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Considerations for other digital health initiatives
This section takes a ‘step back’ to offer some thoughts to the Bill and Melinda Gates Foundation – and other donors - on wider lessons for digital health programs in resource-constrained settings.
● Digital health projects probably cannot operate in only the health sector. When investing in a specific use case, be clear about the concurrent investments needed at other system levels, and those that need to be addressed at a national, government-wide, level. ● Digital projects need multiple entry points. The causal chains are not simple or linear. The simple logic of the original Kuunika design is appealing but did not stand the test of reality. A ‘building blocks’ approach can support flexibility, phased implementation and system transition planning. ● Digital projects need to remain highly adaptive to the changing context, as well as technical developments and requirements. The Foundation’s flexible approach to the funding and management of Kuunika has been the right one, not always seen in other donors. ● A digital health intervention cannot design systems without properly thinking of who will use them, and how they will use the systems in the health centres and districts. ● IT programs are more than just hardware. Much of Kuunika’s success has been in building relationships (formal and informal) across government, creating a flexible team, providing foundational landscape maps and statistics and growing a pipeline of able staff. (It is important to acknowledge, however, that basic infrastructure and hardware can be a key determinant of success). ● BMGF has an important role in promoting the ‘global goods’ nature of IT development on open source systems. ● Understanding the political economy in Malawi, and including major donors, is key and needs to begin from the start. Evidence from Kuunika is that progress may have been considerably influenced by how well potential ‘fault lines’ between departments and between donors have been identified and negotiated over time. ● Political economy is not just a one-off inception exercise but an ongoing skill or project function, requiring experienced project staff able to connect and operate within the system. ● Digital health investments tend to primarily serve the disease focus of donors and their reporting systems; promote harmonized Supplier procurement, as well as buy-in to a shared interoperability infrastructure.
● Long standing principles of aid effectiveness and digital development can be brought together and grounded by giving more force and responsibility to national digital forums – but there is a need to take them beyond just talking shops to become real delivery support bodies. ● Do some fresh thinking on sustainable capacity building for digital governance: go beyond the short term solution of funding and filling posts in line ministries. Peer to peer organisation support and/or
BMGF fellowship schemes may be alternatives. ● ‘Use case’ approaches to digital health investments make sense: they provide a bridge to the health workers at the facility level and the realities of working on the ground. ● But ‘use case’ approaches need to be complemented by a systems focus that works to promote digital health governance at all levels.
