Mobile Doctors and Premium Payments: How Technology Can Improve Insurance for the Poor

"Shagun" is a young woman living in a small village near Yavatmal, India. She makes and sells bread in her village, proudly contributing to her family's income that is often less than $50 a month. One day she was feeling feverish, and wondered if she had malaria. The nearest doctor was two hours away by bus, and she would lose a day's wages and have to pay for transportation to get there. Luckily, her neighbor, "Nalina," had helped her enroll in a health insurance program a few months ago. Nalina was trained by a not-for-profit called CARE Foundation to be a Village Health Champion (VHC) who provides "healthcare at the village doorstep." She has been trained to ask the right questions, and to record basic medical symptoms and vital statistics such as blood pressure, heart rate and temperature, and identify emergency symptoms. For routine diagnoses, Nalina can use a hand-held terminal with a built-in clinical decision support system to provide appropriate medical advice and order prescriptions. In Shagun's case, Nalina liaised with a remote CARE doctor who recommended treatment through an SMS prescription. Over-the-counter drugs were dispensed by Nalina from her medical kit, and within a few days, Shagun was feeling better and back to making bread!

CARE's rural health delivery and microinsurance scheme focuses on the provision of outpatient care in the village setting. Final testing of the technology, training of health workers and product design are being completed. The product will be piloted this fall, with a target outreach of 50 villages that have approximately 100,000 low-income residents by 2012.

ICT to increase outreach, reduce costs and improve client value

CARE's tele-medicine and hand-held terminals represent the frontier of microinsurance: using technological innovation to offer higher quality services to remote clients while keeping costs low. Microinsurance, or insurance designed to serve low-income clients, has become a better-known poverty alleviation strategy in the last ten years. However, there is much to be done before poor people are well-protected. Only about three percent of the low-income people in the world's 100 poorest countries benefit from microinsurance, leaving approximately two billion vulnerable to economic shocks. If microinsurance is to reach these two billion people, technology will be key.

Why technology?

Access to information technology in the global south is increasing at astonishing rates. Subscriptions for mobile phones in developing countries have grown from a few hundred million at the beginning of the century to three billion in 2008, and in Africa there are on average 40 mobile phone subscribers per hundred people (Lloyds 2009). Falling prices of mobile broadband and the increasing availability of 3G, the new generation of wireless technologies, are expected to improve internet access considerably in coming years.

Furthermore, the "global digital divide" could potentially have a silver lining, as developing countries can "leapfrog" obsolete phases of technology and jump directly to new advancements. These advancements, such as satellite data, Global Positioning Systems (GPS) and point of sale terminals, have the power to improve microinsurance in a variety of ways.

According to the World Resources Institute, "Technology does two key things that help drive the development of financial services: it cuts costs, and bridges physical distance." These two issues - high operating costs and clients that are spread out and difficult to access - represent two of the biggest barriers to microinsurance development. The Microinsurance Innovation Facility's partners are testing a variety of technological solutions to overcome both of these challenges.

Bringing Additional Value to Clients

Like Shagun, poor people often live in remote locations, making it difficult for them to access microinsurance. Microinsurers are experimenting with new technological innovations to bridge these distances. Point-of-sale devices are an example of one of these solutions - they allow customers to enroll and make premium payments remotely, saving both time and money. Mobile phones can also be used to improve access: in Kenya, British American Insurance (Britak) has recently launched a new personal accident insurance product that features enrolment and premium payment via cell phones.

Health microinsurance also presents unique opportunities for technological innovation to increase client value. The tele-medicine aspect of CARE's product is another valuable offering, since many poor clients live in areas where physicians are scarce. Technology also plays a key role in health insurance schemes that offer "cashless" claims. This type of coverage allows clients to access medical care without having to pay any money up front, which can be of life-saving value for extremely poor clients who have little access to capital. Well-designed software to manage data that can help the liaison between the insurer and the health care provider and better identify clients and store their information is crucial to making health insurance product work.

Back Office Efficiency

In order to be sustainable, a microinsurance scheme must minimize operational costs. Insurance requires a large number of policyholders in order to reach economies of scale. It can involve costly claims verification processes, cumbersome data management, and a high volume of transactions due to regular premium payments. When this model is translated to a micro scale, maintaining a good ratio of operating costs to premium payments becomes difficult. According to Richard Leftley, CEO of Microensure, "If 50% of a poor client's premium goes toward administrative costs, claims payouts are meager and client value plummets. If you had a dollar to invest in your microinsurance scheme, I'd strongly recommend spending it on back office efficiency.We're trying to bring uniformity, evaluating the possibility of using electronic points of sale to aggregate information on clients." Though back-office solutions lack the glamour of other technological advancements, the further development of affordable management information systems (MIS) will be critical for the future of the microinsurance industry.

The Future of Technology and Microinsurance

According to Pranav Prashad, a Grant Officer at the Facility, "Players in the microinsurance field need to cut costs and they recognize that technology is the solution, but given the current scale of operations, they aren't sure how much to invest and in which technologies." To help assess which strategies work and which don't, the Facility will offer one final call for proposals for Innovation Grants in fall 2010, supported by Zurich Financial Services, with the theme of "Scale and Efficiency". This round will focus on projects that are using technology to make microinsurance more affordable and accessible to low-income clients.

Ten years ago, it would have been difficult to imagine that a poor Indian woman would file a claim and receive a medical diagnosis electronically from her rural home. The next ten years will undoubtedly bring new and equally unexpected technological developments - developments with the power to bring the security of microinsurance coverage to the two billion people who need it most

Recognition of Innovative IT model to support Microfinance

The software designed by our teams in collaboration with P4K technologies was recently awarded NASSCOM's AppFame award.

The software enables a unique handheld device that can be carried by healthcare workers in the field to register, record, triage patients and to transfer health data to a web based electronic health record accessed by remote doctors. The device can also establish tele-link with remote physicians to enable a collaborative treatment planning.

For micro-insurance policy holders enrolled in the program (who pay approximately 10 USD for a family of four, as annual premium for basic primary health services) the entire service chain including administration, authentication, delivery and claims is automated thereby reducing administrative cost of running a complex insurance scheme.

Offering prepaid coverage for basic services at a cost that the people can afford, brings essentials of modern healthcare within the reach of people living at the bottom of the pyramid.

The rules for health innovation in developing world - A Mckinsey Report

 Health care is consuming an escalating share of income in developed and developing nations alike. Yet innovators have found ways to deliver care effectively at significantly lower cost while improving access and increasing quality. They are uncovering patterns for raising productivity, and leaders across health sectors—public, private, and social—should take heed. With the recent passage of health reform legislation in the United States, for instance, tackling costs is imperative there, but it is also an important goal in every other part of the world.



New approaches to the delivery of care abound. In Mexico, for example, a telephone-based health care advice and triage service is available to more than one million subscribers and their families for $5 a month, paid through phone bills. In India, an entrepreneur has proved that high-quality, no-frills maternity care can be provided for one-fifth of the price charged by the country’s other private providers. In New York City, the remote monitoring of chronically ill elderly patients has reduced their rate of hospital admissions by about 40 percent.


Unfortunately, health care can be an isolated and local activity: innovations are not widely known across different systems or beyond sector boundaries. Merely identifying and promoting innovations isn’t enough, however—leaders need to understand whether, and how, the lessons of innovators can be replicated elsewhere. To this end, McKinsey conducted research in partnership with the World Economic Forum to study the most promising novel forms of health care delivery and, in particular, to understand how these innovations changed its economics.


Many of the most compelling innovations we studied come not from resource-rich developed countries but from emerging markets. Two factors help explain why. First, necessity breeds innovation; in the absence of adequate health care, existing providers and entrepreneurs must improvise and innovate. Second, because of weaknesses in the infrastructure, institutions, and resources of emerging markets, entrepreneurs face fewer constraints (this is one upside of the lack of meaningful oversight, which obviously also has many drawbacks). They can bypass Western models and forge new solutions.


The nearly 30 successful innovations we looked at pursued a handful of strategies to change the economics of health care delivery in a fundamental way. In other words, they were not successful by chance. By understanding the opportunities these innovators seized, leaders throughout the health care system can identify opportunities for their own organizations.


A broad scan of innovations across the field, as well as an in-depth analysis of the business models behind 30 of them, showed us that successful ones use at least several if not all of the strategies described below.


Get close to the patient


Innovators can lower distribution costs and improve adherence to clinical protocols by moving the delivery of care much closer to the homes of patients, providing services that take advantage of their established behavior patterns, or both. VisionSpring, an organization that brings affordable eye care to the poor in 13 countries, succeeds because it takes care givers close to patients through a low-cost franchise model. It teaches local “vision entrepreneurs”—members of the mainly poor communities they serve—how to diagnose problems such as presbyopia (an inability to focus on nearby objects) and how to determine what type of mass-produced eyeglass would correct it. The company also provides its entrepreneurs with a “business in a bag” that contains all the required products and equipment. Distribution costs are low because information, products, and services are standardized, and the model is simple to implement, even if the workforce is relatively unsophisticated.


Use existing technology to reinvent delivery


“Repurposing” mobile-phone systems, call centers, and other existing technologies and infrastructure allows innovators to extend health care access, increase the standardization of care, and improve labor productivity. For a fixed fee of $5 a month (payable on phone bills), Mexico’s MedicallHome, for example, offers its one million subscribers access to professional health advice at a cost far below the charge for a physician’s visit. In Mali, Pesinet uses SMS (short message service) technology to make diagnoses of malnutrition more accurate and reduce childhood mortality. Health workers in the field send a child’s age, height, and weight by SMS to a central server, which determines whether the child is at risk and sends a message back to the health worker.


The use of the existing technology infrastructure would be useful in any part of the world where health care resources are scarce. Yet this approach can also provide benefits in developed countries. Technology could be used, for example, to reduce emergency-room overcrowding by providing phone- or Internet-based advice and triage services during evenings and weekends. Similarly, it could be used to deliver care remotely for patients who require ongoing treatment for diabetes, asthma, or other chronic diseases.


‘Right skill’ the workforce


Some smart innovators challenge existing practices—and professional assumptions—about which health workers are allowed to do what. As a result, they can tightly link skills and training requirements to the tasks at hand, thereby lowering labor costs and overcoming labor constraints. In India, LifeSpring uses midwives to provide most of the care at its maternity hospitals. This allows just a single doctor to oversee significantly more patients by focusing on tasks that specifically require a doctor’s attention. The company charges only $40 for a normal delivery, rather than the typical $200. In the United States, MinuteClinic uses nurse-practitioners rather than physicians to staff primary-care clinics.


In some countries, this approach also helps to ameliorate shortages of medical talent. In sub-Saharan Africa, for example, the HealthStore Foundation has trained community health workers to diagnose and treat the region’s top five diseases, which together account for more than half of preventable deaths there.


Standardize operating procedures


Whenever possible, successful innovators use highly standardized operating procedures to minimize waste and improve the utilization of labor and assets. The use of standardized clinical protocols also raises the quality of care and facilitates the transfer of knowledge. In India, Aravind Eye Care System, which provides cataract operations to the blind and the near-blind, standardizes the entire end-to-end patient pathway—from initial diagnosis to surgery, recovery, and discharge—with ruthless efficiency. Also in India, Narayana Hrudayalaya hospitals can offer high-quality cardiac care at dramatically lower prices than its competitors charge because it employs a high-volume, highly standardized model of care. Both organizations use a form of production specialization (a factory-like approach to delivering care), borrowing process flow, management, and improvement techniques from manufacturing industries.


Borrow someone else’s assets


Smart innovators use existing institutions, infrastructure, and networks of people to reduce capital investments and operating costs. They then pass the savings on to consumers. India’s Health Management Research Institute (HMRI) takes advantage of established supply chains by operating medical convoys—mobile health facilities and health workers delivering care in hard-to-reach rural areas—from public hospitals. HMRI also operates a medical hotline (dial 104 for 24/7 advice) that piggybacks on existing mobile-phone systems, as do MedicallHome, Pesinet, and similar organizations. The model benefits from the widespread adoption of mobile phones and a comprehensive cell network across India. MinuteClinic operates its facilities in retail stores to benefit from their foot traffic and lower its overhead costs.


Open up new revenue streams


Many health care innovators extend their activities into other sectors—even shops and restaurants—to capture additional revenue streams, use them to subsidize costs, or both. Business activities in other sectors can even promote core health care services. Thailand’s Population and Community Development Association (PDA), which focuses on family planning and the prevention of sexually transmitted diseases, established a chain of restaurants and resorts to raise revenue—and to get out the message. Greenstar, a Pakistani nongovernmental organization that focuses on family planning, operates an entire network of retail outlets that sell products such as condoms and offer family-planning advice and health services for women and children.



As leaders of health systems ponder their cost, quality, and access problems, they should draw comfort from the fact that at least some potential solutions already exist. Innovators around the globe have demonstrated effective new ways to reach and interact with patients and treat them at significantly lower cost while improving quality. The real challenge is how to implement, not how to invent. Given the pressure on health systems everywhere, their leaders should do everything possible to help organizations adopt successful innovations and thereby reap the benefits they can provide.

Poverty and Illness – Can anything be done?

Poverty, like disease, comes in several varieties. The lack of supporting institutions like educational and healthcare facilities (and services), lack of infrastructure (such as roads, market places, electricity or telephone, sanitation, potable water) lack of leadership and a dependable food supply are more community related problems. These differ from personal experience of poverty and disease, where personal suffering is highlighted.

Just as a symptom is indicative of underlying systemic imbalance, lack of money is a measure and a symptom of poverty. Treating the symptom or the measuring device will not cure the disease. The causes of the social problem of poverty lie in several factors, especially the big five: disease, ignorance, dishonesty, apathy and dependency. Interestingly, many of us have seen these five to co-exist. Poverty and ignorance contribute to disease, and all others contribute to poverty. Therefore poverty and disease are both somehow linked to more subtle infestations of collective consciousness.

Ignorance may not be a person's fault. It might be caused by isolation so that some people do not know some things simply because they have not heard of those things (information) or have heard distorted versions (mis-information). A lower availability of education and information is the first and perhaps the easiest hurdle to cross. Undoing mis-information is even more difficult. The more the people are aware of commonly known reasons, causative factors and consequences; it is more likely that positive behavior will arise. Liberal exploitation of educational opportunities, sharing of stories & personal experiences between close knit groups, leveraging media & social events regularly and repeatedly over a period of time will slowly drive the point home.

Dishonesty, in turn, is a major social problem. When a person in a position of trust diverts a hundred units of value towards personal use (including accountable public health agencies, doctors and healthcare personnel who take shortcuts), the society at large may lose much more than a hundred units of value that could contribute to development and to the reduction of poverty. That is part of what economists call the "multiplier effect." Dishonesty thrives in an atmosphere of apathy, ignorance and dependency, so here is another example of the inter-linking of factors of poverty and disease. Though we may not alter dishonest behavior of others, but we can choose to be honest and transparent in our dealings and in the way healthcare delivery system is designed. We found that people in villages have somehow been used to cheating and exploitation that they tend to have very poor levels of trust in any new intervention. Therefore, it was advantageous to ride the program on social equity and goodwill of previously active agencies, role models and opinion leaders. Allowing the community to choose the premiums, transparently see the utilization of funds, consistently experience value of insurance in emergency and efficacy of treatments would build their trust in micro-insurance driven healthcare program. Importance of quick wins in early phases cannot be less emphasized. Another important designing factor for us was ensuring accountability. The GPS enabled handheld device with authentication and tracking features bridged the need to a great extent. Just an acknowledgement of the fact by the health worker that each action is being tracked - is a deterrent in itself.

 Apathy is both a learnt behavior as well as matter of personal confidence. Shaken confidence in deprived settings makes people apathic. On top of this, health seeking behavior has always been a matter of trust and faith. Therefore it is extremely important for us as healthcare providers to be consistent and positively communicative despite challenges. The caring sentiment toward fellow beings and valuing human life ignites a bond of selfless love which pulls people out of their shells. This has nothing to do with clinical skills, but with the human qualities that we tend to leave behind while maturing as busy professionals.

Dependency on other people to help solve a complex problem is a natural human inclination. In many ways it can become a good contrast to apathy. Charity with a kind heart may help inject sensitivity but unfortunately it does not solve dependency unless the root cause is being addressed. However the same dependant situation can become a doorway to self sufficiency if handled wisely. In dependant situations whether it is poverty or illness, there is a window of motivation - motivation to be healthy or motivation to be wealthy. Channeling this motivation is complex but highly rewarding. We attempted to touch the subject by mixing the two for the family of Village Health Champion. Enabling a low profile local young housewife by education, exposure, training, financial support and public recognition created a role model that other ladies wanted to follow. Involving a self help group (ladies who regularly saved money for health and other emergencies) further consolidated the mutual sharing of independence and responsibility. The local patient is no more a liability on healthcare system- he/she demands and receives the dignity of a consumer because basic healthcare costs are enabled to be within his/her pocket's reach.

These small and seemingly insignificant moves over a period of time may have a more lasting impact than simply becoming another healthcare provider.

Self empowerment is healing

Sometimes I wonder what really is poverty? ... Is it personal, social, spiritual or karmic state of being in relationship to rest of the universe? Is it a sickness that needs to be treated, is it an opportunity for service or is it merely a perceptive bias where a majority of population chasing material wealth coins a term for those who do not conform to their standards? Probably each one could be argued as valid explanation, but more clarity could be gained if we look at the situation from the "so called" poor person's point of view. Everytime I have interacted with them, unfortunately common themes of - helplessness, hopelessness and being trapped in vicious cycle of losses, lack of opportunities with no-one to care for them, - have dominated the story.

Poverty glaringly exists even in most advanced societies and even developed & rich countries. "Haves" and "have-nots", seems to be part and parcel of every social structure. From healthcare perspective people at lowest rung of socio-economic ladder tend to have poorer health status and obviously higher healthcare needs (and resulting expenses) in any country's health statistics. Although poor in America would have better health status than poor in Somalia, but the quantum gaps between countries does not alter American statistical observations about poorer health of its poor. The type of ailments and access to healthcare may vary from country to country but somehow being well-to.do makes people healthier in most societies.

In my more ignorant days I assumed that if we could create good healthcare infrastructure then the health status of people could be transformed. My assumptions were seriously challenged one day while I was serving a tribal community in a remote village in India immediately after my graduation. We saw tuberculosis  being rampant in that community and started distributing antibiotics. To our surprise even after one year of running the clinic the disease not only remained unabated but we started seeing more and more multi-drug resistant cases. Mass campaigns, posters, house-to-house visits nothing worked!

One day we decided to investigate the reason as to what was going on. The discovery opened my eyes. The patients took the medicines from the clinic, took them for while then walked down to the local pharmacist and sold them off for packet of biscuits or a packet of Bidi (leaf wrapped local cigarettes) and resumed life as usual. Somehow for them treating a serious symptomatic condition was not important at all!

As I grew up and travelled around the world I saw the same story being repeated in different forms and shapes almost in all societies. People take bunch of antihypertensives or antibiotics from their doctors and pharmacies only to throw them off into dustbins after a few days. I observed leading journals reporting non-compliance rates as high as 80% even in most advanced healthcare systems. People continue to be non-compliant; they smoke, drink, abuse and skip appointments with doctors, no matter how much we emphasize the importance of healthy behavior. And as one would not be surprised, this sickness behavior is highest in poorer communities!! Affluent people are more likely to follow healthier lifestyle and medication regimens than their counterparts. So, is there any correlation between the habits that make you rich and make you healthy at the same time? Is health a direct outcome of affluence in cause-effect manner or a deeper common root cause is shared by the two in certain common behaviours that determine both?

My understanding of poverty became clearer when I read Nobel Peace Prize winner Mohd. Yunus's fascinating biography "Banker for the poor". What he observed that giving charity to poor people does not make them rich. Most people take easy money to do everything else except the right thing. They will drink, party, visit prostitutes and waste the money in other insignificant efforts and land up poor again. (Not too different story of being given free medicines and expecting cure). Millions of dollars of charity made by World Bank over decades has made no dent on the socio-economic status of poor. Millions of dollars wasted on public health alone has made little improvement in health of population. The real change is seen only in areas wheere both poverty and healthcare are addressed together.

Again I looked at reasons why micro-finance (MF) could transform poverty and noted some very important common patterns. I saw in the success story of MF, that it is only when the people take self initiative they change. When they collaborate and support each other in doing right things (and also when things do not go right), when they gather courage to stand on their own convictions and make investment in themveselves, that people build resources bit by bit. Poor people remain poor because of imiting bliefs and behaviours. In my understanding a major portion of poverty comes from this "self-disempowerment". They do not trust their own abilities to grow ......and repeated sufferings re-enforce those beliefs over generations. They allow themselves to be treated as inferiors. It also dawned upon me that seemingly lazy behaviour and lack of dynamism (also seen in roadside beggers of advanced countries) could be more due to self-resignation, apathy and lack of confidence. They kill their own dreams and complain, they demand from governments, politicians and often expect a savior to come and deliver them.

Doesn't it sound very close to what we see in healthcare settings? People indulge in un-healthy behaviours and expect the doctors, hospitals nad health ministry to solve all their problems? It is not to say that these providers are un-necessary, yes they are required for many situations, but less likely to solve majority of health problems. It is ambitious to expect that top driven vertical programs will have much effect. In the short run they may show some benefits and gain applauses from voters, but in the long run people will continue to treat doctors like messiahs but will not follow much of advice that they are given.

Unfortunately the western healthcare system encourages this paradigm. You approach the system in need and system treats you. Doctors see themselves, their pills and procedures as the only option to save suffering humanity. Typically the western system does not trust people’s capability to heal themselves. There is always an "external solution", which may be good in emergencies and short term, but the long term solution is more likely to come from people's participation in their own health.

Now, resuming the argument that poor are most self disempowered, it will not be surprising to note that they have highest incidence of un-healthy behaviours. They tend to be more non-compliant with health promoting advice and make poorer health choices. Does the solution then lie in creating empowerment or in provision of health services? Probably both ... but my understanding is leaning towards believing that poor people can only be taken to next level of health by building their own skills at community, family and personal levels and not just by asking doctors to serve in village dispensaries.

In my opinion a lasting transformation would not be driven by doctors or public health experts, but self driven by local communities with their help. The difference is subtle... but of great importance !!

Next I would try to touch some of the insights as to how this self-empowerment can be facilitated in so called poor (or self disempowered) communities. Interesting link - http://www.scn.org/cmp/modules/a-mod.htm