Ian Noble Essay Prize winner – Lisa Amani

Posted on Posted in Undergraduate

Ian Noble

Technology in healthcare: How can we best meet the population’s needs

by Lisa Amani

Our needs as a population are changing, and have been for a long time as we continue to advance in our abilities to tackle our health challenges(1,2). But as we tackle existing health problems, and progress beyond health matters, e.g. quicker access to information through the internet, we inevitably seem to introduce novel and bigger challenges. For example, improvements in healthcare provision through the introduction of new drugs, vaccines and improved access has resulted in people living longer and being less likely to die from communicable diseases such as diarrhoea and respiratory tract infections(1,2). However, this demographic and epidemiological transition has in turn left us with an ageing population with a large burden of chronic and disabling diseases such as dementia and chronic heart disease(1,2).

Technology has been at the centre of meeting our health care needs. From the introduction of preventative measures such as vaccines, that led to the eradication of smallpox(3), to the more curative methods such as surgical resection of a brain tumour. I believe technology to once again play a significant part in addressing our new global health challenges. In this essay, a broader definition of health technology is used, i.e. “all methods used by health-care professionals to promote health, to prevent and treat disease, and to improve rehabilitation and long-term care”(4), to highlight the range of functions that technology has in healthcare. I aim to discuss the ways in which we can use technology to meet population’s needs. The exact ways that our needs can be met using technology will not be done extensively as this is beyond the scope of this essay.

The need for innovation
In the United Kingdom, the National Health Service depends heavily on providing healthcare using technology. In 2014, our government spent over £142bn on healthcare alone(5). A significant portion of this was invested in preventative measures such as vaccines, diagnostic devices such as the urine dipstick test, and curative medical and surgical procedures(6).

The NHS believes strongly in providing healthcare free of charge to everyone. This means that we can essentially care for even the most vulnerable in our population. However, as we are facing healthcare challenges increasingly, including microbial resistance and the ageing population, the need for innovation grows. This becomes more imperative given the lack of NHS funding and debts previously reported, as Chris Hopson, the chief executive of NHS Providers, said “the combination of increasing demand and the longest and deepest financial squeeze in NHS history is maxing out the health service”(7). Through addressing health technology innovation, we could essentially enhance the productivity of our services whilst indirectly targeting other vital aspects that make up the healthcare system, including our work force and finances. One way this can be achieved is through reverse innovation.

Reverse innovation
Reverse innovation is ‘a product or service that is developed in a resource-poor setting and then exported to more industrialised nations’(8). These services essentially attempt to meet the needs of populations at very low costs. The West has contributed greatly to the field of innovation, from electrocardiograms to life-saving antibiotics such as penicillin(9). Because of this, it is now commonly thought that innovation is a product of Northern efforts, which is then taken up by the South. However, given the on-going financial struggles of the NHS, we appear to be the ones in need of help. We may now need to look globally at other healthcare systems for a solution.

The Aravind Eye Care System in India, for example, has the best patient outcomes globally at the lowest cost per individual(8). They perform over 350,000 eye procedures every year using a standard checklist strategy adopted from McDonald’s, meaning variations in healthcare are minimised in (e.g.) provider’s costs, resulting in enhanced efficiency. This model of care delivery relies on task shifting, which involves the delegation of responsibilities performed by doctors, such as peri-operative assessments, to other professionals. Within the NHS(8), and other western healthcare systems, doctors complain they are time-restricted, which is bound to become a greater issue given the continuous growth in our population. Adopting their standardised way of healthcare delivery could be the way to address this common western problem.

The NHS spends more money every year. In 2014 alone, £30.6bn was spent on research and development in the UK(6). Therefore, clearly the problem does not lie at the lack of funding to develop better ways of providing healthcare. Throwing in more money does not equal better research outcomes. Though investing in technology is important as it drastically improves health outcomes, a need arises for more efficient spending.

The global South has a reduced financial ability to afford the drugs they need. Life-saving human immunovirus (HIV) drugs were initially being sold at $14 000 per person per year by multinational companies(10). This meant that developing nations were struggling to gain access to antiretrovirals. In 2001, Yusuf Hamied, a drug manufacturer at CIPLA (India), produced HIV drugs costing just $1 a day. This breakthrough transformed HIV from a death sentence to a manageable disease in developing countries. Though patents play an important role in driving innovation, with the increasing health demands faced in the West it may become imminent for us to revise the patency agreement, as at some point the high costs of drugs will mean a high number of lives are compromised due to our inability to fund healthcare to all. Adopting generic drugs worldwide for the more prevalent and/or dangerous illnesses could perhaps become an exception to this patency agreement.

It is not just drugs that low-income countries struggle to access. There is a big gap between where health technology is available and where the need for it is greatest(11). Most technological health advances are widely used in developed countries, but some low-income countries do not have access to the most essential healthcare technologies. Meeting ‘our population’s’ needs should extend beyond the geographical barriers that separate nations, which is why we need to invest in frugal technology.

Frugal technology
Frugal technology is ‘technology that is specifically developed to meet the needs of the world’s poorest people’. Howitt et al(11) argues that technology tends to be produced for the wealthier populations, meaning that these technologies can fail to reflect the needs of developing countries. The latter countries have reduced finances, poor infrastructure and insufficient healthcare workers. Consequently, a significant 40% of the technology deployed here is not used (versus <1% in higher income countries). Thus, Howitt et al argues strongly that we must invest in frugal technologies instead, as this will more accurately meet the needs of developing nations. One example of such an invention is the mobile phone microscope (MPM)(12). Microscopes are an important tool in the diagnosis of some diseases. However, their price and the fact that electricity can be patchy in some developing countries, means they may not be available nor operable. MPM’s are battery-powered and are low-cost, making them ideal for use in low-income settings. One study(13) looked at the use of two different MPM’s in Ghana to diagnose infection with Schistosoma haematobium. Despite high specificities (>90%, compared to light microscopy), their sensitivities were unsatisfactory (circa 55% and 68% respectively), which the author put partially down to tool manipulation difficulties. Hence, the actual cost-effectiveness of this device, and perhaps others, remains questionable. Additionally, frugal technology in general has been criticised for compromising patient safety based on its minimalistic nature(14). Thus, more research is needed to determine how useful these devices are. Nevertheless, for many populations these sub-optimal tools might be their only way forward in achieving better health outcomes, and it therefore becomes necessary for wealthier countries to invest in frugal technology so that the needs of all populations can be addressed.

Conclusion
As the world population increases, and our resources start to run lower, the need for innovation heightens. In the high-income countries, reverse innovation may be key to addressing the financial, workforce and time restrictions – from task shifting to the development of more affordable drugs. In developing countries, due to their reduced financial and structural capacity to perform research and development, it is important we take the responsibility to fund frugal technology and its innovation, or at least provide countries with the means to do so themselves, e.g. through subsidies or research training.

The sole availability of technology is not sufficient to meet population’s needs. Once it has been produced it has to be accessible, financially and physically, and actually operable within the healthcare setting. Frugal technology is thus perhaps the best way forward in developing countries.

Finally, the criticisms of frugal technology should not be dismissed. Perhaps one solution is to combine both forms of innovations, with both high- and low-income countries working together to ensure the health technology produced is not just effective, but also affordable and safe to use.

 

References  

  1. Hay, S I et al. Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet [internet]. 2017 September 16 (cited 10 November 2017); 30(10100):1260-1344. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32130-X/fulltext
  2. Naghavi, M et al. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet [internet]. 2017 September 16 (cited 10 November 2017); 390(10100):1151-1210. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32152-9/fulltext
  3. World Health Organisation. Smallpox vaccines. [internet]. (cited 10 November 2017). Available from: http://www.who.int/csr/disease/smallpox/vaccines/en/
  4. R, D P B. Health-technology assessment in surgery. Surgery [internet]. 1999 April (cited 10 November 2017); 353(supplement 1):S2-S5. Available from: https://www.sciencedirect.com/science/article/pii/S0140673699904130
  5. Office for National Statistics. Statistical bulletin: UK health accounts: 2014. [internet]. (cited 10 November 2017). Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ukhealthaccounts/2014
  6. Office for National Statistics. Statistical bulletin: UK Gross domestic expenditure on research and development:2014. [internet]. (cited 10 November 2017). Available from: goo.gl/Rk4zEJ 
  7. Campbell, D. the guardian. [internet]. 2016 May. Available from: http://www.citethemrightonline.com/digital-internet/the-internet/web-pages-with-individual-authors
  8. Ahmed, F et al. Can reverse innovation catalyse better value health care? Lancet [internet]. 2017 October (cited 10 November 2017); 5(10):e967-e968. Available from: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30324-8/fulltext
  9. Prabhjot, S and Chokshi, D A. Community health workers: an opportunity for reverse innovation – Authors’ reply. Lancet [internet]. 2013 October (cited 10 November 2017); 382(9901):1327. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62136-4/abstract
  10. Lane, R. Yusuf Hamied: leader in the Indian generic drug industry. Lancet [internet]. 2015 December (cited 10 November 2017); 386(10011):2385. Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00839-9/fulltext
  11. Howitt, P et al. Technologies for global health. Lancet [internet]. 2012 August (cited 10 November 2017); 380(9840):507-535. Available from: https://www.sciencedirect.com/science/article/pii/S0140673612611271
  12. Bogoch, I I et al. Mobile phone and handheld microscopes for public health applications. Lancet [internet]. 2017 August (cited 10 November 2017); 2(8):e355. Available from: http://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30120-2/fulltext
  13. Ephraim, R K D et al. Diagnosis of Schistosoma haematobiumInfection with a Mobile Phone-Mounted Foldscope and a Reversed-Lens CellScope in Ghana. Lancet [internet]. 2015 June (cited 10 November 2017); 92(6):1253-1256. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458833/
  14. Finlayson, A E T. Correspondence to the article by Howitt et al (2012) ‘Technologies for global health’. (see reference number 11 above). Lancet [internet]. 2012 November (cited 10 November 2017); 380:1739. Available from: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)61988-6.pdf

Lisa Amani is a fourth year medical student at the University of St. Georges

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