Dr Adib Rizvi of the Sindh Institute of Urology and Transplantation (SIUT) received a ‘lifetime achievement award’ at the recent Lahore Literary Festival (LLF). The award was clearly well-deserved though I did not quite catch the relevance of Dr Rizvi’s medical accomplishments to literature that is the supposed bailiwick of the LLF. That said, it is perhaps important for people in the Punjab and in Lahore to know what Dr Rizvi has accomplished at the SIUT.

Without going into excess detail, SIUT is a major teaching hospital that provides first rate treatment for all sorts of medical problems related to kidneys and surrounding organs. Three to four hundred kidney transplants are performed each year. Besides that thousands of patients receive other forms of treatment including kidney dialysis. And most importantly all treatment is provided free of charge to patients. Free means free and it is free for all patients without any means testing. And that is perhaps what makes SIUT so unique.

There are many other hospitals in Karachi and in other parts of the country that provide excellent care at subsidised rates or even for free to some patients but no other hospital in Pakistan provides such advanced medical care completely free to all patients. The Shaukat Khanum Memorial Cancer Hospital (SKMCH) in Lahore is an outstanding institution and does great charity work, but perhaps only a third of the patients receive completely free treatment and possibly another third receive subsidised treatment. And these free and subsidised treatments are subject to ‘means testing’.

Before I go any further, I must say something about means testing. What that means is that the hospital makes sure that the patient is poor enough to deserve free or subsidised treatment. The problem with this approach is that it subjects many patients to humiliating interrogation to prove that they are poor enough to deserve free or subsidised care. Frankly, in my experience, there are few ‘middle class’ salaried people that can afford the sort of advanced cancer treatment offered by SKMCH without going bankrupt.

Coming back to SIUT and Dr Rizvi, when I heard that he was getting the lifetime achievement award at the LLF, my reaction was both of satisfaction and of an abiding sense of sadness. Satisfaction that a deserving person was being honoured and sadness because it needed a special person to build something like the SIUT. That is the problem with much of what happens in Pakistan. Institutions that are centres of excellence like the SIUT are rarely built without unique individual leadership.

The history of SIUT is interesting. It started as a small unit in a government hospital and because of the efforts of one person developed into what it has become today. But then it was not Dr Rizvi alone who built SIUT. He was able to collect a number of people that believed in him and in his vision both within the medical community as well as in the public willing to provide financial support. And most importantly the political leadership in Sindh decided to make SIUT a truly autonomous institution.

There are a lot of people in medicine that can and wish to do the right thing but they rarely get a chance to prove their capabilities. In a country with as many people as Pakistan, by now there should have been dozens of physicians trying to build SIUT clones all over the country. Where are these people?

No I am not willing to accept that of the thousands of doctors that have been produced just in Karachi alone over the last few decades, there are none that were inspired by Dr Rizvi’s example. And as far as the Punjab is concerned, other than SKMCH there are no other first rate hospitals that approach the concept of free care in a serious way. Yes there are a lot of ‘trust’ hospitals around but few if any of them really attempt to provide free or even heavily subsidised specialised medical care for all patients.

The question I brought up as to why we do not have hospitals like SIUT all over the place can have many answers. First of course is that the SIUT concept of entirely free medical care is difficult to implement when ‘private practice’ remains the primary source of income for most medical and surgical consultants. So no paying patients, no private practice. This is also true of most government-run teaching hospitals. As such there exists at best a two tier system of care in these hospitals, one for paying patients and one for ‘charity’ patients.

Personally, I am not aware of the system of remuneration for doctors working in SIUT but I am sure that they are not allowed any private practice. This if correct presumes adequate salaries to attract and keep first rate medical staff. Here another important point about SIUT. It is primarily an ‘autonomous’ government hospital and has an official budget but much of its expenses are met through charitable private donations.

And that is where people like Dr Rizvi come in. His reputation for financial probity combined with demonstrated skill in creating and running a first rate institution is so well established that he can generate enough donations to run SIUT and its satellite centres. That is also true of Imran Khan who has over the years managed to build and oversee a first rate cancer hospital funded primarily through private donations. Though in case of the SKMCH, significant payments for patient care augment budgetary requirements. Here an important point needs to be made. People in Pakistan are generous and give freely to reliable charities and charitable causes.

It is possible to run completely free medical centres in the public sector without outside donations as was demonstrated on a small scale in Mayo Hospital in Lahore a decade or so ago. Unfortunately, the change in the Punjab government ended that experiment. Perhaps if that system of free care had continued it might have collapsed or succeeded, but we will never know.

Coming back to SIUT, as a part of the government hospital system it functions as a truly autonomous institution. It, therefore, presents the perfect example of ‘public-private’ collaboration. If major medical centres that are presently run by the Punjab government are made truly autonomous then it is possible to create an environment where private donations can augment public budget allocations to provide first rate medical care for free or greatly discounted.

The problem in the Punjab is that the bureaucracy and the political leadership want to keep total control over appointments and personnel matters. As such no major medical tertiary care centre or any medical university in the Punjab is truly autonomous. They are all completely susceptible to political pressure and manipulation.

In such an atmosphere it is virtually impossible to develop external financial support or institutional improvements based on medical and not political agendas. Even somebody like Dr Adib Rizvi would not have been able to build an SIUT clone in Lahore. And that is what made me sad when Dr Rizvi got his award at the Lahore Literary Festival.