Every now and then a friend of mine asks me, why can’t I build a state of the art hospital? I have the financial capability, I have the land and I can pay to get the best doctors to come and work for me. This usually happens when the friend or a dear one of his has a serious medical problem. Indeed Pakistan needs state of the art hospitals that can provide the best possible care available and allow our well-off patients to stay in the country rather than travel abroad when in medical trouble.

Over the last many years I have been asked the question about building a state of the art hospital so many times that now I don’t take such a suggestion seriously. However, I do often think about this and wonder what exactly would be the problems we might confront when embarking upon such an endeavour.

Quite often my friends and colleagues working in the United States ask me the name of a hospital in Lahore where they could send their families for emergency care when visiting Pakistan. My response almost always is that it depends on what the problem is. For instance, if it is a heart problem then I suggest the Punjab Institute of Cardiology (PIC) as the best ‘cardiac’ emergency room. For general emergencies my recommendation is either Jinnah Hospital or else Mayo Hospital. However, once we go beyond emergency care, then there are important questions about the quality of care available in either of these public hospitals.

Let us presume that neither the land nor the finances are a constraint then what is it that would make building such a hospital a problem? The first problem is, of course, to decide whether to build a specialty hospital or a general hospital and the second problem is whether it should only cater to the wealthy or should it also cater to the ‘hoi polloi’?

First let me consider the question of specialty or general hospital. If the purpose is to build a ‘for profit’ hospital that can compete with the best abroad then the ideal situation is to start with a specialty hospital. This will require choosing a specialty that tends to be reasonably lucrative. The classical example is heart disease, especially that of the heart arteries (coronary artery disease).

From an epidemiological standpoint, this disease most often strikes the affluent and the newly affluent. And based on available treatment, it can be well managed and has good outcomes. However as it is, Lahore already has a plethora of private and hybrid hospitals that offer heart ‘stents’ and bypasses at reasonable rates making the competition quite tough. A new hospital specialising in this treatment will have to be particularly superior to the competition and that can be difficult.

Besides heart disease, there are other ‘clusters’ of medical problems or requirements that merit free standing institutions. Obstetrics (child birth), paediatrics, women’s diseases (gynaecology) and other such need a specialised institution that should also include care of the new born (neo-natal care). Other than that there are things like cancer but cancer is a disease that can involve all ages and any part of the body and a specialised cancer hospital by necessity also becomes a ‘general’ hospital that can take care of problems involving all ages and all body systems.

Of course, there are other similar areas that could support specialised hospitals but few specialties are quite as ‘sexy’ or as lucrative as heart disease. And in this connection, one question I am often asked is why can we not make a deal with a major heart hospital in America or England and have them build and run such a hospital in Pakistan as a franchise. Yes it could be done but then building a Cleveland Clinic ‘clone’ poses problems of a different nature. Having American doctors, nurses and ancillary personnel running around in Lahore can well become a security nightmare.

So, whatever it is we might want to do, we will have to use local staffing even though we might get some foreigner to manage it. Essentially, what it boils down to as far as making a state of the art hospital is to have well-trained physicians and staff and a modern facility that has the latest technology and treatment available. It can be done and it is being done already but these hospitals being ‘for profit’ institutions essentially squeeze the last rupee out of every patient. Not a very pleasant idea.

The other choice is to build a general hospital. This just increases the magnitude of financial input and management ‘hassles’. A general hospital must by definition include all important specialties and most importantly have an emergency department that can take care of all comers suffering from a variety of problems starting from the simple to the most complex including major trauma.

The problem for a good specialty hospital masquerading as a general hospital was well illustrated a few years ago when a child died in one of our better ‘private’ hospitals because the hospital was not geared to taking care of ‘paediatric’ emergencies. It is for this reason why our major ‘teaching’ hospitals provide the best emergency care since they have a depth of medical staffing and expertise available ‘in house’ that is hard for any private institution to duplicate.

So in essence my recommendation to any wealthy person desirous of building a hospital is to first decide whether this has to be a money-making exercise or a public service. A money-making proposition can survive once it is properly set up and develops the reputation for offering good medical care albeit at a high price. If it is to be a public service then the problem is of a different nature. Building a hospital and staffing it is just the beginning. Running such a hospital requires continuous financial commitment.

Yes, during the lifetime of a magnate, financial input can be counted on but what happens when things change. Trust funds are an obvious answer, the classical example being the Sir Ganga Ram Hospital in Lahore. But even so, a trust fund that might seem adequate today will become insufficient in the future as technology advances requiring greater investment to maintain an adequate quality of service.

If we take the example of Shaukat Khanum Cancer Hospital (SKCH) in Lahore, it survives because of continuous fund raising led by Imran Khan. Once Khan is no longer around whether SKCH will survive as a hospital of the standard it is at present becomes doubtful. One of the best ‘free’ hospital in Pakistan is the Sindh Institute of Urology and Transplantation (SIUT) in Karachi. This hospital survives due to the dedication and fund-raising abilities of Dr Adib Rizvi. What the future holds for the SIUT is difficult to predict.

The best advice I can then give my wealthy friends that wish to get involved in providing better medical care for the average citizens is, support existing hospitals, especially the trust hospitals and those in the public sector. Adopt a particular department and then subsidise it so it can provide better care.