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impact No. 23

JULY 2018


Didier Drogba Ambassador Deborah L. Birx Dr. Venkatraman Chandra-Mouli Dr. Dรกzon Dixon Diallo Raj Kumar Michael Goettler Chris Elias Brigette Bard Peter Godfrey-Faussett


Cutting edge global health coverage from

3-6 June 2019 | Vancouver, Canada

The world’s largest conference on gender equality and the health, rights, and wellbeing of girls and women.

From keynotes to social enterprise pitches, workshops to film festivals, poster sessions to exhibition booths, there will be countless opportunities to engage, gather inspiration, and build a more gender equal world. More than 6,000 world leaders, influencers, advocates, academics, activists, and journalists under one roof. Will you be one of them?



It’s Time to Reimagine Healthcare


he international community has some pretty audacious goals. We're on target for some, but woefully behind on others. It's clear we won't meet our goals doing business as usual.

The #MeToo movement, an unprecedented expansion of the Mexico City policy by the Trump administration, rising nationalism in Europe, flat-lining aid, and a growing burden of non-communicable diseases in developing countries are all impacting the incredible progress we've made in global health.  This special issue unpacks the complicated topic of power. In particular, we explore how putting more control and care directly in health consumers' hands can fast-track progress.  Inside find out what thought leaders such as PEPFAR’s Ambassador Deborah Birx, Bill & Melinda Gates Foundation’s Chris Elias, Zimbabwe Ministry of Child Health and Care’s Getrude Ncube, World Health Organization’s Dr. Venkatraman Chandra-Mouli, and Pfizer’s Michael Goettler have to say about the impact a shift to Consumer Powered Healthcare can have.

Don’t miss the breakthrough special report, A Healthier World: Reimagining Healthcare in Developing Countries, which includes exclusive consumer research on foreign aid. Americans polled for the special report were asked a series of questions about aid effectiveness. Here's a little of what we learned: There is overwhelming support for foreign aid, but questions remain  about who is best to deliver it.  The vast majority polled think putting more care and control in consumers' hands will lead to better health outcomes. Increasingly, people trust the role philanthropists play in funding global health solutions. We'd like to hear your thoughts on consumer powered healthcare. Leave comments on our Facebook page @PSIhealthylives, tweet us at @PSIImpact or email me at mstowell@psi.org.

MARSHALL STOWELL Editor-in-Chief @MarshallPSI 3


Impact Team Editor In Chief

Art Director

Managing Editors


Marshall Stowell VP, External Relations & Communications MStowell@psi.org

Karen Sommer Shalett Deputy Director, External Relations & Communications KShalett@psi.org Sandy Garรงon Manager, External Relations & Communications SGarcon@psi.org SPECIAL REPORT A Healthier World

Reimagining healthcare in developing countries See Insert


psi.org @psiimpact facebook.com/PSIHealthyLives youtube.com/HealthyBehaviors


Population Services International 1120 19th Street NW Suite 600 Washington, DC 20036 www.psi.org

Population Services International (PSI) is a global non-profit operating in more than 50 countries worldwide, with programs in modern contraception and reproductive health, malaria, water and saintation, HIV, and non-communicable diseases. As PSI looks to the future, the organization will reimagine healthcare to put the consumer at the center and whenever possible bring care to the front door.


I M PAC T M AG A Z I N E N O. 23

Dominique Brown Creative Manager, External Relations & Communications DBrown@psi.org

Margret Aurin Brigette Bard Deborah L Birx Venkatraman Chandra-Mouli, MD Marcie Cook Dรกzon Dixon Diallo, DHL, MPH Manya Dotson Didier Drogba Margot Fahrenstock Peter Godfrey-Faussett Karin Hatzold, MD Karl Hofmann Raj Kumar Michael Lwin Cindy MacCullough Lelio Marmora Getrude Ncube Bright Phiri Celina Schocken Emily Sullivan Kathryn Vizas Jeff Walker

What's Inside?






w/Karl Hofmann

by Members of the STAR Initiative Consortium

by Jeff Walker

7 Questions with Ambassador Deborah Birx


A Call to Action in the Age of #MeToo

Shaping the Market for Innovation


So You Say You Want a Revolution?

by Dรกzon Dixon Diallo, DHL, MP

by Manya Dotson



by Raj Kumar

by Didier Drogba

The Power of an Idea

The Key to Sustainable Improvement in Global Health


The Last Word by Karl Hofmann


PSI TAK ES A SEAT ON TOILET BOARD A third of the world’s

population—2.4 billion people— live without sanitation facilities, exposing millions of men, women, and children to risks of morbidity and mortality.





(Photo credit: Kiran Thejaswi)

HIV self-testing (HIVST) is revolutionizing the way people get tested for HIV. This film spotlights how Unitaid, PSI and partners are building the HIVST market in South Africa and neighboring countries. Through the HIV Self-Testing Africa (STAR) Initiative 5 million self-test kits will be distributed in sub-Saharan Africa by end 2020. Visit: http://bit.ly/starinitiative



The Toilet Board Coalition, with members such as UNICEF, Unilever, and WaterAid, recently invited PSI to join forces. Founded in 2014, the businessled platform enables close collaboration between private, public, and nonprofit sectors to accelerate the business of sanitation and develop new solutions to the global sanitation challenge. With a goal to achieve universal access to sanitation before 2030, the Toilet Board Coalition aims to incubate and scale innovative technologies and services through its partner network.


Join PSI at the 22nd International AIDS Conference (AIDS 2018)

Consumer Powered Healthcare We want to provide an enabling environment for consumers in the developing world to make choices that give them power. It's not our place to empower—that would just reinforce the idea that we have power to give. To disrupt the current healthcare system, we can offer the tools, but it’s the consumers who will make the ultimate changes. healthcare options



Impact Malaria is the US President's M A L A R I A Malaria Initiative (PMI) global service delivery project to reduce malaria mortality and morbidity. The project aims to efficiently and effectively move countries forward along the malaria elimination spectrum under the PMI 2015-2020 Strategy and beyond.   PMI

IMP CT Advancing Malaria Service Delivery

In order to accelerate progress for malaria elimination, PMI Impact Malaria will close gaps in malaria service delivery, unlock the potential of key drug-based approaches, and strengthen malaria health systems to support national governments to effectively administer malaria programs. Worth over USD 163 million, this five-year project will be implemented in up to 27 countries in Africa and three countries in the Greater Mekong Subregion.







Through PMI Impact Malaria, PSI will work with core partners including Jhpiego, the Malaria Elimination Initiative at University of California, San Francisco, and Medical Care Development International.



(Photo credit: Marcie Cook)

July 23-27, 2018 Amsterdam, Netherlands PSI and network members will deliver more than 15 presentations and posters on how we’re working to end AIDS by bringing HIV products and services closer to the people who need them.

NOT TO MISS: MONDAY, JULY 23 — 2:45-4:45 PM Building an HIV Self-Testing Movement: Lessons Learned from the STAR Initiative

Bring care to the front door No, don't shut the front door. Open it! Bring home self-initiating technologies or community health workers with diagnostic and contraceptive technologies to leapfrog the clinic system.

GET A CLOSER LOOK Check out PSI’s booth in Hall 1, #222 to learn how we’re putting consumers in charge of their own HIV prevention and treatment. And be sure to stop every day at 1:30 PM for Hot Talks with leading experts.



got talent? As PSI seeks to bring care closer to consumers, we’ve committed to helping build global capacity for the development community at large—and PSI specifically. Enter Lynn Smith, our new Chief Human Resources Officer, formerly the Chief Human Resources Officer for Pandora. She is tasked with helping PSI discover and cultivate the talent we need to fulfill our commitments. IMPACT: Lynn, PSI prides itself on its business perspective. You come from the corporate sector. How do you see the skill sets of the corporate sector overlapping with what it will take to reach universal health coverage? LYNN SMITH: As I began my candidacy for the HR role at PSI, I was intrigued by the combination of business savvy coupled with passion for the mission—providing healthcare globally. Having worked in both nonprofit and for-profit environments, I believe that the basic tenets of talent remain consistent. The skill set that I have seen since joining PSI



is quite similar to what I have experienced in the corporate sector—determination and focus in support of a very deliberate and clearly articulated strategy. A strategy that remains consistent with PSI’s mission while recognizing the changing environment. Great talent is a linchpin to the success of delivering on our strategy—the right talent, in the right place, focused on the right results. The ability to execute with excellence is key. IMPACT: What do NGOs working in developing countries need to do to build people and leadership right now? LS: The ability to “build people and leadership” is critical to the success of any organization. There is always a shortage of the right mix of talent needed, regardless of the industry or the environment. In developing countries, this can be even more pronounced, given educational, economic, and resource constraints. Identifying ways to build a strong internal bench is a first step. Are there ways to provide visibility, exposure, training to individuals internally? Are there opportunities to provide external support to internal team members? Are there ways to leverage relationships and partnerships to identify external talent? IMPACT: What skills does the development professional of today need to acquire given the shrinking footprint for aid dollars?

LS: We know that funding sources are shifting, and the landscape has become far more competitive. I believe that the development professional of today needs to be able to think innovatively, demonstrate resilience, and explore new ways to secure funding. This requires a move from managing opportunities that come our way to actively seeking opportunities that might not be readily apparent. IMPACT: As PSI launches a new strategic outlook, reorienting to consumer powered healthcare, what do you think is needed from our leadership at PSI? LS: Willingness to role model, engage, and communicate along the way. Being able to continue to drive home our mission of making it easier for people in the developing world to lead healthier lives and plan the families they desire. Continuing to seek forums to drive home “the what and the why” and most importantly, how all PSI-ers play a part in this reorientation. There are many opportunities for PSI-ers to participate and stay connected in this transformation through cross-functional project teams, working groups, one-on-one dialogues, and larger audience communication. Leaders at all levels in the organization play an important role in helping cascade information to their teams.

Care and control in her hands When we learn from our consumers, we can provide

options so the consumers can take charge of their care, choosing how and where to access it

It's time to put more healthcare directly into the hands of consumers. PSI is making four bold commitments to help reimagine healthcare, putting the consumer at the center and, whenever possible, bringing healthcare to the front


door. See below for a few places we're already working toward these goals.



Bangladesh. PSI, together with a consortium of partners led by Chemonics, will implement the USAID-funded Advancing Universal Health Coverage (UHC) in Bangladesh project. The project aims to transform the world’s largest NGO network of maternal and child health clinics across 64 DISTRICTS into a sustainable social enterprise that provides millions of people with quality primary care. The project will introduce innovative business and operational models, create research-based health service packages for the poor, and experiment with new health service delivery channels to towards achieving UHC.

Ethiopia. Up to 32% OF HOUSEHOLDS in rural and peri-urban areas lack access to a toilet, resulting in increased open defecation and exposure to preventable diarrheal diseases and death. Through the USAID Transform WASH project, PSI and partners are working to change this reality for over 1 million households by 2021. The project aims to create a sustainable market for WASH products and services by building demand for improved sanitation and working with market actors to determine the most viable products, prices, market-entry points, and promotions.

Funder: USAID | Partner: Chemonics

Funder: USAID | Partners: IRC WASH, Plan International and SNV



Zimbabwe. With a USD 7 MILLION GRANT from the Swedish International Development Cooperation Agency, PSI and partners will address young people’s sexual and reproductive health and rights (SRHR). This innovative project will increase access to, and use of, quality, inclusive, and integrated SRHR, genderbased violence, and HIV services. Unmarried young women 15-24 and married women 15-49, with a particular focus on survivors of sexual violence and key pop.

Funder: Swedish International Development Cooperation Agency | Partners: Adult Rape Clinic, City of Bulawayo, Department of Health for the City of Mutare, Family AIDS Caring Trust, Family Support Trust, and Matabeleland AIDS Council.

Funder: Centers for Disease Control and Prevention | Partners: Community Media Trust, Health Systems Trust, JPS Africa, Thathenda and University Research Co.

South Africa. Through a five-year USD 6 MILLION ANNUAL GRANT from the Centers for Disease Control and Prevention, PSI affiliate Society for Family Health (SFH) will ensure that voluntary medical male circumcision (VMMC) services are integrated and implemented as a package of comprehensive HIV prevention. SFH will support the transition of direct VMMC service delivery to public sector facilities with an eye on ensuring increased government ownership, coordination, implementation, and ultimately domestic resources.

(Photo credit: Trevor Snapp)

consumer n. \ kən-'sü-mər \ Where's the beneficiary in all this? PSI sees those we serve as having choices, and like a commercial entity, it's our responsibility to delight the consumer so they want to take advantage of available healthcare options




Ambassador Deborah L. Birx

As the US Global AIDS Coordinator since 2014, Ambassador-at-Large Deborah Birx leads the US Government's international HIV/AIDS efforts, including PEPFAR's DREAMS partnership to reduce vulnerability in adolescent girls and young women (AGYW). Here she shares with PSI's CEO and President Karl Hofmann the latest results of this ambitious initiative and ways we can innovate to get closer to ending HIV/AIDS.

KARL HOFMANN: DREAMS has had tremendous success in reducing new infections. What have we learned from the last three years about HIV prevention for AGYW? What do we want to take forward and scale up? What should we leave behind? DEBORAH L. BIRX: We are extremely proud of DREAMS’ accomplishments to date. Through this initiative, we have helped drive a 25-40% decline—or greater—in new HIV diagnoses among AGYW in nearly two-thirds of the highest HIV burden communities implementing DREAMS across 10 African countries. Overall, we’ve reached more than 2.5 million AGYW with services and support through DREAMS. DREAMS continues to be an incredible learning process. We started DREAMS quickly because the data showed that AGYW were experiencing a public health emergency. We created a core package of interventions, and continually modify as we learn from new data and implementation experiences. For instance, we originally included cash transfers in the 10

DREAMS core package, but later removed that component when evidence for its impact on HIV acquisition became less clear. Data from the PEPFAR-supported, CDC-led Violence Against Children Surveys show that girls’ sexual debut is usually before age 16, and that this first sexual experience is often forced or coerced. In response, we are increasing our focus on sexual violence prevention among girls 9 to 14 years of age. For young women, lack of access to jobs in the formal economy is also a challenge. We are examining how to build job skills related to market needs to help young women develop economic independence.

KH: How can AGYW gain greater control of their sexual health?  DB: A number of factors reduce AGYW’s control over their sexual health. Girls often bear the burden of societal expectations surrounding sex and fertility. They often engage in transactional sex to support themselves or their families,


making it difficult to negotiate condom use. As noted, AGYW are experiencing startling levels of sexual violence. Frequently, AGYW’s relationship with sex becomes intertwined with violence and/or financial need. To address these issues, we are implementing comprehensive curricula that teach girls about their bodies, build decision making and assertiveness skills to delay sexual debut, and provide information on methods of protection from HIV and early pregnancy. We are complementing this information with access to clinical services, such as contraceptives, HIV testing, and pre-exposure prophylaxis (PrEP). We are also offering socioeconomic strengthening programs, such as savings groups, to increase AGYW’s economic independence. Finally, we are helping communities and families to surround these youth with support and education.

KH: Can we use new technologies or more flexible approaches—like HIV selftesting—to leapfrog over problems in health systems?  DB: PEPFAR is always looking for new technologies and approaches that are data-

driven and can be taken to scale. This year, our policy guidance emphasized the scale up of HIV self-testing (HIVST), PrEP, and a transition to dolutegravir-based treatment regimens. We are scaling up HIVST to reach young people who are healthy and would not typically seek care at health facilities. When appropriate, we are also offering HIVST kits to people living with HIV that they can offer, in turn to their partners who cannot make it to a facility setting. We are also working with private sector colleagues to explore new approaches to find and reach missing populations with healthcare services. Health systems also need innovations in the supply chain and we are exploring the use of digital health technology to address challenges and improve understanding of how HIV commodities are used.

KH: You’ve been especially outspoken about how sexual violence creates risk for AGYW. What are you hearing from AGYW about the role of sexual violence in their lives, and what can we do to address this pervasive problem? 

ABOVE Ambassador Birx with DREAMS Ambassador from South Africa Nontokozo at World AIDS Day 2017. (Photo credit: Neshan H. Naltchayan/BCIU)

DB: Sexual violence is pervasive with as many as one third of AGYW reporting forced or coerced sex as their first sexual experience. These unacceptable levels of violence are also apparent in the stories we hear as we visit


(Photo credit: DREAMS) 11




DREAMS sites in all of the 15 countries supported by the partnership—stories of victimization from very young ages by boyfriends, uncles, neighbors, strangers, and teachers. But they are also stories of survival and resilience. These young women want to succeed in life; they look for partners like PSI to support their forward movement. PSI can help AGYW by providing evidence-based violence prevention programming, including programming to change harmful norms and practices that can contribute to the acceptability of violence.

KH: How do we balance the opportunities and risks of user-controlled technologies for young people? 


DB: User-controlled technologies are less risky


if they are implemented carefully, and as part of a package of comprehensive prevention services that includes risk reduction education and counseling, condom promotion and provision, voluntary medical male circumcision, and structural interventions to reduce vulnerability to HIV infection.



We must respect the ability of young people to comprehend complicated medical information and use it to make critical decisions for their own health. Contraception is a case in point. For decades, AGYW have been weighing the risks and benefits of various contraceptives and making informed decisions. If we do our job by creating youth-friendly clinics, training youth-friendly providers, and providing clear information and adherence support when needed, young people will be successful at using these new user-controlled technologies.

KH: We’re experiencing a profound political shift in the US and Europe. What messages about HIV prevention are resonating with global leaders right now? DB: People want to get behind success, whether they’re global leaders or community members. We’ve made such incredible gains over the past 15 years since PEPFAR was created. Many high-burden countries are approaching HIV/AIDS epidemic control because they’re bringing proven HIV prevention and treatment strategies to sufficient scale. We need to do a better job of showcasing our successes and painting a vivid picture of the future possibilities that exist if the momentum continues.

KH: Ten years from now, what would you love to see when it comes to the fight against HIV/ AIDS? What changes to the current response could bring about this vision?  DB: We are on the cusp of something extraordinary. With the tools we already have, there’s the historic opportunity—for the first time ever—to control a pandemic without a vaccine or a cure. This will lay the groundwork for eventually eliminating HIV through future scientific breakthroughs. Until we have a vaccine and/or a cure, the main challenge is one of implementation. We need to reach the individuals who we’ve yet to find, retain those who we’re already supporting with services, and create the conditions whereby countries can sustain the HIV/AIDS response and at a lower future cost.


I M PAC T M AG A Z I N E N O. 23

(Photo credit: DREAMS)


CONVENIENT CONTRACEPTION PSI has made a commitment to put care and control in consumer's hands by bringing technology to the front door whenever possible.


he health center was three hours away. Marta explains to her health worker, Ilda, that it was expensive to travel to the health center in Maputo, Mozambique. But Marta recognized her need for contraception and made the journey. Due to limited options at the center, she was offered condoms as a short-term solution. Marta knew her husband wouldn’t agree to use them. “Why would a married couple use condoms?” Marta says. She didn’t know that even married people need to use condoms to protect against HIV. The women hear Marta’s husband cheering at the TV. The community has recently seen an increase in income and prosperity. “Football, again,” Marta explains. Prosperity has also brought demand for better health care to Marta’s community. When a health worker told Marta about a nearby clinic, she soon took the short walk to town for an appointment. These health workers are part of a pilot project to bring choice to Mozambican women. With funding from Stasia Obremskey, a member of Maverick Collective, PSI’s philanthropy and innovation lab, the program supports access to high quality contraception. The Mozambican government aims to raise the country’s contraceptive prevalence rate from 31% to 50% by 2020. At the clinic, Marta is counseled on the risks and benefits of different contraceptives. She chooses Sayana® Press, a new contraceptive which combines the needle and drug in one small cartridge. Marta’s first injection is easy. The nurse swabs her arm, injects the needle, and presses down on the drug-filled well. At the end of the appointment, the nurse puts Marta in touch with Ilda for a follow-up. A fter three months, Ilda arrives at Marta’s home. Marta confirms her interest in receiving another Sayana® Press injection, which Ilda administers with ease. Ilda records the completed visit in her phone and sets up the next appointment. After Ilda leaves, Marta relaxes. She doesn’t have to worry about contraception for three months, when Ilda will return to her doorstep. —With Contribution from Maria Dieter, Coordinator, External Relations and Communications, PSI







n 2006, human rights activist Tarana Burke launched the me too MovementTM through Just Be Inc., building community among survivors of violence, especially women of color (WOC) from low-income backgrounds. In the wake of accusations against former Hollywood mogul Harvey Weinstein in 2017, use of the hashtag #metoo by survivors sharing their stories went viral, elevating the movement globally. Collective storytelling by survivors— the movement’s powerful tool—illustrates how assault, abuse, and exploitation are ongoing and an ever-present risk. All sectors have a responsibility to address these issues, including those of us in global development. One might argue that we have a greater responsibility given our humanitarian mission and reach with vulnerable populations. Most organizations have minimum policies on sexual assault, human trafficking, and child protection, compliant with host country law. However, minimum processes focused on criminal acts leave survivors ignored, ostracized, and further victim to professional backlash. Survivors may be deterred from reporting at all. Minimum policies do not address the systemic sexism and racism that marginalizes women (especially WOC), perpetuates normalized inappropriate behavior, and breeds inequality. The time has come for us to establish comprehensive prevention and response systems for assault, harassment, and exploitation with transparent procedures for reporting of, and objective response to, offenses. There should be multiple channels for reporting, clear lines of accountability, and high standards for enforcement and discipline of offenses,

including offenses that cannot be proven, or are not criminal. Policies should be streamlined across funding agreements and organizations to support monitoring and reporting; and require that partners, subcontractors, and vendors have similar policies or adhere to such policies in terms of agreement. Transparency supports partnerships, organizational reputation, prevents funding loss from investigation and arbitration, and improves efficiency. We must address underlying cultural norms and inequalities leading to inappropriate behavior. Research shows that diversity and gender parity in leadership increases productivity and profitability. Organizations should support the appointment of women, especially WOC, in leadership roles; review, and transparently report, gender pay-gap data; and provide remuneration wherever necessary. The me too movement is a platform for the voices of those with lived experience. We also need a platform for voices within our organizations prioritizing those underrepresented, such as WOC, women with disabilities, and the LGBTQ community. The voices of diverse and representative staff members should inform the design of these systems. Through the me too movement, the world is now listening to the voices of those with lived experience, leading to empathy, and subsequently change. In international development, we must also heed this call, listening to the voices of our workforce and beneficiaries, building empathy across experiences, and eradicating the systemic forces that inhibit wellbeing and hinder us from reaching our goals. —With Contribution from Bethany Corrigan, MPH,

Senior Technical Advisor, Gender and Gender-Based Violence, PSI


I M PAC T M AG A Z I N E N O. 23




e live in an age of disruption. A decade ago, who would have imagined that working professionals would forgo a hotel room to instead crash on a stranger’s couch? Now AirBnB boasts more rooms than Hilton. Even something as time-honored as friendship is being turned upside down. Facebook’s Mark Zuckerberg claims that most people have, on average, just three close friends, and the social network aims to increase that to four. With over two billion people actively engaging on Facebook, this goal may indeed become a reality. In a time when technology is cheap and ubiquitous, and when markets and human connections are reimagined so quickly, a single idea–even an outlandish one–can be immensely powerful. Healthcare has long been marked by such complexity that many view it as a daunting industry, and not a true open market. It’s a spaghetti bowl of providers, payers, patients and, of course, regulators. For the poorest people in the lowest resource settings, this complexity leads to too little care and high out-of-

pocket costs. When a single illness can equate to economic disaster, healthcare looms over the heads of patients, casting a dark shadow of anxiety. The World Bank calculates the financial gap to remove that anxiety at $33 billion per year. This infusion of external financing from developed economies to support fragile healthcare systems could, quite literally, change the world. As we work to close the gap, healthcare is in dire need of an innovative, disruptive, paradigm-changing idea. Consumer Powered Healthcare may be just that! First, the simple shift from “patient” to “consumer” is powerful. The terminology is engaging and relatable for people in all walks of life. Second, the notion that consumers would drive this vastly complex industry immediately helps to simplify it. The focus shifts from the spaghetti bowl to the person eating it. Finally, the power of markets is implicit in this framing. Solid reasons exist as to why healthcare doesn’t operate as a simple open market. That said, technology provides an opportunity to transform the industry and allow for openness, transparency, and accessibility for

ordinary people, driving down costs and increasing quality. Hard work and dedication will be required from each of us. Governments need to invest more heavily in healthcare. Donors need to close the external financing gap. Providers need to innovate, upgrade, and make care available even in the most rural settings and for the most marginalized people. But the spark in an idea like Consumer Powered Healthcare can ignite a world-changing movement. It’s an idea that puts people at the center of healthcare and that’s a disruption that many in the global health community– and in communities around the globe–will welcome.


PRESIDENT & EDITOR-IN-CHIEF Devex – Do Good. Do It Well.™ @raj_devex  15


BRINGING CARE TO THE FRONT DOOR Sandy Garçon Manager, External Relations and Communications, PSI Amid a changing funding landscape, global health stakeholders are looking for innovative and cost-effective ways to deliver consumer-centered healthcare, both inside and outside hospital walls. Thanks to emerging medical and digital technology, there is an unprecedented opportunity to deliver quality health solutions directly to the consumer. From personal diagnostics to mobile technology, these new classes of products and services are making it from the traditional clinic to the household, helping bring care closer to the people who need it most. Consumers in the least developed parts of the world can now become more actively involved in their own healthcare. The following five innovative solutions are shifting control directly to health consumers’ hands for greater health outcomes. (Photo credit: Emily Carter)


The first ever “do-it-yourself ” injectable contraceptive, Sayana® Press combines a lighter dose of the drug Depo-Provera and a needle into an easy-touse cartridge. Injected just under the skin, Sayana® Press requires minimal training, making it especially suitable for administration by communitybased workers—rather than by doctors and nurses. It can even be safely and easily self-administered, where authorized. What’s more, it’s tiny, doesn’t require assembly, and is easily disposable.

Changing the Game An estimated 214 million women in developing countries would like to delay or prevent pregnancy but are not using any method of contraception. Because of its unique contraceptive delivery technology—compact, discreet, easily transportable, and no refrigeration required— Sayana® Press can be provided in low-resource, non-clinic settings. And with three months of contraceptive protection per dose, the product calls for less frequent clinic visits, further increasing women’s autonomy. The Last Mile Funding from the Bill & Melinda Gates Foundation and the Children’s Investment Fund Foundation is making Sayana® Press available for US$ 0.85 per dose to qualified purchasers in over ten countries. Current efforts are underway to unlock new market opportunities through securing government


HIV SELF-TESTING Much as home pregnancy tests put more information directly in the hands of women, HIV selftesting (HIVST) is helping people learn their status in a way that works for them: on their own terms—using either a blood-based or oral f luid self-test kit—at a place and time of their choosing, and with a return of results in minutes.

Changing the Game Three out every 10 people living with HIV worldwide are unaware of their status. HIVST empowers those who may be deterred from learning their status and getting care. Fear of stigma and discrimination, lack of privacy, lack of time, as well as the distance and cost of transportation to the nearest health facility are often cited as reasons. Expanded HIVST use can contribute to reaching first-time testers, people with undiagnosed HIV or those at ongoing risk in need of frequent retesting. This will help address poor coverage particularly among men, youth, key populations (i.e., sex workers and men who have sex with men) and other hard-toreach groups. The Last Mile Regulatory obstacles remain in many countries.Countries must adopt national guidelines and frameworks, with rapid scale-up and implementation. Plans must include continuous evaluation to identify the most sustainable, equitable, and cost-effective approaches for HIVST distribution.

DAPIVIRINE RING First developed for contraceptive use, vaginal rings are a promising tool for HIV prevention. The self-insertable, f lexible silicone ring provides sustained-release of the antiretroviral drug dapivirine locally to the site of potential infection during the time that it’s worn. Designed to be changed monthly, the ring reduces women's risk of acquiring HIV by more than half.

Changing the Game Existing prevention methods have not done enough to stop the spread of HIV among women. Pending regulatory approval, the dapivirine ring would provide women with the first discreet, easy-to-use, and long-acting prevention option. Expanding women’s options increases the likelihood of identifying a solution that works in the context of their lives, so that they can stay protected. The Last Mile Preliminary results from the open label HOPE and DREA M studies are showing protection levels up to 54%, alongside higher rates of adherence. The next step is regulatory approval and guidelines from the World Health Organization. Research is also planned to evaluate the ring’s safety in pregnant and breastfeeding women. Further research has already begun on a dual-purpose ring to provide women three months of protection against HIV and unintended pregnancy.

TIKO Think frequent f lyer miles, but for healthseeking behaviors. This program, created by Triggerise, rewards consumers for accessing health services and products, just as they would be for booking a f light or shopping in certain retail stores. Consumers earn “TIKO Miles” at participating public and private facilities for each milestone they reach in the healthcare system.

Changing the Game A solution designed for cashstarved, informal markets, TIKO aims to reduce the financial and supply barriers to accessing care. TIKO virtual currency can be redeemed for goods and services that consumers and their families need—ranging from groceries, to mobile credits, to hair salon appointments. Along with incentivizing consumers to receive health services, people in cash-strapped communities have more disposable income, which they can use to make personal purchases at local businesses, injecting that money back in the local economy. The Last Mile Currently active in 11 different markets, the TIKO ecosystem connects the local healthcare system, providers, and local shops to a broader network. With a scalable model that works across both geographies and interventions, the customizable reward-based scheme adapts to the unique needs of each community.

“NE X TGE N” BE D NE TS The latest innovation in the fight against malaria is a durable long-lasting insecticide-treated bed net (LLIN) with multiple modes of action, including fast action against mosquitoes and additional efficacy against insecticide-resistant mosquitoes. This new type of LLIN product will remain effective for at least three years.

Changing the Game Vector control has a been a key contributor to the progress against malaria worldwide. But the use of one class of insecticide (i.e., pyrethroids) in LLINs has led to growing resistance in malaria-carrying mosquitoes. Second generation bed nets are a direct response to the spread of pyrethroids resistance in many areas, particularly sub-Saharan Africa. The Last Mile The arrival of next-generation nets will require not only the technology, but also the political commitment and funding to enable scale-up in the countries with the greatest need. Countries with known resistance will require support with demand creation and distribution of next-generation LLINs through campaigns and continuous distribution channels.



POCKET-SIZED HEALTHCARE Understanding our Client's World

Information Provision

Continuum of Care

Linkage to Care

Obtaining Feedback

Tracking Healthcare Uptake

ABOVE: PSI creates apps and other mobile technology to put care and control in consumers' hands.




ive billion people across the world have a phone in their pocket. A nd in Sub-Saharan Africa alone, over half of the population is expected to own a phone by 2025. Consumers use their phones to connect to everything, whether it’s their families, friends, bank accounts or simply their next ride. So why not use this connection for healthcare? Putting healthcare in the palm of the client’s hand, PSI invests in technology that goes beyond traditional behavior change approaches to reach consumers. Our new initiative, called Connecting with Sara, named for the archetype of our target audience, aims to leverage technology to better engage and learn from users throughout their lives as health care consumers. Connecting with Sara is a platform to track and engage with clients through their mobile phones. Using phone calls, text messages

and social media, PSI can use Connecting with Sara to link her to care, provide her with relevant health information, and follow her through the continuum of care. Under Connecting with Sara, PSI has created a new mobile app to enable community health workers to better follow-up with consumers and refer them to health services. The app is currently being used in Tanzania, Zimbabwe and Mozambique. The Connecting with Sara app is just the beginning. PSI is also working on mobile client-satisfaction surveys, chat bots to support online counselors, and apps that allow clients to selfrefer themselves to services, rather than having to wait to meet with a community health worker. Mobile technology allows clients to participate more intimately in their own healthcare, putting care and control directly in consumers' hands. —With Contribution from

Chris Purdy, Sr. Program Manager, Global Business Systems, PSI

First, a Community Health Worker (CHW) meets with a client, creates a unique identifier code to protect the client’s identity and asks permission to contact them about health services in the future.

The client takes their voucher to a provider, where it is redeemed electronically and then displayed in the CHW's app as a completed referral. CHWs check their performance in the app, which their manager can also follow from the local PSI office using DHIS2, PSI’s health management information system.

After issuing a voucher, the CHW later reviews the list of clients with whom to follow-up. The CHW can call or text clients reminders about upcoming appointments.

Information stored in the app is collected, managed, and analyzed in DHIS2.

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AN AFFORDABLE PRICE FOR QUALITY CARE PSI has made a commitment to improve primary care networks.


s the mother of a three-year-old, Ma Hla* had her hands full. But when her husband was imprisoned for three years, looking after her family became even more difficult. Living in Yangon, Myanmar, Ma Hla supported herself and her son by selling traditional snacks. It wasn’t easy to make enough money for the two of them. At night, she would stay up worrying about what would happen if her son got sick. Visiting the doctor costs 4,000 kyat (USD 3). That was more than she could afford. In Myanmar, people often pay doctors in the private system full price for services. In late 2016, a PSI Myanmar staff member arrived at Ma Hla’s doorstep to tell her about a new project that could benefit her family. Each family member would receive a health card, entitling them to significantly reduced costs at the nearest private doctor. The project, funded by the 3MDG Fund with the support of the Myanmar Ministry of Health and Sports, pays doctors an annual amount based on those who are registered to receive their services. The doctor then provides a range of primary healthcare services, including family planning. In return, patients receive quality, subsidized, and affordable care. Ma Hla immediately registered her family. From then on, she only had to pay 500 kyat (less than USD 0.40) to visit the doctor.  “I used to buy medicines from grocery stores because I couldn’t afford to go to the doctor. Now, the cost is the same, but with more care, so we go to the doctor when we get sick,” Ma Hla says. Ma Hla’s family is one of more than Ma Hla’s family is one of more than 2,500 low income households in Yangon benefiting from these innovative health cards. *Name changed for privacy purposes —Courtesy of 3MDG 19


Shaping the




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his era of global health is ripe for disruption. It will take the right innovations to maintain the gains we’ve made. But technology alone isn’t enough. Larger systems must be established for the technology to reach consumers in the developing world. Kenneth Xhimba always recognized the benefit of knowing his HIV status, but he was put off by the lack of privacy and time required


for testing, which could translate to a potential loss of income. The 47-year-old father of seven often relied on "proxy testing"—using his partner’s HIV status to determine his own by virtue of them being involved. “If my wife is negative, then I am too.” Today, only an estimated 70% of all people living with HIV are aware they have the virus. By 2030, the global


(Photo credit: Eric Gauss)

health community intends to have 95% of people living with HIV worldwide know their status, 95% of those who test positive to access treatment, and 95% of those on treatment to be virally suppressed. With a USD 72 million investment from Unitaid, a PSI-led consortium launched the HIV SelfTesting Africa (STAR) Initiative in 2015 to catalyze and shape the global market

for HIV self-testing (HIVST). The aim: reach the first “95” by improving the uptake and frequency of testing among those who are reluctant or have limited access to conventional testing, including men, adolescents and key populations. Kenneth is one of over 5,000 residents of Madala Hostel, a government-run complex built to house migrant workers in Alexandra Township in Johannesburg, South Africa. In this male-dominated hostel, far from home for most, unprotected sex and AIDS are not an openly discussed topics, nor is anyone’s HIV status. Most will only visit the local clinic when they’re extremely ill. “The men here left their villages in hope of finding work in the big city,” explains Kenneth who survives on odds jobs. “They fear an HIVpositive result, so they’re even less likely to go test.” HIVST allows individuals to collect their own specimen (blood or saliva) and perform the test by themselves, getting the results within minutes. There is no need to wait in the queue at the local clinic or risk being seen by a neighbor—making being in control of their own HIV testing process particularly appealing. After 30 years at Madala, Kenneth is well aware of the temptations of hostel life and encourages his son who recently joined him to also take up self-testing. “When you test yourself and know your status, you at least know where you stand and can be more serious about protecting yourself.” Kenneth and his son are part of an unprecedented effort to not only generate demand for HIVST, but also accelerate suppliers’ market entry at affordable and sustainable prices, as well as develop an evidence base to inform global normative guidelines, and make HIVST an integral component of national HIV responses. As with any successful disruption, there are learnings for how to evolve the market quickly from early product development to product introduction and inclusion into national programs to accelerated scale-up.


(Photo credit: Eric Gauss/Unitaid)

Two years in, we take a look at the different players that have helped shape a dynamic and rapidly growing market for this disruptive technology. M AKING THE INVESTMENT CASE FOR SELF-TESTING At Unitaid, we are supporting innovative ways to close the gap in HIV diagnosis. To do so, we must overcome the most common barriers to HIV testing: stigma, discrimination, and lack of accessible services. HIVST has been highlighted as a discreet and convenient approach for reaching the remaining 30% of people who do not know their HIV status. Evidence shows that selftesting increases access to HIV testing in populations with low coverage and higher risk, including men (68%), young people (95%), and other key populations. HIVST helps reach those who would not normally visit healthcare centers—in particular key populations and first-time testers— and empowers consumers to decide when and where they test. Moreover, self-testing can link more people living with HIV to treatment, and link those who test negative to prevention services. Unitaid’s investment has stimulated the HIVST market and 22

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demonstrates HIVST’s public health and economic benefits. Our PSI-led HIV Self-Testing Africa (STAR) Initiative is distributing 4.2 million test kits in six African countries. We are also supporting the MTV Staying Alive Foundation in a unique demand-generation campaign and moving toward investments to stimulate the HIVST market in West Africa. LELIO MARMORA


ADDRESSING SUPPLY SIDE BARRIERS Entering new markets with innovative solutions is a challenge for suppliers as it is difficult to assess the size of the opportunity and to define the investment required to maximize the overall health impact. HIVST manufacturers have had to tread an untrodden path and quickly learn how to overcome numerous hurdles. Among the challenges: navigating the regulatory framework, addressing country-specific policies,

and developing affordable solutions with scalable manufacturing capacity. Each is vital to ensuring reliable and sustainable solutions for large scale programs. The key to adoption is the test platform usability and performance. Without adequate (or any) policing mechanisms, there remain numerous unregulated tests on many markets, posing a serious risk of end-users being unable to tell if they have performed their test correctly and gaining false negative results—the worst possible outcome from both a public and a personal health perspective. Suppliers must develop test platforms that are easy to use from collection, to result, to disposal. Elements such as optimized user instructions that are translated with useful illustrations have a notable impact on usability and performance. Most importantly, suppliers must continue to learn and evolve through engagements with customers, partners, regulators, funders, and collaborators. The ability for us all to now engage, educate, and catalyze the public at large is key to delivering on critical testing programs. Sustainability really has to be the main consideration for all stakeholders; to build confidence and grow a sustainable market where end-users participate, and companies are happy to commit marketing spending. It is also essential for funders to support manufacturers with realistic pricing to allow continued investment in product development and regulatory approvals. BRIGETTE BARD




628,705 HIVST KITS distributed between May 2015 and June 2017



(Photo credit: Eric Gauss)


While WHO recommends HIVST as an additional testing approach, the formation of national policy, regulations, and moving to implementation and scale-up is new to many countries. In November 2016, while 23 countries had policies, only three reported implementation. By April 2018, 43 countries— including Zimbabwe—reported having HIVST policies. To guide the process, Zimbabwe put in place a technical working group tasked with improving the coordination and consolidation of efforts of all stakeholders, resulting in HIVST being included in the national guidelines endorsed by the Minister of Health and Child Care.  With support from WHO and the STAR Initiative, Zimbabwe’s Ministry of Health and Child Care and other relevant bodies are working to fill key regulation and policy gaps to scale-up HIVST interventions.  Going forward, the regulatory system will need continuous improvement, enforcing legal instruments to ensure that substandard and falsified products do not find their way onto the market.   GETRUDE NCUBE


Across all six countries, community-based distribution plays a crucial role in the introduction and awareness-building around selftesting, particularly in remote areas. Often organized in collaboration with local leaders, this helps to reduce stigma around HIV and AIDS in these communities. Going from house to house, distributors discuss the benefits of getting to know one’s HIV status and demonstrate how to use the test kit. “I talk about the privacy and confidentiality, the ease and convenience of using the test kit, and how it could help save people’s time and money,” explains a communitybased distributor in Machinga, Zimbabwe. “Most people go ahead and test on their own, and some ask that I assist them, especially older people. If people test HIV-positive, they often disclose their status to me and I direct them to the healthcare facility where treatment is available.” Generally, people are interested in this new technology and are eager to try the test. Many who choose to test had never tested before, either because of fear of a positive result or because they did not have the opportunity to go to the clinic for testing. “This helps people living with HIV know their status and get on treatment, and for those who test negative, it motivates them to stay negative and to test on a regular basis.” BRIGHT PHIRI



From the beginning, the STAR Initiative aimed to generate crucial information about how to deliver HIVST products effectively, ethically, and efficiently. In all, seven distribution models—varying in the level of support provided to self-testers and point of access—are being investigated for cost, client preferences, and linkage to care and prevention.


health science responds to new infectious epidemics. Community engagement, activism, and the greater involvement of people living with HIV have been central to building global solidarity and political momentum, but also to accelerating scientific developments and regulatory approvals. THE NUMBER OF PEOPLE DYING FROM HIV-REL ATED CAUSES HAS FALLEN FROM OVER TWO MILLION TO ONE MILLION PER YEAR

But to maintain this progress, everybody living with HIV—or at risk of HIV—needs to know their status in order to benefit from the effective treatment and prevention options that are now widely available. Sadly, many people are being left behind. HIVST is a new approach that has been shown to appeal to the very people who are being left behind, including younger people, men, key populations, and partners of those living with HIV. Self-testing offers people the opportunity to screen themselves in privacy or with their partners or friends. When linked to accessible prevention and treatment services, HIVST can be a key element in the push towards ending AIDS. Their use is limited only by our imagination. We need to reinvigorate the social movements that set HIV on the road to success and ensure that we reach the end of that road. PROF PETER


The era of AIDS has witnessed remarkable progress led by social movements that have changed the way that public





(Photo credit: Gurmeet Sapal)


Let’s beat cervical cancer,” WHO DirectorGeneral Dr. Tedros Adhanom Ghebreyesus exclaimed at the World Health Assembly on May 22. With a concerted, focused push we can save the lives of over 283,000 women who die each year from this disease. Beating cervical cancer is attainable because the tools to prevent it are simple, effective, and inexpensive. As longtime women’s health advocates, we recently formed TogetHER, a global partnership focused on building a movement to end cervical cancer. Working with PSI and others, we have witnessed firsthand that when program implementers, advocates, donors, and policy makers focus attention on opportunities to address cervical cancer, and work collaboratively, needless deaths are prevented. TogetHER aims to be the glue that brings this movement together. Scaling up access to prevention tools is critical. Girls need access to safe and effective vaccines against Human papillomavirus (HPV), which is the


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major cause of cervical cancer. Women should receive routine screening to identify precancerous lesions, and immediate treatment when precancer is detected. Both are inexpensive. Direct medical costs of the “screenand-treat” approach can amount to less than USD 25 per precancer case in low-resource settings, and a complete, two-dose HPV vaccination to protect one adolescent girl is available in low-income countries for about USD 9. TogetHER seeks to improve access to these prevention tools by integrating cervical cancer screening into other healthcare services. HIV increases a woman’s vulnerability to cervical cancer, so it is logical to connect services for cervical cancer and HIV/AIDS. Family planning services also complement cervical cancer services, as PSI found in Uganda, where uptake of both services increased considerably when they were provided together in clinics. Screening should be available for all women. Alongside the scale-up of existing tools against cervical cancer, TogetHER is fostering the development and introduction of new diagnostic and treatment tools to reach more girls and women with even greater impact, and at even lower cost. TogetHER will bring together partners working to eliminate cervical cancer as a public health threat. The WHO Director-General’s call to action is an opportunity to focus our efforts on the most effective ways to prevent this type of cancer. TogetHER is answering the call, and together we aim to end cervical cancer.





A Healthier World Reimagining healthcare in developing countries


Traditional government aid for global health in developing countries is declining at a time when the youth bulge is expanding. Can technological advances help us change the way healthcare is delivered? This special report explores the urgent need to

“PSI believes Consumer Powered Healthcare is better healthcare.” Karl Hofmann, President & CEO, Population Services International

reimagine healthcare for the 21st century. Achieving universal health coverage calls for a paradigm shift and innovative and sustainable solutions to some of development’s most vexing problems. We will see better health outcomes faster when we treat a beneficiary more like a consumer—when we engage her in program design, and wherever possible, bring care right to her front door. Getting products and services to those who need it is not enough, we also need to delight consumers with their choices and healthcare experiences. This report offers a roadmap for a new, consumer-centric strategy to accelerate progress towards the UN Sustainable Development Goals.

May 2018

The state of global health The international community has made great strides in global health in the last half-century. According to the World Bank, life expectancy has risen dramatically from 52.5 years in 1960 to 72 years in 2016. Infant mortality rates decreased from an estimated rate of 64.8 deaths per 1,000 live births in 1990 to 30.5 deaths in 2016. There are better diagnostics available to detect illness, and new drugs and treatments that save and sustain life. Overall spending on health is rising faster than the global economy and is expected to surpass $10 trillion by 2020, and $20 trillion by 2040. But significant global health challenges remain. Infectious diseases such as malaria, tuberculosis, diarrheal diseases and HIV threaten populations across the developing world, hampering economic and social development. Many areas are now experiencing the double disease burden as rising middle-class populations, urbanization and changing diets are increasing non-communicable diseases like diabetes and heart disease. Pandemic diseases—from the flu to Ebola—can transform and spread rapidly across the globe, and the world is unprepared for the next outbreak. Climate change will drive disease migration. More urgently, tens of millions of people displaced by war and conflict have acute health needs.

These are enormous challenges, and they will not be met unless we reimagine how to finance and deliver health services. If we stay the current course, we are on a road to failure.

“It’s time to plan for a future where global health spending comes from a wider variety of sources from domestic resources raised by host governments, private companies, foundations and philanthropic organizations, and where appropriate from consumers themselves.” Karl Hofmann, President & CEO, of PSI

A new approach is needed: Consumer Powered Healthcare Many global health experts argue the UN’s health-related Sustainable Development Goals will not be reached without significant changes in how the global community finances health systems. Today’s model that delivers donor aid from wealthy governments and institutions to developing countries is not sustainable. These resources are under greater pressure. Moreover, they are insufficient to provide adequate health to a growing world population. Now is the time to improve the current model, and in doing so provide opportunities for more people around the world to take greater control of their own health. We have a greater opportunity than ever before to create new partnerships to leverage today’s medical, technological and health advances that allow consumers to better care for themselves.

them to do so. This includes medical, technology and healthcare advances, improved services and new treatments that allow people to take better care of themselves in ways that are appropriate. In doing this, the burden can be lifted from strained health systems allowing them to focus on more serious health challenges that can’t be addressed by consumers themselves.

PSI is developing an innovative approach focused on Consumer Powered Healthcare (CPH)—to help shape healthcare markets to work better for consumers in developing countries by approaching health from a consumer’s perspective and by expanding the market for products and services that are affordable, convenient and effective. Without a new strategy, universal healthcare remains out of reach.

Change begins with a need to diversify how healthcare is funded, and by whom. Flat or lower levels of donor aid for health is a reality. But it is also an opportunity for new strategies to innovate, evolve and scale up. Private companies, philanthropists, non-profit organizations, and foundations are increasingly collaborating on health and development—a recognition that progress in either is dependent on progress in both. These actors can unlock significant new sources of financing and create markets and solutions that work better for consumers.

The heart of this approach puts people and countries on a path of greater self-reliance. But for consumers to take greater control of their health, they need innovative solutions that allow




Official Development Assistance

Aid provider to governments

Facilitate greater country investments and cross-sector collaboration

National Governments

Allocate incoming ODA funds

Prioritize health in national agenda and make greater investments toward universal healthcare

Private Sector

Fund projects as part of philanthropy or CSR initiatives

Build markets to provide products and services to consumers

Foundations / NGOs

Fund projects/ implement government programs

Lead innovation of consumercentric models

Traditional government donors, such as the U.S. Agency for International Development (USAID), agree that a more innovative funding strategy is needed. Irene Koek, Senior Deputy Assistant Administrator in USAID’s Global Health Bureau, says global health is a complex field and fundamentally different than it was a decade ago. “A lot of funding in the future is going to come from domestic governments, particularly in middle-income countries, and from domestic and international private sectors. The private sector also has expertise in management and technical skills.”

Change begins with a need to diversify how healthcare is funded, and by whom. Flat or lower levels of donor aid for health is a reality. But it is also an opportunity for new strategies to innovate, evolve and scale up. Dr. Chris Elias, president of the Global Development Program at the Bill & Melinda Gates Foundation, agrees. “Given the ambitious agenda of the Sustainable Development Goals, we have to convince countries to provide higher levels of domestic funding for health. We have to crowd in the private sector in a more effective way and on a larger scale. And there has to be a sound business reason for the private sector to be involved.”

A downturn in donor funding may encourage governments to invest more in the health of their populations. “The trend is for more integrated health financing. Governments need to see it’s a good investment in their overall development. Over the long term, they need more financial ownership of their own health systems,” said Margot Fahnestock of the Hewlett Foundation. Foundations can play an important role in investing in the innovation and risk-taking necessary for something new. “We are good at investing in small-scale experimentation and advocacy work. We can be flexible, take risks, and support groups for long periods,” Margot Fahnestock said. Investing in health-related infrastructure is also important, according to Michael Goettler, Global President of Inflammation and Immunology at Pfizer, Inc. “You need training for medical professionals. You need medicines and treatment, and a supply chain. You need access such as roads and transportation for healthcare providers. You need it to be profitable for the people providing health services. The more you can invest in infrastructure or the more you can innovate to facilitate healthcare delivery, the better the outcomes will be.” Finally, if we want to deliver health products and services more effectively, we need to understand what consumers want. This means offering choices, convenience and on-demand products and services. That is what every business seeks when it designs, commercializes and markets a product or service. Organizations that are seeking to target consumers need to adopt the same mindset.

Young people are today’s largest consumer market, and they need consumer-friendly information about their sexual health. The global youth population between the ages of 14 and 25 is soaring in developing countries. Today, 42 percent of the world’s population is under 25 years. The largest youth population in human history is coming of age, and there is a lot at stake in ensuring they have access to education, job opportunities, and healthcare. With more access to technology than any previous generation, young people today understand the power of being a consumer, and they are increasingly savvy in making consumer choices. Today’s generation wants youth-friendly information about contraception options, and they want products accessible to them in their homes, rather than in a clinic setting. More than 225 million women and girls in the developing world lack access to modern contraception. Tens of millions more receive inadequate antenatal care or deliver their babies outside of a health facility. In addition, about one in three women worldwide experience gender-based violence at some point in their lives, most often from an intimate partner. Contraception is just about the most cost-effective global health investment we can make to reduce maternal deaths and give children a healthier start. It can also grow a more productive workforce. Women with the ability to

control their fertility have better access to education and employment opportunities, which results in economic benefits and improved livelihoods to families and communities.

“Young people need programs that reimagine the way sexual health services are designed, delivered, measured and evaluated. We had better be creative about how to meet this demand, and old ways may not work. We need to listen to youth about their needs.” Karl Hofmann, President & CEO, PSI

“There is a lot of promise in consumer-driven reproductive health, especially in countries where health systems do not reach people. Getting products and services directly to consumers, with their own direct control, is really exciting,” said Margot Fahnestock.

A roadmap to help reimagine healthcare Here are four areas where increased investment by the global community can be a game changer in helping to meet the SDGs:



Bring the latest medical and technological advances that enable consumers to “self-initiate” care. Use evidence and consumer insights to create new opportunities for consumers to access information, social and emotional support, products, services, diagnostics, and treatment to become active participants in their healthcare.

Here are a few ways PSI is meeting this challenge: • Using two-way digital platforms that gather consumer insights, provide tailored information based on consumer needs, link to quality care, track healthcare uptake, get feedback on services and create a continuum of care; • Employing diagnostic technologies like HIV self-testing that have been shown to reach more people than traditional diagnostics, helping people learn their HIV status when and where they choose; and • Promoting sub-cutaneous injectable contraceptives (DPMA-SC / SubQ) that can be safely and easily administered by community health workers and through home- and self-injection.



Ensure all sexually-active young people have access to the widest range of contraceptive options and that access to services is embraced and advocated for and by young people, their health providers, governments, families, and communities. This means reimagining and redefining the way sexual and reproductive health and rights programs are designed, delivered, measured and evaluated. Build greater trust between adolescents and the health system and build lifetime users of contraception.



Partner with governments, the private sector, and others to find solutions for the 400 million people globally who currently lack access to a front line of basic health services. Deploy the latest market, consumer and provider insights to help increase and sustain the equitable use of existing private or public healthcare networks. While solutions will differ country by country, and community by community, they will all focus on building primary healthcare systems from the consumers’ perspective. This is critical to achieving sustained use of products, services, and medicines and quality health outcomes.


In support of the Family Planning 2020 (FP2020) initiative, PSI is committed to reaching 10 million people under the age of 25 with modern contraceptive methods by the end of December 2020.

PSI will improve access in three ways: • Advance private provider quality toward accreditation/certification to enable greater access to financing; • Develop and demonstrate innovative and scalable models for expanding primary care; and • Improve coordination of information for decision-making and increase visibility of consumer needs/behavior through data engagement.


Development assistance for health— particularly for vertical disease management interventions is not increasing. Partner with donors and governments to promote domestic resource mobilization to achieve universal health coverage faster. Facilitate the development and delivery of financing mechanisms at scale, such as social insurance and strategic purchasing of services from non-public primary healthcare access points. Broaden our social enterprise business models, catering to consumers who can pay without financial hardship (another form of domestic financing) and more effectively target subsidy where most needed.

“It’s welcoming that PSI is taking the time to think about how to evolve their model in a changing global environment. New funding from different sources is going to require new engagement models to deliver first-line preventive care to a broader range of people, and to more at-risk and underserved populations.” Dr. Chris Elias President, Global Development Program, Bill & Melinda Gates Foundation

The global health environment is changing rapidly, so is PSI. Increased pressure on national governments, a global youth bulge, emerging technologies and shifting donor priorities and policies require us to think differently about how PSI operates, the value we can bring to health consumers, and how to get ahead of these global challenges. We are evolving our approach, moving from being a development implementer, to embrace our role as an effective implementer and thought partner to explore new ways to shape consumer markets, shift policy and influence funding, and strengthen global capacity. “The more information you can put in the hands of consumers, the better,” said Irene Koek. “PSI’s model is consistent with approaches USAID has supported. Let’s look at the challenges—such as policy, culture and business barriers—that get in the way of our reaching consumers.”

“A lot of stakeholders need to be aligned, and it’s not easy,” said Michael Goettler. “But PSI can take a leadership role in getting the right partnership, including governments, companies and international donors, and scaling up solutions that deliver better outcomes.”

“There needs to be a big emphasis on the quality of experience in consumer-driven healthcare. We have to ensure the same level of quality if we are to bring products and services closer to the consumer,” said Margot Fahnestock.

“Achieving universal health coverage calls for innovative and sustainable solutions, and we believe outcomes will come faster when we treat a donorbeneficiary more like a consumer, and we bring care right to their front door,” said Karl Hofmann.

A consumer-centric health check-list As we implement Consumer Powered Healthcare, we will be asking ourselves a set of questions to ensure we are on the right track. • Are we conducting the right kind of market research, like a human-centered design, with our target consumers before we design and fund our programs? • Are we using consumer market research to test and iterate programs before we fund them and during program implementation?

• Are we building a business case that will attract private sector engagement? • Are we expanding partnerships with companies, foundations and governments to improve market coordination to more effectively reach target consumers? • Are we giving health consumers what they want—choice, convenience, on-demand products, and services? • Do we have in place evaluation metrics to measure consumer satisfaction?

2017 PSI Health Impact LIVES CHANGED (ESTIMATED) 5.17 million unintended pregnancies prevented. 12,600 maternal deaths prevented. 135,800 deaths due to malaria, diarrhea and pneumonia prevented. (MDG 4 & 7) 278,000 HIV infections prevented. SERVICES PROVIDED 1,373,000 long-acting, reversible contraceptives inserted (including implants and intrauterine devices), empowering women and couples to plan for the families they desire. 423,000 voluntary adult medical male circumcisions performed, preventing HIV and other sexually transmitted infections (STIs). 2,335,000 voluntary testing and counseling sessions for HIV and other STIs conducted, reducing transmission rates and increasing access to treatment through referrals.

PRODUCTS DISTRIBUTED 25 million long-lasting insecticidetreated nets, protecting families from malaria. 0.8 billion male and female condoms, preventing transmission of HIV and other STIs and empowering women and couples to plan for the families they desire. 1.7 million diarrhea treatment kits, saving children’s lives by reducing the severity and duration of diarrheal disease. 45,000 courses of directly observed therapy, saving lives by treating tuberculosis. 692,000 pre-packaged antibiotics, saving lives by treating pneumonia. 15 million courses of artemisinin– based combination therapy, saving lives by treating malaria. 10 billion liters of water treated with water treatment products.

In 2017, PSI added an estimated 30.5 million years of healthy life with our products and services.

A RISING ENTREPRENEUR PSI has made a commitment to revolutionize the way adolescents access contraception.


t 21, Épiphanie lives in Dassa-Zoumè, Benin. As a girl, she abandoned her studies to become a street vendor, helping her mother after her parents divorced. But she’s always dreamed of her own vocation. “My mother could not support me, and the only real option I had was to turn to a man for my needs.” With limited resources, Épiphanie was afraid she couldn’t protect herself from an unwanted pregnancy or sexually transmitted infections. Approximately 214 million women and girls like Épiphanie have an unmet need for contraception, and only 14% of women in Benin use any kind of contraception. One afternoon, Épiphanie’s mother told her about Académie de l’Artisanat, a vocational program that was recruiting young women her age—an opportunity that could lead to financial independence. Épiphanie enthusiastically joined the program. It was a weekly course where she learned to bead and sell her crafts. Her instructors also taught her the importance of protecting her body and her future. It was here she learned about contraception. The Académie is part of Transform/PHARE, a five-year project funded by USAID that uses human centered design to gain insights into consumers to increase their demand for contraception. Épiphanie proved to be star pupil in the bead program. After only five weeks she was able to sell the jewelry she made, sometimes making $27 per week. “After a short time, Épiphanie stopped asking me for money for her personal needs,” says her mother. Épiphanie’s journey to independence continues as a member of the Académie. She receives a loan from her mother to purchase beads, she creates the jewelry, and then she showcases it while visiting friends and potential customers. Through her sales, she’s able to repay the loan, and make a profit. “Besides learning a vocation, I’m grateful for the knowledge shared by our instructors at the Académie. Thanks to this, I won’t have an unwanted pregnancy and I’m aware of the risks of sexually transmitted infections. I’m able to plan my life!” says Épiphanie. —With Contribution from Léonce Dossou,

Communications Specialist, PSI/ABMS




mid the championships and career highlights, one of my proudest achievements to date was the creation of the Didier Drogba Foundation (DDF). When we launched in 2007, it was with the hope of making a positive impact in the lives of the people of Côte d’Ivoire, elsewhere in Africa, and around the world. On a personal level, I wanted to do my small part to provide young people in my country with the same opportunities that form the cornerstone of my success today.





(Photo Cred: © The Didier Drogba Foundation)


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This journey has also taught us the need to address one of the major— and often overlooked—challenges facing young people today: access to contraception. Despite major progress, teen pregnancy is a serious and growing issue that affects about 42% of girls in Côte d’Ivoire–70.9% of these are unplanned. Unintended pregnancy is not only a health issue, but one that is both deeply rooted in, and perpetuates, the cycle of poverty. I’ve learned it’s one of the primary reasons girls drop out of school early, diminishing their access to future opportunities. It’s also associated with increased death, HIV infection, and disability, particularly among girls and women 15 to 24 years old. The global health experts we’ve worked with have shared that many young people urgently need health information and access to contraception, but face countless barriers, including health providers who don’t understand their unique needs, don’t have contraceptives in stock, or discriminate against them. I’ve gotten the chance to see first-hand that overcoming these barriers requires us to work differently, smarter, and forge new and creative partnerships. This is why DDF is pleased to announce we are working with PSI and CARE on a transformative initiative to put young people at the center of claiming their sexual and reproductive health and rights. But this isn't about us deciding what's best for youth. It's about young people taking the lead, elevating their voices, and advocating for programs that work for them. We’re joining their team, not the other way around. Putting young people in the driver seat presents a unique opportunity that allows them to hold stakeholders accountable and helps to build engagement between youth and decision makers, and thus, eventually improve the quality of services they receive. I’m excited to work with young people to co-create the tools they need to thrive and then get out of their way, because I believe that’s when communities and countries thrive.


(Photo credit: Benjamin Schilling)

facilitate valuable cross-partner exchange. For example, during a recent FP2020 regional focal point workshop in Cameroon, youth representatives from 15 Francophone countries joined country leaders in helping shape action plans based on their countries’ commitments, costed implementation plans, and other strategies. These action plans incorporate young people’s perspective and serve as a tool for prioritization over an 18-month period. These plans are available on FP2020 country webpages, so that advocates can track and share progress. Through this workshop, in addition to ongoing webinars and calls, country partners can share experiences on youth-focused topics such as preventing rapid repeat pregnancy, providing contraception via school-based referral systems, and/or using data for advocacy. This interchange continues to demonstrate the value of partner collaboration—with young people, for young people—to understand and address gaps. Progress on adolescents and youth is inconsistent and often slow, but it is getting better. Together, we have shifted the conversation from: “Why should we focus on young people?” to “How do we effectively work with young people to improve their wellbeing?” This is a dramatic change. Initiatives like PSI’s Adolescents 360 demonstrate that partnering with young people enhances the quality of programmatic findings and improves the impact on the sexual and reproductive health of youth. FP2020 looks forward to sharing results from such initiatives, along with lessons learned from our own experiences facilitating exchange among countries, so we can continue to improve our collective work. Together, we can ensure that when a young girl creates a plan for her life, she isn’t derailed by an unexpected pregnancy.



rom global to local, the FP2020 community is increasingly focused on meeting the contraceptive needs of adolescents and youth. But are we making progress? Thankfully, the answer is yes. Nearly all 42 country government commitments to FP2020 explicitly recognize the importance of reaching young people with the services and information they need. Using FP2020 as a galvanizing tool to accelerate progress, governments and local civil societies (including youth-led organizations) are working to provide young girls with the contraceptives they want and need to take control over their futures. FP2020 commitments vary based on country context and national priorities. Ethiopia pledged to reduce the unmet need for family planning among 15 to 19-year-olds. Bangladesh committed to fully operationalize its new national adolescent health strategy with a special focus on ensuring that adolescents have access to the widest range of contraceptives possible. And Togo promised that comprehensive sex education will be implemented in all schools by 2022. These efforts demonstrate that country partners are taking important steps toward fulfilling young people’s unique needs and FP2020 goals. To keep up the momentum, country leaders—including young leaders—are sharing lessons. One avenue for this exchange is through the FP2020 partnership. When a country government formally makes an FP2020 commitment, focal points are identified within each country from donor, government, and civil society institutions. This helps



(Photo credit: Benjamin Schilling)





One in five Tanzanian girls has already given birth,” Irene Lukumay pauses, peering up at the 30 health ministers seated in front of her. Presenting for any group gives Irene the jitters. But for the young designer, asking Tanzania’s Ministry of Health to support Adolescents 360 (A360)’s work—well, the stakes were high. Irene is one of more than 260 youth partners that have joined A360, an adolescent and youth sexual and reproductive health (AYSRH) project to reimagine how girls aged 15-19 access contraceptives across developing countries. She, like the dozens of young designers at A360’s core, is at the frontline in revolutionizing how public health practitioners listen to and works with youth to transform the family planning programs of yesteryear. Globally, some 16 million adolescent girls will give birth this year. In Africa alone, an estimated 2.1 million women and girls will experience an unintended pregnancy, a quarter of whom will undergo an unsafe abortion. The need for expanded reproductive health services remains an undisputed priority. Irene has a plan, and with it a voice to break the barriers


I M PAC T M AG A Z I N E N O. 23

blocking girls like her from accessing their right to modern contraception. The air conditioning’s vibration hums in the background of the Ministry room. Irene presses on. “Access to contraception helps reverse the consequences of unintended pregnancy. It allows girls like me the ability to make healthy choices for our bodies, our lives, our futures.” A360, she says, is delivering a solution. A manifesto for an AYSRH revolution.

360 IS ONE TURN OF A REVOLUTION A revolution is not an apple that falls when its ripe. It’s a movement that begins with a spark and swells to crescendo. Shifts in thought ignite a change in delivery. AYSRH approaches over the past three decades have chipped away at the issue, but have failed to deliver change at scale. And with the youth population exploding, what got us here won’t get us to where we need to be. Adult-driven research and decisions. Graphs. PowerPoints. While traditional modes of research and programming yield meaningful data, the numbers, reports, and directives

produced can lack the empathetic ingredient we believe is central to designing resonant health solutions. A360 is a trial by fire. Through a Human Centered Design (HCD) approach enhanced by developmental science, social anthropology, marketing and public health, young designers like Irene serve as decisionmaking members of A360’s motley crew of researchers. At every turn of A360’s innovation gears, youth feed their perspectives on the unique cultural, religious, and societal experiences shaping how girls—and their influencers—perceive contraceptives and the world around them. HCD empowers programmers to work hand in hand with a project’s audience,


(Photo credit: Benjamin Schilling)


(Photo credit: Benjamin Schilling)



igniting a new way of listening with respect and observing with curiosity instead of judgement. It flips the standard practice of designing and pretesting by embracing the fresh perspective of end-users’ lived experiences at every turn. The process brings back what the boardroom air conditioners have too long drowned out: the emotional connection to a body of evidence. Through A360’s research and discovery phase, girls told A360 that they viewed contraception as irrelevant, probably harmful, and at odds with their dreams of motherhood. These insights fueled A360’s blueprint for change: delivering AYSRH solutions that use immediate goal-setting as an entry point to deliver reproductive health services. In Ethiopia, A360 uses financial planning to initiate contraceptive counseling with rural, married girls. In Tanzania A360 offers urban and peri-urban girls a mini life coaching interaction that leads to opt-out private sessions with providers—about anything a girl wishes to discuss. In Nigeria, A360 delivers vocational training that feeds into contraceptive counseling. Across all three countries, A360 programming is driven by girls’ insights and frames contraceptives to



I M PAC T M AG A Z I N E N O. 23

address their immediate needs: confusion about how to practically achieve a better life, desire for financial independence, and a quest for identity. HCD is a problem-solving tool that drives responsive solutions. For A360, it’s provided a revolutionary approach that is catalyzing rapid change: adoption of a contraceptive method through a single, brief contact.

THE FREEDOM TO PLAN FOR THE FUTURE “People think adolescents don’t know about the world,” says Genet Ebuy, a 25-year-old with thick strands of ebony hair pulled back into a low ponytail. Ebuy has worked as an A360 Ethiopia young designer for just over a year. “Young people like me are normally dictated to, not worked with. A360 is different,” she pauses, smiling. “It’s a project that gives us space to be heard.” Across A360 Ethiopia’s target region, more than 580 thousand girls aged 15-19 do not want to get pregnant. Yet at the start of Ebuy’s work, 228 thousand girls did not have access to a modern contraceptive method. In Ethiopia, the cultural imperative for girls to prove their fertility after marriage is strong. But through HCD, girls told A360 that they want their children to have better quality lives—yet they felt anxious about their futures as the country shifts to a cash-based economy. A smaller family, they said, could offer a way to reach their life goals. The insights spurred A360’s development of Smart Start, a tool that approaches contraceptive counseling from a financial planning lens. Through Smart Start’s “Baby Calculator,” girls and their husbands map out the cost of a child in contextually relevant terms (e.g., a sack of grains). The calculator, developed in partnership with young designers like Ebuy, supports couples in understanding the cost benefit of delaying pregnancy. The intervention, implemented in partnership with the Ethiopian government’s community health extension worker system, is seeing that some two in five of girls who aren’t already pregnant or using a contraceptive take up a method during the Smart Start session. One in two married girls who engages with Smart Start leaves with contraception. Most are choosing long acting methods, like implants. Half who take up a method do not already have a child.

LISTENING IS MORE THAN JUST HEARING What people say they desire, is not always what they want. “All people, adolescents included, are poor predictors of their needs,” says Ahna Suleiman. Suleiman is a research scientist at UC Berkeley’s Center on the Developing Adolescent, and a core partner in A360’s research team of unlikely actors. Adolescents are emotional decision-makers who prioritize short term benefits. As Suleiman underscores, “Understanding their emotional landscape requires not only hearing what they say, but also observing how they act [in real world situations]” Girls, for example, told A360 Tanzania that they wanted private contraceptive counseling. Yet when offered a one-on-one meeting at a clinic, our design teams found that only one girl in her group of friends would opt-in. The rest would leave once the girl returned. In follow up interviews, girls expressed hesitancy to engage in counseling


(Photo credit: Benjamin Schilling)


(Photo credit: Benjamin Schilling)


due to the cultural stigma surrounding contraception. Why attend? Although they were curious, they could get the highlights from their friend. A360 Tanzania went back to the drawing board, swapping opt-in for opt-out private counseling. The adaptation removed the friction girls were experiencing from stigma by making it the norm for every girl to engage, unless she chose not to. “Accounting for context is critical to understand the key inflection points for different adolescent populations,” says Suleiman. “Youthcentered solutions must create a space for positive risk taking that hones in on adolescents’ natural motivation for exploration, status seeking, and autonomy.” Suleiman sees these elements woven into the A360 blueprint. Today, approximately one in two girls who attends A360 Tanzania programming takes up a voluntary, modern contraceptive that day. Sometimes the smallest change sparks the biggest impact.


FAILING, LEARNING AND REVOLUTIONIZING—TRANSPARENTLY There are 1.2 billion young people in the world today entering their reproductive years. As


their power drives public health impact.

Still, 2 in 5 adolescent girls aged 15-19 across developing countries will experience an unintended pregnancy. More than half of these will end in abortion. Solving this pervading gap requires that the public health community and others to recalibrate how it operates, says Fuchs-Montgomery, the Deputy Director for Evidence and Innovation at the Bill & Melinda Gates Foundation. The thread, she suggests, lies in establishing transparency— in how we work, broadening with whom we work, how we succeed and

In the two years since its launch, and a

mere nine months since the project early pilot in a handful of sites, A360 has reached some 13 thousand girls with modern contraception, with the numbers climbing every day. A360 proves that solutions work when adolescent voices are injected into the design, delivery, implementation, and evaluation of reproductive health services. It’s a formula to revolutionize how adolescents access contraceptives in Africa, and beyond. “A360 has always been about involving girls, about understanding them, and about bringing them in,” says Lukumay. The Tanzanian young designer served as A360’s advocacy coordinator: the youth voice in the project’s government outreach. “Together we are creating a place for girls to plan for their futures,” Lukumay says, her voice ringing with passion and confidence. “A360 has allowed me to meaningfully bring my insights to life.” —With Contribution from Emma Beck,

Adolescents 360 Associate Communications Manager, PSI

how we fail. Nomi shares what it will take to design for an adolescent and youth sexual and reproductive health (AYSRH) revolution. “Creating solutions with youth is not simply a nice to have. It’s a requirement for success. When I think of an AYSRH revolution, I see young people choosing from a full range of contraceptive methods that best meet their needs and preferences, where they want and from whom they want. Achieving this requires that we—public health practitioners and donors—stop determining solutions for youth and start committing to authentically listening to young people’s lived experiences. Yet as a community, we keep repeating interventions where we have evidence that demonstrates these interventions do not provide robust enough impact. If we are serious about a revolution, we must operate differently. Together, let’s test and share new ways of designing, without the fear of failing. Let’s establish transparency between projects so we can learn from each other in real time. Let’s work collectively to better steward resources, celebrate and learn from failures and do so in a way that cuts across our community. We must build the evidence that brings young people into the center of the story. This isn’t a project-by-project


movement. It’s a cascade of passion, collaboration, investments and


partnership, powering adolescents to thrive—today and into the future.


When we invest now, we are more likely to see young people reach their full potential throughout their reproductive lives.”


I M PAC T M AG A Z I N E N O. 23



Human Centered Design (HCD) introduces an innovative approach for how global health partners can actively listen to adolescents to drive hyper-tailored sexual and reproductive health (SRH) solutions. As Margot Fahnestock says, “It’s a design prescription for a revolution.” Margot, a program officer in the Global Development and Population program at the William and Flora Hewlett Foundation, sat with Manya Dotson, the project director for PSI’s flagship and HCD-based Adolescents 360 program, to explore how HCD sparks a new way of listening to inspire a powerful way of designing.

M ANYA DOTSON: What role does listening play in design?

MARGOT FAHNESTOCK: Design is about translating what people say they want into offerings that account for what people need. HCD forces us to really listen to what clients love to create an environment that motivates them to use our services and return for more.

MD: The Hewlett Foundation entered adolescent and youth SRH work through HCD. Why is HCD a good fit for adolescents?

MF: We found ourselves observing countries that were once making SRH progress for youth,

no longer reaching impact. HCD was our attempt to apply a new methodology to better understand what adolescents needed. It was never about creating a totally different system, but about teaching people to respond to young peoples’ needs in an adaptive way.

MD: What challenges do adolescents face in accessing adolescent and youth SRH care?

MF: Stigma, quality and cost. Traditional adolescent and youth SRH programming fails to address what it means to present for health services in environments that don’t believe young, unmarried women are eligible for contraception.





Youth corners and youth clinics are not effective if they don’t correspond with high quality care in highly relevant settings. Cost remains a pervading barrier. Not all services for adolescents must be free, but we can’t expect young people to pay if we aren’t delivering quality and relevant care.

MD: How can donors support partners to integrate listening into design? MF: We can encourage curiosity, stop prescribing interventions, and give implementers the freedom to experiment. MD: How can partners join this revolution?

S TA R T S M A L L. BE CURIOUS. MD: Why is it hard to listen? MF: It takes work to decipher what someone is saying. HCD gives our partners the creative confidence to know what to do with the information they hear. It takes practice. Just keep trying. MD: How can we better listen to adolescents? MF: Listening is not just hearing but showing that you value what young people say. Put adolescents on your staff. Pay them. Try different ways of translating what you hear into outputs that resonate for clients.

MF: Start small. Be curious. There are many ways that current programs with work plans and funding in place can be more adaptive. HCD is not about breaking down a system but finding small things, like design quality, that can fundamentally change how people experience a service. See what works. The more we try and the more we listen, the further we can get in revolutionizing the future of adolescent and youth SRH programming.


“I don’t need a lecture from you. Can you just give me some condoms?”


“If my parents learn that I am pregnant, they will throw me out of the house.”

By: Dr. Venkatraman Chandra-Mouli, Scientist, Adolescent Sexual and Reproductive Health, World Health Organization’s Department of Reproductive Health and Research and the Human Reproduction Programme


raining alone cannot prepare health workers to deal with questions like the ones above and other challenging situations they often face in providing sexual and reproductive health services to adolescents. There is widespread acknowledgement that a competent and caring health worker is critical to the provision of adolescent-responsive health services. To achieve this, there is strong consensus that we



need to invest in building and supporting the abilities of health workers to respond to their adolescent patients—and, where relevant, their caretakers—effectively and with sensitivity and respect. Almost universally, building competencies and empathy in health workers has been equated to training them. Calls for the training of health workers in various topics abound in global and regional agendas for action, in guidance from international organizations (including the World Health Organization), and in academic publications. The overwhelming

emphasis on training is reflected in the volume of funding provided by donors, in investment cases, and in national policies and strategies. Over the last 25 years enormous amounts of time, effort, and money have been invested to train health workers to be more “adolescent-friendly.” The results—from the perspectives of their clients and patients—are overwhelmingly disappointing. A recent review we published reiterates the widespread consensus that inadequate knowledge and skills hinders the ability of health workers to provide adolescents


“I cannot tell my girlfriend about this infection. That is out of question.”

with appropriate health services effectively, and that judgmental and disrespectful behaviors of health workers are a major barrier to adolescents seeking care initially or returning for follow-up services. We need to take a step back and question our approach to training. This is critical for two reasons. Firstly, training health workers alone does not lead to tangible improvements in health worker performance. There is convincing evidence that without ongoing, complementary support, learning that occurs in workshop settings will not translate into changes of practice in the work place. Despite such

evidence, training alone persists as the current model and is often the only capacity building approach used. Secondly, training programs which have focused curricula, involve small groups, and are conducted by skilled trainers using multiple methods have been shown to be more effective in promoting positive attitudes and in improving health workers’ knowledge, understanding, and skills. However, the pressure to train large numbers of health workers in short time periods generally means that important interactive and participatory elements—crucial to practicing application of knowledge and building skills— are omitted because of logistical, time, and


financial constraints. Further, trainings within cascade training models rapidly deteriorate in quality because both the trainers and the training venue and/or equipment are often inadequate. In addition, there is the added potential for inaccurately transmitted messages as there is little, if any, supervision and mentoring support. What do we need to do differently, then? We should put an end to off-site, one-off in-service training programs. We should replace these training initiatives with a combination of pre-service training and ongoing, off- and on-site training (with a preference for the latter). We should ensure that training initiatives have limited and clearly defined objectives, involve small groups, and use multiple methods, with an emphasis on participatory and interactive elements. Training should be carefully monitored to ensure they are carried out with quality and fidelity. We should combine high-quality trainings with other proven approaches including job descriptions grounded in quality standards, pocket and desk reference tools, supportive supervision, and peer-sharing and collaborative learning. Job descriptions and standards can provide clarity to health workers on expectations and accountability in their scope



REFERENCES of work. Handy, clear, and credible pocket and desk reference tools can also serve as a friendly reminder to health workers what they need to do in practice. Supervision that is consistent, specific, and supportive—building competence and confidence on the one hand, and ensuing accountability on the other—can have a significant positive impact on performance and satisfaction. Finally, ongoing peer-sharing and collaborative learning in a safe environment can address deep-seated biases that are difficult to address let alone overcome, stimulate bottom-up problem definition and problem solving, and foster the development of norms and practices that are respectful and equitable in a group setting (even when they are not in the wider community in the group operates). However, a word of caution. We must not replace one discredited magic bullet with another that is bound to fail. There are, in fact, no magic bullets. Even if health workers have the necessary competencies and positive attitudes, poor infrastructure, missing and/or broken equipment, and stock outs of medicines and other supplies will impede their ability to perform as desired. Furthermore, regardless

“I want to know what my son says to you. I am paying for this consultation. I will not wait outside.”


D M Denno, A J Hoopes, V Chandra-Mouli. Effective strategies to provide adolescent sexual and reproductive health services and to increase

“My mother-in-law does not want me to take the pills and my husband does not want to oppose her.”

demand and community support. Journal of Adolescent Health. 2015, 56: S22-S41. 2.

A Newton-Levinson, J S Leichliter, V Chandra-Mouli. Sexually Transmitted Infection Services for Adolescents and Youth in Low- and MiddleIncome Countries: Perceived and Experienced Barriers to Accessing Care. Journal of Adolescent Health 59 (2016).

of the quality of capacity building and support strategies used, overwhelming workloads, inadequate and untimely salary payments, and managerial arrogance and unfairness can rapidly lead to frustration and demotivation. Providing good quality care to an infant with pneumonia and dealing with his/ her parents with consideration calls for both technical abilities and interpersonal skills and qualities. However, responding to an adolescent who has initiated consensual sexual activity before the age of sexual consent, or one who is pregnant and does not want her parents to know, is more nuanced and complex. It requires the same abilities and qualities, as well as an awareness of laws and policies—and the broader social context—additional empathy and compassion, and appropriate handling of personal opinions and biases. We demand a lot from our health workers; in order for them to deliver, we need to do much more than we are to prepare and support them.


van der Wilt. Human resource management interventions to improve health workers’ performance in low and middle income countries: A realist review. Health Research Policy and Systems. 7.7 (2009). 4.

achieve & maintain high-quality performance of health workers in low-resource settings? www. theLancet.com August 9, 2005 DOI: 1016/SO 140-6736(05) 67028-6. 5.

C J Morgan, P W Deutschmann. An evolving model for training and education in resourcepoor settings: teaching health workers to fish. The Medical

Adolescent Sexual and Reproductive Health, World Health

Journal of Australia. 2003,

Organization’s Department of Reproductive Health and Research


and the Human Reproduction Programme and Dr. Erin K. The Global Fund to Fight AIDS, Tuberculosis and Malaria

K Rowe, D de Savigny, C Lanata. C G Victora. How can we

—With Contribution from Marina Plesons, Consultant,

Ferenchick, Primary Health Care Advisor and Coordinator,

M Dieleman, B Gerretsen, GJ


A Smith. Making the most of existing health workers. World Health Report: 2006 – Working Together for Health. Geneva. WHO. 2006.


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TOILETS TRANSFORM A TOWN PSI has made a commitment to unlock domestic financing, including mobilizing consumers' own dollars.


hen Sudhir got married, he and his wife didn’t have a toilet in their home. They would relieve themselves outdoors, covering the waste with ash. “I worried that my wife would be bitten by a snake, or that there would be f looding,” he recalls. Wanting to support his new bride, Sudhir found a job with PSI as a sanitation solution provider in Patna, Bihar. He joined as part of the Supporting Sustainable Sanitation Improvements (3Si) project. 3Si facilitated the sanitation market by building demand and enabling supply of toilets in Bihar, where 80% of households lacked them. Each day, Sudhir traveled on his bike along a dusty road, heading to neighboring villages to show how a family could get their own toilet. Most families in Bihar don’t have the resources to build a toilet, so PSI created a system of microfinance loans, helping families build affordable sanitation systems. With an initial donation of $1.2 million from the Bill & Melinda Gates Foundation and Unilever, PSI partnered with Friends of Women World Bank to lend this initial money to microfinance institutions, who then loan directly to families or businesses to build toilets. With each step of the loan process, the initial donation accrues more interest. Additionally, as families pay back their loans, other families can be helped. There is then no need for additional foreign capital. After working as a sanitation solution provider, Sudhir realized he could afford a toilet. “My wife said we needed to prioritize building one so we’d have a home to be proud of,” Sudhir said. Sudir and his wife invited his neighbors to learn about his new purchase.“Now everyone in my village has a toilet.” says Sudhir with a proud grin. The couple has three young children now. They’re all potty trained—using the new toilet, of course.   —With Contribution from Maria Dieter, Coordinator, External Relations and Communications, PSI







social enterprises with a focus on production and distribution, imagine the impact if the current paradigm for social entrepreneurs shifted to incorporate both microeconomics and political economy. Social entrepreneurs would be positioned to make significant impact at scale. Thought leaders such as Bill Easterly, Jeff Sachs, Angus Deaton, and Daron Acemoglu would all agree: the government and associated institutions exhibit vast influence over the wellbeing of a country and its people.

oe Koe Tech is seizing a golden opportunity to develop software for 1,000 NGO health clinics, 1,000 hospitals, 1,500 rural health clinics, 400 courts, and 330 municipal government offices across Myanmar. Capitalizing on this unique occasion is proving a lot more difficult than it should be. Here’s the bottom line: if we sought impact investment and venture capital funding, these innovations wouldn’t have the opportunity to flourish because the software development initiatives—which took five long years of blood, sweat, and tears to attain—take too long for investors who need rapid monetization. A surprising source turned these ideas into reality: traditional aid funding and partnerships. One key challenge for social enterprises focused on scale and systems change is that current systems tend to favor social enterprises focused on producing and distributing widgets like solar panels, microfinance loans, IF WE SOUGHT IMPACT INVESTMENT AND VENTURE seeds, irrigation pumps, and other smallholder farmer-focused CAPITAL FUNDING, THESE INNOVATIONS WOULDN’T HAVE inputs. While these are important interventions, the focus on these THE OPPORTUNITY TO FLOURISH BECAUSE THE SOFTWARE types of social enterprises leads, in part, to some of the scale DE VELOPMENT INITIATIVES—WHICH TOOK FIVE LONG YE ARS challenges we see in the social enterprise space.  O F B L O O D, S W E AT, A N D T E A R S T O AT TA I N —TA K E T O O L O N G Although current systems tend to favor FOR INVESTORS WHO NEED R APID MONE TIZ ATION.


I M PAC T M AG A Z I N E N O. 23


(Photo Credit: Steele Burrow Courtesy of Koe Koe Tech)


he traditional aid model that rose out of the post-World War II reconstruction era is widely considered to be lumbering and inefficient. Although there is some truth in this, the model also has seasoned experts well-versed in running large organizations at scale in partnership with governments. Adapting the traditional model to a modern model incorporating social enterprises offers a hybrid model ensuring credibility and stability, whilst encouraging innovation from social enterprises. The model of the future should be just that—partnerships between governments and social enterprises financed and supported by traditional aid mechanisms.

(Photo Credit: Steele Burrow Courtesy of Koe Koe Tech)

(Photo Credit: Steele Burrow Courtesy of Koe Koe Tech)

(Photo Credit: Steele Burrow Courtesy of Koe Koe Tech)

Imagine if donors such as USAID, DFID, DFAT, and the World Bank—all of whom currently finance work by large international nonprofit organizations and private contractors—adjusted their current model to incentivize inclusion of local, incountry social enterprises to be part of implementing consortiums. Koe Koe Tech is a leading example of such a social enterprise. Through our partnership with a prime organization, we are developing software that will improve the lives of countless people across Myanmar. Learning and knowledge transfer from our prime organization is invaluable—it involves sharing expertise and knowledge on processes, systems, and controls to ensure sustained success of our enterprise of 50 employees. Furthermore, the consortium’s reputation allows us to engage the government at scale.  Given the contractual implications, the prime organization is also bound to ensure our success, as our wins are their wins, and our mutual success enhances our reputations with the donor.  This relationship provides far more value than any accelerator, investor, or fellowship. Our prime organization pays us to deliver, and the donor holds us to the highest standards. Experienced members of the consortium guide us to successful implementation, while we retain the creativity, agility, and flexibility to innovate and not get bogged down with paperwork. By contrast, an accelerator typically offers infrequent touchpoints with leaders over Skype. Working closely with consortium experts face-to-face is hands-down the most effective way of learning and building relationships. The most impactful social welfare improvements often come from governments implementing nationwide programs in public health, technology, and economic liberalization (e.g., China), and passing legislation to improve civil rights and liberties. Social enterprises, working alongside the government, offer an exceptional opportunity to make change at scale if the current model shifts.





s overseas development assistance declines, the challenge to finance the Sustainable Development Goals (SDGs) becomes even more urgent. With a USD 2.5 trillion funding gap, many are looking to the private capital markets and private philanthropy to provide the resources required to translate these ambitious goals in concrete action. What would happen if we structured development in a way that partners were only paid when we achieved what we promised? For more than a decade, practitioners have experimented with results-based financing (RBF) models that seek to create the right incentives needed to fix broken systems serving better social outcomes. Development Impact Bonds (DIBs) represent the latest evolution of results-based contracts—and one of many tools in the RBF toolbox. Now, a private investor and the implementer—rather than a traditional funder— absorb the financial risks of under achievement. Both parties are only reimbursed and paid a premium if the predetermined results are achieved. For implementers like PSI, the promise of the DIB model is threefold. We can use the model to increase resources through public-private partnerships; establish payment terms bound to outcomes rather than inputs; and improve our use of existing resources through greater flexibility and better use of data. In 2017, PSI and partners launched the Utkrisht Impact Bond—the largest and most ambitious health sector DIB to date—to tackle maternal and child mortality in Rajasthan, India. Just a few short months postsignature of the DIB, we remain excited about the actual implementation that will take place over the next three years. There have and will continue to be many learnings along the way, all of which will be critical to address if the DIB model is to reach its full potential. Setting up a DIB requires both time and


I M PAC T M AG A Z I N E N O. 23


resources. In the three years it took to establish the Utkrisht Impact Bond, PSI and partners had to determine the most suitable health intervention, identify potential outcome payers and risk-tolerant investors, and align those with a country where a DIB approach had a supportive government partner and market environment. Once these were in place, we had to iterate continuously to respond to investor, outcome payer, and government inputs, as well as rapidly shifting market conditions. Currently, in creating a DIB, emphasis is placed on evaluating the interventions and efficiency of the implementers. Although important, we must also create opportunities to test different DIB structures and evaluate


conditions where one approach and set of players may be more appropriate than others. Is an intermediary always necessary at all stages and for all service providers, for example? Would implementers benefit from more direct engagement with the investors during negotiation of terms and risk/reward pay off? Where do we get the greatest return on the financial investment, including reduced time from ideation to getting to market to final delivery? Additionally, we must consider the government’s eventual role as an outcome payer, if they aren’t from the start. This means engaging them early in the design, structure, and management process. Also, having a longer time horizon for implementation than the traditional grant period could shift attitudes toward risk, allow for adaptation to changing conditions, and drive change both at the country level and within participating institutions. For PSI, a key metric for success in the Utkrisht DIB is how well we learned from this project and changed the way we do business. As we develop the evidence base for DIBs, we will be able to better assess the viability of blended financial mechanisms to drive systems change and influence development outcomes. We expect DIBs to become an invaluable tool to bridge the funding gap for the 17 SDGs.




(Photo credit: Kiran Thejaswi)




Launched in November 2017, the Utkrisht Development Impact Bond (DIB) will train providers (i.e., doctors, midwives and nurses) from up to 500 private sector facilities in the State of Rajasthan, India, to meet and adhere to new government quality standards that will improve the maternal and newborn healthcare provided. An estimated 600,000 women stand to benefit and potentially 10,000 lives could be saved.







Participates in oversight in a non-executive role and lays the ground for government outcome funding in a second phase of the DIB.


Provided the initial working capital so the service providers can begin their work.


Will pay back the investor the original amount invested, plus a premium, only if predetermined targets are met.


I M PAC T M AG A Z I N E N O. 23



Received net grant to deliver results; work with healthcare Led design of the DIB and will providers to improve skills and drive achievement of target outputs and outcomes throughout capacities in critical areas. the three-year term.


Verifies progress (outputs and outcomes) regularly throughout the three-year program.




any of us are learning to address global health concerns by taking a systems view rather than looking at specific, isolated issues or interventions. By partnering with ministries of health and tailoring solutions that are affordable and deliverable, we are successfully scaling more integrated, permanent solutions. Systems change strategy implementation is proving effective with global health groups including End Malaria Council, END Fund (e.g., neglected tropical diseases), the Office of the UN Special Envoy for Health (e.g., community health activities), and many others. While the systems change model continues to evolve, learnings from the health sector are being applied to broader areas including slavery, refugees, and education. Systems change uses tools such as system and road maps, orchestrators and change agents, return on investment analyses, dialogues to establish common measurable outcomes and goals, and pathways for action. These resources enable country leaders, foundations, nonprofits, corporations, multi-lateral and bi-lateral funders, and agencies to work together to achieve significant outcomes. Through this approach, the problem is mutually agreed upon by stakeholders. Together they identify innovations to be applied and then design scaled applications that lead to permanent change.


Funding ministry leadership training through the Aspen Management Partnership for Health

Designing financing for health systems through the Financing Alliance for Health

Donor collaborations focused on specific country efforts (e.g., Liberia, Malawi, and Uganda)

These activities (left) form an aligned and holistic approach aimed at achieving a common systems change goal—scaling up 1 million community health workers to reduce maternal and child mortality. Tasking orchestrators and change agents to help define and steer holistic activities will increase the odds of success. They not only ensure the strategic approach, but also amplify the voice and needs of country leaders, bring together funders in the space, help ensure stakeholder alignment, share knowledge, and measure impact. Increasingly, funding by philanthropists is available to hire the small numbers of people needed who can apply systems change tools and increase our ability to address complex, large scale health challenges.

Tracking data for accountability and progress on malaria and other diseases through ALMA

Working with policy makers at the World Health Organization JEFF C. WALKER

CHAIRMAN, NEW PROFIT VICE CHAIRMAN, COMMUNITY HEALTH, Synthesizing practitioner experience through CHW Impact Coalition and other partners





e live in a fascinating time. For all of us working in global health, we can thank President Trump— yes, thank him—for opening our eyes to some harsh realities, and giving us every reason to urgently change course.  Does anyone feel we need a fresh example of the old adage, “Power Corrupts?” Seems like we get a new reminder every day.  In reality, power dynamics have always existed. They explain so many of our frustrated ambitions, and our most shameful moments. And they've been laid bare anew these past few months, in ways we couldn't imagine even a few short years ago. 

The #MeToo movement exposed something we knew but rarely openly addressed—that the power differential between men and women, between old and young, between the privileged and the poor translates effortlessly into abuse and exploitation.  For too many, it's been a daily, lived experience. For others, it's only now visible.  (And, naturally, it took people with power and privilege to make this reality loud enough to hear, and clear enough for all to see.) If we're honest, power and privilege have a similar effect on global health. Too many of today’s health challenges exist not because medicines don’t work, but because power, money, and race do.  

And wealthy countries have decided what's best for poorer countries for far too long.  Even how we talk about aid is skewed. Take the widespread use of the word "empower," which, if we think about it, reinforces the notion that power is something for me to give to you. Even in empowering you, I win.  #banthewordempower.

(Photo credit: Benjamin Schilling)

Put Power Where It Belongs

It's high time we put more power and control directly into consumers’ hands. For PSI, this begins with a paradigm shift.


As WHO Director-General Dr. Tedros Adhanom Ghebreyesus says, “The people we serve are not the people with power; they are the people with no power.” How has the power dynamic held global health back?  Take specially formulated kid-friendly dosages of TB medications. How is it that they haven’t existed for over a century until now? Because kids don’t have power.  Why is the all-in-one injectable contraceptive Sayana® Press so revolutionary? Because not only is it useful for a woman who doesn't want her partner to know she is using contraception, but because she can also administer it herself. No need even for a provider, with (his) built-in biases. And medication abortion—what is it that generates so much fear and concern among antiabortion activists about this particular therapy, which is highly effective and safe within the first trimester of pregnancy? Because it’s loose in the hands of women, with no intermediary, no physician, no man to exercise control.

We see a future where the health consumer we serve isn't impacted by the political whims of a country far away, where the market that provides products and services is robust and actually works for her, where the funding for the health systems she relies on comes increasingly from her home country, and where she has far greater control over her health decisions—and we have far less. Today, we rededicate ourselves to keep the health consumer at the center of our thinking, we listen closely to understand her actual needs and barriers—we take inspiration from the giants of consumer insights that every day mold our consumer behavior—and we begin to chip away at the imbalance that has frustrated faster global health progress and too often served the wrong people. 







12–15 November 2018 Kigali, Rwanda THE LAND OF A THOUSAND HILLS

REGISTRATION NOW OPEN! Early-bird registration ends

31 AUGUST 2018


Bill & Melinda Gates Institute for Population and Reproductive Health


psi.org @psiimpact facebook.com/PSIHealthyLives youtube.com/HealthyBehaviors


Population Services International 1120 19th Street NW Suite 600 Washington, DC 20036 www.psi.org

Population Services International (PSI) is a global non-profit operating in more than 50 countries worldwide, with programs in modern contraception and reproductive health, malaria, water and sanitation, HIV, and non-communicable diseases. As PSI looks to the future, the organization will reimagine healthcare to put the consumer at the center and whenever possible bring care to the front door.

Profile for Impact Magazine

Impact magazine No.23  

Impact magazine No.23  

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