Rich countries can learn from poor ones about delivering good care at low cost, conference hears

BMJ 2011; 343 doi: (Published 04 October 2011) Cite this as: BMJ 2011;343:d6355
  1. Tessa Richards
  1. 1BMJ

Rich countries that provide wasteful, inefficient, and inequitable health services should be more accountable for the money they spend and should adapt cost effective models of care pioneered in poor countries, delegates agreed at a meeting last week on global health.

The meeting was held by the Salzburg Global Seminar ( and the Dartmouth Center for Health Care Delivery Science in Hanover, New Hampshire ( Al Mulley, director of the Dartmouth centre, drew attention to the low investment in research into how health services are organised and delivered and to the failure to assess rigorously whether they provide value for money in terms of outcomes that matter to patients and populations.

Poor countries have had to innovate to provide essential services, and there is plenty of scope for “reverse innovation,” Dr Mulley said. The term, which is gaining currency in health circles, was coined initially to describe innovations developed in poor countries that are then distributed or marketed in richer ones. The Tata Nano car, developed in India, and cheap portable ultrasound scanners developed in China are often cited as examples.

Many telecare and e-health initiatives are being pursued in poor countries, and last week the US secretary of state, Hillary Clinton, said that her country could learn from Zambia’s e-health records system, where patients hold their own records on smart cards.

In Ghana, Kenya, and Nigeria patients can use mobile phones to identify counterfeit and substandard drugs by keying in ID numbers on scratch bar codes on the packet and also get advice on dosages and side effects. The technology could be extended, the BMJ was told, to report adverse events from drugs.

Reverse innovation is not confined to technology. A lesson that rich countries should “import” from poor ones, speakers suggested, was to deploy their skilled professionals to maximum benefit. The key role of doctors was to “confer agency” to teams and ensure that all members perform at their highest level of skill and knowledge. The value of incorporating lay community health workers into multidisciplinary teams was also emphasised—particularly in chronic disease management, to provide the holistic support that patients need.

Organisations that illustrate these elements include the non-governmental organisation BRAC ( in Bangladesh and the Aravind Eye Care System ( in southern India. The Aravind system was set up in 1972 to eliminate avoidable blindness. Srinivsan Aravind, its director of projects, said that an initial “bottleneck was a lack of support staff for the ophthalmologists,” so school leavers were trained to do routine visual assessments and delivery systems were streamlined along “a McDonald’s style model.”

In the US, lay community health workers have been shown to be cost effective “interventionists” in their own right, said Heidi Behforouz, a family doctor who founded the Prevention and Access to Care and Treatment (PACT) project (, which provides HIV treatment and prevention services to disadvantaged patients in Boston. Lay health coaches are also being successfully integrated into new models of primary care ( Nigel Crisp, former chief executive of the NHS in England, urged rich countries to “use the assets in their communities.” Patients, families, and volunteers linked to professional teams can help make services more effective and sustainable, he said.

Strong and consistent health leadership is needed too, said Agnes Binagwaho, Rwanda’s minister of health. Politicians must have “a clear technical vision” of what health services aim to achieve and “show zero tolerance for non-compliance.”

Dr Binagwaho ( said that despite being told in 2001 that Rwanda did not have the resources to treat patients with HIV, the country capitalised on its donor money, set up universal services for HIV patients, and through them rolled out a comprehensive package of health services.


Cite this as: BMJ 2011;343:d6355


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