Abstract “Less is more everywhere” and so Jugaad innovation continues to slowly bloom within contemporary emerging markets despite its apprehensive start due to various restraints. The much-loved public healthcare system in the United Kingdom (UK), the National Health Service (NHS), has struggled for years to be kept afloat with continuous systemic hick-coughs and overspending. Many systemic challenges within the UK healthcare system can, in simple terms, be classified as political, financial or social and together create one big wicked problem difficult to near impossible to solve. Jugaad or frugal innovation (FI) has traditionally been linked with the developing world. Jugaad innovation introduces clever but affordable ways to do things effectively. Therefore, it is high time that developed countries would get more inspiration and learnt a lesson from its use, as it has great potential to help reduce some of the pressure on seemingly overloaded global healthcare system. Successful FI has the potential to outperform the alternative and can be made at a large scale for a much lower cost (Bound & Thornton, 2012).1. IntroductionAs no formal workshop was held on this topic, my insights and experiences to critically reflect upon this are drawn from the first three days of the course from the seminars and lectures. “Do more with less for many” is how Bhatti and Ventresca (2013) define frugal innovation (FI). Although FI is strongly associated with the developing world, modern healthcare is going through a range of its own challenges that is overload to the system – a large “wicked problem” so to speak. On the whole, over the past 30 years the global health system has endured an increase in population and urbanisation, behavioral changes, rise in chronic diseases, traumatic injuries, infectious diseases, specific regional conflicts and healthcare delivery security (Durrani, 2016).There is a great need to tackle these challenges in another way, other than simply throwing more (or less) money at the situation. This is where FI has been recognised to be powerful due to its affordable but clever solutions responding to limitations in resources, let it be financial, material or institutional (Bound & Thornton, 2012). However, as a concept to be used in healthcare, it still requires wider recognition and acceptance from the developed world. Whilst the essay title refers to global healthcare markets, I feel that the UK market alone can be used for the purposes of analysis and critical reflection. I feel that the systemic challenges it faces are much representative of those faced globally in developed countries in addition to a few NHS specific ones. Due to the broad scope of this topic, this essay will specifically reflect upon the systemic problems in the NHS that ageing and poor self-management, staffing levels and misuse of the system bring, and thereafter delve into why frugal innovation would ease off these pressures. 2. Overview of the structure of the UK and global healthcare market The UK health market comprises of predominantly (79%) the NHS and to a much smaller extent the private sector. The NHS is funded by general taxation supplemented by National Insurance contributions, and by a very small amount of user-charges, relative to the majority of other European healthcare systems (McKenna et al., 2017). The NHS is unique to rest of the world’s healthcare systems, in that it provides equitable care and is well-known to be considered free at the point of access. Nevertheless, this may also be one of the key problems as this model was designed to provide services around treatment and not prevention (Chand, 2018). The private sector again is much smaller, and as per international standards expensive where only 11% of the UK population is thought to have private health insurance (King’s Fund 2014). 3. Systemic challenges in the UK and global healthcare (critical reflection)3.1 An ageing population and poor self-managementOne main factor the UK and the global healthcare system have in common in healthcare is continuous rise in spending (Deloitte, 2019)- but why? The reason for this is multifactorial – a complex combination of issues that interconnect with other problems, and therefore oftentimes are impossible to solve directly. I consider these systemic challenges to be “wicked problems”, reflecting upon what I learned during this module. Some of these culprits are clinical and rising labour costs, amongst others (Deloitte, 2019). One massive factor is an increasingly aged population, however. A study conducted by Kingston and colleagues (2018) found that over the next 20 years we will see life expectancy gains but simultaneously there will be an increase (almost double) in complex co-morbidity (4+) diseases. The healthcare costs for people over 65 begin to rise steeply. At the age of 85 these costs are almost two thirds higher than what a 35-year old costs. The modern human spend more years in ill health than previously, and use more healthcare assets due to multi-morbidity care and hospital stays (Ferguson & Belloni, 2019). It is of course positive that improved understanding of disease and treatment technologies have allowed this to be possible, but on the other hand, there is a lack of prevention and self-management to avoid needing to take these pills in the first place. To me, this is an alarming sign that there is need for drastic changes in order to prevent catastrophic pressure on the healthcare system in the long-term. As Montgomery et colleagues (2017) alludes to, the UK needs to move away from injecting more money into the health services and rather radically change the model where disease prevention, modifying health behaviours and implementing change in healthcare policy will become central. The current system is focused on ‘treatment of disease’ and not ‘maintenance of health’. There is a trend of a passive approach where medications keep us alive at high costs, and living longer with increasingly less independence and reliance on expensive carers (Montgomery et al.,2017). From my own experience in a profession where active self-management is a key part of successful treatment, this is abundantly clear. I have seen many patients expecting a passive approach despite education on self-management. Some of these patients will not return if I have given them home exercises to do, or some of the time, they will return without having done any, but still expecting a change to their pain and condition. Unfortunately, it appears as though the easy way of taking a medicine or “magic bullet” and masking the problem is more appealing than treating the root cause. 3.2 NHS model of free care causing misuse to the systemHaving worked in the NHS and experienced healthcare in Finland, Australia and Holland, in the grand scheme, I have the impression that NHS is easily misused due to the fact it is “free”. For example, attending the emergency department for a common cold, seeing a General Practitioner (GP) for a social interaction or not turning up to scheduled appointments. To illustrate this point, in 2014, 12 million GP appointments were missed per year, which cost the NHS £162 million (NHS England, 2014). There is a debate, whether GPs should start charging for appointments to ease this pressure. However, it is thought that this intervention could affect people from lower socio-economic groups and those with complicated health needs from seeking medical help when truly needed (McKenna et al., 2017). After all, the NHS is praised for being accessible to everyone from all social classes, and it would be a shame to change this culture. Perhaps, FI could lead to some beneficial outcomes in this issue.3.3 Staffing levels A lack of resources to meet demands is linked to poorer staff wellbeing and quality of patient care (Deloitte, 2019). In the UK, one contributor to low staffing levels is a lack of training places in medicine. In addition, funding for nursing and allied health degrees was removed in 2017 causing a drop in student enrolments (Department of Health, 2017). A year earlier a vote for Brexit occurred. The King’s Fund (2017) expects Brexit to cause some negative impact to not only on the regulation and supply of medicines and devices, scientific and medical research, but most significantly the workforce. Since the UK referendum, the registration of EU nurses has fallen by 87%. NHS has relied on migration workers to cover for lack of staffing, and had 1 in 10 free vacancies in 2018. Politicians are nevertheless planning on re-introducing more medical degree places and nursing apprenticeships, but will take years before these enter the workforce (Buchan et al., 2019). This will undoubtedly be off-set by poor staffing retention rates. 4. (My understanding) for the need for frugal innovation approaches to tackle these wicked/systemic challenges in healthcareOriginally, FI started in the emerging markets to develop products and services to fit non-affluent customers (Wayrauch & Herstatt, 2017). It has since been recognised to have the potential to provide cheaper and more effective solutions into healthcare, both in developing and developed countries (Arshad, Radic & Radic, 2016). In order to respond to these complex problems in the NHS and globally, there is a need to be more innovative where the focus is on cost reduction and more effective delivery of care. FI can be considered to be a solution that has a substantial cost reduction, concentration on core functionalities and optimised performance levels (Weyrauch & Herstatt, 2017). It is a more flexible and responsive approach than the traditional research and development programs (Dawda, 2017). In developed countries, healthcare systems are striving to improve outcomes of care, improve patient experience and increase joys of working but at a much lower cost per unit (Dawda, 2017). For these abovementioned reasons, using lateral thinking through frugality has a great scope to solve problems in the challenging healthcare climate. For example, Narayana Health, an Indian FI business model established by a UK- trained heart surgeon. I find this a great demonstration of the potential applicability of a frugal system into the developed healthcare. Narayana Health is a care model that was established to meet the increased demand of heart surgeries in India, where most do not have the financial clout to pay for one. Narayana Health’s aim is to streamline the operating process of open heart surgery with the goal to do more without affecting quality. This has been fulfilled by having surgeons and other staff in Naryana Health only doing the task that they are specialised in by using production-line approach to surgery combined with task-shifting. This creates a much more effective operating theatre than the traditional approach, and the surgeons become very skilled at what they are doing leading to better performance than in the US; mortality rates in Naryana Health is 1.4 percent within 30 days of coronary artery bypass graft surgery, compared with 1.9 percent in the U.S. This approach also subsequently allows them to perform 400-600 surgeries per year; meanwhile in the U.S, the amount is 100-200 per year (Taylor, Escobar & Udayakumar, 2017). By being inspired from such a model of process streamlining, it could lend itself to elective cases in the UK which are under much pressure. A good example is hip and knee replacement surgeries in the NHS which have notoriously long waiting times with an optimistic aim to be seen in 18 weeks (NHS, 2019). However, because of frequent systemic and political issues, there are many occasions elective surgeries have been cancelled or much delayed, such as in 2018 when a winter crisis predicted congestions of the system to serve frail elderly. This forced over 50.000 elective surgeries to be cancelled around the country (Donnelly & Bodkin, 2018). 5. Acceptance of frugal innovationFI is still a fairly underappreciated tool due to resistance of implementation. Many interventions used in the developing world are frugal in one way or the other, and it has been recognised that this should be more widely used in the developed world . One case study we came across on the course is the surgical drill which has a hefty price tag of £20.000-30.000. In the developing world this drill is far too expensive and thus have engineers designed a cover to be used on a cheap household drill so that only the cover, and drill-bit need sterilisation after use. Transferring this idea into the NHS would have an expected saving of 92% compared to buying the expensive drill (Darzi, 2017). Nevertheless, as Darzi comments, “it is questionable how NHS managers and the public reacts if they would implement solutions meant for poor African countries in the sophisticated western healthcare system”. The general perception is that low-income countries might not have a valuable lesson to teach the developed world – and that is why FI lags behind according to Bhatti and colleagues (2017).6. ConclusionSystemic challenges are of many sorts that need to be tackled with behavioural changes, system changes and innovative products. There is no one answer for the overspending the healthcare in the developed world is currently doing. The modern society has become too comfortable on passive care, taking medications and skipping self-management which due to a domino effect of causes creates an overload to the healthcare system. In order to find relief, the implementation of FI into the developed world’s healthcare has the potential to do more for less for many, as long as we welcome it.