doctHERs: SMART healthcare for Textile Workers in Bangladesh

The hazardous working conditions inside Bangladeshi garment factories (which contribute over 80% of the national revenue from exports) have led to over 400 garment workers dead and thousands traumatised. The absence of on-site quality healthcare providers has led to a lack of continuous accountability and greatly exacerbated this problem. 

doctHERs tackles this problem by up-skilling Female Frontline health workers (nurses and midwives), equipping them with technology - both hardware (tablets), software (our cloud-based telemedicine platform) and 4G wifi/broadband connectivity) and then deploying them in SMART telemedicine clinics inside garment factories. These trusted intermediaries are able to connect factory workers on-demand, in real-time to our global network of remotely located female doctors (which includes female physicians fluent in Bengali).

By replicating this model across the garment industry (followed by the corporate sector), doctHERs is creating gender-inclusive employment for female frontline health workers and doctors alike. 

The socioeconomic prosperity of Bangladesh has been challenged in recent years by reports of harsh working conditions within Bangladesh's garment industry (an industry that generates more than 83% of the export revenue for the country and is the 2nd largest garment exporter after China). The industry's 3.5 Million workers, 85% of whom are women, lack practical access to high-quality healthcare on-site. In addition, the long hours (14-16 hour work-days), stressful work and cramped, hazardous working conditions have led to over 400 deaths and thousands of injuries from over 50 factory fires, including the infamous Rana Plaza fire of 2013. More recently, worker strikes over low wages (the legal minimum wage is 8000 taka or ~$95/month) by over 50,000 workers in Dhaka in January 2019 were met by police batons and rubber bullets and led to over 5000 workers also losing their jobs. This has triggered concern within the global retailer industry including buyers such as H&M and threatens the viability of the garment industry in Bangladesh. Improving the working conditions (including to on-site access to quality healthcare including mental health services) is critical to the socioeconomic prosperity of this rapidly developing nation which has so much potential.

Our primary target population are garment factory workers (predominantly women, ~85%) in and around Dhaka where the bulk of the garment industry in Bangladesh is concentrated (e.g Ashulia town, a suburb northwest of Dhaka). 

Our multi-disciplinary team, which includes design thinkers, has immersed itself within the target population, silently observing their daily routine, habits, domestic and work-life so as to develop a more nuanced, human-centred understanding of the non-articulated (unexpressed) needs of these garment workers. Many of the workers we interviewed at the factory site were fearful of losing their jobs and seemed reluctant to respond to our questions. Accordingly, we had to live with them to earn their trust and gain valuable insights, which have helped us to co-create our intervention. A  number of important elements were added to the design of our on-demand, 'just-in-time' tech-enabled, healthcare delivery system based on critical feedback from the garment workers (both male and female).   

One of the key needs that was identified was access to good-quality prenatal care as this is a major factor in worker attrition (and lost productivity). Accordingly, we have integrated a handheld digital ultrasound device which can be manipulated by a on-site nurse, guided and interpreted by a remotely located OB-GYN specialist.

Female Frontline health workers (nurses and midwives) are recruited, trained and equipped with technology - hardware (tablets), software (our cloud-based telemedicine platform) and 4G wifi/broadband connectivity) provided by telecom companies such as Telenor (Grameen Phone in Bangladesh). The female frontline health workers are then deployed in SMART telemedicine clinics inside garment factories where they are able to connect factory workers to our global network of remotely located female doctors (which includes female physicians fluent in Bengali). 

The trusted intermediaries (nurses) are trained to conduct sophisticated diagnostic and interventional procedures under the supervision and guidance of a remotely located (home-based) female doctor.

The SMART clinics are also equipped with a fully stocked pharmacy and a a diagnostic lab with central lab processing conducted by one of our many in-network partners. 

 We have already established proof-of-concept of this social business model as well as customer willingness to pay in other South Asian Markets (e.g. as the winner of the Tommy Hilfiger Social Innovation Challenge in 2019, doctHERs has deployed this model in denim suppliers of Tommy in Karachi (Pakistan) and scaled this model to 80 other corporate and SME clients with industrial value chains. 

doctHERs is unique and innovative in that it uses technology ( a digital health platform) to match the under-utilized capacity of female doctors (who would otherwise be excluded from the global health workforce) to the unmet healthcare needs of garment workers in emerging markets. We  recruit, capacitate, and equip frontline health-workers (nurses, etc) with tablets, software and 4G connectivity. These trusted intermediaries (who also speak the local Bengali dialect) are pivotal to our model as their human touch helps to engender trust with the (female) garment workers in a culture which prefers interpersonal human interaction (as opposed to virtual/tech-based) and is skeptical of 'disruptive innovation'. By leveraging technology, we are able to expand access to quality healthcare to urban, suburban and remote rural populations alike.  

We believe that the effective and gender-equal, socio-economic integration of women into the workforce (output) by leveraging technology (an input) will yield increased economic empowerment for women (outcome) which will ultimately lead to increased returns for both society and participating corporate/business partners (Impact). This theory of change is based on compelling evidence cited by Dalberg (1) and the Cherie Blair Foundation (2) which reports that "female sales agents had superior customer service skills and processed customer queries more quickly than men" 

1. Dalberg: "The business Case for Women's Economic Empowerment"; 2014

2. Cherie Blair Foundation: “Women Entrepreneurs in Mobile Retail Channels”; 2011 

• 1. the current number of people you’re serving  - 750,000+  (in collaboration with Tommy Hilfiger, Unilever, UKDFID, Friesland Campina, Shell, RB, Philips, etc)

• 2. the number you’ll be serving in one year  - 2.5 Million Lives (in South Asia combined)

• 3. the number you’ll be serving in five years: 25 Million lives in South Asia, ASEAN and Sub-Saharan Africa 

Our 1-year goals include: 

• replication of our SMART clinic model in at least 100 fabric and garment factory suppliers to Tommy Hilfiger, GAP, Levis, IKEA, H&M, C&A.
• Direct Impact on 250,000 factory workers in Bangladesh
• Indirect Impact on 1.5 Million lives (families of factory workers) in Bangladesh - spouse, children, parents).
• 20% increase in monthly income of garment workers (compared to baseline, time=0)

Our 5-year goals include: 

• replication of our SMART clinic model in at least 1000 fabric and garment factories in Bangladesh (25% of the total market)
• Direct Impact on 2 Million factory workers in Bangladesh
• Indirect Impact on 10 Million lives (families of factory workers) in Bangladesh - spouse, children, parents)
• 100% increase in monthly income of garment workers (compared to baseline, time=0)

Our potential 1-year barriers include: 

• Deep local market knowledge: we plan to mitigate this risk by collaborating with local tech-enabled entrepreneurs and grassroots-level organisations in the health & wellness space. Potential examples include Jeeon and Friendship. 

• Regulatory: clinical guidelines around telemedicine remain murky at best in South Asia in general so this is a potential risk that needs to be mitigated. 

Our potential 5-year barriers include: 

• Political: working in South Asia requires careful navigation of the political waters. Some high-impact growth ventures have run afoul of the political powers that be so this is something we need to be cognisant of. 

• Labour Unions and/or Manufacturer Associations: After a period of evaluation/watchful waiting, if either labour unions or manufacturer associations feel that their interests are being jeopardised they may try and resist the expansion of our model across the industry. 

Ways to transcend these barriers and/or mitigate these risks include:

• Deep local market knowledge: we plan to mitigate this risk by collaborating with local tech-enabled entrepreneurs and grassroots-level organisations in the health & wellness space. Potential examples include Jeeon and Friendship. 

• Regulatory:  one of the strategies that we have found to be effective in other markets in South Asia is to engage the regulators/policymakers so that we can co-create/participate in the process of devising regulations that promote patient safety while enhancing access to high-quality healthcare. 

• Political: we have already operated in a highly politicised  industrial environment in another South Asian country (Pakistan) and so we have become more adept at remaining apolitical and maintaining good relationships across the political spectrum. Our focus is on the sustainable impact we can create for our target population (which in this specific case is more than 20 Million people in Bangladesh). 

• Labour Unions and/or Manufacturer Associations: Deep listening, practicing empathy with authenticity and uncovering underlining interests, etc are all human-centred behaviours that we have had the opportunity to implement on our path to scale. Our objective will be to try and pursue a win-win approach to all of our interactions with both labour unions and manufacturer associations. Again, we will need to navigate these waters deftly and skilfully in order to avoid any implosions. 

There are currently 4 Million garment workers in Bangladesh working across ~5000 garment factories (the target addressable market or TAM), the vast majority of which are in the Dhaka metropolitan region (including suburbs such as Ashalia). Accordingly, the optimal number of SMART telemedicine clinics we can deploy are 5000 and the maximum monthly revenue we expect to generate is $10 Million (or $120 Million per year) @ $2000/clinic/month - this represents the total market opportunity within the garment industry in Bangladesh which is the industry we will first focus on. 

Core Full-TIme Staff: 30

Independent contract workers (includes frontline health workers and female doctors): 90

Total: 120 staff

We are a multi-discliplinary team of serial entrepreneurs who have an established track record of success in South Asia (we have already scaled one US-based venture operating in South Asia to profitable scale). We also pride ourselves on being a 'motley crew'  of MBAs, gender-inclusive design thinkers, doctors, frontline health workers, tech-geeks, financial wiz-kids and a really smart hedgehog called Spike (I kid you not).  

Many of us have lived more than a decade each in at least 3 continents (N. America, Europe and Asia) and so we also have a global perspective on our business but viewed through the lens of having spent a significant amount of time in emerging markets in South Asia (India, Pakistan and Bangladesh).

We are currently collaborating with the following organisations:

Paying Client-Customers:  Unilever, RB, Shell, Friesland Campina, 

Strategic Partners: Unilever, Telenor

Investors/Donors/Funders: Grey Matters Capital (USA); UKDFID; Grand Challenges Canada; ViVatech, Punjab Population Innovation Fund (PPIF), GSMA

In-Kind Supporters: Accenture, Philips, Innovations in Healthcare, 

Our core business model is very straightforward: we charge corporate partners/suppliers/manufacturers a monthly subscription fee for operating a SMART telemedicine clinic on premises (~$2000/month or ~$0.65/worker/month for a factory unit with 3000 workers). 

Our COS (Cost of Sales) is ~$1000/month/clinic, yielding a gross surplus of ~50%. After deducting SGA (sales, general & administrative) operating expenses, we are able to generate a net profit margin at the unit economic level of ~15%-20%. 

Garment buyers-retailers and garment manufacturers/suppliers are jointly willing to co-finance this monthly fee both to mitigate against reputational risk (worker HSE regulations) as well as to incent their value chains (garment workers) to perform better, promoting sustainability and scalability of our  impact.

We have 3 major revenue streams identified for 2020:

• Earned Income via SMART telemedicine clinics: $250,000 projected for 2020
• Health Service Delivery Contracts for Corporate Value Chains (suppliers, distributors, retailers, etc)  - $1.5 Million projected for 2020
• Growth Capital - Series A - $2.5 Million 2020

(i) One of our key objectives is to provide continuity of high-quality healthcare (to our target population) via a biometric-enabled, portable, cloud-based health e-passport system which is fully integrated with our digital health platform. Given Tiger IT's well-established expertise in this area (biometrics, e-government IDs, etc), it makes sense to partner with an IT services company that already has the requisite expertise (which we lack internally). 

(ii) our tech-enabled healthcare delivery model was designed to be replicated and scaled in South Asia - especially in the textile/garment industry given the significance of this industry to the SAARC regional economies.  It makes strategic sense to collaborate with an IT company that already has established relationships with many stakeholders in the garment industry in Bangladesh.

• (Fashion) Garment Retailers: H&M, C&A, Levis, Zara (Inditex), GAP, Calvin Klein, Uniqlo, Primark

• Companies that use cotton/fabric in their supply chains: IKEA, Walmart, Carrefour, Nike, Adidas, Puma