It Takes More Than Money: The Non-Financial Factors in Sustainability
A few weeks ago I attended a half-day workshop called the “Deep Dive: Sustainable Models for Digital Health Impact.” The meeting was co-hosted by the Global Digital Health Network and the Digital Impact Alliance (DIAL) to explore sustainable business models. About 70 Network members came together with industry business experts to discuss sustainable business for digital health—including how to consider costs, opportunities, and pitfalls in public-private partnerships; how to coordinate with donor communities; and where there may be emerging markets.
The Deep Dive included lessons from social enterprises, consulting firms, collaboratives of multi-domain partners, and even a private equity investor. We explored types of financial sustainability; discussed a variety of digital products, from open source to proprietary technologies; and wrapped our minds around the non-financial factors in ensuring sustainability. My role was to facilitate the latter part of the discussion.
I brought my experience in both for-profit and social enterprises from the past few decades. My pathway has included the common benchmark of business failures before any success, and a healthy respect for reducing risk. If failure is a learning experience, then I’m well-educated. A quick review of my entrepreneurial ventures, in chronological and financial order, includes:
- Total financial disaster.
- Deep disappointment.
- "Well, we broke even."
- "That venture looks too risky. I’ll pass."
So, what did I learn while attending the Deep Dive?
Several experts explored perspectives on digital health financial sustainability. We heard a great presentation on Total Cost of Ownership (TCO) for technology—or “How to find all the ways implementing your technology will cost you more than you think, but you can estimate those costs in advance”. We had breakout sessions on Community-based Surveillance for Zika, Consumer-focused Family Planning Information Services, and Decision Support Tools for Frontline Maternal and Child Health workers. We also had a Knowledge Café on donor coordination and value chain analysis. All of these activities either focused on or highlighted the financial aspects of digital health sustainability.
Granted, financial sustainability is the basis of any successful business venture—digital health or not—but there are other venture-killers lurking out there. As I listened to the speakers and participants, I noted the non-financial issues they touched upon. I held my tongue (very painful!) until the last segment, when I shared my thoughts on what—besides finances—can go right or wrong. Several observations emerged:
- What is the health ministry’s return on investment? Meaning, how does this venture help them fulfill their mission? If it does, you've got a friend. If not, you don’t. Full stop.
- Who else is in this space? In digital health, good ideas often run in parallel tracks, and competitors can be only a click away. Do your due diligence to determine if there are others in your domain, and be ready to differentiate what you offer. If their solution can complement yours, perhaps be prepared to make new friends.
- Success can breed dissatisfaction when expectations are rising—especially when the newness wears off. Be ready with the next generation or version to keep it new.
- Watch out for politics! Changing officials, shifting governing parties, coups, and even armed conflict can undermine your efforts. Practically, there may be little you can do, but it is essential to listen carefully and remain flexible.
- Labor issues are a different kind of politics that can include strikes, slowdowns, and even resistance to your innovation. Think about who really uses your new system and how it affects their jobs. Your innovation may be added to someone's already fully-loaded plate of work. Even if you offer labor savings down the road, it usually requires more effort while the old and new systems are being transitioned.
- Be ready for the "elevator pitch." A ride in an elevator usually lasts only a minute or two. Could you introduce your innovation to someone in that amount of time? The idea is not to get them to buy in right there, but to buy two more minutes of their attention—and then two more.
- Adjust the pace of business. Many in the nonprofit, grant-supported domain are not ready for the speed of the commercial sector. A number of speakers talked about expectations for responsiveness by their partners in the private sector. If you are a grant-supported group, it’s like being on deadline every day.
- Whose shoes are you wearing? The shrewdest business people put themselves, at least metaphorically, in the shoes of their customers and take a long walk. That little pebble of a software bug starts hurting a lot more the hundredth time you step on it. Deploy it to a thousand people and the pain grows exponentially.
- What works in one country may not be successful next door. Nations vary by more than geography—and the differences can be potential potholes. Laws, regulations, languages, cultural practices, political organization, differing types of health systems, different infrastructure—all can derail innovation if you aren't ready for them.
- Finally, "It’s who you know" matters—but so does "Who you don't know." The under-deputy-assistant-interim minister of finance may quash your plans because she was not consulted about funding.
The above list is not meant to be exhaustive. Though we only had 30 minutes to hit the highlights, there was a strong theme: Talk to people face to face, whenever possible. No matter how wonderful your idea/approach/innovation is, you will learn the most about what someone thinks of it if you talk to them in person. There is clinical evidence that when we are talking with someone, building trust, and coming to agreement, our respiration and heart rates actually align. We should seek that alignment more often.