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Sehati & TeleCTG, offers a different approach through the Telehealth concept to achieve our objective of promoting equal opportunities for healthcare services through technology, knowledge, and people empowerment. 

This initiative starts from a strong desire and passion to participate in improving the quality of Indonesia’s human resources. High-quality human resources play an important role in ensuring a nation’s sovereignty. Currently, Indonesia’s Human Development Index (HDI) dropped, we rank 113 out of 188 countries. From a population of about 262 million, approximately 140 million live without an income of IDR 20.000 (USD 1.50) per day while 19.4 million people suffer from malnutrition (UNDP 2015: Human Development Report). With the knowledge and experiences of more than 12 years in maternal and women’s healthcare, we want to contribute and participate through technology empowerment in the First 1,000 Days of Life. We lay out the ecosystem to facilitate wider promotion and preventive healthcare service delivery through information, education, and people empowerment using technology. We collaborate with regulators, doctors (specialists), for the command center, and develop mothers and midwifery communities empowered by Ibu Sehati and Bidan Sehati Application, as well as telemedicine-based medical device, TeleCTG, to assist in diagnosing fetal wellbeing and distress under one database platform for better Antenatal Care, as well as labor management process tracking and monitoring.

Figure 1 – Flow of TeleCTG.

An archipelago with 16,056 geographically-scattered islands, Indonesia has 5.4 million pregnancies each year (1.7 percent growth per year), Of 4,136 ObGyn, 61 percent reside in Java Island. Such conditions result in limited access to doctors, transportation, and medical devices, while Antenatal Care (ANC) as well as labor management is crucial during the first nine months since this time period shapes the rest of your life. The implementation of the Indonesian National Health Insurance System (BPJS) in 2014 shifts the healthcare delivery game in Indonesia. Aiming for 95 percent coverage by the year 2019, the healthcare delivery is structured into stages and primary care is provided in community healthcare centers (PUSKESMAS) or clinics with midwives and General Practitioners (GP) as the providers. Such conditions put midwives in a focal role since they become the front line for maternal and children’s healthcare. However, the majority of midwives in Indonesia are only equipped with vocational education (diploma degrees) and in many cases, the implementation of BPJS reduces the incomes of midwives.

Having such a big role in the maternal healthcare system, we came up with Bidan Sehati Application to support midwives in performing their work through its features. It assists midwives in providing information to pregnant mothers, recording and monitoring the 40 weeks of pregnancy using three parameters set in the application, detecting fetal distress, and performing labor management through TeleCTG application and e-partograph that are embedded in Bidan Sehati Application. TeleCTG enables midwives to directly consult with ObGyn specialists in the Command Center during fetal wellbeing is monitoring that we hope can assist in the referral to more advanced healthcare facilities and timely performance. As a product of Indonesia, TeleCTG is more affordable, portable, and accessible. The three sensors (toco, fetal heartrate, and movement) are connected to the TeleCTG cube that sends digital data from a smartphone via bluetooth to the application in the Command Center. Compact, TeleCTG is easily operated in remote areas as long as an internet network is present which enables midwives to perform fetal wellbeing monitoring. Also, in Bidan Sehati application, midwives who already have become members of the community have the opportunity to enhance their competency and knowledge through routine online training, as well as improve their wellbeing, financially, through Bidan Sehati programs.

Receiving appropriate medical care during pregnancy and being informed are also responsibilities of pregnant mothers. Ibu Sehati Application, that is connected with Bidan Sehati Application enables pregnancy to be monitored by both mothers and midwives. Bidan Sehati Application can also be operated with limited access by cadres, civilians, who are assigned to assist midwives. These tools are not only applicable for public-owned healthcare facilities, for private-owned hospitals and clinics, Bidan Sehati Application can be operated by nurses or midwives, while the Command Center can be monitored by a hospitals’ doctors.

Figure 2 – How Sehati & TeleCTG play roles in First 1,000 Days of Lives.

With Sehati Application and TeleCTG, we encourage proactive and preventive measures through early detection of a large number of potential complications that can occur during pregnancy that we identify by setting parameters within the application. It also enables the tracking of medicine adherence by mothers. Midwives are able to monitor pregnancies through the completeness of parameter-related data that needs to be filled. As from TeleCTG, promptness in providing CTG interpretation would help to determine in a timely manner fetal distress conditions, thus enabling a referral to a more advanced healthcare facility. Sehati Application and TeleCTG could also assist in enhancing the competency of midwifes through online and offline updates and training, as well as consultation with an ObGyn. 

At the moment, there are a number of applications for mothers and midwives, however they are operated separately, not under one platform and database. The presence of TeleCTG is our solution. We are not only practicing telemedicine through Sehati Application and TeleCTG, but we also empower people -- mothers and midwives through access to information and education. In short, we practice telehealth. The benefit of practicing telemedicine is proven by research conducted from 2007 to 2011 on telemedicine support on maternal and newborn health in remote provinces in Mongolia1. This research concludes that telemedicine is an excellent recourse for providing quality clinical management to women at risk of poor pregnancy outcomes in geographically remote areas and it provides efficient utilization of a network for timely and appropriate care - all which can work to prevent pregnancy-related emergencies. However, telemedicine is only a tool, it cannot replace local health care and only serves as a support and educational mechanism – Successful coordination of all parties is vital for a positive outcome. 

Although we are mostly classified as a social entrepreneur, we do not forget the business aspect of our efforts. We want to be financially independent and self-sufficient and for the program to be rolled out without dependency on donations. We strongly believe that our efforts will do good for many people therefore we want to make it into a sustainable business. The funding for our business comes from revenue that we earn through economic activities in our communities, including the sales of TeleCTG as well as its services (SAS approach). In terms of business scaling, besides the economic-value activities in Ibu Sehati and Bidan Sehati communities and applications, TeleCTG is an Indonesian made medical device, and through President Decree no. 6 / 2016, all government owned healthcare facilities are mandated to use it. Presently, there are around 9,800 community health centers, 2,100 hospitals, not to mention clinics and private practices with approximately 400,000 midwives, that currently use TeleCTG. So, in terms of business scalability, this is a lucrative venture.

Author Bio

Sehati Nusantara is the COO and co-founder of TeleCTG International. Sehati has more than 12 years of experience in the healthcare industry and managing hospitals. Together with her husband, Dr. Ari Waluyo, SpOG, who brings more than 14 years of experience as an ObGyn and lecturer on midwifery experience they are focused on their initiative utilizing business principles while also partnering with tech-savvy millennials.

1“Telemedicine Support on Maternal and Newborn Health to remote Provinces of Mongolia,”2007 -2011, Dr. Tsedmaa B, Global Telehealth Conference 2012

India has the world’s largest number of child brides; it is estimated that one in three girls in the country is married before the legal age of 18. This has a spiraling negative impact on her entire life; she doesn’t complete school, is unaware of her rights, has no negotiation skills, and inevitably becomes a victim of domestic violence. She also likely faces early pregnancy and suffers from consequent health issues. 

Breakthrough, for more than 18 years, has been working to make violence and discrimination against women and girls unacceptable, by changing the deep-rooted cultural norms and practices that perpetuate inequity. The bedrock of Breakthrough’s work is the belief that people can become catalysts of change by changing not only their own mindset and behaviors, but those of the people around them as well. Breakthrough has over the years created many award-winning campaigns that aim to build awareness on these issues and to increase people’s agency to bring about change. It has also used the power of partnerships to bring scale to all its initiatives.

In an innovative collaboration with the Vodafone foundation, Breakthrough sought to start a public dialogue on the issue of early marriage so that people in urban areas could contribute to changing the situation in a simple, seamless manner. In India, getting attention and funding for women’s rights can be difficult, especially on issues like early marriage that urban residents often perceive as “rural” problems, far removed from their world. It was therefore necessary that any campaign created engage urban audiences in a manner that was relevant to them. 

Breakthrough’s collaboration with the Vodafone Foundation leveraged the strengths of both partners viz. technology and a deep understanding of the issue, to create a campaign that resonated with urban audiences across the country. Selfies4School, a high impact, multimedia campaign was launched with a simple ask: “Send us a selfie, and we will send 10 girls to school!”

The campaign used the highly popular mobile trend of taking selfies, as a means to connect with urban youth on the issue of early marriage and girls’ education. By keeping the campaign ask as simple as “send us a selfie,” people felt empowered to bring about change and to encourage their friends and family to do the same. The linkage between keeping girls in school and preventing early marriage was explained in a simple, non-intimidating manner, and people across the world were able to take action on it. 

The one-month campaign’s initial target was to send 25,000 girls to school by receiving 2,500 selfies; but this was quickly revised as the target was met in just 10 days. Overall the campaign was a resounding success, Breakthrough eventually received enough selfies to send 58,000 girls to school and raised over USD 500,000 from Vodafone foundation and other supporters. But what was most heartening was the quality of debate and discussion on the issue across online and offline platforms. An issue that was given little public attention previously, was now brought into the mainstream and discussed as a serious matter that needed people to be involved in and encouraged them to take action. The campaign was also featured in many media stories, and we received extensive editorial coverage on both the issue and the novel initiative, enabling us to multiply our reach and the levels of involvement considerably.

Indian Ocean performance in support of the Selfies4School Campaign.
Photo Credit: Breakthrough

What really drove traction for the campaign was the extensive outreach and quality of engagement both online and offline. On the ground, roadshows and activities were conducted across three cities to spread awareness on the issue, and to encourage people to share their selfies directly. Online, a five-week engagement program was developed to ensure high audience involvement. A short film was made for the campaign that was shared widely on social media, encouraging people to upload their selfies onto the campaign page, after they learned about the series of challenges that girls across India face to stay in school. Online engagement activities were conducted through the campaign and stories of young girls from Breakthrough’s program areas were also shared to give people a better understanding of the issue. In addition, celebrities were roped in to endorse the cause. At the end of five weeks, the results were very extremely positive:

  • More than 20 million people were reached by the campaign;
  • More than 7,000 selfies were shared;
  • Foot traffic at the onsite events (Delhi, Mumbai, Bangalore) was estimated at 250,000;
  • Massive Digital Reach:
    • Facebook: 77.96 million impressions;
    • Facebook campaign reach: 25.64 million;
    • Twitter: 1,000 impressions on average;
    • Campaign engagement rate on website: 6.5 percent; 
      • Celebrity endorsements by film & TV stars; and
  • Concert by leading rock band - Indian Ocean, in support of the issue; and extensive media coverage: the campaign was featured in eight National Dailies, 18 Regional Dailies, 22 Online sites, and 2 National TV Channels 

The campaign enabled Breakthrough to attain widespread awareness and action on the issue of girls’ education and early marriage. Breakthrough has always used popular culture to discuss serious issues impacting women and girls; encouraging people to take action for change in a nonthreatening, positive manner. Breakthrough today directly reaches more than 350,000 adolescents across 14 districts of India, working to empower them and to ensure that girls complete their education and are not married at an early age. Selfies4School in partnership with the Vodafone foundation was a big boost to ensuring that girls in India thrive and realize their full potential. 

About Breakthrough

To know more about Breakthrough’s work in bringing an end to discrimination against women and girls, visit www.inbreakthrough.tv.

Author bio

Yogita Verma heads Resource Mobilization at Breakthrough India

Summary

When Pact, a Washington, D.C.-based global nonprofit founded in 1971, first invested in innovation in fall 2013, we looked to determine whether we could institute a dedicated innovation team to source and win unrestricted funding for concepts from across Pact’s country and project staff. The nuanced and complex nonprofit system required a thoughtful, systems-level approach to achieve this. With critical local staff already prioritized to projects and without local-level organic, enabling environments for testing and experimentation, success for innovation at Pact was a journey that went beyond dollars and awards, targeting and transforming our culture and processes. 

Innovation in the Nonprofit Sector

The notion of a research and development (R&D) or “innovation” team traditionally brings to mind a private sector conglomerate reinvesting millions into market analysis, consumer research, and product development. Competitive markets, demand for profit, and customer acquisition drive private sector companies to invest in R&D teams as best practice. A dedicated, internally funded R&D or innovation team intentionally doing market research, technology investment, or product experiments for competitive advantage is much less common in the nonprofit world, despite a shift in the last 10 years toward incorporating more technology, business acumen, and private sector best practices to achieve social impact.

Multiple factors affect this reality. For instance, by imposing a more rigid program implementation structure, the traditional grant-based business model driving nonprofit operations can inadvertently stymy organic innovation spaces.1 Quick and cost-effective program fixes are favored over experimentation. Additionally, donors’ strong focus on evidence-based solutions can discourage nonprofits from actively pursuing untested ideas.2 Moreover, expenses and investments in the nonprofit realm are heavily constrained and calculated, leaving little room for unrestricted funding for anything beyond program implementation.3

Building a Nonprofit Innovation Practice 

Against this backdrop, Pact hypothesized in 2013 that institutionalizing a team and systematic process for an innovation pipeline could enable us to win grants to fund innovation concepts. After much evolution and nearly five years of learning, the hypothesis has largely held true. But, investment in internal staff and seed funds was not enough; the enabling environment for innovation, capacity building, and dedicated project management resources were equally as important. To succeed, an organic innovation ecosystem needed to permeate throughout the organization. 

Shortly after pursuing the original hypothesis, we realized that we would need to revisit the value proposition. Country offices and staff lacked several key ingredients of an organic innovation ecosystem: time and funds to innovate, space and permission to experiment, and a culture of experimentation. Though there was strong social capital to engage with the innovation team, without these tenets and with local champions tied to other priorities, headquarters-based innovation staff struggled to develop new concepts. 

Because of this we strategically pivoted to focus first on creating enabling environments. We developed a three-pronged approach: build internal enabling environments for innovation stemming from the country offices, create external relationships with new partners to co-create new solutions, and use empathetic, participatory techniques, like human-centered design (HCD), to include end-users in co-creating transformative solutions.

Pact’s innovation-focused staff became an official team, functioning as a customer service unit for Pact’s headquarters and country offices and providing ideation techniques, funding opportunities, and project management support to backstop and guide them. We first began sourcing local innovation through an in-country workshop that allowed country teams to build entrepreneurial, creative skills and mindsets while providing a safe and permissive space to experiment. In the first six workshops, the innovation team trained 90 staff, 88 of whom felt that they could apply what they learned in the workshop. And, Cambodia’s resulting governance and accountability digital app received seed funding from USAID within just three months.

Based on these early successes, the innovation team launched a thematic global innovation competition in spring 2016 to foster creativity and friendly competition among the country offices while offering intentional and resourced space to experiment. Two-thirds of country offices participated in the first year, and the second year’s winning idea burgeoned into a revenue-generating project within six months. The combined success of the workshop format and competition demonstrated that an internal incubator, backstopped with technical assistance and capacity building, would be the strongest possible return on investment, allowing Pact to test a variety of concepts and, most importantly, get them ready for external audiences and sustainable implementation. 

To this end, in July 2017, Pact launched Ignite,4 an internal incubator and seed fund offering up to $20,000 to test ideas. Applications require market analysis, consumer identification, and a value proposition (rather than a theory of change) to nudge internal innovators to think more entrepreneurially. In its first nine months, the incubator received 15 submissions and funded six concepts; one has successfully incubated and been adopted into existing Tanzanian programming.

Pact’s innovation team continues to grow in its capacity and successes. We have won two million dollars in external seed funding from donors such as USAID, Hewlett Packard Enterprises, and World Bank. We continue to receive accolades; for example, Cambodia’s digital app was featured in Forbes5 and the 2017 competition winner for a reusable sanitary pad social venture6 was accepted into ScaleX accelerator cohort 3. Moreover, innovation and HCD became formalized metrics in Pact’s business strategy beginning 2014, demonstrating our comprehensive commitment to innovation.

Lessons Learned 

Pact has stayed true to the principle that innovation must come from country offices to ensure local ownership, efficient implementation, and sustainability. In a conscious effort to avoid “ivory tower” innovation, Pact’s headquarters-based innovation team shares resources and creates partnerships with innovators, but actively seeks to thoughtfully source innovation at its organic entry point in the field. Then, where relevant, we marry external entrepreneurs, innovators, or corporate partners with country offices. As an in-house team, we focus on shifting the entire organization’s culture while sourcing new concepts from the local context that can accelerate social impact.

This cross-section between skill and mindset development coupled with new product and service incubation differentiates what R&D looks like in the social impact sector versus the private sector. Acknowledging that the nonprofit sector is not as agile as other industries forces innovators to ensure that operations within this ecosystem are done with social intelligence, empathy, and thoughtfulness, meeting ideas where they are and providing dedicated funding and services to empower the organization’s intrapreneurs. For Pact, this includes funding a six-person in-house team with cross-sector skills in HCD, gamification, digital development, and social enterprise development. This team’s mandate is developing innovative concepts, managing innovation projects, and connecting new innovations to funding sources.

Initially, Pact hypothesized that we could source concepts for our innovation portfolio that already progressed beyond the seed phase, but this proved false. Pact’s innovation model now centers on making small internal investments in new ideas that are supported by clear hypotheses and market research so that concepts can become ready for an accelerator or angel investor. This approach is critical to success because the traditional proposal-based model does not provide the space, time, or funding for such endeavors. 

With this in mind, scale continues to be challenging, largely because adequate funding opportunities are irregular. Small pots of external seed funding for innovation typically require piecemealing projects, slowing implementation of full projects.7 Additionally, inconsistent access to funds forces the team to backburner concepts until resources can be obtained, while losing internal champions as other priorities compete for staff’s already-constrained time. Pact does make a concerted effort to write incubating innovation concepts into traditional donor-funded proposals, but this is challenging because we need to foremost address donor requirements. And, new innovations are often segmented, causing them to lose their original intent and progress. 

Despite these challenges, the journey was ultimately transformative. Perhaps greater than Pact’s portfolio of successful innovations is the resulting shift in organizational culture toward innovation. In spring 2017, Pact formally announced our transformation toward an ambidextrous organization that continues to implement our core traditional development model while exploring how to comprehensively operate new business models, such as social enterprises. Pact’s cultural shift predicated our transformation, drawing on our learned ability to manage multiple innovation streams to strengthen our core business model (continuous innovation) while exploring new business models (disruptive innovation). 

Now, the entire organization is challenged with incorporating new products, services, and platforms into country portfolios. This has led to greater cross-country collaboration and empowered regional connections and conversations, building critical social capital for incubating concepts and a desire to regionally and globally cross-pollinate those concepts. Despite challenges, we are optimistic that under a transformed Pact, innovation, replication and scale will see unprecedented advancement.

Author Bio

Pact Communications

Michelle Risinger is Director of Innovation at Pact and a founding member of Pact’s innovation team. Risinger focuses on creating enabling environments for innovation and using human-centered design to source solutions with base-of-pyramid end-users.

Works Cited

1 Hilda H. Polanco and John Summers, “Cashflow in the Nonprofit Business Model: A Question of Whats and Whens,” Nonprofit Quarterly (October 2017), nonprofitquarterly.org.

2 Jocelyn Watt, “When Restrictions Apply,” Foundations (blog), March 18, 2015, ssir.org

3 Ann Goggins and Don Howard, “The Nonprofit Starvation Cycle,” Stanford Social Innovation Review 7, no. 4 (Fall 2009), ssir.org

4 See http://www.pactworld.org/innovation/ignite.

5 Joshua Wilwohl, “Want To Complain To Cambodia’s Gov’t? There’s An App for That,” Forbes Asia (blog), February 14, 2016 (11:44 pm), www.forbes.com

6 See www.facebook.com/kozogirls/

7 Watt 2015.

Community demonstration of food basket with nutritious food 
Photo Credit: United Way Mumbai

The Complex Problem of Malnutrition in India 

Of the 57 million malnourished children in India,1 20 percent are under five years of age and suffer from wasting due to acute undernutrition. 43 percent of Indian children under five years of age are underweight and 48 percent (61 million children) are stunted due to chronic undernutrition. It is alarming that India accounts for three out of every 10 stunted children in the world.2

The threat of malnutrition in India is real, rapidly growing, and getting more complex with every passing day. The state of Maharashtra has been in the news due to the severe malnutrition and related deaths in tribal and rural communities. Some of the worst affected communities are in Palghar, Raigad, and Karjat, districts that are barely 100 km to the north of Mumbai, India’s financial capital.   

Malnutrition is a recurrent health crisis which demands interventions that go beyond feeding children. Such interventions are aimed at community management of malnourished children. As is the popular belief, it takes an entire village to bring up a child. Providing nutrition, albeit critical, is part of the solution and not the solution unto itself. A child, healthy or malnourished, requires an enabling environment for growth and development. This environment consists of parents, extended family, neighbors, village members, and public health workers among others.

United Way Mumbai’s fight against malnutrition in tribal and rural communities in Maharashtra works on this belief and has endeavored to empower family members and caregivers to stop the cycle of malnutrition through a community-centric approach. 

Leveraging Existing Community Infrastructure and Resources 

Establishing partnerships with the Integrated Child Development Scheme (ICDS) of the Government of India is the first step in leveraging existing community infrastructure and resources. ICDS is the State’s flagship program with a mandate to deliver health services for children below six, pregnant and lactating women, and adolescent girls. The health services include nutrition, immunization, and early childhood education. These services are offered through an Anganwadi (courtyard shelter) center, by a field worker called the Anganwadi Worker. Typically, a center is available per 1,000 people, thus making it not only the largest free service provider in the world, but also the most accessible one. Such a partnership addresses the dual needs of creation or running of an infrastructure and human resources to cook, store, and distribute the food. 

Identification of Undernourished Children

This includes a scientific method of checking the nutritional status of all children under the age of five in a community by tracking their growth parameters, through anthropometric measurements of age, weight, height, and mid upper arm circumference (MUAC) taken every month. The focus is not only on the severely undernourished (SAM) but also on a preventative approach for those children who are moderately undernourished or are in a borderline state of undernourishment and at risk of falling into the malnutrition trap. More often, for varied reasons, many project interventions target, only severely undernourished children. However, moderate or borderline undernourished children are highly susceptible of becoming SAM and thus the vicious cycle of malnutrition continues. Hence, it is imperative to work with this group of children as well, to prevent incidences of malnutrition. 

Nutritional Supplements

One of the most critical aspects of alleviation of malnutrition is provision of nutritional supplements fortified with micronutrients and protein which are therapeutic in nature. On many occasions, the nature of nutritional supplements is determined without consulting the community itself. This raises three critical questions: 

  • Is the food provided acceptable in the community? More importantly is the food acceptable to children who will eat it? Will they like it? What is the dietary preferences of the family? Answers to these questions will address major issues pertaining to why undernourished children remain the way they are or why parents won’t enroll their children in such a program.  
  • Is it accessible? Are raw materials available in the community itself? Is the community aware of how to cook these food items? Is it something that they have used previously or can cook on their own in future? 
  • Is it affordable? Can parents who are poverty stricken afford the food being provided after the intervention ends? Is the raw material within their reach, economically? 

Answers to these questions can be arrived at by initiating community conversations, including house-to-house interactions. Dietary recall (assessing what the community members eat on a 24-hour basis), and participatory rural appraisals for community mapping of resources are some tools that help to serve this purpose. Based on this, a nutritious meal plan is arrived at which is acceptable, accessible, and affordable for the community being intervened. 

Preventing the Cycle of Malnutrition: Using Cultural Practices in the Community 

Enhancing awareness of mothers, caregivers, and community members on maternal care and nutritional needs of children is essential if under-nutrition is to be reduced and controlled. Cultural context and community platforms for providing these messages and building community support to enable the practice of related behavior needs to be created and where they exist, needs to be strengthened. 

One such platform is Godh Bharai, a ceremony that celebrates the impending motherhood of a woman, similar to a baby shower, to welcome the soon to-be-born baby to the family. Godh Bharai literally means to “fill the lap” with abundance. It is conventionally celebrated in the seventh month of pregnancy, and also marks the event after which a lady departs for her maternal home for the delivery. 

While this is traditionally celebrated at home with a few relatives in attendance, we use this opportunity to celebrate motherhood publicly at the Anganwadi centers. This complements existing traditional practices and rituals, and adds cultural flavor to project intervention, thus making it extremely welcoming among women. Community women are invited for the blessing of the pregnant women by offering flowers, vermilion (sindoor), coconuts, bangles, and more, according to local tradition, while keeping in consideration religious and community sentiments. 

Women in the community at God a Bharai ceremony.
Photo Credit: United Way Mumbai 

This provides an exceptional opportunity to have a conversation around safe birth; establish a plan to act swiftly in case of a medical emergency; and provide information about caring for a healthy baby at birth and complementary feeding, malnutrition, and details of various entitlements available for the woman and her family to make use of (services provided by ICDS). 

A nutritious food basket is available for demonstration purposes to the women. The food basket includes food items procured from the community to show that the nutrition that they and their children need is within reach at minimal or no cost. 

Parents Counselling

Picture this; we are sitting in a remote hamlet in a difficult to access tribal area in the mountains. While talking to a group of women who have gathered at the Anganwadi center, we ask what do they spend most of their money on, daily? One of them hesitatingly points to the only shop in the village, which has grocery items and provisions. We are intrigued and want to know on what and how much? 

Then comes the reply, “Up to Rs. 50 (up to 80-90 cents USD) daily to buy chips and cold drink.” This, in a village where the average household income is around two USD per day.  

A few questions later, we realize, they think that since such food products are costly, they must be good, especially when kids seem to love these items and enjoy them happily, and in contrast are reluctant when tasked with eating homemade food. 

We inform them about the nutritious substitutes for these food that would be welcomed by their children that are within their reach. One such food snack is Chikki, a sweet snack made with ground nuts and jaggery. Children eat this happily because it tastes sweet and parents welcome it because it is cost effective and nutritious. 

A recent study by doctors from the All India Institute of Medical Services (AIIMS), and the Sitaram Bharatiya Hospital, both premier medical institutions in Delhi, India, has shown that almost one-third of children with SAM recover with just nutritional counselling of parents and referrals to the nearest primary health center.3 Parents’ counseling through home-based interventions on aspects related to nutrition, health, hygiene, and medical referrals is vital in providing an enabling environment for the children. Of critical importance is inculcating a culture of safe and hygienic food handling at home and general cleanliness in the local environment. Equipping parents and the caregivers in the family to help in growth monitoring to detect growth anomalies helps in timely medical intervention. Parents are educated in the use of MUAC tap, to assist in detecting health issues in their children. 

Capacity Building of Anganwadi Workers 

Capacity building of Anganwadi Workers or the frontline health workers is a step towards sustainability. The success of most of the malnutrition alleviation programs in India depends on the effectiveness of frontline health workers in empowering communities with improved child care practices through counselling, home visits, as well as effective inter-sectorial service delivery. Hence periodic trainings and exposure to best practices is critical. Motivation of the Anganwadi workers is a key factor in efficient delivery of the ICDS objectives. A few ways this can be achieved is to promote a spirit of healthy competition. The. ‘Swachh Anganwadi’ or Clean Anganwadi competition helps to promote cleanliness and hygiene practices among the workers. Winners get recognized among their peers with prizes such as pet jars, cooking gloves, and other household items that enable them to work efficiently.  

All of these interventions are undertaken in an integrated manner to create an enabling environment for the overall development of undernourished children. Success of such interventions can be demonstrated empirically and gauged by the reduction in number of incidences of malnutrition. It is imperative to keep the community at the center while designing interventions to combat malnutrition.  

About United Way Mumbai 

United Way Mumbai is a non-profit organization, part of the United Way Worldwide movement spread across more than 40 countries and territories and engaged in 1,800 communities. United Way Mumbai (UWM) works closely with a network of more than 400 NGOs and a large number of corporations through their CSR programs, workplace giving campaigns, and other events. This includes the designing of CSR policies and strategies, due diligence of NGO partners, program implementation, employee volunteering, impact assessments, and financial and programmatic reporting. 

Over the past 16 years, we have partnered with more than 300 companies and more than one million individual donors investing close to INR 312 crore (approximately 48 million USD) for community development projects. Our six areas of focus are education, health, income, environment, public safety, and social inclusion; and we work in both urban as well as rural communities. Our endeavor is to address the kinds of problems that are too large or complex for any one agency to solve alone. Our role in the development sector is that of a catalyst that drives social change, and the glue that binds together the many stakeholders needed to create it. Through this collective impact model, we aim to facilitate lasting social impact.

Author bio

Anil Parmar is the Director of Community Investment at United Way Mumbai. Anil has wide-ranging experience in program designing, management, monitoring and evaluation, impact assessment, and reporting. He has a keen interest in demonstrating visible community impact through a multi-stakeholder approach -- including government, NGOs, corporate partners, and community stakeholders. Anil has an MBA in Social Entrepreneurship from NMIMS, Mumbai; is a post graduate from the College of Social Work, Nirmala Niketan, and leads the Community Investment projects team at United Way Mumbai. An avid development professional, he is passionate about implementing and scaling high impact projects and pragmatic public advocacy on health and education issues affecting communities.

Works Cited 

1 The Hindu, www.thehindu.com   
Updated March, 22, 2012 15:31 IST 

2 UNICEF India  unicef.in

3 epaperbeta.timesofindia.com  Jul 14 2017 : The Times of India (Delhi) Rema Nagarajan  

Summary

This essay will explore the funder’s experience in building Acceset and examine the relevance of the lean start-up methodology in relation to Acceset’s challenges in building a company. Acceset is a social enterprise that aims to build bridges to help mental health sufferers accept care and empower them with technology and training to reset the lives of fellow sufferers. 

Article

The best guide for social enterprises solving complex and sensitive problems appears to be the five important questions outlined by Peter Drucker, rather than the lean start-up methodology.

Peter Drucker outlined five important questions for social enterprise. The first question was to determine the mission of the social enterprise and why we do what we do (Drucker, 1993). For Acceset, the purpose of our existence lies in addressing the problem of mental health stigmatization and poor accessibility to professional resources for the sufferers. The mission was instructive as it formed the tenet for formulating our company values, identity, and culture. These inform the types of employees we should hire to gear the company towards success.

The problem of the lack of accessibility to mental health support when one urgently needs it is something the founder, Oon Tian Sern, learned from his own family experience. His mother suffered tremendous stress during the Asian Financial Crisis from work. His Dad was retrenched, and family relations were strained. Without adequate support, his mother became schizophrenic. 

This experience proved instruction in shaping the company mission to ensure that, when successful, no families have to go through what the founder experienced while growing up.

One piece of advice from lean start-up was to get out of the block (outside of one’s comfort zone) and talk to people and customers (through street interviews) about the problem (Ries, 2011). This was not applicable to Acceset’s context as no one was willing to talk about mental health back in 2015 because it was a negatively perceived and stigmatized topic. It is a sentiment that is still prevalent in Singapore today, especially among the youth (Ng, 2018). 

In the absence of willing customers and users, Tian Sern had to subscribe to newsletters and tap into research work done on mental health by academic researchers. Dr. Amelia’s research on mental health trends, and the study of youth, and adult response to adversity, showed that both youth and adults have a strong preference to rely on themselves to solve their own problems (Gulliver, 2010). The preference for self-reliance is the most important and significant barrier to seeking help for both youth and adults (Gulliver, 2010). There was also evidence that perceived positive past experiences, social support, and encouragement, can be helpful to sufferers deciding to reach out for professional help (Gulliver, 2010). 

The company also monitored the latest mental health trends from a news app known as Flipchart, as well as from Google Alerts, a free-to-use content monitoring service.

From studying the news, important insights about how the mental health of youth worsen was gleaned. We learned that social media and smartphone addiction directly contributes to the worsening of mental health concerns among youth. For example, a study conducted by the Mental Health Foundation showed that almost one-third of youngsters believe social media is driving them towards isolation, which causes them to experience anxiety or depression because of loneliness (Jones, 2018). 

We also learned about industries where mental health problems are more prevalent. For example, the creative industries are likely to attract individuals with mental health issues and their long hours make creatives more at risk of developing mental health problems (BBC, 2018).

Analysis of this information helped to crystallize a commercial business model for Acceset. It was clear that there may be commercial value in providing a software-as-a-service to corporations to better manage the health of their employees to lower the insurance premiums they pay. 

We moved on to build the prototype of the tech solution after figuring out the business. According to Ries, a minimum viable product (MVP) should have just enough features to satisfy early customers to provide feedback for future development (Ries, 2011). Often, that translated into advice (in our case) such as tapping into free off-the-shelf tech solutions such as Facebook groups, Telegram, Slack, or Whatsapp groups to see if individuals would really talk about their problems. 

This idea might have worked for most enterprises, but it was awkward to apply this advice to our context, given the stigma surrounding mental health. One cannot be certain whether there may be abuses and whether people are ready to open up over social media. The strength of the advice is that by tapping into existing platforms, the effort required is minimal. However, what is minimal may not always be “viable,” depending on the complexity of the problem being solved.

Our decision was to work with developers that we sourced from meetup groups to provide pro-bono software development for the first version of Acceset’s prototype. We took eight months to build the first version of the anonymous communication system that allowed the sufferer to be matched to two trained volunteers who provided active and indirect support to the sufferer. 

Screengrab of the Acceset app platform showing how one sufferer's utilized the outlet to express their emotions and problems.

With the prototype, Acceset went to roadshows to meet youth, non-profit organizations, and counselors to obtain feedback. It was clear that end users, counselors, and non-profit organizations’ directors had very different views on what they perceived to be valuable about the platform. End users wanted more features that provided instantaneous communication while directors of non-profit organizations cautioned against having more instantaneous features as it may increase the risk of abuse if the end users did not use the feature for its intended purpose. Counselors were concerned about the resources required to cope with the increased demand if the platform was successful and the increased workload for them. 

Upon further discussion, we discovered that the common ground of all stakeholders’ feedback was that they valued an efficient and responsible system that improved the outcome and experience of what they are doing. It was an indirect validation of the inefficiency in the social sector. For mental health sufferers, they may not be matched optimally to the most relevant counselor who has the skills to meet their needs (which had not been expressed). For counselors, a mismatch would mean more administrative work to record case information, transferring the case and information to another organization, and doing research on which other organizations could best be of help to the sufferer. 

There appears to be room to build big data to optimize the match between the needs of sufferers and the skills of organizations or counsellors. Yet, it is challenging to roll out innovation in the social sector because the perception is a misstep can have grave consequences. 

It was our aim to build the big data through trials, where we could collect data and analyze it to build the foundation of the algorithm. We reached out to non-profit organizations and schools to support our efforts. What we learned is that the stakeholders prefer risk mitigation over the merit of the innovation. They are more likely to front-load all possible risks and ask for results and evidence-based research before even considering a trial. For most businesses, the purpose of a trial is to improve the technology but for the organizations I approached, the perception is the trial involves humans who may be vulnerable so to iterate based on their experiences may be unethical. 

It was clear that only government institutions can lead the way in managing the innovation and the building of big data for mental health. It was clear also that research collaboration needs to be put in place so that we can roll out bigger trials in schools. In this regard, the traction for a social enterprise may not be whether the product had revenue or users, but whether there was intellectual property and research done for the solution. Acceset is exploring research projects with the National Council of Social Service, as well as the Institute of Mental Health, to see if a collaboration or partnership can be forged to test-bed the tech product. 

To conclude, lean start-up methodology has its place in the entrepreneur ecosystem. How it is applied may differ across small businesses, tech companies, and social enterprise. Especially for companies that are attempting to build AI and big data for a sector that is traditionally conservative and risk-averse, there is a need to creatively interpret and selectively apply the principles within lean start-up methodology to ensure the growth of the company.

Author bio

Oon Tian Sern is the founder of Acceset. He is also a Queen’s Young Leader award winner from Singapore.

Works Cited

BBC. 2018. BBC. March 23. www.bbc.com.

Drucker, Peter. 1993. Peter Drucker's Five Most Important Questions: Enduring Wisdom for Today's Leaders. John Wiley & Sons.

Gulliver, Amelia. 2010. "Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review." BMC Psychiatry 10:113. doi:doi.org.

Jones, Gareth. 2018. Third Force News: The Voice of Scotland's Third Sector. January 4. thirdforcenews.org.

Ng, Kelly. 2018. ‘Crazy, weird, scary’: Survey unveils negative labels youths associate with mental illness. Singapore, March 11. www.todayonline.com.

Ries, Eric. 2011. The Lean Startup. Crown Publishing Group.

3Fold Model: Wealthy, Resilient, and Responsible Farmers

Building wealth and resilience of smallholders through transformative livelihood solutions.  
Source: Pallavi Saini, www.vrutti.org

1. The Challenge and the Opportunity:

When we talk of creating and sustaining millions of jobs in India, the potential of agriculture as a sector and smallholder farmers as a key constituency cannot be ignored. About 100 million1 smallholder farmers employ themselves on their farms, and provide employment to their own family members and a few other individuals. But, still most are poor. Every rupee invested, and invested effectively in smallholder agriculture and farmers has huge potential to not only make their enterprises thrive, but to potentially reduce poverty substantially. Then, where is the problem?

Smallholder agriculture in its current form is unviable; factors that limit it are virtually countless in number and variety. With the marginal landholding combined with poor soil quality, depleting water tables, and limited access to many inputs and services, it is difficult for small farmers to climb out of poverty with their existing portfolio. Entry into new commodities is fraught with production risk, market risk, and accessibility/cost of capital. The solutions that exist are in silos, including many of the large-scale government programs. The fragmented ecosystem is limiting the scale and sustenance of the support available to smallholders.

2. 3Fold: The Concept and Approach:

3Fold is about building wealthy, resilient, and responsible farmers -- making them successful entrepreneurs, sustained job creators, and increasing their income by 300 percent. It believes in the entrepreneurship orientation and potential of the farmers, and advancing the same to achieve the impact. It addresses the key gaps in the lack of integrated services (end-to-end) which is appropriate for the farmers, the need for diversified options (value add to farm and off-farm), augmented by integrators/activators at field level and technology, and the establishment of a sustainable ecosystem at a Cluster level, that enables collaborative actions for collective impact.

3Fold -- The Concept and Approach
Source: N Raghunathan, www.vrutti.org

The focus of the 3fold model is to enable the farmer to be an independent entrepreneur, by helping them acquire business and operational knowledge, and rebuild hope and trust. There are three parts to this Model:

  1. The journey of the farmer (and their families) in 3Fold starts with building a personal growth plan, followed by business planning for their enterprises, and potential diversification. To start with, it is done at the group level (farmer interest groups/village) and later to every individual farmer. Guided by the plan, customized capacity building, and mentoring support (farm advisory) is provided to every farmer. Accelerated and assured services with an integrated package that is farmer and enterprise focused is facilitated with partnerships (for access to seeds, inputs, agricultural machinery services; financial inclusion and access to capital; and access to markets). Opportunities to develop local entrepreneurs for inputs and services (such as farmers’ seed producers, custom hiring centers, bio-pesticides units, etc.) are exploited. Along with this, many schemes and entitlements from government for smallholder farmers are leveraged (particularly NREGS2, NFSM3, NABARD4, etc.). 
  2. To aggregate products, deal with the markets, and sustain support, farmers’ interest groups, women enterprise groups, and farmer producer organizations are set up and they receive enterprise development support and linkages for undertaking group-based enterprises, produce aggregation for marketing, value addition enterprises, and market engagement. Through these group-based approaches, the scale for running enterprises, complementing skills, and dealing with markets are achieved. Accessing services and inputs at a lower cost and sharing risks enable entrepreneurs to take up these enterprises successfully. Moving towards value addition (processing) and marketing (B2B, B2C, B2G) are facilitated through multiple partnerships.
  3. While farmers and their groups initiate and continue their journey in an entrepreneurship mode, it is important that they are supported continuously (handholding, mentoring, advisory, and capacity building), along with exploring continuously opportunities from markets, the scientific community, and public investments. To enable this (to develop and support farmers and their institutions), Vrutti incubates clusters called Business Acceleration Units (BAUs) to establish a strong ecosystem in the agricultural sector so that farming enterprises in these clusters become sustainable and scalable -- institutions, technology, activators, and collaborators. 


    The Journey of the Farmer in 3Fold: The farmer’s journey with 3fold starts with onboarding where they will be attached to an activator and their support will begin.
    Source: N Raghunathan, www.vrutti.org

  4. Through these BAUs, Vrutti stays committed to enabling and empowering farmers on this journey, by owning the program with two key components of integration and dependencies to reduce risks and prevent minor issues from becoming larger problems. To deepen and accelerate impact, each BAU focuses on three to four key commodity chains (that have suitability to operate in the cluster and have market potential to increase incomes), and ensures that farmers, enterprise groups, and producer institutions move up in those commodity chains to maximize the share of consumer pie for themselves. In each BAU, the coverage starts with 1,250 farmers in the first year, reaching 2,500 farmers by the third year, and then accelerates to reach 10,000 farmers in the sixth year.

Overall, farmers access a bundle of services continuously on a sustained basis that are enabled through scientific methodologies (such as capital, market intelligence, and market linkages, access to seeds and inputs, capacity building, etc.). To achieve higher returns for the farmers, the model takes a commodity focus by working on three predominate commodities in each BAU.

The Impact

3Fold model expects the impacts in the following areas: income, resilience, environment, and institutions. Each BAU’s journey is for 10 years, with the incubation investment period of five years. By the end of five years, the BAU reaches 7,500 farmers (10,000 by year six), and establishes the farmers institutions, enterprises, and partnership appropriately augmented by technology and activators.

Apart from this, the resilience of the farmers improves substantially due to the diversified portfolio, better soil health, and water availability; the environment is improved with better water and soil utilization; and additionally, the farmers’ institutions and enterprises become viable and vibrant and create additional employment in the area. The details of these impacts are given in the picture above.

Given the underlying business model of the BAU and Farmer Producer Organizations (FPOs) becoming viable based on the value generated among the farmers, it is also expected that the value generated at each BAU level will be sufficient to take care of the annual operational and support costs, and in a 10-year timeframe of support, we expect that each BAU will also be able to provide a 10 percent funding return to seed a new BAU.

Proof of Concept

Vrutti has been working on this model and evolving it since 2010-11, in multiple locations with the support of a variety of organizations and its own resources. It started with the original model of covering 250 farmers directly by Vrutti, to a current level of coverage of about 2,500 or 10,000 farmers in each BAU level. In terms of the areas of support, Vrutti has tried out all the possible levers -- better package of practices, better varieties; financial services; commodity marketing, retail, and institutional markets for value added products; linking up with government services; FPO capacity building and financial linkages; insurance services, etc. The model has informed the process and evolved over the period. One of the key gaps that we found was that these services needed to be provided in every BAU location, under every activator so that every farmer gets access to all of these benefits based on their business plan. This is where the current model fits well, augmented by the technology (I Got Crops- developed by Mindtree.org5) and activators.

Works Cited

1 Estimates based on Highlights of Agriculture Census 2010-11 (Approximately 84% of 138 operational holdings comprise of small and marginal holdings) pib.nic.in

2 http://www.nrega.nic.in/

3 https://nfsm.gov.in/

4 https://www.nabard.org

5 I GOT CROPS  - Part of Mindtree.org - Digital Platform for Social Inclusion by  http://mindtree.org/

Scalable Solutions for Clean Water Access in Cambodia

Diagram of a KWSH piped water system

Executive Summary

In rural regions of Cambodia, the majority of households lack access to clean and safe water sources. The use of untreated water puts families at serious risk of contracting dangerous waterborne diseases. Khmer Water Supply Holding (KWSH) works to address this issue by providing clean drinking water directly to households in-need throughout rural and semi-rural regions of Cambodia in a scalable and efficient manner. The company operates a consolidated portfolio of small-scale piped water systems (PWS), which are micro-networks that cover the entire water value chain from source to consumer household. Each individual network consists of a filtration system, ground well and water tower for storage, and underground piping that connects to end user households. The service arrives at a lower cost to consumers than alternative water sources, with significant convenience and improved status. KWSH’s consolidated business model allows the company to implement high operational standards across its PWS, leverage commercial debt, and scale each PWS to reach more households. The company currently owns and operates three piped water stations serving ten thousand households in Cambodia.

Social Issue

Contaminated drinking water is one of the most pressing health-related concerns in Cambodia. Health risks related to substandard drinking water include diarrhea, dysentery, typhoid, cholera, hepatitis, parasites, arsenic poisoning, and malnutrition. In Cambodia, approximately 29 percent of the population lacks access to an improved water source making them vulnerable to contracting waterborne diseases. This percentage increases to an appalling 70 percent in rural areas. 

The existing market of scattered individual piped water operators throughout Cambodia is failing to adequately provide clean water needed, especially in rural areas. Although impact investors, donors, and development agencies have strong interest in supporting the piped water sector, single operators struggle to attract adequate funding needed to improve their operations, due to their small individual size, inadequate capitalization, and lack of proper governance.

KWSH’s Solution

KWSH acquires, standardizes, expands, and operates a portfolio of small-scale piped water systems that distribute affordable and safe drinking water directly to households in rural communities of Cambodia. This model of building a portfolio of piped water systems, allows KWSH to implement best practices across all stations and gain access to additional sources of capital. As a result, the company’s PWSs will benefit from improved operational efficiency and additional capital to purchase and install pipelines to connect more households. Social impact is measured by tracking the number of new households, in rural and semi-rural regions of Cambodia, the company is able to connect to its piped water network. 

Competition & Competitive Advantage

KWSH’s business model is more strategic, in terms of social impact, scalability, and financial returns, when compared to a single water operator model. Extensive data shows the underperformance of existing single PWSs due to weak operations, significant leakage, and the inability to finance expansion of their networks. Sector consolidation through merger and acquisition has proven to allow:

  • Mobilization of commercial funding at the holding company level: KWSH is currently in discussions with several local banks.
  • Access to public subsidies and sector focused subsidized funding: KWSH has received a grant from a Development Finance Institution (DFI) and its program designed to expand the delivery of key infrastructure services.
  • Significant economies of scale: KWSH has developed a system to rapidly and effectively improve single operator’s operations, scale, and output quality.  

In addition to single PWS operators, KWSH also effectively competes with alternative water product/service providers in Cambodia (listed below). 

Consumer preference for sourcing water lies with direct distribution to the household (highlighted above), and within this category PWS remains price competitive amongst treated water sources. From a price perspective, PWS operators compete with ceramic filters and chlorination, however market experience has proven consumers’ unwillingness to pay for these products on a large scale as they are not distributed directly to the households. Additionally, chlorination alters the taste of water making it unappealing to consumers. PuR Sachets and Biosand filters require a smaller upfront investment, however the overall cost/cubic meter is significantly higher for PuR Sachets and Biosand filters are inconveniently time consuming to use. Both of these options are also not conveniently distributed to individual households.

Funding

KWSH will finance its expansion through the use of grants, convertible debt, debt, and equity. The company uses capital raised to acquire piped water stations that present an attractive investment opportunity, demonstrated by its potential to scale its outreach. Funding will also be used to expand the network of KWSH’s existing water stations to reach households in harder-to-reach, rural areas. 

Insitor Seed Fund is a majority owner of KWSH due to its equity investment during the company’s initial capital raise. Insitor’s Investment Director is also a member of KWSH’s Board of Directors.

Expansion Strategy and Scaling Impact

As part of KWSH’s growth strategy, the Company plans to acquire underperforming water stations, implement improved water treatment facilities, expand piped networks, and further consolidate the sector. KWSH currently has the capacity to acquire a new station every six months and will expand its capacity to be able to make acquisitions on a quarterly basis. The company will likely acquire a majority stake of each station, while the existing station operator will hold the remaining ownership stake. The Company will help these newly acquired PWSs expand their capacity by implementing standard operational, financial, and technical policies and disciplines that have been developed at KWSH’s first acquired station. In addition, KWSH plans to continue new household connections at its existing three stations to reach their full potential of serving more than 20,000 households.

Author bio

Karen Moik works as an Analyst on Insitor Management’s investment team in Phnom Penh. Prior to moving to Cambodia in 2016, she worked as an Associate on the Corporate Finance and Capital Markets division at Citizens Financial Group in Boston and New York City. She holds dual bachelor's degrees in Mathematics and Economic Development from the College of the Holy Cross in Massachusetts.

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