Interview with Dr Joshua Kibera, CEO and co-founder of The Pathology Network (TPN).

Who is The Pathology Network (TPN)?

TPN is a Kenyan registered company that brings together pathologists into a working group and uses a membership-like business model to recruit hospitals that need pathology services – which is basically all hospitals. The pathology network recruits hospitals into its network as members, and uses a very unique business system to allow these hospitals to access our network of pathologists.

The field of pathology is confusing to many, with some associating it only with autopsies. Can you help us demystify the field of pathology?

Pathology is a branch in medical practice, just like surgery, gynaecology, or paediatrics. It is specific to the identification of disease in the living and in the dead. In the dead, forensic pathology focuses on the identification of disease that caused death – the cause of death is a disease process, and sometimes it’s trauma or something else. But a lot of pathology, actually, focuses on the identification of disease in the living.

“Pathology is a branch in medical practice, just like surgery, gynaecology, or pediatrics… [that] is specific to the identification of disease.”

There are pathologists who look at diseases of the blood (hematopathologists), those who look at chemical changes in the blood (clinical pathologists), and there are pathologists like me who look at tissue pathology, which includes solid diseases like cancers and tumors, growths, etc. (anatomical pathologists). These are all different branches of pathology, and each of them is a specialization on its own. It usually takes four or five years after graduating as a doctor to specialize in any one of them.

Does TPN focus on any particular one of these branches, or does it cover the whole spectrum?

I started TPN to basically address the challenges that we faced in our branch of  pathology, anatomical pathology. A tumor is any growth in the body and it can be cancerous or non-cancerous. You can have something like tuberculosis that can cause a growth, or find that some fat accumulation in the body looks like a growth, which oftentimes can be worrisome. So how do you differentiate that from cancer? I think those of us who practice anatomical pathology are less than 100 in Kenya. How do you distribute all the work across the country equally among these 100 people? This is the problem we were trying to address, and so we brought some of these pathologists on board into TPN so that we could distribute the work within the community in the network (our members). We then realized that the network that we’ve created can be used to solve the problems other branches of pathology face but, at the moment, we haven’t optimized it for those branches yet. We wanted to make it work for anatomical pathology first.

“We are opting to look at quality first before looking at scale.”

What would it take to optimize TPN for other types of pathology?

It will take quite a bit of funding. Pathology is a very scientific discipline which needs vigorous testing, sometimes expensive equipment, and time to test systems to make sure that we are providing results of adequate quality. It’s not something that you can move quickly into without first having identified the right people who have the right skills, and systems to make sure that they will deliver appropriate quality at scale. You also have to ensure that there is a mechanism for detecting when this quality begins to fall below standards so that you maintain those adequate standards. If we say that somebody has cancer, and they don’t have it, that would be a very big blow to The Pathology Network. These are some of the reasons why we are opting to look at quality first before looking at scale.

What is the role of pathology generally in healthcare?

Pathology is the foundation of healthcare. Pathology is like your Excel program in  finance – it helps you to make sense of the numbers that you’re seeing. We’re the ones who work in the background to make sure all those calculations are correct. If it was in the automotive industry, pathology would be the engine. It’s hidden away in a compartment but is the thing that is able to help the car move. 

In the medical profession, nothing can happen without a lab diagnosis. Without a properly functioning lab in the background there is no way of practicing good medicine, because you won’t know what you’re treating. Without pathology, a doctor can’t make sense of what the patient is suffering from.

“Pathology is the foundation of healthcare… Without a properly functioning lab in the background there is no way of practicing good medicine, because you won’t know what you’re treating.”

What challenges in pathology is TPN trying to address, and how severe are they?

The unavailability of a pathologist delays access to treatment. Where it used to take a month to process a sample and deliver results, TPN has reduced that to 7 days (a 75% reduction in turnaround time). This then allows for discussions on treatment between patients and doctors to begin. Delays in diagnosis are very costly for patients. By the time a biopsy is collected, the patient was already unwell. As the patient is waiting for results, the tumor continues to grow. Delay in treatment increases the burden of cancer and death due to late treatment. It also makes treatment more expensive. 

Why is digital pathology important? Who is likely going to benefit the most from this solution? What outcome do you want to achieve with this solution?

In the ‘80s and ‘90s, Kenya trained very few pathologists and the practice did not develop at par with other medical disciplines. As a result, there is currently a shortage of pathologists. Digital pathology addresses this problem. Through our system, 30 full-time pathologists could serve the whole of East Africa. Digital pathology allows for pathology to be practiced remotely while removing the need for a microscope. In some countries like the US and in Europe, digital pathology has been exclusively practiced for the last three years. 

What are some of the successes you have had so far in addressing these challenges?

We identified the obstacles on the path to diagnosis and built software that links hospitals, labs, and pathologists in response. We convert a tissue into a report that is delivered to the doctor and the patient. This is achieved through a lean workflow process and a monitoring system that can accommodate large volumes of work but still maintain good quality and short turnaround times. We are currently serving 20 facilities at 500 tests per month, but we have the capacity to absorb much more work and we can analyse pap smears and complex samples like brain tumours.

Are there any key partners that have supported the delivery of this solution?

Joining the Villgro Africa incubation program gave us a huge boost in self confidence; it said that someone believed in us. Then there was the funding,  which didn’t come with noise. There was no dictation of terms to us but we got asked a lot of critical questions that helped us to think through our work. We also got sales training and investment readiness support including financial modelling. All this has brought us closer to maturity. 

Are there any challenges that you have encountered in your service delivery?

Getting the business model right was tough, especially as pioneers. Keeping the company running as we iterated and pivoted was also not easy. Creating the structures for rapid scaling has been challenging (i.e. building the software systems and finding the right talent). Also, hardware is quite expensive. For instance, a scanner costs $80,000 a piece, and many investors don’t understand the space, which has made fundraising difficult.

Who are the main competitors in your space?

Any lab out there is an indirect competitor, but it could also be a partner.

What do you hope to achieve in the next 5 years?

We would like to be in 11 countries in 5 years. In 10 years, we hope to be so entrenched in the market that we become like Google in our space.

Could you share some key learnings that you have picked up in your entrepreneurial journey and what advice would you give to a fellow entrepreneur in the healthcare sector?

Entrepreneurship is not for the fainthearted. Struggles will come. There was a moment I almost closed the company and returned to employment. As an entrepreneur, you will face that pivotal moment when you will have to decide to quit or stay the course. I had to decide that I will do this until it works. 

Make sure you’re solving a real problem. Stay hungry to learn more. Walk with the right people. Finding the right co-founders and staff is striking gold because you can’t go it alone. Don’t be selfish with equity and power. Develop yourself. Go for entrepreneurship training. I attended an excellent entrepreneurship course by WYLDE that really enlightened me.  Read books. Built to Last is a must read. I’ve also attended excellent entrepreneurship courses from the “university” of Youtube. There is so much good content  you can find there. I’ve enjoyed listening to the likes of Eric Saintz and Reid Hoffman. There is no formula for success, there are only principles. 

“Entrepreneurship is not for the fainthearted. Struggles will come… Make sure you’re solving a real problem. Stay hungry to learn more. Walk with the right people… Develop yourself.”

Globally, 830 women are lost every day due to pregnancy complications, the vast majority of which are preventable and treatable. In Uganda alone, 16 mothers and 94 babies are lost daily. Maternal mortality has been highlighted as a priority by the United Nations Sustainable Development Goals, including the target of providing universal access to sexual and reproductive healthcare services by 2030. 

Many expectant mothers, especially those far from healthcare facilities, go through their pregnancies with very little information on whether what they are experiencing is normal or a cause for concern. Therefore, they are often unsure of whether or not to make the effort to visit a health facility. This can result in either spending significant time and money to see a medical professional unnecessarily or waiting too long to address complications. When a healthcare visit takes place when it is not needed, it is expensive for the patient, adds to the overcrowding in maternity wards, and increases the burden on medical professionals. When complications are addressed later than they should be, this can lead to expensive emergency interventions, such as c-sections, that could have been avoided, or even loss of life. 

The root of this problem is a lack of access to information. The expectant mother often does not have information about what is going on in her body and, therefore, does not know when to be alarmed and when everything is progressing as it should. Medical professionals do not have information about the mothers who come to see them, making it challenging to triage and treat patients effectively. 

Stephen Tashobya, the founder of Wekebere, understands this challenge on a personal level. He says he started Wekebere out of “both pain and passion” after his own sister died during childbirth. By the time she realized she was in labour, she was not able to travel the 100 kilometres to the nearest health facility and her complications were not addressed in time. As his family searched for the reasons why his sister died, he discovered that her case was not unique and that, in fact, many expectant mothers experience very similar challenges. Stephen, who was in his fourth year of university at the time, asked himself, “How do I use the skills attained in school to build a solution that can impact the community and tackle the real problems that are affecting people on the ground level?” 

Teaming up with colleagues who had medical experience as well as programmers like himself, they came up with a device that allows expectant mothers to have information at their fingertips and provide better information to doctors. Their process began as any good invention should: by asking questions. They wanted to understand the root causes and what was actually needed on the ground. After visiting 27 hospitals and speaking with over 100 midwives and mothers, they realized they needed to come up with a solution that could collect and monitor physiological data from both the mother and the fetus and provide information to mothers and the necessary medical professionals.

When it comes to the medical device, they are currently on their fourth generation prototype, which can detect fetal movements, fetal heart rate, and uterine contractions. Their app, which users have already started using for knowledge sharing, is on Google Play Store. They will soon be launching a pilot study in Kawempe National Referral Hospital to ensure the efficacy and safety of their product, after which clinical trials will take place in several regions throughout Uganda.

“This innovation has the power to save so many lives, not only in Uganda, but also throughout Africa. The cost of the problem is also very high, and we believe Wekebere’s solution should help reduce it.” – Immanuel Momanyi, Senior Portfolio Manager at Villgro Africa

As Wekebere continues in the development of their innovation with the support of Villgro Africa, Stephen and his team ultimately hope that they will make an impact when it comes to tackling the root cause of the problem. They hope to reduce maternal and infant mortality as well as neonatal deaths, increase expectant mothers’ utilisation of health services, improve the speed and accuracy of health workers, and reduce healthcare expenses.

An Interview with ilara Health Founder, Emilian Popa

ilara Health’s vision is “a world in which early detection and preventative healthcare are accessible to everyone, everywhere.” In order to achieve this in Africa’s hyper fragmented primary care ecosystem, they are creating a new model of care by partnering with existing primary care facilities in Kenya, and soon across Africa. ilara Health began in early 2019 with providing diagnostic and digital solutions to healthcare facilities. More recently they have started to take a holistic view of clinics’ operations by creating a digital platform that can address their primary challenges.

What is your innovation?

ilara Health was founded to bring point of care diagnostic devices to settings where they were not accessible and/or affordable. As we grew, we realized we needed to go further and help rebuild the primary care ecosystem for this urbanizing demographic across the continent by digitizing it through developing a clinic operating system to enable the introduction of future services.

“Our focus to date has been on building a network of clinics across Kenya through the deployment of diagnostic tools. We are evolving into bringing essential services to the clinic to drive its growth and improve the care it is able to deliver, to ultimately brand and consolidate a core set of clinics. To do this, we’ve needed to develop a clinic operating system to enable the introduction of future services. Our system has been built to address pain points in patient and clinic management that make a clinician’s life more difficult than it should be. This same system generates clinic-wide data that enables us to introduce new services to develop the healthcare ecosystem. This puts us in a unique position to expand our footprint at the clinic level.” – Emilian Popa, ilara Health Founder

What progress have you recently made that you are celebrating?

We have been able to place diagnostic devices in over 650 small clinics (out of about 8,500 private primary care facilities in the country), building our overall network. We have also been accelerating the development of our technology platform, with the goal of implementing it in 300 primary care facilities by the end of the year.

How has being part of the Villgro Africa incubation program impacted your growth?

The primary benefit of participating in the incubation program was Villgro’s local knowledge and understanding of the healthcare and startup ecosystem. We were connected with local healthcare experts as well as startups all across the world who we were able to learn from. In order to succeed, we need to understand our market and also gain insight into other markets, like India, that are five or ten years ahead of where Kenya is today.

“ilara has a very strong team that is very execution focused. We could see the inputs we were giving being put into action very quickly. Looking at their impact numbers, the work they’ve done is amazing. They are sitting on a goldmine of data, which can be useful for so many other things, including pharmaceutical and insurance companies. It’s been a very exciting partnership and there have also been other synergies between ilara and other companies in the portfolio.” – Wilfred Njagi, Villgro Africa CEO

What are you hoping to achieve in the next 6 months to one year?

There are three main pillars we are focusing on:

(1) Continuing to build the network. We are currently in 650 primary care clinics and pharmacies and our goal is to get to 1,000. This would mean we would cover around 25-35% of the serviceable addressable market.

(2) Digitisation of the clinics within our networks. The goal is to reach 300 by the end of the year.

(3) Once we have a platform and operational and financial visibility through data from the medical facilities, we plan to grow value-added services and products for primary care facilities, such as personalized micro-insurance, micro financing, and new digital health technologies based on unbiased datasets in order for them to benefit and for ilara to generate more value. We are currently running several pilots focused on lending and insurance services.

“Beyond incubation I see many opportunities for continuous collaboration. If you look at ilara as a network, it has the possibility of plugging in so many other healthcare innovations into it.” – Wilfred Njagi, Villgro Africa CEO

How to Do More With Less: Cost Cutting Development Strategies

On 1st July 2021, Villgro Africa held its second iteration of the Innovators Forum, a forum committed to building resilience through investment in biomedical and diagnostics innovation and manufacturing in Kenya. Titled “How To Design and Manufacture Ventilators in Kenya,” the discussion served as an accelerated case study on the development, approval and manufacturing of medical devices. 

The conversation was rich, covering the many triumphs and challenges encountered by the brave souls who have ventured into the uncharted territory of medical device development — and did so in the middle of the COVID-19 pandemic, which has been marked by global supply chain upheavals. It was therefore no surprise that one of the challenges highlighted was the difficulty and cost of obtaining components and test equipment. The discussion brought to light the need for cost control, especially in the early proof-of-concept stage. Several opportunities for improvement were identified for the very new Kenyan medtech ecosystem. The following thoughts address the opportunity for cost-cutting in the prototyping stage, which could enable entrepreneurs to move faster towards their commercialization goals.

At the very beginning of a design/development process, these low-fidelity prototypes could be made out of inexpensive, easy-to-obtain materials such as wood, PVC pipes, duct tape, plastic sheets, etc. In the case of user interfaces, they can be simple PowerPoint mockups illustrating user interaction. As the user needs are better understood through feedback and observation, more functional and complete models can then be fabricated.

During the next stage, it may be that specific functionality needs to be proved out by building specific engineering models. These are often sub-systems that can be tested in isolation of the complete system. In the case of ventilators, a good example would be putting together a system to mix oxygen and medical air to test which type of valves and electronic drivers are flexible enough to meet user requirements. This level of development is very engineering heavy and although, ultimately, the functionality meets a user need, the purpose of the prototype is simply to prove technical feasibility. 

At this point, things become less straight forward because, although it is not yet essential to have medical-grade components, the testing often has to be done with high-end components that will mimic the ultimate medical-grade functionality. These will often need to be imported, since the medical device supply chain is currently not fully supported locally. To reduce the cost of development, innovators can look into organizational assistance from bodies such as the Kenya Association of Manufacturers (KAM) that have access to the most current information on government subsidies and incentives for manufacturers. In the example of ventilators, KAM is able to work with innovators on duty remission for raw materials. This can result in tax savings that provide entrepreneurs additional funds for development.

Developing medical devices from initial concept to the point of bringing it to market is a long and complex process. By focusing on the larger picture and understanding the purpose of each step in the process, innovators can learn to prioritize in ways that reduce their costs without hindering their progress. By using a rapid prototyping approach and using appropriate levels of complexity in prototypes, innovators can have a more cost-effective development strategy. Additionally, government subsidies and incentives can further help by reducing the cost of expensive high-tech components.