health

Acumen Fund is excited to announce two new investments, both in the field of eye care. PVRI (Pushpagiri Vitreo Retina Institute) based outside Hyderabad, India, and UHEAL (Upper Hill Eye and Laster Centre), in Kenya, both focus on specific forms of preventable ocular damage.  With similar business models and parallel aims, through our investment in these complementary enterprises, Acumen Fund seeks to identify and and share best practices across continents, while building an effective model for delivering eye care to the poor.

Loss of eye sight has a tremendous economic and social impact on low-income families, eliminating the ability of at least one member to earn an income, and often requiring substantial assistance from at least one other family member. Its prevalence is in large measure a symptom of underlying challenges related to poor nutrition, lack of access to timely diagnostic screening, and the unavailability of appropriate treatment.

Using its flagship hospital in Secunderabad (near Hyderabad) as a hub, PVRI has provided outreach clinics, mobile screening units, and treatment camps in rural areas throughout the region, as well as in-house care to thousands. With the investment by the Acumen Fund, PVRI will be building two additional hospitals and corresponding expansion of outreach units. Gori Hari, CEO of PVRI, notes that the the expansion will allow PVRI to treat “450,000 patients through surgeries or procedures and screen a million patients over 10 years, as well as conduct 1800 camps to screen an additional 450,000 patients.”

Founded by Dr. Kibata Githeko, an opthalmologist specializing in pediatrics and retina care, UHEAL has operated mobile eye units throughout the region to counter long waits endemic in eye care. With Acumen Fund’s investment it will now be able to expand, operating fifteen camps a year, specifically to screen for diabetic retinopathy and to provide non-invasive and laser-based treatments, general eye examinations, as well as some follow-up care.

UHEAL and Acumen will experiment with different pricing models to find the right balance between financial sustainability and social impact, while PVRI will subsidize eye care to low-income communities by charging higher margins to high-income consumers.

The parallel investments will provide added value in the form of shared learnings. As Varun Sahni, the India Director for Acumen Fund has recently noted, “Having two investments with similar models for delivering advanced eye care to the poor creates a unique opportunity for collaboration, and we look forward to sharing best practices across geographies as we work to bring these solutions to scale.”

Does the vision of serving the low income segment of society extend beyond the investors and CEO of a social enterprise?

In my opinion, only an affirmative answer to this question will ensure that the vision of serving the poor is fulfilled (however long it may take…).  Watch what the team of doctors running AyurSEVA Hospitals has to say about their vision and motivation to work for this organization.

A tiny bead of sweat ran down the ridge of my nose.  It reached the end, teetered for a split second, then dropped quietly onto the doctor’s desk.  I sat behind the desk, inside the Vijay Nagar Women of India clinic, which is tucked into a government-built housing project in the Bandra East area of Mumbai.  As the sweat hit the desk, it made a soft splat, and little Natra’s eyes followed it down.  About 3 years old, he seemed pretty interested in the inability of this strange white man to deal with the Mumbai heat – not surprising, all things considered.

Natra and his mother, Surekha, had agreed to take a survey about healthcare administered by Acumen Fund Fellow Joanna Harries and her colleague, Rubina Dsouza.  Joanna and Rubina work for Dial 1298 for Ambulance, a professionally-run, high quality ambulance service run in Mumbai (51 ambulances) and Kerala (30 ambulances). You dial 1298 to get a fully-equipped ambulance with doctor and medical equipment on-board.  1298 is affiliated with the Ambulance Access for All Foundation, whose mission is to provide high-quality service for all Indians, regardless of income. 

But will poor Indians call an ambulance?  That’s what Joanna and Rubina are working to find out.  Service for all is not only a noble goal, it’s good business as well – after all, some 40 to 60 percent of Mumbaikers live below the poverty line, in slums.  If you fail to serve this customer segment, you miss a huge number of calls – and your ambulances can run below capacity.

Effectively serving this market begins with listening, and that’s what Joanna and Rubina are doing.  They have been spending time visiting various Women of India clinics, all of which are located in slum areas, and asking a simple, 5-question survey: what do you do when you get sick?; how do you get to the hospital?; which (if any) ambulances do you call?; why wouldn’t you call an ambulance?; who helps you when you get sick?

Joanna and Rubina and I did eight surveys today, just the tip of the iceberg.  What is interesting is that 1298 takes its commitment to the low-income segments seriously – both in terms of social impact and in terms of business sense.  The company is marketing in a number of innovative ways – tying up with schools, hospitals, train stations, and more.  Slum outreach is an element of their business plan.  Regardless of income level, growing 1298’s customer base is an awareness game – call it marketing, brand management, outreach, whatever – you have to have potential customers know about your service before you earn their business.

‘India is merely a geographical expression. It is no more a single country than the equator’- Winston Churchill

Had I read this quote five months ago, I would have not understood what it meant. But after living, traveling and working in India for exactly that long, I can say that Winston Churchill was exactly right. In India, like in any other large country as the US or Mexico, I expected to find some regional differences in people’s tastes for food or music, their accent, dress code, etc. In my mind, these differences give countries their character and do not have major consequences for business other than the opportunity to bring in some variety to the portfolio of products or services. In India, however, regional differences go FAR beyond the ones I just described. For this reason many authors to talk not about one country but “the many Indias”.

For an enterprise trying to do business across the Indian territory, it is critical to be aware of all the nuances of “the many Indias”. Allow me to illustrate what I mean by this using AyurVAID: Hospitals, the organization I am working in, as an example.

AyurVAID: Hospitals is a local business with the mission of providing high quality, affordable Ayurveda (India’s traditional system of medicine) treatment for chronic illnesses across all socio-economic segments and across India (and some day abroad). In line with this vision, AyurVAID: Hospitals opened six small to medium sized hospitals in three neighboring states: two hospitals in Kerala, three in Karnataka and one in Maharastra. The hospitals are located in urban areas and three of them in the big cities of Mumbai and Bangalore.
At first glance AyurVAID: Hospitals’ strategy of expansion seems very straightforward, but in practice things are let’s say a bit more….complicated. Here is how:

Language- At each location, all sign boards and advertising material have to be translated into at least 2 different languages (English + local language) and 4 in the case of Mumbai (high immigrant population). Our doctors need to speak 2 to 3 languages to communicate with patients, English to communicate with the management and international partners, and Malayalam, the language of Kerala, to speak with the staff.

Human resources- The roots of the Ayurveda system of medicine can be traced back to the state of Kerala. Although today Ayurvedic Medical Colleges train doctors across the country, training institutions for therapists are still highly concentrated in Kerala. Hence, hiring locally becomes a difficult task and most of the therapists have to be relocated from Kerala to other states. Then again, most people in Kerala have a strong affinity for their state and prefer not to leave it.
Systems of medicine- Whereas in other parts of the world, Allopathic or “Western Medicine” is the norm, in India, patients have many other well established options to consider like Ayurveda, Homeopathy, Allopathy and Unani. In competing with these different options, public awareness about Ayurveda is a big challenge. If we take allopathic medicine as an example, most people today know what to expect when they go to a doctor, to a hospital or understand if someone says they need a “dialysis”. On the other hand, Ayurveda means a variety of things to different people, particularly as the distance from Kerala increases. To test this last point, I decided to interview people in the streets and hotels of Kerala (to get some out of state opinions) and asked them one simple question….Observe.

[youtube=http://www.youtube.com/watch?v=34I9lLAhU94&hl=en&fs=1]

All of these factors make the business at AyurVAID: Hospitals challenging and exciting! One success factor as we continue to grow and do business in “the many Indias” will be to strike the right balance between standardization and customization of our services.

Jordan Kassalow, Chairman and co-founder of VisionSpring, was announced today as one of the Skoll Foundation’s newest grantees. The award includes a 3-year, $765,000 unrestricted grant to VisionSpring, a non-profit social enterprise that empowers local individuals to become self-sustaining entrepreneurs by selling affordable eyeglasses to the millions of people in the developing world who need them. VisionSpring is also an Acumen Fund investee (and the Skoll Foundation is an Acumen Fund Leadership Partner - it’s all in the family!)

We’re thrilled to see Jordan - and the entire VisionSpring team - recognized in such a prestigious forum. Congratulations! And we’ll see you at the Skoll World Forum next week (rather, Brian Trelstad, Ann Macdougall and Varun Sahni will…)

Acumen Fund has learned over the years that its most successful entrepreneurs listen constantly to the needs and the nuanced preferences of their customers. A killer new product will certainly fail if it is not designed around the customers’ behaviors and desires. We’ve seen it happen.

As part of Acumen Fund’s monthly breakfast series, we were joined last Friday by Richard Allan, Director of the MENTOR (Malaria Emergency Technical and Operational Response) Initiative, who spoke about a thoughtful new technology for preventing malaria: insecticide-treated wall lining (shown at left, with a customer in the foreground). Imagine a flexible wall-lining that you can unroll in long sheets and attach to the inside walls of a home. Only it is impregnated with an insecticide that kills mosquitoes (and many other pests) on contact. A new company called DART (Durable Activated Residual Textiles), a joint venture between Richard, Acumen Fund, and Vestergaard Frandsen, will produce the product for distribution throughout malaria endemic regions Asia and Africa.

We’ve seen a lot of sexy, new product designs, and we’ve decided not to invest in most of them. So why are we so excited about this new wall lining (think wallpaper)?

For starters, it combines the best features of the two most popular malaria prevention products: the long-lasting insecticide-treated bednet and indoor residual spraying (IRS - this is where the interior walls of a home are sprayed periodically with insecticide). The best nets last about 5 years without needing re-treatment, but they require you to sleep underneath a net every night, which is a significant behavior change and a challenge for any distribution scheme. Indoor spraying requires no behavior change once the walls are sprayed. Unlike with nets, a family does not have to decide to sleep under protection; the spray ensures that they are naturally protected anytime they’re inside the home. Misuse is not really possible. However, the spray’s effectiveness only lasts about 6 months and there are complicated logistics and persuasion required to do the spraying in the first place.

Introducing wall lining. Wall lining will remain effective at least as long as bednets and likely longer, since it will likely see less wear and tear. And, like spraying, it does not require any behavior change once the walls are lined – if you’re in the home, you are protected. In this sense it is the best of both worlds – years of protection without the struggle to change people’s behavior.

Yet, beyond these technological advantages, the product seems to appeal to the customer better (at least as evidenced in early trials). Printed in many different colors and patterns, the wall lining is designed to appeal to the desire for beauty and home improvement that exists in all of us. Who wouldn’t want beautiful blue walls instead of the drab brown of sticks or mud? In fact, this is how Richard got the idea in the first place. In Cambodia, he noticed homes lined with wallpaper for purely aesthetic reasons. Why not combine the customer’s desire for beauty and home improvement with addressing a critical health issue?

Of course, there are many challenges ahead, but in a market dominated by multilateral & NGO distribution schemes, it is rare to see a product so thoughtfully designed with the customer in mind. With ~2 million deaths per year due to malaria and 1/4 of the world population living in malaria endemic regions, we owe it to the customers to design products that work for them but at the same time are as effective as possible.

The entrepreneurs at AyurVAID: Hospitals are testing a business model that promises to overcome the scale up challenge of delivering medical care to the masses based on Ayurveda, a system of traditional medicine. According to RV Raman, Head of Marketing at AyurVAID: Hospitals, there are about 18,962 Ayurveda companies registered in India today. Most of these companies focus on offering ayurvedic products (from medicines to toothpaste!) and spa related services, however no one has been able to come up with a successful, scalable model to deliver health services. (Ironic considering that Ayurveda is a system of medicine that has been around for more than 3,000 years!) In this video Rajiv Vasudevan, CEO of AyurVAID: Hospitals, explains some of the challenges inherent to the Ayurveda “industry” and some of the strategies the team has developed to overcome these obstacles.

[youtube=http://www.youtube.com/watch?v=VT87qBfClV8&hl=en&fs=1]

Full Story can be found at http://www.dnaindia.com/report.asp?newsid=1220060

When I first read this article published yesterday on the DNA Bangalore newspaper I felt moved by Daniel’s story of resilience. Then my thoughts drifted to another character in the story, Dr. Belaku Chandu[1] from AyurVAID: Hospitals. The reason why I found myself thinking of Dr. Belaku is because the article reminded me of her reaction one of those days that Daniel heard the sound of the fire crackers.

I was sitting in the hospital’s kitchen having dinner with the staff and doctors when the noise of the firecrackers filtered the hospital building. Dr. Belaku immediately stopped eating her food, she rose from the table and went in to the hallway. She stopped for a few minutes as if waiting for something to happen and then disappeared into the first floor. Then I heard laughter.

When Dr. Belaku came back to the kitchen and I asked her what was that all about she told me Daniel’s story and how the noise of the firecrackers had affected her in the past few days. With a smile in her face she said, “The first day Daniel was very scared by the noise. She thought it was the noise of shotguns and her nerves started to jerk again. The second day she was just startled and dropped her food tray. Today, she recognized the noise and she just laughed!” She was paying attention to Daniel’s progress day and night.

Dr. Belaku’s story exemplifies the type of personal and organizational commitment that makes a social enterprise thrive. Everyday I spend at AyurVAID: Hospitals I am in awe of how devoted the caregivers and doctors are to the patients and to the organizational mission. Every single one of them believes in the healing powers of Ayurveda for treating chronic illnesses and is committed to AyurVAID: Hospitals’ mission of taking classical Kerala Ayurveda to as many people as possible in India and around the world by offering affordable, high quality services.

This article also highlighted for me the positive ripple effect of investing in a social enterprise. Acumen Fund’s investment in AyurVAID: Hospitals operation’s in India is helping reach people in Africa! Although Daniel may not belong to the low income class at the BOP that Acumen is trying to reach, there is no doubt that she was a person in need of physical and spiritual help, and that her courage in sharing her story of improvement through Ayurveda provided in the AyurVAID: way, will help this team of committed doctors and entrepreneurs communicate to all its promise to solving society’s health needs.

We at Acumen Fund are deeply saddened to learn of yesterday’s terrorist attacks in Mumbai. Our thoughts go out to the victims and their families, our Mumbai-based investees, Fellows and friends and everyone connected to people who have been affected by the attacks. Our personal connection to Mumbai makes the city a home to us, even if we don’t live there.

While watching the TV coverage, I did want to share another feeling of connection, and that was to everyone associated with Acumen-investee Dial 1298 for Ambulance, who have been on the scene and responding to the attacks since they occurred late Wednesday night, as seen in footage on CNN, IBN and other networks.

1298 operates under the ethic of “ambulance service for all.” Per its own policy, it provides free service to all accident and disaster victims - as well as to victims of terrorist attacks. Knowing that a few years ago, the city was so much less equipped to respond to such an emergency underlined the true service that 1298, now with 51 medically-equipped and professionally staffed ambulances, is making to the city where it was founded. We at Acumen Fund feel a great sense of pride, just in seeing how much can be built to change things in a constructive way and in this case, it was due to the hard work of the team at 1298. We thank everyone at the company for the work you do and the ethos of service you hold.

Editor’s note: This post first appeared on VisionSpring’s Business in a Bag blog. Acumen Fund is an investor in VisionSpring, having made them a $500,000 loan in 2006. Thanks to Miriam Stone for giving us permission to cross-post this on the Acumen Fund blog.

BRAC, the largest non-profit organization in the developing world, is a dream partner for a small organization. But landing the partnership is only the first part. What happens next is where it gets interesting…VisionSpring’s Franchise Partner Manager Lalit Kumar reports from the field.

By Lalit Kumar

We often joke here at VisionSpring that working with BRAC is like landing a contract with Walmart. It’s the kind of opportunity that every small NGO dreams of – BRAC is known for its massive scale and incredible efficiency. This partnership will allow us to reach a huge new market of people in need in a time frame that would have previously been impossible. Now we just have to deliver!

We’ve been working with BRAC for two years now. For the last six months, we’ve been selling about 500 glasses per month by empowering BRAC’s network of Shashto Shebikas (community health volunteers) to sell our eyeglasses. Now, with our new plan to scale up, we will provide affordable glasses to almost ten million people in Bangladesh over the next three years.

Our biggest challenge by far is managing the inventory that BRAC needs. At the moment, we’re delivering about 30,000 pairs of glasses every four months, but soon we will need to deliver 30,000 every month. We are mainly focused on getting the glasses into Bangladesh, a complicated process involving multiple inspection agencies. A 2006 Doing Business (http://www.doingbusiness.org) report from the World Bank notes that when a Bangladeshi company imports goods, it has to prepare 16 types of documents and obtain 38 signatures, and that the whole process takes 57 days. I can tell from our experience that it hasn’t improve much in the last few years.

For example, we received a Letter of Credit from a bank in Bangladesh that was valid only from April through June. Simply getting it updated meant that we had to get signatures from BRAC’s bank in Bangladesh, VisionSpring’s bank in New York, VisionSpring’s offices in India and New York, and our vendor and inspection agency in China.

We at VisionSpring are working hard to understand the whole process and constantly improve our delivery time. The first order took us more than 9 months to clear customs and make it in to Bangladesh, and the next order took about 6 months. Our goal is to get the process down to 3 months, which we are able to achieve in other developing countries where we work. We are certainly going through a period of adaptation, but it has been a very exciting time and I look forward to making more leaps of improvement.

After business school at the Institute of Rural Management Anand (IRMA), I was surprised to find that the challenges we face are the same as private sector businesses, only we are addressing them in some of the most challenging markets in the world. There is a reason that most private-sector companies haven’t tried to reach rural markets in Bangladesh; the start-up and logistics costs are simply too high. However, if our partnership with BRAC is successful, we will be able to provide affordable glasses and business opportunity to millions of people in Bangladesh. For us, it is well worth the struggle.

This post first appeared on Acumen investee VisionSpring’s blog, Business in a Bag. We’ll be cross-posting with Business in a Bag from time to time.

The post’s author is Tim Johnson-Aramaki, a student at the University of Michigan’s Ross School of Business, who spent the summer with VisionSpring India working on a data-collection methodology to measure the long-term impact of VisionSpring’s work on the lives of Vision Entrepreneurs and customers. His project is part of a multi-year impact study conducted by Professor Ted London at Michigan’s William Davidson Institute.

Over the last few months, I’ve been working to develop a survey instrument with the VisionSpring team here in Hyderabad and the William Davidson Institute team in Ann Arbor. The first step was survey pre-testing, which involved conducting countless interviews in rural village throughout the state of Andhra Pradesh. These interviews are meant to help us discover whether the questions we’ve come up with are understood by respondents with varying semantic and cultural backgrounds, and if they prompt valid and appropriate responses. Some of the results we’ve gathered have been really interesting.

For example, one of the most critical pieces of data in measuring VisionSpring’s impact is the income of its Vision Entrepreneurs and customers. It also happens to be one of the most difficult things to measure as there are challenges when it comes to discussing money. Through our interviews, we’ve found that while people are relatively open in assigning a number to their income, that number may not be accurate. There are a variety of reasons for this, but one is that they fear the income figures may be passed on to state or national agencies, potentially jeopardizing the public assistance they receive. To avoid this, they often provide income figures lower than that which they actually earn.

The Skoll Foundation funds a fantastic ongoing interview series called the X Interview. Posted online to Social Edge, the X Interview is conducted by a mysterious blogger named Global X. Recently, Global X sat down with Acumen Fund ally (and Advisory Council member), IDEO CEO Tim Brown.

The interview - only 2 minutes, 30 seconds long - covers a few different topics, but Brown focuses mainly on insights he gleaned from a trip to India in the company of Acumen Fund CEO Jacqueline Novogratz:

…he [Brown] was impressed by the systemic thinking and level of innovation that Dr.Govindappa Venkataswamy (Dr. V) had brought to the Aravind Eye Care Hospital in Madurai.

It is now believed to be the best eye care and teaching facility in the world. The lesson?

“By trying to serve those who have the most needs, you can end up being truly innovative, to a point where those innovations have relevance not only in the developing world but in the developed world also.”

Via the new Skoll Foundation blog.