Diarrheal disease, which kills a million children younger than 5 each year, has an image problem. It doesn’t raise much alarm in industrialized countries, where it is merely a nuisance that can be treated with inexpensive, readily accessible remedies. In poorer countries, though, where a large majority of these children are dying, those remedies often cannot be found.
“We can distribute Coca-Cola all around the world, but we can’t seem to get medication to save a child from something as simple as diarrhea,” said the singer Annie Lennox in a 2008 interview.
Lennox has a point. Throughout the developing world, there are signs of this disparity. While visiting a village in Ethiopia last year, I was told that the nearest pharmacy was three hours away by foot. But around the corner, a tiny provisions shop was stocked with soft drinks and potato chips.
Indeed, Coca-Cola’s footprint in Africa is considerable. The company distributes its sugary beverage to every African country and is one of the continent’s largest employers. At the same time, 30 percent to 50 percent of the sub-Saharan African population lacks access to essential medicines. Clinics are few and far between, and drugs in them are often out of stock. A Johns Hopkins study found oral rehydration salts, or O.R.S., a diarrhea treatment, to be unavailable during one of every five clinic visits in Tanzania.
“The public health world didn’t really create a market for O.R.S.,” said Evan Simpson, who manages diarrhea initiatives at PATH, a global health nonprofit. He offered the example of Cambodia, where O.R.S. is free of charge but rarely available, since distributors do not have a financial incentive to carry it.
O.R.S., a simple mixture of sugars and salts, is one of the most cost-effective treatments in the world. Many international development organizations, including BRAC in Bangladesh, have taught mothers how to make it at home, but the prepackaged mixture is generally seen as safer and more reliable.
O.R.S. packets are easy to transport; unlike many medicines, they do not require refrigeration or special handling, and they have a long shelf life. In theory, they could be transported and sold alongside Coca-Cola and other consumer products.
Could this theory be tested in the real world? Is there a way to leverage Coca-Cola’s huge distribution network to get medicines to sick children?
Simon and Jane Berry, a British couple with extensive experience in international development, have spent the past five years trying to answer these questions. They set up a nongovernmental organization called ColaLife in Zambia, since they had previously lived there and knew diarrhea to be a leading cause of death among Zambian children under 5.
In Zambia, O.R.S. is supplied free of charge in clinics. But as in Cambodia, this means that the people in the middle of the supply chain earn little in the process. As a result, O.R.S. is often out of stock. The Berrys wanted to test whether a market-based distribution model like Coca-Cola’s could improve its availability.
With the help of local partners, they created Kit Yamoyo, or “kit of life.” The kit contains several small packets of O.R.S., zinc pills (they limit duration of diarrhea), a bar of soap (handwashing can reduce risk of diarrhea by up to 50 percent), and an illustrated information packet. Most components are locally manufactured. The kit itself acts as a measuring cup and fits snugly in the empty space in Coca-Cola crates.
ColaLife, which operates independently of Coca-Cola, received an outpouring of support from the international community soon after developing the Kit Yamoyo prototype. “The idea of fitting something in a Coca-Cola crate really appeals to the intellectual, socially well-disposed person who’s looking at Africa thinking, ‘how can we help?’” said Simon Berry.
Many of these supporters would be surprised to learn that, to date, virtually no kits have been transported in a Coca-Cola crate. When Simon and Jane started fleshing out the business model, they soon realized that transporting kits using crates was more limiting than it appeared.
Instead, ColaLife has focused on emulating what Adrian Ristow, a project manager for Coca-Cola, says is the company’s “secret ingredient in distribution”: the investment they put into people.
Coca-Cola directly employs 68,000 people in Africa, but works with up to 10 times more, including independent bottlers, wholesalers, distributors and shop owners. Most of their independent partners are the people who deliver the product to the “last mile.” They carry Coke’s product because they have financial incentives to do so.
These partners operate in the same regions where public health systems often fail. “These supply chains are often dependent on the charisma [rather than defined job scope] of the last-mile person,” said Carolyn Hart, who directs John Snow Inc.’s Center for Public Health Logistics. “If we paid as much attention as Coca-Cola to supply chain, and spent as many resources, we could do it, too.”
This is the biggest lesson ColaLife has gleaned from Coca-Cola. Getting a product to remote parts of Africa often depends on developing relationships with — and offering clear financial incentives to — the people who can get it there.
ColaLife’s distribution model is a mixture of public and private systems. It uses the country’s health system to transport Kit Yamoyo from a central warehouse to the district. It then hand the kits to the same people with whom Coca-Cola contracts. Importantly, their financial model offers margins similar to those of other consumer goods (though the final sales price is subsidized).
Last year, before ColaLife had gone to market, I traveled with the team to one of their planned pilot districts. We visited a wholesaler, a distributor and village shopkeepers. One of the shopkeepers, Joy Munanyanga, immediately rattled off a list of mothers the kit could help (including herself), and calculated the extra money she could earn from selling it.
On the same trip, the team introduced the kit to medical officers, nurses, community leaders, and regional government officials. “Once you’ve gotten support from leaders — community, religious, traditional — it becomes easier” to do business in the community, said Albert Saka, a program manager with Keepers Zambia Foundation, a local partner NGO.
Once relationships are developed, Simon Berry said, it is not necessary — at least in Zambia — to physically place the kit inside Coca-Cola crates. Rather, distributors and shopkeepers add it to their stocking lists, along with items like biscuits, cooking oil and washing powder. “Our experience thus far shows that if you create demand for a product in a rural area, the product will get there,” he said.
Berry is also wary of pegging the availability of Kit Yamoyo to the quantity of Coca-Cola being sold. He posed a hypothetical scenario: suppose that in the rainy season (when diarrhea cases are most common) mothers want to purchase 10 times as much Kit Yamoyo as Coca-Cola. If the kits arrive only in Coca-Cola crates, does that mean that most mothers would have to wait?
Carolyn Hart from JSI stretched the hypothetical scenario further. What if Coca-Cola finds that it is more profitable to supply a certain remote village with the beverage only once every two weeks? The company does not supply lifesaving products (in fact, many would argue the opposite), and could probably tolerate an occasional stock-out to improve its bottom line. The same could not be said for ColaLife’s product. The divergent business objectives, said Hart, have radically different implications for the day-to-day operations.
Coca-Cola, for its part, has been reticent about directly entering the medicine distribution business. “One of the strengths of our supply chain is the resolute focus on our beverages,” said Ristow, who directs Coca-Cola’s Last Mile Initiative. “The main issues would come in the complexity of handling a medicine, and the responsibility level of when you carry them in the community.” Instead, Ristow’s initiative consults with existing health systems and helps them replicate the best features of Coke’s distribution chain.
Though the kits aren’t being transported in Coca-Cola crates, Simon and Jane say they are thankful to have designed the package with that constraint. “What it’s done is forced us to think about the packaging much more than usual,” said Berry. The kit’s shape, size and color were all chosen to fit their customers’ needs and wants, unlike most medical goods packaging. And, he added sheepishly, the kit’s “cool” shape has helped with fund-raising efforts.
The product’s design, for instance, helps mothers create the optimal O.R.S. solution. O.R.S. in Zambian clinics comes in large packets to be mixed with a liter of water. However, most diarrhea patients are too young to consume the full liter, so many mothers inadvertently decrease the treatment’s effectiveness by sprinkling insufficient powder in a glass of water. In response, ColaLife created smaller sachets of O.R.S. and put a measurement line on the kit, designed to be a single serving for a young child.
ColaLife started its yearlong pilot in September 2012 in two districts, including one with low population density. It wanted to test whether market incentives would get the product to highly remote locations — thinking that if it succeeded, it would be easier to get the product to other parts of Zambia.
Thus far, ColaLife has received mostly positive feedback from customers regarding Kit Yamoyo. “People are convinced it cures diarrhea,” said Simon Berry. “They say it’s much stronger than the medicine you get at the health center. And there’s some evidence that we’re stopping chronic diarrhea.” (While conclusive data has not yet been published, Berry’s assessment is based on more than 20, 000 kits sold and surveys of more than 1000 households.) The team also found that shops that sell Kit Yamoyo are, on average, two-thirds closer than health centers — making it much easier for a mother to obtain O.R.S. when a child is sick.
However, the kit’s current price might not be viable. To stimulate initial demand for Kit Yamoyo, ColaLife offered free vouchers. The vouchers have since expired, and ColaLife now charges consumers 5,000 kwacha, or one dollar. Sales have dropped by over 60 percent, reflecting the difficulty of moving from a free to a paid model. Even if sales resume, the price is significantly subsidized by external funders, which raises questions about the model’s self-sufficiency.
Despite these hiccups, the public health world has tremendous hope for the lessons ColaLife can offer. “ColaLife could be enticing the manufacturing of O.R.S.,” said Simpson from PATH. “Perhaps they can show us the potential of how huge the market could be.”
Sarika Bansal is a journalist who writes about social innovation and global health. She is also the Director of Partnerships of the Solutions Journalism Network. Follow her on Twitter at @sarika008.