Pharmacy on a Bicycle
The following is an excerpt from chapter one of the book, "Saving Millions."
Pharmacy on a Bicycle: Innovative Solutions to Global Health and Poverty
Eric G. Bing & Marc J. Epstein
240 pages, Berrett-Koehler Publishers, 2013
Every three minutes nearly forty children under the age of five die. That’s almost 7 million children per year. And 40 percent of these children die within the first month of life. In the same three 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 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, getting postnatal care, and receiving appropriate vaccinations.2 A small dose of daily aspirin might reduce risk of death from heart attack or stroke and simultaneously drop 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 inexpensively prevent and treat many of these diseases 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, while reducing costs. These are all critical pieces of the puzzle (Figure 2). Fortunately, the tremendous progress made in these areas over the past two decades gives us reason to be hopeful.
Over the past two decades, deaths for pregnant mothers and children under five years old have plummeted nearly 35 percent. Deaths from malaria are also on the decline – between 2000 and 2009, 43 nations, including 11 in Africa, had a 50 percent or more reduction in deaths or confirmed cases.7 Over 8 million people with HIV are now receiving life sustaining antiretroviral drugs (ARVs), a twentyfold increase from a decade ago.8
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.9 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.
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 local 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
Recent developments in technology, especially mobile devices, can also make distribution solutions for global health challenges cheap and easy. It is estimated that in many low-income countries, up to 90 percent of the population have 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 health solutions can bring 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 global health around the world.
Rapid Diagnostic Tests and Simplified Treatment
New technologies are emerging that allow easier and more effective prevention, diagnosis, and treatment. Rapid diagnostic tests for diseases such as malaria and HIV can be done in the field, reducing the need for and burden on laboratories and technicians.
Many diagnostic tests often require expensive equipment, typically found only in larger, centralized laboratories, clinics, or hospitals. For most diagnostics tests, the patient must travel to the testing center. Even after the taking the time and often the 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 when possible simplifies medication use and can improve medication adherence.11 By simplifying treatments we make it more likely that people will actually use the treatment, and use it properly.
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, small pox and other diseases. 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 may not be sustainable over time. For example, successfully preventing HIV transmission from mother to child has little meaning if the child is soon lost to 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 in 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.
1 You, New, and Wardlaw (2012) Levels and Trends in Child Mortality: Report 2012; World Health Organization (2012) “Maternal Mortality Fact Sheet.”
2 World Health Organization (2009) Investing in Maternal, Newborn, and Child Health: The Case for Asia and the Pacific.
3 Haskell (2003) “Cardiovascular Disease Prevention and Lifestyle Interventions: Effectiveness and Efficacy”; World Health Organization (2012) “Cardiovascular Diseases (CVDs) Fact Sheet”; Mayne (2001) “Nutrient Intake and Risk of Subtypes of Esophageal and Gastric Cancer”; Rothwell et al. (2012) “Effect of Daily Aspirin on Risk of Cancer Metastasis: A Study of Incident Cancers During Randomised Controlled Trials”; Rothwell et al. (2012) “Short-Term Effects of Daily Aspirin on Cancer Incidence, Mortality, and Non-Vascular Death: Analysis of the Time Course of Risks and Benefits in 51 Randomised Controlled Trials”; Raju et al. (2011) “Effect of Aspirin on Mortality in the Primary Prevention of Cardiovascular Disease.”
4 Sankaranarayanan et al. (2007) “Effect of Visual Screening on Cervical Cancer Incidence and Mortality in Tamil Nadu, India: A Cluster-Randomised Trial.”
5 Dandona et al. (2002) “Refractive Error in Children in a Rural Population in India.”
6 Patel et al. (2011) “Lay health Worker Led Intervention for Depressive and Anxiety Disorders in India: Impact on Clinical and Disability Outcomes Over 12 months.”
7 World Health Organization (2011) World Health Statistics 2011.
8 World Health Organization, United Nations Children’s Fund, and Joint United Nations Programme on HIV/AIDS (2011) Global HIV/AIDS Response: Progress Report 2011; World Health Organization (2012) “HIV/AIDS Fact Sheet.”
9 Similar initiatives to reduce malaria deaths such as the President’s Malaria Initiative and Malaria No More improve health outcomes related to development such as the ONE Campaign, and multiple other initiatives and international bodies, such as the World Health Organization, United Nations affiliated bodies, the Clinton Global Initiative, and the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunizations), among others, have also greatly helped. Improvements in maternal and child health have been supported by many organizations that have worked together, such as GAVI, UNICEF, CIFF (Children’s Investment Ford Foundation), and the Gates Foundation. Investments are coming not just from foreign entities but local governments. Domestic HIV investments by low-and middle-income countries reached US$8.6 billion in 2011 – the highest amount ever; Dunham (2008) “Bush Signs Expansion of Global AIDS Programs”; United Nations Development Programme (2011) Towards Human Resilience: Sustaining MDG Progress in an Age of Economic Uncertainty.
10 Zambrano and Seward (2012) Mobile Technologies and Empowerment:Enhancing Human Development through Participation and Innovation; Zuckerman (2009) “Web 2.0 Tools for Development: Simple Tools for Smart People.”
11 Connor, Rafter, and Rodgers (2004) “Do Fixed-Dose Combination Pills or Unit-of-Use Packaging Improve Adherence? A Systematic Review.”
12 Dybul, Piot, and Frenk (2012) “Reshaping Global Health.”
13 Leach-Kemon et al. (2012) “The Global Financial Crisis Has Led to a Slowdown in Growth of Funding to Improve Health in Many Developing Countries”; Institute for Health Metrics and Evaluation (2011) Financing Global Health 2011: Continued Growth as MDG Deadline Approaches.