How Impact Investing Can Reduce Maternal Mortality

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Mary-Ann Etiebet and Jagdeep Gambhir share their perspectives on addressing women’s health issues in poor, remote locations.

In the developing regions of the world, only half of women receive adequate health care. Globally, women of all ages face gender-based inequalities, exclusions, discrimination and violence when it comes to accessing health care. Every two minutes a woman dies during pregnancy and childbirth — or more than 800 women a day. Most of these deaths would be preventable if the women had access to quality maternal health care before, during and after childbirth.

Merck for Mothers, a $500-million, 10-year initiative that Merck CEO Kenneth Frazier launched in 2011, is working to reduce mortality rates among women, especially maternal mortality. It is also leveraging public and private partnerships to streamline supply chains for life-saving medicines and health commodities. Thus far, more than 7.3 million women in more than 30 countries have benefited from the Merck program.

In India, four-year-old Karma Healthcare, based in Udaipur in Rajasthan state, has found ways to harness digital connectivity to provide affordable, quality health care to rural and semi-urban areas. Using a hub-and-spoke model, Karma Healthcare runs 17 so-called e-Doctor clinics connected to large urban hospitals in Rajasthan and three other neighboring states. Each clinic serves a population of 20,000 to 25,000 people. Nurses run the clinics, and they act as conduits between patients and doctors.

Mary-Ann Etiebet, a medical doctor who is the lead and executive director of Merck for Mothers, hopes her program will stimulate continued funding for women’s health needs, especially from the private sector. That calls for an appreciation among potential investors of the broad spectrum of outcomes such programs could achieve. “We need to talk about both financial outcomes around the instruments at play, as well as the development outcomes,” she said.

In addition to health outcomes, those programs have ripple effects in areas like education, economic empowerment, financial inclusion and gender equality, Etiebet noted. “If we’re able to broaden how we think about outcomes, then it’s a slam dunk that these investments make sense at multiple levels.” Private investments are critical in order to bridge a $33 billion gap in meeting the United Nations’ sustainable development goals in maternal and child health globally, she added.

“If we’re able to broaden how we think about outcomes, then it’s a slam dunk that these investments make sense at multiple levels.” –Mary-Ann Etiebet

At Karma Healthcare, the effort is to use digital tools to ensure that women in rural India have access to doctors and health care facilities when most of those resources are concentrated in urban centers. “Our digital model, which is backed largely by data, would end up disrupting and making health care more accessible, affordable and inclusive,” said Jagdeep Gambhir, its founder and CEO. Gambhir is a former Goldman Sachs technology analyst who also brings experience in rural health care delivery. In addition to its own clinics, Karma Healthcare also plans to create an “operational framework for assisted telemedicine, and then franchise it for large-scale impact.” With that approach, it wants to expand from its current presence in four Indian states to have a pan-India presence by 2025.

Etiebet and Gambhir shared their perspectives on addressing women’s health issues with Knowledge@Wharton for its podcast series “From Back Street to Wall Street.” The series is being produced in partnership with Impact Investment Exchange (IIX), a Singapore-based organization that serves as a bridge between investors and development goals in Asia. (Listen to this episode using the player at the top of this page. Here are links to the firstsecond, third and fourth episodes.)

Early Insights

Etiebet was born and raised in Lagos, Nigeria, and from a very early age it was obvious to her that unless women had access to health care and education, their ability to participate fully in communities and the economy would be severely curtailed. Her desire to contribute to improving access to health care for women encouraged her to pursue a career as a physician. She went on to work as a researcher in academia, and as an advocate who also funds innovative programs to improve access to care for women around the world.

Maternal mortality is a serious problem not just in developing countries like India, Kenya or Nigeria, but also in the U.S., where black women are three to four times more likely to die in childbirth than white women, Etiebet said.

Maternal mortality has implications far beyond what might be immediately apparent. “When a family loses its mother, the repercussions are enormous,” said Etiebet. “It’s not just the death, in and of itself. When a mother dies, her infants are less likely to survive. Her other children are less likely to complete their educations or live out their expected life expectancy — and the community suffers.” She learned through her work that what women need is “the information to make the right choices, but also the tools to be able to actually implement those choices.”

Partnerships to Achieve Scale

In order to efficiently achieve large-scale interventions in reducing maternal mortality and infant mortality, it is critical to involve multiple investors and other partners, said Etiebet. The ability to measure outcomes is important to attract potential investors and partners. That translates into investments in data and surveillance systems, which in many cases must be built from scratch.

According to Etiebet, nearly 40% of women in lower- and middle-income countries get critical family planning and maternity health care services from local private providers, especially in settings where “the public sector infrastructure is crumbling, the quality of care delivery is poor and staffing is scarce.” In her work, she sensed the need for “a total market perspective,” but found that data flows – and the financing they help generate tend not to follow patients across public and private sector providers. “So there is this huge opportunity to rationalize how resources are allocated when you look at the total markets, as opposed to bifurcating and creating unnecessary barriers between the public and private sectors.”

“Our digital model, which is backed largely by data, would end up disrupting and making health care more accessible, affordable and inclusive.” –Jagdeep Gambhir

Merck for Mothers has been able to dramatically expand its impact through partnerships. In India, it was instrumental in facilitating a partnership to develop the world’s first health development impact bond called the “Utkrisht Bond” (Utkrisht is Hindi for “excellence”). Apart from Merck for Mothers, the other partners are UBS Optimus Foundation, USAID, Population Services International and Hindustan Latex Family Planning Promotion Trust. The Rajasthan government is also actively involved with an oversight role. The bond provides capital to support 440 small health care organizations and private health facilities in Rajasthan so they can meet and sustain new government quality standards.

The Utkrisht Bond partnership aims to reach 600,000 pregnant women with improved care during delivery. “We estimate that will have the potential to save up to 10,000 lives both mothers and their babies over a five-year period,” Etiebet said.

In another Merck for Mothers project in partnership with USAID in Zambia and Uganda called “Saving Mothers, Giving Life,” maternal mortality ratios decreased by up to 40%. In Senegal, it worked with the government and the Bill & Melinda Gates Foundation to modernize supply chains for health commodities and life-saving medicines by bringing in best practices from the private sector. That initiative helped reduce stock-out rates (or exhaustion of inventories) to less than 2%. The Senegal government used that model for supply chains elsewhere in the country.

The U.S. is also one of Merck for Mothers focus countries. “It’s tragic that in the U.S., we see that maternal deaths are increasing and not decreasing, and that a mother giving birth now has a higher likelihood of dying than her mother did giving birth to her about 25 or 30 years ago,” said Etiebet. “In some cities, like New York City, black women are 12 times more likely to die during childbirth than white women, and this is after you’ve accounted for differences in income, in education, and in other chronic co-morbidities.” The solutions lie in making sure that women have access to integrated care models during their pregnancies as well as managing any pre-existing chronic conditions that pose heightened risks.

Investments as Health Care Game Changers

Merck for Mothers sees a strategic role for its investments, and designs them to be “game-changers,” said Etiebet. “A lot of them are around innovation whether it’s innovation around products, processes, models of care, partnerships or financing.” Ultimately, these innovations need to be scaled and need to be sustained. That is only achievable with government partnership, as well as the partnership of large, institutional organizations such as the World Bank Global Financing Facility or other large regional organizations, she added.

Merck for Mothers would consider its work successful “if the women in the geographies that we are working for not only have access to a high quality of care, but also [feel] that birth is no longer a risky endeavor, or something to be feared,” Etiebet said. Also, they must be able to make informed decisions around what type of care they receive and where they receive it, as well as act on the choices that they have, she added. She also wanted Merck for Mothers to double the number of its beneficiaries from the current level of 7.3 million women worldwide before its program comes to a close, and also help meet the U.N. goal of reducing maternal mortality rates to less than 77 deaths per 100,000 live births.

Overcoming Shortages, Gender Discrimination

Karma Healthcare deals with different challenges in its work in India. In the rural parts of Rajasthan, for instance, women face a pronounced lack of access to affordable, good quality health care. Hospitals are few and so are doctors, many of whom prefer to practice in urban areas.

Rajasthan is India’s largest state by land area, and women often have to travel long distances of 50 km (31 miles) or more to reach urban hospitals. These women also depend on the male members in the family to escort them to the cities, which further reduces their ability to reach urban hospitals before their health conditions worsen.

“With digital connectivity, you can connect a patient sitting in a rural village in Rajasthan to a doctor sitting in New Delhi (420 miles away),” said Gambhir. Secondly, India’s expanding internet penetration allows remote capture of patient data, which doctors in urban areas could evaluate. “Technology models like ours are able to accelerate change [in health care access and delivery].”

According to Gambhir, about half the women in Rajasthan suffer from malnutrition and anemia, and Karma Healthcare focuses on preventive care and early-stage detection of the underlying causes. “When a woman comes to a clinic, you can do symptomatic treatment, but if you do not intervene on the underlying health determinants, then the patient or the woman is going to come back to the clinic again and again.”

“With digital connectivity, you can connect a patient sitting in a rural village in Rajasthan to a doctor sitting in New Delhi (420 miles away).” –Jagdeep Gambhir

Gambhir offered an example of how timely intervention saved a female patient about two years ago. When the 24-year-old mother of two arrived at a Karma Healthcare clinic, a hemoglobin test costing less than a dollar revealed an extremely low count of 2.1, compared to the normal range of 9 to 10 for a healthy woman. “A hemoglobin count of 2.1 is essentially incompatible with life, so one wonders how she was even alive,” he recalled. The clinic staff rushed the woman to a city hospital, where she received a blood transfusion and recovered. A Karma Healthcare staffer also donated blood to her after her husband declined to do so. “It does speak volumes about how the health care of women is perceived in these areas.”

Karma Healthcare uses technology in multiple ways to help achieve better treatment outcomes. Patients visiting its clinics first go through a battery of tests to collect basic information such as blood pressure and hemoglobin levels. Next, a “clinical decision support system” with a semi-artificial intelligence feature is activated to run scans on the patient’s vital parameters. Doctors receive the relevant information online, and converse with the patient over a 42-inch LED TV screen. A nurse is at hand to overcome any language barriers that might arise. Next, the doctor would write digital prescriptions that patients could take to any pharmacy. Those that are seriously ill are referred to hospitals.

One of the biggest challenges in telemedicine has been recruiting doctors in urban centers to be available on call to treat patients in remote areas. Karma Healthcare attempts to overcome that hurdle by ensuring that it compensates doctors “appropriately,” irrespective of whether they see a patient online or in person, said Gambhir. “We do not go to a doctor and say that because it is an online consultation, they should be charging us a lower fee, because that just dilutes the purpose of equity.”

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