Not Invented, But Scaled Here

(Photo courtesy of VisionSpring)

The development sector—whose traditional ways of working are increasingly challenged by global crisis, conflict, and climate change threats that disproportionately impact the poor, women, and girls—has a scaling problem.

On one hand, social enterprises and other small innovative organizations can be an engine for conceptualizing, designing, testing, and validating new solutions to old problems. Yet growing and scaling even the most evidenced, effective, and impactful of those solutions can prove difficult. The high costs of last mile delivery, operational scope required to scale across geographies, and lack of access to patient “mezzanine” capital for growth all conspire to keep these solutions from achieving their potential. It’s logical that these enterprises and organizations would hope for larger NGO actors to adopt and take their proven solutions to scale.

Meanwhile, big international NGOs—BINGOs—have been said to suffer from something that’s been called “Not Invented Here” syndrome. The condition is characterized by an organization’s unwillingness to scale external solutions, often while holding the paradoxical conviction that the whole sector should be scaling its internal solutions. This position is inefficient: It wastes the time, resources, and brainpower put into building and validating powerful solutions that can scale. It’s also ineffective: It stunts the impact potential of innovative solutions, though every BINGO says it wants to exponentially grow impact. This is not so logical.

In 2021, following some inspiring conversations with our friends at the Mulago Foundation, the Impact and Innovation division of CARE—charged with identifying, innovating and scaling solutions that deliver sustained transformative impact beyond CARE’s traditionally grant-funded development and humanitarian work—began exploring the question of how CARE could serve as a platform for scaling the development sector’s best solutions, regardless of origin, with fidelity. After speaking with a few of the talented teams in Mulago’s portfolio, we filtered by opportunity, evidence, and readiness to identify VisionSpring as our first partner for a unique (for BINGOs) external scaling experiment.

Partnering Up

For those who don’t know, VisionSpring is a remarkable organization whose Reading Glasses for Improved Livelihoods (RGIL) intervention has been iterated and refined for sustainable scale (which we define as scaling via other doers/payers at scale) over the course of 20 years. To date VisionSpring has sold 8.7 million pairs of affordable reading glasses to low-income customers in remote areas, creating a path out of poverty by extending productive livelihoods, and generating $1.8B in economic impact. Since developing the RGIL model with BRAC in 2008, VisionSpring has focused on sustainably scaling the solution via like-minded partners already operating in the last mile, rather than growing its own last-mile distribution networks.

At the launch of our partnership, CARE and VisionSpring together selected Zambia as the site for our operational scaling pilot. Though VisionSpring had been wholesaling quality affordable eyewear to mission-aligned partners (such as eye hospitals, clinics, and government hospitals) in the country, they lacked the operational infrastructure to bring the RGIL program to people living on less than $4/day in remote areas. Live Well, a Zambian-led for-profit CARE social business, had a network of 1000+ Community Health Entrepreneurs (CHEs) already delivering basic health consultations and products in the last mile—a well-established cadre large enough to potentially generate economies of scale. It seemed a perfect match.

Our initial pilot launched in April 2022 and ran for two months. It spanned 14 communities, in remote areas of Eastern and Luapula Provinces, and peri-urban areas of Lusaka Province. Over the course of the pilot, VisionSpring trained 200 Live Well CHEs to expand their offerings to include eye exams, presbyopia (farsightedness) diagnoses, and reading glasses. The results of this scaling experiment ranged from heartening and inspiring to unexpected.

(Photo courtesy of Live Well.)

What Did We Achieve?

People who needed glasses got them. Accessing eye care services from remote areas of Zambia is difficult and expensive, given long distances, resultant transport expenses and lost wages, and high prices at eye care facilities. Consequently, many who could benefit from glasses go without. Over the course of our 2-month pilot, Live Well CHEs delivered 2,396 free eye exams, which yielded 1,224 presbyopia diagnoses, and 447 sales of reading glasses (that’s an impressive 37 percent sales conversion rate). Reading glasses were sold at ~60 percent of what Zambian eye care facilities charge ($4 vs. $6.50). Seventy-five percent of first-time eyeglass wearers in the pilot were women.

Community Health Entrepreneurs earned a better living. Live Well is a for-profit social enterprise that aims to improve provision of health care services to underserved Zambians by enabling community health workers (traditionally volunteers) to earn income, making their work more tenable in the long run. Along with health care education and support, Live Well CHEs offered a basket of basic medications and health products related to nutrition, hygiene, malaria prevention, and sexual and reproductive health. The average margin on this basket of goods was 9 percent—enough to generate an income stream, but not enough to create strong incentives that would drive motivation and retention. After introducing reading glasses to the product mix, the 33 percent margin on glasses significantly increased the margin on the Live Well basket of goods. We know the resultant increase in income was meaningful to CHEs, because as the income implications for the 200 CHEs participating in the RGIL pilot became clear, an additional 400 CHEs requested training. This level of demand far outstripped our ability to meet it in the initial pilot and bodes well for further scaling of the program.

Live Well became a more sustainable and scalable business. Live Well’s ambition had always been to scale across Sub-Saharan Africa, but the same low margins that limited CHE income potential also limited Live Well’s profitability and ability to achieve geographic scale. Integrating the RGIL program required an initial investment of $125,000 in grant funding from CARE and VisionSpring, but by the end of the 2-month pilot, the program was generating enough profit to pay for itself. Within the pilot period, CHEs were able to pay Live Well back for inventory supplied on credit, further contributing to the business’ sustainability. With its profitability and sustainability enhanced, Live Well is now better positioned to achieve its scaling goals, and through scaling, its impact goals.

Why Did This Work?

The optimal fidelity model was clear. Over years of experimentation and iteration in varied contexts, VisionSpring had developed and built robust evidence around a solution that was simple, affordable, and cost-effective enough in delivering impact that other doers/payers at scale could implement it. VisionSpring’s ability to quickly adapt the intervention for context and willingness to work alongside Live Well to create supportive structures, optimize the supply chain, build CHE capacity, design and price the product mix, and measure results, were fundamental to the success of the pilot. Live Well’s willingness to learn, adapt, and grow, and commitment to implementing the solution at fidelity, were equally vital.

Key scaling challenges were solved. Obstacles related to operational infrastructure and access can be costly to solve, derailing a social enterprise’s scaling ambitions. These challenges, which had limited VisionSpring’s ability to seed and spread RGIL in Zambia, were overcome when the partnership with CARE/Live Well was established. Live Well had existing CHEs, aligned entrepreneurial vision, organizational structures and personnel for CHE supervision and performance monitoring, supply chain and cash management capabilities, ability to provide CHEs with a revolving credit fund for inventory, and deep relationships in the last mile. Because of this existing infrastructure and access, VisionSpring was able to focus on adapting their model for local context, rather than having to reinvent it from the ground up. At the institutional level, CARE brought to the partnership the commitment to building a long-term relationship, a funding contribution towards the initial pilot investment, and potential for scaling the partnership beyond Zambia across the 100 countries where CARE has robust networks and a last-mile footprint.

The partnership was a win-win-win. We knew that scaling RGIL through CARE’s last-mile footprint would be a win for VisionSpring (which would scale further and faster through Live Well’s CHE network), and for low-income customers (whose economic resilience would be improved by extended livelihoods). What we hadn’t quite anticipated was how significant the win for CARE would be. Live Well, as a community health worker social enterprise, is a complex intervention whose success is measured by its impact on social norms, gender equality, multiple health outcomes, and equitable access to quality health services. By comparison, RGIL is a simple intervention, designed to augment economic resilience by getting reading glasses to those who need them. And yet, integrating VisionSpring’s relatively simple intervention made CARE’s more complex intervention more financially viable, sustainable, and scalable. These wins to CARE are meaningful because they will enable Live Well to scale its business and impact further and faster as well.

Going to Scale

We hope to build on the success of the CARE x VisionSpring scaling experiment by expanding the partnership to more districts in Zambia, and to new regions of Sub-Saharan Africa as Live Well scales. We are cautiously optimistic, and aware that there are some critical questions to be examined, for instance:

• Can the margins, sales conversion rates, profits, and CHE enthusiasm that made the pilot a success sustain over time and across geographies?
• Will the higher profits associated with reading glasses shift CHE incentives and focus away from providing the products and services that are essential to achieving CARE’s priority health outcomes?
• Or conversely, do the higher profits and incentives for CHEs strengthen provision of services related to other health benefits like reproductive health or nutrition? If so, how?

Bolstered by the outcome of our pilot with VisionSpring, CARE is doubling down on scaling evidenced, optimized external innovations. Through our new CARE Scaling Network initiative, we plan to launch 20-30 similar partnerships over the next three years.  We are currently running pilots to scale two other social enterprise solutions—myAgro and Pula—via our flagship Farmer Field and Business School (FFBS) and Village Savings and Loan Association (VSLA) programs. Both CARE programs group people in the last mile—unbanked women in the case of VSLA, smallholder farmers in the case of FFBS—providing a valuable platform for delivering external solutions that will deepen impact for these CARE target populations. In Tanzania, we are partnering with myAgro to scale their smallholder farmer support services model through FFBS and VSLAs, while also empowering volunteer community-based trainers to earn income as myAgro village agents. In Nigeria, we are working with Pula to offer livestock insurance to last-mile pastoralist communities via the platform of VSLAs, filling a critical need for them. We continue to see indications of positive outcomes for target groups, our social enterprise scaling partners, and for CARE’s own interventions. We couldn’t be more excited to see where all this goes.

Whether the goal is to deliver more benefit to our target populations, to make our own interventions more powerful, or just to ensure that the sector's most innovative and impactful solutions have a platform for scale, there are so many good reasons for international NGOs like CARE to scale proven solutions developed by social enterprises and other small innovative organizations. Those partners are experts in adapting their models for context and scalability, which can help get to impact faster. Integrating their solutions into relevant internal interventions may make those complex solutions more viable, which can help take impact further.

There is broad consensus across the development sector that actually solving the world’s most pressing and complex challenges will require that we magnify our impact by 10x, not 2x. Partnerships between established, networked BINGOs like CARE and cutting-edge innovation engines like VisionSpring could be exactly the type of collaboration that gets us there.

The author would like to thank Khanindra Kalita, VisionSpring’s Global Program Manager for RGIL, whose leadership on the design, execution, monitoring, and continuous improvement of the pilot was essential to its success.

Read more stories by Anita Sundari Akella.