An address to the Ismaili Health Professionals Association, USA
By Shamsh Kassim-Lakha, H.I., S.I.
President, Aga Khan University

Princess Zahra Aga Khan,
Secretary of the US Department for Health and Human Services, Tommy Thompson,
The Honourable Shirley Franklin, Mayor of Atlanta, USA,
Dr. Nasiruddin Jamal, Chairman of the Ismaili Health Professionals Association in the United States,
President Alaudin Banji of the Ismaili Council for the USA,
Distinguished guests,
Ladies and gentlemen,

Assalam-o-Alaikum

I'm delighted to have been invited to this distinguished gathering, and to participate once again in a symposium that brings together Ismaili health professionals from all over North America.  Looking around the room, and recognizing many whom I personally know have achieved significant status and reputation in their chosen fields, I am reminded of the very high value the Ismaili community places on human capital.  I'm particularly happy to have met so many old friends. 

Today I'd like to make a small contribution to your symposium by sharing with you some of the work Aga Khan University and other health and education institutions in the developing world are doing to provide access to health care, and to narrow the health care gap.

Let me set the background by informing you about Aga Khan University itself, and the areas in which we have been engaged since receiving our Charter in Pakistan 20 years ago.  I'd like to tell you about our international programmes in East Africa, Central Asia and the United Kingdom, and how we work with governments and institutions to narrow the health care gap in four critical areas -- accessibility, quality, relevance and impact.  By the end of my address, I hope you will conclude that good things are happening in the developing world, and headway is being made in addressing health care issues for the future.  But I hope you will also learn that institutions in the developing world cannot close the health care gap on their own.  They need the help of health care professionals, institutions and agencies in the developed world, working together as partners for the good of humankind.

I guess my definition of the health care gap would be the difference between what health care is and what we would like it to be.  Even in the United States and parts of Europe, where health care is recognised to be among the best in the world, health care is never as good as its participants wish it to be, but compared with the developing world, the heath care gap in the United States is relatively small.

In the developing world, on the other hand, the health care gap is a yawning chasm that ranges from no health care at all to varying standards of quality and accessibility at all levels.  Not just primary, but also secondary and tertiary.

Using Pakistan as a representative but very real example of a developing country, allow me to illustrate. Pakistan is a country of 140 million people. Funds allocated to defence, administration and servicing of the national debt together consume about 70 percent of the national budget.  While this could be considered by many to be an important, and maybe even a necessary allocation, it also means that there is intense competition for the remaining funds among health, education and other social services, as well as all development programmes. Consequently, healthcare remains limited to providing basic health care service to a widely dispersed population. In addition, health care management and leadership have to be strengthened further and a proper health care system put in place, where education, research and services work in collaboration.  Universities already providing health care education need to focus more on research. More funds are needed to enhance the services delivered in private and government hospitals and clinics to enable them to effectively tend to patients.  Emphasis has to be placed on ethical issues.

However, the real gap in developing-world health care is in four key areas.  There is a gigantic gap in accessibility to health care. . . a gap between what people need, what is available and what they can afford.  Second, there is a gap in the quality of health care . . . one institution to another, one practitioner to another.  Third, there is a gap of what is relevant.  For example, between education and services that are relevant to people in developing societies, and research that concentrates on the researcher's interests and what he can get funded, versus research that is relevant to the problems of developing world society.  And lastly, there is a wide gap between the desired impact of health care and education programmes that raise standards and improve services, and actual outcomes in which attempts to implement change and forge new directions are met with staunch opposition from old-school administrators and practitioners. 

To address these problems, and to provide a health care and education role model in the region, His Highness the Aga Khan founded the Aga Khan University.

AKU received its charter in Pakistan in 1983 and was the country's first private, self-governing university.   From its outset, AKU was intended to be an international university.  On the occasion of receiving the University's Charter, His Highness said that AKU should ". . . become an international university, able to mobilise resources from other countries, to coordinate international research, and to encourage the exchange of ideas between nations."   That was twenty years ago.  Today, AKU has eight teaching sites in South Asia, East Africa and the United Kingdom. 

In Karachi, Pakistan, where it all began, there is a Faculty of Health Sciences comprising a Medical College, a School of Nursing and an associated 500-bed tertiary care teaching hospital.  In the same city, on a different campus, the University has an Institute for Educational Development that offers professional development programmes for teachers, with links to two AKU Professional Development Centres for teachers in Northern Pakistan.

In East Africa we have both Advanced Nursing Studies and teacher development programmes in Dar-es-Salaam, Tanzania; Kampala, Uganda; and Nairobi, Kenya.  In Nairobi and Dar-es-Salaam we are working with Aga Khan Health Services to upgrade systems and procedures in Aga Khan Hospital's clinical labs, radiology, pharmacy and medical records to bring them to international standards, as a prelude to AKU starting postgraduate medical education in Nairobi later this year.  Most of our programmes in East Africa were initiated at the invitation of the respective governments, but none could have been mounted without the encouragement and support of Aga Khan Development Network institutions, for which AKU is increasingly becoming a turning plate for developing human resources in health and education. 

In London, England, AKU has its first programme outside of professional education.  Aga Khan University Institute for the Study of Muslim Civilisations opened in 2002 as a new centre for strengthening research and education to enhance knowledge of the heritage of Muslim civilisations.  One of the Institute's initiatives will be to create an index of published works on Muslim civilisations in various languages.  Its faculty will also write abstracts of these works, translate them into major scholarly languages, and distribute them globally on the Internet.  An educational programme on Muslim civilisations will also be offered, including an interdisciplinary masters degree, along with short courses on special topics.

The internationalisation of AKU is not confined to Pakistan and East Africa.  More recently it has undertaken new initiatives in nursing education and teacher development programmes in Afghanistan, Syria and parts of Central Asia.  But perhaps the most significant development on the radar screen is the establishment of a new Faculty of Arts and Sciences which the University hopes to commission in 2007, on a new, purpose-built campus in Karachi.

While planning for a Faculty of Arts and Sciences began almost ten years ago, the reason for it being established is perhaps best illustrated by remarks made in a study of higher education in developing countries by UNESCO and the World Bank in 2000.  In the report, Peril and Promise, its authors noted that the social return on higher education in developing countries has been greatly underestimated, and that the development of a cadre of nation builders through general, liberal arts education must be given priority. 

The Faculty of Arts and Sciences will be a regional, residential, liberal arts facility attracting intellectually endowed students from cities and underprivileged communities of the developing world, especially those in South and Central Asia, East Africa and the Middle East. 

Of particular interest to this audience, is that incoming medical and nursing students at Aga Khan University will be required to undertake liberal arts programmes offered by the Faculty of Arts and Sciences to broaden their education and improve their skills at reasoning and critical thinking.  It will extend the undergraduate medical programme from 5 to 6 years, and will better enable medical practitioners to address health care problems from more than just a health professional's viewpoint.

AKU is a secular university, open to all regardless of faith, gender or ethnic origin.  It embraces the Muslim ethos of ethics and morals which are embedded in the curriculum, the campus environment, and in relationships between faculty and students, physicians and patients.

AKU's programmes are especially designed with the objective of developing professional opportunities for women.  Therefore, it is not by accident that AKU's early programmes are in health and education.  Since the earliest days, nurses and teachers have been predominantly women, and in developing countries especially, there is a high demand for women physicians.  Currently women represent half of the student body in the Medical College, and if you add the number of women in nursing and teaching programmes, their count overall rises to 65 percent.  Over 40 percent of AKU's faculty are women, including Dr. Yasmin Amarsi who is present with us today, the first Dean of a School of Nursing in Pakistan, and Pakistan's first PhD graduate in nursing.

In its quest to bridge the gap in access to quality education, AKU has, from its outset, been fortunate to enjoy close linkages with both academic and funding institutions around the world.  In 1983 President Derek Bok of Harvard and his senior academic colleagues helped us to conceptualise the University's early programmes, and McMaster University in Canada provided significant and on-going support in the development of the School of Nursing.  More recently Oxford University, Sheffield Hallam University in England, and the University of Toronto in Canada have played major roles in the development of the Institute for Educational Development.  Other universities with which AKU enjoys close ties include the Karolinska Institute in Sweden and Johns Hopkins University in the United States, and, especially in Community Health Sciences, the University of Alabama at Birmingham.

AKU could not have achieved its objectives without support from many quarters.  Amongst these are volunteers from numerous professions, and individual donors.  As I look around this room I see health professionals from North America who volunteered their time and expertise to AKU, especially in the earlier years.  Many initiatives that are now well established could not have been undertaken without their help, and I wish to thank you and the many others who are not here for all your support.

Over the years, AKU has also enjoyed the support of international agencies, including USAID, the Canadian International Development Agency, Britain's Department for International Development, the European Commission and the United Nations Development Programme, who provided generous programmatic grants.

In its first twenty years, AKU has made considerable progress, but what about the problems we face? 

It has been anything but smooth sailing.

To begin with, AKU often operates in politically turbulent regions of the world.  More recently the situations in Afghanistan and Iraq, as well as in parts of Sub-Saharan Africa have had a direct or indirect impact on AKU.  Among our biggest challenges is a lack of human resources at all levels, and as AKU expands, and new programmatic and research needs are identified, it suffers acute shortages of financial resources.  Our only consolation is in the words of our Chancellor who said that, "Good universities suffer a genetic defect . they always outstrip their resources."

Having described the current programmes of our University, let me now address the issue of the health care gap in the developing world, and what AKU and some other institutions in the developing world are trying to do about it.  I said I would address the issues of gaps in four areas: accessibility, quality, impact and relevance.   

While it is true that in the USA there are over 30 million citizens who don't have medical coverage, health care is accessible to those in need, either through employer-sponsored health care programmes, through private insurance schemes, or through social services.  It is possible therefore that someone of modest means could be given access to expensive by-pass surgery or similar care they might otherwise not afford.

In Pakistan, as is the case in most developing countries, no such safety net exists.  While a few employers cover health plans for their employees, most do not, and there is no system of widely available and affordable health care insurance.  While there are some notable exceptions in the larger centres, many patients rely on low-cost clinics and free hospitals where they often receive low quality care.  Advanced procedures and expensive medications required to effect treatment are frequently unavailable or not affordable.

From its very inception, the University decided that medical care at AKU should be accessible to all, regardless of faith, gender or ethnic origin, and regardless of ability to pay.  Access is ensured in three ways: heavily subsidized fees, a carefully conceived patient welfare programme supported by an endowment and annual giving, and through Zakat contributions.

About 400,000 patients come to AKU's teaching hospital each year for treatment, over 70 percent from the low and middle income sections of society.  All have access to a heavily subsidized Community Health Clinic in which the services of a general practitioner can be availed for an affordable sum.  Poor patients admitted to the general ward are provided bed and food at costs that are well below the true cost of services. 

For those unable to afford the full cost of these heavily subsidized services, or the additional costs of specialist services, a patient welfare programme is in place.  Based on predefined criteria, patients are asked to pay an affordable portion of their medical care, while funds from a patient welfare endowment cover the balance.  We are fortunate that, through careful husbanding of income generating activities and cost control, the University Hospital is now financially self-sufficient, and generates small annual surpluses which it puts into the patient welfare fund and supports academic activities.  Last year we dispensed over $2 million of patient welfare care.  You may not find that an impressive amount, but when the purchasing power of the dollar in Pakistan is taken into account, that's equivalent to about $12 million in the United States.  Over the last three years, the University Hospital also funded an additional $2 million annually for the treatment of thousands of Afghan refugee patients, in collaboration with the Aga Khan Health Services in Pakistan.

For those patients who are so desperately poor that they still can't afford the cost of care, there exists in the Muslim world a programme of Zakat--mandatory religious contributions which are administered by specially appointed bodies which collect funds and provide needed support to the poor.  At AKU, the Patient Behbud Society for Patients at AKUH disburses Zakat funds to poor patients.  Thus, between the Patient Welfare Programme and Zakat, the University does its best to ensure that  no poor patient is denied medical attention at the first stage. 

Through such multiple strategies we have managed to enable greater access for indigent patients than many other private hospitals.  What is different is that AKU's patient welfare programme provides access, not just to primary and secondary care services available elsewhere, but to tertiary care services as well, including life saving cardiac by-pass operations and extended medical therapy treatments.  And the care provided to the poorest of patients is of the same quality and given by the same physicians as that offered to patients in the Hospital's private wing.

The  principle of access also applies to AKU's students.  Through our education assistance programme, no student who qualifies for admission based on merit is denied access to any of our academic programmes.  All students benefit from heavily subsidized tuition, the fees for which cover no more than 25 percent of the true costs of education.  For those who cannot pay that amount, financial assistance is available.  In the Medical College alone, over 40 percent of the students receive some form of University-provided financial assistance, and in the School of Nursing two-thirds of the students receive help. 

While AKU is doing its best to close the accessibility gap in health care, its efforts would be wasted if the quality of care provided is not of the highest achievable standards.  Let me then address the next health care gap . . . that of quality.

When AKU was established, quality was one of its four basic principles.  AKU defines quality as being the best we can achieve in everything we do.  In the early days, AKU imported quality systems from North America, and we continuously benchmarked our quality standards against other outstanding institutions in the developed world to ensure that quality remained our highest priority.  Today, motivated internally by a passion for quality, we undertake periodic reviews of programmes and activities.  Faculty are subject to regular peer reviews, especially as a requirement for promotion, and medical outcomes are routinely compared against outcome standards in North America.  As a result, quality has never been an issue in evaluations by international funding agencies.   Quality is a part of everything we do, so much so that in the late 1990s the Aga Khan University Hospital embarked on a programme that institutionalised quality for everyone, from the security guard to nursing leaders and department heads to financial accountants.  In 2000, AKUH became one of the first hospitals in Asia to receive ISO 9002 quality certification.  Now we are striving for recognition by the Joint Commission for International Accreditation.  If AKUH receives JCIA certification as expected next year, it will be the first hospital in South Asia to do so, and one of only a few in the entire Asian continent.

Over the years, AKU has succeeded in setting examples for quality every day, and in many ways has become a model for other institutions.  When asked how we keep the campus clean, or evaluate personnel or how we maintain equipment, we share freely with those who ask and assist them in implementing their own quality improvement processes.  By setting examples in quality that others have readily followed, AKU has demonstrated that quality is contagious.  This is evidenced by a number of institutions in Pakistan emulating AKU's example.  Together we are setting new standards, helping to close the quality gap all over the country.  And, it is the University's aspiration that, just as it has begun to do in the Aga Khan Hospitals in Nairobi and Dar-es-Salaam, AKU's campuses outside of Pakistan will have the same effect in other countries of the developing world.

The next health care gap I'd like to address is that of relevance. 

When AKU was established, its mandate was to address the needs of the developing world.   For that reason, the curriculum for undergraduate medical and nursing education was not simply copied from what was done in North America or Britain.  Instead, the attractive features of these programmes were blended carefully with existing programmes in Pakistan, and adapted to address health and education problems of the developing world.  It is for that reason that 20 percent of a medical undergraduate's time at AKU is spent in the field, studying Community Health Sciences.  In their first two years at school, our medical students learn as much about ensuring fresh drinking water supplies and the importance of sewer lines as they do about managing illness.  They are taught to look at communities as their patients, rather than just individuals.  They learn to assess the health and social determinants of disease in communities, to plan appropriate interventions, and to assess the effectiveness of health care.  Those first two years of medical training are in areas that are directly relevant to the needs of people in developing societies.

And so is AKU's research.  There was a medical report on BBC World Television the other day in which the reporter described research in the industrialised world as ". . . all Viagra, botox and profits."   In the developing world, research has to be about chloraquin, ORS and saving lives.  It would be easy for us to tailor our research focus to those areas in which research funds are readily available.  But as important as it is to find solutions to problems of HIV/AIDS in developing countries, it is also important to significantly reduce infant mortality and malnutrition.  Or to discover why 33 percent of Pakistani women suffer severe depression, or 80 percent of the children in a Karachi sample have lead levels significantly above those known to cause neurological impairment.

At AKU we have a requirement that whatever we do, it must be relevant to the needs of the communities in which we serve.  Thus, closing the relevance gap is a key priority.

Let me now come to the last gap in health care that needs to be addressed, that of impact. 

There are two ways to exert impact in health care and education . . .  by changing practices and by changing policies.  This is often done by setting examples that others voluntarily wish to emulate--as in the case of operational improvements in hospital housekeeping or management information systems--or by working with government and individual institutions, sharing ideas and offering the benefit of successful experiences and lessons learned.  In this latter case, it means becoming a dialogue partner on government appointed committees and task forces seeking to implement wide-ranging changes and reforms.

When AKU was established, it was not meant to be just another University in which medical education was oriented only to bedside treatment of disease.  Rather it emphasised a new concept of medical education in which both the management of disease and the origin of disease are addressed.  When community medicine was introduced as a core programme at AKU, there were many sceptics in academia.  But, as the success of the programme in addressing primary health care problems became known, and support was forthcoming from the World Health Organization, other universities sought to introduce community medicine into their curricula.  Today, after many years of on-going dialogue between AKU faculty, the Ministry of Health, and the Pakistan Medical and Dental Council, community-based health care has become an important component of the curriculum in all medical schools.  Its impact on new health professionals is a more rounded knowledge of the origins and management of health problems, and a new emphasis on preventive rather than curative care alone.

In similar fashion, AKU sought to establish new standards for entry to medical college education.  Traditionally, entrance to medical schools in Pakistan was based on student performance in public examinations for higher secondary education at Grade 12 and the filling of quotas.  AKU adopted a far more structured approach to admissions.  Graduation results were certainly important, but so were the results of a separate AKU admissions test and interviews that proved to be better predictors of students' aptitude for medicine, their interpretative skills and their ability to adapt knowledge to problem solving.  Based on dialogues with government, the Medical Council and institutions, public medical universities in Pakistan are now adopting similar admissions tests to those at AKU.  The impact will be a dramatic improvement in the quality of students seeking admission, and ultimately the quality of graduates.

As was true for the Medical College, AKU's School of Nursing was not meant to be just another training institute for registered nurses.  Historically, nursing in Pakistan was seen as a low status, service-oriented career, for which training ended at the diploma level.  By viewing nursing as an academic profession, offering professional development programmes for women to the Bachelors and Masters degree level, AKU has continued to enhance the image and status of the nursing profession, in line with the long standing vision of the Chancellor, His Highness the Aga Khan.  Based on dialogues with AKU, the Pakistan Nursing Council's modernised curriculum aims to develop a new breed of nursing leaders in Pakistan.  Recently AKU has been invited to assist in the development of faculty and curricula for other, degree-level nurse education programmes in the country.

The impact of changes in the field of nursing was not just felt in Pakistan.  AKU's achievements in Pakistan led the governments and the Nursing Councils of Kenya, Tanzania and Uganda to invite the University to establish its Advanced Nursing Studies programmes in all three countries.  The ANS programme will upgrade nursing standards by providing much needed continuing education and career development opportunities for nurses in this region of Africa.

It is examples like these, and many others there isn't time to mention, that make me believe AKU is addressing the impact gap in health care in the developing world. 

In the minute or two still available, let me summarise what AKU and other forward thinking institutions are trying to do in the developing world. 

First of all, we are endeavouring to make health care accessible, not just at the primary level, but at the secondary and tertiary care levels where the need is great and resources are hardest to come by.

We are trying to raise quality standards.  Standards that many institutions in the developing world are committed to raise.  AKU programmes are models for other institutions who see that adherence to quality standards, and enforcement of quality practices that are rooted in indigenous initiatives, can and do lead to lasting and widespread quality improvements.  

Next, AKU and others are trying to ensure that health education, research and care are relevant to the needs of the communities we serve, learning from advanced institutions in the industrialised world but not allowing ourselves to be sidetracked into activities more relevant to developed world problems.

And we are engaging in activities and programmes that not only have high quality and relevance, but also have impact on health and education policies and practices.  Through successes rooted in problem-based research, we are increasingly being invited by policy makers in government and elsewhere to become dialogue partners and referees of choice when it comes to policy making.

But overall, the best description I can offer for the role new universities and institutions are playing in Pakistan and elsewhere in the developing world is that they are becoming agents of change.  They are endeavouring to change the thinking and attitudes of people in emerging nations, so that they may be better prepared to take their place in global society.

So how can we describe AKU's record at closing the health care gap in the developing world? 

Given that AKU has only been around for twenty years, I think it has achieved some modest success.  The fact that governments in East Africa invited AKU to replicate its nursing, medicine and teacher development programmes says something, and the fact that the University is receiving similar requests for assistance from countries in the Middle East and in Central Asia.  I think we have had an impact in another area of importance that I alluded to earlier, that of ethics.  Through ethics committees on campus, AKU is raising ethics awareness in health care as well as research, and international ethics seminars organized by AKU have attracted participants from throughout South and East Asia. 

In all honesty, the long term effect of our endeavours is yet to be seen.  AKU has probably made a good start, and new institutions following its example are raising the bar on quality and standards.  But make no mistake.  The struggle to close the health care gap in the developing world is gargantuan, and it needs the collective effort of not only indigenous universities and institutions, but also the help of established institutions in industrialised nations. 

AKDN, and AKU, and other development institutions like them, cannot take on the challenges of developing world problems alone.  We need partners.  We need linkages with institutions and agencies who can provide expertise, quality bench marks and funding.  We need partnerships with individuals who can give their professional knowledge and skills. 

While the tasks ahead are daunting, progress is being made. 

Let me close my address by summarising AKU's strategy for improving access to health care and closing the health care gap in the words of His Highness the Aga Khan.  At the University's Convocation Ceremony in Karachi in 2000, His Highness said that AKU ". . . is engaged in addressing national needs by developing high quality human resources in the fields of health and education, engaging in problem oriented research, working with government on policy issues, and reaching out to become directly involved in upgrading the delivery of critical social services at the local and regional levels."

While we are beginning to see some early success, AKU has only just started on a very long, upward climb to influence health care changes in the developing world.  We don't have all the answers.  But with dedicated faculty and staff, the help of our Aga Khan Development Network partners, and the support of donors and agencies around the world, we are striving to realise at least one important aspect of our founder's vision.  That is, to make a positive mark on the health care scene in years to come.

Thank you.