Great timing! I just published https://medicaldevicesgroup.net/medical-devices/industry/african-relief-medical-device-program/

I hope it is relevant and Karen can help you. She'll be at 10x.

Julie Omohundro "Is the cost of the sales and distribution in developing nations prohibitively expensive even for devices with known demand?"

If you are talking about the general population, I would say, yes, or it's not really a developing nation. It's a developed nation. There are those in every nation who can afford access to healthcare, whether the general population can afford it or not. So Question 0 is who are you targeting? If you are targeting the general population in a developing nation, I think you would probably sell to agencies or NGOs and they would then distribute, as in Joe's link.

If this is what you have in mind, I would start with WHO, UN, etc. I think WHO in particular has been heavily involved in matters related to availability and use of drugs and devices in developing countries. You might also contact Doctors without Borders, as they would have a lot of firsthand information about conditions on the ground related to effective distribution.

In a nutshell, locate reputable medical technology/equipment/device distributors and educate them. The bigger question is why does anything medical cost more here than in Canada? Or Mexico? I have my opinion on this, based on being in the business of medical technology business development for 31 years now. Just know this, here, beginning Jan 1, 2017, "fee for service" reimbursement is essentially gone. Decisions now must be made based on how using or not using something affects either the physician or the health care systems "merit score". This is a very big change.

Caitlin Morse, PMP Thanks, Joe and Julia. I appreciate your responses! I've worked in the non-profit sector in a few developing nations and agree that the NGO route is one possibility, but I was really asking this group about a business solution. If medical devices are only getting distributed through NGOs , this is not really a sustainable model as it is dependent on the fundraising efforts of the NGO.

I would disagree that the ability to purchase a low -cost medical device makes a country no longer developing. There are many consumers buying cell phones, bottles of Coke or Fanta, international brand of hair products, etc, even in nations that are struggling to provide basic healthcare.

FYI - I don't have a device I am trying to sell. I am looking at how to make the ecosystem more encouraging of local and global innovation.

Any ideas for business or profit-neutral sales models that would create a more sustainable distribution over the long term and encourage more investment in this segment?

Regina Bauman Distributor network is more affordable and can be a good source to collect intelligence.

Regina Bauman Big medical device companies with a large portfolio are more likely to establish a base with direct sales force Small companies rely on a distribution network to gain access to the market and provide intelligence. Even if there is a demand of your product it is better to use a distributor

Caitlin Morse, PMP Regina - agreed distributor networks are less of a capital investment for smaller companies to access the market in the US. There is one mentioned in the article Joe shared, but it seems to not quite have figured out a way to make his business model work yet.

Are you aware of the use of reputable distributors in Central or South America, India, or Sub-Saharan Africa, for example?

Julie Omohundro So it all comes back to your idea of "developing."

Certainly many smaller medical device companies use distributors to sell their devices in all of those areas of the world. Whatever terminology you might use, if a country's economy and infrastructure are such that it has medical device distributors, then, no, the cost of sales and distribution in that country is not prohibitively expensive. But then there is no need for a business solution to sales and distribution in those countries.

Alternatively...whatever terminology you might use, if a country's economy and infrastructure are such that it has no medical device distributors, then the cost of the devices that it can't distribute is moot. The end goal of the government agencies and NGOs isn't to continue to distribute drugs and devices ad infinitum, but to build the country's economy and infrastructure to support, among other things, the distribution of drugs and devices.

Julie Omohundro As for the cost of the devices, that's not really an issue, I don't think. They don't have to purchase them in the US market, so they don't have to pay US prices.

I daresay that most of the medical devices now sold in the US market are manufactured in those same areas of the world, at a cost commensurate with the local economy. I don't know how many US-based device companies have devices manufactured offshore, shipped to the US, and then ship them back out again, but on the face of it, that doesn't make much sense to me. I would think at least some of them are shipping their devices from their offshore manufacturers directly to their offshore distributors, where they are sold at prices unrelated to their US prices.

Sean Harz Another great resource/partner is the Bill and Melinda Gates Foundation, which has done some amazing and innovative work in medical devices for developing nations through organizations like PATH, a non-profit based in Seattle. They have partnered with many med device and Pharma companies to develop cost effective solutions for bringing 1st world devices to 3rd world patients. Imagine something as simple as cold chain storage....how do you distribute a drug/vaccine that needs to be refrigerated to areas where there is no refrigeration?

Julie Omohundro https://procurement.usaid.gov/search/node/medical

I didn't open the announcements to see if they might shed some light, but I did have to smile at the idea of procuring medical devices for China, which seems to be overrun with contract medical device manufacturers these days. Probably the contract will be awarded to a US company that will then contract the work to a Chinese manufacturer. And, maybe it's just me, but somehow I've never thought of Israel as a developing country. Isn't it supposed to be a hotbed of medical device innovation these days?

Andrew Keirns Wouldn't the sales and distribution model mirror key elements of the new approach? Less dependence on an established, mature market approach, with a more revolutionary approach.

Caitlin Morse, PMP Andrew Keirns - sounds interesting. Could you expand on this thought a little more?

Caitlin Morse, PMP Sean Harz, I'm aware of some of the work the Gates Foundation is doing, but I didn't know about their partnership with PATH. Thanks, I'll look into that. I was excited to see the POC diagnostics development work they partnered with Stratos for, but most of their focus seemed to be on the pharma side. I also found similar design efforts from MIT's D-lab and UW grad students and professors as well as some solo entrepreneurs. This is all fantastic innovation that I would love to see more of. As someone who works with medical device development project planning, unit cost models, etc, my next question was how to do get this innovation from the lab to the people who need it most around the world, hence this discussion. If we can find a way to get the distribution model working, not only will innovation be making a bigger impact, but successful distribution will also fuel more innovation.

Caitlin Morse, PMP Sean Harz, Cold Chain storage is a perfect example of the direction I'm going with this! We essentially have 3 options in this situation, right?
1. Modify the product to not require refrigeration
2. Develop a custom solution to provide the needed conditions for the product
3. Improve the infrastructure to provide refrigeration

Salmon works as a great example. I can go with option 2 and mail my fresh salmon in dry ice via FedEx. But as a business model, this is not cost-effective or the best approach as I scale up. I can go with option 3 and purchase refrigerated trucks to transport my salmon to grocery stores that purchase refrigerators. Or I can go with option 1 and sell smoked salmon that doesn't require refrigeration.

In the long term, developing nations are expected to eventually get to option 3 and build up the full infrastructure needed to provide comprehensive healthcare to most/all of their population. But in the meantime, can we come up with an innovative approach?

Abraham Joseph This conversation does not seem to suggest a method for help in designing, manufacturing medical devices in their own countries, for example, India.

Julie Omohundro Caitlin, how would you assess your three options in terms of your goal of sustainability?

Julie Omohundro Abraham, that's the sustainability issue Caitlin raised. It's ultimately up to each country to assess its needs and come up with a plan to achieve its development goals. Many of these agencies follow a model in which countries apply for specific types of assistance. On the whole, though, I don't think sustainability is something that can be imported.

So...what do you think India needs in order to develop the capacity to design and manufacture medical devices? And for what purpose? To export, or to develop a means of making affordable medical devices accessible to local healthcare providers?

Scott EM Roberts Julie, i really dont understand what your comment is on sustainablility, goals. I dont understand what you are talking about. please simplify ....countries have MOH issues, not sustainability goals, at least to my knowledge....

Scott EM Roberts I think the basic issue is that the USA should start thinking in the rest of world mind set (ROW) In the USA you have a complex system which costs 19.7% of GDP and is fragmented, with insurance issues.If you dont have coverage you can die. In ROW, we have state systems which cost on average in EU, 11% of GDP. The coverage in Europe is simple. You are a registered European , therefore you have state coverage. You are not excluded. In the USA , it is a lottery. The question raised is how to commercialize USA products in Europe. Simple. Get ISO, CE Mark (like FDA), Find a good European expert who can dialogue with you, and can help you . find me!! www.s4mdc.com

Julie Omohundro Scott, the goals I referred to are those of the agencies and NGOs, eg:
http://www.un.org/sustainabledevelopment/sustainable-development-goals/
But countries can have sustainability goals, too.

Caitlin Morse, PMP Julie O. - I think we have a miscommunication. The sustainability question I raised was not what you have linked to. While the UN sustainable development goals are admirable, that is not the subject of this thread. I am specifically talking about developing/bolstering a business model that is self-perpetuating without requiring the support of government, NGO or other fundraising efforts.

Erdem Tarhan Sounds familiar. Depending on the device and the market fpr instance in Turkey sales force could be territorial and may reqıire many staff.

Caitlin Morse, PMP Abraham Joseph - "a method for help in designing, manufacturing medical devices in their own countries, for example, India" is definitely one of the solutions. Two questions:
1) From your perspective working in nanotechnology in India, what is needed to encourage design innovation and manufacturing in India for the Indian market? (We are told access to financial capital and lack of engineering talent staying local are the two biggest challenges, but I would be interested in your view)
2) If medical devices were manufactured within India, it is still a very large nation with one of the largest populations on the planet. Does India have established methods of distribution for both urban and rural medical centers to reliability get the supplies they need with a level of quality they can rely on?

Caitlin Morse, PMP Julie O. - to answer your question about the three options:
- I see the current efforts by medical professionals and non-profits to participate in short-term humanitarian trips and facilitate the donation of medical equipment as demonstrating compassion and making a difference in the lives of the individuals they are helping. They would be option 2 in my scenario above - finding a way to work around the ecosystem to accomplish the goal.
- I see the long term development of the national infrastructure and business ecosystem to allow for the design, development and manufacture of medical devices in country to meet the specific needs of the population (as Abraham described) as option 3. It is a huge, but worthwhile undertaking. Hopefully these devices are also be exported to other countries with similar needs and we have collaboration and international cross-pollination that accelerates innovation where possible.
- What I am trying to figure out now is what is the option 1 equivalent?

Caitlin Morse, PMP @Scott - I have lived in both the US and the UK and having family that are still patients in both systems. I have seen benefits and drawbacks to both models, but don't really want to distract this conversation by getting into that here. From the medical device development perspective, the US model does provide significantly more opportunity for capital investment because of the potential for larger gains and so were the US to move to a more European health model, there may be benefits for patients, but there would be significant challenges through the medical device community that would likely stifle innovation further.

The question is not how to commercialize USA products in Europe. As you have said, this process is straightforward and familiar to many members of this group. The question is how can the innovation in the US or the EU that has undergone the rigorous process of verification and validation to obtain FDA or CE approval be leveraged to the benefit of other countries.

Julie Omohundro Caitlin, I think Option 1 is an example of an approach that, if it worked, would be irrelevant, because if the country has an infrastructure to support it, it isn't a developing country.

Julie Omohundro Caitlin, no I don't think we have a miscommunication. The link I posted wasn't intended to illustrate your sustainability question, but as an example of agency and NGOs sustainability goals for Scott.

Julie Omohundro Oops, got the options mixed up. Option 3 is the one that strikes me as irrelevant to a developing country. I think Option 1 is a sustainable model for you, but not for the country. It will allow you to sustain sales of your salmon to the country for as long as it has no refrigeration available. What would be sustainable for the country is the ability to smoke and sell the salmon itself. Unless you are envisioning your operation as one that is in the country, which you might be.

Caitlin Morse, PMP Narasimhan Sriram - it looks like you spent time in the Apollo hospital system in India. What did you think of the availability of needed medical devices in that part of the country?

Caitlin Morse, PMP Erdem Tarhan - It looks like you were educated in the UK and Germany and now working in Turkey with multinational corporations. Thanks for joining the conversation!

Do you have familiarity with the medical device industry there in Turkey? Are there many local companies developing medical devices? Are there jobs for local engineers wanting to work with a Turkish employer to design products or are most working with the multinationals?

As a field service technician, are you primarily encountering the same failures your employer is experiencing with the equipment in other parts of the world or are there failures specific to Turkey due to environmental conditions, healthcare system constraints or practices, etc? Have you had to develop specific expertise?

Caitlin Morse, PMP Sean Harz - do you have experience partnering with PATH? I've been doing some research into the work they do and it seems they are having success in innovation focused on the specific health priorities of the countries they are working with. They also expressed the same concern I did in my original question. They referred to it as "innovation pile-up" - innovative solutions being successfully invented faster than they can be absorbed into the market presumably due to overall infrastructure deficiencies, poverty level of patients, availability of healthcare professionals, slower tech adoption, etc.. Thanks for pointing me in their direction. I only knew of their pharma work.

In Brazil it works exactly like in the US. A lot of sales reps are sitting around for hours before getting 30 seconds to demonstrate their device. There should be a better, cheaper (disruptive) sales model out there?

Julie Omohundro Caitlin, IMO, the only efforts that really contribute to sustainability are those that help build up a solid economic infrastructure of education, transportation, power, water, banking, etc. Once you get those in place, everything else will follow. Until then, other efforts fall under What to do until the infrastructure gets here. They may offer some welcome relief in urgent circumstances, but they don't contribute much to moving things forward.

Erdem Tarhan Hi Caitlin,
The main issue is that there are mostly distributors and multinaitonals selling and servicing the devices. At the moment there are very few local production companies. There are very good qualified engineers but not enough start ups etc. This is also true for other industries. Each year Turkish equal of IEEE has started to make colloqiums to discuss these issues. But the industry is heavily dominated by mukltinationals. These compaines also want to penetrate more directly in the market since private healthcare and goverment spending is more than before.
Further, we do work closepy with our quality and compliance not to break any rules. For medical devices there are not enough regulations from the goverment.

Hi everyone, I work in Egypt , and I can say customers tends to buy good quality with reasonable price, as most of them has bad experience with cheap devices , it was not cost effective, although they are seeking for the after sale service, I mean technical service and clinical support as well

The challenge is not isolated to the development costs, the regulatory and approval costs coupled with SGA overhead often seem to equate to a price point that is prohibitive in less markets even when Channel Partners are utilized.

Ed D. Julie O., I could not agree more. Teach a person to fish and he/she will ......etc

Caitlin Morse, PMP Erdem Tarhan - you make an important point about regulatory infrastructure at the national government level. This is one of a few key areas that would need to be in place for local companies to develop new technologies in a way that customers would have same degree of confidence in the quality of the product.

I would say the key elements would be:
1) Human capital - trained engineers, clinicians, entrepreneurs, etc
2) Investment capital - initial seed funds to get the start-up or project group going until profitability can be achieved.
3) Prototype supply chain - rapid prototyping and supplier input in a key element of the development process that would need to be locally available
4) Regulatory infrastructure - this could be complying with an existing body like the requirements for obtaining a CE mark or FDA approval or a national body instituted by the country's government, but some standard for the company to meet to ensure that it is providing an appropriate level of quality.

Julie Omohundro Erdem Tarhan I recommend you check out the IMDRF and get your Turkish IEEE to lobby for someone from your government to attend their meetings. That might not happen overnight, so an alternative would be for someone from your IEEE to attend.

Membership in the IMDRF seems to be by invitation only, but they always have a public meeting in conjunction with their meeting.The more countries attending those meetings, the better, I think....at least if it is going to be an MDRF that is actually International.

In any case, its documents are there for the taking by any international regulatory agency, trade association, university, or company that wants guidance to follow. http://www.imdrf.org/

Caitlin Morse, PMP Mohamed makes a good point that many others in this group from sales have made before as well: Sales is not just selling, it is the whole customer experience. To create a disruptive solution as Soren asked, requires not only a more efficient approach to selling, but also a way to provide the training, tech support, clinical support, etc that the sales team currently provides.

Caitlin Morse, PMP Steven Ross - agreed. When I talk about development, I am looking at the entire development lifecycle from concept to capital investments for commercialization at production volumes. Any ideas on streamlining the regulatory approval process to be more cost efficient?

Julie Omohundro Erdem, Mohamed, you both appear to be working for multinationals. Does your company make any medical devices in the country where you are located? Or is it just a marketing and distribution outpost for devices manufactured elsewhere?

Beluh Mabasa Ginting every nation/country have authority to determined their regulation such as local approval but the most important thing the regulation must be harmonize to International/IMDRF or regulation base on standard such as ISO/IEC)

Caitlin, I am an experienced sales and business development person with a huge experience in South East Asia in the field of Medical devices. I can give you a complete insight of our market if you write to me. Your idea of affordable devices will work very well here. I am currently developing a breast tumor marker myself. I am sending you a request to connect.

I have been in ophthalmology area in Brazil since 1992 (1992 -1997 how mechanic projectist leadering some projects ... after in comercial area).
The big problem that a I saw during these years is that there is 3 or 4 company that have a good team and that know the customers because the guys work in the same region for many years, creating a strong relations. The distribuitor nomally "sell what the customer would like to buy" (They no offer the product or no spend time to developed the possibility and interesting of customer). If We compare is very different the states that I worked with distribuitor or our sales force (10% x 90% of sales). And during this time a saw the same things in the Latin America with distribuitors ... with sure there are good exceptions!).

Barriers to entry in international markets are not, as I understand them, as impossible as in the US market. The key is finding the right partners, through the medical community. I know of Co.'s that have run, are running, and intend to run human studies outside the US in order to prove efficacy and (if need be) redesign the device for improvements, prior to introduction to the US market.
I would love to talk more about this with you and your husband...

Prakash Maheshwari Hi Caitlin, if you are talking for screening devices then many Indian startup are struggling to sell either to Drs directly or institutions ( govt n private). However we are witnessing a sharp improvement in this. There are many pharmaceutical companies taking lead in supporting the while ecosystem. On the contrary disease monitoring devices are getting more accepted considering the overall increase in awareness and medical practitioners are not having enough time to help patients. I am working with many POC companies in many disease area more from screening / diagnostic purpose.

S&D in most developing nations will be the key to economies of scale , access and better outcomes . Competition would drive down prices and force innovations or stake out ... Apps at best will accelerate awareness however we need remember apart from consumer (patient ) there is Chooser (Dr) and also User (Parameds) .

Bertrand Klaiber Dear Catlin,
Sales and distribution networks in developing nations is one important issue you raised.
Developing low-cost medical equipment is one thing, but in order to make them affordable the distribution margins must be cut from their usual levels as well.
There are some manufacturers developing appropriate medical devices but they need to gain trust from the customers in order to deploy their solutions without the huge spending in sales and marketing like the big firms.
Some international organizations play an important role in promoting appropriate technologies.
Another very important issue is the after-sales services that are under-developed in these markets.
The major brands have not developed the maintenance capacity in these markets where after-sales contract would not be profitable (their devices fail too often in these contexts, remote locations are difficult to reach, hospitals have very limited budgets and generally cannot pay for preventive or curative maintenance,..)

Bertrand Klaiber We have made marketing studies in several African and South-East Asian countries and the principal customer pain is almost always the maintenance. Even when they would pay for it they cannot obtain spare parts, instructions, training, tools, etc.

While the big firms are not developing these markets that they still perceive as unprofitable, small firms must pave the way and develop lean, efficient and cost-effective sales and after-sales capacity.
I believe that several firms should collaborate and leverage each on what the others have implemented.
E.g. if one develops sales and maintenance capacity in a regions for a specific product, we should leverage this investment by deploying other medical equipment from other manufacturers sharing the same view.
For information we are industrializing digital X-ray systems requiring far less maintenance than traditional solutions, and we will train local partners rewarded on both on sales AND servicing.

I am a Biomedical Engineer from Ghana, a country that does not manufacture medical devices. It is essentially a 'marketing and distribution outpost for devices manufactured elsewhere' as Julie O. aptly puts it... and all the points raised about building up a solid economic infrastructure of education, transportation, power, water, banking, etc, are valid.

But what solutions can be provided in the interim, to bring affordable healthcare to developing countries?
Your ideas, Caitlin are wonderful. 'Made for Africa' medical devices is a new topic being discussed with several stakeholders and it seems to be one of the keys to making healthcare affordable to these countries.

In Ghana, the biggest purchaser of medical devices is the Ministry of Health and it does this largely through grants, loans and commercial credit facilities. OEMs are beginning to see the need to empower agents and distributors to move from just providing third-party technical service to actively driving sales.

Beluh Mabasa Ginting Base on Asean Medical Device Directive (AMDD)/Asean free market, the manufacturer must can demonstrated that the medical devices had met or pass the conformity assessment (the systematic examination of evidence generated and procedures undertaken by the manufacturer, under requirements established by the Regulatory Authority, to determine that a medical device is safe and performs as intended by the manufacturer and, therefore, conforms to the Essential Principles of Safety and Performance for Medical Devices- GHTF/SG1/N40:2006). The elements of the conformity assessment are :
- Quality Management System (effective QMS (ISO 13485/14971: safety and performance as a key regulatory consideration for allowing medical device manufactures to market their products)
- System for Postmarket Surveillance
- Registration of Device and Persons
- Technical Documentation (CSDT= Common Submit Dose Template)
- Declaration of Conformity.

Erdem Tarhan Julie O. My company does not make any devices in Turkey. It is sales and post sales activities.

Caitlin Morse, PMP Akofa Bart- Plange - thanks for getting us back to the original question. I think we can all agree that in the long-term we would like to see infrastructural development, but as you said, what about the interim? What about those needing medical care today? What about the mother and baby who died during childbirth this morning? What about the young man watching his family starve because he can't provide for them without knee surgery?
When living in Bolivia, I was able to help get anti-parasite medication to 43,000 children by simply working to get it through customs and distributed. In rural villages, children with parasites can quickly become dehydrated because of the diarrhea and vomiting which can lead to other complications. The medication had been donated, but it needed someone to see it through. I was able to get it into the hands of the visiting nurses who in turn distributed it to those who needed it most.

Caitlin Morse, PMP I recently came across this article: http://www.bbc.com/future/story/20161116-diy-medicine-at-the-edges-of-civilisation

Like most others on this subject, it talks of doctors having to be creative and make do without the tools they need. Some of the reasons we hear are related to corruption, war or civil unrest, etc that have to be addressed on a political level. On the other hand, there are issues like the capital equipment that has been donated not being able to cope with the fluctuating power or lack of power in remote locations, the cost of repairs and lack of parts for repairs, the lack of trained staff to operate complex equipment or the cost of the disposable elements of the devices being too costly - these are issues we can do something about. This group is 339, 020 members of the medical device community. That is a huge team of experts and I have to believe that together we can provide better solutions that we have today.

Gunther Reinhardt Andrew Nelson is right. The best way to enter a market in developing economies is to partner up. There is significantly less regulations which can save money, but there is likely to be more extraneous costs that can be minimised with the correct partnership. Generally speaking a contract sales force with main company oversight might be the best initial distribution and training channel.

Matthew Davies What about the difference in regulation between countries? The USA requires FDA clearance, the EU has the CE mark, but if you have to pass regulatory approval for each country independently that's a whole other level of bureaucracy & time. Partnering with distributors or larger players can help, but only so far. Is there any sort of unified regulation within a subset of African countries analogous to the CE mark?

Hi Caitlin, a long time ago (>20 years) with Nova Biomedical we were pioneering the field of remote technical assistance via sat transmission for blood electrolyte and gaz analysers. It was even use on submarine for nuclear cooling circuit with Na measurement. you can imagine to have low cost remote maintenance using collaborative software. The scheme could be to establish a standardised maintenance freeware that could be operated onsite to detect and plan preventive maintenance and repair. The only thing is still to get some rights from original manufacturer to use their core tech and put this freeware layer of diag on low cost intrument version. Then if something happen on these instruments would follow rigid procedure for detection, shipping spare parts, repair coulb be monitored via low cost computers i. The only thing is that you would need at least a good connection on intenet. The range of "freewarised" instrument could be offered on a market place like amazon..

Penetrating to a developing country with an innovative medical device seems to be a challenge for numerous reasons: Awareness to innovation is low, and so it the tendency to adopt technology as it is often correlated with high cost. Budget allocation by the government for healthcare is often very limited. Furthermore, the infrastructure is immature, both on the technical level (WIFI, cellular connectivity, electricity) and so is the distribution infrastructure and ability of local distributors to handle innovative technology based medical devices (marketing, sales, support and even modern pricing models). Having said that, once you find a good partner that is willing to distribute your products and understands the challenges on one hand and the business potential of being among the first to introduce an innovative approach to the local market place on the other hand, success is possible. There are additional aspects that should be taken into consideration such as device registration.

Ankita Srivastava I am glad you are curious to take cues from developing countries in your quest of reducing cost of medical devices. I have worked a medical device buyer for quite some time in India. It is the same in India as in USA. Sales and distribution network plays a key role. Another popular method is to attend conferences and trade shows. But the biggest difference that I feel is that manpower cost is very high in USA compared to India. But, I think you are on the right track. I second that with upcoming mobile applications and IoT revolution, we might come up with innovative of overcoming these costs.
Also, medical device industry in India is mainly dominated by products and companies from the developed countries like USA, UK, Germany etc. And I am pretty sure (not 100% though) they sell in India at a much less price than in USA. You can IM me if you want to know more.

Laura Henze Russell Which types of devices do you have in mind?

I work for a company that definitely help to reduce health care costs not only in developing nations but in the US as well. We buy surplus inventory from hospitals. These high-end surgical disposables will sometimes expire and end up in a land fill. This surplus usually happens when there's a change in preference from the surgeons or when hospitals are forced to purchase more than what they need because of contracts with OEMs. We buy these surgical disposables for a fraction of the cost and sell them below OEM's cost. More than 70% of our business is US based but we are quickly expanding to the rest of the world. There are no minimum orders, no contracts and customers can buy product by the each. Latin America is a huge market for us. We reach other markets indirectly by selling these materials to Non-Profit organizations that send them to places such as Africa per example.