2014 hult prize challenge
TRANSCRIPT
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Globally, over 250 million slum dwellers suffering from chronic diseases need help. The social and
economic cost of chronic diseases is significant for individuals, families and society. Generics, better
medicine, and digital technologies may offer solutions, but more are needed. Solutions for chronic
diseases in slums are not a priority for governments, the private sector or NGOs. Social enterprises may
be the best option to address this issue. However, building successful social enterprises in slums will
be difficult.
Can we build a social healthcare enterprise that serves the needs of 25 million slum dwellers
suffering from chronic diseases by 2019?
Social Enterprise ChallengeImproving Chronic Disease Care in Slums by 2019
With Special Call to Action by President Bill Clinton
BREAKING THE POVERTY CYCLE
Written by:
Hitendra Patel, Ronald Jonash, Kristen Anderson and Julius Bautista
Hult International Business School Publishing
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Dear Participants:
This year, the Hult Prize has taken additional steps to push boundaries and create even bigger and
bolder opportunities for the next wave of social entrepreneurs. We are taking on more complex
challenges and using powerful accelerators with the hopes of continuing to grow our impact by 10x.
The attached case challenge is a living, breathing document. It reflects the best wisdom from
private, non-profit, and governmental experts who have dedicated their lives to making an impact
in this space. Our knowledge about these complex issues slums, social enterprise, and chronic
disease continues to develop with each passing day organizations are on the ground trying to
make a difference.
In order to ensure this challenge is as accurate and complete as possible, this case is being
released today in beta version. We will continue to source expert information and experience that
will improve the solutions our teams build over the next several months. The final iteration will be
released to coincide with the announcement of regional finalists.
This case challenge will illuminate some of the key issues surrounding chronic disease care in slums
and provide guidance for building a successful social enterprise. Your solutions bring hope that this
problem can and will be solved.
Best of luck,
Dr. Hitendra Patel
Board of Directors
Hult Prize Foundation
A Message from the Authors
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Table of Contents / Figures
Contents
Over 250 million slum dwellers suffering from chronic diseases need help 5
Chronic diseases affect over 250 million people in slums worldwide 5
Slum dwellers have a range of complex healthcare needs 8
Current solutions to address chronic diseases in slums are not working 10
Prevention is not a priority 10Alternate solutions are preferred, which delays correct diagnosis and treatment 10
Clinics are ill-equipped to identify chronic diseases early and provide proper treatment 10
The social and economic cost of chronic disease is significant for individuals, families and
society 11
Individuals suffering from a chronic disease pay with more than their health 11
Families who care for members with chronic disease face financial and emotional stress 11
Chronic disease is costly for society 11
Generics, better medicine and digital technology may offer solutions, but more are neededto counter the increasing slum population 11
Generic pharmaceuticals are increasingly available to slum dwellers 11
Better medicine is making healthcare more accurate 12
Virtual solutions and telemedicine are beginning to offer lower-cost health options 12
However, the impact of chronic disease in slums is expected to increase due to behavioral riskfactors in slums, urban migration and increasing life expectancy 13
Solutions for chronic diseases in slums are not a priority for governments, the private sector or
NGOs 14
Governments see slums as illegal habitats and focus on emergency care 14
The private sector is unable to provide market solutions for chronic diseases in slums 14
NGOs focus on healthcare challenges related to communicable and infectious disease 14
Social enterprises may be the best option to address this issue 15
However, building successful social enterprises in slums will be difficult 16
Social enterprise operations are difficult to manage 16
Inconsistent demand is hard to plan for 16
Fair pricing for health solutions is difficult to implement 16
Consumers with fluctuating income and limited savings are difficult to serve 16
Partners across the value chain are difficult to work with dependably 16
Can we build a social healthcare enterprise that serves the needs of 25 million slum
dwellers suffering from chronic diseases by 2019? 17
Addendum: Create Successful Social Enterprises 18
Find customers who can pay 18
Use existing channels 19Make offerings affordable and accessible 19
Build with local parts and knowledge 19
Go beyond traditional business models 20
Authors 21
Research Team 21
Acknowledgements 21
Selected Reference Sites and Sources 22
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Table of Contents / Figures
Figures
Figure 1. Slum populations are largest in Africa, Asia and Latin America 5
Figure 2. Chronic disease affects tens of millions of slum dwellers 6
Figure 3. Chronic diseases are part of a vicious cycle for slum dwellers 6Figure 4. Over 80 percent of chronic disease deaths comes from four types of diseases 6
Figure 5. The percentage of deaths from chronic disease is expected to increase 7
Figure 6. Slum dwellers need awareness about healthcare, and care needs to be accessible,
affordable and accurate 8
Figure 7. More than half of healthcare costs in developing countries come from expensive
drugs 10Figure 8. Global costs for chronic disease will increase 11
Figure 9. Generic pharmaceuticals are becoming more common as patents expire 12
Figure 10. Technology-enabled health solutions are becoming more prevalent 12
Figure 11. Global urban population is rapidly increasing 13
Figure 12. Chronic disease risk accumulates over ones lifetime 13
Figure 13. Social enterprises may be best suited to address chronic care in slums 15Figure 14. Solutions should work with specific intervention points to make targeted impact 15
Figure 15. Guiding metrics help identify solutions with the most impact 18
Figure 16. The Innovation Value Chain can identify opportunity points 18
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Over 250 million slum dwellers suffering
from chronic diseases need helpChronic diseases affect over 250 million people in slums worldwide
All over the world, poor people are suffering from diseases that can be treated and even cured,
but their suffering continues unnecessarily because they do not have reasonable healthcare.
Healthcare, as it is described in this case, entails the maintenance and improvement of physical
and mental well-being through medical services. People who live in slums lack access to effective
and affordable healthcare.1 It is estimated that close to a billion people worldwide live in slums.2
Slums are poor, densely populated, illegal (or informal) settlements with weak or non-existent
infrastructure near or within an urban area. Slums exist all over the world but are more common in
developing regions in Africa, Asia and Latin America (Figure 13). People who live in these areas lead
difficult lives. Employment is intermittent. Sanitation is poor. Education about choices is insufficient.
Healthcare is nearly impossible to find. Because of the grim conditions in slums, disease comes
sooner, lasts longer, has more serious consequences and is all too often too expensive to treat. As
expected, poor people in these poor countries are more vulnerable and have fewer options and less
access to quality care.4
Cancer, diabetes, andheart diseases are nolonger the diseases ofthe wealthy. Today,they hamper the peopleand the economies of
the poorest populations even more thaninfectious diseases. This represents a publichealth emergency in slow motion. Ban
Ki Moon (UN Secretary General)
Improving Chronic Disease Care in Slums by 2019
Although existing numbers are difficult to assess, it is estimated that over 250 million people in
slums suffer from chronic disease
Chronic diseases, also known as non-communicable diseases (NCDs), are not passed from person
to person.5 They are of long duration and generally slow progression, representing the main cause
for disability and death worldwide.
Identifying appropriate statistics and population measures is always a difficult task. Explicit countsare based on general estimates because of two key factors (1) governments often overlook slums
in official counts and (2) records are limited because of informal employment, land tenure and
networks.6 In terms of morbidity, it is estimated that there are at least 2 billion people worldwide,
and 250 million people living in slums, who suffer from at least one the following chronic diseases:
cardiovascular diseases (CVD), cancer, chronic respiratory diseases (CRD), diabetes or mental
illness. The number of people suffering from chronic diseases is expected to continue rising (Figure
2).
Figure 1. Slum populations are largest in Africa, Asia and Latin America
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For slum dwellers, being unhealthy is the first step that leads them towards a dangerous cycle
(Figure 3). Without their health, slum dwellers productivity is compromised and many are often
too sick to work at all. This leads to wasted time, forgone wages, and deeper and deeper poverty. 7
Proper healthcare that is affordable, accessible and accurate is critical to breaking this cycle and
enabling people to lead happier and more productive lives.
Figure 2. Chronic disease affects tens of millions of slum dwellers
Figure 3. Chronic diseases are part of a vicious cycle for slum dwellers
Both physical and mental chronic diseases have a huge impact on slum dwellers
Physical chronic diseases account for 63 percent of deaths worldwide
Research suggests 80 percent of chronic disease deaths are caused by one of four types of
disease: cardiovascular diseases, cancer, respiratory diseases, or diabetes.8 9
Figure 4. Over 80 percent of chronic disease deaths comes from four types of diseases
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These diseases are expected to take a larger toll in every region around the world.10 Each of these
diseases have different symptoms, affect peoples lives in a distinctive way, and require unique
treatment.
Figure 5. The percentage of deaths from chronic disease is expected to increase
Cardio vascular diseases (CVD) are a group of disorders of the heart and blood vessels. 11 Heart
attacks and strokes are the most common diseases suffered and are the number one cause of
death globally. High blood pressure accounts for the majority of deaths.
Cancer is a disease that can affect any part of the body and is defined by the rapid creation of
abnormal cells which can invade and spread to other organs. Metastases are the major cause of
death from cancer. The most frequent types of cancer differ between men and women; the most
common are lung, stomach, liver, colorectal and breast cancer.12
Respiratory diseases affect the air passages in the lungs. The two most common chronic respiratory
diseases (CRD) are asthma and chronic obstructive pulmonary disease (COPD). Asthma is
characterized by recurrent attacks of breathlessness and wheezing, and COPD patients experience
a persistent blockage of airflow from the lungs.13 14
Diabetes occurs either when the pancreas does not produce enough insulin or when the body
cannot effectively use insulin.15 There are two types of diabetes: Type 1 and Type 2, the latter being
the most common, resulting from excess body weight and a lack of physical activity.
Each of these types of diseases have different risk factors, but overall, it is said that there are
four main behavioral risk factors that contribute to chronic diseases, these include poor nutrition,
physical inactivity, alcohol consumption, tobacco usage and physical inactivity.
Mental disease is a leading cause of disability and lost productivity
Although it is not responsible for a high percentage of deaths, mental illness can have an enormousimpact on health and wellness. This medical condition disrupts a persons thinking, feeling,
mood, ability to relate to others and daily functioning. The different types of mental illness include
depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors.16 There
are at least 60 million people with mental illness in slums around the world.
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Improving Chronic Disease Care in Slums by 2019
Slum dwellers have a range of complex healthcare needs
Figure 6. Slum dwellers need to be aware about healthcare, and care needs to be
accessible, affordable and accurate
Developing solutions for healthcare in slums will require careful consideration of consumer needs.
Consumers, however, may be a person who is suffering from a chronic disease or a family member
or caretaker. Each of the following sections can be examined from the perspective of either patient
or caretaker.
Do I know what I need?
Do I know what makes me ill? The first step to improving health comes from knowing the risk
factors that can make people sick. Education about conditions that cause illness can help families
make the right choices. From basic sanitation and nutrition to physical activity and the dangers of
smoking, education about the causes of disease can go a long way towards preventing it. All too
often children and families suffer needlessly because they do not have enough information about
how their own behaviors may be making them ill.17
Do I know when I am ill? In addition to needing to know what can make them sick, people need to
know what symptoms to look out for once they are ill. Particularly with chronic disease, symptoms
may be subtle. High blood pressure can have no symptoms at all, and many cancers are first noticed
by a feeling of fatigue.18 For slum dwellers who struggle to get enough to eat, medical treatment for
apparently minor outward symptoms would seem a poor use of limited income. Education about
the importance of early detection and treatment can help prevent chronic diseases from being
disabling,19 which can not only improve productivity but also increase quality of life.
Do I know what to do when I am ill? Once someone is ill, its important that individuals, heads
of household, and caregivers know the appropriate subsequent steps to take. Hospitals can be
far away or too expensive for slum dwellers to use. Even if medical facilities happen to be within
a reasonable proximity, urban slum dwellers, who are most often migrators from rural areas, donot know how to use the urban health systems.20 In rural areas, health programs are traditionally
outreach-focused, while urban health centers are typically facility-centric. Because many poor
people in cities are unfamiliar with the processes and expectations of these health programs and
facilities, there is an additional burden on those who are sick and concerned about meeting their
familys basic needs.
Can I trust I got the right care?
Do caregivers and doctors have enough knowledge to care for me? Not only do slums lack medical
professionals (Switzerland: 40.8 per 10,000 residents; Brazil: 17.6 per 10,000 residents; Nigeria: 4.0
per 10,000 residents; and Kenya: 1.8 per 10,000 residents21), these professionals are sometimes
under-trained and are often over-worked.22 This makes it difficult for doctors to communicate basic
health knowledge, and it makes medical care even more burdensome for families by extending
wait times. Weak systems also mean that personal medical records are difficult to track. Individualsrarely have access to their own medical histories, and if they do, they typically lack the ability to
store the information safely and privately.23This means doctors have to diagnose and treat patients
I didnt know...
Khalida, a 32 year-old mother from aChittagong slum, was surprised whenshe was diagnosed with diabetes. Doctorsays it has been years I have got diabetes,and now the situation has become
serious. I didnt have money to comeand see the doctor that is why I did notcome earlier. Today, I came here to takemedicine without even knowing that Ihave diabetes. Now, Khalida is worriedabout her future because she doesnt havemoney for treatment and come to thehospital every week. As Khalidas casedemonstrates, many slum dwellers donot realize that they are suffering fromchronic disease until it too late and costlyto treat.
Source:http://www.dispatchesinternational.org/?p=143
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with imperfect and incomplete information.
Do caregivers and doctors have the right incentives? Corruption often develops because incentives
arent properly aligned. Doctors need to be incentivized to provide the best care for patients, rather
than finding the quickest way to move slum dwellers and other poor patients out of the hospital. 24All players along the value chain need to be incentivized to price treatment and medicine fairly, offer
care extensively, and ensure the highest level of quality to all people.
Are people held accountable? Because of a lack of transparency, holding corporations, clinics
and medical practitioners accountable for their actions is at best difficult. In 2001, pharmaceutical
companies in the private sector came under tremendous scrutiny for their policies and pricing
models on life-saving HIV and AIDS medication.25 This pressure for transparency, however, has not
been equally applied or sustained around the world. Governments, middle men, and black market
dealers all have their own reasons to manipulate the system. A study in Pakistan slums has shown
that only 24 percent of corrupt medical practices come from doctors while 70 percent comes from
other hospital staff.26
Can I find it when I need it?Can I get there? Weak infrastructure means that frequent trips to clinics or hospitals can be too costly
for individuals and families. A survey in India found that 14 percent of respondents were dissatisfied
with the distance they had to travel to receive care. 17 percent were dissatisfied because of the
hours care was available and 35 percent were dissatisfied because of the amount of time they were
required to wait.27 All of these barriers are making healthcare more difficult to access.
Is there a system? Because slums are informal or illegal habitats, most do not have the necessary
infrastructure to build or maintain a health system. Medical facilities and clinics need to have access
to running water and electricity to maintain basic sanitation and be staffed with skilled workers,
both of which may be difficult to find within slums.28 The system that does exist is typically very
fragmented; different facilities offer different capabilities and levels of care and are unable to
communicate with each other.29
Do I have the legal right to care? In some countries, governments guarantee access to healthcare
for all citizens. Although these facilities may be crowded and have long waits, there is some way
for people to get medical treatment at subsidized or no cost. 30 However, there are many countries
(of which most are in the developing world) that have no commitment to universal healthcare.31 For
people in these countries, and particularly those living in illegal slums, there is no guarantee that
healthcare will be provided, even if they are able to make it to a medical facility. Legal coverage,
protection of privacy and government support can be important to making healthcare accessible.
As mentioned, the poor often find themselves in a vicious and reinforcing cycle when it comes to
healthcare. Indrajit Hazarika, a senior lecturer at the Indian Institute of Public Health, Delhi describes
what he has observed: Social exclusion and lack of information and assistance restricts the use
of private facilities by poor people. More importantly, lack of economic resources inhibits the use
of private facilities. These make the urban poor more vulnerable and worse off than their ruralcounterparts.32
Can I pay for it when I need it?
Is the supply chain efficient? People need to be able to pay for the care they receive. Because
infrastructure is difficult to manage not just in slums, but often throughout low and middle-income
countries (LMICs), getting equipment, clinicians and medicine to the market can become more
costly than in developed areas.33 It is estimated that drugs in developing countries are 2.7 times
more expensive in the public sector and 6.3 times more expensive in the private sector than they
are in the developed world.34 Additionally, in many developing countries, regulatory authorities
from the government are unable to consistently fulfill their role in maintaining the quality control of
the testing or distribution of drugs.35 Caring for chronic disease is particularly difficult because the
supply chain is extremely complex and varied by region.
Are cheaper options available? Because the supply chain can add significant cost to medicine,
labor and other equipment, alternatives need to be available to make healthcare more affordable.
Currently, the price of generic drugs varies dramatically by location but could provide affordable
I just cant pay
Shakeela Begum, a 65 year - old housewifefrom a Karachi slum, had a heart attackseveral years ago, and she still hasnt
fully recovered. I cant do as much,because I get tired very quickly, shesays. Nevertheless, shes not taking the
prescribed dose of medication. I know Ishould be taking my medication every daybut this way I can also save some money
for my grandchildren they are young
and have a future, she argues.Source: http://www.who.int/chp/chronic_disease_report/full_report.pdf
No room for me
A 68-year old slum dweller, BharatTiwari, is disappointed because doctorsat a government-funded hospital in New
Delhi have deferred a surgery needed totreat his heart ailment and told him toreturn in two months. Such delays arenot unusual at the overstretched facility.
Bharat and his family were hoping thatsurgery could reduce the high drug costs.
His son says the USD 100 spent everymonth on his fathers medications addsup to a quarter of the family income. Now
Bharat and his family will just have towait.
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Individuals suffering from a chronic disease pay with more than their health
The majority of slum dwellers are daily wage earners who make, on average, less than 5 USD per
day.47 The direct costs associated with chronic disease, even if diagnosed early, are overwhelming.
For example, one chemotherapy session in India costs nearly 1,500 USD. Six months of cancer
treatment in India can range from 4,000 USD to 32,000 USD.48 Without insurance and financing,
slum dwellers bear almost all medical costs out-of-pocket. In addition to the direct cost, chronic
disease impacts an individuals ability to work lowering income and affecting productivity.
Aside from the economic costs, individuals also suffer tremendous emotional and psychological
effects from pain, anxiety, inconvenience and bereavement.49 Individuals are often treated poorly
and ostracized by other community members.
Families who care for members with chronic disease face financial and emotional stress
Those with chronic diseases are not the only people who feel pain. Entire families often bear the
burden when one member suffers from a chronic disease. Management of chronic disease is
complicated, and can require special therapy and training. Families who must help with this care
lose income and productive time from work and school. Lost income and direct costs for care push
many families deeper in to poverty. This vicious cycle is often called the medical poverty trap.50
According to the World Health Organization (WHO), 44 million households (100 million individuals)
fall in to poverty each year because of catastrophic health costs.51 It is estimated that 90 percent of
these people live in low income countries.52 Because of the expense and duration, catastrophic risk
is associated mainly with chronic disease. In Burkina Faso, the possibility of catastrophic economicconsequences increases from 3.3 to 7.8 times in households stricken by chronic disease.53 Living
with sick family members is also a psychological burden, stressing relationships, creating anger and
frustration, and spawning feelings of hopelessness that often only end with the loss of a loved one.54
Chronic disease is costly for society
In addition to threatening human health, chronic diseases have huge impact on economic growth
and societal development. Global costs for chronic disease are enormous ranging from 290 billion
USD for cancer to 2.5 trillion USD for mental illness each year.55 Cumulative losses for the five most
threatening chronic diseases (Figure 8) are estimated at 47 trillion USD over the next two decades.
This sum could eliminate 2 USD per day poverty for 2.5 billion people for more than fifty years. 56
These costs will be felt not just today but for several generations to come.
The social and economic cost of chronic
diseases is significant for individuals,families and society
Improving Chronic Disease Care in Slums by 2019
Generics, better medicine and digitaltechnology may offer solutions, but moreare needed to counter the increasing slumpopulation
Generic pharmaceuticals are increasingly available to slum dwellers
Medication can be exceptionally costly for those living in slums. It is estimated that the vast majority
of healthcare spending is spent on medication each year.57In addition, there is often a poverty
penalty (because of inefficient supply chains, as mentioned above) for those in slums who may
have the greatest need for medicine. The production and sale of generic drugs can drastically lowerthe costs of these medications.58
My family pays the price
Roberto Severino Campos was from ashanty town in Brazil. He worked as a
public transport agent and never paidattention to his high blood pressure orsmoking and drinking habits. Now,he lives with his seven children and 16grandchildren, who must take care ofhim, because after three strokes, he is
paralyzed and has lost his ability to speak.Fortunately his medication and check-ups are free, but sometimes we just donthave enough money for the bus to take usto the local medical centre, explains his
31-year-old daughter Noemia. Robertodepends entirely on his family, and muchof the familys income is used to cover hishealthcare needs. We all wish we couldget him a wheelchair to make his life alittle easier, she says, but unfortunately,
the family cannot afford it.
Source: http://www.who.int/features/galleries/chronic_diseases/roberto/01_en.html
Figure 8. Global costs for chronic
disease will increase
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As patents expire, more and more medications are legally permitted to be sold as generics and are
therefore more likely to meet quality standards (Figure 9).
In addition, the World Trade Organization (WTO) passed an agreement in 1995 known as TRIPS
that allows governments to issue licenses that allow non-patent holders to manufacture andmarket a medicine in a domestic market.59 This agreement has led to more competition in the
generics market and significantly lower prices. Because of the TRIPS agreement, the price of AIDS
medication in Brazil fell by 82 percent.60
Improving Chronic Disease Care in Slums by 2019
Figure 9. Generic pharmaceuticals are becoming more common as patents expire
Figure 10. Technology-enabled health solutions are becoming more prevalent
Better medicine is making healthcare more accurate
As more pharmaceuticals become available as generics, so too are new and better drugs being
discovered and developed. Funding for pharmaceutical research is funded by government grants,
private corporations, and even new breeds of NGOs like the Aravind Eye Care System. New
diagnostic methods, like the pancreatic cancer screening test developed by 15 year-old Jack
Andraka, are allowing people to diagnose faster, cheaper, more reliably and often in the comfort of
their own homes. The entire medical system is continuing to mature and take a more holistic viewof health, integrating modern medicine with more traditional techniques. These trends offer hope
that the developing world will have the opportunity to leap-frog technologies in healthcare, as it has
done with mobile technology in the telecom industry.
Virtual solutions and telemedicine are beginning to offer lower-cost health options
For the last several decades, technology innovations have been decreasing in price and complexity,
allowing more of the worlds population to have access to a variety of different services. The
healthcare industry is no exception. Since the early 1990s, technology enabled programs have
become an increasingly significant part of programs implemented in low- and middle-income
countries (LMICs) (Figure 10).61
The start of something different
A non-prot startup called Watsi uses aglobal crowd-funding platform allowingany person to directly fund medicalservices for individuals from developing
countries who are unable to affordit. Watsi works closely with medical
partners who identify patients in needand determine if patient conditions meet
pre-determined criteria. Watsi postspatient proles online and distributes100 percent of donor funding directlyto chosen individuals. Watsis operatingcosts are covered by other donations,business partners and licensing software
fees. Although this reects tremendousopportunity to provide signicant care inthe developing world, the model does notcurrently support continuing health needsthat often develop from chronic disease.
Source: https://watsi.org/
Knowledge is power
A study of 150,000 women from slumsin India has shown that a simple vinegartest can reduce cervical cancer mortalityrate by 31 percent. Slum dwellers cantafford costly pap smears and traditional
HPV tests. This new method represents aneasy solution that can be carried out bylocal clinics with minimum training andmodern laboratory equipment. Accordingto research estimations, this low-techexam could prevent 22,000 deaths in
India and 72,600 worldwide each year.
Source: http://bigstory.ap.org/article/vinegar-cancer-test-saves-lives-india-study-nds
Technology allows better access
An underserved community of the SantaMarta slum in Rio de Jainero was chosenfor New Cities Foundations UrbanE-Health Project. During an 18 monthtrial, trained nurses visited 100 elderly
patients in one of the steepest favelas inBrazil with a backpack that containedhigh-tech medical monitoring equipmentdeveloped by GE that enabled them todetect an average of 20 different diseaseslike hypertension or diabetes withinminutes. The pilots results reveal thatdespite the initial cost of the apparatus(42,000 USD), the integration of e-healthtechnology into the healthcare systemof underserved urban areas can lead tomajor economic savings for the healthsystem as a whole, increased efciency
for healthcare workers and better accessto vital healthcare for patients who need
it most.Source: http://www.newcitiesfoundation.org/wp-content/uploads/PDF/Research/New-Cities-
Foundation-E-Health-Full-Report.pdf
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Governments see slums as illegal habitats and focus on emergency care
Governments are responsible for providing infrastructure and rule of law.74 Unfortunately, slums are
in flux and often not recognized as legal places of habitat with legal protection and security.75 As
a result, nominal efforts are made by governments in slums to provide roads, schools, electricity,water and security. Moreover, many governments see urbanization as a problem and put more
effort in rural development to slow urbanization. Most governments ignore slums or threaten
residents with eviction.76
Additionally, the type of aid that governments do traditionally provide is often designed to attend to
communicable or infectious diseases. Governments have spent billions of dollars in aid for malaria,
HIV and tuberculosis.77 Among aid provided by the United States government, almost 50 percent
of global health dollars was spent on HIV alone.78 This focus on HIV creates a global mentality
of reactive care from epidemic flare-ups, but it does not address the growing problem of non-
communicable disease education, prevention, diagnosis, treatment and care.
The private sector is unable to provide market solutions for chronic diseases in slums
The private sector builds business and profit out of sustainable consumer demand. Becausehealthcare is difficult to operate with complete and consistent services without significant margins,
purely for-profit ventures may have difficulty operating in slums.79The private sector, in general, has
had difficulty implementing pricing models that work in slum environments.80
Although some private options exist in slums, most of them are quite expensive for the average
slum dwellers limited budgets. Clinics are also hard to monitor and lack transparency that is critical
for ensuring appropriate accountability across the value chain.81
NGOs focus on healthcare challenges related to communicable and infectious diseases
Non-governmental organizations (NGOs) have become major contributors to social development
in recent decades. Some NGOs focus on rural areas and provide relief aid. Others work in urban
areas and focus on development. However, NGOs have challenges in funding, program continuity
and customer perception.82As a result, their impact has been nominal and at times even negative.83
The last decade has shown that non-communicable diseases are a growing concern for the
developed and the developing world.84 Significant research is being done not only on these
chronic diseases and their root causes but also on their impact on slum areas. Unfortunately,
acknowledgement of the problem has not yet turned into viable solutions for slum dwellers with
chronic diseases. NGOs often focus more on communicable and infectious diseases that are easy
to prevent and are still among the leading causes of death in the developing world.85
Solutions for chronic diseases in slumsare not a priority for governments, theprivate sector or NGOs
As conditions within and outside of slums improve, longer life will translate into additional costs
incurred in caring for and managing chronic disease. Chronic diseases cost the developing world
well over 50 percent of total healthcare costs.72This number is expected to increase dramatically as
countries develop. Chronic diseases cost the United States 75 percent of total healthcare costs.73
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Social enterprises deliver both social impact and business profit. They deliver social impact by
improving the health and well-being of the worlds most vulnerable people. While social enterprises
can be either for-profit or not-for-profit organizations, they all aim to utilize a pricing strategy
that will create a sustainable, consumer or partner-driven business model. This helps reduce or
eliminate dependence on donations and cash injections. Slums will benefit from the emergence
of more social enterprises particularly those focused on prevention, diagnostics, treatment, and
sustainable care to chronic disease (Figure 13).
Figure 14. Solutions should work with specific intervention points to make targeted impact
Figure 13. Social enterprises may be best suited to address chronic care in slums
Social enterprises may be the best optionto address this issue
Addressing pain points along the chronic disease timeline (Figure 14) will improve solutions for
slum dwellers throughout the developing world. Bigger, better, bolder, faster and cheaper solutionsare needed in all parts of this chain: from manufacturing to distribution channels to treatment and
continued care. Solutions that integrate the participation of slum dwellers are considered even
more interesting because they create employment, purpose, and economic wealth for these
individuals.86Robust and scalable business solutions that create economic wealth across the value
chain for all stakeholders are needed to improve care for people suffering from non-communicable
diseases in slums.
Efforts are already in place to create solutions around food security and education. For that reason,
we encourage solutions that focus on the early identification of chronic diseases, their treatment
and care.
Social enterprise in motion
A social enterprise called Access Afya iscreating a network of paperless healthkiosks that offer basic healthcare services
for slum dwellers in Kenya. Kiosks arestaffed with a nurse and communityhealth worker and use an electronic
patient management system and textmessages for communicating with
patients. To make each mini-clinic a self-sustaining operation, every patient paysa small fee. In rst six months, more than
500 patients from Nairobi slums haveused and paid for these health services.
Source: http://www.accessafya.com/
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All people are exposed to risk from unexpected changes in the environment, accidents, illnesses,
price increases or cash availability. Unfortunately, low income individuals have limited safety nets,
social networks and buffers to deal with unexpected change, particularly the major expenses
associated with chronic disease care. Social enterprises that target these types of customers will
have to work with value chain players who are also at a higher risk in an environment with limited
government support and infrastructure.
Social enterprise operations are difficult to manage
Finances must be efficient
Social enterprises need to operate with razor-thin margins in an environment of fluctuating demand
and supply. In informal business (which dominates the economic landscape in urban slums),
relationships with suppliers and customers are informal the hierarchy of roles and work is flexible.87
There are few, if any, contracts. Contacts are irregular and hours of operation vary. Managing cash
collection, inventory and supplier payments is key to ensuring a healthy cash position. To reduce
cost, social enterprises will need to grow significantly to enjoy economies of scale. Both working
capital and scaling up can be managed through financing. Unfortunately, financing for companies
working in the slums or targeting poor slum dwellers is limited to a few microfinancing institutions.
Assets must be able to bear risk
Social enterprises working in slums are exposed to higher risk from supply chain inefficiency,
fire hazards, natural disasters, corruption and high crime rates.88 Most insurance organizations
are unable to assess the risk, claims and premiums accurately enough in slums to build a viable
business. Social enterprises have to manage their environment and assets to ensure business
continuity in the face of risk that most enterprises in wealthier regions have insurance for.
Employee training must be flexible and culturally appropriate
Social enterprises should hire from slums to increase social impact; however, these potential
employees may not have the appropriate skills and training for the job.89 Training and on-the-
job skills development will put additional stress on management and operations. Additionally, it
is critical to work with local employees in a way that is culturally acceptable and considerate to
differences in gender sensitivity, religious practice, dietary preferences and other social norms.
Inconsistent demand is hard to plan for
Most services are not derived from homogenous demand.90 Airlines, banks, and particularly health
care clinics may see demand vary by time of day, day of the week or even by season. These
fluctuations can make operations difficult, particularly for social enterprises struggling to leverage
sustainable business models. Operating with peaks and valleys of demand can quickly wipe out
many businesses that must operate on squeezed margins.
Fair pricing for health solutions is difficult to implement
Social enterprises will have to struggle with the same challenges that traditional businesses do
in building business models for the healthcare industry. Healthcare is extremely susceptible to
inelastic demand and what is known as dynamic inconsistency. This means that the need, and
therefore willingness to pay, for services fluctuates dramatically over time. As a result, setting
market prices is difficult to do with fairness and integrity. This inconsistency, combined with a
unique lack of transparency and feedback mechanisms around true pricing, means that healthcare
social enterprises will not be able to use business models leveraging traditional supply and demand
curves.91
Consumers with fluctuating income and limited savings are difficult to serve
Poor people in slums lack adequate education. Those with less education typically make lessmoney and lack access to higher paying jobs.92 The jobs that slum dwellers are able to access
are often irregular and provide fluctuating income.93 Social enterprises will need to have business
models that can accommodate inconsistent consumer income. In addition, slum dwellers who
However, building successful socialenterprises in slums will be difficult
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do not have sufficient education do not typically have enough knowledge about proper chronic
disease prevention, diagnostic, treatment and care options.
Slum dwellers also struggle to build significant savings accounts that are critical to being able to
pay for medical care and services.94 Without a savings account, people sometimes fundraise for
their own medical procedures by begging in their own communities.95 Those lacking in healthcarein slums typically have incomes between 1 USD to 5 USD a day. Social enterprises that target this
segment will have to provide low-cost solutions that consider financing and savings opportunities
within this income level.
Partners across the value chain are difficult to work with dependably
Pharmaceutical producers, medical equipment manufacturers, and distribution networks to
hospitals and clients must ensure quality care. However, most players in the healthcare value chain
are remote and ill-designed for slum environments, which make the whole value chain fragile. Social
enterprises will face significant challenges in building a consistent and predictable supply chain.
Can we build a social healthcareenterprise that serves the needs of 25million slum dwellers suffering fromchronic diseases by 2019?
The purpose of this challenge is to improve health options around diagnostics, treatment and care for
those suffering from chronic diseases in slums around the world. This will lead to better productivity,
more robust healthcare systems for all slum dwellers, and individuals who have significantly higher
quality of life. The winning business solution should have significant and measurable impact.
A list of questions to help develop a good winning business solution is provided in Figure 15. The
solution should have a sustainable business model. It should improve health options. It should have
a stage implementation plan with clear milestones and funding required for each milestone. Overall,
the winning solution should scale rapidly to serve an ever increasing number of people with chronic
disease in a relatively short time. Solutions may be built around any of the following steps in the
chronic disease timeline: diagnostics, treatment or continued and extended care, but must reach
25 million people with chronic disease by 2019.
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To develop a solution, lessons learned by other companies, NGOs and social enterprises in other
industries should be considered. IXL Center uses the innovation value chain to find growth and
opportunity in new areas. There are bright spots around each section of the innovation value chain
market, delivery, offering, production and business model that should be considered as inputs
when developing solutions for the poor (Figure 16).
Find customers who can pay
Target profitable customers and segments
Know your customers needs and behaviors
Plan for consumers who lack trust
Addendum: Create Successful SocialEnterprises
Figure 16. The Innovation Value Chain can identify opportunity points
Figure 15. Guiding metrics help identify solutions with the most impact
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What you should ask:
Who is your target customer?Social enterprises typically target those who earn more than 2
USD/day.
What are your customers needs and purchase behavior? Offerings need to delight customers
and be integrated into existing behaviors.
How will you build trust and credibility for your consumers? Making the wrong decision has
much more serious consequences for the poor, so customers must trust in what they pay for.
Use existing channels
Tap existing channels
Use powerful influencers
Leverage virtual solutions
What you should ask:
What existing distribution channels of major corporations or local business can you work
with?Channels that have already been built may cost money, but they are effective and ready
immediately.
Who or what are the influencers that can accelerate acceptance of your offering? Strong
relationships and word-of-mouth networks can scale social enterprises quickly.
How can you use new and existing technology to move goods and services virtually?Finding
solutions that leap-frog the developed world with technology can be more cost-effective.
Make offerings affordable and accessible
Right-size solutions Hold people and organizations accountable
Focus on human-centered design
What you should ask:
How can you build your offering in pieces?Low-income families can pay for things bit by bit
more easily than all at once.
What can you do to ensure accountability?Audits and monitoring should be embedded to
keep business trustworthy.
Who are you designing for?Your customers are more likely to pay for things that were designed
with them in mind.
Build with local parts and knowledge
Use parts that are available where you are delivering
Apply insight and knowledge of the community
Build with assets of value
What you should ask:
What do you need to replace parts of your offering with locally available supplies?You can
save money and time by building closer to home.
Who has knowledge that can help you be more successful on the ground? Navigating
communities often requires local support and engagement.
What assets will make your enterprise more valuable by itself?Just because something is free,
does not mean it is valuable to your operations.
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Go beyond traditional business models
Provide value exchanges and microfranchises
Create intangible value
Create a business model with flexibility
What you should ask:
How does your solution capture the value you create?Capturing value is a critical step to
making your social enterprise economically self-sustainable.
What do you offer people that is difficult to put a price on?Your offering will be more interesting
if you free up peoples time, or increase self-esteem, dignity, security or happiness.
What are the different stages of your business model?You may need to finance operations
differently during the pilot and early stages than you do at scale.
Companies who are able to think broadly and holistically about the entire business innovation valuechain are more likely to be able to capture value. Social enterprises developed for the Hult Prize,
like Aspire, Reel Gardening, Pulse, Poshnam, Origin and Sokotext, have worked across these
segments to scale offerings that will help end food insecurity in urban slums. They are working on
the ground, today, to produce at lower cost, find offerings that delight consumers, deliver quickly
and effectively, build brands that inspire trust, and use partners and networks to help capture new
value in new ways. How can you do the same for peoples well-being and health?
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The Hult Prize and IXL Center have compiled research for this case from known and credible sources. The authors have attempted to use
accurate information as much as dynamic data can be accurately measured and reported. The authors explicitly disclaim to the extent
permitted by law responsibility for the accuracy, content or avail ability of information located throughout thi s case or for any damage incurred
owing to use of the information contained therein.
AUTHORS
Dr. Hitendra Patel
Managing Director, IXL Center; Hult Professor of Innovation and Growth
Hitendra Patel is the Managing Director of the IXL Center. He helps Fortune 1000 companies identify andimplement new growth engines or helps them build innovation capability. He has written all the cases for the
Hult Prize and is on its advisory board. Previously, Hitendra worked at Monitor, ADL, and Motorola.
Ronald Jonash
Partner, IXL Center
At Arthur D. Little for 25 years, Ron led the effort to translate strategic planning methods to the institutional
and non-profit sector as well as the effort to transition a technology innovation practice to a broader strategicinnovation practice. Ron was also head of the Innovation practice at the Monitor Group for five years before
launching the Center for Innovation Excellence and Leadership and the Global Innovation Management Institute.
Kristen Anderson
Consultant, IXL Center
Kristen is a consultant with the IXL Center. Kristen has worked with the Hult Prize since 2010, when she was a
student in London. In 2012, she wrote the case study with Habitat for Humanity. She specializes in corporate
and MBA Management Consulting training. Kristen also provides coaching and training for innovation andbusiness intelligence action projects around the world.
Julius Bautista
Consultant, IXL Center
Julius works on product development and research efforts at IXL Center. He has contributed to the development
of white papers, articles and books around the topic of innovation. Additionally, Julius co-wrote the One Laptop
per Child (OLPC) case used by Hult Prize for the 2012 challenge. He is also a mentor at the Hult InnovationOlympics helping MBA students generate breakthrough ideas for OLPC to educate more children in developing
countries.
RESEARCH TEAM
Lydia Baluchova
Research Associate, IXL Center
Lydia is a research associate at IXL Center. Prior to IXL Center, she was working as a lawyer in the private andpublic sector in Slovakia. Lydia completed her legal studies in Greece and Slovakia and also has an LL.M in
International Business Law from Central European University in Hungary.
Karla GomesConsultant, IXL Center
Karla has more than four years of consulting experience working in Strategy and Organization (S&O) related
projects where she worked with public and private sector clients for various industries such as energy, financeand construction, among others.
Shinhee Kim
Associate Consultant, IXL Center
Shinhee is an Associate Consultant at IXL Center. Prior to IXL Center, she worked as a HR manager and research
associate for various companies in South Korea. Shinhee is a MBA candidate at Suffolk University and she has
a B.A. from University of Ulsan, South Korea.
ACKNOWLEDGEMENTS
Special thanks to the following individuals and organizations for their input and insight:
Pamela McNamara, Principal, IXL Center
Steve Andrews, CEO, Solar Aid
Joan Bragar EdD, Leadership Consultant, Boston Leadership
Grace Garey, Marketing, Watsi
Akanksha Hazari, CEO and Founder, mPaani
Dr. Isabel Martinez del Rio, Dietitian/Nutritionist, Hospital St. Angelin Chapultepec
Dr. Kishor Mistry MD PhD, Managing Trustee, Koshish-Milap Trust
Jennifer Norman, Director of Public Health Mercy Corps
Dr. Miguel Angel Santos, Henrique Capriles Presidential Campaign Public Policy Team, Harvard Kennedy School of Government
Greg Scarborough, Senior Advisor on Nutrition & Food Security, Mercy Corps
Dr. Ricardo Villasmil, Head of Public Policy, Henrique Capriles Presidential Campaign, Harvard Kennedy School of Government
David Peters MDDrPH MPH, Professor, Chair, Department of International Health, Johns Hopkins Bloomberg School of Public Health
Michael B. Bracken PhD, MPH, FACE, Professor of Epidemiology (Chronic Diseases), Yale School of Public Health
Darrell J. Irvine PhD, Professor of Biological Engineering and Materials Science, David H Koch Institute for Cancer Research, MIT
Minister Rim Chemin, Ministry of Health and Welfare, Republic of Korea
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Improving Chronic Disease Care in Slums by 2019
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Improving Chronic Disease Care in Slums by 2019
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85Scarborough, Greg (Mercy Corps). Interview by author. Phone interview. IXL center - Mercy Corps, September 3,
2013.86Aneel Karnani, Fortune at the Bottom of the Pyramid: A Mirage, Stephen M. Ross School of Business at the
University of Michigan, Ross School of Business Working Paper Series Working Paper No. 1035, July 2006.87Karnani, Aneel. Romanticizing the Poor. Standford Social Innovation Review, 2009. http://www.ssireview.org/
articles/entry/romanticizing_ the_poor (accessed September 10, 2013).88Ibid.89A) Aneel Karnani, Romanticizing the Poor, Stanford Social Innovation Review, 2009, http://www.ssireview.org/articles/
entry/romanticizing_the_poor September 10, 2013 B) United Nations Human Settlements Programme, The Challenge
of Slums: Global Report on Human Settlements 2003, P. 68, http://www.unhabitat.org/pmss/listItemDetails.
aspx?publicationID=1156 September 10, 2013.90Fitzsimmons, James A. and Mona A. Fitzsimmons. Managing Capacity and Demand. Originally published in Service
Management: Operations, Strategy, and Information Technology. Boston: McGraw-Hill/Irwin, 2013.September 10,
2013http://210.46.97.180/zonghe/book/213-%E6%9C%8D%E5%8A%A1%E7%AE%A1%E7%90%86-%E6%9
C%BA%E6%A2%B0%E5%B7%A5%E4%B8%9A%E5%87%BA%E7%89%88%E7%A4%BE-James%20A.%20
Fitzsimmons/CHAPTER13.htm (accessed September 10, 2013).91Scott, Douglas. Applying Economic Principles to Health Care: Resource Allocation in Health Care. Medscape, 2001.
http://www.medscape.com/ viewarticle/414406_3 (accessed 10 September 2013).92Ibid.93Kigali City.Kigali Master Plan implementation projects . Kigali City Official Website. http://www.kigalicity.gov.rw/
spip.php?article495 (accessed September 10, 2013).94Mensch, Barbara S.The effect of a livelihoods intervention in an urban slum in India New York, NY: Population
council, 2004.http://www.popcouncil.org/ pdfs/wp/194.pdf (accessed September 10, 2013).95Garey, Grace (Watsi). Interview by author. Phone interview. IXL Center - Watsi, September 12, 2013.