Digital health in low and lower-middle-income countries – new report

By Anna Pick.

Future Advocacy’s latest report, Digital Health in Low and Lower-Middle-Income Countries (LLMICs) was published today. Funded by the Pathways for Prosperity Commission, the report outlines the potential of digital technologies to transform healthcare in poorer settings. It includes 20 case studies and 12 recommendations aimed at policymakers, donors, international bodies, development agencies, researchers and other stakeholders engaged in digital health, including in the private sector.

Here are five of our key findings:

1 – Digital technologies in healthcare show enormous potential in many areas, and will help LLMICs adapt to complex and evolving health challenges over the coming decades.

The global health landscape is rapidly evolving. While LLMICs still experience high levels of infectious diseases, the global disease burden is shifting from communicable to non-communicable diseases. Climate change, disruption to supplies of food and water, mass migration, changes in diet and lifestyle, and many other trends, will create serious and novel challenges for health systems at every level.

Digital tools – from mobile health apps, electronic medical records, and remote consultations to diagnostic support, outbreak prediction and robot-assisted surgery – can help healthcare systems adapt. Our report documents 20 case studies in which digital tools are already making a real difference. Amongst these are CommCare, an open source platform developed specifically for frontline health workers, Ada Health, a personalised health assessment app already used by 8 million people globally, and ColdTrace, a temperature monitoring system for vaccine storage. 

2 – Providing basic, reliable digital infrastructure to all citizens is essential if digital health applications are to lessen health inequalities.

The global shortfall of doctors, nurses and other health workers is set to grow to 12.9 million by 2035, and the rural-urban divide is stark. Digital tools that extend the reach of community health workers and other care professionals may have a high impact. Populations that lack basic digital infrastructure – electricity, internet connectivity and digital literacy skills – are at risk of being ‘left behind’ by these advances.

According to the International Energy Agency, an estimated 1.1 billion people across the world do not have access to electricity, with many more suffering from poor quality supply.  Meanwhile, the UN’s State of Broadband 2018 report found that 48% of the world’s population do not have internet access.  Only around a third of rural populations in low-income countries are covered by 3G networks. This lack of basic infrastructure is a major barrier to most digital health initiatives. An additional obstacle for applications using AI is that data is often stored in formats that are not machine-readable.

‘Digital tools are ultimately accelerants… the biggest risk of digital health is that, rather than accelerating movement towards equity, it instead accelerates movement toward disparity.’

Skye Gilbert, Executive Director, Digital Square, PATH 

3 – The most effective digital health applications take a system-wide approach, address a real world challenge, and are country-led.

Some of the biggest obstacles to scaling are not technical, but relate to governance, regulation and competing incentives. Our report found that coordination is often lacking among key digital health actors – including donors, multilateral organisations, NGOs, developers and investors. Not only has this led international actors to behave in ways that run counter to LLMIC national strategies and priorities, it is also a major cause of inefficiency and duplication. There was broad agreement among our contributors that the best applications take a system-wide (rather than disease-specific) approach, address a real challenge, and are country-led. 

Important efforts have been made over the past year to improve alignment and coordination. In 2018, the WHO passed a landmark resolution on digital health. The Principles of Donor Alignment for Digital Health, which 30 donors have already signed up to, advocates for pooling money to build digital platforms working across different diseases. Financing tools like the Digital Square Initiative create the means for funders to do so. Further efforts in this area are required.

‘Giving a smartphone to a community health worker just to address HIV is crazy; it’s like buying a laptop just to use Microsoft Word.’

Jonathan Jackson, Co-Founder and CEO of Dimagi, Co-Founder of Cogito Health

4 – All digital health tools should be designed in close collaboration with their user – whether patient, health worker, or manager.

It is essential that digital tools are designed in a ‘human-centred’ way, to address actual needs on the ground. The ‘Principles for Digital Development’, created by development agencies and international organisations, include ‘user-centric design’ as one of nine ‘living guidelines’ for best practices in technology-enabled programmes. This improves trust in new technologies, and increases the likelihood of their retention. Apps may also have an advantage over face-to-face care for culturally sensitive issues such as sexual health and gynaecology.

‘The doctor-patient relationship will change. Patients are already ahead of doctors. It will be more of a partnership than the doctor being the sole decision-maker’.  

Fazilah Allaudin, Senior Deputy Director, Planning Division of the Ministry of Health, Malaysia

5 – Universal internet access, the proliferation of data, and ubiquitous and powerful AI will present new risks and opportunities over coming decades.

The most transformative developments for digital health in LLMICs may not be ‘high tech’, but rather based on improvements to basic and vital infrastructure. Open source, interoperable software, will be transformative in many contexts. The proliferation of high-quality data will enhance global research and open up new opportunities for data-driven decision-making. The monetisation of these datasets presents both risks and opportunities.

We predict that digital health will play more of a role in mental health and social care as populations age. We foresee additional challenges around ‘fake news’ and online misinformation, as has been seen in the anti-vaccination movement. Overcoming these barriers in order to lay the foundations of digital health depends on leadership and, crucially, effective coordination at national and international levels. Sustained efforts will be required to ensure that the benefits reach those people who are worst off, and that existing health inequalities – for instance between rural and urban areas – are not exacerbated.

The most transformative innovation in this area has been ‘open source technology which can be adapted to different contexts and localised’. 

Akaliza Keza Ntwari, Founder of Girls in ICT Rwanda, Member of UN Secretary-General’s High-Level Panel on Digital Cooperation

Overall, if the risks are managed effectively, we envisage a future in which digital health applications play a significant role in helping healthcare systems in LLMICs respond to the complex and evolving challenges they face.

Anna Pick is Research, Advocacy and Communications Coordinator at Future Advocacy.

Read Future Advocacy’s full report on Digital Health in Low and Lower-Middle-Income Countries here.