The Avahan India AIDS Initiative is the Bill & Melinda Gates Foundation’s largest HIV prevention program. Since 2003, Avahan has started and scaled up a large number of HIV prevention programs in India, which are now reaching over 280,000 high-risk individuals in 600 towns. In June, Ashok Alexander, Director of Avahan, delivered a lecture on “The Business of Public Health Delivery” at the François-Xavier Bagnoud Center for Health and Human Rights (to see the video click here). This month, we sat down to talk about Avahan’s model and global health delivery with their Program Officer Aparajita Ramakrishnan.
GHD Blog: Ashok Alexander and you regularly refer to “the business of intervention.” What are the key elements of Avahan’s model of health care delivery, its “business model”?
Aparajita (Avahan): It’s similar to any business model that you can find in the private sector, where there’s a focus on the customer as the beneficiary of the services being sold - or delivered in the case of health. In the private sector that’s buying toothpaste; in the public sector it might be the impact in terms of lives saved. In the context of HIV prevention in India, the recipients of prevention services (sex workers, men who have sex with men, injecting drug users) need to be part of the delivery, as peer workers (a “sales force”) and be leaders of community-based organizations delivering the interventions.
So the question is “Are you able to design for scale?” - meaning do you have a clear denominator? Are you focused in your intervention? Are you integrating across your value chain even within one area? Are you measuring everything you do, which is a very critical piece of any good business?
Then you think about executing for scale, what does that mean, operationally and tactically. Are you organized to the point where you can implement on a large scale? Large businesses do not just implement in one little place, otherwise they don’t make enough money. Similarly, with impact, I think you want to have a greater span.
One of the ways to achieve this is to have a virtual organization of whatever kind – to be able to build an implementation pyramid. In other words, to be able to deliver services simultaneously across large geographies and across many populations. Then, some of the questions you can ask are: How do you manage the supply side to ensure that the product’s sales force, in this case peer educators, are in the right place at the right time? Are they doing the right things? Is their job performance being measured? Do they have accountability?
Along with managing the supply side, it is important to keep a strong sense of flexibility in the program because there’s little such thing as a cut-and-paste model, especially when you’re dealing with a country like India. You need to customize and constantly be flexible. That’s one thing we’ve noticed: a lot of programs in public health don’t have the flexibility to be able to deliver on the fly based on evidence they’ve just gathered.
Finally, we focus on “last-mile” of delivery, which is really about solving the problem of getting your product, service or intervention, all the way down to the health or peer worker in the field. Where does the lapse in “last-mile” delivery occur and how do you fix it? Businesses usually spend a large portion of their time on this issue.
GHD Blog: Can you give an example of “last-mile” delivery and also discuss the notion of “demand creation” in delivery?
Aparajita: For instance, an NGO has been given a population coverage of 500 sex workers in a specific location but that’s all they know. One of the things we do is gather some basic data to identify a denominator, which we usually do through an external agency. Once you have a denominator you immediately hire your peer educators from that community, and then they’re the ones who can reach those 500 people. A lot of the time if you don’t have the right peer educators you won’t reach those 500 people; you’ll reach maybe 10. So if there’s no way you can reach the population you want, then there’s no way you can actually deliver your services.
Creating demand is also very important for funding and implementation, especially in HIV prevention for sex workers, men who have sex with men, and injecting drug users. These populations are marginalized, they’re underground, and they’re very dispersed. Also, creating demand for services can create solutions for sustainability. If a service is being demanded by the community, then whether it’s from the government or from other NGOs, funding can be found.
GHD Blog: What business practices do you think health care organizations need to implement or use better?
Aparajita: Not to say that much of this does not exist in public health, but Avahan has focused on a few areas — 1) measuring what we are doing and 2) attempting to reach scale across all of the aspects of global health delivery: design, execution, and transferring our model to the ‘natural owners’ of interventions. Rather than a situation where sex workers are getting prevention thrown at them, Avahan has focused on creating active and pulsing demand for prevention services among the core groups most affected by and vulnerable to HIV. Avahan has also maintained a degree of flexibility in order to make mid-course programmatic corrections.
GHD Blog: Can you describe the team at Avahan?
Aparajita: Our team is a mix of people. I’m from the private sector with a business background. Some colleagues are from public health, journalism, and communications backgrounds. We also have a mix of technical people. I think to a large extent we are driven by a business mentality, one of “are we achieving results now?” Because we’re in an epidemic timeframe, we don’t have the luxury of waiting 20 years for something to develop on its own organically. We’re very much in the driver’s seat, in the sense that we’re trying to drive a program while working with very, very complex constituents like sex workers and other core communities at risk, state and national governments, donors, and other players. So it’s a tightrope walk in many ways.
GHD Blog: As you plan to transition to the Indian government, how do you think you can transfer this kind of focus?
Aparajita: That’s a good question but is it even possible to transfer? You can transfer many methods and processes, but can you transfer the business intelligence behind it? I think it’s unclear at this point. We hope we can do it, but we understand that there are limitations to that so we do have many backup plans. We’re also strengthening communities to demand services from the government, so that they’re not just relying on us to deliver those services.
GHD Blog: What’s your take on global health delivery?
Aparajita: I think some global health delivery programmes could learn from our real emphasis on management practices, on operations and basic scaling up, and on execution. You need to deliver what’s already known, and do it at scale – this understanding is something we share with the Global Health Delivery [Project] team, and both Jim Kim and Michael Porter. I think what we’re hoping to do is build on that common vision, and really use our model as a case of an organization that delivers at scale. The bottom-line is being able to take the common vision of delivery and see what implications it has for larger policy influence and how people do things.
GHD Blog: Thank you very much for taking the time to talk with us.
The GHD Blog Interviews will regularly feature global experts and implementers’ views and recommendations on health care delivery and practice. This first interview in the series was conducted by Ankur Asthana.
