5 challenges in implementing primary care innovations — and how to overcome them

By Donika Dimovska 26 February 2015

Althei Abbakar receives treatment for eye infection from a medial assistant in a mobile clinic in El Sereif, North Darfur. Photo by: Albert González Farran /UNAMID  / CC BY-NC-ND 

There is no shortage of ideas for improving the state of health care delivery globally, but the challenges come once these ideas “leave the harbor” and face the dangers associated with implementation and execution.

To overcome these challenges, an important tool in the innovator’s toolkit is the idea of rapidly testing ideas and evaluating the results toward an organization’s ultimate goal. The innovator can either make the decision to adopt this idea, adapt it based on learnings, or abandon this idea and learn from what did not work.

As the first point of care for patients, primary care clinics and practitioners play a key role as a gateway to the rest of the health system, and they provide the basic preventive and curative care that saves the most lives. Recognizing that in many low- and middle-income countries, the poor rely on private providers for a large portion of their care, many experts and innovators are exploring market-based solutions to improve primary care. As a result, in recent years the number of primary care chains and franchises has grown. These models show great potential for impact, but chains and franchises continue to face numerous challenges related to quality, affordability, sustainability and scale.

Primary care leaders want and need practical know-how. They recognize that there are not always clear solutions to tough challenges, but they have found that there is value in sharing ideas and experiences, testing new approaches, and sharing the results to enable successful innovations to spread more rapidly between organizations and across geographies.

The following challenges in establishing and scaling primary care innovations, and the solutions to overcome them, are drawn from The Primary Care Innovator’s Handbook: Voices from Leaders in the Field. What ties many of these reflections together is a focus on family- and patient-centric care. Indeed, successful organizations have learned the value of listening to patients and ensuring that all processes revolve around the question: How can we best serve our patients and their families, based on what matters most to them?

Challenge: How do you establish a unique model for your primary care clinic or franchise?

Solution: Identify the gap that your model is filling, and test your ideas with the people you serve.

Once the initial research and experience has been conducted, teams need to ensure that the target communities are invested in the design of services.

Through feedback sessions and active engagement with health workers in the Mukuru slum of Nairobi, Access Afya established trust and open dialogue with the community. By listening to community members, the primary care organization learned what was viewed as a needed service, and where wider needs existed in the spectrum of primary care.

“By focusing on holistic primary care, we focus on keeping patients well, rather than treating them when they are already sick, a type of care that generally isn’t available in Nairobi’s informal settlements,” Access Afya writes.

The process of understanding community needs is not a quick one, but is essential. The value of listening assures that time and resources are not wasted on implementing a model that does not address the gaps expressed by the target community.

Challenge: How do you satisfy patient demands, and expand your service offerings appropriately?

Solution: Develop an expansion strategy, build partnerships and manage expectations.

Successful primary care institutions continually ask patients the question: Is there anything we can do better? A good system to catalog and evaluate recommendations can help innovators to respond to patient needs.

When expanding, it’s important to assess the local context and understand how different expansion approaches contribute to an organization’s overall goal. There are always financial considerations when adding new services which require several steps. Landscape analysis of other primary care services in the area, exploring price sensitivity of services and understanding how to market new services appropriately all have an effect on service expansions.

LifeNet International has grown its organization through the “conversion franchise” model, which allows it to work in partnership with pre-established clinics and build off existing synergies to achieve scale. Franchises allow less control over hiring, firing and managing employees but can offer a faster path for growth in resource-constrained environments where capital to open new company-owned clinics may be lacking.

Challenge: How do you keep your attention on providing the best care, while still running a business?

Solution: Focus on patients first — building a strong customer base translates to long-lasting returns.

Practitioners in global health know there is little truth to the adage, “if you build it, they will come.” Building a health care delivery organization is only the first step. The next crucial one is actually providing care that is high quality and affordable which encourages patients to not only come but to also convince their friends and extended family to come to your clinic for their care because of their experience — thereby building a strong customer base for your organization.

Successful leaders in this space focus on customers and the experience they provide them. Crucial in this customer experience are the providers themselves — a clinic staffed with unhappy providers is unlikely to yield happy patients.

“For us, the key to creating a good patient experience is to listen to our patients and see them as partners in their own health care,” says Penda Health.

Challenge: How do you manage supplies and prevent stock-outs?

Solution: Defeat variability in supply and demand through an organized — but simple — internal system.

With one or two clinics, an organization can rely on the success of a particularly effective individual and on ad hoc processes. However, as clinics add more sites, strong systems become necessary to maintain quality.

The biggest challenge in supply management is variability, both in patient and disease frequency, and stock availability. Most small primary care providers are not yet at a volume and size where they can source directly from pharmaceutical companies.

While there is no silver bullet to managing supply and preventing stockouts, Ross Clinics has established five overarching principles that work:

1. Develop a culture of shared responsibility in clinics: Everyone plays an essential part.

2. Ensure transparency in systems by sharing data with all levels of the organization.

3. Focus on simplicity: Use what works best for your clinic and providers.

4. Ensure that organizational strategies are also best for patients.

5. Do small things well. Even the most mundane daily tasks are crucial to maintaining the system.

Challenge: How do you manage information as you grow and scale?

Solution: Create effective information systems and train the right people to record data.

Effective information systems can be very helpful in scaling an organization and meeting patients’ needs well. Electronic medical records can help a provider in tracking a patient and family over time, as well as allow an organization to analyze trends in illnesses and medical conditions.

As an organization grows, keeping track of both patient data and internal communications becomes a major burden. Enterprise resource planning tools can help systematize organizational processes.

For Swasth India, the benefits of managing clinic operations and centralizing patient data greatly outweigh the cost of these tools. And yet, “Information systems are only as good as the quality of the data entered,” writes Swasth. Its clinics rely on trained staff assistants for data entry so that doctors can focus on best serving the patient.

How can aid organizations better primary care delivery in developing countries? Share your suggestions by leaving a comment below.

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About the author

Danika
Donika Dimovska

Donika Dimovska leads the Center for Health Market Innovations and Center for Education Innovations at Results for Development (R4D). Through these and other projects, she develops new tools and modalities for engaging practitioners, funders, researchers and policymakers working to improve how health and education systems serve the poor in low- and middle-income countries.


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