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You are here: Home / Health / Global Health Technologies: Time To Re-Think The ‘Trickle Down’ Model – Forbes

Global Health Technologies: Time To Re-Think The ‘Trickle Down’ Model – Forbes

02/18/2020 by RSS POST

A new Indian vaccine against diarrhoea

Saving lives of poor children by cheap vaccination, Rotavirus is the leading cause of severe … [+] diarrhoea in children worldwide. The Rota Virus vaccine has been researched in India and now being produced at Bharat Biotech, Hyderabad at its high tech facility. India has developed a vaccine likely to be priced at less than $ 1 the affordable vaccine can prevent millions of deaths in children. Dr. Krishna Ella (in yellow lab coat), Chairman cum Managing Director of the company is hopeful he can market (Photo by Pallava Bagla/Corbis via Getty Images)


Corbis via Getty Images

Technologies (e.g. vaccines, drugs, diagnostics) are critical for addressing global health needs. But the field of global health has a problem – an excessive reliance on the ‘trickle down’ model, where products and innovations are developed in the Global North, and after a decade or two, they slowly trickle down to the Global South, where the biggest needs are, and where technologies often have the greatest impact. This model is not surprising, since every aspect of global health is dominated by high-income countries. Nevertheless, the model needs a re-think.

Seriously, two decades to reach those who need it?

When I was a medical resident in India in the 1990s, I was asked to get vaccinated for hepatitis B, as needle-stick injuries were common. The imported vaccines cost me nearly 3 months of my salary! Today, hepatitis B vaccines are available for less than a dollar in India, thanks to Indian biotech companies. But it has taken two decades for this vaccine to become affordable and accessible. How many hepatitis B infections could we have prevented over two decades?

In the 1990s, anti-retroviral treatment (ART) cost more than $10,000 per patient per year, and that meant very few patients received this life-saving treatment. Today, thanks to some incredible AIDS activism and generic production, ART costs less than US$100 per person per year in many settings. Again, this process has taken 2 decades to play out. How many HIV infections and deaths could we have averted over two decades?

Turns out, nearly every global health technology goes through this long and painful process. R&D, typically, happens in high-income countries (HICs), and the product is usually not affordable in low- and middle-income countries (LMICs) when it is launched. Truth be told, even HICs struggle to afford them!

It then takes herculean efforts over many years to make the new technologies accessible in LMICs. Efforts include extensive advocacy campaigns, product buy-downs, compulsory licensing, patent challenges, efforts to create competition, advanced market commitments, creation of alliances (e.g. Gavi, Global Drug Facility), creation of non-profit R&D groups (e.g. DNDi) etc.

Even after heroic efforts, products developed in HICs might not be appropriate for LMICs. “Even when they are adapted in LMICs, these innovations may amount to using a sledgehammer to kill an ant,” says Nigerian physician Ifeanyi Nsofor, a Senior New Voices Fellow at the Aspen Institute. “This trickle-down approach to global health technologies mostly does not involve scientists, development experts and innovation hubs in LMICs. It also does not take into cognizance the peculiar health needs of LMICs that could be addressed at primary health care,” he added.

Indeed, even after years of effort, many products are still not accessible to folks who need it the most (e.g. insulin, new TB drugs, hepatitis c treatment, and the list goes on). Right now, advocacy groups are running campaigns to lower the price of bedaquiline for TB, insulin, TB molecular test, pneumonia vaccine, among more general efforts to curb outrageous drug prices.

Ren Minghui, the Assistant Director-General for Universal Health Coverage, Communicable and Noncommunicable Diseases at WHO agrees that it takes a long time for new products to reach LMICs. “There are many reasons behind it. For instance, drug regulations for local registration might take time in LMICs, high cost of innovative products vs. limited budgets set obstacles in LMICs, and knowledge transfer needed for the local health professionals,” he says.

Given these challenges, should global health still rely on the ‘trickle-down science’ model? Is there an alternative?

Closest to the problem and closest to the solution

The alternative is to develop technologies & solutions in the Global South, and scale them up, to meet the pressing needs of LMICs. “We cannot rely on HICs to solve our problems,” says Marianne Mureithi, a leading HIV scientist at the University of Nairobi. She has personally witnessed the struggle to get new HIV medications into Kenya, a country where 1.6 million people live with HIV infection.

It stands to reason that people closest to the problem might have a better shot at developing the most appropriate, scaleable & affordable solutions. Krishna Udayakumar, Director of the Duke Global Health Innovation Center says, “Understanding and innovating for local context and demand is an under-appreciated variable, despite the growth in recognition of human-centered design in global health.”

There are plenty of innovations that are emerging from LMICs. India, for example, has scaled-up a rotavirus vaccine that was indigenously developed and produced in India. This was a ‘vaccine by and for India’ according to Gagandeep Kang, an Indian scientist who played a key role. The vaccine costs under $1, and has received WHO pre-qualification. Indian-made typhoid vaccine, and a rapid molecular technology for TB have also received WHO endorsements in recent years. Other medical technologies have been developed by biodesign programs (e.g. Stanford-India Biodesign).

China gave artemisinin to the world, a remarkable anti-malarial drug that is derived from traditional Chinese medicine. China has several indigenously developed molecular diagnostic platforms, and they are already being used within the country for conditions such as tuberculosis. Chinese companies have already developed rapid tests for the 2019 novel coronavirus infection.

Both India and China have made incredible advances in artificial intelligence, digital health, and information technology systems. There is no reason why other LMICs cannot follow in their path. Senjuti Saha, a pediatric infectious diseases researcher in Bangladesh says: “It is imperative that companies/industries in the global south follow in their footsteps. There are so many pharmaceutical companies in Bangladesh making the most complex antibiotics, can they not manufacture vaccines also?”

China Artificial Intelligence Competition

A staff member stands near a computer as it examines magnetic resonance images of a human head … [+] during the CHAIN Cup at the China National Convention Center in Beijing, Saturday, June 30, 2018. A computer running artificial intelligence software defeated two teams of human doctors in accurately recognizing maladies in magnetic resonance images on Saturday, in a contest that was billed as the world’s first competition in neuroimaging between AI and human experts. (AP Photo/Mark Schiefelbein)


ASSOCIATED PRESS

In fact, other LMICs are innovating. Designed in Uganda, a new smart jacket called “Mamaope” can diagnose pneumonia in kids. Recently, a Ugandan innovator won a price for a bloodless malaria test.  Crib A’Glow, is a low-cost phototherapy solution from Nigeria to treat newborn babies with neonatal jaundice. There are many other examples of ‘frugal innovation’ that can be cited. If LMICs were to invest more in their own innovators and entrepreneurs, there is no limit to what can be accomplished.

Better odds of success

There are many reasons why home-grown innovations have better odds of success than the standard trickle-down model.

First, when innovations emerge from LMICs, governments are often key stakeholders and funders. They are therefore more willing to include such products in national policies for scale-up. India’s roll-out of the rotavirus vaccine and the molecular TB test are good examples of this. They were launched with great national pride.

Second, home-grown products often receive faster regulatory approval, since trials are done locally. This alone can avoid years of delay in rolling out innovations. In addition, domestic use does not necessarily require external policy endorsement. For example, WHO endorsement or pre-qualification is not required for India to roll-out its home-grown technologies.

Third, it takes less effort to convince policy makers, national experts, and healthcare workers. “Human behavior is fundamentally such that we develop trust quicker in the efficacy of things we co-create,” says Prashant Yadav, a professor of technology at INSEAD. Home-grown innovations are not received with skepticism, unlike foreign products which are often seen as being ‘pushed by external donors.’

Fourth, cost of goods are lower, as are labor and manufacturing costs. Furthermore, there are no international shipping costs, import hassles and tariffs to deal with. Fewer distributors and intermediaries are needed. Local manufacturing can leverage generic companies and economies of scale.

Fifth, technologies developed in LMICs have the additional benefit of going through a shorter supply chain as compared to the long supply chain that HIC-developed health technologies often have to go though. “Shorter supply chains learn about local information sets quicker and adapt to them faster,” adds Yadav.

Sixth, technologies developed by LMICs are usually designed with local conditions and end-users in mind. They tend to be robust and field-friendly (e.g. able to withstand frequent power failures or extreme heat). Service and maintenance is easier. Undoubtedly, quality issues will arise, and will need to be anticipated and addressed.

In conclusion, it is time for the global health community to re-think the trickle-down approach to technologies. If the end goal is to save lives and do it quickly, then LMIC-driven innovations must be seriously considered. The alternative is to wait for two decades, while people die of preventable and treatable conditions.

Disclosure: I have no financial or industry conflicts to disclose. I have no relationships with any of the companies or innovators cited in this article.

” readability=”208.60767590618″>

A new Indian vaccine against diarrhoea

Saving lives of poor children by cheap vaccination, Rotavirus is the leading cause of severe … [+] diarrhoea in children worldwide. The Rota Virus vaccine has been researched in India and now being produced at Bharat Biotech, Hyderabad at its high tech facility. India has developed a vaccine likely to be priced at less than $ 1 the affordable vaccine can prevent millions of deaths in children. Dr. Krishna Ella (in yellow lab coat), Chairman cum Managing Director of the company is hopeful he can market (Photo by Pallava Bagla/Corbis via Getty Images)


Corbis via Getty Images

Technologies (e.g. vaccines, drugs, diagnostics) are critical for addressing global health needs. But the field of global health has a problem – an excessive reliance on the ‘trickle down’ model, where products and innovations are developed in the Global North, and after a decade or two, they slowly trickle down to the Global South, where the biggest needs are, and where technologies often have the greatest impact. This model is not surprising, since every aspect of global health is dominated by high-income countries. Nevertheless, the model needs a re-think.

Seriously, two decades to reach those who need it?

When I was a medical resident in India in the 1990s, I was asked to get vaccinated for hepatitis B, as needle-stick injuries were common. The imported vaccines cost me nearly 3 months of my salary! Today, hepatitis B vaccines are available for less than a dollar in India, thanks to Indian biotech companies. But it has taken two decades for this vaccine to become affordable and accessible. How many hepatitis B infections could we have prevented over two decades?

In the 1990s, anti-retroviral treatment (ART) cost more than $10,000 per patient per year, and that meant very few patients received this life-saving treatment. Today, thanks to some incredible AIDS activism and generic production, ART costs less than US$100 per person per year in many settings. Again, this process has taken 2 decades to play out. How many HIV infections and deaths could we have averted over two decades?

Turns out, nearly every global health technology goes through this long and painful process. R&D, typically, happens in high-income countries (HICs), and the product is usually not affordable in low- and middle-income countries (LMICs) when it is launched. Truth be told, even HICs struggle to afford them!

It then takes herculean efforts over many years to make the new technologies accessible in LMICs. Efforts include extensive advocacy campaigns, product buy-downs, compulsory licensing, patent challenges, efforts to create competition, advanced market commitments, creation of alliances (e.g. Gavi, Global Drug Facility), creation of non-profit R&D groups (e.g. DNDi) etc.

Even after heroic efforts, products developed in HICs might not be appropriate for LMICs. “Even when they are adapted in LMICs, these innovations may amount to using a sledgehammer to kill an ant,” says Nigerian physician Ifeanyi Nsofor, a Senior New Voices Fellow at the Aspen Institute. “This trickle-down approach to global health technologies mostly does not involve scientists, development experts and innovation hubs in LMICs. It also does not take into cognizance the peculiar health needs of LMICs that could be addressed at primary health care,” he added.

Indeed, even after years of effort, many products are still not accessible to folks who need it the most (e.g. insulin, new TB drugs, hepatitis c treatment, and the list goes on). Right now, advocacy groups are running campaigns to lower the price of bedaquiline for TB, insulin, TB molecular test, pneumonia vaccine, among more general efforts to curb outrageous drug prices.

Ren Minghui, the Assistant Director-General for Universal Health Coverage, Communicable and Noncommunicable Diseases at WHO agrees that it takes a long time for new products to reach LMICs. “There are many reasons behind it. For instance, drug regulations for local registration might take time in LMICs, high cost of innovative products vs. limited budgets set obstacles in LMICs, and knowledge transfer needed for the local health professionals,” he says.

Given these challenges, should global health still rely on the ‘trickle-down science’ model? Is there an alternative?

Closest to the problem and closest to the solution

The alternative is to develop technologies & solutions in the Global South, and scale them up, to meet the pressing needs of LMICs. “We cannot rely on HICs to solve our problems,” says Marianne Mureithi, a leading HIV scientist at the University of Nairobi. She has personally witnessed the struggle to get new HIV medications into Kenya, a country where 1.6 million people live with HIV infection.

It stands to reason that people closest to the problem might have a better shot at developing the most appropriate, scaleable & affordable solutions. Krishna Udayakumar, Director of the Duke Global Health Innovation Center says, “Understanding and innovating for local context and demand is an under-appreciated variable, despite the growth in recognition of human-centered design in global health.”

There are plenty of innovations that are emerging from LMICs. India, for example, has scaled-up a rotavirus vaccine that was indigenously developed and produced in India. This was a ‘vaccine by and for India’ according to Gagandeep Kang, an Indian scientist who played a key role. The vaccine costs under $1, and has received WHO pre-qualification. Indian-made typhoid vaccine, and a rapid molecular technology for TB have also received WHO endorsements in recent years. Other medical technologies have been developed by biodesign programs (e.g. Stanford-India Biodesign).

China gave artemisinin to the world, a remarkable anti-malarial drug that is derived from traditional Chinese medicine. China has several indigenously developed molecular diagnostic platforms, and they are already being used within the country for conditions such as tuberculosis. Chinese companies have already developed rapid tests for the 2019 novel coronavirus infection.

Both India and China have made incredible advances in artificial intelligence, digital health, and information technology systems. There is no reason why other LMICs cannot follow in their path. Senjuti Saha, a pediatric infectious diseases researcher in Bangladesh says: “It is imperative that companies/industries in the global south follow in their footsteps. There are so many pharmaceutical companies in Bangladesh making the most complex antibiotics, can they not manufacture vaccines also?”

China Artificial Intelligence Competition

A staff member stands near a computer as it examines magnetic resonance images of a human head … [+] during the CHAIN Cup at the China National Convention Center in Beijing, Saturday, June 30, 2018. A computer running artificial intelligence software defeated two teams of human doctors in accurately recognizing maladies in magnetic resonance images on Saturday, in a contest that was billed as the world’s first competition in neuroimaging between AI and human experts. (AP Photo/Mark Schiefelbein)


ASSOCIATED PRESS

In fact, other LMICs are innovating. Designed in Uganda, a new smart jacket called “Mamaope” can diagnose pneumonia in kids. Recently, a Ugandan innovator won a price for a bloodless malaria test.  Crib A’Glow, is a low-cost phototherapy solution from Nigeria to treat newborn babies with neonatal jaundice. There are many other examples of ‘frugal innovation’ that can be cited. If LMICs were to invest more in their own innovators and entrepreneurs, there is no limit to what can be accomplished.

Better odds of success

There are many reasons why home-grown innovations have better odds of success than the standard trickle-down model.

First, when innovations emerge from LMICs, governments are often key stakeholders and funders. They are therefore more willing to include such products in national policies for scale-up. India’s roll-out of the rotavirus vaccine and the molecular TB test are good examples of this. They were launched with great national pride.

Second, home-grown products often receive faster regulatory approval, since trials are done locally. This alone can avoid years of delay in rolling out innovations. In addition, domestic use does not necessarily require external policy endorsement. For example, WHO endorsement or pre-qualification is not required for India to roll-out its home-grown technologies.

Third, it takes less effort to convince policy makers, national experts, and healthcare workers. “Human behavior is fundamentally such that we develop trust quicker in the efficacy of things we co-create,” says Prashant Yadav, a professor of technology at INSEAD. Home-grown innovations are not received with skepticism, unlike foreign products which are often seen as being ‘pushed by external donors.’

Fourth, cost of goods are lower, as are labor and manufacturing costs. Furthermore, there are no international shipping costs, import hassles and tariffs to deal with. Fewer distributors and intermediaries are needed. Local manufacturing can leverage generic companies and economies of scale.

Fifth, technologies developed in LMICs have the additional benefit of going through a shorter supply chain as compared to the long supply chain that HIC-developed health technologies often have to go though. “Shorter supply chains learn about local information sets quicker and adapt to them faster,” adds Yadav.

Sixth, technologies developed by LMICs are usually designed with local conditions and end-users in mind. They tend to be robust and field-friendly (e.g. able to withstand frequent power failures or extreme heat). Service and maintenance is easier. Undoubtedly, quality issues will arise, and will need to be anticipated and addressed.

In conclusion, it is time for the global health community to re-think the trickle-down approach to technologies. If the end goal is to save lives and do it quickly, then LMIC-driven innovations must be seriously considered. The alternative is to wait for two decades, while people die of preventable and treatable conditions.

Disclosure: I have no financial or industry conflicts to disclose. I have no relationships with any of the companies or innovators cited in this article.

———
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