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Digital Health Within the Current Global Context

The workshop’s opening session introduced multisectoral perspectives on key themes and considerations in digital health. Ted Herbosa of the University of the Philippines, Florence Gaudry-Perkins of Digital Health Partnerships, David Novillo Ortiz from the Pan American Health Organization (PAHO), and Robert Bollinger of the Johns Hopkins University School of Medicine discussed challenges and opportunities in developing and implementing digital health strategies, the role of different stakeholders, incentives and drivers to adopt digital technologies, and solutions to move forward.

Bollinger set the stage for the discussion by describing the value of digital technology through a public health approach. In public health, regardless of a specific disease or condition, over time, inaction will lead to an increase in costs in terms of lives, disability-adjusted life years (DALYs), and resources. Public health interventions, or actions, focus on preventing, diagnosing, reporting, and/or responding to the disease or condition with the goal of reducing those costs (see Figure 2-1). Innovations in digital technology, whether infrastructure improvements, mobile health, point-of-need diagnostics, big data analytics, and others, when applied to public health interventions, can accelerate or magnify shifts in any of the associated cost curves (see Figure 2-2). As an example, Bollinger noted that GPS-linked, just-in-time allocation of resources could produce an earlier and more effective response to disease outbreaks.

Bollinger noted there are many pilot programs demonstrating that digital technology innovations can, in fact, drive cost and time curves

down and increase the effectiveness of responding to disease. However, he suggested that the challenge is to align initiatives and stakeholders to maximize those effects and to do so at scale. “How do we create a value proposition for the public–private partnerships (PPPs) that are necessary to take these to scale?”

Herbosa recounted how when he was deputy minister of health in the Philippines, there were many technology startups and digital health pilot programs in the country, but none were scaling and coordination was limited. In response, the country, with Herbosa in the lead, established an enterprise architecture for scaling and coordinating digital health initiatives through the National eHealth Strategic Framework and Plan.

Gaudry-Perkins became familiar with the concept of the mobile revolution 7 years ago and learned of the rising penetration rates of mobile phones in Africa and other less-developed regions. She observed that while the technology field was already seizing the opportunities that were arising from the increasing availability of mobile phones across the globe, the health sector as a whole was largely unaware of this phenomenon. She has seen the situation change since then, and the health sector has woken up to the many opportunities mobile technology affords for improving how health care can be delivered.

Novillo Ortiz explained that PAHO, and, more broadly, the World Health Organization (WHO), is convinced that national digital health strategies, such as the one Herbosa implemented in the Philippines, can lead to improved public health planning, prevention, and service delivery capacity. PAHO/WHO is supporting the development of guidelines for different health components of information and communication technology (ICT), such as telehealth, mHealth, and electronic health records (EHRs). PAHO/WHO’s approach, he explained, focuses on guiding countries in regard to the components of digital health strategies, and facilitating information and knowledge exchange among countries that are developing and implementing their own approaches.

Bollinger asked Gaudry-Perkins for her perspective on the current state of the private sector’s engagement in digital health. The first thing to consider, said Gaudry-Perkins, is that the different actors that have a role to play in digital health vary in their maturity. For example, from her perspective, pharmaceutical companies began incorporating digital health technologies into their corporate strategies within the past 2 to 3 years; whereas, the health insurance field got involved a little later. She observes insurers making the same mistakes that other sectors made initially with digital health, which is to try to go forward without striking partnerships with others who can either complement their solutions or provide valuable insights from their experiences.

Even within the technology sector, Gaudry-Perkins noted that most

ICT partners would not be able to deliver a single, holistic solution for scale. “You need connectivity (networks), data centers, mobile devices, software, platforms, the cloud, and on and on,” she said, with each component, in some cases, provided by separate technology companies. Having to work with multiple partners in both the private and public sector highlights a key challenge, added Bollinger. “They are all going to have their own value proposition, their own incentives and drivers, and understanding that ecosystem will be important,” he said.

To illustrate that challenge, Herbosa noted that the private sector’s main driver is profit, while government’s objective is to provide a service, and marrying those two drivers is difficult. Furthermore, he added, while the private sector moves fast and embraces disruptive innovation, government is more resistant to change and often has to pass laws and develop infrastructure to implement new technology. He noted that in the early days of digital health technologies, there were plenty of ingenious mHealth and telehealth strategies, but no framework existed for coordinating these approaches in a way that would stimulate growth and a broader effect.

In Herbosa’s experience, donors in middle-income countries, such as the Philippines, often support digital health initiatives that are prescriptive about how a new technology should be deployed. In many instances he has found that these requirements from donors do not meet what a country has determined are its needs or duplicate something a country is already developing on its own. He suggested that the development of national eHealth strategic frameworks is a means of informing the private sector and donors about each country’s specific needs. As an example, Herbosa recalled how a telecommunications company approached the Philippines about developing a technology-enabled approach to reduce the country’s high maternal mortality rate. The company offered the Philippines a system that would connect primary care facilities with district hospitals and then funded a proof-of-concept study. However, the University of the Philippines already had a project underway in partnership with the National Telehealth Center that connected universities with rural health units. The technology company has since taken its system and is marketing it in other countries where there is a need.

As an example of how the Philippines is using ICT, Herbosa described an information technology (IT)-enabled syndromic surveillance system that it developed with WHO funding. This relatively simple system relies on texts sent to a central office describing the symptoms of people brought to an evacuation center. He explained that if the texts contained many cases of watery diarrhea, he would immediately order chlorine tablets and water filtration systems to the affected region to prevent an epidemic outbreak of cholera. Similarly, if the texts reported infection and fever, he

would send out a measles vaccination team. Another example is the geographical information system used to deploy international medical teams in the aftermath of Typhoon Haiyan in 2013. When the teams arrived, Herbosa said, they all wanted to go to Tacloban, which was the focus of reporting on CNN. However, he knew that there were seven islands heavily affected by Typhoon Haiyan and the geographic information system allowed him to distribute the teams where needed. The result was that major outbreaks of diseases such as cholera were prevented. These examples illuminate Bollinger’s point that digital technology can move the public health cost curves.

Novillo Ortiz commented on the challenge of filling the gap between what a country needs and what the private sector has to offer. Chile and Brazil have taken the approach of issuing public, transparent solicitations for solutions that have engaged the private sector. Another solution has been to use the National eHealth Strategy Toolkit developed by WHO and the International Telecommunication Union (ITU) (WHO and ITU, 2012). He also commented on the importance of taking time to explain the concepts of digital health technologies to the various ministers and other senior government officials who may not know or understand the value of these technologies for improving the health of a nation’s citizens.

OPEN DISCUSSION

As someone who has helped negotiate the United Nations’ Sustainable Development Goals, Simon Bland from UNAIDS said he sees a huge opportunity for technology to extract more value from limited health care funds, but it will require there being enough trained health workers available to use these technologies. He noted that WHO reported in 2013 that there was a 17 million health worker deficit, and on the present trajectory that deficit would still be 14 million by 2030. His question to the members of the panel was whether they have seen a correlation of successful digital health strategies with health workforce strategies, and in particular, if they have seen digital health strategies used to enable community health workers. In his opinion, doing so would create more demand for these technologies, which would create more incentives for private-sector investment to their technologies.

Gaudry-Perkins, addressing the shortage of health workers, noted that there is a successful program in India that has trained hundreds of thousands of community health workers, yet other countries are not following suit because this program has not generated enough evidence of a return on investment or a reduction in disease. Similarly, she said, a telemedicine program supported by the Novartis Foundation demonstrated that 38 percent of the medical problems in Ghana could be dealt with by

a single phone call, but again, this program has not spread because there is a demand for more proof of a return on investment.

Continuing with the theme of human resources, Bollinger asked the panelists about the other human resources needed to support ICT for health, particularly at the provider, clinic, and hospital levels. Herbosa replied by describing his tour of the rural health units that his office provided with computers and training for the local primary health care workers. “What did I see? I saw a computer with a cloth covering it.” What was happening, he said, is that only the young nurses and doctors were using the computer. “The more senior health professionals are the resistant ones, and the people in government are even more resistant,” said Herbosa. He predicted, though, that there will come a time when the younger generation of health care workers hits a critical mass and these systems will be more widely used. In the same way, he said, the younger generation of citizens in general is driving the use of mobile technology and social media for health promotion. “Suddenly, social media has a window in terms of health care,” he said. Novillo Ortiz added that overcoming the lack of human resources prepared to work on digital health involves working with various ministries to change the medical curriculum so health workers are prepared to use health informatics.

Herbosa noted ICT infrastructure can be a challenge for scaling any pilots in low- and middle-income countries (LMICs). In his country, for example, a pilot might show promising results, but scaling it to all 7,107 islands may not be feasible because some of the islands do not have remote technology infrastructure in place. The challenge becomes larger when trying to bring in the private sector in a transparent manner, given that many of the players offering health IT for a country such as his do not have experience working in an LMIC. What is important is to involve all possible stakeholders when planning to scale and to identify what it is that will create value for each stakeholder. “When you do that, you will be able to collaborate,” said Herbosa. “You will have a common goal and will be able to deliver.”

On this point, Gaudry-Perkins commented that one issue she has come to appreciate over the past few years is that a lack of laws and a national framework for digital health will cause even the largest public–private partnerships to falter. A lack of the appropriate regulation for digital health can deter large digital health companies from investing in that country, as they may deem it too risky. She emphasized that getting the right government digital health systems or frameworks in place is an essential step to scaling digital health. A national digital health strategy that has a governance system which has broken the silo between the ministries of health and ICT can enable the private sector to have a one-stop shop in order to get involved. “Once you start getting all of your

cross-sectoral working groups in place within a national digital health strategy, that is when it can be very effective for private sector,” said Gaudry-Perkins.

George Alleyne of the University of the West Indies asked the panelists who would pay for the development of technologies to support digital health. Gaudry-Perkins responded that answering that question is one of the challenges for sustainability and therefore scaling. For many years, philanthropy drove the adoption of digital health in LMICs and this has undoubtedly contributed to the great fragmentation today. As an example, she cited the situation in Mali, where there are 10 mobile maternal health projects, each financed by a different funder and none of which can communicate with one another or with the country’s health agency. In her opinion, the WHO-ITU National eHealth Strategy Toolkit will help avoid this type of fragmentation, though the cost of developing a national health strategy may be beyond the resources available to many LMICs. Rwanda, for example, committed $32 million over 5 years to developing its digital health strategy. The World Bank is financing a project in Gabon right now to implement a national digital health framework and the budget is more than $50 million over 5 years. Costs can include investments in ICT infrastructure development, hospital health management information systems (standards and interoperability), surveillance, Internet-enabled eHealth services, workforce development, policy and regulation, and community-level systems (Broadband Commission for Sustainable Development, 2017; World Bank, 2016).

Gaudry-Perkins suggested what will help countries allocate the necessary funds will be studies such as the one Canada conducted that showed the country has realized a return on investment of $16 billion since 2007 (Broadband Commission for Sustainable Development, 2017). She believes that the “who pays” question will be in part resolved, at least from a government perspective, as these technologies and programs mature and generate evidence. The private sector is already developing business models for digital health technologies, and in her opinion, the insurance industry will eventually have a very important role to play in this respect once it realizes the benefits of digital health tools in disease prevention and better disease management. Consumers may also become a driving force, she added, because of the potential for time saved.

Novillo Ortiz noted that in the Americas, private health care is a powerful force in terms of technology adoption and innovation and that private health care is starting to share the lessons of its experiences with the public sector. In Panama and Costa Rica, for example, the public and private health care sectors are working together. In the private sector, added Gaudry-Perkins, the shift to outcomes-based health care will drive the adoption of digital health technologies. In France, she noted, the

government has recently passed a law that moves one particular health intervention to an outcome-based system and is paying doctors to adopt telemedicine so they can follow their patients at home and avoid unnecessary hospitalizations. The reason this is happening, said Gaudry-Perkins, is that the government became convinced there was a positive return on investment.

Based on her experiences in both government and industry, Gaudry-Perkins said a key is to get high-level executives from both the private and public sectors together at the beginning of such discussions and talk about shared value and how a PPP can be a win for both sides. Too often, she said, such discussions start with either a business division or only the corporate social responsibility unit who do not see the big picture of how such partnerships can benefit entire organizations, not just the units or divisions for which they are responsible. An unidentified participant added that too often, high-level officials have no knowledge about digital health, but when informed about it become quite interested in learning more.

Elsy Dumit from PAHO asked the panelists if they had ideas on how to convince governments, particularly those in LMICs where investment funds are limited, to make needed investments in digital health when the payback may be 10 to 15 years in the future. Gaudry-Perkins responded that there are investments that have short-term returns, and even then it is important to keep reinforcing the political will of the champions for these projects. One approach for doing that, said Novillo Ortiz, is to keep reminding policy makers that digital health is about improving people’s lives. Gaudry-Perkins added that it is critical to break down the silos that currently exist between ministries of health, telecommunications, and whatever agency is in charge of digital initiatives. “A true national digital health strategy cannot happen unless you build governance and break the silos between these worlds,” she said. In her experience, accomplishing that task is the number one challenge to building sustainable support for digital health initiatives.

Herbosa noted that there are many models for PPPs in physical infrastructure. What is needed, he said, are models for PPPs for social infrastructure, including health care. In that regard, the question should not be “Who pays for it, but who pays for what?” said Herbosa. “Everybody pays for it, but what is your share?” Benjamin Makai from Safaricom agreed that “who pays for what?” is the right question, and that often the answer is not a direct one. For example, his telecommunications company participates in health-related projects not necessarily for the money, but because it helps the people who are subscribers to the company’s services stay healthy, which ultimately contributes to the company’s bottom line. Herbosa added another example in which the Philippines’ Department

of Science and Technology realized it could take advantage of the same unused portion of the television spectrum that the education department was using to reach schools in areas without Internet connectivity to connect to primary health care centers. In that case, nobody had to pay for the development of Internet infrastructure in geographically isolated and disadvantaged regions in the Philippines.

Alain Labrique from the Johns Hopkins University Global mHealth Initiative said there is an important shift occurring in which governments are creating the ecosystems in which programs can succeed when they go from pilot phase to spread and scale. He then noted the results of a landscape analysis of projects for frontline health workers that had scaled successfully (Agarwal et al., 2015). The one common factor spanning these programs, he said, was their simplicity. “Simple projects manage to reach scale when they do one or two things really well—and then complexity can be added,” said Labrique.

Labrique asked Herbosa how he has worked to shift the culture of the health care system in the Philippines to act on data in real time and to train health care providers on how to integrate data into their daily decision making. Herbosa shared that most people in the health ministry still wait to make decisions based on official data that is often years old. With a background in disaster and trauma response, Herbosa said he is accustomed to actively acquiring and using data, but he is a rarity in government and the policy-making arena in the Philippines with regard to data use. He also commented that too often, policy makers not only make decisions based on old data but do so without going into the field and seeing what is happening in hospitals and clinics. Labrique replied that perhaps data use should become part of medical training and that policy makers should be given permission to make mistakes and to take actions based on current data. The problem with giving permission to bureaucrats to make mistakes, said Herbosa, is that they lose their jobs when they are wrong. The way to address that issue, he said, is to make data available to policy makers earlier to take some of the uncertainty out of their decision making.

As a final comment, Herbosa said digital health has three goals: increase access to care, prevention, screening, and health promotion; involve the public and private sectors in creating an infrastructure that promotes creativity and disruptive or constructive innovation; and establish an ecosystem that is truthful and transparent. Realizing these three goals, he suggested, will help build support and sustainability for digital health among both high-level decision makers and among those who will use and benefit from digital health technologies.