4a Co-Living - Tiago Miranda - Social design projects


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4a Co-Living - Tiago Miranda - Social design projects

  1. 1. 20 - Bienestar Familia - D4SBPrivate Healthcare Insurance for Low Income FamiliesBienestar Familia
  2. 2. 26 - Colombia · Bienestar Familia - D4SB 27Grameen Caldas is an organization founded in Colombia by GCL in partnership with the public sector represented bythe Caldas Government to facilitate the creation of a Holistic Social Business Movement (HSBM) in the region. The ideaof this HSBM is to set the right environment in Caldas paving the way for social business initiatives with the uniqueobjective of eradicating poverty. To enable this environment, Grameen Caldas set initiatives in micro-finance, jointventures development and in the creation of a social business fund of $7 million. The four main areas of investment areeducation, nutrition, healthcare and housing (sanitation).The Grameen Caldas team initiated Bienestar, a social business project addressing the issues of healthcare in theregion. Our challenge as the Design for Social Business team was to understand the complexity of the healthcaresystem in Caldas, identify its main breakdowns and accordingly explore how design can improve, expand and replicatethe already existing pilot model of Bienestar.Why Colombia?
  3. 3. 28 - Colombia · Bienestar Familia - D4SB 29TheColombianContext
  4. 4. 31ColombiaProfileColombia in NumbersBeing the twenty-sixth largest country by geographical area and the twenty-seventh largest by population, theRepublic 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.People belowthe poverty lineRural and urbanpopulationsUnemployment(total labor force)Literacy rate(age 15 and above)Poverty head count ratioat national poverty lineCapital City: BogotáIncome Level: Lower middle incomeGDP: $435,367,000,00 (2010 est.)GNI per Capita: $8,430 (2009 est.)GINI Index: 0.587 the highest in Latin AmericaTotal Population: 46.3 millions75%urban25%rural54%above88%employed93%literate62.8%not poor37.2%poor46%below
  5. 5. 32 - Colombia · Bienestar Familia - D4SB 33MDG in ColombiaWith a GINI coefficient of 0.587Colombia has the highest inequalityin Latin America.GoalValue1990Value2008Goal 1. Halve the rates for extreme poverty and malnutritionPoverty 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 (%) 3.4 2.9Prevalence of malnutrition (% of children under 5) - 5.1Goal 2. Ensure that children are able to complete primary schoolingPrimary school enrolment (net, %) 68 88Primary school completion rate (% of relevant age group) 67 65Secondary school enrolment (gross, %) 50 82Youth literacy rate (% of people ages 15 - 24) 95 97Goal 3. Eliminate gender disparity in education and empower womenRatio of girls to boys in primary and secondary education (%) 108 104Women employed in the non agricultural sector (% of non agricultural employment) 44 48Proportion of seats held by women in national parliament (%) 5 8Goal 4. Reduce under 5 mortality by two thirdsUnder 5 mortality rate (per 1,000) 35 21Infant mortality rate (per 1,000 live births) 26 17Measles immunization (proportion of 1 year old immunized, %) 82 88Goal 5. Reduce maternal mortality by 3/4Maternal mortality ratio (modeled estimate, per 100,000 live births) - 130Births attended by skilled health staff (% of total) 82 96Contraceptive prevalence (% of women ages 15 - 49) 66 78Goal 6. Halt and begin to reverse the spread of HIV/AIDS and other major diseasesPrevalence of HIV (% of population ages 15 - 49) - 0.6Incidence of tuberculosis (per 100,000 people) 63 45Tuberculosis cases detected under DOTS (%) - 83Goal 7. Halve the proportion of people without sustainable access to basic needsAccess to an improved water source (% of population) 92 93Access to improved sanitation facilities (% of population) 82 86Forest area (% of total land areas) 55.4 54.7Nationally protected areas (% of total land areas) - 74.4CO2 emmissions (metric tons per capita) 1.7 1.2GDP per unit of energy use (constant 2005 PPP $ per Kg of oil equivalent) 7 9.2Goal 8. Develop a global partnership for developmentTelephone mainlines (per 100 people) 6.9 17.2Mobile phone subscribers (per 100 people) 0 73.6Internet users (per 100 people) 0 26.2Personal computers (per 100 people) 0.9 5.5Table 1. Value achieved in Colombia until 2008 according to the Millennium Development Goals.Healthcare Related StatisticsData ValueAccess to an improved water source 93%Access to improved sanitation facilities 86%Mortality rate, infant 17 per 1,000 live birthsChild malnutrition (children under 5) 5%World Bank (2008)Life expectancy at birth m/f (years) 73/80Probability of dying under five 19 per 1,000 live birthsProbability of dying between 15 and 60 years m/f 166/80 per 1,000 live birthsTotal expenditure on health per capita (PPP International $) 569Total expenditure on health 6.4% of GDPGlobal Health Observatory (2009)Table 2. Healthcare related statistics according to the World Bank (2008) and the Global Health Observatory (2009).Averageexchangerate(USD)Figure 3. Colombian expenditure on healthcare (est. 2008).Per Capita Annual Expenditure on Healthcare1995Colombia Region of the Americas’ average2000 2005 20100K1K2K3K» 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.Main Problems of the SystemHealthcare in Colombia
  6. 6. 34 - Colombia · Bienestar Familia - D4SB 35CaldasProfileCaldas department is part of the Colombian Coffee Growing Axis with a total area of 7,291 km2. Caldas’ departmenthas a population of 976,438 inhabitants consisting mainly of 25-29 year olds. The combination of mortality rates andmigration of young people due to the scarcity in the labor markets is leading to an increment on the aging population(40+ year olds).Figure 7. The Caldas region.Figure 6. The Caldas population structure by large groups.40 - 5960+0 - 1718 - 3934.1%32.4%22.4%11.1%200531.6%32.6%23.8%12.0%200929.3%32.9%23.6%14.2%2015Although the matriculation at the Caldas universities in the field of Sciencesof Health were of 3,285 students, and the medicine schools in Colombiahave increased from 21 to 54 in the last 20 years, doctors that graduate areconcentrated in the big cities making it difficult to achieve health coveragefor the entire population.Figure 4. Estimated mortality causes for women (%) Colombia, 2004 Figure 5. Estimated mortality causes for men (%) Colombia, 2004Hypertensive 3.8%Ischemic heart 14.4%Cerebrovascular 9.3%Other CVD’s 5.3%Lung 1.5%Breast 2.5%Colorectal 1.5%Leukemia 1.0%Lymphomas 0.9%Stomach 2.9%Circulatory32.8%Circulatory21.2%Cancers11.5%Other causes13.8%Cancers 19.9%Other causes15.3%Injuries7.6%Injuries38.0%Other NCD’s12.2%Other Cancers9.6%Respiratory6.7%Diabetes5.5%Diabetes 2.5%Hypertensive 2.1%Respiratory 4.9%Ischemic heart 11.3%Cerebrovascular 4.7%Other NCD’s 8.2%Other CVD’s 3.0%All NCD’s77.1%All NCD’s48.2%The average income of a general doctor in Colombiais around $285 (3-4 minimum wages). Around 8% of thedoctors are unemployed and 5% work in different jobs.
  7. 7. 36 - Colombia · Bienestar Familia - D4SB 37Scarcity in the labor market, added to the great reduction inagricultural production have conspired to create higher rates ofinactivity and greatly increase the chances of falling into poverty.Out of the totalCaldas population...It means that 3 out of every5 inhabitants of Caldas arepoor by definition25.7% are registered asSISBEN Level 1 (extreme poverty)36.3% are registered asSISBEN Level 2 (poor)12.2% are registered asSISBEN Level 3The SISBEN Level *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 thelowest quality of life). SISBEN is used to select people for social assistance programs from the government, who have “... a state ofdeprivation 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”.The average size of a householdaccording to SISBEN level in Caldas 4.5Level 14.0Level 23.4Level 3174,14231% are single moms17,83236% are single moms7,51036% are single momsNumber of households as registered by SISBENIs the inactivity ratein the region of CaldasIs the inadequate employment ratedue to income in the Caldas region.
  8. 8. 38 - Colombia · Bienestar Familia - D4SB 39VillamaríaProfileVillamaría is a municipality of the Caldas Region and is situated 9 km away from the capital, Manizales. It has an area of 461 km2 anda population of 50,123 inhabitants.Caldas population± 1,000,000Manizales population± 387,000Villamaría population± 50,000Healthcare Professionals in VillamaríaIn 2009 Villamaria had Colombia had1 doctor for every 2,083 inhabitants 1 doctor for every 740 inhabitants1 dentist for every 4,545 inhabitants 1 dentist for every 1,282 inhabitants1 nurse for every 8,333 inhabitants 1 nurse for every 1,818 inhabitantsTable 3. Number of healthcare professionals in Villamaria compared to the whole Colombia in 2009.
  9. 9. 40 - Colombia · Bienestar Familia - D4SB 41BenchmarksMothers Club, KendubaySub-District HospitalCFWShops KenyaSOSMédcins FranceDistance HealthcareAdvancement - DISHA ASEMBISPre natal/delivery care and educationThe club recruits women attending the hospital’s pre-natal clinic. The women are asked to make a commitmentto deliver their next child in the hospital and meet asa group twice a month to receive health education,including training on safe motherhood practices.Other than that, they are asked to take an active rolein educating other women in their villages about safemotherhood and the risks of delivering at home.Key point: Empowering and integrating localwomen in the healthcare delivery model throughan educational role.Affordable healthcare franchise modelA network of 64 financially self–sustainable centersthat deliver government approved health products andpharmaceuticals at $0.50 per treatment. Distributed inurban, rural and semi-rural areas, these units are locatedwithin an hour distance from their intended customerbase and serve more than 400,000 Kenyans a year. Morethan half of the locations are owned by communityhealth workers while the rest is owned by licensed nurseswhich also provide screening services. The quality of theservices is guaranteed by unannounced audits and thethreat of the closure. In exchange, they bear a brandname, share marketing costs, best practices and benefitfrom a centralized buying platform.Key point: Creating a replicable and affordablemodel that benefits from group synergy and localentrepreneurs.Mobile healthcareThe concept is simple: patients in need of care cancontact a call center 24 hours a day, 365 days a year thatfinds an available doctor and sends him to their home,much like a taxi business. A success that counts with athousand emergency doctors and 62 associations spreadover the territory, and have handled so far 4 million callsand 2.5 million home interventions and consultations;60% of procedures performed at night, Saturdayafternoon, Sunday and holidays. The achieved results area consequence of the reliability and unfailing motivationof the key players.Key point: Providing alternative channels for caredelivery through an extremely flexible organizationalmodel.Mobile healthcare and partnershipsThe goal of DISHA is to deliver high-quality, low-costdiagnosis and care to low-income rural communities thatare not addressed by the existing healthcare systemthrough a mobile tele-clinical van. In this initiative,Philips, an imaging and medical diagnostics company,partnered with a government agency (ISRO) that providessatellite connectivity between the van and the hospital,Apollo, the healthcare service provider which will staffthe van, and a local NGO.Key point: Creating alternative channels to deliverhealthcare and create synergetic partnerships.Discounted medical servicesThrough the use of a multi-tiered pricing model,ASEMBIS has created a financially self-sustained networkof eye care clinics that offer services from basic eyeexaminations to sophisticated surgical procedures at a40-70% discount from the market rate. Its integratednetwork includes non-traditional health professionalsfor vision testing and preventive care, cost-efficient andhigh-volume clinics, and mobile rural clinics; an overalltreating of more than 350,000 patients in 2004. The 8clinics in different regions of Costa Rica, offer nationwidecoverage, and provide a wide spectrum of medicalservices, from basic health to sophisticated surgeries,imaging diagnostics, and almost all specialties.Key point: Creating a network of financiallysustainable healthcare clinics that offerspecialist services and uses alternativeprofessionals to deliver care.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.
  10. 10. 42 - Colombia · Bienestar Familia - D4SB 43Project Goal:Improve access to primaryhealthcare in Caldas, byredesigning the existingBienestar social business model,in order to expand and replicateit in Colombia and possiblyelsewhere.
  11. 11. 44 - Colombia · Bienestar Familia - D4SB 45Observation& Synthesis
  12. 12. 46 - Colombia · Bienestar Familia - D4SB 47The Field Research in Caldas, ColombiaA substantial part of the input gathered for this project comes from the field research conducted in Caldas, Colombiafrom 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 onfield.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.“At the early stages of the process, research is generative—used to inspire imagination and inform intuition aboutnew opportunities and ideas. In later phases, these methods can be evaluative—used to learn quickly about people’sresponse to ideas and proposed solutions”. (IDEO Toolkit).The Research ToolsThe Colombian Healthcare SystemDesign tools used with the different stakeholdersTools Stakeholders GoalsGroup interview Doctors, medicalprofessors and studentsfrom Manizales University.Understanding the complexity of the Colombian healthcaresystem, its stakeholders, how they are connected to eachother and their influence on the system.Discovering the main touch points of the existing healthcareservice and tracing money, time and information flow.Understanding the perspective of doctors, their aspirationsand frustrations.Discussion sessions Grameen Caldas team andBienestar founders.Understanding the Holistic Social Business Movement inCaldas and its goals, as well as the criteria for accessing thefund assigned by the Government to finance social businessesin Caldas.Understanding and analyzing the first outcomes, limitationsand challenges of Bienestar social business pilot phase.Individual interviews Patients, communityworkers and healthcarerelated players suchas doctors, nurses andpharmacists.Understanding the person.Understanding the general healthcare and medical experiencesof users.Understanding the specific experiences related to user profile.Different Regimens Within the Colombian Healthcare SystemRegimen Description Affiliations inColombiamillions / %Affiliations inVillamaríamillions / %Contributive(RC)People with employment contract or independent workers who earn at least two minimum salaries per month are affiliatedto the contributive regime; they have to pay a monthly affiliation to an EPS (12.5% of their monthly wage); 8.5% is paidby employers and 4% is paid by employees, and they should pay moderating fees ‘copays’ established in the POS for thecontributive regime.17.3(39%)16.5(33%)Subsidized(RS)Unemployed people and people from SISBEN 1 and 2, likewise their family; they should pay moderating fees established inthe 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.23.8(51%)15.9(32%)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 3and independent workers with payment capacities. They are covered by the PBS. This plan is a safety net financed by generaltaxes that is composed of public hospitals and health centers. While all citizens are eligible to receive the benefits underthis plan, it primarily serves those who have not yet been enrolled in either the RC or the RS and those who are enrolled inthe RS but require services that are not yet covered under its benefits package.4.2(8%)17.5(35%)Special(RE)People who work for the government, armed forces and teachers of public institutions; this plan is financed by thegovernment and they benefit from their own network of healthcare providers and have very few limitations on the servicesprovided.1.2(2%)N/ATable 6. Definitions of the different regimens within the Colombian healthcare system.Table 4. Description of the design tools used with the different stakeholders.To understand the complexity of the healthcare system, it is important to look into its institutions, the different formsof coverage it provides to the population and the regulations behind it.The public healthcare is regulated by the law 100/1993, which established the SGSSS (General System of SocialSecurity in Health). This system is coordinated, directed and controlled by the state and the funds designated by thegovernment are managed by the FOSYGA (Fund of Solidarity and Guarantees).The main healthcare institutions involved in delivering healthcare services to the population are the EPS’ (HealthInsurance Companies) and the IPS’ (Health Service Providers).The EPS functions as an intermediary between its affiliates and care delivery institutions (IPS) in managingappointments, approvals and the payments of health services. It has to guarantee to its affiliates the minimumestablished by the POS (Mandatory Health Plan), which is a list of treatments, procedures and drugs defined by thegovernment.The IPS is a public or private entity that provides medical procedures. IPS’ are divided in 3 levels of attention and thevast majority only cover the first level.The quality and coverage of health services are directly linked to the affiliation of the patient to the system. There arefour types of regimens:List of AcronymsInitials 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 deSalud(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.
  13. 13. 48 - Colombia · Bienestar Familia - D4SB 49Moreover, the access to generic essential drugs (from a list of 350 medicines) is covered through the POS for thoseunder 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 toprimary 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 tothe system (vinculados) followed by the subsidized regimen. Combined they represent 67% (34,000) of the populationof Vilamaria—against 59% in Colombia. Vinculados alone, represent 35% of the population in Villamaria, amounting toa total of 17,500 people without health coverage.Public Healthcare System Map
  14. 14. 50 - Colombia · Bienestar Familia - D4SB 51The 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 onlyprevention, promotion and consultation services. For second and third level care, patients have to go to Manizales orPereira.Unless it is an emergency, the affiliated patients have to pass through their assigned EPS for approval and schedulingof 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, waitingtime 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 bythe population. The following graph describes the role of each stakeholder in the system and compares their level ofinfluence 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-houseresources are not only a frequent source for their frustrations but a barrier to a proper care service for the patients.Healthcare Service Providers in VillamaríaEntity Public /PrivateLevel ofcomplexityPatientstreated(2009)AssistantStaffAdmin.staffHospital San Antonio Public I Level 41,173 55 34Centro Médico El Parque Private I Level 19,540 6 3Salud Total Private I Level N.A. 6 1S.O.S Private I Level 6,803 6 1Pasbisalud Private I Level 16,383 13 0Table 7. Description of the healthcare service providers in Villamaria.EPS’(healthcare insurance companies)Don’t provide any medical service, but work as an intermediate between their members andthe affiliated IPS’. Manage the money flow between the two.State / Admin Coordinates, directs and controls the public health system (regimen affiliations, EPS’ andIPS’ regulation and POS limitations). Directly finances life-threatening cases outside of thePOS (tutela).IPS’(health service providers)Hospitals, clinics, laboratories. Manage and provide healthcare personnel, infrastructure andsupplies 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).Doctors and HealthPersonnelHired 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 ontheir regimen affiliation (contributivo/subsidiado) or lack of it (vinculado), and to POSlimitations. Often receive inadequate medical services, have no influence in the system andare subject to EPS decisions.Pharmacies Sell medicines and provide health counselling. They are often used as an alternative accesspoint 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 inthe IPS.Stakeholders of the Public Healthcare SystemInfluence on the SystemEPS’ and IPS’ are the main playerswith the biggest influence on thesystem and on the final care receivedby the population.
  15. 15. 52 - Colombia · Bienestar Familia - D4SB 53BienestarBienestar was initiated in 2010 as an alternative healthcare service to the public health system. Based on the Sermodel in Argentina, Bienestar´s mission is to improve the access to primary healthcare services for low incomecommunities 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 linkmembers directly to the affiliated clinics. For USD$5 a year, the cardholder is entitled to discounts up to 50% on thetreatments 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 servicesand the waiting time is reduced. In exchange, affiliated clinics win by increasing the volume of patients and by havinginstant 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 theinfluence of patients on the scale. However, the situation is still not the ideal since the care quality cannot beguaranteed because the affiliated clinics are still managed in the same way as before entering the network.SER System ModelCEGIN is a medical center founded in 1989 which specializes in the provision of medical services to poor womenfrom rural areas of the Jujuy Province. Jorge Gronda launched the SER system within the CEGIN center in 2004. It isa membership card that patients can purchase for USD$3 per year in exchange of preferential rates (more than halfof the market price) on services delivered in these centers. The main idea behind the SER card, beyond increasingaccess 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 qualityhealthcare. 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 peoplesuffering from social exclusion. The pride SER clients take in being part of the network makes them talk positivelyabout 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
  16. 16. 54 - Colombia · Bienestar Familia - D4SB 55As the last part of our field research, we did a series of interviews with different stakeholders of the system, with aspecial 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, theBienestar affiliated clinic owner, a nurse, a pharmacist, a social worker and an EPS customer representative, we tookinto consideration all the different points of view, an important step in developing the further service. Interviews tookplace at people’s houses, around the community, at a pharmacy, a local medicine market, a 2nd level public hospital inManizales and at the Bienestar affiliated clinic, El Parque.IPS(Bienestar-affiliated clinics)Manages and provides discounted health services direct to Bienestar members, in exchangefor a bigger volume of patients. Maintais its role in the public health system. Ensuresappropriate infrastructure, personnel and supplies to provide the care.Doctors &Healthcare PersonnelHired by the IPS to deliver medical services.They are able to deliver better care, since they are not limited by the POS anymore, but arestill limited by their IPS.Bienestar Links patients and Bienestar-affiliated IPS’ through the sale of a membership card thatentitles to discounted health services. An alternative to the actual primary healthcaresystem, it cuts the access barriers imposed by the EPS’ and the POS.Patients(Bienestar members)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.Pharmacies(Bienestar affiliated)Sell medicines discounted by 5% to Bienestar patients in exchange for a bigger volume ofsales.State / Government Regulation and autorization of Bienestar activities.EPS’(health insurance companies)Address the patients to different healthcare providers (IPS’) when Bienestar does not coverthe request (specialists, exams).Stakeholders of the Bienestar SystemInfluence on the SystemInterview Guides - PatientsName Gender Age Occupation Household Structure Household IncomeBienestarUserSisben LevelInsuranceRegimenMaria Elsita Mayo Female 50 Years Housewife Lives with husband and 2 oftheir 5 kids (10yrs twins)No Sisben 2 SubsidiadoNestor Ivan Garcia Male 41 Years InformalconstructionworkerLives with wife and stepsonnext door to his family inlawIncome depends oncouple’s jobYes Sisben 1 SubsidiadoGloria Bettancourt Female 50 Years Unemployed Lives with husband, hermother and their 4 kidsIncome comes fromhusband’s jobYes Sisben 1 SubsidiadoPaula Hernandez Female 29 Years Works at a callcenter at night(her mothertakes care of herdaughters)Lives with husband (worksduring the day) and their 2daughters (10yrs + 4yrs)Income depends oncouple’s jobYes Sisben 1 ContributivoOber Osorio Male 78 Years RetiredpolicemanLives with his daughter Pension No Sisben 2 RegimeespecialGloria Ines Female 48 Years Unemployed Lives with husband, their 3sons and 1 nephewIncome dependson husband’s jobwho works inconstructionNo Sisben 1 SubsidiadoAlbaneli Franco Female 40 Years Housewife Single mother, lives withson (7yrs), mother, 4brothers and 1 nephewIncome is basedon the jobs of thebrothers and sisterYes(+2 familymembers)Sisben 2 SubsidiadoLina Paula Ospina Female 23 Years Unemployed Single mom, lives with hertwo kids (7months + 3yrs)and her grandparentsIncome depends onher fatherNo Sisben 1 SubsidiadoTable 9. Patients’ profiles from the interviews in Villamaria.The Interview Guides
  17. 17. 56 - Colombia · Bienestar Familia - D4SB 5757Table 15. Example of an interview guide used during the field research in Villamaría.Interview Guides - Social WorkerName Gender Age OccupationYurdani 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.Interview Guide - Female Patient1.Understanding the person» 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...)2.Understanding the generalhealthcare & medicalexperiences of userOn the Colombian healthcare system(how they see it, service, time to gettreatment, 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 foralternative 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?Going to the doctor (motivation,decision making, education).» 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?3.Understanding the specifichealthcare experiencesrelated to user profileDoctor / 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 » 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?Interview Guides - NurseName Gender Age Occupation Household Structure Household IncomeBienestarUserSisben LevelInsuranceRegimenEluin Osorio Female 46 years Works at Nueva EPS Lives with son (21yrs), hiswife and grandson (2yrs)Income dependsonly on her jobNo Sisben 2 ContributivoTable 11. Nurse’s profile from the interviews in Villamaria.Interview Guides - EPS User RepresentativeName Gender Age Occupation Household Structure Household IncomeBienestarUserSisben LevelInsuranceRegimenDoralba SeballosMosqueiroFemale 64 Years President ofthe associationof Villamaria’sCaprecon (EPS)users*Lives on her own Government help tothe 3rd age citzensNo Sisben 1 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 - DoctorsName Gender Age OccupationGerman Aristizabal Moreno (Bienestar) Male 45 years Works at and owns Centro Medico El Parque(a Bienestar affiliated clinic), certified as a general practitionerAdrian 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.Interview Guides - PharmacistName Gender Age OccupationBerta Female 75 years Works in her own pharmacy with her daughterTable 13. Pharmacist’s profile from the interview in Villamaria.
  18. 18. 58 - Colombia · Bienestar Familia - D4SB 59“Doctors becomeinsensible”.Maria Elsita Mayo50yrs. Patient“For the health, I don’tthink twice, I pay”.Nestor Ivan García41yrs. Patient“I don’t have a placewhere to send thechildren”.Adrian Zapata32yrs. DoctorPaula Hernández.The difficulties of dealing with the EPS’.Paula Hernández, 29 years, is originally from Manizales. She moved to Villamaría withher mom that now lives in a different house.She rents a house in one of the neighborhoods in Vallamaría where she lives with hernew husband and her two daughters from her previous marriage. She works during thenight for a mobile phone company and therefore sleeps during the day. Paula’s mothertakes care of the two children and some of the domestic chores as Paula rests during theday.One of her daughters, Paola, is 5 years old and was born with a malnutrition problemthat led to an orthopedic issue making it difficult for her to walk. This has caused Paulato face many difficulties in trying to access the right treatment ever since Paola wasborn.During her pregnancy, Paula was diagnosed with a morphological problem that made itdifficult for her to give birth. That is why she blames herself and feels responsible forher daughter’s complication.Paula has been trying to schedule the necessary surgery but she has not been able to doso. Due to the bureaucracy within the system and the long time required, she has beenstruggling 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 thensends her to a pediatrician and finally to a pediatric orthopedist in order to get thetreatments 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 tochoose 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 herdaugher’s problem. Ever since then, she has been very satisfied. “Now the doctor reallytakes care of her and gives me advice on what to do”. Before, she felt that the doctors andnurses 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 hermother who is also sick. Paula’s mother helps her a lot in raising her daughters and doesnot have any kind of healthcare coverage herself, but the income inside the house onlyallows them to have Paola insured.Her two daughters represent her major priority, that is why even if she is enrolled in anEPS she chose to pay extra and take better care of both of them.“The EPS meetingswith the usershappen once amonth. Nonetheless,very few peopleattend them”.Doralba Seballos Montero64yrs. EPS representative
  19. 19. 60 - Colombia · Bienestar Familia - D4SB 61To synthesize the information gathered during the interviews, we created personas based on the different familystructures in Caldas. They represent a general profile of the Colombian reality.The Interview Guides - PersonasPersona 01 - Margarita PerezSex: FemaleAge: 23 years oldSisben: Level 1EPS: 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 2children 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 chronicillnesses. 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 3,000pesos 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 buttakes 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 thecheckup 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.
  20. 20. 62 - Colombia · Bienestar Familia - D4SB 63The Interview Guides - PersonasPersona 02 - Pablo SalazarSex: MaleAge: 41 years oldSisben: Level 1EPS: 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 houseis 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 adoctor 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”.
  21. 21. 64 - Colombia · Bienestar Familia - D4SB 65The Interview Guides - PersonasPersona 03 - Maria GonzalezSex: FemaleAge: 28 years oldSisben: Level 1EPS: 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 worksat 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 theday.Maria has 2 daughters:»» Gloria, 5 years old, suffering from malnutrition»» Mailin, 7 years old, who had apendicitisMaria’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 alsobecause 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 ofher 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 feelsshe 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 ofthe appointments and followups herself.
  22. 22. Low Income Colombian Family Structure
  23. 23. 68 - Colombia · Bienestar Familia - D4SB 69Identification of Problems & NeedsTo understand the weaknesses and opportunities, we made a list of all the problems and needs of each stakeholderbased on the following criteria: time, money, quality and bureaucracy.From this point, we were able to identify the key success factors (KSF) to achieve a desired solution.After that, we individuated the problems and needs that were addressed by Bienestar and the KSF’s that were takeninto consideration by the model. In table 16, the issues addressed by Bienestar are highlighted in green.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 intoconsideration 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. Manypeople are not even covered by any EPS because of several bureaucratic and registration problems during the phases inbetween changing jobs. This situation generates a massive dependency on the other family members, particularly froman economical point of view.During the interviews we also found out about the existence of a basic mistrust towards doctors, blamed for beingmore attentive to the bureaucratic aspect of their work rather than the health problems of their patients. This feelingcontributes to the lack of continuity between patient and doctor relationships and leads to an impersonal, superficialand frustrating environment. For example, the figure of the general practitioner (GP) is being replaced by that of thepharmacist because of an easier access and unpleasant past experiences. In this way, pharmacies are becoming the firstpoint of consultation.Apart from offering a faster and easier access to healthcare, now missing due to all the misconnections andbureaucratic 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, andthat different solutions would be able to solve one or more problems.Bienestar’s pilot trespasses some of the bureaucratic aspects to access primary care through the elimination of theEPS´ role. Nevertheless, it still cannot fully guarantee the quality of the services delivered by the affiliated healthinstitutions, since no changes have been implemented by any affiliated clinics.Problems, Needs & Key Success FactorsProblems Time Money Quality BureaucracyPatients Family members within one household belong to different EPS healthcare plans XPatients cannot choose their own EPS (assigned to them by system) XMany people are not covered by any EPS XFamily members rely on relatives to cover healthcare expenses XNo continuity of patient/doctor relationship XDoctors cannot dedicate sufficient time to patients because of system and bureaucracy XLong waiting time in EPS queue to get doctor appointments X XLong waiting time inside IPS to get diagnosed X XLong waiting time for EPS approval of treatment X XSome treatments are denied by EPS when not belonging to POS (plan obligatorio de salud) X XPatients need to pay a fine if they do not show up at the assigned IPS X XPatients have to cover travel expenses to reach assigned IPS X X XPatients are not properly informed about their medical conditions XPatients don’t trust the doctors XPatients are not aware of the system and its procedures nor their personal rights X XPatients lack knowledge and awareness on prevention methods XPatients have no access to their medical records X XDoctors Doctors are not able to prescribe adequate treatments due to POS limitations X XDoctors are replaced with pharmacists since they are more accessible to patients X XDoctors have no access to patient medical records XLack of access to specialist treatments inside the public health system X XClinics Lack of infrastructure in IPS to accommodate for volume of patients X XIPS are not able to manage their resources/lack of resources to provide quality service to clients XNo way of receiving feedback/complaints from patients XNeeds Time Money Quality BureaucracyPatients Easier access of all family members within household to the same health plan X XInformation about personal health condition XReduce waiting (wasted) time through process XTrust in doctors for appropriate treatment and followup XAffordable visit and treatment expenses XAccess to specialized treatments XDoctors Access to updated patient clinical history XGain the trust of patients XAllocation of time for proper and complete diagnosis of patient X XAbility to prescribe the appropriate treatment for the specific patient condition (independent of POS) XAbility to follow up on patients’ progress and well being XClinics Capability to manage patient overflow X XOptimize resources in order to deliver appropriate services XKeep track of patients’ clinical history X XProvide a better communication channel between patients and doctors XKey Success Factors Time Money Quality BureaucracyPatients,Doctors,ClinicsEqual accessibility to health care for all family members within household XUp-to-date patient database system X XDifferent health services that generate an accessible Medical Network X XTime efficient healthcare service XAffordable primary healthcare visits and treatments for different patient conditions X XFriendly and trustful relationship between patients and doctors XEffective treatments for all patients XFollow up and feedback from patient to measure outcomes for further service improvement XTable 16. Problems, Needs and Key Success Factors identified during the field research in Villamaría, Caldas.
  24. 24. 70 - Colombia · Bienestar Familia - D4SB 71BienestarFamiliaConcept
  25. 25. 72 - Colombia · Bienestar Familia - D4SB 73Bienestar Familia is a concept that is built around the specific family structure of Colombia. Starting fromthe direct family living within one household, Bienestar Familia extends to encompass all members of thecommunity, the ‘larger family.’ Value PropositionOur mission is to deliver quality and affordable family centered healthcare involving thecommunity in the value chain. Our concept is divided into two main parts:This part of the concept consists in improving the primary healthcare experience of thefamily through an unified health plan that covers all the members within a householdand gives them access to affordable services in Bienestar Familia clinics and network ofaffiliated services. The family plan also entitles each family to a family doctor, ensuringcontinuity and trust throughout the care delivery.Based on the fact that different households have different needs, we wanted to makeour offer more flexible by creating a set of scalable memberships that adapt to thespecific family structures and are affordable to all family members.This holistic family approach will offer a welcome family kit - with basic instructions onthe plan and its services and benefits - and a family check up for free as an introductionto Bienestar Familia and to the assigned family doctor. The database will combine thefamily data easing the access to family health records, reducing the time spent onpaperwork and ensuring the effectiveness of the treatment. Moreover, pediatricians willbe available for the children, who are often left unattended, and internists for thosewho suffer from chronic diseases, one of the major health problems of the area.The service will be complemented with family oriented initiatives in prevention andeducation, such as family planning, pre-natal assistance and family counseling.The community becomes an important link in the value chain of Bienestar Familia. Asmentioned before, it is important to use a participatory approach to gather consensusand acceptance for the new business, especially in low income areas where relationshipsinside the community are very strong.This role will be filled by women chosen among the social business members and trainedby Bienestar Familia. The main target will be single moms and unemployed housewiveswanting to complement the family income. Creating job opportunities and empoweringwomen in the community will leverage the value of the model, while simultaneouslyincreasing their self esteem and feeling of belonging. The fairies will be the main pointof sale of Bienestar Familia memberships. A successful enrolment will be the start of thefairy-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 notdelivered by Bienestar Familia - tutela requests, EPS approval - deliver preventionand education, focusing on each family’s specific needs (e.g. infant nutrition, familyplanning, etc) and help individuating patients in financial problems.Most of all, the Fairies will be a key resource to make the services more responsive andsensitive to the needs of its users, thus helping Bienestar Familia’s business modelto evolve accordingly. Moreover, when the model matures and starts expanding, theycan become an important channel of sales and distribution of products from partnercompanies, such as pharmaceuticals or microcredit.Fairies are autonomous and benefit from flexible hours to accommodate the singlemothers’ and housewive’s needs. They will work for a commission of the sales andhealthcare benefits for their family.Ideally, fairy meetings with BF members would happen every month at the clinic. Thesemeetings can be used for co-creation sessions where unmet community needs areindividuated, as well as for target initiatives on education and prevention delivery.The Family Healthcare Plan andThe Family DoctorThe Community Link:Fairy (Health Promoters)
  26. 26. 74 - Colombia · Bienestar Familia - D4SB 75Bienestar Familia System MapThe main touch point of care delivery for Bienestar Familia will be its own healthcareclinic. We believe that this is an important step, since in Villamaria there is a deficiencyof delivery points (IPS’) and doctors working on them (Table 7). This is contradictorywith the fact that in Colombia the number of medical schools have more than doubledin the last 20 years and local universities had 3,285 matriculated students in the field ofSciences of Health in 2008.In addition, by creating a model clinic and managing it, BF will be able to generate a setof quality standards for the services provided to its customers. This standardization willnot only ensure the proper delivery of care, but will also ease the future expansion andreplication of the model throughout Caldas.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 wherethe customers can buy discounted medicines and healthcare products; a reception anda waiting room, for managing the patients flow; a room for the fairies’ meetings andtraining sessions and a BF office space, from where the main activities of this socialbusiness will be managed and coordinated.The healthcare personnel working at the clinic will be composed by family doctors, apediatrician, an internist, nurses, auxiliary nurses and a pharmacist. The administrativepersonnel will include other than the receptionist/call center attendant, the BF networkmanagement staff.Besides the stakeholders directly involved in the social business, Bienestar Familiawill rely on key partnerships to fund, support and complement its activities. Localuniversities with campuses on Sciences of Health will be an important source forrecruiting the healthcare personnel that will work on the clinic. Focusing on newgraduates will allow BF to give a fresh perspective to care delivery and will ease theprocess of standardization.Partnerships will also be made to complement the health services provided by BF and toensure a holistic approach to care. This partnerships will be made with local pharmacies,clinical laboratories and medical imaging centers to give discounted services to BFmembers. They in exchange will benefit of higher volumes for their businesses.Financial partnerships should also be developed with key suppliers that are interestedin sponsoring the social business model. These suppliers can be pharmaceutical andmedical equipment companies, as well as ICT development ones.Finally, Bienestar Familia would work in close contact with Grameen Caldas. They canhelp finance the start up with their social business fund, give valuable consultingservices on social business and help in building the network of partnerships.The following map explains the role and influence of each stakeholder inside theBienestar Familia system. Stakeholders of Bienestar FamiliaInfluence on the SystemPartnersCommunityBienestarFamiliaHumanResourcesFamilies(Patients)Receives quality and affordable healthcare for the whole family when enrolling in BienestarFamilia. Helps the continuous improvement of BF by giving feedback through the Fairies.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.Bienestar Familia Management Manages BF social business with the focus on giving affordable and quality healthcare to itsmembers while being self-sustainable. Oversees plan sales, internal processes, human andfinancial resources, database and physical infrastructure and partnerships.FamilyDoctorDeliver quality primary healthcare and establish a relationship of continuity and trust with thepatient. BF gives them fair salaries and the right conditions to perform quality work.Specialist Doctors(Pediatrician and Internist)Complement the primary care services, deliver children-focused care and continuous treatmentfor chronic patients. BF gives them fair salaries and the right conditions to perform qualitywork.Healthcare Personnel(Nurses)Help doctors during care delivery, initiate contact and check-up of the patient. Perform minortreatments when needed. BF gives them fair salaries and the right conditions to perform qualitywork.AdministrativeStaff(Call-Center/Receptionist)Manage efficiently the costumer flow and help create a stimulating environment. BF gives themfair salaries and the right conditions to perform quality work.Laboratories& PharmaciesSupply young doctors and other healthcare personnel to work on Bienestar Famila clinics.Grameen Caldas Consultancy on Social Business. Increase network of partners. Access to Social Business Fund.Medical Equipment Co.Pharmaceutical Co.& ICT CompaniesInitial sponsors in the first phase. When business is running sponsors will be repaid and theremaining stakeholders will instead be the only owners.(Social business type 2)LocalUniversitiesSupplies young doctors and other healhcare personnel to work onBF clinics.
  27. 27. 76 - Colombia · Bienestar Familia - D4SB 77The Family Healthcare Plan & The Family DoctorThe following maps illustrate the steps that a patient needs to take in order to completea first level treatment cycle. It starts with the public health system where the mainproblems found are highlighted and then goes to Bienestar and the problems solved bythe social business pilot. The objective is to understand how Bienestar Familia wouldintervene to improve the primary healthcare experience.Comparing the two systems, it is evident that with Bienestar, a patient is able to skipthe first part of the process, avoiding delayed treatments and economic losses due towaiting time. Bienestar also improves the quality of care delivery, even though themodel is not able to guarantee it.Public Health System Primary Care Cycle Bienestar Primary Care Cycle
  28. 28. 78 - Colombia · Bienestar Familia - D4SB 79Bienestar Familia, on the other hand, goes deeper in the changes, introducing otherthan the family doctor, an ICT platform to manage patients’ medical files, the clinic’sinternal processes and the scheduling system. This platform will also serve as acommunication channel between BF and the Fairies, who will be able to access it fromtheir cell phones. The database improves the efficiency of the entire process by reducingthe paper work during service delivery and ensuring continuity of the treatments byfacilitating the access to the patient health history.BF will also empower the nursing staff by giving them an active role in the care deliverycycle. Nurses will initiate the patient screening before seeing their family doctor.This will help doctors with their workload, allowing them to concentrate in the mostimportant part of the care.Finally, Bienestar Familia will also offer families specific specialist services, such aspediatricians and internists, to deal with the most complicated cases and to reduce thenumber of patients that need to access the EPS services.Bienestar Familia Primary Healthcare CycleBienestar Familia Offering MapBienestarFamiliaHealthcareServicesMedical Database access to medical recordsefficiencytransparencyCall Center scheduling appointmentsinformationHealthcareFamily Planunified family planfamily doctoraccessFairy healthcare plan salesprevention and educationcustomer serviceFamily Doctor monitoring / preventiondiagnosing / interveningSpecialists(Pediatricians + Internists)monitoring / preventiondiagnosing / interveningPharmacy discounted medicinesAs Bienestar needs to be an accessible solution to low income families while providinghigh-quality services, it is important to understand the whole care cycle and tostandardize the care delivery process. A standardized process will serve as a referencefor the replicable model and future network expansion and will also allow the estimationof costs involved in treating patients over their entire care cycle (Time-Driven Activity-Based cost measuring system). Moreover, this approach combined with outcomemeasurement enables the continuous improvement of Bienestar Familia’s services.The blueprints on the following pages show how the two main processes of BienestarFamilia’s healthcare value chain - the family doctor consultation and Fairies’ membershipsales and feedback collection - can be initially standardized. The same approach shall beused in all other Bienestar processes.
  29. 29. 80 - Colombia · Bienestar Familia - D4SB 81Blueprint of Family Doctor ConsultationBlueprint of Fairies Service
  30. 30. 82 - Colombia · Bienestar Familia - D4SB 83Business Model of Bienestar FamiliaThe BusinessModel Canvas* Orange post-its represent the expansion phase of the business through an affiliate medical network.www.businessmodelgeneration.comRevenue StreamsChannelsCustomer Relationships Customer SegmentsValue PropositionsKey ActivitiesKey PartnersKey ResourcesCost StructureFamily care:family doctors,pediatricians &internistsFamily doctorFairiesLow incomeCaldas familiesBienestar clinicFairiesHealthcaredeliveryMeasure socialimpactICT databaseBrandLocalmedicaluniversitiesMembershipsalescommissionsSalaries:healthcarepersonnel,admin staff,managementClinic costs(supplies +utilities) Annualmembership feeVisits +treatmentsFamiliesunsatisfied withpublic healthcareservicesCall centerStaffGrameen CaldasDoctorsLaboratories& pharmaciesCommunity(Patients& Fairies)Initialinvestment:infrastructure+ ICTImprove accessto primaryhealthcare forlow incomecommunitiesEmpower women& creation ofjobsSocial and Environmental Costs Social and Environmental Benefits- Fairies -a dedicated linkbetween patientsand BFNetworkaffiliation feeNetworkexpansion &managementBF managmentLowers thegovernment’sresponsibilty inproviding adequatehealthcareFamily membershipthat gives accessto quality, efficient& discounted care
  31. 31. 84 - Colombia · Bienestar Familia - D4SB 85Implementation& Expansion
  32. 32. 86 - Colombia · Bienestar Familia - D4SB 87OwnershipImplementationExpansion0. Bienestar Familiaimplementation1. Bienestar Familia startsspreading after establishingstandard processes: VOLUME2. Bienestar Familia has provento be sustainable and reliable(break-even)3. Bienestar (brand) broadensscope of practiceFairies Access: Representatives of familiescan be chosen to become Fairiesand receive a greater discount onhealth care services (or for free)Commissions: Can earn additionalcommissions from sales by their‘downline’ healthcare promoters= exponential awareness due to**multi-level marketing (to becontrolled)Specific training / Specialization:Community Managers on-siteand databaseand / or nursingSpecific training / Specialization:Community Managers on-siteand databaseand / or nursingPre-existing HealthcareProvidersVolume: Ensure a large number ofpatients to existing private clinicsStandardization: Healthcare cyclesto specific patient populationsand medical conditions need to beestablished (use of Time-DrivenActivity-Based - TDAB - care tomeasure costs)Quality control: Standardizinghealthcare cycles will permit betterquality control and assignment ofBienestar quality certificationsBienestar FamiliaStaffAdministrative: Social businessand business administrationIT Management: IT expert(partner) or internships frominformation / computer engineersto build information system andmaintenanceHealthcare area: Young doctorsdue to collaboration between localuniversities and Bienestar FamíliaBienestar Familia Staff: Fairies;Management; Family Doctor;Specialists (pediatrician +internist); Nurses; AdministrativeStaff (call center + receptionist)+ InternshipsLocal Universities Stage: Students from computerengineering and businessmanagement universities canhave an internship with BienestarFamilia administrationStage: Students from medicaluniversities can have an internshipat Bienestar Familia ClinicExperience: Fresh graduates getthe opportuniy to be a part of apromising and innovative socialnetwork inside the healthcaresectorPrincipal ResourcesAlternative SourceRisk AssociatedGovernment of CaldasSocial Business FundMicrofinanceGovernment of CaldasSocial Business FundMicrofinanceGovernment CaldasSocial Business FundMicrofinanceRevenues from cardsRevenues from visitsRevenues from ministry of healthRevenues from sponsors (ICT,pharmaceuticals and medicalequipment companies)Initial investment to buildBienestar Familia ClinicGovernment CaldasSocial Business FundMicrofinanceRevenues from cardsRevenues from visitsRevenues from government healthministyRevenues from sponsors (ICT,pharmaceuticals and medicalequipment companies)Production Equipmentand InfrastructureBienestar Família cardsOffice equipmentMarketing material (posters,brochures)Bienestar’s Família systeminformation: Medical database to which both doctors andpatients can have access to (ifthis information is managed bythe representative of the family(women) - check in time / checkout time / measuring periodicaloutcome of the treatment / etc- then less costs for BienestarFamilia)Bienestar Família Clinic:1 reception + waiting room; 2doctor offices; 1 nurse room; 1dressing room; 1 pharmacy; 2administration offices; 2 toilets;1 storage room; 1 community /meeting roomIntegration: Bienestar’s FamíliaCards and System Information (database with medical records) workflawlessly togetherPhaseResourceHUMANRESOURCESFINANCIALRESOURCESMATERIALRESOURCESResources Mapping for Implementation Plan**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.The Bienestar Familia business model is designed to work as social business owned bythe community (social business type 2). In the initial phase, other stakeholders such asICT, pharmaceuticals, medical equipment sponsors or the Caldas government will takepart as investors. When business starts running properly, they will be repaid leaving thecommunity as the sole owners.In every family there is a legal representative, preferably a woman, that becomes theperson interacting with the organization. The annual membership is a share familyrepresentatives pay to enroll in the program making them owners / stockholders ofthe Bienestar Familia initiative. This means the longer a family has been a member ofBienestar Familia, the more shares the representative owns, becoming preeminent insidethe organization. This will guarantee the renewal of memberships.This implementation plan is intended to be a guideline of potential sequences brokendown into 4 chronological phases. These are related to different types of resourcesavailable allowing us to identify at what stage Bienestar Familia is ready to expandthrough its affiliation medical network.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.From the implementation matrix, we were able to identify the phases that Bienestarneeds to go through in order to become a replicable model. This replicable model adaptsto different scenarios. Each scenario corresponds to a different type of healthcareprovider even if stakeholders are in some cases the same. Each of these scenarios can beimplemented once Bienestar Familia has reached all the phases of implementation.
  33. 33. 88 - Colombia · Bienestar Familia - D4SB 893. Bienestar (brand)broadensscope of practiceFairies Specific training /Specialization:Community Managers onsiteand databaseand / or nursingPre-existingHealthcareProvidersBienestar FamiliaStaffBienestar Familia Staff:Fairies; Management;Family Doctor; Specialists(pediatrician + internist);Nurses; Administrative Staff(call center + receptionist)+ InternshipsLocal Universities Experience: Fresh graduatesget the opportuniy to bea part of a promising andinnovative social networkinside the healthcare sectorPrincipal resourcesAlternative sourceRisk associatedGovernment CaldasSocial Business FundMicrofinanceRevenues from cardsRevenues from visitsRevenues from governmenthealth ministyRevenues from sponsors(ICT, pharmaceuticalsand medical equipmentcompanies)ProductionEquipmentand InfrastructureIntegration: Bienestar’sFamília Cards and SystemInformation (data basewith medical records) workflawlessly togetherPhaseResourceHUMANRESOURCESFINANCIALRESOURCESMATERIALRESOURCESBienestar Familia’s Replicable Model Expansion Through Affiliate NetworkScenario Stakeholders Ownership LocationAOpen NewBienestarFamilia ClinicSocial EntrepreneurDoctors / SpecialistsThe families (members) ownthe new clinic (communitybased ownership)- social business type 2Analogue servicesTo be expanded in differentareasBOpen NewBienestarFamilia PrivateOfficeDoctors / SpecialistsYoung doctorsDoctors own their privateoffice- social business type 1Complementary servicesTo be expanded within thesame areaCBienestarFamiliaOn WheelsDoctors / SpecialistsYoung doctorsDoctors own their privateoffice- social business type 1Complementary services(primary care emergencies)To be expanded in urban,suburbs and rural areas
  34. 34. 90 - Colombia · Bienestar Familia - D4SB 91New Bienestar Familia Clinic New Bienestar Familia Private Office
  35. 35. 92 - Colombia · Bienestar Familia - D4SB 93New Bienestar Familia On WheelsThe Bienestar Familia Healthcare Network
  36. 36. 94 - Colombia · Bienestar Familia - D4SB 95Conclusion
  37. 37. 96 - Colombia · Bienestar Familia - D4SB 97As 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 newsolutions 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 theexisting 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 valuefor 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 Familiato 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 gatheredfrom the prototype phase, Bienestar Familia would then be ready to be implemented in Caldas, Colombia. If the modelproves to be successful, a long term objective would be to adapt and replicate the model to fit in the specific contextof different countries.Conclusion
  38. 38. 98 - Colombia · Bienestar Familia - D4SB 99Bibliographic References» Muhammad Yunus, Building Social Business: The New Kind of Capitalism that ServesHumanity´s Most Pressing Needs (Pubblic Affairs , 2010)» Erik Simanis and Stuart Hart, The Base of the Pyramid Protocol: Toward NextGeneration Bop Strategy (second edition 2008)» Business Model Generation: A Handbook for Visionaries, Game Changers andChallengers. Alexander Osterwalder and Yves Pigneur. Wiley, 2010.» 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 PovertyThrough Profits (Pearson Prentice Hall, 2009)» D.School Bootcamp Bootleg (Hasso Plattner Institute of Design at Stanford, 2009)accessed March 25th 2011, http://dschool.typepad.com/news/2009/12/the-bootcamp-bootleg-is-here.html» Diana Quintero, Jorge Garcia and Felipe Tibocha, Bienestar Business Plan, 2011» Simona Rocchi, “Philips Design Publication. Unlocking new markets viasustainable innovation and design breakthroughs: a few questions for innovation”,2010 http://www.newscenter.philips.com/main/design/news/publications/philipsdesignpublication_unlocking_new_markets_pdesign_srocchi_230606.wpd» Diana Pinto and Ana Lucia Munozs, Colombia: Sistema General de Seguridad Social enSalud, Estrategia de BID 2011-014, (Banco Interamericano de Desarrollo, 2010)» Perfil Epidemiologico 2009 Villamaría, Caldas, Alcadia de Villamaria (Vigilancia EnSalud Publica, 2009)» IDEO, IDEO Toolkit, Accessed June 2011, http://www.ideo.com/work/human-centered-design-toolkit/» 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 laPobreza» Wikipedia, accessed April 2011, http://es.wikipedia.org/wiki/Seguridad_social_de_ColombiaBibliography» SER System, accessed April 2011, http://www.sistemaser.org.ar/» http://healthmarketinnovations.org/program/mothers-club%E2%80%9D-kendu-bay-sub-district-hospital» “Grameen Creative Lab - passion for social business” , accesed March 2011, http://www.grameencreativelab.com/» Medicos Generales Colombianos, http://www.medicosgeneralescolombianos.com/news.htm» http://www.who.int/gho/countries/col.pdf» “General System of Social Security in Health (Colombia)”, Center for Health CareInnovation, last updated Sep 27th 2011, http://healthmarketinnovations.org/program/general-system-of-social-security-in-health-colombia» Asembis, Clinica de Especialidades Medicas, www.asembiscr.com» “Millenium Development Goals” , UN World Health Organization (WHO), http://www.un.org/millenniumgoals» “Data and Research”, The World Bank Group, http://www.worldbank.org» “Data and statistics”, World Health Organization, http://www.who.int/en
  39. 39. 101Sanitation in the Indian Educational ContextAn Opportunity AnalysisSanitation in Schools
  40. 40. 106 - India · Sanitation in Schools - D4SB 107107Poverty in India remains a major issue where the country is estimated to have a third of the world’s poor, particularlyin rural areas. In order to spread and accelerate the social business movement, GCL has expanded and launched itsmost recent office in Mumbai. In addition, the Yunus social business fund in Mumbai is currently under development inorder to encourage the initiation of social business by providing adequate funding across all social sectors in India.As the Design for Social Business team, our challenge in India was to identify opportunities that can lead to theimprovement of sanitation, one of the country’s most pressing problems. With education being one of the mostimportant channels for penetration, we focused our design research on schools in rural and urban areas aroundMumbai for a better comprehension of the effects poor sanitation has on students’ attendance, dropout rates andoverall health.Why India?
  41. 41. 108 - India · Sanitation in Schools - D4SB 109109TheIndianContext
  42. 42. 111111India ProfileIndia in NumbersBeing the seventh biggest country by geographical area, the Independent Republic of India is the second mostpopulous country in the world. With over 1.17 billion people (2010 est.), India is projected to be the world’s mostpopulous country by 2025, with its population reaching 1.6 billion by 2050.Rural and urbanpopulationsLiteracy rate(for people age 15and above)Poverty head count ratioat national poverty lineCapital City: New DehliIncome Level: Lower middle incomeGDP: $1,729,010,242,154 (2010 est.)GNI per Capita: $1,340 (2010 est.)Total population in India1.2 billionTotal population in Europe852.4 millionTotal population in the US320 million29%urban37%illiterate72.5%not poor71%rural63%literate27.5%poor
  43. 43. 112 - India · Sanitation in Schools - D4SB 113113total population1.2 billiontotal populationlacking accessto any kind of toilet638 millionrural populationlacking accessto any kind of toilet630 milliontotal rural population852 milliontotal population lackingaccess to any kind of toilet638 millionrural populationlacking accessto any kind of toilet630 millionSanitation in India. An Overviewchildren under 5die annually due to diarrheaonlyof India’s wastewateris being treated
  44. 44. 114 - India · Sanitation in Schools - D4SB 115115Culture and ReligionMuslim - 13.4%Hindu - 80.5%Others - 6.1%Figure 3. The most common religions in India.UnderstandingSanitationSanitation is understood as providing facilities and services that ensure the safedisposal of human excreta (urine and feces), which are meant to avoid open spacedefecation. The lack of infrastructure combined with inadequate sanitation practicesis a major cause of disease worldwide. Improving sanitation has proven to have asignificant beneficial impact on health both in households and across communities.Sanitation also refers to the maintenance of hygienic conditions, through services suchas garbage collection and wastewater disposal.BRAHMINSPriests & AcademicsKSHATRIYASWarriors & KingsVAISHYASBusiness communityKSHUDRASServants, subordinate to Vaishyas,Khastriyas & BrahminsDALITUntouchables, subordinate to all,responsible for all the lower-order workFigure 4. The caste system in IndiaThere are about 18 official languages in India with Hindi and English being the most spoken. Most of its population isHindu followed by Muslims and other religions which include Sikhs and Christians among others.India Caste SystemThe Hindu caste system hierarchically categorizes people based on their occupations where each person is born into anunalterable social status. The four primary castes are: Brahmin (the priests), Kshatriya (warriors and nobility), Vaisya(farmers, traders and artisans) and Shudra (tenant farmers and servants). The people born outside the caste system arecalled Dalits or “untouchables”. The outcastes’ occupations, regarded as impure, include butchering, rubbish removaland waste disposal.Although today caste discrimination is officially illegal, it remains prevalent mostly in rural areas. The Indiangovernment has made strong efforts in minimizing the significance of the caste system through expanding educationand economic opportunity in the countryside.
  45. 45. 116 - India · Sanitation in Schools - D4SB 117117» By increasing school attendance» By building community pride and social cohesion» By contributing to poverty eradicationCommon Water and Sanitation Related Diseases Improved SanitationSanitation Facilities and PracticesAmong the inadequate sanitation practices, the one that poses the greatest threatto human health is open defecation. When talking about proper sanitation, watercontamination cannot be excluded since in indiscriminate defecation, excreta oftenfinds its way into sources of drinking water and food and is the root cause of faecal-oraltransmission of diseases.Unicef defines a list of common unimproved sanitation related diseases, which include:Diarrhea, Cholera, parasitic worms, Typhoid, and Dysentery among others. Diarrheais the most important public health problem directly related to water and sanitation.About 4 billion cases of diarrhea per year cause 1.8 million deaths, over 90% of them(1.6 million) are among children under five.Bush or fieldDue to the absence of proper infrastructure, excreta is deposited on the ground andcovered with a layer of earth, wrapped and thrown into garbage or defecation is doneinto surface water.BucketRefers to the use of a container for the retention of faeces, urine and anal cleaningmaterial, which are periodically removed for treatment, disposal,or used as fertilizer.Hanging toilet / latrineRefers to a toilet built over a body of water in which excreta drops directly.Pit latrineThis facility uses a hole in the ground for excreta collection. In some cases, thiskind of infrastructure may have a squatting slab or seat raised above the surroundingground level to prevent surface water from entering the pit. An improvement in theinfrastructure consists of a ventilation pipe that extends above the latrine roof and iscovered fly-proof netting (Ventilated Improved Pit Latrine ‘VIP’).Flush toiletThis kind of toilet uses a tank that flushes water and is sealed in order to prevent thepassage of flies and odors (also called water seal). A pour flush toilet also uses a waterseal, but in contrary to the normal flush toilet, it has no tank and uses water poured byhand for flushing.Composting toiletA dry toilet into which carbon-rich materials are added to the excreta which is keptin special conditions to produce inoffensive compost; it may or may not have a urineseparation device.Piped sewer systemPiped system and facilities (sewerage) that collect, pump, treat and dispose humanexcreta and wastewater and remove them from the household.Septic tankAn excreta collection device consisting of a water-tight settling tank. Normally locatedunderground, away from the house or toilet, the treated effluent of the tank usuallyseeps into the ground through a leaching pit or discharged into a sewerage system.‘Improved’ sanitation facilities are those that reducethe chances of people coming into contact with humanexcreta and therefore becoming more sanitary thanunimproved facilities. These include:» Toilets that flush waste into a piped sewer.» Septic tank or pit.» Dry pit latrines constructed with a cover.These kinds of facilities are only considered to beimproved if they are private rather than shared with otherhouseholds.Some 2.6 billion people worldwide – two in five – do nothave access to improved sanitation, and about 2 billion ofthese people live in rural areas. According to the UnitedNations, proper sanitation can foster social development,which at its core, is about human dignity and humanrights. For the people who lack access to a properinfrastructure and practice open defecation, humandignity is under daily assault. A toilet can improve socialdevelopment in a number of ways:» By aiding progress toward gender equality» By promoting social inclusionAbout 4 billion cases ofdiarrhea per year cause 1.8million deaths, over 90%of them (1.6 million) areamong children under five.Sanitation and the Millennium Development Goals (MDG)One single gram of fecescan contain:10,000,000 viruses1,000,000 bacteria1,000 parasite cysts100 parasite eggsTable 1. Parasites found in one gram of feces.Table 2. Differences between improved and unimproved sanitationfacilitiesFigure 5. Millennium Development Goal 7: Ensure EnvironmentalSustainabilityWhat is an improved facility?Improved UnimprovedFlush or pour flush to:» piped sewer system» septic tank» pit latrineFlush or pour flush toelsewhere.Pit latrine without slabor open pitVentilated improved pitlatrine (VIP)Hanging pit or hanginglatrineBucketComposting toilet No facilities (bush orfield); open defecationGoal No. 7c. specifically states “Halve, by 2015, theproportion of people without sustainable access to safedrinking water and basic sanitation”. Which in this casewould be considered as access to improved sanitationfacilities.Though proper sanitation has huge benefits in publichealth, gender equity, poverty reduction and economicgrowth, it is often a relatively low priority within theofficial development plans. Domestic budget allocationsand official development assistance are often scarce, andin many instances, interventions are not targeted to thepopulation most in need.At the current rate of progress, the world will miss thetarget of halving the proportion of people without accessto basic sanitation. Though global sanitation coverageincreased from 49% in 1990 to 59% in 2004. In 2008,an estimated 2.6 billion people around the world lackedaccess to an improved sanitation facility. If the trendcontinues, that number will grow to 2.7 billion by 2015.Figure 5. Icons showcasing a Western style toilet and a Squat toiletthat is more common in India.Western style toiletwith flushSquat toilet
  46. 46. 118 - India · Sanitation in Schools - D4SB 119119water resources are polluted, and 80% of the pollution isdue to sewage alone.Diarrhea accounts for almost one fifth of all deaths (ornearly 535,000 annually) among Indian children under5 years. Also, rampant worm infestation and repeateddiarrhea episodes result in widespread childhoodmalnutrition. Due to this problem, India is losing billionsof dollars each year. Illnesses are costly to families,and to the economy as a whole in terms of productivitylosses and expenditures on medicines, health care, andfunerals. The economic toll is also apparent in terms ofwater treatment costs, losses in fisheries production andtourism, and welfare impacts, such as reduced schoolattendance, inconvenience, wasted time, and lack ofprivacy and security for women.Major factors that have impeded effective implementationof a rural sanitation program include very low prioritygiven to sanitation as a social and community issue,lack of infrastructure and systems to reach all ruralhouseholds, and most importantly, scarcity of water.Sanitation in IndiaIt is estimated that 55% of all Indians(638 million) still lack access to anykind of toilet. Of this total, peoplewho live in urban slums and ruralenvironments are affected themost. In rural areas, the scale of theproblem is particularly daunting,as 74% of the rural populationstill defecates in the open.India Sanitation in NumbersOnly 31% of India’s population use improvedsanitation (2008)In rural India 21% use improved sanitation facilities(2008)145 million people in rural India gained access toimproved sanitation between 1990-2008211 million people gained access to improvedsanitation in whole of India between 1990-2008India is home to 638 million people defecating in theopen; over 50% of the population.Table 3. India sanitation landscape in numbers.India seems to be lagging behind MDG target values in almost all theparameters under consideration. Human development hence remains tobe an area of concern. Education and health are the critical areas andwe continue to be distant from the targeted goals. Infant and childmortality, undernourished population, as well as maternal mortality arespecific areas where much still needs to be achieved. Even though theoverall access to improved sanitation facilities has increased, the gapbetween rural and urban areas is still very high.It is estimated that 55% of all Indians (638 million) stilllack access to any kind of toilet. Of this total, people wholive in urban slums and rural environments are affectedthe most. In rural areas, the scale of the problem isparticularly daunting, as 74% of the rural population stilldefecates in the open.In both environments, cash income is very low andthe idea of building a facility for defecation inside ornear the house may not seem natural. Where facilitiesdo exist, they are often inadequate. The sanitationlandscape in India is still littered with 13 millionunsanitary bucket latrines, which require scavengers toconduct house-to-house excreta collection. Over 700,000Indians still make their living this way.The situation in urban areas is not as critical in termsof scale, but the sanitation problems in crowdedenvironments are typically more serious and immediate.In these areas, the main challenge is to ensure safeenvironmental sanitation. Even in areas where householdshave toilets, the contents of bucket-latrines and pits,even of sewers, are often emptied without regard forenvironmental and health considerations.Sewerage systems, if available, suffer from poormaintenance, which leads to overflows of raw sewage.Today, with more than 20 Indian cities with populationsof more than 1 million people, the antiquated seweragesystems cannot handle the increased load of wastewater.These cities include Indian megacities, such as Kolkata,Mumbai, and New Delhi. In New Delhi alone, existingsewers originally built to serve a population of only 3million cannot manage the wastewater produced daily bythe city’s present inhabitants, now close to a massive 14million.The capacity for treating wastewater is also acutelyinadequate, as India has neither enough water to flush-out city effluents nor enough money to set up sewagetreatment plants. In 2003, it was estimated that only30% of India’s wastewater was being treated. Much of therest—amounting to millions of liters daily— find its wayinto local rivers and streams. According to the country’sTenth Five-Year Plan, three-fourths of India’s surfaceIndia and the Millennium Development Goals (MDG)Goal IndicatorValue(Year)MDGtargetProportion of population below poverty line (%) 27.5(2005)18.75Undernourished people as in % of population 76(2005)31.1Proportion of undernourished children 46(2006)27.4Ratio of girls to boys in primary education 0.94(2007)1Literacy rate of 15 - 24 year olds 82.1(2007)100Ratio of girls to boys in secondary education 0.82(2007)1Under five mortality rate(per 1,000 live births)74.6(2006)41Infant mortality rate(per 1,000 live births)53(2008)27Maternal mortality rate(per 100,000 live births)254(2006)109Rural population with sustainable access to an improvedwater source (%)79.6(2008)80.5Urban population with sustainable access to animproved water source (%)95.0(2008)94Rural population with accessto sanitation (%)44.0(2008)72Urban population with accessto sanitation (%)81(2008)72Deaths due to malaria per 100,000 2(2008)-Deaths due to TB per 100,000 23(2009)-Deaths due to HIV/AIDS 170,000(2009)-Table 4. Progress towards achieving MDGs in India with goals related to sanitation highlighted in gray.