Each year over 10 million men, women, and children in developing countries die as a result of our collective failure to deliver available safe, affordable, and proven prevention and treatment. A recent analysis of innovations in products and practices for global health, from the Hepatitis B vaccine to use of skilled birth attendants, revealed virtually none of these life-saving interventions reaches much more than half their target population—even after as many as 28 years of availability. This reflects a vast gap between knowledge and action in global health.
Successful Health Systems Innovations
Low- and middle-income countries (LMIC) benefit from continued innovations in health products and health practices, such as use of misoprostol to prevent post-partum hemorrhage, and technologies such as internet-based mHealth applications to protect the poor from catastrophic health expenditures. To ensure such innovations achieve large-scale, widespread coverage, they must be accompanied by much more effective health systems innovations.
In the late 1990s, when there were effectively no public health services in Haiti, MSH worked with USAID and local and international service delivery NGOs for perhaps the first large-scale test of performance-based financing (PBF) for health services in a LMIC. For well over a decade now the areas of Haiti in which this innovation in health financing and delivery has been implemented have consistently out-performed national averages for antenatal care, immunization, and other key measures (PDF).
In the mid-2000s, as part of our shared commitment to improving maternal and child health in Afghanistan, the ministry of health, the Hewlett Foundation, and MSH worked together to address unmet family planning needs. In a setting initially thought unfriendly to family planning, we found culturally-based innovations in meaning and message could bring together local religious leaders, healthcare providers, community health workers, and families themselves. Within less than two years the intervention districts achieved up to a four-fold increase in family planning acceptance, often exceeding levels in countries active far longer in promoting family planning.
Other recent global health successes, such as the remarkable scale-up of AIDS treatment over the last decade and the dramatic reduction in malaria mortality in Ethiopia and elsewhere, have each been achieved in part through health systems innovations.
Progressive and Adaptive Health Systems Innovation
“Health systems innovation” refers to new ways of organizing people, processes, and resources to deliver existing health products, practices and technologies. The goal is to achieve greater scale, effectiveness, and efficiency in health care delivery.
In product and technology innovations we hear the terms “incremental innovation” (e.g., making small changes in a new molecule to increase effectiveness or reduce side effects) and “disruption innovation” (e.g., Wikipedia, which ended 244 years of print production by Encyclopædia Britannica, the former market leader). In health systems innovation we must think in terms of “progressive innovation” (adding to or improving an innovation based on lessons from its implementation) and “adaptive innovation” (modifying an innovation to suit the circumstance and needs of individual countries). Let me share a few examples of progressive and adaptive health systems innovation.
One of the most perplexing paradoxes of global health is that the most common source of health care outside the home and the target of half of all out-of-pocket health spending in LMICs is also the most chaotic and least systematically addressed by LMIC health policies—that is, the local drug seller. The missed opportunity for public health impact is huge. Recognizing this, in 2001 Tanzania’s visionary minister of health and the courageous director of the Tanzania Food and Drugs Authority started to work with key local stakeholders and MSH to create the Accredited Drug Dispensing Outlet (ADDO) program, with funding provided by the Bill & Melinda Gates Foundation.
The ADDO program trains, licenses, and monitors dispensers who work in small private-sector shops in the communities where they live. Through progressive innovation the program has expanded to handle third party payment for bednets for pregnant women. Accredited and licensed dispensers now provide appropriate, close-to-the-home medicines, information, and supplies for family planning, HIV & AIDS prevention, and treatment of malaria and diarrhea, and safe delivery kits. The ADDO program has proven to be a scalable, sustainable private sector enterprise that has expanded to the whole country, while at the same time providing rural and urban employment for thousands of dispensers, 90% of whom are women.
A flexible mindset of adaptive innovation is needed when programs such as PBF and ADDO-like community health shops are developed in one country and then taken up by other countries. Since the 1990s, MSH has helped more than a dozen countries to implement PBF. In each instance, adaptation of the basic model to local context and priorities proved essential to success. With PEPFAR and USAID support, we worked with the Rwandan Ministry of Health to ensure that local performance targets—a fundamental element of PBF—were set and implemented across AIDS, child and maternal health, and family planning in a way that reinforced national goals of both integrated service delivery and motivation of health staff performance. In work with public and private sector leaders in Liberia, Uganda, and elsewhere in Africa, Tanzania’s community-based ADDO concept is being adapted to the local context.
Challenges for Frontline Health Systems Innovators
Almost invariably, the best innovations come from those at the frontline. This is as true in global health as in nearly every other field. Whether it is PBF in Haiti, ADDOs in Tanzania, or family planning in Afghanistan, the driving force for these health systems innovations are frontline health leaders responding to an unmet need. Potential frontline innovators face three challenges, however: support to innovate, documenting results, and scaling up success.
To support frontline innovators, good ideas must be identified and incubated by providing time, support, and connections for frontline staff and partners with first-hand knowledge to develop practical solutions. We can then test and develop these ideas on a larger scale. Generating support for new ideas requires effort. Malawi realized that requiring CD4 counts from HIV-positive pregnant women, before providing antiretroviral therapy, wasn’t working for their country due to the health system constraints. The Malawi Ministry of Health decided to pursue a new approach to preventing mother-to-child transmission of HIV. Dr. Erik Schouten of MSH and colleagues described the new approach, which they called “Option B+,” in a 2011 Lancet article. Now, one year later, the World Health Organization (WHO) provided updated guidelines, and other countries are considering adopting Option B+.
Once an innovation is in motion, it can be surprisingly difficult to rigorously document its outcomes, cost-effectiveness, areas for improvement, and ultimate health impact. It has always baffled me that development projects spend tens of millions—or more—on large-scale interventions, but struggle to find the much more modest sums for proper evaluations. Efforts like USAID Forward and the International Initiative for Impact Evaluation are helping. Yet Option B+, which is now a full year into implementation in Malawi and has enrolled over 7,000 women, has yet to garner support for the needed evaluation.
Finally, too often it is assumed by funders, or the innovators themselves, that good ideas will grow themselves, like a hardy new fish species taking over a tropical lake. In global health this rarely happens. The private sector knows that developing an innovative new product or technology is only the beginning; achieving widespread, large-scale use of the product takes time and effort. It is surprising, therefore, that the 2010 Booz Allen report on the Global Innovation 1000 reports that corporations are weakest on the last stage of the innovation cycle—consolidating innovations for broad dissemination.
Tanzania provides a positive example of strategic scale-up. With strong ministry of health leadership and solid technical support, ADDOs now can be found throughout the entire country. Over several expansion phases, support was received from USAID; The Global Fund to Fight AIDS, Tuberculosis and Malaria; Danida; and others. The training and accreditation process was made more economical. The costs for training and accreditation are now paid by the shop owners or dispensers themselves. Realizing their essential role for sustained success, the Rockefeller Foundation supported the establishment of associations of shop owners and dispensers. And seeing the potential for other countries, the Gates Foundation has supported ongoing work to strengthen the model, pilot replication in other countries, and develop and pilot strategies for scale-up, maintenance, and sustainability. I look forward to discussing MSH’s commitment to scale-up ADDOs and other innovations at next month’s Clinton Global Initiative meeting.
Innovations in health products, practices, and technologies have the potential to revolutionize global health. However, they can do so only when supported by health systems innovations. Dynamic health systems innovation requires a mindset of progressive innovation that increases impact based on experience and adaptive innovation that modifies an innovation for maximum impact in new countries. Frontline innovators must be supported to innovate, document results, and scale-up success. Only by recognizing and supporting health systems innovators we can turn good ideas into greater health impact.
Jonathan D. Quick, MD, MPH, is president and chief executive officer of Management Sciences for Health. Dr. Quick has worked in international health since 1978. He is a family physician and public health management specialist.
- “Haiti: Going to Scale with a Performance Incentive Model” (PDF) – Chapter 9 from Center for Global Development’s Performance Incentives for Global Health: Potential and Pitfalls