Leveraging the power of partnerships: spreading the vision for a population health care delivery model in western Kenya

Over the years, AMPATH has been building many of the necessary components of a comprehensive population health model (see Table 1). These include clinical programs covering adult and pediatric HIV, prevention of mother-to-child transmission of HIV (pMTCT), maternal, neonatal, and child health (MNCH), family planning (FP), tuberculosis (TB), diabetes, hypertension, cardiovascular disease, anticoagulation, oncology, palliative care, and mental health, as well as several cross-cutting departments including human resources and administration, grants management, pharmacy, laboratory, informatics, food and income security, monitoring and evaluation, quality improvement, and research [4‐6, 18, 19, 38, 39, 51‐74]. Kenya’s first electronic medical record system, the AMPATH medical record system (AMRS), was initially built to support care at a single rural health center, but has now grown to support HIV, MNCH, and NCD care, as well as monitoring and evaluation, quality improvement, and research, across much of AMPATH’s catchment area. Building on the HIV clinical infrastructure, AMPATH’s chronic disease management program now cares for thousands of patients with hypertension and diabetes at MOH-supported facilities across multiple counties, coupled with advanced cardiovascular care services at MTRH. Similarly, in both MNCH and oncology, community-based screening, care and workforce training have been coupled with advanced diagnostic and treatment services at MTRH. This has become a common pattern of coupling community-based care with specialty, hospital-based services, spanning across the tripartite academic mission of service, teaching and research. As the program has grown, however, the activities of these different components have, at times, become disjointed. The potential to unify our strategy and realize the synergies that existed was upon us. To build a population health care delivery model, AMPATH is breaking down these silos and integrating all of the component elements across each of the World Health Organization’s (WHO) health system building blocks – leadership and governance, financing, workforce, medicines and technologies, information systems, and service delivery [75]. Not only will the care system require integration across the health system building blocks, but service delivery points will require integration from primary to tertiary levels of care, connected by a seamless electronic health information system, such that the health system is designed to manage disease, and promote health, throughout the life course [27]. A population health care delivery model must also be more responsive to, engaged with, and driven by members of the community. A community-centered model of care involves getting out of the clinic and meeting the people where they are, delivering health prevention, promotion and care services in the home or other community spaces, such as workplaces, schools, and among community groups or gatherings [30]. Inherent in this approach is a proactive responsibility to promote health, and not just react to disease. This involves listening to the peoples’ voices in defining their own health priorities and holding their care system accountable to ensure access, quality, equity and the fulfilment of their right to health and social well-being. Lastly, a population health care delivery model requires mechanisms to protect the population from the impoverishing financial consequences of illness, and deliberately work to ensure food and income security. By leveraging microfinance groups as platforms for health promotion and care delivery, and through new partnerships with Kenya’s NHIF, AMPATH has the potential to develop a sustainable, domestic financing mechanism that will ensure universal health coverage for the entire population of western Kenya [76]. Currently AMPATH supplements Kenyan MOH financing of its health care system through a combination of individual philanthropy, private and corporate foundations, and U.S. government funding through PEPFAR-USAID. Our hope is that, over time, the need for external donor funding will decrease as sustainable, domestic financing mechanisms are scaled up.

Dow AgroSciences is a corporate partner with AMPATH, helping build capacity for our agricultural and nutrition programs that support our comprehensive care delivery model. Starting in November 2015, AMPATH partnered with two strategic operations and change management experts from Dow AgroSciences, who had previously worked with the change management consulting firm called Root Inc. Root Inc. has helped many Fortune 500 companies, including Dow, to create breakthrough change in their organizational mission, culture, and strategy. Leveraging this pre-existing partnership with Dow AgroSciences, we were able to engage the change management expertise and tools developed by Root Inc. to help develop our vision and strategy for building a population health care delivery model in western Kenya. Root Inc. uses a unique methodology called a ‘Learning Map®’ visual that represents the vision and strategy through a detailed infographic and conceptual illustration (Fig. 1). This Root Learning Map® module then becomes a metaphor for telling the story of the vision throughout an organization, rapidly creating a common understanding, shared language, alignment of priorities, and an intellectual and emotional connection to the strategy. The Learning Map®, along with supporting data, engaging questions and a facilitated discussion guide, unleashes the power of large groups of people to gain clarity of vision to catalyze change [77, 78].

The development of the Learning Map® started with several conference-calls over a four-month period between an internal planning and leadership team at AMPATH in Kenya, the strategic operations and change management experts from Dow AgroSciences, and a team of consultants and artists from Root Inc. During these meetings, we explained and refined AMPATH’s vision and strategy for population health through a series of sequential, facilitated discussions. These discussions covered the mission and goals of AMPATH; the history and accomplishments of the existing AMPATH-MOH care delivery system; how the components and programs of AMPATH come together to deliver on the vision; the strategic objectives and priorities to achieve the vision; the building blocks within the existing programs that need to be leveraged to realize the vision; and the important internal and external stakeholders, their roles, and the behavior changes needed to make the vision a reality. Through this series of discussions, the Learning Map® was iteratively created, and the discussion guide was built.

The facilitated discussion guide that accompanies the Learning Map® is broken into four main sections: 1) Building the Momentum; 2) Opportunities on the Horizon; 3) Daring to Dream; and 4) Making the Dream a Reality (Fig. 2). Each of these sections is accompanied by a set of cards, including data elements, narrative stories, and questions to be read by participants that help facilitate the discussion, guiding groups of 8–10 participants through a 90-min experience, encompassing the vision of population health for western Kenya, and the strategy to achieve that vision.

Once the Learning Map®, discussion guide, and cards were drafted, the Population Health Learning Map Experience was rolled out in Kenya over a one-week pilot period, including four sessions with senior leadership from the Ministry of Health, AMPATH, MTRH, MUCHS, as well as middle-management across the MOH-AMPATH care delivery system. These sessions served three purposes. First, was to present the vision for population health to key thought leaders and decision makers within the organization. Second, was to elicit feedback surrounding the delivery of the Learning Map®, and more importantly, the vision for population health and our strategy to implement it. Third, was to identify, and subsequently train, facilitators who can then lead staff across all levels of the MOH-AMPATH delivery system through the Learning Map® experience. During this pilot period, the messaging surrounding the Learning Map® was refined, however no major changes were made to the content. This reflected the fact that informal input was sought from many of these key thought leaders during the development phase, and in reality, AMPATH had been organically working towards this vision for many years. The key lesson in this Learning Map® Experience is that “the wisdom is in the room” and the map is just a metaphor, and a tool, for enabling people to share a common vision for change. Through this iterative process, AMPATH’s vision and strategy have crystallized, and we have created a core team of facilitators, or change agents, who are spreading the vision of population health throughout the pilot catchment area of 1 million people in western Kenya. Over the ensuing months, nearly 1000 MOH and AMPATH staff, of all different roles and cadres within the health system, have gone through the Population Health Learning Map® Experience. The Population Health Learning Map® has also been presented to politicians, sitting on the Health Committee of the local County Assembly, to galvanize their support for a robust, public sector, population health care delivery model in their constituencies. Lastly, the Population Health Learning Map® was presented to approximately 30 high-level executives from various pharmaceutical companies and foundations, the Gates Foundation, the National Institutes of Health, and USAID-PEPFAR during the AMPATH Partners Summit to share our vision with key international stakeholders and funders. In a short period of time, and by leveraging a unique set of collaborative partnerships, we have spread the vision for a comprehensive, integrated, community-centered, and financially sustainable model of population health to key stakeholders at all levels of the health system (Fig. 3).