Bienestar Familia: healthcare for low-income families


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A private healthcare insurance for low-income families.

Project Goal:
Improve access to primary healthcare in Caldas, by redesigning the existing Bienestar social business model, in order to expand and replicate it in Colombia and possibly elsewhere.

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Bienestar Familia: healthcare for low-income families

  1. 1. Bienestar Familia Private Healthcare Insurance for Low Income Families 20 - Bienestar Familia - D4SB
  2. 2. “It’s great design that can solve social as well as economic problems. They (designers) took the methodology of product design and applied it to services. Now they are moving beyond that to systemizing design methodologies for all kinds of arenas, including social problems. What better way to deal with the health care crisis than to use design?” Bruce Nussbaum Innovation and Design Managing Editor. BusinessWeek 22 - Colombia · Bienestar Familia - D4SB 23
  3. 3. Index Why Colombia? Bienestar Familia Concept Value Proposition The Family Healthcare Plan and The Family Doctor The Colombian Context 73 73 Colombia Profile 31 The Community Link: Fairy (Health Promoters) 73 Colombia in Numbers 31 The Business Model Canvas 83 MDG in Colombia 32 Healthcare in Colombia 33 Caldas Profile 35 Villamaria Profile 38 Benchmarks 40 Project Goal 43 Ownership 86 Implementation 86 Expansion 86 Conclusion Observation & Synthesis The Field Research in Caldas, Colombia 46 The Research Tools 46 The Colombia Healthcare System 99 60 Identification of Problems & Needs Bibliography 55 Personas 96 52 The Interview Guides Conclusion 47 Bienestar 24 - Colombia · Bienestar Familia - D4SB Implementation and Expansion 68 25
  4. 4. Why Colombia? Grameen Caldas is an organization founded in Colombia by GCL in partnership with the public sector represented by the Caldas Government to facilitate the creation of a Holistic Social Business Movement (HSBM) in the region. The idea of this HSBM is to set the right environment in Caldas paving the way for social business initiatives with the unique objective of eradicating poverty. To enable this environment, Grameen Caldas set initiatives in micro-finance, joint ventures development and in the creation of a social business fund of $7 million. The four main areas of investment are education, nutrition, healthcare and housing (sanitation). The Grameen Caldas team initiated Bienestar, a social business project addressing the issues of healthcare in the region. Our challenge as the Design for Social Business team was to understand the complexity of the healthcare system in Caldas, identify its main breakdowns and accordingly explore how design can improve, expand and replicate the already existing pilot model of Bienestar. 26 - Colombia · Bienestar Familia - D4SB 27
  5. 5. The Colombian Context 28 - Colombia · Bienestar Familia - D4SB 29
  6. 6. Colombia Profile Being the twenty-sixth largest country by geographical area and the twenty-seventh largest by population, the Republic of Colombia is the fourth largest economy of Latin America. With over 46 million people Colombia (2010 est.), has one of the most unequal distributions of wealth with a GINI coefficient of 0.587 (the highest in Latin America). 46% of the population lives below the poverty line and 17% in extreme poverty. Colombia in Numbers 75% urban 54% above 46% 62.8% not poor below 37.2% Rural and urban populations People below the poverty line Poverty head count ratio at national poverty line 88% 93% 25% rural employed literate Unemployment (total labor force) poor Literacy rate (age 15 and above) Capital City: Bogotá Income Level: Lower middle income GDP: $435,367,000,00 (2010 est.) GNI per Capita: $8,430 (2009 est.) GINI Index: 0.587 the highest in Latin America Total Population: 46.3 millions 31
  7. 7. Healthcare in Colombia MDG in Colombia Value Goal 1990 Value 2008 Goal 1. Halve the rates for extreme poverty and malnutrition Poverty headcount ratio at USD$1.25 a day (PPP, % of population) Poverty headcount ratio at national poverty line (% of population) Share of income or consumption to the poorest quintile (%) Prevalence of malnutrition (% of children under 5) 3.4 - 2.9 5.1 Goal 2. Ensure that children are able to complete primary schooling Primary school enrolment (net, %) Primary school completion rate (% of relevant age group) Secondary school enrolment (gross, %) Youth literacy rate (% of people ages 15 - 24) 68 67 50 95 5 35 26 82 21 17 88 Goal 5. Reduce maternal mortality by 3/4 Maternal mortality ratio (modeled estimate, per 100,000 live births) Births attended by skilled health staff (% of total) Contraceptive prevalence (% of women ages 15 - 49) 82 66 130 96 78 Goal 6. Halt and begin to reverse the spread of HIV/AIDS and other major diseases Prevalence of HIV (% of population ages 15 - 49) Incidence of tuberculosis (per 100,000 people) Tuberculosis cases detected under DOTS (%) 63 - 0.6 45 83 Goal 7. Halve the proportion of people without sustainable access to basic needs Access to an improved water source (% of population) Access to improved sanitation facilities (% of population) Forest area (% of total land areas) Nationally protected areas (% of total land areas) CO2 emmissions (metric tons per capita) GDP per unit of energy use (constant 2005 PPP $ per Kg of oil equivalent) 92 82 55.4 1.7 7 93 86 54.7 74.4 1.2 9.2 Goal 8. Develop a global partnership for development Telephone mainlines (per 100 people) Mobile phone subscribers (per 100 people) Internet users (per 100 people) Personal computers (per 100 people) 6.9 0 0 0.9 17.2 73.6 26.2 5.5 Goal 3. Eliminate gender disparity in education and empower women Ratio of girls to boys in primary and secondary education (%) Women employed in the non agricultural sector (% of non agricultural employment) Proportion of seats held by women in national parliament (%) 32 - Colombia · Bienestar Familia - D4SB 3K 104 48 8 Goal 4. Reduce under 5 mortality by two thirds Under 5 mortality rate (per 1,000) Infant mortality rate (per 1,000 live births) Measles immunization (proportion of 1 year old immunized, %) 15% of population (approximately 6.9 million) are without medical insurance. Extreme low quality in health services provided to the poor. Poor infrastructure and shortage in public hospitals. High bureaucracy in accessing the public health system. Private insurance companies delay payment of treatments. 88 65 82 97 108 44 »» »» »» »» »» Per Capita Annual Expenditure on Healthcare Table 1. Value achieved in Colombia until 2008 according to the Millennium Development Goals. Average exchange rate (USD) With a GINI coefficient of 0.587 Colombia has the highest inequality in Latin America. Main Problems of the System 2K 1K 0K 1995 Colombia 2000 2005 2010 Region of the Americas’ average Figure 3. Colombian expenditure on healthcare (est. 2008). Healthcare Related Statistics Data Access to an improved water source Access to improved sanitation facilities Mortality rate, infant Child malnutrition (children under 5) Value 93% 86% 17 per 1,000 live births 5% World Bank (2008) Life expectancy at birth m/f (years) Probability of dying under five Probability of dying between 15 and 60 years m/f Total expenditure on health per capita (PPP International $) Total expenditure on health 73/80 19 per 1,000 live births 166/80 per 1,000 live births 569 6.4% of GDP Global Health Observatory (2009) Table 2. Healthcare related statistics according to the World Bank (2008) and the Global Health Observatory (2009). 33
  8. 8. Caldas Profile Hypertensive 3.8% Ischemic heart 14.4% Circulatory 32.8% Injuries 7.6% Although the matriculation at the Caldas universities in the field of Sciences of Health were of 3,285 students, and the medicine schools in Colombia have increased from 21 to 54 in the last 20 years, doctors that graduate are concentrated in the big cities making it difficult to achieve health coverage for the entire population. Hypertensive 2.1% Ischemic heart 11.3% Cerebrovascular 4.7% Other causes 15.3% Caldas department is part of the Colombian Coffee Growing Axis with a total area of 7,291 km2. Caldas’ department has a population of 976,438 inhabitants consisting mainly of 25-29 year olds. The combination of mortality rates and migration of young people due to the scarcity in the labor markets is leading to an increment on the aging population (40+ year olds). Other CVD’s 3.0% Circulatory 21.2% Other causes 13.8% Cerebrovascular 9.3% All NCD’s 48.2% Injuries 38.0% Other CVD’s 5.3% Cancers 19.9% Respiratory 6.7% Diabetes 5.5% Other Cancers 9.6% Figure 4. Estimated mortality causes for women (%) Colombia, 2004 Lung 1.5% Breast 2.5% Colorectal 1.5% Leukemia 1.0% Lymphomas 0.9% Stomach 2.9% 11.1% 14.2% 22.4% 23.8% 23.6% 32.4% 32.6% 32.9% 34.1% 31.6% 29.3% 2009 2015 Diabetes 2.5% Respiratory 4.9% Other NCD’s 8.2% Figure 5. Estimated mortality causes for men (%) Colombia, 2004 The average income of a general doctor in Colombia is around $285 (3-4 minimum wages). Around 8% of the doctors are unemployed and 5% work in different jobs. 34 - Colombia · Bienestar Familia - D4SB 12.0% 2005 Other NCD’s 12.2% Cancers 11.5% All NCD’s 77.1% Figure 7. The Caldas region. Figure 6. The Caldas population structure by large groups. 0 - 17 40 - 59 18 - 39 60+ 35
  9. 9. Is the inactivity rate in the region of Caldas Out of the total Caldas population... Is the inadequate employment rate due to income in the Caldas region. Scarcity in the labor market, added to the great reduction in agricultural production have conspired to create higher rates of inactivity and greatly increase the chances of falling into poverty. 25.7% are registered as SISBEN Level 1 (extreme poverty) 36.3% are registered as SISBEN Level 2 (poor) 12.2% are registered as SISBEN Level 3 It means that 3 out of every 5 inhabitants of Caldas are poor by definition The SISBEN Level 36 - Colombia · Bienestar Familia - D4SB *SISBEN: The Selection System of Beneficiaries for Social Programs is a social survey done by the government, to rank poor people (from economical strata 1 and 2) according to their quality of life. People are divided in three categories: 1, 2 and 3 (where 1 is the lowest quality of life). SISBEN is used to select people for social assistance programs from the government, who have “... a state of deprivation not only in material welfare (food, housing, education, health, etc.) but (…) also personal and property uncertainty, vulnerability to health, disasters and economic crisis, social exclusion and political life and liberty of making abilities”. 174,142 31% are single moms 17,832 36% are single moms 7,510 36% are single moms Number of households as registered by SISBEN The average size of a household according to SISBEN level in Caldas 4.5 Level 1 4.0 Level 2 3.4 Level 3 37
  10. 10. Villamaría Profile Villamaría is a municipality of the Caldas Region and is situated 9 km away from the capital, Manizales. It has an area of 461 km2 and a population of 50,123 inhabitants. Healthcare Professionals in Villamaría In 2009 Villamaria had Colombia had 1 doctor for every 2,083 inhabitants 1 doctor for every 740 inhabitants 1 dentist for every 4,545 inhabitants 1 dentist for every 1,282 inhabitants 1 nurse for every 8,333 inhabitants 1 nurse for every 1,818 inhabitants Table 3. Number of healthcare professionals in Villamaria compared to the whole Colombia in 2009. Caldas population ± 1,000,000 Villamaría population ± 50,000 38 - Colombia · Bienestar Familia - D4SB Manizales population ± 387,000 39
  11. 11. Benchmarks Many solutions have been implemented throughout the world to improve healthcare access to low income communities. We looked into some of the different approaches to get inspiration for our concept. Mothers Club, Kendubay Sub-District Hospital Distance Healthcare Advancement - DISHA Pre natal/delivery care and education The club recruits women attending the hospital’s prenatal clinic. The women are asked to make a commitment to deliver their next child in the hospital and meet as a group twice a month to receive health education, including training on safe motherhood practices. Other than that, they are asked to take an active role in educating other women in their villages about safe motherhood and the risks of delivering at home. 40 - Colombia · Bienestar Familia - D4SB SOS Médcins France Mobile healthcare and partnerships Discounted medical services Affordable healthcare franchise model Mobile healthcare The goal of DISHA is to deliver high-quality, low-cost diagnosis and care to low-income rural communities that are not addressed by the existing healthcare system through a mobile tele-clinical van. In this initiative, Philips, an imaging and medical diagnostics company, partnered with a government agency (ISRO) that provides satellite connectivity between the van and the hospital, Apollo, the healthcare service provider which will staff the van, and a local NGO. Through the use of a multi-tiered pricing model, ASEMBIS has created a financially self-sustained network of eye care clinics that offer services from basic eye examinations to sophisticated surgical procedures at a 40-70% discount from the market rate. Its integrated network includes non-traditional health professionals for vision testing and preventive care, cost-efficient and high-volume clinics, and mobile rural clinics; an overall treating of more than 350,000 patients in 2004. The 8 clinics in different regions of Costa Rica, offer nationwide coverage, and provide a wide spectrum of medical services, from basic health to sophisticated surgeries, imaging diagnostics, and almost all specialties. A network of 64 financially self–sustainable centers that deliver government approved health products and pharmaceuticals at $0.50 per treatment. Distributed in urban, rural and semi-rural areas, these units are located within an hour distance from their intended customer base and serve more than 400,000 Kenyans a year. More than half of the locations are owned by community health workers while the rest is owned by licensed nurses which also provide screening services. The quality of the services is guaranteed by unannounced audits and the threat of the closure. In exchange, they bear a brand name, share marketing costs, best practices and benefit from a centralized buying platform. The concept is simple: patients in need of care can contact a call center 24 hours a day, 365 days a year that finds an available doctor and sends him to their home, much like a taxi business. A success that counts with a thousand emergency doctors and 62 associations spread over the territory, and have handled so far 4 million calls and 2.5 million home interventions and consultations; 60% of procedures performed at night, Saturday afternoon, Sunday and holidays. The achieved results are a consequence of the reliability and unfailing motivation of the key players. Key point: Creating a network of financially sustainable healthcare clinics that offer specialist services and uses alternative professionals to deliver care. Key point: Empowering and integrating local women in the healthcare delivery model through an educational role. ASEMBIS CFW Shops Kenya Key point: Creating a replicable and affordable model that benefits from group synergy and local entrepreneurs. Key point: Creating alternative channels to deliver healthcare and create synergetic partnerships. Key point: Providing alternative channels for care delivery through an extremely flexible organizational model. 41
  12. 12. Project Goal: Improve access to primary healthcare in Caldas, by redesigning the existing Bienestar social business model, in order to expand and replicate it in Colombia and possibly elsewhere. 42 - Colombia · Bienestar Familia - D4SB 43
  13. 13. Observation & Synthesis 44 - Colombia · Bienestar Familia - D4SB 45
  14. 14. The Field Research in Caldas, Colombia The Colombian Healthcare System Initials To understand the complexity of the healthcare system, it is important to look into its institutions, the different forms of coverage it provides to the population and the regulations behind it. A substantial part of the input gathered for this project comes from the field research conducted in Caldas, Colombia from May 15th to June 5th, 2011. Our stay was supported by the local organizations Grameen Caldas and Bienestar, which helped us individuate and contact the local players, make the arrangements for the activities and guide us on field. The public healthcare is regulated by the law 100/1993, which established the SGSSS (General System of Social Security in Health). This system is coordinated, directed and controlled by the state and the funds designated by the government are managed by the FOSYGA (Fund of Solidarity and Guarantees). This phase of the project was based on qualitative research methods which, combined with the desktop research, helped us in getting a complete overview of the situation and arriving to the desired solution. The main healthcare institutions involved in delivering healthcare services to the population are the EPS’ (Health Insurance Companies) and the IPS’ (Health Service Providers). “At the early stages of the process, research is generative—used to inspire imagination and inform intuition about new opportunities and ideas. In later phases, these methods can be evaluative—used to learn quickly about people’s response to ideas and proposed solutions”. (IDEO Toolkit). The EPS functions as an intermediary between its affiliates and care delivery institutions (IPS) in managing appointments, approvals and the payments of health services. It has to guarantee to its affiliates the minimum established by the POS (Mandatory Health Plan), which is a list of treatments, procedures and drugs defined by the government. The Research Tools The IPS is a public or private entity that provides medical procedures. IPS’ are divided in 3 levels of attention and the vast majority only cover the first level. Design tools used with the different stakeholders Tools Stakeholders Doctors, medical professors and students from Manizales University. Understanding the complexity of the Colombian healthcare system, its stakeholders, how they are connected to each other and their influence on the system. The quality and coverage of health services are directly linked to the affiliation of the patient to the system. There are four types of regimens: Name in Spanish (English) SGSSS Sistema General de Seguridad Social en Salud (General System of Social Security in Health) EPS Entidades Promotoras de Salud (Health Insurance Companies) EPS-S Entidades Promotoras de Salud Subsidiadas (Subsidized Health Insurance Companies) IPS Instituciones Prestadoras de Servicios de Salud (Healthcare Providing Institutions) POS Plan Obligatorio de Salud (Compulsory Healthcare Plan) FOSYGA Fondo de Solidaridad y Garantía (Fund of Solidarity and Guarantees) PBS Plan Basico de Salud (Basic Health Plan) Table 5. Acronyms of the Colombian healthcare system. Goals Group interview List of Acronyms Discovering the main touch points of the existing healthcare service and tracing money, time and information flow. Different Regimens Within the Colombian Healthcare System Regimen Description millions / % Contributive (RC) Understanding the Holistic Social Business Movement in Caldas and its goals, as well as the criteria for accessing the fund assigned by the Government to finance social businesses in Caldas. People with employment contract or independent workers who earn at least two minimum salaries per month are affiliated to the contributive regime; they have to pay a monthly affiliation to an EPS (12.5% of their monthly wage); 8.5% is paid by employers and 4% is paid by employees, and they should pay moderating fees ‘copays’ established in the POS for the contributive regime. Subsidized (RS) Unemployed people and people from SISBEN 1 and 2, likewise their family; they should pay moderating fees established in the POS for the subsidized regime according to their SISBEN level. Of the 12.5% total contribution per individual of the RC, the FOSYGA channels 1.5% into the RS as a solidarity contribution. Understanding and analyzing the first outcomes, limitations and challenges of Bienestar social business pilot phase. Not affiliated (Vinculados) People who are not classified by the SISBEN and don’t have access to the subsidized healthcare services, as well as SISBEN 3 and independent workers with payment capacities. They are covered by the PBS. This plan is a safety net financed by general taxes that is composed of public hospitals and health centers. While all citizens are eligible to receive the benefits under this plan, it primarily serves those who have not yet been enrolled in either the RC or the RS and those who are enrolled in the RS but require services that are not yet covered under its benefits package. Special (RE) People who work for the government, armed forces and teachers of public institutions; this plan is financed by the government and they benefit from their own network of healthcare providers and have very few limitations on the services provided. Understanding the perspective of doctors, their aspirations and frustrations. Discussion sessions Individual interviews Grameen Caldas team and Bienestar founders. Patients, community workers and healthcare related players such as doctors, nurses and pharmacists. Understanding the person. Understanding the general healthcare and medical experiences of users. Understanding the specific experiences related to user profile. Table 4. Description of the design tools used with the different stakeholders. Affiliations in Colombia 17.3 (39%) 23.8 (51%) 4.2 Affiliations in Villamaría millions / % 16.5 (33%) 15.9 (32%) 17.5 (8%) (35%) 1.2 N/A (2%) Table 6. Definitions of the different regimens within the Colombian healthcare system. 46 - Colombia · Bienestar Familia - D4SB 47
  15. 15. Moreover, the access to generic essential drugs (from a list of 350 medicines) is covered through the POS for those under the contributive regime and with certain restrictions for those under the subsidized regime. For those not covered by the system, there is almost no access to any medications at all, since this is strictly limited to primary care medications that do not exceed a value of USD$4. Therefore, it is clear that the population that lacks the most access to adequate healthcare is the one not affiliated to the system (vinculados) followed by the subsidized regimen. Combined they represent 67% (34,000) of the population of Vilamaria—against 59% in Colombia. Vinculados alone, represent 35% of the population in Villamaria, amounting to a total of 17,500 people without health coverage. Public Healthcare System Map 48 - Colombia · Bienestar Familia - D4SB 49
  16. 16. The network of care providers in Villamaria counts with 5 IPS’ (Table 7) of which only one is a public provider. It is also the only one that provides emergency and delivery services. The other entities are private and offer only prevention, promotion and consultation services. For second and third level care, patients have to go to Manizales or Pereira. Entity Hospital San Antonio Public / Private Level of complexity Patients treated (2009) Assistant Staff I Level 41,173 55 34 Coordinates, directs and controls the public health system (regimen affiliations, EPS’ and IPS’ regulation and POS limitations). Directly finances life-threatening cases outside of the POS (tutela). Admin. staff Public Don’t provide any medical service, but work as an intermediate between their members and the affiliated IPS’. Manage the money flow between the two. State / Admin Healthcare Service Providers in Villamaría EPS’ (healthcare insurance companies) Centro Médico El Parque Private I Level 19,540 6 3 Salud Total Private I Level N.A. 6 1 S.O.S Private I Level 6,803 6 Private I Level 16,383 13 0 Hospitals, clinics, laboratories. Manage and provide healthcare personnel, infrastructure and supplies for care delivery according to the POS coverage and to the patients’ EPS affiliation. Private IPS’ are paid by EPS’. Public IPS’ are for non-affiliated patients (vinculados). 1 Pasbisalud IPS’ (health service providers) Table 7. Description of the healthcare service providers in Villamaria. Doctors and Health Personnel Hired by the IPS’ to deliver medical services. In general, they are not able to deliver adequate care since they are limited by their IPS’ and the POS. Patients Access to treatments, exams and medicines, as well as services copays, depend on their regimen affiliation (contributivo/subsidiado) or lack of it (vinculado), and to POS limitations. Often receive inadequate medical services, have no influence in the system and are subject to EPS decisions. Pharmacies Sell medicines and provide health counselling. They are often used as an alternative access point to healthcare, but don’t have any actual medical power. IPS Pharmacies Give or sell prescribed medicines according to insurance coverage of the patient treated in the IPS. Unless it is an emergency, the affiliated patients have to pass through their assigned EPS for approval and scheduling of appointments, a process that often delays the treatment to several weeks and sometimes even months. For Vinculados, the process could seem more direct, but services offered in the public IPS are very limited, waiting time is huge and insufficient resources lead to very scarce services. Briefly, EPS’ and IPS’ are the main players with the biggest influence in the system and on the final care received by the population. The following graph describes the role of each stakeholder in the system and compares their level of influence and power. Patients have little control and decision power which leaves them without much influence within the system. Moreover, doctors and healthcare personnel are subject to IPS´ rules and constraints and to the lack of proper job conditions, a cause for poor motivation and professional fulfillment. Imposed POS limitations together with inadequate in-house resources are not only a frequent source for their frustrations but a barrier to a proper care service for the patients. EPS’ and IPS’ are the main players with the biggest influence on the system and on the final care received by the population. Stakeholders of the Public Healthcare System Influence on the System 50 - Colombia · Bienestar Familia - D4SB 51
  17. 17. Bienestar Bienestar was initiated in 2010 as an alternative healthcare service to the public health system. Based on the Ser model in Argentina, Bienestar´s mission is to improve the access to primary healthcare services for low income communities in the Caldas region, following the social business principles. The main idea behind Bienestar is to eliminate the barriers imposed by the EPS’ by selling membership cards that link members directly to the affiliated clinics. For USD$5 a year, the cardholder is entitled to discounts up to 50% on the treatments delivered by the network. The map on the opposite page illustrates how the Bienestar system works. The model aims to empower patients and to cut the bureaucracy imposed by EPS’. The patients get a better services and the waiting time is reduced. In exchange, affiliated clinics win by increasing the volume of patients and by having instant cash — EPS usually take months to pay the contracted services. The project during our research was in its pilot phase, with one affiliated clinic and 90 members in Villamaria. The map shows some advantages of this stage of the project by eliminating EPS´ authority and by increasing the influence of patients on the scale. However, the situation is still not the ideal since the care quality cannot be guaranteed because the affiliated clinics are still managed in the same way as before entering the network. SER System Model CEGIN is a medical center founded in 1989 which specializes in the provision of medical services to poor women from rural areas of the Jujuy Province. Jorge Gronda launched the SER system within the CEGIN center in 2004. It is a membership card that patients can purchase for USD$3 per year in exchange of preferential rates (more than half of the market price) on services delivered in these centers. The main idea behind the SER card, beyond increasing access to healthcare, is to create a network that will later allow its members to enjoy various advantages. Currently, card holders already enjoy discounts in some pharmacies, and in the long term, his ambition is to develop a system of “social franchise”, and extend the SER cards’ field of action to various fields such as food, construction and transports. The social impact of CEGIN and the SER system allow the people at the base of the pyramid to have access to quality healthcare. Nowadays, over 40,000 people are followed by these clinics (including 20,000 through the SER network). Belonging to the SER networks and enjoying quality care services considerably increases the self-esteem of people suffering from social exclusion. The pride SER clients take in being part of the network makes them talk positively about it, and this word of mouth has been fundamental in the development of CEGIN. Table 8. Description of the SER system running in Argentina. Bienestar System Map 52 - Colombia · Bienestar Familia - D4SB 53
  18. 18. The Interview Guides IPS (Bienestar-affiliated clinics) Doctors & Healthcare Personnel Bienestar Manages and provides discounted health services direct to Bienestar members, in exchange for a bigger volume of patients. Maintais its role in the public health system. Ensures appropriate infrastructure, personnel and supplies to provide the care. Hired by the IPS to deliver medical services. They are able to deliver better care, since they are not limited by the POS anymore, but are still limited by their IPS. Links patients and Bienestar-affiliated IPS’ through the sale of a membership card that entitles to discounted health services. An alternative to the actual primary healthcare system, it cuts the access barriers imposed by the EPS’ and the POS. As the last part of our field research, we did a series of interviews with different stakeholders of the system, with a special focus on the final user, the patient. Our aim was to understand their concerns, expectations and frustrations, as well as listen to their experiences in order to develop a user-centered solution. By interviewing doctors (working in the public system and in the Bienestar affiliated clinic), medicine students, the Bienestar affiliated clinic owner, a nurse, a pharmacist, a social worker and an EPS customer representative, we took into consideration all the different points of view, an important step in developing the further service. Interviews took place at people’s houses, around the community, at a pharmacy, a local medicine market, a 2nd level public hospital in Manizales and at the Bienestar affiliated clinic, El Parque. Interview Guides - Patients Name EPS’ (health insurance companies) Regulation and autorization of Bienestar activities. Address the patients to different healthcare providers (IPS’) when Bienestar does not cover the request (specialists, exams). Stakeholders of the Bienestar System Influence on the System 54 - Colombia · Bienestar Familia - D4SB Household Structure Household Income Bienestar User Sisben Level Insurance Regimen Maria Elsita Mayo Female 50 Years Housewife Lives with husband and 2 of their 5 kids (10yrs twins)   No Sisben 2 Subsidiado Nestor Ivan Garcia Male 41 Years Informal construction worker Lives with wife and stepson next door to his family in law Income depends on couple’s job Yes Sisben 1 Subsidiado Gloria Bettancourt Female 50 Years Unemployed Lives with husband, her mother and their 4 kids Income comes from husband’s job Yes Sisben 1 Subsidiado Paula Hernandez Female 29 Years Works at a call center at night (her mother takes care of her daughters) Lives with husband (works during the day) and their 2 daughters (10yrs + 4yrs) Income depends on couple’s job Yes Sisben 1 Contributivo Ober Osorio Male 78 Years Retired policeman Lives with his daughter Pension No Sisben 2 Regime especial Female 48 Years Unemployed Lives with husband, their 3 sons and 1 nephew Income depends on husband’s job who works in construction No Sisben 1 Subsidiado Female 40 Years Housewife Single mother, lives with son (7yrs), mother, 4 brothers and 1 nephew Income is based on the jobs of the brothers and sister Yes (+2 family members) Sisben 2 Subsidiado Lina Paula Ospina State / Government Sell medicines discounted by 5% to Bienestar patients in exchange for a bigger volume of sales. Occupation Albaneli Franco Pharmacies (Bienestar affiliated) Hired by the IPS’ to deliver medical services. In general, they are not able to deliver adequate care since they are limited by their IPS’ and the POS. Age Gloria Ines Patients (Bienestar members) Gender Female 23 Years Unemployed Single mom, lives with her two kids (7months + 3yrs) and her grandparents Income depends on her father No Sisben 1 Subsidiado Table 9. Patients’ profiles from the interviews in Villamaria. 55
  19. 19. Interview Guide - Female Patient Interview Guides - EPS User Representative Age Occupation Household Structure Household Income Doralba Seballos Mosqueiro Female 64 Years President of the association of Villamaria’s Caprecon (EPS) users* Lives on her own Government help to the 3rd age citzens 2. Understanding the general healthcare & medical experiences of user Bienestar User Sisben Level Insurance Regimen No Sisben 1 »» »» »» »» »» »» »» »» »» On the Colombian healthcare system (how they see it, service, time to get treatment, difference with Bienestar). »» »» »» »» »» »» Have you used the public healthcare system? Did you feel well attended? How did they treat you? How much money from your salary goes to the public system? How do you regard public healthcare? What is your opinion? How long did it take you to get treated? Where did you have to go? Before going to the doctor - look for alternative ways. »» »» »» »» »» »» »» »» Do you go to the pharmacist sometimes for medical advice? When feeling sick you try to talk with someone about it? Do you consult family members, friends, other sources? What kind of illnesses do you feel you can solve without a doctor? How would you do it? What medicines do you always have in your house? Where do you keep them, can you show me? What remedies do you always have in your house? Where do you keep them, can you show me? Do you have a first aid kit? Can you show it to me? Do you use alternative ways of treatment (infusions, teas, ungüentos)? Can you describe an experience related to any of these issues that have happened to you or somebody that you know? »» »» »» »» »» »» »» »» »» »» »» What kind of prevention do you take? (hygiene, nutrition, chlorine in water, iodized salt, etc.) How often do you visit a doctor? When do you feel you need to go to the doctor? How ill do you need to be? What makes you decide against visiting a doctor when a health problem occurs? Where is your nearest healthcare center/doctor? How long does it take you to get there? How do you go to the doctor’s clinic? Do you use public transportation (bus, taxi, chiva, etc)? What do you do when there is an emergency? Do you take the decisions regarding health condition of others in your family? Do you usually go accompanied to the doctor? If so, is it a family member, a friend? What family member? (child, husband) Do you save some part of your budget for health emergencies? Is it a problem with your employer to take time off from work if you need to see a doctor? Doctor - visit »» »» »» »» How is your relationship with your doctor? Describe it in some words. Where do you go to visit your doctor (clinic/hospital)? When going to the doctor, do you feel that you are paying too much/enough for his services? How many times more or less do you go to the doctor per month, per year? Doctor / clinic experience »» »» »» »» »» Do you trust doctors? Do you have a trusted doctor that you always go to or wish you could always go to? Do you prefer a male or a female doctor? List some characteristics that you think are very important in a service. What do you appreciate most in a visit? What is your opinion about nurses, assistants, other staff? Women »» »» »» »» Did you see a doctor on regular basis when you were pregnant? Where did you give birth? Who helped you in giving birth? How often do you take your children to the doctor? Are you aware of regular checkups like Papanicolao? If so, do you have them? Bienestar user Gender 1. Understanding the person Going to the doctor (motivation, decision making, education). Name »» »» »» »» »» »» Why did you choose Bienestar? Do you think the healthcare service has improved with Bienestar? What determined you to enter Bienestar program? Have you advised someone else to use it? Do you have a trusted doctor that you always go to, or wish you could always go to? Is he from Bienestar? Did you notice something different (service experience) using Bienestar from your past experience? What are your expectations from Bienestar? Not Bienestar user »» Have you ever looked for private insurances regarding healthcare? »» Do you know what an insurance is? Have you ever considered it? »» What determined you to enter Bienestar program? Subsidiado * in charge of gathering the complaints from Caprecon users in Villamaria to take them to the Manizales Health Superintendence. Table 10. EPS User Rappresentative’s profile from the interviews in Villamaria. Interview Guides - Nurse Name Gender Age Occupation Household Structure Household Income Eluin Osorio Female 46 years Works at Nueva EPS Lives with son (21yrs), his wife and grandson (2yrs) Income depends only on her job Bienestar User Sisben Level Insurance Regimen No Sisben 2 What is your name, age, marital status, number of children, parents...? Where are you originally from? If not Caldas, where from and why did you move here? Who do you live with? Are all your children living with you or did any leave? Do your parents live with you? Why? What do you do for a living? And the other members of your family? Are you the only person contributing for bringing money home? If not, who else? Do you work outside your house? If so, do you work close to you home? How do you get there? What forms of transportation do you use? Are you a frequent user of medicines? If yes, what medicine do you use and for what health problem? Do you or anyone from your family suffer from any chronic or hereditary disease? (heart disease, stroke, cancer, chronic respiratory diseases and diabetes...) Contributivo Table 11. Nurse’s profile from the interviews in Villamaria. Interview Guides - Doctors Name Gender Age Occupation German Aristizabal Moreno (Bienestar) Male 45 years Works at and owns Centro Medico El Parque (a Bienestar affiliated clinic), certified as a general practitioner Adrian Zapata Male 32 years Works at Centro-Piloto Bas Salud (2nd level public hospital in Manizales) Table 12. Doctor’s profile from the interviews in Villamaria. 3. Understanding the specific healthcare experiences related to user profile Interview Guides - Pharmacist Name Gender Age Occupation Berta Female 75 years Works in her own pharmacy with her daughter Table 13. Pharmacist’s profile from the interview in Villamaria. Interview Guides - Social Worker Name Gender Age Occupation Yurdani Woman 28 years Social worker at the Municipality of Villamaria** ** takes care of social and cultural programs with the local youth (14yrs – 26th) Table 14. Social Worker’s profile from the interviews in Villamaria. 56 - Colombia · Bienestar Familia - D4SB Table 15. Example of an interview guide used during the field research in Villamaría. 57
  20. 20. Paula Hernández. The difficulties of dealing with the EPS’. Paula Hernández, 29 years, is originally from Manizales. She moved to Villamaría with her mom that now lives in a different house. She rents a house in one of the neighborhoods in Vallamaría where she lives with her new husband and her two daughters from her previous marriage. She works during the night for a mobile phone company and therefore sleeps during the day. Paula’s mother takes care of the two children and some of the domestic chores as Paula rests during the day. One of her daughters, Paola, is 5 years old and was born with a malnutrition problem that led to an orthopedic issue making it difficult for her to walk. This has caused Paula to face many difficulties in trying to access the right treatment ever since Paola was born. During her pregnancy, Paula was diagnosed with a morphological problem that made it difficult for her to give birth. That is why she blames herself and feels responsible for her daughter’s complication. “Doctors become insensible”. Maria Elsita Mayo 50yrs. Patient “For the health, I don’t “I don’t have a place where to send the think twice, I pay”. children”. Nestor Ivan García 41yrs. Patient Adrian Zapata 32yrs. Doctor “The EPS meetings with the users happen once a month. Nonetheless, very few people attend them”. Doralba Seballos Montero 64yrs. EPS representative Paula has been trying to schedule the necessary surgery but she has not been able to do so. Due to the bureaucracy within the system and the long time required, she has been struggling to fix a surgery since Paola’s problem can only be solved at a young age. Every time Paola needs a treatment, she has to go through a general doctor that then sends her to a pediatrician and finally to a pediatric orthopedist in order to get the treatments approved and done. “I lose a lot of time”. Paula said. Whenever she books an appointment through her EPS, she usually waits from 15 to 20 days for confirmation without having the possibility to choose neither the doctor nor the hospital she has to go to. She enrolled Paola in the Bienestar plan as she was desperate to find a solution for her daugher’s problem. Ever since then, she has been very satisfied. “Now the doctor really takes care of her and gives me advice on what to do”. Before, she felt that the doctors and nurses of the public system did not really care about her daughter nor her illness. She would like all her family members to sign up for the Bienestar plan, especially her mother who is also sick. Paula’s mother helps her a lot in raising her daughters and does not have any kind of healthcare coverage herself, but the income inside the house only allows them to have Paola insured. Her two daughters represent her major priority, that is why even if she is enrolled in an EPS she chose to pay extra and take better care of both of them. 58 - Colombia · Bienestar Familia - D4SB 59
  21. 21. The Interview Guides - Personas To synthesize the information gathered during the interviews, we created personas based on the different family structures in Caldas. They represent a general profile of the Colombian reality. Persona 01 - Margarita Perez Sex: Female Age: 23 years old Sisben: Level 1 EPS: Caprecom (subsidised) Margarita is unemployed and lives with her grandparents, Sofia and Pedro. Her 26 year old partner, Miguel, lives with them and they have 2 children together. One of the children is 3 years old and the other is 3 months old. Miguel is a construction worker and the source of income to support the children. Margarita’s grandfather: Pedro suffers from ulcer, hernia, prostate, high blood pressure and had the Cafe Salud EPS, which he was denied from because of his many chronic illnesses. He hates going to the doctor and Sofia and Margarita are always finding ways to trick him into taking him there. They had to pay 3,000 pesos for the card when enrolled in EPS and a fine of 8,000 pesos whenever they didn’t show up to an IPS visit. Tutella accepted his request but takes a long time (3 months) to get appointments. Margarita has mastitis (breast milk problems) and goes to the pharmacy instead of the doctor since the doctor is always changing and the checkup time is too short. She would like to study to be a nurse one day. Margarita and Sofia are the decision makers in the house. 60 - Colombia · Bienestar Familia - D4SB 61
  22. 22. The Interview Guides - Personas Persona 02 - Pablo Salazar Sex: Male Age: 41 years old Sisben: Level 1 EPS: Caprecom (subsidised) Paco is a construction worker on freelance terms. He is living with his partner, Angelica, who has a son from a previous relationship. Their house is close to Angelica’s parents’ house who live together with their other daughter and her 2 children. Paco is the income provider of the family. He has a lump in his hand but has never had it checked. He has had previous bad experiences with a doctor where he was given the wrong prescription for a disease in addition to always waiting too long to get a consultation. He enrolled in Bienestar but hasn’t used it yet. He is willing to pay a little bit more to ensure healthcare access in case of emergency. “In health matters, I don’t think twice, I pay”. 62 - Colombia · Bienestar Familia - D4SB 63
  23. 23. The Interview Guides - Personas Persona 03 - Maria Gonzalez Sex: Female Age: 28 years old Sisben: Level 1 EPS: Salud Total (contributivo) Maria and her children live with Franco, Maria’s husband and the children’s stepfather. She works at night in a call center and her husband works at Gommaz. They rent a house which is close to Maria’s parents’ house so her mother can take care of the children while Maria sleeps during the day. Maria has 2 daughters: »» Gloria, 5 years old, suffering from malnutrition »» Mailin, 7 years old, who had apendicitis Maria’s daughter: Gloria goes to a nutrionist which EPS covers but Maria enrolled her into Bienestar so she can have fast access in case of an emergency and also because they get a sense of attention from the doctor which isn’t present with the doctors EPS assigns. Maria’s mother: Fernanda is 50 years old and suffers from uterine cancer, hypertension and cholesterol. Her EPS is with Caprecom (subsidised). She takes care of her husband, Ramon, who is unemployed and sick, and her grandchildren by preparing their meals and accompanying them to school. Maria is the decision maker in the family and takes care of the household between working and sleeping. She has no access to doctors and feels she loses time and money with doctor visits as they don’t giver her the attention needed. For her children’s vaccinations, she has to take care of the appointments and followups herself. 64 - Colombia · Bienestar Familia - D4SB 65
  24. 24. Low Income Colombian Family Structure
  25. 25. Problems, Needs & Key Success Factors Problems Patients Time Money Quality Bureaucracy Family members within one household belong to different EPS healthcare plans X Patients cannot choose their own EPS (assigned to them by system) X Many people are not covered by any EPS X Family members rely on relatives to cover healthcare expenses Identification of Problems & Needs X No continuity of patient/doctor relationship X Doctors cannot dedicate sufficient time to patients because of system and bureaucracy X Long waiting time in EPS queue to get doctor appointments X X Long waiting time inside IPS to get diagnosed X X Long waiting time for EPS approval of treatment X X Some treatments are denied by EPS when not belonging to POS (plan obligatorio de salud) To understand the weaknesses and opportunities, we made a list of all the problems and needs of each stakeholder based on the following criteria: time, money, quality and bureaucracy. X X Patients need to pay a fine if they do not show up at the assigned IPS Patients have to cover travel expenses to reach assigned IPS X X X X X Patients are not properly informed about their medical conditions Patients don’t trust the doctors Going through the synthesis process, we were able to identify several common problems and needs. We realized that the Colombian family structure represents a pillar for developing a solution that would take into consideration the urgent need of convergence of all different plans within the same household. Due to the fact that the EPS is assigned by the working position, individuals cannot choose their personal plan. Many people are not even covered by any EPS because of several bureaucratic and registration problems during the phases in between changing jobs. This situation generates a massive dependency on the other family members, particularly from an economical point of view. Bienestar’s pilot trespasses some of the bureaucratic aspects to access primary care through the elimination of the EPS´ role. Nevertheless, it still cannot fully guarantee the quality of the services delivered by the affiliated health institutions, since no changes have been implemented by any affiliated clinics. Doctors are not able to prescribe adequate treatments due to POS limitations X X X X Lack of infrastructure in IPS to accommodate for volume of patients X X No way of receiving feedback/complaints from patients X Needs Time Money Quality Easier access of all family members within household to the same health plan X Information about personal health condition X X Trust in doctors for appropriate treatment and followup X Affordable visit and treatment expenses X Access to specialized treatments X Access to updated patient clinical history X Gain the trust of patients X Allocation of time for proper and complete diagnosis of patient X X Ability to prescribe the appropriate treatment for the specific patient condition (independent of POS) X Ability to follow up on patients’ progress and well being X Capability to manage patient overflow X X Optimize resources in order to deliver appropriate services X Keep track of patients’ clinical history X Provide a better communication channel between patients and doctors X Key Success Factors Patients, Doctors, Clinics Bureaucracy X Reduce waiting (wasted) time through process Clinics X X IPS are not able to manage their resources/lack of resources to provide quality service to clients Doctors X X Lack of access to specialist treatments inside the public health system Clinics X X Doctors have no access to patient medical records Apart from offering a faster and easier access to healthcare, now missing due to all the misconnections and bureaucratic aspects, it is important to build a continuous relationship between the patient and the doctor. At the end of the analysis, it is clear that many areas of opportunities coexist in the Colombian healthcare system, and that different solutions would be able to solve one or more problems. X Doctors are replaced with pharmacists since they are more accessible to patients Patients During the interviews we also found out about the existence of a basic mistrust towards doctors, blamed for being more attentive to the bureaucratic aspect of their work rather than the health problems of their patients. This feeling contributes to the lack of continuity between patient and doctor relationships and leads to an impersonal, superficial and frustrating environment. For example, the figure of the general practitioner (GP) is being replaced by that of the pharmacist because of an easier access and unpleasant past experiences. In this way, pharmacies are becoming the first point of consultation. X Patients have no access to their medical records Doctors X Patients lack knowledge and awareness on prevention methods After that, we individuated the problems and needs that were addressed by Bienestar and the KSF’s that were taken into consideration by the model. In table 16, the issues addressed by Bienestar are highlighted in green. X Patients are not aware of the system and its procedures nor their personal rights From this point, we were able to identify the key success factors (KSF) to achieve a desired solution. X Time Money Quality Equal accessibility to health care for all family members within household X Bureaucracy X Up-to-date patient database system X Different health services that generate an accessible Medical Network X Time efficient healthcare service X X Affordable primary healthcare visits and treatments for different patient conditions X X X Friendly and trustful relationship between patients and doctors X Effective treatments for all patients X Follow up and feedback from patient to measure outcomes for further service improvement X Table 16. Problems, Needs and Key Success Factors identified during the field research in Villamaría, Caldas. 68 - Colombia · Bienestar Familia - D4SB 69
  26. 26. Bienestar Familia Concept 70 - Colombia · Bienestar Familia - D4SB 71
  27. 27. Bienestar Familia is a concept that is built around the specific family structure of Colombia. Starting from the direct family living within one household, Bienestar Familia extends to encompass all members of the community, the ‘larger family.’ Value Proposition Our mission is to deliver quality and affordable family centered healthcare involving the community in the value chain. Our concept is divided into two main parts: The Family Healthcare Plan and The Family Doctor The Community Link: Fairy (Health Promoters) This part of the concept consists in improving the primary healthcare experience of the family through an unified health plan that covers all the members within a household and gives them access to affordable services in Bienestar Familia clinics and network of affiliated services. The family plan also entitles each family to a family doctor, ensuring continuity and trust throughout the care delivery. The community becomes an important link in the value chain of Bienestar Familia. As mentioned before, it is important to use a participatory approach to gather consensus and acceptance for the new business, especially in low income areas where relationships inside the community are very strong. Based on the fact that different households have different needs, we wanted to make our offer more flexible by creating a set of scalable memberships that adapt to the specific family structures and are affordable to all family members. This holistic family approach will offer a welcome family kit - with basic instructions on the plan and its services and benefits - and a family check up for free as an introduction to Bienestar Familia and to the assigned family doctor. The database will combine the family data easing the access to family health records, reducing the time spent on paperwork and ensuring the effectiveness of the treatment. Moreover, pediatricians will be available for the children, who are often left unattended, and internists for those who suffer from chronic diseases, one of the major health problems of the area. The service will be complemented with family oriented initiatives in prevention and education, such as family planning, pre-natal assistance and family counseling. This role will be filled by women chosen among the social business members and trained by Bienestar Familia. The main target will be single moms and unemployed housewives wanting to complement the family income. Creating job opportunities and empowering women in the community will leverage the value of the model, while simultaneously increasing their self esteem and feeling of belonging. The fairies will be the main point of sale of Bienestar Familia memberships. A successful enrolment will be the start of the fairy-patient relationship. Each fairy will represent a group of families enrolled in BF. They will collect feedback, guide users inside the Colombian healthcare system whenever treatments are not delivered by Bienestar Familia - tutela requests, EPS approval - deliver prevention and education, focusing on each family’s specific needs (e.g. infant nutrition, family planning, etc) and help individuating patients in financial problems. Most of all, the Fairies will be a key resource to make the services more responsive and sensitive to the needs of its users, thus helping Bienestar Familia’s business model to evolve accordingly. Moreover, when the model matures and starts expanding, they can become an important channel of sales and distribution of products from partner companies, such as pharmaceuticals or microcredit. Fairies are autonomous and benefit from flexible hours to accommodate the single mothers’ and housewive’s needs. They will work for a commission of the sales and healthcare benefits for their family. Ideally, fairy meetings with BF members would happen every month at the clinic. These meetings can be used for co-creation sessions where unmet community needs are individuated, as well as for target initiatives on education and prevention delivery. 72 - Colombia · Bienestar Familia - D4SB 73
  28. 28. Families (Patients) Fairies Bienestar Familia Management Receives quality and affordable healthcare for the whole family when enrolling in Bienestar Familia. Helps the continuous improvement of BF by giving feedback through the Fairies. Single mothers chosen by BF and the community to become a 2-way communication channel. Sell BF plans, give information, collect feedback and give focused prevention and education. Manages BF social business with the focus on giving affordable and quality healthcare to its members while being self-sustainable. Oversees plan sales, internal processes, human and financial resources, database and physical infrastructure and partnerships. Family Doctor Deliver quality primary healthcare and establish a relationship of continuity and trust with the patient. BF gives them fair salaries and the right conditions to perform quality work. Specialist Doctors Complement the primary care services, deliver children-focused care and continuous treatment for chronic patients. BF gives them fair salaries and the right conditions to perform quality work. (Pediatrician and Internist) Healthcare Personnel (Nurses) Bienestar Familia System Map Community Help doctors during care delivery, initiate contact and check-up of the patient. Perform minor treatments when needed. BF gives them fair salaries and the right conditions to perform quality work. Administrative Staff Bienestar Familia Human Resources Manage efficiently the costumer flow and help create a stimulating environment. BF gives them fair salaries and the right conditions to perform quality work. (Call-Center/Receptionist) The main touch point of care delivery for Bienestar Familia will be its own healthcare clinic. We believe that this is an important step, since in Villamaria there is a deficiency of delivery points (IPS’) and doctors working on them (Table 7). This is contradictory with the fact that in Colombia the number of medical schools have more than doubled in the last 20 years and local universities had 3,285 matriculated students in the field of Sciences of Health in 2008. Besides the stakeholders directly involved in the social business, Bienestar Familia will rely on key partnerships to fund, support and complement its activities. Local universities with campuses on Sciences of Health will be an important source for recruiting the healthcare personnel that will work on the clinic. Focusing on new graduates will allow BF to give a fresh perspective to care delivery and will ease the process of standardization. In addition, by creating a model clinic and managing it, BF will be able to generate a set of quality standards for the services provided to its customers. This standardization will not only ensure the proper delivery of care, but will also ease the future expansion and replication of the model throughout Caldas. Partnerships will also be made to complement the health services provided by BF and to ensure a holistic approach to care. This partnerships will be made with local pharmacies, clinical laboratories and medical imaging centers to give discounted services to BF members. They in exchange will benefit of higher volumes for their businesses. Other than spaces for the actual care delivery such as doctors’ offices and nurses’ screening rooms, the clinic should also count on an affiliated pharmacy, from where the customers can buy discounted medicines and healthcare products; a reception and a waiting room, for managing the patients flow; a room for the fairies’ meetings and training sessions and a BF office space, from where the main activities of this social business will be managed and coordinated. Financial partnerships should also be developed with key suppliers that are interested in sponsoring the social business model. These suppliers can be pharmaceutical and medical equipment companies, as well as ICT development ones. The healthcare personnel working at the clinic will be composed by family doctors, a pediatrician, an internist, nurses, auxiliary nurses and a pharmacist. The administrative personnel will include other than the receptionist/call center attendant, the BF network management staff. 74 - Colombia · Bienestar Familia - D4SB Laboratories & Pharmacies Grameen Caldas Medical Equipment Co. Pharmaceutical Co. & ICT Companies Local Universities Supply young doctors and other healthcare personnel to work on Bienestar Famila clinics. Consultancy on Social Business. Increase network of partners. Access to Social Business Fund. Initial sponsors in the first phase. When business is running sponsors will be repaid and the remaining stakeholders will instead be the only owners. (Social business type 2) Partners Supplies young doctors and other healhcare personnel to work on BF clinics. Finally, Bienestar Familia would work in close contact with Grameen Caldas. They can help finance the start up with their social business fund, give valuable consulting services on social business and help in building the network of partnerships. The following map explains the role and influence of each stakeholder inside the Bienestar Familia system. Stakeholders of Bienestar Familia Influence on the System 75
  29. 29. The Family Healthcare Plan & The Family Doctor The following maps illustrate the steps that a patient needs to take in order to complete a first level treatment cycle. It starts with the public health system where the main problems found are highlighted and then goes to Bienestar and the problems solved by the social business pilot. The objective is to understand how Bienestar Familia would intervene to improve the primary healthcare experience. Public Health System Primary Care Cycle 76 - Colombia · Bienestar Familia - D4SB Comparing the two systems, it is evident that with Bienestar, a patient is able to skip the first part of the process, avoiding delayed treatments and economic losses due to waiting time. Bienestar also improves the quality of care delivery, even though the model is not able to guarantee it. Bienestar Primary Care Cycle 77
  30. 30. Bienestar Familia, on the other hand, goes deeper in the changes, introducing other than the family doctor, an ICT platform to manage patients’ medical files, the clinic’s internal processes and the scheduling system. This platform will also serve as a communication channel between BF and the Fairies, who will be able to access it from their cell phones. The database improves the efficiency of the entire process by reducing the paper work during service delivery and ensuring continuity of the treatments by facilitating the access to the patient health history. BF will also empower the nursing staff by giving them an active role in the care delivery cycle. Nurses will initiate the patient screening before seeing their family doctor. This will help doctors with their workload, allowing them to concentrate in the most important part of the care. Finally, Bienestar Familia will also offer families specific specialist services, such as pediatricians and internists, to deal with the most complicated cases and to reduce the number of patients that need to access the EPS services. Bienestar Familia Healthcare Services Medical Database access to medical records efficiency transparency Call Center scheduling appointments information Healthcare Family Plan unified family plan family doctor access Fairy healthcare plan sales prevention and education customer service Family Doctor monitoring / prevention diagnosing / intervening Specialists (Pediatricians + Internists) monitoring / prevention diagnosing / intervening Pharmacy discounted medicines Bienestar Familia Offering Map Bienestar Familia Primary Healthcare Cycle 78 - Colombia · Bienestar Familia - D4SB As Bienestar needs to be an accessible solution to low income families while providing high-quality services, it is important to understand the whole care cycle and to standardize the care delivery process. A standardized process will serve as a reference for the replicable model and future network expansion and will also allow the estimation of costs involved in treating patients over their entire care cycle (Time-Driven ActivityBased cost measuring system). Moreover, this approach combined with outcome measurement enables the continuous improvement of Bienestar Familia’s services. The blueprints on the following pages show how the two main processes of Bienestar Familia’s healthcare value chain - the family doctor consultation and Fairies’ membership sales and feedback collection - can be initially standardized. The same approach shall be used in all other Bienestar processes. 79
  31. 31. Blueprint of Fairies Service 80 - Colombia · Bienestar Familia - D4SB Blueprint of Family Doctor Consultation 81
  32. 32. Key Partners Key Activities Value Propositions Measure social impact Local medical universities Low income Caldas families Family doctor Network expansion & management BF managment Family care: family doctors, pediatricians & internists Key Resources The Business Model Canvas Customer Segments Fairies Family membership that gives access to quality, efficient & discounted care Healthcare delivery Community (Patients & Fairies) Customer Relationships Families unsatisfied with public healthcare services Channels Grameen Caldas Fairies Brand - Fairies a dedicated link between patients and BF ICT database Doctors Laboratories & pharmacies Bienestar clinic Call center Staff Cost Structure Initial investment: infrastructure + ICT Revenue Streams Clinic costs (supplies + utilities) Membership sales commissions Social and Environmental Costs Lowers the government’s responsibilty in providing adequate healthcare Salaries: healthcare personnel, admin staff, management Annual membership fee Visits + treatments Network affiliation fee Social and Environmental Benefits Improve access to primary healthcare for low income communities Empower women & creation of jobs * Orange post-its represent the expansion phase of the business through an affiliate medical network. Business Model of Bienestar Familia 82 - Colombia · Bienestar Familia - D4SB 83
  33. 33. Implementation & Expansion 84 - Colombia · Bienestar Familia - D4SB 85
  34. 34. Ownership Phase 1. Bienestar Familia starts spreading after establishing standard processes: VOLUME 2. Bienestar Familia has proven to be sustainable and reliable (break-even) 3. Bienestar (brand) broadens scope of practice Fairies Access: Representatives of families can be chosen to become Fairies and receive a greater discount on health care services (or for free) Commissions: Can earn additional commissions from sales by their ‘downline’ healthcare promoters = exponential awareness due to **multi-level marketing (to be controlled) Specific training / Specialization: Community Managers on-site and database and / or nursing Specific training / Specialization: Community Managers on-site and database and / or nursing Pre-existing Healthcare Providers HUMAN RESOURCES The Bienestar Familia business model is designed to work as social business owned by the community (social business type 2). In the initial phase, other stakeholders such as ICT, pharmaceuticals, medical equipment sponsors or the Caldas government will take part as investors. When business starts running properly, they will be repaid leaving the community as the sole owners. In every family there is a legal representative, preferably a woman, that becomes the person interacting with the organization. The annual membership is a share family representatives pay to enroll in the program making them owners / stockholders of the Bienestar Familia initiative. This means the longer a family has been a member of Bienestar Familia, the more shares the representative owns, becoming preeminent inside the organization. This will guarantee the renewal of memberships. 0. Bienestar Familia implementation Volume: Ensure a large number of patients to existing private clinics Standardization: Healthcare cycles to specific patient populations and medical conditions need to be established (use of Time-Driven Activity-Based - TDAB - care to measure costs) Quality control: Standardizing healthcare cycles will permit better quality control and assignment of Bienestar quality certifications Bienestar Familia Staff Administrative: Social business and business administration IT Management: IT expert (partner) or internships from information / computer engineers to build information system and maintenance Healthcare area: Young doctors due to collaboration between local universities and Bienestar Família Bienestar Familia Staff: Fairies; Management; Family Doctor; Specialists (pediatrician + internist); Nurses; Administrative Staff (call center + receptionist) + Internships Stage: Students from computer engineering and business management universities can have an internship with Bienestar Familia administration Stage: Students from medical universities can have an internship at Bienestar Familia Clinic Experience: Fresh graduates get the opportuniy to be a part of a promising and innovative social network inside the healthcare sector Government of Caldas Social Business Fund Microfinance Government Caldas Social Business Fund Microfinance Revenues from cards Revenues from visits Revenues from ministry of health Revenues from sponsors (ICT, pharmaceuticals and medical equipment companies) Government Caldas Social Business Fund Microfinance Revenues from cards Revenues from visits Revenues from government health ministy Revenues from sponsors (ICT, pharmaceuticals and medical equipment companies) Resource Local Universities This implementation plan is intended to be a guideline of potential sequences broken down into 4 chronological phases. These are related to different types of resources available allowing us to identify at what stage Bienestar Familia is ready to expand through its affiliation medical network. Principal Resources Alternative Source Risk Associated It is only possible when Bienestar Familia has achieved an important volume of patients (achieved through Fairies and family plans), an established flawless system information, and standardized care cycles for its patients. FINANCIAL RESOURCES Implementation Expansion Initial investment to build Bienestar Familia Clinic Production Equipment and Infrastructure MATERIAL RESOURCES From the implementation matrix, we were able to identify the phases that Bienestar needs to go through in order to become a replicable model. This replicable model adapts to different scenarios. Each scenario corresponds to a different type of healthcare provider even if stakeholders are in some cases the same. Each of these scenarios can be implemented once Bienestar Familia has reached all the phases of implementation. Government of Caldas Social Business Fund Microfinance Bienestar Família cards Office equipment Marketing material (posters, brochures) Bienestar’s Família system information: Medical data base to which both doctors and patients can have access to (if this information is managed by the representative of the family (women) - check in time / check out time / measuring periodical outcome of the treatment / etc - then less costs for Bienestar Familia) Bienestar Família Clinic: 1 reception + waiting room; 2 doctor offices; 1 nurse room; 1 dressing room; 1 pharmacy; 2 administration offices; 2 toilets; 1 storage room; 1 community / meeting room Integration: Bienestar’s Família Cards and System Information (data base with medical records) work flawlessly together **Multi-level marketing (MLM) is a marketing strategy in which the sales force is compensated not only for the sales they personally generate, but also for the sales of others they recruit, creating a downline of distributors and a hierarchy of multiple levels of compensation. Resources Mapping for Implementation Plan 86 - Colombia · Bienestar Familia - D4SB 87
  35. 35. Phase Resource Fairies 3. Bienestar (brand) broadens scope of practice Specific training / Specialization: Community Managers onsite and database and / or nursing HUMAN RESOURCES Pre-existing Healthcare Providers Bienestar Familia Staff Bienestar Familia Staff: Fairies; Management; Family Doctor; Specialists (pediatrician + internist); Nurses; Administrative Staff (call center + receptionist) + Internships Experience: Fresh graduates get the opportuniy to be a part of a promising and innovative social network inside the healthcare sector Principal resources Alternative source Risk associated Government Caldas Social Business Fund Microfinance Revenues from cards Revenues from visits Revenues from government health ministy Revenues from sponsors (ICT, pharmaceuticals and medical equipment companies) MATERIAL RESOURCES FINANCIAL RESOURCES Local Universities Production Equipment and Infrastructure Stakeholders Location Social Entrepreneur Doctors / Specialists The families (members) own the new clinic (community based ownership) - social business type 2 Analogue services Doctors / Specialists Young doctors Doctors own their private office - social business type 1 Complementary services Doctors / Specialists Young doctors A Ownership Doctors own their private office - social business type 1 Complementary services (primary care emergencies) Open New Bienestar Familia Clinic B Open New Bienestar Familia Private Office C Bienestar Familia On Wheels To be expanded in different areas To be expanded within the same area To be expanded in urban, suburbs and rural areas Integration: Bienestar’s Família Cards and System Information (data base with medical records) work flawlessly together Bienestar Familia’s Replicable Model 88 - Colombia · Bienestar Familia - D4SB Scenario Expansion Through Affiliate Network 89
  36. 36. New Bienestar Familia Clinic 90 - Colombia · Bienestar Familia - D4SB New Bienestar Familia Private Office 91
  37. 37. New Bienestar Familia On Wheels The Bienestar Familia Healthcare Network 92 - Colombia · Bienestar Familia - D4SB 93
  38. 38. Conclusion 94 - Colombia · Bienestar Familia - D4SB 95
  39. 39. Conclusion As the public health system in Colombia is not able to provide adequate care delivery to the low income communities, the Bienestar team saw a promising area of opportunity to start a social business. Nevertheless, during the pilot phase, problems such as the sales and distribution of membership cards became more evident and the need to explore new solutions was essential for the continuity of Bienestar. Bienestar Familia Healthcare Plan is the result of a design process, with the objective of developing a solution to the existing healthcare system in Colombia taking into consideration what Bienestar has already implemented. Bienestar Familia focuses on improving the access of low-income families to high-quality healthcare by creating value for the whole community: - Generation of new job opportunities for women and decreasing brain-drain of qualified local doctors. - Empowerment of women by giving them sense of ownership and responsibility over the organization. - Establishment of a community-based healthcare infrastructure through a local network that enables Bienestar Familia to provide other analogue services alongside the healthcare system. At this point, Bienestar Familia is a prototype that needs to be tested. Taking into consideration the results gathered from the prototype phase, Bienestar Familia would then be ready to be implemented in Caldas, Colombia. If the model proves to be successful, a long term objective would be to adapt and replicate the model to fit in the specific context of different countries. 96 - Colombia · Bienestar Familia - D4SB 97
  40. 40. Bibliographic References »» Muhammad Yunus, Building Social Business: The New Kind of Capitalism that Serves Humanity´s Most Pressing Needs (Pubblic Affairs , 2010) »» Erik Simanis and Stuart Hart, The Base of the Pyramid Protocol: Toward Next Generation Bop Strategy (second edition 2008) »» Business Model Generation: A Handbook for Visionaries, Game Changers and Challengers. Alexander Osterwalder and Yves Pigneur. Wiley, 2010. Bibliography »» Richard J. Boland Jr. and Fred Collopy, Managing as Designing (Stanford Business Books, 2004) »» C.K. Prahalad, The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits (Pearson Prentice Hall, 2009) »» D.School Bootcamp Bootleg (Hasso Plattner Institute of Design at Stanford, 2009) accessed March 25th 2011, »» Diana Quintero, Jorge Garcia and Felipe Tibocha, Bienestar Business Plan, 2011 »» Simona Rocchi, “Philips Design Publication. Unlocking new markets via sustainable innovation and design breakthroughs: a few questions for innovation”, 2010 philipsdesignpublication_unlocking_new_markets_pdesign_srocchi_230606.wpd »» SER System, accessed April 2011, »» »» “Grameen Creative Lab - passion for social business” , accesed March 2011, http:// »» Medicos Generales Colombianos, htm »» »» “General System of Social Security in Health (Colombia)”, Center for Health Care Innovation, last updated Sep 27th 2011, program/general-system-of-social-security-in-health-colombia »» Asembis, Clinica de Especialidades Medicas, »» “Millenium Development Goals” , UN World Health Organization (WHO), http://www. »» “Data and Research”, The World Bank Group, »» “Data and statistics”, World Health Organization, »» Diana Pinto and Ana Lucia Munozs, Colombia: Sistema General de Seguridad Social en Salud, Estrategia de BID 2011-014, (Banco Interamericano de Desarrollo, 2010) »» Perfil Epidemiologico 2009 Villamaría, Caldas, Alcadia de Villamaria (Vigilancia En Salud Publica, 2009) »» IDEO, IDEO Toolkit, Accessed June 2011, »» The Next 4 Billion: Market Size and Business Strategy at the base of the Pyramid, (World Resources Institute and International Finance Corporation, 2007) »» Despacho del Gobernador, Caldas, Land of Contrasts, Grupo per la Reduccion de la Pobreza »» Wikipedia, accessed April 2011, Colombia 98 - Colombia · Bienestar Familia - D4SB 99