Developing Health Care Clinic Partnerships in Resource-Limited Regions

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AUTHOR:Elizabeth Montgomery Collins, MD, MPH

Section of Retrovirology & Global Health, Center for International Adoption, and Baylor International Pediatric AIDS Initiative, Texas Children’s Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas Address correspondence to Elizabeth Montgomery Collins, MD, MPH, Section of Retrovirology & Global Health, Feigin Center, Suite 630, Houston, TX 77030. E-mail: EGMontgomery@AAP.net

Accepted for publication Jan 27, 2014

Dr Collins designed and drafted the initial manuscript andﬁnal manuscript as submitted.

KEY WORDS

outpatient clinics, public-private partnerships, developing countries, resource-limited, resource-poor, global health, international child health, global child health, capacity building, health care infrastructure, child, start-up

doi:10.1542/peds.2013-3946

Developing Health Care Clinic Partnerships in

Resource-Limited Regions

Establishing a successful health care clinic is challenging anywhere in the world. Dr Collins has drawn on her personal experience working in those parts of our planet where people are living with less than their fair share of its resources. Unfortunately, this comprises the majority of the world’s population. Not surprisingly, establishing medical care services in such places requires at-tention to the total fabric and envi-ronment of the intended population. Clearly, the interrelationship between successful health care delivery and education, sanitation, food availability, and the massive negative effects of poverty in general should factor into understanding the potential beneﬁts of such services in a clinic setting. For those wanting to make a difference that imbeds and persists in the com-munity, the guidance provided in this column provides a brief introduction as to how to begin.

Jay E. Berkelhamer, Section Editor

THINK GLOBALLY, ACT LOCALLY

Even in an era of robust globalization, in which interconnectedness of pop-ulations seems to demand that health care strategies be implemented on a global scale, the actual treatment of disease remains a highly local and individualized affair. At its core, health care is about doctors and other health

care practitioners seeing patients, often in the poverty-stricken, war-ravaged, or ill-governed regions where the patients reside. To implement effec-tive health care strategies in these settings requires more than medical expertise and good intentions. It requires an ongoing local presence— practitioners treating patients—and establishing such a presence requires a plan.

In addition, US government funding for global health initiatives is now approaching $10 billion annually,1 and universities are demonstrating an ever-increasing interest in glob-al heglob-alth collaborations,2 _{so the} quality and quantity of resources available to institutions seeking to launch overseas clinics is almost certain to improve over the next decade.

Although the particulars of opening such clinics will vary markedly by country, there are a number of general considerations that pediatricians and health care organizations should take into account when planning to open medical clinics in resource-limited regions.

KNOW YOUR PATIENTS:

UNDERSTAND THE LOCAL CULTURE

Each resource-poor region operates according to a unique set of customs and values that must be taken into account when delivering health care services to children and families. Without understanding these precon-ceptions, from religious prejudices against vaccines to the stigma associ-ated with certain diseases, health care organizations may ﬁnd it difﬁcult to provide populations with meaningful health care options. Health care pro-viders should tailor their education programs to address such issues, adjusting for differences in literacy levels, social hierarchies, and percep-tions of time and social convenpercep-tions, such as tendencies to take tea breaks, to arrive late during inclement weather, or to favor traditional remedies.

BUILD RELATIONSHIPS: PARTNER WITH GOVERNMENTS AND LOCAL LEADERS

Organizations may find it difficult to understand local attitudes or navigate legal and cultural barriers to setting up a clinic without first building

574 COLLINS

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personal and professional relation-ships with medical, political, social, and religious leaders at the national and local levels. Laws may be nonexistent or subject to arbitrary enforcement, so knowing who to consult for government approvals, and whether such approvals will be forthcoming, is essential.

The ﬁrst step in partnering with gov-ernment entities is to undertake a comprehensive assessment of the area’s health care problems and re-sources. In addition to analyzing the ministry of health’s existing policies, programs, and guidelines, the assess-ment should include an analysis of local demographics, distribution of health care providers and facilities, disease incidence and prevalence, and any environmental factors that may contribute to morbidity and mortality. To ensure no duplication of efforts, an inventory should also be taken of any non-governmental organizations already providing services in the vicinity.

The organization should then share its

ﬁndings with potential government partners and advocate for necessary resources. Host countries will be more inclined to invest time and assets in a clinic if they perceive a long-term commitment, and many developing countries may be motivated by the prospect of a permanent facility. Def-icits in funding or services can then be

ﬁlled by forming partnerships with other interested parties, such as professional organizations, nonproﬁts, religious charities, universities, and private sector corporations.

Organizations should formalize their re-lationship with governments and other partners in writing, with the assistance of both inside and local counsel. Signing a memorandum of understanding allows the parties to define their plan with reasonable specificity without bind-ing themselves to terms that would limit their flexibility. Health care or-ganizations should discuss their needs

in a comprehensive manner, and any incentives offered during negotiations, including contributions or management of money, property, security, and utilities, or the facilitation of licenses, permits, and visas, should be incorporated into the memorandum of understanding.

DEFINE YOUR GOALS: DEVELOP A PROGRAM

Once reliable and committed partners have been identified and vetted, the parties should agree on a business plan. The plan should define which populations and conditions are to be treated, how many patients will be seen, how medicines and other supplies will reach providers, and a detailed budget, including the cost of equipment and operating costs, and the percentage of capital and personnel each partner will contribute. The proposal should specify whether services will be centralized or delivered at remote sites. Keep in mind the logistical difficulties in servicing distant locales, and consider central-izing testing and referral services, and using telemedicine or other mobile methods to reach outlying areas.

The plan should also deﬁne which treatments will be offered, how they will be adapted for local populations, and how records will be kept. Sim-pliﬁcation is key; if possible, prescribe straightforward regimens and select available medications at low risk for causing side effects or requiring laboratory follow-up.

When identifying potential clinic loca-tions, consider the usability of existing structures, the site’s proximity to trained or trainable personnel, patient and provider safety, and ease of access by foot, vehicle, or public trans-portation. Walk through mock scenar-ios with stakeholders and potential employees to identify design in-efﬁciencies before the clinic is built. Consider all the logistics of operating a clinic. How will power be supplied?

What functions can occur without power? Are there refrigerators, com-puters, and emergency generators? Are laboratory and Internet services reli-able? Is there an established medicine supply chain? Are waiting areas, exam-ination rooms, bathrooms, and teaching areas adequate? Are the facilities du-rable and easy to clean? Are emer-gency, pharmacy, social support, or other ancillary services available? How will language barriers be addressed? Will research be conducted? If so, which Institutional Review Board will review and approve such research? Should a new Institutional Review Board be convened in the partnering country?

ENSURE SUSTAINABILITY: INDIGENIZE

The key to sustainability is education. Encourage health care providers to present themselves as instructors offering technical expertise for a long-term integrated plan rather than simply as short-term visiting physi-cians. Continue to monitor and evalu-ate the program’s efﬁcacy, collecting data and reassessing resources on an ongoing basis to maximize the oper-ation’s effectiveness. Create a sense of local ownership by teaching employees how to apply for grants, solicit addi-tional partners, present and publish results, and share their stories through social media. Promote investment in local nursing, allied health, and medi-cal schools to expand the pool of po-tential health care workers for future generations, and consider using di-aspora communities to bridge gaps between foreign institutions and local personnel. Finally, structure wages and beneﬁts to attract and retain talented workers without supplanting existing caregivers. The ultimate goal of any overseas clinic should be its complete indigenization, and a time frame should be set in which this is expected to occur.

MONTHLY FEATURE

PEDIATRICS Volume 133, Number 4, April 2014 575

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PARTNER LOCALLY: TRANSFORM GLOBALLY

The success of even the most ambi-tious global health care strategies, like the Millennium Development Goals (MDGs), or the Sustainable Development Goals (SDGs), still depends on the efﬁ -cacy of local interventions. Public-private partnerships have proven to be an effective means of supporting those interventions in less developed countries, having succeeded, for ex-ample, in supplementing the health care workforce during the HIV/AIDS epi-demic,3,4 _{introducing new} immuniza-tions,5 _{fortifying foods,}6 _{and supplying} antimalarial and onchocerciasis medi-cations for children and adults.7,8

By tailoring care to the targeted commu-nities and by adhering to a well-formulated plan, health care organizations can successfully implement effective part-nerships to create sustainable clinic programs that will not only improve the health of individuals but will also help stop the cycle of poverty and disease throughout resource-limited regions, one clinic at a time.

NOTE

The author is a global health specialist with the Baylor College of Medicine In-ternational Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, which has established Clinical Centers of

Excel-lence on several continents with a va-riety of public and private partners.

RESOURCES

Although a step-by-step guide of how to develop health care clinic partnerships is beyond the scope of this article, the following online tools are available to assist institutions with the more prac-tical aspects of opening overseas clinics.

A BIPAI toolkit with practical instruc-tions on how to start an HIV clinic in resource-poor settings can be down-loaded from http://bipai.org/Educational-Resources/BIPAI-Toolkit.aspx.

A comprehensive and practical guide-book on international clinics from the National Association for Community Health Centers can be found at http:// www.nachc.com/client/IHCTﬁnal.pdf. Resources from The American Medical Association for creating public-private partnerships can be found at http:// www.ama-assn.org/resources/doc/ public-health/clinical-partnerships.pdf.

Checklists and step-by-step guidance for the formation of free clinics in general can be found at http://www. nafcclinics.org/sites/default/ﬁles/ resources/start%20a%20free%20clinic. pdf.

REFERENCES

1. Henry J Kaiser Family Foundation. US fund-ing for global health: the president’s FY 2014

budget request. Global health policy fact-sheet. May 23, 2013. Available at: http://kff. org/global-health-policy/fact-sheet/u-s-funding- for-global-health-the-presidents-fy-2014-budget-request/. Accessed January 20, 2014

2. Merson MH, Page KC. The dramatic expan-sion of university engagement in global health—implications for US policy. A report of the CSIS Global Health Policy Center. April 2009. Available at: http://csis.org/ﬁles/media/ csis/pubs/090420_merson_dramaticexpansion. pdf. Accessed January 20, 2014

3. Kline MW, Ferris MG, Jones DC, et al. The Pediatric AIDS Corps: responding to the African HIV/AIDS health professional re-source crisis.Pediatrics. 2009;123(1):134– 136

4. Damonti J, Doykos P, Wanless RS, Kline M. HIV/AIDS in African children: the Bristol-Myers Squibb Foundation and Baylor re-sponse. Health Aff (Millwood). 2012;31(7): 1636–1642

5. Hajjeh R. Accelerating introduction of new vaccines: barriers to introduction and les-sons learned from the recentHaemophilus inﬂuenzaetype B vaccine experience.Philos Trans R Soc Lond B Biol Sci. 2011;366(1579): 2827–2832

6. Sablah M, Klopp J, Steinberg D, Touaoro Z, Laillou A, Baker S. Thriving public-private partnership to fortify cooking oil in the West African Economic and Monetary Union (UEMOA) to control vitamin A deﬁciency: Faire Tache d’Huile en Afrique de l’Ouest.

Food Nutr Bull. 2012;33(4 suppl):S310–S320 7. Bompart F, Kiechel JR, Sebbag R, Pecoul B.

Innovative public-private partnerships to maximize the delivery of anti-malarial med-icines: lessons learned from the ASAQ Win-throp experience.Malar J. 2011;10:143

8. Colatrella B. The Mectizan Donation Program: 20 years of successful collaboration -a retrospective. Ann Trop Med Parasitol. 2008;102(suppl 1):7–11

FINANCIAL DISCLOSURE:The author has indicated she has noﬁnancial relationships relevant to this article to disclose. FUNDING:No external funding.

POTENTIAL CONFLICT OF INTEREST:The author has indicated she has no potential conﬂicts of interest to disclose.

576 COLLINS

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DOI: 10.1542/peds.2013-3946 originally published online March 24, 2014;

2014;133;574

Pediatrics

Elizabeth Montgomery Collins

Developing Health Care Clinic Partnerships in Resource-Limited Regions

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DOI: 10.1542/peds.2013-3946 originally published online March 24, 2014;

2014;133;574

Pediatrics

Elizabeth Montgomery Collins

Developing Health Care Clinic Partnerships in Resource-Limited Regions

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