More than a decade of experimentation in digital health has seen the rise of a range of innovations that build on the promise that emerging technologies can dramatically improve health care, especially in low- and middle-income settings.
What has also emerged is a range of challenges, as innovators have wrestled with everything from building partnerships to reproducing successful programs in new settings. One of the biggest hurdles has been how to channel the lessons from the proliferation of projects that never grew beyond their pilot stage into scalable interventions.
“There was a surge of investment,” said Dykki Settle, who has been involved in digital health since its beginnings more than 10 years ago. He is now the director of digital health solutions at PATH, an international health organization with a special focus on technology. “It was a highly fragmented, duplicative and wasteful investment. Like the Wild West, everyone going out and staking claims.”
Uganda, overrun with digital health pilots, actually declared a temporary moratorium in 2012.
Since that time, even as they begin to think more creatively about how to make use of ever-growing technology, experts in the digital health field say there has been an emerging consensus to tackle those challenges even as they continue to develop the projects most likely to improve health care for patients in low- and middle-income countries.
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“I don’t think the promise [of digital health] has lost its shine,” Settle said. “I think it’s risen to a higher, better and smarter level.”
What has been achieved
That includes in Tanzania where, three years ago, the country started rolling out an electronic Integrated Disease Surveillance and Response — or eIDSR — system. The strategy, built off of a World Health Organization model, is one of the more traditional — and successful — digital health interventions: A representative from each of the country’s medical facilities submits detailed information each week about the cases seen and illnesses detected, which is then registered in a central database.
Officials at national and regional levels can quickly review the information to detect emerging disease patterns, allowing them to reconfigure drug deliveries or deploy additional human resources.
Tanzania previously had a paper-based IDSR system, where malaria information was reported only once a month. For malaria experts from RTI International, an independent, nonprofit research group based in the United States, this was not frequent enough. The disease is the fourth-leading cause of death in Tanzania, according to the WHO, and the RTI team wanted better data to help plan future interventions.
“We wanted to establish this surveillance system and we didn’t want to get into a parallel system,” said Dr. Ritha Willilo, RTI’s senior technical advisor.
With a goal of creating a system that was both more streamlined and faster, they hit upon an eIDSR model that combined a health worker’s disparate tasks under the existing IDSR model into one comprehensive digital system that includes reporting on 25 priority diseases — including malaria.
With funding from the U.S.-funded President’s Malaria Initiative, RTI has been able roll eIDSR out in eight of Tanzania’s 25 mainland regions since 2013, covering about 30 percent of the country’s health facilities. There is now money to expand to three more.
Willilo said uptake has been good, as health workers realize the tool can help streamline a previously cumbersome process. And at the same time, RTI gets what it wants — better and faster reporting on malaria that helps fuel more targeted interventions and, ultimately, save lives.
The project, she said, is an example of what digital health has and can continue to achieve as successful models continue to evolve and improve.
A new way of working
The Novartis Foundation’s telemedicine project in Ghana was something new entirely.
The project grew out of the needs of community health workers in a remote region in south-central Ghana. The foundation was working with the CHWs to improve the quality of their care in an area where the nearest health facility might be 25 miles away. The problem, though, was most of the CHWs were trained in preventive care, but not in curative or emergency response. The limited access to health services meant they were often called upon to provide those services anyway.
So the Novartis Foundation helped pioneer an initiative to use digital technology to connect the CHWs to nurses and doctors, who could answer their emergency questions and help determine when a patient should be referred to a health center.
“Community health workers are thrilled by the possibility,” said Dr. Ann Aerts, who heads the foundation, which focuses on pioneering innovative health care models. “They feel much more secure.”
Though initially conceived as a district project when it was first introduced in 2011, the potential of the telemedicine initiative soon became apparent. By 2013, it was included in Ghana’s national eHealth strategy and there is now a roadmap for government-led, national scale-up to be completed by next year. Aerts said this was an important lesson for the foundation’s team on looking at the scalability of digital health projects beyond the immediate community where the work is taking place.
“It’s our new way of working,” she said. “We do not start if we are not sure a solution we are pioneering can be scaled.”
Of course, there are challenges beyond just applicability, including securing resources and key partnerships. Electronic medical records require access to electricity. Both the IDSR system in Tanzania and the telemedicine project in Ghana demand reliable telecommunications services. Where these resources are not readily available in communities, digital health projects have to consider the cost of introducing them.
“Innovators have to critically weigh the initial upfront investment to ensure the tool does not drain precious resources,” said Christina Synowiec, a senior program officer at the Results for Development Institute, where she has studied the issue of digital health. “The cost of adopting these systems can be resource-intensive, and in places with low levels of infrastructure to support them, such as access to electricity, they may be impractical.”
When it comes to scalability, it is also critical to make sure national standards are in place so that, once a project is introduced, other communities can easily plug into it.
These, said the Novartis Foundation’s Aerts, are some of the critical reasons to bring partners within the government and private sector on board early in discussions.
“If you don’t have infrastructure already foreseen, it’s very hard to have a digital tool that, by itself, is going to be successful,” she said. “You need to have that infrastructure and those standards first established.”
This issue of interoperability is also becoming increasingly critical in the absence of one overarching global health system, said Dr. Alain Labrique, founding director of the Johns Hopkins University Global mHealth Initiative. In a bid to reduce overlap, the “immediate future might see a common set of standards and national-level backbones into which many different, interoperable systems can connect.”
He said the present conversations around challenges for successful scaling — about resources, standards and interoperability — could partially be credited to the earlier era of prolific digital health pilot experimentation.
“It’s not the technology that we care about. It’s really solving the problems.”— Dr. Alain Labrique, founding director of the Johns Hopkins University Global mHealth Initiative
“Without pilots, we wouldn’t have the courage to talk seriously about what really works in this space, what demonstrates potential for impact and which are the actual systems which we need to be scaling up,” he said. There are even guides now, including a toolkit produced by Johns Hopkins, the WHO and others, to help direct digital health projects to scale.
Solving the problems
Alongside scalability, replicability has become an important component of emerging digital health projects.
PATH has a number of immunization initiatives, for instance, that use digital tools to track vaccine stocks and record immunization records in countries where vaccination coverage is low. The idea is that these models, while introduced in specific settings, can be easily deployed in other countries that face similar problems.
At the outset of a project, Settle said the PATH team “develops a methodology that works with multiple stakeholders to surface generalized requirements, even while thinking about specific requirements. If you build a tool to solve a specific problem, you’re constantly doing one offs and always having to tackle problems from scratch.”
Labrique said this is all part of a larger shift in perspective within the digital health community — away from the initial enthusiasm for digital health purely for its own sake and toward using these technologies to figure out how to enhance existing programs to save and improve lives.
“It’s not the technology that we care about,” he said. “It’s really solving the problems.”
The rise in non-communicable diseases in low- and middle-income countries, for instance, has the Novartis Foundation and others thinking of ways for technology to help people become “managers of their own health,” Aerts said.
Combining these efforts with existing tools that remind people to take their medications or to attend doctor’s appointments create “a very coordinated way of looking after chronic patients,” she said. “We needed 15 years to get to a concept of coordinated care” in developed settings. “But we can really leapfrog that in low-income settings.”
Wired for Impact is an online conversation with Novartis Foundation and Devex to explore how to integrate digital health into global development in a way that is scalable and sustainable, and improves the overall quality of health care delivery to build essential connections between patients, health facilities, health providers and policymakers. Tag #Wired4Impact and @Devex to join the conversation.