In this teaching case, Dr. William Foege - the former director of the US Centers for Disease Control and Prevention who many credit with eradicating smallpox - helps readers understand what it took to eradicate it. The case gives background information on the disease, as well as earlier immunization efforts, and describes how the social, political, and economic complexities of India impacted public health initiatives. As international endeavors to fight smallpox expanded in the 1960s, India continued to account for a disproportionate percentage of new cases. Cases remained high until a more organized and targeted strategy in the 1970s increased staffing, improved reporting, boosted vaccination rates, and expanded national and international resources. Specific national and local strategies, a coordinated and centralized decision making structure, and an understanding of and clear communication with the population were crucial to the nation’s success. The state of Bihar was the most challenging state to address, with cases remaining stubbornly high. A final campaign intensified surveillance, containment, and vaccination efforts in Bihar, and the Global Commission for the Certification of Smallpox Eradication declared India smallpox-free in 1977. The case ends with Dr. Foege wondering what lessons from smallpox eradication in India can be applied to the COVID-19 pandemic, as well as future threats.

Learning Objectives:

This case documents the eradication of smallpox in India. A productive class discussion will allow students to appreciate the following:

• The role of power dynamics in global health
• The role of data and the importance of measuring the right outcome to inform program management 
• Human resource management and its relationship to stakeholder management
• The relationship between disease presentation and public health strategy and decision-making
• How to build on what is known in confronting new contexts, diseases, and environments

Keywords: India, public health, pandemic response, vaccine delivery, workforce management, collaboration, multilateral engagement

This case traces the development of a series of initiatives to intended to reduce stockouts of family planning commodities in Senegal’s public health system and the eventual scale up of the redesigned supply chain to include additional commodities and its transfer of management to the government. After providing some background on the history of Senegal, including its governance and health system, the case explores early efforts to overhaul the supply chain in the country and reproductive health efforts. It then describes the Gates Foundation’s involvement and how the relationship between family planning and supply chain management came to light. The Gates Foundation, along with others, supported the launch of the Informed Push Model with Third Party Logisticians (IPM-3PL), which proved to reduce stockouts dramatically. Despite significant initial support from both government ministries and international donor agencies, as the program scaled IPM-3PL did not survive the transition to a fully government-run model, and the program was eventually discontinued in 2019 after two attempts to hand over the program to Senegal’s National Supply Pharmacy (Pharmacie Nationale d'Approvisionnement; PNA), the government agency in charge of distribution of medicines. The case ends with the director of the PNA contemplating what was next for Senegal and what she could tell others who had been so closely watching the country as an example.

Keywords: supply chain management, private-public partnership, maternal health, third party logisticians, informed push model, scale up, distribution

In November 2020 as the world grappled with a over 50 million cases of Coronavirus disease 2019 (COVID-19) and over 1 million deaths, all eyes were focused on the development and manufacturing of COVID-19 vaccines. This case traces the complex set of activities involved in the development, regulatory approval, production, and distribution of COVID-19 vaccines. It describes the resources, information, cooperation, and decision making that went into this unprecedented effort.  It poses some of the difficult strategic and operational decision dilemmas faced by country governments, purchasers, vaccine developers, and manufacturers in designing the overall supply chain for COVID-19 vaccines.

Learning Objectives: A productive class discussion will allow students to appreciate the development, regulatory approval, production, and distribution processes for a pandemic vaccine; The complexity and inter-relationships between different activities and actors in the vaccine supply chain; The role of manufacturing flexibility in managing uncertain demand and supply; and the importance of a portfolio approach in sourcing/purchasing technology which is under development.

Keywords: product development, supply chain management, manufacturing, public-private partnerships, health care delivery, public health, vaccine development, clinical trials, pandemic response, COVID-19

The case traces the development of a tripartite initiative—known as Project Carbetocin Hemorrhage Prevention (CHAMPION)—between Merck for Mothers, Ferring Pharmaceuticals, and the World Health Organization (WHO) that formed to help prevent postpartum hemorrhage (PPH), one of the leading causes of maternal mortality globally. After providing background on the global burden of maternal mortality and global efforts to amplify the issue and improve outcomes, the case highlights clinical trial results that show administering quality uterotonics (drugs that induce uterine contractions) immediately following childbirth was the most important measure in preventing PPH. However, the recommended therapy—oxytocin—was often compromised at the point of delivery in areas with unreliable cold-chain infrastructure, due to its sensitivity to heat. In this context, the case details how Project CHAMPION brought together three unique actors to advance the development and distribution of a uterotonic that could withstand temperature changes. The case describes negotiations around the undertaking, the large-scale clinical trial of the new drug—heat-stable carbetocin—that took place across 10 countries, enrolling 30,000 women, and the steps undertaken to prepare diverse markets for its debut. The case reveals tension between the mid-size pharmaceutical company, the multilateral World Health Organization, and Merck’s Merck for Mothers initiative. The case ends as a pandemic explodes onto the world stage in 2020, with Project CHAMPION team members wondering how the dilemmas, decisions, and dynamics they navigated could inform emerging COVID-19 vaccine discovery and development efforts working with urgency.  

Learning Objectives: This case will allow readers to appreciate:

1. The potential of public-private partnerships to accelerate drug discovery and development
2. The production and approval processes for a global health product
3. The complexity of developing and preparing a product to enter a fragmented market without clear demand or distribution channels
4. The advantages and drawbacks of investing in a point-of-care intervention for a public health issue that has multiple root causes

Supporting Content: Concept Note: Reproductive, Maternal, Newborn, and Child Health 

Keywords: public private partnership, maternal health, global health, pharmaceutical drug development, corporate social responsibility, postpartum hemorrhage, collaboration, COVID-19

This case describes the development and rollout of bivalent oral polio vaccine (bOPV), starting in 2007, to support the Global Polio Eradication Initiative (GPEI) in eliminating poliovirus. After providing background on the global polio eradication program, the case explores the policy decisions behind the development of bOPV, progression through clinical trials, licensure, and distribution of the vaccine. In particular, the case examines the role of the World Health Organization (WHO) in accelerating the progression through these stages. The case study ends with Steve Cochi and Roland Sutter of WHO reflecting on the successes of bOPV and its impact on the eradication program at a global level.

Teaching Note available through Harvard Business Publishing.

Learning objectives: A productive class discussion will allow readers to understand the importance of product development to respond rapidly to the needs of a global health initiative as well as the complexities of ensuring the engagement of stakeholders involved in vaccine development, and the potential role of the public sector in facilitating product development.

Supporting content: The case entitled Polio Elimination in Uttar Pradesh, India may provide helpful background information.

Keywords: randomized controlled trial, global health, public health, vaccine development, supply chain management, disease eradication, public-private partnership, collaboration, product development

This case explores how Kerala, India developed a reputation for exemplary health outcomes despite low per capita income. After providing historical background, including the social, political, and health system factors that contributed to a culture of seeking health care, the case describes Kerala’s health system and outcomes. The case describes how the fiscal decline in the latter half of the 20th century led to decreased spending on public services, including health, creating an opening for private-sector providers to meet a growing share of the demand for health services and the impact on out-of-pocket health spending. Readers must think about how emerging health threats such as noncommunicable diseases should be addressed in the 21st century, including the health department’s response and a new initiative to increase capacity in the public health sector, including efforts to improve the quality and reliability of health data through an electronic medical record system. The case concludes with Additional Chief Secretary for Health and Family Welfare Rajeev Sadanandan wondering if the new strategy will succeed and if Kerala can maintain its status as a positive outlier in health for the decades to come.

Teaching Note available for registered faculty through Harvard Business Publishing and the Case Centre.

Learning Objectives: to appreciate the relationships between education, literacy, and health; what the components of a health system are; the limitations of health indicators as measures of a national health system’s effectiveness; and, the challenges of sustaining demand and maintaining the supply and quality of public health services over time.

Key words: health care policy, universal health care, demand generation, health care delivery, health system, health outcomes, social determinants of health

This case describes the development and structure of Sri Lanka’s health system, which has yielded health outcomes far superior to any of its South Asian neighbors. The case highlights factors supporting the health outcomes, including the availability of free health services to all citizens, government investment in the health workforce, and the care-seeking behavior of Sri Lankan citizens. After providing an overview of Sri Lanka’s history, geography, demographics, and economy, the case traces the evolution of the public sector health system from the precolonial era through the period of heavy investment in health from the 1930s through 1950s and on into the 21^st century. The case describes the management of the system and the relationship between the national health ministry and provincial and local governments. It examines how health professionals are trained and deployed throughout the system, the supply chain, and financing. The case then examines the growing private health sector, its relationship with the public sector, and the role of innovation. After a summary of the country’s health outcomes, readers are pushed to think about what it will take to address the changing epidemiological burden to continue to boast exemplary health outcomes and provide quality health care to those who need it.

​​​​​​Teaching Note available to registered faculty through Harvard Business Publishing or the Case Centre.

A productive class discussion will allow readers to appreciate the capabilities of a public payer system to improve the health of the population; the influence of the private sector in a “single payer system” and the downstream effects on demand and supply of services; the return on investment for a country offering free public medical and nursing education; and the relationship between literacy, demand generation, and health outcomes.

Keywords: Universal health care, health care delivery, health system, health outcomes, social determinants of health.

Set in India’s most populous state, Uttar Pradesh, this case explores the complexity of addressing maternal and child health and care delivery by looking at health-related behaviors and decision making from the perspective of a frontline health worker. The case is intended to be used in conjunction with GHD-39N (Maternal and Child Health in Uttar Pradesh, India: A Mother’s Story) and GHD-040 (Improving Maternal and Child Health Outcomes in Uttar Pradesh, India).

Teaching Note available through Harvard Business Publishing.

Learning Objectives: A productive class discussion will allow students to appreciate the decisions facing frontline providers and their beneficiaries, and the numerous factors that influence their choices; how households prioritize health among other needs; and the complexity of aligning health programs with beneficiary needs, cultural context, household dynamics, and other factors to impact health behaviors and outcomes.

Keywords: public health, human resources, health care delivery, decision making, maternal and child health, behavioral economics, resource-limited settings, health care policy, data collection, performance management

Set in India’s most populous state, Uttar Pradesh, this case explores the complexity of addressing maternal and child health and care delivery by looking at health-related behaviors and decision making from the perspective of a mother. The case is intended to be used in conjunction with GHD-039 (Working as an ASHA to Improve Maternal and Child Health in Uttar Pradesh, India) and GHD-040 (Improving Maternal and Child Health Outcomes in Uttar Pradesh, India).

Teaching Note available through Harvard Business Publishing.

Learning Objectives: A productive class discussion will allow students to appreciate the decisions facing frontline providers and their beneficiaries, and the numerous factors that influence their choices; how households prioritize health among other needs; and the complexity of aligning health programs with beneficiary needs, cultural context, household dynamics, and other factors to impact health behaviors and outcomes.

Keywords: public health, consumers, health care delivery, maternal and child health, consumer behavior, behavioral economics, resource-limited settings, health care policy, data collection, decision making

This concept note aims to describe the history of reproductive, maternal, newborn, and child health (RMNCH), the current landscape for providing RMNCH care in resource-limited settings, and future directions for research, funding, and advancement of the field. 

Learning objectives: This concept note aims to further students’ and instructors’ understanding of RMNCH presented in the Cases in Global Health Delivery collection.

Keywords: Maternal health, morbidity and mortality, advocacy, service delivery, workforce development, demographic segmentation

Community health workers (CHWs)—lay people who engage in efforts to improve the health of their communities—have been proposed as a way to fill the global health human resource gap by extending services to hard-to-reach populations in remote areas. This concept note provides a brief history of CHWs, considers issues in CHW program design, and outlines future directions for research and funding.

Learning objectives: This concept note aims to further students’ and instructors’ understanding of community health workers presented in the Cases in Global Health Delivery collection.

Keywords: Human resources, primary care, disease management, monitoring and evaluation, resource allocation, global health policy, community health workers, partnerships

This case explores the implementation and evaluation of mental health treatment for victims of conflict-related gender-based violence (GBV) in the Democratic Republic of the Congo (DRC) by the International Rescue Committee (IRC), a humanitarian organization based in New York City. Following the contextual background, the case traces the IRC’s work developing a psychosocial support program for GBV survivors starting in 2002. When the Applied Mental Health Research Group (AMHR) at Johns Hopkins University Bloomberg School of Public Health evaluates the program in 2008, the IRC begins to consider the potential for its work to inform similar interventions. In 2011, the IRC team collaborated with AMHR to implement two concurrent randomized control trials (RCTs): one on the mental health effects of Cognitive Processing Therapy (CPT) and the other on the mental health and financial impact of a social and economic empowerment intervention called the Village Savings and Loans Association (VSLA). While the time and resources that went into completing the trials expanded the monitoring and evaluation capacity within the IRC and added important evidence to the lean body of global mental health literature, conducting the studies stretched the IRC’s local staff thin and required clarification of priorities and purpose. Had the RCTs had been worth it, and for whom? How could the study findings contribute to improving services for vulnerable populations in the region and beyond? 

Teaching Note available through Harvard Business Publishing.

Learning Objectives: A productive class discussion will allow students to appreciate the challenge of meeting human resource needs to provide mental health care, the complexity of implementation and empirical study of mental health services, and the ethics and challenges of conducting randomized controlled trials in conflict settings.

Keywords: public health, human resources, health care delivery, information management, mental health, scale-up, resource-limited settings, health care policy, data collection, public administration

This case describes how the Honduran Ministry of Health developed and implemented a Chagas disease control program with the assistance of the Japan International Cooperation Agency (JICA) and others from 2003 to 2012. After providing background information about Honduras and Chagas disease, the case examines the work of the Guatemalan Ministry of Health and JICA to implement a Chagas disease control program that provided the template for the program in Honduras. The case then describes the adaptation of this model for the Honduran context, including details of the surveillance model and vector control interventions. The case concludes with the program considering how it would maintain its success in spite of decreased funding and changes in leadership.

Teaching Note available through Harvard Business Publishing.

Learning Objectives: A productive class discussion will allow students to appreciate strategies in control of neglected tropical diseases; Chagas disease vector control and surveillance; the role of bilateral cooperation to strengthen health systems management; and how regional disease control initiatives are implemented locally.

Keywords: Information management, scale-up, health care policy, public administration, government policy, resource-limited settings, data-collection

This case takes place in the United States (US) and traces the inception and growth of Project Extension for Community Healthcare Outcomes (Project ECHO)—a web-based "guided practice" model for primary care providers—from 2003 to 2016. After providing background on the US health system, including medical education, health care financing, and the supply and distribution of primary care and specialist providers, the case explores what motivated Project ECHO founder and liver specialist Sanjeev Arora, MD to train primary care providers in rural New Mexico in hepatitis C treatment and management. It describes early replication of the ECHO model in the US and across medical conditions and what the Project ECHO model entailed—including leveraging technology to expand access to specialty resources, best practices, case-based learning, and outcome monitoring, as well as good will among participants. A professional communications campaign, ongoing research, and persistence supported Project ECHO’s growth. The case displays three dimensions of Project ECHO’s early work: creating a new mode to redistribute the expertise of specialists to primary care practitioners, scaling this new care delivery model and measuring its impact, and identifying sustainable funding sources. The case concludes with the US Congress passing the ECHO Act to promote research on the model and Arora contemplating what else he might need to continue to scale to reach his goal of touching 1 billion lives.

Teaching Note available through Harvard Business Publishing. 

Learning Objectives: To understand what is needed to design a service model; the potential for redistribution of expertise among practitioners to enhance value; the role of operational effectiveness in enabling scale up; and the importance of measuring impact for stakeholders.

Keywords: Public health, health care delivery, scale-up, resource-limited settings, human resource, information technology, primary care, information management, data collection, mentorship

This concept note provides a clinical overview of three diseases that feature predominantly in our case study collection: HIV/AIDS, tuberculosis, and malaria. The concept note describes the pathology, causes, and management related to prevention, diagnosis, and treatment of each of the diseases.

Learning Objectives: To further students’ and instructors’ understanding of clinical concepts presented in the Global Health Delivery (GHD) Case Collection.

Keyword: Epidemiology, pathology, disease management, monitoring and evaluation, resource allocation, global health policy, partnerships, reatment and prevention.

Set in rural Tanzania, this case traces the founding and development of the Tanzanian Training Centre for International Health (TTCIH) from the early 2000s through 2015. It begins with an overview of the political, socioeconomic, and epidemiological context of Tanzania, followed by a detailed description of the human resource for health crisis in Tanzania and the landscape of available health care training programs. The case then explores the origins and evolution of TTCIH, launched through a unique collaboration between private industry, a public health institute, local stakeholders and educators, and the Tanzanian Ministry of Health and Social Welfare. It describes the evolution of TTCIH as leaders strive to make it self-sustaining and responsive to Tanzania’s health workforce crisis. The case highlights the challenges of successfully integrating corporate management practices and values into a global health program and the role of strategic leadership to sustain TTCIH.

Teaching Note available through Harvard Business Publishing.

TTCIH Income and Number of Students, 2005–2013

Learning Objectives: A productive class discussion will allow students to appreciate the challenges of designing sustainable, high-quality health training institutions in low-resource settings; the training and resources needed to support task shifting and to address health workforce shortages in health care delivery; and, the importance of maintaining a sound strategy for medical education programs in the midst of changing national health needs and the evolving medical education landscape.

Keywords: Global health, public health, health care delivery, education, government, value creation, Human Resources for Health, health care, nongovernmental organizations, Public-Private partnerships, learning, revenue growth, organizational effectiveness

This case explores what it took to map the prevalence of trachoma infection in 1,531 districts across 26 countries by directly examining 2.39 million individuals in just three years. Dozens of organizations worked together on the largest standardized mapping project in the world as part of an effort to eliminate blinding trachoma globally by the year 2020. After providing some background on trachoma, early control efforts, and the formation of a global coalition, the case explores the events, strategies, technology, and stakeholders that enabled the mapping project. It describes how the stakeholders worked together, the coordination and management mechanisms used, and the investments required. Given that disease elimination had been achieved only once before, in the case of smallpox, the case asks students to consider how the project’s leaders, Tom Millar and Anthony Solomon, could help maximize returns from trachoma mapping so that the campaign could achieve its ultimate goal of global trachoma elimination within the next five years. Were there ways in which they could leverage efforts to map this neglected tropical disease to inform other disease control programs?

Teaching Note available through Harvard Business Publishing.

Life Cycle of Trachoma. Source: The Carter Center/Al Granberg, International Trachoma Initiative. Available at http://www.neglecteddiseases.gov/target_diseases/trachoma/.

Learning Objectives: A productive class discussion will allow students to appreciate what contributes to the development of a productive coalition; what it takes to collect quality data at scale; the challenges and benefits of identifying your target population for public health programming; and the tradeoffs between a targeted campaign addressing one disease and bundling efforts for multiple diseases.

Keywords: Disease mapping, disease elimination, multi-sectoral collaboration, electronic data capture

Set in Karachi, Pakistan, this case examines a private hospital's potential to impact health in a resource-constrained setting. Within Pakistan's health care system and its political, socioeconomic, and epidemiological context, the case focuses on the Indus Hospital, a charity hospital started in 2007. The case explores the effect of financing, leadership, and a mission-driven culture on health care delivery and the hospital's efforts to provide high-quality care for free to poor patients. It concludes with Indus' leaders planning how to expand their service delivery to include primary and preventative care. This is a condensed version of the case The Indus Hospital: Delivering Free Health Care in Pakistan. 

Teaching Note available through Harvard Business Publishing.

Learning Objectives: To understand a private hospital's potential to impact health in a resource-constrained setting, how private financing impacts health care delivery, and the impact of leadership on health care delivery.

Supporting Content: This is a condensed version of the case The Indus Hospital: Delivering Free Health Care in Pakistan.

Keywords: Human rights, workforce management, sustainability, role of civil society, information systems, organizational culture

This case traces the development of surgical and anesthesia services at a rural mission hospital in Kijabe, Kenya. After providing some background of the health system in Kenya, it follows the history of AIC Kijabe Hospital from its founding in 1915 to 2013. The hospital provided high quality surgical services that were supported by many long-term missionary staff members, updated operating theaters, an intensive care unit, and a robust surgical training program. The case describes how the mission of the hospital affects its culture of care provision. It follows the executive director, Mary Muchendu, and her process in turning a mission-focused hospital into a business-focused hospital. The case ends with Muchendu weighing the tradeoffs of providing sustainable growth versus caring for the poor. This is a condensed version of the case Surgery at AIC Kijabe Hospital in Rural Kenya. 

Teaching Note available through Harvard Business Publishing.

This case traces the development of the voluntary medical male circumcision (VMMC) campaign in Nyanza Province, Kenya as it transformed from the subject of a randomized clinical trial into national policy. After providing some background on the cultural, political, and scientific context surrounding male circumcision, the case traces the PEPFAR-funded implementers' advances in delivering male circumcision in Nyanza. It examines the various delivery models used in Nyanza and the evolution of the relationship between implementers as well as on the development of the national strategic plan for VMMC released in 2009. The case ends with the implementers having come together successfully for two rapid, aggressive, 30-day implementation campaigns and the head of Kenya's National AIDS and Sexually Transmitted Infections Control Programme wrestling with how to make such campaigns sustainable and what lessons from the campaign to pass on to the national program. This is a condensed version of the case Voluntary Medical Male Circumcision in Nyanza Province, Kenya.

Teaching Note available through Harvard Business Publishing.

Learning Objectives: To understand how a randomized controlled trial may be translated into a large-scale public health program; how a surgical campaign was designed and implemented for rapid impact; the role of national and international collaboration in large-scale health delivery; and the ethical tradeoffs that arise in large-scale public health programs.

Supporting Content: This is a condensed version of the case Voluntary Medical Male Circumcision in Nyanza Province, Kenya.

Keywords: Project management, AIDS, policy, supply and demand, partnerships, strategy, innovation