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Overcoming Scalability Challenges in CHW Programs_ Cailey Gibson_10.14.11


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Overcoming Scalability Challenges in CHW Programs_ Cailey Gibson_10.14.11

  1. 1. Uganda Ministry of Health<br />Innovations for Scalability: Lessons from Living Goods’ Model in UgandaCombining the best practices in public health, franchising, and microfinance<br />Key Partners<br />CORE Group Fall Meeting<br />Washington, D.C.<br />Cailey Gibson, Living Goods<br />415-632-1909 | cgibson@livinggoods.org | www.livinggoods.org<br />
  2. 2. Living Goods Mission and Key Goals<br />Support Avon-like networks of mobile Health Entrepreneurs who make a good income providing health education and selling life-saving and life-changing health products at prices affordable to the poor - empowering them to make a living and make a difference at the same time. <br />Key Goals<br />Reduce mortality and morbidity rates by 15-30%, focusing on children under 5.<br />Provide living incomes for thousands of health entrepreneurs, save poor families $ on healthcare prevention and treatment, and keep wage earners productive.<br />Become financially self-sufficient at scale.<br />Propagate the replication of the social micro-franchising model across developing world.<br />
  3. 3. Key Elements of the Living Goods System<br />Recruiting and Selection: Referral incentives, wide funnel, tight testing & standards<br />Training and Coaching: Practical learn-by-doing, 2 weeks initial,1 day/month update, all free to agents; ongoing coaching by field agents<br />Monitoring and Quality Control: Employs strict controls with monthly inspections; Replaces agents who do not meet standards<br />Business in a Bag Toolkit: Uniforms, bag, locker, health tools, record books, health flip books, signage<br />Branch Distribution System: Branches support 20-40 agents ~7km walking distance, target 90% in stock rate, agents re-supply weekly<br />Diverse Product Mix:drive sales and enable cross subsidization <br />Marketing, Promotions, Incentives:Door-to-door, mobile phones, community groups, home storefront, regular promotions and prizes<br />
  4. 4. LG’s Diverse Product Mix Drives Sales…<br />… And Enables Cross-Subsidization<br />Prevention<br />Insecticide Treated Bed Nets<br />Water Treatment<br />Condoms<br />Vitamin A, Iron, Zinc<br />Hand Soap<br />Iodized Salt & Fortified Foods<br />Treatment<br />Anti Malarials<br />Oral Rehydration Salts<br />ZInc<br />De-worming<br />OTC Pain & Cold<br />ARI<br />Consumer Staples*<br />Feminine Hygiene<br />Diapers<br />Laundry Soap<br />Toothpaste<br />Lotions & Creams<br />Money Saving or Making<br />Solar Lanterns / Chargers<br />Efficient Cook Stoves <br />Water Filters<br />Reading Glasses<br />>> Fast moving items increase frequent home visits<br />
  5. 5. The Living Goods Health Business in a Bag<br />Locking Storage and Display<br />Cell phone <br />Measuring Tape<br />Thermometer<br />Breath Timer for ARI Diagnosis<br />Visual Referral Guide<br />Visual Dosage Guide<br />Visual Training Tools on 17 Key Health Behaviors<br />Shoulder Bag<br /> Branded Signage<br />Whistle<br />Training Certificate<br />Branded Apron<br />Branded Tee Shirt<br />Price List<br />Sales Register<br />2 Pocket Money Pouch<br />Umbrella<br />Medication Instructions Form<br />Referral Form<br />
  6. 6. Health Impact: LG Targets Increases in Key Health Behaviors<br />Diarrhea <br />Increase adoption of water treatment<br />Increase consistent hand washing<br />Increase prompt treatment of DD with ORS +Zinc<br />Increase referral of acute DD cases to health center<br />Malaria<br />Increase % of kids <5 and mothers sleeping under LLINs<br />Increase prompt treatment of malaria with ACT <br />Malaria prophylaxis in pregnancy<br />Increase referral of acute malaria cases to health centers<br />Nutrition<br />Increase Vitamin A supplementation for <5s<br />Increase use of fortified foods, iodized salt<br />Iron supplementation in pregnancy<br />Maternal & Neonatal <br />First pre natal visit in first 4 mos<br />Nutritional supplements during pregnancy<br />Delivery in health facility<br />Post natal visit within 24 hrs<br />Identify and refer high risk cases to health center<br />Increase use of Family Planning<br />ARI<br />Diagnose and treat ARI infections in the home<br />Increase referrals of acute cases<br />
  7. 7. Challenge: Long-term financial sustainabilityInnovation: Apply microfranchise model to CHW challenge<br />Community Health Promoter<br /><ul><li>Earn a living, motivating income through sale of products, performance incentives</li></ul>Field Distribution/Branches<br /><ul><li> Generate wholesale margins that can fund distribution system</li></li></ul><li>Challenge: Variable quality of care<br />Innovation: Rigorous agent recruitment, selection, and monitoring<br />Utilize community networks, uses referral incentives to recruit<br />Offer comprehensive and ongoing training and coaching<br /><ul><li>Access to health knowledge, business, and behavior change skills; share learnings about how to encourage customers to buy and use products</li></ul>Ensure consistent quality through tight systems and controls<br /><ul><li>Employs strict controls on quality, care, and service backed up by monthly inspections
  8. 8. Replaces CHPs who do not consistently comply with standards</li></li></ul><li>Challenge: Drug stock outs<br />Innovation: Demand driven inventory management system<br />LG branches maintain 100% in stock rates, ensuring CHPs have access to high quality, lowest cost products at all times<br />LG uses following techniques:<br /><ul><li>Weeks on hand; distinguish between critical and non-critical products
  9. 9. Lead times
  10. 10. Protocols for sourcing, negotiating, purchasing, delivery, storage procedures</li></li></ul><li>Q & A and Additional Info...<br />“A lot of programs give lip service to ‘sustainability’ — this is the real deal. Living Goods is one of few models with the potential for game-changing scale.”<br />- Holly Wise, Former Secretariat Director, USAID Global Development Alliance<br />Phone | +415-632-1909 Email | cgibson@livinggoods.orgWeb | www.livinggoods.org<br />
  11. 11. Board and Advisors<br />Board of Directors<br />Randall Spratt: EVP of McKesson, the largest drug distributor in the US<br />Andy Peterson: Procter & Gamble, Director of East and South Africa<br />Charles Slaughter: Founder - TravelSmith, Former President – Healthstore Kenya<br />Holly Wise: Consultant - Wise Solutions LLC, Former Mission Officer - USAID Uganda and Head of USAID’s Global Development Alliance <br />Stephen Jarrett: Former, Deputy Director of Procurement, UNICEF<br />Dr. John Cutler: Chief of Country Programmes, Health Metrics Network Secretariat, WHO<br />Board of Advisors<br />Sir Richard Feachem MD: Founding Executive Director of the Global Fund<br />Bruce McNamer: President and CEO of TechnoServe<br />Christopher Elias: President of PATH, Program for Appropriate Technology in Health<br />Dr. Sam Okware, Uganda Minister for Community Health<br />Kathryn Johnson, Former CEO of Health Forum<br />Erastus Kibugu, Uganda Country Director for TechnoServe<br />Dr. Allen Hammond: Former VP at World Resources Institute, now at Ashoka / E Healthpoint<br />Dr. Paul Polak: Founder of IDE and D-Rev<br />Kevin Starr: Director of Mulago Foundation and The Rainer Arnhold Fellows <br />Dr Sam Okuonzi: Makarere University Uganda, Regional Center for Quality of Healthcare<br />Dr Rebecca Weintraub: Harvard Global Health Delivery <br />
  12. 12. Streamlined Supply Chain Lowers Costs<br />Typical Supply Chain <br />Manufacturer/Importer National Distributor Regional Distributor Local Distributor Rural Seller<br />Living Goods Supply Chain <br />Manufacturer/Importer Living Goods Rural Seller<br /> >> LG prices average 10-30% below market. <br />
  13. 13. Competition – Value Proposition<br /> >> LG delivers lower prices, better quality, and more consistent availability than existing public health centers or private drug shops.<br />
  14. 14. Keys to Financial Sustainability<br />Significantly broaden number of products offered to achieve diverse, cross-subsidized product mix<br />Add higher margin items<br />Focus intensely on the profitability and livelihoods of CHPs<br />Create buying power through scale & sourcing at lowest possible cost<br />Cut out middlemen in existing distribution chain<br />Maintain rigorous cost discipline<br />Increase number of CHPs served per branch<br />
  15. 15. 2 Modes = 2 Opportunities = 2 Avenues for GrowthLiving Goods’ operates in two modes in Uganda: A BRAC-Living Goods partnership and through its wholly owned and operated network<br /><ul><li>LG direct drives innovation in products, promotions, incentives and systems
  16. 16. Launched Q3 2009
  17. 17. CHP selection from community at large
  18. 18. 5 branches and growing
  19. 19. 40 CHPs per branch
  20. 20. 200 CHPs total
  21. 21. Retail sales of $125/CHP/Month
  22. 22. The BRAC partnership leverages their existing branch network and deep health expertise and provides scale
  23. 23. Launched Q1 2008
  24. 24. CHPs selected from existing BRAC lending groups
  25. 25. Using 24 branches out of 90
  26. 26. 20 CHPs per branch
  27. 27. 500CHPs total
  28. 28. Retail sales of $75/CHP/Month</li></li></ul><li>Mobile Platform Drives Health and Sales Gains<br />LG is building a database with cell numbers of every agent and every client<br />Delivering Health Education <br />Text messages educate clients on key health behaviors<br />CHPs can do follow up by text or voice <br />Driving Sales<br />Broadcasts product promotions to improve agent sales.<br />Delivers instant incentives via mobile money or air time credit<br />Driving Prompt Treatment<br />LG educates clients to call or text their CHP at first sign of disease symptoms, creating an “on-call” health worker system. <br />Version 2.0 will have a central text/call for help that automatically dispatches the closest agent and notifies branch<br />Next phase: Improving Monitoring / Adherence<br />All treatments and pregnancies recorded by mobile <br />System sends automatic treatment reminders<br />System sends automated SMS queries to test treatment accuracy<br />Delivers real time reporting to field staff and management<br />
  29. 29. Call Me for Help System<br />Call Me for Help Button<br />Stella Ikila<br />752 830 013<br />Stella Ikila<br />752 830 013<br />Home Stickers<br />Placed in every home with <5 Child<br />Has agent’s cell phone #<br />Teaches family on danger signs <br />
  30. 30. Training and Monitoring<br />Health Promoters’ Training:<br /><ul><li>2 weeks of initial training, materials and meals provided.
  31. 31. 1 week refresher training each year
  32. 32. Monthly coaching visits from a LG field staff</li></ul>Monthly Monitoring: <br />Field agents meet with health promoters at least once a month to re-supply, review records, collect health and sales data, and create outreach plans. Staff also periodically interview community members to measure quality of service and accuracy of diagnoses.<br />
  33. 33. Outreach, Education, and Marketing<br />Living Goods Community Health Promoters use many methods for educating their communities on essential health and improving village access to basic health products.<br /><ul><li>Conducting door-to-door visits, 25-50 visits per week
  34. 34. Giving village health talks at primary schools, places of worship, women’s groups, etc.
  35. 35. Operating stalls at weekly markets
  36. 36. Maintaining daily “store hours” at home
  37. 37. Employing cell phones so ill patients can summon them
  38. 38. Identifying and supporting pregnant women</li></li></ul><li>Data Collection and Evaluation<br />Ongoing Data Collection on Outputs: Health promoters must keep detailed records of patient visits, diseases diagnosed, product sales and referrals to the public health system. Every pregnant mother is registered and monitored. Product sales and volumes are tracked.<br />Evaluation of Outcomes: External randomized control trial evaluation with J-Pal/MIT to measure reduction in morbidity and mortality for children under 5 and key behaviors impacting under 5 mortality<br /><ul><li>Results in 2012</li></li></ul><li>Living Goods Guiding Principles<br />Put Clients First: We guide all our actions by our mission of improving the lives and health of the poor. To succeed in this we must be great listeners. We continuously seek input from our clients to serve them better.<br />Think Big: Because we address problems that afflict billions of people, we seek solutions that have global potential. We create social enterprises that can grow quickly to national scale and readily replicate across many countries.<br />Drive to Sustainability: Impact without sustainability cannot scale. We manage with the long term objective of true sustainability, maximizing internally generated resources, and minimizing or eliminating the need for donor funding. Our focus on sustainability also requires that we operate in a manner that is environmentally sound.<br />Measure, Learn, and Adapt: We set clear goals and demand results. We employ best of class measurement methods to drive learnings for deepening our impact and increasing our efficiency. We measure to drive action.<br />Be Creative and Quick-Footed: We are creative problem solvers who react nimbly to challenges and opportunities. We know that good ideas can come from anyone. We encourage efficient experimentation - learning the most with the least effort. We expect failures and quickly apply their lessons. <br />Be Efficient: Wasting resources deprives our clients, and wasteful organizations cannot be sustainable. Thus we use our limited resources efficiently and collaborate with local partners to leverage existing investment wherever feasible. <br />Master the Art of Collaboration: Impact at great scale cannot be accomplished alone. We seek robust teammates, colleagues and partners and work as a team toward our shared goals.<br />Give Respect: We treat clients, colleagues, partners and vendors with respect at all times. We do not tolerate abuse of any kind. We do not discriminate for any reason. We share the credit and take responsibility for all our actions.<br />Be Honest: We hire for integrity first and do not tolerate dishonesty. We never offer or accept bribes, and are transparent in all our work. We don’t do or say anything we wouldn’t want to see on the front page of the newspaper.<br />Keep it Light: Serving the poor is not a chore. We don’t take ourselves too seriously; we look for humor in difficult situations and find reasons to celebrate.<br />