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East
Africa
Providing high quality health care and raising the health
status of people in East Africa are the broad goals of the
Aga Khan Development Network for the health sector. They
are addressed through an emphasis, in current projects,
on health systems development, strengthened by new regional
programmes and investments. AKHS has facilities in Kenya
and Tanzania that provide over 400,000 patients per year
with care in both rural and urban, and preventive and curative
contexts: its hospitals provide an increasingly comprehensive
range of high-quality clinical services. The Aga Khan Foundation,
with branches in Kenya, Tanzania, and Uganda, works with
a variety of grantees, including AKHS, to improve the health
of vulnerable population groups, especially mothers and
children, and promote health services development on the
national and regional levels. AKF and AKHS have been joined
in their work in health care in East Africa by the Aga Khan
University's Faculty of Health Sciences in the areas of
health service delivery at the Aga Khan University Hospital
in Nairobi (AKUH-N), professional training, especially for
nurses, and epidemiological research.
The AKDN work in health care in East Africa aims to assist
countries in the building of effective, sustainable health
systems linking different kinds of services and levels of
care. It has an especially significant role to play as a
private provider of hospital care in long-established, growing
local institutions.
History
The history of AKHS hospitals and health centres in East
Africa begins with facilities in the cities and towns of
the colonial period - a health centre which expanded into
a maternity and nursing home in Dar es Salaam in the 1930s;
maternity homes in Mombasa and Kisumu which became full-service
hospitals in the 1950s; the Aga Khan Hospital in Nairobi
(AKH-N), which opened in 1958 and is now one of the leading
hospitals in the region ; it became an Aga Khan University
Hospital in 2005. These institutions entered a new period
of development when Kenya and Tanganyika gained independence
in the 1960s. Today, AKDN operates six health centres and
four hospitals in East Africa, including the leading private
hospitals in Kenya and Tanzania. Through these hospital
facilities, it has an urban presence which is unique in
the region today, placing AKHS in a position to develop
models of good practice through the delivery of high quality
diagnostic and curative care, in-service training, care
in the community, and public health services. The corporate
clientele of its hospitals has given AKDN expertise in an
important and neglected area of public health in the developing
world - the promotion of workers' health.
Both AKUH-N and the Aga Khan Hospital in Dar es Salaam (AKH-Dar)
have been expanded in recent years, including increases
in the number of beds. The simultaneous expansion of ambulatory
services and day care allows for the provision of more cost-effective
care. Programmes for the development of clinical specialities,
including cardiology, oncology, paediatrics, orthopaedics,
and traumatology, are increasing the range of secondary
and tertiary services which these hospitals are able to
offer their patients.
The expansion programmes emphasise the introduction of new
diagnostic services, which will improve the function of
both hospitals as referral centres. High-quality, high-technology
laboratory medicine and radiology services are enhancing
the capability of AKH-Dar to provide referral services in
Tanzania. AKUH-N is poised to develop as the institution
of choice for referral for patients on the regional level,
thus strengthening the whole health sector, and is closely
linked with the AKUH in Karachi.
Community-based Primary Health Care
Along with this investment in hospital services, the AKDN
work in the health sector in East Africa also entails a
commitment to developing effective approaches to disease
prevention and health promotion. In a health system framework,
care begins outside the hospital or health centre, with
community-based primary health care. In the 1980s, AKHS
and AKF created primary health care projects in Kisumu and
Kwale, two rural districts in Kenya. The projects have trained
people in the Kisumu and Kwale communities in primary health
care technologies and management, and catalysed community-based
efforts to increase safe water supplies. In other projects
in Kenya and Zanzibar, AKF is working with government services
to develop tools for health sector policy design and resource
allocation. AKDN’s international experience in primary
health care management and information systems, acquired
through its management advancement programme, is an important
resource in this area. AKF is also supporting projects,
which improve the health of vulnerable groups, like women,
by enhancing their socio-economic status.
Assuring the sustainability of their services and improving
access to them is a concern for all the AKDN health institutions
and projects, from the PHC to the tertiary care level. Towards
this end, user fees are set for all services, even the most
highly subsidised. Hospitals use any operating surpluses
to subsidise the increasing cost of care. Developing effective
mechanisms for referral is another way of improving access.
AKDN’s current hospital expansion will improve referral
processes through better diagnostic services at all levels.
In a new region-wide strategy, AKHS is also offering an
increasing range of services on the first level of care,
including care in the community (for conditions which do
not require hospitalisation), primary medical care, workers'
health, health worker training and health systems research.
The Community Health Department (CHD) of Aga Khan Health
Service, Kenya (AKHS,K) works in partnership with community-based
health and social organisations, Non-governmental Organisations
(NGOs), and Ministry of Health where it provides support
from the dispensary level through to the national level.
It works to demonstrate effective provision of primary care
services through capacity building (training), and development
of efficient and useful Health Management Information System
(HMIS) at household (community-based HIS) as well as facilities
at all levels of care.The regional health programme also
includes human resource and training components for personnel
from other institutions in the region, both public and private,
as well as AKDN own facilities. AKUH-N is becoming a major
regional centre for post-graduate education programmes for
nurses, as well as physicians. The Community-based health
programme now consists of 29 members, including a Director,
Project Coordinators, Epidemiologists, Community Health
Development Specialists, Data Managers and Support Staff.
Central
Asia
Tajikistan
Healthcare provision in Tajikistan has less to do with a
shortage of facilities than with the need to rationalise
the existing system and to improve quality. The combination
of the break-up of the Soviet Union and stopping of subsidies,
and the civil war of 1992-1997 hit especially the geographical
area of Gorno-Badakshan, where AKDN started its health activities
in 1997, hard. Health services, previously relatively generously
financed had virtually no budget anymore. Moscow had invested
heavily in the area and developed extensive health and education
systems but at the same time, the society had become deeply
dependent on Moscow for strategic direction and even survival.
The 1990s saw a worsening of the health indicators, with
a decline in life expectancy and increases in maternal and
child mortality. The hospitals and health centres deteriorated,
with buildings not repaired and much medical equipment unusable
due to lack of spare parts, and no drugs or supplies. To
achieve its vision of a sustainable, cost-effective health
system accessible to all, Tajikistan's reform priorities
include implementing effective public health measures; enhancing
primary care; reducing duplication and increasing efficiency
in the hospital system; building the capacity of the health
professionals; and involving the community in developing
and governing the system.
The issue for AKDN has been how to support the system in
a situation where reform is the priority. Contrary to Northern
Pakistan where AKDN had operated almost in exclusion of
government policies and systems, the strategy in Gorno-Badakshan
has been to work very closely with the government, given
its pronounced presence, to help tune its capacities to
a new situation and to support the system towards reform
with the aim to improve access to quality of care and at
the same time pay attention to financial sustainability.
AKHS has implemented, with support from AKF and international
donor agencies, the active participation of the communities
and in partnership with the Department of Health (DoH) of
Gorno-Badakshan, a wide range of interventions in health
promotion, facility rehabilitation and equipping, pharmaceutical
procurement, distribution and sales, and training in new
clinical and managerial practices. Special attention is
being given to "professionalising" nursing. All
the programmatic interventions are designed to protect and
promote the health status of the most vulnerable in Tajik
society, i.e., women of reproductive age and children under
five years of age, and to encourage the health ministry,
within the oblast with its population of 220,000 that is
directly targeted with this set of interventions, and throughout
Tajikistan, to shift from a focus on curative care provided
in general and specialised hospitals to an emphasis on primary
and family care supported by facility-based services. Making
use of this experience, AKHS is now expanding its community
health programme into another geographical area of the country,
Katlon.
Afghanistan
The health status of the populations in Afghanistan is poor.
After more than 20 years of war, the health infrastructure
by the time of AKDN’s entry in 2002 was negligible.
AKDN’s response in the health sector in Afghanistan
so far has been a mix and match from its experience in Northern
Pakistan and Tajikistan. In addition, the Ministry of Health
in Afghanistan, supported by UN organizations, donors and
NGOs including AKHS and AKF has formulated over the last
two years a strategy which includes a basic package of core
services, that any agency wishing to provide health services
to Afghans must deliver first before adding any other services.
At level 1, volunteer male and female community health workers
(CHWs) are trained, supervised and given basic provisions
by the AKDN and remunerated by the communities served. At
levels 2 and 3, Basic Health Centres {BHC : provides for
out-patient care, immunizations, normal deliveries, supervision
of village-based community care with a recommended coverage
at minimum of 10,000 people}, and Comprehensive Health Centres
{CHC : provides in addition to BHC complete obstetrical
care coverage, emergency surgery, and has limited inpatient
capacity; recommended coverage at minimum of 25,000 people}
are constructed or rehabilitated, managed and operated by
AKDN on land donated by the communities to the Ministry
of Health.
Seventeen BHCs and five CHCs are now operational in the
provinces of Badakshan, Baghlan, and Bamyan as well as the
provincial hospital in Bamyan. In the catchment areas of
the health centres a health post is located in every village,
and each health post is staffed by two CHWs- one male and
one female. With these twenty-three facilities and trained
CHWs in all villages a basic essential healthcare provision
infrastructure is put in place for 340,000 people. Per capita
payment arrangements with the government are the current
policy direction in Afghanistan and allow AKDN to partly
share the costs of service provision.
Pakistan
History
The first institution in the Aga Khan Health Service, Pakistan
(AKHS,P) was a 42-bed maternity hospital - formerly
known as the Janbai Maternity Home, which opened in Karachi
in 1924. Today, while maintaining that early focus on maternal
and child health, AKHS,P also offers services that range
from primary health care to diagnostic services and curative
care. It reaches over 1,1 million people in rural and urban
Sindh, Punjab and Frontier, Northern Areas and Chitral.
As the largest not-for-profit private health care system
in Pakistan, its goal is to supplement the Government's
efforts in health care provision, especially in the areas
of maternal and child health and primary health care.
Funding
AKHS,P funds come from a variety of sources.. As a vital
ingredient in social welfare systems, which aim to become
self-sustaining, user fees are consistently set, even for
the most highly subsidised services. This principle is actually
serving to broaden access to AKHS,P services. When facilities
become self-sustaining, AKHS,P uses any operating surpluses
they generate to finance other programmes and to subsidise
services to the very poor.
AKHS,P addresses the health problems of specific local populations
in Pakistan. To do so more effectively, its health care
system is decentralised, and the services it offers vary
according to the needs of its five programme regions in
Karachi, Sindh Punjab and Frontier, Northern Areas and Chitral.
In the rural areas of Pakistan where AKHS,P operates, reaching
people in remote areas with primary health care services,
especially the high-risk groups such as mothers and young
children, continues to be a high priority, as is the provision
of adequate diagnostic services, curative care, and referral
services for the general population. AKHS,P operates 47
health centres in Karachi, 27 in Sindh, 14 in Punjab and
Frontier, 33 in Northern Areas and 31 in Chitral.
In the North of Pakistan, AKHS,P has been implementing the
Northern Pakistan Primary Health Care Programme since 1987.
Working in partnership with local communities, the government,
and other AKDN institutions, like the Aga Khan Rural Support
Programme, the goal has been to find sustainable ways of
financing and delivering primary health care in the high-mountain
valleys. This has led to a village-based approach -- the
designation of community health workers by the local village
organisation, the training of these workers in community-based
disease prevention, and the reorientation of health professionals
(government and private) to primary health care. Since it
began, AKHS,P has trained 977 Community Health Workers and
967 Traditional Birth Attendants in the Northern Areas and
Chitral.
Through this and related programmes, AKHS,P has been working
to promote a new orientation of health services in Pakistan
towards primary health care. Close collaboration with AKF
and AKU has been the cornerstone of this endeavour. The
three institutions are also collaborating in a drive to
build health systems linking preventive and curative care
efforts, as well as the different levels in the AKHS,P system,
from the village health centre to the Aga Khan University
Hospital in Karachi.
India
The mission of the Aga Khan Health Service, India (AKHS,I)
is to provide access to good quality, comprehensive health
care and promote physical, social and mental well-being
in the target population through a sustainable health care
system, including a multi-speciality hospital, based on
the principles of volunteerism and community participation.
It strives to be an integrated health system recognised
for its quality, volunteerism and innovative information,
education and communication.
Organisation
From its base in Mumbai, the Community Health Division operates
through a team of almost 1500 volunteers and 150 staff.
Six Regional Health Boards and 32 Local Health Boards are
responsible for programme implementation. The Local Health
Boards manage preventive and promotive health services through
outreach activities, which are delivered and implemented
by lady health visitors and multi-purpose workers. There
are a total of 281 health committees involved in health
promotion and prevention which field staff visit regularly.
There are 6 health centres, and two diagnostic centres.
These facilities are located mainly in Gujarat.
The Community Health Division seeks to achieve its objectives
by improving the health behaviour of the programme population
in relation to hygiene, use of oral rehydration, immunisation,
maternal care, risk factors for preventable non-communicable
diseases, tuberculosis, information and services for child
spacing. In each region a systems approach with a three-tier
service is being adopted, integrating primary care (promotive,
preventive, and basic curative), developing facilities for
diagnostic and emergency care, and a referral mechanism
for hospital care. Barriers to access to health services
of a satisfactory quality are being identified and will,
if possible, be eliminated. At the primary care level, the
focus has broadened from maternal and child health to family
health. The focus of health promotion efforts is being extended
to include the prevention of non-communicable diseases,
AIDS and gender-sensitisation activities. Research priorities
include risk factors for mental illness, influencing behaviour
in relation to HIV, reproductive health and TB, and health
financing. Improving human resource management is a priority.
A training unit has been instituted to serve the needs of
AKHS,I as well as to provide training for government and
other NGOs.
Prince Aly Khan Hospital is a 137-bed multi-specialty acute
care hospital that, by extending the range and quality of
its clinical services, has become the hospital of choice
for the local population within its catchment area in South
Mumbai. The hospital is ISO 9002 certified -- perhaps the
only one in Mumbai and Maharashtra to have such certification.
Programme development is constrained by severe space restrictions
and AKHS,I is planning the phased development of a 250-bed
replacement hospital providing some sub-speciality services
and having a major emphasis on ambulatory and intensive
care.
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