Lessons from developing nations on improving health care

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Abstract
Carabayllo project Harvard doctors Paul Farmer and Jim Yong Kim have been working for almost a decade in Carabayllo—a poor neighbourhood of 100 000 people in Lima, Peru. Their work, undertaken through Partners in Health, based in Boston, and Socios en Salud, its sister organisation in Lima, has shown that multidrug resistant tuberculosis, previously thought to be untreatable in resource poor settings, can in fact be cured in 80% or more of cases. This success has come from a well developed approach involving, among other things, community health workers, careful expert based treatment planning, anticipatory management of complications, aggressive management of drug supplies, maintenance of local registries, and other local innovations.2 Gaining confidence from the Carabayllo prototype, the World Health Organization and officials in Peru, as well as some important funders, have become intrigued by the idea that first world standards of care can be successfully used in resource poor settings.3 Partners in Health, Socios en Salud, the Peruvian Ministry of Health, and the Institute for Healthcare Improvement have combined forces to organise a programme aimed at improving tuberculosis care to world class levels, building on and adapting the Carabayllo model. The programme uses multidisciplinary teams in 41 community based clinics, in five districts in Lima. These districts together account for almost 30% of the cases of tuberculosis in Peru. The 41 teams have been working for more than two years, and their results compare favourably with those achieved in similar collaborative improvement projects in the United States, Canada, United Kingdom, Sweden, and Norway. Many of the teams have mastered the model for improvement devised by Langley and colleagues,4 and understand measurement, reporting, and local tests of change as well as any teams I have seen in far richer settings. Their goals are ambitious, and they are working with a strong conceptual model founded in modern principles of chronic care management.5 6 The Peru project is still at an early stage, in which successes are measured mostly through process changes and the emergence of bold new aims. We will see in the coming years if the burden of tuberculosis falls as a consequence.