Fighting AIDS in Tanzania

Have a Coke and an Anti-Retroviral
Notes from different corners of the world.
June 9 2011 7:10 AM

Fighting AIDS in Tanzania

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HAI DISTRICT, Tanzania—A Coca-Cola truck rumbled down the road, ferrying its bubbly, sugary cargo to shops and kiosks in the northern part of the country around the edge of Kilimanjaro National Park. The one thing you can be sure of finding in any far-flung corner of Tanzania is a bottle of Coke. A new pilot program—the first of its kind—aims to make anti-retroviral drugs as easily accessible as a bottle of soda by tapping into Coca-Cola's established delivery network throughout Tanzania.

Tanzania's government supply-chain agency, the Medical Stores Department, currently distributes anti-retrovirals, malaria medication, and other drugs to 500 points around Tanzania, but President Jakaya Kikwete wants medicine taken to the doorsteps of all of the country's 5,000 health facilities. Widening the distribution net so broadly could prove a daunting task, since Tanzania's current distribution system is already overtaxed, and even the best health facilities have trouble keeping all the necessary medicines in stock.

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Enter Coca-Cola. The beverage giant, which opened its first bottling plant in Tanzania in 1952, has spent decades finding the most efficient way to reach distant villages and adapting to changing roadway conditions. Through three local bottling franchises, the company is sharing its distribution routes with the government supply-chain agency. The program, a public-private partnership that is now being tried in nine of the country's regions, lets MSD use Coca-Cola's delivery maps and distribution partners to create a new delivery model, with the aim of moving drugs around the country more efficiently. "If anyone is sure how to get stuff the last mile, it's Coke," says Shaaban Husein, director of finance and administration at MSD.

The Coke idea isn't totally new. "When I travel to the developing world, Coke feels ubiquitous," Melinda Gates said in a TED Talk last September. "Coke's success … makes you wonder, 'How is it that they can get Coke to these far-flung places?' If they can do that, why can't governments and NGOs do the same thing?" Gates went on to challenge NGOs both to adopt Coke's real-time monitoring system and to tap into Coke's local talent networks. The Tanzania project aims to do both of these things.

I visited Tanzania in May with a group of international journalists to see the efforts being made to improve the health care system and beat back the scourges of AIDS, tuberculosis, and malaria. Tanzania has a per capita GDP of $550 and ranks 148 out of the 169 countries on the United Nations' human development index, putting it behind Haiti but ahead of Afghanistan in the areas of health, education, and living standards.

A mere 3,000 miles of Tanzania's roadways are paved, and the long rainy season leaves many of the country's 50,000 miles of dirt roads impassable. Some remote villages are accessible only by donkey. It takes more than an hour to drive the 10 miles from the Kilimanjaro Airport to Mererani, home of the country's prized Tanzanite mine. The rutted dirt road is littered with holes, and you have to wonder about road conditions in other parts of the country if this is what a main industrial thoroughfare looks like. Tanzanite was discovered in the foothills of Mount Kilimanjaro outside Mererani in 1967, and it brings the government a reported $20 million in exports annually.

From large trucks to pushcarts to donkeys, Coca-Cola uses a mix of methods to move bottles around Tanzania. The company is good at tailoring the delivery method to conditions. In contrast, MSD has a fleet of Land Rovers and trucks that it currently relies on to distribute drugs, vehicles that can't handle some particularly bad roads. Adrian Ristow, a South Africa-based special-projects coordinator for Coke, said that the pilot program had identified areas where smaller vehicles such as motorcycles could be used to get to hard-to-reach areas. "We're seeing some environments where large vehicles were used that definitely weren't the most efficient way to get the product out to very small clinics with very small drop sizes," Ristow said. While Coke's supply chain has been tapped in the past on an ad hoc basis—in the early part of last decade, UNAIDS collaborated with Coca-Cola in Malawi to distribute information on HIV/AIDS through their distribution routes—this is the first time something has been attempted on this scale.

Coke doesn't have a stellar public-health record—think of the obesity crisis in the West and the bottlers in drought-prone areas of India that were accused of using too much water, leaving little for local farmers. But the power of the company's supply chain is undeniable. Sold at more than 900,000 retail locations throughout Africa, the beverage giant has unrivaled reach in the continent, and Ristow said that if the Tanzania project is a success, the company will consider expanding it in other markets in Africa. This project is one of the ways Coca-Cola is responding to the United Nations' Business Call to Action, which is aimed at harnessing the private sector to help reach Millennium Development Goals. Coke is currently committed to the project in Tanzania until the end of the current pilot, set to end in December.

Sylvestor Matandiko, MSD's director of logistics, led me down the aisles of his agency's central warehouse in Dar es Salaam one muggy May day. Pallets of medicines procured by international donors were lined up in neat rows, and a hole in the warehouse ceiling served as a reminder of the state of Tanzania's health infrastructure. Throwing medicine at a country is not enough—the drugs have to reach the patients, and health care workers have to be in place to administer them.

June 5 marked the 30th anniversary of the first reported case of HIV/AIDS in the United States. Today, 33.3 million people worldwide are living with HIV, a full 22.5 million of them in sub-Saharan Africa, according to UNAIDS statistics. Around 1.35 million Tanzanians have HIV/AIDS, out of a population of 45 million. The availability of anti-retrovirals and the rise in awareness about how the virus is transmitted has helped curb the spread; today 5.6 percent of adults have the virus, down from a high of 7.9 percent in 1997. In some areas near major highways where rates of male circumcision are low, infection rates reach up to 15 percent of adults. The Tanzanian health care system is straining to serve an ever-increasing number of people on lifelong anti-retroviral therapy. As more people begin taking the drugs, it becomes even more essential that the pills be accessible at the community level to ensure consistent access, which helps prevent resistance from developing. Most bottlenecks happen at the middle level—between the regional warehouses and the smaller clinics. And as more than 77 percent of Tanzania's population lives in rural areas, getting drugs that last mile is key.

What do these supply gaps mean for doctors on the ground trying to treat HIV? Dr. Maya Maxym, a Yale-educated American pediatrician in the Pediatric AIDS Corps, spends her days seeing patients at the Child Centered Family Care Clinic at Kilimanjaro Christian Medical Center. The hospital, despite being one of the country's four referral hospitals, suffers from regular shortages. Sometimes while a specific anti-retroviral drug is available, it is not in stock in the right formulation or dosage. The formulation of the medicine—liquid or pill—also matters since babies and toddlers cannot swallow pills. "We [are often out of stock] of liquid formulations, or what we do have is expired, and we have to decide whether it's worse to use expired meds or crush tablets that explicitly say they should not be crushed because absorption is not reliable," Maxym explained. Maxym, who has worked at the clinic since moving to Tanzania in August, said that improving the medical supply chain across the country "would make a huge difference to the long-term health and survival of large numbers of our patients."

Tanzania is the second-largest recipient of grants from the Global Fund, having received more than $649 million since 2004. Some improvements in the medical supply chain have been made: In 1994, MSD had only 7,453 square feet of warehouse space throughout the entire country. Today, the agency has five times that, more than 42,000 square feet. And international donors have realized that as they scale up the amount of medicine they're providing to the developing world, many of the recipient countries aren't able to move such large quantities around their territories efficiently. This means some medicines just sit in warehouses or spoil in transit while the shelves at clinics in remote locales sit empty. "The distribution of bed nets, drugs, and diagnostic tests is the biggest challenge we face," said Christoph Benn, a doctor who has worked in Tanzania and now serves as director of external relations at the Global Fund.

Currently, around 273,000 HIV-positive Tanzanians receive free daily anti-retroviral therapy, up from zero in 2004. But more people are sick enough to start the drugs than are currently receiving them. If the country adopts 2010 WHO guidelines for who should receive anti-retroviral therapy, the number of people who qualify for ARV therapy will shoot upward, meaning more drugs to deliver—and even more stress on the existing supply chains. (Once the drugs reach the clinics, they have to get into the hands of patients, who may still live hours away from clinics. This NPR piece from Mozambique describes a new program that encourages patients to team up to distribute medication.)

Another planned program takes a more direct approach at cola-based aid delivery. ColaLife plans to piggyback on Coke's distribution channels and will insert "aid pods" directly into crates of Coca-Cola in Zambia, said Simon Berry, the project's founder. For the pilot, the aid pods will contain materials mothers can use to combat childhood diarrhea, including oral dehydration salts, zinc supplements, a bar of soap, and a SODIS bag to purify water through sunlight. Childhood diarrhea is responsible for nearly 1 in 5 childhood deaths and kills more children than HIV/AIDS, TB, and measles combined. At first, vouchers will be used to obtain the pods, but eventually Berry says they will be available for sale for a small fee. Other examples of "product piggybacking" to reach isolated rural markets include a project in India that uses the postal service to distribute information about commodity prices, as well as solar lanterns, water purifiers, and seeds to Indian farmers. Another proposed idea would print health information on matchbooks, a product purchased by 97 percent of households in rural India on a monthly basis.

The proof for these projects, of course, will be in the execution. The Tanzania project has already had a successful research-focused six-month pilot in the northeastern region of Tanga. Of course, Coca-Cola has only about six different products to deal with, whereas the government is tasked with distributing hundreds of types of medicines, each with different handling requirements and shelf lives. The pilot in Tanga looked only at "medical commodities that didn't require special handling and treatment"—drugs that, in essence, can be handled like a bottle of Coke—not the more challenging cases, such as vaccines that require refrigeration. "We were comparing apples to apples," Ristow explained about that pilot. And nothing has been done to enhance MSD's aging fleet of vehicles and its limited manpower, problems the Coca-Cola project can't solve.

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