Archive for the ‘developing countries’ Tag
Just how many “me too” cholesterol-lowering agents do we really need? (Photo Courtesy: The Daily Mail)
The pharmaceutical industry’s fundamental business model has become increasingly less attractive in the last two decades, and a number of firms and industry experts have advocated large-scale change (e.g., E&Y’s Pharma 3.0 strategy, McKinsey’s pharma manufacturing revolution) in how pharmaceutical companies do business. In particular, GlaxoSmithKline (GSK) has staked much of its future success on pairing its longstanding strengths in traditional pharmaceutical product development with a top-down mandate to grow the size of its customer base in the 50 poorest countries in the world. Currently, these markets have less than 5% market penetration by Western pharmaceutical companies, and GSK views these underserved populations as missed opportunities for sales and revenue growth.
Last summer, three of us from Saïd Business School’s MBA Program, the London-based the International Centre for Social Franchising, and GSK collaborated to identify innovative, replicable models that would improve GSK’s ability to access and serve populations in developing countries. This work was based on an underlying assumption that a host of creative delivery models existed but were difficult to identify and evaluate. Once found and verified, GSK could partner and contribute as an investor, operational and technical expert, and multinational influencer as a means of scaling up and replicating these initiatives across multiple national markets.
The study team used a mixture of high-throughput quantitative methods and visit-based qualitative interviews. The former helped the team to screen a 1200-item aggregated universe of programs and identify common program type and geographic foci of innovation. The team then traveled to these geographic hotbeds, visiting over 50 delivery models and technical experts spread across Kenya and India. The major findings of this study included both overarching themes that were applicable to nearly every program visited (e.g., poorer customers are highly price-sensitive but will pay a premium if they value a product highly relative to other needs) as well as model-specific themes that relate to specific success factors for a given model type (e.g., social marketing programs usually required a local NGO partner with an established source of trust in the community). Some of the original assumptions of the study team were challenged by the findings. For example, the number of financially-sustainable, scalable projects that were worthy of multinational investment or partnership – and did not already have it – was exceedingly small.
Packaged food manufacturers have a longstanding history of rapidly altering prices, products, and brands to suit the needs of consumers best. What features of such everyday innovation would best suit the pharmaceutical industry? (Photo Courtesy: Paul Mullins)
Recommendations were developed with a variety of near-term actionable items (e.g., what to invest in, how to invest) for GSK as well long-term strategic considerations. The most universally relevant of these findings was a need in the pharmaceutical industry to rethink how it develops business strategies for these new, atypical markets. It could be argued the hunt-and-peck strategies that many pharmaceutical companies are using to experiment with new business models are inherently flawed. Instead, our team of MBAs recommended a variation on an approach popularized by many fast-moving consumer good firms (FMCGs; e.g., Procter&Gamble, Unilever). Although models vary, open innovation frameworks or innovation hubs typically create an internal business unit at large multinationals that standardizes how promising new business models are screened, evaluated, tested, and replicated. For example, many of the new products developed today at Procter & Gamble and Mars are rapidly rolled out in this way. These lean workgroups allow otherwise large, complex companies to nimbly experiment with an approach that accepts failure as learning activities and rapidly identifies promising goods or services for corporate scale. Pharmaceutical multinationals looking to expand in the developing world will need to build a similar series of internal systems and processes to remain competitive.
Contributions to the work described here were provided by Andy Thornton (Oxford MBA 2012), David Wong (Oxford MBA 2012), Jackie Horn (ICSF), and Dan Berelowitz (ICSF). Public findings from the completed study can be found here.
Disclosure: The work our team completed for GSK described above was a professional consulting project with financial remuneration conducted in collaboration between Saïd Business School, the ICSF, and GSK.
A number of recent academic studies have shown that global health experiences are becoming more essential in the eyes of medical trainees. One particular study suggested that the vast majority of current surgical residents are interested in global health experiences. Our research group at Emory has further shown that medical students are likely considering global health offerings when students evaluate residency programs. The reality for residency programs today is that failing to offer opportunities in global health may be harming their ability to recruit the best applicants for their program. However, medical schools and residency programs alike have had difficulty overcoming the logistical difficulties while also maintaining the quality of medical education provided during such experiences.
Drs. Jahnavi Srinivasan and Viraj Master demonstrate point-of-care ultrasound techniques to medical students Lee Hugar and Pete Creighton during Emory Medishare’s surgical camp in Hinche, Haiti.
For the last five years, I have worked intimately with a small group of faculty and students at Emory University School of Medicine to design a for-credit international surgery elective that attempts to demonstrate the feasibility of such a training experience for medical student. A long-form retrospective piece on the effort and how it has evolved to meet the needs of multiple stakeholders has just been published in the Bulletin of the American College of Surgeons. The key takeaway from our group’s experience is that the common criticisms of these short-term trips fail to wholly encompass the range of benefits being provided. If one assesses solely the educational value or exclusively the burden disease effect for the patient population, a perspective that incorporates the cumulative benefit of these programs is lost.
As I have started the transition from medical student to general surgery residency, it has become increasingly important for me to find a way to communicate our message to the next generation of medical students. At Emory, I have no doubt that an exceptional class of rising senior medical students with global health experiences will have no problem continuing to build on the model there. But what can be done for other medical schools that don’t have such a program or have not operationalized it in a manner that can continue across multiple years? After considerable thought and planning, we have released an early version of a website, www.MedStudentTrips.org, that will serve as a repository of public clinical manuals, planning documents, and advice for those looking to replicate the Emory Medishare model at their own school. In passing on such knowledge, I hope to catalyze such efforts at other institutions in the future.
For information on Emory Medishare, the student-faculty medical humanitarian collaborative discussed in this article at http://www.emorymedishare.org.
For those looking to design such a program at their own medical institution, Emory Medishare has posted many of its public resources at http://www.MedStudentTrips.org.
7 years ago, an enterprising Harvard student, Elizabeth Scharpf, began a project to produce sanitary napkins using local workers and local materials in sub-Saharan Africa. Although difficult to quantify, the amassed evidence has suggested that many women in developing countries– particularly school-age girls — are routinely sequestered and miss multiple days of school each month because of the lack of hygiene products to use during menstruation. This issue has been long ignored largely because of the associated stigma around a woman’s menstrual cycle in conservative societies and the lack of health officials familiar with women’s needs. Sustainable Health Enterprises (SHE), the company founded by Sharpf, was an attempt to a) address the needs of rural women through a locally available commercial product AND b) provide a self-sufficient business model to entrepreneurial women in these countries.
The basic model has been to first find local entrepreneurs interested in starting a local sanitary napkin production operation. The raw materials for these sanitary napkins are then sourced locally using banana tree fiber, a waste product of banana harvesting, as a substitute super-absorbent material. The cost savings on materials and production help reduce the cost per pad from US$0.11 to US$0.07.Local women are then trained to produce these with small table-top workshops that can be used in their private homes. These are then collected by the local entrepreneur and sold in markets or with door-to-door sales models.
First-generation SHE Pad. Not exactly what Rwanda’s women were looking for. (Courtesy Ecouterre)
SHE’s success to date has been mixed. Between 2009 and 2011, Scarpf used funding from Echoing Green and Harvard Business School to setup the first franchise model of banana fiber-based sanitary napkin production and distribution in Rwanda. However, using the available public information on SHE’s website and blog, the latest updates dated August 3, 2012 suggest that company is just now completing its supply chain and brand strategy. The largest hurdle seems to have been that the uniqe selling point SHE pads offer — their attractive lower price — are exactly why consumer demand from Rwandan women has not been strong. In a critical oversight, Rwandan women who cannot afford imported pads would rather use their existing coping mechanisms in a pad-less world than use SHE’s product. Although SHE is actively working through these issues and is currently completing a redesign, SHE has yet to prove its model for a new sanitary napkin for the low-income communities.
A particular concerning trend is that efforts to provide locally-produced sanitary napkins have been increasing even though the existing businesses have yet to identify a succcessful business model. At the the University of Oxford’s 2012 TATA Ideal Idol business plan competition in March, one of the finalist was BaNaPads, a similar sanitary napkin effort being attempted in Uganda. No evidence suggests that these me-too ventures are finding solutions to the problems that racked earlier efforts. Although there is a certain attraction to local production and women’s empowerment through independent income generation, the social entrepreneurship and global health communities should be self-critical to such unproven models.
While the work of the organizations above is commendable, none of these efforts have seem to realistically questioned if multinational corporations are already providing female hygiene products in the most financially sustainable way. Patricia O’Hayer, Unilever’s Vice-President for Communications and CSR, challenged the development community in a recent Oxford-based debate to avoid automatically assuming that there was something intrinsically better about local production versus global mass production when it came to making consumer healthcare products. Procter & Gamble and Unilever may be unapologetically “big business,” but their ability to reach economic scale and provide a safe, reliable product may be unmatched in this product category. Entrepreneurial efforts such as these must be compared to existing ways of doing business if they are meant to contribute to societal value creation.
Disclosure: In early 2012, I informally worked with a team from Procter & Gamble on shared interests to bring health-related retail products to rural communities in rural Kenya. There was no material remuneration from this engagement.
Last month had me traveling around the world courtesy of Saïd Business School’s capstone Strategic Consulting Project and our multinational corporate partner who is currently looking to become more invovled in healthcare innovation in developing countries. I just finished my second short stint in Nairobi, and I am thoroughly impressed by a number of developments in Kenya. The current macroenvironment for healthcare in Kenya combined with individuals’ entrepreneurial efforts has produced palpable excitement in the sector that may well signal a new dawn for healthcare in the country. Most interesting, the opportunities for Kenyan private sector healthcare may be the best they have ever been.
One of the most important macroenvironment trends is the improving political stability since the post-election ethnic conflict of 2007-2008. Since then, a new constitution has been ratified and the upcoming elections will be preceded by a number of bureaucratic improvements that will streamline the alignment of commercial ventures with committed policy-making. This political normalization has also allowed for an increasing amount of “business as usual” from the administrative arm of the government including more direct financial management of HIV/AIDS spending and a new eHealth strategic plan. Although the next round of elections scheduled for 2013 may well herald a new wave of vote-rigging and subsequent violence, the two rival political parties from the last election have learned to work together through power-sharing and the knowledgeable city-dwellwers I have spoken to in Nairobi seem optimistic.
Many groups are trying to repeat mPESA’s success in mobile money payments by coming up with similar mobile-related leapfrog applications for healthcare. (Courtesy of OpenIDEO)
Another trend occurring in Kenya is the overwhelming success of modern mobile telecom infrastructure. Nearly every business venture I met with in Kenya includes in its business model a component related to mobile technology. Mobile technology in developing countries has been shown to be a major catalyst for healthcare development but where Kenya stands out is in its mobile phone penetration. Over 70% of Kenyans own and use a mobile phone and nearly a 1/4 of the country’s GDP is transacted through Safaricom’s mPESA mobile payment service (see more).
All of these trends have directly stoked the entrepreneurial efforts of many Kenyans. Zoe Alexander Ltd is a new technology start-up who is leveraging automated telephone systems (“robo-dialing”) and Kenya’s high mobile penetration to deliver personalized audio messages to pregnant mothers that time appropriate antenatal visits and warn mothers’ of “red flag” warning signs during pregnancy. Zoe Alexander and others have also focused on bypassing the existing healthcare infrastructure because of the its overly bureaucratic nature in Kenya. Another example is Changamka Microhealth’s use of health savings accounts to incentivize individuals to save rather than trying to expand the relatively small population footprint of the country’s national social insurance plan. The latter’s bureaucracy was unable to design a means of participating in the plan for individuals that did not work for major Kenyan corporations.
While such initiatives will not radically change the health and wellbeing of the average Kenyan overnight, these efforts should be complimented for their inventiveness and aspirations for self-sufficiency. Through my travels last month, I have heard far too many stories of companies seeking overly traditional approaches to reaching low- and middle-income healthcare consumers. Marketing techniques designed for industrialized countries will not work elsewhere unless modified to local conditions. Home-grown, for-profit healthcare in Kenya may be the first sign of lessons learned.
Disclosure: I, nor my summer employer, have any financial positions in the companies listed here. However, my trip to Kenya was funded as part of business development field research for a multinational corporation.
A community health worker is seen here registering patients at a rural health fair outside Thomonde, Haiti. Community health workers are critical at serving "last mile" healthcare needs and are typically deeply embedded in communities.
It is widely acknowledged that the developing world is in the midst of a healthcare personnel crisis. Even the citizens of middle-income countries that have begun to reap the rewards of increasing standards of living and the emergence of disposable incomes are finding that local health systems lack the healthcare personnel to provide adequate care. The World Health Organization estimates that 57 countries lack the health care personnel needed to reach health-related Millennium Development Goals. Even small increases in the ratio of healthcare workers to the general population correlate with substantial declines in maternal, infant, and child mortality.
Unfortunately, progress is not being made fast enough, and the primary problem is lack of infrastructure. The consulting firm McKinsey & Co. has modeled current workforce education capabilities and estimates that $33 billion and 300 new medical schools would be needed in sub-Saharan Africa alone to meet the continent’s workforce needs. Radical changes to the existing system of healthcare workforce education are needed if health systems are to meet the demands of a world in need of accessible and quality healthcare.
The current paradigm of health workforce education across much of the world involves a massive financial and social investment into the education of highly-skilled, upper-tier medical professionals that typically requires 5-10 years of higher education. However, in a number of developing countries, substantial healthcare services have been provided with less highly trained mid-level providers.
Having trained pharmacists available at dispensaries ensures that patients receiving proper counseling on the use of medications.
Changing the workforce shortage starts with changing the paradigm. New models of healthcare workforce education need to be tried that move away from the high-cost, state-run institutions currently being used. One alternative would be to begin offering private, market-based programs that provide a more flexible path to licensure as mid-level providers. These programs could use a modified version of distance education — already popular in the developing world — and take advantage to the expanding technical capabilities of mobile networks in these communities.
The biggest obstacle to experimenting with new workforce education strategies is the regulatory environment. Many governments in the developing world still find it difficult to license mid-level providers given their unusual place in the medical hierarchy and these governments’ lack of experience with such providers. Additionally, these novel education schemes would need to be accredited as well.
Given these regulatory hurdles, a “bottom-up” approach of market creation is unlikely to work for new education models. Hence, the workforce shortage issue is ultimately a policy problem. If one is able to leverage government policymakers, these new models of medical workforce training represent a great opportunity for addressing the biggest, least recognized problem affecting global health today.
Interested in learning more? See this proposal I previously prepared on how such market-based education solutions could be implemented given the risky regulatory environment.
Ira Leeds
Blue Oceans for Health 