What will it take to bring digital health solutions to scale?

When Mercy Simiyu, country director for Kenya and Somalia at Viamo, considers how its users can take their health into their own hands, the person she often has in mind is her own grandmother.

A social enterprise focused on data collection and information sharing via mobile phones in Africa and Asia, Viamo conducts mobile surveys with interactive voice response technology, which allows people to listen to prerecorded questions and provide answers by pressing numbers on their keypads.

It’s available to people with limited literacy and the most basic mobile phones. Simiyu said someone like her grandmother can dial 321 for free, navigate a menu of options for topics such as health, and listen to audio content recorded by native speakers of their language.

In the countries where Simiyu works, “what the doctor says goes,” she said during a panel discussion at last month’s Global Digital Health Forum, a virtual event hosted by the Global Digital Health Network. But now, she said, people are “hungry for information.”

“The consumer is shifting to be in the middle of decision-making,” she added.

The COVID-19 pandemic has fast-tracked digital health innovation. But a number of challenges stand in the way of digital health realizing its full potential in low- and middle-income countries, from a lack of digital infrastructure to funding that is attached to health verticals or disease-specific initiatives. Experts at the forum highlighted a few ways to take digital health solutions to scale in the year ahead.

Starting with user needs

The pandemic has forced more public health professionals to start by considering the needs of the consumer before asking what the system needs.

“Suddenly, we were in the shoes of our so-called users,” said Debbie Rogers, CEO at Praekelt.org, which developed the MomConnect maternal health messaging service in South Africa and launched Turn.io in 2019 to help other social impact organizations use WhatsApp in their programming.

“What the system needs is important,” she said. “We should have an idea of what impact we want to have. But if we shift the narrative to consumer-first, we’ll find everything is much more effective and scalable.”

MomConnect is an example of a technology developed with consumer needs in mind. The free service can link pregnant women to information on nutrition, fetal development, and postnatal care via their mobile phones. It is now an official program of the South African Health Department, which has worked with Praekelt.org to produce a COVID-19 messaging platform using the same technology.

MomConnect has since been replicated in Uganda, with plans to launch the program in Malawi and the Democratic Republic of Congo.

“I think the first thing we should start with is: What do our citizens and patients need? What will make their lives better?” Rogers said. “Commercial digital products focus almost entirely on the thing that people need and how they’re going to help solve the problem for them, and that’s how you reach a lot of scale.”

Praekelt.org is not the only organization that leverages human-centered design to create public health products, services, and experiences that start with the needs of people. Increasingly, larger international NGOs have begun to embrace human-centered design principles in their programming. And the COVID-19 pandemic could further accelerate the growth of the nascent community focused on “design for health.”

Understanding hidden costs

One of the key factors for the successful adoption of a digital health solution is cost. But in low-resource settings, investors, governments, and implementers often lack visibility on this critical information.

For digital health solutions to go to scale, revenues and expenses over the life cycle of the intervention have to be understood and documented.

But competition often means that organizations bidding for a project keep costs hidden, said Derek Treatman, senior director of technology solutions at Vital Wave, which is focused on scaling digital solutions in emerging markets. This includes information such as salaries.

Even if the ultimate goal is to hand the project over to the government, it may not know the costs of running the program. And often there is a major disparity between the salaries that development organizations can offer compared with those governments can offer, meaning it can be difficult if not impossible for governments to take the reins.

When infrastructure is shared across different digital health programs, it can be tricky to track redundant investments, Treatman added. Hence, there is a need to fund central resources — even for basics like electricity to allow governments to keep the lights on — that are not project-specific.

Finally, Treatman called for long-term support and capacity building for government professionals to support digital health transformation broadly, rather than just specific projects.

Overcoming ‘survivorship bias’

The digital health industry has been accused of “pilotitis,” an endless cycle of building and piloting technologies that never make it to scale.

“In spite of all the disruptive talk about how this new tech never works, in the back of our minds, we still think that it will or that it might,” said Clayton Sims, chief technology officer at Dimagi, which has an open-source mobile data collection app for low-resource settings.

This tendency has to do with “survivorship bias,” in which people draw conclusions from examples that currently exist rather than focusing on what has failed.

“Most new ideas for technology just won’t work even if you build them right,” Sims said. “You can design for scale with the user on an open-source code base and build a viable MVP [minimum viable product] designed for scale and still end up with a system that has no chance of practical success.”

He advised people to expect failure instead of success from new technology.

“If we don’t understand how rare and how specific our biggest successes are, it’s going to be hard not just to replicate them; it’s going to be difficult to avoid abandoning them entirely to chase something new, because survivorship bias makes it easy to look at specific tech systems and see flaws while taking their existence for granted,” Sims said. “How do you justify why you shouldn’t replace the occasionally limited technology underneath a functional system if everyone assumes that a shiny replacement is just as likely to work?”

Breaking down silos

Digital health solutions open new possibilities for the personalization of health care — also known as precision medicine, or the use of technology for targeted prevention and treatment plans. But one of the major challenges that groups like Praekelt.org face in implementing personalized services is that disease areas are supported by different funding streams, Rogers said.

For example, maternal health, HIV, and diabetes are all funded by donors with different priorities.

“And never the three shall meet,” Rogers said. So if a woman is pregnant, HIV-positive, and diabetic, she likely has to seek out three separate services.

“We have to see [that] this is not about disease areas,” she said. “We need to consider how we can create crosscutting innovations that serve people in multiple areas.”

Ultimately, the goal is health, rather than just not being ill, according to Rogers.

“We have a long way to go from ‘it’s a disease that’s funded, and we build up programs for that’ to ‘personally I have one place I can access all my digital health care,’” she said. “It can be through multiple channels, but it knows about me and helps me … live a healthier life,” she continued.

“We really need to be working as a community to break down those silos,” she said.