Developing and adopting complex health innovations – The case of genetically modified mosquitoes for malaria eradication

Background: Malaria, a preventable and curable disease, is still one the primary causes of death worldwide. Around 90% of deaths occur in sub-Saharan Africa. Increased funding and new programmes by international agencies and national governments have led to significant progress in malaria control, but the improvement curve is levelling off. This is due to the limitations of current technologies and difficulties in deploying the interventions on the ground. There are calls for technological innovations which are able to provide interventions that are cost-effective, sustainable, area-wide and equitable. The development of selfsustaining genetically modified (GM) Anopheles mosquitoes is deemed to have these potential attributes, but this technology is not only innovative, but also highly complex and controversial. Using the introduction of GM mosquitoes for malaria eradication in Burkina Faso as an example this study helps to better understand how complex health technology innovations are adopted in low-income countries. Methods: The research uses a mixed methods approach and combines an in-depth analysis of the Burkinabé (Burkina Faso) health system and its wider context, qualitative system dynamics modelling and an econometric analysis in order to investigate the key barriers and enablers that influence the adoption of GM mosquito technology. Results: The research confirms the importance of community trust and acceptance, and health system readiness, in influencing the adoption process. It also emphasises the need for a perspective on the adoption of highly complex innovations which takes more account of the iterative nature of their development, the interrelationship between development and adoption, and the cognitive barriers in stakeholders’ understanding of the technology. Conclusions: The intrinsic complexity of the technology development and local adoption processes, and the fact that the nature of the technology itself means that adoption decisions are societal rather than individual, together have important implications for policy and practice. These need to be taken into consideration both by local policy makers and technology researchers.