Equitable access to comprehensive surgical care: the potential of indigenous private philanthropy in low-income settings.
BACKGROUND
Equitable access to surgical care is necessary for improving global health. We report on the performance, financial sustainability, and policy impact of a free-of-cost multispecialty surgical delivery program in Karachi, Pakistan built upon local private philanthropy.


METHODS
We evaluated trends in surgical service delivery, expenditures, and philanthropic donations from Indus Hospital's first 5 years of operation (2007-2012), projected these over the hospital's current expansion phase, compared these to publicly accessible records of other philanthropic hospitals providing surgical care, and documented the government's evolving policies toward this model.


RESULTS
Between 2007 and 2012, Indus Hospital treated 40,012 in-patients free of cost, 33,606 (84 %) of them for surgical procedures. Surgical procedures increased fivefold to 9,478 during 2011-2012 from 1,838 during 2007-2008. Bed occupancy increased to 91 % from 65 % over the same period. External surgical missions accounted for less than 0.5 % of patients served. Ninety-eight percent (98 %) of all philanthropic donations--totaling USD 26.6 million over 2007-2012--were locally generated. Zakat (obligatory annual religious alms in the Islamic faith) constituted 34 % of all donations, followed by unrestricted funds (24 %) and donations-in-kind (24 %), buildings (12 %), grants (5 %), and return on investments (1 %). Overall, donations received between 2007 and 2012 increased sevenfold, with Zakat increasing 12-fold. During 2013-2014, the Government of Pakistan provided land lease and annual operational grants totaling USD 9 million.


CONCLUSIONS
Local philanthropy can sustain and grow the provision of free, high-quality surgical care in low-income settings, and encourage the development of hybrid government-philanthropic models of surgical care.
Center for Global Surgery, Indus Hospital Research Center, Korangi Crossing, Karachi, 75190, Pakistan, lubna.samad@irdresearch.org.
Lubna
L
Samad
Mehreen
M
Iqbal
Ahson
A
Tariq
Wasif
W
Shahzad
Aamir J
AJ
Khan
D003695:Delivery of Health Care / Q000191:economics / Q000639:trends; D037921:Gift Giving; D005102:Health Expenditures / Q000706:statistics & numerical data / Q000639:trends; D006297:Health Services Accessibility / Q000191:economics* / Q000639:trends; D061889:Healthcare Financing; D006801:Humans; D010154:Pakistan; D011203:Poverty; D013514:Surgical Procedures, Operative / Q000191:economics* / Q000639:trends