Can digital public infrastructure reshape donor-reliant health systems?

Recent cuts to foreign aid have threatened to reverse decades of progress for Africa’s health sector, highlighting the urgent need for more sustainable, locally owned solutions. Digital public infrastructure, or DPI, could prove an essential component in this reimagining of health care across the continent — if done right, said experts. Historically, many African countries have relied on external donors to fund digital health projects. But these were often discrete and lacked integration with other digital services, making them less effective than they could have been. DPI is a foundational system of interoperable digital services, which allows for the reuse, sharing, and mapping of real-time data — enabling faster and more inclusive access to medical care, direct insurance and universal health care payouts, and better management of public health campaigns. If locally owned, it also promises to be more cost-effective and sustainable. “The last year has highlighted the fragility and dependency on the systems of a previous era,” said Garrett Mehl, head of the digital health systems unit at the World Health Organization. DPI “does begin to create the potential for [countries] to gain the kind of financial sustainability that I think they’ve longed for.” Identifying patients for continuity of care DPI consists of three core interoperable building blocks: Identity verification, digital payments, and data exchange. “Those three building blocks are actually critical within the health space, in terms of disease surveillance, in terms of mortality, in terms of providing maternal health,” said Vimbai Tsododo, senior technical adviser at the Institute for Health Measurement, or IHM, a nonprofit working to strengthen health systems across southern Africa. Currently, over 500 million Africans lack a formal ID, making it harder for them to access health care and receive government entitlements, such as vaccines and universal health care payouts. In 2023, IHM helped to establish SmartCare Pro, Zambia’s electronic health record, or EHR, system. The EHR uses thumbprints to digitally identify patients, making their disease and treatment history instantly available as soon as they enter a hospital and ensuring that they receive faster access to treatment. That is particularly important for chronic diseases such as tuberculosis or HIV which need to be tracked over time, said Tsododo. Health care workers can easily ensure that patients do not miss treatments or essential checkups, and that disease progression is monitored. In Rwanda, digital health wallets link patients’ digital ID and health records to their bank account, ensuring that insurance payouts or government entitlements can be sent directly to the correct person. The wallet has “money inside, but you have also your health data inside, so when you are moving, you move with it,” said Sylvere Mugumya, who works on digital health with Rwanda’s Ministry of Health. This ensures continuity of care, even when traveling. Being able to access medical records remotely also facilitates telehealth services, as well as digital referrals to medical specialists, meaning better and more inclusive access to high-quality care in underserved regions. The EHR can also help to promote health-seeking behaviors, said Tsododo. “We started introducing an SMS gateway where within the system, it can send out appointment reminders to mothers to remind them of their ANC [antenatal care] visits, to remind them of their immunization visits,” he said. Data exchange for public health planning Linking patient records to their identity can help to improve public health at the population level too. In Rwanda, “immediately from birth, the vaccination registry at the Ministry of Health [is] connected with a civil registration at the local government,” said Mugumya. “We have very minimal people who missed the doses, because we know them, we know where they are.” Real-time health data can also help health care programs to map precisely where and when health commodities are needed, improving the efficiency of the procurement process and reducing wastage, said Varun Basu, vice president of growth and partnerships at the eGov Foundation, a nonprofit organization catalyzing digital transformation in public service delivery. Rather than running campaigns across a whole province. “When surveillance data is saying that there are 25 malaria cases in this region, you can actually then create a targeted campaign to address only that region,” said Basu. “You know exactly what you need, and therefore the funds required to have the same outcome can come down significantly.” Interoperable digital services can also help to save money by enabling the reuse of data within and across different health care campaigns. Previously, funding flowed programmatically, where donors “might come in and just be interested in malaria or AIDS or a specific issue, and build a full stack solution to try to respond,” said Jordan Sandman, senior manager of research and narrative and investment lead at Co-Develop, a nonprofit fund accelerating the global adoption of safe and inclusive DPI. Health care workers would go door to door, “building their own registries just for this one health issue,” he said, meaning that villages would be revisited multiple times for each new donor or health intervention, and front-line workers would also have to be trained to use each new campaign application. In 2023, eGov Foundation launched its DIGIT Health DPI, renamed Salama, in Mozambique. By integrating fragmented malaria campaign tools, it helps program teams to distribute antimalarial bed nets, run seasonal malaria chemoprevention campaigns, and manage the supply chain under a unified platform. Salama has become a model for a single, integrated campaign tool which countries can use to execute concurrent health campaigns, with versions already launched in seven countries, said Basu. Cross-border data But “it would be nonresponsive to the problem to build systems that just stop at borders,” said Sandman. Cross-border data exchange is important for disease surveillance, so that outbreaks can be mapped and traced back to the individual — particularly for diseases which are notifiable or have pandemic potential, said Mehl. DPI “provides the ability to trace back to the locality, or the facility, or the lab [at] which a specific disease event took place, so that management and treatment and follow-up can take place,” he said. Increasingly, AI models can use this real-time data to help monitor and predict outbreaks. But to be most effective, countries need to ensure that diseases and treatments are recorded in a standardized and consistent way, said Mehl. WHO is working with member states to help them migrate over to interoperability standards, which allows countries to better communicate disease events and “unlocks the potential of AI in a much more substantive way, and a much more accurate-to-the-patient way,” said Mehl. Cross-border interoperability can also help to verify that travelers are healthy through digital health certificates, such as those issued during the COVID-19 pandemic. WHO runs the Global Digital Health Certification Network, an open-source platform to strengthen pandemic preparedness which is like “a DPI for trust,” said Mehl, “for knowing where a health certificate originates, and whether it’s ideally from a trusted source.” Getting DPI right But experts emphasized that DPI is more than just the technology. “The ecosystem is very important, where we think about the governance, the leadership, the policies, the strategies,” said Mugumya. Health data is “a set of information that is very sensitive, particularly when you’re dealing with children’s data,” said Sandman. Policy frameworks, such as the Universal DPI Safeguards Framework led by the United Nations, can help to ensure data privacy and that DPI is equitable and inclusive. Poorly governed DPI risks increasing the digital divide and allowing “for improved discrimination,” said Sandman. A recent report from the Institute of Development Studies found that digital ID systems had blocked some marginalized communities across Africa from accessing essential services. Sustainability also needs to be factored in when building DPI, with the sudden closure of USAID earlier this year acting as “a major wake-up call,” said Tsododo. Even before this year, donor-led projects often proved short-lived, he said. “Funding cycles for a particular project generally ran in three- to five-year cycles,” he said. But at the end of the project, often the government “was unable to bear those costs, and so that system became a white elephant.” IHM began to look instead to open-source technologies, where countries can take the core base code and adapt it to their local needs, which “democratizes the space in which [DPI] operates so that anybody can contribute to the development and building blocks of the nation,” said Tsododo. There is increasingly an understanding “that donor-maintained registries are an undesirable and in some ways unacceptable outcome, that countries need to be owning the systems,” said Sandman. Partnership models can also help to ensure sustainability and build local capacity. In Kenya, the Estonian Centre for International Development, or ESTDEV, is collaborating with local government and businesses to build a new digital registry that will automatically allocate children a unique identification number at birth. Katrin Winter, regional head for Africa at ESTDEV, sees it as a “a win-win partnership,” with Kenya benefitting from Estonia’s expertise on DPI technology and governance, and Estonian businesses benefitting from a huge untapped market with the “opportunity to innovate and to develop your own product and test it in different scenarios,” said Winter. WHO’s Mehl is hopeful that recent budgetary cuts will encourage more donors to similarly focus on building foundational systems, rather than siloed health projects where the primary goal is to generate immediate data showing progress toward health goals. Investments in digital health should be less about the monitoring and evaluation goals of the donor, and more “about the person that the health is being provided for,” said Mehl. “Maybe the shift in [official development assistance] funding has unlocked the potential for investments to be person-centered, not just focused on aggregate performance metrics,” he said.