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Collaborative development of open source-appropriate technologies: a way to reduce the global access gap?
  1. Roberto Aufieri,
  2. Simonetta Picone,
  3. Piermichele Paolillo
  1. Division of Neonatology and Neonatal Intensive Care, Casilino General Hospital, Roma, Italy
  1. Correspondence to Roberto Aufieri, Policlinico Casilino, Via Casilina, 1049, Roma 00169, Italy; r.aufieri{at}

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Healthcare systems in low- and middle-income countries (LMIC), due to scarcity of economic resources, often lack appropriate health technologies necessary for the prevention, diagnosis and treatment of many curable diseases.1 WHO acknowledges that most of the current global health targets and goals would be impossible to achieve without an increase in access to essential medical devices,2 hence promotes the development and local production of appropriate devices.3 Nonetheless, despite the increasing interest and efforts, prices of devices, as well as prices of patents for local producers, continue to not be appropriate for many LMIC. Research, development and production of biomedical devices are mostly performed by companies in high-income countries for high-income markets, and it has been estimated that only 13% of manufacturers are located in LMIC.2 Consequences are that high prices, along with inefficient local production and distribution, among other factors, contribute to set back commercialisation and availability of final products in low-resource settings. This problem has been recently highlighted and defined as the last mile translation.4

In the past few years, information technology achievements have had a profound impact on most people's everyday lives. These have been obtained not only through research and development of novel technologies, but also thanks to the adoption of so-called open source licenses. Open source licenses are conceived to allow everyone to use, copy, modify and freely redistribute, under defined terms and conditions, a piece of software and its source code.5

The most notable example of free and open source software is represented by the Linux operating system. When, in 1991, its creator, Linus Torvalds, released the source codes of this new operating system to the public, asking for the collaboration of other developers, he unwittingly launched what has probably become the biggest collaborative software project ever. Nowadays, Linux is a fast, stable and secure operating system, widely used on web servers, personal computers, smartphones and tablets. The same philosophy, adopted for software licenses, later also found application in the hardware field, resulting in the development of low-cost, versatile products (eg, Arduino, an open source microcontroller) that inspire different uses and applications, and that are, together with the diffusion of three-dimensional (3D) printing, contributing to foster the “maker movement”, a growing community of novel inventors.

3D printing, also known as additive manufacturing, allows printing of solid objects of any shape from its digital model, layer by layer, out of plastic or other material. This novel technology has been shown to be highly cost-efficient and project files can be easily shared, allowing collaborative prototyping. A successful example of a 3D printing based collaborative project is the e-NABLE Project (, where a community of more than 1500 contributors collaborate to prototype open source 3D printed prosthetic hands that can be downloaded and printed by anyone for less than $50 in materials.

Furthermore, the possibility of reducing research costs with the creation of open source scientific hardware by combining 3D printing with open-source microcontrollers running on open source software has been emphasised.6 However, only a limited number of pieces of scientific equipment and devices, including a certified diagnostic electrocardiograph, optics components and syringe pumps for laboratory research, have been conceived and released under an open source license.7–9

The OS4BME (Open Source for Biomedical Engineering) project, in 2013, during the Innovator Summer School (an initiative of the United Nations Economic Commission for Africa), held an intensive course of open source design and rapid prototyping for biomedical engineering at the Kenyatta University (Kenya). Throughout the 1 week course, students designed and assembled an open source neonatal monitor.10

It is our opinion that, in a field where conventional approaches have not yet obtained the desired outcome, future strategies to reduce the medical technology access gap in LMIC should consider the promotion of collaborative development of appropriate open source technology for global health purposes. The use of 3D printing combined with low-cost microcontrollers or single-board computers, could help to reduce costs of prototyping, and open source projects, once available, could be freely used and modified by global biomedical companies.

Trying to stimulate the debate and to provide a platform for online collaboration, we have ultimately started up the WikiBioMed project ( This is a collaborative non-profit project, aimed at creating a multidisciplinary collaborative coworking community that would conceive and prototype open source biomedical devices, shared on a wiki site. However, any initiative aimed at the development of open source appropriate technology for LMIC would be beneficial and therefore is to be encouraged.

It is hoped that, in the future, the adoption of open source licensing along with application of new technologies, as mentioned earlier, will contribute towards increasing access to essential, appropriate and potentially life-saving technology in low-resource settings.


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  • Contributors RA conceived the work, performed the literature research, wrote the first draft of the manuscript and revised subsequent and final drafts. SP, PP conceived the work and revised subsequent and final drafts.

  • RA, SP, PP: read and approved the final manuscript. RA, SP, PP are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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