Addressing Health @ Bottom Of Pyramid

Despite making breathtaking developments in the field of medicine, we are far from making its benefits reach the last mile. Health disparities remain painfully under-addressed almost across the globe.

Though there have been various attempts made globally to solve the problem of Access, Affordability, Awareness, Accountability and Adequacy of Healthcare Services, our efforts are still fragmented despite years of experimentation. Perhaps the lack of resources and collaborative teamwork with existing stakeholders in a complex system undermines committed people from achieving what is often intended.

Unlike other essential services, healthcare is multidimensional that needs re-engineering of entire ecosystem. Though it sounds like a mammoth task but we need to address major elements impacting healthcare "all at once", in order to create a successful healthcare delivery model that is sustainable, scalable and replicable accross geographical boundaries.

Our extensive field research has pointed us in the direction that our Rural Health Care Re-engineering efforts must include atleast 4 interdependant models that should be seamlessly integrated to achieve desired results. Each pillar of the model recognizes the value of collaboration, i.e. by pooling of expertise, fostering partnerships and sharing of resources, skills & experience wherever possible.

1. Service Delivery Model -

This pillar focusses on facilitating locally empowered and motivated agents of change that can deliver need based services in the village itself. These services should be designed on the basis of primary epidemiological data, address consumer preferances and offer a range of services which may be "Demand based" or "Protocol based". The services be broad enough to include preventive as well as therpeutic interventions, leveraging best of modern allopathic system and traditional alternative systems of medicine.

The components of service delivery are not only delivered in the field but also rely upon strength of established hospitals and Institutions. These could be partner hospitals at local district level as well as larger tertiary care facilities that have dedicated administrative, telemedicine and ambulance command center support.

Essential component of service delivery model is meticulous data collection and analysis that generates useful insights for planning of timely and appropriate interventions and to monitor progress. The program would develop in a constantly learning & evolving fashion.

The bed of this model essentially rests upon mutually supporting partner networks. No single player would have enough capability and resources to meet all the challenges at once. Like minded social entrepreneurs can share their strengths and contribute in collaborative fashion into a common platform. NGOs that work towards nutrition, sanitation, education, local empowerment, entrepreneurship and agriculture are indirectly contributing to improving health. Direct partnership can be as simple as doctors contributing their time online at their own convinience, or be large scale biotechnology, pharmaceutical and biomedical engineering companies contributing innovative solutions. Moreover, public health specialists, engineers, programmers, educationists, social activists, agri-business companies, Governments, funding agencies - there is scope for everyone to contribute "coherently" as team players.

2. Technology Model

The technology can enable a vast range of activities which were not possible in the past. The doctors can see the patients, interact with them and acquire relvant clinical information and even advise using Information & Communication Technology. The entire Medical Record can be maintained online in digital format and be interfaced with Hospital Information Systems, Financial Institutions and all other stakeholders.

3. Supply Chain Model

The doctor's prescription can reach the village in digital format but it is of no use unless it gets executed by either medication supply, sample testing, referral or emergency transportation. These products have to reach the consumer in timely manner, with accuracy and accountability. This pillar attempts to solve the problem of logistics - for making preventive and curative solutions, Medicines, Cheap Point Of Care Diagnostics, Health related products reach the last mile.

4. Financial Risk Pooling Model

All said and done, someone has to bear the cost of the service model. Either the Consumer bears it directly or someone else on his/her behalf. It may be Charity, Government, Risk pooling funds or Other mechanisms that bears the cost to make it sustainable. Innovations in financial model can ride on and support the innovations in abve 3 models.

Our vision is to let innovations in these diverse fields be synthesised and matured to achieve single common objective - "To make it possible for all human beings enjoy the fundamental human right to access healthcare when they need it and in cultually appropriate manner".

We have made a small beginning, you are welcome to join hands.

Tuesday, December 7, 2010

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

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