As part of the global agenda of insuring for sustainable development, the Impact Insurance Facility (www.impactinsurance.org) and the PSI Initiative (www.unepfi.org/psi) are organizing a webinar series with the theme, “Making inclusive insurance work”. The third webinar had the topic "Health: telemedicine, insurance and Universal Health Coverage" and was held on 28 February 2017. Speakers: Dr Peter Benjamin (Health Enabled), Jody Delichte (Inclusivity Solutions) and Andrew Smith (Tonic, Telenor’s m-Health service in Bangladesh). Moderator: Lisa Morgan (ILO's Impact Insurance Facility).

1. Making inclusive insurance work series
Health Part 1:
Telemedicine, Insurance and Universal
Health Coverage

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3. The UNEP PSI and ILO webinar series
Making inclusive insurance work - A webinar series by the International
Labour Organization’s Impact Insurance Facility and UN Environment’s
Principles for Sustainable Insurance (PSI) Initiative
As part of the global agenda of insuring for sustainable development, the
Impact Insurance Facility (www.impactinsurance.org) and the PSI Initiative
(www.unepfi.org/psi) are organizing a seven-part webinar series with the
theme, “Making inclusive insurance work”.
Today’s session will focus on “Telemedicine, Insurance and Universal Health
Coverage”

5. • By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental
health and well-being
• Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol
• By 2020, halve the number of global deaths and injuries from road traffic accidents
• By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and
the integration of reproductive health into national strategies and programmes
• Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective,
quality and affordable essential medicines and vaccines for all
• By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination
• Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
• Support the research and development of vaccines and medicines for the communicable and noncommunicable diseases that primarily affect
developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS
Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade Related
Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all
• Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries,
especially in least developed countries and small island developing States
• Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and
global health risks
• By 2030, reduce the global maternal
mortality ratio to less than 70 per 100,000
live births
• By 2030, end preventable deaths of
newborns and children under 5 years of
age, with all countries aiming to reduce
neonatal mortality to at least as low as 12
per 1,000 live births and under-5 mortality
to at least as low as 25 per 1,000 live births
• By 2030, end the epidemics of AIDS,
tuberculosis, malaria and neglected tropical
diseases and combat hepatitis, water-borne
diseases and other communicable diseases

6. health insurance – of any kind – is the most in demand
an alarming percentage of people in the developing
world have little or no access to cover and where they
do, the quality is often poor…
‒ 56% of the global rural and 22% of the global urban
population have no health cover at all
health related debt is often impoverishing
exorbitant OOP health care costs are the leading cause
of bankruptcy, and
in some cases, UHC is years away from being realised, it
is very complex and governments need support
we also find that insurers want to offer something to the
emerging consumer to help with health-induced
financial risks, but don’t know how to do it in a
sustainable way
There is a global health worker deficit of 10.3 million
In our research on low-income
populations, we frequently find that:

7. Availability of services
Inequitable rural/urban distribution
of global skilled health worker
deficits
2015 (millions)
Urban deficit:
More than 3
million
Rural
deficit:
About 7
Global health
worker deficit:
10.3 million
* Threshold: 41.1 per 10,000 population
Source: Global evidence on inequities in rural health protection. International Labour Office, Social Protection Department. Geneva: ILO, 2015.
Globally highest
Rural Staff Access Deficits (SAD)*:
% of national rural population without access
to care due to the absence of health worker
Somalia 98.6
Guinea 98.5
Niger 97.9
Chad 97.7
Ethiopia 97
Liberia 96.9
Haiti 96.6
Burundi 96.4
Central African Rep. 96.1
Tanzania 96.1

8. Making inclusive insurance work:
Telemedicine, Insurance and
Universal Health Coverage
Presenter:
Jody Delichte
Inclusivity Solutions
Presenter:
Andrew Smith
Tonic, Telenor Health -
Bangladesh
Facilitator:
Lisa Morgan
Impact Insurance
Facility
8
Presenter:
Dr Peter Benjamin
HealthEnabled

9. Health Enabled
Presentation by Dr. Peter Benjamin
Director

11. Mobile health
Mobile health (mHealth) is the practice of medicine and
public health supported by mobile devices
Recent: term first used 2003. Istepanian “unwired e-med”
Started as field 2008, Bellagio Conference
Tech is more than cellphones & tablets, including:
‒ Patient monitoring devices
‒ Mobile telemedicine / telecare devices
‒ Data collection software
‒ Apps (120,000 on iStore and Google Play)
‒ Social media, gamification
‒ Health & fitness wearables …ulation
Way in / interface into wider eHealth

12. Education
& Awareness
Diagnostic
Treatment & Support
Disease & Epidemic
Outbreak Tracking
Healthcare Worker
Communication & Training
Remote
Monitoring
Source: Intel. Women and the Web: Bridging the Internet Gap and Creating New Global Opportunities in Low and Middle Income Countries. 2012.
A real possibility: LMICs accounted for more than 80% of the
660 million new mobile-cellular subscriptions added in 2011.
Remote Data
Collection
Why mHealth?
mHealth holds real promise to transform health
outcomes for vulnerable populations by providing:

13. Labrique et al. (2013)
Frameworks and tools for designing,
implementing and evaluating mHealth
Interventions

14. Inclusivity Solutions
Presentation by Jody Delichte
Chief Marketing Officer

16. Present > Future

20. Transtheoretical model of behaviour
change

21. Telenor Health & Tonic: Mobile health
innovation case study
Presentation by Andrew Smith
Chief Operations and Performance Officer

22. mHealth in South East Asia: Opportunity
to transform access, affordability and
quality
800 million new
mobile internet
users
in Asia by 2020 –
with massive need
for protection for
loved ones, and help
to succeed in a
changing world
Tens of millions
driven into poverty
through the cost of ill
health, with major
government, donor,
investor focus on
universal health
coverage – need
for scalable,
commercial models
D
I
Mobile technology
and AI enabling new
virtual primary care
solutions, and
powerful new
distribution
models - quality
healthcare where its
never gone before

23. Tonic

24. We combine…
Deep
Healthcare
expertise
Human centered
design approach
Serious
Technology
chops

25. To create…
a digital front door to
health for all

26. We offer real solutions to real
problems
Patient centered model of
virtual care. Access to
quality primary health care
and expert advice when it’s
needed
Access the right health
information to stay well, and
build my health community
Make quality health care
more affordable.
Help to find the best
place to get the care that
is needed, with exclusive
benefits
Problem:
I can’t find reliable
information about staying
healthy (for me or ones I
love)
Problem:
I can’t get the right
care I need when I
need it. I don’t where to
look.
Problem:
Health care is too
expensive.

27. Our launch product in Bangladesh
Tonic Wellbeing Tonic Daktar Tonic Cash
Health tips via FB / Web /
Android App / SMS,
including health hero’s,
infographics, comic-strips
– backed by medical
evidence base
Access to a qualified
doctor by phone,
24/7: SMS
prescriptions, track
previous health events
and calls, follow up
health tips
1000 BDT when you are
in hospital for three nights
or more. Insurance
delivered over the mobile
(claims, payments,
enrolment)
Tonic Discounts
Largest national
healthcare partner
network – 250+
hospitals, pharmacies,
diagnostic labs, and
lifestyle partners
Save $1-2,000 USD with
one SMS.

28. Tonic engagement and impact – c7
months in…
28
2.85 million members
(current growth: 20,000 per day)
Our impact and engagement to date....
Tonic
Cash
Largest health insurance programme in
Bangladesh. 1,600+ payouts, from contact
to payment 5 days
Tonic Discounts 20,000+ discounts provided on services 200+
hospitals, pharmacies, and diagnostic centers
across Bangladesh
Tonic
Daktar
160,000 medical consultations with our in-
house doctors through telemedicine service
Tonic
Wellbeing
1.5m daily reach with health and wellness
content via Facebook
C9-10% average share(s) with family and
friends – forming a community of health
 Data across the
healthcare journey (200m
data points already….), spot
the healthcare gap, fill it!
 Customer-centricity– net
promoter score of 50+

29. ✔ Symptom & disease management protocols for
conducting telehealth consultations
✔ Comprehensive training program to improve the
delivery of clinical services & regular monitoring of
clinical performance
✔ Custom electronic health record system to assist
doctors in conducting telephone based consultations,
with full clinical coding and patient health history
✔ Organizing monthly Continued Medical Education
where group of our doctors discuss on challenging
clinical cases they encounter over the phone
✔ No major clinical complaints or critical incidents, in
150,000+ consultations
Deep dive: clinical quality
29
Quality

30. Deep dive: affordability
30
Affordability
✔ Discounts provided to the customers through a
nationwide partnership network with 200+ hospital,
pharmacies and diagnostic centers
✔ cBDT 1,000,000 has been disbursed as a part of Tonic
Cash micro insurance claims
✔ $1,000 saved on open heart surgery – largest discount
provided – most redeemed are pathology/tests
✔ Approximate amount of discount provided is BDT 4
million. 20,000 customers with more affordable care.
“My family was going through a very hard time due
to my father’s open heart surgery. I got a discount
of 13,000 only because of Tonic. This was a great
help during that time. I hope Tonic will add more
partners nationwide” : Tonic Member Ibrahim
Cardiac Hospital

31. Where next? Meeting new customer
needs
Chat with
Doctors via
multiple
channels,
when/how you
want
Health checks –
bringing
together real
world and
digital
Distributed
care and
appointment
booking
Micro-
insurance to
cover greater
cost of care,
bundled
packages

32. Where next? Measuring our impact

33. …and all powered by great people

34. Client Education & Behaviour Change
Sensors & point-of-care diagnostics
Registries / vital event tracking
Data collection and reporting
Electronic health records
Electronic decision support
Provider-to-provider communications
Provider workplanning & scheduling
Provider training and education
Human resource management
Supply chain management
Financial transactions & incentives
Frameworks and tools for designing,
implementing and evaluating mHealth
Interventions
Labrique et al. (2013)

35. mHealth around the world
83% of WHO member countries reported having at least one mHealth initiative in their
country.1
77% of responding low-income countries reported at least one mHealth initiative in their
country, making them only ten percent behind high-income countries.1
1World Health Organization. mHealth: New horizons for health through mobile technologies: second
global survey on eHealth. http://www.who.int/goe/publications/goe_mhealth_web.pdf.

37. Ugandan Pilotitis

38. 9 principles of digital development
“Fail fast, learn quickly, do it again”

39. Airtel Insurance (health micro-insurance in 7 African countries)
Aponjon (maternal health messaging in Bangladesh, part of MAMA)
cStock (medical supply chain in Malawi)
iCCM (mobile tool for health workers in integrated community case
mmgt, Malawi)
Kilkari (maternal health messaging via voice & CHW training, India)
mHERO (health worker SMS messages for targeted care, 6 W African
countries)
mSOS (disease surveillance reporting, Kenya)
RapidSMS Rwanda (preventing maternal & child death in 1,000 days,
Rwanda)
U-Report (preventing adolescent AIDS by mobile counselling &
polling, Uganda)
MomConnect (Maternal health messaging, South Africa)
USAID mHealth Compendium: Reaching
scale

40. National Department of Health,
South Africa

42. SMS sent from 1st ANC, delivery, to babies 1st birthday
After 25 months of operation:
‒ SMS sent to 950,000 pregnant women & mothers of infants
‒ MomConnect in over 3,350 (97%) facilities
‒ Six times as many compliments (5,763) as complaints (912)
‒ NurseConnect: 12,000 nurses getting training & support
SMS
‒ Additional PMTCT messaging for HIV +ve pregnant women
‒ Research (small-scale) shows that mothers receiving SMS
messages have better health outcomes
‒ Mobisite, Facebook messenger (and soon WhatsApp)
MomConnect

43. Introduction of proven interventions at
specific key points of entry from before
birth to after five years of age
* Bryce et al. Can the world afford to save the lives of 6 million children each year? The Lancet 2005; 365:2193-2200.

44. INTERVENTION
OF KNOWN
EFFICACY
EFFECTIVE
COVERAGE
Thanks to:
Alain Labrique, JHU

45. INTERVENTION
OF KNOWN
EFFICACY
EFFECTIVE
COVERAGE
mHEALTH:
A Health Systems Catalyst
Thanks to:
Alain Labrique, JHU

48. And begin to align mHealth strategies
with the post-2015 agenda to achieve
universal health access
(Labrique & Mehl, 2015)
Financial Coverage
Effective Coverage
Continuous Coverage
Contact Coverage
Accessibility of health facilities
Availability of human resources
Availability of commodities and equipment
Accountability coverage
Target population
Total population
COST
QUALITY
DEMAND
SUPPLY
AVAILABLITY
E
D
C
B
A
H
G
F
TARGET:universaleffectivecoverageofhealthinterventions
ofknownefficacy
Current gap in determinant
performance
Illustrative mHealth strategies to
close performance gaps
Minimum performance of supply
determinant
mHealth Strategies
Mobile financial transactions
Decision support, POC diagnostics,
Telemedicine, Reminders, Incentives
Persistent electronic health records, Provider-
to-provider communication, Work planning,
Reminders
Behaviour change communication (BCC),
Incentives
Hotlines, Client mobile apps, Client information
content subscriptions
Human resource management, Provider
training, Telemedicine
Supply management, Counterfeit prevention
Client registration, Electronic medical records,
Unique identifiers, Data collection and
reporting, Screening tools, Civil registration
and vital events
E
D
C
B
H
G
F
A
DETERMINANT
LAYERS OF UHC

49. HealthEnabled: Towards scaled
sustainable impactful integrated digital
health
Informed Decision
Making
National Policy
Sustainable Programs
Design for scale, operationalize
& build platforms
Effective Use
Evidence-based
public good tools
HealthEnabled
National
Digital
Health
Systems

50. Health information for all: Wiki Health 100 x 100
Support personal change: Stop smoking, eat better,
exercise
Callcentre triage: 45% resolved during the call
Emergency response: Distress call community
ambulance
Adherence support: Welldoc “prescribed” for diabetes
Pre-emptive health (Support people responsible for
own health)
Towards precision medicine / genomics for public
health
Digital health as the primary contact to
the health system & empowering own
health

53. Health > healthcare. mHealth extends services outside the clinic
mHealth:
‒ Tool for health system efficiency, data collection, mgmt, info flow
‒ Improved point-of-care services, decision support, patient record
‒ Tool for wider holistic health, empowering people
Evidence-based for some:
‒ Data collection
‒ Supply chain / lab results / mgmt
‒ HW decision support, EMR
‒ Behaviour change ?
Great tool for Universal Health Coverage (NHI)
From “mHealth” -> New normal, how to do large-scale public health
In closing

54. “These tools don’t get socially interesting until
they’re technologically boring”
(Clay Shirky, 2010)

55. Market-based, comprehensive health
microinsurance is not viable and has not
reached scale
-50%
-30%
-10%
10%
30%
50%
2008 2009 2010 2011 2012
Life mandatory
Life voluntary
Agriculture mandatory
Health voluntary
Unprofitable,
losses subsidized
Profitable,explicit
subsidy
Profitable,
implicitsubsidy
Profitable,no
subsidies
Composite (Nirapotta– microfinance)
Inpatient+ Outpatient(GK – microfinance)
Inpatient+ value-addedservices (Naya Jeevan)
Inpatient+ Outpatient(RSBY - government)
Hospitalcash (Jubilee/MFW)
Inpatient(ARY – distributionpartner)

56. Evolution so far… and promise of
PPP models
Private or community-based health insurer (CBHI)
Substitute
HMI services a population
that is a) ineligible for public
coverage or b) does not
receive effective public
coverage
Reform designs
underway
No reform in place
Maturity (e.g. time, political commitment, management capacity, infrastructure, resources)
Government
Providerofcoverage
GOAL:
Universal
Health
Coverage
Foundation
CBHI is at the origin of health social
protection; government decides to scale
and exerts regulatory authority over
CBHIs
Partnership
Government outsources specific
pieces of the insurance value chain
to private partners (insurer, bank,
MNO and other organized groups)
Supplement
HMI provides products
covering additional benefits
to public scheme (e.g. telemedicine,
outpatient benefits, lost wages, travel,
etc.)
Primary
Provider
Secondary
Provider

57. Making inclusive insurance work:
Telemedicine, Insurance and
Universal Health Coverage
Presenter:
Jody Delichte
Inclusivity Solutions
Presenter:
Andrew Smith
Tonic, Telenor Health -
Bangladesh
Facilitator:
Lisa Morgan
Impact Insurance
Facility
57
Presenter:
Dr Peter Benjamin
HealthEnabled
Q&A

58. Our next webinars
Making inclusive insurance work - A webinar series by the International
Labour Organization’s Impact Insurance Facility and UN Environment’s
Principles for Sustainable Insurance (PSI) Initiative
The topics and schedule of the next webinars are as follows:
4. SMEs and value chains – 16th March 2017
5. Agriculture and climate risks- April 2017
6. Health Part II – date TBA
7. Insurance regulation – date TBA