Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary (2015)

9

Models for the United States and the Larger Global Context

On the final day of the workshop, participants once again convened in breakout groups to discuss the themes that were raised throughout the workshop and to propose further lines of inquiry. Individuals were selected from each small group to report their views as they related to the statement of task. Points and issues raised by these individuals were informed by their small group discussions and were open to comments and scrutiny by other participants. The comments in the sections below are summaries of the group discussions presented by the group leaders, and they should not be viewed as consensus. The workshop closed with participants reflecting on the ideas and examples shared by the participants throughout the 3-day workshop and how each might use the information to inform their future work.

ESTABLISHING NURSE- AND MIDWIFE-LED ENTERPRISES¹

Akiko Maeda noted that current health systems are not sustainable. She proposed that nurse- and midwife-led enterprises have the potential to effect a paradigm shift toward greater sustainability, but it would require detailed market research to evaluate outcomes. Examination of successes and failures in the United States and abroad would add to the knowledge base. If no models exist in a given setting, an investment climate assessment would provide crucial information. In particular, this would include con-

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¹ This section summarizes information presented by Akiko Maeda, The World Bank.

ducting a landscape analysis of entrepreneurial leadership and identifying an entity to serve as a potential incubator.

In many countries, private investment is flowing in, so Maeda questioned how these funds could be directed toward community-based primary care services led by nurses or midwives. One difficulty is that funds go into high-end technologies that offer quick returns, and social franchises tend to have longer-term benefits. A case would have to be made for the advantages of a sustainable long-term investment, she said; however, once funding was diverted toward these enterprises, Maeda observed that it would need to be scaled up to allow entities to grow. This would also require a degree of tolerance as a certain number of businesses would likely not succeed. And finally, she noted a greater need for communication, social marketing strategy, and awareness building to raise the acceptability of privatization and to build a well-respected brand.

EXPANDING SOCIAL ENTERPRISE AND PROOF OF CONCEPT²

Petra ten Hoope-Bender explained that her group raised some of the same points as the previous group, but also considered how to scale up models that are already established and functioning. She proposed expanding the Philippine franchise model to include primary care. The One Family Health model from Kenya and Rwanda could also expand to include reproductive health. What is important, she argued, is that the proof-of-concept could be realized within a short timeframe rather than risk stagnation of pilot tests. One approach for the United States and elsewhere would be to establish a challenge in which a prize is awarded to whoever expands from a nursing, midwifery, consumer goods, or pharmacy model to a workable primary care model within 2 years.

An essential element of this she spotlighted was local leadership. Some of the successful models that had previously been described were started by Westerners, but even within the United States, long-term sustainability of small and medium-size enterprises would require local ownership. She noted that such models could spread beyond primary care to include other community health prevention interventions such as well-being and fitness. Finally, she emphasized the importance of strong partnerships and buy-in from funders and health and business professionals.

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² This section summarizes information presented by Petra ten Hoope-Bender, ICS Integrare (Instituto de Cooperación Social Integrare).

NURSE-LED ENTERPRISE FOR PREVENTIVE CARE³

Deborah Bae explained that in the United States, the health care system is very fragmented and contains a number of gaps, particularly in the preventive health realm. She described a patchwork system of hospitals, doctor’s offices, minute clinics, community health centers, and many others. She suggested that in the midst of this there could be a role for a nurse-led enterprise that would mirror primary care and offer preventive services reimbursable by insurance. Rather than a bricks-and-mortar clinic, it could instead take the form of a benefits package that could be inserted into existing systems such as health centers and colleges. The package could include a unique mix of mental health counseling, smoking cessation guidance, weight loss programs, nutrition advice, and other population health-based preventive measures. She noted that under the guidelines of the U.S. Patient Protection and Affordable Care Act, 50 percent of premiums can be used to incentivize healthy behavior, so that could be a potential source of funding.

Beth Bafford further emphasized that this concept is not just focused on providing health services; it is focused on building relationships to personalize those services. Patients and clients would know their contact within the system—the health professional they would reach out to would serve as an advocate, mentor, and guide in a holistic approach to health. On the financing side, she acknowledged growing interest in nurse-driven enterprises given the current investment climate. Such a model has potential for revenue and growth, so an investor or venture capitalist could see financing possibilities.

Bae underscored how nurses are well positioned to lead such models, with the additional advantage of promoting the women’s empowerment agenda. Further developing partnerships between nursing and business schools to create a new cadre of nurses with the specific skills and tools necessary for such models is a key facet as well. Within these models, female nurses with an inclination toward business can be intentionally trained for supervisory positions and entrepreneurial roles. Leadership development for nurses that extends beyond the business acumen and intentionally addresses empowerment issues for greater work autonomy and job satisfaction might similarly be considered for midwives and community health workers. This model has the potential to shift thinking from a treatment mentality with “patients” to more service-oriented thinking with “clients.” Such a business model might explore unique modes of entry to the health system that could, for example, engage women at hair and nail salons. This

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³ This section summarizes information presented by Deborah Bae, Robert Wood Johnson Foundation (RWJF), and Beth Bafford, the Calvert Foundation.

would have the dual benefit of increasing a nurse’s client base while providing health education to women in a safe environment.

Bae reflected upon conversations she had with focus groups in the Appalachia region as well as in cities, rural areas, and suburban communities in the United States. The insight for her was a request for better engagement of women in health and health care. Knowing that women play such a vital role in keeping people and families healthy, and that such a large percentage of women work in nursing and midwifery, Bae speculated that greater opportunities for nurse- and midwife-led enterprises could be one strategy for strengthening health systems while empowering women in the United States and around the world.

THE WAY FORWARD

Participants closed the workshop by discussing themes raised throughout the 3 days and proposing potential next steps, including areas of research, scale-up, and investment in nurses and midwives. They also continued to explore challenges and opportunities in moving the needle toward improved population health via health systems strengthening and women’s empowerment. Some concepts discussed by individual participants included

• Health is not just health care but encompasses contexts in which people live, so to improve health, women have to be engaged. One participant explained that women are the “keepers of health” in people’s lives; health is a highly esteemed value for women.
• Women are often deprived of opportunities to focus on business, which results in job prospects that are limited to the public sector. Bringing business skills into nursing and midwifery training, possibly during secondary school, could be one approach to expanding those opportunities.
• One participant cautioned against “over-engineering.” People with entrepreneurial spirit will develop solutions that others have not thought about, so long as they are empowered and provided a platform on which to build their innovation.
• Harmonization and integration were also raised as key elements in bringing disparate solutions together globally. Mechanisms to share knowledge and data can help reduce issues such as “pilot-itis” and can inform novel education and training approaches within the practice environment.
• One participant proposed that solutions to improve health could be rooted in the community, with services built and providers produced to respond to community identified needs.

• Not everyone is suited for entrepreneurship, so what kind of model could support people at different levels of interest in business?
• Empowerment has to be intentional, said one participant, but in order to incorporate it, a business case often needs to be made. At the same time, it is not something that can be given, but develops from within through multilayered conversations and expansion of opportunities.
• Health is not just the business of government, but also of the private sector, communities, professionals, and most importantly the families (particularly the women in those families).
• One participant stated that it is not enough to demonstrate a model works. For the model to thrive and have impact within a health system, it needs to be sustainable.
• Providing universal health coverage would involve a paradigm shift from acute care to community-based primary health care. This could result in more coordinated care in which nurses and midwives play a critical role particularly as an entry point into the health system.
• Academic institutions can be critical partners in sharing knowledge and mobilizing resources. How can institutes of higher education in Africa, Asia, and elsewhere link up with innovative enterprise models? How can both collaborate with the public sector?
• Incubators do not always capture data that could potentially be used for scaling up innovative models in different settings.
• Results-based financing can be a platform for autonomy and accountability and potentially for scalability.

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