Interorganizational Collaborations and Improving Surgical Access to Pediatric Cardiac Care in Pakistan: an NGO’s Perspective ​

The basis of the model is a nationwide, horizontal integration of a CHD based NGO with tertiary care hospitals offering pediatric cardiac treatment. This creates an IOC system that works through in-network referrals. Each IOC hospital is mutually responsible for providing all necessary resources for timely surgeries of patients through a Memorandum of Understanding (MoU). 15% discounts on all standard packages for CHD surgeries is levied as fee-for-service incentives for the network hospitals. The cost of disposables and consumables is also discounted at 15%. In cases of mortality, some IOC hospitals commit to forego all their fees and charges, including hospital and diagnostic services. Surgeons and all medical staff are reimbursed in full on a successful case and partially in the event of a mortality. IOC hospitals continue to receive an estimated 33% hospital service charge. This presents itself as a further incentive to stay in-network and, therefore, provide dependability of a sustained surgical resources. 

Finally, a detailed bill is sent to the NGO at the time of discharge and has to be settled within 60 working days from the date of the invoice and at a maximum of $32,000 outstanding. This credit-reimbursement payment system allows patients to receive surgical treatment at the nearest appointment instead of waiting for surgery while arranging finances. Thus, through referrals, the NGO’s partnerships with hospitals allows (i) distribution of patient volume across the IOC hospitals (ii) an increase in patient turnover because of an alternative revenue source and (iii) overcoming low resources, such as surgical equipment, medicines, and healthcare professionals, through utilization of resources collated via the network. This collaboration presents the added advantage of patient data collection and recording at a single CHD registry maintained by the NGO. Which will facilitate research initiatives, quality improvement and implementation of evidence-based surgical practices. This is imperative because apart from, Bushra, Muneer, & Mehnaz (2013), there is currently no published data on CHD surgical outcomes in Pakistan. Finally, additional funding is sourced by forming IOCs between both national and international corporate social responsibility sectors of other organizations. 

IOCs with other health-based NGOs helps with subsidizing surgeries and increasing patient turn over by (i) adding external funding to the CHD network through donations and by (iii) additional media for increasing referrals. 50% division of expenses between both parties is mandated. Partnerships with international NGOs also offer more resources to help build sustainable pediatric cardiac programs in LMICS. In countries like Pakistan, to improve access to surgery, it is also important to overcome the stigma of seeking treatment and to create an awareness of available treatment options. Global collaborations assist in research-based awareness and advocacy of CHDs. These partnerships also extend towards quality improvement collaboratives and for measuring surgical outcomes using global standard sets. 

Finally, to tackle a deficient health workforce, IOCs with national and international tertiary care hospitals and NGOs provide a platform for capacity building. These IOCs help train junior health professionals in innovative CHD management techniques through medical missions or workshops. The objective is to increase resilience and skill amongst the health professionals to tackle low resources in the country. This also allows training of health professionals in a short period of time. Figure 1 summarizes an NGO’s perspective of an IOC model incorporated into the CHD infrastructure in Pakistan. 

The illustrated model has shown potential in different contexts. For improving health service delivery in other health sectors, Hall et al. (2019) reports its effectiveness in Timor-Leste. The systematic review concluded an improvement in the mental health status of the population because of IOCs between non-clinical and mental health services. In the context of public-private partnerships (PPP), the Poor Patients Relief Program in Nepal provides free health services to the indigenous population. Service delivery is through government engagement with NGOs and private hospitals/clinics (Saxena,2018). The Narayana Health Program in India is an extensive partnership program between multidisciplinary hospitals. This partnership helps provide affordable treatment, covering 30 medical specialties (Saxena, 2018). In Pakistan, IOC in a PPP context has demonstrated success in primary health care. The District Rahim Yar Khan Project incorporates an IOC between Basic Health Units (BHU) and the Punjab Rural Support Program, an NGO (Ejaz, Shaikh, & Rizvi, 2011). In the CHD sector, however, a PPP based IOC presents challenges. Of the 5 hospitals providing CHD surgical services, only 2 are in the private sector.  Additionally, all these centers are present in an urban setting. Promoting IOCs between health NGOs would have to be prioritized for CHD surgical outcome improvement, initially.