Content uploaded by Matthew J Harris
Author content
All content in this area was uploaded by Matthew J Harris on Oct 14, 2018
Content may be subject to copyright.
Global Surgery
Adrian Park
Raymond Price
Editors
The Essentials
123
Editors
Adrian Park
Department of Surgery
Anne Arundel Health System
Johns Hopkins University School
of Medicine
Annapolis, Maryland
USA
Raymond Price
Department of Surgery
Center for Global Surgery
Department of Family and
Preventative Medicine
Division of Public Health
University of Utah
Salt Lake City, Utah
USA
Department of Surgery
Intermountain Medical Center
Intermountain Healthcare
Salt Lake City, Utah
USA
ISBN 978-3-319-49480-7 ISBN 978-3-319-49482-1 (eBook)
DOI 10.1007/978-3-319-49482-1
Library of Congress Control Number: 2017937327
© Springer International Publishing AG 2017
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
yasser.bhatti@imperial.ac.uk
ix
Contents
Part I The 10,000-Foot View: Framing Global Surgery
1 Global Disparities in Surgical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Jonathan L. Dunlap and Adil H. Haider
2 The Transforming Power of High-Quality Surgical Care:
Surgery’s Role in Improving Public Health . . . . . . . . . . . . . . . . . . . . . . 13
Jaymie A. Henry and Raymond Price
3 The Economic Case for Surgical Care in Low-Resource Settings . . . . 35
Nakul P. Raykar, Swagoto Mukhopadhyay, Jonathan L. Halbach,
Matchecane T. Cossa, Saurabh Saluja, Yihan Lin, Mark Shrime,
John G. Meara, and Stephen W. Bickler
Part II The 1,000-Foot View: Sustainable Surgical Training
4 Surgical Training in Low-Resource Settings . . . . . . . . . . . . . . . . . . . . . 51
Rosemary Klein and Adrian Park
5 Delivery of Subspecialty Surgical Care
in Low-Resource Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Russell E. White and Robert K. Parker
6 Academic Global Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Sanjay Krishnaswami, Mamta Swaroop, and Benedict C. Nwomeh
7 E-Learning in Global Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Brian H. Cameron and Susie Schofield
Part III The “100-Foot” Perspective: Preparing for International
Involvement
8 The Importance of Contextual Relevance and Cultural
Appropriateness in Global Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Janaka A. Lagoo and Sandhya A. Lagoo-Deenadayalan
yasser.bhatti@imperial.ac.uk
x
9 Practical Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
John L. Tarpley and Margaret J. Tarpley
10 Basic Bioengineering: Essential Equipment
Use and Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Jim Moore and Richard S. Wood
11 Frugal and Reverse Innovations in Surgery . . . . . . . . . . . . . . . . . . . . . 193
Matthew Prime, Yasser Bhatti, and Matthew Harris
12 Getting Started: Connecting to Global Surgical Opportunities . . . . . 207
Domenech Asbun, Lena Lea Kassab, and Horacio J. Asbun
Part IV On the Ground: The Clinical Essentials
13 General Surgery Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Sherry M. Wren and Micaela M. Esquivel
14 Essential Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Mark J. Harris
15 Tropical Infectious Disease Medicine
for Surgeons: A Primer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
Bruce C. Steffes and R. Gregory Juckett
16 Essential Orthopedics for Global Surgery . . . . . . . . . . . . . . . . . . . . . . 333
Michelle Foltz, Richard A. Gosselin, and David A. Spiegel
17 Gynecology and Obstetrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Morgan Mandigo and Reinou S. Groen
18 Essential Urology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Louis L. Pisters
19 Head and Neck Essentials in Global Surgery . . . . . . . . . . . . . . . . . . . . 443
Wayne Koch, Eleni M. Rettig, and Daniel Q. Sun
20 Essential Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
Dan Poenaru, Emmanuel A. Ameh, Arlene Muzira,
and Doruk Ozgediz
21 Plastic Surgery for the Nonplastic Surgeon
in the Low-Resource Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Louis L. Carter Jr.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Contents
yasser.bhatti@imperial.ac.uk
193
© Springer International Publishing AG 2017
A. Park, R. Price (eds.), Global Surgery, DOI 10.1007/978-3-319-49482-1_11
M. Prime, MBBS, BSc, MRCS (*) • Y. Bhatti, DPhil, MSc, Mot, FHEA
Division of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London,
10th Floor, QEQM building, St. Mary’s Hospital, Praed Street, London W2 1NY, UK
e-mail: mprime@imperial.ac.uk; yasser.bhatti@imperial.ac.uk
M. Harris, DPhil, MBBS, MSc FFPH
Division of Surgery & Cancer, Institute of Global Health Innovation, Imperial College London,
10th Floor, QEQM building, St. Mary’s Hospital, Praed Street, London W2 1NY, UK
Department of Primary Care and Public Health,
Reynolds Building, St Dunstans Road, London W6 8RP, UK
e-mail: m.harris@imperial.ac.uk
11
Frugal and Reverse Innovations
in Surgery
Matthew Prime, Yasser Bhatti, and Matthew Harris
Overview of Frugal and Reverse Innovations and Relevance
to Surgery
In this chapter we outline emerging trends in innovation, specifically frugal and
reverse innovations, and their relevance to global surgery for both high-income and
low- and middle-income countries (LMICs). Increasing attention is being afforded
to bending the growth cost curve by developing new solutions or drawing from dif-
ferent solutions in LMICs.
The Essentials
• Drivers for healthcare in low-income countries are converging with those
in high-income countries.
• Frugal innovations offer potential for low-cost and high-quality global
surgery.
• Reverse innovations diffuse solutions from low-income to high-income
contexts.
yasser.bhatti@imperial.ac.uk
194
Escalating demand for healthcare and constrained resources has traditionally
been seen as challenges limited to LMICs. However slower economic growth rates
and soaring healthcare costs particularly in the USA and the UK are contributing to
unsustainable spending. Economic challenges combined with social challenges
reflected by, for instance, the increasing prevalence of the burden of noncommuni-
cable disease suggests the convergence of challenges facing global healthcare sys-
tems. While consideration for quality healthcare has been paramount in high-income
countries (HICs) and affordability as an added metric has been considered impor-
tant for the socially and economically disenfranchised, both are now becoming
equally important for everyone, even the socially and economically well off.
As global healthcare leaders wrestle with the problem of how to improve com-
petitiveness while simultaneously reducing costs and improving quality, the idea of
developing frugal innovations or adopting reverse innovations as a way of tackling
these challenges is gaining prominence. Popular examples of frugal innovations in
surgery include Narayana Heart Hospital, Aravind Eye Care System, Jaipur or
ReMotion knee prosthetics, and hernia repair using mosquito net mesh.
Frugal innovation and reverse innovation are often conflated, yet there is a clear dis-
tinction. Frugal innovations entail affordability as a key characteristic and have tradi-
tionally been associated with LMICs or emerging markets [1–3]. Reverse innovations
are associated with diffusion of such low-cost or frugal innovations from low-income to
high-income settings [4]. Once frugal innovations are identified or developed, they can
then be assessed for reverse ability from low- to high-income contexts.
Frugal Innovation
By taking out costs and increasing efficiency, transforming care delivery, expanding
access to quality care, improving patient outcomes, and increasing the sustainability
of the health system, frugal and reverse innovations have the potential of benefi-
cially disrupting current and sometimes outmoded health system practices.
Frugal innovation gained much global traction from mainstream publication in
The Economist in 2010, which presented several healthcare innovations, both prod-
uct and process, including the GE’s MAC 400 ECG machine, a medical device
reengineered to focus on simplicity and cost reduction available for $800 [5]. The
definitions of frugal innovation prevalently found in existing literature are governed
by concerns for low cost and sourcing from developing or emerging market coun-
tries and have relevance for global surgery. In the management consulting literature,
Ernst and Young (2011) define frugal innovation as the economical use of resources
to provide products affordable to those on a lower income [6]. In academic litera-
ture, scholars call frugal innovation as simply “toned down” and “good-enough
products” [7] or low-cost products [8, 9]. Definitions by Gupta and Wang [10],
Zeschky et al. [11], Tiwari and Herstatt [12], and George et al. [13] are familiar to
those found in Govindarajan and Trimble’s work on reverse innovation. The process
of frugal innovation may redesign products [11], reconfigure value chains [14], or
rebuild entire ecosystems [15, 16]. In essence frugal innovation is a label that cap-
tures a range of heterogeneous activities, which cut across different sectors [17].
M. Prime et al.
yasser.bhatti@imperial.ac.uk
195
Drawing from extensive study of what entails frugality in innovation, we see
frugal innovations as “means and ends to do more with less for many” [18]. Frugal
innovation can be more affordable for the producer, provider, or patient, but should
ideally have potential impact on a global scale for population-wide or system-wide
benefit. Our adopted definition of frugal innovation is hence broad, such that it
encompasses examples where inputs and outputs are less costly but also where
things are done more efficiently or where innovations provide wider access to larger
populations through their scalability [19].
People often equate frugality with poor quality, especially if its sources are
unconventional, and this makes the diffusion or adoption of the innovation particu-
larly challenging in healthcare where quality and patient outcomes are key metrics
of success. Indeed frugality is about affordability, but in moving beyond early per-
spectives of frugal innovations as simply “good-enough” or “no-frills” products, we
must recognize frugality is also about adaptability and accessibility – key issues
confronting healthcare professionals challenged with improving access to care
while simultaneously reducing costs and improving quality.
Reverse Innovation
Reverse innovation is defined as “any innovation that is adopted first in the develop-
ing world” [20]. This means learning from, or diffusion of, the innovations that
low-income countries have themselves developed and perhaps even scaled to high-
income countries. Woolridge in The Economist refers to both frugal and reverse
innovation in mainstream practitioner outlets, by writing “Frugal innovation radi-
cally redesigns products and services to make them much cheaper for the emerging
middle class – and then re-exports them to the West” [5].
In healthcare circles, this has become somewhat of a movement. In 2012, an
ongoing thematic series in the journal Globalization and Health set out to explore
and promote “reverse innovation.” In 2013, the Ivey International Center for Health
Innovation issued an open call to invite proposals for “reverse innovations” that
could address Canada’s health system challenge [21]. The International Partnership
for Innovative Healthcare Delivery (IPIHD), recently renamed Innovations in
Healthcare (IIH) formed out of a partnership between the World Economic Forum,
Duke University, and McKinsey & Company, operates a “reverse innovation” work-
ing group to address how successful innovations in healthcare delivery from low-
income settings can be replicated in high-income settings. In 2016, the US
Commonwealth Fund commissioned case studies of frugal innovations for applica-
bility to the US health system.
Some reasons for this shift in emphasis on the directionality of learning include
the North-South model of development, rooted in postcolonial assistance, which
has been heralded as archaic [22]. Development has been called into question as an
industry that is often self-serving [23–25] and failing to demonstrate significant
change [26, 27]. Also, the global health landscape has changed dramatically. Power
and influence are more diffuse with a proliferation of significant new actors [28, 29],
11 Frugal and Reverse Innovations in Surgery
yasser.bhatti@imperial.ac.uk
196
and emerging economies continue to challenge established markets. There are many
examples of impressive health innovations originating from LMICs. These have the
potential to disrupt health systems in the Global North; indeed there are many rea-
sons why the bloated healthcare economies of high-income countries could benefit
from leaner innovations and out-of-the-box thinking.
Relevance to Surgery
Surgical procedures that embody frugality and innovation offer potential for disrup-
tive cost reduction and global accessibility. Examples of frugal innovations in sur-
gery are diverse ranging from additive manufacturing or 3D printing to produce
surgical tools to lean manufacturing and task shifting techniques to achieve econo-
mies of scale such as at the Narayana Heart Hospital or in the Aravind Eye Care
System [30–32]. Other examples include the Jaipur prosthetic knee, the Arbutus Drill
Cover for orthopedic surgery, and hernia repair using mosquito net mesh. An under-
standing of these cases and their relevance to the surgical field can help offer lessons
in developing high-impact and cost-effective solutions that address the intensifying
challenges of burgeoning budgets, financial accountability, and finite resources.
Dr. Devi Shetty is a renowned Indian cardiac surgeon and founder of Narayana
Health, who at his hospital in Bangalore has been able to decrease the cost of cardiac
surgery to $1,500 per operation, compared with $144,000 in the USA, $27,000 in
Mexico, and $14,800 in Colombia while at the same time maintaining quality (1.4%
30 day mortality from coronary artery bypass surgery vs. 1.9% in the USA). In effect
his organization has evolved cardiac surgery to a production line: maximizing the
number of operations while improving quality through procedure repetition [5, 30].
Aravind Eye Hospital has been on a mission since 1976 to end blindness in India
seeing 2.5 million patients a year [32]. Today Aravind is the largest eye surgery
provider in the world. Among its highly touted technical and social achievements
are dropping the imported price of intraocular lenses from $200 apiece to locally
produced $5 apiece. It costs $10 to conduct a cataract operation that lasts just
20 min, and currently around 300,000 eye surgeries are completed each year.
Aravind achieves a gross margin of 40% despite the fact that 70% of patients receive
free or heavily subsidized rates. By comparison, the average cost for this eye proce-
dure in the USA is about $1,650. The hospital’s Aurolab, which pioneered the pro-
duction of high-quality, $5 low-cost intraocular lenses, produces 700,000 lenses
each year, of which three-quarters are exported all over the world. However, the
lenses are not exported to the USA since Aravind cannot afford the costly US-FDA
clinical approval process [31]. With less than 1% of the country’s ophthalmic man-
power, Aravind accounts for 5% of the ophthalmic surgeries performed nationwide
[32]. The hospital network uses broadband for rural screenings. “We are going from
village to village to provide eye care to the unreached,” says Aravind’s chairman,
Dr. P. Namperumalsamy [31].
Narayana and Aravind have successfully scaled in home contexts, but are finding
replication elsewhere challenging. Although more evidence is available on the
M. Prime et al.
yasser.bhatti@imperial.ac.uk
197
efficacy and safety of mosquito mesh for hernia surgery, advocacy for the diffusion
for global surgery is limited to resource-constrained contexts [33]. Howitt et al.
(2012) advocate that policy makers and the medical establishment still need to act
quickly in order not to repeat the delay seen in the adoption of oral rehydration
therapy [34]. Even with lack of prevailing evidence, the scale of economic and
social advantages of alternative surgical techniques in low-income countries may
outweigh the minimal clinical disadvantages [35]. See the section in “Chap. 3 The
Economic Case for Surgical Care in Low Resource Settings” that speaks to the
financial calamity resulting from not investing in essential surgery.
Surgery entails products and processes. But products or processes of frugal
innovation are not mutually exclusive – in fact they are interdependent and com-
plimentary – but the delineation helps to provide a helpful starting point for
investigating the different challenges and in identifying the kind of frugal inno-
vations that are likely to have the biggest impact. However, research suggests to
move beyond the focus on technology innovation and think also along social
innovation and institutional innovation as well as needs and motivations of users
or innovators such as user driven, efficiency driven, challenge driven, and social
driven [17].
We know little about the motivations and strategies of frugal innovators and how
clinicians and engineers and designers can better work together to co-develop frugal
and reverse surgical innovations. Interdisciplinary design spaces such as Helix at
Imperial College London provide a place for interaction and lives up to Donald
Schön’s work on reflective practice (1983), where the joint practices of clinicians
and designers come together and can be critically assessed by scholars [36].
This interdisciplinary approach informs healthcare but also other sectors. While
some frugal approaches to process innovation have been inspired by the techniques
and philosophy of lean production, first developed in the car industry, frugal
approaches to produce surgical innovation may have the potential to in turn inform
the car industry in how to design automobiles.
Identifying and Understanding Methods for Frugal
and Reverse Innovations in Surgery
Current academic literature identifying examples of frugal innovations in healthcare
is limited, and authors have often drawn on the examples of Narayana Healthcare
[17, 37, 38] and the Mac 400 ECG4 [11, 38, 39] to build theories or illustrate
The Essentials
• Frugal innovations need to be identified beyond case analysis
• Strategies to evaluate the “reversibility potential” of innovations from
LMICs must be developed
• Innovators are using various methods to achieve frugality
11 Frugal and Reverse Innovations in Surgery
yasser.bhatti@imperial.ac.uk
198
conclusions. Although these examples are important, their impact is limited to the
specific conditions and problems they were developed for. Current work suggests
that innovators are widely embracing the concept of frugality to solve a variety of
different healthcare challenges [40].
Identifying Frugality
In order that frugal innovations can be evaluated, studied, and disseminated into the
health sector, they must first be identified or assessed as “frugal innovations.”
Unfortunately, in-depth case study analysis of all new innovations is not practical;
therefore, tools must be developed to help healthcare leaders more easily scan for
promising frugal solutions; the authors at Imperial College London have developed
an empirically derived frugal identification tool based on the key definitional com-
ponents of affordability, adaptability, and accessibility outlined by Bhatti [17]; sub-
sequent testing has identified a cohort of frugal innovations in healthcare, many of
which are applicable to the field of global surgery [40] (Table 11.1).
Assessing Reverse Ability
For healthcare systems in developed countries to benefit from innovations con-
ceived in resource-poor contexts, strategies must be developed to identify and strat-
ify innovations with the greatest potential. Govindarajan and Trimble [20] state that
“reverse innovations can flow uphill by penetrating marginalized markets after a
delay during which trends close the gap between rich-world and poor-world needs.”
In other words the more deprived areas of a developed economy have challenges
more aligned with developing economies, as such the innovations are more appli-
cable. Further, they propose a framework based on how an innovation demonstrates
convergence in five “needs gaps”: performance, infrastructure, sustainability, regu-
latory, and preference. However, further research is required in healthcare to evalu-
ate how such frameworks might be used in practice.
Methods Used in Frugal and Reverse Innovations
Understanding the fundamental dimensions employed by an innovation to “do more
with less, for many” [19] will help innovators identify important strategies to foster
their own creative efforts. Initial work by Prime et al. (2016) has shown that for
frugal product development, the concept of simplification and user-centered design
is critical [40]. A group from Arbutus Medical, based at the University of British
Columbia (UBC), Canada, working in 14 developing nations worldwide, has devel-
oped the Drill Cover Hex (Fig. 11.1), an ingenious solution to allow surgeons to
safely use a low-cost hardware drill for surgical procedures, by only sterilizing a
drill bit and attachment instead of entire drill, dramatically reducing the cost.
M. Prime et al.
yasser.bhatti@imperial.ac.uk
199
Table 11.1 Frugal innovations for healthcare [40]
Frugal innovation Innovation description
Arbutus Drill Cover Arbutus Medical has developed a $400 alternative to $30,000 surgical
drills, allowing safe and effective treatment of patients in resource-
constrained settings
BRACI Smart Ear BRACI is a product and platform which is able to detect a wide range of
sounds in the environment and deliver a notification about that sound to
any medium the user has specified, for example, in the form of a message
on a screen
eACCESS The eACCESS initiative aims to make critical care specialists available
round the clock in order to provide high-quality care to patients in the ICU
Fosmo Med Fosmo Med is changing the paradigm of pre-filled IV bags by utilizing
innovative forward osmosis technology to create sterile intravenous
solutions at the point of care
JANMA JANMA by AYZH is a US$3 clean birth kit containing six simple tools
recommended by the World Health Organization (WHO) to ensure
sanitation and sterility at the time of childbirth
Miroculus Miroculus has developed an accurate, easy to use, noninvasive, and
affordable microRNA detection platform that can radically improve the
ability of life science research and healthcare providers to diagnose, treat,
and monitor diseases at a molecular level through the examination of
microRNAs
Mother’s Delivery
Kit
Mother’s Delivery Kit contains sterile products a woman needs during
childbirth to avoid potentially fatal neonatal complications, such as
tetanus due to a lack of clean blades and sepsis caused by delivering
children in unsanitary conditions
PEEK vision Peek – the portable eye examination kit – makes eye tests affordable and
easy anywhere in the world by leveraging smartphones with specialist
adapters and software
Possible Possible is a nonprofit healthcare company that, using an innovative health
system model, delivers high-quality, low-cost healthcare to the poor
Pro Mujer Pro Mujer’s “Integrated Women’s Empowerment and Healthcare Model”
ties the delivery of healthcare services to the delivery of microfinance
services to increase coverage and access among low-income women in
Latin America
Pumani BCPAP The Pumani BCPAP is a low-cost respiratory support device used in the
treatment of respiratory illness in infants and young children
Robohand The need for affordable, functional upper limb replacements is immense.
Robohand components are 3D printed using polylactic acid (PLA),
derived from renewable resources such as corn starch, tapioca roots,
chips or starch, or sugarcane
Smile Train Smile Train is an international children’s charity with a sustainable
approach to a single, solvable problem: cleft lip and palate
SughaVazhvu
Healthcare
SughaVazhvu trains underutilized AYUSH (alternative Indian medicine)
physicians to provide evidence-based primary care using clinical
protocols developed in association with the University of Pennsylvania
Ziqitza Healthcare
Limited (ZHL)
Ziqitza Health Care Limited (ZHL) operates 1,280+ ambulances, with
6,000+ staff, in 17 states across India and the UAE. They use a tiered
pricing, user-fee-based business model in India wherein patients are
charged based on ability to pay based on the patient’s destination
11 Frugal and Reverse Innovations in Surgery
yasser.bhatti@imperial.ac.uk
200
Prime et al. (2016) also saw that harnessing emerging technologies such as
digital platforms and 3D printing could achieve more with less [40]. For exam-
ple, a UK team focused on reducing blindness has produced a “portable eye
examination kit” called PEEK, using a smartphone application and lens adapter
(Fig. 11.2). A validation study has demonstrated that image quality is
comparable to a standard desktop retinal camera, furthermore, they suggest
that the ease of image capture will allow community health workers (CHWs)
to perform critical tests to identify the avoidable causes of blindness in
underserved rural communities, which makes this an attractive public health
intervention [41].
As well as employing user-centered design to understand the needs of frontline
health workers, Prime et al. (2016) also report the importance of supporting grass-
roots innovators, such as the South African pioneers behind a 3D-printed prosthetics
company [40]. In May 2011 the founder suffered a woodworking accident severing
all the fingers on his right hand. During his recovery, he discovered that there were
no suitable finger prosthetics and that other limb prosthetics were largely unafford-
able for the everyday South African citizens. Using his engineering and
Fig. 11.1 The Drill Cover
Hex (formerly the Arbutus
Drill Cover) developed by
Arbutus Medical (Image
courtesy of Arbutus
Medical, a medical
company that spun out of
UBC)
Fig. 11.2 “Portable eye
examination kit” (Image
courtesy of Peek Vision)
M. Prime et al.
yasser.bhatti@imperial.ac.uk
201
entrepreneurial skills, he formed Robohand, a company which now produces cus-
tomizable, affordable, 3D-printed prosthetics. Impressively, the designs have been
open- sourced to decrease the barriers to access.
Critical to providing improved surgical care to underserved communities is advances
in service delivery. Prime et al. (2016) demonstrate that care providers can consider
multiple ways to achieve more with less [40]. The economies of scale approach, as
championed by Narayana Healthcare (NH) and the Aravind Eye Care System (AECS),
is a well-known model and has well-documented cost reduction benefits. However,
both NH and AECS employ several other strategies within this model to achieve their
results. For example, AECS uses a cross-subsidization strategy, where service provi-
sion is supported by revenue from manufacturing ophthalmic lenses. Ziqitza Health
Care Limited also use a cross-subsidization model; however, rather than supporting
services from a separate revenue stream, they supplement the cost of transport to public
hospitals with higher charges for those going to private hospitals [40].
A current popular organizational strategy to decrease human resource costs and
combat skills’ shortages is to adopt task shifting or task sharing, whereby tasks are
delegated, if appropriate, to less specialized health workers. For example, surgeons
operating at NH and AECS concentrate their efforts in the operating room, while the
nursing staff provides pre- and postoperative care. Prime et al. (2016) suggest that
in most cases, “task shifting” is supported by a protocol or product, which makes
the previously complex task easier and safer [40].
It is hoped that widespread system adoption of frugal innovations will contribute
to current efforts by healthcare leaders to bend the cost curve. However, like any
innovation there are enablers and barriers to the diffusion process; many of these
solutions originate from nontraditional sources, and as such we should anticipate
that the pathway for adoption will be challenging.
Barriers and Challenges to Frugal and Reverse Innovations
Diffusion of innovation in healthcare is not linear; its pathway is chaotic and thorny
[42]. The “standard” attributes of an innovation ripe for adoption should have a rela-
tive advantage, be compatible with the norms of the adopter context, be perceived
as uncomplicated with observable benefits, and, finally, hold potential for
The Essentials
• Diffusion of innovation is complex, and learning from low-income coun-
tries is even more complicated.
• Frugal and reverse innovations face social and cognitive barriers to adop-
tion mainly associated with source.
• A culture of collaborative innovation is vital to overcome challenges to
adopting frugal innovations from low-income countries.
11 Frugal and Reverse Innovations in Surgery
yasser.bhatti@imperial.ac.uk
202
reinvention [43]. Creating space and time for learning, but also being able to remove
old ways of working, delayering so that new processes do not accumulate are all
important [44].
Innovations from low-income countries are developed in very different regula-
tory environments to high-income countries, and this, on its own, challenges their
spread into other contexts. However, learning from low-income countries and
adopting their innovations into high-income countries is complicated further by
issues related to social and cognitive biases associated with the source of the inno-
vation. The role of the innovator context in the spread of the innovation is an impor-
tant consideration and one which is of particular importance in reverse innovation.
Learning from and adopting innovations from low-income countries has certain
complexities arising from the fact that these countries may be considered, by some,
to be “unusual” sources of innovation [45]. There can often be preconceptions
regarding the relevance of, and likelihood that learning will come from, low-income
countries [21, 45]. A legitimate source is therefore important for innovation diffu-
sion, but little is known about how legitimacy is defined or perceived. The diffusion
of innovation literature is curiously silent on whether one’s view of the source of an
innovation matters in the diffusion process. Greenhalgh et al. (2004) mention that
the innovator context should be a “legitimate” source but then does not explain what
constitutes “legitimate” [43].
Source as Barrier
The effect of source has been well documented in the marketing literature. Bilkey and
Nes (1982) showed that consumers tend to rate products from their own countries more
favorably and that consumer preferences are positively correlated with the degree of
economic development of the source country, probably evoked by the lower price cue
of low-income country products [46]. Up to 30% of the variance of consumer product
ratings can be attributed to the product’s country of origin [47] and respective regula-
tory environments. Products developed abroad in general are perceived as “riskier”
than products developed in one’s own country. Overall, country of origin has signifi-
cant effects on consumer brand attitudes [48], and the country of origin of a product
serves as a conflated, stereotyped measure for other product attributes [47].
In practice, although much emphasis is given to assessing the quality of the
research, we know little about how we individually value the research. We may each
reach a different conclusion as to whether research presents strong evidence and
whether we consider the research useful. There is some evidence to suggest that
these issues of source may be playing out in practice in healthcare research. A rigor-
ous randomized control trial (RCT) may convince a surgeon to change a certain
practice, but may not have the same effect on a primary care physician [42].
Communities of practice develop “ways of working” (clinical, intellectual, profes-
sional) that can be relatively inaccessible to nonmembers of the group. McGivern
and Dopson (2010) refer to this as “epistemic communities” and is a barrier to the
transfer of knowledge, expertise, and experience between groups [49].
M. Prime et al.
yasser.bhatti@imperial.ac.uk
203
Even in research, the issue of source may be influencing researchers’ interpretation
of evidence. Ideally, research findings ought to be judged on the strength of the evidence
and their relevance. However, there is some subjectivity involved in interpreting research
[50]. Research certainly does not “speak for itself” – we give it a voice, and how we
judge whether one piece of research constitutes evidence or not is complex and messy.
Harris et al. (2015) found that there is some evidence to suggest that the country of
origin matters in research evaluation and publication [51]. In their randomized, con-
trolled trial, they showed that a source from a low-income country negatively influenced
US public health professors’ opinion of research abstracts in some instances. Participants
were more likely to refer one abstract, of the four abstracts that were included in the
study, to a peer if the source was from a high-income country compared to a low-income
country (OR 1.28; 95% CI 1.02–1.62), all things being equal [51]. Although the
effect size was small under experimental conditions, it may be “clinically” significant
considering how much research is published and consumed on a daily basis.
Although the regulatory contexts and practice environments are very different in
a low-income country, compared to a high-income country, at a granular level, the
differences are unlikely to be more than with any other high-income country. All
contexts will have cultural, regulatory, economic, and financial differences, and it
can be as challenging to adopt an innovation from a neighboring hospital as from
another country. In the case of reverse innovation, low-income contexts are per-
ceived to be very different, and this perception can influence one’s view of the coun-
try as a potential source of innovation. Cultural relevance is a significant issue and
is as relevant in high- to low-income country diffusion as the other way round.
How to Overcome This Challenge
Reverse innovation is a complex and fragmented process: one with no particular
institution in charge and with blurred lines between supply and demand. Following
Rogers (2003), DePasse and Lee (2013) suggest that due to these unique challenges,
reverse innovation requires a particular type of “crossover” from low-income coun-
try early adopters to high-income country innovators [52, 53]. A culture of collab-
orative innovation will be vital to overcome challenges to adopting frugal innovations
from low-income countries. Reverse innovation requires “spannable social dis-
tances” bridged by policy makers, entrepreneurs, and health system leaders and
utilizing diverse channels such as conferences, learning collaboratives, and online
resources [53]. The actors driving this process may include innovation think tanks,
health policy organizations, and foundations, and their work is to create demand –
demand for the innovation and demand for local service providers interested
(or persuaded) to pilot or adopt the innovation. The recent emergence of “curator”
organizations that collate frugal innovations from around the world, including low-
income countries, is potentially important actors in spanning these social distances.
Curator organizations identify frugal innovations of potential value in home country
contexts and are able to identify innovations from low-income countries that are
“off the radar” of more traditional knowledge sources, such as the peer-reviewed
11 Frugal and Reverse Innovations in Surgery
yasser.bhatti@imperial.ac.uk
204
medical literature. Research is needed to explore the degree to which these knowl-
edge bases help to persuade a greater adoption of healthcare innovations, whether
frugal, reverse, or otherwise. More research is needed to better understand the spe-
cific challenges related to adopting global innovations and specifically those from
low-income countries.
If we are to see greater adoption of frugal and reverse approaches, we have to
make the case that innovations from low-income countries are as legitimate as from
anywhere else. Such convincing can be achieved by supporting teams of frugal and
reverse innovation champions who are tasked and equipped to fit into the health
system. The teams can be comprised of disease identification and system champi-
ons, to evaluation of evidence of impact and cost, to overcoming regulatory and
legal barriers. A culture of collaborative innovation is vital to address the challenges
that lie ahead for effective and sustainable healthcare systems. But the dearth of
“evidence” that accompanies the diffusion potential of frugal innovations – whether
that’s because the evidence is distrusted because of its source or because of a lack
of methodological rigor – needs to be overcome through cultural change.
Conclusion
Affordable and quality healthcare is needed not only for the socially and eco-
nomically disenfranchised but also at more sustainable levels for the socially and
economically well off. In particular, surgical innovations that embody frugality
while upholding standards of quality and safety can be transformative for both
developing and developed healthcare systems. But there are challenges of lever-
aging frugal innovations from development to reverse diffusing them to high-
income countries, particularly in the healthcare sector. While global surgery can
leverage evolving models of frugal innovation for the benefit of global popula-
tions and markets, this effort also presents an opportunity for the practical and
policy discourse in frugal and reverse innovation to benefit from experimentation
and evidence collection that may inform other sectors beyond healthcare. We are
only beginning to understand these issues, and there has been some headway in
collecting evidence of the potential benefits of frugality in healthcare innovations
as well as obstacles to their adoption in LMICs. Yet we need further research on
the development, adaptation, and adoption of frugal innovations and efforts to
diffuse evidence-based policies among decision-makers worldwide to reduce
inequalities in global surgery for generations to come.
References
1. Radjou N, Prabhu J, Ahuja S. Jugaad innovation: think frugal, be flexible, generate break-
through growth. Wiley; United States of America 2012.
2. Bhatti YA, Ventresca M. The emerging market for frugal innovation: fad, fashion, or fit?
(January 15, 2012). SSRN: http://ssrn.com/abstract=2005983. 2012.
3. Bhatti YA, Khilji S, Basu R. Frugal innovation. In: Khilji S, Rowley C, editors. Globalization,
change and learning in South Asia. Oxford: Chandos Publishing; 2013.
M. Prime et al.
yasser.bhatti@imperial.ac.uk
205
4. Immelt JR, Govindarajan V, Trimble C. How GE is disrupting itself. Harv Bus Rev.
2009;87(10):56–65.
5. Woolridge A. The economist. First break all the rules. The Economist, 15th April 2010.
6. Ernst & Young. Innovating for the next three billion: Ernst & Young; London 2011.
7. Hang CC, Chen J, Subramian AM. Developing disruptive products for emerging economies:
lessons from Asian cases. Res-Technol Manag. 2010;53(4):21–6.
8. Govindarajan V, Ramamurti R. Reverse innovation, emerging markets, and global strategy.
Glob Strateg J. 2011;1(3–4):191–205.
9. Hesseldahl P. Frugal solutions – a manual. Denmark: Universe Foundation; 2013.
10. Gupta A, Wang H. Getting China and India right: strategies for leveraging the world’s fastest-
growing economies for global advantage. San Francisco: Wiley; 2009.
11. Zeschky M, Widenmayer B, Gassmann O. Frugal innovation in emerging markets. Res-
Technol Manag. 2011;54(4):38–45.
12. Tiwari R, Herstatt C. Assessing India’s lead market potential for cost-effective innovations.
J Indian Bus Res. 2012;4(2):97–115.
13. George G, McGahan AM, Prabhu J. Innovation for inclusive growth: towards a theoretical
framework and a research agenda. J Manag Stud. 2012;49(4):661–83.
14. Sharma A, Iyer GR. Resource-constrained product development: implications for green mar-
keting and green supply chains. Ind Mark Manag. 2012;41(4):599–608.
15. Bhatti, YA. What is frugal, what is innovation? Towards a theory of frugal innovation.
Academy of Management Annual Meeting, Boston, 3–7 August 2012. Available at: http://
dx.doi.org/10.2139/ssrn.2005910
16. Bound K, Thornton I. Our frugal future: lessons from India’s innovation system. London:
NESTA; 2012.
17. Bhatti, YA. Frugal innovation: social entrepreneurs’ perceptions of innovation under institu-
tional voids, resource scarcity and affordability constraints. Doctoral dissertation, University
of Oxford; 2014.
18. Bhatti YA, Basu R, Barron D, Ventresca M. Frugal innovation – new models and theoretical
developments. Cambridge University Press; 2016 (forthcoming).
19. Bhatti YA, Ventresca M. How can ‘Frugal Innovation’ be conceptualized? SSRN. 2013;
January 13. http://ssrn.com/abstract=2203552
20. Govindarajan V, Trimble C. Reverse innovation. Cambridge, MA: Harvard Business Review
Press; 2012.
21. Johnson C, Noyes J, Haines A, Thomas K, Stockport C, Harris M. Community health work-
ers–learning from the Brazilian model in North Wales. Glob Health. 2013;9:25.
doi:10.1186/1744-8603-9-25.
22. Mosse D. Cultivating development: an ethnography of aid policy and practice. London: Pluto
Press; 2005.
23. Mosse D, Lewis D. In: Mosse D, Lewis D, editors. The aid effect: giving and governing in
international development. London: Pluto Press; 2005.
24. Ebrahim A. NGOs and organisational change: discourse, reporting and learning. Cambridge
Univeristy Press New York; 2005.
25. Easterly W. The white man’s burden: why the west’s efforts to aid the rest have done so much
ill and so little good. The Penguin Press; 2006.
26. Moyo D. Dead aid: why aid is not working and how there is another way for Africa. London:
Penguin Books Ltd; 2009.
27. Hanefield H, Walt G. Knowledge and networks – key sources of power in global health; com-
ment on “Knowledge and Exercise of Power in Global Health”. Int J Healthc Manag Policy.
2015;12(4):119–21.
28. Shiffman J. Knowledge, moral claims and the exercise of power in global health. Int J Health
Policy Manag. 2014;3:297–9.
29. Syed S, Dadwal V, Rutter P, Storr J, Hightower J, Gooden R, et al. Developed-developing
country partnerships: benefits to developed countries? Glob Health. 2012;8:17.
30. Madhaven N. Compassionate heart, business mind: Narayana health has successfully married
affordability and quality health care. Business Today; May 25th, 2014.
11 Frugal and Reverse Innovations in Surgery
yasser.bhatti@imperial.ac.uk
206
31. Rubin H. Aravind eye hospital: the perfect vision of Dr V. FAST company. 19 Dec, 2007.
http://www.fastcompany.com/node/42111/print Accessed 03 Jan, 2012.
32. Mehta PK, Shenoy S. Infinite vision: how Aravind became the world’s greatest business case
for compassion. San Francisco: Berrett-Koehler; 2011.
33. Löfgren J, Nordin P, Ibingira C, Matovu A, Galiwango E, Wladis A. A randomized trial of
low-cost mesh in groin hernia repair. N Engl J Med. 2016;374(2):146–53.
34. Howitt P, Darzi A, Guang ZY, Kerr K. Author’s reply. Lancet. 2012;380:1739.
35. Abeygunasekera AM. Learning from low income countries: what are the lessons?: effective
surgery can be cheap and innovative. BMJ: Br Med J. 2004;329(7475):1185.
36. Schön DA. The reflective practitioner: how professionals think in action (Vol. 5126). Basic
books; 1983.
37. Singh SK, Gambhir A, Sotiropoulos A, Duckworth S. Frugal innovation: learning from social
entrepreneurs in India. London: SERCO Institute; 2012.
38. Ramdorai A, Herstatt C. Frugal innovation in healthcare: how targeting low-income markets
leads to disruptive innovation. Hamburg: Springer; 2015.
39. Grover A, Caulfield P, Roehrich KJ. Frugal innovation in healthcare and its applicability to
developed markets. In: British. Academy of Management. 2014. http://opus.bath.ac.
uk/41361/1/Frugal_Innovation_paper.pdf. Accessed 27 April 2016.
40. Prime M, Bhatti Y, Harris M, Darzi A. (2016). Frugal innovations in healthcare: a toolkit for
innovators. Academy of Management Proceedings. 2016. 2016;1:12622.
41. Bastawrous A, Giardini ME, Bolster NM, Peto T, Shah N, Livingstone IA, et al. Clinical vali-
dation of a smartphone-based adapter for optic disc imaging in Kenya. JAMA Ophthalmol.
2015;1–8.
42. Ferlie E, Fitzgerald L, Wood M, Hawkins C. The (non) spread of innovations: the mediating
role of professionals. Acad Manag J. 2005;48:117–34.
43. Greenhalgh T, Robert G, MacFarlane F, Bate P, Kyriakidou O. Diffusion of innovations in
service organizations: systematic review and recommendations. Milt Q. 2004;82(4):581–629.
44. Parston G, McQueen J, Patel H, Keown OP, Fontana G, Al Kuwari H, Darzi A. The science and
art of delivery: accelerating the diffusion of health care innovation. Health Aff.
2015;34(12):2160–6.
45. Harris M, Weisberger E, Silver D, Macinko J. ‘They hear “Africa” and they think that there
can’t be any good services’–perceived context in cross-national learning: a qualitative study of
the barriers to reverse innovation. Glob Health. 2015;11(1):1.
46. Bilkey W, Nes E. Country-of-origin effects on product evaluations. J Int Bus Stud.
1982;13(1):89–100.
47. Peterson RA, Jolibert A. A meta-analysis of country-of-origin effects. J Int Bus Stud.
1995;26(4):883–900.
48. Bodenhausen G, Wyer R. Effects of stereotypes in decision making and information- processing
strategies. J Pers Soc Psychol. 1985;48(2):267–82.
49. McGivern G, Dopson S. Inter-epistemic power and transforming knowledge objects in a bio-
medical network. Organ Stud. 2010;31(12):1667–86.
50. Kaptchuk TJ. Effect of interpretive bias on research evidence. Br Med J. 2003;326(7404):1453.
51. Harris M, Macinko J, Jimenez G, Mahfoud M, Anderson C. Does the origin of research affect
perception of research quality and relevance? A national trial of US public health academics.
BMJ Open. 2015;5(12):e008993.
52. Rogers E. Diffusion of innovations, 5th edition. Simon and Schuster; 16 August 2003.
53. DePasse JW, Lee PT. A model for ‘reverse innovation’ in health care. Glob Health. 2013;9:40.
(30th August 2013).
M. Prime et al.
yasser.bhatti@imperial.ac.uk
