Putting the 'live' back in delivery

Research has shown that more than half of all childhood mortality could be prevented each year if the world’s children received full access to already existing, often low-cost interventions. Yet, there remains a clear implementation gap and a perpetual challenge to take effective interventions, policies and programs that can save lives and improve health to scale.

At least one-third of the world’s population, for example, has no regular access to essential medicines. So as we search for novel drugs and vaccines, we should keep in mind that a medicine that is 95 percent effective but only gets to 30 percent of the people that need it is limited in its operational effectiveness.

While we are accomplishing incredible feats — like landing a spacecraft on a comet traveling 40 times faster than a speeding bullet — our rate of progress in addressing these health-related challenges has not kept pace. Our problem is visibly not about human ingenuity or ability, but rather the will, funding and multisectoral partnerships necessary to deliver at-scale solutions in efficient and equitable ways. Strengthening our knowledge base and innovating in this area is critical.

The recent Statement on Advancing Implementation Research and Delivery Sciences from Health Systems Global lays out some of the important steps we can take as we pursue this relatively new direction.

The end user: At the heart of everything we do

The need to work with our end users is hardly a new concept.

In his book “The Fortune at the Bottom of the Pyramid,” C.K. Prahalad called for “a better approach to help the poor, an approach that involves partnering with them to innovate and achieve sustainable win-win scenarios where the poor are actively engaged.” He describes a vision of “co-creation of a solution to the problem of poverty” that can only be unlocked if large and small firms, governments, nongovernmental organizations, academia, development agencies and the poor themselves work together with a shared agenda.

Despite this inherent development paradigm, access to medicines at the population level is typically addressed through fragmented, often vertical approaches that usually limit their focus to supply-side issues. Applying a more holistic systems lens that is inclusive of the complex relationships between medicines, health financing, human resources, health information and service delivery and which gives due consideration to demand-side constraints can lead to improved access.

Demand-side constraints influence uptake of services by the end user, their households and communities, while aspects of the health sector and health services that impede uptake make up for supply-side constraints. More classic dimensions of access — availability, geographic accessibility, affordability, acceptability/rational use and quality — can help identify other important barriers.

The need to strike a better balance when considering these various dimensions becomes clear when we look at the case of oral rehydration salts and zinc for the treatment of childhood diarrhea. Overwhelmingly, focus has been placed on supply-side factors, with emphasis placed on cost. However, context is key and without due consideration of the detailed realities on the ground, a solution will never be completely effective.

The history of ORS

Searching for a therapy that could be applied in the field, far away from hospitals and intravenous treatment, scientists conducted much of the research around ORS within the context of cholera epidemics in the late 60s and early 70s. Until that time, even the concept of an oral therapy for cholera was considered quite unbelievable for most people.

By 1971, scientific support for the use of oral rehydration therapy had reached mainstream media with the completion of work by Mahalanabis and Hirschorn. It wasn’t until the late 70s, however, that cholera ceased being the primary target for rehydration research. In 1978, the World Health Organization recognized that in nonepidemic seasons, cholera accounts for less than 5 to 10 percent of all acute diarrheas in cholera-endemic areas. That same year, the advisory group for the WHO’s Control of Diarrheal Diseases program met in

Geneva to study the various tactics that could be leveraged in the global fight against diarrhea. By the time the CDD program was fully operational in 1980, the standard formula for ORS had already been determined at the 1978 meeting based on research available at that time. The investigators who designed those studies believed that the oral solution should consist of one universal form and quantity to facilitate use by untrained villagers and public health workers under very basic conditions. They therefore decided on an arbitrary amount — 1 liter — and hoped for the best. It is this legacy that has shaped guidelines around the nonformulaic aspects of ORS preparation and manufacturing to this day. Development of ORS was therefore based on need and not demand.

From crate to community: The ColaLife story

ColaLife started with the recognition that while the shelves at rural health centers were often empty, those at community-level shops always seemed to be full. One product in particular seemed to be somewhat ubiquitous, and that was Coca-Cola.

It seemed to get everywhere, even to the most remote parts of developing countries. Yet in some of those same places, approximately 1 in 11 children die before their 5th birthday. Many of these deaths are preventable and often due to a lack of access to essential products and services.

By leveraging the same principles and existing networks (of wholesalers and retailers) that facilitate the distribution of Coca-Cola and other fast moving consumer goods, ColaLife is working to open up locally established, private sector supply chains for products such as ORS and zinc. While we began with the concept of “piggybacking” ORS and zinc in the empty spaces between crated bottles of Coke, we have since extended into a range of innovations based partly on Coca-Cola’s expertise and networks, but also by working with our end users and questioning the status quo. This has allowed us to approach the problem of access to ORS and zinc from a health systems perspective, tackling the issue at multiple levels.

Recent evidence has shown that globally, of those children with acute diarrhea, only a third receive ORS and less than 1 percent receive zinc. Speaking with caregivers living in rural Zambian communities (where our trial took place) early in the process, we learned a great deal about local factors that contribute to these types of statistics. These included:

·       Long distances to access points (usually walking)

·       Regular stock-outs at health centers (generally the only place one can access ORS and zinc in rural Zambia)

·       Challenges associated with preparing 1-liter sachets of ORS at home

·       Willingness to pay for a commercially available ORS and zinc product

·       Branding and product preferences

The approach that resulted involved the creation of an innovative diarrhoea treatment kit, as well as the establishment of its value chain. Value chains result in collaborative partnerships between networked players engaged in economic exchange. In our case, players included a local pharmaceutical company, existing district-level wholesalers, and community-level microretailers who purchase goods from the wholesalers and transport them over “the last mile” to the communities they serve.

In a value chain, value flows back from the end user toward the manufacturer, strengthening the chain and building confidence of the players involved, while the product is “pulled” to the end user (as opposed to being “pushed” as is the case with most public supply chain systems for medicines). This means two things: that the end users need to value the product; and they need to have ‘value’ in their hand to purchase the product — whether cash or, for example, a voucher.

Enter the Kit Yamoyo, an innovative diarrhea treatment kit based on human-centered design. Working in collaboration with rural Zambian mothers of children under 5, it was developed with a focus on demand-side dimensions of access. The kit co-packages orange flavored ORS, a blister pack of zinc, a small bar of hand soap, as well as an instructional pamphlet that doubles as the branding for the product. While the packaging itself was originally designed to fit in the empty spaces between crated bottles of Coke, this proved to be relatively unimportant. Far more relevant, was the packaging’s ability to serve as a measuring, mixing and drinking vessel for the 4.2 g sachets of ORS inside (each making up 200 mL of solution).

Upon speaking with caregivers, we learned about the inappropriateness of the typical 1 liter sachet of ORS for home use. Firstly, mothers have no standard way of measuring out a litre of water. They typically use whatever type of measuring vessel is on hand. This can range from a small cup of 150 mL to a large jug of 4 liters, resulting in solutions that are either too concentrated (which can worsen the diarrhea) or too diluted (which can reduce the efficacy). In addition, children under 5 will only consume an average of 400 mL of ORS solution per day, and prepared ORS solution should be discarded after 24 hours to prevent contamination. This either results in wasted solution (if appropriately discarded), or promotes use of the prepared solution past the safety zone of 24 hours.

Our research found that providing the tool necessary for performing the correct behavior (packaging as measuring vessel) helped ensure proper preparation of ORS by over 90 percent of Kit Yamoyo users, while only about 60 percent of those who used the typical 1L sachets from the health centre prepared the solution in the correct concentration. Overall, in the intervention districts, the approach increased coverage of ORS and zinc from less than 1 percent at baseline, to 45 percent at endline, while coverage remained at less than 1 percent in the comparator districts.

Applying a health systems lens which considers both supply and demand side factors, including the details of implementation at the user level gleaned through simply listening to our end users, should be at the heart of any access discussion.

Want to learn more? Check out the Healthy Means campaign site and tweet us using #HealthyMeans.

Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.