Bringing the Avon Lady Philosophy to Rural Ghana

In many rural areas of Ghana, a ringing bell is the traditional way that itinerant sales agents announce their arrival in a village. More and more, those bells are announcing the arrival of the entrepreneurial women from the HealthKeepers Network who are promoting health while also making a living, with the motto “prevention is better than cure.” And they are forging a new way of using the private sector to deliver health and hygiene to rural areas often overlooked by traditional global health programs.

Although different private sector strategies have been tried to promote contraceptive use in Ghana (where the 2008 Demographic and Health Survey indicated a contraceptive prevalence rate for modern methods was 16.6%), the impact of these strategies has been limited due to the long distances to be traveled to reach relatively small numbers of people with limited purchasing power.

When I visited HealthKeepers in a village about an hour outside of Ghana in October 2009, I immediately thought of Avon, a U.S. company I remember from my youth, and its Avon ladies who have sold cosmetics door-to-door since the 1930s. The HealthKeeper difference is that these sales ladies travel by foot, with their products in a basket perched on the top of their heads.

The merchandise includes a mix of health products — such as contraceptives, insecticide-treated mosquito nets, oral rehydration salts and home water treatment tablets —and other carefully selected personal care products which help ensure that the ladies turn enough of a profit to keep them motivated. In 2009, they were also selling low-cost eyeglasses; they gave one of my colleagues an impromptu eye exam under the mango tree.

As a big fan of using the private sector to improve health (I worked 17 years managing and promoting health social marketing programs), I was thrilled to see such an innovative, entrepreneurial program in rural Ghana (next door to Togo, where I was a Peace Corps volunteer in the 1980s). But I was also worried because, at that time, HealthKeepers was almost out of funding and Daniel Mensah, its executive director, didn’t know how it could continue operating much longer without new funding.

So I was pleased to find HealthKeepers at last week’s 2011 International Conference on Family Planning in Dakar, Senegal in a session entitled “Increasing access to family planning methods and other health products in Ghanaian rural communities” and to discover that it was now receiving two-year funding from the U.S. Agency for International Development to expand its work in 18 districts of the Central, Western and Greater Accra Regions. The goal is to reach 1.8 million people by improving access to condoms, oral contraceptive pills and other health products and thereby reducing sexually-transmitted infections (including HIV), teenage pregnancy and maternal mortality.

The results presented in Dakar last week showed that 215 women out of the projected 480 have been recruited and trained by HealthKeepers Network, and they are reaching 45% of the goal of 1.8 million less than a year after the project started. Not everything has gone smoothly. The abstract addressed two issues in particular:

  • The Network has had problems recruiting HealthKeepers and has engaged “finders” — usually from the district assemblies’ offices — to help identify potential candidates.
  • Some HealthKeepers are shy about promoting condoms. The Network has begun applying peer-to-peer support in which successful condom and pill sellers are invited to group meetings to share their selling techniques with their colleagues.

But overall, the project seems to be going well, and many of the HealthKeepers are endearing themselves to the villagers by educating them on use of contraceptives and other family planning methods, according to the conference abstract. “I have been able to create a cordial relationship with my customers, making it easy for them to approach me for the contraceptives,” said HealthKeeper Mabel Martesu.

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