Innovation in the Delivery of Urban Health Services to the Poor

Vamsi K. Valluri

SARD/SAHS Intern

28-Aug-2015

1

Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Agenda

• Background – Urbanization & Health

– India’s NUHM

• Study Methodology – Categorizing Issues

– Innovation Themes

• Select cases

• Recommendations

2

BACKGROUND

3

The Urbanizing World

4

The Urbanizing World

5

The Urbanizing World

6

Indian Situation

• Urban population to go up by over 400 million, by 2050

• Highest share (of 16%) of the world’s new urban dwellers

• Urban share of population to rise from an estimated 32% (2014) to over 50% (2050)

• Deep impact on cities: – Million+ cities, 2010: 42

– Million+ cities, 2030: 68

Share of largest cities to India’s total Urban population

(Pop figures in ‘000s) 1990 2014 2030

Delhi 9,726 24,953 36,060

Mumbai 12,436 20,741 27,797

Kolkata 10,890 14,766 19,092

Chennai 5,338 9,620 13,921

Bengaluru 4,036 9,718 14,762

Hyderabad 4,193 8,670 12,774

Ahmedabad 3,255 7,116 10,527

Pune 2,430 5,574 8,091

Surat 1,468 5,398 8,616

Total in 9 cities 53,772 106,556 151,640

Share/Urban 24.2% 26.0% 18.6%

7

Urbanization and Health Outcomes

• Population growth: migration, reclassification, and natural

• Resource crunch; high density of low cost, low quality housing

• Triple threat: – Infectious diseases exacerbated by poor living conditions

– Non-communicable diseases, e.g. heart disease and diabetes, fuelled by unhealthy diets, physical inactivity, and alcohol/tobacco use

– Accidents, traffic and other injuries, violence, and crime

• Health outcomes also affected by: – Lack of housing and tenure insecurity

– Poor access to clean water, sanitation, food

– Social isolation

• Inequitable access to information, health care

8

Urban Health Opportunities

• High density clusters easier for outreach for communication, marketing, access, and service delivery

• More early adopters who are likely to embrace change

• Potential for sound public-private partnerships

• Quicker access to new technologies that can enhance health awareness, prevention, and treatment

• Burgeoning middle class to drive policies that benefit themselves (and lower-income populations)

• An interplay of “urban health penalty” and “urban health advantage”

9

India’s NUHM

• National Urban Health Mission (NUHM) launched to effectively address the health concerns of the urban poor

• Targets 993 cities and towns that have a population over 50,000

• Plan outlay approximately $3.8 billion (2012-2016)

• ADB program to support NUHM to “increase access to equitable and quality urban health system” launched in 2015

• Key outputs:

– Strengthening urban primary health care delivery system

– Improving quality of urban health services

– Strengthening capacity for planning, management, and innovation and knowledge sharing

10

STUDY METHODOLOGY

11

Identifying the Issues

• India’s Twelfth Five Year Plan (2012-2017), offers a good starting point to identify and categorize the core problems in India’s healthcare system

• Identifies three service delivery related issues: – Availability

– Quality

– Affordability

• The NUHM Framework for Implementation lists 18 key public health issues in urban areas

12

Categorizing the Issues

Issue Category

Poor households not knowing where to go to meet health need Information

No norms for urban health facilities Governance, Quality

Poor environmental health, poor housing Information, Governance

Unregistered practitioners first point of contact – use of

irrational and unethical medical practice Quality

Large private sector but poor cannot access them Affordability, Partnership

Many slums not having primary health care facility Availability

13

Basic Model of the Issues

Service Provider User

Health Service

Interface

Affordability Issue

Quality Issue

Availability Issue

Based on the Twelfth Plan

Service Provider User

Health Service

Interface

Affordability, Information

Issues

Governance, Information,

Quality Issues

Availability, Partnership

Issues

Updated based on the NUHM Framework for Implementation

14

Study Framework

• Interventions to correct the issues

• Key assumptions and notes: – Demand side financing to address affordability issue

– “Information” covers health promotion as well as updates related to the location of health facilities and availability of services

– Governance encompasses issues related to macro level policies as well as micro level management

• Accordingly, the model can be reworked…

15

State User

Health Infrastructure / Service delivery

Interface

Enabling Processes

Information about health promotion, availability of facilities, services

Demand Side Financing to address affordability

Quality

Governance

Partnership with other provision entities: Community, NGO, Private

sector

16

State User

Health Infrastructure / Service delivery

Interface

Enabling Processes

Information

Demand Side Financing

Socioeconomic Output

Partnership with other provision entities: Community, NGO, Private

sector

Information

Health Service

Service Fee

Information (Feedback)

Information (Feedback)

Policy

Resources

Leadership

Quality

Governance

Framework within the health care services ecosystem 17

Case for Innovation

• Limitations of traditional public management: high degree of centralized control, top-down approach, rigidity, and the needs for a sound plan at start and reasonable certainty

• “Three Pillars” approach proposed by Frenk and Gómez-Dantés: – first, the design of a new generation of health promotion and disease

prevention strategies

– second, the extension of universal social protection

– third, the adoption of innovations in the delivery of health services”

• One of the eight core strategies of the NUHM Implementation Framework: “strengthening public health through innovative preventive and promotive action”

18

Contextualizing Innovation

• UNDP describes social innovation as “new ideas that work in meeting social goals”

• Modern social challenges require collaboration, empowerment, experimentation, and evidence-based assessments

• Selection criteria: – Distributive, either neutral or pro poor

– Collaborative, with multiple stakeholders and/or implementers

– Technological, featuring ICT

– Evidence-based, endline or impact evaluation component

– Scalability

19

SELECT CASES

20

Theme Brief Description

Demand Side Financing

Sambhav, PPP-based Health voucher scheme, India Social Franchising and Mobile Money based Health Voucher Scheme, Madagascar Universal Health Care for 30-baht, Thailand

Governance e-Participatory Budgeting in Belo Horizonte, Brazil Applying the Urban HEART Tool in Paranaque City, Philippines WHO Healthy Cities Project

Partnership

BRAC’s Manoshi, Supported by Female Community Workers and Technology, Bangladesh Contracting out EPI to NGOs, Bangladesh “Full scale” Health Care PPP, Lesotho Contrasting Cases of Contracting Health Services, India Case 5: Academic Partnership to Strengthen Public Health Intelligence, Brazil

Quality UNIMED’s Pay for Performance Program, Brazil Results-based Quality Improvement Fund, Belize

Information The Power of Health in Every MAMA’s Hand, Bangladesh and South Africa Sao Paolo’s “Bottom Up” Approach to Health Information System Development, Brazil Urban-focused Health Portals, Bangladesh

21

Demand Side Financing

• Directly links the subsidy and its objective to the beneficiary

• The Economist described conditional cash transfers as “the world’s favorite new anti-poverty device”

• According to WHO, unlike cash, “vouchers tie the receipt of cash to particular goods, provided by particular vendors, at particular times”

• Vouchers work best when the beneficiaries are easily identifiable and well targeted, and have the power of choice

22

Case #1: Sambhav, India

• Multi-stakeholder health voucher program – Supported by USAID and Government of India

– Implemented by Futures Group

– In coordination with local authorities, State governments, private sector and NGOs, and medical schools

– Piloted in Kanpur city and 11 rural blocks from 2006-12

• Kanpur – Major industrial and commercial hub in north India; pop 2.5 million

– Poorly planned and has several polluting industries

– High maternal, infant, and neonatal mortality rates

– Key contrast: two overburdened public hospitals and eight thriving private super specialty hospitals

23

Voucher Management

Unit

Health Worker

State

Service Provider

Client

Target married women of reproductive age, pregnant women and infants, based on a BPL card or a ration card Map households, create awareness, disseminate information, prepare pregnancy micro plans, arrange transportation, and accompany patients for delivery

Trained health workers Created awareness via health workers and through multimedia communication, merchandising, and community events Created local corpus fund of INR 500,000 for emergencies

Receive health advice, a voucher booklet and a personal health record card from trained health worker Redeem vouchers at participating outlets

Private providers were selected based on their location and services offered and accreditation status Reimbursement, based on “price list”, was kept below market rates Received INR 15,000 in advance to “build trust”

24

• Endline Report Findings (non-independent) – In depth interviews with voucher recipients reveal increased

awareness of health practices as well as health facilities information

– Increased awareness among policymakers and private sector about health service issues

– Clients “felt respected by service providers”

– High voucher uptake attributed to health worker intervention

– Poor valued private providers more, as deliveries dipped in the government hospitals and more than doubled in private hospitals during pilot period

25

Governance

• “the sum of the many ways individuals and institutions, public and private, plan and manage the common affairs of the city”

• Broader view of health: – More than the absence of illness

– So outcomes depend on multiple factors

– Influenced by governance systems, efficiencies, and priorities

• Urban poor face the twin challenges of being disadvantaged and being powerless

• According to Trevor Hancock et al, two innovation strategies: – Reinventing government, e.g. increasing participation

– Reinventing governance, e.g. new stakeholders and better decision-making tools

26

Case #2: e-Participatory Governance, Brazil

• Belo Horizonte, in southeastern Brazil, is the country’s third largest metropolitan area with a population of over 5 million

• Brazil’s first planned city; rapid industrialization and influx of workers led to the rise of sprawling slums in the 1970s

• In recent decades, slums and informal settlements have outpaced the core city’s annual growth rate by a factor of 5

• In 1993, implemented a citizen-led model of democratic governance in which civil society controls planning and execution of public services

• Process overseen by inter-sectorial management board

• 50% of the budget is allocated based on IQVU, a customized quality of life index

27

• Step 1: Neighborhood level – Citizens are briefed and projects identified; repeated every two years

• Step 2: Sub-district level (41 in all) – 15 public works and citizen delegates are elected; sites inspected

• Step 3: District level (9 in all) – Based on priorities and costs, 15 works are selected

– Delegates to oversee implementation are elected

• Final stage: regional assembly – Delegates from poorer neighborhoods have more voting power

– Scope for “neighborhood coalitions”

• Process made online to encourage participation; terminals put up in slums to guard against middle class bias

28

• Results (outputs): – Between 1993 and 2010, 1,303 projects worth $700 million

implemented

– 10% projects were health related, apart from works related to slum improvements, water and sanitation projects, school construction, etc

– Per capita investments ranged from $3 in the wealthiest areas to $22 in lower middle class areas to $54 in the poorest areas

29

Partnership

• “collaborative activities among interested groups, based on a mutual recognition of respective strengths and weaknesses, working towards common agreed objectives developed through effective and timely communication”

• PPP, in theory, is a risk sharing mechanism, incentivizes innovation in project design and management, and combines social objectives and private efficiency

• Community organizations and informal entrepreneurs often step in to meet local demand, e.g. slum water supply

• Facing lower entry barriers, they rely on informal mechanisms and can easily customize their products and services

30

Case #3: BRAC’s Manoshi, Bangladesh

• Manoshi provides community-based maternal, neonatal and child health services, to address: – Demand-supply gap: urban Bangladesh is growing rapidly and health

infrastructure is not keeping pace

– Attitudes and awareness: 55% of women in urban slums receive antenatal care, and immunization coverage is just 63%

• Leverages the power of the mobile phone to make trained female community health workers more effective

• Launched by BRAC, one of the world’s largest NGOs

31

• Program builds on BRAC’s Swasthya Shebikas model, first launched in 1998

• Workers receive incentives for identifying and assisting with pregnancies, and also earn commissions through direct sales of health commodities supplied by BRAC

• Well-supervised system of home-visiting and referrals to healthcare facilities, supported by community engagement

• Community worker engagement supplemented by basic delivery centers and BRAC maternity centers (paid)

• Clients have access to 24 hour phone helpline

• Supervisors use them to coordinate medical services and to store and access patient health records

32

• Results (ICDDR, B Impact Evaluation): – Reaches 6.9 million urban slum dwellers in 10 cities

– Women who viewed Manoshi health workers as important members of their social network were twice as likely to deliver with a trained birth attendant and 5 times more likely to use postnatal healthcare services

33

Quality

• Traditionally, the quality of medical services has been regarded as identical to conducting the latest medical treatment and diagnosis at the highest level

• Increasingly, consumers seek highest quality outcomes at the lowest cost and the producers, and information about quality becomes a critical decision enabler

• Research in many settings has shown that demand for immunizations and other primary health care services rises with the quality of those services

34

Case #4: UNIMED “Pay for Performance”, Brazil

• Largest cooperative of its kind: 386 branches, 105,000 physicians, 15 million beneficiaries

• UNIMED Belo Horizonte (UBH): – Covers 800,000 people, including 75% through employers

– 4,700 physicians, six clinics, two hospitals; 258 contract facilities

• Following 1998 health insurance reforms, new regulatory standards implemented and UBH adopted a phased process

• Two-pronged approach: – Incentivize contracted facilities to pursue and achieve accreditation

– Pay physicians for adopting disease management protocols

• Recognized by World Bank “as one of the most successful and best performing in the world” and has been recommended as an accreditation model for other plans

35

• Beginning in 2005, all facilities were offered 7% hike in per diem rate for initiating accreditation process with incremental hikes of up to 15% upon achievement

• Accreditation, based on National Organization of Accreditation (ONA) and ISO standards, done by external auditors

• In 2007, UBH also introduced an incentive program for physicians linked to their “practices and patient outcomes”

• Performance was measured through clinical effectiveness, technical efficiency, and client satisfaction

36

• Key Lessons and results: – Cumulative payment allowed for larger payouts and gave physicians

more time to correct their activities and earn bonus

– UBH roped in other entities, such as Kaiser Permanente, to set reasonable benchmarks, build credibility, and encourage buy in

– Strong evidence based approach led to effective monitoring as well as documenting results

– E.g., reducing the number of hospitalizations for patients enrolled in P4P resulted in savings of $15,000 over 6 months

– Strong HMIS is key to successfully executing pay for performance

37

Information

• ICT is widely recognized as an integral part of the UN Sustainable Development Goals process as well as a way of enabling and measuring outcomes

• information in the health care system can be broadly visualized as either being disseminated outwards as health education and awareness or as amorphous transactional data internal to the system

38

Case: Mobile Alliance for Maternal Action (MAMA)

• Launched by USAID and Johnson & Johnson as a PPP venture

• “aims to improve health and nutrition outcomes among pregnant women and new mothers, and their infants, through the delivery of vital and culturally sensitive health messages”

• Phased approach: pilot, update, official launch

• Active in Bangladesh and South Africa; launched in Mumbai in November 2014 as mMitra

39

Localized Approach

• Launched as Aponjon in Bangladesh in Dec 2012

• Relies on user fees, advertisements, corporate partnerships, and revenue sharing with telcos

• Text as well educational ‘skits’ (via IVR)

• A year into launch, reached 52,000 mothers and guardians, including 17% below poverty line

• Launched in 2013 in SA

• Messaging on HIV+ and breastfeeding in additional to pregnancy and parenting advice

• Beyond mobile: web-based community portal, social networking, to reach younger audience

• 17,500 subscribers as of April 2013

40

Case for Information Democratization

• Ubiquitous role of Information in the framework

• “acquisition and spread of knowledge amongst the common people” leads to democratization

41

One end of the spectrum…

• “choice and voice” revolution; Uber, Yelp, TripAdvisor, etc

• Emergence of consumer-centric mobile apps and portals

• Practo: – Launched in 2010 in India, also available in Indonesia, Philippines, and

Singapore

– Offers doctor search and rating, patient scheduling, and practice management

– Reach in India: 100,000 doctors across 310 cities

– In Metro Manila, it covers 11,000 doctors (70% of market)

• HealthPrior21.com and Maya.com.bd in Bangladesh

42

43

44

Building the Case

RATIONALE

• Evident as a clear solution from the framework

• Need for two-way information: from and to the user

• Creates awareness, enables comparison, encourages participation, overcomes word of mouth limitations

• Facilitates information democratization

FEASIBILITY

• One of largest (and growing) cellular markets with lowest call rates

• Internet mobile users to double to 500 million in 2017

• According to Census 2011, mobile ownership among urban slum HH at 68.3% versus in-premise toilet (at 66%)

45

Completing the loop

INFORMATION Publicly available information about service providers and services Health promotion dissemination User generated reviews and ratings Can be made comprehensive and effective by linking to HMIS

QUALITY Solicit feedback from “official” Aadhar linked users Incentivize users (say through Jan Aushadhi outlets) Quality metrics can be based on “official” users feedback and “unofficial” users ratings

46

The Other Side

• Mobile Seva is India’s national mobile governance initiative

• National Health Portal houses all health policy, education, services, and campaigns related information

“Under the acronym JAM — Jan Dhan, Aadhaar, Mobile — a quiet revolution of social welfare policy is unfolding … nearly 118 million bank accounts have been opened … nearly one billion citizens have a biometrically authenticated unique identity card … about half of Indians now have a cellphone.”

- Arvind Subramanian, Chief Economic Adviser, Govt of India

47

48

49

RECOMMENDATIONS

50

Leverage ICT

• Capitalize on India’s demographic and technological strengths

• Unified, user-centric portable application: – “choice and voice”; facilitates consumer convenience, engagement

and empowerment

– HMIS link for records management, scheduling, and health metrics

– External links for allied services such as Jan Aushadhi

– Medium for health promotion

– Quality assessment through patient satisfaction (and tracking)

– Find and respond to hotspots

51

Reinventing governance and government

• Bangladesh has reinvented governance by supporting the growth of NGOs and community organizations

• BRAC, for example, has grown in scope and scale and partners the government in a wide range of activities

• Brazil’s has reinvented government by making it more inclusive and prioritizing local needs

• The two countries offer a comprehensive set of ideas and interventions that policymakers and other stakeholders can learn from and adapt to Indian settings

52

Thank You

53