Upscaling digital solutions: the experiences of Estonia and India
The first Deep Dive session gave participants the chance to learn in detail about digital solutions in two radically different contexts: Estonia, with 1.3 million residents, and India, with 1.3 billion.
In the first part of the session Madis Tiik demonstrated features of the Estonian e-health system in real time, showing how patients can access their health files through the patient portal and how the eAmbulance service functions. He also presented MyHealth@Hand as an example of a ‘Health 3.0’ individual health account. The app, which was developed in Estonia and Finland and is currently being piloted in Uganda, allows pregnant women and mothers to collect and share health information during and after pregnancy, provides them with personalised AI-based information about staying healthy, and links to a related app for health care workers which allows them to track and record information about their clients. ‘Even in places where there is no integration, you can start building a health information ecosystem on the basis of a personal account,’ Tiik explained.
In the second part of the session, Susanne Ziegler and Shakheel Ahmad of the India-German Social Security Programme (IGSSP) explained how the government of India, with GIZ support, has been designing and implementing a new health insurance scheme for poor and vulnerable families known as Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). PMJAY is the largest cashless health insurance system in the world. It provides families with up to 500,000 Rupees (6,250 Euros) in health services at empaneled secondary and tertiary hospitals per year; the benefits are portable and the scheme is being rolled out countrywide. Digital systems play a fundamental role: hospital empanelment, beneficiary verification, registration, diagnosis and admission, preauthorisation, treatment and discharge, billing and claims management are all handled online. To date, 28.9 million of the 500 eligible beneficiaries have verified their identities and received so-called ‘golden records;’ more than 15,200 hospitals have been empaneled, and 1.8 million people have been treated.
Integrating social protection information systems in contexts of fragmentation
What does it take to overcome fragmentation and build integrated digital information systems? Ralf Radermacher, head of the Sector Initiative Social Protection, started off this Deep Dive session by laying out the conceptual basis for integrated information management systems. He underscored how linking the Management Information Systems (MIS) of individual social protection programmes can bring about significant efficiency gains while also enabling governments to monitor national social protection systems more effectively. Information collected on eligible applicants (‘social registries’) and beneficiaries (‘integrated beneficiary registries’) that is shared between programmes and governments can build a comprehensive picture of the national profile of beneficiaries (and other applicants), as well as the performance of schemes, and be linked to broader intersectoral registries.
Roland Panea, GIZ Nepal; Ole Doetinchem, GIZ Cambodia; and Alexandra Plüschke, GIZ Pakistan, then presented country-specific experiences of integrating fragmented social protection systems, describing first the successes and how they had been attained, and then describing the challenges they are currently grappling with.
Picking up on the fact that missing standards for integration processes seemed to be an issue for all presenters, Saurav Bhattarai, GIZ Nepal, proposed that GIZ could use its networks and experience with integrating digital health information systems to spearhead a global initiative for the development of such standards. Kelvin Hui of the GIZ Sectoral Department seconded this idea and proposed the GIZ-led working group of the Social Protection Interagency Cooperation Board (SPIAC-B) as a first forum where standards could be discussed and shared with international partners supporting a global agenda for digital social protection.
It takes two to tango: Leveraging partnerships and alliances for digital health
Based on detailed examples from Ukraine and Nepal, this Deep Dive session examined how GIZ projects have managed to leverage partnerships to advance progress in digital health.
After Kelvin Hui sketched out some of the major international frameworks and platforms for digital health, Anja Fischer, with the GIZ programme in Ukraine, and Yurii Buhai, a consultant with Study Dive Ukraine, presented their experience with an initiative which succeeded in digitally enrolling patients and primary health care providers into a new single-payer national health service. The starting point in 2016, according to Buhai, was ‘a lot of chaos’ – no clear strategy, no one driving e-health from the side of the Ministry of Health, fragmented and overlapping datasets and registries, and no unique identifiers to link e-health data to individuals. At the same time, more than 120 organisations and institutions signed on to an early Memorandum of Understanding in support of the idea of a digital enrollment platform – each with their own ideas and visions.
‘Sometimes I think that official ‘roadmaps’ are like a Beethoven symphony – written by one person and with precise directions for each individual part,’ says Buhai. ‘But in reality this never happens. In our case there was never a single conductor and the groups involved only roughly know what instruments they were supposed to use to make music. We adopted a “just play” approach.’
It turned out that the key to progress fell into the ‘golden triangle’ at the intersection of civil society, which monitors and innovates; government, which sets the rules; and the private sector, which provides services. Civil society (in this case, led by the trusted NGO Transparency International Ukraine) provided the spark and the innovative ideas which evolved into a ‘minimum viable product;’ businesses played the role of early adopters and drove the change forward; and government picked up the process at the stage at which it needed to be scaled up. As of early 2018, when the open source platform was handed over to the Ministry of Health, more than 27 million patients and 2,000 health facilities were registered on the system.
In Nepal, the leveraging of partnerships for digital health happened largely by accident, as Paul Rückert and Saurav Bhattarai of the GIZ Support to the Health Sector Programme recounted. The programme was only a few months old when a massive earthquake struck Nepal in April 2015. Dozens of health facilities were damaged or destroyed in the most affected districts, along with paper-based health records. This crisis ended up putting in motion a series of digital health collaborations with partners, both inside and outside Nepal, each of which built upon the one before: a joint engineering assessment of damaged facilities with DFID, the results of which were uploaded to an online portal; work with the Ministry of Health to digitise the health management information system as part of ‘building back better’; a co-financing agreement with KOICA to continue this work and to introduce Electronic Health Records in a hospital in Nuwakot District, where both GIZ and KOICA were active; follow-on financing from the Global Fund to extend the digitisation of health information systems to 5 more districts; additional German funding from funds and special initiatives to better target beneficiaries for health insurance and to improve the civil registry system; and, most recently, another contract with the Global Fund to work on an interoperability framework. All of this is in addition to a large collaboration with the Sector Programme Social Protection and Swiss Development Cooperation to develop the open source health insurance software openIMIS.
All told, GIZ Nepal’s programming portfolio on digital health – which started off unexpectedly and has evolved dynamically ever since – has topped 11 million Euros. ‘Without all these partnerships we’d not be where we are now,’ said Rückert. ‘Digitalisation has become our top selling product.’
Karen Birdsall and Anna von Roenne