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Strategic Planning Process. August 28, 2011. Overview. AGENDA. Agenda and p rocess mHealth ecosystem: What we read mHealth ecosystem : What we heard Perspectives on D-tree: What we heard D -tree product strategy Funding and business plans Creating internal alignment

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overview
Overview

AGENDA

  • Agenda and process
  • mHealth ecosystem: What we read
  • mHealth ecosystem: What we heard
  • Perspectives on D-tree: What we heard
  • D-tree product strategy
  • Funding and business plans
  • Creating internal alignment
  • Strategy definition process
  • Appendix

Week 1: Product and Process Review v. 1.0

process
Process

AGENDA

  • Literature review
    • Reports from international agencies and organizations, D-tree published and working papers, external academic and industry articles
  • External interviews
    • 25 interviews with array of top leaders in mhealth, D-tree partner organizations, and donors
  • Internal interviews
    • Interviews and assessments with key staff in Dar es Salaam and Boston
  • Cumulative 11 weeks in Dar es Salaam
    • Project reporting, data analysis, and daily operations
    • Site visits and meetings with donors, peers, allies
  • Feedback and validation with D-tree management team
    • Regular check-ins throughout to summer to adjust research and validate findings
  • Final Report

Week 1: Product and Process Review v. 1.0

mhealth ecosystem overview
mHealthecosystem overview

Excerpts and analysis from the literature review

mhealth hits every part of the health system
mHealth hits every part of the health system

MHEALTH ECOSYSTEM

Whole system efficiency improvement

EpiSurveyor, Child Count+, disease surveillance, data mining EMRs

Telstra/Ericsson breast cancer screening, 3G Doctor, Sana

12580 appt. booking (China), Frontline SMS: Medic, EMRs, Sproxil

Medicine Link (China), MiQuit, Freedom HIV/AIDS, Mobile Medline Plus

Wellcore emergency response, Orange Smartnumbers, Frontline SMS

Directly observed treatments, Ginger.io, self-management applications

mhealth and health market innovations focus in the developing world and rural populations
mHealth and health market innovations focus in the developing world and rural populations

MHEALTH ECOSYSTEM

Geographic mapping of programs with concentrations in South Asia and East Africa

Target populations

Target geography

Source: CHMI

health market innovations and programs can be categorized into 5 major areas of impact
Health market innovations and programs can be categorized into 5 major areas of impact

MHEALTH ECOSYSTEM

  • Organizing Delivery
  • Reduce fragmentation and informality of health care delivery

1

CHMI categorized program focus in more than 1000 programs documented

465

449

354

  • Financing Care
  • Mobilize funds and give purchasing power to the poor

2

234

76

  • Regulating Performance
  • Set standards, enforce and promote quality care

3

  • Changing Behavior
  • Educate and train consumers and providers to seek and deliver better care

4

D-Tree has 6 programs categorized as Enhancing Processes with the sub-type Information Technology; total 264 programs in this category

  • Enhancing Processes
  • Apply new technologies and operational processes to improve quality, access or cost

5

Source: Center for Health Market Innovations

organization type varies by impact area and within disease health focus
Organization type varies by impact area and within disease/health focus

MHEALTH ECOSYSTEM

Franchises make up the majority of family planning organizations that impact organizing delivering while service delivery networks and individual clinics dominate general primary care

Franchising the prevailing method of family planning, but increasingly popular in other areas, emerging as potential mechanism of service delivery for prevention, screening, ongoing care.

Service delivery networks and chains dominate maternal, newborn and child health, HIV/AIDS, TB, and general primary care; mergence of low-cost primary care chains and networks in rural and semi-urban settings (e.g., Kriti, LiveWell, CARE Hospitals, Saude 10, CommHealth)

Week 1: Product and Process Review v. 1.0

as does legal status funding type and technology used
As does legal status, funding type, and technology used

MHELATH ECOSYSTEM

Space still dominated by not-for-profit players with rise of partnerships

Phones are technology used more than 50% of the time in health market innovations

Nearly 60% of health market innovations are donor funded; percentage is far higher in the developing world; 75% are funded by government and/or donors

Source: CHMI

even if current focus on mhealth is a bubble opportunity for ict in healthcare is significant
Even if current focus on mhealth is a bubble, opportunity for ICT in healthcare is significant

MHEALTH ECOSYSTEM

Source: McKinsey GMSA Report

and mobile technology is particularly enabling in certain areas of need
And mobile technology is particularly enabling in certain areas of need:

MHEALTH ECOSYSTEM

Area of need

Examples

  • Bringing healthcare to unserved or underserved populations

Poorest and most vulnerable “tend to live in areas that are remote, that have weak transportation links and limited physical infrastructure”

Remote health workers and patients enabled through data and communication

“The innovative use of mobile technology, can greatly diminish the time and distance involved in obtaining services”

  • Increasing the effectiveness and reducing the costs of healthcare delivery

Standardization, capture and communication of patient and supply data enabled

  • Improving the effectiveness of public health programs (incl. research) and preventing illness (incl. behavior change)

Communication to large populations—both targeted and general—is enabled

“Facility-based care is costly; outreach and community solutions are highly cost-effective and accessible.”

“Facility-based care is costly; outreach and community solutions are highly cost-effective and accessible.”

  • Treating chronic diseases, and keeping people out of hospital

Remote monitoring and diagnostics of patients enabled to reduce costs

China Mobile

most projects focused on simple technologies and mostly public health communication
Most projects focused on simple technologies and mostly public health communication

MHEALTH ECOSYSTEM

Of UNICEF’s 41 mhealth projects, the large majority use SMS technology

Rapid SMS used for data gather/surveillance and health care worker communication

Source: UNICEF, “Mobiles 4 Development,” 2010

even organizations with resources to develop integrated technology are stuck in early stages
Even organizations with resources to develop integrated technology are stuck in early stages

MHEALTH ECOSYSTEM

Of UNICEF’s 41 mhealth projects, most are in early stages (blast messages are considered “one-offs”)

No projects yet have come to full-scale; “pilot-itis” widely cited through mhealth ecosystem yet projects still designed with structure to scale

Barrier to scale is not technology or resources but systemic problems in fragmented ecosystem, human resource constraints, program and funding design

Source: UNICEF, “Mobiles 4 Development,” 2010

without careful planning pilots stay small through structure of system and design of program
Without careful planning, pilots stay small through structure of system and design of program

MHEALTH ECOSYSTEM

  • Main drivers of “Pilot-it is”
  • Key features of projects that scale
  • Complexity and fragmentation of healthcare
    • Lack of historical data to assess points of greatest need/impact
    • Partners to make system change have own agendas
  • Strategic partnerships fit needs assessment and gaps
    • Knowledge of health system, IT systems, local context, gob’t, NGOs, access to funding
    • Clear responsibilities not bogged in admin/negotiations
  • Issue-driven funding insufficient to address system change
    • Organizations support own agenda and “add-on” technology
    • Projects addressing incremental effects are less expensive
  • Technology and design that can replicate and scale
    • Economies of scale are calculated: cost per additional must decrease
  • Defined strategy address specific problem or set of problems
    • Technology, user interface, etc. all designed to specific end-user
    • Metrics to track outcomes part of initial study design
  • Projects developed without vision of scale
    • Impact / efficacy not tracked to make funding case for scale
    • Systems built that cannot possibly scale to multiple sites
pilots generally do not measure impact or effects with rigor necessary in regulatory environment
Pilots generally do not measure impact or effects with rigor necessary in regulatory environment

MHEALTH ECOSYSTEM

  • Regulation not yet an issue in most developing countries:

“[Mobile health applications] are acceptable to individuals and the healthcare sector on the basis of a common-sense view of utility and risk (without the need for lengthy academic or clinical trials or ethical review)”

– China Mobile/Cambridge Study

  • Efficacy measured by project completion, number of users, etc., not impact
  • Impact data—and ability to produce data of this type—may be increasingly valuable when considering major ICT investments, increasing regulation of “diagnostic devices”, etc.
    • Metrics of note and baselines to measure Δs:
      • Demographics: Patients served, Providers served plus relevant demographics
      • Costs: cost per provider, cost per patient, systems savings
      • Health outcomes: diagnoses, treatments rendered, patients returned
      • Efficiencies: time/patient per visit, time/patient/year
      • Economics: life expectancy, death
an increasing entrance of major players threatens incumbents
An increasing entrance of major players threatens incumbents

MHEALTH ECOSYSTEM

  • In past, proliferation of smaller, NGO-supported players and non-profits
  • But health IT potentially lucrative for large companies and other for-profits
  • Non-profits competitive advantage may be local knowledge and content production

Source: China Mobile

partnerships important but true partnerships represent very small percentage of programs
Partnerships important but true partnerships represent very small percentage of programs

MHEALTH ECOSYSTEM

  • Some 60% projects still donor funded; almost 75% donor or government funded
    • Only 22% defined as public-private partnerships and depth or structure of partnerships not reported.
  • Many partnerships from CSR divisions of companies are benefiting from large NGO/non-profit brands, not investing as part of core business
  • Due to systemic problems with scaling mhealth initiatives, growth of national ICT sectors, and sometimes large initial investment, private sector partnerships are desirable, particularly as national networks are accessed, but hard to do right
    • USAID has questioned whether the value of public-private partnerships truly exists; is time and money invested more valuable than direct investment in direct services in short-term and/or long-term?
  • Grameen/Intel
  • For-profit mentality of Grameen makes natural partner to other for-profits
  • Large Grameen org has natural internal partners in bricks & mortar clinics
  • Partner in strategic areas: tech development, channel strategy
  • Novartis / SMS for Life
  • Strategically planned from outset for partners to fill in strategic roles and necessary capacities
  • Clear MOU of partner roles/investments and MoH to pay for and run system
  • Clearly defined goal with clear 1-year end-point
  • Defined value proposition, simple solution
different sectors have different capacities role definition is key
Different sectors have different capacities; role definition is key

MHEALTH ECOSYSTEM

In building strategic partnerships, find partners to fit necessary capacities and make roles explicit

strategic partnerships are not just public private
Strategic partnerships are not just public-private

MHEALTH ECOSYSTEM

  • UNICEF’s partner map

UNICEF one of most recognizable NGOs with broad reach; partnerships are 90% non-profit and public sector

Source: UNICEF, “Mobiles 4 Development,” 2010

mhealth ecosystem what we heard
mHealth ecosystem: What we heard

Excerpts and analysis from external interview

views on the current state of mhealth
Views on the current state of mhealth

EXTERNAL INTERVIEWS

It is what anyone would expect at the front end of a movement: exploratory, experimental, non-economic, non-systematic, problem-specific, solution-specific

The culture is rapidly changing and becoming more accepting of a paradigm shift that involves mhealthat the forefront of public health

The environment is dynamic and innovative and the range of applications being designed is constantly expanding

A lot of interesting pilots are what characterizes mhealth right now but no one can boast impressive numbers of users

All mhealthprojects are “add-on” functions to improve efficiencies in 1 or 2 small areas at UNICEF. Not being thought as a programmatic offering in and of itself.

We’ve lost the plot in mhealthas of late. The funding has been siloedinto issue or geographic focus and the technologies are not being coordinated in a way that will lead to an interoperable system

Source: External Interviews

a mix of believers and skeptics on potential of mhealth

EXTERNAL INTERVIEWS

A mix of believers and skeptics on potential of mhealth

Believers:

Skeptics:

mHealthis a passing fad to some extent. it is an overoptimistic notion to think that mHealth can solve problems with much deeper roots than the solutions that are currently available

mHealth has a lot of power to create efficiencies in small areas but should be seen as a tool for the health system and not a means to address protracted health issues

mHealth is way over-hyped. There is a lot of excitement but it is not going to be transformative because it is being implemented on top of a broken system.

mHealth is similar to the Internet bubble. The mhealthbubble will burst. Finding out how to position an organization in an imminently bursting bubble is the main challenges of players in the mhealthecosystem.

The potential for mhealthto transform healthcare delivery is incredible and is already happening

Source: External Interviews

slide23
Though technology is transformative, ecosystem faces considerable challenges in creating more believers

EXTERNAL INTERVIEWS

Pilots and gadgets vs. Scale and systems:

mHealth offers great potential but not in the way that it is currently being implemented. Not many pilots have succeeded because they were not conceptualized to go to scale but were instead focused on gadgets. This is less of a tech problem and more of a problem of the approach to doing such projects. Understanding, from conception, how the technology can be rolled out on a countrywide scale is essential to anything that will succeed.

The hard part has been done—creating technology that can support an mhealthmovement. Now we have to think about the systems that will support radical change. The vast majority of people that are in mhealthare not systems people and do not have systems background so they’re focusing predominately on tech solutions (i.e. silver bullets) and not the systems. This is the current challenge.

Siloes and interoperability

We’ve lost the plot in mhealthas of late. The funding has been siloed into issue or geographic focus and the technologies are not being coordinated in a way that will lead to an interoperable system

Source: External Interviews

technology is not barrier but key components may not yet allow growth and change
Technology is not barrier, but key components may not yet allow growth and change

EXTERNAL INTERVIEWS

Governments are not on board:

There is not enough understanding on the part of governments about how to guide the mHealth work being done in their countries. This is going to be a necessary component of ramping up support and funding if any of these technologies are going to scale.

Scale is technologically possible but not with the current political and funding landscape. Governments are the only force that could take any of the mHealth pilots to scale.

Proliferation of smart phones is making it difficult to think about potential to scale due to it being cost prohibitive unless there is a subsidy from the government or industry

Governments are not ready to revamp their health systems using mobile technology. Most governments do not even have a policy in place. This needs to happen before seeing mHealth scale in a major way.

Capacity/Human resources:

People are eager to talk about the potential or technology but they overlook the human resources required to run these systems. We can get programmers, even local IT support but we are missing project management skills. We’re trying to build strength in local capacity but it is difficult when we have donors who want to see results within certain time frames

Source: External Interviews

an added challenge in leadership who is responsible for setting the mhealth agenda
An added challenge in leadership: Who is responsible for setting the mhealthagenda?

EXTERNAL INTERVIEWS

Leadership

Role of mHealthAlliance

Donors set agendas and run on five-year, trending timeframes

Not sure there are leaders as of yet

The mHealth Alliance is convening cross sector groups including the ministry of commerce, transport, regulatory affairs bodies, ministry of health and education. The mHealthAlliance is trying to align all pieces of the puzzle

Rockefeller and Gates must take the reigns and coordinate the movement. Tell people to be on one platform over another

There is no regulatory body or global architecture that is coordinated to guide the progress in mhealthright now. We need to be thinking strategically and start setting targets at this point now that we have multiple actors working on many levels in the field. Without strategy or targets, we have no ability to compare data and don’t know the kind of impact that we’re making.

Source: External Interviews

no consensus on area of greatest need and or impact and best technology

EXTERNAL INTERVIEWS

No consensus on area of greatest need and/or impact and best technology

Community Health Worker vs. Facility (Nurse)

Smart Phone vs. Java Basic Phone

  • Pro CHW:
    • “CHWs are the holy grail right now”
  • Pro Facility:
    • “All the applications that are targeting CHWs are a fad and are less impactful. The tech will overwhelm CHWs, which would have negative health consequences”
  • Pro Basic Phone:
    • “The proliferation of smart phones is making it difficult to think about the potential to scale”
    • “It’s bull that you need anything more than a basic feature phone. The limiting factor is the behavioral issues not the technology”
  • Pro Smartphone:
    • “We all know what they can do but they have not trickled down to the field. It’s just a matter of time before they can be use effectively”

Data suggests as many funders support facility as CHW programs

Source: External Interviews

sources of acceleration remain unclear
Sources of acceleration remain unclear

EXTERNAL INTERVIEWS

  • Evidence can be powerful
  • Or not…
  • Anytime a RCT is published is a moment of acceleration in the field. Anyone can do a pilot. The real changemakers are the RCTs, which have the clout to demonstrate real change.

Successful applications will drive growth, not evidence-based, academic research. People love to say that there is no evidence no mater what evidence is available. Evidence is useful and a lot of people are calling for it but it is not clear that these people are decision-makers. In fact, asking for evidence usually is a good indication that you are not a decision maker.

Source: External Interviews

a few market winners are getting the majority of attention competition is increasing
A few “market winners” are getting the majority of attention—Competition is increasing

Week 1: Product and Process Review v. 1.0

perspectives on d tree what we heard
Perspectives on D-tree:What we heard

Excerpts and analysis from external interview

general impressions
General impressions

PERSPECTIVES ON D-TREE

  • Feedback was positive and encouraging
  • Confusion in terms of D-tree’s focus and mission

CHW vs. Facility

Rural vs. Urban

Tanzania or cross regional

What technology

Role of HSPH

Everyone wants to work with D-tree. They are at the forefront. Everybody wants to partner with them because they’re nice, smart, sincere, flexible, nimble, open. These are all characteristics of partners we want.

D-Tree is specialized in maternal health and HIV

D-Tree is innovating tools aimed at health system strengthening

Mission is to find ways to empower rural healthcare workers to do their jobs better

Trying to improve quality of care of CHW by using enabled phones

They are mission driven and committed to achieving high quality work in Tanzania

Source: External Interviews

organizational strengths
Organizational strengths

PERSPECTIVES ON D-TREE

  • Positive track record
  • In the right spaces at the right time
  • Pioneering new fronts of mHealth

Board is invested and supportive of D-tree—demonstrates external belief in the organization’s mission and potential to transform healthcare delivery worldwide

Creating the right protocols for the right parts of the world is what makes (or could make) D-tree indispensable

D-tree’s Bihar project was phenomenal

D-tree is at the leading edge of exploring more sophisticated use of mobile technology, especially when it comes e-IMCI

Source: External Interviews

organizational challenges
Organizational challenges

PERSPECTIVES ON D-TREE

  • Org is structured and staffed to pilot and de-bug technology—not poised to scale
  • Dependent on Marc for driving vision, maintaining daily operations, securing partnerships—he’s wearing too many hats

Disappointed with the development of current protocols as most repeatedly say “refer patient to doctor.” This presupposes that there is a doctor present. This is not always the case.

Marc comes off as professorial and academic, not the prototype of entrepreneurs that high profile donors invest in

Marc is D-tree’s greatest strength and weakness. In either case, he is what is driving the organization

Committed, technical but lacking specialization in medical areas with some protocols such as the nutrition protocol in Zanzibar

Good at pilots but too project focused—need more planning and evaluation of strategy

Hesitant to step up and take on more responsibility with MoH in Tanzania

Source: External Interviews

external challenges
External challenges

PERSPECTIVES ON D-TREE

  • Value of protocols does not translate to general public
  • Resistance to use of smart phones is a challenge for D-tree’s expansion
  • Funding landscape is only getting more crowded

No one understands the value of protocols. There are no low hanging fruit when it comes to protocols. It is subtle. Getting people to adhere to protocols does not mean they are guaranteed to make better decisions.

D-Tree’s strength is not the winning story in mHealth. The staff may see the value in it but others are not paying attention. It might be the case that people will never get excited about protocols no mater what anyone is saying

CHWs are currently seen as the holy grail to improving health outcomes in the developing world

Smart phones are prohibitively expensive and are a liability to CHWs

Lack of overhead due to restricted funding

d tree s current portfolio is diverse but competitive advantage is location based

Competitive Advantage

D-tree’s current portfolio is diverse but competitive advantage is location-based

PRODUCT STRATEGY

  • Evidence-based orientation: Research could provide evidence-base currently lacking in mhealth ecosystem
      • Harvard and academic affiliation
      • Published papers
  • Location-based: Tanzania office with local expertise
    • Contacts in local NGOs and government
      • Understanding of national context and experience in local customization
      • History of success piloting in TZ

D-tree functions as solutions provider to wide range of projects, not developing deep expertise or reputation in a specific medical area or technology

CA is limited to geography and even then has possible weaknesses in resources

d tree is at an inflection point having built credibility and now must define clear direction
D-tree is at an inflection point, having built credibility and now must define clear direction

PRODUCT STRATEGY

  • From interviews and research, it is clear that D-tree needs to define its core offering with an understanding of internal strengths/weaknesses as well as the external environment
    • What is the demand for D-tree’s future core product?
    • Who are the current competitors?
    • Who is likely to enter ecosystem (i.e. future competitors)?

2008

2009

2010

2011

2012 on…

  • 2008-2011:
  • Built reputation as a competent solutions provider
  • Customized technology to context and implemented pilots from start to finish with focus on technology
  • Demonstrated ability to raise and manage $100-200K grants, partners

Where to next?

Continue status quo

Continue with focus on M&E

Specialize as product developer

Consulting and research

Hybrid of above

a more robust competitive advantage depends on building a defendable niche through org focus
A more robust competitive advantage depends on building a defendable niche through org focus

PRODUCT STRATEGY

Decisions on direction start with a definition of D-tree’s organizational structure and focus:

Custom solutions to projects for individual clients, from project design through implementation and training

Single product or system of products that clients purchase with potential customization or add-on services

Expertise in project design and evaluation offered as service to range of providers from MOH to start-ups

benefits drawbacks differing considerations concerning internal structure exist for each option
Benefits, drawbacks & differing considerations concerning internal structure exist for each option

PRODUCT STRATEGY

Week 1: Product and Process Review v. 1.0

regardless of exact focus d tree should anticipate serious competitors in near future
Regardless of exact focus, D-tree should anticipate serious competitors in near future

PRODUCT STRATEGY

  • Mhealth bubble in non-profit, NGO, academic, and private sectors  big players increasingly paying attention and recognizing value of access to certain markets (e.g., health applications as access to women)
  • Investment and expertise needed to bring mhealth solutions to scale does not exist in non-profit sector
  • Existing big player involvement, e.g., McKinsey consultant to Tanzanian Ministry of Health, will increasingly exclude small NGO and non-profit involvement, particularly for non-specialized providers
  • Large solutions providers, e.g., IBM, have the resources and experience to build complex systems rapidly and take advantage of economies of scale. Advantages include:
    • Components outside of mhealth sphere
    • Complex systems integration
    • Complex regulatory knowledge
    • Experience with large-scale roll-out
    • Internal EOS
    • Deeper pockets for trial and failure
  • Threats also exist from small innovators with specific products that are easily adapted
    • Increasingly, mhealth technologies from developed world will be adapted and available for emerging markets as BOP models increasingly viable

Software development is cheap to do and hard to maintain an advantage in; to combat these threats and make a name for itself now, D-tree should adopt specific and deep expertise—do one thing really well

and be strategic about defining product outside current competitor s expertise areas
And be strategic about defining product outside current competitor’s expertise areas

PRODUCT STRATEGY

Product differentiation is essential to success of strategy

Sana “Sana's mission is to revolutionize healthcare delivery for rural underserved populations. To this end, Sana provides an open-source Android-based telemedicine platform for clinical research and best-practice health care delivery.”

Dimagi “Dimagi is an award-winning, socially-conscious technology company that helps organizations deliver quality health care to urban and rural communities across the world. At Dimagi, we build custom solutions that work in resource-poor settings, bridging the gap between developmental needs and technological constraints.”

D-tree must present a clear, differentiated position among competitors

slide42
No structure is without flaws, but re-organizing as a product developer puts D-tree in the best position

PRODUCT STRATEGY

  • Achieve Scale beyond pilots given resources required
  • Effective develop internal assets
  • Compete against a likely less expensive and more agile Dimagi
  • As a solutions provider:

CANNOT

  • As a research and consulting:
  • Currently attract the necessary talent and clients given current staff, scale, and reputation at present
  • Compete against large consulting organizations and NGOs
  • As product-focused organization:
  • Use current assets to differentiate against competitors
  • Create internal expertise and external niche strategy
  • Scale one core product in multiple locations

CAN

  • Strategy analysis:
    • External compatibility (within industry): Increasing competition in all areas where provides solutions
    • Internal compatibility (within organization): Have internal assets in M&E, training, admin, grant writing
    • Sustainability: Best option for sustained competitive advantage
a long term view reveals hybrid possibilities in future
A long-term view reveals hybrid possibilities in future

PRODUCT STRATEGY

Solutions

Provider

Product

Developer

Research/Consulting

In short-term, D-tree must maintain contracts as solutions provider and will function as a hybrid of solutions provider and product developer

Over time, D-tree should transition away from solutions provision and use extensive experience to be a hybrid of product developer and research/consultant

to determine product strategy consider d tree s assets
To determine product strategy, consider D-tree’s assets

Assets:

  • Content:e-IMCI (validated)
  • Organizational: local knowledge of Tanzania, good reputation
  • Partnerships:UNICEF, relationship with Ministry
  • Affiliations: Harvard, Norad?
  • Technology:OpenMRS, select protocols

Week 1: Product and Process Review v. 1.0

defining a core offering as a product developer requires decisions in multiple areas
Defining a core offering as a product developer, requires decisions in multiple areas

PRODUCT STRATEGY

  • Content
  • Focus area
  • Point of Impact
  • Demo- / Geo-graphy
  • Hardware
  • Software
  • Client

Decision support for referrals

MOH/WHO-approved medical protocols

Custom protocols

Data entry

Medical record systems

  • Maternal health
  • FP
  • ANC
  • Child health
  • Nutrition
  • IMCI
  • HIV/AIDS
  • TB
  • Chronic disease
  • Facility
  • Doctor
  • Nurse
  • Counselor
  • Lab
  • Community
  • CHW
  • TBA
  • etc.

Rural

Urban

Tanzania

East Africa

Africa

South Asia

Developing world

Cross regional

Basic phones

Android

Tablet computer

CommCare

ODK Collect

Mango Logic

OpenMRS

Others

Local NGOs

International NGOs

Ministry of Health

Private sector

Academia

recommended potential areas of focus and differentiation either alone or together
Recommended potential areas of focus and differentiation, either alone or together

PRODUCT STRATEGY

  • Content
  • Focus area
  • Point of Impact
  • Demo- / Geo-graphy
  • Hardware
  • Software
  • Client

Decision support for referrals

MOH/WHO-approved medical protocols

Custom protocols

Data entry

Medical record systems

  • Maternal health
  • FP
  • ANC
  • Child health
  • Nutrition
  • IMCI
  • HIV/AIDS
  • TB
  • Chronic disease
  • Facility
  • Doctor
  • Nurse
  • Counselor
  • Lab
  • Community
  • CHW
  • TBA
  • etc.

Rural

Urban

Tanzania

East Africa

Africa

South Asia

Developing world

Cross regional

Basic phones

Android

Tablet computer

CommCare

ODK Collect

Mango Logic

OpenMRS

Others

Local NGOs

International NGOs

Ministry of Health

Private sector

Academia

Given analysis of mhealth ecosystem and competitors, specialized, tested, and bug-free products are best positioned for growth and success

a deep dive into recommended selections reveals reasoning
A deep dive into recommended selections reveals reasoning

PRODUCT STRATEGY

  • Focus area
  • Point of Impact
  • Demo- / Geo-graphy
  • Content

MOH/WHO approved medical protocols

Medical record systems

  • Maternal health
  • FP
  • ANC
  • Child health
  • Nutrition
  • IMCI
  • Facility
  • Doctor
  • Nurse
  • Counselor
  • Lab

Urban

Tanzania

  • Creating e-protocols from validated MoHor WHO paper protocols positions D-tree for:
  • Closer relationship with MoH/WHO
  • Less time creating protocols internally
  • More medical credibility
  • Easier transfer among countries
  • Validated protocols as core, not tech
  • Already considerable strength in this area, may as well state it as such:
  • Considered MCH organization by some donors/NGOs
  • Significant % of current and available funding
  • Trending but fits well into general care
  • Can include PTMTC within vertical
  • Facility focus best D-tree from competitors and integrates better into the health system:
  • Complexity of protocols/technology more easily adopted in facilities
  • Only facilities have HR and resources to manage smartphones
  • Only facilities can give treatment
  • Mostly recommendations for short-term focus:
  • Demography:
  • Urban populations generally better educated and invest more in healthcare
  • Urban populations less expensive to reach
  • Geography:
  • Work only at district level
  • Local knowledge and advantage in TZ
decisions on content and point of impact will determine appropriate software and hardware choices
Decisions on content and point of impact will determine appropriate software and hardware choices

PRODUCT STRATEGY

  • Software
  • Client
  • Hardware

Android

ODK Collect

Open MRS

International NGOs

Ministry of Health

  • Though speed of adoption of 3G technology slower in most developing countries, this hardware best suited to complex medical protocols
  • Video, phone capability for product expansion
  • Software and open source discussions often a foil: technology matters less than functionality. That said, ODK Collect has a community behind it and a pool of developers
  • Additional productdecision about whether software designed only for programmers or can be authored by practitioners
  • NGOs and MoH most eager to add tech component to work and need contractors to do so, but client selection is less about which clients D-tree chooses, and more about howD-tree does business development
  • Proactive instead of reactive
  • Identify strategic partners to fill capacity needs and invest time and energy into development, e.g., instead of leadership going to TZ 4x yearly, go to Geneva to meet WHO
  • Only partner with NGOs who commit money and resources to taking on project themselves at completion
scenario analysis e imci to scale
Scenario analysis: e-IMCI to scale

PRODUCT STRATEGY

  • Content: eIMCI with OpenMRS to scale/evaluate
  • Focus Area: Child Health
  • Point of Impact: Facilities, doctors and nurses
  • Geography: District-level and above, start in TZ  expand to three countries
  • Demography: Urban and rural
  • Hardware: Agnostic, may be easier to scale with basic now, even if it’s not ultimate goal
  • Software: ODK Connect, existing
  • Client: UNICEF, WHO, MoH and district-level health offices

Program sesign

Why it works

  • D-tree among organizations most familiar with protocol, proof in ability to roll out and evaluation
  • Capitalize on research study
  • Most complex protocol in portfolio  use as standard for level of work
  • WHO / MoH validated in many countries  ease of adoption
  • Strong ties to UNICEF / WHO  ability to move more easily to another country
  • Ability to add-on additional content and features, be incremental (e.g., maternal, adolescent, dynamic/probabilistic decision support)
  • Significant funding available
design the system for scale
Design the system for scale

PRODUCT STRATEGY

  • Build incentives to ease adoption, create demand
    • Frontline provider
    • Doctor
    • Patient
  • Eliminate roadblocks
    • Contract local external hardware managers
  • Evaluation
    • Determine metrics to measure impact at outset
    • Track what happens after referral
  • Growth strategy
    • Know where want product to go next (e.g., maternal, probabilistic decision trees, authoring tool, etc.) and design for compatibility
donor funding dominates in all areas of health focus
Donor funding dominates in all areas of health focus

FUNDING ANALYSIS

Government provides care in many areas, it funds care in far fewer; out-of-pocket payments high in select areas

Source: CHMI

slide54

FUNDING ANALYSIS

Patterns of Health Care Funding and Spending: Asia

Patterns of Health Care Funding and Spending: Africa

Week 1: Product and Process Review v. 1.0

slide55
Evidence suggests that high and low income brackets and rural and urban seek and prefer private care

FUNDING ANALYSIS

Service delivery networks and private services could be viable partner once product is developed; unlikely to have money to invest in development of set of protocols

Source: IFC, “The Business of Health in Africa”

donor funding dominates in most countries out of pocket payment significant in pockets
Donor funding dominates in most countries; out-of-pocket payment significant in pockets

FUNDING ANALYSIS

In areas where D-tree operates, particularly Tanzania, donor funding predominates

In the BOP segment, more than 50% of out-of-pocket payments go to purchase pharmaceuticals

Source: CHMI, Ashoka

new innovations in financing have made some change
New innovations in financing have made some change

FUNDING ANALYSIS

Patient financing of health care programs through micro-insurance and contracting steeply rose in last decade; other forms of financing stagnate

Source: CHMI

patient financing differs most dramatically in health care focus areas
Patient financing differs most dramatically in health care focus areas

FUNDING ANALYSIS

Method of payment varies across treatment type; focus on treatment area gives clarity into patient payment profile

Week 1: Product and Process Review v. 1.0

first understand if and where the market for decision support and e protocols exists
First understand if and where the market for decision support and e-protocols exists

FUNDING ANALYSIS

  • Even in areas where there is significant out-of-pocket payment for health care, individuals do not pay for preventative or general care through traditional channels (e.g., government health clinics, private health clinics, etc.)
    • Payments for emergency care, procedures, treatments, or traditional medicine
    • Urban segment may be better fit and easier access
  • Business case for protocol adoption is clear in some settings (e.g., procedural check lists), but demand for increasing standardization of medicine seems low
    • Specialization, routinization more common, e.g., Aravind India, CCBRT
    • Protocol adoption requires behavior change, not just organizational change  much more difficult
    • Business case has not been clearly define  investment required in protocol development, training, etc. to anticipated savings in health care costs due to increased lifespan, better and more accurate treatment, and increased efficiencies
  • Drivers of private sector partners not necessarily in line with D-tree’s mission
    • D-tree’s work is essentially for the public good, not something that will directly benefit any one organization as it currently exists
    • If D-tree sought to market its work to prove that it increases efficiencies, lower costs, while improving outcomes, it could do so but would have to develop projects in different ways and with different metrics  must understand who target partner is and what drivers

Projects that are public good  best source of funding is usually donor community

current funding like product portfolio is diverse
Current funding, like product portfolio, is diverse

FUNDING ANALYSIS

Funding Category

Funding Type

Diversity lends security, but requires significant administration; at this point D-tree should carefully consider person-hours to payoff for grants, contracts, etc.

Source: D-tree 2010 Financials

given funding financing and traditional payor landscape few business plans emerge
Given funding, financing, and traditional payor landscape, few business plans emerge

FUNDING ANALYSIS

  • D-tree traditionally sought donor funding through third-parties, namely in-country or international NGOs through direct fee-for-service contracts or by applying to grants
    • Tanzania  primarily donor funded
    • General, AIDS, maternal healthcare  primarily donor funded
  • Any alternative model would require partnership with another more established body to build D-tree brand recognition to consumers and impact/credibility to governments and insurance
    • While this may be option in the future, at present, the organization needs to invest time and money into product development to define its core value offering

Funding model grew out of need but also fit organizational activity

Changing business model necessarily impacts definition of core product and business strategy

point of care payment model
Point-of-care payment model

FUNDING ANALYSIS: MODELS

  • D-tree does not have recognition among patients for delivering quality care and does not have full spectrum protocol for general or even maternal health clinics
  • Franchise models require significant oversight, thoughtful structuring of incentives and a clear offering
  • Many point-of-care payments are still to traditional medicine
  • In paying for healthcare, almost entirely for procedures or treatments; in some places, pills or injections = quality of care in eyes of consumer
  • D-tree has no pipeline or ability to ensure treatment; creating such a partnership diverts from core organizational focus

Options

  • Patient pays out-of-pocket for services:
    • Drivers: name-recognition, availability/efficacy of treatment, WOM, public health education
    • Opportunities for cross-subsidization if develop services attractive to middle/upper class
    • D-tree branded clinic
      • Clinic in a phone—access local entrepreneurs, franchise
      • Bricks and mortar
      • Telemedicine
    • Partnership/JV with existing clinic
      • Protocol/technology provider with percentage of payments
    • Contractor to existing clinic
      • Content/technology provider, not building own brand
traditional payor models
Traditional payor models

FUNDING ANALYSIS: MODELS

Insurance: D-tree would have to have network of clinics or full-service protocols to be a worthwhile partner to an insurance company, no matter the scale; moreover, D-tree would bear burden of proof that services actually did lower costs of care over lifetime

National government:

Options

Week 1: Product and Process Review v. 1.0

  • Insurance (partnership)
    • Drivers: lower costs, reaching more subscribers
    • Large insurance network
      • Formal insurance companies weak in countries of operation and serve the upper classes where access to health care is good
    • Micro-insurance
      • Micro-insurance on rise but often in the form of subscription services or collective risk pooling for catastrophe, not general or preventative care
  • National government (partnership or contract)
    • Drivers: public good, greater efficacy/same cost, economic benefit, staying on good side of donors
      • Often driven by donor agendas; often unwilling/unable to invest own money
  • Donors/NGOs (partnership or contract)
    • Drivers: lower costs, availability of funding, research, personal vision/agenda
      • Main source of health care funding and innovation in developing countries
medical research models
Medical research models

FUNDING ANALYSIS: MODELS

Week 1: Product and Process Review v. 1.0

  • Pharmaceuticals
    • Drivers: market size, regulation
  • Government
    • National
    • Foreign
  • UN/WHO
  • University
adjacent industries
Adjacent industries

FUNDING ANALYSIS: MODELS

Relevance to D-tree

Week 1: Product and Process Review v. 1.0

  • Telecomm
    • Drivers: Access to new subscribers, loyalty of current subscribers
  • Hardware
    • Drivers: Innovation, turnover, GDP growth
  • Software
    • Drivers: Standards, network effects
t o create true private sector partnerships d tree must clearly define value proposition
To create true private sector partnerships, D-tree must clearly define value proposition

FUNDING ANALYSIS

  • CSR partnerships can be cut at any time and are not real investment for corporations and even these are often with those organization’s whose brand will enhance the corp.
  • Corporations make partnerships that will increase revenues and open new markets
    • Business analysis for corporations: market size, potential access to new users, overall economic outcomes of health intervention, direct and indirect revenue effects, NPV of project
    • Organization analysis: investment required, human resources required, fit with strategy
public academic non profit partners will be much more aligned with d tree s mission
Public / academic / non-profit partners will be much more aligned with D-tree’s mission

FUNDING ANALYSIS

  • Partners in the public / academic / non-profit sectors have similar public good models
  • Public partners
  • Academic partners strengthen D-tree’s credibility, and access to medical expertise, not to mention possible funding for trials of protocols
    • Consider academic partners in countries of operation, e.g., partnerships with medical schools to develop locally appropriate protocols  build internal capacity and serve as organic marketing
  • Non-profit partners
necessary capabilities
Necessary capabilities

INTERNAL ALIGNMENT

  • Management / Leadership
    • Manage staff and staffing effectively
    • Create vision for future and set incremental strategy
  • Business development
    • Identify and develop strategic partnerships for direct contracting, in-kind contributions, etc.
    • Lead donor and account management
  • Technology management
    • Oversee technology development (whether in-house or outsourced) and manage technology portfolio
  • Medical expertise
    • Create and evaluate protocols in rigorous manor; manage medical portfolio; includes M&E
    • Manage relationship with in-country, academic, and international medical institutions
  • Project management
    • Track and manage projects from inception through launch
  • Finance and Administration
    • Manage reporting, cash flow, all administration
capabilities identify a set of leadership roles necessary for the growing organization
Capabilities identify a set of leadership roles necessary for the growing organization

INTERNAL ALIGNMENT

  • Leadership:
    • President (MM): figure-head, vision-leader, face of D-tree to to the world
    • CEO : sets internal strategy with the president, oversees business development teams
    • COO : manages internal operations, project portfolio
    • Chief Technology Office : manages technology portfolio and technology staff
    • Chief Medical Officer : conduit to medical community, oversee development of all protocols
    • CFO : manages cash flow, administration
  • Other functions:
    • Marketing
    • Business Development
    • Project Management (in-country projects)

At current scale, some roles may be staffed by the same person, but spheres of responsibility are important to define in a growing organization

clear structure and standardized processes allow for more streamlined efficient work
Clear structure and standardized processes allow for more streamlined, efficient work

INTERNAL ALIGNMENT

  • Structuring the organization according to function allows verticals to build institutional knowledge on core organizational functions, e.g., medical protocols, evaluation, technology, and project management
  • Standardized processes within functions allow for great efficiencies and creation of best practices

Internal interviews with staff demonstrated that a significant of time among field implementers and project managers is currently being taken up by daily maintenance of technology and writing weekly reports and that many staff do not use institutional documents when working on a new project

strategic definition process
Strategic definition process

Next steps and thoughts and post-process considerations

a long and involved process to shift an organization
A long and involved process to shift an organization

NEXT STEPS

  • Review and validate report internally
    • Refine, expand as necessary
  • Begin to make organizational focus decisions
    • Consult with experts, board, management
  • Finalize key decisions
  • Begin business development toward new strategy while maintaining existing contracts
    • Attempt to transform existing relationships to fit plan
  • Review internal structure and staffing to fit new strategy
  • Draft transformation plan and timeline
  • Hire key roles
considerations for d tree s strategic future
Considerations for D-tree’s strategic future

NEXT STEPS

1. Focus and define expertise & core competency

  • D-tree’s current mission is broad but success comes from focus
  • When the market is small, you can be everything. When the market matures, little people get washed away unless they specialize and can clearly demonstrate their value.
  • Need to make the distinction between focus on more complex protocols for facility workers and simple protocols for CHWs. If no distinction is made, D-tree will be squeezed out of both spaces/specializations by incoming organizations.
  • Need to define the “real intellectual property of the organization” is it the ability to create protocols? Validate protocols? Run pilots or studies that demonstrate the utility of protocols? Could the organization validate protocols being developed by others? All these questions need to get answered to bring d-tree into defining its future niche.
  • Continuing to have training/implementing as part of core strategy will be limiting in the long-term
considerations for d tree s strategic future1
Considerations for D-tree’s strategic future

NEXT STEPS

2. Demonstrate ability to move beyond pilots:

  • We have to start walking the talk. D-tree cannot generalize from its current pilots on the potential impact in Tanzania or beyond
  • D-tree should go deep in Tanzania and prove that it can run e-IMCI successfully in 10-20 clinics. This would solidify value and real impact, which is much harder to do than proving adherence.

3. Define geographical specialization

  • Concentrate on a single country. Tanzania is the smartest option given D-tree’s established relationship with the MoH and peers and its track record of successful pilots
  • Overlooking the opportunity to capitalize on the depth it has in Tanzania

4. Address the referral conundrum

  • If the organization continues focusing on protocol development with CHW, particularly in countries where CHWs are not trained to treat diarrhea, malnutrition, etc., it has to address the referral conundrum. What happens when a CHW goes through the decision tree process and the protocol says the patient should be referred but there is no one to refer them to? What happens if the protocol says they need medication but there is none? What is the value of this process in this case?
suggestions for d tree s strategic future
Suggestions for D-tree’s strategic future

NEXT STEPS

4. Define relationship with HSPH

  • The best thing that D-tree has going for it is HSPH. It would be smart for the organization to position D-tree as a technical/implementation arm of the school of public health

5. Explore two potential streams:

  • 1) Create a vertical expertise—one main issue with a suite of protocols that address all manifestations of this issue; 2) create a geographic focus—only one country or region and offer protocols that address 5-10 specific diseases or conditions.

6. Consider consulting:

  • The field needs a consulting group that can operationalize across organizations and an end-to-end service provider that is technology agnostic. We need a group that can go into a country, assess the situation, identify the best technology, hire the best implementers, upgrade, maintain, build local capacity and evaluate/monitor. This would advance the field infinitely.

7. Strategically position within changing landscape of mHealth:

  • Anybody doing software development in mHealth right now will not be doing it in 2 years if the market picks up. D-tree does not want to make this its focus.
key considerations outside scope of this project
Key considerations outside scope of this project

NEXT STEPS

  • Behavior change
    • Technology is not the problem
  • Protocols not sexy
  • Broken health system
    • No roads, no meds, no doctors use of protocols?
  • Harvard relationship
    • Mhealth course, med students, etc.
  • Babysitting vs. empowering
  • Evaluation
  • TZ vs. US dynamics of staff
    • Human resource capacity in TZ and other countries
thoughts on marketing
Thoughts on marketing

NEXT STEPS

  • Marketing is driven by clear organizational strategy, which defines the positioning of any given organization and product
  • A marketing plan includes analysis and strategy in key areas:
    • Target market:
      • Specific customers (providers, patients, funders)
    • Messaging:
      • Must be clear and consistent across platforms, differentiating D-tree
      • Emphasize metrics and impact such as scale, efficacy, cost-reduction
      • Appeal to emotion with mission and vision but don’t use as primary selling point; very powerful used sparingly
      • Simplicity, clarity, and repetition most powerful
    • Platforms and channels:
      • Online  conduct internal review of competitors and other sites for revamp/modernization
      • PR  MM a powerful front person, speaker; develop PR strategy to place quotations, speaking engagements, etc.
      • Research  in hybrid academic/business healthcare industry good research creates tremendous word-of-mouth
      • Annual report  powerful marketing tool for non-profit
      • Print materials  of decreasing importance; annual report may suffice
      • eNewsletter  inform community of D-tree’s achievements, keep top of mind
      • Pitch deck  designed and regularly updated

Note: Marketing should be done by a specialist; design and copy matter

appendix
Appendix

Week 1: Product and Process Review v. 1.0