How Low and Middle-Income Countries Are Innovating to Combat Covid

Since the Covid-19 pandemic hit, innovators around the world have developed thousands of novel solutions and practical approaches to this unprecedented global health challenge. About one-fifth of those innovations have come from low- and middle-income countries across sub-Saharan Africa, South Asia, and Latin America, according to our analysis of WHO data, and they work to address the needs of poor, marginalized, or excluded communities at the so-called bottom of the pyramid.

Over the past year we’ve been able to learn from and support some of those inspiring innovators. Their approaches are diverse in scope and scale and cover a vast range of pandemic response needs — from infection prevention and control to community engagement, contract tracing, social protection, business continuity, and more.

Here we share seven lessons from those innovators that offer promising insights not only for the ongoing Covid response but also for how we think about, manage, and enable innovation.

1. Ensure that your solutions are sensitive to social and cultural dynamics.

Successful innovations are relevant to the lived realities of the people they’re intended to help. Socially and culturally sensitive design approaches see greater uptake and use. This is true in both resource-constrained and resource-rich environments.

Take contact tracing in Kenya. In a context where more than half of all residents use public transportation every day, the provider of a ticketing app for Nairobi’s bus fleets adapted its software to collect real-time passenger data. The app has been used across one of the world’s most mobile populations to trace Covid-19 cases, identify future clusters, trigger automated warnings to exposed passengers, and monitor the maximum number of people that could safely be allowed in each vehicle.

High-income countries are learning from experiences in more resource-constrained settings. In Massachusetts, where privacy concerns around digital tools runs high, statewide contact-tracing efforts built on the lessons of a Boston-based international NGO, Partners in Health, and its efforts to fight disease in sub-Saharan Africa. The Massachusetts Community Tracing Collaborative program linked private, local, and state stakeholders with an army of more than 1,600 volunteers to trace the possible contacts of anyone experiencing potential Covid symptoms, all thanks to processes, tools, and training provided by Partners in Health. Not only is this more flexible a way of dealing with a rapidly changing crisis; it also put a much-needed human face on the response.

2. Adopt a “radical simplification” mindset.

In high-income countries, businesses and governments sometimes overengineer new products and services, in part owing to a culture and incentive structure that value exciting high-tech solutions over simple low-cost ones.

To meet needs in many low- and middle-income contexts, innovators take existing technologies, tools, or techniques and strip them down, removing elements that aren’t essential and drain valuable resources.

For example, clinicians in Wuhan, China used “prone ventilation” — a technique of placing patients on their stomachs instead of on their backs to help them breath better — as a standard of care during the height of the epidemic there, in early 2020. A simple technique that doesn’t require a machine ventilator, it was seen as especially relevant for those “working in resource-limited settings where few or no ventilators may be available.” By August of 2020 the Africa Centres for Disease Control and Prevention developed a simple tool to help clinicians decide when and where the technique could be useful. A multi-hospital trial in the United States recently indicated that proning can increase oxygenation levels among critically ill patients, and if undertaken within the first two days of an ICU admission, it reduces the risk of death among acute Covid-19 cases by 16%. More trials are under way worldwide.

Radical simplification doesn’t come without trade-offs, however. Innovators need not only to ensure that they don’t lose vital functionality; they must also make sure that “good enough” doesn’t come at the expense of mutual respect, duty of care, and patient rights.

3. Tap the creativity of those closest to the problem.

In the absence of vaccines, bottom-of-the-pyramid Covid innovators have been the first line of defense and response when it comes to infection prevention, detection, and control and to some of the social and economic impacts of the pandemic.

One of the most compelling illustrations is in Vietnam, where a suite of innovative grassroots responses — from the use of robots for hospital cleaning to community-based mutual aid mechanisms that provide food to vulnerable populations — has helped reduce infection and support those at risk greatest risk from the impacts of lockdowns. Such innovation is seen as “of, by, and for all.”

4. Discover novelty through permutations, substitutions, and combinations.

Where it’s not practical or possible to throw more resources at a problem, the principles of combination (bringing two unrelated ideas together to make a new approach), permutation (testing various configurations of an existing solution), and substitution (swapping around the inputs, processes, or outputs of a solution) are widespread.

For example, innovators in low- and middle-income countries have developed numerous solutions that rely almost entirely on off-the-shelf parts that can be found in hardware stores. One example that quickly reached the Indian market is the AgVa portable ventilator, which:

• Doesn’t need an oxygen supply (it oxygenates room air)
• Builds on the computational power of mobile phones and a dedicated app
• Weighs a fraction of typical commercial ventilators, making it easily portable
• Has open-source specifications, making it adaptable for use in other countries and contexts
• Costs less than a tenth of conventional ventilators and can be produced much more quickly.

In the digital health space, open-source tools that were developed in South Africa for routine health system monitoring have seen rapid repurposing for use in the pandemic response, including as systems for viral surveillance and, more recently, for tracking vaccine distribution in both Sri Lanka and Ethiopia.

5. Identify and unlock existing resources.

Bottom-of-the-pyramid innovators don’t have the same access to external investors as innovators in high-come countries do, so they often have to locate and release resources that are locked up within existing ways of doing things. They are, by necessity, skilled at bringing in human and technical resources from a variety of sources and reengineering resource use across existing processes, akin to how big businesses use “lean” or kaizen approaches on a much larger scale.

For example, many ICUs in low-resource countries have reconceptualized their operations in order to manage the dramatic increase in patient numbers resulting from Covid-19. In Saudi Arabia, ICUs have boiled down intensive care to a set of essential tasks, bringing specific staff members with different skill levels into different parts of the process and freeing up specialists to focus on the activities that only they can do. By reengineering resources across existing processes, they have been able to rapidly increase the number of patients who can be seen in the course of a single day or week.

6. Go beyond user-centered — be user-led.

Innovation scholars typically depict the innovation process as a closed funnel whereby innovators develop ideas, create prototypes, and then bring in potential users to provide feedback.

The reality for most innovators during Covid-19 has been quite different: In this context, the product development process cannot — and arguably should not — be insulated from the wider world. Because of both expediency and necessity, engagement with end-users must be ongoing. A need or an opportunity is identified; energy and attention are mobilized; and efforts move forward dynamically. The process creates windows of opportunity for moving ideas from concept to execution to use through intelligent brokering of relationships and ideas.

Successful bottom-of-the pyramid innovations are almost always user-led — essentially co-designed — with innovators spending as much time on relationship management as on innovation management. A makers group in Mumbai, along with its network of small and medium-sized enterprises invited health officials, hospitals, and other institutions to share their PPE needs. Within weeks, a national network of makers was producing more than 1 million masks for hospitals across the country. This effort harnessed the creativity of local makers networks, as described in lesson three, but was sharply focused on the needs of health care providers as the primary end-users of the equipment.

7. In the fog of crisis, facts are crucial. 

The last lesson is one of the most important. Hearsay and rumor are rife in a pandemic, and they cost lives. Innovative solutions must be evidence-based: firmly grounded in analysis and comparative data.

One of the best examples from the first wave of the pandemic is how India used real-time health technology evaluations to inform and adapt its Covid testing regime. The assessments showed that a proposed $7, locally developed paper-based test with a mobile lab facility was as effective as the “gold standard” test that was being used and that required expensive imports, equipment, and fixed facilities. The alternative testing regime was rolled out in cities in the state of Maharashtra and during the massive Kumbh Mela festival and helped save more than $10 million a day. On the basis of this evidence, and in the face of the current, devastating Covid wave in India, the test was recommended to Delhi authorities as a potential tool to support rapid mobile testing in public places, with the national government now weighing how to accelerate its use.

Data and modeling have been essential around the world for tracking and anticipating the pandemic and determining appropriate policy responses. Here too, innovations have helped people in low-resource settings meet specific contextual challenges. For example, in Rwanda, the limited availability of diagnostic test kits led to development of a data-driven “pool testing” method that reduces the number of tests required for an accurate infection count.

Our closing message is simple: As the international community faces the historic challenge of vaccinating the world, more attention and resources must be directed to innovators working to address the needs of people at the bottom of the pyramid — to their ideas, their capabilities, and their dreams. At best, and as we have argued in this piece, those innovators present technically novel, contextually relevant, and socially inclusive alternatives to mainstream innovation-management practices. Covid-19 has shown to disastrous effect that pathogens transcend national boundaries with ease. It is in our collective interest that innovators similarly work without borders.