I am honored and humbled to receive the Urology Care Foundation™ Humanitarian Recognition Award for 2024. I am also thankful to the AUA for giving me this opportunity to highlight our model of free care to the poor in low-income countries.

After graduating from Dow Medical College Karachi in 1961, I proceeded to the UK for fellowships in surgery. I was awarded fellowship from The Royal College of Surgeons (London) and The Royal College of Surgeons (Edinburgh) in 1967. I was extremely impressed and influenced by the National Health Service in the UK, where medical treatment was provided free to all. In 1971, I returned to Pakistan and joined an 8-bed urology ward as assistant professor in Civil Hospital, Karachi. Back home, I came face to face with the “poverty” as I treated the impoverished of our society. Those who could not buy their next meal had to purchase medicines and surgical consumables as they were not provided by the public hospital. I guess humanism was imbibed in my character growing up in a village where rich and poor lived together and poverty was not stigmatized. I decided to engage the community to help these patients in cash and kind, thus leading to the establishment of a community-government partnership to provide “free-of-cost” care to the society. I was lucky as like-minded physicians, surgeons, and allied professionals joined my team on this journey. We all believe that “health is a birthright irrespective of caste, color, creed, or religious belief.” It is important here to give some economic indicators of the Pakistani population. Pakistan is a low-income country where per capita income is $1658/y, 50% live below the poverty line, and 65% reside in rural settings. The government expenditure on health is 1.2% of the gross domestic product.¹

A Model of Community-Government Partnership

The development of this model was gradual. The government provided the infrastructure and staff salaries and the community contributed by cash or in kind to run services. The community was engaged through press, electronic media, and presentations at corporate houses for donations highlighting the free medical services rendered at the urology unit. In recent years, social platforms Facebook, Instagram, and Twitter/X have disseminated the institute’s awareness programs and services. A trust was established in 1986 where government officials and notables of the society were appointed as trustees. For transparency and accountability, the accounts were audited by independent auditing firms. Because of its services, the government helped by elevating the urology ward to Institute of Urology and Transplantation by an act of parliament in 1991. A yearly grant-in-aid was given from the provincial budget.^2,3 Several schemes were initiated to fund treatment and expand facilities: (1) sponsor a patient, (2) fund to purchase equipment, and (3) establish a unit, eg, 20 machine dialysis unit.⁴

The success of the model motivated both the government and the community to help expand services. The government increased the yearly grant-in-aid and business houses came forward for infrastructure development. Business houses constructed a 6-story building worth $5 million in 1990, a 6-story oncology center fully equipped with radiation therapy worth $7 million in 2000, and a 14-story fully equipped transplant center worth $15 million in 2016.⁴ The contributions of the community and government on a year-to-year basis exceed $50 million (Figure 1).

Expanding Facilities in Response to Patients Need

Initially the bulk of the urological workload was patients with stone disease. Many presented with neglected stones in renal failure and end-stage kidney diseases. Nephrology services, including dialysis, were initiated to treat these patients. Thereafter, “free dialysis” brought patients to the institute from all over the country, and this increase led to renal transplantation in 1985.

Table. Growth of Services at the Institute (2013 vs 2023)

The Sindh Institute of Urology and Transplantation (SIUT) motto has been, “All facilities under one roof and remaining at the cutting edge of technology.” Therefore, today the institute, in addition to urology, nephrology, and transplantation, offers surgical and medical facilities for general surgery, vascular surgery, head and neck surgery, internal medicine, gastrointestinal, hepatobiliary, cardiology, oncology including breast cancer, infection diseases, neurology, pulmonology, critical care medicine, ophthalmology, laboratory medicine, radiology, radiotherapy, and nuclear medicine. Technology allows the treatment of more patients due to the benefits of economies of scale. Minimally invasive surgery and extracorporeal shock wave lithotripsy were initiated in 1988, percutaneous nephrolithotomy in 1995, and robotic surgery in 2020. The institute is now the biggest robotic surgery unit in Pakistan providing training to surgeons from within and abroad.

Taking Facilities to the Doorstep of the Patient

Poverty restricts frequent travel within our city and from other cities. Given this, the institute established 5 satellite dialysis centers in Karachi 5 to 10 km away from the institute where the buildings were donated by the community. The government helped establish urology and dialysis centers in the cities of Sukkur, Larkana, and Nawabshah 500 to 600 km away from the institute. Satellite centers have resulted in substantial savings in time and travel costs for the patients. Patients residing near and around Sukkur and Larkana reach these centers within 1 hour, as compared to 7 to 8 hours to Karachi, and travel costs were reduced from $10 to $30 to $1 to $2 per daily visit.⁴

Summary

The model has successfully treated over 30 million patients free-of-cost in the last 50 years. The number of patients dialyzed yearly in all the centers exceeds > 5000 (Figure 2, A). Thus far, more than 7000 renal transplants have been performed, an average of 350/y (Figure 2, B). Urological diseases in both adults and children constitute more than 50% of the workload, where yearly patient volume exceeds 3.5 million. Yearly surgical procedures exceed 140,000, 40% of these for stone disease (Figure 3). The growth of services from 2013 to 2023 is summarized in the Table.

Conclusions

This model of community-government partnership has been sustained for the last 50 years. The hallmark of sustainability is equity and transparency of services and state-of-the-art treatment facilities under one roof. This model has been possible through the generosity of the public, the support of the government, and most importantly, the SIUT team—their dedication and timeless patient care (Figure 4). Our model of community-government partnership may be emulated in other low-income countries to provide free care to the poor of their population.