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East Africa

A young boy receives a polio vaccine at the mobile clinic set up by the AKHS project teamA young boy receives a polio vaccine at the mobile clinic set up by the AKHS project team (Photo: Jean-Luc Ray/AKF)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

AKHS in TajikistanThe Health Programme seeks to make a transition between the hospital-based curative care of the Soviet era to more community-based preventative care (Photo: Jean-Luc Ray/AKF)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 peopleare 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 other parts of 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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