Lower income countries have different healthcare technology needs, in terms of price as well as practicalities
Methods to streamline costs without compromising quality include removing unnecessary functions and using existing infrastructures in novel ways
Technology innovation in resource-poor settings has proved useful for developed countries thus has global benefit
Over the past couple of decades, the technology available to clinicians in the developed world has expanded at a dizzying rate but, alongside this, there has been an increase in prices at every stage of delivery. There is an environment in which only massive injections of funds can bring about progress: the ‘more with more’ attitude to research and development. Such prohibitively high costs impede access to these technologies, with 13% of the global population accounting for 76% of global medical device use. In lower and middle-income countries (LMICs), as well as the lack of adequate funding, these devices are inherently unsuitable to the contexts in which they are required, which are a far cry from sanitized, highly controlled clinical or laboratory environments for which they were designed.
The high-resource model of innovation relies on assumptions that cannot be made in the majority of settings. This is “unsatisfactory innovation”¹ - a piece of technology might be fantastic in theory, but in practice, it has very little utility. Lack of utility is not always cost-related and focusing on price alone is often distracting. For example, no matter how cheap a technology may be, if it is unable to withstand extremes of temperature, heavy usage or frequent power cuts, it will be as inaccessible as the most expensive technologies to many LMICs. Indeed, there are regions of sub-Saharan Africa where 70% of medical devices, most of which are given as donations, lie unused. This may well be because they are unsuitable to the context, or perhaps there is a lack of expertise required to operate them.
According to WHO’s guidelines for healthcare equipment donations, an important factor in “good donation practice” is effective communication between donor and recipient, ensuring that the needs of the recipient country are being met in a way that is useful to them. Placing developing nations at the heart of the decision-making process is a critical step. Already, the emerging healthcare markets of India and China are “bring[ing] new reasons to create appropriate, affordable and accessible innovations for low-income markets”, as Radha Basu puts it.
“Frugal innovation” is an idea that is gaining traction in meeting these new demands. This relies on finding solutions that limit costs and resource requirements without affecting quality, essentially representing a shift from the “more with more” model to “more (and better) with less”. While there isn’t a single template for how frugal innovation can take place, past successful cases have taken the context in which they will be used into account. A powerful example is the Lullaby baby warmer. Developed by a division of GE based in India, it is sold for $3,000, $9,000 less than the equivalent product is sold for in the US. Stripped of non-essential functions, this incubator is an example of a “lean tool”: a simpler but no less effective version of the original device.
Another factor outlined by the WHO as part of good donation practice is the importance of ensuring there are no double standards. If the quality isn’t acceptable in the donor country, it isn’t acceptable in the recipient country. Finding the balance between maintaining the standard of quality required, while catering to complex and resource-poor settings, is a massive challenge but one that can yield impressive results. Siemens scientists working in China, for example, have developed a simplified CT scanner that can operate at 30% of the standard cost using up to 60% less radiation. This has now entered the US market so this technology is “reversely” spreading: a demonstration of how working in resource-scarce settings can be a powerful driver for innovation from which everyone can benefit.
While reductions in initial cost can be extremely compelling, it cannot be the only factor that is taken into consideration. The cost of ownership is even more important, as the need for expensive consumables or replacement parts will rapidly offset any potential benefits to the decreased initial cost. Rice University reduced the cost of bubble CPAP, a device that helps premature babies to breathe, from $6000 to only $160. While this is a remarkable achievement, the requirement for frequent replacement breathing tubes means that the running cost remains fairly high. Designs that don’t simply reduce cost but increase durability, longevity and sustainability are, therefore, hugely important.
Frugal innovation often arises in the form of opportunistic solutions, harnessing infrastructure that is already available. ColaLife made the simple observation that, whilst Coca-Cola can be bought in even the most rural of settlements, in these same places 1 in 8 children die of diarrhoeal disease before their 5th birthday. They harnessed Coca-Cola’s expertise in distribution to create a sustainable supply chain to deliver oral rehydration kits to remote communities. Another example is the emerging field of telemedicine, which harnesses the use of mobile phones and the Internet in global health initiatives. The possibilities are practically endless and there are already a host of projects that indicate the field’s promise, whether it be using SMS to improve adherence to antiretroviral therapy in Kenya, or the development of ultrasound machines that can be directly connected to a smartphone, greatly decreasing cost and allowing for rapid communication of information between clinicians for better diagnostics. This, however, also comes with some very real challenges, particularly issues of data security and patients’ right to privacy.
Overall, tailoring technology to the environment in which it will be used, streamlining it to reduce unnecessary costs and building upon existing infrastructure represent important ways of ensuring advances in medicine and technology are reaching the people who need them most. Such shifts in the way that innovation occurs not only have promise in resource poor settings but also represent a new model for improving access to the highest standard of care globally.
¹: “unsatisfactory innovation” is a term coined by Bengt-Åke Lundvall