A Difficult Week

The 118th Boston Marathon is coming up in a few weeks, and I’ve heard that many more runners (35,000) and spectators (1 million plus) than in previous years are turning out, in part to refute the tragedy of last year.  I will be doing my refuting with my community response team, by setting up runners’ aid stations along the part of the course that passes through our town, and with my biking group on a predawn route ride if cycling is allowed as was in the past.  The preparations reminded me of a posting from last spring and I thought it was worth reposting.

Health Care for All

Last week was a difficult one here in Boston.  It’s really a small town and many people, me included, although not injured or killed in the bombing or the manhunt mayhem, are one or two connections removed from people who were.  Trying to make sense of the tragedy, I realized those connections are needed in healing us after episodes of hate-fuelled violence and also in preventing them.

Also last week, I attended a conference sponsored by the Harvard University Program in Ethics and Health and Harvard’s Global Health Institute on “Universal Coverage in Developing Country Health Systems:  Ethical Dilemmas,” the “universal coverage” here meaning that all citizens have access to a country’s health care system (Conference website).  I tend to stay away from these types of meetings since the participants are usually not practitioners of global health (e.g., government officials from ministries of health or health care delivery NGOs) but rather researchers and analysts whose studies may be used to make or “inform” policies of the practitioners.  However, given my interest in universal coverage (UC) in developing/emerging countries as a potent “pull” mechanism for global health businesses and in the new approaches governments and NGOs are trying to achieve UC (see my posts tagged “delivery” and “international development”) and my realization that a couple of speakers were from the developing/emerging world, I attended and am glad I did.  The conference helped me understand the philosophical, political, and practical underpinnings of UC.

The co-chairs started the by positing that UC is based on the idea that health is important to the well-being (physical and economic) of a society and countries and therefore its provision should at least be overseen, if not managed or even provided (the US not withstanding), by governments.  Then the idea is complicated by three serious questions:  who is covered and when (women and children first or those with ”curable” disease or in the government and military?); what gets covered (maternity, public health, catastrophe, and not what happens when we chose to something?); and how to pay (out of patients’ pockets, insurance premiums, general or special taxes, as a benefit of employment?).  And then underlying answering these questions are ethics, what we as individuals and a society believe is the right and just thing to do, and social equity, how a society distributes its always scarce resources to benefit its members.

The next speaker was Julio Frenk, dean of the Harvard School of Public Health, who described his experience as the minister of health for Mexico in designing and implementing the latest version of that country’s health system.  I was deeply impressed not only by his clear and thoughtful delivery but also by the politically efficient way the country addressed achieving UC (especially compared to the fractured and inefficient method in the US).  The starting point was an employment-based system (health care as a benefit) that only covered half the population of 100 million, the other half either not working, working for themselves, or employed part time or in small companies, and the explicit statement in the Mexican constitution that health was  social right.  The first step was a national debate at all levels that led to the conclusion that, since people have little control of their health (this is true on an individual level, e.g., not all smokers get cancer and some marathoners have heart attacks), everyone should have equal access to health care, and that to make this happen, each person will contribute according to his/her capacity to do so and receive services based on need.

Next the health ministry identified specific goals to be achieved (incidence of disease, infant mortality rates, longevity, etc., I think) and then what interventions were needed and been shown to be cost-effective in reaching those goals.  Dean Frenk said the ministry came up with 260 interventions and/or services that addressed 95% of the need and 67 low incidence but high impact interventions, like cancer chemotherapy.  Next was the hard part, convincing the finance minister that the UC implementation was not going to bankrupt the country and getting his backing to gain legislative approval.  The health ministry won by presenting the details on cost and advocating for a multi-year allocation, but not the number of years, hence not asking for a blank check to be spent each year on whatever the health ministry wanted, but an annual and predetermined amount to be spent as directed by the goals and interventions.  This approach worked (along with putting in place a system of accrediting health care providers to assure quality) and now, after a commitment of 1% of GNP over seven years, 52 million previously uninsured are insured and can access heath care.  For details, Dr. Frenk referred to an article he co-authored published in Lancet last year (Frenk et al. 2012) and I noted a nice summary in Nature (Nature news).  My thought was, could this multi-year effort be replicated elsewhere (like in Massachusetts)?

While I learned something from each of the subsequent speakers and discussion, I’ll skip to those who spoke on my interests, that is, what is being tried and what works (if one is interested in the rest of the conference, the organizers will up a video version in May at PEH).  Here is a short recap:

Lisa Hirschhorn spoke about Rwanda from her experience with the NGO, Partners in Health, and noted that an national insurance program, implemented 2000-2008, has achieved 85% coverage for basic and catastrophic care but that the health care is still a major out-of-pocket expense for the poorest.  She also noted the UC plan includes direct financial assistance to pay for health-related expenses like better food and transportation to clinics and the training of heath care workers to do tasks they were previously not “qualified” to do, so called “task sharing” but its utility had not been determined.

Emanuela Gakidou of the University of Washington described measuring health outcomes in Zambia where a concentration on maternal and child health has decreased child morality by one-third in eight years but infectious disease mortality has not budged despite efforts like increased bed net use for malaria prevention, use of regional hospital rather than clinics, and access to anti-viral treatment.

Richard Levins, a Harvard ecologist and self-described third-generation Communist, spoke glowingly about Cuba where health care is integrated with other social services, is community-based (one clinic per 1000 people), and has achieved some of the best measures of health in the Western Hemisphere.  He also noted a shortage of toilet paper in the hospitals and a need to import 30% of the country’s food.

Peersapol Sutiwisesak of Thailand’s National Health Security Office (NHSO) noted that Thailand undertook a forty-year UC effort, that UC was achieved in 2003, and now, in addition to overseeing the system, his office is offering guidance to other countries interested in the Thai approach.  I wasn’t clear on the details (which can be found at NHSO) but understand it is insurance-based with two tiers of costs/benefits, emphasizes rural capital investments (I guess it assumes that for-profits will concentrate in the cities), is audited yearly by the inspector general, uses a mix of payments methods (e.g., fee-for-service and capitation), and has incentives to providers for improved quality.  The Office also has pooled procurement for medical devices and group that evaluates the cost-effectiveness of new interventions.  I think I noted that he said this combination had significantly decreased the cost of dialysis and led to rejection of the new HPV vaccines since the group and the pharma companies could not agree on a price (I think they did not try hard enough).

Health Care for All

Last week was a difficult one here in Boston.  It’s really a small town and many people, me included, although not injured or killed in the bombing or the manhunt mayhem, are one or two connections removed from people who were.  Trying to make sense of the tragedy, I realized those connections are needed in healing us after episodes of hate-fuelled violence and also in preventing them.

Also last week, I attended a conference sponsored by the Harvard University Program in Ethics and Health and Harvard’s Global Health Institute on “Universal Coverage in Developing Country Health Systems:  Ethical Dilemmas,” the “universal coverage” here meaning that all citizens have access to a country’s health care system (Conference website).  I tend to stay away from these types of meetings since the participants are usually not practitioners of global health (e.g., government officials from ministries of health or health care delivery NGOs) but rather researchers and analysts whose studies may be used to make or “inform” policies of the practitioners.  However, given my interest in universal coverage (UC) in developing/emerging countries as a potent “pull” mechanism for global health businesses and in the new approaches governments and NGOs are trying to achieve UC (see my posts tagged “delivery” and “international development”) and my realization that a couple of speakers were from the developing/emerging world, I attended and am glad I did.  The conference helped me understand the philosophical, political, and practical underpinnings of UC.

The co-chairs started the by positing that UC is based on the idea that health is important to the well-being (physical and economic) of a society and countries and therefore its provision should at least be overseen, if not managed or even provided (the US not withstanding), by governments.  Then the idea is complicated by three serious questions:  who is covered and when (women and children first or those with ”curable” disease or in the government and military?); what gets covered (maternity, public health, catastrophe, and not what happens when we chose to something?); and how to pay (out of patients’ pockets, insurance premiums, general or special taxes, as a benefit of employment?).  And then underlying answering these questions are ethics, what we as individuals and a society believe is the right and just thing to do, and social equity, how a society distributes its always scarce resources to benefit its members.

The next speaker was Julio Frenk, dean of the Harvard School of Public Health, who described his experience as the minister of health for Mexico in designing and implementing the latest version of that country’s health system.  I was deeply impressed not only by his clear and thoughtful delivery but also by the politically efficient way the country addressed achieving UC (especially compared to the fractured and inefficient method in the US).  The starting point was an employment-based system (health care as a benefit) that only covered half the population of 100 million, the other half either not working, working for themselves, or employed part time or in small companies, and the explicit statement in the Mexican constitution that health was  social right.  The first step was a national debate at all levels that led to the conclusion that, since people have little control of their health (this is true on an individual level, e.g., not all smokers get cancer and some marathoners have heart attacks), everyone should have equal access to health care, and that to make this happen, each person will contribute according to his/her capacity to do so and receive services based on need.

Next the health ministry identified specific goals to be achieved (incidence of disease, infant mortality rates, longevity, etc., I think) and then what interventions were needed and been shown to be cost-effective in reaching those goals.  Dean Frenk said the ministry came up with 260 interventions and/or services that addressed 95% of the need and 67 low incidence but high impact interventions, like cancer chemotherapy.  Next was the hard part, convincing the finance minister that the UC implementation was not going to bankrupt the country and getting his backing to gain legislative approval.  The health ministry won by presenting the details on cost and advocating for a multi-year allocation, but not the number of years, hence not asking for a blank check to be spent each year on whatever the health ministry wanted, but an annual and predetermined amount to be spent as directed by the goals and interventions.  This approach worked (along with putting in place a system of accrediting health care providers to assure quality) and now, after a commitment of 1% of GNP over seven years, 52 million previously uninsured are insured and can access heath care.  For details, Dr. Frenk referred to an article he co-authored published in Lancet last year (Frenk et al. 2012) and I noted a nice summary in Nature (Nature news).  My thought was, could this multi-year effort be replicated elsewhere (like in Massachusetts)?

While I learned something from each of the subsequent speakers and discussion, I’ll skip to those who spoke on my interests, that is, what is being tried and what works (if one is interested in the rest of the conference, the organizers will up a video version in May at PEH).  Here is a short recap:

Lisa Hirschhorn spoke about Rwanda from her experience with the NGO, Partners in Health, and noted that an national insurance program, implemented 2000-2008, has achieved 85% coverage for basic and catastrophic care but that the health care is still a major out-of-pocket expense for the poorest.  She also noted the UC plan includes direct financial assistance to pay for health-related expenses like better food and transportation to clinics and the training of heath care workers to do tasks they were previously not “qualified” to do, so called “task sharing” but its utility had not been determined.

Emanuela Gakidou of the University of Washington described measuring health outcomes in Zambia where a concentration on maternal and child health has decreased child morality by one-third in eight years but infectious disease mortality has not budged despite efforts like increased bed net use for malaria prevention, use of regional hospital rather than clinics, and access to anti-viral treatment.

Richard Levins, a Harvard ecologist and self-described third-generation Communist, spoke glowingly about Cuba where health care is integrated with other social services, is community-based (one clinic per 1000 people), and has achieved some of the best measures of health in the Western Hemisphere.  He also noted a shortage of toilet paper in the hospitals and a need to import 30% of the country’s food.

Peersapol Sutiwisesak of Thailand’s National Health Security Office (NHSO) noted that Thailand undertook a forty-year UC effort, that UC was achieved in 2003, and now, in addition to overseeing the system, his office is offering guidance to other countries interested in the Thai approach.  I wasn’t clear on the details (which can be found at NHSO) but understand it is insurance-based with two tiers of costs/benefits, emphasizes rural capital investments (I guess it assumes that for-profits will concentrate in the cities), is audited yearly by the inspector general, uses a mix of payments methods (e.g., fee-for-service and capitation), and has incentives to providers for improved quality.  The Office also has pooled procurement for medical devices and group that evaluates the cost-effectiveness of new interventions.  I think I noted that he said this combination had significantly decreased the cost of dialysis and led to rejection of the new HPV vaccines since the group and the pharma companies could not agree on a price (I think they did not try hard enough).

Medical Walmartinization

I had the opportunity earlier this week to utilize our local, top-notch medical system for a treatment of a serious, but not life-threatening, condition and emerged much improved if not cured.  We here in Boston have medical care in-depth, ranging from physicians and therapists of every type to high-tech centers for cardiology and oncology.  The industry is a major state employer and attracts patients and medical trainees from around the world.  It is expensive, too, with the highest cost per resident in the country, but all the responsible parties- insurers, hospitals, and government- have been making a serious effort for several years to get everyone insured and contain costs.  It seems to be working and, for the better I hope, it provided models for many of the provisions of the Affordable Care Act, the consequences of which we’ll all get to experience.  For an instructive and humorous read on the Act, I suggest the graphic book by Jonathan Gruber and Nathan Schreiber, “Health Care Reform” (four stars and less than $10 at Amazon books).

One thought I had while recovering in the Recovery Room (a good place to do it) was if and how the potent and expensive medical system we enjoy here can replicated through out the world.  It is a daunting task given the vast disparity in countries’ economies that are available to be applied to the problem:  there is a 40 times difference between the gross national income of the United States and Uganda and even a 5x difference for the soon-to-be-largest world economy, China (World Bank data).  One key is to bring costs down.  While progress has been made in increasing access to low-cost care through multi-national efforts, private charities, and governments which have recognized their responsibilities, I think there is a place for commercial efforts, too.  In several past posts, I put my amateur economist hat on and wrote about ways companies powered by profits could address unmet medical need affordably, for example, through insurance programs for basic essential health services (could be under $100 per person per year, “Boot Straps”) and utilizing alternative delivery methods to the current donor-to-government-to-public provider system (“Affordability Revisited”).

One example of a relatively new and successful commercial approach to medical care provision that I have mentioned before is the Narayana Hrudayalaya Hospital system of India (NH system).  Founded in 2001, it now includes 14 hospitals, a telemedicine practice reaching more than 100 facilities (Wiki article), and an insurance program with millions of subscribers (Yeshasvini scheme).  The founder/visionary of the system is Devi Shetty, a former cardiac surgeon, who has focused relentlessly on the  mechanics of delivering quality care, taking what he has called “the Walmart approach” to bringing costs down.  Some specific methods given in a Fast Company article and a review by the Wharton on-line business journal, India Knowledge @ Wharton (Wharton review) are:

  • operating on a very large scale (the largest center has 3,000 beds, more than 20 times as many as the average US hospital);
  • buying directly from suppliers and negotiating best price;
  • minimizing paperwork for surgeons through a large support staff;
  • paying surgeons a fixed salary instead of per operation so the cost to the hospital drops as the number of procedures increases;
  • treating any and all patients from the poorest to foreign medical tourists with services priced by ability to pay; and
  • monitoring costs of operations and reimbursement daily and adjusting the mix of patients to maintain service and income.

As with Walmart, the system has plans for expansion with a goal of a hospital in every major Indian city and overseas joint ventures, for example, in the Cayman Islands and Miami.  Dr. Shetty’s utopian vision:  reducing health care costs by 50% and achieving affordable access to most Indians in 5-10 years (NH press release).  A laudable goal and I wonder if the progressive medical minds of Massachusetts have taken note.

Innovate or Go Away

A few weeks ago, the Center for Health Market Innovations (CHMI) alerted me that it had surveyed likely users of its services and was reporting the results (CHMI blog), and I, being interested in “policies and practices that improve privately delivered health care for the poor in low- and middle- income countries,” followed up.  CHMI is a grant-funded program of the contract consulting company, Results for Development Institute, with the ultimate goal of having its users learn from each other, find resources (like funding), and ultimately improve health in their countries.  From my perspective, as I wrote in a post last December (“Innovate or Die”), the Center’s most important function may be to provide a framework for comparing the effectiveness of the programs, the health market innovations.  Such comparative performance measurement is needed for organizations to know if they are meeting their goals, to learn from others what improved their performance, and to justify the public and private funding they receive.  So the good news is that CHMI measured its own performance; the less-than-good news is that it doesn’t seem to have learned from the results.

According to the CHMI blog posting, about “600 program managers, donors, investors, researchers, policy makers, and other key health system stakeholders” were surveyed by the Center (it’s not clear how many were from outside the grant-funded world) and about 60% said they wanted CHMI to provide more information on what works.  CHMI’s response is that it will continue to collect data as before, but, with only about a 13% rate for self-evaluation (148 out of 1151 programs), CHMI needs to ramp up its effort (CHMI Reported Results), either by doing the evaluations themselves or requiring them.  CHMI also said that almost all respondents wanted more and different information which it will try to collect; my thought is that CHMI should just make it easier for its users to find specific information from the participating programs, e.g., by providing  contact names and email addresses, which it doesn’t (one can send a message to an unidentified recipient).  Finally, CHMI reported that “many innovators are keen to connect with potential partners, including government leaders, to share their ideas [I think the innovators would better off by pitching their programs as effective and affordable].”  So CHMI apparently will be encouraging its “network of partners” (there are nine organizations listed as Partners) to “host competitions and other events to connect innovators with policymakers and other potential funders.”  I interpret this to mean CHMI will enable personal, rather than virtual, connection, but specifics are lacking.

It seems to me that CHMI should move beyond collecting and cataloging data to actively enabling its users to connect to resources  that will help them accomplish their missions of improving health care- knowledge, information, and money.  CHMI should emulate the many successful programs that exist to help innovators and entrepreneurs create successful businesses.  Here in the Boson area, there are two good examples. One is Greenhorn Connect (GC) which operates on a shoe-string budget and has directories of funders and service providers, a calendar of events, a job board, blogs, and news.  My favorite event is “office hours” when someone with knowledge to share shows up at a coffee shop for a couple hours to speak with whomever drops by.  The other is MassChallenge (MC) which has a modest budget from the state government and a bunch of companies.  While the MC is billed as a competition (which is not about learning), and it does award cash to a group of start-ups picked by volunteer, expert judges, it is really framework for aspiring entrepreneurs to learn from each other, and volunteer advisers, mentors, and professionals like attorneys.  In a relatively a short time of about six months, the founding teams work on defining goals and executing plans aimed at creating viable businesses, whether that business will sell shoes (Samanta) or cheap individual water purifiers (Osmopure, Osmopure).  Another start-up support program is VC4Africa (VC4Africa).  It operates on a continental scale as an on-line community that promotes connection between entrepreneurs and investors.  Entrepreneurs publish business ideas, get feedback, meet experts, and seek funding as needed.  Registered investors can find pre-screened ventures and review the ventures that match their investment criteria.  One of VC4Africa’s tools is to organize meet-ups in convenient locations, like pubs, for like-minded people to connect.

One difference between the users of these programs and CHMI is that many of CHMI’s users have more operational experience than an entrepreneur who still has 3-4 attempts at starting a business ahead of her/him.  But then CHMI’s users should be faster learners, making its work easier.  Perhaps, CHMI should look more closely at the results of its performance evaluation, look for models of successful innovation support programs, and engage someone with business start-up accelerator experience to help rethink their services.

Down at the A&P

One may remember that in my posting last week (“Playing the Long Game”), I mentioned that the big pharma company, Novartis, was trying its hand at improving the delivery of health services in rural India.  Based on the limited information I had, Novartis started the program, called Arogya Parivar (“Happy Family” in Hindi), in 2007, and that it involves infrastructure development and health education, now reaches 42 million people, is “generating profits,” and is intended to be a sustainable, scalable business to improve health.  Interested in understanding the model, its economics, and potential for being replicated in other settings by Novartis or its competitors, I looked for more information.  Unfortunately while I found additional details, I did not come up with a description of its business and operating plan or an analysis of its potential and welcome any suggestions on sources of better information.

Novartis provides a general description of Arogya Parivar (AP) as part of its corporate responsibility/access to health care/social business webpage (Novartis CR), and AP’s top guy, Anuj Pasrija, Head of Social Business, Emerging Markets Group (Pasrija profile), has given a few presentations on the program, e.g., to the Associated Chambers of Commerce and Industry of India in November 2010 (Pasrija presentation) and at a corporate social responsibility conference in June 2011 (CSR conference).  I also found two laudatory reviews of AP with some details by an international PR firm (Incanus article) and an Indian-based social enterprise blog (Beyond Profit blog) and a recent “case” write-up by Jain et al. in the International Journal of Business and Management Cases (Jain et al 2012).

From these sources, I summarize AP’s primary features as follows:

  • A grassroots health education program covering diseases specific to a region provided by local, Novartis-trained “health educators” who refer patients to doctors, liaise with local health-related NGOs, and apparently sell drugs on a 10% commission basis;
  • An outreach program through “heath camps” provided by doctors who visit under-served villages and conduct free basic exams (it is not clear if these doctors also sell drugs);
  • A program run with micro-financing institutions to improve the ability of doctors and pharmacies to maintain stocks of drugs and/or improve their operations; and
  • The packaging of AP’s products (80 pharmaceutical, generic, and over-the-counter drugs) in small-quantity (several days of doses), low-priced packs [it is not said how this sales strategy affects compliance].

But while Jain et al. report AP is monitoring the “number of people covered in a health education and awareness program, number of health camps conducted, number of new patients diagnosed and number of doctor referral cards distributed,” they do not provide these data, and apparently AP is not measuring subsequent improvement to the health of its participants.  Based on the numbers from Jain et al. and Incanus article, it looks to me as AP is very widely dispersed, perhaps even overly dilute, that is, a small number of AP employees or affiliates covering a large territory.  There is one supervisor and eight health educators for each “cell,’’ of which in 2009 there were 280, each including between 180,000 and 200,000 inhabitants.  In terms of direct contact, each educator is said to have 30 “patients” or about 0.12% of those in his/her territory.  AP is said to conduct 500 health camps per month which, guessing at 500 attendees each, means the camps reach about 0.05% each month or less than one percent in a year.  As for the economics, Jain et al., as well as the Novartis web page, state AP “achieved break-even within 30 months, and since 2007, sales have increased 25-fold” without giving specifics.  Novartis is apparently satisfied with the economics.  Jain et al. report that Novartis plans to expand the program to cover 350 million people in India in ten years, and Novartis notes on its web page that it is testing similar programs in selected Asian and sub-Saharan countries.

To get more specifics, I turned to a database complied by the Center for Health Market Innovations (CHMI), a project started in early 2010 with Gates and Rockefeller foundation grants that “identifies, analyzes, and connects programs working to improve health and financial protection for the poor.”  I have posted on and praised the CHMI effort (but think less of its utility) (“Innovate or Die” and “Market Tested and Not Yet Approved”).  But two of the weaknesses of the CHMI methodology (self-identification and reporting of results) foiled me:  AP was not in their database.  While I give Novartis and AP an “A” for effort, I’m still in the dark about the program’s business model and potential for improving health among the poorest.  What I (and others struggling with the delivery challenge) needs is something like a Harvard Business School marketing case study like one that was done on the Aravind Eye Hospital chain of India (HBS case list).

Of course, the business model of offering low-priced, low-margin but essential products is a classic one.  In 1912, the founders of the Great Atlantic and Pacific Tea Company, better known as A&P, set up the first in the US, no frills, cash-and-carry Economy Store in Jersey City, NJ, which started an extraordinary period of growth that resulting in 4,638 stores in 1920 and 15,418 stores and $1 billion in sales in 1929 (A&P history).  Can AP be the A&P of health care for the neediest?

Innovate or Die

About a year ago, I reviewed one of the more interesting foundation-funded projects in global health.  Thanks in part to the fortunes amassed by the former robber barons, Bill Gates and John Rockefeller, the Center for Health Market Innovations (CHMI) started in early 2010 and “identifies, analyzes, and connects programs working to improve health and financial protection for the poor.”  In my post (“Market Tested and Not-Yet Approved,” 9/7/10), I noted that CHMI focused on the identifying function, that connecting function was not likely to happen (after all many of the “innovators” are competing for the same grants and have their own agendas), and the analyzing function was the most valuable but needed strengthening.  The central feature of the Center is a database of profiles of organizations, programs, and companies (yes, for-profits are welcome) that CHMI says allows users to “connect,” organizations to self-promote (since all entries are self-reported), and “donors and investors … to identify candidates for funding,” but I think its real utility is as a framework for comparing the effectiveness of the programs.  Such comparative performance measurement is sorely needed for the organizations to know if they are meeting their goals, to learn from others what may improve their performance, and to justify the public and private funding they receive.  A basic lesson of business is:  if you don’t measure what you do, you can’t get better.

CHMI recently released its first annual report (Highlights:  2011), and I was pleased to find that one of the highlights was the launch of a Reported Results Initiative (Initiative).  The strengths of the initiative are that the performance measures are well-thought out (they include decreasing costs, increasing access and quality, achieving a health output, even “sustainability,” see the self-reporting Template) and that the database’s results category is featured on the home page.  But its weaknesses are that participation is voluntary, complete answers are not required (the most complete are apparently from publications or reports to donors), and evidently, CHMI is trying to figure out what to do with the data.  From the Highlights report, page 24:  “[while] it is also important to understand which programs are actually ‘working’- improving the access, quality, and affordability of privately delivered health care for  the poor … [the results of the] initiative will inform [sic] longer term activities such as the development of program performance metrics and the facilitation of formal program evaluation.”  How?  When?

I visited the database and used the nice browsing tools to check out the programs that reported their results and noted:

  • only about 10% of all programs reported results (about 100 out of 990);
  • very few of the reports are complete;
  • the average operational age of reporting organizations is about nine years, which looks longer to me than the larger group’s average;
  • 14 of the 100 are actually geographic variations of the same program (which implies to me that it is a successful franchise and any other programs offering similar services should emulate it);
  • there are nine private, for-profit organizations but none seem to be reporting typical measures of for-profit success (revenues, investors, etc.);
  • most are dependent on donors (45/100), a slightly smaller percentage than the overall group (515/909);
  • other than donor support, nine are supported by membership fees, three by “other third party (e.g., debt, equity),” and 23 by revenue; and
  • only six provided “evidence of sustainability,” I guess, an implied admission of unsustainability by organizations supported by grants or government appropriations.

The majority of the Highlights report summarizes the data in various ways (by location, type, health focus, funding, and organization) and, of interest to me, reports on the way in which 200 of the organizations provide financing for health care, either for their operations or to their customers.  CHMI identifies five methods:

  • government health insurance;
  • micro and community health insurance;
  • cross-subsidization (redirecting revenue from wealthy patients to cover those unable to pay);
  • vouchers; and
  • government contracting.

Also of interest to me is the chapter on “Five Innovative Models” which, since it is not stated, I take to mean “five organizations whose operations are worth emulating.”  Three organizations/programs are profiled in each category, and, briefly, they are:

  • low cost retail pharmacies (all are for-profit);
  • affordable primary care clinic chains (all for-profit);
  • voucher programs (two are public-private, one government);
  • telemedicine outfits (two non-profit, one for-profit); and
  • health hot lines (all for-profits).

It looks to me like these may be models for successful health care businesses.

Clearly, CHMI is gathering a vast amount of potentially useful information about the ROW health care markets, that is, those outside the overly-exploited and -expensive markets of the “developed” countries.  I’ll be using it for business planning purposes and hope others do, too.  And, as I recommended in my first posting, CHMI may also consider adding someone with business experience to their panel of advisers, or even hiring someone with a business background, to facilitate and accelerate the identification, emulation, and growth of those programs that work and are self-sustaining.

 

mmmmmHealth

The idea of using communications technology in health care delivery has been popular for about 30 years but the benefits of telemedicine, and its mobile phone sibling, mHealth, are yet to materialize.  While the high-cost medical sector of the developed world inches toward using communication technology to lower costs, governments, international agencies, nongovernmental organizations, and a few for-profit companies are attempting to use technology to deliver minimum levels of care in the developing world.  Conferences (e.g., mHealth Summit), initiatives (e.g., USAID Mobile Alliance), academic projects (e.g., Open mHealth), consultants (e.g., DiMagi), and student-initiated ventures (e.g., Click Diagnostics) abound, but, as usual, I wonder what effort may have demonstrated success in delivering an improvement to health affordably, that is, at a price people are wiling and able to pay, since my prejudice, possibly mistaken, is that a proven business model is a powerful way to effect large-scale change.

Here in the US, where most care is paid for through third parties (the government or insurers), a handful of start-up companies see a business opportunity in substituting “teleconsultation” for doctor visits, the idea that we harried insurees are more likely to use our cell phones (or computers) to address minor, non-emergency health concerns than to see a doctor, before the problems become serious and more costly to treat.  These companies offer phone consultations with physicians who provide advice, recommend treatment options, and prescribe medication when appropriate.  Examples are Consult-a-doctor (Consult), Teladoc (Teladoc), and Easy Health MD (Easy Health).  The leading company, that is, the one that looks like it will be profitable in the near future is American Well (American Well) which has built an online system that connects consumers with physicians immediately and for physicians to connect to specialists in real time.  The company is four years old and has 90 employees and four large providers as customers:  Hawaii Medical Service Association, the Hawaii franchise of Blue Cross Blue Shield; Blue Cross Blue Shield of Minnesota; OptumHealth, a unit of private health insurance giant, UnitedHealth Group; and TriWest Healthcare Alliance, a Phoenix-based health plan for military personnel and their families (Xconomy article).  As the name implies, all well and good for the US where 16% of the GDP involves health care, but what about the rest of the world?  (I should note that in the above-cited article the American Well CEO says the company is considering how to expand internationally into underserved markets.)

Googlin’ about, I found that the developing world complement to US teleconsultation is the “health hotline” and an excellent 2009 report on its use and potential by the GSMA Development Fund (GSMA DF) which is part of GSMA, the trade association of mobile phone service providers.  The report, called “A Doctor in Your Pocket” (GMSA DF report), points out that health hotlines are used by more than 10 million people in Mexico, India, Pakistan and Bangladesh and new systems are being set up in the Middle East, the Caribbean, Latin America, and Southeast Asia.  Moreover, most have a for-profit model and typically involve a government agency, healthcare provider, and a mobile phone service provider.  The report focuses on four established systems and provides useful data on use, scaling, staffing, customer satisfaction, challenges, and opportunity for and limits to growth.  Some additional interesting points are:

  • the hotlines handle up to 50,000 calls per day;
  • calls are answered by a mix of medical professionals and trained agents, e.g., MedicalHome in Mexico uses 15 doctors and 100 agents per shift to answer 10,000 calls per day;
  • the users are about 50/50 rural or urban poor and middle class;
  • revenue is by fee per call (two of the four) or monthly subscription;
  • all are affiliated with health care providers and in some cases offer discounts on services;
  • liability is not seen as a major risk and in part because medical malpractice suits are rare; and
  • potential revenue is through fees to outside providers for referrals and prescription issuing.

The bottom line of the authors is that while such hotlines are improving the access to medical care for under-served populations, especially the rural poor, there are constraints to increasing their scale, including operational challenges and affordability, and that some regulation (standard-setting) is needed to support market growth.

The authors did not address the investment opportunity and start-up activity but I would think that most of the GSMA’s members have developed or seen medical hotline business plans.  Apparently, one of the report’s author wrote on of these plans since he, along with three others, started a company in India in May of this year, mHealth Ventures (mHealth Ventures), which is offering a subscription-based service called Meradoctor.  It has two low-cost plans and about 900 families as customers to date (USAID blog post).  One opportunity is for the top-tier, rest-of-world hospitals and medical centers to expand their patient base to their countries’ mid- and low-income groups through a patient hotline.  After all, there are just so many wealthy locals and medical tourists to treat.