When in 1995 entrepreneur Jeff Bezos launched Amazon.com from his garage in Seattle (USA), fewer than 1 in 200 people worldwide had internet access and online shopping was just a year old. Today, Bezos’ innovative website has made Amazon.com the world’s largest online retailer, with $60 billion in annual sales – $170 million a day. Online shoppers see Amazon.com as their primary interface—this is the technology innovation. Amazon.com and its accompanying vast information technology capabilities can predict what we want. It catalogues our searches and purchases, and gives us suggestions of what we want.

A brilliant example of the power of technology innovation – right? Only half right. What we don’t see is actually more profound: it’s the power of partnering technology innovation and systems innovation. If you thought Amazon’s secret sauce was simply the technology innovation, think again. In fact, it’s the systems innovation that makes Amazon work. 

Systems model: Amazon.comGraphic by MSH

The Amazon.com website is the technology hub that links four “sub-systems”: consumer service, product vendors, warehousing, and distribution (see diagram). More than 150 million customers are served by websites and call-in centers in over a dozen countries. Starting first with books, then compact disks, Amazon now handles millions of products from virtually every shippable and downloadable category of consumer goods. Through process improvements in distribution and warehousing, Amazon has made it possible to deliver virtually any product within two days—in some cases, less.

In addition to its 41 “fulfillment centers”, Amazon is pursuing further process improvements that are true game changers. For example, to decrease shipping times and further reduce errors, Amazon bought a company called Kiva Systems that builds “picking robots.” And in major cities, Amazon has begun to build automated lockers in drug stores and convenience stores for same-day ordering and pick-up while shopping or returning home.  

In short, what began as a creative technology innovation when the internet was still in its childhood has become a stream of interconnected technology and systems innovations that has led online sales across the globe and an unprecedented 15-fold increase in Amazon’s value from 2001-2011.

Heartfilefinancing.org 1.0

As global health practitioners, we might ask:  can the Amazon model of partnering technology innovation and systems innovation improve the health of those who are in the most need? The answer is a resounding YES. Dr. Sania Nishtar – founder of Pakistan’s non-profit NGO think tank, Heartfile – was following in Jeff Bezos’ footsteps when she launched Heartfile Health Financing to help the poorest of the poor in Pakistan gain access to essential health services.  

Heartfilefinancing.org 1.0Graphic by MSHLike Amazon, Heartfile Health Financing is much more than a website and app on Dr. Nishtar’s iPad. The Heartfile Health Financing website is “integrated with a custom-made technology platform that enables processing of requests, received through registered service requesters. Heartfile (the clearing house) will then ascertain eligibility, verify requests and subsequently authorize cash transfers to underwrite the cost of healthcare.”  

Heartfile Health Financing can be seen as the Amazon of healthcare financing and care provision in Pakistan. The technology platform links together all of the systems components that are necessary for the provision of quality care to the poor. Patients are screened for eligibility through a poverty registry and verified through a system of well-vetted volunteers. Those eligible receive the treatment that they need. Families are protected from medical impoverishment.

Service providers quickly and efficiently receive payment for often costly treatments and surgeries. Funding is targeted to those who fall below the established poverty marker. The system provides funders, initially the Pakistan Poverty Alleviation Fund, with transparency.  They can even track the use of their funds to individual services. The potential for corruption and abuse is mitigated by the eligibility verification system. Everyone wins.

Heartfilefinancing.org 2.0 – The next generation?

Hearfilefinancing 2.0?Graphic by MSHIn 2012, Dr. Nishtar approached Management Sciences for Health to explore taking the Heartfile model to Africa as part of a Clinton Global Initiative commitment with the Aspen Institute and Pakistan Poverty Alleviation Fund. As we looked together at the potential, we saw that, like Amazon.com, the Heartfile Health Financing model presented an exciting range of potential applications. This is especially true in the context of the accelerating movement for universal health coverage.

Instead of thinking of beneficiaries only as individual patients, we could think of them as families in Rwanda needing payment for their community health insurance. Instead of thinking of providers only as doctors and hospitals, we could also think of providers as the full range of service providers, including licensed drug sellers in countries like Ghana and Tanzania. Instead of thinking of the governance function as just the Heartfile health financing team and the volunteers checking eligibility, we could think of the national or local health services or social health insurance programs. And a wide range of funding sources could be tapped, from a wide range of sources, from national value-added taxes to local employers to international donors to individuals in other countries. Imagine, as part of universal health coverage, families in Tokyo or Paris, paying the healthcare costs of families in Mumbai or Kinshasa. 

The power of partnering technology innovations and health system innovations

From polio vaccine to bed nets, new technologies have changed global health. In a tech-driven age, we are attracted to new products and technology. However, a technology innovation won’t fix the problem alone. Heartfile’s website, like Amazon’s, succeeds because of the systems innovations– new ways of organizing people, processes, and resources to achieve greater scale. The end result is a patient who receives the health care that he or she needs without incurring catastrophic debt. Together, technology and systems innovation can lead to stronger health systems generating greater health impact.

Interested in a career in innovation and international development? You’re in luck, says Ingrid Ahlgren in Devex: “the need for new and improved development ideas isn’t going anywhere, and neither are the positions to facilitate them.”

Ahlgren of Devex shares advice on common innovation roles, what's required to land a position, and more from innovation and global development experts, including MSH President & CEO Jonathan D. Quick and Mac Glovinsky of UNICEF. Innovation, “is a big buzzword right now,” says Glovinsky. He says, donors wanting innovation embedded in key functions of development are a key driver of increased attention.

Innovation in development doesn’t mean only new technology, says Quick:

People tend to talk about product and technology innovation, but that’s only half the story.

Yes, you need technology innovations, but you also need health systems innovations in order to get things up to scale.

(More on MSH and health systems innovation)

Ahlgren notes that, for senior positions at an NGO, like MSH, successful candidates: "would need graduate training in medicine or health, such as an MD or MPH, and in business, such as an MBA, as well as extensive experience in global health and a demonstrated interest in innovation."

And, not all "innovation" positions are labeled as such, says Quick:

Most of the innovation positions aren't written thay way.

There are people who are running a program and asked to solve problems and find better way of doing things.

[Innovation] is firstly a way of thinking and bringing different skills sets into solving the problem.

(Find open positions at MSH with keyword "innovation")

Read the full story on Devex

(Note: Devex requires free sign-up to read complete articles.)

Related

• Taking Health Systems Innovations to Scale: From Good Ideas to Greater Health Impact
• Heartfile.org -- The Innovative Amazon.com of Healthcare Financing
• Find careers at MSH

This post originally appeared on the Frontline Health Workers Coalition blog.

Ayelew Adinew was working as a pharmacist in a large public hospital in Addis Ababa, Ethiopia. He looked around and saw that the 100-year old pharmaceutical system was broken.

There was no transparent and accountable system for providing the information needed for effective monitoring and auditing of pharmaceuticals and other commodities. There was not sufficient documentation to track consumption, inventory discrepancies, wastage, product over-stock or under-stock. There were no procedures to ensure the availability of essential medicines. The regulations were outdated and there was no enforcement of the relevant regulations in place to protect the safety of clients, ensure proper utilization of resources, and deter professional malpractice.

Physically, the pharmacy space was too small with no separate area for patient counseling. Essential equipment was missing and there was no transport for procurement. Managing medicines transactions had not been systematized; therefore the dysfunctional work flow was a deterrent to timely service delivery, convenience for clients, and the efficiency of the service provider. The pharmacy system clearly needed reform.

Ayelew Adinew stood on the frontlines of the pharmacy. He could see the fundamental transformation that was needed to fix Ethiopia’s broken pharmaceutical system. Ayelew decided that he could be a more effective agent of change in the public health sector and was hired as a technical specialist for the US Agency for International Development (USAID)-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. SIAPS, led by Management Sciences for Health, is a global health project that uses a systems-strengthening methodology to assure the availability of quality pharmaceutical products and effective pharmaceutical services. The end result is better health outcomes.

At SIAPS, Ayelew believed he would have the support to develop the tools needed to transform Ethiopia’s pharmacies into modern, well-functioning facilities that are auditable and accountable. SIAPS senior management, along with the technical staff, immediately recognized the value of Ayelew’s vision and gave him the support he needed to go forward with this transformative undertaking. According to Ayelew:

I was igniting the fire, SIAPS was adding the fuel.

Working with spreadsheets, Ayelew began to break down each of the steps in all of the processes of a working pharmacy. Ayelew mapped out the flow of medicines and supplies through a health facility system. He created new tools and forms such as vouchers, sales tickets, and dispensing registers to organize and record the information. The next phase was testing the new system.

Debre Markos Hospital is a large referral hospital located in one of the regional states. There, this new system was piloted and given the name, Auditable Pharmaceutical Transactions and Services (APTS). The pharmacy and accounting staff, including cashiers and auditors, were training on the APTS system.

Today, there is legislation in four regions requiring APTS implementation in all pharmacies. Also, the Federal Ministry of Health has signed a directive that covers the entire country requiring implementation of APTS.

One pharmacist, Ayelew Adinew, had a vision for fixing a broken pharmaceutical system that fell far short of serving the people of Ethiopia. With the help of his colleagues at USAID-funded SIAPS, the generosity of the American people, and the support of Ethiopia’s Ministry of Health and other partners in the government, Ayelew was able to rise to the level of a public health champion. Everyone wins.

For more information, please visit www.siapsprogram.org.

Cross-posted with permission from the Bill & Melinda Gates Foundation Blog, Impatient Optimists.

Primary health care has many different definitions, but can be defined simply as the first place where people seek care. Within this definition, private sector providers constitute an important source of primary health care in many parts of the world.

Private providers of primary health

Private providers can run the spectrum–from private hospitals, pharmacies, and non-profit clinics, to informal providers such as faith-based healers and drug shops. A 2013 review suggests that informal providers account for as much as two-thirds of health care visits in Bangladesh and Thailand, and a substantial percentage of visits in Nigeria and Kenya as well.[1]

In developing countries, especially in rural areas where access to health care and pharmacies are limited, private drug shops play a particularly important role. They provide access to essential medicines for many of the illnesses and diseases that burden the poor, and can also provide referrals to local clinics for more serious health issues. In Sub-Saharan Africa people in the lowest wealth quintile seek primary care from drug shops five times more often than people in the highest wealth quintile.[2] 

Private drug shops may even be a preferred source of health services, as caregivers often use private drug shops even when cheaper alternatives, such as community health workers, are available to them.[3]

With so many of the world’s poor seeking care from private drug shops it is important to ensure that these shops provide safe medicines and the best possible advice and care. Historically, that has been difficult due to limited government oversight, regulation, or standards. As a result, available medicines have often included counterfeit, substandard, and expired drugs, and lack of training and knowledge has made diagnosis and treatment unreliable.

Access to essential medicines, Tanzania

Recognizing the extent of the problem with drug sellers in Tanzania, in 2001 the Ministry of Health and Social Welfare (MOHSW) began to work to address this challenge. With 9,226 local retail drugs shops in Tanzania these outlets represented the largest retail source of medicines in in the country.[4] However, an assessment[5] showed that a quarter of these shops illegally sold unapproved or prescription-only drugs, such as broad-spectrum antibiotics, including some that were counterfeit or of substandard quality.

It was in this context that the Tanzanian government and the non-profit organization, Management Sciences for Health (MSH)–with support from the Gates Foundation–launched the Accredited Drug Dispensing Outlet (ADDO) Program. This program aimed to improve access to affordable, quality medicines and pharmaceutical services in retail drug outlets in areas where few or no registered pharmacies existed. The ADDO Program took a holistic approach to upgrading private drug shops that combined training, accreditation, business incentives, and regulatory enforcement with efforts to increase consumer demand for quality products and services.  

After a successful pilot in the Ruvuma region from 2003-2005, the ADDO Program was rolled out in additional districts with the support of the Tanzania Food and Drugs Authority (TFDA) and later the Pharmacy Council of Tanzania. Today, more than two thirds of Tanzania’s informal drug shops had been upgraded and accredited, with an average of thirty upgraded shops per district.[6]

Accredited drug shops, improved health outcomes for the poor

These upgrades represent real changes in quality of care–and thus, real improvements in health outcomes for the poor in Tanzania. The percentage of accredited shops selling unapproved drugs dropped from 26 percent to zero, and 99 percent of drugs passed quality testing.[7] In addition, the proportion of drug dispensers recommending incorrect medicines dropped from 39 percent to 14 percent.[8]

Applying utilization rates from a 2008 survey to today’s numbers shows that Tanzania’s 6,412 accredited shops have approximately 7.6 million case visits every year.⁴ The ADDO Program has increased the availability of quality medicines to underserved populations in Tanzania. Care management in ADDOs has also improved, particularly related to malaria and pneumonia.^8,[9] These successes have improved care and medicine quality for thousands of patients in Tanzania that use these drug shops as their source of primary care.

For some illnesses, these changes can have major implications for health outcomes. Recent data suggests that each ADDO sees an average of 7.2 cases of malaria each week[10] – indicating that these 6,412 shops see about 2.3 million cases of malaria per year. Before this program began, only 6 percent of malaria cases were appropriately managed in the pilot region of Ruvuma. After the ADDO program was implemented, that rose to 63 percent of cases.[11] This translates to approximately 1.3 million more people receiving appropriate medicines for malaria, who might have previously received inappropriate medicines or care. The forthcoming introduction of rapid diagnostic tests in the ADDO shops will improve these results even more.

A decade after the launch of this effort, the ADDO program represents one of the best examples of success integrating informal private sector health providers into the formal health system at a national scale.

Scalable, sustainable

With support from the Bill & Melinda Gates Foundation, MSH is working with the Ministries of Health in scaling up similar programs in Uganda and in Liberia. Even as the Ebola crisis unfolds in Liberia, the drug shops that are already accredited and operating in the country have seen increased foot traffic as public facilities are overwhelmed. Accredited drug shops can play an instrumental role in health service delivery in primary health care, and a key supporting role in times of crisis.

Tanzania’s ADDO Program demonstrates that accreditation schemes and public-private partnerships can impact health access and health equity on a national scale, and improve the quality of medicines and health care that is provided by drug shops.

Related

Watch video: Accredited Drug Dispensing Outlet (ADDO) Program: Improving Access to Medicines in Tanzania