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Financial and Social Responsibility Go
Hand-in-Glove at Non-Profit Maternity Center
By Talli Nauman
Photos by Miguel Angel Torres
A green, yellow and red pyramid-shaped canopy marks the entrance. Inside, the pyramid's semaphoric colors and design are repeated on wall charts, booklets, T-shirts, lapel pins, and even the pens in the director's shirt pocket.
CIMI Gen entrance
"In Mexico, we are pyramid builders," says Dr. Carlos Vargas García, in reference to the country's pre-colonial history. Vargas is Director, Centro de Investigación Materno Infantil del Grupo de Estudios al Nacimiento, or CIMI Gen (The Childbirth Studies Group's Mother-Infant Research Center), the first non-profit maternity clinic and hospital for low-income residents in Mexico City.
Vargas' pyramid symbolizes a unique, alternative maternity healthcare system that has not only raised the quality of available maternity care, but has been successful in lowering its cost. Moreover, Vargas' strategy to make this private medical provider financially self-sustaining within a poor community, has been accomplished with finesse.
A Rare Clinic that Caters to Community Needs
Vargas dedicated many years of his distinguished career in perinatology to service within the Mexican public health system. His experience in the Health Secretariat culminated in his assignment as assistant director of the National Perinatal Institute, the government's respected and best equipped maternity center.
There, Vargas observed that while the institution's ample resources were earmarked for high-risk pregnancies, resources were scant for even the most basic needs of medium- and low-risk pregnancies.
Analyzing the situation, he concluded that this organizational structure was not responding adequately to the demands of the population. It was limiting low-income people's access to decent care and, at the same time, sapping public funding that could be applied more effectively.
In Vargas' pyramid, the broad, horizontal band of green at the base represents the approximately 57 percent of Mexican pregnancies that are classified as low risk. The smaller, yellow band above it, represents nearly 30 percent considered at moderate risk. The small, red band at the tip, represents the 13 percent that are at high risk.
Since 87 percent of pregnancies fall into the mid- to low-risk categories, Vargas reasoned that the best way for obstetric care to be extended to the broader community was by providing them with screening and preventative services.
That, in turn, would reduce their likelihood of becoming high-risk cases. It also would provide an alternative to the costly hospital services associated with high-risk cases. He saw no reason for a woman with a normal pregnancy to have no other recourse other than the National Perinatal Institute.
Thus was born the CIMI Gen pyramid.
When philanthropist Antonio L. Silanes asked Vargas to convert a dilapidated polio treatment center into a reproductive health clinic and hospital, Vargas grabbed the opportunity to test whether a system responding to this data would improve care and create a sustainable new service.
Reciepts given to patients for their payments, showing Cimigen pyramid
When Vargas opened his clinic doors in 1988, the first step was an initial risk screening. Anyone found to be in the risky red category was referred to another facility, such as the National Perinatal Institute, leaving CIMI Gen with only the clients in the yellow and green categories, for whom care was less expensive.
But the pyramid is only the first of a series of applications that account for CIMI Gen's self-sustainability.
Accountability Pays
Silanes gave Vargas only 10 percent of the budget that the doctor estimated for the first year of operations. Vargas wanted to make a lasting endeavor; he swore he would create additional mechanisms for CIMI Gen to pay for itself.
"Many non-governmental organizations run out of money or interest and their services are passed on to the government, and the government doesn't want them either because they're costly," says Vargas. The challenge was how to make the project endure.
To make up the remaining 90 percent of the budget, patients would just have to pay. This became CIMI Gen's cardinal rule. To this day, "One of the norms here is that people pay."
He harked back to a lesson from the early days of his personal and professional experience. He had been taught that clients want to have a sense of financial co-responsibility when they receive services precious to them. He remembered that in his rural hometown of Villa Madero, Michoacan, Doña Ricarda, the legendary midwife, had always been remunerated by even the poorest with whatever they could give her in place of cash.
Years ago, as an unpaid intern fresh out of medical school, he too had received compensation, much as Ricarda did, in appreciation for his work.
Later on, he saw for himself how free healthcare led doctors to treat patients like beggars and how, in turn, patients felt like they were receiving handouts. He concluded that clients need to understand that good treatment is a product of their effort, and care providers are simply facilitators.
"The CIMI Gen model comes from Doña Ricarda," he acknowledges. Ricarda would provide help and support to everyone in a family as soon as she learned of a pregnancy. At births, she encouraged mothers to assume a squatting stance, more adequate than the prone position promoted at conventional birthing wards. She provided continuous guidance for 40 days after the birth, teaching family members how to care for infants.
Ricarda's brand of holistic care is the inspiration behind CIMI Gen. Because this approach is responsive to clients' perennial and evolving needs, it convinces them to pay, keeps them coming back, and results in their recommendation of the Center to others.
Carlos Vargas with couple Nancy Arlette Elizarraraz Galeana and Juan José Mena Lira and their newborn (covered by blanket on bed) at Cimigen
From her, Vargas first learned the value of including other family members in pregnancy, birth and infant care. The CIMI Gen system reflects this, by involving the father in all parts of the process.
"It's really different from the government system," says Juan José Mena Lira, whose second child was recently delivered at CIMI Gen.
"From the beginning, it's much more cordial. I didn't have the opportunity to see the birth of my first son. But here we're together, not apart," he says. "The place is efficient, and it's affordable. We're going to continue coming to the pediatrician."
Low Overheads Translates Into Affordable Services
Doctors and nurses too play a different role in the Center, which is not only efficient, but a mainstay of CIMI Gen's financial viability.
This is based on another lesson Vargas learned from Doña Ricarda: that not all mother and infant care needs to be provided by medical doctors.
So the CIMI Gen system is designed to rely on nurse specialists, with physician attendance only in the minority of instances.
In Mexico, most nurses who specialize in Obstetrics and Gynecology cannot find jobs in which they can
exercise their specialty. By giving nurse specialists opportunities to practice in posts that would otherwise
be difficult for them to attain, CIMI Gen attracts talent that in turn saves money for the Center and its clients, as the nurses' services cost less than doctors'.
Nurse Rosa Isela García arrived at CIMI Gen two years ago to do her government-required internship. She stayed on because she was allowed to work in her specialist field, something that would almost certainly be denied to her in other hospitals.
A Unique Model For Sustainability
Besides keeping costs low, CIMI Gen has devised a sliding scale of rates to fit different family income levels. Like the state and federal System for Integral Family Development (DIF) in Mexico, the Center's charges are related directly to the user's capacity to pay. Vargas has fine-tuned this approach.
At CIMI Gen, a first-time visitor receives an economic evaluation from a nurse and is quoted a price based on the financial circumstances of the family. Visitors who insist that the cost is too high receive a house call from an evaluator, and expenses are adjusted accordingly.
Those whose incomes are equivalent to one or two monthly federal minimum wages (U.S.$100 - $200) make up about 15 percent of CIMI Gen clients. Some 80 percent earn from two to five times the minimum wage, or up to U.S.$500 a month. The rest fall into a third, higher-income category.
The evaluator explains to the client the comparative fees for treatment at CIMI-Gen and other facilities. For example, delivering a baby at the most luxurious private Mexico City hospital can cost U.S.$5,000, at a mid-priced facility U.S.$2,000, at an economic public clinic U.S.$300, and at CIMI Gen U.S.$100.
Patient Nancy Arlette Elizarraraz Galeana and her newborn baby
Another way of hooking clients and promoting institutional stability is by offering packages of services.
Although the humanitarian reason for promoting the package is to encourage families to get well-rounded care and reduce risk, its business advantage is tremendous. It costs patients 15 percent less than if they pay on a per-visit basis, plus it allows CIMI Gen to calculate its expected receipts and adjust outlays accordingly.
The package covers five pregnancy consultations, delivery, hospital recovery, 10 laboratory studies, an ultrasound, two post-partem appointments that include birth control counseling for parents, and five baby checkups during one year.
The cost for a family in CIMI Gen's mid-income group is about U.S.$450. The service contract requires a down payment and, depending on client preference, monthly or bi-monthly payments. Fifty percent of CIMI Gen clients opt for the package.
All payments are received as donations, since CIMI Gen is a non-profit organization; therefore, they are tax-deductible for clients and tax-free for the Center.
Strategies To Widen An Organization's Fee Base
To achieve broad community wellness and attract more clients, CIMI Gen conducts outreach programs. At parks and street-corner fairs, nurses and social workers demonstrate nutritious recipes, distribute information and promote courses the clinic provides for health specialists and for the public. At the clinic, personnel facilitate talks between parents who have experienced delivery and those who have not.
Additionally, the Center has established six external modules to treat and refer outpatients in Iztapalapa District of Mexico City (population of 50,000 families), where it is located. Each is attended by a nurse and
a social worker. They are set up in government offices that provide other social services and don't charge them rent. Because of their strategic locations, they contribute to preventive health, and since their cost is only half of CIMI Gen's, they are popular attractions.
"We have a very captive population," grins Vargas. "They know us and our process well."
After 13 years of applying the two-pronged strategy of quality holistic care and fiscal responsibility, CIMI Gen now attracts clients based on its results-oriented record.
CIMI Gen was the first non-governmental hospital in Mexico to be named a Friend of the Child and Mother, in 1996, as part of a rigorous international certification program by UNICEF, the WHO and federal health authorities.
Program Expansion As Fee Base Increases
Starting with one doctor's office and five employees, the center now has 10 rooms for medical consultation and more than 100 attendants. Its coverage has grown from 1,000 outpatient appointments and 15 births in 1988 to 30,000 consultations and 1,000 deliveries last year.
In its first half-year of operations, CIMI Gen's patron funding only allowed for outpatient consultations. But by applying Vargas' formula, the non-profit Center was able to save enough to do its first delivery in June 1988. By the end of the year, its income from fees accounted for 20 percent of the proposed budget.
Noting that those fees and the amount of available philanthropic support evidently were less than necessary to keep the project going, Vargas says that "the watchword was for the hospital to be self-sustaining in five years."
A master of humorous understatements, he adds, "Foundations function very well when you don't ask them for money."
In the Center's second year, it proposed a budget doubling the size of the first year's budget and accounted for 40 percent of it with money from users' fees. By the third year, the fees accounted for 60 percent of the budget proposal.
Year by year, the Center has added services and facilities, expanding on the basis of clients' fees and demands. From its initial capacity of nothing more than outpatient pregnancy consultations, the Center began to offer birthing and ultrasounds. Next came psychological counseling, followed by nutritional care, and later, general medical surgery and even odontology, plus, the laboratory research needed to accompany all the programs.
According to Vargas, within five years, CIMI-Gen operations had moved toward self-sufficiency.
Ever since, CIMI-Gen has use for outside contributions only for remodeling and occasional major equipment purchases. Salaries, training, research and supplies all come out of the Center's clients' pockets.
Spreading The Model Means Program Growth
Seeing that the formula was working, the Center decided it would try and spread the model.
Vargas recalls a nurse's request: " 'Professor, fill Mexico with CIMI Gens'." Then, chuckling at his own ambitious proposal, he adds, "It should be worldwide. It facilitates things enormously, and it's less expensive."
So CIMI Gen personnel began offering classes and symposia to medical students and practitioners on a fee basis. They also encouraged other institutions to establish similar maternity centers, which created a demand for CIMI Gen training and resulted in income from fees.
At Vargas' urging, the government of the state of Mexico set up 28 modules which are operated by DIF staff that have been trained at CIMI Gen.
CIMI Gen first expanded on the Yucatan Peninsula in the southeastern tourist boomtown of Cancun. There, low-income residents have multiplied during the last 30 years, pouring in from around the country to serve the needs of the new resort mecca. From a fishing village of 70 families, Cancun has grown to 500,000 inhabitants, and with it, has grown the demand for health care.
CIMI Gen's instigator Silanes, who had business property in Cancun, knew of an altruistic organization there that raised money to donate wheel chairs, X-ray machines and other medical equipment to needy institutions and individuals. He proposed that its members convert their project into something like CIMI Gen, and they invited Vargas to visit them on a number of occasions.
Convinced by his model, the group decided to form FUNDA Gen in 1994. At present, this center is building an operating room. Thanks in part to courses from CIMI Gen, it has experienced "fabulous growth, practically following our path," Vargas says.
In the central Mexican state of San Luís Potosí, doctors at a Health Secretariat clinic in the city of Soledad Gutíerrez got wind of CIMI Gen and decided to apply its approach in the public sector. Their general health clinic at one time had up to 600 births a year, but in 1995, when they sought CIMI Gen's training, the number was down to 30. The hospital was in disrepair and morale was low.
Mimicking CIMI Gen, they even went so far as to paint their exterior walls the peach color the Center sports. Within one year they tripled productivity and attended 300 births. "But the most important thing was a change in attitude and interest in the community," Vargas notes. He says he is very pleased that his example could have a positive impact for change within the government.
Interior patio of Cimigen with playground
Near the country's east coast, in Veracruz state's city of San Andrés Tuxtla, yet another CIMI Gen sibling is developing. With the training and supervision of CIMI Gen, its personnel are providing outpatient consultations. Their goal is to create a hospital.
One Major Problem
While Vargas has been able to show that his system is effective and inexpensive, its need to keep fees low and the insistence on relying on them has a drawback: CIMI Gen personnel earn a pittance, which has lead to a rapid turnover. Only people with exceptional dedication remain.
Like Vargas, they must be willing to accept no more than U.S.$500 a month for a six-day week.
Vargas has instituted numerous incentives that allow personnel to surpass his own pay rate. Trips abroad to present the CIMI Gen agenda at health conferences are one. Five-hour shifts that allow people to hold second jobs are another. If an employee conducts more than nine consultations on a shift, bonus pay is provided for up to four more allowable sessions. This results in the possibility of a 50 percent increase in earnings. Nurses who are program directors are paid extra for their administrative duties, as are area coordinators and shift bosses. Holiday premiums and a yearly school-supplies bonus are also part of the benefits.
Sixty percent of CIMI Gen's U.S.$700,000 budget last year went to employee compensation. Yet, not many are
satisfied with income levels. But there are people like nurse specialist Socorro Alanís who discovered the Center in 1991 while doing her social service internship, and she's still there today.
"The recompense is in the training, grants, bonuses, trips and the satisfaction of working here," Alanís says. "Seeing families who are happy with the services we offer, makes it all worthwhile."
Shortly, however, Vargas expects to improve salaries by requiring that all the training and classes CIMI Gen offers draw enough money to finance themselves. This year they will receive a 25 percent subsidy from client fees, but next year, they will receive nothing.
Secondly, in a move to diversify funding sources, he requires that all laboratory research money be gleaned through good proposals to other institutions. This year, client fees will pay for 100 percent of the research. But the following year they will only cover 50 percent, and after that they will not contribute to the research budget.
Keenly practical, Vargas keeps coming up with creative solutions for CIMI Gen's income problems. While other personnel are proposing the purchase of more robes and bedsheets or an ambulance, he is thinking in terms of getting a sewing machine to make the hospital clothing in-house and a mini-van that can be used for multiple purposes.
Cimigen laundry room and employee
Further broadening the client base and the influence of the Center on the community will add to the fee base, he reasons. But to do that, it requires, once again, profound commitment from CIMI Gen care providers. In the final analysis, it is conviction that will keep people involved, expand the project, and make it more lucrative.
Capacity-Building For Future Sustainability
Vargas refers to his own motivations. With bushy, white brows and mustache, an immaculate bald head and business suit, he looks like the quintessential 'establishment' person. What made him leave a prestigious and securely funded government institution? What launched him on the uncharted course of turning it into a singular service provider with a novel financial scheme?
It was first-hand experience with one of the kinds of critical situations caused by gaps in the existing system. When he was 15, his mother lay dying from a complication while giving birth to his brother. In the absence of maternity care and his father, Vargas took charge. He borrowed a vehicle and fetched a medic from a neighboring town. The medic saved her life.
"That was a dramatic moment, the kind one can't forget," he says.
He recognizes that many others who have had striking brushes with fate do not end up as social entrepreneurs. Realizing that people are becoming more self-serving, he has decided to institute mechanisms to foment a culture of responsibility for human development.
This year Vargas plans to initiate a course called Youth Social Innovators for Health, for which he is busy contacting respected specialists. Participants will be introduced to Mexico's health status, and that of the world. It will offer an analysis of the role of health care in personal, family, community and national development. Students will finish the course by elaborating and applying health outreach projects to their localities, with the help of CIMI Gen. This will be the basis for building a participatory movement for solutions to community problems.
With the financial support from Ashoka and the Mexican Center for Philanthropy, he is providing grants for up to 20 participants aged 16 to 20.
Luís Alberto Resendíz Gurría, an accounting assistant who is one of the grantees, believes the course will help participants "to excel and become leaders at work."
Luís Alberto Resendíz Gurría in Cimigen office
If it works, it will produce more people with the kind of ethics and capacity for fostering positive social change that Vargas and the CIMI Gen team have demonstrated.
And not incidentally, the course projects will boost CIMI Gen productivity, a key to sustaining the Center's financial health.
Needs:
- Communication and exchange of experiences
- Economic support for research and computer equipment
- Emergency medical equipment
- Health care workers who share the CIMI Gen vision
- Vehicle
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