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Preface - Why we wrote this book

By Laura J. Frost and Michael R. Reich.

This book emerged from a simple realization: Just because a good health technology exists does not mean that it will be delivered, used, or achieve its potential to bring good health, especially for poor people in poor countries. Over the past several years, this realization has gained increasing acceptance around the world. Acceptance has grown with many organizations in global health—including the Bill & Melinda Gates Foundation, which has invested huge sums of money to support the development of new technologies for global health. In early 2005, the Gates Foundation was criticized in The Lancet for focusing too much on technology development. The author alleged that the Foundation held to “a narrowly conceived understanding of health as the product of technical interventions divorced from economic, social, and political contexts.”(1) Ironically, at just the same moment, the Foundation had asked us to help it address these precise issues. What could the Foundation do to improve the chances that the over 50 products under development with Gates support would achieve their potential in health improvement? They specifically asked us to explore the economic, social, and political contexts in detailed case studies. This book is the result.

For some time, the Gates Foundation has been aware that developing technology alone is not sufficient to improve health conditions in poor countries. This recognition is reflected in the sponsorship announcement on U.S. National Public Radio for programs supported by the Gates Foundation: “making sure life-saving advances in health reach those who need them most.” Bill Gates made a similar point in his speech before the World Health Assembly on May 16, 2005, when he said, “The world has to devote more thinking and funding to delivering interventions — not just discovering them.”(2) And subsequently the Foundation reorganized itself into three divisions—discovery, development, and delivery—to emphasize the critical importance of bringing technologies to the people who need them.

We began this project in March 2005 with the goal of seeking to better understand and more effectively plan for success in the introduction of new technologies to help fight the diseases of the global poor. Throughout the project we have interacted with the team inside the Gates Foundation assigned with this task. We agreed to create a framework for thinking about the challenges of introducing good health technologies in poor countries along with a series of case studies illustrating a range of different kinds of technologies. We intentionally avoided the approach of certain consulting companies that present their analysis and results in a thick deck of fancy PowerPoint slides. The Gates Foundation asked us to develop a series of narratives, rich in contextual and historical detail and based on solid academic research, to convey the multiple complexities in creating access for health technologies in poor countries. We were not looking for simple answers. We sought out broad lessons that could help guide the foundation, its grantees, and others around the world concerned with the gap in access. We called the cases our “access stories,” from which would emerge cross-cutting themes and lessons.

The two senior members of the research team were Michael R. Reich at the Harvard Center for Population and Development Studies, where he was serving as director until July 2005, when he moved to the Instituto Nacional de Salud Pública in Mexico for a year’s sabbatical, and Laura J. Frost at the Center for Health and Wellbeing at Princeton University, where she was researching and teaching until July 2006, when she moved to the Democratic Republic of Congo for two years. In the first year of the project, the research team also included Ilavenil Ramiah, after she completed her post-doctoral studies at Harvard and until she accepted a senior post at UNAIDS in Geneva. Within the Foundation, our main contact was Dan Kress, along with Hannah Kettler; throughout the process they guided and supported us with sound advice, constructive criticism, and warm humor. We also appreciate the enthusiastic support we received from Tachi Yamada after he arrived as the new director of global health at the Foundation in 2006.

We would like to thank the experts who reviewed the book and provided detailed comments. The following people provided comments on individual chapters: Joseph Cook, Dirk Engels, Scott Gordon, Doug Holtzman, Dai Hozumi, Karin Jacquin, Heidi Larson, Carla Lee, Kyle Peterson, Laura Reichenbach, Allan Schapira, Craig Shapiro, Veronika Wirtz, Katherine Wolf, and Patrick Zuber. Several people reviewed and commented on the entire manuscript: Richard Cash, Michael Goroff, Joel Lamstein, Adetokunbo Lucas, and George Zeidenstein. We are especially grateful to the many people we interviewed about the cases for generously giving us their time and sharing their stories. We also appreciate the gracious support we received during the review process and the decision to publish our book, from Barry Bloom at the Harvard School of Public Health and Lisa Berkman at the Harvard Center for Population and Development studies.

The book benefited from superb support we received from research assistants and editors. Beth Anne Pratt, Jennifer Nanni, and Taeko Frost provided research support for Laura on the case studies. James Hammersley contributed to an early draft of chapter 3 during the first half of 2007 and again in early 2008, and Jessica Perkins read and commented on the full manuscript during the summer of 2007. Meghan Reidy assisted in collecting the photographs and arranging for permissions. Sarah Coit Timmins assisted us greatly with bibliographic research and formatting. Carol Maglitta provided superb graphic design for the tables, figures, cover, and text of the book, and guided us through the production process.

We wrote each chapter in a slightly different manner, while achieving a full coauthorship of the entire volume by the end of the process. Laura took the lead on drafting chapters 2 and 9, and Michael wrote the first draft for chapter 1. Laura drafted chapters 4 through 7 (the cases on hepatitis B vaccine, malaria rapid diagnostic tests, Norplant, and vaccine vial monitors), with Michael providing comments and revisions. Michael drafted chapter 3 on praziquantel (with Alan Fenwick and Howard Thompson at the Schistosomiasis Control Initiative), and Laura provided comments and revisions. Laura drafted chapter 8 on the female condom, with Beth Anne Pratt as coauthor, and Michael provided comments and revisions. All chapters went through multiple versions and seemingly endless discussion and alteration, as drafts bounced back and forth between Michael and Laura, as we sought a common style of narrative and a common framework of analysis. Our discussions about access continued as we moved around the continents, crossing national boundaries, dragging drafts to read, communicating by cell phones, land lines, skype, email, texts, and sometimes even face to face, working hard to produce the book’s final draft.

This book expresses our profound belief that access to good health technologies can be addressed and resolved for poor people in poor countries and can produce tangible benefits for them. The two of us have worked on access issues with various public, private, and partnership organizations over the past two decades. This book represents our collaborative effort to show how progress can be achieved—and how to make it happen more rapidly than is now happening.

Finally, we wish to thank our families for supporting us throughout this project and for allowing this book to pervade our lives over the past several years.

Laura J. Frost
Kinshasa, DRC

Michael R. Reich
Brookline, Mass.

May 2008


1: Anne-Emanuelle Birn, “Gates’s Grandest Challenge: Transcending Technology as Public Health Ideology,” The Lancet 366 (2005): 514–519.

2: Bill Gates, “Remarks of Mr. Bill Gates, Co-founder of the Bill & Melinda Gates Foundation, at the World Health Assembly,” Fifty-eighth World Health Assembly, Geneva, Switzerland, 16 May 2005, http://who.int/mediacentre/events/2005/wha58/gates/en/
(retrieved January 2, 2008).



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Access: How Do Good Health Technologies Get to Poor People in Poor Countries? by Laura J. Frost and Michael R. Reich is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License