health

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.

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.

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.

Last week, I had the opportunity to sit down with Jordan Kassalow, Graham Macmillan and Miriam Stone – three staff members at VisionSpring – to conduct a long-form interview. Formerly known as Scojo Foundation, VisionSpring is the pioneering base of the pyramid-focused enterprise working to provide access to eyeglasses in low-income communities around the world.

Acumen Fund is an investor in VisionSpring, having made a $500K debt investment back in 2006. We’ve followed their progress for a long time, up to and including their recent name change and announcement of a 5-year fundraising prospectus.

Rob Katz, Acumen Fund: How, when and why did you get involved with VisionSpring?

Jordan Kassalow, Chairman and Co-Founder, VisionSpring: It was very practical. I spotted a market failure in my blindness prevention work (I’m an optometrist and public health expert by trade.) For many years, my specialty was river blindness control, and when I worked in low-income communities, I saw more people coming to clinics because they couldn’t see up close, while there were relatively few who were coming to us for river blindness. I saw this pattern regardless of whether I was working in Africa, Asia or Latin America. When you’re working on blindness, the overall market relative to general eye care is small. The normal need for eyeglasses is strong, but underserved in the developing world. After many months, I finally realized that, if no one else is doing something about it, why can’t I?

Editor’s Note: This post is authored by Acumen Fund Summer Associate Amy H. Lin. Amy is pursuing an MBA and International Relations MA from the Wharton School, University of Pennsylvania and the School of Advanced International Studies (SAIS), Johns Hopkins University, respectively. Her professional interests are in international development in sub-Saharan Africa. She has worked at the World Bank, with TechnoServe and with the Boston Consulting Group. Amy graduated from Yale with a BA in Political Science.

By Amy Lin

Proving that BoP services and profit can go hand in hand, Nairobi-based Meridian Medical Centre has been profitably operating three outpatient clinics with one-third of its clients earning only $4 a day. In April 2008, Meridian opened a fourth clinic in Donholm, a low-income Nairobi neighborhood, to cater to a low-income clientele interested in high quality outpatient health care at a reasonable price.

Through a new partnership with Acumen Fund and The Blue Link Mirror Fund, Meridian will open 5 more clinics over the next 3 years in higher density, lower income areas. This expansion will begin in Nairobi, but with an eye to expanding to towns on the periphery of Nairobi. As the Kenyan newspaper The Standard reported on June 17, Meridian’s partnerships will leverage both capital and management expertise—strengthening Meridian’s bottom line while meeting BoP needs.

Meridian’s push into lower-income markets is part of a larger trend of companies recognizing the market potential of the BoP. In Kenya, prominent businesses like Equity Bank and Safaricom (a mobile phone company) have enjoyed explosive growth in recent years, largely due to their success at attracting large volumes of low income clients. Investors are also recognizing the opportunity to profitably serve the BoP, as illustrated in the oversubscription of the Safaricom IPO, which drew 236 billion Kenyan shillings ($3.68 billion).

As Meridian and others launch operations targeted at lower income populations to achieve higher growth rates, in Nairobi as well as in peri-urban or rural areas, the BoP will benefit from the greater choice of products and services. Just as he predicted, Adam Smith’s “invisible hand” is using corporate self-interest to achieve a greater public good.

I recently received Dial 1298 for Ambulance’s first newsletter. 1298 is an ambulance service in Mumbai. In 2007, Acumen Fund took a $1.5 million equity stake in 1298 to fund expansion of their service. Since then, 1298 (the number you call when you need an ambulance) has grown faster than expected in Mumbai and is already expanding their service to two new districts in Kerala. The company has captured a lot of press attention, with coverage from the Economic Times, DNA, the Hindustan Times, and others. 1298 currently has 51 ambulances which have taken more than 50,000 trips since inception.

Before 1298 launched its service, Mumbai had only about 12 working ambulances that fitted with intensive care equipment (which were primarily linked to specific hospitals); 9 out of 10 trips were to transport dead bodies. These weren’t ambulances; they were hearses.

1298 is one of a number of Acumen Fund investments that defies easy classification. The operating “special purpose vehicle” organization is structured as a for-profit business company that integrates smart cross-subsidies to achieve a social mission, while the supervising umbrella organization “Ambulance Access for All Foundation” is a not for profit. (If you ever needed proof that our terminology isn’t keeping up with what entrepreneurs are doing on the ground, then there you have it).

The cross subsidy model is deceptively simple. Patients who want to go to a private hospital in a full-service ambulance - staffed with a doctor - pay 1,500 rupees (about US$35). Those who go to public hospitals pay either half price or nothing. 1298’s leadership is committed to having 15-20% of the company’s calls be serviced free or at reduced cost. This simple logic takes away the cumbersome process of identifying who can afford to pay and who cannot.

Acumen Fund Fellow John Tucker was interviewed by VisionSpring’s Miriam Stone. Read the full interview here, in which John reflects on what he’s learned over the past year working in India as a Fellow. Good stuff.