Digital Spark #5: Implementing responsive digital health systems: Lessons from COVID-19

In early 2020, when COVID-19 emerged as a global pandemic and urgent public health crisis, countries all over the world scrambled to develop a rapid and effective response to limit the introduction of COVID-19 through their borders and slow the spread of community transmission. In low- and middle-income countries, it became clear that manual systems would not be sufficient, as they quickly became overwhelmed and could not support efficient service delivery or provide meaningful, real-time data rapidly enough to allow governments to adapt their responses.

From the beginning, governments, donors, and NGOs rushed to identify, develop, and introduce digital solutions to support this effort. We observed similar patterns among various countries working to introduce digital tools for this very purpose; however, governments were often overwhelmed by the number of solutions available, partners were not always coordinated with the government response, and countries did not always have a cadre of digitally enabled health workers already deployed to “hit the ground running.”

There is little doubt that digital technology can and must play an integral role in health systems in years to come.

As the months wore on and COVID-19 spread to all corners of the world, the need for digital health became more and more clear as its absence within health systems was dramatically amplified. Throughout this blog series, we have explored the myriad ways digital health is transforming healthcare, from strengthening the ability of frontline health workers to deliver world-class care, to connecting and motivating people and health system actors, to empowering governments with granular, real-time data that can be used to guide more precise and timely planning and actions based on needs of specific populations. There is little doubt that digital technology can and must play an integral role in health systems in years to come, and growing consensus in the need to support governments to harness technology that they will own and sustain into the future (see our blog post on Embracing Collaboration to Achieve Sustainable Health System Transformation).

Since 2004, D-tree has been working to demonstrate the potential of digital technology to improve people’s health in low- and middle-income countries. In reflecting on the push both to use digital health to support the current COVID-19 response and to position national health systems to be resilient and responsive to future threats, we have learned a number of lessons. While these relate to ways in which health systems can rapidly and effectively support a pandemic, they also provide broader insights related to the field digital health.

Lesson 1: There is no one-size-fits-all solution.

Earlier this year, the World Health Organization released a database of digital solutions developed in an effort to support streamlined responses to COVID-19. These solutions ranged from contact tracing apps, to surveillance tools, to distance learning platforms. The list contained more than 100 solutions. At the same time, many donors were investing in technology companies to build ready-to-use tools which could provide a turnkey solution to governments and implementers globally.

At D-tree, we evaluated dozens of potential solutions on behalf of the Zanzibar government to help them figure out what might be most appropriate for this context. All solutions that we reviewed provided a good base from which to start, but they each required significant additional development and modification if we would use them in Zanzibar.

The structure of health systems, cadres and responsibilities of health workers, and information flows differ in every location. And while solutions offered by tech companies provide an important and significant basis from which to start, further investment is required to contextualize any digital system for the local context. This is an inconvenient truth, as funding is less readily available to adapt these systems to work within each setting .

Lesson 2: Existing health workers and digital infrastructure are critical for an efficient response.

As we have explored in this series, equipping health workers with digital tools on smartphones can be profoundly beneficial in many contexts—and the COVID-19 pandemic is no exception. These mobile apps can contain user-friendly interfaces to walk a health worker through a protocol, automate follow-up visit schedules, and ensure the right data is collected at the right time. Once this data is synchronized, health managers have access to near real-time data to monitor trends and make rapid decisions to further support the outbreak response. If implemented at a national scale, this can potentially transform a country’s ability to respond to and manage a disease outbreak with coordinated, responsive systems (see our blog post on Setting Digital Health Apart).

However, as COVID-19 spread and we worked to support Ministries of Health across a number of countries, we found that governments were encountering similar challenges in deploying this type of coordinated response. While governments were eager to introduce digital solutions to frontline health workers, they faced multiple barriers due to inconsistencies in how the existing national workforce was equipped with, and trained on, digital tools:

• Access to smartphones. Smartphones support a much broader range of functionality than a basic feature phone and would therefore be ideal for the complexity of the COVID response, but a majority of health workers do not have access to these devices. This lack of access is made ever more complicated in the context of a pandemic, when it is difficult to justify purchasing smartphones to support only the COVID response, and more difficult still to acquire them.

• In-person training. Of the health workers with access to smartphones, some may have low general digital literacy, and most would likely be unfamiliar with the specific digital platform. The introduction of a new digital tool would therefore require extensive in-person training in order for health workers to master use of the smartphone, become adept at using the mobile app, and responsibly employ best practices for data privacy and confidentiality (see our blog post on Ensuring Data Protection and Privacy).

• Multiple platforms. In many countries, digital health tools are deployed as part of donor-driven projects led by NGOs; and, in many cases, multiple projects may be running in a given country at once. Therefore, even if existing health workers have access to smartphones and are already proficient in using digital tools, the fact that they are using different digital tools throughout the country makes it difficult for the government to deploy a standardized COVID response tool without additional in-person training.

In contexts where there is no standardized infrastructure in place, rapidly deploying digital tools at the onset of a public health crisis like COVID-19 is immensely challenging. In contrast, a country that has a fully digitally enabled frontline health worker cadre already in place, working from a standardized digital platform, can quickly and easily integrate new information into that framework. A health worker might receive a remote update to the existing app, for example, which contains a COVID module tailored to the local context. Training for this module then becomes much more streamlined and efficient, as health workers need only learn the new COVID-19 content and integrate it into their existing work streams.

Lesson 3: Stand-alone technology solutions will fail; digital systems must be integrated into broader health systems to be effective.

There is a big push to find the best technology solutions to support the COVID-19 response. This is understandable, given the significant potential that technology offers. However, our experience – and lessons from other digital health programs globally – shows that simply introducing a mobile app, no matter how powerful it may be, will not lead to improved health. Digital health programs can reach their full potential only if they are fully integrated within a broader health system; the government demonstrates strong political commitment to implementing a digital tool; strong capacity-building processes are established; and there is buy-in from all stakeholders who are responsible for making the system work—including frontline health workers, supervisors, district health teams, and national ministries of health.

Such integrated systems are critical for a successful digital health intervention, but they are difficult to successfully initiate and set up during a pandemic.

Once a digital solution is developed, the key to effective service delivery is strong and supportive supervision. In the context of a disease outbreak like COVID-19, for example, the mobile apps included in a digital health program supporting frontline health workers might include contact tracing, outbreak surveillance, or outreach and prevention education. It is critical for local supervisors to play an active role in following up with and supporting users in order for such programs to be effective—but supervision does not stop at the community level. District health teams must use the data captured within the system to adapt disease response plans, channel resources to areas that need it most, and monitor changes in disease trends. National ministries of health should then be using data to guide policy changes, resource mobilization, and educational guidance for their populations.

Such integrated systems are critical for a successful digital health intervention, but they are difficult to successfully initiate and set up during a pandemic. Even under ordinary circumstances, it is no small task to harmonize all stakeholders using digital tools and data and rapidly act on that data—and with neither existing system nor established supervisory system, such feats seem almost insurmountable. On the other hand, adding modules to an already-integrated digital system represents a much less daunting deviation from normal operations. It is therefore critical to treat digital health as one part of a strong health system and invest in the infrastructure, capacity-building, and policy environment needed for a digital system to succeed (see our blog post on Employing a Health Systems Strengthening Approach).

At D-tree, we see the critical need for digital technology in striving to strengthen health systems – this is true for ongoing essential health services as well as for acute responses during pandemics and disease outbreaks. We also recognize the complexity around effective integration of technology into health systems, and we see a critical need to look beyond the “app” or “solution” to a more holistic approach. To do this, we must consider factors such as:

• An effective technological design that fits the context and local need;

• The behavior and human systems changes that allow introduction of technology in a way that is most useful to all stakeholders;

• The policies that formalize government commitment to digital systems; and

• The ongoing capacity building processes that support governments to own digital systems and maximize the potential that they hold.

The technology is part of this multi-faceted equation, but it is only one part. When we take a holistic and comprehensive view of digital technology, we can create real and lasting change, enabling health systems to become more resilient and responsive in the face of a global outbreak, both to minimize the damage of a pandemic and to ensure uninterrupted delivery of essential health services.

Critically, though, these considerations must be addressed before the onset of a pandemic. Only then can health systems build a strong enough foundation to withstand the immense strain of a major public health crisis such as COVID-19. If we can be collaborative in our efforts, holistic in our approach, and urgent in our response, we can do more than just introduce cutting-edge technology—we can make it work for all, ultimately leading to improved health and wellbeing worldwide.

This concludes our Digital Spark blog series, in which we have explored the opportunities, as well as the challenges, for digital technology to transform health systems and to work toward increased access to high quality healthcare for all. We hope that these pieces have sparked new and useful discussions as the global digital health community continues to learn and scale transformational digital health systems throughout the world.

Photography by Kevin Ferguson.