Scaling Health Coverage, Quality, and Innovation Through the Public Sector

By Kevin T. Pepper, Janine Schooley, Sara Chamberlain, Indrajit Chaudhuri, Sridhar Srikantiah & Gary L. Darmstadt

India bears the largest share of neonatal and child deaths, and the second-largest share of maternal deaths globally. While the country has made considerable progress in reducing mortality rates, it will have to significantly accelerate progress over the next 10 years to reach the targets for the 2030 Sustainable Development Goal (SDG) related to preventing neonatal and maternal deaths. A major impediment to this goal is the disparate performance of the Indian primary health-care system across geographies and providers.

Stepping into this gap, there is an urgent need for health care innovation in India. Social entrepreneurs seeking to contribute to sustained impact at meaningful scale in the health sector should consider the advantages of partnering with the Indian government at the district, state, and national levels.

Some may wonder why the social innovation community—which has historically gravitated toward market-led solutions—should seek to partner with the public sector. In fact, there are many compelling reasons. As a vehicle for scaling up and sustaining health innovation, partnering with the public sector can tap into significant resources for overcoming barriers, and for improving the quality and coverage of health services.

Importantly, Indian states are “mixed” health systems, with government-funded tertiary hospitals, primary and community health centers, and “sub centers” (all of which are free or charge a nominal fee for the poor); millions of government-supervised frontline health workers (FLWs); and large-scale public health programs operating alongside a widespread but largely unregulated private health sector. While most poor families in India still largely depend on private providers for health care services, the Indian for-profit sector is generally not organized or incentivized to provide affordable and universal health care coverage. In many states, the bulk of private sector providers are unlicensed and unqualified for practicing health care.

In contrast, the Indian public health system—despite its significant limitations in service delivery and quality of care—is mandated to provide affordable health services to all segments of the population, including marginalized, extremely poor, and lower-caste groups. The government can implement policies that minimize catastrophic out-of-pocket payments, and create incentives for affordable and equitable health care.

What’s more, over the last decade India has experienced a massive surge of government investment in public health care. Large-scale national health insurance schemes have increased hospitalization rates, including for marginalized groups. The Janani Suraksha Yojana program under the National Rural Health Mission, for example, has led to significant increases in public and private institutional births by providing cash incentives to pregnant women and health workers to deliver or facilitate delivery, respectively, in hospitals.

Given the increase of government investments in the public health system and the increasing dependence of Indian people on government-managed facilities and services for essential health care, there is a significant opportunity for smart and leveraged, public sector investment.

The Ananya Program in Bihar: Enabling the Scaling of Innovations

In 2010, the Bill and Melinda Gates Foundation (BMGF) launched the Ananya partnership with the Government of Bihar (GoB) and several international NGOs, including BBC Media Action, Project Concern International (PCI), and CARE India. The primary aim of the partnership was to improve reproductive, maternal, newborn, and child health-and-nutrition outcomes across the state. The idea was to develop the government’s capacity to implement evidence-based health interventions that targeted the 1,000-day window between the start of a mother’s pregnancy and a child’s second birthday. Over the last eight years—despite political upheaval, frequent turnover of GoB staff, and challenging operating conditions—several BMGF grantees have scaled innovative tools, platforms, and government system-level capabilities within Bihar and other states.

The following three case studies provide a window into different government-partnership models that emerged from this experience. The lessons that emerged from these efforts can be instructive for funding agencies, NGOs, researchers, the private sector, and social innovators interested in scaling health innovation through the public sector, in India, and in other low- and middle-income countries.

Lesson One: Align User-Driven Design with Government Interests

India’s 2011 census data shows that more than 70 percent of India’s poor live in rural areas, where more than half of women are illiterate and access to reliable health information is limited. Most poor families live in “media-dark” households with little or no access to TV or radio. In these contexts, there is significant opportunity to deliver health information to mothers and caregivers through mobile health solutions. While technical literacy is low and the majority of women don’t know how to use SMS or the Internet, as of 2018, 94 percent of the households in Bihar owned a cell phone, and almost all of the approximately 200,000 FLWs in the state had access to one.

The BMGF grantee BBC Media Action, the British Broadcasting Corporation’s international development charity, recognized this opportunity. In partnership with India’s Ministry of Health and Family Welfare (MoHFW), it successfully scaled a package of two complementary mHealth services, called Mobile Academy and Kilkari, designed to operate in concert. Mobile Academy provides FLWs with a course on preventative health behaviors, including how to communicate more effectively with families. Kilkari reinforces these messages by delivering stage-specific (such as pregnancy or childbirth) audio content directly to women’s mobile phones from the fourth month of pregnancy until their child is a year old.

To make these products effective and scalable, BBC Media Action needed to design and incrementally adapt them through the lens of the end users: beneficiaries and frontline providers of health services in communities, as well as the GoB entities that would eventually fund and manage the services. Design involved extensive, formative research, in collaboration with the GoB and a panel of domestic and international health experts; creating content (including audio content) and interfaces customized for the needs and limitations of mostly illiterate users; and testing protypes with poor, rural women and with FLWs.

When the final products rolled out across Bihar—Mobile Academy in 2012 and Kilkari in 2013—users had to pay a small fee for the services, as BBC Media Action could not cover call costs. But while both services were in demand, up to half of prospective subscribers didn’t have sufficient credit on their mobile phones to activate their subscription to Kilkari. Faced with this constraint, BBC Media Action decided to pursue a public-sector business model, with the goal of making the services free to all users. As a first step, it sought to align with the strategic interests of the Indian government. The MoHFW tracks and registers most pregnancies and births, maintains contact details of all FLWs for every state in India, and at the time, used text messages to send information to the new and expecting mothers in its massive registry. However, few women were reading these messages due to low literacy levels.

Recognizing the audio advantage of BBC Media Action’s services, the government began to scale Kilkari and Mobile Academy nationally in 2016, integrating both services with its databases and making them both free to users. Today, the services are available in five languages in 13 states; women who register their pregnancy or birth at a public health center are automatically subscribed to Kilkari, and FLWs are automatically registered for Mobile Academy. Kilkari has become one of the largest maternal messaging services in the world, reaching 9.6 million subscribers in three years. Likewise, Mobile Academy is now the largest mobile-based training program for FLWs in the world; more than 260,000 have graduated from the course. In March 2019, BBC Media Action transitioned responsibility for the two services to the government and successfully exited the program, and the MoHFW is now scaling the services to eight more states in India.

Lesson Two: Adapt Without Losing Effectiveness

While BBC Media Action effectively used government partnership to scale mHealth technology, PCI—a global development organization working to enhance health, end hunger, and advance women and girls—sought to piggyback on a government-funded, community-based platform. Community-based institutions play vital roles in scaling health-care services and information, including promoting health-seeking behaviors among family members, and holding public and private health providers accountable for delivering high-quality care.

The BMGF identified women’s self-help groups (SHGs) as one of the most promising community-based platforms to improve health and nutrition behaviors in Bihar. SHGs traditionally consist of groups of 10-15 women who meet regularly and are guided by a common purpose (Photo 2). At a minimum, SHGs provide access to savings and credit to group members, and some groups provide additional support for agriculture and other micro-businesses. It is estimated that around 45 percent of all pregnant women and mothers in rural Bihar are either members of an SHG or have family members who are in one.

In 2012, the BMGF provided a grant to PCI in Bihar to expand on the traditional microfinance- and livelihood-focused SHG model, and to encourage SHG members in 26,000 groups to adopt specific health behaviors, including evidence-based nutrition, santiation, and hygiene practices. An evaluation of this “health-layered” program model by the NGO Population Council captured significant improvements in women’s self agency, as well as in critical health and nutrition behaviors for SHG members, including increased adoption of life-saving antenatal care and newborn care behaviors, and women’s use of modern contraceptives.

After establishing the model’s effectiveness, the BMGF and PCI saw an opportunity in 2014 to scale it across Bihar by integrating the approach into a government-managed program called JEEViKA. Under the Department of Rural Development and with support from the World Bank, JEEViKA focuses on improving rural livelihoods through the formation of different community platforms, including SHGs. Initially, JEEViKA SHGs didn’t have a health focus, so PCI led an effort to retrofit existing groups or form new JEEVIKA SHGs with a health, nutrition, and sanitation focus. It also provided technical support to the GoB to manage the scaling of the model.

While PCI was determined to leverage JEEViKA resources, infrastructure, and national reach to scale its model, it had to make difficult design and implementation decisions to ensure that the government program adopted and scaled the core elements of its program model without compromising the program’s effectiveness. Indrajit Chaudhuri, PCI India’s chief of party and assistant country director, recalls: “Being an effective partner to government meant that, at times, we didn’t select our preferred technical design, but rather the option that ensured government buy-in. Showing a lack of flexibility would undermine our goal for government adoption. There is always an option to preserve the effectiveness of the intervention while ensuring that our partners are engaged and feel like they are part of the process.”

Since its inception, JEEViKA has formed more than 825,000 SHGs, reaching more than 10 million women in rural Bihar, and the GoB plans on forming more than one million SHGs by 2020. More than 225,000 JEEViKA SHGs are health layered so far, and the model is gaining traction in other states of India, as well as in Africa and South America.

Lesson Three: Cultivate Credibility

Unlike BBC Media Action and PCI, the NGO CARE India, which works to empower women and girls from poor and marginalized communities, started at scale. When Ananya launched in 2011, CARE India’s first set of investments were focused on designing and testing the effectiveness of a package of health interventions in eight districts in Bihar, covering a population of more than 25 million people. The organization implemented and measured interventions in close coordination with the GoB, which was committed to ultimately absorbing and scaling the most promising approaches across the state.

After just two years, however, CARE India decided to shift its focus after realizing that challenges within the state’s health system—bottlenecks and deficiencies in leadership, funding, infrastructure, and management—were limiting the impact of its interventions. Instead of directly piloting and scaling interventions, it began providing technical support to the GoB to help it achieve its maternal and child health goals. This support was comprehensive, at all levels of the government system, and included assistance related to health system management, human resources, data systems, and policy.

Given the ambitious and complex scope of this collaboration, it was important that CARE India and the GoB build a functional and effective partnership. An important first step was for CARE India to establish credibility with the GoB. It did this in three main ways. First, it was proactively transparent about its goals and motivation for working in Bihar. The organization’s long-term goal and exit plan was to strengthen the capabilities of the GoB health-system leadership so that it could become self-directed and sustainable—not to replace or undermine the GoB’s health programs with a parallel system.

Second, CARE India, which had experience working with other large-scale government health programs in India, sought to demonstrate the value of its technical support. Alongside the GoB, it designed, piloted, and adapted tools and processes at scale through existing GoB systems. It also established a think tank-like unit at the state level to address health system barriers and provide evidence-based policy guidance, and created support systems at the district and state levels to enable health services to function more effectively and efficiently. For example, it helped the GoB improve the supply chain of drugs and consumables by breaking down major issues into smaller, more-maneagable problems; solutions included training stockists and pharmacists in facilities across Bihar, supporting the GoB in rolling out its ICT platform, and developing a procurement manual.

Finally, CARE India sought to provide honest, direct, and data-driven feedback to the GoB by enhancing government data systems and, importantly, inculcating an appetite among staff at all levels for accurate and reliable data to guide decisionmaking. In public health facilities, it initiated clinical case studies and monthly clinical case reviews to more systematically improve clinical care. It also facilitated the integration of data across multiple platforms (including HR, logistics, and financing), made data more accessible through the development of dashboards, and provided coaching on how to put the data into action. All these efforts helped establish CARE India as a credible, useful, and relevant partner.

Conclusion

Given the Indian government’s significant and expanding role in strengthening the primary health care system, effective partnerships that enhance the government’s ability to deliver high-quality health services at scale will be essential to attaining the SDGs.  Effectively scaling innovation through the public health system will require: 1) the design of user-driven products and platforms, 2) alignment with government strategic interests, 3) the ability to adapt interventions, program models, and products without losing their effectiveness, and 4) cultivating credibility, transparency, and trust with government partners. Under the right conditions, government support and resources can do a great deal to accelerate sustainable impact.

Source: SSIR Blog

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