2014 Hult Prize Challenge

8/12/2019 2014 Hult Prize Challenge

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Hult International Business School Publishing 1Version 1.0, October 2013

Globally, over 250 million slum dwellers suffering from chronic diseases need help. The social and

economic cost of chronic diseases is significant for individuals, families and society. Generics, better

medicine, and digital technologies may offer solutions, but more are needed. Solutions for chronic

diseases in slums are not a priority for governments, the private sector or NGOs. Social enterprises may

be the best option to address this issue. However, building successful social enterprises in slums will

be difficult.

Can we build a social healthcare enterprise that serves the needs of 25 million slum dwellers

suffering from chronic diseases by 2019?

Social Enterprise ChallengeImproving Chronic Disease Care in Slums by 2019

With Special Call to Action by President Bill Clinton

BREAKING THE POVERTY CYCLE

Written by:

Hitendra Patel, Ronald Jonash, Kristen Anderson and Julius Bautista

Hult International Business School Publishing


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Dear Participants:

This year, the Hult Prize has taken additional steps to push boundaries and create even bigger and

bolder opportunities for the next wave of social entrepreneurs. We are taking on more complex

challenges and using powerful accelerators with the hopes of continuing to grow our impact by 10x.

The attached case challenge is a living, breathing document. It reflects the best wisdom from

private, non-profit, and governmental experts who have dedicated their lives to making an impact

in this space. Our knowledge about these complex issues slums, social enterprise, and chronic

disease continues to develop with each passing day organizations are on the ground trying to

make a difference.

In order to ensure this challenge is as accurate and complete as possible, this case is being

released today in beta version. We will continue to source expert information and experience that

will improve the solutions our teams build over the next several months. The final iteration will be

released to coincide with the announcement of regional finalists.

This case challenge will illuminate some of the key issues surrounding chronic disease care in slums

and provide guidance for building a successful social enterprise. Your solutions bring hope that this

problem can and will be solved.

Best of luck,

Dr. Hitendra Patel

Board of Directors

Hult Prize Foundation

A Message from the Authors


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Table of Contents / Figures

Contents

Over 250 million slum dwellers suffering from chronic diseases need help 5

Chronic diseases affect over 250 million people in slums worldwide 5

Slum dwellers have a range of complex healthcare needs 8

Current solutions to address chronic diseases in slums are not working 10

Prevention is not a priority 10Alternate solutions are preferred, which delays correct diagnosis and treatment 10

Clinics are ill-equipped to identify chronic diseases early and provide proper treatment 10

The social and economic cost of chronic disease is significant for individuals, families and

society 11

Individuals suffering from a chronic disease pay with more than their health 11

Families who care for members with chronic disease face financial and emotional stress 11

Chronic disease is costly for society 11

Generics, better medicine and digital technology may offer solutions, but more are neededto counter the increasing slum population 11

Generic pharmaceuticals are increasingly available to slum dwellers 11

Better medicine is making healthcare more accurate 12

Virtual solutions and telemedicine are beginning to offer lower-cost health options 12

However, the impact of chronic disease in slums is expected to increase due to behavioral riskfactors in slums, urban migration and increasing life expectancy 13

Solutions for chronic diseases in slums are not a priority for governments, the private sector or

NGOs 14

Governments see slums as illegal habitats and focus on emergency care 14

The private sector is unable to provide market solutions for chronic diseases in slums 14

NGOs focus on healthcare challenges related to communicable and infectious disease 14

Social enterprises may be the best option to address this issue 15

However, building successful social enterprises in slums will be difficult 16

Social enterprise operations are difficult to manage 16

Inconsistent demand is hard to plan for 16

Fair pricing for health solutions is difficult to implement 16

Consumers with fluctuating income and limited savings are difficult to serve 16

Partners across the value chain are difficult to work with dependably 16

Can we build a social healthcare enterprise that serves the needs of 25 million slum

dwellers suffering from chronic diseases by 2019? 17

Addendum: Create Successful Social Enterprises 18

Find customers who can pay 18

Use existing channels 19Make offerings affordable and accessible 19

Build with local parts and knowledge 19

Go beyond traditional business models 20

Authors 21

Research Team 21

Acknowledgements 21

Selected Reference Sites and Sources 22


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Table of Contents / Figures

Figures

Figure 1. Slum populations are largest in Africa, Asia and Latin America 5

Figure 2. Chronic disease affects tens of millions of slum dwellers 6

Figure 3. Chronic diseases are part of a vicious cycle for slum dwellers 6Figure 4. Over 80 percent of chronic disease deaths comes from four types of diseases 6

Figure 5. The percentage of deaths from chronic disease is expected to increase 7

Figure 6. Slum dwellers need awareness about healthcare, and care needs to be accessible,

affordable and accurate 8

Figure 7. More than half of healthcare costs in developing countries come from expensive

drugs 10Figure 8. Global costs for chronic disease will increase 11

Figure 9. Generic pharmaceuticals are becoming more common as patents expire 12

Figure 10. Technology-enabled health solutions are becoming more prevalent 12

Figure 11. Global urban population is rapidly increasing 13

Figure 12. Chronic disease risk accumulates over ones lifetime 13

Figure 13. Social enterprises may be best suited to address chronic care in slums 15Figure 14. Solutions should work with specific intervention points to make targeted impact 15

Figure 15. Guiding metrics help identify solutions with the most impact 18

Figure 16. The Innovation Value Chain can identify opportunity points 18


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Over 250 million slum dwellers suffering

from chronic diseases need helpChronic diseases affect over 250 million people in slums worldwide

All over the world, poor people are suffering from diseases that can be treated and even cured,

but their suffering continues unnecessarily because they do not have reasonable healthcare.

Healthcare, as it is described in this case, entails the maintenance and improvement of physical

and mental well-being through medical services. People who live in slums lack access to effective

and affordable healthcare.1 It is estimated that close to a billion people worldwide live in slums.2

Slums are poor, densely populated, illegal (or informal) settlements with weak or non-existent

infrastructure near or within an urban area. Slums exist all over the world but are more common in

developing regions in Africa, Asia and Latin America (Figure 13). People who live in these areas lead

difficult lives. Employment is intermittent. Sanitation is poor. Education about choices is insufficient.

Healthcare is nearly impossible to find. Because of the grim conditions in slums, disease comes

sooner, lasts longer, has more serious consequences and is all too often too expensive to treat. As

expected, poor people in these poor countries are more vulnerable and have fewer options and less

access to quality care.4

Cancer, diabetes, andheart diseases are nolonger the diseases ofthe wealthy. Today,they hamper the peopleand the economies of

the poorest populations even more thaninfectious diseases. This represents a publichealth emergency in slow motion. Ban

Ki Moon (UN Secretary General)

Improving Chronic Disease Care in Slums by 2019

Although existing numbers are difficult to assess, it is estimated that over 250 million people in

slums suffer from chronic disease

Chronic diseases, also known as non-communicable diseases (NCDs), are not passed from person

to person.5 They are of long duration and generally slow progression, representing the main cause

for disability and death worldwide.

Identifying appropriate statistics and population measures is always a difficult task. Explicit countsare based on general estimates because of two key factors (1) governments often overlook slums

in official counts and (2) records are limited because of informal employment, land tenure and

networks.6 In terms of morbidity, it is estimated that there are at least 2 billion people worldwide,

and 250 million people living in slums, who suffer from at least one the following chronic diseases:

cardiovascular diseases (CVD), cancer, chronic respiratory diseases (CRD), diabetes or mental

illness. The number of people suffering from chronic diseases is expected to continue rising (Figure

2).

Figure 1. Slum populations are largest in Africa, Asia and Latin America


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For slum dwellers, being unhealthy is the first step that leads them towards a dangerous cycle

(Figure 3). Without their health, slum dwellers productivity is compromised and many are often

too sick to work at all. This leads to wasted time, forgone wages, and deeper and deeper poverty. 7

Proper healthcare that is affordable, accessible and accurate is critical to breaking this cycle and

enabling people to lead happier and more productive lives.

Figure 2. Chronic disease affects tens of millions of slum dwellers

Figure 3. Chronic diseases are part of a vicious cycle for slum dwellers

Both physical and mental chronic diseases have a huge impact on slum dwellers

Physical chronic diseases account for 63 percent of deaths worldwide

Research suggests 80 percent of chronic disease deaths are caused by one of four types of

disease: cardiovascular diseases, cancer, respiratory diseases, or diabetes.8 9

Figure 4. Over 80 percent of chronic disease deaths comes from four types of diseases

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These diseases are expected to take a larger toll in every region around the world.10 Each of these

diseases have different symptoms, affect peoples lives in a distinctive way, and require unique

treatment.

Figure 5. The percentage of deaths from chronic disease is expected to increase

Cardio vascular diseases (CVD) are a group of disorders of the heart and blood vessels. 11 Heart

attacks and strokes are the most common diseases suffered and are the number one cause of

death globally. High blood pressure accounts for the majority of deaths.

Cancer is a disease that can affect any part of the body and is defined by the rapid creation of

abnormal cells which can invade and spread to other organs. Metastases are the major cause of

death from cancer. The most frequent types of cancer differ between men and women; the most

common are lung, stomach, liver, colorectal and breast cancer.12

Respiratory diseases affect the air passages in the lungs. The two most common chronic respiratory

diseases (CRD) are asthma and chronic obstructive pulmonary disease (COPD). Asthma is

characterized by recurrent attacks of breathlessness and wheezing, and COPD patients experience

a persistent blockage of airflow from the lungs.13 14

Diabetes occurs either when the pancreas does not produce enough insulin or when the body

cannot effectively use insulin.15 There are two types of diabetes: Type 1 and Type 2, the latter being

the most common, resulting from excess body weight and a lack of physical activity.

Each of these types of diseases have different risk factors, but overall, it is said that there are

four main behavioral risk factors that contribute to chronic diseases, these include poor nutrition,

physical inactivity, alcohol consumption, tobacco usage and physical inactivity.

Mental disease is a leading cause of disability and lost productivity

Although it is not responsible for a high percentage of deaths, mental illness can have an enormousimpact on health and wellness. This medical condition disrupts a persons thinking, feeling,

mood, ability to relate to others and daily functioning. The different types of mental illness include

depression, anxiety disorders, schizophrenia, eating disorders and addictive behaviors.16 There

are at least 60 million people with mental illness in slums around the world.


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Slum dwellers have a range of complex healthcare needs

Figure 6. Slum dwellers need to be aware about healthcare, and care needs to be

accessible, affordable and accurate

Developing solutions for healthcare in slums will require careful consideration of consumer needs.

Consumers, however, may be a person who is suffering from a chronic disease or a family member

or caretaker. Each of the following sections can be examined from the perspective of either patient

or caretaker.

Do I know what I need?

Do I know what makes me ill? The first step to improving health comes from knowing the risk

factors that can make people sick. Education about conditions that cause illness can help families

make the right choices. From basic sanitation and nutrition to physical activity and the dangers of

smoking, education about the causes of disease can go a long way towards preventing it. All too

often children and families suffer needlessly because they do not have enough information about

how their own behaviors may be making them ill.17

Do I know when I am ill? In addition to needing to know what can make them sick, people need to

know what symptoms to look out for once they are ill. Particularly with chronic disease, symptoms

may be subtle. High blood pressure can have no symptoms at all, and many cancers are first noticed

by a feeling of fatigue.18 For slum dwellers who struggle to get enough to eat, medical treatment for

apparently minor outward symptoms would seem a poor use of limited income. Education about

the importance of early detection and treatment can help prevent chronic diseases from being

disabling,19 which can not only improve productivity but also increase quality of life.

Do I know what to do when I am ill? Once someone is ill, its important that individuals, heads

of household, and caregivers know the appropriate subsequent steps to take. Hospitals can be

far away or too expensive for slum dwellers to use. Even if medical facilities happen to be within

a reasonable proximity, urban slum dwellers, who are most often migrators from rural areas, donot know how to use the urban health systems.20 In rural areas, health programs are traditionally

outreach-focused, while urban health centers are typically facility-centric. Because many poor

people in cities are unfamiliar with the processes and expectations of these health programs and

facilities, there is an additional burden on those who are sick and concerned about meeting their

familys basic needs.

Can I trust I got the right care?

Do caregivers and doctors have enough knowledge to care for me? Not only do slums lack medical

professionals (Switzerland: 40.8 per 10,000 residents; Brazil: 17.6 per 10,000 residents; Nigeria: 4.0

per 10,000 residents; and Kenya: 1.8 per 10,000 residents21), these professionals are sometimes

under-trained and are often over-worked.22 This makes it difficult for doctors to communicate basic

health knowledge, and it makes medical care even more burdensome for families by extending

wait times. Weak systems also mean that personal medical records are difficult to track. Individualsrarely have access to their own medical histories, and if they do, they typically lack the ability to

store the information safely and privately.23This means doctors have to diagnose and treat patients

I didnt know...

Khalida, a 32 year-old mother from aChittagong slum, was surprised whenshe was diagnosed with diabetes. Doctorsays it has been years I have got diabetes,and now the situation has become

serious. I didnt have money to comeand see the doctor that is why I did notcome earlier. Today, I came here to takemedicine without even knowing that Ihave diabetes. Now, Khalida is worriedabout her future because she doesnt havemoney for treatment and come to thehospital every week. As Khalidas casedemonstrates, many slum dwellers donot realize that they are suffering fromchronic disease until it too late and costlyto treat.

Source:http://www.dispatchesinternational.org/?p=143


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with imperfect and incomplete information.

Do caregivers and doctors have the right incentives? Corruption often develops because incentives

arent properly aligned. Doctors need to be incentivized to provide the best care for patients, rather

than finding the quickest way to move slum dwellers and other poor patients out of the hospital. 24All players along the value chain need to be incentivized to price treatment and medicine fairly, offer

care extensively, and ensure the highest level of quality to all people.

Are people held accountable? Because of a lack of transparency, holding corporations, clinics

and medical practitioners accountable for their actions is at best difficult. In 2001, pharmaceutical

companies in the private sector came under tremendous scrutiny for their policies and pricing

models on life-saving HIV and AIDS medication.25 This pressure for transparency, however, has not

been equally applied or sustained around the world. Governments, middle men, and black market

dealers all have their own reasons to manipulate the system. A study in Pakistan slums has shown

that only 24 percent of corrupt medical practices come from doctors while 70 percent comes from

other hospital staff.26

Can I find it when I need it?Can I get there? Weak infrastructure means that frequent trips to clinics or hospitals can be too costly

for individuals and families. A survey in India found that 14 percent of respondents were dissatisfied

with the distance they had to travel to receive care. 17 percent were dissatisfied because of the

hours care was available and 35 percent were dissatisfied because of the amount of time they were

required to wait.27 All of these barriers are making healthcare more difficult to access.

Is there a system? Because slums are informal or illegal habitats, most do not have the necessary

infrastructure to build or maintain a health system. Medical facilities and clinics need to have access

to running water and electricity to maintain basic sanitation and be staffed with skilled workers,

both of which may be difficult to find within slums.28 The system that does exist is typically very

fragmented; different facilities offer different capabilities and levels of care and are unable to

communicate with each other.29

Do I have the legal right to care? In some countries, governments guarantee access to healthcare

for all citizens. Although these facilities may be crowded and have long waits, there is some way

for people to get medical treatment at subsidized or no cost. 30 However, there are many countries

(of which most are in the developing world) that have no commitment to universal healthcare.31 For

people in these countries, and particularly those living in illegal slums, there is no guarantee that

healthcare will be provided, even if they are able to make it to a medical facility. Legal coverage,

protection of privacy and government support can be important to making healthcare accessible.

As mentioned, the poor often find themselves in a vicious and reinforcing cycle when it comes to

healthcare. Indrajit Hazarika, a senior lecturer at the Indian Institute of Public Health, Delhi describes

what he has observed: Social exclusion and lack of information and assistance restricts the use

of private facilities by poor people. More importantly, lack of economic resources inhibits the use

of private facilities. These make the urban poor more vulnerable and worse off than their ruralcounterparts.32

Can I pay for it when I need it?

Is the supply chain efficient? People need to be able to pay for the care they receive. Because

infrastructure is difficult to manage not just in slums, but often throughout low and middle-income

countries (LMICs), getting equipment, clinicians and medicine to the market can become more

costly than in developed areas.33 It is estimated that drugs in developing countries are 2.7 times

more expensive in the public sector and 6.3 times more expensive in the private sector than they

are in the developed world.34 Additionally, in many developing countries, regulatory authorities

from the government are unable to consistently fulfill their role in maintaining the quality control of

the testing or distribution of drugs.35 Caring for chronic disease is particularly difficult because the

supply chain is extremely complex and varied by region.

Are cheaper options available? Because the supply chain can add significant cost to medicine,

labor and other equipment, alternatives need to be available to make healthcare more affordable.

Currently, the price of generic drugs varies dramatically by location but could provide affordable

I just cant pay

Shakeela Begum, a 65 year - old housewifefrom a Karachi slum, had a heart attackseveral years ago, and she still hasnt

fully recovered. I cant do as much,because I get tired very quickly, shesays. Nevertheless, shes not taking the

prescribed dose of medication. I know Ishould be taking my medication every daybut this way I can also save some money

for my grandchildren they are young

and have a future, she argues.Source: http://www.who.int/chp/chronic_disease_report/full_report.pdf

No room for me

A 68-year old slum dweller, BharatTiwari, is disappointed because doctorsat a government-funded hospital in New

Delhi have deferred a surgery needed totreat his heart ailment and told him toreturn in two months. Such delays arenot unusual at the overstretched facility.

Bharat and his family were hoping thatsurgery could reduce the high drug costs.

His son says the USD 100 spent everymonth on his fathers medications addsup to a quarter of the family income. Now

Bharat and his family will just have towait.


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Individuals suffering from a chronic disease pay with more than their health

The majority of slum dwellers are daily wage earners who make, on average, less than 5 USD per

day.47 The direct costs associated with chronic disease, even if diagnosed early, are overwhelming.

For example, one chemotherapy session in India costs nearly 1,500 USD. Six months of cancer

treatment in India can range from 4,000 USD to 32,000 USD.48 Without insurance and financing,

slum dwellers bear almost all medical costs out-of-pocket. In addition to the direct cost, chronic

disease impacts an individuals ability to work lowering income and affecting productivity.

Aside from the economic costs, individuals also suffer tremendous emotional and psychological

effects from pain, anxiety, inconvenience and bereavement.49 Individuals are often treated poorly

and ostracized by other community members.

Families who care for members with chronic disease face financial and emotional stress

Those with chronic diseases are not the only people who feel pain. Entire families often bear the

burden when one member suffers from a chronic disease. Management of chronic disease is

complicated, and can require special therapy and training. Families who must help with this care

lose income and productive time from work and school. Lost income and direct costs for care push

many families deeper in to poverty. This vicious cycle is often called the medical poverty trap.50

According to the World Health Organization (WHO), 44 million households (100 million individuals)

fall in to poverty each year because of catastrophic health costs.51 It is estimated that 90 percent of

these people live in low income countries.52 Because of the expense and duration, catastrophic risk

is associated mainly with chronic disease. In Burkina Faso, the possibility of catastrophic economicconsequences increases from 3.3 to 7.8 times in households stricken by chronic disease.53 Living

with sick family members is also a psychological burden, stressing relationships, creating anger and

frustration, and spawning feelings of hopelessness that often only end with the loss of a loved one.54

Chronic disease is costly for society

In addition to threatening human health, chronic diseases have huge impact on economic growth

and societal development. Global costs for chronic disease are enormous ranging from 290 billion

USD for cancer to 2.5 trillion USD for mental illness each year.55 Cumulative losses for the five most

threatening chronic diseases (Figure 8) are estimated at 47 trillion USD over the next two decades.

This sum could eliminate 2 USD per day poverty for 2.5 billion people for more than fifty years. 56

These costs will be felt not just today but for several generations to come.

The social and economic cost of chronic

diseases is significant for individuals,families and society


Generics, better medicine and digitaltechnology may offer solutions, but moreare needed to counter the increasing slumpopulation

Generic pharmaceuticals are increasingly available to slum dwellers

Medication can be exceptionally costly for those living in slums. It is estimated that the vast majority

of healthcare spending is spent on medication each year.57In addition, there is often a poverty

penalty (because of inefficient supply chains, as mentioned above) for those in slums who may

have the greatest need for medicine. The production and sale of generic drugs can drastically lowerthe costs of these medications.58

My family pays the price

Roberto Severino Campos was from ashanty town in Brazil. He worked as a

public transport agent and never paidattention to his high blood pressure orsmoking and drinking habits. Now,he lives with his seven children and 16grandchildren, who must take care ofhim, because after three strokes, he is

paralyzed and has lost his ability to speak.Fortunately his medication and check-ups are free, but sometimes we just donthave enough money for the bus to take usto the local medical centre, explains his

31-year-old daughter Noemia. Robertodepends entirely on his family, and muchof the familys income is used to cover hishealthcare needs. We all wish we couldget him a wheelchair to make his life alittle easier, she says, but unfortunately,

the family cannot afford it.

Source: http://www.who.int/features/galleries/chronic_diseases/roberto/01_en.html

Figure 8. Global costs for chronic

disease will increase


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As patents expire, more and more medications are legally permitted to be sold as generics and are

therefore more likely to meet quality standards (Figure 9).

In addition, the World Trade Organization (WTO) passed an agreement in 1995 known as TRIPS

that allows governments to issue licenses that allow non-patent holders to manufacture andmarket a medicine in a domestic market.59 This agreement has led to more competition in the

generics market and significantly lower prices. Because of the TRIPS agreement, the price of AIDS

medication in Brazil fell by 82 percent.60


Figure 9. Generic pharmaceuticals are becoming more common as patents expire

Figure 10. Technology-enabled health solutions are becoming more prevalent

Better medicine is making healthcare more accurate

As more pharmaceuticals become available as generics, so too are new and better drugs being

discovered and developed. Funding for pharmaceutical research is funded by government grants,

private corporations, and even new breeds of NGOs like the Aravind Eye Care System. New

diagnostic methods, like the pancreatic cancer screening test developed by 15 year-old Jack

Andraka, are allowing people to diagnose faster, cheaper, more reliably and often in the comfort of

their own homes. The entire medical system is continuing to mature and take a more holistic viewof health, integrating modern medicine with more traditional techniques. These trends offer hope

that the developing world will have the opportunity to leap-frog technologies in healthcare, as it has

done with mobile technology in the telecom industry.

Virtual solutions and telemedicine are beginning to offer lower-cost health options

For the last several decades, technology innovations have been decreasing in price and complexity,

allowing more of the worlds population to have access to a variety of different services. The

healthcare industry is no exception. Since the early 1990s, technology enabled programs have

become an increasingly significant part of programs implemented in low- and middle-income

countries (LMICs) (Figure 10).61

The start of something different

A non-prot startup called Watsi uses aglobal crowd-funding platform allowingany person to directly fund medicalservices for individuals from developing

countries who are unable to affordit. Watsi works closely with medical

partners who identify patients in needand determine if patient conditions meet

pre-determined criteria. Watsi postspatient proles online and distributes100 percent of donor funding directlyto chosen individuals. Watsis operatingcosts are covered by other donations,business partners and licensing software

fees. Although this reects tremendousopportunity to provide signicant care inthe developing world, the model does notcurrently support continuing health needsthat often develop from chronic disease.

Source: https://watsi.org/

Knowledge is power

A study of 150,000 women from slumsin India has shown that a simple vinegartest can reduce cervical cancer mortalityrate by 31 percent. Slum dwellers cantafford costly pap smears and traditional

HPV tests. This new method represents aneasy solution that can be carried out bylocal clinics with minimum training andmodern laboratory equipment. Accordingto research estimations, this low-techexam could prevent 22,000 deaths in

India and 72,600 worldwide each year.

Source: http://bigstory.ap.org/article/vinegar-cancer-test-saves-lives-india-study-nds

Technology allows better access

An underserved community of the SantaMarta slum in Rio de Jainero was chosenfor New Cities Foundations UrbanE-Health Project. During an 18 monthtrial, trained nurses visited 100 elderly

patients in one of the steepest favelas inBrazil with a backpack that containedhigh-tech medical monitoring equipmentdeveloped by GE that enabled them todetect an average of 20 different diseaseslike hypertension or diabetes withinminutes. The pilots results reveal thatdespite the initial cost of the apparatus(42,000 USD), the integration of e-healthtechnology into the healthcare systemof underserved urban areas can lead tomajor economic savings for the healthsystem as a whole, increased efciency

for healthcare workers and better accessto vital healthcare for patients who need

it most.Source: http://www.newcitiesfoundation.org/wp-content/uploads/PDF/Research/New-Cities-

Foundation-E-Health-Full-Report.pdf


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Governments see slums as illegal habitats and focus on emergency care

Governments are responsible for providing infrastructure and rule of law.74 Unfortunately, slums are

in flux and often not recognized as legal places of habitat with legal protection and security.75 As

a result, nominal efforts are made by governments in slums to provide roads, schools, electricity,water and security. Moreover, many governments see urbanization as a problem and put more

effort in rural development to slow urbanization. Most governments ignore slums or threaten

residents with eviction.76

Additionally, the type of aid that governments do traditionally provide is often designed to attend to

communicable or infectious diseases. Governments have spent billions of dollars in aid for malaria,

HIV and tuberculosis.77 Among aid provided by the United States government, almost 50 percent

of global health dollars was spent on HIV alone.78 This focus on HIV creates a global mentality

of reactive care from epidemic flare-ups, but it does not address the growing problem of non-

communicable disease education, prevention, diagnosis, treatment and care.

The private sector is unable to provide market solutions for chronic diseases in slums

The private sector builds business and profit out of sustainable consumer demand. Becausehealthcare is difficult to operate with complete and consistent services without significant margins,

purely for-profit ventures may have difficulty operating in slums.79The private sector, in general, has

had difficulty implementing pricing models that work in slum environments.80

Although some private options exist in slums, most of them are quite expensive for the average

slum dwellers limited budgets. Clinics are also hard to monitor and lack transparency that is critical

for ensuring appropriate accountability across the value chain.81

NGOs focus on healthcare challenges related to communicable and infectious diseases

Non-governmental organizations (NGOs) have become major contributors to social development

in recent decades. Some NGOs focus on rural areas and provide relief aid. Others work in urban

areas and focus on development. However, NGOs have challenges in funding, program continuity

and customer perception.82As a result, their impact has been nominal and at times even negative.83

The last decade has shown that non-communicable diseases are a growing concern for the

developed and the developing world.84 Significant research is being done not only on these

chronic diseases and their root causes but also on their impact on slum areas. Unfortunately,

acknowledgement of the problem has not yet turned into viable solutions for slum dwellers with

chronic diseases. NGOs often focus more on communicable and infectious diseases that are easy

to prevent and are still among the leading causes of death in the developing world.85

Solutions for chronic diseases in slumsare not a priority for governments, theprivate sector or NGOs

As conditions within and outside of slums improve, longer life will translate into additional costs

incurred in caring for and managing chronic disease. Chronic diseases cost the developing world

well over 50 percent of total healthcare costs.72This number is expected to increase dramatically as

countries develop. Chronic diseases cost the United States 75 percent of total healthcare costs.73


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Social enterprises deliver both social impact and business profit. They deliver social impact by

improving the health and well-being of the worlds most vulnerable people. While social enterprises

can be either for-profit or not-for-profit organizations, they all aim to utilize a pricing strategy

that will create a sustainable, consumer or partner-driven business model. This helps reduce or

eliminate dependence on donations and cash injections. Slums will benefit from the emergence

of more social enterprises particularly those focused on prevention, diagnostics, treatment, and

sustainable care to chronic disease (Figure 13).

Figure 14. Solutions should work with specific intervention points to make targeted impact

Figure 13. Social enterprises may be best suited to address chronic care in slums

Social enterprises may be the best optionto address this issue

Addressing pain points along the chronic disease timeline (Figure 14) will improve solutions for

slum dwellers throughout the developing world. Bigger, better, bolder, faster and cheaper solutionsare needed in all parts of this chain: from manufacturing to distribution channels to treatment and

continued care. Solutions that integrate the participation of slum dwellers are considered even

more interesting because they create employment, purpose, and economic wealth for these

individuals.86Robust and scalable business solutions that create economic wealth across the value

chain for all stakeholders are needed to improve care for people suffering from non-communicable

diseases in slums.

Efforts are already in place to create solutions around food security and education. For that reason,

we encourage solutions that focus on the early identification of chronic diseases, their treatment

and care.

Social enterprise in motion

A social enterprise called Access Afya iscreating a network of paperless healthkiosks that offer basic healthcare services

for slum dwellers in Kenya. Kiosks arestaffed with a nurse and communityhealth worker and use an electronic

patient management system and textmessages for communicating with

patients. To make each mini-clinic a self-sustaining operation, every patient paysa small fee. In rst six months, more than

500 patients from Nairobi slums haveused and paid for these health services.

Source: http://www.accessafya.com/


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All people are exposed to risk from unexpected changes in the environment, accidents, illnesses,

price increases or cash availability. Unfortunately, low income individuals have limited safety nets,

social networks and buffers to deal with unexpected change, particularly the major expenses

associated with chronic disease care. Social enterprises that target these types of customers will

have to work with value chain players who are also at a higher risk in an environment with limited

government support and infrastructure.

Social enterprise operations are difficult to manage

Finances must be efficient

Social enterprises need to operate with razor-thin margins in an environment of fluctuating demand

and supply. In informal business (which dominates the economic landscape in urban slums),

relationships with suppliers and customers are informal the hierarchy of roles and work is flexible.87

There are few, if any, contracts. Contacts are irregular and hours of operation vary. Managing cash

collection, inventory and supplier payments is key to ensuring a healthy cash position. To reduce

cost, social enterprises will need to grow significantly to enjoy economies of scale. Both working

capital and scaling up can be managed through financing. Unfortunately, financing for companies

working in the slums or targeting poor slum dwellers is limited to a few microfinancing institutions.

Assets must be able to bear risk

Social enterprises working in slums are exposed to higher risk from supply chain inefficiency,

fire hazards, natural disasters, corruption and high crime rates.88 Most insurance organizations

are unable to assess the risk, claims and premiums accurately enough in slums to build a viable

business. Social enterprises have to manage their environment and assets to ensure business

continuity in the face of risk that most enterprises in wealthier regions have insurance for.

Employee training must be flexible and culturally appropriate

Social enterprises should hire from slums to increase social impact; however, these potential

employees may not have the appropriate skills and training for the job.89 Training and on-the-

job skills development will put additional stress on management and operations. Additionally, it

is critical to work with local employees in a way that is culturally acceptable and considerate to

differences in gender sensitivity, religious practice, dietary preferences and other social norms.

Inconsistent demand is hard to plan for

Most services are not derived from homogenous demand.90 Airlines, banks, and particularly health

care clinics may see demand vary by time of day, day of the week or even by season. These

fluctuations can make operations difficult, particularly for social enterprises struggling to leverage

sustainable business models. Operating with peaks and valleys of demand can quickly wipe out

many businesses that must operate on squeezed margins.

Fair pricing for health solutions is difficult to implement

Social enterprises will have to struggle with the same challenges that traditional businesses do

in building business models for the healthcare industry. Healthcare is extremely susceptible to

inelastic demand and what is known as dynamic inconsistency. This means that the need, and

therefore willingness to pay, for services fluctuates dramatically over time. As a result, setting

market prices is difficult to do with fairness and integrity. This inconsistency, combined with a

unique lack of transparency and feedback mechanisms around true pricing, means that healthcare

social enterprises will not be able to use business models leveraging traditional supply and demand

curves.91

Consumers with fluctuating income and limited savings are difficult to serve

Poor people in slums lack adequate education. Those with less education typically make lessmoney and lack access to higher paying jobs.92 The jobs that slum dwellers are able to access

are often irregular and provide fluctuating income.93 Social enterprises will need to have business

models that can accommodate inconsistent consumer income. In addition, slum dwellers who

However, building successful socialenterprises in slums will be difficult


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do not have sufficient education do not typically have enough knowledge about proper chronic

disease prevention, diagnostic, treatment and care options.

Slum dwellers also struggle to build significant savings accounts that are critical to being able to

pay for medical care and services.94 Without a savings account, people sometimes fundraise for

their own medical procedures by begging in their own communities.95 Those lacking in healthcarein slums typically have incomes between 1 USD to 5 USD a day. Social enterprises that target this

segment will have to provide low-cost solutions that consider financing and savings opportunities

within this income level.

Partners across the value chain are difficult to work with dependably

Pharmaceutical producers, medical equipment manufacturers, and distribution networks to

hospitals and clients must ensure quality care. However, most players in the healthcare value chain

are remote and ill-designed for slum environments, which make the whole value chain fragile. Social

enterprises will face significant challenges in building a consistent and predictable supply chain.

Can we build a social healthcareenterprise that serves the needs of 25million slum dwellers suffering fromchronic diseases by 2019?

The purpose of this challenge is to improve health options around diagnostics, treatment and care for

those suffering from chronic diseases in slums around the world. This will lead to better productivity,

more robust healthcare systems for all slum dwellers, and individuals who have significantly higher

quality of life. The winning business solution should have significant and measurable impact.

A list of questions to help develop a good winning business solution is provided in Figure 15. The

solution should have a sustainable business model. It should improve health options. It should have

a stage implementation plan with clear milestones and funding required for each milestone. Overall,

the winning solution should scale rapidly to serve an ever increasing number of people with chronic

disease in a relatively short time. Solutions may be built around any of the following steps in the

chronic disease timeline: diagnostics, treatment or continued and extended care, but must reach

25 million people with chronic disease by 2019.


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To develop a solution, lessons learned by other companies, NGOs and social enterprises in other

industries should be considered. IXL Center uses the innovation value chain to find growth and

opportunity in new areas. There are bright spots around each section of the innovation value chain

market, delivery, offering, production and business model that should be considered as inputs

when developing solutions for the poor (Figure 16).

Find customers who can pay

Target profitable customers and segments

Know your customers needs and behaviors

Plan for consumers who lack trust

Addendum: Create Successful SocialEnterprises

Figure 16. The Innovation Value Chain can identify opportunity points

Figure 15. Guiding metrics help identify solutions with the most impact


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What you should ask:

Who is your target customer?Social enterprises typically target those who earn more than 2

USD/day.

What are your customers needs and purchase behavior? Offerings need to delight customers

and be integrated into existing behaviors.

How will you build trust and credibility for your consumers? Making the wrong decision has

much more serious consequences for the poor, so customers must trust in what they pay for.

Use existing channels

Tap existing channels

Use powerful influencers

Leverage virtual solutions


What existing distribution channels of major corporations or local business can you work

with?Channels that have already been built may cost money, but they are effective and ready

immediately.

Who or what are the influencers that can accelerate acceptance of your offering? Strong

relationships and word-of-mouth networks can scale social enterprises quickly.

How can you use new and existing technology to move goods and services virtually?Finding

solutions that leap-frog the developed world with technology can be more cost-effective.

Make offerings affordable and accessible

Right-size solutions Hold people and organizations accountable

Focus on human-centered design


How can you build your offering in pieces?Low-income families can pay for things bit by bit

more easily than all at once.

What can you do to ensure accountability?Audits and monitoring should be embedded to

keep business trustworthy.

Who are you designing for?Your customers are more likely to pay for things that were designed

with them in mind.

Build with local parts and knowledge

Use parts that are available where you are delivering

Apply insight and knowledge of the community

Build with assets of value


What do you need to replace parts of your offering with locally available supplies?You can

save money and time by building closer to home.

Who has knowledge that can help you be more successful on the ground? Navigating

communities often requires local support and engagement.

What assets will make your enterprise more valuable by itself?Just because something is free,

does not mean it is valuable to your operations.


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Go beyond traditional business models

Provide value exchanges and microfranchises

Create intangible value

Create a business model with flexibility


How does your solution capture the value you create?Capturing value is a critical step to

making your social enterprise economically self-sustainable.

What do you offer people that is difficult to put a price on?Your offering will be more interesting

if you free up peoples time, or increase self-esteem, dignity, security or happiness.

What are the different stages of your business model?You may need to finance operations

differently during the pilot and early stages than you do at scale.

Companies who are able to think broadly and holistically about the entire business innovation valuechain are more likely to be able to capture value. Social enterprises developed for the Hult Prize,

like Aspire, Reel Gardening, Pulse, Poshnam, Origin and Sokotext, have worked across these

segments to scale offerings that will help end food insecurity in urban slums. They are working on

the ground, today, to produce at lower cost, find offerings that delight consumers, deliver quickly

and effectively, build brands that inspire trust, and use partners and networks to help capture new

value in new ways. How can you do the same for peoples well-being and health?


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The Hult Prize and IXL Center have compiled research for this case from known and credible sources. The authors have attempted to use

accurate information as much as dynamic data can be accurately measured and reported. The authors explicitly disclaim to the extent

permitted by law responsibility for the accuracy, content or avail ability of information located throughout thi s case or for any damage incurred

owing to use of the information contained therein.

AUTHORS

Dr. Hitendra Patel

Managing Director, IXL Center; Hult Professor of Innovation and Growth

Hitendra Patel is the Managing Director of the IXL Center. He helps Fortune 1000 companies identify andimplement new growth engines or helps them build innovation capability. He has written all the cases for the

Hult Prize and is on its advisory board. Previously, Hitendra worked at Monitor, ADL, and Motorola.

Ronald Jonash

Partner, IXL Center

At Arthur D. Little for 25 years, Ron led the effort to translate strategic planning methods to the institutional

and non-profit sector as well as the effort to transition a technology innovation practice to a broader strategicinnovation practice. Ron was also head of the Innovation practice at the Monitor Group for five years before

launching the Center for Innovation Excellence and Leadership and the Global Innovation Management Institute.

Kristen Anderson

Consultant, IXL Center

Kristen is a consultant with the IXL Center. Kristen has worked with the Hult Prize since 2010, when she was a

student in London. In 2012, she wrote the case study with Habitat for Humanity. She specializes in corporate

and MBA Management Consulting training. Kristen also provides coaching and training for innovation andbusiness intelligence action projects around the world.

Julius Bautista

Consultant, IXL Center

Julius works on product development and research efforts at IXL Center. He has contributed to the development

of white papers, articles and books around the topic of innovation. Additionally, Julius co-wrote the One Laptop

per Child (OLPC) case used by Hult Prize for the 2012 challenge. He is also a mentor at the Hult InnovationOlympics helping MBA students generate breakthrough ideas for OLPC to educate more children in developing

countries.

RESEARCH TEAM

Lydia Baluchova

Research Associate, IXL Center

Lydia is a research associate at IXL Center. Prior to IXL Center, she was working as a lawyer in the private andpublic sector in Slovakia. Lydia completed her legal studies in Greece and Slovakia and also has an LL.M in

International Business Law from Central European University in Hungary.

Karla GomesConsultant, IXL Center

Karla has more than four years of consulting experience working in Strategy and Organization (S&O) related

projects where she worked with public and private sector clients for various industries such as energy, financeand construction, among others.

Shinhee Kim

Associate Consultant, IXL Center

Shinhee is an Associate Consultant at IXL Center. Prior to IXL Center, she worked as a HR manager and research

associate for various companies in South Korea. Shinhee is a MBA candidate at Suffolk University and she has

a B.A. from University of Ulsan, South Korea.

ACKNOWLEDGEMENTS

Special thanks to the following individuals and organizations for their input and insight:

Pamela McNamara, Principal, IXL Center

Steve Andrews, CEO, Solar Aid

Joan Bragar EdD, Leadership Consultant, Boston Leadership

Grace Garey, Marketing, Watsi

Akanksha Hazari, CEO and Founder, mPaani

Dr. Isabel Martinez del Rio, Dietitian/Nutritionist, Hospital St. Angelin Chapultepec

Dr. Kishor Mistry MD PhD, Managing Trustee, Koshish-Milap Trust

Jennifer Norman, Director of Public Health Mercy Corps

Dr. Miguel Angel Santos, Henrique Capriles Presidential Campaign Public Policy Team, Harvard Kennedy School of Government

Greg Scarborough, Senior Advisor on Nutrition & Food Security, Mercy Corps

Dr. Ricardo Villasmil, Head of Public Policy, Henrique Capriles Presidential Campaign, Harvard Kennedy School of Government

David Peters MDDrPH MPH, Professor, Chair, Department of International Health, Johns Hopkins Bloomberg School of Public Health

Michael B. Bracken PhD, MPH, FACE, Professor of Epidemiology (Chronic Diseases), Yale School of Public Health

Darrell J. Irvine PhD, Professor of Biological Engineering and Materials Science, David H Koch Institute for Cancer Research, MIT

Minister Rim Chemin, Ministry of Health and Welfare, Republic of Korea



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85Scarborough, Greg (Mercy Corps). Interview by author. Phone interview. IXL center - Mercy Corps, September 3,

2013.86Aneel Karnani, Fortune at the Bottom of the Pyramid: A Mirage, Stephen M. Ross School of Business at the

University of Michigan, Ross School of Business Working Paper Series Working Paper No. 1035, July 2006.87Karnani, Aneel. Romanticizing the Poor. Standford Social Innovation Review, 2009. http://www.ssireview.org/

articles/entry/romanticizing_ the_poor (accessed September 10, 2013).88Ibid.89A) Aneel Karnani, Romanticizing the Poor, Stanford Social Innovation Review, 2009, http://www.ssireview.org/articles/

entry/romanticizing_the_poor September 10, 2013 B) United Nations Human Settlements Programme, The Challenge

of Slums: Global Report on Human Settlements 2003, P. 68, http://www.unhabitat.org/pmss/listItemDetails.

aspx?publicationID=1156 September 10, 2013.90Fitzsimmons, James A. and Mona A. Fitzsimmons. Managing Capacity and Demand. Originally published in Service

Management: Operations, Strategy, and Information Technology. Boston: McGraw-Hill/Irwin, 2013.September 10,

2013http://210.46.97.180/zonghe/book/213-%E6%9C%8D%E5%8A%A1%E7%AE%A1%E7%90%86-%E6%9

C%BA%E6%A2%B0%E5%B7%A5%E4%B8%9A%E5%87%BA%E7%89%88%E7%A4%BE-James%20A.%20

Fitzsimmons/CHAPTER13.htm (accessed September 10, 2013).91Scott, Douglas. Applying Economic Principles to Health Care: Resource Allocation in Health Care. Medscape, 2001.

http://www.medscape.com/ viewarticle/414406_3 (accessed 10 September 2013).92Ibid.93Kigali City.Kigali Master Plan implementation projects . Kigali City Official Website. http://www.kigalicity.gov.rw/

spip.php?article495 (accessed September 10, 2013).94Mensch, Barbara S.The effect of a livelihoods intervention in an urban slum in India New York, NY: Population

council, 2004.http://www.popcouncil.org/ pdfs/wp/194.pdf (accessed September 10, 2013).95Garey, Grace (Watsi). Interview by author. Phone interview. IXL Center - Watsi, September 12, 2013.

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