Chapter 3. Approaches to policy problems
3.3 Innovation conceptualization for solutions
3.3.1 Explaining innovation solutions through models and tools
Science has long been presented as a solution to societal problems. The twentieth century saw 'big science' have a transformative effect on society through a 'leap in scale and organization', with physics and chemistry becoming directly useful and science becoming a goal-directed economic endeavour (Riecken, 1969). Some, such as Riecken, have argued that science has more implications for 'action' than social sciences, which can be a "...curious kind of 'understanding'..." (ibid.). Turnbull (2008, pp. 82-4) has argued this basis comes from an enlightenment view of social science identifying problems rather than solving them and where science is the most 'sophisticated expression' of problem-solving rationality. Others, for example Fujimura (1987), talk about how science can produce 'doable problems' in the alignment of 'experiment, laboratory, and social world'.
Innovation poses a new relationship with policy problems. In a conventional and widespread definition of "...bringing a new product into the market or into practical use" (Schroeder, 2007, p.
37) there is an emphasis on economic significance and promotion of economic growth.
Therefore, innovation connects science and technology to the wellbeing of the economy, to create a concept that is viewed as intrinsically positive and desirable. Today the link between science, technology and the economy is argued to be the 'raison d’etre' for science policy and later innovation policy (Webster, 1991, p. 35).
However, innovation as a buzzword is still a contested term in that it is often used ambiguously, with different parties bringing their own meanings to the table. What I would like to draw attention to are the economic meanings as opposed to socio-political meanings. Economists tend to refer to 'technological' innovation in the commercialization of ideas, as described above, particularly technological advancement rather than innovation in ideas, things, and behaviours (Godin, 2010). This is the concept of new products, processes, and services entering the market mechanism.
Innovation applied as a solution to policy problems carries an air of neutrality most often referring to technological innovation but the social and political cannot be demarcated explicitly, so it must be asked who innovation is for in society and why? This question is relevant for global health now more than ever. Innovation is presented as a solution to many of the challenges we face on big global topics such as health, the environment, poverty, and wellbeing. Joly et al. (2010, p. 5) describe how innovation is presented as a solution in itself, a way to “solve human problems” in areas spanning health to sustainability. When looking at policy problems it is common for innovation to be involved (such as OECD, (2011) ‘Fostering
Innovation to Address Social Challenges’). In contrast, a lack of innovation is characterized as a problem, which presents innovation as one-dimensional in character – more innovation being good and less innovation being bad. Accordingly a lack of innovation is presented as part of that problem and it is easy conceptual slippage for the amount of innovation itself to be characterized as a problem.
The main measure of whether there is more or less innovation is through the level of R&D, as a discrete element of innovation whose relationship to economic growth is complex, involving continuous feedback (Webster, 1991, p. 100). Governments set targets and offer incentives for R&D as an activity encouraged for innovation, with the view that the market typically under-invests. However measuring the impact of policies related to science, technology and innovation has faced difficulties. The statistical relationship between economic growth and R&D investment has not proved very forthcoming (ibid.).
R&D investment forms part of a linear model of innovation. As Mata and Louçã (2009) explore, there has been a need to formalize innovation studies through theory development, where a model-building approach was championed. Godin points out: “One of the first (theoretical) frameworks developed for historically understanding the relation of science and technology to the economy has been the ‘linear model of innovation’...” (2006, p. 639). The model generally describes the process of technological change sequentially from an idea (drawing from the science base through basic research then applied research), that moves to development, production and finally diffusion within markets and wider society.40 As a model it outlines a linear progression of discrete stages, shown in the Figure 2 below.
BASIC RESEARCH
The model is linear because it is based on an input-output framework that progresses from one stage to another through a series of steps. For NTDs the assumption is that an input change will result in outputs that mean these diseases are better dealt with. Godin argues that the linear model never existed in the form and usage depicted by later theorists arguing for an abandonment of the model in favour of a new version. Others including David Edgerton
40Godin notes two further generations of the linear model – a statistical correlation between research and economic growth, productivity, industrial competitiveness, and 'National Innovation Systems' (NIS).
Adoption of the linear model fed into a larger policy project justifying government support of science and innovation, as well as the role of “industrialists, consultants and business schools, seconded by
economists” in a theoretical construction of innovation (Godin, 2006, p. 640-1).
(Edgerton, 2004) had made this claim before but Godin and Lane (2013) make a more nuanced argument, pointing out that Edgerton concentrates on the originators of the demand-pull model.
The demand-pull model was an early alternative to the linear model, providing a supply-side view of innovation.41 The supply-side view posits that investment in R&D and scientific discovery leads to innovation, while the demand side comes from the opposite direction in that consumers drive innovation through market demand. With the linear model of innovation, R&D is a means to an end for innovation and economic growth is the dominant and established view.
The linear model of innovation is widely adopted, in making this relationship between R&D, innovation and economic growth (despite critique of the model as not reflecting complexity and collaborative or open ways of doing innovation). We will see what the effect of an emphasis on R&D has for NTDs in later chapters.
3.3.2 Health for development
A similar reversal in the demand-pull to supply-push example of linearity can be found in the relationship between health, innovation, and development. The idea of 'development for health' has been long established. A first point is that poverty and low socio-economic status causes ill health, shown by the political economy of health (Doyal & Pennell, 1979) and social determinants of health (SDH) literatures (Marmot, 2007). A second point, applied to a country level is that the economy needs to develop first for health outcomes to improve. This argument comes from a technocratic interpretation of ‘stages of development’ where economic development is sought first with societal improvement expected to follow. Countries want to move up the escalator of progress through 'Rostow's stages theory' of economic growth "...from a pre-industrial state to full economic maturity" (see Rostow, 1971). This 'stages theory' was prevalent in the early postwar period, where to miss a stage could be a disaster:
"Essentially, the theory says that development proceeds through a linear succession of stages copied from the historical experience of existing industrial countries. This was a historicism in drawing theory from past experiences or examples but also wanted to do away with connections to the past that do not match a pursuit of modernity… the goal was predetermined – it was to be just like contemporary America" (Biel, 2000, p. 74).
The idea would later be reversed, such that health could precede and contribute to development. As Morel describes: “Health, science and technology are increasingly being recognized as prerequisites for economic and social development, and not merely as their consequences” (2003, p. S35). Linearity is reversed from 'development to health' to 'health for development' (see Figure 3 below). I argue that this change had important implications for global health policy. Instead of identifying poor health being caused by underdevelopment,
41Keynesian economics, widely accepted post-war up until the 1970s and encouraged the consideration of demand-side factors.
improved health could be a reason leading to economic development. Here I am using the term economic development as a marker of a country's progress, as is understood through common metrics to measure improvements in a country (e.g. GDP, literacy, life expectancy, poverty rates). Policies addressing health could move away from a systemic emphasis to economic development (on policies and investment in health systems and infrastructure) to vertical programs addressing individual health issues.
The switch in emphasis to 'health for development' can be seen the policy arguments for NTDs as diseases said to be both a cause and a result of poverty and underdevelopment, in a self-reinforcing cycle, with health accepted as a precursor. As a result, demonstrating impact upon economic development reinforces the rationale for intervention in NTDs, as an expected consequence of health improvement.
China was 'proof' as seen through the so-called 'barefoot doctors' that it was economically advantageous to invest in health (Zhang et al., 2008). China's community health workers or 'barefoot doctors' had elementary training in diagnostics, immunization, education, simple treatment, and liaison with the qualified medical sector. They were a cheap resource to improve health and more generally a health intervention being used to promote economic development.
However, they are also an example of a politically driven health intervention.
Adams (1998), explores the linking of politics and medicine. She gives the example of the barefoot-doctor program to reflect "...the call for political solutions to basic health problems" (pp.
166–7). The program was seen by many as a successful intervention, driven by supportive political ideals of the Cultural Revolution, which began in 1966. The Cultural Revolution had meant that, “…high-technology orientations became an object of scorn, and so the basic essentials of scientific medical intervention were recast in a framework that made national medical traditions appropriate for health care in the Chinese countryside" (ibid., p. 167). 'Expert' knowledge was seen to be opposed to 'Red' knowledge and downgraded, with also the discrediting to an extent of stages of development from which 'development for health' was grounded in. A move towards the 'health for development' model allows for NTDs to be more appealing as a concern and has shaped the means of dealing with these diseases. Similarly to
the example of 'barefoot doctors' the shift to 'health for development' is grounded in a view of what expertise can provide legitimate evidence. Therefore, the type of expert knowledge being relied upon becomes central to determining how policy problems and solutions are viewed. I take this consideration of expertise further in the next section, which deals with the various disciplinary lens that have been applied to NTDs.