How to build on what works to improve health markets

DEVEX
Andrew Green

At the AMPATH workshop in Eldoret, Kenya, a woman on anti-retroviral medication is now well enough to learn new livelihood skills. Photo by: Todd Post / Bread for the World / CC BY-NC-ND

Despite the many challenges to developing health markets in low- and middle-income countries, there are programs — often efforts to treat specific illnesses — that have shown enormous success in meeting the needs of some health consumers. Now, to improve markets, innovators in some places are looking to layer additional services onto those systems — and they are pursuing partnerships with a variety of actors in order to do so.

In western Kenya, the Academic Model Providing Access to Healthcare, or AMPATH, is helping provide services to more than 4 million patients. Led by Indiana University, AMPATH is a consortium of North American institutions collaborating with Kenya’s ministry of health and the Moi University School of Medicine. It launched in 1989 based on a teaching and care model that could eventually become a platform for relevant research.

Though AMPATH’s arrival came ahead of a boom in international assistance to the country’s health sector, Dr. Kibachio Joseph Mwangi, a division head in the Kenyan ministry of health and a Moi graduate, said many of those programs have remained focused on treating a specific illness or meeting a particular need. AMPATH showed a flexibility in shifting efforts to meet emerging national priorities — an approach that is now starting to be replicated by others, such as the U.S. President’s Emergency Plan for AIDS Relief.

Amid increasing AIDS-related deaths in the early 2000s, for instance, the AMPATH team helped expand HIV services and then built out a community-based network of care and prevention. Developing this system positioned them to “move back to the original vision of more broad health-system strengthening,” said Dr. Adrian Gardner, executive field director for the AMPATH Consortium. And nine years ago they started expanding into their current model, known as population health.

Address the gaps

Population health is about more than just primary health care. A market for health services in an LMIC falters for many reasons — some obvious, such as the price and availability of services, but some less clearly linked.

“If they’re hungry, even getting patients to take medicine is going to be a problem,” said Dr. Jeremiah Laktabai, who is leading AMPATH’s population health effort. AMPATH is now leveraging existing patient support groups to encourage members to combine their savings and pursue projects that could increase their income.

AMPATH is also experimenting with adding additional activities to the existing HIV prevention and care services, including testing for noncommunicable diseases, including hypertension and diabetes. And they are pioneering efforts to integrate those services into HIV clinics, by offering basic NCD tests as part of the package of care and then offering medicines and treatment for those patients who need them. Similar efforts are being piloted by Dignitas International in Malawi and in Swaziland by ICAP, which is run out of Columbia University.

This layering of services helps overcome another challenge to growing health markets in each of these settings: stigma. Patients who might be worried about the perception of accessing services for one disease — HIV, for instance — might feel more comfortable visiting a clinic that treats a variety of illnesses.

Finding funds requires creativity

There is still the issue of how to pay for a system where people can receive the coverage they need without suffering financial hardship — critical to creating a functioning market.

Dr. Joanna Nurse, head of health at the Commonwealth Secretariat, which is helping enable countries to reach universal health coverage, said it is ultimately the responsibility of individual governments to lead on policy to finance and ensure its achievement. In Kenya, as in many LMICs, government funding for health care is low. The government spent only 3.5 percent of its gross domestic product on health care in 2014, according to the World Bank.

That means partners still have a significant role to play, though Nurse said that raises other concerns.

“Just allowing it to happen from other sources often creates an uncoordinated or ‘siloed’ programmatic approach,” she said. “Ideally partners’ work is incorporated into the wider health system.”

Nurse pointed to Sri Lanka as a positive example, where the government has strengthened coordination between the public and private systems and the work of nongovernmental organizations.

Better collaboration

AMPATH’s population health model is also trying to erase any silos, though finding the funding to do so has required some creativity. The bulk of its money still comes from HIV-related financing, but they also source funds from private actors, including pharmaceutical companies and foundations that have an interest in specific illnesses.

Gardner said private partners have “shown signs of being willing to be more flexible in supporting health systems, as well.” AMPATH recently held a summit with representatives from 15 different companies and foundations to discuss how they could collaborate more closely going forward.

AMPATH is also anticipating the roll out of a government-run community insurance policy — a plan allowing members to access services, while reimbursing the participating health facilities — to help fund population health.

Though the AMPATH collaboration is unique, Gardner said there are parts of the effort that are obviously replicable in other LMICs — including the combination funding and the layering of services onto existing programs. “It took some time and it took vision and flexibility and a willingness to learn from mistakes and keep trying,” he said.

While the nature of new collaborations might depend on an individual setting, Gardner pointed to the partnership with Moi University as a possible model for other institutions.