Solving Rural US Health Care Challenges With Frugal Innovation: Low-Costs, High Returns

With the successful bipartisan passing of the Infrastructure Investment and Jobs Act in November 2021, there is renewed national interest in building sustainable health infrastructure. However, despite these exciting opportunities, rural America has historically been left behind with these developments. Aging health infrastructure, limited access to broadband internet, relative physical isolation from commercial and government services, and less influence on policy changes given the smaller populations are common themes that pose challenges to effective care provision, particularly during the current COVID-19 pandemic. These challenges, however, are not unique to the US and are a well-documented phenomenon in lower- and middle-income countries (LMICs). LMICs have sought to tackle similar concerns through novel “frugal” innovations that may also be applicable in the rural US context. In this Forefront article, we seek to describe challenges in care provision in rural health, investigate examples of frugal innovations in LMICs that could work in the current rural American context, and explore opportunities to encourage the adoption of these innovations.

Rural Health Care Faces Numerous Challenges

US and many LMICs’ rural populations are well-documented to have a lower life expectancy and worse health outcomes compared to their urban counterparts. Education, race, and rurality are strong predictors of mortality risk in these populations. Additionally, rural populations often have older patient populations, higher rates of substance use and mental health conditions, and a greater burden of chronic disease.

In addition to worsening health outcomes, rural health infrastructure has been steadily depleted. Since 2011, there have been more hospital closures than hospital openings in the US. About two-thirds of hospital closures have been in rural areas, where financial challenges pose significant risks to long-term operational viability. Decreasing patient populations and limited public financing support for low-income populations’ care are two possible causes for the closures. Furthermore, since 2013, one-third of all closed US hospitals were more than 20 miles from another hospital, potentially worsening outcomes for patients requiring urgent treatment in the areas of closure. Additionally, fewer urgent care centers and more resource-constrained first responder teams mean that rural patients with urgent time-sensitive health conditions may be at higher risk for mortality. These issues have intensified under COVID-19, and methods to mitigate financial difficulties of rural hospitals are increasingly prevalent, including new adaptations of payer models such as global budgets. The US Department of Health and Human Services has committed more than $1 billion to rural health clinics and hospitals to support COVID-19 testing, vaccination rollout, and resources for inpatient care. Despite this investment, rural populations continue to be significantly affected by COVID-19 infections and mortality. Recent studies have shown that rural US populations with COVID-19 infection have proportionally higher rates of hospitalization and mortality compared to urban populations.  

Logistical challenges to care provision also warrant deeper examination. Limited access to public or private transportation systems affects patients’ abilities to attend clinic appointments, access testing, or receive vaccinations. Many rural populations also have limited internet broadband connectivity, impairing government and health care agencies from providing important information to these groups about COVID-19 pandemic updates, infection prevention, and vaccine education. Poor internet access has also limited the successful adoption of telehealth in rural America.

Opportunities For Rural America Points Toward Frugal Innovation

Despite these challenges, many LMICs have advanced approaches to address similar issues through frugal innovation. Frugal innovations aim to “do more with less” and are economically sustainable solutions generally found in areas with limited public- and private-sector capital. In a June 2021 Time health commentary, the authors identified several COVID-19 innovations that have vastly changed and improved health care processes and health care delivery. The COVID-19 pandemic brought about the rise of telehealth, which has improved patients’ access to care, decreased patient and provider exposure to disease, and preserved limited supplies of personal protective equipment (PPE). Despite these advances, rural patient populations’ poor broadband access and internet connectivity has limited telehealth’s influence in these areas.

Within LMICs, access to health care also has been increasingly limited by the lack of clinics, hospitals, health providers, and medical supplies. At a baseline level, these countries do not have enough providers to provide adequate care to their whole population, and the COVID-19 pandemic has further exposed this gap in care. These barriers have been counteracted by efforts to repurpose community sites as health care access points and to produce medical supplies locally. Furthermore, the use of community health workers (CHWs) in LMIC rural areas has resulted in better dissemination of pandemic information; improved patient education about COVID-19 and COVID-19 vaccines; and enhanced prenatal and primary care in rural, underserved areas where soft infrastructure such as community clinics, public health organizations, and integrated health systems are also in short supply. In these examples, the frugal nature of such innovations, CHWs, and repurposed health access points, does not indicate low quality, but rather improved care approaches under situational constraints.

The current pandemic provides several areas that these innovations could be optimized in rural settings in the US. The first is the distribution of materials such as PPE, testing kits, medications, and even traditional medical services (for example, telehealth). The second is access to information including local, state, and national updates on COVID-19 guidelines and disease reports. Lastly, there is an opportunity to track and help prevent the spread of disease (that is, contact tracing). Since many rural counties have limited resources, solutions that can be integrated within existing services and community members could be game changing. To understand how these frugal innovations can apply, we will examine several case studies of existing solutions in LMICs that may be translatable to rural America.

Case Studies Of Potentially Useful Innovations

Case No. 1—Zipline

One predominant issue COVID-19 has brought to light is the access of vulnerable populations to essential resources (for example, medications) while limiting risk of disease spread. Zipline is addressing this issue through designing drone-based dispensary systems for critical health supplies. Begun in 2016, the company now distributes 65 percent of Rwanda’s blood supply outside of the country’s capital and has expanded its services to more than 2,000 facilities in Ghana as of April 2019. During COVID-19, Zipline has distributed 2.6 million COVID-19 vaccine doses throughout Ghana. Early in the pandemic, Zipline partnered with Novant Health in North Carolina to perform 32-mile flights from a distribution center in Kannapolis to Novant’s Huntersville Medical Center to distribute PPE—gowns and gloves—to frontline health care workers. UPS, Verizon, and a drone company called Skyward are also piloting similar, shorter-range drone programs to facilitate prescription distribution to a Florida retirement community.

There are several advantages to using drones. First, they potentially offer a cheaper distribution alternative to rural areas without existing cost-effective transportation infrastructure. Second, drones may be more reliable and faster than conventional modes of transportation. Thirdly, there are many stakeholders who could use drones to distribute highly disparate items. Pharmacies, for example, could distribute medications while hospitals could transport organs for organ donations, as done by the University of Maryland Medical Center in 2019.

However, there are some significant disadvantages to this approach. Drones are a heavily regulated industry and have received regulatory pushback in recent years for commercial use due to safety and security concerns. Zipline has been able to mitigate this issue by working closely with the Federal Aviation Administration and the North Carolina Department of Transportation while developing their solutions.

Case No. 2—Community Health Workers

CHWs are not a new phenomenon in LMIC rural and urban health communities, yet their importance has been reintroduced during the COVID-19 pandemic. CHWs are trained health care providers who are engaged in communities and neighborhoods to deliver public health information, educate citizens about health issues, especially prevention, and connect citizens with health resources they might otherwise not have access to, due to health illiteracy or lack of internet or smartphone access. In some countries, they can also treat common illnesses and make referrals to higher-level facilities with more skilled providers for treating serious illness. Historically, CHWs have been successful in improving the understanding and care of chronic medical conditions, as well as providing care for common childhood illnesses in low-resource countries. In sub-Saharan Africa, Last Mile Health works to design community-based primary health systems that train CHWs and primary care providers alongside one another to link community-based and professional health care providers together.

During the COVID-19 pandemic, CHWs’ responsibilities have expanded and taken on even greater importance as they help immigrant and rural populations navigate the pandemic by providing education resources, medical supplies, and information to help dispel cultural and societal misconceptions about the COVID-19 virus and vaccines. In Indiana, North Carolina, and Texas, local and state governments have invested funding into CHW training programs and seen the positive effects of CHW interventions in rural communities. Along with their health education roles, CHWs have helped advocate and expose the structural vulnerabilities of rural health systems and the populations they serve. In remote areas that have limited access to health care providers, internet access, or public transportation, CHWs can combat all those barriers by bringing care into their communities at a fraction of the cost of a rural hospital or health system. In some cases, people in these communities would not receive any medical care without the work of CHWs.

Case No. 3—Dimagi

During the early days of the pandemic, contact tracing of COVID-19 cases and patient data were disorganized and fragmented across multiple data platforms. Dimagi is a mobile data collection company founded to assist countries and organizations in low-resource settings with data management and accessibility. Its CommCare application works as an online and offline available data platform that uses already developed or newly created programs to store, manage, and track data for diverse types of health initiatives. During the pandemic, Dimagi has worked in Mali, Togo, Sierra Leone, and other low-resource countries, introducing its CommCare platform to help develop mobile app data collection tools to assist with COVID-19 case and contact tracing, workplace symptom screening tools, lab testing results, and vaccination numbers.

In rural US areas that lack hospitals and providers, Dimagi applications could be used by CHWs to track patient cases, organize COVID-19 lab testing protocols, and coordinate community vaccination programs like it has done in rural Africa. Dimagi’s data collection application is advantageous because it has a user-friendly format that is easy to learn; it can be used in an offline format, and it can be edited and tailored to the needs and specifications of the organization or community that it is serving (that is, contact tracing, vaccine rollout, patient symptoms).

In the US, small case studies have been conducted with the San Francisco Public Health Department and the Centers for Disease Control and Prevention to aid in contact tracing efforts in California. Further large-scale implementation of Dimagi data collection would require data protection approval from Health Insurance Portability and Accountability Act regulations—that might increase operational and liability costs.  

Assessing Opportunities For Innovation Development

COVID-19 has exposed structural challenges in rural American health care: namely the inequalities of access, underinvestment in national and local public health programs, uncontrolled system costs, and a greater burden of costs borne by individuals and families. Frugal innovations can shape the future of this landscape by addressing several of these challenges at minimal costs to the system’s institutions and citizens.

Key similarities exist between rural US communities and LMIC populations that may allow this type of innovation to flourish. These qualities include deeply rooted social fabrics, less administrative restrictions, tight-knit relationships between families and local civic and religious leaders, and locals’ experience identifying and solving problems with limited resources. These LMIC case studies address issues parallel to those facing rural American communities: limited access to medical supplies and their supply chains (for example, Zipline), lack of primary care physicians and clinics (for example, CHWs), and underinvestment in public health services and data collection (for example, Dimagi).

Policy makers and organizational leaders can abide by several tenets to successfully implement frugal innovations:

These tenets are already being applied in diverse, international contexts. In June 2020, the United Nations Industrial Development Organization began a global call to promote “Innovative Ideas and Technologies vs. COVID-19 and beyond.” Fortunately, the potential for similar applications in the US has not gone unnoticed. The Robert Wood Johnson Foundation and the Commonwealth Fund are both studying and investing in innovators to adapt successful international approaches for application in the US.

Although this pandemic has tested our health systems, these challenging times also present opportunities for frugal innovation in rural health care to better serve patients no matter how resource limited or physically distant they might be.

Authors’ Note

Dr. Silimperi works closely with Innovations in Healthcare, a nonprofit organization affiliated with Duke’s Global Health Innovation Center, which she is also affiliated with. Both of these organizations support health care innovators globally, including Dimagi.

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