Transcript Overview of methodology linked to Terms of Reference

CONSULTING EXPERTISE | INNOVATION AND IMPACT | DEVELOPING MARKET INSIGHT
Study on Mobile Applications for the
Health Sector
Workshop on Case Studies & Business Model Analysis
January 20, 2010
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Table of contents
•
Overview of mHealth ecosystem, impact, and services
•
Four example business models:
− WelTel
− Changamka
− HMRI
− Voila Foundation / Red Cross Public Health Advisories
•
Prioritization framework, financing and implementation mechanisms
•
Conclusions
•
Annexes
1
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
The mHealth ecosystem is created through the collision of three sectors – health,
technology and finance – with the backdrop of government policy and regulation
Government
Health
Legislators
Regulators
Legal system
Ministries
Health system
Health care workers
Medical supply chains
Patients
Health
funding
mHealth
applications
mHealth
Service
delivery
Technology
Software
developers
Mobile
operators
Handset
makers
Source: Dalberg research and analysis
Finance
Mobile
platforms
Banks
Insurance
companies
Private investors
Philanthropists
Donors
2
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Framework for mHealth impact
Better
health
Outcomes
Access, affordability, quality, matching of
resources, behavioral norms
Intermediate
outcomes
Multipliers
Complementary
mServices
Complementary capital
investments
ICT maintenance and
repair capacity
ICT literacy
Health literacy
Health training
M&E
mHealth
service
delivery
Outputs
Health system
needs
Health care
best practices
Procurement &
Supply chains
Cultural attitudes
Inputs
Policies &
Strategies
Related
Infrastructure
Financing
Network installations
Distribution channels
Research & Development
Regulation &
Standards
Leadership &
Governance
Communication &
Education
3
Source: Dalberg research and analysis
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Examples of mHealth interventions
Health services
1
Data Collection /
Disease Surveillance
2 Treatment Adherence /
Appointment
Reminders
3
4
Description of mHealth usage and applications
Usage of mobile handheld devices to collect data remotely (e.g.,
by community health workers); additionally, use of remote
diagnostic tools for disease surveillance and treatment; includes
civic participation in reporting outbreaks and disease information
Utilization of messages and voice to communicate treatment and
procedural reminders to patients (e.g., automated SMS reminders
to patients on chronic medication)
Emergency Medical
Response Systems
Emergency response tools , including creation of EMR via mobile
phones, and ambulance services whose reach is extended with
mobile usage in remote areas
Health Information
Systems & Support
Tools for Health
Workers
Collection and analysis of patient data, particularly at clinics or
related to call centers that are used to triage services and treatment;
information to help health worker prioritization; information on
inventory (Note: overlaps with supply chain management)
5
Supply Chain
Management
6
Health Financing
Example Cases
Management of inventory and supply chain steps by mobile
tracking and communication; includes advocacy informed by
supply chain information
Use of smart-cards, vouchers, insurance and lending for health
services linked to mobile platforms (e.g., m-Pesa) or otherwise
enabled using mobile
7
Disease Prevention
and Health Promotion
Use of mobile and SMS-based health information and education to
inform individual patients of preventive care and treatment
Source: Dalberg research and analysis
4
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Table of contents
•
Overview of mHealth ecosystem, impact, and services
•
Four example business models:
− WelTel
− Changamka
− HMRI
− Voila Foundation / Red Cross Public Health Advisories
•
Prioritization framework, financing and implementation mechanisms
•
Conclusions
•
Annexes
5
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Weltel (1/2)
Concept
Value
proposition
• Adherence is a huge issue in treating patients who are HIV-positive and taking antiretroviral therapies (ART), thus,
WelTel provides weekly SMSes from clinic nurses to patients, inquiring regarding their treatment, and patients are
required to respond within 48 hours; if no response is received, the nurse follows up with a call and referral if needed
• Social-enterprise model, funded by PEPFAR and CDC
• Founded in 2007
Advantages:
• With reminders, patients adherence improves, leading to better outcomes in terms of suppressed viral loads
• Cost-effective means of extending health system reach where roads are bad and travel expensive, but mobile service
is inexpensive and reliable; basic handset is required (rather than a smartphone); utilizes existing clinic nurses
• Cost of the offering decreases with scale; also reduces overall health system costs by estimated 1-7% due to ability to
more efficiently following patients, and keeping patients healthier via improved compliance, meaning they use less
emergency health services and avoid development of drug resistance and need for 2nd line medications
• Potential to move “horizontally” beyond HIV given simplicity of system
Results:
• In recent RCT, patients receiving SMSes had better adherence and suppressed viral loads
Beneficiaries and willingness to pay:
• Patients receiving antiretroviral therapies (ART), primarily in
Results of recent clinical trial
the pastoral Masai communities of Kenya; ART funders who can
receive better return on investment
273 265
• Patients at Kajiado and Pumwani Health Centre receiving ART
No.
indicated a willingness to pay up $0.50 to $1 USD.
patients
168
Market
• Current scale: Pilot and RCT in 273 patients
• Costs/revenue: Budget for RCT was $719k
• Estimated costs to scale:
o Scaling to 400k PEPFAR patients on ART would result in
26,000 additional patients with suppressed viral loads
o At $8/patient, this would cost $3.2M, which is
approximately 1-2% of PEPFAR treatment budget
156
132
Total no.
patietns
Treatment
Adherent
patients
Patients receiving SMS
128
Suppress
viral loads
Patients NOT receiving SMS
Source: The Lancet; Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomized trial; November 2010:
Dalberg research, interviews and analysis, 2010. Nation Media, December 2010 http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf; http://www.scidev.net/en/health/hivaids/news/texting-saves-lives-of-hiv-patients-study-confirms.html
6
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Weltel (2/2)
Challenges
across the
ecosystem
• Government / policy: Need for greater medical policy leadership that brings together stakeholders
to build the evidence base and prioritize models in coordinated rather than competitive way
• Funders: Legacy systems and competing interests can slow the pace of change and overall scale
of programs proven to work; similarly, while WelTel can be deployed horizontally across other
disease areas, health systems and their funders continue to be somewhat siloed
• Mobile Network Operators: Poor network coverage can present constraints to reaching patients
• Users: Shared phone access can present difficulties reaching individuals in a timely manner
Potential
actions
• Medical policy leadership and coordination: To address gaps in the evidence base and in
streamlining of systems, need for greater leadership across the technology developers, the health
systems players and funders. This can come from a number of players – including academic
institutions involved in developing models (e.g., British Columbia Centre for Disease Control),
alongside international champions and conveners (e.g., the mHealth Alliance, WHO/ITU)
• Prioritize and integrate funding into large scale systems addressing HIV and beyond: WelTel
has received interest from PEPFAR in rolling out this model beyond the current pilot; more broadly,
there is an opportunity for other large scale funders to prioritize and request these types of
interventions in country funding proposals for HIV programs and health systems (e.g., the Global
Fund’s HSS funding)
Source: Dalberg research, interviews and analysis, 2010. Nation Media, December 2010
http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf
7
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Changamka Micro health Limited, SmartCard (1/2)
Concept
Value
proposition
• A fully digital health savings account, based on a smart card. New cards include credits for a medical
consultation, a lab test, and a prescription. Can be used to pay for outpatient services within a network of
health care providers and topped up using the M-PESA platform.
• For-profit model; receives about 20 percent of the sale price of each card.
• Founded in 2008
Advantages:
• Savings on treatment and services are realized at the point of care across a network of nearly 4 dozen clinics
across Nairobi.
• Security of savings is improved.
• Does not require regular premiums (savings plan for selected treatments)
• Allows subscribers to share the smart card with family members and is not limited to individual use
Results:
• Sale of 8,000 smartcards in first 11 months of operations, selling an average of 500 cards/month
Beneficiaries and willingness to pay:
• Pregnant women and new mothers; based on sales to
date, customers are willing to pay (initial card =
Ksh 500, preloaded with standard services
Required scale for sustainability
23,300
Market
• Current scale: Signed on 25 local providers, and has
extensive waiting list of providers eager to join the
program’ customer base has been growing over time.
• Current revenues: ~Ksh 3.2m ; Sales are falling short
of commercially viable levels: sales of Ksh 23.3m
required to break even
Here the chart on the
Kenya Shillings
(‘000)
current sales and
what +630%
is required to
break even.
3,200
Cards sold
per month:
Source: Dalberg research, interviews and analysis, 2010.
Revenue
(year 1)
Revenue
(required to
break even)
500
8,500
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WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Changamka Microhealth Limited, SmartCard (2/2)
Challenges
across the
ecosystem
Potential
actions
• Users: Introducing a new product and serving a market
whose culture is not accustomed to health savings requires
significant high-touch marketing and consumer education.
• Financing: High costs of customer acquisition are a
challenge. The executive management team attributes this
to a lack of marketing and challenge of promoting health
insurance in Kenya due to negative historical image.
• Technology: Potential to integrate technology and use
mobile transfer and storage of payments rather than
smart-card; would streamline with mPesa platform
and eliminate costs associated with card
• Support scale: Funders who support health service
delivery can consider linking their existing financing or
possibly cash for work programs to Changamka to support
scale
Less than 2% of Kenya’s
population are covered by
health insurance
Insured
38,600
700
Uninsured
37,900
‘000
people
2009
• Product bundling and/or joint marketing: Pursue bundling of product and/or joint marketing efforts
with other adjacent offerings to engage new customers and get them accustomed to the service and
value proposition
• Fundraising to support customer acquisition costs: Pursue financing via private or blended
sources to move towards furthering proof of concept and continuing customer acquisition; this could
include cost-sharing with government or a philanthropic funder to increase the reach of marketing
efforts
Source: Dalberg research, interviews and analysis, 2010.
9
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of HMRI –104 Advice (1/2)
Concept
• Improve local health services through a comprehensive, multiplatform
approach that replaces the traditional health care system with interventions
delivered directly to rural and underserved communities; In addition to 104
Advice hotline, includes mHealth applications for disease surveillance,
prevention counseling, telemedicine, and supply chain management
• Social-enterprise/hybrid model, funded by the government of Andhra
Pradesh state (95% of costs) and the Satyam Foundation (5% of costs)
HMRI estimates that of the
600k unmet requests for
outpatient treatment, 55%
could be treated by phone
100%
600,000
• 104 Advice launched in 2007
Value
proposition
• Advantages: Services may cost as little as one tenth as much versus
government provision; health services are available to rural patients in their
own communities, saving them time and money; services are integrated
across many areas
• Results: 50,000 calls taken per day; 10 million medical records created;
1,500 people employed; ; since it’s inception, the offering has grown from 4
seats attending 200 calls/day to a new facility of 400 seats working 24 hours
per day to attend an average of 50,000 calls per day
• Beneficiaries and willingness to pay: Patients in need of medical
counsel or advice in Andhra Pradesh; willingness to pay is not fully tested;
as the service has been provided free of charge for three years
Market
% requiring
live consultation
45%
% who can
be treated by
phone
55%
• Current scale: 80 million people covered in Andhra Pradesh; An estimated
55% of unmet requests for outpatient treatment (600,000 per day) could be
treated by phone (see chart on the right)
• Estimated costs to scale: Already at scale in Andhra Pradesh
• Competition: Within the state of Andhra Pradesh, HMRI holds a dominant market position, strengthen by its ability
to integrate services across a variety of areas. However, competition will be an issue in other states where for-profit
health hotlines are being delivered by operators and healthcare providers.
Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report; http://124.124.103.76/hmrigovtview/;
http://www.hmri.in/104-Advice.aspx; http://healthmarketinnovations.org/program/health-management-and-research-institute-hmri
10
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of HMRI – 104 Advice (2/2)
Challenges
across the
ecosystem
• Health system and human capital: High staff turnover, especially among doctors; This
challenge is common across health hotlines, and requires increased incentives and/or
creative HR management
• Access to capital – limited public funding for increasing scale: Increased scale and
replication beyond Andhra Pradesh will require additional capital
Potential
actions
• Replication and scale beyond India: given health system constraints in rural areas across the
developing world, this model could be pursued by funders – including national governments and
global health funders of health systems It could be included as an option in funding proposals.
Similarly, it could be integrated into offerings of national governments / MOHs and NGO
implementers based in cities and other areas with higher concentrations of doctors
• Access to finance: In order to finance expansion of this model, there are several avenues that
might be pursued. First, securing funding from large scale funders for health systems, or even
catalytic funders such as angel investors or smaller foundations who invest in health systems could
help with start-up costs. From there, there is the potential to explore a cross-subsidized model in
which 104 Advice - or other product offerings - could be provided to higher end customer segments
to subsidize its advice hotline to the rural poor
Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report;
http://124.124.103.76/hmrigovtview/; http://www.hmri.in/104-Advice.aspx
11
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Voila Foundation / Red Cross Public Health Advisories (1/2)
Concept
Value
proposition
• Voila Foundation (Trilogy International) and the International Red Cross created the SMS Aid Application
system to reach populations at risk post-earthquake in Haiti
• Voila Foundation is the sole funder; non-profit model
• Launched in 2010
Red Cross estimates it has
reached significantly more
people via SMS based
campaigns1
Advantages:
• Rapid access to individuals with limited access to communication (this is
a novel system with an “SMS gateway” that plugs into mobile network
4,000,000
# of
towers and can access any Voila customers who has been using that
people
tower within the last fifteen minutes (i.e., not subscription based)
reached
• Ability to quickly scale to new areas at risk for epidemic
•
Two way communication capabilities, including link to a toll-free *733
hotline in Creole, to reinforce SMSes and complementary interventions
Results:
• Cholera prevention: 4m SMSes sent to reach 0.5m people; 90,000 calls
received to hotline; reinforced by sound trucks and radio
• No studies yet to assess impact in terms of outcomes (behavior,
infection rates), however studies planned to assess number of calls
received via toll-free *733 number
Beneficiaries and willingness to pay:
• All populations within range of cell phone towers in Haiti identified at-risk
for public health situations (e.g., cholera, storm surge)
• Ability to pay has not been tested, but anticipate this would greatly limit
reach and compromise goal of reaching populations most in need
Market
1000%
400,000
Without SMS
With SMS
• Current scale: across Haiti, SMS Aid Application has delivered 26.6m SMSes and reached 1.2m people
(1) Based on disaster preparedness campaigns; Red Cross Beneficiary Communications in Haiti 2010;
Source Voila, International Red Cross; Dalberg research, interviews, and analysis. http://www.trilogyinternational.com/TrilogyVoilaIFRCSMSAidapplicationFINALUS.pdf; http://www.voilafoundation.com/partners.htm
12
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Voila Foundation / Red Cross Public Health Advisories (2/2)
Challenges
across the
ecosystem
Potential
actions
• Technology developers: Limited bandwidth for 2-way communication; Voila is currently upgrading to
accommodate; another challenge is communicating effectively in 140 characters or less of SMS; potential
for innovation in hardware or software to accommodate additional information
• Health workers / Red Cross: Need to scale in line with human capacity of operational teams and their
ability to respond to issues identified via 2-way communication; if not, could create unmet expectations
within the Haitian population
• MNOs: Right now, exclusivity in agreements with sole MNO prohibits reaching customers of other
operators
• Users: Content requires literacy (being addressed by addition of toll free Creole hotline)
• Donors: Additional funding will be needed to scale beyond Haiti
• Increase revenues: N/A; additional donor funding can be sought for roll- out beyond Haiti or to diverse funder
base in Haiti
• Increase customer base: N/A
• Integrate into community health workers’ outreach roles: Potential for CHWs to act on responses
received via 2-way communication
• MNOs: While agreements are exclusive in Haiti, exploring additional partners and more open systems in
countries beyond Haiti where Trilogy does not operate
• Government: Close collaboration with the government and the Haitian Red Cross to use their system to
support services auxiliary to the government, such as blood donor programs
• Donors: Target funders and sponsorship in additional areas in need of disaster response – both from MNO
contributions and/or from large scale funders involved in disaster recovery; potential for co-investment across
multiple funders
Source Voila, International Red Cross; Dalberg research, interviews, and analysis.
13
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Table of contents
•
Overview of mHealth ecosystem, impact, and services
•
Four example business models:
− WelTel
− Changamka
− HMRI
− Voila Foundation / Red Cross Public Health Advisories
•
Prioritization framework, financing and implementation mechanisms
•
Conclusions
•
Annexes
14
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Framework for Ministry of Health prioritization of mHealth interventions
Desired outcomes
1
Key questions
• Understand the key priorities,
needs, opportunities and
constraints in the ecosystem
• What are health needs / priorities?
• What is the current state of / dynamics in the
ecosystem (e.g., infrastructure, regulation,
technology, applications)?
eHealth strategy
development
• Define strategic approach to
eHealth that recognizes
broader ICT/e-Gov priorities
and integrates mHealth
• In which areas could mHealth/ICT play a role?
• What are broader ICT and e-Gov priorities and
initiatives that might complement mHealth?
• What are core regulatory and implementation
requirements (e.g., incentives, financing)
Implementation
planning and
tactics
• Outline core requirements
and tactics for
implementation
• What is the most efficient and appropriate
means to implement (e.g., grants for R&D?
Tender to select partner? Challenge fund?)
• What is the roadmap for implementation (e.g.,
expected activities, timeline and resourcing?)
Evaluate and
refine strategy
and tactics
• Identify lessons learned and
understand impact to refine
strategy and tactics
• What has been the success and impact of the
selected mHealth applications and
interventions in the context of the broader
eHealth strategy?
• What are lessons learned via M&E?
• What refinements need to be made to achieve
desired impact?
15
Review of
local ecosystem
and context
2
3
4
Source: Dalberg research and analysis
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
A range of financing and implementation mechanisms are being explored and
deployed across the technology life cycle of m-applications
Stage of technology
lifecycle
Objectives
Stage 1:
R&D
Stage 2:
Demonstration
• Develop
technology
prototype
• Establish
evidence
base (M&E)
Stage 3:
Deployment
Stage 4:
Diffusion
• Refine
technology
and model
• Achieve
scale of
users
Stage 5:
Maturity
• Further
optimize
product (e.g.,
lower costs)
Tax credits
Types of financing
vehicles
Challenge funds
R&D grants
(including competitive
subsidy, cost sharing
Licensure requirements
Venture capital and
Incubator funds
Type of mechanism
Cost-sharing / subsidies from
large scale funders (e.g.,
PEPFAR, Global Fund, WB)
= Public /
philanthropic
= Blended
(public/private)
Loan guarantees
= Private
Venture capital
(including angel investors)
Corporate
R&D
investment
Insurance / payers
Industry investment (including equity, debt)
Note: Not exhaustive; Arrows do not indicate a continuum or linear relationship across funding vehicles
Source: Dalberg research and analysis
16
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Examples: Challenge funds and venture capital / incubator funds
Description
Challenge
funds
Venture
capital /
incubator
funds
Conditions for deployment
Potential actions by
funders and/or implementers
• Prize fund set up to
incentivize
development of a new
business model or to
catalyze players to
enter and engage in a
new market
• Persistent market challenge – primarily within
one of the following categories:
– Innovation: technological challenge,
requiring R&D and proof of concept (e.g.,
Gates Foundation Grand Challenges
Fund)
– New market development: market for a
product or service does not exist due to
limited profit potential or lack of upfront
capital investments (e.g., Gates /USAID
Haiti Mobile Money Prize Fund; Africa
Enterprise Challenge Fund)
• Requires multiple players who are willing to
compete for the prize
• Often these incentivize appeal more to private
sector players in a competitive market
• In appropriate markets, make
challenge grants and use prize
funds in lieu of “push” funding via
grants
• Approach can be attractive to
funders, in that they only pay for
success
• Also provides a means to engage
and incentivize private sector
players, offering a path to
sustainability
• VC funding and
incubator services are
offered to support startups and entrepreneurs
• Either blended capital
(with philanthropic or
impact investor
components, or purely
commercial)
• Promising early stage, for-profit business
models which lack access to capital and
management training to grow
• Flourishes in environments which are
conducive to business operations
• Examples of VC and incubator funding:
– Commons Capital, a blended capital
venture capital fund, has a Global Health
Fund which invests in mHealth models;
has seen significant increases in its
mHealth deal flow in the past year
– Sproxil, an anti-counterfeiting business
model is an example of a for-profit model
which seeks venture capital funding to
grow its operations and expand beyond
recent, successful pilot in Nigeria
• Funders can choose to back
blended capital VC and incubator
funds focused on mHealth
models, such as those emerging
with Commons Capital or other
impact investment vehicles (e.g.,
via the Aspen Network of
Development Entrepreneurs or
Global Impact Investors Network)
• Existence of such funding could
motivate innovators and
implementers to pursue for-profit
or hybrid (social enterprise)
models rather than the non-profit
models that dominate the current
mHealth space
17
BACK
Source: Dalberg research and analysis
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Table of contents
•
Overview of mHealth ecosystem, impact, and services
•
Four example business models:
− WelTel
− Changamka
− HMRI
− Voila Foundation / Red Cross Public Health Advisories
•
Prioritization framework, financing and implementation mechanisms
•
Conclusions
•
Annexes
18
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Summary findings: High-level requirements across the ecosystem to realize the
potential for mHealth
Creation of
mHealth services
Scaling up and
replication
• Create linkages to
encourage
innovation
• Understand costs
• Support for
business models
and financing
• Monitor and
evaluate to create
an evidence base
for decisions
• Support capacity
and training across
the ICT industry
• Customize content
Enhancing
impact on health
outcomes
• Invest in health and
ICT literacy
• Document
outcomes
• Prioritize
successful models
Fostering an
mHealth
ecosystem
• Support for critical
inputs (e.g.,
entrepreneurship,
incentives for
mobile operators to
partner, etc)
• Investment in
multipliers (e.g.,
creation of eHealth
strategies; support
for mobile money,
etc)
19
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Table of contents
•
Overview of mHealth ecosystem, impact, and services
•
Four example business models:
− WelTel
− Changamka
− HMRI
− Voila Foundation / Red Cross Public Health Advisories
•
Prioritization framework, financing and implementation mechanisms
•
Conclusions
•
Annexes
− Illustrative case studies (Note: more extensive information is
provided where possible based on interviews and analysis in case
study countries)
− Examples of financing and implementation mechanisms
20
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Millennium Village Project's ChildCount+ (1/2)
Concept
• A real-time database covering Kenya’s children, including immunization and health risks; uploaded by
CHWs via SMS; supports Millennium Villages Project interventions (e.g., acute malnutrition
management, diagnosis and treatment of malaria, ORS and zinc). Piloted in Sauri, Kenya.
• Non-profit model; Part of MVP, fully funded by Earth Institute (Columbia), Millennium Promise, UNDP;
with in-kind support provided by Ericsson, Zain, UNICEF
• Launched in 2009
Value
proposition
Advantages:
• Better monitoring reduces child mortality; expands health system’s reach; saves time vs. paper
records; helps CHW prioritization
Results:
• >9,500 children registered by 108 CHWs in 3 months; adoption underway by UNICEF and interest
from other implementing organizations
Beneficiaries and ability to pay
• Pregnant women and children under 5 years old; limited ability to pay
Market
• Current scale: In Sauri, Kenya, 108 CHWs support 8 clinics and one sub‐district hospital in Sauri
Kenya. This includes over 9500 children (registered after 3months), 7,646 nutrition screening
reports, 839 RDT results and registration of 7,803 measles vaccinations.
• Current costs/revenue: Undisclosed
• Estimated costs to scale: Undisclosed
Source: ChildCount+; Dalberg research, interviews and analysis, 2010.
21
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Millennium Village Project's ChildCount+ (2/2)
Challenges
Potential
actions
• Financing for scale and sustainability: The main path to scale and sustainability is either to be funded by a
large scale funder (e.g., USAID, World Bank) or national government who supports health systems. While the
national adoption of the model in Uganda and Nigeria is encouraging, questions remain regarding national
governments ability to sustainably fund the costs of the SMSes and training over time.
• Mobile Network Operators: A key piece of the model has been utilizing toll free SMSes with reverse billing,
which enables individual CHWs to utilize the application without paying directly for each SMS sent. The
process of establishing this arrangement and making the case to operators has been longer than expected or
desired; as the model is replicated and scaled, mobile operator support and model innovation in individual
countries could drive the pace and trajectory of expansion.
• Handset costs: In the Sauri roll-out, higher end, relatively expensive phones were used; this could be a
barrier to scale if costs increase; however, it is anticipated that lower cost phones could be used.
• With emerging evidence base on effectiveness, advocacy for governments to include in, and donors to
fund, in proposals for HSS: ChildCount+ could be an important tool in countries’ strategies for HSS and
maternal/child health. Donors who are shifting towards an HSS platform and increasingly looking for ways to
fund health systems, should ask for and include mobile-based registration programs as a means to address
maternal and child health. This would include large scale health funders such as the USG’s Global Health
Initiative, Global Fund, GAVI, and the World Bank.
• Standardize system for reverse billing, and incentivize MNOs: Additionally, to address the ease of
establishing arrangements with MNOs, the process of setting up reverse billing can be standardized and the
market opportunity made clear to the MNOs (e.g., revenue potential of reverse billing system by increasing
volume); similarly, local governments can incentivize further participation in these types of programs,
particularly at start up. Incentives could include tax credits or licensing arrangements which are linked to
innovative partnerships with local mHealth programs. This would incentivize the MNOs to help develop
creative solutions which ease of implementation and further collaboration between the implementing
organizations (e.g., ChildCount+) and MNOs.
• Build for scale – including integration of offering on lower cost phones: The technology and offering will
need to be integrated onto lower cost phones in order to scale cost-effectively. This is believed to be feasible
based on ChildCount+ interviews, and is planned going forward.
Source: ChildCount+; Dalberg research, interviews and analysis, 2010.
BACK TO APPLICATION TYPES
22
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Episurveyor
Value
proposition
Advantages:
• More and faster analysis – the assumption is that digital data is easier to analyze which will make analysis
more feasible and timely. Faster data means the ability to more quickly respond to changing circumstances.
• Lowered cost of program assessment –Current systems for quality data collection are too costly and only
available to well-funded programs
• Promotion of standardization and meta-analysis – No universal
system for sharing data collection instruments currently exists.
EpiSurveyor survey files, which as electronic files care easy to
catalog, download, share, and use, can provide a common platform
for sharing those data collection instruments that represent best
practices.
• Uses: Managing disease outbreak such as polio or malaria, ongoing
data collection, supply chain management.
• Results: An End Use Verification of the President’s Initiative for
Malaria was carried out in Ghana in order to monitor malaria supply
chain. Results indicated 3 critical areas of impact:
• Time – See graph
• Data quality – Negligible difference. 1.5% difference
between the two methods.
• Ease of use – 100% qualitative assertion that survey
respondents would prefer to replace paper-based data
collection with EpiSurveyor
Market
Speed of data collection
150
142
-18%
117
Time (min)
Concept
• Episurveyor is an open-source cloud computing data collection application designed to lower the barriers to
collecting high-quality data by creating an inexpensive, easy-to-use software for data collection on handhelds
mobile devices.
• Episurveyor’s theory of change is that, if the cost and difficulty of collecting data is reduced, then data is more
likely to be collected.
100
50
0
Paper Based
Episurveyor
• Current scale: Nearly 3000 users; >100 000 records uploaded
BACK TO APPLICATION TYPES
23
Source: Dalberg interviews and analysis; http://datadyne.org/files/Zambia_EpiSurveyor09_Technical%20Report.pdf
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Pesinet
Concept
Value
proposition
Market
• Pesinet combines mobile technology and proximity work of community health agents to
deliver home based care that will offset the limited capacity of existing public health systems
and provide affordable healthcare that can prevent, detect and treat childhood diseases.
• Mobile phone based data collection system allows monitoring and early treatment of common
diseases. First pilot launched in October 2008, with funding from Telcom operators Orange
and Alcatel Lucent.
• Intended outcomes:
• Reduced mortality
• Reduced health spending on benign illnesses
• Increased prevention and sanitation
• Job creation
• Skills development
Advantages:
• Value to patient (mother and child) – cost savings 1 USD subscription includes a
subsidized doctor consultation and highly discounted rates on prescriptions. (vs. USD 1.2 – 2
consultation fee
• Quality – in a local survey, over 95% of respondents were satisfied with the service, pleased
with the price and would recommend it to a friend or family member
• Value to the provider - improved efficiency and operations – greater efficiency realized
through mobile based data collection
• Current scale: Not at scale. 390 children in pilot clinic.
Required break even estimated at nearly triple this number.
BACK TO APPLICATION TYPES
Source: Dalberg interviews and analysis; Pesinet website
24
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Weltel (1/2)
Concept
Value
proposition
• Adherence is a huge issue in treating patients who are HIV-positive and taking antiretroviral therapies (ART), thus,
WelTel provides weekly SMSes from clinic nurses to patients, inquiring regarding their treatment, and patients are
required to respond within 48 hours; if no response is received, the nurse follows up with a call and referral if needed
• Social-enterprise model, funded by PEPFAR and CDC
• Founded in 2007
Advantages:
• With reminders, patients adherence improves, leading to better outcomes in terms of suppressed viral loads
• Cost-effective means of extending health system reach where roads are bad and travel expensive, but mobile service
is inexpensive and reliable; basic handset is required (rather than a smartphone); utilizes existing clinic nurses
• Cost of the offering decreases with scale; also reduces overall health system costs by estimated 1-7% due to ability to
more efficiently following patients, and keeping patients healthier via improved compliance, meaning they use less
emergency health services and avoid development of drug resistance and need for 2nd line medications
• Potential to move “horizontally” beyond HIV given simplicity of system
Results:
• In recent RCT, patients receiving SMSes had better adherence and suppressed viral loads
Beneficiaries and willingness to pay:
• Patients receiving antiretroviral therapies (ART), primarily in
Results of recent clinical trial
the pastoral Masai communities of Kenya; ART funders who can
receive better return on investment
273 265
• Patients at Kajiado and Pumwani Health Centre receiving ART
No.
indicated a willingness to pay up $0.50 to $1 USD.
patients
168
Market
• Current scale: Pilot and RCT in 273 patients
• Costs/revenue: Budget for RCT was $719k
• Estimated costs to scale:
o Scaling to 400k PEPFAR patients on ART would result in
26,000 additional patients with suppressed viral loads
o At $8/patient, this would cost $3.2M, which is
approximately 1-2% of PEPFAR treatment budget
156
132
Total no.
patietns
Treatment
Adherent
patients
Patients receiving SMS
128
Suppress
viral loads
Patients NOT receiving SMS
Source: The Lancet; Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomized trial; November 2010:
Dalberg research, interviews and analysis, 2010. Nation Media, December 2010 http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf; http://www.scidev.net/en/health/hivaids/news/texting-saves-lives-of-hiv-patients-study-confirms.html
25
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Weltel (2/2)
Challenges
across the
ecosystem
• Government / policy: Need for greater medical policy leadership that brings together stakeholders
to build the evidence base and prioritize models in coordinated rather than competitive way
• Funders: Legacy systems and competing interests can slow the pace of change and overall scale
of programs proven to work; similarly, while WelTel can be deployed horizontally across other
disease areas, health systems and their funders continue to be somewhat siloed
• Mobile Network Operators: Poor network coverage can present constraints to reaching patients
• Users: Shared phone access can present difficulties reaching individuals in a timely manner
Potential
actions
• Medical policy leadership and coordination: To address gaps in the evidence base and in
streamlining of systems, need for greater leadership across the technology developers, the health
systems players and funders. This can come from a number of players – including academic
institutions involved in developing models (e.g., British Columbia Centre for Disease Control),
alongside international champions and conveners (e.g., the mHealth Alliance, WHO/ITU)
• Prioritize and integrate funding into large scale systems addressing HIV and beyond: WelTel
has received interest from PEPFAR in rolling out this model beyond the current pilot; more broadly,
there is an opportunity for other large scale funders to prioritize and request these types of
interventions in country funding proposals for HIV programs and health systems (e.g., the Global
Fund’s HSS funding)
Source: Dalberg research, interviews and analysis, 2010. Nation Media, December 2010
http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf
BACK TO APPLICATION TYPES
26
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of TxtAlert (South Africa)
Concept
• On average 30-40% of ARV patients initiated onto treatment in South Africa are lost to follow up’
(LTFU) within the first year. This is due to a variety of reasons, including a lack of government
leadership which leads to conflicting messaging regarding HIV treatment. However, over 90% of
patients at the clinic have/ or have access to cell phones and are comfortable with SMS and Please
Call Me Services
• TxtAlert was designed to reduce the percentage of lost to
follow up patients by improving overall appointment
attendance.
Reduction of LTFU and missed
appointments
Without TxtAlert
Market
Outputs and intermediate health outcomes
• Improved operational efficiency: Reduction in missed
appointments leads to improved admin efficiency.
• Increased patient provider communication through use
of ‘please Call Me’ to phone the clinic at no charge.
• Reduced number of patients lost to follow up reduces
overhead costs and ability to maximize lives saved with
limited supplies of ARVs.
• Current scale: Currently
serving over 15 000 in
Johannesburg, South
Africa.
TxtAlert
30
27
Percentage of patients %
Value
proposition
4
Missed
appointments
4
LTFU
BACK TO APPLICATION TYPES
Source: Dalberg interviews and analysis.
27
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of iChart Emergency Response (1/2)
Concept
• A self-contained mobile phone application that
allows emergency response physicians to upload
patient data and download treatment information,
generating electronic health records
instantaneously
Cloud
Computing
Server
• Non-profit model; Much of the initial budget was
donated as in-kind products and services, and
iChart continues to rely on cash donations for
operation and maintenance
• Deployed in Haiti in 2010
Value
proposition
Reports
iPhone
• Advantages: electronic health records improve coordination of care and reduce medical errors; the system
could provide a basis for a nationwide medical records database; costs of data collection are much lower than
for traditional methods; the status quo without iChart would have been ad-hoc paper or excel based data
collection, which results in patents with incorrect or no documentation of their diagnosis or treatment.
• Results: More than 500 medical records created, though take-up rate has been low
• Beneficiaries and willingness to pay: patients in need post-disaster or in other emergencies; doctors and
health system which can more effectively track patients and allocate resources; low expected willingness to
pay based on systemic nature of the value.
Market
• Current scale: Post-earthquake it was used by more than 140 Palo Alto Medical Foundation physicians,
nurses and support staff. More broadly, there is room to integrate this type of application and attributes with
other forthcoming EMR systems. However, the fact that it relies on an iPhone, at this point, makes it less
attractive and relevant in low resource settings
• Current costs: ~$19,000 for 3 month deployment in Haiti
• Expected costs to scale: Undisclosed
• Competing or complementary interventions: Building off of iChart’s efforts, HHI Hospital in Fond Parisien
created an iPhone web based application in which emergency physicians entered patient diagnosis and
treatment data to a local server, eventually generating medical record reports for 500-750 patients
Source: Dalberg interviews, research and analysis, 2010.; OMI UN/PAHO Report Sept 2010
28
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of iChart Emergency Response (2/2)
Challenges
across the
ecosystem
• MNOs: Poor network signal in many areas limits usage
• Healthcare workers: Practitioners must become used to a
complex application in emergency situations; requires
training
$9,010
• Standards: with no existing emergency EMR standards,
iChart currently is not interoperable with other EMRs
$6,240
• iPhone required: this is not accessible on other types of
smart phones or lower end phones, limiting the potential for
scale and replication, particularly with indigenous CHWs
$2,900
• Ongoing funding: Funding may be limited if donations dry
up; similarly, this tool will need to be evaluated for costeffectiveness overall relative to other potential solutions and
applications, particularly those which can be used on a
lower-end phone. While costs initially were rather high for
the hardware, software, and customization, these could be
expected to decrease in the future as they are amortized
over further usage
Potential
actions
Estimated costs for 3-months of operations
$5,750
$3,840
$0
$1,500
$2,080
$1,260
$2,000
$0
Month 1 (Actuals)
$1,260
Month 2
(Actuals)
$1,260
$0
$1,080
Month 3
(Forecast)
IT hardware
IT customization/ maintenance
IT software
Project management
“Everything was bootstrapped, we even held bake
• Standards development and integration: Alignment on
sales. Sustainable funding is required to move the
emergency EMR standards, and integration with broader
development of the application forward. ”
EMR standards will be critical to ensure uptake and
-iChart Emergency Medical Volunteer Doctor
maximum relevance and uptake of this application.
• Evaluation of relative cost effectiveness: given the
iPhone requirement and current limited usage, it will be critical to evaluate the relative cost effectiveness of this
versus other products and applications when considering deployment in future disaster situations.
• Agreement on approach and usage in emergency response situations: Following evaluation of relative
cost-effectiveness, iChart can be integrated into future post-disaster relief efforts. This will require outreach
and coordination across key agencies and NGOs involved in relief, as often there are many agencies, NGOs
and individuals involved in immediate response efforts. If iChart is believed to be the best option – and one
which an be interoperable – the disaster relief community should align on this as a standard and integrate it
into plans and offering.
Note: There are not “training costs” as no formal training was provided during roll-out, which was feasible in that the iPhone was a familiar device to the
physicians using it, though may not be a sustainable practice in the long-run
BACK TO APPLICATION TYPES
Source: Dalberg interviews, research and analysis, 2010.; OMI UN/PAHO Report Sept 2010
29
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Ziquitza Healthcare Ltd, 1298 Ambulances (1/2)
Concept
Value
proposition
Market
• An easy-to-remember telephone number for the rapid delivery of emergency services via ambulance in urban
and suburban areas
• Social-enterprise model; 1298 is contracted by government as part of a public-private partnership to offer
emergency services through official channels (initially funded by Acumen Fund, and implemented by Ziquitza
Healthcare Ltd. In conjunction with governments in Rajasthan, Mumbai and Kerala)
• Founded in 2005
• Advantages: Extends reach via mobile – 90% of calls to 1298 come from mobile phones, often from people
who would not otherwise have been able to communicate with emergency service providers; radio dispatch
sends the closest ambulance with appropriate equipment and crew to the caller’s location
• Results: 70,000 calls answered in five years; measurable impact on maternal mortality in childbirth (50% of
calls are to support pregnant women, resulting in reduced infant mortality and fewer complications in childbirth)
• Beneficiaries and willingness to pay: Patients in need of emergency services and transport; Customers
are charged on a sliding scale depending on the kind of hospital that patients choose for treatment, with the
poorest patients receiving discounts of 50 to 100%
• Current scale: Grew from 10 ambulances to 280; Expects to have 1,000 ambulances serving millions of
people by 2012
• Current revenues and costs: Full financials undisclosed, but have been awarded $80m in government
contracts for free or subsidized services in several states.
• Estimated costs to scale: Already at scale
• Competition: There are three competing ambulance and emergency services currently operating in Mumbai
and across the country but, at present, the high level of demand outweighs competition.
Source: Dalberg Interviews September 2010; Dalberg Analysis
BACK TO APPLICATION TYPES
30
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Ziquitza Healthcare Ltd, 1298 Ambulances (2/2)
Challenges
across the
ecosystem
Potential
actions
• Financing:
•
Profitability: Ziquitza’s profitability is driven by the ability to operate in high population density areas
where the mix of ‘ability to pay’ allows for cross-subsidization. Alternatively, (recognizing that these
economics are not often available) Ziquitza works in partnership with government and has realized nearly
$80M in government contracts to provide its services.
•
Primary revenue drivers include fees for emergency transfer to private hospitals, fees for general hospital
transfer, and to a lesser extent, contract services from the government.
•
Primary costs include: Fixed costs include the ambulance fleet and call centers; variable costs include
human resources (staff of over 240), fuel costs, maintenance and repairs, and short codes – negotiated for
free based on current government policy
•
Constraints of tiered pricing model and cross-subsidization: The tiered pricing model depends on a
diverse patient mix and cannot be rolled out to rural areas where there are few middle- and high-income
patients; more consumer education may be needed to encourage greater use of existing services
• Grow government contract business: One promising area for revenue growth is with government
contracts, which currently is a smaller share of business. By working with the government, and customizing
services to meet their needs in the markets in which it currently pays for transfers and other services (e.g.,
potentially, employee care), it can increase its revenue potential
• Grow higher-end and lower-end customer base: Additionally, by growing the share of higher end customers,
who can pay fees and help stabilize the top line of Ziquitza’s model, there is a clearer path to profitability.
• Provide subsidies or other incentives for roll-out in rural and/or lower income areas: While profitability
may depend upon growing higher-end customer segments, given the need and utility of serving rural areas and
populations, the government and/or other funders can incentivize profitable expansion by providing subsidies
for lower end customers served and exploring other tools (e.g., policies and credits which lower cost base and
otherwise enable this business model – e.g., such as that which was done with free short code.
Source: Dalberg Interviews September 2010; http://www.scribd.com/doc/11575031/Dial-1298-forAmbulance-HSBC-PPT
BACK TO APPLICATION TYPES
31
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of PEPFAR/Solutions HMIS (1/2)
Concept
• A precursor set in HIV/AIDS clinics of a health information system for Haiti, with mHealth
applications for disease surveillance; Health workers report disease incidence and symptoms via
SMS to a central database; funding for the next five years is from PEPFAR and the U.S. Centers for
Disease Control, with the Haitian government promising to step in afterward
• Non-profit model; Funded by PEPFAR
• Launched in 2008
Value
proposition
• Advantages: Expanded reach of the health care system; data entry is more cost-effective; most Haitians
are familiar with mobile phones and SMS; minimal infrastructure is required; data are updated weekly,
which was previously impossible; lower costs in terms of maintenance and repairs
• Results: Collection of data from 150 clinics
• Beneficiaries and willingness to pay: HIV clinic patients and overall health system users; given data
and information accrues value across the system, willingness to pay resides with health system funders
(e.g., PEPFAR)
• Current scale: Government contract for 700 clinics over five years
Market
• Current costs: cost of implementing SMS based data collection is 7% of computer terminal data
entry, and 13% of ongoing operations cost
• Cost to scale: Undisclosed
Source: http://2006-2009.pepfar.gov/documents/organization/81062.pdf; Dalberg interviews, research and analysis, 2010.
32
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of PEPFAR/Solutions HMIS (2/2)
Challenges
across the
ecosystem
• Health sector: “Vertical” – HIV/AIDS focused approach, built for
HIV/AIDS and hard to expand; no national standards for electronic
health records; no incentive to share data beyond PEPFAR clinics;
lack of integration with other health areas
• MNOs: Poor network strength in remote areas, plus collecting data via
phones can be limited and cumbersome depending on the patient’s
needs and status
Cost for each new clinic –
computer vs. mobile data entry1
$9,580
80
1,000
3,500
-93%
• Training requirements and costs: Need for additional training in
scaling application; raining is essential and largest cost for scaling
5,000
$710
10
700
Computer
Potential
actions
Mobile
• PEPFAR to push for integration and standards to roll-out
Operating costs
Hardware
HMIS: Given PEPFAR’s ownership of this program and
Internet set-up
presence in multiple countries beyond Haiti, it is well
Generator
positioned to push for greater integration – asking for data
not only on HIV/AIDS, but collaborating with other donors
and asking for data that adheres to standards and is possible
to integrate with broader health records and issues. One example of this is the iChart model, profiled in this
study, which also creates medical records, and which is currently not integrated or utilizing the same standards
as PEPFAR’s HMIS.
• Training requirements and costs: Explore potential to bundle training and achieve economies of scale by
coordinating with broader efforts to create training courseware and certification – relevant in Haiti and beyond.
(1) The backend server and infrastructure required for computer or mobile data entry is
separate from these numbers and about the same cost in this case. Source: Dalberg
interviews, research and analysis, 2010.
BACK TO APPLICATION TYPES
33
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of HMRI –104 Advice (1/2)
Concept
• Improve local health services through a comprehensive, multiplatform
approach that replaces the traditional health care system with interventions
delivered directly to rural and underserved communities; In addition to 104
Advice hotline, includes mHealth applications for disease surveillance,
prevention counseling, telemedicine, and supply chain management
• Social-enterprise/hybrid model, funded by the government of Andhra
Pradesh state (95% of costs) and the Satyam Foundation (5% of costs)
HMRI estimates that of the
600k unmet requests for
outpatient treatment, 55%
could be treated by phone
100%
600,000
• 104 Advice launched in 2007
Value
proposition
• Advantages: Services may cost as little as one tenth as much versus
government provision; health services are available to rural patients in their
own communities, saving them time and money; services are integrated
across many areas
• Results: 50,000 calls taken per day; 10 million medical records created;
1,500 people employed; ; since it’s inception, the offering has grown from 4
seats attending 200 calls/day to a new facility of 400 seats working 24 hours
per day to attend an average of 50,000 calls per day
• Beneficiaries and willingness to pay: Patients in need of medical
counsel or advice in Andhra Pradesh; willingness to pay is not fully tested;
as the service has been provided free of charge for three years
Market
% requiring
live consultation
45%
% who can
be treated by
phone
55%
• Current scale: 80 million people covered in Andhra Pradesh; An estimated
55% of unmet requests for outpatient treatment (600,000 per day) could be
treated by phone (see chart on the right)
• Estimated costs to scale: Already at scale in Andhra Pradesh
• Competition: Within the state of Andhra Pradesh, HMRI holds a dominant market position, strengthen by its ability
to integrate services across a variety of areas. However, competition will be an issue in other states where for-profit
health hotlines are being delivered by operators and healthcare providers.
Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report; http://124.124.103.76/hmrigovtview/;
http://www.hmri.in/104-Advice.aspx; http://healthmarketinnovations.org/program/health-management-and-research-institute-hmri
34
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of HMRI – 104 Advice (2/2)
Challenges
across the
ecosystem
• Health system and human capital: High staff turnover, especially among doctors; This
challenge is common across health hotlines, and requires increased incentives and/or
creative HR management
• Access to capital – limited public funding for increasing scale: Increased scale and
replication beyond Andhra Pradesh will require additional capital
Potential
actions
• Replication and scale beyond India: given health system constraints in rural areas across the
developing world, this model could be pursued by funders – including national governments and
global health funders of health systems It could be included as an option in funding proposals.
Similarly, it could be integrated into offerings of national governments / MOHs and NGO
implementers based in cities and other areas with higher concentrations of doctors
• Access to finance: In order to finance expansion of this model, there are several avenues that
might be pursued. First, securing funding from large scale funders for health systems, or even
catalytic funders such as angel investors or smaller foundations who invest in health systems could
help with start-up costs. From there, there is the potential to explore a cross-subsidized model in
which 104 Advice - or other product offerings - could be provided to higher end customer segments
to subsidize its advice hotline to the rural poor
Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report;
http://124.124.103.76/hmrigovtview/; http://www.hmri.in/104-Advice.aspx
BACK TO APPLICATION TYPES
35
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Clinton Foundation / Hewlett Packard (1/2)
Concept
Value
proposition
Market
• The Clinton Health Access Initiative, Kenya’s Ministry of Public Health and Sanitation, and HP aim to provide
technology to capture, manage and return early infant diagnoses (EID) on HIV test results; this will also create
a back-end system for data capture on EID across Kenya
• Non-profit model; HP investment in infrastructure ($1m); Roche funded set up of 4 labs at $250k each, as a
means to generate demand for their reagents; partners who utilize system (e.g., PEPFAR, USAID) pay for use
• Launched at Clinton Global Initiative in 2010
Advantages:
• Increased speed of results: while paper-based system took up to two to three months, the HP system will
return results in 1-2 days; turnaround time for test results is particularly critical for infants, as they must begin
antiretroviral therapy as soon as possible to ensure survival (without immediate treatment, half of HIV positive
infants aren’t likely to survive past age 2)
• Building back-end to capture and analyze data: Data centers will have access to nation-wide data to
inform prioritization of resources and healthcare interventions. Examples of this data includes coverage of
early infant diagnoses, outcomes from preventing mother to child transmission (PMPCT) interventions)
Results:
• Within first year, this program expects to deliver early
Speed of information delivery
diagnoses for approximately 70,000 infants
45
• It also expects to build a database on EID results, and
Number
stream real-time medical data to health practitioners
of days
Beneficiaries and willingness to pay:
• Patients (infants of HIV+ mothers); very limited ability to pay;
similarly, national government will not pay until demonstrate
-97%
impact and scale (likely ~10 years off)
• Current scale: As stated above, will reach ~70,000 infants in
Kenya Aims to reach up to 120,000 infants exposed to HIV in
Kenya each year for testing and treatment; Intend to expand to
more than 3,000 clinics over the next two years
2
• Current costs: $1M investment (HP); $250k for each lab; inkind contributions on technical design from Strathmore
Existing process SMS based printer
University students
• Expected costs to scale: TBC
36
Source: Dalberg interviews and analysis; AllAfrica - http://allafrica.com/stories/201012281280.html
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Clinton Foundation / Hewlett Packard (2/2)
Challenges
across the
ecosystem
• Financing: Questions exist regarding who will pay for the communication costs of the model as it scales.
Currently, partners who utilize the model will pay for it (e.g., PEPFAR), however costs will grow as build out the
back-end system and data captured and analyzed.
• Technology developers: As new applications are developed, primarily as pilots, it will be a missed
opportunity if they do not backward-integrate and build on existing systems, such as the data centers and
back-end in the CHAI/HP model.
• Government and policy-makers: There is a broad need for players who work with government and policymakers to design systems and align resources so that systems such as this can be easily integrated and
scaled, in line with underlying health needs. There is also need for an evidence base which will allow for
understanding of the impact of this system so that it can be refined and eventually funded by national
governments over time.
Potential
actions
• Financing from large scale health funders as proof of concept and evidence base grow: as the model
proves its value – both in terms of EID and data access, large scale funders such as PEPFAR, Global Fund
can provide an avenue for funding of scale and capital needs in line with costs of communication needs and
technology.
• Further investment in and operational approach to linking problems with solutions: This might include
greater formalization and operational capacity in ICT working groups or other local bodies, and would address
the gap between health needs, e-/m-Health strategies and operational execution. This body could work with
government/policy-makers and be a conduit for developing and implementing solutions in line with health
needs, and local constraints and opportunities. It could also be a means to address coordination and greater
standards/interoperability across existing and forthcoming data systems and individual business models.
• Leveraging local capacity: There is strong local capacity in terms of developers and innovators who can be
leveraged for design of data systems, which historically have been paper, and now can be integrated with
mobile and ICT. Similarly, there is an opportunity to further leverage local university students who can support
both M&E and health innovation. Innovation will come from young people who are in school, more than it is
coming from the private or public sector
BACK TO APPLICATION TYPES
Source: Dalberg interviews and analysis; AllAfrica - http://allafrica.com/stories/201012281280.html
37
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of mPedigree – Medicine Validation System (1/2)
Concept
Value
proposition
Market
• The system, developed by mPedigree and HP, assigns a code that is
revealed by scratching off a coating on the drug’s packaging. This
code is texted by the consumer or medical professional to a free SMS
number to verify the authenticity of the drug; If the drug is fake, the
consumer will get a message alert and a hotline number for reporting
• Social enterprise model with mix of non-profit funding (for advocacy)
and revenue from pharma companies (for security codes)
• Founded in 2007; launched in Kenya in 2010
Share and value of counterfeit
drug market in Kenya
100
Counterfeit
30
Value of
counterfeit
market =
$130M
Advantages:
• Increases transparency and raises awareness regarding
70
Authentic
counterfeit medicines
• Provides consumers and medical professionals with a fast and
cost-effective means to verify the authenticity of drugs
• Provides pharmaceutical manufacturers with a way to protect products
Kenya drug market
• Desire to create a global standard to address counterfeiting
Results:
• Intermediate outcomes – as it is early days, the partners have established alignment with partners on a model
in Kenya; toll free SMS established with MNOs; next, will measure drug volume and range of drug categories
in the system
Beneficiaries and willingness to pay
• Beneficiaries are consumers of pharma products (who access SMS and security codes free of charge), and
pharma companies who benefit from their ability to maintain market share and/or enter markets. Pharma has
proven willing to pay – particularly amongst local, generic, pharma manufacturers
• Current scale: If the initial phase is successful the intention is to expand it into a 'public' phase along the
lines of the mPedigree approach in Ghana and Nigeria (i.e. full participation by mobile operators, and thus
free-to-consumer text messaging); The initiative in Kenya marks the first time use of such a platform has
been endorsed at cabinet level in any country; it will now aim to move beyond pilot via mass marketing via
mainstream and social media, and steady replacement of old stock not bearing codes geo-spatially
• Current costs/revenues: Undisclosed; Estimated costs to scale: Undisclosed
• Competition: Competing solutions include Sproxil (successful pilot recently in Nigeria, and plans to enter
East Africa) and PharmaSecure; differentiation in holistic and systemic model which bypasses aggregators
to directly engage with MNOs, engages national governments and utilizes advocacy platform
Source: KCB; Standard Media Kenya; mPedigree; WHO http://www.who.int/medicines/services/counterfeit/impact/ImpactF_S/en/index1.html
38
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of mPedigree – Medicine Validation System (2/2)
Challenges
• Mobile Network Operators: Unclear how long the MNOs will remain interested and provide SMS
messages in-kind; right now, mPedigree is novel and garnering attention, but this may change over time.
Deep contractual relationships and offering-diversification are mitigating factors.
• Government: Takes time to get high-level government buy-in as is the case in Kenya; will need lead time
for additional countries as scale beyond existing base across the continent
• Financing: Near-term investment needs including funding for mass media marketing as move to scale;
Need for patient capital; at scale, believe model can be profitable, but need for near term seed funding
which is not entirely commercial (e.g., impact investing or hybrid venture capital)
• Users: The concept of using the mPedigree system is new to consumers, so there is a degree of marketing
and consumer education needed to ensure uptake and usage
Potential
actions
• Venture / patient capital: Increased investment from impact investors and/or venture capital sources in
mHealth models such as mPedigree. This will likely require both action and investment from philanthropic and
blended capital sources which seek social as well as commercial returns. It will also require connectivity
across players – on the investment, entrepreneur, and technical assistance components of investment.
Emerging convening bodies such as the Aspen Network of Development Entrepreneurs (ANDE) and Global
Impact Investing Network (GIIN) can provide valuable channels for this dialogue and action.
• Public health education: Governments can play a significant role in public health education regarding
counterfeits, and the potential of applications such as mPedigree. While pharma can market components of
individual campaigns, the systemic nature of mPedigree’s model demands a larger scale and public sector led
approach, both to enhance credibility and to reach vast segments of population.
• Advocacy and collaboration across governments: Building on the platform created – particularly that
involving the national government in Kenya, mPedigree can utilize its advocacy capabilities to enlist additional
senior level government support for roll-out in additional countries across the continent. This may also help
address keeping MNO interest.
Source: Dalberg interviews and analysis; KCB; Standard Media Kenya; mPedigree; WHO
http://www.who.int/medicines/services/counterfeit/impact/ImpactF_S/en/index1.html
BACK TO APPLICATION TYPES
39
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Stop Stock-outs (1/2)
Concept
Value
proposition
Market
• A monitoring system for pharmacy inventories designed to give early and timely warnings of low stocks of
essential medicines; used Ushahidi’s crowd-sourcing model and FrontlineSMS software to compile SMSbased reports on supply chain problems from consumers
• Non-profit model, funded by the Open Society Institute
• One time campaign in Kenya, Malawi, Uganda, Madagascar and Zambia in 2009
Advantages:
• Pharmacy supplies run out less often, helping patients to obtain the drugs they need; supply chain monitoring
is decentralized and made less costly; the societal norm of empty pharmacy shelves is questioned and
replaced with action
Results:
• In “Pill Check Week,” 250 reports generated
• Exposure of drug shortages and stock-outs led to extensive media coverage, and the first time admission of
the existence of stock-outs and a vow to improve the situation from a MoH official
Beneficiaries and willingness to pay:
• Patients/consumers of drugs; willingness to pay is limited given the systemic nature of the issue and income
levels of populations most affected
Mapping of stock-outs across Kenya, Malawi, Uganda and Zambia
• Current scale: The one time
campaign was carried out in three
countries; it is not an ongoing service
• Current costs/revenues:
Undisclosed
• Costs to scale: Undisclosed
Source: Stop Stock-outs; Dalberg research, interviews and analysis, 2010.
40
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Stop Stock-Outs (2/2)
Challenges
across the
ecosystem
Potential
actions
• Technology: Data integrity was an issue, as data reported was not always accurate or verifiable; this can
lead to questions regarding the legitimacy of the data and extent of the problem in reported districts
• Health system: While the media attention and MoH statement are encouraging, it is unclear how this
campaign has contributed to supply chain performance improvements, presenting challenges to replication
and scale.
• Integration, financing and ownership: This was a one-time campaign and has not been integrated in
order to monitor supply chain performance and stock-outs; it has not been integrated into other offerings for
stock-out prevention and inventory monitoring tools (e.g., SMS for Life currently in Tanzania, anticounterfeiting efforts such as mPedigree; Similarly, a long term version of the model would require
ownership by government or another large stakeholder; ideally, this would be an independent party from
those managing the supply chain and inventory. This would also require sustainable funding with
independence from the government and funders involved in supply chain operations; however, supply
chain and commodity funders such as the Global Fund might be particularly interested in this as an audit
function
• Improve data quality and authentication system: Develop means to ensure data integrity and
authentication (e.g., in how data is captured, and potentially spot auditing)
• Identify longer term owners – in Kenya and beyond: In local country contexts, identify what
organizations might be able to own this type of program and campaign, and integrate it into their current
operations. For legitimacy, this would need to be parties who are not currently incentivized or measured
based on supply chain performance and inventory management to ensure no conflicts of interest
• Push to have the Global Fund and other funders of health commodities ask for this type of data
and reporting – and fund it in grant proposals: Importantly, funders of commodities and supply
chains, who have a vested interest in stock-out prevention, should ask for stock-out reporting and data in
their grant reporting mechanisms. They should also include this type of program in their grant proposals,
and fund it along with the commodities and other forms of technical assistance which are included in
loans and grants
Source: Dalberg research, interviews and analysis, 2010.
BACK TO APPLICATION TYPES
41
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Changamka Micro health Limited, SmartCard (1/2)
Concept
Value
proposition
• A fully digital health savings account, based on a smart card. New cards include credits for a medical
consultation, a lab test, and a prescription. Can be used to pay for outpatient services within a network of
health care providers and topped up using the M-PESA platform.
• For-profit model; receives about 20 percent of the sale price of each card.
• Founded in 2008
Advantages:
• Savings on treatment and services are realized at the point of care across a network of nearly 4 dozen clinics
across Nairobi.
• Security of savings is improved.
• Does not require regular premiums (savings plan for selected treatments)
• Allows subscribers to share the smart card with family members and is not limited to individual use
Results:
• Sale of 8,000 smartcards in first 11 months of operations, selling an average of 500 cards/month
Beneficiaries and willingness to pay:
• Pregnant women and new mothers; based on sales to
date, customers are willing to pay (initial card =
Ksh 500, preloaded with standard services
Required scale for sustainability
23,300
Market
• Current scale: Signed on 25 local providers, and has
extensive waiting list of providers eager to join the
program’ customer base has been growing over time.
• Current revenues: ~Ksh 3.2m ; Sales are falling short
of commercially viable levels: sales of Ksh 23.3m
required to break even
Here the chart on the
Kenya Shillings
(‘000)
current sales and
what +630%
is required to
break even.
3,200
Cards sold
per month:
Source: Dalberg research, interviews and analysis, 2010.
Revenue
(year 1)
Revenue
(required to
break even)
500
8,500
42
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Changamka Microhealth Limited, SmartCard (2/2)
Challenges
across the
ecosystem
Potential
actions
• Users: Introducing a new product and serving a market
whose culture is not accustomed to health savings requires
significant high-touch marketing and consumer education.
• Financing: High costs of customer acquisition are a
challenge. The executive management team attributes this
to a lack of marketing and challenge of promoting health
insurance in Kenya due to negative historical image.
• Technology: Potential to integrate technology and use
mobile transfer and storage of payments rather than
smart-card; would streamline with mPesa platform
and eliminate costs associated with card
• Support scale: Funders who support health service
delivery can consider linking their existing financing or
possibly cash for work programs to Changamka to support
scale
Less than 2% of Kenya’s
population are covered by
health insurance
Insured
38,600
700
Uninsured
37,900
‘000
people
2009
• Product bundling and/or joint marketing: Pursue bundling of product and/or joint marketing efforts
with other adjacent offerings to engage new customers and get them accustomed to the service and
value proposition
• Fundraising to support customer acquisition costs: Pursue financing via private or blended
sources to move towards furthering proof of concept and continuing customer acquisition; this could
include cost-sharing with government or a philanthropic funder to increase the reach of marketing
efforts
Source: Dalberg research, interviews and analysis, 2010.
BACK TO APPLICATION TYPES
43
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Arogya Raksha
Concept
• Arogya Raksha Yojana is a comprehensive health insurance plan that offers people of rural India affordable
access to high quality healthcare, provided by a network of renowned hospitals and clinics, supported by
leading doctors and surgeons. Since 2005, each year around 75000 lives have been covered under the
scheme.
• In 2010, ARY introduced a mobile based user policy enrolment process that
significantly improved the rate of patient registration.
Advantages:
Value
proposition
• Prior to the introduction of mobile based enrolment,
• While there are costs associated with introducing the new software, the
approach significantly reduces day to day operating costs and
increases insurance uptake. It also eliminates the need for double
entry at the back-end office and thus reduces labor costs (including
both staff time and associated compensation).
Volume of data
captured
# of new
patients
per day
600
Results:
-75%
• Patient enrolment – introduction of mobile based data entry has
increased the rate of patient enrolment from 150 new patients per day
to 6– patients per day.
150
Market
• Current scale: As of Feb 2010, Biocon Foundation has been supporting
the use of mobile based enrolment at ARY for 6months during which
time, 35K enrolments were made, 15K mobile based.
• Rapid enrolment of users under the new system may indicate unmet need
for micro health insurance in the market.
• Competition: Currently this scheme and the approach of mobile based
enrolment is not facing any local competitors. However, other solutions
including Episurveyor could be compared against the software currently
being used.
Source: Dalberg Interviews and research September 2010 http://ifmr.ac.in/cirm/blog/?p=331
Mobile Paperphone based
BACK TO APPLICATION TYPES
44
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of mDhil
Concept
• mDhil provides basic healthcare information to individual Indian consumers via text messaging, mobile web
browser, and interactive digital content.
• Primary channel is a subscription or one off fee for service for SMS based information. Information relates to
general health, sexual health, TB, weight, diet, stress, skin & beauty or diabetes.
• Launched in 2009, and funded by institutional venture capital and angel investors.
Advantages:
Value
proposition
• Increased access to health information: Provides quality, reliable health information, with an initial base of
over 150,000 paid users on SMS subscription services . Health information content focuses on general health,
sexual health, TB, weight, nutrition, stress, skin and beauty, and diabetes.
Beneficiaries and willingness to pay:
• mDhil has grown rapidly reaching 150 000 users in 2010 demonstrating both willingness and ability to pay.
Market
• Cultural issues related to privacy and discussion of sexual health make the service attractive for an
uncalculated percentage of the population (likely focused on teenage and young adult populations).
Subscription services are likely to increase significantly in the first few years but may quickly hit a plateau if
information is not catered to the individual over time.
Source: Online research and Dalberg Interviews September 2010
BACK TO APPLICATION TYPES
45
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Text To Change – Mobile for Reproductive Health (M4RH)
Concept
Value
proposition
Market
• M4RH is a project piloted in 2009 by Family Health International/ PROGRESS(funded by USAID) and
launched and Marie Stopes in 2010 to improve family health and planning services. Developed by TTC, M4RH
includes a series of messages with information related to family planning methods that users can access via
their mobile phones. The messages are currently being evaluated in Kenya and Tanzania.
• The messages are based on evidence-based information, including the World Health Organization family
planning handbook for providers, and crafted specifically for short message service (SMS) or text message
use. Each message is designed and tested to ensure user comprehension within the 160 character limit. The
m4RH system also provides service delivery information so users can locate clinics to provide more
information and the family planning method of their choice. More information on m4RH is below.
Advantages:
• Trust : Preliminary research found that users of the system not only
welcome and trust family planning information via text.
• Extended social marketing : Users are also appear more likely to
share this information with family and friends.
• Patient follow up: In some instances, users noted the value of being
reminded about the advice they had been given by their health
provider. “[The implant messages] remind me of what I had been told
by the provider….I would save the message so that I can keep
refreshing myself when I experience any problems”
• Current scale: M4RH is currently being rolled out across Kenya and
Tanzania.
Feedback from users
“This is important
information and I would share it with
friends so that they do not hear wrong
information”
“[I will tell about the service] my
sisters—the young ones—and
I will talk to them about family planning
methods and escort their wives to the
clinic”
“I will save [the IUD messages] to show
to my husband
and friends”
USAID/FHI: Pilot study of 40 users
BACK TO APPLICATION TYPES
46
Source: Dalberg interviews and analysis; http://datadyne.org/files/Zambia_EpiSurveyor09_Technical%20Report.pdf
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Text4Baby (1/2)
• To replicate a successful mHealth service from the United States that delivers health information to pregnant
women
Concept
• Non-profit model; Text4Baby would rely on philanthropy to cover its startup and operating costs; it presents an
attractive funding opportunity for corporate
sponsors
• Launched in 2010
Value
proposition
900,000
1,000,000
Expected
growth
through
2010
Total
• Advantages: the program has been proven elsewhere; more effective way
of reaching individuals with health information than other forms of outreach
from clinics and CHWs
• Results: In the US, there are over 100,000 subscribers since launch in
February 2010; longer term outcomes have not yet been measured
• Beneficiaries and willingness to pay: Pregnant women; willingness to
pay has not been tested in Haiti context
Market
Text4Baby Expected User Growth
100,000
Users since
Feb. 2010
• Current size: Not yet launched in Haiti; Began in the US, targeting mainly lower income populations; now
expanding to Russia; recent commitment announced by Johnson & Johnson to support roll-out in the
developing world. Haiti has the highest maternal mortality rate in the Western Hemisphere, so the impact of
education is potentially enormous
• Current costs: N/A
• Estimated costs to scale: N/A
47
Source: Dalberg research, interviews and analysis
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Text4Baby (2/2)
Challenges
across the
ecosystem
Potential
actions
• Literacy: Literacy may be the main constraint to the take-up and use of the service;
• Credibility: Users unfamiliar with mHealth applications may also be skeptical that the information is credible;
• Sustainable funding: Finding a source of long-term funding may be difficult
• Incorporate voice as well as text options: This will require a bit of an evolution of the current model,
focused on reaching illiterate populations, to whom the text messages would not be accessible; cost
implications are currently unknown, but would need to be structured in a way in which users would not be
charged for the call; there is potential to leverage technology and platforms being deployed by Voila/Red
Cross which use voice and toll free hotlines as part of its public health advisories
(profiled in this study)
• Increase credibility by partnering with locally legitimate players: This would include locally legitimate
government agencies and/or NGOs (e.g., Partners in Health) who have a track record and reputation for
quality health services. Co-branding in marketing and other areas of implementation could greatly increase
visibility and credibility.
• Securing sustainable funding: While T4B is an attractive offering to potential corporate sponsors (e.g.,
Johnson & Johnson), questions remain regarding longer term, sustainable funding. Over time, funding may
need to transition to either the national government or larger scale, long term donors who have an interest in
Haiti. To accomplish that, T4B would need to begin transition planning before the term of funding with
corporate sponsors might end, lining up longer term alternatives. Once again, it will be critical for larger scale
donors to recognize these types of tools as a priority and cost effective means of engaging in health systems,
and prioritizing funding for them accordingly. This will require advocacy, and M&E to track results and
performance over time s
Source: Dalberg research, interviews and analysis
BACK TO APPLICATION TYPES
48
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Dr. SMS
Concept
• With mobile penetration over 72%, the state of Kerala was well positioned to provide services via SMS.
Initiated by the Kerala State IT Mission in 2008, Dr. SMS aims to enable people to use mobile phones to
receive information on health resources and to provide a comprehensive list of medical facilities available
across the locality, including hospitals with various medical specialties, Doctors expertise in ENT or any other
specialization. The solution is primarily available via SMS but also includes a web portal that provides GIS
based location mapping .
• An SMS with requested facility/specialty sent to the specified number will receive immediate contact details of
requested facility/specialty centre.
• The service also includes a portal for recording and managing Blood Donor details.
Advantages:
Value
proposition
• Access to health information which reduces cost of referrals across
localities and increases the rate at which patients can access specialty
services.
• Supply chain management: Real time visibility into the availability,
location and type of donor blood available across the state.
• Beneficiaries and willingness to pay: Services are provided free of
charge by the Government of Kerala
Pilot Results:
• During the pilot phase, an average of 200 requests were received each
day.
Market
• Current reach: Directory of services available for over 50% of the
state.
Source: Dalberg Interviews and research September 2010
BACK TO APPLICATION TYPES
49
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Voila Foundation / Red Cross Public Health Advisories (1/2)
Concept
Value
proposition
• Voila Foundation (Trilogy International) and the International Red Cross created the SMS Aid Application
system to reach populations at risk post-earthquake in Haiti
• Voila Foundation is the sole funder; non-profit model
• Launched in 2010
Red Cross estimates it has
reached significantly more
people via SMS based
Advantages:
campaigns1
• Rapid access to individuals with limited access to communication (this is
# of
a novel system with an “SMS gateway” that plugs into mobile network
people
4,000,000
towers and can access any Voila customers who has been using that
reached
tower within the last fifteen minutes (i.e., not subscription based)
•
•
Ability to quickly scale to new areas at risk for epidemic
Two way communication capabilities, including link to a toll-free *733
hotline in Creole, to reinforce SMSes and complementary interventions
Results:
• Cholera prevention: 4m SMSes sent to reach 0.5m people; 90,000 calls
received to hotline; reinforced by sound trucks and radio
• No studies yet to assess impact in terms of outcomes (behavior,
infection rates), however studies planned to assess number of calls
received via toll-free *733 number
Beneficiaries and willingness to pay:
• All populations within range of cell phone towers in Haiti identified at-risk
for public health situations (e.g., cholera, storm surge)
• Ability to pay has not been tested, but anticipate this would greatly limit
reach and compromise goal of reaching populations most in need
Market
1000%
400,000
Without SMS
With SMS
• Current scale: across Haiti, SMS Aid Application has delivered 26.6m SMSes and reached 1.2m people
(1) Based on disaster preparedness campaigns; Red Cross Beneficiary Communications in Haiti 2010;
Source Voila, International Red Cross; Dalberg research, interviews, and analysis. http://www.trilogyinternational.com/TrilogyVoilaIFRCSMSAidapplicationFINALUS.pdf; http://www.voilafoundation.com/partners.htm
50
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of Voila Foundation / Red Cross Public Health Advisories (2/2)
Challenges
across the
ecosystem
Potential
actions
• Technology developers: Limited bandwidth for 2-way communication; Voila is currently upgrading to
accommodate; another challenge is communicating effectively in 140 characters or less of SMS; potential
for innovation in hardware or software to accommodate additional information
• Health workers / Red Cross: Need to scale in line with human capacity of operational teams and their
ability to respond to issues identified via 2-way communication; if not, could create unmet expectations
within the Haitian population
• MNOs: Right now, exclusivity in agreements with sole MNO prohibits reaching customers of other
operators
• Users: Content requires literacy (being addressed by addition of toll free Creole hotline)
• Donors: Additional funding will be needed to scale beyond Haiti
• Increase revenues: N/A; additional donor funding can be sought for roll- out beyond Haiti or to diverse funder
base in Haiti
• Increase customer base: N/A
• Integrate into community health workers’ outreach roles: Potential for CHWs to act on responses
received via 2-way communication
• MNOs: While agreements are exclusive in Haiti, exploring additional partners and more open systems in
countries beyond Haiti where Trilogy does not operate
• Government: Close collaboration with the government and the Haitian Red Cross to use their system to
support services auxiliary to the government, such as blood donor programs
• Donors: Target funders and sponsorship in additional areas in need of disaster response – both from MNO
contributions and/or from large scale funders involved in disaster recovery; potential for co-investment across
multiple funders
Source Voila, International Red Cross; Dalberg research, interviews, and analysis.
BACK TO APPLICATION TYPES
51
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Table of contents
•
Overview of mHealth ecosystem, impact, and services
•
Four example business models:
− WelTel
− Changamka
− HMRI
− Voila Foundation / Red Cross Public Health Advisories
•
Prioritization framework, financing and implementation mechanisms
•
Conclusions
•
Annexes
− Illustrative case studies
− Examples of financing and implementation mechanisms
52
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of financing and incentive mechanisms (1/5)
Description
Tax credits
Licensure
requirements
Conditions for deployment
Potential actions by
funders and/or implementers
• Amount deducted from
total tax liability to
incentivize behavior
• At times, governments
can use licensure of
MNOs as a similar tool,
requiring certain actions
or donations (e.g., free
SMSes) in exchange for
license to operate
• Desire for action by MNOs which would not
occur in current operator market due to
limited profit potential or other rationale
business dynamics
• Examples of this include:
– Extension of service and reach of mobile
networks (e.g., into rural areas with lower
population density)
– Lower costs of key inputs to business
models which are constrained by the high
cost of services (SMS, voice, or data)
• National governments can identify
opportunities where tax credits
will motivate operators to action
and include this in policy.
• A national ICT Working Group
can be a forum to solicit input
from MNOs on what the current
constraints and market failures
are, which can in turn be
addressed by appropriately
leveled tax credits
• Government-mandated
requirements of MNOs
in exchange for license
to operate in given
country
• Desire for action by MNOs or to create
market dynamics which would not occur in
current market due to limited revenue or profit
potential or other rationale business
dynamics
• Examples of this include:
– In Chile, regulators set a license
requirement that 3G services should be
available 90% of the country, 90% of the
time, to discourage operators from cherrypicking rich, urban consumers
– In South Africa, licensure requirements
have provided a set quantity of free of
charge SMS services that have benefited
mHealth models which reach patients with
reminders and health hotlines
• Similar to tax credits, in the
context of an eHealth strategy or
ICT Working Group, the
government can identify priority
opportunities for licensure
requirements and structure in a
way that benefits mHealth
business model development
without creating negative market
distortion
BACK
53
Source: Dalberg research and analysis; McKinsey - http://csi.mckinsey.com/en/Knowledge_by_region/Europe_Africa_Middle_East/Getting_mobile_broadband_to_the_masses.aspx.
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of financing and incentive mechanisms (2/5)
Description
Challenge
funds
R&D grants
Conditions for deployment
Potential actions by
funders and/or implementers
• Prize fund set up to
incentivize development
of a new business
model or offering or to
catalyze players to
enter and engage in a
new market
• Persistent market challenge – primarily within
one of the following categories:
– Innovation: technological challenge,
requiring R&D and proof of concept
(e.g., Gates Foundation Grand
Challenges Fund)
– New market development: market for a
product or service does not exist due to
limited profit potential or lack of upfront
capital investments (e.g., Gates
Foundation Haiti Mobile Money Prize
Fund; Africa Enterprise Challenge Fund)
• In order for a challenge fund to be
appropriate, there need to be multiple players
who are willing to compete for the prize. This
could include R&D players or MNOs
depending on the type of challenge and
problem to be solved
• Often these incentivize appeal more to
private sector players in a competitive market
• When the technological or market
challenges are appropriate, make
challenge grants and use prize
funds in lieu of “push” funding via
grants
• Overall, this approach can be
more attractive to funders, in that
they only pay for success, and it
provides a means to engage and
incentivize private sector players,
offering a path to sustainability
• Grant funding which
often is awarded to
academic or research
institutions to conduct
R&D of new products or
services
• Need for scientific or technical innovation in a
mobile application or product which can be
deployed to meet existing consumer or health
system need
• Appropriate when a sole provider is best
suited to provide the R&D and develop the
new product, or when multiple players do not
have appetite to take on the risk associated
with a challenge or prize fund (i.e., absorbing
upfront and sunk costs)
• This mechanism is a more
traditional tool for R&D funding
• Funders – be they national
governments, multilaterals or
foundations – can fund individual
R&D projects in line with priority
health and innovation needs
Source: Dalberg research and analysis
BACK
54
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of financing and incentive mechanisms (3/5)
Description
Venture
capital /
incubator
funds
Loan
guarantees
Conditions for deployment
Potential actions by
funders and/or implementers
• Venture capital (VC)
and incubator offerings
are offered bundle to
support start-ups and
entrepreneurs with
funding and business
advisory services
• These can be either
blended capital (with
philanthropic or impact
investor components, or
purely commercial)
• A VC fund provides
private equity financing
to seed early stage,
high potential
companies for growth
• Incubator funds help
small companies to
grow by offering
business services
• Promising early stage, for-profit business
models which lack access to capital and
management training to grow
• Flourishes in environments which are
conducive to business operations from a
regulatory and market perspective
• Examples of where VC has been deployed or
is needed
– Commons Capital, a blended capital
venture capital fund, has a Global Health
Fund which invests in mHealth models,
and has seen significant increases in its
mHealth deal flow in the past year
– Sproxil, an SMS-based anticounterfeiting business model is an
example of a for-profit model which seeks
venture capital funding to grow its
operations and expand beyond recent,
successful pilot in Nigeria and growing
customer base
• Funders can choose to back
blended capital VC and incubator
funds focused on mHealth
models, such as those emerging
with Commons Capital or other
impact investment vehicles (e.g.,
via the Aspen Network of
Development Entrepreneurs or
Global Impact Investors Network)
• The existence of such funding
could motivate innovators and
implementers to pursue for-profit
or hybrid (social enterprise)
models rather than the non-profit
models that dominate the current
mHealth space
• A contractual
commitment to repay a
fully or partially an
outstanding liability in
the case of default
• Access to credit is limited due to lenders’
inability to accurately price or assess risk, or
due to real risks (e.g., financial, political, etc)
• Appropriate when for-profit models seek
credit to expand their services or grow, and
are too small/risky for bank debt
• Also could be deployed to incentive mobile
operators to expand operations or product
offering, by lowering their overall cost of
capital
• Funders can utilize their financial
assets to provide guarantees
(e.g., “program related
investments” such as those made
by the Gates Foundation and
Acumen Fund) which can provide
a means for banks to get
comfortable with the associated
market and counterparty risk
Source: Dalberg research and analysis Reuters, 2010 http://www.reuters.com/article/idUSTRE62F3FZ20100316;
BACK
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WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of financing and incentive mechanisms (4/5)
Description
Insurance /
payers
Cost-sharing
Subsidies
(from large scale
health donors)
Conditions for deployment
Potential actions by
funders and/or implementers
• Depending on a
market’s insurance and
payer dynamics, there
are opportunities to
have mHealth services
recognized as costeffective - providing a
path to reimbursement
and cost recovery
• This is more relevant in mixed economies
and emerging markets which have greater
coverage via insurance schemes
• In order for insurance to cover mHealth
services, greater evidence base and
pharmacoeconomic studies will be critical
• With an evidence base, and advocacy in
hand, private and public sector insurers and
payers can be motivated to cover mHealth
services as a more cost effective means of
achieving health outcomes
• Funders can invest in evidence
based studies and randomized
control trials to make the case for
successful models (i.e., M&E)
• Implementers and funders can
advocate for insurance schemes
to review and prioritize (e.g., put
on formulary) successful mHealth
services
• Distributing the costs of
developing or acquiring
a certain asset
• Often involves public
and private sector
actors, partnering for
infrastructure or
technology
development
• Relevant for assets which have intangible
qualities or aspects of public goods
• Specific investments must have commercial
benefits and value to private sector players
(e.g., MNOs) but which are not sufficient to
justify the full cost of investment
• Similarly, this investment must have social or
economic value to the government or other
public sector/philanthropic entity to justify its
investment (e.g., extending reach of mobile
network or development of new mHealth
technology)
• Governments and funders can
explore cost-sharing partnerships
for major infrastructure
investments which would extend
reach of mHealth models
• This mechanism can also be
deployed to fund any necessary
customization required for
adoption of a business model in a
new country and cultural context
with specific technical and content
requirements
• In this case, subsidies
can come from the form
of funding from large
scale funders (e.g.,
Global Fund, World
Bank, GAVI) paying for
mHealth services
• No robust payer or insurance market to cover
the costs of healthcare for patient populations
• Need for financing to extend cost effective
services to populations with limited ability to
pay
• Large scale funders of global
health should prioritize mobile
enabled services in funding
proposals for grants and loans
• They should also require data
capture and use of technology by
their grantees to increase
56
transparency and value for money
Source: Dalberg research and analysis
BACK
WORKING DRAFT – FOR DISCUSSION PURPOSES ONLY
Overview of financing and incentive mechanisms (5/5)
Description
Corporate
R&D
Industry
investment
Venture
capital
Conditions for deployment
Potential actions by
funders and/or implementers
• Internal corporate
investments made in
R&D of a new
technology or product
• Profitable market of sufficient size to entice
corporate investment (e.g., mHealth service
which can be purchased by individual
consumers or reimbursed by insurers)
• Competitive advantage versus other players
and products
• While these models tend to be
purely commercial, there is the
potential for cost-sharing in these
types of R&D investments if it
aligns with government or
philanthropic priorities and
incremental funding or
government support can
accelerate the speed of
development and
commercialization
• Post-proof of concept,
commercialization and
overall product
investment and strategy
to capture market share
and increase
profitability
• Corporate strategy, and indications of
product and market potential
• Again, while industry will rationally
invest where profitable
opportunities exist, there is the
opportunity for governments and
other funders to offer incentives
(cost-sharing, tax credits,
licensure requirements) to
incentivize product development,
availability and affordability that
aligns with social mandates
• A VC fund provides
private equity financing
to seed early stage,
high potential
companies for growth
• Similar to earlier description, however for
purely private sector capital, there will need
to be clear market potential and commercial
level of returns
• If commercial capital is utilized for
VC funding, there still is at times a
role for other funders and
implementers in supporting
technical assistance and advisory
services
BACK
Source: Dalberg research and analysis
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