The Quest for Universal Quality: Financing Healthcare in India

The Quest for Universal Quality: Financing Healthcare in India

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.

The Challenge of Scoping

The Challenge of Scoping

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
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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.

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#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 - 

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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’.


Incubating Impact: Supporting start-ups that matter

Incubating Impact: Supporting start-ups that matter

By Nayantara Nath, IIC- Social Alpha Team

With the world’s highest number of registered non-profit organizations—3.1 million[1]—and burgeoning amount of for-profit social enterprises—2 million[2]—the philanthropy sector in India has been on the upswing for the past 5 years[3]. 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.

Looking ahead

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.



[1] ‘India has 31 lakh NGOs more than double the number of schools’, The Indian Express:

[2] The State of Social Enterprise in Bangladesh, Ghana, India & Pakistan, British Council:

[3] India Philanthropy Report 2017, Bain & Company:

Varun Jhaveri, IIC Project Lead, selected to meet President Obama in New Delhi

Varun Jhaveri, IIC Project Lead, selected to meet President Obama in New Delhi

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.

A Mandatory Disruption: Using Digitization to Enhance the Patient Experience

A Mandatory Disruption: Using Digitization to Enhance the Patient Experience

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.   





By Konje Machini

As we edge closer to the end of the fellowship, we’re forced to begin the lengthy process of reflection. Yesterday marked my eleven month in India—the better part of a year. It feels like it was only last week that a group of some thirty or so strangers met in the lobby of Max Palevsky West dorm in Chicago. It was only yesterday that we all got on a sixteen-hour flight to Delhi only to then scatter across the country.

  The team in Vijayawada – September 27th, 2016

The team in Vijayawada – September 27th, 2016

Fast forward many months and things are coming to a close. While we still have a lot to learn, we are no longer so green behind the ears. The Telangana team can hold their own in any conversation on irrigation in India; the team in Jaipur know the ins and outs of community participation in education and quite a bit on Aadhar enrollment for children; IIC SAST have become aces in insurance fraud detection. Even my team has become conversationally fluent in a few of the different dialects of development work. At times, I have felt a bit out of my depths; understanding the complexities of Delhi’s hybrid state-union territory governance structure, making sense of the science behind green crematoriums, or in navigating some of the formalities of proper email etiquette within Indian governmental bureaucracy. And, while I still stumble, it happens with less and less frequency—you could call that progress.

In a month’s time we’ll have to collate all our lessons learned into a digestible thirty-minute presentation. And for some, this reflection has taken place a bit earlier via the job interview process. The question, at the end of day, whether in a job interview or at the final presentations, is what impact have you made. I’ve definitely come to see our value addition as a team on all the projects we’ve been on, but attempting to quantify or qualify this has been a tricky task.

The limited timeline of our fellowship doesn’t necessarily allow us to see each project through to its very end. Of course we have planned with impact in mind, and are taking the care to ensure the sustainability of each of our projects, but this does not guarantee we actually get to see the outcomes of our outputs. Some of us will most likely be long gone before any of the impact takes effect. It’s this that’s led me to reflect not just on project impact but some of the other intangibles we’ll all be taking with us.

A keepsake that comes to mind easily is all that we have learned over the past year. Overcoming hurdles this year is not just a help to current projects, but future ones as well. We will carry with us all the lessons learned from this year and put them to use in future positions and roles. Slightly more tangible than knowledge, are the relationships we formed and can take with us. As a fellowship, unsurprisingly, the fellows have greatly painted my experience. The so-called strangers from the beginning of the fellowship have now become learning partners, resources, and great friends—especially in regards to my team. There are innumerable adventures, sights, friendships, mangoes, and so much more that I will take with me and that have made this fellowship impactful.

  A recent photo of the team at a countrywide workshop for NITI Aayog –  July 11th, 2017

A recent photo of the team at a countrywide workshop for NITI Aayog –  July 11th, 2017

After all, at the end of the day impact is our focus. We spend our time designing, planning and executing our projects with the idea in mind of creating lasting, positive change. As we move to the final presentations aimed at addressing just that topic, I want us all to also take time to reflect on the rest of the puzzle. Even if we don’t see the impact of our projects just yet, it’s not hard to see the broader impact of our time in the fellowship.

Assessing Effectiveness and Scalability of Ed-Tech in India

Assessing Effectiveness and Scalability of Ed-Tech in India

By Rishi Razdan and Alexandra Tate

Most education experts agree that the poor quality of teachers, lack of personalized pedagogical methods, and absence of effective means to track student progress are key issues plaguing the Indian education system – resulting in low learning outcomes and poor retention amongst the 260 million students in Indian schools.

In response to this, a vibrant start-up community, enabled by impact-focused investors such as the Micheal & Susan Dell Foundation, Acumen and Unitus Group, has created an explosion of products and ideas in education. A number of innovative social enterprises, operating in different parts of the education value chain, have emerged from this explosion. ConveGenius is one such social enterprise that designs educational tabs with gamified content. It aims to boost student engagement and retention through fun, interactive pedagogy. The tab can be synchronised with coursework, to act as a supplemental tool, in class or at home. The fully loaded cost of a ConveGenius tab, called CG Slate, including hardware, software and course content, is about INR 7500. However, the cost drops down to as low as three rupees per day in a classroom-based sharing model when five students share one tab. The relative affordability of this product promotes greater social impact by making it accesible to the BoP.

Avanti, another young social enterprise, focuses on preparing high-potential, low-income students for college. Avanti Gurukuls provide educational infrastructure for students and arm competent, passionate teachers with technological tools that personalize learning and track progress. A third of Avanti’s students cleared the JEE mains in 2016 – a resounding validation of their potential to make an impact.

Another impactful, innovative social enterprise solving a problem – albeit, in a different part of the value chain – is OnlineTyari. Government jobs in India, are primarily acquired by middle-class aspirants; those with access to coaching centres and crucial information regarding exam notifications. For lower-middle income groups, especially in small-towns, these entrance exams are a maze due to the lack of organized information, and minimal access to quality coaching or preparatory material. OnlineTyari, tries to solve this problem by providing government job aspirants with access to exam notifications and quality test preparation material – from e-books to news and mock tests – on their mobile app. Their user-base of nearly half a million daily users, with a majority based in tier-II and III cities, exemplifies how digital tools can amplify access to opportunity.

Improving ed-tech assesments using comparative practices

While technology-based innovations have augmented a re-imagination of education across the value chain, doubts regarding their actual impact persist. Education is perceived as an important social good, a consequential good that benefits society at large. Consequently, new products and services in education must prove their effectiveness before they are fully adopted. Proving, beyond reasonable doubt, that education technology products are effective and viable in the Indian system, is key to attracting more investment and driving adoption.

Clinical research practices, used to prove the effectiveness and viability of new treatments, can serve as a model on how to adopt similar practices in ed-tech. In fact, clinical research and educational research face shared ethical and practical constraints, as well as also many possible, shared solutions. For example, clinical researchers have been able to improve the generalizability of study results by increasing the rigor with which outcomes are assessed, e.g. tracking outcomes over a period time, instead of just at a single point. ConveGenius is a prime example of an ed-tech company that has already begun tacking outcomes over time. ConveGenius’ CG Slate consistently tracks student usage and learning outcomes for parents and educators.

Due to ethical constraints, students – like patients – cannot be assigned to another pedagogical method or treatment that researchers believe is inferior. To solve this, clinical researchers often determine the internal validity of a treatment by measuring pre-treatment and post-treatment outcomes, and report the underlying characteristics of the population. The same should be done in ed-tech. The underlying characteristics of the student population must consistently be reported and pre/post-learning outcomes should also regularly be reported. In order for the education sector to improve the external validity of product effectiveness and viability, product assessment tools and methodologies must be published and shared. The entire ed-tech ecosystem can also benefit from a standardization of assessment methods, making assessments more economical and generalizable. Standardized and improved assessments of product effectiveness and scalability will result in better technology for non-profits, safer investments for multilaterals, economies of scale while testing for enterprises, and knowledge sharing where possible for all involved.

Ensuring meaningful impact in rampant growth

The Digital India campaign is driving huge growth in digital infrastructure and digital learning. In order for new infrastructure to be utilized, there must be equal effort and resources spent to integrate and assimilate new technologies into the education system. Rural areas, in particular, have a low adoption-rate of technology due to a lack of technology enablers. Government, non-profits, ed-tech companies, and investors can all play a role in ensuring the seamless integration of technology into new environments and classrooms. This growth in infrastructure is encouraging the development of new ed-tech products as well as the demand for more creative and engaging content.

Ironically, the frenzy of innovation has become an impediment to proving the effectiveness and viability of education technology, primarily due to two reasons. First, a high degree of competition puts immense pressure on entrepreneurs to expedite product development and going to market. The time-constraint makes it impossible to steadily test product effectiveness across a large enough sample. It is widely believed, for example, that it takes three years to significantly impact students’ learning outcomes – time entrepreneurs don’t have. Second, the nascent stage of most Ed-Tech enterprises creates a resource constraint. Designing a great product is often step zero for an enterprise; enterprises need to dedicate a significant amount of resources to integrating their products into existing systems, by conducting trainings and customizing their products for clients. Conducting lengthy pilots with large samples of students is a poor micro-economic decision for them. These deep-seated problems can only be solved through stakeholder collaboration.

Stakeholder collaboration and buy-in on the importance of product assessment can ensure that rampant growth in the ed-tech sector leads to meaningful and lasting impact. Ed-tech start ups will only invest in intensive product assessment methods if investors demand it and the ecosystem values it. Government should encourage information sharing and standardization of assessment tools and methodologies; investors should mandate proper assessments by start-ups; ed-tech entrepreneurs should adopt and share the best practices for assessment; and non-profits should aim to promote and integrate only the products that have been assessed as effective.