Live Well, a CARE Social Business

As Managing Director of Live Well, a health social enterprise in Zambia, Alexandra Burrough is filling a critical need for a visionary leader with business acumen to carry and further ignite the torch of harnessing the market economy in last mile villages. A British national, Alex has lived and worked in Zambia for 10 years having come as a volunteer. Her experience includes serving as Operations Manager for SunnyMoney, a social enterprise focused on lighting up homes across Zambia selling over 300,000 lights. Working for Article 25 (London) helping to secure funding for disaster hit areas around the world to build better. As a VSO in Zambia, Alex experienced the immense barriers to accessing basic goods and services faced by Zambians and committed her life to breaking those barriers. At Zambia Open Community Schools (ZOCS), she fundraised $2.5 million, to support community schools throughout Zambia.

Community Health Workers (CHW) are one of the only options that communities have at the last mile to be able to access help, advice and support. However these CHWs are all volunteers, by training to be a Community Health Entrepreneur not only are they improving there economic status but giving communities access to much needed basic health products. There are over 60,000 CHWs working within last mile communities across Zambia. Through Live Well’s model training methodologies we can enhance and stabilize the access to health products in rural Zambia by incentivizing CHE, increasing their retention rates and accountability and systematizing the support for the expanding network of CHEs in a cost-effective way. By giving access to health products we are elevating humanity.    

Access to quality healthcare is a fundamental human right and a critical development issue. In Zambia the average life expectancy is 59 years and many Zambians suffer from easily treatable or preventable health conditions. The country is well below global averages for health and income. Around 75% of the population lives on less than USD $1.25 per day and almost 50% of children under the age of 5 are stunted due to malnutrition, poor maternal health, and infections. Many Zambians are inadequately served or outside a health system that grapples with a physician to patient ratio of 0.2 per 1,000, limited infrastructure, and a vast landmass.

Although the Government (GRZ) provides free health services and products, stock-outs and long distances from rural areas—where over half (64.1%) of the population lives—mean that the most vulnerable households still lack access to basic healthcare. Getting to clinics is difficult and costly for families who must sacrifice a day’s income to make the trip. People therefore rely heavily on the 60,000 volunteer CHWs who provide much needed health products to rural households and last mile. However, these CHWs are not paid for there vital work. This is where Live Well is able to help.

Live Well is a health social enterprise in Zambia which strengthens access to health products by developing and training a network of Community Health Entrepreneurs (CHEs) who purchase consumer health products from Live Well and resell to their communities. Live Well works with public and private partners to strengthen the healthcare system by providing ongoing training, close supervision, and income generating opportunities. Through Live Well CHEs remain motivated, active and high performing. This increases access to affordable health products and improves healthcare awareness amongst rural areas and last mile communities.

CHEs are trained in business skills, financial management, entrepreneurship, and basic health care and product knowledge so that they can sell health products including soap, toothpaste, painkillers and condoms. They also provide health information in their communities to help support behavioral change. CHEs are generating at least 10% of their household income through Live Well activities which is significant for households where diversified income is the norm. The CHE can spend this income on school fees, hospital fees and/or nutrition options to improve the quality of life for family. Live Well believes in empowerment as opposed to handouts as being the best way to lift people out of poverty.

Live Well targets rural areas where the proportion of persons who report illness is nearly twice that of urban areas. While Live Well specifically targets women and children, the entire family and community benefit from products sold by the CHEs that are not normally available. For example, access to fortified porridge is critical in Zambia where thousands of men, women, and children suffer from one of more forms of malnutrition and only 11% of children 6 – 23 months are fed appropriately. Through the sale of chlorine water purification solution and baby delivery kits, Live Well has been able to improve sanitation, avert malnutrition and stunted growth, and improve hygiene for birthing mothers. Poor sanitation is a major source of public health problems and epidemics in Zambia. Live Well is able to help contribute to a reduction in people having to visit clinics by giving them access to health products. Which in turn leads to a saving for the MoH.
Live Well benefits the CHWs by changing the status quo (training them to become CHEs) and providing them a sustainable income for providing these health services.

Live Well elevates opportunities for all people by supporting marginalized Community Health Workers/Volunteers to become Community Health Entrepreneurs and earn income and return for the investment of their time and effort. With half of Zambia’s population in rural locations they are effectively left behind by the traditional health system. A cadre of motivated CHEs are reaching that population and in turn elevating the health of a previously undeserved population.

Live Well was born out of a project under CARE International where health products where being give out for free to Community Health Workers (CHW) who, at the time, had very limited training on the products. It was realized that with a bit of training these CHWs could become entrepreneurs buying and selling the products which would give them a livelihood and supply critical health products to the last mile. Live Well was formerly registered in Aug 2016.

Since joining Live Well I have been able carry on the vision and the mission and been able to train over 800 CHEs, cut the costs not only to train the CHEs but also the running costs to make sure that Live Well is a viable business through creating a solid business plan which will mean that Live Well is financially independent in the next 5 years. I have also made sure that the product basket is relevant and what the CHEs need in order to be able to make a living out of selling basic health goods through maintaining good relationships with supplier.

I got a taste for living and working in the Southern Africa region when I was 18 living in a small thatched 1 room house for year and it’s there that I realized that women and children can be an afterthought when it comes to education and health. Having realize this I went on to learn how to fundraise and manage projects. I soon realized I had to be back on the ground in Southern Africa and that is what lead me back to the region 10 years ago with all the skills needed to be able to manage projects and social business.

Live Well is close to my heart as an organization, we don’t only empower CHEs but because I am a mother, it’s about being able to get basic health needs to mothers in communities. Clean baby delivery kits is one of our best selling products and I am inspired everyday knowing that we are able support the reduction in infections when women are giving birth. Raising my daughter in Zambia its important to be able to make sure that every woman and child is able to access health products like my daughter and I are able to.

I have over 10 years of experience of living and working in Zambia with 8 years of that running social enterprises. I thoroughly enjoy being able to run an innovative and sustainable program which allows me to give back even more. I like knowing that every dollar we spend and invest into it generates the ability capacity to train more CHEs and deliver more health products to the last mile. My career to date has enable me to learn and acquire different skills that you need to run a social business which include a business mind with a calm approach to any situation. Working for 10 years in Zambia has also allowed me to be able to connect with people at all levels from community members, refugees, CEOs of big businesses and government officials this is key to being able to run a successful social business.  MORE

The greatest challenge that comes with running Live Well is managing the demand for our services and the lack of budget to be able to train CHEs. Having to let staff go because Live Well had to make cuts earlier this year was one of the hardest things I have faced as a CEO, especially because it was simply due to a lack of funds, not because the staff members had done a bad job.

The challenge of becoming financially sustainable and to break even is something that I battle with every day. To find the balance of making sure that Live Well becomes a successful social business with a very limited cash flow is hard. Its important to make key decisions and not have regrets about them and acknowledge and apologize when your wrong. I have also learnt that I am only as good as my team around me so its key to listen and learn from what my colleagues have experienced not only in the field at a sales level but in the office. I have also learnt to appreciate and accept my Board of directors who all have there own ideas on the direction of Live Well.

At Live Well I am not only the CEO but also sales person, procurement and even driver. I make sure that I am able to do all of the roles that I need in my team as if I cannot do the roles then how can i expect anyone in my team to. I have learnt in Zambia that is important to 'get your hands dirty' and work as a team. This was best shown when I drove over 14 hours to a particular area in Zambia where we are working in a refugee settlement. Live Well had been tasked by UNHCR to make sure that training was completed and stock was in place for the newly trained CHEs to be able to start distributing in the settlement, due to lack of staff at the time, it fell to me to make sure that the team got there and we did not face disappointing UNHCR. Once there I helped to organize the training in make shift areas, liaise with the staff on the ground and use my basic french to even help with the training.

Live Well is owned by CARE International US but is fully registered as a business in Zambia.

While last mile models are not new anymore, Live Well’s model to build on the government structure of Community Health Volunteers and supporting them to become entrepreneurs is disruptive in Zambia. From the baseline survey conducted on CHEs, there are differences in outcomes caused by the innovation. It has improved people’s lives, not only though increased livelihoods, but also in terms of health outcomes within communities. Through CHE performance surveys, Live Well is to track how many of them are restocking products worth K150 a week culminating into K600 per month for them to make meaningful profit and for Live Well to be commercially viable. The aim to be financially sustainable also distinguishes Live Well from other community health solutions. Live Well recovers over 100% of the cost of products distributed through CHEs, while still earning a small margin for both Live Well and Live Well CHEs. To be fully sustainable, Live Well will achieve a combination of scale, sales revenue growth, and additional revenue streams through public-private partnerships. To help support costs in recent months, Live Well has been able to sell products to shops and other institutions in areas that CHEs do not work. Live Well is also selling products to other corporate companies and NGOs, which is helping to boost income. To further help increase sales, Live Well has a promotion each month on certain products, helping CHEs to gain further income.

Input

Activity

Outputs

Outcomes

Impact

What is invested into the project

What is being done to bring about the changes

Immediate measurable changes

Broader benefits aiming to achieve

Core objective for long-term change

$X investment from a funder

Recruit and train CHEs

# of CHE working with LW

 Improved knowledge and opportunity 

Increased levels of self-efficacy

Reduction in hours spent on unpaid domestic work

# of CHE trained with LW

Increase income for CHE

Increased participation in HH decision making

Changes in attitudes towards women

Changes in social status

CHE active in communities

# of CHE's per region community

Improved access to essential products

Improved level of malaria prevention

# of people reached

Access to advice on key health and family planning  related issues

Increased knowledge and awareness of family planning

# of products sold by CHEs

Time saved

Decreased dependency on male members of the HH

Partner with distribution outlets

# of distribution partners

Increase availability of healthcare products beyond CHEs

Reduction in water borne diseases

# of products sold through distribution partners

Improve health and nutrition

Currently Live Well has trained 1,700 CHEs and is distributing over 30,000 units of health goods a month. Each active CHE is ecpected to serve at least 5 house holds a day, with and average of 6 people per house hold which means that on average with 500 active CHEs we are able to serve 330,000 people per month.

By 2025, Live Well’s expected impact of its innovation will reach over 1 million consumers. Specifically, Live Well’s goal is to expand the number of CHEs to 7,500 to reach 4,050,000 individuals in five years. Live Well will do this by empowering community-based volunteers and other community members by creating a financially sustainable way to serve the health needs of the communities at the last mile as Live Well CHEs. Live Well could become a nationwide scalable health impact with the products that CHEs sell.

• We will scale to new areas directly and with local partners.
• We will impact CHE livelihoods by increasing the available financial incentives through product sales and performance-based incentives. By helping CHWs earn income as CHEs, we contribute to their motivation and retention, addressing a major health system challenge.
• We will push towards financial sustainability. We will grow our revenue base from sales and partnership contracts; and over time reduce the dependency on donor funding. While some grants will be required for the foreseeable future, we anticipate breaking even in the long term. 

If we achieve the targets outlined above, we will have succeeded in providing not only a successful model to motivate and retain CHWs, but also an approach to finance CHW networks at scale by focusing on entrepreneurship and involving partners in the public and private sector.

Our long-term vision is that every health clinic in Zambia and across the developing world has motivated CHWs who are earning meaningful income in recognition of their duty of service to the community. We want CHWs to live lives of dignity and pride. We want CHWs to be able to put their children through school or invest in home improvements that have long-term effects on the economy. Empowering CHWs as CHEs helps us realize our vision and provides a sustainable, scalable model that can be embraced by developing countries across the globe.

Funding is one of the main barriers that we have faced to scaling up Live Well. Although we are maximizing the revenue generation potential of current Live Well CHEs, we cannot become financially sustainable or scale our business without proper investment capital.  

Live Well can face competitive risk. Almost all Live Well’s suppliers are potential competitors in underserved communities. Live Well expects to continue encountering this challenge during scale up. However, I enagae with suppliers through regular meetings, where I make sure that we achieve the best price for Live Well to live up to the mission statement of providing affordable products in underserved communities. The other risk is CHEs becoming inactive due to sometimes volatile economic situations within their households which may require them to use their working capital for other needs. While Live Well offers intensive training that prepares prospective CHEs to become entrepreneurs and community caregivers and any inactive CHE is a financial loss for Live Well. Having noticed this trend over a period, we have worked to make trainings as cost effective as possible, without compromising the quality. Our aim is to train and retain an adequate number of CHEs so that as some become inactive, Live Will can still sustain the project beyond funding.

Currently we work alongside CARE International Zambia in three projects

under UNHCR, World Food Programs and Southern African Nutrition
Initiative. We also have partnerships with GSK, Barclays and Living
Goods who all helped to get Live Well up and running through
sponsorship.

Most developing country governments and NGOs depend entirely on external donor financing to support CHWs. Implementation is sporadic and most CHWs serve in a voluntary capacity receiving occasional stipends. In the long-term, this is unsustainable. Live Well disrupts the donor-dependency syndrome by empowering CHWs and other community members as community health entrepreneurs (CHEs). Our business model consists of three pillars:

• Entrepreneurship: we train CHWs to earn additional income as healthcare entrepreneurs
• Product: we regularly supply CHWs with products for sale to drive sustainability
• Partnership: we unite expertise and interests from the public, private and social sector

  Our aim to be financially sustainable distinguishes us from other community health solutions. Live Well recovers over 100% of the cost of products distributed through CHWs and earns a small margin, while still affording a motivating income to CHWs. To be fully sustainable, Live Well will achieve a combination of scale, sales revenue growth and additional revenue streams through public private partnerships.

Live Well’s proportional cost recovery at the field-level is 50% (as of 2019). This figure continues to improve gradually over the next four years as we spread our fixed costs over a wider CHE network that generates greater sales revenue. Our platform of CHEs positions us to bring in novel sources of financing from external partners who contract Live Well to deliver health promotion activities or conduct market research on their behalf. Over time, core business revenue (sales) combined with contract revenue from external partners such as NGOs and pharmaceutical companies among others comprises a larger percentage of field-level and HQ-level costs, reducing Live Well’s long-term need for grant funding and creating a pathway to sustainability.

  Currently Live Well has no financial support from external donors. Live Well is surviving off sales alone from health products through sales to the CHEs.

Live Well needs to raise $1 Million over the next three years to become finically sustainable which includes training 7,500 CHEs over the next 3 years

On average Live Well spends $23,000 a month, so for the rest of 2020 we expect expenses to be $138,000. Please note that this does not include training any further CHEs. This is just basic running costs for Live Well paying staff, getting stock into the field to sell and overheads.

Live Well wants to train more CHEs through our current more cost-effective way using a peer to peer system, meaning that current CHEs would also serve as mentors for the new CHEs, we have already seen this work in several of the communities we are working in. We want to boost the capability of CHEs to drive demand by creating blended and easily deployable market activation activities that increase awareness on health and social challenges and tie these to the products in the current basket. With support from The Elevate Prize, LW wants to train a further 600 CHEs through this improved training model, so we can boost retention and reduce recurrent expenditure on training new CHEs. In turn we can deepen engagement in existing communities and impact even more communities, reaching over 105,600 community members and provide increased income for the trained CHEs. Within our training model LW also wants to refine the content by creating opportunities for blended market activations that combine sales and marketing e.g. drama groups, with awareness creation on social and health issues to boost demand.

As for now funding it key to making sure that Live Well is able to scale up therefore it is a priority. I also believe that the model can work with a clear business plan the numbers make sense. M&E is an area of work that Live Well needs support due to limited capacity we are not able to showcase the work that we do effectively.

Any organizations that have a similar way of thinking as Live Well.