Strengthening Democracy by Strengthening Health Systems

Child Mortality

Children under five in Pakistan bear the heaviest burden of mortality, accounting for a staggering 400,000 deaths annually—twice the number caused by the leading global killer, Cardiac Disease. Comparatively, the unforgettable COVID pandemic caused 30,000 deaths in 2.5 years. Shockingly, 80% of these daily 1,000 child deaths are preventable, according to UNICEF, prompting a sense of shame.?Pakistan's child mortality rate, double that of India and Bangladesh, should serve as a catalyst for urgent societal action.

Addressing this crisis involves several key solutions such as birth spacing, vaccination coverage, combating malnutrition, ensuring clean delivery practices, access to safe drinking water and sanitation, and poverty alleviation. Unfortunately, Pakistan's history of resource allocation and implementation in these areas does not inspire confidence. However, there's a ray of hope—quality emergency care has the potential to prevent 50% of deaths in Low- and Middle-Income Countries (LMICs),?a ripe opportunity seized by the ChildLife Foundation.

ChildLife Foundation

The genesis of the ChildLife Foundation stemmed from the 2010 super floods, which spotlighted the deficiencies in Pakistan's public health system. This crisis galvanized philanthropic action, leading to the establishment of ChildLife Foundation. Their initial focus centered on revamping the Children's Emergency Room at Civil Hospital Karachi (CHK), affiliated with Dow University of Health Sciences (DUHS), institutions with longstanding roots in Pakistan's healthcare landscape.

Fast-forward to 2024, and ChildLife has expanded its reach significantly. They're on track to treat to 2 million children in ERs across 313 government hospitals, ensuring that 80% of Pakistan's 100 million children have access to high-quality emergency care within 30 minutes, around the clock, and at no cost. Notably, the survival rates for the most critical cases (those requiring resuscitation) have increased fourfold under their care.

The key to this success lies in their approach, which might hold valuable lessons for other stakeholders. ChildLife's model likely involves a blend of strategic partnerships, innovative healthcare delivery methods, efficient resource utilization, and a strong emphasis on scalability and sustainability. Their ability to mobilize resources, collaborate with existing healthcare infrastructure, and provide quality emergency care, free of charge has set a notable precedent in addressing critical gaps in child healthcare.

Emergency Room (ER) Model

ChildLife has a structured process of operating the children’s ER of government hospitals. It starts with a formal long-term agreement with the government (signed by Secretary of Health of the Provincial Government). Galvanizing political and bureaucratic support is a time-consuming process and is fraught with delays due to frequent changes of decision makers. However, once the track record is established with a provincial government, the demand to replicate comes from the government.

The first step of transforming the ER is tangible and hence easier to fund. It involves capital cost (capex) for renovation of infrastructure such as laying oxygen raceways, providing medical equipment, installing air-conditioning systems, replacing floors, false ceilings, bathrooms, etc. Usually philanthropists stop at this stage.

The second stage is providing for recurring operational cost (Opex) such as human resources and medical supplies. The annual Opex is usually twice the one-time Capex and even the most committed donors run out of motivation in a few years. This staying power has been one of the keys to success for ChildLife’s program.

The third and most critical stage is management commitment to operate the ER as per international best practices. This requires intellectual effort to benchmark and to continuously improve (Kaizen in Japanese). It is the ROI (Return on Investment) that businesses thrive on but often neglect in their CSR/philanthropic ventures. ChildLife has a Balanced Score Card (BSC) composed of 24 KPIs structured around the three pillars of medical care namely Competence, Compliance, Compassion. This translates into regular Mortality and Morbidity meetings, measuring medical protocols, reviewing preventable deaths, focusing on time to triage – to doctor – to treatment, patient and employee satisfaction, etc. This is made possible by having fully automated (paperless) system where patient records are computerized and in the cloud. What gets measured gets done is known as GMP (Greatest Management Principle) in management circles.

Telemedicine (TM) Model

With two-thirds of Pakistanis living in rural area away from large teaching hospitals, they are forced to visit major cities frequently for serious health issues. In addition to the burden of cost and inconvenience of travel, treatment delayed is treatment denied. After six years of operating ERs only, ChildLife piloted an innovative service. A provider-to-provider (vs patient-to-provider) telemedicine service whereby a nurse or doctor based in rural area could seek expert advice of Specialist doctor sitting in a central control room located in Karachi, Lahore or Islamabad. The low-cost camera provides high definition view of the patient in a manner that specialist doctor can ascertain dilated pupils, breathing rates, and heart rhythms on cardiac monitor. In 50% of consultations there is value addition in diagnosis and treatment. Launch of TM service proved to be a watershed moment in ChildLife’s history and within a few years, it spread its network to all Tehsil and District hospitals.

Key Success Factors for Telemedicine:

While telemedicine isn't a new concept globally or in Pakistan, previous endeavors have often fallen short, with 90% considered failures due to unmet objectives. ChildLife identified three critical components for success:

(a)??? Technology - Keeping technology simple proved essential. The use of straightforward, accessible tools played a pivotal role in its success

(b)??? Financial - Linking financial strategies to success metrics was imperative in ensuring sustainable operations

(c)???? Human Component - The human factor posed the most significant challenge. Resistance from patients/attendants due to the perceived lack of human touch, discomfort among ground staff being monitored, and control room staff feeling detached from the medical action were notable obstacles. ChildLife tackled these challenges by fostering a culture of mentoring over monitoring. They elevated TM physicians to coaching roles, granting them high prestige. By gradually resolving these human-centric obstacles.

ChildLife successfully integrated TM into every Secondary care hospital (DHQ/THQ), generating unstoppable momentum and excitement around its implementation. Indeed, success begets success, and this approach redefined the perception and adoption of telemedicine within the healthcare sector.

Public Private Partnership

Pakistan’s most prominent social scientist, Akhtar Hameed Khan of OPP (Orangi Pilot Project) fame, postulated that to achieve impact, one must work at scale which is only possible when working with the government.? Working with government is not for the faint hearted as it requires patience and persistence. The African proverb – if you want to go fast go alone; if you want to go far go together – was probably coined for working with the government. ChildLife was fortunate to arrive at the scene when the Sindh government was openly supportive of public private partnerships specially after its own successes with expansion of NICVD (National Institute of Cardio Vascular Diseases), SIUT (Sindh Institute of Urology & Transplantation), and a host of other nonprofits in health and education.

The government was receptive to ChildLife’s vision of “Every child in Sindh within 30 minutes of quality emergency care”. The government communicated this shared vision at all fora and ChildLife with government’s administrative, political and financial support, turned cartwheels to achieve one milestone after another. Nothing succeeds like success and ChildLife soon became a poster child of health care delivery.

Armed with success in Sindh, ChildLife successfully proposed and implemented its model of emergency care in Balochistan, Punjab and Federal government. First project has been implemented in AJK (Azad Jammu & Kashmir) already and negotiations are ongoing in GB (Gilgit Baltistan) and KPK (Khyber Pakhtunkhwa).

Experts proposing structural reforms have always argued that Pakistan’s problem is of governance and not of resources.

Organizational Best Practices

The Board of Trustees have played an active role in oversight with initiatives like (a) implementing DFAM (Delegation of Financial Authority Matrix), (b) vibrant committees for Audit, HR and Executive matters (EXCOM), (c) establishing internal audit department, (d) pursuing the gold standard in everything. Some examples of gold standard are (a) choosing A.F Ferguson – Pakistan’s top audit firm – as the external auditor, (b) submitting to certifications by PCP (Pakistan Centre of Philanthropy, (c) ISO certification for quality, (d) competing for BCR (Best Corporate Report) in Pakistan and SAFA (South Asian Federation of Accountants), (e) participating in BWP (Best Place to Work) survey, (f) encouraging research submission at ESEM (Emirates Society of Emergency Medicine), and (g) engaging with leading hospitals like Stanford (USA), Johns Hopkins (USA), William Osler Hospital (Canada), Gaslini Institute (Italy), etc.

Organizational success requires aligning the culture of the organization with its strategy. ChildLife has focused on a fostering a culture of kindness as medicine is not a profession but a calling. Employees treated with kindness are more likely to treat patients with compassion than otherwise.

Moving the Goal Post

ChildLife 1.0 was the ER model and Telemedicine drove the 2.0 version. Now leveraging its existing scale, it is encouraging a partnership platform where 24/7 sub-specialty consults for Pediatric Cardiology are being made with NICVD through a three-way video and audio connection. This is now extended to Pediatric Nephrology with SIUT and expected to be replicated for pediatric oncology, intensive care, neurology, gastroenterology, etc.

The partnerships with PPHI (People’s Primary Healthcare Initiative) have helped expand network in its managed facilities and partnership with SIEHS (Sindh Integrated Emergency Health Services also known as 1122 Ambulance) provides the critically needed life-saving transport connection between referring hospitals (spokes) and tertiary care hospital (hubs). With cameras being mounted in ambulances, it will provide another opportunity to intervene during transport through telemedicine.

ChildLife is also extending its learning to establish TM with other multi-site organizations (Indus Hospital, NICVD, etc.) to improve quality of care at their remotely located centers. The resultant learning from sharing with other organization, fuels innovation.

The dream of going to share expertise from Pakistan has been fulfilled this year with first international TM partnership with a hospital in Mombasa, Kenya.

What the Future Holds

The dawn of a new era in health sector with AI (Artificial Intelligence) as a doctor’s assistant is upon us. Decision making model for helping ER and TM physicians through LLM (Large Language Model) and Rule based systems will not only improve diagnosis & treatment decisions but also save the physician’s time.

ChildLife is already experimenting with latest non-electricity-based model of CPAP (Continuous Positive Airway Pressure) for children in respiratory distress. This could be a game changer in locations where vents are in short supply – which is ubiquitous for Pakistan.

Partnerships with Obstetricians to reduce still births and first-day neonatal mortality though HBB (Helping Babies Breathe) program are being piloted as ChildLife team in ER is only an elbow away from the delivery room.

Impact

(a)??? Scale: ?2 Million Lives annually - ChildLife impact of treating millions of children and improving survival rate is obvious. A leading private hospital in Karachi treats 20 thousand children in its ER annually while ChildLife treats 2 million children at comparable quality – free of charge.

(b)??? Domino Effect - As a pace setter, the subtle impact on raising government staff and patients’ expectations of service quality have a dominos effect on the rest of the hospital. We have witnessed improvement in infrastructure and automation in the government hospitals.

(c)???? Training the Future Pediatricians - The pediatric residents at government hospitals spend about 6 months of their 4-year training in ER. The opportunity to work with ChildLife team exposes them to work on latest medical protocols, computerized systems, and trainings in pediatric emergency medicine and soft skills. These young doctors will be treating children for the next 40-50 years.

(d)??? 15X Scale - The Telemedicine program has had amazing impact. The first being the on-the-job coaching of government doctors in secondary care hospitals. TM Specialists provide consults to 10 serious cases daily per site. The government doctors usually treat 150 children daily in OPD (Outpatient Department) and hospital wards. For 300+ hospitals, the indirect impact is improvement in treatment of 15 million children annually (300 hospitals x 150 children/day x 300 days)

(e)??? Quality - Another advantage of the TM program is that consultation is made by a Pediatric Specialist trained in Emergency Medicine. The doctor at the secondary care hospital i.e. District Head Quarter (DHQ) and Tehsil Head Quarter (THQ) is more likely to be a medical officer. This consultation is likely to result in better health outcomes.

(f)???? Poverty Alleviation - Access to TM within 30 minutes of most population reduces the unnecessary referrals to major cities. While the child gets sicker, the poor parents desperately arrange for funds for transport and other costs. The debt undertaken is rarely paid back leading to an intergenerational cycle of debt trap / slavery. World Bank has argued that adverse health event is a major cause for a family to go below the poverty line.

(g)??? Climate Change - The unnecessary referrals have a carbon footprint which negatively impacts climate change. ChildLife was selected as one of the 3 organizations in Health category for the Zayed Sustainability Prize on the sidelines of climate change conference COP28 (Conference of Parties – 28th meeting) this year – out of 5000+ applicants.

(h)??? Proper Referral - In TM, if a referral is needed to a major city, then the medical record is shared with the HUB and they are ready to welcome and treat the child. Thus, parents do not have to run from pillar to post when they arrive at the referred facility.

(i)????? Disaster Relief - During the floods of 2022, ChildLife was able to treat children through telemedicine when roads had been washed away. Similarly, strong infrastructure of ERs built in upper Sindh treated 3 times the patients due to floods without rise in mortality. This was a result of trained local team, purpose-built ERs and inventory of medical supplies. Disasters as a result of climate change are no surprise to Pakistan and ChildLife team and infrastructure provides resilience.

(j)????? System Level Change – All efforts towards social improvement makes a difference. Rarely, an organization can make a system level change. With ChildLife’s presence in almost all government secondary care hospitals, it is poised to make a system level change.

(k)??? Strengthening Democracy - Saving the most critical point for the last. When people are forced to receive health services from private sector, they find out that those without money have little choice. When they receive it from charity hospitals, they are grateful to the philanthropists but in both cases, they feel let down by the government and state. However, when they receive quality service from public sector, their faith in the country grows. This is citizenship - this is nation building - this builds support for democracy. Pakistan Zindabad!

ChildLife Foundation Achievements 2023

(a) 6+ million children treated in emergency rooms since 2012.

(b) Saving children in 200+ government hospitals including all Tehsils of Sindh, all districts of Punjab and Balochistan, AJK on UNICEF’s project, launched 100-bed ER in Multan.

(c) Survival rate of critically ill children increased 4 times. Fully computerized medical record helps in accountability.

(d) Now providing technical assistance on children emergency care internationally (Mombasa, Kenya)

(e) Awards: 1st Prize on Best Corporate Report (BCR) by accounting regulatory bodies (ICAP & ICMAP) COP28 Finalist in Health Category Best Researcher in Emergency Medicine by ESEM (Emirates Society of Emergency Medicine)

(f) Audited by A F Ferguson with all accounts available on website

(g) Capacity building of government doctors through training and special certification with Gaslini institute of Italy.

(h) Signed Partnership Agreements with PPHI, Indus, NICVD, SIUT, SIEHS for increasing access, sub-specialty consultations and safe transfer of children through ambulance.

?Plans for 2024

(a) Treat 2 million children in ER across 313 government hospitals.

(b) Implement new integrated HMIS

(c) International accreditation