Objective: To assess the problem of unlicensed practitioners and quacks in Sindh, Pakistan.
Methods: A cross-sectional study was conducted in 29 districts of Sindh province in Pakistan from December 2019 to January 2020. Initial data available with Sindh Health Department about locations where quacks were practicing was used to identify unlicensed practitioners. A structured questionnaire was developed which contained information about certification of practitioners and an observational checklist was developed to assess infection prevention and control practices (IPC) and injection safety.
Results: A total of 4315 private practitioners were inspected out of which 3022 (70%) were unlicensed health practitioners belonging to different categories. Within the six surveyed divisions of Sindh, the highest proportion of unlicensed practitioners were documented in Shaheed Benazirabad division (n=739; 24.5%) followed by Hyderabad (n=599; 19.8%). In Mirpur Khas, there were 510 (16.9%), in Karachi 310 (10.3%), in Sukkur 484 (16%) and in Larkana there were 380 (12.6%) unlicensed practitioners. Poor IPC was observed in 89.4% (3861/4315) of all health providers. Reuse of syringes and intravenous drip sets was observed among 78.7% (1916/2432) of the untrained providers across the province. It was also found that 155 MBBS doctors had given their names on rent to be used as a signboard outside the clinics of some of the unlicensed practitioners.
Conclusion: The problem of quackery is widespread in the Sindh province. It can be proactively addressed by shutting down all unlicensed practitioners and educating the community to avoid visiting them in order to reduce the probability of exposure to unsafe healthcare practices.
Keywords: HIV outbreak, Quackery, Pakistan, Unlicensed practitioners. (JPMA 71: S-22 [Suppl. 4]; 2021)
According to a World Health Organization (WHO) and World Bank report essential health service is out of the reach of half of world's population.1 The report mentions that every year, large number of households end up spending out-of-pocket on healthcare and are pushed further towards poverty, highlighting widespread gaps in availability of healthcare services in Sub-Saharan Africa and South Asia.1 A WHO guidance document on quality of care places emphasis on six dimensions as the main tenets of quality of healthcare. Quality of care should be: i) effective, ii) efficient, iii) accessible, iv) patient-centred, v) equitable, and v) safe.2 Whitehead et al talk about medical poverty trap related to fees for public services and the expansion of out-of-pocket expenses for private health services. The authors conclude that the main challenge in developing countries is to improve public health services and empower the poorest sections of society to get the healthcare they need.3 World Bank reported that 66.7% of domestic health expenditure in Pakistan had gone to the private sector in 2017.4 Anecdotal reports estimate that there are 600,000 untrained healthcare providers or quacks practicing as private healthcare providers in Pakistan. These quacks are providing healthcare services in rural and urban areas posing as physicians and charge a fee from the patient for the services they render.5 Another report estimates that there are close to 70-80,000 quacks in Punjab which is the most densely populated province of the country.6 There is limited scientific literature available on quackery in Pakistan. Media reports and authors' own field experience has shown that there are a number of reasons for the rapid rise of quacks. Foremost among them is lack of education and awareness in the communities to distinguish between a trained and an untrained provider. For example, exit interviews of patients coming out of a health facility in rural Sindh had highlighted that the qualification of the healthcare provider mattered to only 35% of respondents and proximity of the health facility was reported as a factor by 38% patients suggesting that more than half of the patients were not aware whether the healthcare provider they had visited was a trained one or not.7 Other factors include closure of government health facilities in the afternoon leaving no choice to the patients but to visit whoever is available in the vicinity even if she/he is an untrained healthcare provider.8
Sindh Healthcare Commission was formed in 2013 with the vision to regulate healthcare service delivery in Sindh province and to ensure quality of healthcare services. Its mission is to make provision for the improvement, access, equity, and quality of healthcare service, to ban quackery in all its forms and manifestations and to provide for ancillary matters.9 The Directorate of Anti Quackery within the Sindh Healthcare Commission is responsible to regulate quackery in the province.9
The Sindh province experienced an unprecedented paediatric HIV outbreak in April 2019. A large number of persons, mostly children, were infected with HIV in the rural town of Ratodero in Larkana district. The preliminary investigations had linked the outbreak to unsafe healthcare practices of trained and untrained healthcare providers practicing in the area as private practitioners.10,11 The Health Department of Sindh government instructed Sindh Healthcare Commission to conduct this study in response to the HIV outbreak to assess the problem of quacks in 29 districts of Sindh province and take steps in collaboration with other regulatory bodies to curtail the practice of quackery.
A cross-sectional study was conducted in 29 districts of Sindh province of Pakistan from December 2019 to January 2020. For administrative purpose and engagement of Divisional Inspection and Enforcement Teams, the 29 districts were divided into six divisions which included 1) Karachi; 2) Hyderabad; 3) Mirpurkhas; 4) Sukkur; 5) Shaheed Benazirabad (formerly Nawabshah); and 6) Larkana.
Data available with Sindh Health Department about locations where quacks were practicing was used to identify practitioners and their detail was included in the inspection list.
The Directorate of Anti Quackery informed other regulatory authorities to take actions against those practicing without a valid medical license or a medical degree.
A structured questionnaire was developed which contained information about:
- Certification of practitioners;
- Observational checklist to assess infection prevention and control practices (IPC), injection safety and healthcare waste management.
The categories of persons/places that was obtained from available data suggesting that they were working as practitioners included:
- Non-qualified persons;
- Lady Health Visitors;
- Homeopathic practitioners;
- Medical stores providing injections and intravenous drips using a doctor's name; and,
- Laboratories prescribing medicines using a doctor's name.
The inspection teams documented the observations using the checklist which was prepared for data collection.
A total of 4315 healthcare providers working as private practitioners were inspected out of which 3022 (70%) were unlicensed practitioners working as doctors prescribing medicines, injections and intravenous (IV) drips.
The highest proportion of unlicensed practitioners was found in Shaheed Benazirabad (old name Nawabshah) division (n=739; 24.5%) followed by Hyderabad division (n=599; 19.8%). In Mirpur Khas, a total of 510 (16.9%), in Karachi 310 (10.3%), in Sukkur 484 (16%) and in Larkana 380 (12.6%) unlicensed practitioners were found. Table-1 details the number and types of establishments which were sealed.
The 3022 unlicensed practitioners included untrained and unlicensed persons, lady health visitors, and homeopaths, and medical stores providing injections and IV drips and laboratories prescribing medicines using a doctor's name. The details are provided in Table-1.
Of the 3022, the larger proportion (n=2432; 80.5%) were persons with no medical background or training but were practicing as a medical practitioner, prescribing medicines, injections and IV drips and charging money from the patients.
During the exercise it was also found that 155 MBBS doctors had rented their signboard to non-qualified practitioners who were practicing and prescribing medicines, injections and drips for a charge. Poor IPC was observed in 89.4% (3861/4315) of the health providers.
The study highlighted that quackery is quite widespread in Sindh and to the best of the knowledge of authors this was the first time such regulatory steps were taken at a large scale to seal and shut down practices of many unlicensed practitioners in the province. More than 50% of the surveyed health practitioners were unlicensed and practicing as doctors which is an astounding number. Poor IPC practices were apparent in the large majority of the healthcare providers (89.4%). The study provided a snapshot of the problem that is not restricted to just one province, but is a serious healthcare delivery issue of the whole country.
Khan et al have cited certain contributing factors of public proneness towards quacks in Sindh. These factors include lack of licensed practitioners in the community, sensational and exaggerated claims of quacks to cure the illness, building strong relationship with the patient and the community, and providing immediate symptomatic relief.12 There are multiple other reasons that these unlicensed practitioners or quacks have had a mushroom growth in the past two or three decades. The government's primary health centres are often located far and away from the reach of many rural communities. In addition, they close around 2:00 pm which makes it almost impossible for working persons, even mothers tending to household and kitchen chores to leave everything and visit these centres. On the other hand, the unlicensed private practitioners establish their health facility within a community or village and have flexible working hours which suits the patients and communities. Because of poor literacy and lack of knowledge, patients accept and never question what is prescribed to them. Field experiences have indicated that with passage of time, the clientele of some of the unlicensed practitioners actually increase to many folds compared to a licensed physician.
The problem of quackery is not just restricted to Pakistan, but has been documented in neighbouring countries also. In India, especially in the dental care sector, quackery is quite common and because of inadequate numbers and prohibitive paying power of patients to trained and licensed dental practitioners, patients resort to reaching out to untrained dental practitioners and become prey to their unqualified practices.13
To achieve 2030 Agenda for Sustainable Development, health is central as it relates to many of the Sustainable Development Goals (SDG) and is the specific focus of Goal 3 (ensure healthy lives and promote well-being for all at all ages). Universal health coverage means that all individuals and communities receive the health services they need — including promotive, protective, preventive, curative, rehabilitative and palliative — of sufficient quality, without experiencing financial hardship.14
The study had certain limitation as it did not capture a representative sample. However, a large number of health facilities and providers were included but the authors believe that there may still be many unlicensed healthcare providers who may have been missed. The authors also think that during the visits some poor healthcare practices were observed and it is possible that a sizeable percentage may have been missed.
Out-sourcing of primary healthcare facilities in Sindh has resulted in significantly improved certain aspects quality and responsiveness of primary healthcare services. A small scale study published in 2014 assessed the quality of healthcare services at the contracted Basic Health Units (BHUs) with the Peoples Primary Healthcare Initiative (PPHI) and compared it with those managed by the local district government in the province of Sindh. The findings showed that there was a significant difference between the PPHI and the district government administered BHUs with regard to infrastructure, availability of essential medicines, basic medical appliances, mini-laboratory facilities and vehicles for referrals. These BHUs were found to have sufficient number of trained clinical staff and no punctuality and retention issues whatsoever. The district government administered BHUs presented a dismal picture in all the aspects.15
It is recommended to proactively address the problem of quackery by shutting down all unlicensed practitioners and reduce the demand of their services in the community by effective communication strategies. This will help in improving unsafe injection and infection control practices and healthcare waste management.
Conflicts of Interest: None.
Funding Disclosure: None.
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