Rashid Khalani is the Chief Executive Officer of the Nairobi-based Aga Khan University Hospital (AKUH). In this interview with IJEOMA NWANOSIKE, he discusses why investing in health systems is essential to reversing the brain drain and shares the hospital’s broader vision for advancing training, research, and technology-driven care across Africa.

Medical brain drain remains a major challenge across Africa. Why is it difficult to retain healthcare professionals?
Doctors need three things for them to stay back. First, they became doctors to help others, but they cannot help others if they do not have the right tools. If the radiation oncologist doesn’t have the linac, the medical oncologist doesn’t have the chemo drugs, and the cardiologist doesn’t have the Cath lab, then they cannot practise good medicine. So, you have to provide the right tools for them to practise.

Secondly, you have to create a good environment to practise medicine. That means a multidisciplinary approach, having availability of the technicians, nurses, lab, radiology and all the systems that support the clinician to do what they are trained to do. If that environment is not there, then people get frustrated and they leave.

And the third part is the compensation. If a cardiologist can be paid $10,000 in the UK, why would he stay back and earn $2,000 in Kenya? There is no exception, because they will say, “How will I fund my children’s education?” So, unless you can address these issues, it becomes difficult to retain your best talents.

What role should governments play in tackling this challenge?
For compensation, I will take you to the Abuja Declaration, which stated that African countries need to spend much more on their health so that they can pay the clinicians, nurses, and acquire technology. But I wonder if we are even close, as no sub-Saharan African country is beyond five per cent in health budget.

The intention of governments is right, and many countries are now talking about universal health coverage, but we must do it right, and ethically and non-corruptibly. Otherwise, those funds will not go into equipment, research or education, or to the doctors and nurses. They will go into someone else’s pocket, which will be wrong. So, increasing investment is critical, but governance and accountability are equally important.

How are you addressing retention within the health system?
If you start paying consultants what they deserve such as $10,000, $15,000, $20,000, then your cost increases, because in a hospital your biggest asset is the doctor. And if that asset is expensive, then the price of your services becomes expensive. That is the reality. That is why the government has to come in and contribute through social health funds or universal health coverage to get the right quality of doctors who are rightly paid what they deserve, and without compromising the quality of life for them or their families. That is the balance that needs to be achieved.

How is AKUH contributing to building the next generation of healthcare professionals?
Our founding Chancellor made an important decision that treating patients is not enough.

Treating a patient is episodic, you treat them and they go home, but when you train a doctor and nurse, you’re making a long-term sustainable impact in the family of the individual, and communities where they come from and in the countries where they live.

That is why 2004 was an important milestone for us, when we converted from a hospital into a teaching hospital. Today, we offer undergraduate and residency programmes in multiple disciplines like medicine, surgery, anaesthesia and others, and we are proud of our clinical fellowship programmes. Earlier, if someone wanted to become a neurologist or a radiation oncologist, they had to go to South Africa, the UK or Canada.

But we have data which shows that when people go out, they do not come back and we are making a conscious effort to establish as many clinical fellowship programmes as possible, so that people do not have to go outside for sub-specialised training.

Explain your hospital’s evolution into a leading tertiary institution?
We started in 1958 as a maternity home or a secondary care hospital. But like human beings grow, institutions also grow and evolve. Over the past 60 years, the hospital has grown into what it is today, as a teaching, referral, and tertiary care hospital.

Today, we are a 300-bed hospital, about 3,000 full-time faculty and staff, including 180 faculty, which is extremely important because we are a training institution. We serve about 700,000 patients yearly and 54 outreach centres. We realised that many patients want to come to Aga Khan, but we cannot be everywhere, so we are taking services closer to where people live. For many services, you really do not have to come to a hospital. Why do you have to come to a hospital to get a CT scan, dialysis or even see a doctor? These services can be delivered in outreach settings.

Quality assurance has been a concern in African healthcare systems; how do you ensure high standards?
In 2013, we were the first hospital in the region to be accredited by Joint Commission International. It is a gold standard when it comes to hospital services. Every three years, they come and measure us on about 1,300 different measurable elements. It is an expensive and painful audit.

But when patients come to a hospital, they want confidence that they are getting the right quality that they are putting their lives or their family’s lives in safe hands.

These accreditations give that confidence, and at the same time they push us to be better and to do the right thing repeatedly, whether it is infection control, patient identification or surgical safety.

Technology appears to be central to your model. How are you leveraging innovations?
We were the first hospital in sub-Saharan Africa to get the PET scan and the cyclotron. Cancer is a big disease burden, and you cannot treat cancer if you do not have the right, and accurate diagnosis. We also have advanced imaging systems like 3-Tesla MRI, Spec CT, fully automated laboratories and other specialised equipment. For instance, tests that used to take 48 hours can now be done in less than eight hours. These are the kinds of investments that improve both diagnosis and patient outcomes.

Artificial intelligence is transforming healthcare globally. What steps have you taken in this area?
There is a lot of talk about artificial intelligence, and we recognise that this technology is going to change the way healthcare is delivered. But if your patient documentation is on paper, how do you build technology on top of that? That is why in November 2022, we went live with our electronic health record system. It was a $12 million investment.

Now everything is electronic, nursing and physician documentations, lab, and radiology. That allows us to start building artificial intelligence and third-party platforms on top of it. We are already using AI in X-ray imaging, where it can be read in seconds, in radiotherapy planning and in digital microscopy. Anyone who thinks AI is not going to change the landscape is living in a fool’s paradise. Things will change radically, and we have to change with the world.

AKUH has engaged in research programmes, do you believe that clinical trials are important in Africa?
We are trying to develop new knowledge so that pharma companies do not produce drugs and sell them to us without testing them on us. For instance, in triple-negative breast cancer, we found that the genetic makeup in Kenyan women is different. So, we tell pharma, do not just send your drugs to us, test them on our patients because they may not work the same way or may have different toxicity.

In 2020, we had no clinical trials. Today, we have about 17 to 18 clinical trials with over 500 patients enrolled. We are showing that we in Africa can do clinical research as good as anybody else.

Access to care remains a major concern in developing countries, how do you address affordability?
Because we are a teaching hospital and high-quality hospital, we are not cheap. So, people will ask, how do poor populations access our care? We have a patient welfare programme, and we spend close to $3 million yearly to support patients who cannot afford services.

What are your efforts to localise pharmaceutical production?
We are not producing drugs ourselves, but we are working with partners in India and the UK. We have a factory that will start production in Nairobi. There are about 30,000 drugs in my pharmacy, and we cannot produce all of them. We will start with a few oncology drugs, and then the production will expand. It is an evolutionary process.

What are your efforts to partner with other countries, including Nigeria, to boost healthcare in Africa?
We are open to all partnerships. This is a learning exercise, learning from us and learning from you. If any institution in Nigeria, Uganda, and Ethiopia or anywhere else wants to collaborate, we are open to share knowledge, develop partnerships and do joint programme.

Providing good, quality healthcare is costly, but it is worth fighting for. We are lucky that most of the population require primary care, but those who need specialised care must get it with the right tools, the right doctors and the right systems. These levels of care are required, and they are not far from reality. We can afford them.