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One does not have to watch the news extensively to see evidence of the incredible strain that today’s challenges are putting on health systems globally. Amidst the devastating Covid pandemic that relentlessly pushes on into its second year, there are conflicts crippling whole regions, incalculable numbers of refugees and displaced persons stuck in camps, and a full sheet of infectious and non-communicable diseases continuing to devastate communities with sub-optimal access to healthcare. In many of the low- and middle-income countries (LMICs) most affected, these stories highlight a truth that pertains to far more than just these events: that the health systems themselves are often inadequate for many of the people whom they are supposed to be serving, and more advanced solutions are needed beyond the ones currently being offered.
Rapidly improving technologies offer promise in every sector of health in both low- and high-resource settings. High tech interventions in some LMICs range from medication delivery by drone to remote hospitals, medical imaging that can be done through mobile phones, diagnostic algorithms that reduce the requirements of clinical oversight, and mobile health technologies that can facilitate transition to electronic health recording, to name just a few. While these technologies are badly needed in many areas, there are important ethical factors regarding their appropriate delivery that should be considered when they are implemented in new locations.
Sustainability and health system strengthening
While some emerging technologies are being used for short-term solutions, such as disaster relief and aberrant outbreaks of infectious diseases, the gold standard for global health interventions is to enable them to integrate sustainably within local health systems. Technology that is implemented and only used for short periods of time not only fails to address issues in the long term, but will actually leave gaps in health care delivery system once it stops working. This means that high tech solutions that are introduced into new systems should have the capacity for long-term use and in many cases should include the potential for scaling up to cover larger areas and populations. They must be capable of being used autonomously and being repaired, maintained, and sometimes even produced locally. If not, the introduction of the technologies will deepen the cycles of dependence that local health systems will have on foreign institutions or the technologies may end up being completely neglected, resulting in wasted resources in desperate areas. It is not uncommon, for example, for tropical medicine doctors working in LMICs to report seeing unused medical equipment such as ECG machines or even extremely expensive neonatal resuscitation tables left in an ignored corner of the hospital. Such tools, which have already proven to be lifesaving, still struggle with implementation in certain areas. This underlines the fact that the success of these interventions is due as much to the strategy of implementation and subsequent training as it is to the efficacy of the tool.
To improve the sustainability of new tools, capacity building should be an essential focus where such technologies are implemented. Involvement by members of local health organisations at every level of a programme can not only seek to increase the likelihood of the programmatic success and sustainability of such interventions, but can also improve the technological capability of local health workers. This can be done by ensuring adequate provision of training programmes for local workers and managers when introducing new interventions that involve technological components. Additionally, there should be an infrastructure in place to promote good practice for standardised and optimal use of new interventions, such as standard operating procedure guides (SOP) guides, instructional manuals, and support groups for community health workers and others who may be trialling the interventions in the field, such as via WhatsApp.
Local context and community considerations
It is essential that researchers and proponents of new technologies from high-income countries (HICs) who plan to implement interventions in LMICS have a comprehensive understanding of local contextual challenges and the true limitations of resources in the field. Foreign implementers need to perform a considerable amount of formative research alongside local partners in areas where interventions are to be implemented. When introduced, technologies should also be streamlined to support the way in which local health staff work, in as user-friendly a manner as possible, improving the likelihood of their feasibility and success.
In light of the numerous challenges and risks that can come with the introduction of new technological tools in health systems, it is vital that these technologies are introduced through a needs-driven approach. That is to say, just because high tech tools are available does not mean that they should be introduced unless it is clear that there is a need for what the technology offers in that region and that the potential benefits outweigh the associated risks. When introduced with plans for scaling up, the intervention should also be proven to be cost-effective and not duplicating efforts that existing services are already covering. This reinforces the importance of a comprehensive understanding of local circumstances that is best obtained through local partnerships and extensive research. Additionally, programmes should, whenever possible, try to incorporate feedback from the beneficiaries, including patients receiving care, community health workers, and members of the ministry of health, to aid in an objective and local needs assessment.
As new technologies can, particularly in remote settings, be a source of apprehension, sensitisation to products and materials is integral both to improving local understanding and eliminating cycles of mistrust. Involving local leaders can be fundamental to a programme’s success and may offer a way to mitigate such mistrust, particularly in remote areas where such technologies may not be well understood by local community members. They can also help to ensure that programme delivery is more equitable and targets hard to reach populations, a huge benefit particularly when targeting communicable diseases.[1]
Finally, as m-health interventions and other technologies become more accessible in low-resource settings, the security risks to local users must also be considered. The proliferation of digital data entry and data sharing means that more local workers will have to be trained in good data practices to avoid potential exposure of protected personal data. Once digital data networks are established, they become vulnerable to ransomware attacks and hacking. Implementing institutions for such interventions should also take responsibility for improving local data security and ensuring that they do not give populations any reason for mistrust.
Trials and research for high tech solutions
Research and control trials in LMICS working to examine the efficacy and feasibility of high tech solutions are a vital part of the scientific process. They should be strictly scrutinised – both at the project’s inception and during publication through the peer review process – to maintain the highest standards of research integrity. Recent movements calling to decolonise global health have helped to spotlight an issue that global health research has historically overlooked, research fairness. This term refers specifically to a systematically unfair ecosystem in which local institutions in LMICs have a significant disadvantage in their competitiveness for research funding and for creating subsequent publications. As grants for high tech solutions in particular will likely favour the wealthy and well-equipped institutions, it is all the more important that they make efforts to promote research fairness in the areas where they work. This can be done in part through the formation of local partnerships, promotion of local institutions, promoting authorship in publications of local researchers from LMICs, and subsequent inclusion in the presentation of results.
Beyond research fairness, partnerships should further aim to empower researchers from the global South to also develop innovative technologies. High tech solutions in the global South, created in the country where they were implemented, have in many cases shown better odds of success and scalability than ones that were developed in HICs and then trialled locally.[2] These ‘local’ innovations come with a number of advantages such as involving health ministries as stakeholders (advantageous in both maintaining sustainability and strengthening the existing health system), potentially gaining faster regulatory approval and therefore being more readily available for use, and using lower-cost goods that are available through existing supply chains. Such successes in locally conceived and produced innovations have even resulted in global health experts like Madhukar Pai advocating for a change in the way in which global health technologies are introduced, saying that we should move away from models where everything is developed in the global North and expected to function accordingly in LMICs.
Conclusion
High tech solutions can be an incredible asset in improving health outcomes in low-resource settings in the future. With vast threats to human health at an exceptional moment in history, finding new and effective solutions will be vital to solving the immense challenges that interrupt adequate delivery of health care globally. The global health community would be remiss if it were to ignore these solutions. However, like everything else in the field, we must closely examine and scrutinise every intervention to ensure that it upholds appropriate ethical standards.
References
- Holden K, Akintobi T, Hopkins J, et al. Community engaged leadership to advance health equity and build healthier communities. Soc Sci (Basel). 2016 Mar;5(1):2. doi: 10.3390/socsci5010002
- Pai M. Global health technologies: time to re-think the ‘trickle down’ model [Internet]. Forbes Magazine. 2020 Feb 17. Available from: https://www.forbes.com/sites/madhukarpai/2020/02/17/global-health-technologies-time-to-re-think-the-trickle-down-model/?sh=75b46d7844d9
