Innovation in the Delivery of Urban

Health Services to the Poor
Vamsi K. Valluri
SARD/SAHS Intern
28-Aug-2015

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.

1

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
7
Total in 9 cities
53,772
106,556
151,640

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
Quality
irrational and unethical medical practice
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

User

Health
Service
Interface

Service
Provider

Affordability
Issue

Quality
Issue

Availability
Issue

Based on the Twelfth Plan

User

Affordability,
Information
Issues

Updated based on the NUHM
Framework for Implementation

Health
Service
Interface

Service
Provider

Governance,
Information,
Quality
Issues

Availability,
Partnership
Issues
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

Information about health promotion, availability of facilities, services
Demand Side Financing to address affordability

Health
Infrastructure /
Service delivery
Interface

User

State

Quality
Governance

Enabling Processes

Partnership with other provision
entities: Community, NGO, Private
sector
16

Information
Demand Side Financing
Socioeconomic Output
Information
Policy
Health Service

User

Service Fee

Health
Infrastructure /
Service delivery
Interface

Information
(Feedback)

Resources
Leadership

State

Information
(Feedback)

Quality
Governance

Enabling Processes

Partnership with other provision
entities: Community, NGO, Private
sector

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 GómezDantés:
– 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

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

Receive health advice, a
voucher booklet and a
personal health record card
from trained health worker

Client

Health
Worker

Trained health workers

Voucher
Management
Unit

Created awareness via
health workers and
through multimedia
communication,
merchandising, and
community events

Redeem vouchers at
participating outlets

State

Created local corpus fund
of INR 500,000 for
emergencies
Service
Provider

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 decisionmaking 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
35
an accreditation model for other plans

• 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

QUALITY

Publicly available
information about
service providers
and services

Solicit feedback from
“official” Aadhar
linked users

Health promotion
dissemination
User generated
reviews and ratings
Can be made
comprehensive and
effective by linking
to HMIS

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