Healthcare

1
Healthcare
Disclaimer This study has been conducted by an
independent research consultant
2
Healthcare in Pakistan suffers from underfunding
in public domain and high dependence on poorly
regulated private sector
100
a
Public expenditure
Private expenditure
2006
Health expenditure as proportion of GDP
Source of health expenditure
Pakistan
16

• The government is severely underfunding its
  investment in healthcare
• A large part of demand is met via private
  healthcare spending which is channelled to
  un-regulated private service providers
• Low insurance coverage for health means financial
  access is a key issue

India
20
Bangladesh
37
Egypt
41
Sri Lanka
49
SOURCE WHOSIS, expert interviews
The Aman Foundation www.amanfoundation.org
3
Pakistan has comparable healthcare capacity
relative to peer countries
10
a
Capacity per 10,000 population
Pakistan
Healthcare capacity The capacity of the overall
physical and human resources of a healthcare
system (e.g., hospitals, beds, doctors, nurses)
and their distribution within the country
Not available
India
Bangladesh
61
Egypt
Sri Lanka
SOURCE WHOSIS
The Aman Foundation www.amanfoundation.org
4
However, quality of care provided is lacking . . .
20
a
Multiple sectors likely at play including patient
awareness and willingness to seek care
301
Pakistan
Healthcare quality The existence of safeguards
aimed at raising quality, safety and
acceptability of care are considera-tions of
healthcare supply
India
Bangladesh
742
Egypt
973
Sri Lanka
1 National Institute of Population Studies,
Pakistan 2 2005 data 3 2001 data
SOURCE WHOSIS, Pakistan Ministry of Health
The Aman Foundation www.amanfoundation.org
5
. . . exacerbated by low awareness of basic
healthcare practices . . .
82.0
a
Pakistan

• Healthy behaviour encompasses
• The existence of environmental protec-tion and of
  infrastruc-ture to protect the public from
  disease
• The extent to which healthy behaviour is promoted
  and preventative care is available and used

India
Bangladesh
Egypt
Sri Lanka
SOURCE WHOSIS, Ministry of Pakistan Health
The Aman Foundation www.amanfoundation.org
6
Karachis disease profile reflects a double
burdenof disease
66
b
ESTIMATES

• Noncommunicable disease is increasing with
  greater average life expectancy
• Communicable disease is 80 preventable, often
  through low-cost interventions
• Existing ambulance service focuses on patient
  transport, or is inaccessible
• Despite a marginally declining trend, Pakistan
  ranks 111th out of 169 on maternal and 184th out
  of 191 on perinatal mortality

Noncommunicable disease (NCD)
2.1
Communicabledisease
1.3
Injury
.5
Maternal andperinatal disease
.6
4.6
Total
1 Estimated based on 2002 data extrapolated at
1998-2003 CAGR
SOURCE Team analysis based on WHO data, expert
interviews, UN
The Aman Foundation www.amanfoundation.org
7
. . . which leads to poor health outcomes
a
2005-2006 statistics
63
Pakistan
320
78
63
India
450
57
63
Bangladesh
570
52
68
Egypt
130
29
72
Sri Lanka
58
11
SOURCE WHOSIS
The Aman Foundation www.amanfoundation.org
8
Karachis projected mortality in 2008 exhibits an
increase in share of injuries and
noncommunicable disease
0
b
ESTIMATES
Noncommunicable disease
5.75
Communicable disease
-5.08
Injuries
3.4
Maternal and perinatal disease
-2.1
Total
1 Estimated based on 2002 data extrapolated at
1998-2003 CAGR
SOURCE Team analysis based on WHO data, expert
interviews, UN
The Aman Foundation www.amanfoundation.org
9
Noncommunicable disease comprises largely of
cardiovascular disease
76
b
ESTIMATES
Cardiovascular diseases
Malignant neoplasms

• Contributing risk factors include genetic
  predisposition plus factors such as smoking,
  obesity, and physical inactivity which are in
  line with an urban population.

Respiratory diseases
Digestive diseases
Neuropsychiatric conditions
3
Congenital anomalies
3
2
Diabetes mellitus
Other noncommunicable disease
3
Total
1 Estimated based on 2002 data extrapolated at
1998-2003 CAGR
SOURCE Team analysis based on WHO data, expert
interviews, UN
The Aman Foundation www.amanfoundation.org
10
Lower respiratory infections and diarrhoea are
the biggest causes of mortality in the
communicable disease category
43
b
ESTIMATES
Respiratory infections

• Communicable disease in Karachi still comprises a
  sizable portion of the total disease profile
• Many communicable disease are caused by
  environmental factors, including water, soil, and
  air pollution

Diarrhoeal diseases
Childhood-cluster diseases
Tuberculosis
2
STDs excluding HIV
Other infectious diseases
Total
1 Estimated based on 2002 data extrapolated at
1998-2003 CAGR
SOURCE Team analysis based on WHO data, expert
interviews, UN
The Aman Foundation www.amanfoundation.org
11
Injuries are increasing, with road traffic
accidents comprising the single largest category
13.10
b
ESTIMATES
2.17
Road traffic accidents

• Road traffic accidents are increasing in the city
  of Karachi with increasing access to car
  financing and through greater traffic congestion
  in recent years
• Lack of emergency medical services contributes to
  higher mortality within this category

1.99
Fires
1.92
Self-inflicted injuries
1.74
Drownings, poisoning
1.28
Violence and war
1.25
Falls
Other unintentional injuries
2.76
Total
13.10
1 Estimated based on 2002 data extrapolated at
1998-2003 CAGR
SOURCE Team analysis based on WHO data, expert
interviews, UN
The Aman Foundation www.amanfoundation.org
12
Karachis high rates of maternal and perinatal
disease are largely avoidable
12.7
b
ESTIMATES
Low birth weight

• Nutritional deficiencies cause mortality in their
  own right, but also contribute to low birth
  weight and other maternal and perinatal
  conditions
• Lack of access to medical facilities contributes
  to high maternal and perinatal mortality and
  disability

Maternal conditions
Nutritional deficiencies
Birth asphyxia andbirth trauma
12.7
Total
1 Estimated based on 2002 data extrapolated at
1998-2003 CAGR
SOURCE Team analysis based on WHO data, expert
interviews, UN
The Aman Foundation www.amanfoundation.org
13
Field interviews confirm health need assessment
of Karachi
b
There are three delays in seeking health care for
women- firstly, there is a delay in recognizing
the womans need for medical attention. Secondly,
there is a delay in reaching medical facilities
due to distance, transport availability. The
third, worst delay, is the delay in treatment at
hospitals. Dr. Babar Sheikh, Aga Khan
University
Health is the most neglected area the citys
emergency and ambulance system needs to be
improved. At present, the Edhi system is the only
organised system able to provide efficient health
related transport and work with first responders
trained to provide initial treatment." Karachi
Strategic Development Plan, 2006
SOURCE Expert interviews, publications, press
releases
The Aman Foundation www.amanfoundation.org
14
The top 10 causes of mortality in Pakistan are
largely treatable
2
b
Curabledisease
Cause of death
Lower respiratory infections
IschemicIschaemic heart disease
Diarrhoeal diseases
Perinatal conditions
40 of all deaths in Pakistan are caused by
preventable/ curable diseases
Cerebrovascular disease
Tuberculosis
Chronic obstructive pulmonary disease
Measles
Whooping cough
Congenital anomalies
SOURCE WHO, 2006 Disease Controls Priority
Project
The Aman Foundation www.amanfoundation.org
15
Perspectives from experts show that a focus on
women and children could have high impact
c
International foundations
Research/academia
For too many women it motherhood is associated
with suffering, ill-health and even death.
children are vulnerable to malnutrition and
infectious diseases, many of which can be
effectively prevented or treated World Health
Organization
In Pakistan, 1 mother dies every 20 minutes and
500,000 children under five die every year, which
is unacceptable These issues need to be tackled
on war footing Dr. Babar T. Sheikh, Aga Khan
University
NGOs
Government
the government has spent lots of money - mostly
borrowed or begged on MNCH (maternal and child
health) and yet indicators are so poor relative
to countries such as Nepal, India and
Bangladesh Farid Midhet, Safe Motherhood
Alliance Pakistan
proven health interventions can help in saving
lives of mothers, newborns and children and most
of the causes are preventable and
manageable/treatable Islamabad Declaration
on Maternal and Child Health, Government of
Pakistan, 2005
SOURCE Interviews, press release, web search
The Aman Foundation www.amanfoundation.org
16
c
The ecosystem could cover a wide range of health
issues faced by this segment
ILLUSTRATIVE
Ecosystem element
Telehealth
Ambulance
CHW
Mother child clinic
Illness
?
My son has diarrhoea
?
?
?
What do I feed my 6-month old baby?
?
?
How can my child get vaccinated?
?
?
Im pregnant and I have started bleeding
?
?
I need nutritional supplements so this baby
isnt underweight like the last one
?
?
?
Is my baby developing correctly?
?
?
?
Where can I find a maternity home?
?
The Aman Foundation www.amanfoundation.org
17
Aman should focus telehealth, CHW and clinics in
localities which are home to the poorest one
third of Karachis population
c
NOT EXHAUSTIVE
Potential target areas
Potential new katchi abadis

• Identified areas have large katchi abadis, (high
  density urban slums) accounting for 1/3rd of the
  Karachi population or 5.5m people
• Incomes per day average from 1/family to
  2/family for families as large as 7 people each

SOURCE Katchi Abadis of Karachi, Volume 2 Khuda
ki basti
The Aman Foundation www.amanfoundation.org
18
Community health workers provide effective
delivery of mobile health interventions
c
Key health issues include
Description

• Awareness of pregnancy, maternal conditions
• Childhood diseases (Diarrhea, pneumonia, malaria,
  measles)
• Acute infections, e.g., STDs, skin lesions,
  rheumatic fever
• Chronic diseases, e.g., hypertension, diabetes,
• Awareness of behavioral issues (alcoholism, drug
  addiction)
• NTDs (Hookworm, Ascariasis, Lymphatic filariasis,
  Trachoma)

• A mobile field force of over 660 women trained to
  initiate and follow-up on common health issues
  within their local communities
• Last-mile link between patient and telehealth
  hotline
• Solve issues of access (through physical
  presence) and quality (link to telehealth doctors
  via mobile phones) and cost (overhead costs
  extremely low)
• Gain valuable data on additional needs
• Service features
• 660 women serve the health needs of over 760,000
  households
• Creates jobs for women in served communities
• Capacity for over 190,000 visits per month

Rationale

• Empower women to participate in community and
  also increases opportunity for medical attention
• Bridge crucial gap between diagnosis and
  treatment (last mile)
• Gateway to community for Aman and subsequent
  partners

SOURCE team analysis
The Aman Foundation www.amanfoundation.org
19
Emergency medical services to provide emergency
pre-hospital care and transportation services
throughout the city of Karachi
c
Description
Key health issues include

• Category A and B emergencies, including
• Cardiac arrest
• Road traffic accidents and injuries at home /
  worksites
• Emergency obstetric procedures
• Patient transport, capacity permitting (to
  supplement revenue earnings)

• A network of 150 Advanced Life Saving (ALS)
  ambulances with doctors on board provide coverage
  to city of Karachi
• Stabilize and transport patients from site of
  injury or illness to health care facility
• Solve issues of access (physical and financial)
  and quality of care (trained staff)
• Service features
• 12-15 minute response time target with delivery
  to hospital ER within Golden hour
• 700 EMTs and 450 doctors staff over 290,000
  ambulance trips annually
• Over time, triage to serve more serious (Category
  A and B) calls

Rationale

• Current players are either inaccessible or do not
  provide sufficient service (transport only,
  inadequately equipped to provide en route care)
• Flagship product to establish brand
• Amans initial interaction with public
• Establish Aman as trusted health partner

The Aman Foundation www.amanfoundation.org
20
Unmet market needs are for category A and B
services
c
Services required
Current situation
Current players
Patient type
A Immediately life-threatening
Life support, stabilization qualified medical
practitioner (doctor, nurse, EMT)
Private hospitals have their own ambulances which
are used to transport patients to/from home or
between facilities these are difficult to obtain
and expensive
AKU, South City
Edhi, CHIPPA, Khidmat-e-Khalq
Private hospitals and social sector organizations
provide these services, but staff usually do not
have medical supplies or qualifications to begin
treatment
B Serious but not immediately life-threatening
First aid, basic medication, stitches, bone
setting, etc until medical facility reached
(nurse, EMT)
Several modes of transport exist in Karachi,
including buses, taxis, and rickshaws these are
expensive and time-consuming. No dedicated
transport service for hospitals exists
Edhi, CHIPPA, Khidmat-e-Khalq, buses, taxis,
rickshaws
C Neither serious nor life-threatening
Patient transport services (driver)
SOURCE Team analysis, UK classification system
The Aman Foundation www.amanfoundation.org
21
Amans EMS should target unmet market needs
through strategic deployment of ambulances and
coordination with hospitals and patient transport
services
c
Strategic deployment
Market needs
Optimisation
Coordination
The Aman Foundation www.amanfoundation.org
22
Aman should strategically deploy its ambulances
in areas where the fatality rate from accidents
is highest1
c

• Initially focus on Saddar, Korangi, and Jamshed
  Town due to high volume of traffic fatalities
• Service should be extended as each area becomes
  saturated (i.e. 12-15 minutes response time,
  access to hospital in under one hour) and demand
  for coverage increases

1 TOWNS
SOURCE Road Traffic Injury Research and
Prevention Centre
23
Aman Mother and Child clinic addresses a variety
of needs in a low cost, high quality environment
c
HIGHLY PRELIMINARY
Description
Key health issues include

• Monitoring of pregnancy, maternal conditions
• Obstetric procedures
• Family planning
• Childhood diseases (Diarrhea, pneumonia, malaria,
  measles)
• NTDs (Hookworm, Ascariasis, Lymphatic filariasis,
  Trachoma)

• A low cost/no frills, high quality, high
  throughput clinic focused on mother and child
  healthcare
• Continuum of care approach targets maternal and
  child health
• Low cost, high quality approach builds on volume
  to ensure financial sustainability
• Service features
• Available 24 hours a day
• 20-25 bed capacity with two theatres
• Serving up to 10,000 patients per year
• Qualified paramedical staff, nurses, and doctors
  on site
• Cross-subsidization of underprivileged patients
• Customer service focus

Rationale

• Medical facilities exist, but are either high
  cost or low quality
• Physical access (transport) is an issue
  especially in peri-urban slums
• By focusing service on this segment, Aman
  establishes crucial health relationship early on
  and can easily initiate further health
  interventions

The Aman Foundation www.amanfoundation.org
24
Aman can aspire to create a low cost/high
throughput mother and child clinic
c
High throughput maternity clinic

• Awareness programs

• Community health workers

Basic clinic vaccination and healthcare
Generic pharmacy
CLINIC
Patient transport shuttle service
Ambulance docking station for emergency cases
The Aman Foundation www.amanfoundation.org
25
Definitions
5
Term
Description

• Mortality
• Morbidity
• Emergency/Pre-hospital care
• Prevention
• Diagnosis
• Acute care
• Chronic care
• Palliative care

Death due to a disease Loss in quality of life
due to illness Care provided to patients before
they reach the hospital, usually requiring
immediate medical attention Awareness or
screening for disease that serves to pre-empt
illness Identification of illness through
assessment of symptoms and past history Treatment
of disease that requires medical attention, but
not immediately (versus injury) Management of
long-term disease symptoms to mitigate morbidity
and mortality Pain management, usually for
terminal cases
SOURCE Expert interviews
The Aman Foundation www.amanfoundation.org
26
Key components of Emergency Medical Services (EMS)
Financial feasibility
Care
Reach
Sense
Care includes medical intervention en-route to
a hospital. This comprises having to stabilize
the victims and possibly saving their lives
Reach involves deploying emergency support,
comprising of ambulances, medical equipment and
personnel, to the scene of the emergency
Sense involves identifying or sensing an
emergency situation. The victim or any other
individual present at the scene of the emergency
calls the emergency service provider to give
information about the situation
Foundation

• Trained personnel
• Infrastructure
• Government and stakeholders

The Aman Foundation www.amanfoundation.org