Collaboration, capacity building and co-creation as a new mantra in global health

Interest in global health innovation and healthcare quality improvement has increased among medical professionals worldwide. Over the past 35 years, participation in global health activities among medical graduates in the USA has increased more than 10-fold [ 1 ], with similar trends in other countries [ 2 , 3 ]. This increased interest is not confined to physicians, as evidenced by the ongoing creation of new and professionally diverse degree programs in global health and development in many universities. During this time, the advent of an increased ease of communication and idea sharing across the globe has occurred in conjunction with relative ease of travel to create a technological leap forward that has been called ‘the most transformative single event in development work of our generation [ 4 ]’. Despite this interest, efforts to improve health in low-and-middle-income countries (LMIC), while well intentioned, have fallen short in several areas. First, initiatives are often ad hoc , with entrepreneurial stakeholders arriving for a brief tour of an LMIC, providing short-term care, training or a new technology, and then departing without having created a sustainable human and material infrastructure. These healthcare improvement initiatives, developed in the donor country context, may fail to encompass the unique needs of the LMIC population and critical social, cultural and political context within the LMIC. Such an approach emphasizes the strengths and focus of the donor organization instead of the real needs and capacity of the LMIC. At a minimum, this may waste resources. At its worst, it may create what Peter Buffett has (controversially) labeled ‘philanthropic colonialism’ [ 5 ]. Secondly, technological innovations such as mobile health or ‘mHealth’ have tended to be viewed as isolated solutions rather than tools integrated within larger programs of improvement. Technological innovations are appealing, particularly to entrepreneurial innovators. However, when applied indiscriminately to a weak healthcare infrastructure they can produce inconsequential or short-lived impact that falls far short of their potential to contribute to improved health. Finally, with increased participation in global health among clinicians, public health workers, engineers and computer scientists, the risk of fragmented and redundant efforts among different professional groups is increased. Lack of coordination among well-intentioned professionals and donors may represent a major obstacle to the goal of coordinating the tailored delivery of healthcare services and technology onto an organized health systems and institutional framework. Given the risks noted above, for donors and organizations interested in improving health care in LMICs, we propose a mantra of ‘collaboration, co-creation, and capacity building’. Adherence to this mantra implies a multi-disciplinary strategy, which matches innovative tools to the needs of the population. Such collaborations will require deliberate and thoughtful effort that may run counter to the intensely individualistic entrepreneurial spirit of many innovators who wish to lead global health improvement. By nature, entrepreneurs tend to have several characteristics that make it difficult for them to solve system-level problems. In particular, individualistic entrepreneurs tend not to reach out to other entrepreneurs to develop teams and they may view information as proprietary so as to preserve its business value. In contrast, the approach we propose requires the building of interdisciplinary teams and information sharing for the purpose of learning and establishing best practices. We believe such a change can best be accomplished by convening entrepreneurial teams to develop innovations that are thoughtfully combined to yield solutions greater than and unobtainable by the simple summing of individual parts. For organizations interested in ‘Collaboration, co-creation, and capacity building’, we offer several recommendations, using the examples of Sana, the Consortium for Affordable Medical Technology (CAMTech) Co-Creation laboratories and GHDonline to illustrate successful efforts of organizations that exemplify these core principles. First, any technological solution should be initiated as a response to a clinical need identified by the LMIC partner. Sana, a volunteer organization hosted by the Computer Science and Artificial Intelligence Laboratory at the Massachusetts Institute of Technology has taken this approach. At its core is an open-source mobile tele-health platform that allows for capture, transmission and archiving of complex medical data such as ECG and EEG waveforms, in addition to patient demographic and clinical information. Sana initiates the design process with the identification of a clinical need by committed partners, which include international NGOs, universities, governments and private ventures, with strong emphasis on local stakeholders. Organizations approach Sana with specific clinical applications in mind. Design moves forward only when all stakeholders—healthcare providers, engineers, public health experts, informaticians—are represented. Current projects include early detection of oral cancer in India, screening for and management of hypertension in the Philippines, triage of acute medical conditions in Kenyan slums, screening for newborn hearing impairment in Brazil and collection of longitudinal data in Colombian women who have experienced perinatal pre-eclampsia [ 6 ]. Once a health need is identified, the second recommendation is to build capacity through co-creation. The Co-Creation Laboratories, administratively housed at the Massachusetts General Hospital in partnership with a consortium of partners in Africa and India [ 7 ], emphasize this iterative design process. Starting with the health needs identified by LMICs, the Co-Creation Laboratories work closely with local LMIC partners to tailor technologies through rapid prototyping and iterative creation. Once a prototype is created, it is tested locally and enhanced on the basis of actual user experience in the LMIC setting. In order to facilitate this strategy, the CAMTech Co-Creation Laboratories are physically located in LMICs so that healthcare technologies can quickly be disseminated and evaluated with real-time feedback. Co-creation Laboratories recognize that a multi-disciplinary approach must include the end user. In a process they term ‘role flexing’, the end user becomes ‘a designer, a physician, a policy advisory and anthropologist, and an engineer [ 7 ]’. The last recommendation emphasizes multi-disciplinary collaboration. The GHDonline community provides an excellent platform for cross-disciplinary partnership. GHDonline brings together clinicians (including community health workers), researchers, public health experts, engineers, policy makers, social scientists and students with an interest in global health. Discussion topics range from global surgery and anesthesia to health information technology [ 8 ]. The virtual format allows true collaboration, with participants spanning geographic, professional and socioeconomic boundaries. The approach shifts the LMIC-donor organization dynamics from a ‘culture of dependency’ towards an active partnership model. As our world becomes more globalized and information technology more accessible, health professionals and engineers have shown an increased interest in promoting health in the developing world. Although well intentioned, this new level of involvement also has the potential to deliver fragmented inputs and fail to achieve the improvements that are possible. To avoid this potential fragmentation, new organizations such as Sana, CAMTech Co-Creation Laboratories and GHDonline are concentrating on engendering a coordinated, multi-disciplinary culture of quality and safety through collaboration and focused innovation. There are challenges to this model, most notably the organizational effort required to collaborate effectively and the preference of many entrepreneurs to take an individualistic approach. In addition, professionals from different industries may have paradigms and practices that are difficult to interlace into new and different contexts. Finally, truly effective collaboration requires political leadership in both the organization and the LMIC that can create and sustain the framework for an integrative approach that provides supportive policies, adequate financing mechanisms and fair governance. Nevertheless, we believe that those who are able to follow the mantra, ‘Collaboration, co-creation and capacity building’ stand a far better chance of producing real and lasting improvements in global health. We would like to acknowledge Kris Olson and the Consortium for Affordable Medical Technologies (CAMTech) for their contribution to this article.