2 is Swasti’s flagship program and was incubated by the Catalyst Group - a 26-year-old social impact platform, working in the spaces of social and economic development as well as humanitarian emergencies. Sister organizations of the Catalyst Group are CMS - social impact specialists, Swasti, The Health Catalyst - a Global South public health non-profit, Vrutti - Livelihood Impact Partners were instrumental in bringing i4We to life.
Best described as a system innovation in primary healthcare, i4We combines health and wealth interventions, and focuses on well-being for the most poor and marginalized communities. It is intentionally designed to be affordable, quality assured, and scalable.
The model essentially brings primary care to the doorstep of the poorest and most marginalised through community institution leadership and wellness facilitators and frontline health workers from the community taking the lead. This approach means partnering with members in their well-being journey, actively navigating them through an entire gamut of screening, treatment and care services; tackling social determinants and harmful social norms; bringing in community co-created innovation, all the while using a blended financing model.
The ethos behind i4We is to make well-being real for the most poor and marginalized and take healthcare to where there are no doctors.
Curious about how this works on the ground, I sat down with one of the chief architects of the model, Shama Karkal, CEO, Swasti to understand how it works on the ground.
The thinking around i4We began with a central question - How do you co-create a life of everyday well-being for a community of the most poor and marginalized living in often squalid conditions, with little to no wherewithal, prey to a gamut of diseases and disorders, struggling to survive?
The model was born out of intentional design, packing in the Catalyst Groups’ combined experience in a range of spaces - medical, behavioral, livelihood and social science as well as technology and health financing. Several components were co-designed with the community and marries core evidence with action research, lived experiences and implementation science.
i4We is currently delivered in four settings: urban, rural, factories, and sex workers’ collectives and is adapted to each of these contexts.
The success of i4We lies in it being a self sustaining program owned and run by Community Institutions and Collectives. And this is why, while designing i4We, it was incredibly important to put in place five revenue streams:
- Interest spread on inter-lending among members
- Sale of health products
- Fees for citizenry services, sale of insurance
- Direct sponsorship of ultra-poor families’ health.
These along with the fifth stream of startup grant capital ramp of three to five years enables the model to break even and be self-sufficient. Shama shared that the families in the community who are catered to by i4We are called ‘Members’. She explained why: i4We is not your usual ‘welfare’ initiative. While it focuses on an individual and their family, i4We also brings together the communities to bring forth changes that cannot be achieved by a single entity. Since we all share the responsibility of our wellbeing, and the ownership of making everyday wellbeing a reality for the community, we are members, not beneficiaries of i4We. Members deposit 0.8-1 USD for the services - and this deposit goes into their savings which also accrues interest. They can choose to do this in groups or individually. And as long as they save for themselves, they receive all services and benefits at no cost. They can choose to withdraw this amount whenever they want. This means they are not beneficiaries but independent owners or even shareholders of i4We.
So what do these ‘members’ get out of i4We?
Shama shares that every member of i4We experiences and is entitled to benefits ranging from free screening, treatment, care, health education and advice, financial inclusion - tackling the issue of out of pocket expenses that pushes them further into poverty otherwise, while simultaneously creating savings for the members and earnings for the community institution that can be invested back into the program. Overall, this is twinned with constant and consistent improvement in the community situation - Sanitation, Air, Water, and Food (SAWF), key health determinants, through community action. The model also makes concerted effort to tackle harmful social norms.
What the model intrinsically does is, build and foster community leadership and community institutions. Screening and treatment for high burden conditions with behavioural nudges on prevention and treatment adherence ensure that those who are ill - get well and stay well. The members gradually, through learning about healthcare - become first responders in their families and health champions for their communities; wellness facilitators who are from the community along with the nurse analyze root causes and help families make the necessary changes. System immunization for the communities, which is sometimes missed out at the last mile is something that i4We actively takes up in partnership with Primary Health Care centers. With the community taking up the mantle of running institutions of healthcare - women micro entrepreneurs in the community take the lead in promoting health products at affordable rates while also sustaining livelihood options for them - these are products tried and tested by the community and experienced by them to protect their health - ranging from water filters to menstrual wellness products.
The model is systematic in addressing impediments to wellbeing for the poor while remaining customer focused.
“i4We uses a strong technology strategy which includes an app for the health facilitator, nurse, and the healthcare provider network, AI enables real time analysis and dashboards for action, point of care diagnostics, and a range of innovative health products. It also uses the latest behavioral science theory and practices including survival analysis, nudge, and other tools.”, writes Shiv, the co-founder of the Catalyst Group and a chief architect of i4We.
The i4We team on ground is formed by community members and individuals who are from implementation science. The team is backstopped by a range of multi-sectoral practitioners and partners.
Shama shares that “for 5,000 families, 20 Wellness Facilitators, a nurse, a manager, and a dial-in doctor form a team to deliver preventive, promotive, and curative primary health care. Every cluster of 5,000, has about 500-600 SHGs and one Health Trust, where SHG leaders and local community leaders govern the model. “
The model continuously evolves to address local realities.
“i4We is not your usual ‘welfare’ initiative. While it focuses on an individual and their family, i4We also brings together the communities to bring forth changes that cannot be achieved by a single entity. Since we all share the responsibility of our wellbeing, and the ownership of this task we have set ourselves to complete, we are members, not beneficiaries of i4We.” - Shama Karkal
i4We is modularized with inbuilt processes, tools, and methods that are led by a framework, with teams having flexibility in the approach but accountability for results. Agile implementation is key and enabled with a “plug in” and workflow approach at each component level.
Swasti’s “primary health care landscape” exercise provides a complete arsenal of tools, enabling us to build further on what we know and have experienced, to work. A Social Return on Investment exercise run on i4We in its early days reflected an increase in healthy days (by reducing unhealthy days by 30 percent), reduced undiagnosed conditions (by 30 percent), and showed a Social Return on Investment (SROI) of 300 percent for its investors.
Started in 2017, the model is operational in nine locations in India, covering 56,165+ people and growing rapidly. The model was co-created with a range of partners including Vrutti (a livelihood resource center), Catalyst Management Services, Marks & Spencer, Levi Strauss & Co., Social Venture Partners, and World Health Partners among others.
A year back, Santosh’s ears were filled with bawls of “Ma, no school today. Stomach pain.” Santosh knew that pain. She missed work too. i4We and one water filter later, stomach pain is just another silly excuse.
Immobile, Angoori Devi holds up her Pension papers, her face cracking up in the thousand wrinkles of a 70 year old woman. The smile echoed that of the Wellness Facilitator who put her heart and soul to ensure government social protection benefits reached the last mile.
Rupees Twenty Five, Kavita counted carefully as she made her way to her Self Help Group meeting. Today was the last installment of her monthly savings contribution of Rs. 100 for health benefits. As her headscarf slipped, her face shone with pride in the setting sun.
in the longer run, the model has the potential to significantly reduce mortality and morbidity, empower communities to take ownership of and realize their health rights, address the needs of the poorest and most marginalized communities, create a pathway for micro-entrepreneurs and innovative product solutions to reach those who need it the most, serve as a model for a completely comprehensive, absolutely integrated, healthy health system that address not only high burden diseases but actually goes down to the root cause and tackles social determinants of health, set standards in primary healthcare technology solutions, and eventually create a market for prevention with outcomes that the government and donors are willing to buy. Most importantly, our goal is a self-powered, viable primary healthcare model that can effectively break the intergenerational cycle of ill-health and poverty.
The heart of i4We lies in the fact that it brings together community led governance of a model that is evidence based and takes a holistic approach to address health and wellbeing needs of the community.
The i4We model has demonstrated with significant success improved wellbeing for not just individuals and their families, but even the communities they belong to. The model was conceived to bring together multiple elements (finance, protection, and health) which are usually not seen together as an intervention. But it is obvious from the outcomes that without a balance of all three, the revered ‘wellbeing’ is not achievable. i4We does not depend only on grant funding, but follows a nuanced approach of financing through multiple sources. The intensive investment made in developing strong community leadership through the community based organisations and community champions also ensures longevity of the outcomes. The trust earned by the i4We team on the ground, through quality and empathetic care, has also influenced behaviours around health in the community. Additionally, since this model is layered on existing systems and infrastructure, i4We emerges as a sustainable, replicable and people-focused model.
The health outcomes driven by i4We are a result of a combination of factors - determined investors, a passionate implementation team that marries skills with lived experiences and a community that has been part of the model from the very inception.
Says, Santoshi Tiwari, Community Wellness Director, i4We in rural Rehti, Madhya Pradesh, “In the past year, we have not only protected the health of our members, strengthened the federation and worked on imparting core knowledge to further improve on livelihood skills of women but also ensured that direct employment for them becomes a reality. Today, women from 62 SHGs have started their own grocery store, and 3 SHGs have started a seed bank. The primary health care check-ups we organized have women diagnosed and treated for common health conditions that can be improved if they adopt good health practices at home.
In the last year, our efforts towards consuming clean drinking water have also been successful. The indigenous community that we are working with today have been living in hilly areas where drinking water has high levels of fluoride and iron. Our communities were deep-rooted in their social norms that have not adapted to the changing environment, causing illness. Our efforts, activities, and cooperation have brought about a positive transformation in their activities. They have adopted the right hygiene practices in their day to day life.”
Ways to move forward
Health outcomes cannot be guaranteed with a linear approach. For the vulnerable, unless crucial challenges such as financial security and protection are ensured, health for all will continue to remain a pipe dream. And therefore, it is imperative that public health solutions are designed to address challenges beyond just the obvious. The i4We model demonstrates one such holistic solution, that supports its members navigate their health journey, towards well’thy days.