Abandoned clinics and hospitals. Limited medicines. Decrepit infrastructure. Shortages of trained people. These are the daily realities of health care in many third-world countries.

A key reality we need to recognize is that trying to bring a standard Western medical-care model to poor countries is very often a prescription for failure. The typical care infrastructure in Western countries is capital intensive, expensively staffed, and based on a distinct business model. In countries like Belgium, Canada, France, Germany, the Netherlands, and the United States, fee-for-service doctors are the usual front line of care. Doctors in these countries typically function as profitable, self-contained business units, selling care by the “piece,” not the package, and collecting fees from patients, private insurers, or perhaps the government. They expect a healthy revenue stream and, if cash flow is insufficient, they often simply move to a new, more economically attractive site.

This model does not translate to the third world, where few rural sites can generate sufficient income to attract or keep Western-trained physicians. The few doctors that do practice in such economically depressed areas tend to be temporary and are generally subsidized by various charities. In some countries governments have attempted to hire physicians directly to serve such areas, but pay from the state tends to be nominal, giving doctors little incentive to accept such offers.

Physician-centric, fee-based, Western-style medical-care systems will clearly not work in most of rural Africa or in similar regions in Asia and Latin America. They are too expensive, too unfocused, too haphazard, and there are just not enough doctors. We need to abandon attempts to recreate this business model in the third world and replace it with a team-care model that uses a hub-and-spoke approach to maximize available resources, create new resources where needed, reduce costs, and multiply the quality and quantity of local care delivery. We need people who can provide the basic care villages need—and we need those people to be part of an integrated system. This new model of care would require new categories of basic health care workers who are linked with higher levels of caregivers in more central locations. The frontline caregivers should be the functional equivalent of well-trained military medics—able to diagnose and prescribe drugs for a few common diseases, get advice, and perform first aid, including basic cut suturing, leg setting, and wound repair.

So who can do such work? Optimally, these frontline workers would be people with deep local roots tested for aptitude and trained in schools designed for that purpose. Once trained and working in the field, this frontline corps should be required to participate in continuing education via the Internet.

The Internet and computer-to-computer connectivity comprise the basic tool kit of distributive care, replacing or at least complementing hospitals with virtual-care teams that would be attuned to the needs of individual communities. Beyond helping grassroots caregivers deal with medical problems, an infrastructure of computer-linked corpsmen would be an effective way for central authorities to get a very early lead on both imminent epidemics and specific local care issues. One level up from these grassroots providers would be a set of nurse-level caregivers who would ideally have some midwife training. These nurses would need to be supported by computerized care “kiosks” to provide access to knowledge and, when necessary, to make arrangements for physician follow-up.

One level up from the nurses, and closely linked electronically, would be primary-care physicians, who would function both as direct caregivers and as oversight managers. These physicians could be centrally located in “better” towns where they would be more likely to live. Their job would be to direct care, mentor lower-level caregivers, and see patients who need their expertise. These local physicians would need a clinic of sorts, or ideally a hospital, but these facilities would not need to be full-scale, Western-style hospitals; they would simply need to offer sanitary surgical facilities and recovery areas and basic nursing care. Finally, above these doctors would be a full infrastructure of specialists who could provide both patient care and advice.

We can’t turn Kisiizi Hospital in central Uganda into Massachusetts General—but we can create a care model that says a person in the foothills of Kisiizi who is badly cut or contracts malaria will be diagnosed, treated, and followed-up on by sufficiently skilled caregivers who are better than traditional healers and more accessible than the big, Western-style hospital that might be several days’ travel away.

Can this happen? Botswana and Colombia both have functioning local health plans that accept accountability for patient care of a defined population in a prepaid model. The beauty of that model is that the plans figure out how to pay each local provider in the context of the total care agenda. The folks at the team center—the actual primary care physicians—need a workable business model. Their cash flow can come from a combination of fees, charity care, government funding, and local pre-paid plans, but it has to come from somewhere or they will migrate to more lucrative settings.

Trying to build Western-style hospitals staffed with fully trained physicians will not work for many areas in the world where people need care. But building an infrastructure of local first-aid sites backed by trained nurse sites backed again by local primary care doctors, and all supported by an Internet infrastructure of specialist and actual medical transportation vehicles could work—at a much lower cost and with a much faster rollout.

It’s worth a try. The current approach is not working.

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