How do we know what health market innovations work?
Improving health markets for the poor means making health care more available, affordable, or of higher quality. Disruptive innovations, such as new technologies and/or business models, can help do this by changing the market in an unexpected way to improve the services or products offered. One of the main challenges of researching programs that use disruptive innovations, though, is assessing their real impact. How do you know how much a program is really benefiting the poor? How do you assess which programs most benefit the poor?
We have just published a case series (based on work commissioned by Results for Development and Rockefeller Foundation) of a range of high-profile social enterprises that have demonstrated some social impact. These include well-known examples like Aravind Eye Hospital, Greenstar and newer ones like Ziqitza 1298. Many of them use cross-subsidy to make care more affordable to the poor, or delegate tasks to paramedical staff to reduce cost or increase availability of services in remote areas. However, very few of these organizations have rigorous evaluations of the impact on availability, affordability or quality of care. Often we inferred social impact, but these assumptions could be wrong. For instance, providing services or outreach in remote areas was assumed to increase availability, but most organizations or evaluations do not document the presence of preexisting services or competitors. Reducing cost should increase affordability, but it’s not clear how costs compare to people’s ability to pay or their likelihood of being impoverished. The impact of cross-subsidy depends on the rate of coverage (proportion of poor in need accessing the service) or leakage (proportion of non-poor receiving subsidized services), but this was not reported by any organization we reviewed. Lastly, rigorous measures of quality were reported in only 3 of 10 organizations. Cost-reducing strategies should measure the impact on quality, even if it’s worse. A recent systematic review of cost-effectiveness studies found that less than 1% compared interventions that are cheaper but comparable or slightly worse than the standard.
The promise of disruptive innovation is to provide care that is good enough at lower cost, reach non-consumers, and possibly develop models that could be replicated in high-income countries whose health budgets are bursting. These innovators often need patient capital to get going or scale up, and many may not be financially sustainable even if they are much more effective than currently available services. However, investors or regulators need to know whether the models work to determine which to fund or change policy to facilitate the replication of new models. Currently, there is relatively little rigorous information on the impact of the best documented organizations. CHMI provides an excellent opportunity to pull existing knowledge together, determine what reliable information can be collected, and determine what are truly best practices in this area.
- Onil Bhattacharyya, Sara Khor, Anita McGahan, David Dunne, Abdallah S. Daar, Peter A. Singer. “Innovative health service delivery models: What can we learn from the private sector?” Health Research Policy and Systems 2010, 8:24.
Onil Bhattacharyya, MD, PhD, is a clinician Scientist at St. Michael's Hospital and assistant professor of Health Policy, Management and Evaluation at the University of Toronto. Dr. Bhattacharyya’s work focuses on innovative health service delivery models, quality improvement, and performance measurement, with a particular interest in chronic disease in resource limited settings.