Growing trend of violence perpetrated by patient relatives in health-care settings – why?” – by Hina Hazrat

Growing trend of violence perpetrated by patient relatives in health-care settings – why?” - by Hina Hazrat |

Healthcare system of any country is a critical determinant of nation’s progress, development and economy. Countries with burden of diseases coupled with inappropriate provision of medical needs and health facilities to the citizens seem left behind in queue of development. Therefore, massive attention is given to the stability of healthcare system in developed countries to potentiate quality of life and a progressive milieu. The opposite is observed in Pakistan and in many other developing countries of the world with meagre resources to invest well on healthcare system and on overall health infrastructure. 

Healthcare system comprises all activities that collectively aim to promote, restore or maintain the health of people so that health associated issues can be lessened and thereby maximum efforts can be invested on national development. In the World Health Report 2000, World Health Organization has recommended to spend at least 5% of gross domestic product (GDP) of a country on health. The underlying objective of this recommendation is to achieve national health objectives and to foster process of nation’s growth and development.

Pakistan spends 2.6% of its GDP on health as per WHO 2014 statistics. This clearly depicts the inadequacy of diverse aspects of healthcare system in Pakistan where healthcare needs of the citizens are not efficiently fulfilled and health disparity remains prevalent.


  1. Healthcare System in Pakistan

Pakistan is the sixth most populous country of the world; comprising a population of around 188,925,000 people (WHO, 2015). The health expenditure remains to be lower than 5% of the GDP, which needs to be increased. The rising population and lower expenditure in health sector clearly appear perpendicular to each other. This is propagating health related issues that are rampant across country; which are further worsened by the existing poverty.

In Pakistan, the Ministry of National Health Services, Regulations and Coordination functions for improvement and maintenance of health in country. The federal government engages with budget allocation, whereas budget planning and implementation is done by national, provincial and local governments. Moreover, the healthcare system in Pakistan comprises both, the public and private health facilities which are major divide in the present healthcare system.   

Currently, healthcare system in Pakistan is going through a period of massive turbulences in terms of systemic and structural fragmentation, gender insensitivity, instability, inadequacy of resources, lack of accessibility and inefficient utilization of the resources. This highlights the need for healthcare reform that fills the existing gaps in the healthcare system of Pakistan.


  1. Violence in the Health-Care Settings

Attacks on healthcare workers is a critical issue in existing healthcare system, which brings with itself enormous loss, potentially in terms of harming the people who work to save lives. These inhumane acts further contribute in hampering the treatments of patients by disrupting the decorum of hospitals and triggering the environment of fight and terror around.

According to WHO, report on attacks on health care in emergencies; a total of 338 attacks on health care in emergencies were reported in the year 2014 from 19 countries. Pakistan contributed 8% (n=27) to these total attacks. In the year 2015, a total of 256 attacks from 16 countries were reported. Pakistan contributed 6% (n=16) to these total attacks in healthcare settings in the year 2015. Combining together the figures of the two year 2014 and 2015, Pakistan contributed 7% (n=43) to the total figure of 594 reported attacks on healthcare in emergencies in 19 countries. The alarming reported figure was the 156 (26%) direct attacks on healthcare providers among 594 total attacks.

Prevailing violence in the healthcare settings is due to complex multifactorial reasons. In one way it is representative of fragile healthcare system which is yet to provide patient satisfaction, patient financial protection, quality healthcare service and protection to the healthcare workers. The focus of this essay will remain specifically on the causes of violence committed by patient’s relatives in the healthcare settings.  

  • Violence Committed by Patient’s Relatives in Health-Care Settings

The sentence, “violence committed by patient’s relatives in healthcare settings” clearly depicts the interdependence of patient’s, relatives and healthcare settings on one another. This makes it clear, that violence perpetrated by the patient’s relatives is a dependant factor that comes out as a reaction of dissatisfaction from either the treatment of the patient or the healthcare system. There are also multiple other reasons that directly or indirectly contribute to this notion of violence.

According to World Health Report 2000 (WHO); the objective of health system is not only limited to the provision of healthcare facilities to improve and maintain the health of people, but also it comes under the domain of healthcare system to provide financial protection against cost of illness to the people. Moreover, it is also the responsibility of healthcare system to fulfil the expectations of people from healthcare and also to respond to their needs. Pakistan’s progress in achieving these objectives of a quality healthcare system is stagnant and total far from reality. Therefore, violence and unrest in the healthcare setting is widespread. Dissatisfaction from the healthcare system, financial overburdens, poor healthcare facilities and service; collectively stimulate the milieu of violence extended by patient’s relatives. From the part of healthcare workers; acts of rudeness, delays in treatment, denial to care further exacerbate the prevailing acts of violence by patient’s relatives. Furthermore, acute exposure to inflated bills when no financial protection is provided, makes situation even worse.

With greater health privatization, the attention of healthcare system is shifting more towards financial revenues, and an important aspect of healthcare system, i.e. “patient’s personal care” is being ignored. Hence, the result is growing trend of protests and attacks of dissatisfied patient’s relatives and families on healthcare workers and healthcare facilities. There are diverse reasons present in the country, which have moulded the behaviour and mental health condition of the people by triggering them become aggressive, angry, stressed, depressed and absolutely volatile in controlling their emotions. Existing violence in the country have impacted the mental health condition of people. Moreover, the dynamic turbulences related to poor socioeconomic condition, unstable political situation, poverty, gaps in existing healthcare system, neglected traffic issues which take lives of so many people by delaying ambulance mobility, patients and families’ unreasonable expectations and needs, existing disease burden in country, lack of accessibility to medical needs, gender discrimination in healthcare system, human errors, lack of effective communication, income inequality, fragile and fragmented healthcare system and illiteracy are the potential reasons of perpetuating violence in healthcare settings by patient’s relatives.

We will now delve into specific broad categories, which can be identified as causative agents in shaping people (patient’s relatives in particular) in such a way that phenotype of violence is exhibited;

  1. Declining socioeconomic condition, poverty and illiteracy
  2. Fragmented healthcare system and systemic insufficiency
  3. Neglected aspect of road congestion and traffic jams
  4. Human errors leading to patient’s trust deficit and dissatisfaction
  5. Unreasonable expectations of patients and families
  6. Prevailing violence in country and mental health outcomes
  7. Lack of financial protection


  • Declining socioeconomic condition, poverty and illiteracy

Better socio-economic condition appear parallel to better health outcomes. People in Pakistan face several health associated issues such as, malnutrition, inaccessibility to health facilities, poverty coupled with poor living status. Poor health and lowered health status negatively impacts the economic development of the country. According to Pakistan’s multidimensional poverty index which depends on status of health, education, living standard and income; there exists 9.3% poverty in urban areas and 54.6% in rural areas of Pakistan. As per the results of Pakistan Social and Living Standards Measurement Survey, the literacy rate in 2013-14 was 58%. Falling socioeconomic condition, poverty and illiteracy aggravates the health conditions and contributes to growing disease burden.

According to a research study conducted in 2005 in a government hospital in Karachi, Pakistan, a large proportion of doctors reported to face problems due to patients’ poverty associated inferiority complex; making them feel deprived of quality treatment and service, patient’s non-compliance to follow instructions of doctor and illiteracy and poverty.

Poverty, illiteracy and poor health, result in unstable socioeconomic condition. Stunted economy of the country influences investment in the health sector. Poverty impacts the nutrition, diet and overall stature of health of people. According to Pakistan’s new poverty index, 4 out of 10 people live in multidimensional poverty. All these factors are highly related to medical service inaccessibility, incapability to pay for financial costs of disease treatments, low self-esteem, feeling of deprived medical facilities, and other attributes that trigger violence in healthcare settings by families of patients who feel deprived of fundamental right to health.


  • Fragmented healthcare system and systemic insufficiency

In Pakistan, health sector remains deprived of optimum attention by the government. According to Pakistan Economic Survey 2014-15 report; a collective figure of 1,142 hospitals, 5,499 dispensaries, 5,438 basic health units, 671 maternity and child health centres with only 175,223 doctors, 90,276 nurses and 118,041 hospital beds are available to provide healthcare facilities to a population of around 190 million. This makes it clear that our present healthcare system has resource inadequacy, making people deprived of basic human right to healthcare. 

On one hand Pakistan contributes a lot to disease burden of South Asia. And on the other hand, preventive measures to combat diseases are seem ignored; the healthcare system remains unstructured, fragmented, weak and fragile unable to combat the prevailing number of diseases in country. There is utmost inequality in resource distribution, medical facilities and services provision in the current healthcare system. There exists a huge rural urban divide. The rural areas of Pakistan are deprived of quality health care facilities. Financial expenditures on health sector seem utter regressive in rural Pakistan, and same is seen at provincial and regional levels. Attention on maternal-child healthcare also appear poor.

In the existing healthcare system, there is huge government and private sector health service divide. Hospitals in private sector are expensive, and are beyond reach of masses. Government hospitals are deprived of quality and efficient service, thus are unable to cater the health ailments of high influx of patient’s in the public sector hospitals. Moreover, hospitals in the government sector, are under resourced, crowded with insufficient number of staff and provide inefficient healthcare service. Repetitive usage of syringes and surgical equipment also drives increase in number of infectious diseases in the healthcare settings.

There exists gender divide in the present healthcare system. Girls are reported to be at higher risk of death compared to boys.

All this contributes to patients’ dissatisfaction; reaction of which comes out as protests and violence against the healthcare system from the bereaved families.

According to country statistics and global health estimates by WHO and UN Partners, the top ten causes of death in Pakistan, in the year 2012 were; ischaemic heart disease (8.4%), lower respiratory infections (7.8%), stroke (6.3%), preterm birth complications (5.8%), diarrhoeal diseases (4.8%), chronic obstructive pulmonary disease (4.6%), tuberculosis (4.6%), birth asphyxia and birth trauma (3.9%), neonatal sepsis and infections (3.1%) and diabetes mellitus (3%). Among all stated diseases, ischaemic heart disease stood as the leading cause of death taking lives of 111.4 thousand people in the year 2012. In the year 2013, the confirmed reported cases of malaria were 275 149, whereas the estimated cases were between 1000 000-2100 000.

Pakistan also has high frequency of tuberculosis patients. In the year 2015, a total of 331 809 cases of tuberculosis were reported. Non-communicable diseases such as, cancers, diabetes, cardiovascular diseases and chronic respiratory diseases also contribute to elevating disease burden of country. Amidst all this, it is alarming to see reports of shortage of medicines in country. Sometimes, these medicines are the life-saving ones. Recently, anti-tuberculosis medicines were not found available in market. Lives being at risk because of shortage of medicines, propagate sense of anger among people who feel deprived of basic healthcare facility, hence events like violence are stimulated.   


  • Neglected aspect of road congestion and traffic jams

The term traffic jam, is itself an indicator of negative health crisis in an emergency situation. Traffic jams are found to correlate well with architectural constraints and health emergencies. Keeping our focus only to the association of traffic jams with health emergency; we must understand the negative role played by road congestion coupled with traffic jams in worsening the situation of health emergency. The time when the ambulance has to reach the hospital is spent on standing still in traffic jam; deteriorating the complete purpose of health emergency in such situation.

Awareness of making way for ambulances is indispensable in view of strengthening the falling system of healthcare emergency in traffic jams. It is reported that most haemorrhages result in death because of delay in reaching the medical facility on time, and road congestion and traffic jams are the potential reasons for it. A collaborative project of CityLights Productions and the International Committee of the Red Cross (ICRC) entitled, “Raasta Dou” (In English: Give Space/Make Way) aims to create awareness among masses to make way for the emergency vehicles such as, ambulances during the period of traffic jams.

No one would want to afford to lose life at the cost of traffic jams and road congestions, and if it happens, the reaction may come out as aggression or anger or utter rage. There must be attention given to this aspect, which jeopardizes lives in wink of an eye.


  • Human errors leading to patient’s trust deficit and dissatisfaction

Medical malpractice is an act by the health care provider which alters from standard medical practice. A recent incident of protest to raise voice against botched medical treatment of a 12 year old girl which resulted in loss of arms was reported. In the year 2012, it was reported that over 3000 children were immunized with expired polio vaccines. A total of seven children were reported to have died due to adverse reactions of anti-measles vaccine during the year 2014; 12-day campaign against measles. In the year 2015, protests by parents and relatives were reported against medical negligence that took life of a newborn girl in Rawalpindi. During the same year, it was reported that 35 infuriated protesters took over the hospital facility in Peshawar, after their relative surrendered to his injuries; claiming that it happened due to negligence of hospital staff in providing the medical needs.

Cases of incorrect diagnosis are also reported leading families of the patients’ to greater financial losses. In another incident of protest; the protesters gathered in front of clinic in Faisalabad, entered the building and damaged the furniture; claiming that the 50 year old woman who visited the clinic died of wrong injection. Similar event of protest was reported in the same year, where the family members and the neighbours attacked doctors, damaged the furniture and crashed window glasses; claiming that the patient died of wrong injection. This situation of medical negligence and errors and personal dissatisfaction from the treatment have given rise to patient’s trust deficit on healthcare services.

  • Unreasonable expectations of patients and families

Expectations in terms of healthcare highlights the belief about what is to be experienced in the healthcare system. With advancement in science and technology, the expectations of patients’ and their families from doctors and medical services are increasing proportionally. The families want to save their family members and any mishap in this way brings reactions in the form of anger and attacks by the relatives of the patients towards the medical staff.

Understanding patients’ expectations and managing it accordingly is pivotal in today’s world of hospital healthcare management. The patients’ relatives may consider to use their powers upon dissatisfaction with medical services extended by the hospital. This takes the form of fights, verbal and physical attacks towards the medical staff.

There are two forms of expectations coming from patients and their families. One being the realistic expectations, which are manageable with proper knowledge and related skills. However, the other being unrealistic expectations are tough to manage, but possible. In view of this, it is important to incorporate the learning and training of the medical staff to deal with such behavioural and psychological aspects of patients’ families by counselling and education.

In the multifaceted intervention study conducted by Taylor et al. (2006), an intervention comprising communication workshops for the staff, education film for patient and patient liaison nurse who ensured effective and efficient staff-patient community communication and also played significant role in communication education of staff, led to improvement in patient satisfaction.

There is need of scientific research in the field of maximizing ways and approaches for improving patients’ satisfaction.

The two approaches, namely; patient-centered healthcare and value-based health care can be implemented to reduce and avoid the patients’ and associated families’ reactions towards medical service dissatisfaction. The patient-centered healthcare depicts visualization of healthcare system through the eyes of the patients’. It is an approach that supports the notion of giving due attention to the perspectives of the patients’ which are further mainstreamed in healthcare system. The first and foremost aspect of this approach is giving respect to the values and preferences of the patient. Second aspect is maintenance of complete coordination in patient care. The third aspect is clear communication of information and also patients’ proper education.

Value-based healthcare approach gives attention towards improving the status of healthcare value for patients; the trait that is widely missed in our healthcare system.

The focus from value has shifted towards increasing revenues. Value-based healthcare approach works by highlighting and implementing measures that support the aim of improving value for patients. Secondly, it associates medical practice to medical conditions, and organizes medical practice in alignment to existing medical conditions. Thirdly, it focuses on clear knowledge of results in view of risk associated possible outcomes.

  • Prevailing violence in country and mental health outcomes

In Pakistan, around 50 million people are suffering from mental disorders. Mental health dilemma in country is growing day by day. In context of this essay, emphasis has to be made on the existing situation of the violence in country which contributes to negative mental health outcomes. Constant stress and aggression due to political instability, unrest, and violence do contribute toward elevation of deteriorating mental health situation. Unfortunately, there is lacking of national epidemiological study which can provide consolidated view of the existing mental health issues of Pakistan.

It is not only the violence that has added to the aggravated mental health condition of the country but also, the socioeconomic conditions, inflation and inaccessibility to medical needs; including other social reasons are effective contributors of poor mental health condition. 

The altered behavioural and psychological attributes prone the individual to be more aggressive in reaction toward the medical staff, if the patient’s treatment is considered unsatisfactory. This makes the healthcare workers more vulnerable to attacks by such people, who may harm the worker if the treatment is not marked to be done according to their expectations and they held medical staff responsible for negative outcome of the treatment. The family’s continuous denial of the treatment outcome, and usage of all powers to harm the healthcare staff is in one way reflective of the existing mental health conditions while on the other way it exhibits the intrinsic response of a shock and trauma after hearing a bad news.

There is need to provide apropos counselling to the patients and the families so that improvement in patient satisfaction can be accelerated forward. Also, there is need to provide effective and efficient training for medical staff to meet the current needs in the mental health arena of country.

Anxiety and depressive disorders are correlated with economic burden and these disorders exhibit public health issue in developing countries.

  • Lack of financial protection

Health diseases come with huge financial costs. Protests against the expensive price of life saving drugs in Islamabad were also reported. Amidst prevalent situation of poverty, paying for expensive treatments remains a dream for many. There is need to provide financial protection to the people. Moreover, access to quality health services remains a luxury in Pakistan. People who live in urban areas and those who can afford the expenses of treatments, avail the luxury of healthcare facility.

Lack of financial protection against diseases is a major burden on families who remain devoid of treatment, only because the expense is beyond their reach. Poverty coupled with ill-health further worsens the situation. This plays a critical part in sprouting the concept of inequality or deprivation from basic human right of health. This further comes out as violence and attacks in healthcare setting as a reaction to voice their demand for accessible and affordable healthcare.

  1. Conclusion and Recommendations

Violence in the healthcare setting has not arisen on its own. Several events and circumstances have played part in shaping the violence, attacks and protests perpetrated by patient’s relatives which are reported today. The reasons can be marked as extrinsic and intrinsic factors. Extrinsic factors may include; poverty, illiteracy, lack of financial protection, medical service inaccessibility, fragmented healthcare infrastructure and poor quality treatments. This may also include, the already existing violence in the country that has influenced the mental health condition of the people; triggering them become more stressful, aggressive, volatile with emotions and depressed. Intrinsic factors may include, as reported; unreasonable expectations and sudden unexpected outcomes coupled with a sense of shock, ineffective communication, human errors, and provision of substandard care.

Pakistan has also lagged behind in achieving the health related millennium development goals (MDGs). According to National Health Vision Pakistan 2016 – 2025, provincial governments will increase the expenditure on health to 3% of GDP. This is still lower than WHO recommendation. There is need of sincere efforts to attain accountability, transparency and efficient service delivery system in Pakistan’s healthcare system. Systematic and strategic planning based on scientific evidence is necessary to improve the healthcare system and service delivery. Financial protection in the form of social health insurance, community health insurance and universal coverage must be implemented.

Without working on extrinsic factors, such as declining economy, political instability, illiteracy and poverty, it would be difficult to attain the objectives of healthcare and to meet the healthcare needs of people. Ignorance of this aspect, also leads to violence in healthcare setting.

Future projects should include all stakeholders such as, government and private sector organizations, policy makers, media outlets, and education sector in planning and execution of strategies and campaigns to combat violence. Awareness campaigns for respecting doctors, healthcare workers and laws should be launched. There should be implementation of zero tolerance policy against violence in healthcare. Training of “patient personal care”, which includes clear and effective communication with patients, fulfilment of their needs and expectation, proper counselling of patients and families along with proper knowledge of treatment when necessary, should be given attention. Quality healthcare service should be provided to patients. Provision of security arrangement at workplace must be given attention.

In conclusion, it is important to understand the healthcare need of the people of Pakistan, and in response to it systematic and strategic interventions should be implemented that aim to improve the quality of healthcare and well-being of Pakistan’s population. Violence by the patient’s relatives can be effectively avoided by implementing policies for patient personal care. Ignoring the existing system of fragmented healthcare, declining economy and poverty, violence in the healthcare setting will be further exacerbated.

The author, Hina Hazrat is First Position Holder of ICRC Essay Competition 2016. 


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