Earlier this month, the IIC and SEWA hosted a roundtable discussion to discuss critical challenges and opportunities faced in empowering the economic situations of women in India. A video summary of the roundtable, as well as a PDF of the executive summary of the joint report, is available below.
At just 1.2% of the GDP, India’s public health spending continues to be among the lowest in the world, while public health infrastructure in the country faces significant gaps. The National Health Policy 2017 expresses the intent to universalize health care and provide quality care at affordable rates. But several challenges and uncertainties remain for India to realize this goal. There is a pressing need for innovative models of financing healthcare and ensuring quality health service to all citizens across the country.
To shed light on these issues and address the most pertinent issues regarding the demand and supply of quality healthcare, the International Innovation Corps (IIC) organized a panel discussion titled “The Quest for Universal Quality: Financing Healthcare in India” on January 30, 2018. The panel featured Dr. William Haseltine (Chairman and President, ACCESS Health International), Dr. Shamika Ravi (Director of Research, Brookings India and Member, Economic Advisory Council to the Prime Minister of India), and Dr. Dinesh Arora (Director, Health, NITI Aayog). The panel was moderated by Dr. Anup Malani (Faculty Director of the IIC, and a professor at the University of Chicago Law School, and the Pritzker School of Medicine).
The panel discussed a range of issues about the health sector in India – from the need to develop a process for electronic health records to mapping the exact health demand across the country. Some key themes emerged from the conversation:
‘Quality of Care’ needs to be defined and prioritized
Currently, there is a much greater focus on providing access to healthcare than on ensuring quality of care. Quality of care, while a nuanced concept, is critical to ensuring a comprehensive realization of universal healthcare. Quality needs to be defined through the development of robust metrics through which health outcomes can be assessed.
A shift is required in government spending, with an increased focus on increasing awareness and demand
Until now, the government’s primary focus has been on building medical infrastructure and manpower. There has been little focus on the demand side – with limited efforts to increase the public demand of healthcare in order to strengthen the public medical system. This is also evident in the excessively low utilization rates of Government Public Health care schemes, such as the Rashtriya Swasthya Bima Yojana (RSBY). Thus, a systematic approach to awareness building needs to be adopted to ensure that citizens access the healthcare avenues and schemes provided by the government. Concurrently, with these demand-side gaps in mind, policies with simpler instructions and more streamlined operations need to be designed so that they may be easily accessed.
A strong accountability and performance incentive structure is required to improve service delivery
Comprehensive access to equitable quality care is only possible when there is strong accountability in service delivery. Electronic health records and digitized intermediary processes (such as HMIS) that facilitate studies of patient flow and the management of medical facilities are a step in this direction. At the administrative level, the ranking of states based on their performance on health indicators would likely incentivizes states to invest a greater effort.
Robust medical data infrastructure is critical to enhancing the efficiency of healthcare processes
India’s healthcare system collects an enormous amount and wide variety of medical data. Despite this, there are serious issues across the data management cycle, which greatly reduce the data’s usability and amplify the data gaps. From non-standardized practices in data collection and compilation to inefficient analysis, a range of challenges make the data collected unhelpful and ineffective in decision making. In light of this, it is crucial to develop robust infrastructure, while redesigning existing data management processes.
Ultimately, the real challenge for realizing Universal Health Coverage lies in the implementation of processes. This will require a balanced approach to the demand and supply of healthcare, but a central focus on quality will be critical to this effort. The successful implementation of Universal Health Coverage will also need proven processes and methods to increase accountability, as well as a channel of systematic financing, to ensure that decision making is driven by data and evidence.
by Nitya Nangalia, Team SEWA
Choosing projects in decentralized organizations
Every IIC team starts the year by stepping in the shoes of a project designer. Being consultants we come with little context of the organization, have very tight timelines and are tied to massive expectations. The experience of every team differs based on their client. For our four-member team working with the non-profit SEWA Bharat the challenge increased manifold - how do you identify and define your project for the year in a geographically spread, resource-constrained, decentralized organization working on multiple programs at the same time. Based on our 6-week stint of scoping, we reviewed what worked and what would have helped us better in the scoping process and have five major insights -
#1 Spend time understanding the organization
In the beginning of a consulting project, either the client or consulting team themselves may be eager to produce output from Week I. However, for any incoming team it is important to get enough time to understand the organization and ensuring the client gives you space to do it. If not given time, daily tasks can soon turn you into extended arms of existing work in organization, leaving no way to assess what could have the best fit project for the year based on client needs and the team capacity. We recommend requesting the client some time for a detailed scoping exercise, with an expectation of no deliverables in the meantime. When asked, they do listen - as we happily learnt from our experience.
#2 Prioritise building processes and tools
Once we started work, it was easy to get lost in multiple projects and states. To illustrate, SEWA in one district of Bihar hosts 8 different projects - Advocacy, Social Security, Waste Management, Goat-Nursing, Skill Development, Microfinance, Renewable Energy and Sustainable Agriculture - each working on slightly different models than their sister districts and staffed by people taking on multiple roles. Fortunately, our team spent time building processes which not only saved us from getting lost, but also made it simpler to gather insights by looking at the output.. We recommend the following tools when scoping -
- Define roles for all meetings - meeting leads, scribes, translators
- Build questionnaires for interviews
- Use process maps to get a baseline
- Hypothesize deliverables and estimate effort required for chosen work streams
- Use a consideration matrix to evaluate the feasibility, sustainability, need and interest of proposed projects
In a design thinking approach of convergence and divergence in projects, these tools acted as a very useful way to help us converge on similar parameters across different work streams.
#3 Most people answer the Why - Also address the How
One great learning from our scoping experience is that most of our time was spent in determining what was happening and answering why are we choosing certain projects over others. While we spent time pondering over the feasibility of the project, we did not spend enough time thinking over HOW to make the project possible. One solution our team considers in retrospect is devoting one week of the team’s time in actually working on some tiny area of the project to open up the pandora box of operational challenges yet unforeseen.
#4 Know when to stop.
There is no end to knowledge gain, but the value added from this exercise can soon diminish given time constraints. For us, scoping soon became a research project rather than giving us more actionable insights, also because we were more document biased than relying on personnel interviews. Given the large scope of work we were taking on for the year and the implementation heavy side of the project, scoping was essential but devoting too much time to it would have reduced time for implementation. Every extra minute given to scoping reduces time for actual implementation.
#5 Don’t hesitate to change course, even afters scoping
Even though scoping is important, but we recognize that once a team gets started, the nature of problems change very quickly. We started with six interest areas but the same challenges surfaced in every work stream and diverted our energies on different issues entirely. Our projects transformed within a month of scoping -
Remember, scoping is just the first hunch on what you think you will be working on for rest of the year.
SEWA is a movement for empowerment of women in working in the informal sector. Started in 1972 by Ela Bhatt in Gujarat, the movement has now spread to 14 states across India with almost 2 million women members. The only women’s trade union in India, SEWA believes change comes from the grassroots and is inspired by its members’ belief - ‘We are poor, but so many’.
By Nayantara Nath, IIC- Social Alpha Team
With the world’s highest number of registered non-profit organizations—3.1 million—and burgeoning amount of for-profit social enterprises—2 million—the philanthropy sector in India has been on the upswing for the past 5 years. Yet, the UN Human Development Index (HDI) Report 2016 ranked India as 131 out of 188, with the HDI falling by 27% due to rising regional disparities in education, health parameters and living standards across the country. Experts agree there is a greater need for philanthropic funding and resources directed towards both non-profit & for-profit organizations to address India’s immense development challenges.
Traditional grant-centric funding models are slowly giving way to atypical investment approaches; the philanthropic ecosystem is evolving significantly, owing to the combined efforts of the public and private sector to promote social entrepreneurship, start-ups, and innovation-based interventions. Increasing government impetus and political will, coupled with the rise of incubation centers, accelerators, and impact investors have contributed to the rapid evolution of the sector.
Enter Social Alpha
Social Alpha, a joint initiative of the Tata Trusts and the Department of Science & Technology, is a three-tier ecosystem architecture designed to nurture non-profits and for-profit social enterprises throughout their journey from lab-to-market. These tiers comprise innovation support, incubation of enterprises, and investment in enterprises looking to scale. This architecture is designed to address the gaps left by the state and private sector in terms of provision of strategic guidance, seed capital and execution to social entrepreneurs and innovators.
With a deep focus on impact, Social Alpha has identified that science and technology innovations have the potential to bring about non-linear leapfrogging change in the life of the bottom-of-the-pyramid, by creating high quality yet affordable solutions. However, currently in India, it is difficult for such enterprises to find resources due to high early-stage risk, complex product-development journey, long gestation period, and low returns. Further, it has been documented that tech-entrepreneurs themselves may require capacity building, handholding, and guidance from mentors to take their products to market, and build scalable and sustainable enterprises.
With a lean team dedicated to addressing these needs and a portfolio of 20+ high-risk high-impact enterprises, Social Alpha has entered its second year of operation, and is looking to scale rapidly.
Incubating the Incubator
The IIC-Social Alpha team is working with Social Alpha, across functions and tiers, to develop and strengthen the identification, selection, incubation, and monitoring and evaluation of ‘incubatee’ organizations. Instituting processes that are adaptable at scale is the key implementation challenge that the team has taken into consideration. Adopting a research-based approach, the team has conducted over 60 in-depth exploratory interviews with incubators, accelerators, social entrepreneurs, impact investors, academic experts, mentors and social enterprise consultants, as well as team members of Social Alpha to understand the points of distinction between the functioning of these organizations. Post conclusion of this phase, the team has matched the findings from the external discussions to the key priority areas identified from the internal conversations.
It has emerged from our research the key challenges that most social incubation, acceleration and impact investment programs in India face include: effective scouting of high-impact enterprises, systematically assessing their needs, providing of capacity building, knowledge services & handholding support to advance them on their journey, and evaluating their performance (both in terms of impact and returns) in a timely manner.
Building on insights from external interviews and secondary research, our team has now formulated preliminary recommendations that seek to set a new industry standard in social incubation for efficiency at scale.
The social entrepreneurship and innovation sector in India is still at a nascent stage, with many new entrants in the market testing out experimental structures. In this dynamic environment, there is ample opportunity to pilot new processes and strategies. Our team is looking to design and implement inventive grand challenges and fellowships for scouting of social entrepreneurs, and sector-focused mentorship and capacity building programs in the upcoming months. The team is also looking to adopt an end-to-end digital tool for managing the functions of the incubator, and to formalize the partnerships and associations between organizations in the sector.
The need of the hour is to promote a culture of collaboration in both the social entrepreneurship and philanthropic sector due to a large number of organizations working on overlapping fields. To ensure that expertise, resources, and skill percolate to those who require it, it is necessary that there is increased coordination and knowledge-sharing efforts between players. There is also potential for awareness building to inform and educate the next generation of innovators regarding social entrepreneurship as a viable career option. Levying equal focus on empathy and efficiency at every step in the process, will lead to the creation of a new cadre of problem-solvers who can confidently undertake the mammoth task of countering India’s social challenges.
 ‘India has 31 lakh NGOs more than double the number of schools’, The Indian Express: http://indianexpress.com/article/india/india-others/india-has-31-lakh-ngos-twice-the-number-of-schools-almost-twice-number-of-policemen/
 The State of Social Enterprise in Bangladesh, Ghana, India & Pakistan, British Council: https://www.britishcouncil.org/sites/default/files/bc-report-ch4-india-digital_0.pdf
 India Philanthropy Report 2017, Bain & Company: http://www.bain.com/publications/articles/india-philanthropy-report-2017.aspx
Varun Jhaveri, IIC’s SAST Team Project Lead, has been selected as one of the Young Leaders from India to meet and interact with President Obama in the Townhall organized by the Obama Foundation on December 1, at New Delhi. The platform will assemble similar young leaders working on wide array of developmental issues in the country. The Town Hall will expand the conversation about what it means to be an active citizen and make an impact — and how the Obama Foundation can support emerging leaders in this effort.
By the SAST Team
The state of Karnataka has shown itself to be a pioneer in the Indian healthcare sector over the past decade. In 2009, the Suvarna Arogya Suraksha Trust (SAST) was established by the Government of Karnataka as an implementing agency to facilitate the delivery of healthcare assurance schemes in the state. SAST currently oversees the implementation of nine health insurance schemes, ranging from a program designed to help victims of road traffic accidents to one that provides tertiary care treatment to below poverty line residents of Karnataka. While the existing schemes are thorough and wide-reaching, limited awareness and access to care remains a challenge. In order to close existing gaps in coverage and to ensure that quality care is provided to residents, the government is rolling out a scheme named Arogya Bhagya to provide Universal Health Coverage (UHC) in the state. Upon successful implementation of the scheme, Karnataka will become the first state in India to provide UHC to its residents. As such, the implementation, utilization and monitoring of the scheme will serve as a model from which other states may garner insights.
During the implementation of Arogya Bhagya, there are numerous processes that must be well thought-out and clearly defined in order to ensure that the scheme is comprehensive and successful. The patient experience from the first visit to a healthcare facility up until completion of follow-up care needs to be carefully designed and accounted for. For the same, the operations and administrative processes of SAST when rolling out the scheme must be deliberate and considerate of a host of external and internal factors. How will the referral protocol be structured? What will be the strategy for empanelling hospitals under the scheme? What is the most effective way to maximize enrollment expeditiously? How will the implementation be monitored? Clear answers to these procedural questions are a necessity for Arogya Bhagya to be successfully implemented and impactful.
In thinking about these questions, our team began to notice an opportunity that offered the potential to streamline scheme oversight, improve beneficiary experience and maximize efficiency. While some of the processes that SAST oversees are digitized, for example claims review, many of these critical processes are not carried out on a digital platform. What if digital platforms could be used to track the beneficiary experience from first contact with a healthcare provider until final discharge? The possibilities for improving the patient experience would be significant. For digitizing SAST operations, we noted that it first would be necessary to review SAST procedures and protocol in order to help change processes to make them more logical, transparent, and efficacious.
Our team is now further investigating the role that digitization, process development and clean data collection and analysis could play in our efforts to improve the capacity of SAST and to aid in realizing the vision of UHC. Digitization and refinement of SAST processes would offer a wide-ranging number of benefits to the organization, the beneficiaries, and the medical care providers. By implementing digital mechanisms for collecting and analyzing data, SAST would be able to greater utilize data driven decision making when determining how to improve upon scheme implementation and other processes. The automation of processes would allow for greater access to information for SAST officials, medical care providers and beneficiaries. The information channels could be accessed by a wide range of stakeholders, thereby improving experience and efficiency. In addition, the streamlining of such processes on digital and accessible platforms would facilitate greater transparency and accountability, the importance of which cannot be overstated. These outcomes are merely a few examples of the progress that digitization could facilitate.
Our team envisions that digitization of processes is not merely an impactful disruption that will enhance the implementation of Arogya Bhagya and other SAST schemes, but it is a system that has the capacity to shift the way in which SAST operates and evolves for many years to come. It will be an intervention in keeping with the spirit of change and innovation that Karnataka’s healthcare sector has shown and will continue to show in the coming years.