- outpatient clinics
- public-private partnerships
- developing countries
- global health
- international child health
- global child health
- capacity building
- health care infrastructure
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 attention to the total fabric and environment 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 community, 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 populations 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 effective 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 global health 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 preconceptions, from religious prejudices against vaccines to the stigma associated with certain diseases, health care organizations may find it difficult to provide populations with meaningful health care options. Health care providers should tailor their education programs to address such issues, adjusting for differences in literacy levels, social hierarchies, and perceptions of time and social conventions, 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 personal and professional relationships 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 government entities is to undertake a comprehensive assessment of the area’s health care problems and resources. In addition to analyzing the ministry of health’s existing policies, programs, and guidelines, the assessment 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. Deficits 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 relationship 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 binding themselves to terms that would limit their flexibility. Health care organizations 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 centralizing 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. Simplification 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 locations, 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 transportation. Walk through mock scenarios with stakeholders and potential employees to identify design inefficiencies 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, computers, and emergency generators? Are laboratory and Internet services reliable? Is there an established medicine supply chain? Are waiting areas, examination rooms, bathrooms, and teaching areas adequate? Are the facilities durable and easy to clean? Are emergency, 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 physicians. Continue to monitor and evaluate the program’s efficacy, collecting data and reassessing resources on an ongoing basis to maximize the operation’s effectiveness. Create a sense of local ownership by teaching employees how to apply for grants, solicit additional partners, present and publish results, and share their stories through social media. Promote investment in local nursing, allied health, and medical schools to expand the pool of potential health care workers for future generations, and consider using diaspora 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.
Partner Locally: Transform Globally
The success of even the most ambitious global health care strategies, like the Millennium Development Goals (MDGs), or the Sustainable Development Goals (SDGs), still depends on the efficacy of local interventions. Public-private partnerships have proven to be an effective means of supporting those interventions in less developed countries, having succeeded, for example, in supplementing the health care workforce during the HIV/AIDS epidemic,3,4 introducing new immunizations,5 fortifying foods,6 and supplying antimalarial and onchocerciasis medications for children and adults.7,8
By tailoring care to the targeted communities and by adhering to a well-formulated plan, health care organizations can successfully implement effective partnerships 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.
The author is a global health specialist with the Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) at Texas Children’s Hospital, which has established Clinical Centers of Excellence on several continents with a variety of public and private partners.
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 practical aspects of opening overseas clinics.
A BIPAI toolkit with practical instructions on how to start an HIV clinic in resource-poor settings can be downloaded from http://bipai.org/Educational-Resources/BIPAI-Toolkit.aspx.
A comprehensive and practical guidebook 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.
- Accepted January 27, 2014.
- Address correspondence to Elizabeth Montgomery Collins, MD, MPH, Section of Retrovirology & Global Health, Feigin Center, Suite 630, Houston, TX 77030. E-mail:
Dr Collins designed and drafted the initial manuscript and final manuscript as submitted.
FINANCIAL DISCLOSURE: The author has indicated she has no financial 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.
- Henry J
- Merson MH,
- Page KC
- Kline MW,
- Ferris MG,
- Jones DC,
- et al
- Damonti J,
- Doykos P,
- Wanless RS,
- Kline M
- Hajjeh R
- Sablah M,
- Klopp J,
- Steinberg D,
- Touaoro Z,
- Laillou A,
- Baker S
- Copyright © 2014 by the American Academy of Pediatrics