The size of your pocketbook determines the length of your life ....

“In India, the size of your pocketbook determines the length of your life” – Nephrologist interviewed in Delhi

Jenny Simonson
 

I know this observation, spoken over a coffee in a New Delhi hospital, likely holds true in many parts of the world, but the disparity in healthcare in India is shocking. I spent my summer as an intern with Baxter Healthcare’s Business Model Innovation group, traveling to India and Indonesia to map the current renal care market. I met with physicians, administrators and dialysis patients to understand how renal care is currently delivered to people with kidney failure – a disease that is growing with the rise in diabetes and hypertension in both countries.

India: What really shocked me were the differences when visiting public and private hospitals. The first hospital I went to in Delhi was a large public institution, and the desperation was palpable. I consider myself fairly well traveled and have seen incredible desperate situations in Central America – particularly in Juarez, Mexico. However, I was almost paralyzed when walking into this public hospital – the dirt, the lines, and the heat scared me. The nephrologist I met with sees up to 100 patients a day; the need is extreme.

In the very same day I traveled to a brand new private hospital in the area where I met with a nephrologist who acknowledged the quote above. Patients waited in chairs in air-conditioned rooms – not on the sidewalks in 117-degree heat as I saw earlier.  The nephrologist in the private hospital understood that his patients could afford a higher quality of care, while the majority in India does not. Current estimates indicate that only about 10% of Indian renal failure patients actually receive treatment.

During my time on the ground, I noticed that India is a country of entrepreneurs. I met with a group of local young college and PhD graduates and all worked at a start up companies The country does not have the same level of government involvement as other large emerging markets, like China. The government institutions really lacked the basic necessities to treat patients most in need. One doctor at a large public hospital in Hyderabad just wanted more hospital beds and a proper way to bring patients into the hospital from stretchers. Standalone clinics, like DaVita clinics in the United States, are growing quite rapidly. These clinics recognize the need to make healthcare more accessible and affordable.

Indonesia: In many ways, Indonesia feels like a completely different world than India. The government just passed universal health coverage in January 2014, so theoretically all citizens will be able to receive care for free or a very low fee (around $1-4/month). However, the infrastructure is not ready to meet the needs of the entire population. Dialysis centers are full in many hospitals, and the only way to get an appointment is to wait until a current patient passes away. I spoke with one patient who cannot get dialysis treatment at his local hospital, so he travels 2 hours each way to a hospital with space. This trip is too costly for him to do the prescribed three times per week, so he only goes in for treatment once a week. His healthcare costs are covered, but he still doesn’t receive optimal treatment.

The challenges in each country are different, but innovative solutions will be required to resolve the challenges in each. Through my primary research, I unveiled a window of opportunity for Baxter to bring new ideas and models to expand care and ultimately treat more people in need. Innovative business models will be critical to improving the current healthcare conditions, and I leave this summer feeling so blessed for the opportunity to use my business skills to help address these issues.

Stories of Change in Rural India – It’s Happening!

I would like to share stories of three rural households that we (I and my teammates at Simpa Networks) visited in summer and how our solar solution made a visible impact in their daily lives.

Ameena Begum (The smart, outspoken family leader)

Customer #1: Ameena Begum (seated on chair) and her kids

Ameena’s husband is a milkman. They are daily wage earners with a small, but steady flow of income along with a small farmland that provides seasonal income from food crops. They have 4 young kids who are enrolled in the village school. Their house has two rooms (brick walls and roof) and an open space split into dining room, kitchen and washroom.

Ameena is a smart outspoken woman who is actively involved with a women empowerment NGO and is the decision-maker in house. She is an informal woman leader in village and is capable of rallying other households if she believes in a cause. For lighting needs, they used kerosene oil lamp at night during dinner. Kids were not able to study at all after dark. Also, they didn't use any fan. Their monthly energy bill was ~4$/month.

When we visited the family, they took keen interest in our solar solution. We explained them the benefits of clean energy and cost economics. They instantly agreed for installation. After couple weeks, we visited them again to understand how they were benefiting from it. Ameena shared that her kids are now able to study at night. She also uses one light as a night bulb. Her kids use fan entire day (10-12 hours), which is a no-brainer given the sweltering 110 F summer heat in UP. Additionally, Ameena is a big supporter of solar energy and actively spreads the word about it in the village. She actually helped us get 3 more customers in her village. Also, she helped us understand psyche of people in her village. She narrated how people in her village are afraid of government instalment schemes (solar energy solutions available on monthly payable instalments that user gets to own after 5-7 years) as they have had incidents of ‘sarkaari log’ (meaning government folks) taking away their belongings and livestock for non-payment of instalments.

Ameena and her kids understanding usage of solar lighting system from our technician

Girija Shankar (Young family bread earner)

Girija Shankar is a young farmer-cum-daily wage earner who supports 6 members, including his parents and family. He is in his early 20’s and has a small 1-acre farm. To boost earnings, he visits Lucknow city once every month for daily wage labor and stays there for 1-2 weeks (Note: Poor people like him stay under bridges or slums in cities to save rental costs and take home maximum earnings). He is the decision maker in house, but is also influenced by Village Pradhan who lives next door to his hut. His house has two rooms, one made of brick and another with thatched roof. His younger brother and uncle live next door in separate houses.

Customer #2: Girija Shankar

Their energy needs were fulfilled by kerosene oil lamp, similar to most poor farmers like him. They use lamp during supper and spend ~4$/month on energy. His story of using solar energy is bit unique. He saw his neighbours (the village Pradhan) use our solar lights and fan for a month, was very impressed by it and came running to us when we visited the village next time. In fact, he was in such dire need for a better energy solution that he started working more hours to afford our solar lighting and fan system. Once installed, his family’s happiness knew no bounds. Now, his parents use a night lamp at night and his wife and son enjoy the fan breeze in daytime (7-8 hours fan use). They also requested for an EVD-DVD player to watch religious CDs and listen to songs.

Girija Shankar's house (two rooms in the enclosure)

Front entrance to his house

Just for comparison, in summers, the temperature inside one of the rooms in his house (see left pic) can go as high as 116 F. We visited his house in July and started sweating in 30 seconds!! Once he got solar powered fan with our system, his wife and son (who usually stay indoors) were overjoyed and greeted us with black plums (‘jaamun’ in Hindi) on our next visit.

RamLakhen (Respected farmer in village)

RamLakhen is a farmer with 4+ acres of land possession. He lives with his wife and 6 kids (5 sons and a daughter). In his mid-30’s, RamLakhen is not much of a speaker and lives simple life. However, his wife is very smart and outspoken home-maker who leads discussions in family and plays an important role in every decision. They have good relations with villagers and everyone in their village respects the family.

Customer # 3: RamLakhen’s wife with kids

Before using solar, they were using kerosene lamp and a portable lead-acid battery that supported mini-led lights. They were already looking for a solar solution when they met us. Hearing the success story of our product from nearby villagers and live demonstration, they agreed for installation. They have a very progressive mindset as they thought of solar energy to help their kids study at night and avoid toxic fumes from kerosene oil. They also wanted to let their neighbors benefit from solar light. However, we couldn't do it as our light wires weren't long enough to go from point A to B in their large house.

They found an ingenious solution to the problem themselves. By erecting a 25 feet pole inside their house, they fixed the solar light at its top and put a plastic cover (supported by a slipper!) to protect it from rain. The pic below demonstrates their ‘jugaad’ solution.

Their own light tower!                                  Close-up view (notice the light protected by slipper/plastic)

Their family now doesn't use the soot-colored kerosene lamp anymore. In his wife’s own words, “Ab humne mitti ka tel istemaal karna chhod diya hai” meaning “Now we have stopped using kerosene oil for good after using your solar powered lights”.

These are among the many success stories that I saw through my journey with Simpa. To sum it up, I am now personally responsible for getting 200+ people out of using dirty kerosene oil. They have now more time to devote to their work and earn more money, their children get to study in daytime/night and their neighbors benefit too from bright lights. There is a significant environmental benefit as well. Collectively, these people have saved 1 ton of CO2 emissions in the last 3 months by quitting dirty kerosene and opting for clean energy.

These people have been living their entire life in sheer darkness. Yet, they took a bold step away from herd mentality to think about their own and family’s future by adopting clean energy. The hard fact is, the villages in which these people live are not known yet to government or local authorities. In web reports and government databases, their villages either don’t exist or are considered electrified. Moreover, we found hundreds of households like Ameena, Girija Shankar and RamLakhen who live in off-grid villages.

 

There could be many reasons why these villages are not reported – poor accessibility, political ignorance by state or weaker sense of community. Nevertheless, the message is clear. There are millions in India who need a better way than toxic kerosene to light up their homes. New government at the helm has recognized their needs and has announced a mission to electrify entire country by 2019. Social enterprises like Simpa, with their innovative business model and passionate entrepreneurs, are working tirelessly in rural areas to complete this mission.

Post and photos by Rahul Tapariya.

Empowering farmers to improve their livelihood

Krishi Star’s mission is "to empower farmers to improve their livelihood". It seems like a daunting task to solve this huge problem and seems too easy to fall into trap, raise the white flag and call it quits. The persistence and courage of Krishi Star to shoulder this responsibility is one that I admired most working in this company and this is clear from the passionate work and dedication from its founders and directors.

To alleviate poor farmers out of poverty, I first tried to understand what role and position farmer holds in the value chain. One of my first tasks is to map out the value chain analysis for the vegetable market in India. Getting credible data and information is a challenging hindrance, as I needed to cross-checked multiple resources to ensure the credibility of the information obtained. Primary research conducted by fellow team members revealed themes: contract farming and hoarding at mandis, which spurred my interest to learn more. By understanding the roles taken by various multinational and local agri companies, I was able to map out my analysis of the vegetable value chain in India.

 Vegetable Value Chain Analysis

Figure 1: Vegetable Value Chain Analysis in India

Figure 1 summarized my findings. Seeds, fertilizers, and pesticides are crucial inputs to farmers by an Input supplier. Farmers then provides labor inputs, plough the land, tender to the vegetables over a duration of time, and doing whatever necessary to ensure good harvesting and healthy produce outputs. Upon harvesting, traditionally, farmers then sell produce to small village traders, who then aggregate, sort, grade, package, and transport to the designate Mandi. Mandis are auction houses that facilitate vegetable trade for a designated geographic area. It is where sale activities and price negotiations of produce takes place. Commission agents, large traders, and wholesalers are primary actors in every Mandi. From here, produce are then sold to wholesalers, retailers, and food processors before reaching the final consumer. As can be seen from the diagram, a certain produce goes through a long chain of actors before reaching the final consumer. Farmers have option to sell directly to retail consumers for a higher margin, but this only exists in small percentage in localized market. A more progressive option is via contract farming,  where farmers can directly sell to food processing companies at an agreeable price and quantity without going through any middle men. In contract farming, farmers are given a guarantee of produce purchase at a certain agreed price. However this alternate guaranteed option is not widespread and still remains a progressive option. And here is to why this is the case.

 
What is Mandi and who governs it?

So just who are the Mandis and who governs it? My analysis took a dive into the controversies clouding Mandi government off late. Mandis are created to prevent produce being sold at throwaway prices at the farm gate to intermediaries. Every state is divided into market areas, which are declared as Mandis. Mandis are governed by the Agricultural Product Market Committee (APMC) and <the government mandated all produce to be sold there>. Some notable problems are:

• APMC committee are too bureaucratic and auctions are not entirely fair
• There are no minimum support prices for fruits and vegetables
• Farmers payment were often delayed
• Market cess money collected from sale transactions were not used for its purpose to improve infrastructure-sorting, grading and storage
• Hoarding by large traders and agents, who buy from farmers at low prices and stored in large hoarding houses

In 2003, the Agricultural Produce Marketing (Development and Regulation) Act was established by the government to address problems above. It contained provision for direct marketing, contract farming, and setting up of marketing in private and cooperative sectors. States are encouraged to adopt the Act into State rules governing its respective Mandis. The new rule also called upon public-private partnership to develop post-harvest handling, cold storage, and packing facilities. It also held the APMC committee liable for paying farmers on the same day, publishing data on arrivals, promoting transparency in pricing systems, and promoting public-private partnerships. Although the government has taken the first step to give farmers more options, state Mandis are slow to integrate the new system. Some states went as far as repealing the new rule. The following news is an example of protests and resistance from traders at Azadpur Mandi in New Delhi. http://www.dailymail.co.uk/indiahome/indianews/article-2551129/Delhi-fruit-veg-sellers-launch-indefinite-strike.html

 

Who takes the most money? Produce price fluctuation

Figure 2: Headlines of Tomato price-hike

Farmers put in their laborious work to use to plant and harvest fruits and vegetables, but are they getting enough returns for the hard work? With the traditional long value chain involving layers of middlemen, farmers earnings are squeezed. There are no shortfall of farmers committing suicide reports because they could not earn enough to pay back their loans. Some lost their lands, their only source of cultivation to money lenders. To further exacerbate the situation, produce price is unpredictable. Just this summer, tomato prices skyrocketed to RS100 per kg due to weather reasons and shortfall. Tomato is not the only crop affected by price fluctuations. Although India is a net exporter of onion, it has to import from Pakistan in 2011 and from both China and Egypt in 2013 due to domestic shortages. Price-hike to Rs60-70 per kg (As comparison, local market in Mumbai sells for Rs20-30 per kg) have also forced government to imposed minimum export price on export of onions to discourage overseas shipments.

 

My research has opened my eyes to the difficult issue the company is working to address. As daunting as the task can be, the progress that Krishi Star is making this summer assured me that the company may someday live up to its dreams to become the "Amul of Vegetables" in India.

 

Note to future interns #3:

1. Be prepared to be flexible with your work plan as the environment in startup can be unpredictable and work can be re-allocated very quickly.
2. Monsoon season is excellent time for mosquitoes to breed, so always have a mosquito repellent handy.

Woman. Black. Strong. Sick.

 

Me and Nunga taking a rest.

Barely an hour into the hike, each step up the steep incline on Mount Mulanje reminded me of the weight of my backpack. Midway up the rocks, the guide, my friend and the porter who carried her pack and I all rested. On this small landing sat three small girls who waited and played with each other’s hair as the woman accompanying them spread out torn cloth to gather the firewood she collected. She climbs up here every week. Not long after we arrived, three young women fiercely and confidently stomped down that same steep incline barefooted. They were carrying large piles of firewood on their heads. Their bodies dripped with sweat and their faces were not pleased. They looked hot, pissed and ready to be done.

Gathering firewood on the mountain.

I turned to the guide and asked why these women collected the firewood given that the terrain was so severe.

“Collecting firewood is seen as a woman’s job. It doesn’t matter if they have to climb the mountain. In fact, sometimes they have to go even further up than this to find dry enough wood.”

Something doesn’t seem right about this picture. The hike I did last weekend for fun is what these women have to do every week, sometimes more, just to support their families. Here I am, with my backpack, sunscreen and bottles of water lamenting about the steepness of a hike I made the choice to do. I couldn’t help but wonder whether those pissed off looking women were pissed off looking at me.

Women coming down the mountain with firewood.

“People don’t understand that women have rights,” commented my workmate who invited me over for supper at her home last night. I asked her what the jobs were assigned to men; she informed me that their only task was to construct the house.

“That’s usually a one time thing, isn’t it?” I asked.

“Yes. One time. And when the man and woman leave the field, the man walks free while the woman carries the wood on her head, the tools in her hands and a baby on her back. When she comes home, she must start preparing the food and the man just sits.”

Our conversation continued on about gender roles in the villages and the challenges in changing cultural mindsets. We discussed the state of women’s rights in Malawi, the level of resistance to change and the impact that Joyce Banda, the recently unseated first female president had on it all. Sadly, because of President Banda’s involvement with the political scandal, Cashgate, my workmate stated firmly that women’s issues have been set back, not forward. The number of women in Parliament after President Banda’s term has decreased.

----------

Mercy, Esnath and Ms. Anakoma, the three women who run the lodge where I’ve been living for the past 6 weeks, have become my surrogate aunts. They criticize my hair, give me unsolicited marriage advice and make fun of my cooking. You know, what aunts are supposed to do. They also ask if I had a good day, make sure I’m eating enough (which according to them I never do), have a warm bucket of water for bathing and advise me to stay away from Malawian men. They look after me. Because of them, Balaka has become a second home.

Ms. Anakoma aka "The Big Boss"

Esnath and Ms. Anakoma found me under the tree last Sunday morning and joined me on the ground. They opened up about their health issues. Recently, Ms. Anakoma has been in the hospital. First, she contracted malaria and now is suffering from a respiratory illness and flared arthritis in her back. Esnath also recently returned from the hospital. She’s had an unknown pain in both of her sides for two weeks. The prescription she showed me was just a generic painkiller. When I asked her what they said was wrong with her, she said they didn’t know.

A few weeks ago, I told them about my upcoming trip to Zambia. “I need a holiday,” I exclaimed. They laughed and asked me a very poignant question—what about us? Neither of them had taken a holiday for well over 5 years. They work at the lodge 7 days a week from 5am-7pm. Ms. Anakoma is always on call as she also lives on the property. She takes care of her granddaughters, two bright-eyed three-year old twin girls, by herself. When she’s not doing work at her house, she’s across the property managing the lodge.

Esnath

Esnath doesn’t live on the property, but she’s also always on call. She manages the money, books the reservations, helps distribute meals, and checks in all the guests. She has two sons, ages 11 and 14. She leaves them in the morning sleeping and comes home at night to them sleeping. She never sees them. I told her that made me sad for her, particularly since she’s been spending so much time with me. She said that her kids are used to not seeing their mom, but the look on her face let me know that she too felt great sadness about the situation. She was recently advised at the hospital to drink 4 liters of water per day. When I asked her yesterday how much water she drank, she said barely 1 liter. I pointed at the kitchen sink and gave Esnath my stern aunty look, a look I’ve been perfecting since I was 13 years old (I have 7 nieces and nephews). She immediately grabbed a cup of water, ran it under the faucet and began to drink. “Jude”, as she always endearing calls me, “I am failing to drink enough water”.

Mercy

Mercy, the cook, is about my age. She single-handedly cooks for every guest at the lodge for every single meal with the dullest knives in history. Some days, it’s just me for breakfast (very peaceful and roomy). Other days, like today, the small dining area is filled with over 40 people. Right after she prepares breakfast, she begins cooking lunch; right after lunch she prepares dinner. Everything is deliciously and laboriously made from scratch so cooking takes ALL DAY. Sometimes she cooks on the stove in the kitchen at the same time she’s cooking on firewood outside. She does this all herself.

It’s no wonder the health of these women is failing.

A few days before our chat under the tree, I was cooking with them in the kitchen, my normal evening routine. On this night, they were having a go at me about not being married and whether I would be able to take care of their sons (which they’ve volunteered “to give me”). When I told them that I wouldn’t be cooking for their sons every day, bowing before I serve them food and allowing them to eat first, they joked on about how American women are lazy and can’t work when they’re pregnant. I laughed with them even though clouding the joke was the rising maternal mortality rates that plague Malawian women (and US women as well) and their own personal health struggles.

It doesn’t matter if you work at a lodge or live in the village; there is an unbalanced and unfair burden put on women in Malawi. Though I prefer to stay away from sweeping generalizations, I would also state that this burden is carried by women of color around the globe. Black women, well, we’re a special case. There’s an assumption that we’re strong and resilient. Not only can we handle the burden, we welcome it.

Herein lies the danger of the “strong black woman” trope. It is a weapon of illness disguised in positivity. “Strong” is not a compliment. It’s a stereotype that allows others to assign black women an unfair load. It justifies the abuse and neglect of black women and creates no room for them to be vulnerable and need help. It’s a stereotype that destroys. Check your newspapers. Check your offices. Check your classrooms. The strong black woman virus is everywhere.

I’ve been a victim of this stereotype countless times. But like the women at the lodge, I am a perpetrator of it as well. The myth of the “strong black woman” is killing us, and at the same time it’s precisely what we cling to for survival.

So what next? Well, that’s the part they don’t teach us in school. Health issues for women of color still remain on the margins. Did you know that a black woman in the United States is four times more likely to die from childbearing than a white woman? Maybe. This is what we call “health disparities,” a platitudinous field of study with which I have no interest. It’s a survey of statistical facts comparing one group to another, telling us information we already know. We already know the barriers to racial health equity; the list hasn’t changed for decades.

But do you know why a black woman continues to die more frequently from childbearing- the deep rooted historical structural factors, cultural articulations, political propagandizing and economic reinforcements that lead to this burden of disease. I’m not talking about the Social Ecological Model, the overused and misunderstood theory that posits that behavior influences and is influenced by interrelated factors, from intrapersonal characteristics to public policy. Though the framework has potential to unleash real change into changing the structural mechanisms that create the disproportionate disease burden put on marginalized people, I’ve only witnessed it fool people into believing they understand something that they don’t. Knowledge is power. The appearance of knowledge is dangerous.

What they do teach us in school is to look for these strong black women (you’ll find this directive coded as “soliciting community champions”). They tell us to find the person in the community who is already overinvolved, overworked and overburdened and ask them to support our own projects and research agendas. But what they don’t teach us is to dig deep into the complexity of marginalized groups. Complexity cannot fit on a PowerPoint slide. Integrated analyses cannot be graded on a rubric. Nuance is not a budget line.

I return to Michigan in less than a month and, for better or for worse, the stories of these women will not fade from my consciousness. As I reenter life in the States and become bombarded with racial and gender prejudice once again, my own “strong black woman” struggles will added to the mix.

Emotional Day

I was completely unaware that I had any family in Ethiopia, but I spent a portion of my day today with my oldest “Relative!” Lucy, the famed three million year old fossil of the earliest discovered Hominid is at The National Museum of Ethiopia. Technically Lucy is kept in an air and light free casing in the basement of the museum and I only saw a replica, but I’m alright with that.

Awestruck....

Lucy is estimated to be 3.2 million years old and was located in the Awash Valley of Ethiopia in 1974. There are a number of incredible artifacts at The National Museum of Ethiopia and the lack of funds to keep them protected as they deserve is quite saddening. Any type of casing is only present to keep people out of reach of the items, not for proper preservation. The relics of Haile Selasse and Menelik are covered with dust and visibly deteriorating far too quickly! I was slightly depressed after leaving the main area of the museum, only to receive a great pick-me-up as I was lucky enough to be there for the last day of the "Rastafari: The Majesty & The Movement" exhibit. I could never receive a good answer as to why, but for whatever reason there were no pictures allowed in the exhibit. Interestingly enough, the "No Pictures" rule at the rastafari exhibit was by far the  most strictly enforced rule I have encountered during my entire stay in Ethiopia... 

Habesha people don't smile in pictures

My "Guide" on this day was Yohana, a beautiful young lady that teaches during the day and works at my guesthouse at night. After the museum I she asked me if I wanted to go to the school where she teaches at, I was in for more than a tour! 

March 8 is located in Bole Sub-City of Addis Ababa, Ethiopia. It is a government-funded school that houses roughly 900 students in Pre-school through 8^th grade.  This day ended up being special, it was the end of the year celebration; this includes a kindergarten “graduation” and the passing out of report cards. The report cards, much like in the United States, are signed by respective teachers, district officials and principals. Lacking computer databases and informational support outside of the school itself,  the report card must be produced in order to proceed to the next grade. Since classes are not homogenous in age (they have a crazy idea that students should progress with their abilities, not arbitrarily based on birthday...) the need for physical proof of grade completion holds increased importance. When I was told I would get to hand out the report cards to her class of fourth grade students and their parents I was quite excited... but then...

Kindergarten, or "KG" graduation!

A difference between our system and theirs soon revealed itself. A report card at March 8 actually costs families 150birr (just over $7) to receive. That day in a fourth grade class of 38 students, three families were able to produce what is visually a prohibitive cost in order to receive their child’s ticket to scholastic progression.

The reason for this cost, as with many others, i.e. uniforms, materials, Xeroxed copies of lesson books that are handed down to the point of tatters (only to receive a possible fine for poor condition upon return) is due to trying to make ends meet without sufficient government funding.

The plot again thickened when I found out that in a school of roughly 900 there are around 40 "High need" students that are identified by the staff. The staff then writes fundraising or “sponsorship” letters to local eateries in the attempts to subsidize the cost of food for those in need. The teachers pool their money together in order to provide breakfast and lunch. The combined cost on a daily basis for these students is 15birr. I wish to stress that I use the term “high need” here relative to a student’s peer group. Simply put, these are students that cannot obtain food. There isn’t a cafeteria at March 8 and that may actually make it easier to identify those that do not show up with anything on a daily basis. However, these aren’t the only students that have trouble providing nutrition for themselves, these are the most-vulnerable of a population that is by all metrics, impoverished. Without the personal assistance of teachers who themselves make roughly $110 a month, these children would starve.  

On a much, much lighter note; we decided to make some coffee upon return to the guesthouse and for the first time, I TOOK THE REINS! 

Working the Jebina