Governments and donor organisations have consistently given priority to sanitation, immunisation, children’s health, women’s health and human immunodeWciency virus (HIV) treatment when funding healthcare in resource-limited countries. This has caused a serious impact on surgical health in rural areas where poverty is endemic and more than 80% of the household income is spent on food. In this setting, healthcare is a luxury. Ozgediz et al. concluded that there is tacit global acceptance for allowing patients to live with chronic surgical disabilities such as hernia, or to die from a lack of access to care [1]. Worldwide, 2–3 billion people do not have basic surgical care. Their nearest rural hospital will have minimal infrastructure, lacks staV and has an acute shortage of electrical supply, running water, oxygen and fuel [2–4]. The average rural hospital only performs Wve operations per week, twothirds do not perform hernia repairs and most operations are emergent [5, 6]. Such a catastrophic picture requires imaginative solutions that apply cheaper, alternative and innovative technologies, such as the low-cost (mosquito net) mesh for inguinal hernia repair reviewed by Yang et al. Undoubtedly, this “frugal innovation” will be challenged by the global healthcare industrial complex. Frugal innovation involves the search for tools and techniques that spare resources, yet maintain or improve outcomes [7]. The hernia healthcare industrial complex has developed over 200 diVerent types of mesh which can be applied to repair hernias of the abdominal wall hernia, with costs ranging from about $40 to $6,000. Powerful marketing strategies which spend $2 for every $1 spent on research and development, and which result in an average spend of $5 on the product, encourage the use of the latest design, which is invariably more expensive than its predecessor. These new hernia devices are rarely put to the test of comparative or randomised trials before marketing. Frugal innovators believe that there is no need to adopt every new piece of equipment, material or device. With this approach applied at multiple levels in India, small for-proWt hospitals can oVer operations at one-Wfth of the price demanded at larger private hospitals. The application of mosquito net mesh to inguinal hernia surgery is another example of inexpensive technology which could meet an overwhelming need in healthcare systems with limited resources [8]. Farmer has recently described the use of mosquito net mesh as a fabulously clever, inexpensive and context-appropriate way to treat inguinal hernia [9]. Even though India is a fast-developing country with world-class facilities, including robotic surgery being performed in many metropolitan cities, the fact remains that around 70% of the Indian population resides in rural areas and 40% of Indians live below the poverty line. Even today, 400 million people in India do not have access even to primary surgical care. Therefore, aVordable surgery, including surgery for hernia using cheaper mesh, is the need of the day. During the last 15 years, mosquito net mesh has been used in India for the repair of hernias [10]. The mesh is 3,700–4,000 times cheaper than commercial meshes and is A. N. Kingsnorth (&) Peninsula College of Medicine and Dentistry, Department of Surgery, Derriford Hospital, Plymouth PL6 8DH, UK e-mail: andrew.kingsnorth@phnt.swest.nhs.uk
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