPMC library and Miss Nudrat Alvi, Assistant Librarian, JPMC library for their assistance and useful suggestions and also to our two colleagues Miss Sanjeeda Bano and Miss Seema, Final year students of Sindh Medical College for their cooperation during the study.
1. Park JE. Man and medicine: towards health for all. In: Bhanot B, Preventive and social medicine, 22nd ed. Jabalpur: 2002, pp. 1-11.
2. Park JE. Health care of community. In: Bhanot M, Preventive and social medicine, 22nd ed. Jabalpur: 2002 pp. 611-22.
3. Park JE. Concepts of health and diseases. In: Bhanot B, Preventive and social medicine, 22nd ed. Jabalpur: 2002, pp. 11-44.
4. Nadir A. Deficiencies of medical system in Pakistan. Pak J Med Edu 2003;1:6-9.
5. Farooq U, Ghaffar A, Narru IA, et al. Doctors' perception about staying in or leaving rural health facilities in district Abbottabad. J Ayub Med Coll 2004;16:64-9.
6. Khuwaja AK, Qureshi R, Andrades M, et al. Comparison of job satisfaction and stress among male and female doctors in teaching hospitals of Karachi. J Ayub Med Coll 2004;16:23-7.