H e a l t h C a r e Po l i c y a n d Q u a l i t y • O p i n i o n Harvey et al. Affordable Imaging Innovations in the Developing World
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Health Care Policy and Quality Opinion
Innovating for the Developing World: Meeting the Affordability Challenge H. Benjamin Harvey 1,2,3 Roy Ahn2,3 Daniel D. Price 4 Thomas F. Burke2,3 Harvey HB, Ahn R, Price DD, Burke TF
Keywords: developing world, health policy, maternal health, ultrasound DOI:10.2214/AJR.14.12484 Received December 24, 2013; accepted after revision February 10, 2014. T. F. Burke is a founder of the African Institute of Innovation and Technology, which has received an unrestricted grant from SonoSite. The work was funded in part through a Toshiba America Medical Systems/RSNA Research Resident Grant awarded to H. B. Harvey. Toshiba had no influence in the preparation of the manuscript. 1 Department of Radiology, Massachusetts General Hospital, 55 Fruit St, FND 216, Boston, MA 02114. Address correspondence to H. B. Harvey ([email protected]). 2 Department of Emergency Medicine, Division of Global Health and Human Rights, Massachusetts General Hospital, Boston, MA. 3
Harvard Medical School, Boston, MA.
4 Department of Emergency Medicine, Alameda County Medical Center, Oakland, CA.
AJR 2014; 203:835–837 0361–803X/14/2034–835 © American Roentgen Ray Society
OBJECTIVE. Ultrasound technologies have gained increasing prominence and accessibility in the developing world as manufacturers focus on this region as an emerging market. More extensive ultrasound use holds promise for addressing the disproportionate morbidity and mortality that continues to plague the developing world, particularly in the area of obstetrics. CONCLUSION. In this article, we describe the challenge of making ultrasound technologies affordable to health care providers in resource-limited regions vis-à-vis an innovative group of midwives in Nairobi.
T
he developing world is one of the fastest emerging markets in the health care industry. Many modern health care innovations, particularly technologic advancements, have been inaccessible to developing countries for much of the 20th century because of financial constraints and a general lack of infrastructure. This has changed over the past 10 years as major health care companies look to the developing world to make up for slowed growth in more developed nations [1]. As manufacturers of medical diagnostics and therapeutics focus on less affluent but larger markets, expensive health care technologies originally designed for the developed world are being reengineered into more affordable shaved-down versions that can meet the unique needs of developing countries [1]. Low-cost portable ultrasound machines are a prime example of a reengineered health care technology being targeted at the developing world. Portable ultrasound machines were originally produced to meet urgent diagnostic needs in resource-limited war zones, but manufacturers soon recognized their potential to fill diagnostic gaps in the resource-limited settings of the developing world. This market was first explored
by small-cap ultrasound manufacturers such as SonoSite, which was recently acquired by Fuji Films for nearly $1 billion [2]. More recently, however, large-cap manufacturers of imaging equipment have entered this market, offering their own portable low-cost ultrasound models. Perinatal health is one promising application for portable sonography in the developing world, where 99% of the world’s maternal deaths still occur [3]. Data suggest that most maternal deaths in these regions are due to direct obstetric causes and could be prevented if emergent obstetric care were available at every birth [3]. However, because nearly half of all births in the developing world still occur in nonhospital settings without a skilled birth attendant, lifesaving obstetrical interventions are often delayed, resulting in poor maternal and fetal outcomes [4]. Antenatal ultrasound screening programs hold promise for early identification of certain high-risk pregnancies (e.g., twin gestations, placenta previa, and malpresentation), so that these patients can give birth at an obstetrical care center with surgical capabilities. This is especially true in developing countries such as Kenya and Uganda, where financial barriers to hospital-based
AJR:203, October 2014 835
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Harvey et al. deliveries have been mitigated through subsidized care for the poor [5]. The potential to curb perinatal mortality has resulted in a burst of activity around antenatal screening in the developing world [6]. Our group alone has trained over 250 physicians, clinical officers, and midwives in western Kenya over the past 2 years. Other groups, including Medical Imaging Partnership, RAD-AID, SonoWorld, and Imaging the World, have led similar efforts across the globe, some of which allow in-country providers to transmit ultrasound images to medical centers in the same country or in the United States for help in interpretation [7]. As antenatal screening has gained prominence in the developing world, increasing numbers of providers are seeking to purchase machines and offer this technology as part of their practice. However, despite the low price of these portable machines—averaging $15,000 per machine and representing a fraction of the cost of more traditional ultrasound technologies—these powerful diagnostic tools remain too expensive for most interested providers. The missed market is estimated at over 10,000 providers for maternal care in Kenya alone [8]. In late 2012, we met a special group of six nurse-midwives in Nairobi who have met the challenge of ultrasound affordability in a creative way. Their teamwork and ingenuity have informed the way we view the challenge of integrating expensive health care technologies into the developing world. Industry should take similar heed. These midwives first met at a conference for maternal health in Kenya. They discovered a shared frustration in their inability to offer the power of ultrasound to their patients because of financial barriers. With over 100 years of clinical experience among them, each of the midwives owned his or her own maternal health clinics in and around Nairobi, many of which were located in slums. Despite owning high-volume clinics, most of the providers still did not have adequate collateral to obtain loans at affordable prices. Even when up-front collateral was available, the interest rates offered to them remained as high as 19%. At a dead end, the group embraced the Swahili concept of harambee (meaning “coming together”) and formed a buyers’ coalition. The coalition negotiated a group rate with a local distributor for an affordable model with a limited 1-year warranty; however, the distributor was still unable to offer a workable financing model for the group. To overcome this barrier, the group of
836
six providers met each month at the sales office of the ultrasound distributor. Each member brought 80,000 shillings (approximately U.S. $960) to the meeting. Depending on that month’s circumstances some providers brought less, only 30,000 shillings, and some brought more, up to 200,000 shillings. Pooling their money at each meeting, they provided the distributor with approximately 490,000 Kenyan shillings (U.S. $5800), the negotiated group rate for a single machine. Each month, one of the group members took home a machine. Each subsequent month, they would again meet and pool their money, and another provider would take home a machine. These meetings continued for 6 months until all six providers had obtained an ultrasound machine. Given that major ultrasound manufacturers with sophisticated financing options available to them are vying for what represents over a $1 billion market, why are consumers still required to create their own workable financing structures? Unlike this exceptional group of midwives, most health care providers in Ken ya will not have the ability to form a buyers’ coalition, but like these midwives, other nonphysician providers may be able to pay off an ultrasound machine in less than a year’s time, if given that option. Health technology companies must change their business models to provide affordable financing plans adapted to the unique needs of developing-world markets if they are to achieve significant market penetration. Creativity in pricing and financing could broaden the distribution channels for these important health technologies, much in the way that inexpensive cell telephone technologies have led to their wide adoption throughout rural parts of the developing world. One solution might be for these companies to team up with banks to offer affordable financing over multiple years. Such financing plans are less risky for lenders if the machines remain warrantied throughout the financing period. Additionally, companies could consider leasing equipment to clinics, allowing providers to determine whether there is an adequate market to support the machine, and if so, transitioning to a purchase arrangement. Finally, companies could manufacture scaled-back products specifically for these markets, increasing the companies’ ability to reach new markets without jeopardizing their premium product offerings in developed-country markets. Beyond simply increasing a company’s local market share, increased adoption of
low-cost ultrasound solutions in developing nations could have a secondary benefit for equipment manufacturers. Microsoft, Nokia, and Procter & Gamble have all used developing world markets as laboratories for testing and refining affordable technologies and health care solutions before selling these “emerging-market hand-me-ups” in developed world markets [9]. This business strategy, known as reverse innovation, has more recently been used by GE Healthcare when it introduced its low-priced portable ultrasound model into the U.S. market after initially creating the product for the developing world market [10]. In fact, experts have suggested that “success in the developing world is a prerequisite for continued vitality in developed ones” [10]. Recently, we returned to Nairobi to offer this special group of midwives refresher training on point-of-care maternal ultrasound. Compared with other training sessions that we have held, we were amazed by the palpable dedication and excitement of these clinicians. We attributed this difference to the midwives “having skin in the game” (i.e., ownership of an ultrasound). On average, these providers were performing two or three ultrasounds per week at an average charge of $15 per ultrasound examination. On the basis of equipment and ultrasound gel costs alone, it will take them at least 3 years to pay off a machine. We will continue to follow this group and track their experience as they proceed on this journey. Health care technologies such as portable ultrasound hold special promise for the developing world, where morbidity and mortality from preventable disease remain disproportionately high. However, before patients can benefit from these advancements, health care providers must be able to access them. By leveraging their financial sophistication and access to credit, major manufacturers of health care diagnostics and therapeutics have the potential to develop sustainable solutions to the affordability challenge and to save lives. References 1. FSG. Competing by saving lives: how pharmaceutical and medical device companies create shared value in global health. FSG website. www. fsg.org/Portals/ 0 /Uploads/Documents/PDF/ Competing_Saving_Lives.pdf. Published 2012. Accessed October 17, 2013 2. Matsuyama K. Fujifilm agrees to buy SonoSite for
AJR:203, October 2014
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Affordable Imaging Innovations in the Developing World $995 million to expand in ultrasounds. Bloomberg News website. www.bloomberg.com/news/ 2011-12-15/fujifilm-agrees-to-buy-sonosite-for995-million-to-expand-in-ultrasounds.html. Published December 15, 2011. Accessed on October 17, 2013 3. Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. Int J Gynaecol Obstet 2005; 88:181–193 4. Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS ONE
2011; 6:e17155 5. Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2011; 26:1–11 6. Sippel S, Muruganandan K, Levine A, Shah S. Review article: use of ultrasound in the developing world. Int J Emerg Med 2011; 4:72 7. Ross AB, DeStigter KK, Rielly M, et al. A lowcost ultrasound program leads to increased antenatal clinic visits and attended deliveries at a health care clinic in rural Uganda. PLoS ONE 2013; 8:e78450 8. Kinfu Y, Dal Poz MR, Mercer H, Evans DB. The
health worker shortage in Africa: are enough physicians and nurses being trained? Bull World Health Organ 2009; 87:225–230 9. Jana R. Innovation trickles in a new direction. Bloomberg Businessweek Magazine website. www.businessweek.com/magazine/content/09_12/ b4124038287365.htm. Published March 9, 2009. Accessed January 27, 2014 10. Immelt JR, Govindarajan V, Trimble C. How GE is disrupting itself. Harvard Business Review website. hbr.org/2009/10/how-ge-is-disruptingitself/ar/1. Published October 2009. Accessed June 23, 2014
F O R YO U R I N F O R M AT I O N
Mark your calendar for the following ARRS annual meetings: April 19–24, 2015—Toronto Convention Centre, Toronto, ON, Canada April 17–22, 2016—Los Angeles Convention Center, Los Angeles, CA April 30–May 5, 2017—Hyatt Regency New Orleans, New Orleans, LA April 22–27, 2018—Marriott Wardman Park Hotel, Washington DC
AJR:203, October 2014 837
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Health Care Policy and Quality Opinion
Innovating for the Developing World: Meeting the Affordability Challenge H. Benjamin Harvey 1,2,3 Roy Ahn2,3 Daniel D. Price 4 Thomas F. Burke2,3 Harvey HB, Ahn R, Price DD, Burke TF
Keywords: developing world, health policy, maternal health, ultrasound DOI:10.2214/AJR.14.12484 Received December 24, 2013; accepted after revision February 10, 2014. T. F. Burke is a founder of the African Institute of Innovation and Technology, which has received an unrestricted grant from SonoSite. The work was funded in part through a Toshiba America Medical Systems/RSNA Research Resident Grant awarded to H. B. Harvey. Toshiba had no influence in the preparation of the manuscript. 1 Department of Radiology, Massachusetts General Hospital, 55 Fruit St, FND 216, Boston, MA 02114. Address correspondence to H. B. Harvey ([email protected]). 2 Department of Emergency Medicine, Division of Global Health and Human Rights, Massachusetts General Hospital, Boston, MA. 3
Harvard Medical School, Boston, MA.
4 Department of Emergency Medicine, Alameda County Medical Center, Oakland, CA.
AJR 2014; 203:835–837 0361–803X/14/2034–835 © American Roentgen Ray Society
OBJECTIVE. Ultrasound technologies have gained increasing prominence and accessibility in the developing world as manufacturers focus on this region as an emerging market. More extensive ultrasound use holds promise for addressing the disproportionate morbidity and mortality that continues to plague the developing world, particularly in the area of obstetrics. CONCLUSION. In this article, we describe the challenge of making ultrasound technologies affordable to health care providers in resource-limited regions vis-à-vis an innovative group of midwives in Nairobi.
T
he developing world is one of the fastest emerging markets in the health care industry. Many modern health care innovations, particularly technologic advancements, have been inaccessible to developing countries for much of the 20th century because of financial constraints and a general lack of infrastructure. This has changed over the past 10 years as major health care companies look to the developing world to make up for slowed growth in more developed nations [1]. As manufacturers of medical diagnostics and therapeutics focus on less affluent but larger markets, expensive health care technologies originally designed for the developed world are being reengineered into more affordable shaved-down versions that can meet the unique needs of developing countries [1]. Low-cost portable ultrasound machines are a prime example of a reengineered health care technology being targeted at the developing world. Portable ultrasound machines were originally produced to meet urgent diagnostic needs in resource-limited war zones, but manufacturers soon recognized their potential to fill diagnostic gaps in the resource-limited settings of the developing world. This market was first explored
by small-cap ultrasound manufacturers such as SonoSite, which was recently acquired by Fuji Films for nearly $1 billion [2]. More recently, however, large-cap manufacturers of imaging equipment have entered this market, offering their own portable low-cost ultrasound models. Perinatal health is one promising application for portable sonography in the developing world, where 99% of the world’s maternal deaths still occur [3]. Data suggest that most maternal deaths in these regions are due to direct obstetric causes and could be prevented if emergent obstetric care were available at every birth [3]. However, because nearly half of all births in the developing world still occur in nonhospital settings without a skilled birth attendant, lifesaving obstetrical interventions are often delayed, resulting in poor maternal and fetal outcomes [4]. Antenatal ultrasound screening programs hold promise for early identification of certain high-risk pregnancies (e.g., twin gestations, placenta previa, and malpresentation), so that these patients can give birth at an obstetrical care center with surgical capabilities. This is especially true in developing countries such as Kenya and Uganda, where financial barriers to hospital-based
AJR:203, October 2014 835
Downloaded from www.ajronline.org by UCSF LIB & CKM/RSCS MGMT on 12/12/14 from IP address 169.230.243.252. Copyright ARRS. For personal use only; all rights reserved
Harvey et al. deliveries have been mitigated through subsidized care for the poor [5]. The potential to curb perinatal mortality has resulted in a burst of activity around antenatal screening in the developing world [6]. Our group alone has trained over 250 physicians, clinical officers, and midwives in western Kenya over the past 2 years. Other groups, including Medical Imaging Partnership, RAD-AID, SonoWorld, and Imaging the World, have led similar efforts across the globe, some of which allow in-country providers to transmit ultrasound images to medical centers in the same country or in the United States for help in interpretation [7]. As antenatal screening has gained prominence in the developing world, increasing numbers of providers are seeking to purchase machines and offer this technology as part of their practice. However, despite the low price of these portable machines—averaging $15,000 per machine and representing a fraction of the cost of more traditional ultrasound technologies—these powerful diagnostic tools remain too expensive for most interested providers. The missed market is estimated at over 10,000 providers for maternal care in Kenya alone [8]. In late 2012, we met a special group of six nurse-midwives in Nairobi who have met the challenge of ultrasound affordability in a creative way. Their teamwork and ingenuity have informed the way we view the challenge of integrating expensive health care technologies into the developing world. Industry should take similar heed. These midwives first met at a conference for maternal health in Kenya. They discovered a shared frustration in their inability to offer the power of ultrasound to their patients because of financial barriers. With over 100 years of clinical experience among them, each of the midwives owned his or her own maternal health clinics in and around Nairobi, many of which were located in slums. Despite owning high-volume clinics, most of the providers still did not have adequate collateral to obtain loans at affordable prices. Even when up-front collateral was available, the interest rates offered to them remained as high as 19%. At a dead end, the group embraced the Swahili concept of harambee (meaning “coming together”) and formed a buyers’ coalition. The coalition negotiated a group rate with a local distributor for an affordable model with a limited 1-year warranty; however, the distributor was still unable to offer a workable financing model for the group. To overcome this barrier, the group of
836
six providers met each month at the sales office of the ultrasound distributor. Each member brought 80,000 shillings (approximately U.S. $960) to the meeting. Depending on that month’s circumstances some providers brought less, only 30,000 shillings, and some brought more, up to 200,000 shillings. Pooling their money at each meeting, they provided the distributor with approximately 490,000 Kenyan shillings (U.S. $5800), the negotiated group rate for a single machine. Each month, one of the group members took home a machine. Each subsequent month, they would again meet and pool their money, and another provider would take home a machine. These meetings continued for 6 months until all six providers had obtained an ultrasound machine. Given that major ultrasound manufacturers with sophisticated financing options available to them are vying for what represents over a $1 billion market, why are consumers still required to create their own workable financing structures? Unlike this exceptional group of midwives, most health care providers in Ken ya will not have the ability to form a buyers’ coalition, but like these midwives, other nonphysician providers may be able to pay off an ultrasound machine in less than a year’s time, if given that option. Health technology companies must change their business models to provide affordable financing plans adapted to the unique needs of developing-world markets if they are to achieve significant market penetration. Creativity in pricing and financing could broaden the distribution channels for these important health technologies, much in the way that inexpensive cell telephone technologies have led to their wide adoption throughout rural parts of the developing world. One solution might be for these companies to team up with banks to offer affordable financing over multiple years. Such financing plans are less risky for lenders if the machines remain warrantied throughout the financing period. Additionally, companies could consider leasing equipment to clinics, allowing providers to determine whether there is an adequate market to support the machine, and if so, transitioning to a purchase arrangement. Finally, companies could manufacture scaled-back products specifically for these markets, increasing the companies’ ability to reach new markets without jeopardizing their premium product offerings in developed-country markets. Beyond simply increasing a company’s local market share, increased adoption of
low-cost ultrasound solutions in developing nations could have a secondary benefit for equipment manufacturers. Microsoft, Nokia, and Procter & Gamble have all used developing world markets as laboratories for testing and refining affordable technologies and health care solutions before selling these “emerging-market hand-me-ups” in developed world markets [9]. This business strategy, known as reverse innovation, has more recently been used by GE Healthcare when it introduced its low-priced portable ultrasound model into the U.S. market after initially creating the product for the developing world market [10]. In fact, experts have suggested that “success in the developing world is a prerequisite for continued vitality in developed ones” [10]. Recently, we returned to Nairobi to offer this special group of midwives refresher training on point-of-care maternal ultrasound. Compared with other training sessions that we have held, we were amazed by the palpable dedication and excitement of these clinicians. We attributed this difference to the midwives “having skin in the game” (i.e., ownership of an ultrasound). On average, these providers were performing two or three ultrasounds per week at an average charge of $15 per ultrasound examination. On the basis of equipment and ultrasound gel costs alone, it will take them at least 3 years to pay off a machine. We will continue to follow this group and track their experience as they proceed on this journey. Health care technologies such as portable ultrasound hold special promise for the developing world, where morbidity and mortality from preventable disease remain disproportionately high. However, before patients can benefit from these advancements, health care providers must be able to access them. By leveraging their financial sophistication and access to credit, major manufacturers of health care diagnostics and therapeutics have the potential to develop sustainable solutions to the affordability challenge and to save lives. References 1. FSG. Competing by saving lives: how pharmaceutical and medical device companies create shared value in global health. FSG website. www. fsg.org/Portals/ 0 /Uploads/Documents/PDF/ Competing_Saving_Lives.pdf. Published 2012. Accessed October 17, 2013 2. Matsuyama K. Fujifilm agrees to buy SonoSite for
AJR:203, October 2014
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Affordable Imaging Innovations in the Developing World $995 million to expand in ultrasounds. Bloomberg News website. www.bloomberg.com/news/ 2011-12-15/fujifilm-agrees-to-buy-sonosite-for995-million-to-expand-in-ultrasounds.html. Published December 15, 2011. Accessed on October 17, 2013 3. Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. Int J Gynaecol Obstet 2005; 88:181–193 4. Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS ONE
2011; 6:e17155 5. Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2011; 26:1–11 6. Sippel S, Muruganandan K, Levine A, Shah S. Review article: use of ultrasound in the developing world. Int J Emerg Med 2011; 4:72 7. Ross AB, DeStigter KK, Rielly M, et al. A lowcost ultrasound program leads to increased antenatal clinic visits and attended deliveries at a health care clinic in rural Uganda. PLoS ONE 2013; 8:e78450 8. Kinfu Y, Dal Poz MR, Mercer H, Evans DB. The
health worker shortage in Africa: are enough physicians and nurses being trained? Bull World Health Organ 2009; 87:225–230 9. Jana R. Innovation trickles in a new direction. Bloomberg Businessweek Magazine website. www.businessweek.com/magazine/content/09_12/ b4124038287365.htm. Published March 9, 2009. Accessed January 27, 2014 10. Immelt JR, Govindarajan V, Trimble C. How GE is disrupting itself. Harvard Business Review website. hbr.org/2009/10/how-ge-is-disruptingitself/ar/1. Published October 2009. Accessed June 23, 2014
F O R YO U R I N F O R M AT I O N
Mark your calendar for the following ARRS annual meetings: April 19–24, 2015—Toronto Convention Centre, Toronto, ON, Canada April 17–22, 2016—Los Angeles Convention Center, Los Angeles, CA April 30–May 5, 2017—Hyatt Regency New Orleans, New Orleans, LA April 22–27, 2018—Marriott Wardman Park Hotel, Washington DC
AJR:203, October 2014 837
