This post was written by Dorothy Mangale, a 2nd year MSc student at the Duke Global Health Institute and a member of the SEAD Student Advisory Committee.
The panel on lessons and learning on the road to scale at this year’s SEAD Summit was a prime opportunity to glean important lessons from some of SEAD’s 2015 cohort of innovators. Present at the panel was IPIHD Director, Dr. Krishna Udayakumar (moderator), Samuel Agutu, Chief Executive Officer and co-founder of Changamka Microhealth LTD, Ashvini Vyas, Chief Operating Officer Operation ASHA, Ashwin Naik, Founder and Director of Vaatsalya Hospitals, and Stephanie Weiland, the Executive Director and Burundi Country Director of LifeNet International. The innovators described various challenges; however, despite the variation, some common threads were evident in their narratives.
Sam from Changamka shared that in Kenya where he works, 90% of the population has no health insurance. To subscribe to the Changamka insurance package, clients were asked to subscribe via mobile phone and later attend one in-person interview. This process made scale up laborious so the team altered their distribution strategy rapidly to target organizations (and their employees) rather than individuals. This streamlined their recruitment – granting them access to a more predictable market. Ashwin of Vaatsalya described a different scenario whereby scale up occurred rapidly but at the end of the day, the new sites did not make any money - resulting in their closure. In another example, the innovators described how they dealt with barriers presented in their engagement with community partners. In some cases there was high staff turnover in health facilities. To ensure that the exit of specific people doesn’t jeopardize future activities, the scale up strategy involved training all staff in each facility to prevent losses.
These examples and others highlighted the importance of adapting to circumstances, especially when ideas are unable to serve both clients and innovators effectively. In these situations, the panelists underscored the value of humility by expressing that without a willingness to learn from one’s mistakes, the road to scale can become unexpectedly unmanageable. Additionally, sharing one’s scale up model can be beneficial to an innovator if others adopt it and share the lessons learned with others.
Stephanie from LifeNet International offered candid thoughts on challenges to scale up that often keep her awake at night. Sustaining innovation is first: she worries about how to finance the running costs for her business. Second, sometimes it is unclear how best to scale to a population or even what the best scale up strategy is. Ashwin corroborated these fears and added that every innovator should not expect to have the same experience. In his line of work he has found that different things are challenging at different times. For Vaatsalya, he sometimes fears a loss of momentum through the many challenges, and so he spends time worrying about keeping people inspired.
Echoing Stephanie, Sam added that he too worries about funding. He shared how his company began by making losses when sales levels were low and they witnessed significant adverse selection when in the first iteration: the clients enrolled were all sick, pregnant mothers or those on dialysis resulting in high costs for the company. How did he handle this? Sam explained that flexibility and adaptability were key. His team prioritized identifying research avenues to help figure out the best scale up strategy. They also invested heavily in developing relationships that would help them in the road to scale. His example of the business relationship created between Changamka and Safaricom, Kenya’s biggest mobile phone service provider, illustrated how critical relationships with the appropriate partners can be. Changamka formed a mutually beneficial relationship with Safaricom, based on a good value proposition. This relationship has allowed Changamka to maintain its share of the market. With the assurance of a secure market, Changamka has taken more risks and explored new product development initiatives to expand their scope of clients. These relationships require one to be persistent, avoid emotional pitches and develop a concept that makes good commercial sense.
Despite these worries, the innovators were making efforts to decrease dependence on individual donors. Ashvini shared that Operation ASHA had enjoyed four to five years of financial support from individual donors; however, the team then decided to decrease dependence by making the best use of the resources they had available.
Evaluation is a big part of establishing, implementing and maintaining a scale up strategy. From the conversation it emerged that different measurements are used by different groups. Ashwin explained that for his venture, commercial and social measurements were used to estimate progress. Although Vaatsalya attempts to collect data constantly, their first priority is sustaining the business. As such even evaluation efforts primarily focus on metrics that will help achieve better sales numbers.
On evaluation, Ashwin noted that despite the need for evaluation, the Vaatsalya team’s worry often oscillates to how to recruit people rather than how to evaluate impact. As an early stage innovator, he quipped that they were not in a position to measure impact. However, the Vaatsalya team has chosen to measure business inputs and outputs. In some cases, they try to measure health outcomes but it is expensive and often investors are unwilling to spend money on such activities.
In wrapping up, the panelists reiterated that scale up is a messy, iterative and time-consuming process. It requires thoughtfulness and demands incredible passion and dedication from innovators. Lastly, it requires patience, as faster scale up doesn’t always lead to better outcomes. While evaluation is important for the overall process of scale up, from the innovators’ experience, finding funding or maintaining sales often takes priority over the complex and expensive task of measuring impact. Furthermore, funders are sometimes unwilling to provide financial support for evaluation activities.
The panel on lessons and learning on the road to scale at this year’s SEAD Summit was a prime opportunity to glean important lessons from some of SEAD’s 2015 cohort of innovators. Present at the panel was IPIHD Director, Dr. Krishna Udayakumar (moderator), Samuel Agutu, Chief Executive Officer and co-founder of Changamka Microhealth LTD, Ashvini Vyas, Chief Operating Officer Operation ASHA, Ashwin Naik, Founder and Director of Vaatsalya Hospitals, and Stephanie Weiland, the Executive Director and Burundi Country Director of LifeNet International. The innovators described various challenges; however, despite the variation, some common threads were evident in their narratives.
Sam from Changamka shared that in Kenya where he works, 90% of the population has no health insurance. To subscribe to the Changamka insurance package, clients were asked to subscribe via mobile phone and later attend one in-person interview. This process made scale up laborious so the team altered their distribution strategy rapidly to target organizations (and their employees) rather than individuals. This streamlined their recruitment – granting them access to a more predictable market. Ashwin of Vaatsalya described a different scenario whereby scale up occurred rapidly but at the end of the day, the new sites did not make any money - resulting in their closure. In another example, the innovators described how they dealt with barriers presented in their engagement with community partners. In some cases there was high staff turnover in health facilities. To ensure that the exit of specific people doesn’t jeopardize future activities, the scale up strategy involved training all staff in each facility to prevent losses.
These examples and others highlighted the importance of adapting to circumstances, especially when ideas are unable to serve both clients and innovators effectively. In these situations, the panelists underscored the value of humility by expressing that without a willingness to learn from one’s mistakes, the road to scale can become unexpectedly unmanageable. Additionally, sharing one’s scale up model can be beneficial to an innovator if others adopt it and share the lessons learned with others.
Stephanie from LifeNet International offered candid thoughts on challenges to scale up that often keep her awake at night. Sustaining innovation is first: she worries about how to finance the running costs for her business. Second, sometimes it is unclear how best to scale to a population or even what the best scale up strategy is. Ashwin corroborated these fears and added that every innovator should not expect to have the same experience. In his line of work he has found that different things are challenging at different times. For Vaatsalya, he sometimes fears a loss of momentum through the many challenges, and so he spends time worrying about keeping people inspired.
Echoing Stephanie, Sam added that he too worries about funding. He shared how his company began by making losses when sales levels were low and they witnessed significant adverse selection when in the first iteration: the clients enrolled were all sick, pregnant mothers or those on dialysis resulting in high costs for the company. How did he handle this? Sam explained that flexibility and adaptability were key. His team prioritized identifying research avenues to help figure out the best scale up strategy. They also invested heavily in developing relationships that would help them in the road to scale. His example of the business relationship created between Changamka and Safaricom, Kenya’s biggest mobile phone service provider, illustrated how critical relationships with the appropriate partners can be. Changamka formed a mutually beneficial relationship with Safaricom, based on a good value proposition. This relationship has allowed Changamka to maintain its share of the market. With the assurance of a secure market, Changamka has taken more risks and explored new product development initiatives to expand their scope of clients. These relationships require one to be persistent, avoid emotional pitches and develop a concept that makes good commercial sense.
Despite these worries, the innovators were making efforts to decrease dependence on individual donors. Ashvini shared that Operation ASHA had enjoyed four to five years of financial support from individual donors; however, the team then decided to decrease dependence by making the best use of the resources they had available.
Evaluation is a big part of establishing, implementing and maintaining a scale up strategy. From the conversation it emerged that different measurements are used by different groups. Ashwin explained that for his venture, commercial and social measurements were used to estimate progress. Although Vaatsalya attempts to collect data constantly, their first priority is sustaining the business. As such even evaluation efforts primarily focus on metrics that will help achieve better sales numbers.
On evaluation, Ashwin noted that despite the need for evaluation, the Vaatsalya team’s worry often oscillates to how to recruit people rather than how to evaluate impact. As an early stage innovator, he quipped that they were not in a position to measure impact. However, the Vaatsalya team has chosen to measure business inputs and outputs. In some cases, they try to measure health outcomes but it is expensive and often investors are unwilling to spend money on such activities.
In wrapping up, the panelists reiterated that scale up is a messy, iterative and time-consuming process. It requires thoughtfulness and demands incredible passion and dedication from innovators. Lastly, it requires patience, as faster scale up doesn’t always lead to better outcomes. While evaluation is important for the overall process of scale up, from the innovators’ experience, finding funding or maintaining sales often takes priority over the complex and expensive task of measuring impact. Furthermore, funders are sometimes unwilling to provide financial support for evaluation activities.
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