Advancing Healthcare With the BoP Series


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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 rural patients - are just a few examples presented in the following pages.

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Advancing Healthcare With the BoP Series

  1. 1. Advancing HealthcareWith the Base of the Pyramid A special series by February 21-March 4, 2011
  2. 2. 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 andtechnology leaps that are making a real and lasting impact in market-based solutions to healthcare delivery. Anything from mobiletechnologies - to new patient financing schemes - to re-consideredbusiness models from major pharmaceutical companies - to overhauls inmedical staffing that reach rural patients - are just a few examplespresented in the following pages.In addition to posts from NextBillion staff writers, the series includesarticles from Ashoka and the Center for Health Market Innovations, bothof which have graciously shared learnings and best practices from fellowsand experts in the field.We hope this series provides insights and inspirations for managing someof the most serious challenges facing healthcare delivery with Base of thePyramid caregivers, vendors and patients.
  3. 3. Advancing Healthcare: Reaching Into Rural Pockets With ASustainable ModelTilak MishraFebruary 21, 2011 — 06:00 amEditors Note: This is the first of several blog posts for NextBillionsAdvancing Healthcare with the BoP series.In recent decades, the public sector has had fair success in improvinghealth in developing countries. As a result, infant, child and maternalmortality have declined; the threat of infectious disease has receded; andlife expectancy has increased in all developing regions. Yet, working inisolation, the public sector faces significant implementation and resourceproblems. More specifically, government-run health programs faceparticular challenges in accessing geographically isolated or otherwisedifficult-to-reach populations, in furnishing sufficient oversight ofprogram administration to avoid corruption, and in ensuring healthsubsidies are directed to people who most need them, such as low-income households.
  4. 4. As a result of these resource constraints and under-performance issuesin government-run programs, a high proportion of health care models,first innovated in developing countries, now are being realized anddelivered by private providers that charge fees for their services. Onesuch model is the Rural Micro Health Centre (RMHC), which is aninnovative nurse-managed, doctor-supervised-clinic (NMDSC) beingpromoted 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 toextend access of high-quality, low-cost primary healthcare services tolow-income households living in remote rural India and who cannotaccess existing healthcare systems.This goal crystallized when qualitative and quantitative researchconducted in remote rural pockets of India assessed health-seekingbehaviours and needs. This research also revealed that low-incomehouseholds spent a larger proportion of their income on health care thanthose with higher incomes.A large percentage of these expenses usually go to either a) paying highinterest rates on health care loans; and / or, b) absorbing cost related totravel and lost work time.
  5. 5. (Above, a doctor shares her experience working in a Sughavazhvu clinic.Image courtesy of ICTPH)The ICTPH-Sughavazhvu Healthcare model tries to address these issuesthrough a community-based technology-leveraged outreach interventionat the village level. In this model, the RMHC is managed by a local full-time graduate nurse, and supported by 13 locally hired and trainedcommunity health workers who are full-time volunteer workers. Theseworkers are reimbursed all their costs and paid a nominal honorarium.While the nurse is responsible for the well-being of about 2,200households, each community health worker serves 200 households (orapproximately 1,000 individuals) and manages the screening, follow-up,intervention implementation and clinical assistance.Analyzing the RMHC model, it becomes clear that there are fourinterrelated design components that seem critical to the successfulrealization of this innovative model that is Indias first attempt to delivermanaged healthcare for remote rural Indian populations throughintensively organizing primary health care delivery. These designcomponents are as follows: (1) human resource design; (2) infrastructuredesign; (3) intervention design and, (4) financing design.As part of the first, the rigorous selection process of the communityhealth workers ensures an optimal skill set; also, an 85 percent timeallocation towards field based activities and 15 percent towards clinicalassistance at the RMHC, under the supervision of the nurse, allows for theproper development of the competencies of the community healthworker.As part of the second, each RMHC is equipped with tools to deliver a)diagnostics (through auto-analyzers that facilitates hematology andblood biochemistry); b) ophthalmic interventions (refractive errors andcataract 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 computerbased decision support system); and, e) pharmacy intervention (a drugdistribution licence for Sughavazhvu Healthcare enables the RHMC tostock medicines necessary to fill basic prescriptions recommended by thenurse/doctor).
  6. 6. (Above: A Rural Micro Health Center).As part of the third design, curative interventions envisioned at the RMHCare standardized evidence-based primary care curative protocols, basedon the SOAP (Subjective Objective Assessment Plan) methodology,evolved in partnership with the School of Nursing at the University ofPennsylvania. A Health Management Information System (HMIS) helpsimplement the SOAP methodology for primary care visit, as well asfacilitates the supply chain management of drugs from a centralized drugcentre. The HMIS is also used by the nurse at the RMHC to ensure rationaldrug usage through strict compliance of National Essential DrugGuidelines. Lastly, the HMIS also is used for medical insurance, patientreferral 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 showpromise of shrinking the deficit between low income households abilityto pay and the cost of primary health care. These interventions, alongwith other indirect non-health means, will need to be deployed if thelow-income households are to successfully access all the primary healthcare they need.
  7. 7. The for-profit private sector is a major player in the health care arena innearly all countries. Individuals- both rich and low-income households -are willing to pay for many health services, which stimulates privateprovision of health care. As in any market, there is competition based onprice, and there may also be competition based on quality or othercharacteristics of providers. And for market-based healthcare modeltargeted at low income households to succeed, it is imperative thatquality remain high and costs are kept low as possible. Models such asthe ICTPH-Sughavazhvu Healthcare led RMHC are out there trying to doexactly that. Theyre innovating, and in the process, bringing forwardsolutions to satisfy human needs profitably and creating wealth for thecompany and the community it serves!
  8. 8. Healthcare With the BoP Series: Staying Out of the MedicalPoverty Trap In PakistanRose ReisFebruary 21, 2011 — 01:00 pmDr. Sania Nishtar, founder of HeartfileEditors Note: This post is part of the NextBillion series, AdvancingHealthcare With the BoP. The Center for Health MarketInnovations and Ashoka are both contributors to the series.An adolescent golf champion who grew up to be Pakistans first femalecardiologist, Dr. Sania Nishtar wields influence in forums from the WorldHealth Organization to the Clinton Global Initiative. Recently,through Heartfile, the NGO she founded, she has honed in on one criticalbarrier to health delivery for the poor: serious shortfalls in financing.According to Nishtar, Pakistans social funds for the poor have a verysmall envelope and suffer from a number of deficiencies, including abuseand patronage in targeting, unpredictability of coverage and lack oftransparency. Initiated in 2009, Heartfile Health Financing is a donation-funded program supported by a web-accessible financing platform. Theidea is to enable the poor - the true poor, not those seeking to siphon offfunds intended for the poor - to rapidly get access to health serviceswithout being pushed further into poverty. Heartfiles system allowsdonors to target the poor, but the same mechanism could help otherparties, for instance, transparently distribute a countrys social securityfunds. A CHMI profile can be found here.
  9. 9. Rose Reis, CHMI: The Center for Health Market Innovations documentsprograms that develop an innovation to improve their health marketplace.How does Heartfile do this?Sania Nishtar: The most glaring market failure Heartfile addresses ishealth inequities. Healthcare runs on market principles in countries likeours and it creates two levels of care: That for the poor, and that for therich. The other market failure is abuse; Heartfile Health Financing hasbuilt 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 forhigh-cost treatment. They spend catastrophically, become indebted andthis pushes them into the medical-poverty trap. Many also foregotreatment. Statistics show that healthcare costs are the most commoncause of economic shocks by households.Reis: What about the state social security fund?Nishtar: Government prioritizes primary healthcare. There are limitedwindows 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 purposeis small. It is additionally, unpredictable, since government contributionstend to fall during a funding crunch. And it is all paper based - there is alot 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 needto know the channels. The elderly, marginalized, and the poorest of thepoor dont have the means of accessing the system. Many cannot pay fortransportation to visit offices or understand how to process thepaperwork. The system is paper based and involves lots of delays. It hasin the past taken weeks to months to process the application. Ifsomeone needs, say, coronary artery surgery, and they wait weeks, theyrun the risk of losing their lives. We step in with very quick turnover -ours is less than 72 hours. Additionally, our system guards againstabuse, leakage of funds to the non-poor and other inclusion andexclusion errors.Reis: Given the tendency for misuse of funds for the poor, how do youknow a person requesting funding from Heartfile is actually poor?
  10. 10. Nishtar: We really make sure those who can afford do not accessHeartfiles pool of funds. Status of poverty is verified though a compositemeasure. The doctors impressions about the patient being poor counts.Then our volunteers conduct an interview on site with the patient. Theseare retired people, well-to-do with an honorable presence in society andacceptability in hospital. Volunteers conduct a tele-assessment,connecting via a laptop with trained staff in office. Phone calls are madeto friends, neighbors and family members for validation as well. The finalstep is validation using the patients unique identification number to anational database where all citizens are registered; we identify thosebelow the poverty line.Reis: What is the technology platform Heartfile runs on?Nishtar: It is software custom designed for us and maintained byspecialist vendor. We found them through a competitive bidding process.When we were conceptually designing the system we talked to severalintended users: hospital administrators, community group, volunteers,and the core team at our office. Lots of things got modified throughevaluation and formative insights.Reis: How do users interface with it - through mobile phones, desktopcomputers, smartphones?Nishtar: Patients in need/attending doctors in pre-registered hospitalscan send requests for assistance through multiple channels. Ideally, SMS-on template and web interface, but also through fax, telephone, andletter. We give these choices in order to facilitate interaction of users withthe system. Heartfiles Health Equity Fund, maintained by philanthropiccontributions, supports eligible cases.Reis: What funding do patients access through Heartfile?Nishtar: We created the health equity fund with a grant from theRockefeller Foundation and added the proceeds from my book.Corporations and individual philanthropists also contribute. I tell themthis is a mechanism to target your resources very transparently. Thesystem grants the highest possible level of transparency so that funds areutilized as per the criteria defined by the donor. Capacity to updatedonors on a micro-transaction basis is an innovation by internationalstandards. Donors can track every penny that they give. There is a strongculture of philanthropy in Pakistan, but it was not structurally harnesseduntil now. We hope to be able to make headway in that direction.Reis: Where is this pilot based?
  11. 11. Nishtar: We are working in three hospitals now in Islamabad andRawalpindi-there are five tertiary-level hospitals in these cities that wewill cover this year. We are enrolling patients ward by ward. We startedwith 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 technologyinfrastructure with scale-up as a main consideration. Pakistanstelecommunications infrastructure allows deployment even in remoteareas. The telemedicine-for-assessments and mHealth features will allowscale up with lean operational costs and without need for extensive fieldoperations. My sense is this is also a very good model for other countrieswith people in informal sector and pervasive poverty.Read more about how the fund-tracking website works here and readabout patients treated with Heartfile financing here.
  12. 12. Healthcare Series: Combining Facilities and MobileInnovations to Deliver Better CareChloe FeinbergFebruary 22, 2011 — 08:15 amEditors Note: This post is part of the NextBillion series, AdvancingHealthcare With the BoP. Ashoka and The Center for Health MarketInnovations are both contributors to the series.As this series is showing, the challenges of delivering healthcare arebeing met by extremely innovative ideas, programs and technologies.There is no doubt that there is a plethora of technologies available toaddress many pressing healthcare delivery issues - from electronic healthrecords, to telemedicine, to novel low-cost diagnostics, to innovations insupply chain and distribution, to the many mobile health devices and
  13. 13. applications that are in use around the world today. Training ofcommunity health workers, evaluation of health outcomes, data drivingboth disease surveillance and information for better care - innovationexists in these areas, some including technology and others not. Theinnovations that leave the greatest impression on me, however, are thosethat tackle healthcare delivery at the system level. Different technologiesand innovations in process working together to address healthcaredelivery across multiple aspects of the system is where I believe the realpower resides.Working at Ashoka, with Al Hammond, the co-founder of HealthpointServices, most of my experience is at the healthcare facility level,especially when it comes to innovations in rural healthcare delivery, aspace where Healthpoint and many other players work. Innovations infacility-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, avery important part). Over the past year, I have become increasinglyfamiliar with new mobile health tools that are often not a healthcaredelivery 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 andfacility-based care over there. It is often assumed they both depend oneach other, but that dependence is not always addressed directly.Working with Healthpoint Services, a strategic decision was made not tofocus on mhealth tools at the beginning. The focus was to work on thefacility-based delivery system including the telemedicine, electric healthsystem (EHR), pharmacy, community health workers, diagnostics andwater purification. Now, after 1.5 years of operating, we are making aconcerted effort to pilot different mhealth tools, to see which work best,and design the process so that the mhealth systems harmonize with thefacility system. Together, they will strengthen each other and increase theopportunities for Healthpoint Services to deliver healthcare.The Healthpoint model has been written about at length here onNextbillion before (here, here, and here, to name a few), so lets exploresome of the mhealth innovations I am most excited about, keeping inmind that these tools, in my opinion, are optimized when linked with afacility that can incorporate them into their model.Sensaris SensePack - The idea of combining diagnostics in a smallpackage has been discussed many times before, but this system isdifferent. 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
  14. 14. phone, enabling patient test results and other data to be sent across thephone network and added easily to electronic health records.The system can send data in batches or one case at a time to a clinic orother healthcare facility - or store the data if cell service is poor.Importantly, the tools are truly simple to use. Healthworkers using theSensPack dont need sophisticated medical training or even high levels ofliteracy, and the testing is practically foolproof.Community health workers equipped with SensPacks - like thoseemployed by Healthpoint Services - can bring health education to lastmile, conducting diagnostic screenings and sharing data seamlessly withHealthpont facilities. Adding mobile health applications and tools to analready existing health infrastructure like the Healthpoint Services clinicscreates a reinforcing relationship between two different types of access tohealthcare education and services. New sensors and modules - toaddress the needs of pregnant women and issues of malnutrition as wellas others - are also in development.Fio Corporations GenZero - Where point-of-care diagnosis of infectiousdiseases 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 trainedhealthcare workers in optimal controlled environments. However inpractice, sub-optimal conditions can negatively impact RDT accuracy andusefulness. Inadequate training, poor lighting, and fatigue lead to humanerrors in processing, reading, and capturing data from RDTs. The resultis frequent misdiagnosis and poor quality epidemiologic data. FioCorporation, based in Toronto, Canada, has developed GenZero; arugged, portable universal reader of existing RDTs. A user places an RDTinto GenZero, which digitally analyzes the RDT at the optimal time underoptimal lighting conditions and delivers an objective diagnostic result -
  15. 15. eliminating most sources of human error.GenZero leverages ubiquitous mobile phone infrastructure and GooglesAndroid operating system to combine diagnostic results with patientdemographic data capable of being transmitted for aggregation. GenZerocurrently reads malaria RDTs, soon to be followed by HIV, Syphilis, andother infectious disease RDTs. The application of this tool is clear: healthworkers who want to test for infectious diseases, at the last mile, but whomay have limited training or are working in areas where the margin ofhuman error is high, can benefit from these tools. Given the rate ofmisdiagnosis and overtreatment of certain diseases, these tools will notonly increase the ability to provide evidence-based care, but also willhelp save resources and make sure they are used where needed.The West Wireless Health Institutes Sense4Baby platform is anothermobile tool that will increase the ability of facilities like those ofHealthpoint Services to provide maternal health services efficiently andeffectively.
  16. 16. Imagine what happens when a community health worker is alerted to apregnancy in the community? The health worker provides the Sense4Babytechnology to the expectant mother allowing obstetric monitoring to beprovided at a distance. Basic training and understanding of the deviceand its use can create a bridge between the facility and the patient,providing greater opportunities to provide and receive care. TheSense4Baby prototype will be a main component of the "WirelessPregnancy Remote Monitoring Kit," which was developed by West WirelessHealth Institute, Qualcomm and the Carlos Slim Foundation. The kit isnow being tested with community health workers in Mexico.
  17. 17. Healthcare Series: Integrated Healthcare for the BoP, theRole of Enterprise, GovernmentNext BillionFebruary 22, 2011 — 05:30 pm Jonathan KalanEditors Note: This post is part of the NextBillion series, AdvancingHealthcare With the BoP. This post was written by Heather Esper andand Lisa Smith.Healthcare delivery continues to be a focus for governments as well asBoP organizations given the numerous gaps in providing services andproducts to the BoP. Living Goods is an example of one organizationworking to improve healthcare delivery for the BoP in a sustainablemanner.Living Goods, a social enterprise with more than 600 independent salesagents, uses micro-franchising to distribute products door-to-door inthe developing world. Its focused on a critical and often over-lookedissue at the base of the pyramid: access. Living Goods sells its productsat prices affordable to the poor - typically between 10-30 percent belowretail. The high cost of transportation, frequent product stock outs,
  18. 18. inadequate quality control and inefficient distribution systems all preventthe poor from accessing affordable health products that can dramaticallyimprove their lives. The global market is saturated with products that cansave and change the lives of those living at the base of the pyramid. Butthese products do little good if they dont reach a significant proportionof the people for which theyre designed. This is the gap Living Goodsaims to fill by building an efficient, scalable, and sustainable system fordelivering products designed to fight poverty and disease in thedeveloping world.The Role of GovernmentAt last years Net Impact Conference, Molly Christiansen, Manager ofHealth Practices and Business Development at Living Goods; and StevenChapman, Senior Vice President and Chief Technical Officer at PopulationServices International; spoke about the importance of creatingsustainable, reliable systems for health product delivery. Their discussionof health care delivery focused on several main themes, including qualitycontrol, health communication and public-private sector partnerships.They discussed these themes under the pretense of creating integratedsolutions for health care delivery.They suggested that delivery is currently fragmented due in part to theinherent differences in enterprises and businesses providing qualityhealth goods through a fee-for-product model. They went on to explainhow this model might conflict with government entities providing short-term health fixes for free and then potentially running out of equipmentand supplies quickly. The speakers suggested that aligning the servicesprovided by government groups with enterprise models improves healthcare 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 withnon-profits like Living Goods creates an opportunity for qualityimprovement mechanisms to be set in place. Government groups canhelp create a performance-based financing space where organizationspropose health care distribution models using business strategies, and inthe process, commit themselves to certain performance metrics tied to
  19. 19. funding. These metrics might measure elements of the enterprise modellike the general distribution of health goods or the economicimprovements for community health workers (i.e., increases in income).For example, in Rwanda, mayors meet with the president regularly andpresent the number of outputs they plan to deliver. At the end of theyear, they are graded on their deliverables. Rwanda has found thataccountability to follow through on commitments has increased andimproved performance drastically as a result of the change in fundingmodel. Individuals are no longer funded based on their promises toperform certain tasks, rather their funding is tied to the actualperformance. As a final note, we might suggest that it is additionallyimportant that governments require performance metrics totrack both outputs and outcomes.As seen with Mexicos roll-out of universal health care, stategovernments were given funding based on the number of people thatenrolled (an output), rather than changes in those individuals health (anoutcome). As a result, the biggest criticism of the universal healthcareplan is that there is not accountability for how state governments spendthe money.Beyond performance-based government support there is also discussionin many healthcare circles of the opportunity for the government tobecome 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 ofhealth care products can in turn consolidate redundancies in services andensure consumers are getting the best products available. However, moreresearch needs to be done on this type of government involvementparticularly within countries with stability and/or more systemiccorruption to determine effectiveness.The accountability suggested in the performance-based financing modelabove also creates an opportunity for innovation that might bolsterperformance. This might mean using mobile technologies to trackinventory and report sales of products; thereby improving availability ofmore products to sales representatives (i.e., community health workers inthe Living Goods model). This also might mean improving technologies tobetter serve particular populations with specific health needs. Forinstance, using mobile health technology, a community health worker(CHW) may receive information on prenatal health care over text messageand provide this information to pregnant customers coupled with theirsales of nutritional supplements and vitamins. The integration of healthinformation and effective health communication with sales of healthproducts improves health delivery efforts two-fold: improving the efficacy
  20. 20. of the product through appropriate and consistent use, and whileeducating a population on prevention and future health care practices.Furthermore, in some instances, mobile technology has the ability toincrease reach as behavioral change messages no longer need to takeplace person-to-person such as with Johnson & Johnsonstext forhealth platform.Marketing SolutionsOutside of the opportunities identified through this discussion, severalchallenges were acknowledged.Organizations still appear to struggle with effectively marketinginnovative product packages or portfolios to the BoP. Living Goodsmarkets its products in part by asking CHWs to use the productsthemselves as well as share the benefits with neighbors. Otherorganizations such as E Health Point try to integrate more products andservices together, offering access to clean water coupled with healthcare,for instance.Likewise, transportation and location can be a challenge for distributionof health goods. Living Goods sells its products at the doorstep of thepoor, which saves customers transport costs that can easy eclipse theproduct price alone. PATH, another leading global health organization,has developed needle-free injections, which reduce distributionchallenges by decreasing the demand on transportation via the coldchain. Still, other organizations are experimenting with task-shifting inorder to move skills to health workers with minimal training, or designingways to get around transportation limitations so users dont have to go toa 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 asways to introduce more expensive products and larger product portfoliosto the BoP. Micro-consignment models involve offering products toentrepreneurs without charging them for the cost of the product up front.The seller pays for the product once theyve sold the product. However,distribution and marketing will likely continue to be challenges forenterprises seeking to deliver healthcare for the BoP and an opportunityfor further innovation, so stay tuned for some unique solutions.Questions to ConsiderGiven that universal healthcare coverage is difficult to obtain, there willalways be opportunities to improve health care delivery. As governments
  21. 21. continue to play financing and regulatory roles, enterprises will continueto 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 indelivery.As always, it will be interesting to see the innovation that enterprises willbring to delivering healthcare for the BoP. We realize this discussion ongovernment and enterprise accountability only addresses the tip of theiceberg of current opportunities and challenges. The following are someof the questions we plan to research moving forward, and would love tohear 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 arent working well?How do you feel the challenges (marketing mechanisms, cost sharingmodels, and transportation and distribution models) can be addressed?How is the role of government and enterprises different in the healthcarecontext than in other contexts in which BoP ventures operate?How, if at all, do you think closer relationships due to ties to fundingbetween governments and enterprises will affect BoP models?How are funding relationships brokered particularly within countries withsystemic corruption? Are they pursued?
  22. 22. Advancing Healthcare With the BoP: To Emerging Marketsand Back AgainJosh ClevelandFebruary 23, 2011 — 09:00 am Pfizer and partner Vodafone launched "SMS for Health" International Health PartnersThis is part one of two in a set of articles on reaching BoP markets withhealthcare innovations. This article addresses the perspective of severalmultinational corporations while the subsequent piece will present theperspective from a social enterprise start-up.If your company has a great healthcare innovation that can treat scores ofpoor people, how do you get it to market?How can an organization spread the drastic advancements in biologicalstrip 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 atthe BoP. Those with adequate training either cant buy or dont want tobuy products that can drastically increase ability to cure or prevent
  23. 23. disease, or dont want to live in rural areas where many patients arelocated. How do you reach the people who need healthcare products andservices?And how (if at all) does innovation move the other way - from the BoP todeveloped markets?Over the past month I spoke with leaders in BoP healthcare from globalhealth specialists to global pharmaceutical companies, from huge techfirms to nonprofit start-ups. Ive aggregated many of the perspectives onchannels to market and technology flows that we discussed in thoseconversations 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 pleasecheck out the excellent work from my NextBillioncolleagues here and here.)This article is not meant to be comprehensive - there is far too muchactivity in BoP healthcare to attempt that in one post. Rather, Ivepresented a couple of the case studies from these conversations belowwhere youll find some guidance from leaders in the field on movinginnovations from one realm to another.From New York to Accra and BanjulWhat happens when a large U.S.-based multinational company wants toget a product to market in the BoP? For Pfizer and GE, the approach istwo-fold: part market-based and part philanthropic but both closelylinked to market objectives of the firms.Its a long way from Pfizers headquarters in New York City to Ghanawhere the company has targeted anti-malaria efforts as part ofthe Mobilize Against Malariaphilanthropic program. The program trainsLicensed Chemical Sellers (LCSs) - small retail outlets for medicine andother goods - throughout Ghana to diagnose and treat malaria withArtemisinin-based Combination Therapy (ACT) or refer patients to
  24. 24. hospitals for more severe cases. Atiya Ali, a senior program officer inPfizers Corporate Responsibility department told me that when Pfizerbegan the program in 2007, LCSs provided correct diagnosis andprescriptions in only 14 percent of cases involving malaria. After theirtraining with Pfizers partners, Family Health International and GhanaSocial Marketing Foundation, the average skyrocketed to 72 percent,helping Pfizer get its products to those who need them most. Unlikethe CareShops Ghana experiment, the LCSs that Pfizer partners with arenot obligated to use Pfizer as a sole provider of drugs. Pfizer builds ontheir core healthcare expertise by relying heavily on their Global HealthFellows program for employee-led field support for the Mobilize AgainstMalaria program.Ali manages several of Pfizers philanthropic investments, which helpbuild the companys value by opening long-term opportunities and givesthem a foundation for expanding operations in emerging markets. Toprovide the market-based perspective, I asked Martina Flammer, abusiness lead from the Global Access Team, a relatively new commercialunit within Pfizers Emerging Markets Business Unit, to provide theirapproach. 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 unflatteringhistory of upselling customers on brand-name drugs as a backdrop, I waspleasantly surprised by their innovative approaches.Last year, riding the wave of SMS breakthroughs in internationaldevelopment, Pfizers Global Access Team, in partnership with Vodafone,launched a pilot initiative called "SMS for Health" in The Gambia, designedto use text messaging to manage pharmaceutical supply in healthcarefacilities, reduce stock-outs, and ultimately improve the availability ofmedicine to patients. Dispensary assistants, nurses and store managersthroughout the supply chain have been trained to use a simple codingsystem to text the stock levels and expiry dates for 20 medications andthe rate of 10 pre-specified diseases to a central database, where theinformation is then analyzed on a weekly basis and compiled into web-based reports. The disease and medicine spectrum includes high-priorityhealth areas, such as the rate of malaria, pneumonia, maternal death andanti-infective and malaria treatments. By tracking pre-specified healthevent data, disease rates and treatment types, SMS for Health helpscapture trend information that can be used to predict the seasonalvariation in the rate of disease, enabling appropriate medicine stocks tobe procured and distributed in time so that patients can get thosemedicines when they visit their local healthcare facility. If store managersand healthcare providers complete their updates within the agreedtimeframe, they receive free usage of mobile services. Vodafones Health
  25. 25. Solutions unit provides the required SMS technology to the partnership.The project is supported heavily by the Gambian Ministry of Health andSocial Welfare. And Pfizer and Vodafone are investigating replicating themodel elsewhere in Africa.The partnership spans multiple public, private, and NGO entities. Bothphilanthropic and profit-driven programs rely heavily on Pfizers corecompetencies. And the outcome so far is a win-win-win situation:healthcare facilities better manage supplies, the ministry of healthgathers valuable data on disease trends and is able to more effective treatthose diseases, and Pfizer get more product out efficiently to those whoneed it.From Fairfield, Connecticut to Phnom PenhKrista Bauer, Director of Global Programs at GE, outlined a similar two-pronged market-based and philanthropic approach to getting healthcareinnovations from GE to the BoP. Krista describes GEs main developmentfocus as "building infrastructure and upgrading technical capabilities atgovernment hospitals and rural clinics." Initially, GEs philanthropic armidentifies a target country and then develops deep partnerships with theMinistry of Health. Thereafter, managers work together to identify thebest technology solutions for the target healthcare provider. Through apartnership with Engineering World Health, GE trains local healthemployees to maintain and repair the technology. Meanwhile, thecompany reaps benefits in the form of design feedback, brandrecognition, and reputational boosts.Bauer notes that their efforts in developing countries have raised theprofile of BoP markets as viable consumer bases throughout thecompany, an area that the company is actively pursuing. The recentlyannounced partnership with Embracecame about through their newmarket initiatives unit in part as a result of the success of GEsphilanthropic programs.Like Pfizers approach to global health challenges, GEs relies on the corecapacities of the company in technology provision, uses partnerships withexisting networks wherever possible (Engineering World Health,ministries of health, and others), and pursues a separate butcomplimentary for-profit and philanthropic strategies.... And back againNow that weve covered a couple of models for moving healthcareinnovations to the BoP, what about moving ideas and technologies theother way: upstream to developed markets? A recent McKinsey
  26. 26. report notes that the necessity for innovation and fewer constraints facedby entrepreneurs exploring healthcare solutions in developing economiesmeans that: "They can bypass Western models and forge new solutions."Yet as the Economist reminds us, the actual tech transfer is a bitcomplicated. Regulations get in the way, consumers in the U.S. have littleincentive to lower healthcare costs in the first place, and theorganizations that need to adapt the innovations are bureaucraticbehemoths. Things thus move quite slowly.But that doesnt mean that its not happening. "Our work in Cambodiaproviding technologies to government hospitals and rural clinics hastaught us a lot about how products work - or dont work - in the field,"says GEs Krista Bauer. Product innovation and insight is often cited as aninnovation that moves upstream from developing to developed markets.But many believe that the real potential lies in the workflow innovationsthat dont require the same level of regulatory scrutiny to implement.Youll hear more about these workflow innovations in this series onNextBillion. And it shouldnt take a rocket scientist to figure out why itmight be good to apply the proven methodologies in developedcountries.A bright futureOverall, healthcare at the BoP provides a fertile ground for optimism.Cross-border, cross-sector, cross-functional partnerships in this sectorat the BoP are common. For-profit and nonprofit solutions are becomingmore viable. Innovation flows are becoming more substantial in bothdirections. No, we havent eradicated malaria yet and yes, we are stillwaiting on a cure for polio. Many programs are still "pilots" and start-upsolutions have certainly not yet scaled. GE and Pfizer both pursue someforms of BoP engagement as philanthropic activities for a reason. I wontargue that the attempts presented in this article are anywhere nearperfect 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 thebiggest health issues in both developing and developed countries today.
  27. 27. Learning From Narayana’s Lean Model to Scale ServicesRishabh KaulFebruary 23, 2011 — 02:45 pm Narayana HrudayalayaSo really, the healthcare problem of India as I see it is in its volume. Ofcourse there are hundreds of other problems that are beyond the scopeof this blog post, but the sheer volume of patients who requireimmediate treatment is a critical and daunting challenge. Our hospitalsare small and hence the cost of treatment is exorbitant. The governmenthospitals are either ill-equipped or dont have enough beds. The burdenof quality health care is then passed on over to the private sector.One such sector that needs immediate attention is heart care. Heartoperations by their very nature are one of the most expensive operationsin medical care and require incredibly well-trained staff. The privatehospitals charge a fortune and work at a slow pace. There is clearlysupply demand gap here.And this also means there is a tremendous opportunity.
  28. 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 inBangalore.And since then the results have been phenomenal. Narayana currentlyperforms more number of heart surgeries than most hospitals in theworld and is the highest in India by a huge margin. The mortality ratehere is lower than the best hospitals in New York. Backed by majorinvestors such as JP Morgan and AIG (who own 25 percent of the hospitalgroup), the Narayana hospital in Bangalore and Kolkata are responsiblefor more than 12 percent of Indias heart surgeries.(Above: Dr. Shetty. Image courtesy of Narayana Hrudayalaya)Dr. Shetty has been hailed as the Henry Ford of Heart care primarily dueto this factory-style approach to heart care. However, a Toyota analogywould 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 dont do anyadministrative work and concentrate solely on surgeries) using theeconomies of scale to bring down the costs. This translates into a finalcost which is nearly 40 percent of (turn to the appendix of page 20 for
  29. 29. the entire tiered costing structure, data is from 2008) other privatehospitals.Narayana has worked hard to drive down its per unit costs. Heres how itdid it:Salaries of doctorsInstead of paying the doctor per surgery, which tends to be veryexpensive Dr Shetty pays his doctors competitive fixed salaries (seniordoctors receive anywhere between 100,000-250,000 USD) and thenurges them to increase the number of surgeries per day. This helps bringdown the cost per surgery.Volumes-Extremely high volumes. This is one of the major reasons why they areable to cross subsidize the costs of so many of their patients (about 80percent -plus receive some form of discount or other). The internationalcell ensures that there is a huge inflow of international medical touristsfor whom the price arbitrage works out well.-Because of increased number of shifts and higher number of specializeddoctors, the operation theater is utilized for longer hours contributing tohigh volumes.More value per buckDevi Shetty boasts about the tight monitoring that takes place, be it tooversee that their cost effective hospital designs are properly constructed(more on this later in the post) or that they procure their supplies at afrugal cost without compromising on quality. NH has very strongpurchasing power for medical supplies due to its massive patientvolumes. Innovations here include abolishing long-term contracts infavor of negotiating contracts on a weekly basis, and taking expensivemedical equipment on lease rather than purchasing it.PartnershipsThe hospital has major partnerships with the private and public sectororganizations. Biocon Foundation set up a generic drug shop where itsells drugs 20 to 30 percent cheaper to its members. Lots ofmicroinsurance schemes with the Government of Karnataka (Yeshasvini)and Tamil Nadu etc., which work on flexible payments, have helpedthousands coming from low-income groups to procure NHs services.Apart from this, the hospital thrives on innovation-based partnerships,
  30. 30. such as the one with Texas Instruments. NH and Texas Instruments tiedup to drive down the cost of equipments such as X-Ray plates (the costwas brought down from 82000 USD to 300 USD).Emphasis on Tier 2 CitiesSenior management at NH explained to me that ultimately NarayanaHrudayalayas aim is to penetrate fully into the growing tier 2 cities (forexample Jaipur) and beyond. Getting doctors to operate here will bemainly through goodwill on their part, creating clusters of hospitalswhere patients from one can be referred to another.What are the challenges?I figured with such an elaborate and aggressive plan on setting up moreand more hospitals, NH would in the future face heavy shortage in humanresources. During a chat with one of the VPs of the institute, he agreedthat was a major concern but the recent move by the health ministry toestablish new medical colleges (a 300 Million USD project) is one majorreason why hes keeping his hopes high. He also disclosed that managingthe nursing talent is a bigger issue since their attrition rates tend to behigher.Marketing is another vertical they plan to ramp up. So far most ofmarketing has been via community events, word of mouth and theofficials agree that with expansion plans in place, the marketing of NHsservices has to sync up.Another key challenge for NH is the standardization of their processgiven that in the next few years there are going to be thousands ofNarayana Clinics and Hospitals. For an organization such as NarayanaHrudayalaya, its all about the processes.Whats next?Clearly bringing down the costs is always the first agenda. Dr. Shetty isinvesting a lot in innovative practices that always thrive to bring down thecost of surgeries. He is advising other countries to adopt his model.While it started as a heart facility, Narayana Hrudayalaya is nowexpanding into various other medical branches. They have big plansahead to tackle cancer. In 2009 they opened a 1,400 bed cancer facility inBangalore thanks to a generous grant of around 9 million USD by Bioconhead Kiran Mazumdar Shaw). They also have plans on having 500 newkidney care clinics. These kidney care clinics through donors and
  31. 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 asIndia where everything is larger than life, he believes that every initiativeof his needs to be massive and affordable. This is what drives theirinnovation and what helps them bring down the costs.
  32. 32. Advancing Healthcare With the BoP Series: Dial 104 forHealthRose ReisFebruary 24, 2011 — 08:30 am104 Advice, run by the Health Management Research InstituteEditors Note (Correction): An earlier version of this blog incorrectlystated the terms of a memorandum of understanding between the stateand HMRI. According to HMRI, the MOU signed in February 2009stipulated that the data generated in the implementation of the HMRIscheme is the property of Andhra Pradesh. HMRI could not and has notshared the data with any other entity.Editors Note: This post is part of the NextBillion series, AdvancingHealthcare With the BoP. The Center for Health MarketInnovations and Ashoka are both contributors to the series.A housewife in rural Andhra Pradesh (AP), India has persistent lower backpain. Like 86 percent of other villages in AP, hers lies more than 3kilometers from the nearest hospital and she has no vehicle or time totravel by bus. Before 2007, she would, like most rural residents, beresigned to seeing a local, untrained doctor when her pain worsened.Today, she simply dials 104 from her mobile phone. 104 Advice, run bythe Health Management Research Institute (HMRI), is a 24x7 toll-freehealth helpline providing standardized medical information, advice andcounseling that receives about 50,000 calls each day. Paid for by herstate government, the service uses a database with 400 algorithms and165 disease summaries to answer her questions about the pain and, ifnecessary, recommend a nearby specialist to help resolve her condition.HMRI is one of nearly 700 health programs documented on the Center forHealth Market Innovations (CHMI)s interactive web Through a global network of partners,CHMI collects information on innovative programs in more than 100
  33. 33. countries. Using this information, CHMI identifies and analyzes emerging,innovative models that could be scaled-up or adapted in other countries.CHMI works to better understand which emerging program models trulyhave the potential to improve health and financial protection for the poor.In this focus on call centers, I asked Vijay Reddy, a governmentcontracting specialist who has been following the developments at HMRIsince its incubation at ACCESS Health International, CHMIs 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 technologyand operational processes to improve access to care for 80 million peopleacross the state. About 50 percetn of the calls come from small villageswith no permanent medical facilities or staff.Reis: How did the 104 for Advice start out? Was it always intended to beso large?Reddy: It took about four years to reach this stage in which HMRI receivesup to 50,000 calls per day. After a pilot, government launched 104 acrossAP in 2007.Reis: How was HMRI selected?Reddy: Satyam Computer Services Ltd has been technology partner forEmergency Management & Research Institute (EMRI), which the people inAP came to trust in a lot. Similarly, HMRI was established with SatyamComputer providing technology. Now that a model exists, most otherstates are taking up this model to launch through a competitive,transparent bidding process. This can be controversial. Some feel thelowest bidder might not be the right bidder. In Bhutan, governmentselected not the lowest bidder but a bidder who can transitionmanagement of the call center system to locals. Bhutan was looking atdeveloping competency within the country, so very specifically they putout a call for an organization to take up the initiative, continue it for
  34. 34. several months and hand it over to an organization internal to Bhutan.[Hyderabad-based tech company] Procreate has contracted to start up themodel in Bhutan and it will be implemented any day.Reis: What is the financing model for this model? Does it differ from stateto state?Reddy: Government of Andhra Pradesh pays 95 percent of costs and thepresent private partner, Piramal Health Group, covers the remaining 5percent. I think there is a strong case that the model could only scale soquickly and be sustained in a public-private partnership with technologyenabling things to become very simple to implement. If you look atthe 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] Delhis government isconsidering setting a user fee for the service, but the cost of collectingthe 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 rupeesper transaction.Reis: How does this health advice line benefit peoples lives?Reddy: Many people in rural areas have no access to trained healthproviders. They have no way of judging if their vague health complaint issomething serious. They call 104, give their complaint, and trainedcounselors classify their condition into critical, serious or stable. Theyprovide medical advice as well as counseling on a wide span of issues,from depression to HIV.104 provides ready information about healthcare facilities in thegovernment sector and enables easy access. In Delhi, patients will be ableto make appointments at public and private facilities by calling 104.Hospitals paying for part of the implementation will be able list theiravailability 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 throughpublic private partnership they can be scaled up to most parts of thecountry to reach people in a scattered geography where there issignificant shortage of healthcare professionals in a very short time.I expect these initiatives to create tremendous impact and lessons for thefuture. It is essential to have transparency and accountability in contractmanagement to achieve an expected outcome.
  35. 35. This partnership attempts to combine the capabilities of public sectorwith those of the private sector-and overcome weaknesses in bothsectors. Governments robust and dynamic structure sets them as anenabler with high ownership, safeguarding consumer and public interestsapart from commercial interests with a transparent and well-conceivedcontract.Read more about HMRI, then check out more than 120 otherprograms using ICT to make health processes more efficient (thusaffordable) for the poor.
  36. 36. Piramal eSwasthya, Demystifying the Primary HealthcareModelSriram GuttaFebruary 25, 2011 — 01:00 pm Kavikrut, of Piramal eSwasthyaEditors Note: This is the first of two posts on Piramal eSwasthya as partof NextBillions Advancing Healthcare With the BoP series.Since its inception in 2008, Piramal Groups (parent company PiramalHealthcare) initiative Piramal eSwasthya has worked to "democratizehealthcare" through scalable and sustainable breakthrough healthcaredelivery models. During the past three years, eSwasthya hasexperimented with several innovative approaches to delivering healthcareusing telemedicine, clinical decision support systems and village-basedhealth entrepreneurs. The model has been developed in partnership withHarvard Business School Professor Nitin Nohria and is specifically tailoredto serve the grossly underserved populations in the remotest of ruralareas.
  37. 37. Kavikrut currently heads the Piramal eSwasthya. Having spent the last fiveyears in base of the pyramid (BoP) healthcare he has immense knowledgeabout 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: Its not often that we find someone with abackground 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 MobileMedics five years ago. This wasnt a planned career move and happenedby chance. Lack of existing solutions, a grave challenge, a good businessplan, and a seed fund led me to take the plunge. I spent about 2 years atMobile Medics where we treated 2,000 patients across 12 villages. Thiswas a legacy model that had been tried earlier, although in a non-profitstructure. A mobile van with a doctor, nurse and drugs visited a fewvillages each day to treat the patients. Every village was covered twice aweek on a pre-defined day and time. This model was built to providehealthcare 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. Intraditional models, a doctor could treat up to a 100 patients per day. Wewere looking for a way to increase this dramatically. While Mobile Medicswas looking for funding to further experiment with other delivery models,we met the Piramal Group and saw synergies leading to the absorption ofthe Mobile Medics team to start Piramal eSwasthya. Their structured,well-funded and resourceful model provided a rather conduciveenvironment to design and test more radical healthcare delivery models.NextBillion: Whats unique about the model?Kavikrut: Our model allows each doctor to diagnose over 400 patientsper day spread across 100 villages. The doctors task has beendecentralized and he now does what is core to his expertise, while theother steps in the treatment process have either been handed over toeasy-to-train manpower or automated through sophisticated software. Ina traditional set-up, the doctor diagnoses the problem, records vitals likeblood pressure, pulse rate, etc. and then writes a lengthy prescription.There is also a substantial amount of time spent in talking to the patientboth pre and post prescription to counsel and comfort them. We atPiramal have divided this process and have different stakeholdersmanaging them. The key members of our delivery model are:
  38. 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), Indias 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 minutesAs a recent health expert who visited our centre aptly put it, we havedemystified the whole primary health care delivery process.NextBillion: The CDSS seems like a path-breaking innovation. Does thesystem have any limitations?Kavikrut: Yes, it does. It can only be used for primary health care andonly for certain ailments. Our estimate is that 70 percent of the ailmentsas seen at a general physicians clinic can be diagnosed using CDSS. Andthese are usually the first symptoms of what later turn in to morecomplicated ailments requiring secondary care. So the model helps in
  39. 39. early detection as well as treatment. There will always be a few thatrequire a doctors intervention.NextBillion: Does the use of such technology and various resources likehealth workers, paramedics, and doctors translate in to a higher cost forthe patient?Kavikrut: From the outset, we have tried to keep the model simple andaffordable for the client. We only charge the patient a maximum retailprice (MRP) on the drugs and nothing else. Since the patient never seesthe doctor, we have removed the cost of consultation. This was donebased on client and health workers feedback. Based on my experience, itis possible to make money from the drugs if one manages the supplychain well.NextBillion: A zero cost of consultation seems extremely beneficial forthis price sensitive population. Would eSwasthya be able to cover its costsin the long term?Kavikrut: Yes. At the moment, we get an average of 1.2 patients perhealth worker per day across 50 villages. The model will becomesustainable at a scale of 1,000 villages clocking an average of 1.75patients/PSS/day and thus cover overheads, technology and marketingcosts. Some of our better motivated health workers have consistentlyclocked over three patients per day and so we believe that this isachievable. We plan to scale to 1000 villages by early 2012 througheSwasthya run centres and some government Public private partnershipspilots.NextBillion: It seems like a large segment of patients in each village arestill 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. 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 doctors 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. 41. Piramal eSwasthya (Part 2): Building Acceptance for MobileHealthSriram GuttaFebruary 28, 2011 — 08:03 amA healthworker takes vital signs. Image Credit: Kavikrut, of PiramaleSwasthyaEditors Note: This is the second of two posts on Piramal eSwasthya aspart of NextBillions Advancing Healthcare With the BoP series. Part one ofthe interview with Kavikrut, who currently heads the Piramal eSwasthya,may be found here.Sriram Gutta, NextBillion: How has the model evolved over the last threeyears?Kavikrut, eSwasthya: Based on our learnings from the field and clientfeedback, the model has mainly evolved along the following three areas:
  42. 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 systems 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 dont see the doctor and thus cant 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 wasnt 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 drugsNextBillion: Seems like hiring women workers could be a bottleneckwhen you are looking to scale. What are some of the innovations that youare looking at?Kavikrut: We are currently working with the government of Rajasthan tohire ASHA workers as our health workers. There are a total of 267,000such workers in India - one for every 1,000 population. She has a kit ofover-the-counter drugs, conducts health related surveys and supportsmost government initiatives such as polio camps. The Rajasthangovernment has shown interest in the model and we have now launched aPPP pilot with the Churu collectorate as part of which we are launching
  43. 43. 100+ villages in one block of the district. This is a win-win solution forall. The government can provide primary care consultation now within thevillage, we get access to trained health workers who already have anestablished "health service provider" relationship with the village, and theASHA worker can increase her income by working with us. It is stillpreliminary to talk about the results of this model but if successful, itholds 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 andhigh quality products/service to our clients. Some of our partnersinclude:• 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 behaviorfor 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, weprescribe both a cough syrup and paracetamol. The patient typically buysonly the cough syrup as syrup is the more obvious need to them.Similarly, for skin ailments a patient may ignore the prescribed antibioticand instead only buy the ointment tube that is also part of theprescription. We are working on ways to change this behavior. Some ofthe health workers who have a reputation manage to convince patientsabout the need of buying and consuming all the drugs in theprescription.NextBillion: Is it required for an entrepreneur to have healthcareexperience to be in this space? Why or why not?Kavikrut: Not necessarily. I entered this space without any background inhealthcare and dont think it was a big barrier. It is good to have thebackground but not a deal breaker. It is more important to understand
  44. 44. the business and the mindset of people at the bottom of the pyramidwhen working to deliver essential services such as health, education etc.What we are working on is a healthcare delivery model and not just ahealth product or service per se. It is as much about the supply chain ormarketing as much it is about the clinical treatment side of healthNextBillion: How would you describe your progress so far?Kavikrut: Over the last three years we have achieved a few milestonesthat we believe are important indicators of our experience as well as ourpassion to find solutions healthcare problems. We have treated over40,000 patients through several pilots including a more traditionaltelemedicine model in Tamil Nadu that deployed videoconferencing andMedical Data Acquisition Units. In Rajasthan, we have worked in morethan 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 theHarvard Business School. Through social experiments and meticulouslydesigned operational processes, eSwasthya has also innovated on severalfronts in the context of delivering services and goods to rural consumers.In 2009, the organization was awarded the ISO 9001:2008 Certificationfor its Quality Management Systems across all villages, rural offices andthe Mumbai centre.NextBillion: What would you like the headline of eSwasthyas website tobe in 2020?Kavikrut: The worlds most radical yet simplest healthcare delivery modelfor the BoP. Largest number of patients treated through remotediagnosis. Piramal eSwasthya becomes synonymous with the word"telemedicine.”
  45. 45. Better Living Through InformationRose ReisMarch 1, 2011 — 09:18 ammDhil founder Nandu MadhavaEditors Note: This post is part of the NextBillion series, AdvancingHealthcare 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 Corpsstint, Nandu Madhava realized that many people in emerging marketssuffer from health problems due to a lack of information. Particularlyadolescents knew very little about sexual health and contraception.Madhava realized that providing access to accurate and relevantinformation about these taboo topics was a critical step in empoweringpeople to achieve positive health outcomes. Flash forward across theyears he spent honing his entrepreneurial acumen at investment banksand the Harvard Business School, and the Texas-reared TED fellow isbanking on young peoples thirst for practical health informationpresented via original video and text content - delivered over mobilephones. His company, mDhil (m for mobile, Dhil for heart), is based inBangalores Richmond Town, where it shares an office with the BoP-focused jobs board Reis, CHMI: Describe your audience and its health needs.
  46. 46. Nandu Madhava: Our main focus is the Indian youth audience - we haveexcellent content on topics including sexual health, family planning,contraception, and womens health. A representative customer would bean urban teen or college student who seeks to learn more about relevanthealth concerns. We also have content on chronic and lifestyle diseaseslike diabetes and obesity.Reis: Is your content accessible to all?Madhava: Our core focus is currently urban youth, and this is a hugemarket within India. As the 3G mobile network rolls out across India,broadband mobile services will become available in semi-urban and ruralIndia over the next 24 months. Coupled with the steep price fall in smartphones, we believe we can grow our user base to reach frequentlymarginalized communities. But Im careful to not make a classic start-upmistake: 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, Ivealways engaged public health professionals, physicians and nurses tohelp understand the health challenges seen in India. We have severalhealth professionals on our staff, as well as a health advisory board andwe run our content by Indian NGOs. Looking at World HealthOrganization (WHO) data, many people mistakenly believe that mosthealth challenges are isolated at the bottom of the period in India. Inreality, there are tremendous challenges in accessing accurate andrelevant 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 viamobile carriers in India. We still are active in the SMS business, however,there are two seismic changes happening in mobile: (1) The launch of3G data networks in India, and (2) a proliferation of low-cost smartphones. Both of these changes let us reach end-users with feature richcontent, mainly video and articles with imagery. In the past, we had tocharge users to access our SMS content via mobile carriers. Goingforward, were focusing on a great mobile (as well as desktop) Internetsite where our content is free and advertising supported. There are
  47. 47. already 20 million Facebook users in India, and India is the second largestcountry for mobile advertising after the USA, according toGoogle/Admob. So mobile Internet in India is not a trend that mighthappen, 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, wehave gotten over 15,000 video views - 90 percent of this traffic is fromIndia and 30 percent is viewed over mobile. We work with young directorswho share our vision to create meaningful, empowering content for ayouth audience. Setting basic parameters around issues like length ofcontent, sound quality and good lighting, we give creative freedom to thedirectors. We look for scripts that focus on positive health messages -my goal is not to frighten or belittle our users. We often heard thatmany youth didnt reach out for information in the past due to thepaternalistic and condescending nature of the existing health system. Ilook for empathy in our directors and scripts.Reis: Do you ever receive any negative feedback on your coverage oftaboo topics like sex?Madhava: Well, we approach sexual health in a frank, open, and honestmanner. We work with people who have a deep respect for cultural,gender, and sexual equality for all citizens. We dont seek to shock orupset people; we want to encourage critical thought and respectfuldiscussion. I was recently at an evening event in Bangalore where I satacross the Indian contemporary artist Subodh Gupta. At first, he was a bitchurlish due to my American accent. However, when he found out that mywork focused on positive sexual health discussions, HIV/AIDS prevention,and gender equality for women, he expressed his love and camaraderie. Ithought, "Hey, if a respected artist like Subodh Gupta likes this, then Imust be doing something right".Reis: Do you plan to expand to any new technology platforms?Madhava: Im a big believer of Android in the Asian markets, but thatsaid, will be interesting to see what happens with Nokia and Microsoftnow working together...Reis: You will be presenting on technology trends in India at SXSW this
  48. 48. March. What day should we be there? Also, this makes us wonder, ismHealth the new Arcade Fire? Discuss.Madhava: I love Arcade Fire! Hopefully well be just as cool! Wish usluck...we are speaking at the Technology Summit at SXSW during theweek ... keep an eye out for us.Watch mDhil videos here, then read about 55 other programs in Indiaworking to make people more savvy consumers of healthcare. Know ofanother cool, innovative program? Register and enter it here.
  49. 49. Healthcare Series: To Emerging Markets and Back Again(Part 2)Josh ClevelandMarch 1, 2011 — 03:30 pmA Healthpoint Services clinic in Punjab. Image Courtesy of HealthpointServicesEditors Note: As part of our series, Advancing Healthcare With the Baseof Pyramid series, this is the second in a pair of articles focused onreaching BoP markets with healthcare innovations. This article addressesthe perspective of a social enterprise start-up while the previous piecepresented the perspective of several multinational corporations.
  50. 50. In the previous article in this set, I wrote on the experiences of two largecompanies with reaching BoP markets with healthcare products andservices. Their perspectives can be found here.That article covered the issue of getting good stuff to people who needit from the corporate perspective - with big budgets, thousands of eageremployees, and the ability to use philanthropy as a tool. But what aboutwhen the innovations are just emerging, the organizations building themare small, and youre based in an entrepreneurial team with social impactmotives? For this perspective, I spoke with AlHammond, Ashoka entrepreneur, NextBillion advisor, author, and founderof Healthpoint Services.From biotech startups to North IndiaDistribution 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 organizationprovides North India residents with access to technology in the form oftelemedecine, a diagnostics lab, provision of medicines and clean water.Local people are trained in the provision of all services with doctors inother locations answering queries via telemedicine technology. Like Pfizerand GE, Al deeply understands the value of partnerships. "Partnering iscritical. These are complicated problems and any one organization isunlikely to have the skills it needs. So you need to build an ecosystemthat supports scale, lowers the risk and increases likelihood you cansucceed." In the case of Healthpoint, this meant "building partnershipswith every start up building these technologies that we could find." Forexample, start-ups produce the "labs on a chip" Als team hopes to use toremotely conduct DNA analysis on a sample and receive a readout inabout 5 minutes for the cost of $10. Its a good fit: biotech startups needdistribution and testing; Healthpoint needs the technology to makeHealthpoint attractive and affordable to rural clients.While Pfizer and GEs programs both rely on local partners such asgovernment ministries and LCSs for distribution and access to patients,Als team built a distribution channel from the bottom up. One can argueabout the effectiveness of each approach (and we certainly plan to infuture NextBillion posts) but to Als team, there was no question abouthow to do it. "We started with distribution for our core services," saysHammond, "and will later figure out what additional products andservices to use in that distribution system." Al points out that where mostdistribution systems fail is that they are not economic particularly forsingle-service provision. He predicts that in the coming years, the fourservices Healthpoint provides now will probably double. Only partiallyjoking, he notes that since Healthpoint has broadband wireless access,
  51. 51. they might someday enter the education market. The Healthpoint modelis unique (and capital intensive) precisely because of the permanentinfrastructure that the organization builds in each community. Butdespite that risk, for Healthpoint, "its how we become a part of thecommunity - how they know to trust us and that we are going to stayaround."Although Healthpoint builds its own distribution system to get itsservices 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 lookforward to providing more details on its partnership with P&G shortly).And given similar to obstacles faced by large companies, effectivedistribution systems are critical to the success of the organization.... And back againFor reasons we discussed in the previous piece in this set of articles,moving tech solutions from emerging markets to developed markets is atough business. Many thought leaders (Al Hammond included) believethat the real potential lies in the workflow innovations that dont requirethe same level of regulatory scrutiny to implement. Hammond speculatedthat Walmart could someday take on point of care (POC) diagnostics carethat Healthpoint uses today in North India as an add-on to itsexisting in-store clinic services. Walmarts strongest markets are in therural parts of the U.S., where we have the lowest rates of healthcareprovision and lowest numbers of qualified doctors, not unlike India.If Walmart could use the the POC innovations were proving viable now inIndia to provide a 20-minute, $20 diagnostic result and give the patientthe medicine they need, we could dramatically change healthcare accessin this country.
  52. 52. Listening to Patients: Innovations in EmpowermentEvagelia Emily TavoulareasMarch 3, 2011 — 10:30 am Flickr CreditEditors Note: This guest post is by Evagelia Emily Tavoulareas, MediaMobilizer for Ashokas Changemakers, and was contributed as partofNextBillions Healthcare With the Base of the Pyramid series.The buzz about innovations in healthcare has focused on advancementsin testing, diagnostics, treatments, and improved access to care, butthere is a missing piece of the healthcare innovation puzzle - we donthear nearly enough about people.In July 2010, Ashokas Changemakers and the Amgen Foundation turnedthe healthcare conversation towards the end-user, the patient.Together, Changemakers and Amgen launched the Patients | Choices |Empowerment competition to elevate patients voices to improve healthoutcomes globally.Innovation in Patient EmpowermentThe Changemakers community submitted 277 competition entries from40 countries, sharing solutions that empower patients. The three winningentrants were each awarded $10,000 from the Amgen Foundation tosupport 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. 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 informeddecisions to improve their own quality of care. With innovators,entrepreneurs and experts in the field working together, some interestingtrends also emerged.Social technologies are the futureA significant portion of the entries were related to technology - morespecifically, networking online, information sharing, and mobile phones.Two of the three winners are technology-based initiatives. One usescrowdsourcing to aggregate patient-contributed data to create adatabase for users to compare treatment effectiveness. The other usesthe power of mobile phones to connect patients with blood donorsthrough an SMS helpline, in a region that often faces a shortage of bloodsupply.Both of these technologies (crowdsourcing and SMS) have been used formyriad purposes - from organizing protests to accessing the marketprice of wheat. These existing and emerging technologies may beapplied in a variety of ways, but one thing is for certain: socialtechnologies enable people to connect with each other, and to shareinformation. Since much of patient empowerment is centered oneducation, access to information, and communication with theirhealthcare providers, you can expect to see more use of socialtechnologies in the field of healthcare.Social innovators from India not only sourced two of the competitionwinners, but also the source of the second key insight:India is an emerging leader in healthcare innovationAs a country, India demonstrated its leadership in this sector as home totwo of the three winners and the source of the second largest pool ofentrants (second only to the United States). As one of the most populous
  54. 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 anemerging innovation hub, we can expect to see Indian healthcareprofessionals and innovators tackling the issue of healthcare in excitingnew ways.We also saw the importance of thinking local. While there is much tolearn from the global community, Western medicine and high-techhealthcare systems - trusted local stakeholders are critical to success.Many competition entrants submitted ideas centered on communityengagement and local buy-in. Depending on the cultural context, localacceptance and trust could be more or less critical. Taboo healthcareissues (such as cancer, HIV/AIDS, and mental health) require extrasensitivity to local needs, and engaging trusted members of thecommunity 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 isimportant for us to listen, connect and learn. We must listen to doctorsand patients, connect with innovators experimenting with newapproaches, and learn from what works - and what doesnt. As wecontinue to tackle challenges in healthcare systems around the world, weshould keep in mind the words of Mark Twain:"If you always do what you always did, youll always get what youalways got."Innovation moves the world forward. And what is at the heart ofinnovation? People.
  55. 55. Technology to the People! Taking Telemedicine to Scale inRural IndiaRose ReisMarch 4, 2011 — 09:35 am World Health Partners Sky Telemedicine Centers World Health PartnersThis post was contributed by the Center for Health MarketInnovations (CHMI) as part of NextBillions Healthcare With the Base of thePyramid series.Long known as an IT capital, Indias health infrastructure for years laggedbehind the Tiger-like force of its software industry. No more: In the pastdecade, thanks to growing support from government, private sectorinnovation, and a great leap forward in infrastructure development, so-called Information Communication Technology (ICT) is transforming theway people receive health care.
  56. 56. The "next generation" telemedicine model is proliferating rapidly in India,where 70% of people live in rural areas where health infrastructure is stillinsufficient. Telemedicine uses ICT to "provid[e] accessible, cost-effective, high-quality health care services," in the words of a recent WHOGlobal Observatory for eHealth report. Telemedicine models, in whichrural patients are connected to trained physicians over telephone orInternet, can become the first point of access for a variety of illnesses anddiseases such as eye related issues, intestinal problems, infections andheart disease. Most importantly, patients get into the health system earlyand do not delay care seeking for fear of transportation and costs.Today, CHMI profiles more than 55 telemedicine programs globallyincluding 24 in India (program implementers and CHMIs partners in 16countries are continually adding new programs to the open database).World Health Partners is a not-for-profit franchising organization thatprovides healthcare services to the poor in Uttar Pradesh across Meerut,Muzzafarnagar and Bijnor districts. In less than 18 months, the projectestablished a health service delivery network covering 1,300 rural villagesof Uttar Pradesh through 1,300 shops, 120 telemedicine centers, ninediagnostic centers and 16 franchisee clinics. The projects central medicalfacility in Delhi conducts 80-160 tele-consultations per day. Next up: anexpanded pilot in Bihar, with funding from theBill & Melinda GatesFoundation. Gates has also initiated a rigorous evaluation of the modelshealth impact.Sehat First, another franchise model utilizing ICT, aims to set up 500health centers across Pakistan by 2012. Founded in 2008 by d.o.t.z.technologies as a Karachi-based pilot, Sehat First received an equityinvestment from Acumen Fund. The initiatives telemedicine consultingservice gives patients access through clinic staff to physicians, evenspecialists like gynecologists and pediatricians, over IP-based videophones.Amrita Institute of Medical Sciences (AIMS) and Research Centre usestelemedicine to connect general providers to specialists. In addition tothe flagship hospital at Kochi, the Institute also has established severalsmaller satellite hospitals in semi-urban and rural areas to serve the localpopulace. Students from the health sciences campus in Kochi often areposted to these hospitals, and doctors and other medical staff serve thereas well. Satellite hospitals are linked to the 24/7 telemedicine service ofAIMS Hospital. The technology allows for the transmission of a patientsmedical records and images, and provides a live two-way audio and videolink, which allows a general practitioner at the health center to connectwith a specialist at AIMS.
  57. 57. Raja Bollineni, of CHMI partner organization ACCESS Health International,is charged with mapping ICT-related health initiatives in India. Bollinenigot interested in the promise of so-called e-health when working inRwanda. He proposed a system for Partners in Health to allow people inrural Rwanda to consult on eye problems with specialist ophthalmologistslocated at Central Hospital University Kigali.Although these models have garnered a lot of excitement in India andabroad, Bollineni is quick to point out a number of challenges impedingthe implementation and further growth of these programs, includingcapital investments, infrastructure limitations, lack of supportive policy,and low awareness levels in the communities. One other importantbarrier to sustained growth is the difficulty in getting sufficient volume tosustain your business."Startups shouldnt go in for high-end technology," suggests Bollineni."You can save your capital for other investments, and the tariffs are alsohigh on imported technology." Bollineni suggests that implementers lookat connectivity, and be realistic-even more basic Internet over phone canbe effective, with limitations.Garnering sufficient volumes of revenue is another big challenge forimplementers. "For telemedicine programs to go to scale, they have to beable to attract a sufficient volume of business," says Bollineni. In his view,there are two ways to make them economically viable. The first is toobtain government support for expanding infrastructure. The best way todo this is to create bundled shared services that utilize the sameinfrastructure. He recommends adding on dental services, dermatologyand diagnostics to boost revenues, and points to Punjab-based Healthpoints innovative choice to sell clean water cheaply adjacentto a telemedicine-equipped clinic.How equipped does a clinic have to be to incorporate telemedicine?According to Bollineni, there are many options. Very well connectedclinics use broadband with speeds of 512 kb/second, while IntegratedServices Digital Network (ISDN) lines are the most preferred connectivityoptions for practical reasons to connect remote areas which only requirea minimum bandwidth of 128 kb/second, costing about 171 Rs/hour(less than $4). VSAT too is a good option although a costlier proposal butprovides much faster data transmission than ISDN. Video conferencingrequires 256 kb/second ISDN or IP based support.Among those using high-end technology are Apollo TelemedicineNetworking Foundations tele medicine centers an initiative of ApolloHospitals, the Joint Commission-certified hospital chain that has set up