Development partners commit to overcoming fragmentation and duplication
The rapid adoption of computers, mobile phones and the internet over the last two decades has transformed the way people live all around the world. While most cutting-edge digital innovations still originate in high-income countries, digitalisation in low- and middle-income countries keeps accelerating, with the health sector leading the way. While these countries see opportunities to ‘leap-frog’ some development stages which established health systems have already gone through, they also face considerable risks. These include fragmentation, duplication and inefficiencies when – as is often the case – multiple projects supported by different development partners promote the use of separate information systems that cannot share or exchange data.
At the session ‘Digital health in developing countries’ on the second day of the World Health Summit in Berlin, Kelvin Hui, senior digital health advisor with the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, facilitated a lively debate on these issues with representatives of Malawi’s ministry of health, the Bill and Melinda Gates Foundation (BMGF), the United States Agency for International Development (USAID) and the Norwegian Agency for Development Cooperation (NORAD). The session was co-organised by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) and GIZ and culminated in a joint launch of the Principles of Donor Alignment for Digital Health.
Digital health is still a ‘mixed bag’
Asked to assess the digital health situation in Malawi and neighbouring countries, Andrew Likaka, Director of Quality Management at Malawi’s Ministry of Health, said that he would describe it as a ‘mixed bag’. While the digitalisation of HIV- and other disease-specific programmes is far advanced, few digital health initiatives take account of the health system as a whole, leading to inefficiencies, duplication and fragmentation: ‘Mobile health in Malawi, for example, is a case in point,’ Likaka said. ‘We have about 40 m-health initiatives, yet they are not talking to one another.’
Data have always been – and still are – at the heart of public health
David Stanton, Bureau Lead for Digital Health at USAID, reminded delegates that long before the digitalisation of health systems, data collection and analysis were already at the heart of public health: ‘Florence Nightingale collected mortality data in the hospitals of the crimean war and could show that her infection control measures drastically reduced it by factor of nine or more. Today we still have to do what she did, but we now have the tools to collect and analyse massive amounts of data. This presents opportunities, but also great challenges.’ Stanton pointed to the President’s Emergency Plan for AIDS Relief (PEPFAR) as an example of the efficiency gains made possible by digitalisation: Despite a static budget for the past ten years, PEPFAR’s use of near real time data has enabled a steady increase in the number of people who are on treatment.
We now need investment in systems and human capacities, not just in tools
According to Tim Wood, Senior Programme Officer at BMGF, the past decade has seen massive investment in digital tools and data, including from his own institution. However, ‘the challenge now is to strengthen the systems so that they can take advantage of these tools’. Wood noted that the time has come to move from disease-specific digital health programmes to investments in partner countries’ broader national digital health architectures and in the human capacities to analyse and use data effectively – an area on which his organisation is currently focusing on in Malawi.
Andrew Likaka confirmed that building health workers’ computer skills and changing their mindsets is essential for digitalisation to work: ‘People are used to paper registers and so they hold on to them. Even in facilities that have started to use computers, health workers still fill in their paper registers because they fear that the digital systems could break down.’
David Stanton noted that resistance to change is as common in the US as it is in Malawi. He argued that to motivate front line health workers to enter correct data into the system, they need to know what they get out of it: ‘Instead of just making sure that data are fed up to the apex, where health sector managers can then have the view of the full data landscape, we must remind those at the apex that the information flow must go both ways so that the frontline worker knows why it is worth putting in the effort.’
Digitalisation and empowerment
Asked if lack of electricity and connectivity still poses prohibitive barriers to health sector digitalisation, Haitham El-Noush, Senior Advisor at NORAD’s Department for Education and Global Health, cautioned: ‘Development is never linear. You don’t first build electricity networks and then hospitals and then go digital. It doesn’t work that way.’ By allowing citizens to link up and exchange via mobile phone or internet, digitalisation is an engine of empowerment, enabling them to put pressure on political leaders so that they provide stable electricity to both households and health facilities.
USAID’s David Stanton agreed with El-Noush and shared that before booking a hotel in Berlin he had first checked online user ratings. ‘In some corners of the world this is how people treat health care. They use the internet to find out or share whether a particular doctor or facility treated them nicely and gave them the right medicine.’ Digitalisation provides people with unprecedented opportunities to talk about, and thereby influence, the quality of health care they receive.
DHIS2: a global success story
Having formerly advised Bangladesh’s ministry of health on the adoption of DHIS2, Kelvin Hui of GIZ asked Haitham El-Noush if he could explain the global success of the open source software which NORAD began supporting in 1994. DHIS2 is currently used in over 70 countries and covers 2.2 billion people – almost a third of the world’s population. El-Noush noted that one important lesson is that innovations require long-term investments to render comprehensive results. It has been NORAD’s aim to provide countries with an open source tool that they could use for free and customise to the requirements of their health systems. According to El-Noush, DHIS2 functions best in countries that possess the capacities to manage and run the system, including electricity, the regulatory framework and health financing. In combination with other applications, DHIS2 can serve as backbone of countries’ health information systems, rendering health systems as a whole more robust and more able to deliver quality services.
Strengthening transparency and accountability through digitalisation
Reminding panelists of the human resource crisis faced by Africa’s health care systems, Andrew Likaka pointed out that ‘digital systems allow us to monitor health worker-patient contacts and to find out how and where efficiency can be increased. How many patients are actually being seen, where, by whom and at what cost?’ Another area for which transparency and accountability are crucial is the threat of antimicrobial resistance (AMR): ‘AMR presents a huge problem in Malawi because our diagnostic capacity is weak. To change this we have to look at clinical practice and monitor who gets the antibiotic and who prescribes it. Without digitalisation, where would we even start?’
We cannot leapfrog the digital ‘plumbing’
Digitalisation has reduced health workers’ workloads by removing the need to aggregate paper-based data at the end of each month. Still, as Tim Wood pointed out, too many digital information systems only replicate the structure of the older paper-based system, requesting data that have been entered somewhere else before, rather than linking different applications to existing databases via application programme interfaces. ‘One thing we tend to want to leapfrog is the unsexy plumbing required to establish efficient digital health ecosystems, including the development of data standards and registries, for example for facilities and health workers. Clearly, doing this plumbing work is much less attractive than placing a shiny tool on a tablet, yet this work needs to be done if we want digital health systems to work.’
Ensuring privacy and data protection will be a challenge for years to come
All panelists agreed that in times of accelerating digitalisation countries need data protection legislation that protects citizens’ privacy, as well as enabling institutions’ effective use of data. In Malawi, the parliament just passed an access to information bill. According to Andrew Likaka, however, implementing it is a challenge: ‘When we register patient data who owns the data? The patient? The hospital? How do we protect patients’ privacy? These are the legislative challenges that countries need support for.’
David Stanton fully agreed: ‘With easy access to data comes the risk that privacy and security are violated. This is a challenge we have to tackle in months and years to come. The promise of digitalisation will be stained if we don’t succeed in resolving these privacy issues.’
Development partners step up to tackle digital fragmentation
Next, Tim Wood opened the second part of the session in which the principles of donor alignment for digital health were officially launched. In January of this year, a group of development partners jointly acknowledged that, when it comes to digital fragmentation, development partners have often been part of the problem instead of the solution. The ten principles are meant to guide investments in partner countries’ digital health systems by aligning with countries’ digital strategies, working in a collaborative way with development partners and governments, and by developing global goods instead of reinventing the wheel.
In addition to the panelists, representatives of a handful of the more than 30 signatories to the Principles were present and made short statements in support of their commitment: Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), the US Centers for Disease Control and Prevention (CDC), Swedish International Development Cooperation Agency (SIDA) and the Joint United Nations Programme for HIV/AIDS (UNAIDS).
At the end of the session, Heiko Warnken, head of BMZ’s division of health, population policy and social protection, thanked the panel for their inspired discussion. ‘I have worked in development for the past three decades and alignment is a topic that has been important throughout these years. These Principles are an excellent example of how it can be done. We support digital health in Nepal, Malawi, ECOWAS and other countries, and in each of them we commit to aligning with other partners along the ministries’ plans and policies. We are proud to be part of this process.’
Anna von Roenne