Perhaps the worst of COVID-19 is the fact that the end – and possibly even the way to the end – is not yet in sight. We do not know what the eventual impact will be, and health systems that were already overburdened before the pandemic are reaching their breaking points. Some are already there.
On the other hand, this has been a fascinating time for observers of human ingenuity. Innovations in response to the pandemic are emerging everywhere. New ideas for testing, vaccination and healthcare delivery are underpinning the selfless spirit of frontline workers around the world, and while much has been lost, there is also much to celebrate. The task now is to build resilience – not necessarily for the post-pandemic era, because we do not know when or what that will be; but for now, and for the future. Before COVID, one person in two could not access basic healthcare, and that will only have got worse. Nor will this be the last pandemic.
Shiv Kumar of Swasti Health Catalyst drew on the pandemic experience in India, where the health emergency became a humanitarian emergency extraordinarily quickly, to build new collaborations and partnerships across civil society, the private sector and local governments. This coalition has delivered relief, prepared for a massive vaccination drive, and pushed for telecare in response to an effective collapse of the primary health care system. These experiences suggest that away from the traditional focus on products and finance, the real value comes from people and systems innovations.
Shariha Khalid Erichsen, founder of Mission & Co., supported this point when she described the “Health in Your Hands” initiative (https://youtu.be/VMiBE8urpc0), a platform showcasing innovations that address healthcare needs in low resource, low access settings. These contexts have problems and challenges on multiple levels, many of which have been aggravated by the pandemic. There are huge shortages of healthcare workers; 100 million people around the world are pushed into poverty every year by health expenses; 70% of deaths worldwide are caused by non-communicable diseases; nearly 4 billion people lack access to essential health services; 75% of people who need mental health care cannot get it; and 7,000 new-born babies die every day. The concept of Health in Your Hands is to change the narrative so that last mile delivery is no longer an afterthought but the first priority, driven by individuals and organisations that know how to do this best. The project has set out to aggregate 100 innovations, with 50 already announced and more coming. Partners include NGOs, multilateral agencies, multibillion dollar companies and start-ups connected by a commitment to the people on the ground who know how to deliver. Its task is to build ecosystems that connect them, finance them, and help them work better – not only in health-specific activities but also in response to broader challenges such as WASH and energy access, disrupting how these services are delivered and how diseases are prevented. This project recognises many ways to reach the last mile, and many instruments that can be mobilised to finance them. It works with those already doing good things and facilitates the connections that help them to scale up. Ultimately, most projects need six main things: money; mentors; markets; management; mission; and media and visibility.
The need for such innovation is great because current models for health financing are not. A lot of money comes from public sector domestic budgets, or external development funding that creates pilots but does little to scale them up. Resilient health services require new approaches to financing healthcare, especially in low- and middle-income countries. As pointed out by James Bair, managing Director of Baraka Impact Finance, the size of the annual budget needed to meet SDG3 by 2030 is between 260 and 370 billion dollars per year – at a time when development funding has plateaued. The remaining gap is around $200 billion, a huge figure. There are many ways to address this challenge, and we should pursue them all; but foremost among them is the need for private capital to play a greater role. The fact that it currently does not is frustrating, not least because the commercial opportunities are significant, and because the technological advances of the last 3-5 years offer elegant solutions to longstanding problems of mobile access, remote diagnosis, data aggregation, AI-driven decision support and other potentially profitable things. Entrepreneurs around the world are applying these technologies to create real change and scale up businesses. Even through the narrow lens of return on investment, private capital should be interested. Baraka’s mission is to win minds and hearts – unfortunately, minds must come first. Without convincing minds, private capital will not move.
Baraka addresses the need for capital from entrepreneurs in low- and middle-income countries. When it was founded, most grants needed were around USD 100,000; now, companies in their pipeline tend to be looking for sums more like USD 1-5 million in order to scale up. There is a better story to tell today than ever before. The goal is to marry excellent investment opportunities with impact-driven solutions and investors interested in social impact as well as good returns. COVID-19, for all the damage it has caused, has left us in a place where incredible things are possible.
Existing problems are exacerbated by the fact that finance is not equally distributed across regions, not least because of outdated and inaccurate risk perceptions. Only one per cent of total private capital raised for investment goes to Africa. This is a huge issue. Perception of risk is much higher than warranted in many developing markets, especially in sub-Saharan Africa, despite much evidence to the contrary – including aggregate GDP, spending figures and a range of other compelling metrics.
When innovators are seeking funding, it is important to bring their intention into the story of what they’re trying to do. Investors are often interested in the person behind the innovation as much as the idea. Businesses can fail: these institutions need confidence in the person attempting to solve the problems and make the business sustainable at scale. In addition, well-developed business cases are crucial. There are many entrepreneurs with amazing ideas who understand their ecosystems and the importance of connectedness and networks, and who have ideas on how to accelerate progress; but framing those ideas in ways that are internationally comprehensible and digestible, and concise, is a big challenge.
One lesson from field studies is that it is not always obvious where the innovation is – and it does not always lie in the technology. There are innovative ways to evaluate solutions, even old ones, for impact, sustainability and accessibility. For example, approaching the perennial problem of making diagnostics sustainable, massive extraction of epidemiological data might allow searches for probabilistic approaches that dispense with the need for onsite diagnostics evaluation in favour of massive datasets (though data use in this fashion raises sensitive issues around duty to protect personal information). But this type of innovation requires a deep understanding of ecosystems, which vary from country to country.
Leveraging innovation to build resilience in health services in resource limited settings also requires an understanding of the expectations of national institutions and research centres, and the needs and implementation constraints in remote and vulnerable communities. The key to achieving this is networks. As Marc Bonneville pointed out, the work of the Fondation Mérieux provides a good example. Helping countries tackle public health by strengthening national diagnostic and laboratory capacity, increasing access to innovative diagnostic tools and reinforcing research must be done in close collaboration with local stakeholders – ministries, public health institutions, research centres and others, at national, regional and local level. Implementing diagnostics means considering three major points other than cost: implementation constraints; technical performance; and added value for target populations. Addressing each of these also requires networks—for example, diagnostics usually require centralised structures such as national reference laboratories, and an understanding of how they connect with peripheral community laboratories, and how sample logistics work. If the approach can be decentralised, robustness and value can be assessed more effectively—but only if data processing and exchange systems are in place. Assessing value, whether at global or community level, requires a large array of expertise to design and implement field evaluations; do the science; address uptake; assess cost/benefit ratios for communities and countries; and so on. Tight networks are needed to gather expertise and communities to assess results and propose solutions with direct beneficial impact.
Throughout the pandemic the Fondation Mérieux has strengthened labs to aid quick implementation of innovative COVID-19 diagnostics solutions and established regional and international networks of diagnostic and research centres to foster South/South training and collaboration on diagnostics and public health. It has sourced funding from private and public entities, and coordinated these actions with big multilateral programmes. It has also provided oversight to help make efficient decisions—for example, advising countries on when to eschew sophisticated innovation strategies in favour of leveraging established networks already closely connected to communities. Improving access to innovation means not just providing it to remote communities, but also connecting those communities to one another, forming networks that achieve more than the sum of their parts.
The world is seeing a democratisation of metrics that may prove very significant in the coming years. Old models where rich country researchers with exclusive tools went around measuring impact are giving way to a landscape where assessment capacity is achievable for almost anyone. For example, Joseph Tucker explained how the Social Innovation in Health Initiative (SIHI) has created a set of measurement frameworks (https://socialinnovationinhealth.org/monitoring-evaluation-framework/), research checklists and open access tools to measure the impact of social innovation. This is not just about health outcomes, but also about broader social and environmental metrics. Ease of access to tools opens up exciting new areas of work looking at non-health benefits of social innovation, community engagement and different relationships between beneficiaries and creators of processes.
Digital transformation of supply chains is an area that offers great possible gains. Session Chair Pradeep Kakkattil gave the real-life example of a country procuring drugs and commodities worth 1.2bn annually, of which 20-30% is lost to overstocking, inefficient allocation and expiry because the country has no mechanism for different parts of the system to communicate. Digitising the supply chain, even if it only saved half of the 200m+ lost every year, would be a huge achievement. But supply chain issues are not always just technical and organisational; there are often difficult issues of localised disorganisation and corruption as well. The challenge is often not the technology, but the culture—and not only in low-income countries. There’s only so much you can digitise human nature.
Inclusivity offers one pathway to addressing that problem. It is important to embed inclusivity in solutions that are built and/or implemented in countries and communities that often lack privilege, power or a say in how these solutions affect their lives. Equity must be a goal from the start of every project. The good news in this regard is that there is no shortage of intention. Investors are constantly faced with innovators who won’t even initiate models without thinking how they can scale in an inclusive manner, and who have done a great deal of work on the impact measurement and M&E needed to quantify their success. There is a lot of goodwill out there—much of it from individuals who have sought higher education abroad and returned to low-income countries with knowledge and a desire to improve communities at home. It is also important to recognise that sometimes exclusivity is unintentional, and must be considered at many levels—not just at patient or client level, but also among decision-makers and in the context of structural or organisational inequities that need fixing first. Often the missing piece of the puzzle is the recognition of those who have lived experience and who are excluded, but who have the deepest knowledge of their situation and the conditions they face. They may be seen as recipients, but they are really great assets. Client communities should be prioritised as active participants – valuable resources without whom progress is impossible and goals unattainable.
The question of what innovation approaches are most appropriate for vulnerable groups provoked a range of responses. Certainly, the application aspect of innovation is underrated: while there is a sexiness to new stuff, that which already exists is often more useful. Measurement is also an essential if sometimes under emphasised, part of social innovation. The right framing of an issue can also be powerful. For example, preparing for India’s huge effort to vaccinate a billion people against COVID, framing vaccination not just as a jab but also as a lifesaving enabler that allows people to do their jobs, earn a living and protect their families has helped scale up delivery very rapidly.
The availability of data and open access are further key points. This is one area in which COVID has given a glimpse of a better future. All COVID-19 research has been open access, and the pandemic response has developed with unprecedented cooperation, speed and success – technologically if not politically. Open access has created many opportunities we never knew we were missing.
The concluding Q&A session revealed a strong shared will to develop bridges between different actors. Innovation in collaboration may be the most important type of all – making the most of existing expertise to give the initiatives of the South their proper recognition, and leveraging them to build resilient systems for health everywhere in the world.
Finally, to allow this to happen, the most important job may be to fix our underlying cultures. Technology and innovations can be bought; but the mindset and the ability to embrace innovation – the innovation culture – is priceless.