Q&A: Designing health systems for patients, not donors

Health data and digital technologies will be essential for improving global health outcomes beyond the COVID-19 pandemic, especially in low-income countries facing shortages of health care workers and resources.

According to the World Health Organization, digital health can strengthen health systems by “bringing health services directly to people’s homes and to underserved communities, helping to map outbreaks of disease, and integrating digital tools that make healthcare more responsive and productive.”

Digital health tools, if designed correctly, also have the potential to transform health care delivery to better address the management of chronic diseases such as hypertension and diabetes.

Devex spoke to Anne Stake — the head of strategy, innovation, and technology at social enterprise Medtronic LABS — about how it’s using participatory design to treat noncommunicable diseases; the potential of data in tackling fragmentation in global health; and how to design care models based on the actual needs of patients rather than the interests of donors.

This conversation has been edited for length and clarity.

How is Medtronic LABS using participatory design to put patients and communities at the center of health interventions?

Rather than focusing solely on a specific product or technology, Medtronic LABS designs health care delivery models with and for communities that solve barriers to care at the ground-level. We want to make sure that the patient is at the center of health and health care.

Participatory design is about inviting patients and other stakeholders into the design process from the very beginning. When we're looking to achieve patient outcomes — for instance, in the context of diabetes and hypertension — we start with deep ethnographic research to understand the patient experience and the health system with which they interact. We engage patients on topics outside of health care as well, with conversations about their families, traditions, and life histories, in order to uncover what sort of interventions might actually fit into their daily lives.

Medtronic LABS leveraged participatory design methods to develop our group-based model for chronic disease. Specifically, we assembled groups of diabetic and hypertensive patients and co-designed the service delivery model with them. After a year of sessions testing out different interventions, we had a full end-to-end service model designed by our patients. We’ve seen that participatory design has immense potential to re-orient health care around patients and their needs.

Innovation is often associated with technology, but can also be in health delivery. How are you innovating in both digital health, but also in how you partner with other organizations?

We think about innovation at multiple levels. In terms of digital health, we’re building our platform with key investments in data science and data-driven patient engagement. Beyond software, we’re adding new diagnostic capabilities, expanding to new clinical areas, iterating our field operations, and designing patient-centered service models.

At the same time, Medtronic LABS is innovating around partnerships. Our aim is to reduce the high degree of fragmentation in global health programs through cross-sector collaboration. We’re always improving the ways we work with governments, local entrepreneurs, NGOs, and providers so that we're not duplicating efforts.

To support our partnerships, we’ve been building for modularity, so that when we engage with partners we can “plug and play” our solutions. A good example of this is our work with Kenya’s Ministry of Health, three county governments, and Novartis Global Health. Medtronic LABS is providing the digital health tools and the service delivery model; the Ministry of Health and country governments are providing clinical staff and infrastructure; and Novartis is providing low-cost medication.

Some 71% of deaths worldwide are due to noncommunicable diseases, yet, only 1% of funding goes to NCD care. How are you exploring innovative financing models such as outcomes-based financing and development impact bonds to help fill this gap?

The gap in financing is going to be a persistent challenge until the donor community catches up with the epidemiological transition. Our hypothesis is that innovative finance, including outcomes-based financing, might support increased funding for NCDs while simultaneously shifting health systems towards value-based care.

In value-based care, the system is re-oriented around achieving better outcomes at lower cost. We want to align incentives, so that incentives of patients — getting and feeling better — line up with the incentives of the payor, whether that's a government, insurance company, philanthropic organization, or donor.

Right now, Medtronic LABS and our partners are structuring a development impact bond focused on diabetes and hypertension in sub-Saharan Africa. Because we are confident that we can deliver value at lower cost, we are willing to be paid if and only if outcomes are achieved. Through the bond structure, we hope to de-risk the financing for NCDs and achieve outcomes at meaningful scale.

Ultimately, a shift towards paying for value, catalyzed by outcomes-based models, might support a more integrated and patient-centered global health system rather than one organized around donor interests.

Many health systems were not equipped to address NCDs before COVID-19 hit, and many are even worse off now. What wider shifts need to happen to ensure the prioritization of NCDs moving forward?

In the past, global health support has been organized vertically into diseases like HIV, malaria, and TB [tuberculosis]. While we’ve made immense progress in addressing these challenges, we have also created siloed health systems organized around very specific programs.

We’re seeing promising changes, however. The fact that COVID-19 patients with NCDs are at much higher risk of mortality has underscored the need to think outside these clinical verticals. Most stakeholders now agree that to achieve universal health coverage, the double burden of chronic and infectious diseases must be addressed holistically.

This reorientation requires shifts in how we organize, deliver, and pay for global health. Most health care systems have been set up to manage acute conditions and to treat illness, but we need systems that can manage chronic conditions and incentivize health as well. To do this, we need to shift to value-based care that rewards clinical outcomes at lower cost, to accelerate public-private-social sector partnerships, and to leverage the transformative power of digital technology. 

In what ways has COVID-19 accelerated a digital shift in public health?

Digital health was already a growing space, but when COVID-19 hit we saw a major acceleration. As digital health innovators, we’ve seen an uptick in interest from partners and stakeholders — there has been rapid adoption and a realization that digital technology can improve patient care while optimizing scarce resources.

At the same time, there’s a lot of fragmentation and lack of regulation which limits its potential. Different programs use different tools to collect different data in different systems. In the absence of a strong regulatory environment, the proliferation of digital products might lead to unintended negative consequences.