Erica Frenkel

BFP: What do you do?

EF: Gradian Health Systems is a social enterprise that works to improve access to safer surgery in low-income countries through improved anaesthesia technology. We sell and distribute the CE-marked Universal Anaesthesia Machine (UAM), a general anaesthesia machine designed to function with or without power and/or compressed oxygen, both of which are necessary to run conventional anaesthesia machines. As a social enterprise we are equally committed to providing the peripheral support needed to ensure the sustainability of improvements in surgical care: training of clinical and technical staff at installation, after-sales support & maintenance and global advocacy to incorporate surgery and anaesthesia into the global health agenda.

Within Gradian, I manage internal and external growth strategy. Internally, I try to figure out how to keep a lean US-based team that is effective and capable of growing our impact around the world. Externally, I work with my team to understand each of our markets individually and use that information to develop a sales strategy incorporating the right in-country people and processes.

However, as a start-up with just 6 people we all end up working on all parts of the business to some extent – which is what makes it so much fun!

BFP: What is the best part about your job/project?

EF: The best part of my job is that it feels different every day. Just today I spent the morning reviewing our sales pipeline for our east African markets and then reviewed the footage for a documentary we are hoping to make to tell the story of anesthesia in the countries we work in. The afternoon was spent coordinating our in-country trainers and developing our written statement for the United Nations Sustainable Development Goal planning process.

Really, the only constant is that each day I feel inspired and rewarded by the work I get to do with the others in my office and the many others in countries we work in around the world.

BFP: What’s been your greatest challenge?

EF: There are so many challenges within this work that it’s difficult to pull out just one. With respect to our product, we are trying to disrupt a system whereby machines are either sold or donated to hospitals that just simply don’t fit very well: the hospital experiences regular power shortages; compressed oxygen has been stocked out for the past 2 months; a small part on the machine broke but there is no service contract or engineer to fix it or the part is no longer manufactured; the list goes on… It’s not surprising, then, that there is often an instinct to assume that if something breaks or a part is needed, no one will respond. But our whole business is geared toward being available for just that call. So one of the challenges has been conveying that to our customers and ensuring we balance our follow up (“how are things going?”) with respect for their time.

Distribution is also a tremendous challenge and often the greatest obstacle to scaling. This takes two forms. The first is quite literal: How do you get a piece of equipment from a factory in the UK (or anywhere) to an air- or seaport, through customs and to the hospital it’s bound for? How do you do that many times a week with out any hiccups? It’s incredibly important and incredibly challenging. My colleague who handles most of this wrote a blog piece on this. The second deals with distribution more broadly: Given considerable resource constraints, how do you create a sales pipeline when most customers have to fundraise and governmental processes are long and hard to anticipate? How do you build a service infrastructure to respond immediately to customers when a machine needs attention? How do you do that in a country where biomedical engineers are scarce? Finally, how do you do all this while maintaining a margin that keeps the price of the machine at a level that is affordable?

BFP: How have you overcome these challenges?/What has been the secret of your success?/What advice can you give others?

EF: We haven’t necessarily over come these challenges. They are the focus of much of our work every day. However, over time we realized that we were having the same conversation about these challenges with just about everyone else we knew working in our field or any other that involved moving and supporting a product in underserved markets. To try to tackle these issues we decided to get some of those folks together recently. We haven’t solved anything yet, but stay tuned…

The only advice I can offer at this point is to focus almost maniacally on partnering with the best people possible in the markets to which you are distributing – and investing the time necessary to cultivating those relationships. This has to be seen as the crux of your business – you can have the best product on the market, but without a solid distribution plan, scaling will remain a challenge.

BFP: If someone wants to do what you do, where do they start?

EF: I think there are two forms of experience that are critical to get involved in market-based solutions for global health: living in a developing country and experience working at a start up. If you are based out of a high-income country, it is critical that you understand – really experience – what life is like in the markets you’re working in. There are of course many ways to pursue that. I call on my experiences as a Peace Corps Volunteer nearly every day. Over the course of 2.5 years in El Salvador, I learned not only how one lives in a setting so different from mine, but also how health is impacted by so many factors in one’s life (some controllable, some not). On top of that, I came to appreciate how business is conducted in a wholly different setting than any I’d ever known. Each country we work in is drastically different, but the experience of seeing another way of doing things has stuck with me and guided me through my subsequent work. Whether through Peace Corps or another route – get out there.

Experience at a start-up is so incredibly valuable for just about any field for many reasons. At a small, growing company you learn, among many other things, how to be solutions-oriented and, at a company with a social mission, how to balance altruism with financial sustainability. In both of those pursuits, one is forced to constantly evaluate assumptions and ideas and redirect the course if a new/better approach presents itself. It forces both commitment and creative thinking that is an asset to any team in any setting.

BFP: What do you hope to get out of being a part of the BfP community?

EF: I’m always excited to learn about good work being done around the world and this seems to be a community full of many ways to define that. I’m also really looking forward to hearing how others have approached working at the confluence of business and development.