Delivering cost effective healthcare through reverse innovationBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6205 (Published 14 November 2019) Cite this as: BMJ 2019;367:l6205
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We welcome Skopec et al.'s paper(1) that brings attention to this important concept. We also believe it is vital to work on how to collect and develop these ideas from active clinicians.
As part of the RCGP Junior International Committee, we ran workshops on reverse innovation in 2015 at RCGP and WONCA Europe conferences. Participants were mainly family doctors who had worked abroad, and they shared their experiences of bringing back interventions that had worked- they faced similar issues to those mentionned in the article. Several examples involved reconfiguring approaches rather than product development. Our workshops showed a) that practical ideas may come from health professionals who are clinicians, from different countries, when they get together and talk and b) how these conversations can be facilitated. Other stimulants are funded competitions(2).
The combination of being embedded in a system and having fresh eyes can offer unique perspectives for developing ideas that would be applicable in settings apart from where they were created.
We encourage international collaborations such as exchanges to share best practice and develop
competencies (3) suited to our globalised world. To take this further, more research is
also needed into how to mobilise imaginations, and bring people together to co-create solutions.
1. Skopec M, Issa H, Harris M. Delivering cost effective healthcare through reverse innovation. BMJ. 2019;
2. Snowdon AW, Bassi H, Scarffe AD, Smith AD. Reverse innovation: An opportunity for strengthening health systems. Global Health. 2015;
3. Walpole SC, Shortall C, van Schalkwyk MCI, Merriel A, Ellis J, Obolensky L, et al. Time to go global: a consultation on global health competencies for postgraduate doctors. Int Health. 2016 Sep;8(5):317–23.
Competing interests: CG works in the same overarching department as the authors MS and MH and occasionally for the same social enterprise as MH.
In their recent article, Skopec and colleagues 1 highlighted the huge potential of reverse innovation, and how attempts to adapt innovations from low and middle income countries (LMIC) often remain undocumented. We take this opportunity to highlight our work adapting a participatory group intervention from LMIC for parent carers of Children and Young People (CYP) with Cerebral Palsy (CP), within a community clinical setting in East London.
UK national guidelines recommend a holistic patient-centred approach to meet the complex health, social care and educational needs of CYP with CP, as well as those of their families and carers 2. This includes the provision of tailored information on CP and available services, as well as access to local support groups for both CYP and parent carers. Yet there is limited evidence from the UK and other high-income contexts on how this approach should be delivered. We therefore looked to LMIC for promising programmes that could be adapted and further co-developed with families in the UK.
Our systematic search identified only one such intervention - the Getting to Know Cerebral Palsy (G2KCP) programme 3. Originally developed in rural Bangladesh, it has been adopted by 50 low-income and middle-income country partners worldwide 4-6. The programme aims to improve quality of life (QoL) for parent carers of CYP with CP, and the QoL and functional outcome of the CYP themselves, by increasing knowledge and skills and providing psychological support through a series of 10 peer-led sessions. A pre and post evaluation in Ghana reported significant improvements in parent carers’ quality of life, although further evaluation is required to assess impact on the nutritional or functional status of CYP 7,8.
Additional factors that influenced our decision to adapt G2KCP to the UK context included its congruence with NICE and NHS guidelines, its participatory community based approach and the likely low implementation costs. We are now working with parent carers to adapt programme content, and test feasibility and acceptability, prior to a full-scale evaluation. In doing so, we hope to add to the evidence base of reverse innovation within the NHS, while enabling parent carers of CYP with CP to better meet their needs.
1. Skopec M, Issa H and Harris M. Delivering cost effective healthcare through reverse innovation. BMJ 2019; 367: l6205. DOI: 10.1136/bmj.l6205.
2. National Institute for Health and Care Excellence. Cerebral palsy in under 25s: assessment and management (NICE guideline NG62). 25 Jan 2017.
3. Heys M, Lakhanpaul M, Owugha J, et al. Is there a need to develop and evaluate a community based family and carer programme to improve outcomes for children and young people with cerebral palsy in the UK? . Paediatrics & Child Health (in press).
4. International Centre for Evidence in Disability. London School of Hygiene and Tropical Medicine. Ubuntu-Hub, https://www.ubuntu-hub.org/.
5. Nampijja M, Webb E, Nanyunja C, et al. Randomised controlled pilot feasibility trial of an early intervention programme for young infants with neurodevelopmental impairment in Uganda: a study protocol. BMJ Open 2019; 9: e032705. DOI: 10.1136/bmjopen-2019-032705.
6. Duttine A, Smythe T, Calheiro de Sá MR, et al. Development and assessment of the feasibility of a Zika family support programme: a study protocol. Wellcome Open Res 2019; 4: 80-80. DOI: 10.12688/wellcomeopenres.15085.1.
7. Zuurmond M, O’Banion D, Gladstone M, et al. Evaluating the impact of a community-based parent training programme for children with cerebral palsy in Ghana. PLOS ONE 2018; 13: e0202096. DOI: 10.1371/journal.pone.0202096.
8. Zuurmond M, Nyante G, Baltussen M, et al. A support programme for caregivers of children with disabilities in Ghana: Understanding the impact on the wellbeing of caregivers. Child: care, health and development 2019; 45: 45-53. DOI: 10.1111/cch.12618.
Competing interests: No competing interests
Nurture Early for Optimal Nutrition (NEON) study: an exemplar of public health reverse innovation to improve infant feeding, care & dental hygiene practices in East London.
We read with interest Skopec et al’s article (1) on how the UK healthcare system could benefit from adopting cost-effective innovations from low- and middle-income countries (LMICs). We wish to highlight another innovation currently being co-developed and evaluated in the UK by our team.
The community-based Participatory Learning and Action (PLA) group approach is recommended by the World Health Organisation (WHO) as a cost-effective strategy to improve maternal and neonatal morbidity in rural LMICs (2). This low-cost bottom-up approach mobilises communities to identify, prioritise, implement, and evaluate their own needs and solutions through group discussions (3).
The NEON study aims to utilise an adapted PLA group approach to improve infant feeding, care and dental hygiene practices initially in South Asians in East London via multilingual trained community-based facilitators (4, 5).
Alongside a PLA group facilitator manual covering every cycle step, facilitators will be provided picture cards, healthy baby recipes and community asset maps using “participatory mapping” consisting of local resources and services such as low-cost fruit and vegetable stores. Evaluation metrics will include health (Child BMI z-score, GP healthcare utilisation, children feeding behaviour, parental feeding style, food diary), non-health (children’s cognition, network diffusion) economic and process outcomes.
Our formative study focusing on British Bangladeshis in Tower Hamlets, an inner-city deprived London borough, found that the PLA approach was highly acceptable to participants. However, the feasibility of undertaking a 12 session PLA cycle led by a voluntary community facilitator was questioned.
As a result, we’ve since adapted the model to two shorter cycles (7 & 6 session PLA cycles). This will be co-developed and evaluated in a 3-arm ward-level pilot cluster RCT (12 clusters). If this pilot is successful, a fully powered cluster RCT will follow prior to adaptation in other population groups & topic areas.
1. Skopec M, Issa H, Harris M. Delivering cost effective healthcare through reverse innovation. BMJ. 2019;367.
2. Prost A, Colbourn T, Seward N, Azad K, Coomarasamy A, Copas A, et al. Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. The Lancet. 2013;381(9879):1736-46.
3. Freire P. Education for critical consciousness: Bloomsbury Publishing; 1973.
4. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet (London, England). 2005;365(9463):977-88.
5. Nurture Early for Optimal Nutrition (NEON) study: Aceso Global Health Consultants Ltd 2019 [Available from: https://www.acesoghc.com/neon.
Competing interests: Dr Logan Manikam is funded by the National Institute of Health Research (NIHR) Advanced Fellowship (Ref: NIHR300020) to undertake the pilot cluster randomised controlled trial of the NEON study intervention in Tower Hamlets & Newham. He founded and owns Aceso Global Health Consultants Limited, a micro-consultancy that hosts the Childhood Infection & Pollution Consortium; a multi-country academic-NGO collaboration that utilises approaches such as PLA in developing behaviour change & slum upgrading interventions to reduce the infection burden in under 5 children in urban slums across India, Indonesia & Chile. Prof Monica Lakhanpaul was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames. This Rapid Response was submitted on behalf of the NEON study team, detailed information about the study could be accessed on the website (5), including the NEON study team.
We thank Skopec, Issa and Harris(1) for their fascinating essay on reverse innovation and note that it could herald an age of increased cultural humility for the global north and assist with dissipating prejudices towards innovations from the global south. Bringing in new ideas from ‘outside’ requires disrupting entrenched power and value systems around knowledge. This process of disruption is essential to the process of decolonising medicines and devices. Indeed, it chimes with Timms and Mearns book New Power: Why Outsiders are Winning, Institutions are Failing, and how the Rest of Us Can Keep up in the Age of Mass Participation,(2) which refers to bottom up power surges (like #MeToo) that are overturning old power hierarchies and protectionism around institutions.
The authors rightly raise the possibility of the term “reverse” being problematic. We agree. Linguistic interaction — the words and terms we use — conveys and reproduces social, cultural and political structures. By labelling innovation as reverse, or indeed other incentives like “reverse” mentoring, we may be reinstating the power dynamic we are seeking to undo. Could there be a new term for this type of collaboration? We also believe that the pitfalls of cultural appropriation should be avoided whereby aspects of an oppressed culture are taken out of context by a historically dominant people, who lack the cultural context to properly understand, respect, or utilise these elements.(3)
1 Skopec Mark, Issa Hamdi, Harris Matthew. Delivering cost effective healthcare through reverse innovation BMJ 2019; 367 :l6205
2 Heimans J, Timms H. New Power: Why outsiders are winning, institutions are failing, and how the rest of us can keep up in the age of mass participation. Macmillan; Main Market edition (19 April 2018). ISBN-13: 978-1509814183
3 Connecting up the curriculum – Decolonising the Medical Curriculum [Internet]. [cited 2019 Nov 28]. Available from: https://decolonisingthemedicalcurriculum.wordpress.com/connecting-up-the...
Competing interests: All co-authors have worked on an educational project regarding decolonisation and medical education. MF is in the same Department as MS & MH (authors of the article we are responding to). CD is a member of the Patient Liaison Group at the BMA