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

As a managing director at the Results for Development Institute and leader of its Center for Health Market Innovations (CHMI), Gina Lagomarsino has led efforts to catalogue more than 1,200 innovative health care programs that serve the poor in 110 countries and to facilitate the scale-up of successful programs. An expert in health system design and financing, Lagomarsino also works to expand health coverage and promote national health insurance reforms in low- and middle-income countries, creating vibrant health markets that include high-quality, widely accessible private care.

She’ll be a panelist at the William Davidson Institute’s BoP Summit Oct. 21-23, in a plenary moderated by WDI’s Prashant Yadav. If you’re at SOCAP this week, you can catch her speaking on two panels, one on scaling global health innovations and another on impact investing. She recently spoke with NextBillion Health Care about how to create health care models that are sustainable and scalable. In Part 1 of our interview, she discussed how health care businesses are approaching the BoP and how governments are increasingly embracing the private sector. In Part 2, she talks about whether BoP health care solutions can be applied in the developed world, and the challenges of coordinating donors and the private sector in health promotion efforts.

James Militzer: Do you see any innovative health care approaches in BoP or middle-income countries that could be applied to wealthier countries that are struggling with escalating costs?

Gina Lagomarsino: Well, it’s funny that you say that because we’re actually – hopefully – about to begin a piece of work that would look at the innovative ideas we’ve seen in the developing world and think about how they might be applied to the U.S. in particular, given that our health system is in transition.

I think it would be hard to do a wholesale transplant of any one of the business models we see in the developing world to the U.S., just because the U.S. system is so different. The various professional groups – the doctors, the nurses, etc. – are very organized. There’s a lot more clarity and regulation around what different levels of health care providers can do and obviously the insurance companies are quite powerful. There’s a lot more entrenched ways of doing things. For example, it’s hard to get payment from an insurance company for anything other than a traditional office visit or hospitalization. We’re not really set up to pay for care delivered by phone or computer or other things – which is starting to happen in other places.

But I think the real opportunity – and we’re hoping to do this in the coming months – is to dissect some of the models that we’ve found in places like India and Kenya and the Philippines and understand what components of those models might be applied. For example, some organizations have developed really efficient ways of delivering particular kinds of services by doing that in a high-volume way or by doing so-called task shifting, where lower level personnel might get used to performing a particular task, maybe supported by decision-support software or other kinds of tools. And similarly, I think using various forms of mobile communications to deliver health services is also a really intriguing thing that has emerged in a number of countries. I think that’s something that could be applied even more here.

JM: Businesses that get into BoP health care generally focus on the most profitable services, and ideally donors would focus on the services that businesses won’t or can’t provide. But it doesn’t always work that way. Is there a way to get more effective coordination there?

GL: If we could figure out coordination between donors and the private sector … even just getting all the donors coordinated is a huge challenge. But I actually see a possibility – I do see a real opportunity here. Let’s just take primary care chains as an example. Let’s say they put up their shingles and say, “Come see us when you feel sick” – basically the way we all use our doctors. That’s often what people are willing to pay for out of pocket, so that’s what the entrepreneurs are set up to do.

(Left: Gina Lagomarsino)

But there’s a real opportunity when that person walks in, to also do preventive screenings, preventive treatments – to get them something that they might need medically but that they might not demand, because they don’t know that they need it or because it doesn’t seem important enough to pay for right now. This is where the donors could come in. The donors could say, “We’re willing to fund these particular services that could be an add-on to the basic primary care that people are willing to pay for directly.” And therefore, you begin to educate the providers as well as the patients about what they need. There is an opportunity to layer on some of the specific priority interventions that the global public health community is most concerned about.

JM: Is this kind of coordination happening anywhere?

GL: I think that there are certainly some donors that are thinking this way. And of course there are organizations like Population Services International and Marie Stopes International who’ve gone in many countries and created networks of existing health care providers and then worked through those networks to get providers to deliver services for family planning, malaria, etc. Often those are providers that do a broad range of treatments, but there’s a franchisor that is working with them to try to deliver specific kinds of interventions.

But I think the challenge is that those franchise networks have been developed in a very vertical way. So the donor says, “We want to support family planning,” creates a network of providers, and just promotes family planning. That platform could be used to promote lots of other types of services because those providers are seeing patients for a lot of things. But the way the funding has flowed from the donors means it’s sometimes a challenge for an organization to offer broader services, even though a lot of people have identified the opportunity. I think more and more donors are beginning to recognize this and trying to create more flexible funding so that something like a social franchise network can be used to promote the delivery of a number of different kinds of important health care interventions.

JM: If you could mobilize billions of dollars to address any particular element of global health care, what would you do?

GL: Well, I would work to try to create a very strong public financing system that is set up to provide funding to innovative, high-quality private providers. It would have good systems to monitor quality, good ways to transfer funds so there isn’t fraud, and the incentives set up correctly for different kinds of services to be delivered. Then in those markets, I would hopefully watch a lot of really great entrepreneurs in the health space come out of the woodwork to respond to that new market change, where there’s suddenly revenues to pay for health for poor people.

And I think at the same time you could do some things to really promote the models that have been experimented with, disseminate the learning about what’s working and try to get more people to start up their own health care businesses focused on high-quality care that can be funded through these public financing schemes.