This blog post is the third in a series about the Catalysts for Change initiative in the state of Andhra Pradesh, India. This series follows the journey of Andhra Pradesh as the state reforms its urban healthcare system.
In the first and second blog posts in this series, we introduced our ongoing partnership with the government of Andhra Pradesh to improve urban primary care in the state. As part of this partnership, the government asked us to organize a workshop to examine best practices in primary care from the private sector and to explore how these best practices can be used to inform the design of a new urban primary care system for the state. The new system, and its design, will be managed by the National Urban Health Mission in Andhra Pradesh.
As a first step in the overhaul of urban primary care in the state, the government aims to form experimental public private partnerships – Catalysts for Change – to deliver primary care in urban areas. The workshop provided a valuable opportunity for state leaders to meet top innovators from the private sector and to gauge their potential interest in partnering with the government in this work.
To prepare for the workshop, our team scouted innovators in primary care through the Center for Health Market Innovation Network and invited them to participate in what promised to be a high profile event. ACCESS Health brought together private for profit and not for profit players to present their service delivery models and to explain how the models work. The workshop featured innovations in the areas of primary care, diagnostics, homecare, elder care, and chronic disease management that are applicable to the preventive, curative, rehabilitative, and palliative components of primary care.
The workshop drew the participation of key state leaders, including the Honorable Minister of Health, the Special Chief Secretary for Health, and the Commissioner of Health and Family Welfare. At the workshop, twelve organizations showcased their healthcare models to the state leadership.
Spotlight on Best Practices in Primary Care
Karuna Trust is a not for profit organization with two decades of experience managing primary health centers, in partnership with state governments. Karuna Trust runs sixty nine primary health centers across nine states in India. The success of Karuna Trust enabled the government of Karnataka to issue a formal policy on public private partnerships in healthcare. Karuna Trust has been successful in integrating mental health and dental care into some of its primary care centers. Karuna Trust supports cross learning in the states where it works.
NationWide is the leading family physician based healthcare organization in India. NationWide showcased its effective management of Bachelor of Medicine, Bachelor of Surgery (MBBS) doctors. The presentation highlighted the core strengths of NationWide, such as the use of technology, including electronic medical records; robust governance systems; and regular training to medical and paramedical staff. The training course developed by NationWide may provide a model for how the Andhra Pradesh National Urban Health Mission can maintain the quality of doctors and keep them motivated. The NationWide business model is structured to minimize overdiagnosis and excessive referrals to secondary and tertiary care. NationWide achieves this goal by linking payments with performance outcomes. Sujatha Rao, an expert advisor to the state of Andhra Pradesh, suggested that the state look to the processes and value systems of NationWide when designing the National Urban Health Mission approach to primary care.
Merrygold Health Network is a social franchising network of health centers. Merrygold provides care in three tiers. Merrygold focuses on maternal and child health services, including deliveries, pediatric care, and family planning. Merrygold operates through a network of franchisee private providers.
Ross Clinics are a group of technology driven, family physician health centers. The company makes efficient use of space. Each clinic is around five hundred square feet. Ross Clinics use lean staffing methods. Ross Clinics are particularly notable for their success in breaking even within a short span of time, while maintaining a focus on healthcare outcomes.
NanoHealth helps patients in the urban slums of Hyderabad to manage chronic diseases, particularly diabetes and hypertension. The organization provides a solution for the early intervention and management of chronic care. Chronic diseases now form a bulk of the disease burden in India. As part of the NanoHealth strategy, community workers called Saathis conduct screening camps; refer patients to physicians, as needed; and ensure compliance to treatment with an innovative technology based product called Doc-in-a-Box.
eVaidya is a provider of online and in person healthcare services. eVaidya manages two health centers called Electronic Urban Primary Health Centers (eUPHCs) through public private partnership. These centers are located in Visakapatnam and Vizianagaram. eVaidya is eager to participate as one of the Catalysts for Change in the roll out of the National Urban Health Mission in the state.
Life Circle Senior Services provides subscription based home nursing services to senior citizens and others at the base of the economic pyramid (BoP). Life Circle provides comprehensive in home health assessments and healthcare plans for each patient. Life Circle was eager to participate in the National Urban Health Mission to address the lack of publicly provided elder care services.
SMART Health is an mHealth program developed by the George Institute of Global Health. SMART Health focuses on restructuring the health workforce. SMART Health uses mobile health technology to help healthcare workers provide effective cardiovascular disease care for rural populations. This strategy can be expanded to address other major causes of death in India.
Neurosynaptic Communications provides telemedicine services to rural populations through a product called ReMeDi. Neurosynaptic proposed a technology based strategy for the National Urban Health Mission in Andhra Pradesh. Neurosynaptic proposed a hub and spoke model that provides triage management, primary care and screening at point of care, data management through the cloud, and integration of the services provided by Neurosynaptic to the other initiatives and programs of the government.
Biosense Technologies is a point of care medical device company. Biosense has developed an affordable urinalysis tool called uCheck and a device for noninvasive anemia screening called TouchHb. Biosense has installed its devices at various primary care centers in Chhattisgarh and Rajasthan.
Bangalore based SVYASA (Swami Vivekananda Yoga Anusandhana Samsthana) Yoga University is the first yoga university in the world. The Yoga University presented the use of yoga to support wellbeing and as a form of therapy. The Yoga University made a case for the scope of opportunities to integrate alternative schools of medicine into urban primary healthcare. The Yoga University is working with the Indian Council for Medical Research and the Ministry of Health to support the prevention of diabetes, hypertension, depression, and many other chronic disorders. The Yoga University has been working with the Ministry of Health to develop pilot wellness centers across India.
ProHEALTH advocates physical activity and active lifestyles. The foundation promotes the sport of running, especially among children and youth. ProHEALTH has organized marathons and camps and has conducted programs to train people in rural and urban locations. ProHEALTH sees a place for its work in the Urban Health Mission in Andhra Pradesh. ProHEALTH aims to propose a health promotion model in two urban local bodies. ProHEALTH would like to develop an “Active City and Healthy City” campaign to raise awareness about chronic diseases, to promote physical activity, and to encourage the population to get involved in sports.
The Partnership Vision
Another important objective for the day was to identify challenges in public private partnerships in health, from both the public and private sector sides, and to discuss how these challenges might be addressed in the design of the new Urban Health Mission in Andhra Pradesh. Successful public private partnerships can be difficult to form and to maintain. Both players – the public and the private – face challenges in the relationship. After the presentations from the innovators, workshop discussion turned to the design of the new primary care system and how we can create an environment conducive to public private partnerships in health. Below are some of the key recommendations for the National Urban Health Mission that emerged from this discussion.
The new urban health centers must be a one stop solution for the urban poor. Each urban health center should provide different core and add on services at a single location.
Healthcare that comes totally free of cost is often not valued. The new system should provide a few core basic services free of cost but also create reasonable revenue streams for the provision of additional services. This structure will introduce more accountability and sustainability into the system. When people pay, they also demand high quality care. This arrangement is more appropriate for people above the poverty line.
Payment incentives can drive good performance. The payment structure of the new system should incentivize better performance and improved health outcomes.
The government needs to ensure that payments to the private partners are made on time, all the time. Consistent and timely payments are necessary to ensure that health services can continue uninterrupted. Timeliness of payments encourages good performance. A well laid out monitoring and evaluating structure, supported by a robust information technology platform, would largely solve the issue.
The public sector players must view their private sector counterparts as true partners, and not as external agencies or contractors in the partnership.
The urban primary care system must act as a gatekeeper. Providers at the primary care level should help patients navigate the complex health system and prevent unnecessary hospitalizations. We need to think about how we can design and mandate such a system.
The Department of Medical Education will work with the Department of Health and Family Welfare to address the challenge of shortage of manpower.
From Vision to Action
Over the course of the next couple of months, ACCESS Health will work closely with the government of Andhra Pradesh to collect specific recommendations about the components of the National Urban Health Mission model. The government will then look at each organization and the feasibility of piloting their models in the state.
ACCESS Health welcomes all innovators to join the conversation. Several key questions remain about the design of the urban health model. Please share your ideas and answers. Your input will be a valuable contribution to the design of a robust Urban Health Mission in Andhra Pradesh.