A Collection of Blogs from the Center for Health Market Innovations

Center for Health Market Innovations (CHMI) HealthMarketInnovations.org/Blog

Table of Contents
About CHMI.....3 Center for Health Marketing Innovations Framework.4 Improving Health Markets for the Poor: A Goal Worth Pursuing...5 Gina Lagomarsino Emergency? Call 108 ...............................................................................................................7 Rose Reis Designing a low-cost, high performance primary health care chain in Brazil ...............................9 Virginia Resende Technology to the People! .....................................................................................................12 Rose Reis Non Communicable Diseases: Not Just for the Rich .................................................................16 Maria Belenky How to engage private sector doctors to deliver high quality and afforable priority care services ............................................................................................................19 John Hetherington Improving infant survival by engaging the private sector in Bihar ............................................23 Priya Anant Foreign investors, successful businesses invest in Kenyas white hot health market...................26 Elizabeth Maloba Data, data all around, but plenty of ways to understand what it all means...............................28 Donika Dimovska Innovations in Drug Adherence..............................................................................................30 Trevor Lewis Reaching the Last Mile ..........................................................................................................32 Rose Reis Expanding Access to Essential Medicine ................................................................................34 Prabal V. Singh Community Health workers institutionalize referral network from remote village to hospital............................................................................................................................36 Nadira Sultana Grateful for her baby, now named for her insurance plan ........................................................39 CHMI Team

About CHMI
The Center for Health Market Innovations (CHMI) CHMI identifies, analyzes and connects programs working to improve health and financial protection for the poor. Health Market Innovations are programs and policiesimplemented by governments, nongovernmental organizations (NGOs), social entrepreneurs or private companiesthat have the potential to improve the way health markets operate. These programs and policies harness or improve transactions that occur in the health care marketplace to promote better health and financial protection for the poor. Analytic Partners CHMI is a network of partners coordinated by the Results for Development Institute. CHMIs in-country partners identify, analyze and connect with Health Market Innovations. In-country partners include: ACCESS Health International India , Bangladesh, Brazil BroadReach Healthcare South Africa Consultation of Investment in Health Promotion (CIHP) Vietnam, Cambodia Freedom From Hunger Peru, Bolivia, Ecuador Institute of Health Policy, Management & Research (IHPMR) Kenya, Rwanda, Tanzania, Uganda MercyCorps Indonesia Philippine Institute for Development Studies (PIDS) Philippines The Asia Foundation Pakistan About the CHMI Blog With contributors from more than 10 countries, the Blog showcases innovative practices around the world in market-based health delivery and financing programs. Interviews with program managers about initiatives documented in CHMIs Programs database yield insights about programmatic challenges and lessons learned. CHMIs Blog also highlights upcoming events, new reports and tools.

Center for Health Market Innovations Framework

CHMI identifies five kinds of Health Market Innovations with the potential to improve health market performance with better health and financial protection: Organizing Delivery, Financing Care, Regulating Performance, Changing Behaviors and Enhancing Processes.

Improving Health Markets for the PoorA Goal Worth Pursuing

By Gina Lagomarsino Results for Development Institute, USA Jun 23 2010 We are building the Center for Health Market Innovations (CHMI) because we believe that the poor in developing countries deserve high quality health care without having to pay so much that they go deeper into poverty. Improving the performance of vast, unorganized health marketplaceswith lots of private health care providers, lots of consumer direct spending, and little regulation--will be no easy task. But we think its a goal worth pursuing, given the dominance of health markets in many countries. Over the past few years, we have been collecting and reviewing evidence about the role of private health care providers in developing countries. What we have found complements and underscores years of work by others in the field. Despite the efforts of many governments to provide free care in public facilities, private sector providers are a primary source of care for many people--including the poor. And direct payments from households make up the majority of national health expenditures in many countries. But many of these countries have little or no enforced regulation of private providers, who may or may not have much formal training. Through our research, we found some reasons to be optimistic. We identified a number of programs around the world that have the potential to improve health markets. Programs that better organize fragmented health care providerssuch as franchises and professional associationsmake it easier to create standards and provide training. Programs that educate patients can help them become more savvy consumers of care. And a number of new business models developed by social entrepreneursmany using innovative information technologiescan reduce costs of care or improve access for people in remote areas. Many promising programs are being implemented by NGOs and

social entrepreneurs, often with donor support. See the diagram below to lea rn more about Health Market Innovations. How Health Market Innovations Work But we are convinced that governments must play a crucial role if markets are to deliver better resultsespecially for the poor. Well-functioning health markets require broad stewardship of the entire health system. Governments must see their role as more than just building public hospitals, hiring doctors, and planning public health campaigns. These will continue to be important functions, of course. But governments must also improve their ability to set quality standards for all care providers and then make sure those standards are enforced. They must develop financing mechanisms that spread health risks and costs across the entire population and ensure that the poor have purchasing power. The good news is that a number of countries are starting to realize this. At the May 2010 World Health Assembly, member countries passed a resolution to strengthen the capacity of governments to engage the private sector. Our goal at CHMI is to work with our many partners to better understand what can be done to improve health markets. We will identify and track promising programs around the world. We will analyze this information and evaluate programs to try to figure out what is workingand what is not working. And we will create better linkages among program implementers, funders, researchers, and policymakers whose efforts will be crucial to facilitating improvements in health markets. We hope this new CHMI website will support your efforts by furthering your ability to identify a number of different types of promising Health Market Innovations in different countries and make connections with others in the field. CHMI remains a work in progress. In the coming months, the database of programs will grow significantly as we add more in-country partners to our network and as more users like you suggest programs and contribute information to keep program profiles up-todate. New in-depth CHMI analyses, which are currently in progress, will be published early next year. We also expect to add new interactive online functions.

Emergency? Call 108

Visiting Andhra Pradesh's innovative emergency transport and care service

By Rose Reis Results for Development Institute, USA Nov 5 2010 If you live in an industrialized country, you know what to do if you get in a car accident. You pick up the phone and call 911 (in the states), 112 (in Europe), 000 (Australia) or another distinct number you could recite in your sleep. Someone answers the call, you report your problem, and an ambulance, police car, and/or fire engine is dispatched to come to your aid. In India, emergency transport service was limited until 2005. In that year, the southern Indian state Andhra Pradesh began supporting the operations of a not-for-profit organization called Emergency Management and Research Institute (EMRI) which operates the emergency number 108. People started hearing about this service and each state's 108 call centers may receive more than 12,000 calls every day. The most common emergencies? Deliveries are by far the most common reasons people dial 108, followed by vehicular trauma incidents, which cluster in the late afternoon and evening. People are now calling 108 for emergency assistance in nine states across India, and the service inspired other emergency medical services like 1298.

The public-private partnership approach allowed EMRI to scale up quickly, and the project shows the strengths of what private providers can do with government resources. EMRI's headquarters outside Hyderabad, in Andhra Pradesh, are becoming a huge hub for training of Emergency Medical Technicians, a field so new that no licensing exam exists yet in India. EMRI has trained more than 35,000 people as paramedics and ambulance drivers--actually, "pilots", in EMRI's terminology, because they are trained to perform CPR and other minor functions in the case of large accidents like multi -car collisions. Pranjal Kolwar, a 24-year old from Assam training in the Advanced EMT program, told us that people thought at first this service could not be free (it is, everywhere 108 is operated). Pranjal, like the other trainees we met that day, such as those above from Chhattisgarh was being paid by his state to become an EMT. Even in Assam where the "kutcha" (unpaved) roads make it difficult to travel by car, EMRI ambulances fetch people to hospital. In his experience working as an EMT-Basic paramedic, he saw a lot of pregnancies, and also the aftermath of many fights. He also got a call for empathy. "A woman's husband had died at 5am," Pranjal told us, "she had two husband and her family did not know what to do. They just called 108. They called us to come and put a smile on her face. There was nothing to do, so I just listened to her." "I feel good working here," he said.

Designing a low-cost, high performance primary health care chain in Brazil

CVS's Minute Clinics inspire a smartly designed enterprise aiming to lower financial and time costs to seeking health care for low income Brazilians

By Virginia Resende ACCESS Health International, Brazil Jan 27 2011

Virginia Resende, ACCESS Health Internationals lead for CHMI in Brazil, interviews an entrepreneur opening a smartly designed lowcost chain of clinics. She asks Ingrid Lins e Silva, Founder of Sade 10, how the government can best aid similar social enterprises via financing and regulations. The primary health care market is estimated to generate R$16 billion ($9.5 billion) every year in Brazil. Around 75% of the Brazilian population is not covered by private health insurance, and rely exclusively on public services. Among lower income families, with earnings up to five times Brazils minimum wage per month (R$ 2,550 or $1,500), 85% of people rely exclusively on the Brazilian government for health care. People in poorer neighborhoods often wait for months to get into extremely crowded public health facilities. The cost of private health insurance is high for lower income people, and out of the pocket payments for primary care visits are on average R$145,00 ($85.30). Sade 10, a new chain of primary health clinics, wants to position itself in this niche, offering good services and much lower costs. Inspired by the US drug store chain CVSs Minute Clinics, Breno Arajo conceptualized Sade 10 in 2009. Arajo thought the model was quick, efficient and adaptable to serve lower income patients in Brazil. In 2009, he met Ingrid Lins e Silva in Rio de Janeiro and together they decided to execute Sade 10. Sade 10 will offer primary care and non-invasive exams. Patients arrive at the clinic and pay R$30 ($17.50). A nurse will take patients case histories, take patients vital signs, and report this information to the doctor. Among Sade 10s key mandates is to pay

close attention to patients. Each visit should last around 15 minutes --not less than 10 minutes. Management will also offer R$7 ($4.10) health insurance program, with co-pay of R$15 ($8.80) for the visits. Although expecting high volumes, Sade 10 wants to ensure that all patients are physically examined. Patients will be first checked and screened by a nurse and then sent to the doctor for further examination. The chain of clinics also wants to differentiate themselves from other low income-targeted facilities by hosting patients in a comfortable, clean medical office. The first clinic is set to open in Rio de Janeiro on February 01, 2011. Virginia Resende: What is the mission of Sade 10? Ingrid Lins e Silva, Founder of Sade 10: Sade 10s mission is to create medical clinics that offer convenient, high quality and quick services. These services will have very accessible prices, for people who are willing to pay some money to receive better care than that offered by the public healthcare system in Brazil. Care and respect are essential values for the company and clients; both are seldom found in competitor low cost primary care clinics in Brazil. VR: Who was the most critical and strategic partner for Sade 10? ILS: The most critical partner was Financiadora de Estudos e Projetos (FINEP Research and Projects Financing Agency of the Brazilian government). They awarded us with a grant Prime (Primeira Empresa Inovadora First Innovation Enterprise), choosing our business among thousands in Rio de Janeiro in 2010, the second of three rounds of grants. PRIME provided us with credibility and increased our access to companies and institutions for future partnerships. PRIME is a grant of around R$120,000 (US$70,400) that start-ups can use to hire a good manager and pay for marketing and strategy research. Receiving the financial award was not essential, but being recognized and chosen amongst other entrepreneurs was critical. It sent the market the message that they could trust us, since the government also did. Naturally, the financial support allowed me to dedicate more time to Sade 10 as opposed to my marketing consulting initiative. VR: How can the Brazilian government better assist initiatives like yours? ILS: By reducing bureaucracysimplifying processes and procedureslowering direct and indirect taxes, and increasing grant initiatives such as FINEP and FAPERJ (Fundao de Amparo Pesquisa do Estado do Rio de Janeiro- Research Agency of Rio de Janeiro.)

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These grants should have a wider scope in order to benefit more businesses without many restrictions.

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Technology to the People!

Taking Telemedicine to Scale in Rural India From the NextBillion series Healthcare with the BoP

By Rose Reis Results for Development Institute, USA Mar 8 2011 This post was first posted on NextBillion as part of their Healthcare With the Base of the Pyramid series. Long known as an IT capital, India's health infrastructure for years lagged behind the Tiger-like force of its software industry. No more: In the past decade, thanks to growing support from government, private sector innovation, and a great leap forward in infrastructure development, so-called Information Communication Technology (ICT) is transforming the way people receive health care. The "next generation" telemedicine model is proliferating rapidly in India, where 70% of people live in rural areas where health infrastructure is still insufficient. Telemedicine uses ICT to "provid[e] accessible, cost-effective, high-quality health care services," in the words of a recent WHO Global Observatory for eHealth report. Telemedicine models, in which rural patients are connected to trained physicians over telephone or Internet, can become the first point of access for a variety of illnesses and diseases such as eye related issues, intestinal problems, infections and heart disease. Most importantly, patients get into the health system early and do not delay care seeking for fear of transportation and costs. Today, CHMI profiles more than 55 telemedicine programs globally including 24 in India (program implementers and CHMI's partners in 16 countries are continually adding new programs to the open database). World Health Partners is a not-for-profit franchising organization that provides healthcare services to the poor in Uttar Pradesh across Meerut, Muzzafarnagar and Bijnor districts. In less than 18 months, the project established a health service delivery

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network covering 1,300 rural villages of Uttar Pradesh through 1,300 shops, 120 telemedicine centers, nine diagnostic centers and 16 franchisee clinics. The project's central medical facility in Delhi conducts 80-160 tele-consultations per day. Next up: an expanded pilot in Bihar, with funding from the Bill & Melinda Gates Foundation. Gates has also initiated a rigorous evaluation of the model's health impact. Sehat First, another franchise model utilizing ICT, aims to set up 500 health centers across Pakistan by 2012. Founded in 2008 by d.o.t.z. technologies as a Karachi-based pilot, Sehat First received an equity investment from Acumen Fund. The initiative's telemedicine consulting service gives patients access through clinic staff to physicians, even specialists like gynecologists and pediatricians, over IP-based video phones. Amrita Institute of Medical Sciences (AIMS) and Research Centre uses telemedicine to connect general providers to specialists. In addition to the flagship hospital at Kochi, the Institute also has established several smaller satellite hospitals in semi-urban and rural areas to serve the local populace. Students from the health sciences campus in Kochi often are posted to these hospitals, and doctors and other medical staff serve there as well. Satellite hospitals are linked to the 24/7 telemedicine service of AIMS Hospital. The technology allows for the transmission of a patient's medical records and images, and provides a live two-way audio and video link, which allows a general practitioner at the health center to connect with a specialist at AIMS. Raja Bollineni, of CHMI Partner Organization ACCESS Health International, is charged with mapping ICT-related health initiatives in India. Bollineni got interested in the promise of so-called e-health when working in Rwanda. He proposed a system for Partners in Health to allow people in rural Rwanda to consult on eye problems with specialist ophthalmologists located at Central Hospital University Kigali. Although these models have garnered a lot of excitement in India and abroad, Bollineni is quick to point out a number of challenges impeding the implementation and further growth of these programs, including capital investments, infrastructure limitations, lack of supportive policy, and low awareness levels in the communities. One other important barrier to sustained growth is the difficulty in getting sufficient volume to sustain your business. "Startups shouldn't go in for high-end technology," suggests Bollineni. "You can save your capital for other investments, and the tariffs are also high on imported technology." Bollineni suggests that implementers look at connectivity, and be realisticeven more basic Internet over phone can be effective, with limitations Garnering sufficient volumes of revenue is another big challenge for implementers. "For telemedicine programs to go to scale, they have to be able to attract a sufficient volume of business," says Bollineni. In his view, there are two ways to make them economically viable. The first is to obtain government support for expanding infrastructure. The best way to do this is to create bundled shared services that utilize the same infrastructure. He recommends adding on dental services, dermatology and diagnostics to boost 13

revenues, and points to Punjab-based Healthpoint's innovative choice to sell clean water cheaply adjacent to a telemedicine-equipped clinic (below).

How equipped does a clinic have to be to incorporate telemedicine? According to Bollineni, there are many options. Very well connected clinics use broadband with speeds of 512 kb/second, while Integrated Services Digital Network (ISDN) lines are the most preferred connectivity options for practical reasons to connect remote areas, which only require a minimum bandwidth of 128 kb/second, costing about 171 Rs/hour (less than $4). VSAT too is a good option although a costlier proposal but provides much faster data transmission than ISDN. Video conferencing requires 256 kb/second ISDN or IP based support. Among those using high-end technology are Apollo Telemedicine Networking Foundation's telemedicine centers an initiative of Apollo Hospitals, the Joint Commission-certified hospital chain that has set up more than 100 telemedicine centers in India and 10 overseas to boost their business and make follow up visits more convenient. For start-ups with less capital, Bollineni points to tech "hot beds" developing ICT used for telemedicine in South and West India. "Neurosynaptic has an interface box set which can transmit images and data at very low band widths -this seems to working very well," he said. World Health Partners uses the Bangalore-based company's ReMeDi kit. Mumbai-based Maestros has developed Element 6, a portable medical kit for telemedicine. Bollineni also pointed to technology development and incubation centers at Indian Institute of Technology (IIT) Kanpur, IITM's Rural Technology and Business

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Incubator (RTBI), Centre for Development of Advance Computing (CDAC) centers across India and the School of telemedicine at Sanjay Gandhi Postgraduate Institute of Medical Sciences. Bollineni cautions that the government must continue to play a stewardship role in accelerating this developing sector. More standardization of hardware and software and developing practice guidelines will help program managers implementing telemedicine programs overcome inter-operability, portability and security issues. Bollineni also urges government to implement the ICD 10, an international system of codes that classify symptoms and diseases. With ACCESS, Bollineni is working to build collaborative and co-operative efforts from and among the network providers and the system developers. This April, as part of its work to forge connections between innovators with the Center for Health Market Innovations, ACCESS will be hosting a tele-health roundtable to bring both groups together for dialogue. Join CHMI, then login to contact Bollineni about the meeting.

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Non Communicable Diseases: Not Just for the Rich

CSIS hosts a panel to explore the global response to the shifting burden of disease

By Maria Belenky Results for Development Institute, USA Apr 12 2011 On September 19-20, 2011, the UN General Assembly will convene a highlevel meeting on non-communicable diseases (NCDs), an affirmation that prevention and control of NCDs is finally reaching the global public health agenda. Often thought of as diseases of the rich, NCDs comprise about 60% of global mortality, with approximately 80% of the deaths occurring in low and middle income countries. In fact, current projections show that by 2030, NCDs will overtake communicable diseases as the leading cause of death in rich and poor nations alike as an aging populations and lifestyle changes linked with economic development increase the risk factors for illnesses such as heart disease, cancer, chronic obstructive pulmonary disease and diabetes. How are different actors - both public and private - within developing nations dealing with the shifting burden of disease? To address this issue, the Center for Strategic International Studies (CSIS) hosted a panel discussion focused on the developing nation response to the emergence of NCDs as a major public health concern. To kick off the discussion, Rebecca Firestone of Population Services International (PSI) shared a number of often overlooked statistics to conclusively defeat the diseases of the rich misconception. Although NCDs account for a greater percentage of total deaths in higher-income countries, the NCD death rate per 100,000 is actually higher in many developing nations. Furthermore, risk factors such as smoking disproportionately affect the poor; in Laos, for example, the prevalence of smokers among the lowest quintile is close to 50%, compared to about 20% of the wealthiest quintile.

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How is the international community reacting to these statistics? The unfortunate

answer is that the response is still lagging. In 2007, only 3% of all donor assistance for health went to NCDs, amounting to approximately $.78/DALY attributable to NCDs, compared to $23.9/DALY attributable to HIV, malaria, and TB. One of the likely reasons for this lackluster response is the overwhelming perception that NCDs are just too complicated to prevent and treat in low-resource settings. Still, there is reason to be optimistic. Gina Lagomarsino, Managing Director and CHMI lead at Results for Development, shared a number of approaches that are being employed to make NCD care accessible and affordable to the poor. Several innovative initiatives have been identified over the last year by CHMI partner organizations that attempt to address one or more segments of the NCD continuum of care, from mobile clinics that engage in prevention, diagnosis and monitoring of chronic diseases in rural and remote geographies, to private chains that are paid for through government contracts that engage in long-term disease management, and super-specialty hospitals that provide the full continuum of care at a lower cost, often through government insurance or cross subsidization. Brazil and India appear to be two of the countries leading the way toward making NCD care affordable for lower income populations.

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In Brazil, Nefrocare has established a network of independent low-cost dialysis clinics that take advantage of scale to reduce the cost of service. Nefrocare currently operates 11 clinics in Brazil and 1 in Angola; approximately 90% of its patients are covered through Brazils Unified Health System (SUS). Narayana Hrudayalaya (NH), the largest provider of heart surgeries in India (and one of the largest in the world), uses a high volume-low cost delivery model and cross subsidization to provide reduced-fee or free care to about 60% of its patients. Furthermore, a number of technology providers are developing and rolling out mobile-phone adapted software (see GlicOnline, Mobile Phones for Health Monitoring, MediNet) to help patients better manage conditions such as diabetes and cardiovascular diseases.

Though its evident that a number of independent pro-poor initiatives are indeed tackling NCD care in the developing world, an important issue remains how does the global health community ensure that these efforts are plugged into a wider support system, one that aids the acquisition of low-cost quality drugs and encourages compliance with established operational and quality standards? Nikki Charman, PSIs Global Service Marketing Manager, discussed how the social franchising model already widely used for family planning and the diagnosis and treatment of infectious diseases such as HIV/AIDS, Malaria and TB can be applied to the prevention and control of NCDs. In Myanmar, Sun Quality Health is beginning to offer low cost cervical cancer screenings and cryotherapy (the use of cold temperatures to destroy abnormal tissue) through its network of franchis ed clinics. Similar initiatives are underway in Kenya and Uganda. Although several aspects of these models appear promising, a host of unanswered questions remain. How can providers be incentivized to deliver long-term care? How does a social franchise network coordinate across the continuum of care? How would social franchising address the steep cost of NCD care? Ensuring that countries are prepared to meet the shifting burden of diseases will require collaboration between both the public and private health sectors, as well as crosssectoral support and assistance from the international community. Are we up to the challenge?

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How to engage private sector doctors to deliver high quality and affordable priority care services
Making an impact with social franchising in Asia's second poorest state, where 80% of health transactions take place in the private sector

By John Hetherington Sun Quality Health, Myanmar May 26 2011 In 2010, the Population Services International (PSI) program, Sun Quality Health (SQH), and its sister network of village health workers, Sun Primary Health, performed more than 2.1 million client consultations in Myanmar. John Hetherington, who has managed the network since 2007, talked to CHMI about howin the second-poorest country in the Asia-Pacific regionSQH has assembled one of the broadest service packages of any social franchise network operating today in an attempt to provide high quality, well regulated priority health services to local people. CHMI: You offer a wide range of services under the Sun Quality Health brand. How do you select the services the brand will include? John Hetherington: With a backbone of 1200 doctors in more than 200 townships, we can be entrepreneurial. We first ask, is there a need not being met? And is there an opportunity for a network of providers to offer that service? In Myanmar, the largest health concerns malaria, family planning, pneumonia, diarrheal disease, TB are either too expensive to treat, or doctors dont provide the right quality service. As in many places, we started with reproductive health and family planning, where there is a natural fit for social franchising. Why is it that so many social franchising programs start by offering family planning? JH: I think family planning is unlike other services because everyone from 15-49 is potentially a client meaning, they are theoretically all fertile -- and this makes it different than addressing diseases which require many more inputs to be efficient, targeting, testing, etc., particularly in Asia, where many of the big diseases tend to be concentrated epidemics. With FP, you have the potential to offer (almost) anyone you 19

interact with something that can be of service to them. You have the potential for large scale impact without the precise geographical targeting that you would need to treat an epidemic. Without using the media to market to clients, how does your franchise attract clients? JH: Advertising for medical services is illegal. Here, as in many countries, there are lots of people who go to their local doctors when they are ill or think they are ill. Many of these doctors have practiced for 20-30 years without continuing medical education. These are the doctors we retrain, so [with their clients] we have a captive audience, in a way. How do you set prices? JH: We set prices in a way that they are not a barrier to the poorest person we want to reach in the given target. We make services available at a price people are expecting50 cents to a dollar for a malaria treatment, versus the five to six dollars it would cost otherwise. If we were not subsidizing these services, doctors would not provide them, or they might give patients the wrong drugs--give an injection, for example. Speaking of which, how do you ensure quality? JH: Social franchising is more complex to manage than other channels of social marketingyou need higher levels of training, monitoring and supervision. On our staff, we have close to 80 doctors that, on average, visit each of the 1200 clinics every six weeks. They observe service delivery and answer the franchisee doctors questions. We also send mystery clients to assure that the level of service quality remains intact. We use vignettes in training. These techniques ensure that [franchisees] are not gauging people with prices or giving the wrong treatment. However, we dont own these clinics. We hope the training around good hygiene, infection prevention, client relationships, and counseling improves overall practices, since we dont monitor health areas outside the SQH basket of services. Is it difficult to get providers to participate? JH: No their business increases. Their reputation is better, they have more 20

services to offer, and their customers can get an IUD for 50 cents instead of 50 dollars. In Myanmar, the public sector is not able to serve the needs of most people; 80-90% of people go to the private sector for health care. This is not unique. The private sector, while used by everyone, is atrocious in most places. With proper management, however, it can be made to do less harmand even do very good work. I have had surrealistic conversations with some country officials or [global health policy makers] where someone asks [a policy maker], what is your national protocol for firstline treatment for malaria? Yet, if you look at the data, 99% of people go to a pharmacy and buy drugs off the shelf. Some have to have a philosophical shift to understand this. Describe your relationship with the Myanmar government. JH: There is always a give and take between an NGO and the government. We have a longstanding relationship with the government in Myanmar and some of our staff are former civil servants. [Officials] appreciate that we are improving the quality of services by providing continuing medical education where there is none, and reporting on treatments not captured by the national health management information system. The health minister has also seen the impact of Sun Quality Health. Its not minorits providing something like 25% of all family planning services, and we are detecting and treating more than 12% of all TB cases nationally. We heard you are now offering screening for cervical cancer, which is very unusual even though 80% of cases occur in the developing world. JH: Our franchising director at the time, Dr. Nyo Nyo Mihn learned a couple of years ago at a medical quality conference funded by one of our donors that you can screen [for abnormal cells] with acetic acid and treat abnormal cells with cryotherapy using Co2 in low resource environment, all without electricity. PSIs innovations fund allows us to be entrepreneurial without massive amounts of money, so we are now beginning training. Some people in the health ministry are concerned that private sector doctors should be doing something they consider to be a hospital service. But almost no one is doing cervical screenings anywhere, so again, there is a choice of doing nothing, or doing something in partnership with the health facilities that are actually being accessed by people. We are also piloting a basic package of anti-retroviral therapy with 100 clients, which hasnt yet been done in social marketing. You also provide TB screening and treatment. JH: Starting this intervention in 2004 was our biggest gamble. A recent study showed that the TB prevalence in Myanmar is five to six times higher than what was previously estimated. Now, our franchise does more than 12% of all case detection and treatment in the country. Recently, in a village meeting, a woman spontaneously came up to us in tears. She told us she had been dying from TB and the treatment she got from a government clinic 21

wasnt working for her. A PSI health worker told her to go to a *Sun Quality Health+ doctor. She said, Im healthy now and you saved my life. I was thinking, thats one person, and there are 17,000 people every year getting that service that would otherwise die, and give TB to eight other people. Yet, you still have people outside the country saying you cant work ethically inside the country, and the regime here can also be xenophobic. We can negotiate between those two thingsthe government doesnt see *the program+ as impinging on their sovereignty and the opposition doesnt see it as giving succor to the regime. This model would be interesting to use in other difficult political situations, perhaps in Zimbabwe.

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Improving infant survival by engaging the private sector in Bihar

Hope blooms in Indias most impoverished state

By Priya Anant ACCESS Health International, India Apr 27 2011 If you told me five years back I would be working in Bihar on a sophisticated government contracting program to improve child survival I would have been incredulous. For many years simply driving through the state was not safe, due to very poor law and order situation. The restoration of law and order has been a huge change in Bihar over the last few years. This has emboldened many development agencies and donors to come into the State, and the launch of new initiatives including the one that took me to Bihar recently for a two week visit to interview state health officials. Traveling in Jehanabad and Nalanda districts, I understood songwriter Gulshan Bawras inspiration when he wrote the beautiful lyrics Mere desh ki dharti sonaa ugale, ugale hire moti....mere desh ki dharti, or the earth of my country produces gold, silver and diamonds. Endless fields of golden grain swaying gently in the summer breeze contrasted with the states still-significant problems. Bihar grapples with widespread landlessnessgovernment estimates 10 percent overall, but sample surveys have shown pockets that have over 50% landlesshalf the population living below the poverty line, and a huge burden of maternal and infant deaths. Abundantly endowed with natural resources, Bihar has one of the poorest health indicators in the country, aggravated by poverty. Human Development Index for India versus Bihar was 0.612 versus 0.476 in 2007. Many may be surprised to learn that a large percentage of poor in Bihar seek care from the private sector. 70% of the doctors are in the private sector and the remaining 30% have a right to be there too, beyond office hours, if they choose to. Unfortunately the 23

private sector is largely unregulated and subject to market forces with little government oversight, the rate, nature and quality of services is too often determined by whether the services are available from other sources and how they are priced and provided. Yet as I learned during my visit, there is obvious commitment to change the status quo from a newly invigorated state government with an ambitious agenda to redeem the state. Primary education and health have to be provided for by the government, a senior administrator told me. There is also frantic infrastructure building activity across the state. The State Health Society, Bihar (SHSB) is one of the swankiest state offices that I have been to. The office is imbued with a sense of urgency, including a biometric attendance system for staff. In our interviews about child health programs, senior heads of departments at SHSB shared their concern about the shortcoming of existing staffquality, productivity, and insufficient numbers. Indeed, of the 80,000 odd Accredited Social Health Activist (ASHA) workers across the State, 40% are yet to be trained on the first four of seven modules. Government is responding by stepping up the pace by expanding the trainer institutions. Last year, the state actually could not absorb its funds, and returned Rs. 696 out of the 1,274 Crores (USD 1.39-2.55 billion) unspent to Indias central health ministry, along with an interest of Rs.17 Crores (USD 3.4 million). I am skeptical that more money would translate into improved health care availability and attendant improvement in indicators. I was in Bihar on a project for the state government to engage private sector providers with the goal of improving infant survival, the third phase of ACCESS Health Internationals engagement with our partner, the Norway India Partnership Initiative (NIPI). Earlier phases included a workshop that was focused on understanding experiences in the country as well as global experiences in government contracting or Public Private Partnership (PPP). State and district-level research on the state of the existing private sector highlighted the need and opportunity to engage the private sector. The third phase of our engagement with NIPI is to help the government strengthen the infant care services through the public system as well as create pilots engaging private sector for infant care provision. Our scope of work is to help structure, design the purchase and work with the government to implement and fine tune the design so it can be scaled across the state. We work in Bihar and Orissa as part of this two-year project (the experience will be documented on the Center for Health Market Innovations, like other government contracting initiatives in India). Aside from NIPI, with its agenda to catalyze action, many development partners are working to shore up the states health. DFID provides technical assistance to the State for Public Private Partnership structuring and execution and undertaking health sector reform. UNFPA focuses on improving access to good quality family planning services. 24

The latest entrant, the Bill & Melinda Gates Foundation, has provided two large implementation-focused grants, a consortium led by CARE and a grant for World Health Partners to expand from neighboring Uttar Pradesh to Bihar. The outlays of the development partners vary between Rs.45 to 2,000 Crores (USD 9 million to 4 billion) for the next five year period. But what is common among most partners is the agenda of working with the Government to strengthen health systems. A stewardship role to be played by the government would help these agencies to align missions, work together and with each other in a meaningful manner. The informal channels of communication currently used would then be formalised. Bihar currently has an IMR of 52/ 1,000 live births, against the national average of 50, and aims to reach below 30 by 2012. 53,000 infants were lost last year according to the States data. We are now out on a fact finding mission in Bihar to collect data including facts, figures and human stories to corroborate the need to make infant care services available to the poorest, no matter where it comes from...public or private. The goal is to just help influence decisions to do what is most required to ensure that infants are not lost due to notional boundaries and fixed ideologies around provision roles. With 10 years of program design and implementation experience, Priya Anant leads the India hub of the Center for Health Market Innovations at ACCESS Health International. ACCESS also works in Bihar under a grant from the Norwegian government.

2011 is declared as the year of safe motherhood in Bihar. This was at the unveiling of the declaration in the State Health Society, Bihar office.

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Foreign investors, successful businesses invest in Kenyas white hot health market
Insurance and hospital companies poised to expand operations with foreign capital infusion

By Elizabeth Maloba Institute of Health Policy, Management and Research, Kenya Apr 4 2011 Forecasts of 6% expansion in Kenyas private health sector are drawing the interest of private equity firms in Europe and driving local firms to enter that promising sector. A recent editorial by journalist Edward Okeyo, brought to my attention by a friend, argues that the health sector easily outperforms the stock exchange and maybe even the real estate industry. Okeyo points to a new breed of doctors armed with MBAs and a desire to turn the sector into mainstream business as driving significant recent investments from foreign venture capital firms. In January, the German-based private equity fund Africa Development Corporation (ADC) bought a 25% stake in Resolution Health EA Ltd, an insurance provider planning to expand across Kenya and regionally. Resolution covers 42,000 people and 870 companies in Kenya. Last year, UK-based private equity firm Aureos Capital bought a 26% stake in Nairobi Womens Hospital, investing 199.5 million shillings or $2.5 million USD, with which the hospital company will build three health facilities across east Africa. According to a Reuters report, Aureos will inject $4-7 million into Kenyas healthcare sector this year. According to the Reuters story, the value of health services in Kenya rose to $753.8 million between 2005 and 2009 and an International Finance Corporation study estimates that the sub-Saharan African region requires $25-30 billion in new investments in health in the next decade to meet growing demand.

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Journalist Okeyo also hinted in his editorial that the company Equity Group may be starting up Equity Health before too long, concluding, if its anything like their banking model, I wont be surprised to see a franchise of quality and affordable health facilities complementing their health insurance business. Nairobi Womens Hospital and Resolution Health are not typical pro-poor products, but they serve the poor through CSR programs. Equity on the other hand is a predominantly pro-poor banking model, which is why the author comments that if their health product is anything like their banking product it will be dramatically different from many market offerings. It is yet to start and there is not much known about it. As such we have to wait and see.

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Data, data all around, but plenty of ways to understand what it all means
A visit to a data mecca in Seattle yields information on new data display tools

Posted by Donika Dimovska Results for Development Institute, USA Apr 5 2011 The Global Health Metrics and Evaluation 2011 conference, organized by Seattles Institute for Health Metrics and Evaluation (IHME) with several public health schools, was a provocative gathering of leaders and bright young minds in scientific evaluation and data visualization. Talks focused on designing new countryspecific development indicators (the next MGDs), the growing importance of noncommunicable diseases, and a movement for greater country ownership of data collected indigenously, as well as the responsibility of analysts to producing synthesis for non-academic audiences. See a summary of the conference here by Lancet editor Richard Horton. Also on the docket, and of keen interest to CHMI with its expanding database: A battery of new methods and tools to parse and visualize data (also covered in the New York Times Business section recently). Methods tend to focus on improving predictive validity and objectivity to inform policy decision-making. Data and visualization Afripop.org, initiated in July 2009, produces detailed maps depicting population distribution throughout Africa. Afripop uses fine resolution satellite imagery to show settlement maps that are combined with land cover maps. They then plug in population counts from census data. Esri/ArcGIS digitally creates and "manipulates" spatial areas to help with data management, planning and analysis, business operations, and situational awareness, for example decision support. You can create 3D data, maps, globes, and models on desktop and share them for use on a desktop, in a browser, or on a mobile device. 28

Tableau Public is a free service that lets anyone publish interactive data to the web. Once on the web, others can interact with the data, download it, or create their own visualizations of it (Tableau gallery pictured above). No programming skills are required.

Publically-available databases The Global Health Data Exchange (GHDx) data catalogue, launched by IHME at the conference, has 1,000 datasets in the catalog, including surveys, censuses, administrative data, statistical yearbooks, and hospital data. The CDCs Division of Reproductive Health will use GDHx to disseminate its reports and datas ets for survey data collected for 30 countries receiving technical assistance from the division for the past 35 years. Datasets will cover topics including pregnancies, births, contraceptive use, prenatal care, nutrition, delivery assistance, immunizations, behavioural risk factors, and domestic violence. For US-health data sets, tools and apps, researchers can now navigate to HealthData.gov, just launched last month.

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Innovations in Drug Adherence

An illuminating presentation from the 2011 Unite for Sight Global Health & Innovation Conference

By Trevor Lewis Results for Development Institute, USA Apr 19 2011 This past weekend (April 16-17) saw more than 2000 students, doctors, public health professionals, policy makers, activists, scientists, venture capitalists and philanthropists (and others!) descend on New Haven, CT for the Unite for Sight Global Health & Innovation Conference held at Yale University. Participants hailed from all 50 states and more than 55 countries. Session topics ranged from presentations on maternal and child health, to workshops on innovation dissemination to social enterprise pitches. Unsurprisingly, one topic that surfaced frequently was the use of technology and point-of-care diagnostics. Here is one of the presentations that stood out most to the author: "Wireless Adherence Monitoring Technology," presented by Jessica Haberer, MD, MS, Research Scientist, Harvard Institute for Global Health; Assistant in Health Decision Sciences, Massachusetts general hospital; Instructor, Harvard Medical School Dr. Jessica Haberer focused her presentation on the fact that, even in developed countries, only about 50% of patients adhere to medications for chronic diseases. To deal with this, a number of monitoring practices have been developed, from more subjective self-reporting by patients, to more objective pill counts, reporting of pharmacy data and testing of drug levels. Nevertheless, all of these standard monitoring practices detect lack of adherence too late which can have serious clinical consequences for the patient. New technologies can help in three ways: 1. Mobile phones allow patients to report their adherence through live calls, text message and interactive voice response. The ease of use of mobile phones means that patients can report more frequently and immediately after they take their dose, which helps solves problem of recall bias (forgetting details). In addition, the use of mobile phones can be desirable due to the anonymity that

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they provide. Still, phones do have their limitations. For example, the use of mobile phones depends on network availability and user understanding of the technology itself. In addition, identification problems can arise when phones are shared, as is often the case in developing countries . 2. Wireless pill containers offer an interesting alternative to mobile phones. In this case, patients take their pills from a special container whose cap contains an SMS chip and can alert a health worker every time the container is opened. Current versions of this technology have batteries that last for approximately three months. Early pilots have shown high levels of acceptance of this technology in developing countries, however this option is limited by the high cost per device (USD$100-200). 3. Wireless Ingestion Monitors represent the most futuristic and high tech of the three options. New technology created by MagneTrace uses a specially designed necklace and a magnetize pill to detect when a pill has passed through the esophagus. Alternatively, X out TB employs special strips of paper that react with metabolites in the patients urine (which are only present after ingestion of a pill) to reveal a code that the patient must then text in to a health worker. Other technologies can detect metabolites on the patients breath. These types of solutions hold great promise, but at the moment they are prohibitively expensive and require a significant level of coordination with the drug manufacturers themselves. In Dr. Haberers opinion, while there have been a number of successes in all three of these regions, wireless pill containers seem to hold the most promise for the moment. Nevertheless, only time and testing will reveal which solution is most effective or if any new solutions will step in to save the day.

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Reaching the last mile

Best practices for delivering health care to rural people

By Rose Reis Results for Development Institute, USA Apr 21 2011 Lessons from the Last Mile from the e-magazine Beyond Profit featured the Top 5 models that effectively reach under-served rural populations. The article gave examples from many sectors, including micro-finance institutions, honey makers, and renewable energy companies. Realizing entrepreneurs working to deliver health services to rural populations share similar challenges and opportunities to business managers in other sectors, we sifted through our database for programs hewing to these models. Indeed, the Top 5 models Abby Callard profiles cover some of the most effective programs we know working to serve people living in remote areas. Here are the Top 5 models, applied to health programs from our database. 1. Hub and spokes model In health this model is more complex, and it usually works via tiers of care with the spokes providing basic primary care services. Examples include Carego LiveWell in Kenya and Merrygold Health Network in India. World Health Partners has developed a sophisticated approach to service isolated villages in Uttar Pradesh and Bihar via tiered referral and telemedicine-equipped or real visits to providers. 2. Piggyback This is a model that uses existing trusted networks to deliver information and products to rural villages--the example Beyond Profit gave was Gramin Suvidha Kendra's usage of the Indian Post, with its 330,000 locations, to distribute wheat seeds and water purifiers as well as obtain pricing information. Examples from the CHMI database include MicroEnsure community health insurance, which sells its inexpensive health insurance plans in India and Tanzania through through trusted MFI networks and church group. AYZH uses community self help groups to deliver products.

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3. Local entrepreneurs Reading about Grameen's Village Phone program, we thought of programs like Ghana's HealthKeepers and Uganda's Living Goods which both utilize Avon-like networks of women entrepreneurs to deliver health products like mosquito nets and water purification tablets to the door of people under-served by traditional business distribution. 4. Market linkage Health program models that are community-operated and deliver products are similar to the honey and cotton source Callard's examples. Vitagoat is a nutrition program that employs self-help groups to operate the system. The products are then sold in the market. 5. Local centers In this model, manufacturing facilitates are located in rural areas. In health, hospitals or clinics locate themselves in isolated, rural locations where people previously had to journey for hours or even days to reach a qualified health provider. CHMI profiles at least 27 such facilities. Lifebuoy Friendship Hospital is a converted 38-meter long French oil barge floating in the remote char areas of Bangladesh's Jamuna River with a team of medics and stocked pharmacy. SEWA Rural made its name by serving tribal people in a remote pocket of India's western Gujarat state for the past three decades. Kasturba Hospital in Jagadhia district, run by SEWA with government funding, was a pioneering example of public-private partnership for 10 years. SEARCH is a well-known example of this in Maharashtra. Now, on to The Other Tech Revolution, the next dispatch from Beyond Profit, which profiles Embrace and other low cost technology.

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Expanding access to essential medication

Taking a page from the banking industry to create extension services for drug sales

By Prabal V. Singh ACCESS Health International, India May 5 2011 According to WHO, 449-649 million people in India lack regular access to essential medicines. I have been thinking about this recently since I am involved with a colleague in a study on Drug Accessibility and Affordabilitythe two components of achieving access being physical access and affordability. As for physical access, drugs are dispensed through retail pharmacies (80 percent), hospital-based pharmacies (12 percent), government pharmacies (5 percent), medical professionals (3 percent) and the rest through non government organization run programs, according to research carried out a few years ago by Kotak Institutional Equity Research. Critically, most of these points of sale for drugs are located in urban and semi urban settings while most people in India, some 70%, live in rural areas. As for affordability, the supply chain starts, of course with R&D, and winds its way down to the tiny shops where most people buy their medication, which each chink in the supply chain adding costs. The choice of which medication to take is actually not made even by the consumer but by the prescriber or in some cases by the pharmacist. The consumer is the most ignored stakeholder in the entire supply chain. Are there lessons to be learned about expanding access from the banking industry? One of the strategies being implemented in the financial inclusion initiative is introduction of banking business correspondents. Correspondents are agents of the bank who try to extend banking services to under-served populations. According to the Reserve Bank of India, the central bank, correspondents are often groups: Banks may use intermediaries, such as, NGOs/ Farmers' Clubs, cooperatives, community based organisations, IT enabled rural outlets of corporate entities, Post Offices, insurance agents for providing facilitation services. Such services ma y include (i) identification of borrowers and fitment of activities; (ii) collection and preliminary processing of loan applications including verification of primary information/data; (iii)

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creating awareness about savings and other products and education and advice on managing money and debt counseling *etc.+ Likewise I think we should experiment with having medication or Drug Correspondents (DC). Identification of DCs should be preceded by mapping of areas under-served by pharmaceutical services. Similarly, Tanzania Food and Drug Authority authorized, duka la dawa baridi (convenience store) to sell non-prescription drugs. These stores are dot the country where licensed pharmacies are scarce. To regulate them strictly Tanzanian government converted them into government authorized drug dispensing outlets. Big pharma companies are also working on a rural business initiative, which apart from increasing awareness includes development of low cost rural brands. This is because in India you are not allowed to differentially price a brand across the country. Indias pharma industry is among the worlds largest, and there is potential to reach all Indian consumers effectively. The overall health market size is estimated to be more than $50 billion. The India exports $11 billion in generics in a global pharma market size of about $82 billion. Sales through the private and not for profit sector accounts for around 94%. Government sales account for just 6% in India. The governments National Pharmaceutical Policy for 2002 has noble intentions: It focuses on ensuring availability, affordability, quality in production and distribution, building internal capacities, promoting research and development and creating an enabling environment to attract investments. Yet the reality is worth focusing in on. For acute conditions medication is hard to come by, and for chronic conditions patients must come several times or continually to purchase medicines, exceedingly difficult for rural people. Promising models exist both in the banking sector and in health sector in other countries. It can be possible to expand access -- physical and financial -- of essential medicine to all people in India.

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Community Health workers institutionalize referral network from remote village to hospital
In remote tribal areas, trained local workers can contribute to achieving MDG 5

Posted by Nadira Sultana ACCESS Health International, Bangladesh May 18 2011 Since I joined CHMI earlier this year, I have seen a number of programs that use community level health workers to deliver key interventions that prevent maternal and childhood morbidity and mortality-a hot topic recently. I recently wrote about Sadija Foundation's partnership with Click Diagnostics and my colleagues in India wrote about SEARCH, another program training local people as community health workers. Recently, I traveled to Kaptai, a region in south-eastern Bangladesh, where Basic Medical Workers work relentlessly to achieve MDG 5 in remote areas where no other health facilities exist for poor villagers. The Kaptai Upazila (subdistrict) is part of the Rangamati District of Chittagong Division. Eleven types of tribes (ethnic minorities): Chakma, Marma, Tanchangya, Tripura, Pankua, Lushi, Khiang, Murang, Rakhain, Chak, Bowm,Khumi live in this district. Most of the tribal people live in hilly villages surrounded by Kaptai Lake without basic facilities of water, sanitation, transportation, health and education. Local boats or foot are the means of transportation from village to village and village to Kaptai city area. In HarinChara, one of the most remove villages, there are no public or private sector facilities, just a few traditional

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healers and traditional birth attendant. People have no option but to seek care from those practitioners in times of life and death. In 2006, Christian Hospital Chondroghona (CHC) started organizing mobile health clinics and has started up a well-designed Community Health Program for nearly 50,000 people in 150 disperse remote hill villages in Rangamati. The program ensures community participation by recruiting community health workers called Basic Medical Workers from villages, working in consensus with village headman to create an up to date database of families in each program areas. They encourage each household to own a family health card with unique Identification number, which costs BDT 30 ($.40 USD). Families pay BDT 15/- for subsequent visit for each family member (for post natal visits, mother and baby are considers as a single family member). The local health workers are given two months of training on basic health issues, primary care and health emergency management before they start work with CHC. Health workers regularly visit homes to keep villagers informed on basic health information on various primary care issues: national vaccine program, prenatal and post natal care, nutrition, family planning, quick management of diarrhea, respiratory infection, malaria and other common ailments. They are capable of identifying high risk pregnancy, severe diarrhea and pneumonia case for preventing maternal and childhood morbidity and mortality. Since malaria is one of the reasons of morbidity and mortality of these hilly villages, they are equipped with Rapid Diagnostic Test (RDT) for malaria (Paracheck Pf) and provide initial doses of anti-malarial drugs when necessary. The workers also keep local families up to date on the schedule of the mobile health care facility, encouraging them to use the preventive and curative services offered, and refer them when necessary to hospital. The hospital authority provides special attention to the patients if come with referral documents from these community workers. The mobile health team, which travels six days a week and provides daylong services to each village, comprises of a medical doctor, a nurse/paramedic, a laboratory technician, a pharmacist and a support staff. They perform diagnostic services for prenatal women and malaria tests. Government 37

health workers for EPI and family planning match their schedule with the mobile team. This is a good example of public-private partnership in community health work. There hasn't been a formal evaluation yet of the community health program--it is scheduled to end on December 2012--but the intervention shows remarkable changes in health seeking behavior of tribal people. A female representative of the local government expressed her satisfaction for this intervention along with other women who I met during my visit. Further, the regularly updated household data shows an increased use of antenatal care, family planning and no maternal death since 2008. The program shows notable results.

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Grateful for her baby, now named for her insurance plan
A donor-leveraged community health insurance model that saves mothers and infants lives grows in popularity in two Nigerian states

By the CHMI Team Center for Health Market Innovations, USA April 11 2011 Attahiru Aishetu, a young woman living in Bacita, Kwara State, Nigeria, had obstructed labor: a potentially deadly condition if high quality, emergency care is not available. Fortunately, Attahiru had health insurance and was referred with her card to Ogo Oluwa Hospital where she delivered a baby boy through emergency cesarean surgery. Her family members were surprised when she told them they did not have to raise money for her treatment, since her expenses were covered by her insurance. She named the baby boy, in gratitude, Hygeia, after the community insurance plan that may have saved both their lives. Peju Adenusi, the Executive Direct of the Hygeia Community Health Plan recounted this story when we asked her recently how having insurance for the first time had an impact on peoples lives. To her its such a big deal, something great, she said, it was a turnaround in her life to hold a live baby, and all she had to do was pay about two dollars for care throughout the year. Hygeia Community Health Plan (HCHP) was launched in 2007 in two Nigerian states, Kwara and Lagos, in partnership with PharmAccess and the Health Insurance Fund, a Dutch-based fund that subsidizes the premiums. The plan which is expanding to a new area of Kwara interested us so we rang Adenusi to find out more about how they designed this unique financing scheme. How many people do you cover with HCHP? At the end of March, we had over 75,000 people enrolled, and we hope to get an additional 25,000 with the expansion in both Kwara and Lagos. We serve womens associations, farming communities, trade groups, or entire rural communities. A few examples of groups covered by HCHP: 39

Market Women Associations, Lagos Lady Mechanic Initiative, Lagos Shonga and neighboring communities, Kwara

How did you design the product? We normally do a study on a group we think can benefit from the scheme to determine their income level and what they are willing to pay as a co-payment for insurance. We then do market research to learn more about their health care seeking behavior: focus group discussion, questionnaires, and household surveys. Does the product cover all illnesses for 2 dollars a year? For N300 paid by members, it is quite a robust package. It covers a lot of communicative and non-communicative diseases: Hypertension, malaria, child health (ARI, diarrhea), pregnancy delivery, immunization, even c-sections and minor surgeries. We picked the illnesses covered by looking at the burden of disease in that area. What makes us sta nd out is that the package also covers AIDS medicine, supplied through Global Fund grants. Health insurance is new for many people in Nigeria, so how do you market it? Its not necessarily health insurance specifically but in general the concept of insurance is rather new in Africa, its not really something we are used to. If you ask me how many things do I have insured in the home, I would tell you car is probably necessary, but home? The percentage of people who insure their home is very, very low. People think, there is no guarantee that Ill be ill that year and if Im not ill I wont have to access care. People wonder, how do I access the funds? The only way people become convinced is when they start accessing health care services and realizing what they are getting. They were getting the quality health care services and they tell their peers, this is real. Weve tried it and it works. We encourage them to market the scheme to their peers. They get some commission on each person they bring into the program. Community members trust each other. Why did you start by marketing to women working in the Lagos markets? You need the population for the program. The Lagos Women Market Association is the single largest association in Lagoswe have had more than 40 markets participating in the scheme. 40

Are women and others more likely to seek health care when they are covered by HCHP? Yes, they are. In Kwara for example the level of utilization is now really high. The health care center was almost as good as dead in Shonga3 or 4 visits per monthand when the program started the level of utilization moved up to maybe 1000 visits in a month. With the subsidy coming from the Dutch governments Health Insurance Fund, is Hygeias plan sustainable? Eventually, when people begin to enjoy and appreciate the benefits of self-insurance schemebenefiting from service far above what you have paid for because of the pooling effectthe schemes will have gotten to the level where they would able to pay for health insurance scheme without it being subsidized. Co-payment is not going to be a stagnant figure, we will review it as we move along and try to increase. And actually in Kwara, the state government has passed a bill in December to provide an organizational and financial structure for health insurance for less privileged people of the state. Governor Dr. Bukola Saraki wanted to assist the low income earners in the state. The chairman of the House Committee on Health, Hon. Bisi Oloruntoba noted that the deadly diseases often affect these categories of people in society. What else can governments do to support community health insurance? Governments can encourage cooperatives within groups to serve as financial support or backup for health insurance. If daily earners put aside certain amount of money every day, there is a lump sum that the group can use. My personal suggestion is that these groups should be linked to microfinance institutions properly.

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