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GLOBAL HEALTH

Tackling the Grand Challenges of Global Health

Five Rules for Maximizing the Impact of Medical Innovation in Resource-Limited Settings

Polio Vaccination SOURCE: Bill & Melinda Gates Foundation/ Prashant Panjia Bill Gates, co-chair of the Bill & Melinda Gates Foundation, delivers an oral polio vaccine to a child at a community health post in Nigeria.

Just because we can cure malaria doesn’t mean we have solved malaria. Technological advances in medicine generally fail to have global reach due to limitations in basic and structural provisions. This leads to an unconscionable number of preventable deaths and chronic illnesses, a large number of which afflict children. Bringing the benefits of medical innovation to every member of the human race remains a grand challenge.

When the Gates Foundation initiated the first round of Grand Challenges in Global Health five years ago, the objectives were clear: Revolutionize global health within a few years by flexing the muscle of the Gates’s billions to foster a global health innovation revolution, and solve basic challenges. But all did not go according to plan. Despite billions of dollars in grant funding, we still haven’t solved basic problems like vaccination, malaria, malnutrition, or the spread of HIV in developing countries.

Since that initial round, the foundation has scaled back its originally ambitious agenda by reducing the amount of each grant awarded and tempering proclamations of any imminent revolutions. This past December, a New York Times article highlighted some of the failed projects from the first round of grants. These included a project aimed at developing dried vaccines, and an expensive attempt at a portable lab.

While other projects have had more success, most of them will require more funding and a few more years before they can be widely used where they are most needed. In fact, a majority of the 43 initial projects, some of which were aimed at innovations such as single-dose vaccines, genetically altered mosquitoes, and portable diagnostic machines, will not receive any further funding. Bill Gates seems resigned to a change in approach, acknowledging the initial project was too ambitious.

Even if we accept a change in strategy, examining the reasons for these initial failures can perhaps yield instructive lessons. Research on global health problems is inherently difficult and is hampered by issues that go beyond surface-level financial constraints. In order to conduct global health research that’s efficient and produces results, we need to focus on five key issues: cost, power sources, portability, local needs, and obstacles to training and support.

Cost

The Grand Challenges were aimed at addressing one of the major barriers to innovation and scientific progress on key health problems in the developing world: the lack of research funds. But the issue of cost isn’t simply one of providing research funds. Researchers need to consider the cost of prototypes and end-user costs from the start. The initial projects funded by the Gates Foundation demonstrate why this is such a crucial consideration.

Initially, there were no limits to the size of initial awards. For instance, one project designed to develop portable diagnostic labs received an initial award of $15 million. The problem was that each prototype cost about $1,000 and this cost was never adequately reduced. This grant has not been renewed, with a cheaper alternative having been created by another researcher. Most surprising is that the alternative lab is designed to conduct similar tests using pieces of paper that costs pennies to buy and use—startling, compared to the original $1,000 prototype. Today, the organization Diagnostics for All has developed paper kits for liver function tests, and hopes to have kits that can test anything from malaria to HIV.

Such a stark contrast in costs for similar tests demonstrates why it is so important to factor these costs in project proposals. A $1,000 price tag for a prototype should have been a working sign, especially considering the target recipients. In countries where governments and clinics are poor and patients are even poorer, the affordability of medical technology is essential. Even $1 per day for malaria treatment can be prohibitively expensive when you are living on $1 per day. Technologies with low upfront costs but high lifetime costs, such as special parts or constant replacements, are no improvement upon high-cost prototypes.

Power sources

Power sources are another key problem. In resource-limited settings, power is often spotty, at best. Even in a country like South Africa—with a strong infrastructure and an extensive power grid—power outages are a problem. For instance, a recent power outage in the Mpumalanga district of South Africa was expected to keep the Rob Ferreira Hospital without power for 6 weeks.

Researchers need to anticipate unreliable and inaccessible power sources and think of possible solutions. Can an instrument run on batteries? If an instrument is battery powered, the batteries should be easily accessible, rechargeable, and long lasting. Many health clinics often serve as points of care for widely dispersed populations and, as a result, portable machines should be able to hold charges for long periods. As laptops become more common at global clinics, one possible solution could be the development of tools powered through USB cables, but those laptops will also require adequate power options.

Portability

Related to the issue of power supply is the question of how easily a technology can be used to reach people over a wide coverage area. In rural areas, mobility is one of the biggest concerns. With clinics few and far between, people often delay seeking medical attention until their conditions progress to critical levels. Developing portable devices and medicine that is easy to store and transport allows clinicians in resource-limited settings to provide earlier care to more people. This also creates a mechanism for care when patients are no longer able to make it to the clinic.

But portability isn’t just about size: Clinics need to use portable devices in remote locations. With the increasing use of cell phones even in resource-limited settings, cell-phone-based tools and applications are a great idea. Nonetheless, connectivity issues need to be factored into the development of any such tools. Additionally, instruments also need to be rugged and durable.

Responsiveness to local needs

Another key challenge in global health is that health care barriers often stem from deeper, nonhealth-related issues. Politics, infrastructure, and complex social norms often stand in the way of substantive progress in health outcomes. As a result, global research priorities should be on high-impact, low-disruption solutions. Researchers need to focus on interventions and technologies that can be implemented without requiring extensive structural or operational changes, as these are often impractical and unrealistic.

For example, handheld diagnostic and monitoring tools will probably have a greater immediate impact than larger, more complex technologies. Consequently, focusing on handheld technologies is a more efficient and realistic way to help clinicians in resource-limited settings establish legitimate and practical mobile health care solutions. Clinics, which are often critical points of care, would have their reach expanded to people in remote locations. Such an approach gives providers a fighting chance against opportunistic co-infections that often go undiagnosed simply because people aren’t getting to the clinics. The way to navigate these structural limitations is often through homegrown efforts and direct engagement with, and input from, the target population. How can structural barriers be identified? Ask the locals. What’s the best way to navigate social norms? Engage the affected population.

Training and technical support

Lastly, proposed interventions and tools have to alleviate the dearth of qualified technicians and physicians in most resource-limited settings. For example, when the President’s Emergency Plan for AIDS Relief, or PEPFAR, program made antiretroviral therapy a realistic option in 15 focus countries starting in 2003, clinics went from not having enough medicine for HIV-infected patients to not having enough doctors to prescribe available medicine. Solutions need to be developed to both brain drain and the low number of physicians and technicians in these settings. We need technologies that are easy to use and don’t require extensive training or large amounts of technical support. Smaller, simpler instruments that any can learn to use in a short period are crucial in places where primary health workers may not have a lot of education.

More medical doctors are needed in Africa, but so are medical schools. Then there is the very real problem of brain drain, with the few physicians present vulnerable to leaving for Europe and the United States. These issues cannot be resolved overnight, so solutions need to be developed for the available health workers.

Técnicos: A pragmatic example of success

Several African countries have started to address this personnel issue by focusing on the development of nonphysician clinicians. These clinicians can be trained in a shorter amount of time and can provide wide-ranging support to physicians. In Mozambique, the emphasis is so great that the government has developed specific guidelines for these clinicians, who are called “técnicos.” These guidelines allow técnicos to be able to care for patients and make important decisions such as determining a patient’s HIV stage. While técnicos do not solve the lack of qualified physicians, they provide an important bridge to care for many people. They also relieve pressure on physicians who may each be in charge of a large number of patients. This effort allows health care from qualified clinicians to reach people who might otherwise go without treatment.

The técnicos of Mozambique demonstrate the approach we should take toward the global health challenges in resource-limited settings. Técnicos provide a low-cost solution to an expensive problem and expand the reach of clinics while alleviating heavy training requirements. They also strategically confront the lack of physicians where it’s needed most. Técnicos are a homegrown idea that is locally managed, providing the kind of expertise to address structural barriers. In essence, técnicos are an attempt to solve complicated problems in a straightforward and pragmatic way. This seems to be the best way to deal with complex global health problems.

Global health innovation will only occur with approaches sensitive to the limitations present in resource-limited settings. The Gates Foundation is taking a step toward encouraging this kind of innovation. They now focus on grants for smaller amounts, which foster true ingenuity as project managers have to figure out how to do more with less, much like those they are trying to help.

There’s more they can do, however, to spur the kind of innovation that’s needed in global health. A small step would be to require all research teams to include collaborators from research-limited settings. If a team thinks a dry vaccine will work in a remote village in Zimbabwe, then they should collaborate with health workers and community leaders from that country to come up with strategies and to learn about possible barriers. This approach, already common in the development world, could go a long way to addressing some of these key issues in global health research.

Takunda Matose is a human subjects protection specialist focusing on HIV/AIDS research at Technical Resources International and has a master of bioethics from the University of Pennsylvania.

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