Can Business Transform Primary Health Care Across Africa?

BRIAN KENNY: If you’re looking for high customer satisfaction ratings, the US healthcare sector is not the place to start. The poor showing is particularly frustrating in light of the fact that the US healthcare sector invests around $200 billion a year in R&D to improve medical treatments and services, which just goes to show that innovation in healthcare is hard, but it’s also incredibly important, and sometimes you have to broaden your lens to find the best examples of where it’s happening. Today, on Cold Call, we welcome Professor Regi Herzlinger and case protagonist, Gregory Rockson, to discuss the case, “mPharma: Scaling Access to Affordable Primary Care in Africa.” I’m your host, Brian Kenny, and you’re listening to Cold Call on the HBR Podcast Network. Professor Regi Herzlinger is an expert on consumer-driven healthcare and innovation in healthcare. She has even been called the godmother of consumer-driven healthcare by Money magazine, and she wrote the book, Innovating in Healthcare: Creating Breakthrough Services, Products, and Business Models. Welcome back to Cold Call, Regi.

REGINA HERZLINGER: So wonderful to be here, Brian.

BRIAN KENNY: Great to have you back on the show. Gregory Rockson is the co-founder and CEO of mPharma. He’s an entrepreneur with a bold vision for the future of healthcare in Africa, and he is the protagonist in today’s case. Greg, welcome to the show.

GREGORY ROCKSON: Thanks for having me.

BRIAN KENNY: Great to have you both here. I think people will be really interested in hearing the kind of progress that you’ve made, and sort of re-defining what healthcare can be like in Africa. So why don’t we just get started. We’ll dive right in. And Regi, I’ll ask you to kick us off here by telling us what the central issue is in the case, and what your cold call is to start this discussion in the classroom.

REGINA HERZLINGER: Well, my courses on innovating healthcare is about how to make healthcare innovations happen. Not “woulda”, not “shoulda”, not “coulda”, but how do you actually make them happen? So Africa has a shortage of physicians and, unfortunately, a corrupt and inefficient supply line for much-needed drugs. mPharma, which Greg founded and has brilliantly led, is bringing much-needed primary care physicians to Africa, and a competent supply line. So, for my students, my students love this case. They’re so energized by what Greg is doing. He’s got a lot of plans. He wants to buy more pharmacies. He already has hundreds. He wants to do more telemedicine. He wants to start an insurance company. And my question to them, because the course is about how do you make it happen, is: how should Greg prioritize what he wants to do? After all, he cannot do it all simultaneously.

BRIAN KENNY: Yeah, that’s a great question. I’m sure it kicks off a really rich discussion. I’m wondering how you heard about mPharma and why you decided to write a case about them.

REGINA HERZLINGER: I thought it was a very important innovation in that Greg uses pharmacies as a base for bringing primary care and for assuring an honest and competent supply of drugs. We don’t have that many cases about African healthcare, but African healthcare is a much-needed area, improving the healthcare in Africa, just as in the United States, and a tremendous business opportunity. So I thought the case would be very inspiring for our students, that Africa’s a very viable and interesting environment for healthcare innovation. Two of my students actually have done business plans this year about other innovations they would like to bring to Africa. This is a very, very, powerful example of ESG in action. So that’s why I wrote the case. The response has been overwhelming.

BRIAN KENNY: Yeah, yeah. Greg, let me turn to you for a second. We’re going to get to your background in a minute, but I wanted to start just by asking you… It sounds like you’ve got a lot going on, by the way. You’re a busy guy. So thanks for taking time to be on the show today. I wanted to ask you what the patient experience is like in the parts of the world where mPharma operates.

GREGORY ROCKSON: Thanks. I think to start off with, it’s good to sort of establish the context on why this matters. Africa accounts for 16% of the world’s population, but it also carries 23% of the disease burden. And across many countries that we operate in, the type of experience people have is nothing to write home about. In fact, there was a recent survey on public experience of the public health system by Afrobarometer last year, and the results were quite interesting. 79% of people reported long wait times in their public hospitals, 73% reported a lack of medicines, 60% reported poor conditions at their health facilities, and 54% reported an absence of doctors or medical personnel at these public health facilities. And with the public health system being the biggest provider of healthcare, this is staggering. Because basically, the experience that most people have is not what you would expect any competent health system to provide for patients.

BRIAN KENNY: Maybe you can tell us a little bit about your background, Greg, and what led you to decide to work in this field.

GREGORY ROCKSON: Yeah. So I was born in Ghana, grew up mostly in Ghana. And then I moved to the US after high school. I went to a tiny liberal arts college in the middle of nowhere, a town called Fulton, Missouri, which was actually the town that Winston Churchill delivered his “Iron Curtain” speech, predicting the Cold War. And so I went to Westminster College to study. And after graduating, I had a decision to make. Do I stay in the US and start my professional career, or do I go back home and start to do something different? At that time, I spent my final year in San Francisco, doing an internship. It was at the height of the tech group, when the likes of Airbnb, Twitter, were at their height. And I was really inspired. I was in this place where… The center of innovation. And I guess I got infected by that experience, that I said, “I need to go back home,” to try and make a difference and build something that, in a few decades from now, could be celebrated just as all these entrepreneurs were being celebrated whilst I was in the Bay Area. So, I moved back home. And what led me to mPharma particularly… I was a pre-med student. I studied as a premed student in college. I obviously did not continue. I didn’t want to spend the next 10, 15 years of my life training to be a doctor. So I moved out of the clinical care path because I became more interested in the business of healthcare. How do we build new business models that can actually scale access to care? I wanted to build a new model that could allow patients to actually be able to address some of these challenges without having to rely on the government and public health system. So that’s what led me to mPharma.

REGINA HERZLINGER: I think it’s interesting how many of the great innovators in healthcare services have had an epiphany about healthcare due to personal experiences with the healthcare system. Greg, you’ve had some of that. Would you like to tell us about it?

GREGORY ROCKSON: Yeah. I mean, as a child, I was known to be the kid that spent most of his time in the hospital. In fact, my best friends became the nurses at the hospital. So, I had a condition called thoracic scoliosis, and that required me to do months of physiotherapy at a hospital. I think every week during that a three-month period, I had to spend three days each week in the hospital. I had to go in physiotherapy. And I was privileged because I had… My dad was in the military. And being in the military meant that his children before the age of 18 could have access to military hospitals, which were some of the best hospitals in the country. Did not have to pay for it. But then you had a lot of people who, in order to get access to those hospitals, had to pay out of pocket. You could always see, going to the hospital, families who did not have the resources, the stress that it put on them. All my role models were my doctors who were treating me throughout that experience. And I think from that point, I just made a decision that healthcare is going to be my life’s work.

BRIAN KENNY: I mean, that’s invaluable experience that you had firsthand as somebody who experienced the product and the service up close. Thank you for asking him to share that, Regi. Let me turn to you for a second. You describe mPharma in the case as a patient-centered hospital, a patient-centered business. Tell me how that differs from innovations to cost controls or disseminating technology–why is it so important in the innovation process?

REGINA HERZLINGER: So, I think there are three types of innovations that are needed and possible in healthcare. One is to control the runaway costs. All over the world, no matter how much or little is spent, costs grow faster than GDP. Second one is to disseminate the astounding technology, which most recently saved so many people during Covid. And the third is, as you started Brian, people are very unhappy with their healthcare systems all over the world. They find it inaccessible, they find it impersonal, and they find it too costly. So addressing these needs is very important. And it’s different from innovations that control costs because frequently these innovations do it at the expense of the patient. They raise the amount of money the patient has to pay, they make it more difficult for the patient to access the physicians or other clinicians he or she needs. Innovations that disseminate technology, they’re interested in the patient, but very clinically. Does it have greater effectiveness and safety? Not so much with the issues of access, the issues of personalization that people bemoan they don’t get from their healthcare system. So, Greg has created a system, it’s really amazing, where he leverages the few physicians in Africa through telemedicine, through his many pharmacies. And he provides a patient-centered experience and can ameliorate these great and just dissatisfactions with the personalization and accessibility of healthcare services.

BRIAN KENNY: Well, let’s turn back to that, Greg, for a second. We haven’t really talked about mPharma and the business model that you have there. What are the building blocks that form the foundation of mPharma?

GREGORY ROCKSON: So, at a high level, we have one simple objective: to transform community pharmacies into primary healthcare centers across the continent. Think of it as a CVS Health, expanding with minute clinics, and then expanding with Aetna to build a new health management organization. How we’ve done, to build this at mPharma, is to build our strategy across three core pillars we call receive, deliver, pay. So at the receive pillar, the question we are answering there is, how do people experience the health system? In our studies, what we saw was that… Actually, there was a question that was posed in the survey, was a lot of patients were asked between quality of care and proximity of care, what is the most important factor in deciding where you go and get care? Interestingly enough, most patients pick proximity of care because there’s a baseline of quality for basic primary healthcare needs that should exist. And if it exists, they would rather not want to travel a long distance just to go get this fancy health experience. We asked ourselves, what is the health asset that is already so close to people that if we could expand the type of services this asset could provide, you can actually address the proximity of care question? And that answer for us was the community pharmacy. It’s a space that most patients already relied on. In fact, the pharmacist is the most visited healthcare worker. So, there’s this amazing utility that exists, and we wanted to bring out that utility in the pharmacy. So we built our QualityRx program, where we would invest in pharmacies so that we could actually transform the physical space of the pharmacy into a place that can be convenient for patient care. So basically, remodel how the pharmacy looks and feels, and make sure that it does what a pharmacy should do. So that’s under the receive pillar. And under the deliver pillar, once we’ve been able to remodel the physical infrastructure of the pharmacy to make it conducive for patient care, we then asked ourselves, “If we want this pharmacy to do more than just dispense drugs, what is the basic care coordination team that has to exist within this pharmacy to be able to provide the community with more than just medicines?” And in our analysis, we realized that we needed a basic care coordination team that would consist of a GP, a pharmacist who already exists in the pharmacy, and a nurse. And the reason why this was important was, as Regina mentioned, it would be impossible to put doctors in every pharmacy. But we have a lot of community health nurses that have been trained by the public health system, that cannot be placed in the public hospitals. And so we could actually hire these nurses for a fraction of the cost of a doctor, and have them be physically co-located in these pharmacies so that when a patient actually visits the pharmacy and they want to be seen by a doctor, the nurse is the one that actually does the examination. And if the nurse feels that they’ll need a doctor to join that intervention, they can send a request through our software and the doctor joins virtually. And then the nurse assists the doctor with the consultation that they can do. Bear in mind, in the public health system, it costs the government over $8,000 a month to operate a public health facility. And we are able to do this for $660 a month. We cannot increase access to healthcare if we don’t reduce the cost of healthcare delivery, which our QualityRx model allows us to do. And then the final pillar is what we call pay, which is basically, how do we begin to transition the payment models? Today, the majority of patients pay out of pocket. I would say 99% of our revenues come from out-of-pocket payment because health insurance is very minimal. In Nigeria, as an example, it’s about 3% of the population-

BRIAN KENNY: Wow.

GREGORY ROCKSON: … has health insurance. No one ever plans to fall sick. When you fall sick, you have this immediate catastrophic cost that you have to incur. And because people have not saved to pay for that care, they are found wanting. We actually saw in our data that about 33% of patients come to the pharmacy, they get examined, they go to the counter to fill that prescription, they get the price of the medication, and they say, “I’m sorry, I don’t have enough money to be able to pay for the medication.”

BRIAN KENNY: Right. Right.

GREGORY ROCKSON: So, we knew that okay, to really close that gap, we had to innovate our own payment models. And so we built our own managed care plan called Multi-plus, which cost $1.90 a month. And the reason it was $1.90 is that we looked at what is the current extreme poverty line. And the extreme poverty line are people that spend $1.90 a day. Our view was that it would be very hard to provide health insurance to the poorest of the poor if you have them pay more than a day’s earnings for that healthcare they need each month.

BRIAN KENNY: Of course.

GREGORY ROCKSON: And so, we had to design a plan that would cost someone just a day’s wages to able to get fully covered in a month. And we built this new plan called Multi-plus. It’s still early days, but their data has been extremely, extremely impressive. And we look to scale that across our operations.

BRIAN KENNY: So, what Greg is describing is an amazing amount of innovation over a relatively short period of time, Regi. And I know that this is your core topic, is innovation in healthcare. Why is it so difficult? He’s identified all the areas that I think you would find in most countries. People are dissatisfied with insurance payments. They’re dissatisfied with the quality of care delivery, access to care. How has he been able to innovate in this when others find it so difficult to do?

REGINA HERZLINGER: I think Greg described, inadvertently perhaps, why it’s more possible to do it in Africa than in the US or in Western Europe. And that is, the status quo is very powerful in the US and in Western Europe. In the US, it’s increasingly powerful and increasingly consolidated. Everybody loves innovation, but not if it happens to them. So, in the US, innovators in consumer-facing innovations or cost-controlling innovations face major stumbling blocks from hospitals that don’t want their costs decreased. Insurance companies that like things just the way they are, thank you very much. So, in Africa, because of the absence of this powerful status quo, it’s easier. Not easy. What you’ve done, Greg, is amazing, but it’s easier to get innovations established. In the US, however, there are similar innovations to mPharma. Greg mentioned how convenience is a very important aspect of healthcare to the consumer. And CVS, which has 9,900 stores; Walgreens, which has about 8,000; Walmart that has 5,500 stores; and the ubiquitous Amazon are all going into the delivery of primary care and, of course, because most of them are pharmacies of drugs. What they don’t have that Greg has, at least not to date, is a good NPS score. CVS ranks very, very low in net promoter scores, the satisfaction of its customers and its vendors. And we’ll see how well Walmart and Amazon do in this challenging space.

BRIAN KENNY: Yeah.

REGINA HERZLINGER: Greg is consumer-focused. He’s not primarily trying to control costs, although he does. And he’s certainly not innovating new drugs. He’s trying to help the consumer. That’s what he’s talking about. That kind of focus has led to a terrific net promoter score. I hope our pharmacies will learn from your experiences.

BRIAN KENNY: Yeah. Greg, you made it sound easy when you described the four pillars. I know it wasn’t, as Regi points out. And the case does a great job of describing some of the things that you had to do to even educate pharmacists and pharmacies about how to run their business, how to set up their operation in a way that was more customer-centric. Can you describe a little bit of the things that you tried there?

GREGORY ROCKSON: I’ll say we are still learning because we are still very early days in our journey. I say the opportunity is much bigger than whatever we’ve even scratched today. There were a couple of basic principles. First is that whilst a lot of pharmacists are trained as healthcare professionals, when you run a pharmacy, you are also a business. And most of them did not think of the business side of operating the pharmacy. The other aspect was also beginning to change how patients think of their pharmacy—how do we build trust with patients, that they begin to see their pharmacies in a different light? How did we do this? We liked a very robust community health program where, on a weekly basis, we have nurses that we assign to each pharmacy who visit homes and workplaces around that pharmacy to do preventive health checks. And they use that as an opportunity to talk about the type of services they can now get from the pharmacist that they already know in the community, but now does more. And that was a very great way to begin to actually build trust with the community. So over the last 18 months, we’ve provided wellness checks to about 250,000 people across the communities that we serve. And that allowed them to become… “Wow. First and foremost, my hospital has never sent a nurse to my home. You know what I mean? Check my blood pressure. So, if my pharmacy is sending a nurse to my home to check my blood pressure, then I should start relying on it for more things.” So that was a very critical step to begin to build trust, but also change the perception that people have of their pharmacy. And once we able to do that, that saw an increase in the confidence that people have. Now, Regina mentioned NPS. We have an NPS of about 60, our pharmacies. So that should tell you the level of trust that we are building between the communities we serve and the pharmacies that we have been on it.

BRIAN KENNY: And for those who don’t know, NPS is net promoter score. Regi mentioned it before. And that is sort of the go-to metric that people who are in the customer service industry look to find how they’re doing with customers. That’s a very high score. You also, I think inadvertently, pointed out an important thing that I want to underscore, which is that you had to teach these pharmacists how to run a business that is sustainable. And we talk a lot about the social purpose of the firm on Cold Call. A lot of our faculty write cases about firms that are doing things that are socially good, but none of them would be in business if they didn’t figure out how to do this in a way that was sustainable. So, the business aspect, it always comes back to the business aspect at some level for us. Let’s talk a little bit about the pandemic. You launched this effort right around the time that the pandemic hit. And Regi and I have talked before about other cases that she’s written and just observations that you’ve had, Regi, about how we look for silver linings in a terrible situation, Covid had a silver lining for the healthcare sector in terms of it forcing us to innovate, maybe in ways that would’ve taken much longer otherwise. Is that safe to say?

REGINA HERZLINGER: Absolutely, yes. Everything you say, accurate and eloquently put. So the US, despite our spending about 20% of GDP on healthcare, we have very few hospital beds. We have about three hospital beds per thousand, whereas Germany, which spends proportionately much less than we, they have eight. So when Covid hit, people who needed surgery, people who had heart attacks, people who had cancer, we didn’t have any hospital beds to serve them. And a whole new sector was able to spring up, and that is to get care in alternate sites, to get it in pharmacies like CVS, to get it in ambulatory surgery centers, to get it through telemedicine conferences with a physician or nurse. Many of these innovations were old. They’ve been around for decades, but the status quo suppressed them. For example, a doctor in Utah could not provide medical care through telemedicine to a patient in, let’s say, Massachusetts absent a very complicated regulatory process that permitted her to render that care. Most of that went away during Covid because we had such desperate need for other sites to provide care, and a whole new crop of important consumer-facing, cost-controlling innovations sprang up. So as you say, every cloud has a silver lining.

BRIAN KENNY: Yeah, yeah. Greg, what was the impact of Covid on mPharma? How did you react to what was happening?

GREGORY ROCKSON: Wow. I would say, going through the emotions. It was like, “Oh my god, we are done.” And then, “Oh my god, it’s amazing.” So, I will start with the “Oh my god, we are done.” We had at that point a huge part of our business. We were just at that point building our pharmacy as a primary care business. And what you saw with the pandemic was most patients were afraid to go to hospitals because they were afraid of catching the virus. And so most hospitals saw a huge decline in their revenues. Because if our hospitals are not making money, then we’re also not making money. And then the “Oh my god, it’s amazing” were two things. One is we repurposed our infrastructure. We saw immediately that Covid testing was going to be a very big issue that governments would fail to do. So we created a new plan where we would work with our hospital partners to repurpose their existing laboratories into molecular labs to be able to do Covid testing. And we built that infrastructure. And at its peak, we became the biggest supplier of Covid testing in the private sector in Ghana, Nigeria, and other countries that we were created in.  And the second part of it was whilst people reduced visits to hospitals, they increased visits to pharmacies. And that began to actually tap into this vision that we had that pharmacies are the best place to build a new care delivery model.

REGINA HERZLINGER: And I think it’s important to understand that mPharma is a business. Many people when they think about healthcare, think of businesses as sort of evil. Physicians refer to it all too often as the dark side. So here we have an example of a great business, very well managed and financially secure business, that does so much good, and how businesses can play such an important role in improving healthcare.

BRIAN KENNY: Yeah. Greg, let me ask you a question about scale here. Because you started in one location, you have now scaled to multiple countries. At a time when finding professionals in healthcare is really hard to do, I’m wondering how you’re attracting talent and how you were able to scale up.

GREGORY ROCKSON: When people ask what I spend most of my time doing as CEO, I say it’s making the case for why people should join mPharma and see mPharma as the place for them to not only achieve impact, but also financial success. We give employees equity in the company. Every employee in the company, from office managers to drivers, have equity in the company. When we are successful, I want people to also see their success in their bank accounts as well. I have this principle I share with my team members that every quarter, you’ll get to know someone new, that even if we don’t have a role yet at mPharma for them we get to know them, and if a role opens up, you should know who you will go to. In fact, I’ve always lived by that principle. I always try to know talent out there, even if they work at other places, because whenever I have a role… There’s never a time I’ve had a role that I’ve never known who I should call because I’ve spent the time investing in getting to know people, their interests, and just thinking about how they can fit into mPharma’s grand vision as we continue to unlock some of the steps that we need to take.

REGINA HERZLINGER: So, I don’t want to sound like a meanie, and I don’t want to sound… You know. And I applaud everything you’ve done, Greg, to empower your staff. But if you do an IPO and every single employee has shares of stock, you may live, unfortunately, to regret that decision.

BRIAN KENNY: That sounds like business advice, Greg, that you might want to want to take to heart.

REGINA HERZLINGER: Think about it.

BRIAN KENNY: So, this has been a fabulous conversation, as I knew it would be, but I’m conscious of our time here. And I’ve got two questions left, I’ve got one for each of you, and I’ll give Regi the last word. So I’ll start with Greg here. But Greg, quite simply, what does the future look like for mPharma? What’s your hope and aspiration and how will you know when you’ve achieved it?

GREGORY ROCKSON: In five years from now, I want mPharma to become the biggest health system that operates on the continent. Numbers-wise, I want us to be able to serve 1 million patients a month. Basically, I would want us to have built an infrastructure that rivals the likes of Kaiser Permanente in the US. And the cherry on the top would be that we have a company that is no longer a privately run company, but it’s a company that has achieved success enough that it’s worthy to be listed on the Stock Exchange in the US. That, for me, is what success will look like.

BRIAN KENNY: Wow. Okay. That’s a great vision. Regi, I’ll give you the last word. Again, thanks for writing the case. If there’s one thing you want people to remember about it, about mPharma, what would it be?

REGINA HERZLINGER: It is that a private business in Africa can do so much good, and can do so well as a business. And the steps that Greg took to make it happen, they sound very elemental and they sound easy, but they’re neither one of those. They were hard steps to do, and he’s done them brilliantly.

BRIAN KENNY: Regi Herzlinger, Greg Rockson, thanks for joining me on Cold Call.

REGINA HERZLINGER: Thank you.

GREGORY ROCKSON: Thank you.

BRIAN KENNY: If you enjoy Cold Call, you might like our other podcasts, After Hours, Climate Rising, Deep Purpose, IdeaCast, Managing the Future of Work, Skydeck, and Women at Work. Find them on Apple, Spotify, or wherever you listen, and if you could take a minute to rate and review us, we’d be grateful. If you have any suggestions or just want to say hello, we want to hear from you. Email us at coldcall@hbs.edu. Thanks again for joining us. I’m your host, Brian Kenny, and you’ve been listening to Cold Call, an official podcast of Harvard Business School and part of the HBR Podcast Network.