Investments in this strategy aim to supply essential services and products by developing new transport methods to reach previously inaccessible areas, improving supply chains, and establishing novel community-centered service delivery models to ensure rural populations have access to basic services. The sections below include an overview of the strategy for achieving desired goals, supporting evidence, core metrics that help measure performance toward goals, and a curated list of resources to support collecting, reporting on, and using data for decision-making.

What

Dimensions of Impact: WHAT

Investors interested in deploying this strategy should consider the scale of the addressable problem, what positive outcomes might be, and how important the change would be to the people (or planet) experiencing it.

Key questions in this dimension include:

What is the problem the investment is trying to address? For the people experiencing the problem, how important is this change?

Around the world, and especially in emerging markets, people face countless challenges accessing essential medical commodities (e.g., vaccines, blood transfusions) and services (e.g., skilled birth delivery). This strategy seeks to break down barriers to accessing health care through supply-chain innovations (for access to commodities) and innovations in community engagement (for access to services).

Investments in this theme can improve health outcomes through the following means:

  1. Innovative delivery and transport methods can open access to areas that were previously inaccessible due to difficult terrain. In emerging markets, infrastructure quality exacerbates challenges of physical access, making investments in delivery methods particularly helpful.
  2. Supply-chain innovations can reduce the waste or spoilage of time-sensitive products, such as vaccines.
  3. Technological innovations can deliver crucial services, including health-related information, to rural or hard-to-reach populations.
  4. Outreach-based, community-centered delivery models can improve access to health services in rural areas.

What is the scale of the problem?

The inability to access commodities and services have extensive, diverse implications for global health outcomes.

In maternal health, for instance, there can be many barriers that prevent access to services. Many emerging-market countries feature high maternal mortality rates, attributable largely to lack of skilled attendance at birth (1). Postpartum hemorrhage, frequent in the absence of skilled birth oversight, accounts for 100,000 annual deaths worldwide, or roughly 60% of maternal deaths in developing countries (2). (Strategies that mitigate insufficient access can also address postpartum hemorrhage.)

Vaccinations are a commodity aspect of health care in which obstacles to access, particularly those related to delivery, have immense human consequences. Ten percent of children worldwide did not receive a single vaccination in 2017, leading to countless preventable deaths. Concurrently, 20% of distributed vaccines are spoiled due to high storage temperatures (3), with the resulting shortages and impotent vaccinations leading to unvaccinated children.

Who

Dimensions of Impact: WHO

Investors interested in deploying this strategy should consider whom they want to target, as almost every strategy has a host of potential beneficiaries. While some investors may target women of color living in a particular rural area, others may set targets more broadly, e.g., women. Investors interested in targeting particular populations should focus on strategies that have been shown to benefit those populations.

Key questions in this dimension include:

Who/What is helped through this strategy?

Access to essential medical commodities and services affects many different stakeholders. Below are some groups of people who are most critically and directly impacted by innovations in access to such commodities and services.

Pregnant Women: Pregnant women can greatly benefit from improved access to medical commodities and services. Each year, 287,000 women worldwide die giving birth; innovations in both access to services (e.g., skilled birth attendance) and essential commodities (e.g., oxytocin, which can prevent postpartum hemorrhage but is sensitive to temperature and humidity) could prevent many of these deaths (4).

Infants and Children: Innovations in product and product delivery throughout the supply chain could greatly improve rates of vaccination in children. New methods of storing vaccines for and during delivery, innovative temperature- and humidity-resistant vaccines, and generally improved supply chain logistics can increase vaccination coverage, thus averting child deaths and improving cognitive development (5).

People in Rural Areas: Geographic remoteness presents one large, persistent obstacle to universal health coverage (6). Innovative methods to deliver products and services can facilitate access to health care in remote areas.

People in Geographically Inaccessible Areas: Distance is not the only geographic barrier to universal health coverage; untraversable terrain also prohibits access to products and care. Innovations in supply chain and service delivery can help reach populations in these previously inaccessible areas.

People Affected by Stigma:  In practice, some populations may be prevented from accessing essential medicines and services because of social stigmas around their particular needs, especially for mental health needs. Innovative outreach or educational models can help those affected overcome the social barriers to receiving care.

Providers: Health care providers who face common shortages of essential supplies, due to any of the conditions described, also stand to greatly benefit from innovative models of product delivery.

What are the geographic attributes of those who benefit?

Rural populations in poor countries have the most to gain from investments in this strategy. Geographic remoteness prevents access to both essential medical products and services; for instance, vaccination rates in rural areas are consistently lower than those in urban areas across low- and middle-income countries (7).

Populations living in areas of inaccessible terrain also face challenges that this strategy seeks to resolve, whether these challenges result from geographic factors, either natural (e.g., mountain ranges) or man-made (e.g., insufficient infrastructure and roads).

Finally, geographic barriers, especially remoteness, also inhibit access to essential medicines and services in developed-economy contexts, in addition to emerging markets.

Contribution

Dimensions of Impact: CONTRIBUTION

Investors considering investing in a company or portfolio aligned with this strategy should consider whether the effect they want to have compares to what is likely to happen anyway. Is the investment's contribution ‘likely better’ or ‘likely worse’ than what is likely to occur anyway across What, How much and Who?

Key questions in this dimension include:

Is the investment’s contribution ‘likely better’ or ‘likely worse’ than what is likely to occur anyway across What, How Much and Who?

In the absence of investment, at least two factors might facilitate greater access to essential medical commodities and services for the populations this strategy seeks to target. First, rapid urbanization in emerging markets will lead to proportionally fewer people living in rural, hard-to-reach areas (8). Second, infrastructure in emerging markets will continue to improve with investment by governments and their foreign partners. However, both these trends are long-term, requiring substantial resources and representing immediate opportunities for investors. Investors might also focus on those areas least experiencing or least likely in the future to experience these trends in urbanization and infrastructure development.

How Much

Dimensions of Impact: HOW MUCH

Investors deploying capital into investments aligned with this strategy should think about how significant the investment's effect might be. What is likely to be the change's breadth, depth, and duration?

Key questions in this dimension include:

How many can receive the outcome through this strategy?

This strategy can most influence the roughly 3.4 billion people worldwide living in rural areas (9). Though not all people in rural areas lack access to essential medical products and services, rural populations worldwide generally face worse health outcomes and greater barriers to access (10).

Moreover, most of the global rural population lives in Africa and Asia, where many of the challenges to providing essential medical commodities and services are often exacerbated by relatively high temperatures (affecting, among other things, the viability of vaccine cold chains) and lower incomes (introducing a financial barrier to access that amplifies geographic barriers) (9).

Different deployment methods for this strategy may benefit from specialization depending on context. For instance, innovative community outreach models to bolster service provision in rural areas may be difficult to adapt across contexts, while supply-chain innovations (e.g., drone delivery) face fewer obstacles to scale.

How much change can beneficiaries experience through this strategy?

Access to essential medical products and services is often binary: patients either receive or do not receive a certain treatment, vaccine, or other medical intervention. Treatments, if received, may directly save lives. Consider several examples of impact on both supply-chain efficiency and ultimate outcomes through both product- and service-based models of supply expansion:

  • VillageReach provides technical assistance in Mozambique and other low-income countries to streamline medicinal supply chains and reduce logistical costs and stockouts, thereby improving health outcomes. An independent evaluation showed that VillageReach's system improved cost-effectiveness by 17% and reduced monthly stockout incidence rates in rural facilities from 80% to 1% (11).
  • The Children's Investment Fund Foundation conducted a three-year, randomized evaluation of Living Goods' community-based entrepreneurship model in Uganda, showing a 27% reduction in under-five mortality. Through this model, entrepreneurs are trained and equipped with lifesaving products for deployment in rural, poor communities (12).

Risk

Dimensions of Impact: RISK

Key questions in this dimension include:

What risks do investments in this strategy run in terms of either people/planet experiencing impact or society as a whole? What is the probability that those risks happen?

Risk factors for this strategy include the following:

  1. Execution Risk: Investments using this strategy that aim to expand service provision through community outreach may require tailoring to context. Execution risk may therefore arise with insufficient adjustment to context either (a) in the project’s initial design or (b) during the path to scale, if that path has a more varied context than expected.

  2. Stakeholder-Participation Risk: Investments that seek to expand service provision through community-based outreach may also fail to account sufficiently for the experience of both outreach workers and patients.

  3. Drop-Off Risk: Investments in rural supply-chain innovations may have substantial initial impact, but urbanization, greater integration of urban and rural populations, and improvements to infrastructure over time may reduce this initial impact—or its necessity.

All three risks are minimal for most investors. Community outreach models are typically designed to remain engaged with stakeholders and aware of their needs, and rural populations will likely always benefit from improved supply chains and innovative methodologies for supplying products and services.

What are likely consequences of these risk factors?

Risks for this strategy will more likely dilute potential positive impacts than produce negative ones. For instance, improvements in infrastructure may reduce the impact of investments in this strategy over time by naturally counteracting geographic disparities in access to essential products and services, but innovations in the supply of those products and services will probably not yield negative consequences in the present.

Illustrative Investment

Zipline is an early-stage drone delivery service providing hard-to-reach areas with critical access to lifesaving medical products. The model is simple: remote health workers send an SMS text to request essential medicines and supplies. Those supplies, staged at centralized distribution centers, are delivered to the point of care by drone less than thirty minutes after takeoff. Speed is crucial; since launching in October 2016, approximately one-third of Zipline's flights have been in life-threatening situations. The company now supplies 20% of Rwanda's blood supply outside of Kigali, recently expanded to Tanzania, and plans to expand to the United States in 2018 (13).

Draw on Evidence

This mapped evidence shows what outcomes and impacts this strategy can have, based on academic and field research.

NESTA: 3
Banking the Poor Via Savings Accounts: Evidence From a Field Experiment

Prina, Silvia. “Banking the poor via savings accounts: Evidence from a field experiment.” 2013

NESTA: 3
Savings Constraints and Microenterprise Development: Evidence from a Field Experiment in Kenya

Dupas, Pascaline, and Jonathan Robinson. “Savings constraints and microenterprise development: Evidence from a field experiment in Kenya.” American Economic Journal: Applied Economics 5, no. 1 (2013): 163-92

NESTA: 4
Risk Sharing and Transaction Costs: Evidence from Kenya's Mobile Money Revolution

Jack, William, and Tavneet Suri. “Risk Sharing and Transactions Costs: Evidence from Kenyas Mobile Money Revolution.” American Economic Review 104, no. 1 (2014): 183-223

NESTA: 3
Smoothing the Cost of Education: Micro-Savings in Ugandan Primary Schools

Karlan, Dean, and and Leigh Linden. “Smoothing the Cost of Education: Micro-Savings in Ugandan Primary Schools”

NESTA: 3
Expanding Credit Access: Using Randomized Supply Decisions to Estimate the Impacts

Karlan, Dean, and Jonathan Zinman.“Expanding credit access: Using randomized supply decisions to estimate the impacts.” The Review of Financial Studies 23, no. 1 (2009): 433-464.

NESTA: 3
Payment Mechanisms and Anti-Poverty Programs: Evidence from a Mobile Money Cash Transfer Experiment in Niger

Aker, Jenny C., Rachid Boumnijel, Amanda McClelland, and Niall Tierney. “Payment mechanisms and antipoverty programs: Evidence from a mobile money cash transfer experiment in Niger.” Economic Development and Cultural Change 65, no. 1 (2016): 1-37.

NESTA: 3
Do Rural Banks Matter? Evidence from the Indian Social Banking Experiment

Burgess, Robin, and Rohini Pande. “Do rural banks matter? Evidence from the Indian social banking experiment.” American Economic Review 95, no. 3 (2005): 780-795.

NESTA: 2
Expanding Banking Access to the Rural Poor in Kenya: Challenges and Opportunities

Dupas, Pascaline, Sarah Green, Anthony Keats, and Jonathan Robinson. “Challenges in Banking the Rural Poor: Evidence from Kenyas Western Province.” 2012. doi:10.3386/w17851.

NESTA: 3
Interest Rate Subsidies and Savings Behavior in Kenya

Schaner, Simone. “Interest Rate Subsidies and Savings Behavior in Kenya”, 2009

NESTA: 3
The Long-Run Poverty and Gender Impacts of Mobile Money

Suri, Tavneet, and William Jack. “The long-run poverty and gender impacts of mobile money.” Science 354, no. 6317 (2016): 1288-1292.

Each resource is assigned a rating of rigor according to the NESTA Standards of Evidence.

Define Metrics

Core Metrics

This starter set of core metrics — chosen from the IRIS catalog with the input of impact investors who work in this area — indicate performance toward objectives within this strategy. They can help with setting targets, tracking performance, and managing toward success.

Additional Metrics

While the above core metrics provide a starter set of measurements that can show outcomes of a portfolio targeted toward this goal, the additional metrics below — or others from the IRIS catalog — can provide more nuance and depth to understanding your impact.