Angela Natukunda, manager for the Masajja, Uganda, branch of Living Goods, recently shared a story of a community health promoter whose door to door experience stuck with her. She visited a family whose 4-year-old child had pneumonia, but the father said he recognized the worker — who was going door-to-door to teach good health practices and selling simple health supplies — from when she sold vegetables on the side of the road. There was no way she would treat his child, the father said.
But later that night the man knocked on the door of his next door neighbor, whose own child had been treated for pneumonia earlier that day, and asked whether he might share the treatment. That changed everything. The formerly skeptical father of the now healthy child, who is also a local leader, now occasionally accompanies the Living Goods community health worker on visits in case she meets anyone else harboring similar doubts.
One of the barriers to scaling community health work is the skepticism that people such as the Living Goods entrepreneurs cannot do what doctors can do. While new technologies are improving the work of community health workers, and filling the gaps that are not served by the model, this Avon-like model of door-to-door delivery of products from medicines to water filters to bednets is demonstrating a real impact.
Living Goods is reducing child mortality by 27 percent with its door to door health education and services in Uganda, according to a study released Wednesday by the Center for Economic Policy Research.
“When it comes to putting more tools into the hands of community health workers, while technology is important, the fundamental problem is money,” said Chuck Slaughter, the founder of the San Francisco-based organization. “But in our view technology is also a key part of the solution pushing back against the trends that are happening in shrinking sources of funding for health.”
As Living Goods works with its partners such as BRAC to reach nearly 10 million people by 2020, the organization is using mobile technology not only to drive its impact, but also to provide transparency and accountability to donors and investors, attracting investment and achieving scale. Its plans to develop a new “Payment by Results” mechanism to finance its community health model at scale demonstrates one way technology is attracting capital to health systems work.
Now that Living Goods can provide reliable and real time data on the results of its work, the organization can lower the risk for prospective funders, drawing in new sources of funding as they grow nationally in Uganda and Kenya and extend their reach to other countries.
Accelerating the shifts underway
Medic Mobile, a San Francisco-based nonprofit tech company specializing in mobile health, has worked with both Living Goods, and other community health organizations such as Muso, on building or improving mobile tools for community health workers. When Devex asked Josh Nesbit, the founder of Medic Mobile, about the shifts underway in global health, he wrote back via email outlining seven key areas.
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1. Proactive rather than passive systems of care. This looks like community health workers visiting every family twice per month, actively searching for children who are sick.
2. Paying community health workers a living wage, or equipping them to earn a living wage through entrepreneurial models.
3. People-centered care. We've made progress through vertical programs and funding, but it's time for health workers and health systems to be equipped to provide care for people and families.
4. Making work, challenges, and progress visible. When information comes directly from people in rural villages and urban slums, we have a much more comprehensive view of what's happening, where systems are breaking down, and where strategies are working.
5. Expanded teams of people working together to deliver care. We need to lower barriers for community health workers, traditional birth attendants, nurses, pharmacists, and others to collaborate.
6. Supporting community health workers as care providers, and recognizing the importance of different forms of care, e.g. providing treatment for malaria, accompanying someone on a long journey to a clinic, changing bedsheets, cleaning a floor, helping a family member lift someone out of a chair.
7. Eliminating user fees for essential health services.
“We want technology to accelerate these shifts,” he said.
The question, he added, is who pays?
Tim Wood, senior program officer for integrated delivery at the Bill & Melinda Gates Foundation, told Devex he is inundated by mobile health pitches.*
“The types of things we encounter most frequently is someone that has a mobile phone based service, and you can look at any of the five thousand mobile health pilots that have failed over the past five years to see what happens when you don’t consider the operational details, like what does this look like at scale, or how do I get the government buy-in necessary?” he told Devex. “If anything, the Gates Foundation is skeptical about jumping into tech just for tech’s sake.”
One of the problems he is currently focused on is how to get payments to health workers faster. The Gates Foundation is working together with the World Bank Group and the government of Bihar, India to determine how digitizing cash transfers might improve upon the paper-based government run benefits programs. They developed the Public Financial Management System Health Module and pilots have demonstrated its potential to reduce waiting time and corruption and ramp up financial inclusion.
Meanwhile, another Silicon Valley based startup that is working to solve a separate problem in healthcare delivery is Zipline, a robotics and drone technology company with engineers from companies such as SpaceX and Google that is behind the first commercial drone delivery service in the world. Part of why the company is generating so much interest from the global health community is that its team acknowledges that developing the autonomous vehicles was only the first step in its work on “last-mile” health delivery. For example, Zipline is working to improve blood delivery in Rwanda, which has been a challenge despite the country’s distribution centers, telecommunications networks, and favorable regulatory environment.
“There are so many forms of capital that have not traditionally collaborated well enough to move the ball forward in last mile health delivery,” said Brittany Hume Charm, head of international growth at Zipline, from their headquarters in Half Moon Bay, California, where the sound of a launching drone cut her conversation with Devex short at one point. “There has been a gap in terms of private investment. It’s exciting for me that Zipline has been part of reframing global health as something that has been worthy of venture capital.”
Tapping into new funding streams
Funding for global health from bilaterals and multilaterals is on the decline, after reaching a peak in 2013, and Slaughter said he expects funding from the U.S. will only decrease in the next administration. This means local governments will need to do more to finance their own healthcare programs, and the global health community will have to get more creative in how to attract new financing.
“We need to grow the pie of money for community health, but we are fighting over a shrinking pie, so how do you change the risk and reward tradeoff for funders?” Slaughter said.
There are a number of efforts to tap into new funding streams for global health programs. For example, one of the commitments to emerge from the Clinton Global Initiative annual meeting in September was the Financing Alliance for Health, a partnership between governments, agencies, and organizations including Living Goods, that is designed to leverage $15 million to support approximately 5,000 community health workers.
"Solutions that mobilize international resources along with domestic public and private markets remain the only way to achieve our shared global health goals in a sustainable way,” said David Milestone, deputy director of USAID's Center for Accelerating Innovation and Impact. Next week, his office will launch “Ready, Set, Launch,” a guide providing support for country-level planning for global health innovations. One of its main points is how achieving scale with an existing or new global health innovation requires a clear understanding of how the product will be financed or generate revenue.
And that is a challenge that must be addressed as country by country, community health work is taking off. Earlier this year Liberia announced a new program to reach the nearly 30 percent of its population who must walk more than an hour to get to a health clinic. Increasingly, countries are sharing best practices on ways they can scale community health work to meet global health goals such as reducing maternal and child mortality.
“To deliver on this unprecedented commitment to community health requires a commensurate expansion of investment,” said Ari Johnson, the founder of Muso, a San Francisco-based organization on a mission to reduce maternal and child mortality rates in Mali with frequent health worker visits. “This investment will not come from user fees.”
Charging patients out-of-pocket is ineffective and inefficient, he said, explaining that user fees can delay and reduce access to care for the poor. So nonprofits such as Living Goods and Muso are raising funds, and conducting randomized control trials that not only convey their impact, but also attract investors looking for social returns.
Community health offers a 10-to-1 return on investment, meaning for every $1 invested, investors can expect $10 in return, Johnson said. This kind of ROI opens up opportunities for funding from a combination of sources, from individual giving to private foundations to new financing mechanisms such as impact bonds, he added.
Expanding these funding streams will require strong data feedback loops, including efficient delivery, transparent reporting, rigorous performance management, and that is where technology can come in.
When Living Goods first entered Uganda 10 years ago, it took five years to get government approval, whereas later in Kenya, the process took just four months. The quicker timeline the second time around was due to improved technology that demonstrated the results and led regulators to be more open to the Living Goods model. The example demonstrates how, beyond improving the efficacy of health care delivery, investment in technology can also ensure accountability, attract investment, and even enable policy change, Slaughter said.
Mobile technology transformed every aspect of the Living Goods operation, from allowing the organization to monitor and support its women entrepreneurs from a distance and at a low cost, to pursuing funding from new vehicles for investment such as pay-for-success models and social impact bonds.
“It is time to cross the digital divide,” Slaughter told Devex. “Invest in it but also figure out how it will save or make you money.”
* Update, Nov. 30, 2016: This article has been updated to clarify that Tim Wood is the senior program officer for integrated delivery at the Bill & Melinda Gates Foundation.
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