Having traveled to both East Africa and India over the past several weeks, I’ve been reflecting on what ‘innovation’ means in different contexts. It’s easy to get caught in a technology-centric worldview in places like Bangalore and even Nairobi these days. But when I get past the superficial stories and dig a bit deeper, I realize that impactful innovation is less about shiny tools and technology and more about ‘listening to users’ and transforming social processes to solve problems that matter to people.
My walk through a Delhi slum comes immediately to mind. While there I visited Operation Asha, a 2011 India Development Marketplace winner that is working to arrest the spread of tuberculosis (TB). India is one of the only countries in the world where the rate of infection is growing despite the falling incidence of the disease globally. The previous day, I sat with colleagues from Microsoft Research in Bangalore who explained the simple but critical advances they had made in writing open-source software to verify the identity of patients visiting clinics, aggregating data on missed doses, and using text messages to increase compliance.
It’s hard not to be impressed by Operation Asha’s 97 percent patience compliance rate for patients adhering to recommended dosages and their 94 percent success rate in treating TB in some of the poorest slums in India. But when I probed deeper, I found Operation Asha’s transformative innovation has less to do with scanners and more to do with listening to patients so they can design more effective testing and treatment protocols and reduce transaction costs associated with treatment.
Their field teams learned that most government-run TB clinics were located more than 5km from patients and were open only four hours a day (from 10am to 2pm – working hours?). Although TB meds are free in India, people typically wait in long lines to access medication. They must take public transport to get there and when they arrive, they often find that medications are out of stock. For government run diagnosis and treatment programs the annual costs per patient typically exceeds $1000 USD. Even more efficient NGO providers routinely spend roughly $600 USD per patient per year. But Operation Asha figured out how to achieve better results than public clinics for less than $60 USD per patient per year (10 percent of the cost for an alternative treatment).
The model uses local health care workers to staff clinics, rather than physicians. They run un-branded health kiosks located within 1 kilometer from most of their patients. And operating hours are from 6am to 10pm; with a break during the day when health workers conduct home visits and identify new cases within the community.
When I asked Sandeep Ahuja, CEO and Founder of Operation Asha, the most important thing he learned since founding the organization, I heard something unexpected but entirely logical. Remember the un-branded local clinics? He told me his staff noticed during their first year that patients would routinely walk 2-3 km rather than use centers much closer to their homes (software helped identify these patterns). Why, because TB has a social stigma in India; especially for women. Realizing this was keeping patients away caused Operations Asha to change its entire community outreach strategy.
Based on this data, they convinced the government to remove “TB” signage from their facilities which were co-located with doctor’s offices that administered other health services and made it virtually impossible for anyone to know why patients visited their facilities. They hired and trained local health care workers and administered a performance based salary scheme that rewarded higher patient compliance with higher monthly salaries (recently studied by the Poverty Action Lab at MIT because of its effectiveness).
So what and where is the innovation? There is no doubt that performance metrics and compliance tools, not to mention laptops, finger-print scanners, and SMS-enabled dongles matter. But there are many examples of technology-rich and social process-poor projects that fail everyday in India. What makes this example so interesting is the understanding of social context for treatment and the use of technology to accelerate rates of adoption and compliance.
Building on 5 years of experience, Operation Asha is growing in India and now Cambodia, but not nearly fast enough. TB rates in the country continue to climb and government clinics have yet to adopt approaches demonstrated to be effective by Operation Asha. Their clinics require a $1,500 upfront capital investment per site and they don’t get public funding to sustain operations for two years. Such regulatory hurdles and limited access to growth capital commonly constrain the growth of social innovation.
To address this problem at scale requires a public policy response and an appropriate mix of capital vehicles: possibly grants to fund start-up costs, government subsidies to support operating costs, and other forms of capital to support R&D. More importantly, what’s the cost of not investing? How do we reward and support business model innovation in providing public goods and services where governments and markets fail? We could figure out the net loss to society of sick patients who prematurely die from preventable diseases. With that figure in mind, why not put half of that ‘productivity loss’ to support what’s working in disease eradication?
We did it for small pox in the 1970’s and the world is better for it. But we need the political will, courage and resources to support the most promising models to solve the most pressing social challenges. And once we find them (whether they are public, private, or hybrid), we need to put our collective minds, money, and policy together to scale them up.