In lower- and middle-income countries (LMICs), access to health remains an important issue to solve.
Shortage of healthworkers is one challenge among others: according to the World Bank, there is only 1.2 doctor in LMICs (versus 2.9 in high income countries) and 2.1 nurses or midwives per 1,000 people (versus 8.7 in high income countries). At the same time, 90% of smartphones users will be located in LMICs in 2020. The promise of digital health to address some of the underlying health systems challenges is undeniable. Digital health can significantly support the achievement of Universal Health Coverage (UHC), one of the targets of the third Sustainable Development Goal (SDG). A recent report estimated for example that 1.6 billion people could benefit from quality medical services through digital health solutions. Beyond access, digital health can also play an important role in terms of cost reduction and health systems efficiency and quality. Although not many countries have yet analysed the impact of digital health on their systems, it is notable that Canada estimated that their investments in digital health (implementation of electronic medical records (EMR), telehealth and district information systems) generated savings of CAN$16 billion since 2007.
Many challenges remain to fully leverage the tool of digital health. Fragmentation, data interoperability and lack of appropriate legislation and laws are still prevalent. The Ebola crisis was one of the wake-up calls to the growing realisation that data fragmentation needs to be addressed if ICT tools are to be used for effective data collection and analytics. Data needs to be integrated to make it useful in real-time to healthcare professionals or public health authorities.
A striking example of what we mean by fragmentation is Mali where there are 11 different mobile health initiatives for maternal and child health funded by different institutions. Moreover, most of these institutions use their own tools and systems which are not interoperable with systems used by the national eHealth agency. In LMICs, the number of digital health projects had increased by more than 30% between 2005 and 2011 but two thirds were still in pilot or informal stages. Although this statistic is a bit dated, “pilotitis” has been a common word used in the field of digital health for many years and is still prevalent.
Many countries still do not have the appropriate data security and data privacy regulations in place and this is a current hot topic that hinders the trust of any user. A lack of proper legislation to govern mHealth Apps or connected devices and sensors can also undermine investments in countries.
Beyond these obstacles, other barriers still need to be tackled: insufficient human and technical capacity to analyse health data and meet patients’ needs, resistance to technology, unsustainable financing, lack of coordination between national ICT plans and national digital health strategies, connectivity gaps, quality and performance issues of networks, and lack of reimbursement schemes.
As the cycle of digital health evolves, there is a growing realisation on the fundamental role governments have to play in advancing the use of technology for health by developing the right policies and infrastructure as well as building capacity for digital health. In February 2017, the Broadband Commission Digital Health Working Group (co-chaired by Novartis Foundation and Nokia) published a report called: “Digital Health: A Call for Government Leadership and Cooperation between ICT and Health”. It advocates for governments to take action on national digital health strategies to solve the fragmentation dilemma and help tackle the challenges mentioned above.
As of 2016, 58% of WHO’s member states had developed national digital health strategies. This does not translate in the fact that countries have implemented these and there is therefore still a lot of work ahead. Implementing a strategy is no minor task and represents a significant investment: the Government of Rwanda committed US$32 million for its first 5-year eHealth plan for example. Tanzania’s more recent digital health road map calls for overall investment of approximately $74 million. The above-mentioned report looked into 8 countries that managed to advance effectively the digital health agenda (Canada, Estonia, Malaysia, Mali, Nigeria, Norway, the Philippines and Rwanda) and provides key insights and lessons which other countries can leverage from.
A key finding was that countries achieving success in implementing strategies shared responsibility and investment between the Health and the ICT authorities (typically between Ministry of Health, Ministry of Communication and the eGovernment agency).
Perhaps the most important learning from the global scan that was done, is the utmost importance of having the appropriate leadership and governance in place to enable the effective implementation of a national digital health strategy. Many stakeholders saw this as the most challenging first brick to attain in order to robustly build around the other essential components of a strategy: Strategy & Investment, Standards and Interoperability, Infrastructure, Legislation & Policy & Workforce. Government leadership is vital in fostering an enabling environment for digital health policies and an effective cross-sectorial governance mechanism, the basis for facilitating alignment and cooperation between health and ICT sectors.
In terms of governance and government leadership, some LMICs are true models. In the Philippines, close cooperation between health and ICT ministries has been materialised in a joint MoU and governance mechanisms with clear role and responsibilities, and Rwanda’s very strong high-level commitment of broadband policies and extraordinary intersectoral governance makes it a real example for many countries around the world. It embodies the promise for these countries to leapfrog and avoid the difficulties today faced by high-income countries, often linked to legacy infrastructure and systems.
The digital health ecosystem in LMICs is entering a new phase where the focus is starting to shift to investing in “the roads” for digital applications and services to scale. In other words, a shift to a “system” thinking vs. solutions. This evolution will accelerate the scaling and development of digital health and help in achieving Universal Health Coverage.