Getting Devices to Developing Markets
A major question in the public health arena is whether aid is a stimulus to development or a hindrance to development in the long term. Advocates on both sides of this argument seem to agree that the short-term effects of aid projects are almost always net positive. A child gets a mosquito net, a sick mother gets antiretroviral therapy, a young girl is able to go to school for an extra year. The disagreement arises when outcomes are examined rather than outputs. Two prominent economists, Dambisa Moyo and Jeffrey Sachs, have been publicly debating this issue recently in dueling books and in editorials in the popular press.
In one of many exchanges, Moyo and Sachs debate the overall effectiveness of imported mosquito nets. Moyo argues that the mosquito nets should be made in Africa, so that Africans can sell them to fellow Africans and thus stimulate the local economy. She argues that aid agencies “dumping” nets on the population is destructive to the innovation and initiative on the ground. Sachs argues that before the net programs of the recent past “exactly zero” nets had been produced in Africa, and the infrastructure to do so was not in place. He argues that malaria (or poor health in general) is one of many of the root causes of Africa’s persistent poverty and that by reducing the number of people infected, the overall productivity of a society can be increased. Thus, aid groups distributing nets are acting in the interest of the greater good.
Neither economist is arguing whether mosquito nets are effective in preventing malaria infections, or the output. What they do argue over is the outcome, and since they each use different metrics to measure outcomes, I am certain that they will never reach an agreement on the issue. Of course it is necessary to note that both Moyo and Sachs have vested interests in keeping this debate going. Both are popular authors and serve as “consultants” to foreign governments. Sachs made his career in the late 1980’s and early 1990’s by giving advice to Latin American and Eastern European countries in economic crisis. He is involved with several development projects, including the Millennium Villages project, on which his reputation is highly leveraged. Moyo made her name as an economist at Goldman Sachs and now by promoting “controversial” ideas in the popular press and in general interest books. Her website and promotional materials are clearly aimed at one thing only: selling her books. These comments are not meant to diminish the arguments on either side, but to explore more deeply their individual and institutional motivations.
Since our work is focused on making health care technology accessible, I routinely wrestle with what things should be “given away” and what things should be sold to recover costs or make profit. Many in the leadership of contemporary aid foundations promote the notion that if someone has no financial interest in a technology, if they do not pay something for it, then they will not value it. While this argument seems to hold true for people of some means in some places, I find it to be dangerous. The notion that free cannot be good is a cultural construct. It is much more likely that people cannot value what they do not understand, and in many cases, technologies delivered as foreign aid are opaque to people who were not involved with the development of the technology. Thus, to get people to invest time to learn and use new technologies, one must make those technologies accessible and maintainable in the country of use.
Jose Gomez-Marquez of MIT Innovations in International Health (MIT-IIH) argues that the best route to making healthcare technology accessible in the developing world is by teaching technology innovation to the people in need. Rather than donating technologies that hospitals that are ill equipped to use, troubleshoot and maintain, IIH instead promotes the idea that innovation can be taught. His work focuses on training nurses and other health workers how to identify problems in their immediate environment, and then how to iterate through the design process to solve the problem. MIT-IIH focuses on local need assessments and the provision of “innovation kits” that contain prototyping equipment to the people most likely to effect change.
Our own approach to appropriate technology development is slightly different. The issue I see with Gomez-Marquez’s approach is that while there are many medical technologies that lend themselves to local innovation, there are many that are far beyond the skills one can pick up from a few training sessions focused on innovation. The MIT-IIH approach works for a many problems, but is not universally applicable. In our approach, we try to work closely with people like Gomez-Marquez to identify local problems that can be solved with technology. At each stage in the design process, potential end users are consulted. We operate with an eye toward local manufacture and distribution, but seek to export our engineering expertise. We see local entrepreneurs as potential evangelists for our technologies, the people who will sell it have to see the value, potential and niche. We hope to avoid some of the criticism that Sachs drew from the African entrepreneur,Magatte Wade, by educating ourselves about the market and developing quality products. We see our work as part of a larger system that includes users, patients, community leaders and entrepreneurs.
More than once on a recent trip to clinics in Nicaragua, we were presented with equipment that “did not work,” and the only discernable problem was a blown light bulb. Certainly, sending engineers to Central America to change light bulbs is not a viable solution, since the problem isn’t really the blown light bulb. The core issue is disenchantment with all technology that was not designed with the user in mind. As engineers we can attack that problem by going back to the basics and the first step in every design process: consulting the client.