A key problem affecting global health is the lack of focus of research and development (RnD) on medicines and technologies that are appropriate for low and middle income countries. There are several reasons for this including:
- RnD costs are high and so are focused on issues where there are large affluent markets.
- Low and middle income countries do not have their own health related RnD capacity.
This situation is compounded by international patents and trade agreements that increase the cost of medicines and technologies for low and middle income countries.
The World Health Organisation has been active in working to alleviate this situation recently leading to an International resolution on research, development and innovation (RDI) in May 2013. This will lead to the “implementation of a few health research and development demonstration projects to address identified gaps that disproportionately affect developing countries” but there remains lots of progress to be made in this area if an equitable global health agenda is to be realised.
Intellectual Property Rights (IPR)
International agreements relating t0 IPR (e.g. the Trade-Related Aspects of Intellectual Property Rights – TRIPS Agreement) are particularly controversial when it comes to global health and also global economic development. Countries with strong pharmaceutical and medical industries support restrictive IPR as this supports the profitability of these industries and also helps to ensure that these industries engage in continued research and development activities. For low and middle income industries the priority is to obtain access to medicines at a price that is affordable for their population and also to foster their own research and development capacity.
The HIV/AIDS epidemic brought this conflict of interest into sharp relief and following intense lobbying the Doha Declaration on TRIPS and Public Health was adopted in 2001 which allowed flexibility around the restrictions imposed by IPR when public health interests are at stake. This declaration facilitated the increased access to anti-retroviral treatment in the countries worst affected by this epidemic particularly in Africa.
Since then there have been pressures posed by actors on both sides of the IPR debate. High income countries have increased IP restrictions in individual bilateral agreements while some low and middle income countries have argued that other diseases (such as non-communicable diseases) qualify for a similar flexible approach to IPR as adopted for AIDS/HIV.
Information Communications Technologies (ICTs) and Health
There are a wide variety of technology types that have an important role to play in global health including drugs, diagnostics, medical imaging etc. ICTs are a technology type of particular interest to us through our involvement with Physiopedia. Three types of health ICT are identified as important:
Telemedicine – use of communication technologies for the support of healthcare delivery over a distance (e.g. patient consultation by telephone or web conferencing, support of a local healthcare professional by experts at a distance and health education at a distance).
eHealth – connecting stakeholders to allow the sharing and use of health related data for individual treatment or setting overall policies (e.g. electronic medical records). NB eHealth is also used as an encompassing term for all electronic support of health that includies telemedicine and mHealth.
mHealth – health practices supported by the use of mobile devices (e.g. the use of SMS messages to send reminders that facilitate treatment compliance).
While telemedicine and mHealth offer significant benefits for health in low and middle income countries where access to healthcare expertise is limited and access to mobile devices in increasing (see mHealth Africa infographic), there are many issues to overcome particularly internet connectivity and bandwidth outside of cities.
One example telemedicine project in Mali was discussed. This involved the support of a healthcare professional based in a remote rural area of Mali via a solar powered satellite internet connection with expertise based at a large hospital in the capital city. Despite the successful outcomes recorded the project proved too expensive for more wide scale adoption due to the costs involved with using satellite based connectivity. This example in indicative of a wider problem in this field of “pilot-itus” where many new concepts are tested in small pilot studies which ultimately do not scale, do not include sustainable business models, do not integrate with existing health systems and where the outcomes are poorly evaluated (see the Maximising mHealth review). Another important issue for all adopters of eHealth technologies is data ownership and protection. To what extent does the patient own their health related data and how is that data to be both shared and protected given the many local healthcare providers, national governments and international organisations involved in providing services.
Approaches that involve local innovation, local centres of excellence and south-south collaboration (as opposed to north-south, high income – low income collaboration) are identified as offering the most potential for the successful widespread adoption of these technologies in low and middle income countries. An example includes the RAFT Network which connects healthcare professionals across Africa to deliver distance education.
Links to more information relating to mHealth:
Implications for Physiopedia
- Mindful of the restrictions and costs imposed by conventional copyright licensing (copyright is a form of IPR), Physiopedia will continue to make all contributed content available under a Creative Commons licence that allows sharing and adaptation for non-commercial applications.
- We need to be aware of the limitations and lessons presented by the unsuccessful and successful eHealth pilots in low and middle income countries when developing our own projects to support open physiotherapy education.
- We also need to recognise the benefits of south-south collaborations for low and middle income countries and design projects that encourage this type of partnership rather than focus on high income – low income country relationships.