Author Archive

The Profit Motive

July 10, 2008

Jane Karuru, SHF franchisee in the tiny village of Kirima, near Mt. Kenya, describes what motivates her

The desire to make a decent living and be able support your family is universal, and it’s one of the things that makes SHF’s micro-franchise model effective. Nurses are motivated not only by a commitment to serving health needs in their communities, but also by the desire to make money. Ask any SHF franchisee what they dream of and you’ll hear things like: “To build an extra room on my home,” “To send my kids to a better school,” “To get a better life for my family.”

This has a lot of advantages over government and non-profit models where nurses are salaried and have no incentives to provide better quality care. In general, SHF nurses work longer hours, provide better customer service, and are more responsive to community demands.

But this motivation to make money is also one of the greatest challenges/risks of the SHF model — how do you encourage franchisees to be driven entrepreneurs, while ensuring that they prescribe drugs rationally, maintain standards, and follow franchise guidelines? SHF currently does this by regular monitoring through field officers and strict punishment for violators, but this is time and resource intensive and difficult to scale. And it’s not fool-proof: at times franchisees misrepresent their sales, source products outside of the network, and in the worst cases prescribe drugs irrationally.

The challenge to strike balance financial viability and the delivery of quality health services to the poor will be an ongoing one for SHF — and one that will likely require a lot of experimentation and adaptation as we grow. For now we’re on a major hunt for more Janes, who have both the commitment to community and the drive to build viable enterprises, as we plan to open 15 new outlets in the next 3 months.

Kibera, 5 months post-election

June 10, 2008

Nairobi 6/5/08

June 6, 2008

Untapped Talent

June 4, 2008

In July 2007, Charity Njuju retired from more than 20 years as a nurse with the Kenyan Ministry of Health. Despite the Kenyan law mandating nurse retirement at the age of 50, Charity felt she had many productive years ahead of her. Just as she finalized her retirement paperwork, Charity heard from former colleagues about an opportunity they’d taken advantage of: to become a Sustainable Healthcare Foundation (SHF) franchisee.

“I could tell from the way they looked and the way they dressed that they were comfortable,” Charity recalls with a laugh. “I also knew that as a trained nurse there was a need of helping people. I can’t stay at home and do nothing when there is a need.”

Charity and her retired colleagues represent one of the less obvious benefits of the SHF model: employing the skills and experience of retired nurses that would otherwise go to waste. After retirement, many nurses provide informal services in their homes, but their skills often are under-utilized. Furthermore, while retired nurses receive a small monthly payment from the government, this income is insufficient to support a family. The opportunity to earn a living while continuing to contribute to community health is a powerful combination that encourages nurses to continue working.

The SHF network is attractive to Charity and her retiree colleagues for a number of reasons:

  • Quality, Affordable Drugs: SHF sources its drugs from the Mission for Essential Drugs and Supplies (MEDS), a non-profit supplier of generic medications. As a nonprofit, MEDS is able to provide medication at prices ten to fifteen percent lowed than other wholesalers.
  • Training and Support: SHF offers training as well as ongoing professional education for its nurses. Franchisees also receive regular mentoring and support from trained field officers who visit outlets bi-monthly.
  • Professional Network: SHF offers the opportunity for its franchisees to become a part of a broader network (currently 65) other providers. “When you are on your own it can discourage you,” says Charity.

Today, Charity’s St. James Clinic, which she named after her husband, is completing its first successful month of operation. Charity proudly announces that she treated over 250 patients and is confident that she can be among the best SHEF franchisees.

Charity is beaming with pride as she provides a tour of her clinic: a small waiting room with shelves of hygiene products ranging from small blue bottles of Waterguard to “Marvel Baby” diapers, and a consultation room where she treats patients. Charity selected the location, near Embu in central Kenya, based on her community ties, population density and the fact that the local dispensary is often congested and out of drugs.

Charity sums up the potential of St. James Clinic: “I can provide a better quality alternative, and so I know I can compete.”

The use of talented retired nurses could increase the potential of – and support for – health franchising, in Kenya and beyond. While Kenya has an abundance of qualified nurses, other countries in the region face extreme shortages. Private sector solutions are often criticized for pulling talent away from strained public systems; this conflict does not exist in the case of retired nurses, whose skills would otherwise be underused. Offering retirees an opportunity to generate income while providing valuable care for their communities could help to increase the number of providers in countries where access to essential drugs and care remains limited.

Bridging Social Capital

May 7, 2008
Throughout Kibera today, white hand-painted messages of “No more violence” and “Peace” on doors, walls and storefronts mark the emergence of a new sense of optimism in Kenya. With a peace agreement and coalition government in place, people are embracing a return to normal daily life.  But one of the greatest challenges still lies ahead: how to reunite a country that has been fractured along ethnic, political, and economic lines.

Robert Putnam defines 2 kinds of social capital: Bonding social capital links you to people similar to you, while bridging social capital connects you to people who are different (religion, race, generation). “For a modern and diverse democratic society, bridging social capital is important because, if you have a society that has tons of bonding but no bridging, you have a society that looks like Beirut or Baghdad,” says Putnam.

How do you develop bridging social capital in communities that have become highly segregated and tense? How do you restore trust in areas where neighbors turned on each other just four months ago?

Grassroots initiatives in Kenya have started the effort (most recently I heard of a group called Concerned Citizens for Peace). But ideally this effort will permeate all areas of society — peoples’ jobs, schools, housing, recreation — and be combined with efforts to reduce economic inequality in the country.  I’m reminded of a fellows’ brainstorm session with Jawad in the fall on building community at Saiban, when we used this list of 150 ways to build social capital — and I reflect on how our conversation relates to the big picture of re-untiting Kenya. For now, I have many more questions than answers –but I’m listening and learning each day, and your ideas are welcome!




Meeting customer demand

April 18, 2008

Dorah’s Senye Clinic in Kibera has a new addition today: A small refrigerator that allows her to add immunizations to her list of services.

“I’ve always had to send customers to immunize their children elsewhere,” Dorah describes. “No smart business-person sends customers away.”

With limited resources, Dorah has to work extra hard to meet customer demands. But she continues to find innovative ways to meet her customers needs. And they respond … Dorah is one of the most successful franchisees in the network.

I arrive to Senye today just in time to see Grace bring her 2 month old son to the clinic. Grace could take Trevor down the road for free immunizations, but chooses to pay the small fee at Senye because: 1) Dorah met her demand and 2) Dorah provides unmatched customer service. Despite 12 hour days and a long commute, Dorah treats her customers with dignity, personal attention, and quality care.

Even in a resource-constrained environment, basic business principles remain true: Meeting customer demand and providing quality service means happier and more loyal customers. Grace & Trevor will be back in a month for their next check up.



April 18, 2008

A man crosses the street in rain,
stepping gently, looking two times north and south,
because his son is asleep on his shoulder.

No car must splash him.
No car drive too near to his shadow.

This man carries the world’s most sensitive cargo
but he’s not marked.
Nowhere does his jacket say FRAGILE,

His ear fills up with breathing.
He hears the hum of a boy’s dream
deep inside him.

We’re not going to be able
to live in this world
if we’re not willing to do what he’s doing
with one another.

The road will only be wide.
The rain will never stop falling.

-Naomi Shibab Nye

siblings in kibera

Siblings in Kibera

Kisumu Town, 3 months post-election

March 22, 2008


Back in Kibera, two months later

February 19, 2008

Kibera is relatively quiet on this hot February day, almost 2 months after the Kenyan Presidential election, but the rocks on top of tin rooves and stories of residents reveal what people have been through.

Today is the first time I’ve seen William (a nurse aide at one of our clinics) since we worked together in December, just before the election. At the time he reported: “The biggest challenge for our business in this political era is that there is a lot of insecurity. But I think that is just during this campaign period and after that I think everything will be ok.”

Unfortunately William was wrong in his prediction (along with most of the world). Kibera was one of the hardest hit areas in the post-election violence, which has claimed over 1,000 lives and destroyed parts of the country. “We were all sick, we were afraid all the time,” William describes. Perhaps most telling is William’s three year old son , Meshah, who still won’t leave his his father’s side:

William and his partner Millicent are working hard to keep their business going, but most of their customers have lost their incomes and are unable to pay for services. And though things are calm at the moment, William reminds me that there is a long road ahead: “Everyone is watching the Annan mediation team. Everything depends on what they can do, otherwise things will go right back to chaos.”

Surprise and Delight, Part III

February 18, 2008