Why Pakistan's healthcare crisis is really a pricing problem

A Lahore schooling, the army, and a bypass that changed careers

The episode opens with Muzamil flagging that health is the topic his audience usually flees — too boring, too clinical — and promising to keep this one close to the questions people actually carry into a hospital. His guest is Dr. Muhammad Saleem Khan, chief operating officer of Kulsum International Hospital in Islamabad and the man steering its next chapter, Kulsum Medical City. The credential that matters is time: nearly forty years inside Pakistani medicine.

Saleem was born in Lahore in 1958 and walked the city’s classic ladder — Central Model School, then Government College — before joining the first batch of Army Medical College in Rawalpindi. He is careful to correct an assumption early: he was never really a clinician. After the obligatory years as a captain and major doing clinical work, he moved into management, did a master’s in hospital administration, and became an administrator. Twenty-four years of army service ended when his own body intervened. His family carries hypercholesterolemia; the cardiac episodes, the bypass, the angioplasties caught up with him, and a medical board retired him out.

That exit turned out to be the real beginning. “If I said I learned more in my later life than my earlier one, it wouldn’t be wrong,” he tells Muzamil. The bypass became a dividing line in his own telling — the things he learned afterward, in the private sector, dwarf what came before.

Why the world looks different from inside a private hospital

His first stop after the army was Rehman Medical Institute in Peshawar as director of medical services. The lesson there was blunt: “In military hospitals, the things are all set. You just perform the normal duties. But in the private sector, it’s all open. People are coming, they are paying, there are systems you have to run.” For a man shaped by twenty-four years of fixed military structure, learning to run a business was, in his words, a very big challenge.

He then moved through AFIC, the army’s cardiac institute in Rawalpindi — an ISO-certified setup he points to as proof of a simple principle. Asked why AFIC stands out so clearly from the hospitals around it, his answer is management, and nothing softer. It was run by a cardiologist who implemented protocols, hired the right people, sent them abroad to train, and then supervised the work himself. That, he says, is mentorship, and mentorship is what produces a generation of good doctors. He carries the same habit into Kulsum: when his cardiologists do an angioplasty, someone reviews it.

A short, telling aside: Saleem says he removed the barriers most ex-army administrators keep. His door is open, any staff member can walk in, and decisions get made on the spot. He frames it as a deliberate break from the hierarchy he came from.

Building a cardiac hospital where no one thought patients would come

Saleem joined Kulsum in 2010, before there was a hospital — when there was a map, a visionary owner in Dr. Iqbal, and a lot of skeptics. There was no metro, no public transport reaching the site, and people kept asking the obvious question: a hospital, here, in a commercial district — where will the patients come from? The bet was that Islamabad was short on good-quality cardiology, and that a cardiac-focused hospital would find its demand.

Eleven years on, the bet has paid off so completely that the hospital is out of room. It grew from 40 beds to 100, and now every bed is full with no way to add more. Saleem walks through what runs inside a building that was never purpose-built for it: cardiac surgery, valve replacements, difficult angioplasties, laparoscopic and orthopedic surgery, critical care, and full diagnostics — CT, MRI, radiology, echo. Their emergency door-to-balloon time, the clock from a heart-attack patient arriving to their angioplasty, runs about forty minutes.

The constraint is now physical. “When it is packed, all beds are filled, I don’t have extra beds, I cannot create more beds.” Which is the whole reason for what comes next.

What a 500-bed medical city actually costs

Kulsum Medical City is a hub-and-spoke move. The current building stays as the city-center node — emergency angioplasty, the existing surgical lines — while a new 500-bed hospital rises inside Sector I-8 off Kashmir Highway, with its own interchange. Earth-breaking is expected within months; the build will run two years, phased, opening with 200 to 250 beds that generate revenue while the rest gets built. The “city” part is the attached training pipeline: a medical college, dental college, schools of pharmacy and physiotherapy, a nursing college, and Kulsum University on top.

The reason for the colleges is the same problem that runs through the whole conversation — quality. They aren’t getting good enough nurses or medical officers, so they intend to train their own. Saleem’s model for what “good” looks like is Aga Khan: train people well and they get absorbed everywhere, including abroad. The whole apparatus, he insists, points at one purpose: patient safety and good treatment.

When Muzamil presses on the money, Saleem doesn’t dodge. A good, generic 250-bed hospital costs roughly 25 billion rupees to equip and run — excluding land, which Kulsum already owns. That works out to about a billion rupees per ten beds, top-of-the-line equipment included. And the payback is slow: seven to eight years before the curve turns up. “As a nation we don’t have patience,” he says. After eight years it becomes exponential, but you have to survive the wait — which is why, as Muzamil notes, Pakistani capital pours into property rather than productive assets like hospitals or schools.

The pricing problem underneath everything

This is the spine of the episode, and Muzamil builds it carefully because he knows it will annoy people. The public’s instinct is that doctors charge too much. Saleem’s counter is that the service is, in fact, underpriced — and that the low price starves the entire ecosystem.

Walk the chain. Because the price is too low, hospital owners don’t earn enough to compound — they’re satisfied with one hospital, a good car, a farmhouse, and they don’t go from one to two to four. Because there isn’t enough revenue, they can’t pay doctors the kind of money that would compete with the global market — and the competition is global, not local. And because the margins are thin, the technology and infrastructure stay behind. Raise the price and affordability collapses, which is exactly where insurance comes in: a pool where many people put money together so that no single catastrophic bill lands on one family.

Saleem is clear that health insurance isn’t a simple voucher — there’s a real science to it, co-insurance and layered models that mature systems use. The reason it hasn’t spread is structural. The existing players (Jubilee, Askari and others) do good business, but the base is narrow because it’s almost entirely B2B, and Pakistan runs on SMEs that don’t insure their staff. Individuals never think to buy it, and insurers don’t market to them. “This will be the only model,” he says. “There is no other option” — short of a government suddenly rich enough to run excellent public hospitals, which neither of them expects.

Why young doctors say there are no jobs while demand is everywhere

Muzamil raises the contradiction that breaks his head: young doctors insist there are no opportunities, while demand for care is visibly rising and good doctors see fifty patients where they could see ten. Saleem resolves it without flinching.

The “jobs” young doctors picture are hospital jobs, and most of the hospitals hiring are the small four-room operations mushrooming everywhere. Those don’t pay regularly — salary two or three months late — and offer no real training. “This is not a job. This is just pastime.” The few good hospitals, where you’d actually enjoy working as a professional, are scarce — Kulsum pays its medical officers over 100k for night and intensive-care duty and takes a lot of work in return. So the doctors are, in a sense, right: real jobs are rare.

But the quality complaint cuts the other way too. Saleem says of the manpower available, run fifty applicants through a real exam and you’ll find two or three with genuine exposure. The rest carry certificates and can’t perform. The fix is the unglamorous one — train, supervise, walk alongside them slowly until they can be left with a critical patient. He contrasts this with the American residency-then-board model, with its continuous education, peer review, and published performance records, and notes that in Pakistan specialist certification (FCPS) is gate-kept by the College of Physicians and Surgeons: you can train at a recognized private institute, but only CPSP can pass you. Kulsum Medical City is being built to become exactly that kind of recognized training institute, end to end.

Where AI lands, and the honesty about who comes back

On the technology shift, Saleem is neither dismissive nor breathless. AI will revolutionize the system, but it won’t make doctors obsolete. He reaches for a metaphor: the car can be autonomous, but the driver stays human. Someone has to judge whether a generic solution fits this specific patient — the diabetic who is also a cardiac case with a foot ulcer, the co-morbidities that live in a consultant’s experience rather than in any textbook. The competition, he predicts, shifts to which doctor is more qualified and more technology-savvy. The rest — robotic surgery, remote operation, AI diagnostics — will arrive in Pakistan as it always does, late, after the studies and meta-analyses settle, and then get absorbed.

Some of the episode’s most candid moments come on brain drain. Saleem won’t pretend the returnees are the stars. The top doctors never come back, and neither do their children, who are already on that track abroad. The ones who return often have a reason — a legal issue, a practice that was stopped, a family pulling them home — and yet, he notes plainly, many of them do very good business in Pakistan anyway. The honest version is less flattering than the patriotic one, and he tells it.

The fixes that don’t need a miracle

By the end, the conversation turns to the system rather than the building. Saleem’s diagnosis is mostly organizational, not financial. Pakistan has no linked hospital information system — no facility knows what happened to a patient anywhere else. Build a proper HMIS, integrate it, and a dashboard surfaces hospital performance, critical patients, even epidemics. Regulate the referral structure so people enter at primary care and flow upward by need instead of walking into a tertiary hospital cold. Centralize facilities instead of duplicating them. He insists the government could run this well — “it’s not rocket science” — if someone were willing to take the pain.

What blocks it, he says, is interest and trust. Documenting everything would put drug consumption under control, which threatens the pharmaceutical and disposables businesses whose margins depend on the current slack. He offers an ugly example: a public-sector MRI deliberately kept underused so patients get diverted to private machines where money can be extracted from them. And when Muzamil raises the third parties — the startups that could build the missing information layer — Saleem agrees they get shunned, killed by a trust deficit and by people whose interests the transparency would damage.

Muzamil closes with the question he asks everyone: what does Pakistan look like in 2050? Saleem’s answer is unexpectedly steady. The current turmoil is temporary; things will fall in line once a normal political process and a bona fide government return, and investors, who only ever look for stability, will move. He belongs to a generation that saw electricity arrive in the village and a calculator for the first time and was astonished by addition and subtraction — and now watches AI. “The progress we saw in twenty years is now going to happen in ten, then in five.” Pakistan is late, he admits without argument. But he is certain it catches up.