Scaling Up What Works: Study focuses on using the private sector as a way to increase the effectiveness of primary care services
As Ebola ravages the west coast of Africa, there has rarely been a time when the failure of basic health systems has been so starkly illustrated, and so devastating. This is not a failure of medicine or even funding; it is a failure of organisation, an inability to get basic health services working and a lack of patient trust for the medical establishment. Yet there are examples of great health programmes that can be learnt from, copied and adapted. Scaling up what works must now be the focus to reduce the chance of epidemics and tragedies having such a dramatic effect.
Primary care, the first port of call for a patient’s most basic health care needs, is relatively inexpensive but critical. Accessible, quality primary care can deliver lower mortality rates, fewer hospitalisations and better self-reported health. Good primary care provides ready access to a range of basic health services, which is associated with better health equity, and its focus on referring patients on to more specialised services when appropriate makes care more efficient.
A 2003 Lancet study reported that 90 percent of global child mortality could be prevented each year – 6 million lives saved – through effective primary care interventions. That’s about 100 Premier League football stadia of children saved each year simply though better organisation. That can’t be hard, can it? It turns out it is.
The frustrating failure to meet these basic needs led the Rapid Routes to Scale group (which includes Gates Foundation, GlaxoSmithKline, Merck, Merck Sorono, Save the Children and Novo Nordisk) to come together to fund this report, written by the ICSF (which the author founded) and T-HOPE at the University of Toronto, on how to scale up primary care in low- and middle-income countries. The report highlights that primary care initiatives are often ineffectively scattered and unless they can be scaled up, local communities have to “reinvent the wheel.”
But solutions are at hand. To circumvent the well-known challenges of increasing the reach of government health services, the study focuses on using the private sector as a way to increase the effectiveness of primary care services. Private sector in this case does not mean large corporations making heavy charges; health services for many are made up of small clinics owned by semi-trained community workers who are providing the only local health facility at very low charges.
The first challenge is that patients themselves often don’t value primary care. Often this is because clinics in poor areas are rundown, understaffed and lack crucial medical supplies. It is logical for patients not to want to hurry back. Organisations such as Penda Health, a clinic chain in Nairobi, put a huge focus on the patient experience with real results. (Find past NextBillion articles on Penda health here and here). Staff are trained to be warm, friendly and punctual, and focus on clear communication. Patients have a good experience, recommend it to family and friends and actually want to come back should they need to.
Staffing of primary care facilities is a massive issue due to the chronic and widespread lack of adequately trained health care professionals. We have to accept that there isn’t going to be an influx of highly skilled personnel. But health workers such as clinical officers (similar to a nurse practitioner, typically with two or three years of medical training) are more readily available and community health workers, who have much shorter training than other health professionals, can deliver excellent primary care, as attested to by WHO. So let’s scale up primary care by training more of these health workers and trust them to deliver.
While the leaders of large health care organisations have MBAs and access to ongoing management training, health workers who are responsible for running small clinics have often never received any management training at all. When I recently visited a rural clinic in Kenya, the nurse and clinic owner’s main complaint was that people only ever came for consultations before and after work. I suggested that she charge patients half price if they come during the working day and she almost leapt for joy at the idea. Ideas such as this should be part of a basic knowledge of how to run a clinic and not left to the chance of a random conversation.
We know that simple interventions and changes can improve primary care. The reality of implementation at scale is by no means easy. It requires more than just one organisation – all the players in the health system need to work together, which is why we’re delighted to be tackling these challenges with the Rapid Routes to Scale group.
Our next steps are to work together in a very practical way with primary care organisations, helping them scale up and using that as a way to gain knowledge to support many others. When a disaster strikes again, health workers and the systems in which they operate should be much better prepared to provide care to those who need it most.
Dan Berelowitz is founder and chief executive of the International Centre for Social Franchising, a nonprofit that helps high-potential social projects replicate.
Will Mitchell (principal investigator) and Kate Mossman (research coordinator) also contributed to this blog. Mitchell is a professor of strategic management at the Rotman School of Management at the University of Toronto, where he holds the Anthony S. Fell Chair in New Technologies and Commercialization. Mossman is a research coordinator at Women’s College Hospital, Toronto, and a postdoctoral fellow in the Department of Strategy at the Rotman School of Management at the University of Toronto.