[The following is lightly modified text from an article Lucy and I wrote for CDP]
In early 2015, the global healthcare initiative Saving Lives at Birth (SL@B) issued the fifth call for innovations centred on ground-breaking prevention and treatment approaches for pregnant women and newborn babies in poor, hard-to-reach communities around the time of birth.
My colleague Lucy Sheldon and I, alongside Cambridge Design Partnership, were among the finalists selected from a record 750+ applicants in 2015 to attend the Saving Lives at Birth DevelopmentXChange in Washington DC.
The range of innovations competing for funding was wide – and inspiring. Others finalists we met included Ifkara Health Institute who were aiming to scale their autonomous drone delivery system which can deliver up to 3 pints of blood or small lifesaving medical devices/pharmaceuticals to remote villages not easily accessible by vehicles; Diagnostics For All with their point-of-care, low cost, rapid diagnostic test for anaemia, HIV, HBV and syphilis; and the World Health Organisation (WHO) for a safety and feasibility study on the Odon device for assisted delivery.
Our proposal aimed to reduce the impact of postpartum haemorrhage (PPH), the leading cause of maternal death and disability in the developing world. Uterine Balloon Tamponades (UBTs) have been shown to be effective in treating PPH and are endorsed by the WHO. However there are financial, training and usability issues affecting their deployment in low resource settings. We proposed a human-centred and risk-controlled approach to develop a suite of device features and training strategies – testing them with birth assistants in low resource settings and evaluating which combinations could best empower them, whilst accelerating deployment at minimal risk and minimal cost.
Disappointingly, all the UBT-related finalists – ourselves included – failed to receive funding. However there was a strong reception for our approach and many discussions were had with fellow finalists on how to apply the processes to their own innovations.
A critical component of our proposed process was recognition that medical risk contains a strong cultural and use-environment influence, and that developing a medical device for a low-resource setting while using developed world risk acceptance criteria is not always appropriate. For example, the risks associated with being unable to use a medical device such as UBT or deliver a drug such as oxytocin in a hospital in Europe or the US is minimised by the existence of a number of alternative interventions. However if a midwife in rural India does not have access to, or is unable to administer oxytocin or a UBT effectively, alternative surgical interventions may be hours and hundreds of miles away increasing the chances of disability or death.
An interesting and recurring discussion at DevX was around the challenges and pitfalls of transitioning from an innovation to a solution positively impacting the lives of mothers and babies. One medical practitioner, who works where these solutions are needed most, commented, “Seeing all these innovations is amazing, I wish I could buy one!” Another anecdote shared by an attendee discussed needle use in LRS, “Sterile needles are incredibly inexpensive, yet needle re-use in these settings remains a massive problem, not because of cost, but because of distribution and supply chain issues meaning that the only needle available to deliver a life-saving drug is a dirty one.”
And so if money/cost is not the barrier to saving lives and innovations exist to meet the needs of mothers and their babies, what is stopping these from being available and having impact? This lack of impact is commonly attributed to a range of interdependent factors; coordination of activities across national borders between many parties (donors, implementing partners, ministries of health etc), resource and health infrastructure limitations, immature business models, and inexperienced development teams to name a few.
We believe that failure to impact the lives of mothers and babies is exacerbated by a poor or narrow problem definition driving the design of innovations. Promising technologies, such as inhalable oxytocin, are priorities for funding because they address a known and well defined problem; in this case the heat stability of infused oxytocin in supply chains lacking reliable cold storage. However, a broader analysis of the barriers and risks to impact of a life-saving intervention would likely highlight problems beyond those which technologies in isolation aim to address, challenges such as distribution, culture, gender, awareness, knowledge and even corruption.
It is only through defining and addressing these issues that would enable life-saving and life-enhancing interventions – when so many are currently not being used – to be accelerated. Antara, a Global Health advisory firm, pointed out during DevX that “As global health innovators, we should be asking ourselves ‘How will we make ourselves irrelevant within the next 5-10 years?’” We believe that it is only through defining, prioritising and addressing all the problems that are acting as barriers to the use of lifesaving and life enhancing interventions (the risks of non-use) that impact can truly be accelerated.
Our approach can largely be summarised as: