Marcos Lacayo Bosche

Ashoka Fellow
This description of Marcos Lacayo Bosche's work was prepared when Marcos Lacayo Bosche was elected to the Ashoka Fellowship in 2018 .

Introduction

Marcos Lacayo is improving health outcomes and shifting mindsets on preventive services in Nicaragua by enabling widespread access to tech-enabled screenings, remote physician consultations, and educational campaigns in high traffic areas and online.

L'idée nouvelle

In Nicaragua, a country with an inaccessible and largely curative health care system, Marcos is creating a culture of preventive healthcare by providing screenings and doctor consultations for free or at greatly reduced rates. Marcos’ Estacion Vital empowers Nicaraguans, many for the first time in their lives, with knowledge on the status of their own health, while providing recurring educational tips to promote the identification of problems earlier, helping citizens to prevent diseases and take action before they become chronic. Estacion Vital’s user-friendly health kiosks are located in high traffic areas, where users are assisted to do basic health screenings and connected to physicians via telemedicine.

An innovative partnership with Movistar, the second-largest telecommunications provider in the country, helps Estacion Vital provide preventive health care through the creation of a Health Club available to the company’s 3.5 million cellphone users. The members of this Health Club receive educational health tips via their mobile phones and have access to consultations via telemedicine at even better prices than in Estación Vitals kiosks. All Estación Vital users have access to their preventive health exams and can connect directly with doctors through their smartphones and Estación Vital’s homepage. The combination of in-person kiosk medical exams, health education and access to physicians through different technological platforms has ensured that personalized preventive care get to the root of the country’s healthcare problem. Estacion Vital’s holistic strategy has performed around 247,000 preventive health exams and impacted the lives of more than 60,000 individual users since the launch of the first kiosk in February 2016.

Le problème

In Nicaragua, over 60% of the population is obese or overweight, and more than 600,000 people have diabetes. At least 17% of the population is diabetic or prediabetic. Diabetes is the third largest cause of death in the country, second to only heart disease and strokes, as 1 in 3 people are either pre-hypertensive or hypertensive. Part of the reason for Nicaragua’s worrisome health trends, the worst in the Central American region, is the lack of education on the subject, which itself is caused by barriers to accessing medical care. There are only 0.37 doctors per 1,000 inhabitants in Nicaragua, compared to the average 3.2 doctors per 1,000 inhabitants in Organisation for Economic Co-operation and Development (OECD) countries. Moreover, the cost of being attended to by doctors is disproportionate to the economic level of the majority of the population. Basic preventive or primary consultations cost between $10.00 to $30.00 US Dollars (USD), in what continues to be one of the poorest countries in the hemisphere, with most citizens living on between $120 to $220 USD a month.

Throughout Latin America, lack of access to health education, preventive medicine, and primary care has been one of the biggest contributors to the alarming increase of chronic disease in recent years. In Nicaragua, the particularly high level of poverty, and prohibitively long wait times in public health centers, prevent citizens from actively meeting health needs. What results is a cycle of foregoing preventive care, leading to deteriorating health for most citizens. Subsidized government insurance programs for employed Nicaraguans have also fallen short, as only 700,000 of the country’s 6 million inhabitants receive these benefits due to a lack of a requirement for employers to provide these subsidies. Private insurance on the other hand, at $150 USD per month on average, is only within reach to 15% of Nicaragua’s population, being prohibitively expensive. Compounding the difficulty in solving this problem is the fact that Nicaragua’s health systems are designed to be curative rather than preventive. Most resources, government or otherwise, are directed to curative care. This limitation has further prevented the population from empowering itself with a mentality of prioritizing prevention of disease.

La stratégie

In order to make preventive health mainstream, Marcos has developed a robust, widespread strategy that provides easy access to health consultations and educational services on preventive care for all Nicaraguans.

Marcos’ platform, Estacion Vital, provides free health screenings approved by the Ministry of Health in high traffic areas of Nicaragua. The placement of the kiosks in shopping centers is strategic, given that they are the epicenter of leisure activity for citizens of all socioeconomic groups, even if they are not shopping. In this way, Estacion Vital demonstrates that caring for one’s health can be easy, fun and part of a regular mall outing. With iPads guiding users step by step, and tools measuring blood pressure, temperature, vision, weight or Body Mass Index, each kiosk has an assistant to further assist the user, usually a student working part-time while finishing medical studies. All services are free, except for an additional, optional glucose test costing $2.00 USD, and triglyceride and cholesterol testing for $5.00 USD. Upon finishing the evaluation, users obtain results with customized health recommendations and benchmarks according to the World Health Organization. Users share demographic information, medical history and health habits, in order to periodically receive educational health information and tips explicitly designed for preventive purposes through text message and email for free.

Understanding that screening alone is not enough, the second component of Marcos’ preventive healthcare strategy is giving access to doctors to more citizens via affordable telemedicine services requiring no wait time, either directly through the kiosk or from any place over video, chat, computer, or phone, for the greatly reduced rate of $6.99 USD compared to market rates in private hospitals hovering around $30 USD. When a user elects to use the service, the platform informs all physicians who are on call, and the first one to volunteer helps the patient. For emergencies or serious cases, the physician refers the user to a hospital, since the physician cannot give a complete diagnosis remotely. Physicians are paid per consultation, unless they are full-time, in which case they receive $400 USD per month, a competitive wage for general practitioners, with the added flexibility of being able to work remotely. Though focusing initially on general practice medicine, Estacion Vital will soon add psychology and nutritionist services.

The final component expanding Estacion Vital’s reach nationally is the Movistar Health Club, an opt-in service targeted to customers on the provider’s cheaper, pay-per-use plans to receive daily information tips tailored to their particular risks. Marcos has leveraged Nicaragua’s high cell phone penetration rates, where 66% of the population has cell phone lines, more than half of the 6 million Nicaraguans owning smartphones, and Movistar’s 60% market share in the sector, to reach new users. Club membership is currently 47,000 users, receiving preventive health recommendation text messages from the same health professionals who provide the platform’s telemedicine in categories of blood pressure, obesity, diabetes, exercise, pediatrics, pregnancy, and soon a mental health category. The informative texts can be sent to customers daily, and Movistar debits $0.17 USD per text for the service. Another benefit of club membership is the Estacion Vital telemedicine service’s reduced cost, $2.99 USD instead of the regular $6.99 USD. Marcos is building interest for the club and preventive healthcare in general through highly popular fairs co-sponsored by Movistar, where users can directly speak to physicians, enjoy exercise classes, listen to speakers on topic of mental health, and undergo basic health exams, all for free.

Although still in an early stage, Estacion Vital has measured 30% recurring users, 40% of those, or 7,500 people, have reported concrete improvements in health: for users that had problems related to blood pressure, 78% lowered their results to normal levels. For those visiting due to weight problems, 42% lost 8 pounds or more. In the next 1-2 years, Estacion Vital will expand by installing 4-6 fixed kiosks in areas of high traffic throughout Nicaragua, increasing the number of users to more than 16,000 per month. Furthermore, Estacion Vital will launch mobile kiosks that will give free health exams in remote areas. Marcos is in talks with a shopping center chain he works with that has branches in Honduras in order to be able to scale there within the same time frame. As for increasing impact on Estacion Vital’s current users, he is currently negotiating with pharmacies and hospitals in order to negotiate cheaper products and services for those who are referred to third parties.

La personne

The son of a doctor and a PhD in Public Health, Marcos always knew he wanted a career in health. His parents, avid champions of the Nicaraguan revolution, instilled in him a strong connection to his country and people from a young age. After completing a Master's Degree in Health Administration in the United States, he began working in a hospital there, on a system monitoring safety of newborn babies. The moment he saw his work actually prevent someone from abducting a newborn, he realized the power of technology and this experience sparked in him a calling to develop technology-based solutions for health applications. In 2012, Marcos founded a health software startup in San Francisco to track doctors and equipment in hospitals through GPS sensors, to address the problem of hospital equipment loss. Although the startup ultimately ran out of funds, the idea for Estacion Vital was born in California, where Marcos noticed CVS kiosks providing blood pressure tests, such obvious solutions to improving individual health without needing to go to the doctor. Despite this, he knew that in Nicaragua these systems were woefully absent.

Seeing an opportunity for preventive health systems at home, Marcos sold his house and car to move back to Nicaragua in 2014. With the help of family and savings, as well as the Central American Health Initiative (CAHI) at INCAE Business School and Agora Partnerships—both of which selected him as a fellow to support and mentor his work—he designed and built the first Estacion Vital kiosk. In August 2016, he was awarded Best Entrepreneur in Central America at the Entrepreneurship Innovate Summit. Marcos brings profound technical expertise to the Estacion Vital mission of making healthcare accessible, having completed data science and programming courses in the Silicon Valley. He is also a natural leader: in his undergraduate studies, he was president of the Society of Hispanic Professional Engineers, St. Mary’s University Chapter.