Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary (2015)

6

Innovations and Organizational Strategies to Strengthen Health Systems

Susan Kosman of Aetna Inc. opened this session with a quote from President John Kennedy regarding the space program in the 1960s:

The “moonshot,” which resulted in the moon landing of Apollo 11 in 1969, required not only commitment and collaboration among stakeholders and the public, but also innovation and a shift in organizational paradigms. Kosman asserted that such an approach would be crucial today in investing in and empowering nursing and midwifery to transform health systems.

INVESTING IN WOMEN-OWNED HEALTH ENTERPRISES¹

Monique Dolfing-Vogelenzang spoke about developing alternative approaches to building public goods when state capacity and resources are limited. Her organization focuses on strengthening health systems in sub-Saharan Africa, specifically process, access, and funding. In many countries, there is not enough public funding to cover the cost of patients as well as providers’ income. In sub-Saharan Africa, she noted, most countries budget approximately $20–$40 per year per patient, compared to approximately $4,000 per year in Europe (WHO, 2010). With these constraints, the state cannot cover these costs, and the private sector tends to play an increasingly larger role.

Because health care is a service, she explained, there needs to be balance between supply and demand. Strengthening health systems means organizing demand, including insurance, spending, and patients’ capacity to pay. On the supply side, there needs to be quality provision of care, which

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¹ This section summarizes information presented by Monique Dolfing-Vogelenzang, Medical Credit Fund (MCF).

is often lacking. When it does exist, there are often problems; it is of bad quality, patients have little trust, and there is little willingness to pay.

Ideally, a robust health system would include at least community-based health insurance, or possibly even universal health coverage. However, Dolfing-Vogelenzang pointed out, such a system requires a strong and capable government that can collect taxes; can finance, organize, and regulate the system; and can attract investment. The private sector can fill these gaps in the near term, or partner with the public sector in both the short and long term. The Medical Credit Fund (MCF) was initiated in 2009 by the Dutch company, PharmAccess, to enable primary health care providers in Africa access to investment capital so they can improve the quality of their services and expand their facility. The MCF investment strategy has two risk reduction programs as seen in Figure 6-1 that involve quality measurement and improvement known as SafeCare, and access to risk capital from local banks that are in part guaranteed by MCF.

The SafeCare program aims to develop standards in resource-restricted settings, based on international standards met by good local solutions. Dolfing-Vogelenzang emphasized that it is not an accreditation program, but rather a stepwise improvement system. It is a system that operational-

FIGURE 6-1 The investment strategy: Two risk reduction programs.
SOURCE: Dolfing-Vogelenzang, 2014.

izes regulation and enforcement to measure efficiency and gives insight into how the facility is performing—not only regarding profit and loss, but also patient outcomes. It also provides an opportunity for facilities to self-evaluate, and it engenders trust in patients because of a recognizable brand.

Enrolling a clinic in the SafeCare program entails first running a gap analysis to determine strengths and weaknesses. Financing is usually an identified weakness, though not necessarily as a funding need, but instead in terms of prioritization of funds and financial training. A business plan is developed with input from clinic staff, which might include business training. Additionally, if a clinic chooses, the SafeCare program also assists in the procurement of a loan. After 2 years, the loan is repaid and the analysis is undertaken once more to measure improvement over that time.

Dolfing-Vogelenzang also described that access to finances is another important element of the empowerment discussion. A better understanding of how the funding flows and how investment affects operations enables a greater sense of ownership. Entrepreneurs also learn how to negotiate with suppliers and how to build a case for loans from banks. About 25 percent of the clinics they work with are owned by women. Of those, about 90 percent have applied for loans, with a total of 97 loans disbursed. Sixty-one loans have been repaid. Because the loan repayment has been less than average, Dolfing-Vogelenzang and her colleagues examined the issue further. They found that, in some cases, some of the clinics have run into cash flow problems because insurance payouts from the national system are delayed.

In a brief discussion following the presentation, Dolfing-Vogelenzang noted that the staff at these clinics are not always health professionals (such as nurses, midwives, and physicians) but are sometimes a female relative of a health care professional. In one case she described, an entrepreneur took over a clinic after her husband, a physician, passed away; she was able to implement a number of changes, including an expansion that would not have occurred under her husband’s leadership. Dolfing-Vogelenzang also clarified that access to funding was not always the issue; rather, the structure of staffing could be the issue, specifically the absence or presence of the physician-owner.

GLOBAL LAB FOR INNOVATION²

The University of California, Los Angeles (UCLA) Global Lab for Innovation defines innovation as “a product, service, business model, or work process that accelerates the transformation of care. It may be point innovation or comprehensive, and it is technology-enabled but [focused on more

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² This section summarizes information presented by Molly Coye, University of California, Los Angeles (UCLA).

than] the technology.” The Global Lab scans domestic and international markets for innovations that reduce the cost of and improve access to care. Molly Coye and her colleagues specifically target delivery systems and their decision makers to prioritize and implement successful innovations.

Coye noted that implementers often recognize that there are different ways to accomplish a goal, but uncertainty exists around which way is the most appropriate. The Global Lab for Innovation seeks to “de-risk” the choice by providing useful, systematic information across multiple platforms. This information is presented in a “scorecard” that allows decision makers to choose criteria suitable for their own context and find the innovations that best fit. Coye stated that anyone can post an innovation, and her team scrutinizes those innovations to determine the characteristics of the innovation as components of the “scorecard.” At the same time, the Global Lab contacts other health systems that have adopted the innovations, because their experiences and results serve as a practical test of whether the innovation can be successfully adopted. Coye explained that innovations are “bucketed” by results, impact, and implementation time (see Figure 6-2). The first step is to separate out potential innovations that

FIGURE 6-2 “Bucketing” innovations.
SOURCE: Adapted from Coye, 2014.

are qualified because they are already well recognized in the field and are used by 15 percent of possible adopters (“emerging best practices”), or because they are not reducing use of services but do achieve price reduction (“pricing innovation”). Then, innovations are separated into a “promising innovation” category (that is, the innovation does not yet have results), or into a “documented innovation” category. Documented innovations are further separated by the amount of time to achieve savings (within 1 year or in less than 3 years).

The scorecards created by the Global Lab for Innovation include information that adopters would like to know about each innovation in order to find “best fit” innovations for their organizations, including such questions as, “How does it increase access? Is it solving geographic problems? Is it solving linguistic problems? What is the method or the means? How does it decrease cost?” Coye noted that this last question is critical, and innovators often combine one or more of five means: (1) substituting lower-cost labor or information technology systems, (2) relocating to a lower level of care (such as in the home instead of in the clinic), (3) using telemedicine, (4) encouraging cost-effective decision making by patients or clinicians, and (5) managing the use of diagnostic tests. In addition to cost, other domains assessed include dissemination potential, access, customer centricity, and health outcomes. Future potential domains could also include empowerment and the impact on the health environment.

SUPPORTING SCALING OF IMPACT OF GLOBAL HEALTH ENTERPRISES³

The Social Entrepreneurship Accelerator at Duke (SEAD), mentioned in Chapter 3, is a program designed to build capacity and provide a conduit to convene multiple programs across the university. It has five components:

1. Identification of the best enterprises working in the global health space,
2. Entry into an accelerator platform,
3. Creation of an investment impact network,
4. Engagement of faculty and students, and
5. Research and data collection.

SEAD brought in 11 organizations in its first year, and 6 organizations in its second year (some organizations include SughaVazhvu, a rural primary care clinic in India; salaUno, an eye care clinic in Mexico; and Jacaranda, a

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³ This section summarizes information presented by Krishna Udayakumar, International Partnership for Innovative Healthcare Delivery (IPIHD).

maternity clinic in Kenya described by Petra ten Hoope-Bender in Chapter 4). Organizations are brought through the accelerator over a period of 3 years, with program evaluation, expert coaching and mentorship, online tools, and connections to public- and private-sector partners. In the first year of the program, Udayakumar and his colleagues did a gap analysis and customized interventions for each of the organizations in the program. They identified six challenges these enterprises faced in trying to scale impact:

1. Strategic planning: How do you balance the day-to-day activities and concerns with the direction of the enterprise?
2. Funding and investment: Many enterprises took “scattershot” approaches because they did not understand what type of funding would be best for their growth trajectory.
3. Performance management: Enterprises need to be learning organizations rather than intuitive in their approach.
4. Innovation development: What are the key characteristics of the innovation, and how is it delivered? How do unit economics change when operations are scaled?
5. Organizational leadership: How do you grow human capital through recruitment, retention, and professional development?
6. Ecosystem: Enterprises need to learn about the environment in which they operate.

Udayakumar also shared a few lessons learned, namely that assessing an organization’s stage of development and capabilities was a time-consuming process that required diving in deeply over several months. They also learned that focusing on specific regions would create greater impact than identifying organizations from all over the world; therefore, as mentioned previously, future cohorts will be in South Asia and the East African region. In East Africa in particular, the focus will be on enterprises that strengthen and empower women and girls, including those enterprises that are led by women and that work to improve the health of women and girls.

Scaling up specific programs is only one part of the mission, Udayakumar asserted. They are also focusing on accelerating real-world application of innovations through a series of “living laboratories” in Amsterdam, Nairobi, and Shanghai. These living labs will use a defined population (in these specific circumstances, the urban populations of the previously mentioned cities) as a means of testing a set of innovations in an actual health system, focusing on end-user engagement and collaborative problem solving. Udayakumar explained that three domains are of interest: research and innovation to meet health challenges; talent and education to address workforce development needs; and a culture of entrepreneurship that yields impact.

NURSING AND MIDWIFERY ENTERPRISE: MODELS AND LESSONS LEARNED⁴

Gina Lagomarsino and Carleigh Krubiner shared core ingredients of successful approaches to improve health systems and health outcomes, as well as to empower women. Lagomarsino reiterated that there is a disconnection between a fragmented private sector with small-scale programs of dubious quality and a bureaucratic public sector that does not hold the public’s trust. In between are a number of innovators with potential solutions who are not typically in an enabling environment to obtain capital investment, government contracts, or capacity to scale up. Her program, the Center for Health Market Innovations (CHMI) at the Results for Development Institute (R4D), identifies successful models and supports scale-up with resources and connections. The CHMI established a mechanism by which information on specific models is collected via a network of organizations. Through the analysis of the full range of programs, trends can be observed. These trends not only characterize successful programs in terms of health care delivery and patient outcomes, Lagomarsino commented, but also could highlight elements of the models that can empower women.

She also emphasized the need for appropriate adaptability. Being able to isolate the elements that make a program successful does not translate to just taking those elements, moving them into a different context, and expecting it to work. Effort needs to be applied to assessing that adaptation within the new context. Krubiner and Lagomarsino then presented the findings of a paper they wrote with Marla Salmon; in this paper, they reviewed programs that empower women and strengthen health systems and services through nursing and midwifery (Krubiner et al., forthcoming).

Preliminary Findings from the Global Landscape

Krubiner continued the discussion by delving into the potential empowerment opportunities associated with innovative approaches. She noted that while there is recognition of positive associations between health improvement and women’s empowerment (in both directions), much of the analysis focuses on the empowerment of health consumers, overlooking provider-side inputs. Assessments usually report on the number of interventions developed, coverage of family planning services, and other indicators. She remarked that many innovative approaches to health service delivery

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⁴ This section summarizes information presented by Gina Lagomarsino and Carleigh Krubiner, Results for Development Institute (R4D).

also provide opportunities to empower providers, particularly female health workers.

Through a landscape review of the CHMI database, she identified 94 programs from 56 low- and middle-income countries that specifically include nurses (46 programs), midwives (25), or both (23) to find the key inputs that are associated with empowerment. There are a number of definitions and measures of empowerment, but the CHMI used a pluralistic approach including education, employment, income generation, leadership, ownership of assets, political participation, enhanced self-esteem, and others (see Table 6-1).

Krubiner noted that most of the programs did not specifically self-measure for empowerment, so the CHMI needed to thoroughly examine each program for the above indicators that are most commonly associated with empowerment. The health focus of these programs are skewed toward maternal and child health care, and to a lesser extent, family planning, reproductive health, and HIV/AIDS. Other programs focused on communicable disease, chronic disease, eye care, nutrition, dentistry, and mental health. The majority of programs were not-for-profit, with funding coming from international donors. The model structures that seemed most promising for empowerment included provider training; information and communications technology (ICT); cooperatives, networks, and associations; and social franchises.

Provider Training

Professional training has clear empowerment inputs through certification for income-generating positions, enhanced self-confidence, clinical leadership roles, continued education, and enhanced respect of peers and community members. Four types of training inputs were identified: preservice training and certification, specialty training, continuing education, and bridging opportunities to enter the health workforce, which can serve as an entrance to nursing or midwifery practice. The 47 professional training programs identified under this heading included scholarships or direct funding for students, quality improvement of existing curricula, “training of trainers,” supplemental training, enhanced task-sharing opportunities, recruiting of girls, and strengthening capacity of community health workers.

Information and Communications Technologies (ICTs)

ICTs for health are primarily used for telemedicine, communication outside the clinical setting, decision support applications, data collection and management systems, and financial transactions. ICT platforms pro-

TABLE 6-1 Empowerment Measures

SOURCE: Malhotra et al., 2002.

vide greater opportunities for communication, mentorship, peer support, and outside consults with clinical experts. These tools were found to promote self-esteem, autonomy, greater social and professional connection, access to capital, and better practice through up-to-date knowledge. Nine programs were identified as using ICT as their core platform.

Cooperatives, Networks, and Associations

Collaborative approaches have the power of bringing people together with a shared purpose for collective bargaining, negotiating, social support and peer mentoring, participatory governance, and union activities. Additionally, such groups can facilitate access to capital through pooled-risk structures. These organizations often engage in strategic partnerships with other organizations, and sometimes the government, to leverage partners’ capabilities.

Social Franchises

The franchise model provides nurses and midwives a number of empowerment opportunities, including business ownership under an established brand, autonomy, and income generation. Usually, franchisees are trained on both the clinical and business side, as part of membership. The brand recognition, which included a certain standard of quality, conferred higher status on the nurses and midwives. Twenty-three social franchise models were identified, ranging from maternal and child health clinics to clinics with a broader focus, stand-alone clinics to those embedded within larger health facilities, and one-woman shops to those with multiple staff personnel.

Observations and Discussion

Krubiner observed that while a number of programs provide these empowerment inputs, there is little documentation explicitly reporting on empowerment aims. The few programs that did document this listed empowerment as part of the organizational mission. This brings up the issue of intentionality, she argued, and the need to specifically include empowerment, of both consumers and providers, as a programmatic goal and capture relevant indicators in monitoring and evaluation. However, she cautioned that this analysis looked at “hallmarks” and inputs commonly associated with empowerment. They did not study whether any actual empowerment resulted because of the lack of available data. Finally, she remarked that many of these models are in the pilot stage, and the long-term sustainability of these approaches is still unclear.

In the discussion following the presentation, Krubiner spoke further about the need to establish indicators for empowerment outputs. Participants speculated that this could take a number of forms—from the individual level of generating income or preventing violence at home to the governmental level of tying women’s empowerment to gross domestic product (GDP) growth. One participant noted that many of these models might not be financeable by the private sector, but they could benefit from public funding, given enough interest on the part of the government.

Other participants questioned whether additional empowerment outputs might be measured. For example, is ownership of a business leading to greater autonomy an integral element of empowerment? Others remarked that accountability and a sense of responsibility could also be useful measurements of empowerment.

The role of nurses and midwives was called into question given that each has a specific definition (and role), but both often serve multiple capacities depending on need and context. At the same time, other female health care workers—auxiliary workers, community health workers, and others—are often conflated under the heading of nurse or midwife. This can lead to confusion in terms of measuring the empowerment of providers that impacts their day-to-day responsibilities as nurses and midwives are often tasked beyond their training or job description.

Finally, participants delved further into the idea of intentionality. One participant remarked that a way to ensure its inclusion is to embed empowerment into grant making. Another participant noted that starting with the needs of women, whether the consumer or the provider, is inherently empowering. A third participant cautioned that empowering women, whether consumers or providers, occurs within a context of including men. On a professional level, this also means working toward team-based approaches in which tasks are not assigned by profession but rather by skill and context, and traditional hierarchies are flattened.

REFERENCES

Coye, M. 2014. The Global Lab for Innovation: Building sustainable healthcare. Presented at the IOM workshop: Empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise: Lessons from lower-income countries. Bellagio, Italy, September 10.

Dolfing-Vogelenzang, M. 2014. Women’s empowerment. Presented at the IOM workshop: Empowering women and strengthening health systems and services through investing in nursing and midwifery enterprise: Lessons from lower-income countries. Bellagio, Italy, September 9.

Krubiner, C., M. Salmon, and G. Lagomarsino. Forthcoming. Health market innovations: How strengthening health services in LMIC can empower nurses and midwives. Washington, DC: Results for Development Institute.

Malhotra, A., S. R. Schuler, and C. Boender. 2002. Measuring women’s empowerment as a variable in international development. Washington, DC: Gender and Development Group, The World Bank.

Kennedy, John F. 1961. Special Message by the President on Urgent National Needs. Washington, DC, May 25.

WHO (World Health Organization). 2010. The world health report. Health systems financing: The path to universal coverage. Edited by C. Etienne, A. Asamoa-Baah, and D. B. Evans. Geneva, Switzerland: WHO.