'Guddi Bajis': Tech-enabled RMNCH

The exclusion of women in the workforce in both developing countries and mature markets has resulted in not only a massive loss of human potential but also loss of human life - especially in developing countries such as Pakistan where over 70 million women and girls continue to lack access to quality, affordable reproductive, maternal, neonatal and child healthcare (RMNCH).

'Guddi Bajis' are female frontline health workers in rural villages equipped with: (i) technology inputs (software/hardware), (ii) training (app-enabled, inventory management, digital diagnostics such as handheld antenatal Ultrasound) and (iii) income-generating assets (inventory such as fast-moving consumer goods, health supplies and products and digital financial services). 

This model impacts SDGs 1 (poverty alleviation), 3 (health), 5 (gender equality), 8 (dignified work), 10 (reduced inequalities) and 17 (public-private partnerships). If adopted and scaled by governments, it has the potential to impact 300 million lives by 2030 ('300 by 30').

The exclusion of women in the workforce in both developing countries and mature markets has resulted in not only a massive loss of human potential but also loss of human life - especially in developing countries such as Pakistan where over 140 million people continue to lack access to quality, affordable healthcare. This lack of access has led to some of the highest rates of maternal mortality (157 deaths out of 100,000 live births) and infant mortality (78 out of 1000 live births) in the world. 

In Pakistan, the good news is that the government has trained over 100,000 female Frontline Health Workers (FHWs). The bad news is that over 80,000 of these workers are unemployed or underemployed and both physically and technologically disconnected from the mainstream, public or private health systems. 

Reasons for exclusion of FHWs include: (i) lack of consumer awareness around the availability of point-of-care (PoC) diagnostics in rural communities, (ii) lack of demand in the public sector for the skills of FHWs in the absence of qualified doctors and (iii) rigid public health systems that prohibit FHWs from working part-time or flexi-time.  

Female Health Workers (FHWs), nurses and community midwives are recruited, equipped and trained on ICT hardware/software (tablets, broadband connectivity and point-of-care (POC) diagnostic tools such as handheld ultrasound) and then deployed in a rural, hub-and-spoke model. 

The digital health & wellness hubs are operated by female retailers (Guddi Bajis) with inventory supplied by Unilever and major pharmaceutical companies via a sustainable, social business model. The spokes consist of a group of 4-6 female FHWs who cover a cluster of between 6-8 villages and prioritise end-user cases based on guidance provided by AI-inputs, predictive analytics and remotely located, female doctors.

All FHWs are trained on Basic Life Support (BLS) and Advanced Life Support (ALS) and can escort acute patients/trauma victims in ambulances/ambulettes to the nearest tertiary care centre while delivering life-saving interventions at point-of-care or during transport to the trauma centre, guided by remotely located Emergency Room (ER) physicians and trauma surgeons.

The technologies we apply include the following: (i) HD video-consultation linked to a digital health platform; (ii) AI & big data-enabled Predictive Analytics to help FHWs prioritise the geographies and cases they cover in the field and (iii) Point-of-Care digital diagnostics (e.g. handheld Ultrasound, ECG, fetal heart monitoring, etc).

Our target population consists of over 3 million low-income women and children across 3000+ rural villages in 36 districts of Punjab and Sind (low-income = income less than $3/day). Most of these women work informally as smallholder crop and dairy farmers or as house-makers. In most cases, they do not receive any wages for their informal employment (in the fields or at home)

When designing our model, we immersed ourselves in the target population we are serving so we could observe their natural behaviour. As a result we have a more nuanced understanding of their actual needs (in addition to the needs they verbally expressed). We rapid prototyped our model to deliver different types of frontline health interventions with or without remotely connected doctors. The model which received the most positive feedback and which we continue to iterate on is the Frontline health worker-assisted video-consultation model. We also have created tight customer feedback loops that feed directly into our product and service design.

The two market failures we are addressing - lack of access to quality, affordable RMNCH on the demand side and lack of inclusive employment & workforce exclusion on the supply side are directly related to the MNH challenge. Our tech-enabled, gender-inclusive solution was designed to tackle these two market failures in a manner which enables underserved women to be able to access high-quality MNH. 

The Guddi Baji last-mile retailer project is unique in that it: leverages technology, (ii) up-skills frontline health workers and (iii) involves a large-scale public-private collaboration between Unilever, doctHERs (a 2017 MIT SOLVE winner) and the Punjab provincial government.

We  recruit, capacitate, and equip frontline health-workers (midwives, etc) with laptops, tablets and smartphones. These trusted intermediaries are essential to our model as they help to build trust with health consumers in a culture which values interpersonal human interaction (as opposed to virtual). By leveraging technology, we are able to amplify access to quality healthcare to remote rural and urban slum populations alike.

Our core technology consists of a digital health (telemedicine) platform that connects healthcare providers (female frontline health workers, nurses, community midwives, doctors, therapists, pharmacists and nutritionists) to beneficiaries via HD video-consultation. 

Patients are or will be able to access the platform via 1 of 3 ways: (i) direct call-in to a helpline which routes them to a doctor who calls them back and can have a discussion via Whats App, (ii) via a trusted intermediary (e.g. Guddi Baji FHW) who uses a ClickMedix tablet-based app and (iii) directly via a doctHERs' mobile app (to be launched in July 2020).

Digital Diagnostic devices (e.g. Lumify handheld ultrasound which can be used for antenatal use) can connect to the digital health platform via Bluetooth. In addition, other digital instruments (EKG, pulse oximeter, stethoscope, etc). 

As a technology, telemedicine (the delivery of healthcare via a digital platform that integrates audio and video imaging)  is used widely across the US, industrialised nations and emerging markets. With the rise of COVID-19, the use of telemedicine has grown exponentially. 

US health systems including the Johns Hopkins University hospital system, the Cleveland Clinic, Mayo Clinic widely use this technology for both diagnostic (e.g. tele-radiology) and interventional/therapeutic purposes (e.g. tele-psychiatry).

The integration of AI and predictive analytics into telemedicine is enabling the rapid risk stratification of large populations so that healthcare providers can focus their attention on those patients most likely to benefit from available therapies. While the primary diagnosis continues to be made by the primary care physician (or specialist consultant, e.g. OB-GYN and pediatrics in the case of MNH) 

We believe that the re-integration of women into the workforce (an output) by leveraging technology (an input) will yield increased economic empowerment for women (an outcome) which will ultimately lead to improved maternal and neonatal (MNH) health and increased returns for both society & 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 

Current: 1,050,000 lives 

1 year: 2 Million lives 

5 years: 25 million lives (in collaboration with Unilever, Punjab Government, Federal Government, UKDFID, RSPN,  and other corporate, NGO and social enterprise partners). This work can not be done alone. It requires the integrated efforts of many like-minded souls. 

Also, all of the above numbers reflect direct impact, i.e women who have either received video-consultations (e.g. for antenatal care) or who have received extensive education on special safety/preventive measures to take against COVID-19 or other conditions (e.g gestational diabetes) during their pregnancies.

Our 1-year goals include: 

• integration of other corporate partners into our last-mile retailer value chain program (e.g. Roche, Novartis, Telenor, etc)

• Direct Impact on 2 million women and girl-children across Pakistan

• Indirect Impact on 6 Million lives (families of women - including male members, i.e. husband, son, brother, father)

• 25% increase in monthly income of Guddi Baji  (compared to baseline, time=0)

Our 5-year goals include: 

• Replication/adaptation of our model by the Federal government of Pakistan as well as provincial governments

• Direct Impact on 20 million women and girl-children across Pakistan

• Indirect Impact on 100 Million lives (families of women - including male members, i.e. husband, son, brother, father)

• 100% increase in monthly income of Guddi Baji  (compared to baseline, time=0)

Our potential 1-year barriers include: 

• Deep local market knowledge: of the deep rural villages in which we will are delivering services

• 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 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.

• Informal Worker Labour Unions: Although such unions do not exist at the present time, we need to be aware that this risk exists. ) 

Ways to Overcome 1-year barriers include: 

• Deep local market knowledge: we plan to mitigate this risk by collaborating with local tech-enabled women entrepreneurs (Guddi Bajis) and grassroots-level organisations (e.g. RSPN) in the health & wellness space.  

• Regulatory: One way to mitigate this risk is to be part of the solution - i.e. to engage the government on formulating guidelines that enable innovation while enhancing quality of care and patient safety.

Ways to Overcome 5-year barriers include: 

• Political:  We need to ensure that we work in an apolitical manner and engage governments across the political spectrum.

• Informal Worker Labour Unions: One way to mitigate against this risk is by ensuring that all of our frontline workers are provided with employee benefits that are traditionally enjoyed by workers in the formal sector (e.g. health insurance, paid leave, etc) 

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Office-Based: 50 full-time

Field-Based: 200 (full-time, contract-based); 50 (part-time, contract-based)

(i) The team has done it before. We've scaled a tech-enabled health social enterprise (Naya Jeevan) to full scale in Pakistan; https://naya-jeevan.com/

(ii) The team is a multi-disciplinary group of pharmacists, doctors, nurses, therapists, design thinkers, lateral thinkers, diagonal thinkers, etc. We have people who have the foresight to see 'unreasonable' opportunities that are invisible to our competition. 

(ii) The team is relatively young (average age: 31) but experienced with over 60 years of cumulative corporate experience at companies

(iii) We are alumni of MIT, Harvard, Insead, UCL, Cambridge, NYU, etc and can leverage our faculty and alumni networks.  

(iv) 70% of the senior management team are women (7 out of 10 Departmental Heads) and 100% of our healthcare providers are women. This positions us well to tackle issues that relate to women and children. 

[1] We collaborate with large, multinational corporations (MNCs) such as Unilever, Nestle, Friesland Campina, etc and provide workers (and families including parents) in their value chains (i.e. suppliers, smallholder farmers, distributors, SME retailers, factory workers, etc) with access to a highly curated, continuity-of-care, health & wellness program. This program focuses on the 'missing middle' the low-income population that constitutes that largest segment of the population (~60% or 120 million lives) but who cannot rely on charity or on public sector healthcare (the urban/rural ultra-poor typically receive charitable care).

[2] in the Guddi Baji program, we are integrating additional corporate partners (e.g. Roche, Novartis, Philips, Pfizer, etc) into this urban center to last-mile village program that connects last-mile retailers (Guddi Bajis) to formal corporate value chains linked to Unilever's massive in-country distribution system. 

[3] We collaborate with grassroots-level implementing partners (LSOs such as RSPN http://rspn.org/ and BRC, a rural market activation agency; https://brcpakistan.com/services/)

Our core business model is very straightforward: we charge corporate employers/sponsors a subscription fee for a monthly digital health & wellness plan of ~$5/person/month. Our COS (Cost of Sales) is $2.50/person/month, 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%. 

Corporations are willing to pay this amount both to mitigate against reputational risk (worker HSE regulations) as well as to incent their value chains ( distributors, retailers, etc) to perform better - one of our paths to scale. 

We have 4 major revenue streams:

(i) Earned-Income from Corporate Clients for Delivering Health & Wellness services to workers in their value chains

(ii) Service Contracts - both development agency (e.g. UKAID) and government-based (e.g. Punjab Population Innovation Fund) which are milestone-based and tied to specific outcomes (Pay-for-Performance contracts)

(iii) R&D Innovation grants - provided by corporate foundations (e.g. Pfizer and Philips Foundation) to market test/pilot a novel way of delivering healthcare

(iv) Therapeutic Area/Disease Awareness Campaigns: we partner with companies to conduct disease awareness campaigns which help to raise awareness around specific diseases (e.g. women's health, breast cancer, osteoporosis, nutritional supplementation, etc)

In addition to these revenue streams, we have raised seed-impact investment from a US impact investor (Gray Matters Capital) and are currently finalising the close of our Series A round of $2.5 Million.

Having participated in several SOLVE challenges in the past, we find that the ecosystem network effect that SOLVE has created is phenomenal. Each contest has a unique group of invested stakeholders who we get exposed to. It's get for our product innovation as well as gaining more visibility in terms of the impact we're creating on the ground in the lives of over 1 million women and children.  

To help diversify our revenue base, we are building small teams in the US and Europe (UK and Continental) who can liaise directly with potential corporate clients at the HeadQuarters level. 

We are always looking for like-minded partners with innovative products/services that can be added to the 'market basket' that the Guddi Baji frontline health worker offers to her last-mile communities (e.g. sanitary pads is an unmet need) 

Business Development: Large MNCs with extensive supply chains and distribution systems such as Coca~Cola, Nestle, Pepsi, etc. We can provide our digital health & wellness plan to tens of thousands of workers in their supply chains. 

Product - Innovation & Integration: We are very open to integrating new products into our 'value chain', e.g. we have integrated Philips' Lumify handheld ultrasound device into our Guddi-Baji-assisted telemedicine model.

Impact Finance: Impact funds (corporate, development sector, etc) can invest in doctHERs and help us to globalise our impact across the ASEAN region and Sub-Saharan Africa and even test a variant of our model in the US & Canada with a special focus on indigenous people and migrant workers.

Over the past year, we've been working as an implementing partner on a GSMA-DFID funded program in which we are providing frontline-health worker-assisted telemedicine and tele-veterinary care to the indigenous people of Tharparkar, many of whom have been internally displaced or are at great risk of forced displacement due to climate change. So we have experience servicing the unique needs of Internally Displaced Persons (IDPs) and refugees. 

There is another community that is highly persecuted in Pakistan which is the Shia Hazara community in Baluchistan. We are keen to support them by deploying our model in their IDP camps and settlements, wIth the active support of the Andan Prize for Innovation in Refugee Inclusion. What is innovative about our model is that it is designed for service delivery at scale in unsafe, war or conflict-zones where healthcare providers are unable (or unwilling) to travel to physically. However trusted intermediaries such as local-dialect speaking frontline health workers can help connect these displaced communities to our network of female doctors, pharmacists, therapists and nutritionists. 

We have introduced a sustainable and scalable model of inclusive employment of women, both at the frontlines (with our Guddi Baji, frontline health-worker assisted model, in collaboration with Unilever) and for remote healthcare providers working from home (e.g. female doctors, pharmacists, therapists and nutritionists. 

We will use the $75,000  Innovation for Women Prize to connect women, improve health and transform lives. We will operate a wireless Women's helpline which serves as a triage to 2 different services we will offer under this complimentary program for vulnerable women: (i) mental health support services, especially for women who are experiencing or are survivors of gender-based violence, (ii) women's health (including reproductive health and family planning)

For the first time in the MENASA (Middle East, North Africa and South Asia) region, we are introducing a certification training program on handheld antenatal ultrasonography for frontline health workers and general physicians (GPs) who can guide them/navigate and diagnose/interpret the ultrasound scans remotely while working from home. This is a model that can be very successful in the MENASA region as it is gender-inclusive while being culturally sensitive. 

Women (beneficiaries) can have antenatal ultrasound in the comfort of their homes via a home health visit by a female health worker (who has also been certified as an Ultrasound technician). This type of remote-assisted ultrasonography can scale quickly in primary care settings and become ubiquitous across lower-income populations that are unable to afford the far more expensive Ultrasound machines used in tertiary care environments (e.g. hospitals)

A subset of our beneficiaries (with their informed consent) will wear wearables that will be tracking a variety of biometrics (blood pressure, Heart rate, mobility, etc). Our goal is to build an AI/ predicative analytics model that can predict clinical outcomes prior to their occurrence as well as help us to stratify risk so that we can focus our management efforts on high-risk patients. 

Our 'Guddi Baji' last-mile retailer/frontline-health worker hybrid model provides rural villages communities across Pakistan with the following:

• access to micronutrient fortified food supplied by formal distributors (linked to and leveraging Unilever's supply chain)
• access to a reliable supply of health and hygiene products (e.g. soap for hand-washing, masks for COVID-10, etc)
• Integration of pharmaceutical supply chains which provide last-mile rural communities with access to institutionalised patient access programs (e.g Novartis Access Program 
• Access to primary/secondary healthcare (including MNH, paediatricians, etc via frontline-health worker assisted telemedicine) 

Our team will use the Bill & Melinda Gates Foundation Funded Award to integrate additional RMNCH--related services/products into the current value (e.g. providing beneficiaries with access to affordable, hypoallergenic sanitary pads)

Our goal is to directly impact 30 million lives by 2030 and to indirectly impact 300 million lives by 2030 (through government adoption/adaptation of our model across diverse public healthcare delivery systems). Both of these goals are 'BHAG's (or Big Hairy Audacious Goals as Jim Collins would describe them). While these BHAGs may seem like Moonshots in 2020, one thing we have going for us is really SMART minds linked to a brilliant idea (if we may be permitted to blow our own trumpets). 

As we hurtle towards a more agile, 'just-in-time' workforce, the ability to decentralise customer acquisition and deliver service delivery at point-of-care will be a game-changer. Point-of-Care Ultra-sound (POCUS) which we're fully integrating into our primary healthcare delivery model this year, is just one small step in that direction (albeit one giant leap for Philips).