70% of the rural population in developing countries has no choice but to rely on the private sector, which may or may not have formal education or training, for its healthcare. Gopi has found multiple organizations that address this reality by creating a role for them in the formal sector and putting in place systems that improve the quality of care provided.
The New Idea
Gopi is a pioneer in unlocking the potential of existing informal healthcare providers to respond to the healthcare needs of underserved populations. His innovative social franchising and social marketing model combines the resources and strengths of the rural private and public sector to create low cost effective model for healthcare in rural areas.
Gopi sees health as both, a medical and social problem. He strongly believes that to address health issues at scale one has to factor in existing societal dynamics and build solutions around it. Towards this, Gopi’s first organization Janani that focused on family planning leveraged informal private practitioners to successfully deliver one-fourth of the family planning in the state of Bihar. As it continued to grow and scale, Gopi drew from its learning’s and design principles to create the architecture that harnesses existing local market forces to provide comprehensive health care at scale in low-income countries. He now leverages the strengths of existing players to orchestrate new relationships that create a win-win situation for all while allowing him to maintain a lean organization. Gopi has enabled such informal practitioners to talk to doctors in cities for the first time and build relationships to improve quality. This allows them to diagnose and prescribe medication to patients and provide a higher-standard of care as first point of contact. By bundling less attractive preventive care (e.g. immunization and family planning services) with economically attractive curative health care, he is also creating new economic incentives that strengthen preventive healthcare in rural areas and service people below poverty line.
Gopi has also built the local eco-system, including supply of generic drugs and diagnostic services, to support the growth of these entrepreneurial clinics. Through a network of 700 cost-effective clinics across India and Kenya, Gopi has already provided care to several thousand rural patients, 51% of who are in the two lowest economic quintiles.
A challenge that has faced the health sector for decades has been the absence of qualified doctors. The ratio of qualified doctors to patients in rural India is 1:25,000 and as many as 40 percent of the government primary health centers do not have doctors or diagnostic facilities. Doctors, from both the public and private sector, do not choose to work in remote rural areas on account of the low pay and isolation.
In the absence of qualified doctors from the public and citizen sector, several informal healthcare providers, including ‘quacks’ have mushroomed in rural areas. While some of them may be qualified as opthametrics or pharmacists, others have gained some experience from working as an assistant to a doctor. Without any formal qualification or training, they open clinics in their villages and prescribe medicines.
Despite several allegations of committing fraud by the medical community, a large number of informal practitioners function in every village, without any resistance either from the community or the government authority. They act as the first line of defense in rural areas. In the absence of any formal medical facilities, and the nearest government health center atleast 10 kms away, these local providers are often the only choice for poor rural patients. Further, while there have been cases of malpractice and fraud, many informal providers typically restrict themselves to minor ailments. They often maintain close ties with local qualified public and private doctors and refer complicated cases to them. Providing services round the clock proximate to their homes, they are also the only panacea to the villagers suffering from various ailments and have a great goodwill amongst the local community. In fact a study by the World Bank in India in 2012 (published in the research journal Health Affairs) revealed that the quality of care being provided by trained or qualified doctors is no better than quacks.
Unfortunately, for fear of legal consequences and negative perceptions, there have been few efforts by the government or citizen sector to engage such informal healthcare providers. Given the limitations of the public healthcare system and the inability of citizen sector to create scalable solutions in remote areas, there is an urgent need to explore new designs of healthcare delivery that leverage the strengths and reach of such informal healthcare providers, and local market forces to achieve equity in access to quality healthcare. To achieve this, supply chains need to become more efficient and reliable so that essential products and services reach rural populations in a timely, cost-effective manner. Further, to bring down health costs in the long term, there is a need for new approaches and incentives that make preventive healthcare more economically viable for healthcare providers and inculcate a health seeking behavior.
Gopi’s strategy leverages and brings greater efficiencies to existing resources and networks. His lean team at World Health Partners (WHP) identifies and orchestrates the relationship between different stakeholders to create a robust network of healthcare centers under a common brand name “Sky” in underserved and remote areas.
WHP uses technology and business incentives to combine the entrepreneurial acumen and relationships of existing informal providers with the medical knowledge and diagnostic skills of doctors in cities. At the backend or the “Central Medical Facility”, WHP builds a network of qualified accredited physicians and specialists who offer their services at different times of the week. At the front end, WHP identifies and equips informal providers with appropriate technology that connects to available doctors automatically based on the appointment calendar. Informal providers use cell phones, tablets or telemedicine technology, based on the internet bandwidth of the locality and the investment capability of the provider. For instance, informal providers in smaller villages use cell phones to facilitate an audio conference between the patient and the city-based doctor. In such clinics or “Sky Care” centers, the doctor in turn sends a prescription through an encoded SMS. Informal providers with more resources and in areas with improved connectivity, set up “Sky Life” centers to use a tablet to connect patients through audio and video with doctors. In towns where broadband connection is available, informal providers invest in “Sky Health” centers that are equipped with telemedicine devices (ReMeDi), scanners and other devices. This enables doctors in cities to remotely perform consultations and prescribe with the support of the informal providers or provide transportation to hospitals. By forging relationships between the formal and informal healthcare providers, WHP is reducing the extreme imbalance between medical needs and response.
This model also ensures that WHP is able to cater to different geographical contexts and achieve economies of scale. The decentralized, tiered, branded network of providers work well together and maximize efficiency. Each Sky Health center has 7-10 Sky Care providers /catchment villages underneath it that refer patients requiring more sophisticated care. Lower level providers invest in start up costs and profit from services provided to patients, medicines sold and referrals to higher-level providers. In return for its services, WHP charges a small fee per consultation. This ensures long-term financial sustainability for all providers and WHP.
There is also a well-defined process to make referrals for complicated cases. WHP has built a network of ‘franchise clinics’: vetted clinics nearby operated by qualified physicians to refer surgeries, in-patient care or other specialized procedures. Similarly, WHP partners with existing diagnostic centers in the area to improve accessibility to high-quality, affordable service. Representatives from these centers visit SkyHealth centers on a pre-determined schedule to collect samples and reports are delivered electronically to doctors at the Central Medical Facility. The Central Medical Facility also has a hotline to manage complex maternal and neonatal issues. This incentive based model maintains provider interest and minimizes competition between network levels, while matching patients with the appropriate quality of care.
The technology, ability to consult with doctors in the city, trainings and common branding provides a strong identity and economic incentive for informal providers to partner with WHP and adopt safer practices. They willingly invest in the technology and join the “Sky” network as it positively impacts the value and volume of their business and lends legitimacy to their work. 60 percent of franchisees have realized an increase in income after joining the WHP network. The training from formal sessions by qualified doctors and from observation of day-to-day consultations also strengthens their skills and service quality.
To close the loop and ensure that patients have access to affordable drugs locally, WHP also supplies “SkyMeds” (52 WHP branded medicines, contraceptives and self diagnostic kits) to the informal providers, pre-approved shops and pharmacies using existing local distribution networks. By purchasing SkyMeds generically and in large volumes, distinct price advantages are passed on to the franchisees and community. Medicines are also coded in numbers to make them more accessible to illiterate populations. To ensure last mile product delivery and lab transport, WHP has built a network of ‘Last Mile Outriders’ who supplement existing distribution networks. On motorcycles, the Outriders transport samples to franchised diagnostic centers and also supply medicines and communication materials.
WHP has embedded the social mission of the network into the business and financial processes. By leveraging and advertising innovative pricing mechanisms, cross subsidies and public sector support, WHP ensures that ability to pay does not deter people from seeking quality healthcare service. For example, for persons living below the poverty line, informal providers provide consultations for free and WHP reimburses the providers. WHP also relies on government data on poor families to target subsidized services. To supplement insufficient data, WHP encourages informal providers to map the poor in their catchment areas and enter the information into the client data collection system. More importantly, WHP partners with the public sector and its franchisees to strengthen preventive healthcare services in rural areas. WHP has partnered with Auxillary Nurse Midwife in Uttar Pradesh to make referrals to the clinics from their household visits and insert IUDs. Through this, WHP has already achieved 540,124 couple years of protection, averted 308,642 unwanted pregnancies, increased couple protection in the area by 37 percent at 60percent less cost. Similarly in Bihar, WHP is focused on bringing down the infectious diseases such as tuberculosis, visceral leishmaniasis, childhood pneumonia, and diarrhea by conducting training programs for public and private providers, partnering with government schemes and developing creative marketing plans and pricing structures. For instance, WHP provides an incentive of Rs. 150 in rural Bihar to health providers who help them track and address tuberculosis, a widespread health hazard in these areas. By doing so, WHP builds in financial gain with social impact of the health provider, while simultaneously tackling widespread diseases. Franchisees also see addition of such preventive / public healthcare services as a valuable addition to their curative services.
Seeing the value of providing service proximate to the homes of communities, Gopi’s now plans to grow and strengthen the network of his centers across the poorest regions in India and Africa
Growing up in rural Tamil Nadu, Gopi recognized and appreciated the social and cultural dynamics of rural population first hand. When he left home to join India’s premier engineering college BITs Pilani, he had to suddenly cope with culture and language change. Gopi found that participating in extra-circular activities and other programs helped him cope with the change well.
Upon graduation, seeking to broaden his horizons and engage with larger debates, Gopi spent some time as a journalist. On the side, he began helping a few CSO’s on their communications work. This generated his interest in the social space and he joined eventually joined DKT International, one of the largest private providers of reproductive and family planning products.
At DKT, Gopi saw that on one-hand women needed service and follow up at their doorstep and on the other, the informal healthcare providers in the village were untapped as a resource to deliver service. Seeing the opportunity to connect the demand and supply, he conceptualized and designed Janani, a unique family planning program that engaged them for the first time in India. He began working with them to create a social franchising and marketing network that provided pills, condoms and other services to the rural communities. He designed incentives and strategies that helped direct the energy of the private sector to target people or communities (such as the poorest) that they were not naturally interested in. In addition to Janani franchisees, Gopi also set up Janani clinics that performed deliveries and abortions. During this period, Janani performed close to 50,000 female sterilizations apart from abortions and other reproductive health services.
Gopi strongly believes that when one is looking at building small-scale programs, strategies and principles should be designed to set them up for success. However when one is looking at building large-scale initiatives, the key design principle is to put in place mechanisms /checks and balances that avoid failure. Committed to providing large-scale services, Gopi refined and expanded his idea in WHP to not only plug the deficiencies he saw in the Janani program but to also further scale the solution. Seeing that competition within the village and the vertical programming (i.e. focus on only family planning and reproductive health) made the centers economically viable for the providers in the Janani program, he brought in horizontal programing (compregensive care). Similarly seeing that providers were entrepreneurial and sought to expand their services, he introduced technology that allowed them to expand the quantity and quality of services provided. Gopi is now invested in putting in place culturally appropriate negative feedback loops, processes and partnerships that will support the growth of WHP across the poorest parts of Asia and Africa.