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Healthcare Series

Healthcare Series

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NextBillion.net publishes a series of 14 articles exploring innovative, market-based approaches to healthcare challenges in the developing world.
NextBillion.net publishes a series of 14 articles exploring innovative, market-based approaches to healthcare challenges in the developing world.

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Published by: nextbillion on Mar 14, 2011
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Advancing Healthcare With the Base of the Pyramid

A special series by NextBillion.net February 21-March 4, 2011


• • • • • • • • • • • • • • • A Note from the Editors (Page 3) Advancing Healthcare: Reaching Into Rural Pockets With A Sustainable Model (Page 4) Healthcare With the BoP Series: Staying Out of the Medical Poverty Trap In Pakistan (Page 8) Healthcare Series: Combining Facilities and Mobile Innovations to Deliver Better Care (Page 14) Healthcare Series: Integrated Healthcare for the BoP, the Role of Enterprise, Government (Page 18) Advancing Healthcare With the BoP: To Emerging Markets and Back Again (Page 23) Learning From Narayana’s 'Lean' Model to Scale Services (Page 28) Advancing Healthcare With the BoP Series: Dial 104 for Health (Page 33) Piramal eSwasthya, Demystifying the Primary Healthcare Model (Page 37) Piramal eSwasthya - Part 2: Building Acceptance for Mobile Health (Page 42) Better Living Through Information (Page 47) Healthcare Series: To Emerging Markets and Back Again - Part 2 (Page 51) Listening to Patients: Innovations in Empowerment (Page 54) Technology to the People! Taking Telemedicine to Scale in Rural India (Page 57) The Healthcare Infrastructure Conundrum (Page 61)


A note from the Editors …
At NextBillion, we try to identify problems and bring solutions to light. The following 14-part series, Advancing Healthcare With the BoP, presents both established and unfolding innovations, models and technology leaps that are making a real and lasting impact in marketbased solutions to healthcare delivery. Anything from mobile technologies - to new patient financing schemes - to re-considered business models from major pharmaceutical companies - to overhauls in medical staffing that reach the most rural of patients - are just a few examples presented in the following pages. In addition to posts from NextBillion staff writers, the series includes articles from Ashoka and the Center for Health Market Innovations, both of which have graciously shared learnings and best practices from fellows and experts in the field. We hope this series provides insights into solutions as well as inspirations for managing some of the most serious challenges facing healthcare delivery with the Base of the Pyramid healthcare providers, vendors and patients. We welcome your feedback and your ideas for topics that we should address in future series. Please reach out via email on info@nextbillion,net, or join the conversation at any of our social media channels (Facebook, Twitter and LinkedIn).


Advancing Healthcare: Reaching Into Rural Pockets With A Sustainable Model
Tilak Mishra

February 21, 2011 — 06:00 am

Editor's Note: This is the first of several blog posts for NextBillion's Advancing Healthcare with the BoP series.
In recent decades, the public sector has had fair success in improving health in developing countries. As a result, infant, child and maternal mortality have declined; the threat of infectious disease has receded; and life expectancy has increased in all developing regions. Yet, working in isolation, the public sector faces significant implementation and resource problems. More specifically, government-run health programs face particular challenges in accessing geographically isolated or otherwise difficult-to-reach populations, in furnishing sufficient oversight of program administration to avoid corruption, and in ensuring health subsidies are directed to people who most need them, such as lowincome households.


As a result of these resource constraints and under-performance issues in government-run programs, a high proportion of health care models, first innovated in developing countries, now are being realized and delivered by private providers that charge fees for their services. One such model is the Rural Micro Health Centre (RMHC), which is an innovative nurse-managed, doctor-supervised-clinic (NMDSC) being promoted by the IKP Center for Technologies in Public Health (ICTPH) and SughaVazhvu Healthcare in Tamil Nadu. The goal of the ICTPH - Sughavazhvu Healthcare led RMHC model is to extend access of high-quality, low-cost primary healthcare services to low-income households living in remote rural India and who cannot access existing healthcare systems. This goal crystallized when qualitative and quantitative research conducted in remote rural pockets of India assessed health-seeking behaviours and needs. This research also revealed that low-income households spent a larger proportion of their income on health care than those with higher incomes. A large percentage of these expenses usually go to either a) paying high interest rates on health care loans; and / or, b) absorbing cost related to travel and lost work time.


(Above, a doctor shares her experience working in a Sughavazhvu clinic. Image courtesy of ICTPH)
The ICTPH-Sughavazhvu Healthcare model tries to address these issues through a community-based technology-leveraged outreach intervention at the village level. In this model, the RMHC is managed by a local fulltime graduate nurse, and supported by 13 locally hired and trained community health workers who are full-time volunteer workers. These workers are reimbursed all their costs and paid a nominal honorarium. While the nurse is responsible for the well-being of about 2,200 households, each community health worker serves 200 households (or approximately 1,000 individuals) and manages the screening, follow-up, intervention implementation and clinical assistance. Analyzing the RMHC model, it becomes clear that there are four interrelated design components that seem critical to the successful realization of this innovative model that is India's first attempt to deliver managed healthcare for remote rural Indian populations through intensively organizing primary health care delivery. These design components are as follows: (1) human resource design; (2) infrastructure design; (3) intervention design and, (4) financing design. As part of the first, the rigorous selection process of the community health workers ensures an optimal skill set; also, an 85 percent time allocation towards field based activities and 15 percent towards clinical assistance at the RMHC, under the supervision of the nurse, allows for the proper development of the competencies of the community health worker. As part of the second, each RMHC is equipped with tools to deliver a) diagnostics (through auto-analyzers that facilitates hematology and blood biochemistry); b) ophthalmic interventions (refractive errors and cataract management both pre- and post-operative); c) strip tests (pregnancy, urine analysis and malaria); d) automatic prescription (through a web based electronic health record combined with a computer based decision support system); and, e) pharmacy intervention (a drug distribution licence for Sughavazhvu Healthcare enables the RHMC to stock medicines necessary to fill basic prescriptions recommended by the nurse/doctor).


(Above: A Rural Micro Health Center).
As part of the third design, curative interventions envisioned at the RMHC are standardized evidence-based primary care curative protocols, based on the SOAP (Subjective Objective Assessment Plan) methodology, evolved in partnership with the School of Nursing at the University of Pennsylvania. A Health Management Information System (HMIS) helps implement the SOAP methodology for primary care visit, as well as facilitates the supply chain management of drugs from a centralized drug centre. The HMIS is also used by the nurse at the RMHC to ensure rational drug usage through strict compliance of National Essential Drug Guidelines. Lastly, the HMIS also is used for medical insurance, patient referral and follow-care management. Finally, in order to address patient-financing deficiencies in the system, the RMHC is planning to roll out many financial interventions that show promise of shrinking the deficit between low income households' ability to pay and the cost of primary health care. These interventions, along with other indirect non-health means, will need to be deployed if the low-income households are to successfully access all the primary health care they need.


The for-profit private sector is a major player in the health care arena in nearly all countries. Individuals- both rich and low-income households are willing to pay for many health services, which stimulates private provision of health care. As in any market, there is competition based on price, and there may also be competition based on quality or other characteristics of providers. And for market-based healthcare model targeted at low income households to succeed, it is imperative that quality remain high and costs are kept low as possible. Models such as the ICTPH-Sughavazhvu Healthcare led RMHC are out there trying to do exactly that. They're innovating, and in the process, bringing forward solutions to satisfy human needs profitably and creating wealth for the company and the community it serves!


Healthcare With the BoP Series: Staying Out of the Medical Poverty Trap In Pakistan
Rose Reis February 21, 2011 — 01:00 pm

Dr. Sania Nishtar, founder of Heartfile

Editor's Note: This post is part of the NextBillion series, Advancing Healthcare With the BoP. The Center for Health Market Innovations and Ashoka are both contributors to the series.
An adolescent golf champion who grew up to be Pakistan's first female cardiologist, Dr. Sania Nishtar wields influence in forums from the World Health Organization to the Clinton Global Initiative. Recently, through Heartfile, the NGO she founded, she has honed in on one critical barrier to health delivery for the poor: serious shortfalls in financing. According to Nishtar, Pakistan's social funds for the poor have a very small envelope and suffer from a number of deficiencies, including abuse and patronage in targeting, unpredictability of coverage and lack of transparency. Initiated in 2009, Heartfile Health Financing is a donationfunded program supported by a web-accessible financing platform. The idea is to enable the poor - the true poor, not those seeking to siphon off funds intended for the poor - to rapidly get access to health services without being pushed further into poverty. Heartfile's system allows donors to target the poor, but the same mechanism could help other parties, for instance, transparently distribute a country's social security funds. A CHMI profile can be found here. Rose Reis, CHMI: The Center for Health Market Innovations documents programs that develop an innovation to improve their health marketplace. How does Heartfile do this?


Sania Nishtar: The most glaring market failure Heartfile addresses is health inequities. Healthcare runs on market principles in countries like ours and it creates two levels of care: That for the poor, and that for the rich. The other market failure is abuse; Heartfile Health Financing has built systematic safeguards against abuse and collusion. Reis: Why do many people become poor after falling sick? Nishtar: More than 60 percent of the people in Pakistan pay out-ofpocket for healthcare. The poor do not have the means of paying for high-cost treatment. They spend catastrophically, become indebted and this pushes them into the medical-poverty trap. Many also forego treatment. Statistics show that healthcare costs are the most common cause of economic shocks by households. Reis: What about the state social security fund? Nishtar: Government prioritizes primary healthcare. There are limited windows of help for patients in need of high cost treatment. The fund, called Bait-ul-Mal (house of wealth), which is meant to serve this purpose is small. It is additionally, unpredictable, since government contributions tend to fall during a funding crunch. And it is all paper based - there is a lot of discretion and patronage in that process. Reis: Can the poor not get access to their own state funds? Nishtar: The other problem for the poor is to use these funds you need to know the channels. The elderly, marginalized, and the poorest of the poor don't have the means of accessing the system. Many cannot pay for transportation to visit offices or understand how to process the paperwork. The system is paper based and involves lots of delays. It has in the past taken weeks to months to process the application. If someone needs, say, coronary artery surgery, and they wait weeks, they run the risk of losing their lives. We step in with very quick turnover ours is less than 72 hours. Additionally, our system guards against abuse, leakage of funds to the non-poor and other inclusion and exclusion errors. Reis: Given the tendency for misuse of funds for the poor, how do you know a person requesting funding from Heartfile is actually poor? Nishtar: We really make sure those who can afford do not access Heartfile's pool of funds. Status of poverty is verified though a composite measure. The doctor's impressions about the patient being poor counts. Then our volunteers conduct an interview on site with the patient. These


are retired people, well-to-do with an honorable presence in society and acceptability in hospital. Volunteers conduct a tele-assessment, connecting via a laptop with trained staff in office. Phone calls are made to friends, neighbors and family members for validation as well. The final step is validation using the patient's unique identification number to a national database where all citizens are registered; we identify those below the poverty line. Reis: What is the technology platform Heartfile runs on? Nishtar: It is software custom designed for us and maintained by specialist vendor. We found them through a competitive bidding process. When we were conceptually designing the system we talked to several intended users: hospital administrators, community group, volunteers, and the core team at our office. Lots of things got modified through evaluation and formative insights. Reis: How do users interface with it - through mobile phones, desktop computers, smartphones? Nishtar: Patients in need/attending doctors in pre-registered hospitals can send requests for assistance through multiple channels. Ideally, SMSon template and web interface, but also through fax, telephone, and letter. We give these choices in order to facilitate interaction of users with the system. Heartfile's Health Equity Fund, maintained by philanthropic contributions, supports eligible cases. Reis: What funding do patients access through Heartfile? Nishtar: We created the health equity fund with a grant from the Rockefeller Foundation and added the proceeds from my book. Corporations and individual philanthropists also contribute. I tell them this is a mechanism to target your resources very transparently. The system grants the highest possible level of transparency so that funds are utilized as per the criteria defined by the donor. Capacity to update donors on a micro-transaction basis is an innovation by international standards. Donors can track every penny that they give. There is a strong culture of philanthropy in Pakistan, but it was not structurally harnessed until now. We hope to be able to make headway in that direction. Reis: Where is this pilot based? Nishtar: We are working in three hospitals now in Islamabad and Rawalpindi-there are five tertiary-level hospitals in these cities that we


will cover this year. We are enrolling patients ward by ward. We started with cardiology, then added orthopedics, and recently GI problems. Reis: What is the future for this system? Nishtar: We created this system to be scalable. We created the technology infrastructure with scale-up as a main consideration. Pakistan's telecommunications infrastructure allows deployment even in remote areas. The telemedicine-for-assessments and mHealth features will allow scale up with lean operational costs and without need for extensive field operations. My sense is this is also a very good model for other countries with people in informal sector and pervasive poverty.

Read more about how the fund-tracking website works here and read about patients treated with Heartfile financing here.


Healthcare Series: Combining Facilities and Mobile Innovations to Deliver Better Care
Chloe Feinberg February 22, 2011 — 08:15 am

Editor's Note: This post is part of the NextBillion series, Advancing Healthcare With the BoP. Ashoka and The Center for Health Market Innovations are both contributors to the series.
As this series is showing, the challenges of delivering healthcare are being met by extremely innovative ideas, programs and technologies. There is no doubt that there is a plethora of technologies available to address many pressing healthcare delivery issues - from electronic health records, to telemedicine, to novel low-cost diagnostics, to innovations in supply chain and distribution, to the many mobile health devices and applications that are in use around the world today. Training of community health workers, evaluation of health outcomes, data driving both disease surveillance and information for better care - innovation


exists in these areas, some including technology and others not. The innovations that leave the greatest impression on me, however, are those that tackle healthcare delivery at the system level. Different technologies and innovations in process working together to address healthcare delivery across multiple aspects of the system is where I believe the real power resides. Working at Ashoka, with Al Hammond, the co-founder of Healthpoint Services, most of my experience is at the healthcare facility level, especially when it comes to innovations in rural healthcare delivery, a space where Healthpoint and many other players work. Innovations in facility-centered care are many, however, I would still argue that a clinic, a healthpoint, a hospital - are still only one part of the system (granted, a very important part). Over the past year, I have become increasingly familiar with new mobile health tools that are often not a healthcare delivery system in and of itself, but a driver within that system increasing the knowledge, efficiency, evidence-base, user experience, and accessibility. Still, it is very easy to talk about mhealth over here and facility-based care over there. It is often assumed they both depend on each other, but that dependence is not always addressed directly. Working with Healthpoint Services, a strategic decision was made not to focus on mhealth tools at the beginning. The focus was to work on the facility-based delivery system including the telemedicine, electric health system (EHR), pharmacy, community health workers, diagnostics and water purification. Now, after 1.5 years of operating, we are making a concerted effort to pilot different mhealth tools, to see which work best, and design the process so that the mhealth systems harmonize with the facility system. Together, they will strengthen each other and increase the opportunities for Healthpoint Services to deliver healthcare. The Healthpoint model has been written about at length here on Nextbillion before (here, here, and here, to name a few), so let's explore some of the mhealth innovations I am most excited about, keeping in mind that these tools, in my opinion, are optimized when linked with a facility that can incorporate them into their model. Sensaris SensePack - The idea of combining diagnostics in a small package has been discussed many times before, but this system is different. It combines key medical diagnostic tools - heart rate monitor, glucometer, pulse oximeter, thermometer, and blood pressure monitor in one small backpack, sensors that sync automatically to a mobile phone, enabling patient test results and other data to be sent across the phone network and added easily to electronic health records.


The system can send data in batches or one case at a time to a clinic or other healthcare facility - or store the data if cell service is poor. Importantly, the tools are truly simple to use. Healthworkers using the SensPack don't need sophisticated medical training or even high levels of literacy, and the testing is practically foolproof. Community health workers equipped with SensPacks - like those employed by Healthpoint Services - can bring health education to last mile, conducting diagnostic screenings and sharing data seamlessly with Healthpont facilities. Adding mobile health applications and tools to an already existing health infrastructure like the Healthpoint Services clinics creates a reinforcing relationship between two different types of access to healthcare education and services. New sensors and modules - to address the needs of pregnant women and issues of malnutrition as well as others - are also in development. Fio Corporation's GenZero - Where point-of-care diagnosis of infectious diseases is needed, or where access to central laboratories is limited, rapid diagnostic tests (RDTs) are quickly becoming the standard of care. RDTs are inexpensive, visually read, and accurate when used by trained healthcare workers in optimal controlled environments. However in practice, sub-optimal conditions can negatively impact RDT accuracy and usefulness. Inadequate training, poor lighting, and fatigue lead to human errors in processing, reading, and capturing data from RDTs. The result is frequent misdiagnosis and poor quality epidemiologic data. Fio Corporation, based in Toronto, Canada, has developed GenZero; a rugged, portable universal reader of existing RDTs. A user places an RDT into GenZero, which digitally analyzes the RDT at the optimal time under optimal lighting conditions and delivers an objective diagnostic result -


eliminating most sources of human error.

GenZero leverages ubiquitous mobile phone infrastructure and Google's Android operating system to combine diagnostic results with patient demographic data capable of being transmitted for aggregation. GenZero currently reads malaria RDTs, soon to be followed by HIV, Syphilis, and other infectious disease RDTs. The application of this tool is clear: health workers who want to test for infectious diseases, at the last mile, but who may have limited training or are working in areas where the margin of human error is high, can benefit from these tools. Given the rate of misdiagnosis and overtreatment of certain diseases, these tools will not only increase the ability to provide evidence-based care, but also will help save resources and make sure they are used where needed. The West Wireless Health Institute's Sense4Baby platform is another mobile tool that will increase the ability of facilities like those of Healthpoint Services to provide maternal health services efficiently and effectively.


Imagine what happens when a community health worker is alerted to a pregnancy in the community? The health worker provides the Sense4Baby technology to the expectant mother allowing obstetric monitoring to be provided at a distance. Basic training and understanding of the device and its use can create a bridge between the facility and the patient, providing greater opportunities to provide and receive care. The Sense4Baby prototype will be a main component of the "Wireless Pregnancy Remote Monitoring Kit," which was developed by West Wireless Health Institute, Qualcomm and the Carlos Slim Foundation. The kit is now being tested with community health workers in Mexico.


Healthcare Series: Integrated Healthcare for the BoP, the Role of Enterprise, Government
Next Billion February 22, 2011 — 05:30 pm

Jonathan Kalan

Editor's Note: This post is part of the NextBillion series, Advancing Healthcare With the BoP. This post was written by Heather Esper and and Lisa Smith.
Healthcare delivery continues to be a focus for governments as well as BoP organizations given the numerous gaps in providing services and products to the BoP. Living Goods is an example of one organization working to improve healthcare delivery for the BoP in a sustainable manner. Living Goods, a social enterprise with more than 600 independent sales agents, uses micro-franchising to distribute products door-to-door in the developing world. It's focused on a critical and often over-looked issue at the base of the pyramid: access. Living Goods sells its products at prices affordable to the poor - typically between 10-30 percent below retail. The high cost of transportation, frequent product stock outs,

inadequate quality control and inefficient distribution systems all prevent the poor from accessing affordable health products that can dramatically improve their lives. The global market is saturated with products that can save and change the lives of those living at the base of the pyramid. But these products do little good if they don't reach a significant proportion of the people for which they're designed. This is the gap Living Goods aims to fill by building an efficient, scalable, and sustainable system for delivering products designed to fight poverty and disease in the developing world. The Role of Government At last year's Net Impact Conference, Molly Christiansen, Manager of Health Practices and Business Development at Living Goods; and Steven Chapman, Senior Vice President and Chief Technical Officer at Population Services International; spoke about the importance of creating sustainable, reliable systems for health product delivery. Their discussion of health care delivery focused on several main themes, including quality control, health communication and public-private sector partnerships. They discussed these themes under the pretense of creating integrated solutions for health care delivery. They suggested that delivery is currently fragmented due in part to the inherent differences in enterprises and businesses providing quality health goods through a fee-for-product model. They went on to explain how this model might conflict with government entities providing shortterm health fixes for free and then potentially running out of equipment and supplies quickly. The speakers suggested that aligning the services provided by government groups with enterprise models improves health care delivery in two main ways: 1. Government groups have greater access to financing bulk purchases of products which can then be contracted to NGOs or private sector groups for distribution. 2. Enterprises (NGOs or private sector groups) have a comparative advantage in innovating how these products are distributed in a sustainable way. Additionally, the speakers discussed how linking government groups with non-profits like Living Goods creates an opportunity for quality improvement mechanisms to be set in place. Government groups can help create a performance-based financing space where organizations propose health care distribution models using business strategies, and in the process, commit themselves to certain performance metrics tied to


funding. These metrics might measure elements of the enterprise model like the general distribution of health goods or the economic improvements for community health workers (i.e., increases in income). For example, in Rwanda, mayors meet with the president regularly and present the number of outputs they plan to deliver. At the end of the year, they are graded on their deliverables. Rwanda has found that accountability to follow through on commitments has increased and improved performance drastically as a result of the change in funding model. Individuals are no longer funded based on their promises to perform certain tasks, rather their funding is tied to the actual performance. As a final note, we might suggest that it is additionally important that governments require performance metrics to track both outputs and outcomes. As seen with Mexico's roll-out of universal health care, state governments were given funding based on the number of people that enrolled (an output), rather than changes in those individual's health (an outcome). As a result, the biggest criticism of the universal healthcare plan is that there is not accountability for how state governments spend the money. Beyond performance-based government support there is also discussion in many healthcare circles of the opportunity for the government to become more involved in providing quality standards, inspection, infection control and reducing counterfeits in health care delivery. Governments that play a role in the franchising and quality control of health care products can in turn consolidate redundancies in services and ensure consumers are getting the best products available. However, more research needs to be done on this type of government involvement particularly within countries with stability and/or more systemic corruption to determine effectiveness. The accountability suggested in the performance-based financing model above also creates an opportunity for innovation that might bolster performance. This might mean using mobile technologies to track inventory and report sales of products; thereby improving availability of more products to sales representatives (i.e., community health workers in the Living Goods model). This also might mean improving technologies to better serve particular populations with specific health needs. For instance, using mobile health technology, a community health worker (CHW) may receive information on prenatal health care over text message and provide this information to pregnant customers coupled with their sales of nutritional supplements and vitamins. The integration of health information and effective health communication with sales of health products improves health delivery efforts two-fold: improving the efficacy


of the product through appropriate and consistent use, and while educating a population on prevention and future health care practices. Furthermore, in some instances, mobile technology has the ability to increase reach as behavioral change messages no longer need to take place person-to-person such as with Johnson & Johnson'stext for health platform. Marketing Solutions Outside of the opportunities identified through this discussion, several challenges were acknowledged. Organizations still appear to struggle with effectively marketing innovative product packages or portfolios to the BoP. Living Goods markets its products in part by asking CHW's to use the products themselves as well as share the benefits with neighbors. Other organizations such as E Health Point try to integrate more products and services together, offering access to clean water coupled with healthcare, for instance. Likewise, transportation and location can be a challenge for distribution of health goods. Living Goods sells its products at the doorstep of the poor, which saves customers transport costs that can easy eclipse the product price alone. PATH, another leading global health organization, has developed needle-free injections, which reduce distribution challenges by decreasing the demand on transportation via the cold chain. Still, other organizations are experimenting with task-shifting in order to move skills to health workers with minimal training, or designing ways to get around transportation limitations so users don't have to go to a facility to get products or treatments to distribute. A final challenge discussed as a part of this larger discussion was microconsignment models. Micro-consignment models also are emerging as ways to introduce more expensive products and larger product portfolios to the BoP. Micro-consignment models involve offering products to entrepreneurs without charging them for the cost of the product up front. The seller pays for the product once they've sold the product. However, distribution and marketing will likely continue to be challenges for enterprises seeking to deliver healthcare for the BoP and an opportunity for further innovation, so stay tuned for some unique solutions. Questions to Consider Given that universal healthcare coverage is difficult to obtain, there will always be opportunities to improve health care delivery. As governments


continue to play financing and regulatory roles, enterprises will continue to complement the government and donor-based health interventions (such as advanced market commitments for vaccines, read more here, and the Global Fund for AIDS, TB and Malaria) to address the gaps in delivery. As always, it will be interesting to see the innovation that enterprises will bring to delivering healthcare for the BoP. We realize this discussion on government and enterprise accountability only addresses the tip of the iceberg of current opportunities and challenges. The following are some of the questions we plan to research moving forward, and would love to hear your thoughts: What type of models do you think will be most successful? What type of partnerships do you see working well in different countries? Which aren't working well? How do you feel the challenges (marketing mechanisms, cost sharing models, and transportation and distribution models) can be addressed? How is the role of government and enterprises different in the healthcare context than in other contexts in which BoP ventures operate? How, if at all, do you think closer relationships due to ties to funding between governments and enterprises will affect BoP models? How are funding relationships brokered particularly within countries with systemic corruption? Are they pursued?


Advancing Healthcare With the BoP: To Emerging Markets and Back Again
Josh Cleveland February 23, 2011 — 09:00 am

Pfizer and partner Vodafone launched "SMS for Health" International Health Partners

This is part one of two in a set of articles on reaching BoP markets with healthcare innovations. This article addresses the perspective of several multinational corporations while the subsequent piece will present the perspective from a social enterprise start-up.
If your company has a great healthcare innovation that can treat scores of poor people, how do you get it to market? How can an organization spread the drastic advancements in biological strip tests, online and mobile diagnostics, and "lab on a chip" technologies currently under development in North America and Europe? There are not enough trained doctors to disseminate the innovations at the BoP. Those with adequate training either can't buy or don't want to buy products that can drastically increase ability to cure or prevent

disease, or don't want to live in rural areas where many patients are located. How do you reach the people who need healthcare products and services? And how (if at all) does innovation move the other way - from the BoP to developed markets? Over the past month I spoke with leaders in BoP healthcare from global health specialists to global pharmaceutical companies, from huge tech firms to nonprofit start-ups. I've aggregated many of the perspectives on channels to market and technology flows that we discussed in those conversations here. The key takeaways for reaching these markets are as follows: 1. Partnerships are key for big companies and start-ups alike 2. Good corporate programs build on internal capacity and deep knowledge of the firm 3. Companies can benefit from complimentary philanthropic and marketbased approaches 4. Distribution is the biggest nut to crack *(We only begin to scratch the surface of the distribution paradigm here. To learn more about some innovative strategies in this regard please check out the excellent work from my NextBillion colleagues here and here.) This article is not meant to be comprehensive - there is far too much activity in BoP healthcare to attempt that in one post. Rather, I've presented a couple of the case studies from these conversations below where you'll find some guidance from leaders in the field on moving innovations from one realm to another. From New York to Accra and Banjul What happens when a large U.S.-based multinational company wants to get a product to market in the BoP? For Pfizer and GE, the approach is two-fold: part market-based and part philanthropic but both closely linked to market objectives of the firms. It's a long way from Pfizer's headquarters in New York City to Ghana where the company has targeted anti-malaria efforts as part of the Mobilize Against Malariaphilanthropic program. The program trains Licensed Chemical Sellers (LCSs) - small retail outlets for medicine and other goods - throughout Ghana to diagnose and treat malaria with Artemisinin-based Combination Therapy (ACT) or refer patients to


hospitals for more severe cases. Atiya Ali, a senior program officer in Pfizer's Corporate Responsibility department told me that when Pfizer began the program in 2007, LCSs provided correct diagnosis and prescriptions in only 14 percent of cases involving malaria. After their training with Pfizer's partners, Family Health International and Ghana Social Marketing Foundation, the average skyrocketed to 72 percent, helping Pfizer get its products to those who need them most. Unlike the CareShops Ghana experiment, the LCSs that Pfizer partners with are not obligated to use Pfizer as a sole provider of drugs. Pfizer builds on their core healthcare expertise by relying heavily on their Global Health Fellows program for employee-led field support for the Mobilize Against Malaria program. Ali manages several of Pfizer's philanthropic investments, which help build the company's value by opening long-term opportunities and gives them a foundation for expanding operations in emerging markets. To provide the market-based perspective, I asked Martina Flammer, a business lead from the Global Access Team, a relatively new commercial unit within Pfizer's Emerging Markets Business Unit, to provide their approach. The purpose of this group is to explore sustainable, commercially viable ways of reaching underserved customers in the lowincome sector, with a focus on the BoP. With the relatively unflattering history of upselling customers on brand-name drugs as a backdrop, I was pleasantly surprised by their innovative approaches. Last year, riding the wave of SMS breakthroughs in international development, Pfizer's Global Access Team, in partnership with Vodafone, launched a pilot initiative called "SMS for Health" in The Gambia, designed to use text messaging to manage pharmaceutical supply in healthcare facilities, reduce stock-outs, and ultimately improve the availability of medicine to patients. Dispensary assistants, nurses and store managers throughout the supply chain have been trained to use a simple coding system to text the stock levels and expiry dates for 20 medications and the rate of 10 pre-specified diseases to a central database, where the information is then analyzed on a weekly basis and compiled into webbased reports. The disease and medicine spectrum includes high-priority health areas, such as the rate of malaria, pneumonia, maternal death and anti-infective and malaria treatments. By tracking pre-specified health event data, disease rates and treatment types, SMS for Health helps capture trend information that can be used to predict the seasonal variation in the rate of disease, enabling appropriate medicine stocks to be procured and distributed in time so that patients can get those medicines when they visit their local healthcare facility. If store managers and healthcare providers complete their updates within the agreed timeframe, they receive free usage of mobile services. Vodafone's Health


Solutions unit provides the required SMS technology to the partnership. The project is supported heavily by the Gambian Ministry of Health and Social Welfare. And Pfizer and Vodafone are investigating replicating the model elsewhere in Africa. The partnership spans multiple public, private, and NGO entities. Both philanthropic and profit-driven programs rely heavily on Pfizer's core competencies. And the outcome so far is a win-win-win situation: healthcare facilities better manage supplies, the ministry of health gathers valuable data on disease trends and is able to more effective treat those diseases, and Pfizer get more product out efficiently to those who need it. From Fairfield, Connecticut to Phnom Penh Krista Bauer, Director of Global Programs at GE, outlined a similar twopronged market-based and philanthropic approach to getting healthcare innovations from GE to the BoP. Krista describes GE's main development focus as "building infrastructure and upgrading technical capabilities at government hospitals and rural clinics." Initially, GE's philanthropic arm identifies a target country and then develops deep partnerships with the Ministry of Health. Thereafter, managers work together to identify the best technology solutions for the target healthcare provider. Through a partnership with Engineering World Health, GE trains local health employees to maintain and repair the technology. Meanwhile, the company reaps benefits in the form of design feedback, brand recognition, and reputational boosts. Bauer notes that their efforts in developing countries have raised the profile of BoP markets as viable consumer bases throughout the company, an area that the company is actively pursuing. The recently announced partnership with Embracecame about through their new market initiatives unit in part as a result of the success of GE's philanthropic programs. Like Pfizer's approach to global health challenges, GE's relies on the core capacities of the company in technology provision, uses partnerships with existing networks wherever possible (Engineering World Health, ministries of health, and others), and pursues a separate but complimentary for-profit and philanthropic strategies. ... And back again Now that we've covered a couple of models for moving healthcare innovations to the BoP, what about moving ideas and technologies the other way: upstream to developed markets? A recent McKinsey


report notes that the necessity for innovation and fewer constraints faced by entrepreneurs exploring healthcare solutions in developing economies means that: "They can bypass Western models and forge new solutions." Yet as the Economist reminds us, the actual tech transfer is a bit complicated. Regulations get in the way, consumers in the U.S. have little incentive to lower healthcare costs in the first place, and the organizations that need to adapt the innovations are bureaucratic behemoths. Things thus move quite slowly. But that doesn't mean that it's not happening. "Our work in Cambodia providing technologies to government hospitals and rural clinics has taught us a lot about how products work - or don't work - in the field," says GE's Krista Bauer. Product innovation and insight is often cited as an innovation that moves upstream from developing to developed markets. But many believe that the real potential lies in the workflow innovations that don't require the same level of regulatory scrutiny to implement. You'll hear more about these workflow innovations in this series on NextBillion. And it shouldn't take a rocket scientist to figure out why it might be good to apply the proven methodologies in developed countries. A bright future Overall, healthcare at the BoP provides a fertile ground for optimism. Cross-border, cross-sector, cross-functional partnerships in this sector at the BoP are common. For-profit and nonprofit solutions are becoming more viable. Innovation flows are becoming more substantial in both directions. No, we haven't eradicated malaria yet and yes, we are still waiting on a cure for polio. Many programs are still "pilots" and start-up solutions have certainly not yet scaled. GE and Pfizer both pursue some forms of BoP engagement as philanthropic activities for a reason. I won't argue that the attempts presented in this article are anywhere near perfect or complete, but I will suggest that they are boldly pushing ahead. And that is exactly what we need to see in order to confront some of the biggest health issues in both developing and developed countries today.


Learning From Narayana’s 'Lean' Model to Scale Services
Rishabh Kaul February 23, 2011 — 02:45 pm

Narayana Hrudayalaya So really, the healthcare problem of India as I see it is in its volume. Of course there are hundreds of other problems that are beyond the scope of this blog post, but the sheer volume of patients who require immediate treatment is a critical and daunting challenge. Our hospitals are small and hence the cost of treatment is exorbitant. The government hospitals are either ill-equipped or don't have enough beds. The burden of quality health care is then passed on over to the private sector. One such sector that needs immediate attention is heart care. Heart operations by their very nature are one of the most expensive operations in medical care and require incredibly well-trained staff. The private hospitals charge a fortune and work at a slow pace. There is clearly supply demand gap here. And this also means there is a tremendous opportunity.


This is the challenge world-famous cardiac surgeon, Dr. Devi Shetty (treated Mother Teresa during her final years) of Narayana Hrudayalaya, took a decade ago when he opened his first heart care hospital in Bangalore. And since then the results have been phenomenal. Narayana currently performs more number of heart surgeries than most hospitals in the world and is the highest in India by a huge margin. The mortality rate here is lower than the best hospitals in New York. Backed by major investors such as JP Morgan and AIG (who own 25 percent of the hospital group), the Narayana hospital in Bangalore and Kolkata are responsible for more than 12 percent of India's heart surgeries.

(Above: Dr. Shetty. Image courtesy of Narayana Hrudayalaya)
Dr. Shetty has been hailed as the Henry Ford of Heart care primarily due to this factory-style approach to heart care. However, a Toyota analogy would be more apt, since what sets Narayana apart is its leanness. What that means is a strict emphasis on standardization of processes, relying on core competencies (hence surgeons don't do any administrative work and concentrate solely on surgeries) using the economies of scale to bring down the costs. This translates into a final cost which is nearly 40 percent of (turn to the appendix of page 20 for


the entire tiered costing structure, data is from 2008) other private hospitals. Narayana has worked hard to drive down its per unit costs. Here's how it did it: Salaries of doctors Instead of paying the doctor per surgery, which tends to be very expensive Dr Shetty pays his doctors competitive fixed salaries (senior doctors receive anywhere between 100,000-250,000 USD) and then urges them to increase the number of surgeries per day. This helps bring down the cost per surgery. Volumes -Extremely high volumes. This is one of the major reasons why they are able to cross subsidize the costs of so many of their patients (about 80 percent -plus receive some form of discount or other). The international cell ensures that there is a huge inflow of international medical tourists for whom the price arbitrage works out well. -Because of increased number of shifts and higher number of specialized doctors, the operation theater is utilized for longer hours contributing to high volumes. More value per buck Devi Shetty boasts about the tight monitoring that takes place, be it to oversee that their cost effective hospital designs are properly constructed (more on this later in the post) or that they procure their supplies at a frugal cost without compromising on quality. NH has very strong purchasing power for medical supplies due to its massive patient volumes. Innovations here include abolishing long-term contracts in favor of negotiating contracts on a weekly basis, and taking expensive medical equipment on lease rather than purchasing it. Partnerships The hospital has major partnerships with the private and public sector organizations. Biocon Foundation set up a generic drug shop where it sells drugs 20 to 30 percent cheaper to its members. Lots of microinsurance schemes with the Government of Karnataka (Yeshasvini) and Tamil Nadu etc., which work on flexible payments, have helped thousands coming from low-income groups to procure NH's services. Apart from this, the hospital thrives on innovation-based partnerships,


such as the one with Texas Instruments. NH and Texas Instruments tied up to drive down the cost of equipments such as X-Ray plates (the cost was brought down from 82000 USD to 300 USD). Emphasis on Tier 2 Cities Senior management at NH explained to me that ultimately Narayana Hrudayalaya's aim is to penetrate fully into the growing tier 2 cities (for example Jaipur) and beyond. Getting doctors to operate here will be mainly through goodwill on their part, creating clusters of hospitals where patients from one can be referred to another. What are the challenges? I figured with such an elaborate and aggressive plan on setting up more and more hospitals, NH would in the future face heavy shortage in human resources. During a chat with one of the VPs of the institute, he agreed that was a major concern but the recent move by the health ministry to establish new medical colleges (a 300 Million USD project) is one major reason why he's keeping his hopes high. He also disclosed that managing the nursing talent is a bigger issue since their attrition rates tend to be higher. Marketing is another vertical they plan to ramp up. So far most of marketing has been via community events, word of mouth and the officials agree that with expansion plans in place, the marketing of NH's services has to sync up. Another key challenge for NH is the standardization of their process given that in the next few years there are going to be thousands of Narayana Clinics and Hospitals. For an organization such as Narayana Hrudayalaya, it's all about the processes. What's next? Clearly bringing down the costs is always the first agenda. Dr. Shetty is investing a lot in innovative practices that always thrive to bring down the cost of surgeries. He is advising other countries to adopt his model. While it started as a heart facility, Narayana Hrudayalaya is now expanding into various other medical branches. They have big plans ahead to tackle cancer. In 2009 they opened a 1,400 bed cancer facility in Bangalore thanks to a generous grant of around 9 million USD by Biocon head Kiran Mazumdar Shaw). They also have plans on having 500 new kidney care clinics. These kidney care clinics through donors and


innovations in healthcare will bring down the price of dialysis to Rs 400 (under 10 USD). Narayana Hrudayalaya and Dr. Shetty believe that in a nation such as India where everything is larger than life, he believes that every initiative of his needs to be massive and affordable. This is what drives their innovation and what helps them bring down the costs.


Advancing Healthcare With the BoP Series: Dial 104 for Health
Rose Reis February 24, 2011 — 08:30 am

104 Advice, run by the Health Management Research Institute

Editor's Note (Correction): An earlier version of this blog incorrectly stated the terms of a memorandum of understanding between the state and HMRI. According to HMRI, the MOU signed in February 2009 stipulated that the data generated in the implementation of the HMRI scheme is the property of Andhra Pradesh. HMRI could not and has not shared the data with any other entity. Editor's Note: This post is part of the NextBillion series, Advancing Healthcare With the BoP. The Center for Health Market Innovations and Ashoka are both contributors to the series.
A housewife in rural Andhra Pradesh (AP), India has persistent lower back pain. Like 86 percent of other villages in AP, hers lies more than 3 kilometers from the nearest hospital and she has no vehicle or time to travel by bus. Before 2007, she would, like most rural residents, be resigned to seeing a local, untrained doctor when her pain worsened. Today, she simply dials 104 from her mobile phone. 104 Advice, run by the Health Management Research Institute (HMRI), is a 24x7 toll-free health helpline providing standardized medical information, advice and counseling that receives about 50,000 calls each day. Paid for by her state government, the service uses a database with 400 algorithms and 165 disease summaries to answer her questions about the pain and, if necessary, recommend a nearby specialist to help resolve her condition. HMRI is one of nearly 700 health programs documented on the Center for Health Market Innovations (CHMI)'s interactive web platform atHealthMarketInnovations.org. Through a global network of partners, CHMI collects information on innovative programs in more than 100 countries. Using this information, CHMI identifies and analyzes emerging, innovative models that could be scaled-up or adapted in other countries.

CHMI works to better understand which emerging program models truly have the potential to improve health and financial protection for the poor. In this focus on call centers, I asked Vijay Reddy, a government contracting specialist who has been following the developments at HMRI since its incubation at ACCESS Health International, CHMI's hub in India, to explain why many believe the model for 104 Advice is so promising. Rose Reis: Why do you feel this program is innovative?

Vijay Reddy: HMRI applies new technology and operational processes to improve access to care for 80 million people across the state. About 50 percetn of the calls come from small villages with no permanent medical facilities or staff. Reis: How did the 104 for Advice start out? Was it always intended to be so large? Reddy: It took about four years to reach this stage in which HMRI receives up to 50,000 calls per day. After a pilot, government launched 104 across AP in 2007. Reis: How was HMRI selected? Reddy: Satyam Computer Services Ltd has been technology partner for Emergency Management & Research Institute (EMRI), which the people in AP came to trust in a lot. Similarly, HMRI was established with Satyam Computer providing technology. Now that a model exists, most other states are taking up this model to launch through a competitive, transparent bidding process. This can be controversial. Some feel the lowest bidder might not be the right bidder. In Bhutan, government selected not the lowest bidder but a bidder who can transition management of the call center system to locals. Bhutan was looking at developing competency within the country, so very specifically they put out a call for an organization to take up the initiative, continue it for several months and hand it over to an organization internal to Bhutan.


[Hyderabad-based tech company] Procreate has contracted to start up the model in Bhutan and it will be implemented any day. Reis: What is the financing model for this model? Does it differ from state to state? Reddy: Government of Andhra Pradesh pays 95 percent of costs and the present private partner, Piramal Health Group, covers the remaining 5 percent. I think there is a strong case that the model could only scale so quickly and be sustained in a public-private partnership with technology enabling things to become very simple to implement. If you look at the Piramal initiative in Rajasthan, sustainability has been a big challenge. This is operating as a CSR in only a few villages. Do some states charge a user fee? [SA1] Delhi's government is considering setting a user fee for the service, but the cost of collecting the fee may be more than the fee itself. You spend around 30-40 rupees [less than $1 USD] to collect a user fee and you hardly take in 5 rupees per transaction. Reis: How does this health advice line benefit people's lives? Reddy: Many people in rural areas have no access to trained health providers. They have no way of judging if their vague health complaint is something serious. They call 104, give their complaint, and trained counselors classify their condition into critical, serious or stable. They provide medical advice as well as counseling on a wide span of issues, from depression to HIV. 104 provides ready information about healthcare facilities in the government sector and enables easy access. In Delhi, patients will be able to make appointments at public and private facilities by calling 104. Hospitals paying for part of the implementation will be able list their availability to get more patients. Reis: Health advice lines. Flash in the pan trend, or lasting model? Reddy: With more governments initiating such programs in India through public private partnership they can be scaled up to most parts of the country to reach people in a scattered geography where there is significant shortage of healthcare professionals in a very short time. I expect these initiatives to create tremendous impact and lessons for the future. It is essential to have transparency and accountability in contract management to achieve an expected outcome.


This partnership attempts to combine the capabilities of public sector with those of the private sector-and overcome weaknesses in both sectors. Governments' robust and dynamic structure sets them as an enabler with high ownership, safeguarding consumer and public interests apart from commercial interests with a transparent and well-conceived contract.

Read more about HMRI, then check out more than 120 other programs using ICT to make health processes more efficient (thus affordable) for the poor.


Piramal eSwasthya, Demystifying the Primary Healthcare Model
Sriram Gutta February 25, 2011 — 01:00 pm

Editor's Note: This is the first of two posts on Piramal eSwasthya as part of NextBillion's Advancing Healthcare With the BoP series.

Kavikrut, of Piramal eSwasthya

Since its inception in 2008, Piramal Group's (parent company Piramal Healthcare) initiative Piramal eSwasthya has worked to "democratize healthcare" through scalable and sustainable breakthrough healthcare delivery models. During the past three years, eSwasthya has experimented with several innovative approaches to delivering healthcare using telemedicine, clinical decision support systems and village-based health entrepreneurs. The model has been developed in partnership with Harvard Business School Professor Nitin Nohria and is specifically tailored to serve the grossly underserved populations in the remotest of rural areas.


Kavikrut currently heads the Piramal eSwasthya. Having spent the last five years in base of the pyramid (BoP) healthcare he has immense knowledge about the healthcare space and consumer behavior. In this period, he cofounded two healthcare delivery models (Full disclosure: Kavikrut and I, along with other team mates, together co-founded Mobile Medics ). Sriram Gutta, NextBillion: It's not often that we find someone with a background in finance start a career in healthcare, more so at the BoP. What led you to this field? Kavikrut: My stint with BoP healthcare started when I co-founded Mobile Medics five years ago. This wasn't a planned career move and happened by chance. Lack of existing solutions, a grave challenge, a good business plan, and a seed fund led me to take the plunge. I spent about 2 years at Mobile Medics where we treated 2,000 patients across 12 villages. This was a legacy model that had been tried earlier, although in a non-profit structure. A mobile van with a doctor, nurse and drugs visited a few villages each day to treat the patients. Every village was covered twice a week on a pre-defined day and time. This model was built to provide healthcare that was affordable and accessible. Although successful, doctors became the bottleneck. It was evident that to scale such a model, one needs to reduce the dependency on a doctor to deliver healthcare. In traditional models, a doctor could treat up to a 100 patients per day. We were looking for a way to increase this dramatically. While Mobile Medics was looking for funding to further experiment with other delivery models, we met the Piramal Group and saw synergies leading to the absorption of the Mobile Medics team to start Piramal eSwasthya. Their structured, well-funded and resourceful model provided a rather conducive environment to design and test more radical healthcare delivery models. NextBillion: What's unique about the model? Kavikrut: Our model allows each doctor to diagnose over 400 patients per day spread across 100 villages. The doctor's task has been decentralized and he now does what is core to his expertise, while the other steps in the treatment process have either been handed over to easy-to-train manpower or automated through sophisticated software. In a traditional set-up, the doctor diagnoses the problem, records vitals like blood pressure, pulse rate, etc. and then writes a lengthy prescription. There is also a substantial amount of time spent in talking to the patient both pre and post prescription to counsel and comfort them. We at Piramal have divided this process and have different stakeholders managing them. The key members of our delivery model are:


Piramal Swasthya Sahayika (PSS) - A village-based health worker who acts as the communication link between the patient and the doctor. A PSS records patient history through a simple one-page form, measures vitals such as blood pressure , temperature, weight and then calls a remote paramedic based out of a call centre in a city (currently Jaipur, India). This process takes close to 5-7 minutes per patient. Call Centre Paramedics - The paramedics are mainly graduates who have been trained to use a Clinical Decision Support System (CDSS) to diagnose the problem. This is an algorithm-based system that is based on our belief that it is possible to automate the consultation and prescription process through clinical flowcharts, much like what a doctor would do. As prompted by the software, the paramedic asks a series of questions to the health worker, who in turn asks the same to the patient. The responses are communicated back to the paramedics CDSS - Based on the data made by paramedics, CDSS gives a provisional diagnosis and prescription. This software has been developed by Piramal in partnership with Tata Consultancy Services (TCS), India's largest software service provider. CDSS can process over 70 ailments. This takes a total of 5 minutes Doctor - One doctor per every six to seven paramedics reads through the diagnosis given by CDSS and edits as necessary. At this point, the patient call is live and the doctor can talk to him/her, the PSS or the paramedic if needed. This is currently observed only in 10-15 percent of the cases. The doctor then approves or modifies the diagnosis and prescription provided by the CDSS. This is vocally transmitted to the patient through the health worker, and the doctor spends about 4560 seconds in this process. A SMS is also sent to the health worker and the patient. This makes the entire process at the Call Centre to 7 minutes

As a recent health expert who visited our centre aptly put it, we have demystified the whole primary health care delivery process. NextBillion: The CDSS seems like a path-breaking innovation. Does the system have any limitations? Kavikrut: Yes, it does. It can only be used for primary health care and only for certain ailments. Our estimate is that 70 percent of the ailments as seen at a general physicians clinic can be diagnosed using CDSS. And these are usually the first symptoms of what later turn in to more complicated ailments requiring secondary care. So the model helps in


early detection as well as treatment. There will always be a few that require a doctor's intervention. NextBillion: Does the use of such technology and various resources like health workers, paramedics, and doctors translate in to a higher cost for the patient? Kavikrut: From the outset, we have tried to keep the model simple and affordable for the client. We only charge the patient a maximum retail price (MRP) on the drugs and nothing else. Since the patient never sees the doctor, we have removed the cost of consultation. This was done based on client and health worker's feedback. Based on my experience, it is possible to make money from the drugs if one manages the supply chain well. NextBillion: A zero cost of consultation seems extremely beneficial for this price sensitive population. Would eSwasthya be able to cover its costs in the long term? Kavikrut: Yes. At the moment, we get an average of 1.2 patients per health worker per day across 50 villages. The model will become sustainable at a scale of 1,000 villages clocking an average of 1.75 patients/PSS/day and thus cover overheads, technology and marketing costs. Some of our better motivated health workers have consistently clocked over three patients per day and so we believe that this is achievable. We plan to scale to 1000 villages by early 2012 through eSwasthya run centres and some government Public private partnerships pilots. NextBillion: It seems like a large segment of patients in each village are still using other health care players. Who are some of these? Kavikrut: There are other health practitioners in or near the villages. Some of these are:

Registered medical practitioners/quacks - Unqualified, illegal village based (sometimes travelling) practitioners that provide cheap healthcare consultation and drugs and employ questionable treatment practices such as dispensing loose unpacked drugs and using injectable steroids for treating most primary ailments. Most quacks either have the responsibility passed on over the generations or are trained nurses/compounders who pick up the trade by assisting doctors Government - There is a well established network of primary health centres (PHC) and sub-centres across rural India; however, these

highly depend on the availability of the doctor and are not always available in the neighborhood.

Private clinics - These are based out of nearby cities and towns and offer a doctor's service. An average consultation fee is about Rs 50 and drugs are sold at retail price. However, the real cost incurred when seeking treatment is much higher for the client. This includes cost of transportation, opportunity cost due to the loss of wages, and other incidental expenses in the city. Making this a very expensive option. Quacks - These are the cheapest service providers and are inaccurate, unreliable, and unethical.


Piramal eSwasthya (Part 2): Building Acceptance for Mobile Health
Sriram Gutta February 28, 2011 — 08:03 am

A healthworker takes vital signs. Image Credit: Kavikrut, of Piramal eSwasthya

Editor's Note: This is the second of two posts on Piramal eSwasthya as part of NextBillion's Advancing Healthcare With the BoP series. Part one of the interview with Kavikrut, who currently heads the Piramal eSwasthya, may be found here.
Sriram Gutta, NextBillion: How has the model evolved over the last three years? Kavikrut, eSwasthya: Based on our learnings from the field and client feedback, the model has mainly evolved along the following three areas:


(Clinical Decision Support System) CDSS - Over the years, we have added more ailments to the system. We had started with 40 and now the CDSS can diagnose over 70 ailments. Even the workflows of the existing aliments have been modified based on learnings. We are now looking to deploy a mobile application based system where the PSS (Piramal Swasthya Sahayika (PSS) - A village-based health worker) will enter all data on her phone with many basic CDSS questions moving onto the application. This will make the process faster and hence increasing the system's capacity and accuracy. Client acceptability/marketing - This is a radical service and takes a longer time for client acceptance. Even with the penetration of mobile and Internet, the affluent class is still a little skeptical about ecommerce and mobile banking. Thus, we are not surprised by the skepticism about our model where they don't see the doctor and thus can't attach tangibility to the treatment. We have continuously reinvented marketing techniques and customer involvement for the BOP through drug reminder SMSes, follow-up calls, PR articles that encourage embracing telemedicine among others Health worker - (The) Health worker is one of the most critical parts of our system. It takes a long time to recruit and train the right one. Trying to change their behavior takes a lot of time, resources and money. Over a period of time, we have identified certain traits that are required to be a good PSS. Some of those (include the) need for an additional income, entrepreneurial ability to understand commissions and franchisee model, etc. We started with a fixed salary for the health worker and realized that there wasn't any motivation for her to source more patients and service them well. We then moved to a part fixed and part variable pay which later gave way to a complete variable franchisee type system. Now the health workers need to bring an upfront starting investment and franchisee fee paying for training, medical equipment and a security deposit against drugs

NextBillion: Seems like hiring women workers could be a bottleneck when you are looking to scale. What are some of the innovations that you are looking at? Kavikrut: We are currently working with the government of Rajasthan to hire ASHA workers as our health workers. There are a total of 267,000 such workers in India - one for every 1,000 population. She has a kit of over-the-counter drugs, conducts health related surveys and supports most government initiatives such as polio camps. The Rajasthan government has shown interest in the model and we have now launched a PPP pilot with the Churu collectorate as part of which we are launching


100+ villages in one block of the district. This is a win-win solution for all. The government can provide primary care consultation now within the village, we get access to trained health workers who already have an established "health service provider" relationship with the village, and the ASHA worker can increase her income by working with us. It is still preliminary to talk about the results of this model but if successful, it holds immense promise for scaling the model very quickly. NextBillion: Have you also partnered with private players? Kavikrut: Yes, we have partnered with several players to offer better and high quality products/service to our clients. Some of our partners include:
• •

Tata Consultancy Services - TCS have played a big role in designing the CDSS. All the rules and platform have been provided by them Vision Spring - They have enabled us to add primary eye care also to our service offering by giving access to low cost reading glasses through the health workers. This is an additional source of income for the health workers and provides quality eye care to our clients Medentech and aquatabs - We have worked with these organization that manufacture water purification tablets that help reduce water contamination at the household level

NextBillion: Do you have any interesting insights from patient behavior for the readers? Kavikrut: Yes, many of them. One of them presents a big challenge for us - most patients hesitate from buying the entire prescription. For instance, if a patient comes with cough and also has high temperature, we prescribe both a cough syrup and paracetamol. The patient typically buys only the cough syrup as syrup is the more obvious need to them. Similarly, for skin ailments a patient may ignore the prescribed antibiotic and instead only buy the ointment tube that is also part of the prescription. We are working on ways to change this behavior. Some of the health workers who have a reputation manage to convince patients about the need of buying and consuming all the drugs in the prescription. NextBillion: Is it required for an entrepreneur to have healthcare experience to be in this space? Why or why not? Kavikrut: Not necessarily. I entered this space without any background in healthcare and don't think it was a big barrier. It is good to have the background but not a deal breaker. It is more important to understand


the business and the mindset of people at the bottom of the pyramid when working to deliver essential services such as health, education etc. What we are working on is a healthcare delivery model and not just a health product or service per se. It is as much about the supply chain or marketing as much it is about the clinical treatment side of health NextBillion: How would you describe your progress so far? Kavikrut: Over the last three years we have achieved a few milestones that we believe are important indicators of our experience as well as our passion to find solutions healthcare problems. We have treated over 40,000 patients through several pilots including a more traditional telemedicine model in Tamil Nadu that deployed videoconferencing and Medical Data Acquisition Units. In Rajasthan, we have worked in more than 200 villages in three different districts (Jhunjhunu,Nagaur, Churu) and in the process have trained over 200 health workers. Our pilots, challenges and learnings were recently published as a Case Study by the Harvard Business School. Through social experiments and meticulously designed operational processes, eSwasthya has also innovated on several fronts in the context of delivering services and goods to rural consumers. In 2009, the organization was awarded the ISO 9001:2008 Certification for its Quality Management Systems across all villages, rural offices and the Mumbai centre. NextBillion: What would you like the headline of eSwasthya's website to be in 2020? Kavikrut: The world's most radical yet simplest healthcare delivery model for the BoP. Largest number of patients treated through remote diagnosis. Piramal eSwasthya becomes synonymous with the word "telemedicine.”


Better Living Through Information
Rose Reis March 1, 2011 — 09:18 am

mDhil founder Nandu Madhava

Editor's Note: This post is part of the NextBillion series, Advancing Healthcare With the BoP. The Center for Health Market Innovations (CHMI) and Ashoka are both contributors to the series.
While serving as a translator in Dominican clinics during a Peace Corps stint, Nandu Madhava realized that many people in emerging markets suffer from health problems due to a lack of information. Particularly adolescents knew very little about sexual health and contraception. Madhava realized that providing access to accurate and relevant information about these taboo topics was a critical step in empowering people to achieve positive health outcomes. Flash forward across the years he spent honing his entrepreneurial acumen at investment banks and the Harvard Business School, and the Texas-reared TED fellow is banking on young people's thirst for practical health information presented via original video and text content - delivered over mobile phones. His company, mDhil (m for mobile, Dhil for heart), is based in Bangalore's Richmond Town, where it shares an office with the BoPfocused jobs board BabaJobs.com. Rose Reis, CHMI: Describe your audience and its health needs.


Nandu Madhava: Our main focus is the Indian youth audience - we have excellent content on topics including sexual health, family planning, contraception, and women's health. A representative customer would be an urban teen or college student who seeks to learn more about relevant health concerns. We also have content on chronic and lifestyle diseases like diabetes and obesity. Reis: Is your content accessible to all? Madhava: Our core focus is currently urban youth, and this is a huge market within India. As the 3G mobile network rolls out across India, broadband mobile services will become available in semi-urban and rural India over the next 24 months. Coupled with the steep price fall in smart phones, we believe we can grow our user base to reach frequently marginalized communities. But I'm careful to not make a classic start-up mistake: trying to be all things to all people. Reis: How do you ensure that you deliver relevant information? Madhava: From the outset since I started mDhil three years ago, I've always engaged public health professionals, physicians and nurses to help understand the health challenges seen in India. We have several health professionals on our staff, as well as a health advisory board and we run our content by Indian NGOs. Looking at World Health Organization (WHO) data, many people mistakenly believe that most health challenges are isolated at the bottom of the period in India. In reality, there are tremendous challenges in accessing accurate and relevant health information across economic and gender lines. Reis: What technologies do you use to reach your customers? Madhava: Originally, we focused on delivering SMS subscriptions via mobile carriers in India. We still are active in the SMS business, however, there are two seismic changes happening in mobile: (1) The launch of 3G data networks in India, and (2) a proliferation of low-cost smart phones. Both of these changes let us reach end-users with feature rich content, mainly video and articles with imagery. In the past, we had to charge users to access our SMS content via mobile carriers. Going forward, we're focusing on a great mobile (as well as desktop) Internet site where our content is free and advertising supported. There are


already 20 million Facebook users in India, and India is the second largest country for mobile advertising after the USA, according to Google/Admob. So mobile Internet in India is not a trend that 'might happen', but instead a trend that is happening right now. Reis: How do you produce the videos on your website? Madhava: Since launching our video channel about three months ago, we have gotten over 15,000 video views - 90 percent of this traffic is from India and 30 percent is viewed over mobile. We work with young directors who share our vision to create meaningful, empowering content for a youth audience. Setting basic parameters around issues like length of content, sound quality and good lighting, we give creative freedom to the directors. We look for scripts that focus on positive health messages my goal is not to frighten or belittle our users. We often heard that many youth didn't reach out for information in the past due to the paternalistic and condescending nature of the existing health system. I look for empathy in our directors and scripts. Reis: Do you ever receive any negative feedback on your coverage of taboo topics like sex? Madhava: Well, we approach sexual health in a frank, open, and honest manner. We work with people who have a deep respect for cultural, gender, and sexual equality for all citizens. We don't seek to shock or upset people; we want to encourage critical thought and respectful discussion. I was recently at an evening event in Bangalore where I sat across the Indian contemporary artist Subodh Gupta. At first, he was a bit churlish due to my American accent. However, when he found out that my work focused on positive sexual health discussions, HIV/AIDS prevention, and gender equality for women, he expressed his love and camaraderie. I thought, "Hey, if a respected artist like Subodh Gupta likes this, then I must be doing something right". Reis: Do you plan to expand to any new technology platforms? Madhava: I'm a big believer of Android in the Asian markets, but that said, will be interesting to see what happens with Nokia and Microsoft now working together... Reis: You will be presenting on technology trends in India at SXSW this

March. What day should we be there? Also, this makes us wonder, is mHealth the new Arcade Fire? Discuss. Madhava: I love Arcade Fire! Hopefully we'll be just as cool! Wish us luck...we are speaking at the Technology Summit at SXSW during the week ... keep an eye out for us. Watch mDhil videos here, then read about 55 other programs in India working to make people more savvy consumers of healthcare. Know of another cool, innovative program? Register and enter it here.


Healthcare Series: To Emerging Markets and Back Again (Part 2)
Josh Cleveland March 1, 2011 — 03:30 pm

A Healthpoint Services clinic in Punjab. Image Courtesy of Healthpoint Services

Editor's Note: As part of our series, Advancing Healthcare With the Base of Pyramid series, this is the second in a pair of articles focused on reaching BoP markets with healthcare innovations. This article addresses the perspective of a social enterprise start-up while the previous piece presented the perspective of several multinational corporations.


In the previous article in this set, I wrote on the experiences of two large companies with reaching BoP markets with healthcare products and services. Their perspectives can be found here. That article covered the issue of getting good stuff to people who need it from the corporate perspective - with big budgets, thousands of eager employees, and the ability to use philanthropy as a tool. But what about when the innovations are just emerging, the organizations building them are small, and you're based in an entrepreneurial team with social impact motives? For this perspective, I spoke with Al Hammond, Ashoka entrepreneur, NextBillion advisor, author, and founder of Healthpoint Services. From biotech startups to North India Distribution often is the crux of engagement with BoP markets. In every village where Healthpoint operates, it builds a permanent clinic, which costs roughly $50,000. Through the clinic, the organization provides North India residents with access to technology in the form of telemedecine, a diagnostics lab, provision of medicines and clean water. Local people are trained in the provision of all services with doctors in other locations answering queries via telemedicine technology. Like Pfizer and GE, Al deeply understands the value of partnerships. "Partnering is critical. These are complicated problems and any one organization is unlikely to have the skills it needs. So you need to build an ecosystem that supports scale, lowers the risk and increases likelihood you can succeed." In the case of Healthpoint, this meant "building partnerships with every start up building these technologies that we could find." For example, start-ups produce the "labs on a chip" Al's team hopes to use to remotely conduct DNA analysis on a sample and receive a readout in about 5 minutes for the cost of $10. It's a good fit: biotech startups need distribution and testing; Healthpoint needs the technology to make Healthpoint attractive and affordable to rural clients. While Pfizer and GE's programs both rely on local partners such as government ministries and LCS's for distribution and access to patients, Al's team built a distribution channel from the bottom up. One can argue about the effectiveness of each approach (and we certainly plan to in future NextBillion posts) but to Al's team, there was no question about how to do it. "We started with distribution for our core services," says Hammond, "and will later figure out what additional products and services to use in that distribution system." Al points out that where most distribution systems fail is that they are not economic particularly for single-service provision. He predicts that in the coming years, the four services Healthpoint provides now will probably double. Only partially joking, he notes that since Healthpoint has broadband wireless access,

they might someday enter the education market. The Healthpoint model is unique (and capital intensive) precisely because of the permanent infrastructure that the organization builds in each community. But despite that risk, for Healthpoint, "its how we become a part of the community - how they know to trust us and that we are going to stay around." Although Healthpoint builds its own distribution system to get its services out to those who need them, not unlike Pfizer and GE, Healthpoint relies on partnerships (including those with Ashoka, P&G, local governments, and with other entities) to get things done. (We look forward to providing more details on its partnership with P&G shortly). And given similar to obstacles faced by large companies, effective distribution systems are critical to the success of the organization. ... And back again For reasons we discussed in the previous piece in this set of articles, moving tech solutions from emerging markets to developed markets is a tough business. Many thought leaders (Al Hammond included) believe that the real potential lies in the workflow innovations that don't require the same level of regulatory scrutiny to implement. Hammond speculated that Walmart could someday take on point of care (POC) diagnostics care that Healthpoint uses today in North India as an add-on to its existing in-store clinic services. Walmart's strongest markets are in the rural parts of the U.S., where we have the lowest rates of healthcare provision and lowest numbers of qualified doctors, not unlike India. If Walmart could use the the POC innovations we're proving viable now in India to provide a 20-minute, $20 diagnostic result and give the patient the medicine they need, we could dramatically change healthcare access in this country.


Listening to Patients: Innovations in Empowerment
Evagelia Emily Tavoulareas March 3, 2011 — 10:30 am

Flickr Credit Editors Note: This guest post is by Evagelia Emily Tavoulareas, Media Mobilizer for Ashoka's Changemakers, and was contributed as part ofNextBillion's Healthcare With the Base of the Pyramid series. The buzz about innovations in healthcare has focused on advancements in testing, diagnostics, treatments, and improved access to care, but there is a missing piece of the healthcare innovation puzzle - we don't hear nearly enough about people. In July 2010, Ashoka's Changemakers and the Amgen Foundation turned the healthcare conversation towards the end-user, the patient. Together, Changemakers and Amgen launched the Patients | Choices | Empowerment competition to elevate patient's voices to improve health outcomes globally. Innovation in Patient Empowerment The Changemakers community submitted 277 competition entries from 40 countries, sharing solutions that empower patients. The three winning entrants were each awarded $10,000 from the Amgen Foundation to support their work. The winners included: • CureTogether, United States - A crowdsourced patient experience that uses raw data (submitted by users) to create structured, quantitative information related to treatment options. The website aggregates patient-contributed data on over 550 medical conditions, creating a comparative effectiveness database.


SMS Now! A Life Depends on It, India - An SMS-based helpline that connects patients in need of blood, with blood donors in real-time. Patients in need of blood can contact blood donors in the database by sending a text message. The service has already been used during the Pune and Mumbai Bomb Blasts, where victims were in need of blood. Educating Tuberculosis Patients for Excellent Results, India - An educational program, teaching patients, families and communities about treatment compliance, and minimizing the spread of Tuberculosis. The program is implemented by local counselors, with the support of trusted community leaders in India.

This competition surfaced solutions that allow patients to make informed decisions to improve their own quality of care. With innovators, entrepreneurs and experts in the field working together, some interesting trends also emerged. Social technologies are the future A significant portion of the entries were related to technology - more specifically, networking online, information sharing, and mobile phones. Two of the three winners are technology-based initiatives. One uses crowdsourcing to aggregate patient-contributed data to create a database for users to compare treatment effectiveness. The other uses the power of mobile phones to connect patients with blood donors through an SMS helpline, in a region that often faces a shortage of blood supply. Both of these technologies (crowdsourcing and SMS) have been used for myriad purposes - from organizing protests to accessing the market price of wheat. These existing and emerging technologies may be applied in a variety of ways, but one thing is for certain: social technologies enable people to connect with each other, and to share information. Since much of patient empowerment is centered on education, access to information, and communication with their healthcare providers, you can expect to see more use of social technologies in the field of healthcare. Social innovators from India not only sourced two of the competition winners, but also the source of the second key insight: India is an emerging leader in healthcare innovation As a country, India demonstrated its leadership in this sector as home to two of the three winners and the source of the second largest pool of entrants (second only to the United States). As one of the most populous


countries in the world, India is facing serious public health challenges. With India as a heavy weight in the field of mobile technologies, and an emerging innovation hub, we can expect to see Indian healthcare professionals and innovators tackling the issue of healthcare in exciting new ways. We also saw the importance of thinking local. While there is much to learn from the global community, Western medicine and high-tech healthcare systems - trusted local stakeholders are critical to success. Many competition entrants submitted ideas centered on community engagement and local buy-in. Depending on the cultural context, local acceptance and trust could be more or less critical. Taboo healthcare issues (such as cancer, HIV/AIDS, and mental health) require extra sensitivity to local needs, and engaging trusted members of the community is critical. Other interesting trends:
• • •

The vast majority of entrants have been operating for over five years Most entrants aim to influence public policy The most dominant topics/issues that were being addressed were: o Cancer (various types) o Psychology & Mental Health o Improvement of doctor-patient relationships (and communication)

As innovation in the field of medicine and healthcare charges ahead, it is important for us to listen, connect and learn. We must listen to doctors and patients, connect with innovators experimenting with new approaches, and learn from what works - and what doesn't. As we continue to tackle challenges in healthcare systems around the world, we should keep in mind the words of Mark Twain: "If you always do what you always did, you'll always get what you always got." Innovation moves the world forward. And what is at the heart of innovation? People.


Technology to the People! Taking Telemedicine to Scale in Rural India
Rose Reis March 4, 2011 — 09:35 am

World Health Partners' Sky Telemedicine Centers World Health Partners

This post was contributed by the Center for Health Market Innovations (CHMI) as part of NextBillion's Healthcare With the Base of the Pyramid series.
Long known as an IT capital, India's health infrastructure for years lagged behind the Tiger-like force of its software industry. No more: In the past decade, thanks to growing support from government, private sector innovation, and a great leap forward in infrastructure development, socalled Information Communication Technology (ICT) is transforming the way people receive health care.


The "next generation" telemedicine model is proliferating rapidly in India, where 70% of people live in rural areas where health infrastructure is still insufficient. Telemedicine uses ICT to "provid[e] accessible, costeffective, high-quality health care services," in the words of a recent WHO Global Observatory for eHealth report. Telemedicine models, in which rural patients are connected to trained physicians over telephone or Internet, can become the first point of access for a variety of illnesses and diseases such as eye related issues, intestinal problems, infections and heart disease. Most importantly, patients get into the health system early and do not delay care seeking for fear of transportation and costs. Today, CHMI profiles more than 55 telemedicine programs globally including 24 in India (program implementers and CHMI's partners in 16 countries are continually adding new programs to the open database). World Health Partners is a not-for-profit franchising organization that provides healthcare services to the poor in Uttar Pradesh across Meerut, Muzzafarnagar and Bijnor districts. In less than 18 months, the project established a health service delivery network covering 1,300 rural villages of Uttar Pradesh through 1,300 shops, 120 telemedicine centers, nine diagnostic centers and 16 franchisee clinics. The project's central medical facility in Delhi conducts 80-160 tele-consultations per day. Next up: an expanded pilot in Bihar, with funding from theBill & Melinda Gates Foundation. Gates has also initiated a rigorous evaluation of the model's health impact. Sehat First, another franchise model utilizing ICT, aims to set up 500 health centers across Pakistan by 2012. Founded in 2008 by d.o.t.z. technologies as a Karachi-based pilot, Sehat First received an equity investment from Acumen Fund. The initiative's telemedicine consulting service gives patients access through clinic staff to physicians, even specialists like gynecologists and pediatricians, over IP-based video phones. Amrita Institute of Medical Sciences (AIMS) and Research Centre uses telemedicine to connect general providers to specialists. In addition to the flagship hospital at Kochi, the Institute also has established several smaller satellite hospitals in semi-urban and rural areas to serve the local populace. Students from the health sciences campus in Kochi often are posted to these hospitals, and doctors and other medical staff serve there as well. Satellite hospitals are linked to the 24/7 telemedicine service of AIMS Hospital. The technology allows for the transmission of a patient's medical records and images, and provides a live two-way audio and video link, which allows a general practitioner at the health center to connect with a specialist at AIMS.


Raja Bollineni, of CHMI partner organization ACCESS Health International, is charged with mapping ICT-related health initiatives in India. Bollineni got interested in the promise of so-called e-health when working in Rwanda. He proposed a system for Partners in Health to allow people in rural Rwanda to consult on eye problems with specialist ophthalmologists located at Central Hospital University Kigali. Although these models have garnered a lot of excitement in India and abroad, Bollineni is quick to point out a number of challenges impeding the implementation and further growth of these programs, including capital investments, infrastructure limitations, lack of supportive policy, and low awareness levels in the communities. One other important barrier to sustained growth is the difficulty in getting sufficient volume to sustain your business. "Startups shouldn't go in for high-end technology," suggests Bollineni. "You can save your capital for other investments, and the tariffs are also high on imported technology." Bollineni suggests that implementers look at connectivity, and be realistic-even more basic Internet over phone can be effective, with limitations. Garnering sufficient volumes of revenue is another big challenge for implementers. "For telemedicine programs to go to scale, they have to be able to attract a sufficient volume of business," says Bollineni. In his view, there are two ways to make them economically viable. The first is to obtain government support for expanding infrastructure. The best way to do this is to create bundled shared services that utilize the same infrastructure. He recommends adding on dental services, dermatology and diagnostics to boost revenues, and points to Punjabbased Healthpoint's innovative choice to sell clean water cheaply adjacent to a telemedicine-equipped clinic. How equipped does a clinic have to be to incorporate telemedicine? According to Bollineni, there are many options. Very well connected clinics use broadband with speeds of 512 kb/second, while Integrated Services Digital Network (ISDN) lines are the most preferred connectivity options for practical reasons to connect remote areas which only require a minimum bandwidth of 128 kb/second, costing about 171 Rs/hour (less than $4). VSAT too is a good option although a costlier proposal but provides much faster data transmission than ISDN. Video conferencing requires 256 kb/second ISDN or IP based support. Among those using high-end technology are Apollo Telemedicine Networking Foundation's tele medicine centers an initiative of Apollo Hospitals, the Joint Commission-certified hospital chain that has set up


more than 100 telemedicine centers in India and 10 overseas to boost their business and make follow up visits more convenient. For start-ups with less capital, Bollineni points to tech "hot beds" developing ICT used for telemedicine in South and West India. "Neurosynaptic has an interface box set which can transmit images and data at very low band widths-this seems to working very well," he said. World Health Partners uses the Bangalore-based company's ReMeDi kit. Mumbai-based Maestros has developed Element 6, a portable medical kit for telemedicine. Bollineni also pointed to technology development and incubation centers at Indian Institute of Technology (IIT) Kanpur, IITM's Rural Technology and Business Incubator (RTBI), Centre for Development of Advance Computing (CDAC) centers across India and the School of telemedicine at Sanjay Gandhi Postgraduate Institute of Medical Sciences. Bollineni cautions that the government must continue to play a stewardship role in accelerating this developing sector. More standardization of hardware and software and developing practice guidelines will help program managers implementing telemedicine programs overcome inter-operability, portability and security issues. Bollineni also urges government to implement the ICD 10, an international system of codes that classify symptoms and diseases. With ACCESS, Bollineni is working to build collaborative and co-operative efforts from and among the network providers and the system developers. This April, as part of its work to forge connections between innovators with the Center for Health Market Innovations, ACCESS will be hosting a tele-health roundtable to bring both groups together for dialogue. Contact Bollineni to learn more.


The Healthcare Infrastructure Conundrum
Rob Katz March 4, 2011 — 01:00 pm

The new clinic is opening today. The town council, mayor and other bureaucrats have been summoned. Maybe the state health minister is coming to cut the ribbon. The company promoting the new chain of rural health clinics has sent its CEO, and maybe even its board chair, who has traveled from thousands of miles away in the west. The garlands have been prepared; chairs and a tent have been set up. This is progress. The hospital waiting room is very, very crowded. The nurses and attendants wade through, taking notes and trying to triage patients into wards. The emergency ward is full - it's always full - but maybe some patients can slide into the cardiac ward for today. Or to orthopedics? Where do we have those extra beds? Check the charts - we should be able to figure it out. But the charts aren't done - the residents will fill them only in the afternoon, then we can shift patients accordingly. In the meantime, 14, 25, 30 beds lie empty in various departments while the emergency ward is - always - overcrowded. Of these two fictionalized accounts, which is the reality of healthcare delivery at the BoP? The answer: both are. In the last 15 years, spurred on by the notion of a fortune to be made at the bottom of the pyramid by serving low-income patients, social enterprises and their backers have brought thousands of new clinics,hospitals, franchises and other frontline health infrastructure online. As a sector, we champion these new entrants, and for good reason. They provide high quality services to customers who were previously unable to

afford them, or unable to access them. This new infrastructure combats the poverty penalty and improves lives. But it's not as if the public sector hasn't invested in infrastructure. Urban hospitals, rural clinics, healthworkers - all have been built and financed by developing country governments to the tune of billions of dollars invested. In terms of raw numbers, this far outweighs the amount of impact investment or venture philanthropy that has been pushed into the new infrastructure. But on sites like NextBillion, and in the broader social enterprise community, we rarely talk about the opportunity to improve what's already been built. This could be a critical error. It's far easier to talk about the promise of these new clinics and hospitals, whereas a conversation about what's not working and how to fix it dregs up questions of fault, mismanagement, etc. My argument is simple: some private sector enthusiasm for healthcare could be directed toward management companies - contractors or private service providers - which can apply the tools of business to make this brownfield infrastructure work better, rather than continuing to pour money into high capex businesses building parallel infrastructure. To be sure, it's less sexy and fraught with political and regulatory risk, but it has a tremendous potential that remains untapped. If this post were about roads, then the answer would be clear: If you already have a road between two places, but it's fallen into disrepair, then you fix it - that's the cost-effective solution. Building a brand new road alongside the old one usually does not make sense. For some reason, the same logic does not seem to apply to developing world health infrastructure. At the end of the day, the work we do - and talk about on NextBillion - is about delivering critical goods and services to the poor. The best use of a marginal $1 million investment is actually a critical performance question, and we should ask ourselves: is it cheaper and more effective to fix what's broken, or simply to resign it to the trash heap of history and build anew? Perhaps it's a bit of both. I realize this is a controversial concept, so I welcome thoughts in the comments section below or you can respond via my Twitter account: @robertkatz


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