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Innovation Working Group

A Report of the

Task Force on Sustainable Business Models in Health

DRAFT FOR COMMENT

April 25, 2012

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Fostering Healthy Businesses: Delivering Innovations in Maternal and Child Health

Executive Summary

Problem Put simply, the world is not on track to meet Millennium Development Goals (MDGs) 4 and 5. While there has been noteworthy progress in reducing maternal and child mortality since the declaration of the MDGs in 2000, more than 350,000 women and 3.5 million infants continue to die each year – nearly all from preventable causes. These deaths are concentrated in the developing world and more than half occur in just seven countries: Afghanistan, China, the Democratic Republic of Congo, Ethiopia, India, Nigeria and Pakistan. To accelerate progress and keep MDGs 4 and 5 within sight, governments, donors, businesses and NGOs cannot act alone. We need new models of collaboration among the public and private sectors. We need to think more creatively about new ways to draw on all available expertise and resources to provide health care to those in greatest need. And, as this report argues, we need to tap into the vast potential of private health businesses to deliver high-quality, affordable and accessible care to those at highest risk of maternal and child mortality. The challenge, however, is to ensure scale-up of these health businesses as healthy businesses – ones that are not dependent for their survival solely on the good intentions and one-off grants of donor governments, multilateral agencies and private foundations. The Every Woman, Every Child Innovation Working Group (IWG) has set out to understand the complexities and challenges in achieving financial viability and to recommend ways to overcome barriers to growth and sustainability for companies designed to provide needed interventions for improved maternal and child health outcomes in lower- and middle-income countries. The Emerging and Existing Private Health Sector The past few years have seen an unprecedented burst of activity among entrepreneurs and socially-minded innovators seeking to improve health for some of the poorest people in the world. Their businesses range from direct delivery of care —such as low-cost hospitals and franchise clinics —to ones that facilitate care—such as emergency transport services and mobile technology solutions. Collectively, these businesses comprise an emerging group in the global health and development community worth watching closely to identify how learn from their model,

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enhance their success and fulfill their potential to help reduce maternal and child mortality. At the same time, it is critical that we not overlook the vibrant private healthcare system that already exists – and is growing rapidly – in many lower- and middle-income countries throughout the world. In fact, more than half of people in Africa seek care from private providers; and this rate is even higher in Latin America and South Asia, where private providers are estimated to deliver services to 66% and 80% of the population, respectively. The private healthcare system – a mélange of independent physicians, nurses and midwives, together with private clinics, hospitals, pharmacies and health shops – has tremendous reach into high-need communities. They are based in the communities they serve, have many touch points with families and, as businesses, have learned how to establish trust and build customer loyalty. The frequent criticism of private health care, however, is that it is unregulated and that quality of care is poor. Task Force on Sustainable Business Models in Health Given its reach and ability to innovate, private health care has an important role to play in supplementing public health systems and supporting governments’ efforts to reach the MDGs. But these businesses need support to help them reach scale and have a real impact in saving the lives of women and children. This Task Force on Sustainable Business Models in Health —commissioned by the IWG—has been charged with exploring the landscape of health businesses serving poor women and children in lower- and middle-income countries to understand what it will take for such organizations to reach scale and yield long-term improvements in health. Task Force members brought a wide variety of practical experience to the work (Task Force members are listed on page 4; see the roster of Reference Group members in the Annex). They harnessed their deep knowledge and consulted with dozens of experts in global health and development to learn about promising new business models; creative ways by which longstanding businesses are reaching poorer populations; and the challenges all these businesses continue to confront as they try to grow, to survive and – most importantly – to thrive. Key Findings What we heard consistently is that the leading barriers today’s businesses face fall into three main categories: access to working capital; creating demand for health products and services; and designing the right incentives to serve the poor in a sustainable way.

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Perhaps the most striking finding – which, in retrospect, seems obvious – is that businesses striving to reach people at the bottom of the pyramid face the same constraints and opportunities as any other businesses. The financial, organizational and leadership challenges of managing a successful business are similar, whether a company is trying to serve people who are very poor and lack basic health care or serving a wealthier and healthier customer base. All still struggle with securing working capital, identifying customers in a competitive marketplace, generating adequate cash flow, hiring and retaining a skilled workforce, optimizing operational efficiencies, sourcing and managing inventory and supply, ensuring and improving the quality of products and service delivery, producing convincing outcomes and ultimately providing desired products reliably to customers at affordable prices that ensure the company’s solvency. Recommendations The Task Force’s actionable recommendations center on three complementary areas: changes in policy, financing and incentive schemes to stimulate the expansion of high-quality, accessible and equitable maternal and child health care: Incentives to Reach the Poor Governments and businesses should develop creative incentives jointly to encourage the use of health-related products and services and expand access to quality health care among those with greatest need. Governments are experimenting with performance-based incentives, voucher programs, conditional cash transfers, subsidies and insurance. Similarly, businesses are testing out cross subsidies, no-frills models and medical savings programs to attract and retain a diverse customer base to ensure sustainability. Investment Opportunities Traditional financing for maternal and child health has typically been driven by the donor community. As we look toward more sustainable models, it will be important to consider how to channel resources in a way that spurs entrepreneurial activity and achieves desired health outcomes on a broad scale. Financial cooperatives, social venture capital funds, local development banks and other investment mechanisms are becoming more popular. We need to evaluate and continue to refine the most effective ways to support the incubation and scale-up of health enterprises that serve the poor. Ensuring an Enabling Environment for Health Businesses Governments need to engage businesses more proactively in their effort to improve maternal and child health outcomes. By forging strategic public-private partnerships, implementing commerce-friendly policies and enacting regulatory measures and registration requirements to weed out substandard businesses, governments can

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advance the ability of private health care to make quick and long-lasting positive changes in health – and thus expand on and reinforce what government can achieve on its own. Moving Ahead The IWG is committed to mobilizing its multi-sector membership to carry out these recommendations, working closely with governments, financial institutions, investment firms, multilateral organizations, bilateral donor agencies, healthcare companies, business associations, networks of knowledge-generating centers (often university-based) and others. Our goal is to catalyze a wide-ranging dialogue on innovative methods to establish and develop new enterprises to improve maternal and child health outcomes in lower- and middle-income countries; to encourage experiments in a wide variety of settings; and to disseminate results broadly so that lessons learned will spark additional innovations. Special thanks to our Fellow Task Force members and the many experts from NGOs, investment firms, donor agencies, UN organizations, academic institutions, consulting firms and, most importantly, health businesses, who graciously shared their experience and insights on the key ingredients for healthy businesses – those that will save women’s and children’s lives today and for years to come. Naveen Rao Frederik Kristensen Lead, Merck for Mothers Senior Advisor, Norwegian

Agency for Development Cooperation

Task Force Members Iain Barton, CEO, RTT Health Sciences Stefan Germann, Director, Partnerships, Innovation & Accountability, Global Health and WASH Team, World Vision International Bright Simons, Founder and President, mPedigree Network Narayan Sundararajan, Chief Technology Officer, Grameen-Intel Social Business Ltd. & Program Manager, Intel World Ahead Wendy Taylor, Senior Advisor, Innovative Finance and Public-Private Partnerships, USAID

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Contents

I. Executive Summary

II. Introduction [still to come]

a. Context of maternal and child health b. The Every Woman, Every Child Innovation Working Group c. Problem Statement d. Task Force on Sustainable Business Models e. Objective of report

III. Sustainable business

a. Working definition of “sustainable business” b. Key elements of sustainable business [STILL TO COME] c. The role of sustainable business models in delivering health care to

women and children at the BOP

IV. On the Path towards Sustainability – Summary of Learnings

a. Demand i. Finding: Demand identification precedes solution delivery ii. Challenge: Converting need into demand iii. Case study: LifeSpring Hospitals (India)

b. Reaching the BOP

i. Finding: Businesses and governments can enhance access through cross-subsidies, performance-based incentives and demand-side financing mechanisms

ii. Challenge: Balancing affordability with sustainable pricing to reach the BOP

iii. Case study: Greenstar Social Marketing (Pakistan)

c. Partnering i. Finding: Focusing on core competencies while partnering around

ancillary areas enables enterprises to retain focus while building an ecosystem of care

ii. Challenge: Leveraging existing private-sector channels for healthcare delivery and identifying nontraditional opportunities to collaborate

iii. Case study: Changamka MicroHealth (Kenya)

d. Local context

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i. Finding: Sustainable business models must be contextualized and locally-driven

ii. Challenge: Leveraging local knowledge, human resources and existing networks

iii. Case study: Living Goods (Uganda)

e. Scaling up i. Finding: Governments are essential to catalyzing market-based

models for health care and supporting scale-up ii. Challenge: Establishing an enabling policy environment iii. Case study: Ziqitza Health Care (India)

f. Technology

i. Finding: Technology alone may not be the solution to improving health, but it is a vital tool

ii. Challenge: Breaking the quality perception barrier iii. Case study: Click Diagnostics (Botswana, Bangladesh)

g. Measuring impact

i. Finding: There is a need to evaluate the impact of businesses aiming to deliver care at the BOP

ii. Challenge: Until we are able to measure impact, it will be difficult to know what works and where to encourage scale-up

iii. Case study: RedPlan Salud (Peru)

h. Doing Business i. Finding: The same challenges that apply to traditional businesses

also apply to “sustainable” businesses that seek to deliver maternal and child care at the BOP

ii. Challenge: Obtaining capital, determining appropriate legal structure and finding and retaining talent

iii. Case study: eHealthPoint (India)

V. Recommendations

VI. Annex

a. Reference Group

b. Full case studies

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Every Woman, Every Child Innovation Working Group Task Force on Sustainable Business Models

1. “SUSTAINABLE BUSINESS”

Working Definition of “Sustainable Business” The Task force on Sustainable Business Models defines “sustainable business” to be a market-based, pro-poor model that provides low-income consumers with critical goods and services in a financially-sustainable way.

Key Elements of a Sustainable Business [STILL TO COME]

The Role of Sustainable Business Models and Market-Based Solutions in Delivering Health Care to the BOP Traditionally in most low- and middle-income countries (with the notable exception of India), delivering health care services to the BOP has been primarily the role of governments and NGOs. Over the last two decades, the private sector has played an increasingly larger role in the provision of both health care delivery and health care financing. While private sector players are often thought of as large hospital chains catering to the rich, a number of market-based models focusing on the poor have grown globally. These include low-cost hospitals, health care rural kiosks, micro-franchising organizations, and many other disruptive models that aim to increase accessibility to health care for the BOP. Using a market-based approach, these organizations aim towards financially sustainability, with the revenues from their goods and services covering the cost of operations and capital expenditure. This report aims to identify learnings across the various models, framed around common challenges that sustainable businesses face.

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II. On the Path towards Sustainability – Summary of Learnings

1. DEMAND “Build it and they will come?” The key salient feature that sustainable businesses share is a pro-poor business model focused on providing critical goods and services to low-income individuals in a financially-sustainable way. The key to sustainability and scale, of course, is a strong customer demand. However, in providing these pro-poor goods and services, it can be easy to confuse need with demand. As described by Monitor Inclusive Market’s “Emerging Markets, Emerging Models” report:

“The most common mistake among unsuccessful market-based solutions is to confuse what low-income customers or suppliers ostensibly need with what they actually want. Many enterprises have pushed offerings into the market only to see them fail. People living at the base of the economic pyramid should be seen as customers and not beneficiaries; they will spend money, or switch livelihoods, or invest valuable time, only if they calculate the transaction will be worth their while.”1

One example of a commercial failure targeted the Base of the Pyramid (which later turned into a philanthropic success) is Procter & Gamble’s PUR, which converts contaminated water to drinking water and was developed in partnership with the Centers for Disease Control and Prevention. Three years of test marketing ultimately resulted in a low return on investment and weak penetration rates. As Dr. Erik Simanis from Cornell University’s Johnson School of Management, states: “How did all the market research go wrong? There wasn’t a market there. Yes, when asked, villagers told the researchers that they needed clean water and would be prepared to pay for it. But when it came time to buy and use the product, the villagers decided, for whatever reason, that it didn’t make sense in their lives and simply wasn’t worth the effort.”2 Indeed, as is often the case in selling to consumers at the base of the economic pyramid, sustainable businesses need to begin with the basics: converting need to demand and creating the market. Organizations fail when they see a need and assume the market is there to address this need. Why traditional market research often does not work

1 Karamchandani, Ashish, Michael Kubzansky and Paul Frandano. “Emerging Markets, Emerging Models: Market-Based Solutions to the Challenges of Global Poverty”, Monitor Inclusive Markets, March 2009. 2 Simanis Erik. “At the Base of the Pyramid: When selling to poor consumers, companies need to begin by doing something basic: they need to create the market,” Wall Street Journal, October 26, 2009.

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Interviews and focus groups are common tools that sustainable businesses have utilized from traditional marketing to better understand their customers. Yet as Henry Ford famously quipped: “If I had asked people what they wanted, they would have said faster horses.”3 Steve Jobs agreed: “It’s really hard to design products by focus groups. A lot times, people don’t know what they want until you show it to them.”4 The same is true across all income levels, but the challenge of uncovering long-held assumptions is exacerbated at the base of the pyramid. Let’s return to Procter & Gamble’s PUR. As Dr. Erik Simanis points out: “The development team did everything you’re supposed to do when you enter a new market, seeking out input from thousands of low-income consumers and visiting the homes of slum dwellers and villagers to understand their needs.”5 In the standard model of investment in human capital, individuals invest in a health product or service if the expected benefits outweigh its cost.6 Yet there are often many “invisible” costs at play, often associated with long-held assumptions, that traditional focus groups and community visits often miss. In the case of PUR: “Consider some of the changes a villager would need to make PUR part of her daily routine. She might have to reassess age-old folk knowledge and home remedies and learn about bacteria. Likewise, she might have to jettison long-held beliefs about what clean water looks and tastes like...And the time spent buying the product might interrupt an informal weekly chat with friends. All those disruptive changes outweighed the potential benefits of PUR.”7 While speaking with customers is essential in understanding their desires, simply asking what they “want” is not enough. Crucial is being able to observe their day-to-day activities, ask the right questions, truly listening, and developing empathy. As Malcolm Gladwell argues: “Market research, when it is observational or when it is interpretive, is profoundly useful. But those are two critical things. They require the intervention of the person conducting the research. They require the findings that are gathered are considered, and thought about, and processed and interpreted.”8

3 Goodreads.com, Quotable quotes. http://www.goodreads.com/quotes/show/15297. 4 Linzmayer, Owen. “Commentary: Steve Jobs’ Best Quotes Ever,” Wired Magazine, March 29, 2006. 5 Simanis, 2009. 6 Dupas, Pascaline. “What Matters (and What Does Not) in Households’ Decision to Invest in Malaria Prevention?”, Department of Economics, UCLA; quoting Michael Grossman 1972. 7 Simanis, 2009. 8 Gladwell, Malcolm. “Focus Groups Should be Abolished,” Advertising Age, August 8, 2005.

Finding: Demand identification precedes solution delivery The most successful businesses start with a thorough understanding of consumers and their spending habits: their needs, demands, perception of quality, ability to pay, access to finances and how they make decisions about their health care. Successful businesses capitalize on existing demand, routines and spending habits; and where these do not exist, successful businesses appropriately promote their product or service in a context and channel that fits their target market.

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Often, this level of observation and insight-generation occurs best not in a focus group, but in consumers’ communities and homes through immersion. One of the best examples of this at the base of the pyramid is Hindustan Unilever Ltd. (HUL) who for many years has sent young managers to live in remote rural Indian villages for eights weeks as part of its entry-level leadership training bootcamp. Rural immersions such as this have enabled HUL to better understand both the needs and demands of rural families, leading to the success of initiatives such as its “Project Shakti.” Observing how much time rural women spend at each other’s homes, HUL developed “Project Shakti” to enable women entrepreneurs (called “Shakti Ammas”) to sell Hindustan Lever’s soaps and shampoos door-to-door in rural areas where there is no retail distribution network, little advertising, and poor roads.9

Understanding what consumers want: Innovation and Human-Centered Design In addressing this challenge of converting need into demand, many successful businesses have utilized a design approach to innovation, popularized by design consulting firms such as IDEO, Frog Design, and Idiom. One tool to help social enterprises is IDEO.org’s Human-Centered Design Toolkit, an innovation guide for social enterprises and NGOs. Created with International Development Enterprise (IDE) as part of a grant from the Bill & Melinda Gates Foundation, the Human-Centered Design Toolkit supports sustainable businesses in building listening skills to translate need into demand, prototyping ideas, and developing innovative solutions.10 One example of how human-centered design can bridge the gap between need and demand is IDEO.org’s work with the Global Alliance for Clean Cookstoves (GACC), a public-private initiative of the UN Foundation. Clean cookstoves have the potential to improve health through reducing exposure to smoke from traditional fires -- particularly relevant to women who traditionally spend the majority of their time at home. As the IDEO.org team states, “Despite the significant improvements in cookstove technology in recent years, there has been too little attention paid to the habits, motivations, and

9 Prahalad, C.K. The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits, Wharton School Publishing, 2004. 10 IDEO.org. “Human-Centered Design Toolkit. https://www.ideo.org/projects/human-centered-design-toolkit/completed.

Challenge: Converting need into demand Organizations often focus on need and take demand for granted. The challenges that sustainable businesses face are: (1) truly understanding what their customers want and what drives demand; (2) successfully communicating their value proposition to end customers; and (3) enabling an “easy” point of sale for customers, leveraging their daily habits or rituals. One particular challenge in maternal and child health is preventative care, which is one of the most challenging areas for behavior change across the developed and developing world.

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aspirations of the cookstove’s target market that strongly influence adoption. Our team will focus in particular on bringing some clarity around user preferences and behaviors.”11 Through a deeper understanding of customers through immersion, then, it reasons that opportunities and innovations will be identified to increase demand for clean cookstoves. Sustainable businesses that have utilized the Human-Centered Design Toolkit include VisionSpring, which brings low-cost vision care into communities; and AyurVAID, a chain of Ayurvedic hospitals. In the maternal and child health space, LifeSpring Hospitals (see case study below) utilizes a design-based approach, as does Embrace Global, which has developed a low-cost infant warmer. All these models demonstrate the need to be innovative in developing a completely new product, rather than just a stripped-down version of existing products. As articulated by Jane Chen, CEO of Embrace: “We didn’t just take existing incubators and cost-reduce. We tried to think about the product in an entirely different setting -- for example, the needs of rural mothers.”12 Communicating the Value Proposition: Moving from “Education” to Aspirational Marketing A second challenge that sustainable businesses face in converting need to demand is around communicating the value proposition of its product or service, or “social marketing.” Traditionally, and particularly in the case of global health organizations, social marketing has revolved around educating consumers in an attempt to transition from “bad” behavior (e.g. delivering one’s baby at home without the presence of a skilled clinician) to “good” behavior (e.g. delivering at an institution). This is based on the assumption that if people simply “knew” what they were doing is bad for their health and well-being, they would certainly change their actions and habits. We know even from personal examples that this is not the case (e.g. exercising regularly). Melinda Gates, in a TEDxChange Talk, discusses what nonprofits can learn from Coca-Cola. As she states: “Ultimately, Coke’s success depends on one crucial fact: that people want Coca-Cola...What is the secret to their marketing? It’s aspirational. It associates its product with the kind of life that people want to live.”13 She contrasts the themes of celebration and unity from Coca-Cola’s marketing with the “avoidance” and “education” traditionally used by health and development organizations to market, with messages like: “Use a condom... don’t get AIDS” or “Wash your hands... don’t get diarrhea.” One set, exemplified by K’Naan’s “Wavin’ Flag” and “I’d like to teach the world to sing” builds on customer’s happiness, pride, and unity; the other is almost condescending, focusing on “should’s”. She touches on marketing challenges faced by

11 IDEO.org, “How can we support a market aimed at improving health, livelihoods, and the environment?”, February 21, 2012. 12 Chaykowski, Kathleen. “At-risk babies kept warm by Stanford innovation,” The Stanford Daily, November 18, 2010. 13 Gates, Melinda. TEDxChange, filmed September 2010. http://www.ted.com/talks/melinda_french_gates_what_nonprofits_can_learn_from_coca_cola.html

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global health organizations: “We make a fundamental mistake, we make an assumption and think that if people need something, we don’t have to make them want that.”14 One organization that utilizes aspirational marketing is Population Services International, or PSI. To support behavioral change to encourage health-seeking behaviors, PSI engages in mass media, community theater, and mobile multi-media events. During the cholera outbreak in Haiti in 2010, PSI leveraged the power of communications to arm local Haitians with information. Taking a grassroots approach to social marketing, some of PSI’s tactics during this crisis included mobile vans, entertainment education, and village tape players with megaphones.15 Another organization is Greenstar Social Marketing Pakistan, which was established by PSI in 1991. Greenstar developed and successfully marketed its first social marketing product: Sathi condoms. To sell and distribute their health products, Greenstar trained private health providers through social franchising. Today, one out of every four married couples using modern methods use Greenstar’s family planning products and services.16 Customer-focused delivery channels Identifying customer’s wants and communicating this in an aspirational way is not enough to generate demand and guarantee a sale of a pro-poor product. The final step revolves around the actual point-of-sales. Successful companies make buying their product easy for their customers. This means understanding their daily habits and routines. eHealth Points (launched by Healthpoint Services, Ashoka, and Naandi Foundation in 2009), for instance bundles their products and services together, making it easy for consumers to purchase. Each eHealth Point offers clean drinking water, medicine, and health care services. As Al Hammond, Co-Founder and Executive Chairman of Healthpoint Services, states, “We adjusted the model as we learned more about the market. We found that women won’t carry water far, but they will walk for the clinic. So we added more water to the model and created a cluster.”17 In addition to making point-of-sales easy for customers, successful sustainable businesses develop a portfolio of uses for a particular pro-poor product. As Dr. Erik Simanis argues, “When creating a market from scratch, it’s impossible to predict customer reaction. As we’ve seen, even a seemingly critical product like PUR may not gain a commercial foothold. So, instead of introducing just one product, companies should come up with a bunch of ideas, all centered on the same core technology, in the hopes that one or two may catch on.”18 He continues: “For an example of how this might work, look at the infomercials that show 20 different things you can do with an odd tool for the kitchen or garden. PUR could have followed that approach--why limit the

14 Gates, TEDxChange, 2010. 15 Nerenberg, Jenara. “Lo-Fi Social Marketing is Saving Lives in Haiti,” Fast Company, October 28, 2010. 16 Greenstar Social Marketing Pakistan - Company website. http://www.greenstar.org.pk/. 17 Hammond, Al. Telephone interview. January 20, 2012. 18 Simanis, 2009.

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pitch to water purification? Show how PUR can be used to make great-tasting soups, rice and curries or fruit juices, by adding purified water to fruit pulp.”19 Case Study: LifeSpring Hospitals (India) Innovation through Immersion LifeSpring Hospitals is an expanding chain of low-cost maternity hospitals that serve low-income women and newborns in India. Prior to starting LifeSpring, Founder and CEO Anant Kumar was working in social marketing at Hindustan Latex Family Planning Promotion Trust (HLFPPT). As part of his role heading social franchising, Mr. Kumar spent much of his time in government hospitals. It was here, through his immersion in public hospitals, that he began to observe the long waiting times that pregnant women face when attempting to see a doctor, as well as the type of service they often received in low-resourced public hospitals. He thought there had to be a better way of providing care and conceived of a chain of low-cost maternity hospitals that focus on providing affordable, quality care that treats pregnant women with respect and dignity. Speaking with women within their communities confirmed this belief. Through discussions with pregnant women and their families, Mr. Kumar learned that they desired a better experience, with some going into debt to give birth in expensive private hospitals. Based on these interactions, Mr. Kumar designed LifeSpring Hospital with the tenet that “pregnancy is not a disease.” Human-Centered Design LifeSpring approaches the challenge of converting need into demand through its human-centered design approach. Each hospital is designed to be welcoming and not intimidating, with pink walls, smiling nurses, and information boards laying out all prices transparently. Marketing is approached through outreach workers, often women coming from the very communities they focus on. Observing that attendants (often the pregnant woman’s mother or mother-in-law) were often sitting on the floor, LifeSpring began providing an attendant’s cot next to the woman’s bed -- even in the general ward. Doctors are trained to see women as customers (rather than patients), and customer feedback asks the degree to which doctors treated a customer with dignity and respect. In this way, LifeSpring provides a service that women value, building a demand for low-cost, customer-centered maternal health care. Through its focus on treating women with dignity and respect, women are more likely to come for antenatal checkups prior to their delivery.

19 Simanis, 2009.

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2. REACHING THE BOP Increasing Accessibility Access to health care is one of the key challenges that the BOP faces. This accessibility challenge can be further broken down into both financial accessibility (affordability and cash flow) and geographic accessibility (reach). Market-based solutions in delivering health care to the BOP, therefore, must address the challenge of how to reach their intended consumers. The challenges surrounding this are myriad, and include supply chain, distribution, and transportation costs. Organizations speak of an “innovation pile-up”, where the intended value of billions being spent on research and development may not be realized due to the challenges of reaching “the last mile.”

Enabling Geographic Accessibility Successful sustainable businesses address the challenge of geographic accessibility for their customers. In global health care, this may mean opening rural hospitals (such as Vaatsalya) or tele-medicine kiosks (such as eHealth Point). Going further into communities are direct-to-customer models such as HUL’s “Project Shakti” and Living Goods, whereby women entrepreneurs sell products door-to-door. Enabling Financial Accessibility The challenge of pricing a particular product or service is crucial for market-based models in health care, who must balance affordability for the patient with sustainability for the organization. This challenge is exacerbated as often the consumers of these products or services are engaged in the informal economy or in agriculture, where cash flow is not steady. As Monitor Inclusive Markets advises, pro-poor businesses should price products to match customer cash flows:

“Cash flow is king; business models that ignore the irregularities of cash flows in low-income segments are unlikely to succeed. The issue here is not just that the poor have limited amounts of cash. It’s that they have unpredictable, lumpy cash

Finding: Governments and businesses can increase access to care through cross-subsidies, performance-based incentives and demand-side financing mechanisms: Governments can influence consumption via demand-side financing and performance-based mechanisms such as voucher programs, conditional cash transfers or pay-for-performance schemes. Businesses can reach the BOP by properly building similar incentives into their model, or by targeting a diverse consumer base that would allow for cross subsidy.

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flows. This in turn drives a general aversion to paying higher prices, even for products and services that pay for themselves relatively quickly. Unless the ticket price is sufficiently low and the payback period is sufficiently brief, there will be no sale.”20

Coupled with the financial accessibility challenges of affordability and cash flow come challenges associated with physical payment. As the World Business Council for Sustainable Development states, “Traditional payment schemes may not be suited for communities lacking postal addresses, phones, credit cards, or bank accounts.”21 However, its “Doing Business with the Poor” field guide suggests that prepayment for ongoing services, incentives to encourage payments, and a collective billing system that allows a community to make a common investment are innovative payment solutions for pro-poor businesses.22 Besides these, government subsidies, micro-loans, and credit schemes may help enable revenue collection for products and services targeted at base of the pyramid customers.23 Governments can also play a role in increasing financial access. For instance, the Government of India launched the Janani Suraksha Yojana (JSY) initiative in 2005. A conditional cash transfer scheme, JSY incentivizes women to give birth in a health facility rather than at home. Implementation of JSY in 2007-2008 highly varied by state, with anywhere between 5% to 44% of women giving birth receiving cash payments from JSY.24 Impact assessments have found that JSY has indeed had a significant effect on increasing antenatal care and in-facility births, as well as a reduction of 3.7 perinatal deaths per 1000 pregnancies, and 2.3 neonatal deaths per 1000 live births.25 Coupled with the JSY scheme, the government of Gujarat has also implemented the Chiranjeevi Yojana scheme, a public-private initiative that targets women below the poverty line (BPL), and offers free treatment for delivery, plus medicines, laboratory charges, compensation for foregone wages, and Rs 200 for transportation for the pregnant woman to utilize services at a private hospital. The obstetrician is then paid by the Government of Gujarat. An example of a private hospital that has partnered with the government through these initiatives is Alka Hospital in Gujarat. A 50-bedded maternity hospital, Alka has developed the “Sampurna Suraksha Card” to provide al

20 Karamchandani et al, 2009. 21 Timberlake, Lloyd. Doing Business with the Poor: A Field Guide: Learning Journeys of Leading Companies on the Road to Sustainable Livelihoods Business. World Business Council for Sustainable Development, 2004. 22 Timberlake, 2004. 23 Timberlake, 2004. 24 Lim et al, Stephen, Lalit Dandona, Joseph A. Holsington, Spencer L. James, Margaret C. Hogan, Emmanuela Gakidou, “India’s Janani Suraksha Yojana, a conditional transfer programme to increase births in health facilities: an impact evaluation,” The Lancet, 2010. 25 Lim et al, 2010.

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antenatal care, delivery (including normal and complicated cases), and postnatal care for Rs 1500 (approximately $30 USD).26 A survey aimed at assessing the efficacy of the Chiranjeevi Yojana scheme yielded some valuable findings for demand-side financing on the whole, particularly in India. Of those Chrianjeevi clients surveyed, 96% of them received antenatal care, 71% of which received services from a private hospital or clinic. And when it came time to deliver, roughly 97% of participants delivered at a private hospital, and afterwards, 89% expressed satisfaction with the service they received27. It is also worth noting that nearly every delivery featured in this study was the woman’s first, suggesting a nascent trend towards facility births if the right demand-generating financing mechanism is in place.

Cross-Subsidy Approach To balance affordability and sustainable pricing, several sustainable businesses utilize a cross-subsidy approach to pricing their products and services. For instance, in Aravind Eye Care System has established differential pricing based on patients’ choice of amenities and type of lens. The poorer 70% of their patients are subsidized by wealthier patients who pay market rates. Another example Ziqitza Health Care Limited, whose “Dial 1298 for Ambulance” in Mumbai is financed through cross-subsidy. Patients call the ambulance service, with patients requesting a private hospital charged above cost, while those who are transported to a government hospital pay a nominal cost, and trauma patients do not pay. It has been reported that 20% of patients that have utilized Dial 1298 were subsidized.28 Government partnership has also helped other sustainable businesses reach the base of the pyramid. For instance, eHealth Point is engaged in a public-private partnership with the Rajasthan government, under which the Rajasthan government would provide

26 Center for Health Market Innovations website. “Alka Hospital Company,” 2011. http://healthmarketinnovations.org/program/alka-hospital-sampurna-suraksha-card. 27 Ramesh Bhat, Dileep Mavalankar, Prabal Singh, Neelu Singh, “Maternal Health Financing in Gujarat: Preliminary Results from a Household Survey of Beneficiaries under Chiranjeevi Scheme,” Indian Institute of Management, October 2007. 28 Onil Bhattacharyya, Sara Khor, Anita McGahan, David Dunne, Abdallah S Daar, Peter A. Singer, “Innovative health services delivery models in low and middle income countries: What can we learn from the private sector?” Health Research Policy and Systems, July 15, 2010.

Challenge: Balancing affordability with sustainable pricing to reach the BOP: Businesses that target the BOP must strike a balance between a price that is affordable for their consumers and one that allows for solvency. There are little if any profit margins for businesses at the BOP, yet governments have been largely passive in working with the private sector to reach the lowest quintiles.

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support to open eHealth Points in areas where the formal public health delivery system is low or non-existent, and demand high. These eHealth Points will include screening women and children for anemia, assessing cardiovascular risk, diabetes screening, addressing child malnutrition, ensuring antenatal care, and providing eye camps.29 Similarly, eHealth Point has established a public-private partnership with the government of Punjab, whereby the government builds the building, and eHealth Pointoperates it, thereby lowering capital expenditure. Case Study: Greenstar Social Marketing (Pakistan) Greenstar Social Marketing Pakistan is a non-profit organization focused on social marketing, particularly around the areas of family planning and reproductive health services. Greenstar works through the private sector and with the Government of Pakistan to improve access to affordable health products and services through its network of over 18,000 private doctors.30 Through its social franchising approach, Greenstar has established two networks of care: its Greenstar network of private providers focused on family planning, and a broader network of private health providers under the brand, “GoodLife.” Reaching the Base of the Pyramid To reach the poor, Greenstar focuses on demand-side financing, utilizing a voucher system aimed at low-income individuals for maternal health care and family planning services. Pregnant women participating in Greenstar’s voucher program receive a voucher booklet worth $50 USD, for which the women pay $1.21 USD (Pakistani rupees 100). The voucher booklets are comprised of a $31 USD coupon for delivery, 4 antenatal care visits, one postnatal care visit, and one family planning visit. Health care providers reimburse each woman $3 USD for transportation for the delivery and $0.60 USD for other visits.31 To address the challenge of balancing affordability with sustainable pricing, Greenstar utilizes a cross-subsidy model through its voucher system. Greenstar’s pay-for-performance model consists of supply-side payment to providers and demand-side vouchers that subsidize the costs of reproductive health services and transportation for poor women.32 Coupled with this, Greenstar has developed an outreach strategy to target women who had previously had a home delivery, as well as accreditation and training for private providers through Greenstar’s network.33 75% of its healthcare

29 Center for Health Market Innovations website. “E Health Point.” http://healthmarketinnovations.org/program/e-health-point-0. 30 Center for Health Market Innovations website. “Greenstar.” http://healthmarketinnovations.org/program/greenstar. 31 Bashir, Hamid, Sarfaraz Kazmi, Rena Eichler, Alix Beith and Ellie Brown. “Pay for Performance: Improving Maternal Health Services in Pakistan”, USAID Case Study: Health Systems 20/20 Project, September 2009. 32 Bashir et al, 2009. 33 Bashir et al, 2009.

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outlets are located in low-income neighborhoods, and 70% of its clients report a household income of less than 7000 PKR) per month (or around $2.50 USD per day).34 The Role of Government The Government of Pakistan has played an important role as well, helping enable Greenstar to reach low-income Pakistanis by providing government exemptions for commodity imports and exemptions around Greenstar’s social advertisement campaign.35 The Ministry of Population Welfare (MoPW) facilitates the execution of Greenstar’s operations, and also supports access to foreign assistance.36 34 Company website. http://www.greenstar.org.pk/. 35 Company website. http://www.greenstar.org.pk/. 36 Company website. http://www.greenstar.org.pk/.

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3. LOCAL CONTEXT While building a replicable model is a key to scale, sustainable business models must also be contextualized and locally-driven. As Acumen Fund reflects, “We won’t succeed in the long term without cultivating local leaders, local money, and strong local communities.”37 Acumen argues that to solve the toughest problems of poverty, what’s needed are “robust local solutions whose long-term viability is based not on the decisions of a faraway funder but because they have deep, lasting support from local teams, local capital, and, most importantly, millions of local customers. This approach can take longer to execute, but it’s the only one that lasts.”38

As Acumen Fund states, “There is no currency like trust, and there are no shortcuts to earning it.”39 Consumers tend to trust businesses that are locally-bred and grown. As Acumen puts it, “Low-income communities are often understandably wary of outsiders coming in with ‘solutions to their problems’... Trust is the most precious commodity we can offer. Building it takes time, and it can be destroyed in an instant.”40 eHealth Point combines video-conferencing with licensed medical doctors with in-person lay health workers and clinical assistants, who are recruited from local villages and trained by Healthpoint Services. Additionally, LifeSpring Hospitals has found that its most successful community outreach workers are those who live in the communities in which she serves.

37 Acumen Fund, “Ten Things We’ve Learned About Tackling Global Poverty,” 2011. 38 Acumen Fund, 2011. 39 Acumen Fund, 2011. 40 Acumen Fund, 2011.

Finding: Sustainable business models must be contextualized and locally-driven: Trust underlies brand recognition, and consumers across the income spectrum tend to trust businesses that are locally-managed and attuned to their environment. Word of mouth is often a primary promotional channel, and tends to benefit companies operating on a more localized level.

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Case Study: Living Goods (Uganda) The “Avon” of Pro-Poor Products Living Goods provides low-income families access to affordable health products focused on prevention, treatment, fast-moving consumer goods, and pro-poor innovations (such as clean-burning cookstoves). At the core of their model is a network of community health promoters: a cadre of independent agents who sign a franchising agreement with Living Goods to operate under a Living Goods license. In this way, Living Goods has been able to successfully tap into existing local networks within the communities in which it operates. Due to this asset-light approach that brings the market straight to consumers’ doors, Living Goods has been dubbed the “Avon” of pro-poor products. Tapping Local Knowledge From the outset, the organization’s focus on tapping local knowledge has been strategic and deliberate. When Living Goods began operations in Uganda, CEO and Founder Chuck Slaughter visited local village councils for recommendations on women who were most likely to succeed as community health promoters, thus targeting the most networked and potentially highest-earning women.41 Mr. Slaughter himself became an Avon representative in California to learn more about the Avon model and ideas to successfully train community health promoters. As he later reported: “Avon has a simple but brilliant tool that we shamelessly knocked off.”42 This consisted of developing a social map of each agent’s network, based on a list of everyone they know. Each agent then developed a marketing plan based on this social map. In this way, Living Goods continues to leverage each community health promoter’s local networks to sell goods. Community Health Promoters

41 Katayama, Lisa. “How Health Care Nonprofit Living Goods Learned a Lesson from Avon Ladies,” Fast Company, December 10, 2010. 42 Katayama, 2010.

Challenge: Leveraging local knowledge and existing networks: Successful organizations that serve the BOP are often able to tap into existing local networks, whose proximity to end customers allows these businesses to be more attuned to the demands, routines, and spending habits of their surrounding populations. This local network may consist of microentrepreneurs or small shopkeepers. Sometimes dubbed the “informed” sector, these networks are often (but not always) in the informal sector, often defined as the part of an economy that is not taxed or included in GDP. Organizations that leverage local knowledge and existing networks are better positioned to succeed.

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To join the Living Goods network, aspiring community health promoters sign a franchise agreement and take out two forms of loans: a fixed capital no-cost-loan for uniforms, storage chest, and a thermometer; and a low-interest loan of about $75 a year for purchasing inventory43 Living Goods’ field staff then provide community health promoters with an initial two-week training course, refresher trainings, marketing support, field mentoring, and performance monitoring.

43 Katayama, 2010.

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4. PARTNERING Deciding When to Partner As is the case in traditional businesses, understanding one’s competitive advantage is crucial for social businesses to stay focused on impact and prevent diffusion of their resources across varying activities and initiatives. Clarifying this focus, however, may be difficult when addressing complex and inter-dependent health needs. In the case of a sustainable business addressing the problem of maternal mortality, for instance, a key challenge is identifying which areas are core to the business, and which areas -- while crucial to the overall problem of reducing maternal mortality -- are better addressed through partnerships with external organizations.

The World Business Council for Sustainable Development discusses the three building blocks of successful sustainable businesses: (1) Focus on core competencies; (2) Partner across sectors; and (3) Localize the value creation. 44 Specifically regarding the creation of holistic partnerships, the Council’s advice for pro-poor businesses include:45

• Create partner networks that offset potential risks • Involve partners from the very beginning • Work together to align goals • Ensure that expectations on both sides are clearly set • Design strategies • Partnerships and trust are built over time

In the field of maternal health, ClickDiagnostics and Changamka have both developed innovative partnerships with mobile carriers in Botswana and Kenya respectively (see Changamka case study below). Greenstar, a non-profit, has scaled through partnerships with the private sector through social franchising; and Healthpoint Services announced a learning partnership with Procter & Gamble Company at the m-Health Summit in November 2010. This partnership aims to advance a scalable, self-sustaining model to deliver water, health care, and other benefits. Through the learning 44 Timberlake, 2004. 45 Timberlake, 2004.

Finding: Focusing on core competencies while partnering around ancillary areas enables enterprises to retain focus while building an ecosystem of care: The private sector is already quite active in providing health care at the BOP, and the poor continue to seek care from private providers. Collaboration within the private sector creates “shared value” as businesses capitalize on each other’s competencies while identifying various forms of ROI.

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partnership, Procter & Gamble has provided financial support, experienced people, and in-kind services.46

A recent report by FSG on shared value in global health states that: “Global health stakeholders desire a move away from charity to more sustainable and scaleable ways to provide drugs, vaccines, and medical devices to patients in underserved markets. And these stakeholders want to partner -- in a recent survey, 79 percent of nonprofit organizations reported that pharmaceutical and medical device companies are essential partners in the effort to achieve their mission.”47 The report goes on to discuss a key principle around implementing shared value for global health: “Companies are looking to a new set of partners to help with shared value strategy-setting and specific competencies in adapting products, improving productivity and cost effectiveness, and strengthening the competitive context.”48 Case Study: Changamka MicroHealth (Kenya) Changamka MicroHealth provides products that allow low-income individuals to save money towards doctor visits, medicines, and other health needs. Originally focused on smartcards sold in retail outlets, Changamka is currently shifting its business model to a fully mobile-based platform, a process which is expected to be completed by the end of February 2012. Its focus will remain around outpatient services, maternal health, and e-vouchers for beneficiaries of safe motherhood, family planning, and food programs. Partnerships

46 Healthpoint News Release. “Healthpoint Services Announces Innovative Learning Partnership with Proctor & Gamble.” PRNewswire via COMTEX, November 9, 2010. 47 Peterson, Kyle, Samuel Kim, Matthew Rehrig, Mike Stamp. “Competing by Saving Lives: How Pharmaceutical and Medical Device Companies Create Shared Value in Global Health”. FSG white paper, 2012. 48 Peterson et al, 2012.

Challenge: Leveraging existing private-sector channels for healthcare delivery and identifying nontraditional opportunities to collaborate: The current supply chain for maternal and child health care is plagued with disconnectedness, poor infrastructure, misaligned price points and a quality-affordability-accessibility trade-off. However, those at the BOP still consume products and services related or tangential to health, and these spending habits should be harnessed through nontraditional partnerships.

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Changamka MicroHealth partners across technology platforms, insurance, mobile financing, distribution centers, and a network of hospitals and clinics, thus leveraging existing private sector channels for healthcare delivery, as well as identifying nontraditional opportunities to collaborate, such as with mobile phone operators. On the supply side, Changamka partners with hospitals as well as NGOs (health clinics and networks). Hospitals are taken through an accreditation process to control for quality. Its medical provider network includes Pumwani Maternity Hospital in Nairobi (with capacity to deliver 300 babies per day), as well as 25 clinics and medical centers across Nairobi, Kikuyu, and Mombasa for outpatient services. In July 2010, Changamka began partnering with two more maternity hospitals in the outskirts of Nairobi, two in Mombassa, and one in Nairobi. In the next few months, Changamka plans to partner with six more maternity hospitals in Nairobi.49 On the demand side, Changamka has partnered with mobile phone operators and insurance companies, including Kenya’s Health Insurance Authority.50 Additionally, Changamka MicroHealth has partnered with GA Insurance as an underwriter.51 Clients are able to save on a smart card through mobile money systems (M-PESA) and make payments at designated providers.52 Safaricom is the GSM network provider used to carry out transactions.53 Changamka MicroHealth currently has eighteen distributers across Kenya (including Chandarana Supermarkets, LiveWell Ltd, I & M Bank, and Uchumi Supermarkets) where clients can buy Smart Cards. This model, however, is shifting as Changamka transforms into a mobile-platform model. 49 Agutu, Sam and Zach Oloo. Telephone Interview, January 20, 2012. 50 Phone interview with Sam Agutu and Zach Oloo, January 20, 2012. 51 Center for Health Market Innovations, “Changamka Microhealth Limited,” http://healthmarketinnovations.org/program/changamka-microhealth-limited. 52 Center for Health Market Innovations. “Changamka Microhealth Limited.” 53 Center for Health Market Innovations, “Changamka Microhealth Limited.”

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5. TECHNOLOGY Technology is a powerful tool to address global health challenges... Within the global health space and maternal health in particular, technology has the disruptive potential to create lasting change. Technological innovations in recent years in the maternal health space include clinical innovations such as pocket-sized ultrasound scanners produced by GE and others, and a portable fetal monitor developed by the West Wireless Health Institute.54 Technological innovations also allow patients to consult with a doctor remotely, as well as utilize mobile phones which have become ubiquitous across the developing world to relay information. eHealth Points, for instance, utilizes a clinic model, where tele-medical consultations are conducted via video-conferencing with licensed medical doctors and lay healthworkers/clinical assistance (who are recruited from local villages and trained by Healthpoint Services India).55 Additionally, mHealth SMS messages that allow pregnant women to receive information about their pregnancy linked with their due date.56 Besides arming pregnant women and end consumers with pertinent and timely information and increased access, technology also increases the effectiveness and efficiency of back-end operations. For instance, Dimagi’s CommCare strengthens the effectiveness of community health workers across ten countries, who are equipped with open source software that contains registration forms, checklist, high risk factor monitoring for pregnant women, and tracking of pregnant women.57 At 1298, employees staff the 24-hour control room and tracks calls using Google Earth and global positioning systems on each ambulance.58

...But technology alone is not the answer While crucial, dissemination of information through technology (whether through SMS message or tele-medicine services) is only the first step. Sustainable businesses must help customers make the shift from knowledge (“there are dangers associated with

54 Needleman, Rafe. “GE shows off pocket-size ultrasound scanner,” C/NET News, October 20, 2009. 55 Healthpoint Services company website. http://ehealthpoint.com/. 56 Maternal Health Challenge by IDEO, Nokia, Oxfam. http://www.openideo.com/open/maternal-health/brief.html. 57 Dimagi Company website. http://www.dimagi.com/. 58 Naim, Anjum. “Rushing to the Rescue,” Span Magazine, May/June 2010.

Finding: Technology may not be the solution to improving health, but it is a vital tool: Technology plays a major role in overcoming infrastructure barriers that often inhibit the delivery of health care at the BOP. The appropriate use of technology can bridge a range of private-sector players—both health-related and non-health-related—in the delivery of maternal and child care.

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giving birth at home in the absence of a skilled clinical attendant” via SMS) to a change in behavior (e.g. having an institutional delivery). We all know from personal experience that access to medical information (e.g. the importance of working out and getting adequate sleep) does not often translate to behavior. This is true across the income ladder, yet many organizations still focus predominantly on “education” as their core driver in changing behavior at the BOP. Additionally, a technology must be backed with a strong business model that addresses an unmet demand by the base of the pyramid. As Acumen Fund reflects, “People buy services that they understand; they don’t buy technologies alone. Innovations in delivery - which require genuine input from customers, working partnerships with distributers, and getting economic incentives right - are often more important than elegant designs.”59

Any disruptive model requires a shift in mindset to break the quality perception barrier. One rural telemedicine model in South Asia, for example, spoke of the difficulties in convincing patients that the doctor on the computer screen was a genuine doctor interacting with the patient in real time -- and not merely a video that is played for every patient.60 As Acumen Fund notes: “No matter how great an invention is, the business has to function in the real world where dealers, distributors, business partners, employees, and especially customers must vote in favor of your product each and every day.”61 Case Study: Click Diagnostics (Bangladesh, Botswana) ClickDiagnostics is a global mobile health (mHealth) organization that focuses on addressing the challenges of accessibility, affordability, and shortages of trained health

59 Acumen Fund, 2011. 60 Interviews with Indian social enterprise, February 2012. 61 Acumen Fund, 2011.

Challenge: Breaking the quality perception barrier: Convincing the poor to purchase a new product or service is generally quite difficult, as they tend to be risk-averse and wary of innovation. There is frequently a difference between a consumer’s perception of quality (often provided by “quacks”) and actual, clinical quality (often provided or enhanced by technology).

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professionals. Its platform of mHealth products consists of medical services, patient management, administration and planning, and mPayment and financing. mHealth and Women’s Health Women’s health care is a large focus of ClickDiagnostics’ work. The organization has partnered with BRAC Manoshi in Bangladesh, where ClickDiagnostics designed an mHealth system specifically focused on maternal, newborn, and child health. In Botswana, ClickDiagnostics designed an mHealth system focused on cervical cancer screening, as well as HIV clinical staging, mobile tele pre/post-oral surgery, tuberculosis screening mobile tele-dermatology, and mobile tele-radiology.62 Telemedicine plays a large role in the Botswana model, which revolves around a junior doctor or nurse in a rural clinic capturing patient information through Orange’s 3G mobile broadband, GPRS, and EDGE telecommunication networks. This information can then be sent to a medical specialist in Gaborone or the US, through the Botswana-UPenn Partnership Program.63 62 Click Diagnostics company website. http://clickdiagnostics.com/. 63 “Orange (Botswana) and Botswana-UPenn Partnership Pioneer Mobile Phone Telemedicine,” The Botswana Gazette, July 9, 2010.

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6. SCALING UP The Need for Scale The importance of scalability lies in a pro-poor business’s ability to reach and improve the lives of significant numbers of people living at the economic base of the pyramid. Scale is important due to the sheer magnitude of global health challenges, which require solutions to reach millions of low-income individuals. The Challenge of Scale However, by definition, scale is difficult to reach and takes a long time-frame to achieve. As stated by Monitor Inclusive Markets: “Only a handful of enterprises in low-income markets are commercially viable and operate at scale, even in a huge potential market like India, with its more than 700 million living at or below the poverty line. There and elsewhere, Monitor investigated many celebrated enterprises, most of which served at best a few thousand customers or employed a few hundred producers. Only a small handful -- mostly well-publicized ones like Grameen Bank and Aravind Eye Care -- attained a scale sufficient to transform a “business model” into a “solution.”64

Governments can support entrepreneurialism and commercialized models for care through “social innovation,” which can refer to establishing an enabling policy environment or supporting local businesses through microcredit or microloans. Government’s role in supporting market-based solutions for care—by way of financing or policy—is a key factor in reaching scale, and thereby achieving sustainability. As Acumen Fund reflects, “Governments rarely invent solutions, but they can scale what works.”65 More specifically, Acumen points to the successes it has seen with public agencies partnering with its investees without creating market distortions: “government ministries setting up innovative subsidy schemes that allow fledgling businesses to get off the ground; state governments becoming major customers for some of our most successful companies, providing the capital needed to scale while maintaining the core innovation and quality of services upon which the company was founded.”66 Indeed, the power of the government to help grow pro-poor businesses can be seen in Greenstar Social Marketing Pakistan, which has partnered with the Government of Pakistan to increase distribution and reach of its family planning products and services. Similarly, LifeSpring Hospitals is a joint venture whereby HLL Lifecare Limited, a government enterprise, is a 50% equity holder, alongside Acumen Fund. This 64 Karamchandani et al, 2009. 65 Acumen Fund, 2011. 66 Acumen Fund, 2011.

Finding: Governments are essential to catalyzing market-based models for health care and supporting scale-up.

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partnership has enabled LifeSpring to procure free vaccinations from the state of Andhra Pradesh, a benefit which is passed on to the women that LifeSpring serves.

Businesses targeting the BOP are often constrained by a policy environment that inhibits the growth of the private sector. There is a need for governments and health ministries to invest in and commit to social innovation, which would strengthen the role of the private sector while prioritizing the social needs of civil society. As recommended by Monitor Inclusive Markets: “Address regulations that discriminate against small and medium enterprises in terms of access to finance, ability to compete, subsidized competition, and other activities that distort the playing field.”67 Concurrent with this, they also recommend that governments “encourage and provide incentives to [larger] corporations to share, extend, and adapt existing channels, since often they are the owners of the best networks even to rural areas, and this will often cost less and take less time than building new channels from scratch.”68 Case Study: Ziqitza Health Care Limited (India) Ziqitza Health Care Limited operates emergency medical response services through its Dial “1298” for Ambulance in Mumbai and Kerela, and its Dial “108” for Emergency” in Bihar, Trivandrum, Rajasthan, and Punjab. Dial 1298 was launched in 2005 in association with London Ambulance Service, a UK Government Agency, which helped provide processes, systems, protocols, and training assistance to Dial 1298.69 From ten ambulances in Mumbai in 2007, Ziqitza currently operates more than 800 ambulances in Mumbai, Kerela, Bihar, Trivandrum, Rajasthan, and Punjab, serving over 645,000 individuals since 2005.70 Public-Private Partnerships focused on Scale A core component of their scale-up model has been the development of public-private partnerships through its Dial “108” for Emergency model. This began in Bihar in 2009. The Principal Secretary Health in Bihar designed the 108 emergency model, which included partnership with the private sector as a main component. Specifically, a competitive bidding process was utilized to select a private provider to operate the 108 67 Ashish Karamchandani et al, 2009. 68 Karamchandani et al, 2009. 69 Center for Health Market Innovations, “Ziqitza – 108 Emergency Response Services.” http://healthmarketinnovations.org/program/ziqitza-108-emergency-response-services. 70 Ziqitza Health Care Limited company website. http://zhl.org.in/.

Challenge: Establishing an enabling policy environment.

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emergency model, and an ambulance user fee of Rs 300 (approximately $6 USD) was utilized to incentivize the private sector for better performance and prevent misuse. 71 Through this competitive bidding process, Ziqitza was selected as the principal contracted provider. Following Bihar, Ziqitza developed a similar public-private partnership model with the Punjab State Government, and began offering services in 2011. Since then, Ziqitza has developed public-private partnerships in Trivandrum and Rajasthan as well. Users of the emergency services either pay Rs 300 (as in Bihar) or are provided free services, based on the particular contract with the participating government.72

71 Center for Health Market Innovations, “Redplan Salud.” http://healthmarketinnovations.org/program/redplan-salud-rps 72 Center for Health Market Innovations, “Redplan Salud.”

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7. MEASURING IMPACT Output vs. Outcomes As an organization focused on both financial and social objectives, “success” for a sustainable business rests on both profitability and social impact. While measuring financial performance is fairly straight-forward, measuring social impact is quite difficult. Most sustainable businesses and impact investors measure outputs, or the direct “product” of any activity delivered (e.g. number of safe deliveries or number of vaccinations given to infants). Very few sustainable businesses or investors measure outcomes, or the benefit or change resulting from the activity (e.g. decrease in maternal or infant mortality/morbidity).73 The challenge of measuring impact A key reason for this is simply the difficulty and resource intensiveness such a rigorous study would take, when each social enterprise is focused on doing business, serving its customers, and scaling up (see “Doing Business”, below). As Laura Callanan, who leads McKinsey & Company’s research on social impact assessment and social investing, states: “Social problems are complex, dynamic problems happening in uncontrolled environments. We are used to measuring financial results on a quarterly basis in the corporate world. That just isn’t realistic when it comes to social impact. It’s a long-term endeavor. There are many factors to consider. The variety of detractors and drivers of progress makes it very hard to know the exact role your work plays.”74 Indeed, measuring impact remains elusive.75 There are few studies and independent randomized control trials researching the impact of social enterprises and sustainable business models. Greater evidence attesting to improved quality, lower costs, and better clinical outcomes will give more credibility to the space, particularly regarding the public health community who are often wary of market-based solutions, as well as to impact investors looking to quantify the social return of their investment.

The path forward In recent years, a number of initiatives have launched to begin answering the question: “how much social impact has a particular organization generated?” These include 73 “Monitoring, Evaluation, and Outcomes,” Be Better @ Funding 74 Josh Cleveland, “SOCAP 10: Learning for Social Impact,” Next Billion, October 8, 2010. 75 Working definition for “Social Impact Assessment” as put forth by McKinsey & Company is a “meaningful change in economic, social, cultural, environmental and/or political conditions due to specific actions and behavioral changes by individuals and families, communities and organizations, and/or society and systems. Assessment evaluates characteristics, practices, results, and/or value of activities.” McKinsey white paper: “Learning for Social Impact: What Foundations can do”, April 2010.

Finding: There is a need to evaluate the impact and quality of businesses aiming to deliver care at the BOP.

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Acumen Fund’s “PULSE”, GIIN’s “IRIS”, and the Global Impact Investing Rating System (GIIRS). Additionally, a number of sustainable businesses have begun to measure output and impact using external bodies. Understanding the need to measure and evaluate results, particularly in the health care delivery space, ClickDiagnosis has engaged in a study that assessed the scope to which a mobile-based solution could improve maternal and child health, specifically focusing on efficiency, cost benefit analysis, usability, and value creation.76 A 2008 study published in the Harvard Health Policy Review showed that franchisees of Greenstar Social Marketing Pakistan served a higher proportion of poor clients (35.1%) than government facilities (23.4%), and that Greenstar franchises provided higher quality services (24.9 = mean total quality) than both for-profit private facilities (15.2) and not-for-profit private facilities (18.1).77 More recently, Changamka has partnered with SHOPS (Strengthening Health Outcomes through the Private Sector project, funded by USAID) to begin evaluating Changamka’s model. Specifically, the study focuses on evaluating the impact of maternity savings cards on access to quality care.78 This report, focused on outpatient care and maternal health, will be available in the next three months.79 Additionally, Living Goods has engaged with The Poverty Action Lab towards an independent randomized control trial, focused on how well Living Goods has been able to meet its primary objective of reducing mortality and morbidity for children under five. At the mid-line evaluation, researchers found that the price of malaria medicines were significantly lower in treatment areas, while quality was significantly higher.80

Practical Measurement Impact measurement allows sustainable businesses to understand whether they are truly meeting their social mission objectives, while it allows investors and policymakers to better understand where their investments and policies generate the most social impact. In its white paper on “Learning for Social Impact,” McKinsey & Company points to a set of five best practices to support a learning-driven approach to measuring

76 Alam, Mafruha, Tahmina Khanam, and Rubayat Khan, “Assessing the scope for use of mobile based solutions to maternal and child health in Bangladesh: A case study,” 2010. 77 Bishai, David, Nirali Shah, Damian Walker, William Brieger, David Peters. “Social Franchising to Improve Quality and Access in Private Health Care in Developing Countries”, Harvard Health Policy Review, Volume 9, No. 1, Spring 2008. 78 SHOPS website 79 Phone interview with Sam Agutu and Zach Oloo, January 20, 2012. 80 Phone interview with Joe Speicher, January 31, 2012.

Challenge: Shift impact assessment from a backwards-looking exercise to one that allows organizations to learn and be more effective moving-forward.

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impact:81

1. Hear the constituent voice 2. Assess to learn and do: assessments should be undertaken in a spirit of inquiry,

asking “what do we want to learn?” 3. Apply rigor within reason 4. Be practical: where possible, use tools that already exist 5. Create a learning culture

As the McKinsey report emphasizes, impact measurement must begin with asking the right question. It quotes Jackie Williams Kaye from The Atlantic Philanthropies, who says: “People assume that the question of interest is ‘Did it work?’ Well, that could be the most useful question to explore, but it also could be ‘How did it work?’ or ‘How will it work?’ or “Does it work every time?” or “Why did it work?” Case Study: RedPlan Salud (Peru) The Instituto Peruano de Paternidad Responsible (INPPARES) is the largest private, non-profit provider of family planning services in Peru. In 2002, INPPARES launched RedPlan Salud (RPS), a network of midwives that serves lower-income, able-to-pay clients. RPS providers are licensed midwives with pre-existing clinics serving low-income women in urban and peri-urban areas of Peru.82 Monitoring and Evaluation RPS focuses on monitoring and evaluation to ensure quality assurance on its products. This consists of collecting monthly information on the products sold and services provided by midwives through a reporting form delivered to headquarters. Additionally, every other year, RPS conducts surveys around member midwife satisfaction with the RPS network and client profile gathering (including the frequency of registered services).83 81 McKinsey white paper: “Learning for Social Impact: What Foundations can do”, April 2010. 82 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011. 83 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011.

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8. DOING BUSINESS Still a Business... The same challenges that apply to traditional businesses also apply to sustainable businesses that seek to address health care needs with market-based solutions. These include a myriad of operational, pricing, distribution, and financing challenges -- with the added complexity of balancing direct social impact. The innovation comes in thinking of the poor as business partners and customers. Low-cost models of delivering health care are not merely stripped-down versions of existing models, but rather a wholly disruptive model of care. ...Working in Innovative Ways to Address the BOP As the World Business Council for Sustainable Development states in their “Doing business with the poor field guide”: “Companies may have to develop new ways of packaging, marketing, distributing, advertising, and charging -- the same old business problems, with new solutions... Normal business principles apply and are essential to the success of sustainable livelihood ventures in the same way that they are for conventional businesses.”84 The field guide continues with a discussion of three sound foundations of sustainable businesses:85 (1) Focus on your core competencies when adapting your business model (2) Partner with external resources that offer complementary expertise (3) Localize the value creation by harnessing local intelligence and capabilities

The importance of business fundamentals In their report, “Emerging Markets, Emerging Models,” Monitor Inclusive Markets describes the “all-too-common” problem for companies developing pro-poor products and services: a company believes that “a superior product would sell itself, thus ignoring business fundamentals”, for instance “failing to think through its distribution model and pricing.”86 The report continues: “A great product idea married to a noble mission, however, is rarely enough to make meaningful progress in the face of massive social challenges like improving the lives and livelihoods of billions worldwide living in impoverished conditions. Success requires business models that work in the particular circumstances of the bottom of the economic pyramid, where consumers and channels 84 World Business Council for Sustainable Development, “Doing Business with the Poor: A Field Guide”; Learning Journeys of Leading Companies on the Road to Sustainable Livelihoods Business. 85 World Business Council for Sustainable Development, “Doing Business with the Poor: A Field Guide”; Learning Journeys of Leading Companies on the Road to Sustainable Livelihoods Business. 86 Monitor Inclusive Markets, “Emerging Markets, Emerging Models: Market-Based Solutions to the Challenges of Global Poverty”, Ashish Karamchandani, Michael Kubzansky, Paul Frandano, March 2009.

Finding: The same challenges that apply to traditional businesses also apply to “sustainable” businesses that seek to deliver maternal and child health care at the BOP.

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to reach them are not only extremely price-sensitive, but also cut off from news and facts that might help.”87 In particular, Monitor discusses Servals’ Venus burner, a clean burner that uses 30% less kerosene than conventional models. Despite management expectations, sales of the Venus burner remained low upon launch. The biggest drivers of this low penetration rate were distribution challenges and an expensive price point relative to competitors (as the company had priced the product double traditional burners, due to its fuel efficiency).88 Once the company focused on business fundamentals such as pricing and distribution, however, sales of the Venus burner grew tremendously, crossing one million units in 2008. Specifically, the company reengineered the burner, revised price to be more competitive, and improved dealer margins.89 What Servals’ Venus burner shows is that despite innovative technology and a core mission focused on improving lives, business fundamentals must be in place for the company to thrive. A Delicate Balance: Aligning Incentives At the same time, what differentiates pro-poor sustainable businesses from traditional businesses is this core mission. Sustainable businesses must delicately balance their business objectives with their social objective; successful ones ensure that incentives are aligned to meet each of these goals. Successful sustainable businesses watch whether either of these objectives -- whether social or financial -- are out of balance, and make appropriate changes. For example, LifeSpring Hospitals began with a model of cross-subsidization. Customers who could afford LifeSpring’s semi-private and private wards cross-subsidized poorer customers who stayed in LifeSpring’s general ward (a typical LifeSpring Hospital comprised of 70% of beds in the general ward). Because overall profitability rested on ensuring high occupancy of its semi-private and private wards, however, LifeSpring found a conflicting set of priorities and incentives: while LifeSpring’s social mission targeted women staying in the general ward, its model for sustainability rested on women staying in the semi-private and private wards. This led to differences in approach to how women were marketed to and targeted, dividing the time of important resources such as community outreach workers. To avoid mission drift and remain focused on its core set of customers, LifeSpring ultimately shifted its model from a cross-subsidy approach to a “general ward-only” model. In doing so, it engaged in a rigorous activity-based costing analysis to further 87 Monitor Inclusive Markets, “Emerging Markets, Emerging Models: Market-Based Solutions to the Challenges of Global Poverty”, Ashish Karamchandani, Michael Kubzansky, Paul Frandano, March 2009. 88 Monitor Inclusive Markets, “Emerging Markets, Emerging Models: Market-Based Solutions to the Challenges of Global Poverty”, Ashish Karamchandani, Michael Kubzansky, Paul Frandano, March 2009. 89 Monitor Inclusive Markets, “Emerging Markets, Emerging Models: Market-Based Solutions to the Challenges of Global Poverty”, Ashish Karamchandani, Michael Kubzansky, Paul Frandano, March 2009.

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lower its operational costs, although it also raised prices to ensure the general ward-only model was profitable. Continuing beyond the pilot and roll-out period, LifeSpring engaged in socioeconomic analysis of its customer base to ensure that it was still reaching its target group of women living in families making between $2-5/day (typically the wives of auto rickshaw drivers or vegetable sellers).

By far the most common challenge cited during this study is the difficulty that aspiring sustainable businesses face in accessing capital beyond start-up and angel funding. Many CEOs we spoke with cite that they spend 50% or more of their time raising capital, which can be difficult for early stage ventures that are not yet profitable. Traditional investors typically have a target return and a target exit date, which can be difficult particularly in health care companies with high start-up and capital expenditure costs. On the other hand, traditional foundations typically are wary of donating to private sector providers (who may not even be able to accept grant funding given their legal structure). In the past ten years, there has been an increase in social impact investors such as Acumen Fund, Omidyar Network, SONG Investment Advisors, and Bamboo Finance, who look for a blend of both social and financial returns, and offer patient capital. Indeed, despite the economic slowdown of recent years, there has been retained investor interest in social enterprise, likely due to the industry’s recession-proof nature, social objectives, and small size of deals.90 Aspiring sustainable businesses have experimented with a number of legal structures that leverages financial capital available -- some becoming a private corporation, some registering as a 501(c)(3), and some utilizing a hybrid organizational model. At the same time, practitioners point to “The Blended Value Map” and what Jed Emerson has called for to bring the impact investing industry to the next level: “We must move beyond the current capital chasm that contributes to preventing blended value ventures from achieving scale and blocks potential investors from moving new forms of capital into the market... It is obvious that new investment instruments are required, new syndication opportunities need be advanced, and an evolved, integrated

90 Deepti Chaudhary, “Investors back social initiatives, fund ventures,” Mint - The Wall Street Journal, October 5, 2009.

Challenge: Accessing capital, determining legal structure and hiring talent: Arguably the most prevalent difficulty faced by aspiring profitable businesses in the developing world is accessing capital beyond start-up and angel funding. Coupled with this, talent is a key challenge faced by social businesses.

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capital market must be brought into reality--a market that pursues economic performance with social and environmental impacts.”91 After funding, the challenge of hiring talent came up most frequently during interviews with leaders of sustainable businesses. All organizations face the challenge of hiring amazing talent; this challenge is one discussed by Google, General Electric, and others frequently. This challenge is exacerbated in the case of sustainable businesses, who, due to their low-cost business structure, are often unable to pay competitive top wages in the low- and middle-income countries in which they work. Add to this the specific clinical requirements necessary in the health care sector and the relative dearth of skilled medical professionals in sub-Saharan Africa and rural South Asia and the challenges of hiring talent become clear. Case Study: Healthpoint Services Global As a social enterprise, Healthpoint Services Global struggles with the same operational business challenges as any other enterprise -- with the added challenge of serving the BOP, profitably. In managing and scaling its eHealthPoint kiosks that provide clean water medicine, and health care services, senior leadership point to challenges around talent, financing, and competition; as well as the need for flexibility and innovation in this market.92 Business as Usual: The challenges of talent, funding, and competition As Healthpoint Co-Founder and CEO Al Hammond notes, one of the most difficult challenges that Healthpoint faces is finding good, talented people willing to work in rural areas.93 While growing businesses everywhere may face the challenge of attracting and retaining talent, the challenge is exacerbated in rural areas throughout the developing world. Mr. Hammond suggests that being backed by a well-known investor or funder can help in attracting talent. A second key challenge that social enterprises face is around funding. As in traditional businesses, most early stage social ventures are not yet profitable, yet as Mr. Hammond notes, an enterprise must be profitable in order to attract capital. Like other leaders of social enterprises, much of his time is spent raising money. Healthpoint is completely funded by private investors, and is currently closing its third equity round. The enterprise expects to be profitable as a company in 2013.

91 Jed Emerson, The Blended Value Map: Tracking the Intersects and Opportunities of Economic, Social and Environmental Value Creation, 2003. 92 Phone interview with Al Hammond, January 20, 2012. 93 Phone interview with Al Hammond, January 20, 2012.

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A third key challenge revolves around competition. Just as any other new business must focus on its key differentiator against entrenched competitors, Healthpoint must differentiate itself from other available options, most notably informal providers often referred to as “quacks.” As Mr. Hammond notes, “Quacks are tough competitors for walk-in care, so we are moving towards higher-level services, such as chronic care management and maternal care.”94 On developing Healthpoint’s package of services, he states that: “Another lesson has been around bringing a certain package of services to rural communities. We didn’t have this right when we started. We took those pieces apart and figured out what to improve and ways to do this efficiently. We’re not at the end of that process yet. We’re committed to figuring out how to do this sustainably.”95

94 Phone interview with Al Hammond, January 20, 2012. 95 Phone interview with Al Hammond, January 20, 2012.

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III. RECOMMENDATIONS Demand Social marketing pilot campaign; Journalist training program 1. The IWG could explore establishing a pilot program that tests if social marketing could effectively translate need into demand in target regions. This could be achieved through collaboration with Development Media International, Population Services International or another organization involved in social marketing for global health. 2. The IWG could also organize a journalist training program to leverage media already reporting on maternal and child health in the wider effort to shift behavior and spending habits. This could be achieved by establishing a coalition of media representatives from various countries, much like the African Broadcast Media Partnership against HIV/AIDS. Reaching the base of the pyramid Country-wide insurance or health financing programs 3. The IWG could review what is already known about performance-based incentives for maternal and child health and engage with relevant stakeholders to specify ways to scale programs that work. This could lead to the IWG overseeing a toolkit that would help health ministries assess the pros and cons of the various financing mechanisms available to them. Partnering Catalyzing partnerships along the value chain 4. As a possible extension of the Task Force on Sustainable Business Models, the IWG could lead an effort to structure strategic private-sector collaborations for maternal and child health across all areas of the value chain. It could also explore supporting winners of grant competitions (such as Saving Lives at Birth) with incubation grants that would encourage partnership as a means of reaching scale. Local context Country-level, private-sector forums; Business councils 5. The IWG could host country-level forums that engage local, private-sector actors as well as government representatives around how they could jointly support context-

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specific, market-based solutions that reach women and children. It would be imperative that these meetings proactively target local SMEs and regional companies that span the entire supply chain for maternal and child health in a given country. 6. The IWG could also spearhead the organization of in-country business councils—similar to those set up by the World Economic Forum for AIDS—which would bring together high-level representatives of companies working in maternal and child health. Scaling up Scaling grant challenge winners 7. The IWG could work with winners of grants and other early-stage funding—such as Saving Lives at Birth—on the various routes the individual or company could take in order to achieve scale. This could be addressed through various toolkits tailored to a specific type of company, a specific category of service or a specific region/country, and it could be tied in directly with the recommendation around partnerships. Technology Assessment of mobile and other eHealth platforms for training, stock level management and remote care 8. The IWG could work with organizations like the mHealth Alliance, World Health Partners and Dimagi—as well as companies like Intel, Abbott Labs and Vodafone—to establish a suite of software tools for businesses to use as a means of training their personnel, managing stock levels and even facilitating remote care. The IWG could build on Dimagi’s CommCare training module for health workers, Abbott’s warehouse stock monitoring tool, World Health Partners’ telemedicine program or a number of other existing technologies that are being leveraged for maternal and child health. Measuring impact Accreditation program 9. The IWG could spearhead an accreditation program for private health shops, pharmacies, etc. to ensure high-quality care throughout the maternal and child health supply chain. The program could put forth minimum required standards in the areas of shop/facility location, personnel training, drug availability, drug quality, stock control and sanitation/hygiene. This approach could be modeled after Management Sciences in Health’s ADDO program or the African Union’s health worker accreditation program.

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Doing business

Working capital loan program 10. With a membership that features donor agencies, MNCs and other potential financers/investors, the IWG could organize a working capital loan program for importers, wholesalers, health shops, pharmacies, dispensaries and community-based distributors, whereby they offer loans to businesses that maintain stock of pre-specified maternal and child health products. This service would allow these businesses to obtain additional working capital to run their operations—which is often a major challenge for them—and simultaneously ensure the availability and provision of vital public health products. The IWG could work with the likes of Aureos, IFC, African Development Bank, Results for Development and Abt Associates—who have also spearheaded a loan program for midwives. SS-GATE 11. In the framework of this report, we suggest leveraging the existing “South-South Global Assets and Technology Exchange Platform” (SS-GATE) to assist with the implementation of a number of our recommendations. The South-South Global Assets and Technology Exchange (SS-GATE), launched in 2008 by the Special Unit for South-South Cooperation (SU/SSC) at the United Nations Development Programme (UNDP), is a global and sustainable transaction platform that facilitates market-driven and transparent exchanges of technologies, assets, services, knowledge and financial resources among the private sector, public sector and civil society for inclusive growth of the countries of the South. SS-GATE has been endorsed by the United Nations General Assembly on multiple occasions, including in the Nairobi outcome document of the High-level United Nations Conference on South-South Cooperation (A/RES/64/222). SS-GATE coordinates exchanges through its Web-based platform and 36 “country centers,” local institutions that solicit and facilitate each transaction. The SS-GATE platform comprises 4 tracks: 1) Small and medium enterprise (SME) technology exchange; 2) Creative industries exchange; 3) Financing for under-funded development projects; and 4) Environmental technologies exchange. SS-GATE is currently constructing a new Track 5 on global health in partnership with the Pan American Health Organization (PAHO). A number of successful technology transfers in areas such as housing and food security have already been facilitated. Many other projects are currently being set up that have the potential to be game changers in the South.

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The availability of this existing network of both public and private organizations in various countries in the global South, together with the SS-GATE Web-based tools to foster information exchange, provides an excellent opportunity to move ahead on our Task Force recommendations. SS-GATE’s mandate is well-aligned with that of the IWG and a collaboration opens the prospects of leveraging the expertise of their country centers and partner networks, (e.g. PAHO) to connect on maternal and child health issues and exchange information on best practices and lessons learned. The SS-GATE business model offers the IWG a platform to disseminate and scale-up innovations in maternal and child health throughout the South by addressing the following critical needs:

(1) "match-making" between maternal and child health demands and innovative and regional solutions; (2) engaging new businesses and other organizations aiming to improve maternal and child health through technology and capital transfer; (3) connecting stakeholders to essential services like finance and training; and (4) brokering transactions to expand sustainable businesses in the maternal and child health space.

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ANNEX

REFERENCE GROUP

NAME POSITION ORGANIZATION

Sam Agutu Founder and Chief Executive Officer Changamka MicroHealth

Pedro Arboleda Partner Monitor Group

David Aylward Senior Advisor, Global Health and Technology Ashoka Stephanie Bridges Senior Associate, Health Portfolio Acumen Fund

Barbara Bulc Consultant, Strategic Partnerships PMNCH Bob Collymore Chief Executive Officer Safaricom Ernest Darkoh Founding Partner BroadReach Healthcare

Marguerite Farrell Health Development Officer USAID Martin Fisher Founder and Chief Executive Officer Kickstart Maureen Harrington Director and Head, International Development Group Standard Bank

Claudia Jay Harner Senior Program Officer PATH Beth Jenkins Research Fellow, CSR Initiative, Kennedy School of Government Harvard University

Renee Kaplan Chief Strategy Officer Skoll Foundation

Michael Kubzansky Global Head, Inclusive Markets Initiative Monitor Group

Tore Laerdal Managing Director Laerdal Global Health

Patricia Mechael Executive Director mHealth Alliance

Mario Merialdi Coordinator, Department of Reproductive Health & Research World Health Organization

Judy Njogu Business Development Manager Safaricom Barbara O�’Hanlon Owner O�’Hanlon Consulting

Kyle Peterson Managing Director FSG Alexander Preker Head, Health Industry and Investment Policy World Bank

Steve Rabin Chairman Rabin Martin

Sandhya Rao Senior Private Sector Technical Advisor USAID Jacqueline Sherris Vice President, Global Programs PATH Kari Stoever Operating Advisor Pegasus Capital

Prashant Yadav Senior Research Fellow and Director, Healthcare Research Initiative University of Michigan

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CASE STUDIES

Changamka MicroHealth Overview of Initiative: Launched in 2008, Changamka MicroHealth provides products that allow low-income individuals to save money towards doctor visits, medicines, and other health needs. Originally focused on smartcards sold in retail outlets, Changamka is currently shifting its business model to a fully mobile-based platform, a process which is expected to be completed by the end of February 2012. The company’s existing products (which will be rolled over into the mobile-based platform) include96: (1) Maternity Smartcard, a pre-paid card that costs KSh 250 and provides for antenatal, maternal, and

postnatal services at participating maternity facilities. The card can be topped up through M-PESA or at the hospital terminal.

(2) Outpatient Smartcard, a pre-paid card that costs KSh 450 or Rs 730 (depending on choice of medical provider) and provides for a treatment package including 1 consultation, 1 laboratory test within list, and medicine for diagnosed ailment. These smartcards are available at select supermarkets and other distribution points, and can be topped up through M-PESA.

(3) Smartcard for third party schemes: smart-cards that can be loaded with value as “e vouchers” for beneficiaries for safe motherhood, family planning and child health; school programs; food programs.

(4) In-House Smartcard - this product is aimed at institutions (e.g. universities) to help in administering the health care scheme, particularly through paperless monitoring and control

Theory of Change: Changamka’s mission is to “innovatively use mobile technology to create mechanisms for delivery of easily accessible, affordable, quality healthcare.” If the poor are given a mechanism to save for health care, they will have better health outcomes and less likely to go into debt to pay for health care services. Specifically within maternal health, the objective of Changamka’s maternity product is to reduce maternal mortality (MDG 5) by:97 • Providing sustainable financing to mothers at BOP by enabling them to save for their antenatal,

delivery, and postnatal payments ($50 covers all) • Increasing the usage of quality antenatal and maternity facilities for low-income women in Kenya Model for Sustainability: In order to operate at their desired scale (reaching 95% of the Kenyan population), Changamka has developed partnerships with mobile operators, the government, and hospitals. Specifically, hospitals provide patients a discount on price in return for volumes that Changamka offers. Changamka receives revenue from each patient visit, leading to sustainability of the model.

96 Center for Health Market Innovations 97 Changamka brochure in Health Market Innovations

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Changamka receives funds from grants and subsidies. At the same time, it is putting into place a new model that focuses on partnerships with mobile carriers, and expects to be profitable operationally in eighteen months.98 Impact or Output to Date: As of January 2012, 11,000 outpatient smart cards and 3,200 maternity cards have been distributed, with 2300 women given health education each month.99 Each month, approximately 600 hospital transactions using the cards occur and 500 “top ups” take place.100 Since hospitals have started accepting the maternity cards, they have seen the number of women regularly visiting them increase by 30%.101 Recently, Changamka has partnered with SHOPS (Strengthening Health Outcomes through the Private Sector project, funded by USAID) to begin evaluating impact of the Changamka model. This report, focused on outpatient care and maternal health, is expected to be available by April 2012.102

98 Phone interview with Sam Agutu and Zach Oloo, January 20, 2012. 99 Phone interview with Sam Agutu and Zach Oloo, January 20, 2012. 100 Center for Health Market Innovations 101 Center for Health Market Innovations 102 Phone interview with Sam Agutu and Zach Oloo, January 20, 2012.

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ClickDiagnostics

Overview of Initiative: Incorporated in 2008, ClickDiagnostics is a global mobile health (mHealth) social enterprise that works in Africa, South Asia, the Americas, and has recently piloted a mobile tele-dermatology project in Egypt. Its mHealth platform consists of models focused on medical services (e.g. primary care tele-consultation and triage); patient management (including electronic medical records)’ administration and planning; and mPayment and financing. In the area of women’s health care, ClickDiagnostics has partnered with BRAC Manoshi in Bangladesh, where ClickDiagnostics designed an mHealth system specifically focused on maternal, newborn, and child health. In Botswana, ClickDiagnostics designed an mHealth system focused on cervical cancer screening, as well as HIV clinical staging, mobile tele pre/post-oral surgery, tuberculosis screening mobile tele-dermatology, and mobile tele-radiology.103 Theory of Change: ClickDiagnostics addresses the following challenges: lack of access, whereby patients cannot easily reach doctors; lack of funds, whereby patients cannot afford health care services; and lack of medical resources due to shortages of trained health care professionals.104 Its mission is to “bring affordable and quality health services to under-served communities, by enabling the creation of proactive and self-sustaining health systems driven by mobile technologies, community-level entrepreneurship, and value-based partnerships.”105 Model for Sustainability: The business model that ClickDiagnostics has developed is the following: a community health worker or woman entrepreneur takes out a loan from a microfinance institution in order to purchase a mobile phone, medical equipment, and training certification. She then provides health care to patients, who provide payment for these services. There is a revenue-sharing model between the community health worker and ClickDiagnostics. Additionally, government or health organizations may provide payment to the community health worker for health data collection, and revenue to ClickDiagnostics for health data services.106 Additionally, partnerships help support pilots and play a role in eventual sustainability. In Botswana, for instance, ClickDiagnostics partnered with Orange Botswana, who sponsored pilots utilizing ClickDiagnostic technology in collaboration with Botswana-UPenn Partnership program. Impact or Output to Date: ClickDiagnostics has rapidly expanded its geographic scope to include Africa, South Asia, the Americas, and most recently the Middle East, through its pilot in Egypt. Through its partnership with BRAC Manoshi (funded by the Bill & Melinda Gates Foundation), it has served 18,000 households and 2,000

103 Company website 104 Company website 105 Company website 106 Company website, Click Diagnostics presentation 2008 at Indiana University, Bloomington

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pregnant women in Bangladesh in its mHealth pilot program for maternal health.107 In Botswana, it has screened over 1,500 women for pre-cancer changes of the cervix.108

107 Center for Health Market Innovations 108 “Orange (Botswana) and Botswana-UPenn Partnership Pioneer Mobile Phone Telemedicine,” The Botswana Gazette, July 9, 2010.

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Greenstar Social Marketing Pakistan

Overview of Initiative: Founded in 1991 by Population Services International (PSI), Greenstar Social Marketing Pakistan is a private, not-for-profit organization focused on social marketing, particularly around the areas of family planning and reproductive health services. Greenstar works through the private sector and with the Government of Pakistan to improve access to affordable health products and services through its network of over 18,000 private doctors.109 It is the country’s second-larger provider of family planning services (after the Government of Pakistan), distributing over 26% of contraceptives in Pakistan.110 Theory of Change: The mission of Greenstar Social Marketing Pakistan is to: “improve the quality of life among people throughout Pakistan by increasing access to and use of health products, services, and information, particularly in lower socio-economic population groups.”111 Greenstar focuses on improving access to quality health products and affordability, particularly as 70% of Pakistanis seek care in the private sector where these two areas are key challenges. Model for Sustainability: Greenstar Social Marketing Pakistan’s model rests on social franchising, where private doctors, paramedics, and pharmacists become franchisees and receive subsidized supplies and signage, as well as benefit from advertising for the clinic network and contraceptives.112 Additionally, Greenstar utilizes a cross-subsidy approach to pricing in order to increase access for low-income citizens. Specifically, Greenstar provides vouchers to low-income individuals for maternal health (including antenatal care, delivery, and postnatal care) and family planning services. The vouchers consist of two portions: (1) portion to pay Greenstar provider for providing health services and (2) portion for client transportation costs to reach the provider.113 A nonprofit, non-governmental organization, Greenstar’s primary source of funding is through donors, including USAID and German Development Bank (KfW).114 Impact or Output to Date: Greenstar has trained 24,000 doctors, paramedics, and pharmacists between 1995 and 2006, and 19 family health products are supplied through 80,000 retail outlets across the country.115 3,000,000 clients have been reached through social marketing, with their family planning products protected 1 out of every 4 married couples using modern methods.116 109 Center for Health Market Innovations 110 Center for Health Market Innovations 111 Company website 112 Center for Health Market Innovations 113 Pregnant women participating in Greenstar’s voucher program receive a voucher booklet worth $50 USD, for which the women pay $1.21 USD (Pakistani rupees 100). The voucher booklets are comprised of a $31 USD coupon for delivery, 4 antenatal care visits, one postnatal care visit, and one family planning visit. Health care providers reimburse each woman $3 USD for transportation for the delivery and $0.60 USD for other visits. USAID Case Study: “Pay for Performance: Improving Maternal Health Services in Pakistan”, Health Systems 20/20 Project, September 2009. 114 Center for Health Market Innovations 115 Company website and Center for Market Health Innovations 116 Company website and Center for Market Health Innovations

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A 2008 study published in the Harvard Health Policy Review showed that Greenstar franchises served a higher proportion of poor clients (35.1%) than government facilities (23.4%), and that Greenstar franchises provided higher quality services (24.9 = mean total quality) than both for-profit private facilities (15.2) and not-for-profit private facilities (18.1).117

117 Harvard Health Policy Review, “Social Franchising to Improve Quality and Access in Private Health Care in Developing Countries”, Volume 9, No. 1, Spring 2008. Center for Market Health Innovations

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Healthpoint Services Global

Overview of Initiative: Launched in 2009 by Ashoka, Naandi Foundation, and Healthpoint Services, eHealth Points are units owned and operated by Healthpoint Services India, which provide families in rural villages with clean drinking water, medicine, diagnostic tools, and tele-medical services. Through its service and product bundling through safe drinking water and health, eHealth Points utilize both a preventative and treatment approach to saving lives. eHealth Points utilize a clinic model, where tele-medical consultations are conducted via video-conferencing with licensed medical doctors and lay healthworkers/clinical assistance (who are recruited from local villages and trained by Healthpoint Services India). Additionally, each eHealth Point is equipped with diagnostic tools (e.g. ECG, blood pressure monitor, etc.) and is stocked with pharmaceuticals dispensed by a licensed pharmacist. eHealth Point is in the midst of adding maternal and child health services to its clinic model, in the form defined products that will likely be sold as a package (e.g. antenatal care and medicines).118 Theory of Change: By employing a service delivery model that uniquely leverages the benefits of technology in healthcare, ICT, and water sectors, rural and peri-urban families will have greater access to high quality healthcare and safe drinking water, resulting in better health, enhanced productivity, and improved standard of living -- as well as providing opportunities for employment generation in local areas.119 Model for Sustainability: eHealth Points are designed to be a sustainable social enterprise, with a potential for replication and scale. Services are offered on a fee-for-service basis at each eHealth Point; many of these services are priced at approximately $1.120 For instance, the subscription fee for water treatment per household is Rs 75 (approximately $1.50) per month for 20 liters of clean drinking water daily. The average cost per diagnostic test is Rs 40 (approximately $1), with many tests less than Rs 25 ($0.50) with no test costing more than Rs 200 ($4).121 A tele-medicine consultation is priced at Rs 30 ($0.60).122 With these prices, a stand-alone water point breaks even operationally in six months (and recovers its capital in three years).123 eHealth Points expects to be profitable as a company by next year.124 The company is fully funded by private investors, and it is currently in the midst of closing its third equity round. In bringing its services to market, eHealth Points must take entrenched competition into account: an informal network largely comprised of untrained providers, often referred to as “quacks.” eHealth Points is trying to change behavior and disrupt the cycle of rural people visiting “quacks”, which requires social marketing and integrating with the local community. As these informal providers are tough competitors

118 Interview with Al Hammond, January 20, 2012. The organization is launching a foundation arm to allow for the piloting of new initiatives and businesses such as maternal health. Healthpoint was awarded a $250,000 grant through “Saving Lives at Birth” in August 2011. 119 Company website. 120 Ashoka press release, “Innovative Health Pilot Launched in Rural India by Ashoka and Partners,” October 30, 2009. 121 Company website and eHealth Point information summary on Health Market Innovations. 122 eHealth Point information summary on Health Market Innovations. 123 Interview with Al Hammond, January 20, 2012. 124 Interview with Al Hammond, January 20, 2012.

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for walk-in care, eHealth Points is moving towards higher-level services, such as chronic care management and maternal care. It is believed that maternal health care will be a big differentiator from “quacks”, who are predominantly men. Impact or Output to Date: As of September 2011, eHealth Point has provided more than 29,000 tele-medical consultations, performed 15,000 diagnostic investigations, filled 35,000 prescriptions, and provided safe drinking water to 350,000 users daily. eHealth Point plans to scale its model across India and implement the model in additional countries, such as Southeast Asia and Latin America.125

125 eHealth Point summary brochure.

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INPPARES Overview of Initiative: Founded in 1976, INPPARES is the largest private, non-profit provider of family planning services in Peru. INPPARES provides reproductive health services as well as diagnostic imaging, cardiology, dermatology, and ophthalmology. In 2002, INPPARES launched RedPlan Salud (RPS), a network of midwives that serves lower-income, able-to-pay clients. RPS providers are licensed midwives with pre-existing clinics serving low-income women in urban and peri-urban areas of Peru.126 Theory of Change: RPS aims to serve women and youth within the C and D socioeconomic status (SES) groups, which represent 35% of the population in Peru.127 Through high quality, low cost drugs made available through RPS, low-income women have increased access to affordable healthcare. Model for Sustainability: Midwives sign a one-year agreement where they sell contraceptives, and in exchange receive contraceptives at social marketing prices, training, and benefit from the network’s marketing activities. RPS is able to obtain volume discounts from major pharmaceutical companies and procures approximately 50 products, which are distributed to member midwives through the program’s team of sales representatives.128 Midwives are allowed to provide other services and products that are not part of the RPS bundle. RPS’s business model is such that these 50 products are sold to midwife members at a mark up (although the products remain cheaper than alternative channels due to the large volume discount). This profit margin on the products covers the operational costs of the RPS program.129 Currently, member midwives do not pay a franchise fee, although RPS management is considering the possibility of starting this in order to generate an additional revenue stream.130 Impact or Output to Date: As of 2011, the RPS network has grown to include over 1,600 midwives in Peru.131 The network has grown primarily through word of mouth and through recruitment by RPS’s sales representatives.132

126 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011. 127 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011. 128 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011. 129 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011. 130 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011. 131 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011.

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LifeSpring Hospitals

Overview of Initiative: LifeSpring Hospitals is an expanding chain of low-cost maternity hospitals that serve low-income women and newborns in India. Through its market-based approach, LifeSpring fills the gap of quality maternal health care at affordable rates for India’s low-income population. Prior to LifeSpring, a pregnant woman could deliver at home, at an under-resourced government hospital, or at an expensive private hospital -- often needing to sell assets or take out loans to do so. LifeSpring’s mission grew from this deficiency and in response to women’s demand for an alternative. Its hospitals provide antenatal care, delivery, and postnatal care. Theory of Change LifeSpring believes that a fundamental shift occurs once a woman stops being viewed as a passive “recipient” of health care, and instead seen as an active “customer”, who takes ownership in her health and the health of her newborn. By delivering low-cost, high-quality maternal health care in a way that recognizes women’s dignity, the following outputs will result: (1) From a health perspective, women will be more likely to come for antenatal visits with a skilled

obstetrician and deliver at a hospital that follows evidence-based clinical protocols, as well as bring their newborns for postnatal checkups;

(2) From a financial perspective, women and their families will be less likely to go into debt for maternal healthcare expenditures. At a macro level, LifeSpring will reduce the burden of rising health costs in low-income urban communities.

Model for Sustainability: LifeSpring Hospitals is financed through equity from HLL Lifecare Limited (an Indian government enterprise) and Acumen Fund (a venture philanthropy organization based in New York), as well as debt from the State Bank of India. LifeSpring Hospitals is a 50-50 joint venture between HLL Lifecare Limited and Acumen Fund, a partnership which began in early 2008. On a unit level, each LifeSpring hospital is set up to be operationally profitable in eighteen months of operation. Its low-cost model rests on service specialization and high asset utilization, no frills set-up, and low capital expenditure model. LifeSpring is a for-profit organization, although not profit-maximizing. It prices its services at 30-50% of prevailing market rates: the price of a normal delivery is Rs 4000 (~$70), while a caesarian section is Rs 9000 (~$160) for a two- and five-day hospital stay (all-inclusive), respectively. Additionally, LifeSpring provides prenatal care throughout the length of a woman’s pregnancy; the price of an antenatal checkup with a gynecologist is Rs 75 (~$1.50) for each visit. LifeSpring is profitable on an enterprise level. Impact or Output to Date: As of November 2011, LifeSpring has delivered over 13,000 healthy babies across its twelve hospitals and has provided over 250,000 antenatal and postnatal checkups, with a 49% market share in its flagship hospital. Over the next five years, it plans to scale across India, targeting urban slums. Since its initial expansion in 2007, LifeSpring has been approached by organizations in Pakistan, Bangladesh, Afghanistan, Ghana, Kenya, and Senegal to share learnings and insights on its low-cost model for 132 Clinical Social Franchising Case Study: RedPlan Salud, Instituto Peruano de Paternidad Responsable (INPPARES), The Global Health Group, University of California, San Francisco, June 2011.

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maternal health care; through its model, it hopes to stimulate the emergence of low-cost maternity hospitals globally.

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Living Goods Overview of Initiative: Dubbed the “Avon” of Pro-Poor Products, Living Goods supports microentrepreneurs to sell life-saving and life-changing products door-to-door. Specifically, Living Goods’s microentrepreneurs, or community health promoters, sell products focused on prevention, treatment, fast-moving consumer goods, and pro-poor innovations, such as clean-burning cookstoves and solar phone chargers. In the area of maternal and reproductive health across the product ranges above, Living Goods’ community health promoters sell clean birthing kits, iron folate, pregnancy tests, cotton for use during delivery, rubber gloves, and family planning products. Product assortment allows Living Goods to cross-subsidize critical health products (e.g lowering prices on key impact items and make up the margin elsewhere in product portfolio, e.g. fast-moving consumer goods). Coupled with these products, Living Goods seeks to achieve health impact through education, behavior change strategies, distribution of health products, and through referrals for secondary care. Theory of Change: Through its social franchising model, Living Goods aims to: (1) Reduce child mortality by at least 15% in the areas in which it operates (2) Improve access to life-saving and life-changing innovations (3) Create livelihoods and empower women entrepreneurs (4) Ensure sustainability and be fully self-funded at scale Model for Sustainability: Living Goods’ long-term goal is to create a commercially viable, double-bottom line venture. It identifies three levels of sustainability necessary for this goal: (1) Sales agent level - ensuring franchisees can make an adequate living on margin from their sales. (2) Branch level - generating enough contribution margin to cover direct branch level costs. Each branch

supports 20-40 agents, employs 1-2 branch managers (who have direct P&L responsibility), and has a budget of approximately $6,500 per year. The cost of training a franchisee, or community health supporter, is less than $200 a month.133

(3) Country level - generating enough contribution margin to cover the network costs of administration, finance, training, and marketing

Its main drivers of revenue are two-fold: (1) margins on products sold; (2) financing on inventory loans (on par with a microfinance loan). Additionally, Living Goods has started experimenting with a third revenue stream through wholesale margins. Living Goods does not charge a franchise fee to its agents. Its buying power and ability to cut out intermediaries allow it to set prices 10% - 30% below market.134 Impact or Output to Date: Living Goods has engaged with The Poverty Action Lab towards an independent randomized control trial, focused on how well Living Goods has been able to meet its primary objective of reducing mortality

133 Lisa Katayama, “How Health Care Nonprofit Living Goods Learned a Lesson from Avon Ladies,” Fast Company, December 10, 2010. 134 Center for Health Market Innovations.

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and morbidity for children under five. At the mid-line evaluation, researchers found that the price of malaria medicines were significantly lower in treatment areas, while quality was significantly higher.135 By December 2010, Living Goods had trained over 600 women in 30 branches in Uganda, who in turn served over 450,000 clients.136 The organization’s key performance indicators span social and financial measures, including percent of newborns visited in the first 48 hours by an agent, number of under 5 malaria and diarrhea treatments per agent, and branch profitability.

135 Phone interview with Joe Speicher, January 31, 2012. 136 Lisa Katayama, “How Health Care Nonprofit Living Goods Learned a Lesson from Avon Ladies,” Fast Company, December 10, 2010. Center for Market Health Innovations.

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Ziqitza Health Care Limited

Overview of Initiative: Founded in 2005, Ziqitza Health Care Limited is the first private, for-profit ambulance in India that provides service across the income spectrum. It operates emergency medical response services through two models: (1) Dial “1298” for Ambulance, which works through a cross-subsidy model in Mumbai and Kerela; and (2) Dial “108” in Emergency, which operates as a public-private partnership with state governments in Bihar, Trivandrum, Rajasthan, and Punjab. Theory of Change: Many cities in India lack a reliable emergency response services, forcing individuals to take auto rickshaws or other means of transport to reach hospitals. Ziqitza was founded to address this gap, provides a 24/7 call center with ambulance tracking systems. Its theory of change focuses on improved health outcomes in times of emergencies through reliable emergency response services, which includes ambulances equipped with personnel trained in basic and advanced life support. Model for Sustainability: Ziqitza’s Dial “1298” for Ambulance works through a cross-subsidy model, whereby end users are charged a sliding scale fee based on whether the individual chooses to go to a private hospital versus a government hospital (it has been reported that 20% of users are subsidized)137. Specifically, end users are charged a full rate going to a private hospital or a subsidized rate going to a government hospital. Accident victims, unaccompanied unconscious individuals, and victims of mass casualty incidents are provided with free service. In this model, Ziqitza owns its ambulances, which are made self-sustainable through this cross-subsidy approach Ziqitza’s Dial “108” in Emergency works through a public-private partnership with state governments and is a service provided to emergency victims. Based on the specific contract with the state government, the end user would either pay a user fee or receive service for free. Ziqitza is a private, for-profit company whose investors include Acumen Fund, Emergency Medical Services Corporation, Housing Development Finance Corporation (HDFC), Infrastructure Development Finance Corporation (IDFC), and India Value Fund Advisors. Impact or Output to Date: From ten ambulances in Mumbai in 2007, Ziqitza currently operates more than 800 ambulances in Mumbai, Kerela, Bihar, Trivandrum, Rajasthan, and Punjab, serving over 645,000 individuals since 2005.138 The company’s vision is the be the leading ambulance service provider in the developing world.139 137 Center for Market Health Innovations 138 Company website, Acumen Fund website 139 Company website

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