Archive for the ‘resource-constrained settings’ Tag

Training medical students through international electives   Leave a comment

A number of recent academic studies have shown that global health experiences are becoming more essential in the eyes of medical trainees. One particular study suggested that the vast majority of current surgical residents are interested in global health experiences. Our research group at Emory has further shown that medical students are likely considering global health offerings when students evaluate residency programs. The reality for residency programs today is that failing to offer opportunities in global health may be harming their ability to recruit the best applicants for their program. However, medical schools and residency programs alike have had difficulty overcoming the logistical difficulties while also maintaining the quality of medical education provided during such experiences.

Medishare_ultrasound

Drs. Jahnavi Srinivasan and Viraj Master demonstrate point-of-care ultrasound techniques to medical students Lee Hugar and Pete Creighton during Emory Medishare’s surgical camp in Hinche, Haiti.

For the last five years, I have worked intimately with a small group of faculty and students at Emory University School of Medicine to design a for-credit international surgery elective that attempts to demonstrate the feasibility of such a training experience for medical student. A long-form retrospective piece on the effort and how it has evolved to meet the needs of multiple stakeholders has just been published in the Bulletin of the American College of Surgeons. The key takeaway from our group’s experience is that the common criticisms of these short-term trips fail to wholly encompass the range of benefits being provided. If one assesses solely the educational value or exclusively the burden disease effect for the patient population, a perspective that incorporates the cumulative benefit of these programs is lost.

As I have started the transition from medical student to general surgery residency, it has become increasingly important for me to find a way to communicate our message to the next generation of medical students. At Emory, I have no doubt that an exceptional class of rising senior medical students with global health experiences will have no problem continuing to build on the model there. But what can be done for other medical schools that don’t have such a program or have not operationalized it in a manner that can continue across multiple years? After considerable thought and planning, we have released an early version of a website, www.MedStudentTrips.org, that will serve as a repository of public clinical manuals, planning documents, and advice for those looking to replicate the Emory Medishare model at their own school. In passing on such knowledge, I hope to catalyze such efforts at other institutions in the future.

For information on Emory Medishare, the student-faculty medical humanitarian collaborative discussed in this article at http://www.emorymedishare.org.

For those looking to design such a program at their own medical institution, Emory Medishare has posted many of its public resources at http://www.MedStudentTrips.org.

 

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When “go-local” doesn’t work: sanitary napkins in sub-Saharan Africa   Leave a comment

7 years ago, an enterprising Harvard student, Elizabeth Scharpf, began a project to produce sanitary napkins using local workers and local materials in sub-Saharan Africa. Although difficult to quantify, the amassed evidence has suggested that many women in developing countries– particularly school-age girls — are routinely sequestered and miss multiple days of school each month because of the lack of hygiene products to use during menstruation. This issue has been long ignored largely because of the associated stigma around a woman’s menstrual cycle in conservative societies and the lack of health officials familiar with women’s needs. Sustainable Health Enterprises (SHE), the company founded by Sharpf, was an attempt to a) address the needs of rural women through a locally available commercial product AND b) provide a self-sufficient business model to entrepreneurial women in these countries.

The basic model has been to first find local entrepreneurs interested in starting a local sanitary napkin production operation. The raw materials for these sanitary napkins are then sourced locally using banana tree fiber, a waste product of banana harvesting, as a substitute super-absorbent material. The cost savings on materials and production help reduce the cost per pad from US$0.11 to US$0.07.Local women are then trained to produce these with small table-top workshops that can be used in their private homes. These are then collected by the local entrepreneur and sold in markets or with door-to-door sales models.

SHE Pad Prototype

First-generation SHE Pad. Not exactly what Rwanda’s women were looking for. (Courtesy Ecouterre)

SHE’s success to date has been mixed. Between 2009 and 2011, Scarpf used funding from Echoing Green and Harvard Business School to setup the first franchise model of banana fiber-based sanitary napkin production and distribution in Rwanda. However, using the available public information on SHE’s website and blog, the latest updates dated August 3, 2012 suggest that company is just now completing its supply chain and brand strategy. The largest hurdle seems to have been that the uniqe selling point SHE pads offer — their attractive lower price — are exactly why consumer demand from Rwandan women has not been strong. In a critical oversight, Rwandan women who cannot afford imported pads would rather use their existing coping mechanisms in a pad-less world than use SHE’s product. Although SHE is actively working through these issues and is currently completing a redesign, SHE has yet to prove its model for a new sanitary napkin for the low-income communities.

A particular concerning trend is that efforts to provide locally-produced sanitary napkins have been increasing even though the existing businesses have yet to identify a succcessful business model. At the the University of Oxford’s 2012 TATA Ideal Idol business plan competition in March, one of the finalist was BaNaPads, a similar sanitary napkin effort being attempted in Uganda. No evidence suggests that these me-too ventures are finding solutions to the problems that racked earlier efforts. Although there is a certain attraction to local production and women’s empowerment through independent income generation, the social entrepreneurship and global health communities should be self-critical to such unproven models.

While the work of the organizations above is commendable, none of these efforts have seem to realistically questioned if multinational corporations are already providing female hygiene products in the most financially sustainable way. Patricia O’Hayer, Unilever’s Vice-President for Communications and CSR, challenged the development community in a recent Oxford-based debate to avoid automatically assuming that there was something intrinsically better about local production versus global mass production when it came to making consumer healthcare products. Procter & Gamble and Unilever may be unapologetically “big business,” but their ability to reach economic scale and provide a safe, reliable product may be unmatched in this product category. Entrepreneurial efforts such as these must be compared to existing ways of doing business if they are meant to contribute to societal value creation.

Disclosure: In early 2012, I informally worked with a team from  Procter & Gamble on shared interests to bring health-related retail products to rural communities in rural Kenya. There was no material remuneration from this engagement.

Is Kenya’s healthcare sector ready for a take-off?   2 comments

Last month had me traveling around the world courtesy of Saïd Business School’s capstone Strategic Consulting Project and our multinational corporate partner who is currently looking to become more invovled in healthcare innovation in developing countries. I just finished my second short stint in Nairobi, and I am thoroughly impressed by a number of developments in Kenya. The current macroenvironment for healthcare in Kenya combined with individuals’ entrepreneurial efforts has produced palpable excitement in the sector that may well signal a new dawn for healthcare in the country. Most interesting, the opportunities for Kenyan private sector healthcare may be the best they have ever been.

One of the most important macroenvironment trends is the improving political stability since the post-election ethnic conflict of  2007-2008. Since then, a new constitution has been ratified and the upcoming elections will be preceded by a number of bureaucratic improvements that will streamline the alignment of commercial ventures with committed policy-making. This political normalization has also allowed for an increasing amount of “business as usual” from the administrative arm of the government including more direct financial management of HIV/AIDS spending and a new eHealth strategic plan. Although the next round of elections scheduled for 2013 may well herald a new wave of vote-rigging and subsequent violence, the two rival political parties from the last election have learned to work together through power-sharing and the knowledgeable city-dwellwers I have spoken to in Nairobi seem optimistic.

mPESA Transaction

Many groups are trying to repeat mPESA’s success in mobile money payments by coming up with similar mobile-related leapfrog applications for healthcare. (Courtesy of OpenIDEO)

Another trend occurring in Kenya is the overwhelming success of modern mobile telecom infrastructure. Nearly every business venture I met with in Kenya includes in its business model a component related to mobile technology. Mobile technology in developing countries has been shown to be a major catalyst for healthcare development but where Kenya stands out is in its mobile phone penetration. Over 70% of Kenyans own and use a mobile phone and nearly a 1/4 of the country’s GDP is transacted through Safaricom’s mPESA mobile payment service (see more).

All of these trends have directly stoked the entrepreneurial efforts of many Kenyans. Zoe Alexander Ltd is a new technology start-up who is leveraging automated telephone systems (“robo-dialing”) and Kenya’s high mobile penetration to deliver personalized audio messages to pregnant mothers that time appropriate antenatal visits and warn mothers’ of “red flag” warning signs during pregnancy. Zoe Alexander and others have also focused on bypassing the existing healthcare infrastructure because of the its overly bureaucratic nature in Kenya. Another example is Changamka Microhealth’s use of health savings accounts to incentivize individuals to save rather than trying to expand the relatively small population footprint of the country’s national social insurance plan. The latter’s bureaucracy was unable to design a means of participating in the plan for individuals that did not work for major Kenyan corporations.

While such initiatives will not radically change the health and wellbeing of the average Kenyan overnight, these efforts should be complimented for their inventiveness and aspirations for self-sufficiency. Through my travels last month, I have heard far too many stories of companies seeking overly traditional approaches to reaching low- and middle-income healthcare consumers. Marketing techniques designed for industrialized countries will not work elsewhere unless modified to local conditions. Home-grown, for-profit healthcare in Kenya may be the first sign of lessons learned.

Disclosure: I, nor my summer employer, have any financial positions in the companies listed here. However, my trip to Kenya was funded as part of business development field research for a multinational corporation.

Global Health’s Latest Offspring: “Global Surgery”   1 comment

Outside Hôpital St. Thérèse, Hinche, Haiti

Outside Hôpital St. Thérèse (Hinche, Haiti)

“Global surgery” is a relatively new addition to its parent field of global health. Although the notion of surgeons from the industrialized world sharing skills and equipment with resource-scarce environments has been around for decades (largely arising out of the medical operations of the world powers’ militaries), “global surgery” as an academic interest within traditional global health circles has emerged only recently. The increasing interest in the global burden of surgical disease has largely paralleled the relatively new awareness of noncommunicable disease as a global problem.

I should be clear that a consensus has only just begun to form in the last 10 years around the broadening of the definition of global health. For example, although there is an increasing effort to use “global health” in a more appropriate, literal sense, many well-qualified academics still associate the term with the unique disease burden of low- and middle-income countries. Say “global health” in a professional healthcare setting and poor, non-white people suffering from malaria or HIV is what the majority of the audience will be envisioning. It is only recently that the more complex problems of noncommunicable diseases like diabetes and cancer that span the industrialized and developing world have been authentically engaged by the global health community.

Inside Hôpital St. Thérèse

Inside Hôpital St. Thérèse (Hinche, Haiti)

Within global surgery, I am most interested in the persistent difficulty we have of finding the means of providing even the most basic surgical care for all the world’s communities. Although it will be decades before the poorest countries will have the means of performing complex surgeries like spinal fusions or coronary artery bypasses, the infrastructure and skills necessary to perform hernia repairs and thyroidectomies is well within reach. These latter cases may be less “newsworthy” but they represent substantial quality-of-life improvements for patients suffering from surgically-correctable disease. Although the field of global surgery is still in its nascent stages, a number of expert bodies are catalyzing around the idea of essential surgical care (e.g., ASAP TodayWHO GIEESC) and how best to deliver it.

A note on the pictures: The pictures in this post include two from a humanitarian surgical mission I joined in June 2009. This was the first of a series of many missions (more in a later blog post). I inserted these two images here to demonstrate how even the limited infrastructure of Hôpital St. Thérèse (see “outside” photo) can provide the platform for delivering basic surgical care (see “inside” photo). The bottom picture is provided courtesy of Nick Vittone of AtlantaAperature.com.