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June 1995, Volume 45, Issue 6


Counselling: The Big Gap in Disease Management in Pakistan

Tasleem Akhtar  ( Pakistan Medical Research Council, Islamabad. )

The concept of health promotion rather than illness treatment is well stated by Ian Kennedy, “If we were to start all over again to design a model for modern medicine, most of us, I am sure, would opt for a design which concerned itself far more with the preservation of health, or wellbeing”1. The traditional curative services “  a system of medicine which reacts, responds, which waits to pick up the broken pieces - a form of medicine, in short, concerned with illness, not health”1, are no longer considered adequate for meeting the health needs of populations and communities. The World Health Organization (WHO) defines health as, “a state of complete physical, mental and social wellbeing and not merely the absence of disease”. Health care, therefore, requires inputs from all especially, the individuals and communities themselves for “health is too important a subject to be left to the doctors alone” (anonymous). Without community participation, health care programmes are unable to meet their goals and objectives.
Extensive health education is advocated using all available and effective tools and techniques to enable the populationto more effectively play its role inhealth promotion and disease prevention. In developing countries with low literacy levels Person to person counselling has been found effective, Health care providers have, therefore, a key role to play since owing to their frequent contacts with members of the community especially at times when they are most receptive to advice regarding health promotion, they have a better chance of positively influencing their health related behaviour.
Are the physicians in Pakistan aware of this important role and are they making any attempt to counsel their patients and their relatives? Not much information is available on the subject. In Peshawar, we recently undertook two case manage­ment studies; one, on the management of diarrhoea in children by general practitioners and the other, on the management of acute respiratory infections (ART) in government health care facilities of Peshawar Division2,3. Diarrhoea and ARI are leading causes of infant mortality and morbidity in Pakistan and prevention of further episodes is a basic component of their case management4,5. The key counselling points for the prevention of further episodes of these conditions, infact most childhood diseases, are to explain to the parents the causes of the disease, how to prevent them and improvement of nutrition and immunization. Our studies show that the emphasis of the current case management practices is on drug prescribing and no attempt is made by any category of health care practitioners to educate the parents and caretakers of the suffering children.
In the diarrhoea study the causes of diarrhoea were discussed with less than 10% of the parents, weight was recorded in only about 40% of the children and none was given advice regarding feeding and immunization of the child. In the ART study again, only 18.9% were explained what was wrong with the child, weight recording was done in only 1.2% and counselling on feeding was given to less than 12%. Even to the latter, the advice which was given was in fact mostly (84%) on restriction of sour, oily and cold foods.
Although our studies are limited to one area of the country, there is no reason to believe that health care workers in rest of the country are practicing any differently. Excessive drug prescribing for the diarrhoea and other common child­hood illnesses has been reported from Karachi and Lahore also6,7. The over prescribing and misuse of drugs in case management indicates a disregard for or lack of awareness among health workers regarding the currently recommended management of diarrhoea and ARI. In our ART study, over 90% of the practitioners were unfamiliar with the WHO recommendations for the management of ART. This despite the implementation of a National ARI Control Programme which is promoting the WHO recommended case manage­ment through country-wide training of health care workers for the last four years. The recently concluded Child Survival Project was also concentrating on training health care practi­tioners in effective case management of acute diarrhoea in children since the mid-eighties. The limited success of these programmes needs careful evaluation and discussion and effective strategies need to be evolved to increase community participation in health promotion and disease prevention. Communication between health care workers and the commu­nity must be improved and both the practitioners and the community have to be made aware of the fact that there is much morn to disease management than the writing of a prescription for drugs for “encouraging the poor to go on buying drugs without doing anything to stop disease from recurring is expensive, wasteful and ultimately doomed to failure” 8.


1. Kennedy. 1. Quoted by Black, D. The NHS: A business or service? Threatened values. Proc. R. Coil Edin, 1994;24:9.
2. Akhtar, T. and Akhtar, M. General practitioners management of diarrhoea in children in Peshawar. Report of a study by PMRC Research Centre, Peshawar, Khyber Medical College, 1993, PP. 1-20.
3. Akhtar, T. and Ahmed, N. Management of ARI in Government health care facilities ofPeshawar Division, Report of a study sponsored by ADDR Pakistan Project and UNICEF, Islamabad, 1993, p. 11.
4. Prevention ofdiarrhoea. World health organization programme forthe control of diarrhoeal diseases. revised 1987, pp. 1-71.
5. Management oftheyoung child with an acute respiratoly infection. Federal ARI cell, Minisuy of health, Government ofPakistan in collaboration with UNICEF and WHO, Pakistan. 1992, pp. 1-119.
6. Ahmed, S. R. and Bhutta, Z. A. A survey ofpediatric prescribing and dispensing in Karachi. A report ofhealth action international and department ofpediatrics, Karachi, The Aga Khan University, 1990, p.4.
7. Mubashir, M., Chaudhary, A. J. and Mubashir, H. Current practices and thc factors affecting the management of acute watery diarrhoea in children below 5 years of age by general physicians in Lahore. Report of a study sponsored by Harvard University, USAID, 1993, pp. 1-7.
8. Melrose, D./Bitter Pills. Medicines and the third world poor. Oxfam, Public affairs unit, 1982, pp. 13-14.

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