Reverse innovation in health: Good but not good enough to be standard of care?

The term ‘reverse innovation’ (RI) refers to an innovation from a low- or middle-income country (LMIC) for its unmet needs, which has later been found in use in a high-income country (HIC). Innovations in HICs are normally the by-product of research, whereas limited resources and unmet needs provide the impetus for innovation in LMICs. RI, by definition, must originate from ‘Frugal Innovation’ (FI). This is the development of a tool or method with resources available, but not specifically intended for such purpose. Both FI and RI represent a special type of innovation in health care. Various stages of RI are well known: ¹

Identifying a problem in a LMIC.

Innovating and finding a low-cost solution and broadening its use in LMICs.

Transfer of the solution to a HIC.

Adoption and spread of its use in HICs.

Synonyms of RI include ‘innovation blowback’, ‘value innovation’ and ‘bottoms-up innovation’, contrasting with the more frequent ‘top-down’ approach of innovation from HICs percolating down to LMICs. With its humble origin in the business world, the idea of RI appeals to and finds greater acceptance in several areas of global health care. These include rural health service delivery, skills substitution, decentralisation of management, creative problem-solving, education in communicable disease control, innovation in mobile phone use, low technology simulation training, local product manufacture, health financing and social entrepreneurship. ²

Use of RI in the field of health ³ and surgery ⁴ is fairly well documented with two common search engines showing hundreds of publications. ⁵ Some examples that have been adapted in HICs include the Bogotá bag for temporary abdominal wound closure, Kangaroo mother care for premature infants, the orthopaedic external fixator for complex fractures, shunt valve for normal pressure hydrocephalus, mosquito net mesh for inguinal hernia repair and manual small incision cataract surgery. ³ Many such FIs have the potential to offer efficient cost-effective alternatives to global surgical care; however, in HICs, their acceptance is suboptimal, and their uptake remains grossly under-utilised.^4,5

There are many barriers to adopting RI in HICs; first is the difficulty in obtaining clearance from regulatory and insurance authorities along with manufacturers’ aversions to make cost-effective gadgets for fear of monetary losses. ⁶ Second is the difficulty in identifying innovations for adoption.^2,7 Inherent conscious or unconscious geographic bias against LMICs’ innovations, wrongly perceived differences in respective needs and deep-rooted cognitive association of high quality research with HICs hinder an objective learning process and prevent widespread diffusion of RI from LMICs to HICs.^8,9 This remains the case, despite a majority (>70%) of HIC volunteers working with international global health partnerships between HICs and LMICs realising the suitability of RI after such interaction.^10–12

Some of these barriers may be overcome by developing a standardised method of reporting benefits of RI. This would help ensure easy identification of specific RI to potential users in HICs. ² A practical scoring system could be used for identifying RI for greater in-depth review and evaluation for usage in HICs. This simple tool has already been developed in a modified Delphi process from taking a set of criteria such as unmet gap in HIC, compatibility, novelty and receptivity. ⁷ As numbers of RI increase, HICs must have a framework ready to identify their suitability in order for their uptake to be increased.

In line with political correctness of the times, Lord Nigel Crisp, former Chief Executive of NHS England and Department of Health, has advocated using the term ‘Global sourcing of innovation’ instead of ‘Reverse innovation’, as the latter may hold undesirable patronising overtones. ¹³ Nonetheless, such re-appraisal may help in opening up the idea of co-development. Thus, learning and sharing together from FI might create value for RI in HICs also. Moreover, close collaborative partnerships brought together would build bridges to facilitate quick sharing of specialised knowledge between groups from both sides. ¹⁴ The gap would thereby be closed.

The catchy term ‘RI’ has caught the fancy of academics but very few of RI have attained point-of-care acceptance in HICs. A recent review performed such a reality check by scrutinising ‘actual’ usage of one of the most widely known RI in HICs. It found that, although significantly more economical, mosquito net mesh, found to be as effective, safe and maybe even better than commercial mesh is not being used for hernia repair in HICs. ¹⁵ The authors, very pertinently, question an ethical double standard which accepts RI from LMICs but refuses their benefits in HICs. The grip of huge commercial empires does little actually to promote RI except to re-model the innovation and remove its ‘cheapness’. Kangaroo mother care is still not universally adopted even after more than 30 years of proven benefit, perhaps because re-adaptation with technological complexity is not feasible. Such attitudes hint at a glass ceiling for RI and do not bring any credit to HICs. Unless a corrective system is established, RI is destined to be ever the bridesmaid but never the bride.

FI and RI are much more than solutions to problems of the underprivileged; if a more receptive and open attitude is evolved, much associated knowledge and wisdom will not be missed. Barriers to embracing RIs such as quality concerns, regulations, access, technical feasibility and alignment with public policy are not insurmountable. Although much work remains to be done to overcome such challenges, it must be remembered that need is the mother of invention, and so, FI and therefore RI also will inevitably be a tremendous source of new ideas, whose destiny should not be the dustbin just because of prejudice.