Nearing halfway in 2025, the health systems over the past 5 years have faced increasing challenges and downward trends/stagnancy.[1] The varied reasons behind these trends are the sudden increase in global conflicts (systemic), the growing effects of climate change (physiological), and the pursuit of band-aid solutions over actual on-ground interventions led by policy neglect and institutional amnesia. The trends and suggestions from the field have been taken lightly/counted as isolated events instead of tracking trajectories. 

The following section attempts to demonstrate why the innovators of solutions in the sector must go beyond the clinical side and address the full continuum of care, stakeholders across geographies, and the impending climate threat, with a particular focus on Maternal Health

The Continuum-space 🌌🌀⏳

Just as great minds surpass the scale of history, seminal works do the same. C Wright Mills, in his epochal work “The Promise”, talks about ‘The Sociological Imagination’ which distinguishes the lines between the self and society[2]. This work advocated for the understanding of power relations, social hierarchies, and information asymmetries, forcing actors to ask sharp questions like: ‘What systems produce exclusion? Whose interests are served by this technology? Who remains seen and who remains unheard?’ 

This distinction, combined with the works taken forward from the interdisciplinary minds of the last century, gave birth to what I call “The Promise of the 21st century”, the crux of which formed the basis of “ICT4D: Information and Communication Technology for Development”. ICT4D is termed as a decentralized movement dedicated to making access to digital technologies more equitable, with the goals of bridging the digital divide and advancing global economic development. UNDP even identified ICT4D as a force for economic and social development around the world, particularly among poor and marginalized communities. 

With an interest in contributing to the goal of UHC, my student self was convinced that this is the way to approach, along with, of course, the sister literature of Human Centred Design for Development (HCD4D) and Systems Thinking. Alas, it wouldn't be a stretch to say that ICT4D has overpromised but underdelivered in the public health space, with innovators focusing on technology rather than context, data over action, and pilots over sustainability. There are so many unsolved problem statements in the process innovation front that have been left out or simply deemed unattainable. 

Some examples from my space of Maternal Health:

• Too much technology and data without adding any value: Most of the ‘innovations’ give out apps, dashboards, and reminders. But what does the community health worker do if she has no clarity on what to do when the numbers don’t add up or the reminders don’t consider her schedule of other work? Meena talks about these complications and the ambivalent work that the community health workers are caught between, often conflicting demands of state bureaucracy and the situated nature of their care work.[3] 
• One-size-fits-all approach of building applications leaves much to be desired, as the basic assumptions on which the onset itself is based are broad-based. What happens when the information communication aimed at a particular woman coming through the phone by some platform doesn’t have the primary ownership of the phone itself?. Such shared devices face risks of private health information being exposed through phones and infringe on their privacy.[3]
• Pilotitis: The newest word in my vocabulary. There are tons and tons of projects that lacked sustainability depth but were funded through one source or another and collapsed when the funding ended.
• Low-integration with Health Systems: The ever-stagnated and ever-frustrating problem of double data entry - once on paper, once into the app(s) because the systems themselves were either slow or unreliable during downtime. This data duplication is leading to burnout and data quality issues. The most common example is the dozen or more government health portals that the community health workers are asked to keep updated about, while also keeping a log in the register.
• Superficial technological innovations: This is what I call tools/solutions that look shiny but get rusty when not used properly, where they should be used. The dozens of AI chatbots, the blockchain of immunization records are innovative, yes, but they are not providing on-ground solutions leading to a sole focus on data collection and not action. 

Training of field workers on digital tools. Image credits: Author.

There is much room for improvement and innovation in space, and we have enough literature to seek inspiration too. Providing below some of my favorite seminal works relevant to the discussion:

1. Mark Granovetter. 1985. Economic action and social structure: The problem of embeddedness. American Journal of Sociology. 91(3):481-510. 
2. Meric S Gertler. 2003. Tacit knowledge and the economic geography of context, or The undeniable tacitness of being (there). Journal of Economic Geography. 3:75-99. 
3. Deepak Lal. 2002 (3rd ed.). The Poverty of ‘Development Economics’. Institute of Economic Affairs. pp.35-97, 125-149 (Introduction, Chapters 1, 2, and 4)  
4. Balaji Parthasarathy and Yuko Aoyama. 2016. Deploying ICTs for development: An evolutionary perspective. Information Technologies and International Development. 13:157-170.
5. Yuko Aoyama with Balaji Parthasarathy, 2016. The Rise of the Hybrid Domain: Collaborative Governance for Social Innovation. Cheltenham, UK: Edward Elgar. 

The Conflict-space🗳️⚖️🪧

The world has become less peaceful over the past 16 years, with the average country score deteriorating by 4.5 per cent since 2008. The average level of country peacefulness deteriorated by 0.56 percent in the 2024 Global Peace Index.[4] This is the fifth consecutive year that global peacefulness has deteriorated. The unstable political scenarios and conflict have led to displacement, incarceration, and crime for refugees and internally displaced people. Adding to this problem is the (lack of) media-literacy and media-abundancy problem, which creates so many neglectful blackhole crises that fail to get traction. In addition to the Middle East and Eastern European crises, the ongoing crises in Burkina Faso, Camerron, DR Congo, Mali, Niger, South Sudan, Central African Republic, Chad, Sudan in Central Africa and Honduras in the Caribbeans are far more in number.[5] The Lancet Study on Women’s and Children’s Health in Conflict Settings states that Women and children bear substantial morbidity and mortality as a result of armed conflict, estimated at around 265 million women in 2017[6]. One can only imagine the number having grown multifold in recent times. There is ample evidence of how particular MNCH systems collapsed under conflicts. For example, in Afghanistan, comprehensive emergency obstetric and newborn care (CEmONC) is largely not delivered in most provinces, thus leaving women at risk of dying from treatable maternal complications. Conflicts also exacerbate GBV (Gender Based Violence) against women, inflicting harm and psychosocial distress.[7]

These factors are intertwined with sparse systemic evidence, thus failing to get traction to start a discussion over their resolutions, be it health financing, supplying essential medicine, and other levers of policy interventions. Thus, it is of paramount importance to build solutions that work in such geographies and help create systemic evidence. One such example is of ‘BHISHM Cubes’ by HLL Life Care, presented to the Ukrainian frontlines by the Indian government. The Cube can handle about 200 cases of diverse nature in emergencies such as trauma, bleeding, burns, fractures, etc. It can also generate its power and oxygen in limited amounts.[8][9] 

The literary works talking about "Innovations on the boundaries of society" are quite interesting. Something to start with:

1. Matthew A. Zook. 2007. Your urgent assistance is requested: The intersection of 419 spam and new networks of imagination. Ethics, Place & Environment: A Journal of Philosophy & Geography. 10(1):65-88. 
2. Manuel Castells. 2010 (2nd edition). The perverse connection: The global criminal economy. Chapter 3 (pp.171-214) in Volume III: The End of the Millennium. The Information Age: Economy, Society, and Culture. Blackwell.  
3. Matthew A Zook. 2003. Underground globalization: mapping the space of flows of the Internet adult industry. Environment and Planning A. 35:1261-1286. 
4. Amartya Sen., 2002. Globalization, Inequality, and Global Protest. Development. 45(2):11-16.  

The Climate-space🌍🌡️🌱

The undercurrents in the public health space have started to recognize Climate change as a health threat multiplier within preexisting health inequalities. The 2019 Lancet Countdown report mentioned that women are one of the groups, across a range of social and cultural contexts, that are vulnerable to the impacts of climate change. [10] At the first level, the research and data on the effect of climate change on women need to be disaggregated, especially from vulnerable and marginalised communities.[11] Climate change manifests an array of negative outcomes on maternal health. When it comes to exposure to poor air quality, pregnant women are more likely to experience stillbirths, fetal congenital abnormalities, intrauterine growth restriction, and other adverse birth outcomes.[12] A recent study in 2023 found that women are most susceptible to adverse heat effects in the third trimester of pregnancy, with a 2.4-fold increased risk of stillbirth when exposed to the 99th centile of monthly mean temperature (30.1°C) versus the optimal temperature (21°C) 0–3 months before delivery.[13] 

The current solutions include parametric insurance based on pre-agreed triggers.[14] The solutions space needs to be expanded in terms of ClimatexWomen Health in the form of off-grid renewable energy, climate-smart agriculture/labour kits, and hyperlocal weather information services, which reach people, and climate-contextualized diagnosis of diseases.

Some literature for a brief primer on the context:

1. Mohamed Afifi, Mazen Malkawi & Maha El-Adawy. (‎2024)‎. Women’s health and climate change: a threat or an opportunity. Eastern Mediterranean Health Journal, 30 (‎5)‎, 330 - 332. World Health Organization. Regional Office for the Eastern Mediterranean. https://doi.org/10.26719/2024.30.5.330. License: CC BY-NC-SA 3.0 IGO Journal
2. World Health Organization. (‎2024)‎. Communicating on climate change and health: a toolkit for health professionals. World Health Organization. https://iris.who.int/handle/10665/376283. License: CC BY-NC-SA 3.0 IGO

Having listed the contemporary problem statements, it is only fair to conclude that peripheral innovations will continue to fail when addressed in isolation. Solutions considered and built only for particular fragments without flexibility will collapse when faced with compound circumstances. It is high time to take into account the political-economic, environmental, and conflict geographies while building solutions.

References:

1. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.
2. Sociological imagination. Mills, C. Wright (Charles Wright), 1916-1962.
3. Azhagu Meena S P, Palashi Vaghela, and Joyojeet Pal. 2022. Counting to be Counted: Anganwadi Workers and Digital Infrastructures of Ambivalent Care. Proc. ACM Hum.-Comput. Interact. 6, CSCW2, Article 286 (November 2022), 36 pages. https://doi.org/10.1145/3555177
4. Institute for Economics & Peace. Global Peace Index 2024: Measuring Peace in a Complex World, Sydney, June 2024. Available from: http://visionofhumanity.org/resources
5. Norwegian Refugee Council, The Neglect is the new normal. Available from: https://www.nrc.no/feature/2024/the-worlds-most-neglected-displacement-crises-2023/
6. Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies? Singh, Neha SBhutta, Zulfiqar et al. The Lancet, Volume 397, Issue 10273, 533 - 542
7. Eran Bendavid*, Ties Boerma*, Nadia Akseer, Ana Langer, Espoir Bwenge Malembaka, Emelda A Okiro, Paul H Wise, Sam Heft-Neal, Robert E Black, Zulfiqar A Bhutta, and the BRANCH Consortium Steering Committee. The effects of armed conflict on the health of women and children, The Lancet series in Women’s and Children’s Health in Conflict Settings - 2. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2821%2900131-8
8. https://www.mea.gov.in/press-releases.htm?dtl/38217/Prime_Minister_presents_BHISHM_Cubes_to_Ukraine
9. https://www.lifecarehll.com/Bhishm%20Cube%20Brochure.pdf
10. https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30001-2/fulltext#
11. Sorensen, C ∙ Murray, V ∙ Lemery, J ∙ et al. Climate change and women's health: impacts and policy directions PLoS Med. 2018; 15, e1002603
12. Health Effects Institute. Burden of disease attributable to major air pollution sources in India: Summary for policy makers. 2018. Available from: https://www.healtheffects.org/publication/gbd-air-pollution-india
13. Bonell, A., Part, C., Okomo, U., Cole, R., Hajat, S., Kovats, S., Sferruzzi-Perri, A. N., & Hirst, J. E. (2024). An expert review of environmental heat exposure and stillbirth in the face of climate change: Clinical implications and priority issues. BJOG: An International Journal of Obstetrics & Gynaecology, 131(5), 623-631. https://doi.org/10.1111/1471-0528.17622
14. https://www.undp.org/pacific/blog/insuring-resilience-how-parametric-solutions-are-transforming-climate-adaptation-pacific