While advances in health care in the developed world often emphasize new technologies, in developing lower- and middle-income countries simply expanding the reach of basic primary care services is crucial to improving health. By providing ready access to basic health services and coordinating care with more specialized services as needed, primary care can reduce hospitalizations and mortality, increase life expectancy, and deliver better overall health. Indeed, a 2003 Lancet study reported that 63% of child deaths in the 42 countries that account for 90% of global child mortality could be prevented each year through more effective primary care. That is 6 million lives – 100 football stadiums of children – that could be saved each year.
In developing countries, primary care tends to be delivered by a mix of public and private sector providers. Increasingly, private for-profit and non-profit ventures are becoming central to high-quality primary-care services, and scaling these is essential to maximize their impact. While scaling these services is challenging, our research shows that having the right business skills is critical to success.
As we define it, scaling is the process of expanding primary care services to serve more people, with the aim of increasing health impact. There are considerable hurdles to scaling any health service in resource-constrained settings. Primary care delivery faces additional challenges for scaling because it operates on thin margins, often is not highly valued by patients, and has difficulty attracting trained providers. However, some primary care programs are overcoming these barriers and creating successful care models with substantial scale.
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Together with our partners in the Rapid Routes to Scale group, we set out to identify key drivers of scaling private sector primary care services. We interviewed leaders in 37 private for-profit and non-profit primary care programs identified in the Center for Health Market Innovations database and operating in over 25 developing countries. The programs fell into three groups: those still in the pilot phase, those that had experienced setbacks in their efforts to scale, and those that had successfully scaled to serve at least 40,000 people. Through extensive site visits, interviews, document review, and statistical analysis, we found that successful scaling commonly involves four categories of business skills.
Programs need to create strong relationships with patients who typically do not value primary care and either go to specialists directly or do not seek care at all, as well as those who simply lack access to care. To successfully scale, programs are focusing on the patient experience, investing in effective branding and marketing, and engaging in health education campaigns to promote services.
North Star Alliance is a strong example in SubSaharan Africa. Founded in Malawi in 2005, North Star is now a non-profit network of more than 30 roadside health centers, operating along major transportation corridors across Africa in countries including Kenya, Tanzania, and South Africa, serving hundreds of thousands of patients each year. North Star primarily serves truck drivers and sex workers, operating in the afternoons and evenings to fit its clients’ schedules. The centers hire peer educators to connect with these hard-to-reach populations and gain their trust. To minimize costs and build a visible brand, North Star operates clinics in converted shipping containers, which provide standardized mobile facilities. North Star’s clinics use IT systems that support real-time transmission of patient data among clinics and use biometrics to track patients in order to avoid duplicate files and treatments. This helps the centers increase efficiency, maintain quality standards, track disease trends, and collect demographic information.
Programs need effective financial strategies to help patients access services and to generate income where resources are limited. This can involve providing alternative payment mechanisms such as micro-insurance, health plans, and membership fees, as well as generating complementary revenue to support the main offerings.
Swasth Health Centres, for example, is one of several primary care programs in India that have developed their own IT platforms with electronic medical records for primary care, tailored to be user-friendly for clinicians and staff. While serving half a million patients at its 23 clinics, Swasth generates additional revenue by supplying this software to other providers.
Partnering with public and private sector organizations helps obtain financial support, medical supplies, and health care staff. Successfully scaled programs often pursue creative partnerships through social franchising, which involves contracting a network of private providers to deliver services under the same brand, while forging partnerships with organizations that provide access to a customer base.
The non-profit Karuna Trust now manages 68 health centers in seven Indian states through a public-private partnership model. The result has been improved patient satisfaction and health outcomes at a lower cost, while reaching more than one million people in remote and rural areas of India.
Management and leadership skills
Efficient, high-quality, scalable primary care operations require strong management and leadership skills. A key leadership task is to standardize both clinical and non-clinical operations, including care delivery, IT, clinic design, marketing, and human resources.
Living Goods is a micro-entrepreneur program in East Africa that recruits and trains community health workers to provide basic curative and prevention services while also selling medical and other household products door to door. Living Goods provides its workers with business training as well as branding and “business in a bag” operating resources that include a uniform, record books, and consumer goods for selling. The program conducts regular field visits and testing to monitor quality. This standardized management approach has helped Living Goods reduce child deaths by 27% in areas it serves in Uganda and expand its operations to Kenya, covering more than half a million people across the network.
Ideally, leaders will bring both medical and business education to the scaling challenge. For instance, after completing medical training in the U.S. and returning to India, the founder of Ross Clinics recognized that providing affordable, good quality care was not enough to build a sustained patient base. Understanding the business problem, he applied principles learned at the SP Jain Institute of Management to experiment with methods of generating demand and creating loyalty. For example, the clinics added free dental checkups and discounts on dental treatments as a complementary service that helped increase demand for its core primary care services. He followed this with a focus on system optimization to reduce costs. Founded in 2011, Ross Clinics now operates a chain of more than a dozen primary care clinics, while planning active ongoing expansion.
Increasing access to quality primary care services around the world requires medical leaders who also possess business expertise. The key first step to achieving this dual set of skills is to embrace the mindset that healthcare must be managed as a business in order to provide more efficient, high quality, and innovative services to more people.