Living Goods: Scaling Strategies to Influence the Delivery and Financing of Community Health
As part of this Scaling Snapshot, see also Living Goods’ Organizational Overview, Getting Ready for Scale, and Scaling Pearls of Wisdom. You can find the full scaling snapshot PDF here.
Following initial testing and refinement of its core model and the compelling RCT results, Living Goods pursued an aggressive scaling plan. As detailed below, Living Goods’ scaling pathways have ranged over time from direct implementation of the CHW model, to enabling others to implement the approach, to influencing systems leaders to approach delivery and financing of community healthcare differently.
As Living Goods began to scale around 2014, after spending many years positioning itself for such, it pursued three key scaling strategies to meet its goals. Below you will find more detail about those strategies, along with the organizational implications for pursuing each.
STRATEGY: DIRECT EXPANSION
Living Goods maintains some direct implementation of its model, which ranges from the organization implementing the model itself to the organization closely managing and/or supporting implementation through a partner.
As it scales, Living Goods continues direct implementation for two core reasons. First, direct implementation allows Living Goods to operate “learning labs” to test innovations and identify efficiencies. Second, Living Goods has found that in some places and contexts it is the partner best positioned to deliver programming due to factors such as absence of other well-suited partners. In both Kenya and Uganda, Living Goods directly implements and manages networks of CHWs who, importantly, come from within the governments’ own systems.
It also continues its relationship with BRAC, with Living Goods providing the funding, direction and performance management tracking while BRAC implements through its own network of CHWs. The resulting model closely resembles Living Goods’ own directly managed CHW network. Living Goods’ direct implementation and work with BRAC has continued to grow over time.
In 2009, Living Goods managed 56 CHWs and BRAC managed 440; in sum these CHWs served a population size of 400,000. By end of 2018, Living Goods managed 5,100 CHWs and BRAC managed 4,000; together these CHWs served a population of more than 7 million. In addition, Living Goods has partnered with other international NGOs, CARE and Population Services International (PSI), to support them in developing CHW models similar to Living Goods’.
USE OF TECHNOLOGY Over the past several years, Living Goods has explored how technology can improve reach, quality, and cost of delivery. Initially, Living Goods hired local developers and developed its own feature and smart phone tools. As its scale and ambitions grew, it then worked closely with NGO Medic Mobile to co-create Android-based mobile tools and performance dashboards, such as the Smart Health app which automates diagnosis and captures real-time data to manage geographically dispersed workers. Initially, Living Goods leveraged Medic Mobile’s existing technological staff and expertise. Over time, as Living Goods has decided to invest more in technology solutions, it has hired its own developers to be able to manage some of this work in-house.
In another implementation partnership example, Living Goods and NGO Last Mile Health announced in 2018 that they are partnering to deploy thousands of digitally-empowered community health workers to deliver quality care — at a fraction of the cost of training doctors or nurses. Living Goods will bring to bear its deployment expertise and Smart Health app, while Last Mile Health will run the Community Health Academy to train the CHWs.
YOU SHOULD KNOW: Implications of Direct Expansion
Ease of Fundraising: To date, Living Goods has found it easier to fundraise for its direct implementation work than for advisory or advocacy work. When utilizing partners to implement — and therefore ceding some control — Living Goods sometimes receives pushback from funders who question why it does not do the work directly.
Learning Lab: Maintaining some directly controlled implementation allows Living Goods to maintain credibility and continue to test new aspects of the model.
Impact: In the programs it directly implements, Living Goods maintains control over all metrics and data collection, allowing it to apply the rigor it needs to continue to evaluate impact. Additionally, Living Goods finds that its impact is often highest in the programs it directly implements.
Resource Needs: Direct implementation is resource-intensive for Living Goods, requiring significant on- the-ground presence to manage all aspects of the program.
Scalability: Although Living Goods has been able to scale the direct implementation model (as evidenced above), it recognizes that this cannot be the only scaling strategy given the massive size of the problem it is trying to solve — which it estimates will require over two million CHWs as well as policy and financing initiatives.
STRATEGY: ENABLING PARTNERS
Living Goods provides technical assistance to other community health organizations, and increasingly to local and national governments, to help them adapt and implement robust CHW programs.
Living Goods realizes that it cannot scale its impact though direct, controlled implementation alone; its vision is to have multiple partners engaged in implementation to help meet the size of the problem. Through provision of technical advising to other community health implementing organizations, and through deep engagement with government, Living Goods works to enable partners to extend the reach of proven community health worker approaches.
Enabling Other Implementing Organizations
To aid other implementing organizations in adapting a robust CHW approach, Living Goods provides long-term technical assistance within their regions and operational structures. For example, Living Goods supported NGO CARE in Zambia to set up a social venture, LiveWell, which aligns with Living Goods’ CHW model. In Myanmar, Living Goods supported NGO PSI in designing a CHW entrepreneur network and adapting Living Goods’ learnings to that setting. In both cases, Living Goods helped the organizations secure funding and seconded a full-time staff person to each organization for at least a year to support adaptation and training with a focus on performance management. Implementing this model — where Living Goods provides support but does not control the program — was a shift for Living Goods, as it had to move from a “here is what you have to do exactly” type of partnership to a “here is what you have to do at a minimum” partnership. These new partnerships allowed other implementers to adapt the model to their context and constraints, requiring Living Goods to distill the approach down to a set of core principles.
Supporting a Comprehensive Government Approach
Following a number of years in which Living Goods’ partnerships with implementing organizations were initiated by the organizations themselves, its current partnerships are informed by strategies that Living Goods first develops with host country governments. In its earliest days, as it was developing its model, Living Goods pursued only limited government engagement. However, as it proved its model and increased its aspirations, Living Goods knew that impact would be limited without engaging government more deeply. As Living Goods’ Chief Development Officer, Lisa McCandless, shared, “When you think about solving the problem at the size of the problem, government has to be part of the conversation.”
As a result, Living Goods sees its “north star” as government adoption, meaning government is either financing and implementing, or financing and guiding implementation by others. Living Goods engages with government to co-create a model that works for that particular context, and to identify and support the mix of NGO partners and government departments that can implement the program in the country. In November 2018, Living Goods and Kenya’s Isiolo County Government signed a four-year contract in which the government will outsource operations to Living Goods, paying it to refine and implement its model in Isiolo, with the eventual goal of transitioning ownership to the government body. Living Goods also works with the government to strengthen and support CHWs — including advocating for policy change in areas such as task shifting — and to explore increased public financing.
YOU SHOULD KNOW: Implications of Enabling Partners
Organization Size: Living Goods does not have to expand its size in line with increased reach when supporting other partners to implement the approach. However, it has found it important to provide a seconded Living Goods staff member (or longer-term resources) to translate learnings, at least in the beginning.
Staffing: Providing technical assistance and supporting program adaptation requires a broader and different skillset than that which is required for direct implementation.
Control & Impact: Allowing others to adopt and adapt the model means that Living Goods has less control over decisions and outcomes. For example, partners track different key performance indicators (KPIs), use different baskets, and hew to their own restrictions from funding partners, among other things.
Fundraising: Living Goods has found it more difficult to raise money for the “softer” work of technical assistance (versus the work of direct implementation).
Branding: Partnerships are branded through the partners, with Living Goods’ brand usually invisible. While this is an intentional decision for Living Goods, not all organizations may be comfortable with their brands not visible.
Impact: It can be difficult to determine or aggregate impact across these partners because they employ different KPIs and data collection practices.
STRATEGY: INFLUENCING COMMUNITY HEALTH DELIVERY GLOBALLY
Living Goods seeks broader influence by helping change the conversation about community health globally, engaging with donors and standard-setting organizations.
Over time, Living Goods has seen an opportunity to inform community health care practice on a country and global level and seeks to contribute to that discussion with the evidence it has collected about various approaches. Living Goods works with global stakeholders such as USAID, the World Health Organization (WHO), and The Global Fund to share knowledge on quality community health care provision and advocate for investments into such quality programs. Living Goods does not directly advocate for use of its specific approach, but rather brings its experience, core principles and approaches, and data to the broader conversation.
In another example of its broader network and advocacy work, Living Goods is involved in a coalition of leading CHW organizations called the Community Health Impact Coalition (CHIC). These organizations — including NGOs Last Mile Health, Partners in Health, and VillageReach — compared community health models and discerned eight “Design Principles”; some of these principles were ultimately incorporated into the WHO’s updated CHW guidelines. CHIC continues to work together to share knowledge and advocate for adoption of the principles by other stakeholders.
YOU SHOULD KNOW: Implications of National and Global Advocacy
Staffing: Living Goods created a specific position, Director of Advocacy, to take on this area work, given the need for a different skillset and mindset to implement. Living Goods also built out its government relations/ advocacy teams in-country. It recognized that being an implementing organization is a very different role than being an influencing organization.
Fundraising: Living Goods primarily uses unrestricted core funds to cover its advocacy and influence work, as it finds it challenging to fundraise for such work.
Comparative Advantage: Living Goods has found it important to determine where it has a comparative advantage and a unique voice to lend to the conversation; otherwise, it runs the risk of repeating what others are doing.
Long Time Horizons: Advocacy work can be very time consuming and the path to results can be long. Time spent in meetings and “playing the long game” can be frustrating for an organization used to implementation and faster feedback loops.
Leverage Effects: Living Goods has found that this work has a positive effect on its other strategies, creating a more enabling environment for robust community health approaches.
Published March 2019. Find the full Scaling Snapshot PDF at https://rebrand.ly/livinggoodsscaling.
Authored by Erin Worsham, Kimberly Langsam, and Ellen Martin.
