The answer is evident; poor quality of care at home!

Let’s get started from a story published in Deutsche Welle (DW):

"The Afghan doctors diagnosed a tumor and operated right away," said Mohammad Nabi from his bed at a hospital in Delhi, pointing to a scar on his neck. After the operation, friends had advised the 56-year-old from Balkh in northern Afghanistan to seek treatment in India. Doctors at the hospital in Delhi told him that he never had a tumor, instead merely swollen lymph nodes. "I was tricked. Unfortunately, that's common practice in Afghanistan," Nabi said, visibly upset.

The operation apparently took a lot out of him, and he appeared exhausted. But he could surely get help in India, Nabi said.

We have a lot of mishaps in this story.

The first point that comes to mind in this story is the “missed-diagnosis”.  Why the missed-diagnosis? The approach in this case is unacceptable and should have been labeled as malpractice. I do not want to go to address malpractice here and will explain it later on.Instead, I’d explain this misfortune from a clinical point of view.

First, the tumor could have been differentiated clinically based on the signs and symptoms along with basic laboratory investigations. I admit that sometime physicians may not be able to diagnose this kind of case based on clinical history and they might have needed Computed Tomography Scan (CT-Scan).  So, who read the CT-Scan? The CT imagines clearly manifests the shadows that are created by a tumor and a tumor can be differentiated from a plain swelling of the lymph nodes.

Unfortunately, we do not have competitive and qualified radiologist to read CT scan as well as Magnetic Resonance Imaging (MRI) to count on them. We do have very few of practitioners who worked in radiology either in India or Pakistan for a few months. These so called radiologists have not been accredited abroad and they consider themselves as radiologists.

However, despite of not having accredited abroad, they have been enjoying the “specialist” title at home which surfaces widespread misdiagnosisand malpractices in our health care system.

In the above case, if the radiology shadows were still confused, the next ideal step would have been a minimal invasive procedure which is CT guided biopsy. The biopsy could have sent for histopathology analysis. The analysis could have provided with adequate information to doctors whether it is a tumoror any other lesion.

So, the burning question here is why surgical procedure? I don’t think that standard surgical procedures were followed in this case. Let’s agree with the surgeon and suppose that the patient was suffering from a tumor, did he pursue standard procedures after the surgery took place. The answer is NO. He should have been referred a piece of the removed tissue for histopathology and ensured whether this patient needed further evaluation; oncologist opinion, chemotherapy or radiotherapy.

In an ideal scenario, if this patient was managed and evaluated according to medical standard approaches, then, this patient would have suffered from another dilemma. And that would be sub-standard drugs in our country. The import of low quality pharmaceutical is another tragedy here and I will come to that issue later on.

It is vivid how much suffering this patient have had; miss-diagnosis, inappropriate treatment and miss-leading management. All of the these factors contributed to low quality of care and these poor standards subsequently lead hundreds of thousands of our patients to go abroad (India & Pakistan) for seeking care. Almost all of them had been having very frustrating experience not only with Afghan doctors, but also with the overall Afghan health care system.

Why thousands of afghan patients travel to India and Pakistan to seek medical care?

Medical Education System:  Is our medical education and accreditation system is up-to-date? All the readers know the answer to this question, but the real question is that has the government (Ministry of Higher Education & Ministry of Pubic Health) paid a solid attention towards this issue-you cannot find an affirmative answer to this question either.

There are huge inadequacies in physicians’ preparation for practice in the health care system. The health care system is neither focused on patient-centered care nor on quality and safety.  The government still lacks system on how care should be organized, delivered and financed.

The lecturers in our medical schools use 40 years outdated chapters and old translated text books. The do not have access to up-to-date both learning and teaching materials. Their approach towards giving exams is also century old.

The methods of exams persuade medical students to memorize their chapters, regardless of understanding its concepts. I’ll label it as photographic or eidetic memory. The impact of photographic memory in medical school is discouraging and the information and knowledge they get cannot be retained enough. The students only get prepared for the exams and are less likely to contribute to their academic and occupational success.

Another issue that exists in our medical education system is the lack of opportunity of hands-on (both in first and second year as well as during clinical rotations). The students have been kept confined to the theories, and they have very little to observe. The modern-day science requires medical students to get more involved in practical works rather than setting in the class and memorizing chapters. The medical schools of today consider practical development a key focus on their programs. This means that as well as attending lectures in the class, the students will have the opportunity to observe professional healthcare practitioners, and increasingly to start gaining practical experience their selves.

So, there are two core problems in our medical school system; teaching problem and learning problem. First, the lecturers should keep their selves up-to-dated and learn new methods and ways of teaching. The lecturers or the system as a whole should provide further opportunities for hands-on. They should also change the way of giving exams. The exams must evaluate their cognitive skills in critical and analytical thinking, problem solving abilities, creative skills etc.

The second problem is the medical students themselves. In general, our medical students lack medical professionalism; they lack professional knowledge, skills and attitude. The medical students in our country solely rely on what are being presented for them in the class. They lack strategy, compassion, commitment and dedication. As a consequence, they lack the competence. From my personal perspectives, their goal is to merely get grades and pass the exams. The end product (in the form of physician) is pretty obvious; very annoying. That’s one of the foremost reasons why our people do not trust our doctors.

Kankor is not a realistic tool of measurement: I’m not going to address “Kankor” in full length, because it covers multi-disciplinary departments and it is not limited to medical schools only. Instead, I’ll only pose a few questions for consideration.

I am constantly reminded that not everyone believes that there is a problem. Some of our countrymen think that we are getting the right students into medical schools and I’m totally disputatious with this belief. So, if we are getting the right students into medical schools, why is the end product so frustrating? Why our people do not trust our doctors? Why are they heading towards India and Pakistan for seeking care? Why do we put so much import on the Kankor? And why we (in my opinion) need to de-emphasize the Kankor as a criterion for entry into medical schools.

Graduate Medical Education-GME (Specialization): The syllabus used in the institutions of Afghanistan is extremely old. On one hand, the curriculum for graduate medical education (specialization) is not up-to-dateand on the other hand it is confined to very few core competencies such as medicine, surgery, ENT, psychiatry etc. Other core competencies such as neurosurgery, neurology, oncology, radiology, cardiac surgery are not covered.

The current curriculum is not designed to teach trainees the knowledge and skills to function as competent physicians. The GME curriculum needs fundamental change. The government should consider what should be removed from the GME curriculum, as well as what should be added, to ensure that the curriculum meets the demand of our health care system. Standardized teaching as well as learning materials for GME should be created for all the core competency areas.

The teaching materials as well as teaching methodology in specialization is out of date. The lecturers (faculties) throughout our medical education system (medical schools & specialty) are not well prepared to teach new contents, and employ new methods of teaching and evaluation.

As mentioned above, when a physician completes his/her specialization, he is left alone. There is no mechanism in place to have his continued competency assessed. In this region (India & Pakistan), the medial education grew by accretion during the 20th century. Specialty training after medical school was added to recognize the need for advanced training in a particular specialty field. In response, continuing medical education (CME) was emerged.

But, here in our country when a physician get graduated from medical school, then he is a doctor forever and he does neither needed nor expected to get any further official trainings. The same concept is applied for our (partial) specialists; when they complete their GME, they do not go for any further training. The medical field is constantly getting evolved and there is and will be constant need for CME. There is a need to develop flexible mechanism to allow physicians to assess their competency in a regular manner.

Another drawback of our system is that the medical schools are under MOHE. On the other hand, the GME is in MOPH’s land. Thus, each phase of education, in general, functions in relative isolation from the others. The coordination among accreditation, certification and licensing bodies (MOE, MOHE, MOPH) must be enhanced it should be made sure that all the three ministries are on the same sheet of music.

The government, particularly MOHE and MOPH must consider launching the initiatives to transform medical education. By doing so, MOPH along with MOHE should be remained focused on promoting excellence in patient care by implementing reforms in the medical education as well as training system across the continuum, from premedical preparation (Kankor in our context) and medical school admission through continuing physician professional development. The results of changes in the system of medical education should not be politically-biased, and should merely be evaluated for their feasibility and utility, as well as for learning outcomes.

Launching initiatives and brining reforms cannot be happened over night and a phase-wise plan should be adopted. For example, in the first phase existing strengths, gaps and opportunities for the improvement in physician preparation should be identified. Subsequently, with the involvement of appropriate collaborators, specific changes should be selected for implementation. A true reform of medical education in Afghanistan requires a comprehensive rethinking of the education system, which must be consisted of considering the system drawbacks and pitfalls mentioned above.

In conclusion, both the process and product of the Afghan medical education system has been remained a major concern. The health care system must be changed dramatically and a master plan is critical to be developed in order to bring enormous changes in physicians’ education and trainings.

So, due to lack of competency both in medical doctors and specialist, people who can afford prefer to seek care either in Pakistan or India.

Pharmaceutical Sector: One more key shortcoming in our health care system is the sub-standard pharmaceuticals. Afghanistan remains highly vulnerable to the emergence of substandard and poor quality drugs.  Indeed, it is a multi-million underground business in the country. Our media has surfaced the issues of land mafia and narcotics mafia, but has not unveiled pharmaceutical mafia so far. We do have this kind of mafia in our country and it is pretty obvious for those who are involved in Afghan health care system. 

Despite of having different quality assurance measures in terms of policies, strategies and regulatory functions developed by MOPH, the problem, still, prominently persists. The reason behind this is that all the policy documents have been printed on papers and kept confined to ministry’s shelves.

The policy documents show the commitment of MOPH to ensure that all pharmaceuticals in the country should be effective, safe, of good quality and cost effective. The system has also been put in place which shall ensure that all medicines are screened for quality.

However, the system for screening drugs quality is also a huge business for parties involved. It is estimated that the annual market for is around hundreds of millions of dollars. With all the imported drugs, MOPH provide our nation with a false sense of security. Many products, especially in the private sector, come from questionable sources, often from countries with poor reputations in pharmaceutical production.

Many surveys and assessments digs out many core pitfalls in regulation and control of medicines in our country. These surveys and assessments explore the weak capacity for pharmaceutical regulation and control, but avoid speaking out about substantial corruption in the pharmaceutical sector.

There is no Good Manufacturing Practice (GMP) guidelines and not system for Pharmacovigilance. Standard Operating Procedures for licensing of practitioners is also lacking. But, lacking the aforementioned documents does not seem to be a major concern, because the implementation of already developed documents have been remained a concern.

To make the long story short, many surveys and assessments have been conducted in pharmaceutical sectors, hundreds of gaps were identified, and thousands of recommendations were made to MOPH and the General Directorate of Pharmaceutical Sector, but who cares? Indeed, nobody in our government cares what has been going on in this notorious sector.

Consequently, if a physician who manages and evaluates a patient according to medical standards, he prescribes medicines. Then, the patient should struggle to obtain the medicines with high quality. The result is again thwarting, because the risks of substandard and counterfeit drugs outweigh the advantages and as a result, he or she should heads up toward Pakistan or India.

To wrap it up, the availability of counterfeit or substandard drugs increases morbidity and mortalitylessens the confidence of Afghans in their own health system which consequently leads to substantial economic loss.

The existence of medicines of unacceptable quality was a massive problem before, it remains profound concern in the present, and if left alone, as it is, will still be an immense problem in the future as well.

While addressing the pharmaceutical sector in Afghanistan, I won’t recommend any remedy. Because, the problems have been recognized by all stakeholders, countless recommendations are available in the shelves of MOPH, but no actions. The MOPH has been demonstrating its irresponsibility and incapability when it comes to pharmaceutical. It’s time for action. I’d like to request our government to pay concrete attention towards this acute issue and push the authorities for solid actions with tangible outcomes. If I am asked to explain the pharmaceutical sector in one sentence, I’d say “It is a bleeding wound in the sector”.

Medical Ethics (Physician Professionalism): Our patients step in our health care doors for help with their most pressing needs-relief from pain and suffering, but what they experience over there is extremely disappointed. Our providers have constantly been breeching the Declaration on the Rights of the Patient.

The doctors and all health care providers are expected to adopt highest possible medical professionalism and standards of ethical behavior; compassion, competence, commitment and dedication.  Patients in our country are legitimately disappointed because they have a deep-seated disdain for health care professionals in the sector. The arrogance, condescendence and extreme impoliteness of our health care providers turns our patient off about the provision of health services in the country.

The health care professionals have chosen paths that are inherently filled with stress, deadlines, and treading in deep emotional waters. None of that grants them a free pass to behave like spoiled toddles.

When it comes to moral and ethics, our health care providers are not allowed to be impolite, mean, nasty or snippy, but they do it in many circumstances. This disruptive behavior ultimately affects patient care and patient satisfaction.

In our health care setting,  insults, profanity, or yelling on a patient have been widely observed by almost all of our patients seeking care.There are other disruptive behaviors-such as doctors refusing to cooperate with other health care providers or failing to follow globally accepted protocols which are subtle and even more damaging.

However, more interestingly, MOPH has not established policies to prevent such behavior by health care providers yet. Our health care system critically needs to formulate medical ethics standards, to improve the organizational culture and as a result to address disruptive behavior before it affects patient care.

The existence of disruptive behavior by our health care providers contradicts International Code of Medical Ethics and Declaration of Geneva and many other declarations. The physician-patient relationship is of vital importance in medical practice and therefore of medical ethics. The Declaration of Geneva requires of the physician that “The health of my patient will be my first consideration” and the International Code of Medical Ethics states, “A physician shall owe his/her patients complete loyalty and all the scientific resource available to him/her.”

It is globally accepted fact that all human being deserve respect and equal treatment. So, the question is that are Afghan patients not human beings and they do not deserve to be respected by our health care providers? In our health care setting, disrespectful and unequal treatment of individuals is widespread and is accepted as normal and natural. In order to have patient satisfaction in our own health system and build the confidence of our people upon our system, this behavior should immediately be stopped. 

Discrimination is also ubiquitous in our system. Women and poorer are the most frequent victims of discrimination in our health care system. Women and poorer experience lack of respect and unequal treatment in the district, provincial, regional and national hospitals of our country. “Health for All Afghans” is the slogan of MOPH. However, there is considerable and substantial resistance in the sector to the claim that all people should be treated as equals.

Once again, it contradicts the Universal Declaration of Human Rights (1948). Our health care providers can easily practice discrimination without being held accountable. They also enjoy the impunity to justify their decision to themselves, to the patient and to a third party. They lack compassion which is based on respect for the patient’s dignity and values. If our health care workers possess compassion, our patients will definitely sense their compassion, they will be more likely to trust the system and will be less likely to seek care abroad.

Not only policy, rules and guidelines formulation on the code of medical ethic is required, but the implementation of such policy is also crucial. After development of such documents, it is the responsibility of MOPH to ensure that all health care workers adhere to these rules and guidelines.

Malpractice:A large number of our patient seeking care suffers injuries, physicians violate the applicable standard of care, and our physicians do not owe a duty of care. Negligence in medical practices in our country is a day-to-day business. To name a few, inappropriate prescriptions, errors, mistakes and even blunders during surgeries and miss-diagnosis are common examples, and the government turns a blind eye to the problem.

Considering our current framework, I do not recommend that patient’s claims for malpractice should be entertained. To my understanding, there is one insurance corporation in the country which provides medical malpractice insurance for medical professionals. However, it seems unrealistic to do so in the current context. Thus, MOPH should have at least a mechanism to hold a physician accountable for negligence of professionalism. It will reduce the risk of malpractice and in long run it will build trust of patients on their health system.

Medical Equipment:To the best of my knowledge, we have only one MRI in public sector and two of them are available in private sector. Around six CT-Scans are available with only one in public sector. Other medical devices such as PET Scan, Nuclear Medicine, Mammography, Linear accelerator and Telecobalt unit are available neither in public nor in private sectors.

Our health system is not specialized in advanced technologies including CT Scanners, MRI, PET-CT Scanners, C-Arms (flat detector & image intensifier), Mammography (analog, digital & computed), Portable X-Ray, Bone Densitometers, Radiographic Rooms, and Ultrasound systems. Our system also cannot cope with emergency care and resuscitation.

The system lacks automated external defibrillators, advance life support products, heartstartd AED services, supplies and accessories. Fluoroscopies (both interventional and diagnostic) are not available. The concept of Interventional vascular, neurosurgery and cardiac surgeries is millions miles away. These are the ground realities while addressing our tertiary care system.

On the other hand, all the above-mentioned advanced technologies are available in India and Pakistan and that’s one of the legitimate reasons why our patients go abroad to seek medical care. We hear many excuses from MOPH through print and electronic Media, but the question running in our minds is that, with influx of billions of dollars during the past one decade, why our government was not able to establish at least one institute that could have had all those technologies and services? This is apparently one of the irritating questions that’ll remain unanswered.

In addition, there is neither list of recommended medical devices nor nomenclature system for tertiary care prepared by MOPH. It seems they are not committed to provide the equipment in the public setting and it is not in a position to regulate private sector as well.