Health Technology in Resource-Poor Settings
Introduction
Given the vast inequities in disease burden
between developed and developing countries, donors, advocates, and researchers
are marshalling resources to accelerate the production of new health
technologies that may help to bridge this gap.
“Improving the health
of the poorest people in the developing world depends on the development of
many varieties of health innovations, such as new drugs, vaccines, devices, and
diagnostic tools, as well as new techniques in process engineering and
manufacturing, management approaches, software, and policies in health systems
and services.”(1)
However, developing countries are able to
undertake health innovation to different degrees. In developing
countries, researchers and innovators face tremendous challenges, including the
lack of technical training, research tools, financial resources, and up-to-date
scientific information. These barriers impede activists from developing
and implementing innovative and low cost technologies.
One such health technology that has the potential to save and improve lives is the disposable needle. Increasing numbers of people in developing countries are getting the vaccinations that they need to protect their health, but clean needle practices have not caught up. At least 50 % of injections in developing countries are unsafe, and in some places that number is as high as 70 %.(2)
One such health technology that has the potential to save and improve lives is the disposable needle. Increasing numbers of people in developing countries are getting the vaccinations that they need to protect their health, but clean needle practices have not caught up. At least 50 % of injections in developing countries are unsafe, and in some places that number is as high as 70 %.(2)
Reused needles can increase the risk of HIV,
hepatitis B, and other infections. “In addition, when dirty needles are
not safely disposed of, people harvest them from the garbage and resell them,
and children even play with them in garbage dumps.”(3) Vaccinations are meant as a
preventive measure to ensure good health, yet when they are administered with
unsanitary syringes, patients may actually be harmed. The nonprofit
organization PATH has developed technologies for safe needle disposal and
worked with countries to get the supplies they need to make injections safe.
They have invented “auto-disposable,” one-time-use syringes and helped pioneer
needle removal devices that isolate dirty needles in secure containers.
Simple low-cost technology such as this has the potential to disseminate
rapidly across the developing world, saving millions of lives.
Diagnostic
Technologies
Oftentimes in resource-poor settings, health care
personnel do not have adequate technology to diagnose patients.
Facilities in developing countries frequently lack access to the highly
advanced laboratories that produce reliable diagnoses in wealthy
countries. Furthermore, health care facilities can be far away, serving
widely dispersed populations. A lack of quality equipment can undermine
the entire health care system. If health workers cannot correctly diagnose a
disease, they are unable to treat it effectively. Without diagnostic testing,
health care professionals are forced to rely on evaluating symptoms to diagnose
and treat illness—an imperfect method. This lack of clarity puts individuals,
communities, and the world in danger. Incorrect diagnoses can harm people
and even cost lives. Furthermore, ineffectively treated disease can become a
starting point for epidemics and contribute to the development of drug-
resistant parasites.
Fortunately, there are promising new
tests—inexpensive, portable, easy-to-use diagnostics that are practical at even
small, local health centers. Some of these tests are adaptations of
established technologies. Others are innovative scientific advances. One
such promise lies in modified molecular technologies for affordable, simple
diagnosis of infectious diseases. Early and accurate diagnosis of
infectious disease is important not only for prompt treatment, but also to
limit the spread of disease and avoid the waste of resources on ineffective
treatments. Molecular diagnostic technologies that are either
already in use or are being tested in low-income regions include the polymerase
chain reaction (PCR)(4),
monoclonal antibodies,(5) and recombinant antigens.(6)
Telemedicine
The problem of diagnostics is accentuated by a
lack of health personnel in developing countries, particularly in rural
settings. Not only is there a lack of appropriate diagnostic tools, there
is a shortage of health workers who are able to use this technology. In
order to address this problem, telemedicine, has gained much attention.
Telemedicine can be broadly defined “as the use of telecommunications
technologies to provide medical information and services.” Although this
definition includes medical uses of the telephone, email, and distance education, telemedicine
is increasingly being used as shorthand for remote electronic clinical
consultation.(7)
Telemedicine seeks to deliver the best medical advice
and treatment options to patients irrespective of their location.
Telemedicine’s major constraints include the access to and cost of the
higher bandwidth that is required for transmitting physiological data and
complex medical images. These constraints are more severe in developing
countries where even telephone-line-based access is limited and broadband
access is either not available or is far too expensive.
The promise of telemedicine is also limited by a
number of features which are common to most poor developing countries. These
include large gaps in basic infrastructure availability, and the ability and
willingness of health workers and others to make use of the
opportunities. The constraints suggest that, rather than helping to
improve health care delivery, telemedicine could generate a new "digital
divide” that creates further disparities in health. Additionally,
the rapid changes in technology can result in an inability to continue to use
the technologies.(8)
Case Study:
One Laptop per Child
At the world Economic Forum in January 2005, MIT
professor Nicholas Negroponte unveiled the idea of One Laptop Per Child (OLPC),
a $100 PC that would transform education for the world's disadvantaged
schoolchildren by giving them the means to teach themselves and each other. The
project's goal is "to provide children around the world with new
opportunities to explore, experiment and express themselves."(9) OLPC dedicated a great deal of
effort to designing a laptop that would function well in a developing-country
environment. Their laptop, the XO, is sealed to keep out dirt, has a
display that can be read in bright sunlight, runs on low power, and is rugged.
Despite its considerable innovation, the OLPC
project has been unable to achieve its $100 targeted cost. The current cost of
each unit is listed on the OLPC Website as $199. However, this does not
include upfront deployment costs, which are said to add an additional 5%–10% to
the cost of each machine, and subsequent IT-management costs.(10) Nor does it include the cost of
teacher training, additional software, and ongoing maintenance and support.
These costs are difficult for governments to justify in developing
countries. Additionally, OLPC originally estimated that it would ship
100–150 million XO laptops by the end of 2007, but the program has clearly fallen
far short. Under more modest goals, production was supposed to reach five
million laptops by the end of 2008.(11)
As of December 2009, there were just over 1.4 million XOs in the field.(12)
While these output statistics are available,
there have been few studies that have measured outcomes, or the project’s
impact on targeted communities. Several commentaries have questioned the
project's potential for impact, pointing to its guiding assumption that more
laptops per child equates to educational progress. Many have also
questioned the common view known as technological determinism –that a given
technology will lead to the same outcome, no matter where it is introduced, how
it is introduced, or when. One study on the project’s outcomes points to
several lessons that must be considered when introducing a new technology:(13)
·
Diffusing a new
innovation requires an understanding of the local environment. Social, economic, and cultural environments vary greatly
across and even within countries, and deploying new technologies requires
understanding these environments. Innovators must consider the need for
expertise in sociology, anthropology, public policy, and economics, as well as
for engineers, and establish coherent criteria for selecting countries to
target based on social, economic, and cultural realities.(14)
·
Innovative
technology can be disruptive and trigger a backlash from incumbents. In some cases, teachers and the educational establishment
have resisted the OLPC innovation as it requires a significant change in
pedagogy that might reduce teacher status.
·
Innovative
information technologies do not stand alone. OLPC laptops were not part of any established business
ecology and the program lacked resources to establish its own ecology.
Best
Practices of Technology Design, Implementation, and Evaluation
When designing and implementing new health
technology in the developing world, it is important to ascribe to best
practices in order for products to be successful and ethical.
Important factors to consider include:
·
Impact: How much difference will the technology make in
improving health?
·
Appropriateness: Will the intervention be affordable, robust and adjustable to
health care settings in developing countries, and will it be socially,
culturally and politically acceptable?
·
Burden: Will this technology address the most pressing health needs?
·
Feasibility: Can it realistically be developed and deployed in a time
frame of 5–10 years?
·
Knowledge gap: Does the technology
advance health by creating new knowledge?
·
Indirect benefits: Does it address issues such as environmental improvement and
income generation that have indirect, positive effects on health? (15)
A recent study of health biotechnology in developing
countries found that local public-private partnerships, sustained government
support for research, and the availability of venture capital were important
factors in the ability of an innovative technology to meet national health
needs.(16)
Given that most of the infrastructure for health research in developing
countries resides in the public sector, partnerships between local public and
private research organizations deserve particular attention.(17)
In other words, in order for a health technology to be appropriate, feasible,
and driven by public health goals, it should be designed in coordination with
the public sector.(18)
Furthermore, C. K. Prahalad points out in The Fortune at the Bottom
of the Pyramid that some manufacturers
in developing countries pursue a business model in which they specialize in
high-volume, low-margin production, which leads to low-cost products.
Products produced in this way may be more affordable, an important factor
in access to medicines in developing countries.
An
Appropriate Balance
There is no doubt that technology holds much
promise for improving health in developing countries. This truth, however,
should in no way diminish the importance of proven health strategies. Health
education, for instance, is integral to the control of the AIDS pandemic, as is
the provision of condoms. In addition, improvements in sanitation can
substantially reduce the prevalence of infectious diseases, and basic
nutritional education can help prevent nutrient deficiencies. These tools are
available now, whereas promising biotechnologies are at varying stages of
development. We ought to strive to achieve an appropriate balance between
investment in new technologies and in conventional strategies.
Oftentimes, hype regarding technology can
distract from global concerns. For example, the One Laptop Per Child
initiative has the potential to distract from traditional education
efforts. An additional technology, self-adjusting eyeglasses, allows
patients to be in full control of their prescription, and to change the power
of their glasses at will. As Joshua Silver, designer of the
self-adjusting lenses, told CNN:
"Any model of
delivery of vision correction in the developing world that depends on eye care
professionals won't work. If you find a model that doesn't rely on them, then
you potentially have a solution.” (19)
While this concept may seem promising, it must be
remembered that glasses are medical products, and comprehensive eye exams and
treatment by medical professionals must be promoted and provided. When
glasses are dispensed as consumer products, it creates more substantial
barriers to care while also promoting a false and commonly-held belief that
eyeglasses are fashion accessories. For example, when receiving glasses
from a local community member, it can be impossible for a village patient to
understand that receiving glasses does not constitute a complete eye exam by an
eye care professional.
When patients seek eye care from local community
members who represent themselves as "trained" eyeglass providers, but
are not offered proper examination, diagnosis, and treatment for treatable
conditions such as cataracts, they may begin to believe that there is nothing
that can be done for their eye condition. Thus, trained local community members
must be integrated into a local eye clinic's ongoing outreach programs by eye
care professionals at the same location. The primary role of the
community members should be to help reduce barriers to patient care, and their
close involvement with local eye clinics can be highly beneficial to the
patients.
In conclusion, self-adjusting glasses distract
from global eye care needs and perpetuate the misconception that all eye
diseases can be corrected by eyeglasses. Resources spent on distributing
self-adjusting glasses can be better spent on human and financial resources to
provide comprehensive examinations by eye care professionals. Technology
is needed to facilitate global health delivery, yet at the same time, it should
not seek to replace proven interventions.
Footnotes
(1) C.M. Morel et al., Health Innovation in Developing Countries
to Address Diseases of the Poor, Innovation Strategy Today, 1,
2005, p.1-15.
(4) Harris, E. A Low Cost Approach to
PCR:Appropriate Technology Transfer of Biomolecular Techniques (ed. Kadir, N.) (Oxford Univ. Press,
New York, 1998).
(5) Palmer, C.J. et al.
Evaluation of the OptiMAL test for rapid diagnosis of Plasmodium vivax and Plasmodium falciparum malaria. J. Clin. Microbiol. 36, 203–206 (1998).
(6) Aidoo, S. et al.
Suitability of a rapid immunochromatographic test for detection of antibodies
to human immunodeficiency virus in Ghana, West Africa. J. Clin. Microbiol. 39, 2572–2575 (2001).
(7) Peredinia DA, Allen AA. Telemedicine technology and clinical
applications. JAMA 1995; 273: 483-488.
(8) Chandrasekhar C P, Ghosh J. Information and communication
technologies and health in low income countries: the potential and the
constraints. Bull World Health Organ. 2001;79(9):850–5.
(10) Stecklow, S. and Bandler, J. A little laptop with big
ambitions. WallStreetJournal.com (Nov. 24, 2007.)
(11) O'Donnell, B. Worldwide Mini-Notebook PC
2008–2012 Forecast Update and 3Q08 Vendor Shares. Market Analysis.
IDC, Framingham, MA, Dec. 2008.
(13) Adapted from http://delivery.acm.org/10.1145/1520000/1516063/p66-karemer.html?key1=1516063&key2=0894753621&coll=GUIDE&dl=GUIDE&CFID=73045704&CFTOKEN=69861373.
(15) Daar, A. S., H. Thorsteinsdottir, D. K. Martin, A. C. Smith,
S. Nast, and P. A. Singer. 2002. Top ten biotechnologies for improving health
in developing countries. Nat. Genet. 32:229-232.
(17) Global Forum for Health Research, Monitoring Financial Flows for Health Research,
Vol. 2 (Global Forum for Health Research, Geneva, 2004), pp. 14–15.
(19) Tutton, Mark. "Liquid specs a bold vision for world's
poor." Vital Signs. CNN.com
16 Sept 2009. Accessed 19 January 2010.
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