march '06 > framework
print this page

• search • about us • español

Ashoka Fellow Vera Cordeiro appears in the Solutions Mosaic under Principle: "Design inclusive systems" and Barrier: "Cultural taboos and health illiteracy"

Competition Framework: How to Improve Health for All

By Stephanie Schmidt

The goal of the Competition Framework and the Mosaic of Solutions is to help define the competition topic, describe the core issue, and highlight successful solutions that have overcome traditional barriers. It is a starting point for reflecting on the key challenges around achieving "Health for All" and developing effective responses. The Mosaic of Solutions features innovative strategies of social entrepreneurs, businesses, and public entities around the world as well as principles emerging from these strategies. A refined version of the mosaic will be produced at the end of the competition based on inputs from community members.

So often we are reminded of the global health paradox. Every year, millions of individuals die of causes that could have been prevented by basic, low-cost measures. One child dies every 30 seconds of diarrheal diseases, making it the second-largest global "infectious killer" of children under the age of five, and malaria kills one million people every year, mostly in Africa. But the issue is not limited to developing countries: an estimated 40 million Americans in the United States have no health coverage and are at risk of not getting appropriate and timely treatment as the cost of healthcare is soaring. All this raises important issues: How to break cultural taboos and change behaviors, enabling people to make informed choices about their health and to plan ahead for potential health problems; How to design and implement cost-effective and affordable healthcare systems; How to guarantee a fair system where quality healthcare is accessible to all and ensure that these programs reach their intended recipients; How to enable a coordinated response among types of interventions—education, prevention, pharmaceuticals, healthcare delivery—and actors. Underlying those core questions are two critical elements to aim for to address the global health challenge: scale and cost-effectiveness.

Examples of innovative strategies from social entrepreneurs, businesses and public entities around the world often challenge conventional thinking and provide us with insights about what works and what does not. At Ashoka, our focus is on practical and systemic solutions to make health for all a reality. Many of them started at a grassroots level, coming from entrepreneurs with a large vision. Quite a few were launched by nonmedical practitioners who identified a different angle for addressing a health issue. For this reason, we made the choice to focus this competition on solutions that directly benefit low-income and marginalized populations as opposed to initiatives that consist only in public policies, health rights, or advocacy—though these are definitely needed. Implicit in the title is also the intent to broaden the scope of the competition beyond healthcare per se to acknowledge and include critical components like health education, health financing, and alternatives to conventional healthcare solutions. With that in mind, we would like to challenge the Changemakers community to devise new ideas and strategies, and help spread successful solutions.

Barriers:

Barriers refer to the main challenges—perceived or real—to overcome to make health for all a reality and so guarantee effective, high-quality, and equitable health solutions:

Cultural taboos and health illiteracy: Awareness about basic causes of common diseases and the importance of preventive care is often limited among low-income populations. Moreover, in some cases local customs may lead to increased health risks, for example by discrimination against women and children who are at times constrained from receiving healthcare except in the case of emergency. Some local customs may also misinform people about health issues and prevent them from planning for their family's health, especially when planning is culturally considered as an offense to fate. While several innovative health solutions borrow from traditional medicines, lack of information and awareness is a major risk and cost factor.

High cost of providing quality health products and services: The healthcare industry is characterized by significant investments for pharmaceutical research, medical devices, and secondary/tertiary care. Absorbing these costs is a challenge, particularly in low-resource environments where governments may not be in a position to significantly contribute to financing the health system, or where people may not be able to provide for their own health expenses. Moreover, health issues take a toll on low-income populations. The poorer sections of rural Indian households spend close to 12 percent of their income on healthcare, which contrasts with an average 6 percent spent in the United States. Nearly 60 percent of this population takes loans at annual interest rates of 60-120 percent to pay for either prolonged treatment or hospitalization.

We also have to recognize that some quality issues in healthcare delivery are linked to a certain mind frame. Particularly in developing countries, there is often a lack of incentives to ensure quality throughout the delivery chain, in addition to widespread corruption. In public hospitals, poorly paid health professionals may spent minimal amounts of time with their patients to maximize time in their private practice. On the other hand, patients receiving free treatments may feel that they cannot demand high quality because they pay no fee for service. Also, ostensibly free health services end up turning poor people away because of hidden costs linked to corruption.

All this may lead to the conclusion that providing high-quality care in low-resource settings is simply not feasible. However, inspiring examples are turning the problem on its head and demonstrating cost-effective solutions based on highly leveraged interventions.

Limited outreach of healthcare infrastructure: A large percentage of the world's population is left out of mainstream healthcare systems because of geographic location, an issue aggravated by low-income levels and lack of health education of populations living in remote areas. The traditional top-down health systems are excluding many people who either do not have access to a health professional or are unable to get the right drugs in time (inefficient inventory management and counterfeit medicine are common) or to be transported to the nearest health center for timely care. Undersupply of qualified medical staff is a widespread issue in most developing countries, one exacerbated by the fact that most medical doctors practice in urban areas. These two points can be illustrated by the case of Congo (DRC), an "ophthalmologic desert" with fewer than 20 ophthalmologists for a population of 60 million inhabitants, or by India where some 80 percent of medical doctors have a practice in urban areas while 70 percent of the country's population is rural.

Principles:

Principles represent the main new standards distilled from practical strategies. They are meant to inspire and guide the innovation process going forward:

Adopt market-based models as a scaling up strategy: A range of players in the health sector—for-profit organizations, but also nonprofit and public entities—have increasingly used approaches traditionally considered to belong to the private sector to accelerate the growth of their health initiatives. These include putting the client first to redefine the cost/value relationship and create willingness among low-income people to pay for good value health services; using a microfranchise model to limit the capital cost of expansion while monitoring safety and quality; and creating demand for health products and services and so shifting part of the expense to patients—an interesting parallel with the Internet revolution that enabled many companies to rethink their business models by putting clients and business partners to work. While we do not want to debate the merits of privatizing healthcare here, we recognize the value of market-based approaches in reaching large numbers of people in need.

Design inclusive systems: Many will agree that healthcare is not a typical consumer product but rather a universal human right to be guaranteed regardless of income, gender, ethnicity, or location. Many initiatives have actually included "by design" some kind of safety net to make sure that their solutions would be accessible in case of great need. Moreover, inclusiveness can also be used as a strategic advantage. The business model of the Aravind Hospital, for example, is based on maximizing the volume of surgeries and increasing the customer base to enable economies of scale.

Other organizations that are using market-based approaches as a key strategy to reach scale at the same time aim for "compassionate capitalism" by limiting profit returns. Some of them have actually triggered major players in an industry to lower prices and margins by introducing a compelling competitive force, e.g., Project Impact and Aurolab for intraocular lenses. Finally, providing health solutions in low-resource environments often requires developing a comprehensive response including prevention, social services, a solid referral system, ambulance services and health financing in additional to healthcare. What is needed is a comprehensive system including various types of interventions with financial rates of return ranging from donations to standard market rates. This raises the critical role of cross-sector partnerships in the health sector and the need for different types of investors.

Leverage abundant resources at the community level: Many successful health solutions targeting low-income and other marginalized populations acknowledge the fact that there is a huge potential to use human and natural local resources. These strategies that significantly address the critical issues of outreach and cost-effectiveness include nonprofessional labor ("barefoot doctors") for diagnostic, prevention, and low-cost preventative and primary healthcare; peer groups for behavior change; and selected traditional remedies to compensate for the lack of formal healthcare.

Introduce novel uses of technologies: Although technology is rarely the only response to a health issue and often requires "last mile" complementary solutions, introduction of high tech in low-income settings has helped push geographical barriers and changed traditional cost structures. While still emerging in developing countries, telemedicine, for example, is being tested for secondary or tertiary care in different parts of the world. Experiments have consistently demonstrated the importance of creating trust from the local communities, as well as introducing incentives to start using these new facilities at the local level rather than traveling to the next hospital to meet a doctor in person. Other creative technology-based solutions—like Sulabh's in India that produces additional incomes through biogas and biomass—have resulted in widely improved sanitation and hygiene by uncovering hidden resources and implementing a "win-win" model.

Innovative strategies:

In this mosaic we highlight examples from around the world, from various sectors (public, social, private) and from multiple health-related fields (HIV/AIDS, nutrition, pharmaceuticals, primary healthcare, secondary healthcare, health insurance). We believe that the solutions populating the mosaic have the potential to inspire strategies throughout the health sector. The mosaic illustrates the "More-than-the-sum-of-the-parts" effect by which individual social entrepreneurs can complement the principles and approaches they developed with those created by the rest of the field. It harnesses the full value of individual solutions, while inspiring practitioners to accomplish far more together than apart.

Because innovations usually emerge simultaneously in more than one location and context, you will probably think of other initiatives around the world using the same "how-tos" that are mentioned here. Note that although the best solutions probably speak to more than one principle or one barrier, we have chosen to emphasize one specific innovative aspect. Finally, we would like to recognize that by underscoring a particular aspect of an innovative solution, we have certainly oversimplified what is likely a carefully synchronized systems-changing solution. We encourage all readers to visit the original Web sites to learn directly from these business and social entrepreneurs about the multiple dimensions of their solutions.

As you will see, many of the innovative solutions featured in the mosaic—some 8 out of 22—come from India. Although many other parts of the world have incubated successful solutions for "health for all," it is worth noting that India has a particularly enabling environment for health innovations to bloom given the combination of massive needs (250 million people living below the poverty line), a large rural population (70 percent), and one of the lowest rates of public healthcare spending in the world (1 percent in 2003).

Until May 10, 2006, Changemakers's "Health for All" competition for its Innovation Award is soliciting proposals from social entrepreneurs that address the challenge of providing quality health solutions to low-income and marginalized populations. Finalists will be selected by a panel of judges, and Changemakers's online community will vote to select three winners who will each receive a $5,000 prize.

Stephanie Schmidt is a director with Ashoka's Full Economic Citizenship initiative where she is focusing on developing commercial partnerships between private companies and social entrepreneurs in order to provide improved product and services offerings to low-income communities, particularly in the fields of health, housing and water/irrigation. Prior to joining Ashoka, Stephanie worked on development programs in Rwanda including HIV/AIDS and community health for two years. She started her career in management consulting in Paris and Boston.

Return to Home Page