Democratizing Ultrasound Imaging across Africa

Obstetric ultrasounds are not widely available in Kenyan primary health facilities. Consequently, most pregnant women are referred to large national hospitals, requiring travel and financial resources to access. Acute shortage of trained sonographers further lowers patient retention where equipment does exist. The result: fewer than 1 in 5 Kenyan women attend an obstetric ultrasound, with equally low rates among high-risk groups.

At Ilara we focus on diagnostics. Through our partnership with Butterfly Network, we work to increase access to ultrasound imaging across peri-urban Kenya. We build innovative financing models to make the Butterfly iQ handheld device affordable to small primary care clinics and leverage its telemedicine capabilities to remotely link local clinicians to specialized sonographers. Through this linkage, we increase access to and uptake of life-saving obstetric ultrasounds at the primary care level. At scale, we could improve maternal and neonatal health outcomes across communities where specialist access remains limited. 

Inadequate access to diagnostics disproportionately affects women in places like Kenya where rates of early pregnancy are high. Sub-Saharan Africa accounts for two-thirds of all preventable maternal deaths. In the first trimester, most deaths are due to ectopic pregnancies, natural abortions or gestational trophoblastic diseases, conditions that elsewhere are mitigated early with ultrasounds. Traditionally, ultrasound machines have been expensive and bulky, and have required trained sonographers for accurate readings. As a result, essential imaging equipment has had low penetration in under-developed markets, where these resources have been unattainable. In Kenya, maternal mortality has remained stubbornly high, with 342 maternal deaths for every 100,000 live births in the country. These rates become even more acute in rural and peri-urban areas where antenatal care (ANC) attendance drops precipitously, and obstetric ultrasounds become inaccessible. In 2019, facilities across Kisumu County, western Kenya, saw 595 maternal deaths for every 100,000 live births. Providers in peri-urban locations suffer from low availability of trained sonographers, which inhibits their ability to sustainably provide imaging services, and results in high patient leakage from referrals. To reduce the high maternal morbidity and mortality, it is essential that all women access essential obstetric ultrasound services with trained specialists at ANC. 

We seek to deploy the Butterfly iQ, a cutting-edge, newly-developed, handheld ultrasound device, to areas where imaging services are currently unavailable. At Ilara, we improve asset affordability for our providers by offering flexible asset financing packages so small facilities can access ground-breaking technological advancements at low up-front cost. This revolutionary probe provides 80% of the functionality of a traditional machine at 25% cost, and seamlessly connects to a smartphone. It is the world’s first single-probe whole-body ultrasound device, powered by a semiconductor chip, and can be used in areas with intermittent power supply. This device has in-built telemedicine features, and can remotely connect healthcare practitioners to patients from anywhere in the world through the iQ app. In addition to connecting small facilities to remote specialists, we pair the device with several demand generation and patient retention tools to engage patients to increase awareness of new ultrasound services at the primary care facilities. We run medical camps, push SMS reminders to patients, and engage in health awareness campaigns to improve uptake of obstetric ultrasound services at our sites. Through these mechanisms we aim to maximize asset utilization as it is directly related to the quality of ANC care pregnant women receive. 

Our customers are peri-urban healthcare providers. Across Kenya and similar African markets, they serve over 70% of patients seeking care. They operate in areas suffering from weak access to urban centers and whose residents make $100-$400 a month. These areas have a high concentration of medical facilities but sub-optimal care quality, with limited clinical and diagnostic support. With the right tools, these facilities can bolster the entire healthcare system and play a critical role as the first, and often only, health access point. Strengthening existing primary care will enable millions of individuals to access appropriate care and timely treatment locally. Our research period, which involved 1300 small and mid-sized medical facilities, demonstrated that providers feel unable to meet their patients’ diagnostic needs as they don’t have access to the right tools, technology, and specialized skills. We are working with them to understand how telemedicine and affordable pricing models for new diagnostic technologies can help bridge this need and have jointly piloted this solution in our existing peri-urban facilities. These discussions have encouraged us to scale this product suite to more remote communities to reach millions of Kenyans, and later East Africans, who currently can’t access advanced ANC screenings. 

The Challenge is seeking technology-based solutions that promote maternal and newborn health. It requests solutions to expand access to high-quality care, improve service delivery and diagnostics, and lower barriers to seeking care. Our solution tackles all three dimensions by (1) scaling obstetric ultrasounds services to pregnant women, currently accessed by only 20% of the population; (2) bringing cutting-edge, affordable new devices to small primary care facilities and linking them to remote specialists for reliable sonographer access and improved care delivery; (3) decentralizing imaging services so women are not required to travel to referral hospitals to access basic ANC care.

We leverage the exponential developments in smartphone medicine to bridge the diagnostic gap across peri-urban markets, and bundle these devices with smart financing packages to tackle the two fundamental issues hindering higher uptake of imaging services: high specialization needed to operate legacy equipment and significant upfront capital costs needed to purchase such tools. Our telemedicine-enabled ultrasound devices allow for non-specialized clinicians to pair with trained sonographers to deliver imaging services, and our flexible monthly payments minimize the financial burden placed on these small providers. Moreover, this model allows for these services to exist locally, mitigating patients’ need to travel long distances. Our solution brings advanced ultrasonography to these patients’ communities, so pregnant mothers can enjoy improved maternal health outcomes at home.

Unlike our competitors, we power existing healthcare facilities in any location, and do not focus on building new expensive clinics or laboratories in single centralized hubs; we focus on bringing new technologies to those who need them most, and do not solely focus on rapid tests. Moreover, we are incorporating the fast-paced developments in telemedicine to fill the unmet need for imaging specialists in peri-urban clinics to expand the use of ultrasounds for key target populations, a strategy not pursued by any of our competitors. This makes our solution unique in that we will provide reliable ultrasound services even where sonographers and radiology specialists are absent. 

At Ilara, we identify key new technologies that will alleviate diagnostic gaps in peri-urban markets, source them, and provide flexible forms of financing to local providers to make these new technologies affordable. Our unique model works to guarantee patients in peri-urban locations can access life-saving tests and screenings. We focus on tech-enabled devices built on new deep technologies to make diagnostic delivery easy and affordable at the point of care.

Additionally, we link facilities with remote specialists through the Butterfly iQ’s telemedicine functionality to make sure readings are accurate and reliable. The integrated platform enables specialist control of the device so a trained sonographer can remotely adjust the image to gain depth and capture images and videos. Thus, any local facility staff can conduct scans on pregnant women with assisted readings from specialists located around the world. The device is compatible with most smartphone devices and the platform runs on a Chrome web browser for the trained remote specialist.

Lastly, we are developing a closed-loop patient management and patient engagement system. This vertically integrated system will collect diagnostic data from the Butterfly iQ and stores this data securely in a healthcare DB store (FHIR/DICOM). This data will then securely be communicated to the patient and maintained for continued care, allowing facilities to build patient profiles for the first time. The patient engagement aspects of the platform will include health tips, patient reminders, and chronic care management tools that will be communicated directly to facility patients. 

The technology behind the Butterfly iQ

If we deliver affordable, telemedicine-enabled, obstetric ultrasounds linked to remote sonographers via local primary healthcare providers, we can enable pregnant mothers to access essential ANC imaging services in order to identify risks of pregnancy-related complications early and improve maternal health outcomes.

We spoke with healthcare providers in 2019 to understand pain points in providing care to their communities. They voiced that most women missed critical ANC visits due to lack of key services such as obstetric ultrasounds which led to high patient leakage. Facilities also indicated that they did not have the financial resources or technical skills to provide these services to pregnant women seeking ANC care at their facilities. These realities were backed by researchers in western Kenya who showed that wealthy women had 2x higher odds of receiving ultrasounds when compared to poor women, even across high-risk groups. Thus for women living outside of urban centers, the acute risk of pregnancy complications and resulting morbidity and mortality persists.  Additionally, a study by Cherniak et al shows how demand generation techniques (such as those used by Ilara Health) can significantly increase patient volumes. Demand generation led to a 6x increase in patients visiting clinics in Uganda to receive ultrasound scans, shifting health seeking behavior to promote life-saving screenings that were previously undervalued.

Our logical framework is outlined below:

Activities/Inputs: We provide affordable, telemedicine-enabled, ultrasound devices to local small peri-urban primary care providers, combined with flexible financing, and linked to remote specialists for accurate obstetric scans during pregnancy.  

Outputs: New local primary care facilities are recruited. Pregnant women receive obstetric ultrasounds at ANC supported by local staff and remote specialists. This increases patient trust of telemedicine services as their local providers are integrated into their care.

Outcomes: Maternal and neonatal complications are identified and patients are able to receive appropriate treatment more quickly. Clinics see an increase in patient numbers. 

Impact: Identification of pregnancy-related complications leads to improvements in maternal health outcomes and decreases rates of maternal morbidity and mortality and improves infant health outcomes. 

Since 2019 Ilara Health has worked with 70+ Kenyan clinics, and reached 1000 people. By 2021 we anticipate being in 500 clinics and reaching 8000 patients, across 2-3 East African markets. By 2025 we see ourselves in 10,000 clinics and supporting 12 million patients, across peri-urban sub-Saharan Africa. The health facility ecosystem in sub-Saharan Africa includes over 500,000 similar small primary care providers.  

We plan to target markets where obstetric ultrasounds and key diagnostics are currently unaffordable or inaccessible to patients, making all underdeveloped markets needing tools for better quality care potential targets for our products. By Q4 2020 we are targeting 500 Kenyan facilities, and 5 key priority health areas. By Q4 2022 we plan to expand our services to 2,000 similar healthcare outlets in Uganda and Ethiopia serving an average of 10,000 patients annually. 

By 2025, we see Ilara Health as a pan-continental, decentralized diagnostics network present across 10,000 medical clinics and pharmacies, in Kenya, Uganda, Nigeria, Tanzania and Ethiopia. Our network will support thousands of pregnant mothers and provide ANC services. As a company we plan to roll-out smart devices to tackle a wide range of diseases, from ophthalmology to oncology, reaching 12 million patients annually. It is estimated that over 500 million sub-Saharan Africans are currently struggling to access even a basic blood test but have existing primary care infrastructure in place. By strengthening primary care delivery through this health facility ecosystem we could provide services that already translate to a $1b market.

Cultural: (1) Ultrasounds are undervalued and (2) knowledge about pregnancy-related complications is low. We will need to shift customer perception of obstetric ultrasound utility and importance to promote user uptake. (3) Telemedicine has not existed within the healthcare delivery space, reducing trust in specialist recommendations and guidance. 

Technical: (1) We intend for the underlying tech platform to be GDPR compliant and will require expertise on staff to ensure our platform is fully secure. (2) We will need to train clinical officers on basic sonography sweeping techniques.

Financial: (1) Many of the clinics we work with have low cash flow hindering device roll-out. (2)Further funding required to cover the technology platform development cost.

Logistical: Decentralized projects require extensive logistics to reach far-out customers and clinics. This makes scaling a challenge for full market saturation. 

Cultural: (1) For patients we intend to roll-out health campaigns regarding the importance of ANC visits and obstetric ultrasounds and use healthcare providers as trusted educators for knowledge transfer of their importance. (2) To improve trust in telemedicine services we plan to conduct focused trainings with our local health providers to ensure they are very comfortable with the Butterfly iQ technology. We believe if they act as the trusted clinician and health expert, patients will believe the telemedicine-enabled remote readings and guided scans.

Technical: We are developing clinic-centered training courses and user manuals for easy support and reference. We will also have technical support lines available for facilities using our devices.

Financial: Our subscription payment model will allow clinics to make a small payment each month. We are also looking for grant funding to subsidize some of the device costs so we can reach a larger catchment of primary care clinics. This funding will also help offset some of the technology development cost for the close-looped patient management and engagement platform.

Logistical: We are seeking scaling partners to help attract primary care facilities and accelerate roll-out of devices. Often these serve as the central “hub” to access large numbers of decentralized facilities at once. 

Full Time: 38

Part Time: 5

Ilara Health was founded by entrepreneurs and investors passionate about our mission with multidisciplinary skills in medicine, distribution, software and sales. Key profiles below: 

Emilian Popa Co-Founder/CEO Emilian is a hands-on company builder, investor and entrepreneur. He was an investment professional with DiGAME (Digital Growth Africa), an Africa focused subsidiary of Zouk Capital, which makes growth-stage equity investments in technology-enabled companies across the continent. Emilian has over 9 years’ experience of successfully launching, fundraising, growing, exiting more than 20 technology ventures. Emilian has 7 years of experience with leading consulting firms in Europe, USA and Africa. He holds a joint MBA from Columbia Business School and London Business School. 

Maximilian Mancini Head of Strategy Maximilian has an extensive finance and healthcare background, having spent 3 years at Lazard as a healthcare M&A banker. Prior to that, he graduated from Columbia with a BA in Economics and a concentration in Philosophy, having also spent 1 year studying at St. Peter’s College, Oxford University.

Sameer Farooqi VP Operations Sameer started his career in financial services, working with SNL Financial for 3 years. He later joined Careem and handled various functions including growth, operations, and performance/incentive design. He then expanded the logistics infrastructure for Daraz where he built 14 logistics hubs and a team of 200 people in 5 months. He then moved to a role where he managed the marketplace for Daraz in its five countries. He holds an analytics-focused MBA from the University of Iowa.

Ilara Health has partnerships with the following stakeholders: 

Healthcare Providers: We are already partnered with 70+ healthcare providers in Kenya. These clinics have implemented Ilara Health’s existing diagnostics suite including the Butterfly iQ point-of-care ultrasound device. 

Public Sector: We are engaged with the Kenyan public sector for regulatory support for our new devices. While the public and private sectors in Kenya operate separately, we believe public sector backing could also facilitate roll-out in small primary care facilities across the country.

Scaling Partners: We have partnered with KMET SACCO, a large existing network of clinics and pharmacies (~350 facilities) for accelerated scaling.

Device Partners: We are partnered with many innovative device manufacturers like the Butterfly Network.

Research: We’ve partnered with Columbia University in New York for research support on how accurate diagnostics impact healthcare in East Africa.

Education: We’ve partnered with St George’s, University of London and FutureLearn to develop an online, free COVID-19 preparedness course geared towards the primary care provider in Africa. We hope to use this approach for clinic-focused targeted learnings in the future. 

We think of our business as a service model that can be covered in 3 key steps:

• We source medical devices from third party manufacturers. Our devices are digital and possess different forms of connectivity. Through the relationships we are building with these device manufacturers, we are able to integrate these devices into the tech platform we are building through API access

• The second step is to place these devices at the clinic and pharmacy level, expanding our network and increasing our patient reach. What we do is essentially enable medical facilities to have complete access to these devices whilst paying monthly subscription fees for 24-36 months depending on the device. At the end of these contracts, we either replace or upgrade the device, allowing our customers to be at the forefront of the diagnostic technology evolution. We also give our customers the option to purchase, at a small fee, the relevant device at the end of the contract.

• Our final step is what we call closing the patient loop. The data generated by our devices feeds into our platform, generating a patient EMR. We then use this data to provide our patients with disease management tools, including tips and reminders and referral systems. When additional medical support is needed, we use this platform to send our patients back to an Ilara facility.

Our main revenue comes from cash flows generated by the various point of care (PoC) devices we provide to our partner facilities on 6-24 month subscription agreements with monthly fees. Devices that do not require consumables (like the Butterfly iQ), are offered on a 24-month, 12-month, or a 6-month plan (depending on how much the facility can afford to pay upfront).  Devices that require consumables (like Pixotest) are placed free with a minimum commitment of the number of test strips to be purchased each month, for 6,12, or 24 months (depending on the volume of tests).

We also employ semi-distributed centralized labs to address the need for diagnostic services that cannot be offered within small facilities at the point of care. The lab acts as a hub for multiple small facilities (the spokes). As a capex heavy model, we require asset financing support to fund our working capital cycle and purchase diagnostics assets to  reach about 200 small facilities to operationally break even by Q3 2020. Future growth can then be a function of additional financing raises and positive cash flow generated by the underlying operations.

We believe Solve’s mission to promote the health of pregnant women and newborns directly aligns with what we are seeking to achieve. To this end we seek help from Solve to help overcome the following barriers:

Scaling, Partnerships, and Regulatory Support: We are looking for experts and potential partners in our target markets who can support and guide us through new market entry, local partnerships, and the regulatory landscape as we scale. As we move into more rural areas, we are looking for partners who can support us in building out a distribution model that will work for the last mile. We are also looking for other health companies build our network of health stakeholder partners on a global level. 

Software Development: We are seeking support in developing our tech platform and associated software solutions. As we intend to move into remote care and automated care, we are seeking further technical support in making sure our solutions work seamlessly and ensure patient trust. 

Grant Funding: We’re also looking for in-kind contributions that will allow us to subsidize the Butterfly iQs so small facilities can access these devices at lower up-front costs.

Training: We are finally seeking support to operationalize our telemedicine strategy, building a network of remote sonographers and implement training programs geared towards facilitating clinical officer uptake of basic sonography.

We are seeking new partners at the forefront of medical technology who are looking to equip clinics in Sub-Saharan Africa with tools that will dramatically change the level of care they are able to offer. We are seeking advice in building out a distribution approach that will suit clinics in more rural areas. 

We would be interested to be connected with other Solvers in Sub-Saharan Africa working in health: 

E-Heza: We see E-Heza as a potential partner as we move into Rwanda and other markets. Their approach to managing electronic health records forms a starting point from which we could connect our suite of tools, including those that can be equipped for maternal health e.g. the Butterlfy IQ ultrasound. 

Lifebank: Lifebank is the connection between facilities and life-saving products (blood and oxygen) and vaccines. We see the organization as a great partner to connect our facilities with on-demand blood and oxygen. 

We would be interest to partner with several Solve members including:

Novartis Foundation: The Novartis Foundation vision to support the healthcare needs of low-income individuals in Sub-Saharan Africa with a tech-based approach aligns directly with our vision. We serve low income individuals with tech-based diagnostic solutions. This would be an ideal angle to partner with Novartis Foundation to bring our service offering to their focus countries in SSA, and pilot new diagnostic tools for NCDs.  

The Intuitive Foundation: The Intuitive Foundation is active in technology research for the purpose of promoting health. As we build out our tech platform as a tool to manage health remotely and drive healthcare seeking behaviours, we would be interested to pilot a few approaches with the Intuitive Foundation. 

The Innovation for Women Prize seeks solutions to improve the quality of life for women and girls. Our solution improves women and girls' health by targeting the quality of healthcare pregnant women receive and, in turn, reducing maternal mortality and morbidity. Our solution works to tackle downstream factors to allow women and girls to live more fulfilling lives. Girls equity, economic opportunities, and self-agency are intrisically linked to our solution. Good health is a cornerstone to productivity, with poor health often resulting in lost work output. Additionally, through early detection via ultrasounds and referrals girls can have more agency and informed decision-making about their sexual and reproductive health. Thus we believe that promoting affordable, telemedicine-enabled, obstetric ultrasounds so all women in peri-urban locations can access them easily at their local primary care facility, is key to supporting an equitable and empowered life for women, and to reducing the maternal and infant mortality across the continent. 

With support from this Prize, we can subsidize equipment for 20 peri-urban health facilities so they can access the tools they need to reliably offer obstetric ultrasound services. This will include the purchase of the Butterfly iQ devices, an iOS smartphone or tablet, a secure anti-theft stand, and a monthly data package for each facility. Funding will also go to staffing a remote sonographer hub, where trained specialists will remotely control and read images. In the next 5 years, we intend to equip 10,000 clinics across peri-urban sub-Saharan African to increase access to quality healthcare.

The Health Workforce Innovation Prize is directly aligned with our mission to improve the quality of healthcare pregnant women receive in low-income settings. We increase health worker capacity by training them on essential ANC diagnostics, including obstetric imaging, to expand the breadth and quality of services they offer and, in turn, mitigate preventable deaths in settings where maternal mortality is stubbornly high. We equip providers with affordable ultrasound devices and provide remote sonographer access via telemedicine to facilities that otherwise can‚Äôt access specialist services. Through our tools, trainings, and referral pathways we work to strengthen maternal and primary care services and mitigate pregnancy complications early. 

With support from this prize, we can subsidize equipment for 10 peri-urban health facilities, so they can access the tools needed to reliably offer obstetric ultrasound services. This will include the purchase of the Butterfly iQ devices, an iOS smartphone or tablet, a secure anti-theft stand, and a monthly data package for each facility. Funding will also go to staffing a remote sonographer hub, where trained specialists will remotely control and read images. In the next 5 years, we intend to equip 10,000 clinics across peri-urban sub-Saharan African to increase access to quality healthcare.

The AI for Humanity Prize seeks solutions to improve the lives of individuals through strong data science and machine learning. Our solution seeks to improve healthcare quality in remote locations in order to reduce maternal mortality and morbidity. While we don’t currently use data science tools, we see huge potential to harness the critical health data our services generate to provide smarter resources to our providers for improved clinical decision-making. We believe that once we capture large volumes of data, including obstetric ultrasound scans and vital ANC information through our automated care and remote consultation programs, we can build actionable interventions to improve maternal health outcomes locally and nationally. These data will generate maternal health insights that allow us to bolster the health guidance pregnant mothers receive. At scale, we can develop impactful maternal health programs, make predictions on potential adverse health outcomes, and correlate a diversity of imaging and ANC data with contextual data points from our remote care and automated care platforms. These data-driven tools could be game-changing -- in Kenya maternal mortality has remained stubbornly high even while HIV and malaria mortality have steeply declined. New data driven solutions are desperately needed to avert these preventable deaths.

The Bill and Melinda Gates Foundation Funded Award seeks solutions to improve maternal and newborn health in low- and middle-income countries. Our solution directly aligns with this challenge by targeting the quality of healthcare pregnant women receive and, in turn, reducing maternal mortality and morbidity. Our solution works to tackle downstream factors to allow women and girls to live more fulfilling lives. Girls equity, economic opportunities, and self-agency are intrinsically linked to our solution. Good health is a cornerstone to productivity, with poor health often resulting in lost work output. Additionally, through early detection via ultrasounds and referrals girls can have more agency and informed decision-making about their sexual and reproductive health. Thus we believe that promoting affordable, telemedicine-enabled, obstetric ultrasounds so all women in peri-urban locations can access them easily at their local primary care facility, is key to supporting an equitable and empowered life for women, and to reducing the maternal and infant mortality across the continent. 

With support from this Prize, we can subsidize equipment for 30 peri-urban health facilities so they can access the tools they need to reliably offer obstetric ultrasound services. This will include the purchase of the Butterfly iQ devices, an iOS smartphone or tablet, a secure anti-theft stand, and a monthly data package for each facility. Funding will also go to staffing a remote sonographer hub, where trained specialists will remotely control and read images. In the next 5 years, we intend to equip 10,000 clinics across peri-urban sub-Saharan African to increase access to quality healthcare.

We believe that Ilara Health is an excellent fit for the Future Planet Capital Prize due to our solution’s vast potential to impact millions of lives in Sub-Saharan Africa. SSA accounts for 2/3 of all preventable maternal deaths. In the first trimester, most deaths are due to ectopic pregnancies, abortions or gestational trophoblastic diseases, conditions that elsewhere are mitigated early with an ultrasound. However, primary healthcare facilities in peri-urban Africa simply don’t have access to the imaging equipment and diagnostic tests their patients need. In response, we’ve equipped facilities with the ButterflyIQ portable ultrasound so women can access their scans early to avoid complications.

With support from this prize, we can subsidize equipment for 80 peri-urban health facilities, so they can access the tools needed to reliably offer ANC and obstetric ultrasound services. This will include the purchase of the Butterfly iQ devices, an iOS smartphone or tablet, a secure anti-theft stand, and a monthly data package for each facility. Funding will also go to staffing a remote sonographer hub, where trained specialists will remotely control and read images. In the next 5 years, we intend to scale across 10,000 clinics across peri-urban sub-Saharan African, reaching ~5 million pregnant women.