Roger Martin & Sally Osberg On Social Entrepreneurship
Social entrepreneurs focus on the people most disadvantaged by our current system in order to bring a new equilibrium to modern life.
in fits and starts. IT IS FAIR TO SAY THAT OUR WORLD MOVES AHEAD Sometimes, cataclysmic events — oppressive regimes, wars and other catastrophes — move humanity backwards; but most of the time, our advances are of the ‘normal science’ variety, whereby someone figures out a way to make the current system work a bit better. A business will tweak its product or service to the benefit of users, or a government will tweak existing legislation to produce a benefit for society. Such incremental advances are helpful, and the governments, businesses and non-profit organizations that work to produce them deserve our encouragement and support.
However, every once in a while — backed by revolutionary thinking — a society leaps forward to a fundamentally ‘new equilibrium’. The status quo is left behind — even if it had held firm for centuries. The revolutionary thinkers leading the charge find powerful new ways to structure our systems, fundamentally altering how they work.
This is the realm of the social entrepreneur. In this article we will describe how these intrepid thinkers and actors go about creating transformative change.
Transformation for Good
Andrea Coleman grew up in a family of motorcyclists. From an early age, she wanted nothing more than to become a racer herself; and so she did. After losing her first husband — Grand Prix racer Tom Herron — in a racing accident, she pursued a passion for road safety every bit as intense as her love of riding. Her second husband, Barry Coleman, shares this interest, tracing his own love of motorcycles to his racing beat for UK newspaper The Guardian. Their shared passion brought them together, and subsequently, it led them to Africa.
Along with their friend, Grand Prix racer Randy Mamola, the Colemans spent years persuading their racing peers to raise money for Save the Children’s African programs. In 1988, Save the Children sent Randy and Barry to Somalia, to show them how these hard-won funds were being used.
The money was clearly being put to good use. Yet what the two men saw in Africa — and what Andrea saw on a subsequent trip — shocked them: hemorrhaging women being carted in wheelbarrows to the nearest clinic; health workers covering distances of 20 or more miles of tough terrain each day by foot; countless vehicles left to rust by the side of the road, or stacked up against buildings — vehicles that would still be operating if they had been properly serviced.
What good, they asked themselves, was a healthcare system without reliable transport? And what good were expensive vehicles that were as mobile as millstones? That, in a nutshell, was the status quo they encountered, and it became the starting point for their vision for change.
Like many successful social entrepreneurs, the Colemans saw, in the existing system, an opportunity that was little noticed by others. Most of the attention in global health is on the eradication of and effective treatment of disease. The humdrum issue of ‘transportation infrastructure’ barely registers. By bringing their extensive personal expertise to bear in a new context, the Colemans could see how vital transportation was to the operation of the entire system.
For a social entrepreneur, it is not enough to imagine a way to reduce suffering. Their vision is for systemic change: it shifts an existing equilibrium to a new one — one that ensures an optimal new condition for those who had been disadvantaged by the prior state. As a result, the organization the Colemans formed, Riders for Health, wasn’t interested in simply buying trucks to replace the ones that had broken down: instead, they set out to fix the system that was allowing these vehicles to fall into
disrepair in the first place.
The Riders for Health model sees them partner with African health ministries contracting to manage their vehicles — whether they are used to mobilize outreach health workers on motorcycles, transport samples and supplies to health centres, or serve as ambulances for emergencies. For example, in Rwanda — where they were asked by the Ministry of Health to assess its transportation capability — Barry and his team confirmed what the Ministry already knew: the reason behind an unacceptable record of breakdowns — with as much as 80 per cent of the fleet routinely out of service in rural areas — was poor maintenance. Rwanda was not alone. Riders for Health found that the average life of an unmanaged vehicle in the harsh environment of rural Africa was a little over a year, and motorcycles lasted only eight months.
Here’s how they tackled the problem: first, they took over the management of a partner’s fleet, providing preventive maintenance and driver training. They provided regularly-scheduled maintenance on healthcare service delivery vehicles, keeping fleets running over a much longer lifespan and replacing parts before they wore out. This maintenance could be carried out on an outreach basis, which meant vehicles could be regularly serviced where they were used, rather than at a central location — keeping off-road time to a minimum.
Second, Riders for Health trained health workers on how to operate their vehicles effectively and conduct daily maintenance on them, including checking on oil levels, tires, brakes, lights and other basics. Along with other services — including planning and budgeting for ongoing operating costs like fuel — this Transport Resource Management (TRM) model aimed to produce fleets that would operate with 100 per cent reliability at the lowest possible cost for the longest possible time, regardless of tough conditions. This was a model aimed at transforming one specific aspect of Africa’s healthcare infrastructure, and in doing so, it made the entire system more effective.
The Mission Expands
At the heart of Riders for Health’s work are the African women, men, and children at risk of dying needlessly. But to effectively reach them, the Colemans realized early on that they had to address another part of the system. Having scanned the actors who played pivotal roles in the current health-delivery system — government, healthcare workers and patients — and explored key interactions between them, they came to see that the health of Africans is dependent in large part on the services of one particular group: community health workers.
Addressing the needs of the poor, rural and ill-served population was a key first step to framing the Colemans’ winning aspiration; but for their vision of a new future to take hold, they realized that they would have to align the interests of other key actors, as well. These would include development organizations, government ministries — and the pivotal community health workers.
These front-line public health workers are members of the communities they serve, bridging the gap between the formal health-care system and local communities. When equipped with reliable transportation, they can deliver vital services to large numbers of people over great distances, providing testing for illness, vaccinations, monitoring of pregnant women, screening for malnutrition, distributing bednets, and much more. For these vital workers to do their jobs—and for medicines and supplies to reach rural villages situated hundreds of miles from the nearest town — reliable transportation is critical.
The Colemans imagined a system equipped with the capacity to ensure that even those living in the most remote villages could gain access to life-saving vaccines, bed nets, and medicines and to the routine services of trained community health workers. Such comprehensive access would be enabled by a robust and well-maintained transportation infrastructure that would include trucks, ambulances and motorcycles. Obviously, motorbikes are cheaper to run than four-wheeled vehicles and they can cover more challenging terrain. They are beautifully suited to making community health workers far more mobile and productive — if they are properly maintained.
Gambian community health worker Manyo Gibba used to
walk as far as 20 kilometers per day to serve the 20,000 people in the 14 villages assigned to her. Under such conditions, she was simply not able to check in with her communities regularly — rarely getting to each village more than once a month. When Riders for Health provided her with a reliable motorcycle, showed her how to operate it safely, and trained her to perform routine preventive maintenance, she was able to cover the distances easily, reaching all of the villages at least once a week.
This kind of improved coverage has been the key to better health outcomes in the regions served by Riders for Health. Diagnoses are now made more rapidly, making prompt and optimal treatments possible. Vaccination rates, treatment rates, and bed net delivery rates have all improved. In Zimbabwe, deaths due to malaria decreased by 21 per cent in a district served by Riders for Health, compared with a neighbouring district not served by them, which experienced an increase of 44 per cent during the same period.
Raising Their Sights
The Colemans didn’t start out with a grand vision to transform healthcare delivery in sub-saharan Africa: they started much smaller, with a simple project to supply and maintain transportation for healthcare workers in Lesotho, in partnership with Save the Children. But after six years of hard work — and the stunning record of not one single vehicle breakdown for properly-equipped and trained workers — they raised their sights.
Armed with evidence that their model could work, and determined to make transportation a systemic priority, they began to aim for equilibrium change. They already knew what incremental, temporary improvements looked like: when health authorities bought a shiny new vehicle for a region, healthcare delivery numbers would spike positively — but only until the vehicle inevitably (and in the rough rural African context, relatively quickly) broke down, at which point delivery standards would fall back to their previous unacceptable lows.
As the Colemans evaluated their progress, they began to think about changing their model. They had seen dramatic effects from their management of partners’ vehicles; but what if they went even further?
The Gambia, where they had been active for nearly 20 years, was ripe for experimentation. What if they took over the entire transport function from the Ministry of Health, under a lease agreement? What if they acquired and maintained a brand-new fleet for the Ministry, equipping every healthcare worker with transportation and ensuring coverage for the entire country?
With this new approach, which they call Transportation Asset Management (TAM), Riders for Health assumed responsibility for procuring — and owning — the necessary fleet of vehicles, not just maintaining them. It then leased the fleet, along with its maintenance services, to the Ministries of Health.
Riders calculates its fee on a vehicle-cost-per-kilometer basis, incorporating procurement, financing, operations and maintenance into the number. The fleet structure ensures that the right vehicles are in place for their appropriate purposes, and under this model, health ministries are spared the headaches of acquiring and caring for vehicles. Dr. Malick Njie, the Gambian minister of health who signed on to the new plan in 2007, realized almost at once just how significant the benefits could be. He recalls that, “For the first time in the history of the health sector in the Gambia, we looked at the complete logistics support system. We realized that using old vehicles would not deliver what we wanted to deliver.”
Even so, Njie had his work cut out for him in persuading his colleagues to take up the new approach, with its entirely different cost model. He recalls making the case: “Let’s put our hands together and put our resources together. We have so many programs that have logistics included in them. If we continue the
way we are, you don’t realize it, but we’ll spend more money than we spend now, and we’re still not getting anywhere.”
Business as usual, Njie believed, would lead to siloed thinking rather than transformation: “There are so many Global Fund programs to buy and maintain vehicles. They come in different forms: the malaria program, the HIV program, all of them thinking in only one direction. They manage their own transport maintenance with private servicers; all think in their own buckets.” Thinking outside of these buckets meant joining forces, and implementing TAM in the Gambia.
Eight years on, the results are very promising. Although the Gambia is a small country, covering some 11,300 square kilometers, its conditions are typical of sub-saharan Africa: less than 20 per cent of its roads are paved, and 43 per cent of its population lives in rural areas that are well off the beaten track. Yet, to date, Riders’ fleet has covered over 12 million kilometers in the country without a single breakdown. Riders reports not one transport-related failure in referring women in threatening labour to a hospital or clinic; and childhood immunizations in the Gambia are now approaching 100 per cent — among the highest in the world.
Reflecting on their journey of more than two decades, the Colemans acknowledge that much work remains to be done, even as they look with pride on what they have achieved.
While the change they so clearly envision — a new equilibrium featuring reliable healthcare transportation systems across Africa — has not yet taken hold as they feel it should, there are encouraging signs. New memoranda of understanding are in development with both Rwanda and Nigeria. Expansion into Nigeria alone, with its population of over 173 million, would double Riders’ current reach. More importantly, it would bring the kinds of health gains the Gambia has seen to a country whose population is expected to reach 300 million by 2025. Liberia and Sierra Leone, which have been ravaged by the Ebola virus, have also reached out to Riders, signaling a growing recognition of the value transport plays in health infrastructure.
As inquiry continues into the still-nascent field of social entrepreneurship, we are hopeful that the on–the-ground practice and experience of social entrepreneurs such as the Colemans will continue to inform it. As the field becomes more established and readily understood, we encourage funders to dedicate resources to helping social entrepreneurs build their transformational models. We also encourage leaders in the domains of government and business to adopt and adapt the tools of social entrepreneurship to accelerate their own innovative work.
The Colemans saw, in the existing system, an opportunity that was little noticed by others.