Operation ASHA Provider in South Delhi. Photo: Julia Fan Li.

Bioentrepreneurs concentrate the majority of their time on science discovery and product development and little time considering their product delivery strategy.  Fortunately, in developed economies, once a therapeutic has achieved regulatory approval, the Ministries of Health, doctors, sales force networks and journal publications all can help create awareness and educate healthcare providers and patients for proper use.  

But what about in low-income countries where health systems are weak and there is a lack of medical personnel?  It is estimated that 4 billion of the world’s population live on less than $2 per day and are collectively termed by management scholars as populations living at the Bottom of the Pyramid. Biomedical innovations can be developed anywhere in the world, but therapeutics can help the patient only if they can reach the patient. What about the role of entrepreneurs? Is there a way to build sustainable, market-based solutions to provide local healthcare instead of relying on the public system alone?

There might be. Operation ASHA is a non-government organization working with the Indian government to deliver tuberculosis medicines to the poorest patients within urban slums.  India bears 20% of the world’s tuberculosis disease burden. Drug-sensitive TB is treated by a 6-9 month regimen of generic antibiotics; however, when patients cannot access adequate medical care, the infection can become drug-resistant, co-infect HIV+ patients and is often fatal.  Compliance to the long-term regimen is also difficult.

Operation ASHA has created a network of TB medicines providers in strategically recruited shops, homes, temples and community medical practitioners, allowing patients to easily access the antibiotics.  For example, a TB medicines rack is placed discreetly at the local convenience shop.  The patient can take their medicine under direct observation of the shopkeeper (a OpASHA Provider), reducing the effort, time and money patients invest in taking their medication and encouraging better compliance. For every two TB Providers, an OpASHA Counsellor is assigned to the area. The Counsellor is involved in finding TB cases, sending samples to government laboratories for testing, and educating patients and their families on compliance.  Once a TB patient has been diagnosed, the Indian government provides all TB medicines to Operation ASHA.  If a patient misses a scheduled visit to the Provider, an electronic medical records system (co-developed with Massachusetts Institute of Technology) can notify the responsible Counsellor via SMS.  The Counsellor, who is also a resident within the slum, will make a house-call to check upon the patient and engage in re-counselling and remediation.  Each Counsellor is a full-time employee and is paid a bonus for maintaining low default rates and active case finding of untreated TB patients.

This social-franchising model has achieved excellent results, with increased case detection and decreased default report rates.  It now serves an area of more than 4 million people who live in 1,352 slums in 14+ cities in India.

This helps address the problem with TB – the technological innovations for prevention and cure have been pioneered long ago, but the delivery system for the bottom of the pyramid is weak. Social franchising is an attempt to use business franchising methods to achieve social, rather than financial objectives alone.  In resource-constrained settings, the market discipline of the model, and the aligned incentives for the micro-entrepreneur to the health outcomes and maintenance of the supply chain allows for impressive gains to be made in global health.

There are more examples of global health entrepreneurs using market-based solutions to provide healthcare to the poor, and you can find out more by checking Results for Development’s comprehensive Centre for Market Health Innovations database.

Julia Fan Li