ICTworks

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.

COVID-19 Digital Response

From the beginning, governments, donors, and NGOs rushed to identify, develop, and introduce digital solutions to support this effort. Similar patterns emerged 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,
• Countries did not have a cadre of digitally enabled health workers already deployed to “hit the ground running.”

As the months wore on and COVID-19 spread to all corners of the world, the realization of the need for digital health as an integral part of health systems was dramatically amplified. Even before the onset of this pandemic, digital health has been transforming healthcare:

• Strengthening the ability of frontline health workers to deliver world-class care,
• Connecting and motivating people and health system actors,
• 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.

3 Lessons Learned Deploying Responsive Health Systems

In reflecting on the push to both use digital health to support the current COVID-19 digital response, and also to position national health systems to be resilient and responsive to future threats, at D-Tree we have learned three key 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.

It is imperative that governments, and any organization working with them, evaluate multiple potential solutions in order to determine what might be most appropriate for the local context. Even then, those solutions may provide good bases from which to start, but they likely require significant additional development and modification. After all, 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

Key Takeaway: Recognize the need to tailor digital systems to the local context, and funding must be available to support these processes.

Lesson 2: Existing health workers and digital infrastructure are critical.

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.

However, as COVID-19 spread and we worked to support Ministries of Health across a number of countries, many 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.
• 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.

Key Takeaway: Work to expedite the development and scale-up of national digital health systems for frontline health workers providing essential health services.

Lesson 3: Stand-alone technology solutions will fail

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, lessons from digital health programs globally show 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.

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.

Key takeaway: Invest in long-term health systems strengthening efforts, resulting in responsive and resilient health systems.

The Need for a Holistic View of Digital Health

Yes, effective integration of technology into health systems is complex—but there is a critical need to look beyond the “app” or “solution” to a more holistic approach. To do this, governments and partner organizations 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 all 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.

By Erica Layer, CEO of D-tree International and originally published as Digital Spark #5: Implementing responsive digital health systems: Lessons from COVID-19