Models for Global Health Delivery

by Anjali Sastry on November 8, 2008

Here at MIT Sloan, we love models. We like to analyze; we like plans, descriptions, evidence, and tests. When it comes to what works and what doesn’t in global health delivery, we are not quite comfortable with the state of shared knowledge. In many ways, that is the reason behind this class–and the motivating interest in the emerging science of global health delivery. We want to develop operational, managerial, and social science perspectives on what is being done well in the field, and what could be done even better. And we want to do this with an eye to collaborating with the managers and workers who have invited us in to help them. It’s an amazing opportunity for us, humbling and exciting at the same time, and it demands a discipline of both faculty and students–we’ve little time before the students leave in January, and we have so much to cover!

As a result, we kicked off the class in 2008 by choosing a point of view that focuses on on-the-ground organizations and the people who work in them. This means we have to sidestep many big, important, and vexing issues–for instance, about policy–in favor of looking at specific enterprises. Our hope is that in understanding a little more about our partner enterprises, we’ll also get some insights into the cross-cutting issues. Such focus also fits well with our students’ orientations. Most are second-year MBA students, and are naturally inclined to analyze both problems and opportunities at the level of the organization, its staff, its setting, its stakeholders, its capabilities and its assets.

Note from November 2008

To set the stage, in week two of the course, we started by looking at a few organizations whose models for global health delivery are inspiring us. On day one, we’d caught a glimpse of Zambia’s CIDRZ; in our third class, thanks to Dr. Rebecca Weintraub, we learned more about AMPATH and a bit about TASO. We then looked to the Partners In Health model, the Haitian organization Zanmi Lasante, and thanks to Dr. Peter Drobac, the start of PIH’s work in Rwinkwavu, Rwanda. Read his notes from the field to learn more about Patricie, the patient he told us about in class. And check back for more on Dr. Drobac’s perspective in a blog post to come.

{ 4 comments… read them below or add one }

Samy Esayag November 9, 2008 at 1:32 pm

The PIH model is certainly fascinating. The original model created in Haiti was a clear proof that efficient partnerships can be built to address, in a holistic fashion, the challenges faced by the healthcare system in developing countries. By holistic I mean the idea of expanding health care service to go beyond the treatment of a specific disease. Similar to the notion that a good educator is the one whose teachings go beyond the course content to try to impact the way students think about life, a good doctor or physician in these types of context (developing countries like Rwanda, plagued by severe poverty and malnutrition) seems to be the one whose practice goes beyond providing direct medical treatment to try to impact the way patients live.

At business school, and perhaps even more so at MIT, we understand the value of creating pilot programs (or models) before engaging in the task of creating or reforming very complex systems. Rwanda’s PIH ongoing success story was based on applying the successful Haitian model to a couple of rural health districts (Rwinkwavu and Kirehe), and later expanding this pilot program to target the entire population. To me this is a very powerful insight. The successful case in Haiti could have very easily become a failure elsewhere. Cultural, social and economic conditions (both at macro and micro levels) can influence, for good or for bad, the outcome of any model. When designing a proposed system, policy makers must adapt the given model to the reality in hand. And what better way to “test” this system than by creating a pilot program? Leaders of Inshuti Mu Buzima seem to have known this in advance and, to me, this is the main reason that explains their success so far.

The challenge for PIH going forward will be to absorb enough financing to fund the many social programs they have in mind. This might become a very interesting case study down the road, and hopefully other countries will be willing to replicate this same model -only this time adapting the model to their own, unique, realities.

Ulrick Noel November 9, 2008 at 3:38 pm

Digesting the 2008 World Health Report…. “Primary Health Care: Now More Than Ever”

Today, health systems, even in the most developed countries, are falling short of these objectives. Although remarkable strides have been made to improve health, combat disease and lengthen life spans, people worldwide are dissatisfied with existing health systems. One of the greatest worries is about the cost of health care. This is a realistic concern since 100 million people fall into poverty each year paying for health care. Millions more are unable to access any health care.

The source of the problem is that health systems and health development agendas have evolved into a patchwork of components. This is evident in the excessive specialization in rich countries and donor-driven, single disease focused programs in poor ones. A vast proportion of resources are spent on curative services, neglecting prevention and health promotion that could cut 70% of global disease burden. In short, health systems are unfair, disjointed, inefficient and less effective than they could be. Moreover, without substantial reorienting, today’s struggling health systems are likely to be overwhelmed by the growing challenges of aging populations, pandemics of chronic diseases, new emerging diseases such as SARS, and the impacts of climate change.

In the World Health Report, WHO proposes that countries make health system and health development decisions guided by four broad, interlinked policy directions. These four represent core primary health care principles.

Universal coverage: For fair and efficient systems, all people must have access to health care according to need and regardless of ability to pay. If they do not have access, health inequities produce decades of differences in life expectancies not only between countries but within countries. These inequities raise risks, especially of disease outbreaks, for all. Providing coverage to all is a financial challenge, but most systems now rely on out-of-pocket payments which is the least fair and effective method. WHO recommends financial pooling and pre-payment, such as insurance schemes. Brazil began working towards universal coverage in 1988 and now reaches 70% of its population.

People-centred services: Health systems can be reoriented to better respond to people’s needs through delivery points embedded in communities. The Islamic Republic of Iran’s 17 000 “health houses” each serve about 1500 people and are responsible for a sharp drop in mortality over the last two decades, with life expectancy increasing to 71 years in 2006 from 63 years in 1990. New Zealand’s Primary Health Care Strategy, launched in 2001, has as part of its core strategy an emphasis on prevention and management of chronic diseases. Cuba’s “polyclinics” have helped give Cubans one of the longest life expectancies (78 years) of any developing country in the world. Brazil’s Family Health Program provides quality care to families in their homes, at clinics and in hospitals.

Healthy Public Policies: Biology alone does not explain many gaps in longevity, such as the 27-year difference in Glasgow’s rich and poor neighborhoods. In fact, much of what impacts health broadly lies outside the influence of the health sector. Ministries of trade, environment, education and others all have their impact on health, and yet little attention is generally paid to decisions in these ministries that have health impacts. WHO believes they should all be part of deliberations and that a “health in all policies” approach needs to be integrated broadly throughout governments. This will require a shift in political calculations since some of the greatest health impacts can be achieved through early childhood development program and education of women, but those benefits are unlikely to be seen during a single politician’s term or terms in office.

Leadership: Existing health systems will not naturally gravitate towards more fair, efficient (those that work better) and effective (those that achieve their goals) models. So, rather than command and control, leadership has to negotiate and steer. All components of society – including those not traditionally involved in health – have to be engaged, including civil society, the private sector, communities and the business sector. Health leaders need to ensure that vulnerable groups have a platform to express their needs and that these pleas are heeded. There is enormous potential to be tapped. In half of the world’s countries, health issues are the greatest personal concern for a third of the population. Wise leadership requires knowledge of what works. Yet health systems research is an area that is often severely underfunded. In the United States of America, for example, health systems research claims only 0.1% of the nation’s health budget expenditure. Yet research is needed to generate the best evidence as a basis for health decision.

By aiming at these four primary health care goals, national health systems can become more coherent, more efficient, fairer and vastly more effective.

Progress is possible, in all countries. Now, more than ever, there are opportunities to start changing health systems towards primary health care in all countries. The challenges are different for countries with different income levels, but there are commonalities. There is more money being spent on health than ever before and more knowledge to address global health challenges, including better medical technology. There is also now recognition that threats and opportunities in health are shared across the world. Aid is important for some countries, but the vast majority of health spending comes from domestic sources. Even today, in Africa, 70% of all resources for health come from domestic funds. Thus most countries have the ability to start moving towards and enjoying the benefits of primary health care.

Ulrick Noel November 9, 2008 at 3:39 pm

Gapminder is not new, but it’s brilliant

Gapminder World lets you explore the changing world from your own computer. Moving graphics show how the development of all countries of the world by the indicators you choose. (From gapminder website)

They make data from the UN available in a graphical and animated form. You can look at thinks like:

1. Income
2. Economy
3. Health
4. Births and deaths
5. Education
6. Geography
7. Energy
8. Technology/infrastructure
9. Poverty / inequality
10. Trade
11. And lots more

You can plot them against time, and you can plot them against each other. And, you can watch them as they evolve with time.

Hours of learning and fun. Go check it out.

Keith Caldwell November 29, 2008 at 7:43 pm

A common theme in several of the organizations that we have studied and in several of the projects that teams are working on is the idea of “franchising” or opening new clinics to reach out to some of the poorer areas in the regions that these organizations serve. This was seen with the CFW model and with the microfinance model of the Grameen Health system. As each of these systems seek to make themselves sustainable, a large portion of their model relies on training locals to run these clinics and deliver the care while giving themselves the opportunity to profit. My team is working on the Meridian Medical Centre project which is very similar to the CFW model in that it is attempting to branch out to more communities in a franchise type model that will allow operators to profit through the delivery of a standardized quality of care.

While this model has worked well in the more affluent communities, I believe that this will have some very serious obstacles to overcome as they attempt to branch out into the poorer communities. In the CFW model for example, the franchise fee that is needed for the setup of the clinic, seems to naturally select the most affluent communities. A franchise model is a very localized model, in which the owner and operator will most likely live in the community where the business is to be opened. Because it takes a relatively large fee to start up the clinic, those who can afford it will most likely live in the highest income areas making a reach to the less fortunate areas challenging. Also, we have seen that even in the existing areas only a small portion of the patients are paying. It seems that in order to set up a clinic in a less fortunate area, either the fee would have to be waived or somehow financed (as with the Grameen model) or an affluent operator would have to move to a poorer area. In any of these scenarios, maintaining the quality of care and collecting enough money to make these operations profitable and sustainable seems extremely difficult.

This will be an issue in our project that will need to be addressed. The organization has developed a quality of care manual to set up standards in their branch clinics. We will be faced with the issue of how to deliver the care that is so desperately needed while trying to remain a profitable organization.

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