Global health

“Embedded Innovation in Health,” Anita M McGahan, Rahim Rezaie and Donald C. Cole, Innovating for the Global South:  Towards an Inclusive Innovation Agenda, chapter 5, eds. Dilip Soman, Janice Stein and Joseph Wong (Toronto:  University of Toronto Press, forthcoming)

We propose an alternate framework that aims to advance pro-poor health innovations, while safeguarding their short and long-term social and economic interests.  This approach, which we call embedded innovation, offers the potential to break the impasse on disruptive health innovation. It builds on ideas elaborated in the business literature and aims for inclusive innovation for growth and development .  Embedded innovation for health (EIH) is guided by four core principles. First, embedded innovation is guided by the principle of solidarity with the poor, genuine concern over their welfare, and accounting for the distributive consequences of innovation by ensuring adequate access to and/or ownership over resulting solutions.  Second, it treats the poor as the primary market during the entire innovation process. Third, the innovation process stars with a deep understanding of contextual nuances, involvement of patients and care providers in settings where eventual solutions are to be applied. We use the notion of embeddedness to highlight the totality of the first three principles that work to account for specific demands of poor populations under particular contexts. The fourth important principle of embedded innovation is that, while embedded in local context, it must draw on state of the art knowledge and technologies to arrive at best solutions to health challenges.

“Inclusive Innovation,” Will Mitchell and Anita M McGahan, Innovating for the Global South:  Towards an Inclusive Innovation Agenda, Conclusion, eds. Dilip Soman, Janice Stein and Joseph Wong (Toronto:  University of Toronto Press, forthcoming)

Successful health care innovation starts and ends with understanding the demand side of Innovation adoption. Only with deep and thoughtful engagement with users and their environments will the most insightful supply side initiatives have sustainable impact. In turn, we are beginning to develop organizational models that bring together highly varied skills in matching supply side insights about contextual quality that suits demand side opportunities.

“Human Trafficking Educational Resources for Health Professionals: Review and Recommendations,” Roy Ahn, Elaine J Alpert, Genevieve Purcell, Wendy Macias Konstantopoulos, Anita McGahan, Elizabeth Cafferty, Melody Eckardt, Kathryn Conn, Kate Cappetta, Thomas F Burke, American Journal of Preventive Medicine (forthcoming)

Human trafficking (HT) is an increasingly well-recognized human rights violation that is estimated to involve more than 2 million victims worldwide each year. The health consequences of HT bring victims into contact with health systems and healthcare providers, thus providing the potential for identification and intervention. A robust healthcare response, however, requires a healthcare workforce that is aware of the health impact of HT; educated about how to identify and treat affected individuals in a compassionate, culturally aware and trauma-informed manner; and trained about how to collaborate efficiently with law enforcement, case management and advocacy partners. This article describes existing educational offerings about HT designed for a healthcare audience and makes recommendations for further curriculum development. A keyword search and structured analysis of peer-reviewed and gray literature, conducted in 2011, yielded 27 items that provide basic guidance to health professionals. These resources differed substantially in format, length, scope, and intended audience and none have been rigorously evaluated. There is a clear need to develop, implement and evaluate high-quality HT-focused education and training programs for healthcare providers.

“Global Divergence in Critical Income for Adult and Childhood Survival 2007:  Analyses of Mortality using Michaelis-Menten,” Ryan Hum, Prahbat Jha, Anita M McGahan and Yu-Ling Cheng, eLife (forthcoming)

Life expectancy has risen sharply in the last 50 years. We applied the classic Michaelis–Menten enzyme kinetics to demonstrate a novel mathematical relationship of income to childhood (aged 0–5 years) and adult (aged 15–60 years) survival. We treat income as a substrate that is catalyzed to increase survival (from technologies that income buys) for 180 countries from 1970 and 2007. Michaelis–Menten kinetics permit estimates of maximal survival and, uniquely, the critical income needed to achieve half of the period-specific maximum. Maximum child and adult survival rose by about 1% per year. Critical incomes fell by half for children, but doubled for men. HIV infection and smoking account for some, but not all, of the rising critical incomes for adult survival. Altering the future cost curve for adult survival will require more widespread use of current interventions, most notably tobacco control, but also research to identify practicable low-cost drugs, diagnostics, and strategies.

“Investments in Pharmaceuticals Before and After TRIPS,” Margaret K. Kyle and Anita M McGahan, Review of Economics and Statistics (November 2012), pp. 1157-1172.

The TRIPS Agreement, which specifies minimum levels of intellectual property protection for countries in the WTO, has increased levels of patent protection around the world. Using variation across countries in the timing of patent laws and the severity of disease, we test the hypothesis that increased patent protection results in greater drug development effort. We find that patent protection in wealthy countries is associated with increases in R&D effort. However, the introduction of patents in developing countries has not been followed by greater R&D investment in the diseases that are most prevalent there.

“Globalization of Health Innovation,” Rahim Rezaie, Anita M McGahan, Abdallah Daar and Peter Singer, Nature Biotechnology 30:10 (October 2012), pp. 923-925

Biopharmaceutical innovation has had a profound health and economic impact globally. Developed countries have traditionally been the source of most innovations as well as the destination for the resulting economic and health benefits.  As a result, most prior research on this sector has focused on developed countries.  This paper seeks to fill the gap in research on emerging markets by describing and analyzing factors that influence innovative activity in the indigenous biopharmaceutical sectors of China, India, Brazil, and South Africa. Using qualitative research methodologies, this paper a) shows how biopharmaceutical innovation is taking place within the entrepreneurial sectors of these emerging markets, b) identifies common challenges that indigenous entrepreneurs face, c) highlights the key role played by the state, and d) reveals that the transition to innovation by companies in the emerging markets is characterized by increased global integration. It suggests that biopharmaceutical innovators in emerging markets are capitalizing on opportunities to participate in the drug development value chain and thus developing capabilities and relationships for competing globally both with and against established companies headquartered in developed countries.

“Emergence of Biopharmaceutical Innovators in China, India, Brazil, and South Africa as Global Competitors and Collaborators,” Rahim Rezaie, Anita M. McGahan, Sarah E. Frew, Abdallah S. Daar, and Peter A. Singer  Health Research Policy and Systems 10:18 (2012) available at http://www.health-policy-systems.com/content/10/1/18

Biopharmaceutical innovation has had a profound health and economic impact globally. Developed countries have traditionally been the source of most innovations as well as the destination for the resulting economic and health benefits. As a result, most prior research on this sector has focused on developed countries. This paper seeks to fill the gap in research on emerging markets by analyzing factors that influence innovative activity in the indigenous biopharmaceutical sectors of China, India, Brazil, and South Africa. Using qualitative research methodologies, this paper a) shows how biopharmaceutical innovation is taking place within the entrepreneurial sectors of these emerging markets, b) identifies common challenges that indigenous entrepreneurs face, c) highlights the key role played by the state, and d) reveals that the transition to innovation by companies in the emerging markets is characterized by increased global integration. It suggests that biopharmaceutical innovators in emerging markets are capitalizing on opportunities to participate in the drug development value chain and thus developing capabilities and relationships for competing globally both with and against established companies headquartered in developed countries.

 “Sex Trafficking of Women and Girls in Metro Manila: Identifying Key Trafficking Determinants and Proposing a Local Health System Response,” Timothy P Williams, Elaine J Alpert, Roy Ahn, Elizabeth Cafferty, Wendy Macias Konstantopoulos, Anita M McGahan, Nadya Wolferstan, Judith Palmer Castor and Thomas F Burke, Health and Human Rights 12:2 (2010), pp. 136-147 available at http://www.hhrjournal.org/index.php/hhr/article/view/374/583

This social science case study examines the sex trafficking of women and girls in Metro Manila through a public health lens. Through key informant interviews with 51 health care and anti-trafficking stakeholders in Metro Manila, this study reports on observations about sex trafficking in Metro Manila that provide insight into understanding of risk factors for sex trafficking at multiple levels of the social environment: individual (for example, childhood abuse), socio-cultural (for example, gender inequality and a “culture of migration”), and macro (for example, profound poverty caused, inter alia, by environmental degradation disrupting traditional forms of labor). It describes how local health systems currently assist sex-trafficking victims, and provides a series of recommendations, ranging from prevention to policy, for how health care might play a larger role in promoting the health and human rights of this vulnerable population.

“Innovative Health Service Delivery Models in Low and Middle Income Countries – What can we learn from the private sector?,” Onil Bhattacharyya, Anita M McGahan, Sara Khor, David Dunne, Abdullah Daar and Peter Singer, Health Research Policy and Systems 8:24 (2010) available at http://www.health-policy-systems.com/content/8/1/24

The poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease. They frequently use the private health sector, due to perceived or actual gaps in public services. A subset of private health organizations, some called social enterprises, have developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models. This study aims to characterize these models and identify areas of innovation that have led to effective provision of care for the poor.

“’Sustainability’ in Global Health,” Alice Yang, Anita M McGahan, and Paul E. Farmer, Global Public Health Vol. 5, No. 2 (March 2010), pp. 129-135, reprinted in Munk Monitor (Spring 2013)

‘Sustainability’ has become a central criterion used by funders,  including foundations, governmental agencies and international agencies in evaluating public health programmes. The criterion became important as a result of frustration with discontinuities in the provision of care. As a result of its application, projects that involve building infrastructure, training or relatively narrow objectives tend to receive support. In this article, we argue for a reconceptualisation of sustainability criteria in light of the idea that health is an investment that is itself sustaining and sustainable, and for the abandonment of conceptualisations of sustainability that focus on the consumable medical interventions required to achieve health. The implication is a tailoring of the time horizon for creating value that reflects the challenges of achieving health in a community. We also argue that funders and coordinating bodies, rather than the specialised health providers that they support, are best positioned to develop integrated programmes of medical interventions to achieve truly sustainable health outcomes.

“Economic Valuations in Global Health,” Anita M McGahan and Gerald Keusch, Global Public Health Vol. 5, No. 2 (March 2010), pp. 136-142

This paper deals with three issues concerning economic valuation in global health.  First, we argue that the economic value of health delivery in resource-limited settings is not fully captured through the adding up of successive assessments of individual interventions. Second, we suggest that economic valuations can be used to identify social barriers to the success of health technologies in resource limited settings. Third, we briefly discuss new directions for research on economic valuations given the interdependency between poor health and economic impoverishment.

“Paradoxes of Innovation in Health and their Resolution in Embedded Innovation,” Munk Monitor 2 (Fall 2012), pp. 14-17.

Since the publication of several major critiques of development aid (Easterly 2006, Garrett 2007, Moyo 2009) , many of us in the field of global health – including scholars, clinicians, practitioners, and policy-makers – have struggled with a series of paradoxes that have become increasingly evident in the provision of aid to the poor.  How can these paradoxes be resolved?  Of course there are no easy answers.  In my research in this area, I am developing a construct that I have tentatively called Embedded Innovation with the following characteristics:  collaboration in the field; minimal reliance on competition in experimental processes; maximal reliance on competition to serve the poor; risk and profit sharing; balanced emphasis on prevention and early diagnosis as well as treatment.

“Sex Trafficking, Health Care, and the Health System in Mumbai and Kolkata,” by Timothy P. Williams, Elaine Alpert, Roy Ahn, Elizabeth Cafferty, Anita McGahan, Wendy Macias Konstantopoulos, Judith Castor Palmer, Nadya Wolferstan, Genevieve Purcell, and Thomas F. Burke,“ Human Trafficking, ed. Veerendra Mishra, ed. (Sage, forthcoming)

This article examines the sex trafficking of women and girls in Metro Manila through a public health lens. Through key informant interviews with 51 health care and anti-trafficking stakeholders in Metro Manila, this study reports on insights into sex trafficking in Metro Manila that serve to extend an understanding of risk factors for sex trafficking at multiple levels of the social environment: individual (e.g., childhood abuse), socio-cultural (e.g., gender inequality and a “culture of migration”), and macro (e.g., profound poverty caused, inter alia, by environmental degradation disrupting traditional forms of labor). It describes how local health systems currently assist sex-trafficking victims, and provides a series of recommendations ranging from prevention to policy for how health care may provide an increase role in promoting the health and human rights of this vulnerable population. Promoting health equity requires an integrated response that considers the complex and contextual realities facing this vulnerable population.

“Hidden Business and Open Secrets:  How Human Trafficking is Managed and What You Can Do About It,” with Roy Ahn,  Elizabeth Cafferty, Wendy Macias Konstantopoulos, Tim Williams, Nadya Wolferstan,  Judith Palmer Castor, Elaine Alpert, and Thomas Burke, Rotman Magazine (Fall 2010)

By adopting targeted policies, protecting communities and deploying capabilities in the interests of vulnerable groups, organizations can help to eliminate human trafficking.

“Innovative Health Service Models for the World’s Poor,” with Onil Bhattacharyya, Peter Singer, Abdallah Daar, Sara Khor and David Dunne, Rotman Magazine (Fall 2011)

While healthcare challenges abound in every society on earth, there is an overriding demand for improved health services for the 2.6 billion people who are living on less than $2 a day. Not surprisingly, this group faces considerable barriers, including limited health insurance, low health literacy, and residence in slums or remote areas that are frequently underserved. These barriers must be taken into consideration in the design of  products and services that are delivered to this group.

 “The Influence of TRIPS on Global Trade in Pharmaceuticals, 1994-2005,” with Mercedes Delgado and Margaret K. Kyle, manuscript (April 2011), submitted, R&R

This paper examines the impact of intellectual property rights on trade in knowledge-based products. An explicit goal of the TRIPS (trade-related aspects of intellectual property) agreement of the World Trade Organization (WTO), which required member countries to adopt and enforce laws to protect intellectual property (IP), was to promote “the transfer and dissemination of technology,” particularly from high-income to poorer countries. Using data on trade flows from 1993-2009 for 158 WTO countries, we examine whether developing countries increased their trade in knowledge-intensive goods following TRIPS implementation, and whether this change differed by the direction of trade (import or export), by type of IP (patent, trademark, and copyright), across sectors with varying IP intensity, and across countries of different income levels. We find that post-TRIPS, trade of IP-intensive products in both directions increased relative to sectors with low levels of IP for developing countries  across all types of IP. However, imports from innovative high-income countries into developing countries – an indicator of the dissemination of knowledge into poorer settings – was sensitive to other factors that affected receptiveness to these goods. These findings suggest that the patent system alone may not be sufficient for promoting knowledge diffusion from high-income to developing countries.

“Biopharmaceutical Innovation in China, India, Brazil and South Africa:  Implications for the United States,”with Rahim Rezaie, Sarah E Frew, Abdallah Daar and Peter Singer (February 2011), submitted, R&R

This paper builds upon and updates our previous work and focuses more deeply on new vaccines and therapeutics in the innovation pipelines of indigenous enterprises in China, India, and Brazil. We examined:  a) pharmaceutical innovations based on small-molecule drug development involving new chemical entities (NCEs), b) biotech-based innovations based on large molecules, nucleic acids, and whole cells (collectively referred to as biotechnological entities or BEs), and c) innovations involving traditional medicines, herbal compounds and other biodiversity resources, which are collectively referred to here as plant-based medicines. The third group can involve finished products or the generation of NCEs or BEs as therapeutic leads.

“Biopharmaceutical Innovation in China, India and Brazil after TRIPS,” with Rahim Rezaie and David Wolfe (March 2011), submitted

“Fiocruz:  Public-Private Partnerships in Medicine,” with Peter Klein, Sandro Cabral and Sergio Lazzarini, in process, expected 2013

“Firm Turnover and Generations of HIV Technology,” with Giovanni Valentini and Alfonso Gambardella, in process, expected 2013

“The Gap Between Theory and Practice for Health-Systems Metrics in Resource-Limited Settings,” with Onil Bhattacharyya, in process, expected 2013

“Value Creation, Value Capture, Access, Scaling Up and Sustainability:  Insights from Health Delivery in Resource-Limited Settings,” with Yu-Ling Cheng, Ryan Hum, Anita McGahan, Murray Metcalfe, Peter Singer, Dilip Soman, Janice Stein, Joseph Wong, Stanley Zlotkin, in process, expected 2012