6 Donors/ Funders

6.1 Bilaterals

Bilaterals are all in the digital innovation space either as funders or as developers of digital programmes including learning and training and performance management. All have digital strategies which include health and cover learning and education. Most have signed up to the Principles for Digital Development. The key ones are USAID, DFAT and FCDO and Agence Française de Développement (AFD)

UK Foreign, Commonwealth and Development Office (FCDO)

FCDO is still in a transition phase from DfID and integration is still taking place between the former FCO Prosperity Fund -a separate UK Aid programme and DfID. However digital work in health is directed by DFID’s Digital Strategy 2018-2020 which sets out sets out a vision and approach for doing development in a digital world. It is supported by three main programmes

The Prosperity Fund cross-HMG 'Digital Access Programme' is a DFID-led partnership with FCO and DCMS with a budget of £105 million. It aims to catalyse more inclusive, affordable, safe and secure digital access for excluded and underserved communities in Kenya, Nigeria, South Africa, Brazil and Indonesia.

The Educational Technology Hub’s plan is to accelerate progress in developing world education by 2030 through effective use of digital in education systems. This includes the use of digital, data and technology in schools, in ministries and at home to improve learning, efficiency and value for money. It currently provides innovative support, research on learning outcomes, and direct support for governments and global leadership.

Unlocking Digital Impact for Development is a programme to help to deliver the strategic goals of DFID’s Digital Strategy. The programme budget is £18.5 million between 2019-20 to 2023-24. Delivery will primarily be through the Digital Impact Alliance, housed within the UN Foundation. There is a separate pillar to finance complementary policy research and advice activities with other partners, including Digital Pathways at Oxford, as well as a learning and evaluation pillar.

To date there are no specific digital projects aimed at front line health workers. However, work may be going on at country level as part of more general programmes.

These three have been complemented by the Frontier Technologies hub which is probably of most interest to Gavi as it also hosts digital work to support the COVID response in LIMCS through its COVID Action programme. It works across three main areas: Livestreaming explores the use of frontier technology by working with partners all over the world to test and scale tech with the potential for positive social impact. Futures connects FCDO people with one another and the world of tech, equipping them to apply frontier technologies in their programmes. Hub Research gathers & shares what we learn and dives deeper into areas where tech has the greatest potential for doing good. While the website encourages posting by developers and innovators and shows multiple examples of good digital practice in health systems strengthening there is nothing to date on training g or performance management of frontline health workers. The COVID action section again has good examples of useful technologies but nothing on learning or training or performance management.

FCDO also funds the Digital Impact Alliance (DIAL) (digitalimpactalliance.org) DIAL’s work focuses on streamlining technology, unlocking markets and accelerating the rate at which others can deploy digitally enabled services. It could offer support to developing digital platforms as part of country digital strategies.

Australian Department for Aid and Trade (DFAT)

The most relevant programme for Gavi is the use of radio for training backed up by SMS messaging aimed at supporting front line health workers for the COVID response. The programme is run by UNICEFs across 14 countries of the Pacific. The training will be aired over a period of six months with a total of 33 broadcasts of 30-minutes each that aim to support governments to connect practicing nurses and midwives with the opportunity to learn, share information, and incorporate new WHO guidance on COVID-19.Participating front-line healthcare workers will also have the opportunity to ask questions for future episodes, share learning needs and receive episode summaries through UNICEF’s RapidPro platform, which is a two-way communication system that works with free SMS and messaging apps from smartphones.

The impact of COVID-19 on travelling led to a rapid transition to distance learning in DFAT aimed at nurses supported programmes in the Pacific which it outsourced to Medcast an Australian provider. They are a major provider of online curses aimed at medical and nurse practitioners in Australia New Zealand and the Pacific and have a huge menu of online webinars and courses some free some to be paid for None specifically cover vaccinations but they would have the capacity to provided them.

DFAT also supports the on-line training of veterinary professionals through The Asia Pacific Consortium of Veterinary Epidemiology led by the University of Sydney and para vets through a program lead by Charles Sturt University will develop online training for para-vets in the Pacific. Both would have the capacity to draw up similar programmes for front line health workers.

Usaid

Like other bilaterals USAID has a digital strategy - A vison for action in global health. Its focus is on addressing the fragmentation in the digital landscape and building up national capacity. This is covered in three of its four priorities. The fourth is leveraging global goods such as opensource platforms

One of the most useful tools they have produced is The Global Digital Health Index. The GDHI is an interactive digital resource that enables countries to assess their maturity in digital health and benchmark themselves against other countries. the GDHI was prepared using the WHO/ITU eHealth Strategy Toolkit and used its design process to engage with different data producers and data users. The index provides a quick snapshot of digital health ecosystem maturity at the global and national levels that can be easily shown at presentations and events. It complements the WHO digital health atlas.

Agence Française de Développement (AFD)

AFD runs learning and training programmes through the AFD Campus (ex-Cefeb). IT has a significant digital training component which continues to expand. Currently it has free online courses open to all ("Massive Open Online Courses", in English, or MOOC), training tutored remotely, virtual classes, webinars, serious games, communities of experts, etc. In the end, each AFD partner who wishes to strengthen their knowledge can build an à la carte course.

Courses are in French. Of particular value to Gavi might be the project management and leadership courses.

AFD has also has made a major commitment to support the WHO Academy. Earlier this year, WHO and France signed a Declaration of Intent to reach millions of people with innovative learning via a digital learning platform, with a hub in Lyon and embedded in all six WHO regions.

6.2 Foundations/ Innovation Funders

Bill and Melinda Gates Foundation (BMGF)

BMGF has been at the forefront in terms of digital health, funding the development of platforms as well as more specific programmes and interventions. Their approach and funding structure means that they have more creative freedom in what and how they fund. Their strategy on innovative technology solutions has the very purposeful goal, ‘to identify emerging technologies that have potentially transformative applications for global health’. In 2017, as part of their Goalkeepers initiative, Gates set the following ‘accelerator’: Scaling national community health worker programs. Their strategic interest in both innovative technology and scaling and empowering frontline / community health workers means they have been a key stakeholder and direct funder of many of the initiatives and interventions that this work has explored. Below are some examples (with fuller details in the grid and country case study sections)

• Last Mile Health and their Community Health Academy work (Liberia, Uganda, Ethiopia). Related to this they built the Global Faculty Network, a network of global experts to provide oversight and guidance to the Academy team.

• BBC Media Action’s Mobile Academy in India

• Bull City Learning and their Immunisation Academy Watch work (global)

• The Malaria Consortium’s inSCALE work in Mozabique and Uganda

• Appli Gestion PEV and Outil Suivi PEV in DRC - training of vaccinators through Immunisation Academy, led by Acasus

• OpenSRP - an open-source mobile health platform that allows frontline healthcare workers to electronically register and track the health of their entire client population

• Better Immunisation Data programme run by PATH in Tanzania and Zambia

• Village Reach - Access to Health Programs in Rural Africa

• Dimagi – various initiatives using their CommCare platform

Rockefeller Foundation

The Rockefeller Foundation is heavily involved in the funding of digital health initiatives. In support of countries and those on the frontline in their COVID-19 responses, they are awarding grants totalling $3 million to four organizations: Dalberg, Dimagi, Medic Mobile, and Odyssey Energy Solutions.

Rockefeller is jointly funding Dimagi and Medic Mobile, the two largest developers of apps designed specifically for community health workers (CommCare and Community Health Toolkit respectively) to co-develop a suite of open-source digital solutions to aid countries’ efforts to contain, mitigate, and recover from COVID-19 more efficiently. The aim of the grant is to enable Dimagi and Medic Mobile to engage a wider community of organizations in sharing resources, tools, and lessons learned. The hope is that this collaboration will facilitate the creation of more integrated digital health technologies that can support both the current COVID-19 pandemic response, and address future and existing health challenges.

Dalberg has received a grant to strengthen the Incident Management System (IMS) capacity of West African Emergency Operations Centers to prepare for, detect, and respond to public health emergencies. The foundation’s grant will support work in six West African countries: Senegal, The Gambia, Guinea, Guinea-Bissau, Mali, and Mauritania.

Odyssey Energy Solutions is receiving funding to develop its data platform, which will enable the fast and sustainable deployment of donor capital to energize healthcare facilities with distributed renewable energy technology. The Odyssey platform will align donor efforts, targeting efficient allocation of over $200 million across at least 2,000 health centres in subSaharan Africa.

Rockefeller is also supporting Gavi directly, providing a US$ 5 million investment committed to strengthening the critical role frontline health workers play in delivering immunisation services in Gavi-supported countries through digital tools and innovative information-sharing approaches that help them improve equitable access to life-saving vaccines. The aim is to aims to support the rapid implementation of innovative solutions and how best to use digital technology, leverage new partners, generate insights, and build a strategy to improve health workforce development and performance in Gavi-supported countries.

Johnson and Johnson Foundation

J&J have a keen interest in supporting work that improves the effectiveness of health care workers in developing countries with a focus on the potential of digital interventions. For instance, in Rwanda they are funding Viamo to provide telephonic messages including gaming scenarios to help health care providers deliver better care related to mental health. In Rwanda, they have also provided support to E-Heza Data Solutions, Rwanda’s first point-of-care digital health record system that gives Nurses and Community Health Workers (CHWs) the tools they need to adopt evidence-based clinical care protocols, provide high quality care and utilize realtime data trends to both tailor health education to individual family needs and to improve the health care delivery system while simultaneously satisfying Rwanda Ministry of Health data reporting requirements.

In Sierra Leone they have also been involved in a public-private partnership, MOTS - Mobile Training & Support Service, that provides remote training using IVR Technology on mobile phones as a complement to classroom trainings, with modules on vaccination & outbreak response and disease surveillance.

7 Sustainability

7.1 Sustainability Landscape

Digital learning and training and performance management need to be seen within the wider lens of digital innovation which faces the same challenges as any new intervention in global health. Sustainability is as always, the biggest. There is now a well-established literature on sustainability in development with clear guidelines for good practice to achieve it. Ultimately until a major intervention is embedded in a country’s relevant sector plan with funding provided by the government or by individuals it will not be sustainable. The exceptions are short term time limited interventions which can be financed until completion by a development partner. This can include training and education of individuals where in addition participants may self-finance if there is sufficient motivation. It will not apply to performance management systems which will rely on government uptake.

However, a quick landscape analysis shows that digital innovation is characterised by multiple projects funded for the short term by development agencies with much of the innovation taking place in OECD countries and delivered in LMICs by NGOS both for and not for profit with little evidence of sustainability

This has been recognised for some time by the major development agencies and they have produced ‘The Principles for Digital Development’ (www.digitalprinciples.org) a set of nine guidelines for integrating best practices into technology-enabled development programs for international development and cooperation and endorsed by over 100 development organizations. The endorsement programme was led by USAID. The United Nations Foundation's Digital Impact Alliance is responsible for their use. Gavi is currently not one of the endorsers.

Sustainability is one of the key principles and the detailed guidance for the Principles sets out what is now generally accepted as good practice.

The nature of digital innovation is such that the innovators may be good at coming up with ideas and getting them to market but have little experience in working with governments for sustainability. Conversely staff in governments and the multi-lateral and bilateral development agencies may not be at the cutting edge of knowledge of digital development. Last year when the UK Aid programme had a competition for seed funding for digital innovations for resilient health systems including training there were 560 applications none of which were from governments in LMICs.

However, WHO through its 2020-25 Global Digital Strategy is supporting governments in LMICS in developing country Digital Implementation Plans. If these take off and development partners at country level work through them then they will offer a roadmap to sustainability.

7.2 Global public goods and potential market shaping / funding models

An increasingly important concept in assessing digital solutions is Total Cost of Ownership (TCO) (for government) which is calculated through a comprehensive evaluation of all costs associated with digital solutions, including all expenses pertaining to hardware and software procurement, management and technical support, communications, training, system upkeep, updates, operating costs, networking, security, and licensing costs.

Another important concept is of Global Public Goods for health and how they are financed. In a post-pandemic world, upskilling health workers for greater effectiveness and vaccine coverage is undeniably a global good. Yet some of the largest technology companies maintain that the market for digital health global goods is functioning poorly at scale To maintain service functionality, make continuous incremental improvements, and maintain data protection to digital platforms, there is a recurring cost.

International development assistance tends to happen in cycles – institutions receive new funding for solution development while donors avoid funding recurrent costs in an effort not to create dependency. This approach becomes inefficient, however, given that upfront development costs are high. There are numerous examples of INGOs from the global north building solutions and when the project ends, the goods are lost.

The question of sustainability is a question many countries and organisations are currently struggling with. This is particularly true of software systems with open source licences where the expectation often is that the solution is free when in fact the cost of the license is a very small component of the total cost of ownership of the solution and long term sustainability needs to be financed. Some countries have developed a digital health investment case to guide the development of digital health systems and motivate for funding from the national treasury for identified technologies and systems with proven healthcare benefits.

Ideally a market would exist beyond the initial project investment phase that would incentivise producers and implementers of Digital Health Global Goods (DHGG) to ensure maximum value of the platforms. However, there is currently little market for pricing the ongoing support and maintenance of the deployed global good past the front-loaded investment phase. Because of the lack of market, revenue models for providers of DHGG at scale are unproven and this leads to a lack of investment by tech companies and instability for government implementors. Paradoxically, average costs might be as little as US$2 per (health worker) user per month and could fall as more users were added, allowing more value to be created.

Adding value to existing platforms of apps would make more sense than developing new apps and platforms. Providing bridging funding over a longer period to support ongoing costs until a transfer of full ownership to government, when value is better demonstrated at scale and investment cases made, would also be cost effective. Focusing on strengthening health systems, supporting and aligning with national digital as well as health workforce strategies, would make projects more complex but also more impactful in the long run.

The same issue arises as WHO contemplates how to finance its new Academy. A “Netflix” style subscription model is one possibility, wherein the Academy would need to continuously provide value or lose out to competitors. WHO did a market analysis in 40 countries on what people would be willing to pay for a WHO-branded learning experience. In high income countries (HIC), health professionals would pay in several hundred dollars (and would be willing to pay extra to help subsidise users in poorer countries) and there was willingness to pay in LMICs also. A differentiated subsidy model could allow cross-subsidies from HICs to LMICs

Gavi is a global leader in market shaping strategies in global health, for example, increasing the number of suppliers of the pentavalent DTP-HBV-Hib vaccine from 1 to 5, and reducing the price per dose from $3.50 to $0.68.58 It could consider leveraging its position to address the long term and intractable issue of sustaining Global Goods in the digital medical education space.

7.3 Actions Gavi can support

Gavi cannot be responsible for the sustainability of all digital innovations in learning and performance management at country level. It can however contribute by (a) following the guidelines set out above and signing up and adhering to the principles of digital development when introducing digital innovations at country level (b) making it clear to developers of digital training and performance management programmes that if they wish to be considered for Gavi funding or support they must adhere to the Principles for Digital Development including those for sustainability.

If Gavi supports digital innovations in learning/training and performance management for relevant front line health workers at country level then it should consider doing it as part of its HSS work ensuring it integrates into country digital innovation plans where it can work with governments. The following are some examples of good or emerging practice that it could draw on.

Ensuring Gavi staff and relevant country vaccine programme staff have skills for digital development

Futures is a programme from the Frontier Technology Hub (UK Aid’s innovation platform) that aims to develop FCDO in-country office staff’s knowledge, confidence and skills to use frontier technologies like drones, 3D printers and blockchain to deliver development objectives. It’s built on the concept of exploring ideas together without any predetermined answers, learning from multiple perspectives and hearing from technologists working on the ground who have tangible and relevant experiences to share. It has 25+ activities that FCDO departments can choose from to shape their Futures experience: everything from quick wins like methodology training, speeddating technologists and setting up a virtual Slack/WhatsApp community around the tech ecosystem, to high-investment, high-impact options like setting up a rolling makerspace or a start-up-FCDO secondment programme.

This is supported by Frontier technology live streaming which provides real time online support and partnering staff with digital experts.

Gavi could either set up or buy into a similar programme for its own staff and extend it to relevant vaccine programme staff at country level

Working through the WHO Academy

With $100 million funding from the French government the WHO Academy has been developed and is ready to launch in May 2021. There will be a hub in Lyon with six regional campuses. Its aim is to be a major learning centre for the global workforce. The Academy’s commitment to open source solutions will bring communities together to develop global public goods for digital learning, recognition of learner achievement, multilingual learning, learning technologies and innovations to ensure no one is left behind.

It may offer an opportunity for Gavi to work with partner governments to commission appropriate digital courses for front line health workers which would have legitimacy via accreditation and sustainability.

Moving from projects to programmes

Gavi may well wish to introduce short or longer term digital training and learning programmes for front line health workers as well as longer term performance management programmes that have been developed and demonstrated by an NGO provider. It should do this in collaboration with government and involve them in any selection process. Ideally, they should be part of the National Digital Implementation plans being supported at country level as part of WHO’s global strategy on digital health. It may well be that Gavi HSS funds can be used as a bridge between the initial developer and the government but ideally longer term programmes should not be introduced until government approval is given and a MOU of transfer of future funding in place.

The guidelines for sustainability set out in the ‘Principles for Digital Development’ should be followed. They are:

• Plan for sustainability from the start.

• Develop a definition of sustainability for your initiative.

• Identify and implement a sustainable business model.

• Use and invest in local information technology service providers.

• Engage local governments and integrate national strategies into programming.

• Collaborate instead of competing, and partner to identify the best approach with the greatest impact.

• Build a program that can be adapted as user needs and the context change.

• As mentioned above the innovators and developers of digital training, learning and performance management programmes may well be unaware of the clear evidence

However, developers and innovators of digital learning and training programmes may not be aware of these so Gavi can play a role in making clear to developers who approach Gavi for funding or for support in implementing their programmes at country level that they need to follow these guidelines.

Market shaping and supporting interoperability between different systems

Gavi has good relationships with governments and could use its political capital to help support market shaping for sustainable funding models of Global Goods. It could also use its influence to promote the development of ecosystems that support interoperability between different systems with tailorable app platforms – rather than development of new individual apps.