3 Financial Requirements and Resources for the Future AKU
     
  3.2.1(B) Requirements and Resources for New Programmes in the Faculty
     
    We argued in Section VII above that the only attractive prospect for the future of AKUMC as part of a distinguished international university is to continue to grow in quality and strength. The growth we recommend in this Report, in research and graduate study, in a vigorous programme in Health Policy and Management, and in an enhanced education for all AKUMC students will be costly; it will require the recruitment on a wide international front of outstanding faculty and students. But these costs should not simply be seen as an additional burden on already strained budgets; this growth may be necessary to attract the resources the Faculty of Health Sciences will need to avoid stagnation and mediocrity over the coming decades. Only through programmes that attract national and international attention and support, and make AKUMC an educational magnet for the highest quality of students, can we foresee resources rising adequately.
     
  3.2.1(B1) An Expanded Research Programme
     
    In our general advocacy of expanded research programmes in the Faculty of Health Sciences in Section VII, we did not make specific recommendations on particular foci of this research nor on the level of activity it might involve. We regard closer specification and planning in these matters to be an important anti continuing task for the University, now vigorously initiated by the Acting Rector and a Research Committee of the Faculty. We did however take the views that : (1) research in the Faculty would be an indispensable basis of AKU's distinction in the sciences; (2) research should be an important purpose and activity in all the departments of the Faculty; (3) and, on the other hand, the Faculty should be more than a medical research centre and its research programme should not grow so vigorously as to deny resources to other parts of the University. It is incumbent on us, in keepin.with our general programme, to make some rough estimate of the minimum level of funding needed to assure the basic mission of the Faculty as a productive centre of research.
     
    We have noted that the recent paper from the Research Committee of the Faculty spoke of need for a research endowment yielding $1 million per year plus other support and capital funds. When the Harvard Report recommended an Institute of Biomedical Research in AKU it estimated its initial recurrent costs at $ 3 to $ 4 million/annum in 1983 dollars. Serious research activity does not conle cheaply and it seems clear that targets for AKIJ must be set pragmatically, with one eye oll prospective grant funding and the other on more generally disposable resources it may devote to research.
     
    The support of research on the health problems of the developing countries, both biomedical and that related to health systems and policy, is seriously inadequate at the present time. The recent international Commission on Health Research for Development reported in 1990 that only 5% of global expenditures on health research were directed to problems unique to the developing countries, and that less than 10% of donor assistance for health was devoted to research. The UNESCO World Science Report 1993 recites data showing enormous disparities between the gross expenditures on research and development between OECD and the developing countries (Canada spends more than twice as much as the Middle and Near East, North Africa and Africa South of the Sahara combined); it also calculates that medical research is particularly weakly supported in these regions, as is clinical medicine ' except for Africa South of the Sahara. [cf. tables at pp. 139 and 142]
     
    It would probably be overly sanguine to expect a major change in this situation over the period we tire surveying. The hope for AKU's future in health research must be that it will have the attractions of exceptional creativity and (juality. There are examples of research institutions in developing countries which have won strong and widespread support even outside the sheltering embrace of the Consultative Group on International Agricultural Research (CGIAR); the International Centre for Insect Physiology and Ecology in Kenya is one. We have also been encouraged by optimistic views on the possibility of linking AKU's research to the programmes of major research centres in the United States and other countries.
     
    Building adequate support for strong research programmes will undoubtedly require resourceful and persistent entrepreneurial effort. At some point, an appeal to the pride of Muslim countries is likely to be necessary. We have argued earlier that the Third World is not at all happy to be stumbling along in the wake of scientific progress made elsewhere. The desire to win places on the frontiers of research leads countries to support of fields in which they seem to have exceptional opportunities, as e.g., is now occurring in astronomy in India. We also note that AKUMC has recently been approached by the Pakistan Government to undertake a programme of training specialists in the basic medical sciences to remedy the notorious dearth of such people in the medical schools of Pakistan. Whatever the seriousness of this initiative, it is indicative of a kind of interest that may at some point bring programme funding from a host oovernment that would necessarily involve some research funding. Acceptance of research funding from such "local" sources will, of course, involve serious questions of autonomy and control, but we anticipate that there will be times and opportunities when AKUMC can prudently supplement its research funds from its own and foreign sources in this way.
     
    Another possible source of research funding for AKU's Faculty of Health Sciences is suggested by changing relationships between research and commercial development. The major university centres of medical research in the United States now face decisions over the extent to which they may benefit from lucrative commercial linkages without compromising their sense of obligation to pursue the frontiers of knowledge without regard to financial advantage. This conflict is both sharpened and, in another sense, eased by the narrowed gap between basic research in molecular biology and development of pharniaceuticals. Different positions are being taken by academic leaders, but some, like Dean Tosteson of the Harvard Medical School, believe that medical research centres can enhance their resources through carefully designed commercial linkages without compromising their basic purposes and reputation. When the World Bank reports [World Development Report 1993, p. 144] that more than 90% of household, out-of-pocket health expenditures in Pakistan are devoted to drugs, we can readily understand that there are strong motivations to developing national competencies in these matters. The possibility of attracting private investment and perhaps some forms of support from public funds would seem to be intrinsically promising. The presumption here is that an AKUMC research programme would not have to be focused on health problems that are special to Pakistan or where a Pakistan location has some unique medical characteristics. Like the current growth of software production in India it might simply arise from international comparative advantage in products that otherwise might as well be developed elsewhere. Grants and investments from abroad might thus be attracted along with valuable linkages to major medical research centres in other countries.
     
    We have dwelt at some length on the prospects of funding research in AKU's Faculty of Health Sciences because we are conscious of the difficulty of finding resources for what we regard as an essential development in AKU's future. We find the sum of possibilities encouraging. But we must also ask what level of funding must be at hand, at a minimum, to assure that AKU attains to distinction in medical research. Taking the faculty proposal that staff be able to devote 20-25% of their time to research, a simple calculation suggests that about $ 2.5 million/annum will be needed when the Faculty reaches the $ 13 million annual budgets (in constant dollars) that we have projected. If $ 1 million or $ 1.5 million of this total were to come from "internal" sources a research endwAment of at least $ 20 million plus special gifts would be needed. A target of $ 1.5 million per annum in research grants seems not unreasonably high.
     
    The possibilities of adequate financial resources for developing Health Policy and Management over the next decades look reasonably encouraging. The subject is one in which prospects of research contracts and consultancies on the problems of health systems should continue to grow. The management problems of health systems, from national to local and institutional levels, should also generate continuing needs for graduate and mid-career professional training that could bring substantial fee income. The competencies needed to build a high quality programme in this field lie heavily in the social and managerial sciences. As such they should not be solely at the charge of a unit in Health Policy and Management. For example, professional economic competencies should be drawn from the proposed Institute on Economic Growth, and there are clear relationships with the Community Health Department and the projected Institute of Human Development. This sort of interdependence of component units of the future AKU raises difficult organisation problems which should be considered in detail in a future feasibility study. While from the point of view of financial needs, these interrelations may provide helpful economies, they do not make estimates of net budgetary increases easy. David Bell has estimated [July 5, 1994 fax to F. X. Sutton] that at a minimum, the Health Policy and Management programme might require four to five seniors plus half a dozen juniors, with likely doubling as consulting and educational courses grow. Allowing for some sharing of staff, we assume that an additional $ 2 million per annum would be the minimum addition to the Faculty of Health Sciences budget, a large fraction of whicl; should come from grants and current income. Some of these funds, amounting, say, to $ 500,000 per annum, would ' however, have to be found in the University's general resources.
     
   

Similar considerations of staff sharing apply in the broadening of the education of AKUMC's students. This development should not depend on AKUMC alone. It should draw for course development and planning on the Institute of Islamic Civilisations, on IED staff, and on other parts of AKU as well. Ultimately, it may be found that much of this broadening becomes the responsibility of an Arts and Science Faculty, at least for a sizeable fraction of AKUMC's students. We assume that this development will depend significantly on fee income, and might in fact benefit from offering post-secondary education to some students who did not ultimately gain admission to the regular medical school course. In considering the financial requirements of the College of Arts and Sciences later we offer some relevant estimates of total budgets. We find the basis of estimates on this preliminary programme for the Faculty of' Health Sciences very precarious but guess that at full operation it may require at least $ 500,000 per annum not recovered from fees.
     
    In sum we foresee that the Faculty of' Health Sciences twenty five years hence will require at a minimum, recurrent funding as follows :
     
  For the maturing and expansion of existing programmes $ 13.0m
     
  For research programmes $ 2.5m
     
  For Health Policy and Management $ 2.0m
     
  For broadened education $ 0.5m
     
  Total recurrent annual funding $ 18.0m
     
    We return in the Summary at the end of this Section VIII to review the demands oll endowment and other generally disposable hitiols that these may entail. We shall also then have something to say about capital costs, which we have not included here.

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