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

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

  1. 1. HAND-OVER DOCUMENTMay 2012
  2. 2. 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
  3. 3. WHAT WE HEARD FROM YOU ICTPH IS TRYINGTO 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 Thursday, June 21, 2012  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
  4. 4. WHAT WE HEARD ABOUT ICTPH DURING OURINTERVIEWS“ ICTPH has a unique offering with a very strong client focus. Likely to produce verypositive 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 qualitycare, based on their historic medical records, close to their homes” Thursday, June 21, 2012“ ICTPH’s strong technology focus is a key selling point. Their clients are almost hypnotizedby it”“ Key to expanding their product range towards an insurance based model will be ensuringthat clients understand what an aspirational product they are providing” 3 Source: Project Interviews
  5. 5. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 4
  6. 6. THERE IS AN UNMET NEED FOR PRE-PAID HEALTHSERVICES 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 Thursday, June 21, 2012 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.
  7. 7. HOWEVER, ROLLING OUT AN INSURANCE PRODUCTIS 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 Thursday, June 21, 2012 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.
  8. 8. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 7
  9. 9. CASE STUDIES OF INDIAN CHI PROGRAMS HAVEREVEALED THREE TYPICAL MODELSICTPH are considering utilizing model I for primary healthcare provision and model III forfunding of secondary and tertiary care1 Provider model 2 Insurer model 3 Agent modelProvider & Insurer* Insurer Insurer Provides care Reimburse NGO Provider Premium Premium Provider Premium Care Thursday, June 21, 2012 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
  10. 10. PROVIDER MODEL IMPROVES ACCESS TOHEALTHCARE AND OFFERS FINANCIAL PROTECTIONProvider 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 Thursday, June 21, 2012Provider 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 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 9 insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234
  11. 11. INSURER MODEL EMPOWERS COMMUNITY; RISKOF COST ESCALATION AND POOR QUALITY OF CAREInsurer 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 Thursday, June 21, 2012Insurer 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 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 10 insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234
  12. 12. AGENT MODEL LEVERAGES EXPERTISES BUTPARTIALLY EXCLUDES POOREST PART OF POPULATIONAgent 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 Thursday, June 21, 2012Agent 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 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 11 insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234
  13. 13. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 12
  14. 14. CURRENTLY PRICING HAS BEEN LOOKED AT BYICTPH FROM A COST PERSPECTIVEMonthly variable costs (Rs) associated with a Rural Resulting impact on pricingMicro Health clinic Rs 1,53425,00020,00015,00010,000 739 Rs 994 5,000 tertiary care Secondary / - 480 208Anticipated uptake of services primary Primary direct Thursday, June 21, 2012 In- 183o Accounts for changes in • Incidence of outpatient care 587 • Average primary care expenditure Direct 331 • Incidence of hospitalisationo 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
  15. 15. WHEREAS WILLINGNESS-TO-PAY APPEARSSIGNIFICANTLY LOWERLiterature suggests an WTP Maximum annual TO BE VALIDATED BY SURVEY RESULTSof 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 visitRs 225 Rs 500 100 At a price of 15 Rs per visit around 10 patients wouldRs 60 80 come each day Average 60Rs 20 At a price of Rs 50 40 ($1), no patients Thursday, June 21, 2012 would attend 20Rs 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
  16. 16. THE GAP CAN BE CLOSED BY CHANGING PRODUCT OFFERING AND SEEKING EXTERNAL FINANCINGAve annualcost perperson: For the model to be viable, willingness to pay for services need toRs 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 Thursday, June 21, 2012Annualwillingness offering, as government subsidies or charitable donations)to pay bylocalpopulation: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
  17. 17. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 16
  18. 18. MOST SIMILAR MODELS REQUIRED EXTERNALFINANCING TO BE SUSTAINABLE Comparison of Indian CHI schemes ACCORD-AMS-Ashwinio 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 reimbursementso 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 Thursday, June 21, 2012o 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
  19. 19. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 18
  20. 20. MOST SERVICE PROVIDERS HAVE DECREASED THERANGE 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 environment3) 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 oftreatment 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 Thursday, June 21, 2012 and health economists (NICE) to assess which drugs and products are “cost effective”. The annualincremental 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
  21. 21. GIVEN ICTPH’S OBJECTIVES, FOCUS SHOULD BEON PRIMARY CARE AND HIGH-RISK CONDITIONSHistoric 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 Thursday, June 21, 2012 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
  22. 22. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 21
  23. 23. THERE ARE THREE OPTIONS FOR ICTPH’SOFFERING DESIGN & MARKET ENTRANCE STRATEGY1. Comprehensive pre-paid model and user-fee services in1 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 Thursday, June 21, 201221. Staged approach pre-paid model3  Healthy patients first, user-fee services for others  Specific diseases covered only, user-fee services for others 22
  24. 24. THESE OPTIONS CAN BE EVALUATED ALONGICTPH’S VISION AND KEY SUCCESS FACTORS1 = 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 diseasesVision 3 3 3 1 2 2Affordability 2 2 1 3 2 2Simplicity 3 3 1 2 2 2 Thursday, June 21, 2012Trust 3 2 1 1 1 2Flexibility 3 1 2 2 3 2Effectiveness 3 2 2 2 2 2Overall 17 13 10 11 12 12 23 Source: ICTPH – Pangea workshop
  25. 25. PRO’S AND CON’S OF SELECTED OFFERINGDESIGN OPTIONSTwo 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 Thursday, June 21, 2012 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
  26. 26. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 25
  27. 27. DEFINING A CLEAR POSITIONING IS KEY TOCOMMUNICATING IN A COMPELLING MANNERValue proposition: Positioning:All benefits and costs of the offering to Primary reason for choosing the offeringtarget customers …………………………….. is the best ……….…………………………… (offering) (product category) for ……………………………………………………………………………..… Thursday, June 21, 2012 (target customers) because ……………………………………..………..……………………… (primary reason) 26 Source: ICTPH – Pangea workshop
  28. 28. SUMMARY OF POSITIONING STATEMENTSUGGESTIONS PRELIMINARY Offering Product Category Target customers Primary reason Unlimited access to qualityPre-paid primary care package Packaged healthcare Rural population healthcare: we are a guide to better health for your family "once I possess this, Ill bePre-paid health product families (rich & poor) with healthy". High quality & cost(comprehensive & Packaged healthcare frequent needs effective care - helps them notpreventative) to delay seeking care understand risk & preventionPrepaid healthcare healthcare savings family basic health needs the best Take care of wellness withPre-paid primary care package Packaged healthcare simultaneous capping of health Thursday, June 21, 2012 expenditurePre-paid primary care package primary healthcare product chronic & non-chronic families your health is in our interest dont have to worry aboutPre-paid primary care package Packaged healthcare families health ever again helps meet the expense ofPre-paid primary care package microhealth insurance "you" unexpected incidencesPre-paid primary care package Packaged healthcare help you stay healthy 27 Source: ICTPH – Pangea workshop
  29. 29. MARKETING TACTICS Distribution Incentives Brand Product Mix Thursday, June 21, 2012 Communication Product Price Features 28 Source: ICTPH – Pangea workshop
  30. 30. EXAMPLES OF INCENTIVESPrimarily 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 Thursday, June 21, 2012 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 Source: ICTPH – Pangea workshop
  31. 31. PRIORITISATION OF INCENTIVE INITIATIVES PRELIMINARYCost Additional benefits Premium guarantee Group Reimburse Introductory discount at yr end Thursday, June 21, 2012 free trial Early adopter Add family Voucher benefits for less Impact 30 Source: ICTPH – Pangea workshop
  32. 32. 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 Thursday, June 21, 2012 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 Source: ICTPH – Pangea workshop
  33. 33. PRIORITISATION OF COMMUNICATION INITIATIVES PRELIMINARYCost Video Community Print meetings Community leaders Word of mouth Thursday, June 21, 2012 Direct to customer Audio Impact 32 Source: ICTPH – Pangea workshop
  34. 34. 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? Thursday, June 21, 2012 How to market the new product? What are the Key Success Factors to keep in mind moving forward? 33
  35. 35. FIVE KEY SUCCESS FACTORS FOR COMMUNITYHEALTH 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 Thursday, June 21, 2012  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
  36. 36. 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 Thursday, June 21, 2012 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
  37. 37. ISSUE OF ADVERSE SELECTIONCurrent pricing of our pre-paid service (~ However, it is likely that the population toRs 1,500) assumes that chronic diseases first adopt the pre-paid product will bewill be represented with the same those with chronic diseases who betterfrequency as they are found in the understand annual healthcare costs andpopulation can see greater potential savings Thursday, June 21, 2012 To cover the cost of the increased frequency of chronic disease, costs would have to be further increased 36
  38. 38. Thursday, June 21, 2012 37THANK YOU!
  39. 39. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 38
  40. 40. INDIAN COMMUNITY HEALTH INSURANCE SCHEMES– OVERVIEW AND KEY FACTSDesign / 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 Thursday, June 21, 2012  From a few thousands to 25 lakhFinancial 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 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, 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
  41. 41. THREE DIFFERENT TYPES OF SCHEME DESIGNCase 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 Thursday, June 21, 2012 Community Community Community Provider model allows • Cashless transactions • No reimbursement procedure several months after treatment • Control over cost and quality of health care 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, 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
  42. 42. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 41
  43. 43. SITUATION: LIFESPRING DEFINED IT’S ORGANISATIONAL GOALS IN REACTION TO INDICATORS OF AN UNMET NEED Existing service provision Indicators of an unmet needFour 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 Thursday, June 21, 2012 Organisation Goal To make high quality maternity healthcare affordable and accessible to lower-income women across India 42
  44. 44. APPROACH: LIFESPRING IDENTIFIED THEIR TARGETMARKET AND FACTORS THAT INFLUENCE THIS GROUP Provision of high quality, accessible maternity healthcare to lower-income women at affordable pricesCustomers: 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 Thursday, June 21, 2012All inclusive pricing of services Targeted communication Provision of superior quality ofwith cross subsidising of care strategy care with transparent pricing 43 Note: (1) B70 population: people from the bottom 70% of India’s income pyramid
  45. 45. DESIGNING THE SERVICE: CUSTOMER PROFILINGIDENTIFIED 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 groupsSegment 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 Thursday, June 21, 2012 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
  46. 46. 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 caresubsidise • Postnatal care Thursday, June 21, 2012 • 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
  47. 47. DESIGNING THE SERVICE: CLOSE ATTENTION HADTO 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) Thursday, June 21, 2012 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
  48. 48. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 47
  49. 49. ACCORD-AMS-ASHWINI (AAA) PROGRAM IMPROVESHEALTHCARE 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 Thursday, June 21, 2012 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
  50. 50. COLLABORATING WITH DONORS AND PRIVATE INSURERGUARANTEES PROGRAM’S FINANCIAL SUSTAINABILITY 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 49 25:145-254
  51. 51. WHAT ICTPH CAN LEARN FROM THIS EXPERIENCEKey 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 Thursday, June 21, 2012 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 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 50 25:145-254
  52. 52. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 51
  53. 53. YESHASVINI HEALTH CARE PROGRAM OFFERS ADVANCEDSURGICAL TREATMENTS TO RURAL KARNATAKAWhat 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? Thursday, June 21, 2012 • 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
  54. 54. WHAT ICTPH CAN LEARN FROM THIS EXPERIENCEKey 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 Thursday, June 21, 2012 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
  55. 55. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 54
  56. 56. MICRO HEALTH INSURANCE IN NEPALBackground 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 forConcept 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
  57. 57. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 56
  58. 58. FOUNDATION FOR INTERNATIONALMEDICAL 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/
  59. 59. FOUNDATION FOR INTERNATIONALMEDICAL 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/
  60. 60. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 59
  61. 61. BACKUP: INDIAN CHI SCHEMES (1/7) Thursday, June 21, 2012 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
  62. 62. BACKUP: INDIAN CHI SCHEMES (2/7) Thursday, June 21, 2012 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
  63. 63. BACKUP: INDIAN CHI SCHEMES (3/7) Thursday, June 21, 2012 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
  64. 64. BACKUP: INDIAN CHI SCHEMES (4/7) Thursday, June 21, 2012 Source: ; N. Devadasan, K. Ransonm W. van Damme, A. Acharya, B. Criel, 2005. The landscape of community 63 health insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234
  65. 65. BACKUP: INDIAN CHI SCHEMES (5/7) Thursday, June 21, 2012 Source: ; N. Devadasan, K. Ransonm W. van Damme, A. Acharya, B. Criel, 2005. The landscape of community 64 health insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234
  66. 66. BACKUP: INDIAN CHI SCHEMES (6/7) Thursday, June 21, 2012 Source: ; N. Devadasan, K. Ransonm W. van Damme, A. Acharya, B. Criel, 2005. The landscape of community 65 health insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234
  67. 67. BACKUP: INDIAN CHI SCHEMES (7/7) Thursday, June 21, 2012 Source: ; N. Devadasan, K. Ransonm W. van Damme, A. Acharya, B. Criel, 2005. The landscape of community 66 health insurance in India: an overview based on 10 case studies. Health Policy 78 (2006): 224-234
  68. 68. 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 Thursday, June 21, 2012  Foundation for international medical relief of Children  Indian CHI Backup materials International profiles 67
  69. 69. INTERNATIONAL PROFILE: CONTENTS Executive Summary Healthcare expenditure vs health outcomes Country profiles Thursday, June 21, 2012 68

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