Source: Paigham-e-Imamat, pp. 33-38

Ismaili, (December 1981), pp. 42-45

Ismaili Bulletin, VIII, 3-4 (November-December 1981), pp. 5-10

Selection of Speeches: 1976-1984

Your Excellency President Zia-ul-Haq, Your Excellency Dr Jogezai, Dr Mahler, Mr Perinbam, Distinguished Guests

To you all I extend a warm and sincere welcome to the inaugural session of this conference on "The Role of Hospitals in Primary Health Care".

I am particularly grateful to His Excellency, the President of Pakistan for having accepted to open this conference. We are well aware of the pressure upon his time and particularly during the next few days. I interpret his presence with us, therefore, as further official as well as personal confirmation of the President's commitment to the development of effective health delivery systems. This is also an appropriate time for me to express to His Excellency, the President, my warm gratitude for the support and encouragement he has given to the extension of our health care institutions in the remotest parts of Pakistan, as well as to the new Aga Khan University of Health Sciences.

The World Health Organization has achieved remarkable results in many countries and it requires no introduction from me. I wish to express my gratitude, however, to WHO for sponsoring this conference with the Aga Khan Foundation and to Dr Mahler personally, whose support has made these following days of discussion possible. I am told that Dr Mahler is very rarely able to spend more than two nights in the same place and I express our gratitude to him for devoting to us so much of his time.

The new economic order is clearly of the greatest importance to us all, but I venture to say that few industrialised nations of the North have been so consistently supportive of the concept than Canada. Prime Minister Trudeau has participated in every conference of import and I would like to pay tribute to the Canadian International Development Agency for being, in my view, leader in its field. It is a pleasure to collaborate with it and I am most happy that Mr Perinbam is present today.

I do hope that all of you here today will forgive me if I stray into your professional territory for a few moments before you begin your deliberations. Those of you who work in the area of health may consider it presumptuous of me to do so. However, as the Imam of a Muslim community spread over twenty countries, I have, of necessity, become something of a student of health care. To me, basic health, education and housing are crucial stepping stones in the process of personal and national self-realization and growth.

In the area of health, I am convinced that where health interventions are planned and designed to achieve specific objectives within an overall development effort, then these interventions will support and reinforce government social and economic investments and lead to substantial benefit in the development process. Like yourselves, however, I have found that there is no unseen hand in health and primary care that will provide easy answers to the hard questions about equity, planning, costs, personnel distribution and a host of other areas related to health and primary care. Certainly one of those areas debated is the role and function of hospitals and it is for this reason that we have invited you, our distinguished guests from twenty-seven countries, to this gathering. Are there answers? Can we learn from each other? Are there models or approaches from each other's countries which we can adjust to our own? I would hope so, and trust that through the exchange of information and experience that we would improve our knowledge in this important area, and that each of you will return to your work with renewed enthusiasm and greater understanding of this vital component of health care.

Before you start your meeting, I do have a set of four impressions or, perhaps, questions which I wish to share in the hope that later this week I can return to discuss these issues with you.

First, it seems to me that the challenge of health care in both the developing and developed worlds is one of management -- rather than values. None of us questions the right of every person to good health and to health care. Three members of my own community were official delegates to the Alma Ata Conference and we shared in its deliberations and conclusions. Yet in at least one area, which is so basic to primary care, there now seems to be a real shortfall. This is in the field of prevention. Many hospitals seem to have a limited appreciation of what can be done in this area. Why is this? Personally, I believe that any person who is admitted to any hospital -- including those in the Aga Khan Health Services -- who has malaria, tuberculosis, typhoid or polio, or a host of other preventive diseases, represents a failure in our health care efforts.

Whenever a bed is utilised by a patient whose disease could have been prevented, our efforts in the area of public health and community health have been confounded. Initial efforts made by my grandfather working in health were entirely in preventive and public health. It is in this area where the bulk of our work still takes place. Yet frankly, I feel that we must find new and better ways of rekindling our enthusiasm and dedication to this area. How can hospitals help? I am thinking not only of the developing world where hospitals are relatively few in number, but also of the industrialised world where we must seek to prevent such self-destructive behaviour as smoking, drug addiction and other such illnesses.

Secondly, I look to you for some assistance on hospital and patient referral systems. I have just returned from a fascinating visit to the People's Republic of China. Their hospitals are organised into a system from rural and municipal, not only by specialty needs, but by integrating 'traditional' and 'western medicine' resources. I am told that in certain areas of that vast land, referral links between hospitals at different levels are well-defined and exceptions are clearly understood and recognised. Unhappily, I have found few examples of these systems elsewhere -- at least in the Third World. Within the Aga Khan Health Services, we have literally hundreds of small institutions, dispensaries, health centres, three- or four-bed maternity homes and the like. We are attempting to forge links between the smaller, intermediate and large institutions and between rural and urban centres. As we move ahead in our efforts, I do think we need the reassurance that these referral systems do indeed work efficiently and effectively. I will ask your advice on how we can improve in this field. Can the poor afford the increasing costs of being referred to a higher echelon, and do local health care practitioners really refer patients up the line when they should? These are basic questions which relate to the linking of hospitals to rural primary care activities.

Thirdly, this conference has received considerable help and support from a number of wise and farsighted groups and individuals from Canada, some of whom, such as Mr Perinbam, are with us today. One of their astute countrymen noted three years ago with regard to the health care industry, and I am quoting a speech: "There is no reasonable way in which we can estimate the benefit of this (health) system. Without a way to estimate the benefit, we have nothing to compare the cost. Yet to estimate efficiency, we need some sort of cost-benefit ratio. When worthy politicians, administrators and pundits tell us that they have a 'gut' feeling that hospital budgets are fat or lean, one should remember that the gut is poorly designed for thought."

As I move from country to country, talking to health administrators and government officials about collaboration, I do find increasing concern, indeed alarm, at the rising cost of health care and health delivery systems both in and out of hospitals. Technology is expensive, and people's expectations in the curative area are now high.

However, costs are difficult to identify and quantify. We need greater precision and better answers in the area of cost-benefit and cost effectiveness research, and I do hope that in your deliberations this week, you will keep 'the bottom line' in mind. Perhaps one area in the cost equation, which we might not forget, is the private (non-profit) health care sector. How can our efforts in this area complement governments' efforts? Most developing countries are fortunate in having innumerable private and semi-public philanthropic agencies, but I am under the impression that, in many instances, they do not know of their mutual existence and certainly have been unable to co-ordinate their efforts, neither amongst themselves, nor with the public sector, in order to become more effective.

I do believe that we will make a greater impact by collaborating with each other, by combining our efforts and by planning together. Just as we must do this in each country where the private health sector has a major share of the action, so too must the international donor community do a better job at setting priorities and avoiding duplication and wastage.

The question of cost and hospitals are not easily resolved, but I do hope, in your efforts at model building this week, you keep them in mind and provide some guidelines as to how private institutions can assist governments' efforts.

Fourth and lastly, I would suggest that we come to terms with the definition of the word 'hospital'. The institution has often fallen into disrepute. It is said that hospitals work in a closed circuit, far removed from the health priorities of the countries where they are located. It is often claimed that hospitals are not adapted to the major needs of the countries where they serve. Nevertheless, hospitals continue to be built, they do serve, they employ, they cost, they work in a variety of ways. Thus, when we criticize them, what really are we criticising? Is it the regional teaching hospital, the local hospital, the general or specialised, the urban or rural? I ask you specifically to give us guidelines as to what these hospitals can do in the area of logistics, health education, community development, prevention and applied research.

There is no point in being negative. Hospitals are here and there will be more of them. I look forward to your suggestions in this area. I also think it will be particularly important to insure that the time and material efforts which clearly must be devoted in the years ahead to primary health care do not accelerate what I consider to be an increasingly rapid and perilous collapse in the standards of many existing hospitals. What I suspect of being an impending crisis of hospitals' performance is compounded by at least two issues which will be difficult to bring under control promptly.

The first is the rhythm of development of medicine in the industrialised world is provoking an increasingly rapid availability of new medicine equipment and the cost of this equipment is inflating even more rapidly than inflation in the industrialised world itself. There is a real risk of rapidly increasing obsolescence in the principal equipment of many existing hospitals.

The second issue is the unavailability of newly-qualified management manpower available to the Third World for hospitals, or for that matter, for primary health care. If I am correct in saying that the management of all aspects of hospitals and primary health care is becoming increasingly specialised and complex, then the provision of this manpower at the right level and as promptly as possible must be a central theme for this conference.

Your Excellency, distinguished guests, I have mentioned only four areas of my concern related to hospitals and health care. Given your background in primary care, I am sure you have many more. Many of the problems you will discuss this week are generic and controversial. However, we must be united in our research for creative and constructive solutions. The year 2000 is only nineteen years away, and your deliberations here this week will be crucial elements in assisting all of us in our efforts to achieve health for all by the year 2000.

Thank you.

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