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Saving Millions

Every four minutes over fifty children under the age of five die. That’s almost 7 million children per year. And nearly one-third of these children die within the first month of life. In the same four minutes, two mothers lose their lives while trying to give birth to a child. And nearly every time these tragedies occur, they are happening in a developing country.¹

A Challenge We Can Solve

Pharmacy on a Bicycle is about innovative and entrepreneurial solutions to these global health calamities and about how all organizations—governments, NGOs, businesses, and donors—can use the solutions to maximum effect.

Nearly 7 million children could be saved by simple things such as providing a mother with prenatal care and encouraging her to give her baby breast milk and clean water, get postnatal care, and receive appropriate vaccinations.² A small dose of daily aspirin might reduce risk of death from heart attack or stroke and simultaneously cut the risk for some cancers.³

Deaths from cervical cancer could be cut with a simple drop of vinegar applied to the cervix to help a clinician identify potentially cancerous cells,⁴ kids could learn better with inexpensive glasses,⁵ and depression could be relieved, or a suicide prevented, by talking with a trained lay counselor.⁶

If It’s So Simple, Why Aren’t We Doing It?

So why are people in developing countries continuing to die from diseases we rarely see in developed countries? Most poor outcomes are caused not by lack of effective medicines or medical know-how. The ability to prevent and treat many of these diseases inexpensively has been available for a very long time. But getting the right remedies to the right people in the locations where they are needed, in a way they will use them, and at a cost they can afford is continually a challenge.

This is not a scientific problem. It’s a business challenge.

Solving the Puzzle

In order to save lives in global health, we need to increase health care access, use, and quality of services—all while reducing costs. These are all critical pieces of the puzzle (Figure 2). Fortunately, the tremendous progress made in these areas during the past two decades gives us reason to be hopeful.

Over the past twenty years, deaths for pregnant mothers and for children under five years old have plummeted by nearly 30 percent and 40 percent, respectively.⁷ More than 8 million people with HIV are now receiving life-sustaining antiretroviral drugs (ARVs), a twentyfold increase from just a decade ago.⁸

Figure 2 Solving the Health Care Puzzle

This progress is largely a result of business-oriented approaches to providing and using foreign health assistance. These approaches have focused on country ownership of problems and solutions, clear objectives, specific targets, a framework for accountability, and a commitment to measurable results. These successful efforts have been supported by better coordination among donors, resulting in a more than fourfold increase in health-related development assistance.

The President’s Emergency Program for AIDS Relief (PEPFAR), created by President George W. Bush in 2003 and continued by President Barack Obama, has committed $45 billion to HIV prevention, treatment, and care since it began. PEPFAR is complemented by the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The Global Fund is a multinational effort supported by a large number of countries and private donors, which have provided $32 billion to support health care programs in developing countries. These institutions have helped jump-start global efforts to combat HIV/AIDS. Similar initiatives have helped curtail malaria, reduce maternal and child deaths, and build stronger health systems.⁹

Through strategic alliances, committed partners have not only provided financial resources, but have leveraged their networks and complementary business, technological, and scientific strengths to solve global health problems. Partners have come from a variety of sectors, including governments, international development organizations, foundations, and universities, and they have worked with local organizations and leaders in the communities that are afflicted.

These local partners intimately understand the subtle but critical factors that can mean success or failure of a program or business. Working together they have helped improve access to health services for some populations and conditions, increase the quality of care, and reduce the costs of providing these services.

This progress, coupled with additional technological and business model innovations in global health, helps to make saving lives now even more feasible.

Innovations in Global Health

Mobile Technology

Recent developments in technology, especially mobile devices, can make distributing solutions for global health challenges cheap and easy. It is estimated that in many low-income countries, up to 90 percent of the population has access to a mobile phone.¹⁰ The health care potential of mobile phones is huge, and will become even greater over time.

Effectively using mobile solutions can bring health services to people who need them. Mobile phones are now being used for patient education and awareness, treatment compliance, health care worker training, data collection, disease and epidemic outbreak tracking, and diagnostic and treatment support. These solutions can help increase access, use, and quality, while reducing costs. As a result, mobile technology has the potential to create leapfrog advances in health around the world.

Rapid Diagnostic Tests and Simplified Treatment

New technologies are emerging that allow easier, more effective prevention, diagnosis, and treatment. Rapid diagnostic tests for diseases such as malaria and HIV can be performed in the field, reducing the need for and burden on laboratories and technicians.

Many diagnostic tests require expensive equipment that are typically found only in larger, centralized laboratories, clinics, or hospitals. For most tests, the patient must travel to the testing center. Even after spending the time and money to make the journey and see a provider, the visit may not help them. Equipment may be broken, or there could be long backlogs of tests to be performed. Rapid diagnostics can remove these time-consuming delays and provide point-of-care decisions, improving health care access for rural communities. Further, combining medications into a single tablet whenever possible simplifies medication use and can improve medication adherence.¹¹ By simplifying treatments we can make it more likely that people will actually use the treatment, and that they will use it properly.

Franchises

An additional business approach that provides opportunities to scale global health effectively is the development of health franchises and networks. Franchises can standardize care at local clinics and pharmacies and help reduce costs through purchasing in bulk, improving supply chain management, and increasing quality with other systems of monitoring and support. When run by local entrepreneurs who know community needs, franchises can create local demand. Franchising and networks provide a solution that harnesses this entrepreneurial base while addressing many of the quality challenges faced by independently operated health clinics and pharmacies.

Challenges and Solutions

While there have been notable successes in global health, some very significant challenges remain:

• Lack of Basic Health Care. Most people in developing countries, particularly in rural settings, still don’t have access to basic health care and are dying of preventable causes.

• Fragmented Care. Some of the successful outcomes in global health have benefited from focused attention and commitment to combatting specific diseases, such as AIDS, malaria, diarrhea, pneumonia, and smallpox. Efforts to prevent and treat these various diseases are often provided by different health systems and settings and by different caregivers, leading to care that is fragmented and that may not be sustainable over time. For example, successfully preventing HIV transmission from mother to child has little meaning if the child soon dies from malaria, pneumonia, or diarrhea—diseases that are not the focus of the HIV sector. Building upon the successful disease-specific systems and integrating care between sectors may help expand distribution of health products and services for more people, in more settings, more efficiently.¹²

• Financial Sustainability. There is an urgent need to create financially sustainable health programs, organizations, businesses and systems to ensure long-term impact on global health. As traditional donor countries’ economies have struggled, willingness to maintain consistent levels of assistance has become more tenuous.¹³ Donors, like host countries and communities, want financially sustainable health solutions rather than temporary or quick fixes.

We can build upon these successes now to create significant impacts in health.

The IMPACTS Approach

Our IMPACTS approach (Figure 3) builds upon global health and management lessons learned in practice over the last three decades and integrates the key points that can make significant improvements in global health. The seven-point IMPACTS approach can help increase health care service distribution in ways that enhance access, use, and quality of care, while lowering costs. Though our focus is on health in low- and middle-income countries, the IMPACTS approach has application to higher-income countries whose most vulnerable populations can also fall through the gaps of overburdened health care systems.

Innovation & Entrepreneurship

Innovation and entrepreneurship are foundational to the IMPACTS approach. Innovation is the introduction of new, better ways of doing things. It can involve the creation of more effective processes, services, and products, as well as new technologies. Entrepreneurs are not just creators of new businesses, they are discoverers of opportunities and they can be found in all organizations, including governments, NGOs, businesses, and donor groups. In the context of global health care in low- and middle-income settings, entrepreneurs can find ways to get health products and services to at-risk populations in ways they desire and at a cost that is financially sustainable.

Figure 3 The IMPACTS Approach

Ongoing innovation and entrepreneurship is essential to continually finding ways to increase access to and use of services, while improving quality and lowering costs.

Maximizing Efficiency & Effectiveness

To improve access and reduce costs, it is important to maximize the efficiency with which products and services are produced and delivered. The more efficient a process is, the fewer resources that are required to produce and deliver it. Maximizing efficiency goes hand in hand with maximizing the effectiveness (quality) of the product or service. Efficient and effective health services and products are key in global health.

For example, Aravind Eye Center, a network of specialized eye hospitals in India, uses processes to simultaneously maximize efficiency and effectiveness. The doctors perform thirty to forty surgeries per day by providing unequaled attention to processes. Assistants prepare patients for surgery, and when one patient is finished, another is already in the room, waiting to begin.¹⁴ The high volume of efficient surgeries reduces costs, improves surgeons’ skills, and enhances the quality of care they can provide.

Partner Coordination

Health care in developing countries relies on both the public and private sectors. Even in developing countries there is a private sector for health that includes not only businesses and NGOs, but also traditional health providers, birth attendants, and small clinical practices. In fact, half of all health care expenditures in Africa goes to the private sector.¹⁵

Unfortunately, in many developing countries, the public and private sectors are often poorly coordinated and regulated, resulting in gaps in services, lost opportunities, poor quality, and unsustainable systems. Like their wealthier counterparts, developing countries need strong public and private sectors that are supported, integrated, and regulated so health care is cost-effective, financially sustainable, safe, trusted, and accessible to the people who need it. Better coordination can help reduce gaps and redundancies among competing programs.

Partner coordination can be done on a large scale by a government or on a smaller scale by a local entrepreneur. For example, VisionSpring, a nonprofit organization, uses local entrepreneurs to sell low-cost eyeglasses to the poor on three continents. These entrepreneurs create partnerships with schools and businesses to provide inexpensive glasses so that students and workers can see better and be more productive.¹⁶ These partnerships benefit everyone, the individuals, the entrepreneurs, and the schools, businesses, and communities in which they live.

Accountability

Accountability measures let us know what works and what needs to be improved. The tools we now have for ongoing public health monitoring are considerably more accurate than those available just a few years ago. They enable earlier detection and the opportunity for more rapid effective responses. When something isn’t working, we can identify problems faster and make quick adjustments. Using these tools, global health programs can more effectively establish accountability based on specific measurable goals combined with regular monitoring. This is applicable to all sectors involved: governments, nonprofits, businesses, and donors.

Creating Demand

Demand for a product or service can increase when people are knowledgeable about it and believe they will benefit from using it, and when it is culturally and socially supported. Making health products or services highly available without also creating demand for them is as futile to improving health outcomes as creating high demand while ignoring availability, accessibility, and affordability. For example, insecticide-treated mosquito nets are widely known to prevent malaria, but in some communities they were not used because a white net seemed to resemble a funeral shroud.¹⁷ It was only by providing green or blue nets that demand was created in some places. This is quite understandable. Would you put a coffin in your bedroom and sleep in it at night if someone told you that it would reduce your risk of getting cancer?

Stimulating interest and creating demand for services, as well as creating incentives for clinicians and community workers, is critically important to providing services in developing countries. When the government of Rwanda provided nonmonetary incentives to both pregnant women and community health workers to increase the use of health services, prenatal visits shot up by over 85 percent in just nine months.¹⁸

A critical way of creating demand is through engagement of influential people to champion a cause, a product, or a service. Some champions may be highly visible, such as a politician, sports figure, or musician. Others, such as village elders or religious leaders, may be less visible but highly influential in local communities and extremely important in creating demand for health care among families and individuals.

Task Shifting

In task shifting in health, tasks are shifted from doctors to nurses and from nurses to community providers or patients. Tasks can also be shifted from the specialty sector to a nonspecialty sector. Task shifting helps reduce system bottlenecks and costs by increasing the supply of lower-level providers and settings where quality services can be provided (Figure 4).

In many clinical settings, tasks that doctors formerly performed, such as routine prescription of HIV medications, are now done effectively by nurses.¹⁹ Procedures that nurses formerly performed, like contraceptive implants, can be safely done by trained community health workers.²⁰

Task shifting can be effective not only for clinical services, but for clinical operations as well. For example, the Ugandan Ministry of Health is working to avoid clinic stock-outs by decentralizing supply management and empowering clinic staff through a program called mTrac.²¹ The program allows health workers to notify the National Medical Stores when supplies get low using text messages. In addition, the program allows the Ministry of Health to map real-time facility stocks using data submitted as text messages. As an incentive, staff members who send in results via text message get free airtime on their mobile phones. Through a complementary program, uReport, even community members can engage by anonymously sending a free text message when clinics run out of medications.²² Task shifting to different providers and settings has also been used to improve access to care for many health conditions, from family planning to clinical depression.²³

Figure 4 Task Shifting

In order to shift tasks as well as to improve quality, tasks must be broken into smaller essential parts, and providers must be trained to execute them well and must be consistently supported and regularly supervised. Simplifying procedures and rules helps ensure fidelity by making it clear what is expected of everyone.

Scaling

There are many examples in all fields of quite remarkable high-quality innovations that have been developed for small groups of people—a school, health facility, or business. They are terrific, but they benefit only a few. There are also many examples of programs and institutions that have gone to scale and reach large groups of people, but with a relatively low level of quality. To be maximally effective in saving lives, we must take successful, high-quality programs to scale to reach more people.

The components of IMPACTS are interrelated and complement one another. For example, efficiencies can be improved by task shifting or better coordination in partner contribution. Improved partner coordination, demand creation, and task shifting can facilitate successful scaling. Likewise, scaling can lead to improved efficiencies and help reach accountability targets. And all of these points rest on a foundation of innovative thinking and entrepreneurial action.

A Global Health Impacts Logic Model

We have developed a logic model to depict how global health organizations can have long-term impact. The logic model provides a clear articulation of an organization’s intended impact and the critical activities that drive success (Figure 5). It serves as a visual representation of the relationships among the available resources, necessary activities, and desired results.²⁴ The logic model helps managers, leaders, and stakeholders understand:

• The causal relationships between the various alternative actions that can be taken

• The impact of these actions on the system, the individual, and the community

By carefully identifying these interrelationships and by establishing relevant performance metrics to measuring success, an organization can improve decision making and inform others, internally and externally, who control or influence resources.

The Global Health Impacts Logic Model describes drivers of global health, the actions managers can take to improve performance and the consequences of those actions on individual and community health. Continual feedback loops are also necessary to allow leaders to evaluate and improve their strategies. The logic model is a general framework that managers should customize to fit their specific needs and environment.

A fundamental component of this model is the distinction between short-term outputs, medium-term outcomes, and long-term results (impacts). Outputs and outcomes must be carefully defined and monitored to determine the effectiveness of processes in place to achieve impacts. Ultimately, program success can be seen in the social and economic effects on the community.

Figure 5 Global Health Impacts Logic Model

Starting Here. Starting Now

Millions are dying of diseases that we can easily and inexpensively prevent, diagnose, and treat. Our challenge in global health is not one of lack of medical know-how. It is that we are not getting the right remedies to the right people, where they need them, in a way that they will use them, and at a cost they can afford. We can reach and save millions simply by stimulating innovation and entrepreneurship, maximizing efficiency and effectiveness, coordinating our work with partners, being accountable for results, creating demand for health services, shifting tasks to workers and settings to reach more for less cost, and scaling up to reach more. Now is the time to save millions in global health.

Appendix: Detailed Components of the Global Health Impacts Logic Model

Inputs

The inputs of the logic model include an organization’s internal and external context, resources, and constraints. These guide the decisions of leaders and the processes the organization uses to improve the health of the population. They provide a foundation for understanding the complex factors that leaders should consider when developing programs and making decisions.

Organizational. These inputs include all of the internal contextual factors and resources available. This includes financial capital, personnel, systems, brand recognition, and organizational culture.

External. External inputs significantly affect the choices an organization makes regarding the formulation and implementation of a strategy. These inputs include economic constraints and competing needs, system infrastructure, social and cultural factors, and the business environment, including competition and regulatory guidelines that may vary by country and can change over time.

Processes

After evaluating the inputs and considering the program’s goals, leaders can develop the appropriate processes to improve the health of target populations. Our IMPACTS approach describes these processes.

The processes put in place for an organization are highly dependent on the inputs and desired impacts. IMPACTS elements can be used to leverage system strengths and minimize costs to achieve organizational objectives.

Outputs

The outputs of an organization are the short-term results of the processes in place. In the Global Health Impacts Logic Model, these outputs are related to access, use, quality, and cost. An organization’s activities can affect one or more of these outputs.

Access. Improving access means improving the ability of health care services and products to reach those in need. Often, geographic distances and time constraints prevent individuals from receiving lifesaving care and services.

Use. Providing affordable health care that is easily accessible does not guarantee that target populations will actually take advantage of it and make use of the care. It is important that what is being offered is actually used—and to be used, people must believe that its value is greater than its costs, both financial and nonfinancial.

Quality. High-quality products and services are important to improving health. Improved health cannot be achieved with increased access and use alone. Accountability processes must be in place to monitor quality.

Cost. The cost of producing and providing health products and services is a crucial factor in determining whether it will be available or used. Costs of products and services must not be confused with the amount paid by a consumer. Portions of the total costs may be borne by the consumer, the government, NGOs, donors, and/or other entities. By reducing costs, regardless of who pays for it, you increase the likelihood that a product or service will be accessible, used, and financially sustainable over time.

Outcomes

By improving the outputs (increasing access, use, and quality, and decreasing cost), organizations are more likely to improve health outcomes.

Impacts

The ultimate goal in global health is to improve the long-term health of the target community. Improved health allows individuals to pursue education, to work, to care for others, and to contribute to society. Improved health has benefits to society far beyond health.