The Challenge of Adoption in Health

Why inventing the cure is only half the battle

What do mosquito nets, the measles outbreak, and Bill Gates have in common?

Mosquito nets remind us that many of the world’s gravest problems persist not because of lack of feasible solutions, but due to lack of adoption of those solutions. ‘Adoption’ is everything that happens after the discovery of an idea that determine its success or failure — the delivery systems, the educational efforts, the change in norms or behavior that get people to use/buy/do-the-awesome-thing you invented. As a recent New York Times article chronicling the environmental damage caused by mosquito-net fishing in Africa points out, getting adoption right is hard and when we don’t, unintended consequences can occur that undermine the success of noble efforts.

Kenyan fisherman using bed-nets to catch catfish in Lake Victoria. Photograph by Uriel Sinai for The New York Times

In my own experience working on malaria intervention programs in Ghana, I saw firsthand the challenge of adoption. I saw bed-nets used for fishing, as clothing lines, and in UN-labelled plastic wrappers, unopened because people didn’t know how to hang them up. While there’s no question that bed-nets have reduced the malaria mortality rate over the past decade, the consumer message surrounding their effectiveness — donate a net and save a life — has been over-simplified, creating a misperception that bed-nets are a silver bullet, can be dropped on the continent of Africa and expected to be adopted and utilized correctly.

The recent measles outbreak in the U.S. reminds us that even when life-saving innovations do spread, are widely adopted, and scientifically proven to be effective and safe, our work is still not done — the challenge of adoption persists. When it comes to infectious diseases, not all voices are made equal, and the actions of a few can all-too-easily undermine the decades-long efforts of many.

Bill Gates demonstrates the tremendous power of what I call the development trifecta: big ideas, big (and multiple) bets, and a big wallet. He exemplifies the transformative change that can happen when we apply the same type of investment and experimentalism to both the technical development of lifesaving solutions and to the delivery systems needed to implement them. The media commends the Gates Foundation for funding moonshot R&D efforts like the development of a malaria vaccine and a male birth control pill. However, far less known but equally important is their investment in integrated delivery systems — that is, finding ways to tackle the challenge of adoption through community health worker programs, supply chain innovation, and consumer behavior change. They know that if they don’t radically improve delivery systems, the success of their other investments in drugs and diagnostics will be limited at best. For this reason, the Gates Foundation has invested $7 billion in delivery systems to date, about 30% of the foundations’ grants. The development community should follow suit by providing a similar focus in both investment and experimentation in this area.

Adoption is the thorniest development problem to solve. It’s often the least glamorous, gets prioritized last, and can be prone to failure. It requires trial and error, time, patience, and determination — characteristics not very compatible to fundraising cycles. People want panaceas, silver bullet solutions that are cost-effective, work fast, and scalable. While bang for your buck is certainly important, it cannot come at a cost of experimentation and persistence on adoption.

The Invisibility Problem

There’s a lot of great research theorizing how and why ideas spread, and why others don’t. These social science theories have been adopted and tested extensively in the private sector by companies keen on mastering go-to-market tactics. When it comes to preventative health though, the challenge of adoption is evermore difficult due to what I call an “invisibility problem” — that is, the problem doesn’t manifest until after it becomes a problem.

In a recent New Yorker essay called Slow Ideas, Atul Gawande illustrates this very issue by comparing the very different trajectories of surgical anesthesia and antiseptic, two significant medical advancements discovered in the nineteenth century. Anaesthesia spread like wildfire, widely adopted across America and Great Britain in a mere seven years, whereas antiseptic took decades to be utilized by doctors. Why is this? It wasn’t a matter of cost, availability or ease of use; it was a matter of visibility. As Gawande states:

“One combated a visible and immediate problem (pain); the other [antiseptic] combated an invisible problem (germs) whose effects wouldn’t manifest until well after the operation.”

A similar parallel can be drawn to bed-nets and vaccines, and most other preventative health measures. Bed-nets and vaccines are like health insurance — they serve to protect you against a rainy day, but don’t have any immediate, tangible value upon adoption. In fact, you could argue they actually have negative value. Bed-nets are difficult to hang up, can be annoying to sleep under, and the insecticide treatment makes already hot environments more hot. Vaccines hurt and, as the anti-vaccine camp argues, have health risks associated with them.

So, what can we do about it?

Scientific evidence isn’t enough. Grassroots education efforts can go a long way to making invisible problems more visible, but the most effective way to get people to take preventative health measures is to create value add-ons that provide immediate tangible value upon adoption. This could include things like incentive-based programs — stipends for mothers who vaccinate their children — or verticalized systems that combine something people need (like a bed-net) with something people want (like a cell phone charger).

We experiment in the lab — spend billions of dollars on R&D to find a cure for AIDS and develop new vaccines. But, we don’t apply the same rule of thumb to adoption, experimenting with different ways to get lifesaving solutions to people and utilized in the right ways. We need more individuals and organizations that are willing to take risks on adoption, think outside the traditional development toolkit, and try new ways of doing things.

In September, the United Nations will agree on a new set of goals to tackle global poverty over the next 15 years — an addendum to the Millenium Development Goals. Many of the MDGs, such as combating malaria, measles, and maternal mortality, are problems we already know how to solve. We just haven’t solved them yet because the delivery systems in place aren’t sufficient or the ones that are working aren’t adequately funded. We need to put pressure on our policymakers to commit to adoption, through investment, experiment and measurement. Only when we succeed in this last 10% effort will the impact of lifesaving innovations truly be realized.

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