How to save a life

Last week’s column about ambulance services drew responses from many readers. Most readers who sent me emails agreed with the basic premise that ambulance services need improvement, not only in their response time but also in terms of service delivery and the quality of vehicles that are used as ambulances.

Some readers were angry that this writer had criticised “charity organisations such as Aman, Chhipa, and Edhi, which are doing excellent work through public support, and deserve appreciation rather than criticism”. There is no dispute about their contribution. But a critical appraisal should be taken as constructive rather than destructive.

One reader, M Yasin, was angry at being “ruled by waderas (feudal lords) on [the basis of a] colonial model”. According to him, the colonial model is a form of “lutocracy [kleptocracy] that at its best in stealing public funds”. There is some truth in these statements. But I would rather blame the aristocracy or the elite in Pakistan. Feudal lords may be just one component of the elite. The other clogs in this aristocratic machinery are the civil and military bureaucracy, including generals, judges, and other officers of various ranks that populate departments and sections spanning all tiers of the state. In addition to bureaucratic and feudal elites, we also have businessmen.

Our capitalists and industrialists tend to behave more like ‘robber barons’ than benevolent beoparis (traders). This three-fanged elite structure of the Pakistani aristocracy, comprising bureaucrats, capitalists, and feudal lords, has usurped not only resources but also the fundamental rights of the people, the right to healthcare being just one of them.

If our bureaucracy enjoys health facilities at the state’s expenses, other segments of the elite have no dearth of money at their disposal to spend on top-class medical facilities available both in and out of the country. It is the people who suffer when they are unable to pay even a thousand rupees to an ambulance.

Mudassar Nizamani, another reader, who is the regional finance manager of the People’s Primary Healthcare Initiative (PPHI) Sindh clarified that the PPHI was “working throughout Sindh, except Karachi and Nawabshah, in primary healthcare”. He informs us that ‘PPHI Sindh has 200 [or more] ambulances in rural areas and charging just Rs6 per [kilometre] for Suzuki Bolan and Rs8 per [kilometre] for Suzuki APV ambulances”. For cardio patients, the PPHI offers Toyota Hiace for Rs10 per km.

Good to know. But let me add here that it was initially a so-called public-private partnership between the Sindh Rural Support Organization (SRSO) and the Sindh government.

The PPHI came into being around 12 years back, much before the PPP government came into power. However, the PPP government did try to improve its performance by registering it in 2014 as a not-for-profit company whose board of directors mostly comprised independent private citizens.

Mudassar Nizamani further informs us that “PPHI Sindh is managing 1,000 [or more] rural health facilities, which were deserted around 10 years back”. These facilities provide primary healthcare facilities free of charge. Being in the development sector, this writer has visited many such facilities in Sindh and can testify that some of them are doing some excellent work.

But this is all related to primary healthcare. While appreciating the good work done by the PPHI, we ought to highlight the need to go beyond primary healthcare and cater to patients seeking major operations that cannot be performed locally, apart from in three or four main districts of Sindh. Hence, there is a need for bigger and better ambulances. Suzuki Bolans and APVs offer bumpy rides that add to the miseries of injured patients or those who are in a delicate balance between life and death.

Moreover, the PPHI has only four laboratories, which are located in Hyderabad, Larkana, Mirpurkhas, and Sukkur. The rest of the diagnostic work is done by small-scale private labs whose staff and machinery aren’t up to the mark to perform reliable tests. Although the PPHI is a good model, it does need constant improvement and supervision. If this isn’t done, the initiative may relapse into a futile setup that only saps resources and fails to deliver the entire gamut of medical facilities required in both rural and urban areas – especially by those who are malnourished, poor, and almost always in need of medical aid.

Coming back to ambulance services, Dr Shimail Daud, a former president of the Rawalpindi Chamber of Commerce and Industry, suggested that an “Uber of ambulances” should be launched in the country. According to Dr Daud, such services are already being used in other countries, including India. A Google search by this writer confirmed that in some Indian cities – especially those in South India, such as Kerala – the Uber model is also being used for ambulances. What Dr Daud suggested may be of use in some major cities in Pakistan. But we often wonder if this is even possible in our country where almost half of the population is illiterate and hardly able to get three squares meals a day.

The most detailed and profound email came from Khaqan Sikander, who is head of strategic operations at the Aman Foundation. In addition to taking my feedback positively, he promised that the ambulance service staff would be trained to improve the service, especially in terms of responding to calls and informing callers about the time it would take to reach a particular destination.

According to him, “the number of lifesaving ambulances currently operating in Karachi are only 30 percent of the required figure”. The best news he offered was about the Aman Foundation’s effort “towards reaching an agreement with the government of Sindh to increase ambulatory fleets”.

It is heartening to note that the government of Sindh is also responding positively to such efforts. The Aman Foundation’s ambulances are far better equipped, with more space and proper blinds on their windows. This model needs to be followed by other services, which have many more ambulances that are in dire need of improvement. For any good ambulance service, it is vital to have life-saving equipment with trained staff who can promptly offer first-aid services so that travel time doesn’t harm a patient.

It is the state’s primary responsibility to offer quality health and education facilities for free to its citizens. If it cannot do that, it should at least regulate and support numerous trusts and foundations working across the country. If a ‘foundation’ or ‘trust’ starts fleecing people, the government should intervene to make sure that a private business is not run under the garb of charity work. The market forces have been effective in many other sectors. But if they are employed blatantly, not only in health and education but also in the provision of safe drinking water, they need to be regulated.

Most development and welfare projects fail – including the ones funded by international donors – because they try to do too many things at the same time. While multitasking may be useful for the corporate sector, a more focused approach is required for development and welfare. If this strategy isn’t adopted, projects will keep failing and people will keep suffering, even if millions and billions are spent on services that lack quality. The Aman Foundation, Chhipa, Edhi and many other entities need appreciation and, at the same time, consistent and critical appraisals.

The writer holds a PhD from the University of Birmingham, UK and works in Islamabad.

Email: mnazir1964@yahoo.co.uk