Digitizing the Largest Tuberculosis Program in the World with Andrew Cross of Everwell

Aid, Evolved
Aid, Evolved
Digitizing the Largest Tuberculosis Program in the World with Andrew Cross of Everwell
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Like another airborne disease we are all familiar with, tuberculosis (TB) spreads invisibly through the air. If you catch it and you don’t treat it, you’re likely to die. India has the largest TB burden in the world, with millions of cases diagnosed and over 500,000 deaths every year. Consistent, continuous treatment and management of care is essential to a healthy recovery. This is why the work of Everwell Hub is so critical. Everwell Hub is a comprehensive digital solution for the management of tuberculosis. 1 in 5 newly diagnosed TB patients in the world are managed through the Everwell Hub – making it the most widely adopted solution of its kind in the world.

Andrew Cross co-founded Everwell Health Solutions and has been CEO for most of its existence. He sits down with Aid, Evolved to share what the journey to scale has been like, from the hallowed halls of Microsoft Research to the messy realities of public clinics. At Microsoft Research, he was able to work with cutting-edge tech and world-class researchers. In this environment, Andrew experimented with solutions in computer vision, augmented packaging, and cellular technology.

Then, in 2014, one of his innovations started to stretch beyond the domain of a research lab. 99DOTS, a tool for medication adherence, was seeing significant interest and uptake both by donors and government. Andrew and his small team knew that a research lab would not be the place to scale this technology. So, they set off on their own. This was how Everwell was born.

Everwell’s journey to scale arose from a unique confluence of factors: it was built on a foundation in research and evidence. Andrew’s spin-off from Microsoft was catalyzed by early buy-in from the government. And, serendipitously, Everwell’s birth coincided with a change in health policy around tuberculosis treatment which created new demand for Everwell’s solutions.

But the journey to scale is riddled with challenges. Compared to the research environment, Everwell needed to adapt to support populations at scale which revealed new and different obstacles than at a more limited scale. As one example, their initial approach using incoming calls was blocked by the telecom operators (telcos) because the system enabled patients to call for free, so they had to innovate further to accommodate millions of toll-free calls coming into their system. In today’s conversation, Andrew shares the many ways in which Everwell has needed to adapt and change in order to support the holistic, end-to-end needs of tuberculosis caregivers in India and around the world.

One key learning from his experiences: if you’re scaling innovation, you either need to find environments with the right infrastructure to accept that innovation OR you need build an organization that is able to develop the infrastructure needed to support your innovation

Links

  • Andrew developed the initial concept for 99Dots while working at the Microsoft Research Lab in India and specifically within Microsoft’s Technology for Emerging Markets team. He speaks highly of the championship and early advice this team gave him in commercializing the 99Dots digital adherence innovation.
  • Bruce Thomas was a consultant for the Gates Foundation who has been a source of support and guidance for Andrew, helping him to develop his leadership skills and business acumen.
  • Sriram Rajamani was Andrew’s manager at Microsoft Research. He shared many words of wisdom with Andrew over the years, including this guidance on how to think about marketing: “it’s not about self-promotion. It’s not about you. You’re doing your organization a disservice if you don’t talk about the work. If you think about it as self promotion, you’ll never be comfortable.”
  • Andrew enjoys listening to Hardcore History, a long-form podcast that dives deep into major events in history.

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Excerpt

This is an automatically generated transcript from the full interview. Like humans, machines aren’t perfect, so there may be some inaccurate or amusing transcription errors.

Andrew: The real trigger point was also that we had started getting some visibility outside. We had won some innovation competitions which had visibility from donors, but also from government, which was again quite unique at the time. There was this thing called the Grand Challenges and TB Control, which was equally CO funded from BMG and U.S. at the time. What was really important about that funding call, you could say our competition was that they actually had government representatives on the committee deciding which technologies they liked. And I think that was, again, a huge well, a great thing for us ultimately and for all the innovations that were kind of recognized there, because you almost had buy in from day one that if this is selected, will at least take it to the next step. Well, at least see this at some kind of scale and really measure it. Of course, there’s still research involved. There still needs to be the right thing. But there was buy in that we’re going to invest in this.

Rowena: Super cool.

Andrew: Yeah, I still think that’s quite unique to this day that all the stakeholders were in the room from day one and therefore you sort of you had a lot of jumpstart maybe on on scaling things. So I think all these things were coming together again. The resources were starting to come in. There was interest to scale it up. Microsoft Research was not the right place because of the research angle. So, you know, suddenly we need this new organization. So that’s when in 2015 we founded Everwell and yeah, convincing, convincing people to leave, I think, you know, didn’t obviously want to do right by the team so didn’t in mass take everyone there was our little unit of bill knuckle and I and we we decided to ultimately invest in this and then I think from then on started building a team outside a different type of team.

Rowena: What was your plan of attack? You have the product. You have this idea, this innovation. As you know now, building an organization or scaling it is so much more than like the thing itself. When you started that journey, you know, maybe if I sat you down in that first year and I was like, Andrew, what’s your plan of attack? What would you have said?

Andrew: Yeah. So I think, again, very fortunate that at that time the technology to do this was relatively stable. I mean, we had proven it already in hospitals. I think we partnered with a local hospital in Bangalore called St Johns and already deployed with with people taking medication and already done kind of user studies. And so a lot of that was stable, you could say, already. So I think the real first step for us was to scale this thing up. We had the opportunity, again, buy in from the government and excitement there to start scaling this up actually with the TB HIV program, because there are a lot of overlaps between populations with HIV and populations with TB. And so we really we had this mandate to scale it up and I think it was like 30 sites, you know, in the next six months. So we had to start building a team that was, you know, had expertise in training, capacity building, kind of program implementation, because that’s not what we had at Microsoft Research. We had technology experts, research experts, but the implementation side we had to build. So our first challenge was to build up that team and then basically travel, travel to all these sites where unfortunately my language skills were not up to the mark, but I was fortunate enough to be able to travel to these sites and kind of see the settings and understand and make sure things were still appropriate, but also build a team that had those language skills and the capacity building training skills to start implementing insights and training staff and kind of onboarding patients. So that was the real first challenge for us.

Rowena: That makes sense. What an opportunity for you to have, would you say 99 dots as it was back then? Was it set up initially to be what they call govtech? Like, you know, like there’s a kind of way of working with government. Was that the kind of organization you were or did you find yourself more in the nonprofit or private sector space in those first few years?

Andrew: Yes. So everyone was set up as a for profit with with for various reasons. But one being that we could stand behind our technology in a certain way, we really wanted to invest in a team and invest in a product as as as a company would. So we were a for profit but but always dedicated to social impact and never about the profit itself, especially at the beginning, it was really about championing this idea and scaling it up. So I don’t know, actually I haven’t heard the word govtech or I’m not sure that full context there. But really it was about again, almost that same research mentality. We’re just going to build this. It’s going to be open source, it’s going to be a community, a global good. We’re going to be the champion behind it because you need an engine behind something like this, especially to get it over a first crest. But it really was meant to be kind of a global good and something where we’re in partnership with the government. And every step of the way they gave great feedback on how things should be designed, how it should be integrated, how it can integrate with public care workflows you’ve got, as a pharmacist dispensing medication.

Andrew: How does this work with that? There’s a health and social worker, a field worker that’s visiting houses. How should it work with that? So that was very tightly coupled with the government. They were you know, we were fantastic partners in that sense. And I think that that was, again, attributed to our early success with just that very tight coupling and partnership and championship from the government as well. So I think we at that time, we probably weren’t thinking so far ahead, just just really said our short term mission is to we’ve been asked to scale this, we’re going to scale this. And again, want to emphasize that a lot’s changed in health care and $99 appropriateness for for supporting things in the world we have today. But at that time, there’s actually another well, kind of again, with the theme of infrastructure and innovation, but there’s a big change happening. And that was I mentioned before the drugs at the time were the intermittent regimen, which means not every day you’re taking medication. But I think, again, science and research had shown that a daily dose is actually much less toxic for people and it’s easier to remember. And there’s all these benefits. So the government of India was shifting from these intermittent regimens to a daily dose.

Andrew: So again, with with this Dot’s mentality that we need to observe every dose, it became impractical to to do dots on a daily basis. So we had this again, fortunate timing and I think this is what also helped propel things early on was that everyone wanted to change this daily regimen. It’s better for patients, better for the program. But there’s, you know, maybe mentality wise people weren’t ready for that. You could say relaxing of rules that we’re not observing every dose. So $99 at that time became a way to again make a better situation for patients where the less toxic drugs daily dose and less frequent visits but still work with the program to give them some kind of daily engagement and daily understanding of the adherence rate. So that’s that’s where, again, you always want to think it’s a meritocracy that the best technologies will always win. And I think that that often happens. But in this case, there was also a huge element of timing where it really was a fortunate timing that we had this innovation, there was this program change, and it needed something to be able to really roll out this new daily measurement.

Rowena: That makes that’s phenomenal to hear. It sounds like a lot of things are really coming together for you at the right time. I guess my question was about your your path to scale, you know, and as like, there are a lot of good ideas that people say the government’s going to like this, they’re going to buy it, they’re going to scale it. That’s kind of like the default thing that everyone working in the nonprofit sector wishes could happen. I think you’re in an unusually good place that you had government at the table right from the start. But my question is, in terms of your your your clients or your scale model, your business model was the idea that you would sell it to the state in that state and that state? Or was the idea that you would you working contract with organizations? Were you going to partner with pharmacies like how did what was your path to scale that emerged?

Andrew: Yeah, absolutely. At this time, you know, exclusively working in the public sector. So it was all through government infrastructure and again, very fortunate that we were working directly with the central government, the federal government, you could say, of India. At that time, you know, there’s still a lot of autonomy. And, you know, states run things their own way a lot of times. But some of these big changes like drug changes and kind of technology that happens at a central level. So honestly, you know, the scale up plan was sort of piggybacking the rollout of these new drugs, these new daily regimen, because it didn’t happen overnight in every place, but everywhere. The new daily drugs would launch. We would launch alongside of that with with our 99 dots. So working directly with the central government, that’s how we sort of got scale in the early days.

Rowena: Wow. That’s great. That’s phenomenal.

Andrew: Those were the exciting.

Rowena: Yeah, for sure. And I think that I mean, maybe, maybe it’s an example of of doing it right from the start because you had government at the table. And let me just recount. I think there’s there’s there’s three key assets you had right from the get go. One, you had Microsoft Research Technology in your wheelhouse, too. You had government TV backing right from the start. And three, you had this change in policy which made regular shots, you know, directly observed therapy infeasible. So there was like a change in health policy that really pushed towards the adoption of your system. You must have, it sounds like, very smooth sailing. It sounds like everything just like worked right from the start. Was it just that easy in the first few years?

Andrew: No, of course. I think I’m just I’m definitely highlighting the fortuitous environment that also helped things scale, because I think that’s, again, for other innovators, they’re often frustrated when things don’t go somewhere. Their idea is great, but it’s still not working. So I think the lesson I’ve learned is that there’s a lot of things that contribute to the success. Of course, you know, you work 100 hours a week, you know, you have a great team, you have a great idea. But there’s also other ecosystem factors that can make or break the success of a project. You know, just talking about some of the challenges, I think specifically for this innovation, early days in a small research setting, you can ensure that everyone has a phone. You can ensure that if anything goes wrong, you can quickly reach out to them and support them. But at scale that that’s impossible. You know, that doesn’t work. And that’s the whole point of the challenge is that there’s not enough humans, health care workers to spend that kind of time on an individual basis. So one thing that didn’t work for us, for example, was the toll free lines. I mentioned this missed call system, which again no longer exists now, and we might be part of the cause for that. But, you know, when it’s a small scale project, you can get away with these missed calls.

Andrew: But obviously the telcos are losing money every time that happens. So, you know, as we started to scale up, the so many missed calls were coming on the hour, the lines that we were rented, these are virtual lines. Again, there’s no phones at offices. These are virtual numbers. So many missed calls were coming on that we actually got shut down or kind of telcos wouldn’t support it anymore. So we you know, that was a big challenge for us immediately had all these phone numbers out in the wild. People were calling and suddenly the calls aren’t going through. So we had to quickly adapt and iterate. And basically the solution was to come up with toll free phone numbers. So now these are paid for by us, not by anyone calling, but they’re they’re hosted lines that they’re paid for. So that was one challenge. Again, something that you would never have seen in a research setting, a small setting. Everything works great or can work great, but at scale you run into new challenge. And that was just one of them. So that was that was a big challenge. I mean, there’s there’s enormous challenges with phone access. For example, again, in a city like Bangalore, you might have very high phone access.

Andrew: And again, things have changed over the last ten years and phone access is increasing. But there’s always or there still is disproportionate access to phones by, you know, by gender, by geography, rural versus urban. So there’s still many people that don’t have a daily access to a phone. So that was something, again, we encountered at scale is how do we have solutions for that population or how do we reframe this technology as rather than something for everyone? This is something for people with access to phones who are comfortable calling, etc. So we had a lot of adaptations and challenges trying to make this as accessible as possible because again, you’re this is for the entire population recovering from TB. So that was another big challenge there. And maybe just last one, since I had three good factors, I can mention three challenges. I think the other one was I mentioned the initial sites where these TB HIV sites and I think you want to feel like, well, in a lot of places, TB and all these different disease verticals have been independent for a long time. And so there’s some overlap, but they don’t always aren’t fully aware of each other’s workflow. Sometimes there’s overlap, responsibilities, sometimes there’s challenges kind of courting those too.

Andrew: So that was an early learning. And just as a fun anecdote, one example was in the TB infrastructure, for example, they had a system of obviously geography. You’ve got a country, a state, a region, a district. There’s all these different ways to break down geography. But on the HIV side, they had the same system, but actually not always the same breakup. You might have a district rename something else in one system or different geographical boundaries. And of course, a lot of these things change over time. But you had disparate systems, so suddenly you have to untangle that. In some ways you’re like, you’re solving census level data or you’re understanding, you know, working with both programs say, look, we both got the same district, there’s different names. We need to think of one or else the programs can’t work together. And part of that’s our role. Part of it’s not our role, but those are some of the challenges, again, that you see at scale. And I think again, with the theme of kind of infrastructure wise, it’s almost like you’re having a step back to an infrastructure level to solve that problem before these innovations can even take hold, because you have to solve this problem of naming a district.

Rowena: Yeah, that makes total sense. Like I think when in your mind you had this 99 dots innovation, you had this thing that was going to do phone calls, you didn’t sign up with us for this with the idea that you were going to renegotiate telco revenue models or that you were going to have to deal with phone access in all these different states. But obviously, if those things aren’t there, then your innovation isn’t going to work. How did these challenges directly affect you or your team? Like what did you what did you do when you came up against those kinds of barriers? Did you expand the scope of the work that you’re doing? Did you bring in partners or like how did you evolve in the face of those challenges?

Andrew: I think for the most part, the challenges are what drove the work. I mean, it’s that’s the interesting part. Maybe that’s the engineer in me or that’s just everyone wants you want to solve interesting problems. And sometimes they’re more interesting than others. But I think that’s what made the work always interesting, is that there’s always something new. You never know what’s going to hit the next day. And I mean, there are worse things that could happen, but these are all solvable problems. So I think mostly drove our team. It was exciting. It was a reason to kind of come together and brainstorm, go back to the whiteboard and let’s rethink this from the beginning or let’s let’s find a solution to this. I think that was a lot of the excitement in the early days and maybe, you know, just kind of again, pivoting $99 was the early work. But of course, what we do now is much broader than that. I think part of the challenge, again, that we ran into at that time was that you’ve got this cool innovation, but it doesn’t connect to all these other pieces I mentioned. There’s diagnoses, there’s drug dispensation, there’s subsidies from the government. There’s all these other pieces that are part of care. And if there are digital systems that are not talking to each other, it also limits the ability to scale this up. Because as a health care worker now I’ve got to learn a new system. I’ve got this 99 point software which I use for this, and I’ve got this inventory software which I use for this, and I’ve got diagnostic software. So it is actually limiting our ability to scale because it was an extra burden, it’s an extra step. So that was one of the other challenges that we faced early on.

Andrew: And kind of the realization was, well, you know, there’s a more basic need here that could enable this innovation in others, which is, you know, core infrastructure, core digital system that integrates all these different pieces of care. Why are we thinking of it here in isolation? It’s connected to this cascade of care, as they call it, this recovery journey that someone’s going on. So we need a broader system that connects all of these pieces to really fully to fully realize the power of any particular innovation. Even today, you’ve got different innovations in diagnostics, new machines, AI, all of these things. But if they’re not connected to a core system, they’re always going to be limited to their impact because you care is holistic and they touch different pieces. So I think that was another challenge that we faced where the exciting solution was, Well, do we want to expand the technology that we built, the platform that we’ve built to cover these other aspects of care cover means and sometimes just integrate. It doesn’t mean rebuild what someone else has already done, but kind of design a common language, a common architecture that they can all speak to each other and help integrate them. So the problem you’re solving is that a health care staff can log into one system and see everything from drug supply to adherence to, again, subsidies, financial subsidies for patients, for registration of new patients. So that was that was another big pivot for us is almost taking a step back to take 20 steps forward and kind of work with the government to design this or redesign or support or kind of modernize, you could say, this digital system for how they manage the entire TB program.

Rowena: I think we’re seeing the glimmers of Everwell Hub in this picture. I want to hear all about that.

But let me also just how that I think something that’s really unique about your approach and I think speaks to the strength of how your organization has evolved, which is I think a lot of tech founders are innovators. They have one innovation and they’re attached to it. They’re stuck to it. You know, like I build this widget, I have this software. That’s the one thing that I do. And that’s what, you know, my company is built around it very much sounds like Andrew. Like you looked at the situation with TB, you were like, okay, I have this one adherence tool, this $99 thing, which is about, you know, the the blister packs and how they work. But then you realize that there was a much broader need. And instead of saying that’s somebody else’s job, you said, what do we need to do to deliver this at scale in India? And then you you did it. And that’s how the journey that that you’ve taken. And that’s I think it’s a very strategic decision. It’s a very it’s a very unusual decision. And it’s it’s very necessary in some of the environments that we work in. And it puts a lot of strain on the organization. You know, it means that maybe you started off wanting to just hire people that would manufacture your blister pack or, you know, man, your toll free call centers. But then, you know, as you started to deal with phone procurement, as you started to deal with HIV in response to the problem that you were facing, you needed to expand your services and the scope of what you were doing.

Andrew: I mean, a lot of it came down to our mission. I mean, our maybe in the early days, it was around championing a product or an innovation, but it really was always about improving the access to health care, supporting the government. Like I said, going back to the model we sort of perfected in the Microsoft research days, there is a domain expert partner who’s telling you what the real challenge is. So you can keep pushing your innovation if you want. But if you’re hearing that there’s another core challenge in your mission is to solve these challenges and improve the overall access to care, then I think decision becomes pretty easy. And so I think for us, you know, we heard loud and clear and saw ourselves that there was another limitation that wasn’t related to original problem space or is related of course, but is something it’s something entirely different. And with our mission to positively impact the TB space in India at the time, then it was pretty clear that this is where we need to need to work and that is at that time broader digital infrastructure for for the program. And I think there’s some, you know, as an innovator, you want to you can’t give up the first time. Someone doesn’t like your idea or the first time it doesn’t work. But, you know, at some point, if you’re hearing there’s a bigger challenge or you’re hearing that something’s not working, then it is your responsibility to kind of pivot or or focus.

Andrew: And for us, again, we want to solve the most interesting and most the biggest problems that technology could solve in the space. And we heard this was it. So we ended up pivoting a lot of our, you know, the other $99 work still lived on. But we pivoted a lot of our attention and time to this more core infrastructure work because we saw a bigger opportunity for impact. And I think, you know, there’s other lessons learned along the way around how, again, a particular innovation, 99 dots at that time had a lot of positive impact around ability to change the drugs and kind of empowerment. But then at some point there’s populations that doesn’t work for us. You need to be willing and able to say, well, it’s not appropriate for that environment, so let’s not push that innovation there. In fact, they need something far different that maybe what someone needs is actually financial subsidies so they can afford food, so that the medication can have its proper effect. And so I think there’s a bit of yeah, I think getting at is you want to kind of stick to your guns in some ways because you can’t again give up the first time you hear. No, but you also need to be flexible enough to recognize when the environment is changing and where you can be most useful if that’s your goal.