Marketing Managed Care to Rural Indian Populations - A Pangea Advisors and ICTPH Collaboration

EXECUTIVE SUMMARY
 There is an unmet need for pre-paid health services in ICTPH’s communities
 Healthcare underutilization and high financial risk in rural, low-income populations
 However, rolling out an insurance product is a long-term project, typically
starting with a limited service offering and breaking-even after 2-5 years
 Case studies of Indian CHI programs have revealed three typical models
differing by the role of the NGO: provider, insurer and agent. The provider
model best meets the identified need but implies a higher financial burden
 Operational costs (~Rs 800-1,500 per patient per year, primary care only) and
willingness-to-pay (~Rs 4-225) need to be reconciled, e.g. by limiting product
offering and/or seeking external financing (e.g. subsidies, donations, funds)
 Three options have been identified to design offering and enter pre-paid mkt:

Thursday, June 21, 2012
 Education first, comprehensive pre-paid model later on
 Comprehensive pre-paid model and user-fee in parallel
 Staged approach pre-paid model

 Examples of impactful and cost-effective incentives and marketing tools are:
 Incentives: group discount, voucher for friend referral
 Marketing: word of mouth, direct to customer and audio communication

1

WHAT WE HEARD FROM YOU ICTPH IS TRYING
TO ACHIEVE

 What ICTPH is trying to achieve:
 Ensure that nobody in the villages where ICTPH is present
suffers from high-risk conditions (impeding day-to-day life)
 Demonstrate sustainable healthcare model providing
primary care to ~10,000 people per clinic
 Provide a knowledge base and best practices that can be
applied elsewhere

 How this project hopes to create value

 Review ICTPH’s expansion plan into pre-paid healthcare
 Feasibility, potential pit-falls, success factors
 Provide short and medium-term implementation steps
 Pricing, communication guidelines
 Conduct Research/case studies of best practices
2
Source: Project Interviews

WHAT WE HEARD ABOUT ICTPH DURING OUR
INTERVIEWS

“ ICTPH has a unique offering with a very strong client focus. Likely to produce very
positive outcomes for clients in their communities ”

“ This model provides a lot of bang for your buck from a client resources perspective ”

“ICTPH differs from other healthcare institutions in that it offers patients continuous quality
care, based on their historic medical records, close to their homes”

“ ICTPH’s strong technology focus is a key selling point. Their clients are almost hypnotized
by it”

“ Key to expanding their product range towards an insurance based model will be ensuring
that clients understand what an aspirational product they are providing”

3
Source: Project Interviews

CONTENTS

 Should ICTPH offer a health micro-insurance product?
 What might the model look like?

 How can costs and willingness-to-pay be reconciled?
 Price range
 Financing options
 Services included
 Which offering design is most relevant for ICTPH?

 How to market the new product?

 What are the Key Success Factors to keep in mind
moving forward?

4

THERE IS AN UNMET NEED FOR PRE-PAID HEALTH
SERVICES IN ICTPH’S COMMUNITIES

Low-income levels associated with What global micro-insurance
underutilization of healthcare experiences teach us
 Underutilization of healthcare is common  Micro-insurance has been repeatedly shown to
among rural and low-income populations increase not only hospitalization rates but also
 Poor lack resources to pay for care they more frequent primary-care physician
forego getting necessary care encounters, higher rate of diagnosed chronic
 Thought to have a direct negative affect diseases and better drug compliance among
on health outcomes chronically ill(3)
 Many low-income countries have found it  Community-based health insurance reduces
increasingly difficult to sustain sufficient out-of-pocket spending thus providing financial
financing for healthcare(1) protection
 Increasingly important role of risk in the lives  Evidence is sparse that voluntary community-
based programs can create a viable sustainable

of the poor
 Health risks thought to pose the greatest solution
threat to lives and livelihoods  Difficult to mobilize sufficient people
 Due to health-related out-of-pocket and resources
expenses, an estimated 150 million  While data is inconclusive there is some
people suffer from financial catastrophe evidence that increased access has a positive
worldwide(2) affect patient outcomes

Source: (1) B. Ekman. Community-based health insurance in low-income countries: a systematic review of the
evidence. (2) J. Lammers, S. Warmerdam. Adverse selection in voluntary micro health insurance in Nigeria. AIID
research series 10-06; (3) D.M. Dror, et. al. Field based evidence of enhanced healthcare utilization among 5
persons insured by micro health insurance units in Philippines. Health Policy 73;2005: 263-271.

HOWEVER, ROLLING OUT AN INSURANCE PRODUCT
IS A LONG-TERM PROJECT

Case Studies from around the world confirm
Interviewees insist on long-term effort
this observation
 Will need to role out in phases starting with a  Micro Health Insurance in Nepal:
limited offering to gain trust before expanding  Initial survey – 1 year
 May be able to break even in medium term  Initial 6 month period educating
(2-5yrs) community about concept of micro
health insurance
 Similar model was only able to see 7%  2 years total start enrolling community
community penetration initially members in program
 Research shows that, in general, insurance  FIMRC:
models are difficult to implement  12-yr timeline for implementation due to
extensive community outreach and
 Role of trust and understanding of
education necessary

insurance product
 HIF in Nigeria:
 Financial constraints  1.5yrs after launch still showed low
 Purchasers are extremely sensitive to enrolment (~6% in target population)
price despite low insurance costs and high
satisfaction of the insured(1)

Source: 1. J. Lammers, S. Warmerdam. Adverse selection in voluntary micro health insurance in Nigeria. 6
AIID research series 10-06.

CONTENTS


 Price range


moving forward?

7

CASE STUDIES OF INDIAN CHI PROGRAMS HAVE
REVEALED THREE TYPICAL MODELS
ICTPH are considering utilizing model I for primary healthcare provision and model III for
funding of secondary and tertiary care

1 Provider model 2 Insurer model 3 Agent model

Provider & Insurer* Insurer Insurer
Provides care

Reimburse
NGO Provider
Premium

Premium
Provider

Premium

Care

Community Community Community

Insurance for more advanced care to be avoided in a first step as premiums will most
likely price users out of the market

* Insurer is an entity legally separate from the NGO, can be a third party insurer with interaction only with NGO
Source: N. Devadasan, K. Ranson, W. van Damme, B. Criel, 2004. Community Health Insurance in India – An
Overview. Economic and Political Weekly July 10, 2004; N. Devadasan et al. The landscape of community health 8
insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234

PROVIDER MODEL IMPROVES ACCESS TO
HEALTHCARE AND OFFERS FINANCIAL PROTECTION
Provider model structure
Model characteristics
Provider & Insurer*  NGO plays the role of both health care
provider and patient insurer
Provides care
Premium

Strengths
 Clearly defined, continuous health care
package
Community  Cashless transactions at own health centres
 Strict health care cost and quality control

Provider model examples
Weaknesses
 Need to supplement funds raised from
premiums with subsidies or private donors
(~20-40% of total reimbursements)

* Insurer is an entity legally separate from the NGO, can be a third party insurer with interaction only with NGO

INSURER MODEL EMPOWERS COMMUNITY; RISK
OF COST ESCALATION AND POOR QUALITY OF CARE
Insurer model structure
Model characteristics
Insurer  NGO insures patients and purchases care from
independent providers
Premium

Provider
Strengths
 Absence of third-party insurer allows high
community empowerment
Community

Insurer model examples Weaknesses
 Reimbursement within 2-6 months: financial
and administrative hurdle filters out the
poorest part of population (e.g. Illiterate)
 Poor health care cost and quality control


AGENT MODEL LEVERAGES EXPERTISES BUT
PARTIALLY EXCLUDES POOREST PART OF POPULATION
Agent model structure Model characteristics
Insurer  NGO is the intermediary between patients, a
third party insurer and the health care
providers
Reimburse

NGO Provider Strengths
 Highly competent professionals conduct most
Premium

Care

technical tasks (e.g. Insurance)
 Enhanced resource pooling allows coverage of
more expensive risks
Community
Weaknesses

Agent model examples  Reimbursement within 2-6 months: financial
and administrative hurdle filters out the
poorest part of population (e.g. Illiterate)
 Poor health care cost and quality control
 Premiums likely to price users out of market
 Negotiation power of NGO with provider is key
to enrolment levels and cost containment

CONTENTS


 Price range


moving forward?

12

CURRENTLY PRICING HAS BEEN LOOKED AT BY
ICTPH FROM A COST PERSPECTIVE
Monthly variable costs (Rs) associated with a Rural Resulting impact on pricing
Micro Health clinic
Rs 1,534
25,000
20,000
15,000
10,000 739
Rs 994
5,000

tertiary care
Secondary /
-
480
208

Anticipated uptake of services

primary
Primary direct

In-
183
o Accounts for changes in
• Incidence of outpatient care 587
• Average primary care expenditure Direct 331
• Incidence of hospitalisation
o Anticipates uplift in reported disease burden
Current Scenario Insurance model

“Calculations of the cost per patient are based on an estimate of the number of families, patients, visits
per patient per year and services to be offered based on current needs”
13
Source: Interviews, Financing Health Systems 2011 Dr Zeena Johar

WHEREAS WILLINGNESS-TO-PAY APPEARS
SIGNIFICANTLY LOWER
Literature suggests an WTP Maximum annual TO BE VALIDATED BY SURVEY RESULTS
of Rs 20-60 per patient per expenditure in current
Price sensitivity witnessed by ICTPH
year for health insurance fee-for service
140 When visits were free, ICTPH
would see ~120 patients per
day
120

Price charged by
ICTPH per visit
Rs 225 Rs 500
100 At a price of 15 Rs per visit
around 10 patients would
Rs 60 80 come each day

Average 60
Rs 20 At a price of Rs 50
40 ($1), no patients

would attend
20
Rs 4 Rs 300 0
0 20 Number of patients
40 60
per day

“The key to success is to understand the difference between what we think people
are willing to pay and what they actually are”
14
Source: Research, Project interviews

THE GAP CAN BE CLOSED BY CHANGING PRODUCT
OFFERING AND SEEKING EXTERNAL FINANCING

Ave annual
cost per
person: For the model to be viable, willingness to pay for services need to
Rs 500-800 exceed the costs of providing the services
(1)

In the literature as well as specific case studies, the gap between
willingness to pay and costs has been addressed by:
1) Reducing the range of offered and thus decreasing total costs
2) Seeking external financing (in the form of cross subsidies
across different services within the healthcare providers

Annual
willingness
offering, as government subsidies or charitable donations)
to pay by
local
population:
Rs 4-225 (2)
Note: (1) Suggested range in interviews for limited range of services, Financing article suggest Rs
1,534 per person which attributes 51% expenditure towards preventative and primary care services
with the remainder allocated to secondary and tertiary services
(2) Willingness to pay suggestion of Rs 4-225 from case studies and literature; In survey conducted
on behalf of the project ~3/4 of current patients sampled answered “yes” or “maybe” to whether
they would be willing to pay a flat fee of Rs 150 per month per person for access to the clinic and its 15
services

CONTENTS


 Price range


moving forward?

16

MOST SIMILAR MODELS REQUIRED EXTERNAL
FINANCING TO BE SUSTAINABLE

Comparison of Indian CHI schemes ACCORD-AMS-Ashwini
o All Provider model programs supplement locally o 37% of each premium paid to third-party insurer
raised resources with external resources, for ~20- is supplemented by donors
40% of reimbursements
o Insurer and agent model schemes cross- Yeshasvini Health Care Program
subsidize care provision more extensively than
type I, increasing the chance of reaching a o 42% revenues from government subsidy
sustainable model of provision o 3% profit from donations
o Contingency fund
o “At the current level of premium, financial
sustainability is not achievable even with a vast
International BOP micro-insurance
membership base [...] because the program

o Most NGOs observed in the extensive literature covers high end medical treatment.”
review as part of this project required external
financing (mostly charitable donations) to Lifespring Hospitals
continue to provide care
o “Even with our model of cross-subsidizing general
care, we could not achieve sustainability”
o “We had to review the value-proposition and
ensure the general wards were also profitable”
17
Source: Research, Project interviews

CONTENTS


 Price range


moving forward?

18

MOST SERVICE PROVIDERS HAVE DECREASED THE
RANGE OF SERVICES OFFERED TO REDUCE COSTS
LifeSpring’s considered expansion of the range of services but
1) Were concerned that it might dilute their brand image in the market place – marketing to a very
specific audience proved most effective
2) Additionally, there was a strong feeling that recruitment of medics was assisted by the offer of
being able to perform more services than would be the case in a more generalist environment
3) Finally, the additional costs relating to increased complexity in service offering – both in the initial
CAPEX outlay and ongoing variable costs – were considered off putting

In France, the state have provided a specific list of long term conditions for which (1) incidence is
increasing rapidly and for which (2) the cost of preventative care is significantly less than the cost of
treatment once the disease develops. Treatment for these conditions and for core services will be offered
by the state. Other care must be covered by individuals .

The UK utilise a board of practitioners, patients, pharmaceutical and healthcare product manufacturers

and health economists (NICE) to assess which drugs and products are “cost effective”. The annual
incremental value of the product in question over the nearest established alternative is compared to the
quality life year (QALY) value threshold. Only the treatments creating value over and above the
threshold will be provided under the national monopoly health provider: the NHS

In Italy, the states have constructed positive and negative lists of services based upon a criteria of
effectiveness, appropriateness and efficiency of delivery. Only he services falling onto the positive list
are provided by the state
Source: Project Interviews, International profiles: Health Affairs, Schoen et al: How health insurance
design affects access to care and costs by income in 11 countries; The Commonwealth Fund: 19
International Profiles of Health Care Systems, June 2010

GIVEN ICTPH’S OBJECTIVES, FOCUS SHOULD BE
ON PRIMARY CARE AND HIGH-RISK CONDITIONS

Historic cases seen in ICTPH clinics
100% Interpretation and suggestions
Percentage of total diagnoses

90%  In the survey conducted on behalf of
80% the project, only 2% of patients
70%
stated that what they value most
from ICTPH is the range of services
60%
offered
50%
Underused protocols  Instead proximity to home and the
40%
quality of the services provided are
30%
considered the most important

20% elements by patients
10%
 ICTPH should analyze the potential
0% change in the cost of service
100
111
122
133
144
155
166
177
188
199
210
1
12
23
34
45
56
67
78
89

Service number
provision and the quality of
90% of cases are treated using 30 protocols. The outcomes that would result from
remaining 180 services offered are only used on a reducing the range of protocols
very ad-hoc basis offered
20
Source: ICTPH provided case records

CONTENTS


 Price range


moving forward?

21

THERE ARE THREE OPTIONS FOR ICTPH’S
OFFERING DESIGN & MARKET ENTRANCE STRATEGY

1. Comprehensive pre-paid model and user-fee services in
1
parallel
 Same price for all patients
 One original price for all patients, reimbursement of those
who do not require chronic care
 Different prices based on patients’ pre-conditions

Education first, comprehensive pre-paid model later on


2

1. Staged approach pre-paid model
3
 Healthy patients first, user-fee services for others
 Specific diseases covered only, user-fee services for others
22

THESE OPTIONS CAN BE EVALUATED ALONG
ICTPH’S VISION AND KEY SUCCESS FACTORS
1 = No / very limited alignment, 2 = Medium alignment, 3 = Excellent alignment PRELIMINARY

Staged approach pre-
Vision and Comprehensive pre-paid model
Education paid model
key success
first Reimburse Different Healthy Specific
factors One price
ment prices patients diseases
Vision 3 3 3 1 2 2

Affordability 2 2 1 3 2 2

Simplicity 3 3 1 2 2 2

Trust 3 2 1 1 1 2

Flexibility 3 1 2 2 3 2

Effectiveness 3 2 2 2 2 2

Overall 17 13 10 11 12 12
23
Source: ICTPH – Pangea workshop

PRO’S AND CON’S OF SELECTED OFFERING
DESIGN OPTIONS
Two options for implementation in a staged approach:

Both pre-paid and user fee model Primarily Pre-paid w/ addt‘l user fee

 Advantages:  Pre-paid for the healthy w/ user fee for high
risk and more advanced services
 Gives patients choice and flexibility
Allows slower introduction of insurance
 Slowly introduces the concept of model to facilitate education
insurance while maintaining what Predisposed to success likely to stay healthy
currently offered and understood model Aspirational good, seen as benefit for the
 Can provide comprehensive offering with healthy and for others to strive toward
financing that best suites customer Major disadvantage: not addressing major
need of high risk patients of providing
affordable primary and preventative care

 Disadvantages  Select specific diseases to pre-pay while
Likely that patients will choose what they others remain user-fee
are familiar with and what is cheaper Flexibility in allowing the community to
choose which disease are covered
In the short term, volume will be the
Addresses high-risk, chronically ill patients
major issue
Major disadvantage: cost may sky-rocket as
Needs external financing have adverse selection for worst diseases

24

CONTENTS


 Price range


moving forward?

25

DEFINING A CLEAR POSITIONING IS KEY TO
COMMUNICATING IN A COMPELLING MANNER

Value proposition: Positioning:
All benefits and costs of the offering to
Primary reason for choosing the offering
target customers

…………………………….. is the best ……….……………………………
(offering) (product category)
for ……………………………………………………………………………..…

(target customers)
because ……………………………………..………..………………………
(primary reason)

26

SUMMARY OF POSITIONING STATEMENT
SUGGESTIONS
PRELIMINARY
Offering Product Category Target customers Primary reason
Unlimited access to quality
Pre-paid primary care package Packaged healthcare Rural population healthcare: we are a guide to
better health for your family

"once I possess this, I'll be
Pre-paid health product
families (rich & poor) with healthy". High quality & cost
(comprehensive & Packaged healthcare
frequent needs effective care - helps them not
preventative)
to delay seeking care
understand risk & prevention
Prepaid healthcare healthcare savings family basic health needs
the best
Take care of wellness with
Pre-paid primary care package Packaged healthcare simultaneous capping of health

expenditure

Pre-paid primary care package primary healthcare product chronic & non-chronic families your health is in our interest

don't have to worry about
Pre-paid primary care package Packaged healthcare
families health ever again
helps meet the expense of
Pre-paid primary care package microhealth insurance "you"
unexpected incidences

Pre-paid primary care package Packaged healthcare help you stay healthy

27

MARKETING TACTICS

Distribution
Incentives Brand

Product Mix

Communication Product
Price Features

28

EXAMPLES OF INCENTIVES
Primarily two types: Acquisition and Retention
Acquisition Retention
 Free trial in the beginning  Reimburse at year-end if made all
 Benefit for being an early adopter appointments and followed all
recommendations
 Premium discount
 Offer ICTPH voucher (rather than
 Ability to get next year for same
reimburse cash)
price as this year
 Discount for next year’s package
 Premium back guarantee
 Access to additional benefits for
 Discount/voucher if recommend your
continued use of clinic

friends
 one medication for free
 Group discount
 Ability to add on a family member to
policy at discount rate after a year

Are incentives valid for ICTPH’s purpose? If so, which are applicable?
29

PRIORITISATION OF INCENTIVE INITIATIVES
PRELIMINARY
Cost

Additional
benefits
Premium
guarantee

Group
Reimburse Introductory discount
at yr end

free trial

Early
adopter Add family Voucher
benefits for less

Impact
30

EXAMPLES OF COMMUNICATION STRATEGIES

 Print: pamphlets, flyers, posters
T  Media: video, audio messages, loudspeaker
y announcements
p
 Direct to consumer: patients in clinic, rapid risk
e
assessment interactions

C  Community Leaders: community presidents, local
h heros

a
n  Community meetings: self-help groups, women’s
n meetings, town hall, 100 day worksite, school
e education, post church congregation etc.
l
s  Word of mouth: neighbors who are happy users
31

PRIORITISATION OF COMMUNICATION INITIATIVES
PRELIMINARY
Cost

Video

Community
Print meetings
Community
leaders

Word of
mouth

Direct to
customer

Audio

Impact
32

CONTENTS


 Price range


moving forward?

33

FIVE KEY SUCCESS FACTORS FOR COMMUNITY
HEALTH INSURANCE SCHEMES

Trustful  Trustworthy NGO and healthcare provider
 Strong anchor in local community for maximum
environment
awareness and minimum costs

 Cashless transactions, minimum administrative burden
Practicality  Short distance to patients for accessibility and fluid transfer
of information

 Annual premiums, flexible modes of payment and collection
Affordability period to correct for financial barriers to health care access
 Prices driven by patient willingness-to-pay

 Comprehensive health package with concrete patient benefits
Continuity of care  Incentives to follow-up and preventive care

Public-private-  Services offered complement existing structures
cooperative  Optimal integration with and referral to public / private /
partnerships cooperative sectors for services beyond scheme’s competences
34

THE VISION

Provide comprehensive care to the rural
population…
 Key success factors: Affordable(1), Accessible
 Pitfalls: Pricing users out of the market,

 …In a sustainable manner…
 Key success factors: Trusted, Easy to Understand
 Pitfalls: Implementing too quickly, complex offering

 …Includingaddressing the needs of chronic

disease sufferers
 Key success factors: Widely used, effective care
 Pitfalls: Adverse selection

(1) Willingness-to=pay of the local population needs to be investigated and taken into consideration.
Currently pricing appears to exceed national benchmarks for willingness to pay for health care 35
insurance

ISSUE OF ADVERSE SELECTION
Current pricing of our pre-paid service (~ However, it is likely that the population to
Rs 1,500) assumes that chronic diseases first adopt the pre-paid product will be
will be represented with the same those with chronic diseases who better
frequency as they are found in the understand annual healthcare costs and
population can see greater potential savings

To cover the cost of the increased
frequency of chronic disease, costs would
have to be further increased
36

37
THANK YOU!

APPENDIX

 Case Studies
 Overview of Indian community healthcare models
 Maternity provision in India: LifeSpring
 Health Insurance in Gudalur: AAA
 The Yeshasvini Health Care Program
 Micro health insurance in Nepal

 Foundation for international medical relief of Children
 Indian CHI Backup materials
 International profiles

38

INDIAN COMMUNITY HEALTH INSURANCE SCHEMES
– OVERVIEW AND KEY FACTS
Design / model Premium and maximum costs covered
 Provider model  Premium
See details
 Insurer model on next slide • WTP ~Rs 20-60 per person per year,
although some programs charge Rs 100+
 Agent model
• Usually fixed, sometimes income-dependent
• Annual cash contribution, collection period,
Services offered sometimes payable in kind
• Collected by community or NGO
 Hospital / inpatient care + primary care
 Maximum costs covered: $50 on average
 Sometimes outpatient care, outreach services and
other insurances (e.g. Life)
Population enrolled

 From a few thousands to 25 lakh
Financial sustainability
 30-40% of target population (median)
 4 of 12 schemes observed are self-sustained  Pre-conditions and chronic diseases
 All provider models raise external funds, usually excluded
accounting for 20-40% total reimbursements  Enrolment unit is individual or family

Overview. Economic and Political Weekly July 10, 2004; N. Devadasan, K. Ransonm W. van Damme, A. Acharya,
39
B. Criel, 2005. The landscape of community health insurance in India: an overview based on 10 case studies. Health
Policy 78 (2006): 224-234

THREE DIFFERENT TYPES OF SCHEME DESIGN
Case studies group the models for community healthcare insurance into 3 groups
1 Provider model 2 Insurer model 3 Agent model

Provider & Insurer Insurer Insurer
Provides care

Reimburse
NGO Provider
Premium

Premium
Provider

Premium

Care

Community Community Community

Provider model allows
• Cashless transactions
• No reimbursement procedure several months after treatment
• Control over cost and quality of health care
Overview. Economic and Political Weekly July 10, 2004; N. Devadasan, K. Ransonm W. van Damme, A. Acharya,
B. Criel, 2005. The landscape of community health insurance in India: an overview based on 10 case studies. Health 40
Policy 78 (2006): 224-234

APPENDIX

 Case Studies


41

SITUATION: LIFESPRING DEFINED IT’S ORGANISATIONAL
GOALS IN REACTION TO INDICATORS OF AN UNMET NEED

Existing service provision Indicators of an unmet need
Four main types of providers available  More than 100,000 women in India die each year
 Government hospitals: largely in urban areas, as a result of pregnancy-related complications.
services cited as free though frequently required Another ~100,000 suffer moderate to severe
payments to staff. Quality of care variable and infections
access difficult to more vulnerable groups  Majority of deaths were avoidable if effective
 Small private hospitals: more conveniently institutional services could be provided
located but services provided frequently sub-  Substantial service gap between low-resource,
optimal as practitioners often lacked standard low-quality government hospitals and high-quality
protocols for management of common ailments high-cost private hospitals for lower income
 Large private hospitals: High quality but families
frequently too expensive for poorer populations to  Millions of women did not attempt to utilise the
access services of a medical institution when delivering
 Midwives: Hired privately for births at home.
Some variation in training and experience

Organisation Goal
To make high quality maternity healthcare affordable and accessible to lower-income women across
India
42

APPROACH: LIFESPRING IDENTIFIED THEIR TARGET
MARKET AND FACTORS THAT INFLUENCE THIS GROUP

Provision of high quality, accessible maternity healthcare to lower-income
women at affordable prices

Customers: Cultural elements Competition
• B70(1) population (earnings • Tradition dictates pregnant • In an effort to overcome the
typically between 36,000 and woman’s mother pays for the pervasive distrust of hospitals
Customers
66,000 rupees per year total) cost of delivering her first child government has begun
• Two major segments: • Middle classes tend to view offering families a stipend to
informal, daily wage earners those catering to the lower deliver babies at a
and formal job sector with classes as providing sub-par government facility
annual wages quality of care

All inclusive pricing of services Targeted communication Provision of superior quality of
with cross subsidising of care strategy care with transparent pricing

43
Note: (1) B70 population: people from the bottom 70% of India’s income pyramid

DESIGNING THE SERVICE: CUSTOMER PROFILING
IDENTIFIED TWO MAIN GROUPS OF POTENTIAL PATIENTS

 Target customers were defined as
 the B70 population
 living in peri-urban areas
 within a 5km radius of the clinic
 Further research segmented these customers into two groups

Segment Earnings Preferences Communication
• 36,000 – 66,000 rupees per year • Products with proven • Low literacy rates
• Family earnings from informal sector track record • Limited access to

1 daily wages) • Value opinions of others mainstream media
• Typically had to borrow money for in community
institutional deliveries

• 36,000 – 66,000 rupees per year • High quality of service • Higher literacy rates vs
• Formal job sector with annual wages • Attentive care segment 1
2 • At lower end of wage profile but tend • Privacy • Improved media access
to have more savings for out of • Transparent pricing
pocket expenses vs segment 1 • Clean environment

44

TO SERVE BOTH GROUPS, LIFESPRING WOULD
DIFFERENTIATE THE SERVICE AND CROSS-SUBSIDISE CARE
Customer Medicinal Communication
Clinic services
segment Service method

Services provided at the General wards Outreach workers
all-inclusive price provide health
1: Informal • No air conditioning education in
(including all related
sector (lower or food services community
medicinal and
willingness-to- administrative charges): • No frills service with Loyalty program to
pay) focus on quality of
• Deliveries (normal encourage word of
medicinal care mouth referrals
and caesarean)

Cross • Antenatal care
subsidise • Postnatal care

• Family-planning
services Private & semi-private
wards: Media advertising on
2: Formal • Pediatric care kiosks, buses, TV
(including • Provided some
sector (higher Customer
immunisations and comfort (air-con,
willingness-to- improved furniture) relationship
pay) diagnoses) management to
• Healthcare • Focus on providing track follow up care
education to the individual attention
communities
45

DESIGNING THE SERVICE: CLOSE ATTENTION HAD
TO BE PAID TO OPERATIONAL COSTS
 Maintained only simple, low cost equipment (most sophisticated
was an ultrasound)
 Defined a narrow range of services which could be offered
effectively and inoffensively. Complicated cases were referred to
other facilities
 Allows utilisation of less-trained nurses, standardising protocols,
purchasing medicines in bulk
 Oursourced lab and pharmacy services and partnered with
neighbour organisations
 Utilised technology to facilitate efficiency and information sharing
 Kept turnover rates high (required impactful marketing)

 Paid doctors fixed salaries (allows to focus on care provision rather
than distracting with need to provide repeat service)
 Offered workers non-monetary incentives e.g. social mission and
opportunity to gain more experience than would in a general public
hospital

46

APPENDIX

 Case Studies


47

ACCORD-AMS-ASHWINI (AAA) PROGRAM IMPROVES
HEALTHCARE ACCESS FOR ADIVASIS IN GUDALUR (TN)

What is the AAA program? What services are offered?
 ACCORD: local NGO engaged in overall  Hospital care in Ashwini hospital
development of the Adivasis
 Primary care in village and health centres
 Adivasi Munnetra Sangam (AMS): union
defending rights of the Adivasis is Gudalur
 Ashwini: hospital providing general medicine,
surgery, obstetrics and paediatrics At what price?
 Enrolment in program: Rs25 ($0.54) per year
 Hospital costs (at Ashwini hospital):

To whom? • Insured AMS members: Rs10 ($0.22)
admission fees (all costs covered up to


All AMS members are eligible to join system Rs2,500 per year per patient)
 Three categories of patients with different levels • Uninsured AMS members: meet cost of
of reimbursement at Ashwini hospital: medicines ($2-5)
• Insured AMS member • Non Adivasi: pay entire bill ($15-20)
• Uninsured AMS member  Primary care provided to all Adivasis free of
• Insured non adivasi charge in local health centres

Source: N. Devadasan, B. Criel, W. van Damme, S. Manoharan, P. Sankara Sarma, P. van der Stuyft 2010.
Community health insurance in Gudalur, India, increases access to hospital care. Health Policy and Planning 48
25:145-254

COLLABORATING WITH DONORS AND PRIVATE INSURER
GUARANTEES PROGRAM’S FINANCIAL SUSTAINABILITY

25:145-254

WHAT ICTPH CAN LEARN FROM THIS EXPERIENCE
Key success factors Initiatives Implications for ICTPH

Trustful  Family/village as the enrolment unit  Leverage local anchor
 Credible hospital providing quality care  Carefully select communication
environment  Trustworthy organizations channels that create trust

 Accessible health care centre or  Minimize cash transactions, co-
travel costs reimbursement payment and paper work
Practicality  No cash transactions, low co-payments
 Minimal paper work at health care centre

 Comprehensive health care program  Gradually expand services offered
Continuity of care  Consider alliances and integration

with public and private sectors

 Government provides stability and  Consider partnerships with public
Public-private administrative man power sector, donors and insurers to
partnership  NGO ensures integrity and provides reach and maintain financial
management capabilities sustainability

25:145-254

APPENDIX

 Case Studies


51

YESHASVINI HEALTH CARE PROGRAM OFFERS ADVANCED
SURGICAL TREATMENTS TO RURAL KARNATAKA

What is the Yeshasvini Health Care To whom?
program?
 Poor rural population in Karnataka
 Cooperative venture between public, private
and cooperative sectors
• Yeshasvini Cooperative Farmers’ Health
Care Trust
At what price?
• Department of Cooperation (DOC)
 Initial premium: Rs60 per person per year
 Organizational goal: insuring the rural population
of Karnataka against advanced and expensive • Raised to Rs120 and Rs130
surgical treatments • Maximum Rs200,000 covered per year
• 15% rebate for families of 5+ members
 Major sources of revenues and profit:
What services are offered?

• 42% revenues from government subsidy
 Hospital care mainly in private hospitals, in
• 3% profit from donations
charitable, public and cooperative sector hospitals
in Karnataka • Contingency fund
 Free out patient department consultations  “At the current level of premium, financial
sustainability is not achievable even with a vast
 Diagnostic laboratory tests at special rates
membership base [...] because the program covers
 Adapted regularly based on demand high end medical treatment.”

Source: A. Aggarwal 2011. Achieving Equity in Health through Community-based Health Insurance: India’s 52
Experience with a Large CBHI Programme. Journal of Development Studies 47,11:11657-1676

WHAT ICTPH CAN LEARN FROM THIS EXPERIENCE
Key success factors Initiatives Implications for ICTPH
 High quality hospital network  Quality of care and transparency
Trustful  Dissemination of sufficient information regarding services offered are key
environment  Transparency on service exclusions factors of enrolment in poor areas
 Discrimination for poor patients

Trained community  Ensure continuity of care, prevention  Empower network of local health
 Effective information channels care professionals
staff
 Low premiums balanced by alternative  Carefully investigate financial
sources of revenues sustainability and define sources of
 Payment/enrolment over 5 months revenues
Affordability and  Flexible modes of payment  Design insurance system for

accessibility  Cashless transactions, no paper work affordability and practicality
 Cross-subsidies between rich and poor  Consider cross-subsidies
 Penetration into high risk villages

 Using public administrative  Consider strategic partnerships
Public-private- infrastructure limits costs with public, private and
cooperative  Government backing creates trust cooperative sector
 Access to local cooperative networks
partnership  Private sector for quality health services

Source: A. Aggarwal 2011. Achieving Equity in Health through Community-based Health Insurance: India’s 53
Experience with a Large CBHI Programme. Journal of Development Studies 47,11:11657-1676

APPENDIX

 Case Studies


54

MICRO HEALTH INSURANCE IN NEPAL
Background Timeline and Implementation
• Location: Nepal (Dhading and Banke) • 2009: Baseline Survey completed
• Objective:  12% of households reported illnesses (72% acute, 20% chronic
 Lower health risks and increase utilization of health care by  Children <5yrs and elderly have higher incidences of illnesses
poor families though two community based health but have little access to health insurance
insurance schemes  Many households forced to borrow money (19% of illnesses,
• Organizations: Micro Insurance Academy in conjunction with 53% of hospitalizations)
a number of other international and local partners • April-Oct. 2010: Workshops conducted to educate target
• Financing: Primarily donations communities on micro health insurance
 Engaged participants in processes necessary to begin programs
 Community members finalized structure and benefit packages for
Concept the two programs
 Prepared various awareness tools (e.g., posters, songs, street
• Develop affordable and inclusive micro insurance for
plays for insurance education campaigns)
households belonging to the female clients of micro finance
institution  20 facilitators used tools to raise awareness about micro health
insurance for 2 months
• Tailored to respond to needs and willingness to pay of target
population based off relevant data from baseline survey • Nov. 2010: Executive and administrative members for microfinance
programs selected by community members
• Benefit package:
 Four trainings provided including one on management
 Complements services that are accessible at no cost to
information system used to organize data on beneficiaries
the community already
• Dec. 2010: Enrollment started in Dhading
 May cover any combination of hospitalization,
maternity care, transportation costs, income-loss • Jan. 2011: Saubhagya Micro Health Protection Fund launched
compensation, testing and imaging  5 claims settled in the first month
• Women (from existing women’s groups) in charge of • June 2011: Banke program launched
building and finalizing benefit packages  5,000 enrollments thus far
 Also administer and run the microinsurance programs

Source: http://www.microinsuranceacademy.org/content/micro-health-insurance-nepal-deprosc-dhading-and-nirdhan-banke

APPENDIX

 Case Studies


56

FOUNDATION FOR INTERNATIONAL
MEDICAL RELIEF OF CHILDREN (FIMRC)
Background Mission Implementation and Strategy
• Founded: 2002 as 501C3 nonprofit organization • Construction of pediatric clinics in areas without reliable source
• Location: multiple cities throughout the developing world of healthcare:
 Costa Rica, Peru, Uganda, among others  Facility serves as center for healthcare administration and base
for health education programs
• Mission:
 Improves basic knowledge about normal body and common
 To improve pediatric and maternal health in the developing
diseases endemic to the area
world through innovative and self-sustainable health
improvement programs  Before construction member of project development team visits
proposed site, conducts population survey and health assessment
• Structure:
 Follow-up visits subsequent to initiation help monitor and ensure
 Network of outpatient clinics and partnerships provide
proper use of resources and monitor clinic success
clinical services, extensive community outreach efforts and
health education programs
• Charting system for each child:
Financing Details  Provides continuity of care
• Project related financing provided from business  Documents care each child receives over time
operations:
 >90% revenue is derived from volunteer program • Innovation is key strategic component:
 Global Health Volunteer Program engages ~700  Combine incentive programs with access to acute care and
medical and non-medical individuals/yr who volunteer preventative services
time and make a contribution in exchange for the  Establishes itself as partner in the community with singular goal
experience FIMRC provides of motivating community members to take active interest in their
 Volunteers supplement care being delivered by local own health
professionals  Engage community members to learn about their health in health
 Clinics are directly funded by volunteers’ contributions education sessions
• Cost: $900-$1,300 (site dependent)
 Generally covers everything except for flight and
additional spending money

Source: http://fimrc.org/

FOUNDATION FOR INTERNATIONAL
MEDICAL RELIEF OF CHILDREN – CONT.
Micro Health Insurance Program (MHIP) 5 Major Initiatives
• Non-monetary model established in 2008 to address lack of 1. Health education sessions:
educational and economic resources:  Essential to avoiding preventable illnesses and improving
 12-yr timeline for implementation due to level of community overall baseline health
outreach and health education required to foster sense of  Weekly health sessions presented by staff members and
ownership among community members FIMRC volunteers address immediate and long-term health
 FIMRC modifies program to fit the needs and readiness of each concerns of individual families and community at large
community prior to implementation  Topics include nutrition, health and hygiene, upper
 Combines health education and community development projects respiratory infections, and breast cancer
with improved access to medical services to provide 2. Home visits:
comprehensive health care for the entire family  After informed of health risks and how to prevent them
 Zero financial cost to participants participates must demonstrate application of the knowledge
 Services offered compliment government system and currently and pro-active attitude towards health
available options  Staff perform regular home visits to monitor and reinforce
• Incentives: application of information shared during health lessons
 Participants accrue health credits which can be used to acquire 3. Community participation:
tangible goods that improve baseline health (e.g., water filters  Program participants organize and implement projects and
and mosquito nets) health related events that encourage community-wide
 Earn health credits for active participation and demonstrated positive behavioral change
positive behavioral change 4. Monthly Wellness Visits:
• Results - June 2008 to April 2010  Program participants attend monthly wellness visits to
 Started with 13 families (30 children) compared to test group of monitor healthy growth and development and to catch
20 families -> now 31 families (78 children enrolled) illness before it becomes too advanced
 Living conditions in the test families' homes have greatly  Visits foster trustful and communicative relations between
improved the attending physicians and participants
 Children in test group diagnosed with fewer cases of diarrhea, 5. Quarterly feces exams:
parasites and anemia suggesting holistic and proactive approach  Provides quarterly testing of feces and treatment in the
to care is effective event a child is diagnosed with parasites or worms
Source: http://fimrc.org/

APPENDIX

 Case Studies


59

BACKUP: INDIAN CHI SCHEMES (1/7)

Source: N. Devadasan, K. Ranson, W. van Damme, B. Criel, 2004. Community Health Insurance in India – An 60
Overview. Economic and Political Weekly July 10, 2004


Source: N. Devadasan, K. Ranson, W. van Damme, B. Criel, 2004. Community Health Insurance in India – An 61
Overview. Economic and Political Weekly July 10, 2004


Source: ; N. Devadasan, K. Ransonm W. van Damme, A. Acharya, B. Criel, 2005. The landscape of community 62
health insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234

APPENDIX

 Case Studies


67

INTERNATIONAL PROFILE: CONTENTS

 Executive Summary
 Healthcare expenditure vs health outcomes

 Country profiles

68

EXECUTIVE SUMMARY: DESIGN OF CARE
PROVISION
 With the exception of the United States, public funding of healthcare
services tends to account for 2/3 or more of total healthcare costs
 There is no correlation between either the total healthcare expenditure or
the out-of-pocket expense incurred with avoidable deaths
 Healthcare provision does not fall into a simple division of state provided
vs. insurance or out-of-pocket expense. Instead countries tend to decide
upon a range of core services that should be provided by the state, with
additional products and services provided by insurance or out-of-pocket
expenditure. A number of different mechanisms are utilised in deciding
which services are free to patients at the point of consumption, for
example
 In the UK, drugs and service provision is decided based on a cost-effectiveness
measurement

 In Italy, the government construct positive and negative lists of services based on a
criteria of effectiveness, appropriateness and efficiency in delivery
 In France, the decision is made based on the nature of the condition whereby core
services and treatments for a specific list of long term conditions are provided by the
state
 Fragmentation of care has been seen in the US to lead to poor
communication between providers and sometimes conflicting instructions
for patients and higher rates of medical errors
69

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