Market Based Solutions to Social Change in India

Confidential
2008
AMSTERDAM
Market Based Solutions to Social Change
in India
BEIJING
CAMBRIDGE
CHICAGO
DUBAI
Low-Cost Service Delivery in Health & Education
FRANKFURT
HONG KONG
JOHANNESBURG
LONDON
LOS ANGELES
MADRID
MANILA
MOSCOW
MUMBAI
MUNICH
NEW YORK
PALO ALTO
PARIS
SAN FRANCISCO
SÃO PAULO
SEOUL
SHANGHAI
SINGAPORE
Delhi, June 16, 2008
STOCKHOLM
TOKYO
TORONTO
ZURICH
Copyright © 2008 by Monitor Company Group, L.P.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means —
electronic, mechanical, photocopying, recording, or otherwise — without the permission of Monitor Company Group, L.P.
This document provides an outline of a presentation and is incomplete without the accompanying oral commentary and discussion.
Confidential
Case Study
LifeSpring: Context
India has a high maternal mortality rate, some of it may be attributed to fewer births
attended by skilled health staff
Average number of deliveries in India are ~26
Million per year and only
43% are deliveries by skilled health staff
India has the highest number of maternal
deaths in the world; ~ 117,000 maternal
mortalities per year
Births attended by skilled health staff (%)
of total, (2000–03)1
Indian Maternal Mortality Rate (MMR)
relative to other countries2 (2000)
125%
540
97
100%
99
75%
50%
43
25%
56
17
0%
India
China
Russia
India
China
U.S.
Note: MMR (Maternal Mortality Rate) is the number of deaths from pregnancy-related causes per 100,000 live births in the 15-49 age group
1 Data for the latest year available in 2000-03, 2 Modeled estimates from WDI (Urban-619 and Rural-267)
Source: India-stat, WDI Indicators, NFHS -2 & 3, India Census, CIA World Fact Book, Gupta RK - Institutional and non-institutional deliveries in slum areas of Delhi, Monitor Analysis
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
2
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
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Case Study
LifeSpring: Overview
LifeSpring Hospital provides low-cost, women and child care services in peri-urban
India
Company Overview
Service Description: Maternal Care
LifeSpring
LifeSpring Hospitals
Hospitals provides
provides low-cost,
low-cost, quality
quality healthcare
healthcare
solutions
solutions
–– Private
Private company,
company, joint
joint venture
venture between
between Hindustan
Hindustan Latex
Latex
and
Acumen
Fund
and Acumen Fund
–– 11 hospital
hospital started
started in
in 2005,
2005, 22 more
more operational
operational in
in past
past 22
months,
months, plan
plan to
to have
have 66 hospitals
hospitals in
in AP
AP by
by end-2008
end-2008
 Operating
Operating model
model focused
focused on
on “Service
“Service Quality
Quality at
at aa low
low &
&
transparent
transparent price”
price”
–– Services
Services are
are priced
priced substantially
substantially lower
lower than
than prevailing
prevailing
market
prices
market prices
 Plans
Plans include
include chain
chain of
of 30
30 small
small hospitals
hospitals (20
(20 beds)
beds) by
by 2010
2010
in
AP,
Maharashtra
and
Karnataka
in AP, Maharashtra and Karnataka
 Financially
Financially self
self sustaining
sustaining model
model
–– Broke-even
in
20
months
Broke-even in 20 months of
of operations
operations
–– Initial
project
costs
funded
by
Initial project costs funded by Hindustan
Hindustan Latex
Latex
Provides
Provides maternal
maternal and
and child
child health
health care
care services
services
–– Gynecology,
Gynecology, Obstetrics,
Obstetrics, Pediatric
Pediatric
 In-patient
In-patient service
service is
is limited
limited to
to uncomplicated
uncomplicated
women’s
health
women’s health
 LifeSpring
LifeSpring hospitals’
hospitals’ primary
primary customers
customers are
are women
women
and
children
and children
–– Caters
Caters to
to the
the B60
B60 population
population living
living in
in peri-urban
peri-urban
areas
areas within
within aa 10km
10km radius
radius
 Has
Has served
served 2,314
2,314 in-patients
in-patients and
and 27,316
27,316 out-patients
out-patients
(inception-May
(inception-May 2008)
2008)


8
Hospital Revenue (Rs. Lacs)
6
117%
5.12
4
2.36
Rs. Lacs
2
0
Sep-2006
Source: LifeSpring Newsletter, Secondary Research, Interviews, Monitor Analysis
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
3
Sep-2007
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
Confidential
Case Study
LifeSpring: Pricing
Normal & caesarean delivery charges at LifeSpring are ~1/6th the cost of private clinic
rates
LifeSpring Price Comparison with Possible Alternatives (Rs.)
16,000
30,000
Normal Delivery
Caesarean Section
12,000
20,000
8–10K
Rs.
20–30K
Rs.
8,000
10,000
4,000
1.5K
6K
1.5–2.5K
300–1K
0
0
LifeSpring1
Govt. Hospitals
LifeSpring1
Pvt. Clinic
Govt. Hospitals
Pvt. Clinic
Differential Prices for Key Services at LifeSpring
16,000
Normal Delivery
12,000
12.4K
Caesarean Section
8.7K
Rs.
8,000
6K
4.8K
3.3K
4,000
1.5K
0
General Ward
Semi-Pvt. Room
Pvt. Room
LifeSpring Prices for key services in a General Ward
Note: Pvt. Clinic refers to small 20–30 bed nursing homes, often run by a family in Hyderabad and have private rooms in most cases
Source: Satapathy et al. — Indian Journal of Community Medicine(2004–05), LifeSpring Data, Interviews, Secondary Research, Monitor Analysis
1
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
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Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
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Case Study
LifeSpring: Customer Profile
LifeSpring customers are B60 women who have a household income of Rs. 3k-7k/month
Customer
Customer Details
Details
Urban India Income Pyramid (2004–05)
MHE1:
>Rs 9,625 pm

16%
Customers
Customers are
are from
from local
local slums,
slums, low-income
low-income housing
housing colonies;
colonies;
most
have
daily
wage
job
or
run
petty
businesses
most have daily wage job or run petty businesses
–– Typical
Typical household
household has
has 5-6
5-6 members
members
Majority
Majority come
come from
from 55 km
km catchment
catchment area
area (also
(also focus
focus of
of outreach
outreach
staff);
word-of-mouth
has
lead
to
customers
coming
from
staff); word-of-mouth has lead to customers coming from 15-20
15-20 km
km
distance
as
well
distance as well
“Proximity
“Proximity to
to hospital
hospital is
is one
one of
of the
the key
key criteria
criteria while
while evaluating
evaluating
alternatives.
alternatives. However,
However, recommendation
recommendation from
from relatives/friends
relatives/friends
over-rides
over-rides the
the distance”
distance” –– LS
LS staff
staff
 Choice
Choice for
for delivery
delivery tends
tends to
to be
be either
either at
at home
home or
or institutional
institutional
(government/private)
(government/private)
–– IfIf institutional,
institutional, they
they are
are often
often referred
referred to
to private
private clinics
clinics by
by
quacks
who
have
existing
relationships
with
them
quacks who have existing relationships with them
 Consumer
Consumer research
research suggests
suggests LifeSpring
LifeSpring customers
customers are
are very
very
satisfied
satisfied with
with the
the service
service and
and price
price

MHE1:
Rs 4,575–
Rs 9,625 pm
MHE1:
Rs 2,500–
Rs 4,575 pm
MHE1:
<Rs 2,500 pm
37%
33%
LifeSpring
B60
Customers
14%
Profile of LifeSpring Customers by Occupation
Value to Customer
Pvt. Sector
Employment
24%
32%
Petty Business


4%
10%
Govt. Employee
Daily Wages
Driver
Household Expenditure
Source: NCAER, LifeSpring Newsletter (Sept, 07), Interviews, Monitor Analysis
1 Monthly
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
30%
5
Lower priced than majority of
private clinic alternatives
Quality healthcare at an
affordable price (marginally
higher than low quality
alternatives – government
hospitals/quack)
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
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Case Study
LifeSpring: Activity System
LifeSpring’s activities can be mapped around 4 main areas
Low OPD
Price
Location in high
pop density area
Standardized kits
for surgery / procedures
High
Throughput
Offer vouchers
and baby packs
to increase
repeat patients
Use lower
cost ANM
nurses
Service
Specialization
Community
sales force
Min. equipment
limits capital
expenditure
Rent old or “sick”
hospitals on long
lease to limit capital
expenditure
Targeted
messaging
to mothers /
husbands
Awareness
Camps
"Voucher"
program
Cross-selling
(Gynaec/Obstetrics
/Pediatrics)
Limited medicines;
JIT medicines
removes
cost of storage
Mostly general
ward
Complications
referred away,
early on
No
ambulances
High Asset
Utilization
Fixed salaries
for doctors
‘No Frills’
Frills’
SetSet-up and
Service
Outsource pharmacy,
lab services reduces
costs and pilferage
Source: Interviews, Monitor Analysis
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
6
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
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Case Study
LifeSpring: Service Specialization
LifeSpring has chosen a service which is high incidence and by specializing it can
concentrate on lowering costs and increasing productivity
120
No. of Deliveries / month
Narrow
Narrow specialization
specialization on
on women’s
women’s care
care for
for in-patient
in-patient
–– Services
include
delivery,
c-section,
hysterectomy,
Services include delivery, c-section, hysterectomy,
fibroids,
fibroids, MTP
MTP (abortion)
(abortion)
–– Complications
Complications are
are referred
referred to
to other
other hospitals
hospitals early
early
on
on
Specialization
Specialization enables
enables LifeSpring
LifeSpring to
to do
do the
the following
following

100–110
90

No.
60

30
15–20

Use
Use more
more ANM
ANM nurses
nurses than
than GNM
GNM nurses
nurses
–– ANM
ANM nurses
nurses are
are less
less qualified
qualified and
and are
are therefore
therefore
not
as
expensive
as
GNMs
not as expensive as GNMs
–– Demand
Demand for
for ANMs
ANMs is
is not
not as
as high,
high, thus
thus keeping
keeping
LS’s
attrition
low
LS’s attrition low
Standardization
Standardization
–– Clinical
Clinical protocols
protocols and
and other
other procedures
procedures have
have been
been
standardized
standardized to
to enable
enable clarity
clarity of
of tasks
tasks and
and higher
higher
productivity
productivity
–– Surgery
Surgery kits
kits also
also standardized
standardized
Lower
Lower Other
Other Costs
Costs
–– Bulk
Bulk purchase
purchase of
of limited
limited equipment
equipment and
and medicine
medicine
lowers
lowers medical
medical supplies
supplies cost
cost
0
LifeSpring
Pvt. Clinic
Note: Pvt. Clinic refers to small 20–30 bed nursing homes, often run by a family in Hyderabad
Source: LifeSpring Data, Secondary Research, Interviews , Monitor Analysis
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
7
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
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Case Study
LifeSpring: High Throughput (1/2)
Targeted marketing via multiple channels especially dedicated outreach staff has
contributed to high throughput in the hospital
Customer
Previous
Previous Child
Child // OPD
OPD at
at
Private
Private Hospital
Hospital
Message


Previous
Previous Child
Child // OPD
OPD at
at
Government
Government Hospital
Hospital
Convey “low-cost and highquality” advantage of LS
Relatively easier to convert as
already aware of benefits of
institutional deliveries

Previous
Previous Child
Child at
at Home
Home
(non-institutional)
(non
(non-institutional)
Reinforce “Quality” aspect
of LS offering with focus on

– Transparent pricing
– Trained doctors
– Hygienic environment
Strong focus on customer
education and relationship
building
– Explain warning signs,
high-risks, etc.
“Trust is an important criterion….as most of them have built trust in one hospital/mid-wife where the entire
extended family has been going for years. So, switching to LS isn’t very obvious to them”
Channels
Dedicated
Dedicated Outreach
Outreach
Staff
Staff

3–4 local woman (XII pass) hired
as marketing force, do 6 hours/day
of field work
– Gathers information
on family, medical history
and target the customer
(mother-in-law and husband)
Community
Community Initiatives
Initiatives


Health camps (1/month)
– Doctor visits the community
and advises them on nutrition,
health-related issues
On-going initiatives
– Reinforce brand with free
vaccination camp, free
photograph of your child, etc.
““Voucher”
Voucher”
Voucher” Program
Program

Voucher distribution (1 free OPD &
discount on IPD) to every LS IPD
customer
– Aims to reach out to potential
customers and encourage
experience sharing within
community
“Follow up with families suggested that most woman go to their mother’s house for final delivery. So, we have
started targeting mothers who are expecting their pregnant daughters to visit them for final delivery”
Source: LifeSpring Data, Secondary Research, Interviews, Monitor Analysis
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
8
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
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Case Study
LifeSpring: High Throughput (2/2)
Low OPD fee and proximity to urban slums has enhanced footfall in the hospital
Number of Customers
per Month
2,000
300
Out-Patient Charges
per Customer (Rs.)
IPD
140–160
OPD
100–300
Rs.
Units
150
1,000
1,500–1,600
50
20–30
300–500
0
0
LifeSpring
OPD to IPD
conversion



9%–11%
Pvt. Clinic
LifeSpring
Pvt. Clinic
4%–10%
Low
Low and
and transparent
transparent pricing
pricing
–– OPD
OPD is
is priced
priced at
at Rs.
Rs. 50
50 vs.
vs. Rs.100–300
Rs.100–300 at
at the
the private
private clinic
clinic to
to increase
increase footfall
footfall
–– IPD
IPD pricing
pricing is
is all
all inclusive
inclusive and
and transparent
transparent (conveyed
(conveyed on
on registration)
registration)
Location
Location
–– Located
Located in
in high
high population
population density
density area,
area, where
where target
target customers
customers reside
reside e.g.,
e.g., industry
industry workers
workers
–– Reduces
Reduces transportation
transportation costs
costs to
to customer
customer and
and increases
increases chances
chances of
of repeat
repeat visits
visits
Cross-selling
amongst
the
patients
requiring
healthcare
services
in
gynecology,
Cross-selling amongst the patients requiring healthcare services in gynecology, obstetrics
obstetrics and
and pediatrics
pediatrics
Note: Pvt. Clinic refers to small 20–30 bed nursing homes, often run by a family in Hyderabad
Source: LifeSpring Data, Secondary Research, Interviews, Monitor Analysis
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
9
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
Confidential
Case Study
LifeSpring: High Asset Utilization
LifeSpring ensures high utilization of its most expensive asset, its doctors
Surgeries1 per doctor/week
No. of Operations2 in OT/week
Cost of Doctor/patient3
50–75
22–27
4–6
No.
No.
Rs.
12–20
1–2
LifeSpring
Pvt. Clinic
4–6
LifeSpring
LifeSpring
Pvt. Clinic
80%


The
The drivers
drivers of
of high
high asset
asset utilization
utilization are
are specialization
specialization which
which enables
enables
high
productivity
of
its
skilled
and
unskilled
labour,
and
high
volume
high productivity of its skilled and unskilled labour, and high volume of
of
patients
patients
Use
Use of
of doctors
doctors
–– Doctors
Doctors are
are on
on salaries
salaries rather
rather than
than consultants.
consultants. This
This gives
gives LS
LS the
the
benefits
of
increased
volume
and
productivity
benefits of increased volume and productivity
–– Doctors
Doctors are
are local;
local; lower
lower rate
rate of
of absenteeism
absenteeism improves
improves overall
overall
productivity
productivity
Excluding Deliveries and Caesareans, 2 Includes Caesarean and not Normal Delivery as it is done in a labour room,
Patients at LS-1500–1600 and Private Clinic 300–500 per month and Salary of a doctor at Rs. 20–30k/month
Note: Pvt. Clinic refers to small 20–30 bed nursing homes, often run by a family in Hyderabad
Source: LifeSpring Data, Secondary Research, Interviews, Monitor Analysis
1
Pvt. Clinic
In-Patient (IPD) Facility Utilization
60%–70%
60%
30%–40%
40%
20%
0%
LifeSpring
Pvt. Clinic
3
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
10
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
Confidential
Case Study
LifeSpring: ‘No Frill’ Set-up and Service
Low capital expenditure and ‘no frill’ service enables LifeSpring to limit its non-core
spending

Limit
Limit Capital
Capital Expenditure
Expenditure
–– Rent
Rent old
old or
or “sick”
“sick” hospitals
hospitals on
on long
long lease
lease rather
rather than
than
own
buildings
own buildings
–– Have
Have minimum
minimum expensive
expensive equipment
equipment (most
(most complex
complex
machine
in
the
hospital
is
ultra-sound)
machine in the hospital is ultra-sound)


Refer
Refer complications
complications to
to avoid
avoid investment
investment in
in expensive
expensive
equipment
and
specialist
doctors
equipment and specialist doctors
–– Do
Do not
not own
own ambulances
ambulances
–– Out
Out source
source pharmacy
pharmacy and
and lab
lab services;
services; on
on premises
premises



This
This also
also removes
removes problems
problems of
of pilferage
pilferage and
and
inventory
costs
inventory costs
‘No
‘No frills’
frills’ Environment
Environment
–– Tiered
Tiered room
room system
system


Most
Most beds
beds are
are in
in the
the general
general ward
ward (Normal
(Normal delivery
delivery
rates
are
Rs.1,500
general
ward,
Rs.
3,200
shared
rates are Rs.1,500 general ward, Rs. 3,200 shared
room,
room, Rs.
Rs. 4,700
4,700 private
private room)
room)
–– Rooms
Rooms are
are basic
basic with
with no
no air
air conditioning
conditioning
–– Simple
Simple flooring
flooring and
and minimal
minimal furniture
furniture
–– No
canteen
with
food
services,
No canteen with food services, no
no kitchen
kitchen
Source: Secondary Research, Interviews, Monitor Analysis
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
11
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
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Case Study
LifeSpring: Doctor Profile
Doctors at LifeSpring earn fixed salaries vs. variable consulting fees of their private
clinic counterparts and have strong non-monetary incentives to stay
Total Income (fixed and variable) per month
60K
30k–40k
40K
Rs.
14k–35k
20K
12–18k
0
LifeSpring1
Pvt. Clinic2
Doctors
Doctors are
are salaried
salaried employees,
employees, not
not consultants
consultants (Attrition
(Attrition rate
rate for
for doctor
doctor is
is 4%)
4%)
 There
There are
are aa number
number of
of non-monetary
non-monetary reasons
reasons or
or incentives
incentives that
that keep
keep the
the doctors
doctors at
at LifeSpring:
LifeSpring:
–– Experience
Experience

 High
High throughput
throughput provides
provides significantly
significantly more
more clinical
clinical experience
experience for
for aa doctor
doctor in
in number
number and
and variety
variety of
of cases
cases especially
especially for
for
young
doctors
young doctors

Young
 Young doctors
doctors handle
handle greater
greater responsibilities
responsibilities at
at LS
LS than
than ifif they
they were
were working
working under
under an
an older
older doctor
doctor in
in aa private
private practice
practice
–– Lack
of
Alternatives
Lack of Alternatives

 Doctors
Doctors are
are local,
local, the
the lack
lack of
of clinic
clinic choice
choice in
in their
their area
area restricts
restricts the
the ability
ability to
to switch
switch hospitals
hospitals

Government
service
is
not
appealing
as
the
government
system
is
outdated
 Government service is not appealing as the government system is outdated
–– ItIt is
is very
very restrictive
restrictive in
in terms
terms of
of prescribed
prescribed medical
medical techniques,
techniques, treatments
treatments and
and medications
medications
–– No
No pressure
pressure to
to drive
drive in
in business
business helps
helps maintain
maintain focus
focus on
on clinical
clinical work;
work; also
also provides
provides hassle-free
hassle-free environment
environment where
where all
all
administrative
tasks
are
taken
care
vs.
running
a
private
clinic
administrative tasks are taken care vs. running a private clinic

The range is due to the differences in experience between the senior and junior doctors at LifeSpring
12–18,000 is the basic fixed salary and rest is variable pay dependent on patient volumes and number of hospitals the doctor consults at
Source: Secondary Research, Interviews, Monitor Analysis
1
2
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
12
Copyright © 2008 Monitor Company Group, L.P. — Confidential — MUM
Confidential
Case Study
LifeSpring: Nurse Profile
LifeSpring uses more nurses than private clinics but is able to use them more
productively. It uses ANM instead of GNM nurses, keeping cost and attrition low
Number of IPD customers/month/nurse1
150
130
150
100
100
No.
Cost of nurse/patient
110–130
Rs.
50
50
40–50
0
0
LifeSpring

50
Pvt. Clinic
LifeSpring
Pvt. Clinic
LifeSpring’s
LifeSpring’s specialization
specialization in
in maternal
maternal care
care has
has enabled
enabled them
them to:
to:
–– Achieve
higher
(2.5x)
nurse
utilization
compared
to
a
private
Achieve higher (2.5x) nurse utilization compared to a private clinic.
clinic. However,
However, doctor-nurse
doctor-nurse ratio
ratio is
is in
in same
same range
range as
as aa
private
private clinic
clinic (4–6
(4–6 nurse
nurse per
per doctor)
doctor)
–– Employ
Employ more
more ANM
ANM nurses
nurses than
than GNM
GNM nurses
nurses (9
(9 ANM
ANM && 33 GNM
GNM vs.
vs. 6–10
6–10 GNM
GNM nurses
nurses in
in aa private
private clinic)
clinic)

Qualifications
for
Auxillary
Nurse
Midwifery
(ANM):
 Qualifications for Auxillary Nurse Midwifery (ANM):
–– An
An ANM
ANM diploma
diploma programme
programme is
is of
of an
an 18
18 month
month duration
duration and
and requires
requires aa 10th
10th class
class education
education
–– In
contrast,
a
Graduate
Nurse
Midewifery
(GNM)
is
of
3.5
years
and
requires
a
12th
In contrast, a Graduate Nurse Midewifery (GNM) is of 3.5 years and requires a 12th class
class education
education

Cost
advantage:
ANM
nurses
are
more
limited
in
skill
and
are
thus
less
expensive
than
GNMs
 Cost advantage: ANM nurses are more limited in skill and are thus less expensive than GNMs

 Low
Low Attrition:
Attrition: Demand
Demand for
for ANMs
ANMs is
is not
not as
as high
high as
as that
that of
of GNMs,
GNMs, thus
thus keeping
keeping LifeSpring’s
LifeSpring’s attrition
attrition low
low

ANM’s
are
easily
available
and
similar
skill
as
GNM
in
context
of
maternal
care
 ANM’s are easily available and similar skill as GNM in context of maternal care
IPD customers at LS: 150/month, Nurses at LS: 12, IPD customers at Private clinic:30–40, Nurses at Private clinic: 6–10
Note: Majority of nurses in private clinic are GNM
Source: LifeSpring, Secondary Research, Interviews, Monitor Analysis
1
BZR-SAB-Phase 1b-Low-Cost_Service_Delivery_Health_Education-Final Presentation
13
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