A replicable health fix for the poor

People in low-income urban communities are likely to have health problems, experience limited access to health care

KARACHI:

Her head covered in a green dupatta draped over a long loose frock, clutching a pink registration card she peeks at a nurse from behind her husband at the registration window of the clinic. Nasreen Khatoon* had never thought that good health care service could be accessible to her free of charge. As hospital trips meant long hours of waiting, a doctor in a hurry and an impatient queue of women behind her, she had always believed that attention from doctors and best treatment and medicines are only for rich people. But not anymore. Now she even thinks her baby-on-the-way is a lucky one.

Nasreen who lives in Mehran Town, Korangi, regularly visits the SINA clinic near her house for check-ups as this is her third pregnancy. Her experiences with other hospitals are vastly different from SINA clinic, where she feels safe and welcome.

Named after Ibn Sina, the preeminent Muslim physician, the SINA Health, Education & Welfare Trust is a privately funded not-for-profit organisation, serving low-income urban communities since 1998 with a healthcare system that understands poverty and low-income status. Nasreen goes to one of a network of 38 SINA clinics, of which three are referral clinics and three are mobile.

Pro-poor healthcare

Generally, people in low-income urban communities are more likely to have health problems and experience limited access to health care. Catering to the needs of more than half a million such individuals annually, SINA clinics provide quality primary healthcare through funding. The majority of these are women and children, while over 80% are zakat eligible.

To ensure that the patient is eligible for zakat, SINA takes help from Dar-ul-Uloom zakat evaluator. “It helps to find out whether the patient is eligible or not, based on criteria such as people earning 35, 000 rupees or less a month and some other factors,” says Ambareen Kazim Main Thompson, CEO of SINA health, education, and welfare trust.

Since poverty and location often limit healthcare, SINA clinics are located largely in slums and settlement areas of Karachi such as Machar Colony, Baldia Town, Mehran Town, Korangi Ittehad, Yousuf Sahab Goth, Mewa Shah, Konkar, Mubarak Village, Kakapir, Hingora, Gujar Gadap, etc. Most patients from these areas apply for zakat.

Interestingly, 70% of SINA employees are women, while among their 1.5 million patients, 78% are women and children. “We have a strength of 500 people of which more than 400 are doctors, paramedics, and nursing staff, while more than 50 are lab technicians. “Each clinic has 1-3 doctors with paramedic staff,” says Thompson.

According to the Government of Sindh and SINA statistics, most parents do not take their children to hospitals for immunisation, but SINA clinics have played a huge part in the government’s initiative of vaccinating one million children under two years of age.

“Essential vaccines are provided free of cost and in this way, we are helping parents with easily accessible health care,” says Thompson.

SINA clinics which are a one-stop shop with doctors, lab facilities, and provision of medicines, are run with the help of donors. It was a joint effort by some Memon families to provide healthcare to people in low-income urban areas. Plans are underway to extend the services to some areas of Balochistan.

“The clinics began with 20-25 donors and today the system stands at more than 100 generous donors who want to help improve healthcare in the city,” says Thompson.

The clinics use a computerised system from registration to the provision of medicines. At the registration window, the patient is registered through a tablet in the clinics’ information system. In this way, the patient gets a unique registration number, and a digital profile is created in the SINA system with data that includes vital checks such as blood pressure, weight, and height, right up to further treatment and referrals.

Tools and technology to save time

As a next step, patients are referred to a male or female doctor depending upon the preference or nature of treatment required. The doctor also has a tablet similar to the one at the registration desk, so that when the patient arrives in the doctor’s room, the doctor already has the basic data and mandatory details in his tablet instead of messing about with papers and files, the case is ready to proceed further.

“The data in the tablet also includes a record of symptoms that the patient shares with us, as well as the doctor’s observation,” says Dr Erum Wahid who mostly deals with pregnancy and gynecological issues at the Mehran Town clinic.

“Since the computerised system maintains a record of patients with their name and medical record number, it is easy for any doctor to check the history if the patient visits any other SINA clinic or if another doctor sees the patient at the same clinic, in case the previous doctor is replaced or on leave,” adds Dr Wahid.

This smooth digital system not only saves paper, but also time and effort for both patients and medical staff. Since the clinics have lab test facilities on premises so it saves time, money and effort to commute somewhere else to get tests done.

“The best thing about our success is that we have zero patient drop-outs,” says Thompson. “Here the doctors and staff invest time in the patients by giving them attention and listening to their issues in detail. Whereas research shows that at government facilities, each patient gets 32-45 seconds of interaction with the doctor, and the patient cannot explain their problem in such little time.”

She points out that so far only five clinics are not digitised, but those that are digitised maintain a data of patients from the last four years.

A SINA health care facility is different from an NGO or donor-invested facility, because here the idea is to provide easily accessible health service. The step-by-step facility is connected to the patients and their overall treatment so they feel content that they are being heard and treated well. They also feel happy that the solutions provided for their medical condition are the same as that of a privileged patient in an expensive healthcare system.

“House officers from medical centres such as the Aga Khan Hospital, Indus Hospital, and Jinnah Post-Graduate Medical Centre work at the SINA clinics on a six to eight week rotation programme to get an exposure to our digitised patient care system,” says Thompson, adding that the clinics are CCTV monitored and the thorough process of a check and balance ensures the best value for a patient coming to a SINA clinic.

“Upon arrival at the clinic, the patients are given a colour-coded card at the registration window, based on their zakat eligibility,” says Samoona, a backup supervisor. “They either receive a yellow, pink or green card and a log book as well as a digital record is maintained.”

Next, the vitals are done and doctors check the patient, recommend tests, and prescribe medicines.

“The clinics also have a sample collection facility and our labs provide results in 24 hours which are uploaded to patients’ profiles,” shares Samoona. “A pharmacy at each clinic provides a medicine basket for the patients free of cost which ensures that they will not leave the treatment halfway just because of affordability issues.”

If required, a second round of medicines are given to patients upon provision of empty boxes, strips and wrappers, to ensure that they have been consumed and not thrown away or sold, which is a common practice in the areas where the clinics located.

The idea is to provide free services to public, but a token of Rs 50 is charged to give them a feeling of responsibility. In this way they feel they have spent some money and in order to get value for it in return, they must follow up on their treatment.

“If they don’t spend from their own pocket, they never take the idea seriously and disappear after a couple of visits,” says Thompson adding that there are no charges for tests, but the medicine basket costs Rs100 rupees which would cost a lot more in the market.

Special initiative for kids

SINA clinics have also established the Childlife Foundation which offers a paediatric emergency service. It has been observed that prior to its setup, if 100 children were taken to the government hospital emergency, around 70 children would be admitted to hospital because of gaps, issues and pressure on their system. But in the Childlife Foundation paediatric emergency, only four children out of 100 need to be admitted, and the rest are sent home after receiving correct and prompt treatment so that minor issues do not become full blown problems because of delay etc. “This has considerably reduced the burden on government hospitals,” says Thompson.

SINA’s greatest asset is its unique quality management system, which has adapted quality healthcare protocols used in developed healthcare systems for application in low-income settings. The doctors at SINA clinics are trained to use this protocol-based system and their performance is evaluated on a monthly basis by a medical team at their head office.

By providing accessible, affordable and high quality healthcare, SINA clinics have not only set a benchmark for low income urban areas, but also taken pressure of government and NGO health care setups. With Pakistan’s population at 235,824,862, and health being a basic right, the SINA model should be replicated by the government, NGO and private health care authorities to improve health service to other cities as well.