Pharmacy on a Bicycle

Innovative Solutions to Global Health and Poverty

Eric Bing, Marc J. Epstein

• Publisher: Berrett-Koehler Publishers
• Year: 2013
• ISBN:
  9781609947910
• Edition: 1
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

Every four minutes, over 50 children under the age of five die. In the same four minutes, 2 mothers lose their lives in childbirth. Every year, malaria kills nearly 1.2 million people, despite the fact that it can be prevented with a mosquito net and treated for less than $1.50.Sadly, this list goes on and on. Millions are dying from diseases that we can easily and inexpensively prevent, diagnose, and treat. Why? Because even though we know exactly what people need, we just can't get it to them. They are dying not because we can't solve a medical problem but because we can't solve a logistics problem. In this profoundly important book, Eric G. Bing and Marc J. Epstein lay out a solution: a new kind of bottom-up health care that is delivered at the source. We need microclinics, micropharmacies, and microentrepreneurs located in the remote, hard-to-reach communities they serve. By building a new model that "scales down" to train and incentivize all kinds of health-care providers in their own villages and towns, we can create an army of on-site professionals who can prevent tragedy at a fraction of the cost of top-down bureaucratic programs. Bing and Epstein have seen the model work, and they provide example after example of the extraordinary results it has achieved in Africa, Asia, and Latin America. This is a book about taking health care the last mile—sometimes literally—to prevent widespread, unnecessary, and easily avoided death and suffering. Pharmacy on a Bicycle shows how the same forces of innovation and entrepreneurship that work in first-world business cultures can be unleashed to save the lives of millions.

Part 1
The Prescription

1

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...