I have been very fortunate to have spent the week with the Clinton Health Access Initiative (CHAI) team in Kampala on a knowledge/ideas exchange visit. The visit was made possible because of a mutual interest in access to ORS and Zinc for diarrhoea treatment and a lot of goodwill on the part of several people. Barty, the Private Sector Programmes Manager here, and I met in London a while before either of us were involved in this business and so have maintained contact. In addition, the head of CHAI in Zambia who is a big supporter of ColaLife (and a member of our Steering Committee) has ensured that the other CHAI country heads know what we are doing.
Anyway, this was a bit like David meeting Goliath. CHAI is huge with a huge and well earned reputation for their work on improving access to essential medicines. They made their name from the global level negotiations backed up by the the brilliant supply and demand forecasting work they did to convince the pharmaceutical industry to collaborate and massively reduce the price of ARVs for the treatment of HIV/AIDS and ACTs for the treatment of malaria. Their work has led to vastly improved access to medicines for HIV/AIDS and malaria patients, contributing to a reduction in mortality rates from both of these devastating diseases
CHAI’s work has helped turn HIV/AIDS from being a death sentence, to a chronic, manageable disease.
While CHAI’s work on HIV/AIDS continues, they have turned their attention to the accessibility of other essential health products and services including ORS and Zinc for the treatment of diarrhoea in under 5 children.
It was clear from the outset what I was going to get out of this trip but what was ColaLife going to be able to contribute?
Barty set me up with meetings with all the key people I needed to see and these included:
1. The Country Director of LivingGoods
2. The Chairman and MD of Rene Industries, one of the local pharmaceutical manufacturers here
3. Dr Jesca Nsungwa-Sabiiti, the Head of Child Health at the Ministry of Health
4. Milly and Dorothy from PACE, the Ugandan affiliate of PSI and
5. The Director and General Manager of Gittoes Pharmaceuticals, an importer and distributor
It was also great to meet Phyllis Awor a Research Fellow at Makerere University School of Public Health who I first ‘met’ on a webchat organised by The Guardian’s Global Development Professionals Network. Phyllis is at the forefront in the use of the private sector to support ICCM (Integrated Community Case Management) of childhood illnesses, especially diarrhoea, pneumonia and malaria. She will be publishing her research shortly – Phyllis is one to watch!
So what was I able to contribute? Well fortunately, although CHAI has already done a lot of work on the supply side of ORS and Zinc to Uganda – building on their approach and experience in ARVs and ACTs – their work on product development is only just beginning and this is our strength. So my visit kicked off with a great meeting with Emilie, CHAI’s Head of Innovation for ORS and Zinc before she dashed off to visit ORS and Zinc manufacturers in India, where I was able to share our learning from the trial particularly in the area of small ORS sachets and use of the packaging as a measuring, mixing and storage device and cup.
But I think, the biggest contribution I made to all the meetings was the injection of a bit of inspiration and excitement around the Kit Yamoyo product. Talking about ORS and Zinc in abstract can be a pretty dull process but if you put an aspirational product in front of people the whole tone of the conversation changes. It may be that the current Kit Yamoyo configuration isn’t the right one for Uganda but it gives people something to touch and feel and get excited about. All of a sudden people can see why small sachets are important in a way that they didn’t perhaps appreciate before. This was a feature of all the meetings I participated in and this was very rewarding. However, there is a sharp focus on price here and that comes with some concern about the price. Kit Yamoyo will always be more expensive than 2 one litre sachets of ORS and a blister pack on Zinc in a cardboard box.
This whole trip was made even more enjoyable and productive by our virtual advisory board member Dr Beth Anne Pratt who has returned to live in Uganda (from Zambia) and was able to set the scene for me (and meet from the airport and put me up on my first night). Beth and I have had some great discussions about cost, price, willingness to pay and product desirability. I’ll had over to her to summarise some of these discussions. She’s American so please excuse the spelling 🙂
This is the first time people have seen a combined ORS+Zinc+Measure kit. It gave people something not only to visualize, but also to begin assessing and discussing the meaning of “value” (in the broadest sense of the word). Presenting the kit gives stakeholders not only lessons to build on but, most importantly, something to talk about besides just “cost”.
Suddenly, design, desire, and appropriateness can be built into discussions of price elasticity. Because price elasticity – in a big picture sense as opposed to a purely economics sense – is not simply about price increase/decrease vs. and willingness/ability to pay. There are all these intangible cultural, social, political, and individual factors that feed into the decisions people make about purchasing a product…especially a product such as medicine….especially a product such as life-saving medicine for your child.
People bring a lot of baggage with them when they reach the window of a kiosk and carry out a transaction. And perceived ability-to-pay is important but is not the only determinative of people’s choice. We understand very little about how poor people in remote rural Africa make consumer decisions, and even less on how they make decisions about purchasing “bio-” or “western” medicines. We need to understand more about this. And presenting a product that has been proven to be “in demand” by remote rural Zambians – people living in quite extreme poverty – suddenly lets people talk about “why?”
Kit Yamoyo, make no mistake, will never be the cheapest product out there. Clinic–based ORS (which is free if it’s in stock) is. Even traditional medicine is. But a Kit Yamoyo supplied by the private sector is not. So why do poor people buy it? It touches upon the broader issue of: “Why do poor people still utilize the private health sector even when the public sector is free?” Let’s understand this better. And not just reduce the lives of poor people to a purely economistic “do they have money or don’t they” argument. People’s lives – yes, even poor people’s lives – are infinitely richer than this.
So, we must both aggressively eliminate/bring costs down for the poorest people on the planet in order to achieve the greatest equity possible, while at the same time NOT making the mistake of reducing every consumer choice/decision that a poor person makes to one solely based on cost. Go live in a remote rural village in Africa for a couple of years like I did and you will see that even the very poorest of people, living in the most dire of conditions, seek, as best they can, the dignity of self-determination. I truly believe that affordability of essential medicines is, without a doubt, a human right, and that every individual on the planet should have the affordability barrier eliminated as a factor in his or her decision to seek healthcare.
Back to the nuts and bolts of the trip, another significant outcome is that Dr Jesca Nsungwa-Sabiiti has asked CHAI for a presentation on the Kit Yamoyo at next week’s Diarrhoea & Pneumonia Coordination Committee so I will be working the Damien, CHAI’s Essential Child Medicines Programme Manager at office this morning before I leave.
I know that things move slowly and I know that I am the eternal optimist but I think Uganda will have their own Kit Yamoyo by the end of 2015 and they won’t need much support from ColaLife to achieve this . . . you heard it first here!
Thanks to everyone who made this possible. This afternoon I leave for India…
Thanks to Beth for checking the context of this blog post and contributing to it.