Base-of-Pyramid Health — Clínicas Raíz and the Viability Gate

A four-round, advanced social-enterprise & healthcare-strategy simulation set inside Clínicas Raíz S.A., a for-profit primary-care venture in Quetzaltenango, Guatemala (6 storefront clinics + 18 community health promoters, 48,000 patient visits in 2025, GTQ 14.4M revenue, a thin 6% EBITDA margin of ~GTQ 0.86M, 72% of revenue cash-paying uninsured patients). An impact investor has frozen a GTQ 4.0M growth tranche behind a blunt viability gate: prove you can reach MORE low-income patients, reach operational break-even within 18 months, AND earn an external ESG/social rating high enough to unlock up to GTQ 6M of blended co-financing — all within 90 days, with only 5 months of cash runway. Playing the venture's leadership team, you (1) diagnose the base-of-pyramid affordability map, decomposing the falling access index (0.52, down from 0.61) by income quintile and naming where impact-per-quetzal is highest; (2) design the low-income offer — service-bundle depth, the role of community health promoters versus clinic visits for the half of patients who live hours from a storefront, and a generics-pharmacy strategy — knowing every inclusion adds cost and access while every exclusion protects margin but pushes the poorest out; (3) make the decisive certification-and-pricing call — a third-party accreditation (costly, slow, high-trust ~GTQ 250K), a cheap self-regulation code (~GTQ 40K, weak signal) or none, AND the fee level plus a sliding-scale / cross-subsidy mix, where the demand model means a +GTQ 5 fee lifts margin ~GTQ 0.9M but prices out 6,000 of the poorest visits and a −GTQ 10 cut plus membership expands reach but needs staffing Raíz may not have; and (4) pitch the integrated 18-month viability case to the investor board, choosing how honestly to present the margin/access/ESG scorecard, how fast subsidy declines toward break-even, and whether the ESG rating drove the design or trailed it. The math rewards a community-promoter availability strategy, a credible certification, abatement of subsidy over time, and an honest scorecard — and punishes the five classic errors: raising fees for margin without modelling who drops out, underpricing into permanent subsidy with no break-even path, skipping certification to save cash, treating the ESG rating as paperwork, and designing an affordable offer with no availability strategy for remote patients. Final KPIs track Viability (GTQ M annual EBITDA impact / break-even path), the Access Index (0–100), the ESG / social rating (0–100), and Gate Risk (runway, regulatory-trust and clinic-closure exposure; lower is better).