On 25th February, as the 6th in the Medical Innovation lecture series, Steve Fairman and Prof Jon Meakins, spoke to the question of ‘Service Delivery Innovations in the NHS’. They drew on some interesting examples of how service innovations can be effective – the simple re-positioning of a fridge led to significant cost savings in one service, and enabled healthcare workers to meet stringent clinical care guidelines; empowering senior surgeons in another service reduced cancellations of routine surgical procedures and led to enormous cost savings.
Service innovations, as opposed to the more commonly considered technological innovations, are just as needed in health systems in developing countries. Of the 33 million people living with HIV globally1.5 million people are infected with HIV/AIDS each year and 1.6 million (73% of the total) people die from HIV/AIDS each year. The Millennium Development Goals (MDGs) have placed in the foreground the need to rollout out anti-retroviral treatment (ART) to those that need it – the second target of the 6th MDG calls for universal access to treatment by 2010. Many major donor organizations such as PEPFAR, Global Fund and the Gates Foundation provide resources to this aim and much is now being spent on the development of new and improved treatments. However, in these contexts, where health systems are often under-resourced at best, it can often be the most simple, and inexpensive interventions that can be the most effective at improving the rollout of treatment to those that most need it.
I draw on personal experience of a systems innovation in an HIV/AIDS referral centre in Central Mozambique, to show how inexpensive interventions can help to achieve this goal.
In HIV/AIDS treatment and care, eligibility for Anti-Retroviral Treatment (ART) is based on two important pieces of clinical information. Put very simply, if the CD4 count, a measure of the strength of a patient’s immune system is below 200, then he/she is eligible for ART. But also the patient needs to have a physical examination to determine the clinical ‘stage’. If a patient has any of the infections, or malignancies, that are characteristic of the Immune Deficiency syndrome (AIDS) then he/she is also eligible for ART. So to be put on ART, it is necessary to do a blood test, namely the CD4 count, and to be examined to determine the clinical ‘stage’.
At the time I arrived at the HIV referral centre in Central Mozambique, this system was extremely cumbersome. Firstly, the examination was done first by the doctor, then the patient would be sent to do the blood test, and then re-seen by the doctor to look at the result a couple of weeks later, which in combination with the clinical examination would determine appropriateness for ART treatment. The patient would be referred to the social worker to determine adherence issues, and social circumstances. The case, some days later, would be put before a clinical committee, and once agreed that ART is required, the patient would be referred back to the social worker and the pharmacist to begin treatment. All in all, this process could take well over two months.
But also, doctors’ time was not being utilized effectively. Looking at the profile of the patients being seen by the doctors, although all were HIV positive, most of them did not yet require ART. As a first-come-first-served service, all new patients would be seen by the doctors, but the triage nurse would also refer to the doctors any HIV positive patients requiring treatment of any sort, whether for malaria, for diarrheal illnesses or even for a headache, which would take up the doctors’ valuable ART prescription time.
Even though there were 8 doctors, each seeing on average 20 HIV positive patients every week, the majority of the patients were not requiring ART treatment. Only 18 new patients were being identified as needing ART and being successfully started on it each week. Many were being missed. In the context of ART expansion and rollout, with over 1 million inhabitants in the region, and approximately 20% HIV prevalence, the system was simply not geared up to meet the hidden and the growing demand for ART treatment.
Two important system changes were implemented. Firstly, representing a paradigm shift in patient flow, an appointment system was introduced so that doctors’ time could be better controlled. Secondly, a more targeted triage system was implemented, where ‘ART-nurses’ were trained and given more responsibility with regard clinical staging. Newly registered patients, that did not require urgent care, would be sent immediately by the receptionist to do the CD4 blood test, and then for a full clinical examination by the ART nurse to identify the patient’s clinical stage. They would receive an appointment for the triage nurse one week later where, with the CD4 blood test result in hand, the decision could be made if they fulfill the criteria for ART. If so, they would be referred to the doctor, to be seen immediately and to be put on treatment. If not then they would be referred to the social worker only, for counseling and follow-up.
As a result, many more patients requiring ART were identified and also much earlier in their care. Within about a month, doctors’ consultation times were taken up almost exclusively with patients requiring ART and it was not long before the numbers of patients getting on to ART had tripled from an average of 18 to 50 or more per week.

Systems changes such as these were not straightforward. Nurses had to be trained; senior clinicians had to understand that the changes were necessary; they had to ‘own’ the changes; even an appointment book had to be designed from scratch, and the semi-literate auxiliary staff trained with respect to its use; finally, the patients themselves had to re-learn what the referral centre was for – not a drop-in clinic for all ailments, but for the clinical staging, counseling, starting and maintaining of ART treatment.
However, this innovation required no investment, no research and development, no patenting, and no start-up costs and it had a considerable impact on the service and on patient care. It was the ‘pursuit of perfection’ in patient flow, as Steve Fairman put it, striving to do the best with what you have, that drove this change process. The experience left me wondering – why is it that when such simple changes can lead to such considerable impact, Medical Innovation is in general synonymous with Technological Innovation. Perhaps more time and money needs to be given to the small changes in patient flow, in work patterns, and in efficiency that can bring about, when aggregated together, huge benefits, whether financial or clinical to developing country health systems. Perhaps, instead of investing in lengthy and expensive drug and vaccine developments, might our resources be better used directed towards the identification of discrete improvements in the management of existing services that can lead to a greater overall impact in healthcare?