‘They hear “Africa” and they think that there can’t be any good services’ – perceived context in cross-national learning: a qualitative study of the barriers to Reverse Innovation

Diffusion of innovation in healthcare is not linear; its pathway is chaotic and thorny [1]. In the most comprehensive review of innovation diffusion in services organizations to date, Greenhalgh et al. [2] compile what is referred to as the “standard” attributes of an innovation ripe for adoption. The ideal innovation has relative advantage, is compatible with the norms of the adopter context, is perceived as uncomplicated with observable benefits and finally, holds potential for reinvention. They also note that the adopter context needs to be ready to change and be receptive to the innovation. Innovations should diffuse more readily if the adopter is large, mature, specialized, and has the resources (human, financial, organizational etc.) for change [2]. Adopters must be willing and ready to accept a new idea.

The diffusion of innovation literature is curiously silent on whether one’s view of the source of an innovation matters in the diffusion process. Greenhalgh et al. [2] mention that the innovator-context should be a ‘legitimate’ source but then does not explain what constitutes ‘legitimate’. The marketing literature has been far more active in examining buyers’ perceptions of product country of origin. Buyers’ perceptions of particular extrinsic informational cues are one of the most widely studied phenomena in the international business, marketing, and consumer behavior literatures [3]. In the marketing industry, there has been extensive exploration of the relationship between consumers’ perception of product country of origin and consumer demand [4]. Much of this literature has focused on the likelihood that a source country will evoke either positive or negative consumer connotations [5–8]. Marketing research shows that when consumers see “Made in [Country],” this affects their evaluation of the product [4]. This Country of Origin (COO) effect has significant influences on perceptions of perceived quality or risk [3, 4]. There is a tendency for consumers to evaluate their own country’s products more favorably, as well as a positive relationship between product evaluations and degree of economic development of the product’s country origin [4]. Bilkey and Nes [4] note that a lower GDP cue is related to lower perceptions of quality and value. Products developed abroad in general are perceived as “riskier” than products developed in one’s own country. US-made products are perceived to be of higher quality than products made in low-income countries (LICs) and that specific brands might be evaluated higher or lower when LIC country of origin was revealed. Overall, country of origin has significant effects on consumer brand attitudes [9] and the country of origin of a product serves as a conflated, stereotyped measure for other product attributes [3]. This parallels behavioral research on stereotypes, which suggests that individuals use category membership as a heuristic basis for judgments without considering more detailed information about the object’s characteristics [10]. Psychologists call stereotypes ‘cognitive structures schema’, and believe that this schema simplifies a complex evaluation of something or someone by quickly processing incoming stimuli based on the presence of a few relevant characteristics [11]. This may be compounded by social and cognitive boundaries between different professions can lead to the “non-spread” of innovations. Communities of practice develop ‘ways of working’ (clinical, intellectual, professional) that can be relatively inaccessible to non-members of the group. McGivern and Dopson, refer to this as ‘epistemic communities’ and is a barrier to the transfer of knowledge, expertise and experience between groups [12].

The Reverse Innovation ‘movement’ explores the barriers to adopting low-income country (LIC) innovations in high-income country (HIC) contexts. It is motivated in part by the rapidly changing global health landscape and has gained traction in the US and UK because the unsustainable growth in healthcare expenditure means that there is likely to be a genuine need to learn from LICs [13]. LICs have developed novel innovations and there are multiple opportunities to learn from LICs, for example around improved surgical procedures [14], approaches to improve long-term outcomes in mental illness [15–19] and improved skill mix with scaled use of community health workers [20–22]. However, there are strikingly few examples where LIC innovations have been explicitly adopted in HICs [23]. Drawing on Roger’s diffusion of innovation theory, DePasse advances a diffusion pathway specifically for Reverse Innovation and emphasize that Reverse Innovation is a particular type of innovation diffusion because the learning is non-traditional, going from a low- to high-income country [24]. They suggest that a type of “crossover” is required, where ideas begin to transition from the LIC to the HIC, but shed little light on how this crossover is carried out other than to say that network structures within the adopter context must be receptive to the innovation [24]. In the context of Reverse Innovation, exploration into individual perceptions of sources that may be considered to be non-traditional would seem to be important, particularly given the strong social and cognitive boundaries associated with the healthcare professions, and yet there is little research that explores actors’ views of the innovation’s country of origin and whether it interferes positively or negatively with the adoption process.

We undertook an exploration of the barriers and challenges to Reverse Innovation in the US between September 2014-June 2015. Here we describe our interviews with nearly a dozen US experts in healthcare innovation, international health policy and health systems, including also experts from other spheres such as education and social policy, to examine whether, in their experience translating or attempting to translate innovations from low-income contexts into the US, the source of an innovation matters to actors in the adopter context.

Our research highlights a particular problem in the Reverse Innovation process – that prior expectations, invoked by the LIC cue, are interfering with a transparent and objective learning process. The informants, experienced in transferring or attempting to transfer evidence from low-income countries into the US context, describe a prevalent application of stereotypes towards other contexts, but particularly low-income countries. Actors conflate local context with national context, and draw on flimsy country-level conceptualizations to predict whether what works in one context would or would not work in their own. This process may occur with any context perceived to be different to one’s own, but is more apparent with low-income countries because these are less familiar, and media representations are perhaps more stereotyped than other contexts. The criteria with which people judge one context to be or not be similar to one’s own seem varied and diverse, but do not stop people from making those judgments with some confidence. We expected informants to cite technical differences between LICs and HICs, for example disease profiles and case mix, but instead general national stereotypes were more frequently noted. Advancing on the ‘not-invented-here’ culture, we describe a ‘not-invented-in-a-context-perceived-to-be-similar-to-here’ culture. From an evidence-based medicine perspective, this is less than desirable. Generalizability requires a detailed knowledge of context so that the causal mechanisms that explain the relationship between intervention and outcome may be identified in one’s own context. Context includes the structures and processes, the actors and the institutions, that are involved in a change process and that partially explain the relationship between an intervention and an outcome. An intervention on its own is necessary but not sufficient for an outcome. The delivery model, how it was implemented, the specific barriers and challenges, are part of the process too. Considering that no two contexts are the same, it does not follow that an intervention successful (or unsuccessful) in one location will automatically be successful in another. It is necessary to ‘know deeply’ the innovator context so that any inferences regarding transferability of an innovation to one’s own context can be properly assessed. These local explanatory variables are complex and certainly cannot be inferred from national-level generalizations alone, however our informants’ experiences suggest that this is a common occurrence. We interviewed informants from education, social policy and international law, and found that this experience is not unique to healthcare. McGill et al. found that practitioners working in the design and management of the built environment at local government levels in the UK are more receptive to interventions that have been ‘delivered in a similar country’ – although do not discuss how these actors determine what does or does not constitute similar [30]. Our research suggests that ‘similarity’ is a flimsy, very personal construct based on conflated micro and macro contextual characteristics and that this leads to stereotyped generalizations that can interfere with the Reverse Innovation process.

Although individuals may have explicit biases, implicit biases are not tangible or tied to rational thought. Country level stereotypes contribute to rash generalizations, and these often-negative associations can appear outside of an individual’s conscious awareness [5]. In an attempt to translate the Brazilian Community Health Worker model in to the health system in Wales, Johnson et al. describe confronting issues of ‘pride’ and ‘prejudice’ during the persuasion stage with local stakeholders [31]. Harris et al. (forthcoming) have found that public health academics rate research differently as a result of the source, in some instances [32]. There has been an increased interest in the psychology field in measuring aspects of thinking that may not be overtly accessible to individual consciousness [33] and there is now an extensive literature on what is referred to as the “introspectively unidentified” [34]. Judging probability based on the essential features of a parent population is a heuristic, a mental short cut, which in all likelihood will be inaccurate and lead to false faith in some cases, and missed opportunities in other cases [35].

It is striking that although country of origin cues are considered highly important in the marketing industry, in healthcare research relatively little attention has been given to how individual actors perceive the quality and value of research or evidence from certain contexts. In healthcare research, much more emphasis is placed on the internal validity of the research, its conduct, risk of bias, and fidelity to research methodology, the structural and institutional ingredients to manage change and the characteristics of the innovation itself. The marketing industry has developed techniques of counter-stereotyping and branding to address potential biases towards certain sources [5]. Perhaps these techniques could be adopted in the health industry as well. Greenhalgh et al. note that context and confounders lie at the very heart of diffusion of complex innovations and are not extraneous to the object of study; they are an integral part of it [2]. Rogers touches on the idea of homophily as an impediment in the adopter context, a sociological concept that individuals have a tendency to associate with others of their same kind [36]. Homophily is heightened within healthcare organizations [37] and narrows an individual’s social world, leading to “herd” behavior [38, 39]. As a result of homophily, individuals within the healthcare sector who are most in need of innovation may actually be the least prone to adopt it [40]. Nonetheless, curiously absent is examination of the impact of actor perceptions of the innovator context. Considering that within countries, regions and cities have different economic, social and cultural landscapes, country-level generalizations hold even less merit.

This study is not without its limitations. Our informants are all from the US context only and we have not captured the views or experiences of front-line clinicians or service users as this was beyond the scope of the study and our resources. Although we have described some valuable insights that might stimulate academic debate we cannot generalize our findings to other contexts. Further research should be conducted in other high-income contexts, broadening also the pool of respondents to front-line clinicians and patients. Finally, our interviews were a mix of telephone and face-to-face interviews and it is possible that the different modes might alter the responses. There are, however, lessons to be learned by developed country health systems from experiences in developing countries, and opportunities for Reverse Innovation, where necessity and ingenuity have overcome resource constraints to achieve positive outcomes. We must allow ourselves to ‘know’ these contexts better before assuming they are too different for any learning to hold merit [41].

Acknowledging the limitations of the research study, our findings suggest that those interested in Reverse Innovation should reflect carefully on the value of disclosing the source of the innovation that is being proposed, if doing so is likely to invoke negative stereotyping. There may be merit in adopting some techniques from the cognitive psychology and marketing literatures to understand better the relative importance of source in healthcare research and innovation diffusion and efforts to develop counter-stereotyping techniques may be useful in a diffusion of innovation process.