#1390 2007 · Living Goods (with BRAC Uganda) · Community health / direct selling
Ugandan health workers who sell medicine on commission cut child deaths by 27 percent
问题
Village health workers were unpaid volunteers who visited rarely; children kept dying of treatable disease
背景
Uganda, like most of Africa, ran community health care on volunteers: women trained once, then expected to serve their neighbors indefinitely for free. Attendance decayed, visits became rare, and cheap treatments for malaria, diarrhea and pneumonia still did not reach homes — while evidence piled up that free distribution programs suffered theft and stockouts. Living Goods, a US-based NGO founded by an entrepreneur, started from the opposite premise: a health worker who earns is a health worker who shows up.
From 2007, with BRAC Uganda, it piloted the Community Health Promoter program — Avon-style microfranchising. Women in each village applied competitiously; those selected got two weeks of health-and-business training and a skills test. Each promoter buys a basket of up to 152 products at wholesale prices around 30 percent below market and sells door-to-door at roughly a 20 percent margin, organized into branches with managers who supervise and restock. By end-2016 the program covered more than 5,500 clusters across Uganda, reaching over 4.4 million people.
换别人会怎么做
Train more volunteers and hand out free products — the goods leak from the supply chain and unpaid workers stop visiting; or put salaried civil servants in every village, which treasuries cannot fund and supervisors cannot reach.
他们看到了什么
Volunteerism was the bug: unpaid health work loses to every paid alternative in a poor woman's day. Put the pay inside the work — commission on the products that treat — and showing up becomes rational.
那一手
The promoter earns commission on every insecticide-treated bed net, oral rehydration packet, malaria treatment and soap she sells — so health work competes on equal terms with her other income options instead of relying on goodwill. The visits bundle selling with pregnancy check-ins, danger-sign diagnosis, referral of severe cases and follow-up; the NGOs cover their own costs on a wholesale margin of at least 10 percent, making the delivery system financially self-sustaining at the point of sale, and smartphone apps later standardized protocols and tracked visits.
为什么管用
Commission converts each visit from charity into livelihood: a promoter who visits more earns more, so coverage follows incentives rather than exhortation. Wholesale buying power funds both her margin (~20%) and the NGOs' (at least 10%), so the system finances itself at the point of sale instead of begging annually for grants. Competitive selection plus a skills test filters for ability; branch managers create the accountability and restocking loop volunteers never had. And because prevention (bed nets, ORS) is what carries the commission, the profit-maximizing basket and the life-saving basket are the same objects — the trial showed effects beyond cheaper products, in knowledge, referrals and follow-up visits.
值了多少
Cluster-randomized trial (214 villages, 2011-13): under-5 deaths fell 27%, infant 33%, neonatal 28%; $68 per life-year gained
什么时候会失灵
Commission-driven care skews toward what carries margin: if the basket is badly designed, promoters push profitable goods over needed ones (here most sales were not the highest-margin products, but that discipline required active basket management). Where villagers have no purchasing power, the promoter earns nothing and stops visiting — the model rides on the working poor, not the destitute. Quality of advice depends on training and app enforcement; and the mortality evidence comes from one country and era — replications needed heavy digital support to hold at scale.
后来呢
One of the few community health models with randomized evidence of mortality impact, at a cost per life-year that undercuts most clinic-based interventions; governments and NGOs adopted the paid, digitally-supported promoter design that the trial validated.
资料来源
- [1]Reducing Child Mortality in the Last Mile: Experimental Evidence on Community Health Promoters in Uganda (manuscript)Bjorvatn, Corno, Kaasboll, Svensson & Yanagizawa-Drott (AEJ: Applied manuscript), 2018jakobsvensson.com
- [2]Reducing Child Mortality in the Last Mile: Experimental Evidence on Community Health Promoters in UgandaAmerican Economic Journal: Applied Economics, 2019aeaweb.org