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Dr. Amy Lehman thinks a lot about mosquito bed nets and other health interventions, designed to stave off malaria infection in a part of the world that sees the highest death rates related to the disease.

She’s dedicated her career to figuring out how to get life-saving medical supplies to villages in the South Kivu Province in the Democratic Republic of the Congo—a region in east-central Africa that’s often considered too costly to reach. It borders on Lake Tanganyika, the world’s longest freshwater lake that contains one-fifth of the globe’s freshwater and touches four nations with a total population of over 170 million.

In 10 years, she’s learned two basic truths: insecticide-treated bed nets are not the best way to fight malaria in water-based communities, and the key to reliably, safely, and affordably delivering another health solution lies in developing a supply chain in an area whose main highway often becomes the lake itself.

“We know that bed nets are not the best solution,” said Lehman, AB '96, MBA '05, MD '05, a graduate of the University of Chicago Booth School of Business, the Pritzker School of Medicine, and the College and founder of the Lake Tanganyika Floating Health Clinic (LTFHC). “People were using their bed nets to fish around Lake Tanganyika. Mosquitos are biting people before bedtime, and the bed nets are hard to use if you don’t have a bed or a bedroom.”

What Dr. Lehman needs is more data to show that another solution—like a spatial repellent—works better, and an operation model that accounts for cost, local conditions, consumer demand, product lifespan, delivery frequency, seasonality, and sustainability.

Her group is working to test new approaches to overcome last-mile delivery issues—something they’ve dealt with for years, long before the COVID-19 pandemic exposed cracks in the world’s traditional supply chains. To drive that work, Chicago Booth’s Rustandy Center for Social Sector Innovation connected her to Baris Ata, Booth’s Chookaszian Family Professor of Operations Management and an expert in resource allocation, sustainable operations, and improving efficiency. 

The two of them recently spoke at a Rustandy Center event to share insights from their efforts to build a sustainable supply chain that would allow them to deliver anti-malaria technology by boat, motorbike, canoe, and more on a monthly basis.

“If We Can Make It Work Here, It Could Work Anywhere"

Between 2000 and 2015, the United Nations reported that malaria cases fell by 37 percent globally and death rates by 60 percent. Progress has been uneven, however. Children under five are the most vulnerable group, accounting for 67 percent of global malaria deaths. Over 90 percent of worldwide malaria deaths are still concentrated in a small group of African countries, with Nigeria and the DRC leading the pack.

Baseline data from Dr. Lehman's clinic, including surveys of households, shows that 30 percent of 2,090 fishing parties observed were using insecticide-treated bed nets, which, in turn, poses harm to fisheries, food security, livelihoods, biodiversity, and health. 

Professor Ata’s study, conducted together with Booth PhD student John Montgomery, seeks to test both the efficacy of a new and innovative malaria prevention product that may be better suited for water-based communities and a supply chain delivery model for last-mile communities.

To build a sustainable supply route, they considered potential disruptors: In the DRC, the main highway is a dirt road. Seasonal weather events regularly wash out roads or make the lake inaccessible. The area also experiences political unrest and conflict, so researchers mapped distribution sites and built contingency plans for potential disruptions into their model.

“These are the operating environments that we have to learn how to deal with because that’s where people are dying,” Dr. Lehman said. “That’s where people have the greatest need. Our job is to fundamentally understand how to operate within those types of complex ecosystems.” 

Professor Ata and Montgomery developed mathematical models to evaluate potential solutions. Their model weighs every solution against lives saved per dollar spent, which factors in the cost effectiveness of delivering health products to households on a regular basis.

For malaria prevention, they’ve narrowed focus to a spatial insect-repellant called “The SHIELD,” a SC Johnson innovation that’s the size of a sheet of paper and hung on the wall of a home. The average home would require four sheets and they need to be changed out monthly.

For the supply chain, researchers recommend building storage units for boats near the lake to reduce reliance on roadways, establishing modes of transportation to overcome each type of disruption, and determining a resupply policy that accounts for demand as well as potential disruptions.

“If we can make it work here, it could work anywhere,” Professor Ata said. “Of course, this is not a one-size-fits all model, but the same principles could be applied to different contexts.” He compared planning supply distribution in the region to playing chess, needing to think 10 steps ahead. 

“The Rustandy Center prioritizes research with practical implications,” said Salma Nassar, the center’s director of research initiatives. “We work to develop research partnerships between leading academics and partners in the nonprofit, for-profit, and public sectors. The collaboration between Amy, Baris, and John is poised to provide important insights for building reliable supply chains for health interventions.”

Lessons Learned and the Road Ahead

To test their ideas, the group needs funding to launch a pilot program. Dr. Lehman is seeking local buy-in from authorities and the community. 

It’s easier to stick with bed nets as the solution, she said, because they’re inexpensive, can be distributed every few years, are familiar to donors, and can be effective outside water-based communities. But the group hopes data from a pilot could cause a serious shift in approach and policy. 

Professor Ata thinks this research and learnings around decentralizing operations could be valuable to others navigating supply chain issues and wanting to scale up. Take the COVID-19 vaccine, for example, he said. 

“Creating a vaccine is important, but how do you distribute it to everybody? A lot of times we go with extreme efficiency instead of allowing for flexibility.”

He hopes their models can be adapted to other situations, and plans to release a working paper on the research, alongside Montgomery, later this spring.

Dr. Lehman wants research to prove to the international development community that there are cost-effective ways to serve communities disproportionately affected by a health problem.

“You can only pick so much low-hanging fruit before all the fruit is hard to pick. We’re at that point with malaria control,” she said. “Now what we’re left with are literally the hardest places to serve that have the highest mortality figures. My hope is that we can actually begin to show ‘this is how much it costs’ to serve these people who have this unacceptable mortality rate.”

Watch a video of the research discussion below, and explore ways to support the Lake Tanganyika Floating Health Clinic. If you're interested in this work, sign up for the Rustandy Center's monthly newsletter to receive articles from Booth faculty with ideas for accelerating impact in the social sector and updates on relevant news and events.