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Ideas in Action: Innovation and Entrepreneurship

In much of Africa, Asia, and Latin America, there are few health workers, pharmacies, or clinics, particularly in rural areas, making it difficult to deliver inexpensive, high-quality health care to those most in need. When people in these regions get sick, they often get little care or no care at all.

People with the least access to the formal care system typically rely on informal health care, such as folk remedies from family, friends, or traditional healers, which may be ineffective. Others may travel by foot or even be pushed in a wheelbarrow many miles to seek health care in a larger village. Many who do eventually receive skilled medical attention arrive too late to be saved. Too often, they simply die at home or in transit. Requiring poor people without transportation to come to the few places they can get affordable, quality care is killing them: we must bring quality care to them.

Developing innovative ways to bring care to these people in need is what motivates groups of students and faculty at Rice University in Houston, Texas. They work to address health needs in developing countries, whose low-resource environments have little financial capital, limited human capital, poor roads, intermittent power supplies, and few other typically needed resources. One group of innovators is working to develop appropriate solutions, like a low-cost but effective bubble Continuous Positive Airway Pressure (CPAP) system developed to help infants in poor countries with respiratory problems breathe more easily.¹ Another group is working on projects like a low-cost, electricity-free centrifuge—using a salad spinner, hair combs, and a round plastic container—that can test up to thirty blood samples at once so community outreach workers can accurately diagnose anemia.²

These unmet needs in global health are also what motivate innovators at PATH, an international nonprofit organization, to focus on “transforming global health through innovation.” With over a thousand staff skilled in business, marketing, science, technology, development, and other critical fields, and operational in over seventy countries, PATH works to improve global health by advancing technology, strengthening systems, and encouraging healthy behaviors.³

Both Rice and PATH recognize that global health challenges require business and technology innovation and entrepreneurial solutions. Indeed, the limitations of developing countries, coupled with tremendous opportunities to create sustainable impacts, help drive these health entrepreneurs to be particularly creative and innovative. But while technological solutions are valuable, to make them effective organizations must address a challenge at least as difficult: successfully distributing these innovative health technologies to the customers who need them by solving issues related to what in business is typically called “the last mile.” To this end, business model innovations are also needed. Getting products and services to customers in need is a significant logistics challenge. However, businesses do this all the time. Regardless of the remoteness of a given location, you can almost always find products like a cell phone or Coke that, incidentally, people are buying.

Business model innovation can be developed and implemented by all sectors: governments, NGOs, businesses, and donors. And these same organizations need to be more entrepreneurial to actually make it all work. That is why the first point in the IMPACTS approach focuses on innovation and entrepreneurship.

According to Peter Drucker, a writer and consultant some consider to be the inventor of modern management, “Innovation is the effort to create purposeful focused change in an enterprise’s economic or social potential.”⁴ Innovation is crucial for every organization to thrive. But innovation is required not just within organizations, but in the ways we organize people to accomplish goals, including the delivery of health care. Innovation requires risk-taking. We often cannot know what will work unless we try.

Innovation & Entrepreneurship

James M. Kilts, former chairman and CEO of The Gillette Company (now part of Procter & Gamble), observed, “You need to encourage risk-taking. One of the themes in our company is to remember that the opposite of success is not failure but inertia.”⁵ That puts innovation in the right context: it is critical for growth among all sectors—as important to a microentrepreneur in India, a faith-based organization in Nigeria, and the government of Brazil as it is to a multinational corporation in Japan. Without innovation, organizations stall—and consequently collapse.

Innovation is the key point in achieving progress, regardless of sector or setting. Organizations cannot improve outcomes through cost reduction and reengineering alone. Exactly what type of growth innovation creates depends on the needs of the organization, the internal and external environment, and its competencies. For corporations and microentrepreneurs, innovation can result in revenue growth, a stronger bottom line, improved consumer relationships, more motivated employees, enhanced partnership performance, and increased competitive advantage. For governments and NGOs, it can be all of the above, increasing social impact by successfully meeting the needs of their customers—the communities they serve.

One of the most common misconceptions is that innovation is primarily, if not exclusively, about changing technology.⁶ Mention innovation to many business, NGO, or government leaders and they envision research and development labs where engineers and scientists are creating the next new technology. However, innovation applies to more than technology; it also involves changes in processes and organizational designs. This can include new rules and regulations, clever ways of bringing products or services to people, novel ideas that change the culture, and new attitudes and values that change people’s behaviors, among other things.

Sometimes new or modified regulations and policies can be the critical element in solving a seemingly insurmountable problem, such as seatbelt laws and speed limits to reduce traffic fatalities. Sometimes there is a need to educate people to create demand for products, services, or procedures (such as male circumcision to reduce HIV transmission) that can save lives. Sometimes business models need to change to create efficiencies and become more successful in getting things to the people who need them.

Smart organizations include their customers in the innovation process because customers know the barriers they face and the solutions that will work within their environment, culture, and lives. Often customers are included at the end of the process to see if the innovation was successful, when in actuality they may hold the key to creating innovations that work.

High-performing organizations innovate by designing new business models and improving technologies.⁷ Rarely does a technology change occur without also causing a change in management processes. The reverse is also true. Technology and business model innovations go together and should be thought of and implemented as a whole.

While change is critical, it is by no means easy to initiate, attain, or sustain—as anyone who has tried to lose weight and keep it off can attest. There will often be interpersonal, social, organizational, or political opposition to new technologies or business model innovations. Change, even when necessary and possibly lifesaving, is not always welcomed. And the larger the organization is, the less nimble and flexible it may be and the less open to change Regardless of the size of the organization, when something is not working to achieve our intended impact, we need to be willing and empowered to innovate. Innovation may save lives.

Business Model and Technology Innovation

Business model innovation improves the delivery of products and services to consumers. Technology innovation provides new products and delivers services in new ways. Successful organizations combine business model change and technology change to create innovation. In addition, to successfully integrate a robust model of innovation into the business mindset, leaders must balance the business and technology components of innovation.

There are six levers for change—three in the business model and three in technology (Figure 6).⁸ Innovation involves changes to one or more of these six points, as we discuss below.

Business Model Innovation

Business models describe how an organization creates, sells, and delivers value to its customers. Business model change can drive health care innovation in three areas.

Figure 6 The Six Levers of Innovation

1. Value proposition: what is sold and delivered to the marketplace Changes in the value proposition of the health product or service—essentially, what you sell (or transfer) and deliver to the marketplace—may be an entirely new health product or service or an expanded proposition for an existing offering. This and the other points apply to governments and nonprofits as much as to corporations and microentrepreneurs.

2. Supply chain: how value (health products or services) is created and delivered to the marketplace

The second element of innovative business model change is the supply chain—how value is created and delivered to the market. Changes to the supply chain are usually “behind-the-scenes” changes that consumers typically do not see. This type of business model change affects steps along the value chain, including the way an entity organizes, partners with others, and operates to produce and deliver health products and services. Innovations may also come from redefining relationships with suppliers or from carefully managing relationships with partners whose products and services complement those offered by the organization.

3. Target consumers: to whom products and services are delivered Changes in the target customer segments to whom you provide products or services usually occur when an organization identifies a segment of consumers who would consider its products or services valuable, but who it has been unable to reach in terms of creating demand or effective distribution channels.

Technology Innovation

Sometimes new technologies are a major part of an innovation. Often, they stand out and attract significant attention. At other times the new technologies are hidden out of sight and are only seen by the technical people servicing them. Either way, technology change can fuel innovations in three distinct ways:

1. Product and service offerings: what is provided

A change to the health products or services an organization offers—or the introduction of an entirely new product or service—is the most easily recognized type of innovation because consumers see the changes firsthand. While this type of innovation is very important and can have a significant impact on organizational success, it is not the only form of technology innovation.

2. Process technologies: how value is provided

When we think about technology innovation, we think about innovation that drives the performance of the products or services the organization offers. Product innovation comes to mind because it quickly translates into functionality that the consumer can value and price. But product innovation is only one application of technology. Changes in the technologies that are integral parts of product manufacturing and service delivery can result in better, faster, and less expensive products and services.⁹

These process technology changes are usually invisible to the consumer, but they are often vital to either reducing the cost or improving the quality of a product.¹⁰ Process technologies also include the materials used in manufacturing, since manufacturing and materials are intimately connected. For service providers, process technologies are those elements that allow the service to be delivered. For products and services, process technologies are an essential part of the innovation equation and often enable cost reduction and quality improvement of existing products or services.

3. Enabling technologies that allow value to be provided faster

A third source of technology innovation resides in what we call enabling technology. Rather than changing the functionality of the product or the process, enabling technology allows an organization to execute its strategy much faster and thereby leverage time as a source of competitive advantage. Though the least visible to consumers, changes in enabling technologies, such as information technologies, can be very important because they can help ensure better decision-making and financial management. In health care, mobile phones and telemedicine are enabling technologies that have allowed quality care to reach more people faster.

Three Types of Innovation

A number of innovations, such as purifying water and childhood vaccinations, have revolutionized the way disease is prevented and health care is delivered in developing countries. Other innovations include adapting existing technologies, such as mobile phones, to increase access to care. Understanding these innovations in the context of business model and technology change, but also in the context of incremental versus radical innovations, allows leaders in global health to better understand why some problems have yet to be solved, and helps them discover potentially successful solutions.

Innovations differ widely and thus involve different risks and rewards—and how you innovate affects what you innovate. It is therefore vital to understand the nature of the change required so the innovation effort can be appropriately managed, funded, and resourced. There are three main kinds of innovation: incremental, semi-radical, and radical, according to one system of thought (Figure 7):¹¹

• Incremental innovation leads to small improvements in existing health products and organizational processes. Incremental innovation always firmly embraces existing technologies and management structures. Although some elements may change slightly in incremental innovation, most stay unchanged.

• Semi-radical innovation leads to substantial change to the business model or the technology of an organization. Semi-radical innovations include little or no changes to the elements of one of the innovation drivers—the technology or management.

Figure 7 Innovation Matrix

• Radical innovation results in new health products or services delivered in new ways. Radical innovations include changes in the technology and business model.

For periods of time an organization (a government agency, an NGO, or a business) can be very successful with only incremental changes in technology. Traditional models of technology change predict relatively long periods of evolution (incremental innovation) punctuated by short periods of revolution (radical innovation).¹² Thus, incremental innovation may be a sustainable strategy for long periods of time, before a revolution shakes an industry or even an entire society.

Incremental Innovation

Incremental innovation is the most common form of innovation in most organizations. Most organizations have created many innovative projects through small changes in management or technology.¹³ Incremental innovations are a way to wring as much value as possible from existing products or services without making significant changes requiring major investment.¹⁴ Many management tools are intended to facilitate this type of innovation. For example:

• Quality control methods allow health organizations to constantly improve their health products and services.

• Financial analysis helps health organizations identify opportunities for cost efficiencies.

• Market research that engages communities gains better insight into customer health and needs.

• Supply chain management removes activities that do not add value to increase supply chain efficiency.

In some cases, management processes have not been changed or even reviewed for long periods of time and a more dramatic refinement is required—such as restructuring and reengineering.

While incremental innovation may sound like a minor piece in the equation, it is actually the cornerstone. By providing small improvements in technology and management, better products and services can be continually developed and delivered. For example, the introduction of a simple clinical checklist to remind health care workers to do basic things such as washing hands or checking the patient’s blood pressure is an incremental innovation that can be lifesaving.¹⁵

It is easier to work with incremental change than to undertake semi-radical or radical changes. Incremental innovations appear safer and are more comfortable because they are more predictable. Nevertheless, if we want to make significant improvements in global health, we must be willing to complement incremental innovation with more radical innovations.

Semi-Radical Innovation

A semi-radical innovation can provide crucial changes in an organization’s ability to improve health outcomes in ways incremental innovation cannot. Semi-radical innovation involves substantial change to the management model or technology of an organization—but not to both.¹⁶ For example, simple, inexpensive text message reminders to people taking antiretroviral medication for HIV can greatly improve medication adherence.¹⁷ In this case the technology innovation may improve clinical outcomes, but the business model remains the same. Often change in one dimension is linked to change in the other, although the concurrent change may not be as dramatic or disruptive. Semi-radical change in technology may require incremental improvement in the management model, or vice versa.

Another example of semi-radical innovation is franchising in health care. It can improve the quality and reach of health services while reducing financial risk to the entrepreneur. All clinics and pharmacies offer health services and products, but the business model of an independent clinic or pharmacy is very different from that of a franchised one—much as a local mom-and-pop restaurant is different from a franchise of a restaurant chain like McDonald’s. Small, local establishments are often widely used because they are familiar and close by. Even when their quality is poor, familiarity and proximity make them compelling forces within the community. Well-run franchises, by using a common format for training, services, and products, paired with internal quality control systems, are able to deliver consistent experiences and quality regardless of location. And by using local entrepreneurs, franchises are able to adapt their services to local preferences while still being able to take advantages of economies of scale.

Blue Star in Bangladesh is just such a franchising network. Franchised by the Social Marketing Corporation, an NGO, the network has 4,000 private health practitioners. These franchisees sign an agreement to offer a specific package of services and to send reports to the franchisor, and in return receive training, on-site quality assurance, technical assistance, and low-cost products. This brings high-quality health care to a larger number of people while providing profits for the franchisees.¹⁸ When managed properly, semi-radical innovation in health has the potential to significantly improve outcomes while minimizing financial risk to the provider.

Radical Innovation

Radical innovation is a simultaneous change to an organization’s business model and technology,¹⁹ which usually brings fundamental changes to the field.²⁰ Such changes have the ability to rewrite the rules of the game in global health.²¹ Whether done by governments, NGOs, or businesses, radical innovations may enable them to efficiently and effectively meet critical health and other objectives.

The Jaipur Foot is a radical innovation combining business model and technology advances. Bhagwan Mahaveer Viklang Sahayata Samiti (BMVSS), an Indian NGO, produces this radically innovative artificial lower-limb prosthetic tailored to meet the needs of amputees in low-income regions. Since the poor in India often lack basic things others take for granted, such as chairs to sit on or smooth pavement to walk on, the prosthetic was designed to allow users to squat, sit cross-legged, and work in rugged terrain. In fact, some amputees from high-income countries who have used the Jaipur Foot prefer it over far more expensive prosthetics.

The organization uses local workers to make the prosthetics from locally available resources. Efficient processes, skilled workers, and local raw materials allow them to make these prosthetics in as little as three hours. These efficiencies allow BMVSS to produce the Jaipur Foot for approximately $45 each, in contrast to more traditional products that sell for $10,000 in the U.S. Process efficiencies keep overhead costs down to 4 percent of total operating costs, versus the more typical 20 percent found in many NGOs.²²

While radical innovation can create game-changing advances in global health, it should be approached with caution.²³ Radical innovations are by nature low-probability investments.²⁴ Investing in too much radical innovation—based on unrealistic expectations that “the next new thing” will dramatically improve the ability of the organization to save lives—can consume valuable resources that might be better employed on semi-radical or incremental innovations.

While these ideas are clearly relevant to for-profit corporations, they apply to all types of organizations regardless of whether they are businesses, NGOs, or governments. Each type of organization should foster radical, semi-radical, and incremental innovation to create sustainable improvements in health. The key is to effectively maintain a balanced portfolio of innovation (Table 1).

Effectively Integrating Innovations

Innovations in business models and technologies can succeed only if they are effectively integrated into existing systems and communities. Too often global health products and services have been developed with little sensitivity to local skills, culture, people, resources, infrastructure, and other aspects of community life. Global health technologies need to be designed rather than just adapted for use in low-resource environments with few health professionals, low-maintenance expertise, and poor infrastructure. Products should be effective, very low cost, simple to use, and easy to repair.

Enablers of innovation:

• Leadership commitment to supporting ideas outside the current strategy

• Partnerships that provide access to additional resources

• Availability of resources (internal and external) to support game-changing ideas

Blockers of innovation:

• Incentives focused (primarily) on avoiding risk

• Perceived competition and other barriers to entry with existing organizations

• Regulatory policies (such as permitting only physicians to prescribe medications)

Table 1 Comparison of Incremental, Semi-Radical, and Radical Innovation

Innovation Critical for Low-Resource Settings

Frugal Innovations

New health technology innovations designed for low-resource environments are sometimes called frugal innovations, innovations that fit into an existing environment.²⁵ Frugal innovations are designed to be very low cost and financially sustainable in a poor community, but still of high quality. Frugal innovation is thus driven by financial and environmental circumstances. Rather than limiting innovative thinking, constraints can actually stimulate innovation by forcing us to be particularly creative, leading to simple, inexpensive, yet effective health solutions. Because of their wealth of local knowledge, innovators who live and work in these environments can best understand what is needed by people in those environments.

Reverse Innovations

Reverse innovations have become of interest in both developing and developed countries and have important implications for each.²⁶ Instead of stripping existing Western products of their bells and whistles to reduce costs and to meet the more basic needs of developing economies, reverse innovators design the product, service, or process specifically for the developing country. “In community, for community” ideas focused on meeting local needs are the goal. When that hurdle is passed, they can move from community to region to world. In this way health-related products and services developed for low- and middle-income countries can find additional markets.

For example, General Electric created a very-low-cost electrocardiogram (ECG), an instrument designed to detect heart abnormalities by measuring the electrical impulse of the heart, in India for the Indian environment. The machine has a green button for “go” and a red button for “stop,” and is easy to use—and it is just as effective at picking up abnormalities as more expensive machines, but at one-sixth the price. GE’s low-cost ECG, developed for India, is now marketed globally and is used in over ninety countries.²⁷

Table 2 Key Components of Frugal and Reverse Innovation

Some types of frugal innovation, such as an incubator that warms a newborn baby with a simple lightbulb, may not be marketable in developed countries. Nevertheless, both types of innovation are important ways for solving health problems in developing countries that may also be a benefit to the rest of the world (Table 2).

Why Entrepreneurship?

Entrepreneurial attitudes and approaches are critical to successfully developing and implementing breakthrough and incremental innovations. One often-quoted definition by Harvard Business School Professor Howard Stevenson is: “Entrepreneurship is the pursuit of opportunity beyond the resources you currently control.”²⁸ This definition takes into account both the individual and the society in which the individual is embedded.²⁹ That is, an entrepreneur sees an opportunity, but will not let a lack of resources prevent him or her from trying to take advantage of that opportunity. That mindset is what makes such people entrepreneurial.

Though many think of entrepreneurship as primarily focused on for-profit business activities, it is just as critical and applicable in governments and NGOs. Both the active pursuit of opportunity and the gathering of human and financial resources are fundamental to success. And the public-private partnerships important for significant advances in global health rely on effective collaboration and marshaling of resources.

Social entrepreneurs apply entrepreneurial principles to social ventures. These can be for-profit or nonprofit as long as they are a) entrepreneurial and b) organized to achieve desired social, cultural, or environmental goals. Many current advances in global health are being led by social entrepreneurs in the for-profit, nonprofit, and government sectors. Many challenges for entrepreneurial activities in global health exist regardless of sector in developed and developing nations. Most of these developing countries have a desperate lack of resources and provide tremendous entrepreneurial opportunities. In some regions of the world, more than 80 percent of the nonagricultural working population is active in the informal economy.³⁰

Some call these traders “necessity entrepreneurs” rather than entrepreneurs by choice, since they would often prefer employment with regular wage. But such jobs are typically scarce, so people become traders out of necessity. Large proportions of the population in low-income countries can neither read nor do basic arithmetic, and there are typically large skills gaps and shortages. Whether for a government, a business, or an NGO, big or small, this lack of infrastructure and human capital creates challenges for those looking to alleviate global health problems more effectively. But solutions are available.

The Role of Microentrepreneurship and Microfinance

In developing countries, most businesses are very small. These operations are referred to as microenterprises and often are run by an individual, possibly supported by relatives or friends. These businesses can be involved in a variety of trades, from farming to selling handicrafts, and they play a huge role in the global economy.³¹ Two-fifths of the world’s population—some 2.5 billion people—live on the equivalent of $2 per day or less.³² Microenterprises support many of these people.³³

Most microentrepreneurs aren’t small traders or craftsmen happily operating in local markets. The reality is far more grim. They are often poorly trained but highly entrepreneurial women who exploit every means available to make ends meet for their families. These entrepreneurs are hardworking, resourceful, and ingenious, but their businesses are often weak and stagnant, enabling these women to meet basic needs but falling well short of lifting them out of poverty.

Many microenterprises obtain loans from microfinance institutions. These organizations are critical elements of the financing needed to start a business. Microfinance institutions, which are often structured as NGOs, provide financial services to these poor who can’t be served effectively and economically by the formal financial sector. Microfinance can help entrepreneurs improve their economic and social well-being by providing the financial resources needed to start new businesses, expand existing businesses, or diversify into new products and industries. But loans aren’t enough by themselves. These entrepreneurs need basic management knowledge and skills to help them grow their businesses. Despite the resourcefulness and ingenuity that allow them to develop and operate their businesses at a subsistence level, these business owners lack the knowledge necessary to move beyond that level.

These entrepreneurs are particularly well positioned to deliver health products and services if they receive appropriate training, since they already operate in rural communities. In some developing countries, such businesses employ more than half of the workforce.³⁴ They already operate in remote areas, understand the cultural intricacies needed to market products, and have personal connections with their customers. Given the estimated $158 billion market for health products and services in developing countries, there is great potential for health products to provide both income to microentrepreneurs and a service to communities.³⁵

Businesses and NGOs that supply financial services to the rural poor have recognized the potential benefits, financially and socially, of their clients selling health products in poor communities.³⁶ Many have supplied their clients with items to sell to community members: health kits consisting of rudimentary first aid supplies, insecticide-treated mosquito nets (to prevent malaria), and oral rehydration therapy (to treat diarrhea). Entrepreneurs need little training to sell many of these basic health products, except skills as sales representatives; with such training, they can promote and market these products more effectively.

The flow of supplies from larger distributors to smaller distributors can facilitate bulk purchases of supplies at discounted prices. Such discounts would otherwise be unavailable to small distributors. As part of a distribution network, they can pass these savings on to consumers. Cell phones and the Internet can support large and small providers, even in the most rural settings.

By using technology and proven models for product and service delivery, these providers can coordinate their efforts to minimize the cost of improving health care systems in developing countries. Coordination of products and services can also ensure that the lack of physical infrastructure does not prevent health care systems from improving care for the rural poor.

Innovation and Entrepreneurship in Global Health

Innovation in global health also means being able to think outside the paradigm of medicine, doctors, surgery, and clinical advice as the only solutions. It requires entrepreneurial approaches utilizing both technology and business model innovations. First, it means being able to understand innovative distribution channels that present the opportunity to most effectively distribute resources so the most people get the care they need. This requires recognizing that much of the care needed in developing countries does not require a highly trained, skilled physician. Clinicians, pharmacists, community health workers, microentrepreneurs, traditional healers, and birth attendants can all be taught to deliver many services, reducing costs and increasing effectiveness. Second, it requires acknowledging that much of the low-hanging fruit has remained unpicked not because the benefits are not known, but because transferring and implementing the improvements are quite challenging. Implementing these entrepreneurial approaches can increase access, quality, and use while reducing cost.

Community Health Workers

Community health workers in many countries have been critical to providing resources to low-income settings, particularly in rural areas. These workers are often employees of or volunteers for NGOs or governments and live in the communities where they provide services. They generally receive basic training over a few months and receive ongoing supervision, as well as help linking patients to more highly skilled clinicians. In some countries, such as Rwanda, these workers are selected by the communities in which they will serve. In such roles, community health workers have positions of status or influence in the community, which can serve as a nonfinancial incentive for volunteer programs.

The Ethiopian Ministry of Health created the Health Extension Program to train 35,000 community health workers and deploy them to rural village health posts across the country. The extension workers provide health education, preventative care, and basic family health services. The Health Extension Program shows that community health workers can be used to educate about, distribute, and create demand for health products and services.³⁷

A large number of tasks can be easily shifted from hospitals and clinics to these trained workers. One does not need a nursing degree to distribute condoms and aspirin. Further, trained workers can be given checklists and mobile technologies to facilitate their distribution efforts.

Traditional Birth Attendants

Given that many women are already using them, traditional birth attendants can be part of the solution of getting good health services and medications to those who need them in many rural areas in poor countries. These traditional birth attendants are already interested and motivated health entrepreneurs serving their communities. Good clinical skills can be learned regardless of formal educational background. It would be advantageous in certain settings to help provide traditional birth attendants with the necessary skills and products to perform certain tasks and to certify their quality so those using their services are informed and protected.

Microentrepreneurs

Microentrepreneurs have financial incentives to serve as both health educators and distributors: they earn the trust of customers, build demand for products, and earn income. Aligning the incentives for entrepreneurial success with the goal of increasing access can help bring early disease prevention and health care services closer to those in need. Microentrepreneurship can provide a more robust and sustainable model for delivering basic health care products, education, and services to consumers in developing countries. Encouraging microentrepreneurs to deliver basic interventions can be cost-effective because they often require little training and can recycle the money they make back into ordering more health supplies for their communities.

VisionSpring, a nonprofit that trains entrepreneurs to conduct vision exams and sell glasses,³⁸ and Living Goods, a nonprofit enabling women entrepreneurs to go door to door selling health care products like “Avon ladies,”³⁹ have shown that by aligning the incentives of the entrepreneur with the goal of improved health care distribution, organizations can better serve both their customers and their communities. These organizations provide low-income individuals, primarily women, with entrepreneurial opportunities selling basic health products in their local communities.

The microentrepreneurs operate for-profit businesses and therefore have incentives to provide health care products to their community. The programs have also proven to be scalable and financially sustainable. Importantly, they have successfully merged commerce with community service and found replicable success in bringing health care to the poor, and thus have a number of advantages:

• Familiarity with the local culture

• Ability to provide solutions tailored to local needs

• Community trust based on familiarity with the microentrepreneur

• Operating in community setting

However, utilizing microentrepreneurs must be done with caution. Measures must be put in place to maintain quality, whether initiated by the entrepreneur, his or her network or franchise, or a governmental regulatory body. Microentrepreneurs are typically not health professionals, and their limitations may result in problems:

• Limited health care knowledge and skill

• Lack of monitoring by and accountability to central organization with technical expertise

• Need for training in distributing basic health products and in business skills

Despite these limitations, microentrepreneurs can play an important role in preventing and treating basic diseases.

Micropharmacies

Micropharmacies are small pharmacies often set up on the franchise model. They are run by local entrepreneurs, distributing basic health care products and transferring knowledge to community members. They make medicines more accessible to even the poorest, most remote communities.

When medications are appropriately prescribed, they can maintain or restore health. However, if they are improperly prescribed and administered, rates of illness and death can rise, antibiotic-resistant strains of infectious diseases can spread, and community trust in the health care delivery system can diminish. Because medications can sicken and even kill people if not properly administered, it is crucial to ensure that these products are of high quality and are distributed appropriately. Thus, proper training for clinicians and pharmacists is needed. Aligning financial incentives with improving access to basic medications to the poor will strengthen the overall health care delivery system.

To this end, nonprofit social franchises like the HealthStore Foundation have developed distribution systems that make drugs accessible and provide a brand customers can trust.⁴⁰ These organizations have successfully franchised pharmacies to for-profit entrepreneurs who serve their communities.

As in other microfranchising programs, pharmacy franchisees own their businesses and earn sustainable income for their families. The franchisor lowers the prices patients pay for pharmaceuticals by purchasing on behalf of all its franchisees and leveraging its larger buying power. Franchisees require prior training on the basic treatment of common illnesses, the pharmacology of commonly sold medications, and details of medication dosage and use. Both these organizations demonstrate the potential of merging commercial and NGO models of health care delivery; their methods should serve as a guide for those looking to scale-up quality drug distribution in developing countries.

Microclinics

Microclinics, such as Child and Family Wellness’s network of clinics in Kenya and Rwanda, are small clinics that provide basic medical care, including prevention, diagnosis, and treatment, for a short list of common and preventable diseases. In addition, these clinics make health care accessible to poor communities and minimize opportunity costs associated with traveling to hospitals for basic services. They tend to be staffed by providers, such as community health nurses, who have received formal training to provide appropriate, consistent, high-quality care. Some microclinics also contain micropharmacies and distribute medication. Efforts to align clinicians’ profits with the goal of improved delivery have helped microclinics discover efficient ways to bring diagnosis and treatment closer to people in rural areas.

Finding the Better Way

Improving global health requires getting better solutions to people in better ways. To do this, we must be continually innovative and entrepreneurial. By stimulating innovation in our business models and technologies, we can stay ahead of the curve to achieve greater impacts in health. Some of the most innovative models in health are being created in developing countries where constraints and unmet needs can help stimulate, rather than hinder, radical innovation. Such innovation may help create leapfrog advances in health not only in developing countries, but throughout the world. Entrepreneurial solutions must also be fostered in every sector—government, NGO, and business. Health entrepreneurs can help us complete health care delivery to the very last mile and save lives. Engaging, training, and supporting the health entrepreneurs that already exist in these settings, such as traditional birth attendants, community health workers, and other microentrepreneurs, allows them to be part of the solution, and can accelerate success.