The promise of digital health in LMICs

Having started my career as an emergency physician in countries across Africa — from Angola and Mozambique, to the Sudan and the Caucasus — I was regularly faced with long and often dangerous journeys to reach my patients. I would fly in by plane and then travel on my bike, crossing rivers — it was the only way they could receive the treatment and medical care they needed. Often I couldn’t stay for long, or sometimes I came too late.

At that time, I couldn’t have imagined the possibility of a mobile phone connecting me directly to the patients in those hard-to-reach areas, or allowing me to coach and advise the community health workers so that patients could receive care where and when they needed it.  

Expanding patient reach, improving quality of care

Today’s connectivity and digital health technologies are truly revolutionizing the way health care is delivered in low- and middle-income settings.

Not only can digital health significantly expand patient reach and make health services more cost-efficient, it can also greatly improve the quality of care delivered by local health services.

Telemedicine, for example, allows centralization of expertise (with unlimited geographical reach) to coach frontline health workers and guide them through their patient care. And with e-learning, many more health workers can benefit from the latest updates and refresher courses, whether pre- or in-service training.

In addition, digital technology offers the incredible opportunity to engage patients in the management of their own health, empowering them through targeted messaging and health information.

It also allows the use of real-time health data so that health surveillance systems can become more action-oriented and detect emerging crises in time to organize a proper response.

These are exciting times in global health, as digital health offers unprecedented opportunities to accelerate the achievement of health for all.

However, when we view digital technology as an end in itself, there is the potential to end up with a highly fragmented landscape of digital solutions, putting a strain on local governance and control, and compromising sustainability. For example, the fixed costs of many digital health platforms are not considered when in their pilot phase, and this makes long-term sustainability challenging at best, and impractical in most cases.

In reality, many of the digital health solutions seem to get stuck in the startup phase and rarely make it to scale. This, in turn, seriously hinders the potential to generate evidence on the effectiveness and impact on health outcomes of such solutions.

Focusing on innovation in health care delivery

While we may have a way to go until we have solid proof on how best to use digital health technology to optimize patient outcomes, it is already clear that we must focus on innovating health care delivery, not just on delivering innovation.

Key factors to consider in any initiative aiming to innovate the delivery of health services include the following:

• Design the initiative that includes a digital component around the needs and reality of patients, not around the technology itself.
• Ensure the initiative is co-developed with the end users and the main stakeholders, such as the local authorities, health services and patients.
• Design with the potential for scale in mind from the outset, as well as for interoperability and integration into the health system.
• Establish clear metrics on the initiative and technology, assessing effectiveness, cost effectiveness and health outcomes, as well as the value of the technology in the service delivery.
• Be prepared to learn and adjust as necessary within the timeframe of the initiative and taking lessons learned to the next initiative.

If we can move forward with this guidance in mind, the potential of digital health technology to enable improved health care coverage, equity and quality of care means our ambitions can be bolder and bigger than ever before — far beyond what I ever could have imagined when I was riding by bicycle from village to village, hoping to reach my patients in time.

Telemedicine in Ghana — a case study

In Ghana, the Novartis Foundation worked with regional, national and global partners to implement a model for telemedicine services that is now being expanded by the Ghana Health Services and Ministry of Health to the rest of the country. The initial telemedicine pilot, which ran from 2012-2014, was pioneered in a remote region of the Amansie-West district in Ashanti, where traveling to the nearest health facility could be as far as 40 kilometers.

The initiative aimed to improve access to health services by using digital technology to connect community health workers with doctors, experienced nurses and midwives — reachable 24/7 at the teleconsultation center at the district hospital. This new health service model was to expand access to care in remote areas and improve quality of care through the coaching and empowerment of less skilled community health workers by experienced health care professionals at the hospital.

Another direct benefit of this new way of service delivery was that unnecessary referrals could be significantly reduced, thereby saving resources for both patients and ambulance services.  

The telemedicine pilot was initiated in partnership with the Millennium Villages Project, and involved several global and local partners. In particular, the Ghanaian Ministry of Health and Ghana Health Service were key collaborators early on, ensuring that it was integrated within the existing health system from the start. As of 2013, telemedicine was also incorporated in Ghana’s national e-health strategy as one of the key solutions to strengthen facility infrastructure.

In 2015, the telemedicine pilot was first scaled to the entire Amansie-West district and then expanded to three additional regions (Central, Volta and Upper East). In 2016, telemedicine will be implemented in the Eastern and Greater Accra regions and a roadmap for national scale up by 2017 is in development — fully driven by the Ghana Health Service.

The Novartis Foundation supports the development of that road map by connecting the Ghana health authorities with the necessary experts for the planning of this ambitious undertaking.

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.