Adaptation is the way forward

Learning has propelled Brac in conquering seemingly insurmountable challenges

Brac started its journey as a learning organization. David Garvin defined "learning organization" as "an organization skilled at creating, acquiring, and transferring knowledge, and at modifying its behaviour to reflect new knowledge and insights." David Korten, an organizational development guru, sensed this as early as in 1980 when he identified Brac as a learning organization. 

As has been written extensively, Brac’s learning process transcends different levels and paths. Notable among these are the field-level experiences of workers of different intervention programmes, routine monitoring and management information systems, studies carried out by the erstwhile Research and Evaluation Division (RED), external reviews, and experiences of other development agencies in Bangladesh and outside. 

Most of Brac’s successful programs have been innovated and had evolved within, and their implementation constantly improved for optimum impacts using the mantra "science of delivery." But there are a few exceptions to it as well, demonstrating that Brac is also a successful adapter of ideas innovated or developed elsewhere. I illustrate it here with a prototype example.

Improved vision for better living

Jordan Kassalow is the founder of Vision Spring, a non-profit based in New York. I first met him in 2004 at the US Council on Foreign Relations where he and I (and Jacqueline Novogratz of the Acumen Fund) were in a panel on the role of entrepreneurship in health. At the time I was teaching at Columbia University’s Mailman School of Public Health. Each of us presented the work of our respective organizations.

Brac was not much known to the audience and there was a lot of interest in it, particularly its scale. This event brought Jordan and I closer and, slowly, we became friends. There was a sense of common interest.

Jordan is a popular optometrist in New York with a flourishing practice, but his heart, like mine, was hung up on improving the lives of the poor. In order to help those with poor vision but without the financial means to improve it, his non-profit has been distributing reading glasses in India and El Salvador at a nominal price.

One of the problems faced by people as they grow older is "presbyopia," which people start to experience from age 35 onwards. It impedes one’s ability to read or see things close-by, and may ultimately threaten their total vision. This is very easily addressed by using reading glasses.

It is estimated that about 250 million people in the world are suffering from presbyopia. This leads to a loss in productivity, leading to mental health challenges brought on by the inability to undertake simple day-to-day tasks such as reading newspapers and/or religious texts, among others. It is estimated that the yearly productivity loss due to the condition is around $11 billion (0.016% of global GDP).

Jordan saw for himself how a simple reading glass can transform the life of an individual, and that is why he, and his organization, has been exploring how affordable reading glasses can be delivered to the millions who need them. I started thinking about Bangladesh and the thought of Brac’s army of Shasthya Shebikas (community health workers) jumped to the fore.

Can we train our shebikas to provide the glasses?

A simple solution

Sitting in Jordan’s office, I started wondering about why this 700-year-old technology could not be made available to our people. I started pondering about thousands of craftswomen or artisans of Aarong and Ayesha Abed Foundation, whose livelihoods depend entirely on their eyesight. I knew of many such workers who earn less or even lose their jobs due to fading vision.

An easy solution would have been to consult an ophthalmologist, but more often than not, it was usually beyond the means of such workers. It was also hardly known that an ophthalmologist is neither needed in such situations. In many countries, a separate cadre of professionals exist, who are trained to recommend reading glasses (while the ophthalmologists take care of complex eye diseases and surgeries).

Unfortunately, this has not been the case in Bangladesh. 

I called Faruque Ahmed, the then Director of Brac’s Health Program and discussed with him the idea of training the shebikas to prescribe reading glasses to those with presbyopia. He was excited. We also agreed that, if successful, this would open up new earning opportunities for the shebikas.

I also thought that, if successful, this would make way for a fast scaling up as there were thousands of such shebikas trained and fielded by Brac, not only in Bangladesh but also in other countries including Afghanistan, Liberia, and Uganda.

A promising beginning

Upon my return to Dhaka, I discussed this with Sir Fazle Hasan Abed and other senior leadership including Abdul-Muyeed Chowdhury, Salehuddin Ahmed, and Aminul Alam. Abed bhai was not only the master innovator himself, but he also appreciated any good work done by people and organizations outside of Brac. He immediately embraced it and asked me to try it in a pilot to see if the idea will work with the shebikas as barefoot optometrists.

I had very little scepticism about it in my mind.

I contacted Jordan immediately, whose excitement was at par with mine. To help kick-start the pilot, he sent a senior colleague, Neil Blumenthal, to Dhaka. An experienced field manager of Brac, Abdus Salam (currently Associate Director, Urban Development) was entrusted to lead the pilot in Narsingdi district.

Neil and Salam jointly carried out the pilot, overseen by Faruque and myself. The results were amazing. We found that the Shebikas not only correctly identified the presbyopia of both women and men, but were able to prescribe correctly powered glasses. We were happy to see that all the 100 pairs of glasses that were brought for training purposes were sold out very quickly.

Challenges along the way

However, testing the capability of shebikas was only one part of the challenge. At that time, the glasses were imported from China. Each pair cost Tk60 which was sold by shebikas for Tk100; most of the mark-up was given to the shebikas as incentive.

A second pilot was done in Manikganj with similar outcomes. The pilot also led to development of posters and other communication materials.

The stage was then set for planning a nation-wide scaling up. Neil returned to plan for the projection for the next three years. We decided to immediately import 6,000 pairs from China. But there were complications in such imports, including a substantial tax levy.

With the help of the then Minister of Finance, Abul Maal Abdul Muhith, we got a tax exemption for one year, which helped to jump-start the expansion. This problem has now largely been solved with the establishment of a reading glass production plant in Mirpur.

Steady progress

Over the past few years, the reading glasses project has expanded to 61 of the country’s 64 districts, where the villagers are accessing the services of 25,000 specially trained shebikas. The shebikas prescribe glasses if someone has presbyopia, while those with other issues are referred to qualified ophthalmologists.

To date, the shebikas have examined the eyes of over eight million individuals, and have distributed nearly two million glasses. In 2019, the reading glasses project was extended to Uganda, where the initiative was received with an equal amount of enthusiasm.

It is heartening to see that another of Brac’s innovations (or adaptations) has been transferred to another continent, and is contributing to empowerment and poverty reduction in parts of Africa.

Intensive research carried out by RED on the early impact of the programme is revealing. The income of the users of the glasses is 23 percent more than a comparable group which were not offered the glasses. The use of the glasses has also significantly enhanced the mental health of the users. They are exultant to be able to read their religious books and other reading materials.

In March of 2020, Jordan Kassalow along with other members of the Board of Vision Spring returned to Bangladesh to launch a new project with the Bangladesh Garment Manufacturers and Employers Association (BGMEA). On the last day of the visit, I attended a high-profile event in which Jordan and I sat face-to-face to reminisce about the journey since we first met in New York.

In 2006, the Marriott Business School of Brigham Young University (BYU), USA bestowed Jordan and I the "Innovator of the Year" award for our efforts to make this simple, low-cost technology for poverty alleviation to the doorstep of the poor in low- and middle-income countries.

That was the time when we had just started our pilot project in Bangladesh, and continuing on this, Jordan jokingly said that they (BYU) should give us another award now, this time because we have accomplished so much more since then.

The Brac project has saved millions of people from a degenerative condition, and has given them a new lease on life. For my Brac colleagues and I, this is much more rewarding and satisfying than anything worldly.

Ahmed Mushtaque Raza Chowdhury is a professor of Population & Family Health, Columbia University, New York. Previously, he was the Vice Chair of Brac and the Founding Dean of the Brac University James P Grant School of Public Health.