After years of talk, time for action

It was a tough assessment for a health clinic, and Jim Yong Kim was standing in the middle of one when he made it.

“A lot of these are known as places where you go to die.”

Kim, the Francois-Xavier Bagnoud Professor of Health and Human Rights at the Harvard School of Public Health and professor of social medicine at Harvard Medical School, was at the Bobete health clinic high in the mountains of the tiny African nation of Lesotho.

Bobete would have once fit Kim’s gloomy description, but today it is an exception to that assessment and an example of what Kim and a handful of Harvard faculty members hope more poor, rural health clinics can become. Well-staffed and well-supplied, the clinic is part of an expanding network run in Lesotho and eight other countries by the Boston-based nonprofit Partners In Health.

Through a new academic program at Harvard called the Global Health Delivery Project, Kim, together with Bishop William Lawrence University Professor Michael Porter and Partners In Health co-founder Paul Farmer, the Maude and Lillian Presley Professor of Social Medicine, are gathering examples of public health success stories from around the world. These successes will provide a foundation on which the new program will rest and from which important lessons will be drawn on health care delivery in some of the world’s poorest places.

Porter, who has been working on health-care-related issues for several years, said the program’s idea came out of a meeting he had with Kim about a year and a half ago. They discussed how the most intractable problems in global health delivery were not ones concerning medicine or particular treatments, but rather management problems familiar to the Harvard Business School.

“What we’ve come to understand is that the real constant holding back health care delivery for low-income populations is most often not medical science. Fundamentally, it’s a management problem,” Porter said. “That’s the kind of stuff business schools study all the time.”

Despite many private, nonprofit organizations delivering health care in poor areas, health improvements are slow to be realized. That may be because the organizations often reflect the passions and beliefs of those who run or finance them rather than lessons learned from successful cases, and that oversight is mainly because those cases have never been studied.

Global Health Delivery Project Executive Director Rebecca Weintraub said failed implementation is apparent in the African AIDS epidemic, where, despite as many as 60,000 nongovernmental organizations in Africa that claim to treat patients with HIV, just 10 percent of HIV-positive pregnant women get services to prevent the virus’s transmission to their newborn children.

The Global Health Delivery Project is a collaboration between Harvard Medical School’s Department of Social Medicine, which Kim chairs, the Harvard School of Public Health, Brigham and Women’s Hospital, Harvard Business School, and Partners In Health. It is co-chaired by Kim and Porter.

One of the first steps is to build materials for the project’s classes by putting together exhaustive, real-world cases that lessons can be shaped around. Kim said cases will be drawn from stories of public health successes and failures around the world, such as Bangladesh’s BRAC nonprofit development organization, which grew from humble roots in 1972 to become one of the world’s largest nongovernmental development organizations; Thailand’s drive to ensure 100 percent of sex workers use condoms; Partners In Health’s rural clinics in Rwanda, where the desperate need to fight HIV and tuberculosis is driving expanded primary health care on which HIV and TB treatment is based; and failing efforts to eradicate polio in Uttar Pradesh, India.

Gathering the case studies is an important step in teaching global health, Kim said. Even such notable successes as the eradication of smallpox are not effectively taught in most schools of public health, he said. As a consequence, those who have been involved with successful health care programs mainly know the details of just their own work. If broader lessons are to be learned, Kim said, both successful and unsuccessful cases of health care delivery in challenging settings have to be examined and best practices taken away so that students inspired to enter the field will do so armed with that knowledge.

“Somebody has to do the difficult work of collecting all the details of how programs are either getting it right or wrong in the field,” Kim said. “There are lots of things that we will only know by talking to lots of different people and revising our cases until we get it right.”

By the end of the year, Weintraub hopes to have 15 cases ready. Ultimately, she hopes to be able to draw on 100 or more.

From the cases, program organizers intend to be able to extract common threads that will help to identify important questions for further research and also lead to the development of analytic frameworks for understanding a broad range of global health delivery problems.

While case-based teaching is a hallmark of Harvard Business School, Porter said he doesn’t see a business school approach supplanting medical or public health training. Instead, he said, it will augment those traditional teaching approaches and provide an element missing in teaching how to deliver health care in poor settings.

Weintraub said there’s a large demand for the program. A third of first-year medical students express interest in global health, as do 36 percent of Harvard undergraduates.

The program kicked off its academic efforts with an intersession class held in January. About half of those who attended were international students, and 70 percent were doctors. Many also held degrees in public health.

The program will continue to expand its offerings in the coming years, with plans for a course this summer and full-term courses beginning in September 2008. Ultimately, Kim said, they hope to launch a master’s degree program in Global Health Delivery.

At the undergraduate level, Kim and his group have partnered with the Harvard Initiative for Global Health (HIGH) to offer a new course this fall, Anthropology 1825: “Health, Culture, and Community: Case Studies in Global Health.” The course will draw on faculty field experiences in Asia, Africa, and the Americas. Students will examine several case studies addressing AIDS, tuberculosis, malaria, mental illness, and other topics, and will explore literature from diverse disciplines, including epidemiology, anthropology, history, and clinical medicine.

With the world littered with failed health programs and millions of people dying each year from preventable and curable diseases, Kim said the time has come to develop a new field of health care delivery science, which, like the Harvard Global Health Delivery Project, would combine existing medical, public health, management, and service delivery knowledge to create more effective practices to bring relief to people suffering and dying needlessly around the world. Kim said that while much important work is already being done in health care delivery research, the lack of a field that places this work in the center of medical and public health education has been problematic.

Kim’s push to improve global health care delivery is rooted in his experience with Partners In Health, a nonprofit with close ties to Harvard that was co-founded by Kim, Farmer, and a handful of others in 1987. Those working with the nonprofit recount case after case like that in Bobete, Lesotho. The remote clinics exist to serve the rural poor, but are poorly run, understaffed, and ill-equipped. Despite their location amid poverty, malnutrition, and sometimes raging epidemics, such as the AIDS pandemic, the clinics attract just a handful of patients each day – patients who consider the facilities a place of last resort.

Typically, after Partners In Health arrives, it posts a physician at each site and ensures an adequate supply of medicines. It offers effective care for a nominal fee, which is waived if the patients can’t afford it. Patients come flooding in as word spreads that there’s a place they can go to get well.

The Global Health Delivery Project also aims to work outside the classroom and improve health care practice in these places by fostering online “communities of practice” where professionals can communicate and interact. Plans include a networking site for global health practitioners to get support, advice, and reliable information. Plans also include designing a graphics-free search engine that can be used by physicians working in places with slow or unreliable Internet connections. Organizers are also planning to establish innovation centers in the field, where rigorous academic training can be informed by experience on the ground and by ongoing implementation experiments.

“We want to push this out to the poorest areas of the poorest countries,” Kim said. “We have to do the hard work of capturing experience; we have to do lots of operational, clinical, and other research; we have to innovate; and most importantly, we have to help people stay healthy despite unspeakable poverty.”