Abstract
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Conventional, established medical systems have failed to reach hundreds of millions of the world’s poorest, but an assortment of unconventional, ground-level alternative approaches are succeeding to a remarkable degree, according to Eric Bing, director of Global Health at the George W. Bush Institute, and Marc Epstein, distinguished research professor of management at Rice University in Houston, Texas. The authors profile some of these unexpected success stories. Then, they describe how the world’s businesses, nonprofits, donors, and governments can work together to put each one to work on a worldwide scale.
The world’s health situation, while still deeply troubling, has improved in many respects over the last two decades. Deaths among pregnant mothers, for example, have fallen 30 percent in that time frame, while the number of HIV-positive patients who are receiving antiretroviral drugs has risen twentyfold in just the past decade. Successes result from “strategic alliances,” the authors state. Forward-thinking individuals and organizations within the affected countries are identifying public health problems and partnering with foreign governments, foundations, businesses, and other donors to devise solutions. The actors in each case work as a team to set firm goals for health improvements and to achieve them in spite of stark resource scarcities and a lack of developed infrastructures.
Technological breakthroughs have further buoyed their efforts, and mobile technology has proven to be a particularly useful asset. The vast majority of the population in many developing countries now have access to mobile phones, and health practitioners are learning how to use these mobile phones to help launch public health-education campaigns, collect population data, train health workers, check on patients and encourage them to comply with treatments, and even diagnose patients from afar. Rapid diagnostic test devices, which function just like the apparatus in a typical large doctors’ office but are small enough for a patient to use in their own home, are another significant new help. They make it possible for a health worker to assess a patient’s symptoms, read vital signs, and discern underlying medical conditions, all without fully equipped labs and technician teams, and without the patient having to leave home.
Additional health dividends have resulted from the growth in recent years of health care franchises. A chain of pharmacies or clinics can more easily purchase supplies in bulk, disseminate standards of care over a wide geographic area, and build connections with outside support systems than can independently run a facility. Ideally, the franchise will be run by local entrepreneurs, as they will also know best how to stimulate demand at the local level.
According to Bing and Epstein, the global community can take full advantage of these technological and business trends and, in so doing, build upon this progress in health indicators. They see the best hope for doing so in the implementation of a systematic “IMPACTS” action strategy:
Innovation and Entrepreneurship
The world needs to make health services available to more people while lowering the service costs. Adopting new technologies and new organizational and business practices can make the work of attaining these goals much easier. The authors cite dozens of examples, including the CFW Network, a clinic franchise that lends money to entrepreneurs in Kenya and Rwanda to establish “micro-clinics,” which treat specific conditions affecting their communities, as well as the short list of medical conditions responsible for 70 to 90 percent of child morbidity in developing countries; a portable General Electric electrocardiograph (ECG) machine that costs one-sixth the price of conventional ECGs; and LifeStraw, a water filter that fits into a straw and removes more than 99 percent of waterborne pathogens.
Maximizing Efficiency and Effectiveness
The fewer resources and personnel that health services require, the more accessible and less costly they will be. Bing and Epstein profile several models of outstanding health care efficiency, one of which is Narayana Hrudalaya (NH), an Indian cardiac-care hospital chain that not only treats patients at less than a third the costs of average hospitals in India but also treats a large number of patients for free. Patients select from tiers of service, ranging from free to progressively costlier, with more amenities offered based on how much one is willing to pay. The hospital keeps all expenses to a minimum through such practices as designating each surgeon to perform only certain types of procedures, shifting patient-related tasks to nurses and technicians, and routinely assessing records of each surgeon’s billable services and his or her costs to the system.
Partner Coordination
Governments, businesses, and NGOs can accomplish much more if they combine their efforts in public–private partnerships. One of the authors’ examples, the Global Alliance for Vaccines Initiative (GAVI), brings together a host of organizations and service providers involved in vaccine production and delivery from around the world into one shared cooperative. The participants stimulate vaccine production in each host country and arrange for countries’ governments to buy vaccine supplies at discounted prices. GAVI’s organizers estimate that they have saved the lives of 5.5 million children in developing nations since 2000.
Accountability
Health programs’ leaders need clear goals and steady monitoring to ensure that they are making adequate progress toward achieving them. That is how Rwanda successfully cut both child and maternal mortality rates by 60 percent under the auspices of its Animateurs de Santé program, which commissioned health workers to assess children’s health within their communities, refer patients who needed treatment, and distribute family-planning supplies. In 2006, the government found that mortality rates were not falling fast enough to meet targeted goals, so it began dispensing cash incentives to community health workers and to expectant mothers for prenatal care, in-hospital delivery, and postnatal care. The program reached its goals less than nine months later.
Creating Demand for Products and Services
Just as important as the innovations themselves is making sure that the recipient populations actually use the innovations. Providers and policy makers need to communicate to their publics why they should take up healthy lifestyle habits and avail themselves of health care services. Consider the recent success of Kenya’s Ministry of Health, which dramatically reduced HIV infection rates within Kenya’s Nyaza province by encouraging men to undergo circumcision—circumcised men are up to 60 percent less likely to become infected. The agency recruited community leaders to speak to their own communities about the benefits of undergoing the procedure. The campaign tailored its messages to reach first younger men, and then older men. Large numbers of men from all age brackets assented to circumcision.
Task Shifting
A health system that delegates tasks to first-response and lower-level providers can achieve impressive health outcomes, easing bottlenecks and boosting system efficiency with minimal resources. For example, community health workers can take on many of the roles of doctors in regions where certified doctors are few. The network of clinics that make up Healthpoint Services India demonstrates this by using telemedicine to enable regular communication between doctors in urban hospitals and community health workers in rural communities. The doctors visit communities periodically but use long-distance communication to help identify and monitor patients who need specialized treatment.
Scaling-up Programs
While thousands of individual health initiatives have been saving lives within their own isolated communities, an exemplary few have managed to expand to cover vast geographic regions. Some of these initiatives could scale up even further to work throughout the world. Global scaling-up presents a whole new set of challenges, but an organization will find the task less daunting if it has proven effective at adapting its services to individual populations and changing environments while keeping costs low, and if its workforce is firmly committed to their mission and empowered by upper management to take risks and make decisions.
Bing and Epstein’s case studies in effective scale-ups include the Bangladeshi Rural Advancement Committee (BRAC), now the world’s largest NGO. BRAC started in Bangladesh and now works in ten countries, providing a range of economic development, education, and health services to impoverished communities. It relies heavily on a volunteer force whose members work within their own communities and are thus personally invested in the successful outcomes.
Implementing these medical successes worldwide, via the IMPACTS approach, is all the more feasible thanks to many developing countries’ robust economic growth and the increasing interdependence of all national economies, as well as growth in investments by both businesses and developing countries’ governments in public health. Also critical, partnerships among medical institutions across the globe are expanding and successfully transferring medical skills and technologies from wealthier countries to less-wealthy ones.
The authors conclude that the time is optimal for making massive advancements in the world’s health and bringing the burden of disease down to never-before-seen lows. The developing world and individuals, such as the ones profiled in this book, are showing the way.
[Note: Pharmacy on a Bicycle presents a deluge of individual success stories, whose overall organizational flow comes across as far-flung and uneven. Reading it can feel overwhelming—but in the most positive sense of that word. The two authors cover huge amounts of ground, literally and figuratively, to tie together a dizzying array of accomplishments by forward-thinking innovators and reformers in health care systems the world over. A reader will leave this book with a new appreciation for the degree of progress taking place in many systems within many countries and regions. The sum of these many parts is to profoundly encourage hope for the future of global health.]