NIHR ARC NWL Innovation and Evaluation Theme Publications


1. Dallera G, Palladino R, Filippidis F. Corruption in health care systems: trends in informal payments across twenty-eight EU countries, 2013-19

Health Affairs. 2022 doi: 10.1377/hlthaff.2021.01931 (September 2022)

Corruption is a major challenge in health care systems across the European Union (EU), where it manifests most visibly as informal payments from patients to providers. We examined trends in informal payments across twenty-eight EU member states between 2013 and 2019 in relation to changes in public health care expenditure, using representative data from Eurobarometer surveys. We found that the prevalence of informal payments in EU health care systems increased during those years, but perception of corruption decreased, with significant differences between countries. We also found that higher public health care expenditure was associated with fewer informal payments; however, this relationship became less clear throughout the study period. Our study can inform further research to investigate drivers of informal payments at the health systems level and to understand the directionality of the relationship between informal payments and public health care expenditure. Our findings also point toward the need to couple public health care investments across EU member states with measures to strengthen health systems to effectively confront corruption.

2. Almomania HY, Pascual CR, Grassby P, Ahmadi K. Effectiveness of the SUGAR intervention on hypoglycaemia in elderly patients with type 2 diabetes: A pragmatic randomised controlled trial.
Research in Social and Administrative Pharmacy. 2022 doi: (October 2022)

This paper highlights the effectiveness of a pharmacist-led, individualised, educational intervention, called SUGAR handshake. SUGAR handshake was formulated to prevent hypoglycaemia among elderly patients with type 2 diabetes mellitus (T2DM). The intervention reduced the prevalence of reduce rate and incidence of hypoglycaemia in the elderly, whilst increasing hypoglycaemia-free survival probability. The SUGAR intervention did not increase the risk of fasting hyperglycaemia. This intervention is applicable to any settings in any parts of the world. We invite the clinicians, evaluation experts and researchers to evaluate the feasibility and scalability of this intervention, accordingly.

3. Dallera, G., Skopec, M., Battersby, C. et al. Review of a frugal cooling mattress to induce therapeutic hypothermia for treatment of hypoxic-ischaemic encephalopathy in the UK NHS.

Global Health. 2022 doi: (April 2022)

Hypoxic-ischaemic encephalopathy is a brain injury that occurs when there is insufficient oxygen in the brain of a newborn around the time of birth. This condition affects several newborns in the UK every year. When it manifests severely, it can cause long-term disability or even death. The current standard of treatment is therapeutic hypothermia, that consists of cooling down the body temperature of the newborn to 33.5℃ for 72 hours, starting as soon as possible after the incident. The equipment that is normally used in high-income countries to induce therapeutic hypothermia is technologically sophisticated and therefore very expensive. This paper reviews a cooling mattress made of phase-change materials that was recently developed in India as a safe, efficient, and affordable alternative to expensive high-tech cooling devices, and explores the potential of this frugal innovation for use in the UK NHS. We show that there is a strong case for its adoption in geographically remote areas of the country where cooling equipment might not be immediately available, to ensure that treatment can be started as soon as possible while waiting for the arrival of transport teams to the nearest intensive care unit, using a simple and cost-saving solution.

4. Nakubulwa M, Junghans C, Novov V, Lyons-Amos C, Lovett D, Majeed A, Aylin P, Woodcock T. Factors associated with accessing long-term adult social care in people aged 75 and over: a retrospective cohort study.
Age Ageing. 2022 doi:
doi: 10.1093/ageing/afac038 (March 2022)

This paper explores whether the need for state funded care can be predicted using routine data from health and social care, in order to manage demand and proactively implement prevention. Past attempts of modelling this, either with bespoke data or limited to health data, have not been useful in the main. We conclude that modelling can be useful to a limited extent, but that social care in particular does not lend itself to prognostic modelling. This is because factors that determine the need for care are often unpredictable or not routinely recorded and unlikely to be recorded in the future. We therefore advocate a paradigm shift away from data driven to relational approaches in order to implement prevention timely and effectively.

5. Price R, Skopec M, Mackenzie S, Nijhoff C, Harrison R, Seabrook G, Harris M. A novel data solution to inform curriculum decolonisation: the case of the Imperial College London Masters of Public Health.
Scientometrics. 2022 doi:
10.1007/s11192-021-04231-3 (January 2022)

Imperial College London has developed a novel methodology to automatically analyse the geographic distribution of readings on university reading lists. This collaborative effort between researchers, the Imperial College Central Library, and Imperial College ICT aims to provide course instructors with an efficient way to query the content of their taught courses, and to consider whether certain viewpoints and perspectives are unknowingly given precedence over others. In this paper, we detail the methodology, discuss the results produced from the analysis of one course, and reflect on the role the tool can play in broader efforts to ‘decolonise’ higher education.


1. Issa H, Townsend W, Harris M. Benefiting the NHS through innovation: how to ensure international health partnerships are genuinely reciprocal.
BMJ Global Health. 2021 doi: 10.1136/bmjgh-2021-004936 (December 2021)

International health partnerships are potential vehicles for the NHS to learn and benefit from the innovations of low- and middle-income countries. However, to achieve these, partnerships need to transform their approach to knowledge exchanges. In this perspective article, we describe that to do this effectively, partnerships must be equal, genuinely reciprocal and with explicit shared decision-making so that all partners are willing to learn technical expertise from each other.

2. Selhorst S. O’Toole R, Slobogean G, Harris M, Bhatti Y, Enobun B, O’Hara N. Is a Low-Cost Drill Cover System Non-Inferior to Conventional Surgical Drills for Skeletal Traction Pin Placement?
Journal of Orthopedic Trauma. 2021 doi: 10.1097/BOT.0000000000002064 (November 2021)

In orthopaedic surgery, electric drills are used to drill holes in bones for procedures such as hip replacements or to fix fractures. However, drills are usually very expensive because they need to be made of special material so they can withstand the high temperatures in hot ovens, used to sterilise them before an operation. This article reports a trial in a trauma hospital in Baltimore, US, of a device called Arbutus Drill System, that was developed in Malawi and Uganda. It uses a regular hardware drill instead of an expensive drill, but it is made sterile for an operation by inserting it into a sterile bag. This makes the cost of the equipment a lot lower, and therefore saves money for the health system. Frugal innovations such as these commonly come from low-income countries and is a good example of something we are promoting for use in the UK NHS.

3. Harris, M, Kreindler J, Donnat C, El-Osta A, Filippidis F, Esku T. Are vaccine passports and covid passes a valid alternative to lockdown?.

BMJ. 2021 (November 2021)

Responding to a debate article on the value of vaccine passports to control COVID19 transmission in mass, live events, we argue that such a polarised debate can be avoided if the vaccine status of attendees is used as data for onward modelling of transmission risk at the event, rather than as a passport for entry to the event. Vaccine passports polarise society because on the one hand they serve the public interest around reducing transmission risk, but only by sacrificing individual freedoms. We argue that these are irreconcilable tensions.

4. Hindocha CN, Antonacci G, Barlow J, Harris M. Defining frugal innovation: a critical review.

BMJ Innovations. 2021. doi: 10.1136/bmjinnov-2021-000830 (October 2021)

Frugal innovation can be referred to as an innovative solution to address resource-constraints that are affordable and accessible to low-income consumers. Coupled with the popularity of frugal innovation across various sectors, multiple and diverse definitions have emerged that often lack a theoretical foundation. This subsequently led to an ambiguous conceptualisation that hinders research and adoption in practice. Despite this plethora of perspectives and definitions, scholars do agree that there is a need for a unified definition. This critical review across the management, entrepreneurship, business and organization studies literatures explores the multiple definitions of frugal innovation that have appeared in the last two decades and seeks to examine the commonalities and differences and explores potential themes to provide clarity around what constitutes a frugal innovation. We propose that defining frugal innovation as a concept should not deter from focusing on its core aim and identifying a FI may be best achieved by comparing it to an incumbent alternative, rather than against an ill-defined concept. There is merit in developing a common understanding of FI to support strategies for its successful acceptance and diffusion globally.

5. Stefani G, Skopec M, Battersby C, Harris M. Why is Kangaroo Mother Care not yet scaled in the UK? A systematic review and realist synthesis of a frugal innovation for newborn care.
BMJ Innovations. 2021. doi: 10.1136/bmjinnov-2021-000828 (October 2021)

Kangaroo Mother Care is a technique used at birth to care for underweight or preterm babies. It is standard practice in many regions in the world where incubators might not be available, and it is very safe and effective but not yet used at scale in the UK. In this review of the literature, we explore the barriers and challenges to its use in the UK, finding that neonatal units are not yet architecturally designed to accommodate the mother-baby care that KMC requires.

6. Sharma D, Harris M, Agarwal V, Agarwal P. A plea for standardised reporting of frugal innovations.
BMJ Innovations. 2021. doi: 10.1136/bmjinnov-2021-000710 (September 2021)

Frugal innovations are solutions to healthcare problems that save money without scrimping on quality or safety. However, when researchers write about frugal innovations there are no clear guidelines for them to follow to ensure that they are reporting them in similar ways to each other. This makes it hard for others to compare frugal innovations to each other, or to search for examples of frugal innovation in the literature or internet. In this article, with surgeons and scholars from Jabalpur, India, we propose a framework to help researchers describe and report on frugal innovations. This will help disseminate comprehensive and clear detail on these important solutions.

7. Okere NE, Lennox L, Urlings L, Ford N, Naniche D, Rinke de Wit TF, Hermans S, Gomez GB. Exploring sustainability in the era of differentiated HIV service delivery in Sub-Saharan Africa: A systematic review.
Journal of Acquired Immune Deficiency Syndromes (JAIDS). 2021. doi: 10.1097/QAI.0000000000002688 (August 2021)

The World Health Organization recommends differentiated service delivery (DSD) to support HIV care. DSD is a client-centred approach which adapts HIV services to serve the needs of people living with HIV better and reduce unnecessary burdens on the health system (e.g., home delivery of prescriptions or appointments in community settings rather than hospitals). Despite good patient outcomes, there is limited evidence of DSD intervention sustainability. This review investigated the sustainability of DSD interventions in sub-Saharan Africa (SSA). 34 articles were included in this review and reported 39 different DSD interventions across 10 SSA countries. This work provides insight into how specific sustainability factors support or hinder the sustainability of different DSD interventions. We found that DSD interventions in sub-Saharan Africa may be sustainable but may require additional support in aspects such as resources and stakeholder involvement to enhance sustainability. These results provide a resource for policymakers to make informed decisions about which DSD intervention to implement based on their potential sustainability.

8. Skopec M, Fyfe M, Issa H, Anderson M, Ippolito K, Harris M. Decolonisation in a higher education STEMM institution - is 'epistemic fragility' a barrier?
London Review of Education Special Edition: Decolonising Higher Education. 2021. doi: 10.14324/LRE.19.1.18 (June 20201)

Higher education institutions are beginning to critically reflect on whether underlying prejudices or preconceptions have been informing the ways that educators teach students. For example, focussing mostly on western sources of knowledge, or research from very prestigious universities, means that knowledge from other regions of the world may be being systematically ignored. This article reports on efforts at Imperial College London to address some of these issues and describes several important tensions that may appear through efforts to ‘decolonise curricula’. These include the tension between the social and natural sciences, and whether educators are being objective or not in how they teach. We describe how sometimes it can be a difficult conversation to ask educators about how they teach and may be perceived as confrontational. We make suggestions for how to approach this issue and have been advancing this agenda at Imperial College London.

9. Lennox L, Eftychiou L, Matthew D, Hanna J, Winn T. What risks to sustainability are identified throughout care bundle implementation and how can they be addressed? A mixed methods case study.
BMJ Open. 2021. doi: 10.1136/bmjopen-2021-048815 (May 2021)

Although there is national guidance on how to identify and treat heart failure (HF), variation in HF care persists across UK hospitals. Care bundles (a set interventions supported by research—that when used together cause significant improvement in patient outcomes) have been proposed as a way to deliver reliable care for HF patients. However, specific challenges to sustain care bundles in practice have been highlighted. Lack of sustainability of best practice care for HF poses a significant risk, as this condition requires continuous and consistent care to support the best outcomes and quality of life for patients. The purpose of this paper is to explore how a multidisciplinary team (MDT) planned for and influenced the sustainability of an HF care bundle (HFCB). This work describes the sustainability challenges encountered throughout implementation and how these issues were addressed by the MDT to enhance sustainability over time. Through this leaning, we hope to provide practical lessons for practitioners and researchers who are seeking to embed and sustain care bundles in practice.

10. Lennox L, Barber S, Stillman N, Spitters S, Ward E, Marvin V, Reed JE. Conceptualising interventions to enhance spread in complex systems: a multi-site comprehensive medication review case study.
BMJ Quality & Safety. 2021. doi: 10.1136/bmjqs-2020-012367 (May 2021)

We know that many promising improvements in care fail to spread, remaining isolated within the local setting in which they were created. This leads to variation in care processes and outcomes across healthcare organisations and contributes to healthcare inequalities. This study investigated the spread of a comprehensive medication review (CMR) intervention to (1) describe the work required to spread from the improvement team perspective, (2) identify what stays the same and what changes between the different sites and why, and (3) assess the ‘hard core’ and ‘soft periphery’ (HC/SP) construct as a way of conceptualising interventions. We suggest a new approach to spreading improvements. This approach considers not only the evidence-based intervention (e.g., medication review checklist) but also considers the work to support implementation of the review (e.g., the need for staff education on how to use the checklist) and systems needed to implement the intervention (e.g., changing electronic systems to record the checklist results). We believe this approach will better prepare improvement teams for the realistic work needed to spread interventions in practice.

11. Donnat C, Bunbury F, El-Osta A, Filippidis F, Kreindler J, Esku T, Harris M. A Predictive Modelling Framework for COVID-19 Transmission to Inform the Management of Mass Events.
medRxiv. 2021. doi:
10.1101/2021.05.13.21256857 (May 2021)

Mass, live events such as concerts and festivals have the potential to be super-spreaders for COVID19 transmission because many people are crowded together in confined spaces. Infectious disease researchers have been able to develop ways to predict how viruses spread in different types of spaces, such rooms, halls, theatres and stadiums. It is crucially important to be able to predict the transmission of COVID19 at a specific event, but this is difficult because it depends also on the types of people that attend the event, whether they have been vaccinated or not and whether they have been infected or not. In this article, with researchers from Stanford University, University of Chicago and University of Tartu, we describe an algorithm that can use ticket holders’ data, combined with the transmission modelling equations, to predict transmission at specific events. This is being used to help manage live events such as the Standon Calling festival that took place 22-25 July 2021 and to inform government policy around live event management in the future.

12. Harris M, Kreindler J, El-Osta A, Esku T, Majeed A. Safe management of full capacity live/mass events in COVID19 will require mathematical, epidemiological and economical modelling.
Journal of the Royal Society of Medicine (JRSM). 2021. doi:
10.1177/01410768211007759 (April 2021)

Mass, live events such as concerts and festivals have the potential to be super-spreaders for COVID19 transmission because many people are crowded together in confined spaces. Some solutions to prevent spread include testing people on-the-door or at-home. Testing on-the-door is problematic because it means turning away people that are positive for COVID-19. Testing at-home relies on trust, that the right person is collecting the sample in the right way. In this article, we propose a ticketing-testing system that is a collaboration between the live event organizer, the consumer and test providers to video people taking tests at-home. This ensures samples are correctly collected and builds confidence in the event because there will be a higher chance that attendees are correctly identified as being clear of infection. We are collaborating with scholars in Estonia, Stanford University and University of Chicago to develop this into a tool that calculates the risk of transmission at an event, and it has informed policy in the Department of Culture, Media and Sports.

13. Antonacci G, Lennox L, Barlow J, Evans L, Reed J. Process Mapping in Healthcare: a systematic review.
BMC Health Services Research. 2021 doi: 10.1186/s12913-021-06254-1 (April 2021)

Process Mapping (PM) is a powerful technique for understanding healthcare processes and the journeys of patients and service users. It then enables quality and other improvements in care delivery, patient experience and workflows. If used well, Process Mapping helps us understand “work as is” rather than “work as imagined”. It is therefore a potentially important tool to identify areas for quality improvement or to understand the settings in which new interventions may be introduced. However, there is little research on its use in healthcare. In this paper we review literature on the Process Mapping methodology and on its use in the healthcare setting. Reviewed studies highlighted the value of Process Mapping in supporting healthcare improvement interventions. We found that Process Mapping is used in a variety of healthcare settings (e.g., in-patient services, outpatients, primary care) and approaches to improvement (e.g., to support process re-design within quality improvement initiatives, to provide a visual representation of patient journeys, to support the design of health information systems, to calculate costs). We also identified 10 quality criteria to guide the effective use, evaluation and reporting of Process Mapping exercises. However, by assessing the initiatives reported in the reviewed literature (105 studies) against these criteria, we found inconsistencies in reporting and in adherence to the quality criteria. None of the studies adhered to all the criteria and only 7% studies adhered to 8/10 or 9/10 criteria. Our analysis suggests that poor adherence with quality criteria reflects not just problems in the reporting of Process Mapping, but also with the conduct of the method. We conclude that the full potential of Process Mapping is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application and reporting of the method is required. We encourage the use and further development of the proposed quality criteria to support training, application and reporting of PM.

14. Price R, Skopec M, MacKenzie S, Seabrook G, Nijhoff C, Harris M. A novel data solution to analyse decolonisation of curricula - The case of Imperial College London Masters in Public Health.
Preprint. 2021. doi: 10.31235/ (March 2021)

Movements such as Black Lives Matter and Rhodes Must Fall have thrown a light on how prejudices perpetuate throughout science, medicine and higher education. Increasingly, educators are asking whether the reading lists they provide to students exclude certain regions, or scholars, or types of research, because of entrenched, albeit unconscious, beliefs about what is worth including in the curriculum. This article details a novel method to convert reading lists into machine-readable code, and then graphs and maps, to show where educators are teaching from. Visualising where course material comes from is a helpful first step towards reflecting on issues of prejudice and bias in teaching. We are collaborating with the Central Library to promote the use of this tool across all departments in Imperial College London.

15. Saddi F, Harris M, Pego R, Lozano R, Mundin P, Peckham S. Exploring front liners’ knowledge, participation and evaluation in the implementation of a pay for performance program (PMAQ) in primary health care in Brazil: a qualitative analysis.
Journal of Health Organization and Management. 2021. doi:
10.1108/JHOM-04-2020-0154 (March 2021)

In this research article, we explore the perceptions of frontline health workers of the PMAQ – the Brazilian policy to expand access and quality of primary care. This system encouraged and rewarded improved clinical care in primary care through increased payment and financial reimbursement of clinicians and teams. We found that limited knowledge and understanding of the policy and processes led to reduced engagement in the system by healthcare workers.


1. Skopec M, Grillo A, Bhatti Y, Kureshi A, Harris M. Double standards in healthcare innovations – the case of mosquito net mesh for hernia repair.
BMJ Innovations. 2020. doi: 10.1136/bmjinnov-2020-000535 (December 2020)

A notable example of a frugal innovation is the mosquito net mesh, used for treating inguinal hernias. In the UK, commercial mesh, which is very expensive, is used to treat hernias, however in India and throughout Africa, mosquito nets, which are made of similar material to commercial mesh, has been used instead. It is ten thousand times cheaper, and studies have shown that it is as effective and safe to use. In this article, we build on this knowledge by showing that mosquito net mesh is also much more similar to abdominal wall muscle than commercial mesh. We also argue that the fact mosquito net mesh is recommended only in low-income countries is a glaring double standard. There is a strong case for using it in the UK NHS as well.

2. Shimizu H, Santos LMP, Sanchez MN, Hone T, Millett C, Harris M. Percepções acerca do Programa Mais Médicos e do Processo de Supervisão Acadêmica.
Revista Brasileira de Educação Médica. doi: 10.1590/1981-5271v44.4-20200211 (November 2020)

In this research article, we examine how doctors and policy makers experience the “More Doctors” programme in Brazil, a national policy to expand medical care into deprived regions. Through qualitative research methods, such as interviews and focus groups, we found that the system helped to improve access to care in vulnerable areas but that much more was needed to better integrate clinicians into the wider healthcare system.

3. de Medeiros OL, Barreto JOM, Harris M, Russo LX, da Silva EN. Delivering maternal and childcare at primary healthcare level: The role of PMAQ as a pay for performance strategy in Brazil.
PLoS ONE. 2020. doi: 10.1371/journal.pone.0240631 (October 2020)

In this research article, we estimated the relationship between the PMAQ (the Brazilian policy to expand access and quality of primary care through payment for performance incentives) and the provision of maternal and child healthcare. We found that consultations increased, particularly in the under 2-year-old group, but little evidence that this increase in care provision was sustained over time.

4. Lennox L, Linwood-Amor A, Maher L, Reed J. Making change last? Exploring the value of sustainability approaches in healthcare: a scoping review.
Health Research Policy and Systems. 2020. doi:
10.1186/s12961-020-00601-0 (October 2020)

Sustaining improved outcomes and processes is a recognised challenge to healthcare staff and stakeholders. Various definitions and factors of sustainability make it very complicated for researchers and practitioners to understand or influence sustainability in practice (for this paper, sustainability was defined as: “after a defined period of time, a program, clinical intervention, and/or implementation strategies continue to be delivered and/or individual behaviour change is maintained; the program and individual behaviour change may evolve or adapt while continuing to produce benefits for individuals/systems”(Moore et al, 2017)). To address this challenge many researchers and healthcare practitioners have developed sustainability frameworks, models, and tools to assess sustainability of improvement projects. Although there is increasing interest in using sustainability models or tools, little work has been done to understand how such approaches have been used and how they have impacted research or practice. This review aimed to examine the current evidence on the application and impact of sustainability models and tools in healthcare settings. 68 articles were included in this review. This review provides healthcare practitioners, researchers, and improvement team members with a summary of the current evidence base on sustainability models and tools, including the benefits and challenges that arise through their use and the outcomes they have contributed to. Results found that sustainability models and tools have been used to assess, evaluate, analyse, and guide sustainability measurement and research. Benefits of use include improved understanding of the barriers and risks to sustainability, improved understanding of sustainability factors and improved ability to organise, analyse and interpret sustainably data. The literature also documented challenges including difficulty in applying tools in practice and need for improvement in design. These findings highlight the need for thoughtful consideration of the potential impact prior to use in practice.

5. Al-Saffar M, Hayhoe B, Harris M, Majeed A, Greenfield G. Children as Frequent Attenders in Primary Care: A Systematic Review.
BJGP Open. 2020. doi: 10.3399/bjgpopen20X101076 (October 2020)

Frequent paediatric attendances make up a large proportion of a GP’s workload, but little is known about the clinical and demographic characteristics of these patients. In this review of the literature, we discovered that frequent attendance was associated with mental health problems, younger age, school absence and presence of chronic conditions.

6. Zhou J, Blaylock R, Harris M. Systematic review of early abortion services in low- and middle-income country primary care: potential for reverse innovation and application in the UK context.
BMC Globalization and Health. 2020. doi:
10.1186/s12992-020-00613-z (September 2020)

In the UK, women can access abortion services only through third party providers in the non-profit sector or in hospitals. However, in low-income countries, where access to these services may be more challenging, medical abortion services are provided in primary care clinics, and oftentimes supported by nurses, rather than specialist gynaecologists. This is a more accessible and cheaper provision for women in these settings. In our article, we reviewed all the research literature to identify whether this way of providing early medical abortion services is safe, effective and acceptable to women and healthcare professionals. We conclude that they are, and that the UK NHS could benefit from providing these services in primary care as well, increasing timely access for many women.

7. Joseph E, Ismail S, Gunst M, Jarman K, Prior D, Harris M, Abbara A. A qualitative research study which explores stakeholders’ views on healthcare access for refugees in Greece.
International Journal of Environmental Research and Public Health. 2020. doi: 10.3390/ijerph17196972 (September 2020)

This research study explored the views of key stakeholders providing healthcare for refugees in Greece. Using qualitative interviews, we found that there were significant human resources shortages, weak health systems and legal barriers, impeding access to care for Syrian refugees.

8. Hone T, Sanchez M, Pacheco L, Harris M, de Oliveira F, Powell-Jackson T, de Sousa R, Millet C et al. Low policy fidelity undermines investments in human resources for health: evidence from a quasi-experimental analysis of the More Doctors programme in Brazil.
BMC Health Services. 2020. doi:
10.1186/s12913-020-05716-2 (September 2020)

In this research study, we examined whether the emergency deployment of 17000 Cuban doctors to expand access to primary care in remote regions was consistent with programme criteria. We found that increases in doctor supply was lower in priority municipalities however there was a reduction in mortality in these regions.

9. Younan H, Junghans C, Harris M, Majeed A, Ghani S. Maximising the Impact of Social Prescribing on Population Health in the era of COVID-19.
Journal of the Royal Society of Medicine (JRSM). 2020. doi: 10.1177/0141076820947057 (September 2020)

Social prescribers are community health workers that recommend activities and lifestyle advice to help people with common healthcare problems. However, the evidence for the benefit of social prescribing is quite limited with some studies demonstrating that there is no impact at all. In this article, we compare the role of social prescribers to other types of Community Health Workers in the UK and around the world. We argue that their role would be more effective if they focussed on much smaller areas, were integrated into primary care and provided services universally to all households and age groups in their catchment area, rather than just to those that were referred in from the GP. This model mirrors that used in Brazil to great effect and we continue to advocate for the NHS to adopt this approach.

10. Zhou J, Blaylock R, Harris M. Systematic review of early abortion services in low- and middle-income country primary care: potential for reverse innovation and application in the UK context.
BMC Globalization and Health. 2020. doi:
10.1186/s12992-020-00613-z (September 2020)

In the UK, women can access abortion services only through third party providers in the non-profit sector or in hospitals. However, in low-income countries, where access to these services may be more challenging, medical abortion services are provided in primary care clinics, and oftentimes supported by nurses, rather than specialist gynaecologists. This is a more accessible and cheaper provision for women in these settings. In our article, we reviewed all the research literature to identify whether this way of providing early medical abortion services is safe, effective and acceptable to women and healthcare professionals. We conclude that they are, and that the UK NHS could benefit from providing these services in primary care as well, increasing timely access for many women.

11. Tobias R, Schweickardt JC, Harris M. Access to healthcare in the remote and resource-poor region of the Brazilian Amazon In Gulliford, M. and Jessop, E. eds. Healthcare Public Health: Improving health services through population science.
Oxford University Press. 2020. doi: 10.1093/oso/9780198837206.001.0001 (August 2020)

This chapter describes the Brazilian health system in an extremely remote region, the Brazilian Amazon and how primary care is delivered in this unique and very challenging context. River boat clinics are used to reach distant communities that are cut-off from the rest of the health system and visits follow the seasonal fluctuations of the Amazon River

12. Buitendijk S, Ward H, Shimshon G, Sam A, Sharma D, Harris M. COVID19: an opportunity to rethink global cooperation in higher education and research.
BMJ Global Health. 2020. doi:
10.1136/bmjgh-2020-002790 (July 2020)

In this article, we consider the impact that COVID19 has had on higher education, research and global cooperation. The pandemic revealed fragilities in our public health systems and taught us that there is much that can be learned from experiences around the world. To be prepared for future resilience, we need to cooperate globally, learn globally and teach globally so that the next cadre of global health professionals work towards a more equitable response with solutions that are globally applicable.

13. Harris M, Bhatti Y, Buckley J and Sharma D. Fast and Frugal Innovation in response to COVI19 pandemic.
Nature Medicine. 2020. doi:
10.1038/s41591-020-0889-1 (May 2020)

The COVID-19 pandemic put healthcare systems under immense pressure, and it was necessary to innovate rapidly and under significant financial and human resource constraints. In this article, we reviewed the experiences of many health care systems and discuss examples of frugal innovation responses where clinicians and researchers developed solutions that, whilst cheap and unsophisticated, performed well at the job that was intended. Examples include using ventilator splitting devices so that more than one patient uses a ventilator at the same time, converting train carriages into intensive care units and using spare parts to develop simple ventilator machines. We argue that this type of innovation has merit even under normal conditions because there is always a need to develop nimble, effective solutions at low-cost.

14. Cash-Gibson L, Harris M, Guerra G, Benach J. A novel conceptual model and heuristic tool to strengthen understanding and capacities for health inequalities research.
Health Research Policy Systems. 2020. doi: 1
0.1186/s12961-020-00559-z (May 2020)

Health inequalities have been increasing over the past decades and effective interventions are needed to address them. This research developed a new conceptual framework to explain the research production process and the reasons why most research and models focus on understanding the relationship between research and policy, rather than on the production process itself.

15. Harris M, Dadwal V, Syed SB. Review of the reverse innovation series in globalization and health – where are we and what else is needed?.
Global Health. 2020. doi:
10.1186/s12992-020-00555-6 (March 2020)

Since 2011, when the term Reverse Innovation was coined to describe the process of adopting innovations from low-income countries into high-income countries, there has been a lot of research published to describe examples, understand the challenges and advocate for more learning. The journal Globalization and Health runs an ongoing series on Reverse Innovation and this article summarises the content of this series to-date. We review some of the noteworthy studies, the lessons learned and provide an agenda for researchers and practitioners moving forward.

16. Haines A, Barros E, Berlin A, Heymann D, Harris M. National UK programme of community health workers for COVID-19 response. The Lancet. 2020. doi: 10.1016/S0140-6736(20)30735-2 (March 2020)

The COVID-19 pandemic put the UK public health system under unprecedented strain and the absence of a distributed workforce to trace contacts, provide advice to households, reinforce government messaging and address concerns around vaccination in local communities was rapidly apparent. The Test and Trace system, costing £32bn, was put in place to fill this gap but has proven to be woefully inadequate. In this article, we argue that learning from low-income health systems that have relied on a distributed workforce of Community Health Workers going door-to-door at scale, would have been a better response to cope with this and future pandemics, cost far less, reach more people and address issues of inequality and access to health information, particularly in hard-to-reach groups.

17. Skopec M, Issa H, Reed J, Harris M. The role of geographic bias in knowledge diffusion: a systematic review.
Research Integrity and Peer Review. 2020. doi: 10.1186/s41073-019-0088-0 (January 2020)

Certain regions of the world tend to dominate the research landscape and other regions barely feature at all. This is not only because of the amount or quality of the research produced from these regions, but also because people will focus on research from regions that are well-known, rather than those that aren’t well known. However, in science, it is not appropriate to let the source of research influence one’s view of that research. Judgements should be based on merit alone. Our article sought to review the research literature for studies that have explicitly looked, under controlled conditions, at whether the source of a research study influences how it is viewed. We find that it does, and that research from poorer regions tend to be discriminated against, whether intentionally or not.

18. Harris M, Skopec M, Issa H. Authors' reply to Hunter.
BMJ. 2020. doi: 10.1136/bmj.m36 (January 2020)

In this reply, we address points raised by a commenter regarding our article titled Delivering cost-effective healthcare through reverse innovation (Skopec et al, 2019. BMJ. DOI 10.1136/bmj.l6205). The author of the comment, Hunter, asserts that we erroneously attribute one of our listed innovations, the Ponseti technique for non-surgical treatment of club foot, to a low-income country when, as Hunter points out, it was first used in the US. We concede that attributing an innovation to a specific country can be difficult, as one can never truly ascertain where an idea first began. Although the Ponseti technique was first developed in the US, it was implemented at scale in sub-Saharan Africa, and is now more frequently used in the US and other high-income countries as well. However, we push back on Hunter’s claim that misattributing an innovation to a low-income country can lead to “false ideas and beliefs such as the antivaccination movement.” This implies that recognizing the ingenuity of researchers in low-income countries can put people’s lives at stake. This, we suggest, is a dangerous assertion to make.

19. Lennox L, French C, Reed JE. A qualitative exploration of sustainability processes for improvement: the role of structured sustainability tools. In: Nugus P, Denis J-L, editors. Transitions and Boundaries in the Coordination and Reform of Health Services. Palgrave Macmillan. 2020. doi: 10.1007/978-3-030-26684-4_12 (January 2020)

This book chapter describes how improvement teams influence sustainability, via a case study of the use of The Long Term Success Tool (LTST). Findings offer insight into how planning for sustainability allows teams to maintain focus and mitigate risks to enhance chances of achieving lasting success. This chapter provides valuable learning on how tools such as the LTST can provide a useful approach to understand diverse perspectives, direct attention to areas for improvement and prompt actions to enhance sustainability.

20. French C, Lennox L, Reed JE. Developing pragmatic boundary capabilities: a micro level exploratory study of boundary work for quality improvement. In: Nugus P, Denis J-L, editors. Transitions and Boundaries in the Coordination and Reform of Health Services. Palgrave Macmillan. 2020. (January 2020)

In this book chapter, two QI tools (the Action Effect Method and Long Term Success Tool) are studied to see their impact on 17 quality improvement initiatives in Northwest London. The chapter demonstrates how co-creation and adaptation of ‘boundary objects’ such as QI tools can develop core skills in healthcare teams and facilitate improvements to care. The authors show how clinicians do not accept QI tools uncritically: rather those tools that are likely to support improvement work are adapted by professionals to local contexts and preferences in line with professional ‘know how’.


1. Skopec M, Issa H, Harris M. Delivering cost effective healthcare through reverse innovation.
British Medical Journal. 2019. doi: (November 2019)

Low-income countries have a long history of developing ingenious, low-cost solutions to healthcare problems because, with fewer resources there is a need to do more with less. Although these are sometimes simple workarounds they have proven to be as effective and safe as the more expensive alternatives used in the NHS. In this article, we review several examples of these so-called frugal innovations. These include Kangaroo Mother Care, the Arbutus drill, Mosquito net mesh for hernia repair, Hemafuse device for blood transfusion in emergency situations, Sayeba’s method to stop severe bleeding after giving birth, and many more. We argue that there is much to learn from low-income countries and potential to use these innovations in the NHS.