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The central lesson to be learned from studying the case is to understand the challenges and constraints posed by contextual conditions in designing contracts in public–private partnerships (PPP) for financing and delivering health care in emerging economies such as India.

Perverse incentives, along with contextual conditions, led to extensive opportunistic behaviors among involved agencies, limiting the effectiveness of otherwise highly regarded innovative design of the program.

India’s “Rashtriya Swasthya Bima Yojana” or National Health Insurance Program, launched in 2007 provided free health insurance coverage to protect millions of low-income families from getting pushed into poverty due to catastrophic health-care expenditure. The program was implemented through a PPP using standardized contracts between multiple stakeholders from the public and private sector – insurance companies, hospitals, intermediaries, the provincial and federal government.

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CSS: 10 Public Sector Management.

This case study is designed to enable students to analyze the competitive landscape of a business impacted by technological disruption; evaluate the viability of an organic growth strategy using stakeholder analysis; evaluate the revenue and cost structure of Apollo 24/7 and decide on the future investment strategy; and analyze funding strategies of traditional hospitals versus pure digital players.

To extend its reach, Apollo Hospitals Enterprise (Apollo Hospitals), a leading private sector brick-and-mortar hospital chain in India known for using state-of-the-art technology, launched a unified virtual mobile platform Apollo 24/7 in February 2020, 45 days into the COVID-19 pandemic. The management believed that the digital platform had a unique ecosystem that could not be replicated. The analysts were optimistic about the impact of the decision on the future performance of Apollo Hospitals, as it was expected to lead to higher penetration and increased revenue. They also anticipated the unlocking of value, as and when the venture capitalist (VC) would invest in Apollo Hospitals. However, with increasing operating expenses on account of burgeoning technological and marketing expenses, things did not seem to go going as planned. Three years later, in February 2022 after the Q3 of financial year 2023 results. Suneeta Reddy, the company’s managing director found herself pondering whether the digital platform could boost Apollo Hospitals’ profitability in addition to expanding its reach and increasing affordability when the company missed the analyst estimates. In India, which was then the second most populous country, “incremental access” and “affordability” were what mattered to the patients, However, for the investors and analysts, it was quarter-on-quarter performance. The change in the macroeconomic environment stalled the company’s plan of raising money from VCs.

Furthermore, the financing dilemma also plagued Reddy. She knew there was a difference between financing for conventional businesses that for digital businesses. She also had to take decide between short-term profitability with which investors were obsessed versus long-term sustainability, which involved taking care of stakeholders’ interests.

This case study is basically aimed at postgraduate courses and executive management courses.

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CSS11: Strategy.

Public Health; Leadership; Organisational Development; Organisational Behaviour; Public Administration Management.

Postgraduate level for honours or masters programmes in courses on public health; executive leadership and management programmes; MBA level.

The case unpacks decentralisation as a means to promote and improve local decision-making and accountability through community participation and engagements. Ayanda Nkele was a programme manager in a health district in South Africa. He was faced with many challenges when trying to implement his programme, most of which were related to local authority, responsibilities and decision-making abilities at his level. This case describes briefly the South African health system. and how it functions. It describes the proposed changes to the health system and its transformation towards Universal Health Coverage. The decision space analysis as discussed in the case illustrates the types of decentralisation in the country and how this also applies to Nkele’s level.

Understanding the concepts and principles of decentralisation within the context of strengthening district health services, the re-engineering of primary health care (PHC) and rolling out a National Health Insurance in South Africa. Applying the “decision space” approach to analyse the extent of decentralisation. Grasping the requirement of leaders to be “contextually intelligent” and identify the important contextual variables to take into account when analysing public health care.

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CSS 7: Management Science.

For discussion of social entrepreneurship in middle-income economies, emerging markets generally and Africa, specifically, Quali Health presents interesting questions about entrepreneurial funding, scaling and the interplay between social entrepreneurial activities and the informal sector.

South Africa’s primary health outcomes do not correspond to the country’s spending on public health, with South Africa ranking among the worst globally in the incidence of tuberculosis, HIV prevalence, infant mortality and life expectancy. In part, this poor outcome can be explained by high inequality in access to healthcare, which reflects South Africa’s grossly skewed income and wealth distributions, with the bulk of the country’s population reliant upon an underfunded, inefficient and poorly managed public health system. This substandard service for the working poor in South Africa’s townships with high population densities offered a profitable entrepreneurial opportunity to provide affordable and effective primary care with vast gains in quality and outcomes improved dignity for patients. After receiving her MBA, physician and entrepreneur Dr Nthabiseng Legoete self-funded the launch of Quali Health in 2017. The business model set out to disrupt healthcare delivery for South Africa’s poorest citizens. Drawing patients from the working poor in Diepsloot, Quali Health’s inaugural site was cash flow positive within five months when the facility hit only 30% of installed service capacity. With quick success, Dr Legoete faced the strategic question of how fast to scale and finance the expansion. She also considered a new micro-insurance product for her clientele.

For discussion of social entrepreneurship in middle-income economies, emerging markets generally and Africa, specifically, Quali Health presents interesting questions about entrepreneurial funding, scaling and the interplay between social entrepreneurial activities and the informal sector.

Teaching notes are available for educators only.

CSS: 3 Entrepreneurship.

The case is designed to be used with the digital business model framework developed by Peter Weill and Stephanie Woerner of Massachusetts Institute of Technology (MIT) (Weill and Woerner, 2015) and is referred to as the W & W framework. This approach provides a useful structure for thinking through the strategic options facing environments ripe for digital transformation.

Research for this case was conducted through face-to-face interviews with the protagonist, as well as through a review of their business planning documents and other data and documentation provided by the founder. Some of the market and industry data were obtained using secondary research and industry reports. Interviews were digitally recorded and transcribed to ensure accuracy.

The case follows the story of Kurt Waltenbaugh, a Minnesota entrepreneur who shared the dream of using data analytics to reduce costs within the US health-care system. In early 2014, Waltenbaugh and a physician colleague founded Carrot Health to bring together their personal experience and expertise in both consumer data analytics and health care. From the beginning, they focused on how to use data analytics to help identify high-risk/high-cost patients who had not yet sought medical treatment. They believed that they could use these insights to encourage early medical interventions and, as a result, lower the long-term cost of care.

Carrot’s initial success found them in a consultative role, working on behalf of insurance companies. Through this work, they honed their capabilities by helping their clients combine existing claims data with external consumer behavioral data to identify new potential customers. These initial consulting contracts gave Carrot the opportunity to develop its analytic tools, business model and, importantly, to earn some much-needed cash flow during the start-up phase. However, they also learned that, while insurance companies were willing to purchase data insights for one-off market expansion projects, it was much more difficult to motivate them to use data proactively to eliminate costs on an ongoing basis. Waltenbaugh believed that Carrot’s greatest potential lay in their ability to develop predictive models of health outcomes, and this case explores Carrot’s journey through strategic decisions and company transformation.

This case is intended for either an undergraduate or graduate course on entrepreneurial strategy. It provides an effective introduction to the unique structure and constraints which apply to an innovative start-up within the health-care industry. The case also serves as a platform to explore the critical criteria to be considered when developing a digital transformation strategy and exposing students to the digital business model developed by Weill and Woerner (2015) at MIT (referred to in this instructor’s manual as the W&W framework). The case was written to be used in an advanced strategy Master of Business Administration (MBA) class, an undergraduate specialty health-care course or as part of a health-care concentration in a regular MBA, Master of Health Care Administration (MHA) or Master of Public Health (MPH). It may be taught toward the end of a course on business strategy when students are building on generic strategy frameworks and adapting their strategic thinking to the characteristics of specific industries or sectors. However, the case can also be taught as part of a course on health-care innovation in which case it also serves well as an introduction to the health-care payments and insurance system in the USA. Finally, the case can be used in a specialized course on digital transformation strategy in which case it serves as an introduction to the MIT W&W framework.

The case is particularly well-suited to students who are familiar with traditional frameworks for business strategy and business models. The analysis builds on this knowledge and introduces students interested in learning about the opportunities and challenges of digital strategy. Equally, the case works well for students with clinical backgrounds, who are interested in how business strategy can influence changes within the health-care sphere. Finally, an important aspect of the case design was to develop students’ analytical confidence by encouraging them to “get their hands dirty” and to carry out some basic exploratory data analytics themselves. As such, the case requires students to combine and correlate data and to experience the potentially powerful combination of clinical and consumer data. Instructors should find that the insights from these activities give students unique insights into the potential for of data analytics to move health care from a reactive/treatment ethos to a proactive/intervention ethos. This experience can be particularly revealing for students with clinical backgrounds who may initially be resistant to the use of clinical data by commercial organizations.

After studying this case, the students should be able to: explain the importance of employee engagement; illustrate the role of the participatory management style in an organizational context; discuss why managers may use engagement practices to operate effectively in businesses to lead change and innovation; identify the critical success factors, barriers and outcomes of employee involvement in driving high performance; and discuss the dilemma faced by the managers in the emerging economies while driving the momentum of excellence in the long run.

This is a real case about a leading health-care service company located in the Middle East. The health-care organization’s name is changed to NOVA for reasons of confidentiality. The NOVA is an independent, public joint stock company created to meet the curative needs of the public health-care system in Middle East. The company introduced the Employee Suggestion Scheme named Minara in 2011 in a Federal Government decree, introducing innovation as a major pillar of management in 2013 with intent to encourage organizations build innovative solutions and pioneer initiatives and apply it effectively in services, processes and programmes. Making the Minara programme work in line with the national health agenda, Ms. Fatima who headed the Excellence and Innovation Department took the initiative of accelerating the innovative Programme (Minara). The case data were collected based on both primary and secondary sources. Although the case is based on the real data, it has been ammonised. The case describes the transformation of the innovation process at NOVA through the employee engagement programme (Minara) in meeting the disruptive challenges. This case addresses the challenges faced by the Excellence and Innovation manager who used effective employee engagement practices through the Employee Suggestion Programme in a creative way to bring about innovation in the health-care sector. The case outlines the dilemma faced by the Excellence and Innovation manager in bringing about innovation through the Employee involvement programme in the emerging economic scenario. The case will focus on the analysis of the different aspects of the issues pertaining to employee engagement, employee motivation and the framing of empowerment strategies to bring about innovation and continuous improvement through an effective employee suggestion programme. The case is intended to give budding managers an insight into innovation and employee engagement practices that impact performance in the organization.

This case will be suitable to be used in Human Resource Management and Management of Change and Innovation course at undergraduate and Master’s level.

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CSS 1: Accounting and Finance

After discussing this case, students will be able to understand the challenges faced by social entrepreneurs in starting a health-tech start-up in Africa; create and evaluate lean business models of health-tech companies as a social enterprise; evaluate how health-tech start-ups were developing innovative business models and supply chain networks to make prescription drugs accessible and available in Africa; understand how inorganic growth strategies can help health-tech start-ups scale up; and evaluate what promises investors were seeing while investing in social enterprises in the health-care sector in Africa and what social wealth they were creating.

In August 2022, Gregory Rockson (Rockson), social entrepreneur and founder of for-profit health technology (health-tech) social enterprise in Ghana, mPharma, stated that he had plans to replicate the company’s business model, which provided people access to drugs and at affordable prices, to other African nations, beyond the company’s existing footprint. However, analysts pointed out that the fragmented drug supply chain and poor regulation in the health-care market across Africa could act as a challenge for mPharma to replicate its business model successfully across the African continent. People in Africa were forced to pay higher prices to buy life-saving drugs due to the continent’s fragmented drug supply chain. To add to their woes, pharmacies struggled to keep life-saving and life-sustaining medicines in stock. Often, patients traveled miles to a pharmacy only to find out that the drugs they needed were not in stock. In addition to this, the markets were flooded with counterfeit drugs. And the Covid-19 pandemic only exacerbated the situation. mPharma managed the prescription drug inventory for pharmacies and drug suppliers using its proprietary vendor management information system. By using the technology infrastructure it had built, the company connected patients, pharmacies and hospitals through a cloud-based software. The system enabled doctors to track in real-time which drugs were available and at which location, thus giving patients reliable access to medicines. Patients registering with mPharma with their prescriptions and medical history received an alert on their mobile phones notifying them where the drugs they needed were available. mPharma bought drugs from major drug manufacturers such as Novartis International AG, Pfizer Inc. (Pfizer) and Bayer AG, on behalf of the pharmacies. This enabled the pharmacies to save on the up-front costs of stocking the drugs, reduced supply constraints and ensured availability of drugs to consumers in these underserved markets. The company had a consignment model wherein member pharmacies had to pay only for what they sold. Most pharmacies forecast the number of drugs they needed and purchased them from mPharma at pre-agreed rates. The company took the inventory liability to prevent pharmacies from going out of stock. As mPharma used its purchasing power to buy drugs in large quantities from drug manufacturers and suppliers, it was able to help patients realize cost savings of 30% to 60% in the purchase of medicines. mPharma was focusing on achieving its ambitious goal of dominating the health-care market in Africa in future. However, analysts felt that the company would face challenges related to poor regulation in the health-care market, high prices of drugs and the fragmented pharmacy retail market in the continent.

This case is intended for use in MBA/MS level programs as part of a course on Social Entrepreneurship, Sustainability, Business Model Innovation, Disruptive Business Models, and Supply Chain Management in the Drug Industry.

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CSS 3: Entrepreneurship.

The teaching objectives of the case study will enable the students as follows: to recognise the challenges of information technology (IT) implementation in the health-care sector associated with employee resistance, to apply the technology acceptance model for analysing the degree of employee resistance, to relate the utilisation of Kotter’s 8-step change management approach in successful IT implementation in the health-care sector and maintenance of employee productivity and to classify the leadership traits reflected by the leaders in training the 600 diverse employee population of Al-Ain hospital.

The case highlighted the predicament the government-owned Al-Ain City Hospital, United Arab Emirates, faced following the surge in the incidences of COVID-19 in the country in March 2020. The hospital management decided to initiate the work-from-home arrangement as a non-pharmaceutical intervention of handling the spread of the disease amongst its employees. Fatima Almur, the Information Technology Director in Al-Ain Hospital, asked the Application Support Manager, Aysha Shahwan, to deploy some IT tools significant for remote support to patient care within two weeks. Shahwan faced significant challenges in deploying the IT tools in two weeks given the diverse workforce, with the majority of them having limited knowledge in operating the tools, and hence, their apprehension in the usefulness of the tools. Besides, Shahwan had to deploy some advanced tools for easy and secured access to the electronic health record, telemedicine and telecommuting using mobile phones, tablets or PCs. The deployment of these advanced tools would be jeopardised by employee acceptance and consequent dwindling productivity. Considering the issue of employee acceptance of the change and their limited knowledge, Shahwan had, therefore, to develop training frameworks to boost the former’s perceived usefulness and ease-of-use of the IT tools. Will Shahwan successfully deploy the advanced IT tools to enable the hospital staff, including medical staff and departments, to ensure efficient patient care from a remote location? Will she be able to train the 600 employees across genders, ages and knowledge, use the IT tools and safeguard them from common software threats like email phishing and ransomware? Will the hospital be able to sustain its vision of quality patient care using advanced technologies through this new arrangement of remote support amidst the pandemic when patients are more?

Undergraduate business management.

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CSS 10: Public sector management.

This case study outlined the strategic and organizational issues faced by an entrepreneurial firm operating in an emerging economy. While the traditional view is “more for more” and “less for less” with respect to quality and price, the medical devices sector demands “more for less” in an emerging economy such as India, i.e. the market demands quality products at affordable prices. This case was written to equip students with the knowledge of how entrepreneurs can overcome certain barriers and use technology to recognize and exploit an opportunity, using the Indian health-care industry as an example. The key learning outcomes for the case include the following:

• Entrepreneurs define their own market, come up with innovations and create a completely new market with suitable customer value proposition.

• Entrepreneurial opportunity recognition comes from being prepared, having prior knowledge of customers and the market and having a strong network.

• An entrepreneurial preference for error of omission or commission is the determining factor when deciding whether to exploit a recognized opportunity or not.

• Entrepreneurs exploit an opportunity by giving special emphasis on their entry and risk reduction strategy.

• A technology-based product with a combination of services that will create its own product ecosystem with data is the primary goal.

The Indian health-care sector is one of the largest sectors in India and incorporates the medical devices sector, and the heart monitor segment especially represents a huge untapped opportunity. India has the highest number of deaths because of heart disease in the world, yet there is no mechanism for affordable heart monitoring, which results in large number of deaths. As existing products are either B2B or unaffordable, there is an opportunity to leverage technology to come up with cgiq products similar to blood pressure and sugar monitors. However, there are certain challenges unique to the market and product. The case described how two young entrepreneurs founded a company called Agatsa and overcame certain challenges to create a credit card-sized ECG device and the importance of building an ecosystem in a new market. Some specific issues that the case posed included the following: will it be possible for Agatsa to come up with an ecosystem to monitor heart functioning and will that be accepted by the stakeholders in an emerging market such as India? Should Agatsa have a product-driven strategy or a data-driven strategy? Will Agatsa be able to find the right business model to create and capture value?

MBA in courses such as entrepreneurship development, new venture creation and entrepreneurship in emerging markets.

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CSS 3: Entrepreneurship.

This case study would enable students to understand the concept, process and advantages of mergers and acquisitions as a growth strategy with respect to 1mg. Also, the students would be able to use the threats, opportunities, weaknesses and strengths matrix to map 1mg’s strengths, weaknesses, opportunities and threats.

This case study analyses the transformation journey of 1mg to Tata 1mg, one of the most trusted internet pharmacies in India. This case describes a small start-up that was launched in 2013 and had made many acquisitions since then. This case revolves around Tata Digital’s purchase of 1mg. The case starts out by explaining 1mg’s financial situation and why the company was acquired. This case study focuses on how the integration helped Tata Digital and 1mg realize their respective missions. Furthermore, the case study illustrates the benefits and difficulties of this integration.

This case study is basically aimed at postgraduate management students; it can be used in strategic management and health-care courses. Students can understand the concept of diversification and acquisition with the help of this case study. Students can also gain an insight into the organic and inorganic diversification as a growth strategy.

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CSS 11: Strategy.