Reverse innovation: an opportunity for strengthening health systems

Every developed country in the world is challenged by the increasing demands for health services and the rising costs of health care that are closely associated with rapid advances in technology and aging populations. Canada is no exception; it is facing similar challenges, yet has made less progress in meeting these demands when compared to other developed countries. Within the context of the Canadian economy, health care spending totals $207 billion, representing 11.6% of the national gross domestic product [1]. As demand continues to outpace the capacity to deliver health services, approaches that embrace new technologies and leverage innovative processes will become pivotal to the sustainability of health systems both within Canada and globally. In Canada, a slow uptake and adoption of innovative technologies, processes, and procedures is leading to growing cost pressures on Canada’s publicly funded health systems which continue to be challenged to deliver high quality care and value to Canadians [2].

Canada leads the world in its population percentage with completed tertiary education (51%), inclusive of both undergraduate and graduate degrees [3]. Canada is also among the top four countries in the world to produce new knowledge (i.e. publications, patents, technologies) [4]. Yet, despite a social framework that supports and encourages Canadians to pursue advanced education and new knowledge, Canada receives failing grades when it comes to their ability to adopt innovation. According to McKinsey & Company, Canada placed 13^th out of 17, earning a “D” grade, among developed nations in this economic and future prosperity indicator [2,5]. The economic and future prosperity indicator ranking indicates that as a proportion of its overall economic activity and in comparison to other OECD countries, Canada does not rely on innovation as much as some of its peer comparators [2]. Frequently Canada is viewed a country of pilot projects that are not scaled or adopted across health systems to achieve financially sustainable programs with learnings and/or outcomes that are translated and shared across provincial or national jurisdictions [6].

Health systems require constant innovation to control ballooning costs, to create new knowledge as well as develop more effective and efficient mechanisms of achieving value for Canadians. To accelerate the adoption and scalability of successful innovation and thereby support Canadian health systems to overcome the limitations of pilot programs, reverse innovation can offer Canada opportunities to learn from innovations that are occurring in developing and/or emerging markets and consider how these innovations may be translated into the context of the Canadian health system. These reverse innovations are an important opportunity for learning and building capacity for leading change that has the potential to optimize resource use while also finding innovative approaches to deliver health services in a cost effective, sustainable manner. The purpose of this project was to examine the potential for reverse innovation to offer Canadian health systems a new approach to supporting and strengthening innovation adoption by learning from global health systems. This manuscript documents the use of a competition approach to encourage Canadians to look beyond national boarders, to developing and emerging markets, for innovations that can address current Canadian health system challenges. In an effort to better understand how the concept of reverse innovation could be mobilized amongst Canadians, the Ivey International Centre for Health Innovation issued an open call to invite proposals for reverse innovations that could address Canada’s health system challenges. One of the key objectives of this initiative was to strengthen leadership capacity among future leaders to identify and lead potential reverse innovation projects that address health system challenges in Canada. A growing base of research indicates that a large proportion of cost and value-based innovations are coming from emerging markets – an opportunity for learning which is not evident in the work of Canadian innovators or health systems [7].

As health systems, in particular those of developed nations, quickly consume the current financial resources to maintain delivery of high quality care, the concept of “doing more with less” or “innovation by necessity” plays a prominent role in the future of these health systems. Canada’s limited success in health system innovation is believed to be related to several barriers, including:

Reverse innovation, the two part process whereby innovations are designed and created for emerging markets, and then brought to developed nations, has the potential to positively affect financially burdened, developed health systems through quality innovations at decreased costs [7]. Although Canada could benefit substantially from reverse innovation, we have not been successful at implementing these innovations into the mainstream market. Canada needs to build capacity for learning from developing countries, translating innovations that are occurring into the Canadian context to achieve value for Canadians and sustainability for health systems. For example, GE Healthcare Worldwide has created a portable, durable, rechargeable and low-cost electrocardiogram (ECG) (i.e. MAC i) that was designed to service rural and low-income areas of India [10,11]. Other examples of reverse innovations that have had application to healthcare include crowdsourcing programs that were developed to map disaster impact and response to earthquakes as well as service delivery models that have addressed geographic barriers that restrict access to conventional medical infrastructure in rural Haiti [10]. Reverse innovations, like those created by GE Healthcare and those programs and models developed in Haiti, have the potential to positively affect developed health systems through quality innovations that achieve value at decreased costs.

Currently the concept of reverse innovation is emerging as a potential solution for over burdened, financially constrained health systems [10]. However, the capacity for Canadians to identify and adopt reverse innovations into the Canadian context has not been explored to date. As such there is a need to mobilize Canadian capacity to identify reverse innovations that have the potential to positively impact health systems. The Reverse Innovation Challenge, a cross-sector competition which invites participants to identify and test reverse innovations across the globe to address Canadian health system challenges.

For the purposes of this project, mobilizing capacity for reverse innovation was viewed with the intent of facilitating an environment, for future and current health system leaders, to engage in meaningful, constructive dialogue surrounding the potential for reverse innovation within the Canadian health system. The competition not only created an opportunity for health system leaders to engage the concept of reverse innovation, but also the greater population at large was engaged through different media and news outlets successfully generating awareness of the concept of reverse innovation in Canada.

The approach to adjudicating proposals was based on the two-step process that focused on two central criteria: (1) feasibility of the proposed emerging market design and (2) translation of how the identified reverse innovation is proposed to be adopted into a developed health system [7]. The evaluation criteria were designed to ensure that both of these elements were appropriately addressed and captured in the review process. One of our key assumptions was that it was highly possible that there would be no submissions where the reverse innovation identified had successfully been applied or adopted in the Canadian context. Therefore, the criteria required the proposed innovation must be one that had been implemented and had demonstrated evidence of its potential for adoption and scalability. Seven criteria were designed to help assess the submissions (See Table 1).

The applicants were required to submit a two-minute video that would describe the concept succinctly and in a clear and easily understood language. Finally, each submission required a Canadian project team leader to increase the likelihood of successful implementation and adoption in a Canadian health system.

Given the limited body of research describing reverse innovation in health care, and the novelty of the Reverse Innovation Challenge, an evaluation committee was established to evaluate the submission. The committee members we selected based on their experience and skills to ensure a broad range of perspectives were represented. Each evaluator was assigned a primary and secondary submission to review; assignments were based on the expertise and experience of the reviewer and the fit with the application. The evaluation committee then convened in a daylong session to review the submission videos, hear feedback from the primary and secondary reviewers for each application and then discuss each proposal. The criteria were used to score each submission. Each application was reviewed by the committee using the criteria to score each submission. Each application was assigned two reviewers, scores and reviews were discussed, after deliberate discussion and consideration, the committee reached consensus on the score for each application. Once the committee scored all of the proposals, the proposals were ranked and a short list of the top five proposals was determined and then further discussed and ranked to identify the top three proposals and finally the highest ranked proposal.

The Centre officially launched Colour Outside the Lines: A Reverse Innovation Challenge in Canadian Health Systems in January 18, 2013. The competition closed on May 31st, 2013. The winners of the competition were announced at the Reverse Innovation in Health Care Conference in November 2013.

During the four-month submission process, the Centre received a total of 12 submissions. A list of the projects can be found below in Table 2. Key highlights from the submissions included:

The literature describing reverse innovation presents varied definitions of reverse innovation. The committee engaged in a robust debate and discussion about the definition of reverse innovation and how the applicants were applying it to the Canadian health system. The evaluation committee was comprised of members with a wide range of expertise and leadership experience; all evaluation committee members were considered experts in the field(s) of health systems, innovation and/or reverse innovation. The expertise of the evaluation committee members varied from: information technology (IT), medical devices, finance, international/global health, rural health, aboriginal health, gender/racial health and social enterprise. As a result of the wide array of experiences and interpretations of reverse innovation, the dialogue amongst the evaluation committee lead to a constructive debate pertaining to the value proposition affiliated with reverse innovation. The scoring of the individual competition submissions was varied and was reflective of the different value perspectives of the committee members. Ultimately, differences were resolved through lengthy discussions and consensus agreement between committee members.

The top five submissions were short-listed and two submissions were identified as not meeting the criteria of reverse innovation. The top 5 submissions were able to demonstrate strong proof of concept and value by effectively defining how the innovation would achieve value for the Canadian health system. To varying degrees, the top five submissions also acknowledged and engaged relevant partnerships for successful implementation and potential for scalability. The five finalists were then asked to submit some additional information to provide further clarity on their proposals to the committee. The additional information requests included:

The five finalists were first informed that they were short-listed and then were asked for permission to profile their application online to engage comments and feedback from the public online. Their proposals were posted on the website and comments were welcomed from the public for a one month period. The intention was that evaluation committee would use the public comments aligned with the additional information to inform their final decision. However, due to technical challenges with the website, the comments were not considered in the evaluation process.

The committee reconvened for a second stage evaluation, to evaluate each short listed application to consider the strengths of the additional information provided to the committee. Once again, ranking of the proposals was reviewed and determined based on consensus of the committee. The committee unanimously agreed on the winner of the challenge. The committee further determined that only one submission met the requirements and spirit of the competition (#9); this team was awarded financial support and mentorship to trial their reverse innovation in the Canadian health system context. The decision to award only one prize was made with careful and deliberate consideration by the evaluation committee, based solely on the follow up information provided by each of the top five teams. The winning team was announced on November 26, 2013.