Module 6: Delivery

STAGE 1: Market Assessment

In the global and public health sectors, stakeholders in development (the entities selecting, modifying, and endorsing technologies) are often different from those who buy and those who use the product. In this sense, the market is not subject to typical forces of supply and demand. Among the three entities – “the people who use, the people who choose, and the people who pay the dues” – product valuation assumes different perspectives, affecting decisions and consequences of transactions that define product demand: value in terms of public health impact, procurement costs, and local acceptability over alternatives.(1) Yet other factors may also contribute to product demand or acquisition, including direct donations from the buyer, cost distribution and burden across different segments of the health care system, and sales tactics.

To lay the groundwork for product delivery, stakeholders need to understand the market in which they plan to make their product available. At the minimum, “some measure of the market is needed to convince manufacturing partners to get involved.”(2) However, the challenge with having multiple entities involved in the determination of demand is the disparity between where selection and procurement decisions are made and where products are actually used. Typically, selection and procurement occur at the international or national level, and “local markets can be extremely diffuse and costly to reach, influence, and aggregate into an economically sustainable enterprise.”(3) Despite these obstacles, local agencies are best positioned to influence the uptake of new technologies.

Given the varied levels of programming, the delivery of global health technologies will inevitably require partnerships with commercial companies for innovations to “be converted to a manufacturable product, scaled up, produced efficiently, and distributed to the programs and people in need.”(4) Frequently, these product-development partnerships (PDPs) are between commercial companies and public-sector bodies in order to merge the technical expertise of the private sector with the global health experience of public organizations. PDPs are able to meet market shortcomings, lowering costs and sharing risks such that commercial enterprises (usually driven by profit and the return on investment) have greater incentive to innovate.

Simultaneously, limited market conditions may call for explicit incentives to drive continued technology research and development. Such mechanisms are identified as either “push” or “pull” incentives. Push incentives, such as tax credits or funds for small-business innovation, are intended to reduce costs that can encourage development in early stages. On the other hand, pull incentives create rewards for particular outcomes, much like market conditions that reward production with profit. An example pull mechanism is the priority review voucher, a permit granted for expedited FDA review of products that enable earlier licensure and thus extended market presence for greater revenue.(5)

Although the market for global health technologies may operate with incentivization schemes or specialized coordination, the ultimate objective is to create a suitable market for the introduction of a new technology. A PDP between manufacturers and the public health sector offers a valuable solution to fitting within the unique demands of the market.

Stage 2: Introduction

When conditions are ready for product introduction, existing data from the stages of testing, implementation, and validation according to regulatory bodies can serve as the evidence base to persuade the early adopters and gatekeepers of technology. These groups are the primary “champions of new technology” referenced in Module 4. Interactions with and the exchange of ideas between organizations are part of the process of validating new technology, raising interest, identifying potential collaborators, and justifying behavior change.(6)

Early Adopters

Early adopters typically include the groups previously involved with the input from implementation or clinical trials. As contributors to design, they can “help refine and operationalize the technology, develop training protocols and materials, [and] generate cost-benefit and impact data.”(7) Simultaneously, early adopters are the advocates that will serve as the model practitioners of innovation, demonstrating the benefits critical to market value (discussed in Market Assessment) that will move the technology further along the product pipeline.

Gatekeepers

Alongside early adopters, the support of normative organizations in global health is also critical in technology introduction. These gatekeepers of innovation determine the guidelines for best practices and protocols of use. The most renowned of these bodies is the World Health Organization, which serves to review and make recommendations for a broad scope of essential drugs, technologies, and programs. Endorsement from the WHO is vital to the success of an innovation in countries that require increased confidence prior to purchase and distribution.

Stage 3: Mainstream Dissemination

Following introduction, the dissemination of innovation is reported to occur by the S-curve model. In this model, the Innovators, comprising 3% of the population, are typically the first to absorb technology. They “are willing to take risks, but are not usually influential” in garnering subsequent followers. Nevertheless, during this stage, innovators are observed by the Early Adopters, who include 12% of the population and are more likely to convince other potential consumers due to increased volume. From the Early Adopters, uptake increases rapidly. The next 35% of the population are the Early Majority, usually more dependent on scientific data than on personal anecdotes. Another 35% known as the Late Majority will “only take up an innovation when it appears to have become standard practice and has been taken up by local early-majority practitioners.” Finally, the last 15% of the population tends to resist innovation until forced by new policy.(8)

In the global health technology industry, the typical dissemination model is complicated by the presence of the three different stakeholders: gatekeepers, donors/purchasers, and product users. Each group has its distribution of consumers who must be considered in the context of their own environments and influence. One consistency among the groups, however, is that the progression from Early Adopters to Early and Late Majority users is called the mainstreaming process. Regardless of the group, mainstreaming requires recruiting new, practical advocates of technology, creating new demand and reducing room for uncertainty at the level of implementation (not merely creating policies at the normative level).

In this activity of mainstreaming, field demonstrations to promote local practice and shared experiences between program leaders will help enhance ownership of new technology. In the process of expanding ownership, innovators must be prepared to accept adaptations to technology protocols or policy guidelines, as innovation gathers support among different groups.

Stage 4: International Technology Transfer

Technology can be viewed as the intersection of science and commerce – how science is applied and how commerce develops those applications.(9) As such, technology transfer refers to the movement of technological knowledge (designs, products, training, or tacit knowledge) between organizations, primarily from science to commerce.

However, in the global health field, where technologies are subject to international standards and exchange, it is necessary to distinguish between horizontal and vertical forms of transfer. Horizontal technology transfer is “the movement of an established technology from one operational environment to another,” while vertical technology transfer is “the transmission of new technologies from their generation during research and development activities…to application in the industrial and agricultural sectors.”(10) The dissemination of new technologies to different countries is considered horizontal transfer. When developing countries gain access to new health technologies, there is potential to stimulate technological and economic development with the introduction of novel methods of care. However, if there is little attention paid to the “absorptive capacity and domestic technological learning” of the newest technology recipients, the acquisition and mastery of new products will be more costly and time-consuming than expected.

The limitations to direct international technology (horizontal) transfer involve the need for local adaptation of technology to the particular requirements of the local setting. Despite the potential for universal adaptability, technologies are not “ready-to-use commodities,” as they often involve specialized components or training for implementation.(11) Attention is rarely given to the “absorptive capacities” or “processes of assimilating imported technologies and putting them to work efficiently.” In the course of technology delivery, it is important to consider not only whether the design is appropriate to the setting, but also if the setting is appropriate for the introduction of innovation. Policy and regulatory frameworks often impede smooth international access, and technology transfer becomes a matter of delineating negotiations between multilateral, bilateral, and regional levels of entry.

Footnotes

(1) Free, M. “Achieving appropriate design and widespread use of health care technologies in the developing world.”International Journal of Gynecology and Obstetrics. 85.1(2004): S3-S13.

(2) Ibid.

(3) Ibid.

(4) Ibid.

(5) Elias, C. “Policies and Practices to Advance Global Health Technologies.” A Report of the CSIS Global Health Policy Center. Center for Strategic and International Studies. April 2009.

(6) Free, M. “Achieving appropriate design and widespread use of health care technologies in the developing world.”International Journal of Gynecology and Obstetrics. 85.1(2004): S3-S13.

(7) Ibid.

(8) Ibid.

(9) Rice Office of Technology Transfer. https://ott.rice.edu/.

(10) “What is technology transfer?” World Association for Christian Communication. https://waccglobal.org/.

(11) Ibid.