Unlocking health services in last mile, rural areas

Access to basic health services in rural areas of sub-Saharan Africa is still a challenge. Many families must travel more than 5 km to the nearest health facility to visit a medical expert, which is expensive. Stock-outs of essential medicines, and lack of qualified personnel at the lower-level health facilities are common. These underserved, rural communities, on average 60% of the population, face a high disease burden related to malaria, diarrhoea, and malnutrition. Information on family planning and common diseases is not easily accessible to rural families, creating an even higher disparity between urban and rural health status. National and local governments are deploying community health volunteers to cover these gaps; however, these programs suffer from performance, retention, and sustainability issues. The lack of health knowledge and information, reliable and affordable health products, scarcity of doctors and other qualified health staff pose a great threat to screening, diagnosis, and assurance that people receive necessary and timely treatment. A poorly organized supply chain and uncontrolled flow of medical products further weakens the coping mechanisms of disconnected communities to tackle the health crisis at hand. 

Currently 600 billion people are living in remote areas of sub-Saharan countries, making it a challenge of massive scale.

Healthy Entrepreneurs is a social enterprise with the mission to provide basic health care to all. To address the poor access to health services in rural areas, we empower ‘micro community health entrepreneurs’ to deliver effective and affordable health products and services to the last mile, those hard-to-reach communities in sub-Saharan Africa. Our 8.000 entrepreneurs currently active in Uganda, Kenya, Tanzania, and Burundi are equipped with a smartphone with digital health workflows and health education materials to provide rural families with information and personalized advice. The product basket provides personal care products, over-the-counter medicines, nutritional products, and family planning commodities. These high impact products combined with health advice improve the overall health status of members of the family. Women, children, adolescents, and all other community members greatly benefit from affordable and accessible health services and products provided by our entrepreneurs.

As medical personnel in rural areas is scarce, Healthy Entrepreneurs provides a doctor-at-distance/telehealth service.  Entrepreneurs can contact a medical expert at a distance for screening, diagnosis and treatment prescription through a toll-free line. The medical experts are 24/7 available to provide answers to health questions, monitor and diagnose chronic diseases and prescribe necessary medicines, distributed by the entrepreneur.

This approach offers a full primary health care solution in rural areas through a financial sustainable model. The entrepreneurs earn an income from the sales of health products and health provision. Research into our model shows that these entrepreneurs are more motivated than regular community health workers, refer twice as many patients to the nearest health facility and have a higher self-esteem. Our model allows sub-Sahara African countries to organize community health in rural areas, since it doesn’t require government investments nor does it rely on external donor funding, it also decongests low-level health facilities and provides preventive measures to avoid higher disease burdens.

Families in rural areas spend $100 on average on an annual basis to access health services and products. Around 55% is spend on transport accessing these services. Our solution not only allows these families to save money, it also allows for reliable, affordable and continuously available health products, medicines and health advice. People in rural areas face many health challenges which so far have not been adequately addresses by governments or NGO initiatives. Our social entrepreneurship model is providing community health workers with the possibility to earn an income, rural families to access services, and national governments to improve their health care system. 

Healthy Entrepreneurs has over 10 years’ experience in implementing this community health entrepreneurship model. In these years we have learned many lessons on how to recruit, maintain and manage a network of community health entrepreneurs in rural areas. After an initial proof of concept, the model is scaling. In Uganda we will grow from 6.000 entrepreneurs active today to 18.000 in 2024 covering 95% of rural Uganda.

With a qualified team of supply chain, sales, product and services officers, Healthy Entrepreneurs is well-positioned to manage the growing network of entrepreneurs in the current and new countries. Within our 2030 strategy we will grow to 150.000 entrepreneurs supported by strong international and national teams, managing partnerships with government, the entire operation and all relevant stakeholders including WHO, UN agencies and (inter)national NGOs/ social enterprises.

MIT Solve has a large powerful network of impact-minded leaders who can mentor Healthy Entrepreneurs and other social enterprises to reach the maximum impact. Healthy Entrepreneurs is keen to receive advice from Solve experts on how to scale and better manage a large network of community health entrepreneurs, contributing to reaching SDG1 (poverty reduction), SDG3 (health) and SDG8 (job creation) by 2030.  

Our business model is unique in its focus on health service provision in a rural African setting combined with financial sustainability. Since the Alma Ata 1978 declaration, numerous initiatives have been established to address the persistent inaccessibility of health services in rural Africa. National governments and NGOs supported by external donors, have tried to develop solutions to support community health workers in providing health services. Most of these solutions died out due to lack of funding after ending the initial project. National governments are still struggling to finance community health and prioritize higher levels of healthcare. The tested and recognized Healthy Entrepreneurs’ model has the potential to change community health in all sub-Sahara African countries (and more) while maintaining high standards of care.

The solution offers an opportunity to expand the range of services through the use of telehealth/e-health and e-dispensing, novel point-of-care testing and customer data insights in rural areas. Healthy Entrepreneurs is currently piloting the Doctor@Distance solution with good results. The Doctor@Distance solution offers entrepreneurs the option to contact a medical expert for health advice, screening services and diagnosing of chronic diseases. Through the e-dispensing solution, entrepreneurs are authorized to dispense prescription medicine, reducing transport costs and movements for chronically ill patients. All in all, the Healthy Entrepreneurs model offers an innovative, social entrepreneurial model in sub-Sahara Africa which will be a gamechanger in community health service delivery to hard-to-reach rural communities

Healthy Entrepreneurs will grow its network to 92.000 entrepreneurs by 2027 by expanding in current countries and adding a new country to its operation every year. By the end of 2022 we will have almost doubled our network to 15.000 entrepreneurs active. We expect to start in Burkina Faso, adding a fifth implementing country next to Uganda, Kenya, Tanzania, and Burundi. We will achieve these numbers by replicating our model, as we have done in every new country of implementation. Building a trusted relationship with government and other relevant stakeholders, studying the market, needs, and potential and tailoring the model to the local setting. Then recruiting and onboarding community health workers to become a community health entrepreneur. The entrepreneur will be equipped with a smartphone and a basket of health products on credit. Healthy Entrepreneurs will resupply the entrepreneurs on a bi-weekly basis, based on the orders made by the entrepreneurs. The entrepreneurs can order new stock through their mobile application, paying with mobile money. Currently we have not identified a particular country that will be next, yet this exploration and ambassadorship is ongoing.

Healthy Entrepreneurs will impact more than 23 million families living in remote areas with essential health services, like malaria prevention and treatment, nutritional support or ORS/ Zinc against dehydration. 

Healthy Entrepreneurs measures the progress on our impact goals by different means. We use our internal data on number of entrepreneurs onboarded, number of products sold in which geographical area, and number of health services provided, as the base to assess initial impact on SDG3. In addition to our business data, we regularly collect customer data through surveys among entrepreneurs and final customers. Finally, we allow independent research institutions to assess the impact of our model on the SDG’s and the (public) health system at large. All these insights are used to further improve the operation and service delivery, while mitigating any potential negative side effects of our model.  

Healthy Entrepreneurs’ theory of change starts with the impact we envision that all rural families living in sub-Sahara Africa can access affordable basic health services and health products. This can be realized by deploying a large self-sustaining network of community health entrepreneurs backed by a solid IT structure and a reliable supply chain of health products. In our long-term objective, we envision a network of 250.000 entrepreneurs by 2030, of which 150.000 are part of the Healthy Entrepreneurs’ network and the remaining number are supported by third parties deploying the model. The entrepreneur and their customers will access easily available medical experts through our e-health and e-dispensing solutions. Chronically ill patients don’t need to travel far to the nearest health facility and can access services and medicines at their doorstep. In the medium term we are building our network to 92.500 entrepreneurs and integrating the necessary supply and training support. In the short term we are expanding our services to a new country every year while constantly integrating lessons learned in our model deployment. We assume that community health will remain the first point of entrance to the health system, having a crucial role in prevention and early detection. Pandemics like COVID show that frontline workers are key to disease control and support people closest to where they are. 

Unlocking access to basic health services in remote areas of Sub-Saharan Africa is key to effectively build up a resilient health system which could cope with current and future disease outbreaks and pandemics. Effectively deploying qualified, motivated and financially supported health staff to provide the right basic health services to rural communities is one of the major prerequisites to improve this access.

Healthy Entrepreneurs uses available geospatial data on:

• Location of health facilities
• Administrative boundaries
• Road network
• River network and other potential (seasonal) barriers to movement
• Landcover
• Topography (elevations)
• High-resolution population distribution data
• Climatological (humidity, precipitation, temperature)
• Disease burden (historical information (DHIS2, sources of Healthy Entrepreneurs in the field)

In the accessibility analysis, we combine landcover, road, topography, rivers and other barriers with information about modes and speeds of transport to get a travel impedance surface. Subsequently, in the geographic coverage analysis, we use a cost distance algorithm on this travel impedance surface, with the location of health facilities and the distribution of the population to get the proportion of populations living within a travel time of 1hour to the nearest basic health service. Several travel scenarios (e.g., combined walking and motorised, walking-only) and maximum travel times can be used and compared. Healthy Entrepreneurs partners with the University of Geneva, Institute of Global Health; GeoHealth group and other universities, with extensive experience in conducting this type of analysis and will develop actionable interventions to turn theory into practice. Combining these insights with disease burden, allows Healthy Entrepreneurs to match health services to the needs of last-mile rural communities and respond to disease outbreaks where needed.

Our entrepreneurs are supported with technology to gather relevant health data, provide health information and sell essential health commodities. A "doctor at a distance" accessed through telehealth technology by the entrepreneur, supports diagnosis and treatment of patients that in times of an outbreak or pandemic but even in normal times cannot access a doctor.

Healthy Entrepreneurs collects reliable health information which informs the doctor, but it can also inform national or district health stakeholders about the current health status of rural communities. This data is disaggregated to gender and age category allowing for targeted health interventions to subsets of the rural population. The data generated through our solution will be made available to the national health management information system (HMIS) and data available in HMIS will be used to further strengthen our data analysis. 

In our data analysis process, we gather the expertise of internal and external experts to conduct and check the accuracy of the data and the analysis. Unlocking this data in rural settings in near-to-real-time dashboarding is not available at scale yet, however we believe this solution will be a gamechanger in building and sustaining a resilient health system.

Healthy Entrepreneurs has a diverse team of national and international staff. Leadership teams in the four country offices have a good mix of men and women. As we run a network of 8.000 community health entrepreneurs, we stay in close contact with them to collect valuable information on their wellbeing. Especially women in rural communities face many barriers in gender equity which we support to overcome by providing them with gender sensitive training, income and community awareness.

The economic sustainability is embedded in the social business model. The business case is profitable for all actors in the chain, from final customer, to the community health entrepreneur, Healthy Entrepreneurs and its suppliers. All actors benefit as margins are properly divided along this cost-efficient chain. Healthy Entrepreneurs proactively and diligently manages prices and facilitates and monitors the entrepreneurs to operate in accordance with Healthy Entrepreneurs guidelines.

The business case for Healthy Entrepreneurs is breakeven when ~ 2,500 entrepreneurs are operational in a geographic area. The business case can vary slightly for logistically challenging areas and with specific disease prevalence. Any Healthy Entrepreneurs’ country entity has the capacity to further expand to 10,000 or more entrepreneurs.

The entrepreneurs can continue growing their business by expanding the portfolio of products and services provided. Healthy Entrepreneurs currently offers three levels of service provision and is expected to develop additional products and services, especially with telehealth – expertise at a distance. Entrepreneurs can grow from level 1 to a 2nd and 3rd level of service provision to their clients. They are trained on either non-communicable diseases or infectious diseases, strengthen their ties with the Doctor@Distance and are adding new services and products to their assortment, increasing their income.

For the social and long-term sustainability, Healthy Entrepreneurs continues working with the country governments on policy making, reporting, monitoring progress and impact, and innovation. Healthy Entrepreneurs is a key implementing partner for the country governments in changing the (community) health system. Healthy Entrepreneurs takes care of the entrepreneurs and continues negotiating the best terms – conditions with (international) suppliers to optimize the financial results, the attractiveness of the proposition for entrepreneurs and to ensure access to additional impact investments.

Healthy Entrepreneurs uses a hybrid financing model of grants, equity and debt. Grants are covering start up costs in scaling to new country or geographical region. Once a country operation has more than 2.500 entrepreneurs it could become financial sustainable. Depending on the maximum potential additional investments are made to further grow the network. Equity and debt investments are used to provide the working capital to finance the end-to-end supply chain. Healthy Entrepreneurs at large expects to become financially sustainable by 92.500 entrepreneurs in 2027, whereby revenues can cover all operational expenses. 

Over the years Healthy Entrepreneurs has implemented grant funding to set up operations in Uganda, Kenya, Tanzania and Burundi. In our first investment round in 2020 Healthy Entrepreneurs was able to use debt financing to support the working capital balance. Revenues generated by our network of entrepreneurs grow every month, with even in Uganda in the first 3 month of this year an average 35% revenue increase above targets. Healthy Entrepreneurs is well on target to achieve financial sustainability by onboarding new entrepreneurs every month, increasing revenues per entrepreneur and constantly monitoring expenses.