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Pharmacy on a Bicycle: Innovative Solutions to Global Health and Poverty

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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.

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1 Saving Millions

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Every four minutes over fifty children under the age of five die. Thats 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

Pharmacy on a Bicycle is about innovative and entrepreneurial solutions to these global health calamities and about how all organizationsgovernments, NGOs, businesses, and donorscan 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

 

2 Ideas in Action: Innovation and Entrepreneurship

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In much of Africa, Asia, and Latin America, there are few health workers, pharmacies, or clinics, particularly in rural areas, making it difficult to deliver inexpensive, high-quality health care to those most in need. When people in these regions get sick, they often get little care or no care at all.

People with the least access to the formal care system typically rely on informal health care, such as folk remedies from family, friends, or traditional healers, which may be ineffective. Others may travel by foot or even be pushed in a wheelbarrow many miles to seek health care in a larger village. Many who do eventually receive skilled medical attention arrive too late to be saved. Too often, they simply die at home or in transit. Requiring poor people without transportation to come to the few places they can get affordable, quality care is killing them: we must bring quality care to them.

Developing innovative ways to bring care to these people in need is what motivates groups of students and faculty at Rice University in Houston, Texas. They work to address health needs in developing countries, whose low-resource environments have little financial capital, limited human capital, poor roads, intermittent power supplies, and few other typically needed resources. One group of innovators is working to develop appropriate solutions, like a low-cost but effective bubble Continuous Positive Airway Pressure (CPAP) system developed to help infants in poor countries with respiratory problems breathe more easily.1 Another group is working on projects like a low-cost, electricity-free centrifugeusing a salad spinner, hair combs, and a round plastic containerthat can test up to thirty blood samples at once so community outreach workers can accurately diagnose anemia.2

 

3 A Shift in Perspective: Task Shifting to Save More

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Two of the main challenges in global health are that we have too few skilled health care providers and too few settings equipped to care for the large number of people who lack basic care. Right now, training large numbers of more highly skilled doctors or building many more highly specialized hospitals to care for patients is neither feasible nor the highest priority. One solution to closing this health gap is to task-shift health care to lower-skill-level providers and localized settings.

The goal of task shifting is to create system efficiencies, ease bottlenecks, and increase reach while reducing costs of services (Figure 8). It involves delegating responsibilities for specific tasks to other providers or other settings. The focus in task shifting should be on the ability of the provider or setting to perform specific tasks in ways that maintain quality, improve distribution, and reduce costs.

Task Shifting

Provider-type task shifting typically shifts tasks from providers at upper levels (doctors and others who are highly specialized) to middle (nurses, midwives, and skilled technicians) and lower levels (community workers, family members, and patients). Health personnel can consume up to 70 percent of recurrent health care expenditures in developing countries, so task shifting to lower-cost health care providers not only can save more lives, it can save money.1 Since higher-level providers are in short supply and expensive, task shifting improves efficiency by moving tasks that can be performed by others who are available in much greater numbers and may be significantly less expensive.

 

4 Tipping the Scales: Scaling Up to Save Lives

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Many exciting experiments and innovations in global health have the potential to dramatically improve the lives of millions in developing countries. These solutions do not need further scientific or technological refinement, but rather a business model that can disseminate these products and services to those in need in both urban and rural settings.

A critical part of the solution to creating impacts in global health is scaling up what worksgetting the right solution to the right customerall over the world.

There are poor-quality health programs that, when scaled, remained of low quality. Scaling bad programs may do more harm than good. And a number of health programs have achieved excellent quality outcomes in localized settings, but have generally not been able to replicate and scale their successes to other settings.1 What we need are high-quality global health products and services that can simultaneously achieve scale while maintaining high quality.

Scaling

To scale quality programs in high-resource settings, we need leadership; effective collaboration with communities and governments; and monitoring, evaluation, and accountability.2 But these prescriptions are insufficient for guiding scaling efforts in impoverished regions, where infrastructure is weak, resources are minimal, and education is not necessarily perceived as a right, or even a need. The obstacles are many, yet a handful of programs have successfully reached scale in these extremely challenging conditions.3

 

5 The Warmth of a Mother’s Touch: Maternal and Child Health

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Sadiki lay in pain, exhausted, on the floor of her home in Malindi, a rural village in Kenya. She had been in labor for more than twenty hours. She wondered why this birth was so much more difficult than her previous one. Maybe it was because her husband had been by her side back then. But after a roadside accident made her a widow at twenty-four with a set of twins at home and a baby on the way, all of life seemed different.

After her husbands death, Sadiki received aid from the Caris Family Foundation, an international NGO focused on helping single mothers develop health and business skills. Entrepreneurial by nature and now even more motivated, she began mastering skills and dreamed of opening a small daycare center after the baby was born.

But for now, her only desire was to end the pain.

This baby seemed way too big. So much bigger, she thought, than her twinscombined. Maybe she shouldnt have listened to the community health workers suggestion to get prenatal care. Maybe the supplements theyd given her and the healthier food she was eating had made the baby too big for her small body to handle.

 

6 A Drop of Vinegar: Solutions for Infectious Diseases

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On the surface, David was no match for Goliath. Just a small boy in a tunic, armed only with a slingshot, yet this small boy killed a giant of a man. And so it is with infectious diseases. Minute microbes one cannot even see with the naked eye are able to kill beings much, much larger and, seemingly, more powerful than themselveshuman beings like us.

Most often, however, the people they kill are poor and living in developing countrieslike the Angolan soldier who contracts HIV and gives it to his wife before he dies of AIDS. Or like the baby from Zimbabwe who is bitten by a mosquito that transmits a parasite that causes a fever, then a seizure, before killing her of malaria. Or like the Indian schoolteacher who contracts HPV (human papillomavirus) on her cervix, which turns into cancer and spreads throughout her body before consuming her life. Despite the tremendous advances that have been made in the prevention and treatment of infectious diseases, people in developing countries like Angola, Zimbabwe, and India continue to fall like Goliath.

 

7 The Elephants in the Room: Noncommunicable Diseases

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Noncommunicable diseases (NCDs), including cardiovascular diseases (stroke and heart attack), mental illness, cancer (but not cervical cancer), chronic lung diseases, and diabetes, represent nearly two-thirds of all deaths worldwide. Eighty percent of NCD cases occur in low- and middle-income countries.1 They will result in a potential loss of $47 trillion worldwide over the twenty years from 2010 to 2030the equivalent of 75 percent of the global GDP in 2010if nothing is done to stop them. Cardiovascular diseases and mental illnesses alone will account for 70 percent of that loss.2 Regardless of how we measure it, in terms of lives or money lost, NCDs are costly. Yet for the most part, they are ignored, especially in developing countries.

They are the elephants in the room.

The tremendously negative impact of noncommunicable diseases on global health prompted the United Nations in 2011 to convene a high-level meeting of world leaders to develop a consensus to combat them. The only other health problem that has warranted such action by the United Nations was AIDS.

 

8 Getting There from Here: Priorities, Plans, and Progress

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The seven-point IMPACTS approach provides a framework for saving lives in global health. Frameworks and models, however, dont save lives. People do. It is only when frameworks and models inform the development of plans that guide the actions of people and organizations do we create impacts that change and save lives.

As weve seen throughout this book, the people and organizations that are creating impacts in global health are not acting alone or in isolation. They work in partnership with governments, businesses, NGOs, donors, and others. Though the goals of these various efforts may be very different, such as immunizing children, preventing cervical cancer, or providing affordable care to the poor, they contain common features. They are innovative, entrepreneurial, guided by a plan, and monitored closely. When they hit roadblocks, they find ways around them. When they veer off course, they adjust and get back on track. They are designed to produce impacts.

Many books focus on creating business plans, stimulating innovation and entrepreneurship, managing health systems, and monitoring and evaluation. A number of them are included in the bibliography. Our goal here is to complement those sources with a brief overview of an IMPACTS-guided approach to setting priorities, creating plans, and ensuring accountability. Each is an essential component to helping ensure that time and resources are used efficiently and effectively to achieve output, outcomes, and impacts in global health.

 

9 Busting Barriers: Heeding the Call

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Millions of men, women, and children are dying of diseases we can inexpensively prevent and treat. Now is the time to create impacts in global health and save more lives. Significant technological and business model innovations have been developed that increase access, use, and quality while reducing the cost of health services. For these solutions to save more lives, they must be adapted to new populations and conditions, continually refined, and scaled to reach more people in more regions.

In Pharmacy on a Bicycle we have described many innovative and entrepreneurial solutions that have been developed in many countries by governments, NGOs, businesses, and donors to save lives. Fortunately, a confluence of circumstances makes scaling these solutions all the more feasible now. These circumstances include growing economies in many low- and middle-income countries, economic interdependencies among developed countries, investments by developing countries in health, and significant investments by businesses.

 

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