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8/6/2019 Best Blogs CHMI

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Center for Health Market Innovations (CHMI)HealthMarketInnovations.org/Blog

A Collection of Blogs from the Center forHealth Market Innovations


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Table of Contents

About CHMI...3Center for Health Marketing Innovations Framework.4 Improving Health Markets for the Poor: A Goal Worth Pursuing...5

Gina LagomarsinoEmergency? Call 108 ................................................................ ........................................ .......7

Rose ReisDesigning a low-cost, high performance primary health care chain in Brazil ....... ..... ...... ..... ..... ...9

Virginia ResendeTechnology to the People! ........................................................................... ..........................12

Rose Reis

Non Communicable Diseases: Not Just for the Rich .................................................................16Maria Belenky

How to engage private sector doctors to deliver high quality and afforable priority care services ............................................ ................................................. ...............19

John HetheringtonImproving infant survival by engaging the private sector in Bihar ......... ..... ...... ...... ..... ..... ..... ...23

Priya Anant Foreign investors, successful businesses invest in Kenyas white hot health market ...... ..... ..... ...26

Elizabeth Maloba Data, data all around, but plenty of ways to understand what it all means.... ...... ..... ...... ..... .....28

Donika DimovskaInnovations in Drug Adherence ................................................................... ...........................30

Trevor LewisReaching the Last Mile ................................................................ ..........................................32

Rose ReisExpanding Access to Essential Medicine ................................................................................34

Prabal V. SinghCommunity Health workers institutionalize referral network from remote villageto hospital ............................................... ............................................... ..............................36

Nadira SultanaGrateful for her baby, now named for her insurance plan ...... ...... ..... ...... ..... ..... ..... ...... ..... ...... .39

CHMI Team


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About CHMI

The Center for Health Market Innovations (CHMI)

CHMI identifies, analyzes and connects programs working to improvehealth and financial protection for the poor. Health Market Innovationsare programs and policies implemented by governments, non-governmental organizations (NGOs), social entrepreneurs or privatecompanies that have the potential to improve the way health marketsoperate. These programs and policies harness or improve transactions thatoccur in the health care marketplace to promote better health and financialprotection for the poor.

Analytic Partners CHMI is a network of partners coordinated by the Resultsfor Development Institute. CHMIs in-country partners identify, analyze andconnect with Health Market Innovations. In-country partners include:

ACCESS Health International India , Bangladesh, Brazil BroadReach Healthcare South Africa Consultation of Investment in Health Promotion (CIHP) Vietnam,

Cambodia Freedom From Hunger Peru, Bolivia, Ecuador

Institute of Health Policy, Management & Research (IHPMR) Kenya,Rwanda, Tanzania, Uganda

MercyCorps Indonesia Philippine Institute for Development Studies (PIDS) Philippines The Asia Foundation Pakistan

About the CHMI Blog With contributors from more than 10 countries, theBlog showcases innovative practices around the world in market-basedhealth delivery and financing programs. Interviews with program managers

about initiatives documented in CHMIs Programs database yield insightsabout programmatic challenges and lessons learned. CHMIs Blog alsohighlights upcoming events, new reports and tools.
http://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundationhttp://healthmarketinnovations.org/partner/asia-foundation


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Center for Health Market Innovations Framework

CHMI identifies five kinds of Health Market Innovations with the potentialto improve health market performance with better health and financialprotection: Organizing Delivery, Financing Care, Regulating Performance,Changing Behaviors and Enhancing Processes .
http://healthmarketinnovations.org/sites/healthmarketinnovations.org/files/CHMI_Health%20Market%20Diagram_1.png


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Improving Health Markets for the Poor A Goal WorthPursuing

By Gina LagomarsinoResults for DevelopmentInstitute, USAJun 23 2010

We are building the Centerfor Health MarketInnovations (CHMI)because we believe thatthe poor in developingcountries deserve high quality health care without having to pay so much that they godeeper into poverty. Improving the performance of vast, unorganized healthmarketplaces with lots of private health care providers, lots of consumer directspending, and little regulation-- will be no easy task. But we think its a goal worthpursuing, given the dominance of health markets in many countries.

Over the past few years, we have been collecting and reviewing evidence about the roleof private health care providers in developing countries. What we have foundcomplements and underscores years of work by others in the field. Despite the effortsof many governments to provide free care in public facilities, private sector providersare a primary source of care for many people--including the poor. And direct paymentsfrom households make up the majority of national health expenditures in manycountries. But many of these countries have little or no enforced regulation of privateproviders, who may or may not have much formal training.

Through our research, we found some reasons to be optimistic. We identified a number

of programs around the world that have the potential to improve health markets.Programs that better organize fragmented health care providers such as franchisesand professional associations make it easier to create standards and provide training.Programs that educate patients can help them become more savvy consumers of care.And a number of new business models developed by social entrepreneurs many usinginnovative information technologies can reduce costs of care or improve access forpeople in remote areas. Many promising programs are being implemented by NGOs and
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social entrepreneurs, often with donor support. See the diagram below to learn moreabout Health Market Innovations.

How Health Market Innovations Work

But we are convinced that governments must play a crucial role if markets are to deliverbetter results especially for the poor. Well-functioning health markets require broadstewardship of the entire health system. Governments must see their role as more than just building public hospitals, hiring doctors, and planning public health campaigns.

These will continue to be important functions, of course. But governments must alsoimprove their ability to set quality standards for all care providers and then make surethose standards are enforced. They must develop financing mechanisms that spreadhealth risks and costs across the entire population and ensure that the poor havepurchasing power. The good news is that a number of countries are starting to realize

this. At the May 2010 World Health Assembly, member countries passed a resolution tostrengthen the capacity of governments to engage the private sector.

Our goal at CHMI is to work with our many partners to better understand what can bedone to improve health markets. We will identify and track promising programs aroundthe world. We will analyze this information and evaluate programs to try to figure outwhat is workingan d what is not working. And we will create better linkages amongprogram implementers, funders, researchers, and policymakers whose efforts will becrucial to facilitating improvements in health markets. We hope this new CHMI websitewill support your efforts by furthering your ability to identify a number of differenttypes of promising Health Market Innovations in different countries and makeconnections with others in the field.

CHMI remains a work in progress. In the coming months, the database of programs willgrow significantly as we add more in-country partners to our network and as more userslike you suggest programs and contribute information to keep program profiles up-to-date. New in-depth CHMI analyses, which are currently in progress, will be publishedearly next year. We also expect to add new interactive online functions.


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Emergency? Call 108Visiting Andhra Pradesh's innovative emergency transport and care service

By Rose ReisResults for DevelopmentInstitute, USANov 5 2010

If you live in an

industrialized country, youknow what to do if you getin a car accident. You pickup the phone and call 911(in the states), 112 (in Europe), 000 (Australia) or another distinct number you couldrecite in your sleep. Someone answers the call, you report your problem, and anambulance, police car, and/or fire engine is dispatched to come to your aid.

In India, emergency transport service was limited until 2005. In that year, the southernIndian state Andhra Pradesh began supporting the operations of a not-for-profitorganization called Emergency Management and Research Institute (EMRI) which

operates the emergencynumber 108. People startedhearing about this service andeach state's 108 call centersmay receive more than 12,000calls every day. The mostcommon emergencies?Deliveries are by far the mostcommon reasons people dial108, followed by vehicular

trauma incidents, which clusterin the late afternoon andevening.

People are now calling 108 for emergency assistance in nine states across India, and theservice inspired other emergency medical services like 1298.
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The public-private partnership approach allowed EMRI to scale up quickly, and theproject shows the strengths of what private providers can do with governmentresources.

EMRI's headquarters outside Hyderabad, in Andhra Pradesh, are becoming a huge hub

for training of Emergency Medical Technicians, a field so new that no licensing examexists yet in India. EMRI has trained more than 35,000 people as paramedics andambulance drivers--actually, "pilots", in EMRI's terminology, because they are trained toperform CPR and other minor functions in the case of large accidents like multi-carcollisions.

Pranjal Kolwar, a 24-year old from Assam training inthe Advanced EMT program, told us that peoplethought at first this service could not be free (it is,everywhere 108 is operated). Pranjal, like the other

trainees we met that day, such as those above fromChhattisgarh was being paid by his state to becomean EMT. Even in Assam where the "kutcha" (unpaved)roads make it difficult to travel by car, EMRIambulances fetch people to hospital. In hisexperience working as an EMT-Basic paramedic, hesaw a lot of pregnancies, and also the aftermath of many fights.

He also got a call for empathy. "A woman's husbandhad died at 5am," Pranjal told us, "she had twohusband and her family did not know what to do.

They just called 108. They called us to come and put a smile on her face. There wasnothing to do, so I just listened to her."

"I feel good working here," he said.


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Designing a low-cost, high performance primary healthcare chain in BrazilCVS's Minute Clinics inspire a smartly designed enterprise aiming to lower financialand time costs to seeking health care for low income Brazilians

By Virginia ResendeACCESS Health International, BrazilJan 27 2011

Virginia Resende, ACCESS HealthInternationals lead for CHMI inBrazil, interviews an entrepreneur opening a smartly designed low-cost chain of clinics. She asks Ingrid Lins e Silva, Founder of Sade 10, how the government can best aid similar social enterprises via financing and regulations.

The primary health care market is estimated to generate R$16 billion ($9.5 billion) everyyear in Brazil. Around 75% of the Brazilian population is not covered by private healthinsurance, and rely exclusively on public services. Among lower income families , withearnings up to five times Brazils minimum wage per month (R$ 2,550 or $1,500), 85% of people rely exclusively on the Brazilian government for health care.

People in poorer neighborhoods often wait for months to get into extremely crowdedpublic health facilities. The cost of private health insurance is high for lower incomepeople, and out of the pocket payments for primary care visits are on average R$145,00($85.30). Sade 10, a new chain of primary health clinics, wants to position itself in thisniche, offering good services and much lower costs .

Inspired by the US drug store chain CVSs Minute Clinics, Breno Arajo con ceptualizedSade 10 in 2009. Arajo thought the model was quick, efficient and adaptable to servelower income patients in Brazil. In 2009, he met Ingrid Lins e Silva in Rio de Janeiro andtogether they decided to execute Sade 10.

Sade 10 will offer primary care and non-invasive exams. Patients arrive at the clinic andpay R$30 ($17.50). A nurse will take patients case histories, take patients vital signs,and report this information to the doctor. Among Sade 10s key mandates i s to pay
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close attention to patients. Each visit should last around 15 minutes --not less than 10minutes. Management will also offer R$7 ($4.10) health insurance program, with co-payof R$15 ($8.80) for the visits.

Although expecting high volumes, Sade 10 wants to ensure that all patients are

physically examined. Patients will be first checked and screened by a nurse and thensent to the doctor for further examination. The chain of clinics also wants todifferentiate themselves from other low income-targeted facilities by hosting patients ina comfortable, clean medical office. The first clinic is set to open in Rio de Janeiro onFebruary 01, 2011.

Virginia Resende: What is the mission of Sade 10? Ingrid Lins e Silva, Founder of Sade 10 : Sade 10s mission is to create medical clinicsthat offer convenient, high quality and quick services. These services will have veryaccessible prices, for people who are willing to pay some money to receive better care

than that offered by the public healthcare system in Brazil. Care and respect areessential values for the company andclients; both are seldom found incompetitor low cost primary careclinics in Brazil.

VR: Who was the most critical and strategic partner for Sade 10? ILS: The most critical partner wasFinanciadora de Estudos e Projetos(FINEP Research and ProjectsFinancing Agency of the Braziliangovernment). They awarded us with a

grant Prime (Primeira Empresa Inovadora First Innovation Enterprise), choosing ourbusiness among thousands in Rio de Janeiro in 2010, the second of three rounds of grants. PRIME provided us with credibility and increased our access to companies andinstitutions for future partnerships. PRIME is a grant of around R$120,000 (US$70,400)that start-ups can use to hire a good manager and pay for marketing and strategyresearch. Receiving the financial award was not essential, but being recognized andchosen amongst other entrepreneurs was critical. It sent the market the message thatthey could trust us, since the government also did. Naturally, the financial support

allowed me to dedicate more time to Sade 10 as opposed to my marketing consultinginitiative.

VR: How can the Brazilian government better assist initiatives like yours? ILS: By reducing bureaucracy simplifying processes and procedures lowering directand indirect taxes, and increasing grant initiatives such as FINEP and FAPERJ (Fundaode Amparo Pesquisa do Estado do Rio de Janeiro- Research Agency of Rio de Janeiro.)


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These grants should have a wider scope in order to benefit more businesses withoutmany restrictions.


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Technology to the People!Taking Telemedicine to Scale in Rural IndiaFrom the NextBillion series Healthcare with the BoP

By Rose ReisResults for DevelopmentInstitute, USAMar 8 2011

This post was first posted on NextBillion as part of their Healthcare With theBase of the Pyramid series.

Long known as an IT capital, India's health infrastructure for years lagged behind theTiger-like force of its software industry. No more: In the past decade, thanks to growingsupport from government, private sector innovation, and a great leap forward ininfrastructure development, so-called Information Communication Technology (ICT) istransforming the way people receive health care.

The "next generation" telemedicine model is proliferating rapidly in India, where 70% of people live in rural areas where health infrastructure is still insufficient. Telemedicineuses ICT to "provid[e] accessible, cost-effective, high-quality health care services," in thewords of a recent WHO Global Observatory for eHealth report. Telemedicine models, inwhich rural patients are connected to trained physicians over telephone or Internet, canbecome the first point of access for a variety of illnesses and diseases such as eyerelated issues, intestinal problems, infections and heart disease. Most importantly,patients get into the health system early and do not delay care seeking for fear of transportation and costs.

Today, CHMI profiles more than 55 telemedicine programs globally including 24 in India(program implementers and CHMI's partners in 16 countries are continually adding newprograms to the open database).

World Health Partners is a not-for-profit franchising organization that provideshealthcare services to the poor in Uttar Pradesh across Meerut, Muzzafarnagar andBijnor districts. In less than 18 months, the project established a health service delivery


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network covering 1,300 rural villages of Uttar Pradesh through 1,300 shops, 120telemedicine centers, nine diagnostic centers and 16 franchisee clinics. The project'scentral medical facility in Delhi conducts 80-160 tele-consultations per day. Next up: anexpanded pilot in Bihar, with funding from the Bill & Melinda Gates Foundation. Gateshas also initiated a rigorous evaluation of the model's health impact.

Sehat First, another franchise model utilizing ICT, aims to set up 500 health centersacross Pakistan by 2012. Founded in 2008 by d.o.t.z. technologies as a Karachi-basedpilot, Sehat First received an equity investment from Acumen Fund. The initiative'stelemedicine consulting service gives patients access through clinic staff to physicians,even specialists like gynecologists and pediatricians, over IP-based video phones.

Amrita Institute of Medical Sciences (AIMS) and Research Centre uses telemedicine toconnect general providers to specialists. In addition to the flagship hospital at Kochi, theInstitute also has established several smaller satellite hospitals in semi-urban and rural

areas to serve the local populace. Students from the health sciences campus in Kochioften are posted to these hospitals, and doctors and other medical staff serve there aswell. Satellite hospitals are linked to the 24/7 telemedicine service of AIMS Hospital. Thetechnology allows for the transmission of a patient's medical records and images, andprovides a live two-way audio and video link, which allows a general practitioner at thehealth center to connect with a specialist at AIMS.

Raja Bollineni, of CHMI Partner Organization ACCESS Health International, is chargedwith mapping ICT-related health initiatives in India. Bollineni got interested in thepromise of so-called e-health when working in Rwanda. He proposed a system forPartners in Health to allow people in rural Rwanda to consult on eye problems withspecialist ophthalmologists located at Central Hospital University Kigali.Although these models have garnered a lot of excitement in India and abroad, Bollineniis quick to point out a number of challenges impeding the implementation and furthergrowth of these programs, including capital investments, infrastructure limitations, lackof supportive policy, and low awareness levels in the communities. One other importantbarrier to sustained growth is the difficulty in getting sufficient volume to sustain yourbusiness.

"Startups shouldn't go in for high-end technology," suggests Bollineni. "You can saveyour capital for other investments, and the tariffs are also high on imported

technology." Bollineni suggests that implementers look at connectivity, and be realistic-even more basic Internet over phone can be effective, with limitationsGarnering sufficient volumes of revenue is another big challenge for implementers. "Fortelemedicine programs to go to scale, they have to be able to attract a sufficient volumeof business," says Bollineni. In his view, there are two ways to make them economicallyviable. The first is to obtain government support for expanding infrastructure. The bestway to do this is to create bundled shared services that utilize the same infrastructure.He recommends adding on dental services, dermatology and diagnostics to boost


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revenues, and points to Punjab-based Healthpoint's innovative choice to sell clean watercheaply adjacent to a telemedicine-equipped clinic (below).

How equipped does a clinic have to be to incorporate telemedicine? According toBollineni, there are many options. Very well connected clinics use broadband withspeeds of 512 kb/second, while Integrated Services Digital Network (ISDN) lines are themost preferred connectivity options for practical reasons to connect remote areas,

which only require a minimum bandwidth of 128 kb/second, costing about 171 Rs/hour(less than $4). VSAT too is a good option although a costlier proposal but provides muchfaster data transmission than ISDN. Video conferencing requires 256 kb/second ISDN orIP based support.

Among those using high-end technology are Apollo Telemedicine NetworkingFoundation's telemedicine centers an initiative of Apollo Hospitals, the JointCommission-certified hospital chain that has set up more than 100 telemedicine centersin India and 10 overseas to boost their business and make follow up visits moreconvenient.

For start-ups with less capital, Bollineni points to tech "hot beds" developing ICT usedfor telemedicine in South and West India. "Neurosynaptic has an interface box set whichcan transmit images and data at very low band widths-this seems to working very well,"he said. World Health Partners uses the Bangalore-based company's ReMeDi kit.Mumbai-based Maestros has developed Element 6, a portable medical kit fortelemedicine. Bollineni also pointed to technology development and incubation centersat Indian Institute of Technology (IIT) Kanpur, IITM's Rural Technology and Business


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Incubator (RTBI), Centre for Development of Advance Computing (CDAC) centers acrossIndia and the School of telemedicine at Sanjay Gandhi Postgraduate Institute of MedicalSciences.

Bollineni cautions that the government must continue to play a stewardship role in

accelerating this developing sector. More standardization of hardware and software anddeveloping practice guidelines will help program managers implementing telemedicineprograms overcome inter-operability, portability and security issues. Bollineni also urgesgovernment to implement the ICD 10, an international system of codes that classifysymptoms and diseases.

With ACCESS, Bollineni is working to build collaborative and co-operative efforts fromand among the network providers and the system developers. This April, as part of itswork to forge connections between innovators with the Center for Health MarketInnovations, ACCESS will be hosting a tele-health roundtable to bring both groups

together for dialogue. Join CHMI, then login to contact Bollineni about the meeting.


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Non Communicable Diseases: Not Just for the RichCSIS hosts a panel to explore the global response to the shifting burden of disease

By Maria BelenkyResults for Development Institute, USAApr 12 2011

On September 19-20, 2011, the UNGeneral Assembly will convene a high-

level meeting on non-communicable diseases (NCDs), an affirmation that preventionand control of NCDs is finally reaching the global public health agenda. Often thought of as diseases of the rich, NCDs comprise about 60% of global mortality, withapproximately 80% of the deaths occurring in low and middle income countries. In fact,current projections show that by 2030, NCDs will overtake communicable diseases asthe leading cause of death in rich and poor nations alike as an aging populations andlifestyle changes linked with economic development increase the risk factors forillnesses such as heart disease, cancer, chronic obstructive pulmonary disease anddiabetes.

How are different actors - both public and private - within developing nations dealingwith the shifting burden of disease? To address this issue, the Center for StrategicInternational Studies (CSIS) hosted a panel discussion focused on the developing nationresponse to the emergence of NCDs as a major public health concern.

To kick off the discussion, Rebecca Firestone of Population Services International (PSI) shared a number of often overlooked statistics to conclusively defeat the diseases of the rich misconception. Although NCDs account for a greater percentage of totaldeaths in higher-income countries, the NCD death rate per 100,000 is actually higher inmany developing nations. Furthermore, risk factors such as smoking disproportionatelyaffect the poor; in Laos, for example, the prevalence of smokers among the lowest

quintile is close to 50%, compared to about 20% of the wealthiest quintile.
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How is the international community reacting to these statistics? The unfortunate

answer is that the response is still lagging. In 2007, only 3% of all donor assistance forhealth went to NCDs, amounting to approximately $.78/DALY attributable to NCDs,

compared to $23.9/DALY attributable to HIV, malaria, and TB. One of the likely reasonsfor this lackluster response is the overwhelming perception that NCDs are just toocomplicated to prevent and treat in low-resource settings.

Still, there is reason to be optimistic. Gina Lagomarsino, Managing Director and CHMIlead at Results for Development , shared a number of approaches that are beingemployed to make NCD care accessible and affordable to the poor. Several innovativeinitiatives have been identified over the last year by CHMI partner organizations thatattempt to address one or more segments of the NCD continuum of care, from mobileclinics that engage in prevention, diagnosis and monitoring of chronic diseases in rural

and remote geographies, to private chains that are paid for through governmentcontracts that engage in long-term disease management, and super-specialty hospitals that provide the full continuum of care at a lower cost, often through governmentinsurance or cross subsidization.

Brazil and India appear to be two of the countries leading the way toward making NCDcare affordable for lower income populations.


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In Brazil, Nefrocare has established a network of independent low-cost dialysisclinics that take advantage of scale to reduce the cost of service. Nefrocarecurrently operates 11 clinics in Brazil and 1 in Angola; approximately 90% of itspatients are covered through Brazils Unified Health System (SUS).

Narayana Hrudayalaya (NH), the largest provider of heart surgeries in India (and

one of the largest in the world), uses a high volume-low cost delivery model andcross subsidization to provide reduced-fee or free care to about 60% of itspatients.

Furthermore, a number of technology providers are developing and rolling outmobile-phone adapted software (see GlicOnline, Mobile Phones for HealthMonitoring, MediNet) to help patients better manage conditions such asdiabetes and cardiovascular diseases.

Though its evident that a number of independent pro -poor initiatives are indeedtackling NCD care in the developing world, an important issue remains how does the

global health community ensure that these efforts are plugged into a wider supportsystem, one that aids the acquisition of low-cost quality drugs and encouragescompliance with established operational and quality standards?

Nikki Charman, PSIs Global Service Marketing Manager , discussed how the socialfranchising model already widely used for family planning and the diagnosis andtreatment of infectious diseases such as HIV/AIDS, Malaria and TB can be applied tothe prevention and control of NCDs. In Myanmar, Sun Quality Health is beginning tooffer low cost cervical cancer screenings and cryotherapy (the use of cold temperaturesto destroy abnormal tissue) through its network of franchised clinics .

Similar initiatives are underway in Kenya and Uganda. Although several aspects of thesemodels appear promising, a host of unanswered questions remain. How can providersbe incentivized to deliver long-term care? How does a social franchise networkcoordinate across the continuum of care? How would social franchising address thesteep cost of NCD care?

Ensuring that countries are prepared to meet the shifting burden of diseases will requirecollaboration between both the public and private health sectors, as well as cross-sectoral support and assistance from the international community. Are we up to thechallenge?


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How to engage private sector doctors to deliver highquality and affordable priority care servicesMaking an impact with social franchising in Asia's second poorest state, where 80% of

health transactions take place in the private sector

By John HetheringtonSun Quality Health, MyanmarMay 26 2011

In 2010, the PopulationServices International (PSI)program, Sun Quality Health(SQH), and its sister networkof village health workers, SunPrimary Health, performedmore than 2.1 million client consultations in Myanmar. John Hetherington, who hasmanaged the network since 2007, talked to CHMI about how in the second-poorestcountry in the Asia-Pacific region SQH has assembled one of the broadest servicepackages of any social franchise network operating today in an attempt to provide high

quality, well regulated priority health services to local people.

CHMI: You offer a wide range of services under the Sun Quality Health brand. How doyou select the services the brand will include? John Hetherington: With a backbone of 1200 doctors in more than 200 townships, wecan be entrepreneurial. We first ask, is there a need not being met? And is there anopportunity for a network of providers to offer that service? In Myanmar, the largesthealth concerns malaria, family planning, pneumonia, diarrheal disease, TB areeither too expensive to treat, or doctors dont provide the right quality service. As inmany places, we started with reproductive health and family planning, where there is a

natural fit for social franchising.

Why is it that so many social franchising programs start by offering family planning? JH: I think family planning is unlike other services because everyone from 15-49 ispotentially a client meaning, they are theoretically all fertile -- and this makes itdifferent than addressing diseases which require many more inputs to be efficient,targeting, testing, etc., particularly in Asia, where many of the big diseases tend to beconcentrated epidemics. With FP, you have the potential to offer (almost) anyone you
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interact with something that can be of service to them. You have the potential for largescale impact without the precise geographical targeting that you would need to treat anepidemic.

Without using the media to market to clients, how does your franchise attract clients?

JH: Advertising for medical services is illegal. Here, as in many countries, there are lotsof people who go to their local doctors when they are ill or think they are ill. Many of these doctors have practiced for 20-30 years without continuing medical education.These are the doctors we retrain, so [with their clients] we have a captive audience, in away.

How do you set prices? JH: We set prices in a way that they are not a barrier to the poorest person we want to

reach in the given target. Wemake services available at a price

people are expecting 50 centsto a dollar for a malariatreatment, versus the five to sixdollars it would cost otherwise. If we were not subsidizing theseservices, doctors would notprovide them, or they might givepatients the wrong drugs--give aninjection, for example.

Speaking of which, how do you ensure quality? JH: Social franchising is more complex to manage than other channels of socialmarketing you need higher levels of training, monitoring and supervision.On our staff, we have close to 80 doctors that, on average, visit each of the 1200 clinicseve ry six weeks. They observe service delivery and answer the franchisee doctorsquestions. We also send mystery clients to assure that the level of service qualityremains intact. We use vignettes in training.These techniques ensure that [franchisees] are not gauging people with prices or givingthe wrong treatment. However, we dont own these clinics. We hope the trainingaround good hygiene, infectionprevention, client relationships, and

counseling improves overall practices,since we dont monitor heal th areasoutside the SQH basket of services.

Is it difficult to get providers toparticipate? JH: No their business increases. Theirreputation is better, they have more


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services to offer, and their customers can get an IUD for 50 cents instead of 50 dollars.In Myanmar, the public sector is not able to serve the needs of most people; 80-90% of people go to the private sector for health care. This is not unique. The private sector,while used by everyone, is atrocious in most places. With proper management,however, it can be made to do less harm and even do very good work.

I have had surrealistic conversations with some country officials or [global health policymakers] where someone asks [a policy maker], what is your national protocol for first-line treatment for malaria? Yet, if you look at the data, 99% of people go to a pharmacyand buy drugs off the shelf. Some have to have a philosophical shift to understand this.

Describe your relationship with the Myanmar government. JH: There is always a give and take between an NGO and the government. We have alongstanding relationship with the government in Myanmar and some of our staff areformer civil servants. [Officials] appreciate that we are improving the quality of services

by providing continuing medical education where there is none, and reporting ontreatments not captured by the national health management information system.

The health minister has also seen the impact of Sun Quality Health. Its not minoritsproviding something like 25% of all family planning services, and we are detecting andtreating more than 12% of all TB cases nationally.

We heard you are now offering screening for cervical cancer, which is very unusualeven though 80% of cases occur in the developing world. JH: Our franchising director at the time, Dr. Nyo Nyo Mihn learned a couple of years agoat a medical quality conference funded by one of our donors that you can screen [forabnormal cells] with acetic acid and treat abnormal cells with cryotherapy using Co2 inlow res ource environment, all without electricity. PSIs innovations fund allows us to beentrepreneurial without massive amounts of money, so we are now beginning training.Some people in the health ministry are concerned that private sector doctors should bedoing something they consider to be a hospital service. But almost no one is doingcervical screenings anywhere, so again, there is a choice of doing nothing, or doingsomething in partnership with the health facilities that are actually being accessed bypeople. We are also piloting a basic package of anti-retroviral therapy with 100 clients,which hasnt yet been done in social marketing.

You also provide TB screening and treatment. JH: Starting this intervention in 2004 was our biggest gamble. A recent study showedthat the TB prevalence in Myanmar is five to six times higher than what was previouslyestimated. Now, our franchise does more than 12% of all case detection and treatmentin the country.

Recently, in a village meeting, a woman spontaneously came up to us in tears. She toldus she had been dying from TB and the treatment she got from a government clinic


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wasnt working for her. A PSI health worker told her to go to a *Sun Quality Health+doctor. She said, Im healthy now and you saved my life. I was thinking, thats oneperson, and there are 17,000 people every year getting that service that wouldotherwise die, and give TB to eight other people.

Yet, you still have people outside the country saying you cant work ethically inside thecountry, and the regime here can also be xenophobic. We can negotiate between thosetwo things the government doesnt see *the program+ as impinging on theirsovereignty and the opposition doesnt see it as giving succor to the regime. This modelwould be interesting to use in other difficult political situations, perhaps in Zimbabwe.


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Improving infant survival by engaging the private sectorin BiharHope blooms in Indias most impoverished state

By Priya AnantACCESS HealthInternational, IndiaApr 27 2011

If you told me fiveyears back I would beworking in Bihar on asophisticatedgovernment contracting program to improve child survival I would have beenincredulous.

For many years simply driving through the state was not safe, due to very poor law andorder situation. The restoration of law and order has been a huge change in Bihar overthe last few years. This has emboldened many development agencies and donors tocome into the State, and the launch of new initiatives including the one that took me to

Bihar recently for a two week vis it to interview state health officials.

Traveling in Jehanabad and Nalanda districts, I understood songwriter Gulshan Bawrasinspiration when he wrote the beautiful lyrics Mere desh ki dharti sonaa ugale, ugalehire moti....mere desh ki dharti, or the earth of my country produces gold, silver anddiamonds. Endless fields of golden grain swaying gently in the summer breezecontrasted with the states s till -significant problems. Bihar grapples with widespreadlandlessness government estimates 10 percent overall, but sample surveys haveshown pockets that have over 50% landless half the population living below thepoverty line, and a huge burden of maternal and infant deaths.

Abundantly endowed with natural resources, Bihar has one of the poorest healthindicators in the country, aggravated by poverty. Human Development Index for Indiaversus Bihar was 0.612 versus 0.476 in 2007.

Many may be surprised to learn that a large percentage of poor in Bihar seek care fromthe private sector. 70% of the doctors are in the private sector and the remaining 30%have a right to be there too, beyond office hours, if they choose to. Unfortunately the
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private sector is largely unregulated and subject to market forces with littlegovernment oversight, the rate, nature and quality of services is too often determinedby whether the services are available from other sources and how they are priced andprovided.

Yet as I learned during my visit, there is obvious commitment to change the status quofrom a newly invigorated state government with an ambitious agenda to redeem thestate. Primary education and health have to be provided for by the government, asenior administrator told me.

There is also frantic infrastructure building activity across the state. The State HealthSociety, Bihar (SHSB) is one of the swankiest state offices that I have been to. The officeis imbued with a sense of urgency, including a biometric attendance system for staff. Inour interviews about child health programs, senior heads of departments at SHSBshared their concern about the shortcoming of existing staff quality, productivity, and

insufficient numbers. Indeed, of the 80,000 odd Accredited Social Health Activist (ASHA)workers across the State, 40% are yet to be trained on the first four of seven modules.

Government is responding by stepping up the pace by expanding the trainer institutions.Last year, the state actually could not absorb its funds, and returned Rs. 696 out of the1,274 Crores (USD 1.39-2. 55 billion) unspent to Indias central health ministry, alongwith an interest of Rs.17 Crores (USD 3.4 million). I am skeptical that more money wouldtranslate into improved health care availability and attendant improvement inindicators.

I was in Bihar on a project for the state government to engage private sector providerswith the goal of improving infant survival, the third phase of ACCESS HealthInternationals engagement with our partner, the Norway India Partnership Initiative(NIPI). Earlier phases included a workshop that was focused on understandingexperiences in the country as well as global experiences in government contracting orPublic Private Partnership (PPP). State and district-level research on the state of theexisting private sector highlighted the need and opportunity to engage the privatesector. The third phase of our engagement with NIPI is to help the governmentstrengthen the infant care services through the public system as well as create pilotsengaging private sector for infant care provision. Our scope of work is to help structure,design the purchase and work with the government to implement and fine tune the

design so it can be scaled across the state. We work in Bihar and Orissa as part of thistwo-year project (the experience will be documented on the Center for Health MarketInnovations, l ike other government contracting initiatives in India).

Aside from NIPI, with its agenda to catalyze action, many development partners areworking to shore up the states health. DFID pr ovides technical assistance to the Statefor Public Private Partnership structuring and execution and undertaking health sectorreform. UNFPA focuses on improving access to good quality family planning services.


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The latest entrant, the Bill & Melinda Gates Foundation, has provided two largeimplementation-focused grants, a consortium led by CARE and a grant for World HealthPartners to expand from neighboring Uttar Pradesh to Bihar. The outlays of thedevelopment partners vary between Rs.45 to 2,000 Crores (USD 9 million to 4 billion) for

the next five year period. But what is common among most partners is the agenda of working with the Government to strengthen health systems.

A stewardship role to be played by the government would help these agencies to alignmissions, work together and with each other in a meaningful manner. The informalchannels of communication currently used would then be formalised.Bihar currently has an IMR of 52/ 1,000 live births, against the national average of 50,and aims to reach below 30 by 2012. 53,000 infants were lost last year according to theStates data. We are now out on a fact finding mission in Bihar to collect data includingfacts, figures and human stories to corroborate the need to make infant care services

available to the poorest, no matter where it comes from...public or private. The goal isto just help influence decisions to do what is most required to ensure that infants arenot lost due to notional boundaries and fixed ideologies around provision roles.

With 10 years of program design and implementation experience, Priya Anant leads theIndia hub of the Center for Health Market Innovations at ACCESS Health International.

ACCESS also works in Bihar under a grant from the Norwegian government.

2011 is declared as the year of safe motherhood in Bihar. This was at the unveiling of thedeclaration in the State Health Society, Bihar office.


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Foreign investors, successful businesses invest in Kenyaswhite hot health marketInsurance and hospital companies poised to expand operations with foreign capitalinfusion

By Elizabeth MalobaInstitute of Health Policy,Management and Research, KenyaApr 4 2011

Forecasts of 6% expansion in Kenyasprivate health sector are drawing theinterest of private equity firms inEurope and driving local firms to enter that promising sector.

A recent editorial by journalist Edward Okeyo, brought to my attention by a friend,argues that the health sector easily outperforms the stock exchange and maybe eventhe real estate industry.

Okeyo points to a new breed of doctors armed with MBAs and a desire to turn the

sector into mainstream business as driving significant recent investments from foreignventure capital firms.

In January, the German-based private equity fund Africa Development Corporation(ADC) bought a 25% stake in Resolution Health EA Ltd, an insurance provider planning toexpand across Kenya and regionally. Resolution covers 42,000 people and 870companies in Kenya. Last year, UK-based private equity firm Aureos Capital bought a26% stake in Nairobi Womens Hospital, investing 199.5 million shillings or $2.5 millionUSD, with which the hospital company will build three health facilities across east Africa.According to a Reuters report, Aureos will inject $4- 7 million into Kenyas healthcare

sector this year.

According to the Reuters story, the value of health services in Kenya rose to $753.8million between 2005 and 2009 and an International Finance Corporation studyestimates that the sub-Saharan African region requires $25-30 billion in newinvestments in health in the next decade to meet growing demand.
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Journalist Okeyo also hinted in his editorial that the company Equity Group may bestarting up Equity Health before too long, concluding, if its anything like theirbanking model, I wont be surprised to see a franchise of quality and affordable healthfacilities complementing their health insurance business.

Nairobi Womens Hospital and Resolution Health are not typical pro -poor products, butthey serve the poor through CSR programs. Equity on the other hand is a predominantlypro-poor banking model, which is why the author comments that if their health productis anything like their banking product it will be dramatically different from many marketofferings. It is yet to start and there is not much known about it. As such we have to waitand see.


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Data, data all around, but plenty of ways to understandwhat it all meansA visit to a data mecca in Seattle yields information on new data display tools

Posted by Donika DimovskaResults for DevelopmentInstitute, USAApr 5 2011

The Global Health Metrics andEvaluation 2011 conference,organized by Seattles Institutefor Health Metrics andEvaluation (IHME) with severalpublic health schools, was a provocative gathering of leaders and bright young minds inscientific evaluation and data visualization. Talks focused on designing new country-specific development indicators (the next MGDs), the growing importance of non-communicable diseases, and a movement for greater country ownership of datacollected indigenously, as well as the responsibility of analysts to producing synthesis for

non-academic audiences. See a summary of the conference here by Lancet editorRichard Horton.

Also on the docket, and of keen interest to CHMI with its expanding database: A batteryof new methods and tools to parse and visualize data (also covered in the New YorkTimes Business section recently). Methods tend to focus on improving predictive validityand objectivity to inform policy decision-making.

Data and visualization Afripop.org, initiated in July 2009, produces detailed maps depicting population

distribution throughout Africa. Afripop uses fine resolution satellite imagery toshow settlement maps that are combined with land cover maps. They then plugin population counts from census data.

Esri/ArcGIS digitally creates and "manipulates" spatial areas to help with datamanagement, planning and analysis, business operations, and situationalawareness, for example decision support. You can create 3D data, maps, globes,and models on desktop and share them for use on a desktop, in a browser, or ona mobile device.
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Tableau Public is a free service that lets anyone publish interactive data to theweb. Once on the web, others can interact with the data, download it, or createtheir own visualizations of it (Tableau gallery pictured above). No programmingskills are required.

Publically-available databases The Global Health Data Exchange (GHDx) data catalogue, launched by IHME atthe conference, has 1,000 datasets in the catalog, including surveys, censuses,administrative data, statistical yearbooks, and hospital data. The CDCs Divisionof Reproductive Health will use GDHx to disseminate its reports and datasets forsurvey data collected for 30 countries receiving technical assistance from thedivision for the past 35 years. Datasets will cover topics including pregnancies,births, contraceptive use, prenatal care, nutrition, delivery assistance,immunizations, behavioural risk factors, and domestic violence.

For US-health data sets, tools and apps, researchers can now navigate toHealthData.gov, just launched last month.


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Innovations in Drug AdherenceAn illuminating presentation from the 2011 Unite for Sight Global Health & InnovationConference

By Trevor LewisResults for DevelopmentInstitute, USAApr 19 2011

This past weekend (April 16-17)

saw more than 2000 students,doctors, public healthprofessionals, policy makers,activists, scientists, venture capitalis ts and philanthropists (and others!) descend onNew Haven, CT for the Unite for Sight Global Health & Innovation Conference held atYale University. Participants hailed from all 50 states and more than 55 countries.Session topics ranged from presentations on maternal and child health, to workshops oninnovation dissemination to social enterprise pitches. Unsurprisingly, one topic thatsurfaced frequently was the use of technology and point-of-care diagnostics. Here is oneof the presentations that stood out most to the author:

"Wireless Adherence Monitoring Technology," presented by Jessica Haberer , MD, MS,Research Scientist, Harvard Institute for Global Health; Assistant in Health DecisionSciences, Massachusetts general hospital; Instructor, Harvard Medical School

Dr. Jessica Haberer focused her presentation on the fact that, even in developedcountries, only about 50% of patients adhere to medications for chronic diseases. Todeal with this, a number of monitoring practices have been developed, from moresubjective self-reporting by patients, to more objective pill counts, reporting of pharmacy data and testing of drug levels. Nevertheless, all of these standard monitoringpractices detect lack of adherence too late which can have serious clinical consequences

for the patient. New technologies can help in three ways:

1. Mobile phones allow patients to report their adherence through live calls, textmessage and interactive voice response. The ease of use of mobile phonesmeans that patients can report more frequently and immediately after they taketheir dose, which helps solves problem of recall bias (forgetting details). Inaddition, the use of mobile phones can be desirable due to the anonymity that
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they provide. Still, phones do have their limitations. For example, the use of mobile phones depends on network availability and user understanding of thetechnology itself. In addition, identification problems can arise when phones areshared, as is often the case in developing countries.

2. Wireless pill containers offer an interesting alternative to mobile phones. In this

case, patients take their pills from a special container whose cap contains anSMS chip and can alert a health worker every time the container is opened.Current versions of this technology have batteries that last for approximatelythree months. Early pilots have shown high levels of acceptance of thistechnology in developing countries, however this option is limited by the highcost per device (USD$100-200).

3. Wireless Ingestion Monitors represent the most futuristic and high tech of thethree options. New technology created by MagneTrace uses a specially designednecklace and a magnetize pill to detect when a pill has passed through theesophagus. Alternatively, X out TB employs special strips of paper that react withmetabolites in the patients urine (which are only present after ingestion of apill) to reveal a code that the patient must then text in to a health worker. Othertechnologies can detect metabolites on the patients breath. These types of solutions hold great promise, but at the moment they are prohibitivelyexpensive and require a significant level of coordination with the drugmanufacturers themselves.

In Dr. Haberers opinion, while there have been a number of successes in all three of these regions, wireless pill containers seem to hold the most promise for the moment.Nevertheless, only time and testing will reveal which solution is most effective or if anynew solutions will step in to save the day.


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Reaching the last mileBest practices for delivering health care to rural people

By Rose ReisResults for DevelopmentInstitute, USAApr 21 2011

Lessons from the Last Mile

from the e-magazine Beyond Profit featured the Top 5models that effectively reach under-served rural populations. The article gave examplesfrom many sectors, including micro-finance institutions, honey makers, and renewableenergy companies.

Realizing entrepreneurs working to deliver health services to rural populations sharesimilar challenges and opportunities to business managers in other sectors, we siftedthrough our database for programs hewing to these models. Indeed, the Top 5 modelsAbby Callard profiles cover some of the most effective programs we know working toserve people living in remote areas. Here are the Top 5 models, applied to healthprograms from our database.

1. Hub and spokes model In health this model is more complex, and it usually works via tiers of care with thespokes providing basic primary care services. Examples include Carego LiveWell in Kenyaand Merrygold Health Network in India. World Health Partners has developed asophisticated approach to service isolated villages in Uttar Pradesh and Bihar via tieredreferral and telemedicine-equipped or real visits to providers.

2. Piggyback

This is a model that uses existing trusted networks to deliver information and productsto rural villages--the example Beyond Profit gave was Gramin Suvidha Kendra's usage of the Indian Post, with its 330,000 locations, to distribute wheat seeds and water purifiersas well as obtain pricing information. Examples from the CHMI database includeMicroEnsure community health insurance, which sells its inexpensive health insuranceplans in India and Tanzania through through trusted MFI networks and church group.AYZH uses community self help groups to deliver products.


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3. Local entrepreneurs Reading about Grameen's Village Phone program, we thought of programs like Ghana'sHealthKeepers and Uganda's Living Goods which both utilize Avon-like networks of women entrepreneurs to deliver health products like mosquito nets and water

purification tablets to the door of people under-served by traditional businessdistribution.

4. Market linkage Health program models that are community-operated and deliver products are similarto the honey and cotton source Callard's examples. Vitagoat is a nutrition program thatemploys self-help groups to operate the system. The products are then sold in themarket.

5. Local centers

In this model, manufacturing facilitates are located in rural areas. In health, hospitals orclinics locate themselves in isolated, rural locations where people previously had to journey for hours or even days to reach a qualified health provider. CHMI profiles atleast 27 such facilities. Lifebuoy Friendship Hospital is a converted 38-meter long Frenchoil barge floating in the remote char areas of Bangladesh's Jamuna River with a team of medics and stocked pharmacy. SEWA Rural made its name by serving tribal people in aremote pocket of India's western Gujarat state for the past three decades. KasturbaHospital in Jagadhia district, run by SEWA with government funding, was a pioneeringexample of public-private partnership for 10 years. SEARCH is a well-known example of this in Maharashtra.Now, on to The Other Tech Revolution, the next dispatch from Beyond Profit, whichprofiles Embrace and other low cost technology.


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Expanding access to essential medicationTaking a page from the banking industry to create extension services for drug sales

By Prabal V. SinghACCESS Health International, IndiaMay 5 2011

According to WHO, 449-649 millionpeople in India lack regular access to

essential medicines. I have beenthinking about this recently since I am involved with a colleague in a study on DrugAccessibility and Affordability the two components of achieving access being physicalaccess and affordability.

As for physical access, drugs are dispensed through retail pharmacies (80 percent),hospital-based pharmacies (12 percent), government pharmacies (5 percent), medicalprofessionals (3 percent) and the rest through non government organization runprograms, according to research carried out a few years ago by Kotak InstitutionalEquity Research. Critically, most of these points of sale for drugs are located in urban

and semi urban settings while most people in India, some 70%, live in rural areas.

As for affordability, the supply chain starts, of course with R&D, and winds its way downto the tiny shops where most people buy their medication, which each chink in thesupply chain adding costs. The choice of which medication to take is actually not madeeven by the consumer but by the prescriber or in some cases by the pharmacist. Theconsumer is the most ignored stakeholder in the entire supply chain.

Are there lessons to be learned about expanding access from the banking industry? Oneof the strategies being implemented in the financial inclusion initiative is introduction of banking business correspondents. Correspondents are agents of the bank who try toextend banking services to under-served populations. According to the Reserve Bank of India, the central bank, correspondents are often groups:Banks may use intermediaries, such as, NGOs/ Farmers' Clubs, cooperatives,community based organisations, IT enabled rural outlets of corporate entities, PostOffices, insurance agents for providing facilitation services. Such services ma y include(i) identification of borrowers and fitment of activities; (ii) collection and preliminaryprocessing of loan applications including verification of primary information/data; (iii)
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creating awareness about savings and other products and education and advice onmanaging money and debt counseling *etc.+ Likewise I think we should experimentwith having medication or Drug Correspondents (DC). Identification of DCs should bepreceded by mapping of areas under-served by pharmaceutical services. Similarly,Tanzania Food and Drug Authority authorized, duka la dawa baridi (convenience store)

to sell non-prescription drugs. These stores are dot the country where licensedpharmacies are scarce. To regulate them strictly Tanzanian government converted theminto government authorized drug dispensing outlets.

Big pharma companies are also working on a rural business initiative, which apart fromincreasing awareness includes development of low cost rural brands. This is because inIndia you are not allowed to differentially price a brand across the country.

Indias pharma industry is among the worlds largest, and there is potential to reach allIndian consumers effectively. The overall health market size is estimated to be more

than $50 billion. The India exports $11 billion in generics in a global pharma market sizeof about $82 billion. Sales through the private and not for profit sector accounts foraround 94%. Government sales account for just 6% in India.

The governments National Pharmaceutical Policy for 2002 has noble intentions: Itfocuses on ensuring availability, affordability, quality in production and distribution,building internal capacities, promoting research and development and creating anenabling environment to attract investments.

Yet the reality is worth focusing in on. For acute conditions medication is hard to comeby, and for chronic conditions patients must come several times or continually topurchase medicines, exceedingly difficult for rural people.

Promising models exist both in the banking sector and in health sector in othercountries. It can be possible to expand access -- physical and financial -- of essentialmedicine to all people in India.


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Community Health workers institutionalize referralnetwork from remote village to hospital In remote tribal areas, trained local workers can contribute to achievingMDG 5

Posted by Nadira SultanaACCESS Health International, BangladeshMay 18 2011

Since I joined CHMI earlier this year, Ihave seen a number of programs that usecommunity level health workers todeliver key interventions that prevent maternal and childhood morbidity and mortality--a hot topic recently. I recently wrote about Sadija Foundation's partnership with ClickDiagnostics and my colleagues in India wrote about SEARCH, another program traininglocal people as community health workers.

Recently, I traveled to Kaptai, a region in south-eastern Bangladesh, where BasicMedical Workers work relentlessly to achieve MDG 5 in remote areas where no other

health facilities exist for poor villagers.

The Kaptai Upazila (subdistrict) is part of the Rangamati District of Chittagong Division.Eleven types of tribes (ethnic minorities): Chakma, Marma, Tanchangya, Tripura,Pankua, Lushi, Khiang, Murang,Rakhain, Chak, Bowm,Khumi livein this district. Most of the tribalpeople live in hilly villagessurrounded by Kaptai Lakewithout basic facilities of water,sanitation, transportation,health and education. Localboats or foot are the means of transportation from village tovillage and village to Kaptai cityarea.In HarinChara, one of the mostremove villages, there are no public or private sector facilities, just a few traditional
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healers and traditional birth attendant. People have no option but to seek care fromthose practitioners in times of life and death.In 2006, Christian Hospital Chondroghona (CHC) started organizing mobile health clinicsand has started up a well-designed Community Health Program for nearly 50,000 peoplein 150 disperse remote hill villages in Rangamati. The program ensures community

participation by recruiting community health workers called Basic Medical Workers fromvillages, working in consensus with village headman to create an up to date database of families in each program areas.

They encourage each household to own a family health card with unique Identificationnumber, which costs BDT 30 ($.40 USD). Families pay BDT 15/- for subsequent visit foreach family member (for post natal visits, mother and baby are considers as a singlefamily member).

The local health workers are given two months of training on basic health issues,

primary care and health emergency management before they start work with CHC.Health workers regularly visit homes to keep villagers informed on basic healthinformation on various primary care issues: national vaccine program, prenatal and postnatal care, nutrition, family planning, quick management of diarrhea, respiratoryinfection, malaria and other common ailments.

They are capable of identifying high risk pregnancy, severe diarrhea and pneumoniacase for preventing maternal and childhood morbidity and mortality. Since malaria isone of the reasons of morbidity and mortality of these hilly villages, they are equippedwith Rapid Diagnostic Test (RDT) for malaria (Paracheck Pf) and provide initial doses of anti-malarial drugs when necessary.

The workers also keep local families up to date on the schedule of the mobile healthcare facility, encouraging them to use the preventive and curative services offered, andrefer them when necessary to hospital. The hospital authority provides special attentionto the patients if come with referral documents from these community workers.

The mobile health team,which travels six days aweek and provides day-long services to eachvillage, comprises of a

medical doctor, anurse/paramedic, alaboratory technician, apharmacist and a supportstaff. They performdiagnostic services forprenatal women andmalaria tests. Government


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health workers for EPI and family planning match their schedule with the mobile team.This is a good example of public-private partnership in community health work.There hasn't been a formal evaluation yet of the community health program--it isscheduled to end on December 2012--but the intervention shows remarkable changes inhealth seeking behavior of tribal people.

A female representative of the local government expressed her satisfaction for thisintervention along with other women who I met during my visit. Further, the regularlyupdated household data shows an increased use of antenatal care, family planningand no maternal death since 2008. The program shows notable results.


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Grateful for her baby, now named for her insurance planA donor- leveraged community health insurance model that saves mothers and

infants lives grows in popularity in two Nigerian states

By the CHMI TeamCenter for Health Market Innovations,USAApril 11 2011

Attahiru Aishetu, a young woman living in

Bacita, Kwara State, Nigeria, hadobstructed labor: a potentially deadlycondition if high quality, emergency careis not available.

Fortunately, Attahiru had health insurance and was referred with her card to Ogo OluwaHospital where she delivered a baby boy through emergency cesarean surgery. Herfamily members were surprised when she told them they did not have to raise moneyfor her treatment, since her expenses were covered by her insurance. She named thebaby boy, in gratitude, Hygeia, after the community insurance plan that may have savedboth their lives.

Peju Adenusi, the Executive Direct of the Hygeia Community Health Plan recounted thisstory when we asked her recently how having insurance for the first time had an impacton peoples lives. To her its such a big deal, something great, she said, it was aturnaround in her life to hold a live baby, and all she had to do was pay about twodollars for care throughout the year.

Hygeia Community Health Plan (HCHP) was launched in 2007 in two Nigerian states,Kwara and Lagos, in partnership with PharmAccess and the Health Insurance Fund, aDutch-based fund that subsidizes the premiums. The plan which is expanding to a new

area of Kwara interested us so we rang Adenusi to find out more about how theydesigned this unique financing scheme.

How many people do you cover with HCHP? At the end of March, we had over 75,000 people enrolled, and we hope to get anadditional 25,000 with the expans ion in both Kwara and Lagos. We serve womensassociations, farming communities, trade groups, or entire rural communities. A fewexamples of groups covered by HCHP:
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Market Women Associations, Lagos Lady Mechanic Initiative, Lagos Shonga and neighboring communities, Kwara

How did you design the product?

We normally do a study on a group we think can benefit from the scheme to determinetheir income level and what they are willing to pay as a co-payment for insurance. Wethen do market research to learn more about their health care seeking behavior: focusgroup discussion, questionnaires, and household surveys.

Does the product cover all illnesses for 2 dollars a year? For N300 paid by members, it is quite a robust package. It covers a lot of communicativeand non-communicative diseases: Hypertension, malaria, child health (ARI, diarrhea),pregnancy delivery, immunization, even c-sections and minor surgeries. We picked theillnesses covered by looking at the burden of disease in that area. What makes us stand

out is that the package also covers AIDS medicine, supplied through Global Fund grants.

Health insurance is new for many people in Nigeria, so how do you market it? Its not necessarily healthinsurance specifically but ingeneral the concept of insurance is rather new inAfrica, its not reallysomething we are used to.If you ask me how manythings do I have insured inthe home, I would tell youcar is probably necessary,but home? The percentageof people who insure theirhome is very, very low.People think, there is no guarantee that Ill be ill that year and if Im not ill I wont haveto access care. People wonder, how do I access the funds?

The only way people become convinced is when they start accessing health careservices and realizing what they are getting. They were getting the quality health care

services and they tell their peers, this is real. Weve tried it and it works. We encouragethem to market the scheme to their peers. They get some commission on each personthey bring into the program. Community members trust each other.

Why did you start by marketing to women working in the Lagos markets? You need the population for the program. The Lagos Women Market Association is thesingle largest association in Lagos we have had more than 40 markets participating inthe scheme.


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Are women and others more likely to seek health care when they are covered byHCHP? Yes, they are. In Kwara for example the level of utilization is now really high. The healthcare center was almost as good as dead in Shonga 3 or 4 visits per month and when

the program started the level of utilization moved up to maybe 1000 visits in a month.

With the subsidy coming from the Dutch governments Health Insurance Fund, isHygeias plan sustainable? Eventually, when people begin to enjoy and appreciate the benefits of self-insurancescheme benefiting from service far above what you have paid for because of the

pooling effect the schemes will havegotten to the level where they would ableto pay for health insurance schemewithout it being subsidized. Co-payment is

not going to be a stagnant figure, we willreview it as we move along and try toincrease.

And actually in Kwara, the stategovernment has passed a bill in Decemberto provide an organizational and financialstructure for health insurance for less

privileged people of the state. Governor Dr. Bukola Saraki wanted to assist the lowincome earners in the state. The chairman of the House Committee on Health, Hon. BisiOloruntoba noted that the deadly diseases often affect these categories of people insociety.

What else can governments do to support community health insurance? Governments can encourage cooperatives within groups to serve as financial support orbackup for health insurance. If daily earners put aside certain amount of money everyday, there is a lump sum that the group can use. My personal suggestion is that thesegroups should be linked to microfinance institutions properly.

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