Learning From Coca Cola: The Science of Healthcare Delivery

The global health community today is facing what some have called an “implementation bottleneck”.   There are vast amounts of resources being funneled into global health work, such as vaccines, primary health care, drug therapies, maternal and child health care, and basic surgery.  However, despite vast amounts of money, tools and interventions, the successful delivery and implementation of these resources remain elusive.

In other words, the greatest constraint is not the availability of interventional tools of medicine, but rather their delivery to those who need them most. (1)  For example, full use of existing interventions would cut the 10 million annual child deaths that occur globally by more than 60%.(2)  In addition, a high proportion of the half-million maternal deaths that occur globally every year could also be prevented by promoting access to interventions and services of known efficacy.(3) 

In the rest of the economy, huge gains have been made by better integrating and coordinating all activities required to serve customers. Seamlessly coordinated networks and partnerships have replaced adversarial or arms-length relationships in delivering value for end users. Health care is long overdue for such a transformation.” (4)

Part of the reason for this delivery failure is due to the lack of health infrastructure in much of the developing world.  Because of this reality, the global health community faces an unprecedented challenge of transferring vast amounts of resources to individuals, often in rural and remote locations, with little-to-no infrastructure to work through.   Several steps exist in the process of achieving successful health outcomes: the discovery of a drug or intervention, its development and production, and lastly, its delivery.  It is this final link in the chain that poses the most formidable challenge to the success of global health endeavors.  Three strategies have been suggested to overcome this implementation bottleneck: implementation research, a business framework for health care delivery, and synergies between global health initiatives and health systems.

Implementation Research

In global health there needs to be a focus on the science of implementing the knowledge we have into actual programs and policies.  Implementation is defined as a specific set of activities designed to put into practice a program of known dimensions.(5)  Thus, implementation research focuses on how to promote the uptake and successful implementation of evidence-based interventions and policies.  Such research focuses on “What is happening?” in the design, implementation, administration, operation, services, and outcomes of programs, and also asks, “Is it what is expected or desired?” and “Why is it happening as it is?” (6)   This is important in order to close the gap between knowledge and implementation, as we cannot do so without theoretical models of good implementation systems for the delivery of health care.

While implementation research can provide information about whether a single program is efficiently delivering care, the ultimate goal of such research is to share best practices with other initiatives, NGOs, and policymakers.  Mechanisms should be in place to compare different approaches to the delivery of global health services.  Thus, integral to implementation research is coordination across activities.  Research should be multidisciplinary, encompassing both quantitative and qualitative approaches that require expertise in epidemiology, statistics, anthropology, sociology, health economics, political science, policy analysis, ethics, and other disciplines.  Sharing information in a multi-disciplinary setting can include activities such as case studies which document successful implementation strategies, operations research, and decision analysis.(7)

Learn from Business Models

Global public health can learn from the private sector. In particular, the application of management science can be applied to create a science of healthcare delivery.  “Strategy” is the field of the management sciences devoted to helping organizations define a long-term approach to achieving specific goals.

“Strategy researchers aim to develop frameworks that are grounded in value creation for customers or other stakeholders, and incorporate the complexity of how systems for the delivery of products and services actually work—the activities of delivery and their economics, organizational dynamics, the behavior of other involved actors, and contextual factors that affect how activities are designed in particular settings”.(8) 

For example, The Global Health Delivery Project, formed in 2006 as a partnership between Harvard Medical School and Harvard Business School, advocates this model of healthcare delivery. The goal of the partnership is to systematize the study of global health care delivery and rapidly diffuse innovations to practitioners. This approach involves the careful analysis of global health delivery programs and the creation of analytic frameworks that can guide care delivery system design, operations, and improvement. The ambition of this new academic enterprise is to improve global health care delivery in resource poor settings.

Other practical lessons can be learned from business models. Take, for example, the extensive delivery lines of coca-cola. In remote places in the developing world where it is impossible to access the most basic medications, you can walk across the street and buy a soda.  As one health worker puts it:

“Thousands of smart people spend millions of dollars trying to get life-saving medications to the people who need them. And too often, we fail. But Coke is everywhere in this country, from the fanciest hotels in Dar es Salaam to little shops in the Serengeti. They're doing something right.My co-worker told me that Coke Tanzania has teams dedicated to tracking which vendors buy from specific distribution centers and exactly where bottles are sold. If things aren't working, they identify the kink in the chain and fix it, as soon as possible”.(9)

In fact, there has been talk about using Coca-Cola’s business model and distribution lines to deliver essential medicines.  David J Olson, Director of policy communications for the Global Health Council, has suggested harnessing Coke’s delivery networks to deliver malaria drugs, bed nets, condoms and other essential health products. 

Synergies between GHIs and Health Systems

A major critique of global health today is that it is primarily defined by multitudes of NGOs, programs, and global health initiatives (GHIs) that are focused on singular, discrete problems.  It has been said that global public health programs will have to move beyond a focus on building successful “projects” and become fully functioning health care delivery organizations.

The concept of positive synergies between health systems and GHIs is a strategy meant to address the fact that when resources are supplied to a country’s health services through GHIs, there may be unexpected “spill-over” effects.(10)  Some of these effects are positive and some are negative (fragmented infrastructure, multiple reporting, uneven distribution lines, etc).  Developing a positive synergy refers to actively and systematically managing the relationship between GHIs and already-existing health systems to structure and coordinate the delivery of health care in an efficient and cost-effective manner.

“Maximizing Positive Synergies between health systems and Global Health Initiatives,” a WHO May 2008 consultation report on this process, carefully outlines the need for this type of solution, the knowledge-gathering process and coordination required to achieve it, and offers examples of existing work that is being done in the area.  Within the larger framework of global health, this concept is part of the goal of developing a “science of delivery,” and addressing the proliferation of global health initiatives that operate in isolation.

Conclusion

There is place for a new field in global health research and education: the science of health care delivery.  Before, the standard progression toward better health outcomes was from basic science—what is the pathophysiology of the disease?—to clinical science—what is the diagnosis and appropriate intervention?—to evaluation science—does the intervention work?  Today, we understand the need for an additional step, health care delivery science, in order to successfully and efficiently deliver global health resources to those in need.

Footnotes


(1) Sanders, David, and Andy Haines. (2006). "Implementation Research Is Needed to Achieve International Health Goals." PLoS Medicine. 3 e186, 1-4.

(2) Jones G, Stekettee RW, Black RE, Bhutta ZA, Morris SS, et al. (2003). How many child deaths can we prevent this year? Lancet 362: 65–71.

(3) Wagstaff A, Claeson M (2004) The Millennium Development Goals for health: Rising to the challenges. Washington (D. C.): World Bank Publications.

(4) Porter, Michael and Elizabeth Teisberg. (2007).How Physicians Can Change the Future of Healthcare. JAMA. 297:1103-1111.

(5) Dean L. Fixsen, Sandra F. Naoom, Karen A. Blasé, Robert M. Friedman, Frances Wallace. (2005). Implementation Research:A Synthesis of the Literature, Univeristy of South Florida, Tampa Fl, p. 1-6.

(6) Sanders, David, and Andy Haines. (2006). "Implementation Research Is Needed to Achieve International Health Goals." PLoS Medicine 3: e186, 1-4.

(7) Ibid.

(8) Kim, Rhatigan, Jain, Porter “Values to Value” article in forthcoming lancet on Values in Global Health.

(10) World Health Organization. Maximizing Positive Synergies Between Health Systems and Global Health Initiatives. Geneva: World Health Organization, 2008.