Mosaic of Innovative Solutions: How to Improve Health for All

* Ashoka Fellows and Global Academy Members

Read About the Overall Framework of the Competition

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1. Principles represent new standards emerging from practical applications that are meant to inspire and guide the innovation process going forward. Note that although the best solutions probably speak to more than one principle, we have chosen to emphasize one specific innovative aspect. If you would like to learn about the multiple innovations behind each solution, please click on each name for a fuller description of each case.

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Short Descriptions of Mosaic Cases

1. Foster demand for healthcare

Organization: Population Services International (PSI)
Location: Global
Website: www.psi.org
Mosaic principle: Adopt market-based models as scaling-up strategy
Mosaic barrier: Cultural taboos and health illiteracy

Population Services International (PSI) deploys commercial marketing strategies to promote health products, services, and other types of healthy behavior that enable low-income and other vulnerable people across the world to lead healthier lives. Employing a cross-sectoral model, PSI harnesses the know-how, rigor, and resources of the private sector-including hiring top professionals from marketing, advertising and finance—to achieve bottom—line health impacts.

PSI conducts creative marketing campaigns including theater plays in villages, advertising, and radio shows to raise awareness, create demand, and change behavior. Moreover, by giving wholesalers, retailers, and distributors reasonable profit margins, PSI enlists the support of hundreds of thousands of private merchants to sell healthcare products and services—from condoms to mosquito nets to nutrient packs—at subsidized rates. Management policy is results oriented, and measurable health impact figures on disease and death are meticulously maintained. Staff members are accountable for meeting sales targets of PSI brands and responsible for increased sales to at-risk groups, product assessments in quality of care, and clients' increased knowledge about health.

PSI's approach has resulted in fostering demand for high-quality, appropriate healthcare, attracting the interest of private sector players in this area, and improving the quality of health in poor communities globally.

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2. Change the logic of your distribution model

S. Srinivasan, Ashoka Fellow
Organization: Low Cost Standard Therapeutics (LOCOST)
Location: India
Website: www.locostindia.com
Mosaic principle: Adopt market-based models as scaling-up strategy
Mosaic barrier: High cost of providing quality health products and services

Low Cost Standard Therapeutics (LOCOST) is promoting production and distribution of essential drugs at affordable rates, thus countering the market monopoly of brands that are typically beyond the purchasing capacity of the poor.

While LOCOST started by contracting for the use of spare capacity in the drug industry, it moved into direct production so it could provide affordable medicines to some 300 purchasing NGOs. Through its network of client NGOs and by fixing a maximum retail price, LOCOST was able to cut production costs by eliminating highly priced marketing campaigns and fancy packaging, as well as the middleman. To expand its activities, LOCOST holds its profit margin to 10 percent profit, which compares to an industry average of 50 to 60 percent.

Its direct distribution model through NGOs is ideal for carrying out the educational component critical to LOCOST's operations: awareness-building around the issue of essential drugs and irrational prescriptions.

As sales volumes climb, LOCOST is expanding its product line, aiming to offer more than 80 percent of India's listed essential drugs. Increased profits will also step up LOCOST's public campaign to reduce production of nonessential drugs and redirect resources to quality control, as well as the research and production of more essential drugs. LOCOST's location at the center of the pharmaceutical industry gives it a comparative advantage.

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3. Put customers first

Rebeca Villalobos, Ashoka Fellow
Organization: Asociación de Servicios Médicos para el Bienestar Social (ASEMBIS)
Location: Costa Rica
Mosaic principle: Adopt market-based models as scaling-up strategy
Mosaic barrier: High cost of providing quality health products and services

Blindness is often not only a health problem, but also a broader social issue, as most health systems are not able to provide prevention and treatment to low-income and rural populations. Although 80 percent of blindness is either preventable or curable, there are still over 50 million blind people in the world, most in developing countries.

To respond to this need, Rebeca Villalobos has developed an integrated set of services for high-quality eye care that allows Costa Ricans of all classes to access medical services, ranging from vision tests and low-cost lenses to sophisticated surgical procedures. ASEMBIS has transformed the eye care value chain by creating cost-efficient and high-volume clinics, mobile rural clinics, a multitiered pricing system, and an extensive network of nontraditional health professionals for vision testing and preventive care.

Under this system, higher revenues earned from wealthier patients cross-subsidize the price of healthcare delivery to poorer patients who pay according to their ability. ASEMBIS focuses on top-quality products and services, thereby generating demand among the upper and middles classes who are willing and able to pay market rates. This tiered-pricing allows the organization to offer the same menu of services and products to poorer clients at rates they can afford. User fees thus make the system is entirely financially sustainable, while still accessible to all members of society. And, overall, ASEMBIS services are provided at 40 percent of the cost of private clinics. ASEMBIS has served more than 600,000 people in Costa Rica, and the organization is ensuring a national coverage thanks to its prevention network and regional clinics. After fine-tuning a successful and sustainable solution for eye care, the model is being applied to hearing and dental care.

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4. Establish micro-franchise model

Organization: The HealthStore Foundation (SHEF)
Location: Kenya
Website: www.shefoundation.org Mosaic principle: Adopt market-based models as a scaling-up strategy
Mosaic barrier: Limited reach of healthcare infrastructure

Through its network of 64 health stores across Kenya, The HealthStore Foundation has pioneered a financially sustainable solution to Kenya's inadequate medical infrastructure and the problems in delivering genuine, nonspurious medicines to those in the remotest parts of the country. It has successfully exploited a winning private sector business model—the franchise system—to address public health issues.

In Kenya, 56 percent of the population lives more than an hour away from a health facility, and, when drugs are available, they are often overpriced, of poor quality, out of date, or given inappropriately. Common illnesses—malaria, respiratory infections, diarrheal diseases, and worms—are the cause of 70 percent of child deaths, even though timely treatment with the correct medicines could assure full recovery.

The foundation's health stores are typically set up in villages that are underserved by the existing public and private health infrastructure, providing inadequate access to essential medicines. Health workers are encouraged to run their own outlets under a tightly controlled license from HSF, with each outlet geared to provide a living income for its owner, thereby ensuring sustainability.

HSF oversees strict quality adherence through its tight franchise systems and controls and achieves efficiency through scale and standardization across the entire network. The model leverages the combined buying power of the full network to obtain quality medicines at the lowest possible cost and strictly controlled prices at retail. HSF reckons that its model—if built to significant scale—has the potential to reduce the cost of access to essential drugs to less than 75 cents per person per year, thus making healthcare affordable for even the poorest.

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5. Provide health-related consumer products

Organization: Unilever
Location: Ghana
Website: www.unilever.com
Mosaic principle: Adopt market-based models as a scaling-up strategy
Mosaic barrier: Limited reach of healthcare infrastructure

Multinational giant Unilever is, through its iodized salt product, improving the health of Ghanaians through a cost-efficient strategy that allows the poorest consumer to buy the fortified salt. It has used technology, manufacturing, packaging, pricing, and retail distribution to good effect, turning around the iodine-deficiency statistics in the country.

Seven hundred and forty million people worldwide suffer from low iodine levels, with the highest incidence in developing countries. A deficiency of the mineral leads to mental retardation, goiter, and stillbirths. Iodized salt provides an effortless way to add iodine to one's diet.

The company's challenge lay in selling iodized salt—typically priced at double the cost of ordinary salt—for the same amount and marketing it by citing the health benefits. To keep production and capital costs low, Unilever outsourced production and developed partnerships with local manufacturers, investing time, training, and resources to save on brand development costs, drawing on its experience in India. Its 100gms iodized salt sachets were affordable for even the poorest at 500 Ghanaian cedis (US$0.06) per sachet. Unilever reaped profits from this product after just 18 months, nearly two years ahead of predictions.

Since the launch in 2000 of the company's number one consumer product—sold under the brand name Annapurna—Unilever has helped to nearly double the use of iodized salt in Ghana, with consumption rates going from 28 percent in 1998 to 50 percent in 2002.

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6. Run effective prevention campaigns through cross-sector partnerships

Organization: Basic Support for Institutionalizing Child Survival (BASICS); Environmental Health Project (EHP)
Location: Guatemala, El Salvador, Costa Rica
Mosaic principle: Adopt market-based models as a scaling-up strategy
Mosaic barrier: Limited reach of healthcare infrastructure

For children under five, diarrhea-related illnesses account for significant mortality rates, and in Central America, the range is from 19 percent in Honduras to 45 percent in Guatemala.

Recognizing that handwashing is one of the four measures to prevent such infections in children, the Central American Handwashing Initiative's 1996-1997 campaign message of "I wash my hands for health" advertised the correct handwashing method and was successful in changing handwashing behavior among children and adults alike. The initiative led to a four-and-a-half reduction in diarrheal prevalence in Central America.

Conceived and facilitated by Basic Support for Institutionalizing Child Survival and Environmental Health Project for USAID, the program's Public-Private Partnerships (PPP) approach proved effective in encouraging corporations to recognize that public health objectives are compatible with business opportunities. The approach leveraged all the partners in a win-win, mutually beneficial situation and demonstrated how sustainable social change—in this case, public health—is possible when all stakeholders join hands.

Each of the partners made a contribution in its area of special competence, and thus quickly achieved their objectives. The health ministries met their targets in record time, and with smaller investments. Private sector organizations, such as soap companies, went in for fresh marketing techniques that rapidly expanded their markets while contributing to the public health of the communities in which they do business. Development organizations achieved their strategic objectives and leveraged the collaborative effort for maximum impact. Most importantly, morbidity and mortality rates dropped.

The success of this innovative initiative has spurred others to launch similar programs. To cite just one example: between 2000-2001, Colgate-Palmolive targeted 450,000 children in Guatemala, El Salvador, Costa Rica, and Panama. The PPP approach is spreading fast to other continents as well, and talks between multinationals, governments and CSOs are in full swing.

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7. Address poverty-health vicious circle

Vera Cordeiro, Ashoka Fellow
Organization: Associação Saude Criança Renascer
Location: Brazil
Website: www.saude-crianca.org.br
Mosaic principle: Design inclusive systems
Mosaic barrier: Cultural taboos and health illiteracy

As a physician working in a public hospital serving poor families in Rio de Janeiro, Vera Cordeiro soon realized that most children's health problems were caused or exacerbated by social conditions. Vera founded Renascer to provide holistic treatment to the very poor families of children recently discharged from the hospital with the goal to break the vicious cycle of poverty (disease, hospital admission, discharge, readmission, and possibly death) by tackling the multifaceted factors related to poverty that make children sick. Since its creation in 1991, Renascer has redefined healthcare and created an easily transferable model for locations where socioeconomic factors exacerbate disease. The initiative has spread to an additional 14 hospitals in Brazil with the network Rede Saúde Criança that has served 20,000 people to date.

When a family joins the program, Renascer starts by identifying the most critical problems, develops a customized plan, and schedules regular one-on-one meetings to discuss progress and issues. Treatment plans set out specific time-bound goals such as fixing a roof, modifying a child's diet, getting into the habit of boiling water, and acquiring the documentation to be eligible for government assistance. A well-developed referral system ensures that families get hooked up with appropriate services. It takes about 18 months of regular contact between the mother and the organization to address a range of social problems. The association is founded on a partnership model where it links up with public hospitals, engaging medical staff in identifying vulnerable patients.

As a result of Renascer's intervention, the percentage of at-risk children has dropped from 42 to 10 percent. Thus, at very little extra cost to itself, the public health system is able to provide high-impact care. With the factors causing a child to fall ill reduced—even removed—the overall health of children is improving, which, in turn, is stemming the drain on public health finances.

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8. Introduce disruptive competition

David Green, Ashoka Fellow
Organization: Project Impact
Website: www.project-impact.net
Location: Global
Mosaic principle: Design inclusive systems
Mosaic barrier: High cost of providing quality health products and services

Driven by his vision of "compassionate capitalism," David Green has been instrumental in making top-quality medical technology and products accessible for low-income citizens of developing countries. First working in collaboration with Aurolab, Green's model turned conventional business planning on its head, starting with a predetermined price (what the poor can afford), and then conducting a "forensic" analysis of the entire production and marketing chain to identify every step where costs and margins can be trimmed without compromise on quality.

By partnering with top researchers, medical practitioners, and designers, now-profitable Aurolab is one of the largest manufacturers of intra-ocular lenses in the world, exporting to more than 85 countries. Lenses that are typically sold for $150 in the United States are produced for $3 and sold at a much lower price, helping countless patients who could never afford such treatment preserve their sight and ability to work.

But beyond merely producing medical products, David is challenging traditional business players that have to adjust their prices to stay competitive; he is demonstrating the market opportunity in serving low-income consumers. After lenses and suture products, Project Impact has been applying its model to hearing aids and is considering antiretroviral medicine as a next challenge.

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9. "System-wide" cost savings through preventive care

Jeff Palmer
Organization: Coordinated Care Network (CCN)
Location: USA
Website: www.coordinatedcarenetwork.org
Mosaic principle: Design inclusive systems
Mosaic barrier: High cost of providing quality health products and services

In the U.S., Jeff Palmer's Coordinated Care Network (CCN) has created an innovative system that identifies high-risk patients in underserved communities and gets them into preventive care before their condition deteriorates. The model ensures that low-income citizens receive preventive healthcare through local institutions that the community already knows.

Through proprietary claims surveillance and health risk assessment techniques, CCN prospectively identifies low-income patients who are at greatest risk for expensive health problems and unlikely to go for preventative care. It then preemptively enrolls them in its management program, puts them in preventive services, and thus generates significant savings for public and private health service providers and HMOs (health maintenance organizations). In consideration of these services, the HMO pays CCN a fee and 50 percent of the savings created. The result: improved health outcomes for uninsured and semi-insured, plus large, system-wide cost savings—estimated at 20 to 40 percent—that are reallocated for the care of the uninsured.

CCN also enables a proprietary physician dispensing system, a central pharmacy/mail order facility, and the 340B drug discount program, selling these services to major regional health insurance carriers and health centers. The value to the carriers lies in paying 20 to 30 percent less for medications; members get their prescriptions filled more conveniently. Health centers capture a new profitable revenue stream from prescription reimbursements, and patients regain health faster.

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10. Co-create indigenous programs

Dr. Rani and Dr. Abhay Bang, Ashoka Fellows
Organization: Society for Education, Action and Research in Community Health (SEARCH)
Location: India
Website: www.searchgadchiroli.org
Mosaic principle: Design inclusive systems
Mosaic barrier: Limited reach of healthcare infrastructure

Through their organization Society for Education, Action and Research in Community Health (SEARCH), Rani and Abhay Bang are improving the effectiveness of India's healthcare system by making broadbased and significant changes both in public health priorities and policy and in public delivery of services.

The SEARCH approach involves the community as active partners not only in identifying health problems that they have prioritized but also in designing appropriate and effective healthcare solutions. SEARCH establishes these problems as public health priorities and develops innovative, community-based solutions to solve them.

In the 1980s, backed by extensive research findings, the Bangs signaled a new approach to women's health by shifting the focus from mere reproduction and contraception to gynecological health as a whole. Their identification of the various causes for infant mortality and the interventions tailored to combat this has helped in dramatically reducing child deaths in the developing world.

Recognizing that public health resources are severely stretched, the Bangs are developing village-level health workers equipped to diagnose and treat common illnesses that need neither specialized attention nor hospital care. The Bangs are thus ramping up the efficiency of the public health system, making it a service that responds to client needs and removing unnecessary pressure on its infrastructure. These efficiencies let resources be directed where they are critically needed.

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11. Piggyback on established local practices

Fidela Ebuk, Ashoka Fellow
Organization: Women's Health and Economic Development Association of Nigeria (WHEDA)
Location: Nigeria
Website: www.whedanigeria.kabissa.org
Mosaic principle: Leveraging abundant resources
Mosaic barrier: Cultural taboos and health illiteracy

Fidela Ebuk's Women's Health and Economic Development Association of Nigeria (WHEDA) is promoting community health in Nigeria by tapping into the investing potential and social capital inherent in the country's traditional women's savings groups known as Osusu.

WHEDA's approach catalyzes poor communities to invest in, and take charge of, their health by reorienting the already existing savings infrastructure of Osusu to adopt a pronounced health focus. Its objectives include not only providing a common forum for exchange of information, ideas and insights on health, economic and other issues of general interest to women in rural communities, but also educating and enlightening women on the effects of traditional taboos on their health status.

The model involves the community in health activities like health insurance, bulk medicine purchase, sanitation and immunization campaigns, and pre- and post-natal care programs that increase health literacy and demand for appropriate healthcare. Simultaneously, WHEDA enhances the economic power of members through entrepreneurship training and assistance in setting up microenterprises. Thus, the WHEDA approach creates demand-backed with purchasing power for health products and services—from a large segment of the population historically shut out of the healthcare market.

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12. Use peer networks for behavior change

Linzi Smith, Ashoka Fellow
Organization: Education, Training and Counseling (ETC)
Location: South Africa
Mosaic principle: Leveraging abundant resources
Mosaic barrier: Cultural taboos and health illiteracy

Linzi Smith exploits the social status and authority enjoyed by employed men in South Africa to engage them as socially acceptable, high-impact leaders in the battle against AIDS. Her approach has notched more successes in changing harmful sexual behavior than ostensibly equivalent campaigns have managed over far longer times and at far higher cost.

Smith bases her approach on two ground realities in the country—that men set the rules of sexual interaction, and because of large-scale unemployment, employed men are held in high esteem and the unemployed take their behavior cues from them. Thus the best way to promote safe sex is to educate employed males in safe sex practice and make them role models for other men.

Smith's recruiting ground is businesses and factories where she convinces management that it's good business strategy to build provisions for the impact of HIV/AIDS, thereby combating lowered productivity and profits stemming from absenteeism due to poor health. Once in, her organization, Education, Training and Counseling (ETC), identifies male employee-leaders and trains them to be HIV/AIDS peer educators and counselors. They are motivated to provide guidance and support to each other, and to promote safe sex projects in their communities.

The strategic element of training male lay-leaders allows ETC's method to spread rapidly. Additionally, by working with corporate leadership, ETC taps into the broad corporate network, which also contributes to replication. ETC runs as a business, with the profits used to equip and train underresourced communities.

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13. Build economies of scale

Organization: Aravind Eye Hospital
Location: India
Website: www.aravind.org
Mosaic principle: Leveraging abundant resources
Mosaic barrier: High cost of providing quality health products and services

Aravind Eye Hospital is providing top-quality eye care to the poor in India through a model founded on multitiered pricing that optimizes communities' human and social capital to build economies of scale. A sliding fee-scale allows higher revenues earned from wealthier patients to cross-subsidize the price of healthcare delivery to poorer patients who pay according to their resources—the poorest among them receiving free care.

Leveraging the large presence of welfare organizations working in rural areas and taking advantage of the goodwill they enjoy, Aravind partners with them to hold regular eye-camps that bring in large numbers of patients. Every patient then becomes a promoter by agreeing to try to find five new patients. As patients increase, costs are reduced. Moreover, the large patient base attracts top young surgeons who value this opportunity for gaining rapid experience.

Aravind has mobilized armies of village-level eye care providers by training schoolteachers and village volunteers in vision testing and spreading awareness. It has also leveraged the human resource opportunity presented by the vast numbers of school educated, unemployed rural youth whom Aravind trains as paramedics to provide critical support functions, creating new jobs in the process.

With cost-efficient operations and large volumes of transactions, Aravind's operations register profits to make it self-sustaining. At the same time, all sections of society get the best eye care while paying only what they can afford. Aravind currently performs 200,000 surgeries a year. Although 65 percent of the care is provided for free or below cost, the hospital is able to attain a 50 percent gross profit margin that is reinvested in the operations.

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14. Community-Based Health Financing

Organization: Mutual Health Organizations
Location: Sub-Saharan African countries, including Rwanda, Ghana, Senegal, and Mali
Mosaic principle: Leveraging abundant resources
Mosaic barrier: High cost of providing quality health products and services

By leveraging the region's robust culture of solidarity networks, Mutual Health Organizations (MHOs)—a health insurance model founded on social cohesiveness and mutual assistance—are enabling poor communities in West Africa to access basic health services. This community-based health financing approach encourages communities to share risks and pool funds in order to provide members with affordable coverage for their own and their family's basic health needs.

The structure is similar to microfinance self-help groups (SHGs) where women make monthly or biannual contributions that are pooled to cover future expenses of its members. The organizations also leverage their combined bargaining power to negotiate better rates for a predetermined set of health services provided by affiliated clinics and hospitals. The packages usually include reproductive health care, including prenatal and postnatal care, delivery, and primary care, including treatments for malaria and other common ailments.

Unlike existing government and CSO health schemes, MHOs (a USAID-assisted initiative) enjoy high acceptability because they are completely indigenous, often stemming from local solidarity networks that already exist (for example, women's trade associations). In Rwanda alone, membership grew from 88,000 to more than 200,000 in just three years. The result: in the 11 countries where MHOs are operational, figures for avoidable deaths have taken a nose-dive as families that rarely sought help from health professionals are now more likely than ever to do so because they do not face a cash crunch.

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15. Barefoot doctors

Fazle Abed, Member, Ashoka Global Academy
Organization: BRAC
Location: Bangladesh
Website: www.brac.net
Mosaic principle: Leveraging abundant resources
Mosaic barrier: Limited reach of healthcare infrastructure

By mobilizing an army of barefoot health workers across rural Bangladesh equipped to diagnose and deal appropriately with community health issues, BRAC is sharply reducing deaths from curable illnesses. An important byproduct of this initiative is that it is both creating critical savings for poor communities by eliminating unnecessary hospitalization and enabling the public health system to allocate scarce resources where most needed by reducing nonessential demands on it.

Health volunteers (shastho shebikas) are trained to detect and treat a wide range of common illnesses and disseminate prenatal and postnatal care and advice, well before the illnesses can take a serious turn. They also provide a doorstep service of over-the-counter drug sales, thus saving the villagers from having to make trips to distant town-based drugstores. Simultaneously, they offer referrals by recommending complicated cases to local public and private health facilities. Shastho karmis—trained paramedics—support the work of shastho shebikas and provide additional specialized care like monitoring pregnancies. Collaboratively, the two groups facilitate affordable, grassroots healthcare services for a huge underserved population.

Along with curative care, these health workers provide preventive services through high-impact educational activities focused on health, hygiene, sanitation, and nutrition, and promotion of kitchen gardens for food security. For mass health campaigns, they provide an effective route to reach large groups in a cost-effective way. Countrywide TB, AIDS, and reproductive health campaigns and government-run immunization camps often plug into their outreach capacity.

To support these grassroots health interventions, BRAC has set up well-equipped health centers to provide local clinical services for complicated cases. Simultaneously, leveraging the robust microfinance culture in the country, BRAC is building communities' economic resilience through income-generation and health insurance schemes.

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16. Self-reliant primary health care

Organization: The Foundation for Revitalization of Local Health Traditions (FRLHT)
Location: India
Website: www.frlht.org.in
Mosaic principle: Leveraging abundant resources
Mosaic barrier: Limited reach of healthcare infrastructure

The Foundation for Revitalization of Local Health Traditions (FRLHT) is reducing the pressure on India's overstretched public health system and slashing medical bills of the rural poor by equipping them to become self-reliant in primary health care. It believes that home remedies hold promise for self-reliance in primary health care for millions of households in India and thus making possible the dreams of "people's health in people's hands" in the near future.

Drawing on India's rich tradition of alternative medicine, FRLHT designs "kitchen-garden self-help packages" that enable a community to take charge of its health using preventive, low-cost, and local-specific care by learning how to identify, grow, and process medicinal plants in their backyards. Available in different sizes and prices, the package is promoted by a cross-sector partnership connecting self-help groups, health workers, traditional healer networks, and forest officials. It includes self-reliance in primary healthcare and veterinary care and free health checks and discounts in FRLHT-run herbal medicine clinics. Facilitated by women's self-help groups and reputable NGOs, 150,000 Homestead herbal gardens have been established across the states of Karnataka, Kerala, and Tamil Nadu.

With the larger goal of ethical commercialization to popularize herbal medicines and reduce dependence on high-cost allopathic interventions, the foundation set up Gram Mooligai Company Limited (GMCL). The shareholders of this for-profit, publicly listed venture are self-help groups (SHGs) of small gatherers and cultivators of medicinal plants. The company's production unit undertakes post harvest operations and marketing support for its shareholders, organizing distribution and marketing through local citizen sector organizations, thereby leveraging their community outreach. It also has agreements with select commercial retailers in urban areas: GMCL assures quality herbs at fixed prices to buyers, and simultaneously functions as an organized business platform for its members. SHGs are trained by GMCL, and its research on agro-technology and sustainable harvest techniques further augment its impact.

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17. Establish multi-service Internet kiosks

Satyan Mishra, Ashoka Fellow
Organization: Drishtee
Location: India
Website: www.drishtee.com
Mosaic principle: Introduce novel uses of technologies
Mosaic barrier: Cultural taboos and health illiteracy

Satyan Mishra's Drishtee is delivering villagers from information-peddling middlemen and enabling them to be in a well-informed bargaining position be it when auctioning their land or selling goods.

While one cannot expect villagers to seek health information when awareness about health issues is limited, multiservice Internet kiosks provide an easy access to health information to people by attracting them initially with photo services or agricultural information.

The program is indeed bringing ready, affordable access to vital information-on trade, government records, agricultural data, commodity product rates in different markets, enhanced awareness of health issues and how to access health services—to India's rural masses via Internet kiosks manned by Drishtee-trained locals. The kiosks also serve the dual function of helping villagers with documentation for licenses, compensation benefits, and health insurance.

With Mishra anticipating that Indian companies will soon be outsourcing business to contractors in small towns and villages, e-commerce promises long-term financial benefits to the poor.

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18. Leverage existing technologies for low-resource settings

Victoria Hale, Ashoka Fellow
Organization: OneWorld Health
Location: Global
Website: www.oneworldhealth.org
Mosaic principle: Introduce novel uses of technologies
Mosaic barrier: High cost of providing quality health products and services

Victoria Hale's OneWorld Health is breaking new ground in creating a global system for the low-cost production and distribution of inexpensive, essential drugs for the developing world.

Through OneWorld Health, drug companies can devote significant intellectual, human, and financial resources for humanitarian drug development in countries where labor costs are low, without incurring the commercial risks associated with bringing out new products for relatively small and poor markets.

OneWorld Health's strategy is to draw on available resources and recombine them into win-win partnerships directed at producing drugs cheaply, which OneWorld Health then co-manages for clients. To this end, it leverages existing research and technologies of first-rate pharmaceuticals and helps partner all the players in the health supply chain-drug manufacturers, citizen organizations, health workers, and the governments of developing countries—to work together. It cuts through the conventional barriers of high R&D outlays with too-thin margins for cost recovery from the poorest markets; consumers who pay more than they can afford as quality and authenticity of drugs is related in people's minds to higher pricing; and meager public health resources that limit monitoring and dissemination of drugs.

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19. Identify value-creation opportunities to improve sanitation

Organization: Sulabh International Social Service Organisation
Location: India
Website: www.sulabhinternational.org
Mosaic principle: Introduce novel uses of technologies
Mosaic barrier: High cost of providing quality health products and services

Sulabh has pioneered multiple solutions for meeting the sanitation needs of India's poor through the innovative use of technology to identify value-creation opportunities that ensure self-sustaining models. It replaced expensive and inappropriate conventional septic tanks and sewerage systems for the poor with low-cost, on-site, two-pit power flush models for both rural and urban and residential and public environments. Some 1.2 million individual toilets have been installed, and there are over 6,000 Sulabh public toilets used by over 10 million people everyday.

Sulabh's public toilets function on a low-priced, pay-for-use system. Large client volumes generate adequate funds for maintenance needs and a caretaker for each unit—thereby creating new employment opportunities. Urban units have identified an additional income opportunity: selling advertisement space to businesses.

Sulabh next seized the potential in biogas production by designing a low-cost method of converting waste to biogas that provides affordable on-site waste treatment and at the same time an alternative renewable energy source for cooking, lighting, and electrical generation. Thus, for a small price, Sulabh units meet two fundamental household needs—sanitation and energy—making them highly attractive to poor customers and ensuring growing demand.

Sulabh's production and delivery operations are bolstered by aggressive social marketing campaigns, involving cross-sectoral partnerships that ensure sustained awareness of the "good sanitation=good health" issue. Its network of individual and public toilets is rapidly expanding, fueled by and leading to increasing demand for proper sanitation. The result: a boost to the healthful conditions in poor communities.

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20. Hotline for emergency services

Subroto Das, Ashoka Fellow
Organization: Highway Rescue Project, Lifeline Foundation
Location: India
Website: www.highwayrescue.org
Mosaic principle: Introduce novel uses of technologies
Mosaic barrier: Limited reach of healthcare infrastructure

Through his Highway Rescue Project, Dr Subroto Das has developed a comprehensive system of emergency medical response and care that leverages existing resources and infrastructure into an assembly line of life-saving services. This is an example of additional services needed to make the healthcare system work in low-resource environments.

Timely medical intervention within the first crucial hour—known as the Golden Hour when the chance of fatality is the highest—is critical in emergencies. Piggybacking on medical facilities and state infrastructure—doctors, government authorities, police personnel, petrol station attendants, the corporate sector, and even the rural communities along the highways—the initiative offers a rapid, systemized response to accidents unhindered by bureaucratic or other obstacles.

Das's project delivers on four main counts: networking existing programs to create a pool of resources; introducing professional standards of trauma protocol and revitalizing medical facilities through training and knowledge for doctors and caregivers; reaching out to end-users via a 24-hour emergency helpline; and connecting with influential stakeholders to keep the initiative running smoothly.

Over and above the human and social capital that the project uses to good effect, it has also engineered the efficient use of technology. One call to the hotline ensures that hospitals, ambulance services, cranes, metal cutters, and the police are immediately informed, all of which mobilize quickly into concerted action. A software program devised by the project helps the control room pinpoint the exact location of the accident site on a digital map.

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21. Provide tertiary care through telemedicine centers

Dr. Devi Prasad Shetty
Organization: Narayana Hrudayalaya
Location: India
Website: www.hrudayalaya.com
Mosaic principle: Introduce novel uses of technologies
Mosaic barrier: Limited reach of healthcare infrastructure

Dr. Shetty, a leading cardiologist, is providing affordable state-of-the-art cardiac and other healthcare to all economic sections of Indian society. His hospitals—including Narayana Hrudayalaya (NHH)—accept patients regardless of their ability to pay for treatment.

A major component of Dr. Shetty's ambition is to provide cardiac care to the rural poor with telemedicine. Since cardiac specialists are rare in remote areas, heart attack victims usually turn to general practitioners who sometime prescribe incorrect treatment because of insufficient knowledge of facilities for diagnosing the problem. Dr. Shetty set up India's largest telemedicine network with coronary care units (CCUs) equipped with beds, medication, computers, electrocardiogram machines, and video conferencing devices across India. In addition, Narayana Hrudayalaya trained the general practitioners at the unit level to perform checks on patients and administer treatment. So far some 17,000 consultations provided to about 5,000 in-patients from 60 telemedicine centers benefited from free specialist consultations. While the program started by providing specialist consultations for heart problems, it has expanded into neurology, pediatrics, general surgery, and epilepsy care. Out of the 17,000 consultations, 3,000 to 4,000 patients were cured at NHH, often at a discounted rate.

Almost from the beginning the project was supported by a government agency, the Indian Space Research Organization, that provided connectivity for the units free of charge. Its technology also allowed telemedicine to operate by satellite connection, thus providing clearer images than those coming from phone lines. "The patient must see the compassion on the doctor's face," said Dr Shetty. NHH aims at scaling its telemedicine solution to thousands of medical units, which, once networked, could provide self-sustaining telemedicine services for a few rupees per patient.

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