North Star Alliance is providing much-needed health care to Africa’s mobile workforce, such as truck drivers and sex workers at high risk for HIV infections. To discuss the group’s work, Wharton management professor Aline Gatignon spoke with Luke Disney, North Star’s executive director, a position from which he recently stepped down. Gatignon has done research on creating optimal partnerships to tackle socio-economic problems using data from North Star, in conjunction with the Mack Institute. The research also is part of a joint project through the Wharton-INSEAD Alliance and conducted with INSEAD Prof. Luk Van Wassenhove and doctoral candidate Julien Clement.
An edited transcript of the conversation follows.
Aline Gatignon: Can you tell us a little bit more about the work that North Star is doing?
Luke Disney: North Star Alliance was set up in 2006 by the United Nations World Food Program, with support from TNT Express, an express delivery transport company. [At the time, HIV] was having a devastating impact on supply chains in Africa, particularly sub-Saharan Africa. So, from the World Food Program’s perspective, this was really about their humanitarian supply chain. They were trying to get food from ports out to hungry communities. And in particular, in 2003, 2004, they were responding to a crisis in southeastern Africa. They noticed that they couldn’t find enough trucks to move the food from the ports out to the communities. And this was strange to them, because normally they’re pretty well prepared for crisis situations in these vulnerable areas. They have a list of all the transport companies, they’ve made estimates on the capacity.
But what they hadn’t calculated into their model was the impact of HIV, which was, you know, on the rampage at that point in this part of the world. … The local companies whom they rely on were losing truck drivers at an enormous rate. And that, as a result, was affecting their ability to deliver food. At the same time, … when they did analysis into the situation, they also discovered that the very supply chains they were setting up — and you’ve got to think of long supply chains, hundreds of trucks in some cases, going into areas for periods that can be up to two years in the case of a protracted relief and recovery operation — were also a factor in spreading HIV.
So, you had these communities – isolated or relatively isolated — which all of a sudden have this huge influx of truck drivers coming in. And at that point, they got very concerned, not only because of their own supply chain risk, but of course the ethical implications of trying to do good and at the same time, inadvertently bringing harm to some of these communities.
I remember the first time that I was in Africa, in an isolated community, when I actually met somebody who had full-blown HIV. It was a truck driver named Edward. And he was lying on his back in a hut in the middle of nowhere, literally. And you were just thinking to yourself, “How in God’s name did HIV get to this place?” And the fact that he was a truck driver is probably how he contracted it. And sadly, he brought it back to his village where he infected other people. So that was WFP’s part of the story.
“The local companies whom they rely on were losing truck drivers at an enormous rate. And that, as a result, was affecting their ability to deliver food.”
TNT Express, at that point, was busy expanding in sub-Saharan Africa and of course, as an express delivery company, also very reliant on the transport sector as a backbone to move packages, in this case commercial goods. So together, they had already started working together on improving logistics of food delivery. And they then turned their attention to this issue. And really, coming at it from a logistics perspective, as opposed to from a traditional public health perspective, they started to say, “Right, well, what’s the problem here?”
And the problem is that in sub-Saharan Africa and other places, truck drivers spend an enormous amount of time away from home in Africa. Long distance truck drivers can be away easily, for up to 22, 26 days a month, on these long trips, spending an enormous amount of time at truck stops, which are isolated, parked on the side of road where they interact with women who have been forced into sex work because of the lack of other economic opportunities — women who have no other way of making their living and feeding their families.
So you get these hot spots — what we call disease hot spots — growing around these truck stops, border crossings, ports. And this is where you get high risk groups like sex workers interacting with what we call bridge groups, truck drivers, who then take the disease — HIV in this case — back to their families. And it’s not just diseases like HIV. We also see for example, in the recent Ebola crisis in West Africa, that mobile populations again, play an enormous role in spreading the disease from one place to the next. So that’s how the whole thing got started. And the philosophy was, well if it’s happening at these hot spots, then the traditional health infrastructure of hospitals in highly dense populations in cities and towns is not going to work. We need to get the facilities or the services out to the people in these areas to prevent the disease from being transferred in the first place.
So we started by setting up small container-based clinics. We used shipping containers because they’re cheap and easy to manufacture, move around and also to control the quality. And if you’re inside one, it looks like a doctor’s office that you and I would see here. You know, we kit them all out. They’ve got air conditioning, they’ve got water, lights, electricity, of course. And we started putting down these containers with nurse-run teams — with outreach workers — at the different hot spots, and then building networks of them along the transport quarter.
As drivers move from one place to the next, and sex workers who are also mobile, we could start to build the continuity of care and get into these hot spots where the actual transmission was happening. So we started that in 2006, 2007. North Star Alliance was created as an independent organization to take this forward, because obviously, TNT and WFP had other things to do with their time. And since then, North Star has grown, almost 10 years later, into an organization with 36 clinics in 10 different countries at the moment. We’ve served over a million people. We’ve actually helped establish 50 different clinics in Africa, and transferred some of those to governments, others to other local partners. And the networks continue to grow and expand.
Gatignon: I remember back last May, I was visiting one of your clinics in South Africa. And I actually met a commercial sex worker who was at the clinic. Her name was Michelle. And she was telling me about the huge difference that the clinic had made in her life. She was saying that her ambition was to become the president of the sex workers.
This really made me think that you’re basically giving a voice to populations who don’t have one in these areas. And so, I was wondering if you could maybe tell me a little bit more about how the work that you’re doing is moving from a top-down approach towards health care innovation to maybe a more bottoms-up approach, where you’re really involving these local populations in finding solutions to these kinds of issues.
Disney: I think that’s a really important lesson that we learned in the process. When we started trying to figure out how to do this, we went in with, I guess you could describe it as the typical supply side mentality of an orthodox health care system. We will put a service in place and then expect people to come us and take up the service that we have put there.
“The clarity in your mission and your vision as to what you want to achieve are very important.”
In order to improve and become more effective, and particularly to get people like the sex workers coming into our clinics, we realized very quickly that you can’t just go and say, “This is what we think is the problem in your area.” You need to actually address what they experience as the problems, because preventing disease is not something that you do by just putting in a one-off solution. You need to build long-term relations with your key target groups. And in order to do that, you need to be talking to them about what they think is important to them and what their health considerations are.
So very quickly, because of that bottom-up influx of data, of information we were getting from the communities — they were saying, “You know, HIV is fine, but I’ve got a child that needs to be inoculated. I’ve got a problem with emphysema,” or, “I’ve got a problem with skin rash.” And so, a more primary health care approach was definitely very quickly what they were looking for. We very quickly, I think almost in the first half year, realized that “Okay, we’ve got to position ourselves differently.” Because you need to be working with what their concerns are.
I think you see that tendency spreading across, not only in our sector of the health care industry or the health care field — you see it other places, where we’ve gained a lot of knowledge about what health is. And we’re in the middle of a paradigm shift, in my opinion. We’re moving away from this traditional, orthodox focus on top-down supply side health care services, which says, “Okay, we’ve got hospitals here, doctors.” The health care establishment, including the pharmaceutical industry, is … moving towards working with the communities and people trying to figure out from their perspectives, “Okay, we know they’re going to go through life as a cycle of health better at one point and less healthy at another point.” That’s just how we all work. We’re all in constant flux when it comes to states of health.
So you start to work with these people and help them to navigate those changes in their pattern by leveraging the assets that are closer to them, as opposed to moving into something you’re trying to guess from a top-down perspective, as to what’s going to be the remedy at a given point in time. That’s really changing how people are focusing on health.
Gatignon: One thing that’s really interesting about the way that you’ve actually organized to address this kind of issue and create this bottom-up kind of healthcare solution, is you’ve got a model that is essentially the same for all of the countries you work in. But you work in a number of very different countries and these blue boxes still manage to create this local embeddedness with the communities. And so, what’s the secret to actually managing that mix of a somewhat standardized system that has clear processes and routines, and ways of measuring outcomes, but at the same time, having that local embeddedness?
“North Star has grown … into an organization with 36 clinics in 10 different countries at the moment. We’ve served over a million people.”
Disney: I think it relates back to your previous question, in turning your perspective upside down. Instead of looking at it from, “We’re coming in to solve the health problem,” to a realization that there are so many different factors that influence health, that you can only provide one piece of that puzzle, as a health care provider today. It’s very difficult for everybody to be good at everything, of course, in terms of health care prevention. The person who’s going to help you prevent getting HIV is not necessarily the person who’s going to help you quit smoking.
If you take the mentality that, “I’m a piece of the puzzle. I’m part of a larger system, which impacts these individual’s health,” and you focus on being as good as you can at the one piece of the puzzle — in our case, running a primary healthcare clinic in an isolated area — that’s the starting point. But the more important aspect after that is opening yourself up to engaging the other pieces of the puzzle, to connecting with the government, which is able to provide additional second-tier services, for example. Or, on the other end, the community organizations, such as youth groups or church groups, who are out working with the communities.
By having a very reliable, solid anchor point for different groups to work with, you can find that you can fit into many places, because the basic ideas of health services and primary health care services are pretty standard. How you treat a disease like HIV is fairly standard. There are some variations in treatment protocols, but that’s really to do with the pharmaceutical side. But how you do that basic element is pretty good. The mentality of how to work with other people is different, depending obviously, at the superficial level with what their requirements are. But the underlying mentality also is fairly uniform. And you have to open to it. And that’s where it starts, that idea that we are one piece of the puzzle. We’re going to connect with these other people and help them. And we’re all in this together.
Gatignon: What’s especially interesting is the fact that you’re connecting a bunch of very different puzzle pieces. You have partners that go from USAID or global partners to help fund health care and development, all the way down to the local dance troop that’s doing referrals and advocacy for your clinic. How do you actually manage to, first of all, establish such a diverse group of partnerships, and then how do you actually manage to leverage them in ways that will improve healthcare outcomes?
Disney: The funny thing is, people ask often, “How do you get a big, multinational company like Chevron or Heineken to work with a local dance group from the community?” The flippant, short answer, I suppose, is they don’t have to work together. We can be there as that linking pin, because they both are reliant on high quality, affordable clinical services to be able to do what they want. In the case of a multinational, it could be keeping their local workforce healthy.
In the case of the local community organization, it’s the same thing. Their constituents need to be healthy. But because we have that central linking role, they’re both able to come together in a way that they, perhaps on their own, would not, dealing with each other directly. We just sort of fit a gap that’s between there.
“We started by setting up small container-based clinics. … If you’re inside one, it looks like a doctor’s office that you and I would see here.”
And again, how do you do it? … It starts with that mentality of wanting to do it. But after that, giving your local teams enough agency in the field, that they are empowered. They understand the local circumstances. They know which local community groups are going to be worth working with, and which ones are perhaps not going to be as effective or more difficult. They know the local government partners. They have to work with them on a daily basis. That’s not something you can manage centrally — particularly not from the Netherlands, where our head office is based, or our regional office in Nairobi (Kenya) for East Africa, or Durban for South Africa. They can’t do that.
When you presented your first findings to us, all of us were shocked at the vast size of the networks that we had. And I experience it when I go and visit the clinics, but to truly see, to map that all out, you realize all of a sudden that the impact you’re having as an organization is much larger than you perhaps initially anticipated. A lot of the time, organizations see a tension with decentralization, in the sense of giving people agency at the local level to execute and build those partnerships but at the same time, wanting to be very tight, in terms of their control on key things like quality, for example, and maybe even your branding, in case of commercial companies as well.
The clarity in your mission and your vision as to what you want to achieve are very important. … We train people on that. We work very intensely with our teams, particularly at the lower management levels, the people running the clinics … not only [to ensure] that we’re giving to them and saying, “This is what you should be thinking,” but we’ve involved them in actually creating and defining those cultural keystones, our core values. So, it really is coming from them. And then what we’ve done, is just take that, codify it, repeat it and make people aware of it and constantly remind them. If they know that, and they share that vision, it’s much easier than to give them the agency to operate at a local level, because you can rest assured that they [know] what you want to achieve as a group.
“You need to build long-term relations with your key target groups.”
Gatignon: One of the things they have to be really good at doing is wearing different hats and adapting to very different kinds of partners, right? They’re developing these ecosystems, but that means they have to work with public, private, non-profit sector organizations and bring these pieces of the puzzle together. What are the kinds of implications of having to bring together organizations, partners from different sectors? You were talking about organizational culture. Obviously, that’s going be very different in terms of the way you’re going to partner and approach with a public or non-profit or private sector company.
Disney: Building on the natural culture of the company is a starting point, but it’s not sufficient in itself. I think you have to go beyond. And what we try and work on in groups in our training programs is help people to understand and identify pitfalls that they can get themselves trapped into sometimes … Particularly in certain cultural circumstances at local levels, there may be enormous moral pressure or community pressure to go in a certain direction. And to try and give them the tools and awareness to try and protect themselves from getting into those positions. And if they do get into those positions, how do you get yourself out?
For example, if you’re working with local communities, and in some parts of Africa you may have to deal with the village chief headman, who has certain ideas of how his community should be run, which may be very much at odds with how the local government authorities think that you should be delivering your health care services. So how does the local clinical officer balance those two things? Because those are very competing edges. Now, he or she — and we have a lot of females running our clinics — will know what we want to achieve, but still sitting between those two fires is pretty intense and can get very uncomfortable very quickly.
So what we’ve tried to do is build in escalation mechanisms as well, where they feel that they’re under so much pressure, we try and give them, as I said, techniques for saying, right, well, don’t commit yourself in this when you enter into a conversation, be conscious of the fact that you can’t go beyond this line. And if you feel yourself pressured to do that, and you’re in a tight situation, then we’ve tried to build escalation measures so they can always kick it up the management line. And then we can bring in somebody who doesn’t have that local pressure. And that’s really effective sometimes.