Authored by: Allen Hammond

I wrote before about standing in a room with dozens of MDs sitting at terminals in the world's largest medical call center. Together with an even larger group of lay health workers, they advise thousands of patients per hour. Costs per patient are so low that I described medical call centers and telemedicine approaches as the future of medicine. But that's only part of the story.

Last week I stood in another room in India where perhaps 15 women in clean-room garb were assembling point-of-use rapid diagnostic kits-these were pregnancy tests, but the company makes similar diagnostic kits for malaria, dengue, hepatitis, HIV, glucose levels, etc., more than 30 in all.  Two women dip sheets of special paper into an antibody solution; two more ran a specialized paper cutter to slice the medium into thin strips; still others assembled the strips into plastic housings, sealed them into foil envelopes, inspected the product carefully, and packed them into cartons. 

These few workers turn out about 50,000 "strip test" kits a day. These could be used by consumers directly-most require putting 2 drops of urine or blood or plasma on the strip test and watching a few minutes until it give as "yes" or "no" signal-but are more accurately handled by a lay technician. And here is the key point: Most of these kits sell for less than $.10 each in India (including supplies, labor, packaging, shipping, and profit).  The kits have a built-in error check, are stable for 2 years at room temperature and below, and the company has data to back up a claim of high reliability. And this is not the only company in India making these kinds of diagnostic kits.

But that's today. Next door to the diagnostic assembly building is the company's newer facility, where automated production machinery is being installed that will lower production costs significantly, to mere pennies a test.  So imagine that you could walk into an "instant clinic", get tested in 5 minutes for an insignificant cost, talk to a doctor in a medical call-center about the results if you desired, pick up the medicine you need, and leave-within 20 minutes. Of course, in an industrial country, the price will be higher; the labor for the technician (30 seconds to perform the test, 30 seconds to tell you the result) probably will cost more than the test itself, not to mention shipping, customs duty, FDA approvals, etc. But the result is still a radical shift in the cost paradigm for healthcare delivery.

Within a few years, more sophisticated diagnostic devices will be available too-a "lab-on-a-chip" that analyzes the DNA in the sample and gives a digital readout, at a cost of perhaps $1-$2 a test. We are tracking a pipeline of a dozen such diagnostic devices now in development covering a wide range of diseases and health problems.  But it is hard to escape the feeling that the women I visited last week are the pioneers, already shaping the future of healthcare in a fundamental way.  We will be using their products and tele-medicine in the remote rural part of India (6 hours by train from the nearest airport, plus another hour by car) where we are launching a novel approach to healthcare services.

We may not care in the U.S. whether a test costs a dollar or a dime or a penny-any of those would constitute a revolution of the type the Obama Administration is looking for-but there are 4 billion people in the world for whom low-cost diagnostic kits can be truly transformative, and for whom the difference between a dollar and a few pennies may just determine whether they seek medical care for themselves or their children. 

Authored by: Allen Hammond

"Emerging Markets, Emerging Models", the report on BOP entrepreneurship from Monitor Group is probably the most important new study in the last couple of years. Unlike some recent, fairly derivative reports, this one is based on some intensive original research -covering 270 enterprises and a careful analysis of 9 business models- and focused on the key question: why haven't most BOP efforts scaled?  I highly recommend that you download it and read it in its entirety.

My own observations are fully supportive of the report's conclusions, especially the barriers faced by  single product, go-it-alone distribution channels and the imperative for community-scale infrastructure, for para-skilling services, and for arranging high-through systems that use scarce talent very efficiently.  The last two approaches are essentially complimentary, and can be used in tandem.

I would go a bit further than the report, however, and suggest that overcoming the barriers to BOP businesses is particularly difficult for large corporations, because many of the solutions that appear to work require intimate knowledge of BOP mindsets and often local presence in those communities -not easy for corporate to implement. Moreover, partnering with NGOs or community groups may be the best way to open such channels, and that, too, is a challenge for most businesses (and most NGOs): the right frameworks and toolsets are by and large not yet in place. To me, that suggests that successful models are most likely to be built not by large companies but by social entrepreneurs. The large company role may come later --they can invest in such efforts, and they can buy them when they are already at scale, and they can usefully source new technology to continually upgrade products and services.

Such conclusions are, to my reading, latent in the report but not spelled out. Nonetheless, to say that takes nothing away from the quality and usefulness of this new resource. 

Editor's note: Al Hammond, entrepreneur in residence at Ashoka, will write a series of reports documenting his experiences and the learning involved in started a "base of the pyramid" (BoP) healthcare venture to serve developing countries. This is his first report in the "Notes From the Field" series.

There I was, looking over the shoulder of a woman physician, in a unique 400+ seat medical call center in India, as she dealt with a female patient with abdominal pains. The patient was calling from her home on a mobile, had been initially engaged by a trained lay health worker, and then passed on to the doctor. 

As the doctor asked questions--guided by a software tool called a clinical decision support system--and selected the patient’s answers, the questions on the doctor’s computer screen changed. Within a few minutes, the doctor had isolated the problem, decided that she didn’t need to dispatch an ambulance, selected a medicine, and clicked on another tab that sent an e-prescription by text message to the patient’s phone. 

The patient can take that message on her mobile to a pharmacy and fill her prescription. The whole process took 3-4 minutes for the patient, and was free (subsidized by the state government). But it also didn’t cost the state much, because it only used a few minutes of the doctor’s time, so that she can deal with more than 100 patients in an 8-hour shift. No clinical office to rent or equip. No patient travel involved. Available when needed, 24-7. And trained lay health workers, paid perhaps a fifth of a doctor’s salary, handle 80% of the calls, so only 20% get passed on to doctors.

Thus, in economic terms, a single doctor is in effect overseeing the treatment of more than 500 patients per day. Of course, not all patients have problems treatable remotely—trauma, cancer, heart attacks and others will be referred to hospitals. But for many primary care problems, this is high quality, and very cost-effective, care.

It gets better. Another example concerns a young mother, calling late in the evening, distraught over her baby’s raging diarrhea. A lay health worker, guided by the smart software and short disease summaries, calmed the mother down and told her what to do. But, she asked, suppose it doesn’t work? All the clinics are closed now, and the hospital is hours away. So the health worker said, Why don’t you call us back every 2 hours—we’ll be here.

Imagine how wonderful that kind of help would be even here in the US. But this service is available exclusively to poor rural families in one state in India, for now. And it works—the call center handles 50,000 calls a day and is expanding to handle 3 times that number.

Truly, I felt I was looking at the future of healthcare. There aren’t enough doctors to provide traditional kinds of medical care in rural areas in virtually all developing countries. And there won’t be enough even in the US as the baby boom starts to age. So a more efficient model, based on de-skilling healthcare and using doctors very efficiently and only when their expert judgment is really needed, is inevitable. Maybe the Obama Administration should go take a look.

As for me, I’m convinced—I and my colleagues who are starting a health-based social enterprise in India are planning to partner with this call center in our pilot effort to transform rural healthcare. More about the struggle to finance that effort, in this market climate, in my next post.

The mix of enterprises changes every year.This year was especially rich in BoP energy enterprises with seven entries. The prize winner was Distributed Energy Systems India, or DESI Power (desi means land or village in Hindi), which builds biomass power plants to generate electricity in villages that lack access to it. DESI trains locals to run the plants and also incubates local businesses that need power and enlarge the customer base for the model.

A wearable solar lighting system that stores up power in a cellphone battery and yields several hours of light in the evenings and technology for modifying diesel engines to run on virtually any plant oil were also intriguing.   

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Authored by: Allen Hammond

Today I am posting the results of a unique partnership and a novel experiment in furthering social entrepreneurship, the fruits of an effort launched on this site a year ago.

The partners were Santa Clara University's Global Social Benefit Incubator and World Resources Institute, and the attached white paper bears the names of Jim Koch (of GSBI), myself-then of WRI, now with Ashoka: Innovators for the Public-and Francisco Noguera, who has continued the water work at WRI.

The idea was to extend the scaling impact of the GSBI by recruiting a cluster of social enterprises within a single sector for the 2008 class, to add research on the sector as a whole, to involve water experts as well as the silicon valley VCs and CEOs in mentoring process of the water enterprise cluster so as to use them to provide a preliminary benchmark for the sector-and then to share what we learned so that other water entrepreneurs worldwide could build on that knowledge. 

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During a recent workshop at the M-banking conference in Cairo, Egypt, a number of practitioners and interested parties discussed the state of mobile banking or-more properly-mobile transactions. One of the interesting insights that emerged comes from the experience of the Vodafone company Safaricom in Kenya with its M-PESA mobile transaction service.

Launched in March, 2007, the service has been an astounding success, reaching 2 million customers by May of 2008. New field research by Olga Morawczynski on use of M-PESA's by low-income customers in the Kibera slum of Nairobi-now posted in our resources section-sheds some light on both the how and why.

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