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Green Healthcare: The Power of Frugal Innovation in Environmental Sustainability

  1. Cyan Brown, expert in biodesign1,
  2. Yasser Bhatti, associate professor of strategy and innovation2,
  3. Matthew Harris, clinical senior lecturer in public health3
  1. 1Department of Bioengineering, Biodesign, Stanford University, USA
  2. 2MBS College of Business and Entrepreneurship, Saudi Arabia
  3. 3Department of Primary Care and Public Health, Imperial College London, UK
  1. Correspondence to: C Brown c.brown{at}atlanticfellows.org

Increased adoption of frugal innovation has the capability to offer budget-friendly healthcare while reducing environmental impact, argue Cyan Brown, Yasser Bhatti, and Matthew Harris

The healthcare sector plays a vital role in safeguarding both human and planetary health by cutting down its ecological footprint. Globally, health systems collectively are responsible for 4.4% of net greenhouse gas emissions—equivalent to the emissions of 514 coal power stations annually1—which adversely affect health in multiple ways, including heatwaves and pollutant inhalation.

High income countries are the primary contributors to healthcare pollution, with health systems in Australia, Canada, the United States, and Switzerland each accounting for more than a ton of emissions per individual.2 Collective action has commenced to tackle this: over 50 nations have pledged to establish climate resilient and environmentally friendly health systems. Additionally, two high income countries and 12 low and middle income countries have committed to achieving net zero carbon emissions by or before 2050, including the UK, Belgium, Malawi, and Sierra Leone.3 Numerous healthcare workers and patient groups also actively contribute to climate initiatives within healthcare, such as HealthCare Without Harm and EcoMedics. To fulfill these pledges and manage the intricacies of climate change, various strategies for mitigation and adaptation will be necessary.

A noteworthy strategy revolves around frugal innovations, designed to utilize fewer resources while maintaining patient safety and clinical effectiveness (box 1). An illustration of this is kangaroo mother care, which offers continuous temperature regulation for premature infants via skin-to-skin contact with a parent or caregiver. For stable neonates, this method eliminates the necessity for costly incubators, operating on electricity—leading to both economic and environmental benefits for the healthcare system. Given the potential savings from resource-efficient frugal innovations, national policy makers should pay heed, which necessitates a favorable policy, research, and business development climate.8

Box 1

Origin and definition of frugal innovation

Frugal signifies simplicity, plainness, and prudent use of resources. Frugal innovations are typically characterized as innovations propelled by resource constraints and can encompass products, technologies, and services.4

The genesis of frugal innovation can be traced back to the appropriate technology movement initiated in the 1970s by Ernst Schumacher. This movement emphasized small scale, environmentally friendly, people-centered, and locally managed technology.5

Despite its diverse definitions, frugal innovation enjoys popularity across several sectors, including healthcare.6 Though it may not always aim for sustainability, it often results in sustainable innovation.7

Key criteria for a frugal innovation6

  • Considerable cost reduction—Frugal innovations are markedly less expensive compared to conventional standards. Although the extent of cost reduction is not universally agreed upon, frugal innovations must be affordable for individuals in low and middle income brackets or offer systemic savings. Affordability should be a fundamental feature from the outset

  • Core functionalities—This pertains to the essential requirements of the innovation such as simplicity, user-friendliness, and fulfillment of fundamental functions. This criterion promotes sustainability as focusing on core functions, often by repurposing existing resources, helps minimize waste and consequently reduce environmental impact

  • Optimized performance—Frugal innovations must meet the requisite standards for performance, safety, and regulatory approval, allowing them to effectively serve their primary purpose in various environments

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Frugal innovation can promote sustainability

In several high income countries, both financial and ecological pressures necessitate the reform of the healthcare sector, prioritizing cost-effective and sustainable healthcare expenditure. In the US, for instance, the Affordable Care Act 2010 introduced value-based reimbursement, limiting provider earnings based on the outcomes they achieve for patients.9 Frugal innovation in affluent nations could aid in reducing healthcare costs and the excessive emissions they generate.10 For example, after implementing a frugal innovation to optimize cataract surgery at the Aravind Eye Hospital in India, a single operation generates 30 times less CO2 than a comparable procedure in the UK while also increasing surgical capacity.11

Frugal innovations have been primarily developed and applied in low and middle income countries. In these regions, the main impetus is often mitigating health disparities and rendering more inclusive care, with environmental benefits serving as an additional advantage.12 The innovations range from being non-inferior to the gold standard, sometimes superior, and sometimes merely adequate. Adequate implies certain trade-offs but meeting regulatory standards while decreasing costs. For instance, clay pots can effectively store insulin at cooled temperatures but may lack other features such as precise temperature control (table 1).10

Table 1

Examples of frugal innovations that promote sustainability

Expanding the use of frugal innovations

The methodology of frugal innovation may vary based on its initial development location, as the procedure needs to consider basic user and product requirements alongside specific geographic market and consumer preferences 33 Legal, regulatory, and safety requirements— as well as their monitoring and enforcement—also differ between countries and can affect product and user prerequisites.33

Innovation in affluent nations (occasionally referred to as second degree frugal innovation) emphasizes crafting robust and cost-effective health innovations tailored to user needs based on geographic market preferences. The more cost-effective

Cost-effective innovations present opportunities for low and middle-income nations — a prime example being the Swoop portable MRI unit, which operates without a specialized power source or cooling, contrasting with conventional MRI machinery that is extravagantly costly even for affluent nations (table 1).

Reverse innovation occurs when advancements conceived in low and middle-income nations are embraced by wealthier countries.34 A case in point is the Arbutus medical drill cover, engineered in Malawi and Uganda by Canadian engineers, which enables standard hardware drills to be utilized in sterile surgical settings. Initially designed as a reusable and washable cover in less affluent regions lacking expensive surgical drills, it has now been adopted in the US as a disposable drill cover for use in emergency departments.35 This single-use approach in the US forfeits the ecological benefits of reusable, washable, and sterilisable covers.34

Another perspective to understand frugal innovation is by differentiating between bottom-up or top-down approaches. Bottom-up innovation generally (but not exclusively) involves communities in low and middle-income regions addressing pro-social motives, local requirements, and business interests. This network is largely informal and typically operates on a domestic scale,7 such as We Care Solar, which supplies solar-powered suitcases for childbirth in remote clinics. Top-down frugal innovation is primarily undertaken by large corporations in wealthy countries aiming for market expansion while also fostering development.36 Reduced environmental impact might be the main goal (e.g., the reusable menstrual cup) or a secondary one, akin to portable point-of-care ultrasound units (table 1). The network and stakeholders are mainly formal, and it usually involves a large-scale operation.7 Nevertheless, not all top-down innovations are born in wealthy countries. The General Electric (GE) Mac 400, a lightweight, portable electrocardiograph commissioned by GE’s Indian subsidiary, has significantly impacted the US electrocardiograph market.37

Frugal innovation is relevant beyond emerging markets

Given that innovation often addresses specific needs within a particular context, some product advancements are more suitable for certain settings than others. For instance, the clay pot for insulin storage might hold little attraction in places with ready access to refrigeration. However, as climate-related disasters such as wildfires and floods become more frequent, reliable electricity and access to certain technologies may be compromised, making innovations like the clay pot relevant in more regions. Besides, making trade-offs to lower environmental impact and intentionally simplifying technology choices, especially in affluent nations, can assist in minimizing unnecessary waste and pollution.38

Some of the most environmentally and financially successful innovations in low and middle-income nations, like using kangaroo mother care (KMC) instead of incubators, still encounter resistance in affluent nations, resulting in detriments to both human and planetary health. A systematic review and meta-analysis of seven well-conducted randomized controlled trials revealed that kangaroo mother care enhanced the quality of care for prematurely born, low birthweight infants and reduced perinatal infection rates, hospital stays, and mortality.2 The lack of operational costs or equipment needed further increases its appeal. Despite this evidence, its use in affluent countries is uncommon, with certain hospitals in Sweden and the US being exceptions.39

A hindrance to the broader application of kangaroo care is the necessity for space where parents or caregivers can sleep with their infants in hospital wards, necessitating policy and structural adjustments to facilitate this approach.39 As highlighted by this example, efforts to transfer or adopt innovations into a different environment are likely to face institutional, cultural, and behavioral challenges that might hinder successful implementation.40 Nonetheless, emphasizing the additional benefit of reducing healthcare emissions could alleviate the hesitation some individuals in affluent countries may have about embracing a less complex frugal innovation.

Facilitating frugal innovation

Advancing the development and uptake of frugal innovation requires focusing on three key areas—policy, research, and business model innovation. Policy-wise, embedding environmental considerations in the decision-making criteria for new products or innovations submitted for regulatory approval can enhance sustainability.41 Health technology assessment agencies in the UK and Canada have pledged to include environmental sustainability in their appraisal processes.42 Additionally, hospital value analysis committees, which make procurement decisions, can incorporate sustainability into their criteria to ensure it is prioritized from the beginning of the innovation process. These committees could play a pivotal role in embracing frugal innovations. For instance, it is estimated that if UK acute trusts switched all their high-grade surgical orthopedic drills to the Arbutus drill cover system, each could save nearly £250 000 a year.35 Achieving national goals for reducing the healthcare sector’s carbon footprint depends on local decision-making processes.

Research into understanding the environmental impact of frugal innovations also demands attention. One major priority is advancing lifecycle assessments that measure carbon emissions.4344 For product innovations, considerations should include the safe disposal of medical devices at end-of-life and the repercussions for solid waste that ends up in landfills. Frugal innovations emphasize cost reduction throughout the value chain, from production and servicing to disposal in the product lifecycle value,45 fostering environmentally favorable solutions such as recycling, reusing, and the circular economy. However, many frugal interventions, including many cited here, lack lifecycle assessments, though most are likely environmentally favorable given their resource-minimizing focus. Yet, frugal innovations are not innately sustainable; their entire lifecycle must be evaluated, especially when transitioning from low-income to high-income countries.46

Business model innovation is also crucial for promoting the adoption of frugal innovations.454647 Many advancements stem from clever improvisation by users and suppliers rather than formal R&D. Securing funds for the development of frugal innovations can be challenging. Grants, social impact bonds, and blended finance are potential financing options, as they can support outcomes not solely profit-driven. Appropriate funding and support could facilitate research aiding regulatory and intellectual property clearance for many frugal innovations in multiple regions, essential for scaling.8 Frugal innovations target the triple bottom line (environmental, societal, and economic benefits) by cutting costs rather than generating profits, potentially creating conflict among stakeholders in tech markets.8

Nearing the tipping point

Elevating the adoption or development of frugal innovations in affluent nations may contribute to making the healthcare systemmore eco-friendly. Nevertheless, this must coincide with various efforts to diminish the primary sources of emissions in the medical field. For instance, 40% of healthcare sector emissions stem from the utilization of electricity and gas, particularly for heating or cooling purposes. Although resource-saving innovation can aid by minimizing resource consumption, there remains a requirement to adopt other tactics, such as transitioning to renewable energy sources.2

Affluent nations can adopt resource-saving innovation as part of their decarbonization plan, whereas many less affluent nations implement it out of necessity. The healthcare systems in low and middle income countries are not the primary contributors to the global health carbon footprint, even though numerous serious repercussions of the climate crisis affect the inhabitants of these nations.2 Bringing this disparity to light is a crucial facet of environmental justice.48 The discourse surrounding frugal innovation must shift from emphasis on generating more economical healthcare solutions mainly for less affluent countries, toward creating solutions that assist all nations in cutting emissions and expenses, while upholding quality care. This can be facilitated by intentionally selecting frugal innovations from low and middle income countries, formulating a reason for their application in wealthy countries, and promoting their adoption. Enhancing reciprocal innovation, based on shared learning and collaborations, among affluent and less affluent nations, will greatly advance this goal.123849

Key messages

  • Resource-saving innovations achieve more with fewer resources for a larger audience, and can also decrease healthcare’s global environmental footprint

  • Despite many frugal innovations emerging due to resource constraints in less affluent countries, they are equally relevant in wealthy nations

  • Resource-saving innovations are tailored to user requirements, obstacles, and norms in various geographical settings and therefore necessitate localized environmental impact evaluations

  • Broad dissemination of resource-saving innovations in health calls for changes in financial, policy, and research frameworks.

Acknowledgments

MH receives support from the National Institute for Health and Care Research Applied Research Collaboration Northwest London. The perspectives presented are those of the author(s) and not necessarily reflective of the NIHR or the Department of Health and Social Care.

Footnotes

  • Contributors and sources: CB is a practicing physician with specialization in frugal innovation and biodesign, MH is an experienced lecturer in public health, and YB is a scholar in strategy and innovation. All three authors envisioned the article, CB executed the preliminary drafts, and MH and YB participated in writing, editing, and the final review. CB assumes responsibility as the guarantor.

  • Conflicts of interest: We have reviewed and comply with BMJ policy on conflict of interest disclosures and declare no conflicts.

  • Provenance and peer review: Commissioned; externally peer-reviewed.

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