Reciprocal innovation for transformative global health
Reciprocal innovation evolves the concept of reverse innovation and is defined by three characteristics: (1) global health partnership rooted in the values of reciprocity, mutual learning, and equity across partner institutions in HICs and LMICs, (2) a bi-directional and co-constituted approach to identifying shared health challenges across settings in long-term engagements, (3) identification of high-quality innovations from global health partnerships for demonstration, replication, and dissemination in diverse settings, as demonstrated in Figure 1. Reciprocal Innovation Model.
The concept centers the values of reciprocity and equity in bilateral exchanges and partnerships in global health, which are increasing and being critically examined and documented . Relationships in global health that are truly reciprocal are more apt to promote better science and developing, evaluating, and implementing effective health innovations in HIC and LMIC settings. Additionally, mutual learning allows for a reciprocal innovation to evolve and expand more robustly with proficient improvements that have a considerable impact on both populations. This iterative process allows for flexibility to adapt innovations within the settings where they are implemented. Francis Collins, director of the National Institutes of Health, affirmed the importance of reciprocal innovation in 2009 when he stated that, “Global health research should be a conversation with other countries not one in which the great United States tells the world what the answers are without listening to and learning from their experiences” .
The term reciprocal innovation was coined by the Indiana University Center for Global Health in 2018 and adopted by the Indiana CTSI to capitalize on the collective experiences and strengths in global health research and to, in part, use them to inform the sharing and building of global collective knowledge, data, and innovations in research across Indiana and around the world. Significant inspiration for the concept was derived from Indiana University's long-term partnership with Moi University, which today has grown into the Academic Model Providing Access to Healthcare (AMPATH). AMPATH is a unique and highly successful global health partnership representing over 30 years of collaboration between Moi University and Moi Teaching and Referral Hospital in Kenya and a consortium of North American academic institutions led by Indiana University . AMPATH was founded on the principles of equity, mutual benefit, and long-term commitment, with partners working across a tripartite mission of care, education, and research. In partnership with the Kenyan Government, AMPATH serves a population of 8 million people across western Kenya at more than 500 clinical sites, with comprehensive care programs in HIV/AIDS, oncology, chronic diseases, and maternal child health, among others, and pioneering population health and community-based approaches to care . The partnership facilitates bilateral exchanges for Kenyan and North American faculty, residents, and students, and leverages academic partnerships to build critical clinical and research infrastructure in Kenya, train global health researchers, and conduct research to improve the health of under-served populations in Kenya and globally [30–32].
Indiana CTSI Global Health Program
The Indiana CTSI Global Health Program was established in 2016 to address domestic and global health issues for underserved populations by bringing together research and expertise from three vibrant global health centers: IU Center for Global Health, University of Notre Dame Eck Institute for Global Health, and the Purdue University Institute of Inflammation, Immunology and Infectious Diseases. The Global Health Program is led by seven faculty at the three Indiana CTSI institutions, with expertise in infectious disease, infant and maternal health, non-communicable diseases, population health, biology and chemistry. The program is supported by a full-time program manager to support program activities, including managing stakeholder meetings, the grants program, and creating educational resources for reciprocal innovation, which are described in more detail below. From 2016-2021, 30 grants totaling $610,000 have been awarded to investigators and their partners in the areas of infant and maternal health, infectious disease, access to healthcare, prevention, chronic disease, and treatment. The CTSI Global Health Program also serves as a hub for investigators at Indiana CTSI and partner institutions in LMICs to access resources for reciprocal innovation, including informational videos and how-to guides, and to network and collaborate at annual meetings.
When the Indiana CTSI Global Health program was established, the program launched a small pilot grant program to strengthen global health research among the Indiana CTSI institutions. Pilot grants were mostly focused on research conducted in an LMIC setting and designed to address a specific identified need in that setting. One of these pilot grants is highlighted in Case Study 2.
|Case Study 2: Rapid test for falsified drug detection in Malawi and combating the opioid problem in Indiana
Shared Challenge: Unregulated street drugs in HIC and pharmaceuticals in weak regulatory environments in LMIC are often adulterated, which makes them dangerous to users.
Innovation: A paper test card, the PAD, was developed at the University of Notre Dame to detect falsified antibiotics. The PAD was designed as a rapid and inexpensive screening test to detect these problematic products at the point of use.
Reciprocal Benefit to LMICs: Testing showed that critical antibiotics in markets in Malawi were of good quality, but there were pervasive problems with dispensing practices such as repackaging and selling antibiotics to patients without a prescription.
Reciprocal Benefit to HICs: Using lessons learned from the Malawian implementation, the card was redesigned to detect a wide range of controlled substances and cutting agents found in street drugs in the US and is being tested by harm reduction groups in Chicago to empower people who use drugs to identify particularly hazardous constituents in street drugs.
In 2018, the program underwent a major transition to focus explicitly on reciprocal innovation, and shifted its funding priorities to projects that demonstrated potential for mutual benefit to both a partner LMIC setting as well as in Indiana. To support the transition from a traditional global health program to a reciprocal innovation program, we conducted an environmental scan to assess the available infrastructure and interest among partners and stakeholders in reciprocal innovation. Information gained from the environmental scan was used to organize an initial “stakeholder meeting” that brought together Indiana CTSI institutions, researchers at partner institutions in LMICs, and members of local public health and community organizations. At this meeting, stakeholders identified and discussed health priorities in Indiana and in partner LMIC settings and potential areas for reciprocal innovation research and partnership. Using information from the environmental scan and the stakeholder meeting, a reciprocal innovation grants program and call for applications was created that focused on specific areas for reciprocal innovation identified in the environmental scan and stakeholder meeting.
This unique approach, namely the environmental scan, stakeholder meetings, and grants program, to building and supporting reciprocal innovation is shown in Figure 2. Reciprocal Innovation Process. The process continuously and explicitly engages local and global partners to identify shared health challenges and fosters research collaborations and partnerships to identify, test, and adapt shared solutions. Each of these steps in our approach are discussed in more detail below.
The environmental scan was an essential “first step” in building a reciprocal innovation grants program. The goal of the environmental scan was to engage stakeholders both in Indiana and internationally to: (1) gauge interest and understanding of the concept of reciprocal innovation, (2) catalogue the available infrastructure for reciprocal innovation, including existing partnership, (3) identify the critical challenges to moving forward the reciprocal innovation concept/process, and (4) begin to identify key health priorities both in Indiana and in our partner countries that might be amenable to addressing through a reciprocal innovation approach. The environmental scan also provided a roadmap to identify stakeholders and topics for the stakeholder meeting where global and local partners reviewed the challenges, priorities, and opportunities identified in environmental scans with the goal of developing priority investment areas for the Indiana CTSI’s Reciprocal Innovation and Grant Programs. The environmental scan was first done to gain perspective from both local and international partners so that implementers in each setting could identify and articulate their own challenges, priorities, and opportunities, and then come together to see where they overlap, and focus research efforts there.
An environmental scan of critical areas of need with key health stakeholders in Indiana and at the Indiana CTSI member institution’s key international partner sites was conducted over a six-month period with a special emphasis on the AMPATH partnership in Kenya. The first phase of the scan included interviews with 75 key stakeholders from IU, Purdue, Notre Dame, Indiana state government, local health practitioners, community groups, and long-standing LMIC partners. Semi-structured, in-person interviews were conducted to introduce the concept of reciprocal innovation, assess interest in reciprocal innovation, identify additional key stakeholders and start exploring critical health challenges, stakeholder priorities, and resources and opportunities. Interviewers provided written summaries of each interview to identify key themes. In follow-up to the preliminary stakeholder interviews, 121 Indiana-based and LMIC stakeholders were identified and invited to complete an online questionnaire to provide further input on how the reciprocal innovation program could best serve populations in Indiana and around the globe. Responses from Indiana stakeholders and LMIC stakeholders were tallied individually in order to analyze priorities, challenges, and barriers by country and compared with each other to identify commonalities. Overall, we found that the majority of stakeholders expressed support for the concept of reciprocal innovation and that they could identify several opportunities or candidates for a reciprocal innovation process to address health challenges in Indiana and in Kenya. Among identified barriers to reciprocal innovation the three most cited were 1) lack of funding, 2) challenges in gaining community acceptance of reciprocal innovation projects, and accessing relevant populations, and 3) the lack of protected time and qualified people to conduct reciprocal innovation.
Annual reciprocal innovation stakeholder meetings were started in 2019 to disseminate the concept of reciprocal innovation, engage more stakeholders in the reciprocal innovation process, and to identify key priorities and targets for reciprocal innovation. The first meeting in 2019 focused on Indiana stakeholders and priorities while the second meeting in 2020 focused on East Africa led by long standing partners at AMPATH in Kenya. A third meeting was held in 2021 to deepen connections between global and local investigators and provide support for the upcoming round of reciprocal innovation grants. At the first meeting, key stakeholders included researchers from Indiana CTSI institutions, the Indiana State Department of Health, and local organizations and used small groups to identify key health issues in Indiana and brainstorm potential topics for reciprocal innovation. Stakeholders identified the following priority areas for reciprocal innovation: 1) reducing chronic disease, 2) reducing substance abuse, 3) addressing infant and maternal health, and 4) strengthening access to healthcare. The second meeting focused on East African health priorities for reciprocal innovation, and due to the COVID-19 pandemic was held virtually in 2020. Key stakeholders attended from Moi University, Moi Teaching and Referral Hospital, Kenya Ministry of Health, Indiana CTSI institutions, and global health partners in the AMPATH consortium. Reciprocal innovation priorities identified by East African stakeholders were mental health, non-communicable diseases, infectious disease, infant and maternal health, and access to quality healthcare as top health challenges, illustrating significant overlap and shared health challenges with those identified in Indiana. The third meeting in 2021 was a two-day virtual conference. The first day was a reciprocal innovation workshop where globally- and locally-focused investigators were broken into small groups to build relationships, share reciprocal innovation ideas, and get feedback from CTSI Global Health leadership on potential reciprocal innovation grant projects. The second day was a plenary session hosted by Dr. Roger Glass, Director of the Fogarty International Center and Associate Director for International Research, followed by a panel discussion on the applications of reciprocal innovation and its role during global crises.
Reciprocal Innovation Grants Program
Based on the findings of the environmental scan and shared health priorities identified at the stakeholder meetings, a competitive reciprocal innovation grants program was established. Eligible applicants were investigators from an Indiana CTSI institution who had to either propose a plan to form or have an existing partnership with at least one investigator in an LMIC. The program established two types of grants - a reciprocal innovation planning grant of $10,000 for one year to support partnership development and project planning, and a reciprocal innovation demonstration grant of $50,000 for two years to conduct reciprocal innovation research activities.
Planning grants support preliminary partnership development and project planning that will ideally provide the groundwork for reciprocal innovation projects. The CTSI Global Health Program leadership felt that it was critical to support these early efforts to establish partnerships in reciprocal innovation since the concept and aims of the program were so new to many investigators. Planning grant applications are open on a rolling basis and reviewed by the Indiana CTSI Global Health Leadership team, with the program funding up to two planning grants per year.
Demonstration grants support existing global health research partnerships of the Indiana CTSI partner institutions to pilot implementation and assessment of innovations with a high potential to positively impact outcomes in the identified priority areas. The goal of the demonstration grant is to assist teams in generating pilot data for reciprocal innovation that can then be used to support additional extramural funding. Applications for demonstration grants are released once per year and reviewed by a formal selection committee modeled on an NIH proposal review committee, with representation from the Indiana CTSI institutions, Indiana State Department of Health, and international partners. The involvement of our international partners in the review and selection process for these awards continues to be an important aspect in the process of prioritizing innovations in a reciprocal way. The process was initially developed using teleconferencing and the novel use of video conferencing (at the time) to engage reviewers. We worked diligently to ensure that reviewers who had not participated in NIH style reviews were prepared. The creation of a robust selection process and team was a key feature of this process that was developed early on in the creation of our pilot awards. This provides an important platform for supporting true reciprocity in this process and it is a feature that’s not always present in the selection processes sponsors use. It is worth highlighting this aspect as one of the key components of the reciprocal innovation process the Indiana CTSI established.
Educational Resources for Reciprocal Innovation
To increase awareness and support for the concept of reciprocal innovation, the Indiana CTSI Global Health Program created a series of videos and presentations on reciprocal innovation principles, the grants program, and previously funded projects. Moreover, we found that while global health investigators have strong connections to international partners in LMICs, they often are not well connected to locally-based researchers in Indiana. To support potential connections between locally- and globally-focused investigators, a Global Health Innovation Exchange was created as an online repository of reciprocal innovation projects. The repository is a living dashboard that is used to share updates on project progress, outcomes, and published materials. In addition to the repository, the annual reciprocal innovation stakeholder meetings provide further opportunities to link locally- and globally-focused researchers and foster the development of these partnerships. The program is also working to create additional educational modules for undergraduate and graduate students interested in public and global health, with a goal of increasing interest in reciprocal innovation, providing potential funding opportunities for graduate research projects, and increasing the pipeline of global health investigators harnessing reciprocal innovation approaches in their work.