Course 4: The Science of Global Health Delivery

The global health community today is facing what some have called an “implementation bottleneck.” There are vast amounts of resources being funneled into global health work, such as vaccines, primary health care, drug therapies, maternal and child health care, and basic surgery. However, despite vast amounts of money, tools, and interventions, the successful delivery and implementation of these resources remain elusive.

In other words, the greatest constraint is not the availability of interventional tools of medicine but rather their delivery to those who need them most.(1) For example, full use of existing interventions would cut the 10 million annual child deaths that occur globally by more than 60%.(2) In addition, a high proportion of the half-million maternal deaths that occur globally every year could also be prevented by promoting access to interventions and services of known efficacy.(3)

“In the rest of the economy, huge gains have been made by better integrating and coordinating all activities required to serve customers. Seamlessly coordinated networks and partnerships have replaced adversarial or arms-length relationships in delivering value for end users. Health care is long overdue for such a transformation.”(4)

Part of the reason for this delivery failure is due to the lack of health infrastructure in much of the Global South. Because of this reality, the global health community faces an unprecedented challenge of transferring vast amounts of resources to individuals, often in rural and remote locations, with little to no infrastructure to work through. Several steps exist in the process of achieving successful health outcomes: the discovery of a drug or intervention, its development and production, and lastly, its delivery. It is this final link in the chain that poses the most formidable challenge to the success of global health endeavors. Three strategies are suggested here to overcome this implementation bottleneck: implementation research, synergies between global health initiatives and health systems, and a business framework for health care delivery.

1. Implementation Research

In global health, there needs to be a focus on implementing existing knowledge into actual programs and policies. Implementation is defined as a specific set of activities designed to put into practice a program of known dimensions.(5) Thus, implementation research focuses on how to promote the uptake and successful implementation of evidence-based interventions and policies. Such research focuses on what is happening in the design, implementation, administration, operation, services, and outcomes of programs, and it also asks, “Is it what is expected or desired?” and “Why is it happening as it is?”(6) This is important in order to close the gap between knowledge and implementation, as we cannot do so without theoretical models of good implementation systems for the delivery of health care.

While implementation research can provide information about whether a single program is efficiently delivering care, the ultimate goal of such research is to share best practices with other initiatives, NGOs, and policymakers. Mechanisms should be in place to compare different approaches to the delivery of global health services. Thus, integral to implementation research is coordination across activities. Research should be multidisciplinary, encompassing both quantitative and qualitative approaches that require expertise in epidemiology, statistics, anthropology, sociology, health economics, political science, policy analysis, ethics, and other disciplines. Sharing information in a multidisciplinary setting can include activities such as case studies which document successful implementation strategies, operations research, and decision analysis.(7)

2. Synergies between GHIs and Health Systems

A major critique of global health today is that it is primarily defined by multitudes of NGOs, programs, and global health initiatives (GHIs) that are focused on singular, discrete problems. It has been said that global public health programs will have to move beyond a focus on building successful “projects” and become fully functioning health care delivery organizations.

The concept of positive synergies between health systems and GHIs is a strategy meant to address the fact that when resources are supplied to a country’s health services through GHIs, there may be unexpected “spill-over” effects.(8) Some of these effects are positive and some are negative (fragmented infrastructure, multiple reporting, uneven distribution lines, etc). Developing a positive synergy refers to actively and systematically managing the relationship between GHIs and already-existing health systems to structure and coordinate the delivery of health care in an efficient and cost-effective manner.

A World Health Organization May 2008 consultation report entitled “Maximizing positive synergies between health systems and Global Health Initiatives" reports on this process. The document carefully outlines the need for this type of solution, the knowledge-gathering process and coordination required to achieve it, and examples of existing work that is being done in the area. Within the larger framework of global health, this concept is part of the goal of developing a “science of delivery” and addressing the proliferation of global health initiatives that operate in isolation.

3. Learn from Business Models

Global public health can learn from the private sector. In particular, the application of management science can be applied to create a science of healthcare delivery. “Strategy” is the field of the management sciences devoted to helping organizations define a long-term approach to achieving specific goals.

“Strategy researchers aim to develop frameworks that are grounded in value creation for customers or other stakeholders, and incorporate the complexity of how systems for the delivery of products and services actually work—the activities of delivery and their economics, organizational dynamics, the behavior of other involved actors, and contextual factors that affect how activities are designed in particular settings.”(9)

For example, The Global Health Delivery Project, formed in 2006 as a partnership between Harvard Medical School and Harvard Business School, advocates this model of healthcare delivery. The goal of the partnership is to systematize the study of global health care delivery and rapidly diffuse innovations to practitioners. This approach involves the careful analysis of global health delivery programs and the creation of analytic frameworks that can guide care delivery system design, operations, and improvement. The ambition of this new academic enterprise is to improve global health care delivery in resource poor settings.

Coca-Cola and Delivery at the Base of the Pyramid

In fact, there has been talk about using Coca-Cola’s business model and distribution lines to deliver essential medicines. Certain commodities, such as Coca-Cola, matches, and cell phones, are available in abundance in rural communities throughout the Global South. What enables widespread distribution of these products in remote areas? It is clear that practical lessons can be gleaned from business models and applied to the public health sector. However, the exact mechanisms that drive the success of the private/corporate sector are not clearly understood. Can these same mechanisms be applied to the delivery of health care? What unique aspects distinguish health care from other commodities? We can gain insights into these questions by examining the distribution model of Coca-Cola as well as the delivery networks for products such as matches and cell phones.

In remote places in the Global South where it is impossible to access the most basic medications, you can walk across the street and buy a soda. As one health worker puts it:

“Thousands of smart people spend millions of dollars trying to get life-saving medications to the people who need them. And too often, we fail. But Coke is everywhere in this country, from the fanciest hotels in Dar es Salaam to little shops in the Serengeti. They're doing something right.  My co-worker told me that Coke Tanzania has teams dedicated to tracking which vendors buy from specific distribution centers and exactly where bottles are sold. If things aren't working, they identify the kink in the chain and fix it, as soon as possible.”(10)

David J. Olson, Director of Policy Communications for the Global Health Council, has suggested harnessing Coke’s delivery networks to deliver malaria drugs, bed nets, condoms, and other essential health products. In fact, one organization, Colalife, is trying to develop an “aidpod” that fits between coke bottles and carries “much needed social products such as oral rehydration salts and high-dose vitamin A tablets.”(11) More attention to this idea came as the result of a controversial article published in The Guardian. The author, Sarah Boseley, wrote about the omnipresence of Coca-Cola products and simultaneous lack of basic medicines in the Global South:

“The new battle is now not just to get HIV medicines to people with AIDs, but to get a consistent, affordable supply of essential drugs to all who need them. That means that governments in the west, as well as in developing countries, need to make money available, and turn their attention to supply systems. It can't be left to Coca-Cola barons. It's too important to leave to the market. Not just for Uganda, or Africa, but for all of us.”

In a preemptive response to potential accusations of poor standards of corporate social responsibility, Coca-Cola representative David Cox replied:

“Like Sarah Boseley, Coca-Cola is concerned about the lack of vital medicines reaching Katine and other communities throughout Africa. So we are examining if it is possible to use the success of the distribution system for our drinks, and the expertise behind it, to help tackle this challenge. It is not as easy as it may seem. The reason that Coca-Cola and our other products are so widely available in Africa is largely because of the efforts of independently-owned small businesses that make money for each case they deliver. Any initiative to distribute medicines or other essential public goods has to maintain these commercial incentives or they simply will not work.”(12)

The sentiment expressed by Cox highlights the reality that the Coca-Cola Company is first and foremost a commercial outfit. Thus, the distribution chain works through commercial incentives. While Coca-Cola has used their distribution network to deliver emergency aid in response to local disasters and crises, the sustainable delivery of health care services and/or educational material would need to maintain those incentives. Yet as Boseley mentions in her article, many people believe that market forces are neither sufficient nor stable enough to guide the sustainable provision of health services.

Matches and Cell Phones

Like Coca-Cola, matches are a unique product because of their high demand and low price. In fact, 97% of rural households in India purchase matches on a monthly basis.(13) The near universal presence of matches provides an opportunity to reach underserved markets. By tracking the flow of matches from manufacturers to consumers, we can better understand the distribution system and evaluate the potential for using and replicating such channels.

However, this systematic tracking has not yet been done. Systems research is needed to understand the underlying distribution network for products like matches and Coca-Cola. How do they reach the end-user? How many distributors do they go through and how long does this take? The answers to these questions can provide insights for scaling up other products and services.

Another idea to improve the delivery of health care in the Global South is by harnessing the power of cell phones. The number of cellular subscribers worldwide has surged nearly 25% annually for the past eight years, growing to reach over 60% by the end of 2008.(14) Researchers at MIT’s Legatum Center are investigating new ways to harness cell phones to help people in low- and middle-income nations. Michael F. Maltese, the center's managing director comments on the goals of the project:

"Since mobile phones are dispersed throughout the developing world, they now constitute a platform atop which other services - mobile banking, mobile health, etc. - are now possible."(15)

Improving the delivery of health care in rural areas has been the major focus of these research efforts. Patients in rural areas, for example, often spend an entire day traveling to the nearest clinic in order to receive basic health services. By using a menu of questions downloaded to a cell phone, the idea is that a patient can transmit enough information to a doctor or nurse to get a preliminary diagnosis and to find out whether the condition warrants a trip to the clinic. Like matches and Coca-Cola, the far-reaching penetration of cell phones into rural areas of Africa and other low- and middle-income countries may provide a unique opportunity for the delivery of health care.

Health Care

It is clear that the distribution channels for commodities like Coca-Cola and matches are pervasive and that the idea of harnessing these networks for the delivery of health care has potential. However, in many ways, health care services are a far cry away from beverages and matches. The complexities of health care may hinder it from achieving the same widespread distribution.

One concern is whether health care services should be marketed as commodities. This concern was expressed in the New York Times in 2007, when Arata Kochi, director of WHO’s Malaria Program, wrote: “I’m not sure whether the poorest of the poor actually drink Coca-Cola. Yes, the soft drink has great market penetration, but the world’s poorest remain too poor to actually buy it.” In other words, if basic health care services are to be understood as commodities like Coca-Cola, there will be implications for those who are unable to afford such services.

On the other hand, if we chose to frame health care as a public good, using for-profit businesses to distribute health services could create a real or perceived conflict of interest. This could occur if a company interprets the piggybacking of health materials as an additional marketing opportunity. Furthermore, the soft drink and fast food industries are not known for public health promotion.(16) As The Lancet editors wrote in an editorial highly critical of the industry’s marketing tactics, “if the industry continues on its present trajectory, the public’s opinion of Big Food is going to follow that of Big Tobacco and decay as quickly as a Coca-Cola-drinker’s teeth.”(17)

Another complexity lies in the fundamental difference between the structure of corporations and public health systems. Coca-Cola is a large and powerful corporation. In comparison, the health care field is much more diversified in its products and fragmented in scale. Local health care needs vary from place to place, which makes utilization of mass distribution channels more complex. Furthermore, sustainability remains a real issue. Essential medicines could be delivered through Coca-Cola lines, but who would pay for this sustained distribution?

Lastly, the provision of health care requires trained health workers and physicians. In order for essential medicines to be distributed and effective, patients must be educated on when and how to take them. Effective health care cannot merely be delivered without providing the follow-up needed to assure adequate rates of adherence and resolve potential complications. In order to address the issue of access to health care in the Global South, we must remember that “delivery” is only part of the solution.

Conclusion

There is place for a new field in global health research and education: the science of health care delivery. Before, the standard progression toward better health outcomes was from basic science (what is the pathophysiology of the disease?), to clinical science (what is the diagnosis and appropriate intervention), to evaluation science (does the intervention work?). Today, we understand the need for an additional step, health care delivery science, in order to successfully and efficiently deliver global health resources to those in need.

Footnotes

(1) Sanders, David, and Andy Haines. (2006). "Implementation Research Is Needed to Achieve International Health Goals." PLoS Medicine. 3 e186, 1-4.

(2) Jones G, Stekettee RW, Black RE, Bhutta ZA, Morris SS, et al. (2003). How many child deaths can we prevent this year? Lancet 362: 65–71.

(3) Wagstaff A, Claeson M (2004) The Millennium Development Goals for health: Rising to the challenges. Washington (D. C.): World Bank Publications.

(4) Porter, Michael and Elizabeth Teisberg. (2007).How Physicians Can Change the Future of Healthcare. JAMA. 297:1103-1111.

(5) Dean L. Fixsen, Sandra F. Naoom, Karen A. Blasé, Robert M. Friedman, Frances Wallace. (2005). Implementation Research:A Synthesis of the Literature, Univeristy of South Florida, Tampa Fl, p. 1-6.

(6) Sanders, David, and Andy Haines. (2006). "Implementation Research Is Needed to Achieve International Health Goals." PLoS Medicine 3: e186, 1-4.

(7) Ibid.

(8) World Health Organization. Maximizing Positive Synergies Between Health Systems and Global Health Initiatives. Geneva: World Health Organization, 2008.

(9) Kim, Rhatigan, Jain, Porter “Values to Value” article in forthcoming lancet on Values in Global Health.

(10) Gordon, Mara. “Coca-Cola and Public Health.”

(11) "ColaLife." ColaLife. N.p., n.d. .

(12) King, Mark. "Drug Supply in Katine." The Guardian. Guardian News and Media, 25 Aug. 2009.

(13) "Match Point: How to Reach Rural Markets." NextBillion.net - Match Point: How to Reach Rural Markets. NextBillion.net, n.d.

(14) "Number of Cell Phone Subscribers to Hit 4 Billion This Year, UN Says." Communication and Information Sector's News Service. UNESCO, 26 Sept. 2008.

(15) Kazan, Casey. "MIT Teams: Can 4 Billion Cellphones Change the World for the Better?" The Daily Galaxy: Great Discoveries Channel. The Daily Galaxy, 6 July 2009.

(16) Yamey, Gavin. "Buying a Coke in Africa: Are There Lessons for Malaria?" Speaking of Medicine. The Public Library of Science, 6 Oct. 2009.

(17) Myths and morality at Coca-Cola.  The Lancet; (9671)1224: 11 April 2009.