Advancing Healthcare

With the Base of the Pyramid

A special series by NextBillion.net

February 21-March 4, 2011

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Contents

• 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)

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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 market-
based 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).

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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 low-
income households.

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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.

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(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 full-
time 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).

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(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.

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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!

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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 donation-
funded 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?

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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-of-

pocket 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

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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, SMS-
on 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

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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.

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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

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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.

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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 -

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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.

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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.

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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,

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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 short-
term 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

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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

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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 micro-

consignment 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

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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?

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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

23
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 market-
based 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

24
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 low-
income 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 web-
based 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

25
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 two-
pronged 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

26
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.

27
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.

28
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

29
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,

30
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

31
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.

32
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.

33
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.

34
[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.

35
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.

36
Piramal eSwasthya, Demystifying the Primary Healthcare
Model
Sriram Gutta
February 25, 2011 — 01:00 pm

Kavikrut, of Piramal eSwasthya

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

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.

37
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 co-
founded 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:

38
• 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 45-
60 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

39
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

40
 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.

41
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:

42
• (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 e-
commerce 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

43
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

44
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.”

45
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 BoP-
focused jobs board BabaJobs.com.

Rose Reis, CHMI: Describe your audience and its health needs.

46
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

47
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

48
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.

49
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.

50
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,

51
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.

52
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.

53
• 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

54
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.

55
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, so-
called Information Communication Technology (ICT) is transforming the
way people receive health care.

56
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, cost-
effective, 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.

57
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 Punjab-
based 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

58
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.

59
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

60
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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