Opinion: Why we’re becoming a Digital Public Good — and why we aren’t

A few months ago, Medtronic LABS made the decision to open source our digital health platform SPICE, and pursue certification as a Digital Public Good. DPGs are defined by the Digital Public Good Alliance as: “Open-source software, open data, open AI models, open standards, and open content that adhere to privacy and other applicable laws and best practices, do no harm by design, and help attain the Sustainable Development Goals.” The growing momentum around DPGs in global health is relatively new, coinciding with the launch of the U.N. Secretary General’s Roadmap for Digital Cooperation in 2020. The movement aims to put governments in the driver’s seat, promote better collaboration among development partners, and reduce barriers to the digitization of health systems.

We didn’t make the decision to open-source our technology platform lightly. SPICE is already one of the fastest-growing platforms for data-driven community health in sub-Saharan Africa, with health system partnerships in over five countries. We also see technology as an enabler of robust health services, not the end goal. Because platforms don’t work in a vacuum, we worry that as a DPG, SPICE might be deployed as a stand-alone solution.

Ultimately our decision to make SPICE a DPG came down to two factors. First, we believe that our platform and programs will be able to improve the lives of more people in more geographies. We envision SPICE as a fully open-source resource that governments and a robust community of developers can own and adapt with lower-touch support from Medtronic LABS. Second, we hope to contribute to a collaborative approach to digital development in global health. In the context of immense need and limited resources, we need to break silos and work across sectors and among competitors. Yet, even as we pursue DPG status, we noted misperceptions and identified potential unintended consequences of DPGs that the global health community should consider deeply.

The sustainability question

Increasing impact and contributing to collaboration in digital health drove our decision to become a DPG, but surprisingly the issue of sustainability did not. As part of our due diligence, we spoke with leading digital health experts that work in low- and middle-income countries, or LMICs — from NGOs and bilateral donors to philanthropists and innovators.

Repeatedly we heard that DPGs are more sustainable than proprietary platforms. The arguments go like this: “DPGs are sustainable because major donors choose to support them for the long term.” In other words, they are sustainable because donors decided to fund them. This reasoning struck us as circular and contradictory. Isn’t the very definition of sustainability that major donor support is not required over the long term?

On the other hand, as we spoke to government stakeholders, the rationale for DPGs was clear. Previous experiences with vendor lock-in and lack of ownership are major concerns for health systems. At the time though, the myth that DPGs are free persisted among many government officials. DPGs are not free. Even with government oversight, the technical “owners'' of the DPG need to continually build their platforms to stay relevant. Governments also need adequate resources to continually update the software. Across countries, we’ve seen outdated versions of DPG platforms lead to poorly functioning systems as well as privacy and security risks. With reliance on donor funding and misperceptions around long-term maintenance costs, the sustainability problem remains unsolved for DPGs.

Unintended market impacts

To make our decision, we also considered our impact on the local innovation ecosystem. While donors came together in support of DPGs outlined in the Principles for Donor Alignment for Digital Health, the private sector digital health market also flourished. There are now over 180 digital health start-ups in sub-Saharan Africa. This number is projected to rise, mirroring trends in smartphone penetration and acceptance of digital solutions.

As local innovators try to reach scale, the global health community should consider whether narrow investments in a select few DPGs distort the digital health market. To mitigate this, we’ve seen early efforts to allow local innovators to “plug in” to donor-supported DPG platforms, but we worry that this might not be enough. At Medtronic LABS we plan to watch these trends closely to avoid unintended consequences.

DPGs in name only?

As we work through the steps to apply for DPG status, we noticed that the bar is relatively low. Over the past few years, multistakeholder initiatives such as the Digital Public Good Alliance and Digital Square and multilateral organizations such as the World Health Organization and the United Nations Development Programme have started sourcing and certifying DPGs. These registries are an incredible resource to promote alignment and innovation.

Yet, as we looked through the listed solutions, we realized that many platforms and products are DPGs in name only. Many require payments for features or significant technical development to render the solution useful. At Medtronic LABS, the reason we’re becoming a DPG is to enable any health system innovator to use SPICE and ultimately improve population health outcomes. As the certification landscape evolves, we should ensure that DPGs live up to their promise.

Keep questioning

We believe that making SPICE a DPG will have net benefits for our patients and partners. We offer a fundamentally new take on risk-based, data-driven community health, and we hope that by open sourcing our platform, our approach might be widely adopted. We will also contribute to a digital health landscape that’s additive rather than duplicative. At the same time though, concerns about long-term sustainability, market effects, and certification remain. For anyone working in digital health in LMICs, let’s keep asking the hard questions.