Social enterprise models can show us the way in reimagining health systems

What do sewing machines, digital platforms and micro-savings groups have in common? They are all tools used by social enterprise to create community cohesion – and keep those communities healthier. As part of a series of co-authored op-eds from Primary Care International, Julia Beart, Angela Chaudhuri, Nigel Crisp and Patricia Odero explore the role of agile, responsive social enterprises in creating social good, and their contribution to the Covid-19 response around the globe.

It is now well documented that socio-economically disadvantaged groups are at greater risk of contracting and dying from Covid-19. A previous Primary Care Perspectives piece, The Unpaid Debt of Underinvestment in Public Health, explores this in greater depth.

An important index-based vulnerability risk-mapping survey from our partner Swasti, a global nonprofit headquartered in India, further highlights the ways that this has been playing out in this country. Not only has the rate of infection sped up, but it has spread to the rural areas with poor health infrastructure. This spread has been most intense in the more vulnerable parts of the country including Bihar, Assam, Odisha, Uttar Pradesh, Madhya Pradesh, and West Bengal. This corroborates with the predictions of the index-based vulnerability risk-mapping, which concluded that the most vulnerable areas of the country would be most affected by the pandemic. Health systems in India are under immense pressure, as they are in countless countries around the world.

How, then, are social entrepreneurs mobilising their teams and partnering with the government and with the private sector to protect those at risk and bolster their resilience? In the face of a pandemic not yet showing any signs of abating, what role can social enterprise play in meeting emerging needs?


Connecting the community

Social enterprises are set up to deliver social good. Entrepreneurial in nature and often able to be highly responsive to emerging needs, social enterprises do not usually offer ‘hand-outs’ in the way that those operating a conventional charitable model may do. They must provide real and discernible value to their ‘customers’ – whether these customers are other organisations, specific groups of people, or whole communities – if they are to thrive as organisations.

The Sewing Rooms

Above: Paula Gamester (CEO) and Maureen Fazal (director) of the Sewing Rooms, with some of the masks their groups have been making

A new book by our co-author Nigel Crisp, exploring the role of social enterprise in health creation, Health is Made at Home, considers two such examples and much more.

The Sewing Rooms is a UK social enterprise working particularly closely with groups and individuals who may be isolated, long-term unemployed, with refugee status, or at risk of developing mental health problems; it creates opportunities for training, employment, and wellbeing. One project supported refugee women from Syria to join up with an existing group, ‘Silver Sewers’ (women aged 50+ who are lonely bereaved or isolated), using sewing as a mechanism to connect with each other. The impacts of this were clear: confidence improved among all the participants; some started to meet outside of the project and formed a support network; one woman was supported to set up her own counselling business; and one woman was employed in The Sewing Rooms' own manufacturing department. In addition, all the women participated in the existing wellbeing 'Biophilia' (nature) walks which improved their physical health.

Improved community cohesion is key to improved health and wellbeing

The Tribe Project, meanwhile, creates a hub matching those needing help to those who can provide it, harnessing social action to address the challenges of an ageing population, loneliness and inequality across the UK. As for The Sewing Rooms, improved community cohesion is key to improved health and wellbeing.



Swift and agile

Community cohesion is also critical to Swasti’s Invest for Wellness (i4We) primary healthcare model, which brings effective healthcare to the poor in India (and beyond), substantially improving their ‘healthy days’. The model is anchored by community collectives through which healthcare is bundled with financial services ensuring affordability and viability. It operates on a blended financing model, through grants, pooling group resources, and user fees. Through community-based teams and referral networks, i4We services provide health education and advice – including support to deal with root causes such as chronic illnesses, violence, and addictions, access to primary care and referral to specialist care. Standard protocols, a technology platform, and partnerships augment delivery and quality. During the Covid-19 response, the primary care service has pivoted to ‘tele-care’; health, counselling and social protection schemes delivered via phone. This includes symptomatic Covid-19 surveillance, testing and follow-up care, but also extends to counselling and responding to gender-based violence. Within two months, i4We programmes clocked more than 30,000 calls from nine sites alone.

Swasti India

Above: Swasti’s I4WE model is a nurse-led, integrated and community health and wellbeing model working with poor communities. During the Covid-19 response, the primary care service has pivoted to ‘tele-care’ – health, counselling and social protection schemes delivered via phone

Social enterprises can also be very adept at swift, agile re-purposing of existing products. Dimagi focuses on transforming frontline health services by improving data collection to enhance the quality of healthcare through CommCare, a mobile-based data collection platform. In response to the Covid-19 pandemic, Dimagi collaborated with partners across several countries to customise CommCare to help health systems to meet new demands for immediate and accurate information. Working with the public sector and NGO partners in Nigeria, Sierra Leone, Kenya, Zambia and South Africa, some new use cases for CommCare included contact tracing, workplace testing and community health worker data collection. The platform is now customised to support triaging, contact tracing, provide decision support for frontline health workers and enable logistics management at community level.

Social enterprises can swiftly re-purpose existing products. Dimagi's data platform is now customised to support triaging, contact tracing and decision support for frontline health workers

eanwhile Primary Care International’s (PCI) own Covid-19 open-access e-learning resources for clinicians were released at the end of March. This was some of the earliest content to be designed and disseminated specifically with primary care facilities in resource-poor settings in mind, at a time when other guidance and resources had not yet considered the feasibility of social distancing measures in crowded informal settlements or the logistics of handwashing where facilities are limited. This was achieved through the pro bono efforts of a small team standing in solidarity with healthcare workers around the world and reached people in more than 75 countries within a month of its release.


Why social innovation is needed now more than ever

Social enterprises are often well positioned to contribute to a rich tradition of social innovation. Social ventures have demonstrated their ability to rapidly pivot their service offerings, innovate new use cases for current service delivery models and even develop new technologies to support the Covid-19 response. With the uncertainty on when potential vaccine candidates will be ready for rollout, this entrepreneurial mindset and agility will continue to be needed as health systems seek to build the resilience needed to both manage Covid-19 and minimise disruptions in primary care.

While continuity of healthcare, particularly for those with underlying health conditions, is absolutely fundamental during a pandemic (as highlighted in an earlier op-ed), there is also now a compelling argument that things can and must be done differently in the future.

If a health system has been ‘broken’ for decade, why are we tinkering at the edges trying to fix it? Let us reimagine health systems

If a health system has been ‘broken’ for decades – that is, it is not able to ensure people have access to the care that they need for healthy lives – then why are we tinkering at the edges of this system, trying to fix it?

Let us reimagine health systems whose starting point is not fixing seriously ill people. Let us re-draw the boundaries and reimagine health systems which start at home. What if we were to design health systems where investment in prevention and promotion work in the community were funded in equal measure to investment in hospital-based infrastructure? Where cross-sector collaboration to ensure decent housing and access to social protection was rewarded? Where people felt enfranchised to take control of their own health? Social enterprise models can show us the way.

Header image: Lwala Community Alliance in Kenya, which is developing a Covid-19 digital toolkit to support its direct pandemic response efforts, with guidance from social enterprise Dimagi.

This article is part of Primary Care International’s co-authored Op-Ed series, exploring resilient systems and healthy populations in the context of Covid-19 and beyond. The perspectives of the authors are not necessarily the views of any of their institutions or affiliations. 

  • Julia Beart is CEO at Primary Care International; Angela Chaudhuri is a public health leader, strategist and journalist, and currently serves as a partner in Swasti; Nigel Crisp is author of 'Health is made at home. hospitals are for repairs', co-chair of the UK All-Party Parliamentary Group on Global Health, co-chair of Nursing Now, the global campaign on nursing, and an ambassador for Primary Care International’s social investment campaign; Patricia Odero is regional director (Africa) for Duke Global Health Innovation Center (GHIC) and Innovations in Healthcare
  • Primary Care International is launching a social investment campaign to help it to reach 25,000 healthcare workers by 2025. Find out more by contacting