By Liz Jarman

Living Goods has provided community health services in Africa since 2007. In recent years, we have transitioned to co-financing government-led community health programs based on the belief that when governments lead, sustainable health outcomes follow.

Early on, a randomized controlled trial of our Uganda program found a groundbreaking 27% reduction of child mortality at a cost of less than $2 per person. This impressive result garnered significant attention resulting in a $35 million Audacious award—$70 million with match funding. This transformative gift allowed us to explore ways to scale our model to reach even more families through community health workers (CHWs).

We soon realized that direct service delivery alone could not solve the systemic problem of reaching underserved populations with essential health services. While our approach was cost-effective and impactful, the sheer size of the problem exceeded what any single organization could do. Meanwhile, as the biggest health providers in most countries, governments are the natural leaders and funders at scale.

The Shift to Government-Led

In 2018, we tested providing technical assistance to the Kisii County government in Kenya to strengthen their community health program. We tried this government-led model for a couple years with small improvements increasing in health KPIs—but as soon as we left, the impact was not sustained.

We learned a key insight: providing some training, phones, and capacity building wasn’t enough to drive lasting impact. So we made a few shifts addressing three critical areas:

• Performance management. We codified the elements for delivering results at scale: all CHWs needed to be digitized, equipped, supervised, and compensated (what we called DESC) for a program to be high performing.
• Government commitments. Genuine government buy-in is necessary, as is a shared vision and co-financing agreements for stronger ownership.
• Enabling environment. We needed a greater focus on advocacy to ensure more conducive policies, financing, and budgeting.

In 2019, we tested the prototype of this government-led strategy in Isiolo County. We entered a 5-year co-financing partnership, with government gradually increasing their funding and DESC starting to be more consistently in place, while Living Goods provided hands-on coaching on performance management. This prototype led to more lessons learned, including around contracting, managing political transitions, and upskilling government supervisors in a different way than in our direct operations.

Kisumu Exemplar

In 2021, we launched a government-led model in Kisumu, our first exemplar county. This initiative has significantly improved health outcomes. For example, maternal mortality decreased by 30% due to more skilled hospital deliveries, and child mortality fell from 54 to 39 per 100,000 live births. We have since scaled this approach to Vihiga and Busia counties in Kenya supporting more than 5,000 CHWs.

Our co-financing model follows a phased approach:

• Phase 1 (1 year): Work to find the right government partner and a strong enabling environment. Begin co-creation and align on outcomes, roles, and financing.
• Phase 2 (2-3 years): Fully scale the community health program with a high ratio of Living Goods to government staff at every level. Co-create improvement roadmaps, institutionalizing payments for CHWs through finance bills, enhancing data-driven decision making and performance management approaches, and supporting supply chain improvements and digital tool optimization.
• Phase 3 (4-5 years): Gradually reduce the level of Living Goods staffing and investment as the government’s performance management approach improves and DESC elements are institutionalized.
• Phase 4 (5+ years): Transition to a quality assurance role with minimal Living Goods staffing.

Progress and Challenges

This new model has proven to be more cost-effective than direct service delivery, allowing us to double our reach for every dollar spent.

It is also more sustainable, providing proof of concept that government-led co-financing works and can significantly improve health indicators. Sites using this model achieve approximately 70% of the health key performance indicators in our ‘gold standard’ direct service delivery, which is very promising.

However, scaling this model nationally even at this lower cost remains a challenge. We see this approach as a steppingstone for national adoption of these practices. By shifting the approach from simple data collection to performance management, governments can achieve significantly improved health outcomes.

The Future

With these exemplars thriving, we are seizing the opportunity to refine our partnership model and build on the incredible momentum driving the professionalization of CHWs in Kenya and beyond. Our commitment to partnering with governments remains unwavering as we work to build sustainable, high-impact community health systems that transform lives—especially for women and children—delivering lasting health improvements where they’re needed most.

As I prepare to transition leadership, I am confident that the incoming CEO Emilie Chambert will guide Living Goods into this next chapter with excellence. Emilie brings deep expertise in programming and has a history of working closely with governments. Her leadership will undoubtedly help Living Goods expand its reach and improve health outcomes for more families in the years to come.