34. Case study: USAID promotes co-ordinated investments in digital systems for better health outcomes
The United States Agency for International Development (USAID) recognises the need for a new strategic approach oriented towards strengthening the digitalisation of partner country health systems, promoting more interoperable and co-ordinated digital systems. This case study highlights the work of USAID, in line with its Digital Health Vision, in funding and implementing initiatives to achieve better co-ordination of investments in interoperable and scalable digital health systems.
The author expresses her appreciation to colleagues who commented on this draft including Sherri Haas, Dr. Folake Olayinka, Irena Sargasyan, and Rebecca Saxton-Fox at USAID, and Karin Kallendar at UNICEF.
COVID-19 revealed that a lack of co-ordination (rather than a lack of digital technology and systems) is one of the greatest problems in the digital transformation of health systems.
The digitalisation of health systems presents a critical opportunity for countries to become more nimble and agile in detecting, responding to, managing, and recovering from health threats.
To facilitate the move to interoperable health systems, countries need to move away from investing in siloed systems and work to overcome barriers by finding alignment between partner country priorities and international development funding.
Digital connectivity, as a channel for the delivery of data, information, and services, is a critical health commodity. Indeed, a recent Lancet and Financial Times Commission report posits that digital transformation is a new determinant of health (Kickbusch et al., 2021[1]).
During the COVID-19 pandemic, as with the Ebola epidemic of 2013-2016 (USAID, 2016[2]), efforts to meet the urgent need for accurate information in a rapidly changing environment are hampered by fragmented digital systems (i.e. not interoperable). Digital health systems that are siloed by disease or health promotion area are common and they impede data exchange and use. By making it harder to access, analyse and triangulate health data, the silos obscure health trends and nuance, undermining scope for more targeted health information sharing and service delivery.
This issue is particularly critical in low-income and lower middle-income countries where health system digitalisation often depends on assistance from international partners who have a history of investing in digital systems that are siloed, reflecting their own institutional structures, expertise and technological capacity. COVID-19 (and Ebola (USAID, 2016[2]) before it) revealed that the lack of co-ordination (rather than a lack of digital technology and systems) is one of the greatest problems in the digital transformation of health systems. International development agencies and organisations urgently need a new strategic approach oriented toward strengthening the digital transformation of partner country health systems, promoting more interoperable and co-ordinated digital systems.
The United States Agency for International Development (USAID) recently published a Digital Strategy (2021[3]) and a sector-specific Digital Health Vision (2020[4]) that highlight the importance of assessing and strengthening the country ecosystems in which digital systems are used. Moreover, other countries, India (Government of India, 2020[5]) and United Republic of Tanzania (The United Republic of Tanzania, Ministry of Health, Community Development, Gender, Elderly and Children, 2019[6]) being interesting examples, have begun publishing national strategies for health sector digital transformation, creating a powerful opportunity for funder co-ordination. Several multilateral organisations and development co-operation partners have recommended adopting a similar, systems-level approach to planning for, and investing in, digitalisation. In the health sector, organisations call for strengthening national digital health governance, strategy, policies, and architecture through, for example, the 2018 World Health Assembly Digital Health Resolution (World Health Organization, 2018[7]), the 2020 WHO Global Strategy on Digital Health (2021[8]), and related materials issued by UNICEF ([9]), the Pan American Health Organization ([10]), and the Asian Development Bank (2018[11]).
To strengthen co-ordination, USAID is undertaking a variety of co-investment and co-ordination activities described below. USAID also supports the periodic assessment of country health system digitalisation, enabling funders to align around existing tools and address identified gaps. In the context of fast-moving disease outbreaks like COVID-19, investing in the reuse (Principles for Digital Development[12]) and strengthening of existing digital systems (Digital Square[13]) - already a core part of a country’s health system - is an efficient way to meet urgent needs prior to investing in something completely new or parallel.
In line with its Digital Strategy and in collaboration with other bilateral development agencies and multilateral organisations, USAID is supporting initiatives that facilitate co-ordinated investments in interoperable and scalable digital health systems. These include, for example:
A community of practice made up of endorsers of the Digital Investment Principles ([14]). The community meets regularly to identify and address opportunities to maximise co-ordinated investments.
The UNICEF-WHO Digital Health Center of Excellence, a new, multilateral technical assistance facility on digital health ([15]). It is designed to respond to COVID-19 needs using a co-ordinated, systems-strengthening approach.
New centralised and WHO-administered platforms addressing barriers to information. These include the Digital Health Atlas (World Health Organization[16]), which captures information about the deployment of country-level digital systems, and the Digital Clearinghouse which connects ministries of health and their partners to vetted digital solutions.
The expansion of Digital Square ([17]) ([18]), a funding mechanism designed by the USAID to pool funder investments and align them to priority software systems and country technical assistance requests.
The digitalisation of health systems presents a critical opportunity for countries to become more nimble and agile in detecting, responding to, managing, and recovering from health threats. These benefits will only accrue, however, if the global community fully implements and learns from well-documented lessons.
Despite the clear benefits of moving to interoperable health systems, there are many barriers to finding alignment between country priorities and international development funding. These include a lack of commonly accessible basic information about existing country digital systems and capacity, the complex delivery architectures of funding institutions, the high transaction costs involved in co-ordinating or harmonising projects between multiple funding partners, and the current lack of visibility about past, ongoing, and planned digital health investments by funding organisations.
Open, secure, inclusive, rights-respecting and standards-based digital health systems are critical to the delivery of public services. Many international development co-operation partners are calling for increased consideration of digital public goods (Digital Public Goods Alliance, 2021[19]) that can work across disparate geographical regions and health sectors, building on country assets.
Investments in digital health systems require parallel investment in “analogue” components, such as strengthening the human and institutional environments in which digital systems and data are used, to advance progress towards outcomes of equity, quality, and resource optimisation (see p.38 in (USAID[20])).
To understand how best to direct funding, it is essential to conduct periodic assessments of country digital systems and digital capacity readiness. With the advent of the Digital Health Atlas, there is now a home for information about country digital systems. A similar hub is needed for information about country digital capacity readiness, including data sets such as those published on the Global Digital Health Index.
This case study is also published on the OECD’s virtual peer learning platform Development Co-operation TIPs • Tools Insights Practices as part of its In Practice series. The series presents real life responses to a diverse range of development co-operation challenges, with a focus on results and lessons learnt.
Digital Square, Electronic Immunization Registries in Low- and Middle-Income Countries, https://digitalsquare.org/resourcesrepository/eirlandscape.
References
[11] Asian Development Bank (2018), Guidance for Investing in Digital Health, https://dx.doi.org/10.22617/WPS179150-2 (accessed on 24 November 2021).
[15] Digital Health Center of Excellence (n.d.), Digital Health Center of Excellence, https://www.digitalhealthcoe.org/ (accessed on 24 November 2021).
[14] Digital Investment Principles (n.d.), The Principles of Donor Alignment for Digital Health, https://digitalinvestmentprinciples.org/ (accessed on 24 November 2021).
[19] Digital Public Goods Alliance (2021), Understanding the Relationship between Digital Public Goods and Global Goods in the Context of Digital Health, https://digitalpublicgoods.net/blog/understanding-the-relationship-between-digital-public-goods-and-global-goods-in-the-context-of-digital-health/ (accessed on 24 November 2021).
[18] Digital Square (2021), Digital Square recommits to advancing health equity through digital transformation, https://digitalsquare.org/blog/2021/8/27/digital-square-recommits-to-advancing-health-equity-through-digital-transformation (accessed on 24 November 2021).
[13] Digital Square (n.d.), COVID-19 Map & Match, https://digitalsquare.org/covid19-map-match (accessed on 24 November 2021).
[17] Digital Square (n.d.), Digital Square, https://digitalsquare.org/ (accessed on 24 November 2021).
[5] Government of India (2020), “National Digital Health Mission”, Strategy Overview, https://abdm.gov.in/documents/ndhm_strategy_overview (accessed on 2 December 2021).
[1] Kickbusch, I. et al. (2021), “The Lancet and Financial Times Commission on governing health futures 2030: growing up in a digital world”, The Lancet, https://doi.org/10.1016/S0140-6736(21)01824-9.
[10] PAHO (n.d.), 8 Principles for Digital Transformation of Public Health, https://www.paho.org/en/ish/8-principles (accessed on 24 November 2021).
[12] Principles for Digital Development (n.d.), Reuse and Improve, https://digitalprinciples.org/principle/reuse-and-improve (accessed on 24 November 2021).
[6] The United Republic of Tanzania, Ministry of Health, Community Development, Gender, Elderly and Children (2019), Digital Health Strategy July 2019 - June 2024, https://www.healthdatacollaborative.org/fileadmin/uploads/hdc/Documents/Country_documents/Tanzania/Tanzania_Digital_Health_Strategy_2019_-2024.pdf (accessed on 2 December 2021).
[9] UNICEF (n.d.), UNICEF’s Approach toDigital Health, https://www.unicef.org/innovation/media/506/file/UNICEF%27s%20Approach%20to%20Digital%20Health%E2%80%8B%E2%80%8B.pdf (accessed on 24 November 2021).
[3] USAID (2021), USAID’s Digital Strategy Overview, https://www.usaid.gov/usaid-digital-strategy (accessed on 24 November 2021).
[4] USAID (2020), A Vision for Action in Digital Health, https://www.usaid.gov/digital-health-vision (accessed on 24 November 2021).
[2] USAID (2016), Fighting Ebola with Information, https://www.usaid.gov/sites/default/files/documents/15396/FightingEbolaWithInformation.pdf.
[20] USAID (n.d.), USAID vision for health system strengthening 2030, https://www.usaid.gov/sites/default/files/documents/USAID_OHS_VISION_Report_FINAL_single_5082.pdf (accessed on 24 November 2021).
[8] World Health Organization (2021), Global strategy on digital health 2020-25, https://www.who.int/docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf (accessed on 24 November 2021).
[7] World Health Organization (2018), Digital health. Draft resolution proposed by Algeria, Australia, Brazil, Estonia, Ethiopia, Germany, India, Indonesia, Israel, Italy, Luxembourg, Mauritius, Morocco, Panama, Philippines and South Africa, https://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_ACONF1-en.pdf.
[16] World Health Organization (n.d.), Digital Health Atlas, https://digitalhealthatlas.org/en/-/ (accessed on 24 November 2021).