Beyond the current debate on US health reform, which has us all posting on Facebook “No one should die because they cannot afford health care, and no one should go broke because they get sick “, the fact of the matter is that the accident of your birth largely determines your future health.

And no, it isn’t fair. If you are born in Sierra Leone, 1 out of 6 babies do not survive. In the developed world, 1 out of 10,000 babies die.

The WHO released a landmark report last August on health equity “Closing the gap in a generation”

Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others….Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen.

With a rapidly urbanizing world – projections of 60% of people will live in cities by 2015. Most of these people are escaping rural poverty, and will live in informal settlements in the developing world.

Guidelines must be developed to ensure health equity, but we also need tools to help us plan.

Read the rest of this entry »

As promised earlier, here is a brief account about the design+water workshop I conducted in Mexico in June.

Two months ago, I was in La Paz, Mexico at NGO Fundación Cántaro Azul, helping them build organizational capacity in human-centered design (HCD).  Cántaro Azul works to improve access to safe water and sanitation for disadvantaged communities, not only in Baja California Sur, but in other parts of Mexico, and abroad. Their interest in HCD is two-fold: to improve existing initiatives and to innovate new approaches.

I recently completed the workshop final report for the organization. In the hopes that the work may be helpful to others, I’m posting the synopsis of the report here, along with some workshop photos. If you’re interested in accessing the report, please contact me directly.

Design thinking workshop final report: Safe water options with rural community stores in BCS 

Fundación Cántaro Azul • La Paz, Baja California Sur, México 

Jaspal S. Sandhu, Ph.D. • July 2009 

This document describes the outcomes of a week-long design thinking workshop held at Fundación Cántaro Azul (FCA) in La Paz in June 2009. The workshop aimed to build design thinking capacity at the organization while working on a problem of actual importance to FCA. The most important practical outcomes of this workshop were two complementary models for providing a clean, affordable drinking water choice for rural people in Baja California Sur via community stores. The primary audience for this document is FCA. It is intended to help them with ongoing activities focused on the community store model and in incorporating this approach in their various activities. The workshop was designed and facilitated by Jaspal Sandhu, the report author. Workshop funding was provided by the Blum Center for Developing Economies at the University of California, Berkeley.

Shown below: Field research during Day 2 and Day 3 of the workshop. (1) Using an auto-servicio system in La Paz (top left); (2) interviewing a user at a rural, government-run purificadora in San Antonio (top right); (3) debriefing after the San Antonio research (bottom left); (4) and obtaining water samples to test from a home in Rosario (bottom right).

As with the last post, I’m copying the description of the session I just attended – Vouchers for Health (Session C3) - from the conference website:

Presenters Discuss: the potential of competitive vouchers in increasing access to priority services for currently underserved populations (Nicaragua); how subsidized, targeted vouchers can achieve the goal of improving health of poor women and children, elements that improve access to high quality health care services, how targeted voucher subsidies help meet the goal of contributing to development of a national social health insurance system that is accessible, affordable and acceptable (Kenya); a nationwide, high transaction distribution project for insecticide treated nets (ITNs) that has given rise to the application of technologies in the use of a relational database as a means to track each voucher transaction, ensuring security and traceability, providing spatial analysis using GPS coordinates, leveraging data from this project to others by providing a central data repository to government, and exploring SMS and mobile phones for automating voucher transactions and gathering patient information (Tanzania); and how poor pregnant women were selected for vouchers jointly by field workers and community support group members, how the institutionalization process for the voucher scheme was implemented, and how the health facilities were strengthened to provide quality maternal health care (Bangladesh).

Why should we care about voucher schemes? Three reasons from where I sit. These schemes provide:

1. An attractive model for extending the reach of services without significant infrastructural investment
2. Incentives for competition to improve the quality of service delivery
3. A mechanism for reducing financial barriers for the poor

Despite this promise, my experience over the last few years – including stumbling through a poster presentation about vouchers in Uganda for Ben at APHA in Boston a couple years back – has taught me that the concept tends to be elusive to “outsiders”. The World Bank’s Private Sector Development Blog has a concise overview of output-based aid for those that aren’t familiar. I won’t try to explain myself, since I’ll probably make some errors.

This session brought together diversity in geography – the talks covered Latin America, Africa, and Asia - and in services – anti-malarial bednets, safe motherhood, family planning, STI prevention and treatment. What was most interesting to me then was not the details of any specific program, but what we might be able to learn from having these different experts in the same room.

So what were the common themes?

1. Vouchers work. Nicaragua saw increases in service utilization, condom utilization, family planning uptake, and KAP. Much of this across different subgroup analyses – age, level of sexual activity, type of residence. The others similarly all saw positive gains in what they were trying to achieve.
2. Institutions matter. In Tanzania, the market is being flooded with free ITNs (possibly LLINs) under a new policy to achieve universal coverage – the fate of the 7000 bednet retailers under the Tanzania National Voucher Scheme (TNVS) is unknown. In Kenya, Nairobi and Kiambu saw better results for the voucher scheme because of existing infrastructure. Nairobi actually had provided more voucher-based services than vouchers sold in Nairobi because of women coming in from outlying areas. Tanzania benefits from a manufacturing base that can produce ITNs and a system that encourages people to pay for a portion of their health care.
3. The system will be gamed. The much higher reimbursement for providers of C-sections than vaginal deliveries has led in some cases to higher rates of C-sections than is necessary. April Harding who was moderating said that multiple schemes have been used/proposed for dealing with this, including capitation (e.g. for 100 women, X% will be reimbursed for C-sections). Fraud is also a problem. While nobody discussed incidences of counterfeiting, the Tanzania program has taken big steps to prevent counterfeiting, including watermarks, microprinting, and a bar code. The bigger issue with fraud is related to ineligible participants obtaining and using vouchers intended for other populations, whether by income or geography. Which leads us to the next point…
4. Equitable distribution is hard. Ineligible participants seem to be a problem with all these programs. In Bangladesh they responded by bypassing governmental decisions about who would get vouchers and relied on CSGs (community support groups) to make the decisions. Another trend is that those who are more poor tend to utilize vouchers less – it is unclear if this due to cost, education, and interaction among the two, or something we’re not thinking about.
5. Understanding redemption is complicated. This was my one question. In both Tanzania and Kenya – the others didn’t present these numbers or I didn’t catch them - the rate of redemption (number of people receiving services under the voucher scheme divided by the total number of vouchers distributed) – was around 80%. After I asked the question and before the panelists responded, my neighbors said that: (1) 80% is pretty good, and (2) the Tanzanians unlike the Kenyans don’t pay for their vouchers until they use them. In Tanzania then, the reasons are grounded speculations: perceived value of the ITNs, access, cost. In Kenya, the majority of the outstanding 20% is due to accounting. The real utilization is expected to be much higher since the cutoff for the evaluation excluded women who had received vouchers, but had not yet delivered (safe motherhood program). Still a minor portion of this is due to women who are unable to deliver at contracted facilities due to a lack of transportation or the timing of the pregnancy.

‘The Biggest Challenge Is There Is No Organized Supply Chain’

This headline in Wharton’s newsletter intrigued me, only time for a quick posting, but this is certainly food for thought. Wal Mart is expanding operations in India and there are two quotes of note that we should think about in the context of culture; delivery and distribution of medical/health goods to those in need; and in the context of refrigeration of medication and/or vaccinations:

===========

“The biggest challenge is that there is no organized supply chain in India. We’ve even been surprised by some of the leading manufacturers in India like Unilever, Procter & Gamble, and some other big names, who are actually welcoming the arrival of organized supply chains in India and Wal-Mart pioneering that effort. Because of the lack of that supply chain today, there is no forecasting, there is no understanding of how demand is. It’s largely a push based system. So, I think, getting that transparency across the supply chain will be very unique.”

“The other thing is, there is no refrigerated cold chain for fresh produce in India, so therefore a lot gets wasted. By McKinsey’s own work, which the consulting firm has done, almost 40% of fresh produce in India gets wasted from farmland to the time it reaches the consumer.”

“India is very unique. In fact, I have lived in China, so maybe I can say it with a little bit more liberty that the only thing common between India and China is the one billion people. If you really operate in the two countries, I think, there are very different consumers, very different kinds of legislation, very different levels of economic development, social infrastructure, and governmental management of the economy.”

 
Read the full interview here.

KarmaTube’s video of the week is about wheelchairs which are made from recycled parts. The chairs are made by Wheels for Humanity where, “staff and volunteers at Wheels collect and refurbish used wheelchairs and deliver and individually fit them to impoverished children and adults in developing countries.” It looks like the organization has some important friends. Last Fall, first lady, Maria Shriver joined Wheels in Chiapias to deliver wheelchairs (photos here).

An excerpt from the video – “we take equipment that people consider trash…the wheelchairs we refurbish would normally go into a landfill”. Time: 5:42, Enjoy.

[youtube=http://www.youtube.com/watch?v=_HFjXKBMQKA]