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Good afternoon. Good morning. Good evening everyone. Thank you so much for tune ing in to the Frugal Innovation Skills course. This is module one. Um And it's an absolute pleasure to welcome you all to this event. Um We have a number of people watching live from around the world, which is great to see. And if you're watching this uh in your own time after the fact, then that's great. I'm glad that you've been able to use um this, this feature, this playback feature for you to access training, sort of whenever you can whenever you want to best suits your busy schedules because we all know how busy you are as innovators and surgeons and clinicians um around the world. So today our module is going to cover a range of introductory topics to frugal innovation. And we've got amazing co chairs here. We've got Noel and Anurag who will introduce themselves shortly when they give their talks. And then we also have two guest speakers lined up for you a bit later on this afternoon. So, uh I'm absolutely super excited to see um what they're going to say. And I think you will hopefully take a lot away from, from this and in learning about how to innovate frugally to benefit your own uh careers, your own training. And indeed, um the the outcomes for patient's in low resource settings. So I'm just gonna start my presentation now. Um If you do have any questions in the uh for any of the speakers that are lined up, please do just use the chat function, the chat box uh to the to the right of the screen. Um And I'll do my best to record them and put them to the relevant speakers as we go. Um But yeah, just to make sure that we stick to time, I'm going to make a start. So the presentation that I'm going to give is all around the court frugal innovation skills that I think you will hopefully find beneficial when you're doing frugal innovation projects and developing technologies for low resource environments wherever they may be. Um And I am the Director of Frugal Innovation at the Global Ideal Project which looks at evaluating novel technologies in a frugal way. And I'm a past Presidente of Gas sock and the Gas Akar the, as you know, um I hope by now uh the coordinators of this, this uh this frugal innovation skills course. Um And our contact information is just there at the bottom of the screen. So do feel free to reach out anytime through socials or our website. So some of the learning outcomes from the, the short talk that I'm going to give you. Now, I hope and also uh with input from the rest of the speakers that we've got for you this afternoon. Um At the end of the this module, I want you to be able to define frugal innovation um And um describe some of the innovation principles that make, you know, frugal technologies and frugal solutions in healthcare. I also want you to understand, begin to understand some of the unmet needs in healthcare technologies and how potentially frugal innovation practices may help overcome these. I don't want you to be able to describe the core skills to deliver frugal innovations. And as you move through the rest of the course, you'll begin to slowly apply these skills to your own frugal project. Um And I think at the end of it, I hope that you become inspired to develop some of your own frugal ideas. I hope that even if you take away just a few key principles or a few elements from this module that will spark your ideas to transform them into a more frugal solution, potentially, we all have loads of amazing ideas. And I think that frugal principles that you know can be applied to those ideas are much, are likely to improve the chance of success of your ideas. And I hope that that will be an inspiration for you moving forward. So what is frugal innovation? Well, put simply it's doing better and more with less. So it's recognizing that we have limited resources wherever we may be practicing and being able to use that fact to our advantage is what frugal innovators do. It's about providing an elegant solution to a problem. Frugal often has connotations of being sort of, I don't know, tacky or cheap, but actually, that's not the case, you know, often frugal solutions are low cost solutions, but it's not that they, you know, are rubbish or, you know, flimsy. It's the exact opposite. They are an elegant, robust, sustainable solution to um to a problem, you know, an innovative fix or a neat fix to a problem would be something that, you know, is a frugal innovation and it's about making the most of all of the available resources that you have. And often it's, it's if you have a problem to solve and you had unlimited resources. So if I gave you a healthcare problem or any problem and said you have the unlimited time and unlimited money to solve it, then it would be very easy for you to solve it and probably not particularly satisfying. But if I really constrained the resources that you had at your disposal to solve that problem, you would have to think outside the box, you'd have to think laterally, you would have to overcome that lack of resources through your innovative thinking to solve that problem. And that is what fruit innovation is. And there's a there's an amazing book which I recommend that you read on full innovation, how to do more with less. And we have probably who's one of the authors of this book as a, as a guest speaker later on, which is really exciting. But uh if you want a good introduction, I would recommend reading this book as part of the course reading materials. Why is frugal innovation needed now? Because if it's, if it's such an elegant fix to a complex problem, and it seems like it's going to do a lot to solve uh challenges in healthcare. Why, why is it needed now? Why hasn't it been done already? Why do we need to focus on it now? And I think that we have a number of things happening globally, a number of sort of phenomenon that are happening globally but are all coming together to make frugal innovation super important right now. And number one is that there is a growing disease burden and we know this, if we're clinicians, we see this in the number of patients that we see the complexity of problems that they have. Um if we're not clinicians, if we're engineers or if we're scientists or business people turning into this course, you know, we're all patient's or have relatives to our patient's at some point in our lives. And so we interact with healthcare and you can see the complexity. Um and the, you know, the difficulty of delivering healthcare is growing globally all the time. Number two is that technology advances in healthcare are one of the biggest drivers for the rising costs of delivering healthcare globally. Almost all countries across the world are struggling to fund healthcare robustly. And a large contributing fact, this is the expensive healthcare technologies that we're developing. But ironically, technology is also the answer and specifically frugal technology is the answer. So you've got this growing disease burden and complexity of healthcare, rising healthcare costs driven primarily by healthcare technologies. And this is creating almost the perfect situations for the implementation of frugal innovation. Because frugal innovation can make technologies more cost effective, make them a better use of resources, make them more context specific, make them more robust and so on. And all of this increases the value of the healthcare we can provide for patient's and healthcare services globally. So because we have these factors interacting globally right now, these global forces, frugal innovation is absolutely needed right now. So that's why this course and you interacting with us and learning how to innovate frugally is just the perfect time to do it right now. Also to bear in mind is that it's an inescapable that we need greener solutions to the healthcare challenges that we face healthcare. The delivery of healthcare is one of the largest contributors to the carbon footprint of the of the planet and therefore ways of reducing that through, through innovation are going to be is going to be increasingly more important. And because frugal innovation focuses on making the best use of resources being robust, being sustainable, it often almost automatically leads to greener solutions. And we've seen in a number of government, government policies across the world, industry policies and working practices that there is increasing economic and environmental drivers for us to develop sustainable and green solutions. Uh It will be I I predict that there will be the cycle of frugal practices will create greener solutions and the need for greener solutions will encourage frugal practices. So I think this is just another massive driver and pull for frugal innovation principles to solve challenges in healthcare. And indeed in multiple other sectors. Of course, we're focusing on healthcare hair, but there's no reason why being a good frugal innovator can't benefit you no matter what your industry, where does the best frugal innovation occur. And I think the people that I think for healthcare at least should folks you know that that areas that people should target are those in healthcare. And I do mean surgeons, clinicians, but any healthcare professional, any healthcare professionals are nursing team and allied healthcare professionals should be should you know should be targeted. Science is a really good place, frugal innovation and indeed business and industry because once clinicians and scientists have developed solutions, it's often businesses that need to be created or engaged with to implement those solutions and ensure that they're widely widely used. So an interaction between these three elements. And I've put three different globes in the middle because I think it's important to highlight that this is a global effort, global problem and that low resource settings can be felt can be seen to be anywhere. There's always rule environments everywhere. So I think this is a really important thing no matter where you practice to focus on. Um This is where the best food innovation occurs At the intersection between these three areas, wherever low resource settings arise in the world, just briefly what counts as innovation because I use that word a lot so far for for the purposes of this talk specifically. And my personal definition is that it's doing anything that's new, that increases value. And I like it. This definition is because it's simple and it uses the word value, it's about making a valuable change. Okay. The value doesn't necessarily just have to be financial, although you need economic viability for your solutions to be sustainable, but there are many ways to ensure that is economically viable. But the value can be environmental value, social value, patient value, healthcare value and so on. So try and think about the different ways you can measure value because that will help you develop your solution and get it implemented. And does it have to be a product or technology or? No? Not necessarily. It is an area of interest of mind developing new hardware solutions and technology solutions. But it could be a process solution, it could be a systems innovation or innovation where you're doing something between settings and groups. Indeed, digital solutions would fall into this. I often include them in technology though. So just briefly looking at your innovation pathway overall and we will go into elements of this, we will take deep dives into the different aspects along this cycle throughout the course. But just to give you an overview, once you've identified your unmet need, you've really understood what it is and you formed your anticipatory team. I think it's really important that you examine for any existing solutions. If there are existing solutions, why haven't they been successful in that context? What are the elements about them that make them more difficult to implement in that context? Once you targeted the answer to that question, that is where I think your frugal innovation can occur. How do you make that more frugal, more effective in that setting? You can then adapt that or I D eight new solutions and inform pathways of adoption in that context. You want to make sure that you've done a good, a good, good, good assessment of the market. If you can demonstrate that there is a large population that could benefit from this, that's a very powerful argument to start moving in that direction. It's also important to raise investment because you will, even if you're developing ultra low cost solutions, you will still need investment even if it's just in people's time, it might not be in money. But how do you inspire someone to give them your time to develop a solution? Once you've done that, you need to be strategic about how you generate the necessary evidence to put some backing to your idea. So how, what, what is the specific questions that you're going to need to answer to use this solution in a healthcare setting in a safe, effective cost, effective way. And ultimately, all of this I think is to create an economic argument. And in that economic argument, you need to also include things like the sustainability elements because carbon cost is going to be just as important as financial cost, for example, and the impact on social well being healthcare training, whatever it may be so correct, construct your arguments. And these are what you were used to inform your implementation, implementation strategy. And the reason why I've put this as a circle as a cycle with the hours is because you can keep going like this and become a serial innovator. And I think that's a really important process to um to go through because once you've done it, once you'll get better at it each time and each time you do it will get easier. Okay. So moving on to the kind of uh the meaty information of my talk that I would like you to remember. And uh these are the five principles that I think are best used as if you are approaching the development of your own frugal innovation skills. And the focus here is health technologies. Okay. So the five principles that I think you will need to understand, apply and target your skill progression towards as you move through this course and as you go through innovation projects, frugal innovation projects in the future. These are the five main things, okay. Number one and this is always important to start with is to really understand the unmet need within your specific context. Okay, if you don't work in a specifically low resource settings, you either need to go there or speak to people that do work there. It's that simple. You can't fully understand the context without experiencing it or speaking to those that experience it. Okay. There is no context that has limitless resources that's also really important to remember. Even if you work in a high income country context, you will still have a limit to the resources that you have and full innovation principles can still be applied at your locality to improve healthcare. Okay. There's evidence to say that to to demonstrate that. So don't forget that you need that. You then need to once you understand the context, the low resource specific context, you need to map and define the specific challenges. What are the pain points that they face in? You know that unmet need area. And once you've got those defined, you can then move on to thinking about potential solutions. So number one, you have to really understand the unmet need within that specific low resource context. Number two is you need to make the most of all of the resources available. You need to think outside the box. When you're listing all of your resources, you will often have more resources at your disposal. The new thing, things like time, money, skills, equipment and context knowledge should all be considered okay. Any resource constraints that you do have should be seen as an opportunity to target. Okay. It's a resource gap in my opinion is a target for an opportunity. That is where your opportunity lies. Okay. You know, seeing opportunity in the challenges I think is a fundamental trait of someone who's an innovative a frugal innovator. Okay. And it requires you to think flexibly and favor adaptability. Okay, prioritize flexible thinking, thinking outside the box, lateral thinking, whatever you want to call it and you will be able to understand how to use the resources that you have. The resource constraints targets that you've identified to develop innovative solutions. Okay. So make the most of the resources available. Number three is focus on the minimum core functionalities and this goes for your solutions, your innovations, okay. Describe the key function of your solution in one sentence. You know, too often we get too bogged down in the details. We're focusing on features and extra bits and Bobs that need to be added on. And quite frankly, it's, it's, it actually muddies the water and you'll get your lose focus be would be ruthlessly focused on the minimum core functionalities to solve the problem that you've identified. Okay. Focus on the resource to benefit ratio. Not features, list benefits against the resources that you're using. Never list the feature a pointless feature. Okay. Make the function as simple as possible but no simpler. Okay. So if you can make it simpler, make it simple, make it simpler. But once you've got the most elegant neat solution, then save it and literate on that. So focus on the minimum core functionalities. The fourth principle is to demonstrate value, okay. And this goes back to my definition of innovation, making sure that you can do something new that creates value. And the reason why you want to demonstrate the value is so that you can show stakeholders, you can show people that this is the value that I've generated. Okay. It's all well and good. Just presenting a nice idea. But where is the value and understanding how to measure and present that value is something that will really help you in frugal innovation because it's not always as simple as financial value. Okay. It's social value, its health value, its environmental value. Okay and so on. Think flexibly okay. How do you engage with different types of business models that may benefit from frugal practices? A number of businesses apply frugal principles to their own internal business model and workings. And you can already become inspired by that to see how you might be able to fit your solution into a similar model. Okay, elegant solutions that solve you know large problems at low cost. And if their carbon negative they ultimately of supreme value. Okay, if you have an elegant solution to a large problem that is low cost and that scale that is carbon negative that that will be an incredibly investable solution. Okay. So make sure that you can capture those different elements of the value generated and demonstrate it to the necessary stakeholders. And finally evaluating your solution evaluation is particularly important in healthcare because we're working in a safety critical environment and we need to make sure that we comply with established regulatory processes to ensure that we've got safe, effective cost effective and so on solutions. Okay. But it's very important that we focus on the minimum required evaluation evaluation that the risks, the investment and adoption only surplus to requirements evaluation should never be considered. In my opinion. I think that we just need to make sure that we can get our solutions that are safe and effective solutions adopted efficiently. We can use this evidence to advocate for frugal innovation to, you know, to businesses who may want to help us, you know, implement our solution to healthcare services who may want to pay for it or use it. And of course to the other sciences who may want to, you know, use that principle to develop a different solution or take it to a different level. So you use this evidence to advocate for further innovation and it becomes a cycle. And this kind of cereal innovation process that I was talking about can become something much bigger than just what you started. Okay. The evaluation should inform three things, the implementation, the scale and the reinvestment. That's pretty much all your evaluation needs to do. Okay. So don't you know, do the necessary evaluation and prioritize it, but don't make sure that you do it in a, in a, in a frugal way. And this is just if you wanted to take a screen grab for example of the five principles together, but just very quickly, you need to understand the unmet need within the specific context. You need to make the most of the resources available, focus on the minimum functionalities, demonstrate the value and then evaluate your solutions with frugal evaluation methods. These are the five principles I think you need to apply when you're developing your frugal skills in health tech. And I think taking a principles based approach will allow you to be flexible when you're deciding on which context to think about. And it could hope this the idea is that this will apply to any clinical context, any geographic context, any patient context. These are in my opinion, universal principles that I hope will benefit you no matter what you want to work on in this space of frugal innovation. Briefly, what about the barriers? There are always a number of barriers, but you can increase, you can overcome barriers. Are you by increasing your knowledge? So coming to courses like this, speaking to people who have done it before you building your network, who can you draw upon what intellectual resources do you have at your disposal to speak to that? You know, your network is one of your biggest resources, for example, you know, and you need to make sure that you're using that effectively following the best practice from others. So hopefully, some of the principles that we're going to go through in this course, we'll be able to follow. And also it's about creating a frugal culture, you know, that it's okay to focus on, for example, the triple bottom line of the carbon financial clinical outcomes, for example, that's, that's where we should, that is the future, that is where we should be targeting. And it's painful being at the front of culture change because it's a changed and often people are resistance change, but you need to advocate for effective change. Um And, and you're doing that to improve, you know, the use of frugal innovation practices globally. And once you've gone through this pathway, you know, one time, you will get better the second time and so on and so forth and soon you'll be able to navigate the pathway very, very effectively. I'm sure this is just a plug, particularly if you're interested in the frugal evaluation side of things. So once you've got a solution or if you were look interested in just supporting existing solutions and getting them evaluated and adopted properly, there is a global Ideal project that has been launched very recently. Actually on the website, is there um this has a list of recommendations for you to design appropriate studies in a frugally effective way. And it also has a consultancy service where you can reach out. And if you're working in a low resource environment, you can access these for free to get advice and guidance into how to innovate frugally from an evaluation point of view. So just I thought I'd include that at the end of my talk here. Um Just so that I make sure that each module, we thank our funders and collaborators. I just want to say a huge thank you to the Global Surgery Foundation from the World College of Surgeons of Edinburgh who funded this course. And there are a number of key supporters and collaborators that of delivering this course with us including Life Box MedTech Foundation asset, the NIH our Global Unit on Global Surgery Unit and Medal of course. So that's all I want to say for for now. Thank you very much for listening. Um It's um hopefully been a useful introduction to some of the key principles of food innovation and it's now time to move on to an airbag Mishra who will, I hope share his screen and introduce himself to you all. Um It's a great honor to have him here. It's, um, it's quite late where he is. So I thank you very much for, for joining us problem issue and I'm going to hand over to you now. Yeah, thank you. Thank you. Well, I think uh this is a very exciting and very uh would be a very useful tool at this course. I'm sure. Hello. Hello, everyone. And uh it's, it's kind of evening, late evening here in India. Uh So good evening everyone. Uh I am Anurag my surgeon by profession with a deep interest in rule surgery or low resource surgery or global surgery, whatever terminology you use. Uh And today, I think in the first session, you uh you saw what frugal innovation is, what are the various components? What are the various principles? And what in the next 20 minutes I would do is to add some experiences which we have gathered over years working in fields, working in a kind of a lower source setups across this country. And I am sure that will help uh broadening the view of the whole frugal innovation. India, I think is, is one country which has been uh uh innovating frugally for a lot of uh problems and successfully in some of them. Uh So I think we can have some stories from here. Uh In this session, two things will come out very strongly. One is the need to understand the unmet needs which will very clearly emphasized and also the importance of collaboration. So uh so I also bring greetings from a global group or innovations and global surgery, which will be talking about further slides as well. So uh there will be some reputation what bill has already covered, but that is just to emphasize the value of those points. So please bear with us uh access of safe and affordable surgery and anesthesia care is a dismal uh law and it's a well recognized problem all throughout the country. And uh the as is said that low resource setting can be in any part of the country, however developed, however high in committees and to some countries to some continent. The problem is huge, like for example, in Sub Saharan Africa and South Asia, uh the problem is is pretty huge and some Axion has to be done as quickly as possible. The main thing by frugal innovation or by surgical technologies are not seeing their flight is that only 5.7% of surgical devices which has created, they don't have a surgeon or a or a doctor as a co inventor. So these products are created from innovators with they're all noble ideas and well meaning ideas. But somehow the lack of understanding of the problem or the complexities of its implementation generally leads to failure of these products. And globally, only 9.8% of new surgical devices which are created, they reach their stage of clinical trial and only less than 1% read the widespread adoption. So this is the number which has to be uh tackled so that the frugal technologies, the in the rate they are created, they have, they will start showing their impact in the low resource settings. Uh And also we all understand that there's a huge uh increasing dependency on advancing technology. And mostly it is perceived that the health sector has to run at a much faster pace to catch up to the advances which are happening in technology world. Uh About surgical innovators from the surgeon side. There is a lack of surgical innovators globally uh because they are busy treating patient's. Uh so they lose the sight too uh into the future that what would be the long term solutions or innovations or frugal innovations in those areas, lack of innovation, skills, knowledge and opportunities. Uh even if they are interested, they might not understand the latest technology. So there has to be a collaboration in those areas. And this is the major gap which we also identified through various interactions. That lack of interdisciplinary collaboration is one of the problems uh which is leading to uh reduce number of or less number of surgical liberation's. So, uh what's the need of innovation and collaboration? Uh The first thing is that whether we are creating product for a need or we are creating a need for a product. So as we see in mostly low middle income countries or in low resource settings, a product comes out from the technology houses which then tries to find a solution for itself. We'll have a, let's say, uh ultrasound machine or a reward and then we'll try to see where we can fit it. Whereas logically that it has to be the reverse of it that we identify a need and then we create a product. So I think the first need is uh for the collaborate, for the innovators to collaborate with the people who are facing the need and then work according it in the last session also use uh it was emphasized the importance of identifying the need as the first principle of frugal innovation. So it would be just underlining it again here, the priority of innovation should not be only centered around people who, who, who makes, who calls the shots. So who had the, the uh who got affordable population? So you must have otherwise good to have. So you have to identify what is the core problem, which is generally the low rugs of population or the low resource settings. There, there's a few notice that the the innovations are created mostly for the people who can pay for those products. Uh and roll of end user. I think this is the role of end user does not stop at just naming the need. I think the role of end user has to be throughout the whole innovation cycle because ultimately, these will be the people who will be using it or prescribing it or utilizing it around them. So their role is throughout the whole innovation cycle. So healthcare inno innovation has to be interplay between healthcare innovators and start ups and investors. So we did some uh studies throughout uh various stakeholders were invited to answer for few questions around gaps in the innovation cycle. And the stakeholders included rule, surgeons, patient's uh innovators funders. So I'm just sharing some of them that what they identified as gaps in the innovation cycle. The first gap was research time mostly in low in middle income countries or low resource settings. The clinical load of the work on on the surgeons or medical healthcare providers is so huge that there is no separate time for researching or inventing new technologies. The research infrastructure itself is deficient that there's no support, lack of funding, the population issues are very complex. So to understand them and then implement a solution or a project, a solution around that is a tedious task. And uh generally people give up at a very early stage. There's unsteady focus on healthcare innovations again because we mostly are busy with solving the current problem rather than foreseen the future solutions or future problems. Fabrication of prototype and manufacturing is another concern even if I have an idea, we might find it difficult to create a prototype and then test it uh ahead. Uh interdisciplinary team are not there even if they're, they're, they're not functioning in their, in their uh efficient way. So that is another uh barrier communication gap between the front night knowledge holders and the entrepreneurs. So that mismatch is another thing, priority for the riches. So most of the innovation are built around what the urban population or the rich population uh they want. So that's another thing. There's a long development time for general health related uh innovations. You create an idea, you paid a prototype, you tested, you again, tested, you again, tested the various levels of testing because it has to be applied on patients' and healthcare and to see the result of it is even longer so that the whole development time is very long and very few people uh would want to invest that long pain in a healthcare innovation. It is not very certain to uh confidence that will create profit uh or maybe it will not be huge. So that's another problem, compliance rules, regulations are very stringent around healthcare across the globe. So that's another thing that's credibility. Uh low middle income countries, if you say the innovation has to come from their country. Uh But in those areas, the credibility of a local made solution generally is not very high. So that's an also in a burden on a local solutions which frugal promotes that it has to be based on local uh products, local trains, local available resources. So that's another issue which we need to work on. So these are the various problems which we saw. We also asked that, do they think there's a good communication between doctors, engineers and investors? And a big 74 person said no and only you could say only 816 people said that yes, there is a good communication. So which is not a very encouraging figure. We also asked that what could be the solutions? And if you see these, I just these are just screenshots, you'll see this world appearing again and again, this is the collaboration, collaboration, collaboration, working together, multi resume reteam, networking and maybe some funding. So the main thing uh which is the crux is to come together and start working. So wherever you're working for frugal innovation, collaboration or medical innovation, think the team which is uh multidisciplinary is the answer. So we have a somebody slide I think that's straight and we go to that need to drive innovation work with stakeholders, political inputs, communication. So these are the various solutions which is a summary that study the target population needs, which is uh so try to dig out uh the local population need before you think of doing any innovation around any problem. Uh hackathons is another good idea to create a lot of solutions come out in a very quick amount of time innovation, fellowships, matching and reverse matching between the engineering and medical world. Uh that can be one solution, prioritizing innovation uh in politic political and medical research, research methodology training for everyone, develop the links and teams, doctors insurgents to become a part of startups so that the product is relevant, simplifying approval procedures, long term investment who only focuses on healthcare and frugal. So this is one solution which that is why I think this force think is designed. Mhm Okay. Uh How on a scale of 1 to 5 when they are asked that, how do they feel the need of collaborations? Like I G S will bring surgeons, innovators and then investor together a big uh 77% said yes, it will and will be the five score. There were hardly any 123 score. So this is the collaboration which we created uh in 2022 last year where we hold the first conference in Delhi and totalization was 2 45 from more than 10 countries. And you can see a lot of partners from across the globe participated in the conference. They were around 62 innovations were presented over 24 hours which is a huge number. Uh and some innovative skills were also trained by using workshops. So uh the innovation cycle was already declared described in the first session. Uh The whole vision is to strengthen the ecos innovation ecosystem for global surgery and wherever there is a gap or deficiency, such collaborative networks can create uh health, the innovation side, I think uh this has been covered. So uh whenever we are innovating, if our global's needs, I think we have to look for some key things. It has to be a responsible innovation. So I think, I think has to be about everything and importance of uh maintaining the climate and bringing innovation and carbon footprints has to be very important. We should not be in a blind rush towards innovation that we are ignoring uh these things. So that's why it is the first point. I have kept reverse innovation whenever you got. Uh So it has to be both ways the from the gap, the solution and solution to gap and it should complete the loop. The innovation has to be disruptive that actually should change the way things work and it has to be frugal which has been emphasized in previous cision. So this is our description. So first point again, this is the five points which uh mostly covered. So we we have declared a lot of gaps and uh the group we've met and these are some suggested Axion plans are to do things which can be done. So for example, for need identification, there can be some immersion programs from students from medical engineering backgrounds, you to each other's fair, we can do some studies to just to identify uh needs from global surgery world. So that that can drive the innovation cycle. And that is a very important first step when you want to jump into frugal innovation, educate training for resurgence and other surgeons and healthcare personnel's endangering uh skill sets and innovation, skill set. And I think such programs like this one will be very helpful. Also the other way around uh some basic training about health care basics should be given to the innovators as well. Inadequate communication is a one problem statement between medical and injuring professionals. So again, we can have a repository of collaborators uh or some publicly accessed website. So if I'm a surgeon, I want to innovate, I need the help of uh let's say a robotic engineering expert, they can be a repository where I can just go and uh find the contact and seek help. So such thing would actually power the uh the innovation segment perceived like a gap of like why we said perceived because actually funds are there but mostly the awareness about these funds is not there. So if again, such a repository of such funding opportunities is made available. Uh that can be a great way to again power innovation cycle. Uh in whatever sector we are working building credibility uh to attract investors or to market the innovation. So the action plan can be to have more population based research and able to clinical trials so that we get evidence which can uh convince people, funders and policymakers that innovations is very important and essential. Rather there's a long term patency process and medical device regulation. Uh We have to have a uh we cannot say we can undermine the importance of ethical clearances and regulations. But if there can be a team which can guide these innovators through the healthcare processes, I think that can also be a great help, inadequate manpower in the remote areas. Uh Again, tasked sharing to shifting can be trained to such areas. So towards coming to the end, I think this collaboration is the key. Yes, we have to convert the eye to tea and which is uh only happening. Not we have to deepen our skill sets in our own sphere, but we also have to collaborate with other uh skill set people. So horizontal reach has to be increased and then only it will become an efficient team. So this is very important. Collaboration is indeed the key. And uh so coming together is the beginning, keeping together is progress and working together is success. So I think that is the main philosophy around any innovation work uh which is done. So with that, I will close and maybe I will invite you uh any of the audience who is interested to attend the innovation of Global Surgery second meeting, which is happening in 24 25 April in numbers to Kenya. So please do join. Thank you. Uh well, or do you, is there any questions or something? You can take. Thank you very much. Uh That was amazing over you and some really valuable insights. And I, yeah, I do encourage you guys to check out the, the meeting in Kenya in April. Um Be great to see some of you there. Um All the details on the on the screen now and it's just a really nice opportunity to actually meet face to face and discuss some of the latest things happening in Frugal innovation. Um But yeah, thanks. Thanks so much. Uh Um I'll hand over now to um knoll uh referral to give his talk and I'll let him introduce himself now and share his slides. Thanks very much. Thanks Mary Joe Will and thanks on Rock for an excellent talk. So, my name is No Lorapril. I'm a surgical registrar in the UK and also the Gaza past precedent and currently on the advisory board, I'm also finishing my phd in Surgical Technologies where have been a colleague with Bill. I'm also part of the Admiral Colleges Global Surgery Foundation. I'm really thankful that they have uh supported and funded this course. So following the first two talks are now going to take you into uh sort of more practical examples of what frugal innovation looks like in L M I C setting using uh examples of frugal surgical training through my experience as well as working in a collaborative for the last four years. Last year. Uh Inter graduate college is as well as training organizations have released the technology enhanced surgical training report, callers future of surgery port for trainees globally. Uh And one aspect we highlighted in this report was that frugal innovation is a key factor in addressing uh iniquities that persist in the surgical care uh and remain across the globe. And why, why do we say so? Because we feel that uh if the principles of frugal surgical innovations are applied, especially for trainees who come from uh law and mill income countries. Uh and especially for those who work in the rel settings of L M I see, uh then these principles can champion and promote effective care that they want to provide for their patients'. But it also focuses on, on what or who is available in those settings. Again, highlighting the principles of frugal in emissions that we've heard recently. Uh and, and not merely basing it on the lack of uh resources, the principles also value the people who have dedicated their time, their skills and their commitment for neural communities. And that could be because because of a calling on their life that they were to serve this population or they belong to this population or uh or that is their decision. The frugal surgical training also recognizes the cultural context of where the neural surgeons are operating, but also the population that they serve. The principles also empower the trainees. And that is one of the important aspects that I have learned through uh some of the the Ruhr ulcer surgeons who have been training other oral surgeons in similar settings is empowering uh making them feel important for the very, very reason, the time and effort that they have dedicated for the people. And this also results in better attention as well as it improves their skills. Written. I want to give you an overview of what the problem is and why frugal surgical training is important. And as as some of you would have read this full report on the Lancet Commission on Global Surgery. Um I want to highlight this uh left lower corner about the increasing specialist surgical workforce and that relates not, not just to the surgeons but also the any studies and obstetricians. Um that the density, we want to increase it to 20 specialist surgical anesthesia and obstetric workforce for 100,000 population. And that will have an impact on the increase in the surgical volume, access to the surgical care, timely surgical care within two hours, improve the perioperative mortality as well as reduce the expenditures. This graph again taken from the Lancet Commission highlights the density of where the specialist surgical workforces based. And as you can see, most of it is at least in this map is concentrated in the uh in the European countries as well as North America, but where less so in the sub South Africa and Southeast Asia, some countries uh I can give you a comparison like uh in the UK, the su uh density is about 73 to 74 100,000 population. Whereas in some countries like Zambia, it could be even as low as 0.7 per 100,000 over here. Again, it gives you the first graph gives you an overview of the distribution of the essay. Oh Workforce. Uh And you can see how low the density of this workforce is specialist workforce to be highlighted in this um sub South Africa, as well as Southeast Asia. And by 2020 by 2030 you can see how much more work needs to be done in parts of sub South Africa, Southeast Asia, as well as South America to increase the workforce. And I think we have to start thinking outside the box uh start taking interest in how we, how we plan to increase the surgical workforce. But that's just not the only problem. There are also problems related to adopting technology in low resource settings. Uh The frugal surgical training has two components to it. One the technology itself. But the second bit is the surgical procedure that associates with that technology but also other aspects of innovation, like the process of innovation that will highlight it earlier. But here, it's very clearly highlighted in this Lancet Commission of Technology that was published in Lancet in 2012 that uh the necessary technology even does not exist. So we've not even thought about some of those innovations always of training people, let's say especially to this talk due to several issues like funding or uh the push and pull factors as highlighted, sometimes the technology exists but it's not accessible due to cost human resources or the energy supply and sometimes the technologies uh is accessible but it's not adopted uh due to culture resistance, human inertia. Thank you. I want to just briefly highlight the health technology assessment to you just because um this uh this is a systemic systemic uh systematic evaluation of health technology or intervention. Um which as you can see, the World Health Organization focuses that it not only focuses on the clinical aspect that uh sometimes as as clinicians are interested in but also aspects around the economic aspects, organizational aspects, ethical aspects. Um So it's a more of a holistic approach to evaluate a technology or an intervention uh with a view of informing the policymakers on how they can allocate the funds to this particular technology or to this particular intervention. Uh and specifically to the training of uh the surgeons in in that particular health system, we need to identify what the uh the neural surgical community their priorities are. And based on this consensus statement that was released during the same time as the Lancet Commission, the Association's of Rel Surgeons came up with these three main pillars on how these aspects can fit within, within the health system and the need for innovation and workforce as well as the access to blood was more of the most important aspects around how how the surgical care could be improved. So this was an overview of um what are the aspects around improving uh surgical care in low resource settings with regards to uh the surgical uh specialist surgical workforce density, as well as some of the principles of frugal innovation. And I want to highlight now the exemplar of laproscopic surgery in N M I C setting. Um and just take you through how we have been working in the last 34 years in making laproscopic surgery accessible in low resource setting. Starting from training the the oral surgeons. Now here through the globe search paper, you can see that uh laproscopic surgery rate is extremely low in L M I C setting. But in those countries where laproscopic surgeries performed, you can see that there is much lower rate of surgical side infection or complications. Yeah. Uh One of the studies done by one of the students that I was supervising highlights some of the barriers that are associated with laproscopic training in low resource settings. And these some of the seven uh barriers that were highlighted related to the funding available for the oral surgeons to get access to the training or the equipment like the simulators, some of the oral surgeons that we worked with had never even seen a laproscopic simulator before. Um access to laproscopic training within the surgical training that they are part of uh in some countries, especially Ruhr ulcer. Surgeons do not have laproscopic surgery as part of their training curriculum. Also, unfortunately, to practice, uh we realized that the oral surgeons are a one man, one woman army in there're oral settings and they cannot leave their healthcare set up and go and train for three or four days. That is a big luxury for them. So these are some real issues that have been highlighted in how um sometimes surgical training is not accessible to our oral surgeons. But also um if the training is available, we need to understand how the diffusion of this training will happen and how the diffusion of this technology, let's say laproscopy will happen in there setting. We need to understand that it has to have a low cost to learn the technology that we are proposing should be cheap to manufacture, it should be benefit to those who are manufacturing and eventually it should be of low cost. And finally, there should be a patient demand that we are implementing something because there is a need for it. One of the slides over here demonstrates that in America, for example, in 1989 to 2003, the adoption of laparoscopic cholecystectomy was so steep from year one to year three. Whereas on the right, you can see the adoption of uh laparoscopic cholecystectomy in Mongolia has taken several that although the technology is of create value too low resource settings. The adoption process is not quick but there are also other problems. Although we feel that a gas uh laproscopic surgery with gas is uh the gold standard. But in some settings, they haven't got access to carbon dioxide gas, they haven't got access to the necessities who would give a general anesthetic. And one of the oral surgeons doctor gonna Raj who will be giving the next doc uh came up with this idea of using the gas list laproscopy, which is using this instrument that you can see called the abdominal wall left device. So it essentially uh lifts the abdominal wall uh and creates intraabdominal space for the surgeon to perform uh laproscopic surgery, even using spinal anesthesia for selective surgical abdominal procedures. So, as a group, uh we collaborated with surgeons in India and identified the neural North eastern part of India as highlighted on this map where there is an extreme need to improve access to surgical care, but quality access to surgical care for patient's. We collaborated with organizations like Malena's Medical College where Professor Miss Troy's from an associations of surgeons, rurales, surgeons in India who had already initiated this project back in 2015 2016. And we identified the projects and link them up with those indicators uh of the Lancet Commission in Global Surgery, which was very essential rather than just shooting in the open air without realizing what we want to do. So, we have to be absolutely sure what the project is going to achieve and how we will evaluate the technology through the standards that have been set out by the Lancet Commission. The first study that was published by the Malan as a medical college. It found that the gas less laproscopy was a non inferior alternative to that of conventional laproscopy. So the evidence started flowing in another systematic review of metastases that we conducted found that there was no difference between conventional laproscopy versus gastrus laproscopy and the length of operative stay. And uh complications rates were much lower for gastrus laproscopy compared to that of open surgery and particularly the outcomes were better for gynecological procedures. We conducted cost effectiveness analysis where we identified that if the scale up of laproscopic surgery is done in the Ruhr a Northeast India where majority of the procedures are being done as open. Uh We will it reduce uh we will reduce the uh incremental costs that the patient's are bearing as demonstrated on the graph on the left. And it will also mean that 454 Dali's would be averted uh For those patient's who would have laproscopic surgery. We started training the oral surgeons using the fundamentals of laproscopic surgery training, which is usually the training that is given to American surgeons. A mandatory course that they have to do. Uh These were the oral surgeons who received their training using um standard laproscopic simulators, low cost laproscopic simulators over a three day period, they were trained in the tasks that an American surgeon would be trained in. Um and they were expected to perform at the same level as is expected in this course. And we could see that over the three days period, their performance gradually improved and they were really showing progress in their training. We then uh continue the training in their own settings where they were performing the gas lis laproscopy procedures uh on their patient's using the spinal anesthesia. Uh And, and with uh with the supervisor unscrew abd in the operating theater. So, although this was hand holding for the oral surgeons, it proved to be an effective process mostly because the oral surgeons felt valued that people were taking interest in them in their people and in their surgical skills. So this was a Proctor ship that before that was done in the rel healthcare set up and we could see when our team was there, I was there, we saw the problems that they face sometimes and the studies would not turn up, sometimes electricity will go away. Um So there are some real challenges that are oral surgeons face in these settings. Another aspect we need to bear in mind as we introduce a new innovation in low resource setting. Uh I want to highlight that the gas less laproscopy was initially evaluated and implemented in high income countries in 19 nineties and two thousands. But after ghastly uh conventional laproscopy, taking off gases, laproscopy unfortunately, did not take up in high income countries, but we did identify that there was a rule of gas, less laproscopy in low resource settings. And people are on this diffusion curve where uh when we started as a group, most of us were in this early adoption phase. And then we reached to a point called a tipping point where people see the benefits of this technology, people start believing uh and more and more people start adopting the technology. And the way the division of Gaston's laproscopy happened was because of these champions who are based in uh big centers in Delhi, in south of India, in east of India, who believe that this particular technology will be of benefit to those who are in the Northeastern India. And following the implementation of this procedure in Northeast India, uh the gas less laproscopy now started disseminating in other parts of referral and Northern India, Eastern India as you can see in the graph on the left. So people started to identify the benefits of it. And I want to at this point highlight that what was the factors that were causing the effective diffusion of Gaston's laproscopy? And as Unruh get highlighted, collaboration was one of the key aspects. Um people were ready to work together, people wanted to uh be part of that same mission. Same goal. Also, communication was an extremely important aspect to um two uh tell people why this technology is important but also effective dissemination strategies through social media, through advocacy organizations like gas or other student bodies were also ready to face criticism because sometimes not everybody agrees to the technology that you want to promote. And now we can see that the diffusion of this gas less laproscopy from um parts of India has now moved to uh Eastern Africa and within Eastern Africa, the local champions are disseminating in other parts of Kenya as well as Uganda. And here are some of the photos where uh a small project is now training dural surgeons in several parts of the world. We are also using other means of training like the virtual reality headsets that gives and makes training accessible to people just from their own settings. And finally, the benefits of gasses, laproscopy has been seen in high income countries like this hospital at in Leeds. Uh found that using gas lis laproscopy could considerably reduce the carbon emissions and has proven to be greener alternative of surgery. So um just as a final slide, frugal surgical training, uh the unmet need needs to be identified. Uh It has to be contextual. Uh it has to be accessible, affordable, equitable ethical of the good, good quality and it has to be sustainable. So, these are the main pillars of how frugal surgical innovation can be made accessible in these settings. Thank you very much. Thanks. Thanks so much, Noel for that. Uh brilliant talk and you know, an amazing example of the frugal principles that we've heard about being applied to the Real World project and indeed its relevance for training. So, um thank you so much, fascinating talk. Um It's now a great honor of mine to introduce our next speaker, Doctor Garage. Uh If you can share, if you can turn your camera on, we can see you. Let me just share your slides. Now, um if you just let me know when to advance Doctor Garage, I will do so. And um please introduce yourself. Really look forward to hearing your talk. Thank you for giving your time. Sure. Thank you. I'm probably one of the oral surgeons who have been working in uh Ruhr allow and remote areas for the last four decades. And uh I should start by saying that uh Doctor William Bolton has been very, very frugal in allocating only 20 minutes for the talk. It should spine about four decades. My journey with the Krugel Innovations started Bay back and uh the eighties when I was a medical student and CMC Velo, when we started uh prayer group to support a mission organization were working in that promoted rel areas in India and being located in the hospital, all the missionaries who came for treatment came to a prayer group and shared about the needs in uh remote areas. So what they said was at that time, they were working in uh among the cook front rivals in Gujarat with a population about 300,000 people spanning an area of the diameter about 300 kilometers with absolutely no doctors. So what can a medical student with no money? And uh nothing can do for such a people or such a group of needy people? The frugal innovation start when you have a real passion to do something for what do you think is uh cause which is worthy of uh pursuing. So what we did was uh we said that obviously there are not enough doctors to go to those areas, but there are missionaries who are working in that uh tribal areas. Why don't you teach some some uh medicines how to mean we chose about 25 over the counter medicines and taught them how to use these things too sort of effectively treat the population there. And then uh after they've completed, we actually went there. So when what we realized with it, I mean, we obviously, when we started also, we had no money. So we had collected uh several boxes of uh electro medicines from the various uh church is and uh started in the veranda, one of the first conversation that tribal area for only nothing much is happening. Then we realize that uh even if you're working in a very remote Ruhr Allay area, we need to do a proper planning. So one day we decided to start with the fasting and brave meeting but then it turned out to be feasting prayer. I don't have time to tell all the interesting things. But eventually what happened was the local people saw what we're trying to do and they built a press and walter that I believe there, which had 300,000 people without any. Can you go to the next slide, please? So then uh realize that to serve these sort of people, it's difficult for mission organizations to do a lot of medical work. So then be shifted to a nearby Mission hospital next late. And we realized that uh in the mission hospitals, in addition to planning, we need to be very frugal the next one. So when you realize that that area had a lot of patient's who had upper gi cancers, we wanted to be diagnosed him early and we needed a gastroscope. So then when we went to see N C below to see how they're doing gastroscope, peas, we found that uh I mean, they were very casual in handling the scopes of a fibrotic those days. And uh it was bending so much and uh we thought I scope even if it was so much money did not last long. So we trained the nurses in that since progress in hospital in such a way that one of the nurses start uh passing the instrument based on the instruction that we give. And there was enough specifically to make sure that uh gastroscope does not bend too much and they were the third person. And later on, we also divest a means or even those days when the know laproscopic and camera is easily available to have the pictures so that everybody can have a look at what is happening. So these sort of innovations uh actually made us uh serve them better. And the Chantix people who made the scope were really surprised that not a single broken fiber after many years of use. But then most of the innovation that we were carrying out, but based on uh where is the simple needs that we had there? Because we understood that it's not possible to have whatever we want and we need to manage with what is available there. So when you did not have any section those days, we had this uh glass bottles and a rubber cap over it. So we used to put a Hypodermic syringe um in a needle and suck out the air to create a vacuum. We start using these vacuum trains and then we started using these even those days, the intermittent vacuum therapy for non healing ulcers. And then uh then we started uh what we call the binge para incision where too many did not have any enough people to assist to enough uh people to give anesthesia. We divided the rectus abdominus attachment to the people, uh sympathizes that offered enough relaxation and they wouldn't, sometimes we could do a Cesarean section even with the ketamine when I mean, nobody was there to give anesthesia. So slowly, we wanted to improve the surgical cavity operate mean offering in the Ruhr allay areas. So when we wanted to start uh laproscopic surgeries, remember during the time when we're operating, using E M O and Eater for general anesthesia and uh spinal and a safer most of the surgery that you're doing. So we started using the sister soap that we had for diagnostic laparoscope, ease. And then later we use this to scope for making a small incision and pulling out the appendix and doing appendicectomy and uh pushing it back and so on. So basically all these things uh were there because we wanted to use whatever we had to offer the highest possible quality, high quality surgical care to the patient's and neural remote areas. But then the real innovations started later. Next one, please. Okay. This is uh some of the things that were saying and we started uh doing the urinary, no scope for removing uh renal stones through the normal urinary passage. This is almost 10, 15 years ago. The next one, the copper. Um the actual work started when my daughter started studying in the engineering college. So we had a lot of patient's uh with chronic renal failure and uh we'll be using the Baxter Cathy to for uh CAPD. So then uh what happened was uh that these catheters, even though they're simple catheter is quite expensive, the neural patient couldn't afford them. And the solution that we use for COPD again is uh fairly expensive. And uh beyond the reach of many other rule population. So we took one of these catheters to the engineering college, the head of the department and ask them, would it be possible for them to make these catheters because they're quite expensive, they examined and they said it is possible to make them, but it will be a little expensive because you don't want, you're not making in huge quantities. So we ask them how much they said, uh it'll cost extender rupees while the actual backstroker teeter is ₹14,000. So then we said, can you improve on the cathedral because these catheters tend to get blocked to the momentum. After 23 weeks soon, we had to replace them. So we asked them that there is it possible to have a capital with memory which you can straighten using a still it uh once in two or three days so that uh the momentum doesn't get uh come and block the Cathy Tas. They said it's possible. So then we started working with the engineering colleges and the universities and so on. And I think, I mean, uh Noel and uh don't Andhra talked quite a bit about the way that we developed gas uh laproscopic surgeries because of that. And these collaborations very important because uh it made uh people to work together, come together and uh I understand what is happening. Clearly, the biomedical engineers, we're not allowed to come to the, they didn't have much opportunity to visit the operating rooms inr oral areas. But we took them to the various Ruhr allay areas. They were able to find out what is happening and what are the real need in these areas. And that way some of the various uh possible things that uh is happening and to help us. And right now the latest thing that we are working in San uh laptop cystoscope, you know, as a urologist, uh when they, they mean we need at least a diagnosis, cystoscopy. And the sisters go for minor procedures. We realized that we needed various service in the neural hospital's 5% of any outpatients have urology problems and only 2% of them are able to good way urologists get a proper evaluation and uh proper treatment even every month. The earlier, we used to find at least uh once or twice a month. People coming with green like you're real failure because of the simple things like bilaterally retreat. Calculate. So then, but the problem with the way the mean cystoscope are not really available is because uh it's too much of an investment for a general surgeon or a neural surgeon to start doing cystoscope ease because uh it's it is expensive equipment. So we made a replace the telescope with the camera and now we can just connect these uh laptop sister scopes to an ordinary laptop. And we don't need the the electricity or uh the light source and all the ancillary things which are necessary pulse copy. And we found that uh imaginable thing that we have is as good as that. So somebody I think the frugal innovations, the journey start when you really have a fashion for uh serving the poor or the needy or the what do you feel? And the people who need it. And these modern surgical techniques like the laproscopy surgery or endoscopic surgeries, they are very more relevant for neural population than an eye upon population because they are the ones who need to get back to work very quickly. The urban counterparts who earn quite a bit can afford to take rest where the neural patient need to get back to work very and again, the highest level and they're being turnover of uh patient's inr oral areas. And there again, the minimal invasive surgery helps quite a lot. But then the uh Nobel briefly mentioned the biggest problem in neural areas that the know general Ennis's here. They're known a sociologist, even if you take an a sociologist getting gas is there for anesthesia and for surgery is a logical nightmare. So it is uh and these are the circumstances when you have the thing, the frugal innovation principal audit, doesn't that uh you mean instead of looking for what we don't have, use whatever we have to make the things uh achieve the result that you would like to achieve. And uh it's here, the collaboration which keeps coming again and again, working with the people, makes a lot of group of people who are interested, makes a lot of difference. Because even though we started uh doing a stress, laproscopic surgeries in the royal areas for a long time, it's only a few of us who are doing it. But then when we did a randomized control trial in Molina's at Medical College, and you're able to publish it, then it drew a lot of attention from uh the larger universities, then the engineering team and uh now even the commercial people are coming to come together to work on these sort of projects. So once we think that there is, it's possible, there is always a way ahead. And uh if you use the principle that we learn from frugal innovation, and uh finally, there is always a solution available for whatever be the problem, how big it may look, if you think there is a solution which is possible using water is already available, we can actually work towards getting it. Thank you. Thank you very much to Gain Garage. That was excellent talk and it's really great to hear from your, as you said, you know, many years of experience in this context. Um Sorry, I couldn't give you four decades, but it would be, it would be great to have you back at a later modules. So, thank you very much. Um We'll move on to our next guest speaker if that's okay. Now, uh Prof uh Prabhu who um is uh an absolute Masturah uh frugal innovation and uh is going to give us some, some fantastic insights, I'm sure. And it's absolutely an honor to have some of your time today. Prof so I'll hand over to you. I hope you can share your slides. if there's any problems, I'll be, I'll be in the background. Okay. Thank you so much. Thank you, William. Can you see my slides and hear me? Yes, I can see them. And can he? Thank you so much for inviting me. And it's actually so uh moving to hear actual doctors and surgeons in the Ruhr a context like Young Lodge. And no, I'm talking about that frugal innovations. Uh I'm a mere my academic in comparison. I have spent my career studying innovation in the first part of my car chorea. I studied innovation in large western corporations because the understanding is that's where innovation happens until about 15 years or so ago when I turned my attention to emerging markets like India, where I'd grown up. And when I went to India to study the innovators there, I was struck by how their approach seemed very different. And you've already heard examples of that. Uh First, they were very frugal, very good at making the best use of limited resources in that context. Second, the mindset was very flexible, they were very good at improvising and lateral thinking. And third, very often they're solutions were designed to help people who were outside the formal economy in urban slums, inr oral areas. Let me give you an example of what I'm talking about. By way of contrast, here is something we would regard as an innovation in an affluent society. It's a high end fridge that will talk to you and you can talk back to via the standard PC. And for that pleasure, you pay about $3000. Now, you may see something like this in a country like India, but you're equally likely to see something like this. So the egg expensive fridge is $3000. This clay fridge on the right is about $30. It just uses the cooling properties of water in this reservoir at the top. That water is cool, you can drink it. But when it evaporates through the walls of the box below it drops the temperature by about eight degrees Celsius in a hot dry climate and keeps fruit and vegetables fresh for up to five days. Uh I'll tell you more about the innovator in a moment, but his approach is frugal. His mindset is flexible and his intentions is to be inclusive. Here's another example. Um So this is a baby wall, this is an incubator. It's a beautiful machine from a company like G um but it's about $25,000. And at that price is beyond the reach of most people, particularly those in ruhr away areas. The clinics will not be able to afford this. Even if somebody gives it to them as charity, they may not have a technician there to maintain it and they may not have access to regular electricity in a situation like that. Something like this is very powerful. So the incubator of $35,000 this baby warmer is about $100. Now, obviously, it's not an incubator doesn't have its oxygen tent, but it is designed as a baby warmer to address a large part of the problem that the incubator is solving, namely a problem of infant mortality where if infants are born one or two weeks prematurely, they can't maintain their body temperature. Some cases they may die or be very badly affected. This baby warmer will save them. And interestingly, the 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. They came up with this prototype for their course. When they graduated, they went on to test it with mothers and midwives, inr oral Nepal and India. And then they got venture capital backing from Stanford. They tested in the medical hospital, they were ready to commercialize when they hit a bit of a wall. And at that point, they worked with G healthcare and G healthcare salesforce help them to commercialize it. So my quarters and I we ended up studying literally scores of such innovations, not just in India, but in other developing countries. But in India, when we asked the innovators, how they would describe this frugal, flexible inclusive approach, they often use this Hindi word you guard. So we ended up writing a book called Yogurt Innovation, which we define as the art of overcoming how constraints by improvising an effective solution, not a perfect solution, but a good enough solution. And importantly, one that makes the best use of the limited resources available in that context. Doctor Gan Raj mentioned this point several times after we published this book, People from other parts of the world wrote to say, hey, we have something similar in our country. The Brazilians for instance, said they had two words to describe this phenomenon and you see it not only in emerging markets but also in the West. So what we did in this book was we looked at lots of examples and we tried to extract some principles that we thought were guiding these innovators. And I again, both Noel and Gamma Raj have given you a sense of some of these principles. First, they're very good at doing more with less. They look at what resources they have in that context and use those resources to substitute for resources. They don't have, they keep their solution simple. This helps to economize but also makes it easy to adopt and maintain the solution. There's a lot of lateral thinking. Uh The idea is that if you can't climb the mountain, try and find a way around it, often adversity is the source of the inspiration. Necessity. Literally is the mother of invention for these people. Often they include marginal people, not only as beneficiaries or patient's or customers, but also as part of the solution. And finally, as both our previous speakers are saying these people are passionate, they really care about what they're doing and they have to because what they're doing is quite difficult. It requires perseverance over a period of time. So here's some of the people we cover in the book and I'll start with monsoon pie. This is a person he's uh from a village in the Indian State of Gujarat. He has a high school education. He comes from a family of potters in 2001. There was a very serious earthquake in his state. A lot of people lost their household possessions, including the clay pots in which they store water. One day he opened the local newspaper, there was a picture of someone's clay pot that was broken and the caption read poor man's fridge broken. That given the idea to, to make a fridge. He designed this. As you see, he set up a factory in his village. He trained local women to make these and he went on the sell them including on the internet. And what's interesting is that he really embodies all those six principles of doing more with less keeping it simple, lot of lateral thinking. He makes the best use of limited resources in his available, available to him. He includes marginal people, not only as beneficiaries, but also as part of the solution and so on. Here's another example more in your area of work. This is Doctor V who was very concerned about the fact that so many people in countries like India go needlessly blind because they cannot afford a simple cat track operation. So he set up a set of hospitals in a hub and spoke model. And his idea was if we can do many of these, we get economies of scale will get better and better at this and we make it cheaper and cheaper. So the idea is to do lots of these operations and you do them again and again and you get better and better and they have both paid and free hospitals awards in their hospitals. So you can do some cross subsidy but the doctors rotate between the free and paid. So everybody gets the same quality of treatment and they meet international knobs. The lenses were expensive. So they set up their own factory to make them and now they even export them. You may have heard of Dr David Shetty set up a cardiac hospital in Bangalore. And again, the idea is to use economies of scale is a very large hospital, 1000 bed being lots of surgery, heart surgery every day. And that again, the economies of scale and the division of labor and so on helps to economize. And they've been able to bring the cost down to a little lower $1000 for its uh surgery. Another surgeon in India was trying to make a voice box. So people have lost their voice after cancer surgery. And he worked with toymakers to come up with this voice box that is about a dollar per voice box. So, you know, I could go on telling you about examples from emerging markets. Uh I think you've already heard many, let me also now talk about this phenomenon in the West. So after we wrote that book about emerging markets, we found there's a lot of interest in this phenomenon in the West for the West. And we realized in the West there were some slight differences in the West. This phenomenon was being driven by consumers. We called pro sumers because these are not passive recipients of products and services. They're much more actively involved in the socioeconomic process. And they're driving three movements that underpin a frugal economy, the share ing economy where now people like you and me, we can directly create spare assets with each other. On some digital platform. You think something like M D and B, for instance, second, the Maker Movement, I think this has got very profound implications. Because now small more teams sometimes of our students can do things that only large companies or the government could have done 10 or 20 years ago and not just in software but increasingly in hardware as well. And third is the circular economy where we're moving away from a linear mode of production and consumption that was very wasteful to a circular mode where we try to reduce reuse and recycle. But I want to particularly talk about the makeup movement. Uh And I talked about Manu Prakash at Stanford, who in his lab has come up with a $1 optical origami microscope that literally Children can assemble. Uh You can see how simple it is here, how lightweight it is. Uh And you can even use a smartphone uh to allow the user to take magnified pictures. And then his team also came up with a 20 cent hand powered blood centrifuge inspired by the kind of Wehrli Gig gain uh that kids in many countries have often make themselves. And so, you know, these kinds of devices can be hugely valuable in remote areas where you cannot have sophisticated equipment. You could even make this and do bloods in remote areas. Uh We carry around these very sophisticated computers in our pockets around the world. This company which was spun out of UC Berkeley called Cell Scope has made a whole suite of medical devices that uh plug into the audio jack of the smartphone and then leverage it's come connectivity. So this oughta scope Yah enables a mother to take high resolution pictures of the inner year of her daughter when she has an infection and send uh images to a consultant somewhere else. This device is a fraction of the cost of the standalone device and it enables telemedicine three D printers. Now within striking distance of households, this is about $200. But even if you cannot afford one in your home, you can go to spaces which are called text shops or fab labs or make spaces where you have all these tools including digital manufacturing tools, like three D printers and laser cutters and so on. But more importantly, you have a community of like minded makers. You can bounce your ideas off and get inspiration from the students at Stanford had to come up with a working prototype. So they went to the text shop near Palo Alto, the Stanford in Palo Alto. They had this idea of a blanket that the mother could use to uh swallow the baby. But they realized that's not enough. They needed to have something that would keep temperature fixed and they didn't know how to do that. But at the tech shop, they met someone who happened to your former NASA scientists and he told them about these face changed materials. If waxy substances, you can put in a pad which you can heat either with water or electricity and with hot water and this is crucial without this component, that device would not work. This is Jane Chen with a fan who used to live in the White House. And when he was in the White House, he hosted a mix of fact to celebrate these kinds of innovations because he said this was not just a hobby, this would be the new, a new kind of manufacturing that was more high value add and more sustainable. And so we wrote about this phenomenon of frugal innovation in the West for the West. In a follow up book, I just want to finally close with some examples from COVID. Uh During COVID, I watched uh with amazement at how people around the world we're using these principles to be able to innovate faster, better and cheaper. In the first wave in Northern Italy in rescue are some of the hospitals ran out of the Charlotte valves which were a key input and the supply chains were blocked into the ventilators. And so three D printing maker spaces actually just three D printed these valves and supplied the hospitals. Then the hospitals actually ran out of the ventilators themselves. So they reject UBA uh diving masks to make these CPAP ventilators in India, a maker space in Mumbai created a network of maker spaces around the country who initially were making PPE for local frontline workers and sharing their designs for others around the country to make PPE for their local policemen and nurses. And then in the second wave in India, when India, hospitals were short of oxygen, they had a similar network of uh maker spaces, making open source oxygen concentrators and share in the learning. So I'd like to conclude by saying that over the years, I really believe now that the world needs this kind of frugal, flexible and inclusive innovation. I believe that in the West, we can benefit from engaging with emerging economies and vice versa and then working together, we can improve lives everywhere. Thank you so much. Thank you very much. Uh prof that was fascinating talk and I think it's, you know, it's great to see all the principles that you've, you know, generated over your, your career and all the research that you've done in such a well presented and easy to understand talk. So, thank you so much for that. Um So guys, we, we've come to the end of our scheduled talks this uh this afternoon, this evening today. So um if there's any questions from anyone in the audience um or for any of the speakers, then I think everyone's still online, which is great. Uh Please do feel free to post in the, in the chat in the chat group here. Um I think one of the questions I'll ask if that's okay to start with as the moderator, I'll use my moderator rights to begin because I just wondered if I could ask uh Knowle a question. Uh Noel and your talk, you, you, you spoke about how the, the gas lis innovations that you've developed with your team um have have a powerful sustainability argument, green argument, reducing the carbon footprint and so on. I'm just wondering if you could go into a little bit more detail about any of the lessons you've learned about how frugal innovation can make greener solutions and why you think that might be important for people to consider. I think looking at the reason why I gassed less laproscopy was initially uh implemented in low resource settings. We discussed that it was due to lack of any status and lack of access to carbon dioxide. Uh But those two very components uh if I'm allowed to use that word are the ones that increase the carbon footprint. Uh because of the use of uh anesthetic gases as we know um as as well as the carbon dioxide gas that we use. So it probably we can term it as a byproduct of the frugal principles that actually results in green innovation. And I think as surgical trainees or students or whoever we are on this call or your hearing this call. Uh later on uh biomedical scientists, I think we have to be hyper alert in the settings that we are and in the innovations that we use that is this innovation or is this technology or is this surgical intervention that I'm going to use actually going to result in the reduction of the carbon footprint. And I have been part of this project actively doing that by sort of asking the scrub nurse not to open something that I know I would not need. Um And, and you have seen the Edinburgh College has released the green surgery checklist. So I think um the, the drive to green surgery is actually a result of uh what drove problem mentioned the COVID pandemic because we have realized how to uh function better with less or when the resources are constrained. Uh But also start looking at the positive aspect of how this frugal innovation can actually positively dr green uh green uh green movement you can call it. So I think that that's, that's my take on it really that we can now proactively start thinking about frugal innovation as a positive thing rather than something that is uh that is kept for those who are in the low resource or constrained environment. And I think that's not true. Um uh Finally, I would also would like to say that it's, it's also the quality that uh frugal innovation offers to those who are in the low resource settings. Uh We have to be mindful that um we offer a technology that will improve the quality of the care that the patient receives and not reject that particular intervention that would actually benefit someone in that setting just because they're in the low resource settings. Let's also be mindful that, that frugal innovation, apart from improving the quality of uh surgical care, it also adds those additional benefits that green surgery offers. So it's a double win actually, for those who are in the low resource settings, that would be my thanks very much. No, it's really good insightful. Um take on that topic. I think you're right. It's really important to, I think we can leverage the drivers for sustainable greener solutions to advocate for more frugal practices because they often result in sustainable solutions. So I, I really like that. I think that's a going to be important part of the future. Um I think I might jump back to pro probably if possible. Um whenever I sort of talk about frugal innovation to people for the first time or maybe people aren't as familiar um with the frugal principles as, as as some of the people on this call. Maybe often people say, well, how are you going to make any money out of this? You know, why, why, where is the economics in this? You know, I want to make a really shiny fancy surgical robot that I can sell for millions of pounds because that's where the money is. But actually, that's not the case in the vast majority of solutions. So in a kind of elevated pitch style, how would you sell the idea to someone who's purely focused from the economics of it? Yeah, great question, William. Uh and really, it's a simple logic of profits being based on either the margins that you can charge or the volumes that you can sell. And in the west where you can charge volume margins uh because people can afford to pay and so on. Uh you can charge those margins and then afford to have small volumes and you can make your profit that way. In the emerging markets or developing countries, you really can't charge those margins because most people are low incomes or are less disposable income. So your margins are smaller, but then your volumes are larger. So you can make your profits through volume rather than uh the margins. And you know, this goes back to some of the examples I gave you like uh the Urbani hospitals and uh cardiac surgery in uh Dell and Bangalore. The principle is we'll try and drive down the cost and the margins, but we'll have to do volumes. And in fact, in order to do volumes, you need to drive down the cost and by driving down the cost, you can do volumes and then when you do volumes over time, it drives up the cost. So you get into a positive feedback loop there. Thank you very much. That's really useful. I'm gonna, I'm gonna use that. I think that analogy um and that, that example that you've given. So thank you. Um I think we've got time for kind of one more, one more question. If that's all right. I'll address this to both, uh, prof Misha and Doctor Gan Garage. I don't mind who wants to go first. Um, but I'd be, I'd be really interested as clinicians yourself. Um You know, you might have a driver to use the most high tech solution for something. You know, you might want to get trained on a high tech solution or when you're trying to persuade other clinicians to use your frugal technologies, how have you persuaded other clinicians that the simple frugal solution is the one that they should use. What any, any sort of insights that you can give us to um to help with that problem. Uh Toujeo to go fast. Yeah, see again. Uh you know, the, when I was in Cleveland clinic, when they were testing the Darvin see robot for, I mean prostate radical prostatectomies. So then at that point, most of the urologists, they were happy to do conventional laproscopic says that because they're able to finish it much quick, quickly and they preferred they would, I mean, it, this takes more time and so on. But then a couple of years later, everybody was doing only robotic and nobody did. Uh This thing is again, it depends on how you emphasis the thing. And here the volume is again, very important then thanks to COVID, uh most of them in the bigger places are not doing surgeries. So doctor Baijiu who was in a small machine hospital, he was able to do 80 lab colleagues with the gastric surgery with the supervision with Zoom because we're not able to travel. So once the task shifts and uh when goes too many work, start delegating to people, then the turnover at this. So even gastroscope peas, whenever I do gastroscopy, my intention is to just finish as quickly as possible. And I'm not dental by any means or uh the patient's are not very happy. Then we need to train the nurses to do gastroscope, please. They are very gentle. The patient would actually prefer that. And then I could see because we had a monitor in front of me and I could see what they were doing is any positive for any they can go take over, do biopsies and do what is necessary. Task shifting is another thing which really helps uh in increasing the volume. But I think probably to Andrea will be able to tell us better about how to convince conventional surgeons laugh a scopic surgery. Uh Some we'll look into the machine hospitals and they were doing actually the for the first time in uh the mission hospitals and laproscopy surgeries. And we have these uh ports which are leaking and the in circulators don't give them pressure. So the pressure never go up to more than eight or nine even though they're used to operating at 12. So they themselves prefer the gases, laproscopic surgeries while operating uh in the neural setting because they know that one day just but in uh probably places like marine quality, have a good facilities and we'll probably do that. Drug has to tell us how we can, can. Uh Thanks. Uh My experience is uh we meet two kinds of people, one who are going through the same problems. Uh uh They are feeling the same needs and all that. So for, to convince them, I think it is very straightforward. Uh But in my college, I am in the form a tertiary teaching hospital. I think here also if we explain the value of it and uh as well, also in the stock mentioned that the frugal innovation has to project the value. So the uh then they will accept the value. We just should not sell the idea, we should sell the value. And I think then most of people go with it and accept it. Nobody likes wasting money or energy or any such thing. So we should make it a proper scientific case. Uh One more thing I will say is most of the time when we're selling frugal innovation, people try to just uh sell again, projected as uh that it's okay to be uh accepted as a substandard kind of thing and maybe a nonscientific kind of thing. Whereas I think that should not be the case. Uh For example, in gas less laproscopy, the first thing we started doing is to start collecting the various evidence and then it became a sellable idea. Thank you very much. Both of you. It's really interesting to hear your take, given the different context that you've worked in the right evidence required to persuade people to use it and demonstrating the value need, I think is uh fundamental there. Um Well, guys, this has been, you know, a fascinating discussion and I've just seen that Gerard mcknight has posted a question in there that I think that if it's okay, I'll just quickly answer as well. But thanks for your question, Girard, he says, um getting into innovation space can be challenging. How do surgical trainees and let's extend that to an aesthetic trainees, obstetric trainees, any healthcare trainee or science training, of course, how do they start off in this area? So I think, you know, obviously I'm biased but we're in, you know, we're, we need to speak to our audience. I think something like this course is a really good way of, of, of getting a good introduction, getting a good foundation, you know. Um If you look at a lot of university curricula and postgraduate training curricula, they don't include a lot about innovation skills. And it's something that we're a lot of people on this call are very passionate about changing. Um And it is, is moving in the right direction, I think, but we need more courses like this because it gives people the knowledge and skills and allows them to advocate for good quality innovation in their practice and, and in their training. So I think come along to this course, one thing to say is at the end of this course, we will be able to have a range of uh funding opportunities. We have, we have a yeah, a moderately sized funding pot for people to apply for seed corn funding so that they can take their innovation ideas to the next stage. Often it takes just a little bit of funding to get your, you know, minimal viable product or, you know, your prototype or whatever it is off the ground or just a concept um stage. So that's the kind of thing that we hope to be able to provide through this course. So um that might help people get started off. But I think, you know, you've got your hand up. Very polite of you jump in. I think uh the point of how surgical trainees can start off is actually by exposing them to low resource setting or getting involved in a project. And I'm saying that because when I was an F Y one, which means I had just finished medical school and started my first house job in the UK. And there was a group of surgeons consultants who are going to a mission hospital on the borders of India Nepal. And I felt that I should join them. Although I knew I did, I knew nothing to be able to add anything. But it's actually that trip that change my perspective on global health because I saw the disparities that uh existed in these low resource settings and you know, the lack of technology that was resulting in to death and so on. So for you to really understand the principles of what some uh some themes of points that have been covered today. Sometimes you really have to go into the field work because some things you can never understand remotely. I think that's a really, really good point. Now, I think going to the context, speaking to the people are seeing the context um fundamentally is the best way of doing it. So I fully agree. Um Great. Well, everyone, thank you so much for joining us. I want to say a huge thanks to all the speakers for giving up your time and share in your experience and expertise. It's been truly fascinating and just for, for those, you know, who might want to watch this again, it's available on our metal platform. It will be available for free. You can stream it a limited amount of times for the whole duration of this program. So do do do do check out this and, and um previous modules and indeed the next module will be in April. The date will be announced on gas uh Twitter page and website. Um So do follow us on Twitter Silence for making lists to keep up to date. Um I've seen that uh has had to sign off because he feels like there might be an earthquake there. So I do hope that he is okay. Um I'll give him a call after this talk, so, but don't worry guys, we'll stay in touch with him and yet I hope you have a great rest of the day guys and see you in future modules. Thanks again. All right, bye bye everyone. Thank you. Thank you.