By Gopi Gopalakrishnan & Karen Pak Oppenheimer, World Health Partners
Access to services has always been recognized as one of the chief determinants of health status. In less developed countries, access is weak particularly for rural communities since formally qualified providers are often unavailable and the weak infrastructure makes availability of products, transportation or information inadequate. These communities living in small inhabitations constitute over 70% of the world’s population, and account for an even larger proportion of morbidities.
The public sector, despite persistent efforts, is often unable to provide health care to these remote and poor populations efficiently and effectively — especially preventive services such as family planning and vaccinations which are crucial for meeting a number of MDG goals and to relieve poverty. The only way to supplement the public sector’s initiatives in the delivery of health care is to harness vast private sector resources available. But there are serious challenges: private sector providers only focus on economically viable activities and do not have much interest in serving the poor. For this reason, they prefer to provide lucrative curative care over less profitable preventive services. Moreover, the private sector is extremely fragmented and unregulated, making quality of care suspect.
Any attempt to use private sector providers to deliver health services therefore needs to be predicated on establishing quality benchmarks and generating enough value for the provider so that standards can be enforced by the implementing agency. Equally necessary is the creation of income opportunities through curative care provision and use them, as a quid pro quo, to deliver preventive services. Vertical programs do not make these possible since small populations covered by rural providers do not generate adequate caseloads from a single type of service to build sustainability.
Investments in a health center, however primitive, can generate viable income only if a certain minimum caseload is achieved to spread the costs and if there are opportunities to create multiple revenue streams. What can be made sustainable is a horizontally structured program delivering a range of services so that adequate incomes can be generated, which in turn, enables the project to enforce quality benchmarks and mandate delivery of certain types of services.
This is the pattern which is normally seen in rural areas—a shop selling confections, also sells vegetables, stationary, family provisions and a lot more. A rural health practitioner is a pharmacist selling medicines, a doctor diagnosing illnesses, a nurse putting on dressings and a reception clerk registering patients all rolled into one.
A project tailored on these principles is under implementation in an area covering a population of 3.6 million in western Uttar Pradesh, one of the poorest states of India. Delivering family planning on a health care platform has produced results that are extraordinary and is also cost efficient.
Gopi Gopalakrishnan, President, World Health Partners, has over 20 years of experience in implementing large-scale service-delivery programs in low-resource settings. He founded Janani, a non-profit entity devoted to providing child and reproductive health services, in one of the poorest regions of India. Mr. Gopalakrishnan’s network management strategies have been recognized worldwide as some of the most effective methods of addressing the great unmet need for family planning, and have been supported by the Government of India.
Currently, he is on the global technical advisory board of the International Finance Corporation, an affiliate of the World Bank, and on the Advisory Group on Community Action (AGCA) of the National Rural Health Mission. Mr. Gopalakrishnan was the Director of International Programs of DKT International and received one of the highest civilian honors from the Government of Vietnam for his work as the Country Director of DKT International in Hanoi.
Karen Pak Oppenheimer, MS, MPH is the Vice President of Development and Partnerships at World Health Partners (WHP), an innovative nonprofit organization creating access to health services for the rural poor on a large scale by engaging the private sector and harnessing existing social and economic infrastructure, along with the latest advances in communications, diagnostic and medical technology.
Karen’s work at WHP focuses on program development, partnerships, communications and external affairs. She has worked in both the public and private sectors including the Lawrence Livermore National Laboratory, Oracle Corporation, UCSF, and most recently the nonprofit Venture Strategies for Health and Development.