Pakistan's healthcare system, brain surgery, and Covid vaccines - a neurosurgeon's view

How Pakistan finances healthcare - and what that means in practice

The episode opens with Muzamil introducing Prof. Dr. Ahsan Aurangzeb, framing him as a guest whose expertise sits at the intersection of clinical medicine and health system administration. Dr. Aurangzeb trained at Ayub Medical College, completed neurosurgical training at the Pakistan Institute of Medical Sciences under Professor Khaliquzzaman, and then received a scholarship from the World Federation of Neurosurgical Societies to study microvascular surgery in Japan before returning to Abbottabad as Professor and Head of Neurosurgery.

The conversation moves quickly to how healthcare is actually paid for in Pakistan. Dr. Aurangzeb describes three coexisting models. The first is the public hospital - institutions like Ayub Medical Complex, Lady Reading Hospital, and Faisalabad Medical Complex - where inpatient services are provided free of cost. “In our hospital, whatever facility we have for inpatients is free of charge,” he explains. The second model is the Sehat Insaf Card, a government insurance scheme that allows patients to choose a doctor and hospital, receive treatment, and have the bill settled directly with the provider. The third is fully private, where the patient pays out of pocket for every consultation, investigation, and procedure.

Dr. Aurangzeb acknowledges the Sehat Insaf Card as a genuine initiative but is measured about its current reach. It has been rolled out across Khyber Pakhtunkhwa, but the infrastructure to absorb that demand does not yet exist at scale. “It is a good initiative, but it is an evolving process - it will take time,” he says. The public understanding of entitlements under the scheme is still limited, and the service delivery side needs development before the policy can fully deliver on its promise.

The case for preventive medicine - and why Pakistan ignores it

Muzamil pushes the conversation toward a structural question: is the system treating the right problems? Dr. Aurangzeb’s answer is unambiguous. The most underfunded and undervalued layer of Pakistan’s health system is preventive medicine, and the consequences show up directly in his operating theatre.

He estimates that roughly 70 percent of his neurosurgical workload is road traffic trauma. On Independence Day and Eid nights, young men on motorcycles without helmets fill the emergency wards. “We treat these all day - eight to ten cases a day, clearly,” he says. If helmet use were made mandatory and enforced, a significant portion of that caseload would not exist. The remaining 30 percent of his work is elective - tumours, spine conditions - which is where the specialty’s full technical capacity can be applied.

The broader point he makes is about disease burden. Typhoid, tuberculosis, waterborne illness - these are conditions that should be intercepted before they reach a hospital. In high-income countries, a typhoid outbreak triggers an immediate public health response: the source is traced, the area is contained, the chain of transmission is broken. In Pakistan, the response is largely curative. TB medications are available free of charge, but the system does not invest proportionately in stopping transmission in the first place. “Prevention is better than cure - this is the most neglected system in this country,” Dr. Aurangzeb says.

He connects this to life expectancy data. Japan and China average around 75 years; the United States and Europe are in the high 70s to mid-80s. Pakistan’s average life expectancy is approximately 60. That gap, he argues, is not random - it reflects decades of underinvestment in public health infrastructure and preventive care.

The doctor shortage and the brain drain

Muzamil raises a question that runs through many conversations about Pakistan’s public sector: why are there not enough doctors where they are needed? Dr. Aurangzeb’s answer is structural rather than moral.

Medical colleges have multiplied rapidly. A single city may now have four colleges, each producing graduates. But the quality of training has not kept pace with the quantity of institutions. The result is a large number of graduates whose clinical preparation is uneven. Regulatory bodies are attempting to address this - there are proposals to standardise licensing examinations and bring all colleges under a unified quality framework - but change at that scale takes time.

The more immediate problem is what happens after training. A doctor completes five years of MBBS, then enters a postgraduate training programme, passes specialist examinations, and finally qualifies as a specialist - only to find that the job market in the public sector cannot absorb them at a salary that reflects their training. “The salary structure is such that it is not worth staying,” Dr. Aurangzeb observes. When an opportunity abroad offers a defined working day, a clear contract, and a salary that matches the years of investment, the decision to leave is rational. “Everyone wants to run - it is human nature to want more money rather than working on a subsistence level.”

He is not dismissive of those who leave. He notes that Pakistani-trained doctors perform exceptionally well internationally precisely because the training environment, for all its resource constraints, demands extraordinary endurance and adaptability. The loss to Pakistan is real, but the cause is a salary and working conditions problem, not a loyalty problem.

Technology in neurosurgery - what has changed and what has not

Later in the discussion, Dr. Aurangzeb reflects on how the technical landscape of neurosurgery has shifted during his career. Minimally invasive surgery has advanced significantly. Endoscopic techniques have reduced the physical burden of procedures. Radiosurgery - using a single high-frequency radiation beam - now allows tumours under a certain size to be treated without opening the skull at all. Advanced CT and MRI imaging has transformed diagnostic precision.

“Technology has definitely changed things,” he says. “From where we were to now - there has been definite progress.”

But he draws a clear line between using technology and developing it. Pakistan is a consumer of medical technology, not a producer. When he was working in Japan, research company representatives would come into the operating theatre, observe procedures, and work alongside surgeons to identify what could be improved in their instruments and techniques. That feedback loop between clinical practice and engineering development does not exist in Pakistan. “We are followers - all the frontier research and development is happening in the US, Japan, China. We follow it, we use the technology, but we are not manufacturing it, we are not developing it.”

He does not frame this as a permanent condition. The raw capability exists - Pakistani professionals working abroad demonstrate that consistently. What is missing is the institutional investment and the incentive structure to direct that capability toward domestic innovation.

The doctor-patient relationship and the culture of non-disclosure

One of the more candid passages in the conversation concerns how Pakistani patients and their families relate to medical information. Muzamil raises the observation that patients often arrive at specialists in advanced stages of illness, having tried local remedies and delayed formal diagnosis. Dr. Aurangzeb confirms this pattern and traces it to a broader cultural reluctance to accept difficult realities.

A patient with a brain tumour, for example, may have had a headache for months. They try home remedies, then visit a local practitioner, and only reach a neurosurgeon when they have developed a neurological deficit - vision loss, one-sided paralysis. By that point, the options are more limited and the outcomes harder to predict.

The disclosure problem compounds this. When a serious diagnosis is made, families often ask the doctor not to tell the patient. “We don’t tell the patient - we tell the uncle,” Dr. Aurangzeb says, describing a pattern he finds ethically untenable. Medically and legally, the patient has the right to know their diagnosis, the proposed procedure, its risks, and its alternatives. Informed consent is not optional. But the social pressure to shield patients from bad news is strong, and doctors who comply with family requests to withhold information are not acting in the patient’s interest.

He connects this to a wider observation: Pakistani society has a low acceptance threshold for difficult realities across many domains. The health consequences are direct - patients who do not know what is wrong with them cannot make informed decisions about their own care.

Covid, the third wave, and the question of vaccines

By the end of the conversation, the discussion turns to the immediate crisis. Recording in May 2021, Dr. Aurangzeb describes a third wave that is actively spreading. Positivity rates in parts of Punjab and KP are reaching 14 percent. Gujranwala has become a significant hotspot. He warns that the results of current transmission patterns will become visible in hospitals within ten to fifteen days, because that is the lag between infection and severe illness.

His message on behaviour is direct: stay home, pray at home during Eid, avoid gatherings. “If we are alive, we can do something. Life first.”

On vaccines, he is equally clear. The virus mutates. A vaccine administered today may need to be repeated - possibly every six months - as new variants emerge. This is not a reason to avoid vaccination; it is a reason to understand that vaccination is an ongoing public health tool rather than a one-time solution. He draws a historical parallel to the 1918 Spanish flu, which killed hundreds of millions globally over several years before the virus eventually attenuated. The trajectory of Covid will follow a similar pattern - gradual mutation toward lower lethality - but that process takes years, and in the meantime, vaccines and transmission reduction remain the primary tools available.

Muzamil closes the conversation by asking Dr. Aurangzeb for a vision of what Pakistan could look like if the system worked as it should. The answer is not utopian. It is focused: a country that knows what it is trying to achieve, concentrates its resources on that goal, and stops dispersing effort in too many directions at once. “Everyone wants to do something, but no one is focused. If we become focused, we can bring change.”