Thomas J. Bollyky, June 2015,
This publication is made possible by the generous support of the Robert Wood Johnson Foundation.
R E V E R S E I N N O V A T I O N , I N F O R M A T I O N – C O M M U N I C A T I O N T E C H – N O L O G Y , A N D P E E R – S U P P O R T N E T W O R K S
Two areas are particularly promising for frugal and reverse innovation for NCDs in lower- and higher-income countries alike: information-communication technology (ICT)-enabled health care and patient-care management and support networks that use community health workers, peer-to-peer, or self-management strategies. In many settings, innovations in these areas will be used in combination. ICT-enabled health care is the use of mobile phones, telephone networks, video conferencing, cloud computing, and other Internet and communication technologies to provide needed health services. For instance, the American Society for Clinical Pathology is working with Partners in Health, the Institute for Health Metrics and Evaluation, and other partners to provide cancer pathology services in African countries via a cloud-based network of pathologist volunteers and a web-based link to conventional computers or cell phones in those countries. Such ICT-enabled health-care programs have the potential to achieve all three of the primary goals of health care: improved quality of care, increased access, and reduced cost. By remotely linking physicians directly to patients or through less-skilled health workers, patient access to high-quality health-care services can increase dramatically, especially in rural settings and for services that require a specialist. In turn, reducing the need for travel, in-patient visits, and brick-and-mortar facilities reduces health-care costs. Centralized, ICT-enabled health care allows for greater standardization and use of common protocols, which lowers costs and can improve patient outcomes. One reason ICT-enabled health care and patient management networks are promising areas for reverse and frugal innovation is that the underlying infrastructure and equipment already exists in wealthy and poor countries alike. Mobile phones are nearly ubiquitous globally. In settings where patients lack reliable Internet access and smartphones, community health workers, nurses, or volunteers may be equipped with them. The regulatory, accreditation, and licensing barriers to the use of ICT-enabled health care exist in high-income countries, but are proving navigable. It helps that the concept of telemedicine, or the remote provision of medical care by means of audiovisual technology, is not new. It has been used to provide radiological and pathology services for more than thirty years.25 In 2012, nearly half of U.S. hospitals reported having active telemedicine programs in fields as diverse as dermatology, neurology, and intensive care.26 ICT has been a particularly important enabler in the emerging economies of Brazil, India, and South Africa, and companies are beginning to extend their programs internationally. Clickmedix, a U.S. company supported by a partnership of medical schools, multinational companies, and NGOs, is launching smartphone-based health-care services. These services have been piloted in fifteen countries ranging across the development spectrum from Bangladesh, Peru, and Uganda to China, Taiwan, and the United States, reaching more than seven hundred thousand patients.27 13 Care for chronic conditions invariably involves patients managing their own day-to-day care. This is especially challenging for patients with multiple NCDs, which is often the case in many highincome countries. Networks to support and involve patients in their chronic care have gained currency in both high- and low-income countries. These networks may involve community health workers, peer patients, or education-support self-management. Community health-worker programs have long been used successfully to extend and monitor chronic care among vulnerable populations. Partners in Health used this strategy to provide chronic care for HIV/AIDS and drug-resistant tuberculosis in shantytowns in Haiti and in the highlands of Peru.28 The Department of Public Health for King County and Seattle has used this model to support vulnerable patients with type 2 diabetes.29 Peer networks, which link patients to volunteers with the same condition, were used extensively in international programs on HIV/AIDS, but are increasingly being used for diabetes management.30 Education-supported patient self-management programs have existed for more than a decade in the United States, but are being adapted to support chronic care in low-resource settings in developing countries.31 For example, an asthma self-management program in Tonga has demonstrated promising early results. 32