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uh, last speaker, which is Professor JD, probably who's the director of the Center for India and Global Business at the Judge Business Business School at the University of Cambridge. And he's also a professor of marketing and the visual Nehru professor of Indian Business and Enterprise. He's on the editorial board of a number of leading journals, and his co authored a number of books on frugal innovation and was, additionally the winner of the CME I Management 2016. Book of the, uh, professor problem is going to talk on how to do more and better with less, Thank you very much. Hello, everyone. It's a great pleasure to be with you at this conference. Uh, I'm here to talk about frugal innovation and healthcare, how to do more and better with less. I've spent my career studying innovation, and in the first part of my career I studied innovation in large Western corporations because the understanding was that's where innovation happens. And then about 15 years or so ago, I turned my attention to emerging economies like India where I've grown up, and when I went to India to study how innovation happened there, I was surprised to find. The approach was very different from the Western corporate approach. First, the innovators there were very frugal. They were very good at doing more with limited resources. Second, the mindset was very flexible. There was a lot of improvisation and lateral thinking, and third, a lot of their solutions seemed designed to bring people who were outside the formal economy into the formal economy. Let me give you some examples of what I'm talking about. So here, by way of contrast, is an innovation that we might expect to see in an affluent society. This is a high end fridge that will talk to you, and you can talk back to you by the established PC, and for that pleasure you pay about $3000. Now it's a bit of a caricature, but you often see this with large cuff companies. They have big budgets, big teams pushing the technology frontier. For the sake of doing that, when they come up with something new, they put it into their products to differentiate them, and then because the process is expensive, they charge for it. Now you may see something like this in a country like India, but you're equally likely to see something like this. So the expensive fridge is $3000. This clay fridge is less than $30. It just uses the cooling properties of water in the reservoir at the top, not only to keep the water cool, but also to keep fruit and vegetables fresh for up to five days in a hot, dry climate. It's very frugal. I'll tell you more about the innovator in a moment. His mindset is very flexible, and his intentions are to be inclusive. Now here's another example. This is an incubator, beautiful machine with all the bells and whistles from a company like G. But it's about $25,000 and at that price, it's beyond the reach of most clinics in rural areas in countries like India. Even if somebody gave them these, uh, for free charity, they may not have a technician there to maintain them, and they may not have access to regular electricity. In a situation like that, something like this is very powerful. So the incubators $25,000. This baby warmer is less than $100 now. Obviously, the baby warmer doesn't have, uh, an oxygen tent like the incubator, but it is designed to address a large part of the problem that the incubator is addressing, namely the problem of infant mortality. Where if infants are born one or two weeks prematurely, they may not be able to maintain their body temperature. Some cases they may die. Other cases they may be very badly affected. This baby warmer will save them. And importantly, this baby warmer was not developed by a large company. It was developed by four students at Stanford who took a course called Designed for Extreme Affordability, where the entire objective of the course was to come up with a working prototype that is, 100 the cost of the existing solution. The students could take any problem. This particular group chose this problem of infant mortality. They came up with this for their course after they graduated from Stanford. They went on to test it with mothers and midwives in rural Nepal and India. They got venture capital backing from Stanford. They tested it in the medical hospital, and then at that point they hit a wall because they didn't have a sales force to really commercialize this, so they then partnered with GI Healthcare and GS Salesforce help them to take it to clinics. Now my quarters and I, we looked at scores of such innovations, not only in India but in many other parts of Asia and Africa, in Latin America and in India. When we ask people how they were described as frugal, flexible and inclusive approach, they often use this Hindi word to guard. So my quarters and I then wrote a book book, which we call the guard innovation, which we defined as the art of overcoming harsh constraints by improvising an effective solution not a perfect solution, but a good enough solution and importantly, one that made the best use of the limited resources available in that context. And after we published this book, lots of people from other parts of the world wrote to tell us that they had something like this in their country. The Brazilians told us they had two words to describe a similar phenomenon, and you see this not only in emerging markets but also in the West. What we did in this book was to look at lots of examples of such innovators and then identify some principles that we thought were guiding them. And here are the six we identify first. As I said, they're very good at doing more with less. They look at the resources they have and use those to substitute for resources they don't have. They keep their solution simple. This helps them to economize, but it also enables easy, adopt adoption and maintenance of the solution. Third, there's a lot of lateral thinking and improvisation. The idea is, if you cannot climb the mountain, try and find a way around it both. They're inspired by adversity. Indeed, for them, necessity is literally the mother of invention. They often include marginal people not only as beneficiaries or customers, but also as part of the solution. And finally, these people are very passionate about what they're doing. And they have to be because what they're doing is often very difficult, requires perseverance and persistence. So in our book we talk. We tell the stories of several of these people, and I'll start with month's supply. The person behind the clay fridge he comes from a village in the Indian state of Gujarat. He has a high school education. He comes from a family of potters in too 1001. There was a very serious earthquake in his state, and a lot of people lost their household positions, including the clay pots in which they traditionally store water. And one morning, he said, he opened the local newspaper and there was a picture of someone's clay pot that was broken and the caption red kind of satirically poor man's fridge broken. But he thought about it and said, Why don't I make a poor man's fridge and you see the design in front of you? Uh, he set up a factory in his village. He trained local women to make these bridges, and he went on to sell them, including on the Internet. In many ways, he embodies those six principles of doing more with less using resources, he had to solve this problem. Keeping the solution is simple. Lot of lateral thinking was inspired by the adversity of the earthquake to come up with a solution. He includes marginal people from villages who like to buy fridges and can only afford the old ones like this, but also by employing local women. He creates also local employment and finally you can see him on the Internet talking about his various inventions, You can see how passionate he is. Now here's a different sort of frugal innovator one you might be able to relate to. This is Dr Be from South India, who in 1976 dedicated the rest of his life, too, eradicating this problem of cataract, which a lot of people not only in India, suffered from and could not afford the simple surgery to address. So he ended up setting up a very large chain of these husband spoke clinics and hospitals to try and address this problem by actually using economies of scale. The repeatability reduced cost, and they have done very large numbers of these surgeries. Some of them are entirely free. Others are very low cost. What they have our hospitals, where there are some wards that people pay more for because they have air conditioning, others are cheaper. But doctors rotate between these awards qualities get constant. They have, uh, they meet the international norm in terms of infection rates, and they even set up a factory to manufacture the lens is to reduce the cost of importing them. Another surgeon who has adopted these approaches of the economy of economies of scale and repeatability. Doctor David Shetty was a cardiac surgeon, was trained in Guys Hospital in London. He went back and tried to address the problem of cardiac surgery, which was too expensive for most people to afford. And again, he has a very large hospital with over 1000 beds in Bangalore. They do a large number of operations every day of the year, and in that way they are able to reduce the cost quite significantly, to about $1500. They're hoping to reduce it even further. And the final example of Medic who has done this kind of a frugal innovation is Dr Visual Row, who met a person who just had throat cancer and an operation couldn't speak. And so he came up with this artificial voice box, working with toymakers to come up with a prototype. And this artificial voice box is about a dollar to make himself. Now I've given you examples of lots of these kinds of frugal innovations in countries like India in emerging markets in development economies, and that book that we wrote about it came out in 2012. After it came out, we realized there was a lot of interest in this very same phenomenon in the West for the West. So we started to look at that and we realized that in the West this phenomenon was driven by a group of consumers that we called pro Sumers because these people are more actively involved in the socioeconomic process. And they seem to be driving three movements that underpin a frugal economy one the the sharing economy, which is where people like you and me can now trade spare as sets with each other directly on some digital platforms. If you think about Airbnb, that's a good example. Second, the maker movement where now small teams, sometimes of our own students, can do things that only large companies or the government could have done 10 or 20 years ago, and not only in software but increasingly in hardware as well. And finally, the circular economy, where we're moving away from the linear production and consumption system of the 20th century, where companies would take resources from nature, make products and services that they would sell to us that we would then use and dump back in nature. That process is wasteful and not sustainable. We are now moving to a system where we reduce we use and recycle all the resources that go into the products and services that we consume and produce. Let me talk about the sharing. Actually, let me talk about the make a movement. I'll give you an example of a physics professor at Stanford, Manu Prakash, who's been very interested in this idea of frugal innovation. He first came up with this origami microscope that was about a dollar, which is very light and which you can combine with a smartphone to take. To take magnified pictures can be used in healthcare. And then he went one step further. Inspired by the Children's toy, the whirligig, he came up with a hand powered blood centrifuge that can be used to do bloods in remote areas where you don't have a full lab. And his lab at Stanford is pursuing this approach to frugal innovation in a number of different areas. Now we are we carry around in our pockets. He's very sophisticated and network computers. This company, spun out of UC Berkeley in California called Cell Scope, has made a whole suite of medical devices that plug into the audio, jack up the phone and leverage. It's computing power, and it's connectivity. So here's an auto scope that a mother can use to take high resolution pictures of the inner year of her daughter when she has an infection and send them to a consultant to somewhere else. This device is a fraction of the cost of the standalone device, and, of course, it enables telemedicine. This is a three D printer less than $200 and it's within striking distance or some households. But if you cannot afford it in your home, you can always go to space is like this, which are called tech shops or make spaces or fab labs, where you can get access to a workshop full of all kinds of tools. Traditional tools like lids are also digital manufacturing tools like three D printers, laser cutters, circuit board printers and so on. But most importantly, you get access to a community of like minded tinkerers. You can bounce your ideas off and get inspiration from those students that stand for that I told you about. They had to come up with a working prototype for their course, so they went to the neighboring text shop in Palo Alto, and they were tinkering there. They had this idea of a blanket that the mother could use to swallow the baby, but they knew that that was not enough. You need something that would keep temperature fixed for a period of time, and they didn't know how to do that until they met someone at the tech shop who happened to be a former NASA scientists. And he told them about these face changed materials. Waxy substance is that you can put in a pad and heat with electricity or with hot water, and that will keep the temperature fixed. This is a key component without this device will not work. That's Jane Chen, one of the four students with a fan who used to live in the White House. And when he lived in the White House, he actually celebrated and champion this approach by hosting a make a fair Uh, and the idea was that this isn't just do it yourself hobby. This could be a new form of manufacturing that would revolutionize and revitalize American cities. So we wrote a followup book about this phenomenon, which came out in 2015. And it was all about how large companies in the West were adopting this approach. Now I want to end with some examples of how frugal innovation has sort of accelerated during coated. The first example is from northern Italy in a place called breast cancer, which was one of the first places to really face a massive, uh, sort of problem with povid. And they ran out of a key component in some of their equipment, this particular valve that they needed for their some of their CPAP device. And so they ended up three D, printing them locally with the help of a local maker, space. Then they realized that they had a shortage of the CPAP devices themselves. And so they worked with the Catalan to Remodify to modify scuba diving equipment. And again they used local maker space and three D printers to help them to make several of these devices. In India, a collective of make a space is called, um 19 shared designs and how to do a ppd for frontline staff and made about a million of these units in about a month, which they could then deliver to local frontline police and nurses. And then, in the second wave, when India had a shortage of oxygen concentrators the same collective of over 100 labs around the country made locally an open source oxygen concentrator using these similar principles. So let me conclude by saying that based on my work across over the last 10 years or so, I really believe that the world needs this kind of frugal, flexible and inclusive innovation. I believe the West can benefit from engaging with emerging economies and vice versa, and that large and small can work together to improve lives everywhere. Thank you. Thank you so much. Doctor Prabhu, um, absolutely blown away with all the frugal innovations and want to have a look at that book. So thank you so much. Um, one question from Jamal Ross. He said, Thank you. Very interesting presentation. To what extent does the job guard approach to innovation incorporate prototyping? Is it common to manufacture many iterations? Or do these innovators spend more time in the design phase before producing a prototype? So that question is a really good question, actually, even before they get into coming up with a solution, Um, a lot of time is spent trying to understand the problem. The best frugal innovators actually really immersed themselves in the problem that they're trying to solve from the perspective of the people who are facing the problem and also in the context in which they're facing the problem. Only when they really understood the problem and the context do they then move to the next phase of trying to come up to the solution. And they might try to use existing resources, as I've said, uh, including ubiquitous technologies that may be available in that context. And only then do they come up with a kind of prototypes solution. So that guard approach, I think, is particularly well suited to that fuzzy front end of innovation when you're trying to and in a problem, come up with an affordable solution that you can at least prove as a concept. If it's a software, then a beta version, if it's hardware, then a device that works, Um, I think it's only once you've done that, that you then move on to really trying to scale Uh, and that's when you perhaps need more formal approaches to innovation. So you got is particularly important at the fuzzy front end of innovation. It helps you to come up with a prototype solution, test it and then prove the concept before you can take it to scale. Thank you very much. We've got some questions for Jenny Dunkleman. Now, Jenny, if you can hear us, the first question would like to ask is what sort of materials are you experimenting with to mimic tissues or to make phantoms? Uh, yeah, sorry about that. What sort of materials are you experimenting with to mimic tissues or to make phantoms like in the V V f repair model? Uh, making defensive the variation looking, uh, all kinds of different materials and have mixed of materials. And that's, uh, PVA is one of the materials that we use think, use and also silicon, uh, and also, uh, use a lot of, uh, different concentrations, an additive. So if you are interested in, I'm willing to give you information about that because it's, uh, especially the combination of material is really critical in having the right flexibility and also the When you shoot it, for example, it's too not, uh, of course, it should make the tissue properties if if you should do is to detention is too hard. You should keep a whole, like, normal tissue. And that's we had a really tough, uh, to find the solutions, but I think we managed to get really close. But if you're interested, So please let me know. I can, uh, fight you with the, uh, results. And because we're still in the process of making the article, it's not published yet, so we work on that. Thank you. The second question that came in was, how close are we to getting a reusable ligasure type device for low middle income countries? So for anyone that doesn't use ligasure or, um, some kind of thermal coagulation device, um, you were mentioning about the, you know, the sort of minimal access surgery, uh, instruments that you were making, um, and using, you know, the two a shaft system to allow the product to be reusable. And I think John Dalton was asking, Have we got a reusable ligasure type device? Uh, I think the question was about if the laparoscopic instruments was terrible. Uh, tip is already available for lower. Uh, we are still at this moment. We are in the certification process because we only want to sell them. Also, two l m r. C. When they are really going through the whole certification process. Uh, at this moment, we are in the pre clinical test. Uh, so we did a lot of studies, and, uh, the first patient tests are now planned. Uh, the whole, uh you probably know that the mg are the medical device. Regulations are rather tough. So we are now in that process to make the technical file and everything already And then if it's, uh done, then we will so make it available for low income countries. Because that's where I think the real benefits are. The high income countries focus a lot of robotic surgery. Um, that is, of course, not an affordable solution. We think we can get the added value of this this added risk in the in the instruments also, uh, more, much more affordable way. In the end, it's also my previous the previous speaker. Uh, in the end, we also expect that the high income countries are interesting in the solution because also for them is much more affordable than the what solutions. But we focus on trying to make it, uh, available for Laurie success, especially because it's reusable. You want to do it in combination with this, uh, cleaning a civilization device. Thank you very much. And we've got some questions for Katie now. Sorry, Katie. There's so many questions, So we're just going to limit them to just a few. So could you tell us? About what reasons did surgeons give for opting out of the green equipment? Um, and how can we tackle these concerns? Yeah, well, thanks for all the questions. Festival. Hopefully, that means that there's lots of people thinking about what they want to do. Um, so most of the reasons why the surgeons were concerned that they were going to have to open and convert to an open operation, which the tray is not set up for that is just set up for a laparoscopic procedure. So, um, I don't actually have the data on the number of cases that were eventually opened, but that's certainly something that we should look into. Um, I know, I know. Just anecdotally. I was in one where we decided not to go for the green surgery or the green pathway because we didn't think we were probably going to have to do right Hemi on this patient. And we did. We did open in the end, so that was a right call made by the senior surgeon at the time. Um, that tends to be the main reason. The other reason that we don't use the pathway which isn't necessarily the surgeons choice, is just we might not have an availability of the trade because we only have eight at the moment and just leading on along the green appendicectomy pathway any any chance of national adoption of your amazing pathway? Oh, I'd love that. I think that would be amazing. Um, so actually, the each hospital faces its own challenges. So it's really easy to say, Well, this works in my hospital, so this should work somewhere else. And that's not always the case because everybody knows that every hospital works differently. We are actually working with hs England at the moment on a pilot scheme. So leads is hopefully going to become a pilot scheme for this project, and we're looking at them scaling that into a smaller d g h to see if these if this is scalable and so maybe national is on the cards eventually. Brilliant. Thank you. Um, sort of a difficult question from John Dalton. Uh, is reusable always more sustainable? Big topic. But what if the alternative is more expensive? So yeah, One issue we have in our greenery is trying to convince people to use plastic speculums instead of metal speculum. Because there's such a device is used very often on day to day clinics. Um, so it's not just surgery. I suppose it's in clinics as well. But this kind of theme, yes. So, um, that's a really good question. And the answer is often, Well, not often, but the answer can be know. Sometimes reasonable isn't better. And that's where your process mapping and your carbon calculations come in and are really important. So reusable is usually better because you have a longer life cycle for that equipment. But it depends where that equipment is being sterilised. The process is being used to sterilize it. And, you know, you've got to think about the transport costs as well. Um, I heard a really interesting talk where they actually realized that disposable cystoscopes are actually more environmentally friendly than reasonable, which blew my mind to be honest, but, um but yeah, so it's not always and that's where your process mapping you're planning and your carb and calculations come in. You know, if you if you realise, actually, this is worse for the environment, then you don't do it. Um, in two. And what was the next bit? Yeah. So, um, so again, you know, everybody thinks plastics potentially the worst thing that you could use versus metal and reasonable. But it's all about figuring out that piece of equipment. Some supply companies are actually really good. Now, uh, they've realized that places don't stand for, um just, you know, producing equipment and not thinking about the life cycle of the product and not thinking about the carbon footprint of that product. So some companies and some supply companies are quite open with their life cycle calculations, and they've done them on certain products. So you can often directly compare two products from each other. And that's really, really useful. And I hope more companies do that, Um, that you have to think Well, sometimes incineration, we think is is potentially the worst thing but actually say in our trust, um, the the incineration is offset because it's used to make energy. So when it's burned, it's actually, um, it's actually used to then produce electricity. So, um, some of our incineration is actually not necessarily as bad as as burial. We do have one more question for you, Katie, if you don't mind. I suppose it's about planning and process is at what point do you involve stakeholders like the procurement team. I suppose once you've got your idea up and running, you've got your senior involvement. Is at the stage that you start involving them early or what did you experience? Yes. So I think, uh, you have to. It's obviously dependent on your idea. If your idea is to take a process away, you know, for example, reducing the need for group and saves. You don't really need to involve your procurement team because you're not Actually you're not trying to add anything and you're trying to take away, so they're not really involved in that process. It depends what you're doing. Um, with we had quite a lot of backing because of the green surgery challenge. So there was quite a lot of onus on us and on the trust to actually make these changes. So we started off on a good foot because people said, Oh, we actually have to do something now. Um, and we had a team from the theater team actually involved in the project. So they came with us to the cadaver lab and they did the whole, um, the whole process with us, and that really sparked their interest. So I suppose we only really involved in the wider team at that stage. Um, procurement team came into it when we started to actually trying to implement this in person. But I would say the sooner you speak to them and the sooner you involve them, the better because they'll be able to tell you whether it's possible. There's no point doing a whole lot of work. And then you meet the procurement team quite late on, and they say this just isn't possible in the trust. And then your ideas gone so earlier the better. Thank you very much. Thank you to all our speaker's from the session. Absolutely phenomenal talks. And they've given us all a lot to think about and take that to our interests, I hope. Thank you.