Between 2015-2020 Primary Care International (PCI) and Letshego Group partnered together to support communities across sub-Saharan Africa access quality primary healthcare.
With financial investment and brokerage of stakeholder relationships by Letshego and technical and programmatic expertise from PCI, together we created a multi-country Healthcare Innovation Programme (HIP) that has seen tangible impact on people’s lives.
The programme focused on strengthening primary care and tackling non-communicable diseases (NCDs). It supported the identification of innovative ideas and led to partnerships with a range of partners, from grassroots NGOs to Ministries of Health, with whom we worked to develop and finance projects designed to improve people’s lives and to generate invaluable lessons and scalable models for health workforce capacity building and primary healthcare systems strengthening.
The theory of change which informed the public-private partnerships forged under this programme was based around the key ‘building blocks’ of integrated NCD care which, in order to be accessible to all, must be available within primary healthcare.
Some of the key achievements, and the factors that contributed to these, are highlighted below and the full report can be found here.
In some projects we were able to see a positive impact on the lives of people living with, or at risk of, NCDs, in others we were able to demonstrate positive clinical outcomes as well as a range of anecdotal improvements from patients and from primary health care staff.
In Kenya, there is evidence of patients being retained in NCD care through linking primary care clinics with income generation through microfinance groups. Retention in care is crucial for effective NCD management. Prior to the establishment of the microfinance groups there was no effective local system to provide ongoing care for those with hypertension and diabetes.
“I used to spend most of my time laying down, I couldn’t do anything productive because I felt very weak. I now have a little more energy in my body because I get routine medication. The health workers at the facility treat me very well and are very helpful” (Faustina Kakande, patient in Uganda).
A number of projects demonstrated the effectiveness of PCI’s peer-to-peer, Training of Trainers (ToT) model – also known as cascade training. We saw improvements in the knowledge and skills of participants and the development of in-country NCD trainers, enabling them to embed the learning more widely as well as to become a resource for workforce development in the future.
In Botswana, we worked in partnership with the Ministry of Health and Welfare (MoHW) to roll out new national Primary Care Guidelines on NCD care to health care professionals in primary healthcare centres across Botswana. Following our peer-to-peer learning model, we successfully trained 32 clinicians to be ‘Lead Trainers’: focusing on building confidence and motivation as much as skills and competence. The Lead Trainers cascaded training to 174 primary healthcare workers in eight districts. Evaluations (using pre and post quizzes which test the knowledge base of participants prior to the training and then again after it) showed that the NCD Lead Trainers who were trained by PCI achieved the same levels of participant clinical knowledge and clinical skills improvement, and the same levels of participant satisfaction, as PCI trainers. There is now a cohort of skilled NCD Lead Trainers to deliver the NCD training programme.
“The primary care guidelines have been rolled out successfully with multidisciplinary healthcare teams in all eight pilot districts and we plan to replicate this model in other districts soon. The trained districts will see a programme of structured observations and mentoring of those just trained, to ensure quality of care and sustainability.” (Dr Gontse Tshisimogo, a public health doctor working in the MoHW).
Success factor 1: The relationship with the Ministry of Health
Whether it makes sense to engage at national level from the very beginning, or whether a bottom-up approach initially sharing ideas at district level and forging plans together is a better entry point, it is well known that few NGOs or private sector initiatives can thrive without political and public sector support. At the piloting stage, their insight and approval is essential. When it comes to replication, public sector infrastructure and personnel are a game-changer, offering unparalleled opportunity to scale inclusive, cost-effective models.
Success factor 2: Planning for Scale Up
Many models of care that the HIP engaged with involved cascading of training. Those which cascaded most successfully and sustainably had put considerable thought into this phase of the project whilst still at the piloting stage. A beautifully conceived model which has too many inputs to ever be realistically scaled remains just a model. Those projects which put in place a clear plan for cascade training right from the start of the project demonstrated stronger potential for adoption across other geographies. These plans include consideration of: engagement of trainers, diversity of trainers, alignment with local health policy, implementation in different context and environments and nurturing the program through mentorship to embed approaches and ensure ongoing ownership of the work.
Success factor 3: Understanding importance of a strong primary care system
A strong integrated primary care system, in particular with a focus on a family medicine approach, is essential to tackling NCDs. It helps to work collaboratively with stakeholders at the start of a project to ensure we have a common understanding of these key concepts. In some countries we found that Family Medicine is already quite well-recognised and a developed specialty and this helped ensure support for the project from the start. In other settings, Family Medicine is a relatively newer concept, promoted at the national level but with limited practical support. NCD care projects can bring existing family medicine practitioners together and facilitate the development of a network of motivated clinicians to catalyse change. Understanding the concept and role of the primary health care team in a particular national setting is also important in developing a project. Nurses, other allied health care professionals and community health workers can have key roles in NCD programmes if this is part of a national strategy. Indeed, projects such as those developed through the HIP can provide practical demonstrations of strategic NCD plans.
Innovation has always included new drugs and new treatments, but today it means innovation in every part of healthcare delivery. It means stopping the healthcare costs from spiralling out of control through prevention, early diagnosis without expensive referral, and long-term access to affordable treatment. It means patient record systems in place and helping healthcare professionals feel motivated and keep skills up-to-date. The Healthcare Innovation Programme sought to do this through testing new models of primary healthcare to address the fast-growing burden of NCDs.
Having identified key success factors for project impact and scope to scale, we are now working with our existing partners, as well as seeking new investment, to further generate evidence of the value (and viability) of decentralising the prevention and management of chronic diseases to primary healthcare through co-designing and testing models of care. Demonstrating the cost-effectiveness of models of NCD care in primary care and their impact on the health outcomes of people living with NCDs will enable PCI and our partners to advocate amongst global health leaders and decision makers. Do get in touch if you would like to find out more.