A Prescription For 1 Billion People: Go The Last Mile
October 10, 2013
In the lead up to Opportunity Collaboration, a four-day problem-solving, strategic retreat for nonprofit leaders, for-profit social entrepreneurs, grant-makers and impact investors engaged in economic justice enterprises, the Skoll World Forum is spotlighting a wide range of delegates and speakers working on innovative solutions to tough societal challenges around the world. Opportunity Collaboration will take place in Ixtapa, Mexico from October 13-18.
If there is anything social entrepreneurs and investors attending the upcoming Opportunity Collaboration have in common – it’s courage. Courage has shaped our work at Last Mile Health. Courage has also shaped my own family.
In the 1970s, my parents emigrated from India to Liberia, a West African nation founded by freed American slaves, where I was lucky to be born. We loved Liberia. Its unparalleled beauty was matched by its opportunity. My mother found work as a tutor in Monrovia and my father launched a small general goods store.
But, in 1990, when I was 9 years old, rebels launched a civil war. In just a few weeks we lost everything – our home, our way of living, and when my father went missing for a month we thought we had lost him too.
But, we were the lucky ones. We all escaped and we all survived, my father included. With the help of many Americans, we rebuilt our lives in North Carolina and I followed my dream to become a doctor. But, I never forgot where I came from. Liberia had a lit a torch in my heart and the generosity of Americans who helped us had ignited it. So, eight years ago, I returned to Liberia as a 24 year-old medical student, to help serve the people I had left behind.
What I found was utter destruction – and not just empty shells where buildings once stood. To serve the remaining 4 million people, Liberia was left with just 51 doctors (there were more doctors in my single residency class at Harvard). If you fell sick in a city where the few remaining doctors worked, you would stand a chance. But, if you fell sick in remote villages hundreds of miles away from the nearest clinic, you would die anonymously.
Imagine not living in a city like San Francisco, New York, or London, where a clinic might be around the corner or a short drive away. Imagine, instead, living in an isolated rainforest village and your two-year old son has woken up one morning with a fever. You panic, because you know he likely has malaria and the only way to get your son the medicines he needs would be to carry his frail body on your back, paddle a canoe across the river, then hike for up to two days over log bridges and across the mud in the jungle before reaching the nearest clinic.
It’s an impossible situation. Yet, this isn’t just the story of one mother and one child in one far-off village. Around the world, 1 billion people lack physical access to medical care because they live in remote, last mile villages — too far from the nearest clinic.
The standard solutions — constructing more clinics and deploying more doctors –are necessary, but they are not sufficient: they still haven’t reached last mile villages. Rebukes like it’s “too expensive”, there “isn’t enough infrastructure” and “it’s too far away”, create a suffocating cynicism that plagues health care delivery in the world’s most remote villages
It’s no wonder most don’t dare to go the last mile and why many experts told us not to dare trying either.
But, we chose not to listen. Deep in Liberia’s rainforest, my colleagues and I discovered new opportunity embedded in an old idea. We created Last Mile Health to saves lives in the world’s most remote villages by employing community health workers and giving them all the inputs — training, equipment, and support — they need to perform.
The idea of community health workers is not new. In villages where doctors and clinics don’t reach it has been thought, for at least a few decades, that community health workers – training a local villager to provide basic health care – can save lives.
But, community health workers, at least in their conventional form, too often fail. It’s not their fault. Too many health systems still underinvest in community health workers and therefore they underperform – especially in remote areas.
Let me explain. When deploying a community health worker, the status quo has been to ask a chief in a remote village to select a community member, like Zarkpa, who never finished middle school and never had a job. Without testing if she’s qualified, Zarkpa would be trained for a few days to be a community health worker and then, basically left to fend for herself – unequipped, unsupervised and unpaid.
In effect, she’s treated like an amateur. Zarkpa (and thousands of other community health workers) never reaches her full potential and neither does the health of her village. Village women and children, who have never had primary care, never get it.
At Last Mile Health, we do things differently – not with medical innovation, but entrepreneurial creativity. We make each of the five processes needed to deploy a community health worker – recruiting, training, equipping, managing and incentivizing – more efficient and more effective. In so doing, we transform community health workers from under-performing amateurs into high-performing professionals — strengthening the rural health system.
Here’s how we get it done. Before Last Mile Health recruited her, Zarkpa had to pass four tests, including being vetted by her community, passing a literacy screen, two practical assessments and a probationary period — to make sure she was qualified for the job. We trained her, not for a few days, and not only to educate her community to prevent a few diseases, but for sevral weeks to provide prevention AND diagnosis, treatment, and referral services for the top 10 killers of women and children – so she can play an vital role in fighting the majority of disease killing her people.
Then, we equipped Zarkpa with a backpack full of point-of-care tests, like a hand-held test that diagnoses malaria within a minute, and life-saving medicines, like antibiotics; assigned her an outreach nurse who rides a motorbike out to Zarkpa’s village and coaches her every week – so she continually improves her skills and patients too sick to treat in the village get referred safely; and gave her a paid contract, tying it to her performance – so she’s accountable to the people she serves.
In short, Zarkpa’s not treated like an amateur. With the right inputs, she’s treated like a professional (just like any of us would want to be). And, she performs like one. Zarkpa has mastered over 50 medical skills: she can diagnose and treat children with malaria and pneumonia, screen women for anemia, HIV/AIDS, and high blood pressure, and identify complications of pregnancy and childbirth.
Even professionalized community health workers are not a panacea. But, when integrated with the health system, this work – giving community health workers everything they need to do their jobs well – saves lives in places never thought possible. We launched Last Mile Health from a bombed out building in Liberia’s rainforest in 2007 with $6000 in donations collected at my and my wife’s wedding. Today, partnering with the Liberian Government, we’ve performed over 70,000 patient visits and in the most remote district – Konobo – we have tripled access to care. Today, five times as many children get vaccinated. Today, twice as many children with malaria get treated and all pregnant mothers receive care. And today, that mother no longer feels the panic of not knowing whether she will be able to tow her feverish son to the clinic before it is too late. She and her son have real care right at their doorstep – where it can have the biggest impact.
We could not have come this far without our partners. Our challenge now is to scale-up and go the last mile. There are still 1.5 million people in remote areas of Liberia, and yet millions more around the world, who go without access to care.
We have a plan to start changing that. Earlier this summer, at the Forbes 400 Summit on Philanthropy at the United Nations and subsequently at the Clinton Global Initiative, we announced a 3-year plan with Liberia’s President Ellen Johnson Sirleaf to deploy 300 professionalized community health workers to bring access to care to 150,000 people who’ve never had it. Not only will this create a medical safety that saves lives, it will create jobs – 300 of them – in a country where rural employment is 85%.
We invite those who share this vision to join us in accelerating progress towards these goals.
As a physician who has had the privilege of caring for the sick both in the villages of the country I escaped from and in the cities of the country I escaped to, I know one thing is true: illness is universal, but access to care is not. I also know we can change that. By pairing the best of medical care with the best of social entrepreneurship, there is no challenge we cannot overcome – not even the challenge of bringing quality health care to each and every corner of our planet – if we find the courage to go the last mile.