Neo is improving last mile access to medication for chronic illnesses in South Africa by enabling the adoption of patient-empowering technologies to overcome access barriers and cultivating a more patient-centric and collaborative healthcare ecosystem.
The New Idea
Neo began to understand the inefficiencies of the chronic health care system in South Africa when he had been diagnosed with Tuberculosis. As Neo started visiting the clinic for his repeat medication, he began to discover that despite South Africa’s heavy investment in patient-care, patients on chronic medication were struggling to adhere to their medications – reasons included wait times of 3-5 hours daily; lack of privacy in medicine collections; angry and frustrated nursing and pharmaceutical staff; and inaccessibility to the clinic itself.
Towards addressing all of the above, Neo has engaged the broader health care ecosystem, including government, non-governmental players, private sector and union stakeholders to value and adopt simple and reliable technology not only efficiently increases access to medication, but restores dignity to patient and practitioner alike.
He has started with the introduction of Smart Lockers, a digitally controlled locker system that dispenses medication to patients, using a PIN code sent via SMS to them, after the healthcare worker loads it up with the prescription. It is located in clinics, and not only significantly cuts down waiting time (from 3-5 hours to 36 seconds per collection) but also provides data for the clinics to monitor adherence; and non-collections so that they are able to minimize the wastage of drugs.
Neo works across the value-chain of medicine collections in South Africa, including national departments of health, and large NGOs, towards demonstrating that authentic and sustainable technology can make even big and clunky systems, smooth and agile. He is also looking at identifying private and semi-private stakeholders interested in community well-being, including large mining companies and the taxi union, to adopt this technology, to further build access to chronic medication. Neo’s success in ‘translating’ innovation into the health system is allowing him to position himself and his team as re-engineers of the system, to become open and adaptable to new technology that is relevant for local populations.
Over the past decade, South Africa has experienced an unprecedented growth in patients requiring access to long-term therapies. Not only has South Africa introduced universal access to antiretroviral therapy for patients living with HIV and AIDS (with the largest Antiretroviral (ARV) program in the world, having 3.6M people accessing ARVs through the public system alone), but there has also been a steady increase in the number of patients with non-communicable diseases (NCDs) including Tuberculosis, diabetes and hypertension, requiring chronic therapy that the state is providing for. Despite significant investment, the cure rate for TB is low, and treatment default rates remain high, heightening concern for development of drug-resistant TB. AIDS-associated mortality is high particularly among young adults and children.
Some of this can be traced to the over-extension of public sector healthcare facilities including primary health care (PHC) clinics. The patient per clinic ratio is around 13 718, exceeding WHO guidelines of 10 000 per clinic and the patient-to-pharmacist ratio is 3,389 persons per pharmacist. The increasing patient load has placed an enormous strain on available resources and has contributed towards medicine shortages and declining quality of care. Typically, a patient with a chronic disease is issued with a repeat prescription for six months. Between six-monthly clinical assessments, the patient needs to visit the healthcare facility merely to collect medication. In most cases, 70% of a facility’s prescription load will be directed to servicing repeat prescriptions. Thus, at the clinic, patients will often face stressed clinic staff, distressed fellow patients, and lines that move slowly – lines can last anything between 3-7 hours. Sometimes, they will have to come back another day, to collect medication, as they would not have made it to the front of the line on their prescribed day. There is a clear opportunity cost in terms of time lost (wage losses) as well as transport cost losses in this system. Further, the collection lines are clearly demarcated – those coming in for HIV AIDs, are sent in a separate line, making them immediately visible and vulnerable to stigma in the clinic.
The responsibility to collect medication lies with the patient, and when there are defaulters, nurses and pharmacists start seeing them as the problem, as a drain on the health system. At the same time, patients feel disregarded by clinic staff. At district levels, managers are struggling with under-staffed clinics, and lack of comprehensive patient data to make better decisions on what they need to focus on – from stocking medication, to enabling specific interventions in different treatment areas. And at the national health system level, the high financial investments need to translate to patient outcomes, which are not happening at the scale they ought to. Access to Health national teams work closely with international and national large non-profits including Centre for Disease Control, USAID, Aurum Institute and Peppfar, to scale up delivery of medication, however they often struggle with models heavy on logistics and people resource, leading to similar issues as government clinics. Other innovations in the space, including using drones, and a giant robot arm, dispensing medication into an ATM are far too expensive, and difficult to scale. Manual systems including bicycle delivery exist, however these too are far too labour and effort intensive to reach the hardest to reach areas.
During Neo’s research phase at the clinics, he noticed these different struggles, and further, saw that these different players not only assumed incompetence of each other, but also did not speak with each other. Neo has thus positioned the lockers as a platform, through which these players not only talk to each other, but actively collaborate to allow patients to collect their medications with dignity and privacy.
Neo is creating value for adoption and widespread use of technology innovation within an overburdened health care ecosystem. He is demonstrating this through the Smart Locker system to start with; showing that people-centred innovation that meets the needs of all stakeholders, from macro to micro, can begin to dramatically change patient experience and patient outcomes.
He is doing this by first designing and developing smart, yet simple and reliable technology that is integrated into the existing public healthcare infrastructure but centred around the patient’s convenience. Neo has designed Pelebox, an internet-enabled smart locker system that enables patients to collect their repeat chronic medication in under a minute instead of waiting hours on queues. Pre-packed medication for a particular patient is loaded into the locker, and the system then sends an SMS with a one-time-pin (OTP) to the patients. The patient would then come to a collection unit, authenticate themselves using a one-time-pin (OTP) together with their cellphone number. A locker that has their medication pops open. The smart lockers are positioned currently at the clinic and patients are able to quickly come in and collect their medication at whichever time of the day they like.
At the clinic level, Neo partners and integrates with the patient management system on site. Once the patient has a prescription, the information is shared both with Neo as well as with the service partners of the Department of Health responsible for the delivery of the medication. When the medication arrives to the clinic, and is loaded by the healthcare worker, Neo’s company Technovera gets the information which generates the SMS to the patient. The patient is given 48 hours to collect the medicine, before a reminder is sent. Patients have 7 days to collect the medication from the first SMS, after which the medication is removed and recycled, before it reaches its expiry date.
Data on when and if the patient collected their medication is tracked, and if the patient does come to collect after the medication has been removed from the locker, they are directed to the clinic staff for a discussion on the importance of timely collection of medication. The system keeps track of all collection records and is integrated into a patient records management system, shared with the clinic for better decision making.
Neo has implemented the smart lockers with both the City of Tshwane and the City of Johannesburg, through which he reached 3500 patient collections, with an average collection duration of 36 seconds. At each clinic, Neo is able to reach 1650 patients per month, and he is seeing a 62% utilization at this point of time. He also observed that 94.6% of the patients collect their medicine. Insofar as collection can be used as a proxy for adherence to a treatment plan, it compares favourably to the national average of 77% adherence to ARV treatment, and 53% adherence for Tuberculosis treatment.
Through the Smartlockers, Neo has been able to systematically and diligently identify and transform a range of actors and stakeholders into champions for innovation within the health care system. Starting with the City of Tshwane, he is building strategic relationships across provincial, and national health departments; with the broader health care ecosystem, including USAID, Pepfar, Centre for Disease Control (CDC), and the Global Fund; and creating alliances with mines and taxi associations, towards enabling mine workers and taxi drivers and commuters access to medication in convenient locations. Leveraging on the deep work he did with patients in the early days, he is able to authentically represent the patient voice in the larger ecosystem, enabling system actors to pay attention to details they might not have thought of otherwise (such as the privacy concerns in designating a line for patients on ARVs).
Based on this careful translation of the patient experience into the system, Neo has been successful in signing a three-year contract with the National Department of Health, to set up these smartlockers in clinics in 8 provinces in the country. He has also partnered with health NGO Aurum Institute to set up at 4 clinics where they work, including one that serves sex-workers in a way that guarantees privacy to them. In both these cases, the partnerships also function as a sustainability strategy, enabling Neo to set these lockers up as long-term reliable solution, ensuring that it is not just aligned, but forms an integral part of the larger strategic vision towards access to health.
Through these partnerships, Neo is demonstrating that innovation that is authentic, reliable, and meets the needs of all stakeholders across the board will can drive exponential social impact, enabling a systems-framework that is more people-centred and open to innovation than before. Based on his success in South Africa, partners have already expressed interest in the locker in other parts of Africa and for other potential uses such as distribution of mosquito nets in malaria countries, and sanitary napkins for women.
Neo believes that the lockers can address one part of the access to medication problem in South Africa and elsewhere but that much more must be done to fully address the problem. His engagement of the healthcare ecosystem in a collaborative effort to introduce, sustain, and spread the locker technology is laying the groundwork for long-term change in this sector. He sees Technovera as a channel for future healthcare access innovation, both in identifying other relevant technologies and in cultivating a more efficient and empathetic healthcare system.
Neo grew up in a maximum-security correctional facility, where his father was the first black correctional officer. While society had deemed these individuals unfit, Neo didn’t connect to their crimes. He connected to their background, their families, their kids, where they grew up, who used to visit them, what they were like. His first tennis coach was a prisoner. This created a lifelong perspective to see people as people – not as patients, or workers, or convicts, or whatever they had been typecast as.
In his first corporate job at a steel manufacturing company, Neo was promoted early to be in the executive office, where he had to deal with factory fatalities. When a new CEO wanted to classify a particular fatality (one of several within a matter of months) as a suicide to avoid a compensation pay-out. Neo checked the books and saw that the worker had complained three times about a malfunctioning heater and nothing had been done. He fought his superiors to have the worker’s death classified as an accident, but upon losing that battle, he decided to leave the corporate world.
Neo attempted to create his own company innovating the last mile segment for parcel delivery. During this period, he contracted tuberculosis and, no longer holding a corporate job with private healthcare access, found himself dependent on the public health system. Sitting in the queue at his local clinic for hours on end, he started asking himself how he could address this problem – for himself and the thousands of other patients he saw regularly at the clinic. When he then saw his father go through the same ordeal, he decided to do something. He spent months observing activity at clinics and engaging with patients, nurses, and others. He set out to solve the problem for the patients, but after asking a nurse who he always saw yelling at patients why she was so angry, he began to see that everyone in the system was frustrated for different reasons. He realized that the only way to solve the access problem for patients was to address the problems of all the stakeholders in the system.