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.

Rotman Management Magazine - - FRONT PAGE - By Roger Martin and Sally Os­berg

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.

In clos­ing

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.

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