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Good afternoon. Good morning. Good evening everyone. Thank you so much for tuning in to the Frugal Innovation Skills course. Er, this is module one. 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, er, 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 that best suits your busy schedules. Cos we all know how busy you are as innovators and surgeons and clinicians um around the world. So today our, our module is going to cover a range of introductory topics to frugal innovation and we've got er amazing co chairs here. We've got Noel and Anurag who will introduce themselves er, 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, I'm absolutely er, super excited to see um what they're going to say and I think you hopefully take a lot away from, from this and in learning about how to innovate frugally to benefit your own, er, careers, your own training. And indeed, um, the, the outcomes for patients in low resource settings. So I'm just gonna start, uh, my, um, presentation now, um, if you do have any questions in the, um, er, for any of the speakers that are lined up, um, please do, just use the chat function. Um the chat boxer 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. Um So the, the, the, the presentation that I'm going to give is all around the core 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, uh which looks at evaluating novel technologies in a frugal way and I'm a past president of Gas O and Gas. So are the er as, as you know, um I hope by now um are the coordinators of this, this er this food renovation skills course. Um And our contact information is just there at the bottom of the screen. So do feel free to reach out uh any time 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 er 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 uh 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 er principles that you know can be applied to those ideas are much m are 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 constrain the resources that you had at your disposal to solve that problem, you would have to think outside of the box, you'd have to think. Well, actually you would have to overcome that lack of resources through your innovative thinking to solve that problem. And that is what through innovation is. And there's a, there's an amazing book which I recommend that you read on through innovation, how to do more with less. And we have prof who's one of the, you know, 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 um as part of the course um reading materials. Why is frugal innovation needed now? Because if it's so if, if, if it's such an elegant fix to a complex problem and it seems like it's going to do a lot to solve er challenges in healthcare, why, why is it needed now? Why hasn't it been done already? And 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 that are all coming together to make f 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 tuning into this course, you know, we're all patients or have relatives to our patients 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 factor to 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 patients 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 ine inescapable that we need greener solutions to the healthcare challenges that we face. Um healthcare. The delivery of health care is one of the largest contributors to the carbon footprint of the of the planet. And therefore, ways of reducing that through f 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 you 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. And it will be ii predict that there will be this 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 here, but there's no reason why being a good frugal innovator can't benefit you no matter what your industry, where does the best food innovation occur. And I think the people that I think for healthcare at least should you know that that areas that people should target are those in healthcare. And I do mean surgeons, clinicians, but any healthcare professional, uh any healthcare professionals are nursing team are healthcare professionals should be should you know should be targeted. Science is a really good place for 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 are 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, a global problem and that low resource settings can be, can be seen to be anywhere. There's always rural environments everywhere. So I think that 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 cos I use that word a lot so far um 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 cos it's simple and it uses the word value. It's about making a valuable change. OK? 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 it is economically viable. Um 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 at all? 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've formed your disciplinary 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've 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 to that or ideate new solutions and inform pathways of adoption in that context? You wanna make sure that you've done a good, a good, a 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 um back to your idea. So how, what, what is the specific questions that you're gonna 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, cos carbon cost is gonna be just as important as financial costs, for example, and the impact on social wellbeing, um health care training, whatever it may be so correct, construct your arguments. And these are what you were used to inform you on implementation strategy. And the reason why I've put this as a circle as a cycle of the hours is because you can keep going like this and become a serial innovator. And I think that 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, it'll get easier. OK? So moving on to the kind of the meaty information of my talk that I would like you to remember. And 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. OK? 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. OK? Number one, and this is always important to start with is to really understand the unmet need within your specific context. OK? If you don't work in a specifically low resource setting, 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. OK? There is no context that has limitless resources that's also really important to remember. Even if you work in a um a high income country context, you will still have a limit to the resources that you have. And through innovation principles can still be applied at your locality to improve healthcare. OK. There's evidence to say that to to demonstrate that so don't forget that you need, then 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 than you think things like time, money, skills, equipment and context knowledge should all be considered. OK? Any resource constraints that you do have should be seen as an opportunity to target. OK. It it a resource gap in my opinion is a, is a target for an opportunity that is where your opportunity lies. OK. You know, seeing opportunity and the challenges I think is a fundamental trait of someone who's an innovative, a frugal innovator. OK? And it requires you to think flexibly and favor adaptability. OK. Prioritize flexible thinking thinking outside the box, natural thinking, whatever you wanna 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. OK. 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. OK? 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 you'll lose focus be would be ruthlessly focused on the minimum core functionalities to solve the problem that you've identified. OK? Focus on the resource to benefit ratio, not features, list benefits against the resources that you're using. Never list a feature, a pointless feature. OK? Make the function as simple as possible but no simpler. OK? 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 iterate on that. So focus on the minimum core functionalities. The fourth principle is to demonstrate value, OK? And this goes back to my definition of innovation, making sure that you can um 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. OK? 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 improve your er innovation because it's not always as simple as financial value. OK. It's social value, it's health value, it's environmental value. OK. And so on, think flexibly. OK. 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. OK. Elegant solutions that solve you know large problems at low cost. And if they're carbon negative, they are ultimately of supreme value. OK? If you have an elegant solution to a large problem, that is low cost on that scale, that is carbon negative, that that will be an incredibly investable solution. OK? 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 health care 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. OK? But it's very important that we focus on the minimum required evaluation evaluation that derisk the investment and adoption only surplus to requirements evaluation should never be considered. In 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 food 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 use this evidence to advocate for further innovation and it becomes a cycle. And this kind of serial innovation process that I was talking about can become something much bigger than just what you started. OK. The evaluation should inform three things, the implementation, the scale and the reinvestment. That's pretty much all your evaluation needs to do. OK? So don't you know fo do do the necessary evaluation and prioritize it but don't but 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 that I think you need to apply when you're developing your frugal skills in 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 think 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 by, 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's, 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 we are gonna go through in this course we will be able to follow. And also it's about creating a frugal culture, you know that it's OK 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 change and often people are resistant to change. But you need to advocate for effective change um in, in and, 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 I'm sure this is just a plug, particularly if you are 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. And the website is there. Um this has a list of um 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 um from an evaluation point of view. So just uh 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 wanted to say a huge thank you to the Global Surgery Foundation from the Royal College of Surgeons of Edinburgh who funded this course. And there are a number of key supporters and collaborators that are delivering this course with us including Life Box MDC Foundation asset, the N HR Global Unit on Global Surgery Unit and me all of course. So that's all I want to say for for now. Thank you very much for listening. Um It's um er hopefully been a AAA useful introduction to some of the key principles of um food innovation and it's now um time to move on to an ish. Um, who will, I hope, er, 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, er, prof Mishra and I'm gonna hand over to you now. Yeah, thank you. Thank you. Well, I think uh this is uh very exciting and very uh would be a very useful tool of this course. I'm sure. Uh, 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 an, I'm a 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 the years working in fields, working in a kind of a low resource set up uh across this country. And I am sure that will help uh 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 uh problems and successfully in some of them. Uh So I think uh we can have some stories from here in this session. Two things will come out very strongly. One is the need to understand the unmet needs which uh will very clearly emphasized and also the importance of collaboration. So, uh so I also bring greetings from uh a global group called Innovation and Global Surgery, which we'll be talking about in for the 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 at a dismal uh low 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 income it is and to some countries to some continents. The problem is huge, like for example, in Sub Saharan Africa and South Asia, uh the problem is is pretty huge and some action has to be done as quickly as possible. The main thing why frugal innovation or why surgical technologies are not seeing day of light 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 their all 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 the stage of clinical trial and only less than 1% lead to 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 patients. Uh so they lose the sight to uh into the future that what would be the long term solutions or innovations or fugal 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 reduced number of or less number of surgical innovations. So, uh what's the need of innovation and collaboration? Uh The 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 in low middle income countries or in low resource settings, uh 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 report 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 accordingly in the last session also use. Uh It was emphasized the importance of identifying the need as the first principle of innovation. So it we are just underlining it again. Yeah, the priority of innovation should not be only centered around people who, who who makes uh who calls the shots. So who had the the uh who are affordable population? So the must have otherwise good to have. So you have to identify what is the core problem, which is generally the low drugs of population or the low resource settings. Whereas a few notice that the the innovations are created mostly for the people who can pay for those products and role of end user. I think this is role of end user does not stop by 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 this uh various stakeholders were invited to answer for a few questions around gaps in the innovation cycle and the stakeholders included ruler surgeons, patients, 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 health care providers is so huge that there is no separate time for researching or inventing new technologies. The research infrastructure itself is deficient that there is 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 an unsteady focus on healthcare innovations again because we mostly are busy with solving the current problem rather than foreseeing 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 uh are not there, even if they are there, they're not functioning in their, in their uh efficient way. So that is another uh barrier communication gap between the front line 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 won't. So that's another thing. There's a long development ti time for general health related uh innovations. You create an idea, you create a prototype, you test it, you again tested, you again, tested. There are 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 time in a healthcare innovation that is not very certain uh uh confidence that it will create profit uh or maybe it will not be huge. So that's another problem. Compliance rules regulations are uh very stringent around health care across the globe. So that's another thing. Plus credibility uh in low middle income countries, if you say the innovation has to come from their country. So, but in those areas, the credibility of a local made solution generally is not very high. So that's also a burden on uh local solutions which frugal promotes that it has to be based on local uh uh products, local things, local available resources. So that's another issue which we need to work on. So these are the various uh problems which we saw, we also asked that uh do they think there's a good communication between doctors, engineers and investors? And a big 74 person said no and only, so you could say only 8.6 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'll just, these are just screenshots, you will see this word appearing again and again, this is the collaboration, collaboration, collaboration, working together, multidisciplinary team, 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. I think the team which is uh multidisciplinary is the answer. So we have a summary slide, I think as straight go with 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 Aon is another good idea to create where a lot of solutions come out in a very quick amount of time innovation fellowships, uh matching and reverse matching between the engineering and medical word. Uh That can be one solution, prioritizing innovation uh in politic political and medical research, research methodology training for everyone to develop the links and teams, doctors and surgeons to become a part of startups so that the product is relevant, simplifying approval procedures, long term investment who only focuses on health care and will. So this is one solution which that is why I think this course is designed. The bye. Uh how on a scale of 1 to 5 when they were asked that, how do they feel the need of collaborations like its will bring surgeons, innovators and investor together a big uh 77% said yes, it will. And with a with a five score, there are hardly any 1 to 3 score. So this is the the collaboration which we created uh in uh 2022 last year where uh we hold the first conference in Delhi. And total registration was 2 45. Um 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. So which is a huge number. Uh and some innovative skills were also trained by using workshops. So uh the innovation cycle was already declared uh described in the first session. Uh The whole vision is to strengthen the eco innovation ecosystem for global surgery. And wherever there is a gap or deficiency, such collaborative networks can create uh and help the innovation cycle. I think uh uh this has been covered. So uh whenever we are innovating for global needs, I think we have to look for some key things. It has to be a responsible innovation. So I think I think it has to be about everything and importance of uh maintaining the climate and green 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 this is the first point I have kept reverse innovation whenever you are. Uh uh So it has to be both ways the from the gap to solution and solution to gap and it should complete the loop. The innovation has to be destructive that actually it should change the way things work and it has to be frugal, which has been emphasized in previous decision. So this is a 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 action plans or to do things which can be done. So for example, for need identification, there can be some immersion programs from students from medical and engineering backgrounds into each other's sphere. We can do some studies to just to identify uh needs from global surgery work so that, that can drive the innovation cycle. And that is a very important first step when you want to jump into fal innovation, adequate training for neurosurgeons and other surgeons and health care personnels, endangering uh skill sets and innovation, skill sets. And I think such programs like this one will be very helpful. Also the other way around uh some basic training about health uh care basics should be given to the innovators as well. Inadequate communication is a one problem statement between medical and engineering professionals. So again, we can have a repository of collaborators uh or some publicly accessed websites. So if I'm a surgeon, I want to innovate, I need the help of uh uh let's say robotic uh engineering expert, it 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 cycle 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 uh 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 uh very important and essential. Rather, there's a long term patency process and medical device regulation. Uh We have to have a, 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, tas sharing task shifting can be trained to such uh areas. So towards coming to the end, I think this collaboration is the key. Yes, we have to convert the eye to T 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 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 here. So please rejoin. Thank you. Uh Well, or do you if there are any questions or something we can take? Thank you very much, Anna. That was an amazing overview and some really valuable insights. And I do encourage you guys to check out the meeting in Kenya in April. It would be great to see some of you there, all the details on the screen now and it's just a really nice opportunity to actually meet face to face and discuss some of the the latest things happening in, in frugal innovation. Um But yeah, thanks. Thanks so much uh pros. Um I'll hand over now to um Noel to give his talk and I'll, I'll let him introduce himself now and share his slides. Thanks very much. Thanks, may what you will and uh thanks for an excellent talk. So my name is No, I'm a surgical registrar in the UK and also the Gaza past president and currently on the advisory board. I'm also finishing my phd in surgical Technologies where I've been a colleague with Will. I'm also part of the Edinburgh Colleges Global Surgery Foundation. I'm very thankful that they have uh supported and funded this course. So following the first two talks, I'm now going to take you into uh sort of more practical examples of what frugal innovation looks like uh in LM IC setting um using um examples of frugal surgical training uh through my experience as well as working in a collaborative for the last four years. Last year, uh inter gla colleges as well as training organizations had released the technology enhanced surgical training report called us Future of Surgery report for uh trainees globally. And one aspect we highlighted in this report was that frugal innovation is a key factor in addressing uh the inequities 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 uh especially for trainees who come from uh low and middle income countries. Uh and uh specifically for those who work in the rural settings of LM IC. Uh then these principles can champion and promote effective care uh that they want to provide for their patients. But it also focuses on uh on what or who is available in those settings. Again, uh highlighting the principles of innovations that we've heard recently. Uh and, and not merely uh basing it on the lack of uh the resources, the principles also value the people who have dedicated their time, their skills and their commitment for rural communities. And that could be because uh because of a calling on their life that they were to sell this population or they may belong to this population uh or, or, or that is their decision. The frugal surgical training also recognizes the cultural context of where the rural 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 rural surgeons who have been training other rural 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. Ok? I want to give you an overview of uh what the problem is and why rugal surgical uh 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 anesthetist and obstetricians. Um that uh the density we want to increase it to uh 20 specialist surgical anesthesia and obstetric workforce for 100,000 population. Uh 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 um as well as reduce uh the expenditures. This graph again taken from uh the Lancet Commission highlights the density of where the specialist surgical workforce is based. And as you can see, most of it is at least in this map uh is concentrated in the uh in the European countries as well as North America, but less so in the subs Southern Africa and Southeast Asia, some countries uh I can give you a comparison like uh in the UK. Um the U um density is about 73 to 74 per 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 S AO workforce. Um And you can see how low the density of this workforce is specialist workforce to be highlighted in this um subs Southern Africa as well as Southeast Asia. And by 20 twen by 2030 you can see how much more work needs to be done in parts of sub Southern Africa, Southeast Asia uh 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 uh how we, how we plan to uh increase the surgical workforce. But that's just not the only problem. There are also problems related to uh adopting uh technology in low resource settings. Uh The frugal surgical training has two components to it. One the technology itself. Um But the uh the second bit is uh the surgical procedure that associates with that technology but also other aspects of innovation, like the process of innovation that uh we highlighted earlier. But here, it's very clearly highlighted in this uh Lancet Commission of Technology that was published in Lancet in 2012, that uh the the necessary technology even does not exist. So we've not even uh thought about uh some of those innovations or ways of training people, let's say uh 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 is not accessible due to cost human resources or the energy supply and sometimes the technologies uh is accessible but is not adopted uh due to culture res resistance, human inertia. OK. I want to just briefly highlight the health technology assessment to you just because um this uh this is a systemic, a systemic systematic evaluation of a health technology or intervention um which as you can see, the World Health Organization focuses that it not only focuses on the clinical aspect uh that uh sometimes us as clinicians are interested in but also aspects around the economic aspects, the 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 policy makers on how they can allocate the funds to this particular technology or to this particular intervention. Uh and specifically uh to the training of uh the surgeons in in that particular health system. We need to identify what the uh the rural surgical community their priorities are. And uh based on this consensus statement that was released during the same time as the Lancet Commission, the associations of rural surgeons came up with these three main pillars on how these aspects can fit within uh within the the health system and the need for innovation and workforce, as well as the access to blood work, some of the most important uh aspects around how uh how the surgical care could be improved. So, uh this was an overview of um what are the aspects around improving surgical care in low resource settings uh with regards to uh the surgical uh specialist surgical workforce density uh as well as some of the principles of frugal innovation. And I want to highlight now uh the exemplar of laparoscopic surgery in LM IC setting. Um and just take you through how we have been working in the last 34 years in making laparoscopic surgery uh accessible uh in low resource setting, starting from training the the rural surgeons. Now here through the globe, search paper, you can see that uh laparoscopic surgery rate is extremely low in LM IC setting. But in those countries where laparoscopic surgery is performed, uh you can see that there is much lower rate of surgical site infection or complications here. Uh One of the studies done by one of the students that I was supervising highlights some of the barriers that are associated with laparoscopic training in low resource settings. And these, some of the seven uh barriers that were highlighted related to the funding available for the rural surgeons to get access to the training or the equipment like the simulators. Some of the rural surgeons that we worked with had never even seen a a laparoscopic simulator before. Um access to laparoscopic training within the surgical training that they are part of uh uh in some countries, especially rural surgeons do not have laparoscopic surgery as part of their training uh curriculum. And also port to practice. Uh We realize that the rural surgeons are a one man, one woman army in their rural settings and they cannot leave their healthcare set up and go and train for three or four days. Uh 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 rural 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 laparoscopy will happen in their setting. We need to understand that it has to have a low cost to learn the technology that we are proposing should be uh cheap to manufacture. It should be of 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 great value to low resource settings, the adoption process is not quick, but there were also other problems. Although we feel that a gas um laparoscopic 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 anesthetist who would give a journal study. And one of the uh rural surgeons uh doctor who will be giving the next talk uh came up with this idea of using the gasless laparoscopy, which is using this instrument that you can see called the abdominal wall lift device. So it essentially uh lifts the abdominal wall uh and creates intraabdominal space for the surgeon to perform a laparoscopic surgery. Uh even using uh spinal anesthesia for selective surgical abdominal procedures. So, uh as a group, we collaborated with surgeons in India and identified the rural 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 patients. We collaborated with organizations like Molo Nazar Medical College where where Professor Mitro is from and associations of surgeons, uh rural surgeons in India who had already initiated this project back in 2015, 2016. And we identified the projects and linked them up with those indicators uh of the Lancet Commission in Global Surgery, which was very essential rather than just uh 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 uh through the standards that have been set out by the Lancet Commission. The first study that was published by the Molo Naza Medical College. Uh It found that the gastro laparoscopy was a non inferior alternative to that of conventional laparoscopy. So the evidence started flowing in another systematic review and metasis that we conducted found that there was no difference between conventional laparoscopy versus gasless laparoscopy and the length of operative stay and, um, complications rates were much lower for gasless laparoscopy compared to that of open surgery and particularly the outcomes are better for gynecological procedures. We conducted cost effectiveness analysis where we identified that if the scale up of laparoscopic surgery is done in rural northeast India where a majority of the procedures have been done as open. Uh, we will, it reduce, uh, we will, we will reduce the um incremental costs that the patients are bearing as demonstrated on the graph on the left. Uh And it would also mean that $454 would be averted uh for those patients who would have laparoscopic surgery. We started training the rural surgeons uh using the fundamentals of laparoscopic surgery, uh training, uh which is usually the training that is given to American surgeons, uh a mandatory course that they have to do. Uh These were the rural surgeons who received the training using um standard laparoscopic simulators, low cost laparoscopic 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 uh gradually improved. Uh and they were really showing progress in their training. We then uh continue the training in their own settings where they were performing the gasless laparoscopy procedures uh on their patients using the spinal anesthesia and, and with uh with the supervisor unsedated theater. So, although uh this was uh hand holding for the rural surgeons, it proved to be an effective process mostly because the rural surgeons felt valued that people were taking interest in them, in their people and in their surgical skills. So, this was a proctorship that uh that was done in the rural healthcare set up. And we could see when our team was there, I was there, we saw the problems that they face. Sometimes anesthetist would not turn up, sometimes electricity will go away. Um So there are some real challenges that neuro 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 gasless laparoscopy was initially evaluated and implemented in high income countries in 19 nineties and two thousands. But after gas uh conventional laparoscopy taking off uh gasless laparoscopy unfortunately did not take off in high income countries. But we did identify that there was a rule of a gasless laparoscopy in low resource settings. And people are uh on this diffusion curve where um when we started as a group, most of us were in this early adoption phase. And then we reached 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 diffusion of gas laparoscopy happened was because of these champions who were based in uh big centers in Delhi in south of India, in east of India, who believed that this particular technology will be of benefit to those who are in the Northeastern India. And following the implementation of this uh procedure in Northeast India, uh the gasless laparoscopy now started disseminating in other parts of rural 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 gasless laparoscopy. And as 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 to tell people why this technology is important but also effective dissemination strategies through social media, through advocacy organizations like gas or other student bodies. We're also ready to face criticism because sometimes not everybody agrees to the technology that you want to promote. And now we can see that uh the the diffusion of this gasless laparoscopy 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 where a small project is now uh training rural surgeons in several parts of uh the world. We are also using other means of training like the virtual reality headsets that uh gives and makes uh training accessible to uh people just from their own settings. And finally, the benefits of gasless laparoscopy has been seen in high income countries like this hospital at uh in Leeds, uh found that using gasless laparoscopy could considerably reduce the carbon emissions and has proven to be a 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 brilliant talk and an amazing example of the frugal principles that we've heard about being applied to a real world project and indeed its relevance for training. So, thank you so much. Fascinating talk. Um It's now a great honor of mine to introduce our next speaker, Doctor G. If you can uh share if you can um 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. I really look forward to hearing your talk. Thank you for giving your time. Sure. Thank you. I'm probably one of the rural surgeons who have been working in uh rural 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 span about four decades. My journey with the frugal innovations started way back in uh the eighties when I was a medical student in CMC. When we started uh prayer group to support a mission organization was working in uh promoted rural areas in India and being uh located in a hospital, all the missionaries who came for treatment uh came to our prayer group and shared with the needs and uh remote areas. So what they said was the at that time, they were working in uh among the ribs in Gujarat with a population of about 3000 people spanning an area with a diameter about 300 kilometers with absolutely no doctors. So what can uh 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 that when you have a real passion to do something for what do you think is a cause which is worthy of pursuing? So what we did was, uh, we said that, uh, 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 them some uh medicines to how to, maybe we choose for 25 over the counter medicines and taught them how to use these things to sort of effectively treat the population better. And then, uh after that's completed, we actually went there. So then what we realized with that, uh I mean, we uh obviously when we started also, we had no money. So we had collected uh several boxes of uh electro medicines from the various uh churches. And uh started in the Veranda, one of the first converts in the tribal area for one year, nothing much is happening. Then we realize that uh even if you're working in a very remote rural area, we need to do a proper planning. So one day we decided to start 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 are trying to do and they built a house and the area which had 300,000 people without any. Can you go to the next lane, please? So then uh they realize that uh to serve these sort of people, it's difficult for mission organizations to do a lot of medical work. So then we shifted to a nearby mission hospital next la and uh we realized that uh in the mission hospitals, in addition to planning, we need to be very f proven the next one. So when you realize that that uh area had a lot of patients who had the upper G A cancers, we wanted to diagnose him earlier and we needed a gastroscope. So then when we went to C and C to see how they are doing gastroscopy, we found that uh I mean, they were very casual in handling the scopes of fibrotic those days and uh it was bending so much. And uh we thought uh even if we invest so much money will not last long. So we trained the nurses in that uh s hospital in such a way that one of the nurses will start. Uh I mean, uh passing the instrument based on the instructions that we give and there was a nurse specifically to make sure that the gastroscope does not bend too much. And the, the third person and later on, we also the best means or even those days when there are no laparoscopic and camera is easily available to have the picture so that everybody can have a look at uh what is happening. So these sort of innovations uh may actually made us uh serve them better. And the PX people who made the scope were really surprised that uh not a single broken fiber after many years of use. But then most of the innovations that uh we were carrying out were based on uh where is the simple needs that we had there? Because we understood that it is not possible to have whatever we want and we need to manage with the what is available there. So when you did not have any suction those days, we had this uh glass bottles and a rubber cap for it. So we used to put a Hypodermic syringe and needle and suck out the air to create vacuum. We start using these uh vacuum trains. And then we started using these even those days, the intermittent uh vacuum therapy for nonhealing ulcers. And then uh then we started uh what we call the chin incision. When, when we did not have any enough people to assist or enough uh where people give anesthesia, we divided the rectus abdominis uh attachment to the pubic symphysis that offered enough relaxation and we didn't, sometimes we could do cesarean section even with the ketamine when nobody was there to give anesthesia. So slowly, we wanted to improve the surgical care that we offer. I mean, offering in the rural areas. So when we wanted to start uh laparoscopic surgeries, you remember there was a time when we were operating using uh e and Ether for general anesthesia and the spinal and for most of the surgery that you are doing. So we started using the cystoscope that we had for diagnostic laparoscopies. And then later we use a cystoscope for making a small incision and uh pulling out the appendix and uh 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 patients in rural and remote areas. But then the real innovation uh started later. Next one, please. Ok. This is uh some of the things that you are saying and we started uh I mean, uh doing the ureter rescope uh for removing uh renal stones through the normal urinary passage. This is uh almost 10, 15 years ago. The next one, the the actual work uh started when my daughter started studying in an engineering college. So we had a lot of patients uh with chronic renal failure. And uh we were using the Baxter catheter for COPD. So then uh what happened was uh that these catheters, even though they are simple catheters quite expensive, the rural patient couldn't afford them. And the solution that we use for C APD again is uh fairly expensive and be beyond the reach of many other rural population. So we took one of these catheters to the engineering college, the head of the department and asked 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, you're not making in huge quantities. So we asked them how much they said that it'll cost ₹600 while the actual Cath was ₹14,000. So then we said, can you improve on the catheter because uh these catheters tend to get blocked to the omentum after two or three weeks. So then we had to replace them. So we asked them whether is it possible to have a catheter with memory which you can straighten using a still uh once in two or three days. So that uh the doesn't get uh come and block the catheters. They said it's possible. So then we started working with the engineering colleges and the universities and so on. And I think uh I mean, uh Noel and uh talk quite a bit about the way that we developed uh gastro uh laparoscopic surgeries because of that. And these collaborations very important because uh it made the people to work together, come together and uh and they understand what is happening. Clear, the biomedical engineers were not allowed to come to the, they didn't have much opportunity to visit the operating rooms in rural areas, but we took them to the various rural areas. They were able to find out what is happening and what is the real need in these areas. And that based on the various uh possible things that, uh, it is happening and to help us. And, uh, right now the latest thing that we are working is a laptop, uh, cystoscope, you know, as a urologist. Uh, mean, they, they've been, we need to at least a diagnosis, cystoscopy and the, the cystoscope for minor procedures. We realized that we needed, uh, there service in the rural hospitals. 5% of any outpatients have urology problems and only 2% of them are able to go to a urologist, uh get a proper evaluation and uh proper treatment. Even uh every month earlier, we used to find at least uh once or twice a month people coming with the ra you renal failure because of uh simple things like bilaterally uh calculate. So then, but the problem with the way the, I mean, the cystoscopes are not really available is because uh it's too much of an investment for a general surgeon or a rural surgeon to start doing cystoscopies because uh it's it is expensive to equipment. So we made a replace the telescope with the camera. And now we can just uh connect these uh laptop scos to a or laptop. And uh we don't need the the electricity or uh the light source and all the ancillary things which are necessary for copy. And we found that the image and another thing that we have is as good as that. So summarizing the frugal innovations, the journey starts when you really have a passion for uh serving the poor or the needy or the, what do you feel the people who need it? And these modern surgical techniques like the laparoscopy surgery or endoscopic surgeries, they are very more relevant for rural population than in 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. But the rural patient need to get back to work very and again, the first level and the turnover of uh patients in rural areas. And there again, the minimally invasive surgery helps uh quite a lot. But then the as no, briefly mentioned, the biggest problem in rural areas is that there are no general anesthesia, there are no anesthesiologist, even if you take anesthesiologist, uh getting gasses 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 innervation principle, what it does is that uh you mean, uh instead of looking for what we don't have, use whatever we have to make the things uh or 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 gastro laparoscopy surgeries in the rural areas for a long time, it's only few of us who are doing it. But then when we did a randomized control trial in Mo Medical College, and you were able to publish it, then they drew a lot of attention from uh the larger universities, then the engineering team and the 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 a 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 will be the problem. How big it may look, if you think there is a solution which is possible using whatever is already available, we can actually work towards getting it. Thank you. Thank you very much, Doctor G. That was uh excellent uh talk and it's really great to hear from your, er, as you said, you know, many years of experience in this context. Um Sorry, I couldn't give you four decades, but um it'd be, it'd be great to have you back at er, later modules. So, thank you very much. Um We'll move on to our next guest speaker if that's OK. Now, um pro pr who is an absolute master of frugal innovation and is going to give us 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, I'll be in the background. Ok. 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? Wonderful. Thank you so much for inviting me. And it's actually so uh moving to hear actual doctors and surgeons in the rural context like ra and no one talking about their frugal innovations. Uh I'm a academic in comparison. I have uh spent my um career studying innovation. In the first part of my, 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 had 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, the solutions were designed to help people who are outside the formal economy in urban slums, in rural 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 this tablet 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 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 °C 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. Uh His mindset is flexible and his intention is to be inclusive. Here's another example. Um So this is uh a baby wall. Uh This is an incubator. It's a beautiful machine from a company like GE. Um But it's about $25,000 and at that price is beyond the reach of most people, particularly those in rural 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 is $75,000. This baby is about $100. Now, obviously, it's not an incubator. It 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 design for extreme affordability. They came up with this prototype for that course. When they graduated, they went on to test it with mothers and midwives in rural 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 GE healthcare and GE healthcare sales force helped them to commercialize it. So my coauthors 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 Jar. So we ended up writing a book called Jar Innovation which we defined as the art of overcoming 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. Uh Dr Ganj 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. Uh 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 Gambara 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 is a lot of lateral thinking. 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 patients or customers, but also as part of the solution. And finally, as both our previous speakers were 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 and requires perseverance over a period of time. So here are some of the people we cover in the book and I'll start with man, this is a person, he's uh uh from a village in the Ministry 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 gave him 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 to sell them improving on the internet. And what's interesting is that he really embodies all those six principles of doing more with less keeping it simple. A lot of later thinking he makes the best use of limited resources and is a uh 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 Dr 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 cataract operation. So he set up a uh a set of hospitals in the hub and spoke model. And his idea was if we can do many of these, we get economies of scale, we 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, uh wards 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 nos, the lenses were expensive. So they set up their own factory to make them and now they even export them. Uh You may have heard of Dr Dave, she, he set up a cardiac hospital in Bangalore. And again, the idea is to use economies of scale. It is a very large hospital. 1000 be doing 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 low $1000 for each uh uh surgery. Another surgeon in India, uh, was trying to make a voice box for people who have lost their voice after cancer surgery. And he worked with toymakers, uh, to come up with this, uh, voice box that is, is about a dollar per voice box. So I, you know, I could go on telling you about examples from the emerging markets. Uh I think you've already heard many, uh, let me also now talk about uh, this phenomenon in the West. So after we wrote that book about emerging markets, we found there was a lot of interest in this phenomenon in the West for the West. And we realized that in the West, there was some slight differences in the West. This phenomenon was being driven by consumers. We call prosumer 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 sharing economy where now people like you and me, we can directly trade spare assets with each other on some digital platform. You think something like airbnb, for instance. Second, the Maker Movement, I think this has got very profound implications because now our 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 are 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 maker movement and I'll talk about Manu Prakash 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, uh how light weight it is. Uh And you can even use a smartphone uh to allow the user to take uh magnified pictures. And then his team also came up with a 20 cent hand powered blood centrifuge inspired by the kind of G game 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 Cellco has made a whole suite of medical devices uh that uh plug into the audio jack of the smartphone and then leverage its activity. So this photoscope here enables the mother to take high resolution pictures of the inner ear of her daughter when she has an infection and send those images to a consultant somewhere else. This device is a fraction of the cost of the stand alone device and it enables telemedicine 3d 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 tech shops or fab labs or make spaces where you have all these tools including digital manufacturing tools like 3D 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 tech shop near Palo Alto. Stanford in Palo Alto. They had this idea of a blanket that the mother could use to swallow the baby. But they realized that's not enough, they needed to have something that will keep temperature fixed and they didn't know how to do that. But at the tech shop, they met someone who happened to be a former NASA scientist and he told them about these face change materials, these waxy substances you can put in a pad which you can heat either with water or with 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 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 were using these principles to be able to innovate faster, better and cheaper. In the first wave in Northern Italy in Reka, 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 3D printing maker space actually just 3D printed these valves and supplied the hospitals. Then the hospitals actually ran out of the ventilators themselves. So they reid cuba uh diving masks to make the CPAP ventilators in India. Um A maker space in Mumbai created a network of maker spaces around the country who initially were making PPE for local front line workers and sharing their designs for others uh around the country to make uh 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 sharing the learning. So I'd like to conclude by saying that over the years, II 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 That was a 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 er presented and easy to understand and talk. So, thank you so much for that. Um So guys, we, we've come to the end of our scheduled talks this 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 um in the chat in the chat group here. Um I think one of the questions I'll ask if that's OK to start with as the moderator, I'll use my moderator rights to begin because I just wondered if I could ask Noel, a question, Noel in your talk, you spoke about how the gasless innovations that you developed with your team have a powerful sustainability argument, a green argument, reducing the carbon footprint and so on. I was just wondering if you could go into a little bit more detail about any of the lessons you've learned about how food innovation can make greener solutions and why you think that might be important for people to consider. I think, looking at the reason why Gasless Laparoscopy was initially uh implemented in low resource settings. Uh We discussed that it was due to lack of anesthetist and lack of access to carbon dioxide. Uh But those two very components if I'm allowed to use that word, uh are the ones that increase the uh carbon footprint. Uh because of the use of um anesthetic gasses as we know, um as uh 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 uh results in green innovation. And I think as surgical trainees or students or whoever we are on this call or you're 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? Uh actually going to result in the reduction of the carbon footprint. And I have been part of this project actively uh 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 that Edinburgh College has released the green surgery checklist. Um So I think um the the drive to green surgery is actually a result of uh what probably mentioned the COVID pandemic uh because we have realized how to uh function better with less uh or when the resources are constrained. Uh but also start looking at the positive aspect of uh how this frugal innovation can actually positively drive green uh eu uh 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 uh AAA positive thing rather than something that is uh that is kept for those who are in the low resourced or constrained environment. And I think that's not true. Um II, finally, I would also would like to say that it's, it's also the quality that uh frugal innovation offers uh to those who are in the low resource settings. Uh We have to be mindful that um we, 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, uh it also adds those additional benefits that uh green surgery offers. So it's a double win actually, for those who are in the low resource settings, that would be my take. Thanks very much. No, that's a really good insightful 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 really like that. I think that's going to be important part of the future. Um I think I might jump back to probably if possible whenever I sort of talk about frugal innovation to people for the first time, or maybe people who aren't as familiar with their frugal principles as some of the people on this call may be often people say, well, how are you going to make any money out of this? You know, 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 elevator pitch style, how would you sell the idea to someone who's purely focused on 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 uh 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 a 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 um hospitals and uh cardiac surgery in uh in Bangalore. Uh 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, uh 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 down 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, I'll address this to bother Prof MSER and Doctor Ganna Raj. I don't mind who, who wants to go first. Um But I'd be, I'd be really interested as, as clinicians yourself. Um You know, you might have a driver to use the most high tech solution for something 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 any sort of insights that you can give us to help with that. Uh Doctor go to go first, see again. Uh you know, the, the, when I was in the Cleveland clinic, when they were testing the di one C robot for, I mean prostate uh radical prostatomy. So then at that point, most of the urologists, they were happy to do a conventional laparoscopic surgery, but they were able to finish it much, quick, quickly. And uh they prefer there, I mean, this takes more time and so on. But then uh a couple of years later, everybody was doing only robotic and nobody did the the thing again, it depends on how you emphasize the thing. And here the volume is again, very important. I mean, thanks to COVID, uh most of the, I mean, the bigger places are not doing surgeries. So, Doctor Biju who was in a small mission hospital, he was able to do a lab colleagues with the gastro surgery with the supervision with Zoom because they, they're not able to travel. So once the task shifts and uh I mean, uh I mean, goes to start delegating to people, then the, I mean, the turnover occurs. So even gastroscopy whenever I do gastroscopy, my intention is to just finish as quickly as possible. And I'm not gentle by any means or, uh, the patients are not very happy, then we need to train the nurses to do gastroscopy. They are very gentle patients who actually prefer that. And, uh, I mean, I could see, I mean, because we had a monitor in front of me and I could see what they were doing. Is there any positive finding I could go take over do biopsies and do what is necessary task shifting is another thing which, uh, really helps, uh, in increasing the volume. But I think you probably will be able to tell us better about how to convince, uh, conventional surgeons, laparoscopic surgery. Yeah. Yeah, some, when you came into remission hospitals and they were doing actually the, for the first time in, uh, the mission hospital and laparoscopy surgeries. And we have these, uh, ports which are leaking and, uh, in which doesn't give enough pressure. So the pressure never go up to more than eight or nine even though they are used to operating at 12. So they themselves prefer the gastro laparoscopic surgeries while operating, uh, in, uh, the rural setting because they know the advantages. But then, uh, probably where places like medical college, they have a good facilities. I wanna probably to, to tell us how we can convince them. Thanks. Uh, so, uh, my experience is, uh, we meet two kind 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 from a tertiary teaching hospital. I think here also if we explain the value of it. And uh as will also in his talk mentioned that the frugal innovation has to project the value. So they 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 uh 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 would say is most of the time when we are selling frugal innovation, people try to just uh sell again, project it as uh that it's OK to be uh accepted as a substandard kind of thing and uh maybe a non scientific kind of thing. Whereas I think that should not be the case. Uh For example, in gasless laparoscopy, 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 worked in the right evidence require to persuade people to use it and demonstrating the value and need, I think is uh fundamental there. Um Well, guys, this has been a fascinating discussion and I've just seen that Gerard mcknight has posted a question in there that I think that if it's ok, I'll just quickly answer as well. But thanks for your question, Gerard, he says getting into innovation space can be challenging. How do surgical trainees? And let's extend that to anesthetic trainees, obstetric trainees, any healthcare trainee or a science trainee. Of course, how do they start off in this area? So I think, you know, obviously I'm biased but we need to speak to our audience. I think something like this course is a really good way of getting a good introduction, getting a good foundation. You know, if you look at a lot of university curricula and postgraduate training curricular, they don't include a lot about innovation skills. And it's something that a lot of people on this call are very passionate about changing and it is moving in the right direction, I think, but we need more courses like this because it gives people knowledge and skills and allows them to advocate for good quality innovation in their practice 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 funding opportunities. We have a, you know, a moderately sized funding pot for people to apply for seed funding so that they can take their innovation ideas to the next stage. Often it takes just a little bit of funding to get you a minimal viable product or your prototype or whatever it is off the ground or just concept stage. So that's the kind of thing that we hope to be able to provide through this course. So that might help people get started off. But um I think we, no, you've got your hand up. Very polite of evil jump in. I think uh the point of how surgical trainees can start off is actually by exposing them to a low resource setting or getting involved in a project. And I'm saying that because when I was in fy one, which means I had just finished medical school and started my first house job in the UK. And um there was a group of surgeons consultants who were going to a mission hospital on the borders of India and 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 changed my perspective on global health because I saw the disparities that uh uh existed in these low resource settings. And you know, the lack of technology that was resulting into that and so on. So for you to really understand the principles of what some uh some themes or 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 that 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 huge thanks to all the speakers for giving up your time and sharing your experience and expertise. It's been truly fascinating and just for those 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 check out this and um previous modules and indeed, the next module will be in April. The date will be announced on Gas Os Twitter page and website. So do follow us on Twitter, sign up our mailing lists to keep up to date. I've seen that a has had to sign off because he feels like there might be an earthquake there. So I do hope that he is ok. Um I'll give him a call after this talk. So, but don't worry guys, we'll stay in touch with him and yeah, I hope you have a great rest of the day guys and see you in future modules. Thanks again. Bye bye bye bye everyone. Thank you. Thank you.