Project overview

The Digital Health Exemplars (DHE) research project aims to generate practical insights on how Exemplar countries used digital health technologies to improve primary health care (PHC) systems and contribute to better health outcomes. Insights from this work aim to inform global and national health research, policy, and practice to strengthen the PHC systems that serve billions of people and around the world.

What will we learn?

This project examines countries that have demonstrated notable achievements in digital health maturity (DHM) relative to their PHC system performance and efficiency. By investigating the various trajectories that Exemplar countries have followed at national and subnational levels, the project will provide insights into the drivers of effective digitization at each stage of digital health maturity and the role of digital health in strengthening PHC. This project intends to reflect a holistic, system-level view of digital health in support of PHC systems by examining the following research questions:

The project will build on existing knowledge to generate concrete recommendations for other countries seeking to improve their own digital health systems.

What are the enablers of digital transformation of PHC in Exemplar countries?

• What are effective models for sustainable financing for the digital transformation of health care?
• What country experiences and strategies or approaches reduce fragmentation for better integration, scaling, and impact of digital health interventions?
• What enablers are most critical for the digital transformation of health care? What are common barriers and how have countries overcome them?
• What are effective strategies for engaging governments, the private sector, and other relevant stakeholders? What strategies are effective for mobilizing resources and commitment for digital transformation at the national and subnational levels?

What are the pathways to scaling up and sustaining digital health interventions?

• What are the steps to effectively scale digital health interventions for PHC?
• What is the optimal balance of incentives and strategies to increase the adoption and sustained use of prioritized digital health interventions and the data they generate?
• What strategies ensure the equitable and inclusive design and development of, and access to, digital health interventions?
• What are effective strategies for mitigating the effects of the gender digital divide on digital transformation of health?

What is the impact of scaled-up digital health interventions on health care coverage, access, quality, and outcomes?

• What health system effects (coverage, access, quality, efficiency, and others) are associated with large-scale digital health interventions?
• What health effects or health outcomes (maternal, newborn, and child health; nutrition; noncommunicable diseases; tuberculosis; HIV) are associated with large-scale digital health interventions? What is the cost-effectiveness of large-scale digital health interventions?

How are we conducting this research?

The DHE project has a threefold approach, with workstreams to develop case studies on Exemplar countries, conduct deep dives into key digital health transformation themes, and support peer-to-peer learning to help translate evidence to practice. Partner institutions include the Center for Global Digital Health Innovation at the Johns Hopkins Bloomberg School of Public Health, eHealth Lab Ethiopia at the University of Gondar, Africa Quantitative Sciences in Rwanda, the University of Ghana, the Indian Institute of Health Management Research, and Instituto de Estudos para Políticas de Sáude in Brazil, which are leading the Exemplar country case studies; the World Bank Group, which is facilitating peer-to-peer learning via the Joint Learning Network for Universal Health Coverage’s Digital Health Collaborative; and McKinsey Health Institute, which is leading the preparation of select thematic deep-dive analyses.

The three workstreams are described as follows:

• Retrospective case studies: Country case studies will document the evolution story, determinants of success, and key operations in countries that have already made significant progress with evolving their health systems’ service delivery model by leveraging digital tools. Relevant digital health and health systems documents for each country will be reviewed to understand the current context and historical progression of digital interventions and PHC. Additionally, data will be collected through in-country workshops, key expert interviews, and focus group discussions with key stakeholders. The study will also leverage existing data sources to provide a quantitative picture of Exemplar countries’ progress throughout time. In addition to country-specific case studies, a cross-country synthesis case study of results will compare and distill insights across digital health Exemplar countries.
• Peer-to-peer learning: Practitioner-to-practitioner learning opportunities will be supported to facilitate knowledge exchange on country experiences with common digital health implementation challenges. These methods encourage collaboration to identify pragmatic solutions and cocreate publicly available knowledge products.
• Thematic deep dives: Deep dives studies will unpack and synthesize findings related to key themes in digital health transformation. These themes were selected based on a survey of country demand and were derived from intensive review of various countries’ approaches.

Where are we working?

Exemplar retrospective research focuses on Rwanda, Ghana, India, Brazil, and Finland, including subnational research in India in three states—Andrah Pradesh, Karnataka, and Rajasthan.

Exemplars in Global Health is also working in partnership with the World Bank and the Joint Learning Network for Universal Health Coverage to host the Digital Health Collaborative, which provides peer-to-peer learning for 15 member countries. Those countries are Bahrain, Bangladesh, Cambodia, Ethiopia, Ghana, India, Indonesia, Kenya, Malaysia, Nigeria, Pakistan, Philippines, Senegal, Tajikistan, and Ukraine.

Additional topics in digital health are being further investigated as deep dives to understand various enablers of digital health. For example, McKinsey Health Institute has conducted an initial study on interoperability focused on Canada, Estonia, and Tanzania.

Country selection process

Digital health exemplars (DHE) are countries that have used digital health to improve their PHC system (improved access, quality, efficiency) in a manner that is sustainable, equitable and at scale, sampled across varied contexts, trajectories, and levels of maturity. The DHE project, in collaboration with normative agencies, implementors, the private sector, and ministries of health, identified positive outliers in digital health and PHC performance. DHE identified positive outliers through a multistage process.

First, DHE cross-mapped countries across DHM and PHC performance relative to per capita spending on health. DHM was measured by a composite score based on the digital health system building blocks identified in the World Health Organization-International Telecommunication Union (ITU) National eHealth Strategy Toolkit¹ : leadership and governance; strategy and investment; services and applications; standards and interoperability; infrastructure; legislation, policy, and compliance; and workforce and capacity. Two additional parameters - gender equity and consumer readiness - were included in the index to assess equitable access to and adoption of key health services. The effective coverage index is a composite measurement of primary health system performance created by IHME.²

Second, DHE grouped countries with relatively strong performance into four DHM typologies: emerging, transitioners, advanced, leaders. These DHM typologies were classified based on the quartile distribution of the average DHM composite score, with the goal to study Exemplar countries at varying levels of maturity.

Last, DHE conducted a landscaping analysis to determine the strength of digital programs in short-listed countries. DHE thus selected the Exemplar countries of Rwanda, Ghana, India, Brazil, and Finland (see Figure 1).

Learning how and why these Exemplar countries have leveraged digital health technologies to improve PHC systems and health outcomes can help other countries do the same.

Types of digital health interventions investigated

DHE is exploring how digital health interventions impact PHC service delivery at the health outcomes and/or health systems levels. Each country has implemented many solutions, but DHE chose to focus on a select few in each Exemplar country.

Exemplars in Global Health selected digital health interventions based on four primary criteria:

• Interventions focused on PHC
• Interventions implemented at significant scale (at least two subnational units)
• Ability to study the impact of the digital health interventions
• Data availability and access

The final selection of digital health interventions was based on (1) input from national and state-level stakeholders, (2) evidence of scale and effectiveness, and (3) distribution across health areas within PHC.

Who is involved?

Research teams

• Cross-country research partners
• Center for Global Digital Health Innovation, Johns Hopkins Bloomberg School of Public Health
  • Smisha Agarwal, Co-principal investigator
  • Patricia Mechael, Co-principal investigator
  • shivani pandya
  • Lena Kan
• eHealthLab Ethiopia, University of Gondar
• Binyam Tilahun, Co-principal investigator
• Tesfahun Melese

• In-country research partners’ principal investigators
• Rwanda: Hinda Ruton, Africa Quantitative Sciences in Rwanda
• Ghana: Frances Baaba da-Costa Vroom, University of Ghana
• India: Usha Manjunathan, Indian Institute of Health Management Research
• Brazil: Maria Letícia Machado da Silva and Leonardo Santana Nunes Rosa, Instituto de Estudos para Políticas de Sáude
• Finland: Not applicable*

* No in-country research partner leveraged for Finland; analysis conducted by cross-country research partners with secondary data resources and key informant interviews.

Partners

• World Bank/Joint Learning Network for Universal Health Coverage
• Somil Nagpal
• Mahlet Gizaw
• Marelize Gorgens
• Malarvizhi Veerappan
• Matt Hulse
• McKinsey Health Institute
• Lars Hartenstein
• Molly Bode
• Marilyn Kimeu

Technical advisory group

Research for every Exemplars in Global Health topic is guided by a technical advisory group consisting of a diverse range of topic-specific experts.

• Lav Agarwal (former Joint Secretary, Ministry of Health and Family Welfare, India)
• Nour El Arnaout (Manager, Non-Governmental Organizations Initiative, American University of Beirut)
• Joseline Carias (Chief Operating Officer, RECAINSA)
• Marcelo D’Agostino (Unit Chief, Information Systems and Digital Health, Pan American Health Organization)
• Shrey Desai (Director of Research and Physician, SEWA Rural, or Society for Education, Welfare and Action–Rural)
• Aliyah Lou Evangelista (Senior Manager of Healthcare Information Technology and Telehealth, Department of Health, Philippines)
• Michele Griffith (President, International Society for Telemedicine & eHealth)
• Karin Källender (Senior Health Advisor and Chief of the Digital Health and Information Systems Unit, UNICEF)
• Alain Labrique (Director, World Health Organization)
• Gemechis Melkamu (Director, Health Information Technology Directorate, Ministry of Health, Ethiopia)
• Jennifer Nelson (Senior Specialist, Digital Health Solutions, Inter-American Development Bank)
• Jean Philbert Nsengimana (Chief Digital Advisor, Africa Centres for Disease Control and Prevention)
• David Novillo Ortiz (Unit Head, Data and Digital Health, World Health Organization Regional Office for Europe)
• Somil Nagpal (Lead Health Specialist and Cluster Lead, World Bank)
• Tom Oluoch (Deputy Branch Chief, Epidemiology, Surveillance and Informatics, US Centers for Disease Control and Prevention; former President, Health Informatics in Africa; Founding Chairman, Kenya Health Informatics Association)
• Sathy Rajasekharan (co-Executive Director, Jacaranda Health)
• Chaitali Sinha (Senior Program Specialist of Global Health, International Development Research Centre)
• Tigest Tamrat (Scientist, World Health Organization)
• Kyeng Mercy Tetuh (Coordinator for Event-Based Surveillance, Africa Centres for Disease Control and Prevention)
• Adele Waugaman (Senior Advisor, Digital Health, US Agency for International Development)
• Stephanie Watson-Grant (Deputy Project Director, Country Health Information Systems and Data Use, JSI)