In the midst of all the national and international turmoil around us, one news item that ‘hit closest to home’ for me was the news from India about 12 women who died in a public hospital because they received tainted intravenous solutions. I can empathise with the physicians in that situation. In the Pakistani public healthcare sector, including the largest public hospital in Lahore, circumstances are not so different. Substandard medicines, tainted intravenous solutions as well as sub-par delivery systems for these medicines are being provided much too often. Worse, there is no proper storage facility where medicines and intravenous solutions can be kept at the recommended temperatures leading to spoilage of even good quality supplies. No, it is not all due to corruption but rather is also the result of bureaucratic apathy, incompetence and lack of adequate funding. On top of this, young physicians working in the public sector hospitals are on strike or at least on a work slowdown demanding higher pay. Frankly healthcare delivery in Punjab as well as other parts of the country is in a mess. Obviously Punjab having more people than the rest of the country does have a much greater burden to carry. But healthcare is not a major priority with the provincial or the federal government. To go over everything that is wrong would take much more space than is available. So I will try and focus on a couple of things. The first issue that must be addressed is whether poor people should be provided with free healthcare. My gut response is that indeed the state must provide free healthcare for all those who cannot pay for it. If once we accept this premise then we can look at the three basic components of such healthcare. First are adequately equipped facilities where such care is provided, second the manpower needed to run these facilities and third, the funding to make all this function. Obviously all three are equally important and cannot be looked at in isolation. But of these the most important is still the manpower needed to run these facilities. There is already on paper at least an entire infrastructure in place starting from the basic health centre all the way up to the tertiary care hospitals. Unfortunately, most of these facilities are inadequately equipped and staffed. Yet there is a recurrent need to build major centres rather than support and improve existing facilities. For instance, over the last five years, two new major cardiac institutes have been started in Multan and Faisalabad instead of expanding cardiac facilities in existing tertiary care teaching hospitals in those cities. As it is there are not enough adequately trained senior specialist physicians to provide fulltime medical care at these new cardiac centres and yet more are being planned. This brings me to the question of manpower. Most existing facilities as well as the newly built ones do not have adequate level of staffing. For instance, the newly built Faisalabad Institute of Cardiology does not have full time cardiac surgeons and therefore surgeons from the Punjab Institute of Cardiology in Lahore drive down for a few days every week to provide surgical care. This is indeed a sad state of affairs. Unfortunately, no ‘body’ within the medical profession or in the healthcare bureaucracy has ever made an objective assessment of medical manpower needs based upon population growth and need for certain types of medical care. We keep on building more medical colleges in the public and the private sectors but make no plans to use the services of all these new doctors in an organised way. No wonder then young doctors are in a state of turmoil and are demanding the easiest thing to ask for, more money. Whether we agree or disagree with the demands of these young doctors for serious pay hikes, certain important facts need to be considered. Most importantly that there are no definite career pathways available to young physicians except leaving the country for the Middle East or the advanced westernised countries. Those who cannot leave enrol in local postgraduate training programmes but then often end up in dead end jobs where they can remain for decades. At the same time, most of them do not move out of teaching hospitals to work in primary and secondary healthcare centres. The primary reasons for this being inadequate work facilities and poor living conditions. It is not just pay scales but rather the entire package that is more important. In my opinion, giving young doctors in training a major increase in pay will give them an incentive to prolong their period in training. They should instead receive an ‘honourable’ pay package but more importantly they must be provided opportunities to work in a proper professional environment with a chance to make a decent ‘living wage’ after they finish their training. And all training programmes should be time limited so that if the trainees do not complete the appropriate qualifying examinations over a predefined time period, they have to leave the positions they occupy and make space for new trainees. As far as the question of adequate funding is concerned I realise that Pakistan is a poor country and nobody pays taxes but money is being spent on healthcare. My contention is that public funds are not being utilised appropriately and are too often being wasted on grandiose projects with little medical benefit to ordinary people. Because Pakistan is a poor country it is all the more important that the limited funds available should be used to provide the proverbial ‘best bang for the buck’. In summary, the problems in medical healthcare delivery in the public sector are due to misplaced priorities, corruption, apathy and bureaucratic inefficiency made worse by a lack of planning and inadequate use of ‘human resources’ including physicians as well as ancillary healthcare providers. The writer has practised and taught medicine in the US. He can be reached at smhmbbs70@yahoo.com