© Springer International Publishing Switzerland 2015
Jadelson Andrade, Fausto Pinto and Donna Arnett (eds.)Prevention of Cardiovascular Diseases10.1007/978-3-319-22357-5_24Frugal Innovation: Solutions for Sustainable Global Cardiovascular Health
(1)
Department of Epidemiology, School of Public Health, University of Alabama School of Medicine, Birmingham, AL, USA
(2)
American Heart Association, Dallas, TX, USA
(3)
Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
In recent decades cardiovascular disease (CVD) rates have dropped in some parts of the developed world; however, the incidence of CVD has increased in other regions, especially those characterized by low- and middle-incomes [1, 2]. A cursory summary of global trends for one important CVD risk factor, elevated blood pressure (BP), is illustrative:
High BP (systolic BP (SBP) ≥ 140 or diastolic BP (DBP) ≥ 90 mmHg) is currently the leading cause of global disease burden [3].
In 2008, 1 billion individuals worldwide had uncontrolled BP [4].
From 1980 to 2008, mean systolic blood pressure (SBP) declined by 7.3 mmHg in high-income countries, but increased by 3.3 mmHg in low-income countries [4].
Worldwide, SBP is highest in low-income and middle-income countries [4].
Fewer than half of those who have uncontrolled hypertension are aware of their BP status. Of those receiving drug treatment, only one-third have BP controlled to target levels [5].
Given this global picture of BP and its control (and that of other CV risk factors, such as blood cholesterol levels [6]), trends in CVD event rates are unsurprising. For example, for adults age 35–75 years living in China (classified in 2011 as an upper-middle income country; however, according to the World Bank as of 2014, nearly 100 million people in China still lived below the national poverty level [7]), the rate of coronary events plus strokes increased from 2.3 to 4.4 % annually in the period from 1984 to 1999 [8]. In the low-income countries of Africa, projections suggest that, by 2030, CVD will be the leading cause of death—contributing 13.4 % of total mortality (compared to 13.2 % for HIV/AIDS) [9]. Globally, coronary heart disease is projected to rank as the fifth highest cause of disability-adjusted life-years lost in low-income countries by 2030 [9]. The 2003–2009 Prospective Urban Rural Epidemiological (PURE) study, which recruited 153,996 adults from 628 urban and rural communities in high-, upper-middle-, lower-middle-, or low-income countries, found that an overwhelming majority of individuals in the upper-middle-, lower-middle-, or low-income nations suffering from acute coronary syndrome or stroke receive no treatment [10].
In sum, these CVD risk factor, event, and treatment trends point to a future for low- and middle-income countries that commentators have described as “dismal” and “a population emergency that will cost tens of millions of preventable deaths” in the coming decades [11]. Overshadowing these trends are a number systemic and economic truths: prevention and treatment strategies capable of reducing population level CVD risk factors and event rates exist; however, existing approaches are economically unviable and unsustainable for those populations and nations most in need [11]. Upon publication of the findings of the Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group, which included some of the trends noted above, editors of The Lancet stated with conviction that “Failure to make population-based cardiovascular health a greater priority, particularly in low-income and middle-income countries, is unconscionable.” This chapter discusses a possible paradigm with which solutions to this global crisis may be understood and ultimately addressed.
What Is Frugal Innovation?
The crux of the looming global CVD crisis can be succinctly summarized: CVD event rates can be successfully reduced by targeting modifiable risk factors such as hypertension, tobacco use, dyslipidemia, obesity, and diabetes. However, behavioral and pharmacological interventions to improve risk scores and reduce CVD burden have been developed in high-income countries with established healthcare systems and reimbursement infrastructures in place to provide and pay for goods and services. In short, current solutions are built upon a low-volume, high-cost paradigm that is unsustainable in low- and middle-income countries.
The term “frugal innovation” (sometimes “frugal engineering”) signifies the effort to reduce the cost of a product or a service, usually by reducing its complexity, to make that product or service available to more—typically lower-income—people. In many ways, it turns the traditional innovation and development paradigm on its head: high-tech innovation typically starts with a radical development (e.g., an implantable cardiac pacemaker) and innovation is characterized by incremental improvement, addition of features, increasing complexity, and, very often, increased cost (e.g., an implantable, microprocessor controlled, rate-responsive, MRI-safe cardiac pacemaker with data logging, remote diagnostics, drug-eluting leads, etc.). Frugal innovation is sometimes called “disruptive innovation” because it shakes up existing economic constraints and aims to open new, high-volume markets to affordable solutions. Examples of frugal innovation can be found in many different domains. For example, the Godrej & Boyce Manufacturing Company based in Mumbai, India sought a frugal solution to the problem of food storage in that country. Only about 20 % of households in India have access to refrigeration and about around one-third of all food spoils before it can be consumed. Godrej & Boyce developed the US $70 Chotukool, a 7.8-kg (17.2-lb), 45-l (2746-in.3 ), battery-powered plastic refrigerator that can cool down to 8–10° C (46–50° F) [12]. Frugal innovation is not restricted to physical products but can also include services. For example, through radical outsourcing and contractual arrangements, the Bharti Airtel telecommunications company is able to offer cellular phone service for US $0.01 per minute [13], thereby making telecommunication affordable to millions of people for whom such services were previously out of reach.
These examples illustrate the high-volume, low-cost business model that frugal solutions engender, a model that must be adopted by healthcare industries and infrastructures if the looming global CVD crisis is to be averted.
Frugal Innovation in Medicine and Healthcare
Frugal Device Innovations
The need for frugal innovation in healthcare is well illustrated by the medical device market. In 2010 the device industry—which is dominated by a small number of manufacturers headquartered mostly in high-income countries—generated about US $260 billion in sales; notably, just 13 % of the world’s population accounted for 76 % of total medical device use [14]. However, a number of innovative devices that exemplify the high-volume, low-cost model have been developed and successfully deployed in low-income regions. Perhaps the most famous of these is the Jaipur foot. This prosthetic limb (sometimes referred to as the Jaipur leg) was developed collaboratively by Dr. P. K. Sethi and Pandit Ram Chandra Sharma in 1968 [15]. Although the design of the device was acclaimed upon its invention, it was the business and management skills of Devendra Raj Mehta that transformed the Jaipur foot from a good idea into a global phenomenon and the darling of the frugal innovation movement. The ultralight, durable prosthesis costs about US $45 compared to US $12,000 for a similar US-made device. The light, durable Jaipur prosthesis allows its wearers not only to stand and walk, but also run, climb trees, and pedal bicycles. The success of the Jaipur foot derives not only from its innovative design, but also from the non-profit organization (the Bhagwan Mahaveer Viklang Sahayata Samiti or BMVSS) established by Mehta to bring the prosthesis to those who need it. Since the founding of the BMVSS in 1975, more than 400,000 individuals in some 26 nations have been fitted with a Jaipur foot [16].
There are other frugal medical device success stories. The General Electric (GE) corporation markets a US $3000 (cf. the high-income market device at US $12,000) baby warmer called the Lullaby in 62 countries [14]. A collaboration between biomedical engineers at Rice University, the University of Malawi, Texas Children’s Hospital, and the 3rd Stone Design company resulted in the development of a bubble continuous positive airway pressure (bCPAP, a neonatal respiratory-assist device) machine that costs US $160 to build (cf. the high-income market device sold at about US $6000) [14]. A device invented by Argentinian car mechanic Jorge Odón demonstrates that frugal innovations are not merely less expensive versions of the tools used in high-income nations. The Odón device is a fetal extraction tool that can, in many cases, replace forceps or vacuum extractors during vaginal delivery. The Odón device (currently undergoing trials) consists of an insertion tool, a disposable plastic sheath, and a hand air pump. The lubricated plastic sheath is inserted into the birth canal and is wrapped around the baby’s head; the air pump is used to gently inflate an inner compartment of the sheath, which grips the baby’s head. The sheath can then be pulled to extract the infant. Although the Odón device’s relatively low cost qualifies it as a frugal innovation, the fact that it can be used safely by non-experts in a non-clinical setting greatly increases the device’s potential impact in low-income areas where complicated births must be handled without the services of a trained physician and a modern delivery suite [17].
In general, frugally innovative medical and healthcare devices must have the following characteristics: [14]
Devices must be safe and effective in the hands of the available healthcare workforce (e.g., technicians with minimal training).
Devices must be appropriate for the local infrastructure (e.g., hand- or solar-powered in areas lacking a reliable power supply).
Devices must be appropriate for the local environment (e.g., able to withstand extremes of heat and cold, exposure to dust and moisture).
Devices must be designed for intensive and prolonged use and have a sustainable cost-of-ownership over the lifetime of the device (i.e., durability may be as or more important than initial cost).
Devices must not require constant inputs of high-cost or difficult to procure disposable components (e.g., custom tubes, fittings, batteries, etc.).
Frugal Service Innovations
Frugal innovations manifest not only as tangible hardware technologies, but also as streamlined, well managed organizations that provide a needed service. In the realm of healthcare, the Aravind Eye Hospitals of India best exemplify innovative services. About 12 million Indians are blind, many as a result of cataracts, a disease with an earlier onset in India than in the West. Founded by Dr. Govindappa Venkataswamy in 1976 to address this need, the Aravind Eye organization has grown from a single 11-bed hospital to a network of hospitals and care centers throughout India with nearly 3000 beds. Avarind’s success is due in large part to Dr. Venkataswamy’s obsession with efficiency: Venkataswamy even spent time at McDonalds’ Hamburger University in Illinois studying the time and motion principles and quality control standards the fast food empire employs in its franchises. In Aravind Eye Hospital surgical suites, doctors stand between two operating tables. While one patient is undergoing surgery, the next is being prepared on the adjacent table. After finishing one procedure, the surgeons need do little more than turn to begin work on the next patient. In 1992, faced with rising costs from suppliers, Aravind established Aurolab, an in-network manufacturer of intraocular lenses. Aurolab can supply the lenses at about US $2 per unit (cf. often more than US $600 in high-income markets). Since its foundation, Aravind doctors have treated >32 million patients and performed >4 million surgeries and currently performs 60 % as many eye surgeries annually as the UK’s National Health System. Complication rate after surgery is half that reported in Britain, and the surgeries can be performed at about one one-thousandth of the cost. Most remarkably, the Aravind Eye Hospitals are self-sustaining: paying customers who may opt for higher-end services (such as private, air conditioned rooms) subsidize those who are able to pay little to nothing [18, 19].
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