The retention paradox: Why last-mile agents stay, even when revenues are meager

Nduku, a pregnant woman in rural Makueni, Kenya, faces long, difficult journeys to reach distant health facilities and often leaves without the care she needs because services and supplies are either unavailable or too expensive. Nduku’s experience is not unique. Across Kenya, particularly in remote, low-income communities, access to healthcare remains a critical gap. A 2021 study revealed that the average travel time to the nearest public health facility is over two hours and even longer in rural areas.

Now, imagine a different scenario where Nduku receives regular prenatal care right at her doorstep from a dedicated Community Health Worker (CHW), sparing her those trips and improving both her health and peace of mind. Community-based healthcare not only guarantees quality care and monitoring close to home, but also eliminates the need for travel, essentially making healthcare more affordable by saving time and eliminating transport costs.

While CHWs provide vital access to healthcare, their work can sometimes be exploitative. This primarily female workforce faces time poverty from household responsibilities, financial stress from unreliable pay, and safety concerns.

This is where Healthy Entrepreneurs (HE) comes in, creating business opportunities to alleviate financial stress for CHWs and patients alike. Healthy Entrepreneurs (HE) is a social enterprise that recruits, trains, and supports CHWs to become Community Health Entrepreneurs (CHEs) –delivering basic health services to rural communities while earning an income from selling health and sanitation products. Through a network of over 20,000 CHEs, HE has reached about 18 million people across Kenya, Tanzania, and Uganda.

BFA Global, through the Umbrella Fund project, partnered with HE to understand what drives income growth for CHEs and identify practical ways for women to increase their earnings. Low incomes and limited access to credit consistently emerge as key barriers for women entrepreneurs, so we piloted an inventory credit model with over 200 CHEs in four counties of Kenya (Homabay, Kisumu, Makueni, and Nakuru) to test whether their incomes would rise.

Results were mixed. Credit led to minimal changes in revenues with earnings remaining modest at just over KES 1,500 (~$12) per month from HE product sales. Another finding was more striking: retention. Over 80% of the women had stayed engaged with HE for over seven years. Given their limited income from HE product sales, we wondered: What is driving this long-term participation, and what can we learn from it?

In this blog, we explore these drivers and what they mean for designing interventions (including credit) that create better economic opportunities for women.

Insight 1: Side hustle economics

The primary finding was clear: HE income alone rarely covers household needs. 78% of the CHEs split their time between HE and other ventures – mainly farming, retail or casual labor – spending about four days on HE work and two to three days on these other businesses. Their CHE role provides a reliable, steady slice of household cash rather than a sole source of income.

Our engagement showed that even though CHE work was demanding of their time, women valued the steady income stream. We also discovered there were other benefits that came from belonging to the HE ecosystem– benefits that were having a real impact on household resilience and that women valued just as much or more than the income itself.

1. Transferable business skills boost overall household earnings. The practical training women receive in record keeping, basic bookkeeping, market mapping, and product promotion is regularly applied to other ventures. CHEs report using these skills across their businesses, improving planning, pricing, and reinvestment. “I know how to identify supply and demand – I understand it now. I have transferred these skills to my other business ventures, which are sweater repair service and scrap metal business.”
2. Customer demand and cross‑selling spills over from CHE work. Door‑to‑door visits and community trust create sales opportunities for the CHEs’ other products and businesses. CHEs describe HE days as occasions to promote everything they sell, increasing total household turnover without any extra travel time. “I am able to meet my needs and get to promote my other businesses.”
3. Social capital, status, and networks unlock economic value. Being a CHE improves a woman’s social standing, generates referrals, and embeds them in social safety nets like chamas, peer lending, and stock swaps. This relational capital translates into repeat customers, informal credit, and faster recovery from financial shocks – impacts that income metrics miss.Our conversations with CHEs revealed that HE work also raises their visibility among other organizations, which frequently select CHEs first for training opportunities and provide attendance allowances. This spillover effect was described as a practical benefit of being a CHE – a pathway to additional short‑term income and skills opportunities alongside their core HE role.

Recommendations

For social enterprises like HE with large numbers of last-mile agents, we recommend designing for multiple livelihoods. Acknowledge side hustles and align sales targets with the seasonal cash flow of communities. Offer flexible engagement tiers, classifying agents as seasonal, part‑time, or full‑time with matching KPIs, training, and incentives. Finally, enable and formalize cross‑selling so that agents can bundle your products with goods from other ventures, reducing churn by supporting, not penalizing, entrepreneurial livelihoods.

For funders, invest in technical assistance and pilots that test agent segmentation, seasonally adjusted targets, flexible payment windows, and alternative metrics, as this would generate evidence on what works in communities with different cash flow patterns. Set evaluations to track retention and seasonal coverage alongside sales so that programs can iterate based on what actually works in different contexts.

Insight 2: Credit raised income but financial resilience remains limited

HE has long recognized that a lack of capital, driven by limited access to traditional credit, is a major barrier to CHEs starting and scaling micro-enterprises sustainably. During our pilot, HE introduced a dedicated credit component to their operating model, including two 0% interest . While credit already existed informally within HE, formalizing it built on this foundation and likely strengthened retention.

The first program, “The Booster”, caters to CHEs who have been with HE for at least six months, have a track record of repeat business and are looking to expand their business. The second program, “The Builder”, is for newly onboarded CHWs who want to start micro-ventures through HE.

Of the 253 CHEs in the pilot, about 60% took up inventory credit. However, uptake varied sharply by experience. Nearly all Boosters (99%) opted in compared to just 40% of Builders, showing that those who had been in the system longer saw clearer value.

Interestingly, even though Booster incomes remained largely unchanged during the credit period, their renewal rate remained extremely high at 99%, compared to 43% for Builders. For Boosters, formal credit wasn’t new – it mirrored how they were already operating informally and reinforced the value they already saw in HE. This also helps explain their very low default rate (0.94%). In contrast, the default rate for Builders was 1.48%.

More importantly, inventory credit was not just a short-term liquidity fix. It also helped stabilize incomes, reduce stockouts, and maintain customer relationships. As one CHE put it, “I don’t run out of stock… I can get credit and repay in bits.” This consistency enabled more reliable sales, preserved trust and referrals, and helped women stay in their CHE role over time.

For the Builders, who were newer CHEs, the picture was different. They were still testing whether the model worked for them, and those who didn’t see enough value tended to drop out.

We also noted a real fear of debt, particularly among newer CHEs, and that this was a key factor in their uptake of credit. These women often dipped into family funds or peer groups to repay loans rather than risk the stigma of defaulting. This is well-documented in the literature, where risk aversion and shame around default push women away from borrowing productively. When repayment pressure does build up, many end up taking loans elsewhere to cover existing ones, compounding indebtedness and sometimes pushing them further into poverty and depression.

Recognizing this, HE trained mentors to talk with the women, walk them through their loan terms, and make sure they knew what options were available if they couldn’t make a payment. The goal was that this support would ease their fear of debt and unlock long-term value.

Recommendations

For founders, design credit around agent and customer cash flows. Offer flexible repayment schedules, breathing room, and safety nets that align with income cycles. Pair credit with practical training on using credit for business growth, and provide clear pre‑delinquency support so that agents know what help is available before defaulting on a loan.

For funders, finance risk buffers like micro‑insurance, guarantee facilities, and pilot alternative repayment models that improve resilience. Fund small, early tests of new credit products and pay for evaluations that measure how those products increase income without affecting household well-being.

Before scaling up a product, assess whether credit makes a difference to women’s financial health. Consider tracking household welfare indicators, such as comfort with budgeting and ability to save, and include loan repayment in pilot evaluations (not daily monitoring). BFA’s DORA framework offers a practical guide for designing and scoring these indicators during pilots.

Insight 3: Social capital is the hidden engine of retention

Social capital emerged as a key driver of retention, particularly for women whose access to public status may be limited.

94% of CHEs reported improved quality of life after joining HE. We grouped these non‑monetary gains into four categories:

1. Increased status and stronger identity: The CHE role provides a visible professional identity and public recognition (titles like “Daktari”) that raise social standing and generate repeat referrals, turning social status into an economic asset.
2. Greater confidence and social reach: Training and client interactions strengthened interpersonal skills and networks, helping CHEs sell more effectively and apply these skills to other income-generating activities. “Being a CHE pushed me to start interacting with people, previously I could not but now I am capable of interacting confidently.”
3. Fulfillment from serving the community: Many CHEs derive meaningful purpose from improving others’ well-being, which sustains their daily effort and fosters loyalty to the CHE program. “…I get to help others, not just myself.”
4. Increased agency and household bargaining power: 64% of CHEs reported greater say over household spending – a durable shift that rewires household dynamics and creates informal safety nets beyond cash income. “I used to depend on my husband. Now I have a job and when my husband comes home, he sees that I bought groceries and flour.”

In the book, The Power to Choose, Naila Kabeer argues that respect and public identity can be as valuable as cash income.

However, we recognize that social benefits can sometimes be used to keep women in low-paying or unstable roles – a long-standing critique of the Community Health Worker model. Despite that, most CHEs shared that community respect, a sense of purpose, and a stronger voice in the household are important reasons why they continue in this work. These factors cannot be overlooked. Instead, initiatives need to ensure they complement, rather than substitute, fair pay and appropriate protections for women.

HE’s model allows CHEs to retain the social value of community health work that women care about, while also providing a pathway to earn a livelihood. Social status, recurring clients, social support, and a voice at home, all make remaining with HE a rational choice even when take‑home pay is limited.

Recommendations

For founders, enhancing the reputation of agents can reinforce retention. Build visible recognition into the role so that competence is observable and aspirational (local announcements, badges, simple ceremonies). Accompany peer mentorship with modest stipends and reward actions that build community trust as well as sales.

For funders, direct grants to program elements that not only generate social returns (trust, referrals, and agent status) but also provide opportunities for women to enhance their livelihoods. Also expand measurement to capture agency and household effects with the same rigor as financial metrics. These metrics will provide a fuller picture of long-term impact and inform program design and funding decisions.

Insight 4: Training multiplies skills, confidence, and reach

Training strengthens the non-cash incentives that keep CHEs in the HE ecosystem. By building entrepreneurial confidence and technical skills, HE boosts women’s credibility, generates referrals, and reduces economic and social reasons to leave.

In the pilot, 88% of CHEs reported higher confidence after training (39% said the increase was substantial). CHEs applied transferable skills such as managing stock, record keeping, market mapping, and relationship management to other income-generating ventures, increasing their overall earnings. One CHE noted, “I can now use the knowledge I got from HE training on how to manage business, do record keeping and how to convince customers to buy my products for my other business.”

These financial literacy skills were reinforced through simple, practical tools like color‑coded boxes that helped CHEs track income, savings and reinvestment. The boxes clarified the link between capital, cash flow and profit, and helped CHEs balance household needs with business growth. “The saving containers helped keep money separate for the business,” said one CHE, while another reported, “I was trained by Healthy Entrepreneurs on how to save the little income I get for household consumption while the rest I can invest in the business so that I can expand.”

The HE training model worked because it was practical, focused, and reinforced in the field. CHEs received short, market‑relevant lessons on record keeping, basic financial management, and product promotion, paired with hands-on clinical skills and simple job aids that made concepts easy to use.

Training was followed by regular calls from mentors and peer learning so that CHEs could apply what they had learned and get help when challenges arose. This combination of support mattered, as CHEs reported that skills training changed their behavior – “Record keeping helps me know if I am making profit or loss” – while follow-up from mentors kept motivation and practice alive: “Mentors encourage me and advise on product preferences.”

Together, these elements boosted confidence, credibility, and consistent selling – providing not just skills in a classroom, but durable gains in the field.

Recommendations

For founders, prioritize market‑relevant, high‑value skills tied to local demand and deliver them in short, practical sessions with live demos and low‑tech follow‑ups on WhatsApp/SMS. However, training alone is not enough. Prior research under the WEE Umbrella Fund found that persistent gendered barriers, such as risk aversion, low self‑confidence, time poverty, restricted mobility, and limited financial access must also be addressed to change women’s economic outcomes.

Gamification makes the learning process engaging, so consider using a simple tiered micro‑credential model (Bronze-Silver-Gold) to signal competence. Also, scale selectively,  using a peer mentorship model to build skills and reinforce status.

For funders, invest in pilots that pair training with market access and access to finance, and conduct rigorous learning evaluations to identify what scales. Test the smallest combination of elements that produce measurable changes in income before scaling costly interventions.

The verdict

The pilot with HE showed that retention was driven not by substantial income but by a combination of social, psychological and practical incentives that made the CHE role sustainable.

For enterprise founders, the message is clear: invest in non-cash returns (status, agency, social recognition), adaptable financing, and bundled training solutions rather than relying on higher commissions alone. Doing so converts a marginal job into a resilient livelihood and reduces churn by addressing the economic and social reasons that might cause agents to leave.

Be gender-sensitive in the design and implementation of last-mile enterprise models. Collect and use gender‑disaggregated data to adapt intervention design and include gender‑sensitive safeguards so that women’s social returns and risks are explicitly addressed without disrupting household welfare.

Conduct evaluations that measure differential effects on women and allocate funds for interventions that demonstrably increase women’s social status and personal agency. Provide household support like spouse or family outreach sessions to encourage buy‑in and offer training schedules that allow women to balance their business with household responsibilities.

The women in this pilot stayed because the role gave them something beyond direct income. Building on that finding is what will determine whether last-mile models like this one can sustainably reach the communities that need them most.

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