The Case of Social Entrepreneurship V. Human Rights

by Caitlin Cohen

(Thank you to Nathaniel Whittemore for the inspiration with his blog on this subject)

I come from the People’s Republic of Vermont where “branding” is a dirty word. I am a strange choice to be writing a blog on Social Entrepreneurship. My non-profit, the Mali Health Organizing Project, is focused on universal primary health care, not a traditionally “entrepreneurial” field. Universal primary care isn’t sexy, simple, or scaleable. Yet it is extremely cost effective and addresses 90% of global health needs (WB, 1994). How can we get entrepreneurial about universal primary care? Is there a way to rejigger with the business model to improve financial access to care, as Nathaniel Whittemore suggests in his recent blog, or is there in inherent conflict between running a program run on a business model and a program based on rights?

For universal PHC in the developing world there is one massive flaw with the “business model”: it is incredibly cheap to leave people in the lurch, and it is expensive to provide primary care. Even if you can drastically reduce the cost per positive health outcome, the overall cost of care will increase drastically if yearly clinic visits go from 20% to 100%. And primary care is something everyone needs regularly: no amount of risk-grouping or insurance can make care universal. Lastly, its a cash economy (it is hard to buy IV tubing with a bunch of Kola nuts) and thus there is no room for non-cash trade.

But these legitimate concerns often take a backseat to this pervasive and dubious argument: “People do not value their health care if they do not pay for it.”

I went to a meeting the other day with a Malian doctor and director of a major US NGO with a solid case of “big man syndrome”, who picked up his cell phone every four minutes througout our meeting, and very clearly was counting down the minutes until 5 PM when he could kick me out of his office.  He immediately dismissed the idea of universal primary care not because of the logistic and financial challenges but because he thinks Malians will “undervalue” their care if it is free. As Paul Farmer recently said in a speech he gave to the Skoll foundation, “We need to be aware that each of the terms and concepts and tools we’ve developed can be used to deny the destitute access to goods and services that sometimes should be rights, not commodities. Does anyone really believe that a mother loves her newborn more if she had to pay some sort of users fee for prenatal or obstetrics care?”

Someone misplaced a behavioral economic survey that compared the perceived value of a widget with its price. This logic works, perhaps, for a Rolex or a BMW, but for health? Health is not a widget. Health has a value that is nearly impossible to monetize. And in a place like Mali where 80% of the population is indigent, the argument that “value” and “cash” are synonymous loses any little bit of logic.

So how can we, as social entrepreneurs, avoid having our “business models” become a new form of elite capture? What does a social entrepreneur do when the realities of a global economic crisis menace your work (ahem) and you are forced to consider cost-effectiveness, balancing a financial bottom-line against a social one?? I believe that the balance of human rights and social entrepreneurship could be achieved not in rejiggering business plans but in rejiggering the definition of “cost-effective”.

Here’s a case study: Many social entrepreneur groups in Mali have argued against the distribution of free mosquito nets, claiming that people will not use them if they do not pay for them. They make comparisons like “60% of users who receive free nets use them regularly as compared with 80% of those who pay for them” implying that the extra use is due to their increased perceived value. They almost universally fail to take into account the drop in access that comes with a marginal price increase.

Lets take a fictitious city, Dekunbugu, “the village of problems”. Say our population is a million people:

Case 1: FREE NETS: 60% of a 1000000 people who receive them free use them

Case 2: SUBSIDIZED NETS: 10% of the population can afford the $2, and 80% of those who purchase them use them.

Which program is more cost-effective? If a net costs $5, the former program costs $5,000,000 for 600000 nets-used and the latter costs only $300,000 for 80,000 nets-used. Per “net-used” this is a cost of $8.33 in the former case and $3.75 in the latter case. In short, it is quite “cost effective” to charge unreasonable user-fees that limit access to care. But this calculation makes no mention of the “herd immunity” inherent in controlling the spread of malaria from one person to another if a large number of people use nets. Importantly, it makes no mention of the simple fact that the people served by Case #2 might have access to nets already, and the 900000 who cannot afford $2 for a net certainly do not. Lastly, it assigns zero value to the fact that, while it is expensive, you are reaching 7.5 times as many people with free nets.

I believe that the only legitimate measure of cost-effectiveness is the COST PER POSITIVE HEALTH OUTCOME PER POPULATION, not the cost per mosquito net distributed, not the cost per mosquito-net used, or any other intermediary step. Sadly this proposed measure is darned near impossible to obtain short of spending a ton of money and energy on biomedical monitoring and evaluation. But we will never successfully fund the best possible programs if we continue to consider cost-per-output instead of cost-per-outcome.  Furthermore, we should include rights in our definition of desired outcomes. It is important that we always consider  sustainability, scaleability, and innovation. But it is worth reminding ourselves from time-to-time that a life is it is worth the extra $4.53 per net.