What South Africa's Trial Sites Teach Global Clinical Research
By John Oncea, Chief Editor, Clinical Tech Leader
Liam Devenish has run clinical trials in two very different places: Johannesburg, a major city with a well-developed university research system, and Mafikeng, a town on the South African-Botswana border where he spent a year in clinical practice. He’s since moved to London to study health policy and economics at the London School of Economics, giving him a third data point – the UK’s National Health Service – to compare both against. The comparison he draws isn’t the one most articles about “resource-constrained environments” reach for.
Punching Above Its Weight, Without The Infrastructure To Show For It
South Africa’s clinical research output doesn’t match what you’d predict from its digital infrastructure, and Devenish thinks that’s worth explaining rather than treating as a curiosity. “South Africa is an interesting example of a clinical research environment because by any standard metric, we punch way above our weight,” he said. He points to a well-developed university system and a disease burden including HIV and tuberculosis that gives the country’s research a global relevance few countries can match.
What South Africa doesn’t have is the UK’s ambient digital infrastructure. “If, for example, you compare it to the UK, where everything you do is reliant on an app on your phone – I book my GP appointments, I get my prescriptions, I get all my results – they have this wealth of not just outcomes data, but process data, which they can use at all times to simulate or to stimulate clinical research,” he said. “Whereas in South Africa, in the public healthcare system, that doesn’t exist.”
Technology That Arrives, Then Leaves
The way South African trial sites get their technology is fundamentally different from a system where digital infrastructure is simply part of the healthcare backdrop. “Where an individual research institute or external sponsor wants to do research, they will swoop in and put in the technology that’s required,” Devenish said. “So, data management platforms or whatever technology it is that they want to roll out or whatever technology it is they need to collect data will be used specifically for that purpose and then removed, and there’s no endurance of that.”
The result is a research landscape with pockets of genuine sophistication that don’t build lasting local capacity. “You’ll have a clinical research site that is extremely well-equipped, which will draw from the local population or the local healthcare center, et cetera, but which operates separately from it,” he said. The technology gets built for the trial, not the health system around it, which means every new trial starts closer to zero than it should.
The UK’s Advantage Comes With Its Own Blind Spot
Devenish isn’t holding up the UK as the model to imitate wholesale. The NHS’s deep digitization gives it a genuine research advantage – the process data alone is something South African researchers can’t replicate – but he argues that abundance has created a different kind of inefficiency. “Their priority setting is probably a little bit less developed than in South Africa, because they’ve had more resources and less need to priority set,” he said. “They end up spending their money in probably quite inefficient ways and don’t quite know how to dial that back.”
South Africa’s constraint, by contrast, forces a discipline the UK hasn’t needed to develop. “We’re trying to scale up and change the shape of our healthcare financing architecture,” Devenish said. “We are probably better at understanding where we can more efficiently use our money, but we just have less of it.” It’s a trade rather than a simple deficit: resource scarcity forcing a prioritization skill that resource abundance never had to teach.
Does Rural Actually Mean Simpler?
Comparing Johannesburg to his year working in Mafikeng, Devenish initially points to a structural advantage in the smaller setting: a hub-and-spoke healthcare model that’s more straightforward to navigate than a dense city where “multiple tertiary hospitals each operating at a slightly different level” compete alongside “different research institutes and interests who are all trying to interact in that field.” Fewer people, more direct referral pathways, less institutional politics.
But he’s candid that the comparison doesn’t resolve cleanly. “I’m struggling to answer this question, actually,” he said. “But yes, there is a layer of complexity involved in a big, messy city that I guess isn’t there in a rural setting.” His fuller explanation lands somewhere more specific than simpler is better: South African clinical research, urban or rural, tends to operate as its own self-contained entity, built for the trial rather than embedded in the surrounding health system, a pattern that holds “whether you go to a central Johannesburg clinic or work in Mafikeng on the border of Botswana.”
The Actual Lesson For Global Sponsors
The takeaway isn’t that resource-constrained environments have a hidden efficiency advantage sponsors should chase, and Devenish doesn’t claim otherwise. It’s that infrastructure abundance and infrastructure scarcity each produce their own distortions; one in prioritization discipline, the other in institutional endurance. For sponsors expanding trial diversity into environments like South Africa’s, the practical implication is direct: technology dropped in for a single trial, then removed, replicates the pattern Devenish describes rather than solving it. If a platform is worth deploying, the harder and more valuable question is whether it’s built to outlast the study it was funded for.
This is a companion piece to The Hidden Costs of Clinical Trial Technology Nobody Budgets For, which explores the economic framework Devenish applies to technology investment decisions.