Sustainability*: (almost) everybody wants it. Program managers worry about how they will keep their organization going. Funders worry that they will have to continue to fund programs forever. In private sector healthcare in lower- and middle-income countries, high-end hospitals tend to find sustainability because their clients are willing to pay large amounts for health care. But the key question remains: how do you provide the poor with quality care at an affordable price while still achieving sustainability?
Yayasan Kusuma Buana, based in Jakarta, Indonesia, seems to have found one answer to this question through The Family Clinics. Started in 1981, the Family Clinics provide maternal health services, along with some general primary care services, to low and middle income populations out of five clinics. Four of these clinics are in Jakarta, while the fifth is located in West Java catering to the mostly female employees of the Mark and Spencer clothing factory. Originally funded by USAID in the early 1980s, YKB has been able to use seed funding to help each of its clinics break even after only 3 to 4 years of operation!
A nurse at a Family Clinic consults with a local family.
But how have The Family Clinics achieved this sustainability? While there is no single answer, there are a number of tactics being employed that help attract customers and conserve resources.
- Increasing patient volume: To increase foot-traffic, The Family Clinics accept Jampersal, a government insurance that covers deliveries for all Indonesian women. According to Dr. Firman Lubis, founder of YKB, accepting Jampersal has helped increase foot traffic at the Family Clinics, despite the fact that most women still pay out-of-pocket. Additionally, YKB uses social marketing and in-home education to improve the health seeking behaviors of consumers, while simultaneously increasing their awareness of the Family Clinics. Through these and other tactics, The Family Clinics now see a steady stream of 30-40 patients per day!
- Decreasing costs: To help keep costs down, The Family Clinics make heavy use of midwives, who are significantly cheaper than doctors, for most activities. There are generally 2 midwives per clinic, with a doctor that covers 2 to 3 clinics and additional doctors on call in case they are needed. An added bonus of using midwives is that YKB has found that Indonesian women feel more comfortable when being treated by other women. Another cost saving measure employed by YKB is to buy generic medicines directly from the pharmaceutical companies.
- Incentivizing employees: YKB encourages their employees to provide high quality and efficient care by giving them a share of the clinics’ surpluses. By having a stake in the success of the clinics, employees will want to provide quality care that will attract additional patients, while also avoiding wasteful activity.
YKB seems to have found a successful model, but they aren’t content to just stop there. Moving forward, they want to convert their chain model into a franchise model, receive more seed funding to start new clinics and add on the ability to perform surgeries (e.g. C-sections) – they currently rely on a referral system with nearby hospitals when surgery is necessary. They would also like to provide more general primary care, although this will require additional innovating in order to overcome the costs of relying more heavily on doctors.
At right, a nurse at a Family Clinic examines medicine for a patient.
YKB has many changes planned for The Family Clinics and responsiveness to consumer needs will be key to the successful evolution of this program. As Dr. Lubis explained, one advantage of charging patients for services rather than providing free care: “If they pay, they are able to complain!” We look forward to seeing the exciting changes in store for The Family Clinics.
*Note that some people would include long-term donor funding as sustainable. In this article, we refer to sustainability as independence from donor funding entirely in the long-term.