What a discussion on healthcare revealed about frugal innovation
A wheelchair that costs a third of the imported version. A hearing test device that fits in a bag. A device that stops a woman from bleeding to death after childbirth, built for a twentieth of the price of anything on the market.
None of these are ‘simple gadgets’. All of them are frugal. Wednesday's VOICE session, led by Sanghamitra Chakravarty, spent two hours asking what that word actually means once you get past the price tag.
It started with a blunter point. Early in the session, during a discussion about Appropriate Technology, a movement that predates the term frugal innovation by decades, a participant working in development said it plainly: providers of innovation tend to be the ones who benefit most. The people at the bottom of the value chain often see only a fraction of it.
Nobody disagreed.
For Chakravarty, the answer to what makes an innovation frugal lives somewhere between technology, context, institutions, the people expected to use whatever gets built. Earlier in the week, Oane Visser's session had used agriculture to ask who actually benefits when innovation arrives. Chakravarty came at the same theme from a different angle. Rather than asking who innovation is for, she wanted to know how innovations actually move from prototype to practice, particularly in sectors as technology-heavy as healthcare.
Her argument going in was simple: technology cannot be looked at as a product alone, stripped of context and processes of technology development. Over the next two hours, participants from India, Kenya, South Africa, Colombia and the Netherlands tested that claim against examples from healthcare, entrepreneurship and public policy, and against their own experience of trying to make things work in systems that were not built for them.
Before Frugal Innovation Had a Name
To get there, Chakravarty first took the group back to the 1970s.
Long before frugal innovation became a recognised field, economists and development thinkers were already questioning whether technology built in wealthy countries could simply be dropped into low and middle income countries. One of the most influential voices was E.F. Schumacher, an economist shaped in part by Gandhi and Buddhist thought, whose 1973 book Small Is Beautiful inspired the Appropriate Technology movement. Schumacher called for a study of economics as if people mattered. You couldn't just import a solution from somewhere else and expect it to work, the argument went. Technology had to fit local capability, local resources, local need.
The questions from that era have aged surprisingly well. Who decides which technologies get introduced. Who actually benefits. How anyone determines whether the thing worked at all.
One participant pulled the historical thread into the present, pointing to India's recent push toward technological self-reliance, including a reported ban on Telegram, and what that meant for a country trying to both protect its own innovation and stay plugged into global exchange. Chakravarty agreed it was a real tension. Geopolitics, she said, is making it harder for developing countries to get hold of the tools they need, not easier.
Technologies, the group kept circling back to, can be imported. Maintenance, training and trust cannot.
What Counts as Success?
The conversation shifted to something that sounded simple and was not.
How do you actually judge whether an innovation has worked? One participant argued that plenty of frugal innovations get labelled failures because they never reach commercial scale, even when they solve a real problem for the people using them every day. Another pushed harder: who gets to decide what counts as success or failure in the first place?
The question stuck around. An innovation can fail commercially while still meeting a genuine community need. It can also succeed commercially while doing almost nothing for the people it was supposedly built for. Success, several participants agreed, depends on whose vantage point you're standing in. The entrepreneur's. The investor's. The government's. The community's.
That same scepticism turned on frugality itself. One participant brought up the Tata Nano, once celebrated as the world's cheapest car, eventually discontinued over safety and emissions problems. Solving something cheaply, she said, does not automatically mean solving it well.
Chakravarty agreed, and did not let it go at that. Frugality gets romanticised far too often, she said. No one chooses to be poor, and no one chooses to suffer for the sake of it. If decent public transport already exists somewhere, the case for a cheap private car looks a lot less compelling.
AI-generated illustration, based on documented cases of unused medical equipment in low-resource healthcare settings.
A Graveyard of Medical Devices
The discussion turned concrete when Chakravarty put up a photograph.
A mound of medical equipment piled outdoors under open sky, trees in the background, nothing protecting it from weather or theft. A medical device graveyard, one participant called it, and the room recognised the image immediately. The photo itself was taken at a hospital in Malawi. Chakravarty said growing up in India, she'd been familiar with the sight long before she ever saw this particular picture.
The numbers behind it are worse than the picture suggests. Roughly 90 percent of medical devices in low and middle income countries are imported, and a large share never fit the environment they land in. Across sub-Saharan Africa, around 70 percent of equipment is donated by international agencies, and only a fraction stays operational. Most of it fails for reasons that have nothing to do with the device itself: missing training, absent spare parts, infrastructure that can't support it.
Healthcare technology is overwhelmingly designed for high-income settings, even though many of the world's most urgent health problems sit elsewhere entirely. The result is equipment that arrives in places it was never built for.
The real issue, Chakravarty argued, is not affordability. It's suitability. A sophisticated device nobody nearby can repair may end up less useful than a simpler one designed specifically for where it has to work.
Designing for Context
Three South African companies followed. All three made the room rethink what frugal innovation actually means.
- Shonaquip Social Enterprise builds including paediatric wheelchairs for children in low resource settings, a category that was not available when Shona Mcdonald started her work more than 30 years ago. Adult wheelchairs given to children, Chakravarty noted, can cause secondary disabilities sometimes worse than the original one. Shonaquip's answer was the Madiba Buggy, Africa's first standardised wheelchair, developed in 1996 with a grant from the Nelson Mandela Children's Fund. It handles uneven terrain, can be repaired and maintained locally, and costs a third of imported alternatives. But the wheelchair is only one of the points. What made it work was the network and ecosystem around it: caregivers, government health and education departments, a collaboration with Stanford's Design for Extreme Affordability programme, policy enablers including South Africa's national disability strategy. Roughly a third of Shonaquip's own staff live with a disability themselves, bringing their lived experience into product design and manufacturing.
- eMoyo Technologies, founded by a medical doctor, built a portable hearing test device, the KuduWave, designed to reach patients who would otherwise need a soundproof testing booth that doesn't exist where they live. Worldwide, 466 million people live with hearing loss, disproportionately in developing countries. The device was deployed in South Africa's decentralised multidrug resistant tuberculosis programme between 2015 and 2016, where keeping contagious patients from having to travel mattered nearly as much as the diagnostic itself.
- The third, Sinapi Biomedical, makes the device behind that opening line: Ellavi, a uterine balloon tamponade used to stop postpartum haemorrhage, one of the leading causes of maternal death. Chakravarty was direct about what struck her most when she first came across the case. Such a problem, she said, wouldn't even exist in the context of high-income countries. Of the roughly 112.000 maternal deaths from this cause each year, 99 percent happen in low resource settings. Keeping in mind primary healthcare workers, the device itself is simple to use. What makes it frugal is that it costs a twentieth of the alternatives already on the market, delivered through subsidised public healthcare and licensed to other developing countries facing the same problem.
None of the three fit the stereotype of frugal as simple or low-tech. All three relied on serious engineering and design capability. What made them frugal, in Chakravarty's framing, was that they were built around the realities of the people using them, aimed at expanding who could access them, not at cutting corners to hit a price point. Further, they contributed to building local technological capabilities.
That same pattern, small and local outperforming big and well-resourced, came up again. One participant had worked at a large company that tried something similar. They had a simple idea: move from designing for communities, to designing with them, to eventually letting communities design things themselves. The company really wanted this to work.
In practice it rarely went anywhere, because large companies usually lacked the patience to get close enough to communities for the shift to mean much. It was the smaller, local players, he said, not the big corporations, who kept ending up with the innovations that actually fit.
South Africa's Innovation Paradox
The South African cases brought out some of the most direct talk of the session, and the participants who knew the country best didn't hold back.
They described a place with serious engineering talent and respected universities sitting next to structural barriers that make it hard for anything to survive past the prototype stage. Funding came up again and again. So did regulation, infrastructure, the wide gap between a small working prototype and anything close to implementation at scale.
One participant had watched family members run small businesses in South Africa. The feeling, she said, is close to universal. You're on your own. It's you against the bureaucracy. It's you against financial constraints that never let up. And it's you against a list of factors that keeps shifting under you. Another added the harder mechanics of it. Innovation tends to die somewhere in the prototyping stage, simply because scaling takes resources the original idea never needed.
A second paradox followed close behind the first. When South African innovations do succeed, they often find bigger, more profitable markets elsewhere. The local problem sparked the idea, but commercial success can pull the solution away from the community it was built for, sometimes through outright acquisition by a larger, often foreign, company.
Chakravarty had a story of her own that put a number on the gap. One company hired a contractor, showed him a YouTube video, and two months later he'd built a prototype of a device that would have cost 2.8 million rand from an established manufacturer. When she submitted the research for publication, a reviewer assumed the figure was a typo and asked her to confirm it. She went back to the company. The number held.
Cover picture from Sanghamitra Chakravarty's thesis - showing barriers, valley of death in the backdrop of the table top mountain.
Frugal Does Not Mean Worse
One participant pushed back on his own first instinct. When he hears the word frugal, he said, the instant assumption is that cheaper means inferior: smaller, less robust, missing parts. The wheelchair example made him reconsider. In several ways, it was a better product than its expensive counterparts, not despite being frugal but because of it: built for terrain the imported version was never tested on, and more likely to spread upward into wealthier markets than the other way around. Frugal, he suggested, isn't necessarily cheaper. It's differently optimised, working toward a different goal entirely.
Chakravarty agreed, and went a step further. Calling frugal innovation a poor man's version of the real thing misses what's actually happening on the ground, she said. Designing something that works reliably, at a fraction of the cost, for conditions far harsher than the ones mainstream products are tested in, is not a lesser challenge. It's often more challenging.
The System Around the Innovation
By the end, nobody reached for an easy conclusion.
The discussion had started with a question about what makes innovation frugal. It finished somewhere broader: not just how technology gets built, but who actually ends up better off because of it.
Products matter. Systems matter more. The organisations that carry implementation. The policy that allows adoption. The financing that survives past launch. The capability that remains once the project itself is gone. None of it is as visible as the device or the wheelchair itself, but it's usually what decides whether the thing keeps working a year later, or ends up in a pile outside a hospital somewhere.
By the time the session ran out of time, frugality looked less like a question of cost, and more like a demanding design standard. Something that fits where it lands. Builds capability rather than just using it up. Stays within reach of the people who actually need it. And keeps working long after everyone's stopped paying attention.
VOICE is an eight-week international online programme on frugal and bottom-up innovation, bringing together participants from the Netherlands, India, Kenya and Colombia. Sessions take place every Monday and Wednesday from 14:00 to 16:30 CEST.