Bienestar Familia: healthcare for low-income families

Bienestar Familia
Private Healthcare Insurance for Low Income Families

20 - Bienestar Familia - D4SB

“It’s great design that can solve social as well as economic problems.
They (designers) took the methodology of product design and applied
it to services. Now they are moving beyond that to systemizing design
methodologies for all kinds of arenas, including social problems. What
better way to deal with the health care crisis than to use design?”

Bruce Nussbaum

Innovation and Design
Managing Editor. BusinessWeek

22 - Colombia · Bienestar Familia - D4SB

23

Index
Why Colombia?

Bienestar Familia Concept
Value Proposition
The Family Healthcare Plan and The Family Doctor

The Colombian Context

73
73

Colombia Profile

31

The Community Link: Fairy (Health Promoters)

73

Colombia in Numbers

31

The Business Model Canvas

83

MDG in Colombia

32

Healthcare in Colombia

33

Caldas Profile

35

Villamaria Profile

38

Benchmarks

40

Project Goal

43

Ownership

86

Implementation

86

Expansion

86

Conclusion

Observation & Synthesis
The Field Research in Caldas, Colombia

46

The Research Tools

46

The Colombia Healthcare System

99

60

Identification of Problems & Needs

Bibliography

55

Personas

96

52

The Interview Guides

Conclusion

47

Bienestar


Implementation and Expansion

68

25

Why Colombia?
Grameen Caldas is an organization founded in Colombia by GCL in partnership with the public sector represented by
the Caldas Government to facilitate the creation of a Holistic Social Business Movement (HSBM) in the region. The idea
of this HSBM is to set the right environment in Caldas paving the way for social business initiatives with the unique
objective of eradicating poverty. To enable this environment, Grameen Caldas set initiatives in micro-finance, joint
ventures development and in the creation of a social business fund of $7 million. The four main areas of investment are
education, nutrition, healthcare and housing (sanitation).
The Grameen Caldas team initiated Bienestar, a social business project addressing the issues of healthcare in the
region. Our challenge as the Design for Social Business team was to understand the complexity of the healthcare
system in Caldas, identify its main breakdowns and accordingly explore how design can improve, expand and replicate
the already existing pilot model of Bienestar.


27

The
Colombian
Context

29

Colombia
Profile

Being the twenty-sixth largest country by geographical area and the twenty-seventh largest by population, the
Republic of Colombia is the fourth largest economy of Latin America. With over 46 million people Colombia (2010 est.),
has one of the most unequal distributions of wealth with a GINI coefficient of 0.587 (the highest in Latin America).
46% of the population lives below the poverty line and 17% in extreme poverty.

Colombia in Numbers

75%
urban

54%
above

46%

62.8%
not poor

below

37.2%

Rural and urban
populations

People below
the poverty line

Poverty head count ratio
at national poverty line

88%

93%

25%
rural

employed

literate

Unemployment
(total labor force)

poor

Literacy rate
(age 15 and above)

Capital City: Bogotá
Income Level: Lower middle income
GDP: $435,367,000,00 (2010 est.)
GNI per Capita: $8,430 (2009 est.)
GINI Index: 0.587 the highest in Latin America
Total Population: 46.3 millions

31

Healthcare in Colombia
MDG in Colombia
Value

Goal

1990

Value
2008

Goal 1. Halve the rates for extreme poverty and malnutrition
Poverty headcount ratio at USD$1.25 a day (PPP, % of population)
Poverty headcount ratio at national poverty line (% of population)
Share of income or consumption to the poorest quintile (%)
Prevalence of malnutrition (% of children under 5)

3.4
-

2.9
5.1

Goal 2. Ensure that children are able to complete primary schooling
Primary school enrolment (net, %)
Primary school completion rate (% of relevant age group)
Secondary school enrolment (gross, %)
Youth literacy rate (% of people ages 15 - 24)

68
67
50
95

5
35
26
82

21
17
88

Goal 5. Reduce maternal mortality by 3/4
Maternal mortality ratio (modeled estimate, per 100,000 live births)
Births attended by skilled health staff (% of total)
Contraceptive prevalence (% of women ages 15 - 49)

82
66

130
96
78

Goal 6. Halt and begin to reverse the spread of HIV/AIDS and other major diseases
Prevalence of HIV (% of population ages 15 - 49)
Incidence of tuberculosis (per 100,000 people)
Tuberculosis cases detected under DOTS (%)

63
-

0.6
45
83

Goal 7. Halve the proportion of people without sustainable access to basic needs
Access to an improved water source (% of population)
Access to improved sanitation facilities (% of population)
Forest area (% of total land areas)
Nationally protected areas (% of total land areas)
CO2 emmissions (metric tons per capita)
GDP per unit of energy use (constant 2005 PPP $ per Kg of oil equivalent)

92
82
55.4
1.7
7

93
86
54.7
74.4
1.2
9.2

Goal 8. Develop a global partnership for development
Telephone mainlines (per 100 people)
Mobile phone subscribers (per 100 people)
Internet users (per 100 people)
Personal computers (per 100 people)

6.9
0
0
0.9

17.2
73.6
26.2
5.5

Goal 3. Eliminate gender disparity in education and empower women
Ratio of girls to boys in primary and secondary education (%)
Women employed in the non agricultural sector (% of non agricultural employment)
Proportion of seats held by women in national parliament (%)


3K

104
48
8

Goal 4. Reduce under 5 mortality by two thirds
Under 5 mortality rate (per 1,000)
Infant mortality rate (per 1,000 live births)
Measles immunization (proportion of 1 year old immunized, %)

15% of population (approximately 6.9 million) are without medical insurance.
Extreme low quality in health services provided to the poor.
Poor infrastructure and shortage in public hospitals.
High bureaucracy in accessing the public health system.
Private insurance companies delay payment of treatments.

88
65
82
97

108
44

»»
»»
»»
»»
»»

Per Capita Annual Expenditure on Healthcare

Table 1.

Value achieved in Colombia until 2008 according to the Millennium Development Goals.

Average exchange rate (USD)

With a GINI coefficient of 0.587
Colombia has the highest inequality
in Latin America.

Main Problems of the System

2K

1K

0K
1995
Colombia

2000

2005

2010

Region of the Americas’ average

Figure 3. Colombian expenditure on healthcare (est. 2008).

Healthcare Related Statistics
Data
Access to an improved water source
Access to improved sanitation facilities
Mortality rate, infant
Child malnutrition (children under 5)

Value
93%
86%
17 per 1,000 live births
5%

World Bank (2008)

Life expectancy at birth m/f (years)
Probability of dying under five
Probability of dying between 15 and 60 years m/f
Total expenditure on health per capita (PPP International $)
Total expenditure on health

73/80
19 per 1,000 live births
166/80 per 1,000 live births
569
6.4% of GDP

Global Health Observatory (2009)

Table 2. Healthcare related statistics according to the World Bank (2008) and the Global Health Observatory (2009).
33

Caldas
Profile
Hypertensive 3.8%
Ischemic heart 14.4%

Circulatory
32.8%

Injuries
7.6%

Although the matriculation at the Caldas universities in the field of Sciences
of Health were of 3,285 students, and the medicine schools in Colombia
have increased from 21 to 54 in the last 20 years, doctors that graduate are
concentrated in the big cities making it difficult to achieve health coverage
for the entire population.

Hypertensive 2.1%
Ischemic heart 11.3%
Cerebrovascular 4.7%

Other causes
15.3%

Caldas department is part of the Colombian Coffee Growing Axis with a total area of 7,291 km2. Caldas’ department
has a population of 976,438 inhabitants consisting mainly of 25-29 year olds. The combination of mortality rates and
migration of young people due to the scarcity in the labor markets is leading to an increment on the aging population
(40+ year olds).

Other CVD’s 3.0%

Circulatory
21.2%

Other causes
13.8%

Cerebrovascular 9.3%
All NCD’s
48.2%
Injuries
38.0%

Other CVD’s 5.3%
Cancers 19.9%
Respiratory
6.7%
Diabetes
5.5%

Other Cancers
9.6%

Figure 4. Estimated mortality causes for women (%) Colombia, 2004

Lung 1.5%
Breast 2.5%
Colorectal 1.5%
Leukemia 1.0%
Lymphomas 0.9%
Stomach 2.9%

11.1%

14.2%

22.4%

23.8%

23.6%

32.4%

32.6%

32.9%

34.1%

31.6%

29.3%

2009

2015

Diabetes 2.5%
Respiratory 4.9%
Other NCD’s 8.2%

Figure 5. Estimated mortality causes for men (%) Colombia, 2004

The average income of a general doctor in Colombia
is around $285 (3-4 minimum wages). Around 8% of the
doctors are unemployed and 5% work in different jobs.

12.0%

2005

Other NCD’s
12.2%

Cancers
11.5%

All NCD’s
77.1%

Figure 7. The Caldas region.

Figure 6. The Caldas population structure by large groups.
0 - 17

40 - 59

18 - 39

60+

35

Is the inactivity rate
in the region of Caldas

Out of the total
Caldas population...

Is the inadequate employment rate
due to income in the Caldas region.

Scarcity in the labor market, added to the great reduction in
agricultural production have conspired to create higher rates of
inactivity and greatly increase the chances of falling into poverty.

25.7% are registered as

SISBEN Level 1 (extreme poverty)


SISBEN Level 2 (poor)

SISBEN Level 3

It means that 3 out of every
5 inhabitants of Caldas are
poor by definition

The SISBEN Level


*SISBEN: The Selection System of Beneficiaries for Social Programs is a social survey done by the government, to rank poor people
(from economical strata 1 and 2) according to their quality of life. People are divided in three categories: 1, 2 and 3 (where 1 is the
lowest quality of life). SISBEN is used to select people for social assistance programs from the government, who have “... a state of
deprivation not only in material welfare (food, housing, education, health, etc.) but (…) also personal and property uncertainty,
vulnerability to health, disasters and economic crisis, social exclusion and political life and liberty of making abilities”.

174,142
31% are single moms

17,832
36% are single moms

7,510
36% are single moms

Number of households as registered by SISBEN

The average size of a household
according to SISBEN level in Caldas

4.5

Level 1

4.0

Level 2

3.4

Level 3
37

Villamaría
Profile

Villamaría is a municipality of the Caldas Region and is situated 9 km away from the capital, Manizales. It has an area of 461 km2 and
a population of 50,123 inhabitants.

Healthcare Professionals in Villamaría
In 2009 Villamaria had

Colombia had

1 doctor for every 2,083 inhabitants

1 doctor for every 740 inhabitants

1 dentist for every 4,545 inhabitants

1 dentist for every 1,282 inhabitants

1 nurse for every 8,333 inhabitants

1 nurse for every 1,818 inhabitants

Table 3. Number of healthcare professionals in Villamaria compared to the whole Colombia in 2009.

Caldas population
± 1,000,000
Villamaría population
± 50,000


Manizales population
± 387,000

39

Benchmarks
Many solutions have been implemented throughout the world to improve healthcare access to low income communities.
We looked into some of the different approaches to get inspiration for our concept.

Mothers Club, Kendubay
Sub-District Hospital

Distance Healthcare
Advancement - DISHA

Pre natal/delivery care and education
The club recruits women attending the hospital’s prenatal clinic. The women are asked to make a commitment
to deliver their next child in the hospital and meet as
a group twice a month to receive health education,
including training on safe motherhood practices.
Other than that, they are asked to take an active role
in educating other women in their villages about safe
motherhood and the risks of delivering at home.


SOS
Médcins France

Mobile healthcare and partnerships

Discounted medical services

Affordable healthcare franchise model

Mobile healthcare

The goal of DISHA is to deliver high-quality, low-cost
diagnosis and care to low-income rural communities that
are not addressed by the existing healthcare system
through a mobile tele-clinical van. In this initiative,
Philips, an imaging and medical diagnostics company,
partnered with a government agency (ISRO) that provides
satellite connectivity between the van and the hospital,
Apollo, the healthcare service provider which will staff
the van, and a local NGO.

Through the use of a multi-tiered pricing model,
ASEMBIS has created a financially self-sustained network
of eye care clinics that offer services from basic eye
examinations to sophisticated surgical procedures at a
40-70% discount from the market rate. Its integrated
network includes non-traditional health professionals
for vision testing and preventive care, cost-efficient and
high-volume clinics, and mobile rural clinics; an overall
treating of more than 350,000 patients in 2004. The 8
clinics in different regions of Costa Rica, offer nationwide
coverage, and provide a wide spectrum of medical
services, from basic health to sophisticated surgeries,
imaging diagnostics, and almost all specialties.

A network of 64 financially self–sustainable centers
that deliver government approved health products and
pharmaceuticals at $0.50 per treatment. Distributed in
urban, rural and semi-rural areas, these units are located
within an hour distance from their intended customer
base and serve more than 400,000 Kenyans a year. More
than half of the locations are owned by community
health workers while the rest is owned by licensed nurses
which also provide screening services. The quality of the
services is guaranteed by unannounced audits and the
threat of the closure. In exchange, they bear a brand
name, share marketing costs, best practices and benefit
from a centralized buying platform.

The concept is simple: patients in need of care can
contact a call center 24 hours a day, 365 days a year that
finds an available doctor and sends him to their home,
much like a taxi business. A success that counts with a
thousand emergency doctors and 62 associations spread
over the territory, and have handled so far 4 million calls
and 2.5 million home interventions and consultations;
60% of procedures performed at night, Saturday
afternoon, Sunday and holidays. The achieved results are
a consequence of the reliability and unfailing motivation
of the key players.

Key point: Creating a network of financially
sustainable healthcare clinics that offer
specialist services and uses alternative
professionals to deliver care.

Key point: Empowering and integrating local
women in the healthcare delivery model through
an educational role.

ASEMBIS

CFW
Shops Kenya

Key point: Creating a replicable and affordable
model that benefits from group synergy and local
entrepreneurs.

Key point: Creating alternative channels to deliver
healthcare and create synergetic partnerships.

Key point: Providing alternative channels for care
delivery through an extremely flexible organizational
model.

41

Project Goal:
Improve access to primary
healthcare in Caldas, by
redesigning the existing
Bienestar social business model,
in order to expand and replicate
it in Colombia and possibly
elsewhere.

43

Observation
& Synthesis

45

The Field Research in Caldas, Colombia

The Colombian Healthcare System

Initials
To understand the complexity of the healthcare system, it is important to look into its institutions, the different forms
of coverage it provides to the population and the regulations behind it.

A substantial part of the input gathered for this project comes from the field research conducted in Caldas, Colombia
from May 15th to June 5th, 2011. Our stay was supported by the local organizations Grameen Caldas and Bienestar,
which helped us individuate and contact the local players, make the arrangements for the activities and guide us on
field.

The public healthcare is regulated by the law 100/1993, which established the SGSSS (General System of Social
Security in Health). This system is coordinated, directed and controlled by the state and the funds designated by the
government are managed by the FOSYGA (Fund of Solidarity and Guarantees).

This phase of the project was based on qualitative research methods which, combined with the desktop research,
helped us in getting a complete overview of the situation and arriving to the desired solution.

The main healthcare institutions involved in delivering healthcare services to the population are the EPS’ (Health
Insurance Companies) and the IPS’ (Health Service Providers).

“At the early stages of the process, research is generative—used to inspire imagination and inform intuition about
new opportunities and ideas. In later phases, these methods can be evaluative—used to learn quickly about people’s
response to ideas and proposed solutions”. (IDEO Toolkit).

The EPS functions as an intermediary between its affiliates and care delivery institutions (IPS) in managing
appointments, approvals and the payments of health services. It has to guarantee to its affiliates the minimum
established by the POS (Mandatory Health Plan), which is a list of treatments, procedures and drugs defined by the
government.

The Research Tools

The IPS is a public or private entity that provides medical procedures. IPS’ are divided in 3 levels of attention and the
vast majority only cover the first level.

Design tools used with the different stakeholders
Tools

Stakeholders
Doctors, medical
professors and students
from Manizales University.

Understanding the complexity of the Colombian healthcare
system, its stakeholders, how they are connected to each
other and their influence on the system.

The quality and coverage of health services are directly linked to the affiliation of the patient to the system. There are
four types of regimens:

Name in Spanish (English)

SGSSS

Sistema General de Seguridad Social en Salud
(General System of Social Security in Health)

EPS

Entidades Promotoras de Salud
(Health Insurance Companies)

EPS-S

Entidades Promotoras de Salud Subsidiadas
(Subsidized Health Insurance Companies)

IPS

Instituciones Prestadoras de Servicios de
Salud
(Healthcare Providing Institutions)

POS

Plan Obligatorio de Salud
(Compulsory Healthcare Plan)

FOSYGA

Fondo de Solidaridad y Garantía
(Fund of Solidarity and Guarantees)

PBS

Plan Basico de Salud
(Basic Health Plan)

Table 5. Acronyms of the Colombian healthcare system.

Goals

Group interview

List of Acronyms

Discovering the main touch points of the existing healthcare
service and tracing money, time and information flow.

Different Regimens Within the Colombian Healthcare System
Regimen

Description

millions / %

Contributive
(RC)

Understanding the Holistic Social Business Movement in
Caldas and its goals, as well as the criteria for accessing the
fund assigned by the Government to finance social businesses
in Caldas.

People with employment contract or independent workers who earn at least two minimum salaries per month are affiliated
to the contributive regime; they have to pay a monthly affiliation to an EPS (12.5% of their monthly wage); 8.5% is paid
by employers and 4% is paid by employees, and they should pay moderating fees ‘copays’ established in the POS for the
contributive regime.

Subsidized
(RS)

Unemployed people and people from SISBEN 1 and 2, likewise their family; they should pay moderating fees established in
the POS for the subsidized regime according to their SISBEN level. Of the 12.5% total contribution per individual of the RC,
the FOSYGA channels 1.5% into the RS as a solidarity contribution.

Understanding and analyzing the first outcomes, limitations
and challenges of Bienestar social business pilot phase.

Not affiliated
(Vinculados)

People who are not classified by the SISBEN and don’t have access to the subsidized healthcare services, as well as SISBEN 3
and independent workers with payment capacities. They are covered by the PBS. This plan is a safety net financed by general
taxes that is composed of public hospitals and health centers. While all citizens are eligible to receive the benefits under
this plan, it primarily serves those who have not yet been enrolled in either the RC or the RS and those who are enrolled in
the RS but require services that are not yet covered under its benefits package.

Special
(RE)

People who work for the government, armed forces and teachers of public institutions; this plan is financed by the
government and they benefit from their own network of healthcare providers and have very few limitations on the services
provided.

Understanding the perspective of doctors, their aspirations
and frustrations.
Discussion sessions

Individual interviews

Grameen Caldas team and
Bienestar founders.

Patients, community
workers and healthcare
related players such
as doctors, nurses and
pharmacists.

Understanding the person.
Understanding the general healthcare and medical experiences
of users.
Understanding the specific experiences related to user profile.

Table 4. Description of the design tools used with the different stakeholders.

Affiliations in
Colombia
17.3

(39%)

23.8

(51%)

4.2

Affiliations in
Villamaría
millions / %

16.5

(33%)

15.9

(32%)

17.5

(8%)

(35%)

1.2

N/A

(2%)

Table 6. Definitions of the different regimens within the Colombian healthcare system.

47

Moreover, the access to generic essential drugs (from a list of 350 medicines) is covered through the POS for those
under the contributive regime and with certain restrictions for those under the subsidized regime.
For those not covered by the system, there is almost no access to any medications at all, since this is strictly limited to
primary care medications that do not exceed a value of USD$4.
Therefore, it is clear that the population that lacks the most access to adequate healthcare is the one not affiliated to
the system (vinculados) followed by the subsidized regimen. Combined they represent 67% (34,000) of the population
of Vilamaria—against 59% in Colombia. Vinculados alone, represent 35% of the population in Villamaria, amounting to
a total of 17,500 people without health coverage.

Public Healthcare System Map

49

The network of care providers in Villamaria counts with 5 IPS’ (Table 7) of which only one is a public provider.
It is also the only one that provides emergency and delivery services. The other entities are private and offer only
prevention, promotion and consultation services. For second and third level care, patients have to go to Manizales or
Pereira.

Entity

Hospital San Antonio

Public /
Private

Level of
complexity

Patients
treated
(2009)

Assistant
Staff

I Level

41,173

55

34

Coordinates, directs and controls the public health system (regimen affiliations, EPS’ and
IPS’ regulation and POS limitations). Directly finances life-threatening cases outside of the
POS (tutela).

Admin.
staff

Public

Don’t provide any medical service, but work as an intermediate between their members and
the affiliated IPS’. Manage the money flow between the two.

State / Admin

Healthcare Service Providers in Villamaría

EPS’

(healthcare insurance companies)

Centro Médico El Parque

Private

I Level

19,540

6

3

Salud Total

Private

I Level

N.A.

6

1

S.O.S

Private

I Level

6,803

6

Private

I Level

16,383

13

0

Hospitals, clinics, laboratories. Manage and provide healthcare personnel, infrastructure and
supplies for care delivery according to the POS coverage and to the patients’ EPS affiliation.
Private IPS’ are paid by EPS’. Public IPS’ are for non-affiliated patients (vinculados).

1

Pasbisalud

IPS’

(health service providers)

Table 7. Description of the healthcare service providers in Villamaria.

Doctors and Health
Personnel

Hired by the IPS’ to deliver medical services.
In general, they are not able to deliver adequate care since they are limited by their IPS’
and the POS.

Patients

Access to treatments, exams and medicines, as well as services copays, depend on
their regimen affiliation (contributivo/subsidiado) or lack of it (vinculado), and to POS
limitations. Often receive inadequate medical services, have no influence in the system and
are subject to EPS decisions.

Pharmacies

Sell medicines and provide health counselling. They are often used as an alternative access
point to healthcare, but don’t have any actual medical power.

IPS Pharmacies

Give or sell prescribed medicines according to insurance coverage of the patient treated in
the IPS.

Unless it is an emergency, the affiliated patients have to pass through their assigned EPS for approval and scheduling
of appointments, a process that often delays the treatment to several weeks and sometimes even months.
For Vinculados, the process could seem more direct, but services offered in the public IPS are very limited, waiting
time is huge and insufficient resources lead to very scarce services.
Briefly, EPS’ and IPS’ are the main players with the biggest influence in the system and on the final care received by
the population. The following graph describes the role of each stakeholder in the system and compares their level of
influence and power.
Patients have little control and decision power which leaves them without much influence within the system. Moreover,
doctors and healthcare personnel are subject to IPS´ rules and constraints and to the lack of proper job conditions,
a cause for poor motivation and professional fulfillment. Imposed POS limitations together with inadequate in-house
resources are not only a frequent source for their frustrations but a barrier to a proper care service for the patients.

EPS’ and IPS’ are the main players
with the biggest influence on the
system and on the final care received
by the population.

Stakeholders of the Public Healthcare System
Influence on the System


51

Bienestar
Bienestar was initiated in 2010 as an alternative healthcare service to the public health system. Based on the Ser
model in Argentina, Bienestar´s mission is to improve the access to primary healthcare services for low income
communities in the Caldas region, following the social business principles.
The main idea behind Bienestar is to eliminate the barriers imposed by the EPS’ by selling membership cards that link
members directly to the affiliated clinics. For USD$5 a year, the cardholder is entitled to discounts up to 50% on the
treatments delivered by the network. The map on the opposite page illustrates how the Bienestar system works.
The model aims to empower patients and to cut the bureaucracy imposed by EPS’. The patients get a better services
and the waiting time is reduced. In exchange, affiliated clinics win by increasing the volume of patients and by having
instant cash — EPS usually take months to pay the contracted services.
The project during our research was in its pilot phase, with one affiliated clinic and 90 members in Villamaria.
The map shows some advantages of this stage of the project by eliminating EPS´ authority and by increasing the
influence of patients on the scale. However, the situation is still not the ideal since the care quality cannot be
guaranteed because the affiliated clinics are still managed in the same way as before entering the network.

SER System Model
CEGIN is a medical center founded in 1989 which specializes in the provision of medical services to poor women
from rural areas of the Jujuy Province. Jorge Gronda launched the SER system within the CEGIN center in 2004. It is
a membership card that patients can purchase for USD$3 per year in exchange of preferential rates (more than half
of the market price) on services delivered in these centers. The main idea behind the SER card, beyond increasing
access to healthcare, is to create a network that will later allow its members to enjoy various advantages. Currently,
card holders already enjoy discounts in some pharmacies, and in the long term, his ambition is to develop a system of
“social franchise”, and extend the SER cards’ field of action to various fields such as food, construction and transports.
The social impact of CEGIN and the SER system allow the people at the base of the pyramid to have access to quality
healthcare. Nowadays, over 40,000 people are followed by these clinics (including 20,000 through the SER network).
Belonging to the SER networks and enjoying quality care services considerably increases the self-esteem of people
suffering from social exclusion. The pride SER clients take in being part of the network makes them talk positively
about it, and this word of mouth has been fundamental in the development of CEGIN.
Table 8. Description of the SER system running in Argentina.

Bienestar System Map

53

The Interview Guides
IPS

(Bienestar-affiliated clinics)

Doctors &
Healthcare Personnel

Bienestar

Manages and provides discounted health services direct to Bienestar members, in exchange
for a bigger volume of patients. Maintais its role in the public health system. Ensures
appropriate infrastructure, personnel and supplies to provide the care.

Hired by the IPS to deliver medical services.
They are able to deliver better care, since they are not limited by the POS anymore, but are
still limited by their IPS.

Links patients and Bienestar-affiliated IPS’ through the sale of a membership card that
entitles to discounted health services. An alternative to the actual primary healthcare
system, it cuts the access barriers imposed by the EPS’ and the POS.

As the last part of our field research, we did a series of interviews with different stakeholders of the system, with a
special focus on the final user, the patient. Our aim was to understand their concerns, expectations and frustrations,
as well as listen to their experiences in order to develop a user-centered solution.
By interviewing doctors (working in the public system and in the Bienestar affiliated clinic), medicine students, the
Bienestar affiliated clinic owner, a nurse, a pharmacist, a social worker and an EPS customer representative, we took
into consideration all the different points of view, an important step in developing the further service. Interviews took
place at people’s houses, around the community, at a pharmacy, a local medicine market, a 2nd level public hospital in
Manizales and at the Bienestar affiliated clinic, El Parque.

Interview Guides - Patients
Name

EPS’

(health insurance companies)

Regulation and autorization of Bienestar activities.

Address the patients to different healthcare providers (IPS’) when Bienestar does not cover
the request (specialists, exams).

Stakeholders of the Bienestar System

Household Structure

Household Income

Bienestar
User

Sisben Level

Insurance
Regimen

Maria Elsita Mayo

Female

50 Years

Housewife

Lives with husband and 2 of
their 5 kids (10yrs twins)

No

Sisben 2

Subsidiado

Nestor Ivan Garcia

Male

41 Years

Informal
construction
worker

Lives with wife and stepson
next door to his family in
law

Income depends on
couple’s job

Yes

Sisben 1

Subsidiado

Gloria Bettancourt

Female

50 Years

Unemployed

Lives with husband, her
mother and their 4 kids

Income comes from
husband’s job

Yes

Sisben 1

Subsidiado

Paula Hernandez

Female

29 Years

Works at a call
center at night
(her mother
takes care of her
daughters)

Lives with husband (works
during the day) and their 2
daughters (10yrs + 4yrs)

Income depends on
couple’s job

Yes

Sisben 1

Contributivo

Ober Osorio

Male

78 Years

Retired
policeman

Lives with his daughter

Pension

No

Sisben 2

Regime
especial

Female

48 Years

Unemployed

Lives with husband, their 3
sons and 1 nephew

Income depends
on husband’s job
who works in
construction

No

Sisben 1

Subsidiado

Female

40 Years

Housewife

Single mother, lives with
son (7yrs), mother, 4
brothers and 1 nephew

Income is based
on the jobs of the
brothers and sister

Yes
(+2 family
members)

Sisben 2

Subsidiado

Lina Paula Ospina

State / Government

Sell medicines discounted by 5% to Bienestar patients in exchange for a bigger volume of
sales.

Occupation

Albaneli Franco

Pharmacies
(Bienestar affiliated)

Hired by the IPS’ to deliver medical services.
In general, they are not able to deliver adequate care since they are limited by their IPS’
and the POS.

Age

Gloria Ines

Patients

(Bienestar members)

Gender

Female

23 Years

Unemployed

Single mom, lives with her
two kids (7months + 3yrs)
and her grandparents

Income depends on
her father

No

Sisben 1

Subsidiado

Table 9.

Patients’ profiles from the interviews in Villamaria.

55

Interview Guide - Female Patient

Interview Guides - EPS User Representative
Age

Occupation

Household Structure

Household Income

Doralba Seballos
Mosqueiro

Female

64 Years

President of
the association
of Villamaria’s
Caprecon (EPS)
users*

Lives on her own

Government help to
the 3rd age citzens

2.
Understanding the general
healthcare & medical
experiences of user

Bienestar
User

Sisben Level

Insurance
Regimen

No

Sisben 1

»»
»»
»»
»»
»»
»»
»»
»»
»»

On the Colombian healthcare system
(how they see it, service, time to get
treatment, difference with Bienestar).

»»
»»
»»
»»
»»
»»

Have you used the public healthcare system?
Did you feel well attended? How did they treat you?
How much money from your salary goes to the public system?
How do you regard public healthcare? What is your opinion?
How long did it take you to get treated?
Where did you have to go?

Before going to the doctor - look for
alternative ways.

»»
»»
»»
»»
»»
»»
»»
»»

Do you go to the pharmacist sometimes for medical advice?
When feeling sick you try to talk with someone about it? Do you consult family members, friends, other sources?
What kind of illnesses do you feel you can solve without a doctor? How would you do it?
What medicines do you always have in your house? Where do you keep them, can you show me?
What remedies do you always have in your house? Where do you keep them, can you show me?
Do you have a first aid kit? Can you show it to me?
Do you use alternative ways of treatment (infusions, teas, ungüentos)?
Can you describe an experience related to any of these issues that have happened to you or somebody that you know?

»»
»»
»»
»»
»»
»»
»»
»»
»»
»»
»»

What kind of prevention do you take? (hygiene, nutrition, chlorine in water, iodized salt, etc.)
How often do you visit a doctor?
When do you feel you need to go to the doctor? How ill do you need to be?
What makes you decide against visiting a doctor when a health problem occurs?
Where is your nearest healthcare center/doctor? How long does it take you to get there?
How do you go to the doctor’s clinic? Do you use public transportation (bus, taxi, chiva, etc)?
What do you do when there is an emergency?
Do you take the decisions regarding health condition of others in your family?
Do you usually go accompanied to the doctor? If so, is it a family member, a friend? What family member? (child, husband)
Do you save some part of your budget for health emergencies?
Is it a problem with your employer to take time off from work if you need to see a doctor?

Doctor - visit

»»
»»
»»
»»

How is your relationship with your doctor? Describe it in some words.
Where do you go to visit your doctor (clinic/hospital)?
When going to the doctor, do you feel that you are paying too much/enough for his services?
How many times more or less do you go to the doctor per month, per year?

Doctor / clinic experience

»»
»»
»»
»»
»»

Do you trust doctors?
Do you have a trusted doctor that you always go to or wish you could always go to?
Do you prefer a male or a female doctor?
List some characteristics that you think are very important in a service. What do you appreciate most in a visit?
What is your opinion about nurses, assistants, other staff?

Women

»»
»»
»»
»»

Did you see a doctor on regular basis when you were pregnant?
Where did you give birth? Who helped you in giving birth?
How often do you take your children to the doctor?
Are you aware of regular checkups like Papanicolao? If so, do you have them?

Bienestar user

Gender

1.
Understanding the person

Going to the doctor (motivation,
decision making, education).

Name

»»
»»
»»
»»
»»
»»

Why did you choose Bienestar? Do you think the healthcare service has improved with Bienestar?
What determined you to enter Bienestar program?
Have you advised someone else to use it?
Do you have a trusted doctor that you always go to, or wish you could always go to? Is he from Bienestar?
Did you notice something different (service experience) using Bienestar from your past experience?
What are your expectations from Bienestar?

Not Bienestar user

»» Have you ever looked for private insurances regarding healthcare?
»» Do you know what an insurance is? Have you ever considered it?
»» What determined you to enter Bienestar program?

Subsidiado

* in charge of gathering the complaints from Caprecon users in Villamaria to take them to the Manizales Health Superintendence.
Table 10. EPS User Rappresentative’s profile from the interviews in Villamaria.

Interview Guides - Nurse
Name

Gender

Age

Occupation

Household Structure

Household Income

Eluin Osorio

Female

46 years

Works at Nueva EPS

Lives with son (21yrs), his
wife and grandson (2yrs)

Income depends
only on her job

Bienestar
User

Sisben Level

Insurance
Regimen

No

Sisben 2

What is your name, age, marital status, number of children, parents...?
Where are you originally from? If not Caldas, where from and why did you move here?
Who do you live with? Are all your children living with you or did any leave? Do your parents live with you? Why?
What do you do for a living? And the other members of your family?
Are you the only person contributing for bringing money home? If not, who else?
Do you work outside your house? If so, do you work close to you home? How do you get there?
What forms of transportation do you use?
Are you a frequent user of medicines? If yes, what medicine do you use and for what health problem?
Do you or anyone from your family suffer from any chronic or hereditary disease? (heart disease, stroke, cancer, chronic respiratory diseases and diabetes...)

Contributivo

Table 11. Nurse’s profile from the interviews in Villamaria.

Interview Guides - Doctors
Name

Gender

Age

Occupation

German Aristizabal Moreno (Bienestar)

Male

45 years

Works at and owns Centro Medico El Parque
(a Bienestar affiliated clinic), certified as a general practitioner

Adrian Zapata

Male

32 years

Works at Centro-Piloto Bas Salud (2nd level public hospital in Manizales)

Table 12. Doctor’s profile from the interviews in Villamaria.
3.
Understanding the specific
healthcare experiences
related to user profile

Interview Guides - Pharmacist
Name

Gender

Age

Occupation

Berta

Female

75 years

Works in her own pharmacy with her daughter

Table 13. Pharmacist’s profile from the interview in Villamaria.

Interview Guides - Social Worker
Name

Gender

Age

Occupation

Yurdani

Woman

28 years

Social worker at the Municipality of Villamaria**

** takes care of social and cultural programs with the local youth (14yrs – 26th)
Table 14. Social Worker’s profile from the interviews in Villamaria.

Table 15. Example of an interview guide used during the field research in Villamaría.
57

Paula Hernández.
The difficulties of dealing with the EPS’.
Paula Hernández, 29 years, is originally from Manizales. She moved to Villamaría with
her mom that now lives in a different house.
She rents a house in one of the neighborhoods in Vallamaría where she lives with her
new husband and her two daughters from her previous marriage. She works during the
night for a mobile phone company and therefore sleeps during the day. Paula’s mother
takes care of the two children and some of the domestic chores as Paula rests during the
day.
One of her daughters, Paola, is 5 years old and was born with a malnutrition problem
that led to an orthopedic issue making it difficult for her to walk. This has caused Paula
to face many difficulties in trying to access the right treatment ever since Paola was
born.
During her pregnancy, Paula was diagnosed with a morphological problem that made it
difficult for her to give birth. That is why she blames herself and feels responsible for
her daughter’s complication.

“Doctors become
insensible”.
Maria Elsita Mayo
50yrs. Patient

“For the health, I don’t “I don’t have a place
where to send the
think twice, I pay”.
children”.
Nestor Ivan García
41yrs. Patient

Adrian Zapata
32yrs. Doctor

“The EPS meetings
with the users
happen once a
month. Nonetheless,
very few people
attend them”.
Doralba Seballos Montero
64yrs. EPS representative

Paula has been trying to schedule the necessary surgery but she has not been able to do
so. Due to the bureaucracy within the system and the long time required, she has been
struggling to fix a surgery since Paola’s problem can only be solved at a young age.
Every time Paola needs a treatment, she has to go through a general doctor that then
sends her to a pediatrician and finally to a pediatric orthopedist in order to get the
treatments approved and done.
“I lose a lot of time”. Paula said. Whenever she books an appointment through her EPS,
she usually waits from 15 to 20 days for confirmation without having the possibility to
choose neither the doctor nor the hospital she has to go to.
She enrolled Paola in the Bienestar plan as she was desperate to find a solution for her
daugher’s problem. Ever since then, she has been very satisfied. “Now the doctor really
takes care of her and gives me advice on what to do”. Before, she felt that the doctors and
nurses of the public system did not really care about her daughter nor her illness.
She would like all her family members to sign up for the Bienestar plan, especially her
mother who is also sick. Paula’s mother helps her a lot in raising her daughters and does
not have any kind of healthcare coverage herself, but the income inside the house only
allows them to have Paola insured.
Her two daughters represent her major priority, that is why even if she is enrolled in an
EPS she chose to pay extra and take better care of both of them.


59

The Interview Guides - Personas
To synthesize the information gathered during the interviews, we created personas based on the different family
structures in Caldas. They represent a general profile of the Colombian reality.

Persona 01 - Margarita Perez
Sex: Female
Age: 23 years old
Sisben: Level 1
EPS: Caprecom
(subsidised)

Margarita is unemployed and lives with her grandparents, Sofia and Pedro. Her 26 year old partner, Miguel, lives with them and they have 2
children together. One of the children is 3 years old and the other is 3 months old.
Miguel is a construction worker and the source of income to support the children.
Margarita’s grandfather:
Pedro suffers from ulcer, hernia, prostate, high blood pressure and had the Cafe Salud EPS, which he was denied from because of his many chronic
illnesses. He hates going to the doctor and Sofia and Margarita are always finding ways to trick him into taking him there. They had to pay 3,000
pesos for the card when enrolled in EPS and a fine of 8,000 pesos whenever they didn’t show up to an IPS visit. Tutella accepted his request but
takes a long time (3 months) to get appointments.
Margarita has mastitis (breast milk problems) and goes to the pharmacy instead of the doctor since the doctor is always changing and the
checkup time is too short. She would like to study to be a nurse one day. Margarita and Sofia are the decision makers in the house.


61


Persona 02 - Pablo Salazar
Sex: Male
Age: 41 years old
Sisben: Level 1
EPS: Caprecom
(subsidised)

Paco is a construction worker on freelance terms. He is living with his partner, Angelica, who has a son from a previous relationship. Their house
is close to Angelica’s parents’ house who live together with their other daughter and her 2 children.
Paco is the income provider of the family. He has a lump in his hand but has never had it checked. He has had previous bad experiences with a
doctor where he was given the wrong prescription for a disease in addition to always waiting too long to get a consultation.
He enrolled in Bienestar but hasn’t used it yet. He is willing to pay a little bit more to ensure healthcare access in case of emergency.
“In health matters, I don’t think twice, I pay”.


63


Persona 03 - Maria Gonzalez
Sex: Female
Age: 28 years old
Sisben: Level 1
EPS: Salud Total
(contributivo)

Maria and her children live with Franco, Maria’s husband and the children’s stepfather. She works at night in a call center and her husband works
at Gommaz. They rent a house which is close to Maria’s parents’ house so her mother can take care of the children while Maria sleeps during the
day.
Maria has 2 daughters:
»» Gloria, 5 years old, suffering from malnutrition
»» Mailin, 7 years old, who had apendicitis
Maria’s daughter:
Gloria goes to a nutrionist which EPS covers but Maria enrolled her into Bienestar so she can have fast access in case of an emergency and also
because they get a sense of attention from the doctor which isn’t present with the doctors EPS assigns.
Maria’s mother:
Fernanda is 50 years old and suffers from uterine cancer, hypertension and cholesterol. Her EPS is with Caprecom (subsidised). She takes care of
her husband, Ramon, who is unemployed and sick, and her grandchildren by preparing their meals and accompanying them to school.
Maria is the decision maker in the family and takes care of the household between working and sleeping. She has no access to doctors and feels
she loses time and money with doctor visits as they don’t giver her the attention needed. For her children’s vaccinations, she has to take care of
the appointments and followups herself.


65

Low Income Colombian Family Structure

Problems, Needs & Key Success Factors
Problems
Patients

Time

Money

Quality

Bureaucracy

Family members within one household belong to different EPS healthcare plans

X

Patients cannot choose their own EPS (assigned to them by system)

X

Many people are not covered by any EPS

X

Family members rely on relatives to cover healthcare expenses

Identification of Problems & Needs

X

No continuity of patient/doctor relationship

X

Doctors cannot dedicate sufficient time to patients because of system and bureaucracy

X

Long waiting time in EPS queue to get doctor appointments

X

X

Long waiting time inside IPS to get diagnosed

X

X

Long waiting time for EPS approval of treatment

X

X

Some treatments are denied by EPS when not belonging to POS (plan obligatorio de salud)

To understand the weaknesses and opportunities, we made a list of all the problems and needs of each stakeholder
based on the following criteria: time, money, quality and bureaucracy.

X
X

Patients need to pay a fine if they do not show up at the assigned IPS
Patients have to cover travel expenses to reach assigned IPS

X

X
X

X

X

Patients are not properly informed about their medical conditions
Patients don’t trust the doctors

Going through the synthesis process, we were able to identify several common problems and needs.
We realized that the Colombian family structure represents a pillar for developing a solution that would take into
consideration the urgent need of convergence of all different plans within the same household.
Due to the fact that the EPS is assigned by the working position, individuals cannot choose their personal plan. Many
people are not even covered by any EPS because of several bureaucratic and registration problems during the phases in
between changing jobs. This situation generates a massive dependency on the other family members, particularly from
an economical point of view.

Bienestar’s pilot trespasses some of the bureaucratic aspects to access primary care through the elimination of the
EPS´ role. Nevertheless, it still cannot fully guarantee the quality of the services delivered by the affiliated health
institutions, since no changes have been implemented by any affiliated clinics.

Doctors are not able to prescribe adequate treatments due to POS limitations

X
X

X

X

Lack of infrastructure in IPS to accommodate for volume of patients

X

X

No way of receiving feedback/complaints from patients

X

Needs

Time

Money

Quality

Easier access of all family members within household to the same health plan

X

Information about personal health condition

X

X

Trust in doctors for appropriate treatment and followup

X

Affordable visit and treatment expenses

X

Access to specialized treatments

X

Access to updated patient clinical history

X

Gain the trust of patients

X

Allocation of time for proper and complete diagnosis of patient

X

X

Ability to prescribe the appropriate treatment for the specific patient condition (independent of POS)

X

Ability to follow up on patients’ progress and well being

X

Capability to manage patient overflow

X

X

Optimize resources in order to deliver appropriate services

X

Keep track of patients’ clinical history

X

Provide a better communication channel between patients and doctors

X

Key Success Factors
Patients,
Doctors,
Clinics

Bureaucracy

X

Reduce waiting (wasted) time through process

Clinics

X

X

IPS are not able to manage their resources/lack of resources to provide quality service to clients

Doctors

X

X

Lack of access to specialist treatments inside the public health system
Clinics

X

X

Doctors have no access to patient medical records

Apart from offering a faster and easier access to healthcare, now missing due to all the misconnections and
bureaucratic aspects, it is important to build a continuous relationship between the patient and the doctor.
At the end of the analysis, it is clear that many areas of opportunities coexist in the Colombian healthcare system, and
that different solutions would be able to solve one or more problems.

X

Doctors are replaced with pharmacists since they are more accessible to patients

Patients

During the interviews we also found out about the existence of a basic mistrust towards doctors, blamed for being
more attentive to the bureaucratic aspect of their work rather than the health problems of their patients. This feeling
contributes to the lack of continuity between patient and doctor relationships and leads to an impersonal, superficial
and frustrating environment. For example, the figure of the general practitioner (GP) is being replaced by that of the
pharmacist because of an easier access and unpleasant past experiences. In this way, pharmacies are becoming the first
point of consultation.

X

Patients have no access to their medical records
Doctors

X

Patients lack knowledge and awareness on prevention methods

After that, we individuated the problems and needs that were addressed by Bienestar and the KSF’s that were taken
into consideration by the model. In table 16, the issues addressed by Bienestar are highlighted in green.

X

Patients are not aware of the system and its procedures nor their personal rights

From this point, we were able to identify the key success factors (KSF) to achieve a desired solution.

X

Time

Money

Quality

Equal accessibility to health care for all family members within household

X

Bureaucracy

X

Up-to-date patient database system

X

Different health services that generate an accessible Medical Network

X

Time efficient healthcare service

X

X

Affordable primary healthcare visits and treatments for different patient conditions

X
X

X

Friendly and trustful relationship between patients and doctors

X

Effective treatments for all patients

X

Follow up and feedback from patient to measure outcomes for further service improvement

X

Table 16. Problems, Needs and Key Success Factors identified during the field research in Villamaría, Caldas.

69

Bienestar
Familia
Concept

71

Bienestar Familia is a concept that is built around the specific family structure of Colombia. Starting from
the direct family living within one household, Bienestar Familia extends to encompass all members of the
community, the ‘larger family.’

Value Proposition
Our mission is to deliver quality and affordable family centered healthcare involving the
community in the value chain. Our concept is divided into two main parts:

The Family Healthcare Plan and
The Family Doctor

The Community Link:
Fairy (Health Promoters)

This part of the concept consists in improving the primary healthcare experience of the
family through an unified health plan that covers all the members within a household
and gives them access to affordable services in Bienestar Familia clinics and network of
affiliated services. The family plan also entitles each family to a family doctor, ensuring
continuity and trust throughout the care delivery.

The community becomes an important link in the value chain of Bienestar Familia. As
mentioned before, it is important to use a participatory approach to gather consensus
and acceptance for the new business, especially in low income areas where relationships
inside the community are very strong.

Based on the fact that different households have different needs, we wanted to make
our offer more flexible by creating a set of scalable memberships that adapt to the
specific family structures and are affordable to all family members.
This holistic family approach will offer a welcome family kit - with basic instructions on
the plan and its services and benefits - and a family check up for free as an introduction
to Bienestar Familia and to the assigned family doctor. The database will combine the
family data easing the access to family health records, reducing the time spent on
paperwork and ensuring the effectiveness of the treatment. Moreover, pediatricians will
be available for the children, who are often left unattended, and internists for those
who suffer from chronic diseases, one of the major health problems of the area.
The service will be complemented with family oriented initiatives in prevention and
education, such as family planning, pre-natal assistance and family counseling.

This role will be filled by women chosen among the social business members and trained
by Bienestar Familia. The main target will be single moms and unemployed housewives
wanting to complement the family income. Creating job opportunities and empowering
women in the community will leverage the value of the model, while simultaneously
increasing their self esteem and feeling of belonging. The fairies will be the main point
of sale of Bienestar Familia memberships. A successful enrolment will be the start of the
fairy-patient relationship.
Each fairy will represent a group of families enrolled in BF. They will collect feedback,
guide users inside the Colombian healthcare system whenever treatments are not
delivered by Bienestar Familia - tutela requests, EPS approval - deliver prevention
and education, focusing on each family’s specific needs (e.g. infant nutrition, family
planning, etc) and help individuating patients in financial problems.
Most of all, the Fairies will be a key resource to make the services more responsive and
sensitive to the needs of its users, thus helping Bienestar Familia’s business model
to evolve accordingly. Moreover, when the model matures and starts expanding, they
can become an important channel of sales and distribution of products from partner
companies, such as pharmaceuticals or microcredit.
Fairies are autonomous and benefit from flexible hours to accommodate the single
mothers’ and housewive’s needs. They will work for a commission of the sales and
healthcare benefits for their family.
Ideally, fairy meetings with BF members would happen every month at the clinic. These
meetings can be used for co-creation sessions where unmet community needs are
individuated, as well as for target initiatives on education and prevention delivery.


73

Families

(Patients)

Fairies
Bienestar Familia Management

Receives quality and affordable healthcare for the whole family when enrolling in Bienestar
Familia. Helps the continuous improvement of BF by giving feedback through the Fairies.
Single mothers chosen by BF and the community to become a 2-way communication channel.
Sell BF plans, give information, collect feedback and give focused prevention and education.
Manages BF social business with the focus on giving affordable and quality healthcare to its
members while being self-sustainable. Oversees plan sales, internal processes, human and
financial resources, database and physical infrastructure and partnerships.

Family
Doctor

Deliver quality primary healthcare and establish a relationship of continuity and trust with the
patient. BF gives them fair salaries and the right conditions to perform quality work.

Specialist Doctors

Complement the primary care services, deliver children-focused care and continuous treatment
for chronic patients. BF gives them fair salaries and the right conditions to perform quality
work.

(Pediatrician and Internist)

Healthcare Personnel
(Nurses)

Bienestar Familia System Map

Community

Help doctors during care delivery, initiate contact and check-up of the patient. Perform minor
treatments when needed. BF gives them fair salaries and the right conditions to perform quality
work.

Administrative
Staff

Bienestar
Familia
Human
Resources

Manage efficiently the costumer flow and help create a stimulating environment. BF gives them
fair salaries and the right conditions to perform quality work.

(Call-Center/Receptionist)

The main touch point of care delivery for Bienestar Familia will be its own healthcare
clinic. We believe that this is an important step, since in Villamaria there is a deficiency
of delivery points (IPS’) and doctors working on them (Table 7). This is contradictory
with the fact that in Colombia the number of medical schools have more than doubled
in the last 20 years and local universities had 3,285 matriculated students in the field of
Sciences of Health in 2008.

Besides the stakeholders directly involved in the social business, Bienestar Familia
will rely on key partnerships to fund, support and complement its activities. Local
universities with campuses on Sciences of Health will be an important source for
recruiting the healthcare personnel that will work on the clinic. Focusing on new
graduates will allow BF to give a fresh perspective to care delivery and will ease the
process of standardization.

In addition, by creating a model clinic and managing it, BF will be able to generate a set
of quality standards for the services provided to its customers. This standardization will
not only ensure the proper delivery of care, but will also ease the future expansion and
replication of the model throughout Caldas.

Partnerships will also be made to complement the health services provided by BF and to
ensure a holistic approach to care. This partnerships will be made with local pharmacies,
clinical laboratories and medical imaging centers to give discounted services to BF
members. They in exchange will benefit of higher volumes for their businesses.

Other than spaces for the actual care delivery such as doctors’ offices and nurses’
screening rooms, the clinic should also count on an affiliated pharmacy, from where
the customers can buy discounted medicines and healthcare products; a reception and
a waiting room, for managing the patients flow; a room for the fairies’ meetings and
training sessions and a BF office space, from where the main activities of this social
business will be managed and coordinated.

Financial partnerships should also be developed with key suppliers that are interested
in sponsoring the social business model. These suppliers can be pharmaceutical and
medical equipment companies, as well as ICT development ones.

The healthcare personnel working at the clinic will be composed by family doctors, a
pediatrician, an internist, nurses, auxiliary nurses and a pharmacist. The administrative
personnel will include other than the receptionist/call center attendant, the BF network
management staff.

Laboratories
& Pharmacies
Grameen Caldas
Medical Equipment Co.
Pharmaceutical Co.
& ICT Companies
Local
Universities

Supply young doctors and other healthcare personnel to work on Bienestar Famila clinics.
Consultancy on Social Business. Increase network of partners. Access to Social Business Fund.
Initial sponsors in the first phase. When business is running sponsors will be repaid and the
remaining stakeholders will instead be the only owners.
(Social business type 2)

Partners

Supplies young doctors and other healhcare personnel to work on
BF clinics.

Finally, Bienestar Familia would work in close contact with Grameen Caldas. They can
help finance the start up with their social business fund, give valuable consulting
services on social business and help in building the network of partnerships.
The following map explains the role and influence of each stakeholder inside the
Bienestar Familia system.

Stakeholders of Bienestar Familia
75

The Family Healthcare Plan & The Family Doctor
The following maps illustrate the steps that a patient needs to take in order to complete
a first level treatment cycle. It starts with the public health system where the main
problems found are highlighted and then goes to Bienestar and the problems solved by
the social business pilot. The objective is to understand how Bienestar Familia would
intervene to improve the primary healthcare experience.

Public Health System Primary Care Cycle

Comparing the two systems, it is evident that with Bienestar, a patient is able to skip
the first part of the process, avoiding delayed treatments and economic losses due to
waiting time. Bienestar also improves the quality of care delivery, even though the
model is not able to guarantee it.

Bienestar Primary Care Cycle
77

Bienestar Familia, on the other hand, goes deeper in the changes, introducing other
than the family doctor, an ICT platform to manage patients’ medical files, the clinic’s
internal processes and the scheduling system. This platform will also serve as a
communication channel between BF and the Fairies, who will be able to access it from
their cell phones. The database improves the efficiency of the entire process by reducing
the paper work during service delivery and ensuring continuity of the treatments by
facilitating the access to the patient health history.

BF will also empower the nursing staff by giving them an active role in the care delivery
cycle. Nurses will initiate the patient screening before seeing their family doctor.
This will help doctors with their workload, allowing them to concentrate in the most
important part of the care.
Finally, Bienestar Familia will also offer families specific specialist services, such as
pediatricians and internists, to deal with the most complicated cases and to reduce the
number of patients that need to access the EPS services.

Bienestar
Familia
Healthcare
Services

Medical Database

access to medical records
efficiency
transparency

Call Center

scheduling appointments
information

Healthcare
Family Plan

unified family plan
family doctor
access

Fairy

healthcare plan sales
prevention and education
customer service

Family Doctor

monitoring / prevention
diagnosing / intervening

Specialists
(Pediatricians + Internists)

monitoring / prevention
diagnosing / intervening

Pharmacy

discounted medicines

Bienestar Familia Offering Map

Bienestar Familia Primary Healthcare Cycle

As Bienestar needs to be an accessible solution to low income families while providing
high-quality services, it is important to understand the whole care cycle and to
standardize the care delivery process. A standardized process will serve as a reference
for the replicable model and future network expansion and will also allow the estimation
of costs involved in treating patients over their entire care cycle (Time-Driven ActivityBased cost measuring system). Moreover, this approach combined with outcome
measurement enables the continuous improvement of Bienestar Familia’s services.

The blueprints on the following pages show how the two main processes of Bienestar
Familia’s healthcare value chain - the family doctor consultation and Fairies’ membership
sales and feedback collection - can be initially standardized. The same approach shall be
used in all other Bienestar processes.

79

Blueprint of Fairies Service

Blueprint of Family Doctor Consultation
81

Key Partners

Key Activities

Value Propositions

Measure social
impact

Local
medical
universities

Low income
Caldas families

Family doctor

Network
expansion &
management

BF managment
Family care:
family doctors,
pediatricians &
internists

Key Resources

The Business
Model Canvas

Customer Segments

Fairies

Family membership
that gives access
to quality, efficient
& discounted care

Healthcare
delivery
Community
(Patients
& Fairies)

Customer Relationships

Families
unsatisfied with
public healthcare
services

Channels

Grameen Caldas
Fairies

Brand
- Fairies a dedicated link
between patients
and BF

ICT database
Doctors

Laboratories
& pharmacies

Bienestar clinic

Call center

Staff

Cost Structure
Initial
investment:
infrastructure
+ ICT

Revenue Streams
Clinic costs
(supplies +
utilities)
Membership
sales
commissions

Social and Environmental Costs
Lowers the
government’s
responsibilty in
providing adequate
healthcare

www.businessmodelgeneration.com

Salaries:
healthcare
personnel,
admin staff,
management

Annual
membership fee

Visits +
treatments

Network
affiliation fee

Social and Environmental Benefits
Improve access
to primary
healthcare for
low income
communities

Empower women
& creation of
jobs

* Orange post-its represent the expansion phase of the business through an affiliate medical network.

Business Model of Bienestar Familia

83

Implementation
& Expansion

85

Ownership

Phase

1. Bienestar Familia starts
spreading after establishing
standard processes: VOLUME

2. Bienestar Familia has proven
to be sustainable and reliable
(break-even)

3. Bienestar (brand) broadens
scope of practice

Fairies

Access: Representatives of families
can be chosen to become Fairies
and receive a greater discount on
health care services (or for free)

Commissions: Can earn additional
commissions from sales by their
‘downline’ healthcare promoters
= exponential awareness due to
**multi-level marketing (to be
controlled)

Specific training / Specialization:
Community Managers on-site
and database
and / or nursing

Specific training / Specialization:
Community Managers on-site
and database
and / or nursing

Pre-existing Healthcare
Providers
HUMAN RESOURCES

The Bienestar Familia business model is designed to work as social business owned by
the community (social business type 2). In the initial phase, other stakeholders such as
ICT, pharmaceuticals, medical equipment sponsors or the Caldas government will take
part as investors. When business starts running properly, they will be repaid leaving the
community as the sole owners.
In every family there is a legal representative, preferably a woman, that becomes the
person interacting with the organization. The annual membership is a share family
representatives pay to enroll in the program making them owners / stockholders of
the Bienestar Familia initiative. This means the longer a family has been a member of
Bienestar Familia, the more shares the representative owns, becoming preeminent inside
the organization. This will guarantee the renewal of memberships.

0. Bienestar Familia
implementation

Volume: Ensure a large number of
patients to existing private clinics

Standardization: Healthcare cycles
to specific patient populations
and medical conditions need to be
established (use of Time-Driven
Activity-Based - TDAB - care to
measure costs)

Quality control: Standardizing
healthcare cycles will permit better
quality control and assignment of
Bienestar quality certifications

Bienestar Familia
Staff

Administrative: Social business
and business administration

IT Management: IT expert
(partner) or internships from
information / computer engineers
to build information system and
maintenance

Healthcare area: Young doctors
due to collaboration between local
universities and Bienestar Família

Bienestar Familia Staff: Fairies;
Management; Family Doctor;
Specialists (pediatrician +
internist); Nurses; Administrative
Staff (call center + receptionist)
+ Internships

Stage: Students from computer
engineering and business
management universities can
have an internship with Bienestar
Familia administration

Stage: Students from medical
universities can have an internship
at Bienestar Familia Clinic

Experience: Fresh graduates get
the opportuniy to be a part of a
promising and innovative social
network inside the healthcare
sector

Government of Caldas
Social Business Fund
Microfinance

Government Caldas
Microfinance
Revenues from cards
Revenues from visits
Revenues from ministry of health
Revenues from sponsors (ICT,
pharmaceuticals and medical
equipment companies)

Government Caldas
Microfinance
Revenues from cards
Revenues from government health
ministy
Revenues from sponsors (ICT,
pharmaceuticals and medical
equipment companies)

Resource

Local Universities

This implementation plan is intended to be a guideline of potential sequences broken
down into 4 chronological phases. These are related to different types of resources
available allowing us to identify at what stage Bienestar Familia is ready to expand
through its affiliation medical network.

Principal Resources
Alternative Source
Risk Associated

It is only possible when Bienestar Familia has achieved an important volume of patients
(achieved through Fairies and family plans), an established flawless system information,
and standardized care cycles for its patients.

FINANCIAL RESOURCES

Implementation

Expansion

Initial investment to build
Bienestar Familia Clinic
Production Equipment
and Infrastructure

MATERIAL RESOURCES

From the implementation matrix, we were able to identify the phases that Bienestar
needs to go through in order to become a replicable model. This replicable model adapts
to different scenarios. Each scenario corresponds to a different type of healthcare
provider even if stakeholders are in some cases the same. Each of these scenarios can be
implemented once Bienestar Familia has reached all the phases of implementation.

Government of Caldas
Microfinance

Bienestar Família cards
Office equipment
Marketing material (posters,
brochures)

Bienestar’s Família system
information: Medical data
base to which both doctors and
patients can have access to (if
this information is managed by
the representative of the family
(women) - check in time / check
out time / measuring periodical
outcome of the treatment / etc
- then less costs for Bienestar
Familia)

Bienestar Família Clinic:
1 reception + waiting room; 2
doctor offices; 1 nurse room; 1
dressing room; 1 pharmacy; 2
administration offices; 2 toilets;
1 storage room; 1 community /
meeting room

Integration: Bienestar’s Família
Cards and System Information (data
base with medical records) work
flawlessly together

**Multi-level marketing (MLM) is a marketing strategy in which the sales force is compensated not only for the sales they personally generate, but also for the sales of others they recruit,
creating a downline of distributors and a hierarchy of multiple levels of compensation.

Resources Mapping for Implementation Plan

87

Phase
Resource
Fairies

3. Bienestar (brand)
broadens
scope of practice
Specific training /
Specialization:
Community Managers onsite
and database
and / or nursing

HUMAN RESOURCES

Pre-existing
Healthcare
Providers
Bienestar Familia
Staff

Bienestar Familia Staff:
Fairies; Management;
Family Doctor; Specialists
(pediatrician + internist);
Nurses; Administrative Staff
(call center + receptionist)
+ Internships
Experience: Fresh graduates
get the opportuniy to be
a part of a promising and
innovative social network
inside the healthcare sector

Principal resources
Alternative source
Risk associated

Government Caldas
Microfinance
Revenues from cards
Revenues from government
health ministy
Revenues from sponsors
(ICT, pharmaceuticals
and medical equipment
companies)

MATERIAL
RESOURCES

FINANCIAL RESOURCES

Local Universities

Production
Equipment
and Infrastructure

Stakeholders

Location

Social Entrepreneur
Doctors / Specialists

The families (members) own
the new clinic (community
based ownership)
- social business type 2

Analogue services

Young doctors

Doctors own their private
office

Complementary services

Young doctors

A

Ownership

Doctors own their private
office

Complementary services
(primary care emergencies)

Open New
Bienestar
Familia Clinic

B

Open New
Bienestar
Familia Private
Office

C

Bienestar
Familia
On Wheels

To be expanded in different
areas

To be expanded within the
same area

To be expanded in urban,
suburbs and rural areas

Integration: Bienestar’s
Família Cards and System
Information (data base
with medical records) work
flawlessly together

Bienestar Familia’s Replicable Model

Scenario

Expansion Through Affiliate Network
89

New Bienestar Familia Clinic


New Bienestar Familia Private Office

91

New Bienestar Familia On Wheels

The Bienestar Familia Healthcare Network

93

Conclusion


95

Conclusion
As the public health system in Colombia is not able to provide adequate care delivery to the low income communities,
the Bienestar team saw a promising area of opportunity to start a social business. Nevertheless, during the pilot phase,
problems such as the sales and distribution of membership cards became more evident and the need to explore new
solutions was essential for the continuity of Bienestar.
Bienestar Familia Healthcare Plan is the result of a design process, with the objective of developing a solution to the
existing healthcare system in Colombia taking into consideration what Bienestar has already implemented.
Bienestar Familia focuses on improving the access of low-income families to high-quality healthcare by creating value
for the whole community:
- Generation of new job opportunities for women and decreasing brain-drain of qualified local doctors.
- Empowerment of women by giving them sense of ownership and responsibility over the organization.
- Establishment of a community-based healthcare infrastructure through a local network that enables Bienestar Familia
to provide other analogue services alongside the healthcare system.
At this point, Bienestar Familia is a prototype that needs to be tested. Taking into consideration the results gathered
from the prototype phase, Bienestar Familia would then be ready to be implemented in Caldas, Colombia. If the model
proves to be successful, a long term objective would be to adapt and replicate the model to fit in the specific context
of different countries.


97

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Challengers. Alexander Osterwalder and Yves Pigneur. Wiley, 2010.

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