GE'I'I'ING BEYOND BETTER Chapter 4 Envisioning a New Future 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 congured in the classic oval shape. Motorcycles make twenty or so counterclockwise laps during the course of a race, at speeds of over 100 miles an hour. As the bikes roar around the track, they gradually wear a groove where you'd expect to find itnear 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 lo the cushion doesn't require the rider to be a daredevil. It doesn't take unnatural bravado. Rather, it requires the rider to have condence In his experience and skill, and most of all, in the condition of his motorcycle. The bike must be impeccably maintainedoil, gas, gears, engineand the rider must know it intimately, down to the depth of the tire treads to the millimeter. Taking to the cushion, with the certainty he's prepared in do so, 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.l It is a place where guts and determination are required, and where skill and expertise can pay off. Harry 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 continentthat desperately needs one. Today, on virtually every relevant health indicator, Africa lags. Life expectancy is ten years shorter than the rest or 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 0.2.1 Across the region, some thirty thousand children under the age of ve 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 twentyrtwo million children. Progress remains difficult, despite stated commitments to millennium development goals, decades of foreign aid, and billions of dollars in philanthropy. Africa's health equilibrium remains in a stubbornly miserable state. The current health-care equilibrium in Africa. the Colemans would argue, is kept in place partly by its failing infraaructure. Too often, available medicine and health treatments simply don't reach those who need them. 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 ror 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 healthrcare delivery system, people die (an outcome Barry Coleman calls, vvilh clear irritation, 'pointless'H To Andrea and Barry Coleman, the reality that they encountered a healthcare delivery system hobbled by inadequate transportation management infrastructurewas utterly unacceptable. They envision a very different equilibrium, one that marks a step change in the quality of health care on the continent. The future they imagine isn't perfect, but it is transformed in a very specic way: in this future, Afncan 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, 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 galvaniie the will required by an individual or team to accomplish something signicant. Vision matters, whether for a business opportunity, a Page 107 nf249 o 44% GE'I'I'ING BEYOND BETTER sports championship, or a governmental initiative. Without a compelling image of the fubioe, antl as importantlyclear steps to achieving it, organizations will drift and quite likely fai. Any winning strategy begins with an aspiration that articulates what winning means for an individual, organization, or endeavors 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. even if the improvement is clearly a laudatory one. Social entrepreneurs are driven to get beyond better. The social entrepreneur's vision of winning must speak denitively to the newi transformed societal equilibrium she is prepared to bring about: it must be aimed at equili the amelioration of current conditions; it must be specic yet systemic in its approach, targeted at a ium change rather than at constituency that cannot effect the change alone while also considering the system holistically; nally, more often than not, it must be adaptable and resilient in the face of changing conditions. To get to the stage of envisioning a new equilibrium, social entrepreneurs will have developed clear and comprehensive knowledge about the system they seek to transform, as we saw in ghagtgr 1. Crafting a compelling vision of equilibrium change depends on this rich understanding of the existing status true. A social entrepreneur must be able to assess and understand what is in order to see and describe what could be. when it comes to understanding the world, like so many successful social entrepreneurs, 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. Is it because transportation is such a blue-collar basic that it doesn't get much attention? \"There's a little bit of snobbery in development,' Andrea notes ruefully. Moreover, she says, "People assume the infrastnicture is in place. It isn't.\"5 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 a new context. The distinctive knowledge the Colemans brought to bearjust 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 herhusband, Grand Prix racerTom Herron. In 1979, Herron di d 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 mm that the two rst 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 1588, Save the Children sent Mamola and Barry to Somalia, to show them how iese hardswon funds were being used. The money was clearly being put to good use. Vet 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 healthcare 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 benet. To make a positive social contribution, miery well-intended actor, social entrepreneur or not needs to imagine a benecial outcome for her work. Doing so is not an especially difcult task. It's a straightforward matter to conceive of programs that feed hungry children or that provide refuge for victims of domestic violence. These h'ne outcomes originate in someone's ability to imagine ways to improve life for a disadvantaged segment of the population. but it's worth repeating that, 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 lo a new one. Social entrepreneurs like the Colemans envision a stable and sustainably transformed world that exists at a compelling new equilibrium. It is 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 wanr to x the system that leis 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 eet management. Riders for Health partners with African health ministries, contracting to manage theirvehicles, "whetherthe vehicl are used to mobilize outreach health workers Page 110 0i249 0 45% GE'I'I'ING BEYOND BETTER 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 eet providing preventive maintenance and drivertraining, 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 locationkeeping 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 eets 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 specic part of Africa's healthcare infrastructure, and in doing so, to make the entire system more effective This aspirationand the model to bring it to lifeevolved overtime The same can he 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. That said, the social entrepreneur's aspiration, while distinctive, need not be overwhelming to construct. It is predicated on two essential things: .A systemic yet focused approach, in which specic constituents are targeted but other system actors are understood and accounted for -The articulation of a compelling future stateaiming for and sketching out the superior and sustainable new societal equilibrium through which the specied beneciaries' prior condition, and the system overall. is transformed Targeted Constituents and the Broader System First, the social entrepreneur's winning aspiration identies a specic set of beneciaries. Like business entrepreneurs, social entrepreneurs' top priority is dening target customers or clientsthose who stand to benet most from the specic 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 specic constituency, to change the equilibrium for a dened population. Social entrepreneurs aim to make a difference for someone in particular; for example, they strive to see African girls freed from the dangers of female genital cutting or to enable millions of undocumented Indians to gain access to guaranteed government services. 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. This stakeholder is at the center. but is not the sole concern. In business, a venture rises and falls according to the response of targeted customers, but 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. Molly Melchrng explicitly considered not Just the girls who were Sublected to forced genital cutting, but the whole communityithe families, elders, and religious leaders who upheld this practice as the norm; she considered the government, health-care workers, and agencies as well in order to build a coalition for change. Simply telling the girls that they did not need to submit to cutting would have been [or too narrow an approach. Without considering the other players, it would also have been a lie Focusing on only one actorwithout considering the larger network ofactdrs would have doomed Tdstan's efforts to failure.Typically, the social entrepreneur's winning aspiration will target its principal clients and make clear the case for serving them But to be effective, a social entrepreneur's vision must also take into account other essential actors, articulating a new configuration of interests that, ideally, distributes benets more equitably. So it was for Riders for Health. At the heart of the organization's work are the African women, men, and children at risk of dying needlessly. rhe Colemans recognized that to reach this targeted constituency, they had to address another part of the system, They scanned the actors who played pivotal role: in the current equilibrium of health delivery systems~government health-care workers, and patientsand 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 sewe, bridging the gap between formal health-ca re 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: Page 113 0f249 0 47% GE'I'I'ING BEYOND BETTER testing rur 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. 'i'et 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 conrmed what the ministry already knew: the reason behind an unacceptable record of breakdowns, with as much as 30 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,\"31 Addressing the needs of that poor, rural. and ill-served population was a key rst 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 identied a targeted constituency and identied 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. A Compellingly Superior Future State The second component of envisioning a new equilibrium requires that one imagine and articulate a compellingly superior future state for the targeted constituentsnot an incrementally improved one but a demonstrably superior one. This vision will only be credible if it is specic: no vague language alluding to ways in which beneciaries will be generally "better off"! what the Colemans imagined was a health-care delivery system equipped to reach the entire population it was meant to serve. a system with the capacity to ensure that even those living in the most remote villages gained access to life-saving vaccines. bed nets, and medicines and to the routine services of trained community health workers. Such comprehensive access would be enabled by a robust and wellr maintained transportation infrastructure that would include trucks. ambulances, and, yes, motorbikes, The bikes, obviously. are cheaper to run than four-wheeled vehicles and can cover more challenging terrain They are also beautifully suited to making community health workers far more mobile and productive. if~and it's a big [fithey are conscientiously and properly maintained. There is an old proverb about the way small things can lead to signicant failures: For want of a nail the shoe was lost; For want of a shoe the horse was lost; For want of a horse the battle was lost; For the failure of battle the kingdom was lost All for the want of a horseshoe nail. This little rhyme could perfectly serve as a theme for Riders for Health. The Colemans had traced needless loss of life and suffering hack to a little-remarked and poorly considered source: the vehicles together With the lug nuts, oil lters. and routine maintenanceessential to delivering the life-saving supplies and services. The Colemans didn't start with a grand vision to transform health-care transportation in sub- Saharan Africa. They started smaller. beginning with a project to supply and maintain transportation for health-care workers in Lesotho. in partnership wlth Save the Chlldren, After six years of hard work, with the stunning record of not one single breakdown rur properly equipped and trained workers, the Colemans raised their sights Armed with evidence that the model could work and determined to make transportation a systemic priority, they began to aim for equilibrium change. They already knew what incremental. temporary improvement looked like. They knew that when health authorities bought a shiny new vehicle for a region. delivery numbers would spike positively but only until the vehicle inevitably (and in the rough rural African context, this means relatively quickly) broke down, at which point delivery standards would fall back to their previous unacceptable lows. The Colemans knew they wanted more. So in 1996, they took a big step toward commitment, incorporating Riders for Health as a stand-alone venture and expanding beyond Lesotho. It has mken time. and has not been without its pitfalls, but the Riders for Health model is shifting the equilibrium of healthcare delivery in Africa. Gambian community health worker Manyo Gibba used to walk as far as twenty kilometers a day to serve the twenty thousand people in the fourteen villages assigned to her. Under such conditions. she was simply not able to check in with communities regularly. rarely getting to each village more than once a month. Once Riders for Health provided herwith a reliable Page 115 0f249 0 48% GETTING BEYOND BETTER motorcycle, showed how to operate it safely, and trained her to perform routine preventive maintenance, Gambia, where they'd been active for nearly twenty years, was ripe for experiment. What if they took she was able to cover the distances easily, reaching all her patients at least once a week. over the entire transport function from the Ministry of Health under a lease agreement? What if they This kind of coverage has been the key to improved health outcomes in the regions served by acquired and maintained a brand-new fleet for the ministry, equipping every health-care worker with Riders for Health. Diagnoses are made more rapidly, making possible prompt and optimal treatments. transportation and ensuring coverage for the entire country? Vaccination rates, treatment rates, and bed-net delivery rates have all improved. In Zimbabwe, deaths With this new approach, which Riders for Health calls Transportation Asset Management (TAM) to due to malaria decreased by 21 percent in a district served by Riders for Health, compared with a distinguish it from the existing TRM program, Riders assumes responsibility for procuring-and owning- neighboring district, not served by Riders, which experienced an increase of 44 percent during the same the necessary fleet of vehicles, not just maintaining them. Riders for Health then leases the fleet, along period. 10 with its maintenance services, of course, to the Ministry of Health. Riders calculates its fee on a vehicle- The Colemans had envisioned a changed equilibrium for their ultimate beneficiaries, the rural poor cost-per-kilometer basis, incorporating procurement, financing, operations, and maintenance into the of sub-Saharan Africa. To meet the threshold of equilibrium change, this new state had to have two number. Naturally, motorcycles cost significantly less to operate than ambulances, but the fleet structure important outcomes-it had to meet the health-care needs of those it served in a far more optimal ensures that the right vehicles are in place for their appropriate purposes. Under this model, health way and it had to do so sustainably. Patients and communities clearly gain from regular, reliable visits ministries are spared the headaches of acquiring and caring for vehicles. from their motorbike-equipped community health workers, in contrast to what they'd had previously: Dr. Malick Njie, the Gambian Minister of Health, who signed on to the new plan in 2007, realized intermittent, unpredictable check-ins from weary workers traveling on foot. But just as important is that almost at once just how significant the benefits could be. He recalls that "For the first time in the history the change be sustainable. More vehicles, even if more efficient, were not the definitive answer. The of the health sector in the Gambia, we looked at the complete logistics support system . . . I looked Colemans needed to ensure that the vehicles were good for the long term and perfectly reliable. Hence at what is best. I realized that using old vehicles would not deliver what we wanted to deliver." Even their codified TRM approach. It wasn't enough to tell governments that transportation matters. The so, Njie had his work cut out for him in persuading his colleagues in the Ministry of Finance to take Colemans needed a way to communicate a clear and compelling vision of just how transportation could up the new approach, with its entirely different cost model. Njie recalls making the case: "Let's put our lead to transformative change. They needed to be specific, in terms of approach and methodology. hands together and put our resources together. We have so many programs that have logistics included in them . . . If we continue the way we are, you don't realize it, but we'll spend more money than we spend now, and we're still not getting anywhere." Business as usual, Njie believed, would lead to siloed Adaptability thinking rather than transformation: "There are so many Global Fund programs to buy and maintain vehicles. They come in different forms: the malaria program, the HIV program, all of them thinking in only A vision is not something to be changed lightly. But social entrepreneurs show remarkable versatility one direction. They manage their own transport maintenance with private servicers. All think in their own buckets." in adapting the way they deliver on their visions. They alter their methods, even as the core vision remains unchanged. Again, Riders for Health provides an illustration of this dynamic. By the mid-2000s, Thinking outside these buckets meant joining forces, and implementing TAM in the Gambia. Eight the Colemans had succeeded in embedding the Riders for Health model in seven sub-Saharan African years on, results are very promising. Although the Gambia is a small country, covering some 11,300 countries. Their approach was widely adopted and acclaimed as a best practice in last-mile health-care square kilometers, its conditions are typical of sub-Saharan Africa. Less than 20 percent of its roads are delivery. But wide adoption wasn't what they were after; rather, they saw complete uptake and universal paved, and 43 percent of its population lives in rural areas that are well off the beaten track. Yet, to date, adherence as the goal-the true measure, in their minds, that a new paradigm for health delivery was in Riders fleet has covered over twelve million kilometers in the country without a single breakdown. Riders place. reports not one transport-related failure in referring women in threatening labor to a hospital or clinic. As the pair evaluated their progress, they began to think about changing the model. They had seen And childhood immunizations in the Gambia are now approaching 100 percent-among the highest in the world dramatic effects from their management of partners' vehicles. What if they went even further? The Page 120 of 249 . 49%GE'I'I'ING BEYOND BETTER Reflecting on their journey or more than two decades. the Colemins acknowledge how much remains to be done, even as they look with pride on what they've achieved. \"It is quite a long time to do something, twentyve yearsifootball coaches don't last that long, I've noticed,\" Barry says, with characteristic irreverence. Andrea is more serious, observing, \"I think there is a long way to go, but I am quite optimistic that changes are being made.\" Both are right. While the change they so clearly envision, a new equilibrium with truly reliable health-care transportation systems across Africa, has not yet taken hold as they feel it should. there are encouraging signs, New memoranda of understanding are in development With both Rwanda and Nigeria. Expansion into Nigeria alone, with its population of over 173 million, would double Riders' current reach; more importantly, it would bring the kinds of health gains the Gambia has seen to a country whose population is expected to reach 300 million by 2025. Liberia and Sierra Leone, which have been ravaged by the Ebola virus, have also reached out to Riders, signaling a growing recognition of the value health transport plays in health infrastructure. For social entrepreneurs. 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 Coleman: bring to life what a new equilibrium can mean for those most disadvantaged by the current system. It is this segment of society, held hostage by an unjust status quo, which almost always makes up a social entrepreneur's target (onstituency. And while the degree to which any population is marginalized, oppressed, or made to suffer will vary, social entrepreneurs will make vivid how the new equilibrium will benetthese constituents and the other key players in the ecosystem. In doing so, they will demonstrate their grasp of all that's entailed in creating sustainable change. For it is the winning aspiration that seB in motion the cascade of choices social entrepreneurs must make in order to deliver on their promise. Precisely how they build models to effect that change is the subject of the next chapter. 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