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Access All Areas

It goes without saying that to be successful, a business should pay close attention to customer and patient needs when designing products. Yet, in the growing markets of emerging economies, whose needs should the pharmaceutical industry consider? Does it continue ‘business as usual’, making and selling products that have done well in its traditional markets? Or should it pay attention to the needs, preferences and desires of the millions in the developing world? ‘Design for all’ – also known as universal design, user-friendly design or inclusive design – suggests it is best to design for everyone. In these days of globalisation, with new drivers – such as the Access to Medicines Index – and with potentially vast emerging markets, who are the new users and how can their needs best be understood?

Designing for everyone might sound costly, disruptive, or simply impractical. However, UK-based charity ColaLife, along with the Zambian Ministry of Health, UNICEF, two international packaging businesses, two global beverage companies, two pharma giants and the UK’s Department for International Development, worked together with a range of other stakeholders to improve the design and delivery of a simple diarrhoea treatment kit for children in Zambia – which would of course be potentially relevant for other countries.

What is ‘Design for All’?

‘Design for All’ is not a new concept. It has its roots in the 1950s and 60s, in the built environment and in products that are designed to reduce barriers for people – particularly those with disabilities. It encompasses areas such as simple and intuitive design, equitable use, flexibility, easily understandable information, tolerance for user error, minimised effort and appropriate sizing.

Many designers and innovators will argue that designing for the neediest or the under-served in society can give rise to breakthroughs that, in fact, offer better design and superior products for everyone. On the other hand, in many large companies, the consumer department, finance and even production teams will often shelve a risky or low-yield business case for a new product design – especially if it is a low cost or low margin product that offers a low return on investment. Big Pharma, an African Minister of Health recently said, is more likely to consider innovation in terms of a brand new formulation, potentially worth billions, than to look at a current proven product line and ask: “Does this really meet consumer needs in emerging markets?”

These were some of the aspects that ColaLife was considering, when it was founded in 2009, to focus on developing a new, easy-to-use diarrhoea treatment kit for children in sub-Saharan Africa. The charity’s ambition was to aim for the same fast-moving consumer goods, like Coca- Cola. How is it that unhealthy, sugary drinks can reach even the most remote villages in the developing world, when basic life-saving medicines do not?

Simple Remedy

Why is that an important question? Diarrhoea is still among the top three killers of children in many countries of the developing world. The proven treatment, recommended over a decade ago by WHO and UNICEF, is both cheap and simple: oral rehydration salts (ORS) to counter dehydration together with zinc sulphate tablets, to boost immunity and improve gut health. However, perhaps precisely because it is inexpensive and straightforward, it has for decades escaped the attention of product designers, manufacturers and distributors. For example, less than 1% of children in sub-Saharan Africa get this basic treatment.

There is little about the ORS and zinc combination that says ‘attractive’ or ‘profitable’. Arguably, both are underlying factors in improving access. ORS and zinc can even be legally sold over the counter in most countries from pharmacies, supermarkets or even small general stores in remote villages. Perversely, antibiotics are often sold illegally, as a childhood diarrhoea treatment in unregulated outlets in Africa. So, why not switch to ORS and zinc – which require no cold chain, no expert dispenser, little regulation, and which have no side effects?

The public sector, if anything, fares worse than the private sector at distribution. In Zambia, as in many African countries, health centres frequently stock out of even basic medicines. Moreover, these health facilities are often many miles’ walk from people’s homes. Yet next door to an empty clinic storeroom, invariably, one finds a small, well-stocked shop, selling a wide range of attractive and affordable consumer goods, which people want and will buy. Research in Zambia in 2011 aligned with results of larger studies across a range of countries: very few retail outlets in remote areas in developing countries sold ORS sachets; zinc was almost unknown; and the all-important copackaging of ORS and zinc together was almost non-existent (1). Were medicinal product designers missing a trick? How can a children’s diarrhoea treatment kit be made as ubiquitous as Coca-Cola?

Addressing the Needs of the Poor

Just as ColaLife was founded in 2009, UNICEF and WHO published a policy paper urging the same kind of change that the charity wanted to address. Entitled ‘Why children are still dying of diarrhoea, and what can be done’, it laid out a clear admission: “We know what to do, but access and availability are barriers”. Among other things, the recommendations invited “strengthened distribution systems and new delivery strategies”, even suggesting that marketbased solutions are often the most effective way to deliver key diarrhoea control commodities.

Around the same time, CK Prahalad’s seminal work with the title The Fortune at the Bottom of the Pyramid was republished. Prahalad’s ideal was for culturally sensitive, environmentally sustainable, and economically profitable products serving the four to five billion poorest consumers in developing countries. This vast and wide market penetration achieved by untapped market, argued Prahalad, would be ignored by global companies at their peril. It could be served by highly distributed small-scale operations married to world-scale capabilities and quality. He saw potential to create jobs for the poor, ending the vicious cycle of poverty.

One phrase particularly chimed with what ColaLife aspired to: giving the poor what he called “the dignity of attention and choices”. In other words, taking the time to find out what these customers really wanted, and providing it – even though their individual buying power was low.

By 2011, the charity had raised sufficient funding to design a new diarrhoea kit (2), and together with its value chain in Zambia built on existing market channels. Often informal, these reach even into remote rural areas, and are successfully used for a wide range fast-moving consumer goods that the local people want. As the needs of parents with diarrhoea-ridden children are already known, but not the wants, some research is required to find this out.

Questioning Line

Partnering with a local non-profit organisation, Keepers Zambia Foundation – which understood the cultural and language issues well – some basic consumer research was carried out in remote villages in Zambia, asking parents and carers of children what issues they had in treating children’s diarrhoea. In retrospect, many of the answers were common sense. Zinc was relatively unknown, and because no co-packs existed, it was rarely offered, prescribed, or bought alongside ORS. ORS, however, is well-known in Zambia and in most of sub-Saharan Africa. There is also a confusing tradition around making a home-made sugar and salt solution – now understood, at least in clinical circles, to be far less effective than low osmolarity ORS and zinc. Yet despite their knowledge, respondents said that conventional one litre ORS sachets, whether given out through health centres or occasionally bought in shops, did not meet their needs for home use.

In the African context, women may need to fetch water from many kilometres away. Boiling and cooling takes time and uses precious fuel. A sick child will rarely drink more than 400ml of ORS in a day, and parents are taught to throw away the remainder, for fear of contamination. In rural areas and urban slums, hardly anyone owns a fridge, or a vessel to measure one litre, or even the concept of what one litre looks like. Parents will either attempt to mix up a full litre and end up throwing away more solution than they use, or sprinkle a little ORS powder into any available drinking vessel, producing a solution that is either too strong (resulting in poor acceptability, or worse, osmotic diarrhoea) or too weak (far from optimum efficacy).

Feeding these insights into the design and distribution models, a product was designed to contain the recommended 10 paediatric zinc tablets plus, crucially, smaller sachets of coloured, flavoured ORS, each containing enough powder to make up 200ml of solution, exactly measured in the pack provided. A small bar of hand-washing soap was also included in the same pack, as customers generally knew the importance of washing hands in theory, but in practice, rarely had soap at home. This ORS/zinc co-pack, named Kit Yamoyo ‘the kit of life’, was first designed so that, optionally, it could be slotted into the unused space between bottles in Coca-Cola crates when retailers bought from the wholesaler. In this secondary distribution chain or last mile – the one that really matters in rural situations – 10 kits could ‘hitch a ride’ on the back of a retailer’s bicycle, with each cola crate they carried back to the village.

Improvements


In the trial areas, the new design benefits translated into clear improvements in access and utilisation. Use of ORS and zinc together, among children suffering from diarrhoea in the two weeks prior to the survey, went up from 1% to 45% within a year, while in control districts no change was seen. Treatment duration went up from 2.8 days to 3.5 days, using only four 200ml ORS sachets versus the two 1 litre sachets usually dispensed by health centres. The average distance that parents had to walk with a sick child went down from 7.3km to 2.4km (3).

However, innovation rarely turns out entirely as expected. What was thought to be the key enabler (fitting the kit into unused space in a Coca-Cola crate) was only used by 4% of retailers. Most simply strapped 10 kits onto their bicycle, along with other goods they bought. This rather disappointing revelation turned out to be an opportunity, though – for two reasons: firstly for cost reduction, and secondly, for much greater flexibility in delivery channel, severing the healthgiving kit from any linkage to supply alongside fizzy beverages.

Final Analysis


So what has been learnt? Most importantly, attention to the needs of the developing world’s poor can lead to breakthroughs that benefit all customers. Will this design prove itself in the long term? Can the same lessons on appropriate sizing, flexibility and easy usage translate into improved access for other countries, or for other pharmaceutical products? This is currently being focused on. Perhaps Prahalad was right in saying that this is not just corporate social responsibility, but better business: paying attention to the needs of this growing patient group is not only best for the millions of people at the bottom of the supply chain pyramid, but also best for the company’s bottom line.

References
1. Visit: www.colalife.org/2014/07/22/endlinesurvey-report-published
2. Initial funding came from Johnson & Johnson, DfID (the UK’s Department for International Development), COMESA (the Common Market for Eastern and Southern Africa), among other donors; with expertise sourced from The Coca-Cola Company, SABMiller, J&J, PIGlobal, Amcor, and many others. In the last year, GlaxoSmithKline has also provided a sounding board and a Health Innovation Award and grant, through its partnership with Save the Children
3. Full results in forthcoming papers by Ramchandani R et al, 2016

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A linguist turned project manager, charity fund-raiser and business advisor, Jane Berry spent 12 years in developing countries, including a three-year spell in remote Zambia. In 2009, she co-founded ColaLife, specifically to learn how to transfer the distribution expertise of fast-moving consumer goods like cola to simple medicines.
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