Study on Mobile Applications for the Health Sector

CONSULTING EXPERTISE | INNOVATION AND IMPACT | DEVELOPING MARKET INSIGHT Study on Mobile Applications for the Health Sector Workshop on Case Studies & Business Model Analysis January 20, 2010

Table of contents • Overview of mHealth ecosystem, impact, and services • Four example business models: • WelTel • Changamka • HMRI • Voila Foundation / Red Cross Public Health Advisories • Prioritization framework, financing and implementation mechanisms • Conclusions • Annexes

The mHealth ecosystem is created through the collision of three sectors – health, technology and finance – with the backdrop of government policy and regulation Government Legislators Regulators Legal system Ministries Health Health system Health care workers Medical supply chains Patients Health funding mHealth applications mHealth Service delivery Technology Software developers Mobile operators Handset makers Finance Banks Insurance companies Private investors Philanthropists Donors Mobile platforms 2 Source: Dalberg research and analysis

Framework for mHealth impact Better health Outcomes Intermediate outcomes Multipliers Outputs Inputs Access, affordability, quality, matching of resources, behavioral norms ICT literacy Health literacy Health training M&E Complementary mServices Complementary capital investments ICT maintenance and repair capacity mHealth service delivery Financing Health system needs Health care best practices Procurement & Supply chains Cultural attitudes Network installations Distribution channels Research & Development Policies & Strategies Related Infrastructure Regulation & Standards Leadership & Governance Communication & Education 3 Source: Dalberg research and analysis

Examples of mHealth interventions Health services Description of mHealth usage and applications Example Cases 1 Usage of mobile handheld devices to collect data remotely (e.g., by community health workers); additionally, use of remote diagnostic tools for disease surveillance and treatment; includes civic participation in reporting outbreaks and disease information Data Collection / Disease Surveillance 2 Treatment Adherence / Appointment Reminders Utilization of messages and voice to communicate treatment and procedural reminders to patients (e.g., automated SMS reminders to patients on chronic medication) 3 Emergency Medical Response Systems Emergency response tools , including creation of EMR via mobile phones, and ambulance services whose reach is extended with mobile usage in remote areas Collection and analysis of patient data, particularly at clinics or related to call centers that are used to triage services and treatment; information to help health worker prioritization; information on inventory (Note: overlaps with supply chain management) 4 Health Information Systems & Support Tools for Health Workers 5 Supply Chain Management Management of inventory and supply chain steps by mobile tracking and communication; includes advocacy informed by supply chain information 6 Health Financing Use of smart-cards, vouchers, insurance and lending for health services linked to mobile platforms (e.g., m-Pesa) or otherwise enabled using mobile 7 Disease Prevention and Health Promotion Use of mobile and SMS-based health information and education to inform individual patients of preventive care and treatment Source: Dalberg research and analysis 4

0 Overview of Weltel (1/2) • Adherence is a huge issue in treating patients who are HIV-positive and taking antiretroviral therapies (ART), thus, WelTel provides weekly SMSes from clinic nurses to patients, inquiring regarding their treatment, and patients are required to respond within 48 hours; if no response is received, the nurse follows up with a call and referral if needed • Social-enterprise model, funded by PEPFAR and CDC • Founded in 2007 Concept • Advantages: • With reminders, patients adherence improves, leading to better outcomes in terms of suppressed viral loads • Cost-effective means of extending health system reach where roads are bad and travel expensive, but mobile service is inexpensive and reliable; basic handset is required (rather than a smartphone); utilizes existing clinic nurses • Cost of the offering decreases with scale; also reduces overall health system costs by estimated 1-7% due to ability to more efficiently following patients, and keeping patients healthier via improved compliance, meaning they use less emergency health services and avoid development of drug resistance and need for 2nd line medications • Potential to move “horizontally” beyond HIV given simplicity of system • Results: • In recent RCT, patients receiving SMSes had better adherence and suppressed viral loads • Beneficiaries and willingness to pay: • Patients receiving antiretroviral therapies (ART), primarily in the pastoral Masai communities of Kenya; ART funders who canreceive better return on investment • Patients at Kajiado and Pumwani Health Centre receiving ARTindicated a willingness to pay up $0.50 to $1 USD. Value proposition Results of recent clinical trial No. patients • Current scale: Pilot and RCT in 273 patients • Costs/revenue: Budget for RCT was $719k • Estimated costs to scale: • Scaling to 400k PEPFAR patients on ART would result in 26,000 additional patients with suppressed viral loads • At $8/patient, this would cost $3.2M, which is approximately 1-2% of PEPFAR treatment budget Market Total no. patietns Treatment Adherent patients Suppress viral loads Patients receiving SMS Patients NOT receiving SMS Source: The Lancet; Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomized trial; November 2010: Dalberg research, interviews and analysis, 2010. Nation Media, December 2010 http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf; http://www.scidev.net/en/health/hiv-aids/news/texting-saves-lives-of-hiv-patients-study-confirms.html

l Overview of Weltel (2/2) • Government / policy: Need for greater medical policy leadership that brings together stakeholders to build the evidence base and prioritize models in coordinated rather than competitive way • Funders: Legacy systems and competing interests can slow the pace of change and overall scale of programs proven to work; similarly, while WelTel can be deployed horizontally across other disease areas, health systems and their funders continue to be somewhat siloed • Mobile Network Operators: Poor network coverage can present constraints to reaching patients • Users: Shared phone access can present difficulties reaching individuals in a timely manner Challenges across the ecosystem • Medical policy leadership and coordination: To address gaps in the evidence base and in streamlining of systems, need for greater leadership across the technology developers, the health systems players and funders. This can come from a number of players – including academic institutions involved in developing models (e.g., British Columbia Centre for Disease Control), alongside international champions and conveners (e.g., the mHealth Alliance, WHO/ITU) • Prioritize and integrate funding into large scale systems addressing HIV and beyond: WelTel has received interest from PEPFAR in rolling out this model beyond the current pilot; more broadly, there is an opportunity for other large scale funders to prioritize and request these types of interventions in country funding proposals for HIV programs and health systems (e.g., the Global Fund’s HSS funding) Potential actions Source: Dalberg research, interviews and analysis, 2010. Nation Media, December 2010 http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf

0 Overview of Changamka Micro health Limited, SmartCard (1/2) • A fully digital health savings account, based on a smart card. New cards include credits for a medical consultation, a lab test, and a prescription. Can be used to pay for outpatient services within a network of health care providers and topped up using the M-PESA platform. • For-profit model; receives about 20 percent of the sale price of each card. • Founded in 2008 Concept • Advantages: • Savings on treatment and services are realized at the point of care across a network of nearly 4 dozen clinics across Nairobi. • Security of savings is improved. • Does not require regular premiums (savings plan for selected treatments) • Allows subscribers to share the smart card with family members and is not limited to individual use • Results: • Sale of 8,000 smartcards in first 11 months of operations, selling an average of 500 cards/month • Beneficiaries and willingness to pay: • Pregnant women and new mothers; based on sales todate, customers are willing to pay (initial card = Ksh 500, preloaded with standard services Value proposition Required scale for sustainability Here the chart on the current sales and what is required to break even. 23,300 Kenya Shillings (‘000) • Current scale: Signed on 25 local providers, and has extensive waiting list of providers eager to join the program’ customer base has been growing over time. • Current revenues: ~Ksh 3.2m ; Sales are falling short of commercially viable levels: sales of Ksh 23.3m required to break even Market +630% Revenue(year 1) Revenue (required to break even) Cards sold per month: 500 8,500 Source: Dalberg research, interviews and analysis, 2010.

i Overview of Changamka Microhealth Limited, SmartCard (2/2) • Users: Introducing a new product and serving a market whose culture is not accustomed to health savings requires significant high-touch marketing and consumer education. • Financing: High costs of customer acquisition are a challenge. The executive management team attributes this to a lack of marketing and challenge of promoting health insurance in Kenya due to negative historical image. • Technology: Potential to integrate technology and usemobile transfer and storage of payments rather thansmart-card; would streamline with mPesa platform and eliminate costs associated with card Less than 2% of Kenya’s population are covered by health insurance Challenges across the ecosystem 38,600 ‘000 people Insured 700 Uninsured 37,900 • Support scale: Funders who support health service delivery can consider linking their existing financing or possibly cash for work programs to Changamka to support scale Potential actions 2009 • Product bundling and/or joint marketing: Pursue bundling of product and/or joint marketing efforts with other adjacent offerings to engage new customers and get them accustomed to the service and value proposition • Fundraising to support customer acquisition costs: Pursue financing via private or blended sources to move towards furthering proof of concept and continuing customer acquisition; this could include cost-sharing with government or a philanthropic funder to increase the reach of marketing efforts Source: Dalberg research, interviews and analysis, 2010.

% Overview of HMRI –104 Advice (1/2) • Improve local health services through a comprehensive, multiplatform approach that replaces the traditional health care system with interventions delivered directly to rural and underserved communities; In addition to 104 Advice hotline, includes mHealth applications for disease surveillance, prevention counseling, telemedicine, and supply chain management • Social-enterprise/hybrid model, funded by the government of Andhra Pradesh state (95% of costs) and the Satyam Foundation (5% of costs) • 104 Advice launched in 2007 Concept HMRI estimates that of the 600k unmet requests for outpatient treatment, 55% could be treated by phone 600,000 100% • Advantages: Services may cost as little as one tenth as much versus government provision; health services are available to rural patients in their own communities, saving them time and money; services are integrated across many areas • Results: 50,000 calls taken per day; 10 million medical records created; 1,500 people employed; ; since it’s inception, the offering has grown from 4 seats attending 200 calls/day to a new facility of 400 seats working 24 hours per day to attend an average of 50,000 calls per day • Beneficiaries and willingness to pay: Patients in need of medical counsel or advice in Andhra Pradesh; willingness to pay is not fully tested; as the service has been provided free of charge for three years Value proposition % requiringlive consultation 45% % who can be treated by phone 55% Market • Current scale: 80 million people covered in Andhra Pradesh; An estimated 55% of unmet requests for outpatient treatment (600,000 per day) could betreated by phone (see chart on the right) • Estimated costs to scale: Already at scale in Andhra Pradesh • Competition: Within the state of Andhra Pradesh, HMRI holds a dominant market position, strengthen by its ability to integrate services across a variety of areas. However, competition will be an issue in other states where for-profit health hotlines are being delivered by operators and healthcare providers. Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report; http://124.124.103.76/hmrigovtview/; http://www.hmri.in/104-Advice.aspx; http://healthmarketinnovations.org/program/health-management-and-research-institute-hmri

% Overview of HMRI – 104 Advice (2/2) • Health system and human capital: High staff turnover, especially among doctors; This challenge is common across health hotlines, and requires increased incentives and/or creative HR management • Access to capital – limited public funding for increasing scale:Increased scale and replication beyond Andhra Pradesh will require additional capital Challenges across the ecosystem • Replication and scale beyond India: given health system constraints in rural areas across the developing world, this model could be pursued by funders – including national governments and global health funders of health systems It could be included as an option in funding proposals. Similarly, it could be integrated into offerings of national governments / MOHs and NGO implementers based in cities and other areas with higher concentrations of doctors • Access to finance: In order to finance expansion of this model, there are several avenues that might be pursued. First, securing funding from large scale funders for health systems, or even catalytic funders such as angel investors or smaller foundations who invest in health systems could help with start-up costs. From there, there is the potential to explore a cross-subsidized model in which 104 Advice - or other product offerings - could be provided to higher end customer segments to subsidize its advice hotline to the rural poor Potential actions Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report; http://124.124.103.76/hmrigovtview/; http://www.hmri.in/104-Advice.aspx

0 Overview of Voila Foundation / Red Cross Public Health Advisories (1/2) • Voila Foundation (Trilogy International) and the International Red Cross created the SMS Aid Application system to reach populations at risk post-earthquake in Haiti • Voila Foundation is the sole funder; non-profit model • Launched in 2010 Concept Red Cross estimates it has reached significantly more people via SMS based campaigns1 • Advantages: • Rapid access to individuals with limited access to communication (this is a novel system with an “SMS gateway” that plugs into mobile network towers and can access any Voila customers who has been using that tower within the last fifteen minutes (i.e., not subscription based) • Ability to quickly scale to new areas at risk for epidemic • Two way communication capabilities, including link to a toll-free *733 hotline in Creole, to reinforce SMSes and complementary interventions • Results: • Cholera prevention: 4m SMSes sent to reach 0.5m people; 90,000 calls received to hotline; reinforced by sound trucks and radio • No studies yet to assess impact in terms of outcomes (behavior, infection rates), however studies planned to assess number of calls received via toll-free *733 number • Beneficiaries and willingness to pay: • All populations within range of cell phone towers in Haiti identified at-risk for public health situations (e.g., cholera, storm surge) • Ability to pay has not been tested, but anticipate this would greatly limit reach and compromise goal of reaching populations most in need Value proposition 4,000,000 # of people reached 1000% 400,000 Without SMS With SMS Market • Current scale: across Haiti, SMS Aid Application has delivered 26.6m SMSes and reached 1.2m people • Based on disaster preparedness campaigns; Red Cross Beneficiary Communications in Haiti 2010; • Source Voila, International Red Cross; Dalberg research, interviews, and analysis. http://www.trilogy-international.com/TrilogyVoilaIFRCSMSAidapplicationFINALUS.pdf; http://www.voilafoundation.com/partners.htm

0 Overview of Voila Foundation / Red Cross Public Health Advisories (2/2) • Technology developers: Limited bandwidth for 2-way communication; Voila is currently upgrading to accommodate; another challenge is communicating effectively in 140 characters or less of SMS; potential for innovation in hardware or software to accommodate additional information • Health workers / Red Cross: Need to scale in line with human capacity of operational teams and their ability to respond to issues identified via 2-way communication; if not, could create unmet expectations within the Haitian population • MNOs: Right now, exclusivity in agreements with sole MNO prohibits reaching customers of other operators • Users: Content requires literacy (being addressed by addition of toll free Creole hotline) • Donors: Additional funding will be needed to scale beyond Haiti Challenges across the ecosystem • Increase revenues: N/A; additional donor funding can be sought for roll- out beyond Haiti or to diverse funder base in Haiti • Increase customer base: N/A • Integrate into community health workers’ outreach roles: Potential for CHWs to act on responses received via 2-way communication • MNOs: While agreements are exclusive in Haiti, exploring additional partners and more open systems in countries beyond Haiti where Trilogy does not operate • Government: Close collaboration with the government and the Haitian Red Cross to use their system to support services auxiliary to the government, such as blood donor programs • Donors: Target funders and sponsorship in additional areas in need of disaster response – both from MNO contributions and/or from large scale funders involved in disaster recovery; potential for co-investment across multiple funders Potential actions Source Voila, International Red Cross; Dalberg research, interviews, and analysis.

Framework for Ministry of Health prioritization of mHealth interventions Key questions Desired outcomes • What are health needs / priorities? • What is the current state of / dynamics in the ecosystem (e.g., infrastructure, regulation, technology, applications)? 1 • Understand the key priorities, needs, opportunities and constraints in the ecosystem Review of local ecosystem and context • In which areas could mHealth/ICT play a role? • What are broader ICT and e-Gov priorities and initiatives that might complement mHealth? • What are core regulatory and implementation requirements (e.g., incentives, financing) 2 eHealth strategy development • Define strategic approach to eHealth that recognizes broader ICT/e-Gov priorities and integrates mHealth • What is the most efficient and appropriate means to implement (e.g., grants for R&D? Tender to select partner? Challenge fund?) • What is the roadmap for implementation (e.g., expected activities, timeline and resourcing?) 3 Implementation planning and tactics • Outline core requirements and tactics for implementation • What has been the success and impact of the selected mHealth applications and interventions in the context of the broader eHealth strategy? • What are lessons learned via M&E? • What refinements need to be made to achieve desired impact? 4 Evaluate and refine strategy and tactics • Identify lessons learned and understand impact to refine strategy and tactics Source: Dalberg research and analysis

A range of financing and implementation mechanisms are being explored and deployed across the technology life cycle of m-applications Stage 1: R&D Stage 2: Demonstration Stage 3: Deployment Stage 4: Diffusion Stage 5: Maturity Stage of technology lifecycle • Develop technology prototype • Establish evidence base (M&E) • Refine technology and model • Achieve scale of users • Further optimize product (e.g., lower costs) Objectives Tax credits Types of financing vehicles Challenge funds R&D grants (including competitive subsidy, cost sharing Licensure requirements Venture capital and Incubator funds Type of mechanism Cost-sharing / subsidies from large scale funders (e.g., PEPFAR, Global Fund, WB) = Public / philanthropic = Blended (public/private) Loan guarantees = Private Insurance / payers Venture capital (including angel investors) Industry investment (including equity, debt) Corporate R&D investment Note: Not exhaustive; Arrows do not indicate a continuum or linear relationship across funding vehicles Source: Dalberg research and analysis

Examples: Challenge funds and venture capital / incubator funds Potential actions by funders and/or implementers Description Conditions for deployment • Persistent market challenge – primarily within one of the following categories: • Innovation: technological challenge, requiring R&D and proof of concept (e.g., Gates Foundation Grand Challenges Fund) • New market development: market for a product or service does not exist due to limited profit potential or lack of upfront capital investments (e.g., Gates /USAID Haiti Mobile Money Prize Fund; Africa Enterprise Challenge Fund) • Requires multiple players who are willing to compete for the prize • Often these incentivize appeal more to private sector players in a competitive market • In appropriate markets, make challenge grants and use prize funds in lieu of “push” funding via grants • Approach can be attractive to funders, in that they only pay for success • Also provides a means to engage and incentivize private sector players, offering a path to sustainability • Prize fund set up to incentivize development of a new business model or to catalyze players to enter and engage in a new market Challenge funds • VC funding and incubator services are offered to support start-ups and entrepreneurs • Either blended capital (with philanthropic or impact investor components, or purely commercial) • Promising early stage, for-profit business models which lack access to capital and management training to grow • Flourishes in environments which are conducive to business operations • Examples of VC and incubator funding: • Commons Capital, a blended capital venture capital fund, has a Global Health Fund which invests in mHealth models; has seen significant increases in its mHealth deal flow in the past year • Sproxil, an anti-counterfeiting business model is an example of a for-profit model which seeks venture capital funding to grow its operations and expand beyond recent, successful pilot in Nigeria • Funders can choose to back blended capital VC and incubator funds focused on mHealth models, such as those emerging with Commons Capital or other impact investment vehicles (e.g., via the Aspen Network of Development Entrepreneurs or Global Impact Investors Network) • Existence of such funding could motivate innovators and implementers to pursue for-profit or hybrid (social enterprise) models rather than the non-profit models that dominate the current mHealth space Venture capital / incubator funds BACK Source: Dalberg research and analysis

Summary findings: High-level requirements across the ecosystem to realize the potential for mHealth Creation of mHealth services Scaling up and replication Enhancing impact on health outcomes Fostering an mHealth ecosystem • Create linkages to encourage innovation • Support for business models and financing • Understand costs • Monitor and evaluate to create an evidence base for decisions • Support capacity and training across the ICT industry • Customize content • Invest in health and ICT literacy • Document outcomes • Prioritize successful models • Support for critical inputs (e.g., entrepreneurship, incentives for mobile operators to partner, etc) • Investment in multipliers (e.g., creation of eHealth strategies; support for mobile money, etc) 19

Table of contents • Overview of mHealth ecosystem, impact, and services • Four example business models: • WelTel • Changamka • HMRI • Voila Foundation / Red Cross Public Health Advisories • Prioritization framework, financing and implementation mechanisms • Conclusions • Annexes • Illustrative case studies (Note: more extensive information is provided where possible based on interviews and analysis in case study countries) • Examples of financing and implementation mechanisms

0 Overview of Millennium Village Project's ChildCount+ (1/2) • A real-time database covering Kenya’s children, including immunization and health risks; uploaded by CHWs via SMS; supports Millennium Villages Project interventions (e.g., acute malnutrition management, diagnosis and treatment of malaria, ORS and zinc). Piloted in Sauri, Kenya. • Non-profit model; Part of MVP, fully funded by Earth Institute (Columbia), Millennium Promise, UNDP; with in-kind support provided by Ericsson, Zain, UNICEF • Launched in 2009 Concept • Advantages: • Better monitoring reduces child mortality; expands health system’s reach; saves time vs. paper records; helps CHW prioritization • Results: • >9,500 children registered by 108 CHWs in 3 months; adoption underway by UNICEF and interest from other implementing organizations • Beneficiaries and ability to pay • Pregnant women and children under 5 years old; limited ability to pay Value proposition • Current scale: In Sauri, Kenya, 108 CHWs support 8 clinics and one sub‐district hospital in Sauri Kenya. This includes over 9500 children (registered after 3months), 7,646 nutrition screening reports, 839 RDT results and registration of 7,803 measles vaccinations. • Current costs/revenue: Undisclosed • Estimated costs to scale: Undisclosed Market Source: ChildCount+; Dalberg research, interviews and analysis, 2010.

5 Overview of Millennium Village Project's ChildCount+ (2/2) Challenges • Financing for scale and sustainability: The main path to scale and sustainability is either to be funded by a large scale funder (e.g., USAID, World Bank) or national government who supports health systems. While the national adoption of the model in Uganda and Nigeria is encouraging, questions remain regarding national governments ability to sustainably fund the costs of the SMSes and training over time. • Mobile Network Operators: A key piece of the model has been utilizing toll free SMSes with reverse billing, which enables individual CHWs to utilize the application without paying directly for each SMS sent. The process of establishing this arrangement and making the case to operators has been longer than expected or desired; as the model is replicated and scaled, mobile operator support and model innovation in individual countries could drive the pace and trajectory of expansion. • Handset costs: In the Sauri roll-out, higher end, relatively expensive phones were used; this could be a barrier to scale if costs increase; however, it is anticipated that lower cost phones could be used. • With emerging evidence base on effectiveness, advocacy for governments to include in, and donors to fund, in proposals for HSS: ChildCount+ could be an important tool in countries’ strategies for HSS and maternal/child health. Donors who are shifting towards an HSS platform and increasingly looking for ways to fund health systems, should ask for and include mobile-based registration programs as a means to address maternal and child health. This would include large scale health funders such as the USG’s Global Health Initiative, Global Fund, GAVI, and the World Bank. • Standardize system for reverse billing, and incentivize MNOs: Additionally, to address the ease of establishing arrangements with MNOs, the process of setting up reverse billing can be standardized and the market opportunity made clear to the MNOs (e.g., revenue potential of reverse billing system by increasing volume); similarly, local governments can incentivize further participation in these types of programs, particularly at start up. Incentives could include tax credits or licensing arrangements which are linked to innovative partnerships with local mHealth programs. This would incentivize the MNOs to help develop creative solutions which ease of implementation and further collaboration between the implementing organizations (e.g., ChildCount+) and MNOs. • Build for scale – including integration of offering on lower cost phones: The technology and offering will need to be integrated onto lower cost phones in order to scale cost-effectively. This is believed to be feasible based on ChildCount+ interviews, and is planned going forward. Potential actions Source: ChildCount+; Dalberg research, interviews and analysis, 2010. BACK TO APPLICATION TYPES

8 Overview of Episurveyor • Episurveyor is an open-source cloud computing data collection application designed to lower the barriers to collecting high-quality data by creating an inexpensive, easy-to-use software for data collection on handhelds mobile devices. • Episurveyor’s theory of change is that, if the cost and difficulty of collecting data is reduced, then data is more likely to be collected. Concept • Advantages: • More and faster analysis – the assumption is that digital data is easier to analyze which will make analysis more feasible and timely. Faster data means the ability to more quickly respond to changing circumstances. • Lowered cost of program assessment –Current systems for quality data collection are too costly and only available to well-funded programs Value proposition • Promotion of standardization and meta-analysis – No universal system for sharing data collection instruments currently exists. EpiSurveyor survey files, which as electronic files care easy to catalog, download, share, and use, can provide a common platform for sharing those data collection instruments that represent best practices. • Uses: Managing disease outbreak such as polio or malaria, ongoing data collection, supply chain management. • Results: An End Use Verification of the President’s Initiative for Malaria was carried out in Ghana in order to monitor malaria supply chain. Results indicated 3 critical areas of impact: • Time – See graph • Data quality – Negligible difference. 1.5% difference between the two methods. • Ease of use – 100% qualitative assertion that survey respondents would prefer to replace paper-based data collection with EpiSurveyor Speed of data collection -18% Time (min) Paper Based Episurveyor Market • Current scale: Nearly 3000 users; >100 000 records uploaded BACK TO APPLICATION TYPES Source: Dalberg interviews and analysis; http://datadyne.org/files/Zambia_EpiSurveyor09_Technical%20Report.pdf

t Overview of Pesinet • Pesinet combines mobile technology and proximity work of community health agents to deliver home based care that will offset the limited capacity of existing public health systems and provide affordable healthcare that can prevent, detect and treat childhood diseases. • Mobile phone based data collection system allows monitoring and early treatment of common diseases. First pilot launched in October 2008, with funding from Telcom operators Orange and Alcatel Lucent. • Intended outcomes: • Reduced mortality • Reduced health spending on benign illnesses • Increased prevention and sanitation • Job creation • Skills development Concept • Advantages: • Value to patient (mother and child) – cost savings 1 USD subscription includes a subsidized doctor consultation and highly discounted rates on prescriptions. (vs. USD 1.2 – 2 consultation fee • Quality – in a local survey, over 95% of respondents were satisfied with the service, pleased with the price and would recommend it to a friend or family member • Value to the provider - improved efficiency and operations – greater efficiency realized through mobile based data collection Value proposition Market • Current scale: Not at scale. 390 children in pilot clinic. Required break even estimated at nearly triple this number. BACK TO APPLICATION TYPES Source: Dalberg interviews and analysis; Pesinet website

0 Overview of Weltel (1/2) • Adherence is a huge issue in treating patients who are HIV-positive and taking antiretroviral therapies (ART), thus, WelTel provides weekly SMSes from clinic nurses to patients, inquiring regarding their treatment, and patients are required to respond within 48 hours; if no response is received, the nurse follows up with a call and referral if needed • Social-enterprise model, funded by PEPFAR and CDC • Founded in 2007 Concept • Advantages: • With reminders, patients adherence improves, leading to better outcomes in terms of suppressed viral loads • Cost-effective means of extending health system reach where roads are bad and travel expensive, but mobile service is inexpensive and reliable; basic handset is required (rather than a smartphone); utilizes existing clinic nurses • Cost of the offering decreases with scale; also reduces overall health system costs by estimated 1-7% due to ability to more efficiently following patients, and keeping patients healthier via improved compliance, meaning they use less emergency health services and avoid development of drug resistance and need for 2nd line medications • Potential to move “horizontally” beyond HIV given simplicity of system • Results: • In recent RCT, patients receiving SMSes had better adherence and suppressed viral loads • Beneficiaries and willingness to pay: • Patients receiving antiretroviral therapies (ART), primarily in the pastoral Masai communities of Kenya; ART funders who canreceive better return on investment • Patients at Kajiado and Pumwani Health Centre receiving ARTindicated a willingness to pay up $0.50 to $1 USD. Value proposition Results of recent clinical trial No. patients • Current scale: Pilot and RCT in 273 patients • Costs/revenue: Budget for RCT was $719k • Estimated costs to scale: • Scaling to 400k PEPFAR patients on ART would result in 26,000 additional patients with suppressed viral loads • At $8/patient, this would cost $3.2M, which is approximately 1-2% of PEPFAR treatment budget Market Total no. patietns Treatment Adherent patients Suppress viral loads Patients receiving SMS Patients NOT receiving SMS Source: The Lancet; Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomized trial; November 2010: Dalberg research, interviews and analysis, 2010. Nation Media, December 2010 http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf; http://www.scidev.net/en/health/hiv-aids/news/texting-saves-lives-of-hiv-patients-study-confirms.html

l Overview of Weltel (2/2) • Government / policy: Need for greater medical policy leadership that brings together stakeholders to build the evidence base and prioritize models in coordinated rather than competitive way • Funders: Legacy systems and competing interests can slow the pace of change and overall scale of programs proven to work; similarly, while WelTel can be deployed horizontally across other disease areas, health systems and their funders continue to be somewhat siloed • Mobile Network Operators: Poor network coverage can present constraints to reaching patients • Users: Shared phone access can present difficulties reaching individuals in a timely manner Challenges across the ecosystem • Medical policy leadership and coordination: To address gaps in the evidence base and in streamlining of systems, need for greater leadership across the technology developers, the health systems players and funders. This can come from a number of players – including academic institutions involved in developing models (e.g., British Columbia Centre for Disease Control), alongside international champions and conveners (e.g., the mHealth Alliance, WHO/ITU) • Prioritize and integrate funding into large scale systems addressing HIV and beyond: WelTel has received interest from PEPFAR in rolling out this model beyond the current pilot; more broadly, there is an opportunity for other large scale funders to prioritize and request these types of interventions in country funding proposals for HIV programs and health systems (e.g., the Global Fund’s HSS funding) Potential actions Source: Dalberg research, interviews and analysis, 2010. Nation Media, December 2010 http://ea.nationmedia.com/EA/ea/2010/12/13/PagePrint/13_12_2010_028.pdf BACK TO APPLICATION TYPES

0 Overview of TxtAlert (South Africa) • On average 30-40% ofARV patients initiated onto treatment in South Africa are lost to follow up’ (LTFU) within the first year. This is due to a variety of reasons, including a lack of government leadership which leads to conflicting messaging regarding HIV treatment. However, over 90% of patients at the clinic have/ or have access to cell phones and are comfortable with SMS and Please Call Me Services Concept • TxtAlert was designed to reduce the percentage of lost to follow up patients by improving overall appointment attendance. Reduction of LTFU and missed appointments Without TxtAlert • Outputs and intermediate health outcomes • Improved operational efficiency: Reduction in missed appointments leads to improved admin efficiency. • Increased patient provider communication through use of ‘please Call Me’ to phone the clinic at no charge. • Reduced number of patients lost to follow up reduces overhead costs and ability to maximize lives saved with limited supplies of ARVs. Value proposition TxtAlert Percentage of patients % Market • Current scale: Currently serving over 15 000 in Johannesburg, South Africa. Missed appointments LTFU BACK TO APPLICATION TYPES Source: Dalberg interviews and analysis.

Overview of iChart Emergency Response (1/2) • A self-contained mobile phone application that allows emergency response physicians to upload patient data and download treatment information, generating electronic health records instantaneously • Non-profit model; Much of the initial budget was donated as in-kind products and services, and iChart continues to rely on cash donations for operation and maintenance • Deployed in Haiti in 2010 Concept Cloud Computing Server Reports • Advantages: electronic health records improve coordination of care and reduce medical errors; the system could provide a basis for a nationwide medical records database; costs of data collection are much lower than for traditional methods; the status quo without iChart would have been ad-hoc paper or excel based data collection, which results in patents with incorrect or no documentation of their diagnosis or treatment. • Results: More than 500 medical records created, though take-up rate has been low • Beneficiaries and willingness to pay: patients in need post-disaster or in other emergencies; doctors and health system which can more effectively track patients and allocate resources; low expected willingness to pay based on systemic nature of the value. Value proposition iPhone • Current scale: Post-earthquake it was used by more than 140 Palo Alto Medical Foundation physicians, nurses and support staff. More broadly, there is room to integrate this type of application and attributes with other forthcoming EMR systems. However, the fact that it relies on an iPhone, at this point, makes it less attractive and relevant in low resource settings • Current costs: ~$19,000 for 3 month deployment in Haiti • Expected costs to scale: Undisclosed • Competing or complementary interventions: Building off of iChart’s efforts, HHI Hospital in Fond Parisien created an iPhone web based application in which emergency physicians entered patient diagnosis and treatment data to a local server, eventually generating medical record reports for 500-750 patients Market Source: Dalberg interviews, research and analysis, 2010.; OMI UN/PAHO Report Sept 2010

g Overview of iChart Emergency Response (2/2) • MNOs: Poor network signal in many areas limits usage • Healthcare workers: Practitioners must become used to a complex application in emergency situations; requires training • Standards: with no existing emergency EMR standards, iChart currently is not interoperable with other EMRs • iPhone required: this is not accessible on other types of smart phones or lower end phones, limiting the potential for scale and replication, particularly with indigenous CHWs • Ongoing funding: Funding may be limited if donations dry up; similarly, this tool will need to be evaluated for cost-effectiveness overall relative to other potential solutions and applications, particularly those which can be used on a lower-end phone. While costs initially were rather high for the hardware, software, and customization, these could be expected to decrease in the future as they are amortized over further usage Estimated costs for 3-months of operations Challenges across the ecosystem $9,010 $6,240 $5,750 $2,900 $3,840 $0 Month 1 (Actuals) Month 2 (Actuals) Month 3 (Forecast) IT hardware IT customization/ maintenance IT software Project management • Standards development and integration: Alignment onemergency EMR standards, and integration with broaderEMR standards will be critical to ensure uptake and maximum relevance and uptake of this application. • Evaluation of relative cost effectiveness: given the iPhone requirement and current limited usage, it will be critical to evaluate the relative cost effectiveness of this versus other products and applications when considering deployment in future disaster situations. • Agreement on approach and usage in emergency response situations: Following evaluation of relative cost-effectiveness, iChart can be integrated into future post-disaster relief efforts. This will require outreach and coordination across key agencies and NGOs involved in relief, as often there are many agencies, NGOs and individuals involved in immediate response efforts. If iChart is believed to be the best option – and one which an be interoperable – the disaster relief community should align on this as a standard and integrate it into plans and offering. “Everything was bootstrapped, we even held bake sales. Sustainable funding is required to move the development of the application forward. ” -iChart Emergency Medical Volunteer Doctor Potential actions BACK TO APPLICATION TYPES Note: There are not “training costs” as no formal training was provided during roll-out, which was feasible in that the iPhone was a familiar device to the physicians using it, though may not be a sustainable practice in the long-run Source: Dalberg interviews, research and analysis, 2010.; OMI UN/PAHO Report Sept 2010

g Overview of Ziquitza Healthcare Ltd, 1298 Ambulances (1/2) • An easy-to-remember telephone number for the rapid delivery of emergency services via ambulance in urban and suburban areas • Social-enterprise model; 1298 is contracted by government as part of a public-private partnership to offer emergency services through official channels (initially funded by Acumen Fund, and implemented by Ziquitza Healthcare Ltd. In conjunction with governments in Rajasthan, Mumbai and Kerala) • Founded in 2005 Concept • Advantages: Extends reach via mobile – 90% of calls to 1298 come from mobile phones, often from people who would not otherwise have been able to communicate with emergency service providers; radio dispatch sends the closest ambulance with appropriate equipment and crew to the caller’s location • Results: 70,000 calls answered in five years; measurable impact on maternal mortality in childbirth (50% of calls are to support pregnant women, resulting in reduced infant mortality and fewer complications in childbirth) • Beneficiaries and willingness to pay: Patients in need of emergency services and transport; Customers are charged on a sliding scale depending on the kind of hospital that patients choose for treatment, with the poorest patients receiving discounts of 50 to 100% Value proposition Market • Current scale: Grew from 10 ambulances to 280; Expects to have 1,000 ambulances serving millions of people by 2012 • Current revenues and costs: Full financials undisclosed, but have been awarded $80m in government contracts for free or subsidized services in several states. • Estimated costs to scale: Already at scale • Competition: There are three competing ambulance and emergency services currently operating in Mumbai and across the country but, at present, the high level of demand outweighs competition. Source: Dalberg Interviews September 2010; Dalberg Analysis BACK TO APPLICATION TYPES

g Overview of Ziquitza Healthcare Ltd, 1298 Ambulances (2/2) • Financing: • Profitability: Ziquitza’s profitability is driven by the ability to operate in high population density areas where the mix of ‘ability to pay’ allows for cross-subsidization. Alternatively, (recognizing that these economics are not often available) Ziquitza works in partnership with government and has realized nearly $80M in government contracts to provide its services. • Primary revenue drivers include fees for emergency transfer to private hospitals, fees for general hospital transfer, and to a lesser extent, contract services from the government. • Primary costs include: Fixed costs include the ambulance fleet and call centers; variable costs include human resources (staff of over 240), fuel costs, maintenance and repairs, and short codes – negotiated for free based on current government policy • Constraints of tiered pricing model and cross-subsidization: The tiered pricing model depends on a diverse patient mix and cannot be rolled out to rural areas where there are few middle- and high-income patients; more consumer education may be needed to encourage greater use of existing services Challenges across the ecosystem • Grow government contract business: One promising area for revenue growth is with government contracts, which currently is a smaller share of business. By working with the government, and customizing services to meet their needs in the markets in which it currently pays for transfers and other services (e.g., potentially, employee care), it can increase its revenue potential • Grow higher-end and lower-end customer base: Additionally, by growing the share of higher end customers, who can pay fees and help stabilize the top line of Ziquitza’s model, there is a clearer path to profitability. • Provide subsidies or other incentives for roll-out in rural and/or lower income areas: While profitability may depend upon growing higher-end customer segments, given the need and utility of serving rural areas and populations, the government and/or other funders can incentivize profitable expansion by providing subsidies for lower end customers served and exploring other tools (e.g., policies and credits which lower cost base and otherwise enable this business model – e.g., such as that which was done with free short code. Potential actions BACK TO APPLICATION TYPES Source: Dalberg Interviews September 2010; http://www.scribd.com/doc/11575031/Dial-1298-for-Ambulance-HSBC-PPT

Overview of PEPFAR/Solutions HMIS (1/2) • A precursor set in HIV/AIDS clinics of a health information system for Haiti, with mHealth applications for disease surveillance; Health workers report disease incidence and symptoms via SMS to a central database; funding for the next five years is from PEPFAR and the U.S. Centers for Disease Control, with the Haitian government promising to step in afterward • Non-profit model; Funded by PEPFAR • Launched in 2008 Concept • Advantages: Expanded reach of the health care system; data entry is more cost-effective; most Haitians are familiar with mobile phones and SMS; minimal infrastructure is required; data are updated weekly, which was previously impossible; lower costs in terms of maintenance and repairs • Results: Collection of data from 150 clinics • Beneficiaries and willingness to pay: HIV clinic patients and overall health system users; given data and information accrues value across the system, willingness to pay resides with health system funders (e.g., PEPFAR) Value proposition • Current scale: Government contract for 700 clinics over five years • Current costs: cost of implementing SMS based data collection is 7% of computer terminal data entry, and 13% of ongoing operations cost • Cost to scale: Undisclosed Market Source: http://2006-2009.pepfar.gov/documents/organization/81062.pdf; Dalberg interviews, research and analysis, 2010.

0 Overview of PEPFAR/Solutions HMIS (2/2) Cost for each new clinic – computer vs. mobile data entry1 • Health sector: “Vertical” – HIV/AIDS focused approach, built for HIV/AIDS and hard to expand; no national standards for electronic health records; no incentive to share data beyond PEPFAR clinics; lack of integration with other health areas • MNOs: Poor network strength in remote areas, plus collecting data via phones can be limited and cumbersome depending on the patient’s needs and status • Training requirements and costs: Need for additional training in scaling application; raining is essential and largest cost for scaling Challenges across the ecosystem Operating costs Hardware $9,580 Internet set-up 80 Generator -93% 5,000 $710 10 Computer Mobile • PEPFAR to push for integration and standards to roll-out HMIS: Given PEPFAR’s ownership of this program and presence in multiple countries beyond Haiti, it is well positioned to push for greater integration – asking for data not only on HIV/AIDS, but collaborating with other donors and asking for data that adheres to standards and is possible to integrate with broader health records and issues. One example of this is the iChart model, profiled in this study, which also creates medical records, and which is currently not integrated or utilizing the same standards as PEPFAR’s HMIS. • Training requirements and costs: Explore potential to bundle training and achieve economies of scale by coordinating with broader efforts to create training courseware and certification – relevant in Haiti and beyond. Potential actions BACK TO APPLICATION TYPES (1) The backend server and infrastructure required for computer or mobile data entry is separate from these numbers and about the same cost in this case. Source: Dalberg interviews, research and analysis, 2010.

% Overview of HMRI –104 Advice (1/2) • Improve local health services through a comprehensive, multiplatform approach that replaces the traditional health care system with interventions delivered directly to rural and underserved communities; In addition to 104 Advice hotline, includes mHealth applications for disease surveillance, prevention counseling, telemedicine, and supply chain management • Social-enterprise/hybrid model, funded by the government of Andhra Pradesh state (95% of costs) and the Satyam Foundation (5% of costs) • 104 Advice launched in 2007 Concept HMRI estimates that of the 600k unmet requests for outpatient treatment, 55% could be treated by phone 600,000 100% • Advantages: Services may cost as little as one tenth as much versus government provision; health services are available to rural patients in their own communities, saving them time and money; services are integrated across many areas • Results: 50,000 calls taken per day; 10 million medical records created; 1,500 people employed; ; since it’s inception, the offering has grown from 4 seats attending 200 calls/day to a new facility of 400 seats working 24 hours per day to attend an average of 50,000 calls per day • Beneficiaries and willingness to pay: Patients in need of medical counsel or advice in Andhra Pradesh; willingness to pay is not fully tested; as the service has been provided free of charge for three years Value proposition % requiringlive consultation 45% % who can be treated by phone 55% Market • Current scale: 80 million people covered in Andhra Pradesh; An estimated 55% of unmet requests for outpatient treatment (600,000 per day) could betreated by phone (see chart on the right) • Estimated costs to scale: Already at scale in Andhra Pradesh • Competition: Within the state of Andhra Pradesh, HMRI holds a dominant market position, strengthen by its ability to integrate services across a variety of areas. However, competition will be an issue in other states where for-profit health hotlines are being delivered by operators and healthcare providers. Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report; http://124.124.103.76/hmrigovtview/; http://www.hmri.in/104-Advice.aspx; http://healthmarketinnovations.org/program/health-management-and-research-institute-hmri

% Overview of HMRI – 104 Advice (2/2) Challenges across the ecosystem • Health system and human capital: High staff turnover, especially among doctors; This challenge is common across health hotlines, and requires increased incentives and/or creative HR management • Access to capital – limited public funding for increasing scale:Increased scale and replication beyond Andhra Pradesh will require additional capital • Replication and scale beyond India: given health system constraints in rural areas across the developing world, this model could be pursued by funders – including national governments and global health funders of health systems It could be included as an option in funding proposals. Similarly, it could be integrated into offerings of national governments / MOHs and NGO implementers based in cities and other areas with higher concentrations of doctors • Access to finance: In order to finance expansion of this model, there are several avenues that might be pursued. First, securing funding from large scale funders for health systems, or even catalytic funders such as angel investors or smaller foundations who invest in health systems could help with start-up costs. From there, there is the potential to explore a cross-subsidized model in which 104 Advice - or other product offerings - could be provided to higher end customer segments to subsidize its advice hotline to the rural poor Potential actions BACK TO APPLICATION TYPES Source: Dalberg interviews and research; Doctor in Your Pocket, GSMA 2009.; HMRI 2007-2009 Annual Report; http://124.124.103.76/hmrigovtview/; http://www.hmri.in/104-Advice.aspx

0 Overview of Clinton Foundation / Hewlett Packard (1/2) • The Clinton Health Access Initiative, Kenya’s Ministry of Public Health and Sanitation, and HP aim to provide technology to capture, manage and return early infant diagnoses (EID) on HIV test results; this will also create a back-end system for data capture on EID across Kenya • Non-profit model; HP investment in infrastructure ($1m); Roche funded set up of 4 labs at $250k each, as a means to generate demand for their reagents; partners who utilize system (e.g., PEPFAR, USAID) pay for use • Launched at Clinton Global Initiative in 2010 Concept • Advantages: • Increased speed of results: while paper-based system took up to two to three months, the HP system will return results in 1-2 days; turnaround time for test results is particularly critical for infants, as they must begin antiretroviral therapy as soon as possible to ensure survival (without immediate treatment, half of HIV positive infants aren’t likely to survive past age 2) • Building back-end to capture and analyze data: Data centers will have access to nation-wide data to inform prioritization of resources and healthcare interventions. Examples of this data includes coverage of early infant diagnoses, outcomes from preventing mother to child transmission (PMPCT) interventions) • Results: • Within first year, this program expects to deliver early diagnoses for approximately 70,000 infants • It also expects to build a database on EID results, and stream real-time medical data to health practitioners • Beneficiaries and willingness to pay: • Patients (infants of HIV+ mothers); very limited ability to pay; similarly, national government will not pay until demonstrate • impact and scale (likely ~10 years off) Value proposition Speed of information delivery Number of days -97% • Current scale: As stated above, will reach ~70,000 infants in Kenya Aims to reach up to 120,000 infants exposed to HIV in Kenya each year for testing and treatment; Intend to expand to more than 3,000 clinics over the next two years • Current costs: $1M investment (HP); $250k for each lab; in-kind contributions on technical design from Strathmore University students • Expected costs to scale: TBC Market Existing process SMS based printer Source: Dalberg interviews and analysis; AllAfrica - http://allafrica.com/stories/201012281280.html

Overview of Clinton Foundation / Hewlett Packard (2/2) • Financing: Questions exist regarding who will pay for the communication costs of the model as it scales. Currently, partners who utilize the model will pay for it (e.g., PEPFAR), however costs will grow as build out the back-end system and data captured and analyzed. • Technology developers:As new applications are developed, primarily as pilots, it will be a missed opportunity if they do not backward-integrate and build on existing systems, such as the data centers and back-end in the CHAI/HP model. • Government and policy-makers: There is a broad need for players who work with government and policy-makers to design systems and align resources so that systems such as this can be easily integrated and scaled, in line with underlying health needs. There is also need for an evidence base which will allow for understanding of the impact of this system so that it can be refined and eventually funded by national governments over time. Challenges across the ecosystem • Financing from large scale health funders as proof of concept and evidence base grow: as the model proves its value – both in terms of EID and data access, large scale funders such as PEPFAR, Global Fund can provide an avenue for funding of scale and capital needs in line with costs of communication needs and technology. • Further investment in and operational approach to linking problems with solutions: This might include greater formalization and operational capacity in ICT working groups or other local bodies, and would address the gap between health needs, e-/m-Health strategies and operational execution. This body could work with government/policy-makers and be a conduit for developing and implementing solutions in line with health needs, and local constraints and opportunities. It could also be a means to address coordination and greater standards/interoperability across existing and forthcoming data systems and individual business models. • Leveraging local capacity: There is strong local capacity in terms of developers and innovators who can be leveraged for design of data systems, which historically have been paper, and now can be integrated with mobile and ICT. Similarly, there is an opportunity to further leverage local university students who can support both M&E and health innovation. Innovation will come from young people who are in school, more than it is coming from the private or public sector Potential actions BACK TO APPLICATION TYPES Source: Dalberg interviews and analysis; AllAfrica - http://allafrica.com/stories/201012281280.html

0 Overview of mPedigree – Medicine Validation System (1/2) • The system, developed by mPedigree and HP, assigns a code that is revealed by scratching off a coating on the drug’s packaging. This code is texted by the consumer or medical professional to a free SMS number to verify the authenticity of the drug; If the drug is fake, the consumer will get a message alert and a hotline number for reporting • Social enterprise model with mix of non-profit funding (for advocacy) and revenue from pharma companies (for security codes) • Founded in 2007; launched in Kenya in 2010 Concept Share and value of counterfeit drug market in Kenya 100 Value of counterfeit market = $130M Counterfeit 30 • Advantages: • Increases transparency and raises awareness regarding counterfeit medicines • Provides consumers and medical professionals with a fast and • cost-effective means to verify the authenticity of drugs • Provides pharmaceutical manufacturers with a way to protect products • Desire to create a global standard to address counterfeiting • Results: • Intermediate outcomes – as it is early days, the partners have established alignment with partners on a model in Kenya; toll free SMS established with MNOs; next, will measure drug volume and range of drug categories in the system • Beneficiaries and willingness to pay • Beneficiaries are consumers of pharma products (who access SMS and security codes free of charge), and pharma companies who benefit from their ability to maintain market share and/or enter markets. Pharma has proven willing to pay – particularly amongst local, generic, pharma manufacturers Value proposition Authentic Kenya drug market • Current scale: If the initial phase is successful the intention is to expand it into a 'public' phase along the lines of the mPedigree approach in Ghana and Nigeria (i.e. full participation by mobile operators, and thus free-to-consumer text messaging); The initiative in Kenya marks the first time use of such a platform has been endorsed at cabinet level in any country; it will now aim to move beyond pilot via mass marketing via mainstream and social media, and steady replacement of old stock not bearing codes geo-spatially • Current costs/revenues: Undisclosed; Estimated costs to scale: Undisclosed • Competition: Competing solutions include Sproxil (successful pilot recently in Nigeria, and plans to enter East Africa) and PharmaSecure; differentiation in holistic and systemic model which bypasses aggregators to directly engage with MNOs, engages national governments and utilizes advocacy platform Market Source: KCB; Standard Media Kenya; mPedigree; WHO http://www.who.int/medicines/services/counterfeit/impact/ImpactF_S/en/index1.html

Overview of mPedigree – Medicine Validation System (2/2) • Mobile Network Operators: Unclear how long the MNOs will remain interested and provide SMS messages in-kind; right now, mPedigree is novel and garnering attention, but this may change over time. Deep contractual relationships and offering-diversification are mitigating factors. • Government: Takes time to get high-level government buy-in as is the case in Kenya; will need lead time for additional countries as scale beyond existing base across the continent • Financing: Near-term investment needs including funding for mass media marketing as move to scale; Need for patient capital; at scale, believe model can be profitable, but need for near term seed funding which is not entirely commercial (e.g., impact investing or hybrid venture capital) • Users: The concept of using the mPedigree system is new to consumers, so there is a degree of marketing and consumer education needed to ensure uptake and usage Challenges • Venture / patient capital: Increased investment from impact investors and/or venture capital sources in mHealth models such as mPedigree. This will likely require both action and investment from philanthropic and blended capital sources which seek social as well as commercial returns. It will also require connectivity across players – on the investment, entrepreneur, and technical assistance components of investment. Emerging convening bodies such as the Aspen Network of Development Entrepreneurs (ANDE) and Global Impact Investing Network (GIIN) can provide valuable channels for this dialogue and action. • Public health education: Governments can play a significant role in public health education regarding counterfeits, and the potential of applications such as mPedigree. While pharma can market components of individual campaigns, the systemic nature of mPedigree’s model demands a larger scale and public sector led approach, both to enhance credibility and to reach vast segments of population. • Advocacy and collaboration across governments: Building on the platform created – particularly that involving the national government in Kenya, mPedigree can utilize its advocacy capabilities to enlist additional senior level government support for roll-out in additional countries across the continent. This may also help address keeping MNO interest. Potential actions BACK TO APPLICATION TYPES Source: Dalberg interviews and analysis; KCB; Standard Media Kenya; mPedigree; WHO http://www.who.int/medicines/services/counterfeit/impact/ImpactF_S/en/index1.html

0 Overview of Stop Stock-outs (1/2) • A monitoring system for pharmacy inventories designed to give early and timely warnings of low stocks of essential medicines; used Ushahidi’s crowd-sourcing model and FrontlineSMS software to compile SMS-based reports on supply chain problems from consumers • Non-profit model, funded by the Open Society Institute • One time campaign in Kenya, Malawi, Uganda, Madagascar and Zambia in 2009 Concept • Advantages: • Pharmacy supplies run out less often, helping patients to obtain the drugs they need; supply chain monitoring is decentralized and made less costly; the societal norm of empty pharmacy shelves is questioned and replaced with action • Results: • In “Pill Check Week,” 250 reports generated • Exposure of drug shortages and stock-outs led to extensive media coverage, and the first time admission of the existence of stock-outs and a vow to improve the situation from a MoH official • Beneficiaries and willingness to pay: • Patients/consumers of drugs; willingness to pay is limited given the systemic nature of the issue and income levels of populations most affected Value proposition Mapping of stock-outs across Kenya, Malawi, Uganda and Zambia • Current scale: The one time campaign was carried out in three countries; it is not an ongoing service • Current costs/revenues: Undisclosed • Costs to scale:Undisclosed Market Source: Stop Stock-outs; Dalberg research, interviews and analysis, 2010.

5 Overview of Stop Stock-Outs (2/2) • Technology: Data integrity was an issue, as data reported was not always accurate or verifiable; this can lead to questions regarding the legitimacy of the data and extent of the problem in reported districts • Health system: While the media attention and MoH statement are encouraging, it is unclear how this campaign has contributed to supply chain performance improvements, presenting challenges to replication and scale. • Integration, financing and ownership: This was a one-time campaign and has not been integrated in order to monitor supply chain performance and stock-outs; it has not been integrated into other offerings for stock-out prevention and inventory monitoring tools (e.g., SMS for Life currently in Tanzania, anti-counterfeiting efforts such as mPedigree; Similarly, a long term version of the model would require ownership by government or another large stakeholder; ideally, this would be an independent party from those managing the supply chain and inventory. This would also require sustainable funding with independence from the government and funders involved in supply chain operations; however, supply chain and commodity funders such as the Global Fund might be particularly interested in this as an audit function Challenges across the ecosystem • Improve data quality and authentication system: Develop means to ensure data integrity and authentication (e.g., in how data is captured, and potentially spot auditing) • Identify longer term owners – in Kenya and beyond: In local country contexts, identify what organizations might be able to own this type of program and campaign, and integrate it into their current operations. For legitimacy, this would need to be parties who are not currently incentivized or measured based on supply chain performance and inventory management to ensure no conflicts of interest • Push to have the Global Fund and other funders of health commodities ask for this type of data and reporting – and fund it in grant proposals: Importantly, funders of commodities and supply chains, who have a vested interest in stock-out prevention, should ask for stock-out reporting and data in their grant reporting mechanisms. They should also include this type of program in their grant proposals, and fund it along with the commodities and other forms of technical assistance which are included in loans and grants Potential actions Source: Dalberg research, interviews and analysis, 2010. BACK TO APPLICATION TYPES

0 Overview of Changamka Micro health Limited, SmartCard (1/2) • A fully digital health savings account, based on a smart card. New cards include credits for a medical consultation, a lab test, and a prescription. Can be used to pay for outpatient services within a network of health care providers and topped up using the M-PESA platform. • For-profit model; receives about 20 percent of the sale price of each card. • Founded in 2008 Concept • Advantages: • Savings on treatment and services are realized at the point of care across a network of nearly 4 dozen clinics across Nairobi. • Security of savings is improved. • Does not require regular premiums (savings plan for selected treatments) • Allows subscribers to share the smart card with family members and is not limited to individual use • Results: • Sale of 8,000 smartcards in first 11 months of operations, selling an average of 500 cards/month • Beneficiaries and willingness to pay: • Pregnant women and new mothers; based on sales todate, customers are willing to pay (initial card = Ksh 500, preloaded with standard services Value proposition Required scale for sustainability Here the chart on the current sales and what is required to break even. 23,300 Kenya Shillings (‘000) • Current scale: Signed on 25 local providers, and has extensive waiting list of providers eager to join the program’ customer base has been growing over time. • Current revenues: ~Ksh 3.2m ; Sales are falling short of commercially viable levels: sales of Ksh 23.3m required to break even Market +630% Revenue(year 1) Revenue (required to break even) Cards sold per month: 500 8,500 Source: Dalberg research, interviews and analysis, 2010.

i Overview of Changamka Microhealth Limited, SmartCard (2/2) • Users: Introducing a new product and serving a market whose culture is not accustomed to health savings requires significant high-touch marketing and consumer education. • Financing: High costs of customer acquisition are a challenge. The executive management team attributes this to a lack of marketing and challenge of promoting health insurance in Kenya due to negative historical image. • Technology: Potential to integrate technology and usemobile transfer and storage of payments rather thansmart-card; would streamline with mPesa platform and eliminate costs associated with card Less than 2% of Kenya’s population are covered by health insurance Challenges across the ecosystem 38,600 ‘000 people Insured 700 Uninsured 37,900 • Support scale: Funders who support health service delivery can consider linking their existing financing or possibly cash for work programs to Changamka to support scale Potential actions 2009 • Product bundling and/or joint marketing: Pursue bundling of product and/or joint marketing efforts with other adjacent offerings to engage new customers and get them accustomed to the service and value proposition • Fundraising to support customer acquisition costs: Pursue financing via private or blended sources to move towards furthering proof of concept and continuing customer acquisition; this could include cost-sharing with government or a philanthropic funder to increase the reach of marketing efforts Source: Dalberg research, interviews and analysis, 2010. BACK TO APPLICATION TYPES

0 Overview of Arogya Raksha • Arogya Raksha Yojana is a comprehensive health insurance plan that offers people of rural India affordable access to high quality healthcare, provided by a network of renowned hospitals and clinics, supported by leading doctors and surgeons. Since 2005, each year around 75000 lives have been covered under the scheme. Concept • In 2010, ARY introduced a mobile based user policy enrolment process that significantly improved the rate of patient registration. Volume of data captured • Advantages: • Prior to the introduction of mobile based enrolment, • While there are costs associated with introducing the new software, the approach significantly reduces day to day operating costs and increases insurance uptake. It also eliminates the need for double entry at the back-end office and thus reduces labor costs (including both staff time and associated compensation). • Results: • Patient enrolment – introduction of mobile based data entry has increased the rate of patient enrolment from 150 new patients per day to 6– patients per day. Value proposition 600 # of new patients per day -75% 150 • Current scale: As of Feb 2010, Biocon Foundation has been supporting the use of mobile based enrolment at ARY for 6months during which time, 35K enrolments were made, 15K mobile based. • Rapid enrolment of users under the new system may indicate unmet need for micro health insurance in the market. • Competition: Currently this scheme and the approach of mobile based enrolment is not facing any local competitors. However, other solutions including Episurveyor could be compared against the software currently being used. Market Mobile phone Paper-based BACK TO APPLICATION TYPES Source: Dalberg Interviews and research September 2010http://ifmr.ac.in/cirm/blog/?p=331

Overview of mDhil • mDhil provides basic healthcare information to individual Indian consumers via text messaging, mobile web browser, and interactive digital content. • Primary channel is a subscription or one off fee for service for SMS based information. Information relates to general health, sexual health, TB, weight, diet, stress, skin & beauty or diabetes. • Launched in 2009, and funded by institutional venture capital and angel investors. Concept • Advantages: • Increased access to health information: Provides quality, reliable health information, with an initial base of over 150,000 paid users on SMS subscription services . Health information content focuses on general health, sexual health, TB, weight, nutrition, stress, skin and beauty, and diabetes. • Beneficiaries and willingness to pay: • mDhil has grown rapidly reaching 150 000 users in 2010 demonstrating both willingness and ability to pay. Value proposition Market • Cultural issues related to privacy and discussion of sexual health make the service attractive for an uncalculated percentage of the population (likely focused on teenage and young adult populations). Subscription services are likely to increase significantly in the first few years but may quickly hit a plateau if information is not catered to the individual over time. Preliminary BACK TO APPLICATION TYPES Source: Online research and Dalberg Interviews September 2010

8 Overview of Text To Change – Mobile for Reproductive Health (M4RH) • M4RH is a project piloted in 2009 by Family Health International/ PROGRESS(funded by USAID) and launched and Marie Stopes in 2010 to improve family health and planning services. Developed by TTC, M4RH includes a series of messages with information related to family planning methods that users can access via their mobile phones. The messages are currently being evaluated in Kenya and Tanzania. • The messages are based on evidence-based information, including the World Health Organization family planning handbook for providers, and crafted specifically for short message service (SMS) or text message use. Each message is designed and tested to ensure user comprehension within the 160 character limit. The m4RH system also provides service delivery information so users can locate clinics to provide more information and the family planning method of their choice. More information on m4RH is below. Concept “This is important information and I would share it with friends so that they do not hear wrong information” “[I will tell about the service] my sisters—the young ones—and I will talk to them about family planning methods and escort their wives to the clinic” “I will save [the IUD messages] to show to my husband and friends” • Advantages: • Trust : Preliminary research found that users of the system not only welcome and trust family planning information via text. • Extended social marketing : Users are also appear more likely to share this information with family and friends. • Patient follow up: In some instances, users noted the value of being reminded about the advice they had been given by their health provider. “[The implant messages] remind me of what I had been told by the provider….I would save the message so that I can keep refreshing myself when I experience any problems” Feedback from users Value proposition Market • Current scale: M4RH is currently being rolled out across Kenya and Tanzania. USAID/FHI: Pilot study of 40 users BACK TO APPLICATION TYPES Source: Dalberg interviews and analysis; http://datadyne.org/files/Zambia_EpiSurveyor09_Technical%20Report.pdf

9 Overview of Text4Baby (1/2) • To replicate a successful mHealth service from the United States that delivers health information to pregnant women • Non-profit model; Text4Baby would rely on philanthropy to cover its startup and operating costs; it presents an attractive funding opportunity for corporate sponsors • Launched in 2010 Concept Text4Baby Expected User Growth 900,000 1,000,000 • Advantages: the program has been proven elsewhere; more effective way of reaching individuals with health information than other forms of outreach from clinics and CHWs • Results: In the US, there are over 100,000 subscribers since launch in February 2010; longer term outcomes have not yet been measured • Beneficiaries and willingness to pay: Pregnant women; willingness to pay has not been tested in Haiti context Value proposition 100,000 Users since Feb. 2010 Expected growth through 2010 Total • Current size: Not yet launched in Haiti; Began in the US, targeting mainly lower income populations; now expanding to Russia; recent commitment announced by Johnson & Johnson to support roll-out in the developing world. Haiti has the highest maternal mortality rate in the Western Hemisphere, so the impact of education is potentially enormous • Current costs: N/A • Estimated costs to scale: N/A Market Source: Dalberg research, interviews and analysis

e Overview of Text4Baby (2/2) • Literacy: Literacy may be the main constraint to the take-up and use of the service; • Credibility: Users unfamiliar with mHealth applications may also be skeptical that the information is credible; • Sustainable funding: Finding a source of long-term funding may be difficult Challenges across the ecosystem • Incorporate voice as well as text options: This will require a bit of an evolution of the current model, focused on reaching illiterate populations, to whom the text messages would not be accessible; cost implications are currently unknown, but would need to be structured in a way in which users would not be charged for the call; there is potential to leverage technology and platforms being deployed by Voila/Red Cross which use voice and toll free hotlines as part of its public health advisories (profiled in this study) • Increase credibility by partnering with locally legitimate players: This would include locally legitimate government agencies and/or NGOs (e.g., Partners in Health) who have a track record and reputation for quality health services. Co-branding in marketing and other areas of implementation could greatly increase visibility and credibility. • Securing sustainable funding: While T4B is an attractive offering to potential corporate sponsors (e.g., Johnson & Johnson), questions remain regarding longer term, sustainable funding. Over time, funding may need to transition to either the national government or larger scale, long term donors who have an interest in Haiti. To accomplish that, T4B would need to begin transition planning before the term of funding with corporate sponsors might end, lining up longer term alternatives. Once again, it will be critical for larger scale donors to recognize these types of tools as a priority and cost effective means of engaging in health systems, and prioritizing funding for them accordingly. This will require advocacy, and M&E to track results and performance over time s Potential actions BACK TO APPLICATION TYPES Source: Dalberg research, interviews and analysis

Overview of Dr. SMS • With mobile penetration over 72%, the state of Kerala was well positioned to provide services via SMS. Initiated by the Kerala State IT Mission in 2008, Dr. SMS aims to enable people to use mobile phones to receive information on health resources and to provide a comprehensive list of medical facilities available across the locality, including hospitals with various medical specialties, Doctors expertise in ENT or any other specialization. The solution is primarily available via SMS but also includes a web portal that provides GIS based location mapping . • An SMS with requested facility/specialty sent to the specified number will receive immediate contact details of requested facility/specialty centre. • The service also includes a portal for recording and managing Blood Donor details. Concept • Advantages: • Access to health information which reduces cost of referrals across localities and increases the rate at which patients can access specialty services. • Supply chain management: Real time visibility into the availability, location and type of donor blood available across the state. • Beneficiaries and willingness to pay: Services are provided free of charge by the Government of Kerala • Pilot Results: • During the pilot phase, an average of 200 requests were received each day. Value proposition Market • Current reach: Directory of services available for over 50% of the state. BACK TO APPLICATION TYPES Source: Dalberg Interviews and research September 2010

Study on Mobile Applications for the Health Sector

Study on Mobile Applications for the Health Sector

Presentation Transcript

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