Adventures in Capitalism

Nuru’s all about sustainability. We want our programs to be self-funding as soon as possible. And there are few things more sustainable than profitable business models. One of the best ideas out there on this is the Living Goods model. The idea is basically to use Community Health Promoters (CHP’s, not to be confused with CHWs; everyone wants to brand their health workers) to sell health-promoting goods at a small profit. That profit is the incentive to keep them working. Because research has shown that if you don’t pay people, they don’t work for you forever (seriously, people had to research that).

So four weeks ago, we distributed 200 bars of soap to 50 Nuru health reps. The health reps are organized into teams under 7 field officers. And because a bit of friendly competition makes people do amazing things, we told them that there’d be a prize for the team that sold the most soap. And just like that, the soap sold like hotcakes! We were sold out in a matter of days, selling at 15/=. The Field Officers complained; more of their members wanted soap and couldn’t get it. So I asked them to write a proposal. They did, and I funded it. This was originally supposed to be a proof-of-concept exercise: giving inventory and getting roughly enough money back to pay for the inventory. But we couldn’t let that kind of demand go to waste, so we bought an additional 400 bars and upped the price to 20/=. If this sold, we would actually be profiting (we bought the soaps originally at 16/=). And they did sell. We’re expecting a profit of about 1000/=.

Sounds great, right? All but one thing: the health reps are friends with all their customers. And friends don’t always have the money to pay for things like soap. But if they say they’re good for it, they’re good for it, right? Well not quite. We made it crystal clear to the Field Officers that they were responsible for returning the soaps or the money for the soaps; these were not gifts. And so some of the Field Officers came to collect money from their health reps who, because of their generously, had given the soap out on credit. The Field Officers told them it was their responsibility to pay for the soap and so they did; those who extended the credit paid from their own money. We debriefed today and we asked about what they’d do differently. “We won’t give them the product until they give us the money.” And they didn’t even need me to lecture them on following our instructions better. By holding 7 people responsible, they hold those below them responsible. Isn’t responsibility amazing?

But why did people buy our soap? Were our never-sold-anything-before farmers that good at selling? Or was this, like the discount flyers, something novel. What’s so novel about that? Well apparently nobody has thought of it yet. The door-to-door salesman is a fresh idea here. People in the villages don’t go into town often. And certainly not often enough to buy soap. But they would use soap if they had it, and would buy it if it were available. And now it is available.

What next? The reps are doing market research this week to find out about products, prices and volumes. And I’m looking for wholesalers to get our prices down lower. We hope that in a few months, we’ll promote the better ones to a paid position (possibly full-fledged government CHW’s). They’ll have other responsibilities beyond the selling, but this could be the mechanism by which they could fund themselves.

Disease Intelligence Network

[Some of these posts will include topics that I'm working on. For such topics, I'd really like feedback. Now I know you don't think you have anything to contribute, but that's a lie. I want these to be understandable by everyone, both in vocabulary and concepts. So if there's something you don't understand please point it out. I have no other way to gauge how crazy my writing is becoming. So with that introduction, here is my first Blogged program idea.]

One of the problems in healthcare is that it is slow. If we ever want to find something out, we commission a study which takes a year or so. If we want to change something, it's like turning an aircraft carrier (which, I've been told, is difficult). In the US, it's a system which is quite disconnected and has little incentive to be fast or dynamic (but that's a whole different discussion). But, in starting from a very basic system, is there a way to speed things up?

The first thing that needs speeding is disease information. Collection has been so slow up to now, that only strategic information could be used. How many million people are infected with HIV? Is hypertension on the rise this decade? And when I say strategic, it's like counting the number of men in your army compared to your enemy's. Keeping to the military analogy, tactical is talking about things like how to defend a particular hill; we do no generally use tactical information in modern healthcare.

But in Kenya, disease moves much too fast. Three of the top culprits here are Respiratory Tract Infections, Malaria, and diarrhea. These three conditions don't even last a week (if you're lucky), so no existing system is nearly fast enough. What do we do?

Well it's actually quite easy (if you're Nuru). We ask people about the sickness in their family that week. And since they meet once per week anyways in their Nuru groups, it won't be that hard. And once we have this information, we can begin to do things like targeted interventions with our Nuru Healthcare Representatives (who we hope will become Community Health Workers; more on the details of this later).

Say there is a diarrhea outbreak. Say 10 people in Area A get diarrhea on Monday and Tuesday. On Wednesday, they would then report to the Health Rep during their Nuru meeting. So on Wednesday afternoon, we can equip the Health Reps with anti-diarrheal drugs to take to Area A on Thursday, and with soap to get to Area B next door to prevent diarrhea from spreading there. And it could be the same story with Malaria and respiratory infections.

Today it's diarrhea, but it could ultimately include many more things. To make it fast and efficient, we may make it phone-based (we have internet phones out here) and use online servers to process the data (i.e. a farmer could send a text message to find out what his Malaria risk was that week). We're planning to get GPS on all our farmers, so we could produce a map of our results, helping us to predict outbreaks. We've considered doing regular weighings which could help identify malnutrition, HIV, and TB. We could integrate screenings for other common diseases as well. We've even considered expanding the Disease Intelligence Network to the Poverty Intelligence Network and including all the information we have (farming yields, pests and weed growth, etc), making it a useful set of data for all programs.

The most important part of the Disease Intelligence Network is this: Information->Response. This is what we care about. There are about a million applications to this basic idea, but the unique thing about this is that we have connected information directly with a response, and both are fast enough to make a difference; the thing that makes DIN special is that it is tactical. And, God willing, tactical will mean lives saved.

My Dinner with Charles

Two weeks ago, I was invited to dinner at the home of one of my field officers, Charles Magige. Charles is one of my best officers. He works hard and he's always on time (a very rare and treasured attribute here). Though he never finished secondary school, he has learned leadership quickly.

We had a meeting with our health reps where we talked about several of the initiatives we've got running. It was a good meeting. We debriefed and talked about how the meeting went. Then Nelly, Pius (another rock-star field officer), Charles and I walked to his home. That is 'nyumbani' because he has enough land to have a farm, not 'numba' which is a house without land (like what most Americans live in). I have been told that it is a part of Kenyan manliness to own land; you are not a man unless you own land.

We walked past fields of sprouting maize. Most of it near Charles' is Nuru maize. It's easy to see by the clean rows, clear of weeds compared to the random scattering that happens normally.

We approached his shamba (farm) and I saw his house. It was typical Kurian home. There were two mud-walled, tin-roofed western-inspired homes and two round huts with thatched roofs. These buildings made up three sides of a center dirt courtyard. The fourth side was a wall of wood: planks and sticks nailed together.

I entered and greeted his second wife and his children. Polygamy is condoned here, but divorce isn't. His first wife had left him after stealing his life savings (120,000 KES; ~$1,500. A farmer on one acre can earn about 40,000 KES per year). So he couldn't live life alone, and couldn't divorce her, so he took a 'second' wife.

We waited in his living room (the western tin-roofed building) and the three others talked in Swahili. Every once in a while I caught something or had something translated. The conversation was mostly on farming matters. The recent shortage of good grazing land, ways to fight witchweed, stories about planting tobacco. Charles came in and served us sodas, a very valuable luxury (sodas cost about 45 KES; the four that he served were about equal to a day's wages).

Then Charles' wife came in. She carried a platter about the size of a large pizza tin (mmmm...pizza...), but instead of pizza, it carried a pile of sticky rice six inches high. Following that was a plate of something deep yellow and irregularly shaped. I later found out after tasting it that it was 'local eggs', which are far tastier though smaller than eggs in the US. There was also beef in a bit of stew that tasted wonderfully. And if that wasn't enough for the four of us, there was chai (which is just Kenyan tea with lots of milk and sugar). When the food came, the conversation stopped.

This was my first meal at someone's home, so I paid very close attention to the others. Eating in a foreign culture is always a tricky business. Did they slurp the tea, or drink it quietly? Slurped it; I began slurping. How did they sit? Hunch over; hold the bowl. How did they use their spoons? Is that lip smacking I hear? Then commence lip smacking!

Oh no! I ate too fast and finished my first plate slighty before the others. That meant more food. "Nimesheba" (I am satisfied) only slightly reduced the amount I was compelled to take for seconds. And then, when I couldn't eat any more, 'sweet bananas' were brought out. The banans here are a breed that is about six inches long, and sweeter and smoother than US bananas. I asked Nelly, "How do you say I'm very full!" "Nimesheba sana!" I cried, but to no avail. More bananas. More chai. Still soda to finish! Ay!

We finally finished and set our bowls down. I was full. I neither waste words nor fill easily, so when I way I was full, I mean it. I have no way to estimate how big a sacrifice this was to honor me, his guest, but that was a luxurious meal even by my standards. We stood up to leave, and Charles said "Wait! We must pray!" He gathered all his family in the living room, and Pius prayed for a good few minutes. We greeted everyone and I began to walk home.

Charles wanted to walk with me. The walk took about 45 minutes through a beautiful countryside. I was walking slow (i.e. a normal American pace) and he asked, “Are you tired?”

“No, but I am just having trouble carrying all this food up the hill!” I said, pointing to my distended belly.
“What food?” he asked.
I replied, “All the rice you just fed me.”
He looked confused, “Rice is not food.”
I looked confused, “What is food? What am I full of? Isn’t that food?”
“No,” he replied, in a tone as if he were explaining something very simple, “Food is ugali, not rice.”
Ugali is a paste made from maize that is the local staple. We had always known that “A meal’s not a meal without it!” But they meant that literally!

As I was nearing home (nyumba), Charles told me, "I was very feared today." "Why Charles?" I asked. He replied, "I had never controlled a meeting before."

It never occurred to me. I've been in some sort of leadership position for about as long as I can remember. But this 38 year old man had never had the chance to lead before today.

"You did a very good job! Kazi Nzuri!" I assured him and pondered that the rest of the way home.

Part Time Economy

Figuring out the economics here is hard. I'm used to the US where people work for money, and there's no time left in a day. Here it's completely different. Farm work seems to take half a day. The other half of the day is free. And that's during planting season. The work gets even lighter between planting and harvesting. Workload is cyclical. If workload is cyclical, income comes in spikes. Two big ones per year. Once in the summer and once in the winter. I imagine that means money is more valuable right before harvest, but only having been here when money is cheap, I haven’t observed this trend.

But what does one do with half the day free? Here you'd think that an ambitious person would just get a part-time job. Except that there are no part time jobs. There's no McDonalds to work at. No paper routes. No secretarial work. So people spend it largely with other people and doing things around the town.

The concept of the hour, I am finding, is somewhat foreign. Certainly people know what an hour is, but it's not how they think. I asked my Field Officers today how many hours this week they worked on Nuru stuff. The literally had no idea; they couldn't even guess. It was two or three afternoons and a morning. How many hours was that? They couldn’t even estimate.

People work for free. Many people. I met a university grad in a rural village last week (which is very highly educated here; there might be 5 in our entire location). He was working in the lab at the health facility, not getting paid. Actually, he was subsidizing the cost of the tests to keep his skills sharp. There are many like him. There are teachers who work as 'casuals' in the schools who (sometimes) get paid $26 per month. But, being an agrarian society, they all have farms and so long as they do their farm work in the morning (4-8am), they don't really need to get paid. The chance at a better job is good enough, it seems, to keep them somewhat motivated, at least for a while.

The value of money isn't quite clear to me yet. The things people spend money on and the things they don't perfectly line up. Two dollars is about the cost of a day's labor. It can also buy you two full lunches at a restaurant, four Coca Colas, a motorcycle taxi from Kehancha (~15 miles) or ten days' calories in flour. In the US, it would take closer to $50 to hire someone for a day (legally). With that you could buy 5 lunches, 50 Coca Colas, a car taxi about the same distance, and with frugal home cooking, about 5 days of food.

We gave out discount coupons to try to build the patient base at the local health center (it's an internal competition for my field officers, each of whom were given 80 flyers with their name printed on them; the one who refers the most patients wins). The normal price is about $0.50 for a clinic visit and we were discounting it $0.25. A woman came in today with a deep gash in her leg. I was shadowing the in-charge. "When did it happen?" I asked. He asked in Swahili. "Ten days ago." It was quite infected. Why did she decide today? I'm sure it was partly the increasing pain. But she proudly held the discount flyer. She'd deal with a festering leg wound if fixing it cost $0.50, but it just wasn't worth dealing with it if $0.25 could fix it.
But even if one took this to be the value of money, it’s varies wildly person to person. Roughly half of our patients didn’t walk today; they took the motorcycle taxis. I'd crudely estimate that a quarter of them pay more in transport than they do in clinic fees.
That woman wasn't the only one. There were 25 patients today, the first day of the promotion (the 'sale' lasts two weeks); last week we didn't even have that many. Is that $0.25 price really such a barrier? Or is the perception of a discount that powerful? Are some people really paying $0.50 in transport to save $0.25 in medical fees? These questions and more are being actively pondered by your favorite Nuru FT3 Healthcare Program Manager.