NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Resource-constrained settings are constantly evolving and their challenges are varied and unique. Cohabitation, heterogeneous populations, fragile networks (of people and infrastructure), migratory populations, poor living circumstances, poor hygiene and limited health care access, make low-resource settings a difficult challenge for public health. This reduces life expectancy and quality of life.

Many pilot-based interventions aimed at addressing these challenges are able to create initial impact, but low-resource settings are such unique entities that there are few health care models that have the potential and are able to show scale.

Economic growth drivers are interwoven closely with the risk factors for poor health. Aging populations and urban squalor are increasingly intensifying these factors, leading to poor health and adding to the disease burden. There is a need to decouple these and to develop models that are able to deliver quality, affordable health care – and to do so at scale.

Approaches showing potential to scale

Approaches that innovate around the very challenges presented by low-resource settings are interesting to investigate. Some promising examples include:

Mohalla clinics are an initiative to bring diagnostics and treatment of common ailments such as fever, headache, simple infection, skin rash, etc., closer to people. Designed to offer essential drugs and a large variety of tests, they target patients who would otherwise go to unqualified health care providers. These neighborhood clinics are equipped with medicine-dispensing machines, and the model also aims to create the right patient-to-doctor ratio. By bringing care closer to the patients and communities, and simultaneously freeing up doctors at tertiary care hospitals to focus on more complicated diseases and surgeries, mohalla clinics exhibit the potential to create a blueprint for scale, by creating targeted mass delivery of care.

HCG Hospitals offer a unique gateway approach by creating spokes – part of the hub and spoke business model – deep into low-income and resource-constrained communities. Focusing primarily on routine, diagnosis and follow-up care, the spokes are able to maintain a healthy interaction within the community. These spokes surround four urban hubs in Ahmedabad, Mumbai, Chennai and Bangalore. The specialists are concentrated in the hubs and have access to the best equipment, while the spokes have less specialized doctors who provide care using protocols and low-cost equipment. There is a constant stream of patients, which attracts doctors who seek to rapidly increase their skills, capabilities and knowledge. Protocols are created – including protocols for complex procedures, based on medical history and lifestyle – according to the needs of the communities and are extremely important to provide high-quality care.

Swasth India is exploring a model in which they act as service integrators for low-income and constrained-resource communities. They create partnerships with doctors, laboratories, pharmacies, hospitals, nursing homes, drug companies and insurance companies. All of these partners are brought together on a common platform, and services are delivered through community-based organizations. Creating strong linkages between primary, secondary and tertiary health care ensures completion of the health care value loop. The leveraging of social- and community-based organisations further deepens the goodwill and trust built up by these organisations.

Nephroplus provides affordable dialysis through its dialysis and kidney care. The clinics are operationally extremely lean but maintain high-quality service through implementation of deep clinical protocols and a patient-centric approach. Nephroplus extends care in a holistic manner, even offering a pick-up and drop-off service so as to reduce dependency on patient family members. It has also expanded to clinics (new or existing) in larger hospitals.

Uber is delivering flu shots and wellness kits, making the last mile of care access and delivery on-demand. Health packets consisting of hand sanitizer bottles, tissues and a linkage to nurses are being delivered, independent of the individual’s insurance status. This model has a huge potential impact for resource-constrained settings and communities.

The Innovation µ-Lab (pronounced micro-lab) approach by Intellecap, where I am associate vice president, creates a replicable blueprint for rewiring health care delivery infrastructure. Originally designed for infectious diseases, the infrastructure was rewired for affordable, comprehensive and quality screening, detection, treatment and prevention of non-communicable diseases. This approach deploys best-in-class innovative technologies, protocols and processes and involves a wide variety of players such as community members, aggregators, community leaders, care providers (physicians and independent health workers), clinics, etc. The approach is also experimenting with innovative cost-sharing models between clinics and social marketing firms.

learnings

Sustainable health care models across low-resource settings are built on tools and processes that support urban health systems; create the most cost-effective ways of reaching vulnerable communities; integrate awareness, detection, prevention and management into care; improve disease surveillance and monitoring systems; and improve health information systems.

The innovations above attempt a broad systemization that distinguishes them from other approaches that don’t show a similar potential to scale.

These approaches are embedded deep into communities – they are co-created by the communities – and are based on world-class medical technology. They focus on up-skilling community resources and build on strategic partnerships, making them more likely to succeed from a scale and impact standpoint.

Creating value and translating this value to low-income populations is an important step in creating scalable models. The examples above use technology and innovative processes, create new infrastructure or rewire existing infrastructure, and establish linkages with players in the health care value chain. All of them keep the patients and their needs central to value creation and value translation. Looking beyond the individual and engaging the larger community for co-creation of the solutions is equally important, where the creation of the solution is owned by the community. The delivery of low-cost, quality care requires continuous innovation from a technology and a process standpoint, as well as the ability to shift care delivery (protocols and activities) from high-skilled to lower-skilled professionals.

Scale is utilized to achieve profitability and sustainability while keeping costs low and affordable for low-income populations. Traditional examples of creating scale through offering specialised services – heart care and tertiary eye care, including Aravind EyeCare and Narayana Health – are being supplemented by models that offer more generic services – primary care and general ailments, including mohalla clinics and Uber.

The generic services models are progressively adopting specialised care delivery capabilities and are best positioned to leverage scale, as these are able to get closer to the patients much faster and deeper, and can further build toward specialised services through innovative technology and protocols. The linkage between generic service providers and specialised service providers is essential for scale of low-cost and affordable models.

Nakul Goswami is associate vice president of Intellecap Innovation Labs.

Photo of India’s Prime Minister Narendra Modi inaugurating one of Narayana’s superspeciality hospitals in 2014, via Flickr.