Making inclusive insurance work series

Health Part 1: Telemedicine, Insurance and Universal Health Coverage

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The UNEP PSI and ILO webinar series

Making inclusive insurance work - A webinar series by the International Labour Organization’s Impact Insurance Facility and UN Environment’s

Principles for Sustainable Insurance (PSI) Initiative

As part of the global agenda of insuring for sustainable development, the Impact Insurance Facility (www.impactinsurance.org) and the PSI Initiative (

www.unepfi.org/psi) are organizing a seven-part webinar series with the theme, “Making inclusive insurance work”.

Today’s session will focus on “Telemedicine, Insurance and Universal Health Coverage”

• By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being

• Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

• By 2020, halve the number of global deaths and injuries from road traffic accidents• By 2030, ensure universal access to sexual and reproductive health-care services, including for family

planning, information and education, and the integration of reproductive health into national strategies and programmes

• Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all

• By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

• Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

• Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all

• Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States

• Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

• By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births

• By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births

• By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

health insurance – of any kind – is the most in demand an alarming percentage of people in the developing world have little or no access to cover and where they do, the quality is often poor… ‒ 56% of the global rural and 22% of the global

urban population have no health cover at allhealth related debt is often impoverishingexorbitant OOP health care costs are the leading cause of bankruptcy, andin some cases, UHC is years away from being realised, it is very complex and governments need support we also find that insurers want to offer something to the emerging consumer to help with health-induced financial risks, but don’t know how to do it in a sustainable way There is a global health worker deficit of 10.3 million

In our research on low-income populations, we frequently find that:

Availability of services Inequitable rural/urban distribution of global skilled health worker deficits 2015 (millions)

Urban deficit:More than 3 mil-lion

Rural defi-cit:About 7 million

Global health wor-ker deficit:

10.3 million

* Threshold: 41.1 per 10,000 populationSource: Global evidence on inequities in rural health protection. International Labour Office, Social Protection Department. Geneva: ILO, 2015.

Globally highest Rural Staff Access Deficits (SAD)*:

% of national rural population without access to care due to the absence of health worker

Somalia 98.6

Guinea 98.5

Niger 97.9

Chad 97.7

Ethiopia 97

Liberia 96.9

Haiti 96.6

Burundi 96.4

Central African Rep. 96.1

Tanzania 96.1

Making inclusive insurance work:Telemedicine, Insurance and Universal Health Coverage

Presenter:Jody Delichte

Inclusivity Solutions

Presenter:Andrew Smith

Tonic, Telenor Health - Bangladesh

Facilitator:Lisa Morgan

Impact Insurance Facility

8

Presenter:Dr Peter Benjamin

HealthEnabled

Health Enabled

Presentation by Dr. Peter BenjaminDirector

Mobile health

Mobile health (mHealth) is the practice of medicine and public health supported by mobile devices Recent: term first used 2003. Istepanian “unwired e-med”Started as field 2008, Bellagio ConferenceTech is more than cellphones & tablets, including: ‒ Patient monitoring devices‒ Mobile telemedicine / telecare devices‒ Data collection software‒ Apps (120,000 on iStore and Google Play)‒ Social media, gamification‒ Health & fitness wearables …ulationWay in / interface into wider eHealth

Education & Awareness

Diagnostic Treatment & Support

Disease & Epidemic Outbreak Tracking

Healthcare Worker Communication & Training

Remote Monitoring

Source: Intel. Women and the Web: Bridging the Internet Gap and Creating New Global Opportunities in Low and Middle Income Countries. 2012.

A real possibility: LMICs accounted for more than 80% of the 660 million new mobile-cellular subscriptions added in 2011.

Remote Data Collection

Why mHealth? mHealth holds real promise to transform health outcomes for vulnerable populations by providing:

Labrique et al. (2013)

Frameworks and tools for designing, implementing and evaluating mHealth Interventions

Inclusivity Solutions

Presentation by Jody DelichteChief Marketing Officer

Present > Future

Transtheoretical model of behaviour change

Telenor Health & Tonic: Mobile health innovation case study

Presentation by Andrew SmithChief Operations and Performance Officer

mHealth in South East Asia: Opportunity to transform access, affordability and quality

800 million new mobile internet

users in Asia by 2020 – with massive need for protection for loved ones, and

help to succeed in a changing world

Tens of millions driven into poverty through the cost of ill health, with major government, donor, investor focus on universal health coverage – need for scalable, commercial models

DI

Mobile technology

and AI enabling new

virtual primary care

solutions, and powerful new distribution models - quality healthcare where

itsnever gone before

Tonic

We combine…

DeepHealthcare expertise

Human centered design approach

SeriousTechnology

chops

To create…

a digital front door to health for all

We offer real solutions to real problems

Patient centered model of virtual care. Access to quality primary health care and expert advice when it’s needed

Access the right health information to stay well, and build my health community

Make quality health care more affordable.Help to find the best place to get the care that is needed, with exclusive benefits

Problem:I can’t find reliable information about staying healthy (for me or ones I love)

Problem:I can’t get the right care I need when I need it. I don’t where to look.

Problem:Health care is too expensive.

Our launch product in Bangladesh

Tonic Wellbeing Tonic Daktar Tonic CashHealth tips via FB / Web / Android App / SMS, including health hero’s, infographics, comic-strips – backed by medical evidence base

Access to a qualified doctor by phone, 24/7: SMS prescriptions, track previous health events and calls, follow up health tips

1000 BDT when you are in hospital for three nights or more. Insurance delivered over the mobile (claims, payments, enrolment)

Tonic DiscountsLargest national healthcare partner network – 250+ hospitals, pharmacies, diagnostic labs, and lifestyle partnersSave $1-2,000 USD with one SMS.

Tonic engagement and impact – c7 months in…

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2.85 million members(current growth: 20,000 per day)

Our impact and engagement to date....

Tonic Cash

Largest health insurance programme in Bangladesh. 1,600+ payouts, from contact to payment 5 days

Tonic Discounts

20,000+ discounts provided on services 200+ hospitals, pharmacies, and diagnostic centers across Bangladesh

Tonic Daktar

160,000 medical consultations with our in-house doctors through telemedicine service

Tonic Wellbeing

1.5m daily reach with health and wellness content via Facebook C9-10% average share(s) with family and friends – forming a community of health

Data across the healthcare journey (200m data points already….), spot the healthcare gap, fill it!

Customer-centricity– net promoter score of 50+

✔ Symptom & disease management protocols for conducting telehealth consultations

✔ Comprehensive training program to improve the delivery of clinical services & regular monitoring of clinical performance

✔ Custom electronic health record system to assist doctors in conducting telephone based consultations, with full clinical coding and patient health history

✔ Organizing monthly Continued Medical Education where group of our doctors discuss on challenging clinical cases they encounter over the phone

✔ No major clinical complaints or critical incidents, in 150,000+ consultations

Deep dive: clinical quality

29

Quality

Deep dive: affordability

30

Affordability

✔ Discounts provided to the customers through a nationwide partnership network with 200+ hospital, pharmacies and diagnostic centers

✔ cBDT 1,000,000 has been disbursed as a part of Tonic Cash micro insurance claims

✔ $1,000 saved on open heart surgery – largest discount provided – most redeemed are pathology/tests

✔ Approximate amount of discount provided is BDT 4 million. 20,000 customers with more affordable care.“My family was going through a very hard

time due to my father’s open heart surgery. I got a discount of 13,000 only because of Tonic. This was a great help during that time. I hope Tonic will add more partners nationwide” : Tonic Member Ibrahim Cardiac Hospital

Where next? Meeting new customer needs

Chat with Doctors via multiple channels, when/how you want

Health checks – bringing

together real world and

digital

Distributed care and

appointment booking

Micro-insurance to

cover greater cost

of care, bundled

packages

Where next? Measuring our impact

…and all powered by great people

Client Education & Behaviour Change Sensors & point-of-care diagnosticsRegistries / vital event trackingData collection and reportingElectronic health recordsElectronic decision support Provider-to-provider communicationsProvider workplanning & schedulingProvider training and educationHuman resource managementSupply chain managementFinancial transactions & incentives

Frameworks and tools for designing, implementing and evaluating mHealth Interventions

Labrique et al. (2013)

mHealth around the world

83% of WHO member countries reported having at least one mHealth initiative in their country.1

77% of responding low-income countries reported at least one mHealth initiative in their country, making them only ten percent behind high-income countries.1

1World Health Organization. mHealth: New horizons for health through mobile technologies: second global survey on eHealth. http://www.who.int/goe/publications/goe_mhealth_web.pdf.

Ugandan Pilotitis

9 principles of digital development

“Fail fast, learn quickly, do it again”

Airtel Insurance (health micro-insurance in 7 African countries)Aponjon (maternal health messaging in Bangladesh, part of MAMA)cStock (medical supply chain in Malawi)iCCM (mobile tool for health workers in integrated community case mmgt, Malawi)Kilkari (maternal health messaging via voice & CHW training, India)mHERO (health worker SMS messages for targeted care, 6 W African countries)mSOS (disease surveillance reporting, Kenya)RapidSMS Rwanda (preventing maternal & child death in 1,000 days, Rwanda)U-Report (preventing adolescent AIDS by mobile counselling & polling, Uganda)MomConnect (Maternal health messaging, South Africa)

USAID mHealth Compendium: Reaching scale

National Department of Health, South Africa

SMS sent from 1st ANC, delivery, to babies 1st birthdayAfter 25 months of operation:‒ SMS sent to 950,000 pregnant women & mothers of infants‒ MomConnect in over 3,350 (97%) facilities‒ Six times as many compliments (5,763) as complaints (912)‒ NurseConnect: 12,000 nurses getting training & support

SMS‒ Additional PMTCT messaging for HIV +ve pregnant women‒ Research (small-scale) shows that mothers receiving SMS

messages have better health outcomes‒ Mobisite, Facebook messenger (and soon WhatsApp)

MomConnect

Introduction of proven interventions at specific key points of entry from before birth to after five years of age

* Bryce et al. Can the world afford to save the lives of 6 million children each year? The Lancet 2005; 365:2193-2200.

INTERVENTIONOF KNOWN

EFFICACY

EFFECTIVECOVERAGE

Thanks to: Alain Labrique, JHU

INTERVENTIONOF KNOWN

EFFICACY

EFFECTIVECOVERAGE

mHEALTH: A Health Systems Catalyst

Thanks to: Alain Labrique, JHU

FAILURE TO FOLLOW

GUIDELINES

DRUG OR SUPPLY

STOCKOUT

POOR DEMAND FOR

SERVICES

And begin to align mHealth strategies with the post-2015 agenda to achieve universal health access (Labrique & Mehl, 2015)

Financial Coverage

Effective Coverage

Continuous Coverage

Contact Coverage

Accessibility of health facilities

Availability of human resources

Availability of commodities and equipment

Accountability coverage

Target population

Total population

COST

QUALITY

DEMAND

SUPPLY

AVAILABLITY

E

D

C

B

A

H

G

F

TARG

ET: u

nive

rsal

effe

ctiv

e co

vera

ge o

f hea

lth

inte

rven

tions

of k

nown

effi

cacy

Current gap in determinant performance

Illustrative mHealth strategies to close performance gaps

Minimum performance of supply determinant

mHealth Strategies

Mobile financial transactions

Decision support, POC diagnostics, Telemedicine, Reminders, Incentives

Persistent electronic health records, Provider-to-provider communication, Work planning, Reminders

Behaviour change communication (BCC), Incentives

Hotlines, Client mobile apps, Client information content subscriptions

Human resource management, Provider training, Telemedicine

Supply management, Counterfeit prevention

Client registration, Electronic medical records, Unique identifiers, Data collection and reporting, Screening tools, Civil registration and vital events

E

D

C

B

H

G

F

A

DETERMINANT LAYERS OF UHC

HealthEnabled: Towards scaled sustainable impactful integrated digital health

Informed Decision Making

National Policy

Sustainable Programs

Design for scale, operationalize & build platforms

Effective Use

Evidence-based public good tools

HealthEnabled

National Digital Health

Systems

Health information for all: Wiki Health 100 x 100Support personal change: Stop smoking, eat better, exerciseCallcentre triage: 45% resolved during the callEmergency response: Distress call community ambulanceAdherence support: Welldoc “prescribed” for diabetesPre-emptive health (Support people responsible for own health)Towards precision medicine / genomics for public health

Digital health as the primary contact to the health system & empowering own health

Health > healthcare. mHealth extends services outside the clinic

mHealth: ‒ Tool for health system efficiency, data collection, mgmt, info flow ‒ Improved point-of-care services, decision support, patient record‒ Tool for wider holistic health, empowering people

Evidence-based for some: ‒ Data collection ‒ Supply chain / lab results / mgmt ‒ HW decision support, EMR ‒ Behaviour change ?

Great tool for Universal Health Coverage (NHI)

From “mHealth” -> New normal, how to do large-scale public health

In closing

“These tools don’t get socially interesting until they’re technologically boring” (Clay Shirky, 2010)

Market-based, comprehensive health microinsurance is not viable and has not reached scale

-50%

-30%

-10%

10%

30%

50%

2008 2009 2010 2011 2012

Life mandatoryLife voluntaryAgriculture mandatoryHealth voluntary

Unprofitable, losses subsidized

Profitable, explicit subsidy

Profitable, implicit subsidy

Profitable, no subsidies

Composite (Nirapotta – microfinance)Inpatient + Outpatient (GK – microfinance)Inpatient + value-added services (Naya Jeevan)

Inpatient + Outpatient (RSBY - government)

Hospital cash (Jubilee/MFW)

Inpatient (ARY – distribution partner)

Evolution so far… and promise of PPP models

Private or community-based health insurer (CBHI)

SubstituteHMI services a population that is a) ineligible for public coverage or b) does not receive effective public coverage Reform

designs underway

No reform in place

Maturity (e.g. time, political commitment, management capacity, infrastructure, resources)

Government

Prov

ider

of

cove

rage GOAL:

Universal Health Coverage

FoundationCBHI is at the origin of health social protection; government decides to scale and exerts regulatory authority over CBHIs

PartnershipGovernment outsources specific pieces of the insurance value chain to private partners (insurer, bank, MNO and other organized groups)

SupplementHMI provides products covering additional benefits to public scheme (e.g. telemedicine, outpatient benefits, lost wages, travel, etc.)

Prim

ary

Prov

ider

Seco

ndar

yPr

ovid

er

Making inclusive insurance work:

Telemedicine, Insurance and Universal Health Coverage

Presenter:Jody Delichte

Inclusivity Solutions

Presenter:Andrew Smith

Tonic, Telenor Health - Bangladesh

Facilitator:Lisa Morgan

Impact Insurance Facility

57

Presenter:Dr Peter Benjamin

HealthEnabled

Q&A

Our next webinarsMaking inclusive insurance work - A webinar series by the International Labour Organization’s Impact Insurance Facility and UN Environment’s

Principles for Sustainable Insurance (PSI) Initiative

The topics and schedule of the next webinars are as follows:

4. SMEs and value chains – 16th March 2017 5. Agriculture and climate risks - April 2017

6. Health Part II – date TBA7. Insurance regulation – date TBA