LifeNet International (LN) began in the fall of 2008 with a simple yet ambitious vision to pursue sustainable healthcare for the poor and underserved populations of East Africa.  In the fall of 2009, we launched operations in Burundi, a small post-conflict country in East Africa, and recently concluded an 8-month pilot program there.  During our pilot, we partnered with four local clinics to develop a conversion franchise model for primary healthcare.  The pilot yielded deep insights into the Burundian health sector and held greater implications for the East African region.  In short, we found that church-based healthcare facilities are the latent hope of East Africa for providing quality, sustainable, healthcare to the underserved populations throughout the region.

After a year of stateside research, including two feasibility studies in partnership with the University of Pennsylvania, we landed in Burundi unaware of the true realities on-the-ground.  Burundi ended a 12-year ethnic based civil war in 2005 that killed hundreds of thousands, and destroyed over 30% of GDP and much of the country’s infrastructure.  Burundi now ranks as the fourth poorest country in the world.  Children under-5 die at a staggering rate of 166.3 deaths per 1,000 live births; compared to 7.8 per 1,000 in the US.  The country’s estimated 200 doctors largely work in the capital, Bujumbura, home to only 10% of the 8.3 MM person population.  For the average Burundian, primary healthcare is administered by a nurse with 2 years of high school level training.

Within this bleak context, we observed a number of private clinics functioning on the periphery of the formal health sector, yet providing vital services to underserved communities.  Indeed, these clinics were the fastest growing segment of the health sector and therefore drew our further exploration.  Our pilot project comprised four clinic partnerships across a spectrum of private healthcare providers: two were entrepreneur-owned, one belonged to a Burundian non-governmental organization (NGO), and a local church denomination ran another.  These partnerships were the source of our greatest learning.

LN’s two entrepreneur-owned partner clinics reflect the burgeoning growth of private clinics in Burundi.  Both were located in rural and peri-urban areas on the fringe of Bujumbura, several kilometers from the nearest clinic.  On average, these clinics see between 5 and 25 patients per day, depending on seasonal illnesses, and also offer hospitalization and maternity services.  Patients pay on a fee-for-service basis, though the clinic’s dispensing pharmacy drives the economic engine – as is the case for all clinics in Burundi.  The clinics function with little oversight from the Ministry of Health and bribery frequently regulates rather than adherence to national standards.  Patients visit these clinics due to geographic proximity and a perceived higher quality of care.  This perceived quality of care often represents a constraint of the free market system to provide accurate information to the consumer.  Oftentimes these entrepreneurs turn a blind eye to quality of care yet profit from a perceived premium; another dose of antibiotics is another dose of income.  While providing needed services to their communities, entrepreneur-led clinics often operate on a competing exchange of quality versus profits.  This is a difficult line to walk, even for the most ethical of entrepreneurs.

LN also partnered with an urban clinic owned by a Burundian NGO, but funded largely with international donor funding.  This clinic offered the nicest physical facilities and the most sophisticated equipment, but was also the least frequented.  The staff, well equipped with a doctor and even a psychologist, had incredible turnover due to inept financial management at the NGO level.  Staff turned over so frequently that LN had difficulty implementing our training as many of the staff were new by the next scheduled training session.  Donor funded clinics have potential to provide a subsidized care model that would greatly increase quality of care, however, they must be stewarded and rely on continual donor funding for sustainability.

An unforeseen outcome of our original sustainability thesis was that the church-based clinic outperformed our other pilot clinics in providing the highest quality of care, to the most people, at the cheapest cost.  These findings spurred broader research to other church-based clinics in Burundi and Uganda; our observed findings were similar.  A marked difference exists between church-based clinics and other clinics in both sectors – public and private.  The church holds the greatest hope for structural impact of pro-poor, sustainable healthcare systems.

Church-based clinics function as a hybrid entity within the private sector, in that they prioritize social good over profits but are balanced by a need for financial self-sustainability.  These clinics tend to be larger in size, see a higher volume of patients, and operate with greater management depth.  Most major church denominations operate a multiple-location network of health facilities.  For example, in Burundi, the Anglican church runs six health centers and two hospitals.  The Free Methodist Church runs four health centers, a major hospital in the center of the country and is opening a major teaching clinic this fall for its medical school in Bujumbura.  The Pentecostals mange a network of over 20 clinics.  LN estimates that total church-based clinics represent between 11% and 18% of total health facilities in the country.

Despite their remarkable potential, the church-based health sector is often overlooked in the international and Christian donor communities.  Silo funding for disease specific initiatives such as HIV/AIDS, malaria, tuberculosis, while of vital importance, ignore the 38% of deaths 5 that occur due to a lack of quality primary care.  Because most church clinics focus on primary care they are marginalized from traditional sources of institutional funding.  Additionally, many international donors target government-to-government funding and therefore preclude vibrant private sector alternatives. Historically, the western church has provided western driven solutions to local health needs through direct donations or free care (i.e., doctors and nurses on short-term visits).  While these traditional means are still useful in the poorest communities, the western church must increase the sophistication of its approach to consider sustainable and long-term solutions.   As Burundi transitions from post-conflict country to a developing country the need increases for long-term solutions that enable locally driven innovation to meet locally generated needs.

The LN approach works within local realities to empower sustainable local solutions.  Our pilot project developed a conversion franchise model that overlays a franchising system onto existing clinic operations.  Churches enter into a franchising partnership with LN whereby they receive training, systems, and tools and in exchange agree to uphold LN standards of care and implement clinical best-practices.  The LN franchise focuses on four core components of clinic operations: nursing care, operations management, pharmaceutical supply, and community health outreach.

LN’s church-based partnerships begin with an assessment period that helps LN and the clinic understand the clinic’s most essential operational needs (for example, pediatric care or financial management).  LN incorporates the clinic’s feedback into a custom growth plan that outlines a quarterly training schedule and operational objectives.  At the end of the quarter, LN conducts a quality scorecard evaluation to measure the impact of the franchise and to determine a new custom growth plan for the next quarter.  The partnerships are long-term agreements that ensure that the quality of care continues to increase over time in a manner that permanently impacts the greater health sector.

In addition to its core franchise offering, LN is pursuing strategic for-profit initiatives that leverage its capacity building of local healthcare systems.  LN is currently developing a for-profit loan fund to finance a clinic’s physical capacity needs to renovate, expand, or construct new facilities.  Also under consideration is a for-profit wholesale pharmaceutical supply entity that would provide quality assured medicines to church-based and other health facilities throughout the country.  At present, little regulation exists of Burundi’s pharmaceutical supply chain and no independent quality testing is available in-country.  All profits generated via LN entities will be 100% recycled within the organization to sustain our not-for-profit work in-country.

The Burundian health market will remain blighted by poor regulation, anemic public sector capacity, and a broken medical supply chain for the foreseeable future.  Even so, the church remains a beacon of hope to provide quality and sustainable healthcare to the poorest and most underserved populations.  It is LifeNet’s vision to empower the local church to further their vision and bring healing to all Burundians.