Population & Reproductive Health: PRI & Private Market Opportunities Our agenda

¨ Program-related Investments (PRI) primer

¨ Market scan overview – ers of impact

¨ Reproducve health & broader health sector ¤ Healthcare services ¤ Manufacturing & distribuon ¤ Drugs, devices & diagnoscs ¤ Payment & informaon technology

¨ Empowerment of women & girls: Employment, educaon, and financial services

¨ Key intermediaries: funds & financial innovaons

¨ Discussion & looking ahead

1! A quick primer: Program-Related Investments

The basics: Why PRI’s? • Access innovave industry financing ¨ Loan or equity investment • Support NGO innovaons towards ¨ Can be to a non-profit, for- sustainable business models profit, or intermediary • influence & learn from emerging commercial approaches ¨ Must have clear charitable and • Co-funder network: strengthen & programmac purpose expand

The Packard Foundaon’s approach:

¨ Fit with programmac priories, evidenced by a PO sponsor

¨ Clear ability to re-pay in near- or medium-term (readiness)

¨ Oen catalyc (market building), leveraging other investments Example investment: Afaxys Scanning for market acvity around Populaon & Reproducve Health

Our goals in market scanning: ¤ Idenfy internaonal market opportunies that support Populaon & Reproducve Health ¤ Look to both exisng partners and commercial markets for opportunies ¤ Gain input and perspecve from other investors and grantmakers ¤ Provide input and opportunies to Packard for use in strategy discussions and PRI pipeline

Our goals for today’s conversaon: ¤ Idenfy opportunies for collaboraon and co-funding ¤ Find gaps in the exisng set of opportunies Different Raonales for PRIs

Support and influence emerging Strengthen relaonships with commercial co-funder network approaches

Promote grantee Expand co-funder and NGO network innovaons and business models Find, support, Help grantees and learn about operate more enterprise efficiently and Impact models to inform become more grantmaking sustainable strategies Trends: Reproducve Health

WOMEN’S EMPOWERMENT Funder Community • Hewle Foundaon • Bloomberg • Gates Foundaon • MacArthur Foundaon HEALTH SYSTEMS • Compton Foundaon

REPRO- Funding acvity • Commodity security – e.g. DUCTIVE manufacturing and distribuon HEALTH • Product development – e.g. IUD inserters, peri-coital contracepon • Targeted service delivery – Marie Opportunity to: Stopes and PSI • Connue to support exisng grantees in new ways • Work with exisng foundaon partners • Catalyze potenal market for core PRH work

Trends: Health Systems

WOMEN’S Funder Community EMPOWERMENT • Omidyar Network • Gray Ghost Doen Fund • AfricInvest • TLG HEALTH SYSTEMS • TBL Mirror • USAID • Impact Investment Partners • Aureos • Rockefeller Foundaon REPRODUCTIVE HEALTH Funding Acvity • Improving quality of care – e.g. Opportunity Innovave clinic and retail models • Find new ways to channel core PRH products and services • Assuring quality of care – e.g. mHealth • Work with exisng and new foundaon partners tools for data collecon and analycs • Work with new commercial investors to catalyze BOP health • Improving access to quality care – market Health informaon and finance tools • Learn about new health models, influence key market players

Trends: Women’s Empowerment

WOMEN’S Funder Community EMPOWERMENT • Women’s World Banking • Root Capital • Global Fund for Women • Nike Foundaon HEALTH SYSTEMS • Fund for Gender Equality (UN) • African Women’s Development Fund • Global Partnerships • Pro Mujer

REPRO- DUCTIVE

HEALTH Funding Acvity • Educaon financing Opportunity • Microfinance – loans, savings, insurance • Find new ways to channel core PRH products and services • Targeted SME invesng • Influence determinants of PRH outcomes • Work with new and exisng foundaon partners Defining scope & approach Broadening the Lens on Invesng in Reproducve Rights

WOMEN’S • Educaon for girls & adolescents EMPOWERMENT • Employment & enterprise funding • Media & informaon • Financial services HEALTH

INDUSTRY • Care points: Clinics, retail pharmacies, telemedicine • Distribuon and commodity access • Informaon & educaon delivery

REPRO- DUCTIVE • Drugs and devices for contracepon and aboron HEALTH • Services and informaon delivery targeted at reproducve health Reproducve Health & the Health Industry: A range of risk & opportunity across the value chain

Higher Risk Lower Risk Earlier Stage Working/Expansion Capital DIIME Product Dev. Eniware AYZH Daktari Diagnoscs

LaGray Chemical Manufac- turing Cupid Ltd. Aspen Pharma

Accredited Drug Pharmaco Dispensing Outlets Distribuon Vine Pharmacy Cola Life Nufaika UNICEF Bridge Fund Penda Snapper Hill Service Nairobi Women’s Hospital Jacaranda CareGo Internaonal Provider Livewell Medical Group BulshoKaab (PSI) Medical Credit Fund

Biruh Tesfah AllLife Hygeia Community Financing/ Health Plan Demand Chamganka Micro-health Healthcare Providers Contracepve Prevalence Rates in Packard’s Countries of Interest

The percentage of women of reproducve age who are using (or whose partner is using) a contracepve method at a given point in me. It is usually measured for married women or women living with a partner aged 15-49. • Eastern and Southern Africa • Pakistan: 27% Region Average: 36% • Rwanda 52% • Burundi: 22% • Somalia: 15% • Eritrea: 8% • South Sudan: 8% • Ethiopia: 15% • Sudan: 8% • India: 49% • Uganda: 27% • Kenya: 46% • Tanzania: 34% Healthcare Providers: Market Dynamics

¨ Growth of Non-governmental Clinics, Hospitals & Provider Networks ¤ 50%+ of health expenditure in Africa and 60%+ in India & Pakistan at private providers

¤ Private health industry in Africa expanding n Expected to expand $11-20 billion from 2007-2016 n 50% of health sector investment opportunies projected to be in healthcare provision over next 10 years n Expect 60% for-profit, 23% hybrid social enterprise, mostly SMEs. n Less than 40% of out-of-pocket spending on FP was at public facilies (in Kenya, Ethiopia, Rwanda and Tanzania) ¤ In India, private hospitals chains are an important investment opportunity (e.g. Apollo, Fors) ¤ In India and Africa, clinic chains expanding access to quality care for low-income groups. Operang in urban and peri-urban areas, generang revenue from higher paent volumes

¨ Role of Pharmacies in Provision of Care ¤ Key providers of contracepon and drugs n For example, 85% of drugs in India are sold through retail outlet pharmacies and 40% of all contracepon in Ghana sold at ¤ But are sll part of the informal sector in many countries ¤ For example, over 1,500 retail outlets are registered with the Pharmacists Council of Nigeria but the largest retail chain, Mediplus, has only 10 outlets Healthcare Providers: Success Drivers

¨ Creave Financing & Revenue Streams ¤ Cross-subsidizaon ¤ Insurance offering to enable more paent access ¤ Leveraging alternave financial services, e.g. mobile money ¤ Revolving loan funds or working capital to support franchises

¨ Improving Operaons for Quality & Cost ¤ Standardized pracces to improve quality and lower cost ¤ Reduced scope of intervenons to improve quality and lower cost ¤ Door-to-door markeng & sales (e.g. for contracepon) ¤ Centralized IT backbone for chains & networks

¨ Models achieving success ¤ Small high-end hospitals and clinics ¤ High-Volume, low-cost hospitals and clinics ¤ Retail pharmacies ¤ Telemedicine / pharmacy kiosks Healthcare Providers: An Organizing Taxonomy

Social Private Clinics/ Specialty Integrated Retail Franchises Networks Hospitals Services Pharmacies 100% Jeune Clinic Africa (Uganda) Nairobi Women’s African Med. BushloKaab (Cameroon) Hospital Investments (Somaliland)

Top Resau Meridian Medical LifeSpring (India) Internaonal Med MediPlus (Nigeria) (Madagascar) Center (Kenya) Group (Uganda) GreenStar Pakistan Penda (Kenya) Glocal (India) ANKH Women’s Mimosa (Kenya) Clinic (Kenya) Merrygold Health Jacaranda (Kenya) Santushi (India) Vine Pharmacy Network (India) (Uganda)

Happy Mothers DiMPA (India) Religare Wellness (Nigeria) (India)

KMET (Kenya) E-HealthPoint (India) Apollo Pharm (India)

Saadhan (PSI India) CareGo LiveWell (Kenya) 15 Healthcare Providers by Geography

Lifespring Global Penda Health DiMPA Network Nairobi Women’s Hospital E-Healthpoint Nsambya Hospital Apollo Pharmacy Carego Livewell K-MET Revolving Loan Fund Meridian Medical Centre Living Goods Vine Pharmacy Penda Health

Outpaent clinic chain: Geography Kenya innovave outreach to female factory workers Services Maternal/FP A for-profit enterprise dedicated to providing sexual and Footprint 1 clinic reproducve health services to lower and middle class Kenyans. Population Served Low to middle income • Penda has agreements with several factories to provide care to their female employees Revenues Out of pocket • Outpaent medical centers provide family planning, cervical and breast cancer screening, and STI and HIV treatment • Target populaon: working class women • Nairobi has ~50 factories with 1,000+ female employees • Volume-driven model allows lower price point than majority of other private outpaent clinics in Kenya • Setup costs: $10,000 per clinic

17 Nairobi Women’s Hospital

Private hospital with cross-subsidizaon model Geography Kenya Services Maternal/FP, general Founded in 2001, the Nairobi Women’s Hospital is a recognized leader in Kenyan Obstetrics and Gynecology. Footprint 1 hospital and clinic, • 300,000 paents seen, capacity of 150 beds; recently 300k patients served added a new locaon, another in late construcon Population Served Low to middle income

• Full service: in-paent, outpaent, medical training Revenues Out of pocket, college subsidized • Accredited by the Kenyan naonal insurance • Investors include the Aureos Africa Health Fund, a JV between the IFC, African Development Bank and the Gates Foundaon • Gender Violence Recovery Center – housed at NWH, a non-profit that provides free medical tx & psychosocial support to survivors of gender-based violence

18 Nsambya Hospital

Established hospital in Kampala Geography Uganda expanding its maternity wing Services Maternal/FP, general

• Established non-profit faith-based hospital; Footprint 1 hospital, 361 beds 361-bed terary referral hospital Population Served Low income • It offers specialist services in Surgery, Internal Revenues Out of pocket, Medicine, Pediatrics and Obstetrics and subsidized Gynecology • Targets poor populaon, cheaper than private players; considered an alternave to public services • Acumen Fund invested $1.2M for expanding maternal health care

19 LifeSpring

High Volume, Low-Cost Hospital For Women Geography India

Hospital chain in India providing maternal health services at Services FP/Maternal a lowered price point for India’s working poor. Cross- subsidizaon allows LifeSpring to serve low income Footprint 12 facilities, 80k populaons. clients/year • Prices are 30-50% of market Population Served Low to middle income

• Specialized provision of maternal and child services, Revenues Out of pocket including family planning services and medical terminaon of pregnancy • LifeSpring is currently developing relaonships with government sponsored voucher and insurance schemes • IT focus: seng up datacenter to link all hospitals in the system • Funded by Acumen Fund and closing equity round; will soon consider low cost debt

20 Glocal

Specializaon lowers costs & increases quality Glocal aims to lower the cost of healthcare services by Geography India specializing in a few – they provide only those services Services Maternal, general that address the major disease issues of the region Footprint 3 hospitals • Glocal research: 17 condions make up 85% of disease load; 42 condions make up 95% of disease Population Served Low to middle income load Revenues Out of pocket • By focusing on those condions, Glocal cut CapEx by 50% and reduced cost of services accordingly • 3 hospitals launched • Raised $4M+ in debt financing to open 2-4 addional hospitals • Investors include Sequoia Capital and Elevar Capital

21 DiMPA Network

Provider Training Geography India for Injectable Contracepon Services FP, maternal DiMPA is a network of private OB/GYNs and GP’s Footprint 1,400 doctors trained to provide quality family planning services. Population Served Low to middle income Their focus is on injectable contracepon methods Revenues Out of pocket • Providers enroll, in exchange they get the range of injectables at an affordable price point Technology ITC E-Choupal, hotline • Focus on 45 cies – Uar Pradesh, Uarakhand, Jharkhand • 3330,000 calls to DiMPA’s toll-free hotline (as of 2010) – hotlines provide trained tele-counselors on specific contracepon methods

22 CareGo Livewell / Viva Afya

Hub & spoke model clinic chain Geography Kenya ulizing innovave IT systems Services Maternal/FP, Primary care clinic chain using a hub and spoke model to serve low and general middle income clients in peri-urban areas on the outskirts of Nairobi, Footprint 3 anchor hubs, 3 Kenya. satellite clinics • 3 anchor (hub) clinics managed by MD’s, contain pharmacy/diagnosc facilies; 3 spoke clinics managed by clinical officers/RN’s Population Served Low to middle income • Innovave use of electronic medical records (EPDS soware), transmits info between spoke and hub clinics Revenues Out of pocket • Soware provides diagnosis and treatment suggesons for 315 Technology Software, mobile condions. Addional income from soware licensing to clinics, money hospitals and others • Pilong microinsurance bundles, with services for safe motherhood, well baby, and diabetes (through their own mobile cards and partnership with Chamganka)

23 E-HealthPoint

Indian Pharmacy Services Geography India Leveraging Telemedicine Services General

• Footprint 8 facilities, 33k consultations, EHP units provide rural villages with clean 39k prescriptions drinking water, medicines, diagnosc tools, and telemedicine Population Served General population • Licensed pharmacists dispense meds; Revenues Out of pocket primarily branded generics Technology Telemedicine • Pilots with corporaons to target populaons • Experimenng with payment models to encourage adherence to antenatal care

24 K-MET Revolving Loan Fund Microfinance mechanism to support health outcomes Geography Kenya The Kisumu Medical and Educaonal Trust (KMET) has a FP/Maternal/ FP/Maternal network of social franchises to deliver reproducve health Adolescent products in Kenya. Their revolving loan fund makes small Footprint 204 clinics loans to network members, and in return enforces quality standards through a central agency. Population Served Low to middle income

• 65 private providers and 139 public providers in network Revenue Out of pocket • KMET gets loans at 5%, and disburses loans ranging from $2k to $10k at a slightly marked up rate • Franchises pay nominal fee for use of brand name, access to medical supplies at discounted price, and training • Fund has dispersed $294,538 to 31 formal service providers and 441 community-based service providers • KMET provides training on safe aboron

25 Meridian Medical Centre

Geography Kenya Outpaent Care Providers in Kenya FP/Maternal/Adolescent GYN, general Meridian Medical Services is a fast-growing chain of outpaent health clinics in Kenya. Established in Footprint 20 clinics 1994, they provide a full range of preventave and Population Served Lower middle primary care services, including pediatric, dental and gynecological. Revenue Out of pocket • Poised for growth: 20 outpaent clinics, currently looking to grow to 30 clinics and 3 hospitals in the next two years • Populaon served – “lower middle class” • Funding from TBL Mirror Fund (125k euros) to expand from 3 clinics to 10. Expansion complete in 2 years, exceeded expectaons on margins. Acumen co-invested

26 Living Goods Health Products to the Poor, Door to Door Geography Uganda Network of franchised community health promoters in Services FP, health-related Uganda who sell essenal health products door-to-door at products prices affordable to the poor, providing health educaon in the process. Footprint 450k clients served • Community Health Workers are trained to provide basic Population Served Low to middle health counseling. They sell both health and personal products, ranging from an-malarials and condoms to income soap and toothpaste Revenues Out of pocket • Living Goods’ buying power allows them to sell these goods at 10-30% below market prices • Sales target for each franchise is $2500 per year or a 25% margin • Supported by the Omidyar Network, Mulago Foundaon, Jasmine Social Investments, Segal Family Foundaon, and more

27 Vine Pharmacy

Ugandan private pharmacies serving Geography Uganda middle income populaons Services FP, general health products Growing pharmacy chain in Uganda with 5 outlets Footprint 14 outlets in urban Kampala and Entebbe. Ranked in the “Top 100 Small Enterprises” in Uganda in 2010. Population Served Low to middle income

• Profitable, projects to grow at 23% a year in Revenues Out of pocket coming 3-5 years • Since 1999, has grown to over 20 branches Expansion largely internally financed • Outsourced accounng to smooth procurement process

28 Apollo Pharmacy

Geography India Leading Indian Retail Pharmacy Chain FP/Maternal/Adolescent FP

Apollo Pharmacy is one of the largest retail Footprint ~ 1400 branches pharmacy chains in India, and was started in Population Served General Population 1983 as a subsidiary of Apollo Hospitals, one of the larger private hospital chains in India Revenue Out of pocket • Expanded to over 1400 locaons across the Technology Kiosks country • Sell a variety of contracepve products, including emergency contracepon, generic orals, and condoms • 24-hour telemedicine help line, as well as e- prescripon services, a linked insurance program and informaon kiosks

29 Manufacturing & Last- mile Distribuon

30 Distribution & Manufacturing: Following the Value Chain

¨ Flow of goods into country

¤ Manufacturing ¤ Product registration

¤ Product selection ¤ Forecasting

¤ Procurement ¤ Importation

¨ Flow of goods within country

¤ Ordering/Replenishment ¤ Central Warehousing

¤ Last Mile Distribution/Transportation ¤ Reselling (service delivery points – retail pharmacies and clinics)

¨ Supply chain management (e.g. forecasting, anti-counterfeit measures, inventory management)

¨ Highly varied between countries – balance of public vs. private sector involvement; organization of value chains for public sector, private sector, NGOs

¨ Focus points: wholesaling, last mile distribution, supply chain management Manufacturing: Market Drivers

¨ African manufacturing: nascent market, unclear opportunity for local manufacturing ¤ South Africa largely dominates, 70% of annual producon on connent. Nigeria, Kenya, Ghana is most of the rest ¤ Local final formulators (last stage of manufacturing) approximately 30% of this value. ¤ IFC esmates that 40% of the $2-3 billion invested in African health care between 2007-2016 will be in generic manufacturing.

¨ Indian manufacturing: generics/devices well-developed (opportunity for LARC and emergency methods) ¤ India has a significant number (over 11) of WHO prequalified contracepve manufacturers across a range of products, from IUDs to condoms. n Cupid, Polar, SMB, Indus, HLL Lifecare all examples of this. ¤ Contracepve manufacturing - generic OC has the most tracon amongst indigenous manufacturers ¤ Narrow product lines are highly associated with Indian contracepve manufacturers, with the public sector procurement represenng an outsized poron of their business.

32 Manufacturing: Organizing Taxonomy

¨ Contracepve manufacturing falls into several categories ¤ Device manufacturing (IUDs, condoms) ¤ Acve pharmaceucal ingredient formulaon ¤ Hormonal drug manufacturers (injectable, oral, emergency, misoprostol) ¤ Generic drugs and devices

¨ Challenges of forecasng: when credit is hard to access, manufacturers oen pay for APIs upfront ¤ Oen don’t know how much to order because of lack of forecasng, leads to stock-outs.

¨ Challenges of manufacturing drugs versus devices: emergency & oral contracepon more specialized & complicated manufacturing than IUDs or condoms

33 Service Providers by Geography

Adwia Famy Care Terrametrics Terrametrics

Liberian manufacturer producing environmentally friendly condoms Geography Liberia Terrametrics LLC is developing a latex processing and manufacturing plant. The enterprise will be using Liberia’s re- Services FP emerging rubber harvest to meet the under-served market demand throughout Sub-Saharan Africa for latex products Footprint Pre-production • Beginning with male latex condoms • The founders of the company are all highly experienced, Population Served General Population including former members of the World Bank and faculty from Princeton University. • Terrametrics benefits from incenves exempng them from Revenues Out of pocket import dues up to 90%. • Planng and re-planng of rubber trees and the rehabilitaon of Technology Latex processing small rubber plantaons reduces destrucon of forests, and they will be reliant on alternave land use to logging

35 Adwia

Egypan Misoprostol Manufacturer Geography Egypt Founded in 1984, started producon formulaon and drug delivery in 1998, Adwia produces Services FP Vagiprost

• Key product: Vagiprost - each tablet contains Footprint 2 main compounds, Misoprostol 25mcg (Egypt has legalized over 1000 misoprostol for post partum hemorrhage) employees • Venture Strategies Internaonal has partnered Population Served General population with Adwia for misoprostol provision • Export network in countries in Africa as well as Revenues Out of pocket the Middle East

36 Famy Care

Indian generic oral contracepve manufacturer

Global player in hormonal & reproducve health care Geography India products • Serve some of the largest mullateral bodies (UNFPA, Services FP World Bank, DKT); currently the largest manufacturer of generic oral contracepon Footprint 4 plants • Famy has 4 plants at 2 locaons supported by an R&D facility for complex hormonal and reproducve health Population Served General population care formulaons • Range of products: Revenues Procurement contracts • Emergency contracepon • Intra Uterine Devices (Copper T) • Monophasic, Biphasic, and Triphasic oral contracepon

37 Distribuon: Market Drivers

Industry Overview

¨ Health distribuon & supply chain represents $1.6 -$2.8 billion investment opportunity in Africa for the next ten years

¨ More urban Indian populaons changes last-mile equaon Key Challenges in supply chain management

¨ Private distribuon channels are consistently more effecve in their supply chains (versus gov’t, NGO)

¨ Product availability at retail pharmacies in developing countries: 38% in public facilies, 60% in private facilies.

¨ Need for transparency & supply chain management: demand forecasng, an- counterfeit measures

38 Distribuon: Last Mile Overview

¨ How do supplies get from regional warehouse to service delivery point? ¤ Service provider picks up from warehouse ¤ Supplier-managed delivery n Most wholesalers have a fleet of vehicles for delivery, some use smaller vans to distribute beyond main roads / into rural ¤ Supplier/procurer outsources delivery to 3rd party

¨ Due to hyper-local markets, no clear winners for distribuon models

¨ Some models of interest ¤ Retail franchising to increase SDP procurement power ¤ Shared delivery plaorms across sectors ¤ Vercally integrated delivery plaorms ¤ Outsourcing last mile delivery ¤ Exploring innovave models like microconsignment & mobile money

39 Service Providers by Geography

Sproxil Sproxil Fuel Africa Riders for Health Sproxil

Bar-code verificaon of drug authencity in developing countries Geography Nigeria, Ghana, India, Kenya Sproxil uses Mobile Product AuthencaonTM, an an- counterfeit/tracking soluon for pharmaceucals, Population Served Low to middle income primarily used in emerging markets. Paid for by Revenues Out of pocket product manufacturers, oen free to consumers. • Drugs are tagged with coded labels. Customers Technology Mobile phone send the code over mobile to verify product authencity • Nigerian subsidiary profitable in under 2 years • Drug manufacturers currently pay for the service, and the company ancipates many other uses for the product • Acumen Fund invested $1.8M in Sproxil; raising a B Round of $5.5M to further accelerate growth

41 Fuel Africa Fully Integrated Pharmaceucal Distributors in Africa Geography Africa Fully integrated distributor provides access to key products, Population Served General population addressing one of Africa’s most basic challenges

• Provides procurement, imporng, primary warehousing, Revenues Contracts and primary bulk distribuon logiscs • Tight coordinaon with final mile distributors. Oen replaces regional wholesalers, but outsource rural/final mile work to local companies • Make SME loans to final mile distributors • Mul-year, large volume PEPFAR commitment key to growth • Focuses on imported pharmaceucals – lowers prices by 15-30% for consumers • Regional hubs in Ghana, South Africa, and Kenya

42 Riders for Health

Outsourcing Transportaon Experse Geography Across Africa

Provides transport soluons for healthcare delivery Population Served Rural Population in Zimbabwe, the Gambia, Nigeria, Kenya, Zambia, Lesotho and Tanzania Revenues Contracts • Range of services: Transport Asset Management, vehicle management and Technology Motorcycles maintenance, sample transport, consultancy, demand servicing, and training. • Working in Zambia specifically on family planning and reproducve health • Providing health educaon by doing outreach to rural areas • Doing antenatal work with vehicle fleet in Gambia

43 Drugs, devices and diagnoscs

44 Drug & device market – the ecosystem around family planning

Post-birth care + family planning Kids’ healthcare + (e.g. post partum IUDs) Maternal family planning • Anemia (e.g. immunizaon • Antenatal care Infant/Child visits) • Growth Sanitaon Safe Birth Monitoring • Toilets • Hemorrhage • Clinical Care • Sanitary Pads • Pre/eclampsia • Nutrional • Clean Water • Sepsis Supplement Contracepon • Barrier Aboron • Hormonal • Mifepristone Bundle sanitary + • IUD • Misoprostol family planning • Implants • Medabon Mulpurpose products • Injectable • Manual Vacuum prevenon (e.g. retail pharmacies, • Emergency Aspiraon (e.g. use of • Standard Days retail distribuon HIV/AIDS/STI diaphragms/rings • Microbicides/ • Cervical caps for STIs and networks, kiosks, etc.) Spermicide • Vaginal Rings contracepon) • Diaphragm

45 Devices/Technology Highlights

Aboron Contracepon Maternal/Neo-Natal

- Nonprofit and FP device developers - Manual vacuum - Some private sector acvity in low cost - Wide variety of actors aspiraon kits – e.g. applicators in IUDs (e.g. Biocepve, Devices addressing safe births from WomanCare Global Pregna) simple kits to innovaons - Some PPPs in microbicide: VersElle in key devices (e.g. Ayzh, (FHI360 looking for private partners for WeCare Solar, Evotech) distribuon)

- Some local generic emergency - Private misoprostol contracepves (e.g. Zafa Pharma, Famy - Well established oxytocin, manufacturers exist in Care) but approval issues magnesium sulfate markets. Pharma few low-middle - Nonprofit product developers - MS extremely cheap to make, income countries, partnering with established made in developing countries having trouble with manufacturers (eg Dahua implant) - But certain drugs (like oxytocin) registraon process. - US acvity: Evofem developing N-9 alt face cold chain issues

- Acvity in anemia screening (e.g. - Pregnancy tests, - Low resource seng ultrasounds ToucHB) and blood oxygen (e.g. – portable, USB/phone Lifebox) Diagnoscs e.g. Khushi compable (e.g. Vscan, - Price sensivity (on both ends) InNovaSound, Mobisante) key to driving demand - Partner with exisng distribuon 46 networks Commodity Consumpon: Market Dynamics

¨ Innovaon in contracepve commodies coming from three sources: ¤ Non profit drug companies/research groups like Concept Foundaon, who then license out manufacturing ¤ Small private device makers like Biocepve and Daktari ¤ Some innovaon from large firms like Merck with the Implanon device (with some parallel, lower-cost innovaon at non-profit levels with similar devices)

¨ Women’s health devices developed and created by a variety of actors: ¤ Non profit drug companies/research and technical assistance (Medicine 360, FHI 360, Concept foundaon) ¤ Early stage device companies (Daktari, Diime, Evotech) ¤ Early stage contracepve development (Med 360) ¤ Later stage developing world manufacturer linked to innovave companies (Dahua – Sino Implants, Cupid, Sun Pharmaceucals) ¤ Large mulnaonal firms (Merck, BD)

47 Technology/Device Manufacturing

Potenal for PRI Higher risk, very early – opportunity focus? for tech transfer, local innovaon at universies, incubators Early stage product & device Tradional, Long and expensive approval development and cerficaon processes Largely in India and China, large-scale significant capex req’d device & pharma PRH manufacturing Can reduce costs (e.g. 20-30% for QCIL ARVs) but Some innovaon in new sll expensive and need products, new markets with Local consistently high enough larger capacity & balance manufacturing demand sheets if appropriate demand

48 Service Providers by Geography

Biocepve

Biosense Ayzh Pregna Internaonal WomanCare Global Sun Pharmaceucals DIIME S.H.E.

Global: Daktari Diagnoscs Evotech Cyclebeads Medicines 360 Pregna Internaonal Sun Pharmaceucals 49 Daktari Diagnoscs Early stage tech firm developing CD4 counter backed by Merck • Daktari Diagnoscs makes affordable diagnoscs intended for wide Geography Global use in the developing world • First product is Daktari CD4, a portable CD4 cell counng system Structure For profit used to track the progress of HIV. CD4 cell counts are used as a Investable Yes measure of the immune system • Daktari has received financial support from a wide range of actors: philanthropy, venture capital firms, sovereign wealth funds, and angel investors. Their latest round of financing ($10m) was led by Merck • Launching in Sub-Saharan Africa, with government partners in Kenya, Uganda, South Africa, and Botswana. Procurement will be government led. Unitaid, the French aid program, has also expressed interest in purchasing. Expansion to Brazil and China is currently under consideraon • Large scale manufacturing for Daktari will be done in either Scotland, Canada, or Singapore

50 WomanCare Global

Non-profit PRH product development and commercializaon experts Geography Africa

• Founded out of the Ipas product development division in Structure Non profit 2009, WomanCare Global provides PRH products to private and public partners throughout the world Investable TBD • Focus on “channel management”: regulaons, quality assurance, market and supply chain logiscs • 7 products products ranging across contracepon, pregnancy management and ferlity • Sell sterilizaon, oral contracepves, emergency contracepves, copper IUDs, manual vacuum aspiraon, mifepristone • Country acvity in Ghana, Kenya, Uganda, Tanzania, Zambia, Ethiopia, Tunisia

51 DIIME

Device developers in partnership with Ghanaian teaching hospital Geography Africa

• DIIME’s Hemafuse product performs autologous blood Structure For profit transfusion ulizes the concept of blood salvage, in which the paent’s own blood is removed and retransfused into Investable Yes their body • Using Hemafuse, clinicians are able to extract blood from the woman’s abdomen, quickly filter the blood of any clots or impuries, and safely transfuse it back into the woman’s body through the use of a standard blood bag • Partnership with physicians at Komfo Anokye Teaching Hospital in Kumasi, Ghana • Three more projects in development: a mul-funconal labor and delivery bed, a portable delivery and repair assistance device, and a low-cost infant respiraon monitor

52 Biocepve

Early stage IUD inserter device currently raising money

• Biocepve is develoiping an IUD device inserter intended Geography U.S to reduce the complicaon inherent in current techniques Structure For profit • It reduces the four tool process into an easy procedure using one tool Investable Yes • Biocepve is going through two regulatory processes – the FDA and CE Mark • Biocepve will seek to raise a Series B round of financing of $2,000,000 by November 2012 to perform markeng trials and prepare for commercializaon of the device in 24-28 months • Biocepve will posion itself for acquision aer regulatory clearance or clinical trials by year two or three

53 Biosense

Low cost anemia measurement moving close to market Geography India • ToucHb: hand-held needle-free baery operated device that enables screening for Structure For profit anemia Investable Yes • No special skills required to operate • No recurrent costs -- needles, use of special lancets, micro-cuvees, blong paper etc. • Rechargeable baeries last > 100 tests per charge; yearly maintenance for probe • Incubated at CIIE (out of IIM-Ahmedabad); just completed seed/Series A round

54 Evotech

Low-cost endoscopic camera system used in developing world clinics Geography Global

• Evolving Technologies (EVOTECH) provides low cost Structure For profit medical equipment Investable Yes • Aims to couple the sales of medical equipment with IT (telemedicine and cloud compung services) that enable the delivery of quality care in medically underserved regions • EVOCAM System: first product – a rugged, modular, portable endoscopic camera system • Medical partners include Carego Livewell, Manchanda’s Endoscopic Center in New Delhi, and Tus Ambulatory Service

55 SHE (Sustainable Health Enterprises) Banana fiber-based sanitary pads

Geography U.S/Rwanda • Founded in 2007, uses a split model, with U.S branch established as a non profit, African branch Structure Hybrid run as a for profit Investable TBA • Uses locally sourced banana fiber to create sanitary pads for women and girls • Rwandan pilot launched in 2010 • Trains CHW’s to distribute pads, who in turn hire women to sell the pads door-to-door. They assemble the pads themselves and import materials outside of the raw fiber • Low cost allows price point 15% below market rate

56 Cyclebeads

Ferlity awareness based family planning method Geography Global Structure For profit • CycleBeads® and iCycleBeads apps are based on a natural family planning method called the Standard Investable Yes Days Method® • Based on research done by the Instute for Reproducve Health at Georgetown University – large scale clinical trials to test the Standard Days Method and found it to be 95% efficacious in prevenng pregnancy for those who followed it • Sold via Maternova to its clients including NGOs, government agencies, and health providers

57 Medicines 360

Hybrid model drug company creang low cost next generaon IUDs Geography U.S / Global • Non-profit drug company, developing a new low cost IUD Structure Hybrid • Retains control of public sector sales and Investable Yes conducts commercial / private sector sales made through a licensed pharmaceucal partner • First product under development is an innovave low-cost IUD, based loosely on the high end contracepve Mirena • Medicines360 is currently in clinical trials for this IUD

58 Ayzh Healthcare

Low-cost clean birth kits Geography India made by for profit social enterprise Structure For profit • Conducts market research to assess consumer demand for products, then tests technologies on Investable Yes affordability and appropriateness • Distributes products through exisng infrastructure of retailers, women self help groups (SHGs), and NGOs that already sell products to women in their region • Inial market: southern India • First two products: a clean birth kit and water filtraon system • Have sold over 12,000 products

59 Pregna Internaonal

Large IUD manufacturer doing product development on inserters Geography India / Global

• Founded in 1991, manufactures IUD’s and IUD- Structure For profit supporng devices Investable Yes • Served over 80 million women in over 130 countries • Product range has expanded to 9 different types of IUD • Latest area of product development acvity (2012) is the Etherna, a IUD inseron device. Much like Biocepve, it simplifies the process into two steps and makes IUD inseron safer and more comfortable

60 Sun Pharmaceucals

Medabon manufacturer licensed by Concept Foundaon Geography India / Global

• Manufactures Medabon, combines misoprostol and Structure For profit mifespristone Investable Yes • Product was developed by the Concept Foundaon and licensed to the Indian manufacturer • Has allowed medical aboron to become available for the first me in Cambodia, Nepal, Ethiopia, Ghana and Zambia • Achieved registraon with a stringent regulatory agency in Europe – allowing rapid approval by regulatory authories in several countries either based directly on the European approvals or through a fast-track process

61 Payments & Informaon Technology

62 Mobile technology in health: For payments & informaon

¨ But challenges Remain… ¨ Moore’s law applies & is in effect: ¤ Not the last mile, but the last yard ¤ 87% of the world’s populaon has access n “Width of the counter to mobile between the buyer & seller” à agent networks, SMB ¤ Internet geng faster uptake & less expensive ¤ Regulaons n Kenya: 4th cable just landed in ~2 n KYC, AML: Transacon limits years & cross-border limitaons, interest-bearing accounts, ¤ Cheaper smartphones identy card issues, etc. à rise of Android ¤ Agent liquidity at last mile (what ¤ Operators PEP Intermedius does for M- incenvized: want to Pesa) increase ARPU through SMS, etc. ¤ Non interoperability ¤ “ ” ¤ Mobile users expected CULTURE – markeng, to outnumber desktop targeted products, financial users in 2013 literacy remain a major barrier in US & abroad

63 Payment innovaons: Less than 1/3 of the world’s Implicaons for Care population has a bank account

Segment Innovaon & relevance for health Remiances Tied to health and educaon and targeted health remiances via mobile money (e.g. Willstream) Micro-insurance Insurability based on airme spending or leveraging mobile money; can integrate with health services providers or financial services providers (e.g. MicroEnsure) BUT need robust risk pool Emergency lending Health/funeral-related loans; technology enables rapid turnaround ed to mobile payments (e.g. M-PEPEA)

Bundled/prepaid Delivered via mobile prepayments, leveraging alternave savings mechanisms – services useful for planned health uses like pregnancies & deliveries (e.g. Changamka) Vouchers Target populaons (such as pregnant women) pay a fracon of the price for a set of services with a mobile encoded voucher; also a way to drive demand for certain services (e.g. Yarona Care)

Credit Unions Retail Vendors Banks Informal Lenders Formal Informal Credit Cards Kiosks/ATMs Prepaid Mobile 64 Service Providers by Geography

Microensure

Changamka Microensure

65 Microensure

Specialist insurance intermediary for low income groups • Works with 60+ MFIs reaching 12m acve borrowers. Sell micro-insurance across a variety of spaces including Geography Africa, South health, property, funeral, and agriculture Asia • Premiums ~$5 per person per year Structure Non profit • Work in several different countries with a range of Investable Yes partners – India, Mozambique, Rwanda, Ghana, Tanzania, the Philippines • Underwrien by local insurance companies such as Jubilee Insurance (East Africa) • Maternity care is explicitly covered in the Tanzanian product, which covers families for $40 a year through the Anglican Church and Coffee Growers Union. 600,000 are enrolled

66 Changamka Microhealth Limited

Mobile phone enabled insurance • Issues Smart Cards to the Kenyan working poor, allow them to steadily save money that can be used for doctor visits and medicine Geography Kenya • Card is accepted at 30+ accredited outpaent medical Structure For profit establishments in Nairobi, Kikuyu and Mombasa, including Carego Livewell clinics Investable Yes • Maternity smart card program allows the bearer to obtain ante-natal, maternity and post-natal services at listed prices in parcipang facilies • Underwrien by GA Insurance (Kenya) • Electronic administraon plaorms for voucher programs in healthcare and educaon – aimed primarily at reproducve health vouchers to facilitate service delivery

67 “More people have access to a cell phone than a clean toilet” -- mobile phones are Informaon/Analycs unquesonably now a powerful tool for delivering health informaon in BOP

Collecon Disseminaon

Back End Public Health Community Individual • EMR: CareGo, • Pill checks: Stop • Peer to Peer • Hotlines: mDhil PIH Stockouts educaon: • Telemedicine: • Community • Point of care tools: M2M MeraDoctor Health Worker D-Tree Internaonal • Sharing • SMS Reminders: oversight: • Disaster consumer Remindavax Capacity Kenya management experiences: • Applicaons: • Data collecon • Disease surveillance: awaaz.de CycleTel service: Ghana Datadyne, Ushashidi • Electronic Health Worker mailing lists

Actual buyers in Simple More back end – private innovaons Not many developed Ability to hospitals, clinics driving impact – profitable models market in leapfrog to chains, as well as paperless in “public health” India more increasing demand systems, or “community” efficient in aid transparency immediacy of systems like tools, like for RCTs digital results EMR 68 Spectrum of Informaon & Analycs Plays

Collecon Disseminaon

Back End Public Health Community Individual • EMR: CareGo, • Pill checks: Stop • Peer to Peer • Hotlines: mDhil PIH Stockouts educaon: • Telemedicine: • Community • POC tools: D-Tree M2M MeraDoctor Health Worker Internaonal • Sharing • SMS Reminders: oversight: • Disaster mgmt consumer Remindavax Capacity Kenya • Disease experiences: • Applicaons: • Data collecon surveillance: awaaz.de CycleTel service: Ghana Datadyne, • Electronic Health Worker Ushashidi mailing lists

¨ BUT barriers remain… ¤ Relevance to audience: e.g. Airtel’s Fistula hotline, Sierra Leone – 0.1% of calls were about fistula ¤ Care Infrastructure: Informaon without care providers may not be useful ¤ Monezaon challenge: dependent on 3rd party payers like insurance companies, pharma ¤ Regulatory concerns? Private health data on mobile networks, hotlines, etc

69 Who will pay for informaon & analycs?

Consumers Employers Insurance Health Non-profits / Companies Providers / Retail Governments

Often a low Not frequently Incentivized to Community health Will pay for public willingness to pay incentivized to keep provide information workers or more health data (e.g. – relevance is key employees to beneficiaries but mobile health episurveyor) (e.g. MOTECH) informed re: health not much activity at providers Will pay for certain Relevance could be – some corporates the moment demanding better health campaigns population, service, concerned about tools for collecting (e.g. Voxiva) or geographic- supply chain patient info (e.g. Often limited specific transparency and Dimagi, Carego) – relevance, can’t be “social auditing” willingness to pay as easily targeted though (e.g. Labor Preferred goods/ Voices) services providers may use as marketing

70 Service Providers by Geography

Meradoctor Artoo mDhil Mamakiba Sevamob Stop Stockouts Healthkart Mothers2Mothers

Global: DataDyne OpenMRS

71 Meradoctor

Medical consultaons over phone – a for-profit model Geography India • Telemedicine consultaon service based in India. Structure For profit Subscripon model, 150 rupees for 3 months of unlimited service Investable Yes • In ~7 of 10 cases, MeraDoctor doctors resolve primary health quesons over the phone, caller does not need to visit a clinic, hospital or lab • Clinical performance is monitored for quality on a weekly basis • Members are eligible for discounts of as much as 50% at diagnosc centers and labs across India • Maintains paent medical records • Backed by Aavishkaar

72 Artoo

Mobile plaorms for internaonal development field agents Geography India • Creates mobile products for field agents to improve operaons across healthcare, Structure For profit distribuon and financial inclusion Investable Yes • Uses the cloud to help field agents engage with end users, transmit data, automate analycs and reporng, and learn from training modules • In healthcare, the service can be used for data collecon, paent educaon, and CHW training • Used by Ujivann, the Grameen Foundaon, and Brighter India Foundaon

73 DataDyne

Tiered service for electronic data collecon used by MFI Geography Global • Key product is EpiSurveyor, a mobile electronic data collecon service Structure For profit • EpiSurveyor produczed in 2010. Now 6000 users Investable Yes in more than 170 countries, making it one of the most widely used mobile data collecon system within internaonal development • Used by the World Bank, CDC, UNICEF, WHO/PAHO, John Snow Inc., MSH, USAID, and Abt Associates • “Freemium” model – free basic capacity to any user, paid user licenses for higher funconality • Seeking $2.3 million over three years to deepen market penetraon

74 mDhil

Youth-targeted health info subscripon service for taboo health needs Geography India • mDhil provides basic healthcare informaon to Indian consumers via text message, mobile web browsers and Structure For profit interacve digital content. Launched in 2009 Investable Yes • Subscripon costs ~1 rupee a day • 250k+ subscribers • Targets people ages 16-25; tailoring services to culturally taboo health problems – namely sexual/ reproducve health, contracepon choices, family planning and women’s health • 43k video views of reproducve health and family planning content in a 5 month period • Also do drug adherence reminders via text message

75 OpenMRS

Open source EMR soware • Collaboraon between Partners in Health and the Regenstrief Instute; a community of developers and implementers in 6+ African countries now contribung to Geography Global construcon Structure Non profit • OpenMRS is a Java-based web app, capable of running on laptops in small clinics or large servers for naon-wide use Investable No • Source code allows for a variety of “add-on” modules tailored to providers’ needs. Examples include: • Paent registry. • Clinical tools that prints paent data summary on a med basis. • Drug predicon tools • Synchronizaon tools allowing exchange of paent records with other medical record systems

76 Mamakiba

Jacaranda Health’s mobile applicaon • Paent-facing SMS-based savings calculator and Geography Kenya prepayment tracking tool Structure Non profit • Designed to help low-income women save money and prepay for their maternal health needs, such as antenatal Investable No care and clinical delivery • Designed by Mulple Choices Labs, Mamakiba is the mobile applicaon of Jacaranda Health, social venture in Nairobi. • Serves pregnant women in peri-urban areas who have cell phones linked to M-PESA accounts and want to avoid government hospitals or expensive private clinics • Customer acquision through registraon at Jacaranda Health clinics • Savings calculator esmates the total amount woman needs to save for the selected bundled service and the minimum amount she needs to deposit before the next ANC visit

77 SevaMob

For profit tablet based insurance and basic check ups • Launched in 2011 Sevamob provides primary healthcare and insurance to low income consumers in India for a monthly subscripon. Geography India • Also provides agriculture and animal husbandry advice Structure For profit • Service is delivered by field teams of doctors and sales reps on Android tablets Investable Yes • Basic checkups done at the door, with prescripon services available • Supported by call center and network of 3rd party service providers that pay Sevamob referral fees • Free ambulance service for in-network hospitals • Currently operaonal in Lucknow district. Over 1300 people subscribed

78 Healthkart

India’s first e-health store • Aims to be one-stop (online) shop for consumer healthcare in India • Recently launched generic drug search engine (both for pricing and general informaon) Geography India • Idenfied area of need – well developed retail Structure For profit infrastructure for healthcare products outside of major metro areas. They do all the packaging and delivery of Investable Yes products on the site. • Sell male and female condoms amongst other contracepves • Company ensures authencity of products • Backed by Omidyar Network • Formed partnership with U.S based Vitamin Shoppe to provide their products to Indian market

79 Stop Stock-outs

Non-profit campaign using Frontline Geography Africa SMS to do random pill checks Structure Non profit

• An iniave of Health Acon Internaonal, Oxfam, Investable No and civil society groups supported by the Open Society Instute • Conduct random pill checks – researchers visit health instuons to check on the availability of essenal medicines • Data is communicated via Frontline SMS • Results are reflected in an online map of a given country produced using the mapping tool Ushahidi • Parcipang countries include Kenya, Malawi, Uganda, Zimbabwe and Zambia

80 Mothers2Mothers

HIV posive women trained to conduct educaon on vercal transmission Geography Africa

• Trains and hires mothers living with HIV (“Mentor Structure Non profit Mothers”) to work alongside MD’s / RN’s to address vercal transmission of HIV from mother Investable No to child • 1,800 women employed as Mentor Mothers • Provide individual and group educaon sessions • Use mobile phones to connect women enrolled to care, informaon and support. Mentor Mothers upload user profiles and conduct quesonnaires • M2M works in 7 countries across Africa • Enrolled ~300,000 HIV-posive pregnant women last year – 20% of pregnant women with HIV in the world

81 Empowerment of Women and Girls

82 Key approaches to empowering women & girls – Overlap with health & family planning

Financial services Microfinance Mobile money Health SME finance Financial literacy Health Student finance insurance Bridge Emergency financing lending School SME finance Health & Family Planning FP & sex SME educaon Finance Maternal Health K-12 BPOs Health provider Employment training Educaon Incubaon/ acceleraon

Vocaonal training 83 Women’s empowerment: key examples

Microfinance: Women’s HEFF, Root Capital World Banking, Calvert Women’s Iniave, WINWIN, Agora-Eleos Fdn Varthana LatAm Women’s Fund Financial services SME Finaning: Insurance: PharmAccess Medical Expatcare, Hygeia, Credit Fund AllLife

Bridge Financing: K-12 edu: UNICEF Bridge Fund, Bridge Internaonal APROFA Health & Academies, Omega Family Planning Schools BPO: DesiCrew, Samasource, DDD Provider training: Acceleraon AMREF nurse e- Akili Dada, Agora Employment Educaon learning program, Partnerships Hubert Kairuki Memorial University

84 Range of models in financial services

From personal finance to business lending, there are a number of ways financial services intersect with women’s health in the developing world, where there are significant credit gaps and few bank accounts Packaging Crowdsourcing medical services for Strengthen exisng Fully grant funded treatments or planned health providers or cash grants can procedures; potenal treatments (e.g. retailers by filling a large affect FP outcomes for future revenues? Changamka) financing gap; can be (e.g. Kenya’s Cash (e.g. Watsi) asset-backed Transfer program In "HealthyLife” voucher program in Uganda non- Opportunity to link Providing savings HIV STI paents receive coverage to health- clubs through schools Opportunity to smooth care at contracted clinics related regimens for adolescent girls, demand/supply and (e.g. AllLife) improving financial strengthen supply chains literacy with shorter duraon investments Micro- Bridge mHealth Savings clubs finance funding Cash Crowdsource Insurance Grants Vouchers plaorms Remiances Prepaid Insurance SME financing Less Investable More Investable

85 Range of models in educaon

Target to women or health care worker Very few if any educaon – variety of business models – models developing but mostly done through sll nascent clubs / groups with grant $ Targets low and middle Few business income – more girls sent models in health Clear SME financing to school, lots of acvity in ed but an area Sex/FP educaon gap – target facilies India; may have real estate to watch providing more FP or other assets Grant funded; work on driving goods and services demand but may have affiliated service providers Student Grant funded; work on driving demand but also financing may have affiliated lenders Social Decentralized Educaonal Affordable markeng Financial literacy learning facility financing private schools Less Investable More Investable

86 Range of models in employment

Opportunity to match jobs and job seekers, focus on jobs for women (e.g. Job growth in healthcare Assured Labor) Support BPOs sector; fill SME finance employing women gap where the majority and/or providing of jobs are Skills training addional training or Largely grant funded focus programs, esp. those scholarships (e.g. DDD, on TA and leadership – from targeng women or Samasource) SMEs to scalable businesses health – big gov’t focus to management training in India over next OR support SMEs owned (e.g. WWB Leadership decade by or employing largely Academies) female popuatlions (e.g. Root Capital Women’s Iniave)

Incubaon/ Job placement Vocaonal Outsourcing SME acceleraon (mobile or kiosk) training /BPOs financing Less Investable More Investable

87 Service Providers by Geography

Varthana Medical Credit Fund Samasource Hygeia AllLife Bridge Internaonal Kenya Cash Transfer Samasource

IPPF / APROFA Global: Viana PGH/IPPF UNICEF Bridge Fund Women’s World Banking 88 Hygeia Community Health Plan

Targeng benefits for targeted populaons Geography Nigeria

The HCHP is implemented by PharmAccess with Hygeia Nigeria Structure Hybrid Limited as the local implemenng partner. The benefit package consists of primary care, pregnancy delivery, limited secondary care Investable TBD and medicaon, including HIV/AIDS treatment. The provider network is involved in a connuous quality improvement program. • Hygeia Nigeria Limited has contracted 21 healthcare providers to deliver healthcare to the enrollees • Coverage is $2 annually • Insured closed to 180,000 people insofar • Groups targeted: women’s market associaon in Lagos, farmers cooperave in Kwara, computer retailer associaon in Lagos. • Trying to transion from donor support to full sustainability

89 AllLife

Life insurance benefits for targeted populaons AllLife’s life insurance products target customers carrying HIV in South Africa, offering more affordable coverage for up to Geography South Africa $410,000. With HIV becoming an increasingly livable disease Structure For profit given adherence to ARV regimens, AllLife has decided to e benefit pay outs to adherence to ARV regimens. Investable Yes • Currently raising $14 million • 95% adherence rate • Starng to offer similar products for diabetes paents • Clients average 15% increase in CD4 counts six months aer purchasing insurance • Over 10,000 people covered in this insurance policy

90 Bridge Internaonal Academies

Low-cost for-profit schools in Kenya

Bridge Internaonal Academies provides low cost private Geography Kenya educaon to children in Nairobi. • The academies are “cashless” in that all payments, from Structure For profit tuion payments to school construcon, can be done through mobile phone Investable Yes • They construct the schools using a centralized, low cost design and local contractors. Auding and tracking tools accompanying the construcon efforts • Highly standardized, “Direct Instrucon” curriculum reinforced by SMS data reporng to track individual classes and teachers • Invested in by Omidyar Network • Scaling now – over 60 academies, 16,000 students, more than 1000 employees

91 Viana

Educaon microloans Viana launches student lending markets in countries where they don't exist in order to provide opportunity to a new generaon of skilled and employable young people. Geography Global • Viana loans money to their partner MicroCredit Enterprises for their guarantee pool, who then lends money to local MFIs Structure Non profit • More than 3,000 loans done as part of pilot, worth over $2 Investable Yes million • 99% repayment rate • Aiming for 1 million students loans by 2015 • Currently provides consulng and capital in 12 countries through 21 field partners • Operang across the globe – Ghana, Rwanda, Paraguay and the Philippines • Partnering with MicroCredit Enterprises for debt, $1-2M raise

92 Kenya Cash Transfer for Orphans and Vulnerable Children

Cash grants to extremely marginalized children • The Kenya Cash Transfer for Orphans and Vulnerable Children was a project conducted by the Kenyan Geography Kenya government and funded by UNICEF • Government of Kenya's flagship social protecon program, Structure Non profit reaching 150,000 poor families with OVC age 17 or below Investable No • Households are provided a flat uncondional cash transfer of US$25 per month. The objecve of this study is to assess whether the CT-OVC reduces HIV related behavioral risk among adolescents • Children enrolled on the program were 30% more likely to delay their sexual debut than those who were not enrolled • We find that those aged 11 to 16 at baseline were seven percentage points less likely to engage in sexual acvity four years later • Did not affect condom use

93 Varthana

Financing mechanisms for affordable Geography India private schools in India Structure For profit Varthana aims to support families in India by providing financing to entrepreneurs creang low cost private schools in primarily Tier 2 and Investable Yes Tier 3 cies. The company is based in Bangalore. • The Indian market of students aending locally managed, low cost schools is 80 million students and represents a $12 billion industry • Loans range from USD 5,000 to over USD 50,000 depending on the project and strength of the school and are paid back in monthly installments over 3-5 years • New classroom space, dedicated bathrooms for girls, computer and science labs, benches, desks and new didacc materials are some uses of the financing. • Raising Series A round of $1.3M • Have provided more than 450 loans in 3 cies and a porolio sized over $5

94 PGH IPPF / APROFA

Bridge financing contracepve procurement for a Planned Parenthood affiliate Geography Chile / Global Structure Non profit • Chile’s Asociación Chilena de Protección de la Familia (APROFA) was founded in 1965 as an affiliate of the Internaonal Planned Parenthood Investable Yes Federaon • IPPF supports APROFA by sending the branch $110,000 yearly, delivered in quarterly chunks. This creates a ming issue for APROFA in terms of meeng demand. Also, the smaller quarterly grants reduce volume discounts • They are seeking a loan of $90,000 in advance of their grants for bridge financing • 37% would be spent on condoms, 44% on contracepve implants and 19% on other reproducve health supplies • Longer term, more viable opportunity to support IPPF central facility for all Western Hemisphere members – currently being put together by U.N. Foundaon’s Pledge Guarantee for Health, with USAID’s Development Credit Authority providing a 50% guarantee

95 UNICEF Bridge Fund

Providing Access to Basic Goods and Services to Vulnerable Children Globally Geography Global The UNICEF Bridge Fund is a Revolving Guarantee Bridge Fund providing UNICEF with flexible funding to fast-track procurement of Structure Non profit lifesaving equipment and commodies to some of the worlds most Investable No vulnerable children. • UNICEF is prohibited from securing loans – it must operate solely with cash, or its equivalent • The Bridge Fund offers a soluon to overcome a crical ming gap, by bridging funding to procure commodies unl cash from global funders is received • Lenders provide 1, 3 or 5-year term loans at below market rates (typically, 0-3%) • Fund inially comprised of $10M in net worth grants, $50M PRIs and below-market rate loans, and up to a $50M guarantee • Core impact metrics tracked: Lives saved, cost savings, me savings, stock-out avoided/reduced

www.unicef.org New York, NY 96 Women’s World Banking – ISIS Fund

Global PE for women’s financial services

Women’s World Banking’s ISIS fund is intended to provide financing for microfinance instuons expressly focused on their core constuency Geography Global (MFIs serving 70% women). • Seeking 60m, have raised about 30m from 12 investors Structure For profit • Goal is to invest in 10 to 12 • Targeng MFI’s linking their loans to other products in health Investable Yes insurance, savings for girls ed to their school and financial literacy, housing loans, • Pre-idenfied pipeline inside and out of their 39 member MFI network • Anchor investor is Dutch insurance company with alternave investments arm • Comanaging the fund with Triodos. • Have made two investments so far • Highly successful pilot in Jordan – payouts based on days spent in hospital, 50% of claims for maternal health

97 Samasource

Providing access to microwork to women in developing countries Geography Africa/South Samasource is a nonprofit in San Francisco that works with clients in Asia the United States and United Kingdom to provide digital microwork to people in developing countries Structure Non profit • Over 1000 people have been employed by Samasource in their lile over 3 years of existence Investable Yes • Leverages 16+ intermediaries to provide outsourced computer work to women and youth in India, Kenya and Pakistan, among others • Specific populaon groups can be targeted for the service providers, such as refugees • Impact for the boom of the pyramid is differenated by country – in Kenya, Samasource workers can oen be middle class. In India, workers are much more likely to be poorer and more rural

98 Key Intermediaries: Health Funds & Financial Innovators

99 Developing World Health Funds

Fund Name Geography Thesis Sample Porolio Company Medical Credit Fund Kenya, Tanzania, Financing for health Kakamunga Family Ghana, Nigeria SMEs coupled with Health Center technical assistance Impact Investment India $100M healthcare fund Emerging pipeline: Partners targeng low/middle dialysis clinics, income-relevant B2B reproducve health and B2C companies, clinics, maternal health both devices and clinics services. TBL Mirror Kenya, Uganda, Early-stage VC fund Meridian Medical Tanzania focusing on tech, Centre healthcare, and FMCG in East Africa Oxford Lotus Fund Targeng India, then Focusing on low cost Conversion Sound, moving into other products addressing Polypill Development geographies chronic disease in Company developing countries 100 Developing World Health Funds

Fund Name Geography Descripon Sample Porolio Company Leapfrog Africa/Asia $135M fund targeted towards AllLife Insurance, Apollo Investments insurance products for the poor Insurance

Investment Fund Pan-African IFC, ADB invested SME health fund Hygeia Nigeria, Pyramid for Health in Africa invesng in full healthcare value Pharma, Strategis chain Insurances TLG Mostly SSA Growth capital for consumer Snapper Hill Clinics markets in health, food and IT, with about $20M in holdings. AfricInvest Pan-African Commercial PE firm invesng in LaGray Chemical SMEs in African growth sectors, also has new NBFC to provide debt Aureos Africa Pan-Africa $356M PE fund targeng SMEs Nairobi Women’s Health Fund across value chain; India next Hospital target

101 Impact Investment Partners VC fund focused on healthcare services and Geography India products in India Structure For profit VC Fund • First Fund: India Health Fund. Aim to get at the missing Funders Rothschild middle of SME financing Foundaon, • Finding significant opportunies in distribuon, Impact Assets pharmaceucals, and clinics • IIP also has a philanthropic “impact facility” for porolio companies, offering grants to incenvize socially inclusive and environmentally sustainable strategies • Co-founder Varun Sahni ran Acumen Fund’s Indian operaons and made some well-known health investments • Target fund size: $100m, $5 to 10m cket size; 5-7 year holding period

102 Medical Credit Fund

Public-Private Health Investment Fund Geography Africa The Medical Credit Fund works with local African banks to provide capital for healthcare SMEs. The MCF can reduce banks’ Structure Hybrid risk by partnering with TA providers, who analyze SMEs’ risk and helps with their operaons. The MCF has dispersed 94 loans thus Investable Yes far for a total of $540,000 dispersed. • 162 clinics in system and about 170,000 paents per month • Operaonal in 3 countries: Tanzania, Ghana and Kenya • They are partnered with 3 local banks and 4 technical assistance programs • They receive both private and public funding – the public money goes to technical assistance programs as grants. Private money migates default risk and helps finance the MCF porolio • The average loan ranges from $3,000 to $40,000, depending on growth stage of firm

103 Investment Fund for Health in Africa II PE fund for African Health companies Geography Africa

• $250M fund expecng to return +/- 20% net of fees to LPs Structure For profit VC • Targeng care provision, health insurance, medical producon, Fund medical wholesale and distribuon, and supporng industries Funders AfDB, Pfizer including health related educaon and ICT services, water and sanitaon, food and nutrion and environmental services • IFHA I was a 50 million Euro fund closed in 2010 with investments from the Social Investor Foundaon for Africa, Goldman Sachs, FMO, Pfizer, IFC, AfDb, and APG. • IFHA I has made 7 investments to date and has gross IRR of 33% and has just concluded negoaons for an addional 2 investments which will fully deploy the Fund’s capital • The fund’s managing partners served with major mulnaonals and pharmaceucal companies before heading the PharmAccess Foundaon, one of Africa’s leading NGOs in the healthcare field

104