Waiting for Orders

Organization Culture and Social Anthropology of Medicine in Pakistan

Prof. Dr. Farakh A. Khan

Professor Dr. Farakh A. Khan
D.U. (Vienna) F.R.C.S. (UK)
Professor of Urology

Dr. Farakh A. Khan is an eminent urologist of Pakistan with a thinking mind that does not limit itself to his immediate vocation. He is a free thinker who likes to explore other vistas around him - Music, Photography, traveling amongst other hobbies. He is a keen student of social and cultural dimensions of our society with a open and inquisitive perspective, that is in itself a rarity in our barren cultural landscape.

This article is an excerpt from his book "Waiting for Orders" that he is about to publish. I am very fortunate that he has offered to let me produce the introduction on Hujra.

Employment opportunities for Pakistani Doctors:-

Introduction 

Health care, in Pakistan, has been an important part of the public sector. Over the year’s apathy and neglect by the government led to poor returns from the health care providers. The initial confidence of the 50’s and 60’s of the government’s ability to provide “health for all” transformed into a nightmare by the 70’s. A new slogan “health for all by the year 2000” was evolved in Almaty (1978). Major health care provider, the government, had effectively collapsed and neglect of government health care institutions became the main factor in their deterioration. The objective of the doctors was to escape the stagnant economy, poor job opportunities, lack of postgraduate training and a bleak future by seeking employment abroad. The government used its usual bureaucratic methods by restricting the exodus of doctors with a ban on their exit from Pakistan rather than making Pakistan more attractive for the doctors. This strategy did not work and the exodus continued unabated. By 1974 the new oil rich countries were in desperate need of doctors to look after their population who had been denied health cover in the past due to financial constraints. Foreign doctors, including Pakistanis, were imported in planeloads. Export of doctors became the unwritten official policy and new medical colleges were opened overnight to cater for the new demand. The concept of ‘brain drain’ was put aside and the needs of the people of Pakistan put on hold. Today the oldest hospital, Mayo Hospital Lahore, in the country has been reduced to a third grade institution and a few years down the line its relevance as a health care provider will be seriously questioned. This has been the sad story of social services for the people of Pakistan over the last 52 years.  

Oil boom in the Muslim countries in the early 70’s was the first real economic benefit for the common Pakistani. Unlike the aid packages opening of job opportunities abroad increased buying power of a segment of our poor population. For the first time in the history of Pakistan people, especially from the agriculturally poor areas, had some financial power. Private sector became a viable option and had no problem in competing with the almost collapsed government system, which had set in by the early 60’s. In the 90’s government health service had lost its direction and was out of control. Look what has happened to King Edward Medical College, Lahore. From an A class institution recognised the world over and the best in Asia in 1947 it has been reduced to a non-entity today. An institution, which should have been the pioneer in medical education and research, is begging for new innovations. The structure of the attached teaching hospital is crumbling and has facilities only fit for the management of patients who cannot afford private treatment. It is an institution, which has slowly killed itself without telling the people who work there because they do not care. It is an institution, which is fast becoming irrelevant but has the clout in seniority and hence manages the catastrophe, which is eminent. We cannot see or hear the bells of doom. Perhaps no one cares any more. 

The universal down hill slide of our institutions and systems has been taking place before the 60’s and it was only in 1996 that there has been some awareness. This was perhaps due to pressure by the traditional foreign funding agencies (World Bank, IMF etc.) trying to recover their loans. With the collapse of USSR in 1990 it was clear to the Third World in the American camp that it will not be business as usual. The clear massage of the New World Order was that the American interest was now limited to a few states and the rest have to function through good governance or perish (Khan, 1992). It is sad that news of the collapse of our services and systems has not come from within the related institutions but from agencies outside Pakistan (Mahbubul Haq. The News 10^th April 1997). We suddenly realised that the country was financially bankrupt and institutions ruined. Our governments never gave the true situation of our economy and refused to believe it themselves. Major bank loan defaulter was the government itself. A collapsed system of governance including the justice system created an attitude of ‘Waiting for Orders’ (Hokum Karo). This is our culture of ‘Waiting for Orders’. 

What happened to us? Can we stop this decline? But first of all we have to ascertain the cause of the collapse of the government health service. In a nutshell we are looking at human failure which is expressed in the behaviour and attitudes of people who were appointed by the government to improve, not only the health care system, but also every other aspect of the people of Pakistan. Our system of governmental working is based on ‘safarish’, blind loyalty, and a high degree of ‘secrecy’. A system which has lost confidence not only of the people but also in itself and yet persists in maintaining the old order which led to our downfall in the first place. Today we have created ‘safety nets’ for the rich and the well connected the reverse of what we should have done. With the explosion of the ‘Pakistani Bomb’ in June 1998 we are left with no option but to change. Are we facing a culture, which cannot respond to change for the better? Can we change the present culture? How long will it take for this to change? These are crucial questions for our future. 

Every organisation has a peculiar smell, an aura, a system of working and unwritten view of itself and its environment. A new comer into the organisation feels the change of culture, which is the result of the behaviour and attitudes of the people working and interacting with each other. The culture of each organisation is unique and tends to change marginally in stable situations. During periods of stress and hard times culture responds in an unpredictable manner. Culture of the health care system and its subsidiaries is vitally important for the health and welfare of the people. In the government sector this is an area where a service is provided to the people without returns. The health care workers have the most intimate contact with the people and their problems. This is a challenging new field for research with far reaching applications. 

In 1969 I joined the Department of Urology, Mayo Hospital, Lahore (teaching hospital of the King Edward Medical College) as Senior Registrar. This was my first posting in the government service. The Department, beside new faces and premises, had changed very little from my House Surgeon days (1962-1963). We were understaffed and badly equipped. The Department was still struggling for its existence as a new speciality against intense opposition from the general surgical units. Urology Department finally moved to the present premises in 1977 and started a new era. 

In 1978 I moved from the King Edward Medical College and joined the Postgraduate Medical Institute, Lahore (PGMI) as Director of Surgery. In 1981 I was appointed Professor of Urology in the same institution. This was the third urology unit and the second chair of urology in the Punjab. 

The new urology unit at the PGMI was built from scratch. The staff was new and young. As time passed, unknowingly we created new systems and work ethics. On my move back to the Urology Department at Mayo Hospital in 1994 I was confronted with an institution with a departmental culture, which was very different from what I had experienced before I left the Department in 1978.  The questions that came to my mind were ‘Why people behave the way they do?’  ‘Can we change behaviour?’ and ‘How long will it take to change culture?’ I then decided to study the mechanics of organisational culture making the Department of Urology as the subject of study. What started, as ‘Reorganisation of Department of Urology’ soon became a research project of improving services in a government hospital without outside financial aid or major shift of manpower. In the end we created a model for other departments of the government hospitals. This was an unknown field of research for me. It was surprising that I could find almost no references on this important subject in the medical literature. It is unfortunate that with severe press restrictions in Pakistan in the past there is almost no independent literature on the subject of social and related problems. After 1988 the press became relatively free and critical articles started to appear in the press, which have been an important source of information. It is hoped that workers and administrators of our social services shall publish their experiences in future. 

With almost no guidelines this project was a daunting undertaking. However, my work on societal culture was to prove invaluable. Books on management sciences and organisational culture for the industry in the developed world were interesting but were not strictly relevant to my work. I was thus breaking new ground as the study proceeded. In March 1997 I got access to Internet and whole new world opened up. However, we could only access abstracts and not full text of the publications. In October 1999 the MCB University Press Ltd. UK gave free access to full text for one month for which I am grateful. This opened a new area of vital information. Friends’ living abroad also sent number of important relevant articles, which took time. 

In July 1999 the Mayo Hospital and the College were given autonomy and a new chapter opened up. Role of culture became crucial if autonomy was to work. Autonomy is really democratisation of administration. In a society, which never had democratic tradition to run autonomous institutions it is difficult to grasp the enormity of change. Details of autonomy have been discussed in the book. 

We must clarify that this book is based on research and experience of reorganisation of the Department of Urology at Mayo Hospital over a period of five years. We can draw inferences on other sectors of health care but we have not specifically targeted the health care system in the country. However, our findings are crucial to the wider issues of health planning in Pakistan. I hope future studies will suggest improvements in the health care on a wider canvas.  

This project has been an immense learning experience and hopefully proves the same for others. The findings of this publication are not only relevant to health care workers but also for other fields of human resource development even at the global level. Most important of all we are now convinced that the government services in Pakistan can be radically improved within the present framework. 

Prof. Farakh A Khan

Lahore July 2000