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Developing Nations: Laboratories For Health Care Innovation

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A few months ago, GE Healthcare rolled out a portable electrocardiogram machine, trumpeting the new product's ability to help patients wherever they might need it.

But the most interesting thing about the MAC 800 is not where it can go, but where it came from: China.

Chinese engineers funded by GE Healthcare helped develop the machine for sale in China. Although initially tailored to local needs, the MAC 800 has found a new market - the United States, where hospitals with community programs can easily take it on the road to treat patients.

The company is betting that other products originally created for the developing world ultimately also can be useful here. GE is tapping into the increasingly popular idea that medical innovation should be a global two-way street in which the West benefits from the resourcefulness and frugality poorer nations apply to health problems. The idea isn't new, but it's gaining traction, beyond the creation of products and technology, as public health experts rethink ways to prevent disease and deliver care.

Health care in the developing world holds several "general lessons for richer countries," Nigel Crisp, a former permanent secretary of Britain's Department of Health, observed in a recent Times of London op-ed. "Unconstrained by our history, [developing countries] train people differently, create new sorts of organisations, involve families and communities and concentrate more on promoting health rather than on just tackling disease."

With interest in international health expanding, this type of thinking is likely to become more common. A 2009 survey by the Consortium of Universities for Global Health found that enrollment in global health courses had doubled since 2006. This rapid growth is changing the way people think about health care abroad, says Dr. Michael Merson, director of the Duke Global Health Institute. "I think the old days of development ... where the rich helped the poor, for the most part have passed," he says. "I think we go into this with a true sense of shared partnership."

The Roots Of 'Kangaroo Care'

While some experts doubt the U.S. is really ready to embrace lessons from abroad, there is a growing number of examples. They run the gamut from basic to high-tech - including an electronic medical records program in use in more than 20 countries.

The Boston-based Prevention and Access to Care and Treatment project, which serves HIV/AIDS patients, is modeled on a community health worker program pioneered in Haiti. Since the late 1990s, the project has sought out the most difficult-to-treat HIV patients: those who fail in conventional programs because of factors such as mental illness and poverty. The program reports good results and has been sharing its methods with the New York City health department and hospitals with similar programs.

"Kangaroo care," an approach developed in Colombia, is another example. With a major shortage of incubators, doctors advised mothers to cradle preterm babies in a sling. They did so well that it changed what had been the conventional approach in the U.S., which encouraged only limited human contact while newborns were in incubators.

Merson participated in what became one of the best known illustrations of a borrowed idea. During the 1970s he was in Bangladesh working with other doctors to treat an outbreak of cholera, an acute infectious disease whose symptoms include severe diarrhea. The team made extensive use of a cheaper, simpler treatment for diarrhea, which can result in life-threatening dehydration, and it is now the recommended standard for care worldwide.

"It took a while for pediatricians to use here," Merson says, "but now we have products like Pedialyte and other kinds of oral rehydration fluids that are used to treat kids."

These days, it's increasingly common to find experts without medical backgrounds collaborating on health-related projects for developing countries. One example is OpenMRS, an open-source electronic medical record system that started in 2004 as a collaboration between the Boston-based nonprofit Partners in Health and the Regenstrief Institute, an informatics and health care research organization in Indianapolis. Both programs use the system to manage projects in the developing world. It's especially critical for hospitals that track large numbers of HIV-positive patients, says William Tierney, an informatics expert at Regenstrief.

Without electronic information, "How do you know when patients aren't coming in, so you can go out and chase them down to enhance adherence to the drug?" Tierney asks.

Rwanda, Tanzania and Peru are among the countries where the program has caught on. Since the software platform is open source it can be customized by anyone and tailored to specific programs, which would be more challenging with bigger commercial systems. Now it is being used at Indiana University's School of Medicine - where Tierney is a professor - as well as at sites in Maryland, Boston and Los Angeles.

'What Can The U.S. Learn From Ghana?'

Students now in school might lead a new wave of innovation. Anjali Sastry, a global health delivery and system dynamics researcher who lectures at the MIT Sloan School of Management, says her MBA students are increasingly using what they learn to experiment with different models for care delivery. "Ghana tried a national health insurance system, for instance," she says. "What can the U.S. learn from Ghana?"

Dr. Jaspal Sandhu, a global health designer and researcher with an engineering background, is among those asking such questions. In 2004, Sandhu and two other researchers traveled to Tamil Nadu state in India to closely examine the workings of Aurolad, an affiliate of Aravind Eye Care System, which developed an intraocular lens that significantly reduced the cost of cataract surgery in India. Today, Aurolab exports the lenses to 120 countries, including Canada, Denmark and Israel, though not the U.S.

It's not just the lenses that interest Sandhu, a consultant who has worked with the World Bank, Microsoft and other clients. It's the way the Aravind system works. This includes the use of health workers rather than doctors for certain basic procedures--one of a handful of strategies that could promote "lower costs and shorter waiting periods," he says.

Not every expert is as optimistic. Josh Ruxin, an assistant professor at Columbia University's Mailman School of Public Health, says in the U.S., "hyper-technologization of everything" leads to rejection of simple solutions in favor of "the stuff that has some incredibly overly technical basis."

"I think there are a ton of lessons that can be applied in primary care and at community health centers from countries like Rwanda," says Ruxin, who runs a health and poverty program in that country. "But I haven't sensed that the United States is ready for that."

GE Healthcare, a believer, is investing $3 billion over six years in its "Healthymagination" initiative to create low-cost, high-quality products worldwide. It aims to use "reverse innovation," the same development process that produced the MAC 800. GE learned a hard lesson prior to the initiative. "Quite frankly, when we develop stuff in the U.S. and try to make it available for lower-cost markets, it just doesn't work," says Melanie Varin, GE's general manager of marketing for diagnostic cardiology. Products created that way tend to be too expensive for those markets and are unable to capture "the mindset of the local user."

That experience led GE to pursue its current approach, which is outlined in an October 2009 Harvard Business Review article, coauthored by GE's CEO, Jeffrey R. Immelt. "Once products have proven themselves in emerging markets," the article says, "they must be taken global."

Kaiser Health News is a service of the Kaiser Family Foundation, a nonpartisan health-care-policy research organization unaffiliated with Kaiser Permanente.

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