Empty pharmacy shelves in the West African country of Guinea illustrate the problems of medication access in developing countries. Photo: Julien Harneis (flickr)

Even in the most remote parts of Kenya, there are little shops that sell sodas and mobile phone cards. But too often, the pharmacies of the nation's clinics and public hospitals are empty.

Innovative rural distribution channels are working for Coca-Cola and a new Johns Hopkins study suggests these same methods can work for the distribution of essential medicines.

According to a World Health Organization technical report, “essential drugs are those that satisfy the health care needs of the majority of the population; they should therefore be available at all times in adequate amounts and in the appropriate dosage forms, and at a price that individuals and the community can afford.” To see what makes the cut, check out WHO’s current essential medicines list.

This past May, the pharmacy shelves in Kenya remained bare as the staff awaited a delivery of essential medicines from the national government that was already weeks late. While essential and lifesaving medicines weren't available, junk foods and sodas were.

This is not just a problem in Kenya, but throughout the developing world. Scarcity of basic medicines, health products, and clinicians is an ongoing issue for poor countries with struggling public health systems. In fact, Save the Children published a report this month which claims that "40 million children under five in 25 developing countries live in 'healthcare deserts' where they are deprived even of the most basic health services." In a similar report, the World Health Organization estimates that 30 percent of people worldwide lack dependable access to essential medications — in the most impoverished regions of Africa and Asia, it's 50 percent.

Students at Johns Hopkins Bloomberg School of Public Health's International Vaccine Access Center have taken notice, releasing a study comparing public and private sector distribution structures and how these sectors might collaborate to increase equitable access to medication and health products. “Companies selling soda and mobile phone cards work in the same hard-to-reach markets in Sub-Saharan Africa as essential medicine distributors,” Kyla Hayford, a doctoral student who coauthored the report, explained to Science Daily, “but they have been far more successful at modifying their systems and aligning incentives to overcome distribution barriers.”

Coca Cola, for example, has developed “manual distribution centers” in East Africa that depend on bicycles and carts to deliver crates of sodas to remote and inaccessible outposts. In some places without passable roads, this distribution system accounts for more than 95 percent of sales, according to the IVAC report. Manual distribution could bring vaccines and antibiotics to these isolated communities, too. Mobile clinics and vaccine distribution do exist in places like rural Kenya but they are informal and often spearheaded by a determined health worker or small group of dedicated community health volunteers.

The IVAC study cites that more than 50 percent of hospitals studied in Kenya did not have vital broad-spectrum antibiotics at any given time. Further, Kenya is not just any developing country, but an economic forerunner in Africa with an economy that grew a promising 5.6 percent in 2010, according to moneycontrol.com.

For the IVAC and many others, getting medicine to the developing world is a matter of distribution, distribution, distribution. Public-private partnerships that involve "sharing knowledge, sharing infrastructure, generating appropriate performance monitoring metrics, and investing in product innovation" can help fix this, the study concludes.

But it's no coincidence that vaccines and antibiotics have such a hard time getting to market. The global health system has no arrangement to incentivize their development, production, or distribution. True health equity also requires financial commitments to research and develop lifesaving drugs. Next, they must be produced and sold at prices accessible to the average person in poor countries.

A recent article from The Guardian outlines some ideas about how the poor can become viable consumers and consequently influence the supply-and-demand chain for essential medicines. Poor clientele in developing countries could afford to pay the price of medications in a competitive market with generic production. However, the current system prevents this by allowing companies to patent brand-name drugs and maintain monopolies on their production, often for long periods of time. Instead, The Guardian suggests “annual reward payments based on the product's health impact” be given out to alter the incentive scheme and favor more pro-poor medicine development. If implemented, this policy would reward the research and development of life-saving and essential medicines — those with broad-reaching global health benefits — rather than specific and non-essential medicines which treat the minor ailments of advanced industrial societies.

Increasing access to essential medicines and technologies could prevent and cure diseases for millions in the developing world. The solution is not simple; it’s not just distribution. What makes commercial distribution so effective has to do with profitability and there is no profit to be had in the public health sector. Similarly, the impetus for new drug development depends on what has the potential to make the most money and not necessarily what will save the most lives. But if these techniques can be appropriated and incentives redirected for the greater good rather than profit, the benefits will be tremendous.

Eritrean child receiving a vaccine. Photo: daveblume (flickr)

The Bill & Melinda Gates Foundation announced a $10 billion-commitment over ten years to vaccinate children in developing countries on Friday. The nonprofit is calling on world leaders to join in this effort, aimed at drastically reducing the number of deaths of children under 5 years old.

There are economic benefits to reducing child mortality in developing countries as well. Countries with lower child mortality rates tend to be more economically developed, according to the World Health Organization.

Photo: uncultured(flickr)

Human subjects research has always been rife with ethical concerns, especially when research is being conducted in the developing world. At first glance, demographic and health surveillance (DHS) research can appear to have less potential for harm than direct-intervention drug trials. Not so, says a recent bulletin from the World Health Organization.

DHS research is defined as “long-term monitoring of specifically defined populations, typically residing in a small geographic region.” The authors of the August 2008 bulletin article say that while DHS research has led to many life-saving findings, including vaccine development, the invention of oral rehydration solution, and the link between early cessation of breastfeeding and malnutrition, it comes with a special set of ethical complications.

For example, when a disease surveillance team with the resources to provide comprehensive health care to a community is stationed in a poverty-stricken area, what is their obligation to the community? Do they treat people for only those diseases that they study? Do they only treat study participants? How does project staff go about obtaining informed consent from the community members? If there are monetary gains to be made by study subjects, what consequences might that have? If the DHS group provides health care or other services in a community for a long period of time, what happens to the community when they leave?

Ethical quandaries are certainly not limited to DHS research. As global health and development topics increasingly capture the attention of resource-rich universities and researchers, it is important to remember that the potential for harm rises along with the potential for good.

Malaria nets. Photo: Tomas de la Maza (flickr)

Is malaria's reign of terror coming to an end?

Every year, 500 million people fall seriously ill with malaria — a disease that induces fever, chills, nausea, flu-like illness and, without treatment, coma and death. More than 1 million people die each year from malaria — almost all in the developing world. The near-universal poverty of its victims is one reason it has not received the attention, and therefore the money, necessary to secure its demise.

Even in the face of these scary statistics, malaria may be about to meet it's match. The Economist reports a renewed sense of interest in its eradication, mainly because it jeopardizes the UN's Millennium Development Goals, a set of benchmarks in health, education and human welfare that world leaders committed to attain by 2015.

There's a cost-benefit rationale, too. Malaria costs Africa upwards of $12 billion a year in health expenses and lost productivity. Yet a five-year eradication plan might cost as little as $2.2 billion a year, according to a report by Malaria No More and McKinsey & Company.

With these numbers in mind, last week the UN unveiled a new campaign to fight malaria at its most critical spots. The Roll Back Malaria (RBM) Partnership — created to "enable sustained delivery and use of the most effective prevention and treatment for those affected most by malaria — staged the first World Malaria Day last week. It coincided with a UN plan to spray inside houses and distribute insecticide-treated bed nets to "all people at risk" of the disease by the end of 2010.

Any effort to stamp out malaria must deal with an added layer of complexity. When diminished but not destroyed, malaria can come back with a vengeance. Any letup in the eradication campaign may end up actually increasing the numbers of those at risk.

But considering how much malaria undermines the war on poverty, a risk taken to ensure its eradication may be a risk worth taking.