4a Co-Living - Tiago Miranda - Social design projects

20 - Bienestar Familia - D4SB

Private Healthcare Insurance for Low Income Families

Bienestar Familia

26 - Colombia · Bienestar Familia - D4SB 27

Grameen Caldas is an organization founded in Colombia by GCL in partnership with the public sector represented by the Caldas Government to facilitate the creation of a Holistic Social Business Movement (HSBM) in the region. The idea of this HSBM is to set the right environment in Caldas paving the way for social business initiatives with the unique objective of eradicating poverty. To enable this environment, Grameen Caldas set initiatives in micro-finance, joint ventures development and in the creation of a social business fund of $7 million. The four main areas of investment are education, nutrition, healthcare and housing (sanitation).

The Grameen Caldas team initiated Bienestar, a social business project addressing the issues of healthcare in the region. Our challenge as the Design for Social Business team was to understand the complexity of the healthcare system in Caldas, identify its main breakdowns and accordingly explore how design can improve, expand and replicate the already existing pilot model of Bienestar.

Why Colombia?


The Colombian Context

31

Colombia Profile

Colombia in Numbers

Being the twenty-sixth largest country by geographical area and the twenty-seventh largest by population, the Republic of Colombia is the fourth largest economy of Latin America. With over 46 million people Colombia (2010 est.), has one of the most unequal distributions of wealth with a GINI coefficient of 0.587 (the highest in Latin America). 46% of the population lives below the poverty line and 17% in extreme poverty.

People below the poverty line

Rural and urban populations

Unemployment (total labor force)

Literacy rate (age 15 and above)

Poverty head count ratio at national poverty line

Capital City: BogotáIncome Level: Lower middle incomeGDP: $435,367,000,00 (2010 est.)GNI per Capita: $8,430 (2009 est.)GINI Index: 0.587 the highest in Latin AmericaTotal Population: 46.3 millions

75%urban

25%rural

54% above

88% employed

93% literate

62.8% not poor

37.2% poor

46% below


MDG in Colombia

With a GINI coe�cient of 0.587 Colombia has the highest inequality

in Latin America.

Goal Value1990

Value2008

Goal 1. Halve the rates for extreme poverty and malnutritionPoverty headcount ratio at USD$1.25 a day (PPP, % of population) - -Poverty headcount ratio at national poverty line (% of population) - -Share of income or consumption to the poorest quintile (%) 3.4 2.9Prevalence of malnutrition (% of children under 5) - 5.1

Goal 2. Ensure that children are able to complete primary schoolingPrimary school enrolment (net, %) 68 88Primary school completion rate (% of relevant age group) 67 65Secondary school enrolment (gross, %) 50 82Youth literacy rate (% of people ages 15 - 24) 95 97

Goal 3. Eliminate gender disparity in education and empower women Ratio of girls to boys in primary and secondary education (%) 108 104Women employed in the non agricultural sector (% of non agricultural employment) 44 48Proportion of seats held by women in national parliament (%) 5 8

Goal 4. Reduce under 5 mortality by two thirds Under 5 mortality rate (per 1,000) 35 21Infant mortality rate (per 1,000 live births) 26 17Measles immunization (proportion of 1 year old immunized, %) 82 88

Goal 5. Reduce maternal mortality by 3/4Maternal mortality ratio (modeled estimate, per 100,000 live births) - 130Births attended by skilled health staff (% of total) 82 96Contraceptive prevalence (% of women ages 15 - 49) 66 78

Goal 6. Halt and begin to reverse the spread of HIV/AIDS and other major diseasesPrevalence of HIV (% of population ages 15 - 49) - 0.6Incidence of tuberculosis (per 100,000 people) 63 45Tuberculosis cases detected under DOTS (%) - 83

Goal 7. Halve the proportion of people without sustainable access to basic needsAccess to an improved water source (% of population) 92 93Access to improved sanitation facilities (% of population) 82 86Forest area (% of total land areas) 55.4 54.7Nationally protected areas (% of total land areas) - 74.4CO2 emmissions (metric tons per capita) 1.7 1.2GDP per unit of energy use (constant 2005 PPP $ per Kg of oil equivalent) 7 9.2

Goal 8. Develop a global partnership for developmentTelephone mainlines (per 100 people) 6.9 17.2Mobile phone subscribers (per 100 people) 0 73.6Internet users (per 100 people) 0 26.2Personal computers (per 100 people) 0.9 5.5

Table 1. Value achieved in Colombia until 2008 according to the Millennium Development Goals.

Healthcare Related Statistics Data ValueAccess to an improved water source 93%Access to improved sanitation facilities 86%Mortality rate, infant 17 per 1,000 live birthsChild malnutrition (children under 5) 5%World Bank (2008)

Life expectancy at birth m/f (years) 73/80Probability of dying under five 19 per 1,000 live birthsProbability of dying between 15 and 60 years m/f 166/80 per 1,000 live birthsTotal expenditure on health per capita (PPP International $) 569Total expenditure on health 6.4% of GDPGlobal Health Observatory (2009)

Table 2. Healthcare related statistics according to the World Bank (2008) and the Global Health Observatory (2009).

Aver

age

exch

ange

rat

e (U

SD)

Figure 3. Colombian expenditure on healthcare (est. 2008).

Per Capita Annual Expenditure on Healthcare

1995

Colombia Region of the Americas’ average

2000 2005 20100K

1K

2K

3K » 15% of population (approximately 6.9 million) are without medical insurance. » Extreme low quality in health services provided to the poor. » Poor infrastructure and shortage in public hospitals. » High bureaucracy in accessing the public health system. » Private insurance companies delay payment of treatments.

Main Problems of the System

Healthcare in Colombia


Caldas Profile

Caldas department is part of the Colombian Coffee Growing Axis with a total area of 7,291 km2. Caldas’ department has a population of 976,438 inhabitants consisting mainly of 25-29 year olds. The combination of mortality rates and migration of young people due to the scarcity in the labor markets is leading to an increment on the aging population (40+ year olds).

Figure 7. The Caldas region.Figure 6. The Caldas population structure by large groups.

40 - 59

60+

0 - 17

18 - 39

34.1%

32.4%

22.4%

11.1%

2005

31.6%

32.6%

23.8%

12.0%

2009

29.3%

32.9%

23.6%

14.2%

2015

Although the matriculation at the Caldas universities in the field of Sciences of Health were of 3,285 students, and the medicine schools in Colombia

have increased from 21 to 54 in the last 20 years, doctors that graduate are concentrated in the big cities making it di�cult to achieve health coverage

for the entire population.

Figure 4. Estimated mortality causes for women (%) Colombia, 2004 Figure 5. Estimated mortality causes for men (%) Colombia, 2004

Hypertensive 3.8%

Ischemic heart 14.4%

Cerebrovascular 9.3%

Other CVD’s 5.3%

Lung 1.5%Breast 2.5%Colorectal 1.5%Leukemia 1.0%Lymphomas 0.9%Stomach 2.9%

Circulatory 32.8%

Circulatory 21.2%

Cancers 11.5%

Other causes13.8%

Cancers 19.9%

Other causes 15.3%

Injuries7.6%

Injuries38.0%

Other NCD’s12.2%

Other Cancers9.6%

Respiratory6.7%

Diabetes5.5%

Diabetes 2.5%

Hypertensive 2.1%

Respiratory 4.9%

Ischemic heart 11.3%

Cerebrovascular 4.7%

Other NCD’s 8.2%

Other CVD’s 3.0%

All NCD’s 77.1%

All NCD’s 48.2%

The average income of a general doctor in Colombia is around $285 (3-4 minimum wages). Around 8% of the

doctors are unemployed and 5% work in di¦erent jobs.


Scarcity in the labor market, added to the great reduction in agricultural production have conspired to create higher rates of

inactivity and greatly increase the chances of falling into poverty.

Out of the total Caldas population...

It means that 3 out of every 5 inhabitants of Caldas are

poor by definition

25.7% are registered as SISBEN Level 1 (extreme poverty)

36.3% are registered as SISBEN Level 2 (poor)

12.2% are registered as SISBEN Level 3

The SISBEN Level *SISBEN: The Selection System of Beneficiaries for Social Programs is a social survey done by the government, to rank poor people (from economical strata 1 and 2) according to their quality of life. People are divided in three categories: 1, 2 and 3 (where 1 is the lowest quality of life). SISBEN is used to select people for social assistance programs from the government, who have “... a state of deprivation not only in material welfare (food, housing, education, health, etc.) but (…) also personal and property uncertainty, vulnerability to health, disasters and economic crisis, social exclusion and political life and liberty of making abilities”.

The average size of a household according to SISBEN level in Caldas 4.5Level 1 4.0Level 2 3.4Level 3

174,14231% are single moms



Number of households as registered by SISBEN

Is the inactivity rate in the region of Caldas

Is the inadequate employment rate due to income in the Caldas region.


Villamaría Profile

Villamaría is a municipality of the Caldas Region and is situated 9 km away from the capital, Manizales. It has an area of 461 km2 and a population of 50,123 inhabitants.

Caldas population± 1,000,000

Manizales population± 387,000

Villamaría population ± 50,000

Healthcare Professionals in VillamaríaIn 2009 Villamaria had Colombia had

1 doctor for every 2,083 inhabitants 1 doctor for every 740 inhabitants

1 dentist for every 4,545 inhabitants 1 dentist for every 1,282 inhabitants

1 nurse for every 8,333 inhabitants 1 nurse for every 1,818 inhabitants

Table 3. Number of healthcare professionals in Villamaria compared to the whole Colombia in 2009.


Benchmarks

Mothers Club, Kendubay Sub-District Hospital

CFW Shops Kenya

SOS Médcins France

Distance Healthcare Advancement - DISHA ASEMBIS

Pre natal/delivery care and education

The club recruits women attending the hospital’s pre- natal clinic. The women are asked to make a commitment to deliver their next child in the hospital and meet as a group twice a month to receive health education, including training on safe motherhood practices. Other than that, they are asked to take an active role in educating other women in their villages about safe motherhood and the risks of delivering at home.

Key point: Empowering and integrating local women in the healthcare delivery model through an educational role.

Affordable healthcare franchise model

A network of 64 financially self–sustainable centers that deliver government approved health products and pharmaceuticals at $0.50 per treatment. Distributed in urban, rural and semi-rural areas, these units are located within an hour distance from their intended customer base and serve more than 400,000 Kenyans a year. More than half of the locations are owned by community health workers while the rest is owned by licensed nurses which also provide screening services. The quality of the services is guaranteed by unannounced audits and the threat of the closure. In exchange, they bear a brand name, share marketing costs, best practices and benefit from a centralized buying platform.

Key point: Creating a replicable and affordable model that benefits from group synergy and local entrepreneurs.

Mobile healthcare

The concept is simple: patients in need of care can contact a call center 24 hours a day, 365 days a year that finds an available doctor and sends him to their home, much like a taxi business. A success that counts with a thousand emergency doctors and 62 associations spread over the territory, and have handled so far 4 million calls and 2.5 million home interventions and consultations; 60% of procedures performed at night, Saturday afternoon, Sunday and holidays. The achieved results are a consequence of the reliability and unfailing motivation of the key players.

Key point: Providing alternative channels for care delivery through an extremely flexible organizational model.

Mobile healthcare and partnerships

The goal of DISHA is to deliver high-quality, low-cost diagnosis and care to low-income rural communities that are not addressed by the existing healthcare system through a mobile tele-clinical van. In this initiative, Philips, an imaging and medical diagnostics company, partnered with a government agency (ISRO) that provides satellite connectivity between the van and the hospital, Apollo, the healthcare service provider which will staff the van, and a local NGO.

Key point: Creating alternative channels to deliver healthcare and create synergetic partnerships.

Discounted medical services

Through the use of a multi-tiered pricing model, ASEMBIS has created a financially self-sustained network of eye care clinics that offer services from basic eye examinations to sophisticated surgical procedures at a 40-70% discount from the market rate. Its integrated network includes non-traditional health professionals for vision testing and preventive care, cost-efficient and high-volume clinics, and mobile rural clinics; an overall treating of more than 350,000 patients in 2004. The 8 clinics in different regions of Costa Rica, offer nationwide coverage, and provide a wide spectrum of medical services, from basic health to sophisticated surgeries, imaging diagnostics, and almost all specialties.

Key point: Creating a network of financially sustainable healthcare clinics that offer specialist services and uses alternative professionals to deliver care.

Many solutions have been implemented throughout the world to improve healthcare access to low income communities. We looked into some of the different approaches to get inspiration for our concept.


Project Goal:Improve access to primary healthcare in Caldas, by redesigning the existing Bienestar social business model, in order to expand and replicate it in Colombia and possibly elsewhere.


Observation & Synthesis


The Field Research in Caldas, ColombiaA substantial part of the input gathered for this project comes from the field research conducted in Caldas, Colombia from May 15th to June 5th, 2011. Our stay was supported by the local organizations Grameen Caldas and Bienestar, which helped us individuate and contact the local players, make the arrangements for the activities and guide us on field.

This phase of the project was based on qualitative research methods which, combined with the desktop research, helped us in getting a complete overview of the situation and arriving to the desired solution.

“At the early stages of the process, research is generative—used to inspire imagination and inform intuition about new opportunities and ideas. In later phases, these methods can be evaluative—used to learn quickly about people’s response to ideas and proposed solutions”. (IDEO Toolkit).

The Research Tools

The Colombian Healthcare System

Design tools used with the different stakeholdersTools Stakeholders Goals

Group interview Doctors, medical professors and students from Manizales University.

Understanding the complexity of the Colombian healthcare system, its stakeholders, how they are connected to each other and their influence on the system.

Discovering the main touch points of the existing healthcare service and tracing money, time and information flow.

Understanding the perspective of doctors, their aspirations and frustrations.

Discussion sessions Grameen Caldas team and Bienestar founders.

Understanding the Holistic Social Business Movement in Caldas and its goals, as well as the criteria for accessing the fund assigned by the Government to finance social businesses in Caldas.

Understanding and analyzing the first outcomes, limitations and challenges of Bienestar social business pilot phase.

Individual interviews Patients, community workers and healthcare related players such as doctors, nurses and pharmacists.

Understanding the person.

Understanding the general healthcare and medical experiences of users.

Understanding the specific experiences related to user profile.

Different Regimens Within the Colombian Healthcare SystemRegimen Description Affiliations in

Colombia millions / %

Affiliations in Villamaría millions / %

Contributive (RC)

People with employment contract or independent workers who earn at least two minimum salaries per month are affiliated to the contributive regime; they have to pay a monthly affiliation to an EPS (12.5% of their monthly wage); 8.5% is paid by employers and 4% is paid by employees, and they should pay moderating fees ‘copays’ established in the POS for the contributive regime.

17.3 (39%)

16.5 (33%)

Subsidized (RS)

Unemployed people and people from SISBEN 1 and 2, likewise their family; they should pay moderating fees established in the POS for the subsidized regime according to their SISBEN level. Of the 12.5% total contribution per individual of the RC, the FOSYGA channels 1.5% into the RS as a solidarity contribution.

23.8 (51%)

15.9 (32%)

Not affiliated (Vinculados)

People who are not classified by the SISBEN and don’t have access to the subsidized healthcare services, as well as SISBEN 3 and independent workers with payment capacities. They are covered by the PBS. This plan is a safety net financed by general taxes that is composed of public hospitals and health centers. While all citizens are eligible to receive the benefits under this plan, it primarily serves those who have not yet been enrolled in either the RC or the RS and those who are enrolled in the RS but require services that are not yet covered under its benefits package.

4.2 (8%)

17.5 (35%)

Special (RE)

People who work for the government, armed forces and teachers of public institutions; this plan is financed by the government and they benefit from their own network of healthcare providers and have very few limitations on the services provided.

1.2 (2%)

N/A

Table 6. Definitions of the different regimens within the Colombian healthcare system.

Table 4. Description of the design tools used with the different stakeholders.

To understand the complexity of the healthcare system, it is important to look into its institutions, the different forms of coverage it provides to the population and the regulations behind it.

The public healthcare is regulated by the law 100/1993, which established the SGSSS (General System of Social Security in Health). This system is coordinated, directed and controlled by the state and the funds designated by the government are managed by the FOSYGA (Fund of Solidarity and Guarantees).

The main healthcare institutions involved in delivering healthcare services to the population are the EPS’ (Health Insurance Companies) and the IPS’ (Health Service Providers).

The EPS functions as an intermediary between its affiliates and care delivery institutions (IPS) in managing appointments, approvals and the payments of health services. It has to guarantee to its affiliates the minimum established by the POS (Mandatory Health Plan), which is a list of treatments, procedures and drugs defined by the government.

The IPS is a public or private entity that provides medical procedures. IPS’ are divided in 3 levels of attention and the vast majority only cover the first level.

The quality and coverage of health services are directly linked to the affiliation of the patient to the system. There are four types of regimens:

List of AcronymsInitials Name in Spanish (English)

SGSSS Sistema General de Seguridad Social en Salud (General System of Social Security in Health)

EPS Entidades Promotoras de Salud(Health Insurance Companies)

EPS-S Entidades Promotoras de Salud Subsidiadas (Subsidized Health Insurance Companies)

IPS Instituciones Prestadoras de Servicios de Salud (Healthcare Providing Institutions)

POS Plan Obligatorio de Salud (Compulsory Healthcare Plan)

FOSYGA Fondo de Solidaridad y Garantía (Fund of Solidarity and Guarantees)

PBS Plan Basico de Salud (Basic Health Plan)

Table 5. Acronyms of the Colombian healthcare system.


Moreover, the access to generic essential drugs (from a list of 350 medicines) is covered through the POS for those under the contributive regime and with certain restrictions for those under the subsidized regime.

For those not covered by the system, there is almost no access to any medications at all, since this is strictly limited to primary care medications that do not exceed a value of USD$4.

Therefore, it is clear that the population that lacks the most access to adequate healthcare is the one not affiliated to the system (vinculados) followed by the subsidized regimen. Combined they represent 67% (34,000) of the population of Vilamaria—against 59% in Colombia. Vinculados alone, represent 35% of the population in Villamaria, amounting to a total of 17,500 people without health coverage.

Public Healthcare System Map


The network of care providers in Villamaria counts with 5 IPS’ (Table 7) of which only one is a public provider. It is also the only one that provides emergency and delivery services. The other entities are private and offer only prevention, promotion and consultation services. For second and third level care, patients have to go to Manizales or Pereira.

Unless it is an emergency, the affiliated patients have to pass through their assigned EPS for approval and scheduling of appointments, a process that often delays the treatment to several weeks and sometimes even months.

For Vinculados, the process could seem more direct, but services offered in the public IPS are very limited, waiting time is huge and insufficient resources lead to very scarce services.

Briefly, EPS’ and IPS’ are the main players with the biggest influence in the system and on the final care received by the population. The following graph describes the role of each stakeholder in the system and compares their level of influence and power.

Patients have little control and decision power which leaves them without much influence within the system. Moreover, doctors and healthcare personnel are subject to IPS´ rules and constraints and to the lack of proper job conditions, a cause for poor motivation and professional fulfillment. Imposed POS limitations together with inadequate in-house resources are not only a frequent source for their frustrations but a barrier to a proper care service for the patients.

Healthcare Service Providers in VillamaríaEntity Public /

PrivateLevel of

complexityPatients treated (2009)

Assistant Staff

Admin. staff

Hospital San Antonio Public I Level 41,173 55 34

Centro Médico El Parque Private I Level 19,540 6 3

Salud Total Private I Level N.A. 6 1

S.O.S Private I Level 6,803 6 1

Pasbisalud Private I Level 16,383 13 0

Table 7. Description of the healthcare service providers in Villamaria.

EPS’(healthcare insurance companies)

Don’t provide any medical service, but work as an intermediate between their members and the affiliated IPS’. Manage the money flow between the two.

State / Admin Coordinates, directs and controls the public health system (regimen affiliations, EPS’ and IPS’ regulation and POS limitations). Directly finances life-threatening cases outside of the POS (tutela).

IPS’ (health service providers)

Hospitals, clinics, laboratories. Manage and provide healthcare personnel, infrastructure and supplies for care delivery according to the POS coverage and to the patients’ EPS affiliation. Private IPS’ are paid by EPS’. Public IPS’ are for non-affiliated patients (vinculados).

Doctors and Health Personnel

Hired by the IPS’ to deliver medical services.In general, they are not able to deliver adequate care since they are limited by their IPS’ and the POS.

Patients Access to treatments, exams and medicines, as well as services copays, depend on their regimen affiliation (contributivo/subsidiado) or lack of it (vinculado), and to POS limitations. Often receive inadequate medical services, have no influence in the system and are subject to EPS decisions.

Pharmacies Sell medicines and provide health counselling. They are often used as an alternative access point to healthcare, but don’t have any actual medical power.

IPS Pharmacies Give or sell prescribed medicines according to insurance coverage of the patient treated in the IPS.

Stakeholders of the Public Healthcare SystemInfluence on the System

EPS’ and IPS’ are the main players with the biggest influence on the

system and on the final care received by the population.


BienestarBienestar was initiated in 2010 as an alternative healthcare service to the public health system. Based on the Ser model in Argentina, Bienestar s mission is to improve the access to primary healthcare services for low income communities in the Caldas region, following the social business principles.

The main idea behind Bienestar is to eliminate the barriers imposed by the EPS’ by selling membership cards that link members directly to the affiliated clinics. For USD$5 a year, the cardholder is entitled to discounts up to 50% on the treatments delivered by the network. The map on the opposite page illustrates how the Bienestar system works.

The model aims to empower patients and to cut the bureaucracy imposed by EPS’. The patients get a better services and the waiting time is reduced. In exchange, affiliated clinics win by increasing the volume of patients and by having instant cash — EPS usually take months to pay the contracted services.

The project during our research was in its pilot phase, with one affiliated clinic and 90 members in Villamaria.

The map shows some advantages of this stage of the project by eliminating EPS´ authority and by increasing the influence of patients on the scale. However, the situation is still not the ideal since the care quality cannot be guaranteed because the affiliated clinics are still managed in the same way as before entering the network.

SER System ModelCEGIN is a medical center founded in 1989 which specializes in the provision of medical services to poor women from rural areas of the Jujuy Province. Jorge Gronda launched the SER system within the CEGIN center in 2004. It is a membership card that patients can purchase for USD$3 per year in exchange of preferential rates (more than half of the market price) on services delivered in these centers. The main idea behind the SER card, beyond increasing access to healthcare, is to create a network that will later allow its members to enjoy various advantages. Currently, card holders already enjoy discounts in some pharmacies, and in the long term, his ambition is to develop a system of “social franchise”, and extend the SER cards’ field of action to various fields such as food, construction and transports.

The social impact of CEGIN and the SER system allow the people at the base of the pyramid to have access to quality healthcare. Nowadays, over 40,000 people are followed by these clinics (including 20,000 through the SER network). Belonging to the SER networks and enjoying quality care services considerably increases the self-esteem of people suffering from social exclusion. The pride SER clients take in being part of the network makes them talk positively about it, and this word of mouth has been fundamental in the development of CEGIN.

Table 8. Description of the SER system running in Argentina.

Bienestar System Map


As the last part of our field research, we did a series of interviews with different stakeholders of the system, with a special focus on the final user, the patient. Our aim was to understand their concerns, expectations and frustrations, as well as listen to their experiences in order to develop a user-centered solution.

By interviewing doctors (working in the public system and in the Bienestar affiliated clinic), medicine students, the Bienestar affiliated clinic owner, a nurse, a pharmacist, a social worker and an EPS customer representative, we took into consideration all the different points of view, an important step in developing the further service. Interviews took place at people’s houses, around the community, at a pharmacy, a local medicine market, a 2nd level public hospital in Manizales and at the Bienestar affiliated clinic, El Parque.

IPS (Bienestar-affiliated clinics)

Manages and provides discounted health services direct to Bienestar members, in exchange for a bigger volume of patients. Maintais its role in the public health system. Ensures appropriate infrastructure, personnel and supplies to provide the care.

Doctors & Healthcare Personnel

Hired by the IPS to deliver medical services.They are able to deliver better care, since they are not limited by the POS anymore, but are still limited by their IPS.

Bienestar Links patients and Bienestar-affiliated IPS’ through the sale of a membership card that entitles to discounted health services. An alternative to the actual primary healthcare system, it cuts the access barriers imposed by the EPS’ and the POS.

Patients (Bienestar members)

Hired by the IPS’ to deliver medical services.In general, they are not able to deliver adequate care since they are limited by their IPS’ and the POS.

Pharmacies(Bienestar affiliated)

Sell medicines discounted by 5% to Bienestar patients in exchange for a bigger volume of sales.

State / Government Regulation and autorization of Bienestar activities.

EPS’(health insurance companies)

Address the patients to different healthcare providers (IPS’) when Bienestar does not cover the request (specialists, exams).

Stakeholders of the Bienestar SystemInfluence on the System

Interview Guides - Patients

Name Gender Age Occupation Household Structure Household Income Bienestar User Sisben Level Insurance

Regimen

Maria Elsita Mayo Female 50 Years Housewife Lives with husband and 2 of their 5 kids (10yrs twins)

No Sisben 2 Subsidiado

Nestor Ivan Garcia Male 41 Years Informal construction worker

Lives with wife and stepson next door to his family in law

Income depends on couple’s job

Yes Sisben 1 Subsidiado

Gloria Bettancourt Female 50 Years Unemployed Lives with husband, her mother and their 4 kids

Income comes from husband’s job

Yes Sisben 1 Subsidiado

Paula Hernandez Female 29 Years Works at a call center at night (her mother takes care of her daughters)

Lives with husband (works during the day) and their 2 daughters (10yrs + 4yrs)

Income depends on couple’s job

Yes Sisben 1 Contributivo

Ober Osorio Male 78 Years Retired policeman

Lives with his daughter Pension No Sisben 2 Regime especial

Gloria Ines Female 48 Years Unemployed Lives with husband, their 3 sons and 1 nephew

Income depends on husband’s job who works in construction


Albaneli Franco Female 40 Years Housewife Single mother, lives with son (7yrs), mother, 4 brothers and 1 nephew

Income is based on the jobs of the brothers and sister

Yes (+2 family members)

Sisben 2 Subsidiado

Lina Paula Ospina Female 23 Years Unemployed Single mom, lives with her two kids (7months + 3yrs) and her grandparents

Income depends on her father


Table 9. Patients’ profiles from the interviews in Villamaria.

The Interview Guides

56 - Colombia · Bienestar Familia - D4SB 57 57

Table 15. Example of an interview guide used during the field research in Villamaría.

Interview Guides - Social WorkerName Gender Age Occupation

Yurdani Woman 28 years Social worker at the Municipality of Villamaria**

** takes care of social and cultural programs with the local youth (14yrs – 26th)

Table 14. Social Worker’s profile from the interviews in Villamaria.

Interview Guide - Female Patient1.Understanding the person

» What is your name, age, marital status, number of children, parents...? » Where are you originally from? If not Caldas, where from and why did you move here? » Who do you live with? Are all your children living with you or did any leave? Do your parents live with you? Why? » What do you do for a living? And the other members of your family? » Are you the only person contributing for bringing money home? If not, who else? » Do you work outside your house? If so, do you work close to you home? How do you get there? » What forms of transportation do you use? » Are you a frequent user of medicines? If yes, what medicine do you use and for what health problem? » Do you or anyone from your family suffer from any chronic or hereditary disease? (heart disease, stroke, cancer, chronic respiratory diseases and diabetes...)

2.Understanding the general healthcare & medical experiences of user

On the Colombian healthcare system (how they see it, service, time to gettreatment, difference with Bienestar).

» Have you used the public healthcare system? » Did you feel well attended? How did they treat you? » How much money from your salary goes to the public system? » How do you regard public healthcare? What is your opinion? » How long did it take you to get treated? » Where did you have to go?

Before going to the doctor - look for alternative ways.

» Do you go to the pharmacist sometimes for medical advice? » When feeling sick you try to talk with someone about it? Do you consult family members, friends, other sources? » What kind of illnesses do you feel you can solve without a doctor? How would you do it? » What medicines do you always have in your house? Where do you keep them, can you show me? » What remedies do you always have in your house? Where do you keep them, can you show me? » Do you have a first aid kit? Can you show it to me? » Do you use alternative ways of treatment (infusions, teas, ungüentos)? » Can you describe an experience related to any of these issues that have happened to you or somebody that you know?

Going to the doctor (motivation, decision making, education).

» What kind of prevention do you take? (hygiene, nutrition, chlorine in water, iodized salt, etc.) » How often do you visit a doctor? » When do you feel you need to go to the doctor? How ill do you need to be? » What makes you decide against visiting a doctor when a health problem occurs? » Where is your nearest healthcare center/doctor? How long does it take you to get there? » How do you go to the doctor’s clinic? Do you use public transportation (bus, taxi, chiva, etc)? » What do you do when there is an emergency? » Do you take the decisions regarding health condition of others in your family? » Do you usually go accompanied to the doctor? If so, is it a family member, a friend? What family member? (child, husband) » Do you save some part of your budget for health emergencies? » Is it a problem with your employer to take time off from work if you need to see a doctor?

Doctor - visit » How is your relationship with your doctor? Describe it in some words. » Where do you go to visit your doctor (clinic/hospital)? » When going to the doctor, do you feel that you are paying too much/enough for his services? » How many times more or less do you go to the doctor per month, per year?

3.Understanding the specific healthcare experiences related to user profile

Doctor / clinic experience » Do you trust doctors? » Do you have a trusted doctor that you always go to or wish you could always go to? » Do you prefer a male or a female doctor? » List some characteristics that you think are very important in a service. What do you appreciate most in a visit? » What is your opinion about nurses, assistants, other staff?

Women » Did you see a doctor on regular basis when you were pregnant? » Where did you give birth? Who helped you in giving birth? » How often do you take your children to the doctor? » Are you aware of regular checkups like Papanicolao? If so, do you have them?

Bienestar user » Why did you choose Bienestar? Do you think the healthcare service has improved with Bienestar? » What determined you to enter Bienestar program? » Have you advised someone else to use it? » Do you have a trusted doctor that you always go to, or wish you could always go to? Is he from Bienestar? » Did you notice something different (service experience) using Bienestar from your past experience? » What are your expectations from Bienestar?

Not Bienestar user » Have you ever looked for private insurances regarding healthcare? » Do you know what an insurance is? Have you ever considered it? » What determined you to enter Bienestar program?

Interview Guides - Nurse


Regimen

Eluin Osorio Female 46 years Works at Nueva EPS Lives with son (21yrs), his wife and grandson (2yrs)

Income depends only on her job

No Sisben 2 Contributivo

Table 11. Nurse’s profile from the interviews in Villamaria.

Interview Guides - EPS User Representative


Regimen

Doralba Seballos Mosqueiro

Female 64 Years President of the association of Villamaria’s Caprecon (EPS) users*

Lives on her own Government help to the 3rd age citzens


* in charge of gathering the complaints from Caprecon users in Villamaria to take them to the Manizales Health Superintendence.

Table 10. EPS User Rappresentative’s profile from the interviews in Villamaria.

Interview Guides - DoctorsName Gender Age Occupation

German Aristizabal Moreno (Bienestar) Male 45 years Works at and owns Centro Medico El Parque (a Bienestar affiliated clinic), certified as a general practitioner

Adrian Zapata Male 32 years Works at Centro-Piloto Bas Salud (2nd level public hospital in Manizales)

Table 12. Doctor’s profile from the interviews in Villamaria.

Interview Guides - PharmacistName Gender Age Occupation

Berta Female 75 years Works in her own pharmacy with her daughter

Table 13. Pharmacist’s profile from the interview in Villamaria.


“Doctors become insensible”.Maria Elsita Mayo50yrs. Patient

“For the health, I don’t think twice, I pay”.Nestor Ivan García41yrs. Patient

“I don’t have a place where to send the children”.Adrian Zapata32yrs. Doctor

Paula Hernández. The di�culties of dealing with the EPS’.

Paula Hernández, 29 years, is originally from Manizales. She moved to Villamaría with her mom that now lives in a different house.

She rents a house in one of the neighborhoods in Vallamaría where she lives with her new husband and her two daughters from her previous marriage. She works during the night for a mobile phone company and therefore sleeps during the day. Paula’s mother takes care of the two children and some of the domestic chores as Paula rests during the day.

One of her daughters, Paola, is 5 years old and was born with a malnutrition problem that led to an orthopedic issue making it difficult for her to walk. This has caused Paula to face many difficulties in trying to access the right treatment ever since Paola was born.

During her pregnancy, Paula was diagnosed with a morphological problem that made it difficult for her to give birth. That is why she blames herself and feels responsible for her daughter’s complication.

Paula has been trying to schedule the necessary surgery but she has not been able to do so. Due to the bureaucracy within the system and the long time required, she has been struggling to fix a surgery since Paola’s problem can only be solved at a young age.

Every time Paola needs a treatment, she has to go through a general doctor that then sends her to a pediatrician and finally to a pediatric orthopedist in order to get the treatments approved and done.

“I lose a lot of time”. Paula said. Whenever she books an appointment through her EPS, she usually waits from 15 to 20 days for confirmation without having the possibility to choose neither the doctor nor the hospital she has to go to.

She enrolled Paola in the Bienestar plan as she was desperate to find a solution for her daugher’s problem. Ever since then, she has been very satisfied. “Now the doctor really takes care of her and gives me advice on what to do”. Before, she felt that the doctors and nurses of the public system did not really care about her daughter nor her illness.

She would like all her family members to sign up for the Bienestar plan, especially her mother who is also sick. Paula’s mother helps her a lot in raising her daughters and does not have any kind of healthcare coverage herself, but the income inside the house only allows them to have Paola insured.

Her two daughters represent her major priority, that is why even if she is enrolled in an EPS she chose to pay extra and take better care of both of them.

“The EPS meetings with the users happen once a month. Nonetheless, very few people attend them”.Doralba Seballos Montero64yrs. EPS representative


To synthesize the information gathered during the interviews, we created personas based on the different family structures in Caldas. They represent a general profile of the Colombian reality.

The Interview Guides - Personas

Persona 01 - Margarita PerezSex: FemaleAge: 23 years oldSisben: Level 1EPS: Caprecom(subsidised)

Margarita is unemployed and lives with her grandparents, Sofia and Pedro. Her 26 year old partner, Miguel, lives with them and they have 2 children together. One of the children is 3 years old and the other is 3 months old.

Miguel is a construction worker and the source of income to support the children.

Margarita’s grandfather:

Pedro suffers from ulcer, hernia, prostate, high blood pressure and had the Cafe Salud EPS, which he was denied from because of his many chronic illnesses. He hates going to the doctor and Sofia and Margarita are always finding ways to trick him into taking him there. They had to pay 3,000 pesos for the card when enrolled in EPS and a fine of 8,000 pesos whenever they didn’t show up to an IPS visit. Tutella accepted his request but takes a long time (3 months) to get appointments.

Margarita has mastitis (breast milk problems) and goes to the pharmacy instead of the doctor since the doctor is always changing and the checkup time is too short. She would like to study to be a nurse one day. Margarita and Sofia are the decision makers in the house.



Persona 02 - Pablo SalazarSex: MaleAge: 41 years oldSisben: Level 1EPS: Caprecom(subsidised)

Paco is a construction worker on freelance terms. He is living with his partner, Angelica, who has a son from a previous relationship. Their house is close to Angelica’s parents’ house who live together with their other daughter and her 2 children.

Paco is the income provider of the family. He has a lump in his hand but has never had it checked. He has had previous bad experiences with a doctor where he was given the wrong prescription for a disease in addition to always waiting too long to get a consultation.

He enrolled in Bienestar but hasn’t used it yet. He is willing to pay a little bit more to ensure healthcare access in case of emergency.

“In health matters, I don’t think twice, I pay”.



Persona 03 - Maria GonzalezSex: FemaleAge: 28 years oldSisben: Level 1EPS: Salud Total(contributivo)

Maria and her children live with Franco, Maria’s husband and the children’s stepfather. She works at night in a call center and her husband works at Gommaz. They rent a house which is close to Maria’s parents’ house so her mother can take care of the children while Maria sleeps during the day.

Maria has 2 daughters:

» Gloria, 5 years old, suffering from malnutrition » Mailin, 7 years old, who had apendicitis

Maria’s daughter:

Gloria goes to a nutrionist which EPS covers but Maria enrolled her into Bienestar so she can have fast access in case of an emergency and also because they get a sense of attention from the doctor which isn’t present with the doctors EPS assigns.

Maria’s mother:

Fernanda is 50 years old and suffers from uterine cancer, hypertension and cholesterol. Her EPS is with Caprecom (subsidised). She takes care of her husband, Ramon, who is unemployed and sick, and her grandchildren by preparing their meals and accompanying them to school.

Maria is the decision maker in the family and takes care of the household between working and sleeping. She has no access to doctors and feels she loses time and money with doctor visits as they don’t giver her the attention needed. For her children’s vaccinations, she has to take care of the appointments and followups herself.

Low Income Colombian Family Structure


Identification of Problems & NeedsTo understand the weaknesses and opportunities, we made a list of all the problems and needs of each stakeholder based on the following criteria: time, money, quality and bureaucracy.

From this point, we were able to identify the key success factors (KSF) to achieve a desired solution.

After that, we individuated the problems and needs that were addressed by Bienestar and the KSF’s that were taken into consideration by the model. In table 16, the issues addressed by Bienestar are highlighted in green.

Going through the synthesis process, we were able to identify several common problems and needs.

We realized that the Colombian family structure represents a pillar for developing a solution that would take into consideration the urgent need of convergence of all different plans within the same household.

Due to the fact that the EPS is assigned by the working position, individuals cannot choose their personal plan. Many people are not even covered by any EPS because of several bureaucratic and registration problems during the phases in between changing jobs. This situation generates a massive dependency on the other family members, particularly from an economical point of view.

During the interviews we also found out about the existence of a basic mistrust towards doctors, blamed for being more attentive to the bureaucratic aspect of their work rather than the health problems of their patients. This feeling contributes to the lack of continuity between patient and doctor relationships and leads to an impersonal, superficial and frustrating environment. For example, the figure of the general practitioner (GP) is being replaced by that of the pharmacist because of an easier access and unpleasant past experiences. In this way, pharmacies are becoming the first point of consultation.

Apart from offering a faster and easier access to healthcare, now missing due to all the misconnections and bureaucratic aspects, it is important to build a continuous relationship between the patient and the doctor.

At the end of the analysis, it is clear that many areas of opportunities coexist in the Colombian healthcare system, and that different solutions would be able to solve one or more problems.

Bienestar’s pilot trespasses some of the bureaucratic aspects to access primary care through the elimination of the EPS´ role. Nevertheless, it still cannot fully guarantee the quality of the services delivered by the affiliated health institutions, since no changes have been implemented by any affiliated clinics.

Problems, Needs & Key Success FactorsProblems Time Money Quality Bureaucracy

Patients Family members within one household belong to different EPS healthcare plans X

Patients cannot choose their own EPS (assigned to them by system) X

Many people are not covered by any EPS X

Family members rely on relatives to cover healthcare expenses X

No continuity of patient/doctor relationship X

Doctors cannot dedicate sufficient time to patients because of system and bureaucracy X

Long waiting time in EPS queue to get doctor appointments X X

Long waiting time inside IPS to get diagnosed X X

Long waiting time for EPS approval of treatment X X

Some treatments are denied by EPS when not belonging to POS (plan obligatorio de salud) X X

Patients need to pay a fine if they do not show up at the assigned IPS X X

Patients have to cover travel expenses to reach assigned IPS X X X

Patients are not properly informed about their medical conditions X

Patients don’t trust the doctors X

Patients are not aware of the system and its procedures nor their personal rights X X

Patients lack knowledge and awareness on prevention methods X

Patients have no access to their medical records X X

Doctors Doctors are not able to prescribe adequate treatments due to POS limitations X X

Doctors are replaced with pharmacists since they are more accessible to patients X X

Doctors have no access to patient medical records X

Lack of access to specialist treatments inside the public health system X X

Clinics Lack of infrastructure in IPS to accommodate for volume of patients X X

IPS are not able to manage their resources/lack of resources to provide quality service to clients X

No way of receiving feedback/complaints from patients X

Needs Time Money Quality Bureaucracy

Patients Easier access of all family members within household to the same health plan X X

Information about personal health condition X

Reduce waiting (wasted) time through process X

Trust in doctors for appropriate treatment and followup X

Affordable visit and treatment expenses X

Access to specialized treatments X

Doctors Access to updated patient clinical history X

Gain the trust of patients X

Allocation of time for proper and complete diagnosis of patient X X

Ability to prescribe the appropriate treatment for the specific patient condition (independent of POS) X

Ability to follow up on patients’ progress and well being X

Clinics Capability to manage patient overflow X X

Optimize resources in order to deliver appropriate services X

Keep track of patients’ clinical history X X

Provide a better communication channel between patients and doctors X

Key Success Factors Time Money Quality Bureaucracy

Patients, Doctors, Clinics

Equal accessibility to health care for all family members within household X

Up-to-date patient database system X X

Different health services that generate an accessible Medical Network X X

Time efficient healthcare service X

Affordable primary healthcare visits and treatments for different patient conditions X X

Friendly and trustful relationship between patients and doctors X

Effective treatments for all patients X

Follow up and feedback from patient to measure outcomes for further service improvement X

Table 16. Problems, Needs and Key Success Factors identified during the field research in Villamaría, Caldas.


Bienestar Familia Concept


Bienestar Familia is a concept that is built around the specific family structure of Colombia. Starting from the direct family living within one household, Bienestar Familia extends to encompass all members of the community, the ‘larger family.’ Value Proposition

Our mission is to deliver quality and affordable family centered healthcare involving the community in the value chain. Our concept is divided into two main parts:

This part of the concept consists in improving the primary healthcare experience of the family through an unified health plan that covers all the members within a household and gives them access to affordable services in Bienestar Familia clinics and network of affiliated services. The family plan also entitles each family to a family doctor, ensuring continuity and trust throughout the care delivery.

Based on the fact that different households have different needs, we wanted to make our offer more flexible by creating a set of scalable memberships that adapt to the specific family structures and are affordable to all family members.

This holistic family approach will offer a welcome family kit - with basic instructions on the plan and its services and benefits - and a family check up for free as an introduction to Bienestar Familia and to the assigned family doctor. The database will combine the family data easing the access to family health records, reducing the time spent on paperwork and ensuring the effectiveness of the treatment. Moreover, pediatricians will be available for the children, who are often left unattended, and internists for those who suffer from chronic diseases, one of the major health problems of the area.

The service will be complemented with family oriented initiatives in prevention and education, such as family planning, pre-natal assistance and family counseling.

The community becomes an important link in the value chain of Bienestar Familia. As mentioned before, it is important to use a participatory approach to gather consensus and acceptance for the new business, especially in low income areas where relationships inside the community are very strong.

This role will be filled by women chosen among the social business members and trained by Bienestar Familia. The main target will be single moms and unemployed housewives wanting to complement the family income. Creating job opportunities and empowering women in the community will leverage the value of the model, while simultaneously increasing their self esteem and feeling of belonging. The fairies will be the main point of sale of Bienestar Familia memberships. A successful enrolment will be the start of the fairy-patient relationship.

Each fairy will represent a group of families enrolled in BF. They will collect feedback, guide users inside the Colombian healthcare system whenever treatments are not delivered by Bienestar Familia - tutela requests, EPS approval - deliver prevention and education, focusing on each family’s specific needs (e.g. infant nutrition, family planning, etc) and help individuating patients in financial problems.

Most of all, the Fairies will be a key resource to make the services more responsive and sensitive to the needs of its users, thus helping Bienestar Familia’s business model to evolve accordingly. Moreover, when the model matures and starts expanding, they can become an important channel of sales and distribution of products from partner companies, such as pharmaceuticals or microcredit.

Fairies are autonomous and benefit from flexible hours to accommodate the single mothers’ and housewive’s needs. They will work for a commission of the sales and healthcare benefits for their family.

Ideally, fairy meetings with BF members would happen every month at the clinic. These meetings can be used for co-creation sessions where unmet community needs are individuated, as well as for target initiatives on education and prevention delivery.

The Family Healthcare Plan and The Family Doctor

The Community Link: Fairy (Health Promoters)


Bienestar Familia System Map

The main touch point of care delivery for Bienestar Familia will be its own healthcare clinic. We believe that this is an important step, since in Villamaria there is a deficiency of delivery points (IPS’) and doctors working on them (Table 7). This is contradictory with the fact that in Colombia the number of medical schools have more than doubled in the last 20 years and local universities had 3,285 matriculated students in the field of Sciences of Health in 2008.

In addition, by creating a model clinic and managing it, BF will be able to generate a set of quality standards for the services provided to its customers. This standardization will not only ensure the proper delivery of care, but will also ease the future expansion and replication of the model throughout Caldas.

Other than spaces for the actual care delivery such as doctors’ offices and nurses’ screening rooms, the clinic should also count on an affiliated pharmacy, from where the customers can buy discounted medicines and healthcare products; a reception and a waiting room, for managing the patients flow; a room for the fairies’ meetings and training sessions and a BF office space, from where the main activities of this social business will be managed and coordinated.

The healthcare personnel working at the clinic will be composed by family doctors, a pediatrician, an internist, nurses, auxiliary nurses and a pharmacist. The administrative personnel will include other than the receptionist/call center attendant, the BF network management staff.

Besides the stakeholders directly involved in the social business, Bienestar Familia will rely on key partnerships to fund, support and complement its activities. Local universities with campuses on Sciences of Health will be an important source for recruiting the healthcare personnel that will work on the clinic. Focusing on new graduates will allow BF to give a fresh perspective to care delivery and will ease the process of standardization.

Partnerships will also be made to complement the health services provided by BF and to ensure a holistic approach to care. This partnerships will be made with local pharmacies, clinical laboratories and medical imaging centers to give discounted services to BF members. They in exchange will benefit of higher volumes for their businesses.

Financial partnerships should also be developed with key suppliers that are interested in sponsoring the social business model. These suppliers can be pharmaceutical and medical equipment companies, as well as ICT development ones.

Finally, Bienestar Familia would work in close contact with Grameen Caldas. They can help finance the start up with their social business fund, give valuable consulting services on social business and help in building the network of partnerships.

The following map explains the role and influence of each stakeholder inside the Bienestar Familia system. Stakeholders of Bienestar Familia

Influence on the System

Partners

Community

BienestarFamilia Human

Resources

Families (Patients)

Receives quality and affordable healthcare for the whole family when enrolling in Bienestar Familia. Helps the continuous improvement of BF by giving feedback through the Fairies.

Fairies Single mothers chosen by BF and the community to become a 2-way communication channel. Sell BF plans, give information, collect feedback and give focused prevention and education.

Bienestar Familia Management Manages BF social business with the focus on giving affordable and quality healthcare to its members while being self-sustainable. Oversees plan sales, internal processes, human and financial resources, database and physical infrastructure and partnerships.

Family Doctor

Deliver quality primary healthcare and establish a relationship of continuity and trust with the patient. BF gives them fair salaries and the right conditions to perform quality work.

Specialist Doctors (Pediatrician and Internist)

Complement the primary care services, deliver children-focused care and continuous treatment for chronic patients. BF gives them fair salaries and the right conditions to perform quality work.

Healthcare Personnel (Nurses)

Help doctors during care delivery, initiate contact and check-up of the patient. Perform minor treatments when needed. BF gives them fair salaries and the right conditions to perform quality work.

AdministrativeStaff

(Call-Center/Receptionist)

Manage efficiently the costumer flow and help create a stimulating environment. BF gives them fair salaries and the right conditions to perform quality work.

Laboratories & Pharmacies

Supply young doctors and other healthcare personnel to work on Bienestar Famila clinics.

Grameen Caldas Consultancy on Social Business. Increase network of partners. Access to Social Business Fund.

Medical Equipment Co.Pharmaceutical Co.

& ICT Companies

Initial sponsors in the first phase. When business is running sponsors will be repaid and the remaining stakeholders will instead be the only owners.(Social business type 2)

Local Universities

Supplies young doctors and other healhcare personnel to work on BF clinics.


The Family Healthcare Plan & The Family DoctorThe following maps illustrate the steps that a patient needs to take in order to complete a first level treatment cycle. It starts with the public health system where the main problems found are highlighted and then goes to Bienestar and the problems solved by the social business pilot. The objective is to understand how Bienestar Familia would intervene to improve the primary healthcare experience.

Comparing the two systems, it is evident that with Bienestar, a patient is able to skip the first part of the process, avoiding delayed treatments and economic losses due to waiting time. Bienestar also improves the quality of care delivery, even though the model is not able to guarantee it.

Public Health System Primary Care Cycle Bienestar Primary Care Cycle


Bienestar Familia, on the other hand, goes deeper in the changes, introducing other than the family doctor, an ICT platform to manage patients’ medical files, the clinic’s internal processes and the scheduling system. This platform will also serve as a communication channel between BF and the Fairies, who will be able to access it from their cell phones. The database improves the efficiency of the entire process by reducing the paper work during service delivery and ensuring continuity of the treatments by facilitating the access to the patient health history.

BF will also empower the nursing staff by giving them an active role in the care delivery cycle. Nurses will initiate the patient screening before seeing their family doctor. This will help doctors with their workload, allowing them to concentrate in the most important part of the care.

Finally, Bienestar Familia will also offer families specific specialist services, such as pediatricians and internists, to deal with the most complicated cases and to reduce the number of patients that need to access the EPS services.

Bienestar Familia Primary Healthcare Cycle

Bienestar Familia O�ering Map

Bienestar Familia

Healthcare Services

Medical Database access to medical records

efficiency

transparency

Call Center scheduling appointments

information

HealthcareFamily Plan

unified family plan

family doctor

access

Fairy healthcare plan sales

prevention and education

customer service

Family Doctor monitoring / prevention

diagnosing / intervening

Specialists(Pediatricians + Internists)

monitoring / prevention

diagnosing / intervening

Pharmacy discounted medicines

As Bienestar needs to be an accessible solution to low income families while providing high-quality services, it is important to understand the whole care cycle and to standardize the care delivery process. A standardized process will serve as a reference for the replicable model and future network expansion and will also allow the estimation of costs involved in treating patients over their entire care cycle (Time-Driven Activity-Based cost measuring system). Moreover, this approach combined with outcome measurement enables the continuous improvement of Bienestar Familia’s services.

The blueprints on the following pages show how the two main processes of Bienestar Familia’s healthcare value chain - the family doctor consultation and Fairies’ membership sales and feedback collection - can be initially standardized. The same approach shall be used in all other Bienestar processes.


Blueprint of Family Doctor ConsultationBlueprint of Fairies Service


Business Model of Bienestar Familia

The Business Model Canvas

* Orange post-its represent the expansion phase of the business through an affiliate medical network.www.businessmodelgeneration.com

Revenue Streams

Channels

Customer Relationships Customer Segments

Value PropositionsKey ActivitiesKey Partners

Key Resources

Cost Structure

Family care: family doctors, pediatricians &

internists

Family doctor

Fairies

Low income Caldas families

Bienestar clinic

Fairies

Healthcare delivery

Measure social impact

ICT database

Brand

Local medical

universities

Membership sales

commissions

Salaries:

healthcare personnel,

admin staff,management

Clinic costs(supplies + utilities) Annual

membership feeVisits +

treatments

Families unsatisfied with public healthcare

services

Call center

Staff

Grameen Caldas

Doctors

Laboratories & pharmacies

Community(Patients & Fairies)

Initial investment:

infrastructure+ ICT

Improve access to primary

healthcare for low income communities

Empower women & creation of

jobs

Social and Environmental Costs Social and Environmental Benefits

- Fairies - a dedicated link between patients

and BF

Network affiliation fee

Network expansion & management

BF managment

Lowers the government’s

responsibilty in providing adequate

healthcare

Family membership that gives access

to quality, efficient & discounted care


Implementation & Expansion


Ownership

Implementation

Expansion

0. Bienestar Familia implementation

1. Bienestar Familia starts spreading after establishing standard processes: VOLUME

2. Bienestar Familia has proven to be sustainable and reliable (break-even)

3. Bienestar (brand) broadens scope of practice

Fairies Access: Representatives of families can be chosen to become Fairies and receive a greater discount on health care services (or for free)

Commissions: Can earn additional commissions from sales by their ‘downline’ healthcare promoters = exponential awareness due to **multi-level marketing (to be controlled)

Specific training / Specialization: Community Managers on-site and database and / or nursing

Specific training / Specialization: Community Managers on-site and databaseand / or nursing

Pre-existing HealthcareProviders

Volume: Ensure a large number of patients to existing private clinics

Standardization: Healthcare cycles to specific patient populations and medical conditions need to be established (use of Time-Driven Activity-Based - TDAB - care to measure costs)

Quality control: Standardizing healthcare cycles will permit better quality control and assignment of Bienestar quality certifications

Bienestar FamiliaStaff

Administrative: Social business and business administration

IT Management: IT expert (partner) or internships from information / computer engineers to build information system and maintenance

Healthcare area: Young doctors due to collaboration between local universities and Bienestar Família

Bienestar Familia Staff: Fairies; Management; Family Doctor; Specialists (pediatrician + internist); Nurses; Administrative Staff (call center + receptionist)+ Internships

Local Universities Stage: Students from computer engineering and business management universities can have an internship with Bienestar Familia administration

Stage: Students from medical universities can have an internship at Bienestar Familia Clinic

Experience: Fresh graduates get the opportuniy to be a part of a promising and innovative social network inside the healthcare sector

Principal ResourcesAlternative SourceRisk Associated

Government of Caldas Social Business FundMicrofinance

Government of Caldas Social Business FundMicrofinance

Government Caldas Social Business FundMicrofinanceRevenues from cardsRevenues from visitsRevenues from ministry of healthRevenues from sponsors (ICT, pharmaceuticals and medical equipment companies)

Initial investment to build Bienestar Familia Clinic

Government Caldas Social Business FundMicrofinanceRevenues from cardsRevenues from visitsRevenues from government health ministyRevenues from sponsors (ICT, pharmaceuticals and medical equipment companies)

Production Equipmentand Infrastructure

Bienestar Família cards Office equipmentMarketing material (posters, brochures)

Bienestar’s Família system information: Medical data base to which both doctors and patients can have access to (if this information is managed by the representative of the family (women) - check in time / check out time / measuring periodical outcome of the treatment / etc - then less costs for Bienestar Familia)

Bienestar Família Clinic:1 reception + waiting room; 2 doctor offices; 1 nurse room; 1 dressing room; 1 pharmacy; 2 administration offices; 2 toilets; 1 storage room; 1 community / meeting room

Integration: Bienestar’s Família Cards and System Information (data base with medical records) work flawlessly together

Phase

Resource

HU

MAN

RES

OURC

ESFI

NAN

CIAL

RES

OURC

ESM

ATER

IAL

RESO

URC

ES

Resources Mapping for Implementation Plan

**Multi-level marketing (MLM) is a marketing strategy in which the sales force is compensated not only for the sales they personally generate, but also for the sales of others they recruit, creating a downline of distributors and a hierarchy of multiple levels of compensation.

The Bienestar Familia business model is designed to work as social business owned by the community (social business type 2). In the initial phase, other stakeholders such as ICT, pharmaceuticals, medical equipment sponsors or the Caldas government will take part as investors. When business starts running properly, they will be repaid leaving the community as the sole owners.

In every family there is a legal representative, preferably a woman, that becomes the person interacting with the organization. The annual membership is a share family representatives pay to enroll in the program making them owners / stockholders of the Bienestar Familia initiative. This means the longer a family has been a member of Bienestar Familia, the more shares the representative owns, becoming preeminent inside the organization. This will guarantee the renewal of memberships.

This implementation plan is intended to be a guideline of potential sequences broken down into 4 chronological phases. These are related to different types of resources available allowing us to identify at what stage Bienestar Familia is ready to expand through its affiliation medical network.

It is only possible when Bienestar Familia has achieved an important volume of patients (achieved through Fairies and family plans), an established flawless system information, and standardized care cycles for its patients.

From the implementation matrix, we were able to identify the phases that Bienestar needs to go through in order to become a replicable model. This replicable model adapts to different scenarios. Each scenario corresponds to a different type of healthcare provider even if stakeholders are in some cases the same. Each of these scenarios can be implemented once Bienestar Familia has reached all the phases of implementation.


3. Bienestar (brand) broadens scope of practice

Fairies Specific training / Specialization: Community Managers onsite and databaseand / or nursing

Pre-existing HealthcareProviders

Bienestar FamiliaStaff

Bienestar Familia Staff: Fairies; Management; Family Doctor; Specialists (pediatrician + internist); Nurses; Administrative Staff (call center + receptionist)+ Internships

Local Universities Experience: Fresh graduates get the opportuniy to be a part of a promising and innovative social network inside the healthcare sector

Principal resourcesAlternative sourceRisk associated

Government Caldas Social Business FundMicrofinanceRevenues from cardsRevenues from visitsRevenues from government health ministyRevenues from sponsors (ICT, pharmaceuticals and medical equipment companies)

Production Equipmentand Infrastructure

Integration: Bienestar’s Família Cards and System Information (data base with medical records) work flawlessly together

Phase

Resource

HU

MAN

RES

OURC

ESFI

NAN

CIAL

RES

OURC

ESM

ATER

IAL

RESO

URC

ES

Bienestar Familia’s Replicable Model Expansion Through Affiliate Network

Scenario Stakeholders Ownership Location

AOpen New Bienestar Familia Clinic

Social EntrepreneurDoctors / Specialists

The families (members) own the new clinic (community based ownership) - social business type 2

Analogue services

To be expanded in different areas

BOpen New Bienestar Familia Private Office

Doctors / SpecialistsYoung doctors

Doctors own their private office - social business type 1

Complementary services

To be expanded within the same area

CBienestar Familia On Wheels

Doctors / SpecialistsYoung doctors

Doctors own their private office - social business type 1

Complementary services (primary care emergencies)

To be expanded in urban, suburbs and rural areas


New Bienestar Familia Clinic New Bienestar Familia Private Office


New Bienestar Familia On Wheels

The Bienestar Familia Healthcare Network


Conclusion


As the public health system in Colombia is not able to provide adequate care delivery to the low income communities, the Bienestar team saw a promising area of opportunity to start a social business. Nevertheless, during the pilot phase, problems such as the sales and distribution of membership cards became more evident and the need to explore new solutions was essential for the continuity of Bienestar.

Bienestar Familia Healthcare Plan is the result of a design process, with the objective of developing a solution to the existing healthcare system in Colombia taking into consideration what Bienestar has already implemented.

Bienestar Familia focuses on improving the access of low-income families to high-quality healthcare by creating value for the whole community:

- Generation of new job opportunities for women and decreasing brain-drain of qualified local doctors.

- Empowerment of women by giving them sense of ownership and responsibility over the organization.

- Establishment of a community-based healthcare infrastructure through a local network that enables Bienestar Familia to provide other analogue services alongside the healthcare system.

At this point, Bienestar Familia is a prototype that needs to be tested. Taking into consideration the results gathered from the prototype phase, Bienestar Familia would then be ready to be implemented in Caldas, Colombia. If the model proves to be successful, a long term objective would be to adapt and replicate the model to fit in the specific context of different countries.

Conclusion


Bibliographic References

» Muhammad Yunus, Building Social Business: The New Kind of Capitalism that Serves Humanity s Most Pressing Needs (Pubblic Affairs , 2010)

» Erik Simanis and Stuart Hart, The Base of the Pyramid Protocol: Toward Next Generation Bop Strategy (second edition 2008)

» Business Model Generation: A Handbook for Visionaries, Game Changers and Challengers. Alexander Osterwalder and Yves Pigneur. Wiley, 2010.

» Richard J. Boland Jr. and Fred Collopy, Managing as Designing (Stanford Business Books, 2004)

» C.K. Prahalad, The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits (Pearson Prentice Hall, 2009)

» D.School Bootcamp Bootleg (Hasso Plattner Institute of Design at Stanford, 2009) accessed March 25th 2011, http://dschool.typepad.com/news/2009/12/the-bootcamp-bootleg-is-here.html

» Diana Quintero, Jorge Garcia and Felipe Tibocha, Bienestar Business Plan, 2011

» Simona Rocchi, “Philips Design Publication. Unlocking new markets via sustainable innovation and design breakthroughs: a few questions for innovation”, 2010 http://www.newscenter.philips.com/main/design/news/publications/philipsdesignpublication_unlocking_new_markets_pdesign_srocchi_230606.wpd

» Diana Pinto and Ana Lucia Munozs, Colombia: Sistema General de Seguridad Social en Salud, Estrategia de BID 2011-014, (Banco Interamericano de Desarrollo, 2010)

» Perfil Epidemiologico 2009 Villamaría, Caldas, Alcadia de Villamaria (Vigilancia En Salud Publica, 2009)

» IDEO, IDEO Toolkit, Accessed June 2011, http://www.ideo.com/work/human-centered-design-toolkit/

» The Next 4 Billion: Market Size and Business Strategy at the base of the Pyramid, (World Resources Institute and International Finance Corporation, 2007)

» Despacho del Gobernador, Caldas, Land of Contrasts, Grupo per la Reduccion de la Pobreza

» Wikipedia, accessed April 2011, http://es.wikipedia.org/wiki/Seguridad_social_de_Colombia

Bibliography

» SER System, accessed April 2011, http://www.sistemaser.org.ar/

» http://healthmarketinnovations.org/program/mothers-club%E2%80%9D-kendu-bay-sub-district-hospital

» “Grameen Creative Lab - passion for social business” , accesed March 2011, http://www.grameencreativelab.com/

» Medicos Generales Colombianos, http://www.medicosgeneralescolombianos.com/news.htm

» http://www.who.int/gho/countries/col.pdf

» “General System of Social Security in Health (Colombia)”, Center for Health Care Innovation, last updated Sep 27th 2011, http://healthmarketinnovations.org/program/general-system-of-social-security-in-health-colombia

» Asembis, Clinica de Especialidades Medicas, www.asembiscr.com

» “Millenium Development Goals” , UN World Health Organization (WHO), http://www.un.org/millenniumgoals

» “Data and Research”, The World Bank Group, http://www.worldbank.org

» “Data and statistics”, World Health Organization, http://www.who.int/en

101

Sanitation in the Indian Educational Context An Opportunity Analysis

Sanitation in Schools

106 - India · Sanitation in Schools - D4SB 107 107

Poverty in India remains a major issue where the country is estimated to have a third of the world’s poor, particularly in rural areas. In order to spread and accelerate the social business movement, GCL has expanded and launched its most recent office in Mumbai. In addition, the Yunus social business fund in Mumbai is currently under development in order to encourage the initiation of social business by providing adequate funding across all social sectors in India.

As the Design for Social Business team, our challenge in India was to identify opportunities that can lead to the improvement of sanitation, one of the country’s most pressing problems. With education being one of the most important channels for penetration, we focused our design research on schools in rural and urban areas around Mumbai for a better comprehension of the effects poor sanitation has on students’ attendance, dropout rates and overall health.

Why India?


TheIndianContext

111 111

India ProfileIndia in Numbers

Being the seventh biggest country by geographical area, the Independent Republic of India is the second most populous country in the world. With over 1.17 billion people (2010 est.), India is projected to be the world’s most populous country by 2025, with its population reaching 1.6 billion by 2050.

Rural and urban populations

Literacy rate (for people age 15

and above)

Poverty head count ratio at national poverty line

Capital City: New DehliIncome Level: Lower middle incomeGDP: $1,729,010,242,154 (2010 est.)GNI per Capita: $1,340 (2010 est.)

Total population in India1.2 billion

Total population in Europe852.4 million

Total population in the US320 million

29%urban 37%

illiterate

72.5%not poor

71%rural 63%

literate

27.5%poor


total population 1.2 billion

total population lacking access

to any kind of toilet638 million

rural population lacking access


total rural population 852 million

total population lacking access to any kind of toilet

638 million

rural population lacking access


Sanitation in India. An Overviewchildren under 5die annually due to diarrhea

only

of India’s wastewater is being treated


Culture and Religion

Muslim - 13.4%

Hindu - 80.5%

Others - 6.1%

Figure 3. The most common religions in India.

Understanding Sanitation

Sanitation is understood as providing facilities and services that ensure the safe disposal of human excreta (urine and feces), which are meant to avoid open space defecation. The lack of infrastructure combined with inadequate sanitation practices is a major cause of disease worldwide. Improving sanitation has proven to have a significant beneficial impact on health both in households and across communities. Sanitation also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal.

BRAHMINSPriests & Academics

KSHATRIYASWarriors & Kings

VAISHYASBusiness community

KSHUDRASServants, subordinate to Vaishyas,

Khastriyas & Brahmins

DALITUntouchables, subordinate to all,

responsible for all the lower-order work

Figure 4. The caste system in India

There are about 18 official languages in India with Hindi and English being the most spoken. Most of its population is Hindu followed by Muslims and other religions which include Sikhs and Christians among others.

India Caste System

The Hindu caste system hierarchically categorizes people based on their occupations where each person is born into an unalterable social status. The four primary castes are: Brahmin (the priests), Kshatriya (warriors and nobility), Vaisya (farmers, traders and artisans) and Shudra (tenant farmers and servants). The people born outside the caste system are called Dalits or “untouchables”. The outcastes’ occupations, regarded as impure, include butchering, rubbish removal and waste disposal.

Although today caste discrimination is officially illegal, it remains prevalent mostly in rural areas. The Indian government has made strong efforts in minimizing the significance of the caste system through expanding education and economic opportunity in the countryside.


» By increasing school attendance » By building community pride and social cohesion » By contributing to poverty eradication

Common Water and Sanitation Related Diseases Improved Sanitation

Sanitation Facilities and Practices

Among the inadequate sanitation practices, the one that poses the greatest threat to human health is open defecation. When talking about proper sanitation, water contamination cannot be excluded since in indiscriminate defecation, excreta often finds its way into sources of drinking water and food and is the root cause of faecal-oral transmission of diseases.

Unicef defines a list of common unimproved sanitation related diseases, which include: Diarrhea, Cholera, parasitic worms, Typhoid, and Dysentery among others. Diarrhea is the most important public health problem directly related to water and sanitation. About 4 billion cases of diarrhea per year cause 1.8 million deaths, over 90% of them (1.6 million) are among children under five.

Bush or field

Due to the absence of proper infrastructure, excreta is deposited on the ground and covered with a layer of earth, wrapped and thrown into garbage or defecation is done into surface water.

Bucket

Refers to the use of a container for the retention of faeces, urine and anal cleaning material, which are periodically removed for treatment, disposal, or used as fertilizer.

Hanging toilet / latrine

Refers to a toilet built over a body of water in which excreta drops directly.

Pit latrine

This facility uses a hole in the ground for excreta collection. In some cases, this kind of infrastructure may have a squatting slab or seat raised above the surrounding ground level to prevent surface water from entering the pit. An improvement in the infrastructure consists of a ventilation pipe that extends above the latrine roof and is covered fly-proof netting (Ventilated Improved Pit Latrine ‘VIP’).

Flush toilet

This kind of toilet uses a tank that flushes water and is sealed in order to prevent the passage of flies and odors (also called water seal). A pour flush toilet also uses a water seal, but in contrary to the normal flush toilet, it has no tank and uses water poured by hand for flushing.

Composting toilet

A dry toilet into which carbon-rich materials are added to the excreta which is kept in special conditions to produce inoffensive compost; it may or may not have a urine separation device.

Piped sewer system

Piped system and facilities (sewerage) that collect, pump, treat and dispose human excreta and wastewater and remove them from the household.

Septic tank

An excreta collection device consisting of a water-tight settling tank. Normally located underground, away from the house or toilet, the treated effluent of the tank usually seeps into the ground through a leaching pit or discharged into a sewerage system.

‘Improved’ sanitation facilities are those that reduce the chances of people coming into contact with human excreta and therefore becoming more sanitary than unimproved facilities. These include:

» Toilets that flush waste into a piped sewer. » Septic tank or pit. » Dry pit latrines constructed with a cover.

These kinds of facilities are only considered to be improved if they are private rather than shared with other households.

Some 2.6 billion people worldwide – two in five – do not have access to improved sanitation, and about 2 billion of these people live in rural areas. According to the United Nations, proper sanitation can foster social development, which at its core, is about human dignity and human rights. For the people who lack access to a proper infrastructure and practice open defecation, human dignity is under daily assault. A toilet can improve social development in a number of ways:

» By aiding progress toward gender equality » By promoting social inclusion

About 4 billion cases of diarrhea per year cause 1.8

million deaths, over 90% of them (1.6 million) are

among children under five.

Sanitation and the Millennium Development Goals (MDG)

One single gram of feces can contain:

10,000,000 viruses

1,000,000 bacteria

1,000 parasite cysts

100 parasite eggs

Table 1. Parasites found in one gram of feces.

Table 2. Differences between improved and unimproved sanitation facilities

Figure 5. Millennium Development Goal 7: Ensure Environmental Sustainability

What is an improved facility?

Improved Unimproved

Flush or pour flush to:

» piped sewer system » septic tank » pit latrine

Flush or pour flush to elsewhere.

Pit latrine without slab or open pit

Ventilated improved pit latrine (VIP)

Hanging pit or hanging latrine

Bucket

Composting toilet No facilities (bush or field); open defecation

Goal No. 7c. specifically states “Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation”. Which in this case would be considered as access to improved sanitation facilities.

Though proper sanitation has huge benefits in public health, gender equity, poverty reduction and economic growth, it is often a relatively low priority within the official development plans. Domestic budget allocations and official development assistance are often scarce, and

in many instances, interventions are not targeted to the population most in need.

At the current rate of progress, the world will miss the target of halving the proportion of people without access to basic sanitation. Though global sanitation coverage increased from 49% in 1990 to 59% in 2004. In 2008, an estimated 2.6 billion people around the world lacked access to an improved sanitation facility. If the trend continues, that number will grow to 2.7 billion by 2015.

Figure 5. Icons showcasing a Western style toilet and a Squat toilet that is more common in India.

Western style toilet with flush

Squat toilet


water resources are polluted, and 80% of the pollution is due to sewage alone.

Diarrhea accounts for almost one fifth of all deaths (or nearly 535,000 annually) among Indian children under 5 years. Also, rampant worm infestation and repeated diarrhea episodes result in widespread childhood malnutrition. Due to this problem, India is losing billions of dollars each year. Illnesses are costly to families, and to the economy as a whole in terms of productivity losses and expenditures on medicines, health care, and funerals. The economic toll is also apparent in terms of water treatment costs, losses in fisheries production and tourism, and welfare impacts, such as reduced school attendance, inconvenience, wasted time, and lack of privacy and security for women.

Major factors that have impeded effective implementation of a rural sanitation program include very low priority given to sanitation as a social and community issue, lack of infrastructure and systems to reach all rural households, and most importantly, scarcity of water.

Sanitation in India

It is estimated that 55% of all Indians (638 million) still lack access to any

kind of toilet. Of this total, people who live in urban slums and rural

environments are a¦ected the most. In rural areas, the scale of the

problem is particularly daunting, as 74% of the rural population

still defecates in the open.

India Sanitation in Numbers

Only 31% of India’s population use improved sanitation (2008)

In rural India 21% use improved sanitation facilities (2008)

145 million people in rural India gained access to improved sanitation between 1990-2008

211 million people gained access to improved sanitation in whole of India between 1990-2008

India is home to 638 million people defecating in the open; over 50% of the population.

Table 3. India sanitation landscape in numbers.

India seems to be lagging behind MDG target values in almost all the parameters under consideration. Human development hence remains to be an area of concern. Education and health are the critical areas and we continue to be distant from the targeted goals. Infant and child mortality, undernourished population, as well as maternal mortality are specific areas where much still needs to be achieved. Even though the overall access to improved sanitation facilities has increased, the gap between rural and urban areas is still very high.

It is estimated that 55% of all Indians (638 million) still lack access to any kind of toilet. Of this total, people who live in urban slums and rural environments are affected the most. In rural areas, the scale of the problem is particularly daunting, as 74% of the rural population still defecates in the open.

In both environments, cash income is very low and the idea of building a facility for defecation inside or near the house may not seem natural. Where facilities do exist, they are often inadequate. The sanitation landscape in India is still littered with 13 million unsanitary bucket latrines, which require scavengers to conduct house-to-house excreta collection. Over 700,000 Indians still make their living this way.

The situation in urban areas is not as critical in terms of scale, but the sanitation problems in crowded environments are typically more serious and immediate. In these areas, the main challenge is to ensure safe environmental sanitation. Even in areas where households have toilets, the contents of bucket-latrines and pits, even of sewers, are often emptied without regard for environmental and health considerations.

Sewerage systems, if available, suffer from poor maintenance, which leads to overflows of raw sewage. Today, with more than 20 Indian cities with populations of more than 1 million people, the antiquated sewerage systems cannot handle the increased load of wastewater. These cities include Indian megacities, such as Kolkata, Mumbai, and New Delhi. In New Delhi alone, existing sewers originally built to serve a population of only 3 million cannot manage the wastewater produced daily by the city’s present inhabitants, now close to a massive 14 million.

The capacity for treating wastewater is also acutely inadequate, as India has neither enough water to flush-out city effluents nor enough money to set up sewage treatment plants. In 2003, it was estimated that only 30% of India’s wastewater was being treated. Much of the rest—amounting to millions of liters daily— find its way into local rivers and streams. According to the country’s Tenth Five-Year Plan, three-fourths of India’s surface

India and the Millennium Development Goals (MDG)

Goal Indicator Value(Year)

MDG target

Proportion of population below poverty line (%) 27.5(2005)

18.75

Undernourished people as in % of population 76(2005)

31.1

Proportion of undernourished children 46(2006)

27.4

Ratio of girls to boys in primary education 0.94(2007)

1

Literacy rate of 15 - 24 year olds 82.1(2007)

100

Ratio of girls to boys in secondary education 0.82(2007)

1

Under five mortality rate (per 1,000 live births)

74.6(2006)

41

Infant mortality rate (per 1,000 live births)

53(2008)

27

Maternal mortality rate (per 100,000 live births)

254(2006)

109

Rural population with sustainable access to an improved water source (%)

79.6(2008)

80.5

Urban population with sustainable access to an improved water source (%)

95.0(2008)

94

Rural population with access to sanitation (%)

44.0(2008)

72

Urban population with access to sanitation (%)

81(2008)

72

Deaths due to malaria per 100,000 2(2008)

-

Deaths due to TB per 100,000 23(2009)

-

Deaths due to HIV/AIDS 170,000(2009)

-

Table 4. Progress towards achieving MDGs in India with goals related to sanitation highlighted in gray.


The Indian government provides free and compulsory education for all children up to the age of 14. The country is still grappling with serious problems of inadequate access, quality and inefficiency in the schooling system.

The school system in India works through 3 different models:

» Public » Private » Public Private Partnership (PPP)

Public private partnership (PPP) is an approach used by the government to deliver quality services to its population by using the expertise of the private sector. In this arrangement, a private party performs part of the service delivery functions of the government while assuming associated risks. In return, the private party receives a fee from the government according to pre-determined performance criteria. Such payment may come out of the user charges, through the government budget or a combination of both. Broadly, PPP in school education can operate to provide (1) infrastructural services, (2) support services and (3) educational services. The simplest being one in which the private partner provides infrastructure services but the government provides educational and other support services. The second type is where the private sector provides both infrastructure and support services. While the third type is where the private sector provides infrastructure, support and educational services bundled together.

A variety of public private partnership already exists in the field of education, the most common being the government aided schools system in the country. In 2006-07, 30.05% of higher secondary schools and junior colleges, 27.15% of high schools, 6.75% of upper-primary schools, 3.19% of primary schools and 5.15% of pre-primary schools were run by private institutions with substantial financial assistance from the State Government.

Alliances with different NGO’s also play a strong role in assisting the State or the private sector to complement the education system and to improve its effectiveness. The effectiveness of NGO action is best in evidence in the successful schooling of underprivileged children, communities in remote locations, scheduled caste, scheduled tribe and other children that face social barriers to education.

One of the key challenges of the education system in India is the universalization of good quality basic education. Almost two decades of basic education programs have expanded access to schools in India. The number of out of school children decreased from 25 million in 2003 to an estimated 8.1 million in 2009. Most of those still not enrolled are from marginalized social groups. Two issues remain:

» Reaching some 8 million children not yet enrolled and ensuring retention of all students till they complete their elementary education (8th standard).

» Ensuring education is of good quality so it improves learning levels and cognitive skills. » Also, India still faces challenges in providing quality Early Childhood Development programs for all

children.

The Education System In India Water, Sanitation & Hygiene in Schools

Unsafe water and unhygienic conditions not only have an adverse effect on the health of below five year old children but also have an impact on the health, attendance and learning capacities of school children.

The Plan of Implementation of the World Summit on Sustainable Development in 2002 emphasized sanitation in schools as a priority action, while the Thirteenth Session of the United Nations Commission on Sustainable Development in 2005 reiterated this position and also emphasized the need for hygiene education in schools. Providing adequate water and sanitation in schools is essential if the enrollment, learning and retention of girls is to improve, and is key to meeting MDGs 2 and 3. Lack of appropriately private and sanitary facilities has a greater impact on girls than boys, contributing to decisions on whether they ever attend, and then influencing how long they stay in school. Girls sometimes do not attend school during menstruation or drop out at puberty because of a lack of sanitation facilities that are separate for girls and boys. In addition, adolescent girls are particularly at risk of anaemia aggravated by parasitic infections and ‘iron stress’ when sanitation is inadequate or unavailable at school or at home.

All children perform better and have enhanced self-esteem in a clean, hygienic environment. Properly used and maintained sanitation facilities and an adequate supply of water for personal hygiene and hand washing prevent infections and infestations, while also contributing to overall public health and environmental protection. Programs that combine improved sanitation and hand-washing facilities with hygiene education in schools can improve the health of children for life and can promote positive change in communities. Field assessments show that teaching children the importance of hand washing and other good hygiene habits promotes increased knowledge and positive behavior change, especially when the schools are equipped with an adequate number of safe toilets or latrines and sufficient water for washing.

Adolescent girls are particularly at risk of anaemia aggravated by parasitic infections and ‘iron stress’ when sanitation is inadequate

or unavailable at school or at home.


The Jamshedpur Utilities and Services Company

Benchmarks

Community-Led Total Sanitation (CLTS)

WASH in Schools

Guardian Microfinance Institution

“Community-Led Total Sanitation (CLTS) is an innovative approach for mobilizing communities to build their own toilets and stop open defecation”.

The CLTS approach recognizes that merely building infrastructure and providing toilets does not ensure their usage within a community and often leads to the dependency of these communities on subsidies. Therefore, CLTS focuses on “the behavioral change needed to ensure real and sustainable improvements” by raising awareness, triggering desire for change and supporting communities in taking action and ownership over appropriate local solutions to become open defecation free.

Water, Sanitation and Hygiene education in schools (WASH in Schools) is a program for schools within a community that seeks to implement hygiene education in order to enhance the well-being of children and their families.

Call to Action for WASH in Schools 2010 is the result of collaboration between UNICEF and several international partners supporting WASH in Schools programming. It calls on decision makers to increase investments and on concerned stakeholders to plan and act in cooperation so that all children go to a school with child-friendly water sanitation and hygiene facilities.

Gramalaya Urban and Rural Development Initiatives and Network (GUARDIAN) is a microfinance institution (MFI) and a not for profit institution established in 2007 for providing microcredit to the urban and rural poor in order to create household infrastructures on water and toilets.

With the support of nationalized banks, communities, NGO and donor agencies and through women self help groups (SHG) and women joint liability groups (JLG), Guardian is capable of lending credit to the poorer communities for the promotion of water and toilet facilities.

The Jamshedpur Utilities and Services Company (JUSCO) sets the example for a one-stop integrated urban water system management under a corporate framework. The services cover operation and maintenance of the entire water cycle and include intake, treatment, transportation and distribution of water. In addition, JUSCO maintains a ‘river-to-river’ management through the treatment of wastewater that meets international effluent quality standards.

Many initiatives aiming to improve water supply and sanitation have been tested and applied in India. These include:


Project Goal:Identify opportunity spaces for improving sanitation within the educational sector in India.


Observation


India Trip Program (16th - 26th August)Monday Tuesday Wednesday Thursday Friday Saturday Sunday

15 16 17 18 19 20 21

Arrive to Mumbai Introductions D4SB and GCL India at The Hub

Leave Mumbai to Satara

School visit #1- Dyan Uday School

School visit #2- Adarsh Vidyalaya

School visit #3- Karamveer Bhaurao Patil Vidyalaya

School visit #4- Bhagvan Mahavir Adarsh Vidyalaya

School visit #5- Madhyamik Vidyalaya

Leave Satara back to Mumbai

22 23 24 25 26 27 28

Visit to Sulabh toilet blocks

Teach for India visit

School visit #6- Holy Mother English School

School visit #7- The Divine Child

Community Visit

Chehak Trust visit

School visit #8- Sahyog School in Jari Mari Slum

Sparc visit

Dharavi slum visit

Hub event - a get together with representatives of the social scene in India

The India Field Research Program

For a better comprehension of the sanitation problem in India, we planned our field trip to Mumbai for an intensive 2 week stay of research and observation. Through understanding the context of one of the most pressing problems in India, the problem of sanitation, our objective was to identify opportunity spaces for improving sanitation within the educational sector.

The excursion started off at the rural area of Satara, a city located in Satara District of Maharashtra state of India. We visited 5 schools, talked with the students, teachers, principals, visited their facilities and discussed their problems and needs. After Satara, we headed back to Mumbai, where we got to compare and contrase the differences between the rural and urban areas. We visited several slums in Mumbai and talked with school students, teachers, principals, community leaders, and community members. In addition, we met several NGO’s and organizations that are working on the sanitation problems in India to better understand what is already being implemented.

The following section will describe some of the findings revealed from the interviews and activities that we conducted.

The Rural Area

Table 5. The schedule of our 2 week research in India.


Adarsh Vidyalaya - RahimatpurDyan Uday School - Satara


Bhagvan Mahavir Adarsh Vidyalaya - ThosegarKaranveer Bahurao Patil Vidyalaya - Dhamner


Madhyamik Vidyalaya - Bassappachi Wadi

School General Information

Name of School School Area

School Region

School Mgmnt.

Tuition Fee

School Type

School Level

Midday meals

# of students

# of teachers

1. Dyan Uday School

Rural Satara PPP (receives grants to pay teachers & meals)

Free Mixed, day school (11am-5pm)

Secondary (5th to 10th std.)

Yes, for 5th to 8th std.

160 students (100 boys, 60 girls)

5

2. Adarsh Vidyalaya

Rural Rahimatpur PPP(receives grants to pay teachers & meals)

- Mixed, day school (11am-5pm)

Primary to Secondary (1st to 10th std.)


1500 students

-

3. Karamveer Bhaurao Patil Vidyalaya

Rural Dhamner Public Free Mixed, day school (11am-5pm)


No 300 students (100 boys, 200 girls)

15

4. Bhagvan Mahavir Adarsh Vidyalaya

Rural Thoseghar PPP(receives grants to pay teachers & meals)

Av. 5 Rs./month (depending on cast & level of poverty)

Mixed, day school (11am-5pm)



265 students

-

5. Madhyamik Vidyalaya

Rural Bassappachi Wadi

Public (non-granted school)

Free Mixed, day school (11am-5pm)


Yes 40 students(25 boys and 15 girls)

5

Rural Schools General Information

Table 6. General information from the rural schools visited in Satara.


On Sanitation


School Sanitation InformationLight inside toilet? Which source?

Hand washing facilities on site?

Soap? Drinking water facilities?

Toilets cleaning schedule? By whom?

Is hygiene taught? How?

No, only natural light (the closed toilet is totally dark)

No No No Once a month by a cleaning lady

Yes, it a new program for the 8th std. It is considered a delicate subject

No, only natural light No No Yes Once a day with only water, once a week with disinfectant

Yes, from 7th to 9th standard, women from public centers visits school for hygiene and sexual education

No No No No - No

Yes, windows and artificial lighting

Yes (sinks within each bathroom)

No Yes (one in every floor) Bathrooms are cleaned after the 2 daily breaks and disinfected once a week by 3 male janitors. Naftaline is used in the facilities to keep insects away

Yes, through several boards around the school and lessons

No, urinating facilities are out on the open and squat toilet has a small window

No No Yes The students clean the toilets daily, each class is responsible for one day of the week

Yes, through lessons

School Sanitation InformationSchool Name Toilets inside school Separate toilets for

boys and girls?How many toilets? Indoor or outdoor? Closed or open?

Teachers have separate toilets?

Water for flushing inside toilet (tap)?

Is the (alternative) water source close to the toilet area?

1. Dyan Uday School

Yes Yes girls: 3 outdoor, open, 1 outooor, closed

Yes No, they have to get water with a bucket from a tank

No, it is inside the school, but away from the toilet area

2. Adarsh Vidyalaya

Yes Yes girls: 3 outdoor, open (for urination), 1 outdoor, closed (for defecation) boys: outdoor, open (wall for urination) and 1 outdoor, closed squat toilet (defecation)

No, they use the locked toilet

No, they have to get water with a bucket from a tank

No, it is inside the school, but away from the toilet area

3. Karamveer Bhaurao Patil Vidyalaya

Yes Yes girls: outdoor, open facilities (for urination & defecating) boys: outdoor, open facilities (for urination & defecating)

No No, they have to get water with a bucket from a tank

No

4. Bhagvan Mahavir Adarsh Vidyalaya

Yes Yes girls: 3 squat toilets (indoor, closed) in each of the 3 floors. boys: 3 urinals (indoor, open, separated by walls) and one squat toilet (indoor, closed) in each of the 3 floors

No Not at the time of visit, problems with the water system

Yes

5. Madhyamik Vidyalaya

Yes Yes girls: 3 urinating units (outdoor, open) and 1 squat toilet (outdoor, closed) boys: 3 urinating units (outdoor, open) and 1 squat toilet (outdoor, closed) 1 handicapped toilet

No No, water comes from a separate tank

No

Rural Schools Sanitation Information

Table 7. Information related to sanitation gathered from the rural schools visited in Satara.


Activities Conducted with the Children

School Interviews Additional Notes

One of the bigger schools was funded by the Empathy Foundation of Mumbai. The fund of the trust is managed by a series of business men that give the funding and donations for the construction of different schools (charity model). The money is given to the contractors (1 time deal) which have to build the school and maintain it for 4 years.

In terms of infrastructure, the school had very good interior toilet facilities, one compartment on each of the 3 floors, yet non functional due to a problem in the water pump. Therefore, since 3 months before the time of visit, students had been urinating in the open.

According to the principal of that same school, the number of toilets on site are decided by the government which also provides material for cleaning. According to the government, there should be one toilet seat for every 20 students.

Another school had very poor conditions of their exterior toilet compartment, with lots of worms. The students avoid using the toilets at school and prefer to either wait all day or go to their houses.

Girls usually go to the toilet with a friend to keep an eye. They usually go to the toilet 3 times a day, but a couple of them mentioned that they wait to go home.

One of the schools was started by a trust but the staff salary is not given by the government. They do not have a building. They use a building from another school that was constructed by the government.

During our school visits, we interviewed male and female students of various ages. Due to the sensitivity of the topic being dealt with, we conducted some drawing activities and exercises in order to facilitate the discussion.

We asked the students to:

» Rate from 1 to 10 their toilets at home and at school. » Draw their ideal toilet and its components. » List in order of priority the 5 most essential elements that should be in a toilet. » Enlist the five things that bother them the most of the actual infrastructure.

Drawings From the Activities


Water, Sanitation & Hygiene in Schools - Boys Water, Sanitation & Hygiene in Schools - Girls

“In my previous school, there were no toilets so we had to go in the open, behind a bush or close to the river. We would also go nearby the houses when people were away. The students that lived close to the school would go home to use the toilet”.

Deepali - 15 years old, 10th standard

“I hate the garbage surrounding the toilets in my school”.

Aniket - 13 years old, 8th standard

“Even though we have to clean our own toilets at school, I don’t mind it because at least I’m doing it with my friends and not alone”.

Ashurni -14 years old, 9th standard

“What I don’t like in my school’s toilets is that there is no soap to wash my hands after using it”.

Gaurav -11 years old, 7th standard

“When I have my period, I find it difficult to find a place where I can dispose my pad. Sometimes I go home to change but then I don’t come back to school”.

Shaavari - 11 years old, 6th standard

“I don’t like my school’s toilets because they smell so bad. There are no doors or windows”.

Chaitanya - 12 years old, 6th standard

“I feel uncomfortable to use the toilet when I have my period, but I have no other choice”.

Priyanka - 14 years old, 9th standard

“I don’t like it when dogs come into the school’s toilet while I’m using it”.

Akshay - 13 years old, 8th standard


Sanitation Priorities and Desires Toilet Infrastructure Problems

Most Desired Elements in a ToiletSchool Name Dyan

Uday SchoolAdarsh Vidyalaya

Karamveer Bhaurao Patil Vidyalaya

Bhagvan Mahavir Adarsh Vidyalaya

Madhyamik Vidyalaya

Total

Infrastructure Item girls (9)

boys (0)

girls (15)

boys (11)

girls (10)

boys (10)

girls (8)

boys (8)

girls (7)

boys (6)

girls boys girls + boys

enclosed compartment 9 . 10 . 6 5 8 8 7 6 40 19 59

water tap 9 . 13 . 7 4 4 8 7 5 40 17 57

handwash / soap 7 . 14 . 7 5 6 4 6 5 40 14 54

door 7 . 10 . 6 5 8 3 0 4 31 12 43

squat toilet 4 . 10 . 6 2 5 4 0 4 25 10 35

sink / basin 3 . 12 . 6 4 7 2 0 1 28 7 35

mirror 1 . 10 . 4 2 8 1 7 0 30 3 33

bucket / mug 7 . 2 . 2 2 4 7 5 2 20 11 31

window 4 . 2 . 0 3 8 1 7 5 21 9 30

light 0 . 7 . 4 0 8 2 5 2 24 4 28

water tank 4 . 7 . 3 1 0 1 2 5 16 7 23

towels / tissue paper 0 . 5 . 4 2 2 1 1 5 12 8 20

brush / broom 1 . 0 . 0 3 5 0 4 0 10 3 13

stairs (elevated) 3 . 1 . 0 1 2 0 3 2 9 3 12

dust bin 0 . 7 . 0 3 1 0 1 0 9 3 12

disinfectants 0 . 0 . 0 4 5 0 3 0 8 4 12

drinking water tank 0 . 0 . 0 5 0 0 0 0 0 5 5

flooring 0 . 0 . 0 0 0 0 0 4 0 4 4

hangers 0 . 3 . 0 0 0 0 0 0 3 0 3

urinals 0 . 0 . 0 0 0 1 0 0 0 1 1

doormat 0 . 0 . 0 0 0 1 0 0 0 1 1

Table 8. The items that the rural students listed in the exercise of what, in their opinion, are the most essential elements a toilet should have.

Smelly Dirty Dark

Invasive

Damaged Uncomfortable

leaking roofs

damaged tiles

Figure 7. The most common problems within the toilet facilities listed by the students.


The Urban Area

“For the people of Jogeshwari a void room in a big city is a greater horror than open gutters and filthy toilets”.

Suketu MehtaMaximum city


SULABH International

Sulabh International is a not for profit organization that works to improve the state of sanitation access through developing facilities and educational programs. One of the main goals of Sulabh is to implement affordable sanitation in order to liberate scavengers, the outcastes responsible for cleaning latrines, and ensure them social integration.

The pay-and-use Sulabh public toilet facilities are usually located in public commercial areas where they charge a small fee for users in order to cover maintenance expenses and recover capital investments. The Sulabh toilet blocks that we visited had separate compartments for men and woman, water and soap access in addition to an attendant that receives the payments.

*Despite the absence of a shower, women would bath and wash clothes using a tap close to the floor (seated)

Toilet Block Information

Toilet Block

Management toilet block?

Cost per use?

Separate toilets for men and women?

Open or closed?

How many toilet seats are there (men/women, urinals/seats)?

Water for flusing inside toilet?

Shower? Hand washing facilities on site?

Soap? Light inside toilet? Source?

Workers in the complex?

Toilet cleaning schedule? By who?

Additional notes

Sulabh Toilet Block #1

Built and maintained by SULABH It works like a private company

Urinals are free. Squat toilets and showers: 2 INR

Yes Closed Men: 6 urinals / 7 seats / 1 shower Women: 3 squat toilets / 1 water basin

Yes Yes Yes Yes Yes, neon lights

3 people. 1 cashier at the entrance and 2 cleaners

Continuous cleaning by employees

No facilities for handicapped




Yes Closed Men: urinals 0 / 6 seats / 1 shower Women: 3 squat toilets (no shower faciltity but tap and bucket to shower)

Yes No* Yes Yes Yes, neon lights

2 people. 1 cashier at the entrance and 1 cleaner


No facilities for handicapped




Yes Closed Men: urinals 0 / 6 seats / 1 seat toilet for handicap / 2 showers Women: 5 squat toilets / 1 seat toilet with rail for handicap


3 people. 1 cashier at the entrance and 2 cleaners


Toilet block with air-conditioner.Urinating facilities outside the main structure

Toilet Block 1 Toilet Block 2 Toilet Block 3

Table 9. Information related to Sulabh public toilet blocks in Mumbai.


Teach 4 India

Teach for India, a project of the not for profit organization Teach to Lead, is a nationwide movement whose goal is to eliminate educational inequity in the country. It believes that through a movement of outstanding college graduates and young professionals committed to a 2-year full time teaching in under resourced schools, the country will be able to achieve educational equity for children. Teach for India provides the adequate resources, training and support to the teachers, called Fellows, in order to employ innovative teaching strategies and maximize their effectiveness in the classroom. The movement’s objective in the long run is to have a strong leadership force of alumni who regardless of their career path after their 2 years of service, will work together toward eradicating educational inequity in India.

For the interviews we focused on two schools located in the slums of the rural area; Holy Mother English School in Malwani and The Divine Child in Patham Wadi, Malad East. We also had the opportunity to visit three households of three of their students (Anwar, Akram and Tilak). For our interviews we chose the following profiles: teachers, principal, student families and community members.

Holy Mother English School The Divine Child

School General Information

School Name School Area

School Region

SchoolMgmnt.

Tuition Fee

School Type

School Level

Midday meals

# of students

# of teachers

Holy Mother English School Urban Malwani, Mumbai

Private, board of 7 trustees

150 INR (Free for disabled & orphans)

Mixed day school (morning & afternoon shifts of variable duration)

Kindergarten (Junior &

Senior)

Primary & Secondary (1st to 9th std.)

No 707 students

26 (4 TFI fellows)

The Divine Child Urban Pathan Wadi, Mumbai

Private school, unaided

500 INR per month per student

English day school, mixed

- No 800 students

26 (5 TFI fellows)

School Sanitation InformationSchool Name Toilets

inside school?

Separate toilets for girls and boys?

How many toilets? Indoor or outdoor? Closed or open?




Light inside toilet? Which source?



Toilet cleaning schedule? By whom?


Holy Mother English School

Yes Yes girls 1 boys 1

No Yes Yes Yes, there is a light bulb in the girls toilet

No, students use the tap inside the toilet

No Yes - Yes, it a new program for the 8th std. It is considered a delicate subject

The Divine Child Yes Yes girls: 1 squat toilet (indoor, closed)

boys: 3 urinals (indoor, open)

Yes No Close to the girls’ toilet but not the boys

No, only natural light

Yes, wash basins on ground floor

No - - -

Table 10. General information from the urban schools visited in Mumbai.

Table 11. Information related to sanitation gathered from the urban schools visited in Mumbai.


Prabhavati Prajapati, 35 years old, from Nepal married to a man from Nepal who sells plastic in Mumbai. She is Hindu, and has 4 children, 3 boys and 1 girl and they all live together in their 12m2 house.

She and her husband moved from Nepal 6 to 7 years ago for employment in Mumbai. They find the life difficult in the city but nonetheless better than Nepal. After coming to Mumbai, she learned more about toilets. In Nepal, they did not have toilets, they would go out in nature. Prabhavati never studied but she is proud that her son goes to school and understands things much better than she does. Her husband studied up until the 8th standard and her son, Tilak, is currently in the 4th standard at The Divine Child school and wants to study up until the ‘last standard’. He is the eldest in the family and wants to become a cricket player.

From 8:00 am to 1:00 pm the Prajapati family has access to potable water from the tap in the bathroom. They have 4 buckets on the side to fill up with water. Prabhavati showed us how she makes a filter manually by tying a cloth around the hose that is linked to the tap. The water coming out of the hose and through the cloth becomes ‘drinkable water’.

The house is a single room, with one bed, one stove and a little ‘bathroom’ with a tap used to shower and wash the utensils. There are no toilets in the house, the public toilets are outside and she goes once a day to the toilet. If she needs to use it at night, her husband accompanies her. They pay 10 INR/month for 24-hour access to the toilet. Her children use the toilets at school since they are cleaner than the public ones in the community.

She would like the public toilets to be clean. Even though the people from the municipality clean the toilets, she doesn’t think they do it well.

They have a TV in their well-kept and clean house, hung diagonally over the bed. The bed is covered with a plastic cover since she also uses it to change her baby’s diapers.

She loves to watch family series on the TV alone and with friends, and in her free time, she gets together with her friends to talk about what they cooked and their favorite TV series.

She would like to have a toilet at home because then she is in control of the cleanliness and hygiene.

It is too difficult for her to choose what her favorite part of the house is because she likes all of it but perhaps the little shrine close to the entrance is closest to her heart.

Anwar is 6 years old and lives with his parents in his house in Malwani. He is in the 2nd standard at the Holy Mother English School and enjoys playing cricket and badminton after school.

Anwar’s house has one main room around 10m2 used as the living, sleeping and cooking space and another small room used for washing and bathing. There is also an additional back room used for storage. The house is also used as the work space for their family business of packaging bracelet boxes.

Near their home, there is a common tap that has running water daily from 5:00 am to 7:00 pm. Each family can gain 10 minute access per day to the tap for a fee of 250 rupees per month. Within the 10 minutes, community members connect a hose to the tap and fill up big tanks to store the water needed for the day.

Akram is 9 years old and is in the 2nd standard at the Holy Mother English School. He lives with his parents and 4 siblings in their house in Malwani.

Akram’s father is a cook in a catering company while his mother looks after the children. Their house constitutes of a main room of about 13m2 used as the living, sleeping and cooking room in addition to a smaller area around 1m2 used for washing and bathing.

Akram’s family uses the communal toilet blocks located about 200m away from the house. The toilet block has 6 compartments and serves around 10 to 15 households, approximately 75 people in total. The peak hours to use the toilet blocks are usually from 7:00 am to 10:00 am when one have to queue to get in. The toilet block does not have separate compartments for men and women and no taps with running water so families have to bring their own water in buckets. The access to the toilet block is free but the communities have to provide the soap and cleaning products in return. Someone from the municipality cleans the block once or twice a week but in general they are not well maintained. Many fights break out in the morning due to members not throwing water after using the toilets.

Prabhavati Prajapati. The Story of a Slum Household Anwar and his Family. Storing Water.

Akram’s Family. Sharing the Toilet.


Chehak Trust

Schools General Info

School Name School Area

School Region

SchoolMgmnt.

Tuition Fee

School Type

School Level

Midday meals

# of students

# of teachers

Sahyog Girls’ School Urban Jari Mari, Mumbai

Private school funded by Chehak Trust

Free Girl school, afternoon (1pm-6pm)

4 levels based on knowledge and skills (age range 15 to 21 years old)

No 25 students

3

Table 14. Information related to sanitation from Sahyog Girls’ School.

Table 13. General information from Sahyog Girls’ School.

Sahyog is a community based education and health initiative of the CHEHAK TRUST that works in two slum areas of Mumbai, Jari Mari: Kurla and Dindoshi, Goregaon.

Its activities are mainly focused on improving access to healthcare and education by collaborating with existing organizations and raising community awareness. One of Sahyog’s initiatives is an education program for adolescent girls who have either never been to school or have dropped out from a previous school. The objective is to empower these girls with a set of skills adequate to lead a better life. The education program is free of charge and requires an admission test in order to place the girls in the appropriate level based on their skills and knowledge rather than their age. In addition to academic skills, the teaching methodology focuses on daily life experiences and community work that enable the girls to develop confidence and understanding of their rights. Sahyog also attempts to build relationships with the families in order to support the girls’ role in the community.

“I give 10/10 for our toilet in school because it is very clean. I give the community public toilet 7/10 in the morning when it is still clean and 2/10 in the evening because it becomes very dirty”.

Alfrin - 16 years old, Sahyog Girls School

Most Desired Elements in a Toilet

InfrastructureElements

# of Times Mentioned(11 girls)

enclosed compartment 10

squat toilet 10

flooring 9

bucket / mug 8

water tap 5

door 4

stairs (elevated) 3

handwash / soap 1

western toilet 1

“I don’t like it when toilets are dirty and smelly and specially not when there are insects and cobwebs!”

Yasmin -16 years old, Sahyog Girls School

Figure 8. The main problems the students from Sahyog Girls’ School experienced in public toilet facilities.

Table 12. The items that the female students from Sahyog School listed in the exercise of what, in their opinion, are the most essential elements a toilet should have.

Schools Sanitation InfoSchool Name Toilets

inside school?

Separate toilets for girls and boys?

How many toilets? Indoor or outdoor? Closed or open?




Light inside toilet? Which source?



Toilet cleaning schedule? By whom?


Sahyog Girls’ School

Yes girl school

girls: 1 squat toilet indoor, closed (for urination)

No Yes Yes Yes, light bulb

Yes, wash basin

Yes no Once a day by cleaner

Yes, as part of the Life skills program

Animals & Insects Smell Dirtiness

Privacy Location

shared compartments

spit



Toilet Block


Cost per use?


Open or closed?







Additional notes

Sahyog Toilet Block

Funded by BombayMunicipalCorp. (public

toilet)

Mgmnt. JaiMaharashtraSeva Trust/Group

Urinals are free. Squat toilets: 2 INR

Yes Closed Men: 3 urinals / 6 seats

Some are working

No No No Yes, 1 neon light

1 cashier at the entrance

Not veryoften, theyare very dirty

Facilities in very bad condition

Table 15. Information related to the Sahyog public toilet block.


The Society for the Promotion of Area Resource Centers (SPARC)

The Society for the Promotion of Area Resource Centrers (SPARC) is an NGO that supports the National Slum Dwellers Federation and Mahila Milan in bringing the urban poor together in order to express their concerns and corroboratively seek solutions to the problems they face. Together, these organizations form an alliance which works to improve the lives of slum dwellers in India and around the world through the production of urban development practices and policies. These community-driven practices are focused on building the capacity of organized communities of the urban poor, especially women, in informal settlements to stop forced evictions and develop adequate negotiation skills on their rights for housing, land and basic infrastructure.

We visited one of the Community Based Organizations (CBO’s) of the Dharavi Slum and a toilet block in the neighborhood.


Toilet Block


Cost per use?


Open or closed?







Additional notes

Dharavi Toilet Block

Fundedby WorldBank.Managed& maintainedby the community

Urinals are free.Squattoilets:0.5 INR20 INR perfamily /month

Yes Closed Men: 20 squat toilets Women: 20 squat toilets


1 person (caretaker)

3 times/day: morning, lunch, night

Separate area for children

Table 16. Information related to the Dharavi public toilet block.


Ashansh

Aashansh is a charity-run organization that gives free complementary school support for the children from the Adarsh Megar community. The community is that of pavement dwellers that live with 30/40 rupees a day. Most of the children’s families are fishermen, gamblers or drug dealers. The organization, founded by Ramesh Joshi, an ex-pavement dweller himself, aims at removing children from the streets by providing them with fun education and activities during the evenings in a rented room from a nearby school. We had the opportunity to speak to Ramesh and get to know some of the children that belong to the NGO.

“Education has changed my life”.Ramesh Joshi


Perceptions and Behaviors

Boys

In India, it is not uncommon to not use toilet paper. Toilets in general have access to water, whether in a bucket or through a hose, for cleaning purposes after defecation. As a result, the waste bin is not a common element in toilets either.

Most of the time the urinating facilities for boys are a simple infrastructure on the open (a wall or similar) and in case it is inexistent, it is done in the open.

Defecating facilities are almost always shared the by the entire school and in most cases there is just one.

As for the boys the main issues regarding sanitation are privacy and hygiene. By hygiene we mean maintenance of the toilet facilities as well as access to personal hygiene goods (hand soap, water taps).

Girls

In most of the schools we visited, the toilets for urinating are outside and open with full-time access whereas the toilets used for defecating are locked in order to avoid constant usage and maintain cleanliness. The students need to ask the janitor for the key whenever they need to use it. Therefore, many students avoid using it so as not to go through the hassle of finding the janitor, asking for the key then bringing the key back.

Some of the girls that are on their menstrual cycle avoid coming to school during that period. Some girls that do attend school during their cycle avoid changing pads all day until they get home. Others do change the pad in school but make sure to dispose it away in nature because it is ‘inappropriate’ to dispose it within school territories. The same applies for the female teachers.

Many girls avoid using the toilets in school by making sure they use it at home before leaving and by drinking less fluids during the day. This means an average of 6 hours/day without urinating.

In the schools with toilets in the open, girls usually go with a friend because they are scared of monkeys and snakes.


Synthesis


Problems Related to Toilet Usage

Problems Privacy Hygiene Maintenance Security

Girls Girls avoid using locked toilets for defecating to avoid hassle of asking for, bringing and returning keys X

Girls in menstrual cycle have higher level of absenteeism due to lack of proper facilities X

Girls have difficulties in finding where to dispose pads properly while in school X

Girls go to toilets in the open with friends because they are scared of animals X

Girls feel lack of privacy using toilets at school (open facilities, broken doors...) X

Girls prefer going home to use the toilet rather than using the facilities at school X

General Infrastructures lacking enclosed compartments X X

Poor maintenance of infrastructure X

No on-site access to water for flushing X X

Absence of means for flushing X X

Children cannot wash their hands after using the toilet (hand wash, sink, towels, tissue paper) X

Toilet facilities are often surrounded by garbage X

Presence of animals and insects within the toilet facilities (monkeys, snakes, worms, flies...) X X X

Defecating facilities lack of proper ventilation and lighting X X

Schools cannot ensure a constant water supply X X

Schools do not provide the proper means to keep the toilet facilities clean (brush/broom, disinfectants, garbage bin...) X X

Toilet facilities do not have appropriate floor to keep them clean X

Toilet facilities lack squatting slabs X

Toilet facilities do not have a proper sewage/water system X

Problems, Needs and Key Success Factors Problems, Needs and Key Success Factors

Key Success Factors Privacy Hygiene Maintenance Security

Continuous availability to water within school facilities X

Continuous accessibility to potable and safe drinking water within school facilities X

Proper toilet facilities and infrastructures within school facilities X X X

Continuous high level maintenance of toilet facilities within schools X

Accessibility to a safe and hygienic toilet environment within school facilities X

Proper waste collection and management within school facilities X X

Appropriate black water sewage system and management within school facilities X X

Needs Related to Toilet Usage

Needs Privacy Hygiene Maintenance Security

Girls Girls need to be able to go to the bathroom whenever they feel the need X X

Girls need proper / hygienic means for proper disposal of sanitary pads X

Girls need to have private and safe individual spaces to go to the toilet X X

General Children need privacy when going to the toilet X

Children need access to water for washing hands after using the toilet X

Toilet facilities need to have water for flushing and the means to do so X

Toilet facilities need to be cleaned regularly X X

Toilet infrastructure needs to be properly maintained (doors, tiles, roofs) X

Toilet facilities need to be placed within a clean environment X X

Closed compartments need proper ventilation and lighting / electricity X

Schools need to ensure constant water supply X

Schools need to ensure proper supplies for cleaning / disinfecting toilet facilities X X

Schools need to provide potable water and its relevant infrastructure X

Schools need to provide appropriate toilet infrastructure X

Schools need to have proper waste water management systems X X

* extra commodities: doormat + hangers** curious information (not problem): the need of a mirror within toilets is important especially for the boys

Table 17. The table highlights the main problems encountered by students using toilet facilities in schools and the criteria that best describe the nature of the problem.

Table 18. The table highlights the main needs of students while using toilet facilities in schools and the criteria that best describe the nature of the need.

Table 19. The table highlights the key success factors for improving toilet facilities in schools and the criteria that best describes the nature of the factor.


The sanitation problems and needs of students identified throughout our research and observation are the foundation of which solutions must be built on. The key success factors cluster the problems and needs into the major themes where the opportunities lie.

In order to explore the opportunity spaces for providing solutions to the identified problems, one brainstorming tool we use is to ask ourselves ‘how might we’ questions. The questions below serve as a trigger to ideate for product, services or system solutions regarding the sanitation problems in Indian schools.

improve the hygienic experience of girls and boys using school toilets?make the concept of hygiene more comprehensible and accessible to school students? integrate educational and fun hygiene programs in school systems?empower teachers’ role in influencing hygienic procedures in schools?make hygienic products more accessible in schools?

Opportunity SpacesWater Management

Safety & Privacy Network & Community

Infrastructure & MaintenanceWaste Management

Personal Hygiene

filter and reuse water in rural schools?create a closed water circuit?diversify water source?guarantee good maintenance of the water facilities?collect rainwater and store it for daily use?design easily refillable water tanks to be placed near toilets?

provide schools with on-site waste management systems?generate awareness on proper disposal of sanitation pads?design a friendly and hygienic system for sanitation pad disposal in schools?remodel the Indian way of waste removal (burning garbage) in an environmental friendly approach?

make use of local material to build proper toilet infrastructures?provide a good-quality low-cost toilet module for rural schools?create awareness on the consequences of poor sanitation in day-to-day life?motivate and empower people responsible of cleaning and maintaining toilets?transform the activity of cleaning toilets to be more fun and rewarding?develop the students’ sense of ownership on their school toilets for better maintenance? empower students to have a bigger impact on maintaining cleanliness on school toilets?establish a network of partners/suppliers of basic hygiene products (soaps, hand sanitizer, cleaning products…) to provide to schools?

provide a safe toilet environment where animals are not a threat?ensure privacy of toilet users, especially female users?design alternatives to traditional locked toilet doors?

enhance schools’ influential role within communities to create awareness on sanitation? design a community based savings and financing system that invests on basic sanitation infrastructure?design an affordable and efficient public toilet cleaning service within the community?


Projections


Projections

As our desktop research has shown and our field trip has proven, the sanitation problem in India remains very dominant today. A problem as big as sanitation, governed by politics, bureaucracy and corruption, is definitely a challenging problem to tackle. An ultimate solution for the interdependent sanitation system probably requires the collaboration of many different stakeholders and a major reconstruction of the country’s infrastructure. To reach such a solution might seem overwhelming.

However, as Prof. Yunus advocates in his book Building Social Business, starting small is key and “if your work has a positive impact on five or ten people, you have invented a seed. Now you can plant it a million times”. (p.21) We believe that education is an essential starting point and a main channel of penetration to tackle most social problems. In a country that values education as much as India does, schools have a fundamental role in influencing healthy habits and environments. By developing new perceptions, behaviors and habits on hygiene and sanitation in schools, the change of attitude in students would soon be reflected within whole communities.

Taking into consideration all that we have learned and observed from our desktop and field research, and going back to the “how might we” questions introduced in our document, a future outlook for this project would be to ideate on possible and feasible solutions that address the sanitation problem in India, starting small, starting local and most importantly starting with the users’ point of view.


Bibliography » C.K. Prahalad, The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits

(Pearson Prentice Hall, 2009)

» Erik Simanis and Stuart Hart, The Base of the Pyramid Protocol: Toward Next Generation Bop Strategy (second addition 2008)

» Muhammad Yunus, Building Social Business: The New Kind of Capitalism that Serves Humanity s Most Pressing Needs (Public Affairs , 2010)

» Richard J. Boland Jr. and Fred Collopy, Managing as Designing (Stanford Business Books, 2004)

» D.School Bootcamp Bootleg (Hasso Plattner Institute of Design at Stanford, 2009), accessed March 25th 2011, http://dschool.typepad.com/news/2009/12/the-bootcamp-bootleg-is-here.html

» The Next 4 Billion: Market Size and Business Strategy at the base of the Pyramid, (World Resources Institute and International Finance Corporation, 2007)

» “Data and Research”, The World Bank Group, http://www.worldbank.org

» “Data and statistics”, World Health Organization, http://www.who.int/en

» “Grameen Creative Lab - passion for social business”, accessed March 2011, http://www.grameencreativelab.com/

» Sahyog Chehak Trust, http://sahyogchehak.org/index.php

» SPARC, http://www.sparcindia.org/

» Sulabh International Social Service Organization, http://www.sulabhinternational.org/

» Teach for India, http://www.teachforindia.org/

» UNICEF, http://www.unicef.org/

» “Millennium Development Goals”, UN World Health Organization (WHO), http://www.un.org/millenniumgoals

Bibliography

177

An Opportunity Analysis for Bayer CropScience

Agriculture and Greenhouses

178 - Sicily · Agriculture and Greenhouses - D4SB 179 179

“The farmer has to be an optimist or he wouldn’t still be a farmer”.

Will Rogers


IndexWhy Sicily?

Bayer CropScience 185

Project Brief 185

The Sicilian Context

Sicily Profile 189

Sicily in Numbers 189

Ragusa 190

Greenhouse Cultivation 191

Ragusa and Greenhouse Cultivation 192

Benchmarks 193

Project Goal 194


The Siciliy Field Research Program 198

The Interview Guides 199

Stakeholder Map 210

Time and Money Flowchart 211

Stakholders on the Agrcultural Context. Influence on System 212

Opportunity Spaces 214

Projections

Projections 72

Bibliography 75

183 183

During our journey in defining the scope of design and social business, we had the opportunity to collaborate on a project with a multinational corporation that showed interest in our work and methodology.

Due to the confidential information revealed throughout the research and used throughout our analysis, synthesis and ideation, we will not be able to share the detailed outcomes of our project. However, it is important to acknowledge this project as a valuable tool to understand how social and design can integrate within large corporations.

Why Sicily?

185 185

Identify opportunity spaces for Bayer to develop new products and/or services within the context of greenhouse agriculture in Ragusa - Sicily.

To understand the opportunities for the development of new services, to analyze the needs of farmers, retailers and other stakeholders and to give insights about the innovation process in greenhouse agriculture

Bayer CropScience is the second largest crop protection global company, with sales in 2006 of USD$4,874 million in the crop science sector and USD$8,000+ million for the entire company. Bayer CropScience sells products in the United States, Canada, Mexico, Asia, Europe, Brazil, Australia and other countries. Its customers are commercial dealers and growers in crop production, horticulture, turf and ornamentals and professional products. Products are insecticides (#1), herbicides, fungicides, and seeds.

Bayer CropScience is with annual sales of about EUR 6.8 billion one of the world’s leading innovative cropscience companies in the area of crop protection (Crop Protection), non agricultural pest-control (Environmental Science), seeds and plant biotechnology (BioScience).

Customers include distributors, dealers and farmers.

Project Brief

Bayer CropScience

“Bayer: Science For A Better Life”.

187 187

TheSicilianContext

189 189

Capital City: PalermoPopulation: 5,048,806GDP: 88,327.73GNI (PPP) per capita: 17,533

Sicily Profile

Sicily in Numbers

Even though much of its mountainous terrain is unsuitable for farming, Italy has a large work force (1.4 million) employed in farming. Most farms are small, with the average size being only seven hectares. In this context, Sicily is known for it’s vegetables, which since the sixties have gained much larger markets in the quality of crops in greenhouses, found mainly in the South East, such as the famous Pachino tomatoes, or legumes such as lupine.

Most of the greenhouses in Sicily are located mainly along the strip in the south coast, especially in the province of Ragusa. In particular, in the Vittoria, Comiso, Achates and Santa Croce Camerina zones. There predominate the floriculture, and the fruit and vegetable sectors, while the marine area of Scicli, Pozzallo, and Ispica presents mainly vegetable crops in open fields (Sicily Region). The entire inland of the coastline of Ragusa, from Ipsica to Vittoria (and recently some areas from Gela and Mazara) have constituted for several decades an area of excellence for protected crops.

30%Sicily

Total area of Sicily25,711 Km2

Total area of Italy301,338 Km2

70%Italy

Proportion of Greebouses in Sicily compared to Italy

Area in Km2 of Sicily compared to Italy

Greenhouses Hectars of covered ground


Ragusa Greenhouse Cultivation

The agriculture of the province has many traditional aspects: on the plateau dry crops are prevalent, especially cereals and tree crops. A mosaic of tree crops and vegetable plants characterizes the areas of Ispica and Pozzallo , the hills and the plains of Vittoria, Comiso and Achates. But the industry’s most outstanding and innovative feature is that of the greenhouses, especially on sandy soils, which stretch from Victoria to the coast; millions of square meters of cropland, made with great economy of material, in which there is a production of zucchini, eggplant, tomatoes and flowers (the latter, especially in the area of Victoria) that go through the entire year. The cultivation in greenhouses is presented - in monofunctional or multifunctional areas - in the Ispica region, including Donnalucata and Scicli, as well as along the coast and in between Punta Secca and Santa Croce Camerina and between Acate and Achates. In the early seventies the explosion of the ragusian greenhouses has been, according to Antonio Saltini , one of the most striking phenomena of vitality of the entire Italian agriculture building, on land which offered virtually no income, a flow of income and involving a large number of related areas, from trade of seeds and pesticides to that of polyethylene, from bottled gas for heating greenhouses and refrigeration facilities for road transport.

The wine-growing economy has an important place of Ragusa, there are many wines IGT and DOC products, among which stands the Cerasuolo di Vittoria, produced from the grape Nero d’Avola and Frappato .

Greenhouse cultivation plays an important part in flower and fruit and vegetable growing. In the Mediterranean basin, crops grown in some sort of protective structure cover an estimated surface area of over 40,000 hectares, largely with little technological input. Yet innovation continues, for the structures used and the crop techniques and technical methods.

Construction Types

Greenhouses are almost all built in two basic types: gable roofed with symmetrical or asymmetrical gables, and tunnels with a circular or elliptical section. They also differ in terms of the conditions inside, which rests on the type of crop: cold frame, when there is no temperature control; temperate frame when the night temperature is kept at 10-14°C; and hot houses with a temperature of 16-20°C at night. Some wooden framed greenhouses are still built, but steel is the most widely used material. The frame must be strong to support its own weight, any secondary supports such as metal anchors, the covering, and also factors such as wind and snow. The type of cover material decides the type of structure, its shape and size.

Climatisation

Controlled greenhouse conditions means controlling not only the temperature, but also humidity, illumination and air flows. In hot and temperate greenhouses, heating is the most important component. The ‘greenhouse effect’ is not enough to guarantee the temperature, so artificial heating is almost always indispensable. It is generally produced by hot air generators fitted with fans. The most common type is suspended in the air and blows the hot air through a suspended pipe made of plastic film with holes in it. Heating can also be applied to the substrate in which the plants grow, using PVC pipes buried or laid on the bottom of the growing bench.

The whole operation of a modern greenhouse – shading tarps, mechanised opening and closing, heat regulation, etc. – can be managed fully from a computer on the basis of information from sensors and peripheral microprocessors.

Problems in Greenhouse Cultivation

The troubles which arise in the culture of crops in the greenhouse may be divided into several groups

» failure to supply the essential factors for optimum growth such as light, moisture, carbon dioxide and heat in amounts necessary for each individual crop

» fertilizer deficiencies » fertilizer excesses » toxic gases » attacks by insects, animals, and allied pests and » susceptibility to fungus, bacteria and virus troubles.

“...the industry’s most outstanding and innovative feature is that of the

greenhouses, especially on sandy soils, which stretch from Vittoria to

the coast; millions of square meters of cropland, made with great economy

of material, ...that go through the entire year”.


Ragusa & Greenhouse Cultivation

Figure 1. Greenhouse production in Ragusa compared to the rest of Italy.

Ragusa holds the national record of gross marketable agricultural production, with 47% of the floriculture and vegetable production in greenhouses.

The greenhouses of Ragusa are used mainly for horticulture, especially for tomatoes, eggplants, bell peppers, zucchini and melons. Tomatoes alone, account for 70% of the entire production in the zone.

Technology use in the area is also very limited, especially among the small farmers, and many of them still use the same techniques of 20 years ago. Most of the greenhouses in the area are cold ones, which means that they are not heated, or use automated temperature control mechanisms since they can benefit from milder temperatures than other renowned greenhouse zones such as the Netherlands, and the relation between cost and benefit is still high. Instead, it is widely spread the use of plastic to cover the soil to keep it warmer and to avoid sudden changes of temperature. This help to considerably reduce the production costs, since the use of fuel is very limited, and many times, none. Techniques such as soil-less cultivation (fuori solo) which is one of the biggest trends of the market in the recent years – plants grown outside of the ground in suspended bags containing natural fibers and added nutrients – are still not very diffused because of the high cost of implementation. The use of soil-less cultivation considerably reduces the contamination of the plants by fungus , lowering the need of agrochemicals. In Italy, it accounts for 3% of all greenhouse production while in Holland for over 50%.

The cycles of a crop can vary from farm to farm. They can decide to do one or two cycles per year. One cycle a year, reduces the overall costs, since they planting occurs only once. On the other hand, even if it is more costly doing two cycles, it allows the harvesting in times such as winter or Christmas when farmers can sell their products at higher prices.

Benchmarks

Walking Plant SystemsNutrient Film Technique (NFT)

In Holland, Walking Plant Systems, one of the major suppliers of greenhouse management systems, uses electronic tagging employed in the automatic identification of people and things (Radio Frequency Identification) to keep track of each individual vase and optimize the entire process of greenhouse cultivation. The system created by WPS integrates RFID and image technology to achieve full automation through the plant’s crop cycle, from sowing to sale to the final customer.

The software also means that each plant can receive specific treatment as a function of its needs. RFID also makes retail sales management very reliable.

A simplified hydroponic technique known as Nutrient Film Technique or NFT was developed in England in the 1970s. using small channels at a slope of 1 - 1.5% covered with an opaque plastic roof.

The plants are started in inert materials such as perlite or rock wool and then placed over a channel containing a fine, continuous flow of nutrient. In this way, the roots are always bathed in a veil of nutrient solution continually on the move so there is no need for it to be aerated artificially. Of course, the nutrient is kept moving by a pump with continuous control of pH and heat conductivity.

Other initiatives that have dealt with greenhouse agriculture are:

The agrochemical market. Growing sales of generic products.With few new pesticide active ingredients coming to market, sales of older pesticides are dominating global agriculture. When patents on these older pesticides expire generic producers can start manufacturing. The original research-based companies seek to maintain control while generic producers try to capture a share of the market. Fierce competition is likely to bring about significant changes over the next five years.

Agrochemicals are an aging industry. While over 800 pesticide active ingredients remain on the market, the number of new substances being developed has fallen considerably over the last ten years. In some industrialized country markets older products are losing their registrations. For example, the European Union review has removed over 360 active ingredients to date.

But these and many other chemicals are still available elsewhere. But while aging, the industry has not lost its vigour. The overall global agrochemical pesticide market was valued at US$32 billion in 2004 with generic products making up an increasing percentage of this market. Latest estimates indicate that generic products account for US$18 billion, or around 66% of overall sales1 and by volume, generic active ingredients may account for approximately 95% of all product sales worldwide.

Six research-based agrochemical companies (Bayer, BASF, Dow, DuPont, Monsanto and Syngenta) control around 85% of the overall global market by value. Generic pesticides are key in their product portfolios and these companies play a dominant role in the generic market, with approximately 70% of sales by value, and possibly 65% by volume.

Table 1. Description of the agrochemical market.

Ragusa

195

Project Goal:Provide Bayer CropScience with opportunity spaces for the development of new products and services that aim at improving farmers’ conditions.

197 197



The Sicily Trip Program (13th - 16th September)

Tuesday Wednesday Thursday Friday

13 14 15 16

Arrive to Sicily

Initial dialogue – Building the system map on field workforce together with Bayer representatives

Interviews with farmers, retailers and other stakeholders in the agriculture field throughout the day

Morning interviews

Information sharing and downloading in the afternoon

Complete information download

Leave Sicily to Milan

The Sicilly Field Research Program

In preparation for our field research in Sicily, we developed interview guides for the different stakeholders in the agriculture system that we had identified earlier with Bayer representatives in Milan.

Once in Sicily, we interviewed and conducted card games with 9 farmers, 3 retailers, 1 vivarium, 1 commissioner, 1 quality certification administrator and 1 technician. In addition, we had a group discussion with 3 of Bayer’s representatives that helped us understand the relationships within the complex agriculture system.

A main tool that helped facilitate the conversations with our interviewees was the card sorting game. This visual aid helped the stakeholders express abstract and emotional sentiments through the use of words and images. These include:

» Their relationship and feelings towards all the other stakeholders involved in the process: farmers, retailers, buyers, customers, companies, cooperatives, etc.

» Trust issue and community sense. » Economical barriers/gains and frustrations/satisfactions. » Ideal services for them.

Table 2. The schedule of our 4 day research in Sicily.

The Interview Guides


Interview Guides - FarmersName Age Occupation Activity Specifics Production Specifics Use Of Agrochemicals Important Quotes

Stefano Nicita 31 years Sales Manager “Libretti Srl” - 200ha - 150 employees - commercialization

Tomato, eggplant, pepper, cucumber, zucchini

Prevention - type and brand chosen by the technician in house

“Nowadays it is very difficult to start in agriculture”

Guglielmo Lami

57 years Owner Family business - 0.5ha - from 1 to 2 employees

Grapes, tomato, zucchini Doesn’t pay attention to the brand - products chosen with son (technician) - No protections

“I don’t see agriculture as a possibility” - “We’d like to be part of a coop that looks after us”

Angelo Biagio 42 years Owner Family business - 5ha - from 9 to 10 seasonal workers

Tomato, artichoke, several try-outs

No prevention; products chosen by brand - managed by specialized operators

“I buy what I know”

Giuseppe Melilli

44 years Administrator Family business - 8ha - 15 employees

Tomato, eggplant Helped by a friend technician - doesn’t care about the brands he uses

“I’m willing to pay more for the quality”

Giovanni Lomagno

40 years Owner Biological farm (with 3 associates) - 45ha - 120 employees - commercialization

Tomato, small percentage of other horticultural products

No use of chemicals if not authorized - products chosen by the technician inhouse (both brands and generics)

“Market requires bio and beautiful at the same time” - “Plastic bio”

Salvatore Sciacca

49 years Owner Small family business - 1ha - 2 seasonal workers

Tomato, pepper, cucumber

Choice influenced by the technicians, the retailer, the price and the personal experience - No protections

“I buy the products I find” - “We usually buy the brands that everybody knows”

Galanti Brothers

42 years Owners/Sales Manager

Family business - 15ha - 50/60 workers - commercialization

Different products Products chosen by the technician inhouse

“To maintain yourself in the business you need to have a name and quality”

Iacono 70 years Owner Family business (3 brothers) - 4ha

Grapes, tomato, pepper Depends on the help of the technical forces from the companies (Bayer)

“Everybody looks for his own interest”

Antonio 34 years Owner Small family business - 3ha - 1 fixed/1 seasonal worker

Tomato, eggplant, zucchini, pepper

Chooses based on his personal knowledge - Bayer products too expensive

“Bayer products are good but expensive” - “Better to pay more for a product that works”

Table 3. The table lists some of the data gathered from the farmer interviews.

The Interview GuidesInterview Guides - RetailersName Age Occupation Activity Specifics Products Specifics Suppliers Relationship Important Quotes

Salvatore 41 years Owner (supplies/selling management)

Big retailer - 4 employees

30% plastics - fertilizers and other products

Regarded as partners - Bayer is less flexible with payments but credible and powerful

“We give more credit than we should”

Gianluca/ Salvatore

39 & 40 years Administrator/ Technician

“Farmacia Agricola Agrisol” - Big retailer

Agrochemicals - zinc - wire - other structural material

They have a bigger margin with the generics but prefer selling the brand - Syngenta gives the best service and the fastest delivery - Bayer has a long delivery time but a great technical support system

“Farmers should specialize”

Fabio - Sales Manager “Tutto Per L’agricoltura” Family business (4 brothers + 1 external)

Big variety of products in small storage, mostly agrochemicals

He has power of negotiation because pays always on time

“Clients trust us on products”

Interview Guides - VivariumName Age Occupation Activity Specifics Production Specifics Use of Agrochemicals Important Quotes

Filomena Fontana

39 years Production/sales management

Family business (3 greenhouses - 1 bio)

Tomato, pepper, eggplant, cucumber

They have a technician in house, don’t use chemicals till the plant is in the greenhouse

“The client comes knowing what he wants” - “We give credits only if there’s trust”

Table 4. The table lists some of the data gathered from the vivarium interview.

Table 5. The table lists some of the data gathered from the retailer interviews.

Interview Guides - ComissionerName Age Occupation Relationships in the System Important Quotes

Aristia - Commissioner in Vittoria market and owner of the transformation company “Agromonte”

Has a place in the market where he buys products for his company and for small farmers for the Italian market taking 10% commission

“The market is missing a lot of services” - “There is lack of experience and knowledge

Interview Guides - Quality Certification AgencyName Age Occupation Activity Specifics Important Quotes

Gianni Polizzi - Administrator Give consulting and certification services (the global gap)

“We have to attract young people to join the field” - “We have to innovate culturally and in the mentality of the farmers here”

Interview Guides - BayerName Age Occupation Relationships in the System Important Quotes

Giovanni Inghisciano

57 years C.T.C. for Bayer - Part of crop team Direct relationships with retailers and coops. (Orders) and farmers (promotion of products & technical support)

“I can’t bypass the retailer” - “Too many technicians in the chain and lack of communication between them” - “Bayer’s profit depends on the whole system, each player has an important role in it”

Table 6. The table lists some of the data gathered from the commissioner interviews.

Table 7. The table lists some of the data gathered from the quality certification agency interview.

Table 8. The table lists some of the data gathered from the quality certification agency interview.


“I buy the products I find”“Usually we buy the brands that everybody knows” “I only buy the products I know”


“Nowadays is very difficult to start in agriculture” “I don’t see agriculture as a possibility”


“Market requires bio and beautiful at the same time”“Plastic Bio”

“Bayer’s profit depends on the whole system, each player has an important role in it”


“We give more credit than we should”“I’m willing to pay for a service to be sure to have my money back” “Here we are in the middle age”


SELLING SELLING

PRODUCTION PRODUCTION

Comissioner 2 Exportation

FARMER(small & medium)

Retailer

Retailer(plastic / material)

General market Local market

Supermarket

Technician

Technician

Technical support

Technician

Technician

BAYER

Comissioner 1

FINAL USER

Tranformation company

Technician

Technician

Quality Certification

Agency (Global Gap)

Vivarium

Technician

Seeds

Comissioner 2

Tranformation company

Exportation

FARMER(small & medium)

Retailer

Retailer(plastic / material)

General market Local market

Vivarium

Supermarket

Technician

Technician

Technician

Technician

Technician

Technician

BAYER

Seeds

Comissioner 1

Quality Certification

Agency (Global Gap)

FINAL USER

Relations Between the Di�erent Stakeholders Within the Agricultural Context

Time and Money Flow Between the Di�erent Stakeholders Within the Agricultural Context


MARKET

QUALITY CERTIFICATION AGENCYAgency in charge to give the Global Gap Certification to the farmes

LOCAL MARKETBuys products from commissioner or directly from the producer (can resell to restaurants/private users etc) pays back after 30 days

SUPERMARKETBuys products from commissioner, paying back every 30 days

GDOGroups of big supermarkets buying big amounts of products paying back every 30 days (usually have contracts with producers or commissioner)

COMMISSIONERTaking the 10% of commission buys the crops from the farmers at the general market to resell them to other buyers (local markets, supermarkets, big platforms), pays back the producer in 1 week

PRODUCTION

RETAILERBuys the products from agrochemical companies/plastics companies/other materials companies and resell them to the farmers with a margin; has the power to influence the farmers’ choices

VIVARIUMBuys the seeds to the seed company and sell baby plants to the farmers, according to the request

FARMERProduces crops to be sold on the market

BAYERSells its products to the farmers through the retailer; has influence on farmers’ choices through the technical support forces in field

AGGREGATION

COOPAssociation of producers/sellers looking after their interests and needs; able to have more power in the chain

Stakeholders of the Agricultural ContextInfluence on the System


After collecting all the data and insights gathered from the different activities conducted with the major stakeholders in the agriculture context in Sicily, we identified patterns and clustered the information in main themes. The recurrent patterns and relevant quotes back up the themes which formed the foundation of our brainstorming sessions. These themes include:

» Innovation » Trust issue » Interdependent system » Lack of unity / aggregation » Market instability / prices » Bayer products & pricing » Technical regulation / bureaucracy » Waste management » Lack of professional stakeholders » Young generation

In order to explore the opportunity spaces for providing solutions to the identified problems, one brainstorming tool we use is to ask ourselves ‘how might we’ questions. In this case, we asked ‘how might Bayer...’ questions in order to trigger ideas for innovative solutions that Bayer can develop, be it products, services or systems, in order to fidelize farmers to their portfolio.

Opportunity Spaces

Farmers

Market End User & Vivarium Innovation

Retailers

use their know-how and R&D department to expand the line of products/services to provide infrastructure/ technical innovation to farmers?take advantage of the pre-existing techniques to introduce innovation?

give more importance/empower retailers to sell its products?take advantage of good relations with the retailers to sell their products?improve its delivery system?gain influence over the retailer on the products farmers buy?bypass the retailers’ influence on clients?help farmer with payments to retailers?

help small farmers access new markets/channels?ease the bureaucratic procedures that farmers have to go through?reduce the number of intermediates between the farmer and the consumer?raise awareness regarding quality to end consumers?use vivariums as a channel to increase/market product sales?

encourage/enable specialization of farmers?generate brand awareness by communicating its products using a more familiar approach?generate a service/solution that will help farmers with waste management?create more brand awareness through the active principle of products? play a role in helping farmers in the quality certification process?help farmers trust each other?play a role in bringing farmers together?help in attracting the young generation to the agriculture field?develop farmers’ skills and know-how?empower farmers with managerial knowledge on running farms?

So how might Bayer...

217 217

Projections

223 223

224 - D4SB 225 225

The Team Mandy BouchedidLebanonVisual Communication - Design [email protected]

Barbara Elias da RochaBrazilIndustrial Engineering - Interior [email protected]

Óscar Aníbal PozuelosSpainVisual Communication - Art [email protected]

Tiago Dias MirandaPortugalProduct [email protected]

Simona DanRomaniaMarketing & [email protected]

Chiara EspositoItalyVisual Communication - [email protected]

our tool

dESign THinking

4a Co-Living - Tiago Miranda - Social design projects

Design

Transcript of 4a Co-Living - Tiago Miranda - Social design projects