IN DEGREE PROJECT INDUSTRIAL MANAGEMENT,SECOND CYCLE, 30 CREDITS

, STOCKHOLM SWEDEN 2020

Digital transformation of healthcare services in developing countriesAn exploratory research of healthtech opportunities in Bottom of the Pyramid (BOP) markets

AMANDA RUNDQVIST

AMANDA VON SCHINKEL

KTH ROYAL INSTITUTE OF TECHNOLOGYSCHOOL OF INDUSTRIAL ENGINEERING AND MANAGEMENT

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Digital transformation of healthcare services in developing countries

An exploratory research of healthtech opportunities in Bottom of the Pyramid

(BOP) markets

by

Amanda Rundqvist Amanda von Schinkel

Master of Science Thesis TRITA-ITM-EX 2020:211 KTH Industrial Engineering and Management

Industrial Management SE-100 44 STOCKHOLM

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Digital transformation av sjukvårdstjänster i utvecklingsländer

En utforskande studie av digitala vårdtjänsters möjligheter i

Bottom of the Pyramid (BOP) marknader

av

Amanda Rundqvist Amanda von Schinkel

Examensarbete TRITA-ITM-EX 2020:211 KTH Industriell teknik och management

Industriell ekonomi och organisation SE-100 44 STOCKHOLM

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Abstract The development of new technologies within healthcare open up for important and valuable opportunities for businesses as well as for individuals. Mobile health is one of the most important digital innovation, since patients get the opportunities to self-manage diseases and to receive healthcare services from specialists wherever and whenever. It has already been established in some developed countries, where the technology has, for instance, improved health research among populations and reduced healthcare costs. Currently, it is under investigation if there are also implementation possibilities in developing countries. They are defined as countries with poor infrastructure and decent economic activity, meaning a high number of people live with low income and they tend to have less access to health services than the ones in developed countries. The Bottom of the Pyramid (BOP) refers to the poorest of the economic human pyramid, where almost all of them live in developing countries. In order to enter a BOP market, it is beneficial for businesses to use the 4A:s (awareness, access, affordability, and availability) as a framework. The report aims to investigate if MedTech companies from developed countries can improve access, awareness, availability, and affordability to reliable healthcare in developing countries. It is referring to the BOP due to the focus on an innovation’s (i.e., MedTech app) growth opportunities in developing countries. The report is considered as an exploratory research, undertaking an inductive approach, since it exists limited written resources about the subject. The information has been gathered through primary- and secondary sources. The report’s findings raise the low digital awareness as a threat that could harm the development of new digital innovations in developing countries. By taking use of local collaborations and partnerships, it will develop understandings of the populations’ needs and behaviors, which is a benefit to be able to reach the users’ attention. The telecommunication industries’ growth and the increase of mobile users proves the populations are eager to embrace new digital innovations, meaning the initiative might be right in time. Additionally, the findings concern the limited access to healthcare and currently, the local care is of low quality. The doctors and nurses have limited knowledge and the hospitals are not keeping up with technology, which leads to that the citizens are seeking healthcare outside their own country. However, it could be perceived as a benefit when implementing a new MedTech service, since it does not exist any advanced systems that have to be changed or shut down. Moreover, to ensure the populations will be able to use digital healthcare services, it is important to keep the service affordable. By being supported with correct treatments, and recommendations, it would not be necessary to visit a doctor several times and, therefore, it could also decrease the patient's’ healthcare costs. Finally, digital healthcare services enable for patients to interact with foreign doctors wherever and whenever, which would increase the availability of healthcare services in developing countries.

Master of Science Thesis TRITA-ITM-EX 2020:211

Digital transformation of healthcare services in developing countries

Amanda Rundqvist

Amanda von Schinkel Approved

2020-06-08 Examiner

Niklas Arvidsson Supervisor

Milan Jocevski Commissioner

N/A Contact person

N/A

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Sammanfattning Den ständiga utvecklingen av nya teknologier inom sjukvården öppnar upp för värdefulla möjligheter för företag samt individer. Mobil sjukvård är en av de viktigaste digitala innovationerna då det ger patienter möjlighet att själva hantera sjukdomar och har tillgång till specialistvård närhelst och varhelst. Detta har redan etablerats i ett antal utvecklade länder, där teknologin dels har förbättrat forskningen inom hälsa och dels minskat på sjukvårdskostnader. För tillfället undersöks även möjligheten för implementation av digitala sjukvårdstjänster i utvecklingsländer. De definieras som länder med outvecklad infrastruktur och svag ekonomisk tillväxt, vilket betyder att en stor del av befolkningen lever med låg inkomst och det finns inte samma tillgång till sjukvård som i utvecklade länder. The Bottom of the Pyramid (BOP) hänvisar till de fattigaste i den ekonomiska pyramiden där majoriteten av dem lever i utvecklingsländer. För att ta sig in i en BOP marknad, är det rekommenderat för företag att använda sig av ramverket “the 4As” (awareness, access, affordability, and availability). Syftet med rapporten är att undersöka om MedTech företag i utvecklade länder kan förbättra “the 4As” inflytande på tillförlitlig sjukvård i utvecklingsländer. Den hänvisar till BOP på grund av att fokus är på innovationens (dvs. MedTech applikation) tillväxtmöjligheter i utvecklingsländer. Rapporten betraktas som en utforskande studie och åtar en induktiv strategi med tanke på att det finns begränsat med information om ämnet. Underlaget för rapporten har samlats in via primära - och sekundära källor. Rapportens resultat visar på att den låga digitala medvetenheten skulle kunna begränsa utvecklingen av nya digitala innovationer i utvecklingsländer. Genom att etablera lokala partnerskap och samarbeten, kan en förståelse för befolkningens behov samt beteenden utvecklas, vilket är en enorm fördel för att få deras uppmärksamhet. Dessutom växer telekommunikationsindustrin och mobilanvändandet bland befolkningen ökar, vilket visar på att en digital nyfikenhet finns. Detta innebär i sin tur att det skulle kunna var helt rätt i tid för en etablering av digitala sjukvårdstjänster. Utöver det visar undersökningar på att tillgången till sjukvård för tillfället är begränsad och den lokala vården är av låg kvalité. Läkare och annan sjukvårdspersonal saknar ofta fullständig utbildning, vilket leder till att befolkningen söker sjukvård i andra länder. Avsaknaden av teknologi kan däremot uppfattas som en fördel vid en eventuell implementation av en ny MedTech-tjänst då det inte finns några avancerade system som måste ändras eller stängas ner. För att säkerställa att befolkningen kommer kunna använda sig av digitala sjukvårdstjänster är det viktigt att tjänsten uppfyller befolkningens ekonomiska möjligheter och är prisvärd. Genom att få tillgång till rätt behandling och rekommendationer direkt, behövs inte lika många besök hos läkaren och sjukvårdskostnader kan minska. Slutligen möjliggör digitala sjukvårdstjänster för globala interaktioner med läkare och specialister, vilket skulle kunna öka tillgången och tillgängligheten till sjukvård i utvecklingsländer.

Examensarbete TRITA-ITM-EX 2020:211

Digital transformation av digitala sjukvårdstjänster i utvecklingsländer

Amanda Rundqvist

Amanda von Schinkel Godkänt

2020-06-08

Examinator

Niklas Arvidsson

Handledare

Milan Jocevski Uppdragsgivare

N/A Kontaktperson

N/A

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Table of Contents List of Figures 8

List of Tables 9

Abbreviations 10

1. Introduction 12

1.1 Background 12

1.2 Problem definition 13

1.3 Purpose 13

1.4 Research questions 14

1.4 Delimitations 14

1.5 Disposition of the report 15

2. Research Context 17

2.1 Mobile phone 17

2.2 Health services 17

2.3 MedTech in developing countries 18

3. Theoretical framework 21

3.1 Bottom of the Pyramid 21 3.1.1 The 4As in a BOP market 22

3.2 Innovation management 23 3.2.1 Diffusion of Innovation 23

3.2.2 Innovation Process Model 24

3.2.3 Rationalist and Incrementalist strategies 25

4. Methodology 27

4.1 Research process 27

4.2 Research design 28

4.3 Data collection 31

4.4 Data analysis 36

4.5 Unit of analysis 36

4.6 Quality of research 37

4.7 Ethical consideration 38

5. Case descriptions 40

5.1 Angola 40 5.1.1 Health status 40

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5.1.2 Healthcare system 41

5.1.3 Cooperation for health 41

5.1.4 To start a business 42

5.1.5 Infrastructure development 43

5.2 Nigeria 44 5.2.1 Health status 45

5.2.2 Healthcare system 45

5.2.3 Cooperation for health 46

5.2.4 To start a business 47

5.2.5 Infrastructure development 47

5.3 Other services that have been exported 49

6. Empirics 52

6.1 Awareness 52

6.2 Access 54

6.3 Affordability 55

6.4 Availability 56

7. Analysis and Discussion 59

7.1 MedTech’s impact on the 4As in BOP markets 59 7.1.1 Awareness 59

7.1.2 Access 60

7.1.3 Affordability 61

7.1.4 Availability 62

7.1.4.1 RQ1 summary 64

7.2 Developed countries’ possibilities to enter a BOP market 66

8. Conclusion 70

8.1 Further research 71

Appendix A - Interview questions 78

Appendix B - Contact template 81

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List of Figures Figure 1: Diffusion of innovation (Rogers 2003) 23 Figure 2: Innovation Process Model (Tidd & Bessant, 2013) 24 Figure 3: Research process 27 Figure 4: Mapping of stakeholders 32 Figure 5: Process for registration (PharmAccess Foundation, 2015) 47 Figure 6: Number of internet users in Nigeria from 2017 to 2023 (Statista, 2020) 48

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List of Tables

Table 1: Disposition of the report 15 Table 2: Representation of interviewees 33 Table 3: Examples of secondary sources 35 Table 4: Internet usage and population growth in Angola (Internet World Stats, 2019) 44 Table 5: RQ1 summary (Awareness & Access) 64 Table 6: RQ1 summary (Affordability & Availability) 65 Table 7: RQ2 summary – Focus areas 68 Table 8: RQ2 summary - Appropriate models 69

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Abbreviations BOP Bottom of the Pyramid RQ Research question Ch Chapter The 4As Awareness, Access, Affordability and Availability MedTech Medical Technology Healthtech Healthcare Technology mHealth Mobile Health eHealth Information and communication technologies in healthcare SDG Sustainable Development Goals IHIS Integrated Health Information System GSB General State Budget NHIS National Health Insurance Scheme LGA Local Government Areas NCH National Council of Health HPCC Health Partners Coordinating Committee CITA Companies Income Tax Act NCC Nigerian Communications Commission BBC British Broadcasting Corporation SNG Shell Nigeria Gas

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Foreword This is a Master Thesis within Industrial Engineering and Management, performed at the Royal Institute of Technology (KTH) in Stockholm. In this section we would like to thank the people who have influenced, helped, and inspired us during the report’s development. Firstly, we would like to acknowledge Thomas Ehrengren and Christian Tärnholm at Medicheck for providing us with this Master Thesis opportunity. We are grateful for you having us and for guiding and encouraging us throughout the journey. Secondly, we would like to thank our supervisor at KTH, Milan Jocevski, for delivering insights and support that have been valuable in order to continually improving the report. Thank you for challenging our thoughts, and ideas, it opened up for taking new perspectives into account. Thirdly, we would like to thank our Prof. Cali Nuur and classmates for participating in seminars where we could deliver and receive feedback during the way. Many thanks for listening to our presentations and for the engagement afterward. The advice and recommendations we have received during the seminars have helped us to generate a greater report. Finally, we would like to acknowledge all the participants in the performed interviews. The different expertise and knowledge have created and formed the report’s results and analysis. It has been interesting and inspiring to talk to people with such high competencies and it would not have been possible to generate this report without all of you. Thank you! June 2020 Stockholm, Amanda and Amanda

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1. Introduction The chapter presents the background of the investigation, problem definition, purpose, research questions, and delimitations. The chapter ends with a disposition of the report, which provide the reader with an overview of the content of each chapter.

1.1 Background The mobile phone is a popular technology innovation and is used by approximately 3.6 billion people in the world (Gogging, 2006). Today, the mobile phone is not only used for phone calls or messaging, since it has become a culture and an important factor in the population’s daily lives (Gogging, 2006). The technology has enabled the citizens to perform other activities, such as; shopping online, watching programs, and using social media at any time. Hence, it has opened up for new opportunities, which has contributed to the constant development of new, digital solutions (Gogging, 2006). Digital healthcare is a new technology used by a vast amount of people in the world (Kumar et.al., 2013), where Mobile health (mHealth) is one of the innovations. It gives people the possibility to self-manage diseases and to contact a doctor wherever and whenever. Further, it has improved health research and reduced healthcare costs (Kumar et.al., 2013). Therefore, digital health services have been requested in developed countries and the healthcare sector has optimized the use of them. It makes it possible to reach out to more patients and to provide them with faster care and treatments. (Rivas and Wack, 2018) The number of people using digital health services is constantly rising due to the technology’s benefits to patients (Safavi and Kalis, 2018). It is also noticed that patients of all ages are interested in using them, since information regarding diseases and medicines can be provided without visiting a doctor. It saves time and energy for the patient (Safavi and Kalis, 2018). Moreover, the digital healthcare services are not only a benefit for the patients, but also for hospitals and health centers. They become more effective, since doctors are able to provide patients with medical recommendations online, meaning they can treat more people during a day and also focus more on the patients that actually need a physical meeting (WHO, 2019). It would in turn generate reduced care queues, costs and more time can be spent on practices and research (WHO, 2019). The technology is already established and well working in some countries and it is currently under investigation if there are possibilities for implementation in developing countries, since several of them are in high need of improvements in the healthcare sector (WHO, 2019). Moreover, a developing country is defined as a country with decent economic activity and a high number of people living with low income (Cambridge dictionary, n.d.). The Bottom of the Pyramid (BOP) refers to the poorest of the economic human pyramid, where almost all of them live in developing countries (Kirchgeorg and Winn, 2014). A helpful framework for companies to use to tackle a BOP market is the 4As. The 4As framework consists of; awareness, access, affordability, and availability (Prahalad, 2011). The people in developing countries tend to have less access to health services than the ones in developed countries (Peters

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et.al., 2008). The awareness and availability to healthcare barely exist and it is far to travel to a hospital and the right care or treatment may not be available (Peters et.al., 2008; O’Donell, 2007). In addition, a major problem is the access to effective and high-quality healthcare, since local doctors are lacking knowledge and they deliver wrong recommendations and diagnoses (O’Donell, 2007). Additionally, the lack of resources and medicines contributes to poor effectiveness, and treatment costs become high due to charges and travels to hospitals. Therefore, people living in poverty do not use health services even though they need it (O’Donell, 2007). Sweden is one of the leading countries regarding digital services within healthcare (McKinsey, 2016). Treatment demanding diseases are growing as the population increases and therefore, it is important to improve the healthcare sector by increasing efficiency. Medical technology, also called MedTech, covers the technology that can be used in healthcare and has contributed to several advantages (MedTech Europe, n.d.). For instance, digital solutions enabling online consultation with doctors have contributed to a significant decrease in workload. The opportunity to talk to a specialist online, facilitates for patients that are in need of frequent consultations, for instance, patients with chronic diseases (McKinsey, 2016). However, the possibility to connect with a doctor that can be trusted and deliver correct medicines and treatments is not the same globally. In several developing countries is the population suspicious against the local healthcare services and does not believe that the provided treatments and medicines are reliable (The World Bank, 2019).

1.2 Problem definition The living conditions in developing countries are radically different from the ones in developed countries. They have basic infrastructure, low incomes and high burden of diseases, which all leads to poverty and misery for millions of people. On top of that, the healthcare is barely accessible, and the majority of the populations do not trust the local services and treatments. Hence, it is of importance that companies from more developed countries take on actions and provide alternative ways for the citizens to receive the care they need and deserve. Therefore, the research focuses on to investigate if digital healthcare could improve BOP markets current healthcare services by paying attention to the 4As framework (i.e., awareness, access, affordability, and availability). Hopefully, it could generate important impacts on each segment, which in turn could improve the developing countries' overall health status and living conditions.

1.3 Purpose

The purpose of the report is to investigate developed countries’ possibilities to implement digital healthcare services in developing countries.

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1.4 Research questions RQ1: How could MedTech companies from developed countries improve the access, availability, affordability, and awareness to reliable healthcare in developing countries by introducing online medical advice? RQ2: What are the possibilities for companies from developed countries to enter the healthtech market in developing countries?

1.4 Delimitations The report is delimited to the medical industry, more specifically to digital healthcare services. Furthermore, the report’s definition of developing countries is concerned with the ones that have the characteristics that are explained by the Bottom of the Pyramid, presented in the Theoretical Framework (Ch 3). In the report’s Empiric section (Ch 6), the focus is on Nigeria and Angola as developing countries and Sweden as a developed country. The purpose of investigating specific cases is to use them as references to the real world. It is important in order to develop a greater knowledge of the need for the service and to make it easier for the reader to understand how the Bottom of the Pyramid could be adopted in practice. In the research process, four different sectors have been taken into consideration as presented in the mapping of stakeholders (Figure 3); the users, research fields, regulators, and competition. However, the report is focusing on three of them; the users, research fields, and the regulators. A deeper explanation of them is presented in the Methodology (Ch 4).

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1.5 Disposition of the report The report is divided into eight chapters, which are presented in Table 1.

Table 1: Disposition of the report

Chapter Description 1. Introduction The chapter provides the reader with an introduction to the subject of the

Master Thesis. It includes background information and a problem definition. It continues with the purpose of the research and a defined research- and sub-question. Finally, it concludes with delimitations and this disposition of the report.

2. Research Context The chapter presents written literature about the subject. The chapter is divided into three categories; mobile phones, health services, and MedTech in developing countries. They are all related to new innovations and initiatives that are contributing to the industries’ and countries’ development.

3. Theoretical framework The chapter presents the theories that have been applied when analyzing the collected material, which in turn has generated valuable inputs in order to answer the report’s research questions.

4. Methodology The chapter presents how the report has been executed as well as how the obtained results and findings have been interpreted, more specifically; the research strategy, data collection, and data analysis. The chapter concludes with a discussion about the quality of the research.

5. Case descriptions The chapter presents in-depth overviews of the investigated countries, more specifically each country’s current health status, healthcare system, cooperation for health, and infrastructure development. Additionally, the chapter presents benchmark studies and previous research about other services that have been exported to similar markets.

6. Empirics The chapter presents the results and findings from the conducted semi-structured interviews, where the representation of the interviewees is found in table 1. The chapter is divided into the 4A’s that are discussed in the Bottom of the Pyramid.

7. Analysis and discussion The chapter consists of an analysis and discussion about the findings from both the empiric- and case description sections. The chapter answers the report’s research questions, where the first one is divided in the same way as the empiric section, with regards to the 4A’s.

8. Conclusion The chapter consists of a conclusion about the main findings from both the empiric- and case description sections. The chapter ends with recommendations on further research.

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Chapter conclusion To conclude, the chapter introduces the report’s subject and explains the background of the research. It is described that the mobile phone is one of the most used technologies, which can be used for more than just calling. The different application areas have opened up for new opportunities, for instance, within digital healthcare, where mobile health (mHealth) is such an innovation that provides patients with the opportunity to interact with a doctor wherever and whenever. The technology is already established in several developed countries and currently, it is under investigation if there is an opportunity for implementation in developing countries as well. A need for improvements within the healthcare sector has been identified. Moreover, a great amount of the populations in developing countries lives in poverty and they could be referred to as the poorest of the economic human pyramid, also called the BOP. To be able to understand the characteristics of a BOP market, it is beneficial to use the 4As framework (i.e., awareness, access, affordability, and availability). Furthermore, Sweden is one of the leading countries in digital healthcare, and different initiatives within the are have generated more efficient ways of working. The living conditions for the populations in developing countries are radically different from the ones in developed countries. The existing healthcare services are of low quality and access to reliable healthcare is limited. Therefore, it is of importance that companies from developed countries take on actions and provide the populations with innovative solutions in order to provide them with the care they need and deserve. It is beneficial to focus on the 4As framework when introducing digital care services to BOP markets, and hopefully, it could improve the overall health status and living conditions. Moreover, the purpose of the research was defined: “The purpose of the report is to investigate developed countries’ possibilities to implement digital healthcare services in developing countries.” and, two research questions were developed. They are important to be able to understand if and how MedTech companies from developed countries could improve the healthcare sector in developing countries with regards to the 4As (i.e., awareness, access, affordability, and availability). Hence, it is the identified research area that will be investigated throughout the report and, the disposition of the report is presented in Table 1.

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2. Research Context The chapter presents an introduction, based on secondary sources, to the investigated areas. More specifically it is divided into three categories; mobile phones, health services, and MedTech in developing countries. They are all related to new innovations and initiatives that are contributing to the industries’ and countries’ development. MedTech stands for Medical Technology and considers products, services, and solutions that are used in healthcare to improve the care for patients. (MedTech Europe, n.d.). MedTech offers several possibilities, for instance, it prevents diseases from spreading through detection tools and it is possible to perform diagnostic tests to identify the correct treatment. (MedTech Europe, n.d.). These innovations have improved healthcare and bring value to the patients as well as to the healthcare systems and the healthcare professionals. Additionally, it has increased the number of saved lives and contributed to a more sustainable healthcare (MedTech Europe, n.d.).

2.1 Mobile phone During the last 20 years, telecommunication and information technologies have emerged quickly, and one main reason is due to the high increase of social media users (Licoppe & Heurtin, 2001). It generates new opportunities, which has led to that first-time users of mobile phones are getting younger in ages. According to a survey made by Licoppe and Heurtin (2001), the main benefits of phones are to be reachable and to maintain relationships with relatives and friends. By the end of 2019, the number of mobile phone users worldwide was over 6.8 billion (O’Dea, 2020). Phone calls and text messaging are no longer the only area of use, since reading news and watching entertainment as well as social media have attracted more people to use mobile phones. It has contributed to the fast growth of mobile usage (Rice & Katz, 2003). To develop high-quality applications and to ensure that the phone is easy to use, the word usability is a key element for companies when improving the technology. When developing new mobile phones and applications, companies should focus on three quality characteristics to measure usability; effectiveness, efficiency, and satisfaction. By improving the usability, the mobile phones will have higher quality as well as more applications that facilitates people’s daily lives (Hussain & Kutar, 2009).

2.2 Health services Mobile health services, also called mHealth, are health services that are accessible through a mobile phone or any other personal digital assistants (Kayingo 2012). Mobile technology has transformed the healthcare and provides patients with the opportunity to receive different healthcare services easier (Blake, 2008). The mHealth innovation has improved the medical treatment as well as contributed to economic benefits for the healthcare sector (West, 2012). The adoption of mHealth initiatives has been important globally, were the main reason for the

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development is considering the lack of well-functioning care in developing countries (Kayingo 2012). Furthermore, the increase of mobile phone users in the world, and especially in developing countries, is an important reason for the fast development (Kayingo 2012). Mobile phones have transformed the healthcare and it is, for instance, possible to send pictures or to perform video-calls with specialized doctors located in different countries. It could be valuable for people in rural areas or when there is a need for more doctors than just one (Kayingo 2012). Additionally, it has facilitated for patients with chronic diseases since it is possible to have online consultations, and they do not need to visit a hospital (Steinhubl et.al., 2013). Furthermore, patients, and especially elderly people, could be reminded by their mobile phones to take their dose of medicine. The increased use of mHealth by patients has saved time and money for hospitals and doctors (West, 2012). Additionally, a study made with nurses showed that 16 percent of mobile equipment users have minimized the errors in-clinic treatment (West, 2012).

2.3 MedTech in developing countries Mobile technology has transformed the healthcare and generates important improvements and positive effects on societies. Of all modern technologies, mobile phones are the most used throughout the developing world (Duncombe, 2014). Innovation in applications has made it possible to receive higher quality in healthcare and improve the overall health systems (Kahn et.al., 2010). However, developing countries do not have the same opportunities and high quality on their healthcare, which is related to different reasons; the infrastructure is limited, lack of hospitals as well as resources, and the healthcare workers do not have the right experiences or knowledge (Kahn et.al., 2010). The amount of people that needs specialized doctors has grown rapidly in developing countries (Kahn et.al., 2010). Therefore, the option of self-care has become important. Moreover, the usage of mobile phones and access to the internet is high in developing countries, meaning the opportunities for mHealth are positive. People living far away from hospitals could receive information regarding diseases, diagnostics, and other important news concerning their health situation online. (Blaya et.al., 2010). It would facilitate for the population, since it gives them access to specialized doctors and the healthcare opportunities would be more equal (Blaya et.al., 2010). Africa is a developing continent where curiosity regarding mHealth has arisen (Aranda-Jan et.al., 2014). There is a high burden of diseases, where mHealth could have the potential to prevent them from developing further. Hence, several projects regarding implementing the technology have emerged and since a great amount of the population owns a mobile phone it would make the implementations smoother (Aranda-Jan et.al., 2014). The main benefits of mHealth are; improved communication with citizens in rural areas, decreased costs for patients, easier to book appointments, and improvements in data collection (Betjeman et.al., 2013). Additionally, the population has shown an interest and acceptance in using mobile phones for healthcare services (Folaranami, 2014). However, a potential disadvantage with mHealth, is that a well-developed infrastructure is needed in order to access reliable networks. (Aranda-Jan et.al., 2014) Several African countries face challenges regarding their infrastructure

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development. However, mHealth implementations have improved parts in the health sector, but there are still several areas to improve (Aranda-Jan et.al., 2014). To develop the healthcare in developing countries, international cooperation is crucial (Syed et.al., 2012). By implementing innovations from developed countries in developing countries, the cooperation could contribute to more effective solutions and improved healthcare. (Syed et.al., 2012). As yet, Africa and Europe have established a partnership between hospitals, which has been successful regarding providing services to remote areas by using accurate healthcare technology. Hence, there is high potential for partnerships and the transfer of knowledge from both parts could generate new innovations and solutions to problems. However, it is also important to understand that there is no guarantee that the existing knowledge and innovations in developed countries are appropriate for developing countries. (Syed et.al., 2012).

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Chapter conclusion To conclude, mobile phones are one of the fastest developing innovations and they are used globally. Its development has made it possible for people to use the phone for other purposes than just calling or texting. A recent innovation is mHealth, which provides patients with the opportunity to perform video calls or other online consultations with specialists. It has led to advantages, such as cost savings and increased efficiency in hospitals and other health centers. Moreover, the mobile technology and mHealth have emerged in developing countries, where it has contributed to improvements within healthcare. There is a potential for the current mHealth in Africa to develop further and to be improved by embracing partnerships and collaborations with other countries.

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3. Theoretical framework The chapter presents the theories that have been applied when analyzing the collected material, which in turn has generated valuable inputs in order to answer the report’s research questions.

3.1 Bottom of the Pyramid The Bottom of the Pyramid (BOP) is used as an approach when investigating environments with potential for innovation (Prahalad, 2011). It refers to the lowest socioeconomic segment in the world (Ramdori, 2015). There are different signatures of a BOP market; each individual lives on less than $2/day, it is poor access to education and knowledge, the communication and transaction are in both formal and informal market economy, and lastly, they are extremely open to embrace new technologies and innovations (Prahalad, 2011; Subhan et al, 2017). According to the definition, the total BOP segment is about four billion people (Ramdori, 2015). In other words, the market is approximately half of the world's population. In order to support development and avoid exclusion from formal markets, the BOP markets are highly in need of innovative products. It would in turn generate better living conditions for the populations as well as generate economic growth for the developing country (BoP Innovation Center, 2010). Additionally, low-income segments have unfilled needs that innovative products could improve and generate service to people living in poverty (Ramdori, 2015). The growth and innovation of BOP are strongly connected to the development and adoption of cell phones and it is important to be present in these markets in order to accelerate in most sectors (Prahalad, 2011). It could be challenging for companies to do business in these markets since they diverge from developed markets. Therefore, organizations have to be careful when understanding the characteristics of a BOP market. (Ramdori, 2015). However, it exists divided opinions whether it is fair for businesses to generate profit in a market, where the customers are among the world’s poorest. Critics mean companies should not have a business focus, but rather a customer focus- and a willingness to improve the populations’ lives when entering a BOP market. In other words, it should not be a source for future organisational growth and a way for companies to increase their reputational value. (Simanis, 2013) A criticism of the BOP concept is coming from professor Karnani, who states that by reaching the poor will make them take decisions that are not lying in their own self-interest. Hence, it is seen as unethical and will contribute to negative impacts on the public welfare. (Karnani, 2007) On the other hand, C.K. Prahalad, who is a supporter of the BOP concept, argues that by penetrating new markets it will create new jobs and generate important income opportunities. As aforementioned, these markets are in high need of innovative products as well as new technology that will create economic growth and influence the countries’ developments. (Prahalad, 2011) According to C.K. Prahalad (2011), a profitable innovation in a BOP market is about working within constraints, which he refers to as “the innovation sandbox”. It is considering:

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1. Identification of the need, where initiatives in the BOP market carefully observe the emotional needs of the poor

2. Designing a product or service that is aligned with the global safety standards 3. Ensuring the product or service is scalable, meaning all the parts of a business have to

be considered 4. The product or service is affordable and at the same time delivers profit

The most important as well as complicated part for companies is to align the global standards with local preferences. Moreover, all BOP markets are different from each other and it does not exist one single solution that works in the same way for all of them. Hence, it is of importance to create deep understandings of the citizens’ lives and daily habits (Prahalad, 2011).

3.1.1 The 4As in a BOP market A helpful framework for companies to use when entering a BOP market is the 4As. The 4As framework consists of the segments; Awareness, Access, Affordability, and Availability (Prahalad, 2011). Awareness is related to the product or service and its purpose is to receive the populations’ attention. They have to understand the product’s value and how it will facilitate their daily lives (Prahalad, 2011). It could be done by focusing on sales, marketing development of advertisements, and distribution channels or by having representatives on schools and universities in order to create brand awareness (Anderson et al., 2007). The access is focusing on creating equal opportunities for all individuals to use the product or service and hence, it would not matter if you live in a remote- or urban area. (Prahalad, 2011) Moreover, the product should be affordable, which also is the most complicated segment to achieve, since the quality of the product has to be high while, at the same time, keeping the price low (Prahalad, 2011). The majority of the consumers in BOP markets does also have low incomes, meaning they are sensitive to price and reflect carefully when spending money (Anderson et al., 2007). Lastly, the product has to be available for the whole population in order to establish a strong reputation and a loyal customer base (Prahalad, 2011). It may be difficult to overcome, since unlike developed countries, there are limited distribution channels in BOP markets (Anderson et al., 2007). To summarize, the report has followed Prahalad’s point of view of the BOP concept. It has been of relevance since the report is investigating how a MedTech company from a developed country could improve the access, availability, affordability, and awareness to reliable healthcare in developing countries. It could be done by supporting the citizens with medical advice online, where the idea is not to deliver profit but instead to improve the living standards for the populations. The conditions of the specific case countries are aligned with the BOP’s definition of developing countries. Moreover, to develop knowledge in the area and to ensure the innovation (i.e. MedTech app) has the best prerequisites to enter a BOP market, the 4As as well as the innovation sandbox have been seen as valuable. When performing the interviews and thereafter, structuring the empirics and the analysis section the already defined themes (i.e.,

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awareness, access, affordability, and availability) have played an important role. A more in-depth explanation is presented in the Methodology (Ch 4).

3.2 Innovation management

3.2.1 Diffusion of Innovation Diffusion of Innovation is a theory by Everett Rogers and refers to how well people adapt to changes in the environment. Rogers has identified five different kinds of innovation adopters, they are; innovators, early adopters, early majority, late majority, and laggards. Additionally, he has estimated the percent ratio related to each category. (Rogers, 2003) Innovators adopt a change quickly and they stand for approximately 2,5 % of the population. Their characteristics are described as risk-takers, motivated for change, appreciation of new technologies, and open-mindedness, meaning they understand the importance of the change. The early adopters stand for 13,5 % and aims to be the trend-setters. They are open to changes and does not need to be convinced. The early majority and late majority are the two categories that account for the majority of the percentage, more specifically 34 %. The most important difference is that the early majority adapt to changes before the average person, whereas the late majority is more skeptical. However, both categories need evidence that proves the benefits of the innovation and that it has been adopted successfully by others. The fifth category, the laggards, stands for 16 % and is highly skeptical and suspicious against the innovation. They need more evidence when being convinced the change will improve their current situation. (Kaminski, 2011) Figure 1 presents Rogers’ theory of the diffusion of innovation.

Figure 1: Diffusion of innovation (Rogers 2003)

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The model has been a benefit when understanding how the population in developing countries would react to the new innovation. In this case, it opens up for totally new markets within the countries, and hence, by foreseeing the reactions it is possible to outline a strategy on how to respond to them.

3.2.2 Innovation Process Model It is important for a company to understand how innovation should be managed and organized to become successful. Tidd and Bessant (2013) have identified the key steps that need to be taken into consideration when introducing the innovation. Figure 2 presents the innovation process model.

Figure 2: Innovation Process Model (Tidd & Bessant, 2013)

The first step is to search the environment, both internally and externally, in order to understand potential threats and opportunities related to the change. Secondly, a selection process of the options that was found in the search phase takes place, which also includes a development of arguments and explanations for each option. The third step is the implementation, where the company needs to identify how the innovation should be launched to the market of relevance. In addition, tools and techniques to make it possible should be identified. Finally, value should be captured from the innovation by learning and developing knowledge. It is required in order to maintain their position or gain market share, as well as make successful improvements. (Tidd & Bessant, 2013) The model was useful for the report in order to understand the process of launching or implementing a new innovation (i.e., MedTech app) and hence, to be able to declare the outcome of an action. It has been important to investigate how to successfully bring the innovation to developing countries. Firstly, a careful research process about the countries was necessary to understand the different healthcare systems as well as the current health status among the population. Secondly, the characteristics of each country were investigated more in-

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depth to develop a greater knowledge of the innovation’s capability to succeed. Thirdly, possibilities to enter the healthcare market were identified in order to evaluate the options and hence, be prepared for potential pitfalls and barriers. Lastly, a predicted vision of future scenarios was carried out in order to understand how the innovation could capture value in a developing country. In addition, it may need to be adjusted with time, since it will be noticed how well adapted it is used by the population and government.

3.2.3 Rationalist and Incrementalist strategies Rationalist and incrementalist strategies are of importance for the purpose of the innovation strategy. The rationalist strategy is influenced by the military and consists of three steps; describe and understand the environment, determine a course of action, and carry out and decide the course of action. It is a linear model that intends to help firms to understand trends in a competitive environment, be prepared for future changes, focus on longer terms, and finally, to ensure coherence. (Tidd & Bessant, 2013) The incrementalist strategy assumes that it is impossible to understand changes, which means the future can be predicted to a limited extent. Therefore, the strategy needs to be adapted as soon as new information and understandings arise. The three steps for the process are; make changes, measure and evaluate the effects of the changes, and lastly, adjust them if necessary. (Tidd & Bessant, 2013) The report’s approach to innovation is based on an incrementalist strategy since it currently does not exist a market for the innovation in the countries of relevance and the focus is on the customers rather than on a competitive market as a rationalist strategy has. Instead, the findings are grounded on predictions of how the innovation could generate a more equal and higher quality care. The investigation may change path and is flexible during the process, which depends on the information of the collected material from interviews as well as the secondary sources. Therefore, it is not recommended to follow a linear model as a rationalist strategy promotes, since changes and reflections are needed along the way.

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Chapter conclusion To conclude, the BOP market consists of approximately four billion people, which is half of the world's population. Clearly, it exists divided opinions about the BOP concept and the report has taken on professor C.K. Prahalad’s point of view, meaning new innovations could fulfill the population’s needs and improve their living situations. However, in order to have the best prerequisites when entering the market, it is beneficial to understand “the innovation sandbox” as well as, to pay attention to the 4A framework (i.e., awareness, access, affordability, and availability). The 4As would contribute to an understanding of the market, which is needed to overcome potential challenges. Awareness is related to the product and how to reach the population’s attention and make them understand the value of the product. If the company understands how people will adapt and react to the innovation, they can improve the awareness and implement strategies of how to overcome the challenges. Access is focusing on creating equal opportunities for all individuals, which is important for developing countries since a large part of the population lives in remote areas. Lastly, the product should be affordable, of high quality and keep prices low in order to be available for the whole population. It may be difficult to achieve, but with in-depth investigations of the market and with help from local organisations it would develop important understandings and knowledge. Additionally, “Diffusion of Innovation” is a beneficial model to use to understand the innovation’s development, and “The incrementalist strategy” is focusing on the customers’ adoption and prepares the innovators to change the product due to the responses. It is of importance when implementing an innovation, since reflection and adjustments are beneficial during the implementation process of a new idea.

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4. Methodology The chapter presents how the report has been executed as well as how the obtained results and findings have been interpreted, more specifically; the research process, the research design, the data collection, and the data analysis. The chapter concludes with a discussion about the quality of the research and ethical considerations.

4.1 Research process The research has been executed during a period of five months and to outline and follow a research strategy has been important in order to understand the next step and how to continue with the research. Figure 3 presents the different phases of the research process and their connections.

Figure 3: Research process

During the first phase, which was the thesis development, a discussion with the case company was important to understand their desires and also to develop the problem formulation, the purpose, and the research questions. Thereafter, the data collection process began, consisting of both primary- and secondary sources, with the purpose to identify current research within the subject as well as a research gap. As shown in Figure 3, phase one (i.e., thesis development) and phase two and three (i.e., semi-structured interviews and secondary sources) was an iterative process. It means that after conducting the secondary sources, as well as, performed the semi-structured interviews, new insights and information arose, and the problem formulation changed form. The finalization of the problem definition, as well as the research questions, took place when all the interviews had been conducted. It is possible, since the research process is considered as an exploratory research, which is explained more in-depth later on in this chapter. However, when the data collection was done, the research process entered the fourth phase (i.e., data analysis). It consisted of a coding process, and since the themes (i.e., the 4As) already were decided, this phase consisted of identifying relationships. The analysis of the data leads to the last phase where the research questions were answered. During the whole process, the

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report has been developed as new information has arisen, and hence, it is seen as an iterative process.

4.2 Research design

The research design and strategy is presented below, which has been divided into three segments; (i) Research approach, (ii) Case study and thesis development and (iii) Theoretical framework i) Research approach When identifying the right approach for the research, two different kinds were evaluated; (1) Conclusive research, and (2) Exploratory research.

1. Conclusive research The research design is appropriate to use when the purpose of findings is to reach conclusions or to make decisions. To be able to conduct such a study, the research targets and the sources for data collection have to be clearly stated. Usually, conclusive research processes require quantitative methods for the data- collection and analysis. (Dudovskiy, 2018) The approach was considered as relevant since the next step after presenting the report’s findings is to take action, more specifically; to decide if it exists opportunities for MedTech companies to enter BOP markets in order to improve the current healthcare sector.

2. Exploratory research An exploratory research is investigating the research questions, where the purpose is not to deliver any conclusions or specified answers. It is mainly used for research fields that are not clearly defined and is providing the field with more developed understandings and insights. Moreover, the researcher may need to change path and strategy due to the content of the collected data. The most used and appropriate method for collecting data in an exploratory research is semi-structured interviews. The advantages of exploratory research is above all its flexibility and adaptability to change. Moreover, they create the basis for future research in the field. However, these types of studies is usually perceived as qualitative, meaning it could be difficult to reduce biases due to the low amount of participants in the data collection process. Hence, it is not appropriate to generalize the findings of an exploratory research to a wider audience. (Dudovskiy, 2018) Considering, the research’s objective, where the markets of relevance are unexplored and Medicheck is one of the first to investigate the opportunities to provide them with online medical advice, the report is perceived as an Exploratory research. Hence, it is aligned with the definition of exploratory research, “a problem or opportunity that has not been studied more clearly”. (Saunders et al, 2012) Moreover, quantitative methods for data collection were considered as irrelevant, since the focus was on creating an understanding from a firm's perspective. Therefore, the report could be described as qualitative, which also is aligned with the aforementioned explanation of exploratory research, where the data collection has been based on semi-structured interviews and secondary sources. The focus has been on collecting

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information from carefully selected stakeholders, rather on the amount of interview participants, which also goes under the definition of a qualitative report. In addition, the report is taken on an inductive approach, since it is used to explore and investigate an area where limited written resources exist. During the process, patterns have been identified from observations and the direction of the report’s development has been decided along the way. In other words, the process is not decided in an initial stage and only, generalizations can be drawn from the empirics. It is not until the research is completed, the actual findings and answers can be presented. (Thomas, D.R., 2003) This approach has been applied, due to the unexplored investigation area and changes have been relevant along the development. ii) Case study and thesis development The case company of the thesis is the healthtech company, Medicheck. They are located in Stockholm, Sweden, and provide patients with expert online medical advice by using video calls and messaging on phones, tablets, or computers. Only qualified specialists in both chronic diseases and temporary problems are admitted to interact with the patients, in order to deliver professional healthcare services. Moreover, Medicheck is one of the first Swedish healthcare organisations that are deep-diving into the field of exporting digital care services and the research is proceeding from them when investigating how a MedTech company could enter a BOP market to impact the 4As (i.e., awareness, access, availability, and affordability) to reliable healthcare. Hence, Sweden is defined as the developed country in this thesis. The selection of the thesis’s developing countries, was a quick process, since the case company had already made a decision. Local organizations in two developing countries in Africa, namely; Angola and Nigeria, had reached out to them since a need for their services or similar had been identified. However, to involve the researchers in the process, it was not decided if both the countries should be of interest or just one. Moreover, the research questions were not declared and the researchers had the opportunity to create the direction of the thesis. The procedure was seen as an iterative process, since the research questions as well as the methods and theories to use when answering them, changed with regards to different insights from participants (i.e., classmates, professor, and supervisor) at the seminars at KTH the Royal Institute of Technology and supervisors at the case company, Medicheck. After conducting existing written literature about the case countries, it was stated the field of interest (i.e., healthcare sector) was similar and the researchers decided to focus on both of them. The introduction to the Bottom of the Pyramid (BOP) came from the professor, Cali Nuur, and regarding the characteristics of the case countries, it was stated that they could be identified as BOP markets. Hence, the purpose of the report was defined as:

The purpose of the report is to investigate developed countries’ possibilities to implement digital healthcare services in developing countries.

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Moreover, the iterative process did also form the two research questions:

RQ1: How could MedTech companies from developed countries improve the access, availability, affordability, and awareness to reliable healthcare in developing countries by

introducing online medical advice?

RQ2: What are the possibilities for companies from developed countries to enter the healthtech market in developing countries?

The research questions have been in top of mind during the report’s development and they did also form the dialogues with each interviewee, which is detailly explained in the Data Collection (Ch 4.3). iii) Theoretical framework In exploratory research, it is recommended to use theoretical frameworks that will guide its development and they are based on existing knowledge and testing in practice. They are important to reduce biases and to avoid affection by human nature (i.e., values and beliefs). (Adom et al., 2018) It exist three key advantages with theoretical frameworks;

● To help define the report’s key concepts (i.e., analyzing the findings) ● To evaluate, adopt and/or synthesize appropriate models ● To declare any assumptions (Adom et al., 2018)

Professor S.N Imenda (2014) argues that a research with no theoretical framework misses to develop an accurate direction during the process as well as of the findings, since the theoretical framework supports the research’s problem formulation when finding the solutions. Moreover, to be able to select the theoretical framework, the researcher(s) has/have to understand the problem and the purpose of it. If the selection process is poorly done, it could mislead and confuse the research(s), rather than guiding the process. (Adom et al., 2018) In this case, the theoretical framework shifted form after the first meeting with other students, the professor, and supervisor at KTH the Royal Institute of Technology. At first, other models were of interest, such as; the SWOT analysis and the PESTLE model. They were seen as relevant at that time, since the focus would partly have been on market entry strategies. However, considering the fact that it was not yet declared if it existed any opportunities for MedTech companies to introduce their services to developing countries, the models were concerned as irrelevant for the report. They could be of interest for future research if a decision to enter any of the markets are made. Instead, the selected models should support the research development by guiding it through the process, while in the same time investigate potential answers on the problem statement. Hence the models used for the report are aligned or correlated with; 1) the Bottom of the Pyramid (BOP) and 2) Innovation management

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1. The Bottom of the Pyramid (BOP) The model has been important in order to understand and develop knowledge within the industry of interest (i.e., the healthcare sector) in two in developing countries. Considering the conditions of the investigated countries (i.e., Angola and Nigeria), it was concluded they were aligned with the definition of a BOP market. As described in the Theoretical Framework (Ch 3.1), there exist divided opinions regarding developed countries attempt to create businesses in such markets. The report is undertaking C.K. Prahalad’s point of view due to the purpose of Medicheck’s initiative; the goal is not to deliver profit, but rather to increase the populations rights and possibilities to receive the healthcare services they deserve and hopefully, be able to positively influence the countries’ welfare and living conditions. Moreover, Prahalad believes BOP markets are extremely open for new innovations as well as technologies. It will generate new job opportunities and an economic growth, which in turn will have an important impact on the infrastructure- and other industries’ development. However, Prahalad states it is more difficult to succeed in a BOP market, than in any other market. Hence, it is beneficial to combine the BOP with “The 4As Framework” (Ch 3.1.1), and “The Innovation Sandbox” (Ch 3.1). Hence, to be consistent and to be able to apply the BOP model in a correct manner, the report has followed Prahalad’s suggestion. The 4As (i.e., awareness, access, affordability, and availability) have played an important role, since they have been used as the themes for the report. Their contribution and how they have been used are detaily described in the Data Analysis section (Ch 4.4).

2. Innovation Management By considering the BOP’s contribution when guiding the research through a selected industry in developing countries, the report had to be complimented with models that affected the innovation of interest (i.e., MedTech app). It was important in order to understand what to consider if it should be implemented and how new initiatives would be adopted by the populations. The theories that are corresponding to Innovation Management and that are used for the research are; “The Diffusion of Innovation” (Ch 3.2.1), “The Innovation Process Model” (Ch 3.2.2) and “Rationalist or Incrementalist Strategies” (3.2.3). The former is developed by professor Everett Rogers, and one of his publications is named after the theory. The two other theories are originated by the professors, Joe Tidd and John Bessant. Regarding all the professors’ expertise areas and high competencies within technology and innovation management, the theories were considered as trustworthy to use when analyzing the findings.

4.3 Data collection The information has been obtained by collecting data through primary and secondary sources, where the most important ones have been semi-structured interviews. The aim is to keep them informal, where the interviewees are comfortable with speaking freely and are able to share their main thoughts and opinions about the subject. The researcher has specific topics in mind for the discussion but is keeping the interview flexible in order to collect a great variety of information. (Adams, 2015) To be able to receive the help needed to leverage a reliable report, there have been ongoing dialogues with the representatives at the case company, Medicheck,

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as well as with the assigned supervisor at the Royal Institute of Technology. All of them have delivered valuable inputs and information when executing the report. Semi-structured interviews The primary sources used in the report are semi-structured interviews. The purpose of the interviews was to develop greater knowledge of the healthcare sector in the case countries, Angola and Nigeria. It was of importance to be able to understand if it existed a need for developed countries to implement digital healthcare services in Angola and Nigeria, and also if the locals would make use of it. Moreover, the interviews were highly valuable in order to identify the possibilities to enter the healthtech market in developing countries. To be able to collect a wide range of information, organisations within different industries as well as people with diverse expertise areas participated. In that way, a great variety of perspectives could be obtained. Figure 4 presents the mapping of stakeholders used for the report.

Figure 4: Mapping of stakeholders

In the research process, four different sectors have been taken into consideration as presented in the mapping of stakeholders; the users, research fields, regulators, and competition. However, the report is focusing on three of them; the users, research fields, and the regulators. As aforementioned the research fields have been the most important to explore in order to gather different knowledge and to be able to answer the research questions in the best way. The research fields used for the report are; healthcare, mobile phone- and telecommunication development, developing countries, and digital services, where the performed interviews are covering healthcare, mobile phone- and telecommunication development, and developing countries.

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An overview of the respondents is in Table 2. Table 2: Representation of interviewees

Number Company Role Date Length 1 Medicheck CEO 25/2-20 1.5 hours 2 Medicheck CMO 25/2-20 1.5 hours

3 CGI eHealth strategist 1/3-20 50 min 4 Appy Saùde Business developer 11/3-20 1 hour 5 Oakstone Partners Founder and Managing partner 15/3-20 1 hour

Considering, the report’s qualitative approach, the focus was on performing valuable interviews with stakeholders in different fields, rather than on the number of interviews. Moreover, the selection of interviewees was done together with the case company, which also were one of their desires due to the report’s investigation area and to ensure control over the report’s content and development. A more in-depth explanation of the interviewees and their contributions is described below. The numbering is following the chronological order of the held interviews.

1. Medicheck The interview was held with the CEO at the case company, Medicheck, where the purpose was to declare the reason of the research. The respondent shared information regarding the company’s business, such as; their services and values. The interview was important in order to understand Medicheck’s capabilities to enter a BOP market as well as the background of the initiative. Thereafter, the report could identify which point of view to follow that exist for a BOP market. As described earlier in this chapter, it exist several and divided opinions about companies aiming to enter a BOP market. Therefore, the interview was important in order to select the correct point of view (i.e., Prahalad’s perspective), which also formed the direction of the report’s development.

2. Medicheck The respondent is working as the CMO at the Case company, Medicheck, and did also contribute with valuable information about the company. Moreover, the respondent provided inputs regarding their relationships with local organisations in each case country (i.e., Angola and Nigeria) as well as how to reach the awareness in the specific countries. The CMO had ongoing dialogues with local connections and could therefore also deliver information regarding the populations’ needs and desires.

3. CGI The respondent is working as a eHealth strategist at CGI and has performed several projects within the area. The desires are to transform the healthcare sector around the world by introducing new, innovative solutions. The interview was valuable, since it generated important insights regarding a Swedish company’s opportunities to enter a totally new market and what

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to consider in the marketing procedure. It did also deliver general inputs regarding the healthcare sector worldwide and its ongoing, digital transformation.

4. Appy Saùde The respondent is working as a business developer at Appy, which is a healthtech app available in Angola. The app is working as a ecosystem between patients and hospitals as well as pharmacies and the users are able to receive important information about health centers through the app. The app and its technology is originally developed in Sweden, but is now perceived as Angola’s second most used app. The interview was seen as valuable, since Appy and Medicheck have several similarities. They are both MedTech apps, that are/aims to target a BOP market. It was highly valuable to take part of the business developer’s thoughts on the implementation process as well as on the population’s reactions to it when answering the research questions.

5. Oakstone Partners The interview was held with the Founder and Managing Partner of the company, Oakstone Partners. The respondent is originally an economist and a former investment banker but decided early in the carrier to do something different. Oakstone Partners is an advisory firm that is focusing on creating ethical- and social impact by promoting initiatives that are aligned with their values and believes, where the aim is to address the Sustainable Development Goals (SDGs) in all of them. They have done several projects in central and south America, especially in Brazil, with focus on women’s empowerment, healthcare and financial inclusion. However, the contacts in Africa are many, for example; with several African governments and they have identified a need for new initiatives in the healthcare sector. Therefore, the focus is on Lagos in Nigeria, due to the country’s size, language and poor care services. The interview was important since the respondent has high competence regarding BOP markets, born and raised in one (i.e., India) as well as had performed several projects in these markets, which generated valuable findings. The respondent provided information regarding the population’s needs and habits as well as a business possibility to enter the market and what to consider during the process. Attention: Due to the circumstances with the outbreak of the Coronavirus COVID-19, two of the interviews (i.e., 4 and 5) had to be performed digitally. Moreover, one interview with the embassy in Angola as well as with a contact at Business Sweden had to be cancelled. Their focus shifted and they had to prioritize and handle unpredictable occurrences. To facilitate the work and to guarantee to not miss any important information, questions were defined in advance, presented in Appendix A. However, they were only used as inspiration and have been adapted to the specific interviewee. Before approaching the interviewees, a careful discussion between the researchers and the case company was important in order to reach out in a correct and ethical manner. The discussion lead to an outline for a structure for a contact template, which was useful when contacting the participants and the template is presented in Appendix B. Moreover, the template was important in order to collect relevant information by following its defined topics and questions.

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Secondary sources The secondary sources used in the report are based on literature, reports, journals, and online sources. Their purpose was to deliver important information for the readers in order to update them about the subject before letting them take part in the results and findings. Usually, it is structured as a summary of the collected publications and literature. (The Writing Center, 2020) It was also necessary for the researchers to take part of the information, since it developed understandings and knowledge of the subject, such as; the current state of MedTech technologies as well as its development and transformation within the healthcare sector. The secondary sources for this report contain information about MedTech related to mobile phones, healthcare, and developing countries and they are presented in the Research Context (Ch 2). Moreover, the secondary sources include information about the developing countries, Angola and Nigeria, more specifically; their healthcare system, health status, collaborations for health, and infrastructure development. It is described in the Case descriptions (Ch 5) and was defined as relevant to be able to develop in-depth knowledge regarding the current condition of each country. Additionally, the secondary sources were beneficial to create and perform successful interviews, since the researchers could guide the interview in the right direction. It was valuable to be able to create a report with high quality and accurate recommendations for future work. In addition, when collecting the information, reliable online sources as well as written literature have been used. The online sources were mainly academic- and professional journals and reports created by people and organisations with high expertise within one of the research areas (presented in Figure 4) and reports done by Business Sweden or by the embassies located in Sweden, Nigeria, and Angola. Table 3 presents examples of secondary sources that have been used for the chapters; Research Context and Case descriptions. Table 3: Examples of secondary sources

Title Type Content Authour(s) Year Angola business climate Report The business climate in

Angola Business Sweden 2020

The changing patterns of the Nigerian fast-moving consumer goods market

Report The consumer goods market in Nigeria

Business Sweden 2019

Digital Health: Scaling Healthcare to the World Rivas

Journal Digital health in developing countries

Homero, & Wac, Katarzyna

2018

Nigeria - Country cooperation strategy

Online Possibilities to do business in Nigeria

World Health Organization (WHO)

2018

Angola - Country cooperation strategy

Online Possibilities to do business in Angola

World Health Organization (WHO)

2016

How mobile devices are transforming healthcare

Journal MedTech’s contributions to the healthcare sector

Darrell West 2012

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4.4 Data analysis In order to analyze the collected data correctly a coding process has been important. The process is originally divided into different steps; sampling, identifying themes, creating codebooks, defining relationships among the themes to be able to divide them into categories, and lastly, testing them with the empirics (Denzin et al., 2000). In this case, the themes were already identified since the report has followed the 4As framework when applying the BOP concept, which means the most important parts of the coding process were the sampling and to define relationships. The sampling part was related to the selection of the interview participants, which was done by analyzing each individual's potential to contribute with valuable inputs when answering the research questions. Chapter 4.3 is explaining each interviewee’s contributions and why they are considered as relevant for the research. Moreover, each interview was held by two researchers and they were all transcribed to able to take part of the collected information from all interviews and to ensure to not miss important insights. It is when audio-taped material is transferred to written text, which in turn facilitates for the researchers when observing and analyzing the data. It is especially used in a qualitative research, due to the modest number of interviews. (Denzin et al., 2000) As mentioned, the defined themes derived from the 4As framework and they are; access, availability, affordability, and awareness. According to professor Prahalad, it is recommended to pay attention to them when focusing on a BOP market and each segment is more detailly explained in the Theoretical Framework (Ch 3). However, to be able to inspect the transcriptions and to organize the content from the interviews in the defined themes, an analysis process begun. It is suggested to perform the task by carefully, line-by-line reading the transcriptions, and to search for specific actions, assumptions, and consequences (Denzin et al., 2000). Hence, proofreading and discussions were repeating processes in order to carefully put the information of relevance into context and to find correlations with the themes (i.e., the 4As). Thereafter, the themes formed the structure of the Empiric chapter and the content defined as valuable was integrated into the report by combining quotes from the respondents together with background information of their experiences and businesses. While analyzing the collected material from the interviews, the researchers could also identify linkages and relationships with findings from the Case descriptions (Ch 5). It generated a higher degree of knowledge, and to combine the findings from the primary sources with the ones from the secondary sources, strengthen the report’s reliability. Thereafter, the final findings and the theories (i.e., BOP, Innovation Sandbox, Diffusion of Innovation, Innovation Process Model and Rationalist and Incrementalist strategies) were used together to be able to answer the research questions.

4.5 Unit of analysis When designing a research project, it is important to consider the unit of analysis as well as the unit of observation. The unit of analysis is related to the report’s main focus and what to achieve at the end of the investigation (DeCarlo, 2018). On the other hand, the unit of observation is

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the items that are observed and used when collecting the data of interest. The purpose is to understand and integrate different perspectives about the report’s unit of analysis (DeCarlo, 2018). In this case, the unit of analysis is a MedTech company’s abilities and possibilities to enter the healthtech market in two developing countries, Nigeria and Angola. However, in order to gain in-depth understandings of the subject, different perspectives have been needed. Hence, the unit of observation has firstly concerned an individual perspective by investigating the countries’ populations. It has been important when learning more about their habits, capabilities, and needs. The knowledge has been gained by interviewing people working for established organisations in each country, meaning they have valuable information to share about the locals living conditions. Secondly, a firm perspective has also been concerned by collecting business-related information from the interviewees. It has been done from the same individuals as aforementioned, the case company, and from an eHealth strategist that has done several projects within the field. Thirdly and lastly, a country perspective has been concerned in order to understand the current healthcare systems, how the initiative will be adopted by individuals from different classes, and how to make the access and availability as equal as possible. It has been done by interviews and secondary sources such as literature and articles developed by reliable organisations and experienced individuals.

4.6 Quality of research By using primary sources for the research, it increases the quality of the report. All the participants in the interviews are concerned as reliable, since they have several years of experience within their field (presented in Ch 4.3). To increase the quality further, different research fields (presented in Fig 4) have been investigated, which have delivered more than one perspective. Moreover, in order to minimize the risk of misunderstandings or forgetfulness, the interviews were transcribed and held by two researchers. Thereafter, the coding process was of relevance to interpret the findings and results correctly, which generated a more accurate report. However, in order to further increase the report’s quality, more interviews could have been done with people or organisations in the case countries (i.e., Angola and Nigeria). It has been tough to reach out to them and we believe that the experiences and knowledge of the ones that have participated are concerned as highly trustworthy. Furthermore, the circumstances with the outbreak of the Coronavirus COVID-19 negatively affected two of the planned interviews, since they had to be cancelled. The secondary sources used in the report are collected from reliable online gates or from organisations’ websites, such as embassies or Business Sweden. Examples of secondary sources are presented in Table 3. To be able to reach the most relevant ones, specific keywords related to the topic, such as; developing countries, eHealth, MedTech, mobile phone innovation, telecommunication development, digital services, etc., have been important. It made it possible to narrow the scope and to only collect the sources that were aligned with the report’s investigation area. However, it was difficult to find new information regarding one case country’s (i.e., Angola) number of people who lives a life in misery. Hence, it is important

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to consider that when observing the information, since changes may had occur up to now. Otherwise, the report has tried to not collect information that would be misleading or irrelevant, since it would decrease the report’s quality. Furthermore, some literature and articles have been recommended by professors at the Royal Institute of Technology. The professors are Emrah Karakaya, offering the course “Research Methods in Industrial Engineering and Management” and Cali Nuur, offering the course “Industrial Transformation and Technical Change”. Both of them have a high degree of knowledge in their provided courses and their recommendations are considered as reliable.

4.7 Ethical consideration

During the research process, it has been important to consider potential ethical issues, where the Swedish Research Council’s requirements have played an important role. Due to the fact that the report is focusing on primary sources, it means there exists several aspects that have to be respected when gathering the information. According to the Swedish Research Council’s requirement on information, it is important that the interviewees are aware of the purpose of the interview and what the material will be used for. (Swedish Research Council, 2017) Hence, a contact template, visualized in Appendix B, was created to be able to be fully transparent with the respondents about the reason of the interview. Together, we created a model to use when trying to reach the people of interest for our project. In the introduction section of the model, it was specified why they would be relevant for the research and how they could contribute when developing findings and results related to the research’s investigated areas. It could also be referred to the Swedish Research Council’s requirement on consent, which means that an agreement from the interviewees is needed before using them in the study. (Swedish Research Council, 2017) By reaching out to the interview targets with the help of the contact template, the requirement is followed in accordance with its definition. Moreover, the qualitative research ethics are respecting the people participating in the study by understanding the importance of privacy and autonomy. In that way, harm and disappointments will be minimized. (Leavy, 2014) The Swedish Research Council’s requirement on confidentiality, highlights the importance of clarifying for companies or individuals that they do not have to be identifiable in the report. (Swedish Research Council, 2017) Regarding, the project’s investigation area, the healthcare sector, it is important to protect the interviewees since they may share personal- or business related information that is not appropriate for publicity. Hence, it was clearly declared that the participants’ identities or certain, shared information could be kept confidential.

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Chapter conclusion To conclude, the research has been executed during a period of five months and Figure 3 presents the different phases of the research process. Considering, the research’s objective, where the markets of relevance is unexplored and Medicheck is one of the first to investigate the opportunities to provide them with online medical advices, the report is perceived as an Exploratory research. Hence, it is aligned with the definition of an exploratory research, “a problem or opportunity that has not been studied more clearly”. The case company of the thesis is the healthtech company, Medicheck. They provide patients with expert online medical advice by using video calls and messaging on phones, tablets, or computers. The selection of the thesis’s developing countries, was a quick process, since local organizations in two developing countries in Africa, namely; Angola and Nigeria, had reached out to Medicheck. They had identified a need of their services or similar. The selected Theoretical Framework for the report is aligned or correlated with; the Bottom of the Pyramid (BOP) and Innovation management (i.e., “Diffusion of Innovation”, “Innovation Process Model” and “Rationalist and Incrementalist strategies”). The 4As (i.e., awareness, access, affordability, and availability) have played an important role, since they have been used as the themes for the report. The secondary sources used in the report are based on literature, journals, and online sources and examples of them are presented in Table 3. The primary sources used in the report are semi-structured interviews, and four different sectors have been taken into consideration during the research process, presented in Figure 4. Considering, the report’s qualitative approach, the focus was on performing valuable interviews with stakeholders in different fields, rather than on the amount of interviews. The selected interviewees are presented in Table 2. Moreover, the report followed a coding process, and the the most important parts of it were the sampling and to define relationships between the collected data and the themes (i.e., the 4As). To ensure a high quality of the report, the selected interviewees had several years of experiences in their field and all the interviews were transcribed and held by two researchers. However, due to the outbreak of COVID-19, two interviews had to be cancelled. Additionally, the secondary sources used in the report are collected from reliable online gates, organisations’ websites, such as embassies and Business Sweden, or from lectures held by professors at the Royal Institute of Technology. Lastly, the report has considered potential ethical issues during the research process by observing the Swedish Research Council’s requirements.

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5. Case descriptions The chapter presents in-depth overviews of the investigated countries, more specifically each country’s current health status, healthcare system, cooperation for health, and infrastructure development. Additionally, the chapter presents benchmark studies and previous research about other services that have been exported to similar markets.

5.1 Angola Angola is located in South West Africa with neighbors such as Namibia, Congo, and Zambia. It has a population of 29.78 million people and has a maximum width of about 800 miles (Thornton and Clarence-Smith, 2020). From the 16th century to 1975 Angola was a Portuguese territory and Portuguese colonial policies attempt to make the language the only spoken one in the country. It was used for all kinds of academia and the citizens who were not speaking Portuguese were excluded from all political initiatives. The historical incidents still have strong influences on the country and Portuguese is the main language in the capital city, Luanda, as well as in other parts of the country (Thornton and Clarence-Smith, 2020). However, it is not the only spoken language, since English and Afrikaans are also used nowadays (Thornton and Clarence-Smith, 2020). Moreover, the civil war has affected the country in many ways (Pacific Prime, 2020). It harmed the transportation infrastructure as well as the health-, academic- and social services system. The country’s damages have had negative impacts on its development and the lack of access to education has resulted in an unskilled population. Angola still has scars from the war, which makes it problematic to achieve economic- and educational growth (Pacific Prime, 2020).

5.1.1 Health status Angola is one of the most undeveloped countries in the world and more than one million of its population lives a life in misery (WHO, 2002). According to the World Food Programme (WFP), the same number of inhabitants are in urgent need of food assistance (WHO, 2002). Furthermore, the infant mortality rate is currently among the highest in the world, 51.6 deaths per 1000 live births, and the total life expectancy is 61.21 years (Knoema, 2017; Koema, 2018). There are many health hazards in Angola and diseases are the reason for more than 50% of deaths, where malaria and tuberculosis are the leading ones (WHO, 2016). The National Health Service (NHS), believe the health status and the existing problems mainly related to the following reasons;

● Inadequate maintenance of health centers ● A lack of referral and knowledge within the three levels of the NHS (WHO, 2016).

Level 1 refers to patients whose health conditions are in need of professional support and advice. Patients on level 2 require more detailed care and observation and the focus is on one organ system, whereas level 3 is targeting the ones that are in need of advanced support for two or more organ systems (NHS, 2020).

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● Poor access to human-, financial and technical resources ● Undeveloped health management system, which consists of logistics-, information- and

communication systems ● Inappropriately managed water and sanitation services, meaning the drinking water is

of low quality which has a negative impact on the inhabitants’ health (WHO, 2016).

5.1.2 Healthcare system The healthcare system in Angola consists of public- and private care. Even though the provided care at state hospitals and health centers are for free, there is still a difficulty for the inhabitants to access the treatments. The statistics show that there is one health center per 25 000 persons, one pharmacy per 22 500 persons, one maternity bed per 577 births and one pediatric bed per 13 540 children under 15 years (WHO, 2020). The public care is understaffed, and the local doctors and nurses do not have complete knowledge, meaning the delivered treatment has low quality (Allianz Care, 2020). It mainly depends on the poor access to updated medical technologies and education, which generate a low standard at hospitals. Hence, the inhabitants who can afford private care is choosing that one, since it is more reliable and there is greater access to resources (Allianz Care, 2020). The private clinics offering better care are owned by organisations, such as; Medi-Clinic, Life Healthcare and International SOS (Pacific Prime, 2020). Moreover, some people would rather travel to other countries with better facilities than make use of the ones provided in Angola (Allianz Care, 2020). The best hospitals and health centers are located in the urban areas of the capital city, where it is possible to find a wider range of facilities (Pacific Prime, 2020). However, the majority of the doctors are Cuban, meaning their mother tongue is Portuguese and only have basic vocabulary in English. It becomes a drawback regarding making use of international aid and education from people and countries with access to modern technology and higher medical knowledge (Pacific Prime, 2020). Moreover, the payment method at the hospitals and clinics is only cash. If displacements are necessary, the insurance company has to be informed in order to coordinate with the reimbursement (Pacific Prime, 2020).

5.1.3 Cooperation for health At the moment several organisations and authorities are investigating partnership opportunities in Angola, in order to improve the country’s overall health condition (WHO, 2016). They are, for example, the World Bank, the European Union, the Global Fund, United States Agency for International Development (USAID), Project Management Institute (PMI), Japan International Cooperation Agency (JICA) and other non-governmental organisations (NGO) such as; National, Red Cross World Vision and Doctors Without Borders (MFS) (WHO, 2016). They are all investigating the opportunity to provide aid to the Angolan health sector, mainly with regard to technical and financial backup that are aligned with Angola’s fundamental public policy documents. It is national priorities specified in the National Development Plan (2013-2017) and the National Health Development Plan (NHDP 2012-2025). The NHDP main focuses are to improve the disease recognition and the overall community healthcare as well as

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to develop a human resources management model, a financing model and a national health system organisation (WHO, 2016). Sweden’s impact on Angola is strong, since they believe the Swedish society is developed and ultimately well-structured for the inhabitants (Business Sweden, 2020). In Angola, there are currently 20 established businesses and it is perceived as difficult to enter the country with a new business. It is mainly related to challenges in receiving revenue as well as exporting financing. When rating the country in “the ease of doing business” it is on 173 out of 190 (Business Sweden, 2020). However, Sweden’s ambition is to increase the number of Swedish businesses in Angola and wants to be a part of Angola’s economic growth and infrastructure development. Hence, it will create future opportunities for strategic collaborations and partnerships (Business Sweden, 2020). Between 2021-2025, Swedish subsidiaries hope for significant progress in creating and establishing businesses in Angola (Business Sweden, 2020). Moreover, it is claimed that it will be easier to enter the Angola market, since investor and worker visas will be updated, and there will be lower costs and easier rules on investment (Euronews. 2019). The Government’s new investment law states that investors are not in need of an Angolan partner (Euronews. 2019).

5.1.4 To start a business The main barriers to build a business in Angola are the existing contracts and property registration. The most common ways to start a business in Angola is through corporation, branch office or representative office. (Shield GEO, 2020) A corporation can be formed in two ways, either as a private limited company or as a public limited company. The private ones require investment up to USD 1000 and a minimum of two stakeholders. They can be managed by one or more persons and involve an audit committee. The public ones require five shareholders or more and the amount of investments needed is USD 20 000. The management should consist of a general meeting, a board of directors and a supervisory board. Private investments have to be registered with the National Private Investment Agency (ANIP) and when the initiative is accepted, ANIP issues a Certificate of Private Investment (CRIP) allowing the initiative to take action (Shield GEO, 2020). Branch offices are the most present ones under foreign law in Angola, since it is possible to bring your already established business with you (Shield GEO, 2020). Hence, they are not seen as a particular legal entity of its own and they do not have a governing system. Instead the management is aligned with the parent company. When building a branch, it has to be registered at the tax authorities and at the Social Security, otherwise, the process is similar to the one for incorporation (Shield GEO, 2020). A representative office is mainly used for local representation and is not allowed to drive business and generate revenue. Hence, it is not recommended if the foreign investor is seeking growth opportunities and strives to adopt an economic activity in Angola (Shield GEO, 2020).

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5.1.5 Infrastructure development Angola has Africa’s 5th largest, where its main revenues come from agriculture, mining, and oil and gas (Global Legal Insights, 2020). The economy is perceived as one of the fastest-growing worldwide and the Angolan Government is striving to incorporate and accelerate the country’s growth. They are, for example, taking on actions to develop the energy-, telecom- and transportation infrastructure. Their goal is to enable foreign and local businesses to increase their opportunities in order to create manufacturing and production services. Angola has developed an Energy Plan 2025 in order to improve the infrastructure and compete internationally. Due to the high increase in demand for power, the plan strives to make energy accessible for 50% of the population by 2022 and 60% by 2025 and not only for 42% as it is now (Global Legal Insights, 2020). The focus is on renewable energy, such as solar-, hydro- and biomass resources, where an investment of USD 18 billion has been made (Global Legal Insights, 2020). The development of the telecom sector is related to the mobile network communications, where the aim is to make it accessible for the entire population at affordable prices. By 2022, two of the Government’s visions are to have increased the mobile tele-density from 54 to 59 percent, and the digital tele-density from 21 to 31 percent (Business Sweden, 2020). Currently, Angola’s telecommunication is based on three fixed-line operators; Angola Telecom, MSTelcom, and Startel, where Angola Telecom is the market leader. However, recently the Ministry of Telecommunication informed about the rise of a fourth telecom operator, which will increase the competition within the industry (Business Sweden, 2020). Moreover, Leonel Augusto, the chairman of the Angolan Institute of Communications has pointed out that in 2020 it will be possible to sign up for new “Multi-Service” operating services, which includes fixed telephony, fixed internet, cable TV or mobile voice. He did also mention that Angola has passed 14 million mobile networks and seven million uses mobile internet (2.5G, 3G, and 4G) (CommsUpdate, 2019).

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Table 4 presents the number of internet users and the population growth in Angola.

Table 4: Internet usage and population growth in Angola (Internet World Stats, 2019)

Regarding the health infrastructure, the National Health Policy (NHP) accepted in 2010 several actions and activities that are needed for the development up to 2025. A majority of them is listed below:

● Universal access to treatments and identifies health issues earlier. It is on a municipal level, where organisations and its management has to restructure and amend their services

● Improved resource availability and quality of services. The focus will be on educating the personnel and guaranteeing geographical equality

● Possibility to utilise and provide the right technology and medicals. Starting with a careful overview of the regulations and technical aspects for the production and distribution

● Increase financing in healthcare by going from a 3.5% to a 5% allocation in the General State Budget (GSB) in 2025

● Develop the flow of routine information in the national health system. A communications network will be integrated into the Integrated Health Information System (IHIS)

● Improve the research within the healthcare sector which will keep Angola up to date and also develop the populations competencies and skills

● Increase the health awareness for the governance and the leadership to be able to combine and integrate the different sectors with each other (WHO, 2016).

5.2 Nigeria Nigeria is located in West Africa and stands for approximately half of its population with 200 million people and is one of the most growing countries in the world (Ajayi et.al., 2019). The country has an area of 900 square kilometers and the capital city is Abuja. The former capital,

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Lagos, is the leading commercial and industrial city (Ajayi et.al., 2019). During the 18th century, Nigeria became a British colony and therefore, the main language in the country is English. However, in some parts of the country different African languages are spoken. (BBC, 2019). Nigeria is one of the most populated countries in Africa and the population density has created sanitary problems, such as water shortage. Furthermore, the dumping of garbage in the cities has contributed to an increased health risk, where diseases such as malaria, diarrhea, and HIV/AIDS and the lack of clean water are causing the majority of the deaths (Ajayi et.al., 2019). Moreover, the provided healthcare services are of low quality, which is mainly related to the lack of medical personnel as well as of modern equipment and financing (Ajayi et.al., 2019).

5.2.1 Health status Even though Nigeria is a growing country, half of the population has poor living conditions and lives in poverty (PharmAccess Foundation, 2015). The health and living standards have been improved after Muhammadu Buhari became president, but more initiatives are needed (WorldBank, 2019). Currently, the life expectancy is around 54 years where Malaria is the disease that causes the majority of deaths (PharmAccess Foundation, 2015). The lack of accessibility to health insurance is one reason why Nigerians do not use the local healthcare or even get pushed into poverty since it would cover healthcare costs (PWC, 2019). In Nigeria, almost 90% of the population lives without health insurance coverage and therefore, they have to pay out of pocket when visiting a doctor (Aregbeshola, 2019). The National Health Insurance Scheme’s (NHIS) goal was to reduce the costs for healthcare services and to improve the quality. Unfortunately, it has not been reached, which has resulted in that the vulnerable population can not afford the treatments and hence, they will not visit a doctor although it is needed. For this reason, some of the pregnant women are giving birth in their home instead of at a hospital (Aregbeshola, 2019).

5.2.2 Healthcare system Nigeria's healthcare system is divided into three levels; primary, secondary, and tertiary. The responsibilities for the levels are related to different sectors in the society. Local Government Areas (LGA) are responsible for the primary care, more specifically for the financing part and also to ensure patients are provided with the treatments they need. State Government is responsible for supporting the secondary care and the Federal Government is responsible for policy development, regulation, and the tertiary healthcare level (PharmAccess Foundation, 2015). LGA is the least funded and has not been properly organized or financed. Therefore, it is a weak base for healthcare, since it has poor access to modern equipment, low quality and there is a loss of confidence in the system (PharmAccess Foundation, 2015). In reality, the primary care should also take care of the highest-burden diseases, which they certainly are not able to

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do. It has led to a growth in support from international development partners in order to improve the quality and decrease the number of deaths. Moreover, they have invested in new equipment to develop the diagnostics of diseases. In, for example, India and Turkey, there exist foreign-own hospitals that offer better and higher quality healthcare (PharmAccess Foundation, 2015). Hence, the low quality of healthcare has led to Nigerians seeking care outside the country (PwC, 2016). A survey made by PwC (2016) showed that 90% of the respondents in Nigeria avoid the local treatments, since they do not trust the local doctors regarding providing them with the correct medicines or recommendations. Therefore, they rather travel to other countries when surgeries or other more complicated healthcare services are needed. Primary care stands for 88% of the facilities in the country and they are providing basic health services to the population (Makinde et al., 2018). The majority of health centers offering primary care is owned by the government, while secondary care is mostly privately owned. The secondary care is higher in infrastructure and provide the patient with more specialized care. They stand for approximately 12% of the care and also work as referral centers for primary care. Tertiary care only stands for 0.25% and provide patients with highly specialized services, for example advanced surgeries (Makinde et al., 2018). Nigeria has 15 hospitals, where the variety of treatments and the access to specialized doctors is different between them. The owner or founder of the hospital is the key decision-maker and is responsible for the hospital’s offerings. There are also private-owned diagnostic centers in Nigeria, which is basic laboratory services that are available for everyone in the country (PharmAccess Foundation, 2015).

5.2.3 Cooperation for health To improve Nigeria’s healthcare system, organisations, such as the National Council of Health (NCH), the United Nations Country Team and the Health Partners Coordinating Committee (HPCC), are cooperating in order to develop and finance all the important areas. The three organisations have created plans and programs that will make healthcare more effective (WHO, 2018). They are, for example, implementing health policies and support in order to increase the quality and reduce the deaths (WHO, 2018). The economy in Nigeria has begun to stabilize, and the opportunities for foreigners to start businesses are rising (PWC, 2015). Nigeria is Africa’s largest mobile market and hence, the digital economy has become important and the opportunities within e-business increases rapidly (PWC, 2015). As already mentioned, Nigerians do not completely trust that they will receive the correct treatment or have the opportunity to talk to a professional doctor or a specialist (PWC, 2016). Therefore, several parts of the population are more open to travel abroad to visit a doctor. Services where there are high chances to succeed are within advisory services, medical equipment and devices, and design and infrastructure development (PharmAccess Foundation, 2015).

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Nigeria’s poor infrastructure and energy coverage have contributed to a low rating in “the ease of doing business”, in 2018, their position was on 146 out of 190 (Business Sweden, 2019). For Swedish companies to succeed in the market, it is important to perform an in-depth market analysis and to be aware of all the factors that can affect the company's business. Additionally, to be able to build a strong and successful network, it is important to have knowledge about the local systems and infrastructure (PharmAccess Foundation, 2015).

5.2.4 To start a business Lagos State in Nigeria has one of the most advanced health regulations structure (PharmAccess Foundation, 2015). Therefore, it is important to take the regulations into consideration when entering the market with a new business. When registering a healthcare facility the most important factor to investigate, is the availability of licensed healthcare workers. Furthermore, the registration procedure can vary across the country and takes two months or more (PharmAccess Foundation, 2015). Currently, Nigeria hopes that foreigners invest in the healthcare sector, more specifically in hospitals and diagnostic centers. According to the regulations, the ownership of a facility could be assigned to a foreigner, but there is a rule regarding how many foreign employees they can have. In order to have the opportunity to conduct business in Nigeria, all the different healthcare businesses must register with the Corporate Affairs Commission of Nigeria (CAC). If a local partner is registered with CAC, a foreign company can conduct its business through them. Figure 5 visualizes the process for registration of a company (PharmAccess Foundation, 2015).

Figure 5: Process for registration (PharmAccess Foundation, 2015)

There are several taxes in Nigeria that companies need to be aware of. A few examples are; the Companies Income Tax Act (CITA), Certification of Acceptance, Taxation of non-resident company, and Nigerian Communications Commission (NCC). Nigeria has a complicated tax system, and therefore it is of importance to understand which taxes that needs to take into consideration (PwC, 2015).

5.2.5 Infrastructure development The Nigerian economy is one of the largest in Africa and had a rapid growth during the end of the 20th century (Oxford Business Group, 2019). The main reason was due to the petroleum industry and the increase in oil prices. It contributed to a growth within construction,

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transportation, and manufacturing services. It is noticed that when the oil market is fluctuating, the country’s revenues are unsteady and that in combination with the rapid population growth generated an unbalanced economy (Ajayi et.al., 2019). In turn, it affected the development of the infrastructure negatively. However, recently, local investments have resulted in several projects within transportation, construction and energy, and international investments which have generated improvements for the Nigerian economy (Oxford Business Group, 2019). Nigeria’s media network is one of the largest in Africa and they have over 100 radio stations and TV networks (BBC, 2019). The key source when collecting information is the radio, where the British Broadcasting Corporation (BBC) is one of the most popular channels. Moreover, the state TV reaches over 10 million viewers but the privately own networks are the main leaders (BBC, 2019). Telephone lines have existed in the country since the late 1970s but recently the use of mobile phones has increased rapidly (Ajayi et.al., 2019). The use of the internet expanded at the beginning of the 21st century and Nigeria has approximately 120 million internet users. The main users are younger and educated people and to receive access to the internet, almost everyone uses a mobile phone instead of a computer. Moreover, social media has become popular in Nigeria and is used by 24 million people (BBC, 2019). Nigeria is considered as a mobile-first market where the online usage development skipped using computers and began to use smartphones instead (Clement, 2019). Nigeria is on the top of the list of countries in Africa that uses the internet through their phones. Figure 6 presents the number of internet users in Nigeria and a forecast on how it will develop in forthcoming years.

Figure 6: Number of internet users in Nigeria from 2017 to 2023 (Statista, 2020)

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Nigeria’s population growth also affects the mobile market, which is expected to increase. Currently, approximately 20 % of the population has a smartphone and according to the forecast, it will increase by 60 % by the year 2025 (Holst, 2019).

5.3 Other services that have been exported Babylon is a digital healthcare platform that offers medical advice from doctors through their application. They run their business in the United Kingdom, Ireland, and in Rwanda and have their headquarter in London. In Rwanda they are known as Babyl Rwanda and are the largest digital health service (Babylon Health Rwanda, 2018). They have over two million registered users and have performed over 900 000 thousand consultations. Through Babyl, people can book appointments with doctors and get a diagnosis without visiting a hospital. Thereafter, they will receive a prescription on their phone, which is possible to collect from a health facility. Hence, the laboratory test codes will be available, and the test can be completed at any health center (Babylon Health Rwanda, 2018). The doctors are from Rwanda, have several years of experience, and can speak different languages. The reason for doing business in Rwanda, was mainly due to the country’s access to universal health insurance as well as due to the fact that approximately 75% of the population has a mobile phone. Furthermore, with Babyl it is possible to register to the platform by dial a number with the use of a National ID. It is in turn connected to a sim card, which means that people without a smartphone also can use the service (Kantengwa, 2017). The first Shell company in Nigeria was founded in 1936 by the Shell group. In 1998, Shell Nigeria Gas (SNG) started to distribute gas to industries in Nigeria. SNG is fully owned by Shell company and they have their headquarters in the Netherlands. Currently, SNG is the only gas distribution company in Nigeria, where Shell’s investments have played an important role in their water oil exploration as well as the overall productions. Hence, it has contributed to the country’s economic growth (Shell, n.d.). Siemens has been active in Nigeria since the 1950s, and the year of 1970, they established their first office in the country. Their main focus is on automation, energy, and manufacturing. Siemens in Nigeria has both delivered power distribution services to local companies, offered courses within power training, and corporates with local businesses to develop a strong relationship (Siemens, n.d.). Currently, Nigeria and Siemens signed an agreement for an electrification roadmap, where the goal is to solve the challenges in the power sector and expand its capacity. President Muhammadu Buhari supports the agreement, since it will enhance their current energy system (Siemens, 2019.) The government in Angola has decided to develop and improve the healthcare system in order to be able to provide high-quality healthcare services (Microsoft, n.d.). The country’s main challenges could be solved by introducing new technologies related to healthcare. Therefore, Microsoft has decided to invest in Angola’s health infrastructure and to develop a system that will improve the diagnosis treatment, prediction of diseases, as well as giving doctors more control over the patients’ healthcare data (Microsoft, n.d.). Hence, from Microsoft’s data

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centers, they will launch Microsoft Cloud for the first time. This will contribute to new opportunities for an economical growth and a digital transformation as well as make organizations more secure and safe (Microsoft, n.d.).

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Chapter conclusion To conclude, Angola and Nigeria have undeveloped health management systems, which consists of logistics-, information- and communication systems. The healthcare system in Angola consists of public- and private care. Even though the provided care at state hospitals and health centers are for free, there is still a difficulty for the inhabitants to access the treatments. The public care is understaffed, and the local doctors and nurses do not have complete knowledge, meaning the delivered treatment has low quality. It mainly depends on the poor access to updated medical technologies and education, which generate a low standard at hospitals. Angola has Africa’s 5th largest economy the economy is perceived as one of the fastest-growing worldwide. The development of the telecom sector is related to the mobile network communications, where the aim is to make it accessible for the entire population at affordable prices. By 2022, two of the Government’s visions are to have increased the mobile tele-density from 54 to 59 percent, and the digital tele-density from 21 to 31 percent. The chairman of the Angolan Institute of Communications has pointed out that in 2020 it will be possible to sign up for new “Multi-Service” operating services, which include fixed telephony, fixed internet, cable TV, or mobile voice. Moreover, half of the population in Nigeria has poor living conditions and lives in poverty. The lack of accessibility to health insurance is one reason why Nigerians do not use the local healthcare or even get pushed into poverty since it would cover healthcare costs. LGA is responsible for primary care, which is a weak base for healthcare, since it has poor access to modern equipment, low quality and there is a loss of confidence in the system. Nigerians do not completely trust that they will receive the correct treatment or have the opportunity to talk to a professional doctor or a specialist. Therefore, parts of the population are more open to travel abroad to visit a doctor. Additionally, Nigeria is considered as a mobile-first market where the online usage development skipped using computers and began to use smartphones instead. Nigeria is on the top of the list of countries in Africa that uses the internet through their phones. Finally, there are other services that have been exported. In Nigeria; SNG is the only gas distribution company and Siemens has both delivered power distribution services to local companies as well as offered courses within power training. In Angola; Microsoft has invested in the health infrastructure and Microsoft Cloud will be launched for the first time. It will generate benefits in order to reach economic growth and to embrace a digital transformation.

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6. Empirics The chapter presents the results and findings from the conducted semi-structured interviews, where a presentation of each interviewee is found in Table 2. The chapter is divided into the 4A’s that are discussed in the Bottom of the Pyramid, presented in chapter 3.

6.1 Awareness A MedTech company, called Medicheck, provides patients with medical advice online and their target group comprises people with chronic health conditions. The CEO and CMO explained that they, recently, have started to explore the opportunity to export their services to developing countries, with a focus on Angola and Nigeria. “We have received requests from established countries in Angola and Nigeria to collaborate

with them, since they have noticed there is a need of a service like ours and we very much listen to recommendations from our network. In Angola we may create our own brand to raise awareness, but in Nigeria we will be the technology provider and the local partner

stands for reaching out to the people.” - CEO

“Like any other markets there will be early adopters for this one and we expect a strong growth. However, we understand it may take a while, but it is a long-term solution and with

time people will be aware of its benefits and start to choose digital services to a greater extent.” - CMO

An eHealth strategist at CGI has dealt with several projects within eHealth and hence, the respondent has high knowledge within the area. The respondent discussed how to create awareness in developing countries and mentioned the importance of marketing. The respondent is determined that local partnerships are of importance to be able to understand the patients’ needs and how to reach out to them. “To create awareness in a new market, the most important factor is marketing. It is crucial to understand how to reach the patients, which could be done in different ways, for example,

by defining the target, understand where to find them, and provide a solution that is cost-effective. In this case, I believe the best way to enter the market would be through local

partnerships. They know the patients and how to adapt the product to make it suitable for them.” - eHealth strategist

The healthtech app, Appy Saúde, was founded in 2015 in Sweden and is the second most used app in Angola. People is able to book appointments as well as order and purchase medicines through the app. One of Appy’s business developers talked about the developing countries populations and their poor knowledge of technologies. Hence, to be able to gain users they have to inform the citizens in detail about the service to make them understand why it is important. The eHealth strategist does also mention the digital awareness as a challenge.

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“The population is hardly informed about new technologies, which leads to suspicion when introducing new ways of working. In Sweden, people are comfortable with speaking to a foreign person online but that is not the case in Angola. To be able to implement a new innovation successfully, it requires in-depth explanations of the benefits.” - Business

developer

“I believe the most challenging part would be to create a digital awareness and to handle the locals’ perceptions about healthcare. It does not have to be a man with a white coat.” -

eHealth strategist

However, one of the respondents explained that Angola’s population has become more open to changes. Moreover, both the respondents agreed that it is beneficial to be from Sweden when introducing new innovations, since it is correlated with high quality and advanced technology. Appy’s business developer mentioned that Sweden was one of the first countries to recognize Angola’s independence and the country has several statues of Olof Palme.

“Even though the population has low knowledge of technologies and they are suspicious, I believe they are becoming more and more open for changes. Appy’s utilization rate proves it, since we have reached 50 000 interactions/month and we are also thinking about expanding

with new partners to find other “problems” to solve.” - Business developer

“I certainly believe there is potential for digital healthcare services to grow in the country and Sweden’s reputation is strong. However, local connections and partnerships are crucial

in order to understand the need correctly and how to introduce it to the population.” - Business developer

“From my experiences within eHealth I have learned and understand that the concept “Made

in Sweden” is well known and especially when it comes to healthcare. It is connected with something positive.” - eHealth strategist

One of the respondents is the Founder and Managing partner of the company, Oakstone Partners, which helps governmental and private organisations with semi management or advisory, for example when raising capital. Furthermore, they create businesses where they have identified new opportunities and have recently focused more on healthcare in Lagos, Nigeria. The reasons for selecting Lagos, are above all; the population is quite large and English speaking, and the healthcare is poor. They have already found a local business partner who has a phenomenal track record of success and Medicheck will help them with the project by providing the technology. To create awareness in the country the respondent discussed the importance of involving the government. “[...] when you think about it, it is important to involve the state and the government to start to build health policies. If we could encourage, help, and guide them with new initiatives, I

believe they will be more interested in following the initiatives’ developments.” - Founder & Managing partner

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“I think the technologies are for the better and that they would be at the core for promoters, corporates, or the government when engaging meaningfully with the most impoverished and

vulnerable people.” - Founder & Managing partner

6.2 Access As mentioned Appy’s business developer and the founder of Oakstone Partner are already operating in either Angola or Nigeria and hence, they are aware of the access to healthcare in each country. They discussed the unequal opportunities to get access and that the systems are complicated. “It is complicated to get access to treatments in Angola at the moment. It is mainly due to the infrastructure and the outdated way of handling information. Healthcare services have to be

treated face to face, which is a problem when it comes to online services.” - Business developer

“In Nigeria it is a private health care environment and, obviously, there is a large

discrepancy between the people that have access to it and the people that do not have access.” - Founder & Managing partner

The CEO and CMO of Medicheck discussed the main benefits of the initiative and how it could solve the problem with getting access to healthcare.

“We have understood that the countries are messy at the moment and it is difficult to travel due to the undeveloped infrastructure. We believe it is a benefit that they barely have any

systems or directions of working in the healthcare sector, since then they could straight away adopt modern technology and skip the old ones. In that way, it could be easier to implement

the service in developing countries rather than in developed ones. No systems have to be changed or shut down.” - CEO

“Our partners will stand for investigating the existing rules and laws as well as the price and market situations, since they know the areas and we trust that they will identify the best ways

to create accessibility to the service for the whole population.” - CMO The eHealth strategist and the founder of Oakstone Partner discussed the challenges with increasing the accessibility in developing countries, but also the high degree of opportunities if it would be possible to overcome them.

“The main challenge for digital healthcare services in developing countries would be to increase the accessibility when there is no local market at the moment. However, I see great potentials for digital healthcare services worldwide, since they would improve the overall

health situations.” - eHealth strategist

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“We believe there are massive opportunities on the market that would be a benefit for the people. For instance, it would generate access to different choices of healthcare; such as clinics and doctors, which only would be a positive thing for the patients. “- Founder &

Managing partner “There will be foreign doctors to choose between as well, which will take language barriers away. Nigerian patients have the world at their fingertips, meaning they can talk to a male doctor in the US, to a female doctor in Sweden, or to a local doctor in Nigeria. That is the access opportunities we are hoping to be able to provide.” - Founder & Managing partner

Furthermore, the founder of Oakstone Partner’s explained the importance of establishing local partners to be able to fill the gaps in their services.

“For example, we will not be able to do patient care, and therefore we need to collaborate

with certain hospitals to make sure the patient receives the care they need. We will also have other local collaborations and strategic partnerships with people and organisations that will

complement our service as well as fill the gaps of it.” - Founder & Managing partner

6.3 Affordability The majority of the populations in developing countries have low incomes, which Appy’s representative is aware of and explained how they dealt with the problem. For them it is important that the population has equal opportunities to use the service and it should be as affordable as possible. “Since the majority of the population has low incomes and is price sensitive, they do not have

to pay for the data needed when using Appy. We have a partnership with the largest telecommunication company, Unitel, which I also think would be a benefit for Medicheck’s

initiative.” - Business developer

Furthermore, one of the respondents discussed the importance of keeping prices low to make it affordable for the whole population.

“We are not driving the project to reach profitability, instead the purpose is to create impact for the country. For us, it is important to keep our prices as low as possible, and therefore, I

believe our proposition is highly attractive and robust.” - Founder & Managing partner

Medicheck has not yet reflected on prices in detail, but they know the existing healthcare services are expensive. However, they do not want to be concerned as a cheap option, since their business consists of high-quality services.

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“We believe the price will be similar to the ones that are provided today or perhaps slightly under, but we hope the population will understand that they also pay for comfort and more

reliable care.” - CEO

6.4 Availability In developing countries, one of the main difficulties is to ensure the healthcare is available for the populations and to make sure they have equal opportunities to make use of the services. It is also an important factor why Appy was launched in Angola, to create impact and change the way of working. Moreover, the eHealth strategist discussed prerequisites that are important for a society in order to implement digital healthcare services successfully and to make them available for all individuals. “In Africa, there are huge problems within the availability of healthcare as well as medicals

and that is why we launched Appy in the area. Through Appy, the population can book appointments in advance and also order the correct medicals. It means it does not matter where you live, since it is an online service that is available all day.” - Business developer

“To keep the initiative available for everyone it is necessary to make sure the basic works,

such as; the local systems related to medical and health records as well as data handling.” - eHealth strategist

For the part of the population that do not have access to a mobile phone or any other similar digital equipment, the founder of Oakstone Partner presented a possible solution on how to make the initiative available for them. The respondent did also mention the importance of saving information about the patient in a system, where it would be available for the people with authority. It would minimize the risk of forgetting the patient's’ situation.

“Phase two of our project to address, with the help of state government or central

government, is to understand how to engage meaningfully with the more vulnerable and remote communities. My vision is to establish a small kiosk with some sort of communication device, like an embedded iPad, where people are able to access the service at a low cost. In

that way, they will also be able to have a video call with a healthcare professional.” - Founder & Managing partner

“One important thing that we will be offering, is the opportunity for the patient to upload all

the information about their health status as well as treatments and medicals in a system. It will be available for healthcare professionals.” - Founder & Managing partner

Medicheck explained that they have not figured out if the service will be available during the entire day or not. Medical advice online requires that doctors are connected to the application and due to different time zones etc, it is still under investigation. Concerning the need for a

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mobile phone, their local partners have explained that the telecommunication industry is growing in Angola and Nigeria and a great amount of people are embracing the technology.

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Chapter conclusion To conclude, the chapter presents the empirical findings from the conducted semi-structured interviews and a presentation of each interviewee is found in Table 2. The chapter is divided into four different sections that are aligned with the already defined themes (i.e. awareness. access, affordability, and availability). The answers from the interviews have been analyzed and assigned to the appropriate theme. In other words, a summary of the interviewees (i.e., CEO, CMO, eHealth strategist, business developer, and founder and managing partner) knowledge and competencies are presented as well as, quotes for the reader to better understand the relationship to the themes.

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7. Analysis and Discussion The chapter consists of an analysis and discussion about the findings from both the Case descriptions and the Empirics (Ch 5; Ch 6). This chapter answers the report’s research questions, where the first one is divided in the same way as the Empiric one, with regards to the 4A’s.

7.1 MedTech’s impact on the 4As in BOP markets During the research process, the aim has been to fulfill the purpose of the report that is presented in the Introduction (Ch 1) and below:

The purpose of the report is to investigate developed countries’ possibilities to implement digital healthcare services in developing countries.

In order to achieve the purpose, two research questions were investigated, which also are presented in the Introduction (Ch 1), and the first one will be answered in this section.

RQ1: How could MedTech companies from developed countries improve the access, availability, affordability, and awareness to reliable healthcare in developing countries by

introducing online medical advice?

To facilitate for the reader when taking part of the result, the section is following the same structure as the Empirics (Ch 5), meaning the answer has been divided into the defined themes, namely; the 4As (i.e., access, availability, affordability, and awareness).

7.1.1 Awareness The overall digital awareness is low in both Angola and Nigeria, meaning online services may face problems at an early stage. According to the founder of the advisory firm, Oakstone Partners, and the business developer of the MedTech app, Appy, the populations in Nigeria and Angola have poor technology knowledge, which could harm the innovation’s (i.e., MedTech app) development. They were discussing that new ways of working would create a suspicious society and talking to a foreign doctor online is not what they are used to. However, Medicheck believes that it will be challenging in the beginning, but patience is key and in the long run, it will be successful. With time, the citizens will understand the benefits of the initiative. They are also referring to the model “Diffusion of Innovation”, where they believe the early adopters will be there and spread the word about it. According to the model, the early adopters stand for 13,5% of the population and they are perceived as the trend-setters. By considering the development of the countries’ telecommunication industry, we believe it is a fair observation since there is an increase in mobile users. Nigeria has approximately 120 million internet users, where the majority of them are younger and educated people, in other terms; the early adopters and the future of the population. In addition, almost all of them have a mobile phone and there are 24 million social media users. We can tell there are similar trends in Angola, where the

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Government’s goal is to have increased the mobile density from 54 to 59 percent and the digital tele-density from 21 to 31 percent. Furthermore, according to the business developer of Appy, the telecommunication industry is facing an increase in competitiveness, since a new operator is entering the market. We consider that as a positive factor for Medicheck, since it would lead to an acceleration of the industry’s growth and its development will in turn generate a smoother introduction of online services. According to the chairman of the Angolan Institute of Communication, new “Multi-Service” operating services will be launched in 2020. Regarding Medicheck’s service, which is dependent on access to the internet, it is an important factor to mention. Hence, we believe the countries’ overall digital awareness is on its way. However, as the eHealth strategist mentioned, we are also concerned about how to create awareness when there is no local market at the moment. Are the populations ready to embrace healthcare and treatments as tryouts for digital online services? As it is now, the populations are lacking experiences in online services and they are not comfortable with sharing personal health information online. Would it, therefore, be better to wait with the launch until the society is fully mature and prepared, and in that way, ensure a fully obtained acceptance? On the other hand, it may be an initiative like the one provided by Medicheck that is needed to disrupt the current situations, and at the same time be perceived as market creators. Furthermore, it is important to remember the main reason why they decided to focus on Nigeria and Angola; local organisations reached out to them since they have noticed a need for new healthcare services. Hence, the locals are the ones that knows best how an initiative will be responded to and the business developer of Appy, clearly stated that they have 50 000 interactions/month and the number is continuously increasing. By considering Appy’s business, making it possible to book appointments and purchase medicals online, it can be concluded that the citizens are open to digital health services and an initiative as Medichecks may be right in time.

7.1.2 Access From the secondary sources and conducted interviews, we can tell there is limited access to healthcare in both Angola and Nigeria at the moment. According to the statistics, there is one health center per 25 000 persons in Angola and the majority of them are located in Luanda, the capital city. It means that it is more difficult for the people who live outside the city as well as with lower incomes to access the care. According to reports written by Business Sweden, there is a similar situation in Nigeria, where the citizens are seeking healthcare outside their own country, since they do not trust the local one. The undeveloped infrastructure has also led to poor access to human, financial and technical resources, which has negatively influenced the healthcare sector. Currently, the care is of low quality, since the doctors and nurses have limited knowledge and the hospitals are not keeping up with technology. According to the business developer of Appy, the main challenge to overcome would be to change the current way of working by introducing modern technology. However, Medicheck is informed about the situation and the CEO believes it could be a benefit when implementing their service. According to him, it does not exist any advanced systems

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that have to be changed or shut down. From the secondary sources, we can tell Nigeria skipped the use of computers in their online usage development and is instead perceived as a mobile-first market. Therefore, we agree with the CEO that it is possible to skip a step in an industry’s development process. Moreover, when the technology is in place, the service will increase the accessibility to healthcare for the population. They will not have to travel to receive treatments or health advice, meaning it will save them time and energy. However, it is important to mention that a digital device, such as a mobile phone is needed to be able to make use of the service. Hence, it could be discussed if the accessibility to care for the people with lower incomes will be changed. We believe they are not considering technical devices as one of their main priorities. If that is the case, the initiative will only be a benefit for the people that are already able to access private care or travel to other countries. However, the service is still generating benefits, such as comfort- and quality factors, and hence, it would still facilitate for them when receiving the needed care or medical advice. Moreover, considering the discussion in the aforementioned section, the number of mobile users is increasing in both Angola and Nigeria, meaning that hopefully the people with lower incomes potentially will be able to invest in a phone.

7.1.3 Affordability Angola and Nigeria are two developing countries and according to the secondary sources, a large part of the populations have poor living conditions. Therefore, it is important to keep the service affordable in order to ensure the populations will be able to use digital healthcare services. Appy’s business developer is aware of the situation and started to collaborate with Angola’s largest telecommunication company, Unitel. It means that people do not have to pay for the data when using Appy’s services. We believe, it will be a benefit for Medicheck to take inspiration from them and to evaluate similar collaborations when entering the market, since it would facilitate for the ones that cannot afford additional costs, such as the mobile data. Medicheck believes their services will have similar to, or slightly under current healthcare prices. As mentioned, the citizens in both Angola and Nigeria do not trust the local care and, hence, they find other ways to access it. According to a survey made by PwC (2016) showed that in Nigeria, it is common to travel to another country to receive higher quality care and in both Angola and Nigeria, the upper class is choosing private care before the public one. It leads to that the ones with lower incomes are provided with poor healthcare, which in turn could aggravate their situation even more and the risk of becoming less healthy increases. Hence, we believe that if the populations would be aware of and have access to Medicheck’s services it can provide all of them with high-quality healthcare. Even though the lower class may not own a mobile phone, we assume they would be able to borrow one if needed. Moreover, we believe the majority of the populations would be more open to pay for the service, due to the fact that it is provided by professional and educated doctors. Work done by the National Health Service, World Health Organizations, and PwC shows that there is poor healthcare knowledge in these countries, which leads to a lack of trust among the populations. It strengthens the statement that people will be more open to pay for professional services. Additionally, Medickeck’s CMO means that by being supported with correct treatments and recommendations, it would not be

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necessary to visit a doctor several times. Therefore, it would decrease the locals’ healthcare costs. Eventually and hopefully, it would lead to healthier societies, since they would accept the costs due to the value they receive. Furthermore, Darrell West (2012) discusses the fact that the usage of mHealth has contributed to economic benefits in the healthcare sector. It means that when mHealth has been established in developing countries, there would be a chance to lower the prices. Additionally, according to Medicheck’s CMO, the purpose of the project-driven in Nigeria is not to reach profitability, meaning the prices will be kept as low as possible.

7.1.4 Availability According to Oakstone Partner’s founder, Appy’s business developer, and reports written by Business Sweden, the two developing countries are lacking hospitals. Hence, a great amount of the populations lives far away from one and the available space is limited. In addition, it is difficult to reach them due to the poor infrastructure and therefore, MedTech could be a benefit in order to increase the availability to healthcare. Regarding the rapid growth of chronic diseases in developing countries, the need for specialists has increased, where digital health services would be helpful. They provide the populations with the opportunity to interact with foreign doctors wherever they are, which would generate healthcare services available for more people. Even a visitor in Angola, where the main language is Portuguese, would have the opportunity to receive treatments or advices from a doctor speaking a language the visitor is comfortable with. In that way, the service would also reduce language barriers and misunderstandings. It is a requirement to have access to digital equipment in order to receive the healthcare services. As mentioned in the chapter regarding “access”, it is stated that the telecommunication development is growing, and a great amount of the population has access to a mobile phone. However, there will still be people that cannot afford one, which the founder of Oakstone partners had thought about. In order to ensure healthtech services are available for the whole countries, they are exploring the opportunity to design a kiosk with a sort of communication device. It would be available for people with no phone and hence, they would also be able to organize a video call with a doctor. We believe it is a great initiative, however, it will be important to ensure the device is only used for the healthcare services and not for other purposes. We were also thinking about how it would work in practice if the patients are in urgent need of care and they would not have the possibility to reach the kiosk in order to contact a doctor. It could be declared that it would be a benefit for the ones with a mild disease. When implementing the kiosk, the incrementalist strategy could be of importance and also beneficial for Medicheck to follow. Due to the fact that digital services are nearly unexplored in developing countries, it is practically impossible to understand the populations’ reactions to it, and therefore, an open strategy allowing changes is to recommend. During the process, it is important to analyze the populations’ abilities to use the digital healthcare service through the kiosk and evaluate the findings. Thereafter, the idea may need adjustments in order to ensure

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it is of interest and will improve the availability of healthcare. Furthermore, by listening to the populations it could lead to an increase of users. It would in turn be beneficial for Medicheck, since they would have the opportunity to improve factors affected by the usage ratio such as; the awareness, access, affordability, and availability to healthcare. The eHealth strategist pointed out that, it is crucial to embrace the locals’ opinions in order to ensure the service is suitable for them. Hence, it does also support our argument that by using the incrementalist strategy it could contribute to increased trust among the populations. It is of high priority to declare their rights to reliable and high-quality healthcare as well as to ensure they understand the service is designed after their desires, where the purpose is to improve the societies’ health situations. In addition, Roger’s model, Diffusion of Innovation, could be a benefit when understanding the populations and to make the implementation successful. The kiosk main target is the ones that does not own a mobile phone and they may need to be convinced that talking to a doctor online is safe. In this case, they could be described as the “laggards”, meaning they are skeptical and suspicious against new innovations. Therefore, the incrementalist strategy is suitable, since it is open and allows changes. By combining it with the Diffusion of Innovation, we believe it will increase the chances to succeed with digital health solutions in developing countries.

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7.1.4.1 RQ1 summary

Table 6 and Table 7 visualizes a summary of the aforementioned and discussed findings. It is presenting the opportunities, challenges and models connected to the 4As. Table 5: RQ1 summary (Awareness & Access)

Opportunities

Challenges Useful model(s)

Awareness A local need and interest in digital initiatives have been identified. According to a similar MedTech app used in Angola, its interactions are continually increasing. New “Multi-Service” operating services will be launched in 2020, which means the digital awareness is on its way and the populations are becoming more open to digitalized solutions. If Medicheck decides to enter the healthtech markets, they could be perceived as the market creators.

The digital knowledge is low at the moment, meaning the populations are suspicious against new ways of working. Therefore, a digital transformation could take time.

“The diffusion of innovation”: Medicheck’s aim is to reach the early adopters, who stands for 13.5% of the population. Considering, the countries increase of mobile- and social media users it could be doable. The early adopters are, in most cases, younger and educated people, who are adapting to changes quickly. Medicheck hopes they will embrace the initiative and spread the word about it.

Access No advanced systems exist, meaning the implementation could be smooth. Nigeria is perceived as a mobile-first market, meaning they skipped to use computers in the online usage development. Therefore, Medicheck believes it is possible to skip a step in the healthcare sector as well. The patients do not need to travel to receive the care they need, meaning it will save them time and energy.

There is limited access to healthcare in the countries, and it is more difficult for the people living outside the cities as well as with low incomes to access the care. In turn, the care is of low quality since the doctors’ knowledge- and education level are limited. To ensure the populations have access to the service, collaborations with educated doctors are needed and a digital communication device is a must.

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Table 6: RQ1 summary (Affordability & Availability)

Opportunities

Challenges Useful model(s)

Affordability Collaborate with a telecommunication company to reduce data costs. Patients would be more open to pay for the service, since it is provided by professional and educated doctors. By being provided with correct treatments and recommendations immediately, it will decrease the healthcare costs.

The populations have poor living conditions, meaning they could face problems when paying for digital healthcare services.

Availability The initiative makes it possible to interact with doctors wherever and whenever and is taking language barriers away. To ensure it is available for the ones with no phone, it is under investigation if a kiosk with a digital communication device would be an alternative.

The service is only available for the patients who owns a digital communication device, such as a mobile phone.

“The incrementalist strategy”: Currently, digital services are nearly unexplored in developing countries, and it is almost impossible to predict the populations’ reactions, meaning an open strategy is to recommend. It allows changes and adjustments along the implementation’s process. “The diffusion of innovation”: Useful when understanding the locals’ behaviors and to reach the part of the population that is perceived as the “laggards”.

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7.2 Developed countries’ possibilities to enter a BOP market To fully achieve the purpose of the report, the second research question had to be investigated as well and the answers of RQ1 played an important role for the development of its findings. Hence, this section is answering the following research question:

RQ2: What are the possibilities for companies from developed countries to enter the healthtech market in developing countries?

From the gathered data we can tell there are major possibilities for developed countries to enter the healthcare market in developing countries and by focusing on the 4As when entering the market, it would generate the best results. All of the respondents believed that local partnerships and collaborations are preferable in order to implement a successful innovation in Angola and Nigeria. It is important to understand the market and the locals’ needs and reactions. If they would not be willing to adapt and embrace the product, it is not necessary to fulfill the implementation. However, Appy’s business developer as well as the founder of Oakstone Partners, mentioned Nigeria’s and Angola’s telecommunication and infrastructure development, and they certainly believe both the countries and the populations are evolving the needed capabilities and curiosity to embrace the innovation. When entering the market, it is beneficial for companies to adopt the innovation process model. It is used to understand how to introduce a new innovation in order to capture value. The first step is to search the environment, which Medicheck is currently doing. By making use of local contacts as well as people within the same industry, they create and develop knowledge of the specific situation in each country. In that way, it is possible to identify potential threats as well as opportunities in an early stage. In this case, Medicheck understands that a huge challenge will be to convince the population that the innovation will facilitate their daily lives and they are determined it exists early adopters in each market that will spread the word about the product. The second step in the model is to select the right option when entering the market. As mentioned, Medicheck did not have any information or connections to the countries before the researching process and hence, they highly value local relationships. It would be a challenge to create their own brand from scratch and at the same time successfully adopt the 4As, since all of them are based on in-depth market knowledge. The innovation process model’s third step is the implementation phase, meaning the right tools, contacts, and techniques have to be identified. Medicheck has already found local collaborations, but their role will differ in each one. In Angola they strive to have the same brand as in Sweden, whereas in Nigeria they will be working as the technology provider. This is yet difficult to reflect on, since it is still under investigation. However, when it is completed, the last step is to evaluate the innovation in order to learn how to improve and adjust the product to make it more suitable for the populations as well as to maintain or increase the market position. Moreover, C.K. Prahalad (2011) mentioned the innovation sandbox as an inspiration to use when implementing a profitable innovation in a BOP market. Firstly, the need has to be identified, which is clear in this case. The purpose of Medicheck’s services is to improve and

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to complement the current healthcare systems. They have noticed that Angola and Nigeria are two developing countries with a lack of access to high-quality treatments and care and hence, they believe it will be possible to improve the situation for both the countries. The second parameter is concerning the product’s development, where the design has to be aligned with the global safety standards. It should not be an issue for Medicheck, since they are an established organisation and the design is set and approved. However, we believe the challenging part would be to understand the local standards and to adapt the product accordingly. Hence, it also emphasizes the importance of interpreting local contacts and partnerships. The third and fourth steps are considering the scalability and affordability of the product. The latter has already been discussed, where Medicheck’s goal is not to deliver profit in an early stage but rather to gain users and ensure they understand the product’s value. We believe the service’s scalability will be optimized by considering all the parts of the business together with local organisations. It is recommended in order to fulfill all criteria to ensure a long-term business setup. By combining the innovation sandbox with the innovation process model, we believe it prepares Medicheck for implementations in Angola and Nigeria. However, they have to be complemented with other research and analysis regarding the case countries to fully understand the need and development of the service. According to the secondary sources, other companies from developed countries have entered the market in developing countries and it could be beneficial for Medicheck to analyse, understand, and learn from their successes and mistakes. The implementations have been within industries such as healthcare, energy and gas. It strengthens the fact that the investigation is relevant by proving that it is possible to implement services to BOP markets. In Nigeria, the government has an agreement with Siemens by reason of improving the current energy system. Hence, there is a willingness to cooperate with companies aiming to develop the country’s welfare and infrastructure. It means it exists governmental support, which is important to understand before entering the market. In addition, it is learned from the Case descriptions that Angola’s government is eager to improve the healthcare sector, and therefore, they are open to invest in relevant organisations. The governmental support and willingness increase the opportunities for developed countries to successfully enter the healthtech market in BOP markets.

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Table 8 and Table 9 is summarizing what Medicheck should focus on when entering the healthtech market in Angola and Nigeria as well as how to apply the appropriate models. Table 7: RQ2 summary - Focus areas

Focus

Outcome

Local partnerships and collaborations

Careful observations and investigations of the countries to understand the populations’ needs and behaviors. Make sure they are aware of the service benefits and how it will deliver value to their lives. In that way, it will facilitate for achieving fully acceptance by the populations. It is important to be able to gain users, where the local partnerships will help to get awareness and approvals.

The infrastructure- and telecommunication developments

The both industries are growing, meaning the populations are getting prepared for evolving the needed capabilities and curiosity to embrace the innovation. By following the developments, Medicheck is able to predict the user ratio of their services.

Similar initiatives accomplished by other organisations

Analyze, understand and learn from other organisations’ successes and mistakes. The implementations have been within industries such as healthcare, energy and gas and they are real world examples on that it is possible to implement services to BOP markets.

Governmental support

There is a willingness to cooperate with companies aiming to develop the country’s welfare and infrastructure. It means, it exists governmental support, which increases the opportunities for developed countries to successfully implement initiatives in BOP markets.

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Table 8: RQ2 summary - Appropriate models

Appropriate models Application

The innovation sandbox

It is used to understand how to introduce a new innovation in order to capture value. The process starts with searching the environment, which Medicheck is doing by the help of local connections. In this case, a challenge will be to convince the population that the innovation will facilitate their daily lives and they are determined it exists early adopters in each market that will spread the word about the product. Secondly, the right approach when entering the market needs to be defined. As mentioned, Medicheck values local partnerships, since it would be difficult to create their own brand from scratch and at the same time successfully adopt the 4As. Thirdly, the implementation process begins, meaning the right tools, contacts and techniques have to be identified. Lastly, the innovation has to be evaluated in order to improve and adjust it.

The innovation process model

Firstly, the need has to be identified. It is clear in this case, since Angola and Nigeria are two developing countries with a lack of access to high-quality treatments and the purpose of Medicheck’s services is to improve and complement the current healthcare systems. The second parameter is concerning the product’s development, where the design has to be aligned with the global safety standards. The third and fourth steps are considering the scalability and affordability of the product. Medicheck’s goal is not to deliver profit in an early stage but rather to gain users and ensure they understand the product’s value. The service’s scalability will be optimized by considering all the parts of the business together with local organisations. It is recommended in order to fulfill all criteria to ensure a long-term business setup.

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8. Conclusion The chapter consists of a conclusion about the main findings from the Analysis and Discussion (Ch 7). The chapter ends with recommendations on further research. To conclude, MedTech companies can improve awareness, access, affordability, and availability to reliable healthcare in developing countries. Currently, digital awareness is low in the case countries, but the telecommunication industry is continually developing, and the amount of social media users increases every year. The younger part of the population uses mobile phones to a greater extent, and they are also considered as the society's future. It means that there is a high possibility that digital healthcare services would be attractive to them. The citizens are open and curious about digital health services, which slowly would improve the digital awareness. In addition, it is recommended for MedTech companies, to use the Diffusion of Innovation model to be able to foresee the populations’ reactions. It could help them to understand which part of the populations they should focus on. In turn, it could contribute to deeper understandings of the benefits with a MedTech app and hence, adapt to it easier. Digital healthcare services provide patients with several opportunities, since interactions with specialized doctors- and access to advice or treatments without the need for hospital visits increases. The gathered data shows that both Angola and Nigeria have low-quality healthcare and due to lack of reliability of the local care, a part of the populations travel to receive health advice. However, the lower class that lives in poverty is not able to pay for the traveling costs, meaning they would rather skip to visit a doctor even though they need it. Therefore, the innovation (i.e., MedTech app) would improve access to reliable healthcare, since it would be possible to connect with doctors globally and at any time. It would generate time- and cost savings for the populations. A vast amount of the populations in the studied BOP markets lives in poverty and therefore, the service has to be affordable for them as well. When entering such markets, the goal should not be to reach high profit due to the low incomes and companies should rather strive to increase the user ratio instead of having high costs for each individual. Additionally, a suggestion would be to take inspiration from Appy when implementing a new innovation (i.e., MedTech app) and hence, to collaborate with a telecommunication company. The populations do not need to pay for the mobile data when using the service. Moreover, hopefully users would eventually consider the high-quality healthcare as worthy to pay for. When the service has been established, it would be analyzed and prices could be changed over time due to the situation. Lastly, the availability would be improved since it would be possible for the populations to interact with a doctor wherever they are and at any time. It would facilitate the citizens living far away from a hospital or in rural areas. By being able to interact with foreign doctors, it generates opportunities to connect with the ones speaking the same language. It would contribute to minimized or reduced language barriers as well as misunderstandings. In order to make the service available for people without a mobile phone, a “kiosk” with an integrated digital communication device could be implemented. However, to avoid conflicts, it is important to ensure the device is used for the right purpose. Hence, before the setup, safety

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rules and instructions have to be formed and explained in detail to ensure it is clear for the users. In the end, it could be concluded that there are major possibilities for enter the market in developing countries, and by focusing on the 4As it would generate the best results. In addition, it could be preferable to have local partnerships or cooperate with established companies to understand the market and the population’s needs. It is more challenging to succeed in a BOP market than in other markets and it is important to understand how the product should be implemented. It is, therefore, beneficial to adopt the innovation process model as well as to take inspiration from the innovation sandbox when searching and gathering information about the market of interest. Additionally, the governments in both Angola and Nigeria have shown interest in supporting and cooperating with foreign companies that are willing to implement innovations with the purpose to improve the current systems. The governments encourage and positive attitudes increase the possibilities to enter the markets with success. To conclude, we believe it is possible for MedTech companies to enter the market in developing countries and provide the world's poorest with increased access to high-quality healthcare.

8.1 Further research To enter the healthcare market in a developing country, research and analyses regarding the specific country are needed. Interviews with locals and already established organisations are to recommend, when being able to understand the current healthcare system, the infrastructure-, and telecommunication developments as well as the population’s habits. According to PharmAccess foundation (2015), it is of importance to develop a high knowledge about the specific country to enter it with success. Hence, to clarify and increase the trustworthiness of this report it could be complemented with more interviews with people with a local connection and with organisations that have already entered a BOP market. Moreover, the researchers should apply theories and models together with the gathered data. This report is presenting a suggestion of relevant ones, which have been valuable in order to receive inspiration on what process and strategy to follow. It was concluded that there exist several opportunities for MedTech companies from developed countries to enter BOP markets with the purpose of improving the 4As, meaning another research may be of interest. The purpose of it could be to find an appropriate strategy to use when entering the markets, and hence, other theories and models (i.e., SWOT or PESTLE) could be of relevance. However, additional dialogues and discussions are to recommend before deciding the direction of a future report.

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Appendix A - Interview questions The presented questions below have been used as inspiration when guiding the interview. However, in order to receive the most from them, the questions have been adapted with regard to each respondent's professions.

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Appendix B - Contact template The template below has been used when reaching out to the respondents. It has been of importance in order to not forget any relevant information as well as to declare their confidential rights. However, the template has been adapted with regard to the specific respondent.

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