accelerating global adoption income countries
TRANSCRIPT
Session 1C: Accelerating Global Adoption of VBHC in Lower and Middle Income Countries
Introduction
Presentation
Discussion
Chintan Maru, Leapfrog to Value
Nicole Spieker, PharmAccess
Panelists:• Monisha Ashok, USAID• Nicole Spieker, PharmAccess• Gabriel Seidman, BCG
Moderator:• Chintan Maru, Leapfrog to Value
Global disease burden by region
https://ourworldindata.org/burden-of-disease
LEAPFROG TO VALUEHow emerging markets can adopt value-based care on the path to universal health coverage
INDIA:Showing early signs of the dangers of a volume-based health system
India’s health sector is projected to grow fourfold in one decade, from $70 billion in 2011 to $280 billion by 2020. But will this investment improve outcomes?
• Private hospitals set revenue targets for physicians, who meet them by prescribing care on questionable medical grounds.1
• Primary care providers in the public and private sectors prescribe unnecessary antibiotics at alarming rates2, making India a hotbed for antibiotic resistance3
• Ayushman Bharat, or Modicare, launched in 2018, increases access to acute care in hospitals, without proportionate improvements to preventive services in the primary care setting.4
If India continues on this trajectory, spending may spiral without delivering desired results.
1 M Kay, British Medical Journal, 20152 J Das, Science Magazine, 20163 R Laxminarayan, Lancet ID, 20134 G Brundtland, Lancet, 2018
4
Will developing nations follow the path of developed nations? Or can they chart a higher-value trajectory?
45
50
55
60
65
70
75
80
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Health spend per capitaUSD PPP
Japan
UK
Singapore
Nigeria
DRC
Tanzania, Ethiopia, PakistanIndia
IndonesiaBangaldesh
Brazil
South Africa
Health adjusted life expectancy
USA
Are growing health expenditures delivering the outcomes we expect?
• 20-40% of health spend is wasted through inefficiency (World Health Report 2010)
• 5M avertable deaths per year in LMICs are due to poor quality of care (Lancet 2018)
5
There is a narrow window for health systems to adopt value-based principles, before systems become entrenched around volume
Point of feasibility
Risk of path dependency
Status of health systems development
Nascent
Window of opportunity
to leapfrog to value
Mature
LMIC health systems have a choice whether to follow or leapfrog
• Track inputs and outputs
• Account for charges
Data systems • Track outcomes and true costs of care, in addition to inputs and outputs
• Center care in hospitals
• Emphasize treatment
Provider infrastructure and capabilities
• Center care in primary care and community settings
• Emphasize prevention
Financing and payment policies
• Finance, budget, and pay for care based on inputs and outputs
• Reward stakeholders for value and equity
Follow Leapfrog to value
LEAPFROG TO [email protected]
Measuring outcomes where it matters: Digitalizing maternal and newborn care to transform outcomes in Kenya
Nicole SpiekerICHOM conference 03May2019, Rotterdam
Introducing PharmAccess
Staff:
§ 220 FTE, of which 70% in Africa
Offices in 5 countries:
§ Nigeria (Lagos, Ilorin)
§ Kenya (Nairobi)
§ Tanzania (Dar es Salaam, Moshi)
§ Ghana (Accra)
§ Amsterdam (head office)
Annual budget: EUR 24 million
PharmAccess aims to increase
access to better care. Focusing on
sub-Saharan Africa, we are an
international NGO that works to
improve healthcare markets so that
they can deliver for everyone.
Kenya | Maternal and new born mortality still high, while care utilization is low
362
239
12
Kenya
Avg. developingcountries
Avg. developedcountries +51%
22
19
3Avg. developed
countries
Kenya
Avg. developingcounties
+15%
58%
71%
98%
Kenya
Avg. developingcountries
Avg. developedcountries
-18%
62%
87%
99%
Kenya
Avg. developingcountries
Avg. developedcountries
-25%
# of deaths per 100,000 live births # of death neonates per 1,000 live births
Women attended at least 4 x antenatal care Births attended by skilled personnel
Mortality
MNCH care utilization
The barriers | for maternal and child healthcare
Financial
Quality of care
Social
Poor women struggle to afford out-of-pocket payments of insurance
With subsidies often little transparency and accountability
Pregnant women delay or forgo ANC attendance – increasing risks
Inadequate provision of care for maternal and newborn services
Poorly regulated healthcare facilities
Patients voice and needs are not being heard
100Mactive mobile
money accounts
half of
282mobile money
services operating in Sub-
Saharan Africa
We believe that ..
90%own a mobile
phone
can contribute to Universal Health Coverage and better
health outcomes
massive mobile coverage and mobile money use in Africa
the global digital revolution
Political will+ +
In 2016 we launched…
In partnership with…
And providing near real time medical and financial insights, also outside the hospital
1. Patient falls ill
2. Diagnostics of illness
3. Treatment of illness
Universal care process
4. Claim for diagnostics and treatment
Health financing products create money flow into the system
E.g.: savings, insurance, remittance, donor
Socio-economic classification patient
Diagnostics, procedure, test
Claim data, financial
Data collected along the patient pathway
Money in Data out
Treatment, medicines, adherence
Adding Outcomes: Using the ICHOM set we selected a subset with local stakeholders
16
Visit 1 (ANC 3)Week 28
Birth Visit 5 (PNC 2)Week 6
1 2 3
2 3 51
4
Visit 2 (ANC 4)Week 34
Visit 4 (PNC 1 )Week 2
43
Visit
Patient reported data
Transactional data
Timeline
Enrollment Survey 1Case mix variablesDemographic data• Age • Education level• Social support• Next of Kin IDOBS & Med history• Parity• Multiple gestation• Obstetric history• Medical History• Substance abuse• BMI• Gestation
Survey 2• Immediately after visit 1
Questions• Satisfaction with care• Incontinence• Pain with intercourse• Pre partum depressionIf no/ partial response: • Send reminder
Survey 3• Immediately after visit 2
Questions• Satisfaction with careIf no/ partial response: • Send reminder
Survey 5A/ 5B• 6 weeks after delivery
Questions• Satisfaction with care• Incontinence• Pain with intercourse• Pre partum depression• Success with breastfeeding• Substance abuseSurvey 4
• 5 days after delivery
Questions• Satisfaction with careIf no/ partial response: • Send reminder
Using digital platforms to integrate the care along the patient journey including child care
….Detailed insights into the care process of groups of pregnant women
Age >50
<20
45-50
35-4040-45
30-3525-3020-25
Low Lower middle
Income
55 teenagers10 previous scar17 hypertension
# started
Key indicators
9%
91% 63% 58%46% 31%% visited
33%
67%
% tested &all drugs
33% 30%11% 26%
52%
45%
33%
Source: M-Tiba; PharmAccess analysis
77 141218KES per journey)
497 454 1,810
0-20 20-28 28-32 32-40 40-44 >44
67
3311
30 31 26 Safe journey
Starts 1st trim.
Adheres / visit
Full drugs/checks
$ 48
Billed / journey
Risks • Teenagers % low due to
early enrolment criterium (dropped)• 9% enrolled but did not
do consult in Tri 1
• For only 1 in 3, all tests and drugs are reported• Especially ultrasound
was expected higher but also supplements
• Critical timeframe for detecting risks, but many women only return at later stage•Many visits for UTI’s
obscure real situation
• Some women enrol just before delivery (some adverse selection)• In MJ03, some ANC
referrals took place
• Referrals not always timely, trust issues• Information shared not
always timely & accurate, clear
• Low % PNC in first period• Importance not always
clear
% safe journey
Week
Draft for discussion
79 138 170 186 152 151# women w/ risk 0 21%
Has risks0 0 0 0 0 0Referred
#
Referred
High response rates
• Health Outcomes measurement in emerging markets should have the same benchmark as more
developed markets (NO ‘poor man’s standards)
• However;
• cultural and social differences should be more flexible in implementation, with local ownership on the ground
• Language and literacy is a serious barrier; we should be able to test more flexible with new data collection systems; through automated claims, voice activated systems, etc.
• Affordable design and implementation, also to allow for outcomes on tropical diseases that may not be a priority for developing markets
• Be part of international community and learning, and start experimenting with VBHC Financing for emerging markets
• Call to action: set up ICHOM for emerging markets
Conclusion and way forward:
What questions do you have for our panelists?
Monisha Ashok, USAID
Gabriel Seidman, BCG
Nicole Spieker, PharmAccess