What is happening?
As of August 2009 (Project set-up)
The project kicked off in June 2009. So far:
- CARE sought an insurance partner to bear financial risk for the outpatient product and to support product development, but none was found willing to underwrite a voluntary outpatient product.
- 34 VHCs were recruited to implement community surveys and sell health and hygiene sundries. After gaining 6 months experience, VHCs will “graduate” to operate a HHD, which will enable them to do preventive care and health promotion, door-step diagnosis, referral assistance, and insurance enrolment and servicing. It’s still an open question if the VHCs will be accepted and valued by prospective clients in their new roles.
- Hub-clinic set up: The hub clinic was set up within 8 weeks, but delays occurred to open a pharmacy due to licensing issues.
- The CDSS is being built. Starting with use of the 15 clinical pathways defined by SE Asia WHO. Each pathway will route to: 1) VHC treatment and Rx, 2) remote consultation with doctor (telemedicine), 3) referral to the Clinic or 4) referral to hospital.
- It became apparent quickly that a project undertaking of this scope, with so many facets and stakeholders, would not be easy to coordinate.
As of December 2009
The project experienced delays in the set up phase across several fronts. One general challenge has been the loss of productivity in the villages due to frequent festivals, marriage celebrations, etc., along with political events including elections.
It took longer to plan the action research program. A complex and robust research agenda was envisioned to assess the viability of the financing and delivery model via HHDs, and to measure its impact on the health and well-being of the target population. An external research partner, CIRM and academic advisors from the Harvard School of Public Health were engaged.
HHD and CDSS
Additional development of the CDSS modules (clinical protocols) and testing of the connectivity of the HHD from the village locations to the back office server proceeded.
Six days of training were delivered to VHCs during their first 3 months in the field using a modular approach. The training modules include information about the goals and objectives of the project, professional development, social mobilization, clinical skills and a 1 day village camp for practical experience.
Clinic and referral support
CARE set up a hub clinic in Yavatmal, securing space and hiring staff. Delays occurred to receive a pharmacy license, which hampered the clinic’s ability to become fully functioning. It was also a challenge to find quality doctors to staff the clinic, especially specialists who would come on a rotating basis, so CARE began to explore alternatives to address this need.
The Project Manager quickly realized that more support in the field location (Nagpur / Yavatmal) would be needed to strengthen field operations. It also became apparent that further coordination with the clinical support teams, the hardware and software vendors and the research partner would all require oversight to support coordinated efforts to meet interdependent milestones. Reporting and key performance indicators were also drafted, and those that could be measured, such as activity around VHC training, were implemented.
As of September 2010
Overall the launch date for the health insurance product has been delayed about one year from the initial plan, though during this period much has been done to put the necessary technology, staff, and processes in place.
A number of delays to complete development and field testing of the HHD and its software have occurred, around use of multiple languages, authentication systems, connectivity in the field, clinical pathways and software applications for insurance.
From May onwards the healthcare application delivery is in place excluding the insurance application for biometric card, amount utilization and the backend claims module. CARE is preparing a training manual on the HHD.
Limitations in technology connectivity in the field have occurred; in fact, connectivity is variable from one village to next. Twenty to twenty-five HHDs were analyzed randomly, and it was found that roughly 60-70% connectivity occurred with the HDD compared to nearly 100% with mobile phones. Further, there was also a difference in reliability between mobile phone service providers on a magnitude of up to 30%.
Problems were encountered by the software developer: 1) more time was needed to understand the content and structure of the data tables, and to ensure that the software could be adapted by users (dynamic); 2) the key project person left, leaving insufficient backup to continue the development uninterrupted; 3) most importantly, months into the development, it was discovered that the coding language of the HHD was incompatible with that used by the server. The software developer and a sub-contractor were not able to agree on how to address the resulting change in scope of work to address this gap. Ultimately a new programmer had to be hired to create a functioning interface.
Successful field testing of 2 HHDs commenced on 10th September in 2 villages. A two day training was conducted on the HHD device and a HHD training manual and practical training program was designed.
Research and data collection
A discount voucher based plan of randomized controlled trial has been designed to study the effect of CARE’s intervention (outpatient health financing scheme and preventive package) on various health and health related economic outcomes of the beneficiaries. The final randomized sample is now available for a baseline quantitative study using the census/household listing data.
The baseline study was delayed mostly due to the delay in the product launch, but also due to other administrative requirements, such as finalizing a Memorandum of Understanding with the research partner and obtaining approvals from human subjects research committees.
Additionally, to supplement the initial needs survey done in 2009, a survey on insurance literacy was completed and some data on willingness to pay and understanding of insurance were collected.
Fifty VHCs are available in the field and approximately half are now running community clinics, with others to be phased in January 2011. Currently, a VHC treats about 3-5 patients per day, and collectively they have treated more than 300 patients / month through remote doctor advice supported by mobile phone. Implementation of the HHDs is beginning.
VHC training has been streamlined, to try to enhance skill development and for VHCs to get practical exposure to patients. Interpersonal skills and confidence building were included in the curriculum, and “graduation” ceremonies are being added to increase VHCs’ community image and build trust.
It took 2.5 months to find a Nagpur call center doctor trained at a good standard (i.e., MBBS, an Indian credential). A qualified female doctor was hired 1 April to facilitate communication with female VHCs and to support common woman/child health care encounters. It was discovered that the VHCs (and the doctors) benefit greatly from having the VHCs visit the call center (and vice versa). It was also observed that a majority of doctors may need further training on appropriate prescribing, and how to use a CDSS.
In Jan 2011, training on disease protocols for clinic doctors was implemented, with emphasis on primary care and chronic care diseases to promote quality and consistency of high volume/cost services. The training and monitoring have yielded positive results in decreasing over-utilization of drugs, injections.
Product Design and Price
An insurance survey in 30 villages was completed in May 2010 to have a better understanding of the community’s perception of the insurance product, including premium and benefits. The survey showed virtually no understanding of what the word insurance means, or how it functions.
CIRM estimated that an outpatient product with the envisioned benefits should be priced at Rs 400 (US$ 8.69) product. These projections were more uncertain due to limited regional data to define benefits and willingness to pay, which seems to be Rs 250-350, not higher. It is expected that the majority of patient encounters will generate a prescription, with about 30% expected to have a diagnostic visit. A huge driver of the program’s sustainability should be the use of drugs.
Similarly, the absence of data on cost and incidence of treatment, percentage of referral and risk loading for an outpatient product were additional factors that were difficult to assess. Based on results of the insurance survey and some preliminary data on use of pharmacy and frequency of treatments, CARE determined that a maximum initial price should be Rs 300 (US$ 6.52) for a family of 4. Overall the program is projected to achieve a breakeven at 6000 insured members.
Additional features of the product include:
- The product will be presented as the “Care Arogya Card”
- Sum assured: Rs 2500.
- Additional family members can be added with supplemental premium.
- Chronic conditions such as diabetes, hypertension and asthma are excluded, as are treatments associated with a hospitalization (the cover is for outpatient treatments only)
- Public health vaccinations, immunizations, children nutrition are not covered under the program
- Prevention program: Insured clients will receive at a highly subsidized price a prevention package that includes interventions for airborne, waterborne and vector borne diseases.
- An insurance literacy campaign has been designed and will be rolled out with the product.
- Premium payments will initially be one-time, up-front, but once operations are stable, a monthly installment plan (e.g. 2-3 equal monthly payments) may be tested to increase affordability.
During early 2010 the vendor selected to develop the education materials did not deliver, and finally, 2 new vendors were selected to take over pending deliverables, now due in September. Insurance animation and education materials have been developed and are being translated into the local language, Marathi. Communication materials won’t use the word “insurance”.
One new person will be hired to focus 50% on training/prevention, 50% on insurance. The management team received 2 trainings: public health and management skills. Project management staff is not used to multi-task, as their village culture is to do one thing at a time. A team building event was held in June. More intensive development of back-end insurance accounting applications started.
Insurance Process Manuals are in development and will encompass the delivery of care using the HHD, client servicing by VHCs and processes for staff.
As of July 2011
The product was finally launched in October 2010, beginning in two villages, reaching 25 villages by February 2011, with approximately 1050 covered lives (or around 5% penetration). Initial enrolment appears to have been stimulated by the vouchers, though approximately 25% of enrollees lacked one. Initial enrolment gradually advanced to reach 41 villages and 487 families and 2035 lives as of June 30 2011. There was a corresponding penetration of 6% and incurred claims ratio of 31.33%. Lower enrolment was observed during May and June, due to lower employment (and thus less income), as well as it being marriage season (which diverts disposable income).
The product launch was manual (paper-based) because the technology solution remained fraught with ongoing challenges, most significant of which was to establish sufficiently reliable connectivity in the rural locations. To support a gradual, accurate, transition to the technology a database backup system called “CARE health and insurance processing system (CHIPS)” was implemented. Additional challenges still to be resolved with the HHD and its software included:
- Training and acceptance of the technology by the VHCs: it became apparent on the ground that VHCs needed some time to learn how to complete the biometric (fingerprinting) set up as part of issuing ID cards, as it required several steps which were unfamiliar. CARE shifted this responsibility to a more experienced Insurance Executive who supported multiple VHCs.
- The interface between Marathi (front-end language) and English (back-end language) did not permit printing due to the higher number of lines for the Marathi language. Having the product names and prices in the Marathi language helped the VHCs understand what was being offered so that they could more easily carry out transactions for insured and non-insured clients.
- Changes to the product, e.g. adding or deleting a covered medicine, are not reflected in the HHD in real time. To overcome this and keep things simple, the data residing in the HHD at time a service is delivered are always used to define what services or products are covered.
- Connectivity was not yet 100% reliable. Thus, a method to synchronize data input offline had to be implemented.
- The use of GPRS (internet connectivity) was not reliable enough in all village locations to transmit pharmacy data (prescriptions). Instead, a phone call and SMS transaction method was implemented to ensure accurate and consistent transmission of pharmacy data.
- The initial coding for the HHD to recognize and store biometric data for all 10 fingerprints per person was overly complex and did not permit one to one mapping of each fingerprint. Once the software was modified, the biometric data requirements were simplified to limit reading of 2 fingerprints per hand (or a total of four per person).
Vouchers were distributed in 30 villages under the action research program in October 2010, prior to the product launch. A total of 900 vouchers (30 per village) were randomly distributed, with one third of the vouchers (10 per village) offering a 80% discount on the insurance premium (voucher 1); one third of the vouchers offered a 80% discount on the insurance premium and the preventive products package (voucher 2); the final third of the vouchers (voucher 3) offered one free VHC consultation. Initial findings were that enrolment was (not surprisingly) highest among recipients of voucher 2 (offering the 80% discount for both the product and a preventive products package), since it was the most generous voucher. The least valuable voucher, for a VHC consultation valued at (Rs 50) had virtually no impact on uptake.
The analysis of the baseline study was completed in April 2010. Key findings included:
- Eighty per cent of healthcare expenses are for primary care.
- Given the poor health care amenities and low awareness of good health practices, adding a preventive package to the program would be particularly useful.
- Availability of services more proximate to clients could add value by reducing transportation costs and opportunity cost of lost wages.
In August 2011 a qualitative midline study was completed to ascertain client and non-client awareness, to gauge usage of the product in each village, and to gather client and staff input to improve the product.
Additional and ongoing training was held for VHCs in early 2011. As enrolment increased and VHCs gained experience and visibility, their volume increased from 3-5 patients per day to 20 per day. Collectively, their patient volume rose to 1000 patients per month.
With respect to training, CARE began a rotational training approach, in which VHCs began spending 1 day per month in the Yavatmal clinic, working with patients. Additional medical training was introduced, beginning with glucometers (to test blood sugar), then on the topic of anemia. Refresher training (classroom and field camps) continued for existing skills, such as diagnosis and treatment of fever.
Because of the delays and so many changes occurring to the HHD and related processes, the VHCs required additional re-training on its use. A period of adaptation of at least several months was observed.
VHCs also demonstrated reluctance to sell and service insurance, which was felt to be a factor limiting enrolment. Several modifications were made to jump-start enrolment, including:
- Coordinators with more developed business skills were used to conduct group enrollment camps, which also provided on the job training to VHCs.
- Additional training was provided to supplement the camp experience.
- Families who had visited the clinic were targeted for follow up contact to enroll.
- Organized rounds of household visits were made, and a more detailed tracking of VHC productivity and results with respect to prospecting and enrolling was implemented using a scorecard approach.
- Inviting members to share their experience with prospective clients.
Based on feedback from clients, expanded hours for the community clinic were implemented. Now clients can access treatment 24 X 7 at the village level through a VHW.As a result, 125 patient treatments, including emergencies, per month have been provided in the evening or night, after routine daytime clinic hours.
Product Design and Price
In July2011, CARE introduced two new premium payment options with approximately 30 households in 2 villages. The first option, called “Zatpat Card”, is an installment payment approach. It requires an initial payment of Rs 50, plus Rs 30 per month, with coverage being effective immediately. At the end of the 12 month coverage period, the total premium for the Zatpat Card is Rs 410, compared with the Rs 300 under the one-time payment (up front) option. In a second new payment option, CARE offered 100 households a flexible installment payment method in which households could pre-pay in amounts and at times they choose, until the full premium was paid, at which time the policy would become effective for 12 months.
Additional value added services are under testing and consideration: deeper and more visible discounts (now 25%) for hospital care at CARE’s facility in Nagpur; provision of 1-way transportation to the Nagpur Hospital; facilitating access to a low-cost hospitalization insurance product such as one costing approximately Rs 70 and being offered by New India Insurance Co; offering clients rates at CARE Nagpur Hospital equal to those charged by RSBY (note: RBSY, the Government of India’s subsidized program hospitalization insurance for poor families, is just starting to reach Yavatmal District). Thus far, RSBY implementation in Maharashtra has been limited, and according to news from Mahrashtra ministry, an alternative scheme, such as the Arogyasri scheme in neighboring Andra Pradesh may be implemented.
Despite the easy to understand product design and limited exclusions, some complaints or requests were voiced to add coverage for all drugs, and for vision and dental care. CARE enhanced education about the product via VHCs and with a member passbook, and also increased the number of drugs offered. Additionally, some common palliative items such as over the counter medicines or herbal ointments to relieve headache and backaches were offered to complement the prescription drugs which could be prescribed for the high frequent visits for body ache and general weakness. These items allow the VHC a wider range of options, and create greater choice for clients; at the same time, they potentially limit unnecessary prescriptions and can generate additional revenue for the programme.
A mid-line qualitative assessment was done in July 2011, supplementing ongoing claim review meetings. Key findings were that clients are generally satisfied with the product, but they are confused by the exclusion for chronic care. There were requests to include injections and intravenous fluids under the benefits and have them administered by VHCs, likely due to a belief that these interventions are “better” than drugs because they are perceived to offer immediate relief. Clients also would like more covered services, especially for dental, skin, and women’s and children’s health concerns, along with hygiene and nutrition, that could be delivered in their villages either by the VHC or a visiting doctor. While generally the cost of the product is acceptable, there were requests to better accommodate large families or instalment payments. Clients confirmed that trust in the VHC is a key factor on whether to buy the product. The present process for care delivery was recognized to be mostly manual and somewhat administratively heavy.
Also in July 2011, discussions were held with a Dairy Cooperative Society with approximately 16,000 members in Yavatmal Block to be a distribution partner for the product, since this channel held promise to scale up enrolment much faster in villages with VHCs and also new villages not presently offered the product. CARE felt it could afford a commission of 5-6% of premium, but the Society did not view this to be sufficient relative to other incentives for competing products or activities. Thus, the partnership discussions were ended.
The uptake of the preventive package was generally low, but more sales occurred during monsoon season for malaria products, when risk of malaria is greatest and when education campaigns were in place. Soap is one of the fast moving products for clients, thanks in part to being offered at an 80% discount.
The client passbook, offered since the product launch in Nov 2010, records all transactions and client visits to the community clinic and primary health centre. Additionally, the client passbook contains details about the product, benefits and processes. Based on client feedback, laboratory tests which are covered were added to improve comprehensiveness of the passbook.
An Insurance Manger was hired in June 2010 and is based in Yavatmal. This person also supports the HHD and technology aspects of the project. A pharmacy/inventory supply executive was also hired.
Basic IT training was providedin June and November 2011to clinic staff to support common IT troubleshooting at the clinic.
HHD device training was given to the VHCs for 2 days, emphasizing practical exercises. The VHC is expected to handle enrollment and issue a biometric card. VHCs will be supported in the field for the initial few days when beginning, to reinforce lessons learned in the training, and to be sure they are acquainted with the technology and related processes.
Date of last Learning Journey update: April 2012