Posts tagged ‘pilot’

Addressing Chronic Disease in Latin America: Pro Mujer’s Health Pilot Program One Year Later

By Jana Smith, Project Manager, Health and Human Development Services with contributions by Dr. Gabriela Salvador, MD, MPH, Director of Health & Human Development

BLOG UPDATE (NOVEMBER 8, 2011) – To listen to Dr. Salvador talk about how Pro Mujer is addressing chronic diseases in Latin America, click here to listen to her on an podcast.

While maternal and child health interventions reach a relatively broad demographic in Latin America through the public health care sector, there are still no solutions to address the increasingly serious problem of chronic diseases such as hypertension, diabetes, sexual and reproductive health problems and breast and cervical cancers, among other illnesses.

Growing urbanization throughout the region has led many to lead a more sedentary lifestyle and greater consumption of fast food resulting in shockingly high figures of obesity, and by extension, chronic disease, especially in poor segments of the population. To combat these conditions, prevention or early detection is vital, since most of these diseases are “silent;” this is complicated by the high opportunity costs associated with access to care for women from impoverished communities who work in the informal sector. These women support themselves and their families with daily sales, and therefore must decide between lost income and preventive healthcare, the value of which may not be fully recognized until an illness has reached an advanced stage.

In addition to health implications, these diseases have tremendous economic implications for both developed and developing countries. According to a report published by the World Health Organization in April of 2011, non-communicable diseases cause 60% of deaths worldwide, killing 36.1 million people annually. “Non-communicable diseases will evolve into a staggering economic burden in the coming years…It’s a huge impediment to the mitigation of poverty” said David E. Bloom, Professor of Economics and Demography at Harvard University’s School of Public Health in a June 2011 Bloomberg interview.

Pro Mujer began its operations in Nicaragua in 1996 and was the first replication of the Pro Mujer model after its founding in Bolivia in 1990. In 2005, Pro Mujer in Nicaragua (PMN) began offering health services with great success, particularly in terms of the usage of Pap smears and contraceptive methods. However, its lack of focus on chronic disease, its per service fee structure, and minimal commercial value prevented the program from achieving greater coverage, impact, and long-term financial sustainability and permanence.

In 2009, Pro Mujer decided to begin an ambitious project to rework its health model in Nicaragua. The aim of this innovative health pilot was to provide clients with comprehensive and affordable primary health care services while addressing the increasingly-serious problem of chronic disease. Between October of 2009 and October of 2010, PATH provided technical expertise in analyzing the market and developing key health elements of the program while Global Partnerships provided funding to launch the pilot which officially started in October/November of 2010. In addition, the Linked Foundation provided and continues to provide, invaluable support and funding.

A Pro Mujer neighborhood center and home to the organization's Nicaragua health pilot program.

Together, the team determined that the adjusted model would aim to comply with four key criteria: market responsiveness, potential for health impact, operational viability, and economic sustainability.  Program design was divided in six phases: structured interviews with industry experts, assessment of health-related needs and opportunities, operational assessment of Pro Mujer, market assessment to determine attractiveness of package for clients, pilot design and a financial assessment.

After extensive research and analysis, Pro Mujer rolled out the newly-designed model in October of 2010 at one of Pro Mujer’s community centers in León, Nicaragua. Clients were then able to receive a high-quality, low-cost health package for just US$2.40 a month. The preliminary results have been astonishing and the lessons learned have great implications for Pro Mujer’s operations in other countries as well as other regions around the world.

Dr. Martha Garcia runs the health clinic at the Pro Mujer center in León, Nicaragua.

This comprehensive health package includes:

  • A focus on prevalent conditions with an emphasis on chronic disease:  Early detection of hypertension, diabetes, obesity, sexual and reproductive health problems, breast and cervical cancer, among other diseases, are critical. These conditions were selected due to their prevalence in the target population and a lack of successful attention in the public sector.
  • An upfront fee: The full cost of the package was priced and paid for in two or three annual installments at the time of loan disbursement.  Removing the link between the moment of usage and payment has been shown in many studies to increase access, especially for low-income populations.
  • Services and Delivery:
    • Screening package:  This component includes a systematic delivery of tests (Pap smear, body mass index, blood and urine exam, glucose test, blood pressure, and breast exam) for early detection of key conditions. Screenings are conveniently scheduled during loan disbursement meetings to lower opportunity costs since clients are physically present at Pro Mujer centers at this time.
    • General physician consults:  Clients can utilize these consults to receive interpretations of screening results, follow-up on detected conditions, or for preventive or curative primary care at their discretion. These services are delivered in clinics at Pro Mujer centers and visits are scheduled to remote rural areas to ensure access for all clients.
    • Referral system: Pro Mujer facilitates access to specialists, laboratories, and other key services by negotiating discounts for its clients through strategic alliances.
A Pro Mujer client in Nicaragua receives a consultation.
    • Health education: The health curriculum was redesigned using a new, informal education methodology focused on healthy habits and the importance of early detection.  Its implementation was accompanied by intensive staff training. These health trainings are delivered by trained credit officials during loan repayment meetings to ensure that all clients are reached frequently and to keep down costs for clients.



Nov 2010 -July 2011

% Positive







Pap Smears



Clinical Breast Exams



Glucose Tests



Blood Pressure Measurement



Body Mass Index



When market research was conducted to measure client satisfaction, 81% said that they were satisfied with the package and 78.5% believed that the package was better than comparable services available in the market. Financial analysis shows that the pilot is in line to cover both full direct and indirect costs within a year as projected.

Despite much initial success as shown, the pilot has taught Pro Mujer a great deal about delivering preventive services through microfinance using a business model that will benefit the pilot and the other Pro Mujer country operations as well as other industry players.

Breaking paradigms. Health care is often thought of as a very specialized field which requires specialized staff. Experience throughout the world has shown that non-health personnel can be very effective at transmitting key health messages. Pro Mujer’s pilot has shown that coverage, efficiency, and in the long-term impact, is greatest when loan officers – who already have close relationships with clients – deliver health training.  On the other hand, health services are often thought of as a social service.  Pro Mujer has learned that the marketing and sales techniques of its front-line staff are key to making a primary care service attractive to clients.

A Pro Mujer credit officer provides a health training session on kidney disease prevention prior to facilitating the financial aspects of a communal bank or lending group meeting.

Listening to clients.  Constant monitoring of customer satisfaction has enabled Pro Mujer to adjust the package and plan for more significant changes. Although clients have expressed their satisfaction, preventive packages only have short-term commercial appeal for people who do not have conditions. It is vital to constantly improve the value of the package and surpass client expectations. Payment mechanisms are also key. Although the shift away from a per service fee structure service greatly increased usage, clients prefer to pay for the package in monthly installments along with loan repayments instead of lower, individual loan disbursement amounts.

A Pro Mujer meets with Dr. Garcia

Training is key. It is important to thoroughly train all staff, including those in both health and financial, in health education, social marketing and strategy. Training programs to clients are crucial to raise awareness of the value of early intervention and provide tools to improve lifestyle choices.

Rural delivery is a challenge. Not only is service delivery naturally a greater challenge in remote areas, but administrative procedures such as appointment scheduling and test delivery are also complicated by decentralized service delivery. It is necessary to “piggyback” when possible, carefully monitor and adjust processes, and look towards technology to facilitate access and improve efficiency in the future.

Benita Montalvan, a Pro Mujer credit officer, endures rough terrain in order to deliver preventive health education and facilitate communal bank meetings.

Pro Mujer is currently planning the second phase of the pilot with the lessons learned from the first phase.  Measures are being taken to improve the payment mechanism, as requested by clients, to make the package more accessible. This has been one of the key points of constructive criticism and it is therefore expected that this change will help ensure continued purchase of the package.

In light of the high prevalence of obesity detected through the screening component, Pro Mujer is analyzing how to incorporate nutritional counseling into the service package and investigating ways to reinforce the practical tips delivered in training sessions so that they lead to concrete behavior change.  It is also believed that the services of a nutritionist would add commercial value to the package.

Market research reflects a great demand for medication, specialty consults, and dental care.  Pro Mujer is looking into different options to facilitate access to these services, whether it is by strengthening current alliances or developing new relationships with partner organizations. These high-demand services would increase clients’ willingness to pay and also enable Pro Mujer to incrementally offer a more complete primary care package to its clients. In order for clients to be able to complete specialized treatments that Pro Mujer’s package cannot cover, the organization is evaluating the incorporation of a capped health loan for existing clients.

As we continue to evolve as an organization, this pilot health care program will be instrumental to advancing our mission in support of Latin America women who are living in impoverished communities.


October 4, 2011 at 12:37 pm 3 comments

Meet Maria, a Micro-Entrepreneur from Nicaragua

Eight years ago, Maria and her husband were struggling to support their family in León, Nicaragua, the second poorest country in the Americas after Haiti, where 48% of the population lives below the poverty line.

To help make ends meet, her three children – ages 14, 21, and 23 – would wander the streets after school selling tortillas and other small food items prepared by their parents out of their home.

An initial loan of US$48 provided Maria with the power to invest in her business and buy ingredients such as corn, beans, rice and oil in bulk.

As her business grew, Maria’s income increased and life dramatically improved for her and her family. Her children were able to stop working and instead focus on their studies.

She was able to improve their living conditions by upgrading the plastic covering on their walls with brick and her dirt floors to concrete. The primitive fire pit that she once cooked over, the smoke from which is one of the leading causes of potentially lethal respiratory illnesses, has since been replaced with a large, more modern stove.

Maria was also able to acquire a bicycle enabling her to diversify her business and travel greater distances to sell her products.

Just as Maria and her family reached a high point in their economic well-being, she suffered a major set-back. During a regular Pap screening offered through Pro Mujer’s primary health care services, she received an abnormal result. Maria was quickly referred to a surgeon and able to receive a life-saving operation.

Building upon the success of the past few years, Maria and her family continue to prepare for a brighter future.

July 12, 2011 at 3:03 pm Leave a comment

Voices from the Field: Pablo Salazar, Harvard Business School ’11 and Project Antares Team Member

Pablo Salazar

As a second year MBA student at Harvard Business School (HBS), I was looking for an opportunity to learn about health delivery models that could be applied in Mexico – my home country. I had the fantastic opportunity to get involved with Pro Mujer on a semester-long field study with the objective of helping develop a health service offering for the organization’s Mexico operations.

This opportunity was made possible with the help of an innovative partnership between HBS and Harvard’s School of Public Health (SPH) called Project Antares. Led by Professors Michael Chu of HBS and David Bloom from SPH, Project Antares focuses on sponsoring field studies that look at commercial approaches to delivering high-impact primary health care initiatives (or “interventions” as we call them in the industry) to low-income populations in developing countries. This program provided us with access to the knowledge and advice of two remarkable experts in the field in addition to accessing funding to conduct primary research and visit field operations.

Currently in its fourth year with Pro Mujer and collaborating with Dr. Gabriela Salvador – Pro Mujer’s Director of Health and Human Development and SPH alum – our goal was to create a framework that enabled us to analyze which health offerings are most valued by customers and which ones can have a bigger impact in their lives.

Using this framework as a baseline and a health pilot model already launched in the organization’s Nicaragua operations, Pro Mujer will design a health care pilot within its current organizational structure and business model. This model will include a basket of services that maximize the health impact for Pro Mujer’s clients while balancing it with interventions that have the biggest opportunity to be profitable as well as operationally and financially scalable. If the results of such a pilot are financially and socially positive, we believe there is huge upside potential.

A Pro Mujer client and Doctor at the organization’s health care facilities in Nicaragua.

Project Antares brought together the expertise and brainpower of Callae Snively, Felix Lam and Maaz Shaikh from SPH as well as Margarita de la Piedra, José Hartasanchez and I from HBS.  Definitely one of the most enriching experiences was working in such a diverse group, both in terms of different backgrounds as well as professional experience and skills. We really learned to leverage one another’s strengths in research, analytics and health practice knowledge.

Margarita de la Piedra (HBS 2011) and Callae Snively (SPH 2012)

The project got us dreaming about the fact that if we could either deliver health care to someone who is poor in a profitable way, or through the health offering, enhance Pro Mujer’s competitive position as a women’s development and microfinance organization, we could influence other organizations within the microfinance industry. This pilot as well as the one already at work in Nicaragua has the potential to show that it makes economic sense for microfinance institutions to offer health services. Competition and scalability would then follow.

Whether and when the Mexican pilot will happen remains to be answered and depends on the results of the market analysis currently underway by the Antares team, but the project reminded us of the challenges our world faces and the responsibility as leaders that we have in addressing them. For me, it was a fantastic experience to be able to apply the skills that I have acquired over these last two years at HBS and help an organization like Pro Mujer maximize the positive impact they create for women in Mexico. It was really inspiring to work hand in hand with Pro Mujer’s staff and leadership to understand the challenges that they face on a daily basis.

This project is another example of the field studies supported by HBS’s Social Enterprise Initiative which seeks to ensure that HBS becomes the best place at motivating students to become leaders who make a difference in the world.

Prior to entering HBS, Pablo Salazar worked at Pfizer Mexico for four years in Sales & Marketing. In addition to his involvement with the Antares project, Pablo worked on a field study with GlaxoSmithKline (a valued Pro Mujer partner) to define their long-term strategy in emerging markets. During his time at HBS, Pablo served as one of the main organizers of the School’s XIII Latin American Conference, which gathered diverse leaders interested in the future of the region. Upon graduation, Pablo looks forward to moving to New York and joining McKinsey & Company as a full-time Associate.

May 3, 2011 at 3:24 pm 1 comment

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