Preface

Patient Rights and Safety is the hallmark of any healthcare system. Under the provisions of the Constitution of the Islamic Republic of Pakistan, it remains the responsibility of the State to ensure provision of healthcare to the people. Subsequent to the introduction of the 18th Constitutional Amendment, the Concurrent list has been abolished and this responsibility has been devolved to the provincial Governments. In order to fulfill this constitutional obligation, the Government of Punjab has established an elaborate infrastructure for the delivery of healthcare services and has also set up medical institutions/medical colleges to cater for the needs of trained medical, nursing and paramedic human resource. Realizing the fact that the healthcare delivery system both in the public as well as private sectors lacks standardization and is largely unregulated, the Punjab Government promulgated thePunjab Healthcare Commission Act 2010 (Act XVI of 2010), to establish the Punjab Healthcare Commission (PHC) as an independent health regulatory bodywith the primary mandate to introduce a regime of clinical governance thusensuring improvement in the quality of healthcare services. This enactment also mandates the Commission to ban quackery in all its forms and manifestations. This function of the PHC has become all the more important in the wake ofsubstantial increase in the number of cases of medical negligence bywidespread unchecked providers of medical services who are mostly un-registered and unqualified persons (popularly known as quacks) as well as by the medical professionals which were reported by the media.

The PHC has emerged as a key organization to regulate the healthcare system through registration and licensing of all types of healthcare establishments in public as well as private sectors, byaddressingthe complaints and by taking cognizance of such malpractices.The PHChas initiated the process of developing and enforcing Minimum Services Delivery Standards (MSDS) in all healthcare establishments in Punjab including Allopathic, Homeopathic and Unani systems of healthcare. Though all medical professionals are registered and regulated by their respective Councils according to theirrespective laws/rules/regulations, the review showsthat there is lack of coordinated and structured mechanisms to exclusivelyaddress the issues related tothe quackery. The Government has been launching Anti Quackery campaigns from time to time on reported incidences by using mixed clauses of Drug Act 1976, Allopathic System (Prevention of Misuse) Ordinance, Medical and Dental Degree Ordinance and Rules framed thereunder. Unfortunately, these laws/rules donot provide for stringent corporal and financial penalties to restrict or check quackery, as the culprits are mostly bailed out with a negligible fines.

In view of this situation, the PHC has developed this document proposing amulti-pronged Anti-Quackery Strategies covering the following activities for fulfilling its mandate:

  1. Acceleration of Registration & Licensing of all healthcare establishments (Allopathic, Homeopathic & Tibb) through enforcement and monitoring of MSDS in order to exclude the unqualified and unregistered practitioners.
  2. Persuade the Health Department to enforce the available Laws/ Rules to check the quackery.
  1. Propose to the Health Department, Government of the Punjab to notify Inter-departmental Task Force/Steering Committee headed by senior officialsto oversee the implement of strategic Anti Quackery plans both at provincial & district levels.
  1. Set up Anti Quackery Cell within PHC for coordination of implementation & enforcement of Anti-Quackery activities.
  1. Develop a data base of Healthcare providers at the provincial and district level.
  1. Organizing Public Awareness Campaigns to promote patient rights and safety and the importance of the quality healthcare.
  1. Pursue the Health Department to address the systemic issues of unmet needs through introducing Health Sector Reforms proposed in the Punjab Health sector strategy.

We are confident that these strategic actions would act as linchpin and guide to frame policies and procedures to eliminatequackery in the province and strengthen any quackery drives of the Health Department.

(Dr. Muhammad Ajmal Khan)

Chief Operating Officer

Punjab Healthcare Commission

Table of Contents

Contents Page

Preface 2

  1. Executive Summary 5
  1. The Purpose of Anti Quackery Strategy 6
  2. Definitions 7
  3. What is Quackery? 7
  4. Who is a Quack? 7
  1. Why Quackery is Considered a Menace—A Historical Perspective 8
  1. Manifestations of Quackery 9

5.1 Quackery in the Medical Context 9

5.2 Quackery in the Cultural Context11

5.3 Quackery in the Legal Context12

5.4 Quackery in the Organizational Context18

  1. Rapid Consultation with Professionals19
  1. Rapid Consultation with Allied Healthcare Workers 22
  1. Statistical Overview of Status of Healthcare Providers in Punjab 22
  1. Anti-Quackery Strategies and Potential Risks 24
  1. Proposed Anti-Quackery Strategies24

9.1 Registration of all Healthcare Service Providers as an Exclusion Strategy 25

9.2Support to Legislative Reforms 25

9.3Institutionalization of Administrative Set up within PHC26

9.4Advocacy through Behaviour Change Communication (BCC)27

9.5Inter-Sector Coordination for Enforcement of Anti-Quackery Activities28

9.6Alternative Solutions for Unmet Needs of Patients28

9.7Consultation with Key Stakeholders28

9.8PHC Anti Quackery Strategy Implementation Plan29

Appendices 33

PHC Anti Quackery Strategy Paper

  1. Executive summary

Realizing the fact that the healthcare delivery system both in the public as well as private sectors lacks standardization and is largely unregulated, the Punjab Government promulgated the Punjab Healthcare Commission Act 2010 (Act XVI of 2010), to establish the Punjab Healthcare Commission (PHC) as an independent health regulatory body. The primary mandate of the Commission is to introduce a regimen of clinical governance and ensuring improvement in the quality of healthcare services. This enactment also mandates the Punjab Healthcare Commission to ban quackery in all its forms and manifestations. This function of the Commission has become all the more important in the wake of substantial increase in number of cases of medical negligence by a wide spread unchecked providers of medical services who are mostly un-registered and unqualified persons (popularly known as quacks) as well as by the medical professionals which were reported by the media,

The PHC has emerged as a key organization to regulate the healthcare system through registration and licensing of all types of healthcare establishments in public as well as private sectors, by addressing the complaints and by taking cognizance of such malpractices. . The PHC has initiated the process of developing andenforcing Minimum Services Delivery Standards (MSDS) in all healthcare establishments in Punjab including Allopathic, Homeopathic and Unani systems of healthcare. Though all the medical professionals are registered and regulated by their respective Councils according to their respective laws/rules/regulations, the review shows that there is lack of coordinated and structured mechanisms to exclusivelyaddress the issues related to the quackery. The Government on reported incidences, has been launching anti quackery campaigns from time to time by using mixed clauses of Drug Act 1976, Allopathic System (prevention of misuse) Ordinance, Medical and Dental Degree Ordinance and Rules framed thereunder. Unfortunately, these laws/rules do not provide for stringent corporal and financial penalties to restrict or check quackery, as the culprits are mostly bailed out with a negligible fines.

In view of this situation, the PHC has developed this document proposing a multi-pronged Anti-Quackery Strategies covering the following activities for fulfilling its mandate:

  1. Acceleration of Registration & Licensing of all healthcare establishments (Allopathic, Homeopathic & Tibb) through enforcement and monitoring of MSDS in order to exclude the unqualified and unregistered practitioners.
  2. Persuade the Health Department to enforce the available Laws/ Rules to check the quackery.
  1. Propose to the Health Department Government of the Punjab to notify Inter-departmental Task Force/Steering Committee headed by senior officials to oversee the implement of strategic Anti Quackery plans both at provincial & district levels
  2. Set up Anti Quackery Cell within PHC for coordination of implementation & enforcement of Anti-Quackery activities
  3. Develop a data base of Healthcare providers at the provincial and district level.
  4. Organizing Public Awareness Campaigns to promote patient rights and safety and the importance of the quality healthcare
  5. Pursue Health Department to address the systemic issues of unmet needs through introducing Health Sector Reforms proposed in the Punjab Health sector strategy.

2. The Purpose of Anti Quackery Strategy

The purpose of this strategy document is to provide the Punjab Healthcare Commission witha base for extenuating anti quackery efforts that could be rationally launched and are responsive to the overall mission and vision of the Commission. The document further aims to look at the current situation with a historical perspective and context within which quackery has existed in variousforms and manifestations. The document will act as a precursor and a potential guide to develop PHC Anti Quackery Strategic Plan in the light of PHC Act 2010 and other related laws. The document has attempted to address the reasons of the persistent prevalence of quackery,highlight the measures taken by concerned authorities andthe potentials risks. It further provides an implementation framework for suggestions strategic actions.

The document shall focus onwhat measures PHC should take to ban quackery, andwhat mechanism it should follow while institutionalizingapproved quality standards through licensing of healthcare establishmentsto prevent professional negligence. The issue of quackery by professionals including registered medical practitioners (Allopathic) is largely dealt by the Pakistan Medical and Dental Council (PMDC) Regulations and Code of Ethics. This paper, however, presents the analysis of practices of medicines and surgery by unqualified and unregistered practitioners in our society.

This draft Anti Quackery Strategy document isa document that will require consultations with key stakeholders such as Provincial Health Department, District Governments, Professional bodies such as PMA, paramedical staff associations, patient rights and welfare societies, and representatives of judicial, legal and political activists. The inputsfrom all these stakeholders will not only help refine the proposed anti-quackery strategiesbut will also help buyingin ownership and commitments of the outcomes by its potential stakeholders.To ensure smooth implementation of thestrategies designed to combat quackery issue in the province of Punjab.

3. Definitions

3.1 What is Quackery?

In general term, the “quackery” is defined as the promotion of unproven or fraudulent medical practice[1]. This definition could also cover the quackery amongst professional medical practitioners who practice medicines or surgery beyond their formal qualifications and skills that they actually have.

The Punjab Healthcare Commission (PHC) is established under the PHC Act (XVI) of2010. Its main aim is “to improve quality of healthcare services and ban quackery in the Punjab in all its forms and manifestations”[2].Although no hard core data or information on number and types of quacks practicing medicine or treating people is availableparticular related to Pakistan and/or Punjab, it is a known fact that as a result of quacks’ provision of health services and use of products, a large number of people are reported to have suffered from its negative consequences starting from minor sicknessesto major disabilities or even deaths.

3.2 Who isa Quack?

  1. Quackery a menace - Historical perspective

The issue of quackery came to surface in early 17th century in Britain and its colonies and formerly when the Dutch Society against Quackery was established in 1880. During the same period in USA, where false medicines in this era were often denoted by the slang term snake oil, the passage of the Pure Food and Drug Act on February 21, 1906 in the United States and subsequent creation of the Federal Drug Authority got involved in regulating production, promotion and use of medicines for curing diseases in the USA. Similar acts were passed and bodies were formed in many countries (including Pakistan) in the world. Till the 20th century, quackery was linked to the use of medicines which were manufactured without empirical research (popularly known as experimental medicines). In Indo-Pak sub-continent, quackery is general attributed to faith healing and treatment of ailments by use of local herbs.

In Pakistan, quackery is considered a norm on one side and is a health hazard on the other. It is a means to mint money from innocent patients or care seekers. The health and life of a patient seeking treatmentfrom a person who lacks professional knowledge andskills is in danger being subjected to unprofessional practices.There is a lack of availability of data on the number of people who have been victims of such practices. The patientsare distracted from getting proper treatment on the assumption that they can be well treated by the low cost and easily accessible practitioners.Indiscriminate use of injections by these unqualified/unregistered practitioners (quacks) is major source of the rampant spread of viral hepatitis and other infectious diseases.Many a times these quacks put the life or parts of the body of their patients to further complications by embarking upon those therapeutic procedures or using those medicines regarding which they have little or no knowledge. Indiscriminate and irrational use of lifesaving antibiotics by the quacks is rapidly producing resistance to many micro-organisms. Such resistant strains frequently pose greatchallenge not only to the treating physicians but also endanger the life of patients.

It is a dilemma that no census, Health Management Information System or any other data source provides the extent of the problem of quackery in Punjab.An unpublished note prepared by the Punjab Health Department in response to a Governor’s directive during 2002, provides an analysis of the situation of quackery in Punjab somewhat on similar lines as of this document and had proposed various measures to tackle the issue. The status of action taken on this connection is however, not known.

It may also be noted that the issue of quackery among healthcare professionals (qualified and registered doctors) is primarily addressed under the “PMDC Ordinance and the Code of Ethics of Practice for Medical and Dental Practitioners of Dec. 2001” developed thereunder and/or by the Ordinances/Codes of ethics of Homeopaths, Tibb and Nursing Councils. However, quackery by non-qualified and un-registered medical practitioners is lacking clear policy and procedures which strengthen the implementation and enforcement bodies to combat quackery; such as the Health Department and DistrictGovernments.

  1. Manifestations of Quackery

Quackery can be classified in following manifestations:

  1. Medical treatment by Indigenous practitioners of medicines-mostly un-registered
  2. Performance of surgeriesby those having no formal training and/or qualifications-mostly un-registered
  3. Para Medical/Allied Health Professionals practicing medicines and surgery who are not qualified to treat in that particular field of specialty
  4. Dispensing and Sale of drugs to patients without prescription and withoutlicense

5.1 Quackery in the Medical Context

According to the PHC Act 2010, Sub Section (xxxix) of Section 2, Quack“means a pretender providing health services without having registration of Medical and Dental Council, Council of Tibb, Council for Homeopathy and Nursing Council”.The physicians or surgeons or dentists as practitioners of Allopathic medicineswho are though registered with Pakistan Medical & Dental Council but do not follow the Code ofEthics of practice for medical and dental practitioners,may fall under the definition of quacks.

Nevertheless, Punjab faces a unique challenge of health services being provided by multiple types of health workers who are neither registered with the PMDC nor with their respective Councils. There are many allied health workers who are certified by local medical boards (like Punjab Medical Faculty) and allowed by the government to treat patients under the supervisionof qualified doctors, particularly in government run health facilities in rural areas.

These include but are not limited to the following:

  1. Cadre of Medical Assistants was created in 1972 to meet the shortage of doctors in periphery
  2. Cadre of Medical Technicians (male & female) was created in 1983 with specific objective of creating substitutes of those doctors who were not willing to go to rural areas
  3. Dispensers/Dressers to dispense drugs & conduct minor surgical procedures/First Aidmore commonly found in rural dispensaries and sub-health centres.
  4. Cadre of Lady Health Visitors has been in place since partition and trained in primary healthcare with a focus on woman and child health.
  5. Lady Health Workers Programme introduced in 1994to provide very basic healthcare at community level with a focus onearly identification of disease, treating minor ailments and provide and referral services
  6. Community Midwife: A person given a certificate to conduct normal delivery at the village level where there is no doctor to deal with maternity services
  7. Medical Technologist/Lab Assistant: A person given a certificate to operate medical equipment and look after its maintenance.

Though above mentioned categories of health workers were recruited by the government to work in government healthcare establishments, a large majority of them are working as private practitioners and having their clinics spread all over mainly in urban slums and rural areas of the Punjab, usually operating after official working hours. Irony of having these Cadres of health workers is that,by availing the opportunity as gap fillers in place of “registered/qualified doctors” they are performing serviceseven beyond their scope of work, and are responsible for putting the lives of patients in danger.Since, over the years these practitioners had developed a trust among patients/communities and charge nominal fee, the patients prefer to visit them, even in the presence of qualified doctors in the same localities.

According to the Islamic Code of Medical Ethics endorsed at the First International Conference on Islamic Medicine held in Kuwait on12-16 January 1981)[3], the role of a physician (Doctor) was enunciated in the context given hereunder:

[God addresses us in the Koran by saying, “and make not your own hands throw you into destruction”. Prophet (PBUH) says “your body has a right on you and the known dictum is no harm or harming in Islam”].

[Al-Ghazali considered the profession of medicine as (fardh - Kifaya), a duty on society that some of its members can carry in lieu of the whole. This is natural since the need of health is a primary need and not an anything in life remains enjoyable.] The one of the important characteristic of a Physician is that “he should be amongst those who believe in God, God Fearing, fulfill His rights, are aware of His greatness, obedient to His orders, refraining from His prohibitions, and observing Him in secret and in public.The physician should firmly know that 'life' is God's award only by Him and that 'Death' is the conclusion of one life and the beginning of another. Death is a solid truth ….and it is the end of all but God. In his profession the Physician is a soldier for “Life” only defending and preserving it as best as it can be, to the best of his ability.