3.1. Sociodemographic and geographic characteristics of the social enterprises
394 social entrepreneurs were identified from the ‘health’ and ‘health care’ portfolios of the international organizations reviewed. This was narrowed down to 61 working in primary care. The remaining 333 worked on specific diseases, tertiary care, and social determinants. Of the 61, 10 provide primary care service delivery. The remaining 52 were excluded as they work in other areas of primary health care such as information technology, enhancing processes of primary care, transportation to primary care facility, funding primary care, and direct-selling of health consumables. Of the 10 providing primary care, 9 responded to our interview request.
3.2. Themes of the qualitative analysis
3.2.1 Medical Process: Curative versus Preventive
Curative services were the main type of service offered in our sample organizations. The most common symptoms which these services were utilized for include fever, digestive symptoms and respiratory symptoms, in which curative medications were mainly prescribed. Preventive services were carried out less frequently. For non-communicable diseases, two organizations reported doing health screenings for diabetes and hypertension as part of their main operation. Other organizations offered these services passively, to patients when there is a need, and to the community when dedicated funding was available. For communicable diseases, two organizations offer regular vaccination services, while others only offer vaccinations at the request of patients.
3.2.2. Business Process: Financial sustainability strategies
Strategies for financial sustainability included two components, cost reduction and income generation. Three common strategies were identified in each component (Table 3).
Cost reduction
Eight of nine organizations operate in countries with national health systems that do not reimburse cost of treatment in private facilities. These organizations obtain revenue directly from patients through out-of-pocket payments. Methods to keeping costs low were cross-cutting and included:
- Bulk purchase of generic pharmaceutical products directly from manufacturer. Organizations were able negotiate a lower price and cut costs incurred by intermediaries. The bargaining power of the organizations are related to the size of their networks, which range from 7 to 30 chains/franchises. Six organizations cited this practice as the most effective method of lowering costs. One founder mentioned that their country’s status as the world’s largest producer of generic drugs played a substantial role in their ability to keep cost low.
- Use of paramedical staff to treat patients – Two organizations utilized paramedical staff such as nurses or medical assistants to attend simple cases to save cost in salaries.
- In-house laboratory services – One organization created a centralized laboratory to house diagnostic equipment, saving substantial costs compared to referring these procedures to outside laboratires. This was also the organization with the largest network of chains, at 30, allowing them to benefit from economies of scale from the laboratory.
Interviewees emphasized that being low-cost does not mean being the cheapest in the area. A more important aspect is to offer the lowest cost possible for high quality care:
“I don't think it [our price] is really low. We are not the cheapest, we don't claim to be the cheapest, and we don't want to be the cheapest.”
“I would not say that we are absolutely the cheapest... we try to position ourselves as affordable to the mass market [in this country] as possible.”
Interviewees associate the low-cost of service fee with high volume of patients to become financially sustainable. Scaling mechanisms to achieve high volume are described below under organizational impact.
Income generation
1. Flat-rate pricing – Seven of the nine organizations did not differentiate price based on socio-economic status; patients pay a flat-rate consultation fees in addition to the cost of drugs and diagnostics. Two organizations differed. One systematically assesses socio-economic status using questionnaires and provide highly subsidized or free treatment to high poverty populations. The other identifies a location below the national poverty line and provides highly subsidized or free treatment at that location, charging higher fees in other locations. One founder pointed to flat rate fees as being ‘non-discriminatory’ towards all:
“When people come to our clinic, there is nothing like poor or rich. Every patient is the same. We don't differentiate based on income or anything, so the payment is the same for everyone.”
The founder cited that charging a low flat-rate price to all patients saves direct and opportunity cost of measuring each patient’s socio-economic status.
2. Alternative revenue streams - While most organizations exclusively run healthcare services as their revenue source, three organizations subsidize the cost of health services using alternative revenue streams. Two sell their self-developed health information technology systems (HIT) to other organizations. A third sells eyeglasses as an added revenue stream.
3. Subscription packages – Three of the nine organizations offer subscription packages for patients with diabetes and hypertension. These models are similar in that they are a form of pre-payment where patients pay a yearly flat rate to receive treatment and monitoring services for diabetes or hypertension. All three do not include coverage for hospital referrals. One founder cited this as a basic form of capitation payment that can keep costs low by cost containment-mechanism. Subscription packages were viewed as a basic form of insurance that allows financial pooling which lowers the cost to patients by distributing the cost of treatment among all subscribers.
3.2.3. Social Impact
Management versus Outcome Metrics
All nine social enterprises measure social impact, but with variable metrics and level of rigor. The metrics generally fell into two categories: management and outcome metrics. All organizations measure management metrics including number of new patients, returning patients, and patient satisfaction scores. Outcome metrics are less common; the only one organization measuring outcomes uses metrics specific to chronic disease, such as the proportion of chronic disease patients that has their disease under control. A top-management staff described the difficulty in measuring outcomes for acute diseases as they are only possible when the patient returns because of ineffective treatment or a new complaint. Active measurement of social impact for community members; regardless of whether they have ever utilized service or not, was viewed as difficult. A top-level management staff cited an ‘inherent trust issue’ when attempting to measure health trends in new communities. Another founder mentioned:
“Our key indicators were primarily processes, it is extremely hard to measure outcomes at the population level to say that you know, yes, you have the impact. In terms of utilization, processes and output indicators, we had many; but outcomes were very, very hard. Even though I stayed in the company for 8 years, we only had early signs within chronic care management that we were having a meaningful impact, but I cannot say that we have a population level outcome for the poor.”
Eight of the nine organizations define ‘low-income’ based on geography, identifying all patients within the same vicinity as falling into low socioeconomic status. Hence, the impact of their organization towards low income patients is taken as the number of footfalls in their clinics. Only one organization assessed socio-economic status using questionnaires and hence impact towards patients living in poverty was able to be measured.
Access and Patient Base
Improving access to quality care through availability and affordability was a cross-cutting strategy to reach low income populations. A common strategy adopted by six out of the nine organizations was establishing their clinics in low income neighborhoods. One founder explained:
“We really locate in little towns which are aggregation of villages. We are not present in larger towns. Most people that we had access to were lower middle class or poor people, the richer people were either going to big cities, or did not even stay in the area. So, I think given our core objective was access, where we located our clinics was the deciding criteria of who was our primary audience”.
Of these six organizations, only one operated in rural areas, and five are situated in peri-urban settlements. The remaining organizations that do not operate clinics in low income areas reach the underserved through mobile units, telemedicine and spoke clinics attended by clinical staff from the city on certain days of the week. The patient base for all organizations included all layers of society. All interviewees were not concerned about ‘misuse’ of low-cost services by the middle- and high-income population. Attendance of middle- and high-income patients indicated the good quality of services provided.
“We don't ensure that everyone who is coming is poor. That is not our mandate. Our mandate is health for all. Even I go to the clinic, my boss goes to the clinic. That is the perception that we want to change, that cheap clinics cannot be of good quality. We want everyone from all strata of society to come to our clinic”
“Most of them are poor people, but they don't need to be poor people. Sometimes they just don't have access to health.”
3.2.4. Organizational Impact
Scaling Strategies
All interviewees were organized as chains, franchises or multiple mobile units. Five organizations were chains of clinics, two were franchises, and two were solely operating through multiple mobile clinics. Chains and franchises ranged from 7-30 clinics, while mobile units ranged from 110-116 per organization. Having multiple chains increased the bargaining power for bulk purchase of medicines and allowed for economies of scale from in-house laboratory facilities.
Another scaling mechanism was ‘spoke’ clinics acting as peripheral extensions to main clinics, operating only on certain weekdays. Three organizations used telemedicine to connect patients in rural areas to doctors in main clinics.
Scaling was indicated as important for financial sustainability (Table 3). A top-level management staff mentioned the importance of multiple chains:
“If we only have 5 or 7 branches, we overall lose money as an organization.”
Of the five organizations operating as chains, four achieved financial break-even. Two achieved positive cash flow four months into operation. Of the two that were franchises, both achieved break-even; as did the two that operated through mobile units.
Leveraging health information technology (HIT)
Broad and consistent utilization of HIT has proven to increase health care quality and effectiveness, reducing costs, preventing medical errors, and expanding accessibility (22). All nine organizations utilize HIT in their operations. The common use of HIT among all organizations is the digitalization of patient information systems. Five organizations mentioned that this is important as it improves the efficiency of managing patients and allows patients to access any facility. This is considered important because all the organizations operate either as chains, franchises or mobile units and the transfer or referral of patients from one facility to another is common. Three organizations developed their own patient information system, while others subscribe to a vendor. Three organizations use HIT in the form of telemedicine to increase accessibility and volume. One director emphasizes the role of HIT in her organization:
“We really want to use tech in innovative ways… not to keep technology as the focus point, but technology as an enabler.”
Challenges in engaging with the public sector
Eight of the nine organizations interviewed cited limited engagement with the public sector. These were limited to regulatory transactions such as reporting notifiable communicable disease, licensing of clinical facilities and renewing practice certificates for staff. Outside of regulatory engagements, one founder described their engagement with the public sector as one-sided:
“We are helping them instead of them helping us, for example, when a public service has a problem, we go there with the doctors, like a health care mission”.
One interviewee worked very closely with the public sector, whereby patients’ fees were reimbursed by national insurance schemes, the same medical record system was shared, and monthly audits were conducted for accountability. The organization’s main operations during initial establishment was providing primary care services directly to underserved patients; as public sector engagement grew, the focus shifted to identifying the greatest needs of the public health system and tailoring health services to fulfill them. Today, alongside providing primary care services, a big part of their operation consists of efforts in shortening wait times for diagnostic procedures with backlogs in public facilities. This was done by providing those diagnostic procedures themselves and referring patients back to the public sector for continued care. Since these procedures are reimbursed by the national health insurance scheme, this became an important component of their financial sustainability. This level of engagement was described by a top-level executive to take a long time and huge effort to build trust:
“After a long time, we start to have trust from the mayor, the secretary (of health), the (public sector) doctors. They started saying – You know, this [name of organization] is very interesting, I think they can do more.”
The themes elaborated above are summarized in Table 4.