Before his ordeal, Saleem thought it is better to go a quack for minor ailments instead of standing in a long queue at a government hospital.

Around a year ago, the 38-year-old Saleem would regularly go to a quack in his area with complaints of fever and body ache. However, he soon got a reaction from an injection that the quack gave him, leaving his hand swollen. He ultimately had to get surgery on the hand.

Saleem says the injections gave him immediate relief, so he had started to believe that they were the right treatment for him. However, the episode with his hand brought anguish to his entire family.

He is not the only one to face this problem. Sheikhabad’s Rubina, 48, also went through a similar process after going to a quack.

Burdened with fever, Rubina went to a quack for an easy fix. However, just like Saleem, an injection left her hand swollen and requiring surgery.

Dr Ihtesham Khan, who is a general surgeon and medical officer at at DHQ Abottabad, said that such reactions can happen if injections have wrong contents or are administered from above clothes.

Such injections can cause an infection and lead to development of pus, according to Dr Khan. It can also lead problems in a person’s veins which can require surgeon.

Dr Ameer Taj, president of the Professional Doctors Association, said that the problem stems from not having enough doctors for a high number of patients.

According to Dr Taj, a doctor should be able to set aside 15 to 20 minute to examine each patient. He also said that a duty doctor should not see more than 20 patients in a day.

The US National Centre for Biotechnology Information also says each patient’s examination should last around 20 minutes.

WHO’s recommended dcotor to patient ratio

The latest census says that the total population of Khyber Pakhtunkhwa is 48.5 million people, and Peshawar is the most populous district with 4.7 million people while Torghar is the least populous district with 0.2 million people

According to a document obtained from the Khyber Pakhtunkhwa Health Department, there are 6, 416 doctors and 366 dental surgeons in Khyber Pakhtunkhwa.

World Health Organization (WHO) recommends 1:1000 doctor-patient ratios, but in comparison to available number of doctors and current population of Khyber Pakhtunkhwa, there is 1 doctor or specialist for every 6,024 people. As per WHO’s recommendation, the total number of qualified doctors should be 40,856.

Similarly, WHO suggests 1:4 doctor-nurse ratios, therefore, there should be 1.6 million nurses in KP, however, Health Department data confirms only 3, 885 nurses in the province.

According to the document, there are 742 doctors or specialists in Swat district which is the highest number among all districts of KP. However, Swat still does not meet the WHO ratio because the population of Swat is more 2.6 million which makes 1:3,419 ratio. According to WHO standards, 2, 687 doctors are required in Swat.

In terms of population, Peshawar has the highest population, but according to the document of the health department, there are only 742 doctors or specialists in Peshawar. As per WHO criteria, 4, 758 doctors are needed because the city’s ratio currently stands at has 1:6413.

According to the document, Torghar, Kolai Palas and Lower Kohistan are facing the worst shortage of medical staff as the total number of doctors is only five in Kolai Pals, seven in Lower Kohistan and eight in Tor Ghar while these three districts have no dental surgeon and nurses. As per WHO standards, there should be 200 doctors in Torghar, 340 doctors in Lower Kohistan and 280 doctors in Kolai Palas.

Doctor-patient ratios in other countries

According to the Organization for Economic Cooperation and Development (OECD), Austria and Norway have five doctors for every 1000 patients. France and Great Britain a 3:1000 doctor-patient ratio while Canada, China and Korea have a ratio of 2:1000.

The Ministry of Health in India claims that India achieved the WHO standard in 2018 as there is 1 doctor available for 834 people which are more than the WHO standard, but India has also included AYUSH (Ayurveda, Yoga, Naturopathy, Unani Siddha) in the number of doctors which makes India’s claim controversial.

Why quacks

According to research related on health care seeking behavior by Shaista Naz, an assistant professor of rural development, University of Agriculture in Peshawar, 44% of the population in KP goes to quacks for treatment, while 56% go to qualified doctors.

However, 68% of those seeking treatment from qualified doctors prefer private clinics to avoid standing in queues and express lack of trust in the staff of government hospitals.

Zain ul Abideen, A trainee medical officer at Mardan Medical Complex told Aaj News thatt patients go to quacks instead of professional doctors for four main reasons which include poverty, ignorance, easy access and instant relief.

He said that poverty and inflation are extremely high which means people cannot afford to go to professional doctors. While government hopitals are more affordable, he said, people can miss out ona day’s earnings because of the long waits required. Abideen added that doctors often do not pay attention to patients because they want to get patients to their private clinic.

Doctors can charge between Rs1,000 to Rs3,000 while quacks only ask for Rs200 to Rs500.

He also said that many people are not aware of the dangerous that can result due to treatment by quacks so they keep visiting. He said until they understand the old adage of ‘a little knowledge can be a dangerous thing’, they will keep doing the same thing.

Regarding easy access, he said that access to quacks is very easy because they are always available in the street, while certified doctors have specific days and hours. He also said that professional doctors involve the hassle and expense of additional tests.

Dr. Zain added that the treatment from qualified doctors is long-term unlike quacks who simply administer injections in case of diseases such as pain, fever, cold, cholera. The quacks provide immediate relief, which a qualified doctor never does because it is a dangerous and seriously harmful practice.

‘Even his family was angry with him’

Clinical psychologist Arshi Arbab told Aaj News that the proper attitude of a doctor towards their patient is very important because giving proper time and attention to a patient constitutes half of the treatment.

Consequently, Arbab added, not giving the appropriate amount of attention to a patient can have a psychological effect. The stress of such a situation can cause a patient to start abandoning the treatment. In the case of major depression, may also be inclined towards suicide.

Arbab said that in the same way, dealing with a large number of patients can have negative effects on the mind of doctors. She added that doctors not only treat patients, but also have to deal with their reactions. After facing inappropriate behavior for an extended period of time, doctors can have trouble with their families because because it can lead to anger. The situation can also lead to fatigue which can prevent the doctor from giving time to the family. When the pressure also starts building from family and friends, doctors can also suffer from depression.

She even mentioned a patient he had dealt with who was a doctor. Arbab said that that due to heavy work load there were many changes in the personality of this doctor as he suffered from depression and stress and even friends and family members were angry with him.

What happened to all the medical graduates?

According to a document available on the website of Pakistan Medical and Dental Council, there are 10 public and 11 private medical colleges in KP which award medical degrees to about 2,635 graduates every year, while five public and six private dental colleges graduate 644 dental surgeons.

Data from the Bureau of Immigration and Overseas Employment shows that more and more doctrs are leaving the country every year. According to the data 1,223 doctors have left the country in 2020, 1,691 in 2021, 2,464 in 2022 and 2,000 doctors have left the country so far this year, while a total of 33,343 doctors have left Pakistan since 1971.

A study in the Journal of College of Physicians and Surgeons Pakistan titled ‘Doctors Migration: Perceptions of Pakistani Medical Students’ also found that 53% of medical students want to leave the country because they believe that not only the job opportunities are scarce and salaries extremely low in Pakistan, but the health system is also very weak.

Demand of doctors association

Dr Taj, demanded strict action against quacks and said that qualified doctors are defamed and patients may face very dangerous consequences due to quackery.

“Hardly 500 doctors have been inducted by the Public Service Commission in the last 10 years whereas thousands of students graduate from medical and dental colleges every year,” he said.

“There are no job opportunities for doctors because the government does not have money to pay the salaries of the existing medical staff, so in the last few years, about 15 thousands medical students have gone abroad after graduating”, Dr. Taj lamented.

Health Care Commission’s action against quacks

According to the Khyber Pakhtunkhwa Health Care Commission Act 2015, “Quackery” means any person who is not eligible to be registered or licensed by the Commission or a person or entity who is providing other services contrary to the license.

Under Section 28 of the Act, quackery is an offense punishable with imprisonment for six months or with fine which may extend to a million rupees or with both.

According to the document obtained from the Khyber Pakhtunkhwa Health Care Commission, 6,971 clinics were inspected after receiving complaints during the last one year, in which notices were issued to 1,569 clinics for substandard facilities, while 777 clinics were sealed.

Dr Nadeem Akhtar, Chief Executive Officer Khyber Pakhtunkhwa Health Care Commission, told Aaj News, that the safety of patients is the priority of the Health Care Commission and it is determined to ensure it through the elimination of quacks.

Therefore, not only were awareness campaign conducted across the province, the series of actions against quacks are also going on. However, in order to eradicate this menace and ensure the safety of patients, it is a social responsibility of the people not to get treatment from quacks.

Dr Nadeem stated that quacks are present all over the world and it is not possible to eliminate them, but they can be decreased in number. However, the Health Care Commission does not have enough staff to continue operations, so quacks continue their work after being fined or clinic is sealed.

“Health Care Commission has formed special teams to identify quacks first, who will start work soon after which not only a complete list of quacks will be prepared in the province, but also effective action against them will be possible,” Dr Nadeem determined.

Is the PMDC playing its role?

Muhammad Umair Khan, spokesperson Pakistan Medical and Dental Council (PMDC), said that if any qualified or registered doctor is found to be involved in any illegal work or wrong treatment, the disciplinary committee of PMDC will take disciplinary action against the accused doctor, including fines, license cancellation and even filing a case against the doctor.

In case of license cancellation, the guilty doctor cannot work as a doctor anywhere in the world. “According to the PMDC regulation, the organization can also take notice against the doctor for negligence,” spokesperson confirmed.

Umair Khan mentioned that 22 complaints have been received against doctors from Khyber Pakhtunkhwa since January 1, 2022, of which 2 were acquitted after a full hearing and one doctor was fine 0.5 million rupees with suspension of license for 6 months, while 19 cases are pending.

“PMDC is a very responsible organization which is committed to ensure competent physicians/doctors to treat patients in the country,” Umair Khan stated.

Is the government doing anything?

Dr. Shaukat Ali, Director General Health Services Khyber Pakhtunkhwa, stated that it has been decided to appoint specialist doctors to make Basic Health Units (BHUs) more functional to prevent quackery and improve health facilities while the recruitment of doctors for 6 months on contract basis is being implemented soon to deal with the shortage of doctors, and initially, doctors will be recruited on contract basis for required or vacant posts in each district.

“Citizens should not go to quacks themselves, however, the policy is being worked on for a permanent solution to the problem and as a result of the next general elections, the elected government will be presented with a policy and the recruitment of permanent doctors will be implemented because the caretaker government has no authority to take steps regarding permanent recruitment,” Dr Shaukat Ali ensured.