Can reverse innovation catalyse better value health care?
Authors: Faheem Ahmed, Na'eem Ahmed, Tim W R Briggs, Peter J Pronovost, Devi P Shetty, Ashish K Jha, Vijay Govindarajan
Journal: The Lancet Global Health (2017)

The remarkable progress emerging economies have made over the past few decades has attracted the attention of leaders and policymakers from developed countries across various industries. With intense financial pressures and growing public demand, advanced western health systems could learn from low-income and middle-income countries (LMICs) that have successfully been doing more for less.1Govindarajan V Trimble C Reverse innovation: create far from home, win everywhere. Harvard Business Review Press, Boston, MA2010Google Scholar Health-care innovations from LMICs can inspire health providers faced with the universal challenge of delivering high quality outcomes with increasingly scarce resources. This reverse innovation—referring to a product or service that is developed in a resource-poor setting and then exported to more industrialised nations1Govindarajan V Trimble C Reverse innovation: create far from home, win everywhere. Harvard Business Review Press, Boston, MA2010Google Scholar—challenges the existing narrative whereby high-income countries are thought to be the sole driving force for innovation.2Berwick DM Disseminating innovations in health care.JAMA. 2003; 289: 1969-1975Crossref PubMed Scopus (1317) Google Scholar In this Comment, we explore common challenges shared by health systems in low-income and high-income countries and the opportunities reverse innovation offers in the development of better integrated health services that are highly reliable and cost-effective. The ageing population, with multiple morbidities and complex social needs, has worsened the fragmentation that exists between primary, secondary, and social care in the West. It can be difficult for health systems working towards universal health-care coverage to ensure consistency between different providers. India's Aravind Eye Care system, which performs over 350 000 ophthalmic procedures each year at multiple centres, has better patient outcomes at a lower cost per person than anywhere else in the world.3Govindarajan V Ramamurti R Delivering world-class health care, affordably.Harv Bus Rev. 2013; 91: 117-122PubMed Google Scholar Through standardised checklist processes modelled around McDonald's, Aravind has substantially reduced variations in care in terms of long-term patient outcomes and provider cost, resulting in remarkable operational efficiency across all its rural and urban sites.4Department of HealthDalton Review. Lessons from other sectors and international experience.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385839/Dalton_Other_Sectors.pdfDate: 2014Google Scholar This lean health-care design focuses on task shifting, where routine responsibilities ranging from clerking admissions to preoperative and postoperative assessments are transferred from doctors to less skilled, yet well-trained, staff. A common complaint from western clinicians is that too much of their time is spent on non-clinical and low skilled functions,5Private Sector Innovation Programme for HealthUnderstanding the India low cost model of healthcare delivery: a review of the literature.http://www.psp4h.com/wp-content/uploads/2014/05/Understanding-the-India-Low-Cost-Model-of-Healthcare-Delivery-3.pdfDate: 2014Google Scholar hence delegating tasks and redistributing staff would improve the satisfaction and productivity of clinicians. Integrated specialist providers in India, such as Narayana Health, have consistently high patient outcomes and systems-level productivity.4Department of HealthDalton Review. Lessons from other sectors and international experience.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385839/Dalton_Other_Sectors.pdfDate: 2014Google Scholar Narayana Health, which performs over 10 000 cardiac operations per year, is the world's largest consumer of metallic heart valves, enabling it to maintain superior commercial leverage over manufacturers in any procurement contracts.3Govindarajan V Ramamurti R Delivering world-class health care, affordably.Harv Bus Rev. 2013; 91: 117-122PubMed Google Scholar Efficient use of equipment, such as Narayana Health's extended imaging services, particularly during conventional downtime, has also substantially reduced the cost per unit of health-care streamlining.3Govindarajan V Ramamurti R Delivering world-class health care, affordably.Harv Bus Rev. 2013; 91: 117-122PubMed Google Scholar Furthermore, centralisation of administration and back-office processes offsets time and resources for clinicians. Increased clinical caseloads and operational efficiency attract the best surgeons, who report high levels of satisfaction with increased opportunity to focus on their surgical expertise, despite working longer hours and for less money than their western counterparts.4Department of HealthDalton Review. Lessons from other sectors and international experience.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385839/Dalton_Other_Sectors.pdfDate: 2014Google Scholar As a result, Narayana Health has halved the cost of surgery at its specialist cardiac centres while reducing 30-day mortality rates to 1·4%, compared with 1·9% in the USA.5Private Sector Innovation Programme for HealthUnderstanding the India low cost model of healthcare delivery: a review of the literature.http://www.psp4h.com/wp-content/uploads/2014/05/Understanding-the-India-Low-Cost-Model-of-Healthcare-Delivery-3.pdfDate: 2014Google Scholar Health-care systems that have undergone successive reforms, such as in the USA and UK, will require strong clinician leadership and public engagement to address scepticism from those who are wary of further change. The leadership structure at one of India's largest hospital chains—CARE—mostly comprises clinicians, who share the central aim of empowering doctors to lead and deliver on all executive decisions.4Department of HealthDalton Review. Lessons from other sectors and international experience.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385839/Dalton_Other_Sectors.pdfDate: 2014Google Scholar This approach proactively seeks input from clinicians to shape hospital policy and, in doing so, extends the involvement of clinicians beyond simple engagement exercises to a commitment to shared decision making. Through its support for bottom-up innovation, CARE also embraces the need for decentralised leadership to better meet the demands of local populations. Doctors at Aravind and Narayana Health played an integral role in the architectural design of their hospitals to optimise space and organise wards to meet patient and provider needs.5Private Sector Innovation Programme for HealthUnderstanding the India low cost model of healthcare delivery: a review of the literature.http://www.psp4h.com/wp-content/uploads/2014/05/Understanding-the-India-Low-Cost-Model-of-Healthcare-Delivery-3.pdfDate: 2014Google Scholar In the West, old hospital layouts and infrastructure built on expensive real estate could be redesigned to improve workflows, reduce maintenance costs, and release additional funds.6Lord Carter of ColesReview of operational productivity in NHS providers.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/434202/carter-interim-report.pdfDate: 2015Google Scholar In the UK, Lord Carter's landmark review on productivity in the National Health Service projected that £500 million to £1 billion could be saved through procurement practice and estate management alone, which currently cost £9 billion a year.6Lord Carter of ColesReview of operational productivity in NHS providers.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/434202/carter-interim-report.pdfDate: 2015Google Scholar Worldwide, health-care systems are attempting to implement a population-based strategy that aims to deliver efficiency savings through greater integration and continuity of services. Although LMICs are agile in creating innovative approaches to health-care delivery, they are often criticised for yielding unreliable data from settings of vast health-care inequalities and less strict regulations.7Mohanan M Hay K Mor N Quality of health care In India: challenges, priorities, and the road ahead.Health Aff. 2016; 35: 1753-1758Crossref Scopus (35) Google Scholar This shortcoming in reliability could explain why best practice in the global South is sometimes overlooked and viewed with caution. Although high-level evidence and research on reverse innovations is scarce, health-care leaders are less likely to drive change solely from reading the literature, and instead they benefit from identifying processes first-hand and developing implementation plans through tools such as the Institute for Healthcare Improvement's Live Case Visits.2Berwick DM Disseminating innovations in health care.JAMA. 2003; 289: 1969-1975Crossref PubMed Scopus (1317) Google Scholar Willingness to learn from and contribute to other systems' best practices through active engagement facilitates the bi-directional transfer of ideas, supported by reverse innovation. Not only will this benefit high-income countries that want to adopt best practice from developing settings, but such mutual contributions address concerns that reverse innovation is a contemporary form of post-colonial exploitation. A population-focused approach to health-care delivery in the West is an opportunity to allocate resources more effectively and to integrate fragmented areas of care, both of which are essential to the achievement of better value health care. However, simply reorganising care will not produce results; leadership structures and processes that allow substantial clinician input to co-create solutions are needed, along with standardised care that respects the knowledge and resiliency of front-line staff.8Sutcliffe KM Paine L Pronovost P Re-examining high reliability: actively organising for safety.BMJ Qual Saf. 2017; 26: 248-251Crossref PubMed Scopus (78) Google Scholar Western health systems can learn a lot from health-care providers in LMICs, who have progressed with far fewer resources and in far more challenging conditions. The leadership and management style used by these hospitals in LMICs are similar to other industries that are highly reliable and ultra-safe. The West should look to these nations to learn from their methods of implementation, which include more efficient use of equipment and infrastructure, optimised clinical processes and productivity through task-shifting, and unification of all stakeholders under a shared vision to engage in organisational decision-making built on trust. FA is a director of, and NA is founder of, an international non-governmental organisation, Selfless. DPS is founder and chairman of Narayana Health. VG is a former chief innovation consultant of GE Healthcare. We declare no other competing interests.