Culturally Competent and Financially Sustainable Healthcare

[MUSIC] >> Pushkin. [MUSIC] >> This is an I Heart podcast. [MUSIC] >> Tim Halford here. I'm the host of Cautionary Tales. We've teamed up with a couple of other great shows from the Pushkin Network to bring you a special episode all about mistakes and what we can learn from them. >> They said, swish the ketamine around in your mouth and then spit it out. >> And I swished it around in my mouth for about 30 seconds and then I swallowed it. [MUSIC] >> Listen to the episode on Cautionary Tales available wherever you get your podcasts. [MUSIC] >> This is Solvable. I'm Jacob Weisberg. >> So a lot of funding from international NGOs are focused on earmark on diseases such as HIV, AIDS, malaria. But the downside of focusing on shall I say popular diseases is that you're missing the neglected diseases. >> Providing healthcare around the world is noble work. Governments and international donors often have excellent intentions when they focus on high impact diseases and when they zero in on maternal health. But that can also lead doctors to skip past other health issues. >> For Dr. Lutfi Lachman, focusing on maternal health meant that the impact he could have on the community where he was working was too limited. >> I even got an award from the United Nations because I was focusing on maternity health, but I kind of feel I don't deserve it because it is not something that is very high impact. So now I'm just focusing on what the committee needs. >> That meant walking away from large international grants. It was a scary proposition. But Dr. Lachman knew there had to be a way to establish care for a wider range of ailments and to make those medical clinics financially secure. It was cross subsidization. >> You follow the principles of Muhammad Yunus, the Nobel Prize winner, founder of the Grameen Bank, and I think the inventor really of microfinance. >> Yeah, exactly. I think most people do think of him in the field of economics and lending. But here you've taken some of those ideas and applied them to provision of healthcare. >> So that's the model, cross subsidizing, community helping themselves. I really thought that this is a very good idea. And just this year, we've managed to become fully sustainable. >> Dr. Lutfi Lachman is the co-founder of Hospitals Beyond Boundaries. They hire doctors locally and provide a broad spectrum of care to meet the needs their community's request. >> The problem that I'm trying to solve is providing healthcare for marginalized communities in a financially sustainable way. >> Dr. Lachman didn't come to the idea for hospitals beyond boundaries easily or quickly. It began on a fateful night back when he was in medical school in Malaysia. He and some friends got together to decompress after a long week. They decided to play a game and they broke into two teams like armies. Everyone had small water balloon type ammunition, sort of like a version of handheld paintball. This is in the dark of night and in the jungle. And a warning here, some of this description is a little graphic. >> So it's a game, it was at night and people were separated into teams and we were in the jungle, you can attack each other. So what happened is that it was really dark, I couldn't see anything. And I hear like someone was running towards me and had this plastic bullet smashed directly at my ear. So the pressure was so strong that my eardrum was busted. And it fractured the mastoid bone. So that's where our brain fluids also flows too. When you get brain fluids looking out of your ear, it's pretty dangerous. Because if it gets infected, you can get brain infections. So I was rushed to the hospital and I was admitted for two weeks. I had to be on antibiotics continuously. I was a medical student. I'm not sure with the fear of whether what my future will be. That really changed the trajectory of my life. And so it's not just physical, but mental pain that I go through. So I guess why I wanted to start something is to have a sense of doing something that is part of a bigger community and trying to contribute to that community. >> How soon was it after that injury that you opened the first clinic? >> When I started the organization, it was half a year. But three years after that, that I started the clinic. Because we had to fundraise for the whole three years. I mean, it's very hard to fundraise when you're a medical student. You come to people saying, I wanna build a hospital, I wanna build a clinic. No one trusts you, you're still a student, right? So it took us a long time to get enough funding to start our first clinic. >> So what's the difference? I understand the idea that it's more of the community and I guess more culturally sensitive. Is it that people who otherwise wouldn't seek access to medical care will be more comfortable in the kind of institution you're setting up? >> Yeah, in a conversation of global health, we talk a lot about access. But a lot of people forget that access is not always geographical. That you can have a clinic just next to where you live. But there are other barriers such as a cultural barrier in which you are not comfortable going to the clinic. So one of the first project that we started was building a clinic in Cambodia. And the community around there do have access to clinics in the area. Cambodia has one of the highest densities of NGOs in the world. Second only to Rwanda. And a lot of these clinics are run by foreign NGOs and are meant by foreigners. So I'm not discounting their effort and their expertise. But it's just that a community don't feel comfortable discussing their health and their concerns because of, I guess, language barriers or cultural sensitivity. So in the end, what they decide to is to go back to the community and see traditional healers there. So that's the basis of the idea of hospital donor is just building a hospital or clinic that is modern, available for everyone to come and feel comfortable getting a treatment. >> Yeah, I mean, you're not a native to Cambodia either. You're from that part of the world broadly defined. But you're from Malaysia, which is, I don't know, I think over 1,000 miles away if I'm visualizing the map correctly. So what's different about you as technically, I think, a foreign NGO setting up a clinic versus the kinds of international NGOs you're talking about? >> So what we do is everything behind the scenes we hire from the local community. So we seek doctors from that community, nurses, midwives. And so it is 100% staffed by the local community. So the things that we do are basically fundraising, consultation, giving advice. But in the end, it is them who is running the show and it is them who's getting the credit. And we're not looking for any profit or any credit. It just makes us feel fulfilled and happy to see the clinic being sustainable. And having an impact towards the community. >> Right, so you're providing access to local doctors and local medical workers, presumably a lot of the people who come to your clinic would have access to those kinds of doctors. But is it they couldn't afford them and you're going to subsidize it or pay for it? >> So the model that we use is cross subsidization. So I guess this is another difference between us and other charity clinics that are funded by international organizations. So most charity clinics are giving free treatment for the poor 100%. But they are perpetually dependent on that funding, donations or grants. At Hospitals with Grand Boundaries, we are not dependent on any of those grants or international NGOs, we are open to all patients, not just poor patients. But those who are able to pay will pay the normal fees. And all the profits that is gained from that will be used to fully subsidize the poor. So it's kind of like a virtuous cycle and it's proven to be sustainable. Because you will never know if you're dependent on funding when that funding will happen, if anything happens, I guess that's the difference between us and other clinics. >> So the local providers are paid and are they paid what they normally expect to be paid? >> A bit more, actually. So the rate that we are paying is the same as what other for profit or private clinic in the area would pay their staff. And that is also one of the difference because we don't want to project an image of that because you're a clinic that treats the poor. So the condition or the appearance must be of the poor clinic, right? So and it's open for all. So it also eliminates the stigma of when someone goes to the clinic and the committee sees them going there, so he's a poor person, he going to that clinic. So we're eliminating that stigma. It's also a good way to retain patients because as a clinic doing primary care, it's very important to have your patient seeking treatment with you continuously. Because if someone has a chronic disease, you want to manage them if possible for a lifetime. But we also see a lot of patients who will climb up the socioeconomic ladder, shall I say, started as a poor person and then gets more income and climbs up the short social or economic ladder. And after he has been able to gain more income, he's still able to come to the clinic and now he can pay and contribute to the clinic so that other people will be able to be treated. So it's a very tight knit community and the places that we work. So whenever you come to this clinic, there's a sense of belonging. >> Yeah, I know you follow the principles of Muhammad Yunus, the Nobel Prize winner or founder of the Grameen Bank. I think the inventor really of microfinance and a big principle of him is the kind of sustainability you're talking about, right? >> Exactly. >> Business doesn't have to make much profit or necessarily any profit in the conventional sense. But it has to be able to pay for itself and support itself. But here you've taken some of those ideas and applied them to provision of healthcare. >> Yeah, so a lot of funding from international NGOs are focused or earmark on diseases such as HIV, AIDS, malaria, maternity. So these are all very important diseases. But the downside of focusing on high level and shall I say popular diseases to eradicate is that you're missing the neglected diseases, right? So for example, the place where we work in Cambodia, a lot of patients come with genital and urinary tract infections. This is mostly has to do with hygiene and nowhere can I find funding for that. So when I read the book by Muhammad Yunus, I really thought that this is a very good idea in which cross-epsidizing community helping themselves. So a particular chapter in Yunus book is about a patient who has talasemia. It's a blood disorder. It's genetic, so anyone can get it. So it doesn't select your social economic status. So they're the poor people who has that as the rich people who has that and middle income. So the middle income and the people who with more means are able to pay for the treatment of talasemia. But for the poor, they die by the fifth birthday. So in Muhammad Yunus book, he tells a story of how they cross-epsidize the treatments between the rich and the poor. So I thought that's a really good idea and we're going to do that in Cambodia. Dr. Lechman, I know it was your goal to build a hospital and clinic that would be modern and available for everybody and would be comfortable. How do you make people feel comfortable in a hospital? Oh, it's a lot of, I mean, it's a feel of study by itself. But I believe number one is the interaction with the staff. You'll feel comfortable when the staff are friendly, when they treat you well, they understand your concerns and treat you with respect. And that's also a good thing about running a clinic that is open to all, although you're focusing on the poor. The staff don't know whether you're rich or you're middle class or you're poor. So they have to treat you equally, whether wherever you're from or whatever social economic status you're from. Is it a model that can work all over the world or does it work best in small, closed-knit communities? I mean, how are you thinking about the potential growth of it? Yeah, I would say places like rural areas where everybody is poor and don't have the means to pay, it wouldn't work in those places. There's no like a blanket solution towards the problem of access to healthcare. But the model that we're using is something that would work in places like peri-urban areas and suburban areas. And even in urban areas where people, there are poor people like in Kuala Lumpur, there's still the homeless people, that would be the best model to follow. Yeah, I mean, part of what's so interesting about this idea is that it removes the almost colonial legacy of a lot of this care, the idea that rich countries are providing this out of charity and generosity to very poor people in poor countries. And you're not looking, at least in the main, for foreign doctors to come and volunteer. You're not trying to raise money that I can tell. Is that really viable? I mean, can you really finance this and provide the quality of care without some form of subsidy? Yeah, that's a very good point. And we're very familiar with the story of, you know, as in a European organization or from America coming in a community and becoming kind of like the savior of these communities. But coming into a community and thinking you know best what the community needs is actually a colonial legacy coming in and deciding things without consulting what actually the community wants. Right. And I've also fallen into this trap in the beginning. It's very difficult to find funding for diseases that now we want to treat in the community. So in the beginning, we were focusing on maternity health because there's a lot of funding on maternity health. But after a year, it didn't sustain. Nobody came because a lot of these global goals are a lot of efforts are being done by the government and also by international organizations. So I guess as a social enterprise or as a local NGO, what you need to focus on is the needs of the community and what they want, what not the funder wants. So it really took us a while to think about that. And I even got an award from the United Nations. I was selected as the United Nations Young Leader for Sustainable Development Goals because I was focusing on maternity health. But I kind of feel I don't deserve it because, yes, I did that service, but it is not something that is very high impact. So now I'm just focusing on what the committee needs. It's better for them to decide what to focus on and have the credit. Yeah. Dr. Lachman, I always like to wrap up by asking what our listeners can do to contribute to the solution, to the problem you've taken on. And this one poses a bit of a challenge because what you've been telling me in a way is that you're trying to find a solution to the problem of health care in these places that doesn't require help from abroad. But people listening, I think, who would be excited about this idea, what can they do to be supportive? I believe it's not that we don't need any support or funding from abroad. But my advice is not to earmark or make it specific. Have trust in the community and have some kind of accountability mechanism. Yeah, hopefully that'll work. Dr. Lutfi Lachman is the co-founder of Hospitals Beyond Boundaries, an organization that works to provide culturally competent and financially sustainable health care options, regardless of the financial means of the patients in need. Solvable is brought to you by Pushkin Industries. Our show is produced by Camille Baptista, Senior Producer Jocelyn Frank. Catherine Girardot is our Managing Producer, and our Executive Producer is Mia Lobel. Special thanks to Kobe Guilford, Heather Fein, Eric Sampler, Carly Migliore, and Khadija Holland. I'm Jacob Weisberg. Tim Harford here. I'm the host of Cautionary Tales. We've teamed up with a couple of other great shows from the Pushkin Network to bring you a special episode all about mistakes and what we can learn from them. They said, "Swish the ketamine around in your mouth and then spit it out." And I swished it around in my mouth for about 30 seconds and then I swallowed it. Listen to the episode on Cautionary Tales, available wherever you get your podcasts.