Your Worship the Mayor,
Representatives of International Agencies,
Ladies and Gentlemen,
It is a special occasion for me to be amongst such distinguished representatives of Government, non-governmental and private agencies here today: special because my family and I are deeply involved in social welfare and I particularly appreciate being amongst those who commit their time, resource and effort for the benefit of mankind. I hope you will not think its presumptuous of me to offer some thoughts on questions with which we are all concerned.
You may wonder why I am involved in welfare at all. As the Imam of the Ismaili Muslim Community spread over twenty-five countries, I have necessarily become a student of social problems. Islam is an all-encompassing faith and it gives direction to every aspect of one’s life. It urges the individual to lead a balanced life, one that strives to accommodate both material progress and spiritual well-being. But no man, woman or child can hope to achieve this balance in sickness, illiteracy or squalor. You are all engaged in the most vital business there is – the well-being of the people of the world – and I too, as the leader of my Community, have become deeply involved in the provision of basic health and education, which I believe are crucial stepping stones towards mankind’s self-realisation and growth.
I would like to quote a statistic with which you may well be familiar, but which is so appalling that it can hardly be quoted too often and which starkly illustrates the task facing the world’s welfare organisations. At this moment, less than two decades from the year two thousand when the World Health Organisation aims for health for all, 800 million people are destitute, surviving in conditions of absolute poverty.
I believe profoundly that effective achievements in health services, in education and in welfare generally depend upon a pragmatic approach to the realities which face us. Health and welfare are the predominant items in the governmental budgets of both developed and developing countries. Unhappily avoidable waste and duplication of effort occurs almost everywhere. Our resources, especially in the Third World, are limited. They must be managed as effectively as possible.
My own Aga Khan Health and Education Services, as you all know, operate in the private sector, although they collaborate closely with Governments and with international agencies. Our experience in these fields is considerable.
My grandfather, Sir Sultan Mahomed Shah, was one of the pioneers of immunisation in the 19th Century and the prevention of disease and public health have been major aims of our Health Services ever since. Today our facilities in the developing countries include 112 health centres and sub-centres, 27 medical centres, 18 dispensaries, 5 child care centres, 4 maternity hospitals, and 4 multi-speciality hospitals, excluding the hospital and medical centre currently under construction at Karachi. All are non-profit making. Additionally we use mobile units extensively in the rural areas of India and Pakistan. During 1982 we expect to accommodate 165,000 inpatients days in hospitals and to receive 1,300,000 outpatients visits.
The Aga Khan Education Services were founded in the early 1880s and today constitute a network of educational establishments and programmes in both the developing and, more recently, in the developed world. There are over three hundred institutions in Kenya, Tanzania, Pakistan, India and Syria ranging from day care centres through secondary schools to special schools for the deaf and the dumb. Educational programmes are open to all, regardless of race or religion, and there are currently over 35,000 students enrolled in the five countries, plus over 5,000 recipients of Aga Khan scholarships studying in institutions of higher learning throughout the world.
Utilisation of my schools and health services is today predominantly by other communities. Here in Kenya for example, non-Ismailis accounted for 95 percent of hospital bed occupancy in 1981 whilst 70 percent of the 6,000 students in our schools were from other communities.
So what have we learnt, during the last quarter century in particular, from these widespread activities? How can waste and duplication of effort be avoided? How can scarce resources be managed more effectively? Are new concepts applicable?
We have learnt the importance of regularly monitoring both the performance of both personnel and equipment to provide early warning of inefficiency or impending breakdowns. Do medical institutes take action to remedy the agreeing of equipment? Do teachers modernise the content of their lectures? When we travel in an airliner we expect both the machine and the crew to have been checked regularly because our lives are at stake in the plane. In the long run, sometimes in the short, lives and the fulfilment of human potential are just as much at risk if health centres are out of date or teaching is poor.
Unhappily consistent performance monitoring followed by corrective action is seldom normal practice in the Third World. It ought to be.
Attitudes to the application of welfare have changed substantially over the past twenty-five years. In the 1960s the idea was broadly to pump in money and let people fend for themselves. We have now come to believe that we should envelop the individual with support of all kinds. For example, we cannot always tell which aspect of welfare work will be most effective at village level. But we can, as it were, compound our impact by integrating assistance in health, education, sanitation, building, agricultural expertise and other areas. My Aga Khan Health and Education Services are currently working with UNICEF and other agencies on this concept of total support in rural areas of the Indian sub-continent.
Such support obviously includes primary health care. In this context I should mention that here in Kenya only last July our Health Services in Kisumu took an important step forward. Together with Government officials of Kisumu, of Nyanza Province, of the Lake Basin Development Authority, and of the Ministry of Health they jointly undertook a ‘think tank’ exercise to explore the possibilities of the private sector and Government sector working together to evolve an effective primary health care programme in the Kisumu district. The objective of the seminar was to define what interventions are feasible, and in what manner the initiative of the seminar could be translated into a joint approach to planning a primary health care programme. The seminar concluded that a primary health care programme could be planned, implemented and evaluated jointly through a partnership for progress between the Government and the private sector Aga Khan Health Services.
But above all it seems to me that the challenge of primary health care is one of management. Take patient referral systems. Are there adequate links between the smaller, intermediate and large institutions and between urban and rural health centres? Can the poor afford the costs of being referred to a higher echelon? Do doctors refer patients up the line when they should?
In trying to achieve effective management, do we make full use of the voluntary skills available? Professional people like accountants and lawyers can donate time and knowledge to welfare institutions, injecting valuable professional expertise. Such voluntary work has always been the lynchpin of my own Aga Khan Health and Educational Services at all levels.
Of course social institutions still need upper and middle level full-time management talents, of which there is a severe shortage. Furthermore, if we are to make the kind of all-enveloping approach I have mentioned there can be no distinction between the management standards demanded in social welfare and those required in business. In neither commerce nor welfare should one put in substantial capital – and the capital required in welfare programmes is substantial – without ensuring that management is capable of dealing with the investment fruitfully, although ways of measuring productivity will of course be different.
Take cost effectiveness in education; the Kenya Government’s Harambee Schools, for example, utilise self-help, local enthusiasm and voluntary effort. When a community is involved, there is an automatic process of accountability, as there is in my schools. But is this true at higher levels of State education? In privately run schools accountability is achieved through parent/teacher associations and student and staff evaluations. The parent is a shareholder in the education of his child and in our schools we encourage parents to guide this investment by taking a positive interest in the affairs of the schools.
Furthermore education must be meaningful to the needs of the nation. There must be a relationship between the kind of education provided and the requirements of the country’s economy and demography. This in turn demands control both of the curricula offered and of the quality of teaching, especially in profit-making schools.
Now I know that this can be a sensitive subject. In Africa, as elsewhere, the dream of many less affluent parents is to see their children in white-collar jobs, leaping what I might call the development gap in one jump. The ultimate result of this can be unemployed University graduates wandering the streets, while vacancies for plumbers, mechanics and tractor drivers go unfilled.
Developing nations needs, badly need, that wide strata of skilled workers which has long existed in industrial nations. Educational programmes must therefore take account of this and not only within schools – the parents need to be educated to understand what the future can hold for their children in certain occupations and not in others.
This brings me back to the fundamental point that social institutions require trained professional direction. The people employed, whether they are doctors or nurses, teachers or professors, agronomists, or water experts, or architects, must be able to see prospects of career development before them. They are human resources just as valuable as oil or minerals. Managing them, guiding the structure of social programmes, is a career in its own right. Both the public and the private sectors need these managers and the Third World Universities should establish faculties to train them and to run extension courses for voluntary workers in the field.
Furthermore professional managers of social institutions must themselves be offered career development and incentives comparable to what is obtainable in other fields or they will leave for greener pastures.
In other words, they must be provided by Government with an environment which enables them to foresee growth in their careers, stability in their futures, the chance to realise their full potential. Then, in return, they will be willing partners in building the nation.
I shall be speaking elsewhere about the enabling environment in which private enterprise can help develop a country’s material resources. Interlocking with it is the Enabling Environment which encourages those people who nurture the nation’s fund of human resource. If Government, through its laws and attitudes, creates a climate of stability, then those professional people will not merely contribute to development, they will of their own volition seek to improve standards. But if the environment is wrong, if it is disabling, then standards will fall, the quacks and the crooks and the corrupt will flourish and the good men and women will despair and leave.
This is why the Third World must create the Enabling Environment for social institutions to develop. For if the doctors and teachers and managers do not remain – and there are many countries which they have left – then no amount of money spent on health and welfare will effectively help the 800 million people who are destitute and miserable in the world today.