4

Promising Innovations and Models

Steve Davis from PATH presented several innovative partnerships for health systems strengthening that are engaging multiple sectors and partners to develop unique solutions. Davis introduced these partnerships by first describing PATH’s mission and model for partnership engagement. He emphasized that PATH’s work as the leading organization in global health innovation extends beyond technologies and technological innovation. Innovations require disruptive approaches but not necessarily technology solutions or large budgets, as Davis highlighted with the examples he provided.

The focus of PATH’s mission is to address health inequities in the world, specifically in the lowest-resource settings. With the focus over the past 15 years on the Millennium Development Goals (MDGs) and the new focus on the Sustainable Development Goals (SDGs) for the next 15 years, Davis remarked that it is an exciting time to be working in this space. He shared data on the progress of the global health–focused MDGs to demonstrate the gains that have been made, the current trajectory, and the accelerated targets that have been set for 2035 (see Figure 4-1).

Davis stated that PATH’s goal is to figure out how to bend the curve, that is, to progress from a trajectory that has been driven by substantial growth, economic progress, innovation, and better services and actually bend the curve on maternal and child mortality and morbidity within the next 15 years. Davis sees intentional innovation as a mechanism for bending the curve. If innovation is planned, more can be achieved than only

through accidental discoveries, and PATH is seeking to bring planning and discipline to the field of innovation in global health.

One of PATH’s core platforms is system and service innovation and, through this platform, PATH focuses on health systems strengthening. Davis explained that the organization’s approach to health systems strengthening includes three areas: (1) behavior change communication and demand-generation innovations; (2) health care workforce and capacity-building tools; and (3) data collection, management, and use innovations. In his opinion, the third area is where the most potential exists for health systems strengthening.

In terms of how PATH approaches its work, Davis stressed that in almost all instances, the work is done through partnerships. The partnerships typically include an academic partner, a government partner, and in most cases, an industry partner. On a related point, Davis noted that lately there has been increased discussion on reshaping partnerships and a push toward partnerships based on shared value creation—where there

are recognized business benefits from addressing social needs. In his own view, portfolios of partnerships are complex and include those based on a spectrum from philanthropy to shared value.

EXAMPLES OF INNOVATIVE PARTNERSHIPS FOR HEALTH SYSTEMS STRENGTHENING

Davis shared several examples to explain how PATH is carrying out its work in health systems strengthening through partnerships. Some of the examples focus on creating new tools or new systems while others focus on innovation in the operating model or business pipeline.

Healthy Households Initiative in Cambodia

In this example from Cambodia, Davis noted that the focus has not been on creating new tools or products. Rather, the problem was that existing tools and products were too fragmented, not at scale, and the connective channel was too weak. There were a number of different partnership opportunities with existing basic household commodities, and PATH’s model was to reshape the market (see Figure 4-2). The focus of the partnership was to take an ecosystem approach to reshape the market to connect the products with a more sustainable channel for development

and then provide product design, aggregation, technical assistance, and more knowledge management.

Tuberculosis Care in Mumbai

Davis shared a partnership for tuberculosis (TB) care in Mumbai, India, that exemplifies the confluence of urbanization, health, and economic empowerment. In the slums of Mumbai, there is enormous TB prevalence. About 40 percent of the residents were receiving their TB treatments through private-sector providers. In these areas, there are about 1,100 different types of pharmacies, which are all small, private-sector models. If these small, private providers reported incidences of TB to the Ministry of Health and Family Welfare or the subnational ministry, the patients would often be moved into the public system, thus dis-incentivizing the providers to report. PATH worked with the government leadership to reshape the incentive system to create more incentive to register and get patients into ongoing treatment. It required a reshaping of who was paid for what. Rather than taking consumers away, the idea was to actually take what part of that public dollar would have been used to pay for that patient and give it as a payment voucher to the private-sector provider. PATH is working with several organizations to create a digital platform for these voucher payments. The program is still a work in progress, Davis acknowledged, but the early data after approximately 9 months show that about 6,000 new patients were registered. In his opinion, these data are an early indicator of opportunity for urban health system transformation.

Safe Births and Newborn Care in Southern Africa

Davis shared an example of a partnership in six districts in South Africa and Mozambique, where PATH is partnering with BHP Billiton to design a multiyear set of activities to redesign the clinic-level health model, targeted toward integrated care for mothers and children in the first 1,000 days. The partnership is providing more services and incentives for digital tools to get women into the clinic earlier for prenatal care. Davis noted that PATH is seeing some early data emerging after a couple of years of the project that are showing significant reductions in certain target categories.

The models Davis shared are focused on strengthening components of the health system and addressing broader determinants of health. In response to a question about how to move from partnerships and innovations focused on components of health systems to models that address the whole system more broadly, Davis acknowledged that a broad, whole-

systems approach is challenging and he believes it is important not to dismiss the ability to incrementalize in the health systems space. From Davis’s view, the role of an organization like PATH is to provide assistance at the request of countries; thus, it is up to the country to develop a more comprehensive approach, themselves, with better data and better ideas and tools, and to engage partners to drive the solutions they want.

INNOVATIVE MODELS FOR HEALTH SYSTEMS STRENGTHENING FROM NARAYANA HEALTH

Devi Shetty from Narayana Health in Bangalore, India, discussed how Narayana Health is developing and implementing models to provide high-quality care at lower costs. Building on Davis’s closing comment that it is up to the countries to drive the solutions they want, the examples Shetty shared address specific needs and gaps in providing care that were identified by Narayana Health. The partnerships developed to address these needs and gaps were driven by Narayana Health as a local provider, and partners were sought based on the specifics needed.

Narayana Hrudayalaya in Bangalore is a 3,000-bed health city with four hospitals in one complex, including a cardiac hospital, multispecialty and cancer hospital, orthopedic hospital, and eye hospital. Narayana Health additionally has 30 hospitals across India, and 12 percent of all heart surgeries in India are performed by Narayana.

Before discussing the specifics of Narayana’s model, Shetty remarked that the economy of the 21st century will be driven by the health sector, as it is the one industry that can create the maximum number of jobs that are desperately required. Global health care is a $7 trillion industry—the second largest industry in the world. However, Shetty suggested policy makers have not understood the employment-creating ability of the health industry nor the ability of the health sector to drive the global economy. Poor people in isolation are weak individually, but together they are very strong, Shetty explained. He believes that India will become the first country in the world to dissociate health care from affluence and prove that the wealth of the nation has nothing to do with the quality of health care its citizens can enjoy. Within this context, Shetty shared several of the innovative models Narayana Health has developed to fill the gaps in its journey to providing this level of care and access.

Yeshaswini Micro-Health Insurance

Narayana has worked closely with the state government of Karnataka, where it has operated for the past 15 years. Eleven years ago there was drought in the state, creating even greater vulnerability and instability for

the local farmers. Narayana engaged the government to launch a health insurance program for the poor farmers, in which every farmer paid USD 0.11 per month and the government agreed to become the reinsurer. At the end of 10 years, through this system, 710,000 farmers had a variety of sub-surgeries and more than 95,000 farmers underwent a heart operation. In the first year, 1.7 million farmers paid USD 0.11 per month. The program has grown to include 4 million farmers paying USD 0.22 each per month. Taking the success of this model, Narayana is seeking to tap into the 900 million mobile phone subscribers across India to collect every month about USD 0.50; if Narayana can do this, Shetty believes that 900 million people can be covered for surgical treatment.

Building New Hospitals

For a major transformation in health to happen, Shetty suggested there is a need to build different types of hospitals. There are 100 towns in India, with populations ranging from 500,000 to 1 million, that do not have a subspecialty hospital that can perform heart or brain surgeries. These towns cannot afford to build a hospital in the traditional manner. Normally, it takes approximately USD 25 million and 2 to 3 years to construct a hospital of this size in India. Narayana worked with the largest construction company in India to build and equip a 300-bed subspecialty hospital with the goal of doing it for USD 6 million in 6 months’ time. Shetty noted that the hospital was built, but it took USD 7 million and 8 months’ time. The next one, Shetty believes, can be built for USD 6 million in 6 months.

Care Companion

Recognizing that family members of patients were not being empowered to be caregivers when patients were discharged, 4 years ago Narayana Health launched a program called Care Companion with students from the Stanford Business School. Narayana challenged the students to create a curriculum of short films that teach family members how to care for a patient at home, including recording blood pressure and pulse rate, dressing wounds, administering medications on time, and using physical therapy. As a result of this program, readmission rates were reduced significantly. Shetty stressed that this model was created in partnership with the students at no cost.

Elimination of Bed Sores

The incidence of bed sores following heart operations across the world ranges from 7 percent to 40 percent. About 4 years ago, Shetty and his team worked with hospital nurses to develop a model to eliminate bed sores. Bed sores could start at various points during a patient’s hospital stay and frequently went unnoticed until a full-fledged bed sore developed, and determining when it started is hard. The model Narayana created assigns responsibility for the bed sores, and thus nurses are now inspecting all pressure points to make sure a bed sore did not start while the patient was in the previous nurse’s care. By doing this over the past 3 years, they have eliminated bed sores completely. Now, quite a few hospitals in Europe and the United States are following this protocol. Again, this intervention was developed without any financial investment.

Amaryllis Surgical Gowns and Drapes

Ninety-nine percent of the hospitals in India still use linen for surgical gowns and for draping the patient. Shetty explained that linen is not the safest choice because it is difficult to clean, but disposable gowns and drapes are significantly more expensive. Narayana negotiated with two multinational companies for disposable gowns and drapes for heart operations, and the companies asked for approximately USD 20 to 30 for each. Narayana wanted to pay half that amount, but the companies refused. Narayana then contacted and worked with local business graduates to have disposable gowns and drapes made by local garment workers. In doing so, they reduced the cost of the disposable gowns and drapes to less than the cost of linen ones. Now, Narayana is in the process of getting U.S. Food and Drug Administration approval for the disposable gowns and drapes, and they believe they can reduce the cost of these gowns and drapes for an entire heart operation to about USD 10 or less per operation. Essentially, Shetty emphasized, these changes were made without compromising quality.

Daily Profit and Loss Statement

Shetty shared that every day by noon the senior doctors and senior administrators at Narayana get an SMS (short message service) on their mobile number with the previous day’s expenses and profit and loss statement. He explained that looking at the profit and loss statement at the end of the month is like reading a post-mortem report. But getting the profit and loss statement on a daily basis is a diagnostic tool that helps the senior leadership make the right decisions.

Information and Communications Technology

Shetty stated that the next big thing in health care will be information technology. He believes it will reduce mortality inside hospitals by 50 percent, reduce the cost by 25 percent, and help to provide health care to 100 percent of the population. Narayana is using technology heavily, for example, to connect patients with doctors and pharmacists remotely, to replace intensive care unit (ICU) charts in the ICU, and for online clinics.

Essentially, Shetty concluded, at Narayana Health they are “bullish” about the health care opportunities across the world and are proving that innovative solutions to providing better access and care do not need to be costly to be effective. Their decisions to engage partners in the innovations they create are based on recognized gaps and a need to tap the potential for external partners to find solutions that are safe, high-quality, effective, accessible, and low cost.