Matthew Harris, Decolonizing Healthcare Innovation: Low-Cost Solutions from Low-Income Countries (Routledge, 2023, 272 pp., ISBN 9781032284958).
Book Review by Dr. Tom Bashford and Dr. Brandon Smith
Global health is a burgeoning field, the subject of an increasing number of research articles, academic programmes, and discussion.1 Over the past twenty years, it has rapidly evolved from a donor-driven product of the white-saviour industrial complex to a field that increasingly seeks equity between global populations—equity of health outcomes but also equity in the representation and acknowledgement of expertise. Innovation in global health is therefore a complex concept. Does innovation in this context mean doing new things, or doing the same things differently? Where is the locus of innovation if the desire is for impact at the global level? How do good ideas spread and best serve those communities that can benefit the most from them? Crucially, how do the high ideals of improving health equity across the world through innovation survive the competing interests of clinical medicine, academic research, and commercial interests?
In this wider debate surrounding equity in healthcare innovation, Matthew Harris’s thoughtful and meticulously researched volume is something of a Trojan horse. Luring the reader in with a title focussing on low-cost healthcare innovation, the book is actually an exegesis of colonialism in healthcare more generally, asking the reader to deconstruct not only their view of global health, but of western medicine and its foundational principles of scientific rationalism. This is all to the good, and makes for a challenging, engaging, and highly topical read.
The book is divided into two sections. The first, “decolonization and why it is needed in healthcare innovation,” stands alone as a discussion of some of the complexities around the field of global health, providing a wide-ranging and erudite discussion of a vast literature. Harris has clearly read and thought deeply about the issues involved and his own relationship to them, with a reflexivity and self-awareness that is refreshing and essential when discussing such a complex and emotional topic. He asks the reader to consider the underlying drivers of ongoing colonialism in the literature around health, healthcare, and innovation. He also asks why evidence and expertise from some countries or institutions gain privilege over others and considers how this attitude impoverishes the global community. Crucially, he observes that his book does not provide a complete discussion and points the interested reader to an extensive range of other authors who have written on coloniality, decolonisation, and frugal innovation.
The second section, “low-cost solutions from low-income countries,” discusses in detail a subset of successful innovations that have originated in resource-poor settings. While the first section can be read largely in isolation, this second section significantly benefits those that have taken time to read the first half of the book. Harris describes a refreshing range of pragmatic and tangible innovations, which are a world away from the focus on novel technologies, data, and digital medicine that dominates the emerging literature on healthcare innovation.
Importantly, these innovations are contextualised as not just good enough for them but good enough. They also span a range of clinical modalities and help develop Harris’s central thesis that innovations developed in the Global South are of genuine global value and those seeking to improve any health system should seriously consider them. These include both technological innovations, such as the use of mosquito net mesh for hernia repair or the Arbutus drill system for orthopaedic surgery, and changes to established practice, such as the Ponseti technique for congenital club feet correction.
If one criticism were to be made of the arguments in this book, it is one acknowledged by the author—they are the product of a “white, middle-aged British man who has been trained in some of the most elite medical institutions of the West” (xvii). He therefore draws on a body of literature and thought still dominated by the English-speaking Global North, which perhaps explains two omissions.
First, the book lacks a clear definition of “global health” and the evolution of this term from “international health.”2 Indeed, the very concept of global health can be challenged because it is all too often a lazy shorthand for work done to improve healthcare in under-resourced countries. Are those from a resource-poor country seeking to improve their own healthcare system engaged in global health? Are those from a high-income country working with a single partner from a resource-poor country engaged in global health? There is nothing global about these two endeavours, although both are valuable. Indeed, the term global health originated from a WHO-driven idea of having a global mandate for the promotion of health and care, one that arguably carries the heavy baggage of cultural imperialism. A discussion of foundational definitions is strangely absent in such a thoughtful work.
Second, issues of racism and colonisation exist outside of recent European imperialism and can be found across human populations and history. The act of framing racism and colonialism exclusively through the current relationship between Western Europe and its former colonies is itself a product of the Western gaze, as is framing the experience of resource-poor countries through their relationship with the Global North. Such framings by no means discredit any of the excellent insights that populate this book but, as with the rest of its content, they challenge the reader with an extensive reading list for further consideration.
Harris’s excellent book should be required reading for all those interested in global health—whether they define themselves as innovators or not.
References
[1] Jeffrey P. Koplan et al., “Towards a Common Definition of Global Health,” Lancet 373, no. 9679 (June 2009): 1993–5, doi: 10.1016/S0140-6736(09)60332-9.
[2] Jens Holst, “Global Health – Emergence, Hegemonic Trends and Biomedical Reductionism,” Global Health 16, no. 1 (May 2020): 42, doi: 10.1186/s12992-020-00573-4.
Dr. Tom Bashford is Assistant Professor of Healthcare Systems at the University of Cambridge and leads the university’s International Health Systems Group. He is also a Consultant Anaesthetist at Cambridge University Hospitals NHS Foundation Trust.
Dr. Brandon Smith is a postdoctoral research associate in the International Health Systems Group at the University of Cambridge, with a research interest in frugal and reverse innovation in healthcare.