Why does the government regulate the health sector? One answer could be that a health sector is regulated for the same reason as are other businesses: to combat monopoly and to provide products and services not hazardous to the wellbeing of the general public. However, the health industry differs from other sectors because of the direct involvement of the life of the people. Policymakers ensure that citizens get quality treatment at an affordable price with easy access. It is difficult to maintain a balance between the three. Usually, if the quality is improved, the cost goes up. At times when accessibility is prioritised, quality and affordability become questionable. A well-functioning system is one where all three features are in balance. The absence of any one element means that the system is deficient in one way or the other.
The first effort towards regulating the healthcare sector began in the late nineteenth century. As science developed to understand the role of germs in illness, regulatory frameworks to control the spread of diseases through contingence evolved, making vaccines and quarantine mandatory. To put a tap on the sources of germs, sanitation programs were established to improve the sewer system, provide clean drinking water and inspect food. Similarly; drug safety laws were enacted to control the sale of unsafe medication. In due course, a licensing program for physicians and medical colleges was introduced. The process of registration was further strengthened when hospitals and all other Healthcare Establishments (HCE) were tied to rules and regulations. The result was a set of laws that stopped unqualified doctors from laying claim to be healers and deterred ill-equipped facilities from pretending to be centres of care. Along with government oversight, the private sector as well developed its own accreditation and regulatory framework to provide what is called the third party audit. All of these rules, regulations, standards, accreditations, and evaluations made the healthcare sector eligible to be called a “system.”
Another reason leading to the critical scrutiny of the health sector has been to monitor the use of taxpayers’ money. A common perception is that funds allocated for health are not always deployed optimally. Regulations ensure that health services are provided as and where needed, without any bias. Now that the health sector is highly regulated the question is, “does it work”. Does regulation affect the quality of health care services delivered to the patients?
The US Department of Health and Human Services conducted a research, in 1995, to study the effect of regulations on the quality of care in Board and Care Homes. The result showed improvement in the following six areas:
1. Reducing Prevalence of Unlicensed Homes: States with extensive regulations tend to have fewer unlicensed home facilities.
2. Improving Quality of Care: A regulated healthcare facility was better equipped to cater to the needs of the patients. Their staffs was more knowledgeable, it provided with many other key supportive services, and had devices that helped a patient live more independently in a hospital.
3. Improving Quality of Life: Homes in states with extensive regulation and licensing were more concerned about providing social aid to the patients that improved their quality of life. Reading the material, community rooms, working television and radio were provided adequately. Similarly, the research also debunked the notion that licensing or registration develops an institutional environment. In fact, the regulation made the homes and health facilities more responsive to the needs of the patients resulting in a friendly and need-based atmosphere.
4. Improving Safety: Licensed and regulated facilities had a wide array of safety features such as smoke detectors, a fire extinguisher in the kitchen, secure handrails on stairs, and supportive devices, such as grab bars in the shower, call buttons in the bathroom, and grab-bars by the toilet.
5. Preventing the “Worst” Performance: Regulation helped the healthcare facilities to maintain minimum quality standards. As compared to unlicensed homes, licensed homes had the highest score on safety, physical amenities, and social aids.
6. No Positive Effect: There were nevertheless homes where regulation and licensing made little or no effect. Cleanliness was compromised and untrained and unlicensed staff was hired, which compromised quality.
For many years, Pakistan’s public health sector received the peripheral attention of the policymakers, legislators and law enforcers, which resulted in a parallel development of an exploitative private health sector, riddled with quackery. Together, these developments took a toll on the lives and pockets of the people. Not until the media grew louder and ubiquitous did the health sector receive due devotion. Punjab became the first province to redraw its health sector priorities and enacted the Punjab Healthcare Commission (PHC) Act 2010, leading to the establishment of the PHC.
Accountability is no more a simple one-on-one affair. The world has grown from a straightforward democratic model of accountability that involved only the service provider and receiver, to a stakeholder model of accountability where the public and private sector organisations are accountable to a wide range of stakeholders, including consumers, trading partners, competitors, staff professional bodies, funders and payers and so on.
Therefore, the regulatory framework at the PHC involves the entire spectrum of HCEs, which must comply with both clinical and managerial aspects of the Minimum Service Delivery Standards. From the development of standards to the training of stakeholders through capacity building workshops and seminars and the provision of a responsive complaint management system, the PHC has come a long way in creating awareness about the necessity to come in the ambit of rules and regulations through registration and licensing.
The Commission is at a stage where it is considering coercion and punitive action as a mechanism to enforce healthcare regulation. However, in Pakistan’s scenario, the issue of quality, accessibility, and affordability of treatment goes far beyond regulations. It requires political will of the government to increase the health budget and taper down the growing influence of the private health sector in Pakistan.
n The writer is a freelance journalist
based in Lahore.