Emily Bancroft is President of VillageReach, an organization that works to transform health care delivery to reach everyone. VillageReach won the Skoll Award in 2006. Its initiative in Malawi, Chipatala cha pa Foni, a toll-free hotline that provides health and nutrition information to people in remote communities, is an international model for closing rural healthcare gaps.
VillageReach recently transitioned Chipatala cha pa Foni successfully to the Malawian Ministry of Health which has made the service its primary platform for COVD-19 information. James Nardella, former Skoll Foundation Principal and current Chief Program Officer for Last Mile Health, sat down with Emily in April of 2019 to talk about her personal journey to this work, why government partnerships are a crucial lever for systems change, and her vision for global health equity. James started the conversation by asking Emily what she wanted to be when she grew up.
EMILY: I absolutely wanted to be a marine biologist. I was gonna swim with dolphins. There were no dolphins in Maine, it’s cold there. The ocean is cold, but I was sure that was what I was gonna do. That was first, but then I wanted to be a doctor. It’s a bit of a typical question, typical answer for somebody who works in health, but I think at the time it felt something more realistic than, than the marine biologist answer.
JAMES: But as an undergrad you studied religion, right?
EMILY: I did, and that’s actually a really interesting story. I started out pre-med and I think the path of getting there–when I was a junior in high school I had the opportunity to travel. I had a good friend whose dad was a pediatric surgeon and he worked–every year he’d go down for two weeks to Haiti and he worked at the hospital there. And he was the only pediatric surgeon who was at the hospital regularly.
And so he did this two week rotation and they would save up cases for him to come. And I went one year. They always went on Thanksgiving, and one year my friend asked me do you want to come along with me? So I went and spent two weeks at the hospital with her, and her family and her dad.
And I got to be in the hospital, see what rural health care looked like. The hospital is a very good hospital in Haiti, but in a very rural area. Got to see this issue of people literally waiting. I mean I, I got to come into one of his surgeries and it was a, a girl that had been waiting. She had an obstruction and she’d been waiting for nine months for him to come and do this surgery.
And I remember just feeling it was such a wake up call for me of like this is what healthcare looks like, this is what healthcare looks like around the world. And I got to follow along with the doctor and we were young and they didn’t really know what to do with us, but we were around for two weeks.  So one of the doctors was very nice and let me shadow her and spend time watching what she did.
And it was an incredible formative experience and it was a huge privilege, so I happy to be able to do that sort of travel when I was younger, and so far from what my experience had been, obviously, growing up.
And it was, it was just one of those, those moments in time that you always remember. But what she changed was I got into college and started going down the path of being a pre-medical student, and university where you could make a choice, but medical wasn’t a major. It was just a set of classes you had to take. You could do something else.
So I was gonna be molecular biology major because that’s, it seemed like the right thing to do if you wanted to go on a medical track. And the summer after my sophomore year in college, I went back to Haiti and I felt like Haiti had been sort of this formative experience of that’s where I decided oh yes, I really want to be a doctor instead of a marine biologist.
And so I went back and this time I sort of pieced together some things I could do while I down there. One of them was spending time in a clinic in City Soleil, one of the urban settlements in Port-au-Prince that many people know because it’s sort of notorious for being one of the largest of urban slums in the world.
And the clinic was so incredibly under-resourced. I mean I was there with–there were a few other volunteer doctors and a few Haitian health providers that were there, but there was absolutely nothing that we could really do for a lot of the patients that came in. And it was in that clinic, in that moment that I realized that this wasn’t really just about high school, but what people were coming into the clinic for was really about poverty, was really about other things going on in their life that healthcare was really just a bandaid for.
JAMES: Right.
EMILY: And I had this moment of medicine is incredibly important, doctors and nurses are incredibly important, but there’s something bigger here and there’s something that this clinic can’t provide that’s desperately needed.
So I started down this big journey of well what else is out there. And I think when I was in school, if you wanted to study medicine, you were a doctor. There was no arg–or if you wanted to study health, you were a doctor. There was no other pathway that had been offered out to me and health and medicine were inextricably linked in my mind. And my experience in Haiti sort of made me go wait, this is isn’t–heath is not just about medicine. Health is about a lot of things.
And so I got back, thought, I don’t really want to be in the lab. I want to be something different, I didn’t have to have that choice at the time. And I really wanted to understand culture, and I really wanted to understand why people make the choices that they make.
JAMES: I follow you. I think about how Paul Farmer draws on the, some of the theology around, what’s his name, like theology of the oppressed and
EMILY: Yes.
JAMES: Gutiérrez, is that his name? But the whole notion that–and Paul Farmer draws on this preferential option for the poor that’s a theological idea. It’s based not in healthcare alone, but in the experience of materially poor people. And even in my own experience of running a healthcare program in Kenya, I saw so frequently how materially poor people don’t express their poverty in a single sector or dimension. They don’t say if, if only my child were well, all things would be made right.
They think about their family’s needs in these multiple dimensions, right…the my child is sick, but I’m also concerned about her school life, and I’m concerned about her safety and the violence that she might face.
Or I’m concerned about her rights, and her ability to make a living, and how she might be treated in the world. All those things. I mean anyone who is a parent understands that we don’t separate those different dimensions of our child’s humanity, so why would we expect any patient to do so.
And people are bringing their, their whole selves into a hospital, or into a clinic, or into anything that they do. And so how is, how is public health, how is healthcare, how is medicine addressing people as whole human beings.
EMILY: Yeah.
EMILY: It’s a little ironic that I’ve just told this story about my personal journey in this space. And I work for an organization that does believe that healthcare access, right, and we focus on ensuring that there’s quality access for the world and underserved communities. And so sometimes in my mind I have to reconcile these two because I know that that is not the only aspect of what makes somebody healthy. And that’s been embedded in a lot of my previous work.
But I think the reason that I do feel that this is so important is because there are a number of key things that need to be in place for someone to live a healthy, fulfilled and prosperous life, but we know that people spend–that a healthcare event or a lack of access to care when you need it can be a completely devastating event to a family or to an individual. And we see that in the United States.
We see that in other countries. This is not–this is a humanity problem,  not a problem that’s unique to any one geography, so although I strongly believe it’s not the only piece of the puzzle.  I do believe that that access point to healthcare, whether it’s a community health worker, whether it’s through a hotline that connects you directly to a healthcare provider who can speak to you and actually spend time speaking to you, and help you understand your options, whether it’s information that you access through your friends and your community…I mean these are critical components of making sure that, that when you need care it’s there for you. And if that care is not there, it can be devastating.
And so it’s not the only piece, but I feel like it is an incredibly important piece of the puzzle, and if I can help to make sure about the places that we work are not like that facility that I volunteered at in Port-au-Prince, where there was literally nothing on the shelves. There was literally nothing we could provide to people.
If we could make sure that when somebody does go to access care,  the medicine is there. That the trained health workers are there. That the health workers can spend time with them, that their questions are answered…that they receive the diagnosis they need and the information they need, that can be sort of a shifting of that.
JAMES: But even health equity as a movement has–I would call it a theology behind it, right? It has a belief in human dignity and a belief that all people are deserving of a basic amount of healthcare as a part of their human rights. And that has to do with something we believe as much as a set of services that need to be delivered.
EMILY: Absolutely.
JAMES: And that in my mind is the glue that holds a lot of disparate actors together, whether they’re working in community health, or supply chain management, or hospital based care, a belief that all human beings, regardless of where they were born, deserve healthcare and that where you are born shouldn’t decided whether you live or die. That’s actually, that’s a theological belief or it’s ideological if nothing else.
EMILY: Yeah.
JAMES: I wonder how having studied religion relates to that.
EMILY: It does and it absolutely is, I would say, a theological belief. And it’s that piece of, there are certain, there are certain basic things that we need as human beings. Healthcare is one of those things. We know how to fix so many of the problems, so many of the diseases, so many of the sicknesses that we see. And if we can, we live in a world of incredible inequality and increasing inequality, and if we can’t strongly believe that there’s no reason that, I walk into a facility and have an array of options in front of me; whereas somebody else can walk into a facility in another place and not only not have access to the medicines that they need, but they may not be treated in a respectful or fair way — there’s no reason for that.
We know what to do and it’s just a question of how we do it. I had the benefit at one point in my career to work with Physicians For Human Rights. And it was a really, I think of it as a two-year fellowship with them, working specifically with health professionals in sub-Saharan Africa to really help them use their voice for advocating for the working conditions and the needs of their patients because Physicians For Human Rights was built around the idea that health workers professionals really respected members of the society and educated the or the research behind a lot of the knowledge base that we have behind healthcare.
And if we can engage that voice throughout the world in speaking up for the fact that healthcare is a human right and the fact that everybody does deserve equal access to healthcare. That can be a powerful mechanism. So that was a really amazing experience to get to have to work with healthcare professionals in sub-Saharan Africa and to really see them use their voices to talk about the conditions that their patients were facing and what solutions needed to be in place to address those conditions.
JAMES: Let’s talk about Village Reach. When someone outside of global health asks you what is Village Reach, how do you describe your work? I just think–what do you say to your next door neighbor or a parent of your son when you’re asked what you do?
EMILY: Yeah, I say that what Village Reach cares about is that everyone has access to healthcare, and the way that we do it is in looking at what is it that the health worker needs in order to deliver their job effectively, and what is it about community in order to access them.
I talk a lot about how we believe in a world where nobody will lack access to treatment because medicine aren’t there and the way that we do that is to make sure that health workers have everything that they need to do their job effectively, and that communities have what they need in order to access that care.
And so I’ll talk about how we really believe that no patient should ever, no community should ever lack access to the treatments that they need because the medicines aren’t actually there where they need to be. And how every person then in the healthcare system needs to be able to make decisions about their own health or the health of the communities that they serve. And that data and information is needed to help them do that.
JAMES: in the work that Village Reach does, what’s most fulfilling to you personally?
Emily: I love seeing the idea that hatches as something really small coming from a really investing idea that somebody had in a community and actually seeing that come to fruition into that’s impacting millions of people. So I’ll give you an example: When I, early on in my time at Village Reach, there was a competition that was running where the ministry of health asked people–wanted you to come up with what was their idea for how you could really improve access to, to really improve the lives of women and children.
And so they got thousands of responses from community, and they called three dozen and went through a process. And the winning idea was this idea that there should be very simple. Right now in Malawi, we’ve done time motion studies that have shown this that providers give about 90 seconds talking to a patient and…
JAMES: 90 seconds.
EMILY: 90 seconds, so imagine that you’ve gotten to the health facility. You have–you’re ill, your child is ill, you’re trying to explain what’s wrong, hear what the provider has to say, find out what you’re supposed to do about it and that’s all happening in 90 seconds, a 90 second interaction.
And so this true social entrepreneur I would say, his name is, he had been working in technology and he believe that there was a way to use phones and simple technologies to makes sure people have another point of access to a healthcare facility that  wasn’t just walking into.
And this seems like a no-brainer to us.  I mean I use at home, my doctor’s office hotline to call if my son is sick and I don’t know whether his ear is hurting…should I do something about it, whether I need to come in or whether I can just do something at home. I look up things online. There are all sorts of ways that I access information as a consumer.
JAMES: Right.
EMILY: And those are ways that aren’t always open to somebody in a poor community in Malawi. And so he thought there’s something I can do about this, so at Village Reach we had the opportunity to work with to actually try to bring this idea to fruition. And so at first it was just a small district-wide proof of concept idea where we worked with in his, the technology firm he worked with to develop a hotline system that would link into the electronic medical record system that was being piloted in Malawi, where when people called in to the hotline they would get registered into the health system. They would also have somebody to talk to them.
And I remember when we first started rolling this out in the community and first started–and this was in 2011, so it’s quite some time ago, I really didn’t know if people would pick up the phone and call, because we’re talking about a very transactional, like this is a community where personal relationships and, sort of speaking to somebody one on one is how information is often heard and traveled through.
Asking people to pick up a phone and something that was generally used to make the quickens exchange of information possible because phones are expensive, asking them to to pick that up and actually imagine that the person on the other end of the line could give them some useful information that might be helpful to them, I just wasn’t sure that it would work.
But it did. We found that people were spending about 10 minutes with hotline workers, and that’s a huge difference of spending 90 seconds versus 10 minutes. And we found that people then coming to the health center were actually more consumers of what they needed and that health workers were commenting that those, they could tell those that had used the hotline because they were coming in at the right time and were coming in with the right questions, with the right information.
And so that has now scaled up to something that the ministry of health has provided to 18 million people across Malawi, and it started from this idea that this one person had about how something could be different based on what he had seen in his talking with others, and traveling and seeing things in other parts of the world.
So that to me is the most exciting thing when you can take an idea and actually put it into action, and then see it get integrated into a health system to the point that when I was most recently in Malawi and I was talking with the director of clinical services in Malawi, he said oh, well this service, I mean this is an essential part of our primary healthcare system that puts a healthcare worker into every single household in the country. And that’s what we need.
JAMES: So it’s gone from like a seed of what was possible to something that was–I don’t want to say taken for granted, but now
EMILY: Is an essential part of the primary healthcare system, right, the same way that the national health service hotline here in the UK is seen as an essential for the healthcare system, but to hear that, to think about that had, and then to hear the director of clinical services say oh, this is an integral part of our family healthcare system, we did not know that that’s what that would become.
I want to broaden our, our scope. Just take a minute and think with me, what’s the world that you’re working to create?
EMILY:  It’s, it’s that just world that you just talked about, James. It’s, it’s the idea that no matter who you are, that if you need access to healthcare, that access is available to you. And that’s available in a quality way, so that’s a world where, children thrive. It’s a world where we see communities really rising up and reach the full potential.
Healthcare is not the only thing as we’ve already discussed, but without good health, you can’t finish your education. Without good health you can’t engage in the economy. So the world that we want to see is one where health is not the, the, the–it’s the enabling factor, not the
JAMES: Impediment, right
EMILY: Or the impediment.
JAMES: What stands in your way?
EMILY: I think we are in a world right now where there’s a real scarcity mindset, a fear that we can’t meet the needs of everybody in the way that I think those of us in higher income countries have consumed–that we can’t build a healthcare system that looks the way a healthcare system does in the United States.
It’s not a just healthcare system there either. It’s a high resourced healthcare system that leaves millions of people behind. And yet we’ve set up this paradigm that,  we don’t, we don’t even know how to, how to break out of that and how to say that if we could all figure out a different model that worked for everybody, we could stretch those resources farther.
And instead right now what we see is this sort of fear that we can’t meet the demand, and therefore we have to somehow, limit that demand as opposed to an expansive view of where resources could be distributed differently and in a way that makes, basic primary healthcare and the care people need available to everybody.
JAMES: So you think it’s an issue with mindset, not an actual limit on the resource?
EMILY: I think that we live in a world where there are infinite resources, really, for the things that you care about and the things that you prioritize. I mean I don’t–that sounds naive and that sounds overly optimistic, but the truth is we make choices all the time about what we spend in. We limit ourselves, I think, by saying it’s not possible. I mean this is what I think, Partners in Health has been absolutely incredibly influential in this field, right, in saying there isn’t a healthcare system that’s appropriate for low resource environments.
We need a model that works for everybody and everybody deserves that model. But if the high resource environment is going to, consume more of–I mean this goes for many things in the world, but if we’re gonna over consume our share of the pie, then there isn’t going to be enough to go around. And we need to shift that mentality.
JAMES: You started leading Village Reach basically at the start of 2018, but you’ve been at the organization for some time. What have you learned by making the leap from being a senior staff to being its executive leader?
EMILY: One of the most important things I’ve learned is how to be a good listener. I think that every organization goes through its cycles of, how you do you change as an organization in different phases of your development, and I think, our early phase was about real innovation and real sort of creating a new norm for how, how health services could be delivered.
Our second phase was about figuring out how to really influence global actors to accelerate that change throughout the country at a global level.
And I think our third phase is about stepping back and listening better. And I say that because it’s both internal, we are a very different team than we were. We now have 175 staff spread out in multiple different countries, and how do we make sure that we’re really suing the best of what our staff know in the deep experience that they have into our market and to saying, how are we really address healthcare delivery challenges and are we addressing the right ones, and are we bringing in all of the expertise as well as how do we listen better to what our government partners want, to what communities want.
So that we’re really ensuring that we’re not stuck on the problem as we think that it needs to be solved based on working on this for 18 years, but we’re instead really pivoting to ensure that we’re bringing the, the way our government partners really feel need to be solved at this point.
And so I think taking over the leadership of the organization provides that opportunity to say I have this deep knowledge and I’ve worked with many of our partners for the nine years that I’ve been in Village Reach, yet at the same time, I’m a different leader, and I’m a new leader in the space.
JAMES:Â I’m wondering can you just talk us through your framework from learn, to develop, to scale and sustain? Give us a real example that helps us understand that pathway.
EMILY: Sure.
I think the learned developed skill and sustains framework that we use is a pretty typical innovation pathway, right. I think there are some differences in how that manifests maybe in a more private sector, market based solution to how it manifests in a system, trying to work in a public system, ends with a sort of a complex solution problem.
But basically what we talk about internally is that, our first goal is to a bit of a de-risker to government, to really learn about a problem and to study that problem deeply. And t look and say what are the different ways that this problem will be solved, and to look beyond just, you what are, what are the things that we can really look at and develop a solution, in partnership with the government that can be tested in some way.
JAMES: What’s an example problem?
EMILY: Sure, so looking at supply chains, and this goes back, we’ve been sort of iterating on this particular piece of the solution for this particular problem for a long time. How do you make sure–and I’ll just use the station example because it’s very clear. How do you make sure that having vaccines where they need to be is not very. Again, as I said, there’s still how do you make sure that’s not one of them.
So what we did there was we said okay, well let’s look at the resources that are available in rural areas in Mozambique, we’re doing in Democratic Republic of Congo now. But how do you sort of look at what a supply chain needs and what those resources are in the community, and how do you develop something that you can test.
We basically developed what now is I think a very widely accepted practice of you need a trained person who’s responsible for managing the supply chain. You need a transportation route. That means are resourced and gets medicines up to where they need to be, pass things out where they need to be.
You need a data system that supports who–where your medicines need to go, and where and that. And you need to have the correct financing through the government systems to make that work. And so, originally the financing in the early stages of learning and developing a solution, we have to provide more of that capital to test the solution.
And then once we’ve done that and tested it, and show in fact we can reduce costs for the government…they can get their children vaccinated. They can get supplies where they need to be and the next step is to say okay, now Village Reach could try to scale themselves, but we won’t get very far, so are the impacters of the ecosystem who really need to be the ones to take the solution to scale. And that’s where we move into the scaling system.
JAMES: So here at Skoll we are fostering community. Community involves reciprocity, right, the right to give, receive, ask for and return help. Thinking about our listeners and the community that surrounds the Skoll World Forum, what do you need from those who are listening? And what would you be able to offer?
EMILY: I think what I need is I need to be pushed to make sure that we’re really using our voice and our resources to address most clinical challenges. And one example that we know is, I think, is we have a responsibility to really look at how climate is interrupting health, and yet that’s not something that I think the health community is doing, so I feel like from this community I need those people that keep you honest.
Are you really digging deep enough to make sure that the work you’re doing is contributing in the best way possible to solve some of the most pressing problems facing the world right now and how do we–so I need that, I need that reality check sometimes of, are we doing enough, are we going far enough.
In terms of what we can give, I think I feel strongly that Village Reach has learned both through hard work, humbling experiences and a lot of really great people coming together across the globe to solve problems together, that we’ve really come up with some great lessons around what it takes to integrate your work into public health systems and government systems…and the steps it takes to get there.
And I’m so excited to share that, but also to have all of those push us on that and say but here’s what you didn’t think of, or here’s what we did, too. And so I love that we can sit down with another organization and talk about our models and how we see this sort of shift of governments really taking in this work and scanning it in a way we can’t… how that helps us and how others do it. And I’m excited to have those conversations.
