Seva Team Blog – 2018 IBD

Written by Jocelyn Brown, Rachel Lee, Grant Hannigan, Josue Chavarin, and Gagan Dhaliwal

May 21, 2018

It’s 110 degrees outside. Every bump of the road jostles us back and forth as we sit on stretchers in the back of the hospital ambulance. Weaving down dirt roads that look way too narrow for our vehicle, let alone two lanes of traffic, the driver uses the siren to announce our arrival, to both wandering buffalo and massive trucks filled with just-cut sugarcane. Within minutes of leaving the hospital, we are passing small farming villages. Goats, stray dogs and buffalo rest in the shade of ramshackle structures, along with villagers who stare at us as we drive by. Little fans in the back of the ambulance blow hot air in our faces, making it feel like we’re in the middle of a hot, dry sauna.

After stopping to ask directions several times, we finally locate our first interviewee. Today, Gagan and I are interviewing patients who visited Dr. Shroff’s Charity Eye Hospital in Mohammadi, India, and were told that they needed cataract surgery but haven’t come back yet to schedule it. We’re hoping to learn, through our teenage translators Srishti and Gracy, why they haven’t come back to the hospital. Every trip we take outside of the hospital walls has taught us an incredible amount about the surrounding communities and their day-to-day lives. We also usually come back exhausted and completely wiped from the Indian heat after only a few hours.

The first man we meet is prone on a cot underneath a straw hut and comes out to meet us. He’s shirtless, hunched from the waist around a wooden walking stick, and wearing thick, coke-bottle glasses. The first thing our translator tells us after introducing us is that he drinks alcohol. He doesn’t have any family members who can take him back to the hospital, and so he relies on others for transportation. Boiling in the sun, struggling to get any concrete details about why he might not want to come back to Shroff’s, we quickly decide to move on.

Our next interview is the opposite experience. We pull up to through the center of another village and step out of the ambulance. All of the houses around us seem to be made out of mud and straw. Several children seem to be the only ones who have any energy as they run around playing with each other and a stray dog. The community outreach coordinator for the hospital learns that our next patient is out working in the fields. While other members of the community go fetch him, chairs and water are suddenly precured from nowhere. We see very few women, just glimpses of their colorful garb from open doorways. As we wait for our interviewee, a small crowd of children and interested men starts to form. By the time our interviewee has arrived, a crowd has fully surrounded our little half-moon of chairs.

We’ve worked with our translators ahead of time so they know the types of questions we’re hoping to understand: how did you first hear about Shroff’s? What motivated you to seek care there? Did you understand what the doctor told you about cataract surgery? Why haven’t you returned to Shroff’s for surgery? We receive very brief answers in return: I was very satisfied with my experience. I wouldn’t change anything; the doctors and facilities are the best. Now surrounded with a full crowd of villagers, I wonder how much this man feels like sharing with these foreigners who have suddenly descended upon him and his home.

Conducting our interview with a local farmer

Conducting our interview with a local farmer

As our translators work to glean why this man hasn’t returned to the hospital for surgery (he doesn’t have the time), Gagan and I start to realize the enormity of our task. Our goal is to find untapped sources of new paying patient revenue, so that the hospital can work towards financial sustainability. But as our interviews in the community continue (we only make it through two more before we’re completely wiped by the heat), we realize we will not find the patients we’re looking for here.

We discover that the sugar cane farmers are paid 1-2 times a year for their crop and are making at most $5,000 a year. If these villagers are challenged with the basics of transportation and finding the time to make the trip to the hospital, none of our fancy, MBA pricing models are going to make any bit of difference in this community. Our impression that these patients would price shop for their surgery is immediately dispelled once we realize the simple, minimal lifestyle that describes 80% of this entire state of 200 million people. It’s only Monday of our second week and we certainly have our work cut out for us to identify sources of paying patients.

We gathered quite the crowd!

We gathered quite the crowd!

Greetings from Antigua, Guatemala and the HF Healthcare team!

Written by Michael Sahm​, ​Amy Fan​, ​Rachel Green​, ​Joanna Lyons, and ​Carlos Sanchez

May 31st, 2018

Project Overview

The arch in Antigua

The arch in Antigua

Our client is Nasir Hospital, a private, nonprofit hospital in Sacatepéquez, Guatemala (opening October 2018) that seeks to expand access to quality healthcare services for Guatemalans. The healthcare system in Guatemala is inadequate, as providers across the country lack necessary resources to meet the healthcare needs of citizens. Nasir Hospital’s goal is to provide free care free to approximately 20% of its patients, while still making enough money to sustain operations. Our task was to design a business model which makes this feasible. Today marks the last day of our project, and we feel privileged to have worked with such outstanding people pursuing this cause.

During our trip, we visited several local hospitals and conducted over twenty interviews with doctors, patients, and administrators to better understand Guatemala’s healthcare system. Much of what we saw was eye-opening. For example, public hospitals often lack basic supplies necessary to provide services, forcing patients to purchase their own and bring them to the hospital to receive care. Furthermore, basic hygiene and sterilization pose significant challenges in public hospitals, leading to a high number of hospital-acquired infections and illnesses. These are just a few of the issues which inspired HF Healthcare to build its first hospital in Guatemala.

HF Healthcare Team participating in global telethon for Humanity First

HF Healthcare Team participating in global telethon for Humanity First

Our recommended business model contained several components. First, we defined Nasir Hospital’s position in the marketplace, and crafted a strategy to attract target patients to the facility. Next, we designed an operating model to make the provision of free care financially and operationally feasible. Finally, we recommended service prices and projected patient volumes to create a multi-year financial forecast for the facility. Despite working with minimal data, our interview-centered research allowed us to deliver a quality final recommendation to our client, one we hope will be instrumental to its successful operation in the future.

Life in Antigua

We have been fortunate to call Antigua, Guatemala home during our trip. Antigua is a small city approximately one hour outside of Guatemala City, and is one of Central America’s most popular tourist destinations. It is filled with bars and restaurants (which we explored daily), and is close to some of Guatemala’s best outdoor attractions, including active volcanoes, coffee plantations, and Lake Atitlan.

One of our trip’s highlights was a weekend trip to the Lake. We teamed up with the Cemaco IBD Team from Guatemala City, and stayed at a hotel in Panacachel, a small town which borders the lake. On Saturday, we rented a boat and spent the day visiting different towns all around the lake. It was a special chance to connect with classmates so far away from Berkeley!

HF Healthcare Team participating in global telethon for Humanity First

HF Healthcare Team participating in global telethon for Humanity First

For our second weekend, we chose to stay in Antigua. After working Saturday to participate in a worldwide fundraiser telethon for our client, we started our weekend at Antigua Brewing, where we enjoyed local beer while watching live eruptions from Volcán Fuego.

HF Healthcare and Cemaco teams at the top of Volcán Pacaya

HF Healthcare and Cemaco teams at the top of Volcán Pacaya

The next day, we hiked Volcán Pacaya where we roasted marshmallows in hot spots throughout the summit. We ended our weekend with dinner and souvenir shopping with the Cemaco team, who trekked to Antigua after touring Mayan ruins at Tikal National Park the previous day!

¡Hasta Luego, Guatemala!

As we conclude our project, we feel very grateful for our IBD experience, and have several things to be thankful for. First, for the chance to work on a high-impact project that we know will impact the lives of thousands of patients at Nasir Hospital. Second, to the community members in Guatemala, who were incredibly generous with their time in assisting our project work. We were fortunate to meet several high-profile guests of Nasir Hospital including congresswomen, the family of the President of Guatemala, and an ambassador for Mayan culture and welfare, all of whom recognize the hospital’s potential and are eager to help in any way possible.

HF Team at dinner with Sheba Velasco, international ambassador for Mayan culture and welfare

HF Team at dinner with Sheba Velasco, international ambassador for Mayan culture and welfare

HF Team with the mother and aunt of the President of Guatemala, Jimmy Morales

HF Team with the mother and aunt of the President of Guatemala, Jimmy Morales

Finally, to our friends at HF Healthcare, especially Majid, Patricia, Manuel, and Erick. You went above and beyond in your hospitality, and we are so thankful for your help in making our project experience and trip to Guatemala a once-in-a-lifetime experience. We are confident that Nasir Hospital will be among the best in all of Guatemala, and look forward to following your future successes!

The amazing staff at Nasir Hospital!

The amazing staff at Nasir Hospital!

 

Improving motorcycle based healthcare in India: the conclusion

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The view from a rooftop tibetan restaurant on our last night McLeod Ganj: Hanuman Ka Tibba looms over the foothills, as one of the smaller mountains in the range, it rises to a ‘mere’ 18,500 feet (5,639 m).

We made it through 3 all-too-short weeks in India.  At the end of week 2, we left Bihar and returned to Delhi.  Upon analyzing our data, we found that the Last-Mile-Outrider (LMO) motorcycle program was at a tipping point – it had been able to slowly grow in a highly competitive landscape (pharmaceutical delivery by WHP directly competes with large established incumbent pharmaceutical corporations), and needed to take decisive action in order to grow and reach a minimum self-sustaining size and achieve profitable economies of scale.

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A typical Delhi street scene: The safari comes to us / Aloo Tikki, fried potato pancake with veggies and spices / traffic melees are quintessentially Indian.

Although our team generated a set of actionable recommendations for the LMO program, a part of us wanted to ‘lose’ some paper work, or perhaps a computer would crash.  This would buy us at least another week in India, a place that had begun to feel like home.  We schemed while consuming possibly unsafe amounts of Indian street food, but alas, no paper work was lost and our cloud storage actually worked for once.  Sealing our own fate, we presented our findings to the leadership at WHP.  A summary of the recommendations:

Optimize motorcycle routes by:

  • Gradually raise sales goal in order to achieve self-sustainability- Improve sales conversion rate by:* Changing the sales model from “visit & sell” to “call & deliver”

    in order to reduce non-value generating follow-up visits

    * Adapting frequency of visits based on economic order quantity

    * Reviewing outlets based on sell-trough and success of 4 verticals

    * Test more entrepreneurial approach in 1 district: let LMOs manage all

    day-to-day operations

Implement a structured hiring and training program that:

  • Incorporated structured interviews and short exams
  • Involves high-performing LMO riders in coaching and mentorship
  • Implements a mechanism for anonymous upwards feedback
Aphay Kumar, one of our favorite LMO's showing off his ride.  Note the SkyMed (WHP's brand) bag on the back!

Abhay Kumar, one of our favorite LMO’s showing off his ride.  SkyMeds (WHP’s brand) are strapped on the back!

We have high hopes for not only the LMO program, but WHP’s vision as a whole.  Their rapid prototyping approach to implementing self-sustaining, market based public health, has left a strong and positive impression on a rag-tag group of two consultants and a former military officer.  We look forward to internalizing the lessons from our project and spreading the word on WHP and the ability for small organizations to make big impacts in the world of development.

And of course, we managed to sneak in some weekend adventures.  The first weekend our team pilgrimaged to Dharamshala and McLeod Ganj, in the state of Himachal, in the foothills of the fabled Himalayas.  Dharamshala is the home of the Tibetan exile government and our experience was as if we spent a weekend in Tibet itself.

[Clockwise] Prayer wheels / monks need to stay out of the sun too / bustling downtown at sunset / the team hanging out at a snowmelt river

[Clockwise] Prayer wheels / monks need to stay out of the sun too / bustling downtown at sunset / the team hanging out at a snowmelt river 

On the second weekend, we made a pit stop at the town of Bodh Gaya, in southern Bihar, where we visited the very location that Siddhartha Gautama, otherwise known as Buddha, attained enlightenment over 2500 years ago.  Finally, we finished our sight-seeing with the obligatory Taj Mahal visit.

A monk from Myanmar gave us a monastery tour / leaves from the legendary Bodhi tree (Ficus Religiosa) / Tammy and Wolfgang ponder enlightenment in the rain

A monk from Myanmar gave us a monastery tour / leaves from the legendary Bodhi tree (Ficus Religiosa) / Tammy and Wolfgang ponder enlightenment in the rain

Parting shot

The guestbook at the Tibetan Exile Museum: FREE TIBET

Improving access to healthcare in rural Kenya through mobile technology

Project Background:

Our client was Novartis, a large pharmaceutical company that recently launched a social business program to provide health education to community groups in several rural regions of Kenya. Novartis had previously achieved a highly successful social business program in India and hired our team to see how to build on a similar program in Kenya and also how to introduce aspects of mHealth.  In addition to health trainings, the company organizes health camps where people who often struggle to access healthcare can receive free consultations and lab tests.  Our team was tasked with investigating ways to further improve access to healthcare for people at the base of the pyramid (BOP population usually living on <$2/day) through the use of mobile technology.

Kenya is one of the leading African countries in terms of mobile penetration, and both SMS and voice calling is very inexpensive, creating many terrific opportunities for mHealth interventions. mHealth (mobile health) is generally defined as any program that delivers health messages, information, or does health data collection through the use of mobile phones.

Our first week – Field Research

We arrived in Nairobi and were immediately caught up by the energy of the city, excited to meet our client and get to know a bit of Kenya’s culture and healthcare system.  We spent our first Sunday exploring our neighborhood and local cuisine.  It turns out there is fantastic Indian food in Nairobi! On Monday morning we had our first encounter with rush hour traffic in Nairobi, but made it to our client’s office and had an immensely productive day, getting all of the background information for our client’s program.  The rest of our first week would be spent conducting field research in two regions where the client is currently operating.

Over the course of three days, we shadowed pharmaceutical sales reps, watched Health Educators give trainings to community groups, and were exposed to a full spectrum of healthcare options in rural Kenya.  We observed sales reps interact with pharmacists, physicians, nurses, and other healthcare providers.  Our team members had the opportunity to conduct in-depth interviews with community members to understand how they make decisions about when to access healthcare and how they manage the associated costs.  Interviews provided insight into opportunities for mHealth interventions to improve people’s ability to access and pay for care.

Our research made it abundantly clear that many people at the BOP struggle to access quality care and are often unable to afford better options. Most people had zero savings and paid for healthcare out-of-pocket with cash or money borrowed from friends and neighbors.  Community members were engaged and eager to receive trainings about such topics such as hygiene, nutrition, and avoidance of self-medication.

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First weekend – Masaii Mara safari!

We spent our first full weekend giddily bumping along jutted dirt roads, vying to get the best views of animals in the vast expanse of the Masaii Mara.  Our first evening we watched with a combination of awe and disgust as a pack of female lions hunted and killed a buffalo.  We were lucky to see four of the “big five” animals, only missing rhinos.  One evening we also visited a Masaii village to learn more about the culture, traditional dances, and how the Masaii people fend off predators when they graze their cattle and goats inside national parks full of lions, leopards, and other threats. 

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Week two – Meetings in Nairobi and analysis

Our second week was full of meetings with organizations who are working in mHealth, telehealth, and healthcare financing in Kenya.  We particularly enjoyed meeting with Medic Mobile and getting to see the iHub, a co-working space in Nairobi that looks very similar to the Hub and other shared workspaces in the U.S.  We were excited by the innovation and knowledge sharing opportunities. 

We took time to leverage some of our learnings from the Haas PFPS course and used hundreds of Post-It Notes to do an in-depth brainstorming session on findings from our field research.  Coincidentally, we chose to do this activity one evening at our hotel and hotel management was hugely perplexed by our iterative process of scattering and rearranging Post-It Notes across several tables on the outside patio.  Week two also provided us some real “consulting time,” as we dove deep into PowerPoint, diligently working to present our findings and recommendations in a compelling fashion for our client. 

On Friday we gave our client in Kenya a sneak peak at our deck to get his initial reactions.  He seemed excited about our ideas and was pleasantly surprised about the depth of insight we were able to gather in the field, as well as our operational insights that could be applied beyond mHealth.  We went into the weekend feeling energized and excited for more exploration.

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Second weekend – Nightlife and more exploring in nature

Our second weekend we opted to stay in and around Nairobi and had a fantastic time.  On Friday night we checked out the local nightlife at a restaurant that has one of the only local breweries in the region.  Once the DJ arrived, we made Haas proud and proved our worth on the dance floor, even taking time to learn some new dance moves from local Kenyans. 

On Saturday we left bright and early to drive down to the Rift Valley to visit the famous Hell’s Gate and Lake Naivasha.  We rented bicycles at the Hell’s Gate National Park and biked 8km through natural beauty to the famous gorges.  After a short picnic (during which we spent most of our time fighting off monkeys rather than eating) we went for a hike and were able to see some natural hot springs and scenery.  Before heading back to Nairobi, we went to a viewpoint at Lake Naivasha and saw some flamingos. 

On Sunday morning Aaron and Javier visited Kibera, the largest urban slum in Africa.  Our work has been focused on improving access to healthcare to people at the base of the pyramid, and while most Kibera residents lack access to basic services, including electricity and running water and sanitation is a major issue contributing to health problems, our focus has been on the rural poor.  Someone who lives on less than $2 per day, but has a half acre of land to grow maize and a small vegetable garden has a vastly different experience than someone who lives on less than $2 a day in a 5 kilometer slum with 200,000 other residents.  We have been very interested by updates we receive from one of the other Haas IBD team that is working in Kibera for the Human Needs Project.

On Sunday afternoon we headed to the outskirts of the city for Blankets and Wine, a music festival featuring singers from across Africa.  We were especially excited to see Zahara from South Africa.  One of the other Haas teams joined us and we had a great time sitting in the sun, listening to great music, and doing a bit of dancing. 

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Week three: Recommendations and client visit

We kicked off our third week by focusing on finalizing our recommendations.  We have to admit we got even closer as a team this week.  There is something to be said about spending hours together in a small conference room, meticulously going through minute details in PowerPoint.  Our client arrived from Europe on Wednesday morning and after another amazing Arabian lunch, it was time to unveil the key findings and recommendations from our research.  We took time to report on our findings from our field research, not just as they relate to recommendations for mHealth interventions, but also how to improve the operations and efficiency of the field teams as the program grows. 

In the end, we made three key recommendations about opportunities to use mobile technology to improve access to healthcare in rural areas.  Our recommendations centered around finding ways to use mobile to improve access to information about health and prevention as well as access to finance and savings.  M-Pesa, a mobile savings and payment system that is widespread in Kenya, has done a ton to open Kenya to opportunities in mHealth. 

During our three weeks in Kenya, we had the opportunity to meet with a number of companies and organizations that are working to improve the livelihoods of Kenyans in the BOP, either through helping to set up savings and credit groups, health education, other mHealth interventions, etc.  One of the program managers we met at AMREF made a very important point that partnerships are key to ensure sustainable and scalable interventions: “One thing to realize about the world right now is that no one is going out to do anything alone.  Groups are forming partnerships and consortiums where they all have strengths.  To go alone is risky, but finding complementary partners can lead to great programs.”

We believe Novartis is well positioned to be a leader in social business and sustainable mHealth interventions.  We are incredibly grateful to have had the opportunity to work on this consulting engagement and hope to visit Kenya some day in the future.

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