Health Care: The Cool Stuff Doesn’t Matter If the Basics Aren’t There
By Kevin Starr, Mulago Foundation
I’m on Idjwi island in the Democratic Republic of the Congo (DRC), sitting on the porch sipping coffee as thunderclouds pile atop the brooding mountains across the lake. It’s a gorgeous sight, and this locally grown coffee is better than what I get at my hipster market back home. I’ve got a couple of hours before I leave for home and a lot on my mind after my time here on the island.
Idjwi is on Lake Kivu, between Rwanda and the DRC. Lake Kivu is 50 miles long and a thousand feet deep, and it periodically belches up a cloud of carbon dioxide sufficient to smother a town. The island is home to about a quarter of a million people. It’s pretty and green, but the forests are gone, and steep hillsides erode continually under the burden of endless cycles of planting. Idjwi somehow escaped the violence that convulsed the region over the past several decades, but the average farm size is not much more than an acre, the fertility rate is 8.5 kids per woman, and about half those kids are malnourished. Weirdly, the island gets more lightning strikes than anywhere else on Earth. I have no idea why.
I came to the island to work with Dr. Jacques Sebisaho and his team at Amani Global Works. They built and run a lovely little hospital set at the edge of a wooded cove in the north of the island. Clean and efficient, staffed with a crew of talented and dedicated people, the hospital serves a catchment area of about 80,000 people on an island that has only about 10 miles of passable dirt roads.
Amani’s little hospital is one of the best I’ve seen, but Jacques and his crew know that their basic hospital must become part of a larger network that includes community health workers in every village and clinics within reach of all. In other words, Idjwi needs primary health care.
Primary care is the essential set of frontline services everybody needs: It’s things like vaccinations, malaria treatment, malnutrition screening, oral rehydration, basic surgeries like C-sections, and so on. One useful way to frame it is this: Generalists (doctors, nurses, and community health workers) do primary care, specialists do secondary care, and sub-specialists do tertiary care. It’s nice to have all three, but primary care comes first. It’s the most equitable and cost-effective care, and mostly importantly, it can deal with 95 percent of the diseases that plague people in places like Idjwi.
Good primary care functions as a network that gets stuff and services to those who need them most, and gets critical information back to those who can do something with it. In a place like Idjwi, sick kids whose survival depends on speed-to-treatment won’t make it without that network. Nasty parasitical diseases like filariasis and schistosomiasis are still around in places like Idjwi, and the people who live there will never be rid of them without that network. There’s a huge demand on the island for family planning, but they’ll never meet it … yeah, without that network.
That’s why Jacques and his team are obsessed with figuring out how to deliver a primary care network that can grow to cover the whole island and scale beyond it. They know you can’t really move the health needle unless everyone has local access to decent basic care.
Not everybody does. In the last year, important funders I know and like turned down three world-class organizations focused on primary care networks. In one form or another, they told those organizations, “You’re awesome, but we have enough primary health care in our portfolio.”
Well, no. You don’t. Not by a long shot.
Governments and funders have long made a habit of failing to deliver primary health care to the people who would get the most from it. In 1978, world public-health leaders and associated muckety-mucks gathered in Kazakhstan and produced the famous Declaration of Alma-Ata that proclaimed—in good faith, I think—we would achieve “primary health care for all” by 2000. Well, that didn’t happen, but the World Health Organization (WHO) reaffirmed the declaration in 2008. The Millennium Development Goals included primary care and the Sustainable Development Goals (SDGs) include it again—and as many as a billion people still don’t have it.
What’s up? Why the big fails? Over the years, I’ve noticed three things:
- Doctors like fancy tertiary hospitals, Big Aid likes infrastructure. Health ministries are run by doctors and need Big Aid, so fancy hospitals come first. Then the money runs out.
- It’s always been easier to mobilize resources around particular diseases and needs (HIV/AIDS, malaria, polio, vaccination) than for systems. As a result, programs deliver services through vertical one-issue silos that starve and even undermine primary care.
- There haven’t been a lot of scalable, high-performance primary health care models out there, and some of the big studies of community health workers have been disappointing.
Things are changing. At the top-down level, the Primary Health Care Performance Initiative launched by the Gates Foundation, WHO, and the World Bank in 2015 is just one (big) sign that Big Aid is waking up. From the bottom-up, there are a growing number of entrepreneurial organizations doing cool work in primary care space, much of it inspired by the work of Paul Farmer and Partners in Health. Those emerging organizations represent a really important role and a huge opportunity for private philanthropy. We’re the ones who can nurture and spur the development of promising new models and fuel their growth until they can access Big Aid and scale up through government systems. Here are the kind of new-school models I’m talking about:
- Living Goods, in Uganda and Kenya, establishes Avon Lady-like networks of saleswomen who go door-to-door selling health products, providing treatment for illnesses like malaria, teaching household health, and making urgent clinic referrals. They’ve dropped child mortality by 28 percent and have scaled up considerably with BRAC.
- Muso, in Mali, has built a “proactive care” model focused entirely on speed-to-treatment through motivated community health workers and tuned-up clinics. Muso’s initial work in Bamako demonstrated one of the most precipitous declines in child mortality ever.
- Last Mile Health, in Liberia, fields professionalized frontline health workers who can treat a broad range of diseases in remote regions beyond the range of clinics and doctors. The model has been written into into Liberia’s national health policy and strategy.
- PIVOT, in Madagascar, is developing a “district-level health care system in a box” (my phrase), where deeply embedded, highly usable data systems drive efficiency and performance. The model has already achieved an impressive drop in child mortality.
- Hope Through Health, in Togo, weaves together community health workers and clinics in a tight web that leaves nobody out, and synthesizes the best ideas from sister organizations while working in a country that has been completely off the aid radar.
There are great models out there, but here’s the kicker: Without these kinds of models operating at scale, all the cool gadgets and technologies funders often love to fund don’t matter a damn. If you don’t get the basics right, all the extremely-affordable-mobile-enabled-big-data-driven-digital-platform stuff in the world won’t help you. I’m not demeaning the cool stuff; if you do the hard work to assemble an effective primary care network, it can drive a quantum leap in impact. Basics first, cool stuff second.
Funders: Want to avoid the next Ebola epidemic? Fund primary care. Want to nail the health SDGs? Fund primary care. Want to maintain and accelerate the remarkable gains in child survival? Fund primary care. Want to effectively treat the vast majority of the illnesses that plague the poor? Fund primary care. When you realize all that you can do with primary health care, it becomes downright sexy. Give yourself have the pleasure of participation.
OK, so I’m three cups of coffee into this thing, and the poor guy who is supposed to get me to the boat on time is looking anxious. I’ll finish with this: Fundraising for a picturesque island hospital is a lot easier than fundraising for a primary care system, but Jacques and his crew know that a hospital isn’t nearly enough. They’re ready to go all-out to reach everyone. It’s high time we funders do the same.