1. Innovation Working Group
A Report of the
Task Force on Sustainable Business Models in Health
DRAFT FOR COMMENT
April 25, 2012
[1]

2. 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,
[2]

3. 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.
[3]

4. 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
[4]

5. 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
[5]

6. 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
[6]

7. 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
[7]

8. 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.
[8]

9. 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.
[9]

10. 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.
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.
[10]

11. 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
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.
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.
[11]

12. 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
[12]

13. 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.
[13]

14. 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.
[14]

15. 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.”
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.
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
[15]

16. 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.
[16]

17. 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.
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.
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.
[17]

18. 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.
[18]

19. 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/.
[19]

20. 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
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.
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.
[20]

21. 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.
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.
[21]

22. 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.
[22]

23. 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.
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.
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.
[23]

24. partnership, Procter & Gamble has provided financial support, experienced people, and
in-kind services.46
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.
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.
[24]

25. 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.”
[25]

26. 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
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.
...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.
[26]

27. 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
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).
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.
[27]

28. 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.
[28]

29. 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
Finding:
Governments are essential to catalyzing market-based models for health care
and supporting scale-up.
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.
[29]

30. 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.
Challenge:
Establishing an enabling policy environment.
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/.
[30]

31. 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.”
[31]

32. 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.
Finding:
There is a need to evaluate the impact and quality of businesses aiming to
deliver care at the BOP.
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.
[32]

33. 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
Challenge:
Shift impact assessment from a backwards-looking exercise to one that
allows organizations to learn and be more effective moving-forward.
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.
[33]

34. 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.
[34]

35. 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
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.
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.
[35]

36. 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.
[36]

37. 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).
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.
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.
[37]

38. 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.
[38]

39. 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.
[39]

40. 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-
[40]

41. 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.
[41]

42. 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.
[42]