Consideration of the context of product use matters when developing health technologies. Innovators of healthcare products that target low to medium income countries always seek my perspectives about their inventions. A recent conversation with an innovator developing a device for monitoring blood sugar levels in diabetes made me reflect on what has framed my understanding of the product innovation and development cycle requirements for these regions.
I have served as a physician in rural, urban areas and regions affected by humanitarian crises. I have managed projects and programs for health systems strengthening in the private and public health sectors and I have also provided technical assistance to the Ministry of Health (MoH) in Uganda in partnership with development partners such as UNICEF, USAID and UKAID. A flash back on my typical work day as a clinician in a rural hospital in a region affected by armed conflict gives a picture of some of the essential features that can increase application of innovations in low to medium income countries.
After I completed my medical internship training that qualified me as a general practitioner, I took up the role of a volunteer medical doctor at Anaka Government Hospital as my first professional assignment. I was armed with all the essential skills to provide primary health care services. With this role, I was the doctor of all cases.
Over the years, I have learned to appreciate how healthcare technologies improve the quality of my work, create work efficiencies and increase value to the people I serve. These technologies have to be energy efficient, safe and easy to use with limited reliance on internet or telecommunication connectivity in order to achieve full functionality of the device.
1. Sustainable Energy
It was 1:00 am on my first day at the hospital. The night was very dark. Through my bedroom window, I could see a very bright light moving closer to me. I rubbed my eyes to be sure that I wasn’t dreaming. The sound of footsteps grew louder the closer the light moved towards me. “Are fire flies that big?”, I asked myself. As I thought about possible things that the growing light could be, I heard a loud knock on my window. “Doctor, doctor!”, screamed a female voice on the other side of the window.
Rose the midwife on night duty at the hospital had come to my house to inform me about a medical emergency. She had braved a quarter mile walk from the hospital maternity ward to my house. She carried a kerosene lamp to enhance her visibility of the dark, quiet and lonely path. The bright light from the kerosene lamp that she carried was visible from a one-mile radius because of the flat landscape of the land and scanty vegetation made up of scattered grass and shrubs in the arid climate.
The hospital lacked electricity because it was not on the national grid. The loud generator that provided energy for lighting in the hospital was turned for limited hours (7-9:30pm). This duration was meant to allow health workers to provide evening doses of medication to in-patients. The limited hospital budget could not allow for extended use of the generator. Solar electricity would have been a great alternative, but no solar system had yet been installed in the hospital. Besides, solar panels could easily be stolen unless when secured using specialized welding in place.
The challenges associated with energy sources requires that any medical device should use a wide range of energy sources to ensure that front-line health workers have options for energy to keep the devices functional.
2. Safety and Security
Rose had been accompanied by the night watchman for her safety. The region had been affected by armed conflict for 20 years. Most people at that time typically preferred to move without light in the dark because carrying a light source that would expose them to the rebels. About a week earlier, the Ugandan government and representatives of the Lord’s Resistance Army (LRA) had signed a cease fire truce prohibiting any more fights while both parties negotiated a peace deal. I arrived shortly after this development.
The travel curfews after 5:00pm presented a complicated situation at night. Fortunately, the hospital had an ambulance that government soldiers would accompany whenever there was need to rush an emergency case to Lacor Hospital. Lacor was about an hour away from Anaka Hospital on a dirt bumpy road. My arrival meant that common emergency cases such as obstructed labor that required emergency caesarean sections could be handled at the hospital. With limited workforce, mobility of tools and machines increases utilization and maintains functionality.
Machines that are lightweight, safe and easy to use by the average healthcare worker favor use in the typical setting described earlier. Portability is critical as one might have to move them between storage area of safety and point of care. Hand held devices are popular among health workers and enable sharing of limited resources between various points of care.
3. Telecommunication and Internet Connectivity
Telephone connection to the area was very poor. I could only make phone calls by standing on an anthill that was about 300 meters from my house and the hospital. Limited telecommunication connectivity experienced protected people in the area from developing anxiety from false information about rebel activities in the area. Rumors about the LRA were common whenever we talked to friends and relatives on phone. For example, in a phone conversation with a friend, I was informed of gunshots in the area I worked in which had actually not happened. These rumors caused anxiety among the few health workers who had remained to serve in the region. Telecommunication connectivity came with both advantages and disadvantages.
Devices that can only function with internet or telecommunication connectivity are difficult to use in such settings on the other hand portable devices that require regular software updates might be more useful because of the option to move these devices to areas that can permit critical updates to take place. Portability of the device is essential for easy mobility and continuous functionality.
4. Doctor for All Cases
At the maternity ward, I reviewed two pregnant women who had been referred from a lower level health facility. The women had come in the night because news had reached the surrounding villages that a young female well trained doctor who could deal with all cases including surgeries had arrived at Anaka Hospital. For a while, most emergency cases would be referred to Lacor Hospital that was better equipped. Rose was very experienced with providing integrated maternal and child health services. She taught me some concepts and heuristics she applied when faced with life threatening emergencies that required quick decision making and immediate action to prevent complications of the disease or save a life.
I examined and reviewed the patients with light from the same lamp that Sister Rose had carried for the quarter mile trip to my house. I confirmed that the patients were progressing well with labor. I instructed the midwife to continue monitoring the patients and alert me in case anything deviated from normal. I decided to stay at the hospital for the rest of the night. One of the women had a normal delivery. I performed an emergency caesarean section on one of the ladies because of fetal distress. Three days later, both mothers were discharged with their newborns in good general condition
Typically, the available healthcare workers provide most common treatment and surgeries to the patients they see. Limited specialization among health workers in lower health facilities requires that products are produced with integration of common applications, and consideration of the end user who might not have special skills that specialists in higher level hospitals would have.
5. Regulation and Financing
All medical devices and health care technologies are regulated by regional, national and state regulatory agencies that aim to ensure that products are designed with quality assurance and safety measures to guarantee safety of the end users, health workers who will handle the device and patients on whom the device will employed. All devices are supposed to be tested by regulatory bodies to safeguard their application.
Most healthcare costs are paid for by the government or third parties such as insurance companies, development partners or foundations. Understanding options for financing medical devices can enable innovators design business models that can sustain market access. Consequently, the choice of product materials and design should aim to lower costs for the best value to the customer and payer.
Sustainable energy source, portability, safety, easy to use, non-reliance on internet or telecommunication connectivity are examples of the essential features for the design of products that are developed for low to medium countries. Majority of health facilities located in remote regions and care needs to be done during product design to incorporate these critical features while catering for financing options that allows for product launch and mainstreaming into existing health systems.