Primary Health Care and General Practice in Pakistan

Primary care and general practice in Pakistan

Primary medical care needs in Pakistan are served by private practitioners including generalists and specialty-trained physicians, government-employed physicians, community health workers, and traditional healers. Primary health care faces the challenges of inappropriate training, lack of consumer protection, and a tertiary care orientation of health care services.
Primary care providers deliver cost-conscious, culturally sensitive care but work virtually without any regulation or continuing education. Private practitioners work on a fee-for-service basis with competition from non-physicians providing primary care. Studies have revealed inappropriate prescribing for common conditions such as watery diarrhoea and upper respiratory infections, indicating a need for improvement in primary care medical education.
Health indicators
Pakistan's last census in 1998 enumerated a total population of 130 million with an average growth rate of 2.6 per cent. Estimated life expectancy at birth for both males and females was 63 years. Most of the population resides in rural areas although larger cities have experienced high rates of urban migration. Karachi, the largest city, had a population of 9.2 million in 1998, a dramatic increase from 5.2 million in 1981. Average household size is 6.8 persons.(1) Household health care expenses account for 4.6 per cent of total expenditure and this proportion is greater in rural and lower socio-economic class families.(1)
Health indicators in Pakistan have shown a positive trend with improvements in life expectancy and infant mortality rate. However, the overall health of the population remains poor compared to countries with comparable economic status. This has been attributed to a low literacy rate, lack of clean water and sanitation, and neglect of the health care sector at the government level.
Structure of health care
Health care services in Pakistan have evolved from traditional medicine with a rich legacy to ‘a highly inequitable, western-oriented curative model, which certainly does not fulfil the requirements of a very great majority of the people’.(2) A rapidly growing population, health transition to non-communicable diseases, poverty, and sociopolitical upheavals further strain these services.
The private sector provides the majority of health care while the public sector serves as a safety net for the poor. The private sector itself is varied, ranging from untrained providers working in rural areas to sophisticated technology-intensive hospitals in the larger cities. There are no direct reimbursements to private practitioners by the government as in the Medicare/Medicaid programmes in the United States.
The private sector operates in a fee-for-service mode; competition and financial returns affect the quality of services provided. Providers are sensitive to the health care needs in the cultural and financial context of the patients. Health care consumers are usually at a disadvantage in judging quality, appropriateness of services, or fee structures. Lack of accreditation and regulation makes quality assessment and assurance even more difficult.
Government clinics and hospitals provide essential health care services for those who cannot afford private sector fees—this includes families in the lower and lower-middle socioeconomic classes and government employees. The public sector, operated by provincial health ministries, is limited by centralized control, resource wastage, and poor quality of care. Although direct fees charged are minimal, families end up paying out-of-pocket significantly for ‘covered’ items such as medicines and surgical supplies.(3) Due to the overwhelming demand for public-sector health care, additional cost-shifting occurs in subtle ways such as long waiting lines that force patients to seek care elsewhere. Rationing of services also occurs with the exclusion of under-served groups to the benefit of ‘entitled’ classes such as higher-rank government and military officials, and family contacts of health care providers.
Primary care services
Primary care services are rendered by a variety of providers: allopathic physicians, hakims (traditional physicians dispensing herbal medicines), homeopathic physicians, faith healers, pharmacy dispensers in independent clinical practice, and drugstore attendants (see Fig. 1).

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The private sector provides the majority of first-contact care in urban and rural areas, independent of distance to a public health care facility.(4) This preference is most likely due to public perception of lack of quality of care, long waiting lines, and erratic availability of staff, medical supplies, and medicines at government clinics. Doctors and dispensers at these clinics usually supplement their incomes with private practice, which creates a conflict of interest in treating patients at the government centers.
Prescription writing is not limited to registered physicians (despite the efforts of the Pakistan Medical Association and the Pakistan Medical and Dental Council), resulting in a wide range of primary care providers in terms of qualifications and quality of care. Intense competition results in downward pressure on fees charged with compensatory reduction in quality of care parameters: time per patient encounter, level of clinical sophistication of services provided, and referrals to other providers. There is virtually no documentation of care and medical records are usually not maintained. Clinically inappropriate practices such as prescribing unnecessary injections, systemic steroids, antibiotics, and strong antidiarrhoeal drugs, also become more prevalent to ‘satisfy patient preferencesâ€.(5,6)
Unfortunately, the level of training and the fees charged do not seem to correlate with better health care or improved outcomes. Specialty-trained physicians such as paediatricians and obstetrician–gynaecologists also show inappropriate prescribing for common primary care conditions.(7) Restriction of prescription writing to registered doctors is unlikely to bring about a major improvement in quality of primary care.
Training for primary care
Primary care training is improving at most medical colleges—with certain private medical schools leading with new Family Medicine departments. Primary care is included in the Community Medicine curriculum but taught without involvement of primary care clinics. Medical students learn to extrapolate ‘primary care†from inpatient wards of teaching hospitals and outpatient specialty clinics. The majority of medical graduates practice primary medical care without any further training (only about 10 000 of the 63 000 registered physicians reported specialty training to the Pakistan Medical and Dental Council in March 2001).
The role of postgraduate training in Family Medicine residency programmes remains unclear—academic teaching and research in primary care are potential roles for advanced trainees in Family Medicine. The Aga Khan University, which initiated the first Family Medicine residency programme, has developed a postgraduate curriculum that includes inpatient training, longitudinal outpatient experience, and community involvement.(
The College of Physicians and Surgeons of Pakistan, a public body that conducts specialty-certification examinations, has introduced a Diploma in Family Medicine(9) as well as full specialty certification in Family Medicine. The demand for and future impact of these on primary care in Pakistan is uncertain. Market demands call for a ‘specialist†label and the pressure to specialize remains high. Public understanding of the difference between family physicians and generalists remains limited.
Factors limiting improvement of primary care
Financial disincentives to training, lack of continuing medical education (CME), unethical drug detailing, and inappropriate training contribute to poor quality of primary care. The time spent in practice since medical college graduation has been shown to correlate with worsening prescribing patterns, perhaps indicating a need for CME.(10)
As general practice in Pakistan remains fairly unregulated, market factors tend to dominate its distribution and quality of services. Health care consumers are unable to make informed choices about selecting primary care providers. Low earnings, the absence of a career path, and lack of professional recognition and influence at medical institutions add to the frustrations of primary care physicians.
The Primary Health Care model promoted by the World Health Organization appears to hold the greatest promise for sustainable and affordable primary health care. Unfortunately, it remains difficult to implement beyond small-scale pilot projects. Health care insurance has the potential to escalate medical costs, making it unaffordable to the majority of the population.
Future directions
The scope for improvement in clinical practice of primary care remains great. Targets for cost-effective interventions to improve rational drug prescribing have been identified at the medical college level, and in postgraduate training programmes as well as CME for practising physicians.
Direct enforcement of licensure and CME for practising physicians will probably be difficult and innovative approaches to encourage public and professional demand for quality care and CME certification are needed. ‘Social marketing†has been used in contraception-promoting programmes that use direct-to-consumer marketing techniques to creating public awareness and demand for these services. Social marketing may be useful in promoting primary care CME certification in Pakistan.
Development of primary care curricula that are evidence-based on local research and socially appropriate should be a priority. A concerted national effort to improve primary health care is needed in Pakistan with participation of medical colleges, professional interest groups, government health departments, and informed public representatives. Integrated work among these groups and across the provinces will help ensure consistency, resource-sharing, and appropriate primary care practices. Such integration will allow improved collaboration with the family physician as a focal point in local Primary Health Care, referrals and pre-hospital care, and community leadership in health promotion.