- Email: [email protected]
Technologies for global health – Authors' reply
Correspondence
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Hasegawa T. Strengthening organizations in health sector by total quality management (TQM). Tokyo: Japan International Cooperation Agency, 2006. http://jica-ri.jica. go.jp/IFIC_and_JBICI-Studies/jica-ri/ publication/archives/jica/kyakuin/ pdf/200606_hea.pdf (accessed Aug 15, 2012). Withanachchi N, Handa Y, Karandagoda KKW, Pathirage PP, Tennakoon NCK, Pullaperuma DSP. TQM emphasizing 5-S principles a breakthrough for chronic managerial constraints at public hospitals in developing countries. Int J Public Sector Manage 2007; 20: 168–77. Japan International Cooperation Agency (JICA). Stepwise approach for 5S-KAIZENTQM. http://www.jica.go.jp/activities/issues/ health/5S-KAIZEN-TQM/pdf/leaflet.pdf (accessed Aug 15, 2012).
will have to want it and it will have to do them good. There is natural tension between the conservatism of evidencebased practice and the agility of novel technology development. As both the e-health and m-health movements gather pace, their participants should learn from both approaches. We are all affiliates of MedicineAfrica.com, a social enterprise that provides an online platform for health-care educational partnerships.
Alexander E T Finlayson, Felix Greaves, *Faisal R Ali [email protected]
Peter Howitt and colleagues1 highlight the need to harness innovation for global health. We conceptualise this as marrying the technologist’s “hacker way”, made famous in Mark Zuckerberg’s letter ahead of Facebook’s stock market launch,2 with the more conservative approach of strategic incremental adaptation of evidence-based health care in the developing world. The frugal start-up model of technology entrepreneurship does not seem to sit comfortably in health care, in which the notion of a minimum viable product appropriately provokes immediate concern about patients’ safety. From our experience of using technology to support health-care workers in Somalia,3 where frugality is crucial, we see the emergence of a novel synthesis of the “hacker way” and the “health-care way”. This synthesis will involve the evolution of a new style of entrepreneurship bridging sustainable innovation with disruptive innovation. It will involve a new management style, with a prerequisite of doing no harm and limiting opportunity cost, but nonetheless providing a permissive environment for the creators. Finally, and perhaps most crucially, it will involve new frameworks for assessing technology, influenced as much by Apple user experiences as by Mayo Clinic outcomes. Consumers www.thelancet.com Vol 380 November 17, 2012
Centre for Global Health, King’s College London, London, UK (AETF); Department of Primary Care and Public Health, Imperial College London, London, UK (FG); and Dermatology Centre, University of Manchester, Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK (FRA) 1 2
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Howitt P, Darzi A, Yang G, et al. Technologies for global health. Lancet 2012; 380: 507–35. Anon. Zuckerberg describes ‘The Hacker Way’ at Facebook. Yahoo! News May 18, 2012. http://news.yahoo.com/zuckerberg-describeshacker-way-facebook-230031226--finance. html (accessed Oct 29, 2012). Finlayson AE, Baraco A, Cronin N, et al. An international, case-based, distance-learning collaboration between the UK and Somaliland using a real-time clinical education website. J Telemed Telecare 2009; 16: 181–84.
Authors’ reply Three varied pieces of correspondence show the diversity of issues raised by the topic of technologies for global health. David Sanders and colleagues highlight the potential for mosquito bednets to be used in hernia repair. This is an excellent example of a frugal technology using readily available and relatively inexpensive materials in place of costly bespoke mesh. Studies indicate no difference in short-term clinical outcomes.1 This should be the default approach to hernia repair in low-income and middle-income countries. Arguably it should also be the case in highincome countries, but will inevitably come up against vested interests. Ideally a study needs to show that there is no compromise in quality over the long term with use of
patches from bednets. Policy makers and the medical establishment must then act and not repeat the delay seen in the uptake of oral rehydration therapy. Process innovation from Japan is raised by Chieko Matsubara and colleagues. Japan has indeed made an important global contribution to process innovation, such as via the lean methods of Toyota.2 Although we are not familiar with the 5S-CQITQM approach, the positive results in Tanzania and the efforts of Japanese development partners emphasise an important message for high-income countries. Rather than focusing on donating devices, there is merit in helping low-income health systems adopt efficient ways of working to improve quality. Finally, Alexander Finlayson and colleagues highlight the tension between a “hacker’s way” of rapid technological innovation and the “health-care way” of medical conservatism, rightly (although not always proportionately) focused on patients’ safety. Their proposal for a new framework for assessing technology that includes greater consideration of issues such as users’ and patients’ experience alongside clinical outcomes is a welcome one. Work on such a framework would make an interesting research project to support the expansion of health technology assessment in low-income and middle-income countries—one of the Commission’s recommendations. We declare that we have no conflicts of interest.
*Peter Howitt, Ara Darzi, Zhong-Yang Guang, Karen Kerr [email protected] Institute of Global Health Innovation, Imperial College London, St Mary’s Hospital, London W2 1NY, UK 1
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Freudenberg S, Sano D, Ouangré E, Weiss C, Wilhelm TJ. Commercial mesh versus nylon mosquito net for hernia repair: a randomized double-blind study in Burkina Faso. World J Surg 2006; 30: 178–49. Holweg M. The genealogy of lean production. J Op Manage 2007; 25: 420–37.
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3
4
5
Hasegawa T. Strengthening organizations in health sector by total quality management (TQM). Tokyo: Japan International Cooperation Agency, 2006. http://jica-ri.jica. go.jp/IFIC_and_JBICI-Studies/jica-ri/ publication/archives/jica/kyakuin/ pdf/200606_hea.pdf (accessed Aug 15, 2012). Withanachchi N, Handa Y, Karandagoda KKW, Pathirage PP, Tennakoon NCK, Pullaperuma DSP. TQM emphasizing 5-S principles a breakthrough for chronic managerial constraints at public hospitals in developing countries. Int J Public Sector Manage 2007; 20: 168–77. Japan International Cooperation Agency (JICA). Stepwise approach for 5S-KAIZENTQM. http://www.jica.go.jp/activities/issues/ health/5S-KAIZEN-TQM/pdf/leaflet.pdf (accessed Aug 15, 2012).
will have to want it and it will have to do them good. There is natural tension between the conservatism of evidencebased practice and the agility of novel technology development. As both the e-health and m-health movements gather pace, their participants should learn from both approaches. We are all affiliates of MedicineAfrica.com, a social enterprise that provides an online platform for health-care educational partnerships.
Alexander E T Finlayson, Felix Greaves, *Faisal R Ali [email protected]
Peter Howitt and colleagues1 highlight the need to harness innovation for global health. We conceptualise this as marrying the technologist’s “hacker way”, made famous in Mark Zuckerberg’s letter ahead of Facebook’s stock market launch,2 with the more conservative approach of strategic incremental adaptation of evidence-based health care in the developing world. The frugal start-up model of technology entrepreneurship does not seem to sit comfortably in health care, in which the notion of a minimum viable product appropriately provokes immediate concern about patients’ safety. From our experience of using technology to support health-care workers in Somalia,3 where frugality is crucial, we see the emergence of a novel synthesis of the “hacker way” and the “health-care way”. This synthesis will involve the evolution of a new style of entrepreneurship bridging sustainable innovation with disruptive innovation. It will involve a new management style, with a prerequisite of doing no harm and limiting opportunity cost, but nonetheless providing a permissive environment for the creators. Finally, and perhaps most crucially, it will involve new frameworks for assessing technology, influenced as much by Apple user experiences as by Mayo Clinic outcomes. Consumers www.thelancet.com Vol 380 November 17, 2012
Centre for Global Health, King’s College London, London, UK (AETF); Department of Primary Care and Public Health, Imperial College London, London, UK (FG); and Dermatology Centre, University of Manchester, Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK (FRA) 1 2
3
Howitt P, Darzi A, Yang G, et al. Technologies for global health. Lancet 2012; 380: 507–35. Anon. Zuckerberg describes ‘The Hacker Way’ at Facebook. Yahoo! News May 18, 2012. http://news.yahoo.com/zuckerberg-describeshacker-way-facebook-230031226--finance. html (accessed Oct 29, 2012). Finlayson AE, Baraco A, Cronin N, et al. An international, case-based, distance-learning collaboration between the UK and Somaliland using a real-time clinical education website. J Telemed Telecare 2009; 16: 181–84.
Authors’ reply Three varied pieces of correspondence show the diversity of issues raised by the topic of technologies for global health. David Sanders and colleagues highlight the potential for mosquito bednets to be used in hernia repair. This is an excellent example of a frugal technology using readily available and relatively inexpensive materials in place of costly bespoke mesh. Studies indicate no difference in short-term clinical outcomes.1 This should be the default approach to hernia repair in low-income and middle-income countries. Arguably it should also be the case in highincome countries, but will inevitably come up against vested interests. Ideally a study needs to show that there is no compromise in quality over the long term with use of
patches from bednets. Policy makers and the medical establishment must then act and not repeat the delay seen in the uptake of oral rehydration therapy. Process innovation from Japan is raised by Chieko Matsubara and colleagues. Japan has indeed made an important global contribution to process innovation, such as via the lean methods of Toyota.2 Although we are not familiar with the 5S-CQITQM approach, the positive results in Tanzania and the efforts of Japanese development partners emphasise an important message for high-income countries. Rather than focusing on donating devices, there is merit in helping low-income health systems adopt efficient ways of working to improve quality. Finally, Alexander Finlayson and colleagues highlight the tension between a “hacker’s way” of rapid technological innovation and the “health-care way” of medical conservatism, rightly (although not always proportionately) focused on patients’ safety. Their proposal for a new framework for assessing technology that includes greater consideration of issues such as users’ and patients’ experience alongside clinical outcomes is a welcome one. Work on such a framework would make an interesting research project to support the expansion of health technology assessment in low-income and middle-income countries—one of the Commission’s recommendations. We declare that we have no conflicts of interest.
*Peter Howitt, Ara Darzi, Zhong-Yang Guang, Karen Kerr [email protected] Institute of Global Health Innovation, Imperial College London, St Mary’s Hospital, London W2 1NY, UK 1
2
Freudenberg S, Sano D, Ouangré E, Weiss C, Wilhelm TJ. Commercial mesh versus nylon mosquito net for hernia repair: a randomized double-blind study in Burkina Faso. World J Surg 2006; 30: 178–49. Holweg M. The genealogy of lean production. J Op Manage 2007; 25: 420–37.
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