That’s not how the learning works – the paradox of Reverse Innovation: a qualitative study

In recent years, the North–south model of development, rooted in post-colonial assistance, has been heralded as archaic [11]. Development has been called into question as an industry that is often self-serving [20–22] and failing to demonstrate significant change [23, 24]. Also, the global health landscape has changed dramatically. Power and influence is more diffuse with a proliferation of significant new actors [25, 26], and emerging economies continue to challenge established markets. There are many examples of impressive health innovations originating from low- or middle-income countries [10, 27–44]. These have the potential to disrupt health systems; indeed there are many reasons why the bloated healthcare economies of high-income countries could benefit from leaner innovations and out-of-the-box thinking.

Keeping pace with these changes, the ‘Reverse Innovation’ movement recognizes that knowledge, skills and learning can come from anywhere, and even flow from low to high-income countries. It is no surprise that ‘Reverse Innovation’ has come to be a buzzword heard in many innovation, management and healthcare circles. In 2012, a thematic series in Globalization and Health set out to explore and promote ‘Reverse Innovation’. In 2013, 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 [45]. More recently, the International Partnership for Innovative Healthcare Delivery (IPIHD), recently renamed Innovations in Healthcare (IIH) formed out of a partnership between the World Economic Forum, Duke University, and McKinsey Company, operates a ‘Reverse Innovation’ working group to address how successful innovations in healthcare delivery from low-income settings can be replicated in high-income settings. The Centre for Health Market Innovations (http://healthmarketinnovations.org) and the Institute for Global Health Innovation collate many examples of potentially adoptable innovations (http://www.imperial.ac.uk/centre-for-health-policy/our-work/innovation-research-/).

Don Berwick, former Administrator of the Centers for Medicare and Medicaid Services wrote about the inspiring ideas that Low-income countries held, saying “We may well find ourselves not the teachers we thought we were, but students of those who simply will not be stopped under circumstances that would have stopped us long ago” [31]. Although there is increasingly vocal recognition of the potential to learn from low-income countries, the most recent incarnation, as a process of ‘Reverse Innovation,’ as opposed to other more neutral terminology is steeped in persistent attitudes that learning ought really still go the other way.

It is curious that the ‘Reverse Innovation’ term has gained traction in healthcare circles even when its use connotes a very different process to that in the management literature, where it originated. Its use in the management literature is less loaded, because it describes a process that occurs within the same organizational boundaries of a Multinational Corporation, managing a strategic entry into new markets, and where ownership of the Intellectual Property of the product is clear. When the term ‘Reverse Innovation’ is used in the healthcare space, the actors involved are entirely different, often diffuse, often without direct delivery capacity, and often the ‘owner’ of the innovation may have no interest per se in exporting it. Furthermore, often the innovation may be a technology but it may also be a process, a service, a type of new cadre, or even simply a principle, with no specific intellectual property ownership from the perspective of the innovator context. The motivation for and the driver of the learning process are both also one-sided – all from the high-income context. Low-income country innovators are not explicitly selling or exporting their ideas to high-income countries.

Our study shows that although it may be a strategic lever to persuade actors in an organizational change process in high-income countries, the risk highlighted by respondents here in the US is that the ‘Reverse Innovation’ narrative may send negative signals to potential adopters and also to the innovator contexts. Association of Reverse Innovation with frugality risks potential adopters viewing the innovation as a poor alternative to existing practice. The availability and production of cheap products is not limited to low-income countries, and this type of thinking raises important questions about how people in the US determine the value of goods, and speaks more to the US psyche than those producing innovations themselves. Equally, lean innovations may have been developed in low-income countries from good leadership not from the necessity of poverty. The suggestion that these countries would not have been able to develop innovative solutions had the cost pressure not been present may be offensive. It is not known whether low-income country actors would themselves agree with this sentiment – the perspectives of actors in these settings where the Reverse Innovations are developed have been largely absent from the discussion [46]. Future research might draw on the social marketing literature to better understand how these terms evoke positive and negative connotations.

From the perspective of a high-income country, learning from a context that might be considered to be ‘on par’ with the US would be termed something somewhat less loaded such as diffusion of innovation, or bidirectional innovation. However, learning from a low-income context is has been given the term Reverse Innovation perhaps because it runs counter to the prevailing notion of where knowledge, experience or evidence is considered to generally derive from. This sentiment evokes the same sense of paradox, or even oxymoron, as the phrase ‘patient-centered care’ might [47] or ‘affirmative action’. If care were truly patient-centered it would be inappropriate to refer to individuals as patients – it is a term very much centered on the healthcare professional. ‘Affirmative action’ (the process) aims to redress an important inequity but ‘affirmative action’ (the term) simultaneously reinforces it. Reverse Innovation, similarly, is oxymoronic – as if to say ‘we like your idea but feel threatened that you came up with it – we’re going to pretend that we view you as peers.’ ‘Reverse Innovation’ clearly evokes different things to different people and in our research, the term has complex, multi-layered, sometimes positive, sometimes negative, connotations. Future research should study the impacts and repercussions of the term ‘Reverse Innovation’ within the innovator contexts. But also more research is needed to explore the views of and impact of Reverse Innovation (the term and the process) in the source, low-income country contexts, in particular to examine further the presence (or absence) of any sense of exploitation as noted in our findings. The study of Reverse Innovation, although of benefit to populations in high-income countries, requires also the voice of those in low- and middle-income countries. There is a need for a better understanding of the supply side for innovations, and how to develop the market of ideas from these contexts. Linking in with our notion of ‘cultural arrogance’, there is a need to understand whether actors in low- and middle-income countries are enabled to promote their solutions and innovations to the countries that have historically been the providers, not the beneficiaries, of assistance.

Until this research is available, it is probably sensible to use the term sparingly, that is, think carefully about whom it is used for and by, as it will evoke different things to different people.

Greenhalgh [48] has already called for terms such as ‘knowledge translation’ to be dropped because they constrain how the link between knowledge and practice is conceptualized. They propose that discourse analysis might be used to make explicit the process by which certain types and sources of knowledge become defined as ‘best evidence’ and that a much wider menu of metaphors to illustrate the non-linear, networked generation, circulation and sharing of ‘knowledge’ is needed. Terms such as knowledge sharing, diffusion of innovation, disruptive innovation and social innovation are agnostic with respect to the development and income status of the countries involved in the sharing process but also do little to accurately represent the translation, implementation and scaling of innovation. It is simplistic to describe it as either a linear (translation) or passive (diffusion) process. If the adoption, for want of a better word, of innovations from low- to high-income countries is indeed a different process to that between high-income countries, then a definitive taxonomy is needed to establish how best to describe it, when and to whom.