Ghana
Shared medical appointments can be used as a strategy used to improve timeliness and availability of providers at the point of care.  By grouping patients with similar needs together, facilities can increase efficiency while enabling patients to develop supportive relationships with other patients. This has been documented extensively for antenatal care (ANC) and postnatal care, where women attend group visits with women of a similar gestational age, sharing information and forming relationships within and outside of the facilitated group visit. Compared to individual visits, women are able to spend more time with providers, form relationships with providers and other mothers, and reinforce knowledge with each other.¹ A district hospital in Ghana implemented a group ANC curriculum using seven lesson modules designed by the American College of Nurse-Midwives. Each of the sessions was 60 minutes and involved story-telling, peer support, and demonstration with a focus on delivering information in a manner that was accessible for women with limited literacy. This design was compared to individual ANC with the same providers. Women who attended group ANC visits were more likely to discuss delivery arrangements and transportation with midwives, have saved money for birth, report positive exclusive breastfeeding practices, and have discussed newborn problems with midwives. Thus, group visits for ANC have the potential to contribute to facility efficiency while better equipping women with important maternal knowledge.¹ Similar positive findings from group ANC visits were observed during a group ANC model in Nigeria and Kenya, implemented by Jhpiego.²

United States
Shared medical appointments have been used extensively for NCD management in high-income countries. This model helps limit the repetition of educational medical appointments and builds cohorts of patients with similar needs and concerns.³ A study of shared medical appointments for diabetes in the United States found that the success of these programs depended on patients’ motivation and willingness to learn, and they could also contribute to improved patient satisfaction and productivity.³ While there is limited evidence of shared medical appointments for NCDs in LMICs, the success of shared appointments for ANC suggests that shared medical appointments may continue to be a strategy for improving clinic efficiency for other services as well.

Canterbury, New Zealand
A number of health system reforms have been put in place in Canterbury, New Zealand in the last few decades. These reforms related to multiple aspects of the health system, including financing, education, leadership programs, and infrastructure. A robust case study on all of these elements of Canterbury’s reforms up to 2013 can be found as a written case study and a narrated presentation, both from the King’s Fund. As part of these reforms, provider availability was improved through a focus on education and integrated services. Although Canterbury initiated changes to the health system in the 1990s and early 2000s, a devastating earthquake struck in 2011, and as Canterbury rebuilt in the wake of the earthquake, they were able to do so with an intentional focus on integrated care.⁴ Canterbury established the HealthPathways program in 2008. HealthPathways is a collaboration between multiple levels of the health system, and it established agreements on best practices for a number of health conditions, including guidance on how and when general practitioners should refer patients to higher levels of care or specialists. At the same time, the health system focused on robust reviews of waiting lists for specialists in order to identify patients whose needs could be addressed within primary care. This was coupled with reliable access to clinics with weekend and nighttime staff and strong electronic health management systems that consolidate referrals and centralize communication between levels of the health system. Taken together, these reforms clearly delineated the responsibilities of general practitioners as well as guidelines for when referral is necessary, increased physical access to care, and improved efficiency in referrals.42 As a result, these reforms have shifted a number of services previously provided in hospitals to primary care clinics, improving comprehensiveness of care and availability of primary care services.