Leading article

Technology transfer to the developing world: does new technology have any relevance for developing countries?

P. F. Basch

Department of Health Research and Policy, Stanford University School qf Medicine, California, USA

S U M A4 A R Y. Technology is not limited to equipment and commodities hut includes know-how, under- standing and the ability to control and exploit underlying principles and processes. Diverse technologies, not only those termed ‘biomedical’, affect the incidence and control of all diseases including tuberculosis. ‘New technology’ implies something recently developed, hut any technology is new to those without prior experience. For developing countries, technologic novelty is far less important than relevance, which encompasses, among other things: direct application to reducing risk of infection and disease; affordability and cost-effectiveness; saving foreign exchange; satisfying public demand with political benefit to the government; and promotion of social equity. The value of health gained by the new technology should exceed its cost, hut this is difficult to measure.

It is usually presumed that industrial countries are eager to export technologies, but intellectual property and patent regulations of the importing country may inhibit such transfers. Similarly, ethical issues involving protection of human subjects and informed consent may complicate clinical trials and technology assessment in the developing country environment.

R L? S Cl M 8. La technologie n’est pas limitee a l’equipement et aux marchandises mais inclut le savoir- faire, la comprehension et la capacite de controler et d’exploiter les principes et les procedures essentielles. Plusieurs technologies, et non pas settlement celles appelees ‘biomedicales’, ont un effet sur I’incidence et le controle de toutes les maladies, y inclus la tuherculose. La notion de ‘technologie nouvelle’ implique celle d’un developpement recent, mais toute technologie est nouvelle pour ceux qui n’en ont pas une experience anterieure. Pour les pays en developpement la nouveaute technologique est moins importante que sa pertinence, qui comprend entre autres : une attention suivie portee a la reduction du risque d’infection et de maladie ; aux procedures d’achat et a la rentabilite ; au march6 des changes ; ia la satisfaction de la demande publique en m&me temps qu’un benefice politique au gouvernement ; iI la promotion d’une Cgalite sociale. L’amelioration des niveaux de Sante apportee par la nouvelle technologie devrait depasser les co&s, mais il est difftcile de la mesurer.

II est habituellement suppose que les pays industrialises sont interesses a exporter ies technologies, mais les lois gouvernant la propriete intellectuelle et les brevets du pays d’importation peuvent empecher de tels transferts. De meme, des questions d’ethique comprenant la protection des Ctres humains et le consentement Cclaire peuvent compliquer les etudes cliniques et I’kaluation de la technologie dans le contexte d’un pays en developpment.

R ES U M EN. La tecnologia no se limita a 10s equipamientos y a las mercaderias, sino que tambien incluye el tino, la comprension y la habilidad para controlar y explotar 10s principios y 10s procedimientos fundamentales. Diversas tecnologias, y no solo aquellas llamadas ‘hiomedicas’, afectan el control y la incidencia de todas las enfermedades, incluyendo la tuberculosis. La notion de ‘nueva tecnologia’ implica un desarrollo reciente, pero toda tecnologia es nueva para aquellos que no tienen una experiencia previa. Para 10s paises en desarrollo, la novedad tecnologica es mucho menos importante que su pertinencia, lo que significa, entre otras cosas, una atencion especial con respect0 a la reduction del riesgo de infection y de enfermedad, al abastecimiento y rentabilidad, al sistema de cambio monetario mas conveniente, a la satisfaction de la demanda de1 puhlico, con heneficio politico para el gobierno, a la promotion de una

Correspondence to: Paul F. Basch, Department of Health Research and Policy, Stanford Umversity School of Medicine, Stanford. California 94305-5092, USA.

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354 Tubercle and Lung Disease

igualdad social. Los beneficios en salud obtenidos por la nueva tecnologia debieran superar sus costos, pero esto es difkil de medir.

Habitualmente se presume que 10s pa&es industrializados tienen una gran avidez por la exportation de tecnologias, pero la reglamentacidn referente a la propiedad intelectual y a las patentes, de 10s paises importadores, pueden impedir tales transferencias. Asimismo, 10s aspectos Cticos relacionados con la proteccidn de 10s seres bumanos y el consentimiento bien informado pueden complicar 10s estudios clinicos y la evaluation de la tecnologia en el ambito de un pais en desarrollo.

INTRODUCTION

This report is an adaptation of an address on general

issues in technology transfer presented at the World

Congress on Tuberculosis in Bethesda, Maryland, USA

in November, 1992. It is intended as a brief and pro-

vocative introduction to this subject for students,

health officials and investigators in both developed and

developing countries.

DEFINITION AND SCOPE OF TECHNOLOGY

Technology is a means by which human beings can

surpass the boundaries imposed by their sensory and

physical limitations. By identifying, accumulating and

modifying materials from their environment they can

express their creativity, make useful objects, and aug-

ment their understanding of natural phenomena. Tech-

nology also provides a foundation from which people can

protect themselves against the physical and biotic threats

of a hostile environment that contains Mycobacterium tuberculosis and other respiratory pathogens.

Medical and other health-related technologies

For ‘medical technology’ in particular, the much-quoted definition of the office of Technology Assessment of the

US Congress’ is ‘the drugs, devices, and medical and

surgical procedures used in medical care and the organi-

zational and supportive systems within which such a

care is provided.’ This highly restrictive definition may

be used with the understanding that the state of health of an individual is determined by many factors other

than medical care. Technologies of all kinds, ranging

from the construction of buildings, to motor transport, to electronic data processing, affect the determinants of

disease and the demand for, and provision of, medical care.

Technology transfer

It is likely that most people think of technology transfer in connection with the international movement of complicated products such as computed axial tomogra- phy (CAT) scanners from a developed to a developing country. However, technology transfer is more than the exportation and importation of commodities from a

sending to a receiving country. It encompasses a sharing

of the basic understanding and ability to carry out

methodologies and procedures that may or may not

generate a product. For example, recombinant DNA is

a technology in itself, independent of anything produced

through its application.

Technology transfers vary in complexity, in intent,

and in degree of penetration in the receiving country,

as shown on Table 1. Those technologies introduced

primarily to advance biomedical knowledge through

research in epidemiology, pathogenesis, or prevention of

disease usually fall within the categories that are called

transient or confined, and constitute a minor element

among the total transfers. A much greater proportion is

made up of those technologies (sustained, adapted and

closed) characteristic of the commercial sector. Inde-

pendent of the degree of penetration as described here,

any technology may have profound consequences for

health services. Implicit in the idea of ‘New Technology’ are innova-

tive products or procedures that are attractive largely

because of their recent development. However, novelty

is itself of little value. On one hand, novelty is not an

inherent property of the technology because every

Table 1. Levels of penetration of imported technologies in developing countries

Open technologies

Transient

Confined

Dependent

Sustained

Adapted

Techniques and materials imported for temporary use for a particular short-term purpose such as a research project carried out mainly by foreigners Techniques and materials imported for a unique application over a longer term, as for a specialized institute or organization Techniques and processes that may be widely disseminated but require continued importation of equipment, parts. supplies, reagents, and know-how. Technicians and managers are trained for routine operation The technology is established and functions autonomously with local commodities, supervision and maintenance, but remains at the same technical level as when introduced The technology is established, fully understood, functions independently and incorporates modifications approprtate to local conditions and needs, derived from international and domestic sources

Closed technologies

Sheltered Industrial processes protected by patents and not accessible without royalty payment or commercial agreement

Inaccessible Industrial processes protected by trade secrets and firmlv closed to others

Technology transfer to the developing world 355

technology, however commonplace it may become to

its originators, is new to someone else. On the other

hand, the loss of novelty is inevitable as technologies age, mutate, radiate into various niches, or hybridize

with other technologies. The sole justification for health-related research and

technology is to improve the productivity of the health

sector.’ This means that the application of the technol-

ogy will help to buy more health per peso, franc, rupee. or other resource input. The transfer of biomedical tech-

nology should be clearly beneficial to the importing

country, and improve the quality of life of the people.

The technologic challenge then has less to do with

newness than with relevance - maximizing the desired

beneficial effects. and minimizing the adverse conse-

quences. Some aspects of relevance are shown on

Table 2. It should not be presumed that technology transfer is

one way, from the rich world to the poor world. Many

important drugs such as quinine and emetine were

derived from the pragmatic knowledge of people who

would be considered by current standards to be techno-

logically unsophisticated. Developed countries have

much to learn about the distribution of services to large

numbers of people and the ingenuity necessary to im-

plement technologic innovations in the pathogen-rich

and resource-poor nations.

THE TRANSFER OF TECHNOLOGY

The need for assessment

Ideally, the transfer process is incomplete without an

ex ante appraisal of feasibility, and a post-transfer as-

sessment of the acceptability, efficacy, safety, and cost-

effectiveness of the technology within the conditions

of the receiving country. Any adverse environmental

or physiologic effects of a widespread new technology

should be anticipated and monitored by the receiving

country, but unfortunately this is often neglected.

Table 2. Criteria for relevance of health technology in developing countries

I.

? _. 3

i:

5. 6. 7.

8. 9.

IO.

I I.

Direct application to reduction of disease prevalence or to risk of incidence. Affordability in view of competing priorities. Cost-effectiveness in terms of future costs averted. Sustainability by the importing country after withdrawal of donor support. Public demand and political benefit to the government. Saving foreign exchange. Contribution to national development, economic growth and creation of employment. Promotion of social equity. Addition to national capacity in science and technology, training local scientists and technicians in advanced methods, and reducing emigration of scientific personnel. Agreement with the government’s established health policies and strategies, and with science and technology policies (if any). Minimal opportunity cost. In a zero-sum budget, the totality of health gained by use of the new technology should equal or exceed the totality of health that would have been gained by different uses for the same amount of resources.

Developing countries

These are extremely diverse, although a few general and

familiar characteristics apply: mainly young populations with high-birth, infant, under-5s and maternal mortality rates. and relatively high morbidity from infectious

diseases; low economic productivity of mostly primary

products; want of capital accumulation and savings:

insufficient literacy, especially among females: imma-

ture and unstable political systems; extremes of wealth

and social status, and so on. These are the environments

in which the proposed ‘new technologies’ are to find

an adoptive home. Looking more closely in most developing countries.

we see multiple medical care systems. with private prac-

tice for the affluent, insurance or social security-based

care for middle-class workers, and Ministry of Health

facilities of variable quality and effectiveness for the

poor majority. Many middle income countries have good

services with well-trained, motivated and dedicated

personnel. In others, the situation is less favorable. In

many countries, staff of rural health centers are unable

to work effectively for want of petrol for their vehicles;

technicians can not make blood or sputum fihns for

lack of glass microscope slides and personnel often are

not paid for months. The importation of advanced tech-

nology to such places will be largely ineffectual until

their health services reach a level at which it can be

usefully employed. On the other hand, the introduction

of certain technologies could be capacity-building for

health agencies that otherwise might flounder. Trans-

ferred technology could form a framework upon which

additional services might be provided. For example. a

targeted immunization program could expand to provide

maternal and child health services.

The need for operational research

Under conditions of deprivation the greatest research

need is for operational research, to establish the means

by which the health sector can achieve its mission

effectively (Table 3). In such circumstances. the health of the community would be advanced at least as well

by the promotion of schooling and literacy. window-

screening, paved roads, telephones, electric lines, clean

water, better agricultural tools, seeds. livestock and

similar mundane technologies.

Retaining labor-intensive methods

The typical developing country Government Health

Service. although underfunded, is often not understaffed. Labor-saving but costly devices developed for the high- salary industrialized nations of the North may lose their

economic justification in the labor-rich countries of the South. Workers at all levels of civil service receive few rewards and have little incentive to adopt innova- tions that may threaten their professional stability. Lower level technical workers are commonly trained for

356 Tubercle and Lung Disease

Table 3. Operational research in the health sector

integration with other government ministries, non-governmental and inter-governmental organizations, and the domestic private sector

Public education through schools and the media for better understanding, more appropriate preventive behaviors, improved adherence or compliance with preventive and treatment regimens

Administrative systems for resource management (financial, human and material); data management (monitoring and surveillance; recording, transmission and analysis); decision-making and program implementation

Direct health activities and procedur-es: for greater cost-effectiveness and increased productivity Personal: education, immunization, case-finding, prophylaxis,

diagnosis, treatment and rehabilitation Community: water supply, sanitation, vector control, facilities

regulation, inspection and enforcement Sk@ training and motivation at all levels toward minimizing

errors, improving outcomes and follow-up Facilities: improving access, services and utilization Adverse effects: minimizing harmful consequences to individuals

and the environment of health related procedures and processes

(Research directed toward the application of technology to improve the health of the population through more efficient employment of existing and innovative resources, with quality control throughout)

the repetitive performance of well-defined and routine

tasks. George Nelson of the Liverpool School of

Hygiene and Tropical Medicine has pointed out3 that

60 000 people in India who make a living by reading

malaria slides could be displaced by adoption of alter-

native diagnostic methodologies. Therefore technologic

innovations in unfamiliar surroundings might provoke

unplanned social consequences that are quite distinct

from their nominal scientific purpose.

Further considerations in selecting technologies to transfer

The differing demography of wealthy and poor countries

will modify their rationale for adopting newer technolo-

gies. The relative impact of immunization in averting

illnesses and deaths must be greater in the microbially-

rich countries of the tropics; conversely, technologies

for long-term management of chronic disease patients

may not be suitable where there are few elderly and less

tolerance for prolonged dependency on costly medical

care. In addition to social and cultural compatibility, a com-

pelling issue in the North-South transfer of technology is

its physical adaptability to local conditions in develop-

ing countries. High technology devices are generally

not conceived with the tropical environment in mind, and may not function to design specifications in con- ditions of unstable or intermittent electric power, high temperature and humidity, dust, insects, and similar hazards. Some machines are retrofitted with surge sup- pressors or other protective devices, which are rarely

an integral part of the original design. The necessary chemicals, antigens, isotopes, or whatever needed for research or for routine application may be costly to import, difficult to store properly, and impossible to dispose of without hazard to the environment.

The issue of capital versus recurrent costs is of pri-

mary importance. A visit to virtually any larger health

facility in the tropical country of your choice will

reveal apparatus and equipment from ELISA readers

to X-ray machines disabled for want of supplies and

consumables, maintenance, spare parts, or persons

trained in proper use, care, and repair. Recently, com-

puters have begun to share a similar fate. It is distress-

ingly common to see as much, or more, equipment out

of order than in working condition. Around the world,

thousands of costly microscopes essential for diagnosis

of tuberculosis, malaria, and other diseases are gathering

dust, rust, and fungus merely because no replacement

is available for non-functional light bulbs.

Routes for technology transfer

The habitual dependence of many health ministries on

foreign donors is a conduit for much imported tech-

nology, but carries with it certain dangers. Funding

from country J or country G or country U often entails

the stipulation that the money must be expended for

commodities and equipment from the donor country, a

condition known as ‘tied aid’. When the funding cycle

is over, a different donor country or agency may con-

tinue the project with noncompatible apparatus and

supplies. Ministries of health must keep adapting as

externally funded programs, layered over their own local

health services, come and go. The doctor or administra-

tor who negotiated the original technology transfer

may have received a fellowship for overseas study, or

may have been transferred to another facility or program

in which they are busy ordering something else. The

technician who took a course in implementing the pro-

cedures may for one reason or another be assigned else-

where. In any case, when donor funds are gone there

may not be sufficient foreign exchange to buy reagents

or film or insecticide spray nozzles or whatever is

needed to apply the technology as originally intended. The foregoing is an argument in favor of restraint and

discipline in the acceptance of complex devices and pro-

cedures, and not against the adoption of useful tech- nology, which does indeed exist. For example, in the

Fayyoum Oasis in Egypt, small ultrasound diagnostic

machines, powered by portable generators, are used to

measure the extent of periportal fibrosis and renal im- pairment in local inhabitants. This instantaneous non-

invasive evaluation of schistosomal pathology could have been obtained in no other way except by laparo- tomy, which is clearly not a reasonable option. The Egyptian investigators were absolutely correct in select- ing and applying this advanced technology, whose appropriateness is quite distinct from its complexity.”

In practice, it appears that imported medical technol- ogy in most developing countries comes through several routes, generally without control or supervision by any agency of the receiving government. One major channel is through internationally oriented individuals in the

Technology transfer to the developing world 357

private sector. Often wealthier physicians, either indi-

vidually, in small group practices, or in private hospitals,

have the resources to import materials and equipment

and to maintain these investments in good working

order. Their clients are willing and able to pay for the

services received, and the entire process of the private

importation and application of technology is buffered

from most public-sector bureaucratic impediments.

The influence of commercial companies, particularly

the pharmaceutical industry, is pervasive in most

developing countries. In addition to various perks and

giveaways for professionals, these firms sponsor short

courses, conferences, dinners, and seminars, for which

they distribute posters and programs displaying com-

pany and product names. Calendars and informational

placards featuring corporate logos and drug trade-names

may be the sole adornments on the walls of Health

Ministry offices and health centers. In such an environ-

ment. the introduction and distribution of new pro-

ducts and technologies is regulated only by corporate

initiative.

Another pathway through which biomedical technol-

ogy is introduced is through universities and research institutes, whose academic staffs are in professional con-

tact with colleagues in industrialized countries. These

individuals may attend international conferences, parti-

cipate as visiting scholars, send students, or otherwise

become a part of the worldwide biomedical network.

Third World academicians should not lose themselves

in the attractions of sophisticated methodologies, but

should always think about useful practical applications

within their own countries.

The costs and benefits of importing technology

Government ministries, such as finance, planning and health, will look at the adoption of a new technology (or

any new program, for that matter) primarily in terms of

its costs and its political implications. Technology trans-

fer carries many different kinds of costs, both monetary

and non-monetary.’ Assuming that beneficial and cost-

effective technologies exist, how can these be identified

and designated for transfer?

A clear financial benefit from applied technology may

be relatively simple to estimate. A vaccine that reduces a 3-dose immunization series to a single dose with equal

efficacy, or that does not require a cold chain, or that induces 15% more protection, increases the productivity

of health services. However, the value of the increased

productivity must be at least equal to the marginal cost

of the additional technology, or else there must be some

ancillary benefits, such as those listed on Table 2, to make adoption of the technology worthwhile.

In most cases, however, it is difficult or impossible to

measure the increment in health bought by an increased expenditure. or to allocate scarce funds on a purely rational basis free of political or other bias. How does one compare the amount of health, or quality of life,

bought by a tuberculosis control program with an equal

investment in a new primary health care center? Many

measures have been suggested, such as Years of Poten- tial Life Lost (YPLL) from a specified cause, or Quality

Adjusted Life-Years (QALY) gained from a particular intervention. The interpretation of these indicators

remains more in the realms of art and politics than in

the province of science.

ADDITIONAL CONSIDERATIONS

Intellectual property and the sometimes reluctant provider

The complete transfer of a practical and functional tech-

nology involves know-how, adaptation to local condi-

tions, and, ultimately, manufacturing capacity. To the

extent that patent protection is given to processes or

products, control of intellectual property becomes a

significant factor in enhancing or blocking transfer.

Patent laws vary greatly, and in some countries entire

categories of innovations, particularly pharmaceuticals.

biologicals including hormones and vaccines, and diag-

nostic reagents, which are considered to be for ‘the

general good’ of the people, are not patentable. Living

organisms including those modified by recombinant

DNA technology, are sometimes placed in the same

category.

Although it is generally believed that technology

transfer is greatly desired by the sending country or

company, there are cases in which the originator works

vigorously to prevent unauthorized adoption of its

processes or products by another country with more

lenient laws. Powerful trade and manufacturers’ associa-

tions in industrialized countries are angered when phar-

maceutical companies in developing countries legally

produce drugs for their local market (or even for export)

that are protected by patent laws elsewhere. More omi-

nously, the outright piracy of processes and products

within developing countries may be followed by puni-

tive retaliatory measures such as trade sanctions that

may affect the entire economy.

If local companies are free to duplicate or imitate

products, if sales prices are rigidly controlled. and if the

expectation of profits is poor or non-existent, it is not

surprising that foreign companies are reluctant to enter

a market. In such an event. the health technology policy of the potential importing country will be irrelevant

because those technologies will never be made available.

Ethical issues in technology transfer

Numerous ethical considerations could be invoked, especially the protection of human subjects in clinical trials of technologic tools, especially vaccines and drugs, among marginally literate populations.” The adoption of a vertical program, e.g. for childhood immunization, or control of tuberculosis, brings with it many associated

358 Tubercle and Lung Disease

preventive, diagnostic, and therapeutic measures. Poorer

countries may need to consider carefully their competing

obligations when signing on to complex and costly

programs.

Policies for technology transfer may support collec-

tive (community) priorities, while giving less considera-

tion to the rights of individuals. For example, newborns

are not consulted when they are given BCG immuniza-

tions; and non-volunteer individuals who are identified

as carriers of Mycohacterium tuberculosis, or who have

open infections, may have little choice in accepting or

refusing medication. People are presumed willing to

accept the risk (however small) of serious adverse effects

in the expectation of a larger benefit for themselves and

for their community, even though this is not always the

case.

References

Office of Technology Assessment. Assessing the efficacy and safety of medical technologies. Publication no. OTA-H-75, Washington DC, 1978. Basch P F. Technology transfer and the delivery of health care. In: Science policy in developing countries: the case of Mexico. Mexico City: Fondo de Cultura Economico y Universidad National Autonomo de Mexico 1993: pp 79-91. Nelson G. Opening remarks. Parasitology 1986; 92 (Suppl): s3-s5. Abdel-Wahab M F, Esmat Cl, Narooz S I, et al. Sonographic studies of school children in a village endemic for Schisfosoma munsoni. Trans R Sot Trop Med Hyg 1990; 84: 69-73. Banta D. Andreasen P B. The political dimension in health care technology assessment programs. Int J Technol Assess Health Care 1990; 6: 115-123. Bankowski Z. Bryant J H, Last J M (eds). Ethics and epidemiology: international guidelines. Geneva, Switzerland. Council for International Organizations of Medical Sciences (CIOMS) 1991: 163 + 28 p.