While we agree with the notion that the contribution of STI to sustainable development cannot be overlooked, there is a need to reconsider critically how STI should be supported and organized in order to better support the fulfilment of the 17 SDGs [2
]. In the health sector, more particularly, STI approaches that have been established in the past decades and which entail profit-driven and highly capital-intensive ways of producing new technologies not only threaten the sustainability of health systems worldwide, but they also fail to respond to the most pressing population health needs [3
]. Since the 1980s, most OECD countries have organized the financing of their healthcare systems in such a way that “the healthy support the sick, the young support the old, and the rich support the poor” [5
]. Nonetheless, it is now clear that health systems also perform better when they are supported by “healthy” public policies in domains that are not directly related to health services but which affect variations in health outcomes such as education, transportation, housing and the environment [6
]. These domains are intimately linked to the broader determinants of health [7
We explain below the novel STI approach that underlies RIH and why the current STI approach limits the emergence of innovations that can support sustainable and equitable health systems. In Section 2
, we describe our approach and methodology. In Section 3
, after providing descriptive statistics about a large set of health innovations (n = 105), we discuss three examples in greater detail and present a framework of the relationships RIH entertains with SDGs. Section 4
highlights the key knowledge gaps this framework emphasizes and suggests further research on how new business models, social enterprises and social finance can support the development of RIH. In Section 5
, we conclude on the importance of finding new ways to interface society and STI in the pursuit of the SDGs.
The STI Approach of Responsible Innovation in Health (RIH)
According to the UN Economic and Social Commission for Asia and the Pacific, science, technology and innovation are “inextricably connected” even though they refer to different domains of activities [2
]. Whereas science refers to the “systematic study of the physical or material world (natural science) and of society (social science)”, technology entails the application of scientific knowledge to develop and produce goods or services for practical purposes. Innovation characterizes the novelty or significant improvement of a product, service, process, social organization or commercial method [2
RIH embodies a novel STI approach that draws on and follows suit to the policy-oriented field of research called Responsible Research and Innovation (RRI). The aim of RRI is “to create a society in which research and innovation practices strive towards sustainable, ethically acceptable and socially desirable outcomes” [11
]. RRI shares important affinities with the late 2000s European Union’s “Grand Challenges” and with the SDGs. The Grand Challenges fueled “scholarly interest in the role of STI in strategic responses to collective problems” and acknowledged that such challenges were “qualitatively different from traditional STI concerns, often considered under the logic of national systems of innovation geared towards economic growth” [12
]. Tackling the Grand Challenges calls for “system transformation” since different actors and perspectives across policy issues and geographical domains have to be mobilized in order to agree on STI solutions [12
Acknowledging the “inherently complex yet fluid nature” of STI, RRI can contribute to a renewed STI framework for sustainable development, one that: (1) integrates “the social and environmental as well as the economic dimensions of sustainable development”; (2) adheres to “the principles of openness, inclusivity and collaboration”; (3) incorporates “the role of a more diverse range of actors”; and (4) reflects the “regional and global dimensions of STI” [2
]. As Spangenberg [13
] points out, one should acknowledge that “many sustainability problems have been caused by business activities” and reconsider the role business should play in sustainable development.
Within this perspective, a growing number of RRI scholars recognize that entrepreneurs may deliberately design solutions of greater social and environmental value [14
]. From a RRI standpoint, innovation production could be developed and organized in order to remain economically sustainable, to provide shared value and to foster inclusive and sustainable industrial development with stable sources of income and improved work conditions [1
]. For Stahl and colleagues, RRI could even have a positive impact on businesses: “the adoption of RRI could help a company develop its links with stakeholders including customers; it could facilitate alignment with societal and regulatory expectations and requirements; and it could improve employee satisfaction” [15
]. These potential benefits hinge, however, on the companies’ understanding of the principles and implications of RRI and thus on the ability of RRI scholars to adapt their concepts to the context in which these companies operate. Similarly, Lubberink and colleagues encouraged RRI scholars to recognize that commercialization “is an essential stage within the innovation process”, one that remains largely shaped by the culture of businesses and the constraints that affect their practices.
Commercially-driven innovation processes differ from those in research due to the priority given to achieving economic impact. Furthermore, the interests and values of innovators in the business context may differ from others (e.g., researchers in academia) and Research and Development departments face different constraints regarding confidentiality and public image.
In their review of the literature on RRI in the business context, Lubberink and colleagues observed that efforts to identify whether an innovation had negative implications or could generate additional desirable impacts were “scarce”, but a number of companies were already engaging in systems-thinking, seeking to understand the needs of beneficiaries or consumers and discussing with stakeholders ways to remain responsive to important needs [16
]. Likewise, Auer and Jarmai, who interviewed CEOs of small and medium-sized enterprises in the Austrian medical device sector, underscored that while these entrepreneurs had no prior knowledge of RRI, their enterprises were operationalizing certain aspects of RRI [17
Therefore, as Figure 1
summarizes, the current literature supports the notion that RRI embodies a novel STI approach that could enable entrepreneurs to address significant societal challenges, including the SDGs. However, further reflections and empirical studies are needed since “there are deep-seated contradictions” that can limit the potential success of RRI as well as its implementation in the business context [15
H1.2. Why the Current STI Approach in Health Innovations Needs to Be Transformed
In the health sector, scholars have begun to reconsider the extent to which the STI approach that was established in the 1980s to finance, design and bring to market new drugs and medical devices, is still to be promoted [18
]. This STI approach increases inequalities and undermines the sustainability of health systems around the world, be they publicly or privately funded [7
]. For Fineberg, sustainable health systems should be (1) affordable to patients and families, employers and third-party payers; (2) acceptable
to patients and health professionals; and (3) adaptable
to new diseases, changing demographics, scientific discoveries and technological innovations [23
]. All three characteristics are directly affected and typically constrained by the STI approach of the medical device and pharmaceutical industries, which now both operate on a global scale [24
The economic contexts in which health innovation took shape during the second half of the 20th century supported shifting dynamics between the demand for, and the supply of innovations [25
]. In the 1950s, the post-war economy in industrialized countries contributed to the demand by supporting the development of health systems. As the knowledge gained through military R&D benefitted STI in the medical sector, the emergence of universal healthcare coverage provided the capacity to pay for these new technologies in industrialized countries. Then, in the 1980s, the growth of health spending entered into conflict with a market economy ideology that imposed budgetary constraints and fiscal austerity in government-led programs. In these years, disparities in access to novel drugs and devices increased within and between countries. To protect equity, “the governments of most OECD countries have become heavily involved in the regulation, financing and sometimes the provision of medical care” since the “problem of reconciling rising demand and increasing costs” mainly fell in the public sector even though private companies were responsible for price increases [5
This tension between innovation and access represents a thorny issue for health policymakers [4
]. For instance, Sofosbuvir-based medicines with “a US list price of about $
90,000” per 3-month treatment course have recently “challenged government budgets and led to rationing” [27
]. By offering cure rates of over 90%, these drugs represent an important breakthrough for patients with hepatitis C infection, which largely affects vulnerable groups such as people who inject drugs or suffer from HIV/AIDS. According to Roy and King [27
], “one argument for the high prices has been that the curative drugs represent a major advance in value to patients and health systems” and they are indeed “more cost effective than many expensive medicines that provide only marginal benefit”. The company’s ability to charge high prices relies on its monopoly, while the public sector is paying “twice”, it supports STI and then purchases innovative products.
Equity and sustainability challenges also arise because health innovations rely on health services that are labor-intensive, require specialized personnel and are thus concentrated in large urban centers [5
]. New health technology often requires substantial infrastructure, which may not exist in many poor countries. Considering that “as many as 50% of all patients with cancer would be expected to benefit from radiotherapy”, the lack of radiotherapy facilities in many countries in sub-Saharan Africa is “particularly troubling” [28
]. For Pramesh et al. [29
], India faces “a problem common to other emerging and high-income economies” since it struggles with the unsustainable prices of cancer drugs. Even in a rich country like the United States, the difficulty of deploying technologies and qualified personnel to remote and/or rural areas induces significant inequalities in access to basic primary care [30
]. MacDonnell and Darzi [31
] suggest prioritizing innovations that simultaneously improve outcomes and reduce labor intensity. This includes innovations that support general practitioners, community health and social care providers and the patient’s capacity for self-care.
The problems raised by the current STI approach to health innovations are not limited to the healthcare sector. Rather, its socioeconomic underpinnings affect how the SDGs can be fulfilled in rich and poor countries alike: (1) higher unit costs of innovations ultimately result in greater inequalities in access since third-party payers are forced to either increase insurance premiums or engage into rationing; and (2) a greater share of a country’s Gross Domestic Product (GDP) spent on healthcare entails a reduced ability to maintain a diversified economy in which the other determinants of health (education, food insecurity, land use, etc.) can be properly addressed. This is troublesome considering that a healthy population represents “a precondition for, an outcome of, and an indicator of” the economic, social and environmental dimensions of sustainable development [32
Another reason why it is important to critically examine the current STI approach to health innovations lies with the recognition that it is largely driven by speculative investments, where short-term returns prove more important than long-term health gains. Public resources around the world are used to support health technology-based entrepreneurial activities, which remain highly dependent upon venture capital [33
]. One must thus consider how capital investors’ preferences and financial markets affect the kinds of innovation being introduced in health systems [18
]. From the investors’ standpoint, with an estimated 21.6% net profit margin, health technology is highly attractive [35
]. Lehoux and colleagues observed that capital investors prefer to invest in technologies that are likely to find their “purchaser” swiftly and “do not automatically see value in ventures that address pressing needs unless these ventures can compete as winners in the healthcare ‘marketplace’” [21
]. Innovations that are seen as less risky by venture capitalists are those that address very large and easy to reach markets, that offer to physicians, the means to generate revenues and that will be acquired within a relatively short timeframe by established medical device manufacturers [20
]. This short-term logic enables recouping one’s investment, but it reproduces the technology creation paradigm that makes health systems unsustainable and produces, ultimately, marginally innovative technologies [36
Overall, the literature underscores the STI dynamics that contributed to shaping today’s health innovation creation paradigm, which threatens the equity and sustainability of health systems. It also highlights the relevance of examining more closely the STI approach that RIH embodies and which could support the fulfillment of SDG3 (Good health and well-being) while concurrently addressing SDGs related to the determinants of health and sustainable economic development.