OK, so the title is enough to make you shiver: it smacks of making money off the poor and at least hints at exploitation.  That’s not what we want.

Yet what we have learned, from our admittedly small sample of projects in sub-Saharan Africa, that many clinics, programs, and hospitals operating in conditions of excess need and excess demand do not get the word out to their “markets.”  In one setting in a low-income area of Nairobi, awareness of a clinic’s existence fell off very rapidly with distance from the clinic–within hundreds of meters. In other cases, programs suffered from uneven or low demand. Clearly issues related to the opportunity cost of taking a day off, the challenges of physical travel, and the service and medication costs are all factors affecting access to health care. But so too is knowledge–and here’s where marketing comes in.

Can we draw any lessons from the business school approaches to marketing that could be used in a resource-constrained setting? We examined one case, based on one student team’s experience last year. The situation that the team entered in January 2009 is presented in a traditional teaching case written by the students themselves: Empowering Lives in Kenya: The Chebaiywa Clinic.

Now for the thought-experiment. What could Empowering Lives International-Kenya borrow from our study of marketing? From the sorts of things our MBAs learn in classrooms, summer internships, and on the job?

There may be some object lessons from the field. Consider this reflection on water purification technology reaching a low-income market. What do you make of the author’s arguments?

And post comments to share resources in this area. Here’s one to get you started:  Vachani, Sushil and Smith, N. Craig, Socially Responsible Distribution: Distribution Strategies for Reaching the Bottom of the Pyramid (December 5, 2007). INSEAD Business School Research Paper No. 2008/21/ISIC. Available at SSRN. There’s a dearth of research in this area, and what we can find is often oriented toward consumer products. What about health services and medical products? How to spread the word and generate demand? Is there need to connect what public health experts have learned from vast experience in the field with a business perspective?

We had a fascinating series of discussions about the potential for business models for addressing unmet needs for healthcare in resource-limited settings. To frame the discussion, we considered C. K. Prahalad’s framework, looking first at one of the earliest presentations of the ideas in a piece coauthored with Stu Hart: “The Fortune at the Bottom of the Pyramid” from strategy+business, first quarter 2002. Since then, a new edition of Prahalad’s book has come out.  Here’s a recent interview with him by a Wharton publication; and the book publisher’s site includes a downloadable copy of the introduction. There’s also a snazzy book site for the 2009 edition that includes a wide range of downloadable material–the bonus content, in particular, is worth exploring.

Is there a fortune to be made in healthcare? For people earning a dollar a day?

Since I’m thinking about influential Indians at the moment, I’d like to juxtapose the Prahalad framework with Dr. Devi Shetty and his Narayana Hrudalaya Hospital in Bangalore. A recent Wall Street Journal article calls him the “Henry Ford of Heart Surgery.” Take a look at the business model for this hospital. What do you think?

Student teams are hard at work on collaborative projects designed to address bottlenecks that limit the delivery of health care in the five countries in sub-Saharan Africa where our dozen teams are working with host organizations this year. What tools from the MBA toolkit will they draw on?

Many of our efforts address management, improvement, and expansion challenges and opportunities. One tool that may find use in several projects is the balanced scorecard (here’s an introduction of sorts, presented as an overview of a new book by leading proponents of the approach). A well-designed scorecard serves as a dashboard for monitoring operational performance, guiding change, interacting with stakeholders, and aligning the organization. We found one example of it used in a report on Service Delivery from the WHO’s Toolkit on Monitoring Health Systems Strengthening.

By the way, for more on this particular work on balanced scorecards in Afghanistan, further resources include: Peters, D.H., Noor, A.A., Singh, L.P., Kakar, F.K., Hansen, P.M., Burnham G. “A Balanced Scorecard for Health Services in Afghanistan.” Bulletin of the World Health Organization 2007, 85: 146-151. (http://www.who.int/bulletin/volumes/85/2/06-033746.pdf )

Hansen, P.M., Peters, D.H., Niayesh, H., Singh, L.P., Dwivedi, V., Burnham, G. “Measuring and Managing Progress in the Establishment of Basic Health Services: The Afghanistan Health Sector Balanced Scorecard.” International Journal of Health Planning and Management 2008, 23 (2): 107-117.

The Ethiopian health sector is taking 0n a national balanced-scorecard project to improve performance. And US examples of healthcare applications of the approach abound (some examples).

Now, the notion of non-profit dashboards has been around for a while. How are balanced scorecards different from these? Some of the issues are laid out in this blog post. What are the implications for global health delivery? Which aspects of which approach are most useful? Do the same ideas apply to small, resource-constrained organizations?

To carry out Global Health Delivery work in sub-Saharan Africa, you need to learn about the country, context, and health sector. What are the resources that will take you beyond things like About.com and Lonely Planet guidebooks–where do you find professionally appropriate sources of data?

Your first stop should be our library resource page.  Make sure to set aside time to go there now: check all the tabs, know what’s there, and use what’s most useful.  Definitely consult the incredibly knowledgeable librarians for in-person help or click on the email help on the library web pages to send a request that will be filtered to a specialist. Don’t neglect the items in the navigation bar on the right side of this page: that’s why they’re there.

Our GHD colleagues shared a list of their key sources, too.

As many already know, relevant resources include the WHO (along with the general site, there’s the Regional Office for Africa and WHOSIS for updated health indicator information); USAID; UNDP; and the Global Fund.

Then there’s general country information—there are sources like index mundi. Our Dewey library colleague suggested that you check out the EIU Country Intelligence link on the country page of the library guide. That and other country sources that he lined up tend to subsume data from the CIA World Fact Book, World Bank and International Monetary Fund, but it may be worth looking to the individual agencies too if you’re really hunting down something.

Also, your focal country’s Ministry of Health is clearly a must-see site.

Depending on your project, UNICEF, PEPFAR and UNAIDS are great sources of information.

Finally, we’ve been asked for more about the cultural, social, and political issues: clearly key for understanding the setting of any project! Not only are these things relevant for the tasks and design of your project, but also for your own experience on the ground. For our class, we designed a context briefing assignment precisely to get everyone thinking about and learning about these key aspects of the settings for the on-site work. Our plan is to share resources and ideas you’ve gleaned, so we’ll be looking at our students’ briefings to pull out things to share widely. We also lined up more broad resources that will help round out the understanding that you’re developing of the settings for your work. It’s easy to add more and extend, so please let us know what you’ve found useful, or what you’d most like help with, and we’ll update as we go.

How to deliver more, and better, health care in resource-limited settings? At the MIT Sloan School of Management, treat the question as an academic one, but we’re not just academic. We’re also involved in action because we work directly with organizations on the front lines of delivering health care in sub-Saharan Africa to deliver jointly-designed solutions to their pressing health delivery challenges, and a dozen teams of students will be working on site in January to do just that.

In the classroom, we’ve been looking at business models, organizational design, funding and finance, and in the weeks ahead we will learn more about various ideas for addressing the implementation gaps in global health. But it’s also clear to us from our own conversations over the past month that if the appropriate personnel, supplies, and medications don’t reach the people who need them, everything else is moot–the models and funding are means to this end.
Stockouts of essential medications are in some ways the clearest indication of the extent of the need–and the extent to which health systems fail to meet citizens’ needs. An activist view of the situation and the the extent of current needs is offered by Stop Stock-outs, a campaign bringing together a variety of organizations to advocate for changes and document the need: for more in the campaign’s goals, see its statement.  Take a look on the site at their “Pill-Check Week” effort to document stockouts (map); it’s linked to an innovative SMS-based tool and open-source software, as described in a recent  article in the technology press; here’s another story and a recent thread in ghdonline.org/tech. The stopstockouts.com site also includes country-specific news, factsheets, and resources.

This got me thinking about ACT UP, the influential AIDS activist organization. In ACT UP NEW YORK: ACTIVISM, ART, AND THE AIDS CRISIS, 1987–1993, a current Harvard Carpenter Center for the Visual Arts exhibit, you can learn more about the organization’s approach and message. And at MIT Sloan we were reminded of the power of ACT UP when Dr. Jim Kim, in a 2007 Dean’s Innovative Leader Series talk, linked their activism to his telling of why the Global Health Delivery Project needs the contributions of experts in management, systems, and logistics. In many ways, this talk was the call for our current class and related work.

So, here are my questions. What’s today’s version of the AIDS Coalition To Unleash Power? What role could researchers, faculty, and students play? Where does advocacy fit in?
Check out the exhibit at Harvard, which includes gallery talks, as well as a series of linked talks at the Harvard Kennedy School of Government’s Carr Center, and  some thoughtful comments about Stop Stockouts at the Global Health Ideas blog. Then come back here and share your comments!

We all agree that Riders for Health are pretty cool–Ducati are sponsors, and the pictures and videos on their website make us wish we could hang out with them.

But Riders also offers us a model for global health delivery worth exploring in detail. The organization is successful in their focused approach: they deliver motorcycle transportation for health workers to reach communities and patients in settings where access is crucial (here’s some evidence on the link between health and transportation). Recently, the Riders for Health model expanded to include their owning of the key assets–the motorcycles themselves–instead of only supplying their fuel and maintenance. They have also expanded to managing larger fleets (see the Gambia Transportation Asset Management program and a 2007 presentation of the precursor program in the Gambia in a mini case and video). Riders have also built a training facility to teach people how to manage and keep up vehicles for health service delivery. And an innovation in the motorcycle sidecar now enables some patients to be transported, as the last video shows.

Riders delivers mobility at prices well below what local programs, NGOs, and Ministries of Health pay for their own transportation (see this 2005 Due Diligence Study of Riders’ Operations). So, we wondered, why do they run on a breakeven basis? Why not charge a little more, and become financially sustainable, while still saving their clients much money? What do you see as the issues to consider here?

Reflecting on the Riders for Health model, we asked: how is it revolutionary? Well, its innovation lies in the narrow focus: there are many things Riders does not do, and what it does do–from what we can tell–it does well. It also is innovative in choosing to use simple, rugged, standardized, easy-to-maintain motorcycles, and not Land Rovers or other vehicles that may carry more supplies and people but which may also not end up in use in the settings where Riders motorcycles now operate. So, relying on standard, low-tech motorcycles is incremental in the sense that such vehicles were already in use in the settings where Riders works; but it’s radical because few others would consider a motorcycle to be the right choice for addressing barriers to global health delivery, although eRanger has hit upon a similar idea. eRanger invested in the vehicle itself with “versatile and robust vehicle design to enable access over the toughest terrain to deliver its varied cargo safely and in one piece, ready to go into action quickly and easily.” A May 2009 Guardian article explored its use in reducing maternal deaths in Uganda. By the way, there are even bicycle ambulances  in Nepal and Namibia ; we uncovered a growing set of case studies of mobility on health that document the effects of a range of approaches. (And if you are looking to assess a rural setting in which you suspect mobility for health is needed, a good starting point is this how-to guide: A Methodology for Rapid Assessment of Rural Transport Services.)

Rider’s operational structure relies, unsurprisingly, on a hub-and-spoke model. Recently, some healthcare experts have been asking if the entire model of care in resource-limited settings should adopt such a structure: see my earlier blog post about such an alternative to doctor-centric care delivery models.

But in some ways what I consider most innovative about the Riders for Health model is their commitment to preventative maintenance. Pro-active, scheduled maintenance (made possible only by well-developed processes and routines, high availability of supplies and parts, and effective record-keeping in the form of service logs for each vehicle) combined with frequent, simple checks to catch problems before they worsen means that Riders for Health users can count on their vehicles to be available when they need them. Now, what’s the lesson in this all for global health delivery, writ large?

Go to the map page for quick overviews of each project and urls. And do let us know of any errors!

View G-Lab GHD 2009-10 in a larger map

Can clever models for delivering health care within the community enable care to reach the poorest? How much can wise ways of enrolling health workers into the care delivery effort address the apparently massive shortage of RNs, MDs, technical experts and other trained personnel?  According to the WHO:

Health workers are all people whose main activities are aimed at enhancing health. They include the people who provide health services — such as doctors, nurses, pharmacists, laboratory technicians — and management and support workers such as financial officers, cooks, drivers and cleaners. Worldwide, there are 59.8 million health workers. About two-thirds of them (39.5 million) provide health services; the other one-third (19.8 million) are management and support workers. Without them, prevention and treatment of disease and advances in health care cannot reach those in need.

We explored Bangladesh’s BRAC and its work in health care.  Our focus was the rural tuberculosis treatment program delivered by Shasthya Shebikas (also spelled Shastho Shebikas), women selected by village leaders as front-line, community-based health workers to funnel potential patients towards testing and then to offer medications and support to allow patients to recover from the disease.

This video, from a 2007 PBS series, offers an introduction to BRAC’s accomplishments in health-care delivery in resource limited settings.

The BRAC model includes training, performance monitoring, and continual assessment of what works and what doesn’t. Ian Smillie’s recent book, Freedom from Want: How Social Entrepreneurship Transformed 100 Million Lives, and Other Inspiring Stories from the Biggest Non Profit You’ve Never Heard Of, tells the BRAC story in dramatic detail. He describes the organization this way:

It is a leader because it is good at what it does. It also happens to be big, and there is an important correlation. A lot of good projects are never taken to scale. Pilot projects remain pilots because nobody picks them up. BRAC has found ways to take simple solutions to major health problems – such as diarrhea in children, a major killer – to every village in the country. It graduates half a million literate girls from its non-formal primary schools every year. Its dairy produces 90,000 litres of milk a day, all of it from people who have borrowed small amounts to buy one or two cows. BRAC is 80 percent self-financing, and it is now taking its work to other countries in Asia and Africa. This would be remarkable for a Canadian or a British NGO, but in a Bangladeshi NGO it is stunning.

For a broad introduction to BRAC, please see their youTube channel.

Back to their efforts in tuberculosis. What has been the impact of the 80,000 Shebikas who have delivered TB care in Banglasdesh via BRAC’s programs? A readable 2009 overview by Miriam Katz is entitled Collaboration In The Health Sector: The Case Of Bangladesh And Tuberculosis. And if you want details about the program, review BRAC’s Global Fund application for a wealth of information. To assess performance and need, you may also want to explore information on the country’s overall profile in TB.

For the  Kaiser Network on 11/11/2007, Jalaluddin Ahmed of BRAC Bangladesh presented “Case of Shasthya Shebika in Bangladesh;” and in more recently another informative BRAC presentation addressed Pay for Performance of Community Health Workers: BRAC’s Experience ( Taskeen Chowdhury, BRAC, at Pay for Performance Workshop,  January 19-23 2009 Cebu, Philippines). As further evidence of scaling up, BRAC’s TB program has now expanded to Afghanistan.

Now, what does the BRAC model have to do with human resources in global health? We examined it as an example of drawing on local communities for the daily health care delivery that diseases like TB necessitate. To analyze how the model may apply in other cases, draw on some of the useful resources listed here.

The HRH Global Resource Center is a global library of human resources for health (HRH) resources focused on developing countries. Access online support, many articles, and other resources.

The Global Health Workforce Alliance was created in 2006 as” a common platform for action to address the health workforce crisis. The Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators and professional associations dedicated to identifying, implementing and advocating for solutions.”  Look around the site for lots of useful information, from case studies to introductions to the key issues such as the global shortage of health workers and its impact and migration of health workers.

Studies on task shifting (such as this one) may help us to consider the question that frames this post: can creative and carefully tested ways of working with community health workers help meet the need for health care globally?

CFWshops is a business-format franchise of retail clinics operating in Kenya (and now Rwanda, Ghana, and Uganda). Our guide: CFW board member and expert on franchising–he actually wrote the book!–Michael Seid. We are are deeply grateful that came all the way to MIT to join us and it was fascinating to hear his take on the franchising model and its application to global health delivery in resource-limited settings. This Franchise Times piece presents his story about getting involved with CFWshops and a second one reports 2007 developments.

To follow along with what we learned, start by with the organization itself. We watched videos from PBS’s Now series, “Enterprising Ideas,”  featuring the CFWshops model and presenting a more recent update as the organization embarked on expansion in 2008. From the show’s page you can check out the additional materials posted on the show’s site.  A useful additional resource is a 2008 presentation by the organization’s CEO.

For the perspective of an Acumen Fund fellow who worked with the organization, please see Catherine Casey’s blog posts; also see this youTube video documenting a CFW franchisee’s point of view.

My earlier post on franchising as a solution contains many useful resources about research in this area, as well as some thoughtful comments from last year’s students.

In class we explored why franchising could be effective in this case, asking what are the advantages and disadvantages of this existing model?  We also looked at potential pitfalls. Where could you see scope for innovating around existing models like this one?

We asked students to come up with their own franchising ideas. There were some great ones–and we didn’t even hear all of them!  Post your ideas in the comments below.

We explored an unavoidable question: where, in the system, should we aim to intervene in order to deliver better health care? To students of public health, this is a well-known question; for students of management and engineering, guided by a trauma surgeon, the discussion was a rich one and led to ideas and questions that gave us new perspective on the question of how we can help deliver better health care. At the end, we left with new questions about health systems and the interrelationships between interventions tackling poverty, access to services, information sharing, linking formal and traditional approaches to health care, and much more.

We’d already touched on the prevention-vs-treatment question in our HIV wargames discussion last week, but this time we expanded the boundaries of our analysis further. We imagined the case of Jose, a hypothetical but representative patient who presented at a tertiary-care hospital in Angola. Jose had a distended abdomen which surgery revealed was the result of multiple bowel perforations and which the team repaired as best they could. After the operation, Jose spent a week in an ICU but did not survive.

Where should improvement efforts focus if we want to avoid cases like Jose’s? The ICU needs to be better equipped, for sure. Staffing levels and nurse training need to be improved. We traced Jose’s journey to the hospital, mapping multiple points where the system failed to deliver the care he needed, and learning about the implications of his family’s poverty, lack of access to information, and poor transportation. We looked at the cause of his ills: typhoid. How could it have been addressed? At the district hospital where he went before the tertiary-care hospital? By improving water sources and sanitation? By stocking rural health posts with the appropriate antibiotics? Better diagnostics? Better pay for health workers? Valuing primary care more?

We couldn’t answer these questions, of course, but we did lay out an approach that I’m hoping orients us all towards finding the solutions that help to address multiple issues at once: delivering health care while also reducing poverty and protecting the environment, for instance. We can’t assume that such solutions always exist, of course, but in searching for them, perhaps we can get a little closer towards making the system better.

A final couple of notes: regarding primary care–we examined a few readings before class. One addressed the definition of primary care and others presented the basic idea behind the WHO’s call for primary care for all, issued over 30 years ago (see this issue of the Lancet for more). If primary care were delivered as advocated by the Alma Ata declaration, would Jose have avoided getting sick?

Recent attention to the link between water, sanitation, and health shows why ensuring clean water in resource-limited settings is crucial:

Worldwide, over one billion people lack access to an adequate water supply; more than twice as many lack basic sanitation. Areas without adequate supplies of freshwater and basic sanitation carry the highest burdens of disease which disproportionately impact children under the age of five. The lack of access to and availability of clean water and sanitation has had devastating effects on many aspects of daily life. While poverty has been a major barrier to gaining access to clean drinking water and sanitation in many parts of the developing world, access to and the availability of clean water is a prerequisite to the sustainable growth and development of communities around the world.

For more–an executive summary, or the entire book–please refer to the
recent publication by Eileen R. Choffnes and Alison Mack, Rapporteurs (Forum on Microbial Threats, Institute of Medicine), Global Issues in Water, Sanitation, and Health: Workshop Summary–it explains how sanitation and water are linked to health, describes waterborne diseases, and lists needed improvements.

And a huge thank-you to Dr Robert Riviello for leading us in this discussion and teaching us about some of the challenges he and his colleagues face.