Opinion

The SIUT – a New Health Model for Pakistan
By Zubeida Mustafa
Karachi, Pakistan

Many describe Pakistan as a failed state. It is said to be dysfunctional where nothing works. One may not argue with that but there are exceptions. Step into the neat six-storey building of the Sindh Institute of Urology and Transplantation (SIUT) and you will discover a world bustling with activity. The SIUT is like a Utopian island in an ocean of inertia and lassitude that is Pakistan.

The SIUT can be nothing else given the large number of patients (700,000 in 2011) who come here in search of relief from pain. They get what they come for, that is, the state-of-the-art treatment from a highly trained team of health professionals. They are grateful for it for in addition they also receive compassion, empathy and dignity – fast vanishing qualities in the world of medicine globally.

That is not all. The real miracle of the SIUT is that all the care and treatment it provides its patients, many of whom are critically ill with kidney diseases, is free of charge with no questions asked. No patient is asked to pay a penny for any service, diagnostic, therapeutic or curative, and no one has to prove his poverty to qualify for treatment to this hospital that can only be described as an aberration -- a wonder -- in the modern world of capitalism. A look at the data released by the hospital is mindboggling.

Parameters	1998	2011
No. of patients	136,000	842,000
Outpatients	49,033	202,456
Inpatients	5378	33,743
Emergency	13,451	107,292
Minor & Major surgical procedures	17,881	66,040
Lithotripsy sessions	2508	4249
Dialysis sessions	42,470	187,284
Transplants	99	356
Radiology tests	15,416	203,216
Laboratory Investigations	500,000	6,086,547
Medical expenditure	$1.4 million	$ 10 million
Total staff	634	1396

Be sure that these people are all indigent. The question that immediately comes to mind is: how does the SIUT manage when others can’t. Given the breakdown of the government’s role in the social sectors a new trend is for philanthropists to open schools and hospitals for the not so wealthy. But not a single one of such health facilities now operating in the country can match the SIUT in the numbers it reaches out to and the quality of services it provides at no charge.

To understand the SIUT you have to understand its philosophy, which makes it so distinct from others. For that you have to meet its founder and driving spirit, Dr Adibul Hasan Rizvi, under whose stewardship this hospital has grown from an eight-bed urology unit of the Civil Hospital Karachi in 1972 to emerge as the most modern and efficient 400-bed hospital in the public sector in the country that caters to the needs of the masses.

Dr Rizvi is a man who is widely recognized as the best urologist in Pakistan. In spite of his fame he still remembers the Hippocratic Oath he took when he passed his MBBS from the Dow Medical College, Karachi fifty years ago. His forte is his surgical skills that he has honed over the years with frequent training abroad and research at home. His second equally important asset is his strong sense of ethics and humanism that he imbibed from his family in early childhood. He has not outgrown them either.

The product of these social processes is a simple unassuming and self-effacing man with a sharp intelligence which enables him to diagnose his patient’s illness accurately and then use his deft fingers to handle the most intricate piece of surgery neatly.

From the start Rizvi had a dream that envisioned a society free of oppression and exploitation. In such an environment it was inconceivable for him to employ his skills and knowledge for commercialization of health care. He viewed health care as a birthright of every citizen that must be provided by the state with justice and dignity. He believes that no one should be allowed to die simply because he cannot afford to pay the cost of treatment. Rizvi has refused to stoop low to exploit the helplessness and desperation of an ill person.

Hence the need for a model which is what SIUT is all about. Its growth has been need-based. In the early years the most common complains that brought patients to this ward were renal stones and prostate enlargement. Stones and infections were causes of kidney failure. That opened the door to dialysis to provide relief to the patients. But dialysis was not the perfect solution and in came transplantation in 1985. To get at the root of kidney failure a lithotripter was acquired to destroy stones through a non-invasive procedure.

The government whose health budget has conventionally been a meager one could think of no solution excepting setting up private-public partnerships to meet the financial shortfall in the social sectors. That has proved to be a non-starter because the private sector has moved in to take control of the project it has been involved with. There are so many of such projects around which are gradually becoming commercialized while failing to meet the needs of the masses.

Seen against this backdrop, the SIUT’s model which evolved over time has proved its feasibility. Having started as a government organization, the SIUT just moved on to open its doors to community participation. By inspiring confidence in its performance it could invite the public to come forward to participate in this venture. Since it continues to be a public sector body not under private ownership people identify with it. This is important as the SIUT provides free of cost treatment, transplantation and dialysis as well as life-long after-care and medicines to transplantation patients and organ donors.

The government’s funding is not enough. Dr Rizvi has great faith in the goodness of the Pakistani people to whom he turns for donations. His donors include affluent individuals, business houses, corporations, small traders and Pakistani expatriate abroad who find the SIUT something back home to be proud of.

This has resulted in the emergence of a triangular partnership between the government, the community and the medical staff of the SIUT that provides the services. At the center of this triangle is the patient whose welfare holds all the partners together.

Each of the partners has a vested interest in this model. They want to sustain it as long as poverty exists in Pakistan which unfortunately seems to be a permanent fixture of the country. The SIUT has all the features that make it a “people’s hospital” without the negative qualities that characterize a public sector facility in Pakistan. Dr Rizvi says that in this model the medical community that provides care to the patient becomes the advocate of his concerns. Thus his non-medical problems which affect his health are not ignored and solutions are found facilitating the patient’s recovery.

A Trust operates the SIUT and a Board of Governors manages it. The staff comprises a director under whom are the medical, paramedical and support staff. Financially the government, which owns the infrastructure, provides about fifty per cent of the budget, the remaining being donated by the community.

To reassure the donors the SIUT adopts cost-effective strategies without compromising the quality of health care. Generic drugs and basic model dialysis machines are used. Dialysers are re-used and in-house dialyzing fluid is prepared. By adopting a need-driven approach to growth the SIUT has avoided waste as expansion takes place only when the capacity and need have been established. Overhead costs are negligible quite unlike other organizations which spend massive amounts on overheads.

The idea is to be as self-sufficient as possible and provide the institution with the state-of-the-art technology without any ostentation. An egalitarian spirit allows accessibility to all. There are no private wards, nor do the senior doctors, including the director, have private offices. All are equal. In the cafeteria, the same food is served to all whether doctors, paramedics or ward boys who eat together.

Operating like a big family, the SIUT expects its staff to show compassion and humanism to their colleagues as well as their patients and their families. The socio-economic concerns of every patient are addressed with sympathy and care. The healing touch eases the patient’s emotional, psychological and economic stresses.

The community trusts Dr Rizvi as the taste of the pudding is in its eating. No patient who knocks at the SIUT’s door is turned back. “A doctor cannot decide who is to live and who is to die because we have run out of beds,” says Dr Rizvi. So he takes them all even if it means improvising beds for them. “Neither can I rob a mortally ill person of hope when he comes in search of comfort,” he adds. But hospitals are known to do this.

All this makes the SIUT the apple of the public’s eye. Now the community’s financial potential is being affected by the recession that is gnawing at Pakistan’s economy. The number of patients is increasing as poverty is on the rise. Where does one go from here?