Healthcare With the BoP Series: Staying Out of the Medical Poverty Trap In Pakistan
An adolescent golf champion who grew up to be Pakistan’s first female cardiologist, Dr. Sania Nishtar wields influence in forums from the World Health Organization to the Clinton Global Initiative. Recently, through Heartfile, the NGO she founded, she has honed in on one critical barrier to health delivery for the poor: serious shortfalls in financing.
According to Nishtar, Pakistan’s social funds for the poor have a very small envelope and suffer from a number of deficiencies, including abuse and patronage in targeting, unpredictability of coverage and lack of transparency. Initiated in 2009, Heartfile Health Financing is a donation-funded program supported by a web-accessible financing platform. The idea is to enable the poor – the true poor, not those seeking to siphon off funds intended for the poor – to rapidly get access to health services without being pushed further into poverty. Heartfile’s system allows donors to target the poor, but the same mechanism could help other parties, for instance, transparently distribute a country’s social security funds. A CHMI profile can be found here.
Rose Reis, CHMI: The Center for Health Market Innovations documents programs that develop an innovation to improve their health marketplace. How does Heartfile do this?
Sania Nishtar: The most glaring market failure Heartfile addresses is health inequities. Healthcare runs on market principles in countries like ours and it creates two levels of care: That for the poor, and that for the rich. The other market failure is abuse; Heartfile Health Financing has built systematic safeguards against abuse and collusion.
Reis: Why do many people become poor after falling sick?
Nishtar: More than 60 percent of the people in Pakistan pay out-of-pocket for healthcare. The poor do not have the means of paying for high-cost treatment. They spend catastrophically, become indebted and this pushes them into the medical-poverty trap. Many also forego treatment. Statistics show that healthcare costs are the most common cause of economic shocks by households.
Reis: What about the state social security fund?
Nishtar: Government prioritizes primary healthcare. There are limited windows of help for patients in need of high cost treatment. The fund, called Bait-ul-Mal (house of wealth), which is meant to serve this purpose is small. It is additionally, unpredictable, since government contributions tend to fall during a funding crunch. And it is all paper based – there is a lot of discretion and patronage in that process.
Reis: Can the poor not get access to their own state funds?
Nishtar: The other problem for the poor is to use these funds you need to know the channels. The elderly, marginalized, and the poorest of the poor don’t have the means of accessing the system. Many cannot pay for transportation to visit offices or understand how to process the paperwork. The system is paper based and involves lots of delays. It has in the past taken weeks to months to process the application. If someone needs, say, coronary artery surgery, and they wait weeks, they run the risk of losing their lives. We step in with very quick turnover – ours is less than 72 hours. Additionally, our system guards against abuse, leakage of funds to the non-poor and other inclusion and exclusion errors.
Reis: Given the tendency for misuse of funds for the poor, how do you know a person requesting funding from Heartfile is actually poor?
Nishtar: We really make sure those who can afford do not access Heartfile’s pool of funds. Status of poverty is verified though a composite measure. The doctor’s impressions about the patient being poor counts. Then our volunteers conduct an interview on site with the patient. These are retired people, well-to-do with an honorable presence in society and acceptability in hospital. Volunteers conduct a tele-assessment, connecting via a laptop with trained staff in office. Phone calls are made to friends, neighbors and family members for validation as well. The final step is validation using the patient’s unique identification number to a national database where all citizens are registered; we identify those below the poverty line.
Reis: What is the technology platform Heartfile runs on?
Nishtar: It is software custom designed for us and maintained by specialist vendor. We found them through a competitive bidding process. When we were conceptually designing the system we talked to several intended users: hospital administrators, community group, volunteers, and the core team at our office. Lots of things got modified through evaluation and formative insights.
Reis: How do users interface with it – through mobile phones, desktop computers, smartphones?
Nishtar: Patients in need/attending doctors in pre-registered hospitals can send requests for assistance through multiple channels. Ideally, SMS-on template and web interface, but also through fax, telephone, and letter. We give these choices in order to facilitate interaction of users with the system. Heartfile’s Health Equity Fund, maintained by philanthropic contributions, supports eligible cases.
Reis: What funding do patients access through Heartfile?
Nishtar: We created the health equity fund with a grant from the Rockefeller Foundation and added the proceeds from my book. Corporations and individual philanthropists also contribute. I tell them this is a mechanism to target your resources very transparently. The system grants the highest possible level of transparency so that funds are utilized as per the criteria defined by the donor. Capacity to update donors on a micro-transaction basis is an innovation by international standards. Donors can track every penny that they give. There is a strong culture of philanthropy in Pakistan, but it was not structurally harnessed until now. We hope to be able to make headway in that direction.
Reis: Where is this pilot based?
Nishtar: We are working in three hospitals now in Islamabad and Rawalpindi-there are five tertiary-level hospitals in these cities that we will cover this year. We are enrolling patients ward by ward. We started with cardiology, then added orthopedics, and recently GI problems.
Reis: What is the future for this system?
Nishtar: We created this system to be scalable. We created the technology infrastructure with scale-up as a main consideration. Pakistan’s telecommunications infrastructure allows deployment even in remote areas. The telemedicine-for-assessments and mHealth features will allow scale up with lean operational costs and without need for extensive field operations. My sense is this is also a very good model for other countries with people in informal sector and pervasive poverty.