Over the past two decades, the spread of new diseases such as HIV/AIDS, severe acute respiratory syndrome (SARS), hepatitis C, and dengue haemorrhagic fever, as well as outbreaks of traditional diseases such as typhus and diphtheria, has generated a renewed awareness of the global threats posed by infectious diseases. Indeed, infectious diseases, such as cholera, meningococcal disease, and measles, cause 63 percent of all childhood deaths and 48 percent of premature deaths. About 300 million people have acute cases of malaria, 90 percent of them in Sub-Saharan Africa.^[1] Infections also cause cancers, cardiovascular, and respiratory/digestive deaths. The overall toll of infectious diseases is significant around the world.

The threat of rapid national, regional, and global spread of infectious diseases poses a new challenge: early detection, and coordinated and rapid reaction by public-health authorities locally and globally. A basic surveillance system built on a low-cost communications infrastructure is critical. The innovation from Voxiva Inc. in tackling such a challenge in Peru is proving to be robust, with applications in developed countries such as the United States as well as developing countries such as Afghanistan, Iraq, China, and India.

Continuing threats of emergent diseases, such as SARS, threaten state and regional economies. According to the Asian Development Bank (ADB), the SARS outbreak will have a significant economic cost (in addition to the loss of life it will cause). ADB estimates that SARs will cost Asia approximately $7 billion in lost economic output, and the region as a whole could lose up to $28 billion.^[2] However, early disease detection, clear and rapid communication, and coordinated action by health authorities can inhibit the spread of infectious diseases. According to the World Health Organization, “Reporting systems are the intelligence network that underpins disease control and prevention. Without this framework in place, it is impossible to track where disease is occurring, measure progress in disease control targets, monitor anti-microbial drug resistance, or provide an early-warning system for outbreaks and the emergence of new diseases.” Surveillance data also is needed to assess where resources should go for maximum cost-effectiveness. Research in public health, around the world, has resulted in four simple conclusions to minimize the spread of disease:

Voxiva Inc. considered these four factors when tackling a challenge with their technological solution. Though Voxiva first designed their platform around an epidemiological application, these criteria have applied to other types of cases found the world over, such as reporting crime, supplying blood to hospitals, and testing new vaccines. Though these solutions might seem obvious for people who never leave home without a mobile phone, Voxiva looked beyond the U.S. borders to rural areas where 70 percent of the world’s poor live with limited access to telecommunications.^[3]

Voxiva exists to bridge a communications gap, at the same time targeting a market that makes less than $2 a day. Its value added is socially admirable, and at the same time it seeks to be profitable. Its basic assumption is that there are a lot more telephones in the world than computers, and that telephones are a much more accessible and practical tool for conveying urgent data and information. Voxiva challenges an implicit assumption held by many: Computer usage must proliferate in rural communities in order to connect the poor. In bypassing this assumption, Voxiva provides a solution divorced from hardware configuration. Instead, it adds value by streamlining the flow of critical information through the existing telecommunications infrastructure.

Voxiva was co-founded by Paul Meyer and Dr. Pamela Johnson, who both have extensive experience in linking humanitarian projects with business enterprises. Meyer was founder and chairman of IPKO, the first and largest Internet service provider in Kosovo; Johnson was previously the coordinator for child survival at the U.S. Agency for International Development overseeing public health programs in fifty countries. Voxiva leverages the convergence between the public and private sector, creating a social venture with the goal of creating a better world by promoting public health in developing economies. These ventures are driven by profits, scalability, and ROI as much as the social good it can do.

The health-care industry relies heavily on the management of critical information, and technological solutions hold great promise for providing support for challenging and complex interdependent managerial decisions and interventions that characterize health practice. The health-care sector is second only to the business sector as a major user and promoter of tools and methodologies to harvest knowledge through intensive use of ICT.^[4] As a social venture, Voxiva (with their credibility and track record) has positioned itself not only as expert in public health, but also as a business truly interested in solving public-health problems. As a result, Voxiva attracts a unique type of worker: The ideal Voxiva employee is part McKinsey consultant, part Microsoft technician, and part Peace Corps volunteer.

Voxiva’s pilot launch application, Alerta, gave voice to marginalized communities in rural Peru that were only part of a health-care system according to a zone map, but not in practice. Voxiva’s Alerta brought these remote and disaggregated groups into the fold years before their governments thought it was possible. Voxiva’s primary challenge was to deconstruct a complex information reporting system into the “lowest common denominator” necessary to achieve the defined goals. This included not only the reporting structure, but also developing a user-friendly audio interface and assisting organizations accustomed to “snail mail” to leverage real-time information.

Voxiva piloted a system that connected approximately 204,000 individuals in two sparsely populated districts south of Lima to the national health surveillance system. The population density of Chilca-Mala was 15 residents and of Cañete 24 residents per square kilometer, respectively. The system incorporated 76 health clinics, health centers, and district centers (SBS) that are part of the four levels of the Ministry of Health. In total, Peru has 135 health posts (operations), 53 district-level health centers (or SBSs), and 34 state-level health centers (or DISAs that play a vital role in disaster-outbreaks management), along with the Department of Epidemiology (or the OGE), and the Ministry of Health (or the MINSA) located in the capital, Lima.

Figure 1. National public-health surveillance, Peru.

To improve communication, Voxiva’s reports are available 24 hours a day, 365 days a year, in near real time, through text messaging to cell phones or e-mail.

The pilot ran from March 2002 through early September 2002. Preliminary results showed that prior to Alerta’s installation, 28 health posts reported on a weekly basis, whereas 22 reported on a monthly basis to the Chilca-Mala SBS. The MINSA required that health posts and centers report on a weekly basis, but because of the cumbersome process of transporting the reports, many only reported monthly. After Alerta’s deployment, 12 of the 22, which had previously reported on a monthly basis, began reporting on a weekly basis because of access to a telephone in their village. During the pilot, 26,264 cases were reported over 4,167 calls. Two hundred and four users, including front-line health workers and management, utilized the program.

A survey conducted in August, as the pilot neared its end, revealed that 90 percent of the respondents who used the system believed the faster responses from supervisors was the primary benefit of the system, and 70 percent of the users cited the increased communication with their colleagues and supervisors as a primary benefit of the system. In addition, 50 percent believed that reporting was easier, 40 percent believed more cases were reported, and 40 percent believed they saved time over the previous paper-based system. The time used to make a call has fallen from three minutes and 32 seconds to two minutes and 21 seconds, where the time has seemingly stabilized. Anecdotally, there seemed to be early adoption with younger medics as well as an increased interest in computers among all doctors.

There were several reasons for noncompliance. Because Alerta was a pilot, all health posts were required to use the previous paper-based surveillance system; some officials did not want to report twice. Reports were submitted inconsistently because of unfamiliarity with the system. Juan Rodriguez, director of the pilot program, said, “We expected the phone would be a familiar enough device where training would be minimal. Instead, we found that training is still required because of unfamiliarity with IVR and voicemail. For instance, a training session was held in July 2002 in Chilca-Mala to provide additional training for voicemail use.”

The lessons learned from the Alerta pilot launch included the following:

The pace of business within international development is much slower than that of Wall Street. The benchmarks are different, and one significant indicator is the value of time. In the public sector, time is seen as a commodity; whereas with corporations, time translates into actual liquidity and must be accounted for in every respect. This clash of cultures is one tension Voxiva faces on several levels. Time spent on relationship building in the Peru office might or might not result in a funded proposal or pilot now, but is crucial as a door opener for future possibilities.

In many ways, Voxiva’s original intent to target the developing countries’ health markets has paid off in the United States, where Voxiva seems to be a novelty based on its rare social mission as a start-up company with operations in Peru. In Peru, on the other hand, multi- and bilateral development aid in South America is big business. Many businesses position themselves as having a social mission or just convert to NGOs to gain more access to development funds. The idea of social responsibility for companies is an unfamiliar concept and as such misunderstood and distrusted. In the United States, however, any organizations associated with public funds, especially civil society, are seen as a threat to business sectors’ status quo and regarded as inefficient and bureaucratic; moreover, NGOs from developing countries are suspected of being corrupt.

In short, Peru’s development aid market is saturated; many groups are all vying for a piece of the pie. Voxiva-Peru’s challenge is to become a viable business seeking public-sector funds. With pressure to realize new contracts quickly, the Lima office is applying two short-term tactics: networking within the circles of friends, former colleagues, family, and public offices with healthy budgets. In Peru, this translates into pitching to the mayors of wealthy districts of Lima and their corresponding municipalities. Alternatively, Voxiva Peru has a choice to cultivate inroads into the private sector, which has a greater ability traditionally to make faster decisions. This effort, however, is also filled with its own menu of complications. First, there is the risk that if they do find a market, as small as it might be, there will be competition within the IT market. Many large IT corporations who have deep pockets to court the donor community might be disposed to do so with the additional benefit of satisfying their role as a socially conscious business. Second, because Voxiva has no propriety ownership, a low profile might be in order. In addition to these factors, their positioning as an IT company within health has its complications, especially with operations in the developing world. The biggest worry with investors is recuperating investment in a sector so heavily managed by the public sector in Latin America. It is harder to see the who, when, and how the payback will occur without the help of large international donors stepping in to fund the infrastructure of public services.

Two years after the successful launch of Voxiva and close to break even, Meyer still relentlessly challenged his employees to create innovative applications that deliver on two bottom lines: social and business. His track record and the story behind Voxiva was compelling to many investors. Trust, credibility, and social zeal helped him to raise another $3 million during second quarter of 2003. Meyer is focusing on pulling in the right people who are smart and driven with initiative to innovate new solutions applying the formula of success: the power of the Internet, the reach of the phone. He constantly finds himself weighing the business opportunities versus the social benefits, short-term results over long-term impact, and fighting the inclination to grow all at once into different social sectors.

His successful run so far as a social entrepreneur is paying off. Over the summer of 2003, Voxiva-Peru launched their second application: Citizen’s Alert, in Lima, Peru. This time the social good was safety. The pilot was funded by the mayor of Miraflores, a popular neighborhood of Lima with upscale restaurants and shops that cater to tourists. When the elite of Lima caught wind of this public service, they also demanded it be applied in their neighborhoods. The outcome favored all citizens of Lima since the four mayors consolidated their resources and scaled up the program to apply to the greater Lima area, population seven million. (The price structure is on a per-user basis.) Following on the heels of this launch were requests from their client base in the United States—proving again that challenges found in developing countries do not differ greatly from those in our backyard.