Who Pays When the Market Will Not?

In the earlier pieces I described a promising field model and then its hidden catch: that paying a frontline woman by the product she sells corrupts her advice and does not even pay her well. That leaves a hole, and an honest reader will have spotted it at once. If she is not to earn from selling the product, and a non-profit cannot simply put her on a government salary, then who pays for the health work she does?

Here is the hard truth the sector keeps walking around. A health good the poorest cannot afford will never fund itself through a woman selling it. The self-sustaining social enterprise, the one that needs no durable payer, does not exist for this kind of work. Across every women-led last-mile model that has been studied, the finding is the same: strong demand, and costs that product margins alone never cover.¹ Even at vast scale the woman earns very little. After two decades and well over a hundred thousand women, a typical Project Shakti seller still takes home around 700 to 1,000 rupees a month.² The networks that pay women a real income do it by selling a basket of higher-margin goods and services, not one thin health product.⁶ So the pad cannot be her livelihood, and selling it cannot fund the health work.

Stop asking the wrong question

The sector keeps hunting for a model that is self-sustaining. That is the wrong question, and chasing it is how we end up with thin-margin sellers and five-shop pilots that never grow. The right question is plainer and harder. Who is our durable payer for the part the market will not fund, and what does paying that way do to the woman's advice?

There are only a few durable payers, and each comes with a cost.

The public purse

At real scale, the lasting answer is the state. It pays frontline health workers a wage, as Brazil does with its community health agents,⁴ or it reimburses their work through public insurance, as several US states now do through Medicaid.⁸ This is exactly what the World Health Organization recommends: pay the health worker a proper wage from a durable public source, and do not make her income ride on sales or piece-rate performance.³ The catch for a non-profit is that it does not control this purse. Its real job, then, is to prove a model well enough that a government or an insurer will adopt and fund it, and to design for that handover from the first day rather than to run the programme forever itself.

A commercial basket that carries the health good

The second payer is the market, used honestly. Let the woman earn from a basket of goods and services that do carry a margin, and let the health product and her advice ride along on top. This is how the large women-entrepreneur networks actually pay a woman more than a pad ever could.⁶ The catch is the one from Part 1. She is a seller again, so her advice is only protected if she is paid for the health work separately from what she sells, and the health function is only ever as funded as the basket's margin allows. It also will not reach the woman who has no cash at all, which is the woman who needed it most.

Outcome money

The third payer buys results. An impact bond or an outcome contract has a government, a donor pool or an impact investor pay for verified outcomes, a girl who takes up a service, a girl who stays in school, rather than for products moved. Done well, this points the incentive back at the girl, which is the fix Part 1 asked for. But it does not escape the question of who pays. Triggerise's Tiko platform, which rewarded girls, providers and frontline women alike, needed a donor behind every reward, could not sustain that in India and closed there, and now runs in Kenya on a development impact bond backed by an outcome funder.⁵ Outcome money moves the subsidy to a results-buyer. It does not remove it. And the reward must sit with the organisation, not be passed down to the woman as pure piece-rate pay, which the WHO warns distorts her work.³

Patient capital, and the honest conclusion

There is a fourth, rarer payer: a corpus or a standing corporate commitment that funds the function year after year. It is still a subsidy. It is simply a stable one.

That is the whole menu, and it is worth saying plainly that none of it is free. Every workable model is a choice of durable payer with a known cost: the public system you must hand over to, the basket that keeps her a seller, the outcome funder you must keep convinced, the endowment few will ever raise.

The self-sustaining women's enterprise that needs no payer is a story we tell funders.

It is also why so many promising pilots stall exactly where they are.

I have built most of these models over twenty years, the private-sector market ones, the public-system ones, and an alliance that tied women's health to their income across four countries. The ones that lasted were not the clever ones. They were the ones where we named our durable payer on the first day and designed the woman's pay so that her advice stayed honest.

Three questions before you call it sustainable

So before anyone, a funder, a board, a founder, calls a women-led health model sustainable, make them answer three plain questions. Who pays for the part the market will not fund? For how long? And does that payment reward her for selling, or for the girl being well? If they cannot answer all three, they do not have a sustainable model. They have a grant with a better story, and the woman at the end of it will pay for the gap with her time and, quietly, with her trust.