Yesterday we were invited to sit in and meet the CEO of GSK, Andrew Witty, as he announced the new GlaxoSmithKline Open Innovation Strategy To Aid Poor Countries. The following entry is by one of our new bloggers, Sarah Searle (@sarahsearle on twitter) from the Johns Hopkins International Health program:

“Big Pharma as a Catalyst for Change”: GSK “Open Innovation” strategy

It’s estimated that one-third of the world’s population go without essential drugs–often drugs for treating diseases that disproportionately affect the world’s poorest. The pharmaceutical world proves to be especially difficult to navigate for those seeking to provide such medicines to underserved populations, however. Pharmaceutical science is a field with billions of dollars in R&D, ironclad patents and intellectual property rights that are prohibitive to making drugs available to the poor. Andrew Witty, CEO of GlaxoSmithKline, claims that he’s looking to change this nature of big pharma, in the same way that the open source movement has revolutionized the tech world.

I love the word “innovation” combined with anything related to global health, so the prospect of sitting in on a blogger’s roundtable with GlaxoSmithKline CEO Andrew Witty was exciting enough just from the topic at hand: “Breaking Down Barriers to Innovation and Access to Medicines in the Developing World.”

The ante was upped in a press conference this morning, when Andrew Witty announced GSK’s “Open Innovation” strategy to make drugs more available and break down barriers to access. This strategy includes several components.

“Open Lab” initiative
$8 million in seed funding has been provided establish an “Open Lab” at GlaxoSmithKline’s research facility in Spain. As many as 60 scientists from around the world will be able to work at this lab, which will be devoted to research for drugs that target diseases of the developing world.

13,500 malaria-combating compounds in the public domain
This is perhaps the most exciting announcement. GlaxoSmithKline has been collaborating for years with PATH and other organizations in the development of a malaria vaccine. Scientists at GSK have screened all compounds that have ever been created in their labs, and identified 13,500 compounds that successfully combat P. faciparum, the deadliest form of malaria. The big news? The chemical structures and other recorded data regarding these compounds will be open sourced, in hopes that malaria vaccine research will be accelerated.

New pricing model for GSK’s malaria vaccine candidate
GlaxoSmithKline is in the process of developing the world’s most advanced candidate for a malaria vaccine—it’s the only vaccine in Phase III clinical trials, and could be available to the public as early as 2012. Maintaining that a tiered pricing model simply isn’t feasible for a drug which is needed almost exclusively by the world’s poor, Witty announced a pricing model for the vaccine which covers the cost of the vaccine with a marginal return for GSK, all of which will supposedly be channeled back into R&D for “next-generation” malaria vaccines.

It goes without saying that some present at the roundtable were wary of the corporate world’s ability to selflessly decide change the mechanics of drug information and pricing in order to benefit the world’s poor. Witty has struck a nice balance between acknowledging that GSK is a profit-driven company but maintaining that he strives to keep a “restless” socially-conscious agenda.

And let’s be honest—GSK won’t be suffering much financially with this move. First of all, the malaria drug market isn’t very competitive to begin with, because of the very fact that it is a poor person’s disease. Secondly, GSK is already the developer of the leading candidate for a malaria vaccine. It’s unlikely that, even with the compound information made publicly available, anyone can come up with a vaccine to rival GSK’s in any short amount of time.

Indeed, as Witty acknowledged, making drugs and drug knowledge more universally available is an investment in the future. Drugs will not be provided for free, he stressed, but rather provided at a marginal price that won’t completely alienate other pharmaceutical companies from healthy competition for lifesaving drugs.

Regardless of motivation, it’s refreshing to see big pharma recognizing the issues of access to medicines for the world’s poor. Moreover, Witty’s emphasis on being in step with progressive intellectual property movements is laudable. Whether or not GSK’s initiatives will stimulate other pharmaceutical companies to follow suit remains to be seen.

Related articles by Zemanta

• Glaxo’s Witty Tries To Fix An Industry Problem (invivoblog.blogspot.com)
• Drug firm boost to malaria fight (news.bbc.co.uk)
• Glaxo offers free access to potential malaria cures (guardian.co.uk)
• GSK offers to share data to help fight malaria fight (telegraph.co.uk)
• GSK offers scientists labs, data to fight malaria (seattletimes.nwsource.com)
• Malaria researchers given crucial data (cbc.ca)
• GlaxoPfizer tieup opens new era in Aids battle (telegraph.co.uk)

The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. This is the sixth and final in a series of posts from the conference.

It’s now been a month since Forum 2009, so it’s time to wrap up any remaining thoughts from the meeting. My intention with these posts was never to provide a comprehensive view of the conference. If you’re looking for that, or simply additional insights into the meeting, I recommend the following resources:

1. Priya Shetty’s coverage of Forum 2009 for the SciDev.Net blog, five posts
2. TropIKA.net comprehensive coverage of Forum 2009, including daily reports and session reports

On my Cancún-bound flight out of Havana, on the morning of the 20th, the woman sitting next to me asked me for help with her Mexican immigration forms. As I was helping her, I asked what she did. “Terapista”. She asked what I was doing in Cuba. Attending “un congreso de investigaciones de salud pública”. She was a Cuban physical therapist going on a three month medical mission to Tecate in the Mexican state of Baja California, via Cancún, Mexico City, and Tijuana. I spent most of the short flight asking about her experiences on previous missions, all to Mexico, and probing for more details about the Cuban health system. Most memorably, she was quite proud of a unique surgical treatment the Cubans have developed for Parkinson’s disease.

I spoke about the medical assistance Cuba lends to other countries in an earlier post. The photo below of the 20 convertible peso note reinforces this. It touts Operación Milagro (Wikipedia link in Spanish), a joint program between Cuba and Venezuela with official aims similar to Cuba’s other medical mission efforts.

While I was speaking to this terapista on the plane, it occurred to me how important the setting of the conference was given the innovation theme. I don’t think that this was lost on many of the conference participants given external interest in the Cuban system, Cuban participation on panels, and various site visits. Still, there were three circumstances that limited knowledge exchange between the visitors and the Cubans:

1. Language barriers. There wasn’t very much communication between the several hundred Cuban participants and the external participants, especially those from outside Latin America. This was due in no small part to language barriers. Simultaneous translation took place during the larger sessions (UN-style headsets), but the smaller sessions didn’t have any and the informal exchange was visibly limited between the two groups.
2. An apparently flawless system. The Cuban health system may have been the talk of the week, but it was presented without fault. Even though it may be one of the best systems on the planet, it is not immune to needing improvement. Without a realistic understanding of the challenges, it was hard to understand the true effectiveness of the system. (In comparison, Minister of Health Chen Zhu was frank in talking about elements of the Chinese health system that need improvement, for example indicating in his plenary talk that many public clinics in China operate like private clinics.)
3. No U.S. government employees in attendance. There were certainly Americans at Forum 2009, but because of the restrictions associated with the U.S. embargo – it’s a bloqueo the Cubans said, since an embargo implies wrongdoing – there were almost no representatives of U.S. government institutions. I didn’t realize this myself until a colleague from the WHO pointed it out to me. He cited the example of his colleagues from the CDC who were not permitted to attend. Looking through the participant list, I only spotted one, someone from USAID. It’s unfortunate because there was a big opportunity for learning in both directions. In any case there were strong suggestions that we are months away from ending the embargo/bloqueo. Time will tell.

And here’s a post Aman wrote for Global Health Ideas about the Cuban health system two years ago: Lessons from Cuba: Healthcare Infrastructure and Information Systems.

The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. This is the fifth in a series of posts from the conference. Only one or two more after this one.

My reason for attending Forum 2009 was to participate in a session title “Innovation for Remote Populations”. This post is a about that session. What follows is taken from my recent report to the Global Forum for Health Research – edited only slightly.

Innovation for Remote Populations

Thurs-19-Nov-2009, 14:00-15:45, Global Café, Palacio de Convenciones, La Habana, Cuba

Coordinators/Facilitators:

• Patricia Mechael, mHealth and Telemedicine Advisor, Millennium Villages Project, Earth Institute, Columbia University, USA & Egypt (organizer & facilitator)
• Tim Hurson, Facilitators Without Borders (facilitator)
• Charles Gardner, Global Forum for Health Research (focal point)

Speakers (alphabetical order):

• Simon Adebola, NEPAD Council Global Health Commission, Geneva
• Najeeb al-Shorbaji, Director, Knowledge Management and Sharing, WHO
• Caren Serra Bavaresco, Student, Epidemiology, Universidade Federal do Rio Grande do Sul, Brazil
• Karl Brown, Associate Director, Rockefeller Foundation
• Arul Chib, Assistant Professor, Wee Kim Wee School of Communication, and Assistant Director, Singapore Internet Research Center, Nanyang Technological University
• Dziedzom Komi de Souza, Ph.D. Student and Research Assistant, Parasitology, Noguchi Memorial Institute for Medical Research, Ghana
• Bastiaan Hoefman, co-Founder, Text2Change
• Bernardita Labarca, Project Coordinator, Zoltner Consulting Group, Chile
• Claire O’Neill, Chairperson, Cell-Life-South Africa
• Ravi Ram, Head, Monitoring & Evaluation, African Medical Research and Research Foundation (AMREF), Nairobi Kenya
• Marco Salmen, OHR-GMCP Initiative for HIV/AIDS, Global Micro-Clinic Project, United States
• Jaspal S. Sandhu, Design Researcher, College of Engineering, University of California, Berkeley, USA
• Joel Selanikio, co-Founder and Director, Datadyne.org, USA
• Garance Upham, General Secretary, Direction, Safe Observer International, France

Additional participants – from the audience:

• Elmer Zelaya – Fundación Chica/Nicaragua
• Timothy Dye – SUNY Upstate Medical School/USA
• Jane Kengeya – WHO
• Oyewale Tomori – Redeemer’s University/Nigeria
• Lishandu/Zambia (full name/affiliation not available)
• Vargas/USA (full name/affiliation not available)

Summary:

1. Diverse users and uses: The speakers presented a variety of mHealth/eHealth applications involving a wide variety of users, including both the health workforce and community members, e.g. educating teenagers about HIV/AIDS in South Africa (O’Neill), Internet access in western Kenya to improve uptake of HIV VCT (Salmen), mobile emergency response systems in Aceh (Chib), electronic IMCI in Tanzania (Brown), text-based health education and health service promotion in Uganda (Hoefman), training for health workers as a downloadable game package for phones in Kenya (Ram), telemedicine to improve the skills of health workers at primary levels in Brazil (Bavaresco), delivery of health information to communities in Chile (Labarca), a general set of tools for mobile data collection being used worldwide (Selanikio), and handheld computers to support rural healthcare delivery in Mongolia (Sandhu).
2. mHealth/eHealth is about enabling access: A common theme across diverse applications was that information and communication technologies are being used to enable access to health information and services in places where access is difficult because of remoteness and/or cost.
3. Coordination among the various players: Coordination among donors and projects is necessary to avoid unnecessary duplication of effort and to share what works. This is the role of the mHealth Alliance, supported by Rockefeller Foundation among others (Brown). While there were questions from the program side as to what data donors want (Chib), there was a simultaneous sentiment that donors need “stepwise” guidance (al-Shorbaji).
4. De-emphasizing technology: The mHealth Alliance has recently been discussing development of an “mHealth Toolkit”, to provide a common technical architecture and platform for those planning to implement mHealth programs (Brown). The existence of free technology platforms – in this case DataDyne’s tool – enables programs to focus on developing health content (Labarca). It is important to have a generalizable tool, as DataDyne has done, that can be used by anyone; if individual governments must approve technology “you’ve lost the battle” (Selanikio). Programs must focus on understanding people and applications more than technology; in response to a question from Dye about the use of ethnography in this field, three examples were given: ethnography of teen chat rooms in South Africa (O’Neill), multi-year ethnographic fieldwork as the basis for the program in western Kenya (Salmen), and design ethnography of the information management practices of rural health workers in Mongolia (Sandhu).
5. Defining good evaluation: There are challenges to seeing change in population health outcomes (Chib). It is difficult to measure behavior change (Hoefman) and to evaluate systems that provide health content to people (Labarca). Ethnography should be considered more seriously as a complementary evaluation strategy in mHealth (Sandhu). In evaluation, the metrics should match the intervention – mHealth is another intervention; in addition, we want to see the unintended effects of technology (Ram).
6. New modalities of engaging people: Mobile phones enable fundamentally new ways of engaging with people. As opposed to mass communication that is often used in social marketing, phones allow for interpersonal communication that can be tailored and cost-effective (O’Neill). There are two modalities, moving messages out to people and demand-driven services, where people demand the information that they need (Ram). Salmen lent his support to the importance of demand-driven services and argued that phones will bring more equity. This is all supporting the shift to citizen-centered healthcare (Mechael).
7. Cautions moving forward: In natural disasters, the cellular network is the first to go (Zelaya). An open question: Who owns the data? (al-Shorbaji). Nobody is thinking about “real sustainability” (Adebola). Reliable phone networks are a challenge (Lishandu). We should be careful that we don’t become too dependent on one tool (al-Shorbaji).
8. Need to think more creatively: We should be bolder with approaches; if we are, poor countries “could leapfrog” in health and development terms (Upham). Many of the applications discussed focused on SMS and telephony capabilities; we should think about leveraging more advanced capabilities of mobile phones (Kengeya).
9. Who should design technology? There is an assumption that Africans cannot develop software, but that is not true (Adebola). DataDyne software was already developed by Africans (Selanikio). Africans should develop software, but they shouldn’t redesign what has already been built (Brown).

Conclusions/Recommendations:

1. There is a need for increased knowledge-sharing about mHealth/eHealth within the global health community. This should definitely include policymakers. As Prof. Tomori elegantly stated, while we are thinking about how to reach remote populations, we should think about “hard-to-reach” African leaders.
2. While there was discussion of both eHealth and mHealth, the discussion focused primarily on the latter.
3. There is a need for a continuing dialogue about mHealth. It is unrealistic to expect policy recommendations to come out of this meeting given the state of the field (many open issues) and the limited engagement at the meeting.
4. Major mHealth topics to be discussed at future meetings: definitions; standards, including how to conduct evaluation; and successes and failures from the field.
5. The value of the meeting was threefold: (1) it helped extend the network of those working in mHealth; (2) it provided those outside the field with an understanding of the opportunities and challenges of using mobile phones to improve population health; and (3) it placed a much-needed emphasis on prioritizing people and applications over technology.
6. Mechael suggested reviving the Mobile Metrics and Evaluation Group as a means of maintaining an active mHealth community discussion outside of official meetings.

Other observations:

1. The fishbowl format was successful in eliciting relevant commentary from a large group of speakers as well as from the audience. Time was an issue, though, as several invited speakers only spoke once and several audience members had comments or questions that they were unable to share.
2. One key issue that was not explored – as I stated at the end of the session – was the link between social entrepreneurship and mHealth. This is especially relevant to issues of demand, incentivization, and sustainability.
3. There is a need for an ongoing discussion of these issues at Forum 2010 and beyond – while the conversation will continue in other settings, the Global Forum for Health Research should continue to be involved because of its systems focus, its emphasis on actionable research, and the unique mix of parties (policymakers, donors, implementers) it brings together.

The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. I was in Jamaica the week following the conference and completely offline. Now that I’m back in the U.S., I’m planning at least two more posts about Forum 2009. This is the fourth in a series of posts from the conference.

In early 2009, Oxfam released a report Blind Optimism critical of the private sector’s role in healthcare in poor countries. It drew attention to the cause of those who believe that any private involvement in healthcare in these countries is harmful. The arguments, evidence, and position of the report were flawed in numerous ways; sound responses to the report were provided by April Harding and the World Bank:

• Oxfam — This Is Not How to Help the Poor
• World Bank responds to new Oxfam health report

The reasonable conclusion one would come to from working in the field and from studying health systems is that a mix of private and public approaches will be most effective – and that the need for different approaches should be dictated by local context. Ideological extremism – pro-private or pro-public – doesn’t serve anyone, most especially the people who need access to health.

At Forum 2009, there was much stronger representation of the private sector than at the previous meetings. In addition to pharma and biotech, there were several sessions and plenary speakers dedicated to talking social entrepreneurship. One of these speakers was Al Hammond, Senior Entrepreneur-in-Residence at Ashoka. Al spoke during Wednesday’s plenary - Enhancing national environment for innovation: perspectives on low- and middle-income countries (TropIKA.net post about the session) – about Ashoka’s Healthcare for All pilot Punjab, India.

During Q&A Claudio Schuftan of the People’s Health Movement criticized Dr. Hammond and Ashok [sic] for: (1) bringing electronics to people where there is no electricity or way to repair devices, (2) supporting the interests of multinational corporations, and (3) making people dependent on products. Dr. Hammond began his response by saying, “We are aware that there is hostility towards private sector approaches”. He explained that they use market approaches to achieve efficiency and that all the programs he presented are social enterprises started by NGOs. Based on the success of the three pilots so far, the Punjabi government has requested 600 additional units. “Take what you will from that”, he ended.

Dr. Schuftan’s comments are well-aligned with the Blind Optimism ideology. Such comments attempt to polarize policymakers, donors, and implementers. In doing so, they actually keep us from thinking critically about the private sector and social entrepreneurship. Fortunately, this was not the overall tone of the meeting.

At the end of a session examining the role of governmental policy in supporting social entrepreneurship, Julius Mugwagwa of the Open University (UK) asked a question about the “backlash” that might occur if something went very wrong with one of these social entrepreneurial models. This is the type of balanced discussion we really need.

Nota bene: These are a few highlights from CGI – please do add your inspirations/ideas in the comments!

Clinton Global Initiative – Making things happen through Commitments

Action speaks louder than words. At CGI, you’ve got to commit – and that has an amazing impact.

What will your commitment be?

CGI was the birthplace, in past years, of projects like Matt Damon’s water program (water.org, expanding this year to Haiti), the Goldman Sachs 10,000 Women Initiative, and so many more. In the five years of CGI, there have been 1,400 commitments made (participants are required to make commitments to existing projects or commit to creating new projects), valued at $46 billion dollars, and impacting the lives of 200 million people in 150 countries. This year’s meeting will give birth to 30 more of these programs – more by Andrew Mersman over at Passport Magazine/ Change by Doing blog.

Check out CGI Commitments here.

Innovation!

Business Week highlighted innovation as a top priority for the global economy, and President Obama announced a new strategy for innovation: A Strategy for American Innovation: Driving Towards Sustainable Growth and Quality Jobs. Download white paper.

Judith Rodin of the Rockefeller Foundation identified innovation strategies that could be applied to social problems – user-driven innovation, crowd sourcing and collaborative competitions reported here by Alexandra Cheney at Fast Company.  And Innovate Today: 8 Ways Business can End Poverty - superb post by Steve Enders over at tonic.

A few people – including Muhammed Yunus and Ngozi Okonjo-Iweala of the World Bank at CGI had an Innovation Wish List. Yunus talked about the edible yogurt pot, and Judith Rodin announced a new initiative to help the poor – the Global Impact Investing Network. This gets my vote for one of the most exciting developments to come out of CGI – read the Economist article.

Investing in Women and Girls

Women make up half of the world’s population, but do 2/3 of the world’s work, produce 50% world’s food, earn 10% world’s income, own 1% of world’s property.

Read the rest of this entry »

Mayo Clinic, Global Health and Design Thinking. You might be wondering what those three terms have to do with each together. This is my partial recap on time spent at the Mayo Clinic this past week where I saw one potential vision of what the future of healthcare might look like. It was a great privellege to hang out at the Mayo Clinic for what was the best conference I have attended in a long long time or maybe ever (Amy Tenderich at Diabetes Mine also has a recap that I encourage you to read). The Mayo Center for Innovation hosted a TED style event – Transform, a collaborative symposium on innovations in health care experience and delivery, all the videos are online (highly recommended viewing). It is going to take me a few months to digest what happened there and wrap my mind around everything I heard. There were over 430 people from 23 states, 7 countries and over 1,350 tweets. The caliber and just genuine niceness of every person I interacted with was on some other level, the conversations were rich, deep and thoughtful. The conference organizers *created an open purposeful environment* that led to an incredible experience. The folks at Mayo certainly shaped and designed a great space to achieve the symposium goals (this all reminded me of the Winston Churchill quote – “We shape our buildings and afterwards, our buildings shape us”).  Let me stop before you think I have joined a cult. The direct connection to global health here – it was discussed by keynote speakers and my first tweet from Mayo was “this place reminds me of Aravind (Aravind Eye Care System). Jaspal, Mahad and I have written several articles and cases studies on Aravind and I continue to believe it is a premiere model for innovation and care delivery. More on this in a bit.

The Global Health Convergence: “Design Thinking” and Innovation
There were many things that made this event great, however, in terms of extending your horizons and making you think, one of the most refreshing things was to see some convergence of disciplines and people from a variety of backgrounds. This is very hard to do and cannot be underrated. We all live in a sea of fragmentation,  in systems, in professions and fragmentation in how we solve problems. This is even reflected on a micro level – look at the mainstream peer reviewed journals in healthcare where you see severe fragmentation amongst the physician, nursing and pharmacy focused journals (some of this is for good reasons and some of it’s not). This conference was in part about ditching that fragmentation and about a convergence of ideas, people and relationships working collaboratively. In addition to innovative projects, new models of delivering care and how the process of innovation can be conceptualized, managed, and enabled was discussed. Much of this was encompassed under the umbrella of Design Thinking (innovating and problem solving using various methods). Tim Brown, CEO of IDEO, was a headliner on this front and re-emphasized a call for design to big, an ethic of design for social impact/change, which Jaspal and I have covered on this blog before (see our previous post – 8 Links for Design and Global Health).

If you were too look at the methods of design thinking you would see an amalgamation and convergence of mostly existing methods from a variety of disciplines (from engineering to ethnography to epidemiology to psychology to health services research to name a few examples). As Tim Brown said in his talk: “Design thinking begins with integrative thinking which is the ability to hold opposing constraints and opposing ideas and from those create  new solutions…this means balancing societal needs (desirability) with what’s possible (feasibility) and what’s sustainable (viability)“. When Tim Brown said “Design should not be left in the hand of designers” he hit the nail on the head – design thinking can be incorporated by non-”designers” to help innovate and solve problems. What we do has to be a participatory, collaborative effort. Tim Brown wrote more about this participatory perspective (How to Design a Participatory System in a post crisis economy world). There are many critically important reasons why this is a key factor, one of which goes back to Paulo Freirean educational tenets – people who participate in their own education, become engaged in the transformation of their own world. The other reason is because even though as brilliant as Tim Brown is, (and all the people working at organizations like his) he doesn’t have all the answers, or even the correct ones (read his other piece at FastCompany on HSAs where his point is highly debatable about the solution and at best has over simplified the problem).

The bottom line that I took away is that we need more of a participatory system, we should be open to new ways of approaching problems (“design thinking”) and we can provide some structure to the process of innovation. Besides design thinking the other major theme I want to point to is global health – as I said above in the keynote presentations global health made an apperance. Both Clay Christensen and Tim Brown mentioned the Aravind Eye Care System and Jaspal spoke entirely about global health. We have said on this blog before that there are many lessons that can be learned from outside our system where innovation is taking place due to extreme necessity, it’s not a choice (a lot of this is taking place over the web and with mHealth – mobile phones for health). In Global Health, there are hundreds, maybe thousands of innovative experiments going on using a wide area of technology (devices, drugs, the web, mobile phones, etc.), however, how we track these experiments, talk about failure, and share what has been learned seems to be highly inefficient and lacking.  We have covered a lot of this ground over the past three years, the easiest summary of examples can be found in this post:

42 “Extremely affordable” Innovations in Global Health

Clay C, Tim B, and Jaspal all pointed to global health as a place we can learn from. While there are some serious limitations, there is a ton to learn from the use of mobile phones in developing countries and how that might apply here – because overseas usage of phones is far beyond what is being done in the US. The other area to keep an eye on is chronic diseases. In some places, there is going to be an explosion of chronic conditions and new models will have to be devised to handle that tidal wave. I would love to see Amy Tenderich and her community do a brainstorming session on design for diabetes in developing countries. On this front see two previous posts:

1. Reverse South to North innovation – Borrowing innovation: health services, financial services, and clean tech
2. A massive wave of chronic disease in India and China

Let me leave you on a note of caution, a “design thinking” approach (remember using existing methods) can offer some powerful alternatives. However, there can also be something seductive about design thinking and a rapid approach (we’ve cautioned this on the graphics/visual side before). If you fall into that seduction, then this is just a fad for you, it’s on us to be rigorous, thoughtful and corrective when need be:

“The myth of innovation is that brilliant ideas leap fully formed from the minds of geniuses. The reality is that most innovations come from a process of rigorous examination through which great ideas are identified and developed before being realized as new offerings and capabilities.” IDEO website.

I have many more thoughts on this, if I get the time I’ll jot down a few more notes and quotes from the conference, in the meantime, it is well worth watching the videos from Transform.

As promised earlier, here is a brief account about the design+water workshop I conducted in Mexico in June.

Two months ago, I was in La Paz, Mexico at NGO Fundación Cántaro Azul, helping them build organizational capacity in human-centered design (HCD).  Cántaro Azul works to improve access to safe water and sanitation for disadvantaged communities, not only in Baja California Sur, but in other parts of Mexico, and abroad. Their interest in HCD is two-fold: to improve existing initiatives and to innovate new approaches.

I recently completed the workshop final report for the organization. In the hopes that the work may be helpful to others, I’m posting the synopsis of the report here, along with some workshop photos. If you’re interested in accessing the report, please contact me directly.

Design thinking workshop final report: Safe water options with rural community stores in BCS 

Fundación Cántaro Azul • La Paz, Baja California Sur, México 

Jaspal S. Sandhu, Ph.D. • July 2009 

This document describes the outcomes of a week-long design thinking workshop held at Fundación Cántaro Azul (FCA) in La Paz in June 2009. The workshop aimed to build design thinking capacity at the organization while working on a problem of actual importance to FCA. The most important practical outcomes of this workshop were two complementary models for providing a clean, affordable drinking water choice for rural people in Baja California Sur via community stores. The primary audience for this document is FCA. It is intended to help them with ongoing activities focused on the community store model and in incorporating this approach in their various activities. The workshop was designed and facilitated by Jaspal Sandhu, the report author. Workshop funding was provided by the Blum Center for Developing Economies at the University of California, Berkeley.

Shown below: Field research during Day 2 and Day 3 of the workshop. (1) Using an auto-servicio system in La Paz (top left); (2) interviewing a user at a rural, government-run purificadora in San Antonio (top right); (3) debriefing after the San Antonio research (bottom left); (4) and obtaining water samples to test from a home in Rosario (bottom right).

Image courtesy of kiwanja.net

Late last week I read news from three different sectors, all about “South-North” innovation transfer, a topic we’ve discussed here before, particularly in the context of mHealth. Earlier this year Fast Company reported on the concept of trickle-up innovation, citing the examples of yogurt microplants in Bangladesh (Group Danone, Grameen Bank) and Mosoko, touted as Craigslist for the next billion in Kenya (Nokia). In addition to these cases of MNCs from the global North testing out concepts in the South, Fast Company presented examples of corporations from the South, including ICICI (banking, India), Natura (cosmetics, Brazil), and Goodbaby (infant products, China).

Here are the three articles from this past week:

1. HEALTH SERVICES: To Fix Health Care, Some Study Developing World, Wall Street Journal, 2 Jul 2009. The University of Alabama-Birmingham AIDS clinic turned to Zambia for a model of increasing the number of patients who showed up for treatment. Based on early successes, they are continuing under the project name “Zambama”.
2. FINANCIAL SERVICES: DOCOMO to Launch Mobile Remittance Service, NTT DOCOMO press release, 2 Jul 2009. Later this month Japan’s DOCOMO will enable individual subscribers to use their mobile phone to remit money to other subscribers. Such a branchless banking/financial remittance service is certainly prompted by Safaricom’s M-PESA service from Kenya.
3. CLEAN TECH: Worldchanging Interview: Shawn Frayne, 2 Jul 2009. The interview is about wind technology, but touches on broader issues related to South-North innovation flow. Frayne thinks that “the constraints of the developing world can provide the necessary inspiration to make significant technological leaps that can benefit the Global South and Global North simultaneously”.

There are various other examples from the last several years suggesting a growing trend in countries from the North learning from the South. Here are examples just around financial services for the poor:

• Opportunity NYC was the first conditional cash transfer (CCT) program in the U.S., based on the Oportunidades program developed in Mexico.
• Less than one month ago international development micro-lender Kiva launched a pilot program in the U.S.
• Grameen Bank supports microcredit in places like Norway

Add to that the various management principles we’ve learned from the Aravind Eye Care System and Mumbai’s dabbawallas. Extending the argument presented by Fast Company, these examples show that South-North innovation transfer doesn’t have to be focused on corporations.

While it’s enticing to think about mining untapped innovation potential in the South for the benefit of the North, the real potential is much broader. Innovation can (and does) flow in all directions, not just South-North, but also North-South, South-South, and within countries. The challenge is to learn from different ways of approaching the same problem. Or even similar problems: see how Kaiser-Permanente visited a flight school to reduce medication errors and how the NHS worked with Formula 1 team to improve ICU procedures.

Given this potential, the big, open question is this… How do we increase global sharing of ideas and models to spur innovation?

As with the last post, I’m copying the description of the session I just attended – Vouchers for Health (Session C3) - from the conference website:

Presenters Discuss: the potential of competitive vouchers in increasing access to priority services for currently underserved populations (Nicaragua); how subsidized, targeted vouchers can achieve the goal of improving health of poor women and children, elements that improve access to high quality health care services, how targeted voucher subsidies help meet the goal of contributing to development of a national social health insurance system that is accessible, affordable and acceptable (Kenya); a nationwide, high transaction distribution project for insecticide treated nets (ITNs) that has given rise to the application of technologies in the use of a relational database as a means to track each voucher transaction, ensuring security and traceability, providing spatial analysis using GPS coordinates, leveraging data from this project to others by providing a central data repository to government, and exploring SMS and mobile phones for automating voucher transactions and gathering patient information (Tanzania); and how poor pregnant women were selected for vouchers jointly by field workers and community support group members, how the institutionalization process for the voucher scheme was implemented, and how the health facilities were strengthened to provide quality maternal health care (Bangladesh).

Why should we care about voucher schemes? Three reasons from where I sit. These schemes provide:

1. An attractive model for extending the reach of services without significant infrastructural investment
2. Incentives for competition to improve the quality of service delivery
3. A mechanism for reducing financial barriers for the poor

Despite this promise, my experience over the last few years – including stumbling through a poster presentation about vouchers in Uganda for Ben at APHA in Boston a couple years back – has taught me that the concept tends to be elusive to “outsiders”. The World Bank’s Private Sector Development Blog has a concise overview of output-based aid for those that aren’t familiar. I won’t try to explain myself, since I’ll probably make some errors.

This session brought together diversity in geography – the talks covered Latin America, Africa, and Asia - and in services – anti-malarial bednets, safe motherhood, family planning, STI prevention and treatment. What was most interesting to me then was not the details of any specific program, but what we might be able to learn from having these different experts in the same room.

So what were the common themes?

1. Vouchers work. Nicaragua saw increases in service utilization, condom utilization, family planning uptake, and KAP. Much of this across different subgroup analyses – age, level of sexual activity, type of residence. The others similarly all saw positive gains in what they were trying to achieve.
2. Institutions matter. In Tanzania, the market is being flooded with free ITNs (possibly LLINs) under a new policy to achieve universal coverage – the fate of the 7000 bednet retailers under the Tanzania National Voucher Scheme (TNVS) is unknown. In Kenya, Nairobi and Kiambu saw better results for the voucher scheme because of existing infrastructure. Nairobi actually had provided more voucher-based services than vouchers sold in Nairobi because of women coming in from outlying areas. Tanzania benefits from a manufacturing base that can produce ITNs and a system that encourages people to pay for a portion of their health care.
3. The system will be gamed. The much higher reimbursement for providers of C-sections than vaginal deliveries has led in some cases to higher rates of C-sections than is necessary. April Harding who was moderating said that multiple schemes have been used/proposed for dealing with this, including capitation (e.g. for 100 women, X% will be reimbursed for C-sections). Fraud is also a problem. While nobody discussed incidences of counterfeiting, the Tanzania program has taken big steps to prevent counterfeiting, including watermarks, microprinting, and a bar code. The bigger issue with fraud is related to ineligible participants obtaining and using vouchers intended for other populations, whether by income or geography. Which leads us to the next point…
4. Equitable distribution is hard. Ineligible participants seem to be a problem with all these programs. In Bangladesh they responded by bypassing governmental decisions about who would get vouchers and relied on CSGs (community support groups) to make the decisions. Another trend is that those who are more poor tend to utilize vouchers less – it is unclear if this due to cost, education, and interaction among the two, or something we’re not thinking about.
5. Understanding redemption is complicated. This was my one question. In both Tanzania and Kenya – the others didn’t present these numbers or I didn’t catch them - the rate of redemption (number of people receiving services under the voucher scheme divided by the total number of vouchers distributed) – was around 80%. After I asked the question and before the panelists responded, my neighbors said that: (1) 80% is pretty good, and (2) the Tanzanians unlike the Kenyans don’t pay for their vouchers until they use them. In Tanzania then, the reasons are grounded speculations: perceived value of the ITNs, access, cost. In Kenya, the majority of the outstanding 20% is due to accounting. The real utilization is expected to be much higher since the cutoff for the evaluation excluded women who had received vouchers, but had not yet delivered (safe motherhood program). Still a minor portion of this is due to women who are unable to deliver at contracted facilities due to a lack of transportation or the timing of the pregnancy.

Today was the opening day for the 36th Annual International Conference on Global Health (#GHC36), being held in Washington D.C. by the Global Health Council.  This conference looks like it will be a promising five-day dosage of:

(also known as this year’s theme)

After arriving in the morning, I caught the tail-end of an auxiliary event held by Chemonics International (www.chemonics.com), an international development consulting firm, that provided a snapshot of many of their multi-sectoral approaches in harnessing the facets of the private sector for health.  Chemonics was founded 34 years ago, and the firm is grounded by the acronym AIMS – achievement, innovating, measurable, sharing.  Interestingly, Chemonics uses a total market approach for one of their projects – the only project within USAID’s worldwide portfolio that does so.  In the international health space, cost-effectiveness analyses, willingness-to-pay studies, and other economic models seem to be increasing in use, and these were among several strategies for their activities.

Some of their other current activities include involving the private sector with:
•  DOTS – the tuberculosis strategy for control and prevention – in countries where the private sector is the health provider of choice (approximately 70% of individuals seek true care from the private sector in the Philippines)
•  HIV/AIDS prevention and treatment with capacity enhancement through economic rehabilitation
•  stimulating rural competitiveness in Bolivia and providing business support in Kosovo
•  management information systems with computers at each health clinic (in development: a $200, 1.6 gigabyte computer with capabilities to connect with a SIM card)
•  market access for rural development by increasing the value of agriculture and by encouraging gardens in Nepal

This last one got my mind working.  I read once that in Nepal, women carry heavy loads up to 20 kg for up to 20 kilometers for up to an estimated 20 hours a week to attempt to satisfy high household energy demands. Can you imagine?  (If you are curious, you can search for an image of a “doko” which is the contraption that allows women to carry such heavy loads.  Dokos are usually equipped with a carrying strap that can wrap around a woman’s forehead.)  Not only does a woman’s body require more caloric intake after retrieving wood for fuel and fetching water for the household, but the load lifting and carrying puts a strain on abdominal muscles.  This can lead to uterine prolapse and miscarriage if these household activities are performed during or after pregnancy. Encouraging gardens would improve nutrition, but if these gardens were linked with solar food dryers, households could benefit from having nutritious food year round and not just during harvest season.

This emphasis on weaving together the private sector can have positive effects on worldwide health and quality of life, but it is important that these approaches are evidence-based and involve collaborations with the public sector.  Through this snapshot of projects, Chemonics International demonstrated how new technologies and proven strategies with a multi-sectoral approach can lead to healthy communities.

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Tomorrow, I am looking forward to hearing Ashifi Gogo speak during the plenary session on “Transformations: Discovering New Strategies using Proven Technologies”.  Gogo is a founder of mPedigree, a non-profit that advocates for mobile health solutions to counterfeit drugs – an issue that truly has global implications and demands a critical need for worldwide tracking.

On Thursday, the conference has Hans Rosling scheduled as the special keynote speaker, and he will be speaking about “Facts and Fiction about Global Health”.  If you haven’t seen Rosling lecture, he is quite animated and is pushing forward a movement towards user-friendly, global trend data visualization, on top of his 20-years of experience in global health research.