reach52: Making healthcare go further

I’m Edward Booty, the founder and CEO of reach52, a Singapore-headquartered social enterprise looking to deliver health for all.  I’m a passionate believer in rewriting the rulebook on shared value to create health access – creating innovative new healthcare delivery models, powered by public and private partnerships, allowing those in-need to access essential health services.

Prior to reach52, I worked in access-to-medicines for Novartis in India; led the digital health consulting practice of Capgemini in the UK; followed by a  stint with the Department of Health strategy in the UK, looking at new care models for diabetes and maternal health. I graduated from the London School of Economics in 2010, in Management.

I’ve long held a sense that the world is unsustainable, unjust and unfair. Thus, I decided to dedicate my career to health equity, and have a personal mission to connect 250 million people to healthcare in my lifetime. 

52% of our planet, or 3.7 billion people cannot access healthcare. We are not on track to meet the Sustainable Development Goal of 70 maternal deaths / 100k live births.

reach52 has built offline-first apps allowing us to train 1-2 women per village to collect indicator data, then run targeted public health programs and 1:1 campaigns in partnership with government. We also work with private sector to facilitate a social marketplace of discounted medicines, insurance plans and diagnostic services. In this way, we directly impact health equity for lower-income rural communities in Asia.

Scaling supports SDG 3 (access to essential health services at low cost in rural areas), and SDG 5 and 8 (creating good, paid jobs for women in rural areas, to support health access).

We are driven by the fact that 52% of the planet cannot access essential healthcare, while a further 100 million are forced into extreme poverty each year due to out-of-pocket payments.

There is a significant shortage of skilled health workers in countries where we work. Nationally, Cambodia has only 0.6 nurses and midwives per 1000 people. While figure in Philippines are higher, there is typically only 1 government doctor across entire rural catchment areas of 50K+ people.

Out-of-pocket health expenditure presents additional barriers to health access, constituting more then $0.55 of every $1 spend on health in our focus countries. Governments share of overall health spending ranges from 1/3 to less than ¼ (compare this with more than ½ in China).

We make NCDs an area of focus, as they cause roughly 2/3rds of deaths in our focus countries. However, as this health burden is relatively new for LMICs and often requires chronic treatment, there are very few resources devoted to prevention and treatment.

 We also focus on MCH. In Region VI, Philippines, maternal mortality is at 86 deaths per 100,000 live births; under-five and neonatal mortality are at 46 and 33 deaths per 1,000 live births, respectively. 

reach52 explainer video

• We build technology (offline-capable Android apps) that enable women/community health workers (CHWs) in disconnected communities to provide health services
• They first go door-to-door and conduct individual health surveys with all residents
• Based on this data and insight, we work with local government and health providers to run precision primary health services. This includes health promotion events, clinics, public health campaigns
• Village stores and local NGOs also use our apps, partnering to delivering programs in a targeted way to their clients Through these channels, residents can order products from our virtual health marketplace
• Our marketplace focusses on access to MCH services (diagnostics and ultrasound screening), low-cost insurance and access to prescription/OTC medicines
• We work with local distributors to manage the last-mile delivery of these products, directly into the village through the field-force network of women we have trained
• We generate revenue through small margins on our orders/ deliveries. We also do research and sponsored programs for health worker education and designing access programs (paid for by pharma companies mainly)
• We have integrated Facebook / Messaging app for direct-to-patient support (i.e. mothers can use chatbots to get health support, or check what they should do to support safe pregnancy)

Our main target is families living on $2-8 USD per day, generally 1-5 hours from the nearest primary health facility and 3-8 hours from the nearest hospital/secondary care facility.

To understand needs, we comprehensively blend four main elements:

• Hiring in local markets and from local communities, so our core team is embedded with our beneficiaries and close to them
• When we launch in a village, our peer workers go door-to-door and collect data about resident needs (approx. 70 World Health Organisation aligned health and socio-economic indicators)
• We blend this with rich qualitative research from our dedicated research team, allowing us to position any interventions in a socially and culturally sensitive way
• We conduct ongoing monitoring, speaking with residents, as well as community and healthcare leaders to gain iterative input
• Partner with external organizations on project evaluation activities

Ultimately, the needs boil down to the fact that health facilities are far away (with a cost and time of travel), too expensive, and unreliable with frequent stock outs of commodities etc. In addition to access issues, quality of care is a concern, including counterfeit/substandard medicines.

A wealth of data indicate that lower-income rural populations are traditionally ‘left behind’ when it comes to attaining health access. Schemes designed to promote universal health care can frequently have the affect of increasing health inequity, as they fail to engage marginalized and hard to reach populations. reach52 works to design and facilitate services for those communities which are typically excluded and underserved. Our beneficiaries live far from health facilities and typically do not benefit from poverty reduction schemes because they are only near-poor. 

I worked in India for global pharma company wanting to discount their product, keeping it for-profit, to enable better health access, and a new business model. This project didn’t work, as a single company had to build (and pay for) the ‘infrastructure’ to connect lower-income groups, and there was a lack of data or digital platforms. I went back to the UK and worked in healthcare consulting, with a focus on enabling digital primary care and getting people out of hospitals.  I had the idea then– can we build a digital-first and patient-centered primary health model for low-income countries, leap-frogging the sustainability challenges of developed health systems?  Then finance it through building marketplace of affordable products to fill-the-gaps in public sector – giving a revenue stream, whilst allowing socially-minded businesses to expand into emerging markets. CSR/sustainability/social impact/ESG was just starting to rise too, so I felt businesses were on the cusp of becoming more ‘social’. I tried to start it part time whilst in consulting, and saw good traction/interest but was on a killer project and just couldn’t find the time. I started saving as much as I could for startup capital, and got a one way flight to Singapore… 

I don’t have a single reason. I moved to Singapore to set up reach52 with a one-way flight and my life savings. On the plan I remember crying a bit as I had 2 elderly grandparents who were quite unwell, and I realised I would never see again due to the life choice I had made. However, within 3 months of being in Singapore my youngest sister (and the youngest person in my extend family) had died of meningitis and a series of errors made to spot it by the UK health service. This cruel irony broke my family. She wanted to be a midwife, so I’ve been pretty focused on achieving the reach52 mission as a result of that. I have always been good with dealing with stress or pressure as a result of what I felt over that time. I also believe that I’m unfairly privileged due to being born in the UK, white and male. I don’t believe humans should be entitled by birth, so I want to focus on being a good human, not the barriers put up by our notions of nations/countries – we only live once, and money or wealth doesn’t really matter. 

At a high-level, I am a driven, passionate and relatively articulate person who really, really cares about what I do, and the impact I want to create. Even when hiring people, I look for passion and drive not skills. And I do believe that what me and my team is going has the power to transform the health of millions, and rethink how healthcare models are delivered to achieve Universal Health Coverage, and the Sustainable Development Goals.

More specifically,  I have worked across pharma/private sector healthcare on supply chain, digital transformation for public sector, and in a range of other health-focussed consulting projects with different stakeholders. This really has allowed me to ‘feel’ my way through the complex and conflicting interrelationships that exist within the health sector to try and craft a new model that works for everyone; enabled by technology and data.

As a result of my background, I am able to speak about our programs in business-style to pharma, but then also effectively engage with governments and NGOs (which is a different language and style). I also know I can see ‘the big picture’ but simplify it for partners to help them, and our team, get onboard with what we are doing (and unlock projects and capital to scale).

I often joke that I have just the right balance of knowledge of healthcare in different sectors with youthful naivety that makes me think I can change it. 

There’s a lot to choose from! The most memorable was when I went to Manila to set up our office there, visited the slum district we would work in first, and got drugged, mugged and abducted… I was missing for about 48 hours (I have no memory of it), had 4 credit cards maxed out, and was reported a missing person to the embassy – who involved the police, and I was found in my apartment building (no idea how I got there…). When I had to get a police report it was corrupt/asking for payments. I was living alone in Manila for the next year, and it was pretty daunting, but just had to rationalise it and get on with the job / delivering our first project. Although harrowing, I learnt a lot from that… in terms of taking precautions, but also the realities of some people needing to earn a living in poorer areas. I realised the challenges of working with governments in lower-income countries around corruption. I heard the money is often used to pay family members health costs (a top expenditure of poorer people) so like to think the stolen money saved someones life ?

Generally, I find a lot of people in my personal and professional life asking me for advice and support on various life and career issues. I try to give balanced and reasoned feedback based on thinking through the big picture.  Many of my team ask my advice for problems in their personal life, which I always support.

I like to lead through example – hard work, honesty, and being nice to people. Specifically and most recently, I have led reach52 well through the COVID pandemic. Back in late-Feb/early-Mar, I very quickly came up with a COVID plan in a week, reorganized the entire organization (as most of our operations were shut down), kept very positive and upbeat, had weekly calls, organised virtual socialising (workouts, quizzes etc), maintained morale, won our biggest single contract ever, and continued to grow company. No one lost their job or took a pay cut, despite our financially tough times. We have a strong partner pipeline and not lost a single member of staff. Their feedback (as part of our mid-year reviews) has been positive and one of respect for what reach52 did quickly, and how we supported the team.

A vast majority of solutions and interventions in our space are paper-based, vertical programs that are generally grant funded.

We do not find any start-ups or innovators working in our communities, but we do face competition. Most notably this is ‘do nothing’ (i.e. mothers simply choose to not travel and get recommended services). Additionally, there are quack doctors and herbal healers; unlicensed midwives and birthing attendants; and home remedies (sometimes including self-medicating with consumer health products). If a person/pregnant women does want to engage in health services, our main competitors would be travelling to the nearest town or city to a primary or secondary health facility; which involves the time and cost of travel. There are also occasional, sporadic NGO programs (such as medical missions, or newborn malnutrition assessments).

We are innovative because we are:

• Tech and data driven, allowing for personalised and relevant targeted interventions, that can be tracked and monitored
• Run by the community and local women, making our model community-led and localised to the context
• Generating sustainable revenue already, allowing us to sustain and scale our operations
• Focussed on a true end-to-end model not a vertical program, that holistically addresses primary care
• Integrating public and private sector, ensuring we leverage all publicly available services first, but look to marry them with affordable private sector products and services. This gives a unified patient experience, in an area where accessing healthcare is incredibly challenging

Activities

Our activities include:

• Individual-level data collection of residents in our partner-communities
• Community learnings through employment of participatory research methods to understand needs and priorities of residents
• Empowering women in the community through recruiting and training to serve as our frontline peer workers, to co-facilitate reach52 programs and solutions at the local level
• Engagement with local health systems, through sharing tech and data; providing stipend for CHWs; frontline health worker training; facilitating integrated outreach activities
• Cooperation with the private sector, in helping them to understand community needs, to help to implement CSR initiatives, and create social impact aligned to their core business
• Facilitation of services, including pre-natal at-home POCUS ultrasound; soil-transmitted helminth infection control campaigns; ANC/MCH health promotion events; rural clinics; and telehealth services
• Provision of a marketplace of good/services, including diagnostic and testing services; medicines; consumer health products; and insurance policies, delivered or provided directly to rural/remote villages
• Digital engagement, through our interactive chatbots and other online properties

Outputs

As a result of our activities, we produce the following outputs:

• Availability of Qualitative and quantitative data involving health indicators, as well as knowledge attitudes and practices involving a range of health and health-system related topics
• Provision of new services directly in community, which previously did not exist, including point-of-care ultrasonography
• Increased access to lower-cost medicines
• Improved digital linkages between outlying communities and government health facilities
• Upskilling for community health workers
• Improved sectoral coordination between stakeholders by uniting on a single platform

Outcomes

Our anticipated medium and longer-term outcomes include:

• Reduction in NCD-related morbidity and mortality in partner-communities
• Reduction in maternal mortality, through improved identification of at-risk pregnancies
• Improved child health outcomes, through and increase in ANC “contacts” per pregnancy and child health-focused workshops

At present we serve 53,000 users. All these users were acquired and onboarded in 2018. We spent 2019 building the partnerships and end-to-end service model we now have, focussing on the user experience and building a digitally-enabled primary health system that can be delivered anywhere on earth. This involved adding insurance, diagnostics and managing last-mile supply chain solutions to really address the root cause of primary care barriers.

In the next year we will serve 1.8 million people, over half of which will be women. This is based on our current agreements with government and partners (i.e. the agreed scope of work we have with our sub-national government partners).

In 5 years, we aim to connect 38 million people to essential healthcare. This is based on our realistic growth model, and leveraging the existing partnerships we have to enter new markets and communities. 

We align our impact goals with SDG 3 (Good Health and Wellbeing) as well as 5 and 8 (Gender Equality, and Good Economic Opportunity). In addition, as we make healthcare more accessible and affordable, we focus on how many screenings and health services are accessed, as well as the number of marketplace transactions (i.e. number of sales of diagnostics and other health services) as key output indicators. To measure our impact within these core outputs, we track our SROI (Social Return on Investment); which is currently $1:$2.10 (i.e. for every $1 we make in revenue, we save lower income people $2.10 in their costs of accessing healthcare.

We will continue to scale our proven impact through three core channels, all of which have been trialled or ramped up in 2020:

• We continue to implement the services ourselves, hiring and training women in communities, and engaging directly with government
• We work through partners on the ground, such as NGOs/cooperatives/village stores (already doing this with 2 NGOs in Cambodia)
• We scale through our Facebook Messenger and patient-facing app, using Facebook Ads and organic digital marketing, to connect digitally-literate users directly (Facebook Messenger bots and ads launched, patient facing app in development and due Q4 2020)

We ultimately look to drive a high number of users, accessing high quality services, and saving money. This supports lower-income communities to access healthcare, whilst also helping businesses sell affordable products to a new customer/patient segment (if they discount/make products affordable). 

As we have spent last year focussing on deep research and understanding the root causes of healthcare access, social barriers, cultural norms and then building a solution and supporting partnerships to address these, we are confident that our model is unique and can be scaled. That said, there are of course barriers that we face.

• Financial, with a global recession looming, raising capital is likely to get harder and local spending power might go down as lower income communities are hit harder from the economic fallout of COVID-19
• Regulatory and licencing, as we deliver medicines (pharmacy/distribution licences) and insurance (insurance agency licences) we need to make sure we comply to regulations – that are often inflexible and do not support pro-poor innovations (e.g. telehealth and ePrescriptions are banned in the Philippines – and have only recently been permitted while COVID-19 is blocking physical movement of doctors
• Quality control, as we are using non-medically-trained women in communities to provide health support, which is easier at a small scale but we need to ensure quality is maintained as we scale
• Fraud and gaming the system, such as for affordable medicines meant for poorer communities, we need to manage ‘leakage’ and black/grey markets as we scale up
• Working with governments can be tough (with barriers ranging from straight corruption through to just slow pace and bureaucracy)
• Competitors could enter our markets that will affect our cashflows and financials

In the same order:

• We are manging our costs well, applying for grants (whereas we used to solely rely on business financing and contracts). Also maximising our channels and partnership options through a fast-paced focussed on business development. Regarding residents’ ability to pay, we are focussing on lowering the cost of essential products, versus focus on discretionary health services/products
• We already understand how to either get the licences ourselves, like we are in Cambodia, or work through partners, like we are in the Philippines (as foreign owned companies cannot run a pharmacy without high capitalisation costs). There is no single answer for outdated regulation, apart from coming up with new ideas, doing constant checks with legal and compliance, and accepting that the most efficient solution can sometimes not be used in certain environments/tolerating inefficiency
• We are embedding checks and balances into our apps and processes to give clear tasks and monitor effectiveness, as well as train people well and conduct random spot-checks/audits to check we are following suitable processes
• We are investing heavily in supply chain and inventory tracking, which helps solve this problem and in turn creates a strong value proposition for our business partners
• We work with governments directly, but also look to leverage partners such as NGOs who are already approved to operate
• Competitors are generally not focussing on our area, but given the nature of our work we welcome the entry of additional resources and organizations to support the health of lower-income populations

We have built partnerships in eight main categories:

Government and healthcare providers

• Philippines and Cambodian local government, working with them to prioritise launch sites, extend their services to rural areas

Medtech

• Philips, providing Lumify ultrasounds and funding for our maternal health programs
• Medtronic, providing funding and devices for diabetes screening
• Abbott, for hepatitis B testing kits

Pharma and consumer health

• Novartis, access to NCD medication
• Gilead, access to discounted Hep B medication
• Johnson and Johnson, providing funding for health worker education and scaling our COVID-19 digital solutions
• Zuellig Pharma, for distribution and supply chain support

Insurance and financial services

• Malayan, low-cost insurance in the Philippines
• Forte, and Prevoir, low-cost insurance in Cambodia

Local community partners

• NGOs (TGF, KHANA etc) who are well-embedded in rural communities, and we work through their network to implement our solution
• Vitamin Angels, providing pre-natal and early childhood vitamins (17,000+ doses so far)
• Small village store owners, who provide our tech to, becoming a health access channel

Telcos and tech companies

• Globe Telecom, free data and sim cards for service delivery in Philippines
• Facebook, part of their Accelerator, now giving Ad credits to promote our services
• Microsoft, hosting our platforms for free on Azure

Academia and research

• National University of Singapore, giving tech and big data interns/students
• IQVIA, data analysis and policy work for gender-based violence
• Singapore Management University, interns in digital and comms space

Multilaterals and donors/grant makers

• DBS Foundation, provision of funding to grow into India
• Grand Challenges Canada, funding for gender-based violence reporting

When we launch in a community, a resident can:

• Access our services through a channel of their choosing, focussing on building a great experience – through a local woman that we hire and train, through Facebook Messenger, or through their local village store. This builds familiarity and trust
• Regardless of channel, the residents can then share their needs and problems
• Based on this, we then offer health events, targeted and relevant health advice, free and low-cost screening services, access to discounted medicines, insurance plans and other health products
• These channels provide a single and easy to understand single point of contact for government health services, improving the reliability and transparency of accessing services
• The services are delivered in the community generally, saving the cost and time of travel to towns and cities
• The resident can access care, and save money compared to other services
• This is specifically true for MCH, where we already offer targeted services for nutrition, prenatal screening, telehealth, online programs and access to other high-quality services for pregnant mothers and young children
• To provide these services, we work with businesses to get access to discounted products/services, as well as supply chain companies such as DKSH and Zuellig Pharma to provide last-mile supply chain to real rural areas 

We already make money in four ways.

1. Marketplace commission and delivery fees

• Diagnostic fees, such as ultrasounds performed for ~$5 USD. This cost includes a 35% margin for us to cover overheads. This price is still much cheaper than the pregnant mother going to a hospital (where the same scan is around $10, plus around $5-10 in transport fees)
• Around $1.20 per medicine or consumer health product delivered from the marketplace
• 20-30% commission on selling insurance plans

Sponsored programs and patient engagement. Partners (such as big pharma) sponsor programs and activities. These focus on:

• Public health and disease awareness, such as screening programs or health events
• Health worker education and system strengthening
• Sponsoring to scale up our digital services, such as scaling our chatbot services

Market research and insights. We work with private sector to help them understand what rural communities need and then design access/discounting programs. This includes:

• Collecting data on patient needs, and sharing this anonymously (disease burdens etc)
• Understanding patient needs, willingness-to-pay and helping partners get products people want and are willing to pay for
• Doctor and pharmacy insights

Grants and in-kind support. While we originally eschewed grants, we started applying in late 2019 to support scale-up and have now won 3.

• We focus on grants for things that are hard to fund through a business model, such as training community health workers or expansion to new markets

As a summary of our most recent funding:

• Johnson and Johnson, $150,000 grant, for health worker education and scaling our digital/Facebook solutions for COVID-19 and system strengthening
• Gilead Sciences, $50,000 revenue, for Hepatitis B screening program and health worker education
• DBS Foundation, $200,000 grant, for expanding our services into India and promoting health equity there
• Grand Challenges Canada and IQVIA, $60,000 revenue, for gender-based violence reporting and policy work
• Singtel, $10,000 revenue, funding to scale digital solutions for COVID
• Verge Capital and Zuellig Pharma, $500,000 equity, funding to scale up

If possible, we would kindly request this is not made public or we can remove the figures as it is confidential information but we found the question contradictory (i.e. we need to provided the breakdown, but also need to show discretion – which in our case would be to share it with you, but not have it publicly available for browsing given the confidential nature of commercial partnership contracts). 

We are actively raising funds at the moment. We are looking to raise $2-3m USD, covering our growth and expansion into new communities (ex: user growth, connecting more lower-income residents to primary care and expanding our marketplace (ex: more business partnerships and projects, to offer additional affordable health services.  We will also continue to invest in our tech product, services offered, and key management/core team hires to enhance the core of our organisation.

At present, we are looking at convertible debt as the main financing instrument, and have 3-4 partners currently doing due diligence on reach52 for this.

At present our costs are around $60,000 USD per month ($720,000 per annum). With new hires planned and additional growth expenses our costs will be approximately $100,000 USD per month ($1.2m per annum) in the coming months. We expect this to roughly increase 2-3x year-on-year as we grow and scale to new regions and markets and expand our core team. 

As we grow, our service is becoming multi-faceted and complex – across both the technology elements (software coding, integration and scaling), public health, partnership management, new market entry and growth strategies. We are interested in accessing the community of peers and mentorship available to help improve the efficacy of our model, especially around quality of care.  We know we can attain heath outcomes that are equal to those enjoyed by urban residents. We are specifically looking to increase our work in the clinical space, to support the prevention, diagnosis and disease management work that is currently ongoing in a collaborative way. We also would benefit from improved tracking of program outcomes. In working with our evaluation partner, we are able to track outputs, and have data to demonstrate the efficacy of our work. However, we are always looking to grow the evidence base to support the impact of our model on mothers and children.

We are seeking partners in the following areas:

• Private sector- We are interested in additional partnerships with companies offering goods and services for our social marketplace (including insurance, medicines, diagnostics, and consumer health). We are also interested in strategic partnerships to help us reach additional communities with our digital solutions and/or social marketplace
• NGOs- Increased partnership with community NGOs, to deploy using their existing resources and relationships, creating additional social impact for their beneficiaries
• Government/healthcare systems- The public sector is an important partner, as we first seek to strengthen community’s ability to access existing health services. We also promote quality of care through upskilling of community health workers
• Academic organizations- Additional academic partnerships would allow us to grow the body of evidence for our solution and improve our M&E framework
• Multilateral orgs- Allows us to grow recognition and allow us to have a voice in the global health community

NGOs and multi-laterals

• Gates Foundation/Grand Challenges
• Rockefeller Foundation

MIT

• 2 of the grant judges are from the following MIT faculties/departments: 

• Center for Gynepathology Research 
• Urban Science & Planning 

• Data + Feminism Lab 

• MIT's Abdul Latif Jameel Clinic for Machine Learning in Health or J-Clinic 

• specializes in developing new healthcare AI tools 
• earlier this year, Takeda announced that it will work with MIT’s school of Technology to establish an education program focused on developing new machine learning approaches to drug development and more; the program will be based on J-Clinic 

• MIT Sloan Health Systems Initiative 

• faculty that conducts research in areas such as healthcare analytics, operations, and incentives, collaborating with industry partners to produce work that has practical application and measurable impact 
• mission is to improve health by discovering transformative and sustainable innovations through research and education with leaders in the field