Child health advocates point out that after more than 20 years, oral rehydration therapy use, which is cheap and could save millions of children, has plateaued at 38% coverage. See Bryce et al 2008 Lancet. Others draw attention to the "product pile up" - referring to the significant resources invested to develop products which could save lives and contain costs, like malaria Rapid Diagnostic Kits. But they don't get adopted by the providers.
Almost everyone agrees this inability to get these great products used is the very weak link in many well-funded global health programs (bednets anyone?). Many advocates focus on prices, and sometimes patents, as if these were the main barriers to use, and improved health. Most health systems analysts know the problem is way more complicated than that. Unfortunately there is all too little policy-relevant research done in this area. Happily, Laura Frost and Michael Reich have contributed to filling this gap in their just-out book "Access". Note: the book can be downloaded for free.
The heart of the book is a set of well-structured case studies of successful (and not) initiatives to take effective health products through the complex phases of discovery, development and dissemination. The case studies are structured using a useful conceptual framework developed by Frost and Reich, referred to as the "Four A's"(see picture): Architecture, Availability, Affordability, and Adoption.
"Frost-Reich Conceptual Framework"
Architecture - the discussion of architecture illuminates the critical issues surrounding how the relevant global actors collaborate to address access problems. These challenges are often overlooked, though it is clear that global partnerships vary hugely in their functionality (compare the Roll Back Malaria partnership to the Global Alliance for Vaccines Initiative), and equally clear that how well these collaborations work directly influences their ability to achieve increased coverage of the products on which they are focusing. The cases underscore the importance of the organizational architecture of the key actors' collaboration - which must enable them to connect availability, affordability and adoption activities.
Availability - refers to the logistics of making, ordering, shipping, storing, distributing, and delivering a health technology to ensure it reaches the end-user. These supply chain issues are fairly well covered elsewhere, but the issues are very nicely synthesized in the book.
Affordability - pricing is often analyzed in the global health literature, with most attention to the access problems created by high prices. However, Frost and Reich draw attention to some trade-offs. While most view a high price as a barrier to access, many experts may not understand how a low price can undermine access. This was precisely what happened in the case of magnesium sulfate (for the treatment of pre-eclampsia and eclampsia) which producers couldn't be bothered to register in developing countries. Why? Because the drug's low price and relatively small market meant that the anticipated profits were too low for the producers to justify registering and actively promoting the drug. The small market for narrow-spectrum antibiotics similarly limits profits, and hence uptake.
Adoption - their discussion of adoption issues brings out the challenges of: getting regulatory agencies and producers to undertake product registration; and, getting providers and patients to use the products. The analysis is a refreshing break from the common focus on overcoming logistical problems alone, while overlooking the difficulties of getting providers to use the product. A sad illustration of what happens when you forget this challenge can be found in the case of the recently developed malaria Rapid Diagnostic Kits (see Chapter 5). Donors have been able to get the kits delivered to providers. But the providers tend to not use the kits, or ignore the test results.
In addition to the framework, the case studies are particularly valuable. Products covered include: praziquantel; the hepatitis B vaccine; malaria rapid diagnostic tests; the Norplant contraceptive device; vaccine vial monitors; and, female condoms. The authors use a consistent structure to present and analyze the access challenges for each product. The format makes them easier to understand, and makes the insights from cross-case comparison easier to grasp.
Here is my take on the many insights from the concluding chapter, "No Success without Access":
1.Developing a safe and efficacious technology is not enough. Products don't fly off the shelf on their own. The clinical focus, not accompanied by systems analysis leads to problems at many levels.
2.Access depends on effective product advocacy.
3.Access requires four key groups to be engaged in product adoption: global actors; national policy makers; providers; and, end-users.
4.Cost can be a barrier; access strategies must address affordability; however, driving down prices is not always the answer - it can lead to reduced interest by producers, importers, producers, wholesalers.
5.Supply-side action is almost always needed:
- Producers are often not aware of market opportunities; procurement agencies are often not aware of products and suppliers
- For new products, finding interested, capable producers is needed, and can be hard.
6.Action is often needed to relieve service delivery capacity constraints (Frost and Reich refer to this as health infrastructure):
-Capacity building actions are usually necessary, and they need to be done based on a sophisticated understanding of both potential provider and end-user barriers to uptake. Frost and Reich acknowledge that they focus least on this level. While they do point out the common problems that crop up here, their framework does not provide guidance on analyzing these problems and identifying solutions. Admittedly, this topic could easily fill another book.
This book's cases make clear that strategic selection of action at every level is needed, and they give guidance on the global and national level, but not so much at the local provider/ end-user level. Such a great book should not be criticized for not doing everything though, they did what they did very well. The book is a great resource, and will be particularly useful teaching classes on developing country health systems.