When Raj Panjabi, co-founder and CEO of Last Mile Health, fled Liberia with his family at 9 years old, his parents repeated the mantra that no condition is permanent. When he returned to his home country following a 15-year civil war, there were 51 doctors left to serve a country of 4 million people, and rural areas were lacking doctors almost completely. But Panjabi thought back to that mantra in taking on what he calls “the tyranny of distance,” or the fact that the people who are furthest away from health services are often those who need them most.
“No one should die because they live too far from a doctor or clinic,” he said as he accepted the Skoll Award for Social Entrepreneurship at the Skoll World Forum in Oxford, U.K., last week. “Unjust conditions don’t change on their own. We’ve got to make that change. And making change, especially in moments of crisis, requires us to be two things: reformers and radicals.”
This year's forum on social entrepreneurship focused on stories of finding common ground.
Together with his co-founders, Panjabi started Last Mile Health to bring primary health care to remote areas in Liberia by partnering with governments to help them design, scale and sustain networks of community health professionals. He was one of four Skoll awardees this year who received a $1.25 million, three-year core investment from the Skoll Foundation to scale the work of their organizations. Panjabi spoke with Devex about issues ranging from the importance of systems entrepreneurship to the power of community health work for job creation.
You spoke on a panel about systems entrepreneurship, in which collaborations across sectors allow us to move from a proliferation of projects to large-scale change. Can you expand on your work as a systems entrepreneur and what it takes to move from social to systems entrepreneurship?
We’re a nonprofit organization currently working in one country. There are lessons that we’re learning with our government partners, the government of Liberia, that could be useful to other government partners. Likewise, what others are learning in India, for example, could be useful to what’s happening in Liberia. That's offered an opportunity for social entrepreneurs to work on systems change efforts.
To do that, one needs to have a set of skills and perhaps work values that are complementary to what a social entrepreneur typically has. We’ve found that the additional skills one needs are the ability to negotiate with partners, the ability to sometimes advocate for the cause over your own organization — that’s often the case — and the ability to build and broker partnerships.
There’s also a need for a change and reorientation in work values, which is to put the success of the cause over the success of the organization. It's not that the organization doesn’t need to be successful, but it should be seen as a means to achieve success for the cause. We say that capitalized Last Mile Health — the organization — is important inasmuch as it advances lowercase last mile health — the cause. That’s the idea of getting a health worker for everyone, everywhere, everyday.
Another Skoll World Forum session focused on ending pandemics in our lifetime, something of which you have direct experience from the Ebola crisis in Liberia. Can you speak about how pandemics demand systems entrepreneurship?
In Liberia, before the Ebola crisis, we were doing work with the Liberian government to help them understand how to deliver primary health care to its most remote communities. About 30 percent of the rural population lives one hour or more from the nearest clinic. The vaccination rates in remote areas compared to other rural areas were worse than the difference between urban areas and rural areas by a massive amount. If one is to try and figure out how to get health care to 1.2 million people — the 30 percent of the Liberian rural population that lives in remote areas — those populations are spread across 2.5 million acres of forest in Liberia. No one organization can do this.
We were working on the problem. Ebola struck in remote rural areas across the border in Guinea but then spread initially, before it hit cities, in remote and rural areas in Liberia where spending on healthcare was extremely minimal. The Liberian government addressed the issue, local communities mobilized, and Ebola was brought under control, though with severe pain and loss.
The recognition that bringing healthcare to areas where zoonotic epidemics — those that jump from animals to humans, such as Zika, Ebola and HIV — are likely to start is critical. Therefore the Liberian government said they would like to work on a systems change effort. We are going to be the lead designer of this. We want to revise our policy to change community health workers from being volunteers to being paid, so they stay on the job; to change their supervision structure from being peer-supervised by another community health worker to having clinical supervisors, so that care can be advanced; and linking community-based monitoring to the clinic system.
Bernice Dahn has a message for the global development community: Trust recipient governments.
How do you get that done? It’s not one partner, Last Mile Health’s model, that gets scaled. It’s Last Mile Health, which is good at supervision structures in remote areas and working in those settings. It’s Partners in Health, which is extremely good at HIV and tuberculosis treatment, in particular. It’s the International Rescue Committee, which is good at family planning in the country. All of us rallied behind the government. USAID, UNICEF, the World Bank, philanthropists in this area and others said: “We’d like to help you post-Ebola to set up a national community health workforce that could be a frontline defense to help stop the Ebola crisis from coming back or stopping it in its source, but also [to tackle] the everyday crisis of premature death — malaria, pneumonia, diarrhea, complications in childbirth. They’ve created something called the National Community Health Assistant program. It has its own targets — 4,000 workers workers in four years to serve 1.2 million people — and each of us are trying to serve that goal in the various regions we work in. We’re collaboratively creating a monitoring framework around it.
World Bank President Jim Yong Kim mentioned in an interview with Jeff Skoll that if you don’t match aspirations with opportunity, bad things can happen. Can you expand on the connection you see between this message and your work in community health?
One of the conversations happening in the technology industry is: “How do we create more jobs?” And community health workers are a great way to create jobs — taking health tasks that I might do as a physician, which are high impact and can be taught safely, and monitored and supervised, to people who are 10th-grade educated. What’s exciting about that is that you’re redistributing resources so that you can create more jobs. Liberia will have 4,000 jobs for rural, young and previously unemployed people who might have career paths.
Beyond improving the efficacy of health care delivery, investment in technology can also ensure accountability, attract investment, and even enable policy change.
The conversation happening in adjacent industries is about: “Is technology stealing our jobs?” And I’m not arguing that it isn’t, in some ways. In this situation, the revolution that’s happened in the last 50 years in handheld test kits for malaria, for example, means that you can do some of the testing in an off grid, off road, off network site, by a community member who’s been trained as a health worker. It’s more possible now because you don’t have to use a microscope at a hospital to make the diagnosis.
You’re seeing some of the same things happen in communications technology with the advent of smartphones, and the ability to monitor data through those. Each of our community health workers has a smartphone. That’s made it more possible for us to track supply chains, more possible to provide decision support to a community health worker, and I see that only increasing. If we are smart, we can understand that humanity needs technology but technology needs humanity just as much. Imagine if we could create those jobs and technology could be an assistant to that. That would be new employment that leads to greater healthcare, and I’m very excited about the possibility of doubling down on that.
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