This essay by Christopher Elias, MD, MPH, is reprinted from The Lancet, Medicine and Creativity, vol. 368, December 2006, S40–S41. Dr. Elias was president and CEO of PATH from 2000 to 2012.
Global health has been getting much more attention lately, in settings as varied as the World Economic Forum, TIME Magazine, and even rock concerts—and for good reason. There is a new global determination to address the great disparity in health status between rich and poor people, communities, and nations, and this determination is reflected in explicit commitments of political will and substantial financial and intellectual resources. With the emergence of institutions such as the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the exceptional commitments of the G8 nations, and the unprecedented generosity of Bill and Melinda Gates and Warren Buffett, the global health community is finally matching its ambitions to the challenges at hand.
To ensure that health is within reach of everyone requires substantial creativity—doing more of what we have done for years will never produce solutions fast enough or on the scale needed to close the gap between rich and poor. One of the first steps in this process is simply to ask different questions—to stop debating whether to develop new tools or to deploy the ones we have, to stop dwelling on the false choice between “hard” technologies, such as vaccines, and “softer” behavioural interventions. It is time to reframe the debate. Only solutions that creatively integrate the need for new and culturally relevant technologies with stronger systems and substantial behaviour change have a chance of reducing the health inequity between rich and poor countries.
The pace of scientific innovation continues to accelerate. Each year we learn the names of rapidly advancing new approaches—genomics, proteomics, nanotechnology. We often assume that these frontiers of science will benefit only the richer nations of the world—but creative design can harness them to meet the needs of the world’s poorest communities. In fact, resource-poor settings can actually drive innovation, demanding ingenious product designs that are less expensive, are easier to use, and require less infrastructure. It is also sometimes easier to disrupt the technological status quo in the absence of entrenched commercial interests organised around existing products and systems.
The high-tech, high-cost centralised laboratory model that is ubiquitous in more developed countries is of limited use in poorer countries. Where these facilities exist, they serve mainly affluent populations; at the periphery, most health-care services have basic equipment, health-care workers have little training, power and water supplies are tenuous, and capacity is limited for maintaining complex equipment and handling fragile reagents. Design specifications that meet these challenging conditions might ultimately even leapfrog the health technologies available in industrialised regions, where a surfeit of resources means that we sometimes tolerate very expensive and inefficient tools.
Consider, for example, the lab-on-a-card technology that PATH is pursuing with several partners (see margin). This approach uses new developments in microfluidics and nanotechnology to produce multianalyte, point-of-care diagnostics to help identify sexually transmitted infections and manage the care of patients with fever or diarrhoea in poor communities. It is designed to lower costs and curtail the time and infrastructure required to transport specimens and return test results. Such technology could reduce overtreatment (and thus drug resistance); help shorten the duration of illnesses; and, in childhood diarrhoea, combined with responsive treatment improve nutritional status and child development overall. Once fully developed, the technology will have broad application, in rich countries as well as poor.
As more resources become available for global health, product-development partnerships are bringing the innovation capacity of the private sector to bear on some of the thorniest problems of poor countries. Weak supply chains and fragile health systems in resource-poor environments produce unpredictable and unstable markets, discouraging private-sector interests from investing in the research and development needed to produce new technologies for diseases that disproportionately affect the poor. Development of technologies for these markets is simply too expensive and uncertain to attract investment from traditional capital markets. Leadership and resources from governments, civil society, and philanthropy are needed to stimulate action.
Product-development partnerships provide a creative means for industry to participate in solving some of the world’s most important problems—vaccines for malaria and other neglected diseases, new tuberculosis drugs, and specialised diagnostics and delivery devices—while remaining true to its commercial purpose. These partnerships take many forms and typically involve highly creative approaches to management of intellectual property rights, negotiation of affordable access, and shared risk taking. All are based on a core win-win proposition—the public sector supports some (typically not all) of the costs of product development or helps lower some of the risk (eg, by building capacity at clinical trial sites and facilitating regulatory approval), and the private sector commits to manufacturing the products and making them accessible to low-resource markets (eg, through dedicated product supply or preferential pricing). Such partnerships save the public sector money and, importantly, time in championing the development of innovative solutions for resource-poor communities.
Product development depends on user testing to indicate design flaws, suggest refinements, and produce new features. In transferring technology from the industrial world to developing countries, user testing is even more vital, because of the great distance, cultural and otherwise, between designers and users. Industrial-world designers must have feedback from developing-world users to create appropriate technologies. And the unexpected responses of end users are an ideal driver of creativity and ingenuity. An example is the novel “one size fits most” SILCS contraceptive diaphragm (see margin). Designed to eliminate the need for fitting by a specialised clinician, this device went through more than 50 cycles of feedback and refinement. Colour, not at first a design target, turned out to be a key factor in user acceptability, and the result is an unexpected lilac colour that is preferred across cultures and age groups.
Engagement of the ultimate beneficiaries of programmes is equally important for behavioural and health-system innovations, particularly for introduction and scale-up of proven health interventions, such as childhood vaccines, tuberculosis treatment, and insecticide-treated bed nets for malaria prevention. Approaches include engaging “users” as peer facilitators; using innovative communications strategies to help communities reconsider current practices and develop their own culturally relevant solutions; and ensuring local ownership of the design, implementation, and evaluation of health-systems improvements.
Today we have the fattest pipeline of new technological innovation for diseases primarily affecting resource-poor environments that the world has ever seen. Global concern about pandemic disease and bioterrorism has also heightened interest in tools for preventing and treating the infectious diseases that are so common in the developing world. As a result, many product-development partnerships have begun to succeed in advancing robust portfolios of new drugs, diagnostics, vaccines, and medical devices.
This has created a new problem, however: the potential for an innovation pile-up. Recent investments in new technology development have not yet been matched by similar efforts to strengthen health systems in resource-poor settings. The danger is that new innovations will not move smoothly into widespread use, even in places where they are desperately needed, because of weaknesses in health systems, such as shortages of health workers, fragmented or corrupt procurement and supply chains, poor quality assurance, and lack of sustainable financing. Failure to bring new products into use could also become a disincentive for the creative partnerships that drive the development of innovations for the poor.
The solution is not to slow down the engine of technological innovation, but to speed up efforts to strengthen health systems. Such efforts deserve the same energy, intelligence, and resources that we devote to new technological innovation. Even greater creativity will be needed, given the complexity of health systems and their interdependence with a broad range of cross-sector issues—water and sanitation, civil service reform, and health financing policies. Efforts to scale-up malaria prevention and HIV and tuberculosis treatment programmes have depended on close partnerships with local government, effective collaboration between key financing and technical partners, and a strong commitment to monitoring and evaluating both health and economic effects. A broad range of local and national partners must be embraced as we accelerate the search for health-systems innovations that promote replication and scale-up for impact.
We have an unprecedented opportunity to improve the lives of people around the world by harnessing new developments in science and technology to produce creative solutions that are accessible to all people, wherever they live. Achievement of lasting impact will depend on new partnerships—with industry, with people and their communities, and with health systems. The question is no longer “can we do this?” It’s “how soon can we do this?” We have the tools we need at hand. Innovation is the creative spark needed to ensure that health is within reach for everyone.
I thank PATH staff members Bernhard Weigl, Glenn Austin, and Dawn McCarra Bass for their contributions. The lab-on-a-card project has received funding from the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and the Bill & Melinda Gates Foundation; the SILCS contraceptive diaphragm project has been supported by the US Agency for International Development and the Gates Foundation. PATH holds the patent for the SILCS diaphragm. The opinions expressed are those of the author and do not necessarily reflect the views of the US Agency for International Development.