A crucial challenge facing the development sector is the inability of communities living in rural and hinterland areas, which often account for 75 percent of the population in developing countries, to access vital health and reproductive health services. For over 60 years, the focus was on strengthening the public sector for this responsibility. In countries where this has worked – Iran, Cuba, Vietnam to name a few – the results were immediate and effective. Even in India, states like Himachal Pradesh, Goa, and Tamil Nadu have used the public sector effectively.
There are, however, many other areas where the public sector has not been successful. In India, states such as Bihar and Uttar Pradesh (UP) are prime examples – services and technologies which are more than two generations old do not reach the rural poor in these states. Immunisation coverage in UP, for example, is less than 30 percent even though other parts of the country benefited from these vaccines 30 years ago.
In 2008, World Health Partners (WHP) was founded to harness the growing dynamism and energy around entrepreneurship in our globalised world to provide health and family planning goods and services to the poor. Grounded in basic economic principles, WHP drew on private-sector capacity through social franchising, innovations in management of labour and low-cost technologies to develop a scalable and sustainable health service delivery model to bring the benefits of modern health and reproductive healthcare to those most in need.
Calibrated Resources Within an Operational Framework
The operational strategy of WHP divides skills, resources and competencies on the basis of location, and interconnects them to either provide care or facilitate care by a sister network provider. Both provision and facilitation entitle the provider to an income which ensures the sustainability of operations. Services delivered cover a whole range- curative care, which is favoured by private providers, gives financial viability and serves as the main commercial anchor- but the provision of a minimum level of preventive care provision is a non-negotiable part of the service package. The WHP model draws its lessons from Janani which organised skilled and semi-skilled providers into an operational framework for delivering family planning care. (Janani currently accounts for 20 percent of family planning across Bihar).
Female members drawn from the families of makeshift pharmacies, rural health practitioners or informal paramedics are the resource pool despite their educational qualifications often being far below par. However, they are effective managers and exhibit innate business and social skills which produce quick response from the community; training provided to these informal providers enhances their knowledge in technology and healthcare provision.
Local communities are mobilised through advocacy-building and other social mobilisation measures, word-of-mouth publicity, a responsible mix of mass-media and infotainment, and the social marketing of user-friendly health services.
The operational strategy of WHP divides skills, resources and competencies on the basis of location, and interconnects them to either provide care or facilitate care by a sister network provider.
Bundling of Preventative and Curative Services
Part of WHP's strategy is to bundle traditionally separate preventative and curative services and ensure both are provided at its centres. While most rural clinics earn profits from curative services and by referring more serious cases to high levels of care, WHP structures its network in a way that incentivises the incorporation of preventive services. The provision of curative services allows the rural provider to ensure a basis of profit. As a quid pro quo, however, a predetermined volume of preventive care has to be delivered if the providers want to continue in the networks. Local communities are mobilised through advocacy-building and other social mobilisation measures, word-of-mouth publicity, a responsible mix of mass-media and infotainment, and the social marketing of user-friendly health services. This unique and innovative model is not only designed to serve those in need but also offers business opportunities to WHP's partners and stakeholders.
Uttar Pradesh Pilot Project
In late 2008, WHP launched a pilot project to provide services to over 1,000 villages in three underserved districts of Uttar Pradesh (UP), home to an estimated 3.6 million people, of whom more than three million live in rural villages.
The WHP provider network in UP included 1,100 rural providers linked to 102 telemedicine centres, 14 urban medical clinics and nine pathology labs (see figure 3, p.16 ). The telemedicine centres, branded Sky Health Centres, connect with general practitioners at a central facility through a closed telecommunication system called ReMeDi, developed by Neurosynaptic Communications (www.neurosynaptic. com). This comprehensive system allows doctors to examine patients visually, to perform sophisticated diagnostic tests, and to provide therapeutic recommendations. ReMeDi has been specifically designed for rural settings, keeping in mind problems posed by unreliable power supply and inaccessibility, on the one hand, and the need for durability and ease of use on the other hand. Many of the applications have also been customised specially for WHP to suit the service delivery network.
A supply chain that makes products, including medicines and contraceptives, available across the project area caters to all providers aside from 1,800 pharmacies. A nurse-midwife from the public sector also visits the rural centres once a month to provide paramedical contraceptive services (such as IUDs and DMPA) and, in tele-consultation with the doctors, gynaecological services.
A strong advertising campaign promotes the network provider and services. Clients are informed about quality benchmarks which force the providers to adhere to quality norms. While the project currently caters to the section immediately above the poverty line, the same infrastructure will be used to deliver services to the below poverty line sections. Financial instruments, including coupons, insurance and vouchers, with accreditation and validation processes on a biometric platform, will be integrated.
The WHP programme in Uttar Pradesh achieved instant and dramatic results. Within six months of its launch, the project started delivering family planning results which were a third of what the public sector provides in the project districts. The impact is equally high for healthcare delivery which is primarily to women and children (over 57 percent of healthcare clientele are women) and people of reproductive age. By providing preventive care such as family planning, antenatal care or immunisation with adjacent aspects of curative care, the impact is up to seven times the famous Janani programme in Bihar which the team members were administering before joining WHP.
Since inception, the project has provided over 31,000 tele-consultations with qualified physicians to villagers, in addition to 188,401 couple years of protection (CYP) through the project's family planning services, averting an estimated 107,650 unwanted pregnancies. This increased couple protection by 37 percent, from 28 to 38.3.
Moving Forward: Targeting the Poorest of the Poor, Expansion to Bihar and Incorporation of More Innovative Technologies
The current project structure provides care to clients who can pay; prices are kept low through high volumes and donor subsidies. The project will work towards the use of coupons, vouchers, insurance, and tap into government subsidies to deliver care to poor families living below the poverty line. WHP is also currently developing a telephone hotline as another avenue to increase clients' access to the WHP network while simultaneously giving providers in the network a way to reach out to the target population.
WHP sees its prime function as an integrator of a variety of skills and technologies available in various parts of the world. The project has benefited significantly through partnerships which are set up for long-term rather than on turnkey basis. Besides Neurosynaptic Communications (telemedicine), the project also partners with iWeb (financial and data warehousing systems), University of Berkeley, California (microscopy), University of Colorado (rural lighting), Intel (low energy laptops) and many others to help deliver quality health services to the rural poor. Additional point of care diagnostic devices currently in exploration includes the oximeter, otoscope, dermascope and ultrasound.
WHP has just began its expansion to Bihar, India, the third most populous state in India. Fifty-five percent of these 100 million people live below the poverty line and 85 percent live in rural communities. The project will focus on leveraging the WHP service delivery model to improving disease management of several infectious diseases: tuberculosis, visceral leishmaniasis, diarrhea and pneumonia. In addition to internet-based telemedicine, the project will also incorporate the use of mobile phones for collecting patient information, disseminating health information, streamlining financial transactions, and monitoring providers and patients.
The WHP model is designed to be implemented on a large scale, and to deliver a wide range of services. This approach not only allows us to reach a greater population and have a greater impact, but also leverages the economies of scale to increase bargaining power and to reduce costs. The model is designed not only to serve those in need but also to offer business opportunities to all partners and stakeholders, creating viability for providers in the network - a key to building sustainability. WHP has made enormous strides in remote rural healthcare provision over the past two years. With the integration of mHealth, mPayments and low cost point of care diagnostics, along with replication of the model in Bihar, the WHP model is moving closer towards becoming an efficient and powerful model for serving the rural poor in other parts of the world.