Course 4: Health Technology in Resource-Poor Settings

Introduction

• Given the vast inequities in disease burden between developed and developing countries, donors, advocates, and researchers are marshalling resources to accelerate the production of new health technologies that may help to bridge this gap.

  “Improving the health of the poorest people in the developing world depends on the development of many varieties of health innovations, such as new drugs, vaccines, devices, and diagnostic tools, as well as new techniques in process engineering and manufacturing, management approaches, software, and policies in health systems and services.”(1)

  However, developing countries are able to undertake health innovation to different degrees.  In developing countries, researchers and innovators face tremendous challenges, including the lack of technical training, research tools, financial resources, and up-to-date scientific information.  These barriers impede activists from developing and implementing innovative and low cost technologies.
  One such health technology that has the potential to save and improve lives is the disposable needle.  Increasing numbers of people in developing countries are getting the vaccinations that they need to protect their health, but clean needle practices have not caught up.  At least 50 % of injections in developing countries are unsafe, and in some places that number is as high as 70 %.(2)

  Reused needles can increase the risk of HIV, hepatitis B, and other infections.  “In addition, when dirty needles are not safely disposed of, people harvest them from the garbage and resell them, and children even play with them in garbage dumps.”(3)  Vaccinations are meant as a preventive measure to ensure good health, yet when they are administered with unsanitary syringes, patients may actually be harmed.  The nonprofit organization PATH has developed technologies for safe needle disposal and worked with countries to get the supplies they need to make injections safe. They have invented “auto-disposable,” one-time-use syringes and helped pioneer needle removal devices that isolate dirty needles in secure containers.  Simple low-cost technology such as this has the potential to disseminate rapidly across the developing world, saving millions of lives.

  Diagnostic Technologies

  Oftentimes in resource-poor settings, health care personnel do not have adequate technology to diagnose patients.  Facilities in developing countries frequently lack access to the highly advanced laboratories that produce reliable diagnoses in wealthy countries.  Furthermore, health care facilities can be far away, serving widely dispersed populations.  A lack of quality equipment can undermine the entire health care system. If health workers cannot correctly diagnose a disease, they are unable to treat it effectively. Without diagnostic testing, health care professionals are forced to rely on evaluating symptoms to diagnose and treat illness—an imperfect method. This lack of clarity puts individuals, communities, and the world in danger.  Incorrect diagnoses can harm people and even cost lives. Furthermore, ineffectively treated disease can become a starting point for epidemics and contribute to the development of drug- resistant parasites.

  Fortunately, there are promising new tests—inexpensive, portable, easy-to-use diagnostics that are practical at even small, local health centers.  Some of these tests are adaptations of established technologies.  Others are innovative scientific advances. One such promise lies in modified molecular technologies for affordable, simple diagnosis of infectious diseases.  Early and accurate diagnosis of infectious disease is important not only for prompt treatment, but also to limit the spread of disease and avoid the waste of resources on ineffective treatments.  Molecular diagnostic technologies that are either already in use or are being tested in low-income regions include the polymerase chain reaction (PCR)(4), monoclonal antibodies,(5) and recombinant antigens.(6)

  Telemedicine

  The problem of diagnostics is accentuated by a lack of health personnel in developing countries, particularly in rural settings.  Not only is there a lack of appropriate diagnostic tools, there is a shortage of health workers who are able to use this technology.  In order to address this problem, telemedicine, has gained much attention. Telemedicine can be broadly defined “as the use of telecommunications technologies to provide medical information and services.”  Although this definition includes medical uses of the telephone, email, and distance education, telemedicine is increasingly being used as shorthand for remote electronic clinical consultation.(7)

  Telemedicine seeks to deliver the best medical advice and treatment options to patients irrespective of their location.  Telemedicine’s major constraints include the access to and cost of the higher bandwidth that is required for transmitting physiological data and complex medical images. These constraints are more severe in developing countries where even telephone-line-based access is limited and broadband access is either not available or is far too expensive.

  The promise of telemedicine is also limited by a number of features which are common to most poor developing countries. These include large gaps in basic infrastructure availability, and the ability and willingness of health workers and others to make use of the opportunities.  The constraints suggest that, rather than helping to improve health care delivery, telemedicine could generate a new "digital divide” that creates further disparities in health.   Additionally, the rapid changes in technology can result in an inability to continue to use the technologies.(8)

  Case Study: One Laptop per Child  

  At the world Economic Forum in January 2005, MIT professor Nicholas Negroponte unveiled the idea of One Laptop Per Child (OLPC), a $100 PC that would transform education for the world's disadvantaged schoolchildren by giving them the means to teach themselves and each other. The project's goal is "to provide children around the world with new opportunities to explore, experiment and express themselves."(9)  OLPC dedicated a great deal of effort to designing a laptop that would function well in a developing-country environment.  Their laptop, the XO, is sealed to keep out dirt, has a display that can be read in bright sunlight, runs on low power, and is rugged.

  Despite its considerable innovation, the OLPC project has been unable to achieve its $100 targeted cost. The current cost of each unit is listed on the OLPC Website as $199.  However, this does not include upfront deployment costs, which are said to add an additional 5%–10% to the cost of each machine, and subsequent IT-management costs.(10)  Nor does it include the cost of teacher training, additional software, and ongoing maintenance and support.  These costs are difficult for governments to justify in developing countries.  Additionally, OLPC originally estimated that it would ship 100–150 million XO laptops by the end of 2007, but the program has clearly fallen far short. Under more modest goals, production was supposed to reach five million laptops by the end of 2008.(11)  As of December 2009, there were just over 1.4 million XOs in the field.(12)

  While these output statistics are available, there have been few studies that have measured outcomes, or the project’s impact on targeted communities.  Several commentaries have questioned the project's potential for impact, pointing to its guiding assumption that more laptops per child equates to educational progress.  Many have also questioned the common view known as technological determinism –that a given technology will lead to the same outcome, no matter where it is introduced, how it is introduced, or when.  One study on the project’s outcomes points to several lessons that must be considered when introducing a new technology:(13)

  • Diffusing a new innovation requires an understanding of the local environment. Social, economic, and cultural environments vary greatly across and even within countries, and deploying new technologies requires understanding these environments. Innovators must consider the need for expertise in sociology, anthropology, public policy, and economics, as well as for engineers, and establish coherent criteria for selecting countries to target based on social, economic, and cultural realities.(14)

  • Innovative technology can be disruptive and trigger a backlash from incumbents. In some cases, teachers and the educational establishment have resisted the OLPC innovation as it requires a significant change in pedagogy that might reduce teacher status.

  • Innovative information technologies do not stand alone. OLPC laptops were not part of any established business ecology and the program lacked resources to establish its own ecology.

  Best Practices of Technology Design, Implementation, and Evaluation

  When designing and implementing new health technology in the developing world, it is important to ascribe to best practices in order for products to be successful and ethical.   Important factors to consider include:

  • Impact:  How much difference will the technology make in improving health?

  • Appropriateness: Will the intervention be affordable, robust and adjustable to health care settings in developing countries, and will it be socially, culturally and politically acceptable?

  • Burden: Will this technology address the most pressing health needs?

  • Feasibility: Can it realistically be developed and deployed in a time frame of 5–10 years?

  • Knowledge gap: Does the technology advance health by creating new knowledge?

  • Indirect benefits: Does it address issues such as environmental improvement and income generation that have indirect, positive effects on health? (15)

  A recent study of health biotechnology in developing countries found that local public-private partnerships, sustained government support for research, and the availability of venture capital were important factors in the ability of an innovative technology to meet national health needs.(16)  Given that most of the infrastructure for health research in developing countries resides in the public sector, partnerships between local public and private research organizations deserve particular attention.(17)  In other words, in order for a health technology to be appropriate, feasible, and driven by public health goals, it should be designed in coordination with the public sector.(18)  Furthermore, C. K. Prahalad points out in The Fortune at the Bottom of the Pyramid that some manufacturers in developing countries pursue a business model in which they specialize in high-volume, low-margin production, which leads to low-cost products.  Products produced in this way may be more affordable, an important factor in access to medicines in developing countries.

  An Appropriate Balance

  There is no doubt that technology holds much promise for improving health in developing countries. This truth, however, should in no way diminish the importance of proven health strategies. Health education, for instance, is integral to the control of the AIDS pandemic, as is the provision of condoms.  In addition, improvements in sanitation can substantially reduce the prevalence of infectious diseases, and basic nutritional education can help prevent nutrient deficiencies. These tools are available now, whereas promising biotechnologies are at varying stages of development. We ought to strive to achieve an appropriate balance between investment in new technologies and in conventional strategies.

  Oftentimes, hype regarding technology can distract from global concerns.  For example, the One Laptop Per Child initiative has the potential to distract from traditional education efforts.  An additional technology, self-adjusting eyeglasses, allows patients to be in full control of their prescription, and to change the power of their glasses at will.  As Joshua Silver, designer of the self-adjusting lenses, told CNN:

  "Any model of delivery of vision correction in the developing world that depends on eye care professionals won't work. If you find a model that doesn't rely on them, then you potentially have a solution.” (19)

  While this concept may seem promising, it must be remembered that glasses are medical products, and comprehensive eye exams and treatment by medical professionals must be promoted and provided.  When glasses are dispensed as consumer products, it creates more substantial barriers to care while also promoting a false and commonly-held belief that eyeglasses are fashion accessories.  For example, when receiving glasses from a local community member, it can be impossible for a village patient to understand that receiving glasses does not constitute a complete eye exam by an eye care professional. 

  When patients seek eye care from local community members who represent themselves as "trained" eyeglass providers, but are not offered proper examination, diagnosis, and treatment for treatable conditions such as cataracts, they may begin to believe that there is nothing that can be done for their eye condition. Thus, trained local community members must be integrated into a local eye clinic's ongoing outreach programs by eye care professionals at the same location.  The primary role of the community members should be to help reduce barriers to patient care, and their close involvement with local eye clinics can be highly beneficial to the patients.  

  In conclusion, self-adjusting glasses distract from global eye care needs and perpetuate the misconception that all eye diseases can be corrected by eyeglasses.  Resources spent on distributing self-adjusting glasses can be better spent on human and financial resources to provide comprehensive examinations by eye care professionals.  Technology is needed to facilitate global health delivery, yet at the same time, it should not seek to replace proven interventions. 

Footnotes

(1) C.M. Morel et al., Health Innovation in Developing Countries to Address Diseases of the Poor, Innovation Strategy Today, 1, 2005, p.1-15.

(2) Path.org Accessed 19 January 2010.

(3) Ibid.

(4) Harris, E. A Low Cost Approach to PCR:Appropriate Technology Transfer of Biomolecular Techniques (ed. Kadir, N.) (Oxford Univ. Press, New York, 1998).

(5) Palmer, C.J. et al. Evaluation of the OptiMAL test for rapid diagnosis of Plasmodium vivax and Plasmodium falciparum malaria. J. Clin. Microbiol. 36, 203–206 (1998). 

(6) Aidoo, S. et al. Suitability of a rapid immunochromatographic test for detection of antibodies to human immunodeficiency virus in Ghana, West Africa. J. Clin. Microbiol. 39, 2572–2575 (2001).

(7) Peredinia DA, Allen AA. Telemedicine technology and clinical applications. JAMA 1995; 273: 483-488.

(8) Chandrasekhar C P, Ghosh J. Information and communication technologies and health in low income countries: the potential and the constraints. Bull World Health Organ. 2001;79(9):850–5.

(9) One Laptop Per Child. Accessed 19 January 2010.

(10) Stecklow, S. and Bandler, J. A little laptop with big ambitions. WallStreetJournal.com (Nov. 24, 2007.)

(11) O'Donnell, B. Worldwide Mini-Notebook PC 2008–2012 Forecast Update and 3Q08 Vendor Shares. Market Analysis. IDC, Framingham, MA, Dec. 2008.

(12) One Laptop Per Child. Accessed 19 January 2010.

(13) Adapted from http://delivery.acm.org/10.1145/1520000/1516063/p66-karemer.html?key1=1516063&key2=0894753621&coll=GUIDE&dl=GUIDE&CFID=73045704&CFTOKEN=69861373.

(14) Rogers, E.M. Diffusion of Innovations, Fifth Edition. Free Press, New York, 1995.

(15) Daar, A. S., H. Thorsteinsdottir, D. K. Martin, A. C. Smith, S. Nast, and P. A. Singer. 2002. Top ten biotechnologies for improving health in developing countries. Nat. Genet. 32:229-232.

(16)Nat. Biotechnol. Suppl. 22 (125), (2004).

(17) Global Forum for Health Research, Monitoring Financial Flows for Health Research, Vol. 2 (Global Forum for Health Research, Geneva, 2004), pp. 14–15.

(18) R. Saha et al., IP Strategy Today 9, 23 (2004).

(19) Tutton, Mark. "Liquid specs a bold vision for world's poor." Vital Signs. CNN.com 16 Sept 2009. Accessed 19 January 2010.