Mutinta’s five-month-old daughter has diarrhea. In developed nations, a stomach complaint like that might be a mere nuisance. However, in Zambia’s vast countryside—without electricity, water, soap, and medicine—diarrhea is a matter of life and death. Here, over 11,000 children die of diarrhea each year, while across the world there are 700,000 diarrhea-related deaths annually. Malnutrition, made worse by diarrhea, contributes to 45 percent of all child deaths and causes many more children to fail to reach their full mental and physical potential.
Mutinta is only 25, but she has four children. She knows her daughter is in grave danger. Before the sun breaks on another hot day, she and her husband set off on the eight kilometer walk to the nearest health clinic. They take 25.00 Kwacha for the journey ($5.00 USD). Because Mutinta’s family is not desperately poor, this is not a story of hopeless poverty. Rather it is a story about choice—what the writer and economist C.K. Prahalad calls giving customers at the bottom of the pyramid “the dignity of attention and choice.” And at the moment, Mutinta has few choices.
Zambia is an emerging African economy. Although 77 percent of the rural population is categorized as below the poverty line, the Zambian Central Bank says the economy grew by 7.3 percent last year, up from 6.8 percent in 2011. Yet there are fewer than 70 retail pharmacies in a country twice the size of California. With vast distances to cover, public sector health supplies don’t reliably reach rural areas beyond the district town, where 60 percent of the population lives in villages. Mutinta’s family is typical: farmers living modestly and happily in their close-knit community. They grow much of their own food and they trade; there is a small shop close by selling cooking oil, salt, biscuits, soap, and the ubiquitous fizzy drinks found everywhere in Africa. As Health Minister Joseph Kasonde says: “You will find Coca-Cola in any village, at any time. But you won’t find medicines…There is something there to learn from.”
This is how my husband, Simon Berry, and I find ourselves back in Zambia, nearly a quarter of a century after leaving a remote rural project in Mpika, funded by the British Aid Programme. The Zambian Ministry of Health welcomes innovation, and we are called innovators, although it seems to us more a blend of enthusiasm and curiosity—that childlike inability to stop asking why? Why are children still dying of diarrhea? Why doesn’t every mother have access to an anti-diarrhea kit, as the World Health Organization (WHO) recommends? Why does Coca-Cola reach remote villages, yet simple medicines do not? Why do so many people find this blameworthy, instead of wondering why it happens? Why do “poor people” so often get to choose between free or nothing, when free actually turns out to be unaffordable (due to the distances people need to travel to access the service)? Why do designers of products and services so rarely ask these consumers at the “bottom of the pyramid” what they want?
Our starting point was the Coca-Cola conundrum, now well known in health circles. But in the eighties, when my husband first tried to raise it with anyone who would listen (mainly me), it was a non-question, with no answer. Maybe Coca-Cola would modify their crates to carry medicine (I doubted it). Maybe they would take out just one bottle and replace it with a medicine flask? (Who knew?) In rural Mpika, a Telex machine connected us to the world beyond, sometimes. No one had heard of corporate social responsibility. The guy who invented Facebook was barely born. Global health decisions happened in ivory towers. Our neighbors’ child died, along with 12 million others. Coca-Cola didn’t pick up the phone.
Fast-forward 20 years later, and the Coca-Cola idea popped up again in an online debate on a computer screen in our living room in England. There was the top guy in Atlanta, suddenly reachable from our dining table. He didn’t answer our question that day, but that was the beginning of something. Simon was off again on his pursuit of Coca-Cola, and the difference is this: now you can ask any question, however obscure, or share any idea, and someone will respond: it might be a respected supply chain academic; WHO’s top diarrhea expert; or a UNICEF strategist. Within months, we had help from all of these and more—plus 1,000 supporters on Facebook, the BBC, and a top level contact at Coca-Cola: Salvatore Gabola, who was then Global Director of Stakeholder Relations.
“Don’t ask them to take out a bottle,” I said, “There’s space in the crate, between the bottles.” Doubtful, Simon made up a prototype pack from cardboard, and we measured its volume with rice. It was a funny shape, but the available space was half a liter. The AidPod—christened by Eddie Mair of the BBC—was born. The AidPod became our initial idea for harnessing Coca-Cola’s delivery expertise. If Coca-Cola reaches remote communities, why not design a medical pack which fits in the space between crated bottles of soda?
To be fair to Coca-Cola, they didn’t say no to the odd idea of putting 10 anti-diarrhea kits in the space in their crates. They said it was up to their independent bottlers. They advised on contacts. They warned us, regularly, that the idea might not be as simple as it sounded: “Yes, but what’s the value chain?” they repeated. At the time, we barely understood that question. We do now.
We’ve come to understand that it is this ethereal concept, the value chain, that gets our carefully designed Kit Yamoyo to the shop in Mutinta’s village. Our kit contains the WHO/UNICEF “gold standard” of oral rehydration salts (ORS) and zinc, plus soap. Yes, it fits in a crate, and that’s clever. But Mutinta doesn’t care about that—and, as it turns out, most of the shop keepers we work with don’t either. She wants an affordable, attractive, easy-to-use kit, so she is confident exactly how much water to mix with the ORS, even in the dark. Kit Yamoyo delivers just that: the packaging measures exactly 200 milliliters, matching the provided specially designed child-size ORS sachets. She wants her child to like the look and taste. She wants a treatment that works, and she wants it close to home. The shop keeper wants a profit, and to be knowledgeable about the product, to give him standing in his community. He could use space in a Coca-Cola crate to carry 10 Kits on his bicycle, 20 kilometers back to the village—but mostly it’s convenient to strap a bag of five kits to the handlebars, or put a whole box on the back. The wholesaler and distributor want a product delivered as cheaply, conveniently, and reliably as possible—a profitable product with a ready market. The local manufacturer needs help to make that happen.
If you can get all those things right—and it turns out that this is what we have done— then you have created a value chain. The market works its magic, achieves things that the government can’t, and meets the needs and aspirations of poor people in remote villages, just like Coca-Cola does, for just under a dollar a bottle. Kit Yamoyo currently retails at about the same price, and we are going to have to work hard, beyond the trial period, to balance affordability and sustainability without distorting that all-important value chain.
What does this mean to Mutinta and Nchimunya? On that day in May, they reached the nearest health post after two hours walking. They found no staff there; this is not uncommon. Even the bigger rural health facilities rarely have a doctor or nurse. They are often staffed by environmental health technicians, and about half of the time key medicines are out of stock. But Mutinta and her husband were well prepared. They could pay for transport to Bbilili Rural Health Centre, another 45 kilometers away, and Nchimunya was admitted. Bbillili was also stocked out of both ORS and Zinc, and had been for most of the year. But there, health center staff work closely with our trained shopkeepers. Bbillili is one of the bigger shopping villages—a dusty main street with about a dozen kiosks of concrete and tin, where chickens scratch and children watch the men pay K2.50 (about $0.50) to play pool under a thatch in the middle of the road.
With her last 5.00 Kwacha ($1), Mutinta bought Kit Yamoyo, and the health center staff supervised her as she used it to rehydrate Nchimunya and administer the Zinc tablets—so important for strengthening the immune system and preventing diarrhea from reoccurring. By the third day, Nchimunya had greatly improved and on the fifth she was discharged to go home.
We met Mutinta and her husband in July 2013, a few months after her hospital admission. Nchimunya was looking fat and healthy. Mutinta says many mothers would be wiser to spend 5.00 Kwacha on Kit Yamoyo in a shop near to their home, than to waste time hoping that traditional herbs will work, or spend a great deal more money on transport and buying food away from home. Next time Nchimunya is ill, Mutinta hopes her local shop will have Kit Yamoyo in stock, so she will have a choice. The job of ColaLife—the charity we have created to test and roll out Kit Yamoyo over the next few years—is to make sure that choice is available in villages across Zambia.