Here’s the good news: Over the past 10 years the digital health community has begun to heal from a severe case of pilotitis. As a community of innovators and health systems researchers, we increasingly recognize that creating and testing new digital health tools in the absence of investments in the enabling ecosystem is likely to produce limited, short-term, and small-scale impact. Without concerted efforts to fertilize the soil in which the seeds of innovation are planted, those seeds will never mature beyond a sapling. That is, unless we pay attention to the policy and regulatory environment, the telecommunications and electrical infrastructure, and most importantly, the availability of trained and appropriate human resources to facilitate scale-up and sustainability, we cannot expect national-scale digital health projects to thrive.
In the last five years especially, the development of shared values (some might say as lessons from dramatic and sometimes unexpected failures in ICT4D) has helped prevent the “wheel reinvention” that characterized the early days of digital health.
Recent exciting developments will shepherd the construction of global goods and open-source or multi-purpose platforms that promise to further accelerate forward progress—while allowing countries to leapfrog ahead without having to recreate the essential building blocks of digital systems every time.
These are steps in the right direction.
Thinking Differently About Digital Health
I recently returned from a workshop hosted by the World Health Organization (WHO) and the nonprofit PATH, with Ministry of Health staff from Kenya, Rwanda, Tanzania, and Uganda. The goal of the workshop was to test a systematic approach for articulating requirements for digital health registers, and other “building block” digital health systems. This was a great experience of working with multiple ministry stakeholders to focus attention on the macro layer of health system problems, thinking through the architecture and implementation team necessary to deploy, scale, and sustain a digital system at national scale.
In addition to the very granular details of the system functions and workflows, participants thought through plans for monitoring system performance, data use for decision-making, worker training and satisfaction, and even budget commitments necessary for long-term system maintenance and device replacement.
There are many examples across the landscape of the progress being made in thinking about digital health differently. Broad consensus around the shared values of digital development have been enshrined in the Principles for Digital Development. Guidance for large-scale implementation of digital solutions is becoming increasingly available—from the WHO MAPS Toolkit, to upcoming guidance from the Digital Impact Alliance (DIAL) on how to maintain systems at a national scale. Interoperability backbones, such as OpenHIE, and other foundational building blocks such as master facility registries, health workforce registries, and technology to automatically match and de-duplicate patient records from multiple sources are being developed by members of the revitalized and highly collaborative digital health community of practice.
The reality is that building awareness of best practices and creating shared resources is no easy task, nor are the philosophical changes necessary to focus on keeping these newly created “global goods” current and useful. There are still discoordinated investments that are producing fragmented solutions. While many donors are well-intentioned, various drivers and incentives may force investments that do not follow a process of building upon the work of others, or even scanning the landscape for innovations that might be reused or repurposed to fit a new need. Such lapses in appropriate process, sadly, perpetuate the chaotic digital environment that we find ourselves in, making the long-term task of cleaning up after well-intentioned development agencies another headache for under-resourced ministries of health.
How do we, as a community, ensure that ministries of health have the tools at their disposal to make informed decisions about their digital health investments?
Guidance to facilitate the selection of appropriately skilled and experienced vendors, for example, may help to promote and sustain better long-term public-private partnerships where necessary. Technology checklists that require solution providers to demonstrate their software’s capacity for interoperability and extensibility may prevent costly repeat investments when requirements change a year or two into the program.
A skilled and informed client, whether a large nongovernmental organization or a ministry of health, can identify the solutions that are best aligned with the problems being faced by the health systems. With vendors constantly pushing shiny new solutions, governments are often frustrated by not being able to differentiate among products.
This chaos has, in the past, allowed many stakeholders to benefit without a view to the long-term challenges left in their wake. This will not be the case for much longer. We are nearing a stage of digital maturity in many markets, where ministries of health have clearly prioritized problems, are looking for strategies backed by evidence, have developed lucid implementation strategies which leverage digital resources to augment health system interventions, and have access to a library of demonstrated tools with clear cost-of-ownership data available.
While the global community can play a large role in making the above scenario a reality, ministries must take the lead in setting the agenda for digital health investments and in developing the policies, human resources and infrastructure that enable an ecosystem that supports the use of digital health at scale.
I leave you with a challenge: to focus on innovations and technologies that align with the capacity of governments to scale and sustain, adhere to the Principles of Digital Development, and avoid wheel reinvention.
Dr. Alain Labrique is founding director of the Johns Hopkins University Global mHealth Initiative, and has a joint appointment in health sciences informatics at the Johns Hopkins University School of Medicine. He is an associate professor of international health and holds a joint appointment in epidemiology at the Johns Hopkins Bloomberg School of Public Health. His research focuses on infectious diseases.