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Building Health Care Innovations—and Relationships—in South Africa

Smiling woman holding a receipt in front of a pharmacy machine.
A woman examines a receipt from one of Right to Care’s pharmacy dispensing units. (Photo credit: Right to Care)
Apr 7, 2022

Like so many other scrappy start-ups that have found success—think Apple, Amazon, or Google—the South African health care nonprofit Right to Care has its own story of humble beginnings.

Working out of a makeshift workshop in his Johannesburg home in 2008, Kurt Firnhaber, former Chief Operations Officer for Right to Care, collaborated with an engineer friend to create a pharmacy dispensing unit (PDU) that could serve up frequently prescribed medications, helping to get life-saving medicines to South Africans in need.

“It’s like an ATM machine, but for medications,” smiled Firnhaber, proudly displaying pictures on his phone of the unit’s glowing keypad and the robotic arm that fetches prescriptions from the PDU’s stock of approximately 3,000 medicines. Modifying German parts that they adapted to handle differently packaged South African prescriptions, Firnhaber and his colleague created the PDU to mechanize a process that had become a bottleneck to care for thousands of chronically ill South Africans.

“The bones of the technology existed,” said Firnhaber, “but you couldn’t apply what had been done in Europe and use it in South Africa.” Nevertheless, they knew that the key building blocks—good connectivity nationwide and a national health data system capable of being integrated with the machines—were suited to their innovative approach.

At that time, South Africa, a country of over 52 million people, was graduating only several hundred pharmacists each year—far too few to adequately staff the country’s pharmacies. Due to this shortage, patients had to wait in lengthy lines, frequently missing full days of work—an impossible trade-off for many low-income South Africans with chronic conditions. The result was long queues; many others would go without vital medications altogether, which would also lead to drug resistant HIV among patients.

Moreover, although HIV/AIDS medications such antiretroviral therapy were finally allowing countries like South Africa to begin treating the disease as a chronic condition, versus a terminal one, those medical advances would only reduce mortality rates if patients could easily receive these and other life-saving medicines.

With funding from USAID and other donors, the PDUs became a success and were installed in several key locations around the country, enabling people with chronic conditions and regular prescription needs to quickly and easily obtain their medications through the automated system. The PDUs became foundational technology for Right ePharmacy, a subsidiary that was spun off of the parent organization Right to Care.

Establishing Trust and Securing NICRA

The PDU was not the first or last time that Right to Care would innovate on a development challenge. The organization began in 2001 as a partnership with an insurance company that received a $500,000 grant from USAID to support HIV coverage in the private sector, but it grew to implement large USAID programs on medical male circumcision, HIV testing, and health system strengthening.

In its early days, the organization initially received a “high-risk grant” from USAID funding. It was small, unknown, and unproven. But the organization made the most of the chances it got, building its relationship with USAID through both reliable implementation and regular, transparent communication.

Former USAID Acquisition and Assistance Specialist Beatrice Lumande recalled, “What was instrumental was the trust that was built between Right to Care and the contracting office. We scheduled monthly meetings with Right to Care visiting our office, and we would just talk, brainstorming about what they required and how they should proceed.”

A key to their relationship with USAID was being open, transparent, and communicative. And this openness went both ways. Dana Rose, USAID’s Contracting Officer in the Southern Africa Regional Mission at the time when Right to Care was growing as a partner, had developed a reputation as the person who always would pick up the phone—no matter the time of day—and who always was there with answers or just to listen. 

I always treat partners as ‘partners.’ I am committed to ensuring USAID’s positive impact on people’s lives and that starts with developing trusting relationships with our implementers,” said Rose.

She stressed the importance of humanizing the regulations that guide how USAID works. “Contracting officers have a traditional role in implementing USAID activities, but we are people too,” remarked Rose with a grin. “I strongly believe in the importance of establishing relationships. This requires taking time to get to know our local partners, brainstorm ideas through regular meetings, and overcome challenges, together.”

Sometimes there were disagreements, but strong relationships allowed these to be overcome. For example, early on, Right to Care sought a negotiated indirect cost-rate agreement, or NICRA, which many other larger partners had and which they believed would give them financial flexibility that would enable growth.

Rose initially pushed back: “I always worried that we would undermine the stability of a local organization.” She had seen this way of approaching indirect costs doom some small organizations. But Right to Care was clear about its need, and Rose knew and trusted the organization enough to recognize that they understood the risks and rewards of this arrangement. “They were always telling me, you don't have to protect us—we can do that on our own,” said Rose.

Rose subsequently worked to secure the NICRA for Right to Care, one of the first times this had been done for a local organization in South Africa, and this support was recalled over a decade later as a key factor enabling the organization’s success. 

Growing Smart

As Right to Care grew, and USAID’s confidence in the organization strengthened, they began managing other subrecipients, which came with its own risks and challenges. So what did Right to Care do? They innovated again, developing an electronic system, RightMax, for tracking subpartner expenses and receipts in order to streamline that oversight. The system, which was developed in 2009, eventually was adopted by other organizations too, including the Global Fund.

Firnhaber explained the system this way: “So you would put a barcode on your receipt, and you would scan the barcode. The system would ask you five or six basic questions for USAID, and then you would take your receipts and scan them right into the system.”

This process gave Right to Care confidence that they would not have to cover expenses for subrecipients who made mistakes in their financial reporting. “It significantly reduced staff time on both ends, and we got incredibly clean audits for all the subrecipients,” noted Firnhaber.

To keep up with the demand for its services, Right to Care not only invented systems like RightMax but it also had to grow as an organization. It added an average of one staff member a day for three years, but that hiring was carefully managed. The organization wanted to represent South Africa’s diversity in its hiring, so it was very intentional and proactive about finding and developing talent. Over 70 percent of Right to Care’s management team was Black or non-white, representing the diversity of South Africa, and the organization continues to advance these efforts.

“Instead of taking the traditional approach of ‘We’ve got these job openings, let’s put them on the website and see who will apply,’ if we would meet people that we knew would be a good fit, we would say ‘We don’t have a position for you right now, just come and work for us, and let’s figure out where you’re going to fit in,’” stated Firnhaber.

With passionate and valued staff, as well as a prominent and active board of directors, Right to Care became a nexus for other organizations. Rose noted that “they were very well-networked with local organizations, which I think is a powerful point for how an organization can be successful.”

Today, Right to Care continues to serve as a prime partner for USAID in southern Africa, with a staff of approximately 3,000 and operations in seven countries.

Tips for Partners

Conversations about Right to Care's trajectory yielded the following advice for new and potential partners:

  • Focus on relationships. Partnership is about people. USAID wants you to be successful, and USAID staff care deeply about you, your organization, and the development work you do. Build relationships with the USAID staff who want to help you.
  • Hire the right staff. Your organization will be stronger if you are proactive, rather than reactive, about hiring.
  • Understand NICRA. NICRA can be valuable, but it is not right for every organization. Find out more in this blog post.
  • Network with other partners. A lot of information gets shared among partners, including possibilities to collaborate, new approaches, etc. Be the organization that everyone knows.
  • Be open and transparent with your USAID Contracting Officer (or Agreement Officer) and your Contracting Officer’s Representative (or Agreement Officer’s Representative). Both you and USAID benefit when you communicate regularly about issues, questions, and ideas.
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