A critical, ongoing decision that our organization faces is how, and when, to start new programs. This is a challenge confronted by health delivery organizations and governments throughout the world.  It is, however, an issue on which there is not a large body of literature nor evidence-base to guide program planners.  Here, we describe how our organization makes goes about expanding upon and developing our programs. 

Primary Factors

Epidemiological Need

Our programs should fundamentally be driven by epidemiology.  All the below concerns are ultimately secondary to the prevalence of a disease and the morbidity it causes.  If a disease is highly prevalent, or if it is a more rare disease that causes significant morbidity and mortality, then it is our mission to address that disease.

Effectiveness of available treatments

The overall effectiveness of a treatment can be nicely summarized by the number needed to treat (NNT).  The NNT is defined as the number of patients that must receive the treatment to receive some defined benefit, whether that benefit is a life saved, a disease cured, or a symptom alleviated.  For example, helicobacter pylori treatment causes significant symptoms and can lead ultimately to life-threatening peptic ulcer disease.  The treatment for this is a relatively straightforward short-course regimen of antibiotics and antacids and has an NNT of 2-4 in curing the infection.  Since h. pylori is also a highly prevalent condition, we have implemented this treatment.

Community Demand

Taking into account what community members themselves desire is critical to establishing true community-based programs. Community demand is partly driven by local epidemiology.  Oftentimes, however, it is not completely overlapping.  In some communities, for example, treatment of diseases affecting women, such as maternal complications or domestic violence, may be in less high demand than less epidemiological important or treatable conditions affecting men. The term "community" itself represents several overlapping and diverse sub-groups each with their own unique demands.

Human Resources

Recruiting, training, monitoring, and retention of health workers of all different types is central to our overall approach to health services delivery.  In some cases, expanding programs requires building the capacity of existing generalist personnel.  In others, particularly in surgical fields, recruiting new personnel is required.

Material Resources and Infrastructure

Even with the above factors in place, there are times when the supplies chains and infrastructure constraints slow the roll-out of an otherwise essential technology or program.  One illustrative example of this is diagnostic radiology.  By the above criteria, arguably an x-ray would be the first component to initiate a diagnostic radiology program. Certainly there is epidemiological need, the community has demanded it, the x-ray is an essential and effective technology, and we have the human resource capacity to implement.  Procuring x-ray equipment suitable for our scenario has been challenging.  In the meantime, there arose a unique opportunity to receive a donated ultrasound machine from GE and develop a program overseen by colleagues at the Yale Section of Emergency Medicine.  We rolled out ultrasound quite simply because it was a needed technology for us and because, through the GE/Yale connection we had developed the institutional capacity to implement it.  X-Ray had to be postponed until we had the material resources in place. 

Bringing the factors together to make decisions

Together, as a team, we work to take the available evidence and factors into account and decide on how to responsibly and effectively roll out new services.  Doing this in a systematic way is an ongoing challenge that we will continue to document.

Upcoming Programs on which to decide

Domestic/Gender Violence

Malnutrition

Mental Health/Depression/Psychosis

CHF

COPD

Diabetes

CAC