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
- Mark Skopec, research assistant1,
- Hamdi Issa, doctoral student2,
- Matthew Harris, clinical senior lecturer in public health1
The process of reverse innovation, where ideas originating in low resource settings are adopted by higher income countries, challenges the notion of developed countries as the instigators of healthcare transformation.1 Between 1985 and 2009, the annual growth rate of patent applications in low and middle income countries was 19%, leading them to double their share of global patent applications (from roughly 4% to 8%).2 As healthcare services increasingly seek to optimise their cost effectiveness, the efficient and scalable solutions used in lower resource environments provide an opportunity for wider learning.
Reverse innovation is a broad term, encompassing innovations that have been ideated, trialled, tested, and adopted in low and middle income countries, before being used by healthcare providers in high income countries.234 The term itself has problems, arguably perpetuating the view that innovation normally flows from high to low income settings, thereby undermining the shift in knowledge translation that it seeks to promote.5 Nevertheless, reverse innovation presents a broad range of opportunities and challenges in healthcare. Several reverse innovations have the potential to provide considerable efficiency benefits and cost savings to the NHS.
Examples and opportunities
In 2009, General Electric developed the GE Mac 400, a handheld portable electrocardiogram (ECG) device, originally designed for use in rural India.3 It costs $1000 (£775; €900), a fraction of the cost of similar devices sold in high income countries (GE Healthcare lists the price of hospital class units as between $2000 and $10 000). The engineers who developed the Mac 400 recognised which features of the hospital class units were most essential and which could be sacrificed to decrease costs. The Mac 400 is battery powered, has a simplified operating system using only two buttons, and is equipped with a printer to print examination results. The Mac 400 might not offer the same detail or variety of functions available to in-hospital users, but its portability has made ECG examinations more widely available.6 The device proved highly successful, so General Electric began to market the device in the US as well, where doctors in isolated rural communities face the same challenges as those in low and middle income countries. The low price of the handheld device, coupled with its clinical efficacy in the field, has made many doctors in the US wonder why they should pay the premium price for traditional ECG machines when they can get one that is just as effective for a fraction of the cost.3 Thus, innovations initially developed for low resource settings have the potential to provide savings in high income settings.
Reverse innovation is not limited to technologies or products. Kangaroo care is a practice that involves skin-to-skin contact between a preterm infant and their parent for as much time as possible every day. This method was first introduced in Colombia nearly 25 years ago, when access to expensive neonatal intensive care units was limited.7 Its positive impact (reducing infant mortality, infection, and length of hospital stay and improving mother-infant bonding, breastfeeding, and maternal satisfaction) is well documented and has led to its routine use in maternity units throughout the world.7
The Ponseti technique for treating congenital talipes equinovarus, commonly known as clubfoot, was expanded and used at scale in low and middle income countries such as Malawi8 and Uganda,9 which are home to 91% of the 174 000 children born with clubfoot each year,1011 as an alternative to expensive surgical correction. Since then, multiple studies have been published on the efficacy of the treatment,812 and it is now the gold standard treatment for clubfoot in the UK.13
Development agencies in high income settings are increasingly recognising the opportunities of reverse innovation. The Norwegian government’s international development department, Norec, mandates that all international partnerships it funds must be mutually beneficial, through exchange of personnel and expertise with low and middle income partners. In the UK, institutions such as the Tropical Health Education Trust, through its health partnership schemes, and Health Education England, through its earn, learn, and return schemes and the Global Health Exchange, are looking to identify innovations from low and middle income countries that might benefit the NHS. Efforts include facilitating employment of overseas professionals in the NHS or identifying innovations overseas and then promoting them in the UK. Tropical Health Education Trust’s In Our Mutual Interest report and the chief medical officer’s annual report in 2019 both call for NHS organisations to actively engage in mutual two way learning with low and middle income countries.1415
Table 1 shows innovations that have been conceived, developed, trialled, or scaled in low income settings that warrant further consideration for piloting in the NHS. More details and additional examples can be found in supplementary table 1. The scope of reverse innovations is broad and the innovations considered here have a range of different advantages, evidence bases, and potential efficiency savings underpinning the rationale for their adoption in the UK.
In some cases, modelling studies have sought to quantify potential benefits. A study examining the potential effects of adopting the Brazilian family health strategy, wherein community health workers would provide household health promotion throughout the UK, showed that it could facilitate 753 592 additional screenings for cervical cancer, 365 166 for breast cancer, and 482 924 for bowel cancer, as well as provide measles, mumps, and rubella (MMR) vaccinations for an extra 16 398 children at 12 months and 24 716 MMR2 vaccinations at 5 years, all by identifying people eligible for these services who had not yet been reached.17 The Arbutus medical drill cover, a sterilisable pouch that converts a regular hardware drill into a surgical grade drill, would offer cost savings between 85% and 94% compared with the existing technology used in the NHS and could save individual trusts up to £250 000 a year.19 Mosquito net mesh is made of the same material as commercial mesh, but is considerably cheaper ($0.0043 compared with $108) and has been used successfully for hernia repair in India and several sub-Saharan countries.2930 With 70 000 surgical hernia repairs undertaken in the UK in 2001-02, the use of the mosquito net mesh would present a major cost saving.
Innovations from low and middle income countries are not inherently beneficial to high income health systems. Each one should be assessed on its merits and with consideration of the adoptive environment. The potential market for Prepex, for example, a non-surgical circumcision device used throughout sub-Saharan Africa to prevent HIV transmission in adults, is likely to be quite small in the UK, where circumcision is mostly for religious reasons and conducted shortly after birth.
The innovations are often neither patented nor owned by anyone, presenting challenges in terms of obtaining regulatory approval and promoting entry to new markets. This is the case for using mosquito net mesh for hernia repair. Frugal innovations are also often repurposed technologies, and this is a challenge when it comes to obtaining CE marking, which is for a specified purpose and can require premarket studies approved by the Medicines and Healthcare Products Regulatory Agency, as is the case for the Arbutus medical drill cover system.
Reverse innovation does not always provide the intended benefits. Conditional cash transfer (CCT) programmes in Mexico and Brazil have been used to provide incentives for students to attend school and perform well in exams,3132 as well as to encourage patients to adhere to drug regimens or weight loss programmes.3334 Oportunidades in Mexico has been among the most successful CCT programmes35 and led the New York City mayor’s office to implement a similar programme for low income families living in the city.36 The overall effects were mixed; although poverty and material hardship decreased over the course of the pilot, educational effects were most pronounced among academically prepared ninth graders (14-15 year olds) but not their less proficient peers.36 The programme resulted in a small rise in the rates of health coverage, but no increase was observed in preventive visits to the doctor. The failure to show benefit in one setting does not undermine the potential or rationale for reverse innovation, but it does indicate that tailoring to contexts, careful evaluation, and a preparedness to adapt the intervention will be important. Implementation of any new innovation in a complex system requires resources, time, and engagement, so pilot projects, starting with feasibility and acceptability studies, adapting the innovation where necessary, and building the evidence base for adoption, are essential.
Reverse innovations, by virtue of their origin, tend to be frugal—doing more, with less, for more people, driven by the necessity to use resources more efficiently.3738 The resulting technologies, techniques, or models strive to deliver care at a comparable level to best practice in high income settings but at a fraction of the cost. Some reverse innovations might be slightly less effective, but because of their extremely reduced cost can reach a far broader proportion of the population, resulting in a greater overall impact. Thus, future discussion of reverse innovation must consider possible trade-offs in terms of cost and standards in the quality of care that we are willing to accept. Anticipated cost savings might not be realised in high income settings owing to, for example, different cost structures and salary scales.
Every innovation will present specific challenges related to its nature, its features, and the context in which it is applied. But general challenges are also worth considering, such as how to define what is and what is not a reverse innovation. Von Zedtwitz and colleagues defined several types of reverse innovation based on the location of the original idea, its development, and scaling up.2 So reverse innovation can include innovations that actually originate in high income countries before being tested and scaled up in low and middle income countries and then re-entering high income markets after proof-of-concept has been established. The Ponseti technique is a good example of this. Although it was widely adopted in low and middle income countries, it was developed by Ingnacio Ponseti Vives, an orthopaedic surgeon at the University of Iowa in the 1950s.11
Following the trajectory and spread of reverse innovations is challenging. Attempts to adopt innovations from low and middle income countries, whether successful or failed, are rarely published or even documented.11 Identifying high value, low cost innovations from low and middle income countries in the first place can be challenging. These innovations are often quick fixes to intractable local health service delivery problems and are not patented, evaluated, or documented. Some notable databases are available—such as the Centre for Health Market Innovations and the World Health Organization Compendium for Technologies for Global Health—but many remain under the radar. In the UK, the NHS’s extensive commitment to overseas volunteering and partnership is an opportunity to identify innovative practice and, if well documented, could become a repository for innovative solutions discovered in these settings.
Much progress is being made to level the playing field in global health innovation, but extreme inequity remains in terms of the production, publication, and consumption of healthcare research and innovation, favouring the global north.394041 The country of origin of a product serves as a cue for quality, reliability, and safety in the marketing and consumer research literature,4243 and products from low and middle income countries are discounted early on because of this extrinsic cue. Country of origin effects are therefore likely to play a vital role in the adoption and propagation of healthcare innovations that have been ideated, developed, and primarily marketed in low and middle income countries.24445 We need to challenge the biases that continue to favour the dominant, often North American and Eurocentric, narrative around distribution of global innovation. By considering the value of adopting innovations from low and middle income countries in high income settings, as well as recognising the scientific contributions of the countries from which they originate, we can create an innovation landscape that is more equitable. The related decolonisation movement—which encourages us to challenge entrenched power structures and promote a diversity of knowledge sources, in particular from low income countries, and is a focus in many higher education institutions in the global north—is a useful impetus to make us aware of the unconscious biases that undermine social and cognitive justice.4647
Despite the growing literature around reverse innovations, and the notable potential for cost and efficiency savings, only a select few have been successfully implemented in the health systems of higher income countries. Many specific and general challenges impede the adoption and diffusion of reverse innovation in the UK. But given the wide variety of low cost, high value innovations originating in low and middle income countries, we need a concerted effort to identify potential reverse innovations, stimulate the demand for them in the NHS, and fund their pilot testing in local contexts. Beyond the potential for radical cost reduction, reverse innovations are also a source of new ideas, enabling practitioners in high income countries to broaden their horizons, while levelling the playing field in global knowledge production.
Low resource countries are increasingly recognised as sources of frugal healthcare innovations—whether technologies, process, or models—that do more, for less, for many
These innovations offer the potential for cost saving if adopted in high income settings, such as the NHS—this process is often referred to as reverse innovation
Each innovation comes with its own specific barriers to adoption, such as regulatory hurdles or community standards
General challenges include identifying the potential innovations, resourcing and managing their adoption, and the perception that innovations from low resource countries are not adequate or appropriate for high income settings
The resource constraints facing high income country health systems, such as the NHS, mean that adopting frugal innovations from low resource countries is timely and needed
Contributors and sources: MH initiated the article. MS drafted the manuscript. MH and HI reviewed and edited subsequent manuscript drafts. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. MH is the guarantor and accepts full responsibility for the finished article, had access to any data and controlled the decision to publish. MS studies the role that unconscious biases, particularly bias against low income countries, plays in the diffusion of knowledge in healthcare. HI has researched the role of international health partnerships in reverse innovation with a focus on knowledge hierarchies. MH has led qualitative and quantitative research studies in Reverse Innovation including curating innovations, measuring cognitive biases against low income country research, and examining cultural barriers to adoption of innovation from low income countries. He has lived and worked in Brazil, Ethiopia, and Mozambique as a general practitioner and public health doctor.
Funding: The authors received no funding for this article. MH is supported in part by the NW London NIHR Applied Research Collaboration. Imperial College London is grateful for support from the NW London NIHR Applied Research Collaboration and the Imperial NIHR Biomedical Research Centre. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: MS has nothing to disclose. HI has nothing to disclose. MH is an honorary adviser for the Tropical Health Education Trust and a non-executive director of Primary Care International.
Provenance and peer review: Not commissioned; externally peer reviewed.