'Emphasis on primary healthcare services missing from public sector' An interview with Rafiq Rangoonwala, Trustee SINA

SINA is a not-for-profit organization dedicated towards providing affordable access to quality primary healthcare in urban slums of Karachi since 1998. Rafiq Rangoonwala is one of the trustees of the organization. He is also the President of Pakistan Food Association, and CEO Quick Food Industries, and has spent over 39 years leading different food brands in Pakistan and abroad. Following are the edited excerpts of BR Research's conversation with Rafiq about his plans for the organization and its future goals.

BR Research: Describe the objectives set out for SINA and the gaps it aims to fulfill in the market for primary healthcare service?

Rafiq Rangoonwala: SINA was formed in 1998 by Dr Asif Imam who wanted to give back to the community. The first clinic was opened at that time in one of Karachi's slums. The purpose was to target areas where help is needed most. As a result a lot of patients that need primary health services end up going to hospitals that are providing tertiary care. Primary healthcare typically provides health services for common ailments such as flu or fever that can have immediate solutions. Tertiary health services are specialized tackling chronic diseases.

But when primary healthcare patients overburden tertiary hospitals that are already bursting at the seams, it becomes a problem. And this has taken place due to massive population growth in terms of birth rates and urban population expansion due to rural to urban migration. The numbers of hospitals - including both public and private hospitals - do not have enough resources to support the increasing number of patients. Because of the growing number of patients who can be treated at the primary healthcare level, often the critically ill patients are left out of the healthcare system.

SINA fills this gap. Essentially, we are providing support to these existing hospitals. We are located in urban slums across Karachi. We have 30 clinic locations with about hundred doctors and last year we treated over eight hundred thousand patients. About eighty to ninety percent of the patients are Zakat-deserving.

We perform an extensive research before deciding a new site for a clinic based on different factors including demand-we don't just set up a clinic based on availability of land or donor request. We have to be very vigilant because over eight percent of donations are Zakat-based and have to be utilized most carefully.

Our clinics are carefully maintained and follow protocols of global standards. More than eighty percent of patients treated are women and children.

BRR: Does SINA also have testing laboratories?

RR: Every SINA clinic has a lab collection point, which is a basic collection point of samples. There are certain tests we do in-house at centralized laboratory, and others we get done through partners.

BRR: What is the process for identifying key areas or pockets where primary healthcare service is absent and critical?

RR: We have a team that surveys the city continuously. We collect data from different prospective neighbourhoods, including slums, through support from heads of communities or local unions on the number of households, and people living in the slums. We physically survey living conditions. We perform house-to-house visit to ensure that data collected is reliable. This gives us a sense about needs of households in different slums, demographics and whether the recipients accept Zakat or not.

BRR: You mentioned earlier that more than eighty percent of patients are women and children. Why is that?

RR: Unfortunately, in many of these communities, when a man gets sick, he may visit a doctor or even a quack to receive treatment but when women fall sick, they try desi totkas, or home-made remedies. Poor households don't want to spend money on women medical treatment or health. Our clinics make sure that women and children are provided with free healthcare, testing and medicines.

We maintain medical records/history of patients treated at our facilities which makes it easier for us to serve them, encouraging them to make return-visits when needed. We also have ultrasound facilities in some of our clinics. These particularly serve pregnant women allowing our doctors to offer immediate consult.

Many of these women cannot leave their homes for too long, let alone travel to Jinnah or Civil Hospital which may be both time-consuming and costly.

A wife or a mother of small children cannot stand in queues all day when she is the primary caregiver of her dependents - whether children or the elderly - and the primary homemaker. She needs a place at walkable distances, with short waiting period, and has the comfort that the clinic has her medical history. SINA checks all those boxes.

BRR: Are all services free of cost?

RR: We collect a token twenty rupees for registration on a patient's first visit. Beyond that, there are no fees for doctor consultation, tests, or medicines. We also have a list of referral clinics where patients may be recommended to if SINA staff feels that it cannot provide adequate care, or the illness requires secondary or tertiary level intervention.

BRR: What is the existing capacity per clinic and does the organization employ marketing efforts to encourage footfall?

RR: Depending on the size of the clinic, we may treat 150 to 200 patients per clinic and 3,000 to 3,500 patients from all clinics in a day. We plan to open more clinics in locations where some of our clinics may be under pressure. Some clinics need capacity enhancements. But we have a policy to never turn people away. As for footfall, the best marketing is word of mouth. When the clinic provides patients with good healthcare, and they get the right medicine regardless of its cost and are treated back to health for free, they spread the word. We have contracts with a few pharma companies for some medicines which allow us to procure authentic medicines. Others are procured from the market. Pharmacists on our team ensure that medicines purchased from secondary market are not fake.

BRR: Describe in more detail your data collection and record-keeping practices. Does SINA intend to set up a research unit?

RR: We have well-kept records of patient history, doctor interaction, treatment provided, and medicine administered.

Our clinics have paperless environment. We are the only ones in South Asia to have such a system in place on primary healthcare level. We have extensive data on prevalent diseases in each neighbourhood which is not available anywhere else.

This is a wealth in itself and helps us serve the communities better. If anyone is interested, we are more than happy to share the database with them provided the use is not for commercial purposes. We also intend to set up a research unit.

BRR: Pakistan's healthcare policy focus is tilted towards treatment and not prevention. Given your extensive experience and databank, have you taken any steps towards prevention?

RR: We have started health welfare community service. Moreover, we conduct awareness sessions during clinic hours. Many major diseases can be prevented through proper awareness. Common examples are water borne diseases, especially in slums of Karachi. Water treatment comes at a cost, but boiling water at home is practically free. Whereas drinking unclean water has widespread consequences. This is the kind of simple awareness that our healthcare volunteers share with the communities. Another example is mental health awareness. We help a lot of our patients in learning how to manage stress. In some of our clinics, we have advisory services by mental health professionals.

BRR: As you noted, there is a wide gap in the primary healthcare market and SINA is currently filling only a part of it. In addition, how do you ensure quality of health service?

RR: Yes, today if primary healthcare clinics number in hundreds, they should be number in thousands. But that's only part of the solution.

At the same time, existing facilities also need to be properly equipped with trained medical professionals, treatment protocols and authentic medicines. For instance, our practitioners undergo rigorous training sessions followed by mandatory exam appearance prior to starting work at the clinics.

We also have internal auditors and each clinic is audited periodically and if doctors don't perform up to the mark, we let them go. Our auditors have defined KPIs that evaluate the performance of the clinics. They look at customer satisfaction and quality of service delivery. Similarly, management has its own KPIs which include number of patients, cost per patient, number of clinics, employee turnover, among other things. Cost management is done by monitoring doctors' efficiency - without it, our per patient costs increase. We also have a proprietary system to monitors protocols; manage data for patient history and treatment, and doctor assistance. This helps us operate the clinics efficiently.

BRR: What is your fund-raising mechanism?

RR: Our donors are all local, both institutional and individuals. They may be big corporations, or local businesses. Since we don't advertise, we don't receive funds from the general public. We approach many corporations and are also approached by many. Some corporations such as pharmaceutical companies may give discounted medicines.

It all comes down to professional reputation, as public healthcare delivery is a credibility driven business. Donors want the assurance that their funds are being utilized efficiently and effectively. Some donors even support us by giving immovable land or supporting the construction of the facilities. They may also take care of two to three years of operational expenditure of the clinics as well.

BRR: As you pointed out, your organization is at the center of data collection on slums, households and primary health. Do you think you will be in the position to advocate policy given your expertise? In addition, do you foresee yourself partnering with government to expand your model of primary healthcare to other parts of the country?

RR: We will eventually want to do that because this model is easily replicable. More importantly, without public-private partnership, we cannot reach the masses. The government has requisite infrastructure in place, in whatever form it is.

Currently, we are working on strengthening our model and getting the protocols right. I would like to emphasize that awareness for primary healthcare is extremely important and is currently missing, not only in the general public but also from the public sector. Awareness needs to be built. Once this goal is achieved, public sector will be more open toward lending policy focus to this area.