Criteria to assess potential reverse innovations: opportunities for shared learning between high- and low-income countries.

BACKGROUND: Low- and middle-income countries (LMICs) are developing novel approaches to healthcare that may be relevant to high-income countries (HICs). These include products, services, organizational processes, or policies that improve access, cost, or efficiency of healthcare. However, given the challenge of replication, it is difficult to identify innovations that could be successfully adapted to high-income settings. We present a set of criteria for evaluating the potential impact of LMIC innovations in HIC settings. METHODS: An initial framework was drafted based on a literature review, and revised iteratively by applying it to LMIC examples from the Center for Health Market Innovations (CHMI) program database. The resulting criteria were then reviewed using a modified Delphi process by the Reverse Innovation Working Group, consisting of 31 experts in medicine, engineering, management and political science, as well as representatives from industry and government, all with an expressed interest in reverse innovation. RESULTS: The resulting 8 criteria are divided into two steps with a simple scoring system. First, innovations are assessed according to their success within the LMIC context according to metrics of improving accessibility, cost-effectiveness, scalability, and overall effectiveness. Next, they are scored for their potential for spread to HICs, according to their ability to address an HIC healthcare challenge, compatibility with infrastructure and regulatory requirements, degree of novelty, and degree of current collaboration with HICs. We use examples to illustrate where programs which appear initially promising may be unlikely to succeed in a HIC setting due to feasibility concerns. CONCLUSIONS: This study presents a framework for identifying reverse innovations that may be useful to policymakers and funding agencies interested in identifying novel approaches to addressing cost and access to care in HICs. We solicited expert feedback and consensus on an empirically-derived set of criteria to create a practical tool for funders that can be used directly and tested prospectively using current databases of LMIC programs.

A pragmatic randomized control trial and realist evaluation on the implementation and effectiveness of an internet application to support self-management among individuals seeking specialized mental health care: a study protocol.

BACKGROUND: Mental illness is a substantial and rising contributor to the global burden of disease. Access to and utilization of mental health care, however, is limited by structural barriers such as specialist availability, time, out-of-pocket costs, and attitudinal barriers including stigma. Innovative solutions like virtual care are rapidly entering the health care domain. The advancement and adoption of virtual care for mental health, however, often occurs in the absence of rigorous evaluation and adequate planning for sustainability and spread. METHODS: A pragmatic randomized controlled trial with a nested comparative effectiveness arm, and concurrent realist process evaluation to examine acceptability, effectiveness, and cost-effectiveness of the Big White Wall (BWW) online platform for mental health self-management and peer support among individuals aged 16 and older who are accessing mental health services in Ontario, Canada. Participants will be randomized to 3 months of BWW or treatment as usual. At the end of the 3 months, participants in the intervention group will have the opportunity to opt-in to an intervention extension arm. Those who opt-in will be randomized to receive an additional 3 months of BWW or no additional intervention. The primary outcome is recovery at 3 months as measured by the Recovery Assessment Scale-revised (RAS-r). Secondary outcomes include symptoms of depression and anxiety measured with the Personal Health Questionnaire-9 item (PHQ-9) and the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7) respectively, quality of life measured with the EQ-5D-5L, and community integration assessed with the Community Integration Questionnaire. Cost-effectiveness evaluations will account for the cost of the intervention and direct health care costs. Qualitative interviews with participants and stakeholders will be conducted throughout. DISCUSSION: Understanding the impact of virtual strategies, such as BWW, on patient outcomes and experience, and health system costs is essential for informing whether and how health system decision-makers can support these strategies system-wide. This requires clear evidence of effectiveness and an understanding of how the intervention works, for whom, and under what circumstances. This study will produce such effectiveness data for BWW, while simultaneously exploring the characteristics and experiences of users for whom this and similar online interventions could be helpful. TRIAL REGISTRATION: Clinicaltrials.gov NCT02896894 . Registered on 31 August 2016 (retrospectively registered).

Assessing health program performance in low- and middle-income countries: building a feasible, credible, and comprehensive framework.

BACKGROUND: Many health service delivery models are adapting health services to meet rising demand and evolving health burdens in low- and middle-income countries. While innovative private sector models provide potential benefits to health care delivery, the evidence base on the characteristics and impact of such approaches is limited. We have developed a performance measurement framework that provides credible (relevant aspects of performance), feasible (available data), and comparable (across different organizations) metrics that can be obtained for private health services organizations that operate in resource-constrained settings. METHODS: We synthesized existing frameworks to define credible measures. We then examined a purposive sample of 80 health organizations from the Center for Health Market Innovations (CHMI) database (healthmarketinnovations.org) to identify what the organizations reported about their programs (to determine feasibility of measurement) and what elements could be compared across the sample. RESULTS: The resulting measurement framework includes fourteen subgroups within three categories of health status, health access, and operations/delivery. CONCLUSIONS: The emphasis on credible, feasible, and comparable measures in the framework can assist funders, program managers, and researchers to support, manage, and evaluate the most promising strategies to improve access to effective health services. Although some of the criteria that the literature views as important - particularly population coverage, pro-poor targeting, and health outcomes - are less frequently reported, the overall comparison provides useful insights.

An international comparative public health analysis of sex trafficking of women and girls in eight cities: achieving a more effective health sector response.

Sex trafficking, trafficking for the purpose of forced sexual exploitation, is a widespread form of human trafficking that occurs in all regions of the world, affects mostly women and girls, and has far-reaching health implications. Studies suggest that up to 50 % of sex trafficking victims in the USA seek medical attention while in their trafficking situation, yet it is unclear how the healthcare system responds to the needs of victims of sex trafficking. To understand the intersection of sex trafficking and public health, we performed in-depth qualitative interviews among 277 antitrafficking stakeholders across eight metropolitan areas in five countries to examine the local context of sex trafficking. We sought to gain a new perspective on this form of gender-based violence from those who have a unique vantage point and intimate knowledge of push-and-pull factors, victim health needs, current available resources and practices in the health system, and barriers to care. Through comparative analysis across these contexts, we found that multiple sociocultural and economic factors facilitate sex trafficking, including child sexual abuse, the objectification of women and girls, and lack of income. Although there are numerous physical and psychological health problems associated with sex trafficking, health services for victims are patchy and poorly coordinated, particularly in the realm of mental health. Various factors function as barriers to a greater health response, including low awareness of sex trafficking and attitudinal biases among health workers. A more comprehensive and coordinated health system response to sex trafficking may help alleviate its devastating effects on vulnerable women and girls. There are numerous opportunities for local health systems to engage in antitrafficking efforts while partnering across sectors with relevant stakeholders.

Emergence of biopharmaceutical innovators in China, India, Brazil, and South Africa as global competitors and collaborators.

Biopharmaceutical innovation has had a profound health and economic impact globally. Developed countries have traditionally been the source of most innovations as well as the destination for the resulting economic and health benefits. As a result, most prior research on this sector has focused on developed countries. This paper seeks to fill the gap in research on emerging markets by analyzing factors that influence innovative activity in the indigenous biopharmaceutical sectors of China, India, Brazil, and South Africa. Using qualitative research methodologies, this paper a) shows how biopharmaceutical innovation is taking place within the entrepreneurial sectors of these emerging markets, b) identifies common challenges that indigenous entrepreneurs face, c) highlights the key role played by the state, and d) reveals that the transition to innovation by companies in the emerging markets is characterized by increased global integration. It suggests that biopharmaceutical innovators in emerging markets are capitalizing on opportunities to participate in the drug development value chain and thus developing capabilities and relationships for competing globally both with and against established companies headquartered in developed countries.

Governing partnerships with technology companies as part of the COVID-19 response in Canada: A qualitative case study.

Cross-sector partnerships are vital for maintaining resilient health systems; however, few studies have sought to empirically assess the barriers and enablers of effective and responsible partnerships during public health emergencies. Through a qualitative, multiple case study, we analyzed 210 documents and conducted 26 interviews with stakeholders in three real-world partnerships between Canadian health organizations and private technology startups during the COVID-19 pandemic. The three partnerships involved: 1) deploying a virtual care platform to care for COVID-19 patients at one hospital, 2) deploying a secure messaging platform for physicians at another hospital, and 3) using data science to support a public health organization. Our results demonstrate that a public health emergency created time and resource pressures throughout a partnership. Given these constraints, early and sustained alignment on the core problem was critical for success. Moreover, governance processes designed for normal operations, such as procurement, were triaged and streamlined. Social learning, or the process of learning from observing others, offset some time and resource pressures. Social learning took many forms ranging from informal conversations between individuals at peer organisations (e.g., hospital chief information officers) to standing meetings at the local university's city-wide COVID-19 response table. We also found that startups' flexibility and understanding of the local context enabled them to play a highly valuable role in emergency response. However, pandemic fueled "hypergrowth" created risks for startups, such as introducing opportunities for deviation away from their core value proposition. Finally, we found each partnership navigated intense workloads, burnout, and personnel turnover through the pandemic. Strong partnerships required healthy, motivated teams. Visibility into and engagement in partnership governance, belief in partnership impact, and strong emotional intelligence in managers promoted team well-being. Taken together, these findings can help to bridge the theory-to-practice gap and guide effective cross-sector partnerships during public health emergencies.

Overcoming vaccine deployment challenges among the hardest to reach: lessons from polio elimination in India.

After more than 30 years of efforts to eliminate polio, India was certified polio free by WHO in 2014. The final years prior to polio elimination were characterised by concentrated efforts to vaccinate hard-to-reach groups in the state of Uttar Pradesh, including migrant workers, religious minority Muslims and impoverished communities with poor pre-existing social support systems. This article aims to describe the management strategies employed by India to improve the deployment and acceptance of vaccines among hard-to-reach groups in Uttar Pradesh in the final years prior to polio elimination.Three main management principles contributed to polio elimination among the hardest to reach in Uttar Pradesh: bundling of health services, local stakeholder engagement and accountability mechanisms for public health initiatives. In an effort to market the polio campaign as an authentic health-oriented programme, vaccine acceptance was improved by packaging other basic healthcare services such as routine check-ups and essential medications. India also prioritised local stakeholder engagement by using influential community leaders to reach vaccine hesitant groups. Lastly, the accountability mechanisms developed between non-profit organisations and decision-makers in the field ensured accurate reporting and identified deficiencies in healthcare worker training. The lessons learnt from India's polio vaccination programme have important implications for the implementation of future mass vaccination initiatives, particularly when trying to reach vulnerable communities.

Eliminating malaria in conflict zones: public health strategies developed in the Sri Lanka Civil War.

Despite the 26-year long civil war, Sri Lanka was declared malaria-free by WHO in 2016. This achievement was the result of nearly 30 years of elimination efforts following the last significant resurgence of malaria cases in Sri Lanka. The resurgence occurred in 1986-1987, when about 600 000 cases of malaria were detected. Obstacles to these efforts included a lack of healthcare workers in conflict zones, a disruption of vector control efforts, gaps in the medication supply chain, and rising malaria cases among the displaced population.This article seeks to describe the four strategies deployed in Sri Lanka to mitigate the aforementioned obstacles to ultimately achieve malaria elimination. The first approach was the support for disease elimination by the government of Sri Lanka and the Liberation Tamil Tigers of Elam. The second strategy was the balance of centralised leadership of the federal government and the decentralised programme operation at the regional level. The third strategy was the engagement of non-governmental stakeholders to fill in gaps left by the conflict to continue the elimination efforts. The last strategy is the ongoing efforts by the government, military and non-profit organisations to prevent the reintroduction of malaria.The lessons learnt from Sri Lanka have important implications for malaria-endemic nations that are in conflict such as Ethiopia, Afghanistan, Yemen and Somalia. To accomplish the World Health Assembly goal of reducing the global incidence and mortality of malaria by 90% by 2030, significant efforts are required to lessen the disease burden in conflict zones. In addition to the direct impacts of conflict on population health, conflicts may lead to increased risk of spread of malaria, both within a country and consequently, abroad.

Innovative health service delivery models in low and middle income countries - what can we learn from the private sector?

BACKGROUND: The poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease. They frequently use the private health sector, due to perceived or actual gaps in public services. A subset of private health organizations, some called social enterprises, have developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models. This study aims to characterize these models and identify areas of innovation that have led to effective provision of care for the poor. METHODS: An environmental scan of peer-reviewed and grey literature was conducted to select exemplars of innovation. A case series of organizations was then purposively sampled to maximize variation. These cases were examined using content analysis and constant comparison to characterize their strategies, focusing on business processes. RESULTS: After an initial sample of 46 studies, 10 case studies of exemplars were developed spanning different geography, disease areas and health service delivery models. These ten organizations had innovations in their marketing, financing, and operating strategies. These included approaches such a social marketing, cross-subsidy, high-volume, low cost models, and process reengineering. They tended to have a narrow clinical focus, which facilitates standardizing processes of care, and experimentation with novel delivery models. Despite being well-known, information on the social impact of these organizations was variable, with more data on availability and affordability and less on quality of care. CONCLUSIONS: These private sector organizations demonstrate a range of innovations in health service delivery that have the potential to better serve the poor's health needs and be replicated. There is a growing interest in investing in social enterprises, like the ones profiled here. However, more rigorous evaluations are needed to investigate the impact and quality of the health services provided and determine the effectiveness of particular strategies.

Which COVID policies are most effective? A Bayesian analysis of COVID-19 by jurisdiction.

This paper reports the results of a Bayesian analysis on large-scale empirical data to assess the effectiveness of eleven types of COVID-control policies that have been implemented at various levels of intensity in 40 countries and U.S. states since the onset of the pandemic. The analysis estimates the marginal impact of each type and level of policy as implemented in concert with other policies. The purpose is to provide policymakers and the general public with an estimate of the relative effectiveness of various COVID-control strategies. We find that a set of widely implemented core policies reduces the spread of virus but not by enough to contain the pandemic except in a few highly compliant jurisdictions. The core policies include the cancellation of public events, restriction of gatherings to fewer than 100 people, recommendation to stay at home, recommended restrictions on internal movement, implementation of a partial international travel ban, and coordination of information campaigns. For the median jurisdiction, these policies reduce growth rate in new infections from an estimated 270% per week to approximately 49% per week, but this impact is insufficient to prevent eventual transmission throughout the population because containment occurs only when a jurisdiction reduces growth in COVID infection to below zero. Most jurisdictions must also implement additional policies, each of which has the potential to reduce weekly COVID growth rate by 10 percentage points or more. The slate of these additional high-impact policies includes targeted or full workplace closings for all but essential workers, stay-at-home requirements, and targeted school closures.

Are global and regional improvements in life expectancy and in child, adult and senior survival slowing?

Improvements in life expectancy have been considerable over the past hundred years. Forecasters have taken to applying historical trends under an assumption of continuing improvements in life expectancy in the future. A linear mixed effects model was used to estimate the trends in global and regional rates of improvements in life expectancy, child, adult, and senior survival, in 166 countries between 1950 and 2010. Global improvements in life expectancy, including both child and adult survival rates, decelerated significantly over the study period. Overall life expectancy gains were estimated to have declined from 5.9 to 4.0 months per year for a mean deceleration of -0.07 months/year2; annual child survival gains declined from 4.4 to 1.6 deaths averted per 1000 for a mean deceleration of -0.06 deaths/1000/year2; adult survival gains were estimated to decline from 4.8 to 3.7 deaths averted per 1000 per year for a mean deceleration of -0.08 deaths/1000/year2. Senior survival gains however increased from 2.4 to 4.2 deaths averted per 1000 per year for an acceleration of 0.03 deaths/1000/year2. Regional variation in the four measures was substantial. The rates of global improvements in life expectancy, child survival, and adult survival have declined since 1950 despite an increase in the rate of improvements among seniors. We postulate that low-cost innovation, related to the last half-century progress in health-primarily devoted to children and middle age, is reaping diminishing returns on its investments. Trends are uneven across regions and measures, which may be due in part to the state of epidemiological transition between countries and regions and disparities in the diffusion of innovation, accessible only in high-income countries where life expectancy is already highest.

Progress in human embryonic stem cell research in the United States between 2001 and 2010.

On August 9th, 2001, the federal government of the United States announced a policy restricting federal funds available for research on human embryonic stem cell (hESCs) out of concern for the "vast ethical mine fields" associated with the creation of embryos for research purposes. Until the policy was repealed on March 9th, 2009, no U.S. federal funds were available for research on hESCs extracted after August 9, 2001, and only limited federal funds were available for research on a subset of hESC lines that had previously been extracted. This paper analyzes how the 2001 U.S. federal funding restrictions influenced the quantity and geography of peer-reviewed journal publications on hESC. The primary finding is that the 2001 policy did not have a significant aggregate effect on hESC research in the U.S. After a brief lag in early 2000s, U.S. hESC research maintained pace with other areas of stem cell and genetic research. The policy had several other consequences. First, it was tied to increased hESC research funding within the U.S. at the state level, leading to concentration of related activities in a relatively small number of states. Second, it stimulated increased collaborative research between US-based scientists and those in countries with flexible policies toward hESC research (including Canada, the U.K., Israel, China, Spain, and South Korea). Third, it encouraged independent hESC research in countries without restrictions.

How industries change.

It's fairly obvious: To make intelligent investments within your organization, you need to understand how your whole industry is changing. But such knowledge is not always easy to come by. Companies misread clues and arrive at false conclusions all the time. To truly understand where your industry is headed, you have to take a long-term, high-level look at the context in which you do business, says Boston University professor Anita McGahan. She studied a variety of businesses from a cross section of industries over a ten-year period, examining how industry structure affects business profitability and investor returns. Her research suggests that industries evolve along one of four distinct trajectories--radical, progressive, creative, and intermediating--that set boundaries on what will generate profits in a business. These four trajectories are defined by two types of threats. The first is when new, outside alternatives threaten to weaken or make obsolete core activities that have historically generated profits for an industry. The second is when an industry's core assets--its resources, knowledge, and brand capital--fail to generate value as they once did. Industries undergo radical change when core assets and core activities are both threatened with obsolescence; they experience progressive change when neither are jeopardized. Creative change occurs when core assets are under threat but core activities are stable, and intermediating change happens when core activities are threatened while core assets retain their capacity to create value. If your company's innovation strategy is not aligned with your industry's change trajectory, your plan for achieving returns on invested capital cannot succeed, McGahan says. But if you understand which path you're on, you can determine which strategies will succeed and which will backfire.

Trans-national scale-up of services in global health.

BACKGROUND: Scaling up innovative healthcare programs offers a means to improve access, quality, and health equity across multiple health areas. Despite large numbers of promising projects, little is known about successful efforts to scale up. This study examines trans-national scale, whereby a program operates in two or more countries. Trans-national scale is a distinct measure that reflects opportunities to replicate healthcare programs in multiple countries, thereby providing services to broader populations. METHODS: Based on the Center for Health Market Innovations (CHMI) database of nearly 1200 health programs, the study contrasts 116 programs that have achieved trans-national scale with 1,068 single-country programs. Data was collected on the programs' health focus, service activity, legal status, and funding sources, as well as the programs' locations (rural v. urban emphasis), and founding year; differences are reported with statistical significance. FINDINGS: This analysis examines 116 programs that have achieved trans-national scale (TNS) across multiple disease areas and activity types. Compared to 1,068 single-country programs, we find that trans-nationally scaled programs are more donor-reliant; more likely to focus on targeted health needs such as HIV/AIDS, TB, malaria, or family planning rather than provide more comprehensive general care; and more likely to engage in activities that support healthcare services rather than provide direct clinical care. CONCLUSION: This work, based on a large data set of health programs, reports on trans-national scale with comparison to single-country programs. The work is a step towards understanding when programs are able to replicate their services as they attempt to expand health services for the poor across countries and health areas. A subset of these programs should be the subject of case studies to understand factors that affect the scaling process, particularly seeking to identify mechanisms that lead to improved health outcomes.

Human trafficking: review of educational resources for health professionals.

CONTEXT: Human trafficking is an increasingly well-recognized human rights violation that is estimated to involve more than 2 million victims worldwide each year. The health consequences of this issue bring victims into contact with health systems and healthcare providers, thus providing the potential for identification and intervention. A robust healthcare response, however, requires a healthcare workforce that is aware of the health impact of this issue; educated about how to identify and treat affected individuals in a compassionate, culturally aware, and trauma-informed manner; and trained about how to collaborate efficiently with law enforcement, case management, and advocacy partners. This article describes existing educational offerings about human trafficking designed for a healthcare audience and makes recommendations for further curriculum development. EVIDENCE ACQUISITION: A keyword search and structured analysis of peer-reviewed and gray literature, conducted in 2011 and 2012, yielded 27 items that provide basic guidance to health professionals on human trafficking. EVIDENCE SYNTHESIS: The 27 resources differed substantially in format, length, scope, and intended audience. Topic areas covered by these resources included trafficking definitions and scope, health consequences, victim identification, appropriate treatment, referral to services, legal issues, and security. None of the educational resources has been rigorously evaluated. CONCLUSIONS: There is a clear need to develop, implement, and evaluate high-quality education and training programs that focus on human trafficking for healthcare providers.

Global divergence in critical income for adult and childhood survival: analyses of mortality using Michaelis-Menten.

Life expectancy has risen sharply in the last 50 years. We applied the classic Michaelis-Menten enzyme kinetics to demonstrate a novel mathematical relationship of income to childhood (aged 0-5 years) and adult (aged 15-60 years) survival. We treat income as a substrate that is catalyzed to increase survival (from technologies that income buys) for 180 countries from 1970 and 2007. Michaelis-Menten kinetics permit estimates of maximal survival and, uniquely, the critical income needed to achieve half of the period-specific maximum. Maximum child and adult survival rose by about 1% per year. Critical incomes fell by half for children, but doubled for men. HIV infection and smoking account for some, but not all, of the rising critical incomes for adult survival. Altering the future cost curve for adult survival will require more widespread use of current interventions, most notably tobacco control, but also research to identify practicable low-cost drugs, diagnostics, and strategies.DOI:http://dx.doi.org/10.7554/eLife.00051.001.

Economic valuations in global health.

This paper deals with three issues concerning economic valuation in global health. First, we argue that the economic value of health delivery in resource-limited settings is not fully captured through the adding up of successive assessments of individual interventions. Second, we suggest that economic valuations can be used to identify social barriers to the success of health technologies in resource-limited settings. Third, we briefly discuss new directions for research on economic valuations given the interdependency between poor health and economic impoverishment.

'Sustainability' in global health.

'Sustainability' has become a central criterion used by funders - including foundations, governmental agencies and international agencies - in evaluating public health programmes. The criterion became important as a result of frustration with discontinuities in the provision of care. As a result of its application, projects that involve building infrastructure, training or relatively narrow objectives tend to receive support. In this article, we argue for a reconceptualisation of sustainability criteria in light of the idea that health is an investment that is itself sustaining and sustainable, and for the abandonment of conceptualisations of sustainability that focus on the consumable medical interventions required to achieve health. The implication is a tailoring of the time horizon for creating value that reflects the challenges of achieving health in a community. We also argue that funders and coordinating bodies, rather than the specialised health providers that they support, are best positioned to develop integrated programmes of medical interventions to achieve truly sustainable health outcomes.

Sex trafficking and health care in Metro Manila: identifying social determinants to inform an effective health system response.

This social science case study examines the sex trafficking of women and girls in Metro Manila through a public health lens. Through key informant interviews with 51 health care and anti-trafficking stakeholders in Metro Manila, this study reports on observations about sex trafficking in Metro Manila that provide insight into understanding of risk factors for sex trafficking at multiple levels of the social environment: individual (for example, childhood abuse), socio-cultural (for example, gender inequality and a "culture of migration"), and macro (for example, profound poverty caused, inter alia, by environmental degradation disrupting traditional forms of labor). It describes how local health systems currently assist sex-trafficking victims, and provides a series of recommendations, ranging from prevention to policy, for how health care might play a larger role in promoting the health and human rights of this vulnerable population.