A new book published earlier this year looks at what we can learn from innovations in healthcare in low and middle-income countries.

Dr Matthew Harris is Clinical Senior Lecturer in Public Health. His research spans global health, innovation diffusion, and primary care and health services research with a particular focus on bidirectional learning between the NHS and low-income countries.

Matt recently published a book entitled: Decolonizing Healthcare Innovation Low-Cost Solutions from Low-Income Countries. Jack Stewart sat down with Matt to learn more about the concept of healthcare innovation and what we can learn from low-income countries.

Can you tell us about the concept of decolonizing healthcare?

MH: "The origins of our modern healthcare systems began in 15th Century Europe, at a time when the scientific method and colonial capitalism were emerging simultaneously. The worldview that gave ‘permission’ to Europeans to colonize South American and African countries and cultures is the same worldview that modern medicine was constructed on – control of other cultures and the control of biological systems is basically rooted in the same perspective. It is about establishing parameters and systems that define, organize and control.

There are clear victories in modern medicine arising from this ‘coloniality’, but it also leads to important failures as well. Decolonization is all about surfacing how coloniality impacts the way in which we practice medicine and the way in which we control how medical knowledge is produced and consumed. For example, although modern, Western, medicine has had significant successes, (think of vaccination, sanitation, diagnostic technologies and so on) it also systematically ignores other ways of practicing medicine, other knowledges and cultures that can be really helpful to understand the limitations of our own approaches to healthcare.

Decolonizing healthcare, then, is all about understanding how we have arrived at the knowledge that we have, asking what has been excluded and who has been excluded from that knowledge construction. For example, here in the UK we very rarely pay attention to the innovations that emerge from low-income country contexts. Traditionally these contexts have been recipients of our Western knowledge, and very little expertise, innovation or know-how, filters back into the NHS. There is an unspoken rule, as Edward Said puts it, of asymmetrical ignorance. We, in the UK, can afford to ignore knowledge from the Global South, but the Global South cannot afford to ignore our knowledge. This might not be particularly perceptible, but is rooted nevertheless in coloniality i.e. West is Best."

How did you first get interested/involved in the subject area?

MH: "Although I am a UK citizen, trained in medicine and public health in the UK, early in my career I had the unusual experience of living and working in a very impoverished community in northeast Brazil as a family doctor. I wasn’t working there as part of an NHS partnership, or charity organization, rather I requalified in medicine in Brazil, learned to speak Portuguese, and I was an employed doctor within their own primary care system.

After four years, I returned to the UK and began to wonder why on earth don’t we have a primary care system here that is built on an army of Community Health Workers, like they have in Brazil, and in fact in many low-income countries. Community Health Workers, when used systematically, integrated into primary care, visiting all households proactively in defined geographies, and paid properly, not working just as volunteers, can lead to extraordinary results for populations and the whole health system. If we had that system in the UK, it would solve problems as diverse and far-reaching as the workforce crisis, bed-blocking, coordination of care, uptake of preventative services, and many more things besides.

Speaking with senior health system leaders here though always led to a common refrain – ‘what could we possibly learn from Brazil!?’. The arrogance, and the frank ignorance, made me feel very much like how many researchers and clinicians from low-income countries feel – ignored, unheard, diminished. It was a spectacular own goal too – because the prejudicial attitude toward this, and many other innovations from low-income countries, means we miss opportunities to learn and improve patient care in the UK. I became interested in understanding where this attitude comes from, and what else we could learn from low-income countries and the book speaks to both of these things."

What are some of the barriers to innovations from low- and middle- income countries being adopted?

MH: "I think of this as there being barriers that are specific to the innovation itself, and then general barriers that relate to the learning process. Each innovation, whether it is a device, a technique, a system, or model of care, or a new workforce role, will have specific issues when translating it into a new setting. These might be to do with the regulatory environment, or the cost of the technology, or the amount of training that is required to use the innovation or deliver it, the impact of it on workflows and processes within the hospital or clinic where it will be used. These are all easy to identify by thinking of the innovation and where it will be used, and systematically surfacing the sorts of issues that might arise.

In the book, I provide a structured way to consider any innovation so that you can articulate what the issues might be to use it in another context i.e. is it likely to work here, and what would we need to do to make that happen? However, the general barriers are often a bit harder to identify.

These are to do with the source of the innovation and what we think of that. People call this ‘country-of-origin effects’. Because of coloniality, innovations coming from Brazil, Ethiopia, Rwanda, and Bangladesh, just as examples, might not be quite as well received as innovations coming from the US, Germany, Canada, Australia and New Zealand. In the book, I discuss how these cognitive biases are rooted in coloniality and how we think of the institutions in the former countries as being part of a ‘periphery’ in the global knowledge economy, whereas countries in the latter group as part of a ‘core’ or ‘mainstream’ part of the global knowledge economy. It is therefore far harder to persuade people of the value of innovations when they come from countries we consider to be peripheral to our own purview."

Can you give some examples of innovations that have been successful?

MH: "In the book, I give several examples of successful healthcare innovations from low-income countries but this is in no way an exhaustive list. I also focus on innovations that we call ‘frugal’ healthcare innovations i.e. ones that do more with less, but although these commonly emerge from these contexts (because they have been doing more with less for a lot longer), it doesn’t mean these are the only types of innovations that come from there.

In plastic surgery, Brazilian researchers have discovered that Tilapia fish skin can be used very cheaply, and effectively, to treat second and third degree burns. In Bangladesh, obstetricians can treat post-partum hemorrhage using just a condom tied to a catheter to the same effect as the expensive devices we have in the UK. In India, and throughout sub-Saharan Africa, mosquito net mesh is used to treat inguinal hernia and is just as effective as the commercial mesh we use in the UK, but a tiny fraction of the cost. And again in countries like Uganda and Malawi, ordinary hardware drills can be used in orthopaedic surgery by putting them inside sterilisable, cloth bags that are very inexpensive to use.

In the book I also talk about the translation of the Community Health and Wellbeing Worker (CHW) role from Brazil into the NHS. In Brazil, there are 270k CHWs and it has led to sharp reductions in cardiovascular disease mortality amongst many other things. Since 2021, we’ve been supporting localities as diverse as Westminster, Calderdale, Bridgewater, Cornwall and Hampshire to recruit and deploy CHWWs in the same way as in Brazil and we’re starting to see some really exciting benefits to patient care and population health outcomes. For example, in Westminster, we found that with just four CHWWs working for less than a year, the likelihood that residents eligible for immunizations, screening or health checks would get those services was much increased when a CHWW visited them, compared to when they hadn’t. Our work was mentioned by the Lord Bishop of London in the House of Lords in June 2023 and cited in the Fuller Stocktake Report 2022.

How do you suggest we move forward to break these barriers and improve innovation flow across the globe?

MH: "I think we need to be intentional at learning from low-income countries and active at surfacing prejudice towards these settings. We need to consider how we train our doctors and public health students so that they enter the workforce better able to identify good innovation, irrespective of the source, and better able to understand how medical knowledge is constructed and the social process that is involved in that. It is a skewed and systematically inequitable system. I think NHS volunteers that go overseas have a responsibility to ensure that they are purposeful in learning as well as teaching, and to be effective in bringing that learning back home."

Why is reverse innovation (utilising Low-Cost Solutions from Low-Income Countries) important in current modern times?

MH: "Reverse innovation aims to improve innovation flow from low- to high-income countries, but at the same time, paradoxically, it reinforces the very world view it is trying to break down by presupposing that innovation normally flows the other way! Its more than a semantic issue. Nevertheless it is so important because we, in the NHS, have to start to make choices about the types of technologies we use and develop. If we can do something at a fraction of the cost, without scrimping on quality or safety, then we must do that and learn from the countries that are expert at that sort of innovation."

What impact can Low-Cost Solutions from Low-Income Countries have?

MH: "We calculated that swapping all the expensive orthopaedic drills we use in the UK for the inexpensive hardware drills could save the NHS £100m. We spend about £8bn per annum on burns treatment for about 4m patients. If we used Tilapia fish skin at just $11 for a course of treatment, then perhaps that would have only cost £400m, a huge difference! Even if only a small proportion of those patients used Tilapia then the savings would be significant. We calculated that it would cost about £2bn per annum to employ enough Community Health Workers in the UK to visit every household once per month, like they do in Brazil. For what we spent on the Test and Trace system during the COVID19 pandemic, we could have employed that army of CHWs (around 100k would be needed) to support all health and social care needs of every household for twenty years! This is the sort of opportunity we need to be looking for, actively. We can’t keep complaining that there isn’t enough money in the system when what we are doing is far more expensive than it needs to be."

What advice would you give to those starting out a career in healthcare evaluation or innovation, on how can they affect change in a meaningful way?

MH: "I think it is important to be as conscious as possible of the extent to which our healthcare systems, the medicine we practice, and the knowledge that we have, is constructed socially and is a very human process, not necessarily firmly, or ontologically, sound. This way, you will remain curious and critical and open to other world views and opportunities, wherever they may be from. Oh, and to read my book!"

Decolonizing Healthcare Innovation Low-Cost Solutions from Low-Income Countries is available via the publishers Routledge