Karachi will soon be a 'Child Safe' city - Dr. Ahson Rabbani, CEO ChildLife Foundation

The ChildLife story is one of philanthropy, dedication, and simply caring. Founded just five years ago, ChildLife Foundation has established three state-of-the-art emergency rooms in the National Institute of Child Health (NICH) the largest and busiest pediatric hospital in Sindh Civil Hospital, and Sindh Government Hospital (in Korangi). In addition, it has 17 primary care clinics scattered around Karachis slums and is running preventive health programmes as well. The NGO has quietly been bringing about a revolution in Karachis public health system, upgrading the infrastructure and systems of the hospitals it operates in. ChildLife treats a million patients every year free of cost.

Dr. Ahson Rabbani is the CEO of ChildLife Foundation. He has a doctorate in business administration with prior education in engineering. After working for multinationals for a decade, he switched to the social sector in order to pursue his passion for social marketing. For the last 15 years, he has played leading roles at several of Pakistan's largest philanthropic foundations like; The Citizens Foundation, Aman Foundation, and Greenstar Social Marketing. He is a believer in leveraging local philanthropy and creating public-private partnerships for scaled impact.

BR Research was fortunate enough to tour the NICH emergency room and hear the ChildLife story (unjustly summed up in the opening brief paragraph), followed by a discussion with Dr. Rabbani about the broader health and policy issues in Pakistan. Below are edited transcripts of the interaction.

BR Research: How did ChildLife transform the dilapidated emergency room of NICH into this modern facility today?

Dr. Ahson Rabbani: The ChildLife experience has been a learning experience and weve seen in the transformation of three pediatric emergency rooms that we go through three large phases. The first phase is when we do infrastructure improvement paint the walls, air conditioning, tiling, getting cardiac monitors, beds etc. Thats the easy part, which is what people usually write checks for. It improves the optics but not the care.

The second phase is when you add human resource. Government staff is usually heavily understaffed at least those present are. So, the second element is staffing with trained people and continuous training. Once you add people, you realise that in Pakistan, systems and processes in hospitals are very few. There may be exceptional cases such as AKU, where there are protocols, accountability, documentation, etc. So, this is the third element systems.

Systems require protocols; people are trained according to protocols and held accountable according to the protocols. Thats when patients survive. For example, it is a proven fact in emergency medicine that delay in administering antibiotics by one hour increases the risk of mortality by 10 percent. Is this a protocol, are people knowledgeable about it, are they doing it? Is someone measuring it? Time is of the essence. In pediatrics, we dont talk about the golden hour, its the golden minute. There are a lot of preventable deaths if you have systems such as Triage in place. The quality care rule is Care not documented, Care not given.

BRR: What is the state of Pakistans public health system?

AR: A hospital is just one element of the health system. Theres preventive health, primary, secondary, and tertiary hospitals.

Preventive health refers to awareness campaigns, immunisation, LHW programme, etc. Primary care refers to simple diseases such as fever, cough, cold, which could be treated at your local clinic. The moment it gets serious and requires in-patient service, you need to reach a hospital. A secondary hospital is one that has basic facilities, including operation theatre and admission place. A tertiary hospital has some specialties. For instance, a secondary hospital would have a general surgeon, while a tertiary hospital would have cardiac and neuro surgeons.

What has happened is that we inherited a very good health system, on paper. Pakistan has 5,000 basic health units (BHUs) or primary care units, relating to 5,000 union councils. These arent functional. So, when the rest of the system doesnt work, everybody comes to the tertiary care.

Pakistan has the structure, but its a matter of making it functional. If the 5,000 BHUs are functional, the secondary hospitals are functional, then the load on tertiary hospitals will go down. How? Accountability.

BRR: Why do you say accountability and how can this issue be addressed?

AR: The hands of the management are really tied in the government sector. Theres a funny adage, You can fire the PM but not a peon, because the rules are complex and there are political repercussions to it. I know some very good people out there who get frustrated, because they dont have the management latitude to implement anything. If you want to hire or remove a doctor, you need to go through the Ministry, which makes it a long process and political interference comes into it. Thats why people dont take decisions.

If the head of a primary care clinic or a secondary hospital is held accountable and given the power, the system could improve. This is what KPK is trying to do, whereas Punjab is trying to subcontract their hospitals to NGOs or private parties, giving them the budget and monitoring and regulating them for certain Performance Indicators. Different countries are trying different models, and we are still struggling with what model works for us.

BRR: And your model is the latter. But to what extent have you help build the institutional capacity of NICH? What would happen if you leave tomorrow?

AR: Working in partnership has benefits. By working with them, we realise their challenges. Ive seen that when we improve our infrastructure, some of the government wards have improved their infrastructure as well. As we computerise and automate, there is a positive impact; we automated the emergency room, and Ive seen the pharmacy and some departments take steps toward automation in this hospital. We try to make sure these systems talk to each other.

We dont think that we are indispensable. Its a question of how long it will take to go back to the old state. What we feel is a true contribution would be that while we are doing this as an interim solution, health sector reforms should come from government and civil society engaging with each other. But we cant wait for those reforms and not save children today.

We say lets become part of the solution rather than criticise the government. We have jumped in. We believe we act as a catalyst, and the government on demand by the people would improve its performance by making the hospitals independent or handing them over to third parties. The NGO sector is not large enough to take over the 962 hospitals in this country. Government reform is the most sustainable version. I dont think its an issue of shortage of money. Lets use the existing money correctly first. Make the head of the organisation responsible for it, give them the management, and hold them accountable.

BRR: Sindhs current budget for health is between one and two percent. Do you think its enough?

AR: More resources are definitely required, but you also have to raise the question of putting good money after bad. Lets first use the current money correctly before putting in more money. The systems need to come into place to see how the money is being utilised about the staffing measures, availability of doctors, medicines, protocols, attendance. The system needs to improve before you can put in more money.

Its a question of how effectively the money is being spent. My personal opinion is you need to improve before you pump more money in.

BRR: You do not generate any revenue. Where do you get your funding?

AR: We are a five-year old organisation, and we are proud to say that all funding comes from Pakistan/Pakistani diaspora all over the world. Our annual budget is close to $5.6 million. Around 20 percent of the expense of the NICH is borne by the Sindh government. We are looking forward to more government support, and theres been some development.

BRR: Any plans of expansion?

AR: We wish to expand our network of emergency rooms across Karachi because we have a dream that we want to make Karachi the third-most populous city in the world a child-safe city. Within the next 12-18 months, we plan to have five ERs all over Karachi, so that any poor childs parents can get them to a hospital within 30 minutes.

Karachi is the first step. We want to improve our systems, our capacity, and then go out. Were looking to step out of Karachi by 2018. And by the way, about 20 percent of the children we treat in Karachi are coming from interior Sindh or Balochistan because they are referred to Karachi for better health services!

BRR: What is the success rate of your ER and how does it compare to before you took over?

AR: Around 93 percent of the children that come in are treated, stabilised, and sent home. Seven percent are admitted to the ward after being stabilised. At least for those 93 percent, we provide coverage end-to-end.

As for how things were before us, the exact data is unavailable but the survival rate of critically ill children has increased to 90 percent. This translates into saving 50 lives every day approx. 20,000 per year.

BRR: Of the 93 percent children you treat and send home, how many return?

AR: There is a globally accepted performance indicator of unplanned re-attendance within 72 hours which we are trying to build in. Currently we can share that patient satisfaction is 74 percent based on SMS responses which is higher than the global average.

BRR: What are the most common causes of neonatal death in Pakistan? How can we prevent them?

AR: Neonatal deaths in Pakistan are very high and havent gone down in the past 20-30 years. We have made improvements in the under-five mortality, but theres been hardly any progress in under one-month mortality. The reason is lack of continuum of care.

You need to look at the mothers health before pregnancy, her health during pregnancy, food, ante-natal checkups, birth preparedness plan, and then also optimal spacing; too frequent children leads to low birth weight babies.

The childs health is tied to the mothers health. Low birth weight, sepsis, neonatal infections, delivery complications, etc. are the reasons for high neonatal deaths. Maternal mortality and neonatal mortality are tied with pregnancy care. The childs immediate nutrition mothers milk, as compared with other cultural practices has to be looked into.

BRR: Stunting is a big issue in Pakistan. How can we address it?

AR: Malnutrition is at an epidemic level and key reason for under-five deaths their body is not strong enough to take one or two bouts of serious illnesses. Malnutrition leads to stunting and to change the status quo we need to focus on breast feeding, weaning foods, and a balanced meal. Those things are available but its a matter of being available to the public that needs it the most.

Under our preventive health programme, the counselors that go house-to-house counsel mothers about nutrition, and the severely malnourished children are referred to the primary care clinic where they are given special foods to overcome the malnutrition. The issue was always implementation we know that children and mothers are dying, we know the solutions, and they are free in most cases; its just about implementing them across the board, especially in the poorest neighbourhoods.