To succeed, Riders for Health needed to partner closely with community health workers. Photo courtesy of Riders for Health.
Who drives transformation in our society and how do they do it? Roger Martin and Sally Osberg argue in their new book, Getting Beyond Better, that the answer is social entrepreneurs, who target unjust and unsustainable systems — or “equilibria” — and transform them into entirely new, superior, and sustainable equilibria. In this excerpt, they tell a story illustrating how vision is the key to successful transformation.
To serious motorcycle racers like Andrea and Barry Coleman, flat-track racing is the most primal, authentic, and thrilling form of competition, harkening back to the origins of the sport at the turn of the twentieth century. The track itself is dirt and configured in the classic oval shape. Motorcycles make 20 or so counterclockwise laps during the course of a race, at
of over 100 miles an hour. As the bikes roar around the track, they gradually wear a groove where you’d expect to find it—near the center, just hugging the inside. Along the outside, the kicked-up dirt and dust forms what’s known as the cushion. Throughout the race, riders tend to stay in the groove, avoiding the cushion, where the ride is riskier because the dirt is soft and traction is uncertain.
But sometimes a rider will venture out into the cushion to overtake the competition. Taking to the cushion doesn’t require the rider to be a daredevil. It doesn’t take unnatural bravado. Rather, it requires the rider to have confidence in his experience and skill, and most of all, in the condition of his motorcycle. The bike must be impeccably maintained — oil, gas, gears, engine — and the rider must know it intimately, down to the depth of the tire treads to the millimeter. Taking to the cushion signals a rider’s determination to break out from the pack, to risk failure, and to win.
Social entrepreneurs, Barry Coleman explains, consistently ride in that cushion, where there is plenty of potential to get ahead and just as much to slide out of control. It is a place where guts and determination are required, and where skill and expertise can pay off. Barry should know. He and his wife aren’t just race enthusiasts, they are social entrepreneurs: founders of Riders for Health, an organization that manages transportation systems for the delivery of health care in seven countries across sub-Saharan Africa.
For the Colemans and Riders for Health, winning means nothing less than a new health-care delivery equilibrium on a continent that desperately needs one. Today, on virtually every relevant health indicator, Africa lags. Life expectancy is 10 years shorter than the rest of the world. Child mortality is double the global average. Whereas the United States has 2.4 doctors for every thousand citizens, sub-Saharan Africa has just 0.2. Across the region, some thirty thousand children under the age of five die every day from diseases that are easily treated or prevented with available vaccines and medicines, including diarrhea, measles, and malaria. Immunization programs, even with the massive scale-up in supply made possible by the multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria (“Global Fund”) and a host of NGOs, still fail to reach an estimated 22 million children. Progress remains difficult, despite stated commitments to millennium development goals, decades of foreign aid, and billions of dollars in philanthropy.
The miserable health-care equilibrium in Africa, the Colemans would argue, is kept in place partly by its failing infrastructure. Too often, available medicine and equipment can’t get where they are most urgently needed. Health workers waste hours each day walking and waiting, rather than delivering care. Communities go weeks and months without meaningful access to health care, even in times of desperate need. All of these problems result from gaps in infrastructure, but it was one gap in particular that tweaked the notice of this pair of motorcycle enthusiasts: African health systems were failing because they lacked the underlying transportation systems needed for reliable health-care delivery.
It isn’t the stuff of banner headlines. But in Africa (or, for that matter, anywhere else), if reliable transportation is not part of the health-care delivery system, people die. To Andrea and Barry Coleman, the reality that they encountered — a health-care delivery system hobbled by inadequate transportation management infrastructure — was utterly unacceptable. They envision a very different equilibrium, a future transformed, in which African health ministries are equipped with reliable, affordable, and effective transportation systems that deliver the health-care services their people need, when, where, and how they need them. And it turns out motorbikes have an important role to play.
Poor transportation infrastructure makes health care delivery even more challenging (LEFT) and the Colemans saw the key as being vested in the discipline of motorbike fleet management (RIGHT). Photo courtesy of Riders for Health.
Vision and the Social Entrepreneur
Much has rightfully been made of the need for a clear and compelling vision in any endeavor. A vision can set direction, mobilize followers, align activities, and galvanize the will required by an individual or team to accomplish something significant. Without a compelling image of the future, and — as importantly — clear steps to achieving it, organizations will drift and quite likely fail. Any winning strategy begins with an aspiration that articulates what winning means for an individual, organization, or endeavor.
Social entrepreneurs, too, must articulate their winning aspirations, and do so in the context of transformative change. They must go beyond simply articulating an improvement to the system. Social entrepreneurs are driven to get beyond better. The social entrepreneur’s vision of winning must be aimed at equilibrium change rather than at the amelioration of current conditions; it must be specific yet systemic in its approach, targeted at a constituency that cannot effect the change alone while also considering the system holistically; and it must be adaptable and resilient in the face of changing conditions.
Andrea and Barry Coleman saw in the existing system an opportunity that was little noticed by others. Most of the attention in global health is on the eradication or effective treatment of disease. By contrast, the humdrum issue of transportation infrastructure barely registers. Andrea notes, “People assume the infrastructure is in place. It isn’t.” The Colemans could see that it wasn’t, and they could also see just how vital transportation was to the operation of the whole system. They were able to do so because they had deep and extensive personal expertise that could be brought to bear on this new context – and this expertise just happened to be about motorbikes.
Andrea had grown up in a family of motorcyclists, and from an early age wanted nothing more than to become a racer herself. “The day I was sixteen, I put my L-plates on, took three months and then passed my test. I just wanted to be out riding motorcycles,” she recalls. And so she did, sharing a love of racing with her husband, Grand Prix racer Tom Herron. In 1979, Herron died in a racing accident, spurring Andrea to develop a passion for safety every bit as intense as her love of riding. Her second husband, Barry Coleman, traces his own interest in motorcycles to his racing beat for the Guardian. It was through this shared interest that the two first met and their relationship began.
Racing also brought them to Africa. Together with their friend, the legendary Grand Prix racer Randy Mamola, the Colemans had spent years persuading their British racing peers to raise money for Save the Children’s African programs. In 1988, Save the Children sent Mamola and Barry to Somalia, to show them how these hard-won funds were being used. The money was clearly being put to good use. Yet what the two men saw in Africa, and what Andrea too saw on a subsequent trip, shocked them: hemorrhaging women being carted in wheelbarrows to the nearest clinic; health workers covering distances of twenty or more miles of tough terrain a day by foot; countless vehicles left to rust by the side of the road or stacked up against buildings, vehicles that would still be operating had they been serviced properly. What good, they asked themselves, was a health-care system without reliable transport? And what good were expensive vehicles that were as mobile as millstones? That, in a nutshell, was the status quo. It became the starting point for the Colemans’ vision for what should change.
Transformation, Not Amelioration
At one level, looking to the future and imagining what could be different is an entirely obvious step in the pursuit of social benefit. Doing so is not an especially difficult task. It’s a straightforward matter to conceive of programs that feed hungry children or that provide refuge for victims of domestic violence. These fine outcomes originate in someone’s ability to imagine ways to improve life for a disadvantaged segment of the population. For the social entrepreneur, the task demands more. It is not enough to imagine a way to reduce suffering. The vision must be for systemic change; it must shift the existing equilibrium to a new one. Social entrepreneurs like the Colemans envision a stable and sustainably transformed world that exists at a compelling new equilibrium – one that ensures, in particular, an optimal new condition for those disadvantaged by the current state.
The Colemans and Riders for Health are not interested in buying trucks to replace the ones that have broken down. They want to fix the system that lets such vehicles fall into disrepair, and that puts the wrong vehicles in the wrong place for the wrong tasks. For the Colemans, the changed system is vested in the discipline of fleet management. Riders for Health partners with African health ministries, contracting to manage their vehicles, “whether the vehicles are used to mobilize outreach health workers on motorcycles, transport samples and supplies to health centers, or are ambulances for emergency referrals.”
In this approach, Riders for Health takes over management of a partner’s fleet, providing preventive maintenance and driver training. First, it provides regular scheduled maintenance on health-care delivery vehicles, keeping fleets running over a much longer lifespan, and replacing parts before they wear out to avoid unexpected breakdowns. This maintenance can be carried out on an outreach basis, which means vehicles can be regularly serviced where they are used rather than at a central location—keeping off-road time to a minimum. Second, Riders for Health trains health workers on how to operate their vehicles effectively and to conduct daily maintenance on them, including checks on oil levels, tires, brakes, lights, and other basics. Along with other services, including planning and budgeting for ongoing operating costs like fuel, this Transport Resource Management (TRM) model aims to produce fleets of vehicles that operate with 100 percent reliability at the lowest possible cost for the longest possible time, regardless of tough conditions. It is a model aimed at transforming one specific part of Africa’s health-care infrastructure, and in doing so, to make the entire system more effective.
This aspiration — and the model to bring it to life — evolved over time. The same can be said for many social entrepreneurs. A vision of a transformed future may not spring fully formed from their minds. The work of transformation is challenging stuff, and so is the task of envisioning a truly transformed future. But it need not be overwhelming. The first essential step is taking a systemic yet focused approach, in which specific constituents are targeted but other system actors are understood and accounted for.
Targeted Constituents and the Broader System
Like business entrepreneurs, social entrepreneurs’ top priority is defining target customers or clients — those who stand to benefit most from the specific offering of the venture. This close focus on the customer animates the social entrepreneur as much as it does the business entrepreneur. Each gets out of bed every day to serve a specific constituency, to change the equilibrium for a defined population. Social entrepreneurs aim to make a difference for someone in particular.
Those who have the most to gain from a social entrepreneur’s efforts are typically those most disadvantaged by the current equilibrium. But determining a primary constituency is not where the social entrepreneur stops. In business, a company’s outcomes are also affected by other actors in the larger ecosystem, including those operating the channels through which it reaches customers, the suppliers from whom it buys inputs, the partners with whom it collaborates, the regulators who dictate the terms of the industry, and the competitors who target the same customers. Any successful business must think holistically about how best to serve the needs of its customers within the context of the larger system. So too must social entrepreneurs be careful to consider their principal constituents in the context of the systems in which they participate.
Thus, at the heart of Riders for Health’s work are the African women, men, and children at risk of dying needlessly. The Colemans recognized that to reach this targeted constituency, they had to address another part of the system. They scanned the actors who played pivotal roles in the current equilibrium of health delivery systems—government, health-care workers, and patients—and explored key interactions between them. As they did, they came to see that the health of Africans is dependent in large part on the services of community health workers.
These frontline public health workers are members of the communities they serve, bridging the gap between formal health-care systems and local communities. When equipped with reliable transportation, this workforce is able to deliver its vital services to greater numbers of people over greater distances: testing for illness, providing vaccinations, supervising treatment, monitoring pregnant women, screening for malnutrition, distributing bed-nets, and much more. For these community health workers to do their jobs, and for medicines and supplies to reach rural villages situated hundreds of miles from the nearest town, reliable transportation is essential. Yet development organizations and government agencies traditionally fail to account adequately for it. Vehicle requisition is often part of a project budget or a regional service plan, but the emphasis is on procurement rather than operations. Money is allocated to acquire new vehicles but rarely to properly maintain them.
The result is predictable. In Rwanda, for example, where the Colemans were asked by the Minister of Health to assess its transportation capability, they found its fleet of ambulances showed clear and at times disturbing signs of poor maintenance. Barry Coleman and his team confirmed what the ministry already knew: the reason behind an unacceptable record of breakdowns, with as much as 80 percent of the fleet routinely out of service in rural areas, was poor maintenance. Rwanda is not alone. Riders for Health notes that “the average life of an unmanaged vehicle in the harsh environment of rural Africa is a little over a year. A motorcycle will last eight months.”
Addressing the needs of that poor, rural, and ill-served population was a key first step to framing the Colemans’ winning aspiration. But for their vision of a new future to take hold, they knew they would have to align the interests of other key actors as well. These would include donors and donor agencies, development organizations, government ministries, and community health workers. They identified a targeted constituency and identified key players in the surrounding ecosystem who would also need to be addressed in order to meaningfully impact the targeted constituency. Envisioning a transformed equilibrium begins with this assessment of actors.
And for social entrepreneurs generally, the act of envisioning a new future begins with belief in the power of human beings to transform their lives. Effective change agents like the Colemans bring to life what a new equilibrium can mean for those most disadvantaged by the current system.