4

Tipping the Scales: Scaling Up to Save Lives

Many exciting experiments and innovations in global health have the potential to dramatically improve the lives of millions in developing countries. These solutions do not need further scientific or technological refinement, but rather a business model that can disseminate these products and services to those in need in both urban and rural settings.

A critical part of the solution to creating impacts in global health is scaling up what works—getting the right solution to the right customer—all over the world.

Scaling Social Enterprises

There are poor-quality health programs that, when scaled, remained of low quality. Scaling bad programs may do more harm than good. And a number of health programs have achieved excellent quality outcomes in localized settings, but have generally not been able to replicate and scale their successes to other settings.¹ What we need are high-quality global health products and services that can simultaneously achieve scale while maintaining high quality.

Scaling

Quality at Scale: Is It Possible?

To scale quality programs in high-resource settings, we need leadership; effective collaboration with communities and governments; and monitoring, evaluation, and accountability.² But these prescriptions are insufficient for guiding scaling efforts in impoverished regions, where infrastructure is weak, resources are minimal, and education is not necessarily perceived as a right, or even a need. The obstacles are many, yet a handful of programs have successfully reached scale in these extremely challenging conditions.³

Some have distinguished different types of scaling.⁴ Some scaling reflects geographic replication (for example, opening more distribution or treatment centers). Others reflect nonreplication options by affiliating with new partners or creating change in the environment, the community, or policy. Even with geographic replication, the challenges of moving to scale globally are significantly greater than opening another center a few miles away.

Previous scaling studies have focused largely on the strategic and organizational mechanisms and characteristics common to scaling efforts, both in developed-world contexts and in social enterprise more broadly. Among the factors important for scale are a theory of change;⁵ organizational culture, structure, and leadership;⁶ networks and affiliate interactions;⁷ strategies for information sharing; and assessment of market readiness.⁸ Others have argued that efforts to scale must be enhanced by activities that improve broader environmental features, such as regulations and infrastructure.⁹

A Model for Scaling Global Health

Our health model describes the factors most critical to bringing high-quality health programs to scale. This global health-scaling model can be used to develop high-quality, scalable programs that will be successful over long periods of time and across multiple geographic regions. It identifies the unique characteristics that enable some organizations to succeed where many private, NGO, and governmental programs are failing. Further relevant discussion of this model can be found in its application to education in developing countries.¹⁰

Scaling research has identified important scaling levers that can be helpful in scaling global health. These levers are 1) programs aligned to the clients’ unique needs; 2) processes that enable programs to be offered at minimal cost; and 3) passion for organization goals and social impact (Table 6).¹¹

Table 6 Levers for Scaling for Social Impact

A number of organizations use all three of these levers. Though we have highlighted only one lever for each of the organizations discussed in the following sections, the organizations in fact make use of all three.

Program Scaling Levers

The first lever—program—refers to both the content and the delivery of the global health program. The role of this lever is to develop, conceptualize, and plan an initiative that meets the needs of the individuals as well as the larger community.

Available resources vary widely across regions, and programs must accommodate this fact. A strong program will consider local needs and experience. If a program is to be widely adopted, it must be tailored to the needs of individuals, families, and the broader community. If people do not sense the usefulness of the health products and services, we can expect little commitment on either the demand or supply side.¹³ Taking sociocultural context into consideration will further ensure the highest quality of products, services, and delivery, and will require tailoring the program to specific needs.¹⁴ Significant adaptation of successful programs is often necessary to achieve scale.

Process Scaling Levers

While the program levers focus on the quality characteristics of the program to be scaled, process levers focus on the mechanics of maintaining and replicating that quality at scale. In developing countries, efficiency in deploying and managing resources is essential; successful organizations build and manage their programs with scaling in mind. The need to maintain extremely low costs drives process engineering and standardization. The need for flexibility in diverse and changing conditions drives continuous monitoring and reconfiguration.¹⁵

Controlling costs is among the greatest challenges in achieving quality at scale.¹⁷ Global health programs almost uniformly operate under significant resource constraints, but in the developing world funding constraints are typically severe.¹⁸ Thus, organizations must consistently focus on maximizing the productivity of expenditures while eliminating activities that do not add value.

Efforts to systematize processes are sometimes perceived as “McDonaldizing” health. But although the primary objective is minimizing costs, such efforts also provide consistent, high-quality service delivery in challenging environments. As countries try to rapidly increase provision of quality global health services, for example, they often hit roadblocks such as lack of qualified health or administrative staff, or lack of adequate sites, resources, and materials for construction.¹⁹ Obstacles such as these can often be overcome through the development of routines that accommodate the use of widely available human and material resources.²⁰

While standardization of processes is essential for cost management, organizational actors should be empowered to tailor programs and activities to best meet the ongoing needs of clients and to improvise when circumstances make processes ineffective or impossible to execute properly.²¹

Ongoing health and administrative training provides the base level of support and capacity development essential for success. Training encourages professional development and aids in developing the necessary relationships among health workers and the various NGO, government, and business leaders pivotal to ensuring sustainable success in scaling.²² Once effective processes and support mechanisms have been established, ongoing oversight is needed to ensure that programs are scaling effectively and program delivery and quality standards are maintained.²³ Continuous monitoring and evaluation provide the transparency necessary to drive accountability for actions and results.

A clear logic model lays out the relationships among investments, actions, and ultimate outcomes and provides a framework for accountability and achieving goals such as improved health, poverty reduction, and quality of life. As a result, each organization should also be engaged in monitoring and evaluation at a variety of stages, including resources obtained and employed, activities conducted, services delivered, direct program outcomes, and social impact.

The systems of accountability rely both on diagnostic metrics and interactive discussions about the knowledge to be gleaned from the measures and ways to best redesign programs and processes. These systems productively channel information toward continual program improvement.²⁴

Passion Scaling Levers

Passion provides the motivation and energy to move from plans and ideas to successful health programs. Simultaneous achievement of excellence and scale under challenging developing-country conditions requires an entire range of dedicated stakeholders with a strong belief in the organization and its mission.²⁵

Engagement is a core element of passion and motivates stakeholders to achieve success despite the constraints and other barriers faced by new global health programs. Most global health organizations have ongoing funding and staffing challenges. Yet all key organizational participants need to be highly engaged with their organizations and projects. Both volunteers and paid staff must be strongly committed to both their organizations and to the clients served, since working in developing-world health typically involves harsh working conditions along with a variety of risks and uncertainties.

Employees in successful organizations such as BRAC tend to operate with a sense of ownership of the organization and its programs, a factor that increases their passion to help the program succeed. Employees are empowered to pursue opportunities and are provided with the freedom to take risks and to directly discuss issues with key organizational decision makers. Empowerment is an important aspect of program ownership, which is essential in programs operating at scale.²⁶

In developing countries roads flood, electricity goes out, health funding is pulled, contracts are violated, and idealized plans become impossible to execute. Employees need the power and organizational support to rapidly and flexibly address new challenges, and the organization must be able to learn from these solutions and reconfigure operations to accommodate them in the future. To address the needs of ever-changing circumstances, organizations must foster collaborative and open environments that enable exchange of ideas and sharing of concerns.²⁷

Prior work on social enterprise scaling has emphasized higher-level scaling levers, such as staffing, communication, alliance building, lobbying, earnings-generation replication, and stimulation of market forces.²⁹ Our approach looks at a more fundamental core of scaling drivers. Quality programs, effective processes, and even passion are treated as givens by most current scaling literature. But the very poor quality of many large global health systems, the high resource requirements of most high-quality systems, and the lack of a push toward growth and impact suggests that these more fundamental levers cannot be overlooked.

Moving to Scale

Scaling global health programs for the poor remains a significant challenge, yet the need for high-quality, low-cost health is enormous. Only a handful of organizations have been able to scale programs effectively. Our model describes the most successful organizations in an effort to articulate the factors these organizations considered most essential in their success. These three levers are essential and include a high-quality program suited to the health needs of the individual and community, efficient processes and effective systems for supporting and overseeing those processes, and passionate engagement at all levels supported by distributed authority to adjust to changing needs.

Developing a program that clients in those environments will embrace requires marketing that can integrate significant local knowledge and a deep understanding of the lives of the clients. This requires programs of extremely high quality that have been developed by experts to meet the unique needs of individuals and communities in need.³⁰ It also requires overcoming the many barriers to achieving scale:

• Shortage of financial resources

• Shortage of human resources in health

• Shortage of human resources in enterprise management

• Lack of infrastructure—roads, hospitals, electricity, water, and other factors

• Lack of education

• Lack of coordinated government, NGO, and for-profit activities

• Lack of innovative, entrepreneurial, and skilled leadership in government, NGO, and for-profit enterprises

• Lack of focus on mission and priorities

Designing processes that can operate effectively under extreme resource constraints also requires special attention and effort. Despite constraints, government leaders and communities expect health programs to deliver high-quality products and services. Thus, they need to recognize the importance of service quality and develop scripted processes that make possible high levels of consistency with expected outcomes and enhanced by frameworks enabling communication and support among health workers.

Finally, developing and maintaining the passion needed to work with these difficult-to-serve populations, and to overcome the continuous variety of problems and risks that arise, requires an organization that can find and support devoted and engaged participants. This includes recognizing the importance of regularly engaging with staff to maintain high levels of passion for the organization and its mission while operating in extremely challenging circumstances. Extensive communication is essential.

By focusing heavily on the fundamentals of program, process, and passion, organizations operating in even the most challenging conditions can achieve scale while maintaining outstanding quality. Researchers and practitioners seeking to develop scaling models to meet market challenges can benefit by using these fundamental organizational levers to deliver high-quality health care to everyone who needs it.³¹

Partnership Coordination

Achieving scale in global health requires partners. No one entity can or should try to address all health issues alone. A variety of partnerships can be created between entities and sectors: between private businesses, between governments, and between government and private businesses. We will focus on public-private partnerships and franchising because of their ability to create more effective means of achieving desired impacts.

Partner Coordination

Public-Private Partnerships

Public-private partnerships allow governments, NGOs, and businesses to collaborate and work in ways no single organization or sector could do alone. Though sometimes complicated to successfully implement, partnerships create potential win-win opportunities to build sustainable markets for health products and services that would be difficult to create without coordination. These strategies often lead to bold actions that can lead to dramatic improvements in reducing illness and death.³²

Public-private partnerships can be created for a variety of causes, including product development, improved access to care, advocacy and education, regulation and quality assurance, and strengthened health services. There are significant benefits to such partnerships, including the infusion of private capital; the management and increased efficiency found in private companies; the creation of cost-effective, high-quality goods and services for target populations; and the ability to overcome challenges that arise when any single actor attempts to tackle global health issues.³³

Despite the potential benefits, partnerships can be difficult to maintain, especially when goals and values fail to align. There must be evaluation methods to measure outcomes and a strong legislative and governance framework to deal with multiple parties, since there is a real possibility of conflicts when trying to combine the priorities and values of for-profit companies, NGOs, and governments. Initial coordination and ongoing monitoring and evaluation can be problematic when one is dealing with different organizations with different goals and values. This can have a negative effect on the long-term sustainability of health care systems in poor countries. But with clear communication and a clear agreed-upon mission and purpose among all parties involved, many of these issues can be overcome.

The GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation) is one example of successful management innovation through a public-private partnership. The GAVI Alliance is a partnership among the key drivers of immunization in the world, including organizations involved in immunization strategy and policy setting, advocacy, fundraising, vaccine development and procurement, and in-country support and immunization delivery. The alliance helps each country stimulate demand for immunizations and create mechanisms for service delivery. It also negotiates prices with pharmaceutical companies and, once a price is set, supports countries in buying vaccines.

The GAVI partnership thus creates a win for the countries, which are able to purchase vaccines at deep discounts; a win for the pharmaceutical companies, which now have guaranteed and stable sales; and a win for children, who receive lifesaving vaccines. Since 2000, GAVI estimates that this partnership has enabled it to save 5.5 million lives through vaccination of children in developing countries (see chapter 5 for details on GAVI).³⁴

Of course, public-private partnerships are not the only kinds of partnerships. There can be any number of partnerships between entities operating in the global health arena. Many, if not most, require the creation of multidisciplinary teams, where people with different kinds of expertise can come together and to create better health outcomes for a given population. The varieties are endless. At the upper level, uReport, a crowd-sourcing solution using SMS, was developed by a combination of government, university, and NGOs, in Uganda and elsewhere, and a private telecom company. Partnerships do not have to be international conglomerations—they can simply include two local entrepreneurs who work together to improve effectiveness and efficiency and increase profits. One could, for example, create a partnership by placing a micro-pharmacy next to a clinic. The result will be, in each case, to increase scale. To make each of these collaborations work requires entrepreneurship on the part of those seeking to create them.

Partnerships through Franchising

Franchises are another kind of partnership, typically pairing entrepreneurs with NGOs or for-profit businesses. Through franchising, microentrepreneurs can access some of the advantages of big businesses, including economies of scale and training. The franchisee runs its business on a profit/loss basis, so it has a strong incentive to provide good products and services at an affordable cost. One of the roles of the franchisor is to provide a common brand to assure quality while using its buying power to reduce the overall cost of inputs and supplies to franchisees. In addition, the franchisee receives support from the central organization and benefits from brand recognition.

Meanwhile, franchising benefits the central organization because it is able to reach more places more easily without attempting to exercise the kind of central control that can result in bad decisions being made by people far away from where the problems arise. As a result, franchising allows organizations to scale up their operations rapidly and efficiently. Franchising also provides entrepreneurial opportunities for community members, helping the organization gain credibility by putting a local face behind each of the branches.³⁵

To work, a franchise organization needs to have a successful and proven initial management concept, sufficient demand for the product or service, a strong supply chain to ensure that goods are delivered regularly so that stocks do not become depleted, and a well-respected brand. The network model needs to be extremely simple, and the organization needs to focus on well-documented successes. Location is important as well. Franchisees should be close to customers, but spread out enough to ensure that there is enough demand per store.³⁶

There are also several challenges to attracting and retaining franchisees. The franchisees may need access to financing for the initial startup costs—and one can expect that franchisees will have to compete for financing opportunities. Local political and regulatory environments matter a great deal—the same operation might be legal in one place but illegal in another. To maintain the brand’s value, the organization has to maintain quality control, since any negative reputation for the brand will impact all franchisees, and this is only complicated by the need to manage and interact with a large number of geographically dispersed franchisees.³⁷

Many of these problems can be solved by having a comprehensive and ongoing set of training programs, as well as regular meetings at all levels. There should be a feedback system for franchisee input into decision-making. Providing effective advertising and strong brand recognition will help keep franchisees operational by creating demand. Finally, help services and financial and managerial reports can be offered to assist franchisees in improving their businesses. By doing these things, an organization should be able to set up a successful franchise operation—one that can get health goods and services to the people who need them, when they need them, and where they need them.³⁸

The solutions highlighted above involve the creation of franchises, which is one way of creating a hierarchical network in a hub–spoke model, with a central organization able to send smaller and smaller fingers out into more and more rural areas. This model works because franchise models are able to take advantage of economies of scale. A benefit of locating a business or organization in urban areas is that one can achieve economies of scale—the larger you get, the cheaper it becomes to make your product or provide your service.

However, most of the people we need to reach in places like Africa and Asia are rural. The franchise model allows us to both create economies of scale and reach rural areas. We can see this in the fact that it is impossible to drive through even the most rural areas of the United States without eventually running into a Shell gas station, a 7-Eleven, or a McDonald’s. For rural people in particular, hospitals and large clinics and pharmacies are not realistic options. Microclinics, micropharmacies, and even people on motorcycles or bicycles have to fill the gap. By franchising to local entrepreneurs who understand the local population, large companies are able to reach more people in more places, while the entrepreneurs are able to take advantage of the fact that they are offering a well-known brand.³⁹

Pros and Cons of Franchising

Pros	Cons
• Standardization	• Limited flexibility
• Use of a proven business model	• Franchise fees
• Collective purchasing power	• Vulnerability to negative franchise reputation
• Economies of scale
• Common branding

Scaling What Works

To succeed, we need to harness all of the IMPACTS elements to deliver health care goods and services. Given the effective health products and services at our disposal, the real problem—and the main focus of this book—is how to get these solutions to those who need them.

To have significant impact in global health, we need to scale up what works. Scaling requires a focus on ensuring that the critical elements of the program are present, efficient processes to ensure quality are in place, and an empowered workforce can adapt a program to local contexts. Furthermore, partnerships must be created within and between sectors. No one party is capable of tackling global health alone. Partnerships allow for a sharing of strengths and can create a sum that is greater than individual parts. In order to achieve the most strides in global health, we must look for strategic partners to collaborate with.

In Part 2, we will show how some organizations in developing countries are working to create impacts in health. These organizations exemplify many or all of the IMPACTS elements, and we will see a wide variety of providers and organizations, small microentrepreneurs, governments, NGOs, and multinational corporations all working together to benefit the lives of others.