Pharmacy on a Bicycle

Traditional pathways to delivering health care to the global poor are failing. Five million children die each year before their fifth birthday due to lack of basic health education, services, or low-cost treatments. Bing and Epstein show how focusing micro-innovations at the level of care is the way to end these grim health statistics.

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Preface
• Introduction Why Pharmacy on a Bicycle
• Part 1 The Prescription
• Part 2 IMPACTS in Motion
• Part 3 Moving Forward
• Notes
• Bibliography
• Index
• About the Authors

“In this compelling, practical, and very human book, Bing and Epstein offer real-life solutions to ending millions of preventable deaths around the world. By integrating tools from public health, medicine, and business, they have created an approach-IMPACTS-that has potential for saving millions of lives, not only in low- and middle-income countries, but in resource-poor, hard-to-reach settings within wealthier nations.”
-Helene D. Gayle, MD, MPH, President and CEO, CARE USA

“Powerful medicine for a world that is ailing from growing health disparities and a must-read for anyone providing care for-or caring about-the world's most vulnerable people. Short on abstraction and long on practical solutions, this is an inspiring call to action that awakens the entrepreneur in all of us.”
-Julie Gerberding, MD, MPH, President, Merck Vaccines, and former Director, Centers for Disease Control and Prevention

“This is what needs to be done in order to save lives! The creativity and originality of this book provide the impetus to bridge the final mile in global health. Bing and Epstein exemplify cost-effective and successful innovative solutions-a must-have for all working in global health.”
-Christine Kaseba-Sata, obstetrician and gynecologist and First Lady of the Republic of Zambia

“Pharmacy on a Bicycle demonstrates how, even in the most dire circumstances, entrepreneurs can develop cost-effective, sustainable, innovative solutions that have the potential for replication and scale. Not only are the examples inspiring and instructive, but the IMPACTS framework has applications that extend well beyond global health.”
-Professor J. Gregory Dees, cofounder, Center for the Advancement of Social Entrepreneurship, Duke University

“This book provides workable answers for applying tested entrepreneurial techniques to the unique challenges of the very poor. Among the fertile minds of its readers, it will inspire new solutions from many successful examples. This book will save lives!”
-Marc J. Shapiro, Chair of the Board of Trustees, Baylor College of Medicine, and former Vice Chair, JPMorgan Chase & Co.

“By engaging emerging leaders with diverse skills and backgrounds, Bing and Epstein recognize how we can solve the problems we face in global health now. They demonstrate how partnership is fundamental to improving health access for all-an essential read for tomorrow's leaders in global health!”
-Barbara Bush, CEO and cofounder, Global Health Corps

“So many of the solutions to the world's most tragic health-care problems are simple and inexpensive-if we can get them to the people who need them most. Bing and Epstein show how that can be done by unleashing the entrepreneurial spirit of the world's poor.”
-Sir Fazle Hasan Abed, KCMG, founder and Chairperson, BRAC

“Bing and Epstein show how people from around the world are creating successful innovative, ‘outside the box' solutions to take health services the last mile. Stakeholders across the public, private, and nonprofit sectors will find the lessons shared in this book highly useful.”
-Dr. Agnes Binagwaho, Minister of Health, Republic of Rwanda

“Bing and Epstein tackle the most important problem vexing global development: how do we spread what we know works to places and people who need it? This book offers powerful frameworks and examples that spark practical insights into what it will take to truly solve many of our most challenging problems.”
-Jeff Bradach, cofounder and Managing Partner, The Bridgespan Group

“Drs. Bing and Epstein remind us that many of the deaths and much of the disease among mothers and children can be halted through simple and low-cost solutions. They combine their medical knowledge with cutting-edge business school methodologies to identify and summarize the opportunity for innovative solutions to combat disease and poverty. It's a must-read for people who care deeply about the world's poorest people.”
-Peter Hotez, MD, PhD, Dean, National School of Tropical Medicine, Baylor College of Medicine, and President, Sabin Vaccine Institute

“If you ever wondered why easily preventable and curable diseases cripple human potential across the developing world, this book has answers. Bing and Epstein are on a mission to make sure that access to basic health care is never a barrier for anyone to reach his or her full potential. This book will leave you with the hope that seemingly insurmountable development challenges can be transformed into solvable problems when creative partnerships are formed across sectors and mutual accountability is established.”
-Ambassador Sally Cowal, Senior Vice President and Chief Liaison Officer, PSI

“Pharmacy on a Bicycle is about saving lives-simply, effectively, and inexpensively. Through their focus on innovative and entrepreneurial solutions, Bing and Epstein show how to take health care the last mile-to a place that's accessible, in a way that's acceptable, and at a cost that's affordable. Chock full of successful examples of ways this is already happening, it will leave you inspired and filled with hope!”
-Rich Stearns, President, World Vision USA

“While so much of the focus on health is a debate about the science, Pharmacy on a Bicycle is a timely reminder that simple, cost-effective solutions exist and can be scaled to provide access to quality care. A practical guide to successful program delivery-showing how millions of lives can be saved globally.”
-Paul Bernstein, CEO, Pershing Square Foundation

“This is the first book I know of that goes beyond inspiring stories of social entrepreneurs to provide a comprehensive and practical guide to the entrepreneurial process itself. Every policy maker and aspiring social entrepreneur will benefit from the practical steps to successful entrepreneurship articulated in this book.”
-Kirk O. Hanson, University Professor and Executive Director, Markkula Center for Applied Ethics, Santa Clara University

“We firmly believe that the world can dissociate health care from affluence. Change in policies is all we need to turn this dream into reality. Pharmacy on a Bicycle has many valuable propositions to make it happen.”
-Dr. Devi Shetty, Chairman, Narayana Hrudayalaya Group of Hospitals, Bangalore, India

“Bing and Epstein have written an eminently readable and absorbing book that will be essential for any organization interested in empowering underserved populations to improve their health and well-being. Bravo!”
-Stanley S. Litow, Vice President of Corporate Citizenship and Corporate Affairs, IBM, and President, IBM International Foundation

Introduction

Why Pharmacy on a Bicycle

Dawa paced in front of Pemba's door, trying to hide his concern.1 He had run out of his medication, and Pemba had been kind enough to share his. Both men had been told to never stop taking their medications because HIV was a virus that could quickly develop resistance, and then the drugs would no longer work. Now Pemba was beginning to run out of his supply as well.

Dawa and Pemba were running low on medicine because a bandh, or strike, was making it impossible to get to the pharmacy. In Nepal, during a bandh, it was wise to avoid going out in a car, because if you did, you could get your tires slashed, your windows broken, or your vehicle set on fire. The bandh was in its second week, and the men had nowhere to turn once their medications ran out.

Crises stimulate action. In dire straits, we become innovative and entrepreneurial. Which is what happened in this case. The Saath-Saath Project, a local HIV program, partnered with a hospital and some community health workers to create a pharmacy-on-a-bicycle brigade. If the patients couldn't go to the pharmacy, then the pharmacy would go to them.

It was a risky proposition. Would the bandh enforcers respect the riders' mission? Nobody knew. But lives were at stake. That is why Suraj, a community health worker and person living with HIV himself, was one of the first to volunteer. Suraj set out early in the morning after loading his satchel with medications. By midday his pharmacy on a bicycle reached Dawa and Pemba-right before their pills ran out. Because of quick thinking, a partnership, and a bicycle, Dawa and Pemba didn't miss a single dose. This simple solution may have saved their lives.

If all we had to worry about was the occasional strike, most of our problems in global health would be solved. But a bandh that lasted thirty-two days only exacerbated Nepal's problems of deep poverty and a population living in hard-to-reach areas. Such problems are found in many developing countries, and regardless of whether they are caused by instability, conflict, geography or cost, they make it difficult to bridge the “final mile” in global health.

Over the last few decades the authors have examined health care in remote rural and dense urban settings across a variety of low- and middle-income countries in Africa, Asia, and Latin America. Some countries were stable, others were in civil war. We have spoken with presidents and health ministers, tribal leaders and CEOs, and patients and their families. We have worked alongside dedicated and compassionate clinicians-doctors, nurses, community workers, and traditional healers-and we have consulted with governments, businesses, NGOs, and donors. We have examined health care from a variety of perspectives, and we always reach the same conclusion:

Millions are dying of diseases we can easily and inexpensively prevent, diagnose, and treat.

Pharmacy on a Bicycle is a bold yet practical approach to alleviating problems in global health and poverty. Fortunately, we are not starting from scratch. There are many examples of successful programs that are already saving lives. We need to leverage these innovative and entrepreneurial solutions and create even more to save lives by increasing access, use, and quality of care, while reducing costs.

In Pharmacy on a Bicycle, we show how we can save lives while saving money through a seven-point approach we call IMPACTS (Figure 1). Here are the key components:

Figure 1 The IMPACTS Approach

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Implementing the IMPACTS approach will help bring care to those who need it most.

How to Use This Book

This is a book about taking health care the last mile-sometimes quite literally-to a place that's accessible, in a way that's acceptable, and at a cost that's affordable.

In other words, this book is about solutions.

There are people and organizations already doing many things that work. Now we need to scale those models to reach the masses of people who deserve quality health care. What works may come from governments, NGOs, businesses, or donors. All are part of the solution to the problems we face, and all have a role to play.

• Government. Governments can help create an environment, supported by sound policies, regulations, and resources, where basic, high-quality health care is expected. Ministries of health are the backbones of strong national health systems upon which services are built. Local and national government leadership and commitment are essential for success and financial sustainability.

• Nongovernmental Organizations. NGOs, including faith-based organizations, have long provided essential health care, social services, and advocacy in developing countries throughout the world. They are critical to providing quality care in diverse and hard-to-reach communities.

• Businesses. For-profit businesses offer not just resources but models of efficiency, innovation, entrepreneurship, and distribution: ways to create demand and reduce costs. In addition, local businesses, along with microenterprises, are often created and based within communities, and owners understand the local culture and needs. Microenterprises in health care, which include small clinics and pharmacies, can help distribute services and products to those in need. So too can traditional healers and traditional birth attendants, particularly in rural areas. For a variety of reasons, these smaller providers and traditional sectors may not be integrated into formal health care systems. But when given appropriate training, support, and oversight, they can help us complete the final mile.

• Donors. International agencies, foreign governments, and foundations provide essential financial and technical support to country-led health programs. Such donors are essential to enable governments and local implementers to provide needed services.

Innovative partnerships that bring these sectors together can help save more lives. In addition, the approaches used by these sectors overlap and complement each other as they grow and evolve. For example:

• Effective governments in many developing countries are now adopting sound internal business strategies and practices to manage public resources to deliver health services.

• Many NGOs in low- and middle-income countries operate like businesses to ensure that their resources are effectively used and have real impact. Some NGOs are even creating for-profit spinoffs to enhance their chances of creating financially sustainable programs.

• Businesses, large and small, seek not only to be financially profitable, but also to create social good in the countries where they work. This approach goes beyond corporate social responsibility-it is part of their business model.

• Donors are increasingly requiring recipients to reduce costs, demonstrate impact, and achieve greater financial sustainability once support ends.

These new, blended approaches are also helping to change the perceptions of target populations from beneficiaries to customers. This change in orientation recognizes that a patient is a customer and that the customer is in charge. All people, regardless of income, are customers of health products and services. When customers perceive little value in or encounter barriers to using a health product or service, it is likely that they won't use it-even if it's free and potentially lifesaving. Our job, therefore, is to find innovative and entrepreneurial ways to motivate customers to use health products and services that can save their lives.

Pharmacy on a Bicycle is filled with practical examples of innovative and entrepreneurial solutions to health care delivery in a wide variety of settings in developing countries. While this book focuses on low- and middle-income countries, many elements are readily applicable to populations in higher-income countries as well.2 Innovation is much more than discovery; entrepreneurship is much more than maximizing profits. The innovator creates solutions. And the entrepreneur finds efficient, effective, and economical ways to get solutions to customers.

We encourage those readers who develop or manage health programs to read Pharmacy on a Bicycle with an entrepreneurial lens and find ways you and others can take some of these ideas to the next level to deliver health services. Regardless of your specialty, population, or setting, you may see a solution to a problem you're working on, even if it was developed to combat a different disease, for a different population, under different circumstances, or in a different country.

If you see a model that might work for you, try it. If you see a model that, with some modifications, might serve your needs, then change it. If you see several models you think could work well together, then combine them. And as with any other model, new or old, monitor it regularly and evaluate it periodically to ensure that it's producing the intended impact.

Regardless of your reason for reading this book, in presenting the IMPACTS approach and spotlighting successful real-world applications of its core points, we hope to activate your inner innovator and entrepreneur so that you can see existing solutions or create new solutions to the challenges you face.

We have divided the book into three sections:

Part 1: The Prescription includes four chapters that deal with the basics-the essential ingredients, the model, and the core elements of our approach.

• Chapter 1 provides an overview of the issues, the IMPACTS approach, and the model that describes how to save millions of lives and billions of dollars in global health care.

• Chapter 2 describes the roles innovation and entrepreneur-ship play in improving global health.

• Chapter 3 describes how task shifting, maximizing efficiency and effectiveness, creating demand, and focusing on accountability can better deliver health services and products and improve outcomes.

• Chapter 4 provides an overview of how to scale up interventions and the importance of coordinating the roles of partners to reach more people.

Part 2: IMPACTS in Motion provides three chapters of real-world applications of each point of the IMPACTS approach and how they are being used with different diseases and in different settings.

• Chapter 5 focuses on applications in maternal and child health issues.

• Chapter 6 reviews applications in some infectious diseases.

• Chapter 7 discusses issues and applications to some noncommunicable diseases.

Part 3: Moving Forward includes two chapters that show you how to move to the next steps in order to better deliver quality care to those who need it most.

• Chapter 8 discusses the importance of priorities, planning, and monitoring progress to save lives.

• Chapter 9 explains how organizations can influence their settings and environments to improve impact and provides recommendations for future steps.

Each chapter in Parts 1 and 2 is concluded by “Food for Thought” questions designed to help you discover ways to apply the concepts to your own setting. At the end of the book, you will find information on www.pharmacyonabicycle.com, a website where you can find and share additional innovative and entrepreneurial solutions for improving global health and alleviating poverty.

The organization of Pharmacy on a Bicycle will make it easy to find the important foundational components (Part 1: The Prescription), real-world applications (Part 2: IMPACTS in Motion), and recommendations for planning and next steps (Part 3: Moving Forward). How you choose to approach and combine them is up to you.

Now is the time. We can save lives by bringing low-cost, quality care to those who need it most, regardless of whether it is delivered by a community health worker on foot, by a doctor using telemedicine, by a nurse on a mobile phone, or by a pharmacy on a bicycle.