Transformation: supporting a shift from analogue to digital health systems
Digital health can fundamentally shift how we think about primary health care and universal health coverage – but we must be willing to challenge the status quo that has been cemented in decades of practice and reimagine Health For All
Among the most severe consequences of the Covid-19 pandemic has been the decline and even regression in global progress towards the Sustainable Development Goals. With poor countries disproportionately affected, the risk of growing inequities is exacerbated, compounded by shrinking fiscal space for health systems strengthening and decreasing global political appetite for health sector investments after multiple years of high pandemic-related expenditures. The onerous task, therefore, of doing more with less is shared universally, as the 2030 deadline looms.
One obvious solution to the complex challenge of improving health system performance to reach the goal of universal health coverage is to use digital technologies to improve efficiency, coordinate care across verticals, strengthen programme performance through trustworthy, real-time data, and focus on the centrality of services that meet people where they are in their health journeys. Digitalisation has arguably been the most important recent shift in key sectors such as banking and education. And digital health – using appropriate technologies to improve the delivery of and access to curative and preventive health services – is rapidly maturing.
Genesis
In 2019, as it shifted to focus on country priorities and reduce fragmentation, the World Health Organization established the Science Division and its Department of Digital Health and Innovation to meet the growing demands for evidence-based guidance and technical support. The department developed a comprehensive Global Strategy on Digital Health (2020–2025) to outline key actions required to enable countries to strengthen health systems through evidence-based digital health approaches. The department and its mandate were built on over a decade of technical foundations in eHealth, telemedicine and mHealth – with clear guidance on core building blocks needed for an enabling ecosystem, a consensus taxonomy proposing a shared language for digital health and evidence-based guidelines on digital interventions for health system strengthening. Across six regions, WHO expertise in digital health is being bolstered, as are regional strategies, informed by extensive consultation.
Post-pandemic, one highly sought area of technical support is in shepherding digital health system transformation. Globally, opportunities were missed to leverage digital health to manage the Covid-19 response because of a lack of the enabling foundations necessary to rapidly develop, adapt and scale digital systems locally. Independent of income status, countries without core infrastructure, policy and legislation, technical architecture, national interoperability standards and workforce capacity were less able to respond using these technologies. One key reason for these gaps was inadequate investment in the enabling environment, with funders preferring the short-term wins and lower risk profiles of time-and-scope–delimited digital projects instead of digital public infrastructure. The value of a more systematic, strategically planned approach has been supported by several country exemplars of robust digital pandemic responses (for example India, Singapore and Rwanda) – where investments in digital architecture such as national identification schema, data governance policies and national interoperability standards have been made for over a decade. These contributed to improved technical capacity to implement systems, and also generated public trust – leading to better engagement and participation. The WHO, in partnership with multiple agencies, is working on a common roadmap to support governments in developing, costing and implementing a digital transformation strategy.
At the recent World Health Assembly, the interim report on the Global Strategy on Digital Health was received with widespread support and encouragement. The rapidly growing global digital health ecosystem requires accelerated action in strengthening capacity to enable equity within and across regions. This means creating a workforce that can advise governments and their populations on effective digital health norms and standards, and ensuring recommended health and data content is available to the health systems and the populations they serve. It means meeting the need for timely, relevant guidance on norms, standards, policies and governance models to foster enabling ecosystems that surround effective digital investments. And it means ensuring that quality-assured technological building blocks are accessible to governments and supporting institutions to build high-performing, user-centred solutions that increase the likelihood of an equitable digital future. Political will, resource allocation and technical capacity are rapidly converging – and appropriate support to governments from the WHO together with partner agencies will catalyse this opportunity.
In August 2023, the WHO launched the Global Initiative on Digital Health, a network of networks to help coordinate, align and amplify best practices across the six WHO regions and partners within and outside the UN system. This work focuses on accelerating the Global Strategy on Digital Health with its primary objective to support member states in developing resource- and maturity-appropriate costed strategies, followed by identifying quality-assured technical support to help establish the necessary policy and governance environment. The initiative will also promote access to vetted building blocks (such as digital public infrastructure and generic digital public goods) to kick-start locally owned and managed solutions. The WHO maintains country-facing technical resources to assist in these processes, from a standardised maturity assessment to the Digital Health Atlas (a national/regional portal for the systematic documentation of digital projects and investments), to a digital clearinghouse that assures the quality of technical products for interoperability and technical compliance to guidelines and best practices.
The WHO also launched, this year, the Global Digital Health Certification Network, assuming custodianship of the European Union’s highly successful Digital Documentation of COVID Certificates network – connecting over 80 countries through a brokered transitive trust, allowing individuals to travel with credentialled health certificates freely within and across borders. This important piece of global digital health architecture enables future cross-border uses, including for patient-mediated summary patient records, digital paediatric immunisation cards and even telemedicine.
Digitalisation versus transformation
As health moves from an analogue to a digital paradigm, it is important to differentiate digitalisation from transformation. Digitalisation can be interpreted as the migration of extant processes – often with origins in decades-old systems predicated on the many limitations of paper-based documentation, reporting and planning. We must ask whether tomorrow’s digital health systems are merely computerised versions of the dysfunctional analogue systems of the past – or have they been reimagined with the possibilities unlocked by a digital reality? When freed from the physical register, patient summaries and future scheduled tasks can be shared across a connected health workforce, enabling timely, continuous care in ways previously impossible. Real-time visibility of programme coverage requires new ways of monitoring and the governance/policy architecture to respond and adapt resource allocation weekly, if not daily.
Digital health can fundamentally shift how we think about primary health care and universal health coverage – but we must be willing to challenge the status quo that has been cemented in decades of practice. Digital transformations have implications for established processes that affect entire ecosystems – political, societal and economic. Disruptive change to large systems is rarely embraced with enthusiasm, given the complexity and unpredictability of downstream impacts. Driven by the strong moral imperative of accelerating progress towards the SDGs and, more importantly, ensuring people have access to the care they need, when and where they need it, we must collectively challenge ‘business as usual’, and reimagine Health For All.
