From infrastructure to impact: why foundations matter in digital health
Digital systems were an often crucial factor in how well countries were able to respond to the pandemic. Now, as the global community faces competing crises, it’s time to lay the foundations so that countries can adequately respond, creating a healthier, safer and more equitable world
Since the Covid-19 pandemic, the need for resilient and trustworthy health systems has become increasingly clear. The pandemic and subsequent global health polycrises have highlighted the weaknesses of existing infrastructure, equity and preparedness, underscoring the pivotal role that digital health technologies play in building systems that are robust, responsive and efficient and that also foster trust.
During the pandemic, countries with well-established digital health systems were better equipped to respond swiftly and effectively. Digital health technologies proved indispensable, from tracking infection rates to facilitating remote consultations. These systems enabled the rapid dissemination of information, ensured continuity of care and supported the vaccination programmes. However, these technologies also fell short of their expected or anticipated impacts in many instances – as social networks were abused to spread or amplify harmful disinformation or as disconnected, non-interoperable systems failed to optimise care continuity.
Digital health transformation
The World Health Organization has long been at the forefront of exploring and promoting digital health to enhance global health systems – working to distil the evidence and best practices, define the necessary enabling ecosystems and help countries articulate clear strategies to guide systems investments. Over 120 countries can boast having achieved this first step on their digital transformation. In 2023, the WHO launched the Global Initiative on Digital Health, a platform to bring stakeholders together to move from strategies to implementation – mobilising political, economic and technical support for the digital transformation, grounded in Digital Public Infrastructure. GIDH aims to address the necessary political support to enable transformation, which has been slow to materialise in many countries. Clear governance, dedicated financing and robust foundations are often-neglected, requisite ingredients to shift to today’s digital reality.
A strategy without the accompanying policies and legal mandate provided to a named custodian in government rings hollow. The necessary fiscal space to implement those provisions must be protected, with clear deliverables to create (and enforce) a national ‘backbone’ framework of standards, interoperability, ethics and data governance. In 2021, as the culmination of a process begun in 2018, followed by the National Digital Health Blueprint a year later, India launched the Ayushman Bharat Digital Mission, tasked with custodianship of the national digital health transformation. Setting national standards for interoperability, data security, digital identification and financial transactions, it helps maintain and enforce a national digital ecosystem.
In 2023, Kenya passed the Digital Health Bill, which unambiguously defined these necessary precursors for success, including the Digital Health Agency, with personnel, funding and goals – spanning digital health standards and interoperability, data governance and digitally enhanced health services.
These governments exercised leadership to shift from digital experimentation to the transformation of the health system. Many lament the state of donor-driven agendas and highly vertical investments in digital solutions to specific sectoral bottlenecks. Having government in the ‘driver’s seat’ is the initial treatment for this condition – setting a clear vision, and enabling the policy structures to shepherd resources towards prioritising national foundations alongside specific investments in HIV, tuberculosis, or maternal and child health programmes. This core leadership capacity also supports the integration of non-state and private sector health systems by creating incentives that allow interoperable systems to access national health insurance funding. More importantly, interoperability across systems provides people with the flexibility to choose their providers.
Reinventing and investing
This ‘ecosystem play’ also enables the fundamental concept of transformation – different from the mere digitisation of analogue systems. When national-scale investments are made in Digital Public Infrastructure, and specifically the Digital Public Infrastructure for Health, health system processes can be reimagined or reinvented.
Otherwise, we often are merely converting systems designed in an analog, paper-dominated era into a digital equivalent, porting over those inefficiencies. We miss the opportunity to share critical information instantly, monitor and respond in real time, and link data from previously disparate systems to benefit patient outcomes as well as satisfaction. In Saudi Arabia, the SEHA virtual hospital has successfully scaled a virtual-first consultation at the patient’s convenience to address critical emergencies, with appropriate triage to a brick-and-mortar facility when needed. Remote, rural facilities have teleconsultations with highly specialised clinicians on demand, with remote patient monitoring to help improve critical outcomes. The confluence of the post-pandemic public frustrations with traditional healthcare services and the continued digital transformation of other sectors will spur demand for more innovative, person-centred health systems – not only for those who can afford them, but for all.
As the WHO joins the World Bank, the International Telecommunication Union, the United Nations Development Programme, UNICEF and others to call for systematic investments in DPI, we send a common message: “sustainable, impactful digital transformation requires robust foundations”. From strengthening local production and entrepreneurship to the pursuit of
person-centredness, to fiscal accountability for health sector expenditures – critical for finance ministry and development bank support – investment in foundations has been missing in the digital health value chain.
Continuing the positive momentum
This is changing. Rwanda, over a decade ago, chose to invest in information and communications technology as a cross-cutting enabler for development. A forerunner for digital transformation across the public sector, Rwanda launched a ministry dedicated to innovation and ICT, supported by chief digital officers tasked with coordinating digital transformation efforts across multiple ministries. Today Rwanda is recognised as a unique test-bed for health sector innovations, including a drone-delivery system for emergency medical supplies, now scaling to Kenya, Ghana, Nigeria and Cote d’Ivoire, and a regulatory environment that is enabling the careful testing of artificial intelligence solutions with clear national oversight.
However, financial pipelines commensurate with the anticipated scale of change are in short supply. The World Bank has invested almost $4 billion in digital health over the past decade – but much more is needed. Innovative partnerships with the private sector and cross-sectoral investments in DPI may be key to unlocking this capacity. Transform Health calculated an investment of $12.5 billion being required over the next five years to support 78 low- and lower-middle-income countries, averaging around $2.5 billion per year. Over two-thirds of this investment would be earmarked for health-sector specific DPI, but does not include the necessary investment in the enabling digital environment, including electrification, connectivity and measures to ensure access among lower socio-economic subgroups who benefit the most.
Health system transformations do not happen with the wave of a magic wand; these are deliberate, non-partisan commitments that require persistent support that goes beyond usual political cycles. Digital foundational investments, infrastructure and architecture require long-game decisions that lead to a healthier, safer and more equitable world for everyone, everywhere.
