Beyond Scaling Up: Pathways to Universal Access W O R K S H O P B R I E F I N G 3 • J U L Y 2 0 1 0

Building evidence from local innovation: building place into science Alice Street, University of Sussex and Ann Kelly, London School of Hygiene and Tropical Medicine

The presentations by Alice Street and Ann Kelly stressed the importance of incorporating local context into the research and pilot process, and highlighted the problems and limita-tions which can arise when local realities and constraints are ignored.

Street gave an account of a clinical trial looking at the replacement of oral medicine for malaria with suppositories, which took place in Madang General Hospital in Papua New Guinea. While the research was successful in establishing the value of using suppositories, researchers had a very narrow outlook and no efforts were made to look at the needs of the hospital itself. Opportunities to build capacity in the hospital and interest in the research were missed. For example, there were no adequate laboratories in the hospital, so samples were being sent back to Australia. Research funds were used to build a separate laboratory, but for the purposes of research only. The research knowledge was therefore divorced from the infrastructure and capacity context, which has implications for the introduction and expansion of the intervention being piloted.

Kelly gave a contrasting account of a pilot which attempted to embed itself in the context in which it was taking place; the

use of doorway screens as a malaria preventative in a community in Gambia. The screens were designed and adapted according to local materials, housing structures and labour, for example ceiling screens were redesigned with zippers to let thatch through. As in Papua New Guinea, the research was successful from an academic perspective. However in terms of becoming a large scale intervention the pilot faced a lot of challenges, in particular there were questions about who would pay for it on a large scale. The pilot was perhaps too localised, and did not sufficiently address the issue of sustainability.

These case studies demonstrated how health systems research is a key part of the health system strengthening process. The way research is framed affects how findings can later be applied on a large scale; in this case, neither project was sustainable on a large scale. Street and Kelly urged policy makers to ask themselves what is being scaled up, and argued for greater attention to the different and specific ways in which local context is articulated by research practice, and the tensions between scaling up research findings (innovations) and building local capacity as defined by participants.

Useful links

View Street and Kelly’s presentation from the workshop http://www.slideshare.net/katecommsids/beyond-scaling-up-how-place-is-built-into-science

Left Screens were designed and adapted according to local materials, housing structures and labour

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Beyond Scaling Up: Pathways to Universal Access W O R K S H O P B R I E F I N G 3 • J U L Y 2 0 1 0

Assessing supply chain innovations in essential medicinesMaureen Mackintosh, Open University

Mackintosh’s presentation used the example of medicines supplies in Tanzania to show how innovation in the distribution of medicines is a complex area of health system policy. The ‘supply chain’ metaphor in health policy originates in industrial contracting and invokes a top-down, managed model of delivery. However in Tanzania access to medicines is mainly market-based: people pay out-of-pocket for most essential medicines, and those who are unable to pay are therefore excluded. In 2006, research found that 95% of those interviewed while seeking care had paid for their own medicines; 8% had not been able to afford medicines and 15% had bought a part-dose. Dispensing part-doses is a norm in the private sector (90% of dispensers practised this) and widely accepted in the NGO sector (66% of dispensers).

Mackintosh identifies three types of supply chain for drugs in Tanzania:

1 International supply of HIV/AIDS and TB drugs are purchased through large international tenders. The drugs are generally provided free at point-of-use and have greatly increased access to prescription-based treatment. However this supply chain model is expensive, highly subsidised and its sustainability is problematic. Internationally funded procurement largely excludes local suppliers.

2 Public sector and NGO wholesale procurement of medicines for public and NGO facilities. These facilities generally require payment and in practice often exclude the poorest. However prices are relatively low in the public sector, and there is quality control in this supply chain, although there are problems of stock-outs. Public and NGO procurement encourages local manufacturers and is thus linked to upgrading of local industrial capabilities and employment in the production of basic medicines.

3 Private market wholesale supplies purchased locally and internationally: the private market ‘supply chain’ supplies about half the essential medicines available; regulation has improved but there are continuing problems of quality, exclusion and under-dosing.

There is a need for evaluation of alternative supply chain innovations to allow policy makers to identify effective solutions. Mackintosh suggested that supply chain innovations should be judged on the proportion of paid-at-point-of-purchase medicines, cost per patient and the local capability for sustaining delivery. Impact on monopoly power in the supply chain should also be taken into account.

Useful links

View Mackintosh’s presentation from the workshop http://www.slideshare.net/katecommsids/beyond-scaling-up-supply-chains

Watch an interview with Mackintosh on you-tube http://www.youtube.com/watch?v=gG2KwAzkEDE&feature=related

Supply chain innovations should be judged on the proportion of paid-at-point-of-purchase medicines, cost per patient and the local capability for sustaining delivery.

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www.futurehealthsystems.org www.steps-centre.org

Participants asked whether high medicine costs in the private sector should be the concern of the health system or of other ministries who are responsible for government taxes and tariffs driving up prices. There was also discussion of South African firms buying Tanzanian ones in order to produce cheaper drugs for the South African market.

Participants were also concerned with the implications for donors. One participant noted that research that takes context into account is a strong selling point for donors. It is difficult to make research part of health service provision.

Discussant: Ian Scoones (IDS)

Scoones suggested that discussions were presenting a picture of multiple narratives about multiple systems; plural informal systems motivated by public private partnerships and local entrepreneurship, driven by information communication technologies and linked into global drivers (such as supply chains). He suggested that more political analysis would be useful and asked how do you regulate supply chains without assuming a regulatory infrastructure that doesn’t exist? Answering these questions and developing innovation requires experimentation, learning and pragmatic approaches to understanding the world.

Discussant: Elizabeth Ekirapa-Kiracho (Makerere School of Public Health)

ekirapa-Kiracho re-emphasised that innovation requires adaptation and that there is a strong need to organise local and international networks to share learning and help achieve appropriate outcomes. In-country link ups are very important and must be built. Local level engagement needs to be communicated to the international level to help donors decide their priorities.

Beyond Scaling Up: Pathways to Universal Access W O R K S H O P B R I E F I N G 3 • J U L Y 2 0 1 0

This briefing was prepared by Peroline Ainsworth andKate Hawkins on behalf ofthe Future Health Systems Consortium.

The authors express their appreciation for the financial support (Grant # H050474) provided by the uK Department for International Development (DFID) for the Future Health Systems Research Programme Consortium. This document is an output from a project funded by DFID for the benefit of developing countries. The views expressed are not necessarily those of DFID.

The STePS Centre is a collaboration between the Institute of Development Studies and SPRu Science and Technology Policy Research at the university of Sussex with a network of partners in Asia, Africa and Latin America and is funded by the economic and Social Research Council. The economic and Social Research Council is the uK’s largest organisation for funding research on economic and social issues.

Session discussion