Archive for the ‘global health’ Tag

Increasing pharmaceutical market penetration in the developing world through in-house innovation hubs   Leave a comment

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.

Training medical students through international electives   Leave a comment

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,, 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

For those looking to design such a program at their own medical institution, Emory Medishare has posted many of its public resources at


When “go-local” doesn’t work: sanitary napkins in sub-Saharan Africa   Leave a comment

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.

SHE Pad Prototype

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.

FoetoH – Good science. Good medicine?   1 comment

I recently came across FoetoH, a fetal heart rate monitoring device that has been developed at the University of Oxford. Unlike other forms of fetal health monitors, FoetoH is designed to be used by laypeople and in a real-time manner. Rather than giving health information output in complex jargon or graphs, the device provides a stoplight-style assessment (green, yellow, red) of a developing fetus’ current health. The scientific breakthrough was developing an exercise belt-like device (think exercise heart rate monitors) that a mother-to-be wears all the time that communicates with a handheld unit (or iPhone app) which facilitates data storage and interpretation.

The idea of FoetoH is attractive because of its synthesis of the latest technology trends (i.e., mobile-based health applications, user-oriented design) and advanced health monitoring devices. The marketing materials of FoetoH are excellent and describe this device as potential breakthrough to help address the more than 2 million stillborn babies born each year around the world. The basis of this claim is that mothers who know their pregnancy is in trouble (indicated by a “yellow” or “red light” on the device) could receive emergent medical care to improve fetal outcomes.

Unfortunately, such a simplified product and health solution obscure some major logical flaws in their existing argument. For FoetoH to contibrute to a reduction in worldwide stillbirths, the device needs to prove itself to be more than just effective at measuring fetal heart rates. FoetoH’s founders need to be able to demonstrate that identifying changes in fetal heart rates is an effective way of identifying AND preventing still births. Why do I raise this issue? The limited data available on still births demonstrates that the majority of still births are due to genetic and environmental insults that go well beyond impaired cardiovascular support of the fetus. Many of these stillbirths are due to unknown  genetic causes, infectious disease, or severe malnourishment, and fetal distress (erratic fetal heart rates) is an end-stage sign of imminent still birth. In these cases, last-minute emergency care would have virtually no chance of preventing “fetal demise” (technical term for still birth). It is also unclear that FoetoH’s real-time monitoring is any more effective than current guidelines for antenatal care which include regular physician visits and routine ultrasound scans at pregnancy milestones.

Moreover, it is unlikely that most mothers at risk for stillbirth would be able to gain access to the FoetoH device. Its currently reported cost of manufacturing is approximately $80. A public sector price is likely at least twice as expensive with a market price even more. Given that the vast majority of stillbirths occur in impoverished women from developing countries, the target population who could potentially benefit from such a device would be unlikely to be able to afford it. Even if such devices were provided free of charge to high-risk mothers, the limited benefit of using the device I raised in the prior paragraph would likely outweigh the high cost to health systems.

These issues are not lost on healthcare device makers familiar with the product. At Oxford’s recent TATA Idea Idol business plan pitch competition – where FoetoH was a finalist – judge Will Chadwick of TATA Interactive Systems noted that the only realistic market for FoetoH were overly concerned mothers from the industrialized world who were willing to pay for a device that provided peace of mind rather than a clear-cut medical benefit over existing practices.

In fairness to FoetoH, its TATA Idea Idol team went on to win this year’s competition despite Chadwick’s misgivings (so someone clearly thinks FoetoH has something going for it). In the end, the science and potential commercial market for the device were convincing enough to beat out a number of strong competitors. FoetoH is a useful reminder for clinicians. Sound science and commercial availability do not make good medicine. Healthcare providers have to always maintain a critical eye and question new healthcare good and services to ensure that they are consistent with the individual provider’s aims and means of care as well.

Global Health’s Latest Offspring: “Global Surgery”   1 comment

Outside Hôpital St. Thérèse, Hinche, Haiti

Outside Hôpital St. Thérèse (Hinche, Haiti)

“Global surgery” is a relatively new addition to its parent field of global health. Although the notion of surgeons from the industrialized world sharing skills and equipment with resource-scarce environments has been around for decades (largely arising out of the medical operations of the world powers’ militaries), “global surgery” as an academic interest within traditional global health circles has emerged only recently. The increasing interest in the global burden of surgical disease has largely paralleled the relatively new awareness of noncommunicable disease as a global problem.

I should be clear that a consensus has only just begun to form in the last 10 years around the broadening of the definition of global health. For example, although there is an increasing effort to use “global health” in a more appropriate, literal sense, many well-qualified academics still associate the term with the unique disease burden of low- and middle-income countries. Say “global health” in a professional healthcare setting and poor, non-white people suffering from malaria or HIV is what the majority of the audience will be envisioning. It is only recently that the more complex problems of noncommunicable diseases like diabetes and cancer that span the industrialized and developing world have been authentically engaged by the global health community.

Inside Hôpital St. Thérèse

Inside Hôpital St. Thérèse (Hinche, Haiti)

Within global surgery, I am most interested in the persistent difficulty we have of finding the means of providing even the most basic surgical care for all the world’s communities. Although it will be decades before the poorest countries will have the means of performing complex surgeries like spinal fusions or coronary artery bypasses, the infrastructure and skills necessary to perform hernia repairs and thyroidectomies is well within reach. These latter cases may be less “newsworthy” but they represent substantial quality-of-life improvements for patients suffering from surgically-correctable disease. Although the field of global surgery is still in its nascent stages, a number of expert bodies are catalyzing around the idea of essential surgical care (e.g., ASAP TodayWHO GIEESC) and how best to deliver it.

A note on the pictures: The pictures in this post include two from a humanitarian surgical mission I joined in June 2009. This was the first of a series of many missions (more in a later blog post). I inserted these two images here to demonstrate how even the limited infrastructure of Hôpital St. Thérèse (see “outside” photo) can provide the platform for delivering basic surgical care (see “inside” photo). The bottom picture is provided courtesy of Nick Vittone of