Table 3.

Examples of Social innovations in health described using the new research checklist

Item number	Research checklist item	Castro-Arroyave, Monroy & Irurita (2020)(2)	Awor, Nabiryo & Manderson (2020)(16)	Yang, Zhang, Tang et al. (2020)(3)
1	Brief name	Integrated vector control of Chagas disease	Imaging the World, Africa (ITWA)	Pay-it-forward to increase STI testing among MSM in China
2	Problem	Chagas disease affects about six million people and some 65 million people are at risk of contracting the disease. Chagas disease is a zoonosis that is strongly associated with poverty in rural Latin America. Houses made of adobe or plant material, common in rural Latin America, provide a perfect habitat for triatomine bugs, the vectors of Chagas disease.	Uganda has only one radiologist/sonographer per one million people. Combined with lack of advanced imaging technology and low incomes, rural populations greatly lack access to diagnostic imaging services, for example for timely diagnosis and treatment of pregnancy complications. This can increase the risk of severe illness and death in pregnant women.	WHO recommends that men who have sex with men (MSM) receive gonorrhea and chlamydia testing, but many evidence-based preventative services need to be paid out-of-pocket, creating financial barriers and health inequity for the poor. In China, dual gonorrhea and chlamydia tests are available in many Chinese hospitals for approximately $22, yet the testing rate among Chinese MSM are low (12.5% for gonorrhea and 18.1% for chlamydia).
3	Rationale	Social Innovation in Health Initiative (SIHI) hubs can be used for generating new solutions. Partners developed a call to identify social innovation initiatives in health in Central America in 2017 related to CHAGAS. “The knowledge acquired by researchers from University of San Carlos (USAC) in Guatemala about how to improve houses with local material, to avoid the colonization by triatomine bugs that transmit Chagas disease, gave rise to the need to transcend the traditional vision of research and to move towards a perspective that involves the community, promoting their empowerment and participation.”	Imaging the World Africa (ITWA) is a Ugandan-registered NGO which focuses on incorporating low-cost ultrasound services into remote health care facilities where imaging infrastructure is weak where there are no radiologists. By bringing obstetric imaging services closer to rural women, ITWA’s program can help timely identification and treatment of pregnancy complications.	Innovative strategies to expand access to preventive services like gonorrhea and chlamydia testing are needed, especially in low-and-middle income countries. Public sector responses to subsidize preventive services are limited and altering prices is difficult. Pay-it-forward strategy has the potential to increase trust and community engagement in health services and help reduce the financial barriers to testing.
4	Social innovation	The project was an effective and innovative social approach for the control and prevention of Chagas disease in the municipality of Comapa, Guatemala. The approach consisted in designing a strategy to address predetermined risk factors for the colonization of dwellings by the vectors. The interventions included filling the cracks and crevices in the floors and walls using a combination of locally available materials, raising awareness and training of leaders and members of the community to adopt the home improvements and contribute to cultural changes such as maintaining animals outside homes to eliminate the risk of colonization of homes by triatomine vectors.	ITWA is a social enterprise and it applies commercial approaches to maximize access to affordable imaging services remote and underserved populations. Their model incorporates the use of ultrasound imaging devices at the point of care, training midwives and nurses (non-radiographers) to conduct ultrasound scans and real time off-site radiology review of the scan by experts (using telemedicine approaches). Together, the use of technology/telemedicine, provision of affordable imaging services, training, task shifting and community participation contribute to much better access to imaging services in rural areas.	The pay-it-forward intervention invites MSM who visits a community HIV testing site to also test for gonorrhea and chlamydia. Individuals are told that the testing fee is 150 yuan (US $22) but they can receive a free gift test, because a previous visitor who cared for them donated towards testing fees. After the test, individuals are asked to donate toward future testing for others on a voluntary basis. Compared to the standard-of-care and also the pay-what-you-want arms, pay-it-forward significantly increased test uptake.
5	End users	Residents of affected communities near Comapa, Guatemala	Low income pregnant women from rural communities in Uganda	Men who have sex with men (MSM) in China
6	Stakeholder involvement	The eco-health approach (based on environmental, social and biological risk factor management) described here is intersectoral as well as interdisciplinary. This involved Financial backing from a variety of sources, University oversight, collaboration and partnership with the Government, Ministry of Health of Guatemala, international non-government organizations (NGOs), and local and regional agencies, and local politician involvement.	All the following stakeholders work together to ensure availability and access to the services: the lower level government and private health facilities which do not routinely provide imaging services; the district health authorities and health workers/midwives who undertake imaging training and the service provision; the expert radiologists in Uganda and abroad; and the low income mothers who are not able to pay high costs of ultrasound scan services in the private sector.	Throughout the design, development, implementation and evaluation of the program, community members are closely involved. First, the pay-it-forward program was developed using crowdsourcing (a practice in which a group solves a problem and shares it with the community) to solicit community input. Program procedures were designed iteratively with community partners (including staff members and volunteers from community-based organizations). Second, the name of program in Chinese (the local language) was crowdsourced from the public using an open contest. Third, participants write hand-written postcards to present to subsequent participants to show a sense of care and community. Finally, several of the community members are co-authors of the published research study.
7	Inputs	“Families received training and materials (volcanic ash and lime from nearby areas) to undertake house improvement. The municipality helped supply the volcanic ash (used also in road construction), and personnel in the Ministry of Health learned the procedure and helped in monitoring.”	ITWA utilizes the Digital Imaging and Communications in Medicine software to compress and share ultrasound images via the internet. In addition to the onsite and offsite experts and staff, there must be a cellphone, laptop, internet connection and the ultrasound machine for use, at the point of care.	In order to carry out the program, a community-based testing site is needed. Community partners need to have trained staff or volunteers to help individuals understand the testing procedures and collect testing samples. A partner local hospital or laboratory is also needed to carry out the lab tests.
8	Provider	University researcher guided, implemented by community members with local leaders. “Overall, the team at LENAP orchestrated the home improvement strategy in rural areas and conducted the laboratory tests, the Ministry of Health continued spraying and providing treatment, while staff at the health center obtained blood samples that are transported to a laboratory, and continuously monitored patients for symptoms of illness. The Mayor’s office provides the transportation of local materials for house improvements in the villages.”	Nurses and midwives are trained and equipped with skills and knowledge to conduct obstetric ultrasound scans. Through the use of their telemedicine platform, the ultrasound images can be immediately viewed and interpreted by volunteer participating radiologists around Uganda.	Researchers, staff and volunteers at the community-based HIV testing sites were trained with skills and knowledge to help individuals understand testing procedures and collect testing samples. Lab technicians at a local dermatology hospital laboratory carried out nucleic acid amplification testing.
9	Implementat ion strategy	By reducing the presence of the vector and the risk of Chagas disease in the intervention areas, the eco-health approach created social value in its most evident form: saving lives from preventable deaths. “Inter-disciplinarity was both an input, a methodological approach and a tangible result of this effort to reduce the presence and incidence of Chagas disease.” “The eco-health approach (based on environmental, social and biological risk factor management) described here is intersectoral as well as interdisciplinary.”	The implementation strategy combines point of care activities (ultrasound imaging, training, task shifting, and telemedicine) with community engagement and pragmatic funding pricing to promote sustainability.	The program was delivered as part of a research study. Participants were randomized in groups of ten and men who presented with their partners were assigned to the same group. There’s a 1/3 chance to be assigned to the pay-it-forward arm (the other two arms were pay-as-you-want and standard of care). If individuals would like to be tested, they would be tested right away on site. The program ran for approximately one month.
10	Monitoring and evaluation strategy	Through qualitative informant interview. “Polymerase chain reaction (PCR) techniques allowed the researchers to evaluate changes in the bug’s food source after housing improvement, thereby confirming a reduced risk of human-vector contact.” “Infestation rates decreased dramatically… Spatial analysis of the before and after distribution of vectors.”	Data are routinely collected on selected service provision indicators as well as pricing indicators, for better service provision and for sustainability.	This program was carried out as a randomized controlled trial. The process of design, development, implementation and evaluation were carefully monitored and documented.
11	Setting	The initiative began in four villages and was later scaled up to more than 17 villages in three different countries with diverse ecosystems and ethnic populations	The ITWA diagnostic services are provided in remote and underserved districts in Uganda. Starting from 1 district, growth has continued to at least 6 districts.	This takes place in community-based HIV testing centers in major cities in China (Guangzhou and Beijing).
12	Adaptability	“The housing improvement strategy and other components of the intervention in the field were then implemented and evaluated. This test provided visibility to the changes that the intervention generated in the homes and in the daily lives of communities, and provided the bases to replicate, implement and scale up the innovation in neighboring countries including El Salvador, Honduras and Nicaragua.”	Since its inception, the ITWA program has been expanded both in terms of geographic areas and the services they provide. The program was expanded to six other districts and a total of 11 health facilities by 2016. Wider scale up is envisioned over the next 5 years. Ultrasound sonography was extended to include echocardiography in selected areas.	Pay-it-forward strategy has the potential to be adapted to other context other than the current one. The program was designed with several aspects to enhance generalizability to other community-based testing sites: no doctors were involved in implementation, protocols were streamlined into routine services, and messaging was simplified. Whether the current program can be adapted to more resource-constrained settings need to be further explored.
13	Financing	Deployed program through international donors. International Development Research Centre (IDRC) of Canada, funded the development of the innovation and supported the scale up to El Salvador and Honduras (2011); the Japanese International Cooperation Agency (JICA) funded the transfer of the program to Nicaragua (2014).	Funding is a combination of grants (Phillips, Grand Challenges) as well as minimal client contributions for the service.	The program received funding support from the US National Institutes of Health; the Special Program for Research and Training in Tropical Diseases sponsored by UNICEF, UNDP, World Bank and WHO; the National Key Research and Development Program of China; Doris Duke Charitable Foundation; and the Social Entrepreneurship to Spur Health Global.
14	Social impact	Eco-social model. Three processes emerged, giving shape to this experience and contributing towards interdisciplinarity, intersectorality and community empowerment. These three processes generated a multidisciplinary research team of dynamic partners in governmental, NGO agencies, academia and the community. These processes were not just methodological choices and outcomes of an eco-health approach, but will also be crucial to future social innovations in health.	The social impact includes: improved maternal and health outcomes which directly impact wellbeing of families; increased number of women seeking antenatal care; and increased husband/partner involvement in ANC services. With increased awareness, families and husbands became interested in seeing their unborn child through ultrasonography and preparing for the delivery of the baby.	The program promoted community engagement in health services. In China, men who have sex with men still face social stigmatization and may face difficulties visiting the clinic for sexual health testing services. By partnering with community-based organizations, the program was able to not only provide affordable testing resources, but also empower the community partners to provide more health services to their community. The pay-it-forward action could also build collective agency and social cohesion. From a policy perspective, this type of program could also be useful as a temporary measure to generate testing demand and build trust in new services, before the introduction of more comprehensive public-funded programs.
15	Health impact	Infestation rates decreased dramatically inside homes and as long as the walls were kept smooth and without crevices, the triatomine bug was unable to establish itself and reproduce within the households. Spatial analysis of the before and after distribution of vectors [21] substantiated this change. Actual incidence of Chagas was not measured	ITWA has expanded to 11 rural health facilities in Uganda and has trained over 150 health workers and conducted over 200,000 ultrasound scans since 2010. Data are used to aid health care decision making for the individual pregnant woman as well as at the specific health facility level. ITWA reports that results of obstetric ultrasound scans have contributed to improved management in about 23% of the total pregnancies.	Pay-it-forward strategy increased STI testing. 56% men in the pay-it-forward program agreed to receive the gonorrhea and chlamydia test, compared to 46% in the pay-as-you-want group and 18% in the standard-of-care group.
16	Limitations	First, the period of time for researchers to learn about the initiative and conduct interviews with the communities and other partners was short. Second, the household improvement experience for the control of Chagas disease has been transferred to other countries, but in this case study only the Guatemala initiative was considered - therefore these results may not be generalizable to other contexts. Third, the researchers/authors recognize that evaluation of the cost-benefit relationship of the intervention could contribute to the replicability and sustainability of social innovation in health initiatives.	Not listed	First, the program was examined in two metropolitan cities in China and making inferences to other settings should be done with caution. Second, this program was evaluated in a research context rather than a practice one. The cost-effectiveness analysis used a short-term time zone and did not calculated the disability-adjusted life-years averted or quality- adjusted life-years gained.
17	Strengths	Using an intersectoral approach, much more than just health outcomes were achieved.	Through task-shifting and development of e-health/telemedicine ultrasound radiology service, the ITWA program made it possible for rural pregnant women to receive timely, affordable care closer to home. The business model and implementation strategy focus on self-sufficiency and sustainability, which together are necessary for scaling up this innovation.	Compared to the conventional approach, pay-it-forward strategy significantly increased testing uptake and were able to reach more members of key population. The program made gonorrhoea and chlamydia testing more affordable and accessible.