Innovation in the Delivery of Urban

Health Services to the Poor

Vamsi K. Valluri
SARD/SAHS Intern
28-Aug-2015

Disclaimer: The views expressed in this paper/presentation are the views of the author
and do not necessarily reflect the views or policies of the Asian Development Bank
(ADB), or its Board of Governors, or the governments they represent. ADB does not
guarantee the accuracy of the data included in this paper
and accepts no responsibility for any consequence of their use. Terminology used may
not necessarily be consistent with ADB official terms.

Agenda
Background
Urbanization & Health
Indias NUHM

Study Methodology
Categorizing Issues
Innovation Themes

Select cases
Recommendations

BACKGROUND

The Urbanizing World

The Urbanizing World

The Urbanizing World

Indian Situation
Urban population to go up by over 400 million, by 2050
Highest share (of 16%) of the worlds new urban dwellers
Urban share of population to rise from an estimated 32%
(2014) to over 50% (2050)
Deep impact on cities:
Million+ cities, 2010: 42
Million+ cities, 2030: 68

Share of largest cities to Indias total Urban population

(Pop figures in 000s)
1990
2014
2030
Delhi
9,726
24,953
36,060
Mumbai
12,436
20,741
27,797
Kolkata
10,890
14,766
19,092
Chennai
5,338
9,620
13,921
Bengaluru
4,036
9,718
14,762
Hyderabad
4,193
8,670
12,774
Ahmedabad
3,255
7,116
10,527
Pune
2,430
5,574
8,091
Surat
1,468
5,398
8,616
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Total in 9 cities
53,772
106,556
151,640

Urbanization and Health Outcomes

Population growth: migration, reclassification, and natural
Resource crunch; high density of low cost, low quality housing
Triple threat:
Infectious diseases exacerbated by poor living conditions
Non-communicable diseases, e.g. heart disease and diabetes, fuelled
by unhealthy diets, physical inactivity, and alcohol/tobacco use
Accidents, traffic and other injuries, violence, and crime

Health outcomes also affected by:

Lack of housing and tenure insecurity
Poor access to clean water, sanitation, food
Social isolation

Inequitable access to information, health care

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Urban Health Opportunities

High density clusters easier for outreach for communication, marketing,
access, and service delivery
More early adopters who are likely to embrace change
Potential for sound public-private partnerships
Quicker access to new technologies that can enhance health awareness,
prevention, and treatment
Burgeoning middle class to drive policies that benefit themselves (and
lower-income populations)
An interplay of urban health penalty and urban health advantage

Indias NUHM
National Urban Health Mission (NUHM) launched to effectively
address the health concerns of the urban poor
Targets 993 cities and towns that have a population over 50,000
Plan outlay approximately $3.8 billion (2012-2016)
ADB program to support NUHM to increase access to equitable
and quality urban health system launched in 2015
Key outputs:
Strengthening urban primary health care delivery system
Improving quality of urban health services
Strengthening capacity for planning, management, and innovation and
knowledge sharing
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STUDY METHODOLOGY

11

Identifying the Issues

Indias Twelfth Five Year Plan (2012-2017), offers a good
starting point to identify and categorize the core problems in
Indias healthcare system
Identifies three service delivery related issues:
Availability
Quality
Affordability

The NUHM Framework for Implementation lists 18 key public

health issues in urban areas

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Categorizing the Issues

Issue

Category

Poor households not knowing where to go to meet health need Information

No norms for urban health facilities

Governance, Quality

Poor environmental health, poor housing

Information, Governance

Unregistered practitioners first point of contact use of

Quality
irrational and unethical medical practice
Large private sector but poor cannot access them

Affordability, Partnership

Many slums not having primary health care facility

Availability

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Basic Model of the Issues

User

Health
Service
Interface

Service
Provider

Affordability
Issue

Quality
Issue

Availability
Issue

Based on the Twelfth Plan

User

Affordability,
Information
Issues

Updated based on the NUHM

Framework for Implementation

Health
Service
Interface

Service
Provider

Governance,
Information,
Quality
Issues

Availability,
Partnership
Issues
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Study Framework
Interventions to correct the issues
Key assumptions and notes:
Demand side financing to address affordability issue
Information covers health promotion as well as updates related to
the location of health facilities and availability of services
Governance encompasses issues related to macro level policies as well
as micro level management

Accordingly, the model can be reworked

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Information about health promotion, availability of facilities, services

Demand Side Financing to address affordability

Health
Infrastructure /
Service delivery
Interface

User

State

Quality
Governance

Enabling Processes

Partnership with other provision

entities: Community, NGO, Private
sector
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Information
Demand Side Financing
Socioeconomic Output
Information
Policy
Health Service

User

Service Fee

Health
Infrastructure /
Service delivery
Interface

Information
(Feedback)

Resources
Leadership

State

Information
(Feedback)

Quality
Governance

Enabling Processes

Partnership with other provision

entities: Community, NGO, Private
sector

Framework within the health care services ecosystem

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Case for Innovation

Limitations of traditional public management: high degree of
centralized control, top-down approach, rigidity, and the
needs for a sound plan at start and reasonable certainty
Three Pillars approach proposed by Frenk and GmezDants:
first, the design of a new generation of health promotion and disease
prevention strategies
second, the extension of universal social protection
third, the adoption of innovations in the delivery of health services

One of the eight core strategies of the NUHM Implementation

Framework: strengthening public health through innovative
preventive and promotive action

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Contextualizing Innovation
UNDP describes social innovation as new ideas that work in
meeting social goals
Modern social challenges require collaboration,
empowerment, experimentation, and evidence-based
assessments
Selection criteria:

Distributive, either neutral or pro poor

Collaborative, with multiple stakeholders and/or implementers
Technological, featuring ICT
Evidence-based, endline or impact evaluation component
Scalability
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SELECT CASES

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Theme

Brief Description

Demand Side
Financing

Sambhav, PPP-based Health voucher scheme, India

Social Franchising and Mobile Money based Health Voucher Scheme, Madagascar
Universal Health Care for 30-baht, Thailand

Governance

e-Participatory Budgeting in Belo Horizonte, Brazil

Applying the Urban HEART Tool in Paranaque City, Philippines
WHO Healthy Cities Project

Partnership

BRACs Manoshi, Supported by Female Community Workers and Technology, Bangladesh

Contracting out EPI to NGOs, Bangladesh
Full scale Health Care PPP, Lesotho
Contrasting Cases of Contracting Health Services, India
Case 5: Academic Partnership to Strengthen Public Health Intelligence, Brazil

Quality

UNIMEDs Pay for Performance Program, Brazil

Results-based Quality Improvement Fund, Belize

Information

The Power of Health in Every MAMAs Hand, Bangladesh and South Africa
Sao Paolos Bottom Up Approach to Health Information System Development, Brazil
Urban-focused Health Portals, Bangladesh

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Demand Side Financing

Directly links the subsidy and its objective to the beneficiary
The Economist described conditional cash transfers as the
worlds favorite new anti-poverty device
According to WHO, unlike cash, vouchers tie the receipt of
cash to particular goods, provided by particular vendors, at
particular times
Vouchers work best when the beneficiaries are easily
identifiable and well targeted, and have the power of choice

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Case #1: Sambhav, India

Multi-stakeholder health voucher program
Supported by USAID and Government of India
Implemented by Futures Group
In coordination with local authorities, State governments, private
sector and NGOs, and medical schools
Piloted in Kanpur city and 11 rural blocks from 2006-12

Kanpur

Major industrial and commercial hub in north India; pop 2.5 million
Poorly planned and has several polluting industries
High maternal, infant, and neonatal mortality rates
Key contrast: two overburdened public hospitals and eight thriving
private super specialty hospitals
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Target married women of reproductive age, pregnant women and infants, based on a
BPL card or a ration card
Map households, create awareness, disseminate information, prepare pregnancy
micro plans, arrange transportation, and accompany patients for delivery

Receive health advice, a

voucher booklet and a
personal health record card
from trained health worker

Client

Health
Worker

Trained health workers

Voucher
Management
Unit

Created awareness via

health workers and
through multimedia
communication,
merchandising, and
community events

Redeem vouchers at
participating outlets

State

Created local corpus fund

of INR 500,000 for
emergencies
Service
Provider

Private providers were selected based on their location and services offered and
accreditation status
Reimbursement, based on price list, was kept below market rates
Received INR 15,000 in advance to build trust

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 Endline Report Findings (non-independent)

In depth interviews with voucher recipients reveal increased
awareness of health practices as well as health facilities information
Increased awareness among policymakers and private sector about
health service issues
Clients felt respected by service providers
High voucher uptake attributed to health worker intervention
Poor valued private providers more, as deliveries dipped in the
government hospitals and more than doubled in private hospitals
during pilot period

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Governance
the sum of the many ways individuals and institutions, public
and private, plan and manage the common affairs of the city
Broader view of health:
More than the absence of illness
So outcomes depend on multiple factors
Influenced by governance systems, efficiencies, and priorities

Urban poor face the twin challenges of being disadvantaged

and being powerless
According to Trevor Hancock et al, two innovation strategies:
Reinventing government, e.g. increasing participation
Reinventing governance, e.g. new stakeholders and better decisionmaking tools

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Case #2: e-Participatory Governance, Brazil

Belo Horizonte, in southeastern Brazil, is the countrys third
largest metropolitan area with a population of over 5 million
Brazils first planned city; rapid industrialization and influx of
workers led to the rise of sprawling slums in the 1970s
In recent decades, slums and informal settlements have
outpaced the core citys annual growth rate by a factor of 5
In 1993, implemented a citizen-led model of democratic
governance in which civil society controls planning and
execution of public services
Process overseen by inter-sectorial management board
50% of the budget is allocated based on IQVU, a customized
quality of life index
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 Step 1: Neighborhood level

Citizens are briefed and projects identified; repeated every two years

Step 2: Sub-district level (41 in all)

15 public works and citizen delegates are elected; sites inspected

Step 3: District level (9 in all)

Based on priorities and costs, 15 works are selected
Delegates to oversee implementation are elected

Final stage: regional assembly

Delegates from poorer neighborhoods have more voting power
Scope for neighborhood coalitions

Process made online to encourage participation; terminals put

up in slums to guard against middle class bias

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 Results (outputs):
Between 1993 and 2010, 1,303 projects worth $700 million
implemented
10% projects were health related, apart from works related to slum
improvements, water and sanitation projects, school construction, etc
Per capita investments ranged from $3 in the wealthiest areas to $22
in lower middle class areas to $54 in the poorest areas

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Partnership
collaborative activities among interested groups, based on a
mutual recognition of respective strengths and weaknesses,
working towards common agreed objectives developed
through effective and timely communication
PPP, in theory, is a risk sharing mechanism, incentivizes
innovation in project design and management, and combines
social objectives and private efficiency
Community organizations and informal entrepreneurs often
step in to meet local demand, e.g. slum water supply
Facing lower entry barriers, they rely on informal mechanisms
and can easily customize their products and services
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Case #3: BRACs Manoshi, Bangladesh

Manoshi provides community-based maternal, neonatal and
child health services, to address:
Demand-supply gap: urban Bangladesh is growing rapidly and health
infrastructure is not keeping pace
Attitudes and awareness: 55% of women in urban slums receive
antenatal care, and immunization coverage is just 63%

Leverages the power of the mobile phone to make trained

female community health workers more effective
Launched by BRAC, one of the worlds largest NGOs

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 Program builds on BRACs Swasthya Shebikas model, first

launched in 1998
Workers receive incentives for identifying and assisting with
pregnancies, and also earn commissions through direct sales
of health commodities supplied by BRAC
Well-supervised system of home-visiting and referrals to
healthcare facilities, supported by community engagement
Community worker engagement supplemented by basic
delivery centers and BRAC maternity centers (paid)
Clients have access to 24 hour phone helpline
Supervisors use them to coordinate medical services and to
store and access patient health records

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 Results (ICDDR, B Impact Evaluation):

Reaches 6.9 million urban slum dwellers in 10 cities
Women who viewed Manoshi health workers as important members
of their social network were twice as likely to deliver with a trained
birth attendant and 5 times more likely to use postnatal healthcare
services

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Quality
Traditionally, the quality of medical services has been
regarded as identical to conducting the latest medical
treatment and diagnosis at the highest level
Increasingly, consumers seek highest quality outcomes at the
lowest cost and the producers, and information about quality
becomes a critical decision enabler
Research in many settings has shown that demand for
immunizations and other primary health care services rises
with the quality of those services

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Case #4: UNIMED Pay for Performance, Brazil

Largest cooperative of its kind: 386 branches, 105,000
physicians, 15 million beneficiaries
UNIMED Belo Horizonte (UBH):
Covers 800,000 people, including 75% through employers
4,700 physicians, six clinics, two hospitals; 258 contract facilities

Following 1998 health insurance reforms, new regulatory

standards implemented and UBH adopted a phased process
Two-pronged approach:
Incentivize contracted facilities to pursue and achieve accreditation
Pay physicians for adopting disease management protocols

Recognized by World Bank as one of the most successful and

best performing in the world and has been recommended as
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an accreditation model for other plans

 Beginning in 2005, all facilities were offered 7% hike in per

diem rate for initiating accreditation process with incremental
hikes of up to 15% upon achievement
Accreditation, based on National Organization of
Accreditation (ONA) and ISO standards, done by external
auditors
In 2007, UBH also introduced an incentive program for
physicians linked to their practices and patient outcomes
Performance was measured through clinical effectiveness,
technical efficiency, and client satisfaction

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 Key Lessons and results:

Cumulative payment allowed for larger payouts and gave physicians
more time to correct their activities and earn bonus
UBH roped in other entities, such as Kaiser Permanente, to set
reasonable benchmarks, build credibility, and encourage buy in
Strong evidence based approach led to effective monitoring as well as
documenting results
E.g., reducing the number of hospitalizations for patients enrolled in
P4P resulted in savings of $15,000 over 6 months
Strong HMIS is key to successfully executing pay for performance

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Information
ICT is widely recognized as an integral part of the UN
Sustainable Development Goals process as well as a way of
enabling and measuring outcomes
information in the health care system can be broadly
visualized as either being disseminated outwards as health
education and awareness or as amorphous transactional data
internal to the system

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Case: Mobile Alliance for Maternal Action

(MAMA)
Launched by USAID and Johnson & Johnson as a PPP venture
aims to improve health and nutrition outcomes among
pregnant women and new mothers, and their infants, through
the delivery of vital and culturally sensitive health messages
Phased approach: pilot, update, official launch
Active in Bangladesh and South Africa; launched in Mumbai in
November 2014 as mMitra

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Localized Approach
Launched as Aponjon in
Bangladesh in Dec 2012
Relies on user fees,
advertisements, corporate
partnerships, and revenue
sharing with telcos
Text as well educational
skits (via IVR)
A year into launch, reached
52,000 mothers and
guardians, including 17%
below poverty line

Launched in 2013 in SA
Messaging on HIV+ and
breastfeeding in additional
to pregnancy and parenting
advice
Beyond mobile: web-based
community portal, social
networking, to reach
younger audience
17,500 subscribers as of
April 2013

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Case for Information Democratization

Ubiquitous role of Information in the framework
acquisition and spread of knowledge amongst the common
people leads to democratization

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One end of the spectrum

choice and voice revolution; Uber, Yelp, TripAdvisor, etc
Emergence of consumer-centric mobile apps and portals
Practo:
Launched in 2010 in India, also available in Indonesia, Philippines, and
Singapore
Offers doctor search and rating, patient scheduling, and practice
management
Reach in India: 100,000 doctors across 310 cities
In Metro Manila, it covers 11,000 doctors (70% of market)

HealthPrior21.com and Maya.com.bd in Bangladesh

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Building the Case

RATIONALE
Evident as a clear solution
from the framework
Need for two-way
information: from and to
the user
Creates awareness, enables
comparison, encourages
participation, overcomes
word of mouth limitations
Facilitates information
democratization

FEASIBILITY
One of largest (and
growing) cellular markets
with lowest call rates
Internet mobile users to
double to 500 million in
2017
According to Census 2011,
mobile ownership among
urban slum HH at 68.3%
versus in-premise toilet (at
66%)
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Completing the loop

INFORMATION

QUALITY

Publicly available
information about
service providers
and services

Solicit feedback from

official Aadhar
linked users

Health promotion
dissemination
User generated
reviews and ratings
Can be made
comprehensive and
effective by linking
to HMIS

Incentivize users (say

through Jan Aushadhi
outlets)
Quality metrics can
be based on official
users feedback and
unofficial users
ratings

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The Other Side

Mobile Seva is Indias national mobile governance initiative
National Health Portal houses all health policy, education, services, and
campaigns related information
Under the acronym JAM Jan Dhan, Aadhaar, Mobile a quiet revolution
of social welfare policy is unfolding nearly 118 million bank accounts have
been opened nearly one billion citizens have a biometrically authenticated
unique identity card about half of Indians now have a cellphone.
- Arvind Subramanian, Chief Economic Adviser, Govt of India

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RECOMMENDATIONS

50

Leverage ICT
Capitalize on Indias demographic and technological strengths
Unified, user-centric portable application:
choice and voice; facilitates consumer convenience, engagement
and empowerment
HMIS link for records management, scheduling, and health metrics
External links for allied services such as Jan Aushadhi
Medium for health promotion
Quality assessment through patient satisfaction (and tracking)
Find and respond to hotspots

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Reinventing governance and government

Bangladesh has reinvented governance by supporting the
growth of NGOs and community organizations
BRAC, for example, has grown in scope and scale and partners
the government in a wide range of activities
Brazils has reinvented government by making it more
inclusive and prioritizing local needs
The two countries offer a comprehensive set of ideas and
interventions that policymakers and other stakeholders can
learn from and adapt to Indian settings

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Thank You

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