Leveraging Digital Health for Effective Public Health Program Implementation in India

Abstract

The World Health Organization (WHO) underscores the critical role of information in health systems, highlighting its pivotal impact on healthcare outcomes. Digital health represents a transformative shift in healthcare delivery by leveraging Information and Communication Technologies (ICTs) such as mobile applications, electronic health records, telemedicine platforms, and data management systems to improve access to care, efficiency and decision-making in health services. Initiatives like India’s Ayushman Bharat Digital Mission (ABDM) and national digital health roadmap underscore a commitment to digital solutions. However, there are hurdles to the implementation of digital health, including design complexity and aversion to change. To ensure easy integration into national health programs, WHO promotes a digital health enterprise model that places a strong emphasis on aligning digital technologies with health system processes, governance, and infrastructure to enable coordinated and scalable digital health implementation. Digital health plays a crucial role in planning, operationalization, and monitoring of healthcare interventions. Therefore, identifying these key factors that contribute to successful implementation is essential. A systematic implementation approach is essential, including situational analysis, interdisciplinary collaboration, clear intervention goals, appropriate technology selection, realistic planning, cost considerations, and robust monitoring. Embracing digital development principles in a digital health enterprise approach holds promise for overcoming health system challenges and enhancing program outcomes, thereby advancing healthcare objectives.

BACKGROUND

Health information system – A mortar among building blocks of health system

Information is a determinant of health. Envisaging this, WHO has identified information as one of the six pillars of the health system, which supports the other pillars, viz., a. leadership/governance, b. health workforce, c. finance, d. medical products, e. vaccines and technologies, and f. service delivery.[1]

The overall goals and outcomes of a health system are to achieve improved health outcomes. As per the health system framework, this could be achieved by providing wider access and sufficient coverage, with people’s safety supported by quality services.[2] For a populous country like India, the information generated by each pillar of the health system is voluminous. Information generated through health service delivery is abundant across various public health programs and critical to monitor. This mandates a cost-effective, user-friendly, and efficient digital health application for the Indian health system.

Digital health refers to the use of information and communication technologies (ICTs), data systems, and digital tools to support decision-making by individuals, healthcare providers, and health systems, with the aim of improving health outcomes and health system efficiency.[3] Digital health encompasses all concepts and activities at the intersection of health and ICTs. This includes eHealth, mHealth, Electronic Logistics Management Information System (eLMIS), Telemedicine, Lab Information Systems, and Health Information Systems (HIS).[4] India leveraged the urgency created by the COVID-19 pandemic to introduce digital health interventions at program management, provider, and patient levels.[5] One step ahead, before the pandemic, the national digital health blueprint was launched in 2019.[6] During the September 2021 pandemic, India launched the Ayushman Bharat Digital Mission (ABDM), which seeks to implement standardized protocols using a federated architecture through the Health Information Exchange and Consent Manager (HIE-CM).[7]

DISCUSSION

Challenges and opportunities in the implementation of digital health

Though these recent developments seem exciting, the health system’s adoption of new technology has many challenges. By design, health systems are self-organizing, and resistant to change but constantly changing the linkages.[8] In this context, most digital health interventions fail to sustain in public health. Top-down design and extensive data entry requirements can pose field-level challenges. For example, digital reporting platforms often require frontline health workers to enter multiple detailed fields during each patient interaction, which may increase workload and reduce time available for direct patient care. Literature suggests that user-centered design, minimal data entry, and faster and user-friendly applications pave way for sustainability and usability of digital health interventions.[9]

WHO suggests a digital health enterprise approach for effective digital health implementation within the health system at all levels aligning digital technologies with health system processes, governance, and infrastructure to enable coordinated and scalable digital health implementation. It comprises various elements such as well-mapped business processes, key data points, systems framework, and appropriate technologies. Such an enterprise is mandated to support the operations of the health system, including the point-of-service software applications, devices, hardware, and the underlying information infrastructure. Delivery of health services will be accelerated and amplified by using digital and data technologies developed through this enterprise approach.

A non-enterprise approach may face challenges pertaining to integration, coverage, cost-efficiency which could impact the long-term sustainability of digital health interventions. Major pitfalls for such failure are as follows: (1) shortcuts in the development and non-consideration of user, design, and system analysis, (2) selection of unsuitable technology for the usage and scale, (3) premature commitment and poorly planned budget, and (4) inadequate piloting and absence of evaluation.[10]

Implementing a unified digital health system across diverse states and union territories presents a noteworthy opportunity to standardize health data management and improve accessibility to healthcare services. This can enhance decision-making, facilitate better resource allocation, and ultimately lead to improved health outcomes nationwide.[11]

Characteristics of the digital health interventions

For a public health program, digital health is a vital tool for planning, operationalizing, and monitoring patient and program outcomes. This paper identifies four key characteristics necessary for a reasonable digital health system.

Before designing a digital health tool for a program, it is required to identify specific targets and goals for the program as recommended by the World Health Organization.[12] This will help to address the key indicators to be recorded and reported by the digital health tool. The first characteristic of a digital health tool is measuring the right indicators for the planning and execution of the program. For example, for a hypertension control program, the digital health tool should inform the program manager to list the facilities with more patient dropouts.[13]

Operationalizing a program involves timely decision-making. More often, a data-driven decision in a public health program aids in planning resources and avoiding health service interruption. The second characteristic of a digital health tool is to provide periodic data for operationalizing the program. For example, in a diabetes control program, the digital health tool should report the facilities with inadequate drug stocks. Similarly, a digital tool should inform a clinician about the previous blood sugar level of a patient being consulted. In health service delivery, a healthcare provider needs to know whether the treated patient achieved the intended health outcomes.[14]

A health program is expected to check whether the implementing units achieve health outcomes after the due investment of resources. A third characteristic of a digital health tool is to inform the concerned so that they gain command of the process and provide oversight on the outcomes. For example, healthcare providers need to be notified by digital tools about the continuum of care of people screened for cervical cancer. Similarly, through digital tools, program managers would require information about the performance of care delivery for cervical cancer by facilities.[15]

One of the advantages of using digital tools is less redundant paperwork. The fourth characteristic of a digital health tool is reducing administrative burdens and improving healthcare providers’ and managers’ health service efficiency. A digital system is expected to automatically generate periodic reports on the work process and service delivery. For example, a staff nurse entering the hypertension patient registration and follow-up details in a digital tool should facilitate the program manager to easily view and generate automatic reports for a continuum of care for hypertension.[16]

The above four essential characteristics assist an implementer or software developer in understanding what a digital public health tool should have. However, the steps of developing a digital public health program still vary, where the primary intention is to support the program manager and healthcare provider in tracking the health outcomes.

In the past two decades, a range of digital health strategies have been experimented with to tackle health system obstacles; most implemented were siloed stand-alone applications for specific programs. For example, the Pregnancy and Infant Cohort Monitoring and Evaluation (PICME) system has been developed to track and monitor maternal and child health services, including pregnancy registration, antenatal care, delivery, and immunization services.[17] For a stable digital health system, a digital health enterprise approach is required, crafted on principles of digital development.[18] The enterprise approach aids the health system in delivering health services, accelerated and amplified by these technologies. The technologies include software applications, devices and hardware and the underlying information infrastructure (such as the digital health platform).[19] The Principles for Digital Development serve as a compass to promote sustainable and inclusive development to ensure that all people can benefit from digital initiatives and from the broader digital society.

Steps in implementing digital health interventions for public health programs

Prior to developing a digital public health tool for effective implementation of a program, an understanding of the existing data use within the health system is critical. The following steps are depicted in Figure 1. The first step is conducting a situational analysis on existing information systems such as the flow of data, the use of tools, and the use of data or information for public health decision-making is essential. In addition, an assessment of the existing digital health infrastructure and enablers for implementation could be done using standardized tools.[20,21,22,23] This assessment distinguishes the existing digital health system architecture’s level of maturity. Understanding the existing health system context and designing digital solutions that are tailored or modified to the needs of end-users are the digital development principles to be followed in this step.

Figure 1.

Key steps in the design and implementation of digital health tools

Forming a team is the second step following the assessment. The team should comprise of qualified, motivated and knowledgeable individuals with adequate dedicated time in three groups: governance, management and operations. Absence of this would lead to generating a weak, unstable digital health system, which will carry the high risk of expensive failures on investments. The governance group bears the responsibility of furnishing comprehensive direction and guidance for implementation. The management group will oversee the completion of the process to formulate a budgeted implementation plan. The operations group will work with the guidance of the management team, offering essential technical expertise as needed. Being collaborative is the suggested digital development principle at this step.[24]

The team will define the intended requirement of developing a digital health tool. Thus, the third step is defining the purpose of a digital health tool. The Collaborative Requirements Development Methodology (CRDM) is a participatory approach used to identify system requirements through structured collaboration among key stakeholders, including program managers, healthcare providers, technical experts, and end-users which enables the team to define and document the requirements in a standardized and collaborative way.[25] This methodology helps in answering the question, How do the health system processes work now? How should the process work? How can a digital health tool support in achieving the expected process? Standardized categories of health system challenges address the common bottlenecks.[26] Sometimes digital health may not be a suitable solution for the bottlenecks. On characterizing the requirement, exploration and selection of the right digital health solution aligned with the health system challenge are the fourth and fifth steps, respectively. In this step, the team will outline the requirements for the planned digital health intervention, determine whether such an intervention already exists and understand the maturity of digital health in the setting, which explains the readiness of the enabling health system.[27] The WHO Classification of digital health interventions exhibits the diverse ways that technology supports health system needs and addresses challenges. Tools such as national ehealth strategy toolkit,[27] global digital health monitor[28] and HIS interoperability toolkit[29] are few resources to assess the maturity and readiness of an enabling environment. Digital development principles to be adopted in this step are the following: open standards, reuse, and improvement principles. On the selection of a suitable digital health intervention, preparing a realistic implementation plan that is responsive to the enabling environment is the sixth step. The management and operational group prepares the plan covering the seven foundational building blocks of digital health, viz., (1) leadership and governance, (2) strategy and investment, (3) services and applications, (4) standards and interoperability, (5) infrastructure, (6) legislation, policy and compliance, and (7) workforce. Each block has specific considerations in the implementation plan. For example, there are certain test considerations in the services and applications block. Conducting usability testing, end-user acceptance test, functionality test and load tests ensures the delivery of intended services by the digital health intervention.[25] Building the system for sustainability is the digital development principle to be followed in this step.

Cost considerations for specific digital health interventions on a carved-out implementation plan are the seventh step. The team should grasp the factors influencing costs in each phase, precisely calculate the funding requirements, and identify sources for co-financing within the health system and programs. Five phases of budgetary implications are development, deployment, integration and interoperability, scaling up and sustainment. Certain tools such as Program cost checklists and Digital Square’s Total Cost of Ownership (TCO) Tool are available to estimate the costing for digital health.[30,31,32] The team is intended to monitor the fidelity and quality of implementation, evaluate the impact on anticipated processes and outcomes, identify measures necessary to encourage data utilization, and explore how adaptive management strategies could enhance efficiencies and outcomes. Using evidence to improve outcomes is the digital development principle that shall be followed in this step.

Monitoring the implementation and data use effectively is the eighth step. This involves periodic assessment of monitoring and evaluation of digital health interventions, data use and adaptive management driven by data. There are various standardized methods of digital health intervention.[29,33] The sustainability of a digital health intervention hinges on several critical factors. Initially, comprehending the policy landscape within the health system, encompassing current strategies and practices, is pivotal. In addition, the technical capability of the health system to sustainably manage digital health interventions over the long term is essential. This involves formulating a capacity-building plan for essential infrastructure and ensuring adequate human resources. Furthermore, the degree of engagement and involvement of health system actors in adapting the digital health solution is crucial, highlighting institutional roles. Lastly, the feasibility of the costs associated with maintaining and replacing the digital health solution within the system serves as the fourth determinant of sustainability.

CONCLUSION AND RECOMMENDATIONS

The digital health technologies are crucial for developing adaptable, cost-effective interventions that meet the diverse needs of healthcare delivery. Implementing digital health interventions is a dynamic process, requiring adherence to digital development principles at every stage to ensure optimal outcomes. Digital health tools hold great promise for hastening public health program outcomes. However, challenges such as resistance to change and interoperability issues need ongoing attention and innovative solutions. Future research should focus on exploring these challenges further to refine implementation strategies and enhance scalability. Additionally, there is a need for deeper exploration into the long-term impacts of digital health initiatives on health equity, access to care, and patient outcomes across diverse populations. Frameworks such as the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework and evaluation approaches developed by the World Health Organization, along with longitudinal studies, can help assess the long-term effectiveness and cost-effectiveness of digital health interventions.[29,34]

While digital health offers transformative potential, its success depends on alignment with health system needs and effective implementation. Future research should focus on evaluating the scalability, sustainability, and real-world impact of digital health interventions. By advancing research and strengthening implementation practices, stakeholders can ensure that digital health solutions are effectively unified into health systems to improve program performance and health outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.