Table 5 T-HOPE framework: comparison of programs using mHealth (five programs)

Overview

A for-profit hospital using management software and a high- volume, low-cost approach to provide heart surgeries.

A not-for-profit program using a telemedicine call center and community health workers to provide primary care services.

A not-for-profit program where community health workers collect children’s health data on mobile phones, with monitoring by a primary care doctor.

A not-for-profit program that provides reproductive service delivery at medical centers and a call center.

A PPP with a charitable organization operating government primary health centers, some of which provide telemedicine services.

Health Output (A2)

Program mHealth 1, 2, 4, and 5 serve several thousands of patients a year, while Program mHealth 3 is more focused.

From 2001 to 2007, the program performed over 23,000 surgeries and 34,000 catheterization procedures.

From 2008 to 2011, the program treated 40,000 patients in 200 villages.

From 2009 to 2012, over 1400 children were enrolled in the program by their parents; 900 children are actively being served.

In 2010, the program had 15,000 monthly average clients, providing consultations, lab services, vasectomy, tubal ligation, IUDs, injectables, implants, pills, condoms, and emergency contraception.

In 2012, the program reached 1 million people through its primary health centers.

Health Outcome (A3)

Programs mHealth 3, 4, and 5 report strong levels and gains in health outcomes that merit study on how the programs and/or other sources achieved them.

Behaviour change and improved access increased the rate at which subscribers visit health facilities; a subscriber to the program visits the health care center at least 3 times per year on average, whereas the average user rate in the district is 1.05.

In 2010, with 71,454 CYPs generated, it achieved a 31 % increase in CYP’s over the previous year.

From 1996 to 2007, in states served by the organization’s primary health care centers: Infant mortality dropped from 75 % to 24 %; still birth from 38 % to 10 %; perinatal mortality from 68 % to 17 %; neonatal mortality from 70 % to 10 %; child mortality (1 ~ 5 years) from 12 % to 3 %; under-5 mortality from 88 % to 27 %.

Affordability (B1)

All five programs offer more affordable services than other options available locally.

In 2012, the program charged US$2,400 for heart surgery, compared to US$5,500 charged at an average private hospital in the country.

In 2012, the program provided free consultations.

In 2012, families paid a monthly subscription fee of about US$1 for the package of services per child. This is the equivalent of a kilo of onions, a price affordable to low-income families in the urban areas.

In 2012, the cost of a medical consultancy in facilities is US$4.30 compared to US$10 in the local market.

All services at primary health centers are provided free of cost.

Availability (B2)

Programs mHealth 3, 4, and 5 provide models for gains in availability of health care services.

In 2012, the program improved access to immediate health care for 20 % of the local families by an average of 15 km; travel time was reduced by 4 hours or more.

In 2012, the call center operated Monday to Friday, 8:30 am to 7 pm, and Saturday, 9 am to 1 pm. The call center has a national number and can be called by individuals anywhere in the country.

In 2012, all primary health centers operated 24 hours a day, 7 days a week.

Pro-poor targeting (B3)

Program mHealth 3 has a particularly high proportion of poor patients, while program mHealth 1 provides subsidies to a meaningful share of its patients.

The program has subsidized poor patients to the tune of US$2.5 million, which benefited close to half of the patients that came to the program for treatment.

90 % of the program’s subscribers report having unstable earnings.

User Satisfaction (C2)

Programs mHealth 2 and 3 have high patient satisfaction rates, with program mHealth 3 having a slightly higher rating. Program mHealth 4 provides an example of how to increase patient ease.

The program has received an 85 % patient satisfaction rating consistently over the last year from patient feedback surveys.

A 2009 evaluation survey carried out by a PhD student under the supervision of a national agency showed that 96 % of the enrolled families are satisfied with the service.

Market research found that clients were intimidated by white-coated doctors and sterile environments, which they associated with illness rather than health. With trained staff performing most consultations and providing advice in friendlier environments, clients report feeling more at ease.

Management Quality (C3)

Programs mHealth 2, 3, 4, and 5 offer examples of activities that can strengthen management, operations, and delivery.

The program is an ISO 9001- 2008 certified company.

The program uses a qualitative health monitoring system to ensure both low and higher income populations are served.

The program uses a standardized assessment tool for all regional programs. The evaluations improve technical and financial performance, while creating transparency and accountability.

The program uses a hospital management information system developed by a major university to improve hygiene and good maintenance.

Economic Efficiency (C4)

Programs mHealth 1, 3, and 4 offer models of achieving different aspects of financial efficiency.

The program brought down the cost of electrocardiogram machines from US$750 to less than US$300.

The operational cost to provide call center services is US$0.21/min per call to the call center, which allows the nonprofit to provide affordable services.

The operating cost of each primary health center is about US$50,000, lower than comparable facilities.

Non-Economic Efficiency (C5)

Programs mHealth 1 and 2 serve more patients in a day than other local options, while program mHealth 4 provides faster service than other local options.

The program performs 32 heart surgeries a day, about 8 times more surgeries per day than the average for other comparable hospitals.

In traditional models, a doctor could treat up to a 100 patients per day. The program’s model allows each doctor to diagnose over 400 patients per day spread across 100 villages.

The program’s tubal ligation procedure takes 20 minutes compared to 2 hours observed at other facilities.

Human Resources Supply (C6)

Programs mHealth 2, 3, 4, and 5 provide models of training for health workers.

The program has trained over 200 local village women to become health workers.

The program started offering training sessions in 2011 for its teams as well as medical teams in the partnering health center.

The program offers ongoing training to staff to assure quality of care.

The medical officer, staff nurse, pharmacist and laboratory technician are required to stay in the same town/village where the primary health care center is located. Auxiliary nurse/mid-wife are trained to do pap smears.

Political Support (C7)

All programs partner with governments actors, using multiple models to gather support and gain contact with clients.

The program developed micro-insurance schemes with state governments, which work on flexible payments, and have helped thousands coming from low-income groups to procure services.

The program partners with the state government.

The program organized an informational event for the surrounding population in front of the District Chief’s home. Counsellors presented to the District Chief, and then the program’s employees followed suit with an information session. The program also partners with the Ministry of Health.

The program has negotiated agreements with the Ministry of Health and with local governmental units that enable them to provide services at municipal health centers. The municipality schedules visits from program staff, organizes clients, and provides places for services.

The program operates as a PPP, with the charitable organization managing government primary health centers in several states.

Financial Management (C8)

The programs offer models to learn about varied mixes of fee, donor, and government sources of revenues

Over 50 % of revenue came from heart surgeries, while 9 % came from coronary care charges and 8 % of from outpatient fees. In the financial year that ended in March 2005, the hospital earned 20 % operating profits before interest, depreciation, and taxes.

The program receives 50 % of its operating costs from subscription fees, while the other 50 % is sought from donors. The program reports that it has not yet found a sustainable economic model.

The program works with an annual revenue of about US$1.5 million; of this, 50 % is raised from fee revenue from clinic services.

90 % of operating costs are covered by state governments; the charitable organization covers 10 % of costs through donations from individual donors.