Putting the “live” back in Delivery

This article was submitted to Devex and an edited version was published here. This is the full version of the article and includes the footnotes which were omitted from the Devex version.

“The stagnant low ORS coverage over the past decade indicates a widespread failure to deliver one of the most cost-effective and life-saving child survival interventions and underscores the urgent need to refocus attention and funding on diarrhoea control.”
UNICEF, 2012

Access: A Fundamental Component of Implementation & Delivery Sciences

Research has shown that more than half of all childhood mortality could be prevented each year if the world’s children received full access to already existing, often low-cost interventions.1,2,3 Yet, there remains a clear implementation gap, and a perpetual challenge to take effective interventions, policies, and programs that can save lives and improve health to scale. At least one third of the world’s population, for example, has no regular access to essential medicines. So as we search for novel drugs and vaccines, its worth keeping in mind that a medicine that is 95% effective but only gets to 30% of the people that need it is limited in its operational effectiveness.

While we are accomplishing incredible feats – like landing a spacecraft on a comet travelling 40 times faster than a speeding bullet – our rate of progress in addressing these health related challenges has not kept pace. Our problem is visibly not about human ingenuity or ability, but rather the will, funding, and multisectoral partnerships necessary to deliver at-scale solutions in efficient and equitable ways. Strengthening our knowledge base and innovating in this area is critical. The recent Statement on Advancing Implementation Research and Delivery Sciences (IRDS) from Health Systems Global lays out some of the important steps we can take as we pursue this relatively new direction.

The End User – At the Heart of Everything We Do(?)

The need to work with our end users is hardly a new concept. In his book, The Fortune at the Bottom of the Pyramid, C.K. Prahalad called for “a better approach to help the poor, an approach that involves partnering with them to innovate and achieve sustainable win–win scenarios where the poor are actively engaged…” He described a vision of “co-creation of a solution to the problem of poverty” that can only be unlocked if large and small firms, governments, NGOs, academia, development agencies, and the poor themselves work together with a shared agenda.

Despite this inherent development paradigm, access to medicines at the population level is typically addressed through fragmented, often vertical approaches that usually limit their focus to supply-side issues. Applying a more holistic, systems lens, inclusive of the complex relationships between medicines, health financing, human resources, health information, and service delivery, which gives due consideration to demand-side constraints, can lead to improved access. Demand-side constraints influence uptake of services by the end user, their households and communities, while aspects of the health sector and health services that impede uptake make up supply-side constraints.4 More classic dimensions of access – availability, geographic accessibility, affordability, acceptability/rational use, and quality – can help identify other important barriers.5

The need to strike a better balance when considering these various dimensions becomes clear when we look at the case of Oral Rehydration Salts (ORS) and zinc for the treatment of childhood diarrhoea. Overwhelmingly, focus has been placed on supply side factors, with emphasis placed on cost. However, context is key, and without due consideration of the detailed realities on the ground, a solution will never be completely effective.

The History of ORS

Searching for a therapy that could be applied in the field, far away from hospitals and intravenous treatment, scientists conducted much of the research around ORS within the context of cholera epidemics in the late 1960s and early 70s. Until that time, even the concept of an oral therapy for cholera was considered quite unbelievable for most people.6

By 1971, scientific support for the use of oral rehydration therapy had reached mainstream media with the completion of work by Mahalanabis and Hirschorn. It wasn’t until the late 70s, however, that cholera ceased being the primary target for rehydration research. In 1978, the WHO recognized that, “In non-epidemic seasons… [cholera] accounts for less than 5% to 10% of all acute diarrhoeas in cholera endemic areas”.7 That same year, the Advisory Group for the WHO’s Control of Diarrhoeal Diseases (CDD) program met in Geneva to study the various tactics that could be leveraged in the global fight against diarrhoea. By the time the CDD program was fully operational in 1980, the standard formula for ORS had already been determined at the 1978 meeting based on research available at that time.8 The investigators who designed those studies believed that the oral solution should consist of one universal form and quantity to facilitate use by untrained villagers and public health workers under very basic conditions. They therefore decided on an arbitrary amount – 1L – and hoped for the best.9 It is this legacy that has shaped guidelines around the non-formulaic aspects of ORS preparation and manufacturing to this day. Development of ORS was therefore based on need and not demand.

From Crate to Community: The ColaLife Story in Brief

ColaLife started with the recognition that while the shelves at rural health centres were often empty, those at community-level shops always seemed to be full. One product in particular seemed to be somewhat ubiquitous, and that was Coca-Cola.

It seemed to get everywhere, even to the most remote parts of developing countries. Yet in some of those same places, approximately 1 in 11 children die before their 5th birthday.10 Many of these deaths are preventable and often due to a lack of access to essential products and services.

By leveraging the same principles and existing networks (of wholesalers and retailers) that facilitate the distribution of Coca-Cola and other fast moving consumer goods, ColaLife is working to open up locally established, private sector supply-chains for products such as ORS and zinc. While we began with the concept of “piggybacking” ORS and zinc in the empty spaces between crated bottles of Coke, we have since extended into a range of innovations based partly on Coca-Cola’s expertise and networks, but also by working with our end users and questioning the status quo. This has allowed us to approach the problem of access to ORS and zinc from a health systems perspective, tackling the issue at multiple levels.

Recent evidence has shown that globally, of those children with acute diarrhoea, only a third receive ORS and less than 1% receive zinc. Speaking with caregivers living in rural Zambian communities (where our trial took place) early in the process, we learned a great deal about local factors that contribute to these types of statistics. These included:

  • Long distances to access points (usually walking)
  • Regular stock-outs at health centres (generally the only place one can access ORS and zinc in rural Zambia)
  • Challenges associated with preparing 1L sachets of ORS at home
  • Willingness to pay for a commercially available ORS and zinc product
  • Branding and product preferences

The approach that resulted involved the creation of an innovative diarrhoea treatment kit, as well as the establishment of its value-chain. Value-chains result in collaborative partnerships between networked players engaged in economic exchange. In our case, players included a local pharmaceutical company, existing district-level wholesalers, and community-level micro-retailers who purchase goods from the wholesalers and transport them over “the last mile” to the communities they serve. In a value-chain, value flows back from the end user toward the manufacturer, strengthening the chain and building confidence of the players involved, while the product is “pulled” to the end user (as opposed to being “pushed” as is the case with most public supply chain systems for medicines). This means two things: 1) that the end users need to value the product, and 2) they need to have ‘value’ in their hand to purchase the product – whether cash or, for example, a voucher.

Enter the Kit Yamoyo, an innovative diarrhea treatment kit based on human-centered design. Working in collaboration with rural Zambian mothers of children under 5, it was developed with a focus on demand-side dimensions of access. The kit co-packages orange flavored ORS, a blister pack of zinc, a small bar of hand soap, as well as an instructional pamphlet that doubles as the branding for the product. While the packaging itself was originally designed to fit in the empty spaces between crated bottles of Coke, this proved to be relatively unimportant. Far more relevant, was the packaging’s ability to serve as a measuring, mixing and drinking vessel for the 4.2g sachets of ORS inside (each making up 200ml of solution).

Upon speaking with caregivers, we learned about the inappropriateness of the typical 1L sachet of ORS for home use. Firstly, mothers have no standard way of measuring out a litre of water. They typically use whatever type of measuring vessel is on hand. This can range from a small cup of 150ml to a large jug of 4 litres, resulting in solutions that are either too concentrated (which can worsen the diarrhea) or too diluted (which can reduce the efficacy). In addition, children under 5 will only consume an average of 400ml of ORS solution per day, and prepared ORS solution should be discarded after 24 hours to prevent contamination. This either results in wasted solution (if appropriately discarded), or promotes use of the prepared solution past the safety zone of 24 hours.

Our research found that providing the tool necessary for performing the correct behavior (packaging as measuring vessel) helped ensure proper preparation of ORS by over 90% of Kit Yamoyo users, while only about 60% of those who used the typical 1L sachets from the health centre prepared the solution in the correct concentration. Overall, in the intervention districts, the approach increased coverage of ORS and zinc from less than 1% at baseline, to 45% at endline, while coverage remained at less than 1% in the comparator districts.

Applying a health systems lens which considers both supply and demand side factors, including the details of implementation at the user level gleaned through simply listening to our end users, should be at the heart of any access discussion.

You can learn more about ColaLife and our story at www.colalife.org

Also, for more on this and related topics, please follow us on Twitter @colalife

 

Footnotes

  1. http://www.jhsph.edu/research/centers-and-institutes/ivac/resources/solutions-child-morbidity-mortality.html
  2. http://www.who.int/maternal_child_adolescent/documents/pdfs/lancet_child_survival_knowledge_into_action.pdf
  3. http://www.who.int/maternal_child_adolescent/documents/pdfs/lancet_child_survival_prevent_deaths.pdf
  4. http://heapol.oxfordjournals.org/content/28/7/692.full.pdf
  5. http://www.ncbi.nlm.nih.gov/pubmed/17954679
  6. http://rehydrate.org/ors/pdf/history-of-ort.pdf
  7. http://www.ncbi.nlm.nih.gov/pubmed/716378
  8. http://whqlibdoc.who.int/hq/1999/WHO_CHS_CAH_99.12.pdf
  9. http://rehydrate.org/ors/pdf/history-of-ort.pdf
  10. http://data.unicef.org/child-mortality/under-five