Venture Capital and Global Health

  A discussion paper in preparation for the September 2005 Workshop

Elizabeth Bailey, Meg Wirth and David Zapol


Funding for this paper was provided by The Bill...
Table of Contents

Executive Summary

Executive Summary                                              growing market criterion.

developing global health products.                                designed a fund concept that enables the
A Preface on Terminology                                        term 'global health' could also encompass non-
sectors with explicit social and financial return                 Venture philanthropy. A model for charitable giving
Introduction                                                    innovation; and to highlight the reasons for the
Part I: Why Has Venture Capital Failed                               with investors placing $800,000 in a company in the
patient.'   16 The key benefits of the venture capital                 the venture capitalist perception of resource-poor
innovation may provide some interesting insights              patient need is relatively straightforward, regulatory
into ...
as well as the creation of new drug development
Figure 4
Most industry data is self-reported, making common                          2004, received $2 million in funding from LSGP...
Figure 8                                                             even made it to Phase III clinical trials (Figure 8)....
large return. Loosely, if the fund is to return 30%,               investors into a syndicate.
then the incoming investmen...
Part II: Can Double Bottom Line or                            an IRR of under 10% were non-profit funds, and that
Social Ve...
Figure 11
                      Non-profit Venture Fund             For-profit Social/DBL Venture Fund      Traditional Vent...
PATH is exploring the possibility of a social venture          holding companies, need to be created to facilitate
fund or...
benefit that could be attributed          to   the
     technology once in widespread use.
At present, foundations experime...
Part III: Next Steps                                                and in the developing world—to invite them to
Appendix A: Examples of Equity-Financed Global Health Innovations

Company                  Product                    ...
Venture Capital and Global Health
Venture Capital and Global Health
Venture Capital and Global Health
Venture Capital and Global Health
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Venture Capital and Global Health

  1. 1. Venture Capital and Global Health A discussion paper in preparation for the September 2005 Workshop Financing Global Health Ventures Organized by Commons Capital and CIMIT/MAP
  2. 2. Authors: Elizabeth Bailey, Meg Wirth and David Zapol Acknowledgments: Funding for this paper was provided by The Bill and Melinda Gates Foundation and the conceptualization of the paper was influenced by multiple exchanges with Hannah Kettler. Thanks to Josh Ruxin and Columbia University's Earth Institute for providing space and support for part of this work. Discussions with Reuben Abraham, Thomas Atterstam, Yanis Ben-Amor, Cathy Clark, Lisa Conte, Magdalene Cook, Jonathan Donner, Rob Fogler, Michael Free, Charles Gardner, Jacqueline Kohr, Rustom Masalawala, Carol Nacy, Willy Osborn, Jason Salter, Paul Wilson and many others informed the paper.
  3. 3. Table of Contents Executive Summary 4 Introduction The Limitations of Venture Capital for Global Health Global Health Market Risk Lack of Momentum in Global Health Markets Shortage of Intellectual Capital in For-Profit Global Health Traditional Venture Capital's Need for an Early Exit High Return Expectations Mitigating Risk through Syndication The Emerging Field of Double Bottom Line and Social Venture Capital Next Steps A Preface on Terminology 6 Introduction 8 Part I: Why Has Venture Capital Failed Global Health? 9 An Overview of the Venture Capital Model: Market, Momentum and Management An Overview of the Venture Capital Model Continued: Fund Structure Conclusion Part II: Can Double Bottom Line or Social Venture Capital Offer Any Solutions For Global Health Innovation? 16 What Is 'Double Bottom Line' or 'Social' Venture Capital? Social/DBL Venture Capital and Global Health Foundations as Global Health Investors Conclusion Part III: Next Steps 20 Markets Momentum Management Fund Structure Other Appendix A: Examples of Equity-Financed Global Health Innovations 21 Appendix B: A Case Study of Napo Pharmaceuticals 22 Company Financing History Endnotes 24 3
  4. 4. Executive Summary growing market criterion. Lack of Momentum in Global Health Markets Introduction While public-private partnerships (PPP's) have In September 2005, a group of approximately 50 recently created a flurry of activity in neglected individuals representing various stakeholders will disease drug development, there has been markedly convene in Cambridge, Massachusetts to discuss less activity regarding commercialization and the role of venture capital in global health innovation. distribution for such products. Areas such as This paper was developed as background for this regulation, reimbursement, procurement and workshop and seeks to explore why traditional distribution remain under explored, thereby creating venture capital (VC) has largely been unavailable to additional risks for the already wary VC investor. companies that are developing products for neglected diseases and global health markets. In Shortage of Intellectual Capital in For-Profit addition, it begins to explore whether double bottom Global Health line (DBL) or social venture capital may be a better VCs look to invest in companies led by experienced model to provide equity financing to these types of entrepreneurs who have a proven track record with companies. venture investors. Because the global health and The Limitations of Venture Capital for Global venture capital communities have not collaborated Health extensively up to this point, 'seasoned' executives with skill sets from both fields are rare. Venture capital has made a significant contribution to the health care industry in the developed world in Traditional Venture Capital's Need for an the form of accelerated innovation, extending and Early Exit improving the quality of life, and generating strong The fundamental structure of a VC fund also creates returns for investors.   1 However, despite the fact obstacles to global health investing. In particular, that the venture capital model is predicated on a the life cycle of a fund is anywhere from seven to ten high risk tolerance, global health investments appear years which encourages exiting investments in the to present too many unfamiliar risks to VC investors. two to five year timeframe in order to generate Specifically, venture capitalists look for: strong financial returns for the fund's investors.   3 • large and growing markets in excess of $1 This relatively short time horizon in the context of billion; long biotech development timelines often means that • momentum to help get a product through investors exit an investment long before a product development; and gets to market. In a developing market context, this • a proven management team. creates a potential problem for the ultimate commercialization and distribution of global health Unfortunately, these basic criteria are often not met products. in the context of global health businesses. High Return Expectations Global Health Market Risk The need for quick exits is in part driven by the Global health markets have not been well defined or expectation of strong financials returns, where a characterized, and this uncertainty around their size, shorter time to exit often yields a higher internal rate growth, segmentation and general dynamics has of return (IRR). VC investors can look for returns as created a formidable obstacle to traditional venture high as 60%, especially given that there is an investing. Although some efforts have been made to expectation that many deals will ultimately return better delineate global health markets   2, estimates nothing. Venture capitalists typically believe that vary widely and more work needs to be done in this these kinds of return expectations are unachievable area to give funders greater clarity on prospective given perceived smaller markets, with less investments. In the meantime, some companies momentum and relatively inexperienced have pursued a 'dual market strategy' where their entrepreneurs. Moreover, the private and public products have a demand in both the developed and markets that provide liquidity for traditional biotech developing world in order to meet the large and investors are not readily apparent for companies 4
  5. 5. developing global health products. designed a fund concept that enables the participation of multiple foundations in a single Mitigating Risk through Syndication venture fund to allow for alignment of One of the strategies VC funds use to mitigate risk is foundation investment and mission. syndication—investing alongside other venture • Commons Capital: A DBL venture fund that funds. While this was not a priority in the Internet has primarily invested in socially responsible boom of the late nineties, it is now the dominant health care companies that focus on the practice in the industry. In the second quarter of domestic market is exploring a new for-profit 2005, 81% of the 167 biotech and health care venture fund in the areas of diagnostics and venture deals were syndicated with at least two devices (with a particular emphasis on venture funds.   4 This desire for co-investment women's health). creates a vicious cycle for global health companies; if few to no venture firms are investing in global • The Foundation Strategy Group: The health ventures, then even a progressive-thinking consulting groups Social Investment Fund for VC investor that sees an opportunity may ultimately Health Care Delivery would invest in private have to pass because of an inability to attract other companies in developing countries targeting investors into a syndicate. downstream distribution and delivery of health care products to be used by the poor in urban The Emerging Field of Double Bottom Line and semi-urban areas. and Social Venture Capital • PATH: This non-profit organization is exploring Double bottom line and social venture capital refer to a social venture fund or other financing for-profit and non-profit equity financing vehicles with vehicle, leveraging its existing capabilities in explicit social and financial return expectations. This technical collaboration, co-design and new model may offer a better option for companies development, licensing, policy harmonization developing novel products for global disease, as it and market development, to get high impact adds important social criteria to the investment primary health care products through the value equation. Most of the social/DBL funds operate like chain and into widespread use. traditional VC funds in terms of identifying experienced entrepreneurs, creating viable business These funds will need to make significant inroads models, co-investing with other VC firms and into better understanding markets for new products, managing their investments through board seats.  5 finding global health and business experienced However, the desire for positive social impact can entrepreneurs, developing viable investment sometimes have important implications in terms of vehicles and strategies, and generating new options financial return expectations. for exiting investments, in order to achieve strong financial and social returns. In addition, foundations, A few social venture funds that have targeted the as potential investors for these funds, will have to priorities of global health in their investment decide what types of financing vehicles will align strategies have mainly adjusted their return best with their internal mission and organizational expectations. Acumen Fund, Programs for practices, and have the most promise for delivering Appropriate Technologies in Health (PATH) and the needed global health products to the developing Rockefeller Foundation's ProVenEx are three such world. examples. ProVenEx was able to achieve an exit for its investment in Biosyn, a microbicide development Next Steps company, which was sold to a public company Because the existing and proposed social/DBL (Cellegy). venture funds present more questions than answers Other organizations are in various stages of at this point, the Financing Global Health Ventures conceptualizing new global health focused VC workshop is intended to refine these inquiries and funds. These include: begin to develop solutions to the problem of global health innovation. • ASM Resources: The for-profit venture arm of the American Society for Microbiology has 5
  6. 6. A Preface on Terminology term 'global health' could also encompass non- communicable diseases including cancer, heart The stakeholders brought together for this workshop— disease, diabetes and others that are not the namely 'venture 'capitalists' and 'philanthropists'—do primary focus of this paper. not necessarily speak the same language. Even Internal Rate of Return (IRR). A present-value- within their worlds, there is often disagreement and based measure used for determining the debate on essential terms. While we acknowledge compounded annual rate of return on investments the importance of terminology and note that this held for a time period of one year or more. workshop will not resolve such disagreements, we want to ensure that we begin with a common set of Neglected diseases are defined as seriously overall concepts. This section lays out certain key disabling or life-threatening diseases for which terms as we use them in this paper and plan to use treatment options are inadequate or do not exist. them for the workshop. These largely communicable diseases primarily affect people in developing countries. A distinction is Blended value. The idea that the value created by made between neglected diseases like malaria and an organization is fundamentally indivisible— TB in which pharmaceutical companies might have a meaning that 'economic value', 'social value' or marginal interest and 'the most neglected diseases' 'environmental value' are simply parts of one which almost exclusively affect people in developing essential value. Blended value builds upon and countries who are too poor to pay for treatment— transcends the concepts of the double and triple illnesses like Chagas disease, schistosomiasis, bottom lines (defined below). onchoscerciasis, African trypanosomiasis and Double bottom line (DBL) investing. Financing leishmaniasis. 6 vehicles (such as venture funds) with explicit social Program-related investments (PRI's). Investments and financial return expectations. Some argue that by a foundation to support an activity related to the DBL investing holds social and/or environmental philanthropy’s strategy. Though they are usually value generation as a primary goal. Social venture structured as loans, PRI's can be equity investments capital and program-related investments are types of as well. By employing the foundation’s assets as DBL investing. investments with financial returns, this form of Equity. Ownership of a company which is sold in investment acts as a 'recyclable grant': the financial order to provide cash for a growing company. Unlike returns can be reinvested for other charitable debts (loans or bonds) which require full repayment purposes effectively augmenting a foundation's plus interest, equity appreciates and depreciates overall dollars. By definition, rates of return on PRI's based on the firm's value. For example, stocks are must be below market on a risk-adjusted basis, and publicly traded equities and are thought to reflect the most are set at very low interest rates.  7 PRI's were underlying value of the firm. Because equity defers created via a 1969 tax act—with a recent surge in all payment to the investor until the time of sale, it is PRI's as an investment vehicle occurring in the late a preferred form of capital for early-stage companies 1990's and continuing in tandem with the growing that use cash to invest in R&D and do not have interest in venture philanthropy. dependable revenues to 'maintain' debt. Public-private partnerships (PPP's) are defined in Global health ventures. We use this term the 'global health space' as public-health-driven, not- somewhat loosely to imply companies (potential or for-profit organizations that spur drug development actual) which target neglected diseases (defined for neglected diseases in conjunction with industry below) and health problems of the poor in the groups.  8 Examples of PPP's in this space include: developing world—including but not limited to HIV/ Medicines for Malaria Venture (MMV), the AIDS, malaria, TB, Chagas disease, leishmaniasis, International AIDS Vaccine Initiative (IAVI), the etc.. We note also that health issues like acute Global Alliance for TB Drug Development (GATB) respiratory infection, maternal mortality, malnutrition and the Foundation for Innovative New Diagnostics and sexually transmitted infections disproportionately (FIND). affect the poor—thus such issues should also be Social venture capital. A financing vehicle that included in efforts to spur innovation in this field. The invests in for-profit companies in a wide range of 6
  7. 7. sectors with explicit social and financial return Venture philanthropy. A model for charitable giving expectations. Within this definition there exists a that arose in the 1990's based on the application of spectrum of types of social venture capital funds – venture capital investment principles to social varying from those with minimal emphasis on the investments. Funders 'invest' not just money but financial returns to those that expect traditional energy and expertise in the organizations they market returns on investments as well as some level support. Venture philanthropists manage a 'portfolio' of social returns. Social venture capital is a type of of organizations and seek to increase its social double bottom line (DBL) investing. impact by providing management support and expecting results and accountability from the Stages of investment. An inconsistency arises organizations they fund.   9 Venture philanthropy when discussing 'stages' of investment across the focuses on leadership, bold ideas, developing strong global health and venture capital communities: teams, active board involvement and long-term 'Early-stage' or 'later-stage' investment could refer to funding. Market-based mechanisms are used to the age or stage of a company or to the stage of bring 'ideas' and 'products' to scale. 10 product development (e.g., R&D, pre-clinical, Phase I trials). Because this report is focused on the potential role of venture capital in global health investments, we have outlined very general terminology that corresponds with the stages of company development. It is also important to note that there is no consensus on this term even among investors. This is Figure 1 compounded by the fact that industry data is self-reported. Private Investment Stages Track Company Growth for Health and Biotech 11 (usual sources of capital) Triple bottom line (TBL) investing focuses corporations not just on the Often before a product or company is formed: friends and Seed economic value they add, but also family and government/foundation research grants. on the environmental and social Company is ready to conduct business, no revenues typically value they add – and destroy. At its at this stage (also called Development); company in business Start-up narrowest, the term is used as a for less than 18 months: 'angel' or accredited individual framework for measuring and investors and government research grants. reporting corporate performance Typically first round with venture capitalists, often once service against economic, social and is being delivered; partnerships with pharmaceutical Early stage environmental parameters. For companies formed; some pre-clinical data results, etc.; brevity in this paper, we use the company in business for less than 3 years: venture capital. term DBL to include TBL as well. Needing capital for running trials, expanding to new markets or Venture capital refers to equity Expansion launching products and services; company in business for more than 3 years: later stage venture capital. investments in new or young companies. Venture capital is a Product or service may be widely available. Company can be subset of private equity, often generating on-going revenue; maybe positive cash flow. More included in the term 'alternative likely to be, but not necessarily profitable. Also can include investments' by institutional "older" companies that still have products in clinical trials. May Later stage include spin-outs of operating divisions of existing private investors such as foundation companies and established private companies: later-stage endowment managers. Private venture capital, private placements of equity and debt by equity also includes other non-debt, merchant or investment bankers or other late-stage financiers. relatively illiquid (i.e. can't be easily Mezzanine is a later-stage financing with an eye towards an bought or sold like public stocks) Other later- IPO. investments such as timber, oil and stage Turnaround focuses on faltering companies, public or private. gas, real estate or management investments Buyout looks to acquire controlling interests in firms. buyouts. Recapitalization reconfigures a company's debt and equity. 7
  8. 8. Introduction innovation; and to highlight the reasons for the dearth of VC investment in the global health space. Citizens of the developing world suffer from a high In addition, we begin to look at an emerging model burden of preventable disease and inadequate of social/DBL venture capital and explore its access to diagnostics, vaccines, treatments and potential for helping to solve global health problems. technologies readily available in developed Though venture capital is not typically paired with economies. Lack of interest in health issues unique discussions of neglected diseases and the health to the developing world on the part of the health care burden of the poor, we begin to look at the possibility industry and medical researchers contributes to the of market opportunities at this intersection. growing global health gap between rich and poor Specifically, we examine whether traditional and countries. This tremendous market failure, evident in social/DBL venture capital may serve to catalyze the gap between the developing world's health innovation in some sectors of global health. needs and the paltry supply of drugs and related products', is a phenomenon that negatively impacts millions of lives and impedes development. An emerging international agenda for HIV/AIDS, TB and malaria has sparked a flurry of new public-private partnerships (PPP's) and innovative global alliances that seek to eliminate these long-standing scourges.  12 And as a result, the landscape of drug development has changed dramatically in the last several years—with 63 active neglected-disease drug development projects and 18 new products in clinical trials. But despite new organizational models and alliances, capital is all too often the rate-limiting factor—prohibiting faster, more extensive innovation for neglected diseases. 13 We believe that for-profit enterprise has an important role to play in addressing developing countries' health problems. Entrepreneurial business can be flexible, scalable, efficient, sustainable and focused on user needs to a degree often unequalled by non- profit or government-controlled initiatives. But typically private equity or venture capital funding is unavailable for companies addressing neglected diseases, due to the perception of higher investment risks and lower purchasing power in developing countries; barriers to market entry; and the absence of delivery, training and monitoring infrastructures. The current public-private partnerships dominating the global health scene have paved the way for continued innovation, but social/ double bottom line (DBL) venture capital is one mechanism with enormous potential that has yet to be adequately explored. This paper was developed as background for the September 2005 Workshop Financing Global Health Ventures. The central purpose of the paper is to review the underpinnings of venture capital (VC) and its potential as a funding mechanism for health care 8
  9. 9. Part I: Why Has Venture Capital Failed with investors placing $800,000 in a company in the Global Health? neurological device arena, an area Martinez determined had an annual market of roughly $500 We had to bring in a heavy from Pfizer to explain to million and was expected to grow in the next few our C.E.O. why he shouldn't pursue the developing years to $800 million. Investors and founders are world market. He had all kinds of aspirations to striving to sell or take public this new company within bring his drug to the poor, but thankfully, we talked five years with sales in the range of $40-to-50 him out of it. million, driving a firm valuation of $100-to-200 —Anonymous venture capitalist million. The hope is that a modest investment in a company that targets a large and growing market Despite the fact that venture capital is predicated on can generate a strong return for investors in a a high risk tolerance, it is widely accepted in the VC relatively short amount of time. community that global health investments targeting neglected diseases are This type of venture s i m p l y t o o r i s k y. Figure 2 investing—that which Venture capitalists site promises high returns myriad reasons for why Percentages by sector invested in 2004 over short time frames such investments are by care venture funds (2 to 5 years)—has $6.33 billion total outside their risk profile blossomed over the —from political Health care past 20 years in health instability to insufficient services and and technology. Last technology infrastructure to an 11% year, the over 100 inability of the poor to health care venture pay for products—but funds in the U.S. u n f o r t u n a t e l y, t h e invested $6.33 billion discussion has largely split between stopped there. To begin Medical biotechnology (61.1%), to understand why devices and Biotechnology medical devices and equipment 61% venture capitalists have 28% equipment (28%), and not extended their health care services model to finance and technology companies focused on (10.9%).  14 (See Figure neglected diseases in the developing world, it is first 2). Most of the biotech investments focused on necessary to understand the guiding principles of chronic diseases in the developed world (e.g., heart venture investing. disease, cancer and diabetes) whose markets are perceived to be large and growing, while little to no An Overview of the Venture Capital Model: venture money went to fund products aimed at Market, Momentum and Management diagnosing or treating neglected diseases. 15 Emmanuel Martinez, managing director of venture There is no question that venture capital has been firm GreenHills Capital Partners, recently described instrumental in spurring innovation in the health care his criteria for investment as the three M's: 'market and biotech sectors by funding the early size, momentum and management.' Like most development of new products. A recent report venture capitalists, Martinez wants to see that there published by the National Venture Capital is a $500 million to $1 billion market for a product; Association analyzed contributions to health care— that the company has momentum through product mainly in leading causes of death in the U.S.—by innovation (perhaps protected by intellectual the venture capital industry and concluded: 'Venture property) and will capture a significant proportion of capitalists bridge the significant gap between the market quickly; and that the team that is leading discovery, development and thorough testing of life the company has the experience required to achieve sciences innovations by providing both monetary the operational goals and financial returns promised. and non-monetary support, thus speeding the time it These criteria have led GreenHills recently to work takes to move a product from the lab to the 9
  10. 10. patient.'   16 The key benefits of the venture capital the venture capitalist perception of resource-poor model it identified included: settings is that they do not represent large markets. • Moreover, these markets present additional risks— Acceleration of innovation. Venture-backed political volatility, corruption and fragmented medical innovations are developed and made infrastructures, among others—that are quite available to patients as much as three times unfamiliar and daunting to venture capitalists. Other faster compared to a bootstrapping approach formidable unknowns include intellectual property to product development. rights, validation, regulatory barriers, manufacturing • Extending lives. More than 70 million partners and uptake of the technology or innovation Americans have had their lives extended or by global gatekeepers like the World Health quality of life improved as a direct result of Organization.   19 Lack of understanding of such venture-backed diagnostic and therapeutic markets prevents companies from determining how innovations (25 million annually). they might profit from a certain health innovation. • Because of this, many companies working to Return on investment. Product revenues develop global health products—such as AVANT provide a return of over $50 for every venture Immunotherapeutics, LabNow and Napo dollar invested in recently launched products… and as much as $750 for every venture dollar Pharmaceuticals   20—have pursued 'dual-market technologies' (i.e., those products that have a invested in products launched 10 to 15 years demand in both the developed and developing ago. 17 worlds) that they can depend on for at least one Clearly the VC model works, but we still have to mature marketplace. answer why it has not been applied to global health and neglected diseases. Martinez's three M's- While some organizations have attempted to delineate the markets associated with global health, market, momentum and management-can provide estimates have varied widely. Market estimates of important insight into the motivations of venture products for the 'big three'—Malaria, Tuberculosis capitalists and why investments in global health are and HIV—exemplify this wide range (See Figure 3). bypassed. Market BIO Ventures for Global Health (BVGH), a new non- profit spun out of the Biotechnology Industry Economists have concluded that pharmaceutical Organization, is making some strides in this area innovation is directly affected by market size.  18 It is and is working to develop business cases of specific no surprise then that venture capitalists look to fund diseases that characterize some promising global the development of products that can be sold into health markets. Similarly, some recent work has large and growing markets. $1 billion is a typical been done examining the potential for Advanced benchmark, and big dollar diseases such as cancer, Purchasing Commitments to create market pull for CNS and diabetes meet or exceed this market size. global health products. 21 Many venture capitalists argue that having a large New research into the upsurge in neglected-disease market is the first requirement for a s u c c e s s f u l Figure 3 investment, because Anticipated Product Expected Peak Market Expected R&D Cost Expected it allows a particular Return** company to capture $ million U.S. (years) $ million U.S. (years) only a portion of a malaria vaccine* 417 to 1,200 (15) 500 to 2,000 (10) 16 to 22% IRR market and still warrant a strong new TB drug* 222.5 to 445 (3) 115 to 240 (9.8) 15 to 32% IRR valuation. HIV microbicide* 20 to 900 (5) 775 (10.5) 7 to 14% IRR Very little has been done to define and *References: Rockefeller Foundation Microbicide Initiative 2002, Global Alliance for TB Drug Development 2001, Boston Consulting Group 2005 quantify 'global health' markets, but **Returns estimates were variable by scenario. The middle of the range is presented here. 10
  11. 11. innovation may provide some interesting insights patient need is relatively straightforward, regulatory into the types of business models best suited for this environments and payer dynamics across the work. A report by the London School of Economics developing world vary significantly (versus the more reveals some 60 current neglected-disease drug consistent policies in the U.S., the E.U., Canada and projects are conducted by smaller-scale commercial Japan). Pricing is therefore a key consideration, as firms.   22 These small firms operate at a different developing countries may have very high volume scale and are motivated by far smaller commercial markets but require pricing many orders of returns than large multinational pharmaceutical magnitude below developed countries. There is also companies. The report details the following three much ambiguity surrounding the eventual procurers categories of small companies which might make of health innovations—whether they are central inroads into neglected-disease innovation: purchasing agents like UNICEF or the Global • Fund 25 or the public or private sectors in developing First, some small companies see neglected- countries. When looking for comparables in a market disease markets as sufficiently attractive to to help delineate these issues, we again note the warrant investment and will pursue these even lack of existing companies that fit the global health without public support—for example, Zentaris, business profile. a small company that developed and registered the new anti-leishmaniasis drug, Some experts maintain that there is no shortage of miltefosine. appropriate technologies for the developing world, • but stress that the rate limiting factor is distribution— Some small firms can use 'add-on' neglected- delivery mechanisms and service components must disease R&D to promote their Western be developed in order to serve these markets commercial goals (e.g., to expand information effectively. Indeed, the severity of this roadblock has on their core commercial compounds, or to spawned new ideas for distribution- and help establish proof-of-concept for a infrastructure-focused venture funds and technology that can subsequently be businesses.   26 This is an area that will ultimately transferred to commercial markets). require more collaboration among the various global • Finally, commercial contract research health constituents in order to stimulate greater organizations increasingly see neglected- interest in the venture capital community. disease R&D as an interesting niche sector. 23 Despite longstanding lack of momentum for The report notes that small companies’ potential for neglected diseases, public-private partnerships neglected-disease product development remains (PPP's) for drug and product development have underexplored and underexploited. started to dramatically rewrite this dismal script. The 63 neglected-disease drug projects underway at the And finally, though it is beyond the scope of this end of 2004 include two new drugs in registration paper, we must fully analyze the extent to which stage and 18 new products in clinical trials. venture funds and/or companies located within Researchers estimate that these efforts have the developing countries would be a more efficient way to cultivate and reach these markets with products potential to deliver eight to nine new neglected- disease drugs within the next five years.   27 In for neglected diseases. 24 addition, increasing international pressure to Momentum address the burden of neglected diseases as part of When VC funds assess 'momentum', they look at an overall development agenda provides additional market trends driving toward eventual product momentum on which new models for venture adoption. By examining market dynamics such as financing might build. 28 patient and physician demand, regulatory and Management reimbursement developments and business The last M—management—represents the most comparables, they are able to evaluate whether nebulous category of the three. Venture capitalists there is sufficient evidence to suggest the ultimate success of their venture. When these criteria are generally look to invest in entrepreneurs with proven track records—those who have built and sold applied to global health ventures, the analysis companies generating strong financial returns for becomes, at the very least, difficult. While gauging 11
  12. 12. as well as the creation of new drug development Figure 4 PPP's which now conduct three-quarters of all identified neglected-disease drug development, offer Formation and a potential new wellspring for such talent. 29 Fund Raising Looking ahead, it is clear that the business and (Year 1) global health communities need to work more closely to share institutional know-how, and that opportunities to collaborate on such knowledge sharing should be a major priority. Exit VC Fund Invest (Years 3-10) An Overview of the Venture Capital Model Lifecycle (Years 1-7) Continued: Fund Structure Turning to the fundamental structure of the VC fund, we highlight additional limitations to its applicability Re-invest to global health ventures. Specifically, issues of timelines, exits, return expectations and the desire to (Years 2-7) syndicate investments pose high hurdles for prospective investments and make investing in global health that much more challenging than venture investors. While there are many 'seasoned' biotech innovations targeting the developed world. entrepreneurs in the health and biotech sectors, Lifecycle of a VC Fund global health ventures require a more complex blend of for-profit business acumen and international A typical venture fund has a life of seven to ten health experience that is quite rare given the historic years. The first year is spent forming a limited separation of the two fields. This lack of human partnership and fund-raising, often with some initial capital needed to build global health companies has investment out of early committed capital. After the therefore been a major impediment to attracting fund's launch, management invests actively through investment. Moreover, the venture capitalists who year seven (of a ten-year fund) and often re-invests pride themselves on industry expertise and value- in existing portfolio companies during this period. added investment also lack the necessary While actual performance across VC funds varies experience of getting global health products to tremendously, most have a stated objective to exit market in a commercially sustainable model. The their investments within 2 to 5 years (See Figure 4). pharmaceutical industry’s creation of new neglected- In the biotech industry, which is known for its long disease institutes that employ some 200 scientists, development timelines, this can mean Figure 5 that investors often pursue a liquidity event long before a product actually gets to market. Stages of Company Growth—When Founders, Friends and Family Venture Capital Steps In Angel Investors Although venture capital investment can occur across the entire lifecycle Investment of a company, there are stages of Venture Capital Risk Private Equity, Investment Banks development when VC firms are more active (See Figure 5). As we discussed in the Preface on Seed Start-Up Early More Terminology, stages of investment are Growth Established not well defined in the venture capital industry and are particularly Stage of Enterprise Growth problematic in the health care sector. 12
  13. 13. Most industry data is self-reported, making common 2004, received $2 million in funding from LSGPA (a terminology that much more elusive. Recognizing Pennsylvania VC fund) and others. The company, these hurdles, we have tried to create a generalized which is developing a low-cost non-invasive blood outline of how a company is financed, citing some glucose monitor for diabetics, has generated pre- specific company examples. clinical data from animal studies and plans to move into clinical trials with its recent venture financing. At the seed and start-up stages of an evolving firm, risk is typically borne by those close to the firm—the The largest investments by VC funds occur in the entrepreneur, 'friends and family' and angel 'later-stage' development of a firm (e.g., expansion investors. Angels are accredited individual investors and later-stage investments), when a company is who make investments alone or as part of a group of running additional clinical trials, launching products individuals willing to take a calculated risk and and services or expanding into new markets (See perhaps lend their own entrepreneurial experience Figures 6 and 7). These stages encompass a wide to aid a new venture.  30 This funding usually occurs range of activities, and they are often more related before any kind of product is developed and before a to an impending investor exit than to the stage of company is even formed, product development. Figure 6 when the company is Expansion and later-stage younger than 18 months. investments by VC funds in Q1 2005 Venture Investments in Biotech/Pharma While a few specialize in the first quarter of 2005 seed and start up include: investments, most larger VC 350 300 Kalobios Inc., founded in funds do not invest quite so Amount Invested 250 2003, received $10.6 million early due to the extremely ($millions) 200 150 in 'expansion stage' venture high level of risk and the fact 100 50 funding from 5AM Ventures, that only very small amounts 0 Later Expansion Early Seed/Startup GBS Venture partners , of capital are needed at this Stage (25 deals) Stage (10 deals) MPM Capital and Sofinnova point. (13 deals) (17 deals) Ventures. The company is Stages of Investment VC funds typically begin to developing antibody enter the picture once the products for cancer and company is launched (past Figure 7 infectious diseases, and it the seed and start-up plans to enter clinical trials in stages) and in the 'early 2005. stage' of product Q1 2005 Venture Investments in Medical Devices/Equipment PediaMed Pharmaceuticals development. For a biotech Inc., founded in 1999, company, this can mean that 300 received $15 million in 'later- a company has generated 250 200 stage' venture funding from significant pre-clinical data Amount Invested 150 Blue Chip Venture Company, or that it has actually entered ($millions) 100 Child Health Investment clinical trials. Examples of 50 0 Company and Essex early-stage venture capital Later Expansion Early Seed/Startup Stage (25 deals) Stage (2 deals) Woodlands Health Ventures. investments in 2005 include: (16 deals) (15 deals) The company focuses on Stage of Investment Immune Control Inc., a drug pediatric products, and it has development company several products already on founded in 2001 on cancer and autoimmune the market and some in pre-clinical and clinical diseases, received $5 million in funding from development. Domain Associates (a VC fund) in the first quarter of As a general rule, venture investment takes place 2005. The company is getting ready to submit an after individuals have seeded and started a investigational new drug application to the FDA in company, and continues until a company is sold or 2005 and to begin its Phase I and II clinical trials. until private equity investors take over (assuming GlucoLight, a medical device company founded in product success). 13
  14. 14. Figure 8 even made it to Phase III clinical trials (Figure 8). 31 Moreover, out of the ten venture-backed biotech 2004 Venture-Backed Health Care IPO's drug companies that were merged or acquired in (Byproduct Stage) 2004, only two of them actually had a product that Pre-clinical/ Phase III was either FDA-approved or on the market (Figure Phase I & II 17% 40% 9). 32 The VC life cycle is not currently effective at satisfying one fundamental goal of the global health community: getting products into the hands of the patients that need them. The long development Marketed cycle inherent in biotech R&D in the U.S. does not 43% discriminate between chronic diseases and neglected diseases, and it takes an average of 10 to 15 years to get most drugs from research to market. 33 Because there is a faster average time to market for devices (5 to 7 years) and diagnostics (3 Figure 9 to 7 years), it is no surprise that almost 65% of the health care IPO's in 2004 with a product on the 2004 Venture-Backed Biotech M&A Deals market were either device or diagnostic (Byproduct Stage) companies.  34 Therefore, while the market size for Pre-clinical/ Phase I & II devices and diagnostics may typically be smaller 80% than pharmaceuticals, these segments may present better opportunities for employing venture capital to get products to market. Recent venture capital activity may suggest a new opportunity to leverage the venture financing to get Phase III Marketed 0% global health products to the commercialization 20% stage. In an attempt to lower risk, many health care VC funds have moved to expansion and later-stage investments where products are closer to market (Figure 10). 35 Figure 10 As will be discussed below, this may also have implications for venture investment return Q1 2005 Venture Capital Health Care expectations, as later-stage investments tend to Investments generate lower financial returns. 45 40 Return Expectations 35 30 The need for quick exits is in part driven by the 25 Startup/Early expectation of strong financial returns, where a 20 Stage Expansion/Later shorter time to exit often yields a higher internal rate 15 Stage of return (IRR). Since most companies fail, and the 10 5 VC manager even expects approximately 30% of the 0 Biotech Devices/Equipment portfolio to be worth nothing, the remaining companies must return much higher profits for the whole partnership to make the expected investor Exit return. In other words, the winners must carry the losers and still make high returns for the fund as a Of the 42 initial public offerings (IPO's) for venture- whole. This means that every deal a VC considers backed biotech and health care companies in 2004, must have at least the potential of making a very almost 60% were pre-product, and 40% had not 14
  15. 15. large return. Loosely, if the fund is to return 30%, investors into a syndicate. then the incoming investments each must promise to Conclusion return an IRR of 60% or more. This is the high bar, or 'hurdle rate' that confronts companies seeking Venture capitalists look for management, market and venture capital. VC funds are willing to take risks, momentum within areas that they know and but a big market, visibility on market adoption and understand well. At the highest level, they seek a clarity on exit are essential. market size of $1 billion, the momentum to capture a reasonable share of the market within five years, The issue of 'exit' is not only a matter of when but management that has delivered value to investors in also how. Exits result from IPO's, management the past, and a syndicate of partners with which to buyouts or acquisitions, and are the only way that an invest. VC funds are structured around limited equity investor can realize returns from an partnerships spanning 10 years from formation to investment—that is, by liquidating the investment. liquidation that encourages an exit from investments Thus, in order to create a company which will be within the 2 to 5 year timeframe. While historical attractive to venture capitalists, it is essential to have patterns strongly suggest that traditional VCs will not companies and public markets interested in the make forays into global health, an analysis of recent investment. This means that the work of convincing venture activity reveals some potential entry points venture capitalists to invest in a company is not (e.g., devices and diagnostics, and later-stage merely about a matter of its value (financial or investments), assuming some novel market social), but also of convincing the markets at large delineation and pull mechanisms that do not that there is value that can be bought and sold. The currently exist. lack of a mature market of larger companies delivering global health innovations means that there are probably only a handful of potential acquirers for any new company. And accordingly, IPO's on the public markets for companies with global health products in their portfolios have been rare.  36 Thus, the traditional exit that venture capitalists expect is not readily apparent for most global health companies—a major deterrent to investment. Syndication The venture capital boom of the late 1990's saw many funds investing in deals on their own. However, syndication or co-investment among venture funds has become much more common in order to mitigate the financing risk that many companies face. Most venture financing is done in stages, and venture investors are well aware that subsequent funding is usually needed as companies progress through the development cycle. To that end, having multiple venture funds invest in a company helps to ensure that future funding will be available. In the second quarter of 2005, 81% of the 167 biotech and health care deals were syndicated with at least two venture funds.   37 This desire for syndication among health care VC funds can create a vicious cycle for global health companies; if few to no venture capitalists are investing in global health ventures, then even a progressive-thinking venture capitalist that sees an opportunity may ultimately have to pass because of an inability to attract other 15
  16. 16. Part II: Can Double Bottom Line or an IRR of under 10% were non-profit funds, and that Social Venture Capital Offer Any most for-profit funds target a 30 to 50% IRR (although investors in the health sector have Solutions For Global Health Innovation? historically averaged 15 to 20% IRR),  38 most funds operated according to the traditional venture norms: We are beginning to see how angel investors, venture fund managers, foundations and financial By and large, double bottom line funds operate like institutions can, linked together, become a typical small- to medium-sized venture capital significant force for social change, supporting funds. They say they concentrate on identifying entrepreneurial companies that are accelerating great entrepreneurs, building successful business the transition to a sustainable economy. There is models, aligning with strong co-investors, and much to celebrate in this story. And there is much actively managing their portfolio companies that remains to be done. through participation on their boards. Even the —Woody Tasch, chairman & C.E.O. of Investors' foundations and non-profit hybrids in this group Circle (about 17% of the funds) use VC techniques to actively manage portfolios such as taking seats on As we have discussed, traditional venture capital as boards. Nearly all of the funds report that they it is currently configured has significant limitations measure their success first in financial terms, and with respect to market size, investment lifecycle, then on social or environmental terms. 39 return expectations, exits, experienced entrepreneurs and syndication opportunities when Of the 59 funds, 33 invested in the health care industry. This survey included new, foundation- applied to global health ventures. However, a new based funds that blend social and financial returns form of venture capital is emerging that may offer like Rockefeller Foundation's Program Venture some solutions to the lack of funding available to companies developing global health products. We Experiment (ProVenEx) and noted that such funds are just starting to evaluate what is possible when are often willing to 'accept sub-market financial returns.' It also covered established venture firms investors add social criteria to the investment like MedVenture Associates, which invests in equation and whether this new approach may be medical- and health-related fields and seeks to better suited to address global health innovation than existing models. maximize investor returns. What Is 'Double Bottom Line' or 'Social' Social/DBL Venture Capital and Global Venture Capital? Health Several social/DBL venture funds have stepped up While there is much debate on terminology, 'double bottom line' and 'social' venture capital in this to experiment with global health venture investing discussion refer to for-profit and non-profit equity (See Figure 11). The existing and proposed funds are varied in nature—ranging from non-profit to for- financing vehicles with explicit social and financial profit in structure with differing return expectations— return expectations (see Preface on Terminology). In but share a common goal of wanting to invest in 2003, Columbia Business School's Research Initiative on Social Enterprise (RISE) surveyed global health companies in some capacity. private equity firms (primarily VC funds) investing in Provenex, begun in 1998, is the Rockefeller early-stage ventures and found $2.7 billion in assets Foundation's financing vehicle for working directly in 59 funds with approximately $500 million already with the private sector. It is an $18 million fund that deployed into social/DBL companies. The 59 funds makes health and other investments to further the surveyed identified themselves as 'interested in foundation's programmatic goals, seeking both a investing to achieve social or environment impact as social and financial return on investment. well as financial return’, although these funds vary Investments are structured using market principles widely in their emphasis on the mix of social, and include loans, equity investments and loan environmental and financial returns (e.g., screening guarantees to for-profit companies, non-profit out 'negative' investments, 'positive' screens, agencies and community development investment incorporation of planned philanthropy). funds. This fund has already tackled the critical issue of 'exit'. A $3.6 million investment in Biosyn, a While the RISE report notes that all funds looking for 16
  17. 17. Figure 11 Non-profit Venture Fund For-profit Social/DBL Venture Fund Traditional Venture Fund Investments in for-profits and Investments in for-profit Investments in for-profit companies grants to non-profits; Initial companies with an Definition with an expectation of both financial capital for fund is from donors, expectation of financial and social returns not investors returns Type of investment Grants, loans and equity Equity Equity No financial return from non- profit grants; moderate financial Seeks competitive financial returns, Financial return return from for-profit though may trade financial for social Financial returns only expectation investments (returns go back returns into revolving fund) Social return High social return Moderate social returns None required expectation Calvert Special Equities Acumen Fund Oxford BioScience CEI Ventures Examples ProVenEx Austin Ventures Commons Capital PATH Warburg Pincus Solstice Capital pharmaceutical company with a microbicide the alignment of investments with foundation product   40 was made through a subsidiary. Biosyn missions. This model combines the strengths of has since been acquired by a publicly traded existing ASMR investment infrastructure with company and its lead product is in pivotal Phase III motivated participants to create a risk-mitigated, clinical trials in West Africa. early-stage biotechnology venture fund suitable for focused investments in companies working on global Acumen Fund, a non-profit venture fund created in health. 2001, has invested in several health technologies including bed-nets for malaria prevention, Commons Capital, a social/DBL venture fund that telemedicine and affordable hearing aids. Acumen has primarily invested in socially responsible health Fund's model differs from ProVenEx in that it is a care companies that focus on the domestic market, non-profit and, while interested in financial returns is exploring a new for-profit venture fund focused on from the perspective of sustainability, does not seek creating sustainable global health businesses. financial returns as a primary consideration. Commons Capital's goal is to attract capital from Nevertheless, direct experience with investing in both foundations and private investors in a for-profit entrepreneurs in the developing world and a focus fund that provides financing and a high level of on measuring impact make this model an important technical assistance to global health entrepreneurs one for careful study of lessons learned. developing products mainly in the areas of diagnostics and devices (with a particular emphasis ASM Resources Inc., Commons Capital, Foundation on women's health). Strategy Group and Programs for Appropriate Technologies in Health (PATH) are in various stages Foundation Strategy Group's SI Fund for Health of conceptualizing new social/DBL venture capital Care Delivery would invest private capital to funds in the field of global health. ASM Resources demonstrate the viability of private health sector Inc. (ASMR), the for-profit venture arm of the businesses in developing countries. Specifically, the American Society for Microbiology, has designed a private capital would target downstream distribution unique fund that enables the participation of multiple and delivery of health care products and services to foundations in a venture fund. This structure creates be used by the poor in urban and semi-urban areas. the opportunity for foundations to support Potential investments include hospitals, clinics, commercial entities whose goal is to bring pharmacies, diagnostic labs and other health retail treatments and cures to the bedside while ensuring operations. 17
  18. 18. PATH is exploring the possibility of a social venture holding companies, need to be created to facilitate fund or other financing vehicle to fund global health the cycle of financial return. Perhaps global health product companies. This new financing mechanism business professionals need to be trained—where would be used in conjunction with PATH's they do not already exist—and offered substantial established mechanisms of technical and business technical assistance as part of any investment. collaboration, co-design and development, licensing, Perhaps social venture capital can cut across the policy harmonization and market development to development and commercialization cycles and help get high-impact primary health care products foster partnerships with investors at all stages. And through the value chain and into widespread use. what is sorely needed to facilitate all of these ideas is a real or virtual marketplace—where investors and In addition to these specific funds, Investors' Circle entrepreneurs can share ideas and collaborate (IC) is the nation's oldest angel network focused on around investments in for-profit global health social enterprise. IC has placed over $100 million companies. mostly in equity investments since 1992. These angels not only make direct investments in Foundations as Global Health Investors companies, but also view pooled vehicles as Foundations have the potential to be important opportunities to make directed investments in players in social/DBL investing line landscape growing companies without individual company risk. because of their global health expertise, convening IC's showcasing numerous global health companies power, interest in building sustainable institutions at its national conferences has led to angel and flexibility in crafting new financial models. A investment in several of them.   41 Internationally, burgeoning trend toward 'venture philanthropy' is angel networks are in their infancy, but as this model shifting grant-making toward market-based moves into India and China, angel networks may be principles and focusing on investments in an important source of support for social sustainable projects and ventures. entrepreneurs. This trend is bolstered by additional dollars made While these investor groups have incorporated available through program-related investments social impact into their investment strategy and in (PRI's), the financial vehicle foundations often use some cases lowered return expectations accordingly for making social/DBL investments. Importantly, to allow for global health investments, there are still PRI's may play a role in leveraging other funding many unknowns: Specifically, issues of market through a couple of pathways: First, foundations assessment and opportunity recognition, time to may act as a first investor signaling the 'worthiness' market for new products, finding global health and of the investment for other investors, for-profit and business experienced entrepreneurs, co-investment not-for-profit; second, a foundation's PRI investment, with other VC funds, staging of investment and which typically garners a 'lower' return (when opportunities for exit are still big unanswered structured as debt), can leverage other funding questions. Because social venture capital is still in sources with higher return expectations. 42 its infancy and constantly being redefined, it may offer a more flexible approach to investing than An analysis of the barriers to development of traditional venture capitalism. In addition, new neglected-disease technologies points to a few key investors such as foundations and socially- criteria which need to be in place to adequately conscious individuals are defining 'return' in new stimulate donor interest in such investments: 43 ways and realize that novel approaches are needed • A clear and well-supported understanding of to solve global health problems. the need. Traditional venture capital has shown the world how • Well-developed technology performance to bring medical innovations to the people who need characteristics to meet the need. them in the domestic context. What social/DBL venture capital can do is to take those lessons and • A network of qualified partners willing to build on them along with lessons from the global commit if resources are made available. health community. Perhaps longer time horizons are • A realistic view of the hurdles involved. needed for venture funds in order to get products to market. Perhaps new exit opportunities, such as • A credible projection of the value in terms of 18
  19. 19. benefit that could be attributed to the technology once in widespread use. At present, foundations experimenting with PRI's in global health are not necessarily collaborating with other foundations. However, it is possible to envision a collaborative effort where foundations would pool funds to prioritize key global health innovations. Another possibility is a hybrid fund where foundations, traditional and social/DBL venture capitalists pool their investments and technical assistance in a way that speeds innovation for key global health innovations. Conclusion Social/DBL venture capital is an evolving field and may offer some antidotes to the bottlenecks in the traditional venture capital model for global health. The goal will be to leverage what works in venture capital and apply new social criteria and a more flexible approach to serve this emerging global health marketplace. The three M’s can guide the development of these new models, but the realities of health care in the developing world will need to be integrated for any businesses to be truly sustainable. Importantly, other research has also supported the notion that social/DBL equity investing may present a viable funding mechanism for small growing biotech companies that are interested in developing new products for global disease. 44 19
  20. 20. Part III: Next Steps and in the developing world—to invite them to start global health companies? While the traditional venture capital industry is quite 12. What sorts of partnerships with non-profits and mature and unlikely to turn its full attention to global others with global health expertise are health innovation in the near term, the social/DBL necessary? venture capital field is still in its infancy and holds Fund Structure some promise. However, the existing social/DBL models present more questions than answers at this 13. Would a longer timeline for investment vehicles point. The Financing Global Health Ventures help global health companies get products to workshop in September 2005 will focus on refining market? these inquiries in an attempt to start developing 14. Are there specific holding companies that should solutions to spur investment in global health be developed to create exit opportunities for innovation. Below are topics of interest to be global health investments? discussed by workshop participants. 15. What financing gaps should social/DBL venture capital aim to fill? Markets 16. How should financial and social returns be 1. How can we better define and quantify global balanced in the context of global health health markets? ventures? 2. What mechanisms might be employed to create 17. Should global health venture funds be the sole more certainty in these markets? funders (vs. syndication with traditional venture 3. Are there specific segments (industry sectors, capital) in an investment seeking to ensure indications and geographies) that offer more social goals? promise for global health venture capital? Other 4. Would companies or funds geographically closer to these markets be better suited to invest in 18. How can foundations find ways to 'invest' in neglected diseases and health problems in the global health companies and build the developing world? marketplace for such companies? 5. Is a dual market strategy viable and preferable 19. What are the major barriers to investing in global to a sole focus on a developing world market? health for traditional venture capital, and how might these be overcome? 6. Are there specific market pull strategies that would encourage venture investors? 20. How might we explore social/DBL venture capital in the emerging market setting? Momentum 21. What are the lessons learned from the first wave 7. What infrastructure needs to be in place to of social VC funds? facilitate better distribution of global health 22. How can we facilitate a common ‘marketplace’ products? for investors and entrepreneurs interested in 8. Are there specific markets that offer more addressing neglected diseases? momentum in terms of ease and intelligibility of their regulatory processes? 9. What lessons can be learned from the work of We invite participants of the Financing Global Health the PPP's, and how can venture capital build on Ventures workshop to ponder these questions, bring the momentum they have created over the past new ones to discuss and help us envision a new few years? future of sustainable investing and enterprise for global health. Management 10. What technical assistance could be offered to 'train' entrepreneurs in global health and business? 11. How might we tap into the network of successful entrepreneurs in the biotech community—here 20
  21. 21. Appendix A: Examples of Equity-Financed Global Health Innovations Company Product Equity Investor A to Z Inc African manufacturer of bed nets Acumen Fund (Debt) AAR Health East African HMO –(Health Aureos Capital services) Acambis Vivotif—oral typhoid Oxford Bioscience BioSyn (now Cellegy) Savvy—HIV Microbicide ProVenEx and Warburg Pincus Celera ViroSeq—HIV-1 genotyping system Burrill & Co. Chemogen Rapid urine-based TB diagnostic CEI Ventures LabNow CD4Now—Remote CD4 diagnostic Austin Ventures, Perseus-Soros device for HIV/AIDS Biopharmaceutical Napo Pharmaceuticals Crofelemer—Anti-diarrheal drug Angel Investors PointCare Technologies CD4 monitoring device for HIV/ Angel Investors, Strategic AIDS Partners Sequella Transdermal Patch—TB Diagnostic Angel Investors Shelys Antimalarial drug Aureos Capital VaxGen AIDS vaccine Burrill & Co. VaxInnate West Nile vaccine Oxford BioScience Voxiva Alerta—epidemiology surveillance Angel Investors 21