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Aga Khan Hospital: in search of excellence.

In a country where per capita annual income is US$ 370 and where the State spend less than 1% of its GNP on Health2 and Medical facilities, AKH should supposedly a blessing with its state-of-the-art machines and efficiently trained staff. But this is not so as AKH is a private hospital and thus not within the reach of a common man which statistically means 95% of the population of Pakistan. In a country where the majority is deprived of the most basic necessities of life and two square meals a chore, who could afford Rs. 250 per day for a bed in a general ward not to mention Rs. 2500 for a private room.

Pakistan spent .85% of its GNP on Health in 1990-91, .78% in 1989-90 & 92% in 1988-89. These are pathetic figures. Pakistan's Health Budget is a farce even by any so-called Third-World country's expenditure on national health. Somali with its per capita income of US$ 290 spent 2.7% of its GNP on health in 1990, India 1.8%, Sri Lanka 1.9%, in 1990. According to the World Bank Report 1990, the per capita income of Bangladesh was estimated to be about US$ 188 while it was spending 8 per cent of its GNP on health.

Reverting to AKH, the total land area of AKH is 84 acres. The land was supplied by the then Government of Late President Zia-ul-Haq free of cost white US$ 300 million was put into the project by Prince Karim Aga Khan, the founder of the project. So far 654 beds are completed and furnished but only 370 are operational. WHY?; shortage of nursing staff. The enrollment for three years Diploma averages ninety students. There is a dropout rate of 15% in the first year. A further 30% dropout after the completion of the diploma. Mr. Nasir Pirani PR AKH with whom I had the pleasure of talking and who graciously answered some of my queries, says that though there is one year mandatory training period after diploma but beside this there is no contracts to bound the nursing staff to serve AKH. This is a grave situation; 30% dropout after completion of diploma, 15% in the very first year of the course. The disaster is catastrophic.

But as if to prove that striving for excellence is an attitude not to be subdued, AKH has recently started a five-year bachelor program in nursing. But it is a pity that 284 precious beds are lying vacant due to staff shortage.

The break down of 370 operational beds is as follows; 4 VIP Rooms, 61 private rooms, 50-60 semi private rooms (two beds for room), and the rest of the beds are in general ward (five beds to a ward).

The haunting question that whether AKH is within the means of an ordinary person of Karachi, I was firmly assured that it is. The answer went like this, AKH offers two types of charity programs for patients who could ill-afford the cost of treatment at the facility. There is a direct charity. In this program the patient or his relations are directed to the Welfare Department, which after requiring the necessary paperworks from the patient or the relatives and making sure that the case is genuine and information honest pays the AKH from its account so as to keep the account ledgers balance. These patients are billed later on but if that do not have the resources that are not forced to pay, the PR stressed. The second type of charity is charity by subsidy. Mr. Pirani informed me that it costs Rs. 500 per-day to maintain a bed in the general ward but it is provided to the patient at Rs. 225 per-day. This is a deficit of Rs. 275 per-day which is paid from the coffers of AKH. So where does the revenue to keep the AKH financially afloat comes from? Private wing is the money generating organ. It is lucrative. General ward is subsidized and thus a finance drainer. Thus the money transfusion takes place from private wing profits to general wing deficit. When I asked regarding the statistics of these charities the figure of twenty-five million Rupees annually were given for each of these two charities.

From 1985 to 1990 the operational cost of AKH was in the red. It was only in 1991 and 1992 that it has broken even. This is a sign of Organisational and Administrative maturity and should be an occasion of humble jubilation for everyone attached with AKH. Furthermore this breakeven has allowed AKH to purchase new medical machines and equipments.

I fancy myself to be a critical observer of the world around me and feel that I ill-afford not to be objective. It is clamorously eulogized that the Medical Students of AKH spend 20% time of their studies among slums of Karachi, the slums which lack even the most rudimentary human necessity -- not to talk of health facility. It is drummed into our aching ears that by so doing they are performing a great service to suffering humanity. These students are presented as a modern day saints with a halo around their heads. But how many of them return these their learning grounds when they are no more students but real live doctors. Dr. Richard Smith writing in the British Medical Journal of 8.4.89 quotes Jack Bryant, professor of community health sciences AKH, "that the largest needs of Pakistan will be met mainly through community ... health services in poor and remote settings whereas the largest part of the training of the medical students takes place in an elegant setting where technology is supreme." Dr. Smith comments right after quoting Professor Bryant," Will the students, many of them from wealthy families, be willing to work long term in poor communities?" That's an appropriate and vital question that should be addressed by people of authority. Furthermore these students cover fewer than 10 of the 500 katchi abadis of Karachi. It is easy to see that though the students gain from these poverty ridden slums there is no reciprocation or a chance of reciprocation for the indigents of these indigents. Is there any prospect of a for-real positive change in the health uplifting of these masses. Dr. Smith observes, "But a medical school that is rather like Harvard sited in one of the poorest and most densely populated cities in the world inevitably faces difficulties. Will it be able to make a real impact on the health of the poor in Pakistan or will it become a staging post for practice in the West or in the private sector in Karachi?" I stress once again to have an objective frame of mind and let us not be a part of band-wagonistic effect. I also want to make myself perfectly clear that though this article would be aggressively critical but it should in no way be construed as an anti AKH. Something is better than nothing and if the Health welfare situation in our homeland is not to be at par lets work to improve it taking as our human understanding and knowledge as our guide and as well as the point of reference.

Karachi has a long list of in-patient facilities. These facilities vary in their quantity of occupancy, quality of care, presence of ultra-modern machines and laboratories etc. etc. But they all have one thing in common. With a negligible exception they all cater to the pockets and to the maladies of the patients. The health professionals these days are conditioned to behave more like entrepreneurs and less like masihas. I am not negating the fact that like every other professional they should safeguard their interests and their financial well-beings but I am rather against that prevalent attitude which pays no heed to the moral obligations and social conscientiousness of such a humane profession. This should not be the attitude of the creme de la creme of the society. AKH, in order to make any profound difference should stay far out of this maddening crowd by paying attention to the human side of its students and also taking re-enforcements of policies and criterion. Policies that are far-fetched, humane, as well as far reaching and beneficial for the most. I sincerely feel that AKH has the capacity and capability to attain just such noble aims and objectives, not to mean that just such are not the objectives of AKH to start with. This could be a blessed didactic for the rest of the morally deficient health facilities. AKH being the pioneer could pave the way for the humane side, that plus factor, in the health profession of today. The seemingly incurable metastasis could be cured and AKH should be in the vanguard of just such movement.

AKH, being the harbinger of the ultra-modern health facility to Pakistan, certainly have lots of answers in the field of medicine. It has to conduct relevant medical studies and necessary researches in the context of this geographical locale Pakistan. But the right questions should be self-asked before they could be elaborately answered. The old saw be our guiding light, "Prudens quaestio dimidium scientiae -- to know what to ask is already to know half".

AKUMC is not only anti-anachronistic in its health and scientific facilities but also in its rates and fees for the treatment. A bed in general ward costs Rs. 250 per day. There are five beds in general ward with one telephone for the ward and no A/C. A semi-private bed (two beds to a room) costs Rs. 600 per day with a common telephone and A/C. A private bed costs Rs. 1300 per day. This includes A/C, telephone, and television. The VIP room costs Rs. 3000 per day. There is A/C, telephone with remote control television for the patient as well as an ante-room for visitors equipped with television.

The vital statistics for the year 1991 are as follows: [right arrow] A total of 18,825 inpatients were

treated at AKUMC. A total of 7,030

surgeries were performed at AKUMC. [right arrow] A total of 228,265 were dealt-with

through three different kinds of OPD

offered, namely: 1. Emergency 2. Community Health Centre 3. Consulting Clinic.

As far as the budget of AKUMC is concerned even after number of requests, and in spite of promises from the Public Affairs Department assurances, the only statistics given to the writer was the figure of expenses: Rs. 326.28 millions for 1992. When I enquired about the revenue, I was told that I should put it the same as the expenses since the hospital is breaking even. I stressed that detailed breakdown would do this article an utmost good but I was tried to be shrugged off with a hint of indignation. I wish that the statistics pertaining to the budget of AKUMC could have been a part of this article so to give you, dear reader, a clearer picture of the state of financial affairs of AKUMC. But please bear with me the burden of this dissatisfaction.

AKUMC has two ambulances to cater to the need of those in necessity. There is a flat rate of Rs. 200 from any location in the city.
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Author:Aslam, Syed M.
Publication:Economic Review
Date:Aug 1, 1992
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